Bone mesenchymal stem cell-conditioned medium attenuates the effect of oxidative stress injury on NSCs by inhibiting the Notch1 signaling pathway

Numerous studies have demonstrated the therapeutic effect of bone mesenchymal stem cells on spinal cord injury (SCI), especially on neural stem cells (NSCs). However, the predominant mechanisms of bone mesenchymal stem cells (BMSCs) are unclear. Recently, some researchers have found that paracrine signaling plays a key role in the therapeutic capacity of BMSCs and emphasized that the protective effect of BMSCs may be due to paracrine factors. In this study, we aimed to investigate the potential mechanisms of BMSCs to protect NSCs. NSCs were identified by immunocytochemistry. The oxidative stress environment was simulated by H₂ O₂ (50, 100, 200 μM) for 2 h. The apoptotic rate of the NSCs was detected via flow cytometry. Lactate dehydrogenase (LDH), malondialdehyde (MDA), and superoxide dismutase (SOD) activity were evaluated via corresponding assay kits. Western blot was used to detect the expressions of Notch1, HES1, caspase-3, cleave caspase-3, Bax, and Bcl-2. We found that H₂ O₂ could significantly induce the apoptosis of NSCs, increase LDH, MDA levels, and decrease SOD activity by activating the Notch1 signaling pathway. DAPT (the specific blocker of Notch1) and BMSC-conditioned medium (BMSC-CM) could significantly prevent the apoptotic effect and oxidative stress injury on NSCs that were treated with H₂ O₂ . We also revealed that BMSC-CM could decrease the expression of Notch1, Hes1, cleave caspase-3, Bax, and increases the expression of Bcl-2 in NSCs, which was induced by H₂ O₂ . These results have revealed that BMSC-CM can neutralize the effect against oxidative stress injury on the apoptosis of NSCs by inhibiting the Notch1 signaling pathway.

Vascular endothelial growth factor pathway promotes osseointegration and CD31hiEMCNhi endothelium expansion in a mouse tibial implant model: an animal study

AIMS

It is increasingly appreciated that coordinated regulation of angiogenesis and osteogenesis is needed for bone formation. How this regulation is achieved during peri-implant bone healing, such as osseointegration, is largely unclear. This study examined the relationship between angiogenesis and osteogenesis in a unique model of osseointegration of a mouse tibial implant by pharmacologically blocking the vascular endothelial growth factor (VEGF) pathway.

MATERIALS AND METHODS

An implant was inserted into the right tibia of 16-week-old female C57BL/6 mice (n = 38). Mice received anti-VEGF receptor-1 (VEGFR-1) antibody (25 mg/kg) and VEGF receptor-2 (VEGFR-2) antibody (25 mg/kg; n = 19) or an isotype control antibody (n = 19). Flow cytometric (n = 4/group) and immunofluorescent (n = 3/group) analyses were performed at two weeks post-implantation to detect the distribution and density of CD31^hiEMCN^hi endothelium. RNA sequencing analysis was performed using sorted CD31^hiEMCN^hi endothelial cells (n = 2/group). Osteoblast lineage cells expressing osterix (OSX) and osteopontin (OPN) were also detected with immunofluorescence. Mechanical pull-out testing (n = 12/group) was used at four weeks post-implantation to determine the strength of the bone-implant interface. After pull-out testing, the tissue attached to the implant surface was harvested. Whole mount immunofluorescent staining of OSX and OPN was performed to determine the amount of osteoblast lineage cells.

RESULTS

Flow cytometry revealed that anti-VEGFR treatment decreased CD31^hiEMCN^hi vascular endothelium in the peri-implant bone versus controls at two weeks post-implantation. This was confirmed by the decrease of CD31 and endomucin (EMCN) double-positive cells detected with immunofluorescence. In addition, treated mice had more OPN-positive cells in both peri-implant bone and tissue on the implant surface at two weeks and four weeks, respectively. More OSX-positive cells were present in peri-implant bone at two weeks. More importantly, anti-VEGFR treatment decreased the maximum load of pull-out testing compared with the control.

CONCLUSION

VEGF pathway controls the coupling of angiogenesis and osteogenesis in orthopaedic implant osseointegration by affecting the formation of CD31^hiEMCN^hi endothelium. Cite this article: Bone Joint J 2019;101-B(7 Supple C):108-114.

Floral adaptations of two lilies: implications for the evolution and pollination ecology of huge trumpet-shaped flowers

PREMISE

Evolutionary transitions among floral morphologies, many of which provide evidence for adaptation to novel pollinators, are common. Some trumpet-shaped flowers are among the largest flowers in angiosperms, occurring in different lineages. Our goal was to investigate the role of pollinators in the evolution of these flowers using Lilium.

METHODS

We investigated floral traits and pollinators of L. primulinum var. ochraceum and L. brownii var. viridulum and reviewed reports of visitors to huge trumpet-shaped flowers. Using a published phylogeny of Lilium, we reconstructed ancestral floral morphological states in Lilium to elucidate the origins of trumpet-shaped lilies.

RESULTS

Both lilies are largely self-incompatible and show floral syndromes indicative of hawkmoth pollination. The short trumpet-shaped lily can be pollinated by short-tongued (<40 mm) but not long-tongued hawkmoths (>65 mm), while the huge trumpet-shaped lily can be pollinated by both. A literature review including 22 species of trumpet-shaped flowers suggests that their pollinator guilds commonly include both short- and long-tongued moths. A phylogenetic reconstruction indicates that trumpet-shaped lilies possibly have multiple origins from tepal-reflexed ancestors, at least six of which have evolved huge flowers (>50 mm).

CONCLUSIONS

Adaptation to short-tongued hawkmoths may have initiated the evolution of trumpet-shaped lilies. Huge trumpet-shaped lilies may have evolved as a response to selection by long-tongued hawkmoths, without excluding the short-tongued ones. This evolutionary pathway leads to a functionally more generalized pollination system instead of an increasingly specialized one and is not necessarily associated with pollinator shifts.

A critical review to traumatic brain injury clinical practice guidelines

The aim of this study was to assess the quality of clinical practice guidelines of traumatic brain injury (TBI) and investigate the evidence grading systems.A systematic search of relevant guideline websites and literature databases (including PubMed, NGC, SIGN, NICE, GIN, and Google) was undertaken from inception to May 2018 to identify and select TBI guidelines. Four independent reviewers assessed the eligible guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. The degree of agreement was evaluated with intraclass correlation coefficient (ICC).From 1802 records retrieved, 12 TBI guidelines were included. The mean scores for each AGREE II domain were as follows: scope and purpose (mean ± SD= 74.2 ± 9.09); stakeholder involvement (mean± SD= 54.6 ± 11.6); rigor of development (mean ± SD=70.1 ± 13.6); clarity and presentation (mean ± SD=78.4 ± 11.5); applicability (mean ± SD= 60.5 ± 13.6); and editorial independence (mean ± SD=61.7 ± 14.8). Ten guidelines were rated as "recommended." The ICC values ranged from 0.73 to 0.95. Seven grading systems were used by TBI guidelines to rate the level of evidence and the strength of recommendation.Most TBI guidelines got a high-quality rating, whereas a standardized grading system should be adopted to provide clear information about the level of evidence and strength of recommendation in TBI guidelines.

Ramosissimin, a new flavonol from Tararix ramosissima, induces apoptosis in rheumatoid arthritis fibroblast-like synoviocytes

Tamarix ramosissima is a traditional Chinese herbal medicine used for rheumatoid arthritis (RA) treatment in Northwest China. Chemical investigation of EtOH/H2O extracts of T. ramosissima led to the discovery of a new flavonol, ramosissimin (1), together with the known flavonoids compounds quercetin (2), quercetin-3'4'-dimethylether (3) and kaempferol (4). By means of high resolution electrospray ionization mass spectroscopy (HRESIMS) and 1D and 2D-NMR experiments, and after comparison with literature data, the structures of the compounds were determined. The effect of compound 1 on the viability of RA fibroblast-like synoviocytes (RA-FLS) was evaluated by MTT assay. Apoptosis-inducing effect of compound 1 in RA-FLS was further investigated by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) assay and activated caspase-3/7 level assessment using luminescent assay. The results revealed that ramosissimin displayed remarkable proliferation inhibitory effect in RA-FLS. Furthermore, compound 1 could significantly induce cellular apoptosis of RA-FLS and increase activated caspase-3/7 levels. It is suggested that ramosissimin may inhibit the proliferation of RA-FLS by inducing apoptosis.

Altered autonomic control of heart rate variability in the chronically hypoxic fetus

KEY POINTS

Fetal heart rate variability (FHRV) has long been recognised as a powerful predictor of fetal wellbeing, and a decrease in FHRV is associated with fetal compromise. However, the mechanisms by which FHRV is reduced in the chronically hypoxic fetus have yet to be established. The sympathetic and parasympathetic influences on heart rate mature at different rates throughout fetal life, and can be assessed by time domain and power spectral analysis of FHRV. In this study of chronically instrumented fetal sheep in late gestation, we analysed FHRV daily over a 16 day period towards term, and compared changes between fetuses of control and chronically hypoxic pregnancy. We show that FHRV in sheep is reduced by chronic hypoxia, predominantly due to dysregulation of the sympathetic control of the fetal heart rate. This presents a potential mechanism by which a reduction in indices of FHRV predicts fetuses at increased risk of neonatal morbidity and mortality in humans. Reduction in overall FHRV may therefore provide a biomarker that autonomic dysregulation of fetal heart rate control has taken place in a fetus where uteroplacental dysfunction is suspected.

ABSTRACT

Although fetal heart rate variability (FHRV) has long been recognised as a powerful predictor of fetal wellbeing, the mechanisms by which it is reduced in the chronically hypoxic fetus have yet to be established. In particular, the physiological mechanism underlying the reduction of short term variation (STV) in fetal compromise remains unclear. In this study, we present a longitudinal study of the development of autonomic control of FHRV, assessed by indirect indices, time domain and power spectral analysis, in normoxic and chronically hypoxic, chronically catheterised, singleton fetal sheep over the last third of gestation. We used isobaric chambers able to maintain pregnant sheep for prolonged periods in hypoxic conditions (stable fetal femoral arterial P O 2 10-12 mmHg), and a customised wireless data acquisition system to record beat-to-beat variation in the fetal heart rate. We determined in vivo longitudinal changes in overall FHRV and the sympathetic and parasympathetic contribution to FHRV in hypoxic (n = 6) and normoxic (n = 6) ovine fetuses with advancing gestational age. Normoxic fetuses show gestational age-related increases in overall indices of FHRV, and in the sympathetic nervous system contribution to FHRV (P < 0.001). Conversely, gestational age-related increases in overall FHRV were impaired by exposure to chronic hypoxia, and there was evidence of suppression of the sympathetic nervous system control of FHRV after 72 h of exposure to hypoxia (P < 0.001). This demonstrates that exposure to late gestation isolated chronic fetal hypoxia has the potential to alter the development of the autonomic nervous system control of FHRV in sheep. This presents a potential mechanism by which a reduction in indices of FHRV in human fetuses affected by uteroplacental dysfunction can predict fetuses at increased risk.

Oncologic outcomes of nephron-sparing surgery in patients with T1 multifocal renal cell carcinoma

OBJECTIVE

This study is performed to explore the pathological characteristics and oncologic outcomes of T1 multifocal renal cell carcinoma (RCC).

METHODS

The clinical data of 600 patients (442 males and 158 females) between the age of 29 and 73 years, diagnosed with T1 RCC were collected from three hospitals in China, out of which 421 cases had undergone nephron-sparing surgery (NSS) and 179 cases had undergone radical nephrectomy (RN) between December 2010 and January 2015.

RESULTS

Tumor was identified with multifocality in 32 patients (5.33%), out of which 21 were set to receive NSS, and 11 to receive RN, respectively; 21 cases of clear cell tumor, 8 cases of papillary tumor, 1 case of chromophobe tumor and 2 cases of Xp.11.2 translocation RCC. Among 568 cases of monofocal tumors, 400 patients underwent NSS, and the remaining 168 patients underwent RN, respectively. After a median follow-up of 5 years, 13 patients were found with recurrent tumors out of those who had undergone NSS, 11 with monofocal tumors and 2 with multifocal tumors containing satellite tumor nodules (p = 0.13). Out of the 32 individuals with multifocal RCC, 4 cases were reported to have died of cancer, 2 of NSS and 2 of RN. From these findings, the cancer-specific survival for NSS and RN was estimated to be 90.48% and 81.82%, respectively (p = 0.48).

CONCLUSION

The findings from the study suggested that there were pathological differences in multifocal renal tumors, and that papillary carcinoma may be more common than clear cell carcinoma. The recurrence rate and survival rate of multifocal RCC were similar to monofocal tumors. Tumor recurrence may be related to satellite tumor nodules, which can only be detected once surgery is performed.

Milk Fat Globule Membrane Inhibits NLRP3 Inflammasome Activation and Enhances Intestinal Barrier Function in a Rat Model of Short Bowel

BACKGROUND

The milk fat globule membrane (MFGM) contains various bioactive components which have been shown to maintain gut barrier integrity. This study aimed to evaluate the protective effects of MFGM on intestinal barrier function and its possible mechanisms in a rat model of short bowel syndrome (SBS).

MATERIALS AND METHODS

Five-week-old male Sprague-Dawley rats were divided into 3 groups (n = 8 per group), consisting of Sham group and rats submitted to massive small-bowel resection then supplemented with either water (SBS) or 1.5g/kg/d MFGM (SBS+MFGM) by daily gavage. Rats were sacrificed on day 15 postoperation. Intestinal adaptation, gut permeability, bacterial translocation (BT), expression of tight junction proteins, mucin 1 (MUC1), and nucleotide-binding oligomerization domain leucine-rich repeat and pyrin domain-containing protein 3 (NLRP3) pathway in the ileum were evaluated.

RESULTS

Both SBS+MFGM and SBS groups exhibited lower body weight and higher ileum villus height than Sham group, but no difference was detected between each other. SBS group had significantly higher intestinal permeability and BT rate than other groups (P < .05). Compared with SBS rats, SBS+MFGM group showed higher expression of tight junction proteins and MUC1, lower expression of NLRP3 and caspase-1 in the ileum, as well as lower interleukin (IL)-1β but higher IL-18 levels in ileum tissue.

CONCLUSIONS

Supplementation of MFGM helps to modulate NLRP3 inflammasome activation and enhances gut barrier integrity in rats after massive small-bowel resection, which provides experimental support for potential applications of MGFM in intestinal barrier dysfunction, although further studies are needed.

Mild Hypothermia Pretreatment Attenuates Liver Ischemia Reperfusion Injury Through Inhibiting c-Jun NH2-terminal Kinase Phosphorylation in Rats

BACKGROUND

Mild hypothermia is known to be protected against ischemia reperfusion (IR) injury. But the exact mechanisms of protection have not yet been fully understood and its usage has been limited. Mild hypothermia pretreatment (MHP) is used to investigate the mechanisms of the protective effects against liver IR injury.

METHODS

Anesthetized male Sprague-Dawley rats were randomly divided into five groups including the normal group (N), sham group (S), MHP group, normothermia pretreatment (NP) + IR group, and the MHP + IR group. In the pretreatment groups, mild hypothermia (32.2 ± 0.3°C) and normothermia (37 ± 0.5°C) pretreatment were applied for 2 hours, respectively. Then the IR groups suffered partial (70%) hepatic ischemia for 1 hour and reperfusion for 6 hours. At last, hepatic injury, apoptosis, and protein expression were assessed.

RESULTS

Levels of serum alanine transaminase, hepatic injury, hepatocyte apoptosis, and c-Jun N-terminal kinase (JNK) phosphorylation were significantly higher in the IR groups. But when compared to NP, all these changes induced by IR were markedly attenuated by MHP. Serum alanine transaminase levels were 383.4 ± 13.1U/L in the MHP + IR group and 951.3 ± 39.4 U/L in the NP + IR group. The histologic score of liver injury in the MHP + IR group was 4.83 ± 1.17, whereas in the NP + IR group it was 10.5 ± 1.05. The proportion of apoptotic cells in the MHP + IR group was 11.58 ± 0.60, but in the NP + IR group, it was 44.95 ± 1.61. The phosphorylation of JNK was also significantly reduced in the MHP + IR group. All these differences are statistically significant (P < .05).

CONCLUSIONS

MHP could markedly reduce liver IR injury, and these protective effects may be mainly exerted via inhibition of JNK phosphorylation.

Two-stage open reduction and internal fixation versus limited internal fixation combined with external fixation: a meta-analysis of postoperative complications in patients with severe Pilon fractures

Objectives

Two-stage open reduction and internal fixation (ORIF) and limited internal fixation combined with external fixation (LIFEF) are two widely used methods to treat Pilon injury. However, which method is superior to the other remains controversial. This meta-analysis was performed to quantitatively compare two-stage ORIF and LIFEF and clarify which method is better with respect to postoperative complications in the treatment of tibial Pilon fractures.

Methods

We conducted a meta-analysis to quantitatively compare the postoperative complications between two-stage ORIF and LIFEF. Eight studies involving 360 fractures in 359 patients were included in the meta-analysis.

Results

The two-stage ORIF group had a significantly lower risk of superficial infection, nonunion, and bone healing problems than the LIFEF group. However, no significant differences in deep infection, delayed union, malunion, arthritis symptoms, or chronic osteomyelitis were found between the two groups.

Conclusion

Two-stage ORIF was associated with a lower risk of postoperative complications with respect to superficial infection, nonunion, and bone healing problems than LIFEF for tibial Pilon fractures.

Level of evidence

2.

Histopathologic analysis of stage pT1b kidney neoplasms for optimal surgical margins of nephron-sparing surgery

Objective

To evaluate the pathological features and define the optimal surgical margins (SM) of nephron-sparing surgery (NSS) for kidney neoplasms 4–7 cm (stage pT1b) on preoperative imaging.

Materials and methods

The retrospective study included 748 patients who were diagnosed stage pT1b renal tumors and underwent either radical nephrectomy (RN, n = 475) or NSS (n = 273) from January 2004 to March 2017. The tumor size, pathological subtype, Fuhrman grade, status of peritumoral pseudocapsule (PC) and tumor multifocality were recorded. The relationship between peritumoral PC and positive SM was calculated statistically by Fisher’s exact probability test.

Results

The mean tumor diameter was 5.4 cm (range: 4.1–7.0 cm), 65 (8.7%) cases were discovered with multifocal lesions and 686 (91.7%) were surrounded with peritumoral PC in all 748 specimens. 57 (8.3%) of 686 cases were proved with tumor infiltrated beyond PC [infiltration (+)], and the presence of PC infiltration (+) was significantly correlated with positive SM (p = 0.016). The infiltrative depth of tumor cells into renal parenchyma beyond PC was all limited in 3 mm and the proportion of ≤ 1, 1–2 and 2–3 mm was 21.1% (12/57), 59.6% (34/57) and 19.3% (11/57), respectively.

Conclusions

Our report indicates a 3 mm excisional margin is acceptable to ensure negative SM when operating NSS on stage pT1b kidney neoplasms.

N-Methylcytisine Ameliorates Dextran-Sulfate-Sodium-Induced Colitis in Mice by Inhibiting the Inflammatory Response

This study aimed to investigate the anti-inflammatory effects of N-methylcytisine (NMC) in a dextran sulfate sodium (DSS)-induced colitis model and explore its possible mechanisms. Experimental colitis was induced by administering the mice with 5% DSS for 7 days. Different doses of NMC (1, 4 and 16 mg/kg) and 5-aminosalicylic acid (100 mg/kg) were given orally once every day for 7 days. The protective effect of NMC was evaluated using the disease activity index, colon length and results of histopathological examination. The possible mechanisms of NMC were explored by evaluating the expression levels of tumour necrosis factor-α, interleukin-1β and interleukin-6 (IL-6) using ELISA and analysing the protein expression levels of nuclear factor (NF)-κB p65, p-NF-κB p65, p-IκB, IκB, IκB kinase (IKK) and p-IKK using western blots. Results demonstrated that the oral administration of NMC attenuated the DSS-induced clinical symptoms and pathological damage. In addition, NMC treatment significantly reduced myeloperoxidase activity and level of pro-inflammatory cytokines. Further studies revealed that NMC blocked the activation of NF-κB by inhibiting IκB and IKK phosphorylation. These findings suggested that NMC exerts anti-inflammatory effects on DSS-induced colitis, and its mechanism may be related to the suppression of NF-κB activation. Thus, NMC may have potential therapeutic value in the treatment of colitis.

Abstract OT2-03-03: Delivery of a single fraction lumpectomy cavity boost using a novel immobilization device and treatment delivery system

Background: The lumpectomy cavity (LPC) boost has been shown in 2 randomized studies to improve local control in breast cancer. Hypofraction is now being used for delivery of the LPC boost in some early-stage patients. This trial delivers the LPC boost in a single fraction using a novel breast immobilization device/treatment delivery system.

Trial design: Patients are enrolled in this trial after standard resection with lumpectomy/sentinel lymph node biopsy (as appropriate) and chemotherapy (as indicated per standard of care). At the time of CT simulation for whole-breast radiation therapy (RT), the radiation oncologist evaluates breast size and LPC position. If consented for treatment, the patient receives a single fraction “boost” treatment of 8 Gy in 1 fraction followed by standard whole-breast RT to start within 7 days of completion of the boost. Whole-breast radiation is delivered in the supine or prone position with the following fractionation schemes: 4005 cGy in 15 fractions or 5000 cGy in 25 fractions.

On the day of the boost treatment, the patient is fitted with the breast immobilization device, with a plastic inner cup that is fitted so that the breast fills all or most of the cup. A rigid outer cup with a built-in stereotactic fiducial system is attached. Moderate negative pressure is applied to immobilize the breast within the cup system. Patients then undergo CT simulation in the prone position. Clip placement and LPC cavity location must meet eligibility criteria before proceeding with treatment planning and delivery.

Eligibility criteria:

Eligibility criteria: age &gt;60 yo; female only; dx of invasive ductal or lobular carcinoma or ductal carcinoma in situ; estrogen receptor positive; successful completion of lumpectomy ± sentinel lymph node biopsy with negative margins for invasive or noninvasive cancer; greatest tumor dimension &lt;4 cm before surgery; weight &lt;330 lb; height &lt;76 inches; nonlactating and nonpregnant. Various additional dosimetric factors must be met prior to treatment. If these are unable to be met, the patient will become ineligible for treatment.

Specific aims: The aim of this study is to demonstrate the feasibility and safety of delivering the LPC boost RT using a single fraction with a novel immobilization device/treatment delivery system while ensuring coverage of the target volume with appropriate dose homogeneity and conformity. Secondary aims are evaluation of patient comfort, acute toxicity (1 month), and late toxicity (1 year).

Statistical methods: A Simon 2-stage design is utilized for this trial. After evaluating the device and treatment on 8 patients in the first stage, the trial was designed to be terminated and device rejected if the dose distribution was acceptable for ≤5 patients. The first stage was completed in spring 2017 and progressed to the second stage, designed to include a total of 17 patients.

Accrual and target accrual: Target accrual for this study is 14 patients successfully treated while meeting all protocol constraints. As of 6/2017, 16 patients have been enrolled, of whom 13 have been successfully treated while meeting all protocol constraints.

Citation Format: Nichols EM, Becker S, Hong J, Cohen RJ, Mishra MV, Citron W, Cheston SB, Niu Y, Mutaf Y, Yu CX, Feigenberg SJ. Delivery of a single fraction lumpectomy cavity boost using a novel immobilization device and treatment delivery system [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-03-03.

Novel interstitial deletion in Xp22.3 in a typical X-linked recessive family with Kallmann syndrome

Kallmann syndrome (KS) is a clinically and genetically heterogeneous condition characterised by hypogonadotropic hypogonadism with anosmia or hyposmia. More than nineteen genes causing KS have been reported to date. KAL1, first identified to causing the X-linked form of KS, accounts for 10%-20% of KS patients. In this study, we designed a panel including 17 known genes causing KS for genetic diagnosis and research and report a typical and rare family of which three generations had been affected by KS. A novel CNV in Xp22.3 was identified through targeted next-sequencing technology and high-resolution microarray. The breakpoint (chrX:8536480 and chrX:8730416) was defined, and the size of deletion is about 0.24 Mb. The CNV including KAL1 and FAM9A had a negative effect on the expression of KAL1, resulting in decreased level of KAL1 mRNA in whole blood. In addition, the proband had significant improvement in testicular volumes and secondary sex characters except spermatogenesis after regular treatment, which indicates the CNV may have a negative effect on spermatogenesis. Our study expands the genotypic spectrum of KAL1 mutations associated with KS and provides a practical pipeline for genetic diagnosis or research.

Preliminary study of 1940 nm thulium laser usage in peroral endoscopic myotomy for achalasia

Esophageal achalasia is a type of motility disorder characterized by incomplete relaxation of lower esophageal sphincter (LES) and absence of esophageal peristalsis. Peroral endoscopic myotomy (POEM) is a new treatment option for achalasia that is less invasive, more effective, and safe as compared to surgery. High-frequency electrotome is commonly used in POEM, but takes longer time to make the tunnel in the esophagus and causes many complications. The thulium laser decreases the risk of bleeding and perforation in endoscopy but has not been reported in digestive diseases, especially in POEM. Therefore, the aim of this study is to evaluate the feasibility of the 1940 nm thulium laser in POEM. From March 2015 to August 2015, five patients with achalasia at the Digestive department, Beijing Friendship Hospital, Capital Medical University, Beijing, China were included. Before the procedure, the patients' gender, age, and duration of symptoms were recorded. Eckardt symptom score and LES thickness, which measured by endoscopic ultrasonography, were recorded. While the subtypes of achalasia (according to the Chicago classification), lower esophagus sphincter resting pressure (LESRP) and integrated relaxation pressure (IRP) were measured by HRM for all patients. Barium esophagram was also used to rule out anatomical lesions, esophageal varices, or neoplasia, which may cause similar symptoms. All examinations were performed one week before POEM. POEM was performed with the 1940 nm thulium laser under general anesthesia. Eckardt score, procedure duration, myotomy length, and complications were recorded one week after POEM. All the patients were followed-up at two weeks and four weeks after POEM. POEM was successfully performed in all five patients. The mean age of the patients was 38.8 years (24-54 years). Achalasia subtypes were type I (n = 1), II (n = 2), and III (n = 2). The operation duration was 186, 180, 111, 75, and 126 minutes for the five cases. Pre/postprocedure Eckardt scores were 3/0, 7/0, 5/1, 6/0, and 9/0. Pre/postprocedure LESRP (mmHg) were 45.3/26.4, 18.0/1.1, 25.8/10.4, 16.5/11.2, and 24.2/20.8. Pre/postprocedure IRP (mmHg) were 27.3/15.5, 15.4/4.2, 5.7/6.8, 15.5/10.1, and 13.1/14, respectively. No adverse events occurred during the procedure. After POEM, subcutaneous emphysema occurred in case 1 on the first day, which relieved spontaneously after two days without special intervention. Infection occurred in case 5 on the day of POEM was healed with antibiotics three days later. The 1940 nm thulium laser is feasible for POEM procedure. Further studies are needed to determine whether the 1940 nm thulium laser is better than high-frequency electrotome.