Associations of intrauterine growth restriction with placental pathological factors, maternal factors and fetal factors; clinicopathological findings of 257 Japanese cases

Intrauterine growth restriction (IUGR) is the leading cause of fetal mortality and morbidity. As an etiology, each of placental findings, maternal factors and fetal factors has been reported to be associated with IUGR, although a comprehensive approach to examine all of these parameters as a cause of IUGR has not been reported. In the present study, therefore, we comprehensively examined the placental findings and maternal and fetal factors in the cases of IUGR (n=257, mean maternal age, 30 years; gestational weeks, 34 weeks) and normal growth pregnancies (n=258, mean maternal age, 30 years; gestational weeks, 33 weeks), and determined risk factors for IUGR. The prevalence of pregnancy hypertension (PHT) (19% vs. 8%, P<0.01), smoking habit (3% vs. 0.7%, P<0.05) and fetal anomaly (3.5% vs. 0.8%, P<0.05) were higher in IUGR cases than normal growth pregnancies. Pathologically, the prevalence of infarction (33% vs. 14%, P<0.05), fetal vessel thrombosis (22% vs. 6%, P<0.001) and chronic villitis (11% vs. 3%, P<0.001) were higher in IUGR cases than those in normal growth pregnancies. A multivariable regression analysis revealed that maternal factors (PHT), fetal factors (anomaly), and placental findings (infarction, fetal vessel thrombosis, and chronic villitis) are independently associated with increased risk of IUGR (all P<0.01).

Management of developmental dysplasia of the hip in young adults

The term developmental dysplasia of the hip (DDH) describes a spectrum of disorders that results in abnormal development of the hip joint. If not treated successfully in childhood, these patients may go on to develop hip symptoms and/or secondary osteoarthritis in adulthood. In this review we describe the altered anatomy encountered in adults with DDH along with the management options, and the challenges associated with hip arthroscopy, osteotomies and arthroplasty for the treatment of DDH in young adults.

Cite this article: Bone Joint J 2013;95-B:732–7.

Epidemiological impact of mass tuberculosis screening: a 2-year follow-up after a national prevalence survey

OBJECTIVE

To assess the epidemiological impact of mass tuberculosis (TB) screening in the community and the prognosis of bacteriologically negative individuals with abnormal findings on chest radiography (CXR).

METHODS

A follow-up study consisting of two parts--a register match of notified TB cases with 22,160 participants in a national TB prevalence survey, and a repeat medical examination for the subjects of a prevalence survey with abnormal findings on CXR--was conducted 2 years after the prevalence survey in Cambodia.

RESULTS

Thirty-four cases with new smear-positive TB were detected by register match, giving a standardised notification ratio of 0.38 (95%CI 0.27-0.52). An additional seven new smear-positive TB cases and 93 new smear-negative, culture-positive TB cases were detected by medical examination. The incidence rates of bacteriologically positive TB were 8.5% per year (95%CI 6.3-11.2) in cases with a CXR suggestive of active TB and 2.9% per year (95%CI 2.2-3.7) in those with a CXR with other abnormalities.

CONCLUSIONS

Detection and treatment of smear-negative, culture-positive TB cases as well as smear-positive TB cases was associated with a rapid reduction in subsequent incidence of new smear-positive TB. Sputum culture-negative individuals with abnormal CXR findings are at a high risk of disease progression, and require follow-up and potentially preventive treatment.

Leisure-time physical activity is a significant predictor of stroke and total mortality in Japanese patients with type 2 diabetes: analysis from the Japan Diabetes Complications Study (JDCS)

AIMS/HYPOTHESIS

Our aim was to clarify the association between leisure-time physical activity (LTPA) and cardiovascular events and total mortality in a nationwide cohort of Japanese diabetic patients.

METHODS

Eligible patients (1,702) with type 2 diabetes (mean age, 58.5 years; 47% women) from 59 institutes were followed for a median of 8.05 years. A comprehensive lifestyle survey including LTPA and occupation was performed using standardised questionnaires. Outcome was occurrence of coronary heart disease (CHD), stroke and total mortality. The adjusted HR and 95% CI were calculated by Cox regression analysis.

RESULTS

A significant reduction in HR in patients in the top (≥ 15.4 metabolic equivalents [MET] h/week) vs the bottom tertile (≤ 3.7 MET h/week) of LTPA, adjusted by age, sex and diabetes duration, was observed in stroke (HR 0.55, 95% CI 0.32, 0.94) and total mortality (HR 0.49, 95% CI 0.26, 0.91) but not in CHD (HR 0.77, 95% CI 0.48, 1.25). The HR for stroke became borderline significant or nonsignificant after adjustment for lifestyle or clinical variables including diet or serum lipids. The significantly reduced total mortality by LTPA was independent of these variables and seemed not to be, at least mainly, attributed to reduced cardiovascular disease.

CONCLUSIONS/INTERPRETATION

In Japanese persons with type 2 diabetes, LTPA of 15.4 MET h/week or more was associated with a significantly lower risk of stroke partly through ameliorating combinations of cardiovascular risk factors. It was also associated with significantly reduced total mortality but independently of cardiovascular risk factors or events. These findings, implying differences from Western diabetic populations, should be considered in the clinical management of East Asians with diabetes.

Recognition of endoscopic diagnosis in differentiated-type early gastric cancer by flexible spectral imaging color enhancement with indigo carmine

BACKGROUND/AIMS

To evaluate the usefulness of flexible spectral imaging color enhancement with indigo carmine (I-FICE) in early gastric cancer (EGC) demarcation.

METHODS

The study participants were 29 patients with differentiated-type EGC. The endoscope was fixed and images of the same area of EGC demarcations in each lesion were obtained using four different methods (WLE, flexible spectral imaging color enhancement (FICE), CE, and I-FICE). FICE mode at R 550 nm (Gain: 2), G 500 nm (Gain: 4), and B 470 nm (Gain: 4) was used. Four endoscopists ranked the images obtained by each method on the basis of the ease of recognition of demarcation using a 4-point system. We calculated the standard deviation of pixel values based on L*, a*, and b* color spaces in the demarcation region (Lab-SD score).

RESULTS

The median ranking score for I-FICE images was significantly higher than that obtained from the other methods. Further, the average Lab-SD score was significantly higher for I-FICE images than for images obtained by the other methods. There was a good correlation between the ranking score and Lab-SD score.

CONCLUSION

EGC demarcations were most easily recognized both subjectively and objectively using I-FICE image, followed by CE, FICE and WLE images.

[Treatment of psychiatric symptoms in schizophrenia spectrum disorders with comorbid sleep apnea syndrome: a case report]

Sleep apnea syndrome (SAS) is characterized by apnea and hypopnea during sleep. SAS manifests various symptoms, and can become a risk factor for a variety of diseases. Typical psychiatric presentations of SAS are depressive symptoms, and those resembling negative symptoms in schizophrenia. We report two patients with schizophrenia spectrum disorders. Both patients showed the partial improvement of psychiatric symptoms with pharmacotherapy. After diagnosing comorbid SAS and subsequent treatment with continuous positive airway pressure (CPAP), the psychiatric symptoms improved. The first case was a 54-year-old woman, who presented with auditory hallucinations and delusions and was diagnosed with schizophrenia at 32 years of age. Her positive symptoms responded immediately to medication; however, her negative symptoms persisted despite switching to atypical antipsychotics. We diagnosed her with SAS using pulse oximetry and portable polysomnography (PSG), and, after treatment with CPAP, her fatigue and shallow sleep improved, as well as her quality of life (QOL). The second case was is a 61-year-old man, who presented with delusions of persecution and was diagnosed with delusional disorder at 49 years of age. His delusional symptoms fluctuated under medication, and repeatedly worsened under stressful situations. We suspected SAS as a Complicating factor, and diagnosed him with severe SAS using PSG. After treatment with CPAP, his hypertension and delusions of persecution improved. Screening for SAS is available in psychiatric hospitals and outpatient clinics. We believe that the possibility of comorbid SAS in psychiatric patients should be more widely acknowleged in clinical psychiatry.

Effect of low-frequency rTMS on motor neuron excitability after stroke

OBJECTIVES

The purpose of this study was to test the effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) over the non-lesional hemisphere on motor neuron excitability of the paretic upper limb in post-stroke patients by electrophysiological examination.

MATERIALS AND METHODS

Thirteen post-stroke patients with spastic upper limb hemiparesis were studied (age, 57.5 ± 11.1 years; time after stroke, 55.2 ± 51.4 months). Low-frequency rTMS of 1 Hz was applied for 20 min to the motor cortex of the non-lesional hemisphere. The M-response amplitude and F-wave parameters were recorded in the abductor pollicis brevis muscle following stimulation of the median nerve in both the affected and unaffected upper limbs. The F-wave frequency, F-max/M ratio (ratio of maximum F-wave amplitude to M-response amplitude), and F-mean/M ratio (the ratio of mean F-wave amplitude to the M-response amplitude) were measured before and after the 20-min rTMS, analyzed for both limbs.

RESULTS

Application of low-frequency rTMS did not result in significant changes in the frequency of F-wave and F-max/M ratio in both upper limbs, but significantly decreased F-mean/M ratio in the affected upper limb (P < 0.005), but not in the unaffected limb.

CONCLUSIONS

Low-frequency rTMS applied to the non-lesional hemisphere might be potentially useful therapeutically for post-stroke patients with spastic upper limb hemiparesis.

Development of a new scoring system for predicting the 5 year incidence of type 2 diabetes in Japan: the Toranomon Hospital Health Management Center Study 6 (TOPICS 6)

AIMS/HYPOTHESIS

The aims of this study were to assess the clinical significance of introducing HbA(1c) into a risk score for diabetes and to develop a scoring system to predict the 5 year incidence of diabetes in Japanese individuals.

METHODS

The study included 7,654 non-diabetic individuals aged 40-75 years. Incident diabetes was defined as fasting plasma glucose (FPG) ≥7.0 mmol/l, HbA(1c) ≥6.5% (48 mmol/mol) or self-reported clinician-diagnosed diabetes. We constructed a risk score using non-laboratory assessments (NLA) and evaluated improvements in risk prediction by adding elevated FPG, elevated HbA(1c) or both to NLA.

RESULTS

The discriminative ability of the NLA score (age, sex, family history of diabetes, current smoking and BMI) was 0.708. The difference in discrimination between the NLA + FPG and NLA + HbA(1c) scores was non-significant (0.836 vs 0.837; p = 0.898). A risk score including family history of diabetes, smoking, obesity and both FPG and HbA(1c) had the highest discrimination (0.887, 95% CI 0.871, 0.903). At an optimal cut-off point, sensitivity and specificity were high at 83.7% and 79.0%, respectively. After initial screening using NLA scores, subsequent information on either FPG or HbA(1c) resulted in a net reclassification improvement of 42.7% or 52.3%, respectively (p < 0.0001). When both were available, net reclassification improvement and integrated discrimination improvement were further improved at 56.7% (95% CI 47.3%, 66.1%) and 10.9% (9.7%, 12.1%), respectively.

CONCLUSIONS/INTERPRETATION

Information on HbA(1c) or FPG levels after initial screening by NLA can precisely refine diabetes risk reclassification.

MUC1 enhances hypoxia-driven angiogenesis through the regulation of multiple proangiogenic factors

Pancreatic cancer is one of the most lethal malignancies due to its aggressive growth and rapid development of distant metastases. In this context, mucin 1 (MUC1) overexpression and hypoxia are frequently observed events. However, their functional relationship remains largely unknown. This study provides evidence that MUC1 is overexpressed by hypoxia and contributes to hypoxia-driven angiogenesis. Using the conditioned medium obtained from hypoxia-stressed AsPC1 cells treated with MUC1 siRNAs, we demonstrated that MUC1 enhanced the endothelial tube formation, proliferation and migration ability, which induced by hypoxia-conditioned medium (HCM). In addition, MUC1 was significantly induced by hypoxia, especially in the pancreatic cancer cells derived from metastatic tumors (AsPC1, HPAF2 or Capan1), and MUC1-cytoplasmic tail (MUC1-CT) accumulated in the nucleus under hypoxia. As noted in a previous report, MUC1-CT was recruited to genomic regions upstream of the connective tissue growth factor (CTGF) accompanied with β-catenin and p53, resulting in the hypoxic induction of CTGF. Moreover, hypoxia-induced MUC1 partially regulated two other hypoxia-inducible proangiogenic factors including vascular endothelial growth factor-A and platelet-derived growth factor-B. The neutralization assay revealed that endothelial tube formation induced by HCM was clearly suppressed by antibodies against these three factors, suggesting the importance of these factors in hypoxia-driven angiogenesis. In summary, this is the first report demonstrating a pivotal role of MUC1 in controlling the hypoxia-driven angiogenesis through the regulation of multiple proangiogenic factors in pancreatic cancer. Our findings provide the novel insights into the understanding of complex interactions between pancreatic cancer cells and tumor microenvironments.

Characterization and purification of angiogenic factor derived from highly liver metastatic colon cancer cells

We investigated the effects of serum-free conditioned medium (SFCM) of colon cancer cells on human umbilical vein endothelial cells (HUVECs). SFCM of highly liver metastatic cell line (LM-HS) strongly enhanced proliferation, migration and tube formation of HUVECs. Moreover, it was suggested that a main angiogenic factor derived from LM-H5 may be VEGF based on HPLC, SDS-PAGE analysis and neutralizing experiment using anti-growth factor antibodies. These findings suggest that angiogenesis is related to the processes of metastasis of colon cancer, and that VEGF synthesized by colon cancer cells acts as a key factor inducing angiogenesis.

Establishment and characterization of a new human gallbladder carcinoma cell line (OCUG-1) producing TA-4

A new human cell line (OCUG-1) was established from peritoneal effusion of a patient with malignant gallbladder carcinoma. OCUG-1 cells proliferated mainly in clusters of cells partially floating in a monolayered sheet. The population doubling time is 47.1 h. DNA analysis showed that OCUG-1 cells were aneuploid and had two G(0)/G(1) peaks. The number of chromosomes was distributed in a broad range from 52 to 139. Subcutaneous injections of the cells induced tumor formation in all nude mice. The reconstituted tumors were poorly differentiated adenocarcinoma. High levels of SLX, CA19-9, SPan-1 and TA-4 were found in the serum of the original patient, but OCUG-1 cells produced only TA-4. We speculate that OCUG-1 may be a transitional form from adenocarcinoma to squamous cell carcinoma. Since OCUG-1 produces a high level of TA-4, it will be useful for the study of the biological nature of this carcinoma and the relationship between the expression of TA-4 and squamatization.

High normal HbA(1c) levels were associated with impaired insulin secretion without escalating insulin resistance in Japanese individuals: the Toranomon Hospital Health Management Center Study 8 (TOPICS 8)

AIMS

We aimed to characterize the association of insulin resistance, impaired insulin secretion and β-cell dysfunction in relation to HbA(1c) levels in a non-diabetic range in Japanese individuals without clinically diagnosed diabetes.

METHODS

This cross-sectional study included 1444 individuals without a history of outpatient treatment of diabetes or use of insulin or oral hypoglycaemic agents. The homeostasis model assessment of insulin resistance and beta-cell function, insulinogenic index, Matsuda index and disposition index were calculated using data from 75-g oral glucose tolerance tests and compared across quintile (Q) categories of HbA(1c) levels.

RESULTS

Fasting plasma glucose and 30-min and 60-min plasma glucose (PG) levels were significantly higher when HbA(1c) exceeded 36 mmol/mol (5.4%). A HbA(1c) concentration of 36-37 mmol/mol (5.4-5.5%) (Q3) was significantly associated with a 15% lower homeostasis model assessment of β-cell function value and 31% lower insulinogenic index value compared with HbA(1c) ≤ 32 mmol/mol (≤ 5.1%) (Q1) (P <0.01). Further, a HbA(1c) concentration of 38-40 mmol/mol (5.6-5.8%) (Q4) was associated with 17% (P <0.01) and 24% (P <0.05) reductions in those indexes, respectively. However, the homeostasis model assessment of insulin resistance was not significantly elevated and the Matsuda index was not significantly lower unless HbA(1c) exceeded 41 mmol/mol (5.9%). Individuals with HbA(1c) ≥ 41 mmol/mol (≥ 5.9%) (Q5) had a 69% lower disposition index than those with a HbA(1c) concentration of ≤ 32 mmol/mol (≤ 5.1%) (Q1).

CONCLUSIONS

Elevated HbA(1c) levels ≥ 41 mmol/mol (≥ 5.9%) were associated with substantial reductions in insulin secretion, insulin sensitivity and β-cell dysfunction in Japanese individuals not treated for diabetes. High normal HbA(1c) levels of 36-40 mmol/mol (5.4-5.8%) were also associated with impaired insulin secretion without marked insulin resistance in Japanese individuals.

Screening for pre-diabetes to predict future diabetes using various cut-off points for HbA(1c) and impaired fasting glucose: the Toranomon Hospital Health Management Center Study 4 (TOPICS 4)

AIM

To evaluate various screening criteria for pre-diabetes to identify which combination of impaired fasting glucose and elevated HbA(1c) values performs most effectively in predicting future diabetes in a large cohort of Japanese individuals.

METHODS

The study included 4670 men and 1571 women without diabetes (diabetes: fasting plasma glucose ≥ 7.0 mmol/l, HbA(1c) ≥ 48 mmol/mol (≥ 6.5%), or self-reported clinician-diagnosed diabetes). Pre-diabetes was diagnosed by a combination of impaired fasting glucose (fasting plasma glucose 5.6-6.9 mmol/l or 6.1-6.9 mmol/l) and elevated HbA(1c) [39-46 mmol/mol (5.7-6.4%) or 42-46 mmol/mol (6.0-6.4%)].

RESULTS

During a 5-year follow-up, 338 incident cases of diabetes occurred. The combination of HbA(1c) 39-46 mmol/mol (5.7-6.4%) and fasting plasma glucose 5.6-6.9 mmol/l yielded the highest sensitivity (86%) and generated a large population-attributable per cent risk (78%) for predicting development of diabetes. Among individuals classified as having pre-diabetes by any of the four combined criteria, 20.5-32.0% reverted to the normoglycaemic state as having neither elevated HbA(1c) nor impaired fasting glucose at the last follow-up examination. At 5.6 years after the baseline examination, however, pre-diabetic individuals who fulfilled both HbA(1c) 42-46 mmol/mol (6.0-6.4%) and fasting plasma glucose 6.1-6.9 mmol/l had a 100% cumulative risk of developing diabetes.

CONCLUSIONS

The combination of HbA(1c) 39-46 mmol/mol (5.7-6.4%) and fasting plasma glucose 5.6-6.9 mmol/l would have the best performance in reducing the likelihood of missing future cases of diabetes. Identifying pre-diabetic individuals who strictly fulfil HbA(1c) 42-46 mmol/mol (6.0-6.4%) and fasting plasma glucose 6.1-6.9 mmol/l would predict definite progression to diabetes.

Living donor liver transplantation from an asymptomatic mother who was a carrier for ornithine transcarbamylase deficiency

Liver transplantation (LT) has been adopted as a radical treatment for ornithine transcarbamylase deficiency (OTCD), yielding favorable outcomes. Despite the fact that it is an inheritable disease, a blood relative who is heterozygous for the disorder must sometimes be used as a liver donor for living donor LT. There is ongoing discussion regarding the use of heterozygous donors, however, to our knowledge, no cases where donation was determined based on the Ornithine transcarbamylase (OTC) activity before LT have been reported. Between May 2001 and April 2011, 17 patients were indicated for living donor LT because of OTCD at our facility. There were three cases with heterozygous donor candidate (17.6%). All heterozygous candidates underwent a liver biopsy to measure their OTC activity before LT and made efforts to secure the safety of the both donor and recipient. Two of 3 candidates had headaches sometimes, and their activity was less than 40%, and thus they were not employed as the donor. One candidate with 104.4% activity was employed, yielding favorable outcomes. Our current experience supported the effectiveness of our donation criteria, however it is necessary to collect sufficient data on a large number of patients to confirm the safety of the procedure.

Impact of psychological stress caused by the Great East Japan Earthquake on glycemic control in patients with diabetes

We examined the relationship between psychological stress and the worsening of glycemic control in diabetic patients at the time of the Great East Japan Earthquake. HbA1c levels in diabetic patients before and after the disaster were evaluated with the General Health Questionnaire (GHQ) and other questions including those on changes in diet, exercise, psychological stress and drug intake in 320 consecutive diabetic patients who had been followed in a diabetes clinic. Logistic regression analysis revealed that the total GHQ scores (odds ratio [OR] 1.03 [95% confidence interval 1.01-1.06]; p<0.01) and interruption of drug intake (OR 4.48 [1.57-12.7]; p=0.01) were independently associated with worsening of glycemic control defined as an increase in the HbA1c level equal to or greater than 0.5%. Among the scores on the GHQ, those for somatic symptoms (OR 1.18 [1.01-1.38]; p=0.03) and sleep disturbances or anxiety (OR 1.26 [1.08-1.46]; p<0.01) were independently associated with glycemic control. These results suggest that psychological stress during a disaster has independent effects on worsening of glycemic control.

Veno-occlusive disease/sinusoidal obstruction syndrome associated with potential antibody-mediated rejection after pediatric living donor liver transplantation: a case report

A 9-month-old girl with biliary atresia underwent successful living donor liver transplantation from her 42-year-old ABO blood-type incompatible mother. The postoperative course was uneventful until postoperative day (POD) 13 when the recipient displayed an increased volume of drained ascites and decreased her platelet count showing low-velocity portal venous inflow without hepatic venous outflow obstruction. We suspected potential veno-occlusive disease/sinusoidal obstruction syndrome (vod/sos) due to an acute cellular rejection (ACR) episode and performed a liver biopsy (LB). We diagnosed severe episode (Rejection Activity Index Score; P3V3B1 = 7) and started steroid pulse therapy. We performed a second LB on POD 27 because the patient showed weight gain and tender hepatomegaly, diagnosing moderate ACR (P1V3B1 = 5). We started a second course of steroid pulse therapy, but the patient's clinical findings did not improve. On POD 43, her third LB finding showed P1V1B1 with improved processes from ACR, but still displaying severe congestion and fibrotic obliteration of small hepatic veins. We suspected that her immunologic responses were associated with antibody-mediated rejection (AMR) because her anti-HLA class I and class II antibodies were positive by flow panel-reactive antibody method and donor-specific antigen class II and C4d staining were also positive. We added mycophenolate mofetil and administered high-dose intravenous immunoglobulin to control the AMR, and anticoagulant therapy for the VOD/SOS. Her clinical findings and graft venous abnormalities finally improved; she was eventually discharged without sequelae on POD 72.

[Diagnosis and treatment in circadian rhythm sleep disorders]

Circadian rhythm sleep disorders (CRSD) are characterized by misalignment between major sleep episode and desired sleep phase, or symptoms associated with internal desynchronization between endogenous circadian rhythm and overt sleep-wake rhythm. Endogenous circadian rhythm is mainly regulated by master circadian clock located in the suprachiasmatic nucleus. Light entrains the circadian clock according to a phase-response curve. Furthermore, social time cue affects human sleep-wake rhythm. Instructions concerning sleep hygiene including light environment play fundamental role for the treatment in CRSD. In addition, light therapy and oral melatonin administration have application to delayed sleep phase type. Diagnostic classification and treatment in each types of CRSD are reviewed in this article.

Spontaneously complete regression of pseudolymphoma of the remnant pancreas after pancreaticoduodenectomy

BACKGROUND

Pancreatic pseudolymphoma is extremely rare.

METHOD

We present multiple pseudolymphomas in the head and body of the pancreas. The hypoechoic lesions observed by endoscopic ultrasound were enhanced in late-phase angio-computed tomography and homogeneously hypointensive in T1-weighted magnetic resonance imaging (MRI). (18)F-fluorodeoxyglucose positron emission tomography showed strong accumulation in the lesions. The lesions were suspected to be non-functioning islet cell carcinoma. The intraoperative pathological diagnosis for the specimen obtained by a pylorus-preserving pancreaticoduodenectomy was non-neoplastic lymphoid cells. The remnant lesion in the pancreatic body was preserved.

RESULTS

Macroscopically, the mass was well-circumscribed gray-white colored lesion. The pathological diagnosis was pancreatic pseudolymphoma. The lesion in the remnant pancreas spontaneously disappeared within one year after the operation.

CONCLUSION

The differential diagnosis of pancreatic pseudolymphoma from malignant tumor is very difficult, however, the image findings demonstrated here may be informative. The spontaneous disappearance of pancreatic pseudolymphoma was firstly observed in the present case.

A new model of gastric bleeding induced in rats by aspirin plus clopidogrel under stimulation of acid secretion. Prophylactic effects of antiulcer drugs

We set up a new model of gastric bleeding induced by the luminal perfusion of aspirin (ASA) in rats pretreated with clopidogrel under conditions where acid secretion is stimulated, and examined the effect of antiulcer drugs on the bleeding. Under urethane anesthesia, acid secretion was stimulated by i.v. infusion of histamine (8 mg/kg/h), and two catheters were inserted into the stomach, one from the esophagus and another from the duodenum. The stomach was perfused with 25 mM ASA at a rate of 0.1 ml/min using an infusion pump, and gastric bleeding was measured as hemoglobin concentration in the perfusate collected every 15 min. Clopidogrel (30 mg/kg) was given orally 24 h before the perfusion. Various antiulcer drugs were given intraduodenally 30 min before the ASA treatment. Perfusion of the stomach with ASA provoked little gastric bleeding or damage even when acid secretion was stimulated. Pretreatment with clopidogrel significantly increased the bleeding and damage caused by ASA. The bleeding and lesions produced by ASA plus clopidogrel were significantly prevented by pretreatment with famotidine and omeprazole. Mucosal protective drugs such as rebamipide, irsogladine and teprenone also prevented gastric bleeding response to ASA/clopidogrel under conditions of acid secretion, although the effect was less pronounced than that of the antisecretory drugs. We conclude that clopidogrel increases gastric bleeding induced by ASA when acid secretion is stimulated. Both antisecretory and mucosal protective drugs are effective in reducing gastric bleeding under such conditions. This model is useful for the screening of drugs that protect against gastric bleeding.

Fascin-1 expression in canine cutaneous and oral melanocytic tumours

Fascin-1 expression was examined in 9 cutaneous melanocytomas and 47 oral melanomas. The cases were scored on the basis of extent and intensity of staining, and combined scores were calculated. Fascin-1 expression was observed in 5/9 (56%) melanocytomas and 46/47 (98%) melanomas. The combined score for fascin-1 was significantly greater in stage III/IV melanomas than in stage I/II melanomas (P < 0.05). In addition, strong fascin-1 staining was associated with a significantly shortened survival time (P < 0.05). The results of this study suggest that fascin-1 overexpression correlates with the malignancy of canine melanoma and has the potential to be a new immunohistochemical marker to predict the clinical course of canine melanoma. In addition, targeted therapy for fascin-1 may represent a new strategy for the treatment of canine melanoma.

The published research paper: is it an important indicator of successful operational research at programme level?

Is a published research paper an important indicator of successful operational research at programme level in low-income countries? In academia, publishing in peer-reviewed scientific journals is highly encouraged and strongly pursued for academic recognition and career progression. In contrast, for those who engage in operational research at programme level, there is often no necessity or reward for publishing the results of research studies; it may even be criticized as being an unnecessary detraction from programme-related work. We present arguments to support publishing operational research from low-income countries; we highlight some of the main reasons for failure of publication at programme level and suggest ways forward.

Incidence and progression of diabetic retinopathy in Japanese adults with type 2 diabetes: 8 year follow-up study of the Japan Diabetes Complications Study (JDCS)

AIMS/HYPOTHESIS

The aim of this study was to determine the incidence and progression rates of diabetic retinopathy and their associations in Japanese individuals with type 2 diabetes.

METHODS

This is a part of the Japan Diabetic Complications Study (JDCS), a multi-centred randomised trial of type 2 diabetes patients aged 40-70 years with an 8 year follow-up. There were 1,221 patients without diabetic retinopathy at baseline; incidence of diabetic retinopathy was defined as the development of any diabetic retinopathy. There were 410 patients with mild non-proliferative diabetic retinopathy at baseline; progression of diabetic retinopathy was defined as the development of severe non-proliferative diabetic retinopathy or proliferative diabetic retinopathy. We used multivariate proportional Cox hazard models, and generalised additive models were also applied to identify potential threshold effect.

RESULTS

The incidence and progression rate of diabetic retinopathy was 38.3/1,000 person-years and 21.1/1,000 person-years, respectively. Higher HbA(1c) (adjusted HR [aHR] per 1% [10.9 mmol/mol] 1.36 [95% CI 1.28-1.45]), longer duration of diabetes (aHR per 5 year period 1.26 [95% CI 1.17-1.35]), higher systolic blood pressure (aHR per +10 mmHg 1.01 [95% CI 1.00-1.02]) and higher body mass index (aHR per 1 kg/m(2) 1.05 [95% CI 1.00-1.09]) were associated with incident diabetic retinopathy. The association between HbA(1c) and incident diabetic retinopathy was linear; the association with duration of diabetes increased rapidly between 5 and 10 years. Higher HbA(1c) was also associated with progression of diabetic retinopathy (aHR per 1% [10.9 mmol/mol] 1.66 [95% CI 1.41-1.96]).

CONCLUSIONS

Observed incidence and progression rates of diabetic retinopathy seemed lower than that in western populations. HbA(1c) was the only factor associated with both incidence and progression of diabetic retinopathy. The strength of the association between duration of diabetes and incidence of diabetic retinopathy increased rapidly during a period of 5 to 10 years duration of diabetes.

TRIAL REGISTRATION

C000000222 ( www.umin.ac.jp )

FUNDING

This study is supported by the Ministry of Health, Labour and Welfare, Japan.

Transgenic rabbits expressing human lipoprotein lipase

To study the functions of lipoprotein lipase (LPL) in lipid and lipoprotein metabolism and the relationship between LPL and atherosclerosis, we generated transgenic rabbits expressing the human LPL gene. A total of 4045 Japanese whiterabbit embryos were microinjected with a 3.8-kb SalI/HindIII fragment containing the chicken beta-actin promoter, human LPL cDNA and rabbit beta-globin with poly (A) signals, and then transplanted into 116 recipient rabbits. Of the 166 pups born, six pups were transgenic as confirmed by Southern blot analysis. ANorthern blot analysis revealed that human LPL was expressed by a number of tissues including the heart, kidney, adrenal gland and intestine. One transgenic rabbit showed up to 3-foldincreased LPL activity in post-heparin plasma compared to thatin nontransgenic rabbits. Human LPL expression in various tissues of transgenic rabbits was further elucidated by in situ hybridization and immunostaining. Since rabbits are superior to mice as a model of atherosclerosis, this transgenicrabbit model should provide a valuable tool for the study of LPL in lipid metabolism and atherosclerosis.

Hereditary cerebellar degenerative disease (cerebellar cortical abiotrophy) in rabbits

A pair of rabbits gave birth to a set of littermates (F1) with symptoms of early-onset ataxia. Microscopic examination revealed cerebellar degenerative disease in 5 of 6 littermates. Light microscopy was used to compare the thickness of each cerebellar layer in affected animals in contrast to a normal control. Affected animals showed narrowing of the molecular layer of the vermis, reduced density of Purkinje cell dendrites and irregular thickness in their branchlets, and reduced density of granular cells and scattered pyknotic cells in the granular layer. Pyknotic cells were apoptotic granular cells, confirmed by positive staining using the TUNEL method. Electron microscopy confirmed the thinning of the molecular layer seen by light microscopy and also showed a reduced number of parallel fibers, which indicate granular cells axons, and a reduced number of synaptic junctions between Purkinje and granular cells. Purkinje cells had electron-dense, irregularly shaped cytoplasm with irregularly shaped nuclei, and some of these cells had a central chromatolysis-like region. These findings support a diagnosis of cerebellar cortical abiotrophy, a hereditary condition that causes nerve function impairment leading to early-onset progressive degeneration of the cerebellar cortex.

Low transition rate from normo- and low microalbuminuria to proteinuria in Japanese type 2 diabetic individuals: the Japan Diabetes Complications Study (JDCS)

AIMS/HYPOTHESIS

The aim of the study was to determine the transition rate and factors associated with the progression of normo- and low microalbuminuria to diabetic nephropathy (overt proteinuria).

METHODS

For 8 years we prospectively observed 1,558 Japanese patients with type 2 diabetes mellitus whose basal urinary albumin:creatinine ratio (UACR) had been measured as <17.0 mg/mmol at entry. The incidence of nephropathy (UACR >33.9 mg/mmol) was determined by measuring UACR twice a year.

RESULTS

Progression to nephropathy occurred in 74 patients. The annual transition rate was 0.67%, and was substantially higher for the low-microalbuminuric group than for the normoalbuminuric group (1.85% and 0.23%, respectively; hazard ratio for the low-microalbuminuric group 8.45, p < 0.01). The hazard ratio for an HbA(1c) of 7-9% or ≥9% was 2.72 (p < 0.01) or 5.81 (p < 0.01) relative to HbA(1c) <7.0%, respectively. In comparison with individuals with a systolic blood pressure (SBP) of <120 mmHg, the hazard ratios for patients with an SBP of 120-140 mmHg or ≥140 mmHg were 2.31 (p = 0.06) and 3.54 (p < 0.01), respectively. Smoking also affected progression to proteinuria (hazard ratio 1.99, p < 0.01). In contrast, 30.3% of the low-microalbuminuric group returned to normoalbuminuria (i.e. were in remission).

CONCLUSIONS/INTERPRETATION

These results suggest that if patients with type 2 diabetes mellitus are receiving treatment from diabetologists for hyperglycaemia and hypertension when they are in the early stages of nephropathy (i.e. normo- or low microalbuminuria), their rate of transition to proteinuria is considerably lowered, and that differentiating patients with low microalbuminuria from those with high microalbuminuria might be clinically useful.

TRIAL REGISTRATION

UMIN Clinical Trials Registry C000000222.

Low serum potassium levels and risk of type 2 diabetes: the Toranomon Hospital Health Management Center Study 1 (TOPICS 1)

AIMS/HYPOTHESIS

Evidence has suggested that low serum potassium concentrations decrease insulin secretion, leading to glucose intolerance, and that hypokalaemia induced by diuretics increases the risk for diabetes in hypertensive individuals. However, no prospective study has investigated the association between serum potassium and the development of type 2 diabetes in a healthy cohort comprised of Asian individuals not being administered antihypertensive medications. This study aimed to investigate whether low serum potassium is associated with increased risk of type 2 diabetes in apparently healthy Japanese men.

METHODS

We followed 4,409 Japanese men with no history of diabetes, use of antihypertensives, renal dysfunction or liver dysfunction (mean ± SD age, 48.4 ± 8.4 years). Cox proportional hazards regression was used to estimate HRs for incident diabetes (fasting plasma glucose level ≥ 7.0 mmol/l, HbA(1c) ≥ 6.5% or self-reported) including serum potassium concentration as either a categorical or a continuous variable.

RESULTS

During a 5 year follow-up, 250 individuals developed type 2 diabetes. The lowest tertile of serum potassium (2.8-3.9 mmol/l) was independently associated with the development of diabetes after adjustment for known predictors (HR 1.57 [95% CI, 1.15-2.15]) compared with the highest tertile (4.2-5.4 mmol/l). Every 0.5 mmol/l lower increment in the baseline serum potassium level was associated with a 45% (12-87%) increased risk of diabetes.

CONCLUSIONS/INTERPRETATION

Mild to moderately low serum potassium levels, within the normal range and without frank hypokalaemia, could be predictive of type 2 diabetes in apparently healthy Japanese men.

[Anesthetic management for a patient with scoliosis combined with central core disease]

We gave general anesthesia to a patient with scoliosis combined with central core disease (CCD). CCD is a slowly progressive autosomal dominant congenital myopathy. CCD is presented typically in infancy with hypotonia and delay of motor development, characterized by predominantly proximal weakness pronounced in the hip girdle. Orthopedic complications are common with congenital dislocation of the hips, scoliosis and foot deformity. CCD is due to mutations in the skeletal muscle ryanodine receptor (RYR1) gene at chromosome 19q13.1, which is also implicated in the malignant hyperthermia (MH). A patient with CCD is at risk of MH, with an abnormal response to suxamethonium and volatile anesthetics. The anesthetist ought to be aware of the diagnosis of CCD and to plan anesthetic management accordingly, avoiding potentially MH-triggering agents. We used total intravenous anesthesia (TIVA) in this case, and he showed no MH symptoms perioperatively. This report demonstrates that anesthesia in a patient with CCD could be successfully maintained with TIVA.

Multiscale imaging characterization of dopamine transporter knockout mice reveals regional alterations in spine density of medium spiny neurons

The dopamine transporter knockout (DAT KO) mouse is a model of chronic hyperdopaminergia used to study a wide range of neuropsychiatric disorders such as schizophrenia, attention deficit hyperactivity disorder (ADHD), drug abuse, depression, and Parkinson's disease (PD). Early studies characterizing this mouse model revealed a subtle, but significant, decrease in the anterior striatal volume of DAT KO mice accompanied by a decrease in neuronal cell body numbers (Cyr et al., 2005). The present studies were conducted to examine medium spiny neuron (MSN) morphology by extending these earlier reports to include multiscale imaging studies using correlated light microscopy (LM) and electron microscopy (EM) techniques. Specifically, we set out to determine if chronic hyperdopaminergia results in quantifiable or qualitative changes in DAT KO mouse MSNs relative to wild-type (WT) littermates. Using Neurolucida Explorer's morphometric analysis, we measured spine density, dendritic length and synapse number at ages that correspond with the previously reported changes in striatal volume and progressive cell loss. Light microscopic analysis using Neurolucida tracings of photoconverted striatal MSNs revealed a highly localized loss of dendritic spines on the proximal portion of the dendrite (30 μm from the soma) in the DAT KO group. Next, thick sections containing MSN dendritic segments located at a distance of 20-60 μm from the cell soma, a region of the dendrite where spine density is reported to be the highest, were analyzed using electron microscope tomography (EMT). Because of the resolution limits of LM, the EM analysis was an extra measure taken to assure that our analysis included nearly all spines. Spine density measurements collected from the EMT data revealed only a modest decrease in the DAT KO group (n=3 mice) compared to age-matched WT controls (n=3 mice), a trend that supports the LM findings. Finally, a synaptic quantification using unbiased stereology did not detect a difference between DAT KO mice (n=6 mice) and WT controls (n=7 mice) at the EM level, supporting the focal nature of the early synaptic loss. These findings suggest that DAT KO mice have MSNs with highly localized spine loss and not an overall morphologically distinct cell shape. The characterization of morphological changes in DAT KO mice may provide information about the neural substrates underlying altered behaviors in these mice, with relevance for human neurological disorders thought to involve altered dopaminergic homeostasis. Results from this study also indicate the difficulty in correlating structural changes across scales, as the results on fine structure revealed thus far are subtle and non-uniform across striatal MSNs. The complexities associated with multiscale studies are driving the development of shared online informatics resources by gaining access to data where it is being analyzed.

Estimation of Effective Diffusivity in Compacted Ben Tonite

Effective diffusivities of radioactive nuclides in compacted bentonite were calculated theoretically by using an electric double layer theory. Comparison between calculated diffusivities and measured ones show good agreements.

The effective diffusivity is dominated by pore structure and pore diffusivity Dp. The pore structure can be characterized by effective porosity ε eff, constrictivity δ, and tortuosity Γ. The δ was assumed to be unity. The ε eff and the Γ were determined experimentally. The Dp was estimated by means of the electric double layer theory. In the estimation, smectite interlayer was assumed the space between parallel plane sheets of smectite crystal lattice.

Diffusion experiments were carried out by using Cs+ for monovalent cation, C1- and Tc04- for monovalent anion, and tritiated water for neutral molecule. The measured and calculated effective diffusivities in different densities showed the same tendency of cation > neutral > anion. The dry density of bentonite became higher, the discrepancy between the estimated and the measured diffusivities became larger. The calculation was limited by the applicability of the electric double layer theory in the near surface region of smectite.

[A report on attempted suicide cases involving patients accepted by public health care institutions]

We investigated attempted suicide cases, both successful and failed involving patients, accepted by public health care institutions in Shiga Prefecture, whose population is about 1. 4 million, from the 12th January 2010 to 14th February 2010. Prefectural emergency hospitals, fire stations, and pathologists cooperated in the investigation, and the cases were reported with the age and sex as well as the means and results of the attempts. How these institutions cooperated in the cases was also reported. A total number of 104 people attempted suicide, in which 40 people (38.5%) succeeded, 54 people (51.9%) failed, and the outcome was unknown in 10 people (9.6%). Forty-one people (39.4%) were in their 30s, being the most common age group. Successful suicides were most prominent among elderly males, and failed attempts were most prominent among young females. Hanging and poisonous gassing were the common means of suicide among the successful cases, and overdose, drinking, and wrist -cutting were the common means among the failed attempts. Sixty-four people (61.5%) were admitted to public emergency hospitals, 51 people (49.0%) were rescued by fire workers, and 34 people (32.7%) were sent for autopsy following police reports on fatal cases as suicide. Successful suicides and males were mostly sent for pathological examination without any coordinated care from different medical institutions, whereas, failed cases and females were often taken care of by several institutions. Five people (4.8%) were referred for psychiatric help. Suicide intervention needs to take account of differences in the sex, age, means, and other characteristics of those who attempt suicide. Each institution plays an important role, and they need to cooperate in order to establish an effective intervention.

Infiltration of T lymphocytes and expression of icam-1 in the hippocampus of patients with hippocampal sclerosis

We and others have previously shown that reactive microglia express the major histocompatibility complex (MHC) class I and class II antigens in the hippocampus of patients suffering from epilepsy. Although the MHC glycoproteins serve as restriction elements for T lymphocytes, there is little information available regarding T lymphocytes in hippocampal sclerosis. In the present study, we investigated T lymphocyte infiltration in human hippocampi in four cases of epilepsy with hippocampal sclerosis, as well as in four control cases without neurological disease. No CD8- or CD4-positive T lymphocytes were seen in hippocampi from the control cases. In contrast, CD8- and CD4-positive T lymphocytes had infiltrated into the hippocampi of patients with hippocampal sclerosis. In addition, expression of intercellular adhesion molecule-1 was diffusely upregulated in the hippocampi with hippocampal sclerosis. These results indicate that T lymphocyte infiltration is involved in the pathology of hippocampal sclerosis.

Diffusion and sorption of neptunium(V) in compacted montmorillonite: effects of carbonate and salinity

Diffusion and sorption of radionuclides in compacted bentonite/montmorillonite are key processes in the safe geological disposal of radioactive waste. In this study, the effects of carbonate and salinity on neptunium(V) diffusion and sorption in compacted sodium montmorillonite were investigated by experimental and modeling approaches. Effective diffusion coefficients (De) and distribution coefficients (Kd) of237Np(V) in sodium montmorillonite compacted to a dry density of 800 kg m−3were measured under four chemical conditions with different salinities (0.05/0.5 M NaCl) and carbonate concentrations (0/0.01 M NaHCO3).Devalues for carbonate-free conditions were of the order of 10−10–10−11 m2s−1and decreased as salinity increased, and those for carbonate conditions were of the order of 10−11–10−12 m2s−1and showed the opposite dependence. Diffusion-derivedKdvalues for carbonate-free conditions were higher by one order of magnitude than those for carbonate conditions. Diffusion and sorption behaviors were interpreted based on mechanistic models by coupling thermodynamic aqueous speciation, thermodynamic sorption model (TSM) based on ion exchange, and surface complexation reactions, and a diffusion model based on electrical double layer (EDL) theory in homogeneous narrow pores. The model predicted the experimentally observed tendency ofDeandKdqualitatively, as a result of the following mechanisms; 1) the dominant aqueous species are NpO2+and NpO2CO3−for carbonate-free and carbonate conditions, respectively, 2) the effects of cation excess and anion exclusion result in opposite tendencies ofDefor salinity, 3) higher carbonate in solution inhibits sorption due to the formation of carbonate complexes.