Current characteristics and management of congenital esophageal stenosis: 40 consecutive cases from a multicenter study in the Kyushu area of Japan

PURPOSE

Congenital esophageal stenosis (CES) is rare, and the available clinical data are limited. We explored the current diagnosis, treatment and outcomes of CES.

METHODS

A questionnaire survey was performed using medical records at pediatric surgical centers in the Kyushu area.

RESULTS

Over 10 years, 40 patients (24 males) had CES. The incidence of associated anomalies was 52.5% (21/40), and that of esophageal atresia was 20.0% (8/40). The mean age at the diagnosis was 12.0 months (range, 1 day-8.8 years). Seven (17.5%) patients were diagnosed in the neonatal period. Ten (25.0%) developed CES due to tracheobronchial remnants, 27 (67.5%) due to fibromuscular stenosis (FMS) and 1 (2.5%) due to membranous stenosis + FMS. Thirty-six (90.0%) were treated by balloon dilatation (mean, 3 times; range, 1-20). Perforation at dilatation occurred in 7 (17.5%) patients, and all were diagnosed with FMS. Eighteen (45.0%) patients underwent radical operation (3 primary, 15 secondary to dilatation).

CONCLUSIONS

Our study clarified the characteristics and outcomes of CES, including neonatal diagnoses. CES occurred in 1 in every 33,000 births in the Kyushu area. Careful attention should be paid, even in cases of dilatation for FMS. CES requires long-term follow-up for symptom persistence after adequate and repeated treatment.

The novel preventive effect of Daikenchuto (TJ-100), a Japanese herbal drug, against neonatal necrotizing enterocolitis in rats

PURPOSE

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease of premature infants. Daikenchuto, a Japanese herbal drug, has several effects on the digestive system, so we investigated its preventive effects in a rat model of NEC.

METHODS

NEC was induced in newborn rats via asphyxia (100% N₂ for 90 s; every 4 h) + LPS (4 mg/kg/day [administered orally on days 0 and 1]). The effects of Daikenchuto were evaluated in four groups (control: 0 g/kg/day, I: 0.3 g/kg/day, II: 0.6 g/kg/day, and III: 1.0 g/kg/day). Daikenchuto was administered into the stomach through a microcatheter. The incidence and severity of NEC were pathologically assessed using the NEC grade in accordance with Dovorak's previous report. Cell positivity for inflammatory cytokine (IL-6) was also evaluated.

RESULTS

Daikenchuto reduced the incidence of NEC in control, Groups I, II, and III to 68.7, 30.0, 30.7, and 13.3%, respectively. High-dose Daikenchuto significantly improved the incidence of NEC, and the rate of IL-6 positive cells in group III was significantly lower than in the control group (p = 0.04).

CONCLUSION

We evaluated the effect of Daikenchuto against NEC and found that it reduced the incidence rate of NEC due to a decrease in the IL-6 production.

Nerve growth factor regulation and production by macrophages in osteoarthritic synovium

Nerve growth factor (NGF) functions to modulate osteoarthritis (OA)-associated pain. Although recent studies suggest that tumour necrosis factor (TNF)-α and interleukin (IL)-1β mediate NGF activity in human synovial fibroblasts, the regulation of NGF expression in human synovial macrophages remains unclear. Here, we examined the role of macrophages in the production and regulation of synovial (SYN) NGF in osteoarthritic knee joints by examining the mRNA expression of TNF-α and IL-1β in freshly isolated CD14-positive (macrophage-rich fraction) and CD14-negative cells (fibroblast-rich fraction) in synovial tissue from OA patients by quantitative polymerase chain reaction. We also examined the effects of IL-1β and TNF-α on NGF mRNA expression in cultured CD14-positive (macrophage-rich fraction) and CD14-negative cells (fibroblast-rich fraction). In addition, to examine the contribution of macrophages to NGF, TNF-α and IL-1β expression, we injected clodronate liposomes systemically into STR/Ort mice, an osteoarthritis animal model, to deplete macrophages. TNF-α and IL-1β mRNA levels in CD14-positive cells from the SYN of OA patients was significantly higher than that in CD14-negative cells, while NGF expression did not differ markedly between the two cell fractions. In addition, treatment of human cultured CD14-positive and -negative cells with IL-1β and TNF-α enhanced NGF mRNA and protein levels. Expression of NGF, IL-1β and TNF-α was also reduced significantly in STR/Ort mice upon macrophage depletion. These findings suggest that IL-1β and TNF-α regulate NGF expression and production in synovial macrophages and fibroblasts in osteoarthritic joints.

The changing profile of safe techniques for the insertion of a central venous catheter in pediatric patients - improvement in the outcome with the experiences of 500 insertions in a single institution

BACKGROUND

The ability to safely insert a central venous catheter (CVC) is critical to avoid associated complications. The aim of this study was to explore appropriate technique to maintain the safety of pediatric patients during CVC.

METHODS

We reviewed the surgical records of CVC insertion techniques and associated complications of 503 tunneled CVC insertions performed from 2000 to 2015.

RESULTS

Two hundred thirty CVCs (45.7%) were inserted into the subclavian vein using the landmark technique for 10years (first period). Only two pneumothoraxes (0.9%) were experienced. In 2009, we adopted ultrasound-guided venous catheterization from the internal jugular vein, and 103 CVCs (20.5%) were inserted (second period). This procedure led to penetration into the innominate vein (1.0%) by dilater sheath. Patient underwent repair of the penetrated vessel. After this serious complication, 170 CVCs (33.8%) were inserted using the venous cutdown procedure except two catheters. We had two cases whose accessible veins were occluded because of frequent catheterization using venous cutdown technique. No mechanical complications were experienced.

CONCLUSIONS

The venous cutdown method is the safest technique for inserting a tunneled CVC in pediatric patients. However, multiple vein occlusions because of repeated catheterizaion by venous cutdown lead to the exhaustion of accessible vessels.

LEVEL OF EVIDENCE

Treatment Study - Level IV.

Long-term outcome of bowel function for 110 consecutive cases of Hirschsprung's disease: Comparison of the abdominal approach with transanal approach more than 30years in a single institution - is the transanal approach truly beneficial for bowel function?

BACKGROUND

We compared the long-term outcomes of the bowel function (BF) in Hirschsprung's disease (HD) patients who underwent transanal endorectal pull-through (TA) with those who underwent the Soave-Denda (SD) procedure.

METHODS

Patient data were collected from 1984 to 2015 from 110 HD patients who underwent definitive diagnosis and operation. The follow-up data were analyzed retrospectively. BF was evaluated according to the evacuation score (ES) of the Japan Society of Anorectal Malformation Study Group at 3, 5, 7, 9, and 11years of age.

RESULTS

The operative procedures performed were as follows: SD: 71 (64.5%), TA: 38 (34.5%), and Duhamel: 1 (1.0%). We compared SD with TA. The ES improved chronologically after both procedures, and patients achieved satisfactory results at least 10years after operation. There was no significant difference in the total ES at all ages. The incontinence and frequency of bowel movement scores of TA patients were significantly lower than those of SD patients at several points.

CONCLUSION

TA is simple, less invasive, and adaptive for neonates and small infants. However, regarding the bowel function, TA is not always superior to SD. The surgical technique of TA must be improved according to a detailed understanding of the anatomy.

LEVEL OF EVIDENCE

Retrospective study - level III.

Conservative treatment of massive hemothorax in a girl with neuroblastoma

We report the case of a 1-year-old girl with stage 4 neuroblastoma who developed massive hemothorax due to tumor invasion before treatment. She presented with tachypnea, worsening anemia, and oxygen desaturation. Hemothorax was diagnosed based on chest radiography, ultrasonography, and diagnostic thoracic puncture results. High neuron-specific enolase, vanillylmandelic acid, and homovanillic acid as well as computed tomography strongly supported a diagnosis of neuroblastoma. Chemotherapy along with intermittent puncture drainage, oxygen, and blood transfusion reduced the accumulated blood, and hemothorax disappeared within 1 week. Thus, it is possible to avoid invasive treatment for massive hemothorax by initiating chemotherapy for chemosensitive solid tumors, including neuroblastoma.

Abdominal wall regenerative medicine for a large defect using tissue engineering: an experimental study

PURPOSE

Treatment for a large abdominal wall defect remains challenging. The aim of this study was to optimize tissue engineering therapy of muscle constructs using a rat model.

METHODS

Experimental abdominal wall defects were created in Wister rats. The animal model was divided into three groups: collagen sponge (CS), hybrid scaffold (HS) and hybrid scaffold containing bone marrow liquid (HSBM). Hybrid scaffolds comprised collagen sponge and poly L-lactide (PLLA) sheets. Abdominal wall defects were covered by three kinds of sheets. Thereafter, the bone marrow liquid was spread onto the sheets. Rats were killed at 4, 8, and 16 weeks. Pathological examinations were performed using hematoxylin-eosin and desmin antibody staining.

RESULTS

The CS group showed abdominal hernia, whereas the HS and HSBM groups did not. Vascular formation was confirmed in all groups. Muscle tissue was recognized at the marginal area of the sheet only in the HSBM group.

CONCLUSION

The HS and HSBM groups show a greater intensity than the CS group. Muscle tissue regeneration is solely recognized in the HSBM group. Our experimental data suggest that the triad of scaffold, cell, and growth factor is fundamental for ideal biomaterials. The HSBM may be useful for reconstruction of abdominal wall defects.

Efficacy of ethanol locks to reduce the incidence of catheter-related bloodstream infections for home parenteral nutrition pediatric patients: comparison of therapeutic treatment with prophylactic treatment

PURPOSE

Children with intestinal failure (IF) requiring central venous catheters (CVCs) often experience frequent catheter-related bloodstream infections (CRBSIs), which is a serious and life-threatening complication. To reduce the incidence of CRBSI, prophylactic ethanol lock therapy (ELT) was initiated.

METHODS

Patients with IF received home parenteral nutrition via a silicone tunneled CVC. All of them had received therapeutic ELT from January 2009 (first period) and prophylactic ELT from December 2012 (second period). Prophylactic ELT refers to ethanol lock for 2 h during the monthly hospital visit. We compared the CRBSI rate and number of CVC replacements between both periods.

RESULTS

Four patients received 19 CVCs for a total of 5623 catheter days. In the first period, there were 12 CRBSIs in 1823 catheter days (rate 6.77 per 1000 catheter days). In the second period, there were 9 CRBSIs in 3800 catheter days (rate 3.13 per 1000 catheter days). Overall, the rate of CVC replacement decreased from 4.92 to 1.72 per 1000 catheter days (p = 0.04). No adverse reactions were experienced during ethanol instillation.

CONCLUSION

Monthly prophylactic ELT for IF patients is considered to be a safe and effective modality for reducing the replacement of CVCs due to CRBSIs.

Putting the brakes on reproduction: Implications for conservation, global climate change and biomedicine

Seasonal breeding is widespread in vertebrates and involves sequential development of the gonads, onset of breeding activities (e.g. cycling in females) and then termination resulting in regression of the reproductive system. Whereas males generally show complete spermatogenesis prior to and after onset of breeding, females of many vertebrate species show only partial ovarian development and may delay onset of cycling (e.g. estrous), yolk deposition or germinal vesicle breakdown until conditions conducive for ovulation and onset of breeding are favorable. Regulation of this "brake" on the onset of breeding remains relatively unknown, but could have profound implications for conservation efforts and for "mismatches" of breeding in relation to global climate change. Using avian models it is proposed that a brain peptide, gonadotropin-inhibitory hormone (GnIH), may be the brake to prevent onset of breeding in females. Evidence to date suggests that although GnIH may be involved in the regulation of gonadal development and regression, it plays more regulatory roles in the process of final ovarian development leading to ovulation, transitions from sexual to parental behavior and suppression of reproductive function by environmental stress. Accumulating experimental evidence strongly suggests that GnIH inhibits actions of gonadotropin-releasing hormones on behavior (central effects), gonadotropin secretion (central and hypophysiotropic effects), and has direct actions in the gonad to inhibit steroidogenesis. Thus, actual onset of breeding activities leading to ovulation may involve environmental cues releasing an inhibition (brake) on the hypothalamo-pituitary-gonad axis.

The protective and anti-inflammatory effects of glucagon-like peptide-2 in an experimental rat model of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease, that affects premature infants. Glucagon-like peptide-2 (GLP-2) is an intestinotrophic hormone and reduces the inflammation. We suspected that GLP-2 would have protective and anti-inflammatory effects in an experimental rat model of NEC. NEC was induced in newborn rats by enteral feeding with hyperosmolar formula, asphyxial stress and enteral administration of lipopolysaccharide (LPS). Rats were randomly divided into the following four groups: dam-fed, NEC, NEC+GLP-2(L) given 80 μg/kg/day of GLP-2, and NEC+GLP-2(H) given 800 μg/kg/day of GLP-2. GLP-2 was administered subcutaneously every 6 h before stress. All animals surviving beyond 96 h or any that developed signs of distress were euthanized. The clinical sickness score in the NEC+GLP-2(H) group was significantly lower than that in the NEC group. The NEC score and the survival rate in the NEC+GLP-2(H) group was significantly improved compared with those in the NEC and the NEC+GLP-2(L) groups. Villous height and crypt depth in both the GLP-2 treatment groups were significantly increased compared with those in the NEC group. There were no significant differences in the crypt cell proliferation indices among the groups. Ileal interstitial TNF-α and IL-6 level in the NEC+GLP-2(H) group was decreased to the same levels in the dam-fed group. High dose GLP-2 administration improved the incidence and survival rate for NEC. It also decreased mucosal inflammatory cytokine production. These results support a potential therapeutic role for GLP-2 in the treatment of NEC.

Species and sex differences in propofol glucuronidation in liver microsomes of humans, monkeys, rats and mice

Propofol (2,6-diisopropylphenol) is a short-acting anesthetic commonly used in clinical practice, and is rapidly metabolized into glucuronide by UDP-glucuronosyltransferase (UGT). In the present study, propofol glucuronidation was examined in the liver microsomes of male and female humans, monkeys, rats, and mice. The kinetics of propofol glucuronidation by liver microsomes fit the substrate inhibition model for humans and mice, the Hill model for monkeys, and the isoenzyme (biphasic) model for rats. The K(m), V(max), and CL(int) values of human liver microsomes were 50 μM, 5.6 nmol/min/mg protein, and 110 μL/min/mg protein, respectively, for males, and 46 μM, 6.0 nmol/min/mg protein, and 130 μL/min/mg protein, respectively, for females. The rank order of the CL(int) or CL(max) (in vitro clearance) values of liver microsomes was mice humans > monkeys > rats (high-affinity phase) rats (low-affinity phase) in both males and females. Although no significant sex differences were observed in the values of kinetic parameters in any animal species, the in vitro clearance values of liver microsomes were males < females in humans, males = females in rats (low-affinity phase), and males > females in monkeys, rats (high-affinity phase), and mice. These results demonstrated that the kinetic profile of propofol glucuronidation by liver microsomes markedly differed among humans, monkeys, rats, and mice, and suggest that species and sex differences exist in the roles of UGT isoform(s), including UGT1A9, involved in its metabolism.

In vitro glucuronidation of propofol in microsomal fractions from human liver, intestine and kidney: tissue distribution and physiological role of UGT1A9

Propofol (2,6-diisopropylphenol) is intravenously administered for anesthetic induction and maintenance, and is rapidly metabolized into its glucuronide, mainly by UDP-glucuronosyltransferase 1A9 (UGT1A9). In this study, propofol glucuronidation by liver microsomes (HLM), intestinal microsomes (HIM) and kidney microsomes (HKM) of humans were examined. The expression of UGT1A9 protein in HLM, HIM and HKM was analyzed by immunoblotting. The staining band intensities for UGT1A9 of HIM and HKM were 12% and 119% those of HLM, respectively. The kinetics of propofol glucuronidation by HLM and HKM exhibited substrate inhibition, whereas the kinetics by HIM followed the Michaelis-Menten model. The K(m), V(max) and CL(int) values of HLM were 41.8 μM, 5.21 nmol/min/mg protein and 126 μl/min/mg protein, respectively. The K(m) value of HIM was significantly higher (6.7-fold) than that of HLM, and the V(max) and CL(int) values were significantly lower (56% and 8.3%, respectively) than those of HLM. The K(m) value of HKM was comparable to that of HLM, and the V(max) and CL(int) values were significantly higher (2.1- and 3.7-fold, respectively) than those of HLM, respectively. These findings suggest that UGT1A9 expressed in the kidney as well as in the liver plays an important role in propofol glucuronidation. The information gained in this study should contribute to an appropriate use of drugs metabolized by UGT1A9.

Long-term outcome in Japanese patients with lupus nephritis

The objective of this study was to clarify the long-term outcome in patients with lupus nephritis (LN) according to the International Society of Nephrology and Renal Pathology Society classification. This retrospective analysis comprised 186 Japanese patients given a diagnosis of LN by renal specimen with a mean observation period of 12 years. Primary end point was defined as death or end-stage renal disease, and standardized mortality ratios were calculated. Five patients presented with histopathological class I, 62 with II, 21 with III or III+V, 73 with IV or IV+V and 25 with V. Fourteen deaths occurred, corresponding to an overall standardized mortality ratio of 3.59 (95% confidence interval 2.02-5.81, p < 0.0001). Kaplan-Meier analysis revealed a 10-year overall survival of 95.7%. Nephrotic proteinuria (≥3.5 g/day) at baseline was identified as an independent poor prognostic factor for overall survival in Cox regression analysis. Kaplan-Meier analysis revealed a 10-year renal survival as 94.3%. Male gender and nephrotic proteinuria at baseline were identified as independent poor prognostic factors for renal survival in Cox regression analysis. In conclusion, LN was associated with a 3.59-fold increase in mortality compared with the general population. Male gender and nephrotic proteinuria were predictive for poor renal outcome.

In-gas-cell laser ion source for KEK isotope separation system

The KEK isotope separation system (KISS) is an element-selective isotope separator under development at RIKEN. The in-gas-cell laser ion source is a critical component of the KISS, a gas cell filled with argon gas of 50 kPa enclosed in a vacuum chamber. In the gas cell, nuclear reaction products are stopped (i.e., thermalized and neutralized) and transported by a laminar flow of argon to the ionization region just upstream of the gas outlet, and thereby an element of interest among those reaction products is selectively ionized by two-color resonant laser irradiation. Recently, we succeeded to extract laser-ionized Fe ions by injecting an energetic Fe beam into the gas cell. Recent off- and on-line test results were presented and discussed.