Establishment of pure NOTES procedure using a conventional flexible endoscope: review of six cases of gastric gastrointestinal stromal tumors

An increasing number of reports have recently been published on hybrid natural orifice transluminal endoscopic surgery (NOTES). These reports do not address how to complete an operation with a flexible endoscope alone (pure NOTES), but rather how to combine use of an endoscope and a laparoscope. Surgical procedures using flexible and rigid endoscopes have been developed using different processes and concepts. Recognizing this conceptual difference, we conducted a study to address how to establish a pure NOTES procedure. Six patients with gastric gastrointestinal stromal tumors (GISTs) underwent hybrid NOTES. Each case was retrospectively reviewed to determine the appropriateness of the treatment and the usefulness of the endoscopic submucosal dissection (ESD) method, double-scope method, spaced perforation method, duodenal balloon occlusion method, and loop clip technique. The development of operative procedures that take advantage of the characteristics of flexible endoscopes, even with conventional flexible endoscopic devices and conventional endoscopes alone, may contribute to the realization of pure NOTES.

Effect of Buffer Electrodes in Crystallization of Zinc Oxide Thin Film for Thin Film Bulk Acoustic Wave Resonator

A thin film bulk acoustic wave resonator (TBAR) has been fabricated using a ZnO thin film on a SiO2 diaphragm by MEMs techniques. The ZnO/SiO2 structure TBAR can be designed to cancel a temperature coefficient of frequency (TCF) by the ZnO/SiO2 thickness ratio, because the TCF of ZnO is negative, and that of SiO2 is positive. The ZnO thin film on the SiO2 shows a c-axis orientation almost equivalent to that of the ZnO thin film on a glass substrate by RF sputtering. However, the crystallinity of the ZnO thin film is influenced by the surface conditions of substrates. ZnO thin films have been deposited on Au/Cr, Au/NiCr and Au/Ti. The Au/Ti/ZnO/Au/Ti/SiO2 structure TBAR shows the best resonant characteristics in this experiment. The resonant characteristics of the TBAR depend on the crystallinity of the ZnO thin film. The resonant resistance of the TBAR at 205MHz using a Au/Ti under electrode is about 10% less than that using an Au/Cr electrode. The x-ray diffraction result shows that the crystallinity of ZnO is greatly influenced by the crystallinity of the lower electrode. The buffer layer between an Au electrode and substrate has an influence on both the crystallinity of the ZnO thin film and the resonant characteristics of the TBAR through the Au electrode.

Association between the neutrophil myeloperoxidase index and subsets of bacterial infections

The mean myeloperoxidase index (MPXI) is calculated during the routine complete blood count performed using the autoanalyzer ADVIA120/2120. The pattern of changes in the neutrophil myeloperoxidase levels in patients with specific infectious diseases was analyzed by assessing the MPXI levels. In patients with bacterial sepsis, identified by positive blood-culture tests, with (n = 29) and without (n = 51) systemic inflammatory response syndrome, the mean MPXI significantly reduced to -3.18 and -2.06, respectively. In contrast, among patients with nontuberculous nonseptic bacterial infections (n = 40), the mean MPXI significantly elevated to 5.51, while tuberculosis patients (n = 37) and patients with viral infection (n = 60) showed an unchanged MPXI (mean values, -0.46 and -1.06, respectively). Among the parameters of inflammation, only the C-reactive protein values showed a weak correlation with the MPXI levels. [Conclusion] These results indicate that MPXI is correlated with some specific infectious states, i.e. MPXI is low in bacterial sepsis and high in nontuberculous nonseptic bacterial infections. MPXI appears to be an independent and useful biomarker for the diagnosis and follow-up of infectious diseases, especially when the MPXI values are obtained at regular intervals during the disease courses of the patients.

Avulsion of flexor digitorum profundus secondary to recurrent enchondroma

We report a case of avulsion of the flexor digitorum profundus secondary to recurrent enchondroma. The tumor was curetted with bone grafting of cancellous bone from the distal radius, and the fragment avulsed by the flexor digitorum profundus tendon was fixed to its original site using a pullout suture through the distal phalanx to the nail. The lesion healed and function recovered 6 years after surgery.

Arsenic trioxide induces down-regulation of gp46 via protein oxidation: proteomics analysis of oxidative modified proteins in As2O3-treated HTLV-1-infected cells

Adult T-cell leukemia (ATL) is a severe chemotherapy-resistant malignancy associated with prolonged infection by the human T cell-lymphotropic virus 1 (HTLV-1) retrovirus. Epidemiology studies strongly indicate that an increase in HTLV-1 virus load is an important factor during the onset of ATL. Therefore, inhibition of the growth/transmission of HTLV-1 infected cells is a promising strategy in preventing the disease. In our previous study, we revealed that arsenic trioxide (As2O3), a drug used to treat acute promyelocytic leukemia (APL), exerts an inhibitory effect on syncytium formation between HTLV-1 infected cells and HeLa cells via suppression of HTLV-1 envelope protein gp46 expression at low concentrations. In this study, we analyze the mechanism of action of As2O3 using a proteomics approach. Our results suggest that down-regulation of gp46 might be related to As2O3-induced oxidation of the 71-kDa heat shock cognate protein (HSC70) and the 78-kDa glucose-regulated protein (BiP/GRP78). We postulate that AS2O3 exerts an inhibitory effect on HTLV-1 virus transmission via down-regulation of gp46-production, which might be caused by oxidative modification of various proteins such as chaperones.

Detecting early oral cancer: narrowband imaging system observation of the oral mucosa microvasculature

The aim of this study was to analyze and describe the intrapapillary capillary loops (IPCL), which are a feature of early oral neoplastic lesions, using a narrowband imaging (NBI) system. Forty-one patients (26 men, 15 women; mean age, 52.34 years; range, 23-83 years) presenting with non-neoplastic or neoplastic lesions, and normal cases, were examined using the prototype Evis Lucera Spectrum (Olympus Co.). The images were analyzed and an IPCL classification was devised. All normal cases (n=10) had regularly distributed capillary loops of the same shape (type I). Non-neoplastic lesions (n=8) had mild changes of the capillary loops (types II and III) and neoplastic lesions (n=23) were irregularly distributed and had several loop shapes (types III and IV). The microvascular organization of non-neoplastic lesions was notably different from that of neoplastic lesions. A brownish area was found in five cases of early carcinoma. The narrowband imaging system is a potential approach for clinically analyzing microvascular organization and IPCL. It could be useful for diagnosing oral squamous cell carcinoma at an earlier stage and for determining the margin of resection.

Creation of an improved mutant TNF with TNFR1-selectivity and antagonistic activity by phage display technology

Tumor necrosis factor-alpha (TNF), which binds two types of TNF receptors (TNFR1 and TNFR2), regulates the onset and exacerbation of autoimmune diseases such as rheumatoid arthritis and Crohn's disease. In particular, TNFR1-mediated signals are predominantly related to the induction of inflammatory responses. We have previously generated a TNFR1-selective antagonistic TNF-mutant (mutTNF) and shown that mutTNF efficiently inhibits TNFR1-mediated bioactivity in vitro and attenuates inflammatory conditions in vivo. In this study, we aimed to improve the TNFR1-selectivity of mutTNF This was achieved by constructing a phage library displaying mutTNF-based variants, in which the amino acid residues at the predicted receptor binding sites were substituted to other amino acids. From this mutant TNF library, 20 candidate TNFR1-selective antagonists were isolated. Like mutTNF, all 20 candidates were found to have an inhibitory effect on TNFR1-mediated bioactivity. However, one of the mutants, N7, displayed significantly more than 40-fold greater TNFR1-selectivty than mutTNF. Therefore, N7 could be a promising anti-autoimmune agent that does not interfere with TNFR2-mediated signaling pathways.

Immature platelet fraction measurement in patients with chronic liver disease: a convenient marker for evaluating cirrhotic change

Platelet number is often used as an indicator of the severity of liver disease. Although inadequate thrombopoietin production and decreased platelet production have been proposed as major causes of cirrhotic thrombocytopenia, the underlying mechanism has not yet been fully clarified. We examined whether the measurement of the immature platelet fraction (IPF) in thrombocytopenic patients with liver dysfunction is useful as a rapid and noninvasive method for the differential diagnosis of chronic liver diseases. We examined 20 liver cirrhosis patients, 56 patients with chronic hepatitis, 9 patients with fatty liver, and 86 patients without liver disease. The percentage value of IPF (IPF%) was measured using an XE-2100 multiparameter automatic hematology analyzer. Using a receiver operating characteristic curve, we found diagnostic significance of the absolute platelet count and the absolute number of the IPF between cirrhotic patients and noncirrhotic patients, and developed a powerful multivariate discriminant analysis (MDA) function based on the platelet count and the IPF%. The diagnostic accuracy obtained by the MDA function was superior to that obtained by the absolute number of platelets and the IPF. We therefore propose our IPF% measurement for the diagnosis of liver cirrhosis.

FLG mutation p.Lys4021X in the C-terminal imperfect filaggrin repeat in Japanese patients with atopic eczema

BACKGROUND

Mutations in the gene encoding filaggrin (FLG) have been shown to predispose to atopic eczema (AE).

OBJECTIVES

Further to establish population genetics of FLG mutations in the Japanese population and to elucidate effects of FLG mutations to filaggrin biosynthesis in skin of patients with AE.

METHODS

We searched for FLG mutations in 19 newly recruited Japanese patients with AE. We then screened 137 Japanese patients with AE and 134 Japanese control individuals for a novel mutation identified in the present study. In addition, we evaluated FLG mRNA expression by real-time reverse transcription-polymerase chain reaction and profilaggrin/filaggrin protein expression by immunohistochemical staining in the epidermis of the patients carrying the novel mutation.

RESULTS

We identified a novel FLG nonsense mutation c.12069A>T (p.Lys4021X) in one patient with AE. Upon further screening, p.Lys4021X was identified in four patients with AE (2.9% of all the patients with AE). In total, there are at least eight FLG variants in the Japanese population. Here we show that about 27% of patients in our Japanese AE case series carry one or more of these eight FLG mutations and these variants are also carried by 3.7% of Japanese general control individuals. There is a significant statistical association between the eight FLG mutations and AE (chi(2) P = 6.50 x 10(-8)). Interestingly, the present nonsense mutation is in the C-terminal incomplete filaggrin repeat and is the mutation nearest the C-terminal among previously reported FLG mutations. Immunohistochemical staining for filaggrin revealed that this nonsense mutation leads to remarkable reduction of filaggrin protein expression in the patients' epidermis.

CONCLUSIONS

We clearly demonstrated that FLG mutations are significantly associated with AE in the Japanese population. The present results further support the hypothesis that the C-terminal region is essential for proper processing of profilaggrin to filaggrin.

Critical role ofRecAandRecFproteins in strand break rejoining and maintenance of fidelity of rejoining following γ-radiation-induced damage to pMTa4 DNA inE. coli

PURPOSE

This study was undertaken to understand the roles of RecA and RecF proteins in strand break rejoining and maintenance of fidelity of the process following exposure of E. coli to gamma-radiation in vivo.

MATERIALS AND METHODS

A plasmid DNA construct, pMTa4, was transformed into isogenic repair proficient (wild) and deficient (recF and recA) E. coli strains and gamma-irradiated up to 30 Gy in vivo. The plasmid DNA was isolated under repair non-permissive (R-)and permissive (R+) conditions and analyzed by gel electrophoresis for the yields of single strand breaks (SSB) and double strand breaks (DSB) and their repair. The clonogenic survival of the E. coli was also recorded. The effects of gamma-irradiation on recA reconstituted with cell free extract of wild strain or ultra-violet (UV)-irradiation were also monitored.

RESULTS

None of the strains used in this investigation showed effects of radiation-induced oxidative base damage. The dose dependent increase in SSB and DSB on pMTa4 in wild and recF mutants in R- condition were abolished upon repair incubation. The recA mutant exhibited a disturbed yield of SSB and DSB along with formation of gamma-radiation-induced 'ladder'. The 'ladder' was not observed after repair incubation, UV-irradiation or gamma-irradiation in presence of cell-free extract of wild strain. The survival of recA mutants was seriously compromised.

CONCLUSIONS

Wild, recF and recA strains of E. coli could repair gamma-irradiation-induced oxidative damage to base or nucleotide (NT) in vivo. In absence of either RecA or RecF proteins, efficiency of rejoining of strand went down; RecA proteins seemed more critical than RecF in this. High fidelity or correct rejoining of strand breaks, on the other hand, seemed to require simultaneous presence of both RecA and RecF proteins.

The Role of Simulator Promis2 in Learning Laparoscopic Skill

Introduction: Laparoscopic surgery is unique and complex in nature, so the training is necessarybefore proceeding to operation room. Many computer aided simulators have been developed forthe purpose. Our objective is to assess the improvement of basic laparoscopic skills after training insimulator.Methods: The fi fth year medical students underwent training of three laparoscopic skills usingPromis2 simulator twice weekly for 4-6 weeks. The skills are laparoscopic orientation, target pointingand objects transferring. Time, path length of instruments and economy of movements were recorded.The comparisons were made for these parameters between session fi rst and the last using a Mann-Whitney U test.Results: Ten volunteers completed the exercises in less time (186.3±55.4 seconds) than the fi rstexercise (215.7±57.4 seconds) (P=0.0027). Both the right and left hand instrument path lengths werealso improved from 4425.8±1284.3 mm in the fi rst exercise to 3925.3±1313.6 mm in the last exercisein the left side (P=0.0219) and likewise from 4273.8±1859.4 mm to 3831.3±1717.4 mm in the right side(P=0.0027). Economy of the movement in the left handed instrument improved from 1114.4±453.5mm in the fi rst exercise to 966.8±411.1 mm in the last (P=0.0443) and in the right handed instrumentfrom 845±398.8 mm to 771.4±370.5 mm according to the software of Promis2 simulator (P >0.005).Conclusions: Training in Promis2 simulator improves the basic laparoscopic skills. The candidatesbecome consistently faster with shorter path lengths and had smoother instruments movements.They also became signifi cantly more consistent in their performance.Key Words: laparoscopy, promis2, simulator, training