Cholelithiasis prevalence and risk factors in individuals with severe or profound intellectual and motor disabilities

BACKGROUND

The prevalence and risk factors of cholelithiasis in individuals with severe or profound intellectual and motor disabilities (SPIMD) are poorly characterised. Thus, we aimed to investigate the prevalence and risk determinants of cholelithiasis in a cohort with SPIMD under medical care in a residential facility.

METHODS

We categorised 84 patients in a residential hospital for persons with SPIMD into groups: those with (Group CL) and without (Group N) cholelithiasis. Gallstones were detected via computed tomography, ultrasonography or both. We evaluated gastrostomy status, nutritional and respiratory support, constipation, and bladder and kidney stones. Data were significantly analysed using univariate and multivariate logistic regression analyses.

RESULTS

The prevalence rate of cholelithiasis in our SPIMD cohort was 27%. There were no significant differences in sex, age, weight, height, or Gross Motor Function Classification System between the two groups. However, more patients received enteral nutrition (39.13% vs. 6.56%; P = 0.000751) and were on ventilator support (56.52% vs. 19.67%; P = 0.00249) in Group CL than in Group N. Enteral nutrition [odds ratio (OR) 10.4, 95% confidence interval (CI) 1.98-54.7] and ventilator support (OR 20.0, 95% CI 1.99-201.0) were identified as independent risk factors for the prevalence of cholelithiasis in patients with SPIMD.

CONCLUSIONS

Patients with SPIMD demonstrated an increased prevalence of cholelithiasis, with a notable association between nutritional tonic use and respiratory support. Therefore, to emphasise the need for proactive screening, it is crucial to devise diagnostic and therapeutic strategies specific to patients with SPIMD. Further investigation is essential to validate our findings and explore causative factors.

Endoscopic Ultrasonography-Guided Fine-Needle Aspiration for Duodenal Subepithelial Lesions Showing a Hypoechoic Mass on Endoscopic Ultrasound Imaging

BACKGROUND/AIMS

For duodenal subepithelial lesions showing a hypoechoic mass on endoscopic ultrasound imaging, the utility of endoscopic ultrasound-guided fine-needle aspiration and the frequency of histological types have not been the focus of previous literature. This study aimed to clarify this.

MATERIALS AND METHODS

This prospective observational study enrolled 22 consecutive patients who underwent endoscopic ultrasoundguided fine-needle aspiration for duodenal subepithelial lesions with hypoechoic mass on endoscopic ultrasound. Immunohistochemical analysis was performed for all endoscopic ultrasound-guided fine-needle aspiration and surgically resected specimens. The main outcome measures were the technical results of endoscopic ultrasound-guided fine-needle aspiration and the frequency of histological types of duodenal subepithelial lesions with hypoechoic mass.

RESULTS

Thirteen fine-needle aspiration specimens were obtained from the duodenal bulb and eight from the descending duodenal region. The puncture was not performed because of intervening vessels in one patient. The diagnostic rate was 81% (95% confidence interval: 58.1-94.6, 17/21 patients). In 12 patients receiving surgical resection (excluding one cancellation of endoscopic ultrasoundguided fine-needle aspiration), the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration was 75% (95% confidence interval: 42.8-94.5, 9/12 patients). No complications were observed. The histopathological diagnoses included 11 cases of gastrointestinal stromal tumor (50%), 2 cases of leiomyoma (9%), 2 cases of metastatic cancer (9%), 2 cases of benign inconclusive, and 1 case each of carcinoid, malignant lymphoma, leiomyosarcoma, gauzeoma, and aberrant pancreas (4.5% each). The frequency of malignant tumors in the duodenal subepithelial lesions with hypoechoic mass group was 73% (16/22 patients).

CONCLUSIONS

Endoscopic ultrasound-guided fine-needle aspiration for duodenal subepithelial lesions with hypoechoic mass was safe and accurate. As duodenal subepithelial lesion with hypoechoic mass has a reasonably high possibility of containing malignant tumors, it is desirable to perform endoscopic ultrasound-guided fine-needle aspiration.

Intravenous vagal stimulation catheter, JOHAKU, rapidly decreases heart rate and myocardial oxygen consumption without worsening hemodynamics

Background

Rapid reduction of heart rate (HR) is the most evident physiological response of vagal nerve stimulation (VNS). Since HR reduction is the most potent factor to decrease myocardial oxygen consumption rate (MVO2), the appropriate VNS can exert cardio-protective effects. It is also known that VNS reduces inflammation, oxidative stress, and sympathetic overload. In addition, the VNS during ischemia-reperfusion is known to attenuate myocardial damage by studies in various animal species. Despite the presence of preclinical evidence of VNS benefits, the lack of the device has limited the translation of this technology to clinical practice. We have recently developed an intravenous VNS catheter (JOHAKU, Neuroceuticals Inc.) that can stimulate the right vagal nerve via superior vena cava (SVC) (Figure 1) on temporary basis.

Purpose

We aimed to confirm the feasibility of JOHAKU as a device to modulate heart rate and MVO2 rapidly by a canine experiment.

Methods

In eight beagle dogs, JOHAKU was inserted from the right femoral vein and placed at the SVC level. The stimulation intensity was adjusted to 10–20 V (20 Hz). We simultaneously recorded electrocardiogram and intraarterial blood pressure (BP). In three of eight dogs, we measured the left anterior descending coronary artery flow and oxygen saturations of arterial and coronary sinus blood to calculate MVO2. We compared HR, BP, and MVO2 during JOHAKU stimulation to ones at baseline.

Results

As shown in Figure 2, JOHAKU attenuated HR immediately after stimulation. Compared with baseline, JOHAKU significantly reduced HR (baseline: 135±13 vs. 5 min on stimulation: 107±13 bpm, p<0.05), and did not affect mean BP significantly (96.2±22.8 vs. 89.4±26.6 mmHg, P=0.59). HR promptly recovered to baseline level after JOHAKU stopped. JOHAKU also reduced MVO2 (0.57±0.43 vs. 0.48±0.38 ml/min, p<0.05).

Conclusion

JOHAKU rapidly attenuated cardiac metabolism burden via the rapid HR reduction. The controllability of HR by JOHAKU without affecting BP enables us to apply the VNS even for patients with hemodynamic instability, such as heart failure and acute myocardial infarction.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical and Research Development

Vinyl bag cover method to avoid droplet-containing aerosol escape from endoscopic forceps channel caps during COVID-19 pandemic (with Video 1 and Video 2)

Endoscopists are at high risk of allowing transmission of coronavirus disease 2019 (COVID-19) during gastrointestinal endoscopy (GIE) procedures under pandemic conditions. The main avenues of droplet-containing aerosol generated during GIE are the mouth, anus, and endoscopic forceps channel. Although the usefulness of personal protective equipment for preventing COVID-19 dissemination has been well reported, measures to address infected aerosol escaping during endoscopic forceps use have been neglected. Pathogen-contaminated aerosol from the endoscopic forceps channel, leading into the gastrointestinal lumen, has been confirmed and is a highly problematic source of infection. We developed a technique that entails covering the forceps entry/exit hole with a vinyl bag, thereby preventing contamination of the endoscopy room by the infected aerosol that escapes from this hole. The technique can be used in daily clinical endoscopic practice. Furthermore, this shielding technique is useful for all patients who undergo GIE, regardless of the purpose of the procedure such as for making a diagnosis, administering therapy, or in an urgent situation. In this letter, we introduce our novel, easily performed, inexpensive method of infection prevention by disallowing infected aerosol to escape from a COVID-19-infected patient into the air during a procedure that requires the use of endoscopic forceps.

Mice with cleavage-resistant N-cadherin exhibit synapse anomaly in the hippocampus and outperformance in spatial learning tasks

N-cadherin is a homophilic cell adhesion molecule that stabilizes excitatory synapses, by connecting pre- and post-synaptic termini. Upon NMDA receptor (NMDAR) activation by glutamate, membrane-proximal domains of N-cadherin are cleaved serially by a-disintegrin-and-metalloprotease 10 (ADAM10) and then presenilin 1(PS1, catalytic subunit of the γ-secretase complex). To assess the physiological significance of the initial N-cadherin cleavage, we engineer the mouse genome to create a knock-in allele with tandem missense mutations in the mouse N-cadherin/Cadherin-2 gene (Cdh2 R714G, I715D, or GD) that confers resistance on proteolysis by ADAM10 (GD mice). GD mice showed a better performance in the radial maze test, with significantly less revisiting errors after intervals of 30 and 300 s than WT, and a tendency for enhanced freezing in fear conditioning. Interestingly, GD mice reveal higher complexity in the tufts of thorny excrescence in the CA3 region of the hippocampus. Fine morphometry with serial section transmission electron microscopy (ssTEM) and three-dimensional (3D) reconstruction reveals significantly higher synaptic density, significantly smaller PSD area, and normal dendritic spine volume in GD mice. This knock-in mouse has provided in vivo evidence that ADAM10-mediated cleavage is a critical step in N-cadherin shedding and degradation and involved in the structure and function of glutamatergic synapses, which affect the memory function.

Effective reflection distance and its association with pressure augmentation index under a variety of acute hemodynamic perturbation

 

Effective reflection distance (ERD), a conceptual distance to a major reflection site from the aortic root, is associated with aging and pressure augmentation index (AIx) in clinical population. However, it is poorly understood how ERD varies and associates with AIx within a subject when the hemodynamic condition is changed extensively by acute pharmacological interventions.

Methods

In 13 anesthetized dogs, we measured aortic pressure (AP) and flow (AF) and femoral arterial flow (FF). Using AP, AF and FF, ERD based on an arterial model comprising a tube with frequency-dependent load (ERD_TL) was determined as a physiologically valid reference. ERD was also determined by wave separation (ERD_WSA) and pressure-only analyses (ERD_AW). Hemodynamic condition was changed by administrating zatebradine (bradycardic agent), nitroprusside, noradrenaline, dobutamine, and dextran.

Results

ERD_TL shortened significantly in response to infusion of nitroprusside or dobutamine. ERD_TL was significantly and negatively associated with AIx in multivariate analysis (Figure/Table). Changes in ERD_WSA or ERD_AW, and their association with AIx were not necessarily concordant with those observed in ERD_TL.

Conclusion

For the first time, we demonstrated that under diverse hemodynamic conditions, ERD_TL can change sensitively, and associates with AIx physiologically. This substantiates importance of tight attention to medication at clinical analysis of wave reflection phenomena. ERD_WSA or ERD_AW may not be a surrogate of ERD_TL.

Responses of ERD to drugs

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Japan Society for the Promotion of Science (JSPS)

Donepezil markedly prevents the progression of chronic heart failure and renal dysfunction in renal artery stenosis-induced hypertensive rats

Introduction

Parasympathetic activation by donepezil has been shown to improve prognosis in chronic heart failure (CHF) rats following myocardial infarction. We examined whether donepezil is effective in the treatment of another CHF model complicated with renal artery stenosis (RAS)-induced hypertension.

Methods

RAS was created by ligating the left renal artery up to 50% in SD rats, at the same time, we implanted a blood pressure (BP) transmitter for confirming RAS-induced hypertension (7-week post-RAS: systolic BP = 154±7 mmHg; diastolic BP = 115±8 mmHg). In the 11th week after induction of RAS, surviving animals were randomly assigned to untreated (UT, n=10) or donepezil treated [DT, n=10, dissolved in drinking water (3mg/kg/day)] group. After a 6-week treatment, the effects of donepezil were evaluated by hemodynamics, blood levels of neurohumoral markers, and morphology.

Results

Compared with UT, DT significantly prevented the progression of the left kidney atrophy (2.38±0.13 vs. 1.51±0.34 g/kg, P<0.05) and kidney fibrosis (left: −64%, P<0.001; right: −55%, P<0.01). DT also significantly prevented the progression of CHF, through suppressing cardiac hypertrophy (2.30±0.06 vs. 2.57±0.08 g/kg, P<0.01), cardiac fibrosis (−70%, P<0.01), and cardiac dysfunction [cardiac index: 102±3 vs. 86±3 ml/min/kg, P<0.05; left ventricular (LV) end-diastolic pressure: 12±2 vs. 20±2 mmHg, P<0.05; LV dp/dtmin: 5856±259 vs. 4924±227 mmHg/sec, P<0.05]. DT not only decreased serum levels of creatinine (0.54±0.02 vs. 0.63±0.03 mg/dl, P<0.05) and uric acid (1.4±0.2 vs. 1.9±0.2 mg/dl, P<0.05); but also decreased plasma levels of norepinephrine (273±38 vs. 846±242, P<0.01), AVP (2729±347 vs. 4783±695 pg/ml, P<0.05), BNP (360±13 vs. 460±39 pg/ml, P<0.05), angiotensin II and aldosteron, and suppressed the systemic inflammation.

Conclusions

Donepezil treatment markedly prevented the progression of CHF and renal dysfunction, and improved the neurohumoral markers in the CHF rat model complicated with RAS-induced hypertension, suggesting that donepezil may be used as a new pharmacotherapy for CHF patients complicated with RAS-induced hypertension.

Funding Acknowledgement

Type of funding source: None

A minimally-occlusive cuff method utilizing ultrasound vascular imaging for stress-free blood pressure measurement

Objective

Occlusive cuff inflation in ambulatory blood pressure (BP) monitoring disturbs the daily life of the user, and affects efficacy of monitoring. To overcome this limitation, we have developed a novel minimally-occlusive cuff method for stress-free measurement of BP. This study aimed to experimentally evaluate the reliability of this method, and improve the precision of this method by implementing a machine learning algorithm.

Methods

In this method, a thin-plate-type ultrasound probe (Size: 5.6mm-thickness × 28mm × 26mm; weight: 10g) is placed between the cuff and the skin, and used to measure the ultrasonic dimension of the artery (Figure 1). The cuff pressure (Pc), arterial dimension at systole (Ds) and diastole (Dd), systolic BP (SBP) and diastolic BP (DBP) during cuff inflation are theoretically related by the following equations,

SBP-Pc = P0·Exp[α·Ds]

DBP-Pc = P0·Exp[α·Dd]

Where P0 and α are constants, and α indicates arterial stiffness. Since multiple sets of the two equations can be defined over multiple cardiac beats while measuring Pc, Ds and Dd during mild cuff inflation (Pc is controlled less than 50 mmHg, Figure 1), it is possible to estimate SBP (SBPe) and DBP (DBPe) as solutions of the equations. In 6 anesthetized dogs, we attached the cuff and the probe to the right thigh to get SBPe and DBPe, which were one-time calibrated in each animal against reference SBP and DBP measured by using an intra-arterial catheter. We also determined the pulse arrival time (PAT), which is a commonly employed parameter in cuff-less BP monitoring. In all the dogs, BP was changed extensively by infusing noradrenaline or sodium nitroprusside.

Results

DBPe correlated tightly with DBP with a coefficient of determination (R2) of 0.85±0.08, and predicted DBP with error of 3.9±7.9 mmHg after one-time calibration (Figure 2). PAT correlated poorly with DBP (R2=0.49±0.17), and predicted DBP less accurately than this method. SBPe correlated well with SBP (R2=0.78±0.08) (Figure 3). However, even after one-time calibration, difference between SBPe and SBP was 2.6±18.9 mmHg, which was not acceptable. To improve the precision in SBP prediction, we used supervised machine learning approach with use of a support vector algorithm (Python, Scikit-learn), which regressed feature variables (SBPe, DBPe, Ds, Dd heart rate, and PAT) against teacher signal (reference SBP). The support vector algorithm, once trained, predicted SBP with acceptable accuracy with error of 0.7±6.9 mmHg (Figure 3).

Conclusions

This method reliably tracks BP changes without occlusive cuff inflation. Once calibrated, this method measures DBP accurately. With the aid of machine learning, precision in SBP prediction was greatly improved to an acceptable level. This method with machine learning approach has potential for stress-free BP measurement in ambulatory BP monitoring.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Japan Society for the Promotion of Science

Donepezil as a novel therapy for suppressing the progression of cardiovascular remodeling in obesity-induced hypertensive rats with reperfused myocardial infarction

Introduction

Acetylcholinesterase inhibition by donepezil has been shown to improve long-term survival in permanent myocardial infarction (MI)-induced chronic heart failure rats. This study examined whether donepezil is applicable to the treatment of obesity-induced hypertension with reperfused MI (RMI).

Methods

Four-week-old SD rats were fed a high-fat diet (57% kcal as fat) for 15 weeks. We implanted a blood pressure (BP) telemetry into the animals (8-week-old) for monitoring artery pressure. After a 1-week recovery, RMI was created by occluding the left coronary artery (30min) followed by reperfusion. Surviving animals were randomly assigned to untreated (UT, n=16) or donepezil treated (DT, n=16, 3 mg/kg/day) group. After a 10-week treatment, the effects of donepezil were evaluated by hemodynamics, blood biomarkers, immunohistochemistry, and morphology.

Results

The high-fat diet caused obesity and hypertension (9-week-old: systolic BP = 134±4 mmHg; diastolic BP = 92±2 mmHg) in the normal rats. Compared with UT, DT significantly decreased the heart rate (296±5 vs. 318±8 bpm, P<0.05). DT significantly prevented the progression of cardiac remodeling and dysfunction [cardiac index: 91±4 vs. 73±9 ml/min/kg, P<0.01; left ventricular (LV) end-diastolic pressure: 11±1 vs. 20±2 mmHg, P<0.01; LV dp/dt max: 5347±206 vs. 3637±433 mmHg/sec, P<0.01], through increasing capillary density (+120%/field, P<0.001), reducing cardiac fibrosis (−50%, P<0.01) and myocardial infarcted area (17±2 vs. 24±2%, P<0.05), suppressing cardiac hypertrophy (2.35±0.04 vs. 2.70±0.14 g/kg, P<0.01) and coronary artery remodeling (wall thickness: 30±1 vs. 37±2 mm, P<0.01; media-to-lumen ratio: 2.3±0.2 vs. 6.2±1.6, P<0.001). Additionally, DT not only decreased plasma levels of insulin, norepinephrine, BNP, angiotensin II, but also improved the systemic inflammation.

Conclusions

Donepezil treatment significantly suppressed the progression of cardiovascular remodeling and dysfunction following RMI in obesity-induced hypertensive rats, suggesting that donepezil may be used as a potential candidate for post-RMI therapy in obesity-induced hypertensive patients.

Funding Acknowledgement

Type of funding source: None

P105 Chronic vagal nerve stimulation suppress thirst through decreasing vasopressin secretion in the rats with chronic heart failure

Introduction

Chronic right cervical vagal nerve electric stimulation (VS) exerted prognostic benefits in heart failure rats. Exploring the mechanism is significant for clinical application. This study examined the effect of VS on arginine vasopressin (AVP) secretion and drinking behavior in the rats with chronic heart failure.

Methods

After a week recovery of myocardial infarction (MI), surviving rats after were randomly instrumented to VS group and sham stimulation (SS) group. A drop sensor was used to record real-time fluid consumption. Blood samples were collected weekly from the 3rd week during the 6 weeks treatment.

Results

Vagal stimulation did not change the daily fluid consumption (Mean ± SE, 76.2 ± 1.1 vs. 77.8 ± 2.1 ml/kg/day, n = 6, P < 0.05). Thirst, which is defined as per drinking volume (PDV), significantly increased during the early weeks after MI (Fig A), while VS significantly suppressed PDV (Fig B is the data of 6th week) by increasing the drinking intervals. The level of plasma AVP was increased to about 2 fold during 6 weeks observation in the SS group, however, VS suppressed this upregulation (Fig C).

Conclusion

These results suggest that VS may activate vagal afferent components which related to inhibition of AVP secretion and then suppressed the augmentation of thirst. Frequent drinking small volume may benefit for homeostasis in CHF.

Abstract P105 Figure. Drinking behavior and AVP

P3501Oral administration of donepezil markedly prevents the progression of chronic heart failure in renal artery stenosis-induced hypertensive rats

Introduction

Parasympathetic activation by donepezil has been shown to improve prognosis in chronic heart failure (CHF) rats following myocardial infarction. We examined whether donepezil is effective in the treatment of another CHF model complicated with renal artery stenosis (RAS)-induced hypertension.

Methods

RAS was created by ligating the left renal artery up to 50% in SD rats, at the same time, we implanted a blood pressure (BP) transmitter for confirming RAS-induced hypertension (7-week post-RAS: systolic BP = 154±7 mmHg; diastolic BP = 115±8 mmHg). At the 11th week after induction of RAS, surviving animals were randomly assigned to untreated (UT, n=10) or donepezil treated [DT, n=10, dissolved in drinking water (3mg/kg/day)] group. After a 6-week treatment, the effects of donepezil were evaluated by hemodynamics, blood levels of neurohumoral markers, and morphology.

Results

Compared with UT, DT significantly prevented the progression of the left kidney atrophy (2.38±0.13 vs. 1.51±0.34 g/kg, P<0.05). DT also significantly improved cardiac remodeling, through suppressing the progression of cardiac hypertrophy (2.30±0.06 vs. 2.57±0.08 g/kg, P<0.01), cardiac dysfunction [cardiac index: 102±3 vs. 86±3ml/min/kg, P<0.05; left ventricular (LV) end-diastolic pressure: 12±2 vs. 20±2 mmHg, P<0.05; LV dp/dtmin: 5856±259 vs. 4924±227 mmHg/sec, P<0.05]. DT not only decreased serum levels of creatinine (0.54±0.02 vs. 0.63±0.03 mg/dl, P<0.05) and uric acid (1.4±0.2 vs. 1.9±0.2 mg/dl, P<0.05); but also decreased plasma levels of norepinephrine (273±38 vs. 846±242, P<0.01), angiotensin II (17±2 vs. 23±2 pg/ml, P<0.05), AVP (2729±347 vs. 4783±695 pg/ml, P<0.05) and BNP (360±13 vs. 460±39 pg/ml, P<0.05), and suppressed the systemic inflammation (CRP: 190±12 vs. 382±58 mg/ml, P<0.01).

Conclusions

Donepezil treatment markedly prevented the progression of cardiac remodeling and renal dysfunction, and improved the neurohumoral markers in the CHF rat model complicated with RAS-induced hypertension, suggesting that donepezil may be used as a new pharmacotherapy for CHF patients complicated with RAS-induced hypertension.

P4605Landiolol, a beta-blocker, optimizes cardiac energetics and peripheral microhemodynamics better than ivabradine while reducing heart rate at hemodynamic resuscitation of experimental septic shock

Background

Septic shock is associated with sympathetic over-activation characterized by tachycardia, which is associated with poor survival. Though several kinds of drugs are available to reduce heart rate (HR), it is not clear which drug should be used to reduce HR effectively in initial hemodynamic resuscitation in septic shock.

Purpose

The aim of this study was to experimentally investigate comparative effects of landiolol (a β-blocker) and ivabradine (an If-channel inhibitor) on initial hemodynamic resuscitation in a canine model of endotoxin shock.

Methods

We used 19 anesthetized dogs. Seven dogs were allocated to control (CT) group, six dogs to landiolol (BB) group, and six dogs to ivabradine (IVA) group. In all the groups, endotoxin shock was induced by intravenous infusion of Escherichia coli lipopolysaccharide (4 mg/kg) over 1 h. After induction of endotoxin shock, we started hemodynamic resuscitation to restore mean arterial pressure (AP) and cardiac output (CO) by infusing noradrenaline (NA) and Ringer acetate solution (RiA). Dose of NA and RiA were automatically titrated with use of a computer-controlled drug infusion system that we developed previously. Hemodynamic resuscitation was continued for 4 h. During resuscitation, the BB group was given landiolol infusion at a low-dose range (1–10 μg/kg/min, manually titrated), while the IVA group was given ivabradine at 0.25 mg/kg bolus-injected every 2 h.

Results

The drug infusion system automatically restored AP to 70 mmHg and CO to greater than 90% of baseline level in all the groups. The restored AP and CO were not significantly different among the three groups (Figure A, B). There were no significant differences in the computer-controlled infusion rate of NA and cumulated volume of RiA infused among the three groups (Figure C). During the first 2 h of resuscitation, HR was significantly reduced in the BB and IVA groups in comparison to the CT group (Figure D). However, only in the BB group, cardiac oxygen consumption was significantly lower than that in the CT group (Figure E). Blood lactate level decreased significantly after hemodynamic resuscitation only within the BB group (Figure F).

Figure 1

Conclusions

In the initial hemodynamic resuscitation of septic shock, both low-dose landiolol infusion and ivabradine injection may be used to reduce HR. However, to optimize cardiac energetics and peripheral microhemodynamics, low-dose landiolol infusion may be preferable to ivabradine injection.

Acknowledgement/Funding

This work was supported by JSPS KAKENHI Grant Number 15K01307, 18K12126.

Randomized clinical trial of extensive intraoperative peritoneal lavage versus standard treatment for resectable advanced gastric cancer (CCOG 1102 trial)

BACKGROUND

A survival benefit of extensive intraoperative peritoneal lavage (EIPL) has been reported in patients with gastric cancer with positive peritoneal cytology. The hypothesis of this study was that EIPL may reduce peritoneal recurrence in patients with advanced gastric cancer who undergo surgery with curative intent.

METHODS

This was an open-label, multi-institutional, randomized, phase 3 trial to assess the effects of EIPL versus standard treatment after curative gastrectomy for resectable gastric cancer of T3 status or above. The primary endpoint was disease-free survival (DFS); secondary endpoints were overall survival, peritoneal recurrence-free survival and incidence of adverse events.

RESULTS

Between July 2011 and January 2014, 314 patients were enrolled from 15 institutions and 295 patients were analysed (145 and 150 in the EIPL and no-EIPL groups respectively). The 3-year DFS rate was 63·9 (95 per cent c.i. 55·5 to 71·2) per cent in the EIPL group and 59·7 (51·3 to 67·1) per cent in the control group (hazard ratio (HR) 0·81, 95 per cent c.i. 0·57 to 1·16; P = 0·249). The 3-year overall survival rate was 75·0 (67·1 to 81·3) per cent in the EIPL group and 73·7 (65·9 to 80·1) per cent in the control group (HR 0·91, 0·60 to 1·37; P = 0·634). Peritoneal recurrence-free survival was not significantly different between the two groups (HR 0·92, 0·62 to 1·36; P = 0·676). No intraoperative complications related to EIPL were observed.

CONCLUSION

EIPL did not improve survival or peritoneal recurrence in patients who underwent gastrectomy for advanced gastric cancer. Registration number: 000005907 (http://www.umin.ac.jp/ctr/index.htm).

Randomized clinical trial of duct-to-mucosa pancreaticogastrostomy versus handsewn closure after distal pancreatectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) remains a major cause of morbidity after distal pancreatectomy. The aim of this study was to investigate whether duct-to-mucosa pancreaticogastrostomy of the pancreatic stump decreased clinical POPF formation compared with handsewn closure after distal pancreatectomy.

METHODS

This multicentre RCT was performed between April 2012 and June 2014. Patients undergoing distal pancreatectomy were assigned randomly to either duct-to-mucosa pancreaticogastrostomy or handsewn closure. The primary endpoint was the incidence of clinical POPF. Secondary endpoints were rates of other complications and length of hospital stay.

RESULTS

Some 80 patients were randomized, and 73 patients were evaluated in an intention-to-treat analysis: 36 in the pancreaticogastrostomy group and 37 in the handsewn closure group. The duration of operation was significantly longer in the pancreaticogastrostomy group than in the handsewn closure group (mean 268 versus 197 min respectively; P < 0·001). The incidence of clinical POPF did not differ between groups (7 of 36 versus 7 of 37; odds ratio (OR) 1·03, 95 per cent c.i. 0·32 to 3·10; P = 1·000). The rate of intra-abdominal fluid collection was significantly lower in the pancreaticogastrostomy group (6 of 36 versus 21 of 37; OR 0·15, 0·05 to 0·45; P < 0·001). There were no statistically significant differences in the rates of other complications or length of hospital stay.

CONCLUSION

Duct-to-mucosa pancreaticogastrostomy did not reduce the incidence of clinical POPF compared with handsewn closure of the pancreatic stump after distal pancreatectomy. Registration number UMIN000007426 (http://www.umin.ac.jp).

Clinical Value of Pet with 18F-Fluorodeoxyglucose and L-Methyl-11C-Methionine for Diagnosis of Recurrent Brain Tumor and Radiation Injury

We studied 15 patients clinically suspected to have recurrent brain tumor or radiation injury, using positron emission tomography (PET) with 18F-fluorodeoxyglucose (18FDG) and L-methyl-11C-methionine (11C-Met). PET with 11C-Met (Met-PET) clearly delineated the extent of recurrent brain tumor as focal areas of increased accumulation of 11C-Met, and was useful for early detection of recurrent brain tumor. PET with 18FDG (FDG-PET) showed focal 18FDG-hypermetabolism in one patient with malignant transformation of low grade glioma, and demonstrated its usefulness for evaluation of malignant transformation. 18FDG-hypometabolism was observed in all patients with radiation injury, but was also found in one patient with recurrent malignant brain tumor. 11C-Met uptake in 3 patients with radiation injury was similar to that of the normal cortical tissue. FDG-PET can be used to initially exclude recurrent brain tumor which is seen as 18FDG-hypermetabolism. The combined use of Met-PET in addition to FDG-PET can improve the accuracy of differentiation of recurrent brain tumor with 18FDG-hypometabolism from radiation injury.

AEGA: A New Real-Coded Genetic AlgorithmTaking Account of Extrapolation

This study proposes a new real-coded genetic algorithm (RCGA) taking account of extrapolation, which we call adaptive extrapolation RCGA (AEGA). Real-world problems are often formulated as black-box function optimization problems and sometimes have ridge structures and implicit active constraints. mAREX/JGG is one of the most powerful RCGAs that performs well against these problems. However, mAREX/JGG has a problem of search inefficiency. To overcome this problem, we propose AEGA that generates offspring outside the current population in a more stable manner than mAREX/JGG. Moreover, AEGA adapts the width of the offspring distribution automatically to improve its search efficiency. We evaluate the performance of AEGA using benchmark problems and show that AEGA finds the optimum with fewer evaluations than mAREX/JGG with a maximum reduction ratio of 45%. Furthermore, we apply AEGA to a lens design problem that is known as a difficult real-world problem and show that AEGA reaches the known best solution with approximately 25% fewer evaluations than mAREX/JGG.

Concurrent analysis of human equilibrative nucleoside transporter 1 and ribonucleotide reductase subunit 1 expression increases predictive value for prognosis in cholangiocarcinoma patients treated with adjuvant gemcitabine-based chemotherapy

BACKGROUND

The aim of this study was to investigate the predictive and prognostic values of intratumoural human equilibrative nucleoside transporter 1 (hENT1) and ribonucleotide reductase subunit 1 (RRM1) expression in advanced cholangiocarcinoma patients treated with adjuvant gemcitabine-based chemotherapy (AGC).

METHODS

Intratumoural hENT1 and RRM1 expression levels were investigated immunohistochemically in 127 patients with advanced cholangiocarcinoma who underwent surgical resection (68 with AGC and 59 without AGC). The impacts of hENT1 and RRM1 expression on survival were evaluated.

RESULTS

High intratumoural hENT1 and RRM1 expression levels were observed in 86 (68%) and 67 (53%) patients, respectively. In a multivariate analysis of 68 patients who received AGC, high hENT1 (P=0.044) and low RRM1 expression (P=0.009) were independently associated with prolonged disease-free survival (DFS), whereas low RRM1 expression (P=0.024) was independently associated with prolonged overall survival (OS). Moreover, concurrent high hENT1 and low RRM1 expression was a powerful independent predictor of prolonged DFS (P<0.001) and OS (P=0.001) when the combined classification of hENT1 and RRM1 was introduced.

CONCLUSIONS

Concurrent analysis of hENT1 and RRM1 expression may increase the predictive value of these biomarkers for survival of advanced cholangiocarcinoma patients treated with AGC.

Sympathetic afferent stimulation inhibits central vagal activation induced by intravenous medetomidine in rats

AIM

To examine whether sympathetic afferent stimulation (SAS) inhibits central vagal activation induced by α2 -adrenergic stimulation.

METHODS

In anaesthetized Wistar-Kyoto rats, a cardiac microdialysis technique was applied to the left ventricle, and the effect of α2 -adrenergic stimulation by medetomidine on myocardial interstitial acetylcholine (ACh) levels was examined in the absence (n = 6) or the presence (n = 6) of SAS delivered from the left stellate ganglion. The effect of electrical vagal efferent stimulation on myocardial interstitial ACh release was also examined in the absence or the presence of SAS (n = 6).

RESULTS

Intravenous medetomidine (0.1 mg kg(-1) ) significantly increased myocardial interstitial ACh levels in the absence of SAS (from 1.95 ± 0.79 to 3.36 ± 1.61 nM, P < 0.05), but not in the presence of SAS (from 1.67 ± 0.67 to 2.01 ± 0.78 nM). In contrast, electrical vagal nerve stimulation increased myocardial interstitial ACh level to the same degree regardless of SAS (from 1.66 ± 0.16 to 3.93 ± 0.72 nM without SAS vs. 4.05 ± 0.89 nM with SAS).

CONCLUSION

Sympathetic afferent stimulation inhibited medetomidine-induced ACh release, but not electrical stimulation-induced ACh release, suggesting that SAS inhibited medetomidine-induced vagal activation via central mechanisms. While central vagal activation by α2 -adrenergic agonists could be an alternative to electrical vagal activation, blocking sympathetic afferent input may be important to increase the efficacy of α2 -adrenergic agonists in enhancing vagal nerve activity.

High-frequency dominant depression of peripheral vagal control of heart rate in rats with chronic heart failure

AIM

To examine whether dynamic characteristics of the peripheral vagal control of heart rate (HR) are altered in chronic heart failure (CHF).

METHODS

The right vagal nerve was electrically stimulated according to a binary white noise signal, and the transfer function from vagal nerve stimulation (VNS) to HR was estimated in the frequency range from 0.01 to 1 Hz in five control rats and five CHF rats under anaesthetized conditions. The rate of VNS was changed among 10, 20 and 40 Hz.

RESULTS

A multiple linear regression analysis indicated that the increase in the VNS rate augmented the ratio of the high-frequency (HF) gain to the steady-state gain in the control group but not in the CHF group. As a result, the dynamic gain of the transfer function in the frequencies near 1 Hz decreased more in the CHF group than in the control group.

CONCLUSION

Changes in the dynamic characteristics of the peripheral vagal control of HR may contribute to the manifestation of decreased HF components of HR variability observed in CHF.

Primary hepatic carcinoid tumor

We report the case of primary hepatic carcinoid tumor of which diagnosis was made by fine needle biopsy of a liver mass. The patient was treated successfully by left hepatic trisegmentectomy. This patient presented with complaints of generalized fatigue, but denied the presence of flushing, diarrhea, or other endocrine symptoms. Physical examination was unremarkable. A biopsy specimen revealed Grimelius stained cells that were immunoreactive for chromogranin A. Careful pre- and intraoperative examinations revealed no other primary lesions. Argyrophilia of the tumor cells suggested that the tumor was of fore five cases of primary hepatic carcinoid tumors previously reported in the literature are also reviewed.

Central vagal activation by alpha(2) -adrenergic stimulation is impaired in spontaneously hypertensive rats

AIM

To elucidate the abnormality of vagal control in spontaneously hypertensive rats (SHR) by measuring left ventricular myocardial interstitial acetylcholine (ACh) release in response to α(2) -adrenergic stimulation as an index of in vivo vagal nerve activity.

METHODS

A cardiac microdialysis technique was applied to the rat left ventricle in vivo, and the effect of α(2) -adrenergic stimulation by medetomidine or electrical vagal nerve stimulation on myocardial interstitial ACh levels was examined in normotensive Wistar-Kyoto rats (WKY) and SHR under anaesthetized conditions.

RESULTS

Intravenous medetomidine (0.1 mg kg(-1) ) significantly increased the ACh levels in WKY (from 2.4 ± 0.6 to 4.2 ± 1.3 nmol L(-1) , P < 0.05, n = 7) but not in SHR (from 2.5 ± 0.7 to 2.7 ± 0.7 nmol L(-1) , n = 7). In contrast, electrical vagal nerve stimulation increased the ACh levels in both WKY (from 1.0 ± 0.4 to 2.9 ± 0.9 nmol L(-1) , P < 0.001, n = 6) and SHR (from 0.9 ± 0.2 to 2.2 ± 0.4 nmol L(-1) , P < 0.001, n = 6). Intravenous administration of medetomidine (0.1 mg kg(-1) ) did not affect the vagal nerve stimulation-induced ACh release in either WKY or SHR.

CONCLUSION

Medetomidine-induced central vagal activation was impaired in SHR, whereas peripheral vagal control of ACh release was preserved. In addition to abnormal sympathetic control, vagal control by the central nervous system may be impaired in SHR.

Maternal and preterm fetal sheep responses to dexmedetomidine

BACKGROUND

The α(2) adrenergic receptor agonist dexmedetomidine has some unique pharmacologic properties that could benefit pregnant patients (and their fetuses) when they require sedation, analgesia, and/or anesthesia during pregnancy. The purpose of the present study was to delineate maternal and fetal responses to an intravenous infusion of dexmedetomidine.

METHODS

This study was conducted on surgically-recovered preterm sheep instrumented for physiologic recording and blood sampling. Maternal and fetal cardiovascular and blood gas parameters and fetal cerebral oxygenation levels were recorded before, during, and after 3h of dexmedetomidine infusion to the ewe at a rate of 1 μg/kg/h.

RESULTS

Drug infusion produced overt sedation but no apparent respiratory depression as evidenced by stable maternal arterial blood gases; fetal blood gases were also stable. The one blood parameter to change was serum glucose, By the end of the 3-h infusion, glucose increased from 49±10 to 104±33mg/dL in the ewe and from 22±3 to 48±16mg/dL in the fetus; it declined post-drug exposure but remained elevated compared to the starting levels (maternal, 63±12mg/dL, P=0.0497; and fetal, 24±4mg/dL, P=0.012). With respect to cardiovascular status, dexmedetomidine produced a decrease in maternal blood pressure and heart rate with fluctuations in uterine blood flow but had no discernable effect on fetal heart rate or mean arterial pressure. Likewise, maternal drug infusion had no effect on fetal cerebral oxygenation, as measured by in utero near-infrared spectroscopy.

CONCLUSIONS

Using a clinically-relevant dosing regimen, intravenous infusion of dexmedetomidine produced significant maternal sedation without altering fetal physiologic status. Results from this initial acute assessment support the conduct of further studies to determine if dexmedetomidine has clinical utility for sedation and pain control during pregnancy.

Influence of ion source configuration and its operation parameters on the target sputtering and implantation process

In the work, investigation of the features and operation regimes of sputter enhanced ion-plasma source are presented. The source is based on the target sputtering with the dense plasma formed in the crossed electric and magnetic fields. It allows operation with noble or reactive gases at low pressure discharge regimes, and, the resulting ion beam is the mixture of ions from the working gas and sputtering target. Any conductive material, such as metals, alloys, or compounds, can be used as the sputtering target. Effectiveness of target sputtering process with the plasma was investigated dependently on the gun geometry, plasma parameters, and the target bias voltage. With the applied accelerating voltage from 0 to 20 kV, the source can be operated in regimes of thin film deposition, ion-beam mixing, and ion implantation. Multi-component ion beam implantation was applied to α-Fe, which leads to the surface hardness increasing from 2 GPa in the initial condition up to 3.5 GPa in case of combined N(2)-C implantation. Projected range of the implanted elements is up to 20 nm with the implantation energy 20 keV that was obtained with XPS depth profiling.