[Magnesium homeostasis and its disturbances]

Magnesium homeostasis is maintained through normal functions of the kidney, intestine, and bone. In the kidney, approximately 80% magnesium is filtered by the glomeruli. In general, 95% filtered magnesium is collectively reabsorbed in the proximal tubule (15%-20%) , thick ascending limb of Henle (TAL, 65%-75%) , and the distal convoluted tubule (DCT, 5%-10%) . In the TAL, magnesium reabsorption regulated by the paracellular pathway via claudin-16 is driven by electrochemical voltage. Chloride channel Kb and renal outer medullary potassium channels control this lumen-positive voltage. In the DCT, the transcellular pathway via transient receptor potential melastatin 6 (TRPM6) plays a fundamental role in the final 5%-10% magnesium reabsorption. The functions of TRPM6 depend on Na-Cl co-transporters and Na( + )-K( + )-ATPase. Defects in these regulatory proteins may cause inherited or drug-induced disorders of magnesium metabolism. Recently, some proteins have been confirmed to be responsible for magnesium homeostasis ; however, further research is required to elucidate the mechanisms underlying the maintenance of magnesium homeostasis.

Composition and plaque patterns of coronary culprit lesions and clinical characteristics of patients with chronic kidney disease

Coronary artery disease is a serious complication of chronic kidney disease (CKD); however, there is little information about coronary plaque morphology in these patients. Here we identified the characteristics of coronary culprit plaques and their clinical manifestations in 78 patients with CKD divided into four groups based on their estimated glomerular filtration rate. Patients were examined by Virtual Histology-Intravascular Ultrasound, a tomographic imaging method that can visualize atherosclerotic plaques in vivo using radiofrequency analysis of ultrasound backscatter signals. These ultrasound analyses showed an increase in the relative volumes of both dense calcium and necrotic core with decreasing renal function. The necrotic core/dense calcium ratio was significantly higher in patients with acute myocardial infarction compared to those with stable angina pectoris. Furthermore, the necrotic core/dense calcium ratio decreased in advanced CKD. Thus, the plaque composition of coronary culprit lesions changed from necrotic core-rich to extensively calcium-rich plaques as renal function decreased, suggesting that such coronary culprit composition was associated with stability, particularly in advanced CKD.

Systematic evaluation of vascular access by color-Doppler ultrasound decreased the incidence of emergent vascular access intervention therapy and X-ray exposure time: a single-center observational study

Arteriovenous fistula has superior patency over other accesses, but vascular access intervention therapy (VAIVT) for stenosis or thrombosis still remain major reasons for hospital admission of dialysis patients. The aim of this study was to examine the usefulness of systematic evaluation of vascular access by color-Doppler ultrasound (CDUS). This study was a single-center observational design study. We planned screening CDUS to evaluate all vascular accesses once per year, and additionally, follow-up CDUS of post-interventional patients 1 month, 3 months and 6 months after their recent VAIVT. This systematic evaluation was started from September 2009. The observational period between September 2008 and August 2009 was defined as period A. The observational period between September 2009 and August 2010 was defined as period B. We compared the incidence of emergent VAIVT and X-ray exposure time during the period A to B. 131 patients with AV fistula were assigned. 13 patients were excluded due to death, hospital transfer or re-operation of their accesses. During period A, 57 VAIVTs were carried out, and 37 cases (65%) were emergent. During period B, 42 VAIVTs were carried out, and 11 cases (25%) were emergent. The incidence of emergent intervention therapy was lower during period B than period A (P < 0.001). The amount of X-ray exposure time per patient was decreased in patients who received VAIVT during both periods (P < 0.03). Systematic evaluation of vascular access by CDUS decreased the incidence of emergent VAIVT and X-ray exposure time.

Carvedilol ameliorates low-turnover bone disease in non-obese type 2 diabetes

BACKGROUND

Diabetic bone disease is a major complication in diabetes mellitus and is characterized by low-turnover bone formation. Recent studies have demonstrated that oxidative stress could be associated with diabetic bone disease and that β-adrenergic antagonists could increase bone formation. Our study investigated the effect of carvedilol (β-blocker), possessing an antioxidant effect, on diabetic bone disease.

METHODS

We used the non-obese, type 2 diabetes model Spontaneously Diabetic Torii (SDT) rats in this study. Sprague-Dawley rats were used as controls (control, n = 6). SDT rats were divided into four groups: diabetic (DM, n = 8), DM+insulin (DM+I, n = 7), DM+carvedilol (DM+C, n = 8), and DM+N-acetylcysteine (DM+N, n = 10) at 20 weeks. The rats were sacrificed at 30 weeks, after which blood and urine samples, bone mineral density, histomorphometry, and oxidative stress were evaluated.

RESULTS

The number of 8-hydroxydeoxyguanosine-positive cells in bone tissue was significantly lower in the DM+C and DM+N groups than in the DM group. Mineral apposition rate and bone formation rate per bone surface in the DM+C and DM+N groups were significantly higher than those in the DM group, and these parameters were better in the DM+C group than in the DM+N group.

CONCLUSION

Our data suggest that carvedilol has stronger effects on diabetic low-turnover bone disease beyond that which can be attributed to its antioxidative stress mechanism.

A clinical trial protocol for second line treatment of malignant brain tumors with BNCT at University of Tsukuba

We have evaluated the efficacy and safety of boron neutron capture therapy (BNCT) for recurrent glioma and malignant brain tumor using a new protocol. One of the two patients enrolled in this trial is a man with recurrent glioblastoma and the other is a woman with anaplastic meningioma. Both are still alive and no severe adverse events have been observed. Our findings suggest that NCT will be safe as a palliative therapy for malignant brain tumors.

Boron neutron capture therapy combined with fractionated photon irradiation for glioblastoma: a recursive partitioning analysis of BNCT patients

Eight patients to received Boron Neuron Capture Therapy (BNCT) were selected from 33 newly diagnosed glioblastoma patients (NCT(+) group). Serial 42 glioblastoma patients (NCT(-) group) were treated without BNCT. The median OS of the NCT(+) group and NCT (-) group were 24.4 months and 14.9 months. In the high risk patients (RPA class V), the median OS of the NCT(+) group tended to be better than that of NCT(-) group. 50% of BNCT patients were RPA class V.

Prognostic factors in glioblastoma multiforme patients receiving high-dose particle radiotherapy or conventional radiotherapy

The aim of this study was to evaluate the influence of prognostic factors related to patient selection on survival outcomes. Survival outcomes were retrospectively analysed in a consecutive series of 67 newly diagnosed glioblastoma multiforme (GBM) patients who had received either conventional fractionated photon radiotherapy (CRT) or high-dose particle radiotherapy (HDT). In the CRT protocol, a total dose of 60.0-61.2 Gy was administered. In the HDT protocol, an average dose of approximately 30 GyE in a single session and additional fractionated photon irradiation of total dose 30 Gy were administered to patients receiving boron neutron capture therapy; and a total dose of 96.6 GyE was administered to patients receiving proton therapy. Most of the patients had received chemotherapy with nimustine hydrochloride (ACNU) alone or with ACNU, procarbazine and vincristine. The median overall survival (OS) and progression-free survival times for all patients were 17.7 months [95% confidence interval (CI), 14.6-20.9 months] and 7.8 months (95% CI, 5.7-9.9 months), respectively. The 1- and 2-year survival rates were 67.2% and 33.7%, respectively. For patients treated with HDT, the median OS was 24.4 months (95% CI, 18.2-30.5 months), compared with 14.2 months (95% CI, 10.0-18.3 months) for those treated with CRT. The Cox proportional hazards model revealed radiation modality (HDT vs CRT) and European Organisation for Research and Treatment of Cancer recursive partitioning analysis class to be the significant prognostic factors. Age, sex, pre-operative performance status, treatment with or without advanced neuroimaging, extent of surgery and regimen of chemotherapy were not statistically significant factors in predicting prognosis. The median OS was 18.5 months (95% CI, 9.9-27.1 months) in patients of 65 years and older, compared with 16.8 months (95% CI, 13.6-20.1 months) in those 64 years and younger (p=0.871). The positive effect of HDT treatment is unlikely to reflect patient selection alone. Randomised trials with strictly controlled inclusion criteria to ensure the comparable selection of patients are required to demonstrate conclusively that prolonged survival can be attributed to high-dose particle radiotherapies.

Effects of AST-120 on left ventricular mass in predialysis patients

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of death in chronic kidney disease (CKD) patients. One of the proposed mechanisms assumes that accumulated uremic toxins play an important role in the progression of CVD in CKD. Recently, it has been reported that AST-120 may attenuate progression of CVD through absorption of uremic toxins. In this study, we examined the association between the use of AST-120 and cardiac abnormalities in CKD patients.

METHODS

This was a cross-sectional study of predialysis CKD patients hospitalized in our institution between April 2008 and October 2009. We divided 107 patients into two groups based on whether AST-120 had been administered for more than 6 months (AST-120 group: n = 43) or not (control group: n = 64). Echocardiography and laboratory tests were performed for all patients; we examined the relationship between clinical characteristics and cardiac abnormalities.

RESULTS

The number of patients with left ventricular (LV) concentric change was significantly smaller in the AST-120 group than in the control group. In multivariable analysis, the administration of AST-120, gender, and pulse pressure were significantly correlated with LV concentric change.

CONCLUSIONS

Our findings suggest that AST-120 prevents the development of LV concentric change in predialysis CKD patients.

The status of Tsukuba BNCT trial: BPA-based boron neutron capture therapy combined with X-ray irradiation

The phase II trial has been prepared to assess the effectiveness of BPA (250 mg/kg)-based NCT combined with X-ray irradiation and temozolomide (75 mg/m(2)) for the treatment of newly diagnosed GBM. BPA uptake is determined by (18)F-BPA-PET and/or (11)C-MET-PET, and a tumor with the lesion to normal ratio of 2 or more is indicated for BNCT. The maximum normal brain point dose prescribed was limited to 13.0 Gy or less. Primary end point is overall survival.

Role of oxidative stress and indoxyl sulfate in progression of cardiovascular disease in chronic kidney disease

Several abnormalities of the cardiovascular system are observed in most cases of chronic kidney disease (CKD). Mechanisms underlying these abnormalities are complicated, and several factors contribute to their pathogenesis. Of these factors, oxidative stress and uremic toxins are considered to play key roles in the progression of cardiovascular disease (CVD) in CKD. Oxidative stress increases significantly in CKD and accelerates proteinuria and renal dysfunction. In addition, oxidative stress has been reported to induce cardiac hypertrophy and fibrosis. Indoxyl sulfate, a uremic toxin, has recently been suggested to play a crucial role in the development of CVD. Recent in vitro data suggest that indoxyl sulfate increases oxidative stress. Some reports have shown that AST-120, which is an oral charcoal adsorbent, can reduce oxidative stress by lowering serum indoxyl sulfate levels. Recently, we have also demonstrated that indoxyl sulfate is associated with the production of oxidative stress, and that increased oxidative stress is significantly correlated with cardiac hypertrophy and fibrosis. Furthermore, results of our basic and clinical studies suggested that AST-120 can prevent progression of cardiac hypertrophy by reducing oxidative stress in CKD. Thus, one of the main targets of the management of CKD and CVD is the control of oxidative stress and uremic toxins, such as indoxyl sulfate.

New insights into the role of fibroblast growth factor 23 in chronic kidney disease

Fibroblast growth factor 23 (FGF23) is a recently identified bone-derived hormone that regulates phosphate and 1,25-dihydroxyvitamin D metabolism. FGF23 principally acts in the kidney to induce urinary phosphate excretion and suppress 1,25-dihydroxyvitamin D synthesis in the presence of FGF receptor 1 (FGFR1) and its coreceptor Klotho. FGF23 also acts in the parathyroid to decrease parathyroid hormone synthesis and secretion. In patients with chronic kidney disease (CKD), circulating FGF23 levels are progressively increased to compensate for persistent phosphate retention, but this results in reduced renal production of 1,25-dihydroxyvitamin D and leads to hypersecretion of parathyroid hormone. In patients undergoing dialysis, FGF23 levels are markedly elevated in response to hyperphosphatemia and active vitamin D therapy, but fail to suppress the secretion of parathyroid hormone, presumably due to decreased expression of the Klotho-FGFR1 complex. In these patients, FGF23 can be used as a predictor of future development of refractory hyperparathyroidism. FGF23 also plays a central role in the pathogenesis of post-transplant hypophosphatemia in kidney transplant recipients. Furthermore, recent studies suggest that FGF23 could be an independent predictor of mortality in dialysis patients, indicating its potential role as a sensitive biomarker of disordered phosphate metabolism. This brief review summarizes recent insights into the role of FGF23 in the pathogenesis of mineral and bone disorders in CKD.

Oxidative and nitrosative stress and progression of diabetic nephropathy in type 2 diabetes

BACKGROUND

The role of nitric oxide (NO) is controversial in diabetes nephropathy progression and the mechanisms remain unknown, especially in non-obese type 2 diabetes. To examine mechanisms of nephropathy progression in non-obese type 2 diabetes, we used spontaneously diabetic Torii (SDT) rats, a newly established model of non-obese type 2 diabetes.

METHODS

Fourteen male Sprague-Dawley rats were used as a control (20 weeks, n = 6; 30 weeks, n = 8), and 20-week-old male SDT rats were divided into 2 groups: diabetic (DM, n = 8) and DM + insulin (n = 8) groups. Twenty- and 36-week-old rats were sacrificed, and blood, urine, and histomorphometric analyses, mRNA expression analysis of endothelial NO synthase (eNOS) and NADPH oxidase, and blood pressure measurement were performed.

RESULTS

At 36 weeks, NO metabolites, and 8-hydroxydeoxyguanosine (8-OHdG) were significantly higher in the diabetic group than in the other 2 groups. Further renal studies showed increased glomerular volume and mesangial area, and intensified eNOS, 8-OHdG, and nitrotyrosine immunostaining in the diabetic group. Oxidative and nitrosative stress were positively associated with increased glomerular volume and mesangial area, which were mostly recovered by insulin therapy.

CONCLUSIONS

NO and oxidative stress increased in SDT rats, suggesting that these play key roles in nephropathy progression in non-obese type 2 diabetes.

Obstructive acute renal failure related to amantadine intoxication

We report the case of a 69-year-old woman with seizures and acute renal failure with hyperkalemia. She presented with bladder turgescence and hydronephrosis on admission and was diagnosed as obstructive acute renal failure. Urethral catheterization was performed after a single-session hemodialysis. It resulted in immediate improvement of renal function and consciousness, and subsequent disappearance of seizures. Improvement of serum creatinine level to 0.7 from 10.6 mg/dL was associated with a fall in blood level of amantadine hydrochloride from 4.40 to 0.47 microg/mL. Physicians should be aware of urinary retention in patients treated with amantadine as a first sign of intoxication that could lead if untreated to obstructive acute renal failure. And we recommend to check the overdose symptoms, even those with normal renal function, treated with amantadine.

Intracellular uptake of a new boronated porphyrin EC032

We measured the toxicity and intracellular uptake of a newly developed boronated porphyrin EC032, and verified the fluorescence-based boron concentration measuring methods. Toxicity study showed that concentration required to produce a 50% reduction in viability (IC(50)) of EC032 was more than 0.25 mM. Fluorescence study showed the intracellular uptake of EC032 increased up until 24 h after its exposure to C6, 9L, U87, and U251 cells. There was also a linear correlation between ICP-AES and fluorescence intensity as an arbitrary unit about measurement of boron concentration. Fluorescence-based boron concentration measuring methods are very simple and useful methods, especially for screening of slight test dose of porphyrin compounds.

Dose distribution and clinical response of glioblastoma treated with boron neutron capture therapy

The dose distribution and failure pattern after treatment with the external beam boron neutron capture therapy (BNCT) protocol were retrospectively analyzed. BSH (5 g/body) and BPA (250 mg/kg) based BNCT was performed in eight patients with newly diagnosed glioblastoma. The gross tumor volume (GTV) and clinical target volume (CTV)-1 were defined as the residual gadolinium-enhancing volume. CTV-2 and CTV-3 were defined as GTV plus a margin of 2 and 3 cm, respectively. As additional photon irradiation, a total X-ray dose of 30 Gy was given to the T2 high intensity area on MRI. Five of the eight patients were alive at analysis for a mean follow-up time of 20.3 months. The post-operative median survival time of the eight patients was 27.9 months (95% CI=21.0-34.8). The minimum tumor dose of GTV, CTV-2, and CTV-3 averaged 29.8+/-9.9, 15.1+/-5.4, and 12.4+/-2.9 Gy, respectively. The minimum tumor non-boron dose of GTV, CTV-2, and CTV-3 averaged 2.0+/-0.5, 1.3+/-0.3, and 1.1+/-0.2 Gy, respectively. The maximum normal brain dose, skin dose, and average brain dose were 11.4+/-1.5, 9.6+/-1.4, and 3.1+/-0.4 Gy, respectively. The mean minimum dose at the failure site in cases of in-field recurrence (IR) and out-field recurrence (OR) was 26.3+/-16.7 and 14.9 GyEq, respectively. The calculated doses at the failure site were at least equal to the tumor control doses which were previously reported. We speculate that the failure pattern was related to an inadequate distribution of boron-10. Further improvement of the microdistribution of boron compounds is expected, and may improve the tumor control by BNCT.

The study on the patency of the perforating arteries after stent placement in atherosclerosis induced rabbits

SUMMARY

The number of successful case reports with percutaneous transluminal angioplasty (PTA) / stenting for intracranial atherosclerotic stenoses is recently increasing with the advent of flexible coronary stents. However, it is not well known whether the perforating artery is occluded or not after stent placement in the atherosclerotic stenotic vessels. We investigated this issue using five New Zealand white rabbits. We deployed stainless steel stents in the atherosclerosis-induced abdominal aorta across the lumbar artery in which the diameters of the abdominal arteries were similar to those of human intracranial arteries. We evaluated the patency of lumbar artery by angiography and scanning electron microscopy three months after stent placement. The lumbar arteries were patent in four out of five rabbits. However, SEM findings demonstrated stent struts were covered with thick neointima and the ostia between stent struts were partially occluded. It is possible that stent placement in the atherosclerotic arteries can cause the obliteration of the perforating arteries.

Kernohan's phenomenon associated with left ruptured occipital arteriovenous malformation

A 23-year-old woman presented with ipsilateral hemiparesia due to rupture of a left occipital arteriovenous malformation (AVM). Emergency decompression (the onset-operation interval was 46 minutes,) was carried out and the patient could leave the hospital upon recovery without neurological deficits. In general, Kernohan's phenomenon is caused by the gradual displacement of the cerebral peduncle against the tentorial edge caused by compression by the contralateral mass. This phenomenon is very rare among the cases with spontaneous intracranial hemorrhage and only three cases including the present one have been reported in the literature. In all cases the onset-operation intervals of were very short. Kernohan's phenomenon associated with a ruptured AVM is a rare condition and emergency decompression is required.

Morphological description of two bucephalid trematodes collected from freshwater fishes in the Uji River, Kyoto, Japan

The morphology of two species of bucephalids (Bucephalidae; Digenea; Trematoda), which since 1999 has caused a fish disease at the Uji River, Kyoto Prefecture, Japan, is described. Parabucephalopsis parasiluri Wang, 1985 was first recorded in the Uji River in 2000, and Prosorhynchoides ozakii (Nagaty, 1937) in 2005. The definitive host of both species is the Lake Biwa catfish (Silurus biwaensis), and the second intermediate hosts include many fish species from several families. P. parasiluri is an introduced parasite that invaded with its first intermediate host, golden mussels (Limnoperna fortunei), from the Asian continent. P. ozakii may also be an introduced species, although its first intermediate host has not been identified.

Reversal of expression of 15-lipoxygenase-1 to cyclooxygenase-2 is associated with development of colonic cancer

AIMS

Two different pathways of linoleic acid (LA) metabolism have opposite effects on the development of colonic cancer: a protumoral prostaglandin cascade metabolized by cyclooxygenase (COX)-2, and an antitumoral peroxisome proliferator-activated receptor (PPAR)-gamma ligands metabolized by 15-lipooxygenase (LOX)-1. The aim was to examine the switching of the two LA metabolic pathways in colonic adenomas and carcinomas.

MATERIALS AND METHODS

The expression of 15LOX-1 mRNA and COX-2 protein was examined in 54 adenomas, 21 pTis carcinoma-in-adenoma lesions and 36 pT3/p Stage II carcinomas of the colon by in-situ hybridization and immunohistochemistry, respectively.

RESULTS

15LOX-1 expression was found in 89% (48 of 54) of adenomas, 43% (nine of 21) of adenomas and 10% (two of 21) of carcinomas in carcinoma-in-adenoma lesions, but not in pT3 carcinomas (P < 0.0001). In contrast, COX-2 production was found in 11% (six of 54) of adenomas, 52% (11 of 21) of adenomas and 71% (15 of 21) of carcinomas in carcinoma-in-adenoma lesions, and 92% (33 of 36) of pT3 carcinomas (P < 0.0001). Concurrence of 15LOX-1 down-regulation and COX-2 up-regulation was found in 6% (three of 54) of adenomas, 33% (seven of 21) of adenomas and 71% (15 of 21) of carcinomas in carcinoma-in-adenoma lesions, and 92% (33 of 36) of pT3 carcinomas (P < 0.0001).

CONCLUSIONS

These results suggest that switching of LA metabolism by reversal of the expression of 15LOX-1 and COX-2 is associated with acquisition of malignant potential in colonic neoplasia.

Prospective evaluation of contrast-enhanced ultrasonography with advanced dynamic flow for the diagnosis of intestinal ischaemia

This study aims to prospectively evaluate the importance of contrast-enhanced ultrasonography with advanced dynamic flow in the diagnosis of intestinal ischaemia in bowel obstruction. 50 patients admitted for bowel obstruction were included in this study. Of these, 17 patients had intestinal ischaemia (bowel strangulation, nine; superior mesenteric artery thromboembolism, four; non-occlusive mesenteric ischaemia, four), whereas 33 patients had simple obstructions. The definitive diagnosis of intestinal ischaemia was established by surgery. After administration of SHU 508A, the least peristaltic and/or the most dilated segments were imaged by this method. Colour signals depicted in the bowel wall were classified as normal, diminished or absent. The ultrasonographic findings were later correlated with the clinical outcomes and surgical findings. The colour signals were absent in 12 patients (bowel strangulation, six; superior mesenteric artery thromboembolism, four; non-occlusive mesenteric ischaemia, two), were diminished in four patients (bowel strangulation, two; non-occlusive mesenteric ischaemia, two) and were normal in 34 patients (simple obstruction, 33; bowel strangulation, one). Assuming that the diminished and absent colour signals indicate the presence of intestinal ischaemia, the sensitivity, specificity, positive predictive value and negative predictive value of the method were 94.1%, 100%, 100% and 97.1%, respectively. Our preliminary experience suggests that contrast-enhanced ultrasonography with advanced dynamic flow is a highly sensitive method for the diagnosis of intestinal ischaemia in patients with bowel obstruction.

Randomized clinical trial of single- versus multiple-dose antimicrobial prophylaxis in gastric cancer surgery

BACKGROUND

The optimum duration of antimicrobial prophylaxis in elective gastric cancer surgery is still open to question. This multicentre randomized clinical trial compared a single-dose with a multiple-dose regimen of antimicrobial prophylaxis for prevention of surgical-site infection.

METHODS

Between May 2001 and December 2004, 501 patients undergoing elective surgery for gastric cancer in ten centres were allocated randomly to single- or multiple-dose antimicrobial prophylaxis. The primary outcome measure was the incidence of surgical-site infection, analysed by intention to treat.

RESULTS

Some 243 patients who received a single dose and 243 who received multiple doses of antibiotics were included in the final analysis. The surgical-site infection rate was 9.5 per cent (23 of 243) and 8.6 per cent (21 of 243) respectively (difference 0.9 (95 per cent confidence interval - 4.3 to 5.9) per cent). Antimicrobial prophylaxis had no major adverse effects.

CONCLUSION

The incidence of surgical-site infection in elective gastric cancer surgery was similar with both antibiotic prophylaxis regimens.

Brain abscess following intracerebral haemorrhage

We report two cases of brain abscess, which developed at the site of an intracerebral haemorrhage (ICH) in a 75-year-old man and a 32-year-old-man. The patients recovered after surgical treatment and systemic antibiotic therapy. The route of infection could not be detected in either case. The literature contains only 13 reported cases of brain abscess as a complication of ICH. Although the interval from initial ICH to abscess formation ranged from 4 to 20 weeks, almost all patients had episodes of high fever, indicating the presence of systemic infection and bacterial seeding, 0-14 days after the onset of their ICH. Therefore, abscess formation appears to be caused by haematogenous seeding of infection in patients with ICH. Abscess formation should be considered when a patient deteriorates clinically with a febrile episode after an ICH.

A minimally invasive endoscopic transsphenoidal approach with an endonasal septal pushover technique by using a modified nasal speculum

Whereas the endoscopic endonasal transsphenoidal approach has been applied in patients with pituitary lesions as a potentially efficacious and less invasive surgical technique, the sinonasal step of a series of the surgical procedures is generally not well known to neurosurgeons. This is one of the reasons why the endoscopic technique has not been fully been adopted as a routine surgical procedure approaching towards the sella. The present paper describes the technical details of a purely endoscopic approach using an endonasal septal pushover technique. We also present a newly designed nasal speculum specialized for this endoscopic endonasal technique. As compared to the endoscopic endonasal approach previously reported, the surgical procedure required for sphenoidotomy with the aid of the modified speculum was simplified and thereby less time-consuming. This technique has been performed in 40 patients with several types of pituitary lesions. All patients recovered rapidly without significant rhinological complications. Despite a limited number of cases, our experience suggests that this simplified endoscopic technique could encourage a more routine use of endoscopes in the endonasal approach for pituitary lesions.

Myeloablative allogeneic hematopoietic stem cell transplantation for Philadelphia chromosome-positive acute lymphoblastic leukemia in adults: significant roles of total body irradiation and chronic graft-versus-host disease

Disease-free survival in Philadelphia chromosome-positive ALL (Ph + ALL) is very poor, and allogeneic hematopoietic stem cell transplantation (allo-HSCT) is currently considered the only procedure with curative potential. To identify factors affecting transplant outcome, we analyzed the data from 197 Ph + ALL patients aged 16 years or older who had undergone allo-HSCT. The 5-year survival rates were 34% for patients in first complete remission (CR), 21% for those in second or subsequent CR, and 9% for those with active disease (P < 0.0001). Multivariate analysis showed four pre-transplant factors as significantly associated with better survival: younger age, CR at the time of transplantation, conditioning with total body irradiation, and HLA-identical sibling donor (P < 0.0001, P < 0.0001, P = 0.0301, P = 0.0412, respectively). Severe acute GVHD increased the risk of treatment-related mortality (TRM) without diminishing the risk of relapse, whereas chronic GVHD reduced the risk of relapse without increasing the risk of TRM. Thus, patients who developed extensive chronic GVHD had better survivals (P = 0.0217), and those who developed grade III-IV acute GVHD had worse survivals (P = 0.0023) than did the others.

Trial of Remote Telemedicine Support for Patients with Chronic Respiratory Failure at Home through a Multistation Communication System

To create and test a multistation telemedicine support system, three remote locations were connected: the homes of two patients with chronic respiratory failure, the hospital of the attending physician, and the hospital of the pulmonary specialist. Real-time connections were set up between the three locations. Medical history and biologic variables were noninvasively recorded, including blood pressure, arterial oxygen saturation, three-lead electrocardiogram, and end-tidal carbon dioxide. Both physicians shared in these data real-time. If necessary, the respiratory specialist could provide medical advice to the attending physician based on the patient's condition. The trial program resulted in the same information being exchanged remotely using the multi-station telemedicine system that would be exchanged in a direct, face-to-face encounter. This result, together with the improvement in quality of life and the establishment of appropriate treatment and cooperation between the respiratory specialist and attending physician, suggests our system can be considered useful and promising for further use.

IL-4-producing CD8+ T cells may be an immunological hallmark of chronic GVHD

Chronic graft-versus-host disease (cGVHD) occurs in approximately 60-80% of those who survive over 100 days after allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, the pathophysiology of cGVHD is poorly understood. To gain more insight into the immunological mechanism of cGVHD, we examine cytokine production of peripheral blood T cells from 19 patients in the chronic phase of allo-HSCT. The percentage of IFN-gamma-producing CD8(+) T cells among CD8(+) T cells was significantly higher in patients with or without cGVHD than in normal control subjects (P<0.001). On the other hand, the percentage of IL-4-producing CD8(+) T cells among CD8(+) T cells was significantly higher in patients with cGVHD (mean 3.3%; range 1.3-8.2%) than in patients without cGVHD (mean 1.2%; range 0.8-1.7%) and normal control subjects (mean 1.1%; range 0.1-1.6%) (both P<0.001). By contrast, the percentage of IL-4-producing CD4(+) T cells was not different among patients with and without cGVHD and normal controls. These findings suggest that IL-4-producing CD8(+) T cells may be an immunological marker of cGVHD.

Reduced-intensity stem-cell transplantation for adult acute lymphoblastic leukemia: a retrospective study of 33 patients

Efficacy of reduced-intensity stem-cell transplantation (RIST) for acute lymphoblastic leukemia (ALL) was investigated in 33 patients (median age, 55 years). RIST sources comprised 20 HLA-identical related donors, five HLA-mismatched related, and eight unrelated donors. Six patients had undergone previous transplantation. Disease status at RIST was first remission (n=13), second remission (n=6), and induction failure or relapse (n=14). All patients tolerated preparatory regimens and achieved neutrophil engraftment (median, day 12.5). Acute and chronic graft-versus-host disease (GVHD) developed in 45 and 64%, respectively. Six patients received donor lymphocyte infusion (DLI), for prophylaxis (n=1) or treatment of recurrent ALL (n=5). Nine patients died of transplant-related mortality, with six deaths due to GVHD. The median follow-up of surviving patients was 11.6 months (range, 3.5-37.3 months). The 1-year relapse-free and overall survival rates were 29.8 and 39.6%, respectively. Of the 14 patients transplanted in relapse, five remained relapse free for longer than 6 months. Cumulative rates of progression and progression-free mortality at 3 years were 50.9 and 30.4%, respectively. These findings suggest the presence of a graft-versus-leukemia effect for ALL. RIST for ALL is worth considering for further evaluation.