Enzyme replacement therapy in two patients with classic Fabry disease from the same family tree: Two case reports

BACKGROUND

The pathophysiology of Fabry disease (FD)-induced progressive vital organ damage is irreversible. Disease progression can be delayed using enzyme replacement therapy (ERT). In patients with classic FD, sporadic accumulation of globotriaosylceramide (GL-3) in the heart and kidney begins in utero; however, until childhood, GL-3 accumulation is mild and reversible and can be restored by ERT. The current consensus is that ERT initiation during early childhood is paramount. Nonetheless, complete recovery of organs in patients with advanced FD is challenging.

CASE SUMMARY

Two related male patients, an uncle (patient 1) and nephew (patient 2), presented with classic FD. Both patients were treated by us. Patient 1 was in his 50s, and ERT was initiated following end-organ damage; this was subsequently ineffective. He developed cerebral infarction and died of sudden cardiac arrest. Patient 2 was in his mid-30s, and ERT was initiated when the patient was diagnosed with FD, during which the damage to vital organs was not overtly apparent. Although he had left ventricular hypertrophy at the beginning of this treatment, the degree of hypertrophy progression was limited to a minimal range after > 18 years of ERT.

CONCLUSION

We obtained discouraging ERT outcomes for older patients but encouraging outcomes for younger adults with classic FD.

Cerebral infarction by paradoxical gas embolism detected after laparoscopic partial hepatectomy with an insufflation management system: a case report

BACKGROUND

Laparoscopic surgery has reduced surgical morbidity and postoperative duration of hospital stay. Gas embolism is commonly known as a risk factor for all laparoscopic procedures. We report a case of severe cerebral infarction presumably caused by paradoxical CO₂ embolism in laparoscopic partial hepatectomy with an insufflation management system.

CASE PRESENTATION

A male in his 60 s was diagnosed with recurrence of liver metastasis in the right hepatic lobe after laparoscopic lower anterior resection for rectal cancer. We performed laparoscopic partial hepatectomy with an AirSeal® under 10 mmHg of intra-abdominal pressure. During the surgery, the patient's end-tidal CO₂ and percutaneous oxygen saturation dropped from approximately 40-20 mmHg and 100-90%, respectively, while the heart rate increased from 60 to 120 beats/min; his blood pressure remained stable. Postoperatively, the patient developed right hemiplegia and aphasia. Brain magnetic resonance imaging showed cerebral infarction in the broad area of the left cerebral cortex. Thereafter, transesophageal echocardiography revealed a patent foramen ovale, suggesting cerebral infarction due to paradoxical gas embolism.

CONCLUSIONS

A patent foramen ovale is found in approximately 15-20% of healthy individuals. While gas embolism is a rare complication of laparoscopic surgery, cerebral infarction must be considered a possible complication even if the intra-abdominal pressure is constant under 10 mmHg with an insufflation management system.

Benign multicystic peritoneal mesothelioma occurring in bilateral inguinal canals metachronously: a case report

BACKGROUND

Benign multicystic peritoneal mesothelioma (BMPM) is a benign tumor that usually occurs in middle-aged females. Although several published studies have reported the occurrence of this tumor in the abdominal cavity, few have documented its development in the inguinal region.

CASE PRESENTATION

We present a case of a 48-year-old female presenting with a bulge in her left inguinal region. Physical examination revealed a golf ball-sized nodule in the left inguinal region that could not be pushed back into the abdominal cavity. Contrast-enhanced computed tomography showed a multicystic tumor; therefore, the patient was diagnosed with inguinal hernia or hydrocele of the Nuck's canal. We performed surgical resection and hernia repair using the mesh plug method. The resected specimen was 80 mm in length and contained a multicystic tumor. Pathological examination showed that the cyst wall was lined by a single layer of cuboidal to single layer squamous epithelium. Immunohistochemistry revealed positivity for calretinin in the epithelial cells, for which a diagnosis of BMPM was established. The patient returned to our hospital after 5 years with symptoms similar to the previous episode, but this time in the right inguinal region. Imaging studies showed a tumor in the right inguinal region with the same characteristics as the previous one. The patient underwent tumor resection and hernia repair using the same technique. The resected tumor was 45 mm in length and had characteristics similar to the previously resected tumor. The presence of calretinin and D2-40 on immunohistochemistry led to the diagnosis of BMPM. There was no recurrence of BMPM for 33 months after the secondary surgery.

CONCLUSIONS

Here we present the first report of metachronous BMPM occurring in bilateral inguinal canals. Although the pathogenesis of BMPM remains unclear, reactive changes have been suggested to cause tumors originating from the groin. The treatment of choice for BMPM is surgical resection. For diagnosis, pathological examination with immunostaining can be useful. The most appropriate postoperative follow-up for inguinal BMPM is controversial, and the accumulation of more inguinal BMPM cases is needed.

A case of gastrointestinal bleeding due to right hepatic artery pseudoaneurysm following total remnant pancreatectomy: A case report

Introduction

Pseudoaneurysm is a serious complication after pancreatic surgery, which mainly depends on the presence of a preceding pancreatic fistula. Postpancreatectomy hemorrhage following total pancreatectomy is a rare complication due to the absence of a pancreatic fistula. Here we report an unusual case of massive gastrointestinal bleeding due to right hepatic artery (RHA) pseudoaneurysm following total remnant pancreatectomy.

Presentation of case

A 75-year-old man was diagnosed with intraductal papillary mucinous carcinoma recurrence following distal pancreatectomy and underwent total remnant pancreatectomy. After discharge, he was readmitted to our hospital with melena because of the diagnosis of gastrointestinal bleeding. Gastrointestinal endoscopy was performed to detect the origin of bleeding, but an obvious bleeding point could not be detected. Abdominal computed tomography demonstrated an expansive growth, which indicated RHA pseudoaneurysm. Emergency angiography revealed gastrointestinal bleeding into the jejunum from the ruptured RHA pseudoaneurysm. Transcatheter arterial embolization was performed; subsequently, bleeding was successfully stopped for a short duration. Because of improvements in his general condition, the patient was discharged.

Discussion

To date, very few cases have described postpancreatectomy hemorrhage following total remnant pancreatectomy. We suspect that the aneurysm ruptured into the jejunum, possibly because of the scarring and inflammation associated with his two complex surgeries.

Conclusion

Pseudoaneurysm should be considered when the fragility of blood vessels is suspected, despite no history of anastomotic leak and intra-abdominal abscess. Our case also highlighted that detecting gastrointestinal bleeding is necessary to recognize sentinel bleeding if the origin of bleeding is undetectable.

237 EFFECT OF A PTEN INHIBITOR ON OVARIAN CONTENTS OF APOPTOSIS-RELATED PROTEINS AND ANTI-MÜLLERIAN HORMONE (AMH) IN A/J MICE

Strain/individual differences in superovulation efficiency with gonadotropins constitute a serious problem in mouse reproduction (Suzuki et al. 1996 Reprod. Fertil. Dev. 8, 975–980). Because PI3K/Akt signalling pathway is involved in ovarian folliculogenesis and phosphatase and tensin homologue deleted from chromosome 10 (PTEN) negatively regulates the process, I have been studying the effect of PTEN inhibitors on ovarian folliculogenesis and ovulation in mice to improve superovulation efficiency. In the present study, I compared ovarian contents of apoptosis-related proteins and anti-Müllerian hormone (AMH, an activity/number indicator of preantral and early-antral follicles) in A/J mice to examine the possibilities of an exogenous PTEN inhibitor to suppress follicular atresia and to promote folliculogenesis. At PMSG injections, 0 (control, n = 5) or 2 mg kg–1 B.W. (treated, n = 5) of a PTEN inhibitor, dipotassium bisperoxo (picolinato) oxovanadate (V), dissolved in Ringer solution were also injected to 28-day-old A/J female mice. Ovaries were collected 24 h after the injections. Ovarian protein contents of six proteins (shown in results) were measured by quantitative Western blots with β-actin as an internal control using whole ovary homogenates. Quantitativity of the Western blots were confirmed by calibration curves produced using a dilution series of sample mix (see Suzuki et al. 2011 Exp. Anim. 60, 193–196, for method details). Observed values were compared between control and treated groups by ANOVA. No significant difference in ovarian protein contents of apoptosis-related proteins (cleaved caspase-3, cleaved caspase-9, cleaved PARP, BAX, and BCL-2) was found between the 2 groups (P = 0.951, 0.548, 0.095, 0.226, and 0.363, respectively; n = 5). On the other hand, ovarian AMH protein was more abundant in the treated group than that in the control group (P = 0.009). Although these results should be confirmed by more precise quantification methods such ELISA or RIA to eliminate possible lack of difference in apoptosis-related proteins due to methodology, they suggest that PTEN inhibitors can promote ovarian folliculogenesis but not suppress follicular atresia. This work was supported by a grant from the Ministry of Health, Labour and Welfare of Japan.

Reduction of the Incidence of Delayed Gastric Emptying in Side-to-Side Gastrojejunostomy in Subtotal Stomach-Preserving Pancreaticoduodenectomy

BACKGROUND

One of the most common morbidities of pancreaticoduodenectomies is delayed gastric emptying (DGE). The recent advent of subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) attempts to lessen this troublesome complication; however, the incidence of DGE still remains to be 4.5-20%. This study aims to evaluate whether the incidence of DGE can be reduced by the side-to-side gastric greater curvature-to-jejunal anastomosis in comparison with the gastric stump-to-jejunal end-to-side anastomosis in SSPPD.

METHODS

Between October 2007 and September 2012, a total of 160 consecutive patients who had undergone SSPPD were analyzed retrospectively. In the first period (October 2007-March 2010), gastrojejunostomy was performed with end-to-side anastomosis in 80 patients (SSPPD-ETS group). In the second period (April 2010-September 2012), gastrojejunostomy was performed with the greater curvature side-to-jejunal side anastomosis in 80 patients (SSPPD-STS group). The postoperative data were collected prospectively in a database and reviewed retrospectively.

RESULTS

The incidence of DGE was 21.3% in the SSPPD-ETS group and 2.5% in the SSPPD-STS group (P = 0.0002). According to the classification of the International Study Group of Pancreatic Surgery (ISGPS), the incidence of DGE of grades A, B, and C were 5, 5, and 7 in the SSPPD-ETS group and 0, 2, and 0 in the SSPPD-STS group, respectively. The overall morbidity and postoperative hospital stay of the two groups were not significantly different.

CONCLUSIONS

The greater curvature side-to-side anastomosis of gastrojejunostomy is associated with a reduced incidence of DGE after SSPPD.

A case-matched comparison of single-incision versus multiport laparoscopic right colectomy for colon cancer

PURPOSE

To minimize the parietal trauma associated with multiple surgical access sites, single-incision laparoscopic surgery for colectomy has been emerging with the improvements in instrumentation and surgical techniques. The purpose of this study was to compare the clinicopathological outcomes between single-incision laparoscopic right colectomy (SILC) and multiport laparoscopic right colectomy (MLC) for right colon cancer.

METHODS

Thirty-five consecutive patients undergoing SILC from a prospective single-institution database were case matched according to demographic data to an equivalent number of patients who underwent MLC.

RESULTS

The SILC patients had decreased scores for maximal pain assessed by a visual analog scale on postoperative days 1 and 3, and used fewer postoperative systemic narcotics. The median length of the hospital stay for the SILC patients was significantly shorter compared with the MLC patients. The postoperative morbidity rates were similar between the groups. The oncological findings were not significantly different between the groups.

CONCLUSION

SILC is a feasible and safe alternative to conventional MLC for patients with right colon cancer.

354 COMPARISON OF OVARIAN CONTENTS OF AKT ISOFORMS AMONG 4 STRAINS OF MICE

Strain/individual differences in superovulation efficiency with gonadotropins constitute a serious problem in mouse reproduction (Suzuki et al. 1996 Reprod. Fertil. Dev. 8, 975–980). Because the PI3K/Akt signalling pathway is involved in ovarian folliculogenesis, quantitative difference of protein components in the PI3K/Akt signalling pathway among mouse strains may explain the strain difference in superovulation efficiency. The present study compared ovarian contents of AKT isoforms among 4 strains to examine the involvement of the PI3K/Akt signalling pathway in superovulation. Ovarian protein contents of AKT1, AKT2, and AKT3 isoforms in 4-week-old females of 4 mouse strains were measured by quantitative Western blots with GAPDH as an internal control using whole ovary homogenates (see Suzuki et al. 2011 Exp. Anim. 60, 193–196, for method details). Observed values were compared among strains by 1-way ANOVA after normality (Shapiro-Wilk) and equal variance (Levene) were confirmed. Ovarian protein contents of all 3 AKT isoforms in A/J, C57BL/6N, DBA/2, and C3H/He (arbitrary unit, mean ± s.e.m., n = 4) were significantly different among strains by 1-way ANOVA (P < 0.05). Ovarian AKT1 contents were 1.01 ± 0.10a, 0.98 ± 0.07, 0.89 ± 0.03, and 0.84 ± 0.02b, respectively. Ovarian AKT2 contents were 1.39 ± 0.13a, 0.74 ± 0.10b, 1.03 ± 0.07c, and 0.91 ± 0.19bc, respectively. Ovarian AKT3 contents were 1.24 ± 0.38, 1.55 ± 0.24a, 1.11 ± 0.09, and 0.67 ± 0.18b, respectively. a–cValues with different superscripts in each isoform are significantly different by Tukey test (P < 0.05). Thus, significant quantitative differences in ovarian AKT isoforms among strains suggest that the ovarian PI3K/Akt signalling pathway acts differently among strains. This activity difference of the pathway may explain the strain difference in superovulation efficiency in mice.This work was supported by a grant from the Ministry of Health, Labour and Welfare of Japan.

214 SUPEROVULATION IN A/J MICE USING A COMBINATION OF GONADOTROPINS AND THE PTEN INHIBITOR bpV(pic)

Strain and individual differences in superovulation constitute a serious problem in mice. Gonadotropins stimulate the maturation of developing ovarian follicles, but not primordial follicle activation (PFA), which is negatively controlled by the Phosphatase and Tensin Homologue Deleted from Chromosome 10 (PTEN). PTEN inhibitors may increase the number of developing follicles by promoting PFA. If so, subsequent gonadotropin injections may make more follicles ovulate. This study tested whether PTEN inhibitors promote superovulation by gonadotropins and examined the fertilizability of ovulated oocytes in vitro. Method: Immature females of the low responder A/J mouse strain were used. Based on preliminary results regarding peaks in the daily changes in the ovary weight/body weight ratio and ovarian anti-Müllerian hormone protein content after injections of the PTEN inhibitor, dipotassium bisperoxo (picolinato) oxovanadate (V) [bpV(pic)], the number of ovulated oocytes was examined using four combinations of the bpV(pic) dose and interval between the bpV(pic) and pregnant mare serum gonadotropin (PMSG) injections: 1) 3 μg and PMSG on Day 3; 2) 3 μg and PMSG on Day 4; 3) 30 μg and PMSG on Day 1; and 4) 30 μg and PMSG on Day 2. Ovulation was induced by hCG 48 h after PMSG injection. In vitro fertilization of the obtained oocytes was performed using TYH medium and epididymal sperm from adult ICR male mice (Day 1). Subsequently, the oocytes were cultured in KSOMaa+0.1% bovine serum albumin for 4 days. The numbers of two-cell embryos and blastocysts were recorded on Days 2 and 5, respectively. Results: The average number of oocytes collected in treatments 1 to 4 was 1) 7.2 ± 0.7 v. 9.4 ± 1.6 [control v. bpV(pic), mean ± s.e.m., n = 5]; 2) 7.8 ± 0.7 v. 9.0 ± 1.4; 3) 9.8 ± 1.6 v. 11.2 ± 1.0; and 4) 9.4 ± 1.0 v. 7.4 ± 1.9. More oocytes tended to be collected in the bpV(pic) groups in treatments 1 to 3, but the differences were not significant on ANOVA. The corresponding percentages of two-cell embryos on Day 2 after insemination were 1) 78.7 ± 7.7% v. 83.7 ± 5.6%; 2) 76.0 ± 4.2% v. 65.2 ± 4.2%; 3) 53.5 ± 13.0% v. 68.6 ± 9.1%; and 4) 78.2 ± 9.7% v. 55.2 ± 5.7%. The respective percentages of blastocysts on Day 5 after insemination were 1) 62.7 ± 6.5% v. 69.5 ± 8.1%; 2) 67.9 ± 7.7% v. 41.6 ± 5.6%; 3) 74.9 ± 11.3% v. 79.2 ± 7.8%; and 4) 78.0 ± 3.8% v. 60.5 ± 4.3%. On weighted ANOVA with angular transformations, the two-cell embryo and blastocyst rates were significantly lower in bpV(pic) groups than in control groups for treatments 2 and 4. Discussion: More oocytes tended to be collected in the bpV(pic) groups in 3 of the 4 experimental treatments. Different injection intervals between bpV(pic) and PMSG influenced both the superovulation efficiency and fertilizability of the oocytes. This new method using both PTEN inhibitors and gonadotropins is a promising method for improving superovulation efficiency, although the optimal injection scheme should be determined. This work was supported by a grant from the Ministry of Health, Labour, and Welfare of Japan.

319 REDUCED SUPEROVULATION EFFICIENCY BY HIGH-DOSE TREATMENT OF DEHYDROEPIANDROSTERONE IN MICE

Strain differences in in vitro fertilizability still constitute a serious problem in mouse reproduction. To improve the in vitro fertilizability of mouse oocytes, we examined the effect of implanting time-release pellets of dehydroepiandrosterone (DHEA), a testosterone precursor, in female mice on oocyte fertilizability. The DHEA pellets (0.25, 1.5, or 5 mg pellet–1, 21-day release form, Innovative Research of America, Sarasota, FL, USA) or corresponding placebo pellets were implanted subcutaneously in 9-week-old female 129X1/SvJJmsSlc mice. On Day 18 of implantation, superovulation was induced in these females by injections of pregnant mare serum gonadotropin (PMSG) and hCG 48 h apart. On Day 21, IVF was conducted using oocytes collected from the oviducal ampullae of these females and epididymal sperm from Slc : ICR male mice using TYH medium. Then, the embryos were cultured in vitro in Whitten’s medium for 96 h. Plasma steroid levels and expression of 5 ovarian proteins (PTEN and receptors for FSH, androgen, oestrogen, and progesterone) at oocyte collection were measured by enzyme immunoassay and quantitative Western blots, respectively. Embryo development into 2-cell and blastocyst stages at each dose at 24 h and 96 h after insemination, respectively, were compared between DHEA and placebo groups using weighted ANOVA with angular transformations. Other observed values were compared using Student’s t-test. Treatment with DHEA suppressed the numbers of ovulated oocytes in the 1.5 and 5 mg groups (DHEA v. placebo: 21.0 ± 2.6 v. 32.5 ± 2.8 and 19.9 ± 1.4 v. 27.1 ± 1.6, respectively, n = 10; P < 0.05), but not in the 0.25 mg group (26.6 ± 3.2 v. 24.8 ± 2.4). Treatment with DHEA did not affect the percentages of 2-cell embryo formation at any dose, ranging 50 to 60%. In the 0.25 mg group, DHEA treatment tended to increase blastocyst formation rate (1.8 ± 0.8% v. 0.4 ± 0.4%; not significant). However, the treatment at 1.5 mg suppressed the rate (0.0 ± 0.0% v. 3.1 ± 0.7%; P < 0.05) and treatment at 5 mg did not affect the rate (1.3 ± 0.9% v. 0.8 ± 0.6%). Plasma testosterone levels were increased by DHEA at 1.5 and 5 mg (338.2 ± 39.8 v. 197.0 ± 8.9 pg mL–1 and 534.9 ± 111.4 v. 241.8 ± 34.4 pg mL–1, respectively, n = 6; P < 0.05), but not at 0.25 mg (247.4 ± 22.0 v. 252.5 ± 35.6 pg mL–1, n = 6). No significant difference was induced by DHEA in plasma DHEA, progesterone, or oestradiol at any doses. Ovarian PTEN protein was more abundant in DHEA group than in placebo group at 5 mg (P < 0.05), tended to be more abundant at 1.5 mg (P ≈ 0.14), and was not different at 0.25 mg (P ≈ 0.35). The amounts of the 4 receptor proteins were not significantly changed by DHEA at any dose. These results suggest that DHEA at a low dose (e.g. 0.25 mg pellets for 21 days) might have a potential to improve in vitro fertilizability of mouse oocytes. Higher doses of DHEA reduced superovulation efficiency, perhaps because of the high testosterone level induced by the high-dose treatment of DHEA. The high testosterone level might upregulate ovarian PTEN expression, which might suppress ovarian primordial follicle activation. A more detailed study is needed to determine the optimal dose, timing, and duration of DHEA treatment for the improvement of female fertilizability.

Triclosan-coated sutures reduce the incidence of wound infections and the costs after colorectal surgery: a randomized controlled trial

BACKGROUND

In colorectal surgeries, surgical site infections (SSIs) frequently cause morbidity; an incidence of up to 20% has been shown in previous studies. Recently, to prevent microbial colonization of suture material in operative wounds, triclosan-coated polyglactin suture materials with antimicrobial activity have been developed; however, their significance in colorectal surgery remains unclear. This randomized controlled trial was conducted to assess the value of triclosan-coated polyglactin sutures in colorectal surgery.

METHODS

A total of 410 consecutive patients who had undergone elective colorectal operations were enrolled in this trial. Of those patients, the 206 in the study group underwent wound closure with triclosan-coated polyglactin 910 antimicrobial sutures, and the 204 patients in the control group received conventional wound closures with polyglactin 910 sutures.

RESULTS

The study group and the control group were comparable regarding risk factors for SSIs. The incidence of wound infection in the study group was 9 of 206 patients (4.3%), and that in the control group was 19 of 204 patients (9.3%). The difference is statistically significant in the 2 groups (P = .047). The median additional cost of wound infection management was $2,310. The actual entire additional cost, therefore, of 9 patients in the study group was $18,370, and that of 19 patients in the control group was $60,814.

CONCLUSION

Triclosan-coated sutures can reduce the incidence of wound infections and the costs in colorectal surgery.

[Long-term survival of a patient with giant liver metastatic breast cancer treated with trastuzumab]

We report the long-term survival of a patient with metastatic breast cancer treated with trastuzumab and chemoendocrine therapy. The patient was a 60-year-old female. She underwent right mastectomy with axillary lymphadenectomy I c for advanced right breast cancer in 1999. In 2007, she consulted our hospital for treatment of recurrent giant liver metastasis. A giant liver metastasis up to 15 cm in diameter was detected by CT upon arrival. After 4 years of trastuzumab and chemoendocrine therapy, she was diagnosed as in progressive remission with good quality of life. Breast cancer with liver metastasis often can be life-threatening. Therefore, an optimal chemotherapy should be applied as soon as possible. Trastuzumab and chemoendocrine therapy showed efficacy for the treatment of a HER2-positive breast cancer with recurrent giant liver metastasis.

Octacalcium phosphate collagen composites with titanium mesh facilitate alveolar augmentation in canine mandibular bone defects

This study was designed to investigate whether bone regeneration by implantation of octacalcium phosphate and porcine atelocollagen composite (OCP/Col) would be enhanced if mechanical stress to the implanted OCP/Col were alleviated. OCP/Col discs were implanted into an arc-shaped mandibular defect in male adult beagle dogs divided into untreated, OCP/Col, and OCP/Col/Mesh groups. In the OCP/Col/Mesh group, mechanical stress towards the implanted OCP/Col was alleviated by a titanium mesh. Bone regeneration in the three groups was compared after 6 months. Macroscopically, the alveolus in the OCP/Col/Mesh group was augmented vertically more than in the other two groups. Morphometric analysis by micro-CT showed the bone volume in the OCP/Col/Mesh group was significantly greater than in the other two groups. The augmented alveolus in the OCP/Col/Mesh group consisted of outer cortical and inner cancellous structure. Histologically, the OCP/Col/Mesh-treated alveolus was augmented by matured bone tissue along the inside of the titanium mesh. The implanted OCP/Col in the OCP/Col/Mesh and OCP/Col groups had almost disappeared. These results indicated that vertical bone regeneration by OCP/Col was efficient and successful when the mechanical stress to the implanted OCP/Col was alleviated. OCP/Col should be a useful bone substitute with active structural reconstitution.

179 EFFECTS OF DEHYDROEPIANDROSTERONE ON SPERM FERTILIZABILITY IN VITRO AND TESTICULAR GENE EXPRESSION

Strain differences of in vitro fertilizability still constitute a serious problem in mouse reproduction. To improve the in vitro fertilizability of mouse sperm, we examined the effects of implanting time-release pellets of dehydroepiandrosterone (DHEA), a testosterone precursor, on sperm fertilizability and testicular gene expression. DHEA pellets (5 mg pellet–1, 21-day release form; Innovative Research of America) or placebo pellets were implanted subcutaneously in 9-week-old male mice from 2 strains: C57BL/6CrNSlc (B6) and 129X1/SvJJmsSlc (129X1). After 21 days, in vitro fertilization was conducted using epididymal sperm from these males and oocytes from superovulated 4-week-old Slc:ICR females. The percentages of 2-cell embryo formation in the placebo and DHEA groups were 78.2 ± 14.2% vs 89.3 ± 2.5%, respectively (mean ± standard error of the mean, n = 4 per group) using B6 sperm and 40.9 ± 8.8% vs 41.3 ± 3.1%, respectively (n = 4 per group) using 129X1 sperm, indicating no significant effect of DHEA treatment (P > 0.05 by 2-way ANOVA). However, a strain difference was quite evident (P < 0.05 by 2-way ANOVA). Quantitative Western blotting using testicular protein extracts with glyceraldehyde-3-phosphate dehydrogenase as an internal control showed that the expression of androgen receptor protein (AR) was significantly higher in B6 than in 129X1 males (P < 0.05 by 2-way ANOVA), whereas there was no significant effect of DHEA on the amount of AR in either strain (P > 0.05 by 2-way ANOVA). In B6 testes, 2-dimensional electrophoresis indicated that 1 protein spot was denser in DHEA-treated males than in placebo-treated males. In 129X1 testes, DHEA did not change the density of the corresponding spot. Mass spectrometry of the spot suggested that it was Cu/Zn superoxide dismutase (SOD1). Thus, 21-day-release pellets of 5 mg DHEA had no significant effect on sperm fertilizability in vitro in 2 strains, but the DHEA pellets induced a strain-dependent testicular protein expression, which might be because of the differential AR expression. Although DHEA treatment of male mice has the potential to improve sperm fertilizability in vitro, a more detailed study is needed to determine the optimal dose, age and duration of DHEA treatment. This work was supported by a grant from the Ministry of Health, Labour and Welfare, Japan.

Effects of an angiotensin 2 receptor blocker plus diuretic combination drug in chronic heart failure complicated by hypertension

The effects of 24 weeks' treatment with an angiotensin 2 receptor blocker (ARB)/diuretic combination drug were investigated in an open-label study of 61 patients with stabilized chronic heart failure. Renin-angiotensin-aldosterone system inhibitors were replaced with a tablet containing hydrochlorothiazide 6.25 mg plus candesartan 8 mg, administered orally, once daily, in patients with systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg while under optimal treatment. Both SBP and DBP declined significantly during the ARB/diuretic combination treatment. Diuretics administered previously were discontinued during the study period in 15 patients, decreasing the number of drugs being taken. During ARB/diuretic combination treatment, the blood urea nitrogen level worsened but no significant changes were noted in potassium or estimated glomerular filtration rate, which had been a matter of concern. Additionally, the level of brain natriuretic peptide, an indicator of the severity of heart failure, was improved, indicating effectiveness and safety of the ARB/diuretic combination drug.

The effect of synthetic octacalcium phosphate in a collagen scaffold on the osteogenicity of mesenchymal stem cells

Although the efficacy of the in vivo osteogenic capabilities of synthetic octacalcium phosphate (OCP) crystal implantation can be explained through its stimulatory capacity for the differentiation of the host osteoblastic cell lineage, direct evidence that OCP supports bone regeneration by osteogenic cells in vivo has not been shown. Mesenchymal stem cells (MSCs) isolated from 4-week-old male Wistar rat long bones were pre-incubated in osteogenic or maintenance medium in the presence or absence of basic fibroblast growth factor (bFGF). OCP/Collagen (OCP/Col) or collagen disks were seeded with MSCs that had been pre-incubated in osteogenic medium containing bFGF, which exhibited the highest differentiation induction, and then incubated for an additional day. The disks were implanted in critical-sized calvaria defects of 12-week-old male Wistar rats and the specimens were analysed radiographically, histologically, histomorphometrically, and by micro-computed tomography (CT) imaging at 4 and 8 weeks after the implantation. The OCP/Col·MSCs group rapidly induced more bone regeneration, even within 4 weeks, compared to the OCP/Col group without MSCs. The bone mineral density of the OCP/Col·MSCs group was also greater than the OCP/Col group. The Col·MSCs group did not exhibit prominent osteogenicity. These results indicate that OCP crystals in a collagen matrix efficiently promote exogenously introduced osteogenic cells to initiate bone regeneration if the cells are pre-treated in a suitable differentiation condition.

Use of quantitative intra-operative electrodiagnosis during partial ulnar nerve transfer to restore elbow flexion

The transfer of part of the ulnar nerve to the musculocutaneous nerve, first described by Oberlin, can restore flexion of the elbow following brachial plexus injury. In this study we evaluated the additional benefits and effectiveness of quantitative electrodiagnosis to select a donor fascicle. Eight patients who had undergone transfer of a simple fascicle of the ulnar nerve to the motor branch of the musculocutaneous nerve were evaluated. In two early patients electrodiagnosis had not been used. In the remaining six patients, however, all fascicles of the ulnar nerve were separated and electrodiagnosis was performed after stimulation with a commercially available electromyographic system. In these procedures, recording electrodes were placed in flexor carpi ulnaris and the first dorsal interosseous. A single fascicle in the flexor carpi ulnaris in which a high amplitude had been recorded was selected as a donor and transferred to the musculocutaneous nerve. In the two patients who had not undergone electrodiagnosis, the recovery of biceps proved insufficient for normal use. Conversely, in the six patients in whom quantitative electrodiagnosis was used, elbow flexion recovered to an M4 level.

Quantitative intra-operative electrodiagnosis is an effective method of selecting a favourable donor fascicle during the Oberlin procedure. Moreover, fascicles showing a high-amplitude in reading flexor carpi ulnaris are donor nerves that can restore normal elbow flexion without intrinsic loss.

ENBD tube placement prior to laparoscopic cholecystectomy may reduce the rate of complications in cases with predictably complicating biliary anomalies

BACKGROUND

The risk factors predisposing to bile duct injury or postoperative bile leakage associated with laparoscopic cholecystectomy (LC) include the presence of an accessory hepatic duct, the anomalous cystic duct confluence, and duct of Luschka. One method to prevent bile duct injury is preoperative placement of an endoscopic nasobiliary drainage tube (ENBD assisted LC). The aims of this investigation are first, to report the incidence of bile duct anomalies according to the classification system proposed by Wakayama Medical University and second, to evaluate the efficacy of ENBD assisted LC with regard to prevention of intraoperative bile duct injury and postoperative bile duct injury or leakage.

METHODS

A total of 1,835 consecutive LCs performed at our institution during a recent 10-year period were reviewed.

RESULTS

Anomalous cystic duct confluence was detected in 11 cases and an accessory hepatic duct was detected in 37 cases. These anomalies were risk factors for bile duct injury in our series. However, there was no significant difference in the length of surgery, conversion rate to laparotomy, or frequency of bile duct injury or leakage between the standard LC group and ENBD assisted LC group.

CONCLUSION

A bile duct anomaly was seen in 2.6% of LC cases. Placement of an ENBD tube prior to LC in predictably complicating bile duct anomalies may have successfully decreased the incidence of complications.

94 EFFECT OF OVARIAN SIZE ON THE VIABILITY OF CRYOPRESERVED SYRIAN HAMSTER OVARIES

Ovaries can be used in place of gametes as a resource for cryopreservation. Thus far, we have shown that in the Syrian hamster, pups can be successfully produced through the transplantation of fresh and cryopreserved ovaries. In this study, we attempted to simplify the ovarian cryopreservation procedures to facilitate the easy application of these techniques. In particular, the procedure would be easier and quicker if the ovaries did not have to be cut into small pieces before ovarian cryopreservation. Therefore, we examined the effects of ovarian fragment size on subsequent offspring production. Ovaries were cryopreserved by vitrification according to methods described for mouse ovaries (Migishima et al. 2003 Biol. Reprod. 68, 881–887). In brief, ovaries were collected from 3-week-old J2N-n strain (white coat) females. Because we had previously confirmed that quarter-sized ovaries could be used for cryopreservation, intact (∼3.5 × 2 mm) and half-sliced ovaries (∼2 × 1.5 mm) were cryopreserved by vitrification using DAP213 solution (2 M dimethyl sulfoxide, 1 M acetamide, and 3 M propylene glycol; Nakagata 1989 J. Reprod. Fertil. 87, 479–483). Thawed ovaries were transferred into the ovarian bursae (single intact ovary or two half-sliced ovarian pieces per ovarian bursa) of 3-week-old recipient females with agouti-coat (Slc:Syrian) under isoflurane anaesthesia. Not all of the recipients’ ovaries were removed immediately before transfer; both the donor’s and a small portion of the recipient’s ovaries were present in each ovarian bursa. Successful ovarian transplantation was verified by examining the coat colour (non-agouti colour) of offspring produced in test matings between mature recipients and J2N-n males. Of the 3 and 6 recipients that received intact and sliced ovaries, respectively, 2 and 5 recipients delivered pups. Based on the coat colour of the pups, 1 of the 5 recipients delivered a pup produced from transplanted half-sliced ovaries. Our results indicate that half-sliced-size ovaries (smaller than a 2-mm cube) can be successfully used for cryopreservation in the Syrian hamster. Specifically, it is not required to slice the ovary into smaller pieces. This work was supported by a grant from the Ministry of Health, Labour and Welfare, Japan and Grant-in-Aid for Scientific Research (C).

Bone regeneration by octacalcium phosphate collagen composites in a dog alveolar cleft model

Octacalcium phosphate (OCP) and porcine atelocollagen sponge composites (OCP/Col) markedly enhanced bone regeneration in a rat cranial defect model. To assess clinical application, the authors examined whether OCP/Col would enhance bone regeneration in an alveolar cleft model in an adult dog, which was assumed to reflect patients with alveolar cleft. Disks of OCP/Col or collagen were implanted into the defect and bone regeneration by OCP/Col or collagen was investigated 4 months after implantation. Macroscopically, the OCP/Col-treated alveolus was obviously augmented and occupied by radio-opacity, and the border between the original bone and the defect was indistinguishable. Histological analysis revealed it was filled and bridged with newly formed bone; a small quantity of the remaining implanted OCP was observed. X-ray diffraction patterns of the area of implanted OCP/Col indicated no difference from those of dog bone. In the collagen-treated alveolus, the hollowed alveolus was mainly filled with fibrous connective tissue, and a small amount of new bone was observed at the defect margin. These results suggest that bone was obviously repaired when OCP/Col was implanted into the alveolar cleft model in a dog, and OCP/Col would be a significant bone regenerative material to substitute for autogeneous bone.

Octacalcium phosphate: osteoconductivity and crystal chemistry

Octacalcium phosphate (OCP), which is structurally similar to hydroxyapatite (HA), is a possible precursor of bone apatite crystals. Although disagreement remains as to whether OCP comprises the initial mineral crystals in the early stage of bone mineralization, the results of recent biomaterial studies using synthetic OCP indicate the potential role of OCP as a bone substitute material, owing to its highly osteoconductive and biodegradable characteristics. OCP tends to convert to HA not only in an in vitro environment, but also as an implant in bone defects. Several lines of evidence from both in vivo and in vitro studies suggest that the conversion process could be involved in the stimulatory capacity of OCP for osteoblastic differentiation and osteoclast formation. However, the osteoconductivity of OCP cannot always be secured if an OCP with distinct crystal characteristics is used, because the stoichiometry and microstructure of OCP crystals greatly affect bone-regenerative properties. Osteoconductivity and stimulatory capabilities may be caused by the chemical characteristics of OCP, which allows the release or exchange of calcium and phosphate ions with the surrounding of this salt, and its tendency to grow towards specific crystal faces, which could be a variable of the synthesis condition. This paper reviews the effect of calcium phosphates on osteoblastic activity and bone regeneration, with a special emphasis on OCP, since OCP seems to be performing better than other calcium phosphates in vivo.

A double-suicide autopsy case of potassium poisoning by intravenous administration of potassium aspartate after intake of some psychopharmaceuticals

We report a curious double-suicide autopsy case of both male and female who died of potassium poisoning by intravenous administration of concentrated potassium aspartate solution. The plasma concentrations of potassium of the male and female subjects were as high as 49.7 and 62.8 mEq/L, respectively. In addition to the high concentrations of potassium, toxic levels of phenobarbital, promethazine and chlorpromazine, and relatively low levels of etizolam and brotizolam were also detected from whole blood and urine specimens of both cadavers. Twenty empty plastic bottles (10-mL capacity) labeled ‘ASPARA® Potassium Injection 10 mEq’ were found at the suicide spot. To our knowledge, this is the first description for suicidal death by potassium aspartate; in all of the previous literature, they used potassium chloride intravenously or per os.

Appositional Bone Formation by OCP-Collagen Composite

Synthetic octacalcium phosphate (OCP) has been shown to enhance bone formation and to biodegrade if implanted into bone defects. Here, we hypothesized that an OCP-atelocollagen complex (OCP/Col) is biodegradable and can induce bone formation in a thickness-dependent manner when implanted into the calvaria. OCP/Col disks (diameter, 9 mm; thickness, 1 or 3 mm) were implanted into a subperiosteal pocket in the calvaria of 12-week-old Wistar rats for 4, 8, and 12 weeks and subsequent bone formation was monitored. X-ray diffraction analysis and Fourier transform infrared spectroscopy showed that OCP in the OCP/Col implants was converted into a carbonate-rich apatite after 4 weeks. Although thinner disks tended to be replaced by new bone, thicker disks were progressively resorbed by osteoclast-like cells until 12 weeks, possibly via the increased mechanical load in the subperiosteal pocket. Therefore, OCP/Col can increase appositional intra-membranous bone formation if the appropriate size of the implant is applied.

Curative intended radiation therapy for young patients with invasive uterine cervical carcinoma: Clinical outcomes in 105 patients in a Japanese multi-institutional study

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Background: Recently, the number of young patients with invasive uterine cervical carcinoma is increasing in Japan because of earlier sexual activity and low rate of receiving screening test of uterine cervical carcinoma in Japan. However, no large studies have been performed so far to evaluate the clinical outcomes of curative intended radiation therapy for young patients with invasive uterine cervical carcinoma in Japan. Then, the current study was designed. Methods: One hundred and five patients under 40 years old were registered in the mulitiinstitutional study. The median age was 34.5 years old (range: 24–39 years old). According to FIGO, clinical stage was as follows. Stage Ib/IIa/IIb/IIIa/IIIb/IVa were 10/4/38/2/47/3, respectively. The median maximal tumor diameter was 5.5 cm (range: 2–9.2 cm). Curative intended radiation therapy was the combination of high-dose rate intracavitary brachytherapy (HDR-ICBT) combined with external beam radiation therapy (ERT). The total dose of ERT ranged from 44 Gy to 68 Gy. The total dose of HDR-ICBT to point A ranged from 12 Gy to 48 Gy. Eighty five patients received chemotherapy. Results: The 5-year overall survival rate and local control rate of all patients was 58.4 % and 59.3 %, respectively. The 5-year overall survival rates of stage Ib/IIa/IIb/IIIa/IIIb/IVa were 90.0 %/not available (NA)/73.8%/100%/37.4%/0%, respectively. The 5-year local control rates of Stage Ib/IIa/IIb/IIIa/IIIb/IVa were 80.0 %/50.0 %/73.8 %/100 %/54.6 %/NA, respectively. Sixteen patients experienced grade 3 or greater late radiation morbidity. Conclusions: Clinical outcomes of stage I-II in the young were equivalent to the Japanese standard treatment results of all ages. However, clinical outcomes of stage IIIb and IVa in the young were worse than those of all ages (5-year OS of all ages in Japan: IIIb: 50 %, IVa: 25 %).

No significant financial relationships to disclose.