Empiric antimicrobial therapy in the intensive care unit based on the risk of multidrug-resistant bacterial infection: a single-centre case‒control study of blood culture results in Japan

BACKGROUND

Infections and sepsis are the leading causes of death in intensive care units (ICUs). Antimicrobial agent selection is challenging because the intervention is directly related to the outcome, and the problem of antimicrobial resistance (AMR) must be considered. Therefore, in this study, we aimed to clarify the epidemiological data and examine whether the detection rate of multidrug-resistant (MDR) bacteria differed depending on the presence or absence of the risk of MDR bacterial infections to establish guidance regarding the choice of antimicrobial therapy for ICU patients.

METHODS

This retrospective case‒control study was performed in a single ICU in Japan. Patients admitted to the ICU who underwent blood culture (BC) analysis were considered for inclusion in this study; patients were at risk of MDR bacterial infections, and controls were not. The primary outcome measure was the detection rate of MDR bacteria in BCs collected from patients and controls. The secondary outcome measure was the selection rate of anti-Pseudomonas and anti-methicillin-resistant Staphylococcus aureus (MRSA) drugs for patients and controls.

RESULTS

Among the 1,730 patients admitted to the ICU during the study period, BCs were obtained from 186 patients, and 173 samples were finally included in the analysis (n = 129 cases; n = 44 controls). No MDR bacteria or Pseudomonas aeruginosa were detected in the controls (14 (11%) vs. 0 (0%)) (P = 0.014) However, there was no difference in empiric antimicrobials, including anti-MRSA (30 (23%) vs. 12 (27%)) (P = 0.592) and anti-Pseudomonas aeruginosa (61 (47%) vs. 16 (36%)) (P = 0.208) drugs, that were administered to the two groups.

CONCLUSIONS

Even in critically ill patients in the ICU, MDR bacteria are unlikely to be detected in patients without the risk of MDR bacterial infections. Therefore, for such patients, a strategy of starting empiric narrow-spectrum antimicrobial therapy rather than empiric broad-spectrum therapy should be considered. This strategy, in conjunction with daily updates of clinical and epidemiological data at each facility, will promote the appropriate use of antimicrobials and reduce the emergence of MDR bacteria in the ICU.

TRIAL REGISTRATION

None.

Effect of Arginine Vasopressin on Intraoperative Hypotension Caused by Oral Administration of 5-Aminolevulinic Acid

5-Aminolevulinic acid (5-ALA) is used for the photodynamic diagnosis of malignant tumors and has been effectively utilized to improve the complete resection rate and reduce the risk of tumor recurrence. However, intraoperative hypotension is a common adverse effect of oral 5-ALA, and it occasionally progresses to severe prolonged hypotension requiring high-dose catecholamine administration. We report a case of intraoperative hypotension due to oral 5-ALA in which arginine vasopressin (AVP) administration was effective for increasing the blood pressure. A 77-year-old man scheduled for a craniotomy for glioma was administered 5-ALA orally before surgery. After the induction of anesthesia, his blood pressure decreased substantially. Although we administered various vasopressor agents, hypotension was prolonged. However, after starting a continuous administration of AVP, the systolic blood pressure increased, and the hemodynamic parameters remained stable during the remainder of the operation. 5-ALA administration may lower blood pressure by inducing nitric oxide production, and AVP inhibits inducible nitric oxide synthase messenger RNA expression and interleukin-1β-stimulated nitric oxide production. In light of these mechanisms, AVP may be a reasonable treatment agent for hypotension induced by 5-ALA.

An infantile traumatic brain injury with a bright tree appearance detected before the late seizure

INDRODUCTION

Infantile traumatic brain injury (TBI) rarely follows a biphasic clinical course and exhibits a bright tree appearance (BTA) on magnetic resonance imaging (MRI). This is termed infantile traumatic brain injury with a biphasic clinical course and late reduced diffusion (TBIRD). TBIRD has clinical features similar to those of acute encephalopathy with biphasic seizures and late reduced diffusion (AESD). It remains to be clarified which patients with infantile TBI will develop TBIRD and the prevention and treatment of TBIRD.

CASE AND REVIEW

We report a case of TBIRD that exhibited BTA 1 day before the late seizure and review 12 cases of TBIRD. All patients developed a subdural hematoma (SDH), were younger than 2 years, and presented with a biphasic phase within 3-6 days. The median interval between BTA and TBI was 5 days. Of the 5 cases examined with MRI before the biphasic phase, only our case was detected with BTA 4 days after TBI.

CONCLUSION

Predicting the biphasic clinical course may be possible by examining MRI after TBI in patients under 2 years of age who develop SDH with unconsciousness, seizure, or hemiplegia, and these patients should be strictly followed up for 1 week.

Lead-free MCP to improve coincidence time resolution and reduce MCP direct interactions

Achieving direct imaging of the annihilation position of a positron on an event-by-event basis using an ultrafast detector would have a great impact on the field of nuclear medicine. Cherenkov emission is the most attractive physical phenomenon for realizing such an ultrafast timing performance. Moreover, a microchannel-plate photomultiplier tube (MCP-PMT) is one of the most promising photodetectors for fully exploiting the fast timing properties of Cherenkov emission owing to its excellent single photon time resolution of 25 ps full width at half maximum (FWHM). However, as the MCP structure generally contains a lead compound, the gamma rays frequently and directly interact with the MCP, resulting in the degradation of its timing performance and generation of undesirable side peaks in its coincidence timing histogram. To overcome this problem, we have developed a new MCP-PMT based on an MCP consisting of borosilicate glass, thus drastically reducing the probability of the photoelectric effect occurring in the MCP. To evaluate its insensitivity to gamma rays and its timing performance, a coincidence experiment was performed and showed that the probability of direct interactions was reduced by a factor of 3.4. Moreover, a coincidence time resolution of 35.4 ± 0.4 ps FWHM, which is equivalent to a position resolution of 5.31 mm, was obtained without any pulse height/area cut, improving to 28.7 ± 3.0 ps when selecting on the highest amplitude events by careful optimization of the voltage divider circuit of the new MCP-PMT. The timing performance of this new MCP-PMT presents an important step toward making direct imaging possible.

Additional medical costs associated with ventilator-associated pneumonia in an intensive care unit in Japan

BACKGROUND

Additional health care costs associated with ventilator-associated pneumonia (VAP) vary widely per country; none of which have been explored in Japan. Thus, we aimed to examine the economic and clinical effects of VAP in Japan.

METHODS

This was a retrospective matched case-control study of 22 patients with VAP who were treated in the intensive care unit of Yokohama Rosai Hospital between January 2012 and December 2018. Twenty-two matched controls were selected based on 5 variables (ie, sex, age, diagnosis and surgical procedure, underlying disease with or without advanced malignant tumor, and best motor response). The additional health care costs incurred owing to VAP were calculated from the difference between the mean costs of VAP and control cases.

RESULTS

VAP incurred an additional cost of approximately United States Dollars (USD) 34,884 per case. The length of hospitalization itself was the major factor contributing to additional medical costs, generating a difference of 9,824 USD.

DISCUSSION

VAP not only worsens patient outcomes but also generates significant additional medical costs. Patients who had developed VAP required more medical resources such as the performance of a tracheostomy.

CONCLUSIONS

VAP incurs a higher mean total hospital medical cost. Thus, appropriate infection control strategies should be implemented.

A case of complete atrioventricular block in secondary hemophagocytic syndrome/hemophagocytic lymphohistiocytosis recovered by plasma exchange and cytokine absorbing therapy with AN69ST continuous hemodiafiltration

We report a case of incipient systemic lupus erythematosus (SLE) that rapidly progressed to complete atrioventricular block (cAVB). A 20-year-old man was admitted with facial erythema, painless oral aphtha, polyarthritis, and myalgia of each extremity. On admission, he developed first-degree atrioventricular block, pericarditis, pleuritis, renal failure, hemophagocytic lymphohistiocytosis, neurophychiatric SLE (left cerebellar infarction), and Staphylococcus aureus bacteremia. He was subsequently diagnosed with SLE based on several positive findings on immunological tests (including positive for antinuclear antibody). Despite immediate glucocorticoid pulse therapy and plasma exchange (PE) along with antibiotic, he developed cAVB that required temporary pacing on day 2. Because it was thought that hypercytokinemia exacerbated pericarditis, which progressed to myocarditis and cAVB, we decided to PE and cytokine-adsorbing therapy with AN69ST-continuous hemodiafiltration (CHDF). Other than renal failure, his organ dysfunctions improved with the multidisciplinary therapy. CAVB improved and temporary pacing was no longer required on day 11. Even a first-degree atrioventricular block can rapidly progress to cAVB; therefore, strict attention to electrocardiogram is necessary in severe SLE cases. When presenting with organ dysfunctions caused by hypercytokinemia such as severe SLE cases or SLE with severe infection cases, use of the combination of PE and AN69ST-CHDF might be beneficial.

Simple Cleanup Procedure for Analysis of Buprofezin Residues and Its Metabolite in Crops by Gas Chromatography

An analytical method for determining residues of buprofezin (2-tert-butylimino-3-isopropyl-5-phenylperhydro- 1,3,5-thiadiazin-4-one) and its p-hydroxy metabolite (p-hydroxybuprofezin, one of its major metabolites in plants) in crops such as rice, citrus, and tomato was investigated. On the basis of the basicity of these compounds, a liquid–liquid partition, rather than column chromatography, was used for cleanup. Samples were extracted with acetone or methanol, and the concentrated extracts were partitioned between n-hexane and 1N HCI. After the aqueous layer was neutralized with 10N NaOH, the compounds were extracted with n-hexane, and the extract was analyzed with a gas-liquid chromatograph (GLC) equipped with an alkali flame ionization detector (AFID). p-Hydroxy- buprofezin was detected after acetylation with acetic anhydride–pyridine because its peak was broad and showed tailing on GLC. The limits of detection for buprofezin and p-hydroxybuprofezin were 0.005 ppm in hulled rice, citrus flesh, and tomato and 0.01 ppm in rice straw and citrus peel. Recoveries of both compounds fortified at 0.1 or 0.2 ppm were 75–97%.

Ventilatory and behavioural responses of the marbled sole Pseudopleuronectes yokohamae to progressive hypoxia

This study identified ventilatory and behavioural responses in the marbled sole Pseudopleuronectes yokohamae under experimentally induced progressive decreases in dissolved oxygen (DO) levels. Ventilation frequency showed an increase with decreasing DO levels from normoxia to 2·75 mg O₂  l^-1 , followed by a decrease in ventilation frequency at decreased DO levels from 2·00 to 0·75 mg O₂ l^-1 . At DO levels below 2·00 mg l^-1 , behaviours at the bottom were suppressed, whereas avoidance behaviours increased. A decrease in avoidance behaviours was observed from 1·00 to 0·75 mg O₂ l^-1 . Upside-down reversal and incapacitation at DO levels of 1·00-0·75 mg O₂ l^-1 suggested that sublethal effects on P. yokohamae were induced. The responses observed before the sublethal DO level could be interpreted as an effort to maintain oxygen uptake, reduce routine activities and facilitate avoidance. The observed DO level thresholds that induce behavioural responses, in addition to sublethal effects, indicate hypoxia-tolerance that is important for understanding the effects of hypoxia on coastal ecosystems.

Contribution of fetal ANXA5 gene promoter polymorphisms to the onset of pre-eclampsia

OBJECTIVE

A common haplotype M2 consisting of minor SNP alleles located in the ANXA5 gene promoter region has been described as a risk factor for various obstetric complications such as recurrent pregnancy loss, pre-eclampsia and pregnancy-related thrombophilic disorder. However, the question of whether it is the maternal or fetal genotype that contributes to the onset of these disorders remains to be resolved.

METHODS

We analyzed ANXA5 gene variants in the blood and placental tissues from pre-eclampsia patients and normotensive controls. ANXA5 expression was examined by qRT-PCR, Western blotting and immunostaining. Results were compared between M2 and non-M2 carriers.

RESULTS

The M2 haplotype was found to be significantly frequent in placentas from pre-eclamptic patients relative to the controls (25.5% versus 10%, P = 0.044), In contrast, no significant differences were observed in maternal blood (13.0% versus 11.3%, P = 0.597). The placental expression of ANXA5 mRNA was found to be lower in M2 carriers. When examined by Western blot and immunostaining, the ANXA5 protein levels were found to be affected more by the placental than the maternal genotype. Histological examination of the placentas from the pre-eclamptic patients demonstrated that a placental M2 haplotype correlated more closely than maternal M2 with the severity of perivillous fibrin deposition.

CONCLUSIONS

Although preliminary, these results suggest that hypomorphic M2 alleles in the in placental ANXA5 promoter, whether transmitted maternally or paternally, might be an essential determinant of an increased risk of pre-eclampsia via local thrombophilia at the feto-maternal interface.

Upregulation of HtrA4 in the placentas of patients with severe pre-eclampsia

High temperature requirement A (HtrA) family proteins are serine proteases that may serve in the quality control of misfolded or mislocalized proteins. Recently, possible involvements of HtrA1 in the normal development of the placenta and in the pathogenesis of pre-eclampsia were reported. In this study, we characterized HtrA4, a previously uncharacterized HtrA protein family member, in pre-eclampsia. Elevated expression levels of placental HtrA4 in pre-eclampsia patients were observed by qRT-PCR. Western blotting also showed an increased production of HtrA4 at the protein level in pre-eclamptic placentas. In normal chorionic villi, HtrA4 protein was more abundant in the cytoplasm of cytotrophoblasts than in syncytiotrophoblasts. In contrast, the amount of HtrA4 protein in syncytiotrophoblasts was dramatically increased in pre-eclamptic placentas. Circulating HtrA4 was detected at higher levels in sera from women with pre-eclampsia than from those with normotensive pregnancies. Serum HtrA4 levels were higher in patients with early onset and inversely correlated with the weights of the newborn and placenta. Furthermore, serum levels correlated with serum PAPP-A and PAPP-A2 levels, indicating a functional role for HtrA4 in the common pathway. These data suggest that increased HtrA4 may be involved in the onset of pre-eclampsia, and elevated levels in sera imply a potential application as a biomarker for this disorder.

Cardiogenic shock due to takotsubo cardiomyopathy associated with serotonin syndrome

A 65-year-old woman, with valvular heart disease, atrial fibrillation, and depression, presented to the emergency room due to dyspnea with shock state accompanied by agitation. An electrocardiogram showed ST segment elevation in leads II, III, aV_F, I, aV_L, and V_4-6. An echocardiography revealed extensive akinesis in the apex, but hyperkinesis in the base, with apical ballooning appearance. An emergent coronary angiography showed no obstructive disease. The patient required intubation under mechanical ventilator, and an intra-aortic balloon pump to recover from shock state. She had been taking maprotiline, a tetracyclic antidepressant, and had added dextromethorphan, a cough suppressant, just before admission. The patient was diagnosed with takotsubo cardiomyopathy associated with serotonin syndrome due to serotonergic drug interactions. After discontinuation of these drugs and administration of serotonin antagonist under mechanical supportive care, she became hemodynamically stable. Apical ballooning was completely resolved 2 weeks later, and she was discharged well. We diagnosed serotonin syndrome manifesting as excessive serotonin toxicity that resulted in a hyperserotonergic and hyperadrenergic state, causing takotsubo cardiomyopathy. Here, we report a case of takotsubo cardiomyopathy associated with serotonin syndrome. This case suggests that serotonin syndrome should be recognized promptly and complications, including takotsubo cardiomyopathy, need to be treated appropriately. <Learning objective: We must closely monitor serotonergic agents because serotonin syndrome can occur from a combination some serotonergic drugs, even when each is used at a therapeutic dose. Serotonin syndrome can lead to not only serotonergic but also hyperadrenergic state that may be a trigger of takotsubo cardiomyopathy. Serotonin syndrome should be diagnosed surely to ensure the prompt initiation of the treatment included discontinuation of the precipitating drugs because the disease occasionally progresses rapidly to fatal condition.>.

A rare synaptonemal complex protein 3 gene variant in unexplained female infertility

Synaptonemal complex protein 3 (SYCP3) plays a critical role in homologous chromosome pairing and recombination in meiosis, and mice deficient in this gene show infertility in males and subfertility in females. The aim of our current study was to determine whether genetic alterations in the SYCP3 gene are associated with female infertility in humans. We examined sequence variations of the SYCP3 gene in genomic DNA from 88 Japanese women with unexplained infertility and 165 samples obtained from a fertile control group. Case-control study using seven tagging single nucleotide polymorphisms revealed no significant association between common SYCP3 variants and unexplained infertility. However, only infertile women were homozygous for the minor allele of a novel rare variant in the coding region, c.666A>G (222Q>Q). The minor allele frequency was significantly higher in the infertile cohort (P< 0.05). This variant is predicted to create a cryptic splice site, although the expression of a mini-gene harboring the variant in HeLa cells or mouse testis did not demonstrate any effects on gene splicing. Our current findings therefore suggest that the c.666A>G variant in the SYCP3 gene might possibly contribute to female infertility in humans, although larger studies are needed to assess the possible effects of SYCP3 gene variation on human female infertility.

Insulin-mediated regulation of decidual protein induced by progesterone (DEPP) in adipose tissue and liver

We analyzed the profile of the genes expressed in human adipose tissue and identified the fat-derived molecules, adiponectin and aquaporin 7, which modulate glucose and lipid metabolism. The same Bodymap analysis revealed abundant expression of the decidual protein induced by progesterone (DEPP) in the white adipose tissue. Northern blot analysis confirmed that human DEPP mRNA was highly expressed in white adipose tissue. Mouse DEPP mRNA was detected in heart, lung, skeletal muscle, and white adipose tissue under feeding state. In contrast, under fasting state, mouse DEPP mRNA was enhanced in lung, skeletal muscle, and white adipose tissue and it appeared also in the liver and kidney, suggesting up regulation of DEPP by fasting. Because fasting-induced DEPP expression was observed in insulin-sensitive organs, we investigated the regulation of DEPP in white adipose tissue and liver. During adipogenesis of mouse 3T3-L1 cells, DEPP mRNA increased in a differentiation-dependent manner similar to adiponectin and aquaporin 7. Treatment of cultured 3T3-L1 mature adipocytes, rat H4IIE, and human HepG2 hepatoma cells with insulin significantly decreased DEPP mRNA levels in dose- and time-dependent manners. IN VIVO experiments showed significant decrease of hepatic and adipose DEPP mRNA levels in refed mice, compared to fasted animals, and also showed significant increase in DEPP mRNA in streptozotocin-induced insulin-deficient diabetic mice. These results indicate that DEPP is a novel insulin-regulatory molecule expressed abundantly in insulin-sensitive tissues including white adipose tissue and liver.

Overproduction of the follistatin-related gene protein in the placenta and maternal serum of women with pre-eclampsia

OBJECTIVE

To characterise the follistatin-related gene (FLRG) in pre-eclampsia, one of the differentially expressed genes in pre-eclamptic placenta.

DESIGN AND METHODS

We examined and compared the messenger RNA (mRNA) and protein levels of FLRG in placentas and maternal sera from women with uncomplicated pregnancy, and those with pre-eclampsia using real-time reverse transcription polymerase chain reaction, Western blot, immunohistochemistry, and enzyme-linked immunosorbent assay.

SETTING

Antenatal clinics in a teaching hospital.

POPULATION

Women with uncomplicated pregnancy (n = 21) and those with pre-eclampsia (n = 21).

RESULTS

FLRG mRNA is overexpressed in pre-eclamptic placental tissues (P < 0.01). Upregulated FLRG protein consists of both an immature 28-kDa cellular product and a mature 33-kDa secretory form, which are differentially glycosylated. FLRG is normally produced at its highest levels in endothelial cells and at moderate amounts in syncytiotrophoblast cells, but in pre-eclampsia, the syncytiotrophoblast FLRG levels are dramatically increased. We also determined the maternal serum concentrations of FLRG in our uncomplicated pregnancy subjects and in our pre-eclamptic groups, and found that they are significantly elevated in pre-eclampsia in a similar manner to activin A and inhibin A. However, the increase in FLRG in these cases is independent of activin A or inhibin A, and is associated with low-birthweight outcomes.

CONCLUSION

Our current data show the placental and secretory changes of FLRG protein in pre-eclampsia, and also indicate the potential usefulness of FLRG as an additional diagnostic marker for pre-eclampsia.

Blockade of Angiotensin II type-1 receptor reduces oxidative stress in adipose tissue and ameliorates adipocytokine dysregulation

Dysregulated production of adipocytokines may be involved in the development of atherosclerotic cardiovascular disease in metabolic syndrome and chronic kidney disease (CKD) associated with metabolic syndrome. The aim of this study was to determine the effects of treatment with angiotensin II (Ang II) type-1 receptor blocker (ARB) on the regulation of adipocytokines. Olmesartan, an ARB, significantly blunted the age- and body weight-associated falls in plasma adiponectin both in genetically and diet-induced obese mice, without affecting body weight, but had no effect on plasma adiponectin levels in lean mice. Olmesartan also ameliorated dysregulation of adipocytokines in obesity, such as tumor necrosis factor-alpha, plasminogen activator inhibitor-1, monocyte chemotactic protein-1, and serum amyloid A3. Olmesartan significantly reduced reactive oxygen species originating from accumulated fat and attenuated the expression of nicotinamide adenine dinucleotide phospho hydrogenase oxidase subunits in adipose tissue. In cultured adipocytes, olmesartan acted as an antioxidant and improved adipocytokine dysregulation. Our results indicate that blockade of Ang II receptor ameliorates adipocytokine dysregulation and that such action is mediated, at least in part, by targeting oxidative stress in obese adipose tissue. Ang II signaling and subsequent oxidative stress in adipose tissue may be potential targets for the prevention of atherosclerotic cardiovascular disease in metabolic syndrome and also in metabolic syndrome-based CKD.

Microarray analysis of differentially expressed fetal genes in placental tissue derived from early and late onset severe pre-eclampsia

Although it has been well documented that pre-eclampsia is caused by a combination of maternal and fetal susceptibility genes, little is known about the precise etiology of this complicated disorder. To investigate how the expression of fetal genes contributes to the mechanisms underlying the progression of this disease, we have analyzed differentially expressed genes using placentas from 13 normal pregnancies and 14 pregnancies with severe pre-eclampsia. We performed genome-wide expression profiling using high-density oligonucleotide microarrays, followed by validation using real-time PCR. Among the 47,000 genes that were screened in the microarray, 137 genes were found to be differentially expressed between normal and pre-eclamptic tissues. Among these candidates, 70 were up-regulated and 67 were down-regulated. The up-regulated genes included leptin and inhibin A, which are well-known biological markers for pre-eclampsia, as well as FLT1, which was recently proved to be tightly linked with the etiology of this disease. Gene ontology analysis further revealed several biological processes that could be associated with the development of pre-eclampsia, including response to stress, host-pathogen interactions, lipid metabolism, and carbohydrate metabolism. Analyses of biological mechanisms highlighted some important pathways that may be involved in this disorder, such as the TGF-beta and CEBPA-related pathways. Furthermore, when our present subjects were classified as either severe cases of early onset or late onset pre-eclampsia, the expression of 11 genes could be correlated with the severity of this disorder. These genes may therefore prove to be novel biological markers by which the severity of this condition could be predicted. Our data are likely to be a useful future resource in the elucidation of the disease-process and in the identification of novel markers for pre-eclampsia.

[Staged operation of off-pump coronary artery bypass grafting using aortic connector system, and concomitant surgery for abdominal aortic aneurysm and gastric cancer; report of a case]

Recently the patient of the atherosclerotic disease associated with malignant disease has been increased. A 75-year-old man was referred to our section with an infrarenal abdominal aortic aneurysm (AAA) and a gastric cancer (GC). Preoperative coronary angiogram revealed the significant stenoses of the right coronary and the left anterior descending coronary artery. We selected the staged operation of off-pump coronary artery bypass grafting (CABG) [OPCAB] and the concomitant surgery for the AAA and the GC. Operative invasion could decrease with the surgical procedure of the OPCAB and the concomitant surgery compared to the conventional CABG or the separate operation. We used the aortic connector system during OPCAB to prevent such the serious complications of the aortic dissection or the systemic embolism due to the calcified ascending aorta.

[The ischemic mitral valve regurgitation due to acute coronary thromboembolism; report of a case]

A 71-year-old man with congestive heart failure due to acute myocardial infarction was referred to our hospital. He was under the support of mechanical ventilation and the intraaortic balloon pumping (IABP) and coronary angiogram revealed the thromboembolism of the obtuse marginal artery. We completed the revascularization by the direct percutaneous coronary intervention. However, grade II mitral valve regurgitation and heart failure were worsening. Mitral valvuloplasty and the modified maze procedure through the partial lower sternotomy were performed. He is still in good condition 4 years later. Ischemic mitral valve regurgitation due to the coronary thromboembolism is very rare. Careful follow-up on the grade of ischemic mitral valve regurgitation is necessary even after the early coronary recanalization. The surgical approach of the partial sternotomy should be used in such a case of acute mitral valve regurgitation.

Clinical results of aortic arch replacement using a four branched prosthetic graft

AIM

The aim of this study was to evaluate the operative techniques of total arch replacement, the clinical results and the survival curves of patients following this procedure.

METHODS

Since December 2001, 92 patients have undergone surgical treatment for aortic dissection and aneurysm. The total aortic arch replacement was performed in 24 of these patients. There were 16 men and 8 women, and the age range was 42 to 81 years with a mean age of 59.4 years. As the operative technique for total arch replacement, we used the 4-branched prosthetic graft, selective cerebral perfusion (SCP), continuous cold blood cardioplegia (CCBC), and open distal anastomosis under circulatory arrest. The combined operations were coronary bypass grafting in 4 patients, aortic valve suspension in 1 patient and a Bentairs procedure in 1 patient. Eleven (73.3%) patients with acute dissection required emergency operation.

RESULTS

The hospital mortality rate was 25% (6 of the 24 patients). The causes of death were multiple organ failure (MOF) due to renal and mesenteric ischemia in 3 patients, cerebral infarction in 2 patients, myonephropathic metabolic syndrome (MNMS) in 1 patient, respectively. The data concerning extracorporeal circulation was 204+/-53 min in total pump time, 136+/-43 min in aortic cross clamp time, 83+/-14 min in SCP time and 48+/-10 min in circulatory arrest time, respectively. The long-term result in actuarial survival rate was 76% for 5 years.

CONCLUSION

We consider the technique of total arch replacement using 4-branched prosthetic graft, SCP, CCBC, and open distal anastomosis is a useful operative method in patients with aortic aneurysm.

Relationship between the classification of vascular invasion severity and the prognosis of uterine endometrial cancer

The objective of this research is whether the classification of vascular invasion severity can be used as a prognostic factor in cases of uterine endometrial cancer. Sixty-five patients with stage I to III uterine endometrial cancer were included in the study. All patients were seen between 1987 and 1997, and the types of their cancers were histologically confirmed. The degree of vascular invasion was classified according to three different systems: (1). positive or negative; (2). negative, mild, or severe; and (3). negative, mild, moderate, or severe. For each classification, the disease-free survival rate was calculated according to various pathologic factors using the Wilcoxon test; multivariate analyses were performed using the Cox proportional hazard model. Patients with severe vascular invasion showed a significantly lower disease-free survival rate than did patients with moderate or less severe invasion. In the multivariate analysis, severe vascular invasion was shown to be an independent prognostic factor indicating a high relative risk. We conclude that the severity of vascular invasion is an important histopathologic factor in determining the prognosis of uterine endometrial cancer. Vascular invasion classification systems employing three subjective or four objective categories may be more appropriate than a positive/negative classification system for judging the prognosis in cases of uterine endometrial cancer.

Relationship between the classification of vascular invasion severity and the prognosis of uterine endometrial cancer

The objective of this research is whether the classification of vascular invasion severity can be used as a prognostic factor in cases of uterine endometrial cancer. Sixty-five patients with stage I to III uterine endometrial cancer were included in the study. All patients were seen between 1987 and 1997, and the types of their cancers were histologically confirmed. The degree of vascular invasion was classified according to three different systems: (1) positive or negative; (2) negative, mild, or severe; and (3) negative, mild, moderate, or severe. For each classification, the disease-free survival rate was calculated according to various pathologic factors using the Wilcoxon test; multivariate analyses were performed using the Cox proportional hazard model.

Patients with severe vascular invasion showed a significantly lower disease-free survival rate than did patients with moderate or less severe invasion. In the multivariate analysis, severe vascular invasion was shown to be an independent prognostic factor indicating a high relative risk. We conclude that the severity of vascular invasion is an important histopathologic factor in determining the prognosis of uterine endometrial cancer. Vascular invasion classification systems employing three subjective or four objective categories may be more appropriate than a positive/negative classification system for judging the prognosis in cases of uterine endometrial cancer.

Development of a gamma ray monitor using a CdZnTe semiconductor detector

The aim of this study was to develop a new X ray and gamma ray monitor using the CdZnTe semiconductor detector, which has high sensitivity at room temperature. The pulse height spectra and the detection efficiencies of a 10 mm x 10 mm by 2 mm thick CdZnTe detector were measured in the energy range of 10 keV to 1.8 MeV by using monoenergetic X ray and gamma ray sources. The measured results showed very good agreement with the results calculated using the EGS4 Monte Carlo code taking into account the charge collection efficiency in the detector. By using two CZT detectors of 10 mm x 10 mm x 2 mm and 3 mm x 3 mm x 2 mm coupled with a filter, the weighted sum of a few energy channels with different cut-off energies was finally found to achieve a flat energy response with an equivalent dose (counts per microSv) within +/-30% or +/- 10% deviation.

Enhancement of the aquaporin adipose gene expression by a peroxisome proliferator-activated receptor gamma

The current study demonstrates that aquaporin adipose (AQPap), an adipose-specific glycerol channel (Kishida, K., Kuriyama, H., Funahashi, T., Shimomura, I., Kihara, S., Ouchi, N., Nishida, M., Nishizawa, H., Matsuda, M., Takahashi, M., Hotta, K., Nakamura, T., Yamashita, S., Tochino, Y., and Matsuzawa, Y. (2000) J. Biol. Chem. 275, 20896-20902), is a target gene of peroxisome proliferator-activated receptor (PPAR) gamma. The AQPap mRNA amounts increased following the induction of PPARgamma in the differentiation of 3T3-L1 adipocytes. The AQPap mRNA in the adipose tissue increased when mice were treated with pioglitazone (PGZ), a synthetic PPARgamma ligand, and decreased in PPARgamma(+/-) heterozygous knockout mice. In 3T3-L1 adipocytes, PGZ augmented the AQPap mRNA expression and its promoter activity. Serial deletion of the promoter revealed the putative peroxisome proliferator-activated receptor response element (PPRE) at -93/-77. In 3T3-L1 preadipocytes, the expression of PPARgamma by transfection and PGZ activated the luciferase activity of the promoter containing the PPRE, whereas the PPRE-deleted mutant was not affected. The gel mobility shift assay showed the direct binding of PPARgamma-retinoid X receptor alpha complex to the PPRE. DeltaPPARgamma, which we generated as the dominant negative PPARgamma lacking the activation function-2 domain, suppressed the promoter activity in 3T3-L1 cells, dose-dependently. We conclude that AQPap is a novel adipose-specific target gene of PPARgamma through the binding of PPARgamma-retinoid X receptor complex to the PPRE region in its promoter.

Visceral fat is a major contributor for multiple risk factor clustering in Japanese men with impaired glucose tolerance

OBJECTIVE

The significance of abdominal visceral fat accumulation was evaluated in Japanese men with impaired glucose tolerance (IGT).

RESEARCH DESIGN AND METHODS

The IGT subjects (n = 123) were aged 55 +/- 9 years with a BMI of 24 +/- 3 kg/m(2). The 148 control subjects with normal glucose tolerance (NGT) were matched for age and BMI. IGT and NGT were classified according to the 1985 World Health Organization criteria. Abdominal fat distribution was analyzed by computed tomography at umbilical level. Plasma lipid, glucose, and insulin concentrations and blood pressure (BP) were measured.

RESULTS

In subjects with IGT, the average visceral fat area (VFA) was significantly greater than in subjects with NGT. Fasting insulin, the sum of insulin concentrations during an oral glucose tolerance test, insulin resistance according to a homeostasis model assessment for insulin resistance (HOMA-IR), systolic BP, and serum triglyceride were significantly higher, whereas the DeltaI(30-0)/DeltaG(30-0) was significantly lower, in subjects with IGT. Subjects with IGT and NGT were then divided into three subgroups according to the number of risk factors they possessed (dyslipidemia, hypertension, neither, or both). In both IGT and NGT subjects, BMI, VFA, subcutaneous fat area, fasting insulin, HOMA-IR, and insulin secretion of the homeostasis model assessment were significantly higher in the double-risk factor subgroup than in the no-risk factor subgroup, and VFA was a potent and independent variable in association with the presence of a double risk factor.

CONCLUSIONS

Visceral fat accumulation is a major contributor for multiple risk factor clustering in Japanese men with IGT and NGT.

Pinonaldehyde and some other organics in rain and snow in central Japan

Solvent-extractable organic compounds in the rain and snow collected at local cities in the mountainous region in central Japan, were analyzed by GC/MS and GC. Pinonaldehyde (2,2-dimethyl-3-acetyl-cyclobutyl-ethanal), an atmospheric reaction product of alpha-pinene, was detected in the rain and snow for the first time, and n-alkanes (C17-C33), fatty acids (C8-C23), and benzoic acid were also detected as major organic components. Concentrations of pinonaldehyde, C17-C33 n-alkanes, C8-C11 fatty acids, C12-C23 fatty acids and benzoic acid ranged between <0.02-13, 0.10-35, 0.55-5.7, 4.2-19 and <0.02-6.0 microg/l, respectively. Their composition showed some difference in summer and winter. In summer, fatty acids and benzoic acid were more abundant, while pinonaldehyde and n-alkanes were much less. Higher photochemical reactivity and higher bioactivity in summer could explain these seasonal changes except for pinonaldehyde, which would suffer from further oxidation in the atmosphere after its photochemical production from alpha-pinene. Predominance of pinonaldehyde and C12-C23 fatty acids in the rain and snow showed a remarkable contrast to n-alkanes in aerosol phase, which were the most abundant components. It indicated that oxygenated products from biogenic compounds might be important as cloud condensation nuclei in forest areas.

Recovery of an impalement and transfixion chest injury by a reinforced steel bar

A 36-year-old man was admitted to our hospital because of impalement injury due to a downwards fall upon some reinforced steel rods. An emergency operation was performed using percutaneous cardiopulmonary support (PCPS). The steel rods were taken out in the operating room. The heart, great vessels, vertebrae, and spinal cord were not involved in the impalement wounds. We performed a bronchoplasty of the torn and separated right main bronchus, and repaired the impaled left lung without any pulmonary resection. He recuperated without sequelae.

Coronary artery bypass grafting in octogenarians

Preoperative profiles, postoperative complications, and the early and late results in 32 patients 80 yrs. of age and older (elderly group) who underwent coronary artery bypass grafting were compared with those in patients under 80 yrs. of age (control group). In the elderly group, the prevalence of patients with preoperative creatinine clearance (Ccr.) <50 l/day (34.4%), unstable angina pectoris (78.1%) and left main trunk disease (40.1%) was significantly higher than those in the control group. The incidences of arrhythmia and intensive care unit(ICU) syndrome were also significantly higher in the elderly group than in the control group, however, there was no death due to these complications. In the elderly group, one patient (3.1%) died in the hospital due to low cardiac output syndrome (LOS), while three patients (2.4%) of the control group died in the hospital. As for the long-term results, the 5-yr. survival rates for the elderly group and the control group were 82.6% and 85.2%, respectively, and the effectiveness of surgery was remarkable, with improved postoperative activity in 96.9% of the elderly group. These findings indicate that although the elderly patients have higher risks by undergoing surgery and have a disadvantage in the rate of postoperative complications, the postoperative improvement in activity and survival rate can be similar to those in the younger patients.

Genomic structure and insulin-mediated repression of the aquaporin adipose (AQPap), adipose-specific glycerol channel

Aquaporin adipose (AQPap) is a putative glycerol channel in adipocytes (Kishida, K., Kuriyama, H., Funahashi, T., Shimomura, I., Kihara, S., Ouchi, N., Nishida, M., Nishizawa, H., Matsuda, M., Takahashi, M., Hotta, K., Nakamura, T., Yamashita, S., Tochino, Y., and Matsuzawa, Y. (2000) J. Biol. Chem. 275, 20896-20902). In the current study, we examined the genomic structure of the mouse AQPap gene and its regulation by insulin. The mouse AQPap gene spanned 12 kilobase pairs in chromosome 4 and consisted of 8 exons and 7 introns. The first two exons, designated exon 1 and exon 1', are alternatively spliced to common exon 2, and thus the AQPap gene possessed two potential promoters. The exon 1-derived transcript is dominant in both adipose tissues and adipocytes on the basis of RNase protection assay and promoter analysis. The mRNA increased after fasting and decreased with refeeding. Insulin deficiency generated by streptozotocin enhanced the mRNA in adipose tissue. Insulin down-regulated AQPap mRNA in 3T3-L1 adipocytes. The AQPap promoter contained heptanucleotide sequences, TGTTTTT at -443/-437, similar to the insulin-response element identified previously in the promoters of insulin-repressed genes. Deletion and single base pair substitution analysis of the promoter revealed that these sequences were required for insulin-mediated repression of AQPap gene transcription. The phosphatidylinositol 3-kinase pathway was involved in this inhibition. We conclude that insulin represses the transcription of AQPap gene via insulin response element in its promoter. Sustained up-regulation of AQPap mRNA in adipose tissue in the insulin-resistant condition may disturb glucose homeostasis by increasing plasma glycerol.

Galectin-12, an Adipose-expressed Galectin-like Molecule Possessing Apoptosis-inducing Activity

Galectins constitute a family of proteins that bind to beta-galactoside residues and have diverse physiological functions. Here we report on the identification of a galectin-like molecule, galectin-12, in a human adipose tissue cDNA library. The protein contained two potential carbohydrate-recognition domains with the second carbohydrate-recognition domain being less conserved compared with other galectins. In vitro translated galectin-12 bound to a lactosyl-agarose column far less efficiently than galectin-8. Galectin-12 mRNA was predominantly expressed in adipose tissue of human and mouse and in differentiated 3T3-L1 adipocytes. Caloric restriction and treatment of obese animals with troglitazone increased galectin-12 mRNA levels and decreased the average size of the cells in adipose tissue. The induction of galectin-12 expression by the thiazolidinedione, troglitazone, was paralleled by an increase in the number of apoptotic cells in adipose tissue. Immunocytochemical analysis revealed that galectin-12 was localized in the nucleus of adipocytes, and transfection with galectin-12 cDNA induced apoptosis of COS-1 cells. These results suggest that galectin-12, an adipose-expressed galectin-like molecule, may participate in the apoptosis of adipocytes.

PPARgamma ligands increase expression and plasma concentrations of adiponectin, an adipose-derived protein

Insulin resistance and its dreaded consequence, type 2 diabetes, are major causes of atherosclerosis. Adiponectin is an adipose-specific plasma protein that possesses anti-atherogenic properties, such as the suppression of adhesion molecule expression in vascular endothelial cells and cytokine production from macrophages. Plasma adiponectin concentrations are decreased in obese and type 2 diabetic subjects with insulin resistance. A regimen that normalizes or increases the plasma adiponectin might prevent atherosclerosis in patients with insulin resistance. In this study, we demonstrate the inducing effects of thiazolidinediones (TZDs), which are synthetic PPARgamma ligands, on the expression and secretion of adiponectin in humans and rodents in vivo and in vitro. The administration of TZDs significantly increased the plasma adiponectin concentrations in insulin resistant humans and rodents without affecting their body weight. Adiponectin mRNA expression was normalized or increased by TZDs in the adipose tissues of obese mice. In cultured 3T3-L1 adipocytes, TZD derivatives enhanced the mRNA expression and secretion of adiponectin in a dose- and time-dependent manner. Furthermore, these effects were mediated through the activation of the promoter by the TZDs. On the other hand, TNF-alpha, which is produced more in an insulin-resistant condition, dose-dependently reduced the expression of adiponectin in adipocytes by suppressing its promoter activity. TZDs restored this inhibitory effect by TNF-alpha. TZDs might prevent atherosclerotic vascular disease in insulin-resistant patients by inducing the production of adiponectin through direct effect on its promoter and antagonizing the effect of TNF-alpha on the adiponectin promoter.

Leg edema, ST-T abnormalities, and high BNP values are important signs of heart failure in the elderly

This study was aimed at the mechanism of the circulatory failure characteristic of the elderly through elucidating the cause of leg edema frequently found in patients under treatment in health care facilities for physical or mental handicaps. ECG and measurement of atrial (ANP) and brain (BNP) natriuretic peptides were carried out on 156 patients (mostly females aged 84 years on average) and echocardiographic assessment was done on 44 patients. Non-specific ST-T abnormalities were frequently found in patients with moderate or severe leg edema (61 vs. 37% in those with slight or no edema). BNP levels were markedly increased in patients with either leg edema or ECG abnormalities (Group B) and with both (Group C) compared with those without either (Group A), with averages of 35.5+/-23.9, 91.3+/-80.1, and 184.3+/-139.0 pg/ml, respectively, for Group A, B, and C. UCG examination revealed marked regurgitation of cardiac valves, more frequently in patients with BNP over 50 pg/ml than in those with less (14/24 vs. 2/20), with a difference in extent of 5.7 versus 1.6 on an arbitrary scale. In addition to left ventricular hypertrophy, dilatation of the left atrium and inferior vena cava was frequently observed in patients with higher BNP levels. It is concluded that both cardiac valve regurgitation and myocardial damage represented by ST-T abnormalities on ECG result in heart failure characteristic of the elderly, and that an increase in BNP is an important sign of such heart failure.

The expression of SPARC in adipose tissue and its increased plasma concentration in patients with coronary artery disease

OBJECTIVE

Adipocytes secrete various cytokines and matrix proteins. Several of them precipitate in obesity-associated diseases, including atherosclerosis. In the current study, we have examined the expression of secreted protein, acidic and rich in cysteine (SPARC) in adipose tissue and its significance in obesity and coronary artery disease (CAD).

RESEARCH METHODS AND PROCEDURES

The SPARC mRNA expressions both in vivo and in vitro were detected by Northern blot analysis. Plasma SPARC concentrations were measured by enzyme immunosorbent assay. First, we investigated the plasma SPARC levels of 88 unrelated adult Japanese subjects (62 men and 26 women; average age: [+/- SD] 50 +/- 12 years; body mass index [BMI]: 16 to 46 kg/m(2)). Additionally 31 subjects with CAD diagnosed by coronary angiography (20 men and 11 women) were also investigated.

RESULTS

Human adipose tissues expressed abundant SPARC mRNA. SPARC expression in adipose tissues was upregulated in obese db/db mice. Markedly enhanced expression of SPARC mRNA was observed in 3T3-L1 fibroblasts during adipocyte differentiation. Consistent with these results, plasma SPARC levels proved a positive correlation with BMI in humans (r = 0.27; p < 0.01). Interestingly, plasma SPARC concentrations were significantly elevated in age- and BMI-matched subjects with CAD (p < 0.05).

DISCUSSION

SPARC was expressed in adipose tissues and its expression was enhanced in obese mice. In human, plasma SPARC levels were elevated in obesity and CAD patients. This elevated SPARC may be involved in the progression of CAD.

Involvement of pRB-related p107 protein in the inhibition of S phase progression in response to genotoxic stress

pRB family pocket proteins consisting of pRB, p107, and p130 are thought to act as a set of growth regulators that inhibit the cell cycle transition from G1 to S phases by virtue of their interaction with E2F transcription factors. When cells are committed to progressing through the cell cycle at the late G1 restriction point, they are hyperphosphorylated by G1 cyclin-cyclin-dependent kinase and are functionally inactivated. Consistent with such a G1 regulatory role, pRB and p130 are abundantly expressed in quiescent cells. In contrast, p107 is present at low levels in the hypophosphorylated form in quiescent cells. As cells progress toward late G1 to S phases, the levels of p107 increase, and the majority become hyperphosphorylated, suggesting a possible role of p107 in post-G1 cell cycle regulation. In this study, we have demonstrated that a nonphosphorylatable and thus constitutively active p107 has the potential to inhibit S phase progression. The levels of the phosphorylation-resistant p107 required for the S phase inhibition are significantly less than those of endogenous p107. We further show herein that the exposure of cells to the DNA-damaging agent, cisplatin, provokes S phase arrest, which is concomitantly associated with the accumulation of hypophosphorylated p107. Furthermore, the S phase inhibitory response to cisplatin is augmented by the ectopic expression of wild type p107, although it is diminished by the adenovirus E1A oncoprotein, which counteracts the pocket protein functions. Because p107 is a major pRB family protein expressed in S phase cells, our results indicate that p107 participates in an inhibition of cell cycle progression in response to DNA damage in S phase cells.

Collective inhibition of pRB family proteins by phosphorylation in cells with p16INK4a loss or cyclin E overexpression

The activity of the retinoblastoma protein pRB is regulated by phosphorylation that is mediated by G(1) cyclin-associated cyclin-dependent kinases (CDKs). Since the pRB-related pocket proteins p107 and p130 share general structures and biological functions with pRB, their activity is also considered to be regulated by phosphorylation. In this work, we generated phosphorylation-resistant p107 and p130 molecules by replacing potential cyclin-CDK phosphorylation sites with non-phosphorylatable alanine residues. These phosphorylation-resistant mutants retained the ability to bind E2F and cyclin. Upon introduction into p16(INK4a)-deficient U2-OS osteosarcoma cells, in which cyclin D-CDK4/6 is dysregulated, the phosphorylation-resistant mutants, but not wild-type p107 or p130, were capable of inhibiting cell proliferation. Furthermore, when ectopically expressed in pRB-deficient SAOS-2 osteosarcoma cells, the wild-type as well as the phosphorylation-resistant pRB family proteins were capable of inducing large flat cells. The flat cell-inducing activity of the wild-type proteins, but not that of the phosphorylation-resistant mutants, was abolished by coexpressing cyclin E. Our results indicate that the elevated cyclin D- or cyclin E-associated kinase leads to systemic inactivation of the pRB family proteins and suggest that dysregulation of the pRB kinase provokes an aberrant cell cycle in a broader range of cell types than those induced by genetic inactivation of the RB gene.

Adipocyte-derived plasma protein, adiponectin, suppresses lipid accumulation and class A scavenger receptor expression in human monocyte-derived macrophages

BACKGROUND

Excessive lipid accumulation in macrophages plays an important role in the development of atherosclerosis. Recently, we discovered an adipocyte-specific plasma protein, adiponectin, that is decreased in patients with coronary artery disease. We previously demonstrated that adiponectin acts as a modulator for proinflammatory stimuli and inhibits monocyte adhesion to endothelial cells. The present study investigated the effects of adiponectin on lipid accumulation in human monocyte-derived macrophages.

METHODS AND RESULTS

Human monocytes were differentiated into macrophages by incubation in human type AB serum for 7 days, and the effects of adiponectin were investigated at different time intervals. Treatment with physiological concentrations of adiponectin reduced intracellular cholesteryl ester content, as determined using the enzymatic, fluorometric method. The adiponectin-treated macrophages contained fewer lipid droplets stained by oil red O. Adiponectin suppressed the expression of the class A macrophage scavenger receptor (MSR) at both mRNA and protein levels by Northern and immunoblot analyses, respectively, without affecting the expression of CD36, which was quantified by flow cytometry. Adiponectin reduced the class A MSR promoter activity, as measured by luciferase reporter assay. Adiponectin treatment dose-dependently decreased class A MSR ligand binding and uptake activities. The mRNA level of lipoprotein lipase as a marker of macrophage differentiation was decreased by adiponectin treatment, but that of apolipoprotein E was not altered. Adiponectin was detected around macrophages in the human injured aorta by immunohistochemistry.

CONCLUSIONS

The adipocyte-derived plasma protein adiponectin suppressed macrophage-to-foam cell transformation, suggesting that adiponectin may act as a modulator for macrophage-to-foam cell transformation.

Carotid intima-media thickness in Japanese type 2 diabetic subjects: predictors of progression and relationship with incident coronary heart disease

OBJECTIVE

To examine carotid intima-media thickness (IMT), predictors of its progression, and its relationship with incident coronary heart disease (CHD) in type 2 diabetic Japanese patients.

RESEARCH DESIGN AND METHODS

Carotid IMT of 287 subjects with type 2 diabetes (mean age 61.6 years) without CHD or cerebrovascular disease was examined at baseline and after a mean follow-up of 3.1 years.

RESULTS

The annual progression of IMT (means +/- SEM) was 0.04+/-0.004 mm/year. Stepwise multivariate analysis demonstrated that independent risk factors for progress of IMT were the initial IMT (P<0.001), the average HbA1c level (P<0.001), and age (P = 0.001). Both the initial IMT (odds ratio [OR] 4.9, 95% CI 1.7-14.1) and a low average HDL cholesterol (OR 0.2, 0.1-0.8) were identified as predictors of incident nonfatal CHD (angina pectoris or nonfatal myocardial infarction; 3-year incidence 10.1%) after adjusting for age, sex, average HbA1c, and other risk factors.

CONCLUSIONS

The predictors of the progression of carotid IMT in Japanese type 2 diabetic subjects were its baseline thickness and the average HbA1c during the follow-up. Baseline carotid IMT and low HDL cholesterol predicted the incidence of nonfatal CHD.

Portal blood flow and liver regeneration in auxiliary partial orthotopic liver transplantation in a canine model

Functional competition has been shown to lead to a detrimental outcome in auxiliary liver transplantation. We evaluated the interaction in auxiliary partial orthotopic liver transplantation between the native liver and the graft in terms of portal flow and regeneration. The need for diversion of the portal flow to the graft was also assessed. Reduced-size liver grafts were transplanted orthotopically after partial hepatectomy in beagles. There were two groups: the preserved group, where portal inflow to the native liver was preserved, and the ligated group, where it was interrupted. Portal flow was measured serially and liver regeneration was evaluated on postoperative day 5. Functional competition was not observed in the preserved group. On the other hand, ligation of the native liver portal vein had no obviously detrimental effects on the remnant native liver. This leads to the conclusion that the portal vein to the native liver can be safely ligated to prevent functional competition.

Aryl radical cyclizations: one-Pot syntheses of protoberberine and pavine alkaloids

Treatment of 2-(2'-bromo-beta-phenethyl)isocarbostyrils 7 with AIBN-Bu(3)SnH in boiling benzene gave 8-oxoberbines 3 in good yields. A similar treatment of 2-(2'-bromo-beta-phenethyl)isoquinolinium bromides 6 and their nor- and homoanalogues (10,11) induced 6-, 5-, and 7-exo radical closures in a one-pot manner to give protoberberines 2, dibenzo[b,g]indolizidine 14a and, dibenzo[a, h]-1-azabicyclo[5.4.0]undecane 15a, respectively. A one-pot radical cyclization of 1-(2'-bromobenzyl)isoquinoline methiodide 18a gave a pavine alkaloid, (+/-)-algemonine (19a).

Aquaporin adipose, a putative glycerol channel in adipocytes

Adipose tissue is a major site of glycerol production in response to energy balance. However, molecular basis of glycerol release from adipocytes has not yet been elucidated. We recently cloned a novel member of the aquaporin family, aquaporin adipose (AQPap), which has glycerol permeability. The current study was designed to examine the hypothesis that AQPap serves as a glycerol channel in adipocytes. Adipose tissue expressed AQPap mRNA in high abundance, but not the mRNAs for the other aquaglyceroporins, AQP3 and AQP9, indicating that AQPap is the only known aquaglyceroporin expressed in adipose tissue. Glycerol release from 3T3-L1 cells was increased during differentiation in parallel with AQPap mRNA levels and suppressed by mercury ion, which inhibits the function of AQPs, supporting AQPap functions as a glycerol channel in adipocytes. Fasting increased and refeeding suppressed adipose AQPap mRNA levels in accordance with plasma glycerol levels and oppositely to plasma insulin levels in mice. Insulin dose-dependently suppressed AQPap mRNA expression in 3T3-L1 cells. AQPap mRNA levels and adipose glycerol concentrations measured by the microdialysis technique were increased in obese mice with insulin resistance. Accordingly, negative regulation of AQPap expression by insulin was impaired in the insulin-resistant state. Exposure of epinephrine translocated AQPap protein from perinuclear cytoplasm to the plasma membrane in 3T3-L1 adipocytes. These results strongly suggest that AQPap plays an important role in glycerol release from adipocytes.

Postoperative adhesion prevention with an oxidized regenerated cellulose adhesion barrier in infertile women

OBJECTIVE

To evaluate the efficacy of an oxidized regenerated cellulose adhesion barrier as an adjuvant in preventing postoperative adhesions in infertile women undergoing reconstructive surgery.

STUDY DESIGN

Thirty-eight cases of reconstructive surgery that could be followed up for more than two years (myomectomy 19, cystectomy 5, tuboplasty 10, uteroplasty 4) at the Fujita Health University Hospital were evaluated retrospectively. The barrier (Intercede, Johnson & Johnson) was used to cover the surgical site in 23 of these cases (Intercede group); no adjuvant was used in 15 cases, which represent the surgical control group (Intercede - group), including 23 second-look operation cases (16 in the Intercede and 7 in the control group). Postoperative adhesion prevention and pregnancy rates were estimated.

RESULTS

At the second-look operation, six cases (37.5%) in the Intercede + group and six (85.7%) in the Intercede - group had postoperative adhesions. No significant difference was found in either intensity or area covered with adhesions between the two groups. Eighteen cases (78.3%) in the Intercede and seven (46.7%) in the Intercede - group conceived during the follow-up period.

CONCLUSION

The use of Intercede significantly reduced the rate of postoperative adhesion formation, with a statistically significant increase in the pregnancy rate as compared to the surgical controls.