Cytopathological alterations and therapeutic approaches in Binswanger's disease

Binswanger's disease (BD) is a condition characterized by prominent brain atrophy with ventricular dilatation, diffuse white matter (WM) lesions and a scattering of lacunar infarcts. BD patients have dementia, and have vascular risk factors, focal cerebrovascular deficits and evidence of subcortical cerebral dysfunction. From our clinical studies, the most effective prophylaxis against the development of BD is to manage the hypertension, especially a high nocturnal blood pressure, in the early stage patients showing only a scattering of lacunes and/or mild WM lesions. The pathogenesis of BD is likely to be chronic cerebral ischemia due to hypertensive small artery disease with capillary collagenosis, which causes the multiple lacunes and the alterations in the glia and axons. In addition, arterial hypertension and a subsequent dysfunction of the blood-brain barrier (BBB) may cause the WM lesions. A compromised BBB will permit the entry of serum components, immunoglobulins, complements and fibrinogen into the perivascular neural parenchyma. These substances may subsequently activate both astro- and microglia and thus damage the myelin structures. Experimentally, immunosuppressants, cyclosporin A and FK 506 suppressed both the glial activation and WM changes after chronic cerebral hypoperfusion. The pro-thrombotic state of the microcirculation in BD patients may also contribute to local inflammation and the BBB dysfunction, because thrombin and prostanoids are involved in various tissue reactions including brain edema and glial activation. Therefore, novel therapeutic approaches using the administration of anti-thrombin and cyclo-oxygenase-2 inhibitors as well as immunosuppressants may be useful for preventing the progression of BD.

[Descending necrotizing mediastinitis]

We treated of 3 patients with descending necrotizing mediastinitis that is often to be fatal. There are 3 important issues regarding the treatment of this disease. First, the precise sites of abscess should be determined by computed tomography (CT) scans from the neck to diaphragm. Second, effective drainage of the neck and mediastinal abscess should be carried out immediately when the sites of abscess are determined. Third, drainage under video-assisted thoracic surgery (VATS) is an appropriate treatment because VATS is less invasive and provides an easier placement of the drainage tubes at abscess sites.

Relationship of smoking and smoking cessation with oral health status in Japanese men

BACKGROUND AND OBJECTIVE

Smoking has been associated with the number of natural teeth a person has and with the likelihood of periodontitis. The purpose of this study was to determine the relationships between the number of teeth present and periodontal diseases with smoking habits in a cohort of Japanese men.

MATERIAL AND METHODS

The study group comprised 1088 men, 40-75 years of age. Oral examinations were conducted in dental clinics. Information on smoking status and on oral health behavior was collected from self-administered questionnaires. The relationship between oral health status and smoking status was estimated using adjusted odds ratios.

RESULTS

Compared with those whom had never smoked, the odds ratios of having more than eight missing teeth and having periodontitis, among current smokers, were 1.67 and 1.74, respectively. In those who had stopped smoking for 11 years or longer, there was no increase in the odds ratio of having more than eight missing teeth and periodontitis, compared with those whom had never smoked.

CONCLUSION

Smoking has a positive association with missing teeth and periodontitis. However, smoking cessation is beneficial for oral health. The odds of having more than eight missing teeth, or of having periodontitis, in those who had never smoked was similar to that of individuals who reported that they had stopped smoking for 11 years or more.

[Complete resection of an advanced mediastinal nonseminomatous germ cell tumor with multiple distant metastases after down-staging by chemotherapy]

A mediastinal nonseminomatous germ cell tumor was completely resected after down-staging by chemotherapy despite the presence of multiple distant metastases. A 22-year-old female was admitted for superior vena cava (SVC) syndrome. Her SVC was obstructed by a large anterior mediastinal tumor; she also exhibited distant metastases on a left rib, in the liver, and multiple in the lung. The blood alpha-fetoprotein (AFP) level was extremely elevated to 57,530 ng/ml. Four courses of BEP therapy [cisplatin (CDDP), bleomycin (BLM), etoposide (VP-16)] and a high dose chemotherapy followed by a peripheral blood stem cell transplantation made the tumor become smaller and effected its down-staging. Residual mediastinal tumor with an intravascular tumor in SVC was completely resected. The SVC was reconstructed by an artificial vessel graft. A mediastinal nonseminomatous germ cell tumor, even though it has multiple distant metastases, can achieve down-staging and complete resection by a chemotherapy based on scientific evidence.

Comparison of preoperative whole-body positron emission tomography with MDCT in patients with primary colorectal cancer

OBJECTIVE

Preoperative use of emission tomography with(18)F-fluorodeoxyglucose (FDG-PET) in patients with primary colorectal cancer remains controversial. This study evaluated the additional value of FDG-PET in comparison with routine multidetector row computed tomography (MDCT) in patients with primary colorectal cancer.

METHOD

Retrospective analysis was performed in 65 patients with colorectal cancer who underwent whole-body FDG-PET. Results of FDG-PET were compared with routine preoperative evaluation by MDCT regarding detection of primary tumour, lymph node involvement and distant metastases. All images were evaluated before surgery.

RESULTS

Tumour detection rate was 100% (63/63) for MDCT and 98% (62/63) for FDG-PET. Lymph node involvement was pathologically confirmed in 35 patients. MDCT and FDG-PET displayed sensitivities of 89% (31/35; 95% CI: 73-97%) and 43% (15/35; 95% CI: 26-61%) and specificities of 52% (11/21; 95% CI: 30-74%) and 95% (20/21; 95% CI: 76-100%), respectively. Liver metastases were present in 22 patients. MDCT and FDG-PET showed accuracies of 98% (64/65; 95% CI: 92-100%) and 97% (63/65; 95% CI: 89-100%), respectively. FDG-PET detected additional extrahepatic metastatic lesions and affected treatment plan compared with MDCT in 10 patients.

CONCLUSION

Preoperative FDG-PET is not superior to MDCT for detection of primary tumour, lymph node involvement or liver metastases, but may have potential clinical value in patients with advanced colorectal cancer by detecting extrahepatic distant metastases.

Early childhood caries and related risk factors in Mongolian children

OBJECTIVES

The aims of this study were to investigate the dental caries experience among 1-5 year-old children in the two areas of Ulaanbaatar city, and to examine the relationship of dental caries experience with socioeconomic status, eating behaviors, oral hygiene habits, dental plaque accumulation and Mutans Streptococci level.

METHODS

In 2004/2005, 670 children from the two areas were examined and a questionnaire survey was conducted. Mutans streptococci (MS) levels in the children's and mothers' dental plaque were evaluated using Dentocult SM.

RESULTS

Dental caries prevalence (72%) and mean dmft (4.4) were very high in both areas, however, children in the central area showed higher caries severity than those in the suburban area in 3-5-year-olds (p < 0.05). Higher family income and education level of the mothers were significantly associated with children's higher caries experience. Furthermore, dental caries showed a significant positive relationship with sweets intake and a negative relationship with tooth brushing habits of the children. The children's caries experience was significantly and positively associated with modified debris index (m-DI) scores, and the MS levels in their own and their mothers' dental plaque. Area, sweets intake, prolonged breastfeeding, and high MS level in the dental plaque resulted in significant odds ratios for the development of caries.

CONCLUSIONS

The prevalence of dental caries amongst 1-5 year-old children in Ulaanbaatar City, Mongolia was found to be high and was associated with socioeconomic, demographic and behavioural factors.

The analysis of EGFR expression and EGFR mutations in advanced pancreatic cancer

e15629

Background: The standard chemotherapy of advanced pancreatic cancer is still gemcitabine and recently gemcitabine + EGFR tyrosine kinase inhibitor (TKI)is noted to be positive on Phase III study. In lung cancer, EGFR mutations (the deletion of exon 19, the point mutation of exon 18, 21) have been reported to be correlated with the effect of EGFR TKI. On the other hand, such EGFR mutations were not reported to be recognized by the direct sequencing method in pancreatic cancer. This time we examined EGFR expressions and EGFR mutations in advanced pancreatic cancer. Methods: We examined EGFR expressions immunohistochemically and EGFR mutations by Loop-Hybrid Mobility Shift Assay (LH-MSA) which is more sensitive than the direct sequencing method in the tissue obtained from percutaneous biopsies in advanced pancreatic cancer patients. In addition we examined the correlation between EGFR expressions and survivals by the log-rank test. Results: The subjects were 31 inoperable pancreatic cancer patients. Patients received chemotherapy (gemcitabine: 10, S-1: 8, gemcitabine+S-1: 12, no treatment: 1).The UICC stages were as follows:stage II; 2, stage III; 6, stage IV; 23. The tissues were obtaind from liver; 12, pancreas; 19. EGFR expressions were positive; 15, negative; 16. EGFR expressions were not correlated with survival (p=0.386). Although LH-MSA were performed successfully in all patients, the same EGFR mutations as lung cancer were not detected. Conclusions: EGFR expressions were not correlated with survivals and the same EGFR mutations as lung cancer were not detected in inoperable advanced pancreatic cancer.

No significant financial relationships to disclose.

The expression of P-glycoprotein is increased in vessels with blood-brain barrier impairment in a stroke-prone hypertensive model

AIMS

We previously reported that the blood-brain barrier (BBB) function was impaired in vessels in the hippocampus in 3-month-old stroke-prone spontaneously hypertensive rats (SHRSP). In this study, we examined gene and protein expressions of P-glycoprotein, a representative efflux transporter of cerebral vessels, in the BBB-damaged hippocampal vessels of SHRSP and in the vessels of Wistar Kyoto (WKY) rats as controls, to clarify roles of the efflux transporter in the BBB-damaged vessels.

METHODS

The expression of P-glycoprotein in hippocampal and cortical samples was examined by real-time quantitative reverse transcriptase-polymerase chain reaction (RT-PCR), Western blotting and immunoelectron microscopic techniques.

RESULTS

Real-time RT-PCR and Western blotting analyses revealed that the gene and protein expressions of P-glycoprotein were increased in the hippocampal samples of 3-month-old SHRSP compared with hippocampal samples of 3-month-old WKY rats or with cortical samples of SHRSP. The gene expression of P-glycoprotein was also increased in the hippocampal samples of 4-week-old SHRSP. Immunoelectron microscopic examination revealed that immunosignals of P-glycoprotein were seen in the luminal and ab-luminal cytoplasmic membranes of endothelial cells and the basal lamina, that the labelling density of P-glycoprotein in the vessel wall was higher in the hippocampus of 3-month-old SHRSP than in other groups and that the immunosignals of P-glycoprotein were occasionally co-located with those of albumin.

CONCLUSIONS

These findings indicate that the expression of P-glycoprotein is increased in BBB-damaged hippocampal vessels in hypertensive SHRSP compared with those in WKY rats.

Circadian characteristics of urinary melatonin from clinically healthy young women at different civilization disease risks

Rhythm characteristics in the about-daily (circadian) and about-yearly (circannual) frequency ranges were assessed for urinary melatonin. Clinically healthy women in Minnesota, USA, and Kyushu, Japan, were sampled around the clock once in 1-4 seasons. Possible differences that could reflect the large difference in breast cancer incidence in these two geographic locations were investigated. Each subject's risk of developing breast cancer, cardiovascular diseases resulting from an elevated blood pressure, and emotional conditions was numerically evaluated according to epidemiologic questionnaires. A prominent circadian rhythm characterizes urinary melatonin in both populations, peaking in the middle of the night. The American women exhibit a larger circadian rhythm-adjusted mean (mesor) than do the Japanese women. A circannual rhythm is also apparent in the North American women, but not in the Japanese women. The circadian mesor of urinary melatonin correlates negatively with the risk score of emotional depression and positively with that of developing cardiovascular diseases.

Advanced pancreatic cancer: the use of the apparent diffusion coefficient to predict response to chemotherapy

The purpose of this study was to determine if the apparent diffusion coefficient (ADC) on diffusion-weighted MRI could predict the response of patients with advanced pancreatic cancer to chemotherapy. Diffusion-weighted MRI was performed in 63 consecutive patients with advanced pancreatic cancer who were subsequently treated with chemotherapy. The ADC values of the primary tumour with a middle b-value (400 s mm(-2)) and a high b-value (1000 s mm(-2)) were determined; cystic or necrotic components were avoided. The patients were classified into two groups: (i) those with progressive disease and (ii) those who were stable 3 months and 6 months after initial treatment. The groups were compared with respect to the ADC and clinical factors, including gender, age, Union International Contre le Cancer (UICC ) stage, initial tumour size and chemotherapy agents used. Local tumour progression rates were evaluated using the Kaplan-Meier method. The middle b-value ADC of the pancreatic cancers ranged from 0.93-2.42 x10(-3) mm(2) s(-1) (mean, 1.50 x10(-3) mm(2) s(-1)), and the high b-value ADC ranged from 0.72-1.88 x10(-3) mm(2) s(-1) (mean, 1.20 x10(-3) mm(2) s(-1)). The high b-value ADC was significantly different between the progressive and stable groups at 3 months' and 6 months' follow-up (p = 0.03 and p = 0.04, respectively). The rate of tumour progression was significantly higher in those with a lower high b-value ADC than in those with a higher b-value ADC (median progression time, 140 days vs 182 days; p = 0.01). In conclusion, a lower high b-value ADC in patients with advanced pancreatic cancer may be predictive of early progression in chemotherapy-treated patients.

Surgical repair of refractory strictures of esophagogastric anastomoses caused by leakage following esophagectomy

Refractory strictures of esophagogastric anastomosis caused by leakage following an esophagectomy are a severe complication, for which either repeated balloon dilations or bougies are not necessarily effective. In such a case, surgical repair is quite difficult because the esophageal substitute such as the stomach or colon is usually located in the mediastinum and severely adhesive to the neighboring organs. Furthermore, in case the resected stricture is too long for direct re-anastomosis to be performed, a free jejunal graft or a new esophageal substitute should be prepared. This paper proposes a procedure for the re-reconstruction of refractory stricture in the case of a retrosternal reconstruction with a gastric conduit, which frequently employs pull-up route. The anterior plate of the manubrium was divided medially from the notch to the symphysis with the sternal saw. The manubrium is then removed, bite by bite, like breaking up rocks, with a bone rongeur forceps, starting with the anterior plate, then the posterior plate, from upper median part to the lower and lateral part of the sternum until it reaches the symphysis and the sternoclavicular and the sternocostal joints. It is safer to destroy the manubrium little by little from the anterior side so that the posterior periosteum, which is likely to adhere tightly to the gastric conduit, can be preserved. After the manubrium is almost completely resected and the posterior periosteum of the manubrium is preserved, a median longitudinal incision is carefully made on the periosteum so as not to damage the gastric conduit that may be adhesive to the periosteum. The periosteum was gradually opened bilaterally separating the periostium and the gastric conduit. Although gastroenterological surgeons may hesitate to remove the manubrium, removing the manubrium and preserving the posterior periosteum make it possible to avoid injuring the gastric conduit and to provide a wide view around the stenosis for safely resecting the anastomotic stricture. Furthermore, this procedure allows direct re-anastomosis between the cervical esophagus and the gastric conduit without a complicated reconstruction such as a free jejunal graft. This procedure is strongly recommended as an alternative option so that a second reconstruction can be performed both safely and steadily.

[Pulmonary atresia with intact ventricular septum showing Fontan-like circulation after biventricular repair]

A 6-year-old girl was referred to our institute for cardiac evaluation. She had been diagnosed as pulmonary atresia with intact ventricular septum (PAIVS) at 16 days after birth and she had underwent balloon atrial septostomy and bilateral Blalock-Taussig shunts. A cardiac catheterization at 5 months showed that her right ventricular end diastolic volume was 58% of normal, the Z value (standard deviation units) of the diameter of the tricuspid valve was -3.3, and a biventricular repair was performed. After the operation, she suffered from severe congestive heart failure for 10 months. A cardiac catheterization at the age of 6 years demonstrated that the pulmonary blood flow was generated during the diastolic phase like Fontan circulation. Although biventricular repair had been performed at 5 months, the circulation may be less advantageous for long term survival than if the patient had undergone the staged Fontan procedure. Careful and continuous hemodynamic assessment is essential for surgical therapy of PAIVS.

Masticatory ability and functional tooth units in Japanese adults

The purposes of this study were (i) to examine the relationship between the number of natural teeth and the number of functional tooth units in Japanese adults, (ii) to evaluate how functional tooth units relate to subjective masticatory ability and (iii) to determine the minimum number of natural teeth and functional tooth units needed to maintain adequate self-assessed chewing function. A self-administered questionnaire was given and dental examination was conducted for 2164 residents aged 40 to 75 years. Counts were made on the number of functional tooth units of natural teeth (n-functional tooth units), the sum of natural teeth and artificial teeth on implant-supported and fixed prostheses (nif-functional tooth units) and the sum of natural teeth and artificial teeth on implant-supported, fixed and removable prostheses (total-functional tooth units). The average number of natural teeth, n-functional tooth units and nif-functional tooth units decreased with age, but these were often replaced by functional tooth units from artificial teeth on removable prostheses. Total-functional tooth units in 50-59 year old people were slightly lower compared with those in other age groups. Subjects who reported that they could chew every food item on an average had 23.4 total natural teeth, 12.6 posterior natural teeth, 7.6 n-functional tooth units, 8.6 nif-functional tooth units and 10.4 total-functional tooth units, and subjects without chewing difficulties had fewer functional tooth units from removable prostheses. Maintaining 20 and more natural teeth and at least eight nif-functional tooth units is important in reducing the likelihood of self-assessed chewing difficulties.

Involvement of retinoic acid-inducible gene-I in inflammation of rheumatoid fibroblast-like synoviocytes

Interferon (IFN)-gamma is a major cytokine that regulates T helper 1-type immune reactions and serves as an important mediator in the pathogenesis of autoimmune diseases. Retinoic acid-inducible gene-I (RIG-I) is an IFN-gamma-inducible gene and known to be involved in the inflammatory and immune reactions. In the present study, we found high levels of RIG-I expression in synovial tissues of rheumatoid arthritis (RA), while the expression in osteoarthritis tissues was low. Treatment of cultured fibroblast-like synoviocytes with IFN-gamma markedly induced the expression of RIG-I. Knockdown of RIG-I in fibroblast-like synoviocytes, with specific siRNA, resulted in the inhibition of the IFN-gamma-induced expression of chemokine (C-X-C motif) ligand 10 (CXCL10)/IFN-gamma-inducible protein-10 (IP-10), a chemokine with chemotactic activity towards T cells. These findings suggest that RIG-I may play an important role in the pathogenesis of synovial inflammation in RA, at least in part, by regulating the IFN-gamma-induced expression of CXCL10/IP-10.

The varicella zoster virus vasculopathies: clinical, CSF, imaging, and virologic features

BACKGROUND

Varicella zoster virus (VZV) vasculopathy produces stroke secondary to viral infection of cerebral arteries. Not all patients have rash before cerebral ischemia or stroke. Furthermore, other vasculitides produce similar clinical features and comparable imaging, angiographic, and CSF abnormalities.

METHODS

We review our 23 published cases and 7 unpublished cases of VZV vasculopathy. All CSFs were tested for VZV DNA by PCR and anti-VZV IgG antibody and were positive for either or both.

RESULTS

Among 30 patients, rash occurred in 19 (63%), CSF pleocytosis in 20 (67%), and imaging abnormalities in 29 (97%). Angiography in 23 patients revealed abnormalities in 16 (70%). Large and small arteries were involved in 15 (50%), small arteries in 11 (37%), and large arteries in only 4 (13%) of 30 patients. Average time from rash to neurologic symptoms and signs was 4.1 months, and from neurologic symptoms and signs to CSF virologic analysis was 4.2 months. CSF of 9 (30%) patients contained VZV DNA while 28 (93%) had anti-VZV IgG antibody in CSF; in each of these patients, reduced serum/CSF ratio of VZV IgG confirmed intrathecal synthesis.

CONCLUSIONS

Rash or CSF pleocytosis is not required to diagnose varicella zoster virus (VZV) vasculopathy, whereas MRI/CT abnormalities are seen in almost all patients. Most patients had mixed large and small artery involvement. Detection of anti-VZV IgG antibody in CSF was a more sensitive indicator of VZV vasculopathy than detection of VZV DNA (p < 0.001). Determination of optimal antiviral treatment and benefit of concurrent steroid therapy awaits studies with larger case numbers.

[Comparison of the images in virtual bronchoscopy under different conditions]

OBJECTIVE

We report herein the comparison of the virtual bronchoscopy (VB) images which were constructed with 2 different computed tomography (CT) scanners combined with 3 different applications in 2 healthy adult volunteers.

METHODS

CT scanners were multi-detector row CT (MDCT) [64 detectors] and MDCT (16 detectors). Applications, by which VB images were made, were Leonardo (Leo), Ziostation (Zio), and Plus XNVZ2 (Plus). The image quality was evaluated by 3 expert bronchoscopists.

RESULTS

The change of the threshold value was necessary in Leo for practical use in subsegmental bronchi and more distal area, but unnecessary in Plus or Zio. When Plus was used, the VB images from the data obtained with MDCT (16 detectors) and MDCT (64 detectors) had almost equal quality.

CONCLUSIONS

Although the process to construct VB images was different in each application, it was regarded that Plus was not inferior to Zio or Leo in VB image quality.

Development of a knee joint motion simulator to evaluate deep knee flexion of artificial knee joints

A purpose of this study is to examine the effect that quadriceps femoris force gives to rotation angle and joint reaction force of total knee prosthesis during deep knee flexion such as a unique sitting style called 'seiza' in Japanese. For the evaluation, we developed the knee motion simulator which could bend to 180 degrees continually simulating the passive flexion performed by clinicians. A total knee prosthesis, which is a specially-devised posterior stabilized type and capable of flexion up to 180 degrees, was inserted into bone model. And this prosthesis pulled by three kinds of quadriceps femoris forces to perform parameter study. The results obtained in this study were showed the same tendency with those in the past cadaveric experiment. It is suggested that the rotation angle and joint reaction force of total knee prosthesis are affected by shape of prosthesis, a vector of quadriceps femoris force, and bony aliments during deep knee flexion.

[Multidisciplinary treatment of lung cancer in 21st century]

Lung cancer is the leading cause of cancer deaths in Japan. Recently, big progress in the treatment of lung cancer has been achieved, such as new anti-cancer drugs, molecular targeted therapy, stereotactic radiotherapy, etc. Multidisciplinary approach has been required to the therapy for lung cancer patients. In this paper, we introduce The 21st Century Multidisciplinary Center in Kanazawa Medical University, and the Hokuriku Training Program for Making Specialists in Cancer Treatment.

The expression of osteopontin is increased in vessels with blood-brain barrier impairment

AIMS

We previously reported that the blood-brain barrier (BBB) function was deteriorated in vessels located along hippocampal fissures in stroke-prone spontaneously hypertensive rats (SHRSP). In this study, we examined changes of gene expression in the BBB-damaged vessels of SHRSP.

METHODS

Vascular samples were microdissected from the hippocampi of SHRSP and Wistar-Kyoto (WKY) as a control and the difference in gene expression between the BBB-damaged vessels in SHRSP and vessels without BBB damage in WKY was examined by a microarray. The differences in gene and protein expression between brain tissues in the two strains of rats were examined using real-time quantitative reverse transcriptase-polymerase chain reaction (RT-PCR), Western blotting and immunohistochemistry.

RESULTS

The microarray assay revealed that the ratio of osteopontin gene expression in the vascular tissue of the hippocampi of SHRSP to that of WKY was the highest among 8435 genes. Real-time RT-PCR analysis revealed that the gene expression of osteopontin was significantly increased in the hippocampal samples of SHRSP compared with that in the hippocampal samples of WKY rats or with that in the cortical samples of SHRSP. Immunohistochemical and Western blot analyses showed that the osteopontin protein expression was seen in perivascular ED1-positive macrophages/microglial cells located around hippocampal fissures and significantly increased in the hippocampi of SHRSP compared with that of WKY.

CONCLUSIONS

These findings indicate that the expression of osteopontin is increased in BBB-damaged vessels in hypertensive SHRSP compared with that in vessels without BBB impairment in WKY rats, suggesting a role for osteopontin in BBB function.

Changes in survival during the past two decades for breast cancer at the Kyoto University Hospital

AIMS

To report the changes in survival over 20 years of 775 breast cancer women operated between 1982 and 2003 at the Kyoto University Hospital in Japan, reflecting changes in clinical practice over that period.

RESULTS

Survival curves have significantly improved between the periods 1982-1989 and 1990-2003. The 5- and 10-year survival rates between these periods were 80.3% and 85.1%, and 67.5% and 75.0%, respectively. Moreover, there was a difference in overall survival curves of patients of stages II and III, of 35-54 ages, or of positive estrogen receptor (ER) status between these periods.

CONCLUSION

The present study presented the recent advance of the survival rates might be due to the rational development of breast cancer treatment, and suggested the possibility that the patients of stages II and III, of 35-54 ages, or of positive ER status were received benefits by these treatments.

Immediate interlocking nailing versus external fixation followed by delayed interlocking nailing for Gustilo type IIIB open tibial fractures

PURPOSE

To compare immediate interlocking nailing with external fixation followed by delayed interlocking nailing, for Gustilo type IIIB open tibial fractures.

METHODS

23 patients with Gustilo IIIB open tibial fractures were treated with either immediate unreamed interlocking nailing (n=9) or external fixation followed by delayed unreamed interlocking nailing (n=14). Patient age, sex ratio, fracture site, fracture type, and severity were similar in both groups. The time to union, deep infection rate, and nonunion rate in the 2 groups were compared.

RESULTS

In the immediate and delayed nailing groups, respective mean times to union were 21 (standard deviation [SD], 14) months and 14 (SD, 8) months; nonunion rates were 44% (4/9) and 36% (5/14), and deep infection rates were 22% (2/9) and 7% (1/14). All corresponding differences were not statistically significant.

CONCLUSION

Prospective, randomised, multicentre studies are needed to assess whether there are significant differences between the 2 treatment methods.

Middle cerebral artery occlusion causing intracerebral hemorrhage: radiologic findings

Middle cerebral artery (MCA) occlusion usually leads to cerebral infarction but rarely causes cerebral hemorrhage without infarction. We retrospectively investigated the unique radiographic manifestations in cases of cerebral hemorrhage without infarction. Computed tomography (CT) and angiographic images obtained in four patients (aged 26 to 70 years) with MCA occlusion associated with intracerebral hemorrhage were reviewed. Two patients also underwent magnetic resonance imaging (MRI), and one of these underwent magnetic resonance angiography as well; these images were also examined. Cranial CT revealed periventricular hemorrhage with ventricular penetration in one patient and with putaminal penetration in two. Solitary ventricular hemorrhage was found in the fourth patient. Angiography showed ipsilateral occlusion at the M1 portion of the MCA, accompanied by moyamoya-like vessels. No aneurysm or arteriovenous malformation was detected. MRI showed absence of the flow void in the affected MCA and an abnormal flow void in dilated collateral vessels in the basal ganglia. MCA occlusion can cause periventricular or ventricular hemorrhage, which appears to result from bleeding from fragile dilated collateral vessels and, thus, to have an etiology similar to that of adult moyamoya disease. MRI shows promise as a tool for evaluating the occlusion site.

Reduction therapy of ALT levels and prevention of HCC development in patients with HCV-associated cirrhosis

1529

Background: Approximately 30 million people worldwide are estimated to have liver cirrhosis (LC) associated with hepatitis C virus (HCV). In addition, patients with HCV-associated liver cirrhosis (HCV-LC) have a high risk of developing hepatocellular carcinoma (HCC). Namely, 60–80% of the patients may develop HCC in 10 years. So, preventing these patients from developing HCC is an urgent problem to be solved. To find a way to prevent the development of hepatocellular carcinoma (HCC) from hepatitis C-virus associated liver cirrhosis (HCV-LC), an analysis of the HCV-LC patients who had reduction therapy of ALT levels was performed. Patients and Methods: Seventy-four consecutive HCV-LC patients of Child Stage A were followed for > 10 years for the development of HCC. They were divided into two groups: In group A, the reduction therapy for ALT levels is aggressively performed and in group B, the reduction therapy was not performed aggressively. Results: Initial ALT was higher in group A than in group B, but there was no significance. After reduction therapy, ALT level was significantly high in group A in the first year. However, there were no significant differences between ALT levels in groups A and B of after the second year. In total, 39 patients out of 74 (52.7%) developed HCC within 13 years from the beginning of the study and 35 patients did not developed HCC in the same observation period. The incidence of HCC development in group B [65.7% (23/35)] was significantly higher than in group A [41.0% (16/39)] (p=0.039). The median HCC developing time in group A (12.8 years) was significantly longer than in group B (3.8 years) (p=0.0013). Multivariate analysis demonstrated that reduction therapy and ALT levels were the significant factors affecting HCC development. The incidence of HCC development in group B was 5.8 times higher than in group A. The high and unclassified ALT groups were 4.6 times and 2.2 times higher than in the low ALT group. Conclusion: The chances of surviving for more than 10 years without developing HCC in the HCV-LC patients of Child Stage A were far more favorable in group A than in group B. These results suggest that aggressive reduction therapy for ALT levels in HCV-LC patients could significantly prevent HCC development.

No significant financial relationships to disclose.

The utility of an investigational real-time RT-PCR assay system for the detection of micrometastases in sentinel lymph nodes of breast cancer confirmed by 0.2 mm histological interval analysis

10560

Background: Comparison between real-time RT-PCR and histological analysis for the detection of lymph node metastasis in breast cancer patients is difficult because of the necessary use of different tissue for the two tests. In order to minimize this challenge this study used histology sections taken every 0.2 mm and all tissue between the sections was analyzed by real-time RT-PCR. Methods: 129 Lymph nodes (LNs) were obtained by Sentinel LN biopsy and/or axillary dissection from 80 breast cancer patients. All LNs were cut in half. One half of each LN was used for the routine intra-operative diagnosis. The other half was used for the 0.2mm histological interval analysis. All 10μm sections cut for histology at 0.2 mm intervals were analyzed using frozen section H&E under a light microscope. All remaining tissue between the sections used for histological analysis was assayed by real-time RT-PCR using the genetic markers mammaglobin and cytokeratin-19 (investigational GeneSearch Breast Lymph Node Assay, Veridex, LLC, Warren, NJ, USA). Cutoffs were pre- set for the real-time RT-PCR to detect only metastasis greater than 0.2 mm. Results: Compared to the histological diagnosis using 0.2 mm interval frozen sections, the real-time RT-PCR results were as follows; sensitivity of 100.0% (34/34), specificity of 93.7% (89/95) and overall accuracy of 95.3% (123/129). Conclusions: These data suggest by utilizing the 0.2 mm histological interval analysis, sampling discrepancies are minimized and a high level of sensitivity and overall accuracy is seen for the real-time RT-PCR assay. Assay specificity calculations may be less than 100% due to interpretation challenges in frozen section histology, especially in the cases of smaller metastases and/or lobular cancer, causing a small percentage of clinically relevant metastasis to be missed.

[Table: see text]

The correlation of perfusion-weighted MRI with VEGF in resected pancreatic cancer

15092

Background: Perfusion-weighted magnetic resonance imaging (MRI) can detect angiogenesis in brain malignant tumors, and as angiogenesis increases in various carcinomas the prognosis becomes worse. We evaluated the usefulness of perfusion-weighted MRI as a prognostic predictor in pancreatic cancer patients in ASCO 2005. This time, we examined the correlation of perfusion-weighted MRI with vascular endothelial growth factor (VEGF) and microvessel density (MVD) immunohistochemically in resected pancreatic cancer patients. Methods: Perfusion-weighted MRI was performed on 14 consecutive resected pancreatic cancer cases. Imaging acquisition was continually repeated with echo-planar sequence every 2 sec for 2 min with bolus injection of gadolinium. We made the time intensity curve of perfusion-weighted images and calculated the signal ratio (SR). We investigated the expressions of VEGF and CD34 (for calculating MVD) immunohistochemically. MVD was assessed per 200x field. We compared SR with VEGF expression and MVD. The correlations were evaluated with t-test. Results: All cases showed transient decreases in tumor signal intensity (SR range: 18.2–66.0%) in perfusion-weighted MRI. The expressions of VEGF were divided into two groups (high and low expression). MVD ranged from 6 to 34 and was divided into two groups at the median value. The correlation of SR in perfusion-weighted MRI with VEGF expression was significant (p=0.002). High SR correlated with high VEGF expression. The correlation of SR in perfusion-weighted MRI with MVD was not significant. Conclusions: Perfusion- weighted MRI correlated with VEGF expression in pancreatic cancer.

No significant financial relationships to disclose.

A phase II multicentric trial of combined chemotherapy with gemcitabine plus S-1 in patients with advanced pancreatic cancer

15129

Background: While gemcitabine (GEM) is the standard drug for chemotherapy against advanced pancreatic cancer, the development of multidrug therapies for improved outcome is important. We conducted multicentric combined chemotherapy with GEM and S-1 trial and reported the results of the phase I trial last year. And this phase II study evaluated the efficacy and feasibility. Methods: The subjects had unresectable pancreatic ductal cancer. Eligibility criteria were pathologically-proven, Karnofsky performance status 80 to 100%, age 20 to 74 years, adequate hematological, renal, and liver functions and written informed consent. The method of administration was single administration of GEM on the first day of the week 1000 mg/m2, with concurrent administration of S-1 at 80 (<1.5 m2) to 100 (=1.5 m2) mg/day × 7 days, repeated every other week until the progressive disease or life threatening adverse events. This administration dose was determined from the result of the phase I study. The primary endpoint was median survival time. And the secondary endpoints were the overall response rate and the toxicities. Results: 40 patients(pts) were enrolled. Average age was 62.9±8.3 years (34–73 years). Thirty nine pts were conducted this therapy except one who refused this study before the start of administration. Thirty eight pts were evaluable for response, partial response, stable disease, progressive disease were observed in 7 (17.5%), 21 (52.5%) and 10 pts (25.0%), respectively. The median survival time at this stage is 276±51 days in this ongoing study. Grade 3 and 4 toxicities were mainly leucocytes(10 pts), neutrophils(8 pts) and anorexia(6 pts). Conclusions: The GEM plus S-1 combined chemotherapy is effective and feasible in patients with advanced pancreatic cancer.

No significant financial relationships to disclose.

E2F1 overexpression associated with TS and survivin gene expressions in non-small cell lung cancer

7669

Background: The thymidylate synthase (TS) expression is related to 5-FU sensitivity. The survivin expression is associated with tumor apoptosis, an indicator to predict the efficacy of chemotherapy. Recently, TS and Survivin have been reported to be E2F1 target genes. We investigate the clinical significance of the E2F1 gene expression in relation to gene expressions of TS and Survivin among non-small cell lung cancer (NSCLC). Methods: One hundred and twenty-seven NSCLC patients were investigated. Quantitative RT-PCR was performed to evaluate gene expressions of E2F1, TS, and survivin. The Ki-67 proliferation index and the apoptotic index using TUNEL method were also evaluated. Results: The E2F1 gene expression was significantly higher in stage II to III tumors than in stage I tumors (p=0.006). The E2F1 gene expression significantly correlated with the Ki-67 proliferation index (p<0.001), while no correlation was observed between the E2F1 gene expression and the apoptotic index. Regarding E2F1-target genes, the E2F1 gene expression significantly correlated with the TS gene expression (p<0.001). The E2F1 gene expression also significantly correlated with the survivin gene expression (p<0.001). The TS expression and the survivin expression significantly correlated with the Ki-67 proliferation index (p<0.001 and p<0.001, respectively). There was a significant inverse relationship between the survivin expression and the apoptotic index (p<0.001). The overall survival was significantly lower in patients with high-E2F1 tumors than in those with low-E2F1 tumors (p=0.002), especially among patients with stage II to III NSCLCs (p=0.018). The Cox regression analysis demonstrated that the E2F1 status was a significant prognostic factor for NSCLC patients (p=0.026). Conclusions: The present study revealed the E2F1 gene expression to correlate with TS and survivin gene expressions, and tumor proliferation. E2F1 overexpression could occur to produce more aggressive tumors with high proliferation rate and chemo-resistance during progression of NSCLCs. The suppression of E2F1 by RNA interference would be a useful strategy for cancer gene therapy.

No significant financial relationships to disclose.

Octaarginine-modified multifunctional envelope-type nanoparticles for gene delivery

This study describes a multifunctional envelope-type nano device (MEND) that mimics an envelope-type virus based on a novel packaging strategy. MEND particles contain a DNA core packaged into a lipid envelope modified with an octaarginine peptide. The peptide mediates internalization via macropinocytosis, which avoids lysosomal degradation. MEND-mediated transfection of a luciferase expression plasmid achieved comparable efficiency to adenovirus-mediated transfection, with lower associated cytotoxicity. Furthermore, topical application of MEND particles containing constitutively active bone morphogenetic protein (BMP) type IA receptor (caBmpr1a) gene had a significant impact on hair growth in vivo. These data demonstrate that MEND is a promising non-viral gene delivery system that may provide superior results to existing non-viral gene delivery technologies.

α-Lipoic acid attenuates x-irradiation-induced oxidative stress in mice

The development of nontoxic but effective radioprotectors is needed because of the increasing risk of human exposure to ionizing radiation. We have reported that alpha-lipoic acid confers considerable radio-protective effect in mouse tissues when given prior to x-irradiation. In the present study, alpha-lipoic acid supplementation prior to x-irradiation with 4 and 6 Gy significantly inhibited the radiation-induced decline in total antioxidant capacity (TAC) of plasma. Radiation-induced decline in non-protein sulfhydryl content (NPSH) of different tissues, namely, brain, liver, spleen, kidney, and testis, was also ameliorated significantly at both 4 and 6 Gy doses. Maximal augmentation of radiation-induced protein carbonyl content was observed in spleen followed by brain, kidney, testis, and liver. Maximal protection in terms of carbonyl content was observed in spleen (116%) at 6 Gy dose, and minimal protection was found in liver (22.94%) at 4 Gy dose. Maximal increase in MDA (malondialdehyde) content was observed in brain, followed by testis, spleen, kidney, and liver. Protection by alpha-lipoic acid pretreatment in terms of MDA content was maximal in brain (51.67%) and minimal in spleen. The findings support the idea that alpha-lipoic acid is a free-radical scavenger and a potent antioxidant.

Small interfering RNA expression vector targeting hypoxia-inducible factor 1 alpha inhibits tumor growth in hepatobiliary and pancreatic cancers

Hepatobiliary and pancreatic carcinomas are hypovascular tumors that can proliferate under hypoxic conditions. Recent reports have demonstrated that hypoxia-inducible factor 1 alpha (HIF1alpha) plays an important role in the survival of these cancers. Given these findings, the inhibition of the HIF1alpha pathway might prove to be a powerful tool in the treatment of these cancers. To inhibit HIF1alpha expression, we used small interference RNA (siRNA) expression vectors in this study. The transient transfection of siRNA expression vectors significantly reduced both HIF1alpha mRNA levels (13% of control) and protein levels (41% of control) and significantly inhibited the growth of cancer cell lines (P<0.05). VEGF, Glut1, and aldorase A expressions were also significantly reduced by transfection with these vectors (P<0.05), and we found that these vectors induced apoptosis but not cell cycle arrest. In a subcutaneous tumor model using nude mice, transfected MIA PaCa-2 cells, stably expressing siRNAs, barely formed tumors compared to control (P<0.05). This study thus demonstrates the usefulness of siRNA expression vector in targeting HIF1alpha and points to a potential clinical role in the treatment of pancreatic and hepatobiliary carcinomas.

Circulating ghrelin concentrations are lowered by intracerebroventricular insulin

AIMS/HYPOTHESIS

Ghrelin is a peptide that is mainly produced by the stomach and stimulates food intake, adiposity and weight gain. Previous studies have documented that plasma levels of ghrelin are reduced by insulin, but the mechanisms that mediate this effect are unclear.

METHODS

To determine whether phosphatidylinositol 3-kinase (PI(3)K) and/or mitogen-activated protein kinase (MAPK) are involved in this insulin action, we tested the intracerebroventricular (i.c.v.) effect of specific inhibitors of PI(3)K (LY294002 and wortmannin) and MAPK (PD98059 and UO126) on the insulin-mediated reduction of ghrelin levels in rats.

RESULTS

Intracerebroventricular treatment with insulin reduced ghrelin levels. Inhibition of PI(3)K specifically blocked the insulin-induced reduction in ghrelin concentration, whereas inhibition of MAPK had no effect on insulin-mediated actions. Moreover, pretreatment with i.c.v. PI(3)K inhibitors blocked the reduction of ghrelin levels after OGTT-induced hyperglycaemia and hyperinsulinaemia.

CONCLUSIONS/INTERPRETATION

These data demonstrate that changes in insulin action in the central nervous system regulate circulating ghrelin levels and that PI(3)K is a specific mediator of this action.

Development of a novel systemic gene delivery system for cancer therapy with a tumor-specific cleavable PEG-lipid

For successful cancer gene therapy via intravenous (i.v.) administration, it is essential to optimize the stability of carriers in the systemic circulation and the cellular association after the accumulation of the carrier in tumor tissue. However, a dilemma exists regarding the use of poly(ethylene glycol) (PEG), which is useful for conferring stability in the systemic circulation, but is undesirable for the cellular uptake and the following processes. We report the development of a PEG-peptide-lipid ternary conjugate (PEG-Peptide-DOPE conjugate (PPD)). In this strategy, the PEG is removed from the carriers via cleavage by a matrix metalloproteinase (MMP), which is specifically expressed in tumor tissues. An in vitro study revealed that the PPD-modified gene carrier (Multifunctional Envelope-type Nano Device: MEND) exhibited pDNA expression activity that was dependent on the MMP expression level in the host cells. In vivo studies further revealed that the PPD was potent in stabilizing MEND in the systemic circulation and facilitating tumor accumulation. Moreover, the i.v. administration of PPD or PEG/PPD dually-modified MEND resulted in the stimulation of pDNA expression in tumor tissue, as compared with a conventional PEG-modified MEND. Thus, MEND modified with PPD is a promising device, which has the potential to make in vivo cancer gene therapy achievable.

Evaluations of biomarkers associated with 5-FU sensitivity for non-small-cell lung cancer patients postoperatively treated with UFT

The sensitivity to 5-fluorouracil (5-FU) has been reported to be associated with target molecule thymidylate synthase (TS), fluoropyrimidine-metabolising enzymes such as orotate phosphoribosyltransferase (OPRT), and dihydropyrimidine dehydrogenase (DPD). We performed an immunohistochemical study on the clinical significance of TS, OPRT, and DPD expression using 151 resected non-small-cell lung cancer (NSCLC) patients postoperatively treated with a combination of tegafur and uracil (UFT). Eighty-two carcinomas were TS-positive, 105 carcinomas were OPRT-positive, 68 carcinomas were DPD-positive. No correlation was observed in the HSCORE between the TS and OPRT expression (r=0.203), between the TS and DPD expression (r=0.098), or between the OPRT and DPD expression (r=0.074). Regarding the survival of NSCLC patients treated with UFT, the 5-year survival rate of patients with TS-negative tumours was significantly higher than that with TS-positive tumours (P=0.0133). The 5-year survival rate of patients with OPRT-positive stage II to III tumours was significantly higher than that with OPRT-negative stage II to III tumours (P=0.0145). In addition, the 5-year survival rate of patients with DPD-negative tumours was also significantly higher than that with DPD-positive tumours (P=0.0004). A Cox multivariate regression analysis revealed the TS status (hazard ratio 2.663; P=0.0003), OPRT status (hazard ratio 2.543; P=0.0005), and DPD status (hazard ratio 2.840; P<0.0001) to all be significant prognostic factors for the survival of resected NSCLC patients postoperatively treated with UFT.

Usefulness of FDG-PET in predicting the prognosis of advanced pancreatic carcinoma with chemotherapy

14043

Background: 18F-fluorodeoxyglucose (FDG) PET is a new diagnostic imaging technique that takes advantage of increased glucose metabolism by the tumor cells. High uptake of FDG is reportedly associated with poor survival in head and neck cancer (Heikki et al., 1997, Nuclear Oncology). FDG uptake diminishes with elevated levels of plasma glucose. We herein evaluated the usefulness of FDG-PET in predicting the prognosis of advanced pancreatic carcinoma (APC). Methods: FDG-PET was performed on 32 consecutive patients with APC between July 2001 and April 2004. The patients fasted for at least 5 hr before the study. The plasma glucose level was controlled under 150 mg/dl by using oral antidiabetic or insulin therapy in advance. FDG-PET images were acquired 45 min after intravenous injection of FDG. We did not measure the plasma glucose level directly before imaging. The FDG uptake in the primary tumor was quantitated as the standardized uptake value (SUV), and the maximum SUV (SUVmax) was measured in the regions of interest. All of the 32 APC patients received chemotherapy (26: gemcitabine, 1: gemcitabine + UFT, 5: TS-1). We analyzed the correlation between SUVmax and the overall survival. Then, we excluded the diabetics (n = 8) and compared SUV in the non-diabetic patients (n = 24). The overall survival curve was plotted according to the method of Kaplan and Meier. The difference in the overall survival was calculated using the log-rank test, and a multivariate analysis was conducted. Results: 32 patients were examined. All cases showed FDG uptake in the pancreatic tumor (SUVmax ranged from 2.73 to 9.67). The overall survival ranged from 38 to 945 days with a median of 261 days.These patients were classified into two groups at a median SUVmax value of 4.81. There was no significant difference in the overall survival between these two groups (p > 0.05). The non-diabetic patients (n = 24) were classified into two groups at a median SUVmax value of 5.51. The high SUVmax group had shorter overall survival than the low SUVmax group (p = 0.039). The multivariate analysis using Cox hazard model also revealed that SUVmax was a significant, independent factor that influenced the survival (p = 0.043) in the non-diabetic patients. Conclusions: FDG-PET may be a useful modality in determining the prognosis of APC.

No significant financial relationships to disclose.

Continuous low-dose intravenous lidocaine is effective for visceral pain secondary to peritoneal carcinomatosis in terminal cancer patients

8533

Background: Lidocaine, a local anesthetic, is often used as an anti-arrhythmic and as an analgesic of best support care (BSC) for patients with neuropathic pain. However, little is known about the effect of low-dose lidocaine on the abdominal pain of terminally-ill patients with peritoneal carcinomatosis. Aim: To evaluate whether visceral pain is controlled and activities of daily life (ADL) are improved during continuous lidocaine infusion. Methods: 28 terminally ill patients with peritoneal carcinomatosis due to the gastrointestinal (26) and gynecologic (2) cancers were studied. Despite aggressive pain management with opiates, non-steroidal anti-inflammatory drugs and other adjuvants, debilitating pain persisted. After a test dose of 2mg/kg intravenously, lidocaine was administered at low-doses (0.4 and/or 0.8mg/kg-h) through a vein and continued for more than 24 hours. Pain was quantitated on a faces rating scale from the level 0 (no pain) to 5 (severe pain); doses of opiates, amounts of oral intake, side effects, and ADL were measured before and after lidocaine. Results: Age (mean±SE) was 62±2, and percentage of males was 54%. Patients were not hypercalcemia but were slightly malnutrished (albumin 2.9±0.1g/dl) and anemic (hemoglobin 10.3±0.4g/dl). The duration of lidocaine administration in hospital was 18±3days. Abdominal symptoms improved within 1.2±0.1days after beginning lidocaine, and pain scale decreased from 2.7±0.2 to 0.6±0.2; p<0.001. In 68% of patients, the pain level became zero. Blood concentration of lidocaine at 0.8mg/kg-h was 3.0±0.4μg/ml 1 week later. 68% of patients needed no increase in opiate dosage during lidocaine administration. Waist size did not decrease, however, oral intake increased (p=0.002) during lidocaine administration. No obvious side effects, such as perioral numbness, were seen except for emotional lability noted in 4 patients. 43% patients were able to be discharged for continued end-of-life comfort care with home parenteral nutrition and continuation of lidocaine administration. Conclusions: We suggest that continuous, low-dose intravenous lidocaine is BSC and is a very effective approach for analgesia and improvement of ADL in patients with peritoneal carcinomatosis.

No significant financial relationships to disclose.

A phase I multicentric trial of combined chemotherapy with gemcitabine plus S-1 in patients with advanced pancreatic cancer

14047

Background: While gemcitabine (GEM) is the standard drug for chemotherapy against advanced pancreatic cancer, the development of multidrug therapies for improved outcome is important. We conducted multicentric combined chemotherapy with GEM and S-1 and report the results of the phase I trial. Methods: The subjects had unresectable pancreatic ductal cancer. The method of administration was single administration of GEM on the first day of the week from Level 1 to Level 4 at 400 to 1000 mg/m2, with concurrent administration of S-1 at 40 to 100 mg/day × 7 days, repeated every other week as a collaborative trial conducted at 3 facilities. The purpose was to determine the optimal dose with adverse events as an indicator. Results: Eighteen patients were enrolled (3 each at Levels 1, 2, 3 and 4’, 6 at Level 4). Average age was 60.9 years (38 - 71 years). There was no dose limiting toxicity (DLT) up to Level 3. Level 4 was the maximum tolerated dose since DLT was observed in 4/6 patients (mucositis 2, rash 1, anorexia 1), and no DLT was observed in 3 additional patients at Level 4’. The resulting recommended dose was Level 4 (GEM 1000 mg/m2, S-1 100 mg/day). For reference, partial response was observed in 5 patients, and median survival time at this stage is 336±39 days. Conclusions: The recommended dosage of GEM + S-1 combined chemotherapy for unresectable advanced pancreatic cancer was determined in a phase I trial. We intend to proceed to a phase II trial.

No significant financial relationships to disclose.

Preoperative evaluation of the extrahepatic bile duct structure for laparoscopic cholecystectomy

BACKGROUND

The incidence of aberrant bile duct injury associated with laparoscopic cholecystectomy (LC) has not yet been adequately examined. This study aimed to clarify the types of normal cystic ducts and the incidence of aberrant extrahepatic bile ducts, and to search for a method of avoiding injuries during LC.

METHODS

Aberrant hepatic ducts were retrospectively categorized into five types according to the pattern of the cystic ducts and the accessory hepatic ducts by preoperative endoscopic retrograde cholangiography or multidetector three-dimensional computed tomography using drip infusion cholangiography. The aberrant bile ducts were classified as type A (merging at the right side of the common bile duct), type B (merging at the anterior side), or type C (merging at the posterior left side).

RESULTS

The intrahepatic bile ducts and cystic duct were clearly shown for 1,044 of the 1,278 patients who underwent LC. Secondary branches of aberrant cystic ducts were observed in 37 cases (3.5%), and accessory hepatic ducts were observed in 30 cases (2.9%). A comparison of the difficulties encountered with LC for each type based on the merging patterns of cystic ducts showed that type C needed a much longer operation time for LC than the other types.

CONCLUSIONS

A preoperative evaluation of the bile duct tract and the accessory hepatic duct before LC is important. Patients with a cystic duct merging normally into the posterior left side of the common hepatic duct (type C) experienced difficulty when undergoing LC. The authors have safely performed LC with the use of an endoscopic nasobiliary drainage tube in type D cases (cystic duct merging with the right hepatic duct), in type IV cases (cystic duct merging with an accessory hepatic duct).

MRP-1/CD9 gene transduction regulates the actin cytoskeleton through the downregulation of WAVE2

Motility-related protein-1 (MRP-1/CD9) is involved in cell motility. We studied the change in the actin cytoskeleton, and the expression of actin-related protein (Arp) 2 and Arp3 and the Wiskott-Aldrich syndrome protein (WASP) family according to MRP-1/CD9 gene transduction into HT1080 cells. The frequency of cells with lamellipodia was significantly lower in MRP-1/CD9-transfected HT1080 cells than in control HT1080 cells (P<0.0001). MRP-1/CD9 gene transduction affected the subcellular localization of Arp2 and Arp3 proteins. Furthermore, MRP-1/CD9 gene transduction induced a downregulation of WAVE2 expression (P<0.0001). However, no difference was observed in the expression of Arp2, Arp3 or other WASPs. A neutralizing anti-MRP-1/CD9 monoclonal antibody inhibited downregulation of WAVE2 in MRP-1/CD9-transfected HT1080 cells (P<0.0001), and reversed the morphological effects of MRP-1/CD9 gene transduction. Furthermore, downregulation of WAVE2 by transfection of WAVE2-specific small interfering RNA (siRNA) mimicked the morphological effects of MRP-1/CD9 gene transduction and suppressed cell motility. However, transfection of each siRNA for Wnt1, Wnt2b1 or Wnt5a did not affect WAVE2 expression. Transfection of WAVE2-specific siRNA also did not affect expressions of these Wnts. These results indicate that MRP-1/CD9 regulates the actin cytoskeleton by downregulating of the WAVE2, through the Wnt-independent signal pathway.

The HAUSP gene plays an important role in non-small cell lung carcinogenesis through p53-dependent pathways

Herpesvirus-associated ubiquitin-specific protease (HAUSP) directly stabilizes the tumour suppressor p53 by de-ubiquitination. Therefore, the HAUSP gene might play an important role in carcinogenesis. In this paper, HAUSP expression and p53 gene status have been studied in relation to the expression of p53 target genes in 131 patients with non-small cell lung cancer (NSCLC). p53 gene status was evaluated by polymerase chain reaction-single-strand conformation polymorphism (PCR-SSCP) followed by sequencing. Quantitative reverse-transcription polymerase chain reaction (RT-PCR) was performed to evaluate the gene expression of HAUSP, p21, and bax. Immunohistochemistry was performed to evaluate the protein expression of p53, HAUSP, mdm2, p21, and bax. Fifty-nine carcinomas (45.0%) showed reduced expression of HAUSP, and 58 carcinomas (44.3%) had mutations of p53. Concerning tumour histology, HAUSP mRNA expression was significantly lower in adenocarcinomas than in squamous cell carcinomas (p = 0.0038), while the frequency of p53 mutation was significantly higher in squamous cell carcinomas than in adenocarcinomas (p = 0.0461). There was no significant difference in HAUSP mRNA expression according to p53 gene status. In total, 93 carcinomas (71.0%) showed either mutant p53 or reduced HAUSP expression. The down-regulation of HAUSP was associated with reduced p53 protein expression (p = 0.0593 in tumours with wild-type p53 and p = 0.0004 in tumours with mutant p53). Furthermore, p21 and bax protein expression was significantly lower in tumours with either mutant p53 or reduced HAUSP expression than in tumours with both wild-type p53 and positive HAUSP expression (p = 0.0440 and p = 0.0046, respectively). In addition, the simultaneous evaluation of both HAUSP expression and p53 gene status was a significant indicator of poor prognosis in adenocarcinoma patients (hazard ratio 4.840, p = 0.0357). These results suggest that reduction of HAUSP gene expression may play an important role in NSCLC carcinogenesis, especially in adenocarcinomas, through p53-dependent pathways.

[Fontan completion after balloon angioplasty of multiple pulmonary artery stenosis in a child with pulmonary atresia with intact ventricular septum; report of a case]

A 5-year-old boy was referred to our institute for cardiac evaluation having been previously seen at another center. He had been diagnosed a pulmonary atresia with intact ventricular septum just after birth, and undergone Blalock-Taussig shunts. Although his central pulmonary artery pressure was high (mean pressure 26 mmHg) after bilateral Blalock-Taussig shunts, multiple peripheral pulmonary artery stenosis protected his pulmonary vascular bed from pressure load. We released the multiple pulmonary artery stenosis partly by catheter intervention and partly by surgical operation, and staged Fontan operation was completed. The surgery in combination with catheter therapies would expand the indication of Fontan-type operation, and it would contribute to the patients' postoperative prognosis.

Gender differences in postoperative pain after laparoscopic cholecystectomy

BACKGROUND

Some evidence suggests that females have a lower pain threshold and a lower tolerance to painful stimuli. This study investigated gender differences in postoperative pain after laparoscopic cholecystectomy (LC) on the basis of visual analog pain scale (VAS) scores and the clinical course.

METHODS

The 100 patients in this study (46 males and 54 females) underwent LC for cholecystolithiasis or gallbladder polyps without intraoperative complications. An 8-mm Penrose drain was retained for 42 h below the liver bed. All the patients were hospitalized for 4 days after LC, and the pain reported by patients, the time course of changes in the highest body temperature, the leukocyte count, and the C-reactive protein level were studied comparatively for the male and female patients.

RESULTS

The VAS scores were significantly higher for the female patients than for the male patients at 24 h (62.7 +/- 24.6 vs 47.0 +/- 23.3; p = 0.0015) and at 48 h (39.2 +/- 24.3 vs 28.3 +/- 19.1; p = 0.0137) after LC. The female patients used analgesics more frequently and had significantly higher body temperatures than the male patients on day 1 (37.2 +/- 0.6 vs 36.9 +/- 0.4; p = 0.0037) and day 2 (36.9 +/- 0.6 vs 36.6 +/- 0.4; p = 0.0037) after surgery.

CONCLUSIONS

Early postoperative pain after LC was more severe in female patients, and patients with high VAS scores tended to use analgesics more frequently.

Oxidative damage in cerebral vessels of diabetic db/db mice

BACKGROUND

Oxidative stress in diabetes mellitus has recently received increasing attention as it has been proven to be associated with the development of diabetic vascular complications. Our aim was to examine whether microvascular changes, including oxidative damage, were induced in the brains of diabetic animals.

METHODS

The expression of 8-hydroxy-2'-deoxyguanosine (8-OHdG), a marker of oxidative DNA damage, the binding of cationized ferritin, a marker for evaluating endothelial glycocalyx, to the endothelial cells of capillaries and vascular permeability of intravenously injected horseradish peroxidase were examined in the cortices of 12- and 20-week-old db/db and db/+m mice.

RESULTS

Immunostaining for 8-OHdG was clearly seen in the vessels of the cortex of 20-week-old db/db mice, but was hardly seen in those of mice in the other groups. The immunopositive area of 8-OHdG was significantly increased in the cortex of 20-week-old db/db mice compared with that of 20-week-old db/+m mice. No extravasated leakage of horseradish peroxidase was seen in any groups of mice, while the numbers of cationized ferritin particles binding to the endothelial cells was significantly decreased in 12- and 20-week-old db/db mice compared with that of db/+m mice at the same age, respectively.

CONCLUSION

These findings suggest that changes in endothelial glycocalyx are induced in db/db mice and, in addition, the long-term diabetic condition of these mice induces oxidative DNA damage to the cerebral vessels.