Improvement of Coracoid Process Union Rates: A Comparative Study of Conventional Open and Arthroscopic-assisted Bristow Procedures for Treating Anterior Shoulder Instability in Rugby Players

BACKGROUND

The Bristow coracoid transfer procedure is a reliable technique for treating anterior shoulder instability in patients with large glenoid bone loss or those involved in collision sports. However, its success is marred by its inferior bone union rate of the coracoid process as compared to the Latarjet procedure. This study aimed to evaluate whether arthroscopic confirmation of the secured coracoid fixation during the Bristow procedure improves the bone union rate and clinical outcomes as compared to the open procedure.

METHODS

We retrospectively reviewed 104 rugby players (n = 111 shoulders) who underwent an open (n = 66 shoulders) or arthroscopy-assisted (AS-assisted; n = 45 shoulders) Bristow procedure at our center from 2007 to April 2019. In the AS-assisted group, the screw fixation and coracoid stability and contact were confirmed under arthroscopic visualization. Graft union was evaluated through computed tomography at 3 months, 6 months, and 1 year postoperatively. Patient-reported outcome measures were assessed based on the American Shoulder and Elbow Surgeons (ASES) score, Rowe score, and satisfaction rate. Recurrence, the rate of return to play (RTP), and the frequency of pain after RTP were also assessed.

RESULTS

The mean follow-up period was 73.5 (range: 45-160) months for the open group and 32.3 (range: 24-56) months for the AS-assisted group. In the former, the rates of bone union were 50%, 72.7%, and 88.9% at 3 months, 6 months, and 1 year, respectively. In contrast, the AS-assisted group had significantly greater bone union rates-88.9%, 93.3%, and 95.6% at 3 months, 6 months, and 1 year, respectively. Both groups showed significant improvement in the ASES and Rowe scores compared to preoperative values as well as high satisfaction rates (open: 92%; AS-assisted: 95.7%). There were no statistically significant differences in the recurrence and RTP rates as well as the frequency of pain after RTP between the two groups.

CONCLUSION

The AS-assisted procedure allows early and high bone healing without compromising the clinical outcomes.

Unrecognized glenoid fracture in opposite shoulders with symptomatic anterior instability

BACKGROUND

The purpose of the present study was to investigate the characteristics of unrecognized glenoid fracture in opposite shoulders with symptomatic anterior instability.

METHODS

Participants were 38 patients, who had complaints of instability on only one side (symptomatic shoulder) and had no complaints despite of a glenoid fracture on the other shoulder (asymptomatic shoulder) from 2011 to 2020. Factors that could influence the onset of symptoms including glenoid rim morphology were retrospectively investigated.

RESULTS

Among the asymptomatic shoulders, 16 had a single traumatic event and 22 had no history of trauma. The glenoid morphology was normal in 6, erosion in 12 and bony Bankart in 20 on the symptomatic side, whereas the respective shoulders were 0, 16 and 22 on the asymptomatic side. Bone union of bony Bankart was complete in 9, partial in 3 and non-union in 8 on the symptomatic side, whereas the respective shoulders were 18, 3 and 1 on the asymptomatic side. The mean glenoid defect size was 10.4% and 7.8%, and the mean bone fragment size was 5.0% and 4.5%, respectively. The mean medial displacement of bone fragments was 2.6 mm and 1.0 mm, respectively (p < 0.001). A larger glenoid defect (≥10%) was recognized in 19 symptomatic shoulders and 10 asymptomatic shoulders. Among them, erosion was solely recognized in 5 symptomatic shoulders. In shoulders with bony Bankart, all 10 asymptomatic shoulders had a completely or partially united fragment with less than 2 mm displacement. On the other hand, among 14 symptomatic shoulders, united fragment was solely recognized in 8 shoulders, in which medial displacement was less than 2 mm in 3 shoulders.

CONCLUSIONS

Even if a glenoid fracture occurred, symptom such as instability or pain was not always recognized by all patients. Regardless of glenoid defect size, shoulders with a completely or partially united bone fragment and with less than 2 mm displacement were found to be asymptomatic.

Freeze-dried noncoagulating platelet-derived factor concentrate is a safe and effective treatment for early knee osteoarthritis

PURPOSE

While a wide variety of platelet-rich plasma (PRP) solutions has been developed, innovation continues. In this case, the freeze-dried platelet factor concentrate (PFC-FD) represents another step in PRP refinement. The preparation of PFC-FD at a central laboratory with freeze drying for shelf stabilization should provide additional quality improvements if clinical effectiveness can be demonstrated. Therefore, this study was undertaken to assess the safety and effectiveness of PFC-FD in a prospective open-label trial of patients suffering from knee osteoarthritis (OA).

METHODS

312 consecutive knee OA patients (67% female, mean age 63 ± 10 years), were prospectively recruited in an outpatient knee clinic in Japan. Of these, 10 (3.2%) were lost to follow-up at < 12 months and 17 (5.5%) sought additional knee therapy during the follow-up period. The primary outcome of interest was achievement of the OMERACT-OARSI responder criteria with secondary outcomes of adverse events and PROMs scores 1, 3, 6, 12 months following a single PFC-FD injection.

RESULTS

285 patients (91%) completed 12 month PROMs. The 17 who sought additional therapy were considered failures leaving an effective sample size of 302 for our primary outcome in which 62% of patients achieved OMERACT-OARSI responder status by 12 months. This varied by OA class with Kellgren-Lawrence grade 4 patients 3.6 times less likely to be responders than grade 1-2 patients. 6% of patients experienced a non-serious adverse event, primarily pain or swelling at the injection site.

CONCLUSIONS

PFC-FD provides an observable clinical improvement in 62% of knee OA patients at 12 months post-injection with very little risk of any clinically relevant adverse event. Of course, nearly 40% of patients did not experience an observable clinical improvement, primarily among those with worse KL grades.

LEVEL OF EVIDENCE

Therapeutic, Level II.

Repair of osteochondral defects: efficacy of a tissue-engineered hybrid implant containing both human MSC and human iPSC-cartilaginous particles

Both mesenchymal stromal cells (MSC) and induced pluripotent stem cells (iPSC) offer the potential for repair of damaged connective tissues. The use of hybrid implants containing both human MSC and iPSC was investigated to assess their combined potential to yield enhanced repair of osteochondral defects. Human iPSC-CP wrapped with tissue engineered constructs (TEC) containing human MSC attained secure defect filling with good integration to adjacent tissue in a rat osteochondral injury model. The presence of living MSC in the hybrid implants was required for effective biphasic osteochondral repair. Thus, the TEC component of such hybrid implants serves several critical functions including, adhesion to the defect site via the matrix and facilitation of the repair via live MSC, as well as enhanced angiogenesis and neovascularization. Based on these encouraging studies, such hybrid implants may offer an effective future intervention for repair of complex osteochondral defects.

Small extracellular vesicles derived from human adipose-derived mesenchymal stromal cells cultured in a new chemically-defined contaminate-free media exhibit enhanced biological and therapeutic effects on human chondrocytes in vitro and in a mouse osteoarthritis model

Human small extracellular vesicles (sEVs) derived from adipose-derived mesenchymal stromal cells (ASC) have been reported to suppress the progression of osteoarthritis (OA) in animal studies and subsequently, translation of this potential to assess their clinical efficacy is anticipated. However, fabrication protocols for sEVs to eliminate potential contamination by culture medium-derived components need to be established prior to their clinical use. The purpose of the present studies was to elucidate the influence of medium-derived contaminants on the biological effects of sEVs, and to establish isolation methods for sEVs using a new clinical grade chemically-defined media (CDM). The quantity and purity of ASC-derived sEVs cultured in four different CDMs (CDM1, 2, 3 and 4) were evaluated. The concentrates of the four media incubated without cells were used as the background (BG) control for each set of sEVs. The biological effect of sEVs fabricated in the four different CDMs on normal human articular chondrocytes (hACs) were evaluated in vitro using a variety of methodological assessments. Finally, the sEVs with the highest purity were tested for their ability to suppress the progression of knee OA mouse model. Analysis of the BG controls revealed that CDM1-3 contained detectable particles, while there was no visible contamination of culture media-derived components detected with CDM4. Accordingly, the sEVs fabricated with CDM4 (CDM4-sEVs) exhibited the highest purity and yield. Notably, the CDM4-sEVs were the most efficient in promoting the cellular proliferation, migration, chondrogenic differentiation, and anti-apoptotic activity of hACs. Furthermore, CDM4-sEVs significantly suppressed the osteochondral degeneration in vivo model. Small EVs derived from ASCs cultured in a CDM without detectable contaminants demonstrated enhanced biological effects on hACs and the progression of OA. Thus, sEVs isolated with CDM4 most optimally meet the requirements of efficacy and safety for assessment in their future clinical applications.

The prevalence of shoulders with a large glenoid defect and small bone fragment increases after several instability events during conservative treatment for traumatic anterior instability

Background

Unstable shoulders with a large glenoid defect and small bone fragment are at higher risk for postoperative recurrence after arthroscopic Bankart repair. The purpose of the present study was to clarify the changes in the prevalence of such shoulders during conservative treatment for traumatic anterior instability.

Methods

We retrospectively investigated 114 shoulders that underwent conservative treatment and computed tomography (CT) examination at least twice after an instability event in the period from July 2004 to December 2021. We investigated the changes in glenoid rim morphology, glenoid defect size, and bone fragment size from the first to the final CT.

Results

At first CT, 51 shoulders showed no glenoid bone defect, 12 showed glenoid erosion, and 51 showed a glenoid bone fragment [33 small bone fragment (<7.5%) and 18 large bone fragment (≥7.5%); mean size: 4.9 ± 4.2% (0-17.9%)]. Among patients with glenoid defect (fragment and erosion), the mean glenoid defect was 5.4 ± 6.6% (0-26.6%); 49 were considered a small glenoid defect (<13.5%) and 14 were a large glenoid defect (≥13.5%). While all 14 shoulders with large glenoid defect had a bone fragment, small fragment was solely seen in 4 shoulders. At final CT, 23 of the 51 shoulders persisted without glenoid defect. The number of shoulders presenting glenoid erosion increased from 12 to 24, and the number of shoulders with bone fragment increased from 51 to 67 [36 small bone fragment and 31 large bone fragment; mean size: 5.1 ± 4.9% (0-21.1%)]. The prevalence of shoulders with no or a small bone fragment did not increase from first CT (71.4%) to final CT (65.9%; P = .488), and the bone fragment size did not decrease (P = .753). The number of shoulders with glenoid defect increased from 63 to 91 and the mean glenoid defect significantly increased to 9.9 ± 6.6% (0-28.4%) (P < .001). The number of shoulders with large glenoid defect increased from 14 to 42 (P < .001). Of these 42 shoulders, 19 had no or a small bone fragment. Accordingly, among a total of 114 shoulders, the increase from first to final CT in the prevalence of a large glenoid defect accompanied by no or a small bone fragment was significant [4 shoulders (3.5%) vs. 19 shoulders (16.7%); P = .002].

Conclusions

The prevalence of shoulders with a large glenoid defect and small bone fragment increases significantly after several instability events.

Association Between Preoperative Glenoid Bone Loss and Postoperative Outcomes After Coracoid Transfer Combined With Open Bankart Repair: Comparison of the Bristow and Latarjet Techniques

Background

Whether the extent of glenoid bone loss (GBL) affects clinical outcome after coracoid process transfer (CPT) is still unclear.

Purpose

To evaluate postoperative outcomes after CPT combined with open Bankart repair in young rugby players in terms of the extent of GBL and between the Bristow and Latarjet techniques.

Study Design

Cohort study; Level of evidence, 3.

Methods

The authors investigated 101 shoulders in 91 competitive rugby players who underwent CPT combined with open Bankart repair by the Bristow (group B; 66 shoulders) or Latarjet (group L; 35 shoulders) procedure between 2007 and 2017. The extent of GBL was calculated from the en face view of the glenoid on preoperative 3-dimensional computed tomography scans and was used to categorize shoulders into 4 grades (grade 0, 0%; grade 1, >0% and ≤10%; grade 2, >10% and ≤20%; grade 3, >20%). At the minimum 2-year follow-up, the authors analyzed the relationship between GBL or GBL grade and postoperative outcome scores (American Shoulder and Elbow Surgeons score, Rowe score, Western Ontario Shoulder Instability Index, and patient satisfaction), return-to-play (RTP) times, graft failure (insufficient union or translocation), and recurrence.

Results

The mean GBL in all shoulders was 10.9% ± 9.2% and was not significantly different between the 2 groups. There were no significant correlations between GBL and any outcome measure in either group. The mean RTP time was significantly shorter in group L versus group B (4.8 ± 1.1 vs 5.8 ± 1.8 months, respectively; P = .002), but it was not associated with GBL. In group B, the rate of graft failure was not significantly higher in shoulders with grade 0 or 1 GBL versus grade 2 or 3 GBL (8 [25.0%] vs 4 [11.8%], respectively; P = .21). In group B, graft failure was confirmed in 12 shoulders (18.2%), compared with 1 shoulder (2.9%) in group L. Postoperative recurrence occurred in significantly fewer shoulders in group B than in group L (2 [3.0%] vs 5 [14.3%], respectively; P = .047).

Conclusion

The extent of GBL did not affect outcome scores after CPT, regardless of operative procedure.

Mechanistic insights into glenohumeral kinematics derived from positional relationship between the contact path and humeral tuberosity

Although three-dimensional (3D) glenohumeral (GH) motion has generally been expressed only by rotational elements, its mechanistic details, including GH rotations, remain unknown owing to a lack of geometric investigations. This study aims to investigate the positional relationship between the contact path and humeral tuberosities at the GH joint during arm elevation and to consider the mechanism of GH kinematics. Shoulder kinematics were captured using two-dimensional and 3D single-plane image registration techniques in 15 young healthy subjects during flexion, scaption, and abduction. The glenoid movement relative to the humeral head was calculated to describe the contact path on the humeral head. From the start to 45° of flexion, scaption, and abduction, the glenoid center moved from the anteromedial to the anterior, central, and posterior portions of the humeral head, respectively, as the GH joint rotated externally. From 45° to the maximal elevation for all elevation planes, the glenoid center moved upward to the humeral head and came close to the bicipital groove (BG) at maximal elevation, while the glenoid maintained a constant inclination at 20°-40° relative to the humerus. To investigate this mechanism, the position of humeral tuberosities relative to the glenoid was calculated, and the BG was found to face the supraglenoid tubercle, the attachment site of the long head of biceps (LHB). GH external rotation mainly occurred depending on the elevation planes in the early phase of elevation, and it might be kept constant by the LHB and rotator cuff in the mid- to end range of elevation.

Anterior glenoid rim erosion in the early stage after arthroscopic Bankart repair affects postoperative recurrence

Background

Recent studies reported that anterior glenoid rim erosion can occur in the early period after arthroscopic Bankart repair (ABR) for traumatic anterior shoulder instability. However, it is unknown whether such erosion is a risk factor for postoperative recurrence. This study evaluated risk factors for postoperative recurrence after ABR, specifically aiming to elucidate whether reduction of postoperative glenoid width due to anterior glenoid rim erosion is one of such factors.

Methods

A total of 220 shoulders that underwent ABR alone between 2013 and 2020 were retrospectively investigated. Patient age at surgery, whether the patient was a collision/contact athlete, anchor placement, preoperative glenoid bone defect (%), localization of the Hill-Sachs lesion, and change of glenoid width (%) in the 6 months after surgery were investigated for their statistical relation to recurrence by univariate and multiple logistic regression analysis.

Results

Postoperative recurrence occurred in 32 of 220 shoulders (14.5%). In univariate analysis, being a collision/contact athlete was the only variable with a significant effect on recurrence (odds ratio [OR], 2.555; 95% confidence interval [CI], 1.123-5.814; P = .03). Change of glenoid width reduction was larger in those with recurrence than without recurrence, but the difference was not statistically significant (-7.0 ± 6.6% vs. -5.0 ± 9.3%; P = .14). However, in multivariate logistic analysis, preoperative glenoid bone defect (%) (adjusted unit OR, 1.076; 95% CI, 1.018-1.137; P = .010) and postoperative change of glenoid width (%) (adjusted unit OR, 0.946; 95% CI, 0.900-0.994; P = .028) had a significant influence on postoperative recurrence.

Conclusion

Glenoid width reduction due to anterior glenoid rim erosion after ABR is a risk factor for recurrence.

Clinical Safety and Effectiveness of Adipose-Derived Stromal Cell vs Stromal Vascular Fraction Injection for Treatment of Knee Osteoarthritis: 2-Year Results of Parallel Single-Arm Trials

BACKGROUND

There are currently no disease-modifying treatments available for knee osteoarthritis (OA), although cultured adipose-derived stromal cells (ASCs) have shown promise in experimental models. However, given the regulatory limits on the use of cultured cells in humans, previous trials have focused primarily on the stromal vascular fraction (SVF) intra-articular injection. Therefore, the therapeutic value of ASCs for knee OA remains unknown.

PURPOSE

To study ASC versus SVF intra-articular injection in patients with Kellgren-Lawrence (KL) knee OA grades 2 to 4 in parallel single-arm trials.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 80 patients were enrolled, with 42 (72 knees) receiving ASC intra-articular injection and 38 (69 knees) receiving SVF. Patient-reported outcome measures were assessed at 1, 3, 6, 12, and 24 months using the Knee injury and Osteoarthritis Outcome Score 5 (KOOS5) and pain visual analog scale (VAS). The percentages of patients achieving the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) were also calculated. Per protocol, a subset of the ASC group received an ASC booster injection after 6 months. A repeated-measures analysis of variance compared results between treatment arms and by KL grade over time.

RESULTS

Patient-reported outcome measures improved substantially after both treatments (P < .05 at all time points), with the ASC group more likely to achieve the MCID (50% vs 24%; P = .01) and PASS (45% vs 24%; P = .04) for the pain VAS and the MCID (43% vs 16%; P = .02) for the KOOS5 at 12 months, although not at 24 months. Knees treated with ASC for KL grade 2/3 OA had significantly superior outcomes compared with those with KL grade 4 OA for the KOOS5 (P = .01) and pain VAS (P = .03), but no such difference was observed in knees treated with SVF. Three patients receiving ASCs (7%; all KL grade 3) sought additional nonoperative treatment by 24 months versus 9 patients receiving SVF (24%; all KL grade 3) (P = .06). ASC booster injections conferred no additional benefit. Notably, patients in the ASC cohort reported more injection-site pain and swelling after the booster injection than after the initial injection (P < .01).

CONCLUSION

This represents the first head-to-head comparison of ASCs and SVF for the treatment of knee OA in humans. ASC and SVF injections both substantially improved knee pain and function at all follow-up time points, although ASC injections demonstrated significantly better improvements with regard to the MCID and PASS for the pain VAS and the MCID for the KOOS5 at 12 months. There appears to be no benefit to a booster ASC injection after initial treatment. Given less donor-site morbidity and equivalent superior outcomes at 2 years, the use of ASCs over SVF in the treatment of knee OA may be warranted.

Open Bristow Versus Open Latarjet for Anterior Shoulder Instability in Rugby Players: Radiological and Clinical Outcomes

Background:

Coracoid transfer is a reliable method for managing anterior shoulder instability in athletes who play contact sports; however, differences between the Bristow and Latarjet procedures are unclear.

Purpose:

To compare clinical outcomes and rates of bone union and bone resorption of the coracoid process between the open Bristow and open Latarjet procedures in rugby players.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Rugby players who underwent an open Bristow or an open Latarjet procedure were retrospectively reviewed for anterior shoulder instability, and 66 shoulders in the Bristow group and 35 in the Latarjet group were included. Graft union and resorption were evaluated using computed tomography at 3 months to 1 year postoperatively. Patient-reported outcome measures (American Shoulder and Elbow Surgeons score, Rowe score, and satisfaction rate) were obtained at a mean follow-up of 74 months (range, 45-160 months) for Bristow and 64 months (range, 50-76 months) for Latarjet procedures. Recurrence and the rate of return to play (RTP), frequency of pain after RTP, and retirement rate after RTP were also assessed.

Results:

In 97.1% of the Latarjet procedure cases, bone union of the coracoid was achieved at 3 months postoperatively; however, bone union was achieved in only 72.7% of the Bristow procedure cases at 6 months postoperatively. Bone resorption of the coracoid process occurred in 6.1% of shoulders after the Bristow procedure, whereas 100% of shoulders showed bone resorption after the Latarjet procedure. No statistical differences were found in outcome scores between the 2 procedures. Subluxation and persistent pain after returning to sports were identified at a significantly higher rate in the Latarjet group (5 shoulders [14%] and 9 shoulders [26%], respectively) than in the Bristow group (2 shoulders [3%] and 2 shoulders [3%]) (P = .0471 and P = .001, respectively).

Conclusion:

The Latarjet procedure had an advantage in the early and high rate of bone union but was at a disadvantage in bone resorption compared with the Bristow procedure. Subluxation and pain after returning to sports were more frequent in patients who underwent the open Latarjet procedure than in those who underwent the open Bristow procedure.

Accuracy of shoulder joint injections with ultrasound guidance: Confirmed by magnetic resonance arthrography

BACKGROUND

Intra-articular glenohumeral joint injections are essential procedures for treating various shoulder disorders. Fluoroscopy-guided injections have been extensively used; however, they pose a risk of radiation exposure and are expensive and time-consuming. Recently, it has been suggested that ultrasound-guided injections are accurate and cost effective procedures.

AIM

To evaluate the accuracy of ultrasound-guided glenohumeral injections using a posterior approach that is confirmed using magnetic resonance arthrography (MRA).

METHODS

The study included 179 shoulders of patients with recurrent anterior instability (150 patients; 103 and 76 right and left shoulders, respectively; 160 males and 19 females; average age = 20.5 years; age range: 14-63 years) who underwent MRA for preoperative diagnosis. They were injected with 12 mL lidocaine (1%) using the ultrasound-guided posterior approach and then underwent magnetic resonance imaging. Two shoulder surgeons, except for the injector, evaluated the transverse relaxation (T2)-weighted images of axial planes and classified the intra-articular condition of injected contrast into three groups based on one of the three following scenarios: no leakage, injection into the glenohumeral joint without leakage; minor leakage, practical intra-articular injection with some leakage outside the posterior rotator cuffs; and major leakage, inaccurate injection with mass leakage without any contrast into the joint. The inter-rater reliability between two assessors was also evaluated by calculating Cohen’s kappa coefficient. The learning curve was assessed regarding the inaccurate injection rate by analyzing Spearman’s rank correlation coefficient.

RESULTS

Of the 179 injections, 163 shoulders (91.0%) had no leakage, 10 shoulders (5.6%) had minor leakage, and six shoulders (3.4%) had major leakage. In total, 173 shoulders (96.6%) were intra-articularly injected; thus, we could detect anterior labrum and capsular pathologies. Regarding the inter-rater reliability, the kappa coefficient was 0.925, indicating consistency in the evaluations by both examiners. Regression analysis of the inaccurate injection rate for assessingtechnical learning showed a logarithmic curve with a downward trend (R² = 0.887, P < 0.001). Three (50%) of the six inaccurate injections classified into “major leakage” were observed in the first 30 injections, indicating that the accurate injection showed a leaning effect.

CONCLUSION

Ultrasound-guided intra-articular glenohumeral injections using a posterior approach had high accuracy; however, injection accuracy depends on clinical experience.

Potential of Soluble Decellularized Extracellular Matrix for Musculoskeletal Tissue Engineering - Comparison of Various Mesenchymal Tissues

Background

It is well studied that preparations of decellularized extracellular matrix (ECM) obtained from mesenchymal tissues can function as biological scaffolds to regenerate injured musculoskeletal tissues. Previously, we reported that soluble decellularized ECMs derived from meniscal tissue demonstrated excellent biocompatibility and produced meniscal regenerate with native meniscal anatomy and biochemical characteristics. We therefore hypothesized that decellularized mesenchymal tissue ECMs from various mesenchymal tissues should exhibit tissue-specific bioactivity. The purpose of this study was to test this hypothesis using porcine tissues, for potential applications in musculoskeletal tissue engineering.

Methods

Nine types of porcine tissue, including cartilage, meniscus, ligament, tendon, muscle, synovium, fat pad, fat, and bone, were decellularized using established methods and solubilized. Although the current trend is to develop tissue specific decellularization protocols, we selected a simple standard protocol across all tissues using Triton X-100 and DNase/RNase after mincing to compare the outcome. The content of sulfated glycosaminoglycan (sGAG) and hydroxyproline were quantified to determine the biochemical composition of each tissue. Along with the concentration of several growth factors, known to be involved in tissue repair and/or maturation, including bFGF, IGF-1, VEGF, and TGF-β1. The effect of soluble ECMs on cell differentiation was explored by combining them with 3D collagen scaffold culturing human synovium derived mesenchymal stem cells (hSMSCs).

Results

The decellularization of each tissue was performed and confirmed both histologically [hematoxylin and eosin (H&E) and 4’,6-diamidino-2-phenylindole (DAPI) staining] and on the basis of dsDNA quantification. The content of hydroxyproline of each tissue was relatively unchanged during the decellularization process when comparing the native and decellularized tissue. Cartilage and meniscus exhibited a significant decrease in sGAG content. The content of hydroxyproline in meniscus-derived ECM was the highest when compared with other tissues, while sGAG content in cartilage was the highest. Interestingly, a tissue-specific composition of most of the growth factors was measured in each soluble decellularized ECM and specific differentiation potential was particularly evident in cartilage, ligament and bone derived ECMs.

Conclusion

In this study, soluble decellularized ECMs exhibited differences based on their tissue of origin and the present results are important going forward in the field of musculoskeletal regeneration therapy.

The Development Process of Bipolar Bone Defects From Primary to Recurrent Instability in Shoulders With Traumatic Anterior Instability

BACKGROUND

Recurrence of glenohumeral joint instability after primary traumatic anterior instability is not rare, and bipolar bone loss is one of the most critical factors for recurrent instability, but the development process of bipolar bone defects is still unclear.

PURPOSE

To investigate the development process of bipolar bone defects from primary to recurrent instability among shoulders with traumatic anterior instability evaluated at least twice by computed tomography (CT).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

There were 44 patients (47 shoulders) with recurrence after primary instability in which bone morphology was evaluated by 3-dimensional reconstructed CT at primary instability (initial CT) and after recurrence. As CT was performed 3 times for 3 shoulders including primary injury and the second episode of instability (first recurrence), there were 50 CT evaluations. Morphological changes between the initial CT evaluation at primary instability and the second CT evaluation at first recurrence were investigated for 25 shoulders, with the mean interval since initial CT being 9.8 months (range, 2-23 months). Changes between initial CT evaluation and final CT evaluation after ≥2 recurrences were also investigated for 25 shoulders, while the mean number of instability episodes including primary instability was 8.0 (range, 3-40) and the mean interval since initial CT was 18.5 months (range, 5-56 months).

RESULTS

At primary instability, the prevalence of Hill-Sachs lesions (66.0%) was almost double that of glenoid defects (34.0%), but their prevalence was different between shoulders with primary subluxation (42.3% and 23.8%, respectively) and those with primary dislocation (84.7% and 42.3%, respectively). After recurrence, glenoid defects became significantly more frequent (at first recurrence, 72%; after ≥2 recurrences, 76%), while Hill-Sachs lesions showed a smaller increase (88% and 80%, respectively), so there was no difference between the prevalence of the 2 lesions. The sizes of glenoid defects and Hill-Sachs lesions also enlarged after recurrence, and large bone defects were frequently recognized after recurrence. While bipolar bone loss was not so frequent at primary instability (29.8%), bipolar bone loss increased significantly after recurrence (at first recurrence, 72%; after ≥2 recurrences, 72%). All Hill-Sachs lesions were on track at primary instability, but off-track lesions were recognized in 3 of 47 shoulders (6.4%) after recurrence.

CONCLUSION

In most shoulders with recurrent instability, a Hill-Sachs lesion developed first, followed by a glenoid defect, leading to bipolar bone loss. Off-track Hill-Sachs lesions were detected only after recurrence.

Bipolar Bone Loss in Male Athletes With Traumatic Anterior Shoulder Instability: An Evaluation Using a New Scoring System

Background:

The combination of a glenoid defect and a Hill-Sachs lesion in a shoulder with anterior instability has recently been termed “bipolar bone loss,” but the prevalence and influence of this condition on postoperative recurrence after arthroscopic Bankart repair are still unclear.

Purpose:

To investigate bipolar bone loss in male athletes using a new scoring system and to evaluate its efficacy by comparing it with the glenoid track concept.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

The sizes of both lesions were evaluated retrospectively in 80 male athletes (85 shoulders) using computed tomography. The glenoid defects and the length, width, and depth of the Hill-Sachs lesions were classified into 5 size categories and were allocated scores from “0” for no defect to “4” for the largest defect. Patients were then classified into 5 classes according to the total score for both lesions: class 1, 0-1 point; class 2, 2 points; class 3, 3 points; class 4, 4 points; and class 5, ≥5 points. The prevalence of bipolar bone loss and postoperative recurrence rates for patients with at least 2 years of follow-up were compared among the classes. The recurrence rate for each class was also compared between shoulders with an off-track lesion and shoulders with an on-track lesion as well as among 3 sporting categories: rugby, American football, and other sports.

Results:

Based on the combination of glenoid defect size and Hill-Sachs lesion length, the postoperative recurrence rate was 0% for shoulders in class 1, 12.5% for class 2, 33.3% for class 3, 28.6% for class 4, and 31.3% for class 5, while the recurrence rates were 0%, 16.7%, 28.6%, 27.3%, and 31.6%, respectively, for the combination of glenoid defect size and Hill-Sachs lesion width and 0%, 8.3%, 26.7%, 28.6%, and 35.3%, respectively, for the combination of glenoid defect size and Hill-Sachs lesion depth. Postoperative recurrence was frequently recognized regardless of the presence of off-track Hill-Sachs lesions. No recurrence was recognized in class 1 shoulders among rugby players, in classes 1 and 2 among American football players, and in classes 1 through 3 among other athletes based on the combination of glenoid defect size and Hill-Sachs lesion size.

Conclusion:

Our scoring system for bipolar bone loss was useful to evaluate the influence on postoperative recurrence in male athletes. The postoperative recurrence rate was influenced by the extent of bipolar bone loss and the sporting category regardless of the presence of off-track lesions.

The mode of actions of the Adacolumn therapeutic leucocytapheresis in patients with inflammatory bowel disease: a concise review

Patients with active inflammatory bowel disease (IBD) have elevated and activated myeloid leucocytes which infiltrate the colonic mucosa in vast numbers. Myeloid leucocytes such as the CD14(+) CD16(+) monocytes are major sources of tumour necrosis factor (TNF)-α, and therefore selective granulocyte/monocyte (GM) adsorption (GMA) should promote remission or enhance efficacy of pharmacological therapy. However, studies in IBD have reported both impressive as well as disappointing efficacy outcomes, indicating that patients' demographic factors might determine responders or non-responders to GMA. Nonetheless, this non-drug intervention has an excellent safety profile, and therapeutic GMA is expected to expand. In this review, attempts have been made to compile an update on the mode of actions (MoA) of the Adacolumn GMA. The MoA of GMA appears to be more than adsorption of excess neutrophils and TNF-producing CD14(+) CD16(+) monocytes per se. Adsorbed GMs release interleukin (IL)-1 receptor antagonist, hepatocyte growth factor and soluble TNF receptors, which are anti-inflammatory. Additionally, a sustained increase in lymphocytes including the regulatory CD4(+) CD25(+) T cells (lymphocyte sparing) is seen post-GMA. The impact of GMA on the immune system is potentially very interesting in the context of treating immune-related diseases. Future studies are expected to add intriguing insights to the MoA of GMA.

The mode of actions of the Adacolumn therapeutic leucocytapheresis in patients with inflammatory bowel disease: a concise review

Patients with active inflammatory bowel disease (IBD) have elevated and activated myeloid leucocytes which infiltrate the colonic mucosa in vast numbers. Myeloid leucocytes such as the CD14(+) CD16(+) monocytes are major sources of tumour necrosis factor (TNF)-α, and therefore selective granulocyte/monocyte (GM) adsorption (GMA) should promote remission or enhance efficacy of pharmacological therapy. However, studies in IBD have reported both impressive as well as disappointing efficacy outcomes, indicating that patients' demographic factors might determine responders or non-responders to GMA. Nonetheless, this non-drug intervention has an excellent safety profile, and therapeutic GMA is expected to expand. In this review, attempts have been made to compile an update on the mode of actions (MoA) of the Adacolumn GMA. The MoA of GMA appears to be more than adsorption of excess neutrophils and TNF-producing CD14(+) CD16(+) monocytes per se. Adsorbed GMs release interleukin (IL)-1 receptor antagonist, hepatocyte growth factor and soluble TNF receptors, which are anti-inflammatory. Additionally, a sustained increase in lymphocytes including the regulatory CD4(+) CD25(+) T cells (lymphocyte sparing) is seen post-GMA. The impact of GMA on the immune system is potentially very interesting in the context of treating immune-related diseases. Future studies are expected to add intriguing insights to the MoA of GMA.

Intensive granulocyte and monocyte adsorption versus intravenous prednisolone in patients with severe ulcerative colitis: an unblinded randomised multi-centre controlled study

BACKGROUND AND AIM

Several uncontrolled studies have reported on the efficacy of adsorptive depletion of peripheral blood granulocytes and monocytes/macrophages (GM) in patients with moderate or severe ulcerative colitis. This study was to compare the efficacy and safety of intensive GMA with intensive intravenous prednisolone in patients with severe ulcerative colitis.

METHODS

Seventy patients with clinical activity index 10-23 were randomly assigned to intensive GMA with the Adacolumn, at 2 sessions/week in the first 3 weeks and then 1 session/week for up to 11 sessions (n = 35) or intravenous prednisolone, 40-60 mg/day for 5-10 days (n = 35). No patient received immunomodulators within 8 weeks prior to entry. Clinical response based on intention to treat was assessed at weeks 2, 6 and 12.

RESULTS

Four patients in the prednisolone group and two patients in the GMA group discontinued in week 1. At weeks 2, 6 and 12, the remission (clinical activity index < or = 4) rates (%) in the GMA group were 17.1, 54.4, 74.3, respectively. The corresponding values in the prednisolone group were 25.7, 51.4 and 48.6. Further, at week 12, 27 patients (77%) in the GMA group and 5 patients (14%) in the prednisolone group were steroid free (P = 0.0076). In the GMA group, flushing and light-headedness were observed in 5 patients versus typical steroid side effects in 29 patients of the prednisolone group.

CONCLUSIONS

In this clinical response to GMA was comparable or better than prednisolone. Further, the response to GMA was slower than to intravenous prednisolone, but was more sustainable than the latter.

Effect of Helicobacter pylori infection and its eradication on nutrition

AIMS

To investigate the effects of Helicobacter pylori infection and eradication on nutrition.

METHODS

The body weight, height, blood pressure, gastric juice pH and fasting serum levels of glucose, total protein, albumin, total cholesterol and triglyceride were measured in H. pylori-positive and H. pylori-negative subjects, and the effect of eradication of H. pylori on these parameters was determined. The development of gastro-oesophageal reflux disease after treatment was also examined. Eight patients underwent a pancreatic function test before and after H. pylori eradication therapy.

RESULTS

The incidence of hypoproteinaemia in H. pylori-positive subjects was significantly higher than that in H. pylori-negative subjects. After eradication of H. pylori, the gastric juice pH values were significantly decreased, and the body weight and serum levels of total cholesterol, total protein and albumin were significantly increased. The incidence of hyperlipidaemia significantly increased and that of hypoproteinaemia significantly decreased in the group with eradication. Pancreatic function improved significantly after eradication of H. pylori. No significant changes in these parameters were observed in the group without eradication. Obese patients had a higher risk of the development of gastro-oesophageal reflux disease after eradication of H. pylori infection.

CONCLUSIONS

The eradication of H. pylori appears to improve some nutritional parameters.

Comparison of lansoprazole and famotidine for gastric acid inhibition during the daytime and night-time in different CYP2C19 genotype groups

BACKGROUND

The acid inhibitory effect of lansoprazole depends on the S-mephenytoin 4'-hydroxylase (CYP2C19) genotype status. The effect of famotidine is independent of this genotype.

AIM

To investigate the acid inhibitory effects of lansoprazole vs. famotidine during the daytime and night-time with reference to different CYP2C19 genotypes.

METHODS

Fifteen healthy volunteers were given 20 mg famotidine twice a day or 30 mg lansoprazole once a day for 8 days. On post-dose day 8, 24-h intragastric pH monitoring was performed.

RESULTS

During the daytime, the intragastric pH with lansoprazole was significantly higher than that with famotidine in the heterozygous extensive metabolizer group, whereas no significant difference was observed in the homozygous extensive metabolizer group. During the night-time, the intragastric pH with famotidine was quite similar to that with lansoprazole in the heterozygous extensive metabolizer and poor metabolizer groups. However, during the night-time, the intragastric pH with famotidine was significantly higher than that with lansoprazole in the homozygous extensive metabolizer group.

CONCLUSIONS

An insufficient acid inhibition by lansoprazole during the night-time in the homozygous extensive metabolizer group could be compensated for by famotidine. CYP2C19 genotype testing appears to be useful for predicting the optimal acid inhibitory drug treatment collated with circadian intragastric pH change.

Effects of CYP2C19 genotypic differences in the metabolism of omeprazole and rabeprazole on intragastric pH

BACKGROUND

Omeprazole is mainly metabolized in the liver by CYP2C19, a genetically determined enzyme, whereas rabeprazole is mainly reduced non-enzymatically and partially metabolized by CYP2C19. The therapeutic effects of rabeprazole are therefore assumed to be less affected by an individual's CYP2C19 status.

AIM

To investigate the acid inhibitory effects and plasma levels of omeprazole and rabeprazole with reference to different CYP2C19 genotypes.

METHODS

Fifteen healthy volunteers took a daily dose of 20 mg of omeprazole or rabeprazole for 8 days. On post-dose days 1 and 8, 24-h profiles of intragastric pH were recorded and plasma concentrations of omeprazole, rabeprazole and their metabolites were determined.

RESULTS

After single and repeated doses of omeprazole, the intragastric pH values and plasma concentrations of omeprazole and its metabolites were significantly dependent on the CYP2C19 genotype. Significant differences in the same kinetic and dynamic parameters were also observed after single doses of rabeprazole. Although the plasma levels of rabeprazole differed among the different CYP2C19 genotype groups after repeated doses, no significant differences in intragastric pH values were observed.

CONCLUSIONS

The acid inhibitory effects of omeprazole and rabeprazole are significantly dependent on the CYP2C19 genotype status, as well as on their intrinsic pharmacokinetic and pharmacodynamic characteristics and dosing schemes.

Involvement of alpha-PAK-interacting exchange factor in the PAK1-c-Jun NH(2)-terminal kinase 1 activation and apoptosis induced by benzo[a]pyrene

Benzo[a]pyrene [B(a)P], a potent procarcinogen found in combustion products such as diesel exhaust and cigarette smoke, has been recently shown to activate the c-Jun NH(2)-terminal kinase 1 (JNK1) and induce caspase-3-mediated apoptosis in Hepa1c1c7 cells. However, the molecules of the signaling pathway that control the mitogen-activated protein kinase cascades induced by B(a)P and the interaction between those and apoptosis by B(a)P have not been well defined. We report here that B(a)P promoted Cdc42/Rac1, p21-activated kinase 1 (PAK1), and JNK1 activities in 293T and HeLa cells. Moreover, alpha-PAK-interacting exchange factor (alpha PIX) mRNA and its protein expression were upregulated by B(a)P. While overexpression of an active mutant of alpha PIX (DeltaCH) facilitated B(a)P-induced activation of Cdc42/Rac1, PAK1, and JNK1, overexpression of mutated alphaPIX (L383R, L384S), which lacks guanine nucleotide exchange factor activity, SH3 domain-deleted alphaPIX (Delta SH3), which lacks the ability to bind PAK, kinase-negative PAK1 (K299R), and kinase-negative SEK1 (K220A, K224L) inhibited B(a)P-triggered JNK1 activation. Interestingly, overexpression of alphaPIX (Delta CH) and a catalytically active mutant PAK1 (T423E) accelerated B(a)P-induced apoptosis in HeLa cells, whereas alphaPIX (Delta SH3), PAK1 (K299R), and SEK 1 (K220A, K224L) inhibited B(a)P-initiated apoptosis. Finally, a preferential caspase inhibitor, Z-Asp-CH2-DCB, strongly blocked the alphaPIX (Delta CH)-enhanced apoptosis in cells treated with B(a)P but did not block PAK1/JNK1 activation. Taken together, these results indicate that alphaPIX plays a crucial role in B(a)P-induced apoptosis through activation of the JNK1 pathway kinases.

Microsatellite instability of papillary subtype of human gastric adenocarcinoma and hMLH1 promoter hypermethylation in the surrounding mucosa

Gastric cancer has striking heterogeneity in histological pattern, cellular phenotype, genotype, biomarkers, and biological behavior. We focused on the specific morphological papillary phenotype of gastric adenocarcinoma and attempted to identify its distinct molecular characteristics. In our comparative study, early stage papillary (papillary-dominant) gastric cancer showed a significantly higher and more widespread high-frequency microsatellite instability (MSI-H) than other morphological types. Analysis of mutations in a panel of five putative microsatellite instability (MSI)-associated genes in the MSI-H cases revealed that papillary or papillary-dominant cancer displays a unique profile of mutations compared to profiles previously reported in gastric cancer. Immunohistochemical staining and methylation analysis revealed that silencing of hMLH1 by methylation in its promoter region was responsible for the failure of mismatch repair in papillary-type gastric cancer, whereas aberrant promoter methylation of hMLH1 was not found in any cases without the unique mutator phenotype. Promoter hypermethylation of the hMLH1 genes was found to a lesser degree in the adjacent non-tumor mucosa in four of the 10 cases with tumor having the mutator phenotype. Microsatellite instability itself could not be detected in the adjacent non-tumor mucosa. Inactivation of hMLH1 expression by promoter hypermethylation may be an early event in carcinogenesis of this type of gastric cancer, preceding the development of the clear MSI phenotype of papillary carcinoma.

Effects of genotypic differences in CYP2C19 status on cure rates for Helicobacter pylori infection by dual therapy with rabeprazole plus amoxicillin

Rabeprazole is a potent proton pump inhibitor and is mainly reduced to thioether rabeprazole by a non-enzymatic pathway and partially metabolized to demethylated rabeprazole by CYP2C19 in the liver. We intended to determine a cure rate for Helicobacter pylori infection by dual rabeprazole/amoxicillin therapy in relation to CYP2C19 genotype status prospectively. Ninety-seven patients with gastritis and H. pylori infection completed the dual therapy with 10 mg of rabeprazole bid and 500 mg of amoxicillin tid for 2 weeks. At 1 month after treatment, cure of H. pylori infection was assessed on the basis of histology, a rapid urease test, culture, polymerase chain reaction (PCR), and 13C-urea breath test. CYP2C19 genotype status was determined by a PCR-restriction fragment length polymorphism method. Of the 97 patients, 33 were homozygous extensive metabolizers (homEM), 48 were heterozygous extensive metabolizers (hetEM), and 16 were poor metabolizers (PM). Cure of H. pylori infection was achieved in 79 of the 97 patients (81.4%, 95%CI = 71.9-88.7). Significant differences in cure rates among the homEM, hetEM, and PM groups were observed; 60.6% (95%CI = 42.1-77.3), 91.7% (95%CI = 80.0-97.7), and 93.8% (95%CI = 69.8-99.8), respectively (P = 0.0007). Twelve patients without cure after initial treatment (10 homEMs and 2 hetEMs) were successfully retreated with rabeprazole 10 mg q.i.d. and amoxicillin 500 mg q.i.d. for 2 weeks. The cure rates for H. pylori infection by dual rabeprazole/amoxicillin therapy depended on the CYP2C19 genotype status. This dual therapy appears to be effective for hetEM and PM patients. However, high dose dual rabeprazole/amoxicillin therapy was effective even for homEM patients. Therefore, the genotyping test of CYP2C19 appears to be a clinically useful tool for the optimal dual treatment with rabeprazole plus amoxicillin.

Effects of cyclooxygenase-2 inhibitor on gastric acid secretion in Helicobacter pylori-infected C57BL/6 mice

BACKGROUND

Helicobacter pylori-associated body gastritis inhibits gastric acid secretion. The aim of this study was to determine the effects of H. pylori infection on gastric acid secretion and further determine whether cyclooxygenase-2 was involved.

METHODS

C57BL/6 mice (n = 40) were inoculated with the Sydney strain of H. pylori. Control mice (n = 40) were treated with vehicle only. Half of the infected and control mice were fed an experimental diet containing etodolac (10 mg/kg/day) from 1 week after inoculation until the end of the experiment. Before, 12 and 24 weeks after inoculation, the gastric acid secretion, prostaglandin E2 (PGE2) levels in the gastric mucosa, and gastritis scores according to the updated Sydney system were determined. Immunohistochemical staining of COX-2 protein was also performed.

RESULTS

No significant changes in gastric acid secretion, gastritis scores or PGE2 levels in the gastric mucosa were observed in uninfected groups with or without etodolac treatment during the study period. In the H. pylori-infected group without etodolac treatment, gastric acid secretion was significantly decreased with increases in PGE2 levels in the gastric mucosa 24 weeks after inoculation compared with the controls. Gastritis score for activity was significantly higher, and strong staining for COX-2 protein was observed in the H. pylori-infected group. In the H. pylori-infected group with etodolac treatment, PGE2 in the gastric mucosa was decreased and acid secretion was restored to the same level as in the control group.

CONCLUSION

One of the mechanisms by which H. pylori infection inhibits gastric acid secretion is increased release of PGE2 produced by COX-2, which is induced by H. pylori infection.

Involvement of cyclooxygenase-2 in hyperplastic gastritis induced by Helicobacter pylori infection in C57BL/6 mice

BACKGROUND AND AIMS

The hyperplastic changes observed in Helicobacter pylori-associated gastritis have been considered to increase the risk of gastric cancer. The aim of this study was to determine whether cyclooxygenase-2 is involved in the hyperplastic changes in mice infected with H. pylori.

METHODS

Seven-week-old, male C57BL/6 mice (n=40) were inoculated with the Sydney strain of H. pylori. Control mice (n=40) were treated with vehicle only. Half of the infected and control mice were fed an experimental diet containing etodolac (10 mg/kg/day) from 1 week after inoculation until the end of the experiment. The thickness of gastric pits, COX-2 mRNA and protein levels, and prostaglandin E2 (PGE2) levels in the gastric mucosa were determined before and 12, and 24 weeks after inoculation.

RESULTS

The thickness of gastric pits, COX-2 mRNA and protein levels, and PGE2 levels were significantly increased at 24 weeks after inoculation of H. pylori compared with the control groups. Treatment with etodolac resulted in significant decreases in PGE2 production and in the thickness of gastric pits in the infected groups at 24 weeks after inoculation.

CONCLUSIONS

Our findings suggest that COX-2 is involved in the development of hyperplastic gastritis caused by H. pylori infection via the production of PGE2.

Effects of Helicobacter pylori infection on gastric acid secretion and serum gastrin levels in Mongolian gerbils

BACKGROUND AND AIMS

Body gastritis caused by Helicobacter pylori infection appears to inhibit gastric acid secretion. The aim of this study was to determine the effects of H pylori infection on gastric acid secretion and clarify its mechanisms with reference to interleukin 1beta (IL-1beta).

METHODS

(1) Mongolian gerbils were inoculated orally with H pylori. Before, six, and 12 weeks after inoculation, serum gastrin levels, gastric acid output, and IL-1beta mRNA levels in the gastric mucosa were determined. Pathological changes were also determined according to the updated Sydney system. (2) Effects of recombinant human IL-1 receptor antagonist (rhIL-1ra) on gastric acid output and serum gastrin levels were also determined.

RESULTS

(1) Scores for activity and inflammation of gastritis and serum gastrin levels were significantly increased, and gastric acid output was significantly decreased six and 12 weeks after inoculation with H pylori. IL-1beta mRNA levels in the gastric mucosa were also elevated six and 12 weeks after inoculation with H pylori. (2) Acid output and serum gastrin levels in the infected groups returned to control levels after rhIL-1ra injection.

CONCLUSIONS

Gastric acid secretion is decreased and serum gastrin levels are increased in Mongolian gerbils infected with H pylori. This change in gastric acid secretion appears to be mediated by IL-1beta induced by H pylori infection.

Intra-abdominal desmoplastic small round cell tumor (IDSRT)

Intra-abdominal desmoplastic small round cell tumor (IDSRT) is a rare neoplasm that develops in the abdominal cavity in young people. We experienced a 27-year-old man who visited with ascites of unknown cause. Compression of the colon was found by barium enema examination. On colonoscopic examination, diffuse white elevated lesions, about 5 mm in diameter, surrounded by rubedo, so-called aphthoid lesions, were also observed. IDSRT was diagnosed by biopsy at laparotomy, and chemotherapy with cyclophosphamide, etoposide, doxorubicin, and cisplatin was performed. The tumors shrank temporarily (partial response), but subsequently grew in size again. The patient died during the second course of chemotherapy after relapse. We present one case report, together with a review of the literature.

Effect of genotypic differences in CYP2C19 on cure rates for Helicobacter pylori infection by triple therapy with a proton pump inhibitor, amoxicillin, and clarithromycin

BACKGROUND

Proton pump inhibitors such as omeprazole and lansoprazole are mainly metabolized by CYP2C19 in the liver. The therapeutic effects of proton pump inhibitors are assumed to depend on CYP2C19 genotype status.

OBJECTIVE

We investigated whether CYP2C19 genotype status was related to eradication rates of H pylori by triple proton pump inhibitor-clarithromycin-amoxicillin (INN, amoxicilline) therapy and attempted to establish a strategy for treatment after failure to eradicate H pylori.

METHODS

A total of 261 patients infected with H pylori completed initial treatment with 20 mg of omeprazole or 30 mg of lansoprazole twice a day, 200 mg of clarithromycin three times a day, and 500 mg of amoxicillin three times a day for 1 week. CYP2C19 genotypes of patients were determined with polymerase chain reaction-restriction fragment length polymorphism analysis. Patients without eradication after initial treatment were retreated with 30 mg of lansoprazole four times daily and 500 mg of amoxicillin four times daily for 2 weeks.

RESULTS

Eradication rates for H pylori were 72.7% (95% confidence interval, 64.4%-81.8%), 92.1% (confidence interval, 86.4%-97.3%), and 97.8% (confidence interval, 88.5%-99.9%) in the homozygous extensive, heterozygous extensive, and poor metabolizer groups, respectively. Thirty-four of 35 patients without eradication had an extensive metabolizer genotype of CYP2C19. Nineteen of those patients were infected with clarithromycin-resistant strains of H pylori. However, there were no amoxicillin-resistant strains of H pylori. Re-treatment of H pylori infection with dual high-dose lansoprazole-amoxicillin therapy succeeded in 30 of 31 patients with extensive metabolizer genotype of CYP2C19.

CONCLUSION

The majority of patients without initial eradication of H pylori had an extensive metabolizer CYP2C19 genotype but were successfully re-treated with high doses of lansoprazole and an antibiotic to which H pylori was sensitive, such as amoxicillin, even when the patients were infected with clarithromycin-resistant strains of H pylori.

Molecular cloning and characterization of OsPSK, a gene encoding a precursor for phytosulfokine-alpha, required for rice cell proliferation

We previously characterized an OsPSK cDNA encoding a precursor of phytosulfokine-alpha (PSK-alpha), a peptide plant growth factor. Southern blot analysis suggested that OsPSK is a single-copy gene in rice, which we have isolated and characterized. The OsPSK gene consists of one large intron and two exons. The 5-amino acid PSK-alpha sequence located close to the COOH-terminus of the precursor is encoded in the second exon. A putative TATA box was found at position -68 with respect to the transcription initiation site. Upstream of this sequence, several potential regulatory elements, including one CAAT-box, three CCAAT-boxes, one enhancer core-like sequence, and three E-boxes could be identified. By constructing plasmids with various lengths of the 5'-upstream regions of the OsPSK gene fused to the coding sequence for bacterial beta-glucuronidase (GUS), we demonstrated a region 1.9 kb upstream of the transcription initiation point, which contains most of the putative 5'-regulatory elements, to be sufficient for maximal-level GUS expression in transformed rice Oc cells. The promoter of the OsPSK gene gave significantly higher levels of GUS expression than the CaMV 35S promoter. These results suggest that the OsPSK promoter could be useful for the constitutive expression of a foreign gene at high levels in transformed rice culture cells. Northern blot analyses suggest that the expression of OsPSK is reinforced by auxin and cytokinin.

Effects of higenamine on regulation of ion transport in guinea pig distal colon

Effects of higenamine on Na+, K+ and Cl- transport were studied on stripped guinea pig distal colonic mucosa in vitro using Ussing chambers. Addition of 10(-5) M higenamine induced a biphasic change in short circuit current (Isc): a transient increase followed by a long-lasting decrease that was accompanied by an increase in transepithelial conductance (Gt). The initial phase with an increase in Isc was partially inhibited by serosal bumetanide and abolished by mucosal diphenylamine-2-carboxylate, a chloride channel blocker, indicating transient induction of Cl- secretion. The second phase with a decrease in Isc was composed of two effects: the inhibition of the amiloride-sensitive electrogenic Na+ absorption and the stimulation of the bumetanide-sensitive K+ secretion. However, the initial transient increase was not observed at the lower concentration of higenamine (10(-8)-10(-6) M). All the changes in Isc and Gt induced by higenamine were suppressed by the non-selective beta-adrenergic receptor antagonist propranolol and by the beta2-adrenergic receptor antagonist ICI-118,551, but not by the beta1-adrenergic-receptor-selective antagonist atenolol or by the alpha-antagonists phentolamine, prazosin and yohimbine. These results suggest that higenamine inhibits electrogenic Na+ absorption and stimulates electrogenic K+ and Cl- secretion through beta2-adrenergic receptors in guinea pig distal colon.

Preoperative diagnosis of ileal lipoma by endoscopic ultrasonography probe

The occurrence of tumor in the small intestine is relatively rare. It has been demonstrated that lipoma of the ileum is a cause of intussusception. We report a 59-year-old man admitted to our hospital for lower abdominal pain. Diagnosis of intussusception was made by abdominal x-ray and ultrasonography. Enema contrast studies revealed ileocolic intussusception. Colonoscopy revealed a tumor with an submucosal tumor (SMT)-like head and coil-spring appearance in the ascending colon. Endoscopic ultrasonography (EUS) revealed a hyperechoic submucosal lesion with features compatible with lipoma. Subsequently, this was confirmed histopathologically after resection. To our knowledge, this is the first report of preoperative diagnosis of ileal lipoma by EUS.

Optimal propofol plasma concentration during upper gastrointestinal endoscopy in young, middle-aged, and elderly patients

BACKGROUND

Suitable propofol plasma concentrations during gastroscopy have not been determined for suppressing somatic and hemodynamic responses in different age groups.

METHODS

Propofol sedation at target plasma concentrations from 0.5 to 4.0 microgram/ml were performed randomly in three groups of patients (23 per group) who were undergoing elective outpatient gastroscopy: ages 17-49 yr (group 1), 50-69 yr (group 2), and 70-89 yr (group 3). Plasma propofol concentration in which 50% of patients do not respond to these different stimuli were determined by logistic regression: verbal command (Cp50ls), somatic response to gastroscopy (Cp50endo), and gag response to gastroscopy (Cp50gag). Hemodynamic responses were also investigated in the different age groups.

RESULTS

Cp50ls concentrations were 2.23 microgram/ml (group 1), 1.75 microgram/ml (group 2), and 1.40 microgram/ml (group 3). The Cp50endo values in groups 1 and 2 were 2.87 and 2.34 microgram/ml, respectively, which were significantly higher than their respective Cp50ls values. Cp50endo value in group 3 was 1.64 microgram/ml, which was close to its Cp50ls value. Because of a high degree of interpatient variability, Cp50gag could not be defined. Systolic blood pressure response decreased with increasing propofol concentrations.

CONCLUSIONS

The authors determined the propofol concentration necessary for gastroscopy and showed that increasing age reduces it. Propofol concentration that suppresses somatic response induces loss of consciousness in almost all young patients.

Alterations of GTP-binding proteins (Gsalpha and Gq/11alpha) in gastric smooth muscle cells from streptozotocin-induced and WBN/Kob diabetic rats

We investigated possible impairment of the signal transduction system in gastric myocytes of streptozotocin-induced diabetic (STZ) and spontaneous diabetic WBN/Kob (WBN/Kob) rats. Gastric motility 10 weeks after the onset of diabetes mellitus was significantly reduced in both diabetic rats compared with control, and the decreased motility was not recovered by the administration of insulin to maintain normal blood glucose levels. There was no significant difference between both types of diabetic rats and control rats in total number of [3H]quinuclidinyl benzilate ([3H]QNB) binding sites (Bmmax: 545-587 fmol/mg protein) on gastric smooth muscle cell membranes or in the affinity of [3H]QNB for the binding sites (Kd: 0.06-0.07 nM). Immunoblot analysis using polyclonal anti-G-protein antibodies indicated increased expression of Gsalpha in gastric smooth muscle cell membranes, but no significant change in Gialpha or Gq/11alpha expression in STZ rats, and decreased expression of Gq/11alpha with no significant change in Gsalpha and Gialpha in WBN/Kob rats. The cAMP production in gastric smooth muscle cell membranes was augmented in the absence and presence of 100 microM isoproterenol, and 100 microM forskolin in STZ rats, whereas no significant change of cAMP production was observed in WBN/Kob rats irrespective of the presence of the stimulants. These findings suggest that long-standing diabetes may induce alterations in signal transduction at downstream receptors in gastric myocytes, resulting in the impairment of gastric motility, although the mechanism of reduced contractile activity may differ between STZ and WBN/Kob rats.

Phytosulfokine-alpha, a peptide growth factor found in higher plants: its structure, functions, precursor and receptors

Phytosulfokine-alpha, a sulfated pentapeptide growth factor universally found in both monocotyledons and dicotyledons, strongly promotes proliferation of plant cells in culture. It is similar to animal polypeptide hormones in that it is processed from a larger precursor, preprophytosulfokine, although the putative processing sites do not conform to consensus sequences for endoproteolytic processing sites flanking animal prohormones. Like the animal preprohormones, preprophytosulfokine also has a signal peptide at the N-terminus for targeting to secretory pathways. The preprophytosulfokine gene has been confirmed to be expressed in vivo as well as in vitro.

Cure of refractory duodenal ulcer and infection caused by Helicobacter pylori by high doses of omeprazole and amoxicillin in a homozygous CYP2C19 extensive metabolizer patient

A 53-year old female patient with duodenal ulcer and Helicobacter pylori infection was treated three times with a proton pump inhibitor-based triple therapy, such as lansoprazole-clarithromycin-amoxicillin (INN, amoxicilline) and lansoprazole-minocycline-cefaclor. However, the H pylori infection was not cured. A culture test revealed that her infection was a clarithromycin-resistant but amoxicillin-sensitive strain of H pylori. Moreover, a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis revealed that she was a homozygous extensive metabolizer of cytochrome P450 (CYP) 2C19 (wt/wt). The usual dose of the proton pump inhibitor was therefore assumed to be insufficient for her and then she was treated with a high dose of omeprazole (120 mg/day) and amoxicillin (2,250 mg/day) for 2 weeks. The H pylori infection and the ulcer lesion were then cured. One of the factors associated with success or failure of cure of H pylori infection by the proton pump inhibitor-based triple therapy appeared to be CYP2C19 genotype status. Dual treatment with a sufficient dose of a proton pump inhibitor plus amoxicillin could cure H pylori infection even after the failure to cure H pylori infection by a usual proton pump inhibitor-based triple therapy in patients with the wt/wt homozygous extensive metabolizer genotype of CYP2C19.

Ovarian mucinous cystadenocarcinoma as a cause of Zollinger-Ellison syndrome: report of a case and review of the literature

Gastrin producing ovarian tumor is a rare cause of the Zollinger-Ellison syndrome. We report the case of an ovarian carcinoma showing increased plasma gastrin concentration. A 60-yr-old woman presented with epigastric pain and diarrhea. Physical examination showed a large mass in the lower abdomen. Computed tomography revealed a large multilocular ovarian cyst. Upper gastrointestinal endoscopy examination showed multiple ulcerations of the stomach and duodenum. The plasma gastrin level was 1500 pg/ml. No tumors were found in the pancreas and duodenum, and salpingo-oophorectomy was performed. Histologic examination revealed a mucinous tumor of borderline malignant potential. Immunoperoxidase studies for gastrin showed many gastrin-producing cells within the epithelium of the tumor. There have been 11 cases (including our patient) of gastrin-producing ovarian tumor reported in the literature. We review here the relevant literature. Although ovarian gastrinoma is extremely rare, it should be considered as a possible cause of the Zollinger-Ellison syndrome in women.

Existence of a plant tyrosylprotein sulfotransferase: novel plant enzyme catalyzing tyrosine O-sulfation of preprophytosulfokine variants in vitro

An in vitro assay system to detect tyrosylprotein sulfotransferase (TPST) activity of higher plant cells was established, using synthetic oligopeptides based on the deduced amino acid sequence of a phytosulfokine-alpha (PSK-alpha) precursor. TPST activity was found in microsomal membrane fractions of rice, asparagus and carrot cells and it was confirmed that acidic amino acid residues adjacent to the tyrosine residues of acceptor peptides were essential to the sulfation reaction. The asparagus TPST exhibited a broad pH optimum of 7.0-8.5, required manganese ions for maximal activity and appeared to be a membrane-bound protein localized in the Golgi apparatus. These enzymes should be defined as a new class of plant sulfotransferases that catalyze tyrosine O-sulfation of a PSK-alpha precursor and other unknown proteins.

A patient with undifferentiated carcinoma of gallbladder presenting with hemobilia

Hemobilia is relatively rare among hemorrhages in the digestive tract, and hemobilia caused by tumors of the biliary tract is particularly rare. We treated a 74-year-old-man with undifferentiated carcinoma of the gallbladder presenting with hemobilia. During hospitalization for neurogenic bladder at the Department of Urology, he showed progressive anemia. Since hemorrhage in the digestive tract was suspected, endoscopy of the upper gastrointestinal tract was performed, and bleeding from the papilla of Vater was observed. On ultrasound examination, findings were indicative of cholecystic cancer, and hemorrhage from the cystic duct was found on percutaneous transhepatic cholangioscopy. On perioral cholecystoscopy, however, masses of coagulated blood were found only in the gallbladder. Abnormalities such as dense staining of tumors or extravasation were not found on angiography. The patient died of hepatic failure due to rapid invasion of the liver by the tumor, associated with biliary infection and disseminated intravascular coagulation. At autopsy, a nodal tumor was found in the gallbladder, and the cavity of the gallbladder was filled with coagulated masses of blood. Direct invasion of the tumor to the liver, diaphragm, and transverse colon was found. The histopathological diagnosis was undifferentiated carcinoma (pleomorphic large-cell type).

Relation between interleukin-1beta messenger RNA in gastric fundic mucosa and gastric juice pH in patients infected with Helicobacter pylori

The effects of Helicobacter pylori infection on gastric acid secretion has not been clarified. The aim of this study was to elucidate the effects of H. pylori infection on gastric juice pH in relation to gene expression of interleukin-1beta (IL-1beta), which is reported to inhibit gastric acid secretion. Gastric juice pH and serum gastrin levels were measured in patients with peptic ulcer disease. The amount of IL-1beta mRNA in gastric fundic gland mucosa was also measured by a competitive reverse transcription-polymerase chain reaction method. These parameters were determined before and after treatment with lansoprazole and amoxicillin. Before treatment a significant positive relation was observed between the amount of IL-1beta mRNA in gastric fundic gland mucosa and gastric juice pH. After treatment significant decreases in the amount of IL-1beta mRNA, gastric juice pH, and serum gastrin levels were observed in patients with eradication of H. pylori, whereas no significant changes were observed in patients without eradication. These results suggest that H. pylori infection induces IL-1beta and suppresses acid secretion, resulting in increases in gastric juice pH and serum gastrin levels. Eradication of H. pylori decreases IL-1beta induction, resulting in an increase in gastric juice acidity and normalization of serum gastrin levels.