Salvage esophagectomy after definitive chemoradiotherapy for synchronous double cancers of the esophagus and head-and-neck

Head-and-neck cancer is frequently associated with esophageal cancer. Because the operative procedures for these synchronous double cancers are too invasive, definitive chemoradiotherapy tends to be applied as an initial treatment. A salvage esophagectomy for either recurrent or residual disease after definitive chemoradiotherapy in patients with such double cancer has never been reported. We reviewed 21 patients with esophageal cancer who underwent a salvage esophagectomy after definitive chemoradiotherapy. Among them, the treatment course of five patients who underwent a salvage esophagectomy for patients with synchronous double cancers of the esophagus and head-and-neck region was analyzed. Because head-and-neck cancer was well controlled after chemoradiotherapy in all five patients, a salvage esophagectomy was indicated for either recurrent or residual esophageal cancer after definitive chemoradiotherapy. Anastomotic leakage developed in four patients; however, no other complications including pulmonary complications were recognized. All of them were discharged to home and three of them are still alive without any recurrence for 20-43 months. A salvage esophagectomy should be considered as a treatment option for either recurrent or residual esophageal cancer with well-controlled head-and-neck cancer after definitive chemoradiotherapy when complete resection of the esophagus is expected.

Arterial Occlusion Sites on Magnetic Resonance Angiography Influence the Efficacy of Intravenous Low-Dose (0·6 mg/kg) Alteplase Therapy for Ischaemic Stroke

Aims

To determine the predictors of efficacy, including magnetic resonance imaging information, for low-dose intravenous alteplase therapy for stroke patients.

Methods

Seventy-eight patients were prospectively enrolled in a single Stroke Unit (SU) receiving alteplase at a dose of 0·6 mg/kg during the initial 27 months after its approval in Japan. Ischaemic changes and vascular lesions were identified using computed tomography, diffusion-weighted magnetic resonance imaging, and magnetic resonance angiography. Early ischaemic signs were assessed using the Alberta Stroke Program Early CT Score.

Results

The median baseline National Institutes of Health Stroke Scale score of 78 patients was 12. In 19 patients (24%), the National Institutes of Health Stroke Scale score improved by ≥8 points at 24 h. After multivariate adjustment, occlusion at the internal carotid artery (odds ratio 11·82, 95% confidence interval 1·73–142·74), Alberta Stroke Program Early CT Score on diffusion-weighted imaging ≤6 (15·23, 1·88–351·50), and a lower National Institutes of Health Stroke Scale score (1·24, 1·08–1·47, per 1-point decrease) were inversely correlated with early improvement. Four patients (5%) had symptomatic intracranial haemorrhage. At 3 months, 76 patients (98%) survived, and 36 of 78 patients (46%) overall, but only two of 19 patients (11%) with internal carotid artery occlusion, had a favourable functional outcome, corresponding to a modified Rankin scale score 1. After multivariate adjustment, internal carotid artery occlusion (odds ratio 15·84, 95% confidence interval 3·12–128·69) and Alberta Stroke Program Early CT Score on diffusion-weighted imaging ≤6(15·62, 1·78–410·12) were independent predictors of poor outcome.

Conclusions

Intravenous alteplase therapy at a dose of 0·6 mg/kg resulted in a relatively good overall outcome when compared with outcomes reported by western studies using an alteplase dose of 0·9 mg/kg. However, patients with occlusion at the internal carotid artery did not respond to this low-dose alteplase therapy.

Biochemical characterization of plasma-derived tissue factor pathway inhibitor: post-translational modification of free, full-length form with particular reference to the sugar chain

BACKGROUND

Tissue factor pathway inhibitor (TFPI) is a physiological protease inhibitor that inhibits the initial reactions of the extrinsic blood coagulation pathway. Most TFPI in human plasma is associated with lipoproteins; however, the most functionally active form is thought to be the free, full-length form (f-pTFPI). Cell culture derived TFPI and recombinant TFPI (rTFPI) exhibit variations in their respective anticoagulant activity, which may be caused by post-translational modifications, such as the frequent differences in sugar chain structures among recombinant proteins. Sugar chain structures in rTFPI expressed in Chinese hamster ovary (CHO) cells have been reported previously, but those of plasma TFPI have not been.

OBJECTIVES

To purify f-pTFPI and analyze the sugar chain structures.

RESULTS AND CONCLUSION

f-pTFPI was purified to homogeneity from blood plasma using a combination of anion-exchange, heparin affinity, immunoaffinity, and reversed-phase chromatographies, resulting in a yield of 76%. f-pTFPI showed a partially phosphorylated glycoprotein comprising a total of 276 amino acids by peptide mapping. The sugar chain structures were analyzed by two-dimensional sugar mapping combined with exoglycosidase digestion of the pyridylamino sugar chains and the following results were obtained. (Sialyl) Galbeta1-3GalNAc was linked to Thr(175), partially to Thr(14) and Ser(174); sialyl complex-type sugar chains to Asn(117) and Asn(167), whereas Asn(228) was not glycosylated. Neuraminidase-resistant acidic sugar chains including sulfated sugar chains were not observed significantly. The protease inhibitory activities of f-pTFPI towards activated factor (F) X and tissue factor-activated FVII complex were identical to those of full-length rTFPI expressed in CHO cells.

Effects of environmental novelty on fear-related behavior and stress responses of rats to emotionally relevant odors

Although various emotional behaviors and activation of the hypothalamic-pituitary-adrenal (HPA) axis of rats are induced by the exposure of 2,5-dihydro-2,4,5-trimethylthiazoline: TMT, a component of fox odor, these odor-induced responses are influenced by the external environment. Our previous study demonstrated that exposure to green odor, a mixture of cis-3-hexenol and trans-2-hexenal, attenuated stress-induced elevation of the plasma ACTH level in rats. The present study investigated the effect of TMT or green odor on emotional behavior and the HPA axis stress response with or without the influence of environmental novelty. We exposed rats to TMT or green odor in "familiar" or "unfamiliar" environments and compared the various responses, including fear-related behaviors, non-defensive behaviors and plasma ACTH concentrations. TMT induced enhanced freezing behavior, reduced exploration behavior and elevations in plasma ACTH concentrations in two environmental conditions. Comparing TMT-induced responses in an unfamiliar environment with the familiar environment showed that environmental novelty enhanced TMT-induced fear-related behaviors and elevations of plasma ACTH concentrations. These results revealed that TMT causes fear and stress responses in both familiar and unfamiliar environments, although the novelty of an unfamiliar environment enhances these TMT-induced responses. On the other hand, green odor did not induce any responses in either environment. These findings indicate that odor-induced responses are influenced by the surrounding environment.

IL-12p40 is essential for the down-regulation of airway hyperresponsiveness in a mouse model of bronchial asthma with prolonged antigen exposure

BACKGROUND

We previously reported a mouse model of bronchial asthma showing eosinophilic inflammation, but not airway hyperresponsiveness (AHR), after prolonged antigen exposure. This model showed an increase of IL-12 in the lung.

OBJECTIVE

The aim of this study was to investigate the role of IL-12p40 in a murine asthma model with prolonged antigen exposures.

METHODS

An ovalbumin (OVA)-induced asthma model was first established in wild-type (WT) and IL-12p40-deficient (IL-12p40(-/-)) mice. Both strains of mice were further exposed to either OVA (prolonged exposure group) or phosphate-buffered saline (positive control group) 3 days per week for 3 weeks. During week 4, both groups of mice were given a final challenge with OVA.

RESULTS

Prolonged antigen exposures resulted in marked suppression of airway eosinophilia in both WT and IL-12p40(-/-) mice. However, AHR persisted in IL-12p40(-/-) but not in WT mice. There were no significant differences of IL-5, IL-13 or IFN-gamma levels in bronchoalveolar lavage fluid between WT and IL-12p40(-/-) mice. The hydroxyproline content of the lung and peribronchial fibrosis were, however, significantly increased in IL-12p40(-/-) mice.

CONCLUSION

The results suggest that endogenous IL-12p40 is essential for inhibition of AHR and peribronchial fibrosis, but not eosinophilic inflammation, in a murine asthma model with prolonged antigen exposures.

Circulating KL-6/MUC1 as an independent predictor for disseminated intravascular coagulation in acute respiratory distress syndrome

OBJECTIVES

Acute respiratory distress syndrome (ARDS) patients show high levels of circulating mucin including KL-6/MUC1 (soluble MUC1 mucin). Because cancer mucin can bind vascular endothelial cells and platelets via selectins, mucin-selectin interactions are reported to trigger platelet aggregation and intravascular coagulation. Therefore, we hypothesized that KL-6/MUC1 is involved in the pathogenesis of disseminated intravascular coagulation (DIC) in ARDS. The aim of the current study is to evaluate the association between circulating KL-6/MUC1 and DIC in ARDS patients.

DESIGN

Observational study with structured follow-up.

SETTING

Intensive care unit in Hiroshima University Hospital.

SUBJECTS

Fifty-six newly diagnosed patients with ARDS.

INTERVENTIONS

Circulating levels of KL-6/MUC1 were measured during diagnosis and serially measured during the clinical course along with indices of respiratory failure, inflammation, coagulation and fibrinolysis and multiple organ dysfunction.

RESULTS

Acute respiratory distress syndrome patients complicated with DIC showed significantly higher levels of serum KL-6/MUC1 than patients without DIC during the clinical course. Amongst the parameters analysed at diagnosis of ARDS, KL-6/MUC1 was an independent predictor for DIC complication. The baseline level of circulating KL-6/MUC1 at diagnosis of ARDS was significantly correlated with an increased DIC score following ARDS diagnosis. Using an optimum cutoff level of KL-6/MUC1 obtained by a receiver operating characteristic curve, the sensitivity and specificity for predicting future DIC development in ARDS patients were 88.9% and 55.3%, respectively.

CONCLUSIONS

These results suggest that KL-6/MUC1 is associated with DIC development in ARDS patients. Elevated levels of KL-6/MUC1 at diagnosis could be a predictor of DIC complication in ARDS.

Blood flow to the promontory in cochlear otosclerosis

OBJECTIVE

To investigate Schwartze sign with measurements of blood flow to the promontory in patients with cochlear otosclerosis.

DESIGN

Prospective clinical study.

SETTING

Tertiary referral centre.

PARTICIPANTS

Five patients with cochlear otosclerosis and five control subjects. Significant decalcification around the cochlea was observed by computed tomography (CT) in patients with cochlear otosclerosis. However, no recognizable lesion was observed at the oval window in two patients. One patient had mixed hearing loss and four patients had sensorineural hearing loss without an air-bone gap.

MAIN OUTCOME MEASURES

The relationship between CT findings and the presence or absence of Schwartze sign was investigated. Blood flow to the promontory was measured through the tympanic membrane using laser speckle flowgraphy and laser Doppler flowmetry.

RESULTS

The Schwartze sign correlated significantly with otosclerotic lesions invading the promontory. Patients with otosclerosis exhibited elevated and pulsating blood flow to the promontory with the Schwartze sign.

CONCLUSIONS

Computed tomography demonstrated that cochlear otosclerosis can exist without the oval window lesion. Schwartze sign can be used as a sign of the otosclerotic invasion to the promontory. The reddening of the Schwartze sign is likely due to increased blood flow.

Imaging of endolymphatic and perilymphatic fluid at 3T after intratympanic administration of gadolinium-diethylene-triamine pentaacetic acid

By optimizing the inversion time of a 3D inversion-recovery turbo spin-echo sequence at 3T, we obtained separate images of endolymphatic and perilymphatic space 24 hours after intratympanic administration of gadolinium contrast material. In patients with Ménière disease, endolymphatic hydrops were detected not only in the cochlea but also in the vestibule. Fusion of the 2 types of images visualized the entire fluid space of the labyrinth and the spatial relationship of the 2 spaces.

[Tracheoplasty for tracheal cuff stenosis post long-term tracheostomy]

We encountered a case of tracheal stenosis post tracheostomy, so-called cuff stenosis. A 43-year-old man with ventricular septal defect (VSD) was treated by oral endotracheal intubation because of heart-failure and pneumonia, and tracheostomy was performed. He was placed on artificial ventilation for almost 3 months. Four months after discharge, he complained of dyspnea and was treated by oral endotracheal intubation again. At that time bronchofiberscopy demonstrated severe circumferential stenosis of the trachea 4 cm from the tracheostomy spot and that was compatible with the cuff site. Although the stenotic portion was dilated by an endotracheal tube, 47-days after dilation, the portion was restenosed to almost 7 mm in diameter. Therefore, surgical treatment was necessary and tracheoplasty was performed by end-to-end suture after 2 cm (4 ring) resection of trachea. Tracheoplasty is the most reliable method of treating cuff stenosis after tracheostomy.

Evaluation of the basic properties of the BANGkit gel dosimeter

We evaluated the basic properties of a commercially available BANGkit gel dosimeter, which is a normoxic type of BANG gel. This gel-kit has the same composition as the BANG 3 gel, but is fully oxygenated. To exclude oxygen, oxygen scavenging ascorbic acid and copper sulfate as a catalyst are used. The properties that we examined are the effects of the concentrations of copper sulfate and ascorbic acid on the response, the reproducibility, the long-term stability, the temperature effect at irradiation and the dose-rate effect. In our results, the excellent linear fit of the R2-dose response in a dose range for clinical use and its reproducibility were observed. The precision of a linear fit was preserved for about 3 weeks. The temperature at irradiation showed a significant effect on the dose response. Although the dose-rate dependence in the high-dose range was observed, it was negligible for the clinical dose range up to 270 cGy. In conclusion, this gel dosimeter is thought to be utilizable in clinical practice, while we have to pay attention to the temperature during the entire measurement processes, and additionally there is room for improvement in the linearity and the dose-rate dependence in the high-dose range.

Inhibitory or scavenging action of ketoconazole and ciclopiroxolamine against reactive oxygen species released by primed inflammatory cells

BACKGROUND

Reactive oxygen species (ROS) released from inflammatory cells constitute one of the critical causative factors in inflammatory skin diseases such as seborrhoeic dermatitis and atopic dermatitis.

OBJECTIVES

To investigate inhibitory effects of ketoconazole (KCZ) and ciclopiroxolamine (CPO), both of which have been used for the treatment of seborrhoeic dermatitis, on ROS released from inflammatory cells.

METHODS

The methyl-Cypridina-luciferin analogue-dependent chemiluminescence method was employed for the detection of ROS production by phorbol 12-myristate 13-acetate (PMA)-stimulated inflammatory cells. Moreover, the radical scavenging activities of both agents were examined by using a hypoxanthine-xanthine oxidase system and the stable radical 1,1-diphenyl-2-picrylhydrazyl (DPPH). NADPH oxidase activity was determined in particulate (membrane) fractions prepared from PMA-stimulated RAW 264 x 7 cells, a macrophage-like cell line.

RESULTS

Both of these antifungal agents inhibited PMA-stimulated ROS production. However, only CPO significantly scavenged both ROS generated by the hypoxanthine-xanthine oxidase system and DPPH, and the scavenging activity of CPO seemed to act on ROS other than superoxide anions. Although KCZ inhibited PMA-stimulated ROS production, it did not show radical-scavenging activities. The inhibition of ROS production by KCZ is probably attributable to the inhibition of NADPH oxidase activity.

CONCLUSIONS

The mechanism of the inhibitory action of KCZ against PMA-stimulated ROS production is distinct from that of CPO. Knowledge of the inhibitory or scavenging effects of both antifungal agents on ROS released from inflammatory cells may be useful in developing a therapeutic strategy for dermatitis.

Focal brain glucose hypometabolism in patients with neuropsychologic deficits after diffuse axonal injury

BACKGROUND AND PURPOSE

Neuropsychologic deficits are well-known sequelae of traumatic brain injury. However, the cerebral correlates of these deficits are still unclear. The aim of the present study was to elucidate the regions of cerebral dysfunction correlated with such neuropsychologic deficits after traumatic brain injury.

METHODS

Sets of fluorine-18 fluorodeoxyglucose-positron-emission tomography (FDG-PET) images in the resting state were obtained from 12 patients with neuropsychologic deficits after diffuse axonal injury and from 32 healthy volunteers. The cortical metabolic activity of each subject's PET image sets was extracted using 3D stereotactic surface projection (3D-SSP). A "normal" data base was created using the extracted datasets of the healthy subjects. The patients' datasets were compared with the normal data base by calculating a statistical Z-score on a pixel-by-pixel basis in searches for focal metabolic abnormalities.

RESULTS

Group comparisons revealed hypometabolism in the cingulate gyrus with additional involvement of the lingual gyrus and cuneus. Individual case-by-case analyses disclosed differences in the site and extent of the hypometabolism in the cingulate gyrus of each case. Predominant hypometabolism was found in the anterior cingulate gyrus of 6 patients, the middle cingulate gyrus of 2 patients, and the posterior cingulate gyrus of 4 patients.

CONCLUSION

Interpretation of FDG-PET using 3D-SSP facilitates the identification of regional hypometabolism in the cerebral cortex of patients after diffuse axonal injury. Dysfunction of the cingulate gyrus, lingual gyrus, and cuneus may play a crucial role in neuropsychologic deficits after traumatic brain injury.

Sarcoidosis of the tongue: a case report

A case of sarcoidosis involving the tongue is described in a 48-year-old Japanese man. A definite diagnosis of sarcoidosis was made for the clinical lesion and pathological examinations. Sarcoidosis is a multisystem granulomatous disease that may affect any organ. Sarcoidosis of the tongue is particularly rare.

Psychological effects of forest environments on healthy adults: Shinrin-yoku (forest-air bathing, walking) as a possible method of stress reduction

OBJECTIVES

Shinrin-yoku (walking and/or staying in forests in order to promote health) is a major form of relaxation in Japan; however, its effects have yet to be completely clarified. The aims of this study were: (1) to evaluate the psychological effects of shinrin-yoku in a large number of participants; and (2) to identify the factors related to these effects.

METHODS

Four hundred and ninety-eight healthy volunteers took part in the study. Surveys were conducted twice in a forest on the same day (forest day) and twice on a control day. Outcome measures were evaluated using the Multiple Mood Scale-Short Form (hostility, depression, boredom, friendliness, wellbeing and liveliness) and the State-Trait Anxiety Inventory A-State Scale. Statistical analyses were conducted using analysis of variance and multiple regression analyses.

RESULTS

Hostility (P<0.001) and depression (P<0.001) scores decreased significantly, and liveliness (P=0.001) scores increased significantly on the forest day compared with the control day. The main effect of environment was also observed with all outcomes except for hostility, and the forest environment was advantageous. Stress levels were shown to be related to the magnitude of the shinrin-yoku effect; the higher the stress level, the greater the effect.

CONCLUSIONS

This study revealed that forest environments are advantageous with respect to acute emotions, especially among those experiencing chronic stress. Accordingly, shinrin-yoku may be employed as a stress reduction method, and forest environments can be viewed as therapeutic landscapes. Therefore, customary shinrin-yoku may help to decrease the risk of psychosocial stress-related diseases, and evaluation of the long-term effects of shinrin-yoku is warranted.

The immunohistochemical expression of p21WAF1/Cip1 and Proliferating cell nuclear antigen in laryngeal squamous cell carcinomas

The purpose of this study was to assess the significance of the expression of p21WAF1/Cip1 and proliferating cell nuclear antigen (PCNA) in human laryngeal squamous cell carcinomas. Forty-eight patients (25 supraglottic, 23 glottic) who had undergone operations between 1998 and 2003 were included in this study. The Envision immunohistochemistry method was utilized to stain these tissue specimens. The results showed that the immunostaining of p21WAF1/Cip1 do not show any correlation with differentiation, N stage, metastasis, survival, recurrence or the laryngeal site of involvement. A significant inverse correlation was detected between p21WAF1/Cip1 and the T stage. In contrast, the percentage of PCNA labelled cells showed a significant correlation with the T stage, but not with other clinicopathological parameters. There were differences in the expression of p21WAF1/Cip1 and PCNA between the supraglottic and the glottic carcinomas. In conclusion, our findings suggest that p21WAF1/Cip1 and PCNA may play an important role in the progression of carcinoma of the supraglottic larynx.

Visualization of a high protein concentration in the cochlea of a patient with a large endolymphatic duct and sac, using three-dimensional fluid-attenuated inversion recovery magnetic resonance imaging

OBJECTIVE

To evaluate the inner ear of a patient with an enlarged vestibular aqueduct and acute hearing deterioration, using three-dimensional fluid-attenuated inversion recovery (3D FLAIR) magnetic resonance imaging (MRI).

BACKGROUND

Three-dimensional fluid-attenuated inversion recovery MRI has been recently developed to detect haemorrhage and high concentrations of protein. Application of this method to inner-ear diseases has not been fully described.

METHOD

We used 3D FLAIR MRI to evaluate a patient with an enlarged vestibular aqueduct and acute hearing deterioration.

RESULTS

On 3D FLAIR MRI, this patient had high signals in the endolymphatic duct and sac, the vestibule and the cochlea and was diagnosed as having a high protein concentration in the inner ear. These high signal areas were not detected by T1- and T2-weighted MRI.

CONCLUSION

This is the first published case in which a high protein concentration in the cochlea of a patient with an enlarged vestibular aqueduct was detected by 3D FLAIR MRI. These findings strongly supported the theory of the pathophysiology of hearing deterioration in patients with an enlarged vestibular aqueduct, which states that hyperosmolar fluid in the enlarged endolymphatic sac refluxes into the cochlea, resulting in damage to the hair cells. Thus, these finding may help clarify the cause of hearing deterioration in the presence of a large endolymphatic duct and sac.