A case of a large solitary fibrous tumor arising from the retroperitoneum resected completely using an intra-aortic balloon

Solitary fibrous tumors (SFTs) are rare mesenchymal cell-derived tumors that can cause substantial bleeding during surgery due to hyper-vascularization. We report a case of a large retroperitoneal SFT resected completely using an intra-aortic balloon. A 71-year-old female with a history of type 2 diabetes mellitus presented with a tumor that was diagnosed as an insulin-like growth factor-II-producing benign SFT using computed tomography-guided biopsy. The tumor had grown from 6 to 20 cm in diameter within 4 years, with concurrent and severe hypoglycemia. Preoperative computed tomography findings showed substantial blood flow toward the tumor. The retroperitoneal tumor was observed to be widely attached. Substantial hemorrhaging during tumor resection was observed despite vascular embolism. We inflated the intra-aortic balloon for 45 min and resected the tumor completely. In conclusion, large SFT resection requires preoperative tumor blood flow evaluation and preparation of both a vascular embolism and an intra-aortic balloon.

Scoliosis, diabetes mellitus and total laminectomy at the 4th lumbar vertebra are independent risk factors for post-laminectomy fracture around the isthmus

OBJECTIVE

We aimed to identify the risk factors and clinical outcomes for post-laminectomy fracture around the isthmus, which can cause back pain or radiculopathy.

METHODS

We performed a retrospective cohort study involving all patients who underwent laminectomy splitting the spinous process for lumbar spinal stenosis between 2010 and 2014. The primary outcome measure was post-laminectomy fracture around the isthmus. Clinical outcomes were evaluated based on reoperation rate. To evaluate risk factors for fracture, the following parameters were collected: (1) patient characteristics and concomitant diabetes mellitus, (2) lumbar scoliosis and sagittal alignment parameters, and (3) surgical data, such as rate of total laminectomy. Logistic regression analysis was performed to identify the independent risk factors for post-laminectomy fracture.

RESULTS

Twelve of the 92 patients suffered a post-laminectomy fracture around the isthmus. Logistic regression analysis revealed that diabetes mellitus (odds ratio [OR]: 15.41; 95% confidence interval [CI]: 2.93-80.98; P=0.001), L4 total laminectomy (OR: 14.68; 95% CI: 1.51-142.76; P=0.021), and lumbar scoliosis (OR: 5.72; 95% CI: 1.16-28.21; P=0.032) were independent risk factors. The fracture group included 2 patients (16.7%) who required reoperation at the decompression level for recurrent leg pain, whereas the non-fracture group included 2 (2.5%) who underwent reoperation at a level different from the index procedure.

CONCLUSIONS

Post-laminectomy fractures around the isthmus were significantly associated with scoliosis, diabetes mellitus, and total laminectomy at L4. Total laminectomy at L4 is best avoided to reduce the risk of post-laminectomy fracture in patients with scoliosis or diabetes mellitus.

Impact of sitagliptin on endometrial mesenchymal stem-like progenitor cells: A randomised, double-blind placebo-controlled feasibility trial

BACKGROUND

Recurrent pregnancy loss (RPL) is associated with the loss of endometrial mesenchymal stem-like progenitor cells (eMSC). DPP4 inhibitors may increase homing and engraftment of bone marrow-derived cells to sites of tissue injury. Here, we evaluated the effect of the DPP4 inhibitor sitagliptin on eMSC in women with RPL, determined the impact on endometrial decidualization, and assessed the feasibility of a full-scale clinical trial.

METHODS

A double-blind, randomised, placebo-controlled feasibility trial on women aged 18 to 42 years with a history of 3 or more miscarriages, regular menstrual cycles, and no contraindications to sitagliptin. Thirty-eight subjects were randomised to either 100 mg sitagliptin daily for 3 consecutive cycles or identical placebo capsules. Computer generated, permuted block randomisation was used to allocate treatment packs. Colony forming unit (CFU) assays were used to quantify eMSC in midluteal endometrial biopsies. The primary outcome measure was CFU counts. Secondary outcome measures were endometrial thickness, study acceptability, and first pregnancy outcome within 12 months following the study. Tissue samples were subjected to explorative investigations.

FINDINGS

CFU counts following sitagliptin were higher compared to placebo only when adjusted for baseline CFU counts and age (RR: 1.52, 95% CI: 1.32-1.75, P<0.01). The change in CFU count was 1.68 in the sitagliptin group and 1.08 in the placebo group. Trial recruitment, acceptability, and drug compliance were high. There were no serious adverse events. Explorative investigations showed that sitagliptin inhibits the expression of DIO2, a marker gene of senescent decidual cells.

INTERPRETATION

Sitagliptin increases eMSCs and decreases decidual senescence. A large-scale clinical trial evaluating the impact of preconception sitagliptin treatment on pregnancy outcome in RPL is feasible and warranted.

FUNDING

Tommy's Baby Charity.

CLINICAL TRIAL REGISTRATION

EU Clinical Trials Register no. 2016-001120-54.

Clearance of senescent decidual cells by uterine natural killer cells in cycling human endometrium

In cycling human endometrium, menstruation is followed by rapid estrogen-dependent growth. Upon ovulation, progesterone and rising cellular cAMP levels activate the transcription factor Forkhead box O1 (FOXO1) in endometrial stromal cells (EnSCs), leading to cell cycle exit and differentiation into decidual cells that control embryo implantation. Here we show that FOXO1 also causes acute senescence of a subpopulation of decidualizing EnSCs in an IL-8 dependent manner. Selective depletion or enrichment of this subpopulation revealed that decidual senescence drives the transient inflammatory response associated with endometrial receptivity. Further, senescent cells prevent differentiation of endometrial mesenchymal stem cells in decidualizing cultures. As the cycle progresses, IL-15 activated uterine natural killer (uNK) cells selectively target and clear senescent decidual cells through granule exocytosis. Our findings reveal that acute decidual senescence governs endometrial rejuvenation and remodeling at embryo implantation, and suggest a critical role for uNK cells in maintaining homeostasis in cycling endometrium.

Cardiovascular and adenylate cyclase stimulant properties of NKH477, a novel water-soluble forskolin derivative

The cardiovascular effects of NKH477 (6-(3-dimethylaminopropionyl)forskolin hydrochloride), a novel water-soluble forskolin derivative, were investigated in dogs. Intravenous (i.v.) injections of NKH477 (1-30 micrograms/kg) caused dose-related increases in left ventricular dP/dtmax (LVdP/dtmax), coronary and femoral artery blood flow (CBF, FBF), heart rate (HR), and myocardial oxygen consumption (MVO2) and a dose-related decrease in blood pressure (BP) in anesthetized dogs. The regression analysis between CBF and MVO2 showed that NKH477 did not influence substantially the balance of oxygen supply and demand. Infusions of NKH477 (0.15-0.6 microgram/kg/min i.v.) also increased LVdP/dtmax, cardiac output (CO), and HR and decreased BP, pulmonary arterial diastolic pressure, and total peripheral resistance (TPR) in a dose-dependent manner. In contrast to forskolin, NKH477 administered intraduodenally (0.05-0.2 mg/kg) and orally (0.15 and 0.3 mg/kg) clearly exhibited cardiovascular actions, as it did in i.v. administration, indicating that NKH477 is orally active. No arrhythmias were induced by NKH477 in any study. NKH477, like forskolin, showed adenylate cyclase stimulant activity in guinea pig ventricular membrane but did not inhibit Na+, K(+)-ATPase or phosphodiesterase (PDE) activity. Thus, NKH477 can be characterized as a potent, orally active, water-soluble forskolin derivative, which suggests that NKH477 is a useful inodilator for treatment of heart failure, especially in the severe stage with beta-adrenoceptor downregulation.

Mechanisms of inhibitory action of phenylephrine in guinea-pig taenia coli

The effect of phenylephrine, an alpha-agonist, on the Ca movements and the influence of removal of external Na+ on the relaxant activity of phenylephrine were examined in the taenia coli of guinea pigs. Phenylephrine (10(-7)-10(-5)M) caused dose-dependent relaxation of the taenia coli contracted by 20 mM KCl in Locke-Ringer solution. Phenylephrine (10(-5) M) suppressed the spike discharges of the taenia coli evoked by 20 mM KCl without affecting the membrane potential, and this was accompanied by the muscle relaxation. Phenylephrine also inhibited the cellular 45Ca-uptake in the taenia coli, but had no discernible effect on the 45Ca-efflux from the smooth muscle. These effects of phenylephrine were not observed in a Na-free solution or in the highly depolarized smooth muscle. These findings suggest that the inhibition of Ca-influx in the taenia coli may be involved in the phenylephrine-induced relaxation in the partly depolarized tissue. Reasons for reduction of phenylephrine action encountered under the Na-free condition were also discussed.