Aging reduces the numbers of hepatocytes synthesizing DNA in response to EGF and epinephrine

Primary cultures of hepatocytes were prepared from young (6 month) and old (24 month) Wistar rats and exposed to epinephrine or epidermal growth factor. Incorporation of [3H]thymidine into DNA was determined both radiochemically and autoradiographically. The numbers of responding cells and degree of response per cell were determined and the results confirmed by FACScan analysis. Such analyses clearly demonstrate a reduced number of hepatocytes capable of responding to the above stimuli in cultures obtained from old rats. Thus, changes in numbers of responding cells may be an important mechanism involved in reduced responsiveness of the aged liver to agents which stimulate DNA synthesis and cell division.

Morphogenesis and development of superficial spreading tumor of the colon and rectum

The aim of this study was to clarify the morphogenesis and mechanism of a wide intramucosal extension of a superficial spreading (epithelial) tumor (SST; defined as an epithelial tumor with wide intramucosal spreading involving a diameter of 30 mm or more) in the colon and rectum. For this purpose favorable sites, histological components, and histological growth patterns were compared between 95 cases of SST (16 adenomas and 79 carcinomas) and 2356 non-SST cases, which served as controls. The frequency of SST was significantly higher in the cecum and rectum, and lower in the sigmoid colon when compared to the locations of the control. Among the SST cases, 82.3% of superficial spreading carcinoma (SSC) had an adenomatous component and 96.2% had a cytologically low-grade carcinoma (CAL). In intramucosal SSC, the adenomatous and/or CAL component was predominant, and the proportion of high-grade carcinoma (CAH) was significantly smaller in intramucosal SSC in comparison with the control group. In the mucosal spreading area of SST, 78.9% were tubulovillous in histological type and 86.3% showed a replacing growth pattern. These results indicate that an SST initially develops as an adenoma in at least 85.3% of cases and CAL in 14.7% cases at most; spreads superficially in the mucosa by a replacing growth mechanism that forms a tubulovillous and villous structure; and is affected by intestinal peristalsis less than non-SST.

[Quantitative measurements of regional cerebral blood flow using technetium-99m-L,L-ECD SPECT activated with acetazolamide: fundamental study of measurement's accuracy, comparison with 123I-IMP ARG method]

We measured regional cerebral blood flow before and after acetazolamide administration using a serial noninvasive method with 99mTc-ECD developed by Matsuda and Takeuchi et al., and compared the accuracy of measured values with those obtained by the conventional 123I-IMP ARG method. When the regional cerebral blood flow was measured for 80 brain regions in 5 subjects without scatter correction, a differential of 0.5 +/- 8.4% was obtained between values measured before and after physiological saline administration as a placebo. A differential of -0.2 +/- 12.6% was obtained when the same regions were measured with scatter correction. These findings indicated that placebo administration did not affect measured values, regardless of whether scatter correction was performed. When 64 regions in 4 subjects at rest were measured on two successive days, a differential of -1.1 +/- 9.0% was obtained between the values measured on the two days. A differential of -4.0 +/- 11.7% was obtained for the same regions following acetazolamide administration. These findings showed that measurements were reproducible both when subjects were at rest and when they were administered acetazolamide. The above two methods were used for measurement of 80 brain regions in the same 5 subjects for comparison. Measurements of subjects at rest and with acetazolamide administration were performed on separate days. The regression line y = 0.99x + 1.47, r = 0.80, was obtained for the subjects at rest, and y = 0.86x + 7.76, with r = 0.76, for the subjects following acetazolamide administration. These findings demonstrated a good correlation between the values obtained using the two methods. The values obtained using the method of Matsuda and Takeuchi et al., before and after acetazolamide administration were thus consistent with those reported previously using the conventional method, and the former method proved to be both simple and reliable.

Direct extracranial-intracranial bypass for children with moyamoya disease

To improve cerebral hypoperfusion in the ischemic type of Moyamoya disease, we have applied superficial temporal artery-middle cerebral artery (STA-MCA) double anastomoses in combination with encephalo-myo-synangiosis (EMS) for 19 hemispheres of 10 children (age from 5 to 11 years at surgery). Two branches of the STA were anastomosed to the two cortical arteries which were selected in the watershed area of the cerebral hemisphere estimated as a hypoperfusion area on the preoperative angiograms. Before surgery transient ischemic attacks (TIAs) developed from every month to every 6 months in association with hyperventilation or sobbing. No perioperative completed stroke or wound complications was observed, although single TIA developed in four patients within 1 month after surgery. Postoperative angiogram demonstrated that, not only the preoperative watershed area, but also the most of the middle cerebral artery territory was oppacified via the 2 branches of the STA in all 19 hemispheres. In a mean follow-up period of 4 years, no ischemic episode was induced by hyperventilation, and there was no mental or neurological deterioration. STA-MCA double anastomoses, to the cerebral watershed area, in combination with EMS are safe and effective even for younger children with Moyamoya disease.

Parathyroid hormone-related protein upregulates interleukin-1beta-induced nitric oxide synthesis

The effect of parathyroid hormone-related protein on interleukin-1beta-induced nitric oxide production was studied in rat vascular smooth muscle cells. Interleukin-1beta time- and dose-dependently enhanced the production of nitrite, a stable metabolite of nitric oxide. Parathyroid hormone-related protein(1-34) alone up to 10(-7) mol/L had no obvious effect, but significantly increased the cytokine-induced nitrite production. RNA analysis revealed that the synergistic effect of parathyroid hormone-related protein(1-34) resulted from a potentiation of the expression of inducible nitric oxide synthase and GTP-cyclohydrolase I, the rate-limiting enzyme in the synthesis of tetrahydrobiopterin, which is a cofactor of nitric oxide synthase. The increased nitric oxide release induced by interleukin-1beta or interleukin-1beta with parathyroid hormone-related protein(1-34) was completely inhibited by coincubation with 3x10(-3) mol/L N(G)-monomethyl-L-arginine, a competitive inhibitor of nitric oxide synthase, or with 10(-3) mol/L 2,4-diamino-6-hydroxypyrimidine, an inhibitor of GTP-cyclohydrolase I. Endothelin-1 potentiated interleukin-1beta induction of nitric oxide, which might be mediated by endogenous parathyroid hormone-related protein. Neutralization of exogenous or endogenous parathyroid hormone-related protein with antibody attenuated the synergistic effect of parathyroid hormone-related protein, but did not affect interleukin-1beta induction of nitric oxide. These results suggest that locally produced parathyroid hormone-related protein acts as a synergistic regulator upregulating interleukin-1beta-induced nitric oxide synthesis in the cardiovascular system, and thereby may affect vascular tone and/or vascular remodeling after vascular injury in some pathological processes such as atherosclerosis and hypertension.

Interleukin-6 production in human fibroblasts derived from periodontal tissues is differentially regulated by cytokines and a glucocorticoid

Interleukin-6 (IL-6) is thought to be a major mediator of the host's defense against infection, and it regulates immune responses in inflamed tissue. In this study, we investigated the regulation of IL-6 production in human gingival fibroblasts (HGF) and human periodontal ligament fibroblasts (HPLF). Pro-inflammatory cytokines including interleukin (IL)-1 alpha, IL-1 beta and tumor necrosis factor (TNF)-alpha stimulated IL-6 production in HGF and HPLF in a time- and dose-dependent manner. This IL-1 alpha, IL-1 beta, or TNF-alpha-induced IL-6 production was enhanced, but the cAMP accumulation they induced was inhibited by the addition of indomethacin. This result suggests that endogenous prostaglandin E2 (PGE2) partially inhibits IL-1 or TNF-alpha-induced IL-6 production and that the enhancement of IL-6 production by IL-1 or TNF-alpha may not be caused through endogenous PGE2-induced cAMP-dependent pathway. Dexamethasone (DEX), a glucocorticoid which is a inhibitor of nuclear factor kappa B (NF-kappa B activation, markedly inhibited IL-1 (alpha or beta) or TNF-alpha-induced IL-6 production; so this production may be partially mediated through NF-kappa B. IL-1 (alpha or beta) and TNF-alpha enhanced IL-6 production synergistically. IL-6 production in HGF or HPLF stimulated with IL-1 beta was augmented by the addition of interferon (IFN)-gamma, but was slightly suppressed by the addition of IL-4. Endogenous IL-6 enhanced IL-1 (alpha or beta)-induced IL-6 production in the presence of IL-6 soluble receptor (IL-6sR). Accordingly, in inflamed periodontal tissues, gingival fibroblasts and periodontal ligament fibroblasts stimulated with pro-inflammatory cytokines such as IL-1 or TNF-alpha, may produce IL-6, and this production can be differentially modulated by endogenous PGE2, IL-6sR, T cell-derived cytokines such as IFN-gamma or IL-4, and glucocorticoids.

Porphyromonas gingivalis lipopolysaccharide-stimulated bone resorption via CD14 is inhibited by broad-spectrum antibiotics

In the present study, we examined mechanisms of Porphyromonas gingivalis lipopolysaccharide (P-LPS)-stimulated bone resorption via CD14, one of the lipopolysaccharide (LPS) receptors, and also assessed the inhibitory action of several kinds of antibiotics on the LPS-induced stimulation. First, we observed by using mouse embryonic calvarial cells that P-LPS stimulated bone resorption through the action of endogenous interleukin-1beta (IL-1beta) and interleukin-6 (IL-6) via CD14 because (i) P-LPS-stimulated expression of IL-1beta and IL-6 genes in calvarial cells was inhibited by an anti-mouse CD14 antibody, (ii) stimulated bone resorption was markedly inhibited by both IL-1beta and IL-6 antibodies, and (iii) P-LPS-stimulated bone resorption was clearly neutralized by an anti-mouse CD14 antibody. Next, we examined the effects of several kinds of antibiotics on P-LPS-stimulated bone resorption via CD14. Two of them, chloramphenicol and erythromycin, inhibited P-LPS-stimulated bone resorption in a dose-dependent manner. In an additional experiment, we observed that chloramphenicol clearly inhibited P-LPS-stimulated expression of the CD14, IL-1beta, and IL-6 genes in calvarial cells. These results suggest that chloramphenicol might be a useful antibiotic as an anti-inflammatory agent against P-LPS-stimulated periodontal destruction occurring via CD14 in periodontal disease.

Long-term palliative treatment of hepatocellular carcinoma extending into the portal vein and bile duct by chemoembolization and metallic stenting

We present a patient with hepatocellular carcinoma accompanied by portal vein and bile duct tumor thrombi. The patient was treated with a spiral Z-stent covered by a polyethylene sheet placed in the bile duct, a Wallstent placed in the portal vein, chemoembolization, and external radiation therapy. The patient is alive with patency of both endoprostheses 18 months later.

Laparoscopic splenectomy for splenic hamartoma

Advances in imaging techniques have made pre-operative diagnosis of splenic tumors possible. A case of successful laparoscopic splenectomy for splenic hamartoma is described here and the indications of this technique are discussed.

Interleukin-2 modulates the responsiveness to angiotensin II in cultured vascular smooth muscle cells

Preincubation with interleukin-2 (IL-2), a T cell-derived cytokine, enhanced the increase in intracellular Ca2+ ([Ca2+]i) induced by angiotensin II (AII) in vascular smooth muscle cells (VSMC). IL-2 itself did not affect the basal [Ca2+]i level or the maximal response of [Ca2+]i increase induced by AII. Furthermore, IL-2-induced enhancement was not observed in the absence of extracellular Ca2+, suggesting that IL-2 enhances Ca2+ influx induced by AII. IL-2 also enhanced the stimulation of DNA synthesis induced by AII, although IL-2 alone did not stimulate DNA synthesis. Genistein, an inhibitor of protein tyrosine kinases, significantly inhibited IL-2-induced enhancement of both Ca2+ influx and DNA synthesis induced by AII. A neutralizing antibody against heparin-binding epidermal growth factor-like growth factor (HB-EGF) partially inhibited IL-2-induced enhancement of DNA synthesis induced by AII. These findings suggest that autocrine HB-EGF is partially involved in the mechanism of IL-2-induced enhancement of DNA synthesis. On the other hand IL-2 stimulated both glycosaminoglycan (GAG) and prostacyclin syntheses and enhanced the stimulation of both GAG and prostacyclin syntheses induced by AII. Therefore, IL-2 may play important roles in the pathogenesis of atherosclerosis and vascular disease by modulating the responsiveness to AII in VSMC.

NF-kappaB inhibitors stimulate apoptosis of rabbit mature osteoclasts and inhibit bone resorption by these cells

Interesting, recent studies have suggested a possibility that transcriptional factor NF-kappaB may play a functional role in the survival of mouse osteoclasts. However, it has not been known whether NF-kappaB is involved in apoptosis of and bone resorption by mature osteoclasts. Thus, using NF-kappaB inhibitors, we examined the functional role of NF-kappaB in the induction of apoptosis in rabbit mature osteoclasts. PDTC, a potent inhibitor of NF-kappaB, stimulated markedly apoptosis of the osteoclasts and inhibited bone resorption by these cells. These effects also was observed when three other inhibitors of NF-kappaB were used. And a gel mobility shift assay showed that PDTC also inhibited NF-kappaB binding to its consensus sequence in the cells. These results suggest a regulatory role for NF-kappaB in apoptosis in and bone resorption by rabbit mature osteoclasts.

[Cerebral infarction and asymptomatic arteriosclerosis obliterans in the elderly]

We examined the associations between cerebral infarction (CI), asymptomatic arteriosclerosis obliterans (ASO), and known risk factors for these diseases. The subjects were 67 elderly patients (11 men and 56 women, mean +/- SD age of 79.6 +/- 8.5 years). in 44 patients CI was diagnosed by CT scan; 23 were classified as having cortical infarction and 21 as having lacunar infarction. In 41 patients asymptomatic ASO was diagnosed by an ankle-pressure index (API) of less than 0.9. To identify risk factors for these diseases, we examined the association among these diseases and hypertension (blood pressure > or = 140/90 mmHg), hypercholesterolemia (total cholesterol concentration > or = 220 mg/dl), hypertriglyceridemia (triglyceride concentration > or = 150 mg/dl), low HDL-cholesterolemia (HDL-C concentration < 40 mg/dl), high LDL-cholesterolemia (LDL-C concentration > or = 150 mg/dl), and glucose intolerance (fasting blood sugar concentration > or = 110 mg/dl). The incidence of asymptomatic ASO in the subjects with CI was significantly higher than that in the subjects without CI (chi 2 test; p < 0.05, odds ratio 6.4), including cortical infarction (p < 0.05, odds ratio 8.9) and lacunar infarction (p < 0.05, odds ratio 3.8). Patients with lacunar infarction were more likely to have hypertension than were controls (p < 0.05). Cortical infarction was not associated with these risk factors. Both low HDL-C and high LDL-G were more common in patients with asymptomatic ASO than patients without asymptomatic ASO (p < 0.05). These results indicate that CI and asymptomatic ASO are strongly associated in the elderly, especially in subjects with cortical infarction, and that aging itself contributes to cortical infarction.

LIMB SALVAGE USING DISTRACTION OSTEOGENESIS

We report the results of distraction osteogenesis (callotasis) for the reconstruction of extensive defects after the excision of skeletal tumours in the limbs. Bone transport was performed in ten patients (five osteosarcomas and five giant-cell tumours), shortening-distraction in three (two osteosarcomas and one Ewing’s sarcoma), and distraction osteogenesis combined with an intramedullary nail to reduce the time of external fixation in six (three osteosarcomas, two chondro-sarcomas, and one malignant fibrous histiocytoma).

The mean length of the defects after excision of the lesion was 8.4 cm. The mean external fixation index was 39.5 days/cm for the group treated by bone transport, 34.1 days/cm for the shortening-distraction group, and 24.0 days/cm for the group treated by distraction and an intramedullary nail. Functional evaluation gave excellent results in 12 patients, good in five and fair in two. There were ten complications in 19 patients, all of which were successfully treated.

We also classified reconstruction using distraction osteogenesis into five types based on the location of the defects after resection of the tumour: type 1, diaphyseal; type 2, metaphyseal; type 3, epiphyseal; type 4, subarticular reconstruction; and type 5, arthrodesis.

Our results suggest that reconstruction using distraction osteogenesis provides bone which will develop sufficient biomechanical strength and durability. It is beneficial in patients with an expectation of long-term survival and in growing children.

Sarcomatoid hepatocellular carcinoma with osteoclast-like giant cells: case report and immunohistochemical observations

Hepatocellular carcinoma (HCC) with osteoclast-like giant cells (OGC) developed in the cirrhotic liver of a 42-year-old male. Serum protein induced by vitamin K absence or antagonist II was elevated preoperatively. The patient died of the disease on the 28th postoperative day. Histologically, the tumor consisted of OGC and mononuclear cells (MC). The OGC were characterized by benign-appearing nuclei, whereas the MC had atypical nuclei with a considerable number of mitoses. A vaguely trabecular pattern was observed in the focal area of the tumor, but no evidence of overt HCC was found. Immunohistochemical analysis revealed that both OGC and MC were diffusely positive for histiocytic and mesenchymal markers. Some MC were focally positive for cytokeratins 7, 8 and 19, and for albumin. Our clinical, histological and immunohistochemical findings suggest that the MC were derived from hepatocytes, with some mesenchymal features, but the OGC were non-neoplastic and reactive histiocytes.

Preoperative assessment of advanced gastric carcinoma using computed tomography

OBJECTIVES

The role of computed tomography (CT) for the staging of gastric carcinoma is controversial. The purpose of this study was to evaluate the utility of CT in assessing the perigastric spread of advanced gastric carcinoma.

METHODS

The study included 56 patients who underwent dynamic CT and laparotomy for the treatment of node-positive gastric adenocarcinoma. Preoperative CT findings were compared with surgical findings, and diagnostic accuracy was estimated.

RESULTS

Sensitivity, specificity, and accuracy of preoperative CT in determining the perigastric tumor spreads were 33, 97, and 73% in pancreatic invasion, 36, 97, and 70% in level III lymph node involvement, and 89, 98, and 96% in liver metastasis. Peritoneal dissemination was not detected in 15 of 56 patients (27%), and stage IV disease was not diagnosed correctly in 18 of 40 patients (45%).

CONCLUSIONS

Radiologists and surgeons must remember that pancreatic invasion, extended lymph node metastasis, and peritoneal dissemination are sometimes overlooked in CT examination in patients with advanced gastric carcinoma.

Limb salvage using distraction osteogenesis. A classification of the technique

We report the results of distraction osteogenesis (callotasis) for the reconstruction of extensive defects after the excision of skeletal tumours in the limbs. Bone transport was performed in ten patients (five osteosarcomas and five giant-cell tumours), shortening-distraction in three (two osteosarcomas and one Ewing's sarcoma), and distraction osteogenesis combined with an intramedullary nail to reduce the time of external fixation in six (three osteosarcomas, two chondrosarcomas, and one malignant fibrous histiocytoma). The mean length of the defects after excision of the lesion was 8.4 cm. The mean external fixation index was 39.5 days/cm for the group treated by bone transport, 34.1 days/cm for the shortening-distraction group, and 24.0 days/cm for the group treated by distraction and an intramedullary nail. Functional evaluation gave excellent results in 12 patients, good in five and fair in two. There were ten complications in 19 patients, all of which were successfully treated. We also classified reconstruction using distraction osteogenesis into five types based on the location of the defects after resection of the tumour: type 1, diaphyseal; type 2, metaphyseal; type 3, epiphyseal; type 4, subarticular reconstruction; and type 5, arthrodesis. Our results suggest that reconstruction using distraction osteogenesis provides bone which will develop sufficient biomechanical strength and durability. It is beneficial in patients with an expectation of long-term survival and in growing children.

Prognostic factors of node-negative gastric carcinoma: univariate and multivariate analyses

BACKGROUND

The presence or absence of lymph node metastasis closely correlates with survival of patients with gastric carcinoma. Although prognostic significance of the number and level of lymph node metastasis has been clarified, clinicopathologic features and prognostic indicators of node-negative gastric carcinoma have not yet been studied.

STUDY DESIGN

The records of 435 patients who underwent curative D2 or D3 gastrectomy for gastric carcinoma between 1977 and 1987 were analyzed retrospectively. Clinicopathologic data of 252 patients having no lymph node metastasis were compared with those of 183 patients with lymph node metastasis. Prognostic factors were investigated by univariate and multivariate analyses.

RESULTS

Compared with node-positive cases, node-negative cases were characterized by frequent location in the lower two thirds of the stomach (85 percent), tumor size less than 4 cm (54 percent), grossly superficial type (69 percent), and tumor invasion not beyond the muscularis propria (77 percent). The 10-year-survival rate for patients with node-negative tumors was 93.4 percent. Multivariate analysis demonstrated that depth of wall invasion and age of patient were independent prognostic factors.

CONCLUSIONS

Node-negative gastric carcinoma is associated with a favorable outcome because of small progression of the disease. The depth of wall invasion and patient age were the most important prognostic factors.

MR cholangiopancreatography and MR urography: improved enhancement with a negative oral contrast agent

At magnetic resonance (MR) cholangiopancreatography and MR urography with an oral negative contrast agent, low signal intensity was produced in phantoms. In 20 patients suspected of having biliary tract and pancreatic diseases and in 20 healthy volunteers, the signal intensity in the gastrointestinal tract was almost completely eliminated with the negative contrast agent. Differences in image quality between pre- and postcontrast images were statistically significant.

Repeated injection sclerotherapy is preferable to combined therapy with variceal ligation to avoid recurrence of esophageal varices:--a prospective randomized trial

BACKGROUND/AIMS

The aim of this prospective randomized study is to investigate the safety, efficacy, complications and recurrence of varices after repeated endoscopic injection sclerotherapy (EIS), and combined therapy of endoscopic variceal ligation (EVL) and repeated EIS, for the treatment of esophageal varices.

MATERIAL AND METHODS

Sixty-one consecutively treated cirrhotic patients were examined. Thirty patients were placed randomly in the EIS group and the other 31 in the EVL+EIS group. For the EIS group, EIS was repeated at weekly intervals using 5% ethanol- amine oleate (EO) until all the varices had been eradicated. In the EVL+EIS group, EVL was done at the initial session, then EIS was repeated at weekly intervals from one week after EVL.

RESULTS

There was no significant difference between the EIS and EVL+EIS groups with regard to the rate of eradication (80.0% vs 74.2%), the total number of treatment (4.1 +/- 0.8 sessions of EIS vs EVL and 3.0 +/- 0.5 sessions of EIS) and hospitalization time (4.9 +/- 1.6 vs 4.4 +/- 1.0 weeks). The total volume of EO used for the EVL+EIS group was significantly less than that for the EIS group (26.3 +/- 8.3 vs 47.1 +/- 11.6 ml, p < 0.01) and the incidence of minor complications at the initial treatment in the EVL+EIS group was significantly (p < 0.01) lower than that in the EIS group. Follow-up endoscopy showed that the rate of attaining circumferential ulceration and the following fibrotic scarring in the EVL+EIS group was significantly lower than that in the EIS group (21.7% vs 91.7%, p < 0.01) and that the incidence of variceal recurrence was significantly higher in the EVL+EIS group than in the EIS group (39.1% vs 8.3%, p < 0.05) over a median follow-up of 12.3 months.

CONCLUSION

The combined therapy of EVL and repeated EIS seems favorable from the viewpoint of fewer complications, but repeated EIS is preferable to combined therapy to avoid recurrence of the esophageal varices.

Porphyromonas gingivalis fimbria-stimulated bone resorption is inhibited through binding of the fimbriae to fibronectin

Our most recent study demonstrated that fibronectin is one of the Porphyromonas gingivalis fimbria-binding proteins. In this present study, we demonstrate with mouse embryonic calvarial cells that P. gingivalis fimbria-stimulated bone resorption is inhibited by human fibronectin. The fibronectin inhibition was dose and culture time dependent and was completely neutralized by antifibronectin antibody. The inhibitory action of fibronectin depended on fimbrial interaction with the heparin-binding and cell-attachment domains in the fibronectin structure.

Clinical and angiographic assessments and treatment of patients with recurrent varices after transabdominal transection of the esophagus

BACKGROUND/AIMS

Risk factors regarding the recurrence of esophageal varices and were researched preoperative clinical and angiographic findings in patients with variceal recurrence and/or rebleeding after transabdominal esophageal transection were analyzed.

MATERIALS AND METHODS

Clinical and angiographic assessments of recurrence of varices after transabdominal esophageal transection were made on 55 patients with portal hypertension. In all these patients, postoperative endoscopy was performed at 3-6 monthly intervals.

RESULTS

Varices recurred in 13 patients and 4 patients re-bled during the 5-106 month follow up. There was a significant increase in the rate of recurrence in patients with a history of hematemesis, and in those with a higher grade of development of cephalad collateral vessels in the lesser splanchnic area, as seen on the preoperative portography. Eight of the 13 patients were then effectively treated by endoscopic injection sclerotherapy.

CONCLUSIONS

Despite transabdominal transection of the esophagus, varices may well recur if the patient has had a history of hematemesis and a higher grade of development of cephalad collateral vessels. In such cases endoscopic injection sclerotherapy should be done.

ICG clearance in assessing cirrhotic patients with hepatocellular carcinoma for major hepatic resection

Objective: To deWne the safety of major hepatectomy for hepatocellular carcinoma (HCC) associated with cirrhosis and the selection criteria for surgery in terms of hospital mortality.

Design: Major hepatectomy for HCC in the presence of cirrhosis is considered to be contraindicated by many surgeons because the reported mortality rate is high (26% to 50%). Previous workers recommended that only selected patients with Child's A status or indocyanine green (ICG) retention at 15 minutes of less than 10% undergo major hepatectomy. A survery was made, therefore, of our patients with HCC and cirrhosis undergoing major hepatectomy between 1989 and 1994.

Setting: A tertiary referral center.

Patients: The preoperative, intraoperative, and post-operative data of 54 patients with cirrhosis who had major hepatectomy were compared with those of 25 patients with underlying chronic active hepatitis and 22 patients with normal livers undergoing major hepatectomy for HCC. The data had been prospectively collected.

Intervention: Major hepatectomy, defined as resection of two or more liver segments by Goldsmith and Woodburn nomenclature, was performed on all the patients. Main Outcome Measure: Hospital mortality, which was defined as death within the same hospital admission for the hepatectomy.

Results: Preoperative liver function in patients with cirrhosis was worse than in those with normal livers. The intraoperative blood loss was also higher (P=.01), but for patients with cirrhosis, chronic active hepatitis, and normal livers, the hospital mortality rates (13%, 16%, and 14%, respectively) were similar. The hospital mortality rate for patients with cirrhosis in the last 2 years of the study was only 5%. Patients with cirrhosis could tolerate up to 10 L of blood loss and survive the major hepatectomy. By discriminant analysis, an ICG retention of 14% at 15 minutes was cutoff level that could maximally separate the patients with cirrhosis with and without mortality.

Conclusion: Major hepatectomy for HCC in the presence of cirrhosis is associated with a mortality rate that is not different from the rate for patients with normal livers. An ICG retention of 14% at 15 minutes would serve as a better selection criterion than the 10% previously used.

The significance of esophageal variceal pressure in patients with cirrhosis

We measured the portal circulatory hemodynamic parameters in 10 cirrhotic patients with portal hypertension and esophageal varices to determine the significance of esophageal variceal pressure. In 4 patients (group I), the temporary portal vein occlusion produced significant elevations in both the esophageal variceal pressure and the portal venous pressure. The results of the portal circulatory hemodynamic assessment in this group were consistent with the predominance of the backward flow mechanism. In the remaining 6 patients (group II), however, portal vein clamping resulted in a slightly increased esophageal variceal pressure with an enormous increase in the portal pressure. The forward flow mechanism thus appeared to be predominant in group II. In other words, the results of the pressure measurements were consistent with the functional separation of the hemodynamics in the esophageal varices and portal trunk in group II and the functional hemodynamic continuity in group I. This functional separation between the esophageal varices and the portal trunk in group II might therefore have resulted from the increased blood flow in the lesser splanchnic region.

Transcriptional regulation by transforming growth factor beta of the expression of retinoic acid and retinoid X receptor genes in osteoblastic cells is mediated through AP-1

We now report that transforming growth factor beta1 (TGF-beta1), a potent regulatory cytokine of bone remodeling, is a powerful stimulator for gene expression of retinoic acid receptors (RARs) and retinoid X receptors (RXRs) in osteoblastic MC3T3-E1 cells. TGF-beta1 transcriptionally stimulated the expression of RARalpha, RARgamma, and RXRalpha genes, but did not do so for RARbeta, RXRbeta, and RXRgamma genes. We also observed that AP-1, a transcriptional factor, plays an important role in the signal pathway for expression of RARalpha, RARgamma, and RXRalpha genes stimulated by TGF-beta1 because stimulation of the expression of these genes in the cytokine-treated cells was markedly inhibited by a mixture of antisense c-fos and c-jun. A gel mobility shift assay demonstrated that TGF-beta1 is able to increase, in a dose-dependent manner, the binding of nuclear proteins to direct repeat 5, a consensus sequence with high affinity for RAR-RXR heterodimers. The mobility shift assay, using specific antibody for each receptor, showed that direct repeat 5-binding proteins may be RAR and RXR isoforms. The stimulated binding to direct repeat 5 was inhibited strongly by H-7, an inhibitor of serine/threonine kinase, and by curcumin, an inhibitor of AP-1. The present study suggests a novel pathway for TGF-beta1 action in osteoblastic cells via stimulation of RAR-RXR transcriptional activity in a ligand-dependent fashion.