Difficulties in disclosing secondary findings by facilities performing comprehensive germline genetic testing for rare diseases in Japan

In Japan, a limited number of laboratories perform comprehensive genetic testing for rare diseases; this study investigated the attitudes of these laboratories toward the disclosure of secondary finding (SF). Following a preliminary survey, we identified laboratories conducting comprehensive genetic testing for participation. Subsequently, an online survey involving 20 selected facilities was conducted. The response rate was 80% (16/20). Of the 14 facilities, 71.4% had SFs. While 42.9% of them had a policy to disclose SFs with clinical utility, only 14.3% actively searched for actionable variants that could be included in the American College of Medical Genetics and Genomics list. Japan was less enthusiastic than the USA regarding SF disclosure. With regard to the reasons for not disclosing SFs, the factors "the thought that participants may have a low desire for SFs" and "uncertainty regarding their wish" were considered more important than in the USA. A content analysis of what was sought as a solution to this difficulty revealed a need to improve databases on pathogenicity and actionability and collect public thoughts on the issue. The factor "to promote entry in research" was not considered a critical reason for disclosing SFs, indicating that the thirst for information was not possibly due to anxiety but rather due to scientific interest. Japanese medical professionals may not be confident that society requires the disclosure of SFs. To improve the environment, it is necessary to survey the public regarding their thoughts on SF disclosure and discuss this issue in society.

Challenges of secondary finding disclosure in genomic medicine in rare diseases: A nation-wide survey of Japanese facilities outsourcing comprehensive genetic testing

Comprehensive genome analysis may reveal secondary findings (SFs) including pathogenic variants of genes other than those originally targeted. Comprehensive genetic analysis of rare diseases is generally performed as research in Japan. Therefore, the status and difficulties in SF disclosure remain unclear. To obtain information for the appropriate disclosure of SFs in rare diseases, we conducted a survey on how SFs are handled in clinical practice by facilities that outsource comprehensive genetic testing to other facilities. The response rate was 66.7% (40/60). Among the responding facilities, 55% had a policy of disclosing SFs with clinical utility and considered targeting actionable SFs with high penetrance. These facilities had difficulties in determining the disclosure targets (51%) and in genetic counseling (38%). Improving genetic literacy, establishment of surveillance systems, and providing insurance coverage for medical care to unaffected carriers were commonly cited as solutions to these difficulties. A comparison of the willingness to disclose SFs between overseas and in Japan showed more reluctance in Japan (86% vs. 65% for actionable SFs and 62% vs. 16% for non-actionable SFs). The group with difficulty in determining disclosure targets was significantly more likely to discuss this at conferences with other facilities and to refer guidelines. This suggests that the group with difficulties was unable to make decisions solely at their own facility and sought collaboration with other facilities. These findings suggest the necessity for a system that allows consultation with experts across facilities and guidelines that set forth policies for determining SFs.

Shared decision making between patients with Fabry disease and physicians in Japan: An online survey

Background

Fabry disease is a rare, progressive genetic lysosomal disorder that can cause multisystem organ dysfunction. With increasing treatment options for Fabry disease, it is imperative that patients discuss and select treatment plans in conjunction with their physicians. Although shared decision making (SDM) should be recommended for clinical decision making in disease management, evidence is limited as to how patients in Japan are involved in the choice of their Fabry disease treatment and if other gaps exist with physicians in the perception of Fabry disease management.

Objective

The main objective of the study was to assess the degree of agreement between patients and treating physicians in the SDM process as assessed by the SDM-Q-9 and SDM-Q-Doc questionnaires. In parallel, this study also investigated other factors that might impact the SDM process.

Methods

This was a cross-sectional web-based questionnaire survey of Japanese patients with Fabry disease and their treating physicians conducted from February 2021 to June 2021. Online surveys were developed for patients and physicians, consisting of seven items, including the Japanese version of the 9-item SDM Questionnaire for patients (SDM-Q-9) and physicians (SDM-Q-Doc). Physicians were divided into two cohorts: non-paired and paired with patients. Only the paired cohort physicians answered the SDM questionnaire.

Results

A total of 99 physicians and 30 patients answered the respective questionnaires. Among these, 13 physicians were included in a paired SDM analysis with patients. Mean (standard deviation [SD]) patient age at diagnosis of Fabry disease was 47.5 (15.8) years, and 14 (46.7%) were male. Both physicians in the paired cohort and patients considered patient-reported outcomes (both 76.7%) and the findings from laboratory testing as important (90.0% and 60.0% respectively). However, regarding symptoms that affect quality of life of patients, perception gaps were identified in that physicians in the paired cohort placed less importance on patient-reported outcome-related symptoms such as sweating abnormalities and gastrointestinal symptoms than their patients (0% [0/17] and 44.4% [8/18], 11.8% [2/17] and 38.9% [7/18], respectively). In the paired analysis, there was no significant difference in total SDM score between patients and physicians (p = 0.82). However, the largest discordance in perception between patients and physicians was identified for the explanation of the advantages and disadvantages of the treatment options (weighted Kappa coefficient = 0.14).

Conclusion

This survey revealed a gap in the perception of disease burden affecting patients' quality of life, and a recognition gap between physicians and patients when they discussed the advantages and disadvantages of treatment options. To improve the SDM process in Fabry disease management and treatment, practical solutions for bridging these gaps should be considered.

Janus Hydrogel Microbeads for Glucose Sensing with pH Calibration

We present fluorescent Janus hydrogel microbeads for continuous glucose sensing with pH calibration. The Janus hydrogel microbeads, that consist of fluorescent glucose and pH sensors, were fabricated with a UV-assisted centrifugal microfluidic device. The microbead can calibrate the pH values of its surroundings and enables accurate measurements of glucose within various pH conditions. As a proof of concept, we succeeded in obtaining the accurate value of glucose concentration in a body-fluid-like sample solution. We believe that our fluorescent microbeads, with pH calibration capability, could be applied to fully implantable sensors for continuous glucose monitoring.

Imaging of electrostatic field vector distribution

This paper reports on the visualization of a two-dimensional distribution of electrostatic field vectors around an electrified object using the electric field imager (EFIM) device. The EFIM device is made of a virtually connected pair of plate electrodes in parallel and in proximity, between which an electronic circuit for detection and optical indication is embedded. The EFIM device is not only accurately sensitive to the electrostatic field but also possessed of agility and mobility together with directivity and noninvasiveness. It was successfully demonstrated that electrostatic field vectors were visualized quantitatively, and their spatial distributions were mapped in combination with rather simple, mobile, and low-cost equipment. The advantages and disadvantages of the EFIM visualization scheme are discussed together with the future prospect of the EFIM device.

Attitudes toward and current status of disclosure of secondary findings from next-generation sequencing: a nation-wide survey of clinical genetics professionals in Japan

The management of secondary findings (SFs), which are beyond the intended purpose of the analysis, from clinical comprehensive genomic analysis using next generation sequencing (NGS) presents challenges. Policy statements regarding their clinical management have been announced in Japan and other countries. In Japan, however, the current status of and attitudes of clinical genetics professionals toward reporting them are unclear. We conducted a questionnaire survey of clinical genetics professionals at two time points (2013 and 2019) to determine the enforcement of the SF management policy in cases of comprehensive genetic analysis of intractable diseases and clinical cancer genome profiling testing. According to the survey findings, 40% and 70% of the respondents stated in the 2013 and 2019 surveys, respectively, that they had an SF policy in the field of intractable diseases, indicating that SF policy awareness in Japan has changed significantly in recent years. Furthermore, a total of 80% of respondents stated that their facility had established a policy for clinical cancer genome profiling testing in the 2019 survey. In both surveys, the policies included the selection criteria for genes to be disclosed and the procedure to return SFs, followed by recommendations and proposals regarding SFs in Japan and other countries. To create a better list of the genes to be disclosed, further examination is needed considering the characteristics of each analysis.

A statistical model for activation of Factor C by binding to LPS aggregates

Published data on Factor C activity at various LPS and Lipid A concentrations (Nakamura et al. in Eur J Biochem 176:89, 1988; Kobayashi et al. in J Biol Chem 37:25987, 2014) were rearranged to show that Factor C exhibited its maximum activity at a specific concentration of LPS. A statistical model was proposed for examining whether a single LPS molecule binding activates Factor C (monomeric activation) or dimerization of Factor C is necessary for the activation (dimeric activation). In the monomeric activation model the plots of the relative activity of Factor C against the molar ratio of LPS to Factor C were different from those in the published data. The plots in the dimeric activation model lie on a bell-shaped curve, whatever the Factor C concentration, matching the published data and indicating the appropriateness of that model. We suggest that Factor C is activated by multiple molecular interactions of Factor C with LPS aggregates on which it dimerises and that this explains why larger aggregates are less effective at activating Factor C than smaller ones.

Levobupivacaine-dextran mixture for transversus abdominis plane block and rectus sheath block in patients undergoing laparoscopic colectomy: a randomised controlled trial

We performed a randomised controlled double-blinded study of patients having laparoscopic colectomy with bilateral transversus abdominis plane block plus rectus sheath block, comparing a control group receiving 80 ml levobupivacaine 0.2% in saline with a dextran group receiving 80 ml levobupivacaine 0.2% in 8% low-molecular weight dextran. Twenty-seven patients were studied in each group. The mean (SD) maximum plasma concentration of levobupivacaine in the control group (1410 (322) ng.ml(-1) ) was higher than the dextran group (1141 (287) ng.ml(-1) ; p = 0.004), and was reached more quickly (50.6 (30.2) min vs 73.2 (24.6) min; p = 0.006). The area under the plasma concentration-time curve from 0 min to 240 min in the control group (229,124 (87,254) ng.min.ml(-1) ) was larger than in the dextran group (172,484 (50,502) ng.min.ml(-1) ; p = 0.007). The median (IQR [range]) of the summated numerical pain rating score at rest during the first postoperative 24 h in the control group (16 (9-20 [3-31]) was higher than in the dextran group (8 (2-11 [0-18]); p = 0.0001). In this study, adding dextran to levobupivacaine decreased the risk of levobupivacaine toxicity while providing better analgesia.

Early optimization of antimicrobial therapy improves clinical outcomes of patients administered agents targeting methicillin-resistant Staphylococcus aureus

WHAT IS KNOWN AND OBJECTIVE

Antimicrobial stewardship is required to ensure the appropriate use of antimicrobials. However, no reports have been published on clinical outcomes of implementation of antimicrobial stewardship in patients receiving pathogen-specific antibiotics.

METHOD

To evaluate the clinical outcomes of patients who received drugs, we conducted a single-centre, retrospective study of the effects of an antimicrobial stewardship programme targeting methicillin-resistant Staphylococcus aureus (MRSA).

RESULTS

The time to administer effective antimicrobials was significantly (median number of days, 3 before vs. 0 after, P < 0·001) shortened, and the rate of de-escalation was significantly elevated (47·1% vs. 96·2%, P < 0·001) after implementation of daily review. The 60-day clinical failure associated with Gram-positive bacterial infection was significantly reduced (33·3% vs. 17·6%, P = 0·007) after intervention.

WHAT IS NEW AND CONCLUSIONS

Daily review of administration of antimicrobials targeting MRSA was highly effective in improving clinical outcomes by optimizing early antimicrobial therapy.

Bone marrow lesions, subchondral bone cysts and subchondral bone attrition are associated with histological synovitis in patients with end-stage knee osteoarthritis: a cross-sectional study

OBJECTIVE

The aim of this study was to examine the osteoarthritis (OA)-related structural changes associated with histological synovitis in end-stage knee OA patients.

METHODS

Forty end-stage knee OA patients (female: 88%, mean age: 71.8 y) were enrolled. All participants underwent 3.0-T MRI. The structural changes, such as cartilage morphology, subchondral bone marrow lesion (BML), subchondral bone cyst (SBC), subchondral bone attrition (SBA), osteophytes, meniscal lesion and synovitis, were scored using the whole-organ MRI scoring (WORMS) method. Synovial samples were obtained from five regions of interest (ROIs) of the knee joint during total joint replacement surgery. The associations between the histological synovitis score (HSS) and WORMS or the synovial expression levels of cyclooxygenase (COX)-2, interleukin (IL)-1β, IL-6 and transforming growth factor (TGF)-β were examined using Spearman's correlation coefficient.

RESULTS

Among the seven OA-related structural changes, the BML, SBC, SBA and synovitis were significantly associated with the HSS (r = 0.33, 0.35, 0.48 and 0.36, respectively), while other morphological changes were not. Although synovial COX-2, IL-1β or IL-6 expression levels were not associated with the HSS, the synovial TGF-β expression levels were associated with the HSS.

CONCLUSION

The presence of BML, SBC and SBA was associated with histological synovitis in end-stage knee OA patients.

Wnt3a signaling induces murine dental follicle cells to differentiate into cementoblastic/osteoblastic cells via an osterix-dependent pathway

BACKGROUND AND OBJECTIVE

Dental follicle cells, putative progenitor cells for cementoblasts, osteoblasts and periodontal ligament cells, interplay with Hertwig's epithelial root sheath (HERS) cells during tooth root formation, in which HERS is considered to have an inductive role in initiating cementogenesis by epithelial-mesenchymal interaction. However, the specific mechanisms controlling the cementoblast/osteoblast differentiation of dental follicle cells are not fully understood. Canonical Wnt signaling has been implicated in increased bone formation by controlling mesenchymal stem cell or osteoblastic cell functions. This study examined the possible expression of canonical Wnt ligand in HERS and the role of Wnt signaling during the cementoblast/osteoblast differentiation of dental follicle cells.

MATERIAL AND METHODS

The expression of Wnt3a, a representative canonical Wnt ligand, in HERS was assessed by immunohistochemistry. The differentiation and function of immortalized murine dental follicle cells were evaluated by measuring alkaline phosphatase (ALP, Alpl) activity and osteogenic gene expression.

RESULTS

We identified the expression of Wnt3a in HERS during mouse tooth root development by immunohistochemistry as well as in cultured human epithelial rest cells of Malassez by real-time polymerase chain reaction, while no expression of Wnt3a was detected in cultured dental mesenchymal cells. Exposure of immortalized murine dental follicle cells to Wnt3a-induced ALP activity as well as expression of the Alpl gene. Pretreatment of cells with Dickkopf-1, a potent canonical Wnt antagonist, markedly attenuated the effect of Wnt3a on ALP expression. Furthermore, Wnt3a induced transcriptional activity of runt-related transcription factor 2 (Runx2) and expression of osterix at gene and/or protein levels. Treatment with osterix-small interfering RNA significantly inhibited Wnt3a-induced ALP expression at gene and protein levels.

CONCLUSION

These findings suggest that HERS has a potential role in stimulating cementoblast/osteoblast differentiation of dental follicle cells via the Wnt/β-catenin signaling pathway.

Expression of umami-taste-related genes in the tongue: a pilot study for genetic taste diagnosis

OBJECTIVE

Expression of taste-related genes in the tongue was analysed to develop a technique for genetic diagnosis of umami taste disorders.

MATERIALS AND METHODS

Tissue samples were collected from healthy volunteers by scraping the foliate papillae of the tongue. Immunocytochemistry staining of gustducin, a taste-cell-specific G protein, and gene expression analysis by real-time polymerase chain reaction of β-actin, gustducin (GNAT3) and umami receptors (T1R1, T1R3 and mGluR1) were performed. Changes in umami receptor expression following application of umami substances onto the tongue were analysed.

RESULTS

Gustducin-positive cells were observed in the samples, indicating the presence of taste cells. Gene expression of β-actin, GNAT3, T1R1 and T1R3 was detected in all seven samples tested, while that of mGluR1 was detected in four samples. Sequence analysis by NCBI Blast showed that each polymerase chain reaction product had a 99% rate of identification of its target sequence. Stimulation of the tongue with monosodium glutamate significantly upregulated the gene expression levels of T1R1 and T1R3, indicating that this method can detect alterations in umami-related gene expression.

CONCLUSION

Evaluation of the expression of the umami receptor genes, T1R1 and T1R3, in the tongue may be clinically useful for objective genetic diagnosis of umami taste disorders.

Preoperative hydroperoxide concentrations are associated with a risk of postoperative complications after cardiac surgery

This study aimed to assess whether preoperative oxidative stress levels can predict postoperative complications in patients undergoing cardiac surgery. Ninety-five cardiac surgery patients received an assessment of preoperative oxidative stress by measurement of hydroperoxide values in blood via the d-Rom test. Area under the receiver operating characteristic curve and also multivariate logistic regression were used to evaluate the prognostic significance of preoperative hydroperoxide concentrations in predicting the occurrence of major organ morbidity and mortality (MOMM). MOMM included death, deep sternal infection, reoperation, stroke, renal failure requiring haemodialysis and prolonged ventilation (>48 hours). The ability of preoperative hydroperoxide concentrations to predict MOMM was not significantly different from that of the European system for cardiac operative risk evaluation (EuroSCORE) (area under the receiver operating characteristic curve 0.822 versus 0.821 respectively, P=0.983). The optimal threshold value of hydroperoxide concentration to differentiate between patients with and without MOMM was 450 UCarr (sensitivity, 87.0%; specificity, 81.9%). Duration of intensive care unit stay, mechanical ventilation time and hospital stay were significantly longer in patients with preoperative hydroperoxide concentrations ≥450 UCarr (H group) compared to those patients with preoperative hydroperoxide concentrations <450 UCarr (L group). An increase in preoperative hydroperoxide concentrations remained associated with an increased risk of MOMM (odds ratios: 1.01, 95% confidence interval: 1.00 to 1.03) and prolonged intensive care unit stay (odds ratio 1.01, 95% confidence interval: 1.00 to 1.02), after adjusting for age, gender and EuroSCORE. In conclusion, an increased hydroperoxide concentration before cardiac surgery is an independent risk factor for severe postoperative complications.

Influence of MILR1 promoter polymorphism on expression levels and the phenotype of atopy

The recently identified cell surface immunoreceptor MILR1 (mast cell immunoglobulin-like receptor 1; synonyms, Allergin-1) has been shown to suppress immunoglobulin E (IgE)-mediated, mast cell-dependent responses in both mice and humans. We performed a mutation search of MILR1 together with a genetic association study to determine whether polymorphisms in MILR1 are associated with atopy in human. Mutation screening of MILR1 was performed using DNA from 146 unrelated Japanese. Genotyping of the identified polymorphisms was done with 1505 individuals from the general Japanese adult population. Atopy, as defined by positive responses for specific IgEs against at least one of the 26 common allergens, was evaluated using MAST-26. Five polymorphisms (rs6504230, c.-170_-166delAGGAA, rs8071835, rs143526766 and rs12936887) and two rare missense variants (Val273Ala and Leu311Val) were identified by mutation screening. The C allele of rs6504230 had protective effects against atopy (P=0.002). A luciferase reporter assay using the promoter region of MILR1 revealed that the C allele of rs6504230 was associated with increased expression of MILR1, which was in accordance with the results of expression quantitative trait loci analysis using human leukocytes. Our data indicates that the rs6504230 polymorphism affects MILR1 expression levels in humans, leading to a susceptibility to producing specific IgE antibodies against common allergens.

Ultrasound-guided single shot caudal block anesthesia reduces postoperative urinary catheter-induced discomfort

BACKGROUND

Urinary catheter-induced discomfort during the postoperative period can be distressing, and sometimes results in severe restlessness and agitation, especially in middle-aged and elderly male patients. Recent advances in ultrasound technology have increased the consistency, safety, and ease of a caudal block even in older patients. We speculated that an ultrasound-guided caudal block would be reliable and safe as treatment for such postoperative discomfort.

METHODS

Adult male patients (ASA I-II) undergoing cervical laminoplasty were allocated to either the caudal block (CB, N.=24) or non-block (NB, N.=24) group. Following anesthesia induction, urinary catheterization was performed using a 16 French Foley catheter. Thereafter, an ultrasound-guided caudal block was performed with 8 ml of 0.3% ropivacaine and 100 µg of fentanyl for patients in group CB, while group NB did not receive a caudal block. We assessed urinary catheter-induced discomfort as mild, moderate, or severe at 0, 2, 6, 10, and 18 hours after surgery, and compared the incidence and severity of discomfort between the groups using a randomized double-blind design.

RESULTS

All caudal blocks were successfully performed with 1 or 2 needle insertions. The incidence of urinary catheter-induced discomfort was significantly reduced in group CB as compared to NB at 0, 2, and 6 hours, while severity was also reduced at 0 and 2 hours. No patient required re-catheterization due to urinary retention after catheter removal. There were no other complications related to the caudal block.

CONCLUSION

Preoperative ultrasound-guided single shot caudal block anesthesia safely reduced postoperative urinary catheter-induced discomfort in our male patients.

The factors associated with pain severity in patients with knee osteoarthritis vary according to the radiographic disease severity: a cross-sectional study

OBJECTIVES

Knee osteoarthritis (OA) pain is suggested to be associated with inflammation and detrimental mechanical loading across the joint. In this cross-sectional study, we simultaneously examined the inflammation and alignment of the lower limb and examined how the pain components varied depending on the disease progression.

DESIGN

One-hundred sixty female medial type of early- [n = 74 in Kellgren-Lawrence (K/L) 2] to advanced-stage (n = 96 in K/L >2) knee OA subjects (70.5 years on average) were enrolled. Knee pain was evaluated using a pain visual analog scale (VAS) and the pain-related subcategory of the Japanese Knee Osteoarthritis Measure (JKOM-pain). The serum interleukin (sIL)-6 level reflecting synovitis, and the high sensitivity C-reactive protein (hs-CRP) level were measured to evaluate the severity of inflammation. The anatomical axis angle (AAA) was measured as an alignment index. The β-coefficient was estimated after adjusting for age and the body mass index (BMI) using a multiple linear regression analysis.

RESULTS

Multiple linear regression analyses showed that the sIL-6 levels, but not AAA, associated with the pain VAS [β = 10.77 (95% confidence interval (CI): 4.14-17.40), P < 0.01] and JKOM-pain scores [β = 3.19 (95% CI: 1.93-4.44), P < 0.001] in the early stage. Conversely, AAA, but not the sIL-6 levels, was found to be associated with the pain VAS [β = -1.29 (95% CI: -2.51 to -0.08), P < 0.05] and JKOM-pain scores [β = -0.49 (95% CI: -0.82 to -0.16), P < 0.01] in the advanced stage.

CONCLUSIONS

The presence of a higher level of sIL-6 and the varus alignment of the joint is associated with pain in early- and advanced-stage knee OA patients, respectively.

Transversus abdominis plane block in combination with general anesthesia provides better intraoperative hemodynamic control and quicker recovery than general anesthesia alone in high-risk abdominal surgery patients

BACKGROUND

Patients with severe cardiovascular disease are frequently hemodynamically unstable during abdominal surgery. Improving the safety of such patients by stabilizing intraoperative hemodynamics remains a major concern for anesthesiologists. Transversus abdominis plane (TAP) block in combination with general anesthesia may facilitate optimum anesthetic management of these high-risk patients.

METHODS

Patients with cardiovascular disease classified as American Society of Anesthesiologists (ASA) physical status 3 were enrolled. The patients were undergoing elective abdominal surgery and were randomized to a group receiving general anesthesia and TAP block (Group T, N.=33) or a group receiving general anesthesia alone (Group G, N.=35). We compared the groups for intraoperative hemodynamic stability, anesthesia emergence time, amounts of anesthetics and opioids given, and frequency of emergency treatment with cardiovascular agents. A preliminary study demonstrated that systolic blood pressure and heart rate were maintained stable within 70-110% of their preanesthesia values throughout surgery in ASA 1 elderly patients without cardiovascular disease. Thus, the hemodynamically stable time was defined as the time when systolic blood pressure and heart rate were 70-110% of their preanesthesia values. The ratio of hemodynamically stable time to total operative time was used as an index of hemodynamic stability.

RESULTS

The median (minimum-maximum) percentage of hemodynamically stable time was longer in Group T (91[50-100]%) than Group G (79[40-91]%, P<0.01). The mean sevoflurane concentration, amount of fentanyl given and frequency of vasopressor use were lower in Group T than Group G (P<0.05). Anesthesia emergence time was shorter in Group T (14[4-30] min) than Group G (18[9-52] min, P<0.01). No worsening of cardiovascular complications was observed.

CONCLUSION

For abdominal surgery in patients with severe cardiovascular disease, combining TAP block with general anesthesia promotes intraoperative hemodynamic stability and early emergence from anesthesia.

Is the 7/2(1)- isomer state of 43S spherical?

We report on the spectroscopic quadrupole moment measurement of the 7/2(1)(-) isomeric state in (16)(43)S(27) [E*=320.5(5) keV, T(1/2)=415(3) ns], using the time dependent perturbed angular distribution technique at the RIKEN RIBF facility. Our value, |Q(s)|=23(3) efm(2), is larger than that expected for a single-particle state. Shell model calculations using the modern SDPF-U interaction for this mass region reproduce remarkably well the measured |Q(s)|, and show that non-negligible correlations drive the isomeric state away from a purely spherical shape.

Pleth variability index predicts hypotension during anesthesia induction

BACKGROUND

The pleth variability index (PVI) is a new algorithm used for automatic estimation of respiratory variations in pulse oximeter waveform amplitude, which might predict fluid responsiveness. Because anesthesia-induced hypotension may be partly related to patient volume status, we speculated that pre-anesthesia PVI would be able to identify high-risk patients for significant blood pressure decrease during anesthesia induction.

METHODS

We measured the PVI, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) in 76 adult healthy patients under light sedation with fentanyl to obtain pre-anesthesia control values. Anesthesia was induced with bolus administrations of 1.8 mg/kg propofol and 0.6 mg/kg rocuronium. During the 3-min period from the start of propofol administration, HR, SBP, DBP, and MAP were measured at 30-s intervals.

RESULTS

HR, SBP, DBP, and MAP were significantly decreased after propofol administration by 8.5%, 33%, 23%, and 26%, respectively, as compared with the pre-anesthesia control values. Linear regression analysis that compared pre-anesthesia PVI with the decrease in MAP yielded an r value of -0.73. Decreases in SBP and DBP were moderately correlated with pre-anesthesia PVI, while HR was not. By classifying PVI >15 as positive, a MAP decrease >25 mmHg could be predicted, with sensitivity, specificity, positive predictive, and negative predictive values of 0.79, 0.71, 0.73, and 0.77, respectively.

CONCLUSION

Pre-anesthesia PVI can predict a decrease in MAP during anesthesia induction with propofol. Its measurement may be useful to identify high-risk patients for developing severe hypotension during anesthesia induction.

An exploration of unmet information needs among breast cancer patients in Japan: a qualitative study

Informational need assessment has become an important part of health care in order to provide information effectively in clinical settings. Literature on information needs in the West suggests that breast cancer (BC) patients needed more information than doctors had provided, and information that fully met their needs was associated with patients' long-term well-being. Since few studies on this issue have been conducted in Japan, where the general consultation style is less open and more indirect, compared with that in the West, the application of the findings in the West is questionable. The purpose of this qualitative study was to explore perceived information needs among female BC patients in Japan. Twelve Japanese women with BC participated in semi-structured face-to-face interviews. Grounded theory using verbatim transcripts extracted two main themes: information needed to minimize physical and psychological impacts of treatment and information needed for the resumption of normal life. These were closely related at two time points. Physical support after discharge was perceived as relatively insufficient, especially by women experiencing post-operative arm complications. More open and direct communication was preferred between patients and doctors/family members in the recovery phase. Unmet needs for information may lead to patients' distress.

XBP1 may determine the size of the ameloblast endoplasmic reticulum

Ameloblasts progress through defined stages of development as enamel forms on teeth. Pre-secretory ameloblasts give rise to tall columnar secretory ameloblasts that direct the enamel to achieve its full thickness. During the maturation stage, the ameloblasts shorten and direct the enamel to achieve its final hardened form. Here we ask how the volume of selected ameloblast organelles changes (percent volume per ameloblast) as ameloblasts progress through six defined developmental stages. We demonstrate that mitochondria volume peaks during late maturation, indicating that maturation-stage ameloblasts maintain a high level of metabolic activity. Also, the endoplasmic reticulum (ER) volume changes significantly as a function of developmental stage. This prompted us to ask if X-box-binding protein-1 (XBP1) plays a role in regulating ameloblast ER volume, as has been previously demonstrated for secretory acinar cells and for plasma cell differentiation. We demonstrate that Xbp1 expression correlates positively with percent volume of ameloblast ER.

Application of devices for safe laparoscopic hepatectomy

The continuing evolution of a variety of laparoscopic instrument and device has been gradually applied to the laparoscopic hepatectomy in many countries. Recent experience has persuaded us that there are great potential benefits derived from laparoscopic hepatectomy and much has been learned about patient selection, the grade of surgical difficulty with respect to tumor location, and the required instrumentation. Among these efforts, various ways of hepatic parenchymal transection with mechanical devices have been attempted and continuing to innovate to perform safe laparoscopic hepatectomy Important technologic developments and improved endoscopic procedures are being established equipment modifications. For safe laparoscopic hepatectomy, it is important to have all necessary equipment. The intraoperative laparoscopic ultrasonography, microwave coagulators, ultrasonic dissection, argon beam coagulators, laparoscopic coagulation shears, endolinear staplers and TissueLink monopolar sealer are essential. This procedure is in need that well experienced endoscopic surgeon and well-experienced liver surgeon should be collaborated in laparoscopic hepatectomy and the indications are strictly followed based upon the location and size of tumors. Finally critical determinant for success and safe laparoscopic hepatectomy is through familiarity with the relevant laparoscopic instruments and equipments. Laparoscopic hepatectomy is expected to develop further in the future as a new surgical instrument, equipment and method, which improves patients' quality of life.

Continuous intravenous lidocaine controls abdominal pain secondary to peritoneal carcinomatosis as a consequence of diffusion into ascites

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Background: Our team reported at the 42nd ASCO meeting that continuous, low-dose intravenous (IV) lidocaine is an effective method for pain relief in terminal patients with peritoneal carcinomatosis. Our aim was to explore the mechanism by which abdominal pain of terminally-ill patients with peritoneal carcinomatosis was improved by continuous IV lidocaine. Methods: 48 patients with peritoneal carcinomatosis due to GI (46) and GYN (2) malignancies were administered lidocaine at low-doses (0.4 and/or 0.8mg/kg- h) for >24 hours, because opiates, NSAIDs, and other adjuvants were ineffective in relieving their abdominal pain. Pain (faces rating scale; 0-no pain, 5-worst pain), oral intake, side effects, and activities of daily life were quantified. Two days after beginning lidocaine, ascites was sampled to measure ascitic concentration of lidocaine, tumor markers and cytology. Results: Mean age (±SE) was 60±2. The volume of ascites was estimated to be 2,700±400ml by the ultrasound 5 points methodology. Abdominal symptoms improved in 1.5±0.2days after beginning lidocaine, and the pain scale decreased from 1.9±0.2 to 0.5±0.1; p<0.001; 75% of patients had improvement in pain of whom 78% had complete relief of pain. Oral intake increased from 18% to 49% of baseline (p<0.001), and 67% in those with improvement in pain had an increased volume of oral intake. There were no obvious differences in response to 0.4 and 0.8 mg/kg-h in patients receiving both doses. Serum concentrations of lidocaine at 0.4 and 0.8 mg/kg-h were 1.7±0.2 and 3.2±0.2 μg/ml, respectively; lidocaine concentrations in the ascites were 1.2±0.2 and 2.1±0.2 μg/ml. No patient complained of pain at the time of peritoneal puncture. Side effects included bradycardia of <60 beats per minutes (3 patients). The duration of lidocaine administration was 23±3 days; 43% of patients were able to be discharged home for end-of-life care, with parenteral nutrition and continuation of lidocaine administration or oral mexiletine (300–450 mg/day) for adjuvant analgesia. Conclusions: Lidocaine diffuses into ascites and almost equilibrates with serum concentrations acting as a peritoneal anesthesia which, as a result, controls abdominal pain in patients with peritoneal carcinomatosis.

No significant financial relationships to disclose.

In vivo suppression of mafA mRNA with siRNA and analysis of the resulting alteration of the gene expression profile in mouse pancreas by the microarray method

Maf is a family of transcription factor proteins that is characterized by a typical bZip structure, and one of the large mafs, mafA is a strong transactivator of insulin. To explore the role of mafA in the pancreas, we modified the mafA mRNA level in vivo in mice by the RNA interference (siRNA) technique and analyzed the resulting alteration of the expressed gene profile with a microarray system. The mafA expression level in siRNA-treated mice was reduced approximately 60% compared with control-siRNA-treated animals. Microarray analysis revealed changes in the expression level of several genes in the siRNA-treated mice, with prominent down-regulated expression of the genes encoding insulin, glucagon, and adipocytokines, suggesting possible role of mafA in the pathophysiological states of impaired metabolic responses or inflammatory reactions.

Bacterial translocation in small intestinal ischemia-reperfusion injury and efficacy of Anti-CINC antibody treatment

The involvement of bacterial translocation in small intestinal ischemia-reperfusion injuries and the efficacy of using anti-CINC antibodies for treatment were investigated. A model for ischemia-reperfusion injury of the small intestine was constructed by clamping the supramesenteric artery (for 90 min) in rats. Anti-CINC antibodies and saline were given just before the induction of ischemia in the treatment group and the control group, respectively. Six hours after reperfusion, bacteria were detected in the mesenteric lymph nodes, but the 'bacteria-positive' rate was significantly lower in the treatment group than in the control group. Bacterial cultures and endotoxins in the blood were negative in both groups up to 24 h later. The plasma cytokine levels showed similar variations, although the increases were significantly lower after reperfusion in the treatment group. In addition, the degrees of neutrophil infiltration and mucosal injury were attenuated in the small intestine, and the structure of the liver was maintained. Furthermore, the 1-week survival was improved. These results suggest that bacterial translocation occurred predominantly via the lymphatic system and that anti-CINC antibody treatment exerted a protective effect against small intestinal ischemia-reperfusion injury.

Origin, splicing, and expression of rodent amelogenin exon 8

Amelogenin RNA transcripts undergo extensive alternative splicing, and MMP-20 processes the isoforms following their secretion. Since amelogenins have been ascribed cell-signaling activities, we asked if a lack of proteolytic processing by MMP-20 affects amelogenin signaling and consequently alters amelogenin splice site selection. RT-PCR analyses of amelogenin mRNA between control and Mmp20(-/-)mice revealed no differences in the splicing pattern. We characterized 3 previously unidentified amelogenin alternatively spliced transcripts and demonstrated that exon-8-encoded amelogenin isoforms are processed by MMP-20. Transcripts with exon 8 were expressed approximately five-fold less than those with exon 7. Analyses of the mouse and rat amelogenin gene structures confirmed that exon 8 arose in a duplication of exons 4 through 5, with translocation of the copy downstream of exon 7. No downstream genomic sequences homologous to exons 4-5 were present in the bovine or human amelogenin genes, suggesting that this translocation occurred only in rodents.