[A Case of Breast Mucinous Carcinoma with Bladder Metastasis Effectively Treated with Endocrine Therapy and Chemotherapy]

A 57-year-old Japanese woman underwent partial mastectomy of the right breast and sentinel lymph node biopsy in July 2005. The diagnosis was mucinous carcinoma with negative margins and no lymph node metastases(pT1cN0M0, pStage Ⅰ A). Postoperative adjuvant therapy included radiation therapy and oral administration of anastrozole for 5 years. In December 2015, we observed enlargement of left supraclavicular lymph nodes; a needle biopsy revealed lymph node metastases from breast cancer. We administered toremifene and the swelling disappeared. The patient was subsequently referred to the hospital for urinary frequency in November 2016. Imaging demonstrated a bladder tumor. Transurethral biopsy of bladder revealed adenocarcinoma with mucin production consistent with breast primary. After systemic chemotherapy(UFT, eribulin), endocrine therapy(fulvestrant), and molecular targeted therapy(palbociclib), her urologic symptoms were relieved. However, 2 years and 8 months after diagnosis of bladder metastasis, the patient showed disease progression and decided to discontinue all chemotherapy and pursue palliative care. We also present a review and discussion of the relevant literature.

Whole-Genome Sequencing of the NARO World Rice Core Collection (WRC) as the Basis for Diversity and Association Studies

Genebanks provide access to diverse materials for crop improvement. To utilize and evaluate them effectively, core collections, such as the World Rice Core Collection (WRC) in the Genebank at the National Agriculture and Food Research Organization, have been developed. Because the WRC consists of 69 accessions with a high degree of genetic diversity, it has been used for >300 projects. To allow deeper investigation of existing WRC data and to further promote research using Genebank rice accessions, we performed whole-genome resequencing of these 69 accessions, examining their sequence variation by mapping against the Oryza sativa ssp. japonica Nipponbare genome. We obtained a total of 2,805,329 single nucleotide polymorphisms (SNPs) and 357,639 insertion-deletions. Based on the principal component analysis and population structure analysis of these data, the WRC can be classified into three major groups. We applied TASUKE, a multiple genome browser to visualize the different WRC genome sequences, and classified haplotype groups of genes affecting seed characteristics and heading date. TASUKE thus provides access to WRC genotypes as a tool for reverse genetics. We examined the suitability of the compact WRC population for genome-wide association studies (GWASs). Heading date, affected by a large number of quantitative trait loci (QTLs), was not associated with known genes, but several seed-related phenotypes were associated with known genes. Thus, for QTLs of strong effect, the compact WRC performed well in GWAS. This information enables us to understand genetic diversity in 37,000 rice accessions maintained in the Genebank and to find genes associated with different phenotypes. The sequence data have been deposited in DNA Data Bank of Japan Sequence Read Archive (DRA) (Supplementary Table S1).

Effects of Sulfonylureas on Periodontopathic Bacteria-Induced Inflammation

Interleukin-1β (IL-1β) is an inflammatory cytokine produced by monocytes/macrophages and is closely associated with periodontal diseases. The NLRP3 inflammasome is involved in IL-1β activation through pro-IL-1β processing and pyroptotic cell death in bacterial infection. Recently, glyburide, a hypoglycemic sulfonylurea, has been reported to reduce IL-1β activation by suppressing activation of the NLRP3 inflammasome. Therefore, we evaluated the possibility of targeting the NLRP3 inflammasome pathway by glyburide to suppress periodontal pathogen-induced inflammation. THP-1 cells (a human monocyte cell line) were differentiated to macrophage-like cells by treatment with phorbol 12-myristate 13-acetate and stimulated by periodontopathic bacteria, Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, or Fusobacterium nucleatum, in the presence of glyburide. IL-1β and caspase-1 expression in the cells and culture supernatants were analyzed by Western blotting and enzyme-linked immunosorbent assay, and cell death was analyzed by lactate dehydrogenase assay. Stimulation of THP-1 macrophage-like cells with every periodontopathic bacteria induced IL-1β secretion without cell death, which was suppressed by the NLRP3 inhibitor, MCC950, and caspase-1 inhibitor, z-YVAD-FMK. Glyburide treatment suppressed IL-1β expression in culture supernatants and enhanced intracellular IL-1β expression, suggesting that glyburide may have inhibited IL-1β secretion. Subsequently, a periodontitis rat model was generated by injecting periodontal bacteria into the gingiva, which was analyzed histologically. Oral administration of glyburide significantly suppressed the infiltration of inflammatory cells and the number of osteoclasts in the alveolar bone compared with the control. In addition to glyburide, glimepiride was shown to suppress the release of IL-1β from THP-1 macrophage-like cells, whereas other sulfonylureas (tolbutamide and gliclazide) or other hypoglycemic drugs belonging to the biguanide family, such as metformin, failed to suppress IL-1β release. Our results suggest that pharmacological targeting of the NLRP3 pathway may be a strategy for suppressing periodontal diseases.

P1520 Aortic flow reversal caused by aortic regurgitation deteriorates renal function

Background

Chronic kidney disease is a growing public health problem. Renal dysfunction is known as a strong risk factor for cardiovascular disease and end-stage renal failure. The presence of pan-diastolic flow reversal in the abdominal aorta is a very specific sign of severe aortic regurgitation (AR). A higher aortic reverse/forward flow ratio is associated with lower intrarenal forward flow. However, the influence of AR on renal function has been poorly understood. We hypothesized that the aortic flow reversal reduces the renal artery forward flow and accordingly leads to renal dysfunction in patients with severe AR.

Methods

The study consisted of 21 consecutive patients (mean age 69 ± 11 years) with severe AR who underwent aortic valve replacement (AVR). We compared echocardiographic indices and the glomerular filtration rate (GFR) before and 603 ± 541 days after AVR.

Results

Blood pressure was 122 ± 16/54 ± 8 mmHg before AVR and 123 ± 16/76 ± 11 mmHg after AVR. After AVR, left ventricular (LV) end-diastolic dimension decreased from 57 ± 9 to 44 ± 5 mm and LV ejection fraction increased from 58 ± 12 to 60 ± 11 %. Estimated GFR significantly increased from 62.9 ± 18.9 to 71.8 ± 18.1 mL/min per 1.73 m2 after AVR (p = 0.003).

Conclusions An increase in aortic flow reversal caused by severe AR reduces forward flow into the kidney and thereby deteriorates renal function. This study demonstrated a key mediating role of central hemodynamic factors, particularly an exaggerated aortic flow reversal in renal dysfunction and severe AR.

Translocator protein 18kDa antagonist ameliorates stress-induced stool abnormality and abdominal pain in rodent stress models

BACKGROUND

Irritable bowel syndrome (IBS) is a functional gastrointestinal (GI) disorder characterized by abdominal pain and abnormal bowel habits, both of which are exacerbated by psychological stress. The translocator protein 18kDa (TSPO) is a marker of reactive gliosis in a number of central nervous system (CNS) diseases and responsible for many cellular functions, including neurosteroidogenesis. Although it has been reported that psychological stress disturbs neurosteroids levels, the pathophysiological relevance of TSPO in IBS is poorly understood.

METHODS

We examined the effects of a TSPO antagonist, ONO-2952, on stress-induced stool abnormality and abdominal pain in rats, and on anxiety-related behavior induced by cholecystokinin.

KEY RESULTS

Oral administration of ONO-2952 attenuated stress-induced defecation and rectal hyperalgesia in rats with an efficacy equivalent to that of a 5-HT₃ receptor antagonist. In addition, ONO-2952 suppressed cholecystokinin-induced anxiety-like behavior with an efficacy equivalent to that of psychotropic drugs. On the other hand, ONO-2952 did not affect spontaneous defecation, gastrointestinal transit, visceral nociceptive threshold, and neurosteroid production in non-stressed rats even at a dose 10 times higher than its effective dose in the stress models.

CONCLUSIONS AND INFERENCES

These results suggest that TSPO antagonism results in antistress action, and that ONO-2952 is a promising candidate for IBS without side effects associated with current treatment.

Proton pump inhibitor after endoscopic resection for esophageal squamous cell cancer: multicenter prospective randomized controlled trial

BACKGROUND

Whether proton pump inhibitors (PPIs) relieve heartburn or precordial pain after endoscopic resection (ER) for esophageal squamous cell carcinoma (ESCC) remains unclear. The aim of this study was to investigate the efficacy of PPI therapy for these symptoms after ER for ESCC.

METHODS

We conducted a multicenter prospective randomized controlled trial among 15 hospitals in Japan. In total, 229 patients with cT1a ESCC were randomly assigned to receive PPI therapy for 5 weeks after ER (the PPI group, n = 115) or follow-up without PPI therapy (the non-PPI group, n = 114). The primary end point was the incidence of gastroesophageal reflux disease (GERD)-like symptoms after ER from a self-reported questionnaire (Frequency Scale for Symptoms of GERD). Secondary end points were ulcer healing rate at 5 weeks, incidence of pain, improvement rate of symptoms in those who started PPI therapy because of GERD-like symptoms in the non-PPI group, and adverse events.

RESULTS

No significant difference was observed in the incidence of GERD-like symptoms after ER between the non-PPI and PPI groups (30 % vs 34 %, respectively). No significant differences were observed in the ulcer healing rate at 5 weeks (84 % vs 85 %) and incidence of pain within 1 week (36 % vs 45 %). In nine of ten patients (90 %) who started PPI therapy because of GERD-like symptoms in the non-PPI group, PPI administration relieved GERD-like symptoms. No adverse events related to PPI administration were observed.

CONCLUSION

PPI therapy is not efficacious in reducing symptoms and did not promote healing of ulcers in patients undergoing ER for ESCC.

Role of macrophage colony-stimulating factor (M-CSF)-dependent macrophages in gastric ulcer healing in mice

We examined the role of macrophage colony-stimulating factor (M-CSF)-dependent macrophages in the healing of gastric ulcers in mice. Male M-CSF-deficient (op/op) and M-CSF-expressing heterozygote (+/?) mice were used. Gastric ulcers were induced by thermal cauterization under ether anesthesia, and healing was observed for 14 days after ulceration. The numbers of macrophages and microvessels in the gastric mucosa were determined immunohistochemically with anti-CD68 and anti-CD31 antibodies, respectively. Expression of tumor necrosis factor (TNF)-α, cyclooxygenase (COX)-2, and vascular endothelial growth factor (VEGF) mRNA was determined via real-time reverse transcription-polymerase chain reaction (RT-PCR), and the mucosal content of prostaglandin (PG) E(2) was determined via enzyme immunoassay on day 10 after ulceration. The healing of gastric ulcers was significantly delayed in op/op mice compared with +/? mice. Further, significantly fewer macrophages were observed in the normal gastric mucosa of op/op mice than in +/? mice. Ulcer induction caused a marked accumulation of macrophages around the ulcer base in +/? mice, but this response was attenuated in op/op mice. The mucosal PGE(2) content as well as the expression of COX-2, VEGF, and TNF-α mRNA were all upregulated in the ulcerated area of +/? mice but significantly suppressed in op/op mice. The degree of vascularization in the ulcerated area was significantly lower in op/op mice than in +/? mice. Taken together, these results suggest that M-CSF-dependent macrophages play an important role in the healing of gastric ulcers, and that this action may be associated with angiogenesis promoted by upregulation of COX-2/PGE(2) production.

[Surgical treatment of postinfarction ventricular septal rupture]

BACKGROUND

Postinfarction ventricular septal rupture (VSR) is a lethal complication with high mortality. The aim of this study was to evaluate our surgical strategy and results of VSR.

PATIENTS AND METHODS

Between 1996 and 2008, 13 consecutive patients underwent operation for VSR at our hospital. All patients required emergent operation because of severe cardiogenic shock. Surgical procedure consisted of endocardial patch repair with infarct exclusion, so called "Komeda-David operation". In patients with multiple coronary artery disease, myocardial revascularization was done simultaneously.

RESULTS

These patients were divided into 2 groups according to the location of VSR. There were 9 patients of anterior VSR. Two of them could not be weaned from cardiopulmonary bypass and died of severe low output syndrome (LOS) at early postoperative period. The site of infarction in both patients was broad anteroseptal region including right ventricle. On the other hand, there were 4 patients of inferior VSP. Two of these patients were lost due to LOS. One patient was complicated with left ventricular free wall rupture. In another patient, infarction was extended proximally toward the mitral annulus and papillary muscles. Both cardiopulmonary bypass time and aortic crossclamp time were significantly longer in inferior VSR than in anterior region. There was no late death in 2 groups.

CONCLUSIONS

Despite improvements of surgical procedures, such as infarct exclusion technique, the operative mortality remains high in cases with broad infarction and/or right ventricular infarction. In these particular circumstances, in should be mandatory to consider the optimal timing of operation and the modification of surgical technique itself.

Prospective randomized controlled study on the effects of perioperative administration of a neutrophil elastase inhibitor to patients undergoing video-assisted thoracoscopic surgery for thoracic esophageal cancer

Sivelestat sodium hydrate (Ono Pharmaceutical Co., Osaka, Japan) is a selective inhibitor of neutrophil elastase (NE) and is effective in reducing acute lung injury associated with systemic inflammatory response syndrome (SIRS). We conducted a prospective randomized controlled study to investigate the efficacy of perioperative administration of sivelestat sodium hydrate to prevent postoperative acute lung injury in patients undergoing thoracoscopic esophagectomy and radical lymphadenectomy. Twenty-two patients with thoracic esophageal cancer underwent video-assisted thoracoscopic esophagectomy with extended lymph node dissection in our institution between April 2007 and November 2008. Using a double-blinded method, these patients were randomly assigned to one of two groups preoperatively. The active treatment group received sivelestat sodium hydrate intravenously for 72 hours starting at the beginning of surgery (sivelestat-treated group; n= 11), while the other group received saline (control group; n= 11). All patients were given methylprednisolone immediately before surgery. Postoperative clinical course was compared between the two groups. Two patients (one in each group) were discontinued from the study during the postoperative period because of surgery-related complications. Of the remaining 20 patients, 2 patients who developed pneumonia within a week after surgery were excluded from some laboratory analyses, so data from 18 patients (9 patients in each group) were analyzed based on the arterial oxygen pressure/fraction of inspired oxygen ratio, white blood cell count, serum C-reactive protein level, plasma cytokine levels, plasma NE level, and markers of alveolar type II epithelial cells. In the current study, the incidence of postoperative morbidity did not differ between the two groups. The median duration of SIRS in the sivelestat-treated group was significantly shorter than that in the control group: 17 (range 9-36) hours versus 49 (15-60) hours, respectively (P= 0.009). Concerning the parameters used for the diagnosis of SIRS, the median heart rates on postoperative day (POD) 2 were significantly lower in the sivelestat-treated group than in the control group (P= 0.007). The median arterial oxygen pressure/fraction of inspired oxygen ratio of the sivelestat-treated group were significantly higher than those of the control group on POD 1 and POD 7 (POD 1: 372.0 [range 284.0-475.0] vs 322.5 [243.5-380.0], respectively, P= 0.040; POD 7: 377.2 [339.5-430.0] vs 357.6 [240.0-392.8], P= 0.031). Postoperative white blood cell counts, serum C-reactive protein levels, plasma interleukin-1beta, tumor necrosis factor-alpha levels, and plasma NE levels did not differ significantly between the two groups at any point during the postoperative course, nor did serum Krebs von den Lungen 6, surfactant protein-A, or surfactant protein-D levels, which were used as markers of alveolar type II epithelial cells to evaluate the severity of lung injury. Plasma interleukin-8 levels were significantly lower in the sivelestat-treated group than in the control group on POD 3 (P= 0.040). In conclusion, perioperative administration of sivelestat sodium hydrate (starting at the beginning of surgery) mitigated postoperative hypoxia, partially suppressed postoperative hypercytokinemia, shortened the duration of SIRS, and stabilized postoperative circulatory status after thoracoscopic esophagectomy.

Spectral broadening of mid-infrared femtosecond pulses in GaAs

We achieved efficient spectral broadening for mid-IR pulses of few-microjoule energy. The spectral bandwidth of the femtosecond pulses at the center wavelength of 5000 nm increased from 540 nm to 2060 nm (from 220 to 910 cm(-1) in frequency) by nonlinear propagation in a gallium arsenide single crystal. The spectral broadening was accompanied by nonlinear absorption loss of 25%. The demonstrated scheme should be available at any operation wavelength within the material transparency range and provides a useful tool in nonlinear vibrational spectroscopy.

[Surgical strategy for aortic root reconstruction in patients with Stanford type A acute aortic dissection]

BACKGROUND

Although the aortic root dissection is a common finding in patients with type A acute aortic dissection, it is potentially fatal. Several procedures are available for reconstruction of the aortic root, and the choice depends on the mode of dissection; rupture, coronary ostial disruption or pre-existing cardiovascular diseases (annulo-aortic ectasia, aortic regurgitation: AR). The purpose of this study was to evaluate our surgical strategy of type A acute aortic dissection with proximal involvement.

METHODS

Between 1996 and 2008, 100 patients with type A acute aortic dissection underwent emergency operation at our hospital. Fifteen of them received aortic root intervention simultaneously.

RESULTS

In the initial 3 patients, the dissected aortic root was reinforced by fibrin glue and concomitant coronary bypass grafting was performed. During the follow-up term, residual aortic insufficiency was noted in 2 patients. Aortic root reconstruction was performed in 12 patients. Of these, the most recent 2 young patients underwent a new type of aortic valve sparing procedure, so called "partial remodeling". The postoperative echocardiography demonstrated no AR. There was no operative death in this series, and the long-term results were good.

CONCLUSION

The excellent outcome was demonstrated with the change of surgical strategy. Special care should be taken for precise recognition of the proximal extension of the aortic dissection at operation. Although we recommend consideration of the partial remodeling procedure as an alternative, close observation is mandatory in this particular circumstance.

[Konno procedure for congenital aortic stenosis associated with complex left ventricular outflow tract obstruction]

Two successful cases of Konno procedure for congenital aortic stenosis and left ventricular outflow tract obstruction (LVOTO) were reported herein. A 3-year-old child previously underwent definitive repair of complete atrioventricular septal defect. Follow-up echocardiography revealed progression of valvular aortic stenosis and subaortic tunnel stenosis. Second patient was a 30-year-old male with congenital aortic stenosis, severe LVOTO and funnel chest. Both patients underwent Konno procedure, and their postoperative courses were uneventful. The Konno procedure is effective and stenotic lesion could be enlarged sufficiently even in complex LVOTO. Especially in the patient of advanced age, care should be taken to fragility of the left ventricular muscle and coronary malperfusion caused by the procedure itself.

Influence of Helicobacter pylori eradication on reflux esophagitis in Japanese patients

The relationship between Helicobacter pylori eradication and reflux esophagitis is controversial. We analyzed the development of reflux esophagitis and the change in the grade of pre-existing reflux esophagitis after eradication. Enrolled were 559 Japanese patients who received eradication therapy for H. pylori. The grade of reflux esophagitis by endoscopy before and after therapy was evaluated retrospectively. No esophagitis was present before eradication in 526 patients. H. pylori was and was not eradicated in 429 and 97, respectively. Reflux esophagitis developed in 40 of the eradication group and in three of the treatment failure group, with prevalence higher with successful eradication (P = 0.04). Successful eradication and hiatus hernia were significant risk factors for reflux esophagitis development. Twenty-seven of 33 patients with pre-existing reflux esophagitis had successful eradication and six treatment failure. The reflux esophagitis grade worsened in two (Los Angeles classification from A to B) and improved in 14 patients after eradication. With treatment failure, reflux esophagitis worsened in none and improved in three patients. There showed no significant change in the grade of pre-existing reflux esophagitis after H. pylori eradication but the sample size was too small to evaluate the difference. In conclusion, the eradication of H. pylori increases the prevalence of reflux esophagitis, and hiatus hernia was a significant risk factor for the development of reflux esophagitis.

Influence of Helicobacter pylori eradication on reflux esophagitis in Japanese patients

The relationship between Helicobacter pylori eradication and reflux esophagitis is controversial. We analyzed the development of reflux esophagitis and the change in the grade of pre-existing reflux esophagitis after eradication. Enrolled were 559 Japanese patients who received eradication therapy for H. pylori. The grade of reflux esophagitis by endoscopy before and after therapy was evaluated retrospectively. No esophagitis was present before eradication in 526 patients. H. pylori was and was not eradicated in 429 and 97, respectively. Reflux esophagitis developed in 40 of the eradication group and in three of the treatment failure group, with prevalence higher with successful eradication (P = 0.04). Successful eradication and hiatus hernia were significant risk factors for reflux esophagitis development. Twenty-seven of 33 patients with pre-existing reflux esophagitis had successful eradication and six treatment failure. The reflux esophagitis grade worsened in two (Los Angeles classification from A to B) and improved in 14 patients after eradication. With treatment failure, reflux esophagitis worsened in none and improved in three patients. There showed no significant change in the grade of pre-existing reflux esophagitis after H. pylori eradication but the sample size was too small to evaluate the difference. In conclusion, the eradication of H. pylori increases the prevalence of reflux esophagitis, and hiatus hernia was a significant risk factor for the development of reflux esophagitis.

[Postoperative management using ultra-short-acting beta-blocker (landiolol) in patients with aortic stenosis after aortic valve replacement]

Paroxysmal atrial fibrillation and other types of tachyarrhythmia are common, but might be potentially fatal complications in patients undergoing aortic valve replacement due to aortic stenosis. We report the effects of ultra-short-acting beta-blocker (landiolol) in treating 2 patients with postoperative tachycardia. The heart rate was controlled adequately without subsequent hypotension and postoperative course was uneventful. This strategy seems to be safe and beneficial in this particular circumstance.

Satisfaction with bispectral index monitoring of propofol-mediated sedation during endoscopic submucosal dissection: a prospective, randomized study

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) is one of the most complex and lengthy endoscopic procedures, so deep sedation during ESD is indispensable. Our study aims were to determine whether bispectral index (BIS) monitoring is useful in titrating and reducing the dose of the sedative propofol during ESD, and to measure the satisfaction of patients and endoscopists involved in this complex and lengthy endoscopic therapy.

PATIENTS AND METHODS

We performed a prospective, randomized clinical trial from July 2006 to February 2008. A total of 156 patients, with gastric neoplasm to be treated using ESD, were randomized to two groups. The BIS group (n = 78) was monitored for propofol sedation using BIS, and the no-BIS group (n = 78) was monitored by standard methods only. The two groups were compared by evaluating the doses of propofol administered to patients and the satisfaction scores (scale of 0 - 10) of patients and endoscopists.

RESULTS

Although there were no significant differences between the two groups in the mean dose of propofol used (BIS group vs. no-BIS group, 5.32 mg/kg/hour vs. 4.85 mg/kg/hour; P = 0.10), the satisfaction scores of the patients (9.15 vs. 7.94; P < 0.01) and endoscopists (8.53 vs. 6.42; P < 0.001) were significantly higher with BIS monitoring.

CONCLUSIONS

Monitoring with BIS during the ESD procedure did not lead to a reduction in the dose of propofol required, but did lead to higher satisfaction scores from the patients and endoscopists. A complicated and prolonged endoscopic treatment such as ESD can be carried out with optimal safety, control, and comfort by using BIS to monitor propofol sedation.

[Does transradial cardiac catheterization affect coronary artery bypass grafting?]

Recent technological advances have enabled the miniaturization of catheters for coronary angiography and intervention. As a result of this advancement, the transradial approach is becoming more popular. The advantages of this approach include a lower incidence of access site complications, earlier patient ambulation, improved patient satisfaction, and lower cost. The cardiologists of our institute have introduced this technique without delay and have taken the initiative in Japan. However, there are concerns regarding the effect of transradial cardiac catheterization on the condition of radial artery grafts for coronary artery bypass grafting (CABG). In this study, we evaluated the influence of transradial catheterization on CABG. We retrospectively evaluated 157 patients who had undergone CABG using the radial artery. The condition of the grafts was assessed intraoperatively. Postoperative coronary angiography was carried out 3 months after the surgical intervention. The patency of the grafts was assessed by 2 cardiologists. One-quarter of the radial artery grafts were affected by transradial catheterization. Since most of them were located only at the puncture site, the graft itself was capable of being used for grafting after the resection of its affected distal end. The patency rate was not affected by transradial catheterization.

Relationship between muscle oxygenation kinetics and the rate of decline in peak torque during isokinetic knee extension in acute hypoxia and normoxia

To investigate whether low FiO2 affects muscle oxygenation and the rate of decline in peak torque (DR) during isokinetic knee extension, subjects performed 50 isokinetic knee extensions at 180 degrees /s and at 0.5 Hz while inhaling low O2 gas (12 %O2; H) or air (N). Muscle oxygenation kinetics was assessed by near-infrared spectroscopy, and whole-body V.O2 and HR were measured. We calculated total-, oxy- and deoxy-hemoglobin/myoglobin concentrations (TotalHb/Mb, OxyHb/Mb, DeoxyHb/Mb), and the slopes of the change in OxyHb/Mb during exercise. SpO2 decreased in H while DR and V.O2 did not differ between the conditions. During exercise, OxyHb/Mb was lower in H than in N, and DeoxyHb/Mb was higher in H than in N. TotalHb/Mb began to increase from the resting level earlier in H. HR was higher during the latter half of the exercise in H. The slopes of the change in OxyHb/Mb were the same in the two conditions. Our results show that low FiO2 decreases SpO2 and muscle oxygenation during maximal isokinetic knee extension. However, low SpO2 and muscle oxygenation did not affect the rates of decline of peak torque. These results suggest that the decline in peak torque occurs for reasons other than O2 availability.

Helicobacter pylori eradication reduced the incidence of gastric cancer, especially of the intestinal type

BACKGROUND

Although Helicobacter pylori infection is closely associated with gastric cancer development, follow-up studies after H. pylori eradication are still scarce.

AIM

To clarify the cancer preventive effect of H. pylori eradication, with special attention to differences in effect according to histology.

METHODS

Patients who underwent H. pylori eradication therapy and were followed-up endoscopically for at least 1 year were analysed. The incidence of gastric cancer and factors associated with cancer development were investigated.

RESULTS

A total of 1807 patients were enrolled. Six of 1519 H. pylori eradicated and five of 288 persistent subjects developed gastric cancer. Four of the eradicated subjects developed the intestinal type and two the diffuse type, while four of the persistent subjects developed the intestinal type and one the diffuse type. Kaplan-Meier analysis indicated a significantly lower incidence in eradicated patients than in persistent patients. The incidence of intestinal type was significantly lower than in eradicated patients, while the diffuse type could not be evaluated because of the low incidence.

CONCLUSIONS

Helicobacter pylori-eradicated patients had a reduced incidence of gastric cancer compared with H. pylori-persistent patients, particularly the intestinal type, suggesting that H. pylori is strongly associated with intestinal-type gastric cancer.

Therapeutic efficacy of leukocytapheresis in a pregnant woman with severe active ulcerative colitis

Leukocytapheresis has recently been used to induce remission in patients with ulcerative colitis (UC) who fail to respond to corticosteroids. We could not find a report in the literature on leukocytapheresis for UC with gestational exacerbation. We have recently encountered this unique condition and report the details here. A 30-year-old Japanese woman with left-sided severe UC was corticosteroid-dependent and had recurrence of the active disease during tapering of corticosteroid. She declined any dose increase and the use of any immunosuppressive agent because she was in the 13th week of pregnancy. Then, concomitant leukocytapheresis was performed without increasing the corticosteroid dose. Recovery was rapid and dramatic. Mucous and bloody stool decreased after the first session, and she had remission 2 weeks later. She underwent a total of four sessions without complications. After 6 weeks, she was discharged from our hospital and underwent maintenance treatment as an outpatient with mesalazine and corticosteroid tapering. Subsequently, she gave birth to a healthy baby girl by an uncomplicated vaginal delivery while keeping the remitted stage of UC.

[Impacts of aortic valve replacement on cardiac function in patients with aortic stenosis]

To prevent patient-prosthesis mismatch (PPM) after aortic valve replacement (AVR), we set up our original standard criteria for the selection of the size of the prosthetic valve. We also routinely perform supra-annular enlargement in patients with small aortic annuli. The objective of this study was to assess the impact of our procedure on the postoperative cardiac function of patients suffering from aortic stenosis (AS). We retrospectively reviewed 102 consecutive surgical patients with AS from 1999 to 2004. The patients were classified into the following 3 groups based on the sizes of their prosthesis (group S : 19 mm prosthesis, n = 34; group M : 21 mm prosthesis, n = 51; and group L : > 23 mm prosthesis, n = 17). Cardiac function was evaluated using echocardiography preoperatively, immediately postoperatively, and 6 months after the operation. There were no hospital deaths during the study period. A favorable hemodynamic outcome of all 3 groups was achieved. Our surgical strategy for AS was thought to be useful to prevent PPM after AVR.

Endoscopic submucosal dissection for early gastric cancer: results and degrees of technical difficulty as well as success

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) is a new method for the curative treatment of early gastrointestinal neoplasms, which was developed in order to increase the en bloc and R0 resection rate, especially for lesions larger than 20 mm in diameter. Drawbacks of ESD include the fact that it is technically a substantially more difficult procedure and that it is associated with a higher perforation rate. A retrospective study was therefore carried out to analyze cases in relation to the procedure time and resection success, and these factors were correlated with the characteristics of the lesions.

PATIENTS AND METHODS

From January 2002 to November 2005, 196 lesions in 185 patients with early gastric cancer were treated using ESD in our hospital. The rates of curative en bloc resection, the incidence of perforation, and the procedure times were analyzed in relation to lesion size (small, 20 mm or less in diameter; large, over 20 mm), location (upper, middle, or lower third of the stomach) and the presence or absence of ulceration.

RESULTS

The rate of curative en bloc resection was 84 % (93 % of the lesions overall were resected in one piece), with a perforation rate of 6.1 % (all perforations were managed endoscopically) and a mean procedure time of 68 min. The rate of curative en bloc resection differed significantly depending on the location of the lesion (upper vs. middle vs. lower, 74 % vs. 77 % vs. 91 %; P < 0.05), as well as on the size of the lesion (> 20 mm vs. 20 mm or less, 59 % vs. 89 %; P < 0.0001). There were also significant differences in the mean procedure times in relation to the location of the lesion (upper vs. middle vs. lower, 105 min vs. 81 min vs. 45 min; P < 0.0001) and the size of the lesion (> 20 mm vs. 20 mm or less, 124 min vs. 55 min; P < 0.0001), as well as the presence of ulceration (positive vs. negative, 97 min vs. 65 min; P < 0.05). With regard to perforation rates, significant differences were also observed in relation to the location of the lesion (upper vs. middle vs. lower, 22.6 % vs. 2.8 % vs. 3.2 %; P < 0.0005) and size of the lesion (> 20 mm vs. 20 mm or less, 16.2 % vs. 3.8 %; P < 0.005). No local recurrences of curatively resected lesions (n = 119) were observed after a follow-up period of 1 year.

CONCLUSIONS

The difficulty of ESD depends on the location and size of the lesion, as well as on the presence of ulceration. We would recommend that trainees should begin by carrying out ESD on lesions with a diameter of less than 20 mm without ulceration that are located in the lower third of the stomach.

Endoscopic submucosal dissection for early gastric cancer: results and degrees of technical difficulty as well as success

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) is a new method for the curative treatment of early gastrointestinal neoplasms, which was developed in order to increase the en bloc and R0 resection rate, especially for lesions larger than 20 mm in diameter. Drawbacks of ESD include the fact that it is technically a substantially more difficult procedure and that it is associated with a higher perforation rate. A retrospective study was therefore carried out to analyze cases in relation to the procedure time and resection success, and these factors were correlated with the characteristics of the lesions.

PATIENTS AND METHODS

From January 2002 to November 2005, 196 lesions in 185 patients with early gastric cancer were treated using ESD in our hospital. The rates of curative en bloc resection, the incidence of perforation, and the procedure times were analyzed in relation to lesion size (small, 20 mm or less in diameter; large, over 20 mm), location (upper, middle, or lower third of the stomach) and the presence or absence of ulceration.

RESULTS

The rate of curative en bloc resection was 84 % (93 % of the lesions overall were resected in one piece), with a perforation rate of 6.1 % (all perforations were managed endoscopically) and a mean procedure time of 68 min. The rate of curative en bloc resection differed significantly depending on the location of the lesion (upper vs. middle vs. lower, 74 % vs. 77 % vs. 91 %; P < 0.05), as well as on the size of the lesion (> 20 mm vs. 20 mm or less, 59 % vs. 89 %; P < 0.0001). There were also significant differences in the mean procedure times in relation to the location of the lesion (upper vs. middle vs. lower, 105 min vs. 81 min vs. 45 min; P < 0.0001) and the size of the lesion (> 20 mm vs. 20 mm or less, 124 min vs. 55 min; P < 0.0001), as well as the presence of ulceration (positive vs. negative, 97 min vs. 65 min; P < 0.05). With regard to perforation rates, significant differences were also observed in relation to the location of the lesion (upper vs. middle vs. lower, 22.6 % vs. 2.8 % vs. 3.2 %; P < 0.0005) and size of the lesion (> 20 mm vs. 20 mm or less, 16.2 % vs. 3.8 %; P < 0.005). No local recurrences of curatively resected lesions (n = 119) were observed after a follow-up period of 1 year.

CONCLUSIONS

The difficulty of ESD depends on the location and size of the lesion, as well as on the presence of ulceration. We would recommend that trainees should begin by carrying out ESD on lesions with a diameter of less than 20 mm without ulceration that are located in the lower third of the stomach.

Effect of CYP2C19 polymorphism on the safety and efficacy of omeprazole in Japanese patients with recurrent reflux oesophagitis

BACKGROUND

The polymorphic enzyme cytochrome P450 2C19 affects omeprazole metabolism. This influence on metabolism might affect serum gastrin levels, and safety, during long-term treatment of reflux oesophagitis.

AIM

To examine the relationship between cytochrome P450 2C19 genotype and the safety profile of long-term omeprazole treatment.

METHODS

A total of 119 Japanese patients with recurrent reflux oesophagitis underwent cytochrome P450 2C19 genotyping prior to receiving daily omeprazole 10 mg or 20 mg for 6-12 months, during which adverse event frequency, serum gastrin levels and endoscopic findings were monitored.

RESULTS

The incidences of adverse events, serious adverse events and adverse events leading to withdrawal did not differ between homozygous extensive metabolizer (n = 46), heterozygous extensive metabolizer (n = 53) or poor metabolizer (n = 20) groups. In all genotype groups, serum gastrin increased during the first 3 months of dosing but stabilized thereafter. No significant differences were seen either in the rate of reflux oesophagitis healing or symptom improvement among genotype groups.

CONCLUSIONS

Long-term treatment with omeprazole was well-tolerated in Japanese patients, irrespective of their cytochrome P450 2C19 metabolic genotype, indicating that dose adjustment depending on metabolic genotype is not required during treatment with omeprazole.

Living-Related Small Bowel Transplantation: Two Cases Experiences

We have recently performed living-related small bowel transplantation for 2 patients. The first patient was a 14-year-old boy with total parenteral nutrition (TPN)-dependent short-bowel syndrome associated with hypoganglionosis of the entire intestine. He received a bowel graft from his 43-year-old mother. The second patient was a 27-year-old woman, who had massive enterectomy due to volvulus and developed vitamin deficiencies and severe metabolic disorders as a result of long-term TPN. She underwent living-related bowel transplantation from her 57-year-old mother. Blood types were ABO identical, cytotoxic cross matches were negative, and cytomegalovirus statuses were positive-to-positive in both cases. Up to one third of the donor bowel was harvested from the donor distal ileum more than 30 cm away from the ileocecal valve. The graft vessels were connected to infrarenal aorta, and inferior vena cava. The immunosuppressive regimen consisted of daclizumab, tacrolimus, and steroid. The graft surveillance was accomplished using zoom endoscopy and mucosal biopsy. The first patient developed progressive acute cellular rejection (ACR) on the 9th postoperative day (POD)-9 requiring OKT-3 therapy, which was effective. Two months after transplantation, he was weaned from TPN, tolerating oral intake with a fully functioning graft. The second patient experienced no episode of ACR and was weaned off TPN on POD-29 with a functioning graft. Her metabolic disorder dramatically improved after bowel transplantation. Both donors had no complication and were discharged from the hospital on POD-10. Living-related bowel transplantation is an extreme option of treatment for patients with short-bowel syndrome.

[Extrapleural pneumonectomy for malignant pleural mesothelioma]

Standard treatment for malignant pleural mesothelioma (MPM) has not been proved yet. However, it has been recognized that extrapleural pneumonectomy (EPP) is a treatment of choice for epithelial MPM when combined with adjuvant therapies though EPP may frequently cause fetal complications. We report 5 cases of MPM with EPP, including 1 with good prognosis. Sixteen patients with MPM were admitted to our hospital between 1988 and 2003. Five patients underwent EPP, among which 4 were male and 1 female with ages from 46 to 61 years old. Histologically, 3 of them were epithelial and 2 were biphasic. Those with biphasic experienced acute respiratory failure and empyema, and died 81 days and 8 months after the surgery respectively. Among those with epithelial MPM, 2 are alive with no recurrence at 129 and 29 months after the surgery, and the other, followed by postoperative radiotherapy, died at 12 months. More cases with EPP or randomized controlled trials regarding EPP are necessary to evaluate efficacy of EPP for MPM.

Effect of injection volume on the pharmacokinetics of oil particles and incorporated menatetrenone after intravenous injection as O/W lipid emulsions in rats

Oil-in-water lipid emulsions are promising drug carriers for lipophilic drugs, however, the pharmacokinetics after entering the circulation should be clarified at clinical injection volume in order to utilize them in a clinical situation. In the present study, the standard lipid emulsions, consisting of soybean oil, egg yolk phosphatides and menatetrenone with diameters of about 150 nm, were prepared using a microfluidizer system. The pharmacokinetics of menatetrenone and the oil particles after intravenous injection as standard lipid emulsions at various injection volumes, from the clinical injection volume (0.1 ml/kg) to the experimental injection volume (3.0 ml/kg), were examined in rats. The plasma concentrations of menatetrenone and the oil particles were similar after administration, showing that menatetrenone was not released even after entering the circulation. Menatetrenone was delivered to the liver and spleen at the clinical injection volume, and more menatetrenone was delivered to the liver at clinical injection volume compared with the experimental volume. Moreover, additional information on injection volume-dependency was also obtained from these findings. These results at various injection volumes suggested that the standard lipid emulsions can be utilized as a useful drug delivery system at the clinical injection volume, especially for liver and spleen targeting.

A case of non-functioning pituitary adenoma with Cushing's syndrome upon recurrence

A 49-year-old woman presented with left visual disturbance. No signs of Cushing's disease were evident. Basal levels of serum cortisol and plasma adrenocorticotropic hormone (ACTH) were 16.8 microg/dL and 66.0 pg/mL, respectively. MRI demonstrated an irregularly shaped large pituitary tumor, and the patient then underwent transsphenoidal surgery. By light microscopy the tumor represented a chromophobic adenoma with a few of the adenoma cells showing immunoreactivity for ACTH. On the basis of clinical and light microscopic examinations, the diagnosis of silent corticotroph adenoma was made. Electron microscopy, however, demonstrated the honeycomb Golgi complex that has been reported as a typical finding of gonadotroph adenomas. MRI taken 7 months after the first operation revealed adenoma regrowth. Transcranial surgery was performed, and histology demonstrated a chromophobic pituitary adenoma with most cells immunopositive for ACTH. She was treated with gamma knife postoperatively. Three months later, MRI revealed remarkable shrinkage of the adenoma, but she developed typical signs and symptoms of Cushing's disease. Thus, the hormone immunostaining and biological activity of pituitary adenomas may change with time.

MR assessment of meniscal movement during knee flexion: correlation with the severity of cartilage abnormality in the femorotibial joint

PURPOSE

The purpose of this study was to assess the degree of meniscal movement during knee flexion on MR images and to correlate it with the severity of cartilage damage in the femorotibial joint.

METHOD

Sagittal MR images were obtained at extension and 45 degrees of flexion in 35 knees. A shortening ratio in the distance between the anterior and posterior horns at 0-45 degrees of knee flexion was calculated in each meniscus and was correlated with the degree of cartilage abnormality in the femorotibial joint.

RESULTS

The shortening ratio of the meniscus was reduced in knees with cartilage abnormality in the femorotibial joint. The shortening ratio of the medial meniscus was inversely correlated with the degree of cartilage abnormality in the medial femoral condyle and with that in the medial tibial plateau.

CONCLUSION

Restricted shortening ratio of the meniscus may be related to cartilage damage in the femorotibial joint.

The release of noradrenaline in the locus coeruleus and prefrontal cortex studied with dual-probe microdialysis

The present study was undertaken to investigate and compare the properties of noradrenaline release in the locus coeruleus (LC) and prefrontal cortex (PFC). For that aim the dual-probe microdialysis technique was applied for simultaneous detection of noradrenaline levels in the LC and PFC in conscious rats. Calcium omission in the LC decreased noradrenaline levels in the LC, but increased its levels in the PFC. Novelty increased noradrenaline levels in both structures. Infusion of the alpha(2)-adrenoceptor agonist clonidine decreased extracellular noradrenaline in the LC as well as in the PFC. Infusion of the alpha(2A)-adrenoceptor antagonist BRL44408, or the alpha(1)-adrenoceptor agonist cirazoline into the LC or PFC caused a similar dose-dependent increase in both structures. When BRL44408 or cirazoline were infused into the LC, few effects were seen in the PFC. Infusion of the 5-HT(1A)-receptor agonist flesinoxan into the LC or the PFC decreased the release of noradrenaline in both structures. When flesinoxan was infused into the LC, no effects were seen in the PFC. When the GABA(A) antagonist bicuculline was applied to the LC, noradrenaline increased in the LC as well as in the PFC. It is concluded that the release of noradrenaline from somatodendritic sites and nerve terminals responded in a similar manner to presynaptic receptor modulation. The possible existence of dendritic noradrenaline release is discussed.

Dural congestion accompanying meningioma invasion into vessels: the dural tail sign

Our purpose was to verify the histological appearance of the dural tail accompanying meningiomas on MRI. We studied seven patients such a dural tale. We examined the point of attachment of the tumour and the adjacent dura mater histologically. In all patients, rich vascularity and dilated vessels were observed in the dura mater at the point of attachment of the tumour; tumour cells invaded the dura mater and vessels, packing the latter. In the adjacent dura mater, showing as a dural tail on MRI, there was tumour-cell invasion in only one patient. Vascular congestion around the vessels compacted by the tumour cells in the dura mater and dilated vessels were seen in all patients. We therefore suggest that the mechanism of the dural tail sign is as follows. First, tumour cells invade vessels and pack them at the point of tumour attachment. Then, vessel congestion is induced in the adjacent dura mater, as a result of which it enhances markedly, giving rise to the dural tail sign.