Involvement of limbic structures in patients with isolated rapid eye movement sleep behavior disorder

This study aimed to investigate the alterations in limbic structure volumes and limbic covariance network in patients with isolated rapid eye movement (REM) sleep behavior disorder (iRBD) and to compare them with healthy controls. We retrospectively enrolled 35 patients with iRBD and 35 healthy controls who underwent three-dimensional T1-weighted brain MRI. Volumetric analysis of subcortical limbic structures, including the hippocampus, amygdala, thalamus, mammillary body, hypothalamus, basal forebrain, septal nuclei, fornix, and nucleus accumbens, was performed. Furthermore, the limbic covariance network was examined using graph theory based on the limbic structure volumes. Some of the limbic structure volumes differed significantly. The right amygdala and hypothalamus volumes were lower in the patients with iRBD than in the healthy controls (0.101% vs. 0.114%, p = 0.016, and 0.027% vs. 0.030%, p = 0.045, respectively). However, there were no significant differences in the limbic covariance network between the groups. This study demonstrated that the volumes of the right amygdala and hypothalamus are lower in patients with iRBD, even without cognitive impairments, than in healthy controls. However, there were no significant differences in the limbic covariance network between the groups. The involvements of the limbic structures could be related to the conversion to neurodegenerative diseases in patients with iRBD.

847Interim analysis of the device-detected cardiac tachyarrhythmic events and sleep-disordered breathing (DEDiCATES)" study; focused on baseline characteristics

Funding Acknowledgements

This work is supported by Boston Scientific.

Background/introduction: Sleep-disordered breathing (SDB) is one of the common comorbidities in cardiac implantable electronic devices (CIED) patients. It’s feasible to detect SDB using specialized diagnostic function of CIEDs showing comparable performance in diagnostic accuracy of SDB to conventional polysomnography. To date, few studies have investigated the prognostic value of CIED-detected SDB in cardiovascular risk.

Purpose

In the Device-Detected CArdiac Tachyarrhythmic events and Sleep-disordered breathing (DEDiCATES) study, we aim to determine whether device-detected sleep-disordered breathing (SDB) events are associated with increased risk of cardiac arrhythmias or other cardiovascular (CV) outcomes. Here, we present interim baseline data of the study population to investigate the baseline prevalence and severity of device-detected SDB in CIED patients.

Methods

The study was designed as a prospective, multicenter, and observational study to include 600 patients. Eligible patients have dual chamber CIEDs with SDB detection function which reports the average number of sleep disturbance events per hour per night in the form of a Respiratory Disturbance Index (RDI). The daily RDI values were collected to measure the severity and burden of SDB. The baseline severity of SDB was determined according to RDI data recorded during the first 1 week, 1 month, and 3 ± 1 months after CIED implantation; patients with RDI≥ 30/h for at least one night are classified into the severe SDB group. 

Results

A total of 313 patients who completed the first device interrogation at 3 ± 1 months were included for analysis. The mean age and CHA2DS2VASc score were 69 and 3.1, respectively. Forty-nine percent of patients were men, and 35.5% were classified as high risk for SDB by Berlin questionnaire. The rate of severe SDB increased with longer monitoring period (83.8% at 1week, 91.6% at 1 month, and 96.4% at 3 ± 1 months). There was no baseline demographic difference between the severe and non-severe SDB groups, except that baseline body mass index (BMI) was higher in the severe group (24.5% vs. 21.5%, p = 0.01). The mean RDI was 36.3, 34.2, and 33.0 per night during the first 1 week, 1 month, and 3 ± 1 months, respectively. Considering the limitation of the categorical criteria of baseline severity, we arbitrarily reclassified the patients according to median mean RDI value. Men were more frequent and BMI was higher in the above-mean RDI group compared to the below-mean RDI group. Using logistic regression analysis, we identified that BMI and male gender were associated with patients with above-mean RDI.

Conclusions

Conventional categorical classification of SDB severity seems to be limited in its ability to discriminate high risk patients. Thus, more suitable RDI-related variables need to be identified in future outcome analysis.

Abstract Figure. Prevalence of baseline severe SDB

Autonomic function test in progressive lacunar infarction

OBJECTIVE

Neurological progression is a major problem in managing the patients with acute lacunar infarction. The purpose of this was to investigate whether autonomic dysfunction is associated with neurological progression in patients with acute lacunar infarction.

MATERIALS AND METHODS

The study comprised 60 patients with acute lacunar infarction. All enrolled subjects underwent autonomic function tests including the 30° head-up tilt test, Valsalva test, heart rate response to deep breathing, and sympathetic skin response. The primary endpoint is the neurological progression, and the secondary endpoint is the 3-month outcome.

RESULTS

Increased initial National Institute of Health stroke scale (NIHSS), decreased time to admission from onset, decreased rise of heart rate in the 30° head-up tilt test, abnormal blood pressure response in the Valsalva test, and decreased rise of systolic blood pressure in stage IV of the Valsalva test are associated with neurological progression of acute lacunar infarction; an abnormal blood pressure response in the Valsalva test is significant in logistic regression analysis of neurological progression. Advanced age, increased initial NIHSS and modified Rankin scale, decreased expiration/inspiration ratio of heart rate to deep breathing, decreased rise of systolic blood pressure in stage IV of the Valsalva test, and neurological progression were associated with an unfavorable 3-month outcome; neurological progression was significant in logistic regression analysis of 3-month outcome.

CONCLUSIONS

An abnormal blood pressure change in the Valsalva test is associated with neurological progression in patients with acute lacunar infarction, and neurological progression can induce an unfavorable 3-month outcome.

Progressive topological disorganization of brain network in focal epilepsy

OBJECTIVE

Increasing evidence has suggested that epilepsy is a network disease. Graph theory is a mathematical tool that allows for the analysis and quantification of the brain network. We aimed to evaluate the influences of duration of epilepsy on the topological organization of brain network in focal epilepsy patients with normal MRI using the graph theoretical analysis based on diffusion tenor imaging.

METHODS

We prospectively enrolled 66 patients with focal epilepsy (18/66 patients were newly diagnosed) and 84 healthy subjects. All of the patients with epilepsy had normal MRI on visual inspection. All of the subjects underwent diffusion tensor imaging that was analyzed using graph theory to obtain network measures.

RESULTS

The measures of characteristic path length and small-worldness in the patients with focal epilepsy were significantly decreased, even after multiple corrections (P < .01). Moreover, the measures including mean clustering coefficient and global efficiency in the patients with epilepsy had strong tendency to decrease compared to those in healthy subjects (P = .0153 and P = .0138, respectively). When comparing the measures among the patients with newly diagnosed/chronic epilepsy and healthy subjects using ANOVA, the characteristic path length (P = .006), small-worldness (P = .032), and global efficiency (P = .004) were significantly different. In addition, the duration of epilepsy was negatively correlated with global efficiency (r = -.249, P = .0454).

CONCLUSIONS

We newly found a progressive topological disorganization of the brain network in focal epilepsy. In addition, we demonstrated disrupted topological organization in focal epilepsy, shifting toward a more random state.

Effective connectivity in temporal lobe epilepsy with hippocampal sclerosis

OBJECTIVE

We hypothesized that temporal lobe epilepsy (TLE) patients with and without hippocampal sclerosis (HS) showed differences in their limbic networks. This study aimed to evaluate the role of the thalamus in TLE patients with HS.

MATERIALS AND METHODS

Twenty-nine TLE patients with HS and 30 controls were enrolled in this study. In addition, we included eight TLE patients without HS as a disease control group. Using whole-brain T1-weighted MRIs, we analyzed the volumes of the limbic structures, including the hippocampus, thalamus, and total cortex, with FreeSurfer 5.1. We also investigated the effective connectivity among these structures using SPSS Amos 21 based on these volumetric measures. Moreover, we quantified correlations between epilepsy duration and the volumes of these structures.

RESULTS

There was a statistically significant effective connectivity from the hippocampus to the thalamus in TLE patients with HS. Moreover, the volumes of the left and right thalamus were negatively correlated with epilepsy duration (r=-.42, P=.0315 and r=-.52, P=.0062, respectively). However, neither TLE patients without HS nor normal controls had a significant effective connectivity from the hippocampus to the thalamus.

CONCLUSIONS

The limbic networks of TLE patients with and without HS could be different, and the thalamus might play a critical role in TLE patients with HS.

A New Chemical Compound, NecroX-7, Acts as a Necrosis Modulator by Inhibiting High-Mobility Group Box 1 Protein Release During Massive Ischemia-Reperfusion Injury

BACKGROUND

Necrotic cell death is common in a wide variety of pathologic conditions, including ischemia-reperfusion (IR) injury. The aim of this study was to develop an IR injury-induced hepatic necrosis model in dogs by means of selective left hepatic inflow occlusion and to test the efficacy of a new chemical compound, NecroX-7, against the IR injury-induced hepatic damage.

METHODS

A group of male Beagle dogs received intravenous infusions of either vehicle or different doses of NecroX-7 (1.5, 4.5, or 13 mg/kg) for a 20-minute period before a 90-minute left hepatic inflow occlusion followed by reperfusion.

RESULTS

The gross morphology in the NecroX-7-treated groups after occlusion appeared to be less congested and less swollen than that in vehicle-treated control group. Circulating alanine transaminase and aspartate transaminase levels in the control group were elevated during the course of IR, and were effectively blocked in the 4.5 and 13 mg/kg NecroX-7-treated groups. The serum levels of high-mobility group box 1 protein showed a peak at 8 hours after occlusion in control group, and this elevation was significantly blunted by 4.5 mg/kg NecroX-7 treatment. Histologic analysis showed a marked ischemia or IR injury-induced hepatocytic degenerations, sinusoidal and portal vein congestions, and inflammatory cell infiltrations in the control group, whereas the treatment groups showed significantly diminished histopathology in a dose-dependent manner.

CONCLUSIONS

These results demonstrated that NecroX-7 attenuated the hepatocyte lethality caused by hepatic IR injury in a large animal setting. We conclude that NecroX-7 may provide a wide variety of therapeutic options for IR injury in human patients.

Cerebral hemodynamics in orthostatic intolerance with normal head-up tilt test

OBJECTIVES

Orthostatic hypotension (OH) and postural orthostatic tachycardia syndrome (POTS) are well-known causes of orthostatic intolerance (OI). In addition, there are OI patients who are characterized by the symptoms of OI and lack of abnormal findings in head-up tilt (HUT) test. The aim of this study was to determine the cerebral hemodynamic changes in HUT test of OI patients with normal HUT (OINH).

MATERIALS AND METHODS

Two hundred and sixty-one OI patients and 50 healthy controls were enrolled in this study. All subjects underwent transcranial Doppler test while performing the HUT test. Forty-five patients had OH, 33 patients had POTS, and 183 patients had OINH. Blood pressures, heart rate, cerebral blood flow velocities (CBFVs), end-tidal carbon dioxide (ET-PCO2 ), cerebral critical closing pressure (CCP), cerebral perfusion pressure (CPP), and cerebral vascular resistance (CVR) were measured during HUT test. We compared the hemodynamic parameters of OINH with those of OH, POTS, and healthy controls.

RESULTS

Reduced CBFVs, CPP, and ET-PCO2 and elevated CCP were observed in the HUT test of all four groups. CVR was reduced in three OI patients. The drops in systolic CBFV, CPP, and CVR of OINH patients were greater than those of healthy controls. The changes in parameters in the HUT test of OINH group were not different from those of OH and POTS groups except prominent decrements of CPP and CVR in OH group.

CONCLUSION

Our findings suggest that OINH is true OI sharing the common pathomechanism of OH and POTS.

Brain morphology in juvenile myoclonic epilepsy and absence seizures

OBJECTIVE

We evaluated the differences in brain morphology among patients with juvenile myoclonic epilepsy according to the occurrence of absence seizures.

MATERIALS AND METHODS

Twenty-one juvenile myoclonic epilepsy patients with (n = 6) and without (n = 15) absence seizures were enrolled. We analyzed whole-brain T1-weighted magnetic resonance imaging using FreeSurfer 5.1. Measures of cortical morphology, such as thickness, surface area, volume, and curvature, and the volumes of subcortical structures, the cerebellum, and cerebrum, were compared between the groups. Moreover, we quantified correlations between clinical variables and each measures of abnormal brain morphology.

RESULTS

Compared to normal controls, patients without absence seizures demonstrated thinning of the cortical thickness in the right hemisphere, including the post-central, lingual, orbitofrontal, and lateral occipital cortex. Compared to normal controls, patients with absence seizures had more widespread thinning of the cortical thickness, including the right post-central, lingual, orbitofrontal, and lateral occipital cortexes as well as the right inferior temporal cortex. Additionally, the volume of cerebellar white matter in patients without absence seizures was significantly smaller than that in normal controls. Patients with absence seizures had a much smaller cerebellar white matter volume than normal controls or patients without absence seizures. Moreover, there was significantly positive correlation between the age of seizure onset and the volume of cerebellar white matter in patients with juvenile myoclonic epilepsy.

CONCLUSIONS

We demonstrated that there were significant brain morphology differences in patients with juvenile myoclonic epilepsy according to the presence of absence seizures. These findings support the hypothesis that juvenile myoclonic epilepsy may be a heterogeneous syndrome.

Hepatic differentiation of porcine embryonic stem cells for translational research of hepatocyte transplantation

Porcine embryonic stem cells (ES) are considered attractive preclinical research tools for human liver diseases. Although several studies previously reported generation of porcine ES, none of these studies has described hepatic differentiation from porcine ES. The aim of this study was to generate hepatocytes from porcine ES and analyze their characteristics. We optimized conditions for definitive endoderm induction and developed a 4-step hepatic differentiation protocol. A brief serum-free condition with activin A efficiently induced definitive endoderm differentiation from porcine ES. The porcine ES-derived hepatocyte-like cells highly expressed hepatic markers including albumin and α-fetoprotein, and displayed liver characteristics such as glycogen storage, lipid production, and low-density lipoprotein uptake. For the first time, we describe a highly efficient protocol for hepatic differentiation from porcine ES. Our findings provide valuable information for translational liver research using porcine models, including hepatic regeneration and transplant studies, drug screening, and toxicology.

Expression pattern analysis of hepatocellular carcinoma tumor markers in viral hepatitis B and C patients undergoing liver transplantation and resection

BACKGROUND

This study was conducted to compare the expression patterns of serum alpha-fetoprotein (AFP) and proteins induced by vitamin K absence or antagonist-II (PIVKA-II) in hepatocellular carcinoma (HCC) patients undergoing liver transplantation (LT) and resection at a high-volume single institution.

METHODS

First, 663 liver transplant recipients with HCC were selected. They were divided into hepatitis B virus (HBV) (n = 628) and hepatitis C virus (HCV) groups (n = 35). Their medical records were retrospectively reviewed. Second, another cohort of 2709 patients who underwent HCC resection included 2258 HBV, 143 HCV, and 308 non-HBV non-HCV (NBNC) patients.

RESULTS

In the transplantation group, pretransplantation AFP level >20 ng/mL was observed in 42.5% of HBV patients and 60% of HCV patients (P = .042). PIVKA-II level >40 mAU/mL was observed in 30.6% of HBV patients and 42.9% of HCV patients (P = .127). In the resection group, a preoperative AFP level >20 ng/mL was observed in 51.7% of HBV patients and 43.3% of HCV patients (P = .052). PIVKA-II level >40 mAU/mL was observed in 59.7% of HBV patients and 56.6% of HCV patients (P = .47). Preoperative AFP level >20 ng/mL and PIVKA-II level >40 mAU/mL were observed in 35.7% and 61% of NBNC patients, respectively. Receiver-operator characteristic curve analyses revealed that the expression pattern of PIVKA-II in patients with elevated AFP level was not predictable and vice versa, regardless of background liver diseases.

CONCLUSIONS

This study indicates that serum AFP and PIVKA-II may be expressed variably regardless of the types of background liver disease. Further large-volume multicenter studies are needed to evaluate the possibility of the etiology-dependent expression of tumor markers.

Does lumbar puncture at night prevent post-dural puncture headache?

OBJECTIVES

The aim of this study was to identify the patient-related risk factors for post-dural puncture headache with same standardized procedures.

MATERIALS AND METHODS

The inclusion criteria were patients (i) who underwent lumbar puncture for diagnostic purposes, (ii) with ≥10 years of age, and (iii) with no structural lesions that could cause headache from brain-computed tomography or magnetic resonance images. The primary endpoint for this study was post-dural-puncture headache as a dependent variable. The differences were analyzed with demographic and cerebrospinal fluid profiles as independent variables.

RESULTS

Four hundred and thirteen patients met the inclusion criteria for this study, and 36 patients developed post-dural puncture headache. Patients with post-dural puncture headache were younger, had lower body mass index, and had less diabetes and hypertension. In cerebrospinal fluid profile, the counts of white blood cell and protein, and cerebrospinal fluid pressure were lower in patients with post-dural puncture headache than those without post-dural puncture headache, but glucose ratio was higher. Interestingly, patients who underwent puncture at daytime developed more post-dural puncture headache than those who were performed puncture at nighttime. After adjusting the clinical variables, multiple logistic regression analysis showed that younger age, lower cerebrospinal fluid pressure, and puncture at daytime were independently significant variables for predicting post-dural puncture headache.

CONCLUSIONS

We confirmed the risk factor for post-dural puncture headache such as young age, and newly found that patients who underwent puncture at daytime developed more post-dural puncture headache than those who were performed puncture at nighttime.

The natural history of arteriovenous access and risk factors associated with access thrombosis after successful kidney transplantation

INTRODUCTION

The purpose of this study was to determine the natural history of arteriovenous (AV) access after successful kidney transplantation (KT) and to identify the risk factors of spontaneous access closure in kidney transplant recipients.

METHODS

We performed a retrospective review of 115 patients who underwent KT with functioning access from June 2010 to July 2012. AV access patency was checked and recorded daily during the hospital stay and at every visit to the outpatient clinic. Patients were divided into 2 groups according to the patency of access, and risk factors of access thrombosis were assessed. Access patency was followed up until patency was lost or the study was closed.

RESULTS

At the end of follow-up, 18 (15.7%) AV accesses had spontaneously closed. Mean time to closure was 119 ± 163 days, and 12 of 18 were closed within 90 days after KT. AV access spontaneously closed in 8.5% of male patients, compared with 27.3% of female patients (P = .007), 12.2% of cases with native access compared with 35.3% of cases with artificial access (P = .016), and 11.3% of cases with wrist access compared with 25.7% of cases with elbow access (P = .049). Spontaneously closed AV accesses tended to have a lower mean access flow compared with functioning accesses (P = .019). On multivariate analysis, female sex and AV access flow volume affected spontaneous AV access closure (odds ratio 4.749, 95% confidence interval 1.919-35.383, P = .008; odds ratio 0.998, 95% confidence interval 0.996-0.999, P = .010, respectively).

CONCLUSIONS

Our results suggest that AV access thrombosis occurs more frequently during the early postoperative period, particularly in female patients or patients with low flow access, whereas it is a rare event in male patients or patients with high access flow, especially in the late postoperative period.

Porcine bioengineered scaffolds as new frontiers in regenerative medicine

Porcine organs are attractive for xenotransplantation, if severe immunologic concerns can be overcome. Recently, reengineered organs, with heterologous cellular materials removed but preserved organ architecture and vasculature have been created using small rodents in an effort to produce customized bioengineered organs. However, few studies have been performed to generate bioengineered organs from porcine sources. The aim of this work was to produce 3-D bioengineered scaffolds from major porcine organs, preserving the native morphology and vascular structures with complete removal of cellular and nuclear materials. We decellularized porcine heart, liver, and kidney using a peristaltic pump system with 1% sodium dodecyl sulfate. The preservation of major architecture and vasculature was confirmed by gross findings, ultrasonography, and angiography. Hematoxylin and eosin staining revealed no evidence of nuclear or cytoplasmic residues. Quantitative DNA analysis demonstrated a substantial reduction (0%-8%) of porcine DNA in the scaffolds. These results suggested that 3-D bioengineered scaffolds of porcine organs may have tremendous potential to produce non-immunogenic transplantable organs as well as beneficial tools for biomedical studies on organ re-engineering and repair.

Comparison of open and laparoscopic live donor left lateral sectionectomy

BACKGROUND

The present study was undertaken to determine whether laparoscopic live donor left lateral sectionectomy (LLS) in paediatric liver transplantation is a feasible, safe and reproducible procedure, compared with open live donor left lateral sectionectomy (OLS).

METHODS

A retrospective review was conducted of all consecutive live donor procedures for paediatric liver transplantation performed between May 2008 and October 2009. All live donor hepatectomies were carried out by a single surgeon.

RESULTS

A total of 26 live donor procedures for paediatric liver transplantation were performed, of which 11 were LLS and 11 OLS; four left hepatectomies were excluded. The LLS group had a significantly shorter hospital stay (mean(s.d.) 6·9(0·3) versus 9·8(0·9) days; P = 0·001) and time to oral diet (2·1(0·3) versus 2·7(0·4) days; P = 0·012). Duration of operation, blood loss, warm ischaemia time and out-of-pocket medical costs were comparable between groups. There was no death in either donor group and only one complication, a wound seroma, in the OLS group.

CONCLUSION

LLS seemed to be a safe, feasible and reproducible procedure, and was associated with reduced hospital stay.

Effect of necrosis modulator necrox-7 on hepatic ischemia-reperfusion injury in beagle dogs

OBJECTIVE

The liver is susceptible to ischemia-reperfusion (IR) injury during inflow occlusion for hepatectomy. There is no effective pharmacologic agent available to prevent the release of high-mobility-group box 1 (HMGB1) or to ameliorate IR injury. This pilot study sought to develop a model in beagle dogs for the purpose of testing the efficacy of a necrosis modulator, necrox-7, to prevent hepatic IR injury in beagle dogs.

METHODS

Six male beagle dogs were randomly assigned to the control group (group A; n = 3) or the treatment group (group B; n = 3). Under general anesthesia, group B received intravenous infusion of necrox-7 (13 mg/kg over 20 minutes) followed by 60 minutes of left hepatic inflow occlusion and 60 minutes of reperfusion. Both groups were tested for serum biochemicals, hematology values, liver biopsies, and plasma HMGB1 levels over a 48-hour period.

RESULTS

The maximum alanine transferase (ALT), aspartate transferase (AST), and lactate dehydrogenase (LDH) levels among group A versus group B were: ALT 868.3 ± 337.4 IU/L vs 274.3 ± 72.6 IU/L (P = .041); AST 1,024.7 ± 246.5 IU/L vs 505.3 ± 66.7 IU/L (P = .024); and LDH 962.7 ± 226.2 IU/L vs 552.7 ± 62.4 IU/L (P = .039). Liver biopsy demonstrated marked necrosis and inflammatory infiltrates in group A, whereas group B showed little evidence of IR injury. The plasma HMGB1 concentration was significantly lower among group B versus A.

CONCLUSION

This pilot study developed a hepatic IR injury model, demonstrating that necrox-7 reduced hepatic necrosis secondary to IR injury in a large animal setting.

In vitro inhibitory effects of Wen-pi-tang-Hab-Wu-ling-san on human cytochrome P450 isoforms

WHAT IS KNOWN AND OBJECTIVE

Although Wen-pi-tang-Hab-Wu-ling-san (WHW), an oriental herbal medicine, has been prescribed for the treatment of chronic renal failure (CRF) in Korean clinics, no studies regarding WHW-drug interactions had been reported. The purpose of this study was to evaluate the possibility that WHW inhibits the catalytic activities of major cytochrome P450 (CYP) isoforms.

METHODS

The abilities of various WHW extracts to inhibit phenacetin O-de-ethylation (CYP1A2), tolbutamide 4-methylhydroxylation (CYP2C9), omeprazole 4'-hydroxylation (CYP2C19), dextromethorphan O-demethylation (CYP2D6), chlorzoxazone 6-hydroxylation (CYP2E1) and midazolam 1-hydroxylation (CYP3A4) were assessed using human liver microsomes.

RESULTS AND DISCUSSION

WHW extract at concentrations up to 100 μm showed negligible inhibition of the six CYP isoforms tested (CYP1A2, CYP2C9, CYP2C19, CYP2D6, CYP2E1 and CYP3A4), with apparent IC(50) values (concentration of the inhibitor causing 50% inhibition of the original enzyme activity) of 817.5, 601.6, 521.7, 310.2, 342.8 and 487.0 μg/mL, respectively.

WHAT IS NEW AND CONCLUSION

Our in vitro findings suggest that WHW extract at concentrations corresponding to a clinically recommended dosage range has no notable inhibitory effects on CYP isoforms. Therefore, we believe that WHW extract may be free of drug-herb interactions when co-administered with other medicines. However, in vivo human studies are needed to confirm these results.

The appearance of the adrenal glands on computed tomography in multiple endocrine neoplasia type 1

AIMS

To review the morphology of the adrenal glands in multiple endocrine neoplasia type 1 (MEN1) on computed tomography (CT) to compare the results with established normal values for adrenal size and nodularity and to correlate adrenal size with serum cortisol secretory dynamics.

MATERIALS AND METHODS

Two observers independently reviewed the adrenal CT in 28 patients with MEN1, measuring the maximum width of the body of the gland and the medial and lateral limbs. Incidence and location of nodules >5 mm within the gland were recorded. Following exclusion of known cases of Cushing's syndrome, adrenal gland size was compared with previously documented normative data. Adrenal gland size was compared between patients with normal and abnormal cortisol dynamics.

RESULTS

Comparison of mean adrenal size in MEN1 patients with normative data showed that the adrenal limbs were significantly larger in MEN1 than normal (P<0.0001 in all four limbs). Adrenal body was also significantly larger (P<0.05). Nodules were demonstrated in 17 (60%) of patients (versus 0.4-2% in the normal population). No statistically significant correlation was demonstrated between adrenal limb hyperplasia and abnormal cortisol dynamics.

CONCLUSIONS

In patients with MEN1, adrenal limb hyperplasia and adrenal nodules are significantly more common than in the normal population, a phenomenon not previously documented in a quantitative manner. There was no significant correlation between adrenal limb hyperplasia and abnormal cortisol dynamics.

Molecular variation in pigmentation genes contributing to coat colour in native Korean Hanwoo cattle

Pigmentation genes such as TYR (tyrosinase), TYRP1 (tyrosinase-related protein 1), DCT (previously TYRP2, or tyrosinase-related protein 2), ASIP (agouti) and MC1R (melanocortin receptor 1) play a major role in cattle coat colour. To understand the genotypic profile underlying coat colour in native Korean Hanwoo cattle and Angus black cattle, portions of the above-mentioned genes were amplified. Sequence analysis revealed variation in the TYRP1 (exon 5) and MC1R genes. Restriction enzyme analysis of these two genes could distinguish between different colours of Hanwoo cattle. Quantitative estimates of melanin and eumelanin in hair from three different-coloured Hanwoo phenotypes and Angus black showed significant differences at the breed and phenotypic levels. Finally, sequence variants in MC1R were associated with total melanin and eumelanin in breeds as well as in Hanwoo phenotypes.

Acute symptomatic seizures in CNS infection

To determine the frequency and aetiology of acute symptomatic seizures in central nervous system (CNS) infections and to assess the clinical factors predicting the occurrence of the seizures, we retrospectively reviewed the medical records of patients diagnosed with CNS infections from 2000 to 2005. One hundred and forty-seven patients were included in the study. The clinical variables between those with and without acute symptomatic seizures were compared. Of the 147 patients, 23% (34/147) had acute symptomatic seizures. A significant relation between clinical variables and the occurrence of acute symptomatic seizures was found: encephalitis as the aetiology of the CNS infection, Glasgow Coma Scale (GCS) < or =12, and neurological deficits. By multiple logistic regression analysis, age of onset >42 years, encephalitis, and GCS < or =12 were found to be independently significant clinical variables for predicting the occurrence of acute symptomatic seizures. Encephalitis and GCS < or =12 are significant clinical variables for predicting the occurrence of acute symptomatic seizures in CNS infection, suggesting that patients with a greater extent of parenchymal damage are more vulnerable to acute symptomatic seizures.

Small-sized liver graft does not increase the risk of hepatocellular carcinoma recurrence after living donor liver transplantation

PURPOSE

Following implantation into adult recipients, living donor liver grafts usually undergo liver regeneration. This regeneration process may provoke the growth of occult hepatocellular carcinoma (HCC) cells in the recipient body. To assess the risk of HCC recurrence, we analyzed the influence of graft-recipient weight ratio (GRWR).

METHODS

The 181 recipients with HCC within the University of California at San Francisco (UCSF) criteria were divided into four groups according to GRWR: low GRWR (<0.8; n = 30), mid GRWR (0.8-1.0; n = 65), high GRWR (>1.0; n = 64), and whole liver graft group (>1.5; n = 22).

RESULTS

There were no differences in overall patient survival (P = .105) and recurrence-free survival (P = .406) among these four groups. GRWR <0.8 was not a significant risk factor for HCC recurrence. Similar outcomes were obtained in HCC patients who met the Milan criteria (n = 170).

CONCLUSIONS

We think that small living donor liver graft and subsequent liver regeneration do not increase the risk of posttransplant HCC recurrence when HCC is within the Milan or UCSF criteria.

Suitable whole blood levels 2 hours after neoral in liver transplant patients: experiences at a single center

Whole blood levels 2 hours after Neoral (C2) administration were observed to correlate better with area under the curve (AUC(0-4)) than trough levels (C0), suggesting that C2 may be the best single time point predictor of Neoral absorption. Owing to concerns about drug toxicity due to excessive immunosuppression, C2 adjustments to target blood levels may represent an advance. The present study measured C2 and levels to determine which correlated more closely with AUC(0-4).

METHODS

Between August 2003 and July 2004, 40 adult liver transplantations were performed in our center. All patients received Neoral twice daily. They were maintained at a C0 level of about 200 ng/mL. C0 levels were measured daily. C2 levels were estimated on postoperative days 3, 5, 7, 14, and 28. AUC(0-4) performed on postoperative days 3, 7, and 28 was calculated using the trapezoidal rule.

RESULTS

The mean AUC(0-4), C0, C1, C2, C3, and C4 were 1100.3 +/- 484.8 ng/mL, 197.1 +/- 84.7 ng/mL, 240.7 +/- 166.2 ng/mL, 307.8 +/- 162.6 ng/mL, 302.8 +/- 138.9 ng/mL, and 300.3 +/- 142.8 ng/mL, respectively. C2 correlated with AUC(0-4) (R2 = 0.868: P < .05) better than C0 (R2 = 0.245: P < .05), C1 (R2 = 0.604: P < .05), or C4 (R2 = 0.583: P < .05).

CONCLUSIONS

Neoral dose monitoring according to a mean C2 range of 307.8 +/- 162.6 ng/mL correlated better with AUC(0-4). Further studies are required to determine suitable C2 levels in liver transplant patients.

Evaluation of the methods for pupil size estimation: on the perspective of autonomic activity

The purpose of This work is to find the optimal calculation method about pupil size to estimate an activity of autonomic nerve system. To evaluate its state, we have to calculate an accurate pupil size from the image of free-rotated and yawed eye for 5 minutes. But calculation of the pupil size from image takes a long time. So we suppose three methods which considered cost (time), accuracy and evaluate for each. 'Method' 1 is to calculate the vertical pupil diameter from images, 'method 2' is to calculate the pupil size from whole image (method 2-1; by binarization and method 2-2; by binarization with shape evaluation) and 'method 3', the most accurate method, is from three-dimensional transformation of pupil image. As a result, for seven subjects, each method is takes about 6, 44, 124, 311 minutes to evaluate five-minute images (300,000 pixels/frame, 30 frames/sec). Also, the result of correlation between the parameter Lf/Hf ratio of heart rate variability, commonly used method for estimate the state of autonomic nerve system, and it of pupil size variability is, for each case, 0.34, 0.2, 0.69, 0.69.

Refined Suture Techniques to Prevent Bleeding From Accidental Slippage of Vascular Clamps During Living Donor Hepatectomy

Accidental slippage of vascular clamps during living donor hepatectomy can induce brisk bleeding and even imperil the donor. After practicing more than 1000 cases of living donor hepatectomy, the investigators realized that specialized suture techniques were important to secure the vascular closure to prevent unnecessary bleeding. For secure division of intrahepatic vein branches, we devised a continuous penetration suture method in which the orders of procedures were changed to clamping-closure-cut sequence. For secure division of the main and accessory hepatic vein branches from the inferior vena cava, we applied stay sutures at each corner and midpoint of the hepatic vein stump so as not to permit its slippage. After application of these methods, we did not experience any episode of accidental clamp slippage. We are sure that these suture techniques are beneficial to prevent unnecessary bleeding during living donor hepatectomy and to make surgeons feel at ease during the living donor operation.

A case report of split liver transplantation for two adult recipients in Korea

We report a case of split liver transplantation (SLT) for two adult recipients, which was the first successful case in Korea. The brain-dead donor was a 22-year-old man weighing 65 kg, but his liver volume was estimated as 2120 mL on computed tomographic volumetry. As it seemed to be too large for a 60-kg recipient candidate, SLT was planned after assessment of lobar liver volume and middle hepatic vein anatomy. The right lobe was mobilized first and the liver parenchyma transected along the right border of the middle hepatic vein. The 1240-g right lobe (segments 5 to 8) graft was implanted into a 57-year-old male patient with acute-on-chronic liver failure in the same manner as a living-donor graft. After that, routine procedures of cadaveric multiorgan procurement were performed. The 670-g left lobe (segments 1 to 4) with a retrohepatic vena cava, common bile duct, and aortic patch was implanted into another 37-year-old male recipient. These two recipients recovered uneventfully surviving 12 months to date. We integrated the surgical techniques learned from hundreds of adult-to-adult living donor liver transplants into this first trial of two adult SLT.

Intraoperative assessment of hepatic venous congestion with direct clamping of the hepatic vein trunk for living donor liver transplantation

We devised a hepatic vein clamping method to assess the amount of hepatic venous congestion (HVC) before liver transection. From February 2003 to May 2003, this method was applied to 5 of 58 living donor livers especially to assess donor safety. The left portal vein and proper hepatic artery as well as the middle hepatic vein (MHV)-left hepatic vein (LHV) trunk were clamped simultaneously to assess the HVC in the remnant right lobe before performing extended left lobectomy. As three donors demonstrated the extent of the HVC equivalent to about 40% of the right lobe volume (RLV), their operations proceeded according to the preoperative plan. The territory of HVC after liver transection was the same as that observed with direct clamping of the hepatic vein. However, one donor showed massive HVC more than 50% of RLV and the operative plan was adjusted to harvest only the left lobe without the MHV trunk for donor safety. To assess the HVC in the remnant left lobe, the isolated LHV trunk was occluded after clamping the donor's proper hepatic artery. The whole left lobe except for a small area at the anterior portion of the medial segment became discolored on LHV clamping: the opposite demarcation appeared on MHV clamping. The amount of HVC was so small that we harvested the right lobe with the MHV trunk. All donors and recipients recovered uneventfully. We believe that this direct clamping method makes the assessment of HVC feasible before parenchymal transection of a donor liver.

Novel method for cell immobilization and its application for production of oligosaccharides from sucrose

AIMS

The purpose of the present investigation was to develop a novel method for cell immobilization.

METHODS AND RESULTS

Aureobasidium pullulans cells were mixed with an alginate solution, and the mixture was extruded to form small gel beads as hydrated-immobilized cells. The beads were then placed at -15 degrees C for 6-24 h to induce freeze-dehydration. The freeze-dehydration resulted in shrinkage of beads as a result of water removal reducing bead volume by 82% and bead weight by 85%. The dehydrated beads were successfully used for the production of fructo-oligosaccharides in a model reactor system.

CONCLUSIONS

Dehydrated beads may provide some commercial advantages over conventional immobilized cells.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study shows that bioreactor performance can be improved up to two times by the use of the dehydrated beads.

Kuwanon G: an antibacterial agent from the root bark of Morus alba against oral pathogens

Kuwanon G was isolated from the ethyl acetate fraction of methanol extract of Morus alba and its structure was elucidated by 13C-NMR, 1H-NMR and FAB-MS. Antibacterial activity of kuwanon G was investigated by the minimum inhibitory concentration (MIC) test and the viable cell count method. MIC of kuwanon G against Streptococcus mutans causing dental caries was determined to be 8.0 microg/ml. The bactericidal test showed that kuwanon G completely inactivated S. mutans at the concentration 20 microg/ml in 1 min. Kuwanon G also significantly inhibited the growth of other cariogenic bacteria such as Streptococcus sobrinus and Streptococcus sanguis, and Porpyromonas gingivalis causing periodontitis. Transmission electron microscopy (TEM) of kuwanon G treated cells demonstrated remarkable morphological damage of the cell wall and condensation of the cytoplasm.

Adult-to-adult living donor liver transplantation at the Asan Medical Center, Korea

Between February 1997 and December 2001, 311 adult-to-adult living donor liver transplants (A-A LDLTs) were performed at the Asan Medical Center for patients above 20 years of age. Indications for A-A LDLT were: chronic hepatitis B (203), chronic hepatitis C (5), hepatocellular carcinoma (64), alcoholic cirrhosis (9), cryptogenic cirrhosis (4), secondary biliary cirrhosis (5), primary biliary cirrhosis (1), Wilson' s disease (2), autoimmune hepatitis (1), hepatic tuberculosis (1), cholangiocarcinoma (1), fulminant hepatic failure (14) and primary non-function of cadaveric liver graft (1). Of 311 A-A LDLTs, 36 were of medical high urgency, 20 were for acute and subacute hepatic failure, 15 were for hepato-renal syndrome and 1 was for primary non-function. Recipient age ranged from 27 to 64 years. Donor age ranged from 16 to 62 years. There was no donor mortality. Implanted liver grafts were categorized into seven types: 175 modified right lobe (MRL), 70 left lobe, 32 right lobe, 20 dual grafts, 10 left lobe plus caudate lobe, three extended right lobe and one posterior segment. In MRL, the tributaries of the middle hepatic vein were reconstructed by interpositioning a vein graft. Indication for dual graft implantation was the same as single graft A-A LDLT, and four of 20 were emergency cases. Of 20 dual grafts, 14 received two left lobes, four received a left lobe and a lateral segment, one received a right lobe and a left lobe and one received a lateral segment and a posterior segment. Graft volume ranged from 28% to 83% of the standard liver volume of the recipients. There were 33 (10.6%) in-hospital mortalities (< 4 months) among the 310 patients after 311 A-A LDLTs. Of the 36 patients receiving emergency transplants, 31 survived. These encouraging results justify the expansion of A-A LDLT in coping with increasing demands, even in urgent situations. We have aimed to introduce the establishment of the efficacy of A-A LDLT in various end-stage chronic and acute liver diseases, as well as new technical advances to overcome small graft-size syndrome by using dual-graft implantation and MRL, both of which were first developed in our department.