Development of 8-17 XNAzymes that are functional in cells

DNA enzymes (DNAzymes), which cleave target RNA with high specificity, have been widely investigated as potential oligonucleotide-based therapeutics. Recently, xeno-nucleic acid (XNA)-modified DNAzymes (XNAzymes), exhibiting cleavage activity in cultured cells, have been developed. However, a versatile approach to modify XNAzymes that function in cells has not yet been established. Here, we report an X-ray crystal structure-based approach to modify 8-17 DNAzymes; this approach enables us to effectively locate suitable XNAs to modify. Our approach, combined with a modification strategy used in designing antisense oligonucleotides, rationally designed 8-17 XNAzyme ("X8-17") that achieved high potency in terms of RNA cleavage and biostability against nucleases. X8-17, modified with 2'-O-methyl RNA, locked nucleic acid and phosphorothioate, successfully induced endogenous MALAT-1 and SRB1 RNA knockdown in cells. This approach may help in developing XNAzyme-based novel therapeutic agents.

POS0687 INHIBITION OF BONE EROSION, DETERMINED BY HIGH-RESOLUTION PERIPHERAL QUANTITATIVE COMPUTED TOMOGRAPHY (HR-pQCT), IN RHEUMATOID ARTHRITIS PATIENTS RECEIVING A CONVENTIONAL SYNTHETIC DMARD (csDMARD) PLUS DENOSUMAB VS csDMARD THERAPY ALONE: RESULTS OF AN OPEN-LABEL, RANDOMIZED, PARALLEL-GROUP STUDY

Background

Denosumab, a human IgG2 monoclonal antibody with high affinity for RANKL, is approved for treatment of bone erosion (ER) in patients with RA, based on the results of clinical trials. However, its effectiveness in combination with conventional therapy in RA patients has not been fully investigated in clinical practice.

Objectives

This exploratory study aimed to compare, in patients receiving conventional synthetic disease-modifying anti-rheumatic drugs (csDMARD) for treatment of RA, the effectiveness of combined use of csDMARD and denosumab vs csDMARD alone, in terms of inhibition of ER determined by HR-pQCT.

Methods

Detail protocol of this open-label, randomized, parallel-group study has been published previously.1 RA patients with moderate or low disease activity and progressive ER were eligible, and were randomly assigned to receive denosumab in addition to the csDMARD (denosumab) group or to continued use of the csDMARD alone (csDMARD) group. Denosumab was administered every 6 months during the 12-month study period. The primary endpoint was change in ER-depth at the second and third metacarpal bones, determined by HR-pQCT at month 6. For the primary endpoint, a linear mixed effect model analysis was performed using treatment group, sex, anti-cyclic citrullinated peptide (CCP) antibody (positive vs negative), and baseline disease activity (DAS28-ESR) as fixed effects, patients as random effects, and baseline values as covariates. For extension data, measurement time-point and the interaction between treatment group and measurement time-point was further added as fixed effects. The adverse events (AEs) were recorded.

Results

A total of 46 patients were randomized to denosumab and csDMARD groups (both N=23), and baseline characteristics were similar between both groups. Although the difference was not significant, the estimate mean (95%CI) change of ER-depth at month 6 from baseline as the primary endpoint was −0.57 (−1.52, 0.39) in the denosumab group vs −0.22 (−0.97, 0.53) in the csDMARD group, respectively. At months 6 and 12, ER-depth, -width, and -volume (extension data) were numerically lower in the denosumab group than in the csDMARD group (Table 1). Compared with patients in the csDMARD group, those in the denosumab group had significantly higher volumetric bone mineral density (vBMD) at month 12. AEs were reported in 12 (52.2%) and 13 (56.5%) of patients in the denosumab and csDMARD groups, respectively. The most common AEs of denosumab groups was hypocalcemia (reported in 4), and all the events were causally related with denosumab. Serious AEs were reported in 1 (4.3%) and 2 (8.7%) of patients in the denosumab and csDMARD groups, and which were not related to treatment drug.

Table 1.

ER and microstructure in denosumab group vs csDMARD group

MonthDenosumab group (n=21)csDMARDs group (n=22)Difference (Denosumab- csDMARDs)n1Estimate Means [95%CI]n1Estimate Means [95%CI]Estimate Means [95%CI]ER-depth617−0.46 [−1.31, 0.39]25−0.20 [−0.89, 0.49]−0.27 [−0.86, 0.32]1217−0.56 [−1.41, 0.29]22−0.20 [−0.90, 0.49]−0.35 [−0.95, 0.24]ER-width617−0.26 [−1.10, 0.57]25−0.06 [−0.73, 0.61]−0.20 [−0.81, 0.40]1217−0.27 [−1.10, 0.56]22−0.03 [−0.70, 0.64]−0.24 [−0.85, 0.38]ER-volume616−6.21 [−23.89, 11.46]24−1.71 [−16.07, 12.66]−4.51 [−16.67, 7.65]1217−6.25 [−23.94, 11.44]21−3.18 [−17.56, 11.20]−3.07 [−15.32, 9.17]vBMD6426.41 [2.78, 10.03]442.46 [−1.33, 6.24]3.95 [−0.05, 7.94]12389.20 [5.46, 12.95]423.66 [−0.15, 7.46]5.55 [1.46, 9.63]*

These were extension data.

This is the efficacy analysis set which excluded 3 patients from the full analysis set.

*; p<0.01

n, number of patients; n1, number of measurement points

Conclusion

Our results suggest that adding denosumab to csDMARD therapy may help prevent ER, promote ER repair, and improve bone microstructure.

References

[1]Iwamoto N, et al., Trials. 2019;20(1):1–8.

Disclosure of Interests

Naoki Iwamoto Speakers bureau: Daiichi Sankyo Co., Ltd., Grant/research support from: Daiichi Sankyo Co., Ltd., Ko Chiba Speakers bureau: Daiichi Sankyo Co., Ltd., Shuntaro Sato: None declared, Kazuteru Shiraishi: None declared, Konosuke Watanabe: None declared, Nozomi Ohki: None declared, Akitomo Okada: None declared, Tomohiro Koga: None declared, Makiko Kobayashi Employee of: Daiichi Sankyo Co., Ltd. (retired at submission), Kengo Saito Employee of: Daiichi Sankyo Co., Ltd., Naoki Okubo Employee of: Daiichi Sankyo Co., Ltd., Atsushi Kawakami Speakers bureau: Daiichi Sankyo Co., Ltd., Grant/research support from: Daiichi Sankyo Co., Ltd.

Temperature-dependent activity of kinesins is regulable

Cytoskeletal transport in cells is driven by enzymes whose activity shows sensitive, typically Arrhenius, dependence on temperature. Often, the duration and outcome of cargo transport is determined by the relative success of kinesin vs. dynein motors, which can simultaneously bind to individual cargos and move in opposite direction on microtubules. The question of how kinesin and dynein activity remain coupled over the large temperature ranges experienced by some cells is one of clear biological relevance. We report a break in the Arrhenius behavior of both kinesin-1 and kinesin-3 enzymatic activity at 4.7 °C and 10.5 °C, respectively. Further, we report that this transition temperature significantly changes as a function of chemical background: addition of 200 mM TMAO increases transition temperatures by ∼6 °C in all cases. Our results show that Arrhenius trend breaks are common to all cytoskeletal motors and open a broad question of how such activity transitions are regulated in vivo. STATEMENT OF SIGNIFICANCE: Many cytoskeletal motors studied to date follow Arrhenius kinetics, at least from room temperature up to mammalian body temperature. However the thermal dynamic range is typically finite, and breaks in Arrhenius trends are commonly observed at biologically relevant temperatures. Here we report that the thermal dynamic range of kinesins is also limited and moreover that the location of the Arrhenius break for kinesins can shift significantly based on chemical backgrounds. This implies that the balance of multiple motor cargo transport along the cytoskeleton is far more tunable as a function of temperature than previously appreciated.

Biodegradable Surgical Staple Composed of Magnesium Alloy

Currently, surgical staples are composed of non-biodegradable titanium (Ti) that can cause allergic reactions and interfere with imaging. This paper proposes a novel biodegradable magnesium (Mg) alloy staple and discusses analyses conducted to evaluate its safety and feasibility. Specifically, finite element analysis revealed that the proposed staple has a suitable stress distribution while stapling and maintaining closure. Further, an immersion test using artificial intestinal juice produced satisfactory biodegradable behavior, mechanical durability, and biocompatibility in vitro. Hydrogen resulting from rapid corrosion of Mg was observed in small quantities only in the first week of immersion, and most staples maintained their shapes until at least the fourth week. Further, the tensile force was maintained for more than a week and was reduced to approximately one-half by the fourth week. In addition, the Mg concentration of the intestinal artificial juice was at a low cytotoxic level. In porcine intestinal anastomoses, the Mg alloy staples caused neither technical failure nor such complications as anastomotic leakage, hematoma, or adhesion. No necrosis or serious inflammation reaction was histopathologically recognized. Thus, the proposed Mg alloy staple offers a promising alternative to Ti alloy staples.

Efficacy of and prognosis after steroid pulse therapy in patients with poor reduction of jaundice after laparoscopic Kasai portoenterostomy

PURPOSE

High-dose postoperative steroid therapy after Kasai portoenterostomy is reported to improve jaundice clearance and a strong anti-inflammatory activity might prevent fibrous tissue formation which is often observed at the porta hepatis in revision surgery. We started steroid pulse therapy for the patients with cessation of decrease in jaundice and aimed to evaluate the efficacy in this study.

METHODS

The demographics and outcomes of patients who underwent laparoscopic Kasai portoenterostomy and received steroid pulse therapy within 2 months postoperatively between September 2014 and December 2018 were retrospectively reviewed; the therapy was determined successful when the serum total bilirubin level decreased to or below two-thirds of the pre-therapy level after 2 weeks. Patient data in the successful group were compared with those in the unsuccessful group.

RESULTS

Steroid pulse therapy was successful in seven of 16 patients (43.8%). The percentage of patients whose serum total bilirubin level decreased to normal was significantly higher in the successful group at 3 months (85.7% vs. 11.1%, P = 0.0028) and after all (100% vs. 33.3%, P = 0.011).

CONCLUSIONS

Steroid pulse therapy was effective for some patients. Unsuccessful cases may have little chances of jaundice clearance; revision Kasai portoenterostomy would be a good option.

Spleen stiffness by 2-D shear wave elastography is the most accurate predictor of high-risk esophagogastric varices in children with biliary atresia

AIM

Esophagogastric variceal hemorrhage is a cause of poor prognosis in patients with biliary atresia (BA). To prevent variceal hemorrhage, simple and reliable screening methods for high-risk esophagogastric varices (HR-EGV) are needed. We evaluated the efficacy of liver stiffness (LS) and spleen stiffness (SS) as measured by 2-D shear wave elastography (2D-SWE), which was reported to be more accurate than transient elastography, for detecting HR-EGV in children with BA.

METHODS

Thirty-four children with BA were enrolled. Both LS and SS were measured by 2D-SWE. The presence of large esophageal varices or esophageal varices of any size with red wale marking and/or the presence of gastric varices along the cardia were defined as HR-EGV. Clinical data were collected and previously reported prediction indices for varices were calculated.

RESULTS

Liver stiffness and SS were obtained from all patients. Fourteen patients showed HR-EGV. Significantly different variables between patients with and without HR-EGV were as follows: spleen diameter (116 mm vs. 95 mm), clinical prediction rule (104.7 vs. 124.7), King's variceal prediction score (78.8 vs. 99.4), aspartic aminotransferase-to-platelet ratio index (2.03 vs. 0.98), LS (2.63 m/s vs. 1.87 m/s), and SS (4.44 m/s vs. 3.69 m/s). The highest area under the receiver operating characteristic curve for detecting HR-EGV was that for SS (0.900), and the cut-off SS of 4.12 m/s yielded 92.9% sensitivity and 90% specificity. The intraclass correlation coefficient for intra-observer reproducibility was 0.828.

CONCLUSIONS

Spleen stiffness from 2D-SWE offered the most accurate predictor of HR-EGV in BA children.

Abstract P3-06-04: Clonal evolution of non-malignant proliferative lesions into breast cancers

[Introduction] Non-malignant proliferative lesions in the breast have been implicated in the development of invasive breast cancer. Previous studies showed that adjacent atypical proliferative lesions and breast cancers shared common genetic alterations, suggesting that these evolved from the same ancestral cell. However, the clonal structure of atypical proliferative lesions and their clonal dynamics during progression to cancer are poorly understood. In this study, we compared genetic profiles (with and without pathogenic germline mutations) of normal mammary ducts, non-malignant proliferative lesions, and cancer tissues from the same patients to illustrate the clonal evolution of cancer from a non-malignant epithelial cell.

[Methods] Multiple samples were collected from different proliferative lesions within the cancer-borne breast, including invasive cancers, using micro-dissection from formalin-fixed, paraffin-embedded surgical specimens. Somatic mutations and copy number alterations (CNAs) were then evaluated by whole exome sequencing.

[Results] We analyzed a total of 34 samples from 5 premenopausal females carrying estrogen receptor-positive cancers, where the samples were obtained from normal ducts (N = 6), non-atypical (N = 1) and atypical (N = 8) proliferative lesions, and non-invasive (N = 16) and invasive (N = 3) cancers. The number of somatic mutations per sample ranged from 1 to 276 and increased with disease progression, regardless of the germline mutation status. Two cases with bilateral cancers had a pathogenic germline mutation of either BRCA2 or TP53, where no somatic mutations or CNAs were shared by individual proliferative lesions, suggesting multifocal independent cancerous evolutions. By contrast, in the remaining three unilateral cases, no pathogenic germline mutations were detected, but all proliferative lesions, which were separated by a distance of 7-25 mm, shared one or more driver alterations, such as an AKT1 mutation (UID: KU01), concurrent 1q gain and 16q loss (der(1;16)) (UID: KU02), and a GATA3 mutation and der(1;16) (UID: KU03), while harboring private mutations and/or CNAs of their own. The phylogenetic analysis based on the number of shared mutations predicted an early origin of these founder mutations, which frequently predated decades before the onset of cancer.

[Conclusions] Our results suggest that early breast cancer development is shaped by the evolution of multiple precancerous clones. These clones are originated from a common ancestor that acquired a founder mutation long before the onset of cancer, followed by branching evolution of multiple clones that acquired additional driver mutations of their own, from which an invasive cancer ultimately develops. In hereditary cases, this process is thought to be substantially promoted multi-focally from within the entire breasts by a germline mutation shared by all mammary cells, frequently resulting in bilateral and/or multifocal breast cancers. Our findings provide unique insight into the early development of breast cancer.

Citation Format: Nishimura T, Yoshida K, Kawata Y, Takeuchi Y, Kakiuchi N, Shiozawa Y, Aoki K, Hirata M, Kataoka TR, Sakurai T, Baba S, Shiraishi Y, Chiba K, Takeuchi K, Haga H, Miyano S, Toi M, Ogawa S. Clonal evolution of non-malignant proliferative lesions into breast cancers [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-06-04.

Introduction of resection of intrahepatic bile duct stenosis-causing membrane or septum into laparoscopic choledochal cyst excision

PURPOSE

We previously showed that meticulous probing and resection of the intrahepatic bile duct stenosis (IHBDS)-causing membrane or septum was effective in preventing hepatolithiasis after choledochal cyst excisions in open surgeries. Then, we introduced this maneuver into laparoscopic choledochal cyst excisions in 2014 and performed routine resections since then. The aim of this study was to show the feasibility of this method in laparoscopic surgery.

METHODS

We retrospectively reviewed the demographics and outcomes of patients who underwent laparoscopic choledochal cyst excisions at our hospital between January 2014 and December 2017. The patients who underwent surgical treatment for IHBDS-causing membrane or septum were compared with those who did not undergo the procedure. The outcomes of the patients with IHBDS were also compared between patients who were ≥ 3 years of age and those < 3 years at operation.

RESULTS

Seventeen of 35 patients underwent laparoscopic resection of IHBDS-causing membrane or septum. There were no complications related to the procedure although the operative time and intraoperative bleeding amount increased in the patients with IHBDS who were ≥ 3 years of age.

CONCLUSIONS

Meticulous probing and excision of the IHBDS-causing membrane or septum is safe and feasible during laparoscopic choledochal cyst excision.

Single-stage laparoscopic transanal pull-through modified Swenson procedure without leaving a muscular cuff for short- and long-type Hirschsprung disease: a comparative study

PURPOSE

The Soave procedure (SO) is performed most commonly for Hirschsprung disease. SO reduces the risk of injury to the pelvic structures; however, a residual aganglionic muscle cuff could interfere with bowel movement and lead to obstructive enterocolitis. The Swenson procedure is considered ideal in terms of peristalsis. Currently, laparoscopic surgery provides better visualization and facilitates precise dissection, possibly leading to feasible performance of the laparoscopic modified Swenson procedure (SW). We present our operative technique and the efficacy of the SW compared with that of SO.

METHODS

We retrospectively reviewed the records of 16 and 27 patients who underwent SW and SO, respectively, between 2012 and 2017.

RESULTS

Operative time, blood loss, length of stay, and frequency of bowel movements showed no significant difference between the two groups. In the SW group, temporary dysuria occurred in one patient, postoperative enterocolitis in two, wound infection in one, and severe perianal excoriation in four, whereas in the SO group, obstructive symptoms occurred in three patients, small-bowel obstruction in one, and severe perianal excoriation in three. The complications and outcomes were comparable between both groups.

CONCLUSION

Laparoscopic SW was safe and feasible for the short-term follow-up outcomes.

Investigation of the feasibility and safety of single-stage anorectoplasty in neonates with anovestibular fistula

PURPOSE

Anovestibular fistula (AVF) is the most common type of anorectal malformation in females. Delayed anorectoplasty with fistula dilatation is commonly performed during infancy; however, we have been actively performing anorectoplasty in neonates. We report the surgical complications and postoperative defecation function associated with single-stage anorectoplasty performed in neonates.

METHODS

Patients who underwent surgery for AVF between 2007 and 2017 at two institutions were retrospectively studied. The operation time, amount of bleeding, time to start oral intake, perioperative complications, and Kelly's score were compared among patients who underwent surgery as neonates and those who underwent surgery as infants.

RESULTS

Eighteen neonates and 17 infants underwent anterior sagittal anorectoplasty. The median operation time and time to start oral intake were significantly shorter in the neonatal group (72 min; 3 days, respectively) than in the infant group (110 min, p = 0.0002; 5 days, p = 0.0024, respectively). Postoperative wound disruption was significantly more frequent in the infant group. Of the ten patients each in the neonatal and infant groups, there was no significant difference in Kelly's score at age ≥ 4 years.

CONCLUSION

Single-stage anorectoplasty in neonates with AVF can be feasibly performed and does not impair postoperative defecation function.

LEVELS OF EVIDENCE

III.

Oral administration of eicosapentaenoic acid suppresses liver fibrosis in postoperative patients with biliary atresia

PURPOSE

Biliary atresia (BA) is characterized by progressive inflammation of the biliary system. This inflammation persists and causes liver fibrosis, although jaundice disappears after Kasai portoenterostomy (KP). We aimed to confirm whether the oral administration of eicosapentaenoic acid (EPA) suppresses liver fibrosis in postoperative patients with BA.

METHODS

We reviewed patients who underwent laparoscopic KP (lapKP) between January 2014 and September 2017. From December 2016, 30 mg/kg/day of EPA was orally administered to patients who opted to take medicine (EPA group). Patients who did not receive EPA were assigned to the non-EPA group. Mac-2 binding protein sugar chain modified isomer (M2BPGi) and hyaluronic acid (HA) levels were compared between the two groups in patients showing disappearance of jaundice at 6 months after the first lapKP.

RESULTS

Seventeen patients in the non-EPA group and 11 in the EPA group were enrolled. At 6 months after the first lapKP, 10 patients in the non-EPA group and six in the EPA group were without jaundice. M2BPGi and HA levels were significantly lower in the EPA group.

CONCLUSIONS

Liver fibrosis was suppressed in patients without jaundice 6 months after lapKP, who were administered EPA. We believe that periductular inflammation was alleviated by EPA supplementation.

Long-term outcomes and complications after laparoscopic-assisted anorectoplasty vs. posterior sagittal anorectoplasty for high- and intermediate-type anorectal malformation

PURPOSE

Laparoscopic-assisted anorectoplasty (LAARP) is a minimally invasive procedure in which the levator ani muscle is left to potentially improve postoperative fecal continence. This study aimed to retrospectively evaluate postoperative complications and long-term outcomes of fecal continence after LAARP and compare them to those after posterior sagittal anorectoplasty (PSARP).

METHODS

Forty-five male patients with high and intermediate anorectal malformation (aged ≥ 4 years) who underwent LAARP or PSARP (LAARP 29, PSARP 16) from 1999 to 2013 were included. Postoperative complications and postoperative fecal continence were retrospectively evaluated and compared. Postoperative complications were also compared before and after introducing a urethroscope during fistula resection.

RESULTS

Complications after LAARP and PSARP were seen in 12 vs. 2 cases (p = 0.09) of mucosal prolapse and in 9 vs. 1 case (p = 0.07) of posterior urethral diverticulum (PUD), respectively. The incidence of PUD decreased after introduction of a urethroscopy from 40% in 8/20 cases to 11% in 1/9 cases. No significant difference was found in terms of fecal continence in both groups.

CONCLUSION

Through our study, greater improvement of postoperative fecal continence after LAARP has not been shown. LAARP was at higher risk for mucosal prolapse and PUD. However, precise dissection of the urethral fistula could be performed after the introduction of urethroscopy.

Characterization of Na x Li0.67+y Ni0.33Mn0.67O2 as a positive electrode material for lithium-ion batteries

The relationship between the charge–discharge properties and crystal structure of Na_xLi_0.67+yNi_0.33Mn_0.67O₂ (0.010 ≤ x ≤ 0.013, 0.16 ≤ y ≤ 0.20) has been investigated. Li/Na_xLi_0.67+yNi_0.33Mn_0.67O₂ cells exhibit gradually sloping initial charge and discharge voltage–capacity curves. The initial charge capacity increased from 171 mA h g⁻¹ for thermally-treated Na_0.15Li_0.51Ni_0.33Mn_0.67O₂ to 226 mA h g⁻¹ for Na_0.010Li_0.83Ni_0.33Mn_0.67O₂ with an increase in the Li content. The initial maximum discharge capacity was 252 mA h g⁻¹ in the case of Na_0.010Li_0.83Ni_0.33Mn_0.67O₂ between 4.8 and 2.0 V at a fixed current density of 15 mA g⁻¹ (0.06C) at 25 °C. The predominance of the spinel phase leads to the high initial discharge capacity of Na_0.010Li_0.83Ni_0.33Mn_0.67O₂. This study shows that chemical lithiation using LiI is effective to improve the electrochemical properties.

The relationship between the charge–discharge properties and crystal structure of Na_xLi_0.67+yNi_0.33Mn_0.67O₂ (0.010 ≤ x ≤ 0.013, 0.16 ≤ y ≤ 0.20) has been investigated.

Novel thoracoscopic navigation surgery for neonatal chylothorax using indocyanine-green fluorescent lymphography

BACKGROUND

Postoperative chylothorax after surgery for esophageal atresia/tracheoesophageal fistula (TEF) is a rare but serious complication, especially in neonates. This study aimed to identify the thoracic duct and ligate chylous leakage sites, using thoracoscopic navigation of an indocyanine-green (ICG)-based near-infrared (NIR) fluorescence imaging system.

METHODS

From November 2014 to April 2017, thoracoscopic intraoperative ICG-NIR imaging was performed in 10 newborns (11 surgeries) with first TEF operation or with persistent postoperative chylothorax after TEF operation. NIR imaging was performed 1h after an inter-toe injection of ICG. Thoracoscopic ligations against the NIR-detected leakage sites were performed with sutures.

RESULTS

The thoracic duct or lymphatic leakage was directly visualized in each patient. In 8 surgeries with first thoracoscopic TEF operation, one case had suspected minor chylous leakage without postoperative chylothorax. Another case with no chylous leakage at the first operation resulted in chylothorax at postoperative day 11. In three neonates with postoperative chylothorax, leakage points were detected near the ablation site of the azygos vein during the first operation. These points were properly ligated, and postoperative chylous leakage ceased with no adverse events.

CONCLUSIONS

Thoracoscopic ICG-NIR imaging encourages the repair of refractory chylothorax and seems reliable.

LEVEL OF EVIDENCE

IV.

Usefulness of fetal magnetic resonance imaging for postnatal management of congenital lung cysts: prediction of probability for emergency surgery

BACKGROUND

Emergency rescue lung resection is rarely performed to treat congenital lung cysts (CLCs) in neonates. Many reports have described fetal CLC treatment; however, prenatal predictors for postnatal respiratory failure have not been characterized. We hypothesized that fetal imaging findings are useful predictors of emergency surgery.

METHODS

We retrospectively studied patients with CLC who underwent lung surgery during the neonatal period in our hospital between January 2001 and December 2015. The demographic data, fetal imaging findings, and intra- and postoperative courses of patients who underwent emergency surgery (Em group) were compared with those of patients who received elective surgery, i.e., non-emergency surgery (Ne group).

RESULTS

The Em group and Ne group included 7 and 11 patients, respectively. No significant difference was noted in gestational age, time at prenatal diagnosis, birth weight, and body weight at surgery. The volumes of contralateral lung per thoracic volume were significantly smaller in the Em group than in the Ne group (p = 0.0188). Mediastinal compression was more common in the Em group (7/7) than in the Ne group (4/11) (p = 0.0128).

CONCLUSIONS

This is the report describing neonatal emergency lobectomy in patients with CLC evaluated by fetal MRI using the lung volume ratio and mediastinal shift. In patients with CLC, mediastinal shift and significant decreases in contralateral lung volumes during the fetal stages are good prenatal predictors of postnatal emergency lung resection.

The efficacy of resection of intrahepatic bile duct stenosis-causing membrane or septum for preventing hepatolithiasis after choledochal cyst excision

BACKGROUND/PURPOSE

We previously found that many patients who developed hepatolithiasis after choledochal cyst excisions had intrahepatic bile duct stenosis (IHBDS). In 1992, we started resection of the membrane or septum which was found at the site of IHBDS during choledochal cyst excisions. Since intrahepatic stones usually take years to form, the efficacy of this procedure has not been proved.

METHODS

The records of patients who had IHBDS-causing membrane or septum and underwent choledochal cyst excision with Roux-Y hepaticojejunostomy between January 1979 and December 2006 were retrospectively analyzed. The patients who underwent surgical treatment for IHBDS-causing membrane or septum were compared with those who did not undergo the procedure.

RESULTS

Sixty-nine patients met the criteria, and seven patients who were followed up for less than 5years were excluded from the study. Thirty-three patients underwent surgical treatment for IHBDS, and three of them developed intrahepatic stones. Meanwhile, 10 of 29 patients who did not undergo the procedure developed intrahepatic stones. A statistically significant difference in intrahepatic stone formation was observed between the two groups in a log-rank test (P=0.016).

CONCLUSIONS

Meticulous probing and excision of the IHBDS-causing membrane or septum are effective for preventing hepatolithiasis after choledochal cyst excisions.

TYPE OF STUDY

Retrospective Comparative Study.

LEVEL OF EVIDENCE

Level III.

Comparison of outcomes of thoracoscopic primary repair of gross type C esophageal atresia performed by qualified and non-qualified surgeons

PURPOSE

Although thoracoscopic repair of esophageal atresia has become widespread, most studies are based on operations performed by expert surgeons. Therefore, the outcomes of operations performed by non-expert surgeons are not well known. The aim of this study was to compare outcomes based on operator skill level.

METHODS

We retrospectively reviewed the demographics and outcomes of patients with Gross type C esophageal atresia, who underwent primary thoracoscopic repair at our hospital between January 2014 and August 2016. Outcomes of surgeries performed by qualified surgeons, as determined by the Japanese Society for Endoscopic Surgery were compared with those of non-qualified surgeons. All operations were performed by or under the supervision of one qualified surgeon.

RESULTS

Nine operations were performed by qualified surgeons and six operations by non-qualified surgeons with >10 years of experience in surgery. None of the patients developed anastomotic leakage or recurrent tracheoesophageal fistula. However, the operative time and rate of stricture formation at the beginning of the weaning period were significantly higher in the latter group (P = 0.008 and 0.044).

CONCLUSIONS

Although supervision of experts would improve results in thoracoscopic repair of esophageal atresia, the results indicate that good skill is necessary to avoid anastomotic stricture.

A Novel Laparoscopic Surgery Model with a Device to Expand the Abdominal Working Space in Rats: The Influence of Pneumoperitoneum and Skin Incision Length on Postoperative Inflammatory Cytokines

PURPOSE

Experimental models of laparoscopic surgery generally use large animals owing to a sufficient abdominal working space. We developed a novel laparoscopic surgery model in rats. We performed intestinal anastomosis to demonstrate the feasibility and reliability of this model.

MATERIALS AND METHODS

We designed a device for rats that expanded the abdominal working space and allowed us to manipulate the intraperitoneal organs by hand under direct vision with pneumoperitoneum. We performed small bowel resection and intestinal anastomosis in rats using this model. To elucidate the effects of pneumoperitoneum and skin incision length, rats were randomly divided into four groups with differing surgical techniques: small incision group, large incision group, small incision + pneumoperitoneum group, and large incision + pneumoperitoneum group. Intraoperative abdominal pressure and postoperative cytokines were measured.

RESULTS

One experimenter completed small bowel resection and hand-sewn anastomosis under direct vision without any difficulties or assistance. Carbon dioxide pneumoperitoneum was maintained at 8-10 mmHg during surgery in both pneumoperitoneum groups. Necropsies revealed no evidence of anastomotic leakage at 24 h after surgery. The interleukin-6 and C-reactive protein concentrations were significantly greater in large incision group than in small incision group, but were not significantly different between small incision + pneumoperitoneum group and small incision group. These cytokines concentrations were the greatest in large incision + pneumoperitoneum group.

CONCLUSIONS

Our laparoscopic surgery model in rats is a simple and reliable experimental model. The length of skin incision might be a more influential determinant of surgical invasiveness than pneumoperitoneum.

Independent Risk Factors and 2-Year Outcomes of Acute Kidney Injury after Surgery for Congenital Heart Disease

BACKGROUND

Data are limited regarding risk factors for acute kidney injury (AKI) following cardiac surgery in children with congenital heart disease (CHD). This observational study was performed to examine temporal trends in AKI incidence according to the Pediatric Risk, Injury, Failure, Loss, End-Stage Renal Disease (pRIFLE) criteria, identify independent risk factors for AKI after cardiac surgery, and examine associations between AKI and long-term mortality.

METHODS

We retrospectively evaluated 418 patients (259 males, 159 females; median age, 5 months) who underwent cardiac surgery for CHD between April 2007 and August 2013. Patients were followed up for 2 years. AKI was defined according to the pRIFLE criteria as ≥25% decrease in estimated creatinine clearance.

RESULTS

AKI developed postoperatively in 104 cases (24.9%). Approximately 80% belonged to the "Risk" category according to the pRIFLE criteria, and only 21 cases (5%) required renal replacement therapy (peritoneal dialysis in all cases). Multivariate analysis revealed 3 independent risk factors for onset of AKI: young age (<1 year), surgery in Risk Adjustment in Congenital Heart Surgery (RACHS-1) category ≥4, and long cardiopulmonary bypass (CPB) time (≥90 min). Twenty-three patients (22%) with AKI died during the 2-year follow-up. In multivariate cox hazard regression analysis, the most significant contributor to risk of mortality was AKI.

CONCLUSIONS

Postoperative AKI was strongly associated with young age, high RACHS-1 category, and prolonged CPB time. In addition, mortality rate was higher in patients who survived after recovery from AKI than in those without AKI, even among the lower pRIFLE categories.

New Navigation Surgery for Resection of Lymphatic Malformations Using Indocyanine Green Fluorescence Imaging

Patient: Male, 15

Final Diagnosis: Lymphatic malformations

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: Navigation surgery

Specialty: Surgery

Frequent somatic mutations in epigenetic regulators in newly diagnosed chronic myeloid leukemia

Although tyrosine kinase inhibitors (TKIs) have significantly improved the prognosis of chronic myeloid leukemia (CML), the ability of TKIs to eradicate CML remains uncertain and patients must continue TKI therapy for indefinite periods. In this study, we performed whole-exome sequencing to identify somatic mutations in 24 patients with newly diagnosed chronic phase CML who were registered in the JALSG CML212 study. We identified 191 somatic mutations other than the BCR-ABL1 fusion gene (median 8, range 1–17). Age, hemoglobin concentration and white blood cell counts were correlated with the number of mutations. Patients with mutations ⩾6 showed higher rate of achieving major molecular response than those<6 (P=0.0381). Mutations in epigenetic regulator, ASXL1, TET2, TET3, KDM1A and MSH6 were found in 25% of patients. TET2 or TET3, AKT1 and RUNX1 were mutated in one patient each. ASXL1 was mutated within exon 12 in three cases. Mutated genes were significantly enriched with cell signaling and cell division pathways. Furthermore, DNA copy number analysis showed that 2 of 24 patients had uniparental disomy of chromosome 1p or 3q, which disappeared major molecular response was achieved. These mutations may play significant roles in CML pathogenesis in addition to the strong driver mutation BCR-ABL1.

Oral alendronate in pediatric chronic recurrent multifocal osteomyelitis

Chronic recurrent multifocal osteomyelitis (CRMO) primarily affects children and adolescents, and is characterized by episodic sterile osteomyelitis over several years. No definitive treatment is available. Non-steroidal anti-inflammatory drugs (NSAID) are common first-line agents, but provide limited improvement in bone pain and do not affect disease duration. Several agents are utilized in the case of non-response to NSAID, including corticosteroids, methotrexate, and tumor necrosis factor-blocking agents. Bisphosphonates are increasingly being used. Most case series involve cyclic i.v. pamidronate, but this restricts the social lives of children and their families. Although oral medication has advantages over cyclic i.v. infusion because it does not require repeated hospital admissions, there have been no reports on treatment with oral bisphosphonates, such as alendronate, in pediatric CRMO patients. This case report describes the use of oral bisphosphonate as an alternative treatment in CRMO patients in whom standard therapy has failed.

Laparoscopic resection of neuroblastomas in low- to high-risk patients without image-defined risk factors is safe and feasible

Background

Several studies have reported that minimally invasive surgery (MIS) might be considered for resecting neuroblastomas without image-defined risk factors (IDRFs); however, there are no studies comparing the outcomes of laparotomy and laparoscopy in IDRF-negative patients. Thus, we investigated the feasibility of laparoscopic surgery and compared the two abovementioned approaches.

Methods

To compare the effects of laparotomy with those of laparoscopy in patients with neuroblastomas without IDRFs, the following items were retrospectively compared: largest tumor dimension, volume of blood loss, time required to initiate postoperative feeding, locoregional recurrence rate, survival, etc.

Results

Nine patients without IDRFs (three at low-to-medium risk and six at high risk) underwent laparotomy, and seven patients without IDRFs (two at low-to-medium risk and five at high risk) underwent laparoscopy. Median duration of surgery was 221 (130–304) and 172 (122–253) min in the laparotomy and laparoscopy groups, respectively, showing no significant difference. Median postoperative time required for resuming meal consumption was significantly longer in the laparotomy (4 days; 2–5) group than that in the laparoscopy group (3 days; 2–3; p = 0.023). Median blood loss was significantly higher in the laparotomy group (5 ml/Kg;2.6–16) than that in the laparoscopy group (2.1 ml/Kg;0.1–4.0; P = 0.037). Median follow-up period was 81 (52–94) and 21 (17–28) months, locoregional recurrence rates were 22 and 0% at 1 year, 1-year progression-free survival rates were 78 and 100%, and overall survival rates were 67 and 100% in the laparotomy and laparoscopy groups, respectively, with no significant differences.

Conclusions

MIS for the treatment of neuroblastomas without IDRFs in low- to high-risk patients is safe and feasible and does not compromise the treatment outcome.

Identification of cell-type-specific mutations in nodal T-cell lymphomas

Recent genetic analysis has identified frequent mutations in ten-eleven translocation 2 (TET2), DNA methyltransferase 3A (DNMT3A), isocitrate dehydrogenase 2 (IDH2) and ras homolog family member A (RHOA) in nodal T-cell lymphomas, including angioimmunoblastic T-cell lymphoma and peripheral T-cell lymphoma, not otherwise specified. We examined the distribution of mutations in these subtypes of mature T-/natural killer cell neoplasms to determine their clonal architecture. Targeted sequencing was performed for 71 genes in tumor-derived DNA of 87 cases. The mutations were then analyzed in a programmed death-1 (PD1)-positive population enriched with tumor cells and CD20-positive B cells purified by laser microdissection from 19 cases. TET2 and DNMT3A mutations were identified in both the PD1+ cells and the CD20+ cells in 15/16 and 4/7 cases, respectively. All the RHOA and IDH2 mutations were confined to the PD1+ cells, indicating that some, including RHOA and IDH2 mutations, being specific events in tumor cells. Notably, we found that all NOTCH1 mutations were detected only in the CD20+ cells. In conclusion, we identified both B- as well as T-cell-specific mutations, and mutations common to both T and B cells. These findings indicate the expansion of a clone after multistep and multilineal acquisition of gene mutations.

Specific fluorescence labeling of target proteins by using a ligand–4-azidophthalimide conjugate

Two distinct model studies demonstrate that the ligand–4-azidophthalimide conjugate strategy is useful for specific fluorescence labeling of target proteins.

Dutasteride-mediated morphological changes in the genitourinary tract associated with altered expression patterns of the androgen and estrogen receptors in male rats

We evaluated the effects of dutasteride on the genitourinary tract using fifteen 8-week-old male Sprague-Dawley rats. Animals were divided into three groups comprising five animals each and treated as follows. Group A was a control group, members of Group B received oral administration of dutasteride 0.1 mg/kg/day from the age of 8 to 16 weeks, and members of Group C were castrated at the age of 8 weeks. All rats were killed at the age of 16 weeks for the sample collection of blood, bladder, prostate, seminal vesicles, and penis. Then, we evaluated the pathological examination for evaluating the tissue fibrosis and hormonal receptor expression. The results showed that the mean size of the prostate and seminal vesicles was smaller in Group B and Group C than in Group A. Serum and tissue concentrations of both testosterone and dihydrotestosterone were remarkably reduced in serum and all tissues in Group C compared with Group A. On the other hand, in Group B, only dihydrotestosterone was reduced in serum and penis. Histopathological examination revealed that Group C showed statistically significant histological changes, such as an increase in fibrotic tissue in the bladder, prostate, and penis. Similarly, Group B showed fibrotic changes in the prostate and penis compared with the Group A. Immunofluorescent staining revealed that the androgen receptor was more strongly expressed than the estrogen receptor beta in Group A. On the other hand, in Group C, weak expression of the androgen receptor and strong expression of the estrogen receptor beta was noted. In Group B, these changes were noted in the prostate and penis. These findings suggest that dutasteride cause morphological changes not only in prostate but also in penis. These changes are associated with altered expression patterns of androgen receptor and estrogen receptor.

Two-Stage Thoracoscopic Repair of Long-Gap Esophageal Atresia Using Internal Traction Is Safe and Feasible

BACKGROUND

The treatment of long-gap esophageal atresia remains an issue for pediatric surgeons. Many techniques for treating long-gap esophageal atresia have been proposed, but the optimal method has not been established. The thoracoscopic esophageal elongation technique has recently been developed. We previously reported a case in which two-stage thoracoscopic repair was performed using internal esophageal traction without esophageal tearing, and we retrospectively reviewed the outcomes of this procedure in this study.

METHODS

Five patients underwent thoracoscopic treatment involving internal esophageal traction for esophageal atresia involving a long gap or vascular ring over a 5-year period.

RESULTS

Between November 2010 and November 2015, 5 patients were treated with thoracoscopic traction. All of these patients successfully underwent thoracoscopic-delayed primary anastomosis. Conversion to open thoracotomy was not required in any case. The postoperative complications experienced by the patients included minor anastomotic leakage in 2 cases, anastomotic stenosis in 1 case, gastroesophageal reflux (GER) in 4 cases, and a hiatal hernia in 1 case. None of the patients died.

CONCLUSIONS

Two-stage thoracoscopic repair for esophageal atresia involving a long gap or vascular ring is a safe and feasible procedure; however, we must develop methods for treating minor anastomotic complications and GER due to esophageal traction in future.

Left thoracoscopic two-stage repair of tracheoesophageal fistula with a right aortic arch and a vascular ring

A right aortic arch (RAA) is found in 5% of neonates with tracheoesophageal fistulae (TEF) and may be associated with vascular rings. Oesophageal repairs for TEF with an RAA via the right chest often pose surgical difficulties. We report for the first time in the world a successful two-stage repair by left-sided thoracoscope for TEF with an RAA and a vascular ring. We switched from right to left thoracoscopy after finding an RAA. A proximal oesophageal pouch was hemmed into the vascular ring; therefore, we selected a two-stage repair. The TEF was resected and simple internal traction was placed into the oesophagus at the first stage. Detailed examination showed the patent ductus arteriosus (PDA) completing a vascular ring. The subsequent primary oesophago-oesophagostomy and dissection of PDA was performed by left-sided thoracoscope. Therefore, left thoracoscopic repair is safe and feasible for treating TEF with an RAA and a vascular ring.

Clusterin produced by Sertoli cells inhibits heat stress-induced apoptosis in the rat testis

The objectives of this study were to determine whether the inhibition of clusterin expression in rat Sertoli cells enhances heat stress-induced apoptosis. The scrotums of rats were immersed in a water bath of 43 °C for 15 min. Testicular weight and germ cell number markedly decreased after the heat treatment in a time-dependent manner. In contrast, clusterin mRNA and protein expression levels were significantly up-regulated and peaked on day 21. The apoptotic index was markedly increased 1 day after the heat treatment. We then purified Sertoli cells from the rat testes, and an expression vector containing siRNA targeting the clusterin gene was transiently transfected into Sertoli cells. Following exposure to heat stress at 41 °C for 12 h, clusterin mRNA was markedly up-regulated after transfection with the control vector; however, the transfection of siRNA targeting the clusterin resulted in >70% reduction in the expression of clusterin mRNA. Furthermore, the apoptotic index in these Sertoli cells was significantly higher after the treatment with siRNA targeting the clusterin than control, and the most prominent difference was observed within 24 h after the heat treatment. These results suggest that an increase in the secretion of clusterin by Sertoli cells protects the testes from heat stress-induced injury.

Inhibitory Effect of Acylphloroglucinol Derivatives on the Replication of Vesicular Stomatitis Virus

The antiviral activity of natural phloroglucinols and of synthesized mono- and diacylphloroglucinols, and 2,6-diacyl-4,4-dialkylcyclohexa-1,3,5-triones was investigated. A correlation between the acyl chain length and inhibitory activity against vesicular stomatitis virus (VSV) was observed. Potent antiviral activity was found in di-isovalerylphoroglucinol. 2,6-Diacyl-4,4-dialkylcyclohexa-1,3,5-triones inhibited replication of the virus with low cytotoxicity.

PRPF8 defects cause missplicing in myeloid malignancies

Mutations of spliceosome components are common in myeloid neoplasms. One of the affected genes, PRPF8, encodes the most evolutionarily conserved spliceosomal protein. We identified either recurrent somatic PRPF8 mutations or hemizygous deletions in 15/447 and 24/450 cases, respectively. 50% of PRPF8 mutant and del(17p) cases were found in AML and conveyed poor prognosis. PRPF8 defects correlated with increased myeloblasts and ring sideroblasts in cases without SF3B1 mutations. Knockdown of PRPF8 in K562 and CD34+ primary bone marrow cells increased proliferative capacity. Whole RNA deep sequencing of primary cells from patients with PRPF8 abnormalities demonstrated consistent missplicing defects. In yeast models, homologous mutations introduced into Prp8 abrogated a block experimentally produced in the second step of the RNA splicing process suggesting that the mutants have defects in proof-reading functions. In sum, the exploration of clinical and functional consequences suggests that PRPF8 is a novel leukemogenic gene in myeloid neoplasms with a distinct phenotype likely manifested through aberrant splicing.

Landscape of genetic lesions in 944 patients with myelodysplastic syndromes

High-throughput DNA sequencing significantly contributed to diagnosis and prognostication in patients with myelodysplastic syndromes (MDS). We determined the biological and prognostic significance of genetic aberrations in MDS. In total, 944 patients with various MDS subtypes were screened for known/putative mutations/deletions in 104 genes using targeted deep sequencing and array-based genomic hybridization. In total, 845/944 patients (89.5%) harbored at least one mutation (median, 3 per patient; range, 0-12). Forty-seven genes were significantly mutated with TET2, SF3B1, ASXL1, SRSF2, DNMT3A, and RUNX1 mutated in >10% of cases. Many mutations were associated with higher risk groups and/or blast elevation. Survival was investigated in 875 patients. By univariate analysis, 25/48 genes (resulting from 47 genes tested significantly plus PRPF8) affected survival (P<0.05). The status of 14 genes combined with conventional factors revealed a novel prognostic model ('Model-1') separating patients into four risk groups ('low', 'intermediate', 'high', 'very high risk') with 3-year survival of 95.2, 69.3, 32.8, and 5.3% (P<0.001). Subsequently, a 'gene-only model' ('Model-2') was constructed based on 14 genes also yielding four significant risk groups (P<0.001). Both models were reproducible in the validation cohort (n=175 patients; P<0.001 each). Thus, large-scale genetic and molecular profiling of multiple target genes is invaluable for subclassification and prognostication in MDS patients.