A Seroprevalence Study on Residents in a Senior Care Facility with Breakthrough SARS-CoV-2 Omicron Infection

The Omicron variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began spreading rapidly in the community in November 2021, becoming the dominant variant in the Republic of Korea in 2022. Although its pathogenesis in healthy individuals was low, the severity and hospitalization rate was higher in the elderly and immunocompromised patients. We aimed to investigate the immunogenicity in acute and convalescent phases of breakthrough infection by Omicron in elderly individuals. Serological data were assessed by electrochemiluminescence immunoassay, enzyme-linked immunosorbent assay, and plaque-reduction neutralization tests. SARS-CoV-2-specific antibody and immunoglobulin G levels in the acute phase were higher in third dose-vaccinated elderly than in first and second dose-vaccinated patients. The neutralization antibody titer was detected only in third dose-vaccinated patients, and the titer was higher for the Delta than the Omicron variant. In the convalescent phase of Omicron infection, the neutralization antibody titer of vaccinated patients was higher for the Delta than the Omicron variant except in unvaccinated individuals. We demonstrated that the cause of the vulnerability to Omicron variant infection in third dose-vaccinated elderly was due to the low neutralization antibody level against Omicron. A fourth dose of vaccination is required in the elderly to reduce hospitalization and mortality caused by the Omicron variant.

Perioperative risk and benefit of antiplatelet therapy in patients undergoing non-cardiac surgery within 1 year after percutaneous coronary intervention with second-generation drug-eluting stents

Background

Antiplatelet therapy (APT) in patients undergoing non-cardiac surgery (NCS) after percutaneous coronary intervention (PCI) is still on debate due to its opposite effects which are to prevent from cardiovascular events and to cause bleeding. There is no apparent consensus on how to determine perioperative APT strategy within 1 year after PCI. Therefore, we investigated the risk and benefit of APT in NCS within 1 year after PCI.

Methods

Patients undergoing NCS after PCI with second-generation drug-eluting stents are retrospectively included from multicenter cohort of 8 medical centers in Korea. Perioperative clinical event within 30 days after NCS was recorded. Net adverse clinical event (NACE) including all cause death, major adverse cardiac event (MACE, a composite of cardiac death, myocardial infarction, and stent thrombosis) and major bleeding were evaluated. To overcome bias, propensity score covariate adjustment was performed using logistic regression analysis to generate propensity scores for patients of both APT strategies.

Results

Total 1130 patients (median age 69 years, female 30.5%) undergoing NCS within 1 year after PCI were eligible in the cohort. Study population included 55.1% patients suffered from ACS and 22.5% underwent complex PCI. NCS included 45.8% intermediate-to-high risk surgery and 10.7% urgent or emergent surgery. APT was continued during NCS in 62.7% of the patients. More patients continued DAPT (48% vs. 32%, p<0.001) among the patients who underwent NCS within 6 months after PCI than those who underwent NCS after 6 months. There were 49 NACE (4.3%), 16 MACE (1.4%) and 23 major bleeding events (2.0%), respectively. Continuing APT was associated with a lower risk of NACE (Adjusted hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.27–0.89; p=0.020)) and MACE (Adjusted HR, 0.35; 95 CI, 0.12–0.96; p=0.042). Subgroup analysis showed a tendency that continuing APT might be favorable than discontinuing APT in terms of MACE in patients who were diagnosed with ACS, underwent complex PCI, or underwent NCS within 6 months after PCI.

Conclusions

About two thirds of the patients were continuing APT during NCS. Our findings may support a careful consideration of APT continuation for some of the patients who are undergoing NCS within 1 year after PCI.

Funding Acknowledgement

Type of funding sources: None.

Amifampridine to treat Lambert-Eaton myasthenic syndrome

Lambert-Eaton myasthenic syndrome (LEMS) is a presynaptic autoimmune disabling neuromuscular disease caused by antibodies against presynaptic voltage-gated calcium channels. It reduces the quantal release of acetylcholine (Ach), causing muscle weakness, reduced or absent reflex and dysautonomia. About half of LEMS patients have associated small cell lung cancer. For symptomatic treatment, amifampridine (3,4-diaminopyridine [3,4-DAP]) is ideal because it increases the release of Ach at the presynaptic membrane. Since the first use of 3,4-DAP in LEMS patients in the 1980s, 136 LEMS patients were treated with amifampridines in the open-label studies and 208 patients in the eight randomized studies. These studies showed that amifampridine is the most effective drug for symptomatic treatment in LEMS. Now, 3,4-DAPP (3,4-DAP phosphate) is approved for adult LEMS patients and 3,4-DAP for pediatric patients. The recommended dose is 80 mg a day, divided 3 or 4 times a day. Side effects are usually mild, and the most frequently reported are paresthesia.

Osteoporotic fractures in patients with systemic lupus erythematosus and end stage renal disease

Background The incidence of end stage renal disease (ESRD) in patients with systemic lupus erythematosus (SLE) is rising. However, the relationship between osteoporotic fractures and SLE in the setting of ESRD remains uninvestigated. The purpose of this study was to compare the frequency of incident osteoporotic fractures in patients with ESRD with and without SLE, to identify risk factors for fractures in patients with SLE and ESRD, and to examine the contribution of these fractures to mortality. Methods Retrospective cohort study of patients with SLE ( n = 716) and a 5% random sample of controls without SLE ( n = 4176) in the United States Renal Data System (USRDS) from years 2006-2008 enrolled in Medicare Part D. Results Fractures occurred in 10.6% ( n = 76) of patients with SLE and ESRD and 12.1% ( n = 507) of patients with ESRD without SLE ( p = 0.24). Older age (adjusted relative risk 1.02, 95% confidence interval 1.01-1.04) was associated with an increased risk for fracture in patients with SLE and ESRD. In multivariable analyses, vertebral and hip fractures more than doubled the risk for mortality. Conclusions The frequency of osteoporotic fractures in patients with SLE and ESRD is similar to the general population of patients with ESRD. Vertebral and hip fractures are significant contributors to mortality in patients with SLE and ESRD. Fracture prevention, in particular, for elderly patients with SLE and ESRD, should be considered. Summary SLE is not an independent risk factor for fractures in patients with ESRD. However, among patients with SLE and ESRD, vertebral and hip fractures are significant contributors to mortality.

GM-CSF and IL-4 produced by NKT cells inversely regulate IL-1β production by macrophages

Natural Killer T (NKT) cells are distinct T cell subset that link innate and adaptive immune responses. IL-1β, produced by various immune cells, plays a key role in the regulation of innate immunity in vivo. However, it is unclear whether NKT cells regulate IL-1β production by macrophages. To address this, we co-cultured NKT cells and peritoneal macrophages in the presence of TCR stimulation and inflammasome activators. Among cytokines secreted from NKT cells, GM-CSF enhanced IL-1β production by macrophages via regulating LPS-mediated pro-IL-1β expression and NLRP3-dependent inflammasome activation, whereas IL-4 enhanced M2-differentiation of macrophages and decreased IL-1β production. Together, our findings suggest the NKT cells have double-sided effects on IL-1β-mediated innate immune responses by producing IL-4 and GM-CSF. These findings may be helpful for a comprehensive understanding of NKT cell-mediated regulatory mechanisms of the pro-inflammatory effects of IL-1β in inflammatory diseases in vivo.

Who may benefit from robotic gastrectomy?: A subgroup analysis of multicenter prospective comparative study data on robotic versus laparoscopic gastrectomy

AIMS

Robotic gastrectomy for gastric cancer has been proven to be a feasible and safe minimally invasive procedure. However, our previous multicenter prospective study indicated that robotic gastrectomy is not superior to laparoscopic gastrectomy. This study aimed to identify which subgroups of patients would benefit from robotic gastrectomy rather than from conventional laparoscopic gastrectomy.

METHODS

A prospective multicenter comparative study comparing laparoscopic and robotic gastrectomy was previously conducted. We divided the patients into subgroups according to obesity, type of gastrectomy performed, and extent of lymph node dissection. Surgical outcomes were compared between the robotic and laparoscopic groups in each subgroup.

RESULTS

A total of 434 patients were enrolled into the robotic (n = 223) and laparoscopic (n = 211) surgery groups. According to obesity and gastrectomy type, there was no difference in the estimated blood loss (EBL), number of retrieved lymph nodes, complication rate, open conversion rate, and the length of hospital stay between the robotic and laparoscopic groups. According to the extent of lymph node dissection, the robotic group showed a significantly lower EBL than did the laparoscopic group after D2 dissection (P = 0.021), while there was no difference in EBL in patients that did not undergo D2 dissection (P = 0.365).

CONCLUSION

Patients with gastric cancer undergoing D2 lymph node dissection can benefit from less blood loss when a robotic surgery system is used.

Novel strategy for a bispecific antibody: induction of dual target internalization and degradation

Activation of the extensive cross-talk among the receptor tyrosine kinases (RTKs), particularly ErbB family-Met cross-talk, has emerged as a likely source of drug resistance. Notwithstanding brilliant successes were attained while using small-molecule inhibitors or antibody therapeutics against specific RTKs in multiple cancers over recent decades, a high recurrence rate remains unsolved in patients treated with these targeted inhibitors. It is well aligned with multifaceted properties of cancer and cross-talk and convergence of signaling pathways of RTKs. Thereby many therapeutic interventions have been actively developed to overcome inherent or acquired resistance. To date, no bispecific antibody (BsAb) showed complete depletion of dual RTKs from the plasma membrane and efficient dual degradation. In this manuscript, we report the first findings of a target-specific dual internalization and degradation of membrane RTKs induced by designed BsAbs based on the internalizing monoclonal antibodies and the therapeutic values of these BsAbs. Leveraging the anti-Met mAb able to internalize and degrade by a unique mechanism, we generated the BsAbs for Met/epidermal growth factor receptor (EGFR) and Met/HER2 to induce an efficient EGFR or HER2 internalization and degradation in the presence of Met that is frequently overexpressed in the invasive tumors and involved in the resistance against EGFR- or HER2-targeted therapies. We found that Met/EGFR BsAb ME22S induces dissociation of the Met-EGFR complex from Hsp90, followed by significant degradation of Met and EGFR. By employing patient-derived tumor models we demonstrate therapeutic potential of the BsAb-mediated dual degradation in various cancers.

Integration of reverse transcriptase loop-mediated isothermal amplification with an immunochromatographic strip on a centrifugal microdevice for influenza A virus identification

A novel centrifugal microdevice which could perform reverse transcriptase loop-mediated isothermal amplification (RT-LAMP) and immunochromatographic strip (ICS) based amplicon detection was demonstrated for simple and cost-effective influenza A virus identification. The proposed centrifugal microdevice consists of the sample and running buffer loading reservoirs, the RT-LAMP chamber, and the ICS for detecting gene expression. The entire process could be completed sequentially and automatically by simply controlling the rotation speed and by optimizing the microfluidic design. Monoplex and multiplex RT-LAMP reactions targeting H1 and/or M gene were executed at 66 °C for 40 min, and the resultant amplicons were successfully analysed on the ICS within 15 min. Influenza A H1N1 virus was subtyped by detecting H1 and M gene on the ICS even with 10 copies of viral RNAs. Highly specific and multiplex viral typing of the integrated RT-LAMP-ICS microdevice was also demonstrated. The combination of the rapid isothermal amplification with the simple colorimetric detection on a strip in a single centrifugal microdevice will provide an advanced genetic analysis platform in the field of on-site pathogen diagnostics.

IFN-γ-producing NKT cells exacerbate sepsis by enhancing C5a generation via IL-10-mediated inhibition of CD55 expression on neutrophils

A role for NKT cells has been implicated in sepsis, but the mechanism by which NKT cells contribute to sepsis remains unclear. Here, we examined WT and NKT-cell-deficient mice of C57BL/6 background during cecal ligation and puncture-induced sepsis. The levels of C5a, IFN-γ, and IL-10 were higher in the serum and peritoneal fluid of WT mice than in those of CD1d(-/-) mice, while the mortality rate was lower in CD1d(-/-) mice than in WT mice. C5a blockade decreased mortality of WT mice during sepsis, whereas it did not alter that of CD1d(-/-) mice. As assessed by intracellular staining, NKT cells expressed IFN-γ, while neutrophils expressed IL-10. Upon coculture, IL-10-deficient NKT cells enhanced IL-10 production by WT, but not IFN-γR-deficient, neutrophils. Meanwhile, CD1d(-/-) mice exhibited high CD55 expression on neutrophils during sepsis, whereas those cells from WT mice expressed minimal levels of CD55. Recombinant IL-10 administration into CD1d(-/-) mice reduced CD55 expression on neutrophils. Furthermore, adoptive transfer of sorted WT, but not IFN-γ-deficient, NKT cells into CD1d(-/-) mice suppressed CD55 expression on neutrophils, but increased IL-10 and C5a levels. Taken together, IFN-γ-producing NKT cells enhance C5a generation via IL-10-mediated inhibition of CD55 expression on neutrophils, thereby exacerbating sepsis.

GM-CSF and IL-4 produced by NKT cells inversely regulate IL-1β production by macrophages (INC6P.402)

NKT cell is a distinct T cell subset that links innate and adaptive immune responses. IL-1β, produced by various immune cells, plays critical role in the regulation of innate immunity in vivo. However, it is unclear whether NKT cells regulate IL-1β production in vivo. Here, we demonstrate that NKT cells regulate production of IL-1β by macrophages via producing GM-CSF and IL-4. Among cytokines secreted from NKT cells, GM-CSF enhanced IL-1β production by macrophages through regulating pro-IL-1β expression and NLRP3-dependent inflammasome activation, whereas IL-4 enhanced M2-differentiation of macrophages, thereby decreasing IL-1β production. Furthermore, NKT cells aggravated IL-1β-mediated peritonitis by producing GM-CSF, but attenuated peritonitis via producing IL-4. Taken together, our findings suggest the NKT cells exert double-sided effects on IL-1β-mediated innate immune responses by producing IL-4 and IL-1β.

Effect of multiple invasive foci on breast cancer outcomes according to the molecular subtypes: a report from the Korean Breast Cancer Society

BACKGROUND

In this study, the prognostic impact of the presence of the multifocal or multicentric tumor (MMT) and its association with molecular subtypes were investigated.

PATIENTS AND METHODS

We investigated the breast cancer metastasis and survival in patients with multifocal or multicentric invasive foci in the same breast. The study population includes 2882 patients in the Seoul National University Hospital Breast Care Center (SNUHBCC) dataset and 41 179 patients in Korean Breast Cancer Registry (KBCR) dataset.

RESULTS

From SNUHBCC dataset, we observed a significant role of MMT in developing distant metastasis and death when the tumors were triple-negative subtype. This subtype-specific prognostic importance of MMT in overall survival was also seen in KBCR dataset (HR, 1.32; 95% CI, 1.02-1.69). In tumors <2 cm, the hazard ratios (HRs) for node metastasis and death were similar along the tumor size change in triple-negative subtype, while other subtypes showed a stepwise increment, suggesting the biologic importance of small invasive foci in this subtype.

CONCLUSIONS

Our results demonstrate the prognostic importance of MMT in patients with triple-negative breast cancers. Small additional invasive foci in triple-negative breast cancer patients should be considered as clinically relevant tumor deposits.

Direct engagement of TLR4 in invariant NKT cells regulates immune diseases by differential IL-4 and IFN-γ production in mice

During interaction with APCs, invariant (i) NKT cells are thought to be indirectly activated by TLR4-dependently activated APCs. However, whether TLR4 directly activates iNKT cells is unknown. Therefore, the expression and function of TLR4 in iNKT cells were investigated. Flow cytometric and confocal microscopic analysis revealed TLR4 expression on the surface and in the endosome of iNKT cells. Upon LPS stimulation, iNKT cells enhanced IFN-γ production, but reduced IL-4 production, in the presence of TCR signals, depending on TLR4, MyD88, TRIF, and the endosome. However, enhanced TLR4-mediated IFN-γ production by iNKT cells did not affect IL-12 production or CD1d expression by DCs. Adoptive transfer of WT, but not TLR4-deficient, iNKT cells promoted antibody-induced arthritis in CD1d(-/-) mice, suggesting that endogenous TLR4 ligands modulate iNKT cell function in arthritis. Furthermore, LPS-pretreated WT, but not TLR4-deficient, iNKT cells suppressed pulmonary fibrosis, but worsened hypersensitivity pneumonitis more than untreated WT iNKT cells, indicating that exogenous TLR4 ligands regulate iNKT cell functions in pulmonary diseases. Taken together, we propose a novel direct activation pathway of iNKT cells in the presence of TCR signals via endogenous or exogenous ligand-mediated engagement of TLR4 in iNKT cells, which regulates immune diseases by altering IFN-γ and IL-4 production.

Comparison of cystatin C- and creatinine-based estimation of glomerular filtration rate according to glycaemic status in Type 2 diabetes

AIMS

The influence of hyperglycaemia on the performance of glomerular filtration rate (GFR) estimating equations remains to be determined. We compared the performance of creatinine-based GFR with cystatin C-based GFR in patients with Type 2 diabetes according to glycaemic status.

METHODS

In a cross-sectional study of 210 patients with Type 2 diabetes, we staged glycaemic status by HbA(1c) tertiles [HbA(1c) ≤ 75 mmol/mol (9.0%) (n = 70), HbA(1c) 76-95 mmol/mol (9.1-10.8%) (n = 70), HbA(1c) >95 mmol/mol (10.8%) (n = 70)] and measured GFR. Isotopic GFR was measured using renal dynamic imaging with (99m) Tc-diethylene-triamine-penta-acetic acid. Estimated GFR (eGFR) was measured using creatinine-based formulae (Cockcroft-Gault-eGFR, the Modification of Diet in Renal Disease equation-eGFR and the Chronic Kidney Disease Epidemiology Collaboration formula-eGFR) and a cystatin C-based formula (cystatin C-eGFR).

RESULTS

The isotopic GFR of all patients was 93.1 ± 34.1 ml min(-1) 1.73 m(-2). All methods for estimating GFR underestimated isotopic GFR [Cockcroft-Gault-eGFR (68.8 ± 38.6 ml min(-1) 1.73 m(-2) ) (P < 0.05), Modification of Diet in Renal Disease-eGFR (74.8 ± 31.3 ml min(-1) 1.73 m(-2) ) (P < 0.05), Chronic Kidney Disease Epidemiology Collaboration-eGFR (72.9 ± 26.6 ml min(-1) 1.73 m(-2)) (P < 0.05) and cystatin C-eGFR (83.5 ± 33.2 ml min(-1) 1.73 m(-2)) (P < 0.05)]. In all patient groups, cystatin C-eGFR was less biased and more accurate than the creatinine-based formulae, especially in the group with HbA(1c) > 95 mmol/mol (10.8%) where there was no difference between cystatin C-eGFR and isotopic GFR.

CONCLUSIONS

Performance of cystatin C-eGFR was superior to creatinine-based GFR in patients with Type 2 diabetes with HbA(1c) >95 mmol/mol (10.8%).

NKT cells enhance C5a generation by CD11b+Gr-1+ peritoneal cells via IL-10 and IFN-gamma mediated cross-talk, thereby promoting sepsis in mice (45.9)

Both NKT cells and complement protein C5a have been implicated in the pathogenesis of sepsis, but the issue of whether NKT cells regulate C5a generation during sepsis has been unclear. To investigate this issue, we examined immune responses in WT and NKT cell-deficient mice during cecal ligation and puncture (CLP)-induced sepsis. The levels of C5a, IFN-gamma, and IL-10 during sepsis were higher in the serum and peritoneal fluid of WT mice than in those of CD1d-/- mice. Furthermore, the mortality rate was lower in CD1d-/- mice than in WT mice. Adoptive transfer of liver mononuclear cells (LMCs) of WT mice increased mortality and C5a generation during sepsis in CD1d-/- mice, whereas transfer of IL-10- or IFN-gamma-deficient LMCs did not. In co-culture experiments, IL-10 and IFN-gamma produced by NKT cells enhanced C5a generation by CD11b+Gr-1+ peritoneal cells. Furthermore, treatment with anti-C5a antibody during sepsis decreased CD4+ T-cell apoptosis, serum D-dimer levels, and numbers of bacterial colony-forming units, but increased responsiveness against lipopolysaccharide in WT and WT-LMC-treated CD1d-/- mice, increasing survival rates. Taken together, these results suggest that CD1d-restricted NKT cells enhance C5a generation through IL-10- and IFN-gamma- mediated cross-talk with CD11b+Gr-1+ peritoneal cells, thereby aggravating CLP-induced sepsis.

Comparison of Invariant NKT Cells with Conventional T Cells by Using Gene Set Enrichment Analysis (GSEA)

Background

Invariant Natural killer T (iNKT) cells, a distinct subset of CD1d-restricted T cells with invariant Vαβ TCR, functionally bridge innate and adaptive immunity. While iNKT cells share features with conventional T cells in some functional aspects, they simultaneously produce large amount of Th1 and Th2 cytokines upon T-cell receptor (TCR) ligation. However, gene expression pattern in two types of cells has not been well characterized.

Methods

we performed comparative microarray analyses of gene expression in murine iNKT cells and conventional CD4⁺CD25^-γδTCR^- T cells by using Gene Set Enrichment Analysis (GSEA) method.

Results

Here, we describe profound differences in gene expression pattern between iNKT cells and conventional CD4⁺CD25^-γδTCR^- T cells.

Conclusion

Our results provide new insights into the functional competence of iNKT cells and a better understanding of their various roles during immune responses.

Intra-arterial tirofiban infusion for partial recanalization with stagnant flow in hyperacute cerebral ischemic stroke

Early reocclusion is a major concern associated with poor clinical outcomes in patients with an ischemic cerebral stroke. This occurs most frequently in patients with partial initial recanalization. This study focuses on partial recanalization with stagnant antegrade flow after intravenous (IV) tPA or spontaneously, treated with the administration of intra-arterial (IA) tirofiban. Three patients with initial M1 occlusion on diagnostic studies had an occluded segment that was recanalized with stagnant flow after IV tPA or spontaneously. In all cases, IA tirofiban was administrated. We evaluated the distal blood flow and the degree of vascular narrowing in the pre and post-procedure angiography and at follow-up in addition to the clinical status. In all patients, severe vascular narrowing with stagnation of blood flow was detected in the initial M1. After infusion of IA tirofiban, improvement of the distal blood flow was achieved rapidly within 40 minutes in all patients. The severe vascular narrowing resolved rapidly in two patients without residual stenosis. In one patient, moderate vascular narrowing was still present. The median baseline National Institutes of Health Stroke Scale (NIHSS) scores were 18 and the median post-procedural NIHSS scores were 2 at two weeks. No intracerebral hemorrhage occurred in any of the patients. Treatment with IA tirofiban was safe and effective in patients with partial initial recanalization. It can be suggested that detection of any partial recanalization is time for administration of glycoprotein IIb-IIIa receptor inhibitor in hyperacute ischemic stroke.

Invariant NKT cells producing IL-4 or IL-10, but not IFN-gamma, inhibit the Th1 response in experimental autoimmune encephalomyelitis, whereas none of these cells inhibits the Th17 response

Experimental autoimmune encephalomyelitis (EAE) is mediated by Th1 and Th17 cells. Invariant NKT (iNKT) cells prevent EAE in an IL-4-, IL-10-, and IFN-γ-dependent manner. However, which of the iNKT cell-produced cytokines regulates the Th1 or Th17 response in EAE remains unclear. Wild-type B6 and Jα18(-/-) mice were immunized with MOG(35-55) peptide to address this issue. Clinical scores for EAE, IL-17, and IFN-γ transcript levels, and IL-17- or IFN-γ-expressing CD4(+) T cell percentages in the CNS and draining lymph nodes were higher in Jα18(-/-) than in B6 mice, but all of these parameters in the CNS were reduced by the adoptive transfer of wild-type or IFN-γ-deficient iNKT cells into the Jα18(-/-) mice before immunization. In contrast, adoptive transfer of IL-4- or IL-10-deficient iNKT cells into Jα18(-/-) mice decreased IL-17 transcript levels and the percentage of IL-17-expressing CD4(+) T cells in the CNS but did not affect clinical scores, IFN-γ transcript levels, or the percentage of IFN-γ-expressing CD4(+) T cells in the CNS. Taken together, IL-4- and IL-10-producing iNKT cells inhibit the Th1 cell response, but not the Th17 cell response, although wild-type iNKT cells suppress both the Th1 and Th17 responses in the CNS during EAE. Moreover, IFN-γ-producing iNKT cells have a minimal role in the regulation of the Th1 and Th17 responses in EAE.

Transport and metabolism of the antitumour drug candidate 2'-benzoyloxycinnamaldehyde in Caco-2 cells

The transport and metabolism of the antitumour drug candidate 2'-benzoyloxycinnamaldehyde (BCA) was characterized in Caco-2 cells. BCA disappeared rapidly from the donor side without being transported to the receiver side during its absorptive transport across Caco-2 cells. Its metabolites 2'-hydroxycinnamaldehyde (HCA) and o-coumaric acid (OCA) were formed in both the donor and the receiver sides. HCA, in a separate study, also disappeared rapidly from the donor side, mostly being converted to its oxidative metabolite OCA during its absorptive transport across Caco-2 cells. OCA was transported rapidly in the absorptive direction across Caco-2 cells with a P(app) of 25.4 +/- 1.0 x 10(-6) cm s(-1) (mean +/- standard deviation (SD), n = 3). OCA was fully recovered from both the donor and the receiver side throughout the time-course of this study. Formation of HCA from BCA was inhibited almost completely by bis(p-nitrophenyl)phosphate (BNPP), a selective inhibitor of carboxylesterases (CES), and phenylmethylsulfonyl fluoride (PMSF), a broad specificity inhibitor of esterases in Caco-2 cells, suggesting that this hydrolytic biotransformation was likely mediated predominantly by CES. Conversion of HCA to OCA was inhibited significantly by isovanillin, a selective inhibitor of aldehyde oxidase (AO). Inhibitors for xanthine oxidase (XO) and aldehyde dehydrogenase (ALDH), which are known to be involved in the oxidation of aldehydes to carboxylic acids, did not have a significant effect on the biotransformation of HCA to OCA in Caco-2 cells. In summary, the present work demonstrates that BCA is hydrolysed rapidly to HCA, followed by subsequent oxidation to OCA, in Caco-2 cells. The results provide a mechanistic understanding of the poor absorption and low bioavailability of BCA after oral administration.

Wide thumb and the first web reconstruction using a neurovascularised instep free flap

Deformed hands result in palmar defects of the thumb. The sensate instep free flap can be used for wide palmar coverage of the thumb. Three hands with palmar defects of the thumb extended to the first web space underwent soft-tissue reconstruction using a neurovascular instep free flap. These flaps provided sensate coverage with static two-point discrimination values of 8-15 mm. Key pinch strengths of reconstructed thumbs were nearly half of those on the normal side. Donor foot morbidity was minimal with no hyperkeratosis. The neurovascular instep free flap supplies sensate, similar pliable and tough glabrous skin to the palmar surface of the thumb extended to the first web area.

Genetic polymorphisms of the bovine fatty acid binding protein 4 gene are significantly associated with marbling and carcass weight in Hanwoo (Korean Cattle)

The objective of this study was to investigate an association between polymorphisms in the FABP4 gene and phenotypic variation for marbling and carcass weight (CWT) in a population of Hanwoo steers. We re-sequenced 4.3 kb of the FABP4 gene region in 24 Hanwoo bulls and identified 16 SNPs and 1 microsatellite polymorphism. Of these 16 SNPs, three SNPs [g.2774G>C (intron I), g.3473A>T (intron II) and g.3631G>A (exon III, creating a p.Met >Val amino acid substitution)] were genotyped in 583 steers to assess their association with carcass traits. The g.3473A allele showed a significant increasing effect on CWT (P = 0.01) and the g.3631G allele was associated with higher marbling score (P = 0.006). One haplotype of these three SNPs (CAG) was significantly associated with CWT (P = 0.02) and marbling score (P = 0.05) and could potentially be of value for marker assisted selection in Hanwoo cattle. The CAG haplotype effect for CWT was larger (11.14 +/- 5.03 kg) than the largest single locus effect of g.3473A>T (5.01 +/- 2.2 kg).

CD4(+)CD25(+) regulatory T cells attenuate Hypersensitivity Pneumonitis by suppressing IFN-gamma production by CD4(+) and CD8(+) T cells

HP results from the repeated inhalation of environmental antigens; however, the roles of CD4(+)CD25(+) T(reg) cells in HP are unknown. Therefore, we investigated the functions of CD4(+)CD25(+) T(reg) cells in SR-induced murine HP. More severe HP was observed in CD4(+)CD25(+) T(reg) cell-depleted mice than in control mice in terms of histological alterations, inflammatory cell numbers in BALF, and the serum level of SR-specific IgG, which were restored by the adoptive transfer of CD4(+)CD25(+) T(reg) cells. The CD4(+)CD25(+) T(reg) cell-depleted mice also showed elevated levels of IFN-gamma, TGF-beta, and reduced IL-4 production in the lungs. Moreover, IL-10 production of CD4(+)CD25(+) T(reg) cells and direct contact between CD4(+)CD25(+) T(reg) cells and CD4(+) or CD8(+) T cells in BALF resulted in reduced IFN-gamma production. Taken together, CD4(+)CD25(+) T(reg) cells play a protective role in SR-induced HP by suppressing IFN-gamma production by T cells.

Role of type II NKT cells in the suppression of graft-versus-host disease

Natural killer T (NKT) cells, a distinct subset of T cells that recognize glycolipids on CD1d molecules, express both TCR and NK receptors and are critical in regulating various immune responses by modulating the Th1/Th2 balance. Upon activation, NKT cells produce large amounts of IL-4 and IFN-gamma, resulting in the enhancement or inhibition of immune responses. Recent studies have shown that NKT cells are heterogeneous in terms of the expression of a specific Valpha chain of TCR (Valpha14-Jalpha18 in mice and Valpha24-JalphaQ in humans) and reactivity against the glycolipid alpha-galactosylceramide (alpha-GalCer). Accordingly, NKT cells are classified into type I (invariant) and type II (non-invariant) cells in mice and humans. Although the functional roles of type I NKT cells are well characterized in various immune diseases, little is known regarding the function of type II NKT cells. Recent study has demonstrated that type II NKT cells in donor bone marrow play protective roles in graft-versus-host disease (GVHD), in which the complicated immunologic processes are involved. In this review, we discuss the pathogenesis of GVHD and the distinct functions of type II NKT cells in the development of GVHD.

Liver X receptor mediates hepatitis B virus X protein-induced lipogenesis in hepatitis B virus-associated hepatocellular carcinoma

Although hepatitis B virus X protein (HBx) has been implicated in abnormal lipid metabolism in hepatitis B virus (HBV)-associated hepatic steatosis, its underlying molecular mechanism remains unclear. Liver X receptor (LXR) plays an important role in regulating the expression of genes involved in hepatic lipogenesis. Here we demonstrate that LXRalpha and LXRbeta mediate HBV-associated hepatic steatosis. We have found that HBx induces the expression of LXR and its lipogenic target genes, such as sterol regulatory element binding protein-1c (SREBP-1c), fatty acid synthase (FAS), and peroxisome proliferator-activated receptor, and this is accompanied by the accumulation of lipid droplets. RNA interference with LXR expression decreases the amount of lipid droplets as well as the expression of the lipogenic genes, and this indicates that HBx-induced lipogenesis is LXR-dependent. LXRalpha and HBx colocalize in the nucleus and are physically associated. HBx induces the transactivation function of LXRalpha by recruiting CREB binding protein to the promoter of the target gene. Furthermore, we have observed that expression of LXR is increased in the livers of HBx-transgenic mice. Finally, there is a significant increase in the expression of LXRbeta (P = 0.036), SREBP-1c (P = 0.008), FAS, and stearoyl-coenyzme A desaturase-1 (P = 0.001) in hepatocellular carcinoma (HCC) in comparison with adjacent nontumorous nodules in human HBV-associated HCC specimens.

CONCLUSION

Our results suggest a novel association between HBx and LXR that may represent an important mechanism explaining HBx-induced hepatic lipogenesis during HBV-associated hepatic carcinogenesis.

Comparison of inflammatory markers and angiographic outcomes after implantation of sirolimus and paclitaxel-eluting stents

OBJECTIVE

We compared the degree of systemic inflammation and its relation to the angiographic outcomes after drug-eluting stent (DES) implantations.

METHODS

We implanted a single DES in 79 stable angina patients (50 men; 60.4 (9.5) years of age; sirolimus-eluting stent (SES), n = 38; paclitaxel-eluting stent (PES), n = 41). The high-sensitivity C-reactive protein (hs-CRP) and interleukin 6 (IL-6) levels were determined before and at 24 hours, 72 hours, and 4 weeks after the percutaneous coronary intervention (PCI). An angiography and intravascular ultrasound (IVUS) were performed.

RESULTS

The hs-CRP and IL-6 levels at baseline did not differ between the two groups. The hs-CRP increased significantly from baseline at 24 hours and 72 hours after the PCI in both groups and there was a significant increase in the IL-6 level at 24 hours after the PCI in both groups. However, there was no significant difference between the two groups in any of the hs-CRP or IL-6 measurements. At follow-up, the late lumen loss was significantly higher in the PES group than in the SES group (0.57 (0.56) mm vs 0.28 (0.58) mm, respectively, p = 0.020). The neointimal hyperplasia (NIH) volume in the PES group was significantly higher than that in the SES group (23.1 (22.7) vs 3.8 (7.1) mm(3), respectively, p = 0.000). The percentage luminal volume reduction was higher in the PES group than in the SES group (18.9 vs 3.9%, p = 0.002). The absolute values or change in the inflammatory markers did not correlate with the NIH or stent volume reduction.

CONCLUSIONS

Our study showed that the benefits obtained from the SES, which reduce neointimal proliferation, are not probably mediated by the attenuation of the systemic inflammatory markers hs-CRP or IL-6.

Lymph node dissection around the splenic artery and hilum in advanced middle third gastric carcinoma

AIM

To evaluate the clinicopathological factors influencing lymph node metastasis around the splenic artery and hilum and the effect of spleen-preserved lymphadenectomy in advanced middle third gastric carcinoma.

METHODS

We retrospectively studied 131 patients with advanced middle third gastric carcinoma who had received D2 lymphadenectomy and lymph node dissection around the splenic artery and hilum, from 2000 to 2004. Of these patients, 62 simultaneously underwent splenectomy and 69 underwent spleen-preserved lymphadenectomy.

RESULTS

The incidences of Nos. 10 and 11 lymph node metastases were 21% and 15%, respectively, in advanced middle third gastric carcinoma. A tumor size larger than 5 cm, metastases of Nos. 1 and 7-9 lymph node were independent risk factors for metastasis of No. 10 and/or No. 11 lymph node. The spleen-preserved group had a slightly better survival rate and a relatively lower rate of postoperative complications than the splenectomy group. No. 10 and/or No. 11 lymph node metastasis was an independent prognostic factor, while splenectomy was not.

CONCLUSIONS

It is necessary to remove the lymph nodes around the splenic artery and hilum to achieve radical resection in advanced middle third gastric carcinoma patients with risk factors. Our results demonstrate that spleen-preserved lymphadenectomy is a good option for those patients.

Biphasic insulin aspart 30 treatment in patients with type 2 diabetes poorly controlled on prior diabetes treatment: results from the PRESENT study

AIM

The safety and efficacy of biphasic insulin aspart (BIAsp30) were evaluated in patients uncontrolled on previous treatment (human insulin +/- oral hypoglycaemic agent [OHA] or OHA only) in routine clinical practice.

METHODS

This was a large, multi-national, multicentre, prospective, 6-month study in type 2 diabetes mellitus patients who were prescribed BIAsp30. Changes in glycated haemoglobin (HbA(1c)), fasting plasma glucose (FPG), postprandial plasma glucose (PPPG), proportion who achieved target HbA(1c) < 7% and rate of hypoglycaemic episodes were assessed. This paper evaluates outcomes in patients by diabetes duration (< 5, 5-10, 10-20 or >/= 20 years) stratified by prior therapy.

RESULTS

After 6 months of treatment, glycaemia improved significantly across the duration subgroups. The improvement was better in insulin-naïve group versus prior insulin group: HbA(1c) decreased approximately 2.2%-points versus approximately 1.6%-points, FPG decreased approximately 4.5 mmol/L versus approximately 2.9 mmol/L and PPPG decreased approximately 6.8 mmol/L versus approximately 5.0 mmol/L. Target HbA(1c) was achieved by about one in four patients although insulin-naïve patients achieved this at comparatively lower BIAsp30 dose. Body weight remained relatively unchanged. Hypoglycaemic episodes appeared to be more frequent in the prior insulin group which decreased during the treatment period.

CONCLUSIONS

According to this observational study, in clinical practice, initiating or transferring uncontrolled patients to biphasic insulin aspart improved glycaemic control without using a strict insulin algorithm.

HBx modulates iron regulatory protein 1-mediated iron metabolism via reactive oxygen species

Hepatitis B virus X protein (HBx) is involved in viral metabolism and progression of liver disease. Iron metabolism plays a significant role in liver disease. In this report, to elucidate the relationship between iron metabolism and HBx, we established the Huh7 cell lines in which HBx was stably expressed (Huh7-HBx). In Huh7-HBx, we observed that transferrin receptor 1 (TfR1) expression decreased and ferritin heavy chain (FtH) expression increased as well as reactive oxygen species (ROS) level increased. We also found that these modulations were caused by the downregulation of iron regulatory protein 1 (IRP1). Furthermore, the levels of total iron and labile iron pool (LIP) were altered in Huh7-HBx. In addition, antioxidant N-acetylcystein (NaC) increased IRP1 expression by depleting HBx-induced ROS. We also confirmed these alterations of TfR1 and FtH in the primary hepatocytes of HBx transgenic mice and in HepG2.2.15 cells that constitutively replicate the intact HBV genome. In conclusion, these results suggest that HBx modulates iron metabolism via ROS leading to pathological status in liver diseases.

DMPK-associated myotonic dystrophy and CTG repeats in Alabama African Americans

Myotonic dystrophy type 1 (DM1) is a result of a CTG expansion in the 3'-untranslated region of the DMPK gene. DM1 is rare among African blacks who have fewer large CTG repeats in the normal range than other racial/ethnic groups. Neither the prevalence of DM1 nor the relationship of CTG expansion to clinical status in African Americans (AAs) is well documented. We describe two AA brothers with DM1, each of whom had CTG repeats of 5/639; their father was reported to have DM1 and had CTG repeats of 5/60. Other family members had CTG repeats of 5-14. An unrelated AA patient from a second kinship also had DM1; an analysis revealed CTG repeats of 27/191. In 161 Alabama AA control subjects, we observed 18 CTG alleles from 5 to 28 repeats; the most common allele had five CTG repeats. The frequency of CTG repeats >or=15 were greater (p < 0.0003) in Pygmy, Amhara Ethiopian, Ashkenazi Jewish, North African Jewish, Israeli Muslim Arab, European white, and Japanese populations than in the Alabama AA population. These data suggest that the risk for DM1 in AAs is intermediate between that of African blacks and whites of European descent.

Congenital neuromuscular disease with uniform type 1 fiber and RYR1 mutation

BACKGROUND

Congenital neuromuscular disease with uniform type 1 fiber (CNMDU1) is a rare form of congenital myopathy, which is pathologically diagnosed by the presence of more than 99% of type 1 fiber, with no specific structural changes. Its pathogenic mechanism is still unknown. We recently reported that almost all patients with central core disease (CCD) with ryanodine receptor 1 gene (RYR1) mutations in the C-terminal domain had type 1 fibers, nearly exclusively, in addition to typical central cores.

OBJECTIVE

To investigate whether CNMDU1 is associated with RYR1 mutation.

METHODS

We studied 10 unrelated Japanese patients who were diagnosed to have CNMDU1 based on clinical features and muscle pathology showing more than 99% type 1 muscle fibers. We extracted genomic DNA from frozen muscles and directly sequenced all 106 exons and their flanking intron-exon boundaries of RYR1.

RESULTS

Four of 10 patients had a heterozygous mutation, three missense and one deletion, all in the C-terminal domain of RYR1. Two missense mutations were previously reported in CCD patients. Clinically, patients with mutations in RYR1 showed milder phenotype compared with those without mutations.

CONCLUSION

Congenital neuromuscular disease with uniform type 1 fiber (CNMDU1) in 40% of patients is associated with mutations in the C-terminal domain of RYR1, suggesting that CNMDU1 is allelic to central core disease at least in some patients.

Effects of insertion conditions on tissue strain and vascular damage during neuroprosthetic device insertion

Long-term integration of neuroprosthetic devices is challenged by reactive responses that compromise the brain-device interface. The contribution of physical insertion parameters to immediate damage is not well described. We have developed an ex vivo preparation to capture real-time images of tissue deformation during device insertion using thick tissue slices from rat brains prepared with fluorescently labeled vasculature. Qualitative and quantitative assessments of damage were made for insertions using devices with different tip shapes inserted at different speeds. Direct damage to the vasculature included severing, rupturing and dragging, and was often observed several hundred micrometers from the insertion site. Slower insertions generally resulted in more vascular damage. Cortical surface features greatly affected insertion success; insertions attempted through pial blood vessels resulted in severe tissue compression. Automated image analysis techniques were developed to quantify tissue deformation and calculate mean effective strain. Quantitative measures demonstrated that, within the range of experimental conditions studied, faster insertion of sharp devices resulted in lower mean effective strain. Variability within each insertion condition indicates that multiple biological factors may influence insertion success. Multiple biological factors may contribute to tissue distortion, thus a wide variability was observed among insertions made under the same conditions.

Improved therapeutic outcomes of DLBCL after introduction of rituximab in Korean patients

The addition of rituximab to cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) has been shown to improve the outcome in all age groups with newly diagnosed diffuse large B-cell lymphoma (DLBCL). We conducted a retrospective analysis to evaluate the impact of this combination therapy on DLBCL outcomes in Korea. From October 2001 to June 2004, newly diagnosed DLBCL patients in nine Korean institutes were included. All of these 81 patients were treated with three or more cycles of rituximab plus CHOP (R-CHOP) combination chemotherapy (R group), and followed for a minimum of 12 months. For comparison, a historical cohort of patients was used and analyzed for "Clinicopathologic characteristics of Korean non-Hodgkin's lymphomas (NHLs) based on Revised American Lymphoma (REAL) classification" in 1999. Among the 1,098 NHL patients, the data of 214 DLBCL patients, who were treated with CHOP chemotherapy in first-line, were analyzed (C group). We compared outcomes between the C group and the R group. A total of 295 patients were evaluated (C group, 214; R group, 81). The complete response (CR) rate was higher in R group (73 vs 91%, p=0.001). The 2-year event-free survival (EFS) rate was significantly higher in R group (78 vs 85%, p=0.0194). This survival benefit was maintained in high-risk patients according to the international prognostic index (IPI) (p=0.0039), regardless of age. However, there was no significant difference in low-risk patients. The addition of rituximab to CHOP combination chemotherapy for DLBCLs showed improved outcomes, particularly in high-risk group according to the IPI. Long-term follow-up results will be needed to confirm these results.

Multifocal motor sensory demyelinating neuropathy: Inflammatory demyelinating polyradiculoneuropathy

The authors present two cases that provide the first autopsy findings in multifocal acquired demyelinating sensory and motor neuropathy (MADSAMN). Both cases documented multifocal but asymmetric demyelinating neuropathy with rare axonal degeneration. One case clearly documented an inflammatory polyradiculoplexoneuropathy, confirming the inflammatory nature of this neuropathy. This study showed that MADSAMN is an inflammatory demyelinating polyradiculoneuropathy that shares histologic features observed in chronic inflammatory demyelinating polyradiculoneuropathy and multifocal motor neuropathy (MMN), suggesting a similar immunopathogenesis for these entities.

The distribution of inhibitory and excitatory synapses on single, reconstructed jaw-opening motoneurons in the cat

In a previous study, we reported that the distribution of inhibitory input, in contrast to excitatory input, decreased somatofugally along dendrites of cat jaw-closing alpha-motoneurons [J Comp Neurol 414 (1999) 454]. The present study examined the distribution of GABA, glycine, and glutamate immunopositive boutons covering horseradish peroxidase-labeled cat jaw-opening motoneurons. The motoneurons were divided into four compartments: the soma, and primary, intermediate, and distal dendrites. Ninety-seven percent of the total number of studied boutons had immunoreactivity for at least one of the three amino acids. The proportion of boutons immunoreactive for GABA and/or glycine was lower than the proportion of boutons immunoreactive for glutamate. Boutons immunoreactive to glycine alone were more numerous than boutons double-labeled for GABA and glycine, which, in turn, occurred more frequently than boutons immunoreactive to GABA alone. The percentage synaptic covering (proportion of membrane covered by synaptic boutons) of the putatively excitatory (glutamate containing) and putatively inhibitory (GABA and/or glycine containing) boutons decreased somatofugally along the dendrites. Such systematic variations were not seen in the packing density (number of boutons per 100 microm(2)); the packing density showed a distinct drop between the soma and primary dendrites but did not differ significantly among the three dendritic compartments. Overall, the packing density was slightly higher for the putatively excitatory boutons than for the inhibitory ones. When taken together with previous analyses of jaw-closing alpha-motoneurons the present data on jaw-opening alpha-motoneurons indicate that the two types of neuron differ in regard to the nature of synaptic integration in the dendritic tree.

Preclinical application of radioimmunoguided surgery using anti-carcinoembryonic antigen biparatopic antibody in the colon cancer

Radioimmunoguided surgery (RIGS) has been known as a sophisticated tool to detect micrometastasis intraoperatively. A preclinical model of RIGS was designed to test the possible clinical applicability of the biparatopic antibody in detecting colorectal cancer. The biparatopic antibody was constructed using two anti-carcinoembryonic antigen (CEA)-specific antibodies, T84.66 and PR1A3, reacting against two different epitopes. (125)I-labeled biparatopic antibody was introduced via the principal colonic arteries at the end of operation in 10 operable patients with colon cancer. After 24 h, the radioactivities of the tumors and lymph nodes were counted using the gamma-detecting probe. The radioactivity count was performed ex vivo. The accurate detection in the primary tumors and metastatic lymph nodes were 100 and 88.7% respectively. False-positive detections occurred in 24 of 256 lymph nodes (9.4%), whereas false-negative detections occurred in 5 of them (2%). The most frequent cause of false-positive detection was dissociated radionuclides trapped in the lymphatic tissues. False-negative detections occurred mainly from weak targeting by radiolabeled antibody, probably due to weak expression of tumor CEA. Conclusively, as most detection errors appear to be reduced within 3 days in vivo, the biparatopic antibody can efficiently be applied to the clinical RIGS, thereby facilitating accurate detection and removal of occult cancer foci in colorectal cancer.

Sensory neuropathy in vasculitis: a clinical, pathologic, and electrophysiologic study

BACKGROUND

Vasculitis is not usually considered as a cause of symmetric sensory neuropathy.

OBJECTIVE AND METHODS

To present the clinical, pathologic, and electrophysiologic features of 17 (16%) cases of sensory neuropathy in vasculitis (SNV) among 106 cases with histologically proven vasculitic neuropathy that were collected over the last 30 years.

RESULTS

In 41% of cases, SNV was found as systemic vasculitic neuropathy in association with primary vasculitic disease. The most common clinical presentation was symmetric polyneuropathy, seen in 53% of cases. The most common nerve conduction pattern was diffuse neuropathy pattern of axonal degeneration. Sural nerve biopsy was diagnostic in 88% of cases. In two cases, muscle biopsy was necessary for the definite diagnosis of vasculitis. Non-systemic SNV is usually benign. Of 11 patients followed for longer than 2 years, none developed motor weakness due to neuropathy.

CONCLUSION

Sensory neuropathy, regardless of symmetry, can be due to vasculitis.

Increased DNA fragmentation and ultrastructural changes in fibromyalgic muscle fibres

OBJECTIVE

To determine whether there is evidence of increased DNA fragmentation and ultrastructural changes in muscle tissue of patients with fibromyalgia (FM) compared with healthy controls.

METHODS

Muscle tissues from 10 community residents with FM and 10 age and sex matched healthy controls were examined "blindly" for the presence of DNA fragmentation by two different methods: terminal deoxynucleotidyl transferase (TdT) staining (TUNEL) and the FragEL-Klenow DNA fragmentation detection kit. Ultrastructural analysis of tissue was performed by electron microscopy.

RESULTS

DNA fragmentation was detected by both methods in 55.4 (SEM 2.5)% of the nuclei in muscle tissue of patients with FM compared with 16.1 (4.1)% (p<0.001) of the nuclei in healthy controls. Contrary to expectation, no typical features of apoptosis could be detected by electron microscopy. The myofibres and actin filaments were disorganised and lipofuscin bodies were seen; glycogen and lipid accumulation were also found. The number of mitochondria was significantly lower in patients with FM than in controls and seemed to be morphologically altered.

CONCLUSION

The ultrastructural changes described suggest that patients with FM are characterised by abnormalities in muscle tissue that include increased DNA fragmentation and changes in the number and size of mitochondria. These cellular changes are not signs of apoptosis. Persistent focal contractions in muscle may contribute to ultrastructural tissue abnormalities as well as to the induction and/or chronicity of nociceptive transmission from muscle to the central nervous system.

The natural history of hydronephrosis after radical hysterectomy with no intraoperatively recognisable injury to the ureter: a prospective study

OBJECTIVE

To investigate, in a prospective study, the natural history of hydronephrosis of the urinary tract after radical hysterectomy.

PATIENTS AND METHODS

From December 1997 to March 2001, 34 patients with localized cervical cancer underwent radical hysterectomy by one gynaecologist, with no intraoperatively identifiable injury to the ureter. Intravenous urography was used routinely before and at 2 and 4 weeks after surgery. The degree of hydronephrosis was graded I-IV.

RESULTS

Urography before surgery showed no abnormal finding in any of the patients, except in one with a unilateral duplex kidney. Hydronephrosis was found in 10 units in the upper tract (grade II in eight, III in one and IV in one) in seven patients (21%) 2 weeks after surgery (one right, three left and three bilateral). All the ureteric narrowing was in the distal ureter. The hydronephrosis disappeared in four units in three patients, but became worse in two units in two patients with bilateral pathology in the fourth week. At 3 months after surgery no hydronephrosis had deteriorated and the hydronephrosis in all units had disappeared by 6 months. The presence of hydronephrosis was significantly correlated with pathological stage and age (P < 0.05).

CONCLUSION

Hydronephrosis was detected after radical hysterectomy even with no intraoperatively recognisable injury to the ureter, but in most the hydronephrosis improved spontaneously and needed no ureteric stenting or surgical intervention.

Subacute inflammatory demyelinating polyneuropathy

OBJECTIVE

To report the clinical, electrophysiologic, and histologic characteristics of subacute inflammatory demyelinating polyneuropathy (SIDP) and to present the diagnostic criteria of this disease.

METHODS

For a diagnosis of "definite SIDP," there were four mandatory criteria: 1) progressive motor and/or sensory dysfunction consistent with neuropathy in more than one limb with time to nadir between 4 and 8 weeks, 2) electrophysiologic evidence of demyelination in at least two nerves, 3) no other etiology of neuropathy, and 4) no relapse on adequate follow-up. Supportive criteria included high spinal fluid protein level (>55 mg/dL) and inflammatory cells in the nerve biopsy. A diagnosis of "probable SIDP" required progression of demyelinating neuropathy over a 4- to 8-week period.

RESULTS

Sixteen definite SIDP patients were identified among 29 probable SIDP patients. An antecedent infection was found in 38% of cases. The two most common neuropathy types were a symmetric motor-sensory neuropathy and a pure motor neuropathy. Cranial nerve deficits and respiratory failure were rare. Spinal fluid protein was high in 93% of cases. Demyelination was documented by the motor nerve conduction in 88% of cases and by the near-nerve needle sensory nerve conduction in two cases. Almost all patients were treated with prednisone and some with additional immunotherapies. Complete recovery was achieved in 69% of cases and partial recovery in others. Definite SIDP had all the characteristics of CIDP with three exceptions: a higher rate of antecedent infection, no relapse rate, and a high rate of recovery to normal.

CONCLUSION

Subacute inflammatory demyelinating polyneuropathy is a definite entity bridging the gap between Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy.

Delayed-onset pineal abscess following transsphenoidal surgery for pituitary adenoma: a case report

A 41-year-old woman suffered fever, speech disturbance and confusion four months after transsphenoidal surgery for pituitary macroadenoma. Meanwhile, the patient had been well except for transient asymptomatic postoperative pneumocephalus without cerebrospinal fluid (CSF) rhinorrhoea. Brain computed tomographic scan revealed a peripherally enhancing pineal abscess which superimposed on a preexisting pineal cyst. CSF findings showed elevated leukocyte count and positive bacterial culture. Three weeks of intensive antibiotic therapy and surgical evacuation of the pineal abscess ensued. The patient showed restricted postoperative recovery with moderate hypothalamic dysfunction. A unique case of delayed-onset postoperative pineal abscess which complicates the preexisting asymptomatic pineal cyst is presented and the possible explanation for this is speculated with review of the available literatures.

Postexercise facilitation of reflexes is not common in Lambert-Eaton myasthenic syndrome

Postexercise facilitation (PEF) with clinical reflexes, H-reflex, and T-reflexes at the ankle and knee was systematically studied in 16 patients with Lambert-Eaton myasthenic syndrome (LEMS). PEF was observed in ankle and knee deep tendon reflexes in five patients, in H-reflex in three patients, and in T-reflexes in six patients. When all reflex tests were combined, 7 (43.7%) of 16 patients showed PEF by at least one test. The authors conclude that the PEF of reflexes, the most helpful diagnostic clinical marker for LEMS, is not common.

High glucose dialysis solutions increase synthesis of vascular endothelial growth factors by peritoneal vascular endothelial cells

OBJECTIVE

Increased peritoneal vasculature has been reported in long-term peritoneal dialysis (PD), and vascular endothelial growth factors (VEGFs) have been found in dialysate. High concentrations of glucose or lactate, glucose degradation products (GDPs), and low pH of dialysis solutions are all possible factors in increased peritoneal VEGF synthesis. In this study, we investigated the effects of high glucose dialysis solutions on VEGF synthesis by peritoneal vascular endothelial cells (PVECs).

METHODS

The PVECs were isolated from rat omentum and were incubated for 4 hours in three different culture media [M199 media (control), conventional dialysis solutions containing 4.25% glucose diluted with an equal volume of M199 media (HGD), and M199 media containing 118 mmol/L mannitol as an osmolar control (mannitol)]. Levels of VEGF protein in the culture supernatant were measured by ELISA, and mRNA expression was determined by Northern blot analysis. Data are presented as percent of control.

RESULTS

After incubation for 4 hours, the number of cells did not differ between the 3 groups. Levels of VEGF in culture supernatant were significantly higher in the HGD group (124% +/- 19%, p = 0.006) as compared with the control and mannitol (85% +/- 10%) groups. The mRNA expression of VEGF appeared to be higher in the HGD group (128% +/- 49%) than in the control and mannitol (94% +/- 18%) groups.

CONCLUSION

High glucose dialysis solutions increased VEGF synthesis by PVECs. The relationship between VEGF synthesis by PVECs and neovascularization of the peritoneum observed in long-term peritoneal dialysis patients has to be studied further.

Clinicopathological features of genetically confirmed Danon disease

BACKGROUND

Danon disease is due to primary deficiency of lysosome-associated membrane protein-2.

OBJECTIVE

To define the clinicopathologic features of Danon disease.

METHODS

The features of 20 affected men and 18 affected women in 13 families with genetically confirmed Danon disease were reviewed.

RESULTS

All patients had cardiomyopathy, 18 of 20 male patients (90%) and 6 of 18 female patients (33%) had skeletal myopathy, and 14 of 20 male patients (70%) and one of 18 female patients (6%) had mental retardation. Men were affected before age 20 years whereas most affected women developed cardiomyopathy in adulthood. Muscle histology revealed basophilic vacuoles that contain acid phosphatase-positive material within membranes that lack lysosome-associated membrane protein-2. Heart transplantation is the most effective treatment for the otherwise lethal cardiomyopathy.

CONCLUSIONS

Danon disease is an X-linked dominant multisystem disorder affecting predominantly cardiac and skeletal muscles.

Knowledge and attitudes of Korean parents towards their son's circumcision: a nationwide questionnaire study

OBJECTIVE

To evaluate knowledge about the foreskin and circumcision, and to understand the attitudes of parents to circumcision in Korea, where circumcision in childhood is widely practised with no particular religious or medical background.

SUBJECTS AND METHODS

A nationwide study involving questionnaires was conducted on 5500 parents with at least one son attending elementary school. Responses were obtained from one of the parents.

RESULTS

The response rate was 76.1% (4183); circumcision was most common in boys when aged 11 years, followed by neonatal circumcision. Of the parents, 91.3% believed that circumcision is necessary, while 2.1% believed it to be unnecessary. The principal reasons given for circumcision were 'to improve penile hygiene' (82.4%), followed by 'to improve future sexual potency' (7.5%). Among those who did not believe circumcision to be necessary, the most common reason was the expectation of spontaneous retraction of the prepuce with age (55.1%). Most (88.4%) of the parents believed that smegma is not a clean material, and is infected by microorganisms. Most parents (80.6%) thought that circumcision would prevent genital tract infection of the future spouse. Peer pressure was one of the most influential factors in deciding upon circumcision; 41.9% of the parents were anxious that their child might be ridiculed by his peer group unless he was circumcised, while 27.4% of the parents believed that their child might be ridiculed if he was circumcised. Mothers were more positive about circumcision than fathers (P < 0.05). Parents with a higher education and higher socio-economic status were also more positive about circumcision (P < 0.05). Mothers were prone to emphasize improved sexual potency (P < 0.05). There was no significant difference in response between urban and rural areas.

CONCLUSION

This study indicates that common beliefs held by parents about the prepuce or circumcision differ significantly from current medical knowledge, and these beliefs have a major influence on the practice of circumcision in Korea. More clinical research on the natural history of the foreskin is needed, and it is critical that both children and parents are informed about the potential benefits and disadvantages of circumcision.

Natural history of refluxing distal ureteral stumps following upper tract surgery in children with ectopic ureter or ureterocele

BACKGROUND

It is a difficult problem to manage refluxing distal ureteral stumps after an upper tract approach in the ectopic ureter and ureterocele. We evaluated the natural history of the remaining refluxing distal ureteral stumps through a close follow-up.

PATIENTS AND METHODS

From 1991 to 1998, nine patients with the ectopic ureter or ureterocele, whose age ranged from one to 20 (median 5.0) months, had undergone an upper tract surgery for ectopic ureter (2) or ectopic ureterocele (7). The upper tract surgery for ureterocele or ectopic ureter included a total nephrectomy (2), a partial nephrectomy (6) or a proximal ureteroureterostomy (1), leaving distal ureteral stump. We evaluated the clinical results of the remaining ureteral stumps every 6 or 12 months. The postoperative follow-up period was 51 (median; range 21-96) months.

RESULTS

Among the 9 patients, 5 showed disappearance of the reflux and a markedly reduced stump size in the follow-up study. Improvement was noted in 4 patients within 6 months and in 1 by 20 months postoperatively. Two patients subsequently underwent a bladder level surgery due to problems not associated with the ureteral stump itself. Two patients have been followed up for 30 and 39 months, but without any improvement. An intermittent asymptomatic bacteriuria was noted in all patients during the follow-up, but no patient suffered from symptomatic urinary tract infection requiring an additional surgery.

CONCLUSIONS

Since refluxing distal ureteral stumps were spontaneously resolved in more than half of the cases and did not cause significant problems during the follow-up, it is not necessary to remove the refluxing ureter simultaneously at the time of the upper tract surgery.