Characteristics of the Mucosal Surface on Scanning Electron Microscopy in Patients with Remitting Ulcerative Colitis

BACKGROUND

Ulcerative colitis (UC) is characterized by chronic intestinal epithelial damage, and previous studies have evaluated the epithelial structure of patients with active UC using electron microscopy.

AIMS

This study aimed to assess the intestinal epithelial structure using scanning electron microscopy (SEM) and the features of patients with UC who are in remission.

METHODS

In total, eight healthy controls and 20 patients with UC were enrolled, and colonic tissue samples from the cecum and rectum were collected. Then, we compared the epithelial surface structure on SEM between patients with UC who are in clinical remission and healthy controls.

RESULTS

In healthy controls, the colonic surface comprises small lobes (termed units), with one crypt located in the middle of each unit. In patients with UC, we found irregular unit and crypt mouth size, double crypt sign (> 1 crypt per unit), and lower number of small vesicles in the intestinal epithelial cells. Compared with healthy controls, patients with UC often presented with irregular unit size, double crypt sign, and irregular crypt mouth size in the rectum. The small vesicles were observed less frequently in patients with UC than in healthy controls.

CONCLUSIONS

SEM revealed a unique epithelial structure in patients with UC who are in remission.

Development of an Indigo Naturalis Suppository for Topical Induction Therapy in Patients with Ulcerative Colitis

BACKGROUND

Indigo naturalis (IN) consists of ligands for the aryl hydrocarbon receptor and exhibits anti-inflammatory effects. Previously, we demonstrated that an 8-week treatment with oral IN is effective in inducing a clinical response in patients with ulcerative colitis (UC). Some UC patients with proctitis are refractory to topical mesalamine or corticosteroids and therefore require an alternative topical treatment.

OBJECTIVES

We aimed to prospectively evaluate the safety and efficacy of IN suppositories in UC patients.

METHOD

We performed an open-label, single-center, prospective pilot study from February 2018 to October 2018. A total of 10 patients with active UC, who had moderate to severe inflammation from the rectum to the sigmoid colon, were enrolled. The patients received a daily dose of 50 mg IN suppository for 4 weeks. The primary endpoint was safety at week 4.

RESULTS

Although 1 patient experienced anal pain, no serious adverse events were observed. At week 4, the rates of clinical remission and mucosal healing were 30 and 40%, respectively. Mayo rectal bleeding subscores significantly improved after treatment (1.80 ± 0.13 vs. 0.90 ± 0.28; p = 0.009). Approximately 80% of the patients with a baseline Mayo endoscopic subscore in the rectum (r-MES) of 2 achieved mucosal healing, but those with a baseline r-MES of 3 did not.

CONCLUSIONS

We found that 4 weeks of IN suppository can be tolerated by UC patients, but its efficacy was limited by the severity of the disease. Further investigation will be needed in order to confirm the optimum dose of IN suppository for patients with UC.

Mucosal concentrations of N-acetyl-5-aminosalicylic acid related to endoscopic activity in ulcerative colitis patients with mesalamine

BACKGROUND AND AIM

5-Aminosalicylic acid (5-ASA) is a fundamental treatment for mild-to-moderate ulcerative colitis (UC). 5-ASA is taken up into the colonic mucosa and metabolized to N-acetyl-5-ASA (Ac-5-ASA). Few studies have assessed whether mucosal 5-ASA and Ac-5-ASA concentrations are associated with endoscopic remission. This study aimed to investigate differences in 5-ASA and Ac-5-ASA concentrations according to endoscopic activity.

METHODS

This single-center, prospective, cross-sectional study was conducted between March 2018 and February 2019. UC patients who were administered with 5-ASA medication for at least 8 weeks before sigmoidoscopy were enrolled. Mucosal 5-ASA and Ac-5-ASA concentrations were measured using liquid chromatography with tandem mass spectrometry. The primary endpoint was defined as the difference in mucosal concentrations of 5-ASA and Ac-5-ASA, according to the Mayo endoscopic subscore (MES).

RESULTS

Mucosal concentrations were analyzed in 50 patients. In the sigmoid colon, the median 5-ASA concentration in patients with MES of 0 (17.3 ng/mg) was significantly higher than MES ≥ 1 (6.4 ng/mg) (P = 0.019). The median 5-ASA concentrations in patients with Ulcerative Colitis Endoscopic Index of Severity ≤ 1 (16.4 ng/mg) were also significantly higher than in patients with Ulcerative Colitis Endoscopic Index of Severity ≥ 2 (4.63 ng/mg) (P = 0.047). In the sigmoid colon, the concentration of Ac-5-ASA was higher in patients with MES of 0 (21.2 ng/mg) than in patients with MES ≥ 1 (5.81 ng/mg) (P = 0.022).

CONCLUSIONS

The present study showed that mucosal Ac-5-ASA concentrations, as well as 5-ASA concentrations, are higher in UC patients with endoscopic remission. Ac-5-ASA may be useful for a biomarker of 5-ASA efficacy.

Glycolysis gene Hif1a negatively regulates the induction of intraepithelial CD4+CD8aa+ T cells

Intestinal CD4 T cells reside in both lamina propria and intraepithelial lesion. We previously reported CD4+CD8aa+ intraepithelial lymphocytes (DPIELs) exhibit anti-inflammatory function against intestinal inflammation. Recently, metabolic status is important both for induction and for keeping cells in active phase. For example, Tregs use oxphos for cellular metabolism, while Th17 cells mainly use glycolysis. It is still unknown the metabolic status in tissue resident T cells and the effect of metabolic related gene for cell development in gut. By using mito-tracker and seahorse system, we first evaluated the metabolic status of tissue resident CD4 T cells. Then we used mouse model by deletion of the glycolysis related gene to uncover the development of intestinal resident CD4 T cells. The ratio of mitochondrial membrane potentialhipopulation of CD4IELs was increased in Germ free mice than in SPF mice. Most of DPIELs express the mitochondira membrane potentiallo. Although total CD4 positive IELs increased glycolysis compared to the splenic naive CD4 T cells, DPIELs expressed less pS6 and reduced glycolysis related gene, Hif1a. Next, We generated conditional Hif1a and Vhl ko mice (CD4cre: Hif1af/f: Hif1a (ΔCD4), CD4cre: Vhlf/f: Vhl (ΔCD4), CD4cre: Hif1af/f: Vhlf/f (DKO)) respectively to understand whether Hif1 was negatively regulated the induction of DPIELs or not. The ratio of DPIELs was increased in Hif1a (ΔCD4), DKO mice and decreased in Vhl (ΔCD4) mice. These results reveal total CD4IELs uses preferentially glycolysis, but glycolytic related gene Hif1a is negatively regulated the induction of DPIELs.

New classification of CD4+CD8a+ double positive cells in Crohn’s disease patients

The gastrointestinal tract absorbs nutrition while providing a defense response to foreign antigens including enteric bacteria or food. Once the antigen enter the intestine, inflammatory mononuclear cells are accumulated quickly, however some tissue resident T cells, such as regulatory T cells (Tregs) block the excessive tissue damage. We previously demonstrated that mouse CD4+CD8a+ double expressing (DP)cells and Tregs complementary play an immuno-suppressive role in IE and LP, and a part of IE DP cells is originally developed from Tregs in LP. However, DP cells are not well characterized in human especially in inflammatory bowel disease (IBD) patients.

We obtained human small intestinal tissue from 9 colon cancer patients as normal tissue, and 5 Crohn’s disease(CD) patients, dividing into inflamed and non-inflamed lesion, and analysed by Flow cytometry. We confirmed DP cells are located in both IE and LP in human. First, we demonstrated the ratio of DP cells in normal tissue was as same as in non-inflamed lesion of CD patients. As we expected, the ratio of DP cells in inflamed tissue of CD patients was significantly decreased compared to normal tissue and non-inflamed lesion of CD. Then, we analysed the surface marker of Human DP cells. Surface staining of CD27 and CD45RA showed distinct difference between DP cells and the other CD4 T cells. DP cells expressed more memory T cell marker (CD27−CD45RA−) and less effector T cell marker (CD27+CD45RA−) than the other CD4 subset. Futher more, the more fraction of IE DP cells expressed CD103 than LP DP cells. Conclusively, these data indicated that human DP cell reside both in IE and LP and that DP cells are not a single characterized population, and the DP cells were decreased in inflamed lesion in CD.

The herbal medicine ‘Indigo naturalis’ altered gut microbiota to accumulate IL-22+ ILC3s

Ulcerative colitis (UC) is a chronic inflammation of the large intestine led by the dysregulation of adaptive and innate immune responses. Recently, specific microbiota has been reported to instruct the immune cells and immune response. We have recently proved the clinical efficacy of “indigo naturalis (IN)”, a Chinese herbal medicine, on patients with UC by the multicenter randomized-controlled trial (INDIGO study, Gastroenterology 2018).

4%IN-fed mice ameliorated DSS-colitis (IN-DSS mice) compared to the normal diet-fed mice (ctrl-DSS mice). The number of IL-22+ ILC3s in the colonic lamina propria in IN-DSS mice increased more than the one in ctrl-DSS mice. We also confirmed that IN-fed diet mice significantly altered gut microbiota composition compared to the normal diet-fed mice.

We next inoculated feces obtained from IN-fed mice or normal diet-fed mice to antibiotic treated mice (IN-FMT mice, ctrl-FMT mice respectively). Interestingly, IN-FMT mice significantly restored the pathology of DSS-induced colitis than ctrl-FMT mice with increased number of IL-22+ ILC3s. We showed IN induced specific microbiota which accumulated IL-22+ ILC3s in gut.

The Biomarker Salivary SP-D May Indicate Small Airway Inflammation and Asthma Exacerbation

BACKGROUND

Noninvasive and child-friendly biomarkers are important tools for understanding the various phenotypes of childhood asthma. Objective: The aim of this study was to examine the usefulness of salivary surfactant protein (SP) D in assessing the pathophysiology of childhood asthma.

METHODS

We measured salivary concentrations of SP-D and forced oscillation technique (FOT) indexes in 19 healthy controls and 21 asthmatic children. Regression equations for the predictive values of FOT indexes were generated from healthy controls. We analyzed the correlations between salivary SP-D concentration and percentages of the predictive values of FOT indexes, as well as the severity of exacerbation.

RESULTS

We found that salivary SP-D levels were higher in asthmatic children than in healthy controls. In the asthmatic children, salivary SP-D levels correlated with the percentages of predicted differences in resistance between 5 Hz and 20 Hz (%R5-R20), which represented the resistance of peripheral airways, and with the severity of asthma exacerbation.

CONCLUSIONS

Salivary SP-D may reflect asthmatic inflammation in peripheral small airways and may be a useful marker for monitoring the degree of exacerbation in childhood asthma.

Association study of genetic variants on chromosome 7q31 with susceptibility to normal tension glaucoma in a Japanese population

The caveolin 1 to caveolin 2 (CAV1-CAV2) gene region on chromosome 7q31 has been reported to be associated with susceptibility to primary open angle glaucoma (POAG) and normal tension glaucoma (NTG) in previous studies. We investigated whether genetic variants in the CAV1-CAV2 region are associated with NTG in Japanese patients. Two hundred and ninety-two Japanese patients with NTG and 352 Japanese healthy controls were recruited. We genotyped three single-nucleotide polymorphisms; that is, rs1052990, rs4236601, and rs7795356, in the CAV1-CAV2 gene region and assessed the allelic diversity among cases and controls. The frequency of the minor allele (G) of rs1052990 was significantly decreased in NTG cases compared with controls (P=0.014, OR=0.71), whereas NTG or POAG cases had a significantly higher frequency of the allele than controls in previous studies. Conversely, rs7795356 did not show any significant association with NTG cases, and rs4236601 was monomorphic in the Japanese study population. Our findings did not correspond with previous positive results, suggesting that CAV1-CAV2 variants studied in the present study are not important risk factors for NTG susceptibility in all populations. Further studies are needed to elucidate the possible contribution of the CAV1-CAV2 region to the development of glaucoma.

Development of a recombinant yeast assay to detect ah-receptor ligands

Endocrine systems of humans and animals are disturbed by dioxin-like compounds, which are ligands of the aryl hydrocarbon receptor (AhR). It is important to determine the accumulation of dioxin-like compounds in the environment for maintenance of human health. In this study, we developed a new method for screening ligands of the AhR using a yeast hybrid system. Reporter genes constructed by the insertion of dioxin response elements were integrated into HIS and lacZ yeast genomes. Then yeast was transformed with GAL4-activated domain-fused AhR and aryl hydrocarbon receptor nuclear translocator expression constructs. At 10(-4) M of beta-naphthoflavone, which is an AhR ligand, the absorbance of optical density at 600 nm (OD 600) and beta-galactosidase activity was significantly increased. beta-galactosidase activity was increased when the concentration of 3-methylcholanthrene (MC) was increased. ATP concentration increased as concentration of MC increased up to 10(-10) M but decreased at higher concentrations. The concentration of ATP in the cell suspensions increased linearly with OD 600, used as an index of cell density (r(2) = 0.8366, F = 209.9, p < 0.0001, n = 44). The established yeast assay could possibly be used in the future to detect dioxin-like compounds in environmental samples.

The Endoscopic Surgical Skill Qualification System for gastric surgery in Japan

INTRODUCTION

Laparoscopic surgery has been increasing in popularity in recent years. In 2004, the Japan Society for Endoscopic Surgery developed its Endoscopic Surgical Skill Qualification System (ESSQS) to assess surgeons.

METHODS

To earn the ESSQS accreditation, applicants must submit an unedited operative video in which they perform either a distal gastrectomy or pylorus-preserving gastrectomy with lymph node dissection for gastric cancer. The videos are assessed by two separate judges based on detailed criteria for common and procedure-specific technical-grade slips. Common criteria from all fields of gastrointestinal and general surgery are used to evaluate the basic laparoscopic surgical skills and autonomy of the operator. The target organ determines the procedure-specific criteria are set to assess whether or not adequate oncological clearance has been achieved.

RESULTS

Between 2004 and 2009, 154 (44.6%) out of 345 applicant surgeons assessed under the ESSQS for gastric surgery have been accredited. Interrater agreement was acceptable and ranged between 0.21 and 0.59.

CONCLUSION

The ESSQS system may facilitate improvement in surgical technique and the standardization of laparoscopic surgery in Japan.

A phase II study of preoperative chemotherapy with S-1 (S) and cisplatin (P) followed by D3 gastrectomy for gastric cancer (GC) with extensive lymph node metastasis (ELM): Survival results of JCOG0405

70

Background: GC with ELM, especially in case of M1(LYM), is regarded unresectable in many countries, while challenge is ongoing in Japan to treat them by intensive chemotherapy followed by super extended surgery. In our previous phase II study (JCOG0001) for the same population, iritotecan plus P (IP) chemotherapy followed by surgery showed remarkable survival of 27.0% at 3 years but its toxicity led to rather high treatment related death (TRD). Development of safer and more effective treatment is urged.

Methods: Eligibility criteria included histologically proven gastric adenocarcinoma; bulky nodal involvement around major branched arteries to the stomach and/or para-aortic nodal metastases; cM0 (except para-aortic nodes); negative lavage cytology; not linitis plastica type; PS of 0 or 1. Patients (pts) received two or three 28- day cycles of induction chemotherapy of S (80 mg/m2 from day 1 to 21) and P (60 mg/m2 on day 8), and then underwent D3 gastrectomy. Primary endpoint was R0 resection and key secondary endpoint was 3-year survival. Other secondary endpoints included response rate and adverse events.

Results: Between 02/2005 and 06/2007, 53 pts were enrolled and 2 pts were ineligible. Only surrogate endpoints of efficacy and feasibility were reported in ASCO-GI 2008, which included clinical response of 64.7%, R0 of 82.4%, pathological response of 51.0%, and no TRD with low toxicities. The 3-year overall survival, which we first clarified in this report, was 58.8% (95% CI, 44.1-70.9%).

Conclusions: Preoperative SP followed by D3 gastrectomy demonstrated excellent 3-year survival with low mortality compared with preoperative IP, which was far better result than expected against this unresectable population. This multimodal treatment is highly promising for GC with ELM.

[Table: see text]

Positional relationship between recurrent intracerebral hemorrhage/lacunar infarction and previously detected microbleeds

BACKGROUND AND PURPOSE

Although MBs, ICH, and LI are secondary to cerebral microangiopathy, it remains unclear whether the location of subsequent ICH/LI corresponds to the previous location of MBs. We performed this study to clarify the positional relationship between recurrent ICH/LI and previously detected MBs.

MATERIALS AND METHODS

We evaluated patients with recurrent ICH/LI who had MBs, as shown on prior T2*-weighted MR imaging. We assessed retrospectively whether the location of recurrent ICH/LI corresponded to that of the prior MB. Patients with ICH were divided into the deep ICH group and the lobar ICH group, and the positional relationship between hematoma and previously detected MBs was evaluated.

RESULTS

A total of 55 patients, including 34 with recurrent ICH and 21 with recurrent LI were evaluated. Although the location of the LI corresponded to prior MBs in only 1 patient (4.8%), the location of ICH corresponded to prior locations of MBs in 21 patients (61.8%) (OR, 32.3; 95% CI, 3.86-270.3; P < .001). Among the patients with ICH, the correspondence ratio was higher in the deep ICH group (19 of 24 patients, 79.2%) than in the lobar ICH group (2 of 10 patients, 20%) (OR, 15.2; 95% CI, 2.42-95.3; P < .002).

CONCLUSIONS

The close positional association between recurrent ICH and prior MBs suggests that MBs represent hemorrhage-prone microangiopathy. In addition, different correspondence ratios between the deep ICH group and the lobar ICH group may be attributable to their different pathogenesis.

Ancillary N.O.T.E.S. procedures for early stage gastric cancer

The potential for performing truly scarless, safe surgery that at the same time may be less morbid is tempting both patients and physicians alike to seriously consider Natural Orifice Transluminal Endoscopy Surgery (NOTES) for a range of clinical applications. Given the move towards gastric-preservation by minimally invasive techniques for definitive management of early gastric cancer, this radical approach may find a niche within future clinical care paradigms for early stage malignant lesions of the stomach. Indeed already selected T1,N0 adenocarcinoma is being treated and even cured by advanced endoscopic techniques such as Endoscopic Submucosal Dissection. NOTES may initially therefore find a role in furthering the application of such endeavour by ensuring oncological providence in the treatment of those T1 lesions with higher risk of lymphatic metastases that currently are advised to lie outwith the scope of pure endoscopic resection (for reasons of oncological propriety rather than technical capacity). One such means NOTES could supplement ESD is by providing for direct sampling of sentinel nodes from the perigastric lymph basins. Subsequently perhaps a NOTES technique may develop capable of performing localized, full-thickness gastric wedge or sleeve resection for T2,N0 adenocarcinoma (and indeed perhaps other pathologies such as small gastrointestinal stromal tumors). This review examines how advancing technology along with progressive surgical thinking and innovation could lead to NOTES becoming absorbed into clinical care pathways for early gastric malignancy.

HLA-DRB1 alleles influence clinical phenotypes in Japanese patients with ulcerative colitis

The human leukocyte antigen (HLA) region has been implicated in the disease susceptibility of inflammatory bowel disease by several linkage and association studies. In Caucasians, HLA-DRB1 has been reported to determine the clinical phenotypes of ulcerative colitis (UC). Others and we previously reported that HLA-DRB1*1502 was strongly associated with UC in the Japanese population. However, the contribution of HLA-DRB1 to the clinical phenotypes in Japanese UC has not been elucidated yet. The aim of this study was to determine whether HLA-DRB1 alleles were associated with the clinical phenotypes in Japanese patients with UC. A total of 353 patients with UC were recruited. Patients were classified into subgroups by sex, age at diagnosis, disease extent, need for steroid therapy or need for surgical treatment. The allele frequency of HLA-DRB1*08 was significantly higher in patients whose disease extended beyond the rectum (left-sided and extensive UC) than in those with proctitis [odds ratio (OR)=2.20, Pc=0.043). The allele frequency of HLA-DRB1*09 was significantly higher in patients with UC diagnosed at the age of 40 years or older than in those with UC diagnosed before the age of 40 years (OR=2.31, Pc=0.022). Besides these positive associations, no significant differences were found in the allele frequencies between the other subgroups. We conclude that HLA-DRB1*09 is associated with the age at diagnosis and HLA-DRB1*08 is associated with the disease extent of UC in Japanese. These results indicate that HLA-DRB1 is not only associated with the overall UC susceptibility but also associated with the clinical phenotypes in Japanese.

Association between cerebral microbleeds on T2*-weighted MR images and recurrent hemorrhagic stroke in patients treated with warfarin following ischemic stroke

BACKGROUND AND PURPOSE

Although accumulating evidence suggests the presence of microbleeds as a risk factor for intracerebral hemorrhage (ICH), little is known about its significance in anticoagulated patients. The aim of this study was to determine whether the presence of microbleeds is associated with recurrent hemorrhagic stroke in patients who had received warfarin following atrial fibrillation-associated cardioembolic infarction.

MATERIALS AND METHODS

A total of 87 consecutive patients with acute recurrent stroke, including 15 patients with ICH and 72 patients with cerebral infarction, were enrolled in this study. International normalized ratios (INRs), vascular risk factors, and imaging characteristics, including microbleeds on T2*-weighted MR images and white matter hyperintensity (WMH) on T2-weighted MR images, were compared in the 2 groups.

RESULTS

Microbleeds were noted more frequently in patients with ICH than in patients with cerebral infarction (86.7% versus 38.9%, P = .0007). The number of microbleeds was larger in patients with ICH than in patients with cerebral infarction (mean, 8.4 versus 2.1; P = .0001). INR was higher in patients with ICH than in patients with cerebral infarction (mean, 2.2 versus 1.4; P < .0001). The frequency of hypertension was higher in patients with ICH than in patients with cerebral infarction (86.7% versus 45.8%, P = .0039). Multivariate analysis revealed that the presence of cerebral microbleeds (odds ratio, 7.383; 95% confidence interval, 1.052-51.830) was associated with ICH independent of increased INR and hypertension.

CONCLUSION

The presence of cerebral microbleeds may be an independent risk factor for warfarin-related ICH, but more study is needed because of strong confounding associations with elevated INR and hypertension.

Butyrophilin-like 2 gene is associated with ulcerative colitis in the Japanese under strong linkage disequilibrium with HLA-DRB1*1502

The human leukocyte antigen (HLA) region has been implicated in the pathogenesis of inflammatory bowel disease (IBD), which is classified into Crohn's disease (CD) and ulcerative colitis (UC). Recently, an association between sarcoidosis and the butyrophilin-like 2 (BTNL2) gene was reported. BTNL2 is located in the HLA region and its messenger RNA is expressed most abundantly in the intestine. In this study, we performed a case-control association study of BTNL2 in the Japanese patients with IBD and performed linkage disequilibrium (LD) analysis between BTNL2 and HLA-DRB1. We analyzed eight polymorphisms selected after direct sequencing and found that none of the polymorphisms were associated with the Japanese CD cohort. In contrast, five polymorphisms were significantly associated with UC, especially three single nucleotide polymorphisms (BTNL2_19, BTNL2_22 and BTNL2_23) were associated as a haplotype. The most frequent haplotype (GGC haplotype) was a low-risk haplotype (P= 0.000052), whereas the other TCT haplotype was a high-risk haplotype (P= 0.0000085). Among the eight polymorphisms, the strongest association with UC was found in BTNL2_19 (OR = 1.92, P= 0.0000035). As expected, the BTNL2_19-T allele showed strong LD with DRB1*1502 (D'= 0.92). When BTNL2_19 was tested as conditional on the DRB1*1502 carrier status, the significant association disappeared, suggesting that the association was because of its strong LD with DRB1*1502. We conclude that BTNL2 does not contribute to the susceptibility to Japanese CD but is associated with Japanese UC because of the strong LD with HLA-DRB1*1502. The strong LD between BTNL2 and HLA-DRB1 raises another issue about the potential role of BTNL2 in other diseases associated with HLA-DRB1.

A Schwannoma of the S1 Dural Sleeve was Resected while the Intact Nerve Fibers were Preserved Using a Microscope. Report of a Case with Early MRI Findings

In this report, we describe a small schwannoma of the dural sleeve and mention that it is often difficult to differentiate this tumor from lumbar disc herniation, especially a sequestered hernia, or a discal cyst. Gadolinium-enhanced MR images were a useful preoperative examination modality for differentiating this lesion from other diseases. Microscopically, the intradural tumor was successfully removed. The dura mater of the S1 nerve root was opened microsurgically, allowing the nerve fibers involved in the tumor to be identified. The involved fibers were cut around the tumor, and the lesion was resected while the intact nerve fibers were preserved. Based on histological examination of the resected specimen, the tumor was diagnosed as a schwannoma with multilocular cystic degeneration. Microsurgery allowed the tumor to be removed with minimal impairment from cutting of nerve fibers in the nerve root.

Plasma total homocysteine levels are associated with advanced leukoaraiosis but not with asymptomatic microbleeds on T2*-weighted MRI in patients with stroke

Both leukoaraiosis and asymptomatic microbleeds are associated with small-artery diseases. Although an association between hyperhomocysteinemia and leukoaraiosis has been reported, no studies have evaluated the association between total homocysteine (tHcy) level and presence of microbleeds in stroke patients. We evaluated the association between tHcy level and leukoaraiosis or microbleeds in stroke patients. In 102 patients with stroke (69.5 +/- 10.3 years old, 54 men and 48 women), microbleeds on T2*-weighted MR images were counted, leukoaraiosis on T2-weighted images was graded and fasting plasma tHcy concentrations were measured. Plasma tHcy level was significantly higher in patients with advanced leukoaraiosis than in those without advanced leukoaraiosis (13.9 +/- 4.6 micromol/l vs. 10.2 +/- 3.4 micromol/l, P < 0.0001). Plasma tHcy level was not significantly different in patients with microbleeds and those without microbleeds (11.3 +/- 4.1 micromol/l vs. 11.4 +/- 4.3 micromol/l, P = 0.9441). Elevated tHcy level is significantly and independently associated with advanced leukoaraiosis [odds ratio (OR), 1.330; 95% CI, 1.130-1.565] but not with the presence of microbleeds. Elevated tHcy level appears to be associated with ischemic small-artery disease rather than with bleeding-prone small-artery disease.

Combinations of the presence or absence of cerebral microbleeds and advanced white matter hyperintensity as predictors of subsequent stroke types

BACKGROUND AND PURPOSE

Previous studies have shown microbleeds to be a risk factor for intracerebral hemorrhage and white matter hyperintensity (WMH) to be a risk factor for ischemic stroke. This study was performed to determine whether combinations of the presence or absence of microbleeds and advanced WMH are risk factors for subsequent recurrent stroke types.

METHODS

In 266 patients with stroke, microbleeds on T2*-weighted MR images were counted, and WMH on T2-weighted images was graded. Patients were divided into 4 groups by the combinations of the presence or absence of microbleeds and advanced WMH and were followed up for stroke recurrence.

RESULTS

During a mean follow-up period of 564.8 +/- 220.5 days, 26 patients developed recurrent strokes, including 10 intracerebral hemorrhages and 16 ischemic strokes. Patients with microbleeds without advanced WMH (n = 42) developed only intracerebral hemorrhages (n = 8), and the recurrence rate of intracerebral hemorrhage in those patients estimated by the Kaplan-Meier method was the highest in the 4 groups (14.3% in 1 year and 21.2% in 2 years). In contrast, patients with advanced WMH without microbleeds (n = 39) developed only ischemic strokes (n = 6), and the estimated recurrent rate of ischemic stroke in those patients was the highest in the 4 groups (10.5% in 1 year and 17.4% in 2 years). Cox proportional hazards regression analysis revealed that microbleeds were associated with intracerebral hemorrhage (hazard ratio [HR], 85.626; 95% confidence interval [CI], 6.344-1155.649) and that advanced WMH was negatively associated with intracerebral hemorrhage (HR, 0.016; 95% CI, 0.001-0.258). Advanced WMH was associated with ischemic stroke (HR, 10.659; 95% CI, 2.601-43.678).

CONCLUSION

It appears that patients at high risk of subsequent intracerebral hemorrhage or ischemic stroke can be identified by combinations of the presence or absence of microbleeds and advanced WMH.

Both N-terminal and C-terminal regions of steroid sulfatase are important for enzyme activity

Steroid sulfatase (STS) is localized in the endoplasmic reticulum and catalyzes desulfation of 3beta-hydroxysteroid sulfates. X-linked ichthyosis (XLI) is an inherited skin disorder caused by deficiency of STS enzyme activity. We previously reported a case in which XLI with a one-base change in the STS gene and variation in amino acid Q560P developed. In this study, we performed molecular analysis to determine the importance of terminal regions of STS and the effect of mutant STS on STS enzyme activity. To examine the effect of terminal truncated STS on the enzyme activity, N- and C-terminal truncated STS expression vectors were transfected into COS-1 cells. The activity of truncated STS lacking the N-terminal regions declined, and the activity of C-terminal-truncated STS declined with extension of the truncated C-terminal region. Although the results of pulse-chase experiments showed that a one-base mutant STS (Q560P) and C-terminal-truncated STS (deltaC2 (1-559)) had no effects on protein synthesis and degradation, the mutant STS and C-terminal-truncated STS have dominant negative effect on STS enzyme activity when the STS mutant or truncated STS protein and a wild-type STS protein coexist in cells. Results of coprecipitation of the truncated STS with an STS-FLAG fusion protein showed that STS formed a dimer conformation in cells. In this study, we have shown that both the N-terminal region and C-terminal region are important for STS enzyme activity. The C-terminal mutant has a dominant negative effect on wild-type STS.

Second-look arthroscopy of cartilage changes of the patellofemoral joint, especially the patella, following acute and recurrent patellar dislocation

OBJECTIVE

The purpose of this study was to clarify some pathogenesis of the cartilage changes of the patellofemoral joint in patellar dislocation knees.

METHODS

A first arthroscopy was performed in a total of 60 knees, including 30 knees of acute patellar dislocation (APD) and 30 knees of recurrent patellar dislocation (RPD). At the time of the first arthroscopy, 58 knees sustained open medial patellofemoral ligament repair/reconstruction, and 2 knees had only arthroscopy examination. In APD knees, the second-look arthroscopy was performed 16.7 months after the first arthroscopy, and in RPD knees, 25.2 months after the first arthroscopy.

RESULTS

In most APD knees, cracking primarily on the central dome of the patella did not have a remarkable change but in several knees that had a high number of cracking or interlaced cracking, cracking became worse with fibrillation. Osteochondral defect site primarily on the medial facet showed fibrillation and/or ulceration (erosion). In most RPD knees, fissuring primarily on the central dome did not have a remarkable change, and fibrillation and/or erosion mainly on the medial facet also did not have a remarkable change. However, in four knees with the continuation of patellar dislocation, the patellar cartilage changes had definitely worsened. On the other hand, in the first and second-look arthroscopy, most APD and RPD knees had no remarkable cartilage lesions or cartilage changes of the femoro-trochlear aspect.

CONCLUSIONS

One of the pathogenesis of fissuring in RPD knees seems to be cracking occurring at the time of APD. Two of the pathogenesis of fibrillation may result from the reparative reaction of the cartilage in osteochondral defect site and the cartilage change due to a high degree of cracking damage mainly on the central dome in APD injury. The continuation of patellar dislocation definitely makes the patellar cartilage lesions worse.

Ultrastructural study of the extra-articular Leeds-Keio ligament prosthesis

BACKGROUND

There have been several histological studies of the Leeds-Keio ligament in anterior cruciate ligament reconstruction, but there have been few of the Leeds-Keio ligament in the extra-articular portion.

AIMS/METHODS

To report the histological and ultrastructural findings of two cases of medial patellofemoral ligament reconstruction using the Leeds-Keio ligament, removed 6.1 years and 8.7 years after implantation.

RESULTS

In both cases, the tissue over the Leeds-Keio ligament was a ligament-like tissue. Electron microscopy showed that the diameter of the collagen fibrils in the tissue over the Leeds-Keio ligament was unimodal in the case investigated 6.1 years after implantation but bimodal in the case investigated after 8.7 years.

CONCLUSIONS

The tissue over the Leeds-Keio ligament may continue to grow with prolonged periods of mechanical stress.

Mapping of a disease susceptibility locus in chromosome 6p in Japanese patients with ulcerative colitis

Ulcerative colitis (UC) is a multifactorial disorder with both genetic and environmental factors. HLA-B*52 and DRB1*1502 are reported to be strongly associated with UC in Japan. However, the actual susceptible gene has not been identified yet. In this study, to map precisely the susceptible locus for UC, we performed association mapping in the chromosome 6p using 24 microsatellite markers distributed over 16 Mb. A total of 183 patients with UC and 186 healthy controls (HC) were included in this study. In all, 15 markers around the human leukocyte antigen (HLA) region showed statistical significance in the genotypic differentiation test concerned with the allelic distribution between the UC and HC. Especially, the markers between the centromeric region of HLA class I and the telomeric region of class III showed remarkably low P-values and the allele239 of C2-4-4 in class I marker showed the strongest association (Pc=2.9 x 10(-9): OR=3.74, 95% CI=2.50-5.60). Furthermore, we found strong linkage disequilibrium (LD) between the allele239 of C2-4-4 and HLA-B*52 in haplotype analysis. These results provide evidence that, in Japanese, important determinants of disease susceptibility to UC may exist in HLA, especially between the centromeric region of class I and the telomeric region of class III, under the strong LD with HLA-B*52.

Significance of serum soluble thrombomodulin level in acute cerebral infarction

The purpose of the present study was to investigate sequential changes in serum soluble thrombomodulin (sTM) concentrations in patients with acute cerebral infarction (ACI), and to correlate sTM concentrations with the severity of ACI evaluated by Japan Stroke Scale. Eighty-three consecutive patients with ACI were enrolled, and blood examinations were carried out soon after admission and 1 month after. sTM concentrations at admission in patients with cardioembolic infarction (3.2 +/- 1.2 ng/ml) were significantly lower than those of lacunar infarction (3.9 +/- 1.2) (P < 0.05). Serial examinations revealed that sTM concentrations increased significantly 1 month after admission (3.8 +/- 1.2), compared with those at admission (3.6 +/- 1.2) (P = 0.02). Of three ACI subtypes, sTM concentrations during 1 month significantly increased in atherothrombotic infarction (P = 0.002) or, not significantly, in cardioembolic infarction (P = 0.09). The sTM concentrations at admission showed a significant inverse correlation with the severity of ACI (P = 0.04). Although sTM concentrations serve as a useful marker for endothelial cell damage, they are decreased in patients with severe ACI, especially in atherothrombotic and cardioembolic infarctions. Lower sTM concentrations may play some important role in disease progression or in the recurrence following ACI, although the exact mechanism of this unique result should be clarified.

Laparoscopic approach for early gastric cancer within a paraesophageal hiatal hernia

We present a case of early gastric cancer located in gastric volvulus associated with paraesophageal hiatal hernia. Two lesions of EGC were diagnosed in the distal third of the stomach, most of which had herniated into the left chest through a large hiatal defect in an organoaxial fashion. Routinely, laparoscopic-assisted distal gastrectomy (LADG) is our preferred approach for EGC, and the presence of hiatal hernia in this case did not alter our approach. Laparoscopic repair of hiatal hernia was performed successfully followed by LADG. A review of the literature supports a minimally invasive approach for both procedures and shows it to be safe, effective, and technically feasible. Further, LADG is shown to be oncologically adequate in terms of tumor margins and lymph node dissection, but its relevance to long-term disease-free survival still needs to be studied in well-designed prospective trials.

Characterization of binding between SF-1 and Sp1: predominant interaction of SF-1 with the N-terminal region of Sp1

The transcription factor specificity protein 1 (Sp1) binds to GC boxes and interacts with many transcription factors to regulate gene expression. Steroidogenic factor-1 (SF-1) is an orphan nuclear receptor and plays a major role in regulation of the human steroidogenic acute regulatory (StAR) gene. We demonstrated that there is interaction between SF-1 and Sp1 on the human StAR promoter. In the present study, we examined the mechanism of the interaction between Sp1 and SF-1 on the human StAR gene promoter. Results of glutathione S-transferase (GST) pull-down assays and a mammalian two-hybrid assay showed that SF-1 interacted with Sp1 through the N-terminal domains of Sp1. Results of electrophoretic mobility shift assays using nuclear extracts showed that Sp1 is associated with SF-1-DNA complex formation. The density of SF-1-DNA complex was much greater when recombinant Sp1 was added to the incubation mixture. These results suggest that Sp1 interacts with SF-1 and that Sp1 enhances SF-1-DNA complex formation to regulate human StAR transcription.

Expression of enzyme associated with steroid hormone synthesis and local production of steroid hormone in endometrial carcinoma cells

Endometrial carcinoma is a common malignancy of the genital tract. In the present study, we examined the expression of human steroidogenic acute regulatory (StAR) protein, P450 side-chain cleavage enzyme (P450 scc), 17alpha-hydroxylase/17,20-desmolase (P45017alpha) and aromatase (P450 arom) in endometrial carcinoma cells to clarify the ability of these cells to produce steroid hormones. The results of RT-PCR analysis showed that StAR, P450 scc and P45017alpha genes were expressed in endometrial carcinoma cells. To examine the protein expression of StAR and P450 scc, we performed Western blotting using extracts from carcinoma cells. StAR protein and P450 scc were detected in both HHUA and HOUA-1 cells. The production of pregnenolone in HHUA cells increased 2.4-fold with transfection of a StAR expression vector and 4.3-fold with transfection of an F2 side-chain cleavage system. The RT-PCR product of 3beta-hydroxysteroid dehydrogenase was present in endometrial carcinoma cells. In endometrial carcinoma cells, the production of progesterone also increased with over-expression of StAR and the F2 system. Results of steroid metabolic assays showed that endometrial carcinoma cells produced not only 17alpha-hydroxyprogesterone but also androstenedione. Endometrial carcinoma cells express enzymes that are associated with the production of steroid hormones. Locally produced steroid hormones may have effects on tumor proliferation and tumorigenesis.

Antioxidant activity and hypoglycemic effect of ferulic acid in STZ-induced diabetic mice and KK-Ay mice

Antioxidant activity and biological properties of ferulic acid (FA) are well recognized. This study was designed to estimate the potential utility of FA administered orally at low dosage for improvement of hyperglycemia in diabetes. With this aim we have evaluated the hypoglycemic effect of FA in two type diabetic animal models: (1) streptozotocin (STZ)-induced diabetic mice, a model of insulin-dependent diabetes mellitus (IDDM); (2) KK-Ay mice, a model of non-insulin dependent diabetes mellitus (NIDDM). In addition, we measured the production of thiobarbituric acid-reactive substances (TBARS) in brown adipose tissues of diabetic mice at the end of FA feeding experiment. FA at 0.01% and 0.1% of basal diet showed to suppress significantly blood glucose levels in STZ-induced diabetic mice. In KK-Ay mice 0.05% FA suppressed effectively blood glucose levels. In addition, FA inhibited the lipid peroxidation in brown adipose tissue of diabetic mice. Taken together, these findings suggest that dietary FA may be useful in alleviating oxidative stress and attenuating the hyperglycemic response associated with diabetes.

CYP1A1 polymorphism and risk of gynecological malignancy in Japan

The incidence of endometrial cancer and ovarian cancer in Japan has been increasing in recent years. Results of epidemiologic studies suggest that the onset and multiplication of these cancers are associated with estrogen. Estrogens are metabolized by cytochrome P450 1A1 (CYP1A1) and converted into catecholestrogens, which are carcinogens. CYP1A1 has several polymorphisms, the major one being T6235C transition in the non-coding 3'-flanking region (MspI polymorphism), and another being A4889G transition in exon 7 (Ile/Val polymorphism). These polymorphisms can affect the metabolites of estrogens and contribute to the susceptibility to gynecological malignancy. In this study, to determine whether CYP1A1 polymorphism plays a role in the development of gynecological malignancy in the Japanese population, we assessed the association of CYP1A1 polymorphism in Japanese patients with gynecological malignancy in comparison to that in controls. The odds ratios (ORs) of Ile/Val polymorphism were 1.16 in ovarian cancer patients and 1.70 in endometrial cancer patients. The ORs of MspI polymorphism were 1.33 in ovarian cancer patients and 0.88 in endometrial cancer patients. No significant association was found between these CYP1A1 polymorphisms and gynecological malignancy. Although the frequency of CYP1A1 polymorphism in the Japanese population is higher than that in the Caucasian population, CYP1A1 polymorphism is not related to gynecological malignancies in Japanese population.

Sentinel node detection using 99mTc-rhenium sulphide colloid in breast cancer patients: evaluation of 1 day and 2 day protocols, and a dose-finding study

Sentinel node (SN) biopsy is a promising replacement for standard axillary lymph node dissection for the staging of early breast cancer, and various techniques have been studied to identify SNs with dye or radioactive colloid. This study assesses the effect of the dose of radioactivity and the time before biopsy in order to set standards for the use of 99mTc-rhenium sulphide for the detection of SNs in breast cancer patients. Sixty patients with stage T1-2 N0 M0 breast cancer underwent SN biopsy, which was immediately followed by standard axillary dissection to confirm the SN results. For SN biopsy, 99mTc-rhenium colloid was injected peritumorally. A 1 day (morning injection and afternoon surgery) or 2 day (day before afternoon injection and morning surgery) protocol was applied. A dose-finding study was performed simultaneously using 7.4-37 MBq for the 1 day protocol and 37-74 MBq for the 2 day protocol. A scintigram was taken at 2 h for the 1 day protocol and 16 h for the 2 day protocol. After the injection of blue dye, SN biopsy was performed with a gamma probe, followed by standard axillary node dissection. The radiation exposure received by the surgical team during the operation was monitored. Histopathological comparison between SNs and axillary nodes was performed. Patient characteristics that might affect the radiocolloid uptake by SNs were assessed. SNs were identified in all patients regardless of the dose or administration protocol used. Two patients showed false negative pathological SN results, and the negative predictive value was 96% and the positive predictive value was 100%. In addition, radiation exposure to the surgical team and the amount of radioactive surgical waste were low, especially at lower doses. Two groups of patient characteristics were related to SN uptake. One was the body mass index (BMI) and the other was the age or menopausal status. Patients with a larger BMI tended to take up a smaller amount of 99mTc colloid. Older or post-menopausal patients showed lower SN uptake. 99mTc-rhenium sulphide colloid is an efficient radiopharmaceutical for SN detection. Both 1 day and 2 day protocols have equally good efficacy, and the recommended dose is 7.4 MBq for the 1 day protocol and 37 MBq for the 2 day protocol. Patients with larger BMI and older or post-menopausal patients tend to take up less 99mTc colloid.

Hyperkeratosis and leukocytosis in transgenic mice carrying MHC class I chain-related gene B (MICB)

Major histocompatibility complex (MHC) class I chain-related gene A and B (MICA and MICB) are located very close to HLA-B. MICA is reported to be strongly associated with Behçet's disease (BD), a multisysytemic inflammation disorder characterized by oral apthous ulcers, skin lesions and genital ulcers. These two molecules are highly conserved at the amino acid levels. To determine the function of MICB in vivo and the relationship between the expression of MICB and BD experimentally, we produced several transgenic mouse lines (termed CAG-MICB) expressing human MICB cDNA under a ubiquitous promoter. They exhibited a 50% increase in the number of white blood cells compared with their non-transgenic littermates, and also exhibited a 10-20% reduction in body weight compared with non-transgenic littermates. Exfoliation of the skin first appeared around 7 days after birth and disappeared after 2 weeks of age. This was repeatedly observed in the transgenic offspring of two independent CAG-MICB lines examined. Histopathological analysis of skin of young mice exhibiting skin abnormalities revealed hyperkeratosis of the epidermis and thickening of the granular layer with slight infiltration of inflammatory cells in the dermis without any vasculitis. Other remarkable abnormalities associated with BD have not been observed in the CAG-MICB lines. Furthermore, fluorescein angiography of eyes of the CAG-MICB lines was performed, but there were no marked changes of BD-related uveitis in the ocular fundus. These findings suggest that (i) MICB expression is related to temporary skin inflammation, and (ii) expression of MICB is not directly associated with BD.

CYP1A1 polymorphism and risk of gynecological malignancy in Japan

The incidence of endometrial cancer and ovarian cancer in Japan has been increasing in recent years. Results of epidemiologic studies suggest that the onset and multiplication of these cancers are associated with estrogen. Estrogens are metabolized by cytochrome P450 1A1 (CYP1A1) and converted into catecholestrogens, which are carcinogens. CYP1A1 has several polymorphisms, the major one being T6235C transition in the non-coding 3′-flanking region (MspI polymorphism), and another being A4889G transition in exon 7 (Ile/Val polymorphism). These polymorphisms can affect the metabolites of estrogens and contribute to the susceptibility to gynecological malignancy. In this study, to determine whether CYP1A1 polymorphism plays a role in the development of gynecological malignancy in the Japanese population, we assessed the association of CYP1A1 polymorphism in Japanese patients with gynecological malignancy in comparison to that in controls. The odds ratios (ORs) of Ile/Val polymorphism were 1.16 in ovarian cancer patients and 1.70 in endometrial cancer patients. The ORs of MspI polymorphism were 1.33 in ovarian cancer patients and 0.88 in endometrial cancer patients. No significant association was found between these CYP1A1 polymorphisms and gynecological malignancy. Although the frequency of CYP1A1 polymorphism in the Japanese population is higher than that in the Caucasian population, CYP1A1 polymorphism is not related to gynecological malignancies in Japanese population.

Analysis of microsatellite polymorphism around the HLA-B locus in Iranian patients with Behçet's disease

We have previously suggested that in a Japanese population the susceptible locus for Behçet's disease (BD) is HLA-B51 itself. To confirm this finding in another population, we performed HLA class I typing using the PCR-SSP method and analyzed eight polymorphic markers distributed within 1100 kb around the HLA-B gene using automated sequencer and subsequent automated fragment detection by fluorescent-based technology with the DNA samples of 84 Iranian patients with BD and 87 healthy ethnically matched controls. As a result, three microsatellite alleles (MICA-A6, MIB-348, C1-4-1-217) and HLA-B51 were found to be strongly associated with BD. Of these alleles HLA-B51 is the most strongly associated allele. There were no alleles that were increased in allele frequency at any microsatellite loci centromeric of MICA or telomeric of HLA-B51. Therefore, HLA-B51 was confirmed to be by far the most strongly associated gene with BD in an Iranian population.

Correlation of MR imaging findings and open exploration of medial patellofemoral ligament injuries in acute patellar dislocations

The purpose of this investigation was to correlate magnetic resonance (MR) images of medial patellofemoral ligament (MPFL) injuries with gross macroscopic findings. Twenty-seven knees with MPFL injury following an initial patellar dislocation were examined using axial proton-density and T2-weighted fast spin-echo MR imaging. MR findings were subsequently correlated with open exploration. MPFL injury was observed in 26 (96%) of the 27 knees. From the MR images, discontinuity, irregularity and/or high-signal intensity changes anterior to the femoral attachment were seen in 13 (82%) of the 16 knees with substantial-tear type injuries of the MPFL. In 8 (80%) of the 10 knees with avulsion-tear type injuries, detachment of the MPFL from the femoral attachment, accompanied with or without high-signal intensity changes, was confirmed. MPFL injury types could be accurately diagnosed on 21 (81%) out of 26 knees using MR imaging. MR imaging was an acceptable method in diagnosing MPFL injury types.

Efficacy of intraperitoneal and intravenous chemotherapy and left upper abdominal evisceration for advanced gastric cancer

BACKGROUND

The study was carried out to evaluate the efficacy of intraperitoneal (i.p.) and intravenous (i.v.) chemotherapy, as well as left upper abdominal evisceration (LUAE), for patients with advanced gastric cancer.

METHODS

We carried out a retrospective study of 348 patients who underwent gastrectomy for advanced gastric carcinoma between 1978 and 1998 at our institution and who had macroscopic type 3 or 4 cancer (Japanese classification) with depth of invasion to the serosal surface, but no liver metastasis or lymph node metastasis around the abdominal aorta. Cumulative survival rates were compared in patients who underwent gastrectomy together with: (1) intraoperative i.p. chemotherapy alone, (2) postoperative i.v. chemotherapy alone, (3) both i.p. and i.v., or (4) no chemotherapy. Then patients were stratified according to the presence of peritoneal dissemination (P+) and its absence (P-). In P+ patients, survival was compared between those who received i.v. chemotherapy and those who did not, and between those who received i.p. chemotherapy and those who did not. Then, survival was compared between patients with high and low immunosuppressive acidic protein (IAP) levels. Finally, we compared cumulative survival rates in patients (stratified as P+ and P-) who underwent LUAE with cumulative survival rates in those who underwent total gastrectomy combined with resection of the pancreatic body, tail, and spleen (PS).

RESULTS

For P- patients, there was no survival advantage with adjuvant i.p. or i.v. therapy when compared with surgery alone. For P+ patients, however, there was an improvement in survival when patients received both i.p. and i.v., compared with survival with surgery alone (P < 0.05). In P+ patients aged less than 60 years, there was improvement in survival for those who underwent i.p. therapy together with surgery (P < 0.05), but not for those who had i.v. chemotherapy after surgery. When LUAE was examined, there was a survival advantage for this procedure when there was no peritoneal dissemination. Four long-term survivors (surviving for more than 5 years) were identified in our study. Three of the 4 patients were aged less than 60 years, and all 4 had macroscopic type 4 gastric cancers.

CONCLUSION

Although the prognosis for patients with invasive type gastric cancer remains poor, there have been a few long-term survivors, in whom this survival was associated with aggressive combination therapy, including surgery, i.p., and i.v. therapy. P+ patients aged less than 60 years and patients with type 4 gastric cancer may stand to benefit most from such therapy. For P- patients, the role of adjuvant i.p. or i.v. therapy continues to be ambiguous, although LUAE in this population may be superior to PS.

Synthesis and conformational property of tannin-like p-tert-butylcalix[4]arene 1,3-diesters stabilized by intramolecular hydrogen bonds

Tannin-like p-tert-butylcalix[4]arene 1,3-digallate was synthesized, and its conformational property was investigated by dynamic (1)H NMR and X-ray crystallography. It was found that the 3-OH (or 5-OH) group of the galloyl group in p-tert-butylcalix[4]arene 1,3-digallate is placed at the position where an unusual nonbonded close contact is observed between the OH group and the aromatic ring of the galloyl group facing each other. The calixarene 1,3-diesters of various hydroxybenzoic acids were also prepared, and the conformational properties of those calixarenes were compared with that of p-tert-butylcalix[4]arene 1,3-digallate. A significant contribution of the 3- and 5-OH groups in pendant groups toward the close contact was found. It was suggested that the conformation of p-tert-butylcalix[4]arene 1,3-digallate was stabilized by intramolecular hydrogen bonds including OH.O and OH-pi interactions.