Randomised clinical trial: rabeprazole improves symptoms in patients with functional dyspepsia in Japan

BACKGROUND

The efficacy of proton pump inhibitors (PPIs) for treating functional dyspepsia (FD) is not well established.

AIM

This study, named the SAMURAI study, aimed to assess the efficacy and dose-response relationship of rabeprazole in Japanese patients with FD in a multicentre, double-blinded, randomised, placebo-controlled trial.

METHODS

Investigated FD was diagnosed using the Rome III criteria. Subjects who did not respond to 1 week of single-blind placebo treatment in a run-in period were randomly assigned to 8 weeks of double-blind treatment with rabeprazole 10 mg, 20 mg, 40 mg or placebo, once daily. Dyspeptic symptoms were assessed by a dyspepsia symptom questionnaire (7-point Likert scale) and symptom diary.

RESULTS

Of 392 subjects entered into the run-in period, 338 were randomly assigned. Although there was no significant difference between placebo and rabeprazole groups in complete symptom relief for four major dyspeptic symptoms, the satisfactory symptom relief of rabeprazole 20 mg was significantly higher than placebo according to the dyspepsia symptom questionnaire (45.3% vs. 28.2%, P = 0.027) and the symptom diary assessment (48.7% vs. 30.0%, P = 0.016). The efficacy was not influenced by syndrome type or Helicobacter pylori status. No statistically significant differences in the incidence of adverse events were seen among treatment groups.

CONCLUSIONS

Rabeprazole 20 mg once daily but not 10 or 40 mg significantly provides satisfactory symptom relief for functional dyspepsia (ClinicalTrials.gov, Number NCT01089543).

Treatment of a Gilbert's Syndrome Patient with Irinotecan, Leucovorin and 5-Fluorouracil

The patient was an elderly male who had radical surgery for sigmoid cancer in 2001. Owing to metastasis of his cancer to the left supraclavicular lymph nodes in 2002, the patient was admitted to our hospital for systemic chemotherapy. We started treatment with irinotecan, leucovorin, 5-fluorouracil (IFL). After administering 100 mg/m2 of irinotecan, 250 mg/m2 leucovorin and 600 mg/m2 5-fluorouracil to the patient on day 1, grade 3 leukopenia developed rapidly and grade 4 thrombocytopenia was observed on day 5. We excluded irinotecan from the medication and continued the administration of 5-fluorouracil and leucovorin, but his tumors had not been reduced sufficiently. Based on some examination results, we assumed that the patient had Gilbert's syndrome and that the severe side effects that occurred were due to prolongation of SN38 metabolism. We again administered irinotecan but at reduced dose (25 mg/m2). Four courses of this modified IFL were administered safely and the response was favorable.

The involvement of CD36 in monocyte activation by antiphospholipid antibodies

Background

CD36, known as a scavenger receptor, is a transmembrane glycoprotein expressed on monocytes, platelets and endothelial cells, recognizes multiple ligands, including phosphatidylserine, and regulates atherogenesis and thrombosis. The objective of this study is to investigate the possible involvement of CD36 in the pathophysiology of thrombosis in patients with antiphospholipid syndrome (APS).

Methods

First, rs3765187, a missense mutation linked to CD36 deficiency, was investigated by TaqMan polymerase chain reaction (PCR) genotyping method in 819 Japanese, including 132 patients with APS, 265 with systemic lupus erythematosus (SLE) in the absence of APS, and 422 healthy subjects. Then, the involvement of CD36 in antiphospholipid antibody (aPL)-induced tissue factor (TF) expression was examined using CD36-null mice or anti-CD36. Purified IgG from patients with APS and a monoclonal phosphatidylserine-dependent antiprothrombin antibody were used in these experiments. TF expression was tested by real-time PCR and flow cytometry.

Results

Minor allele carrier of rs3765187 was less frequent in patients with APS (3.8% p = 0.032), but not in patients with SLE in the absence of APS (7.9% p = 0.32), compared with healthy subjects (10.2%). The aPL-induced TF expression was significantly suppressed on peritoneal macrophages from CD36-null mice compared to wild type and significantly inhibited by anti-CD36 on human monocytes.

Conclusions

The gene mutation linked to CD36 deficiency was less frequent in patients with APS. The deficient or suppressed CD36 function significantly reduced aPL-induced TF expression in vitro. Taken together, in a susceptible background CD36 scavenger receptor function may be involved in the thrombotic pathophysiology in patients with APS.

Estimation of glomerular filtration rate in rabbits by a single-sample method using iodixanol

To estimate the glomerular filtration rate (GFR) in conscious rabbits, a single-sample method using the non-ionic contrast medium iodixanol was compared with a three-sample method using the standard agent inulin. Iodixanol and inulin were co-administered intravenously to male New Zealand White rabbits at 60 mg I/kg and 40 mg/kg, respectively, and blood was collected 30, 60, 90 and 120 min later. Serum iodixanol and inulin concentrations were separately determined by high performance liquid chromatography and colorimetry, respectively. Serum urea nitrogen (UN) and creatinine concentrations were also determined. Based on the data from healthy and cisplatin-treated rabbits, the GFR estimated by iodixanol was well consistent with that by inulin. Further, when the GFR decreased to more than 60% of the reference value, serum creatinine concentrations became elevated. However, serum UN concentrations exhibited wide fluctuations, presumably due to a difference in renal handlings. The single-sample method using iodixanol was considered to be an expedient tool in both clinical and research settings, because the stress due to a multi-sample method was reduced.

A vasodilating β1 blocker celiprolol inhibits muscular release of uric acid precursor in patients with essential hypertension

Although nonvasodilating β1 blockers increase the levels of uric acid in serum, it is not known whether vasodilating β1 blockers have a similar effect. In the present study, we evaluated the effect of celiprolol on the release of hypoxanthine, a uric acid precursor, from muscles after an exercise. We used the semi-ischemic forearm test to examine the release of lactate (ΔLAC), ammonia (ΔAmm), and hypoxanthine (ΔHX) before and 4, 10, and 60 min after an exercise in 18 hypertensive patients as well as 4 normotensive subjects. Before celiprolol treatment, all the levels of ΔHX and ΔAmm, and ΔLAC were increased by semi-ischemic exercise in hypertensive patients, and the increases were remarkably larger than those in normotensive subjects. Celiprolol decreased both systolic and diastolic pressure. It also decreased the levels of ΔHX and ΔAmm without changes in ΔLAC after an exercise. These findings also were confirmed by summation of each metabolite (ΣΔMetabolites). Celiprolol caused a marginal decrease of serum uric acid, but the difference was not statistically significant. On the other hand, nonvasodilating β1 blockers did not suppress the levels of ΔHX and ΔAmm, whereas they significantly increased ΔLAC after an exercise. Celiprolol improved energy metabolism in skeletal muscles. It suppressed HX production and consequently did not adversely affect serum uric acid levels.

Esophageal submucosal dissection under steady pressure automatically controlled endoscopy (SPACE): a randomized preclinical trial

BACKGROUND AND STUDY AIMS

A new overtube system has been developed for steady pressure automatically controlled endoscopy (SPACE) in the gastrointestinal tract. The objectives of this study were to validate the feasibility and safety of SPACE in the esophagus, and to evaluate its potential advantages over conventional (manually insufflating) endoscopy in endoscopic submucosal dissection (ESD).

METHODS

This was a multicenter preclinical trial using acute porcine models (n = 20). In Experiment 1 (feasibility/safety study), SPACE was attempted in the esophagus with continuous monitoring of cardiopulmonary parameters and intraluminal pressures in the downstream bowel. Different insufflation pressures were tested to optimize the insufflation condition. Each session was video-recorded and scored by blinded reviewers. In Experiment 2 (randomized trial), esophageal ESD was attempted using either SPACE or conventional endoscopy, and results were compared.

RESULTS

In Experiment 1, SPACE was performed safely without intraluminal pressure elevation in the downstream bowel. According to video review, SPACE provided more stable, reproducible, and rapid visualization than conventional endoscopy. The insufflation pressure was optimized at 14 mmHg for esophageal SPACE. In Experiment 2, ESD was completed in all animals. The ESD time was significantly shorter with SPACE compared with conventional endoscopy (1326 vs. 1616 seconds; P = 0.009). Responses to questionnaires showed that 94 % - 100 % of participants considered SPACE to provide improved exposure and more uniform tissue tension than conventional endoscopy. Other data were comparable.

CONCLUSIONS

SPACE is feasible, safe, and potentially effective for complicated endoscopic procedures, such as ESD. SPACE improves and standardizes endoscopic exposure and tissue tension. A clinical study is required to further confirm its safety and clinical effectiveness.

A standard for absorbed dose rate to water in a 60Co field using a graphite calorimeter at the National Metrology Institute of Japan

A primary standard for the absorbed dose rate to water in a ⁶⁰Co radiation field has been newly established at the National Metrology Institute of Japan. This primary standard combines the calorimetric measurements using a graphite calorimeter with the ionometric measurements using a thick-walled graphite cavity ionisation chamber. The calorimeter is operated in the constant temperature mode using AC Wheatstone bridges. The absorbed dose rate to water was determined to be 12 mGy s⁻¹ at a point of 1 m from the radiation source and at a water depth of 5 g cm⁻². The uncertainty on the calibration coefficient in terms of the absorbed dose to water of an ionisation chamber using this standard was estimated to be 0.39 % (k=1).

Predominant prevalence of arterial thrombosis in Japanese patients with antiphospholipid syndrome

Objective: To study the clinical and immunological manifestations of antiphospholipid syndrome (APS) in the Japanese population by a single-centre registration. Methods: In this retrospective cohort study, 141 consecutive patients with APS, fulfilling the Sydney revised Sapporo criteria for definite APS, who visited our autoimmune clinic from 1988 to 2010, were recruited and followed up. All the patients were interviewed and underwent a general physical examination by qualified rheumatologists on the day of blood sampling. Results: The population comprised 119 woman and 22 men with a mean age at diagnosis of 44 years (range 9–79 years). Seventy patients (49.6%) had primary APS, and 71 (50.4%) had systemic lupus erythematosus. The prevalence of thrombosis was 85.8 per cent, arterial thrombosis was found in 93 patients (66.0%) and venous thrombosis was found in 46 patients (32.6%). The most common thrombosis was cerebral infarction [86/141 (61.0%)] followed by deep vein thrombosis [33/141 (23.4%)]. Among 70 pregnant women, 45 (64.3%) had obstetric complications. Lupus anticoagulant was detected in 116 patients (82.3%), anticardiolipin antibodies in 83 (58.9%), anti-β2 glycoprotein I antibodies in 73 (51.8%) and phosphatidylserine-dependent antiprothrombin antibodies in 98 (69.5%). Conclusion: High prevalence of arterial thrombosis was noted in Japanese patients with APS. The profile of heterogeneous and complex clinical manifestations was substantiated in Japanese patients with APS.

Alternaric acid stimulates phosphorylation of His-tagged RiCDPK2, a calcium-dependent protein kinase in potato plants

Calcium-dependent protein kinases (CDPK) are an essential component of plant defense mechanisms against pathogens. We investigated the effect of alternaric acid, a host-specific toxin produced by the plant fungal pathogen Alternaria solani (Pleosporaceae), on a putative plasma membrane and cytosolic kinase RiCDPK2 of potato (Solanum tuberosum) and on hypersensitive cell death of host potato cells. Alternaric acid, in the presence of Ca²⁺ and Mg²⁺, stimulated in vitro phosphorylation of His-tagged RiCDPK2, a Ca²⁺-dependent protein kinase found in potato plants. We concluded that Ca²⁺ and Mg²⁺ play an important role in the interaction between alternaric acid and RiCDPK2. Based on our observations, alternaric acid regulates RiCDPK2 kinase during the infection process in an interaction between host and A. solani, leading to the inhibition of hypersensitive cell death in the host. We suggest that alternaric acid is a primary determinant by which A. solani stimulates CDPK activity in the host, suppressing hypersensitive cell death.

Haemoglobin A1c cut-off point to identify a high risk group of future diabetes: results from the Omiya MA Cohort Study

AIMS

Using the HbA(1c) level to define diabetes has several advantages and these advantages also apply to define a high-risk group. However, the risk of diabetes increases as HbA(1c) increases and a certain degree of arbitrariness in the cut-off for the high risk group is unavoidable. The aim of this study was to determine the HbA(1c) cut-off for defining a high-risk group that corresponds to the fasting plasma glucose cut-off by comparing the risk of diabetes against the fasting plasma glucose and HbA(1c) levels in the Japanese population.

METHODS

A retrospective cohort study was conducted using data from annual health examinations performed in Omiya city. A total of 11,271 subjects between the ages of 40 and 79 years without diabetes at baseline were followed for up to 7 years. According to the new diagnostic criteria, diabetes was defined as an fasting plasma glucose level ≥ 7 mmol/l or an HbA(1c) level ≥ 48 mmol/mol (≥ 6.5%) or a self-report. The HbA(1c) cut-off corresponding to the fasting plasma glucose cut-off was determined using the incidence, hazard ratio, and a receiver operating characteristic analysis.

RESULTS

Eight hundred and sixty subjects developed diabetes. The incidence, hazard ratio, and receiver operating characteristic analysis all indicated that an HbA(1c) cut-off of 39 mmol/mol (5.7%) corresponded to an fasting plasma glucose level of 5.6 mmol/l.

CONCLUSIONS

Our results suggested that the HbA(1c) cut-off for high-risk of diabetes should be 39 mmol/mol (5.7%), consistent with the American Diabetes Association recommendation. Further research is needed to determine whether our results are applicable to other populations.

Aberrant activation of ALK kinase by a novel truncated form ALK protein in neuroblastoma

Anaplastic lymphoma kinase (ALK) was originally identified from a rare subtype of non-Hodgkin's lymphomas carrying t(2;5)(p23;q35) translocation, where ALK was constitutively activated as a result of a fusion with nucleophosmin (NPM). Aberrant ALK fusion proteins were also generated in inflammatory fibrosarcoma and a subset of non-small-cell lung cancers, and these proteins are implicated in their pathogenesis. Recently, ALK has been demonstrated to be constitutively activated by gene mutations and/or amplifications in sporadic as well as familial cases of neuroblastoma. Here we describe another mechanism of aberrant ALK activation observed in a neuroblastoma-derived cell line (NB-1), in which a short-form ALK protein (ALK(del2-3)) having a truncated extracellular domain is overexpressed because of amplification of an abnormal ALK gene that lacks exons 2 and 3. ALK(del2-3) was autophosphorylated in NB-1 cells as well as in ALK(del2-3)-transduced cells and exhibited enhanced in vitro kinase activity compared with the wild-type kinase. ALK(del2-3)-transduced NIH3T3 cells exhibited increased colony-forming capacity in soft agar and tumorigenicity in nude mice. RNAi-mediated ALK knockdown resulted in the growth suppression of ALK(del2-3)-expressing cells, arguing for the oncogenic role of this mutant. Our findings provide a novel insight into the mechanism of deregulation of the ALK kinase and its roles in neuroblastoma pathogenesis.

Prognosis of high-grade endometrial cancer: a comparison of serous-type and clear cell type to grade 3 endometrioid-type

OBJECTIVE

To evaluate prognosis of high-grade endometrial cancers, comparing serous (SC) and clear cell (CCC) types to grade 3 endometrioid carcinoma (ECG3).

METHODS

Among patients with endometrial cancer treated in two decades, medical records of patients with high-grade endometrial cancer were retrospectively investigated.

RESULTS

Of 447 endometrial cancers, 107 (24%) high-grade endometrial cancers were identified, with the increasing incidence in the last decade (28% vs 19%; p = 0.026). There were 24 SC, 14 CCC and 69 ECG3. Median age was 62, 68, and 61 years, respectively, with the CCC type showing an elder age than the ECG3 type (p = 0.012). The rates of patients with Stage IIIc-IV, lymph node assessment or complete resection at primary surgery, and post-operative chemotherapy were not significantly different; however, response rate to first-line chemotherapy in patients with measurable disease was lower in SC than ECG3 (3 / 11, 27% vs 14 / 19, 74%; p = 0.037), regardless of regimens. Five-year overall survival (OS) was 40%, 71%, and 71% respectively, and five-year progression-free survival (PFS) was 25%, 71%, and 61%, respectively, showing SC with worse prognosis than ECG3 on both OS (p = 0.026) and PFS (p = 0.0028). According to the multivariate analysis, age > or = 70, Stage IIIc-IV and incomplete resection were independent prognostic factors on poor OS, whereas SC, Stage IIIc-IV and incomplete resection were on poor PFS.

CONCLUSIONS

The increasing trend of high-grade endometrial cancer and different outcomes according to histological subtypes, especially poor PFS and chemotherapeutic response in SC, were suggested.

Large cell neuroendocrine carcinoma arising in mature cystic teratoma: a case report and review of the literature

BACKGROUND

Malignant transformation of ovarian mature cystic teratoma is rare, and occurs in approximately 1% of all cases. The most common histology arising in mature cystic teratoma is squamous cell carcinoma. Less frequently, malignant transformation is represented by an endocrine tumor. To date, only five cases of large cell neuroendocrine carcinoma (LCNC) arising in a mature cystic teratoma of the ovary have been reported.

CLINICAL CASE

A 69-year-old woman presented with a 15-cm left ovarian mass, and was diagnosed with Stage IV large cell carcinoma neuroendocrine carcinoma (LCNC) arising in mature cystic teratoma (MCT) of the left ovary. The patient received adjuvant chemotherapy with paclitaxel and carboplatin, however, residual tumors increased in size. Six months after the debulking surgery she succumbed to the disease. A literature review revealed LCNC of the ovary showed excessively aggressive phenotype in malignant transformation from ovarian mature cystic teratoma.

CONCLUSION

The present case of LCNC arising in MCT had an exceedingly poor prognosis, which was suggested in the previous five cases reported.

Normal serum CA125 half-life and normal serum nadir CA125 level in patients with ovarian cancers

The normal serum CA125 half-life and distribution of the normal serum nadir CA125 value in patients with epithelial ovarian carcinoma (EOC) have not been determined yet. Among patients with EOC, 41 patients met the inclusion criteria of the present study: the patients that underwent complete cytoreductive surgery and six cycles of platinum-containing chemotherapy, and who had no recurrent disease more than five years. Serum CA125 half-life (T1/2) during primary surgery and primary chemotherapy was calculated and serum nadir CA125 level was evaluated by logarithmic-transformed serum CA125. Median value of nadir CA125 was 7 U/ml (range 3-20 U/ml), and the mean ln (serum nadir CA125) was 1.96 +/- 0.45. Mean T1/2 was 10.4 days in all patients, and T1/2 value was associated with the preoperative serum levels of CA125. Predicted slope of CA125 regression curve was also influenced by the preoperative CA125 value. The present study provides fundamental information with regard to normal half-life time and normal nadir of CA125 in EOC patients.