Hyperbilirubinemia as a predictor of severity of acute appendicitis

Objective

This study aimed to investigate the clinical significance of preoperative hyperbilirubinemia in Japanese patients and to assess its clinical potential as a predictor of the severity of acute appendicitis.

Methods

We studied 318 patients with appendicitis who underwent appendectomy between July 2010 and June 2017. We analyzed preoperative data including age, sex, white blood cell count, C-reactive protein (CRP) level, fever, peritoneal irritation signs, and serum total bilirubin level as potential risk factors for complicated (perforated or gangrenous) appendicitis, using multivariate analysis.

Results

Complicated appendicitis was significantly more frequent in patients with hyperbilirubinemia (>1.1 mg/dL), high CRP level (>0.5 mg/dL), positive peritoneal irritation signs, and fever (>37.3°C). Multivariate analysis revealed older age (>64 years), hyperbilirubinemia, high CRP level, and fever (odds ratios 3.36, 1.75, 7.61, and 2.43, respectively) as risk factors for complicated appendicitis. Multivariate analysis also identified hyperbilirubinemia, high CRP level, and fever (odds ratios 1.99, 5.90, and 2.72, respectively) as risk factors for complicated appendicitis among patients aged <65 years.

Conclusions

Hyperbilirubinemia, high CRP level, and fever may be useful predictors of the severity of acute appendicitis, with hyperbilirubinemia being especially useful among patients aged <65 years.

A Surgical Case of Inflammatory Myofibroblastic Tumor of the Liver: Potentially Characteristic Gross Features

We herein reported a very rare surgical case of inflammatory myofibroblastic tumor (IMT) of the liver, showing potentially unique and specific gross findings on its cut surface: our IMT demonstrated a relatively well-demarcated and partly infiltrative and likely extrahepatic (ie serosal) but not intrahepatic mass, appearing firm and hemorrhagic, and yellow-whitish in color. The patient, who was a woman in her early 70s with 2-year follow-up for lung cryptococcosis and traffic accident, incidentally presented with unenhanced and low-density, heterogeneous mass on abdominal dynamic CT in the peripheral right lobe of the liver. We could conclusively diagnose the current lesion as the hepatic IMT after thorough analyses including a wide panel of immunohistochemical antibodies. Despite that, all clinicians and pathologists should be aware that the potentially characteristic, extrahepatic gross feature of IMT of the liver might also be one of the powerful supplementary tools for reaching its correct diagnosis. One of our aims in the presented case report is to emphasize that the hepatic IMT should be considered clinicopathologically in the differential diagnosis of mass lesions on the liver.

Localized malignant pleural mesothelioma arising in the interlobar fissure: a unique surgical case masquerading clinicopathologically as primary lung adenocarcinoma

An 80-year-old male with previous workplace exposure to asbestos presented with a history of an increase in the pulmonary-to-hilar mass, measuring more than 50 mm in diameter, likely in the right lower lobe. We first interpreted it as suspicious of primary lung adenocarcinoma with direct invasion to the right hilar lymph node. A right middle and lower lobectomy with partial resection of upper lobe was performed, and gross examination showed a hilar tumor lesion, involving the middle/lower lobe to hilar lymph node and looking whitish to yellow-grayish, partly adjacent to the right pulmonary artery. On microscopic examination, the tumor was located on the extrapulmonary, interlobar pleural fissure, predominantly composed of a proliferation of atypical epithelioid cells, often arranged in an irregular and fused tubular growth pattern with an involvement of pulmonary artery. Immunohistochemically, these atypical cells are positive for several mesothelial markers, including calretinin, cytokeratin 5/6, and WT-1, whereas negative for thyroid transcription factor 1. Furthermore, p16 deletions were specifically detected by fluorescence in situ hybridization, and electron microscopy showed numerous, significantly elongated microvilli. Taken together, we finally made a diagnosis of localized malignant pleural mesothelioma, epithelioid-type, arising in the right interlobar fissure between lower and middle lobes. We should be aware that, owing to its characteristic features, clinicians and pathologists might be able to raise interlobar fissure localized malignant pleural mesothelioma as one of the differential diagnoses, based on careful clinicopathological examinations.

[Local Recurrence of Rectal Cancer under Perineal Skin after Abdominoperineal Resection]

A woman in her early 50s underwent abdominoperineal resection with left lateral lymph node resection for advanced rectal cancer. The pathological diagnosis was RC, RbP, well-differentiated, type 5, 65×47mm, pT3(A), pN0(0/40), M0, pStage Ⅱ. The local recurrence discovered under the perineal skin 2 months later was treated by resecting the tumor and both inguinal lymph nodes. Adjuvant chemotherapy containing UFT plus LV was also initiated for 6 months. She remains free of recurrence 1 year after resection of the local recurrence.

[Assessment of Short-Term Outcomes of Laparoscopic-Assisted Distal Gastrectomy in Elderly Patients Using Comorbidities as Predictive Factors]

Laparoscopic-assisted distal gastrectomy(LADG)is a recently developed minimally invasive surgery for management of early gastric cancer. We describe short-term results obtained from a retrospective study of LADG, performed in elderly patients, using comorbidities as predictive factors. We studied 160 patients diagnosed with gastric cancer who underwent LADG between January 2005 and October 2016. We compared 48 patients, aged≥75 years(elder group), with 112 patients, aged <75 years(non-elder group), who underwent LADG. Preoperative physical status was assessed using the American Society of Anesthesiologists physical status(ASA-PS)score, Charlson comorbidity index(CCI), and the prognostic nutritional index (PNI). Demographics of patients, primarily, sex, tumor lesion, and histology did not significantly differ between the groups. However, the mean ASA-PS score and CCI were significantly higher, and the PNI was significantly lower in the elder group. Surgical duration, volume of blood loss, lymph node clearance, and length of postoperative hospital stay did not significantly differ between the groups. Cardiorespiratory and surgical complications developed in 2(4.2%)and 3(2.7%), and in 5(10%) and 12(11%)patients in the elder and non-elder groups, respectively. However, the rates of intra and postoperative complications were not significantly different between them. LADG can be considered a safe and effective minimally invasive surgical procedure for management of early gastric cancer in elderly patients.

[Case Report of Long-Term Survival for Stage IV Advanced Sigmoid Colon Cancer with Para-Aortic Nodes by R0 Resection and Chemotherapy]

The patient was a man in his early 30s. He underwent sigmoidectomy with D3+ #216 for advanced sigmoid colon cancer with metastatic para-aortic lymph nodes. The pathological diagnosis was colon cancer(S), type 2, moderately differentiated, pT4a(SE), pN3(19/33), pM1a(LYM), pStage IV , KRAS wild-type, EGFR(+). He received FOLFOX plus bevacizumab(Bmab) as adjuvant chemotherapy. One year postoperatively, he experienced recurrence as multiple lung metastases. FOLFIRI plus panitumumab, SOX plus Bmab, CapeOX, nivolumab and FOLFIRI plus ramucirumab were then administered. The patient has survived for 4 years and 11 months from operation.

Equivalence of the Acute Cytokine Surge and Myocardial Injury after Coronary Artery Bypass Grafting with and without a Novel Extracorporeal Circulation System

Cardiopulmonary bypass (CPB) contributes to a morbidity-inducing systemic Inflammatory response after cardiac surgery. We compared this response in patients receiving coronary artery bypass grafting (CABG) with (CPB group; n = 7) or without (off-pump group; n = 8) the Minimal Extracorporeal Circulation (MECC®) system. Serum concentrations of tumour necrosis factor (TNF)-α, soluble TNF receptors, pro- and anti-inflammatory interleukins (ILs) and other myocardial injury markers were measured after anaesthetic induction, at 1 h, 4 h and 24 h after completing all anastomoses or serially. Soluble TNF receptor type I (sTNFRI) and IL-8 peaked early after CABG in both groups and did not decline. Serum sTNFRI was significantly higher in the CPB compared with the off-pump group at 1 h, whereas IL-8 was significantly lower in the CPB group throughout. The MECC® system, therefore, produces an equivalent acute cytokine response and degree of myocardial injury to off-pump CABG, and may be useful when CABG cannot be performed without CPB.

Complete Response Obtained with S-1 Plus CDDP Therapy in a Patient with Multiple Liver Metastases from Gastric Cancer

A 58-year-old woman with advanced gastric cancer underwent total gastrectomy in May 2012. The histological diagnosis was poorly differentiated adenocarcinoma, cT4a (SE), pN1, cM0; fStage IIIA. Chemotherapy by S-1 was started after surgery. Six months after the operation, two metastatic nodules were noticed on the liver. Therefore, the chemotherapy was switched to S-1 plus cisplatin (CDDP) in November 2012. TS-1 (80 mg/body) was administrated from day 1 to 21 followed by 14 days rest as one course. CDDP (70 mg/body) was infused on day 1. After 3 courses of this combination chemotherapy, remarkable diminution of the metastatic lesions on CT images was observed. Because of the adverse event of Grade 2 nausea, the patient was forced to discontinue chemotherapy. The patient underwent partial resection of the liver (Hr-0: S8, S7) at 1 year after the first operation. The resected specimens showed no sign of malignancy, although uneven fatty deposition was observed more frequently than in the surroundings, and designated as histologically complete response (CR). The patient has been alive 30 months after the second operation without any recurrent sites. Thus, combined use of peroral S-1 and CDDP should be recommended for multiple liver metastases after gastrectomy.

Protective effect of eicosapentaenoic acid on insulin resistance in hyperlipidemic patients and on the postoperative course of cardiac surgery patients: the possible involvement of adiponectin

Accumulated studies have shown that ω-3 polyunsaturated fatty acids such as eicosapentaenoic acid (EPA) have protective roles against inflammatory responses such as hyperlipidemia, diabetes mellitus (DM) and cardiovascular diseases. Here we examined the effects of administering EPA to hyperlipidemic patients and other patients undergoing cardiac surgery to determine whether this treatment would increase plasma EPA levels and to clarify the association between EPA treatment and adiponectin production in hyperlipidemic patients. We also assessed the effect of preoperative EPA administration on postoperative adverse events such as postoperative atrial fibrillation (POAF) and postoperative infection in the cardiac surgery patients. The EPA administration significantly increased the serum EPA concentrations in both patient populations (p＜0.001). In the hyperlipidemic patients, the EPA administration significantly increased plasma adiponectin levels (p＜0.05), accompanied by a decrease in insulin resistance designated by the HOMA-IR (homeostasis model assessment of insulin resistance) score (p＜0.05) and Hs-CRP (high sensitivity C-reactive protein) value (p＜0.05). In the cardiac surgery patients, no significant effect of EPA on cardiac adverse events such as POAF was observed. However, our results clearly demonstrated that both the neutrophil-to-lymphocyte ratio and the 2nd-line antibiotic requirement in the EPA group were significantly decreased compared to the untreated control group (p＜0.05). We suggest that EPA administration may exert anti-inflammatory effects in patients with hyperlipidemia and in those undergoing cardiac surgery, possibly through an increase in plasma adiponectin levels.

[Bacteria isolated from surgical infections and its susceptibilities to antimicrobial agents - Special references to bacteria isolated between April 2011 and March 2012]

Bacteria isolated from surgical infections during the period from April 2011 to March 2012 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 785 strains including 31 strains of Candida spp. were isolated from 204 (78.8%) of 259 patients with surgical infections. Five hundred and twenty three strains were isolated from primary infections, and 231 strains were isolated from surgical site infection. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from surgical site infection aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. was highest, followed by Streptococcus spp. and Staphylococcus spp., in this order, from primary infections, while Enterococcus spp. was highest, followed by Staphylococcus spp. from surgical site infection. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae, Pseudomonas aeruginosa and Enterobacter cloacae, in this order, and from surgical site infection, E. coli was most predominantly isolated, followed by P. aeruginosa, K. pneumoniae, and E. cloacae. Among anaerobic Gram-positive bacteria, the isolation rate of Eggerthella lenta was the highest from primary infections, followed by Parvimonas micra, Collinsella aerofaciens, Lactobacillus acidophilus and Finegoldia magna, and from surgical site infection, E. lenta was most predominantly isolated, followed by P micra and L. acidophilus, in this order. Among anaerobic Gram-negative bacteria, the isolation rate of Bacteroidesfragilis was the highest from primary infections, followed by Bilophila wadsworthia, Bacteroides thetaiotaomicron, Bacteroides uniformis and Bacteroides vulgatus, and from surgical site infection, B. fragilis was most predominantly isolated, followed by Bacteroides caccae, B. thetaiotaomicron, Bacteroides ovatus and B. wadsworthia, in this order. In this series, vancomycin-resistant MRSA (methicillin-resistant Staphylococcus aureus), vancomycin-resistant Enterococcus spp. and multidrug-resistant P. aeruginosa were not observed. We should carefully follow up B. wadsworthia which was resistant to various antimicrobial agents, and also Bacteroides spp. which was resistant to many β-lactams.

[Bacteria isolated from surgical infections and its susceptibilities to antimicrobial agents--special references to bacteria isolated between April 2010 and March 2011]

Bacteria isolated from surgical infections during the period from April 2010 to March 2011 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 631 strains including 25 strains of Candida spp. were isolated from 170 (81.7%) of 208 patients with surgical infections. Four hundred and twenty two strains were isolated from primary infections, and 184 strains were isolated from surgical site infection. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from surgical site infection aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. such as Enterococcus faecalis, Enterococcus faecium, and Enterococcus avium was highest, followed by Streptococcus spp. such as Streptococcus anginosus and Staphylococcus spp. such as Staphylococcus aureus, in this order, from primary infections, while Enterococcus spp. such as E. faecalis and E. faecium was highest, followed by Staphylococcus spp. such as S. aureus from surgical site infection. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae, Klebsiella oxytoca, Enterobacter cloacae, and Pseudomonas aeruginosa in this order, and from surgical site infection, E. coli and R aeruginosa were most predominantly isolated, followed by E. cloacae and K. pneumoniae. Among anaerobic Gram-positive bacteria, the isolation rates of Parvimonas micra, Eggerthella lenta, Streptococcus constellatus, Gemella morbillorum, and Collinsella aerofaciens were the highest from primary infections, and the isolation rate from surgical site infection was generally low. Among anaerobic Gram-negative bacteria, the isolation rate of Bilophila wadsworthia was the highest from primary infections, followed by, Bacteroides fragilis and Bacteroides ovatus, and from surgical site infection, B. fragilis was most predominantly isolated, followed by Bacteroides thetaiotaomnicron, in this order. In this series, vancomycin-resistant MRSA (methicillin-resistant S. aureus), vancomycin-resistant Enterococcus spp. and multidrug-resistant P. aeruginosa were not observed.

[Effects of a Kampo medicine on postoperative infection]

We studied the effects of preoperative administration of Hochuekkito (TJ-41) on the host response of patients undergoing gastrectomy or colectomy in a prospective, randomized, multicenter clinical trial. Forty-eight patients were randomized into two groups: one received 7.5 g/day of TJ-41 for 7 days before surgery (n = 22); and the other served as the control group (n = 26). The body temperature and pulse rate in patients in the TJ41 group were significantly better controlled during the study compared with those in the control group. The concentration of serum cortisol on the first postoperative day in the TJ-41 group was also significantly lower compared with that in the control group. These results clearly indicate that the preoperative administration of TJ-41 may ameliorate an excessive postoperative inflammatory response and prolonged immunosuppressed state, resulting in fewer postoperative infectious complications.

Clinical Value of Neopterin In Infectious Complications

Neopterin, a pteridine intermediate metabolite in the biopterine synthetic pathway, is synthesized and secreted by monocyte/macrophages upon stimulation, mainly by gamma-interferon by activated T cells. C-reactive protein (CRP) is one of the major acute phase reactants and its release is thought to be mediated by interleukin-6. Soluble IL-2 receptor (sIL-2R) is released by activated T cells. Plasma concentrations of neopterin, CRP and sIL-2R were synchronously analyzed in 25 determinations of 5 patients with severe infectious complications. A marked increase in neopterin, CRP and sIL-2R levels was observed. The increase in neopterin was significantly correlated to that of neopterin which is a marker of macrophage activity. These results suggest that macrophages are involved in the stimulation of sIL-2R release. In contrast, the increase in neopterin was not correlated to that of CRP and the lack of correlation between neopterin and CRP indicated that independent mechanisms control the synthesis of these two markers.

[Radiofrequency ablation therapy combined with hepatectomy for liver metastasis of colorectal cancer]

Radiofrequency ablation (RFA) therapy combined with hepatectomy was performed in 5 patients with synchronous liver metastases of colorectal cancer. RFA of liver metastases was performed using a Cool-tip electrode (Radionics; Burlington, MA, USA). The ablation time used in each session varied according to the tumor size and intraoperative impedance. In 2 patients, hepatectomy and resection of the colorectal primary lesion were performed synchronously. In patients with multiple liver metastases, relative curative resection was performed using the complementary RFA. In the other 3 patients, synchronous hepatectomy was considered difficult and systematic chemotherapy was performed after resection of the colorectal primary lesion. After systematic chemotherapy, the range of hepatectomy was restricted for liver injury, but relative curative resection was performed using RFA therapy. Computed tomography performed after hepatectomy showed that the region that underwent RFA appeared necrotic with a safety margin. The average observation period was 25 months (maximal survival period, 50 months) and 3 of the patients are alive.

Analysis of surgical outcomes of diverticular disease of the colon

We analyzed retrospectively the surgical outcomes of diverticular diseases of the colon at the surgical division of Fukuyama Medical Center. Data were collected from 39 patients who underwent surgery for diverticular disease at Fukuyama Medical Center. Thirty-nine patients were admitted between 2005 and 2010. The mean age of the 39 patients was 63.6 years. The collected data included patient demographics, patient history, type of surgery and complications. Patients were divided into 2 groups, Elective vs. Emergent group, right vs. left colon group and laparotomy vs. laparoscopic approach. Multivariate analysis of the logistic model of morbidity revealed a significantly higher rate in the left colon and the Cox proportional hazards model clearly showed fewer postoperative hospital days with the laparoscopic approach. Surgical procedures should be decided in reference to the particular clinical and pathological features of diverticular disease to gain an acceptable morbidity and mortality rates.

[Bacteria isolated from surgical infections and its susceptibilities to antimicrobial agents--special references to bacteria isolated between April 2009 and March 2010]

Bacteria isolated from surgical infections during the period from April 2009 to March 2010 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 671 strains including 16 strains of Candida spp. were isolated from 174 (79.1%) of 220 patients with surgical infections. Four hundred and eleven strains were isolated from primary infections, and 244 strains were isolated from surgical site infection. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from surgical site infection aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. was highest, followed by Streptococcus spp., and Staphylococcus spp. in this order, from primary infections, while Enterococcus spp. was highest, followed by Staphylococcus spp. from surgical site infection. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae, Enterobacter cloacae and Pseudomonas aeruginosa, in this order, and from surgical site infection, E. coli was most predominantly isolated, followed by P. aeruginosa and E. cloacae. Among anaerobic Gram-positive bacteria, the isolation rate of Eggerthella lenta was the highest from primary infections, followed by Parvimonas micra, Streptococcus constellatus and Finegoldia magna, and from surgical site infection, E. lenta was most predominantly isolated. Among anaerobic Gram-negative bacteria, the isolation rate of Bilophila wadsworthia was the highest from primary infections, followed by Bacteroides fragilis, Bacteroides ovatus and Bacteroides thetaiotaomicron, and from surgical site infection, B. fragilis was most predominantly isolated, followed by B. ovatus, B. wadsworthia and B. thetaiotaomicron, in this order. In this series, we noticed no vancomycin-resistant Gram-positive cocci, nor multidrug-resistant P. aeruginosa. We should carefully follow up B. wadsworthia which was resistant to various antibiotics, and also Bacteroides spp. which was resistant to many beta-lactam antibiotics.

[Bacteria isolated from surgical infections and their susceptibilities to antimicrobial agents --special references to bacteria isolated between April 2008 and March 2009]

Bacteria isolated from infections in abdominal surgery during the period from April 2008 to March 2009 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 712 strains including 18 strains of Candida spp. were isolated from 173 (80.5%) of 215 patients with surgical infections. Three hundred and sixty-six strains were isolated from primary infections, and 346 strains were isolated from postoperative infections. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from postoperative infections aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. was highest, followed by Streptococcus spp., and Staphylococcus spp. in this order, from primary infections, while Enterococcus spp. was highest, followed by Staphylococcus spp. from postoperative infections. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa, in this order, and from postoperative infections, P aeruginosa was most predominantly isolated, followed by E. coli, Enterobacter cloacae, and K. pneumoniae. Among anaerobic Gram-positive bacteria, the isolation rate of Eggerthella lenta was the highest from primary infections, followed by Parvimonas micra, Streptococcus constellatus and Gemella morbillorum, and from postoperative infections, E. lenta was most predominantly isolated. Among anaerobic Gram-negative bacteria, the isolation rate of Bacteroides fragilis was the highest from primary infections, followed by Bacteroides thetaiotaomicron, Bacteroides ovatus and Bilophila wadsworthia, and from postoperative infections, B. fragilis was most predominantly isolated, followed by B. thetaiotaomicron, B. wadsworthia and B. ovatus, in this order. In this series, we noticed no vancomycin-resistant methicillin-resistant S. aureus, and Enterococcus spp., nor multidrug-resistant P aeruginosa. We should carefully follow up B. wadsworthia which was resistant to various antibiotics, and also Bacteroides spp. which was resistant to many beta-lactam antibiotics.

[Bacteria isolated from surgical infections and their susceptibility to antimicrobial agents--special reference to bacteria isolated between April 2007 and March 2008]

Bacteria isolated from infections in abdominal surgery during the period from April 2007 to March 2008 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 707 strains including 24 strains of Candida spp. were isolated from 181 (79.0%) of 229 patients with surgical infections. Three hundred and ninety-five strains were isolated from primary infections, and 288 strains were isolated from postoperative infections. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from postoperative infections aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. was highest, followed by Streptococcus spp., and Staphylococcus spp. in this order, from primary infections, while Enterococcus spp. was highest, followed by Staphylococcus spp. from postoperative infections. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae, Pseudomonas aeruginosa and Enterobacter cloacae, in this order, and from postoperative infections, P. aeruginosa was most predominantly isolated, followed by E. cloacae, E. coli and K. pneumoniae. Among anaerobic Gram-positive bacteria, the isolation rate of Parvimonas micra was the highest from primary infections, followed by Streptococcus constellatus and Gemella morbillorum, and from postoperative infections, Anaerococcus prevotii was most predominantly isolated. Among anaerobic Gram-negative bacteria, the isolation rate of both Bacteroides fragilis and Bilophila wadsworthia were the highest from primary infections, followed by Bacteroides thetaiotaomicron and Campylobacter gracilis, and from postoperative infections, B. thetaiotaomicron was most predominately isolated, followed by B. fragilis, Bacteroides caccae and B. wadsworthia in this order. In this series, we noticed no vancomycin-resistant Gram-positive cocci, nor multidrug-resistant P aeruginosa. There were nine strains of coagulase-negative Staphylococci which show higher MIC against teicoplanin more than 4 gg/mL, but all of them had good susceptibilities against various anti-MRSA antibiotics. We should carefully follow up B. wadsworthia which was resistant to various antibiotics, and also Bacteroides spp. which was resistant to many beta-lactam antibiotics.

Refractory response to growth factors impairs liver regeneration after hepatectomy in patients with viral hepatitis

BACKGROUND/AIMS

Liver regeneration after surgical resection is important. The present study was designed to understand the effect of background liver damage on the rate of liver tissue regeneration after hepatectomy and the mechanism of any defective regeneration.

METHODOLOGY

The subjects were 40 patients who underwent liver resection. They comprised 22 patients with chronic viral hepatitis-hepatocellular carcinoma (liver damage group) and 18 patients with hepatic metastases from colorectal cancer (normal liver group). Liver regeneration was evaluated by histopathological and immunohistochemical examination of the surgically resected tissue and by CT-scanning of the regenerated liver mass. The resected liver specimens were stained for c-met, gp-130 and nuclear factor-kappaB (NF-kappaB) proteins.

RESULTS

Liver regeneration was significantly less in the liver-damage group than in the normal-liver group. Histopathological examination showed marked inflammatory cell infiltration in the liver-damage group. Expression of c-met, but not gp-130, was significantly higher on parenchymal cells of the liver-damage group than the normal-liver group. NF-kappaB expression in parenchymal liver cells was significantly higher than in non-parenchymal cells of the normal-liver group. In the liver-damage group, liver regeneration correlated negatively with the staining intensity of NF-kappaB protein in non-parenchymal cells. These findings suggest that non-parenchymal cells are constitutively activated in the damaged liver, probably explaining the refractoriness of hepatocytes to cytokine-induced proliferation after hepatectomy, in spite of increased receptor (c-met) expression.

CONCLUSIONS

The refractory response of injured hepatocytes to cytokines may explain the impaired postoperative liver regeneration in patients with damaged liver.

Immunohistochemical staining of liver grafts with a monoclonal antibody against HCV-Envelope 2 for recurrent hepatitis C after living donor liver transplantation

AIM

We evaluated the expression of hepatitis C virus (HCV) antigen on liver grafts by immunohistochemical staining (IHS) using IG222 monoclonal antibody (mAb) against HCV-envelope 2 (E2).

METHODS

The study material was 84 liver biopsy specimens obtained from 28 patients who underwent living donor liver transplantation (LDLT) for HCV infection. The biopsy samples were examined histopathologically, and by IHS using IG222 mAb against HCV-E2. Serum HCV-RNA level was measured in all patients. The IHS grades were compared among the three groups classified according to the time elapsed from LDLT (at 1-30, 31-179 and > or =180 days post-LDLT) and among four post-transplant conditions, including acute cellular rejection (ACR).

RESULTS

Immunoreactivity to IG222 was detected in 78.6% of the specimens obtained during the first month after LDLT, and there were no significant differences on the IHS grades between the three groups classified according to the time elapsed from LDLT. The IHS grades were significantly stronger in definite recurrent HCV (n = 12) and probable recurrent HCV (n = 7) than in definite ACR (n = 7) and other complications (n = 8). There were no significant differences in serum HCV-RNA levels among the four post-transplant conditions. There was no significant correlation between the IHS grades using IG222 mAb and serum HCV-RNA levels when data of 84 liver biopsy specimens were analyzed.

CONCLUSIONS

Constant HCV-E2 expression was observed in liver biopsy specimens obtained 1 month or longer. The strong HCV-E2 expression on liver grafts were associated with recurrent hepatitis C after LDLT, but the serum HCV-RNA levels were not.

Specific Removal of Monocytes from Peripheral Blood of Septic Patients by Polymyxin B-immobilized Filter Column

Lipopolysaccharide (LPS) is one of the major causes of septic shock. The polymyxin B-immobilized filter column (PMX) was developed for the adsorption of endotoxin by direct hemoperfusion and has been used for the treatment of LPS-induced septic shock. In this study, we demonstrated that PMX also specifically bound monocytes from the peripheral blood leukocytes of septic patients by mean of an analysis of bound cells using immunocytochemical and electron microscopic techniques. The specific removal of monocytes from septic patients may produce beneficial effects by reducing the interaction between monocytes and functionally associated cells including vascular endothelial cells.

[A case of resection of synchronous multiple liver metastases from colorectal cancer after FOLFOX chemotherapy]

A 41-year-old man with multiple liver metastases from sigmoid colon cancer received a radical resection of the original tumor and 16 courses of weekly high-dose 5-FU(WHF)chemotherapy via hepatic arterial reservoir. The metastatic lesions showed stable disease(SD), and systemic chemotherapy by mFOLFOX6 was begun via CV port. After 14 courses of mFOLFOX4, abdominal CT revealed liver metastases were remarkably reduced in size. Hepatic resection of lateral segment and radio frequency ablation(RFA)for S6 were enforced, and the patient was uneventfully discharged. Pathological findings of lateral segment revealed no residual cancer cells, indicating that the histological effect of mFOLFOX6 was Grade 3.

Stimulation of adenosine A2A receptor inhibits LPS-induced expression of intercellular adhesion molecule 1 and production of TNF-alpha in human peripheral blood mononuclear cells

LPS stimulates CD14/Toll-like receptor (TLR) 4, leading to induce TNF-alpha production. Cell-to-cell interaction through the engagement between intercellular adhesion molecule (ICAM) 1 on monocytes and its ligand on T cells has been suggested to play a role in the TNF-alpha production by LPS-treated human peripheral blood mononuclear cells (PBMCs). Adenosine is reported to inhibit LPS-induced TNF-alpha production. However, little is known about the mechanism of the inhibitory effects induced by adenosine on the LPS-induced immune responses. We found that adenosine inhibited the expression of ICAM-1 and the production of TNF-alpha by human PBMC via adenosine A2A receptor in the presence of LPS. However, the stimulation of A1R or A3R enhanced the actions of adenosine. Adenosine had no effect on the expression of CD14 and TLR-4, suggesting that the inhibitory effects of adenosine on the LPS actions might be independent of the expression of CD14 and TLR-4. Thus, adenosine differentially regulates the expression of ICAM-1 and the production of TNF-alpha through plural subtypes of receptors.

Deficient response of IL-6 impaired liver regeneration after hepatectomy in patients with viral hepatitis

BACKGROUND/AIMS

Liver regeneration after surgical resection is still a serious concern. The present study is designed to understand the relations between liver injury/regeneration and cytokines after hepatectomy with viral hepatitis.

METHODOLOGY

Twenty-one consecutive patients undergoing liver resection were studied, which included two patients with biliary tract cancer, three patients with hepatic metastases from colorectal cancer, and sixteen patients with primary liver tumor. They were also divided into two groups according to the existence of chronic viral hepatitis: 10 patients with viral hepatitis and 11 patients without viral hepatitis.

RESULTS

Viral hepatitis reduced pre-operative liver function (ICG-R15 and platelet count) with raised levels of sFas. Interestingly, this also reduced postoperative surge of IL-6, but not HGF, though they were equally at basal levels pre-operatively. Recovery of liver size, calculated with resected liver mass and volumetry with CT scan, was deteriorated in liver with viral hepatitis, but any difference of postoperative liver damage was observed between two groups.

CONCLUSIONS

Viral infection, somehow, increased sFas level pre-operatively, but does not influence the post-operative liver injury. Deficient response of IL-6, but not HGF, may be a major cause for poor liver regeneration after hepatectomy in patients with viral hepatitis independent from liver injury.

Significant correlation between surgical stress of hepatectomy and changes in the serum levels of HGF, IL-6 and soluble Fas in patients with viral hepatitis

BACKGROUND/AIMS

Liver damage after hepatectomy is still a serious concern. The present study was designed to clarify the relations between liver injury/surgical stress and cytokines after hepatectomy, in patients with viral hepatitis.

METHODOLOGY

Ten consecutive patients undergoing hepatectomy were studied, all with hepatocellular carcinoma due to viral hepatitis. Blood samples for interleukin-6 (IL-6), soluble IL-6 receptor (sIL-6R), hepatocyte growth factor (HGF), soluble Fas (sFas), soluble Fas Ligand and soluble tumor necrosis factor receptor (sTNFR) assays were collected before the operation and at the end of the operation.

RESULTS

There was a significant and positive correlation between the change in the serum level of HGF and preoperative liver function (ICG-R15). Notably, there were significant correlations between surgical stress and IL-6, HGF and sFas, but not sIL-6R and sTNFR. Furthermore, there was significant correlation between postoperative liver function (total bilirubin, albumin) and HGF, IL-6.

CONCLUSIONS

There was a close relationship between surgical stress and HGF, IL-6 and sFas after hepatectomy in patients with viral hepatitis. It was useful for the evaluation of surgical stress of hepatectomy to estimate the serum level of HGF, IL-6 and sFas.

Preoperative oral administration of pentoxifylline ameliorates respiratory index after cardiopulmonary bypass through decreased production of IL-6

Activation of inflammatory response during cardiopulmonary bypass (CPB) may lead to considerable post-operative mortality. Recently, pentoxifylline (PTX), a methylxanthine derivative, has been reported to be effective in inhibiting proinflammatory cytokine production. This study aimed to determine whether or not PTX prevented CPB-induced systemic inflammatory response syndrome (SIRS) in patients undergoing cardiovascular surgery. Thirty adult patients were randomly separated into 2 experimental groups and 1 control group of 10 patients each. The experimental group received peroral PTX administration (Group 1: 600 mg/day, Group 2: 900 mg/day), while the control group did not. In Group 1 and Group 2, PTX administration was started on preoperative day 5 and continued for 5 days. Serum levels of PTX and IL-6 were measured just before and at 4 h after CPB using HPLC and ELISA, respectively. Respiratory index (RI) before and at 4 h after CPB was calculated, and serum levels of C-reactive protein (CRP) and fibrinogen on postoperative day 1 were also determined. There were no significant differences in age, body weight, sex, surgical procedures, CPB time, haemodynamics or risk factors among the 3 groups. Serum IL-6 level and RI index after CPB in Group 2 were significantly decreased compared with those in Group 1 and the control group. These results, therefore, suggested that preoperative daily administration of 900 mg/day PTX contributed to the attenuation of CPB-induced SIRS and had a beneficial effect on the postoperative course after cardiovascular surgery.

[Bacteria isolated from surgical infections and its susceptibilities to antimicrobial agents--special references to bacteria isolated between April 2006 and March 2007]

Tendency of isolated bacteria from infections in abdominal surgery during the period from April 2006 to March 2007 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 474 strains including 23 strains of Candida spp. were isolated from 170 (75.2%) of 226 patients with surgical infections. Two hundred and twenty-six strains were isolated from primary infections, and 224 strains were isolated from postoperative infections. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from postoperative infections aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Staphylococcus spp. was higher from postoperative infections, while Enterococcus spp. was higher from primary infections. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae, Enterobacter cloacae and Pseudomonas aeruginosa, in this order, and from postoperative infections, P. aeruginosa was the most predominantly isolated, followed by E. coli and E. cloacae. Among anaerobic Gram-negative bacteria, the isolation rate of Bilophila wadsworthia was the highest from primary infections, followed by Bacteroides fragilis and from postoperative infections, B. fragilis was most predominately isolated, followed by Bacteroides caccae, Bacteroides thetaiotaomicron and B. wadsworthia in this order. In this series, we noticed no methicillin-resistant Staphylococcus aureus, nor multidrug-resistant P. aeruginosa. There were three strains of methicillin-resistant coagulase-negative Staphylococcus aureus, but all of them had good susceptibilities against various anti-MRSA antibiotics. We should carefully follow up B. wadsworthia.

Mechanism of impaired regeneration of fatty liver in mouse partial hepatectomy model

BACKGROUND AND AIM

The mechanism of injury in steatotic liver under pathological conditions been extensively examined. However, the mechanism of an impaired regeneration is still not well understood. The aim of this study was to analyze the mechanism of impaired regeneration of steatotic liver after partial hepatectomy (PH).

METHODS

db/db fatty mice and lean littermates were used for the experiments. Following 70% PH, the survival rate and recovery of liver mass were examined. Liver tissue was histologically examined and analyzed by western blotting and RT-PCR.

RESULTS

Of 35 db/db mice, 25 died within 48 h of PH, while all of the control mice survived. Liver regeneration of surviving db/db mice was largely impaired. In db/db mice, mitosis of hepatocytes after PH was disturbed, even though proliferating cell nuclear antigen (PCNA) expression (G1 to S phase marker) in hepatocytes was equally observed in both mice groups. Interestingly, phosphorylation of Cdc2 in db/db mice was suppressed by reduced expression of Wee1 and Myt1, which phosphorylate Cdc2 in S to G2 phase.

CONCLUSIONS

In steatotic liver, cell-cycle-related proliferative disorders occurred at mid-S phase after PCNA expression. Reduced expression of Wee1 and Myt1 kinases may therefore maintain Cdc2 in an unphosphorylated state and block cell cycle progression in mid-S phase. These kinases may be critical factors involved in the impaired liver regeneration in fatty liver.

Small liver graft regenerates through immediate increase of HGF and IL-6--possible involvement of sinusoidal tensile/shear stress in small liver graft

BACKGROUND/AIMS

The mechanisms whereby grafts in the recipients can be primed for regeneration following living donor liver transplantation (LDLT) are poorly understood. The present study was designed to understand the mechanism for posttransplant regeneration in small-for-size liver graft.

METHODOLOGY

Out of LDLT cases, we examined patients with end-stage liver cirrhosis and subsequent transplantation. A total of 16 patients were divided into 2 groups, group L (large graft) and group S (small graft). We examined the serum biochemical markers and cytokines preoperatively and postoperatively. We also carried out hemodynamic analysis by measuring the portal and arterial peak velocity.

RESULTS

The differences in ages, preoperative biochemical markers and MELD score between the two groups were not statistically significant. Though differences in the preoperative levels of IL-6, sIL-6R and HGF were not significant between the two groups, IL-6 and HGF levels in group S significantly increased postoperatively. Immediate and significant increase of Vp max was also observed in group S. Two weeks after LDLT, the regeneration rate in group S was significantly higher than that in group L.

CONCLUSIONS

These findings may allow us to speculate that immediate increase of portal pressure, reflecting sinusoidal tensile/shear stress, accelerates liver regeneration through immediate induction of IL-6 and HGF.

Preoperative proximal splenic artery embolization: a safe and efficacious portal decompression technique that improves the outcome of live donor liver transplantation

Terminal liver cirrhosis is associated with marked severe portal hypertension, which increases the risk of intraoperative hemorrhage and graft hyper-perfusion, especially, in small-for-size graft. In cases with developed collateral vessels, we often face difficulties in perihepatic dissection with blood stanching against bleeding during recipient hepatectomy. For aseptic preoperative portal decompression, we established the proximal splenic artery embolization (PSAE) technique. Sixty adult living donor liver transplantation recipients with viral/alcoholic hepatic failure were divided into two groups; PSAE group (n = 30) and non-PSAE (n = 30). In the PSAE group, the splenic artery was embolized proximal to the splenic hilum 12-18 h before surgery. PSAE enabled shortening of operating time, reduced blood loss, led to less need for transfusion, and significantly reduced the post-transplant portal venous velocity and ascites. PSAE was not associated with complications, e.g., splenic infarction, abscess, or portal thrombosis. Six of the non-PSAE patients required additional surgical intervention to resolve postoperative hemorrhage and three patients required secondary PSAE for arterial-steal-syndrome. The hospital mortality rate of PSAE patients (3.3%) was significantly better than that of the PSAE group (13.3%, P < 0.05). Preoperative noninvasive PSAE makes more efficient use of portal decompression; thus, it can potentially contribute to improvement of outcome.

Effect of adenosine receptor subtypes stimulation on mixed lymphocyte reaction

The cell-to-cell interaction through binding of intercellular adhesion molecule (ICAM)-1 on monocytes to their ligands lymphocyte function-associated antigen (LFA)-1 on T-cells plays important roles in cytokine production and T-cell proliferation. Interleukin (IL)-18, which plasma levels are elevated in patients during acute rejection following organ transplantation, induces the expression of ICAM-1 on monocytes, production of interferon (IFN)-gamma and IL-12 and lymphocyte proliferation during human mixed lymphocyte reaction. Activation of the adenosine A(2A) receptor on during reperfusion of various tissues has been found to markedly reduce ischemia-reperfusion injury. In the present study, we examined the effect of adenosine at increasing concentrations ranging from 0.1 to 100 microM on the IL-18-enhanced expression of ICAM-1, production of IFN-gamma and IL-12 and lymphocyte proliferation during human mixed lymphocyte reaction. Adenosine inhibited the IL-18-initiated immune responses. The IC(50) values of adenosine for inhibition of the IL-18-enhanced ICAM-1 expression, IFN-gamma production and lymphocyte proliferation were 20 microM, respectively. The actions of adenosine depended on the stimulation of adenosine A(2A) receptor. An inhibitor of protein kinase A (PKA) at 100 microM inhibited the actions of adenosine, suggesting that PKA might be involved in the actions of adenosine. On the other hand, the stimulation of adenosine A(1) and A(3) receptor blocked the actions of adenosine A(2A) receptor stimulation. These results suggest that adenosine inhibits the immune responses during mixed lymphocyte reaction via adenosine A(2A) receptor.

Action profiles of statins and calcineurin inhibitors during human mixed lymphocyte reaction

The cell-to-cell interaction through binding intercellular adhesion molecule (ICAM)-1 and CD40 on monocytes and their ligands such as lymphocyte function-associated antigen (LFA)-1 and CD40 ligand (CD40L) on T-cells plays roles in cytokine production and T-cell proliferation. Interleukin (IL)-18, which is elevated in the plasma during acute rejection after organ transplantation, induces the expression of ICAM-1 and CD40 on monocytes, the production of interferon (IFN)-gamma and IL-12 and the proliferation of T-cells during the human mixed lymphocyte reaction (MLR). In addition to the cholesterol lowering effect, statins improve patient survival and decrease rejection episodes in transplant recipients. In the present study, we investigated the difference of effect of statins and calcineurin inhibitors during MLR. 3-Hydroxy-3-methylglutaryl coenzyme-A (HMG-CoA) reductase inhibitors, fluvastatin and pravastatin and statin-derived LFA-1 inhibitors, LFA703 and LFA878, which did not inhibit HMG-CoA reductase, suppressed the production of IFN-gamma and IL-12 and the lymphocyte proliferation as well as the expression of ICAM-1 and CD40 on monocytes regardless of the presence of IL-18. However, the calcineurin inhibitors, tacrolimus and cyclosporine A (CsA), inhibited the IL-18-enhanced cytokine production and lymphocyte proliferation without any effect on the adhesion molecule expression. Thus, the action mechanism of stain is different from that of calcineurin inhibitors.

[Bacteria isolated from surgical infections and its susceptibilities to antimicrobial agents--special references to bacteria isolated between april 2003 and march 2004]

Tendency of isolated bacteria from infections in abdominal surgery during the period from April 2005 to March 2006 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 384 strains including 18 strains of Candida spp. were isolated from 161 (70.3%) of 229 patients with surgical infections. One hundred and ninty-five strains were isolated from primary infections, and 171 strains were isolated from postoperative infections. From primary infections, aerobic Gram-negative bacteria and aerobic Gram-positive bacteria were predominant, while aerobic Gram-positive bacteria were predominant from postoperative infections. The isolation rate of aerobic Gram-positive bacteria, such as Enterococcus spp. and Staphylococcus aureus were higher from both types of infections. Among anaerobic Gram-positive bacteria, the isolation rate of Peptostreptococcus spp. was the highest from both types of infections. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Pseudomonas aeruginosa, Klebsiella spp. in this order, and from postoperative infections, E. coli was the most predominantly isolated, followed by Klebsiella pneumoniae and P. aeruginosa. Among anaerobic Gram-negative bacteria, the isolation rate of Bacteroides fragilis group was the highest from both primary and postoperative infections. In this series, we noticed no vancomycin-resistant Gram-positive cocci, nor multidrug-resistant P. aeruginosa. But cefazolin-resistant E. coli producing extended spectrum fl-lactamase was seen in 5.0 per cents. We should be carefully followed up the facts that the increasing isolation rates of B. fragilis group and Bilophila wadsworthia which were resistant to both penicillins and cephems.

The immunosuppressive effects of nicotine during human mixed lymphocyte reaction

Cell-to-cell interaction through binding intercellular adhesion molecule (ICAM)-1, B7.1, B7.2 and CD40 on monocytes and their ligands on T-cells plays roles in cytokine production and T-cell proliferation. Interleukin (IL)-18, which is elevated in the plasma during acute rejection after organ transplantation, induces the expression of ICAM-1, B7.1, B7.2 and CD40, production of interferon (IFN)-gamma and IL-12 and proliferation of lymphocytes during human mixed lymphocyte reaction. Nicotine is known to inhibit the production of pro-inflammatory cytokines from macrophages through the stimulation of nicotinic acetylcholine receptor alpha7 subunit. In the present study, we examined the effect of increasing concentrations ranging from 0.1 to 100 microM of nicotine on the expression of ICAM-1, B7.1, B7.2 and CD40, production of IFN-gamma and IL-12 and proliferation of lymphocytes during mixed lymphocyte reaction treated with IL-18 at 100 ng/ml for 48 h. Nicotine inhibited the expression of adhesion molecules, cytokine production and lymphocyte proliferation. The IC50 values of nicotine for inhibition of the IL-18-enhanced ICAM-1 expression, IFN-gamma production and proliferation were 1, 1 and 2 microM, respectively. A non-selective and a selective antagonist for nicotinic acetylcholine receptor alpha7 subunit, mecamylamine and alpha-bungarotoxin abolished the effects of nicotine. The actions of nicotine might depend on stimulation of nicotinic acetylcholine receptor alpha7 subunit. Nicotine induced prostaglandin E(2) production during mixed lymphocyte reaction. The inhibitors of cyclooxygenase (COX)-2 and protein kinase A (PKA) at 100 microM inhibited the actions of nicotine, suggesting that the endogenous prostaglandin E(2) might be, at least, partially involved the actions of nicotine.

Effects of adenosine on adhesion molecule expression and cytokine production in human PBMC depend on the receptor subtype activated

BACKGROUND AND PURPOSE

Adenosine suppresses immune responses through adenosine(2A) (A(2A)) receptors, by raising intracellular cAMP. Interleukin (IL)-18 up-regulates the expression of intercellular adhesion molecule (ICAM)-1 on monocytes, leading to production of pro-inflammatory cytokines such as IL-12, interferon (IFN)-gamma and tumor necrosis factor (TNF)-alpha by human peripheral blood mononuclear cells (PBMC). We have previously demonstrated that elevation of cAMP inhibits this IL-18-induced expression of adhesion molecules. In the present study, we examined the effect of adenosine on the IL-18-induced up-regulation of ICAM-1 on human monocytes and production of IL-12, IFN-gamma and TNF-alpha by PBMC.

EXPERIMENTAL APPROACH

The expression of ICAM-1 was examined by flow cytometry. IL-12, IFN-gamma and TNF-alpha were determined by ELISA assay.

KEY RESULTS

Adenosine inhibited the IL-18-induced up-regulation of ICAM-1 on human monocytes and it abolished the IL-18-enhanced production of IL-12, IFN-gamma and TNF-alpha. While an A(2A) receptor antagonist reversed the action of adenosine, an A(1) or A(3) receptor antagonist enhanced them. An A(2A) receptor agonist, CGS21680, mimicked the effects of adenosine and its effects were abolished not only by the A(2A) receptor antagonist but also by A(1) or A(3) receptor agonists. Activation via A(2A) receptors resulted in elevation of cAMP in monocytes, whereas the stimulation of A(1) or A(3) receptors inhibited it, suggesting that intracellular signal transduction following ligation of A(2A) receptors might be blocked by activation of A(1) or A(3) receptors.

CONCLUSIONS AND IMPLICATIONS

Adenosine differentially regulates IL-18-induced adhesion molecule expression and cytokine production through several subtypes of its receptors.

Stimulation of alpha7 nicotinic acetylcholine receptor inhibits CD14 and the toll-like receptor 4 expression in human monocytes

The lipopolysaccharide (LPS)-receptor complex, CD14/toll-like receptor 4, is known to play a role in the immune responses during sepsis. Excessive inflammation and tumor necrosis factor (TNF)-alpha synthesis have been reported to cause morbidity and mortality in endotoxemia and sepsis. Cell-to-cell interaction through the engagement between intercellular adhesion molecule 1, B7.1, and CD40 on monocytes and their ligands on T cells has been suggested to play a role in the inflammatory response such as TNF-alpha and interleukin 10 production. Nicotine, with the stimulation of the nicotinic acetylcholine receptor alpha7 subunit (alpha7-nAChR), has now become the focus of attention because of its anti-inflammatory effects. However, little is known about the mechanism of the inhibitory effects induced by nicotine on the LPS-induced immune responses. In the present study, we found that nicotine suppressed the expression of CD14, toll-like receptor 4, intercellular adhesion molecule 1, B7.1, and CD40 on monocytes and the production of TNF-alpha, but not interleukin 10, in human peripheral blood mononuclear cells in the presence of LPS. The actions of nicotine were reversed by a nonselective and a selective alpha7-nAChR antagonist, mecamylamine and alpha-bungarotoxin, respectively. Therefore, nicotine might inhibit the LPS receptor complex expression via alpha7-nAChR, thus leading to a decrease in the adhesion molecule expression and TNF-alpha production. Moreover, we demonstrated that a nuclear factor-kappaB and a p38 mitogen-activated protein kinase inhibitor mimicked the actions of nicotine in the presence of LPS. These results suggested that the nuclear factor-kappaB and p38 mitogen-activated protein kinase might be involved in the actions of nicotine.

Protective effects of nafamostat mesilate on liver injury induced by lipopolysaccharide in rats: possible involvement of CD14 and TLR-4 downregulation on Kupffer cells

Nafamostat mesilate (NM) is a synthetic protease inhibitor with various biological effects. To determine its effect on liver injury related to sepsis, we investigated the effects of NM on lipopolysaccharide (LPS)-induced liver injury. Wistar rats were allocated into two groups; the NM group underwent intraperitoneal NM administration 30 min before LPS administration, and the control group underwent PBS administration. Serum AST and ALT levels were significantly decreased in NM-treated rats. Reduced levels of TNF-alpha, IL-1beta, and IFN-gamma were observed after LPS administration in NM-treated rats. No significant differences were observed in IL-6 levels between the NM and the control group. In contrast, HGF levels were significantly increased only in control rats. NM treatment decreased protein and mRNA levels of TLR-4 and CD14. Our data suggest that NM treatment has protective effects against LPS-induced hepatotoxicity through downregulation of TLR4 and CD14 in liver, which decreased TNF-alpha, IL-1beta, and IFN-gammaproduction in liver.

Effect of nicotine on IL-18-initiated immune response in human monocytes

Nicotine is thought to inhibit the production of proinflammatory cytokines from macrophages through an anti-inflammatory pathway that is dependent on nicotinic acetylcholine receptor alpha7 subunit (alpha7-nAChR). IL-18, an important proinflammatory cytokine, is reported to induce the expression of adhesion molecules on monocytes, thus enhancing cell-to-cell interactions with T-cells and contributing to IL-18-initiated cytokine production. Accordingly, inhibition of IL-18 suppresses systemic inflammatory responses. In the present study, we found that nicotine inhibited the IL-18-enhanced expression of ICAM-1, B7.2, and CD40 on monocytes, and the production of IL-12, IFN-gamma, and TNF-alpha by PBMC. A nonselective and a selective alpha7-nAChR antagonist, mecamylamine, and alpha-bungarotoxin abolished the effects of nicotine, suggesting that this depends on alpha7-nAChR stimulation. It is reported that nicotine induces prostaglandinE2 (PGE(2)) production in PBMC through the up-regulation of cyclooxygenase (COX)-2 expression. PGE(2) is known to activate the EP2/EP4-receptor, leading to an increase in cyclic adenosine monophosphate (cAMP) levels and protein kinase A (PKA) activity. Consistent with this, we found that COX-2 and PKA inhibitors prevented the effects of nicotine on adhesion molecule expression and cytokine production, indicating that the mechanism of action of nicotine may be via endogenous PGE(2) production.

alpha7 Nicotinic acetylcholine receptor stimulation inhibits lipopolysaccharide-induced interleukin-18 and -12 production in monocytes

Nicotine inhibited interleukin (IL)-18 and -12 production in lipopolysaccharide (LPS)-stimulated monocytes, and the action of nicotine was antagonized by a non-selective and a selective alpha7 nicotinic acetylcholine receptor (alpha7-nAChR) antagonist, suggesting that the stimulation of alpha7-nAChR may be involved in the action of nicotine. Nicotine is reported to induce prostaglandin E(2) (PGE(2)) production in monocytes through the up-regulation of cyclooxygenase (COX)-2 expression. PGE(2) is known to increase cAMP levels and to activate protein kinase A (PKA). COX-2 and PKA inhibitors prevented the action of nicotine, indicating that the mechanism of action of nicotine may be via endogenous PGE(2) production.

Hypothesis: the antitumor activities of statins may be mediated by IL-18

Statins, which inhibit 3-hydroxy-3-methylglutaryl coenzyme-A (HMG-CoA) reductase, are thought to reduce the risk of cancer through the inhibition of Ras farnesylation and serum lipid level. A pleiotropic proinflammatory cytokine, interleukin-18 (IL-18), is reported to exhibit significant antitumor activities through the activation of cytotoxic T lymphocytes and natural killer cells and the inhibition of angiogenesis. Previously, we found that pravastatin, fluvastatin, and simvastatin induced the production of IL-18 in human monocytes. The addition of mevalonate abolished the IL-18 production induced by pravastatin, fluvastatin, and simvastatin, indicating that the IL-18 production might be a result of the inhibition of HMG-CoA reductase. We present a new hypothesis that the production of IL-18 might play roles in the action of statins on cancer.

Cimetidine Induces Interleukin-18 Production through H2-Agonist Activity in Monocytes

The present study demonstrates a possible mechanism for the improvement of gastrointestinal cancer patients' prognosis by the histamine receptor type 2 (H2R) antagonist cimetidine. This agent, but not the H2R antagonists ranitidine and famotidine, induced the production of an antitumor cytokine, interleukin (IL)-18, by human monocytes and dendritic cells (DC). In fact, ranitidine and famotidine antagonized cimetidine-induced IL-18 production. Cimetidine induced the activation of caspase-1, which is reported to modify immature IL-18 to mature/active IL-18, and the elevation of intracellular cAMP, leading to the activation of protein kinase A (PKA). The PKA inhibitor H89 abolished the IL-18 production induced by cimetidine. Moreover, the effects of cimetidine on IL-18 production were reproduced in peripheral blood mononuclear cells from wild-type mice, but not in those from H2R knockout mice. In conclusion, cimetidine, a partial agonist for H2R, has a pharmacological profile different from ranitidine and famotidine, possibly contributing to its antitumor activity on gastrointestinal cancers.

Ex vivo adenoviral gene transfer of constitutively activated STAT3 reduces post-transplant liver injury and promotes regeneration in a 20% rat partial liver transplant model

Signal transducer and activator of transcription-3 (STAT3) is one of the most important transcription factors for liver regeneration. This study was designed to examine the effects of constitutively activated STAT3 (STAT3-C) on post-transplant liver injury and regeneration in a rat 20% partial liver transplant (PLTx) model by ex vivo adenoviral gene transfer. Adenovirus encoding the STAT3-C gene was introduced intraportally into liver grafts and clamped for 30 min during cold preservation. After orthotopic PLTx, liver graft/body weights and serum biochemistry were monitored, and both a histological study and DNA binding assay were performed. STAT3-C protein expression and its binding to DNA in the liver graft were confirmed by Western blotting and electrophoretic mobility shift assay (EMSA), respectively. This treatment modality promoted post-Tx liver regeneration effectively and rapidly. The serum levels of alanine aminotransferase/aspartate aminotransferase (AST/ALT) and bilirubin decreased in rats with STAT3-C. However, albumin (a marker of liver function) did not. Ex vivo gene transfer of STAT3-C to liver grafts reduced post-Tx injury and promoted liver regeneration. Thus, the activation of STAT3 in the liver graft may be a potentially effective clinical strategy for improving the outcome of small-for-size liver transplantation.

The immunosuppressive effects of ciprofloxacin during human mixed lymphocyte reaction

Interleukin (IL)-18, which is elevated in the plasma during acute rejection after organ transplantation, is known to induce the expression of intercellular adhesion molecule (ICAM)-1, B7.1, B7.2, CD40 and CD40 ligand (CD40L) on monocytes, the production of interferon (IFN)-gamma and IL-12 and the proliferation of lymphocytes during the human mixed lymphocyte reaction (MLR). Ciprofloxacin (CIP), which is useful for the clinical treatment of infections due to its antibacterial properties after transplantation, was shown to suppress the IFN-gamma and IL-12 production, the lymphocyte proliferation and the ICAM-1, B7.1, B7.2 and CD40 expression on monocytes during MLR in the presence of IL-18. CIP also induced the production of prostaglandin (PG) E2. In order to determine whether the effects of CIP on the expression of the activation markers were due to CIP-dependent production of PGE2, we examined the effect of cyclooxygenase (COX)-2 and protein kinase A (PKA) inhibitors on the actions of CIP. Thereby, the inhibitors were found to abolish the actions of CIP. These results therefore suggest that CIP might exert its immune modulatory effects via the production of PGE2.

[Bacteria isolated from surgical infections and its susceptibilities to antimicrobial agents--special references to bacteria isolated between April 2003 and March 2004]

Tendency of isolated bacteria from infections in general surgery during the period from April 2004 to March 2005 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 645 strains including 17 strains of Candida spp. were isolated from 226 (79.0%) of 286 patients with surgical infections. Three hundred and seventeen strains were isolated from primary infections, and 345 strains were isolated from postoperative infections. From primary infections, anaerobic Gram-positive bacteria and anaerobic Gram-negative bacteria were predominant, while aerobic Gram-positive bacteria were predominant from postoperative infections. The isolation rate of aerobic Gram-positive bacteria, such as Enterococcus spp. and Staphylococcus aureus were higher from both types of infections. Among anaerobic Gram-positive bacteria, the isolation rate of Peptostreptococcus spp. was the highest from both types of infections. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Pseudomonas aeruginosa, Klebsiella pneumoniae and Citrobacter freundii in this order, and from postoperative infections, P. aeruginosa was the most predominantly isolated, followed by E. coli, E. cloacae, and K. pneumoniae. Among anaerobic Gram-negative bacteria, the isolation rate of Bacteroides fragilis group was the highest from both primary infections followed by Bilophila wadsworthia. While the isolation rate of B. fragilis group was also the highest from postoperative infections, the following bacteria were Bacteroides thetaiotaomicron and B. wadsworthia in this order. In this series, we noticed no vancomycin-resistant Gram-positive cocci, but a few strains of moderately arbekacin-resistant MRSA. Carbapenem-resistant P. aeruginosa but not multidrug-resistant was seen in 13.3 per cents. Also cefazolin-resistant E. coli probably producing extended spectrum beta-lactamase was seen in 7.0 per cents. We should be carefully followed up the facts that an increasing isolation rates of B. fragilis group and B. wadsworthia which were resistant to both penicillins and cephems.

THE EFFECT OF CIPROFLOXACIN ON CD14 AND TOLL-LIKE RECEPTOR-4 EXPRESSION ON HUMAN MONOCYTES

CD14/toll-like receptor (TLR)-4 complex on monocytes/macrophages can bind lipopolysaccharide (LPS) and transduce the signals intracellularly. An antibacterial drug, ciprofloxacin (CIP), has been reported to modulate the inflammatory and immune responses. In the present study, we examined the effects of CIP on the LPS-induced activation of monocytes isolated from human peripheral blood mononuclear cells (PBMC). CIP suppressed the expression of CD14, TLR-4, intercellular adhesion molecule (ICAM)-1, B7.1, B7.2, and CD40 and the production of tumor necrosis factor (TNF)-alpha induced by LPS in monocytes. CIP induced the production of prostaglandin (PG)E2 and increased intracellular cyclic adenosine monophosphate (cAMP) levels. Cyclooxygenase (COX)-2 inhibitors, NS398 and indomethacin, reversed the effects of CIP on TNF-alpha production and reduced the levels of different surface antigens, whereas a protein kinase A (PKA) inhibitor, H89, did not. Therefore, CIP might regulate the TNF-alpha production induced by LPS by inhibiting the expression of LPS receptor complex, which seems to be mediated by COX-2 but not the cAMP/PKA pathway.

The role of a protease inhibitor against hepatectomy

BACKGROUND/AIMS

Nafamostat Mesilate (NM) is a synthetic serine protease inhibitor that is capable of inhibiting the various coagulation factors. To determine whether NM may also be useful in attenuating operative invasiveness, we investigated the effects of perioperative administration of NM on postoperative serum levels of proinflammatory cytokine IL-6 and hepatocyte growth factor (HGF).

METHODOLOGY

Thirty patients undergoing hepatectomy with hepatocellular carcinoma, biliary carcinoma and metastatic colorectal cancer were enrolled in this study. These patients were separated into two groups; high invasive group (resected liver volume: 1000cm3 <) and less invasive group (resected liver volume: 1000cm3 >). The high invasive group of 11 patients received perioperative administration of NM (Group NM), while the less invasive group of 19 patients did not (Group C). Serum levels of IL-6, HGF and soluble IL-6 receptor (sIL-6R) were simultaneously measured on preoperative and postoperative day ('day 0', 'day 7').

RESULTS

Serum IL-6 levels on day 0 were significantly elevated and returned to preoperative levels on day 7 in both groups, and the serum IL-6 level in Group NM on day 0 was significantly lower than that in Group C on day 0. Serum HGF levels on day 0 and day 7 were significantly higher in Group NM than those in Group C. Compared with healthy control subjects, the higher serum level of HGF on the preoperative day in all patients was attributable to tumor-burden. The sIL-6R levels on day 0 decreased in both groups, and their levels in Group NM were significantly lower than those in Group C, suggesting that increased synthesis of IL-6/sIL-6R complex which could accelerate liver regeneration.

CONCLUSIONS

These results suggested that perioperative administration of NM may attenuate surgical stress by decreasing production of proinflammatory cytokine IL-6, and may accelerate liver regeneration through stimulation with the IL-6/sIL-6R complex and possible involvement of increased production of HGF.