Status of alternative angiogenic pathways in glioblastoma resected under and after bevacizumab treatment

Glioblastoma multiforme (GBM) acquires resistance to bevacizumab (Bev) treatment. Bev affects angiogenic factors other than vascular endothelial growth factor (VEGF), which are poorly understood. We investigated changes in angiogenic factors under and after Bev therapy, including angiopoietin-1 (ANGPT1), angiopoietin-2 (ANGPT2), placental growth factor (PLGF), fibroblast growth factor 2, and ephrin A2 (EphA2). Fifty-four GBM tissues, including 28 specimens from 14 cases as paired specimens from the same patient obtained in three settings: initial tumor resection (naïve Bev), tumors resected following Bev therapy (effective Bev), and recurrent tumors after Bev therapy (refractory Bev). Immunohistochemistry assessed their expressions in tumor vessels and its correlation with recurrent MRI patterns. PLGF expression was higher in the effective Bev group than in the naïve Bev group (p = 0.024) and remained high in the refractory Bev group. ANGPT2 and EphA2 expressions were higher in the refractory Bev group than in the naïve Bev group (p = 0.047 and 0.028, respectively). PLGF expression was higher in the refractory Bev group compared with the naïve Bev group for paired specimens (p = 0.036). PLGF was more abundant in T2 diffuse/circumscribe patterns (p = 0.046). This is the first study to evaluate angiogenic factors other than VEGF during effective and refractory Bev therapy in patient-derived specimens.

An exploratory prospective phase II study of preoperative neoadjuvant bevacizumab and temozolomide for newly diagnosed glioblastoma

PURPOSE

This multi-institutional phase I/II study was conducted to confirm the safety and explore the clinical utility of preoperative Bevacizumab (Bev) for newly diagnosed glioblastoma (GB).

METHODS

Patients were enrolled based on magnetic resonance imaging (MRI) findings typically suggestive of GB. Preoperative Bev and temozolomide (TMZ) were administered at doses of 10 mg/kg on day 0 and 150 mg/m2 on days 1-5, respectively. Surgical resection was performed between days 21 and 30, inclusive. The safety and efficacy were evaluated in a total of 15 cases by progression-free survival (PFS), changes in tumor volume, Karnofsky Performance Scale (KPS) and Mini-Mental State Examination (MMSE) scores after preoperative therapy.

RESULTS

Tumor resection was performed on a mean of day 23.7. Pathological diagnosis was GB, isocitrate dehydrogenase (IDH)-wildtype in 14 cases and GB, IDH-mutant in 1 case. Severe adverse events possibly related to preoperative Bev and TMZ were observed in 2 of the 15 patients, as wound infection and postoperative hematoma and thrombocytopenia. KPS and MMSE scores were significantly improved with preoperative therapy. Tumor volume was decreased in all but one case on T1-weighted imaging with contrast-enhancement (T1CE) and in all cases on fluid-attenuated inversion recovery, with mean volume decrease rates of 36.2% and 54.0%, respectively. Median PFS and overall survival were 9.5 months and 16.5 months, respectively.

CONCLUSION

Preoperative Bev and TMZ is safe as long as the instructions are followed. The strategy might be useful for GB in some patients, not only reducing tumor burden, but also improving patient KPS preoperatively.

TRIAL REGISTRATION NUMBER

UMIN000025579, jRCT1031180233 https://jrct.niph.go.jp/latest-detail/jRCT1031180233 . Registration Date: Jan. 16, 2017.

Targeted embolisation for coexisting conus medullaris arteriovenous malformation and cauda equina arteriovenous fistulas with a varix on a shared drainer†

BACKGROUND

The coexistence of vascular malformations in the conus medullaris and cauda equina has been rarely reported, and the complex angioarchitecture in multiple arteriovenous lesions remains poorly understood.

CASE DESCRIPTION

A 17-year-old woman presented with a sudden-onset, stepwise worsening of weakness and pain in the bilateral legs. Angiography revealed conus medullaris arteriovenous malformation and cauda equina arteriovenous fistulas. One of the drainers was shared between the coexisting lesions and harboured a varix. Targeted embolisation of a fistulous point in the conus lesion was performed with precaution to prevent occluding the common drainage route, which led to symptom improvement with angiographical diminishment of the varix.

CONCLUSIONS

Recognising that communications between drainers can be observed in multiple spinal arteriovenous lesions is important in facilitating a safe embolisation. Cautious assessment of angiogram with fusion images of cone-beam computed tomography and volumetric T2 magnetic resonance imaging can help in establishing the diagnosis and treatment strategy.

Neuroprotective effects of genome-edited human iPS cell-derived neural stem/progenitor cells on traumatic brain injury

Despite developing neurosurgical procedures, few treatment options have achieved functional recovery from traumatic brain injury (TBI). Neural stem/progenitor cells (NS/PCs) may produce a long-term effect on neurological recovery. Although induced pluripotent stem cells (iPSCs) can overcome ethical and practical issues of human embryonic or fetal-derived tissues in clinical applications, the tumorigenicity of iPSC-derived populations remains an obstacle to their safe use in regenerative medicine. We herein established a novel treatment strategy for TBI using iPSCs expressing the enzyme-prodrug gene yeast cytosine deaminase-uracil phosphoribosyl transferase (yCD-UPRT). NS/PCs derived from human iPSCs displayed stable and high transgene expression of yCD-UPRT following CRISPR/Cas9-mediated genome editing. In vivo bioluminescent imaging and histopathological analysis demonstrated that NS/PCs concentrated around the damaged cortex of the TBI mouse model. During the subacute phase, performances in both beam walking test and accelerating rotarod test were significantly improved in the treatment group transplanted with genome-edited iPSC-derived NS/PCs compared with the control group. The injury area visualized by extravasation of Evans blue was smaller in the treatment group compared with the control group, suggesting the prevention of secondary brain injury. During the chronic phase, cerebral atrophy and ventricle enlargement were significantly less evident in the treatment group. Furthermore, after 5-fluorocytosine (5-FC) administration, 5-fluorouracil converted from 5-FC selectively eliminated undifferentiated NS/PCs while preserving the adjacent neuronal structures. NS/PCs expressing yCD-UPRT can be applied for safe regenerative medicine without the concern for tumorigenesis.

A case of refractory chronic subdural hematoma and internal carotid artery stenosis sequentially treated with surgical drainage, middle meningeal artery embolization, and carotid artery stenting

Background:

Both chronic subdural hematoma (CSDH) and ischemic cerebrovascular disease are commonplace in the clinical context, and their combination is sometimes experienced. We describe a unique and challenging case in which both therapeutic interventions were indispensable and performed in a sequential manner. This report aims to discuss the management of hemorrhagic and ischemic conditions where CSDH and carotid artery stenosis coexist.

Case Description:

An 83-year-old male presented with the left cerebral infarction due to the left internal carotid artery (ICA) stenosis. The coexisting left CSDH was surgically drained first. Then, the left middle meningeal artery (MMA) was endovascularly embolized to prevent hematoma recurrence under antiplatelet therapy, before the left carotid artery stenting (CAS) was successfully conducted. The subdural hematoma gradually grew but remained asymptomatic. However, he later presented with another stroke due to the progressive right ICA stenosis that had been conservatively treated initially. Emergency right CAS was required eventually.

Conclusion:

Under the circumstances where CSDH is present but antiplatelet therapy is inevitable, MMA embolization could be a reasonable treatment option to avoid additional surgical procedures. Furthermore, early intervention should be considered even for asymptomatic carotid stenosis in terms of shortening the administration period of antiplatelet agents.

[Glioblastoma That Does Not Improve with Standard Treatment: Standard and Personalized Treatment Making The Most of Limited Modalities]

The standard treatment for glioblastoma is maximal surgical resection followed by postoperative temozolomide administration combined with radiation therapy. Although treatment outcomes have improved in recent years, glioblastoma remains a fatal malignant brain tumor. In addition to standard treatment, it is important to understand the characteristics of additional therapies or limited therapeutic modalities, such as bevacizumab, photodynamic therapy, BCNU wafers, tumor treating fields, and genomic medicine. Furthermore, combination therapy should be applied, depending on the individual patient's condition, to treat this intractable disease.

Imaging of the venous plexus of Rektorzik using CT-digital subtraction venography: a retrospective study

PURPOSE

The venous plexus of Rektorzik (VPR), first described by Rektorzik in 1858, is a venous plexus around the internal carotid artery in the carotid canal. However, the VPR has never been investigated using the recently developed imaging modalities. In this study, we analyzed the VPR using computed tomography-digital subtraction venography (CT-DSV).

METHODS

This study included 253 patients who had undergone head CT-DSV. The presence or absence of the right and left VPRs and their connecting veins were visually examined by two researchers.

RESULTS

The VPR was observed in 60 patients (24%), 39 of which showed VPR only on the right side, 10 only on the left side, and 11 on both sides. VPR was significantly more common on the right side (p = 0.0002) and was observed more frequently around the horizontal segment of the internal carotid artery than around the vertical segment. The most common veins identified as distal and proximal VPR connections were the cavernous sinus (63/71, 89%) and the anterior condylar confluence (27/71, 38%), respectively. The mean age was significantly lower in patients with the VPR than in those without (53 vs. 57 years, p = 0.02).

CONCLUSION

The VPR was significantly more frequent on the right side and in younger patients but was not a radiographically constant structure. In most cases, the VPR connected the cavernous sinus and anterior condylar confluence. Preoperative evaluation of VPR may lead to refined surgical procedures.

A Combined Assessment Method of Phase Angle and Skeletal Muscle Index to Better Predict Functional Recovery after Acute Stroke

OBJECTIVES

We aimed to investigate whether combination assessment of phase angle (PhA) and skeletal muscle index (SMI), was a possible predictor of physical function at discharge from the hospital in patients with acute stroke.

RESEARCH METHODS AND PROCEDURES

In this retrospective cohort study that was conducted from May 2020 and July 2021, we determined PhA and SMI using bioimpedance analysis (BIA) in patients with acute stroke. Patients were classified as normal, low PhA + SMI group, pre-sarcopenia (low SMI only), and dynapenia (low PhA only) using cut-off points (men: SMI < 7.0 kg/m2, PhA < 4.05 degrees; women: SMI < 5.7 kg/m2, PhA < 3.55 degrees). The main outcome was physical function based on functional independence measure motor (FIM-motor) score at discharge. Multiple regression analysis was used to determine the association between low PhA + SMI and FIM-motor score.

RESULTS

We included 244 patients (161 men; mean age, 73.9 years). low PhA + SMI was found in 21 (8.6%) patients. Multiple regression analysis showed that low PhA + SMI was independently associated with the FIM-motor score at discharge (β= -0.099, 95%CI: -0.193,-0.005, p = 0.039). The PhA cutoff values for determining good functional results using receiver operating characteristic (ROC) curves were 5.36 for men (sensitivity = 0.769, specificity = 0.586, area under the curve [AUC] = 0.682), and 3.85 for women (sensitivity = It was 0.881, specificity = 0.481, AUC). Further, pearson correlation coefficient showed that PhA was significantly related to FIM-motor score in patients with mild or moderately severe stroke (mild: r = 0.472, p < 0.001; moderate: r = 0.524, p < 0.001).

CONCLUSIONS

Combination of low PhA and SMI values at baseline, was an independent predictor of physical function at discharge in patients with acute stroke. The findings highlighted the importance of measuring PhA and SMI using BIA in patients with acute stroke.

Acute circumflex coronary artery occlusion; dilemma in diagnosis and management

Background

Acute coronary syndrome (ACS) with occlusion of the circumflex coronary artery (LCX) poses diagnostic dilemma that may lead to a delay in reperfusion.

Purpose

We sought to assess the diagnostic significance of initial electrocardiography (ECG) changes in patients with acute LCX occlusion in relation to its clinical characteristics and the management.

Methods

From consecutive 1269 patients with ACS who were admitted to our institution during a 5-year period (2015–2019), 138 patients with ACS due to LCX occlusion were analyzed for clinical, ECG and angiographic presentation, and the door-to-balloon (DTB) time. ECG changes were classified into 4 different patterns: 1) ST-elevation in inferior/lateral leads (ST-E); 2) ST-depression in V1-V4 (ST-D); 3) no significant ST changes (No-ST); and 4) others.

Results

(1) No-ST pattern was found in 47 patients (34%), ST-E in 47 patients (34%), ST-D in 25 patients (18%) and others in 19 patients (14%). (2) Occlusion site: Proximal LCX; 16 patients with No-ST (34%), 6 patients with ST-E (13%), 13 patients with ST-D (52%). Distal LCX; 28 patients with No-ST (60%), 35 patients with ST-E (74%), 11 patients with ST-D (44%) (p=0.007). (Table) (3) Echocardiographic identification of left ventricular asynergy; 31 patients with No-ST (66%), 38 patients with ST-E (81%), 22 patients with ST-D (88%). (4) No-ST group was associated with longer DTB time; 245 min (170–562 min), compared to 93 min (83–121 min) in ST-E group and 97 min (70–129 min) in ST-D group (p&lt;0.0001). DTB time ≤90 min was significantly uncommon in No-ST group (11%), compared to ST-E group (46%) and ST-D group (43%) (p=0.0004). (Figure)

Conclusion

One-third of the patients with LCX-ACS showed no ST changes, resulting in significantly longer DTB time. Improving diagnostic accuracy with anticipation for LCX-ACS and the use of echocardiographic examination and also the possible application of posterior leads (V7-V9) recording is challenging but critical to avoid delayed reperfusion and to improve outcomes in these patients without ECG changes.

Funding Acknowledgement

Type of funding sources: None.

Exploiting digital droplet PCR and Next Generation Sequencing technologies to determine the relative abundance of individual Eimeria species in a DNA sample

DNA-based diagnostic assays for detecting infections with Eimeria species have been limited to providing identification and presence/absence data for samples containing oocysts. Modern technologies that generate quantitative data, such as droplet digital PCR (ddPCR) and Next Generation Sequencing (NGS), utilize a relatively short amplicon size containing sufficient species-specific variation for reliable species level identification. Targeting the cytochrome c oxidase subunit III gene in the mitochondrial genome, we established protocols using these technologies to determine the relative abundance of the number of copies/μL of Eimeria species in a sample. Samples from chickens of known and unknown Eimeria species composition were analyzed to determine the suitability of these technologies as diagnostic assays. All technologies demonstrated robust capability of identifying and quantifying the Eimeria species in samples. The new quantitative assays described herein will produce invaluable detail of Eimeria species infections for an array of situations in commercial chicken production systems, enabling further characterization of the disease profile and allowing for the development or enhancement of new intervention strategies.

Impact of higher detection rate of residual pulmonary thromboemboli one-year after acute pulmonary embolism: modified CT scan imaging method with modified CT obstruction index

Background

Recently, post pulmonary embolism (PE) syndrome or chronic thromboembolic disease after acute PE, has been recognized as important long-term complications. Furthermore, patients may develop with chronic thromboembolic pulmonary hypertension.

Purpose

We aimed to evaluate the frequency of residual pulmonary thromboemboli after acute PE by using our “higher”-resolution CT scan imaging method to detect residual thromboemboli down to sub-segmental pulmonary arteries.

Methods

This study was a prospective multi-center observational study. We enrolled consecutive 34 patients with acute symptomatic PE whose informed consent was obtained, and followed up for one year. One year after the onset of acute PE, patients were referred to our hospital and multiple examination including CT scan, 6-minute walk test (6MWT), questionnaire of SF-36, echocardiography and laboratory testing were performed. Additionally, we have modified the CT obstruction index (CTOI) to quantitatively evaluate the thromboemboli down to sub-segmental pulmonary arteries.

Results

Mean age was 60.5±15.8 years, and 56% were male. No patient was categorized as low recurrent VTE risk which was caused by transient factors, one patient was associated with active cancer, and 12% had known thrombophilia. In 85% of the patients, this onset was the first obvious episode of PE. At diagnosis, elevated B-type natriuretic peptide (BNP) (≥100 pg/ml) or N-terminal (NT)-proBNP (≥500 pg/ml) was observed in 45% of the patients. Median tricuspid regurgitation peak gradient (TRPG) by echocardiography was 30.9 (19.3–50.1) mmHg. Among all, 35% of the patients received single-drug approach with DOACs. At discharge, all of the patients except two were treated with DOACs.

One year after the onset, 21% of the patient were in NYHA II and others were in NYHA I. It was notable that pulmonary thromboemboli was detected by our CT scan in 76% of the patients. Modified CTOI was median 11.9 (1.8–24.4) % as shown in the figure.

In multiple regression analysis, TRPG at diagnosis and BNP at one month were significantly associated with mCTOI (β=0.536, p=0.002 and β=−0.482, p=0.003, respectively). Additionally, lowest SpO2 during 6MWT after one year from the onset, tended to inversely associate with mCTOI (β=−0.341, p=0.052).

Conclusions

Using our modified CT scan imaging method and modified CTOI, residual pulmonary thromboemboli was able to be detected more frequently than the previous studies. Residual pulmonary thromboemboli could be one of the cause of the post PE syndrome and lead to exercise-induced desaturation.

Figures

Funding Acknowledgement

Type of funding source: None

Clinical course of pulmonary embolism patients treated with DOACs: comparing prognosis, recurrent thromboembolism, and major bleeding between patients with and without cancer

Background

Venous thromboembolism (VTE) is the third frequent acute cardiovascular syndrome in the Europe and Japan. Since direct oral anticoagulants (DOACs) are widely used now, the morbidity and mortality of pulmonary embolism (PE) patients especially associated with cancer needs to be re-evaluated.

Purpose

We evaluated the clinical course of patients with PE mainly treated with DOACs.

Methods

This retrospective observational study was conducted in a single center. The data were collected from the medical record of consecutive patients who received inpatient treatment of PE. In this study, we have compared PE patients with cancer (cancer PE) to those without cancer (non-cancer PE) and evaluated the mortality, recurrent of VTE and major bleedings.

Results

In total, 140 patients were enrolled: 94 patients were cancer-related, and 46 patients were without cancer (Table). The type of the tumor in cancer PE patients were as follows: gastric 8 (9%), esophageal 5 (5%), pancreatic 12 (13%), lung 14 (15%), lymphoma 2 (2%), gynecologic 17 (18%), renal 2 (2%), bile duct 8 (9%), colon 12 (13%), and others 17 (18%).

Kaplan-Meier curve showed that the cumulative all-cause mortality was significantly higher in the cancer PE group (35/94 (37%) vs. 2/46 (4%), P&lt;0.001 (log rank), HR 10.3 [95% CI:2.5–43.3]). The cumulative incidence of recurrent VTE was significantly higher in the cancer PE group (7/94 (7%) vs. 0/46, P=0.03 (log rank)). There was no significant difference in the cumulative incidence of major bleeding between the cancer PE group and the non-cancer PE group (8/94 (9%) vs. 5/46 (11%)).

Conclusions

The risk of recurrent VTE was still higher in cancer PE patients compared to non-cancer PE patients, although DOACs were used. Meanwhile the incidence of major bleeding was comparable in both groups, the risk of bleeding might be acceptable with using DOACs especially in cancer PE patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

Cerebrospinal fluid leakage due to nasoseptal flap partial necrosis: A pitfall for skull base reconstruction of endoscopic endonasal surgery

Background:

Vascularized nasoseptal flaps allow for the reconstruction of large dural defects and have remarkably reduced the incidence of postoperative complications during endoscopic endonasal skull base surgery. Nevertheless, some complications related to nasoseptal flap have been reported. Flap necrosis is a rare, but serious issue is associated with meningitis and cerebrospinal fluid (CSF) leak.

Case Description:

We performed endoscopic endonasal removal of the tuberculum sella meningioma in a 39-year-old woman with a history of Turner syndrome using abdominal fat, fascia, and a vascularized nasoseptal flap for dural and skull base defect reconstruction. After surgery, she developed CSF leak, and reoperation revealed partial necrosis of the septal flap that caused leakage. At this time, with a concern that removal of the necrotic part may lead to the insufficient size of the flap, we filled the gap tightly with fat pieces. However, the CSF leak recurred, and thus, we performed debridement of the necrotic region and reformed the multilayered reconstruction, following which she no longer experienced CSF leakage.

Conclusion:

Our case suggested that partial rather than total flap necrosis could occur, possibly due to variances of vascular anatomy, leading to focal ischemia. Debridement of the necrotic region may be an important solution for recurrent cerebrospinal leakage secondary to partial necrosis of a nasoseptal flap.

Best practices for the management of local-regional recurrent chordoma: a position paper by the Chordoma Global Consensus Group

Chordomas are rare, malignant bone tumors of the skull-base and axial skeleton. Until recently, there was no consensus among experts regarding appropriate clinical management of chordoma, resulting in inconsistent care and suboptimal outcomes for many patients. To address this shortcoming, the European Society of Medical Oncology (ESMO) and the Chordoma Foundation, the global chordoma patient advocacy group, convened a multi-disciplinary group of chordoma specialists to define by consensus evidence-based best practices for the optimal approach to chordoma. In January 2015, the first recommendations of this group were published, covering the management of primary and metastatic chordomas. Additional evidence and further discussion were needed to develop recommendations about the management of local-regional failures. Thus, ESMO and CF convened a second consensus group meeting in November 2015 to address the treatment of locally relapsed chordoma. This meeting involved over 60 specialists from Europe, the United States and Japan with expertise in treatment of patients with chordoma. The consensus achieved during that meeting is the subject of the present publication and complements the recommendations of the first position paper.

Fear of Fear and Broad Dimensions of Psychopathology over the Course of Cognitive Behavioural Therapy for Panic Disorder with Agoraphobia in Japan

OBJECTIVE

To examine the relationship of fear of fear and broad dimensions of psychopathology in panic disorder with agoraphobia over the course of cognitive behavioural therapy in Japan.

METHODS

A total of 177 Japanese patients with panic disorder with agoraphobia were treated with group cognitive behavioural therapy between 2001 and 2015. We examined associations between the change scores in Agoraphobic Cognitions Questionnaire or Body Sensations Questionnaire and the changes in subscales of Symptom Checklist-90 Revised during cognitive behavioural therapy controlling the change in panic disorder severity using multiple regression analysis.

RESULTS

Reduction in Agoraphobic Cognitions Questionnaire score was related to a decrease in all Symptom Checklist-90 Revised (SCL-90-R) subscale scores. Reduction in Body Sensations Questionnaire score was associated with a decrease in anxiety. Reduction in Panic Disorder Severity Scale score was not related to any SCL-90-R subscale changes.

CONCLUSIONS

Changes in fear of fear, especially maladaptive cognitions, may predict broad dimensions of psychopathology reductions in patients of panic disorder with agoraphobia over the course of cognitive behavioural therapy. For the sake of improving a broader range of psychiatric symptoms in patients of panic disorder with agoraphobia, more attention to maladaptive cognition changes during cognitive behavioural therapy is warranted.

Total spondylectomy following carbon ion radiotherapy to treat chordoma of the mobile spine

The main form of treatment of a chordoma of the mobile spine is total en bloc spondylectomy (TES), but the clinical results are not satisfactory. Stand-alone carbon ion radiotherapy (CIRT) for bone and soft-tissue sarcomas has recently been reported to have a high rate of local control with a low rate of local recurrence. We report two patients who underwent TES after CIRT for treating a chordoma in the lumbar spine with good medium-term outcomes. At operation, there remained histological evidence of viable tumour cells in both cases. After the combination use of TES following CIRT, neither patient showed signs of recurrence at the follow-up examination. These two cases suggest that CIRT should be combined with total spondylectomy in the treatment of chordoma of the mobile spine.

Carbon ion radiotherapy for sacral chordoma

The National Institute of Radiological Sciences in Chiba, Japan has offered carbon ion radiotherapy (CIRT) since 1994 using carbon ion beams generated by the heavy ion medical accelerator in Chiba (HIMAC). The total number of cases treated with the HIMAC exceeded 5000 in July 2009. Here, we present a retrospective analysis of CIRT for sacral chordoma. The study included 95 patients with medically unresectable sacral chordomas treated between 1996 and 2007. The median age of the patients was 66 years. Of all the patients, 84 had not been treated previously and 11 had a locally recurrent tumour following previous resection. The carbon ion dose ranged from 52.8 to 73.6 GyE (median 70.4 GyE) in a total of 16 fixed fractions over 4 weeks. The median clinical target volume was 370 cm(3). The overall survival rate at 5 years for all 95 patients was 86%, and follow-up survival time was 42 months (range, 13-112 months). The 5-year local control rate was 88% and median time to local failure was 35 months (range, 13-60 months). Of the 95 patients, 91% remained ambulatory with or without a supportive device. Two patients experienced severe skin or soft tissue complications requiring skin grafts. 15 patients experienced severe sciatic nerve complications requiring continuing medication. CIRT appears effective and safe in the management of patients with sacral chordoma and offers a promising alternative to surgery.

Differential expression of wheat genes during cold acclimation

Overwintering crops such as winter wheat display significant increase in freezing tolerance during a period of cold acclimation (CA). To gain better understanding of molecular mechanisms of CA, it is important to unravel functions and regulations of CA-associated genes. Differential screening of a cDNA library constructed from cold acclimated crown tissue of winter wheat identified three novel CA-associated cDNA clones. Nucleotide sequence analysis showed that the clones encode a high mobility globular protein (HMGB1), a glycine-rich RNA-binding protein (TaGRP2), and a LEA D-11 dehydrin (DHN14). Accumulation of the three mRNAs during 14 days of CA was differentially regulated. In response to drought, and ABA, DHN14 mRNA rapidly accumulated while HMGB1 and TaGRP2 mRNA levels remained unchanged. The possible functions of each of these genes in cold acclimation are discussed.

Insulin resistance and impaired myocardial fatty acid metabolism in dialysis patients with normal coronary arteries

We investigated whether insulin resistance is associated with impaired cardiac fatty acid metabolism in maintenance hemodialysis patients without coronary artery disease. We studied 55 nondiabetic (63+/-11 years old) and 51 diabetic (61+/-10 years old) hemodialysis patients with normal coronary arteries, using single-photon emission computed tomography (SPECT) with an iodinated fatty acid analogue, iodine-123-beta-methyl iodophenyl-pentadecanoic acid ((123)I-BMIPP), to evaluate cardiac fatty acid metabolism. SPECT imaging was graded regionally from 0 (normal) to 4 (absence of tracer) to calculate a summed score for 17 left ventricular segments. Insulin resistance was determined using the homeostasis model assessment index of insulin resistance (HOMA-IR). HOMA-IR correlated with summed BMIPP score in nondiabetic and diabetic patients. Stepwise multiple regression analysis showed that HOMA-IR was independently associated with BMIPP summed score in nondiabetic (beta=0.774, t=9.218, P=0.0001) and diabetic patients (beta=0.792, t=9.079, P=0.0001). Left ventricular ejection fraction was lower in nondiabetic subjects with BMIPP summed score of at least 6 plus HOMA-IR of at least 4 than in others with lower values for both assessments (53.1+/-13.8%, n=20 vs 67.7+/-9.1%, n=23, P=0.0002); this was also true in diabetic subjects (50.9+/-15.2%, n=24 vs 71.0+/-13.6%, n=11, P=0.0007). Association between insulin resistance and impaired cardiac fatty acid metabolism may contribute to left ventricular dysfunction in patients with maintenance hemodialysis without coronary diseases.

Delimitation of the fertility restorer locus Rfk1 to a 43-kb contig in Kosena radish (Raphanus sativus L.)

We are pursuing a positional cloning strategy to isolate the fertility restoration gene Rfk1 from radish. Random polymorphic DNA-sequence-tagged site (RAPD-STS) markers tightly linked to the gene in radish were isolated, and a RAPD map surrounding the Rfk1 locus was constructed. We surveyed 948 F2 plants with adjacent RAPD-STS markers to isolate recombinants for bulk segregant analysis. This analysis was effective in isolating tightly linked amplification fragment length polymorphism (AFLP) markers surrounding the gene of interest. Ten tightly linked AFLP markers were obtained and used to construct a high-resolution map of the region. The closest AFLP-STS markers flanking Rfk1 were 0.1 cM and 0.2 cM away. Using the four adjacent AFLP markers, we screened lambda and cosmid libraries. The lambda and cosmid clones were aligned by examination of end sequences and restriction fragment length polymorphism (RFLP) patterns for each clone, and by hybridization to the DNA isolated from recombinants. Finally, we constructed a 198-kb contig encompassing the Rfk1 gene and comprising 20 lambda and two cosmid clones. By analysis of the breakpoints in recombinants with the rfk1/rfk1 or Rfk1/- genotype, the Rfk1 locus could be assigned to a 43-kb region comprising four lambda clones and one cosmid clone. This pinpoint localization in the radish genome has made it possible for us to identify the gene by sequence analysis and genetic transformation of cytoplasmic male-sterile Brassica napus plants.

Therapeutic effects of milnacipran, a serotonin and noradrenaline reuptake inhibitor, on post-stroke depression

Depression is common after stroke. While several reports have been published on the use of antidepressants such as selective serotonin reuptake inhibitors and tricyclics for the treatment of post-stroke depression (PSD), no previous study has examined the use of a selective serotonin and noradrenaline reuptake inhibitor (SNRI) for this condition. The present study investigated the efficacy and safety of milnacipran, a SNRI, for the treatment of PSD. A 6-week open study was conducted in 12 patients (two males and 10 females) aged 53-88 years. All patients were diagnosed with major or minor depressive disorder according to DSM-IV, where onset was subsequent to a cerebral infarction or haemorrhage (stroke). Severity of depression was assessed using the 21-item Hamilton rating scale for depression (HAM-D). The maximum total daily dose of milnacipran was in the range of 30-75 mg b.i.d. Three patients experienced side-effects, but none of the side-effects were serious. Two patients dropped out of the study. At the end of the study, 58.3% (7/12) of the total patient population and 70% (7/10) of the patients completing the study were in remission (a final HAM-D score of less than 7 and no longer meeting criteria for major or minor depression). These results suggest that milnacipran may be an effective treatment for PSD.

Analysis of recurrence of squamous cell carcinoma of the uterine cervix after definitive radiation therapy alone: patterns of recurrence, latent periods, and prognosis

PURPOSE

A retrospective analysis was performed with emphasis on the patterns of recurrence, latent period, and prognosis in patients with cervical squamous cell carcinoma of the uterus treated with definitive radiation therapy alone. Late recurrence, which was observed more than 5 years after the initial radiation therapy, was finally focused on and discussed.

MATERIALS AND METHODS

Between 1976 and 1994, 256 patients with squamous cell carcinoma of the uterine cervix without hematogenous metastasis were treated with definitive radiation therapy alone. The patients were staged as follows according to the FIGO classification: 26 in Stage I, 56 in Stage II, 124 in Stage III, 28 in Stage IVa, and 22 in Stage IVb. All the patients were treated with external beam irradiation and low-dose-rate intracavitary brachytherapy.

RESULTS

A total of 74 patients had recurrence. The recurrence appeared in 67 cases (90.5%) within 5 years. Metastasis to para-aortic and/or supraclavicular nodes developed later than other types of recurrence. Among patients with lymphogenous metastasis, there were more 5-year survivors after recurrence than with other types of recurrence. Patients with early recurrence, within 2 years of the initial therapy, had a worse prognosis than those with recurrence more than 2 years after treatment. Seven patients (2.7%) in all developed late recurrence more than 5 years after the treatment. The first site of recurrence was an abdominal para-aortic or supraclavicular node in all patients, excluding one patient who developed intrapelvic lymph node metastasis. Six patients had pelvic node metastasis detected with lymphangiography at the initial treatment. Median survival after late recurrence was 16.0 months. Two of 7 patients survived more than 3 years after secondary radiation therapy, and the remainder died of recurrent disease.

CONCLUSION

Patients with para-aortic and/or supraclavicular node metastasis that developed late after the initial treatment are more likely to survive due to secondary radiation therapy. Careful follow-up is emphasized for long-term survivors.

Amino acid sequence and characterization of a rice bran ribonuclease

A base-nonspecific and acid ribonuclease (RNase Os) belonging to the RNase T2 family was purified from rice bran to a homogeneous state by SDS-PAGE. The primary structure of RNase Os was determined by protein chemistry and molecular cloning. The RNase Os was a simple protein and consisted of 205 amino acid residues. Its molecular weight was 22578 and its amino acid sequence showed that it was most similar to barley RNase among the known RNase T2 family enzymes having 157 amino acid residues identical with barley RNase. However, its N-terminus was blocked by a gamma-pyroglutamyl residue. The optimal pH of RNase Os was around 5.5. The base preference at the B1 and B2 site of RNase Os was estimated from the rates of hydrolysis of 16 dinucleoside phosphates, to be guanine as the case of RNase LE from tomato. RNase Os was successfully expressed from yeast cells using the E. coli yeast expression vector pYE-RNAP.

Multiple mechanisms regulate expression of low temperature responsive (LOT) genes in Saccharomyces cerevisiae

Using cDNA subtraction screening, we identified five Saccharomyces cerevisiae genes whose expressions is up-regulated when culture temperature was down-shifted from 30 to 10 degrees C. Among these LOT (low temperature-responsive) genes, three (LOT1, LOT2, and LOT3) were identical to FBA1, RPL2B, and NOP1, encoding a fructose biphosphate aldolase, a ribosomal protein L2B, and a nucleolar protein for rRNA processing, respectively. No functions were assigned for LOT5 and LOT6, which are identical to YKL183w and YLR011w, respectively. Northern hybridization analysis revealed that these genes are not uniformly regulated in response to the change of growth temperature. In addition, all the LOT genes, except for LOT1/FBA1, were induced by a low concentration of cycloheximide. The data indicate that multiple mechanisms, including translational functionality may be involved in the regulation of LOT gene expression in yeast.

Bombelli's valgus-extension osteotomy for osteoarthritis due to acetabular dysplasia: results at 10 to 14 years

Severe osteoarthritis due to acetabular dysplasia (n = 17) was treated with valgus-extension osteotomy, and the patients' clinical outcomes 10-14 years after operation were evaluated according to clinical factors (Japanese Orthopaedic Association hip score; JOA score) and by roentgenography. The mean JOA score 10 years or later had improved by 22 points compared with the preoperative score. On roentgenography, joints which had preoperative roof osteophyte had better postoperative formation of roof osteophyte. The JOA score was higher in the 12 joints which had osteophyte 5 mm or longer than in those joints with osteophyte that was 5 mm or shorter. Postoperative joint space widening occurred in 15 joints (88.2%) 3-6 months postoperatively, and it reached the maximum at 3-5 years. In patients who had a large bone cyst in the femoral head preoperatively, the cyst collapsed, and deformation of femoral head occurred after operation, but remodeling of the joint surface occurred naturally and the congruity improved. In the 6 joints in which the preoperative acetabular head index was less than 60% and the acetabular angle was larger than 30 degrees, the JOA score at 10 years or later was lower than that of the other joints. Based on these findings, valgus-extension osteotomy was evaluated as a useful surgical method for advanced or terminal osteoarthritis in young or middle-aged patients. Predictive factors for long-term prognosis would be the preoperative length of roof osteophyte, joint space widening, and the degree of femoral head covering.

Acute canine model for drug-induced Torsades de Pointes in drug safety evaluation-influences of anesthesia and validation with quinidine and astemizole

An acute in vivo model for drug-induced torsades de pointes (TdP) for use in safety evaluation of drugs was developed using dogs with acute complete atrioventricular (AV) block. In order to study the effects of anesthetic agents on the inducibility of TdP, arrhythmias were induced by programmed electrical stimulation (PES) before and after cumulative intravenous administration of quinidine under anesthesia with sodium pentobarbital, halothane, or isoflurane. Both prolongation of the QTc and the incidence of TdP were greatest in dogs anesthetized with halothane and were smallest in those given pentobarbital, suggesting that halothane is the most suitable anesthetic for this TdP model. To further validate this model, astemizole was administered intravenously to other dogs under halothane anesthesia. Astemizole at 0.3 mg/kg caused slight prolongation of the QT interval but did not induce any arrhythmias. At 1 mg/kg, however, TdP were induced in 5 of 10 animals and in an additional 2 animals at 3 mg/kg. Single and multiple ectopic beats preceded the induction of TdP, and the ectopic beats were observed in a dose-dependent manner. The plasma concentrations of quinidine in dogs with TdP were equivalent to or less than quinidine levels in humans with TdP, while those of astemizole were higher in dogs. In conclusion, this acute canine model of TdP with halothane anesthesia, complete AV block, PES, and simultaneous measurements of plasma drug concentration would be valuable for assessing the risk of drugs, especially I(Kr) blockers, to induce TdP in humans.

Small cell lung cancer with a brain metastasis controlled for 5 years: a case report

We report a case of small cell lung cancer whose initial presentation was a solitary brain metastasis. On chest radiography the primary tumor was unclear and only detected by bronchofiberscopy. A small single pulmonary metastasis was noted in the right lower lobe. Subtotal resection and external irradiation were applied to the brain tumor and external irradiation was applied to the lung. Concurrently one course of systemic chemotherapy was administered. The tumors in the brain and lung had disappeared by the end of the treatment. The patient has been alive and well for 5 years without recurrence.

Plasma soluble interleukin-2 receptor levels during and after upper abdominal surgery

Soluble interleukin-2 (IL-2) receptor (sIL-2R) is reported to be up-regulated in inflammatory disorders. Although sIL-2R may modulate perioperative inflammatory responses, it remains unclear whether upper abdominal surgery affects plasma sIL-2R levels. We evaluated the influence of major abdominal surgery on plasma sIL-2R levels. Ten patients scheduled for upper abdominal surgery received anaesthesia with isoflurane, nitrous oxide, and epidural block. Plasma sIL-2R and IL-6 levels were determined at pre-anaesthesia, 0, 2, and 4 hours during surgery, and on postoperative days 1 (POD1) and 3 (POD3). The plasma levels of sIL-2R decreased significantly and achieved their minimum value at 4 hours (677.0 +/- 125.3 pg/ml, P < 0.01 compared to pre-anaesthesia value; 924.5 +/- 178.8 pg/ml, 95% confidence interval = 122.2-550.4). The plasma sIL-2R levels increased on POD1 (1336.5 +/- 174.0 pg/ml) and POD3 (1629.0 +/- 262.8 pg/ml), and reached a level significantly higher than the baseline (P < 0.05 and P < 0.001, 95% confidence interval = 93.4-730.6 and 402.8-1006.2, respectively). The plasma sIL-2R levels on POD3 significantly correlated with the peak IL-6 levels (r = 0.67, P < 0.05). The plasma sIL-2R levels on POD3 correlated with the amount of intraoperative bleeding (r = 0.66, P < 0.05). In conclusion, we found that major abdominal surgery induces characteristic changes in plasma soluble IL-2 receptor levels.

Expression of plant group 2 and group 3 lea genes in Saccharomyces cerevisiae revealed functional divergence among LEA proteins

To study functions of late embryogenesis abundant (LEA) proteins, which accumulate in plant cells under water deficit conditions, in vivo functional analyses were carried out using a yeast (Saccharomyces cerevisiae) heterologous expression system. Two lea genes, tomato le4 (group 2) and barley HVA1 (group 3), were expressed under the GAL1 promoter, and the gene products were detected using specific antisera. The growth of the transformants was scored and compared with a control strain to analyze the effect of these proteins on yeast cells under stress conditions. The yeast cells expressing HVA1 showed shorter lag period when transferred to a medium containing 1.2 M NaCl as compared to a control strain, while the cells expressing le4 did not show improved growth. Attenuated growth inhibition in a medium containing 1.2 M KCl was observed in the yeast cells expressing le4 and HVA1. No obvious growth improvement was observed in a high sorbitol medium in the cells expressing either le4 or HVA1. Increased freezing tolerance was observed in both lea-expressing cells, while no effect on heat tolerance was observed. These results support the hypothesis that different LEA proteins play a distinctive role in the protection against cellular dehydration.

The coupling of differential display and AFLP approaches for nonradioactive mRNA fingerprinting

We have modified the differential display of 3'-end restriction fragments of cDNA technique by combining it with the amplified fragment length polymorphism (AFLP) approach and silver staining. Modified oligo-dT primers were used for a reverse transcription step. ds cDNA was digested with the Mse I restriction enzyme and then ligated with an AFLP adapter. The modified template was amplified with oligo-dT primers in a preamplification step (asymmetric PCR) that enriched the template for 3'-end sequences; subsequently, the enriched template was amplified with an AFLP primer having a selective extension and an anchored oligo-dT primer (conventional PCR step). We demonstrated that the asymmetric preamplification step facilitates the preferential amplification of 3'-end fragments and the resulting PCR products can be clear resolved on silver-stained gel. The presented procedure takes advantages of silver-stained gels, generates reproducible display patterns, and allows reliable reamplification of isolated fragments which contain both upstream and downstream primer sequences.

Regulation of gibberellin biosynthesis genes during flower and early fruit development of tomato

Gibberellins (GAs) are essential for the development of fertile flowers in tomato, and may also be required immediately after fertilization. In the GA-biosynthetic pathway, the reactions catalyzed by GA 20-oxidases have been implicated as site of regulation. To study the regulation of GA biosynthesis in flower and early fruit development, we isolated three tomato GA 20-oxidase cDNA clones, Le20ox-1, -2 and -3. The three genes showed different organ-specific patterns of mRNA accumulation. Analysis of the transcript levels of the three GA 20-oxidase genes, as well as those of copalyl diphosphate synthase (LeCPS) and GA 3 beta-hydroxylase (Le3OH-2) during flower bud and early fruit development, revealed temporally distinct patterns of mRNA accumulation. Up until anthesis, transcripts were observed for LeCPS, Le20ox-1, -2 and Le3OH-2, with an accumulation of Le20ox-1 mRNA. In contrast to the high level of Le3OH-2 transcripts in the fully open flower, mRNA levels of Le20ox-1, -2 and LeCPS were reduced at this stage. After anthesis, LeCPS and Le20ox-1 transcripts increased again. In addition, Le20ox-3transcripts increased whereas the transcripts of Le3OH-2 decreased to an undetectable level. In situ hybridization results demonstrated that during early stages of bud development, Le20ox-2 transcripts were localized in the tapetum and placenta. The presented results supply novel data about localization of GA biosynthesis gene transcripts, and indicate that transcript levels of GA biosynthesis genes are all highly regulated during flower bud development.

[Intraoperative transient incomplete left bundle branch block in a patient with left axis deviation in pre-anesthetic electrocardiogram]

We encountered a case of transient incomplete left bundle branch block (TILBBB) during standard mastectomy under general anesthesia. The patient was a 40 year-old female (70 kg, 164 cm) without any abnormalities on preanesthetic examinations except -61 degrees left axis deviation in exercise electrocardiogram. Adriamycin 20 mg was administered preoperatively. After the skin incision, heart rate increased from 104 min-1 to 130 min-1 and the cardiac axis gradually rotated leftward with increasing Q wave depth on leads I and aVL. We diagnosed this as blockade of the anterior branch in the left bundle branch. After the administration of fentanyl (0.2 mg) and sevoflurane (3%), the heart rate decreased to 105 min-1 and the electrocardiogram returned to the initial wave form. This anesthetic course indicated that adriamycin had slightly damaged the cardiac muscle and inadequate anesthesia had caused tachycardia and transient left bundle branch block. Left axis deviation on preoperative exercise electrocardiogram suggests that the left bundle branch can easily be blocked with an increasing heart rate. Adequate depth of anesthesia would have prevented the increase in heart rate and abnormality in the cardiac conduction process.

[A procedure for electroretinogram (ERG) recording in mice--effect of monoiodoacetic acid on the ERG in pigmented mice]

A procedure for recording the electroretinogram (ERG) in pigmented mice, C57BL, based on the ERG recording technique reported previously in albino mice, ICR, and giving careful consideration to the influence of anesthetics and dark-adaptation, was developed in order to examine retinal toxicity. Pigmented mice were given a single i.v. injection of monoiodoacetic acid (IAA), a known retinotoxic compound, via a tail vein at a dose of 30, 45 or 60 mg/kg, and the ERG was recorded periodically over the next 14 days. In addition, the retinas were examined histopathologically on day 15. The results were as follows. 1. The oscillatory potentials were not distinct in the ERGs from mice anesthetized with pentobarbital as compared to the ERGs from non-anesthetized mice. ERG waveforms obtained from mice anesthetized with a mixture of urethane, xylazine and ketamine or xylazine and ketamine were almost the same as those obtained from non-anesthetized mice. Therefore, the ERGs were recorded under mixed anesthesia, ketamine and xylazine, in the following study. Stable ERGs could be recorded after 40 min of dark-adaptation. 2. IAA at doses of 30 and 45 mg/kg caused slight depression of the amplitudes of the a-, b- and c-waves; however, these changes were no longer observed 7 days after dosing. At a dose of 60 mg/kg, the ERG waves were markedly depressed 1 day after dosing, and recovery was not observed until day 14. 3. Upon histopathologic examination of the retinas, a remarkable decrease in visual cells and thinning of the rod and cone layers and outer plexiform layer were observed with IAA at a dose of 60 mg/kg. 4. Using this newly developed recording technique, it was confirmed that stable ERGs could be recorded from pigmented mice repeatedly for 14 days, and the effects of IAA on the ERG could be detected. Histopathological abnormalities in the retinas correlated well with the changes in the ERGs. These results indicate that the newly developed ERG recording procedure is useful for evaluating retinal toxicity in pigmented mice.

[Liver metastases from breast cancer 14 years after radical mastectomy; successful treatment with hepatic arterial infusion chemotherapy and systemic endocrine therapy--a case report]

The patient was a 73-year-old woman who was admitted to our hospital for epigastric discomfort and body weight loss. She had undergone radical right mastectomy in March 1982. Ultrasonography and computed tomography revealed multiple tumors in the liver. Three of the tumor markers (CA-125, CA 19-9, and CA 15-3) were positive. US-guided fine needle aspiration biopsy of the liver tumor showed small atypical cells with solid cell nests. Immunohistochemical tests revealed estrogen receptor was positive. We diagnosed the patient as recurrent breast cancer metastatic to liver, 14 years postoperatively. The liver tumors were successfully controlled with the combination of intra-arterial infusion chemotherapy (5-fluorouracil, epirubicin, and mitomycin C) along with systemic endocrine therapy (medroxyprogesterone acetate and fadrozole hydrochloride hydrate).

Ent-kaurene synthase from the fungus Phaeosphaeria sp. L487. cDNA isolation, characterization, and bacterial expression of a bifunctional diterpene cyclase in fungal gibberellin biosynthesis

ent-Kaurene is the first cyclic diterpene intermediate of gibberellin biosynthesis in both plants and fungi. In plants, ent-kaurene is synthesized from geranylgeranyl diphosphate via copalyl diphosphate in a two-step cyclization catalyzed by copalyl diphosphate synthase and ent-kaurene synthase. A cell-free system of the fungus Phaeosphaeria sp. L487 converted labeled geranylgeranyl diphosphate to ent-kaurene. A cDNA fragment, which possibly encodes copalyl diphosphate synthase, was isolated by reverse transcription-polymerase chain reaction using degenerate primers based on the consensus motifs of plant enzymes. Translation of a full-length cDNA sequence isolated from the fungal cDNA library revealed an open reading frame for a 106-kDa polypeptide. The deduced amino acid sequence shared 24 and 21% identity with maize copalyl diphosphate synthase and pumpkin ent-kaurene synthase, respectively. A fusion protein produced by expression of the cDNA in Escherichia coli catalyzed the two-step cyclization of geranylgeranyl diphosphate to ent-kaurene. Amo-1618 completely inhibited the copalyl diphosphate synthase activity of the enzyme at 10(-6) M, whereas it did not inhibit the ent-kaurene synthase activity even at 10(-4) M. These results indicate that the fungus has a bifunctional diterpene cyclase that can convert geranylgeranyl diphosphate into ent-kaurene. They may be separate catalytic sites for the two cyclization reactions.