Successful management of bleeding complications in patients supported with extracorporeal membrane oxygenation with primary respiratory failure

Background:

Extracorporeal membrane oxygenation (ECMO) is a lifesaving procedure in patients with severe respiratory insufficiency failing conventional support. Bleeding complications are common due to the necessity for anticoagulation and circuit-related factors.

Methods:

A retrospective review was conducted in patients requiring ECMO for respiratory failure from 7/2010 to 6/2011 to identify episodes of major bleeding, bleeding management and outcomes.

Results:

Twenty-one patients were supported with ECMO during the study although five experienced massive bleeding related to chest tube insertion, jejunal arterio-venous malformations, distal perfusion cannula dislodgement and ventricular rupture. Patients required aggressive resuscitation or endoscopic or operative intervention, totaling 28 procedures. There were no instances of dehiscence, infection or sepsis related to interventions. Anticoagulation was stopped six hours before and restarted 24 hours after major interventions, with no thrombotic or neurologic complications. All patients weaned off ECMO were discharged.

Conclusions:

ECMO bleeding complications can be managed successfully via surgical and endoscopic approaches in this high-risk population.

Acoustic characteristics of ataxic speech in Japanese patients with spinocerebellar degeneration (SCD)

BACKGROUND

In English- and German-speaking countries, ataxic speech is often described as showing scanning based on acoustic impressions. Although the term 'scanning' is generally considered to represent abnormal speech features including prosodic excess or insufficiency, any precise acoustic analysis of ataxic speech has not been performed in Japanese-speaking patients. This raises the question of what is the most dominant acoustic characteristic of ataxic speech in Japanese subjects, particularly related to the perceptual impression of 'scanning'.

AIMS

The study was designed to investigate the nature of speech characteristics of Japanese ataxic subjects, particularly 'scanning', by means of acoustic analysis.

METHODS & PROCEDURES

The study comprised 20 Japanese cases with spinocerebellar degeneration diagnosed to have a perceptual impression of scanning by neurologists (ataxic group) and 20 age-matched normal healthy subjects (control group). Recordings of speech samples of Japanese test sentences were obtained from each subject. The recorded and digitized acoustic samples were analysed using 'Acoustic Core-8' (Arcadia Inc.).

OUTCOMES & RESULTS

Sentence duration was significantly longer in the ataxic group as compared with the control group, indicating that the speaking rate was slower in the ataxic subjects. Segment duration remained consistent in both vowels and consonants in the control group as compared with the ataxic group. In particular, the duration of vowel segments, i.e. the nucleus of Japanese mora, was significantly invariable in the control group regardless of differences between subjects as well as in segments compared with the ataxic group. In addition, the duration of phonemically long Japanese vowels was significantly shorter in the ataxic group.

CONCLUSIONS & IMPLICATIONS

The results indicate that the perceptual impression of 'scanning' in Japanese ataxic cases derives mainly from the breakdown of isochrony in terms of difficulty in keeping the length of vowel segments of Japanese invariable during speech production. In addition, the tendency toward irregular shortening of the length of phonemically long Japanese vowels is thought to reinforce the impression of 'scanning' in ataxic speech in Japanese cases.

Genetic variants at CDC123/CAMK1D and SPRY2 are associated with susceptibility to type 2 diabetes in the Japanese population

AIMS/HYPOTHESIS

Recently, rs10906115 in CDC123/CAMK1D, rs1359790 near SPRY2, rs1436955 in C2CD4A/C2CD4B and rs10751301 in ODZ4 were identified as genetic risk variants for type 2 diabetes by a genome-wide association study in a Chinese population. The aim of the present study was to ascertain the role of these four variants in conferring susceptibility to type 2 diabetes in the Japanese population.

METHODS

We genotyped 11,530 Japanese individuals (8,552 type 2 diabetes cases, 2,978 controls) for the above single nucleotide polymorphisms (SNPs) and used logistic regression analysis to determine whether they were associated with type 2 diabetes.

RESULTS

In accordance with the findings in a Chinese population, rs10906115 A, rs1359790 C and rs1436955 G were found to be risk alleles. Both rs10906115 and rs1359790 were significantly associated with susceptibility to type 2 diabetes in our study (rs10906115 OR 1.15, 95% CI 1.08, 1.22; p = 6.10 × 10(-6); rs1359790 OR 1.14, 95% CI 1.06, 1.21; p = 2.24 × 10(-4)). Adjustment for age, sex and BMI had no significant effects on the association between these variants and the disease. We did not observe any significant associations between the SNPs and any metabolic traits, e.g. BMI, fasting plasma glucose (determined for 1,332 controls), HOMA of beta cell function (900 controls) and HOMA of insulin resistance (900 controls; p > 0.05).

CONCLUSIONS/INTERPRETATION

The SNPs rs10906115 A and rs1359790 C are significantly associated with susceptibility to type 2 diabetes in the Japanese population, confirming that these alleles are common susceptibility variants for type 2 diabetes in East Asian populations.

Mycotic pseudoaneurysm of the ascending aorta after heart transplantation: case report

Mycotic pseudoaneurysm of the ascending aorta is a rare but potentially life-threatening complication after orthotopic heart transplantation. We present a case of a 53-year-old man who developed a mycotic pseudoaneurysm of the ascending aorta after orthotopic heart transplantation. The pseudoaneurysm was surgically resected and the ascending aorta was replaced with allograft. The Gram stain and multiple cultures of the pseudoaneurysm wall revealed that the causative microorganism was coagulase-negative Staphylococcus. To the best of our knowledge, this is the first case report that describes mycotic pseudoaneurysm owing to coagulase-negative Staphylococcus infection after heart transplantation. Although S aureus and Pseudomonas aeruginosa are common pathogens in previously published literatures describing mycotic pseudoaneurysms in heart transplant recipients, coagulase-negative Staphylococcus is aslo an important and virulent pathogen that can cause mycotic aortic pseudoaneurysm in immunosuppressed patients. Once diagnosed, aggressive surgical treatment with prudent operative strategy, appropriate postoperative antibiotic therapy and close follow-up by radiographic study are mandatory in managing patients with this potentially fatal condition.

The significance of PITX2 overexpression in human colorectal cancer

PURPOSE

The paired-like homeodomain transcription factor 2 (PITX2) gene encodes a transcription factor controlled by the WNT/Dvl/CTNNB1 and Hedgehog/TGFB pathways in the pathogenesis of colorectal cancer (CRC). Although PITX2 is reportedly involved in various functions, including tissue development by controlling cell growth, its significance in CRC remains unclear. We report our findings regarding abnormal PITX2 expression in human CRC.

METHODS

PITX2 expression was evaluated in 5 human CRC cell lines and 92 primary CRC samples. Cell growth was evaluated after inhibition of PITX2 expression or after exogenous introduction of PITX2.

RESULTS

PITX2 expression was seen in all the five CRC cell lines. The study of tissue samples indicated that PITX2 expression was significantly higher in cancerous tissue than in paired control tissue (P = 0.0471). Patients with lower PITX2 expression showed a poorer overall survival rate than those with higher PITX2 expression (P = 0.0481). Multivariate analysis demonstrated that PITX2 expression was an independent prognostic factor. Experimental knockdown and introduction of PITX2 also demonstrated that the level of PITX2 expression is inversely associated with cell growth and invasion in vitro.

CONCLUSIONS

PITX2 expression is significantly related to the biological behavior of CRC cells and appears to be correlated with clinical survival. Thus, this study revealed a previously uncharacterized unique role and significance of PITX2 expression in CRC.

Absence of CD71 transferrin receptor characterizes human gastric adenosquamous carcinoma stem cells

BACKGROUND

Although the importance of cancer stem cells (CSCs) in overcoming resistance to therapy and metastasis has recently been reported, the role of CSCs in gastric cancer remains to be elucidated.

METHODS

MKN-1 cells were used to study markers of CSCs in gastric adenosquamous carcinoma, as these cells are suitable for determining multidifferentiation ability. Changes in expression of CD44, CD49f, CD133, and CD71 following 5-fluorouracil (5-FU) treatment were assessed.

RESULTS

After 5-FU treatment, only the CD71- fraction was significantly increased. Investigation of CD71 indicated that the CD71- cell fraction was present in the G1/G0 cell cycle phase and showed high resistance to the anticancer agent 5-FU. Limiting dilution and serial transplantation assays revealed the CD71- cell fraction to have higher tumorigenicity than the CD71+ cell fraction. The CD71- cell fraction showed multipotency to adenocarcinoma and squamous cell carcinoma. A three-dimensional (3D) invasion assay and immunohistochemical analysis showed CD71- cells to be highly invasive and to exist in the invasive fronts of cancer foci.

CONCLUSION

The present study suggests that use of CD71- as a marker for adenosquamous carcinoma may provide a useful model for studying CSCs.

[Cancer stem cells in solid tumors]

In this review, we discuss recent issues about cancer stem cells, especially in solid tumors. Cancer stem cells show the ability to self-renew; and they possess multi-potential differentiation and tumorigenic potential. Cancer stem cells are reported to show resistance to anticancer drugs and radiotherapy, and therefore, they are involved in progression, recurrence, and metastasis in cancer. The existence of cancer stem cells in leukemia has long been known, since early times. In recent years cancer stem cells have been identified in solid tumors of breast, prostate, lung, brain, colon, and pancreas, owing to the development of identification techniques using cell surface markers. Although many features remain to be addressed, it is expected that cancer stem cells could be a main target for cancer therapy in the near future.

[A case of recurrent sigmoid colon cancer with adrenal and para-aortic lymph node metastasis successfully treated by operation and chemotherapy]

We report a case of 57-year-old woman suffering from advanced sigmoid colon cancer with adrenal and para-aortic lymph node recurrence. Sigmoidectomy was performed for sigmoid colon cancer in January 2002. Pathological staging was Stage II (pT3, pN0, pM0, Cur A). She received a UFT + CPT-11 regimen as preoperative chemotherapy for liver metastasis (S2, S7) from December 2002. A partial liver resection (S2, S7) was performed for liver metastasis in July 2003, and the UFT + CPT-11 was introduced as adjuvant chemotherapy. However, adrenal and para-aortic lymph node recurrence was detected in February 2007, and mFOLFOX6 was performed as preoperative chemotherapy. Right adrenalectomy and para-aortic lymph node dissection was performed in July 2007. mFOLFOX6 as postoperative chemotherapy was done, mFOLFOX6 + bevacizumab was started because of CEA increase. The chemotherapy was performed for 23 courses and temporarily stopped due to adverse reactions, such as peripheral neuropathy (grade 2), general fatigue (grade 1), and nausea (grade 1). She had no recurrence for almost 3 years after a resection of adrenal and para-aortic lymph node metastasis.

[An experience of curative resection of local recurrent rectal cancer with high-level sacrectomy after preoperative chemo-radiation therapy]

A 54-year-old male had huge pre-sacral recurrent mass (54 × 41 mm) at the level of S1 sacral bone six months after he underwent a high anterior resection for advanced rectal cancer. He was considered inoperable although he had no distant metastasis. We planned a surgical resection for the recurrent tumor after the chemo-radiation therapy (radiation + CPT-11, UFT, Leucovorin). The tumor had a good response (33 × 29 mm) for CRT allowing a dissection area between sacral bone and posterior tumor margin. The surgical resection was performed. We dissected recurrent tumor and sacral bone below S2 and preserved S1 nerve roots under direct vision in order to prevent complications such as walking disorder and spinal fluid leakage. The operative time was 870 minutes and the blood loss was 3,600 g. There were no intraoperative complications. Macroscopically, surgical margin was well secured and a pathological examination of resected specimen revealed microfoci of cancer cells. The post operative hospital stay was 36 days. The patient is alive without any evidence of recurrence 72 months after surgery. He has no walking disability, and a good quality of life.

[A case of lateral lymph node metastasis of submucosal rectal cancer]

We report a case of lateral lymph node metastasis of submucosal rectal cancer. A 54-year-old man was pointed out with stool occult blood reaction positive. Screening colonoscopy revealed an 18 mm 0-Is rectal cancer in Rb 6 cm from anal verge. Endoscopic mucosal resection (EMR) was performed. Tumor appeared to be well treated, but pathological findings demonstrated the tumor invasion into submucosally (1,300 µm) with lymphovascular invasion ie ly (+) and v (+). Laparoscopic low anterior resection was then performed and no metastasis of lymph nodes (pSM, N0/stage I) was found. But he suddenly had an elevation of CEA (4 ng/mL to 26 ng/mL) after 14 months and following MRI and PET-CT revealed a recurrence in a right lateral lymph node (#283). Chemoradiation therapy (CRT) with CPT-11, UFT and LV was performed. After CRT, lateral lymph nodes and para aortic lymph nodes dissection were performed. Despite of the chemotherapy, he died after 13 months from a recurrence of lateral lymph node metastasis.

[A long-term survival case of rectal cancer with Virchow's lymph node metastasis by multimodality therapy]

A 57-year-old man was diagnosed as having advanced rectal cancer that was suspected for a prostatic gland invasion. CPT-11 plus UFT/LV-based chemoradiotherapy (CRT) was administered. A total radiation dose was 50.4 Gy. After completion of CRT, rectal tumor has shrunken, but Virchow's lymph node metastasis was found on PET CT scan. Therefore, the main rectal tumor was resected first, and chemotherapy was then planned. After an abdominoperineal resection, mFOLFOX6 was started. We have stopped mFOLFOX6 after 9 courses because of grade 3 peripheral neuropathy. FOLFIRI was administered thereafter for 27 courses until the confirmation of the shrinkage of the Virchow's lymph node. With a request from the patient, the chemotherapy was stopped for 7 months. Virchow's lymph node has re-grown. We restarted chemotherapy with FOLFOX + bevacizumab regimen. Although the re-grown Virchow's lymph node was unresectable, a tumor in the rectum was resected for a control of local symptom. We, then, introduced a sequential systemic chemotherapy. After that, we could continue the treatment for 38 months without spoiling the QOL. The patient is alive and come to see us as an outpatient.

[Follow-up of dysphagia in the elderly--clinical survey of deglutition disorder at a private ENT office]

In a one-year-plus follow-up study in 17 of 26 cases involving apparent liquid aspiration during videoendoscopic screening, subjects were instructed in swallowing using video images and in choosing food, utensils, and posture. The amount of sputum decreased in 10 case (59%), and sputum sticking in the throat disappeared in 4 (18%). Body weight also increased in 4 (24%). Choking coughs noted in 11 during initial videoendoscopy disappeared in 2 (18%). We thus, concluded that detecting dysphagia symptoms early and providing follow-up could help prevent aspiration pneumonia.

[Screening test is for dysphagia in the elderly]

In screening tests for dysphagia conducted using videoendoscopy in 81 subjects over 75-years-old apparent liquid aspiration was found in 26 (32%). In 2 of these 26 saliva aspiration was observed. Logistic analysis of aspiration versus clinical symptoms, including endoscopic findings, showed a significant correlation between aspiration and longer time required for meals, bending forward during swallowing, choking during meals, hypoesthesia of the larynx, delayed swallowing reflex and difficulty in spitting. Results were considered clinically significant although they did not appear to fully agree with those of previous studies. The usefulness of videoendoscopy was confirmed.

Notch pathway as candidate therapeutic target in Her2/Neu/ErbB2 receptor-negative breast tumors

Whereas the Her2/neu/erbB2 receptor (Her2) could be a molecular target of the receptor-positive breast cancer, the therapeutic targets of Her2-negative cancer largely remain to be established. The expression of Her2 was evaluated in 48 primary breast cancer tumors by immunohistochemistry. The identified Notch pathway was studied in genotoxin-dependent suppression of breast cancer-initiating cell growth. Immunohistochemical assessment of Her2-negative tumors revealed significant association with overexpression of Notch1 and Notch3. Knockdown of Notch pathway resulted in sensitization of breast cancer cells to deionizing radiation, leading to cell death; the effect was more significant in stem marker CD44+ than in CD44- cells, and more profound in the Her2-negative than in positive cancer cells. The present study indicates that inhibition of Notch signaling could antagonize survival signal of Her2-negative breast cancer-initiating cells carrying genomic damage, and suggests that targeted suppression of the Notch pathway may give the rationale for sensitizing Her2-negative cancer-initiating cells to a therapeutic approach.

Abnormal expression of TRIB3 in colorectal cancer: a novel marker for prognosis

BACKGROUND

TRIB3 is a human homologue of Drosophila tribbles. Previous studies have shown that TRIB3 controls the cell growth through ubiquitination-dependent degradation of other proteins, whereas its significance in the prognosis of colorectal cancer (CRC) is not yet fully understood.

MATERIALS

This study comprised 202 patients who underwent surgery for CRC, as well as 22 cell lines derived from human gastrointestinal cancer. The correlation of gene expression with clinical parameters in patients was assessed. The biological significance was evaluated by knockdown experiments in seven colorectal cancer cell lines.

RESULTS

A total of 20 cancer cell lines (90.9%) expressed the TRIB3 gene. The assessment in surgical specimens indicated that the gene expression was significantly higher in the cancerous region than in the marginal non-cancerous region. Patients with high TRIB3 expression were statistically susceptible to a recurrence of the disease, and showed poorer overall survival than those with low expression. The assessment of TRIB3 knockdown in five cell lines showed that small interfering RNA (siRNA) inhibition resulted in a statistically significant reduction in cell growth.

CONCLUSION

These data strongly suggest the usefulness of TRIB3 as a marker for predicting the prognosis of CRC patients, showing a basis for the development of effective treatments for CRC.

Replication study for the association of new meta-analysis-derived risk loci with susceptibility to type 2 diabetes in 6,244 Japanese individuals

AIMS/HYPOTHESIS

Additional susceptibility loci for type 2 diabetes have been identified by a meta-analysis of genome-wide association studies (GWASs) in European populations. To examine further the roles of these new loci, we performed a replication study for the association of these single-nucleotide polymorphism (SNP) loci with the disease in three independent Japanese populations.

METHODS

We genotyped seven of the 11 SNPs that emerged in stage 2 of the meta-analysis for European GWASs (rs864745 in JAZF1, rs12779790 near CDC123/CAMK1D, rs7961581 near TSPAN8/LGR5, rs4607103 near ADAMTS9, rs10923931 in NOTCH2, rs1153188 near DCD and rs9472138 near VEGFA) for three independent Japanese populations (first set, 1,630 type 2 diabetes patients vs 1,064 controls; second set, 1,272 type 2 diabetes patients vs 856 controls; third set, 486 type 2 diabetes patients vs 936 controls) using a TaqMan assay. The association of the SNP loci in each population was analysed using a logistic regression analysis, adjusting for age, sex and BMI, and the data were evaluated by a meta-analysis.

RESULTS

A meta-analysis for the three case-control studies identified a nominal association of rs864745 in JAZF1 with type 2 diabetes (OR 1.148, 95% CI 1.034-1.275, p = 0.0098, corrected p = 0.069). The association of other loci did not reach statistically significant levels (nominal p > 0.05).

CONCLUSIONS/INTERPRETATION

From these results the contribution of these seven loci in conferring susceptibility to type 2 diabetes is considered minor in the Japanese population, if they are present.

Extremely low frequency magnetic fields and the promotion of H2O2‐induced cell death in HL‐60 cells

PURPOSE

To test whether exposure to an extremely low frequency magnetic field (60 Hz, 5 mT) affects hydrogen peroxide (H2O2)-induced cell death in human leukaemia HL-60 cells.

MATERIALS AND METHODS

Cells were treated with H2O2 with or without exposure to an extremely low frequency magnetic fields. Viable cells, apoptotic and necrotic cells were determined by annexin V flow cytometry assay. The levels of apoptosis-related proteins (caspase-3, caspase-7, Bcl-2 and Bax) and poly(ADP-ribose) polymerase were detected using Western blotting.

RESULTS

Simultaneous treatment with exposure to the magnetic field and H2O2 (85 or 100 microM) for 24 h increased the number of apoptotic and necrotic cells significantly, and significantly decreased the number of viable cells compared with cells treated with H2O2 alone. The protein levels of Bax and Bcl-2 showed no differences between H2O2-treated cells and those treated with both H2O2 and an extremely low frequency magnetic field. Exposure to the magnetic field also had no effect on H2O2-induced caspase-3 activation. However, the protein levels of active caspase-7 in cells simultaneously exposed to an extremely low frequency magnetic field and H2O2 for 2 and 8 h was higher than that of H2O2 treatment alone. In addition, simultaneous exposure to an extremely low frequency magnetic field and H2O2 caused poly(ADP-ribose) polymerase cleavage and induced early inactivation at 2 h, while H2O2 treatment alone did not produce this effect until 4 h.

CONCLUSIONS

The data suggest that although the magnetic field itself cannot induce apoptosis and necrosis, it exerts a promoting effect on H2O2-induced cell death, and it demonstrates that caspase-7 as well as poly(ADP-ribose) polymerase might be involved in this process.

Relationship between salivary Chromogranin-A and stress induced by simulated monotonous driving

The purpose of the present study was to evaluate the use of salivary Chromogranin-A (CgA), which is already used in general as a mental stress marker, for studying the stressful situation created by simulated monotonous driving. After informed consent, 25 healthy male and female subjects were studied under constant environment-controlled conditions. We measured the following physiological variables: blood pressure (BP), cardiac output, total peripheral resistance (TPR), normalized pulse volume (NPV) as an index of alpha-adrenergic sympathetic activity to the finger arteriolar vessels, levels of cortisol and CgA during monotonous driving. The induced stress led to the expected decreases in NPV and increases in TPR and BP caused by peripherally related sympathetic acceleration. However, CgA levels were found to fall gradually in accordance with the gradual increase of subjective rating of stress (SRS) and significantly (p < 0.01) decreased over the period of the simulated monotonous driving. Our hypothesis for the gradual decrease of CgA levels during the simulated monotonous driving is as follows. CgA, catestatin and catecholamines are co-released into the extra-cellular environment. Peripheral sympathetic activity was accelerated by stress resulting from the simulated monotonous driving. Upon peripheral vessel constriction, an increase in TPR then increased BP which, in turn, activated catestatin. Consequently, secretion of CgA was blocked by the co-secreted catestatin from chromaffin granules. The results obtained strongly indicate that, although CgA has been reported as a possible marker of stress, CgA levels are not increased in the stressful situation of simulated monotonous driving.

Prevalence of chronic obstructive pulmonary diseases in general clinics in terms of FEV1/FVC

BACKGROUND

The prevalence of chronic obstructive pulmonary disease (COPD) continues to increase all over the world. Nonetheless, COPD is often misdiagnosed in general clinics because of insufficient use of spirometry.

OBJECTIVES

To estimate the prevalence of COPD in general clinics in Japan, we performed spirometry to screen patients who consulted general clinics.

METHODS

Patients 40 years of age and older who consulted clinics in Nagasaki Prefecture, Japan, for non-respiratory diseases and who met certain inclusion criteria had their airflow limitation measured by spirometry. We defined COPD as forced expiratory volume in the first second (FEV(1)) over forced vital capacity (FVC) (FEV(1)/FVC) of < 70% in patients without active pulmonary disease, including physician-diagnosed asthma.

RESULTS

Of the 1424 patients included in the study, 193 (13.6%) showed airflow limitation. Airflow limitation was significantly related to older age, male gender and cumulative pack-years. FEV(1)/FVC in patients with hypertension and chronic hepatitis were significantly lower than in patients without these diseases when adjusted for age, gender and pack-years.

CONCLUSIONS

We showed that there are potentially a number of cases with COPD that are undiagnosed by general physicians in Japan. Measuring airflow limitation by spirometry in smokers with coexisting diseases, such as hypertension and chronic hepatitis, may be very beneficial because COPD is thought to be a systemic disease. The distribution of spirometers to general clinics is definitely needed to detect undiagnosed COPD.