Telepathology in intraoperative frozen section consultation of breast cancer sentinel node biopsy in Fukushima, Japan following the 2011 triple disaster: diagnostic accuracy and required time during the early implementation phase

In breast cancer surgery, some medical facilities lack the necessary resources to conduct sentinel lymph node biopsy and its intraoperative frozen section consultation. In the coastal rural area of Fukushima, Japan, which has suffered from physician undersupply following the 2011 triple disaster of earthquake, tsunami and nuclear disaster, we explored the feasibility of telepathology by evaluating the diagnostic accuracy in remote intraoperative frozen section consultation of sentinel lymph node biopsy and its required time. Although examination time has room for improvement, telepathology can be one possible solution in resource-limited areas.

High accuracy spectroscopy of 3- and 4-body Λ hypernuclei at Jefferson Lab

JLab E12-19-002 Experiment is planned to measure the Λ-binding energies of 3ΛH [Jπ = 1/2+ or 3/2+(T = 0)] and 4ΛH (1+) at JLab Hall C. The expected accuracy for the binding-energy measurement is |ΔBtotal Λ | ≃ 70 keV. The accurate spectroscopy for these light hypernuclei would shed light on the puzzle of the small binding energy and short lifetime of 3ΛH, and the chargesymmetry breaking in the ΛN interaction. We aim to perform the experiment in 2025.

Impact of low-dose or under-dose direct oral anticoagulant on coagulation and fibrinolytic markers in patients with atrial fibrillation

Background

Atrial fibrillation (AF) is known to increase the risks of cerebral and systemic embolism. Apart from vitamin K antagonists, edoxaban, a direct oral anticoagulant (DOAC), has been approved for oral anticoagulation in patients with non-valvular AF. On the other hand, DOACs are sometimes prescribed at off-label under-doses for patients who have undergone ablation for AF. Prothrombin fragment F1+2 is an activation peptide released from prothrombin during thrombin formation. The purpose of this study is to compare the effects of DOAC doses on coagulation and fibrinolytic markers.

Methods and results

A total of 88 patients with AF (age: 68±11 years, male:45%, paroxysmal AF n=49, persistent AF n=39) were recruited. All patients were received edoxaban (60mg or 30mg) once a day. For the purpose of the study, patients were divided into three groups according to whether they had been treated before the ablation procedure under an appropriate standard dose group (n=30 [34.1%]), appropriate low-dose group (n=35 [39.8%]), or off-label under-dose group (n=23 [26.1%]). We examined the coagulation and fibrinolytic markers, and echocardiographic parameters before ablation. All patients were followed up for 12 months after AF ablation. Creatinine clearance was significantly higher in appropriate standard-dose group than in appropriate low-dose or off-label under-dose group (101.1±38.4, 57.1±15.9 and 73.2±14.6 mL/min, respectively; P<0.001). There were no significant baseline differences in AF type, history of stroke/transient ischemic attack (TIA), plasma B-type natriuretic peptide, protein C, fibrinogen, D-dimer level, left ventricular ejection fraction or left atrium dimension among the three groups. Prothrombin fragment F1+2 level was significantly lower in the appropriate standard-dose group than the appropriate low-dose and off-label under-dose groups (105.9±29.4, 142.6±41.3 and 142.8±84.9 pmol/L, respectively; P=0.011, Figure). One patient in the appropriate low-dose group had a TIA and 1 patient in the off-label under-dose group had a bleeding event during the follow up period after ablation.

Conclusion

Our results suggest that an appropriate standard dose of edoxaban is needed to suppress hypercoagulability in patients with AF.

Funding Acknowledgement

Type of funding sources: None. Prothrombin fragment F1+2 level

Prognostic factors in patients with acute myocardial infarction underwent extracorporeal membrane oxygenation in hospital or out-of-hospital cardiac arrest

Background

Patients with acute myocardial infarction (AMI) who require extracorporeal membrane oxygenation (ECMO) have worse outcomes than those who do not, and patients with AMI with out-of-hospital cardiac arrest (OHCA) also have worse outcomes than those without OHCA. However, there have been still unclear points regarding the prognostic factors of AMI patients who underwent ECMO with or without OHCA. The aim of this study was to investigate the prognostic factors of AMI patients who underwent ECMO with and without OHCA, respectively.

Methods/Results

Ninety-eight consecutive patients (age:67±11 years, male:83.7%) who underwent ECMO for AMI were enrolled from November 2008 to December 2020. The primary endpoint was in-hospital mortality within 30-day, and we investigated the risk factors associated with 30-day mortality in AMI patients underwent ECMO with or without OHCA, respectively. In the group with OHCA (n=47), 30-day death occurred in 22 patients (47%). BMI, lactate and serum creatinine levels after the introduction of ECMO were significantly greater in patients with than without 30-day death (27.0±5.2 vs 21.0±2.9 kg/m2, p<0.001, 12.1±4.3 vs 7.5±3.6 mmol/L, p<0.001, 1.68±1.24 vs 1.41±1.07 mg/dL, p=0.039, respectively). The multivariate regression analysis showed that lactate level was independently associated with the poor outcome (Odds ratio: 1.32, 95% CI: 1.11–1.57, p<0.001). ROC curve analysis showed that the cut-off values: 7.8mmol/L of lactate had moderate accuracy to predict 30-day mortality (sensitivity:76%, specificity:86%, AUC:0.81). In the group without OHCA (n=51), 30-day death occurred in 20 patients (39%). The frequency of ventricular tachycardia / fibrillation (VT/VF) at initiation of ECMO was significantly higher (61.3% vs 25.0%, p=0.021), the frequency of mechanical complication was significantly lower (6.5% vs 30.0%, p=0.045) in patients without 30-day death than with 30-day death. The multivariate regression analysis showed that VT/VF at initiation of ECMO was independently associated with good outcome (Odds ratio: 0.21, 95% CI: 0.06–0.73, p=0.01).

Conclusions

With OHCA, increased lactate was the risk factor that was significantly associated with poor outcome in AMI patients underwent ECMO. Without OHCA, AMI patients who underwent ECMO due to rhythm trouble such as VT/VF had a good outcome. ECMO patients with AMI may have different prognostic factors with or without OHCA.

Funding Acknowledgement

Type of funding sources: None. Patient characteristics

Development of a high-sensitivity and portable cell using Helmholtz resonance for noninvasive blood glucose-level measurement based on photoacoustic spectroscopy

We describe the possibility of high-sensitivity noninvasive blood glucose measurement based on photoacoustic spectroscopy (PAS). The demand for noninvasive blood glucose-level measurement has increased due to the explosive increase in diabetic patients. We have developed a noninvasive blood glucose-level measurement based on PAS. The conventional method uses a straight-type resonant cell. However, the cell volume is large, which results in a low detection sensitivity and difficult portability. In this paper, a small-sized Helmholtz-type resonant cell is proposed to improve detection sensitivity and portability by reducing the cell dead volume. First, the acoustic property of the small-sized Helmholtz-type resonant cell was evaluated by performing an experiment using a silicone rubber. As a result, the detection sensitivity of the small-sized Helmholtz-type resonant cell was approximately two times larger than that of the conventional straight-type resonant cell. In addition, the inside volume was approximately 30 times smaller. Second, the detection limits of glucose concentration were estimated by performing an experiment using glucose solutions. The experimental results showed that a glucose concentration of approximately 1% was detected by the small-sized Helmholtz-type resonant cell. Although these results on the sensitivity of blood glucose-level measurement are currently insufficient, they suggest that miniaturization of a resonance cell is effective in the application of noninvasive blood glucose-level measurement.

Abstract P4-15-03: Regulation of miRNA-29c and its gene targets in preneoplastic progression of triple negative breast cancer

Introduction: Little is understood about the early molecular drivers of the triple negative breast cancer making identification of women at risk and development of targeted therapy for prevention a significant challenge. Methods: Here, by deep sequencing of TNBC- cell line based breast cancer progression system we have identified miRNA-29c and its functional gene targets to be potentially involved in the normal to preneoplastic transition during TNBC progression. We have used cell line based functional assays that are relevant in early tumorigenesis such cell proliferation (ki67), and colony formation assay to study the growth inhibitory potential of these miRNA and their gene targets. To identify direct gene targets of miRNA-29c, we cloned the 3'untranslated region containing miRNA-29c binding sites from predicted gene targets in a luciferase reporter vector, pmiRGLO and studied the potential of miRNA-29c overexpression on the repression of luciferase reporter activity indicating their direct gene regulation. Results: Our deep sequencing results and their further validation by QPCR revealed miRNA-29c to be lost during the TNBC progression, and its forced expression to inhibit cell proliferation and colony formation of preneoplastic (MCF10AT1) and ductal carcinoma in situ (MCF10DCIS) cells. We found miRNA-29c to directly bind in 3'UTR of TGIF2, CREB5, AKT3 and CDK6 and regulate their expression as shown by our luciferase assays. We also found miRNA-29c binding to 3'UTR of these gene targets to be functionally relevant as TGIF2, CREB5 and AKT3 were able to rescue the inhibition in cell proliferation and colony formation assay caused by loss of miRNA-29c in preneoplastic cells. Further confirming the relevance of these miRNA-29c gene targets and pathways in TNBC tumorigenesis, inhibition of PI3K, which is upstream of AKT3, inhibits cell proliferation in MCF10AT1 and DCIS cells. We also examined the regulation of tumor suppressor miRNA-29c to study the mechanisms responsible for its loss during breast cancer development. We found c-myc and EZH2 driven epigenetic mechanism as well as DNA methylation in part to cause the loss of miRNA-29c during TNBC progression. Consistently, we found a pan HDAC inhibitor and a DNA methylation inhibitor to relieve the suppression of miRNA-29c. Conclusions: Together, these results indicate that loss of miRNA-29c plays a central role in preneoplastic development of breast cancer and efforts directed at inhibition of its target pathways or rescue of miRNA-29c itself may provide novel opportunities for prevention of TNBC.Introduction: Little is understood about the early molecular drivers of the triple negative breast cancer making identification of women at risk and development of targeted therapy for prevention a significant challenge. Methods: Here, by deep sequencing of TNBC- cell line based breast cancer progression system we have identified miRNA-29c and its functional gene targets to be potentially involved in the normal to preneoplastic transition during TNBC progression. We have used cell line based functional assays that are relevant in early tumorigenesis such cell proliferation (ki67), and colony formation assay to study the growth inhibitory potential of these miRNA and their gene targets. To identify direct gene targets of miRNA-29c, we cloned the 3'untranslated region containing miRNA-29c binding sites from predicted gene targets in a luciferase reporter vector, pmiRGLO and studied the potential of miRNA-29c overexpression on the repression of luciferase reporter activity indicating their direct gene regulation. Results: Our deep sequencing results and their further validation by QPCR revealed miRNA-29c to be lost during the TNBC progression, and its forced expression to inhibit cell proliferation and colony formation of preneoplastic (MCF10AT1) and ductal carcinoma in situ (MCF10DCIS) cells. We found miRNA-29c to directly bind in 3'UTR of TGIF2, CREB5, AKT3 and CDK6 and regulate their expression as shown by our luciferase assays. We also found miRNA-29c binding to 3'UTR of these gene targets to be functionally relevant as TGIF2, CREB5 and AKT3 were able to rescue the inhibition in cell proliferation and colony formation assay caused by loss of miRNA-29c in preneoplastic cells. Further confirming the relevance of these miRNA-29c gene targets and pathways in TNBC tumorigenesis, inhibition of PI3K, which is upstream of AKT3, inhibits cell proliferation in MCF10AT1 and DCIS cells. We also examined the regulation of tumor suppressor miRNA-29c to study the mechanisms responsible for its loss during breast cancer development. We found c-myc and EZH2 driven epigenetic mechanism as well as DNA methylation in part to cause the loss of miRNA-29c during TNBC progression. Consistently, we found a pan HDAC inhibitor and a DNA methylation inhibitor to relieve the suppression of miRNA-29c. Conclusions: Together, these results indicate that loss of miRNA-29c plays a central role in preneoplastic development of breast cancer and efforts directed at inhibition of its target pathways or rescue of miRNA-29c itself may provide novel opportunities for prevention of TNBC.

Citation Format: Bhardwaj A, Tachibana K, Ganesan N, Rajapakshe K, Singh H, Gunaratne P, Coarfa C, Bedrosian I. Regulation of miRNA-29c and its gene targets in preneoplastic progression of triple negative breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-15-03.

Mutation in insulin receptor attenuates oxidative stress and apoptosis in pancreatic beta-cells induced by nutrition excess: reduced insulin signaling and ROS

Type 2 diabetes results from the failure of beta-cells to adequately compensate for insulin resistance. Although the reduction of beta-cell mass is because of increased cell death and/or inadequate replication or neogenesis, the mechanism underlying beta-cell mass reduction is not fully understood. Here, we clarify the role of insulin signaling pathway in the beta-cell apoptosis using insulin resistant model mice. Wild-type mice and those carrying a mutation in the insulin receptor (mIR) were fed either regular chow or a high-fat diet for 6 weeks and subsequently investigated for beta-cell apoptosis, endoplasmic reticulum stress, and oxidative stress. Insulin tolerance tests revealed that mIR mice fed a high-fat diet (mIRHF) had higher insulin resistance. Beta-cell apoptosis was increased 2-fold in the wild-type mice fed a high-fat diet (wHF) compared with control mice, whereas beta-cell apoptosis in mIRHF mice did not increase compared with that in mIR mice. The expression of endoplasmic reticulum stress markers in isolated islets did not differ between the groups. Staining of 8-hydroxy-2'-deoxyguanosine and 4-hydroxy-2-nonenal in islets of wHF mice significantly increased, but the staining in mIRHF mice was not different from that in control group. Gene expression of the antioxidant enzyme MnSOD was significantly higher in mIRHF mice than those in the other 3 groups. A mutation in the insulin receptor attenuated the oxidative stress and apoptosis in beta-cells even though high caloric nutrient was loaded. Our results suggest that reduced insulin signaling protects beta-cells thorough decline of oxidative stress.

Prevalence and risk factors of soil-transmitted helminth infection in Nepal

BACKGROUND

The purpose of this study is to evaluate the prevalence and intensity and examine the risk factors of soil transmitted helminth (STH; i.e., roundworm [Ascaris lumbricoides], hookworms [Ancylostoma duodenale and Necator americanus], and whipworm [Trichuris trichiura]) infections in Nepal.

METHODS

Five hundred and ninety-four adults (256 men and 338 women) were selected via convenience sampling from five communities in Nepal. The Kato-Katz method was used to assess the prevalence and intensity of STH infection in this population.

RESULTS

Prevalence of STH infection ranged from 3.3% in Birendranagar in Chitwan, 3.5% in Kuleshor in Kathmandu, 11.7% in Kanyam in Ilam, 17.0% in Dhikurpokhari in Kaski and 51.4% in Khokana in Lalitpur District [corrected]. Multivariable regression analysis revealed that not using soap for hand-washing was significantly associated with the prevalence and infection intensity of roundworm, hookworms and whipworm. Similarly, not wearing sandals or shoes outside was significantly associated with the prevalence and infection intensity of roundworm and hookworms, but not with infection intensity of whipworm. Literacy, being underweight or overweight, anemia and occupation were not associated with prevalence and intensity of roundworm and hookworms infection, but there was an association between occupation and the prevalence of whipworm infection.

CONCLUSION

STH infection was associated with individual hygiene behavior, but not with nutritional status or socio-demographic characteristics. Health policy focusing on changing individual hygiene behaviors might be useful in addressing STH infection in Nepal.

Polymyxin-B hemoperfusion for acute exacerbation of idiopathic pulmonary fibrosis: serum IL-7 as a prognostic marker

BACKGROUND

Acute exacerbation (AE) of idiopathic pulmonary fibrosis (IPF) has an extremely poor prognosis. Direct hemoperfusion with a polymyxin B-immobilized fiber column (PMX-DHP) has been used to improve oxygenation for acute respiratory distress syndrome. The study aim was to retrospectively determine the predictive factors affecting the prognosis of AE of IPF treated with PMX-DHP.

METHODS

We studied patients suffering from AE of IPF, treated with PMX-DHP combined with high-dose corticosteroid therapy. Stored serum taken before and after PMX-DHP therapy was analyzed for 27 cytokines and chemokines.

RESULTS

Nineteen patients with AE of IPF were studied. The median survival time after diagnosis of AE was 22 days. Survival rates after diagnosis of AE were 47.4% at 30 days, 31.6% at 60 days, and 26.3% at 90 days. Serum levels of Interleukin (IL)-7, an anti-fibrotic cytokine, in survivors at day 30 following PMX-DHP therapy ('Survivors') significantly increased after the treatment, compared to serum levels of non-survivors at day 30 after the therapy ('Nonsurvivors'), which did not demonstrate a significant change. Serum levels of IL-1beta, interferon-y and chemokine ligand (CCL) 2 levels were not significantly altered in 'Survivors', but were significantly changed in 'Nonsurvivors.' Multivariate Cox proportional-hazards analysis showed that an increase in IL-7 levels after PMX-DHP therapy and treatment without intubation (other than invasive positive-pressure ventilation) were significantly better prognostic factors.

CONCLUSION

The results suggest that serum IL-7 may be a useful prognostic factor for patients with AE of IPF treated with PMX-DHP, possibly reflecting underlying anti-fibrotic mechanisms.

[Subscapular elastofibroma]

Elastofibroma is a tumor that is localized mainly at the subscapular region. We report 2 cases of subscapular elastofibromas. Case 1, 75-year-old woman was seen at the hospital because of a left dorsal tumor. Computed tomography (CT) scan revealed the tumor of 6 cm in diameter in the inferior angle of left scapula. The patient underwent excision of the tumor. Case 2, 90-year-old man underwent excision a tumor of 5 cm in diameter in the inferior angle of right scapula simultaneously with the operation of right lung cancer. Histological examinations showed increased elastic fiber with elastica van Gieson staining. These specimens confirmed the diagnosis of elastofibroma There have been no signs of recurrence after surgery.

Health status of married women residing five communities in Nepal: unexpectedly high prevalence of anemia in a well-off community of Kathmandu

The high prevalence of anemia and underweight among reproductive age women is a serious health concern in Nepal. The objective of the present study was to describe anemia prevalence and nutritional status of married women in Nepal. Total of 278 women were included in the present analysis. The five communities included an urban commercial area (W) in Kathmandu, an agricultural village (K) in Lalitpur District, an agricultural village in Chitwan District (C) and one in Ilam District (I) with intensive cash cropping, and another rural village in Kaski District (P) with high number of international out-migration of males. The study procedure included anthropometric measurements, blood collection for hemoglobin measurement, and stool collection for examination of hookworm infection, and a structured interview on their reproductive history including contraceptive use. The altitude adjusted prevalence of anemia was 65%, 23%, 16%, 49% and 58% in communities C, I, K, P and W respectively. The hookworm prevalence of each community was not associated with the anemia prevalence. In the urban well-off community W, although 38% of the women had BMI > or = 25 and only 2% of women had BMI<18.5, 58% of the women were anemic. A logistic regression analysis on the anemia risk at the individual level showed no effect of helminth infection, but a significant negative effect of Depo-Provera (depot-medroxyprogesterone acetate) use. Causes of high anemia prevalence among the women resided in the urban well-off area should be investigated in future studies.

Effects of Open Lung Approach Policy on Mechanical Ventilation Duration in Postoperative Patients with Chronic Thromboembolism with Pulmonary Hypertension: A Case-Matched Study

Patients with chronic thromboembolism with pulmonary hypertension (CTEPH) often develop severe hypoxaemia after pulmonary thromboendarterectomy. There is reluctance to apply high positive end-expiratory pressure (PEEP) to those patients, whereas high PEEP is important for acute hypoxaemic respiratory failure due to alveolar collapse. Open lung approach (OLA) policy, a combination of recruitment manoeuvre and PEEP titration, may improve oxygenation and lung mechanics in acute hypoxaemic respiratory failure, but the effect of OLA on the outcome is unknown. We designed a case-matched, retrospective study to investigate whether OLA policy improved the outcome of postoperative patients with CTEPH.

Among 113 postoperative patients with CTEPH, 40 were chosen before and after the introduction of an OLA policy to create 1:1 ratio of case-match according to gender, age and preoperative total pulmonary resistance index (conventional treatment group vs OLA group). In the OLA group, recruitment manoeuvre was applied and then PEEP was titrated to maintain oxygenation every 12 hours. Gas exchange and duration of mechanical ventilation were compared between the groups.

The OLA group showed higher PaO2/FiO2 ratio at 12 hours after the surgery than the conventional group (P=0.0021). In the OLA group, duration of mechanical ventilation was shorter than the conventional treatment group (median, 23.5 hours vs 43 hours, P=0.0064). The OLA group showed lower cardiac index, higher pulmonary artery pressure and higher total pulmonary resistance index after the surgery than the conventional group.

The introduction of the OLA policy may have shortened mechanical ventilation duration despite what appeared to be less favorable early postoperative hemodynamics in patients after the surgery for CTEPH.

Phase I study of cisplatin/carboplatin/irinotecan (CPI) regimen in patients with ED small-cell lung cancer

18202

Cisplatin/irinotecan(IP) is standard regimen for ED-SCLC in Japan. Cisplatin (CDDP)-based treatment requires copious hydration, which can lead to a deterioration of outpatients’ quality of life. CDDP and carboplatin (CBDCA) have a common active form, but are associated with different adverse reactions. We considered that the combined use of these two agents could increase the dose intensity of active form platinum complexes without enhancing their toxicities. The IP was modified to nearly half the dose of CDDP/CBDCA to facilitate outpatient administration. We conducted a phase I study to determine the maximum tolerated dose (MTD) and dose limiting toxicity (DLT) of this modified regimen for patients with ED-SCLC and stage IV NSCLC. Eligibility criteria included: PS 0–1, age <75 yrs, no prior therapy, measurable disease, adequate organ functions. DLT was defined as follows: 1) grade 4 neutropenia lasting 4 days or febrile neutropenia, 2) grade 4 thrombocytopenia, 3) prolongation of treatment due to toxicity, 4) grade 3 or worse non-hematological toxicity. Three patients were enrolled at level 1(CDDP/CBDCA: 25 mg/m2/AUC2), 3 patients at level 2 (25 mg/m2/AUC 2.5) and 3 patients at level 3 (30 mg/m2/ AUC 2.5), respectively. DLT was not observed at level 1, 2, 3. At dose level 4 (30 mg/m2/AUC3), two of three patients experienced DLT, suggesting this level to be the MTD. The recommended dose for phase II study is CDDP 30 mg/m2 on day 1, CBDCA AUC 2.5 on day 1 and irinotecan 60 mg/m2 on days 1, 8, 15. A phase II study of this regimen in ED-SCLC is ongoing.

No significant financial relationships to disclose.

Laser excitation of high-frequency capillary waves

The laser-induced surface deformation (LISD) technique was applied to generate high-frequency capillary waves on liquid surfaces up to several tens of kHz in a noncontact manner. The dynamic response of the fluid near the surface was theoretically derived under the condition of periodical radiation pressure. The result of the numerical calculation predicts the propagation of induced capillary waves out from the excitation region. The efficiency of the wave generation was experimentally examined by changing the width of the excitation laser beam at the surface. The observed LISD spectra were well reproduced by the theory, showing that the effective frequency band can be extended up to over 100 kHz. The propagation of the optically generated wave was measured with a laser probe sweeping the position of the observation. The spatial profile gives the surface tension and the shear viscosity of the sample liquid. The frequency domain measurement was also carried out and the spectrum obtained at a fixed point agrees with the theory, demonstrating the rapid measurement of frequency-dependent phenomena.

Whether or not prophylactic excision of the extrahepatic bile duct is appropriate for patients with pancreaticobiliary maljunction without bile duct dilatation

BACKGROUND/AIMS

The standard treatment for patients with a pancreaticobiliary maljunction (PBM) without bile duct dilatation remains controversial.

METHODOLOGY

We followed up 29 patients with such PBM who mainly underwent a cholecystectomy alone. The ages of the patients ranged from 3 to 76 years (average age 47.3 years) and the ratio of males to females was 8 vs. 21. When the diameter of the common bile duct was less than 10mm, such bile ducts were diagnosed to have no dilatation. The main clinical indications for surgery were cholecystolithiasis in 15 patients, choledocholithiasis in 3, cholecystocholedocholithiasis in 2, gallbladder polyp in 2, adenomyomatosis in 2, cholecystitis in 2, and protein plug in 1.

RESULTS

The amylase levels of gallbladder bile in 20 patients ranged from 115 to 460,200 IU/mL (a mean of 191,698 IU/mL). One patient died of gastric cancer 182 months after surgery and two patients died of other diseases 153, 171 months after surgeries, respectively. The remaining 26 patients have all been doing well for 36 months to 326 months after surgery (a median follow-up period, 160.5 months). The 10- and 15-year survival rates were 100% and 89.7%.

CONCLUSIONS

In conclusion, a prophylactic resection of the extrahepatic bile duct and biliary diversion could be unnecessary for patients with PBM without bile duct dilatation.

Transdermal drug delivery using ultrasound-theory, understanding and critical analysis

This review focuses on a unique transdermal drug delivery enhanced by the action of ultrasound, referred as sonophoresis. Sonophoresis is an active form of transdermal delivery which enhances the transport of permeants, such as drugs through cell membranes as a result of ultrasonic energy. Ultrasonic sound waves cause acoustic cavitation, the resultant effects of which microscopically disrupt the lipid bilayers of the stratum corneum and thereby influencing the influx of permeants. Sonophoresis increases the penetration of various low molecular weight drugs as well as high molecular weight proteins. The objective of this review is to account the role of ultrasound parameters and the associated cavitational effects, gained through a number of investigations, in order to facilitate the understanding of this method.

Longitudinal growth and height velocity of Japanese children with Down's syndrome

AIM

To determine the natural growth pattern of Japanese children with Down's syndrome.

METHODS

Longitudinal height data of 85 patients (43 males, 42 females) from birth to final height were analyzed. Based on these data, semi-longitudinal standard growth curves and height velocity curves for Down's syndrome were drawn.

RESULTS

The means +/- SD of final height of males and females with Down's syndrome were 153.2 +/- 5.6 and 141.9 +/- 4.2 cm, respectively. They were -3.0 SD and -2.8 SD for Japanese standards. Mean peak height velocities were 8.9 and 7.5 cm y(-1), and the ages at peak height velocity were 11.6 and 10.2 y for males and females, respectively.

CONCLUSION

The mean height of patients with Down's syndrome was around -2 SD for normal children before puberty. Their pubertal growth spurt starts about 1 y earlier and their peak height velocity was about 1.3-1.4 cm shorter than for normal children.

Proteases augment the effects of lipopolysaccharide in rat gingiva

OBJECTIVES

Lipopolysaccharide (LPS) and proteases have been implicated as important factors in the initiation and progression of human periodontal diseases. A single application of LPS or proteases is insufficient to induce periodontal pocket formation or periodontitis. The aim of the present study was to assess the combined effect of lipopolysaccharide and proteases on rat periodontal tissues, and create a periodontal disease model.

MATERIALS AND METHODS

Forty male Wistar rats were divided into four groups: combination group (treated with both LPS and proteases solutions); LPS group; proteases group; and control. Each solution was introduced daily into the palatal gingival sulcus of maxillary molars for 8 weeks. The tissues were evaluated histometrically and immunohistochemically.

RESULTS

In the LPS group, elongation of rete ridge, apical migration of junctional epithelium (JE), increased numbers of B cells in connective tissue, and resorption of alveolar bone were observed. In the proteases group, the increase in the number of infiltrating polymorphonuclear leukocytes and blood vessels in the connective tissue was greater than that of the LPS group.

CONCLUSIONS

The effects of LPS on periodontal tissues differed from those of proteases. The addition of proteases augmented and increased the effects of LPS, which were apical migration, intraepithelial cleavage of JE, and increased B cell density. The lesions in the combination group resembled established lesions of human periodontitis, with the exception of the low density of plasma cells.

Final height and pubertal growth in Japanese patients with congenital hypothyroidism detected by neonatal screening

AIM

To investigate the final adult heights and pubertal growth patterns in Japanese patients with congenital hypothyroidism (CH) detected by neonatal screening.

METHODS

A retrospective chart review was conducted of female patients >15 y of age (n = 18) and male patients >18 y of age (n = 9), who were detected by neonatal screening and kept on continuous thyroid hormone replacement therapy. Final height standard deviation scores (FHSDS) and target height standard deviation scores (THSDS) were determined. Parameters characterizing the pubertal growth process (such as age at onset of pubertal growth spurt and age at peak pubertal growth) were obtained from each patient's growth rate chart. Menarchial age was determined in each female patient by reviewing the medical record. The impact on FHSDS of the etiology of CH, the severity of CH, the time of initiation of therapy and the adequacy of treatment during the first year of life was assessed.

RESULTS

All patients had received initial thyroid hormone treatment no later than 50 d of age, and had reached their final height. The mean FHSDS for female and male patients were +0.17 +/- 0.99 and -0.03 +/- 0.99, respectively. The mean FHSDS-THSDS for female and male patients was +0.09 +/- 0.77 and -0.19 +/- 0.53, respectively. No difference was seen in pubertal growth parameters for either gender compared with that of the reference population, except for a greater peak height velocity and pubertal height gain in male patients. The mean menarchial age was identical to that of the reference population. No significant relationship was found between the FHSDS and any of the factors investigated.

CONCLUSION

The adult height of patients with CH detected by neonatal screening was equivalent to that of the reference population and their target height. As long as early intervention and satisfactory management are ensured, severe CH does not appear to reduce final adult height.

Effects of epinephrine and phosphodiesterase III inhibitors on bupivacaine-induced myocardial depression in guinea-pig papillary muscle

BACKGROUND

This study was designed to investigate the effects of epinephrine and the phosphodiesterase III inhibitors amrinone and milrinone on bupivacaine-induced myocardial depression in guinea-pig papillary muscles using an electrophysiological method.

METHODS

Electrophysiological studies of the effects of bupivacaine, epinephrine, amrinone and milrinone in normal and high K(+) Tyrode's solution were measured with guinea-pig papillary muscles. Specifically, epinephrine, amrinone and milrinone reversal of bupivacaine-induced depression was measured.

RESULTS

Bupivacaine reduced the action potential duration (APD), the maximum rate of rise of the AP (V(max)) and contractile force. Although epinephrine increased the contractile force similarly to amrinone and milrinone, it shortened the APD at 50% repolarization (APD(50)) and 90% repolarization (APD(90)). A high concentration of amrinone shortened APD, while milrinone did not affect APD except for a prolongation of APD(20). In high K(+) Tyrode's solution (25 mM), epinephrine, amrinone and milrinone increased the APD and the contractile force. Epinephrine reversed bupivacaine depression of APD and contractile force to control levels. Amrinone and milrinone restored not only the contractile force but also APD. There was an incomplete recovery of APD(50) for amrinone and the prolongation of APD(20) for milrinone.

CONCLUSIONS

Our results suggest that bupivacaine decreases the Ca(+) current (I(Ca)) and Na(+) current (I(Na)). Epinephrine and amrinone may increase I(Ca) and the delayed outward current (I(k)), whereas milrinone may increase I(Ca). The profound cardiovascular depression caused by bupivacaine was effectively reversed by amrinone and milrinone in a manner similar to epinephrine.

Hypothalamo-pituitary hypothyroidism detected by neonatal screening for congenital hypothyroidism using measurement of thyroid-stimulating hormone and thyroxine

The optimal strategy in neonatal screening for congenital hypothyroidism is still a subject of controversy. In Kanagawa Prefecture in Japan, simultaneous thyroid-stimulating hormone (TSH) and T4/fT4 determination has been used, while the results of our program may provide valuable information. Cumulative findings were analysed to determine the type and frequency of thyroid disorders in infants detected by simultaneous TSH and T4/fT4 determination, and the TSH and T4/fT4 screening strategy was validated. A total of 1284130 neonates were screened between October 1979 and September 1997 and infants followed because of low T4/fT4 without elevated TSH (T4 < 51.5 nmol/L or fT4 < 9 pmol/L and TSH < 15 mU/L) were retrospectively analysed. The first survey was carried out within 6 mo of birth and the second in 1998; 258 infants were diagnosed with congenital hypothyroidism at the first medical evaluation, 15 of them with hypothalamo-pituitary hypothyroidism. However, in the second survey, only 8 children were confirmed as having hypothalamo-pituitary hypothyroidism, therefore the incidence detected by the present strategy was 1/160516. Of 8 children with hypothalamo-pituitary hypothyroidism, mental retardation was prevented in 3 owing to early treatment.

CONCLUSIONS

Simultaneous measurement of TSH and T4/fT4 is a useful strategy for detecting hypothalamo-pituitary hypothyroidism, but more studies are needed to show the cost-benefits of using this strategy.

Prophylactic cranial irradiation of acute lymphoblastic leukemia in childhood: outcomes of late effects on pituitary function and growth in long-term survivors

It is well known that prophylactic cranial irradiation is highly effective in preventing central nervous system (CNS) relapse of acute lymphoblastic leukemia (ALL). Nevertheless, there have been very few reports on the late effects, especially pituitary function and growth, in long-term survivors who were treated with 18 Gy cranial irradiation in childhood. The subjects consisted of 35 children with ALL who were treated with prophylactic 18 Gy cranial irradiation at Kanagawa Children's Medical Center between October 1981 and February 1995. All patients received cranial irradiation after first attaining complete remission with induction chemotherapy, according to the treatment protocols prescribed by the Tokyo Children's Leukemia Study Group (TCLSG) and Tokyo Children's Cancer Study Group (TCCSG). Their ages at the time of cranial irradiation ranged from 2.2-15.0 years (mean 6.8). We evaluated their pituitary functions by measuring their pituitary hormone values 0.7-11.3 years (mean 6.0) after cranial irradiation and their growth by analyzing their height standard deviation score (SDS) at diagnosis of ALL and their final height SDS at the mean follow-up period of 8.2 years after cranial irradiation. Height SDS is defined as the difference between the patient's height and the mean height of their age and sex, divided by the standard deviation of their age and sex. Eight of 35 patients had ALL relapse, involving the bone marrow in seven patients and the CNS in only one. Six of the eight patients with relapse died 1.5-6.6 years after cranial irradiation and the other two patients were salvaged by further intensive therapies. The remaining 27 relapse-free patients have survived for 1.4-15.8 years (mean 10.1) after cranial irradiation. Twenty-six of the 29 survivors are long-term survivors of more than 5 years. Although there was one patient with an abnormal result in each value of growth hormone (GH), adrenocorticotropic hormone (ACTH), and prolactin (PRL), and two patients with abnormal results in thyroid-stimulating hormone (TSH) values, none of the patients had clinical symptoms of pituitary hormone abnormality and none required hormone supplements. The final height SDS decreased significantly compared with the height SDS at diagnosis of ALL in the long-term survivors (P = 0.001) and the height SDS of the patients who had received cranial irradiation at a young age tended to decrease gradually (P = 0.019). However, no patient showed severe growth failure. It is considered that prophylactic 18 Gy cranial irradiation plus chemotherapy for ALL in childhood can effectively prevent CNS relapse and is unlikely to produce clinically significant late effects, although it may cause slight pituitary hormone abnormality.

Development of safe and efficient novel nonviral gene transfer using ultrasound: enhancement of transfection efficiency of naked plasmid DNA in skeletal muscle

Although clinical trials of stimulation of angiogenesis by transfection of angiogenic growth factors using naked plasmid DNA or adenoviral vector have been successful, there are still unresolved problems for human gene therapy such as low transfection efficiency and safety. From this viewpoint, it is necessary to develop safe and efficient novel nonviral gene transfer methods. As therapeutic ultrasound induces cell membrane permeabilization, ultrasound irradiation might increase the transfection efficiency of naked plasmid DNA into skeletal muscle. Thus, we examined the transfection efficiency of naked plasmid DNA using ultrasound irradiation with echo contrast microbubble (Optison) in vitro and in vivo experiments. First, we examined the feasibility of ultrasound-mediated transfection of naked plasmid DNA into skeletal muscle cells. Luciferase plasmid mixed with or without Optison was transfected into cultured human skeletal muscle cells using ultrasound (1 MHz; 0.4 W(2)) for 30 s. Interestingly, luciferase activity was markedly increased in cells treated with Optison, while little luciferase activity could be detected without Optison (P < 0.01). Electron microscopy demonstrated the transient formation of holes (less than 5 microM) in the cell surface, which could possibly explain the rapid migration of the transgene into the cells. Next, we studied the in vivo transfection efficiency of naked plasmid DNA using ultrasound with Optison into skeletal muscle. Two days after transfection, luciferase activity in skeletal muscle transfected with Optison using ultrasound was significantly increased about 10-fold as compared with plasmid alone. Successful transfection was also confirmed by beta-galactosidase staining. Finally, we examined the feasibility of therapeutic angiogenesis using naked hepatocyte growth factor (HGF) plasmid in a rabbit ischemia model using the ultrasound-Optison method. Five weeks after transfection, the angiographic score and the number of capillary density in rabbits transfected with Optison using ultrasound was significantly increased as compared with HGF plasmid alone (P < 0.01), accompanied by a significant increase in blood flow and blood pressure ratio (P < 0.01). Overall, the ultrasound transfection method with Optison enhanced the transfection efficiency of naked plasmid DNA in vivo as well as in vitro. Transfection of HGF plasmid by the ultrasound-Optison method could be useful for safe clinical gene therapy to treat peripheral arterial disease without a viral vector system.

Graves' disease in patients with 22q11.2 deletion

We report 4 female patients and 1 male patient with a 22q11.2 deletion and Graves' disease diagnosed at age 27 months, 7, 10, 17, and 16 years, respectively. The clinical presentations were typical for hyperthyroidism, but 1 female infant had seizures in addition to symptoms of hyperthyroidism. All patients had elevated serum levels of thyroid hormones in association with suppressed thyroid-stimulating hormone levels. From these observations, we suggest that Graves' disease may be a part of the clinical spectrum associated with the 22q11.2 deletion syndrome.

High-resolution scanning electron microscopic evaluation of cell-membrane porosity by ultrasound

The effect of low-intensity ultrasound on HL-60 cells (human promyelocytic leukemia cells) in the presence of the photo sensitizing drug merocyanine 540 (MC 540) was evaluated morphologically, using a high-resolution scanning electron microscope and a transmission electron microscope. Exposure of HL-60 cells to ultrasound without MC 540 resulted in a decrease of finger-like processes in the cells. The cells showed many undulating ruffles on the surface. Distinct pits or holes in the membrane were not observed in these cells. The surface of HL-60 cells treated only with MC 540 was relatively smooth compared with that of control cells. HL-60 cells exposed to ultrasound in the presence of MC 540 showed apparent surface deformation. Numerous crater-like depressions of heterogeneous dimensions were observed in many cells. In addition, various-sized pores were noted in the cell membranes of more damaged cells. These results indicate that cell degeneration was induced by a rapid change in cell membrane porosity during sonication in the presence of MC540.

The Japanese Study Group of Insulin Therapy for Childhood and Adolescent Diabetes (JSGIT): initial aims and impact of the family history of type 1 diabetes mellitus in Japanese children

The Japanese Study Group of Insulin Therapy for Childhood and Adolescent Diabetes (JSGIT) was established in July 1994 with the chief aim to improve the quality of therapy for type 1 diabetes in children, an entity far less common in Japan than in Europe. We proposed four initial research topics: (i) to determine the current status of medical care and glycemic control in Japanese children with type 1 diabetes mellitus; (ii) to standardize the measurement of hemoglobin A1c; (iii) to establish a registry of a large cohort of patients in order to enable prospective studies to improve the quality of therapy for children with type 1 diabetes in Japan; and (iv) to enable participants of the JSGIT to hold a workshop twice annually. We registered a total of 736 patients from 45 hospitals throughout Japan. Intervention via insulin treatment was instituted after 2 yr for those patients whose hemoglobin A1c level was more than 8.1%. The proportion of patients receiving multiple insulin injections increased after intervention; however, average hemoglobin A1c in females remained significantly higher than in males. We identified two forms of diabetes in Japanese children: a rapidly progressive form and a more slowly progressive form. There was a significantly higher prevalence of a family history of diabetes in first-degree relatives in the slowly progressive form. These preliminary findings are the result of the first collaborative study of childhood diabetes in Japan.

TGF-beta1 up-regulates paxillin protein expression in malignant astrocytoma cells: requirement for a fibronectin substrate

Cytokines can influence the interactions between members of the integrin cell adhesion receptor family and the extracellular matrix thereby potentially affecting cell function and promoting cell adhesion, growth and migration of malignant astrocytoma tumor cells. As malignant astrocytoma cells synthesize TGF-beta1 in vivo, we analysed the effects of TGF-beta1 on signaling events associated with integrin receptor ligation, focusing on the effects on paxillin, a phosphorylated adaptor protein, that acts as a scaffold for signaling molecules recruited to focal adhesions. TGF-beta1-stimulation of primary astrocytes and serum-starved U-251MG malignant astrocytoma cells attached to fibronectin induced a substantial increase in the levels of paxillin protein (fivefold increase at 2.0 ng/ml) in a dose- and time-dependent manner compared to the levels observed on plating onto fibronectin in the absence of stimulation. In the astrocytoma cells, this resulted in an increase in the pool of tyrosine-phosphorylated paxillin, although it did not appear to alter the extent of phosphorylation of the paxillin molecules. In contrast, in primary astrocytes the protein levels were upregulated in the absence of a parallel increase in phosphorylation. The TGF-beta1-stimulated increase in paxillin levels required ligation of the fibronectin receptor, as it was not induced when the cells were plated onto vitronectin, collagen or laminin. The increase in the pool of paxillin on TGF-beta1 stimulation of the fibronectin-plated astrocytoma cells was associated with an increase in translation, but was not associated with an increase in the steady-state levels of paxillin mRNA. Stimulation with TGF-beta1 on a fibronectin substrate increased subsequent attachment and spreading of U-251MG cells onto fibronectin and, to a lesser extent, vitronectin, but not collagen. Our results indicate that physiologic levels of TGF-beta1 stimulate the expression of paxillin protein at the level of translation through a process that requires engagement of the fibronectin receptor, and promotes attachment and spreading of malignant astrocytoma cells on fibronectin.

[Two pediatric cases of malignant hyperthermia caused by sevoflurane]

We experienced two cases of malignant hyperthermia (MH) triggered by sevoflurane. Case 1 was a six-year-old girl, 15.8 kg, undergoing strabismus repair. She had flat back, elevated diaphragm and high arched palate. Anesthesia was induced and maintained with sevoflurane and nitrous oxide in oxygen. Her trachea was intubated without the use of muscle relaxant. Thirty minutes after the induction of anesthesia, ETco2 was over 60 mmHg despite hyperventilation. Muscle rigidity of legs and the rise in temperature were noted. MH was diagnosed and dantrolene i.v. was administered. Her maximum esophageal temperature was 40.2 degrees C. ETco2 and temperature returned to baseline values after dantrolene administration. Creatine phosphokinase (CK) level was 252 U.l-1 preoperatively, and 1690 U.l-1 next day. Case 2 was a year-and-9-month-old boy undergoing accessory ear resection. Anesthesia was induced with sevoflurane and nitrous oxide in oxygen. His trachea was intubated with an aid of vecuronium. Forty minutes after administration of sevoflurane his temperature rose to 38.6 degrees C with heart rate 191 bpm and Spo2 93%, and muscle rigidity of legs. MH was diagnosed and dantrolene was administered. His highest temperature was 39.3 degrees C and was reduced promptly after dantrolene. Postoperatively he was noted to have downslanting palpebral fissures, micrognathia, low set ears, and a single crease of the fifth finger and diagnosed as King syndrome which is reported to have association with MH. Both patients had no history of anesthesia nor abnormal family history. Both of them were rescued with dantrolene and recovered without sequelae.

Turner syndrome and Xp deletions: clinical and molecular studies in 47 patients

Although clinical features of Turner syndrome have primarily been explained by the dosage effects of SHOX (short stature homeobox-containing gene) and the putative lymphogenic gene together with chromosomal effects leading to nonspecific features, several matters remain to be determined, including modifying factors for the effects of SHOX haploinsufficiency, chromosomal location of the lymphogenic gene, and genetic factors for miscellaneous features such as multiple pigmented nevi. To clarify such unresolved issues, we examined clinical findings in 47 patients with molecularly defined Xp deletion chromosomes accompanied by the breakpoints on Xp21-22 (group 1; n = 19), those accompanied by the breakpoints on Xp11 (group 2; n = 16), i(Xq) or idic(X)(p11) chromosomes (group 3; n = 8), and interstitial Xp deletion chromosomes (group 4; n = 4). The deletion size of each patient was determined by fluorescence in situ hybridization and microsatellite analyses for 38 Xp loci including SHOX, which was deleted in groups 1-3 and preserved in group 4. The mean GH-untreated adult height was -2.2 SD in group 1 and -2.7 SD in group 2 (GH-untreated adult heights were scanty in group 3). The prevalence of spontaneous breast development in patients aged 12.8 yr or more (mean +/- 2 SD for B2 stage) was 11 of 11 in group 1, 7 of 12 in group 2, and 1 of 7 in group 3. The prevalence of wrist abnormality suggestive of Madelung deformity was 8 of 18 in group 1 and 2 of 23 in groups 2 and 3, and 9 of 18 in patients with spontaneous puberty and 1 of 23 in those without spontaneous puberty. The prevalence of short neck was 1 of 19 in group 1 and 7 of 24 in groups 2 and 3. Soft tissue and visceral anomalies were absent in group 1 preserving the region proximal to Duchenne muscular dystrophy and were often present in groups 2 and 3 missing the region distal to monoamine oxidase A (MAOA). Multiple pigmented nevi were observed in groups 1-3, with the prevalence of 0 of 7 in patients less than 10 yr of age and 15 of 36 in those 10 yr or older regardless of the presence or absence of spontaneous puberty. Turner phenotype was absent in group 4, including a fetus aborted at 21 wk gestation who preserved the region distal to MAOA. The results provide further support for the idea that clinical features in X chromosome aberrations are primarily explained by haploinsufficiency of SHOX and the lymphogenic gene and by the extent of chromosome imbalance in mitotic cells and pairing failure in meiotic cells. Furthermore, it is suggested that 1) expressivity of SHOX haploinsufficiency in the limb and faciocervical regions is primarily influenced by gonadal function status and the presence or absence of the lymphogenic gene, respectively; 2) the lymphogenic gene for soft tissue and visceral stigmata is located between Duchenne muscular dystrophy and MAOA; and 3) multiple pigmented nevi may primarily be ascribed to cooperation between a hitherto unknown genetic factor and an age-dependent factor other than gonadal E.

Synthetic studies toward gambierol. Convergent synthesis of the octacyclic polyether core

[structure: see text]. A convergent synthetic route to the octacyclic polyether core of gambierol, a marine polycyclic ether toxin, has been developed. The synthesis involves construction of two fragments representing the ABC and EFGH ring systems followed by their coupling via a B-alkyl Suzuki reaction.