Endoscopic submucosal dissection for proximal duodenal subepithelial lesions: a retrospective cohort study

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) has been used to remove subepithelial lesions (SELs) in recent years; however, duodenal ESD is associated with high rates of immediate or delayed bleeding and perforation. Whether ESD can be recommended for the treatment of duodenal SELs remains controversial. Therefore, we evaluated the efficacy and safety of ESD for duodenal SELs.

METHODS

We conducted a retrospective cohort study in 62 patients (62 lesions) who underwent ESD for duodenal SELs between January 2012 and December 2020. The therapeutic outcomes from ESD for duodenal SELs and procedure-related complications were analyzed.

RESULTS

En bloc resection and complete resection rates associated with duodenal ESD were 90.3% and 100%, respectively; four patients had a positive microscopic margin on pathologic examination. The median procedure time was 45 min (range 20-106 min). During the procedure, two patients received emergency surgery for uncontrolled bleeding and perforation, respectively. After the procedure, delayed bleeding occurred in three patients (4.8%), which was successfully managed by clipping, and delayed perforation occurred in two patients (3.2%) and needed emergency surgery. Risk factors related to complications were analyzed. Lesion size was found to be significantly associated with the complications (P = 0.028). No recurrences were detected, and no distant metastasis was observed in any patient during a median follow-up period of 45.5 months (range, 6-103 months).

CONCLUSION

Duodenal ESD is relatively safe and feasible for duodenal SELs, especially for lesions no more than 2 cm in size.

Changhai advanced endoscopy courses for ERCP (CHANCE) training program: A short-term training model in China

BACKGROUND

There is huge shortage of ERCP practitioners (ERCPists) in China, and ERCP training is urgently needed. ChangHai Advanced eNdoscopy Courses for ERCP (CHANCE) is a 4-month program for ERCP training since 2004. This study evaluated the efficiency of this short-term training model, and reported on the ERCP careers of the trainees following completion of the CHANCE program.

METHODS

This study was a retrospective investigation included all the CHANCE trainees from Jan 2004 to Dec 2014. Questionnaires were sent to all trainees. The career competence percentage, ERCP careers and predictive factors of career competence were investigated and analyzed.

RESULTS

A total of 413 trainees participated in the CHANCE program over 11 years covered by the survey and 258 questionnaires were valid for the study. The mean (SD) age of the trainees was 35.36 (4.17), and the male to female ratio was 4.4:1. The average follow-up time was 7.77 (3.44) years. A total of 173 (67.1%) trainees had achieved career competence. In terms of ERCP careers, the mean annual ERCP volume was 120.60 (96.67), with a complication percentage of 8.2%. Hospital qualification, compliance with follow-up learning guidance, participating academic activity, and practitioner type were identified predictive factors of career competence.

CONCLUSIONS

As a short-term training program, the CHANCE achieved an acceptable career competence percentage, providing endoscopists more chances to learn ERCP and giving them appropriate training guidance for career competence. This training mode is worth promoting in developing countries with shortage of ERCPists.

[Study on epidemic trend of hemorrhagic fever with renal syndrome in Zhejiang province, 2005-2020]

Objective: To analyze the epidemiological characteristics and spatiotemporal distribution of hemorrhagic fever with renal syndrome (HFRS) in Zhejiang province from 2005 to 2020, and provide scientific information for the precise prevention and control of HFRS. Methods: Data on HFRS cases in Zhejiang province during 2005-2020 were collected from the China National Notifiable Infectious Disease Reporting Information System (NNDS) for a descriptive analysis, and software ArcGIS 10.2 was used for global autocorrelation and local autocorrelation analyses. Spatiotemporal clusters were scanned with SaTScan 9.4.4 and visualized with ArcGIS 10.2. Results: A total of 7 724 HFRS cases were reported in Zhejiang province from 2005 to 2020, including 25 deaths. There were two incidence peaks each year, in late spring and early summer (May-June) and in winter (November-January). The top three areas with high cumulative cases were Ningbo (1 875, 24.27%), Taizhou (1 642, 21.25%), and Shaoxing (1 123, 14.54%). Among the reported cases, with a male to female ratio of 2.73∶1(5 656∶2 068). The majority of HFRS cases were middle-aged and elderly people, with cases aged 41-70 years accounting for 60.95%. Most HFRS cases were farmers, accounting for 69.89% (5 398/7 724). The spatial distribution of HFRS in most years was correlated. SaTScan was used for retrospective spatiotemporal scanning and three clusters were detected: the first type clusters were in 21 counties in eastern Zhejiang province and central Zhejiang province, among which 4 were in Ningbo, Shaoxing and Jinhua, 8 were in Taizhou, and 1 was in Lishui (RR=13.69, LLR=5 522.60, P<0.001); the second type clusters were in Longquan and Qingyuan counties (RR=31.20, LLR=1 232.46, P<0.001); the third types of clusters were in Changxing and Anji counties of Huzhou in northern Zhejiang province (RR=3.42, LLR=23.93, P<0.001). Conclusions: HFRS mainly occurred in middle-aged,elderly and male farmers in Zhejiang province. The incidence was high in late spring, early summer and winter in eastern Zhejiang province. Precise prevention and control measures are needed for populations at high risk before the epidemic season.

Endoscopic submucosal dissection versus esophagectomy for early esophageal squamous cell carcinoma with tumor invasion to different depths

Endoscopic submucosal dissection (ESD) is a minimally invasive alternative to esophagectomy for early esophageal squamous cell carcinoma (EESCC). The aim of this study was to compare the efficacy and safety of ESD and esophagectomy in EESCC with different depth of invasion. The data of EESCC patients who received ESD or esophagectomy between Jan 2011 to Dec 2018 at our center were retrospectively analyzed. Overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and procedure-related variables were compared between ESD and esophagectomy patients. 222 EESCC patients underwent ESD, while 184 underwent esophagectomy. No significant differences were found between the two groups in OS (P=0.417), DSS (P=0.423), and RFS (P=0.726). Procedure duration, post-procedure hospital stay, and hospitalization cost were all lower in ESD patients. Oncologic outcomes were similar between the two groups in propensity score-matched analysis. The R0 resection rate was comparable between ESD and esophagectomy groups in the T1a-M1/M2 and M3/SM1 EESCC subgroups; no significant differences were found in OS, DSS and RFS. In the SM2/SM3 EESCC subgroup, although the prognosis of the two treatment groups was similar, the R0 resection rate was significantly lower in ESD patients than in esophagectomy patients. Thus, we concluded ESD could be a first-line treatment for T1a-M1/M2 and M3/SM1 EESCC as oncologic outcome is comparable to that achieved with esophagectomy with minimal invasion, lower cost and lower incidence of serious adverse events. However, in SM2/SM3 EESCC patients, esophagectomy may be preferable.

Fibromodulin is upregulated by oxidative stress through the MAPK/AP-1 pathway to promote pancreatic stellate cell activation

BACKGROUND/OBJECTIVES

Fibromodulin (FMOD) expression in chronic pancreatitis (CP) tissues and its effect on PSC was unknown. Our aim was to investigate the role of FMOD in regulating PSC profibrogenic phenotype and the molecular mechanism of CP.

METHODS

Rat CP models were induced by dibutyltin dichloride. Pancreatic fibrosis was evaluated by Sirius Red staining. The expression of FMOD and α-SMA was measured, the correlation between FMOD expression and fibrosis was investigated in CP models and CP patients. The effects of FMOD on PSCs were examined by CCK-8 and migration assays. We investigated the mechanisms underlying FMOD expression using MND and a MAPK pathway inhibitor. Luciferase reporter and chromatin immunoprecipitation assays were used to investigate the effects of AP-1 on FMOD expression.

RESULTS

Sirius Red staining revealed high collagen deposition in model rats. Higher expression of FMOD and α-SMA was observed in fibrotic tissues, and the expression of FMOD was correlated with that of α-SMA and the areas of Sirius Red staining. Upregulation of FMOD increased the expression of collagen I and α-SMA and the proliferation and migration of PSCs. MND induced FMOD and α-SMA expression, and knockdown of FMOD abated α-SMA expression. ERK and JNK inhibitors attenuated FMOD expression as induced by MND. AP-1 upregulated the expression of FMOD. AP-1 binds to the FMOD promoter and transcriptionally regulates FMOD expression.

CONCLUSION

FMOD levels are upregulated in fibrosis tissues in CP and it is a critical downstream mediator of oxidative stress. FMOD induces PSC activation and maintains the fibrosis phenotype of PSCs.

Endoscopic retrograde cholangiopancreatography in Billroth II gastrectomy patients: Outcomes and potential factors affecting technical failure

BACKGROUND/AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) in Billroth II gastrectomy patients is technically demanding and factors affecting its technical difficulty have not yet been clarified. This study aimed to investigate the outcomes of ERCP in Billroth II gastrectomy patients and identify potential factors affecting its technical failure.

PATIENTS AND METHODS

A large retrospective study of 308 consecutive patients (391 procedures) with Billroth II gastrectomy-who underwent ERCP from January 2002 to December 2016-was conducted. The outcomes of ERCP and potential factors affecting its technical failure were analyzed.

RESULTS

The success rate of duodenal ampullary access, selective duct cannulation and the accomplishment of expected procedures was 81.3% (318/391), 86.5% (275/318) and 97.3% (256/263), respectively, and the technical success rate was 70.3% (275/391). The overall ERCP-related complication rate was 15.3% (60/391). The multivariate analysis indicated that first-time ERCP attempt [odds ratio (OR) 4.29, 95% confidence interval (CI) 2.34-7.85, P < 0.001], Braun anastomosis (OR 3.65, 95% CI 1.38-9.64, P < 0.009), and no cap-assisted gastroscope (OR 3.05, 95% CI 1.69-5.51, P < 0.001) were significantly associated with technical failure.

CONCLUSIONS

ERCP is safe, effective and feasible for Billroth II gastrectomy patients. Previous ERCP history, absence of Braun anastomosis and the use of a cap-assisted gastroscope are the predictive factors for its technical success.

Predictive factors for extraction of common bile duct stones during endoscopic retrograde cholangiopancreatography in Billroth II anatomy patients

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) for extraction of common bile duct (CBD) stones in Billroth II anatomy patients is still a technical challenge and factors affecting stone extraction have not yet been clarified. This study aimed to analyze our experience and evaluate potential factors affecting CBD stone extraction.

METHODS

A retrospective analysis of CBD stones patients with a history of Billroth II gastrectomy, who underwent therapeutic ERCP for stone extraction at our center from August 1999 to December 2017, was conducted. The outcomes of ERCP and potential factors affecting stone extraction were examined.

RESULTS

A total of 227 patients were enrolled, and 176 patients (77.5%) achieved technical success. The success rate of duodenal ampullary access and selective biliary cannulation was 84.1% (191/227) and 92.1% (176/191), respectively. The mean CBD diameter was 15 mm (range 6-35 mm), and the largest stone size was 13 mm (range 4-36 mm). CBD stones were ultimately removed in 137 patients (77.8%), and 105 patients (59.7%) for the first session. Mechanical lithotripsy was used in 17 patients (9.7%). The overall ERCP-related complication rate was 6.3% (11/176), including bleeding in 3 patients (1.7%) and mild pancreatitis in 6 patients (3.4%). The multivariate analysis indicated that CBD stone number ≥ 2 (OR 2.171; 95% CI 1.095-4.306; p = 0.027), and the largest CBD stone size ≥ 12 mm (OR 3.646; 95% CI 1.833-7.251; p < 0.001) were patient-related risk factors for failed stone removal; while the use of endoscopic papillary (large) balloon dilation (EPBD/EPLBD) (OR 0.291; 95% CI 0.147-0.576; p < 0.001) was a procedure-related protective factor for successful stone extraction.

CONCLUSIONS

ERCP is safe and effective for extraction of CBD stones in Billroth II anatomy patients. The number and the largest size of CBD stones, and the use of EPBD/EPLBD are predictive factors for CBD stone extraction.

Endoscopic submucosal dissection for gastric gastrointestinal stromal tumors: a retrospective cohort study

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) has been used to remove submucosal tumors. However, with regard to the potential malignant behavior of gastrointestinal stromal tumors (GISTs), whether ESD can be recommended for treatment is still controversial. Therefore, we evaluated the efficacy and safety of ESD for removal of GISTs in the muscularis propria (MP) layer and to assess the possible risk factors for a gastric-wall defect (GWD).

METHODS

For 168 GISTs located in the MP layer from 168 consecutive patients, the baseline information, complications, and therapeutic outcomes were recorded. Subsequently, risk factors for a GWD were analyzed.

RESULTS

Most GISTs (106/168) were located in the fundus of the stomach. Tumor shapes in 154 patients (91.7%) were regular, and the median size of the tumor was 1.5 (range 0.5-6.0) cm. The en bloc resection rate was 100% and the median procedure time was 46.5 (33-181) min. A GWD was observed in 71 patients (42.3%) and delayed bleeding occurred in 2 patients (1.2%), and they were treated by clips. A total of 117 patients with a GIST were at very low risk, 37 patients were at low risk, and 14 patients were at mild risk. No local recurrences or distant metastases were observed during a median follow-up of 25 (6-67) months. Univariate and multivariate logistic regression analyses identified the tumor type to be an independent risk factor for a GWD during ESD (odds ratio 29.82, 95% confidence interval 10.87-81.80, P < 0.001).

CONCLUSION

ESD is a safe and feasible method for gastric GISTs, especially for tumor types A and B. Endoscopic ultrasound can aid evaluation of the tumor type before ESD, which is an independent risk factor correlated with a GWD upon ESD.

Outbreak of Occupational Brucellosis at a Pharmaceutical Factory in Southeast China

Brucellosis is an occupational disease affecting workers in butcher shops, the milking and dairy product industry, causing more than 500 000 new cases around the world. As a national statutory B infectious disease in China, morbidity of brucellosis is rapidly increasing in recent years. We report an occupational outbreak of brucellosis infection in a pharmaceutical factory. Exposure was a result of manual operation in the process line, close contact with sheep placentas, insufficient disinfection and repeated using of protective suits and infected by aerosol dissemination. Improved preventive methods, appropriate public health measures and spread of health education would be helpful to prevent the occupational outbreak of brucellosis in future.

[Anterior retropharyngeal debridement combined with posterior atlantoaxial fusion for atlantoaxial Tuberculosis]

OBJECTIVE

To evaluate the clinical efficacy of anterior debridement combined with posterior atlantoaxial fusion for atlantoaxial Tuberculosis.

METHODS

From February 2005 to February 2013, 7 patients, 3 males and 4 females, with atlantoaxial Tuberculosis underwent anterior debridement combined with posterior atlantoaxial fusion in Department of Orthopedics Zhengzhou University People's Hospital were selected.In the preoperative and final follow-up, Japanese Orthopaedic Association score (JOA), neck disability index (NDI) and Frankel Classification were used to evaluate neurological function and calculate improvement rate.At final follow-up, clinical efficacy was evaluated by Odom's grade.Situation of internal fixation, fusion of upper cervical were assessed by X-ray, CT scan and MRI scan.

RESULTS

Bony fusion were achieved in 7 cases after operation in 12 months. Tuberculosis were reached clinical cure between 17 and 21 months. At follow The JOA score increased from (11.1±0.7) preoperatively to (15.3±0.5) in final follow-up(P<0.05), and the NDI decreased from (34.0±4.6) preoperatively to (10.1±1.3) in final follow-up (P<0.05). At last follow-up, according to Odom's standard, excellent were obtained in 5 cases, good 1 cases and ordinary 1 case. Frankel Classification of all cases improved from D class to E.

CONCLUSIONS

The treatment of anterior retropharyngeal debridement combine with atlantoaxial fusion, and local anti-tuberculosis drug using intraoperative, not only could obtain reliable clinical efficacy, completly removal of lesions, but also obtain strong stability, which plays an important role in the treatment of atlantoaxial Tuberculosis.

Genetic variation in WDR1 is associated with gout risk and gout-related metabolic indices in the Han Chinese population

Gout is the most common form of inflammatory arthritis affecting men, and current evidence suggests that genetic factors contribute to its progression. As a previous study identified that WD40 repeat protein 1 (WDR1) is associated with gout in populations of European descent, we sought to investigate its relationship with this disease in the Han Chinese population. We genotyped six WDR1 single nucleotide polymorphisms in 143 gout cases and 310 controls using Sequenom MassARRAY technology. The SPSS 16.0 software was used to perform statistical analyses. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by unconditional logistic regression, with adjustments for age and gender. In an analysis using an allelic model, we identified that the minor alleles of rs3756230 (OR = 0.64, 95%CI = 0.450-0.911, P = 0.013) and rs12498927 (OR = 1.377, 95%CI = 1.037-1.831, P = 0.027) were associated with gout risk. In addition, we found that the "A/A" genotype of rs12498927 was associated with increased risk of gout under codominant (OR = 2.22, 95%CI = 1.12- 4.40, P = 0.042) and recessive models (OR = 2.24, 95%CI = 1.20-4.17, P = 0.012). We also determined the "A/G" genotype of rs12498927 to be significantly associated with higher urea levels in gout patients (P = 0.017). Our data shed new light on the association between genetic variations in the WDR1 gene and gout susceptibility in the Han Chinese population.

Genetic polymorphisms in very important pharmacogenomic (VIP) variants in the Tibetan population

Genetic polymorphisms of very important pharmacogenomic (VIP) variants are important for personalized medicine. However, these have not been extensively studied in the Tibetan population. In this study, 82 VIP variants were detected in the Tibetan and Han (HAN) populations from northwestern China. Subsequently, we compared the differences between the Tibetan population and ten populations, including the HAN, Japanese in Tokyo (JPT), Mexican ancestry in Los Angeles (MEX), Toscans in Italy (TSI), African ancestry in Southwest USA (ASW), Luhya in California Webuye, Kenya (LWK), Gujarati Indians in Houston, Texas (GIH), Maasai in Kinyawa, Kenya (MKK), Yoruba in Ibadan, Nigeria (YRI), and Utah residents with Northern and Western European ancestry from the CEPH collection (CEU). Using the χ(2) test, we identified differences in the frequency distribution of 4, 4, 7, 10, 11, 11, 13, 15, 19, and 20 loci in the Tibetan population, compared to the HAN, JPT, MEX, TSI, ASW, LWK, GIH, MKK, YRI, and CEU populations, respectively [P < 0.05/(82*10)]. rs2115819, rs9934438, and rs689466, located in the ALOX5 (arachidonate 5-lipoxygenase), VKORC1 (vitamin K epoxide reductase complex, subunit 1) and PTGS2 (prostaglandin-endoperoxide synthase 2) genes, respectively, in the Tibetan population were different from those in most of the populations. Our results complement the information provided by the database of pharmacogenomics on Tibetan people, and provide an avenue for personalized treatment in the Tibetan population.

A pediatric case of severe fever with thrombocytopenia syndrome in Zhejiang Province, China

This report describes a pediatric case of severe fever with thrombocytopenia syndrome (SFTS), which is an emerging disease that is caused by a novel bunyavirus. Interestingly, the previously reported SFTS cases typically involved elderly patients, while our case involved a 5-year-old child from Zhejiang Province, China. In this report, we describe our investigation of the clinical and epidemiological characteristics of this case, to improve our understanding of this emerging disease. Our principle finding was that the present case's clinical symptoms were milder than those that have been reported in adult cases of SFTS. Therefore, we recommend more careful screening of pediatric patients who present with mild symptoms that are consistent with SFTS.

Clinical characteristics and treatments for upper gastrointestinal submucosal tumors located in different sites

AIM: To investigate the clinical characteristics and treatment methods for upper gastrointestinal submucosal tumors located in different sites.

METHODS: One hundred and fifty-nine patients with upper gastrointestinal tract submucosal tumors were included. Endoscopic submucosal dissection (ESD) was performed, and the resected lesions were subjected to pathological examination. Gender and age composition ratio, maximum diameter of lesions, operation time and the rate of complications were compared among tumors located in different sites. All patients underwent gastroscopy two and six months after operation.

RESULTS: There were 28 lesions in the esophagus, 12 in the cardia, 44 in the gastric fundus, 48 in the gastric body (including 2 cases of residual stomach), 22 in the gastric sinus, and 5 in the duodenum. Complete resection was performed in 155 (155/159, 97.5%) cases, and 154 cases were resected as a whole piece (154/159, 96.9%). In the esophagus, 16 cases were resected by submucosal tunneling endoscopic resection; in the gastric fundus, 16 cases were resected by endoscopic filtering resection. There was no significant difference in operation time between submucosal tunneling endoscopic resection and ordinary ESD for tumors in the esophagus. There was also no significant difference in operation time between endoscopic filtering resection and ordinary ESD for tumors in the gastric fundus. The pathologic diagnoses mainly included leiomyoma, stromal tumors and ectopic pancreas. The major complications were perforation, intraoperative bleeding and postoperative delayed bleeding. A total of 19 cases developed perforation and underwent endoscopic filtering resection to close the wound successfully. Intraoperative bleeding was managed successfully with electric coagulation forceps and titanium clip in all patients. The two cases with postoperative delayed bleeding were managed successfully by emergency endoscopic titanium clipping. All patients underwent gastroscopy after two and six months, which revealed that the wound healed well, and no recurrence occurred.

CONCLUSION: Upper gastrointestinal submucosal tumors located in different sites show different clinical and pathological features, and different ESD operation methods should be selected.

A long-term follow-up study on endoscopic management of children and adolescents with chronic pancreatitis

OBJECTIVES

Data on therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for chronic pancreatitis (CP) in children and adolescents, especially with long-term follow-up of consequences, are rarely reported. The aim of this study was to determine the long-term follow-up results of therapeutic ERCP for CP in children and adolescents.

METHODS

All patients with CP who received therapeutic ERCP at Changhai Hospital from January 1997 to May 2009, with the age at first onset of pain being less than 18.0 years, were included. Attempts were made to contact all adolescents and follow-up data were recorded. Clinical data were assessed before and after every ERCP.

RESULTS

Follow-up information was available in 42 (91.3%) of the 46 patients who received therapeutic ERCP. There were 20 boys and 22 girls, with the age at first onset being 11.8+/-4.5 years. A total of 110 therapeutic ERCP sessions were performed in the 42 patients. The post-ERCP complication rate was 17.3%, including mild and moderate pancreatitis (n=17) and mild cholangitis (n=2). The mean follow-up period of time was 61.4 (range: 24-132) months. Five patients underwent subsequent surgery because of refractory abdominal pain after endotherapy. Of the remaining 37 patients who received therapeutic ERCP alone, abdominal pain improved in 30 (81.1%) patients, and was completely relieved in 24 (64.9%) patients during the period of follow-up.

CONCLUSIONS

Therapeutic ERCP may offer long-term improvement in pain in children and adolescents with CP.

Chronic pancreatitis in Chinese children: etiology, clinical presentation and imaging diagnosis

BACKGROUND AND AIMS

There is a paucity of literature regarding the clinical profile of chronic pancreatitis (CP) in children. The aims of this retrospective study were to determine the etiology and clinical presentation, and to present our experience in diagnosing CP in children in China.

METHODS

Clinical data of children who were treated for CP at Changhai Hospital from January 1997 to August 2006 were reviewed.

RESULTS

A total of 427 CP patients presented to our center. There were 42 (9.8%) children with CP, including 21 males and 21 females, with a mean age of 11.7 years at the first onset. The main etiological factor was idiopathic (73.8%). Of the patients, 78.5% had episodes of mild to moderate abdominal pain and 54.8% had multiple (> or = 4) episodes. The mean duration of symptoms prior to the diagnosis was 41.6 months and a definite diagnosis was not made until 2 years later in 57.1% of these patients. The positive rates of ultrasound (US), computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) (or magnetic resonance imaging [MRI]) for detecting ductal changes and intraductal stones or pancreatic calcification were 51.4% and 45.4%, 71.4% and 87.5%, 80.0% and 61.5%, respectively.

CONCLUSION

The main etiological factor of Chinese children with CP is idiopathic. The main symptom in these patients is multiple episodes of mild to moderate abdominal pain, which often lead to a delay in the definite diagnosis. CT and MRCP (or MRI) should be used as the first investigation in the evaluation of these cases.

Structural identification of bitespiramycin metabolites in rat: a single oral dose study

Bitespiramycin is a macrolide antibiotic consisting of a mixture of some nine spiramycin ester derivatives. It has a similar spectrum of antibiotic activity to that of spiramycin but has superior pharmacokinetic properties. In this study, a rapid and facile LC/ESI-MSn method was applied to study the metabolism of bitespiramycin in rat following a single oral dose (80 mg kg-1). Concentrations of parent drug constituents and metabolites were determined in plasma, urine, feces and bile. Concentrations of parent drug constituents and metabolites in plasma were very low. In urine, feces and bile, parent drug constituents and 38 metabolites were identified on the basis of their chromatographic and mass spectrometric properties. The identity of 17 metabolites was confirmed by comparison with reference substances. The principal metabolites were the corresponding spiramycins formed by hydrolysis of the 4''-(3-methylbutanoate) groups. Other important metabolic pathways were: hydrolytic loss of the forosamine and mycarose sugars; aldehyde reduction; cysteine conjugation of the aldehyde group; and hydrolysis of the lactone ring. Products formed by lactone ring opening were found only in urine, and those formed by aldehyde reduction were found only in feces. Aldehyde reduction and hydrolytic loss of forosamine represent novel biotransformation pathways for spiramycin derivatives.

Chemokine gene expression in pancreatic tissue and effects of oxymatrine in early acute necrotizing pancreatitis

AIM: To investigate the expression of cytokine-induced neutrophil chemoattractant (CINC) and monocyte chemoattractant protein-1/JE (MCP-1/JE) genes in the pancreas, and to assess the influence of Chinese herb extraction oxymatrine (Oxy) on the expression of CINC and MCP-1/JE genes and the therapeutic effects in early acute necrotizing pancreatitis (ANP).

METHODS: ANP was induced by retrograde infusion of 50 g/L sodium taurocholate into the biliary pancreatic duct of rats. Fifty-six rats were randomly divided into three groups: sham operation (SO) group, ANP 3 h, 6 h, 12 h groups, and Oxy 3 h, 6 h, 12 h groups. The activity of serum amylase (Amy), the serum levels of glutamic-pyruvic transaminase (ALT) and creatinine (Cr) were determined. Pathological changes of the pancreas were observed. The expression of CINC and MCP-1/JE genes in the pancreas was assayed.

RESULTS: Compared with that in SO group, the expression of CINC and MCP-1/JE genes in the pancreas in ANP groups were all increased greatly (0.61 ± 0.08, 0.76 ± 0.10, 0.89 ± 0.12, 0.42 ± 0.06, 0.65 ± 0.08, 0.94 ± 0.12, P < 0.01). Following the induction of ANP, the expression of CINC and MCP-1/JE genes was both up-regulated, which was significantly correlated with the pathological changes of the pancreas (r = 0.89 and 0.82, respectively, P < 0.05). Oxy attenuated the increase of CINC and MCP-1/JE gene expression (0.34 ± 0.05, 0.45 ± 0.06, 0.51 ± 0.06 vs 0.31 ± 0.04, 0.34 ± 0.04, 0.36 ± 0.05, in ANP 3 h, 6 h, 12 h groups and Oxy 3 h, 6 h, 12 h groups, respectively P < 0.01). Serum Amy, ALT and Cr levels were reduced, (Amy: 25.391.93 mkat, 37.66 ± 4.27 μkat, 96.00 ± 9.19 μkat; ALT: 94.5 ± 58.3 nkat/L, 283.8 ± 115.5 nkat/L, 469.7 ± 157.3 nkat/L; Cr: 81.4 ± 17.7 μmol/L, 89.1 ± 18.7 μmol/L, 110.7 ± 12.8 μmol/L, P < 0.05 or P < 0.01), and the pathological changes of pancreas were ameliorated by Oxy.

CONCLUSION: CINC and MCP-1/JE might play important roles in early ANP. The expression of CINC and MCP-1/JE gene in the pancreas can be inhibited by Oxy. Oxy therapy was effective in experimental ANP.

p38 mitogen-activated protein kinase signal transduction pathway in pathogenesis of severe acute pancreatitis in rats

AIM: To study the dynamic changes of p38 mitogen-activated protein kinase (p38 MAPK) phosphorylation and to assess the effect of p38 MAPK phosphorylation inhibitor in severe acute pancreatitis (SAP) in rats.

METHODS: The SAP model was induced by bili-pancreatic duct retrograde infusion with 5% sterile sodium taurocholate solution. Eighty Sprague-Dawley (SD) rats were randomly divided into sham-operation (SO) group (n = 30), SAP-NS group (n = 25) and SAP-CNI1493 group (n = 25). In the SAP-CNI1493 group, SD rats were administered with 10 mg/kg inhibitor CNI-1493 (i. v.) 30 min before induction of SAP. In SAP-NS group, rats received same volume isotonic saline (i. v.) as CNI-1493. Pancreatic tissues and serum samples were collected before and 15 min, 0.5 h, 1 h, 3 h, 6 h after operation. Western blot analysis was performed to determine the phosphorylations of p38 MAPK in the pancreas homogenates. Serum levels of interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) were measured by ELISA; Pathological changes of pancreas were examined and scored with light microscopy.

RESULTS: In the SO group, basal p38 MAPK phosphorylation was detected. In the SAP-NS group, the p38 MAPK phosphorylation in the pancreas homogenates reached the maximum at 15 min, remained at a similar level at 30, 60 and 180 min, and declined to the same level as that in SO group at 6 h. In the SAP-NS group and SAP-CNI1493 group, the densities of the band detected by Western blot were 5 200±360, 3 500±250 at 15 min, and 4 910±320, 2 500340 at 30 min (P <0.01). In SAP-CNI1493 group, the serum levels of IL-1β and TNF-α were decreased significantly as compared with those in SAP-NS group (P <0.01). The severity of tissue damage in the SAP-CNI1493 group at 3 h were significantly attenuated in comparison with that of the SAP-NS group (P<0.01).

CONCLUSION: The p38 MAPK plays an important role in the pathogenesis of SAP. Inhibition of p38 MAPK phosphorylation may be a potential approach for prevention and treatment of SAP.

Diagnostic and therapeutic value of ERCP in children with pancreatitis

AIM

To explore the diagnostic and therapeutic value of endoscopic retrograde cholangiopancreatography (ERCP) in children with pancreatitis.

METHODS

27 children with pancreatitis treated with ERCP from Feb 1997 to Feb 2002 were analyzed retrospectively.They included 9 boys and 18 girls ranging in age from 4 to 17 years (14.8±2.9). Fourteen patients suffered from acute pancreatitis (AP) and thirteen from chronic pancreatitis (CP).

RESULTS

Diagnostic ERCP was done in 9 patients and theraputic ERCP in 18. The ERCP findings were as follows: The morbidity of biliary tract disease was 7.7% in CP group, while it was 95.7% in AP group (P <0.05). 61.5% of CP group had no definite etiology, higher than the 7.1% in the AP group.ERCP showed that 76.9% had pancreatic duct dilatation in CP group, much higher than the 14.2% in AP group. The incidence of common bile duct stricture or/and dilatation, choledocholith were 49.7%, 35.7% respectively in AP group, while none in CP group. In the following 6 to 68 months after ERCP, 92.6% had no recurrent pancreatitis or abdominal pain. After a second ERCP intervention in 2 patients with recurrent abdominal pain, none had abdominal pain any more. The overall ERCP related morbidity was 51.85%, including hyperamylasemia in 6 cases (22.2%), pancreatitis in 6 (22.2%), and hemorrhage from papillosphincterotomy in 2 (7.4%).

CONCLUSION

Diagnostic and therapeutic ERCP had significant clinical improvement in children with pancreatitis, but had a much higher complication rate in children than in adults, mostly associated with therapeutic procedures. Therefore, more precautions should be given to pediatric patients in doing ERCP to decrease the adverse events.

Use of arsenic trioxide (As2O3) in the treatment of acute promyelocytic leukemia (APL): I. As2O3 exerts dose-dependent dual effects on APL cells

Recent clinical studies in China showed that As2O3 is an effective and relatively safe drug in the treatment of acute promyelocytic leukemia (APL). We found previously that As2O3 can trigger apoptosis of APL cell line NB4 cells, which is associated with downregulation of bcl-2 gene expression and modulation of PML-RAR alpha chimeric protein. To further understand the mechanisms of this alternative therapy for APL, we investigated in this report the effects of a wide range of concentrations of As2O2 on cultured primary APL cells, all-trans retinoic acid (ATRA)-susceptible (NB4 cells) and ATRA-resistant (MR2 subclone) APL cell lines. The results indicated that As2O3 had dose-dependent dual effects on APL cells: inducing preferentially apoptosis at relatively high concentrations (0.5 to 2 micromol/L) and inducing partial differentiation at low concentrations (0.1 to 0.5 micromol/L). The rapid modulation and degradation of PML-RAR alpha proteins, which was induced by As2O3 at 0.1 to 2 micromol/L, could contribute to these two effects. Bone marrow and peripheral blood examination showed that myelocyte-like cells, probably as a result of partial in vivo differentiation, and degenerative cells increased after 2 to 3 weeks of continuous in vivo As2O3 treatment when leukemic promyelocytes decreased. In conclusion, combination of induction of apoptosis and partial differention could be the main cellular mechanisms of As2O3 in the treatment of APL, and PML-RAR alpha could play an important role in determining the specific effects of As2O3 on APL cells.

In vitro studies on cellular and molecular mechanisms of arsenic trioxide (As2O3) in the treatment of acute promyelocytic leukemia: As2O3 induces NB4 cell apoptosis with downregulation of Bcl-2 expression and modulation of PML-RAR alpha/PML proteins

It has been shown recently in China that arsenic trioxide (As2O3) is a very effective treatment for acute promyelocytic leukemia (APL). APL patients resistant to all-trans retinoic acid (ATRA) and conventional chemotherapy can still respond to AS2O3. In this study, we addressed the possible cellular and molecular mechanisms of this treatment by using NB4 cells as a model. The results show that: (1) As2O3 triggers relatively specific NB4 cell apoptosis at micromolar concentration, as proved by morphology, histogramic related nuclear DNA contents, and DNA gel eletrophoresis. (2) As2O3 does not influence bax, bcl-x, c-myc, and p53 gene expression, but downregulates bcl-2 gene expression at both mRNA and protein levels. (3) As2O3 induces a significant modulation of the PML staining pattern in NB4 cells and HL-60 cells. The micropunctates characteristic of PML-RAR alpha in NB4 cells dissappear after treatment with As2O3, whereas a diffuse PML staining occurs in the perinuclear cytoplasmic region. In addition, a low percentage of untreated NB4 cells exhibits an accumulation of PML positive particles in a compartment of cytoplasm. The percentage of these cells can be significantly increased after As2O3 treatment. A similar PML staining pattern is observed in apoptotic cells. (4) ATRA pretreatment does not influence As2O3-induced apoptosis. These results suggest that induction of cell apoptosis can be one of the mechanisms of the therapeutic effect of As2O3. Moreover, this apoptosis induction occurs independently of the retinoid pathway and may be mediated, at least partly, through the modulation of bcl-2, as well as PML-RAR alpha and/ or PML proteins.

Effect of retinoic acid isomers on proliferation, differentiation and PML relocalization in the APL cell line NB4

Retinoic acids exert a wide physiological role in development and differentiation. Retinoic acids have also been used in the treatment of human cancers, particularly in acute promyelocytic leukemia (APL). A structure-function relationship of the RA isomers in terms of clinical effect has been observed since all-trans retinoic acid (ATRA) induces a high complete remission rate while 13-cis retinoic acid (13-cis RA) shows much poorer effect. In this study, we examined the effect of RA isomers, including ATRA, 13-cis RA and 9-cis RA, on the proliferation and differentiation of NB4 cells. A number of parameters such as cell growth curve, dynamics of cell cycle, expression of clusters of differentiation and reduction of nitro blue tetrazolium (NBT) as well as immunofluorescence staining of PML were used to evaluate the effects of three isomers at two concentrations (10(-8) M and 10(-7) M). It has been shown that during the first 48 h of RA treatment, the APL cell differentiation was coupled with the cell proliferation. Although similar effects of proliferation inhibition and differentiation induction were observed among the three isomers at 10(-7) M, significant differences appeared at a concentration of 10(-8) M, 9-cis RA showed a higher activity than that of ATRA, while ATRA showed better results than 13-cis RA. Our results provide further evidence that 9-cis RA could be a promising molecule in differentiation induction of malignant cells.

Deferoxamine inhibition of Cr(V)-mediated radical generation and deoxyguanine hydroxylation: ESR and HPLC evidence

Electron spin resonance (ESR) and high-performance liquid chromatography (HPLC) techniques were utilized to investigate the effect of deferoxamine on free radical generation in the reaction of Cr(V) with H2O2 and organic hydroperoxides. ESR measurements demonstrated that deferoxamine can efficiently reduce the concentration of the Cr(V) intermediate as formed in the reduction of Cr(VI) by NAD(P)H or a flavoenzyme glutathione reductase/NADH. ESR spin trapping studies showed that deferoxamine also inhibits Cr(V)-mediated .OH radical generation from H2O2, as well as Cr(V)-mediated alkyl and alkoxy radical formation from t-butyl hydroperoxide and cumene hydroperoxide. HPLC measurements showed that .OH radicals generated by the Cr(VI)/flavoenzyme/NAD(P)H enzymatic system react with 2'-deoxyguanine to form 8-hydroxy-2'-deoxyguanine (8-OHdG), a DNA damage marker. Deferoxamine effectly inhibited the formation of 8-OHdG also.

Effect of hypovolemia on forearm vascular resistance control during exercise in the heat

To determine the influence of hypovolemia on the control of forearm vascular resistance (FVR) during dynamic exercise, we studied five physically active men during 60 min of supine cycle ergometer exercise bouts at 35 degrees C in control (normovolemic) and hypovolemic conditions. Hypovolemia was achieved by 3 days of diuretic administration and resulted in an average decrease in plasma volume of 15.9%. Relative to normovolemia, hypovolemia caused an attenuation of the progressive rise in forearm blood flow (P less than 0.05) and an increase in heart rate (P less than 0.05) during exercise. Because mean arterial blood pressure during hypovolemic exercise was well maintained, the attenuation of forearm blood flow was due entirely to a relative increase in FVR. At the onset of dynamic exercise, FVR was increased significantly in control and hypovolemic conditions by 13.2 and 27.1 units, respectively. The increase in FVR was significantly different between control and hypovolemic conditions as well. We attributed the increased vasoconstrictor bias during hypovolemia to cardiopulmonary baroreceptor unloading and/or an increased sensitivity to cardiopulmonary baroreceptor unloading. We concluded that reduced blood flow to the periphery during exercise in the hypovolemic condition was caused entirely by an increase in vascular resistance, thereby preserving arterial blood pressure and adequate perfusion to the organs requiring increased flow.

On the hydroxyl radical formation in the reaction between hydrogen peroxide and biologically generated chromium(V) species

Electron spin resonance (ESR) measurements on solutions and isolated powders provide direct evidence for the involvement of Cr(V) species in the reduction of Cr(VI) by NAD(P)H. ESR analysis of an isolated Cr(V)-NAD(P)H solid yields g parallel = 1.9831 and g perpendicular = 1.9772, indicating that the unpaired electron occupies the dz2 orbital of the Cr(V) ion, with square-pyramidal geometry. Addition of hydrogen peroxide (H2O2) to the NAD(P)H-Cr(VI) reaction mixtures suppresses the Cr(V) species and generates hydroxyl (.OH) radicals. The .OH radicals were detected via ESR spin trapping, employing 5,5-dimethyl-1-pyrroline-N-oxide and alpha-(4-pyridyl-1-oxide)-N-tert-butylnitrone as spin traps. The dependence of Cr(V) and .OH radical formation on the H2O2 and Cr(VI) concentrations indicates that the Cr(V) species react with H2O2 to generate the .OH radicals. Similar results were obtained by using various diols (arabinose, cellobiose, FAD, fructose, glyceraldehyde, ribose, and tartaric acid), alpha-hydroxycarboxylic acids, and glutathione. Investigations with superoxide dismutase showed no significant participation of O2- in the generation of .OH radicals. These results thus indicate that the Cr(V) complexes, produced in the reduction of Cr(VI) by cellular reductants, react with H2O2 to generate .OH radicals, which might be initiators of the primary events in the Cr(VI) cytotoxicity.

Diminished baroreflex control of forearm vascular resistance in physically fit humans

The stimulus-response characteristics of cardiopulmonary baroreflex control of forearm vascular resistance (FVR) were studied in five unfit [UF, maximal O2 consumption (VO2 max) = 38.5 ml X min-1 X kg-1] and six fit (F, VO2 max = 57.0 ml X min-1 X kg-1) subjects. We assessed the relationship between reflex stimulus, i.e., changes in central venous pressure (CVP) and response, i.e., FVR, during selective unloading of the cardiopulmonary mechanoreceptors with lower body negative pressure (0 to -20 mmHg). The linear relationship between FVR and CVP, the gain of this baroreflex, was significantly diminished in the F subjects, -2.42 +/- 0.57 U/mmHg, compared with the UF, -5.15 +/- 0.58 U/mmHg. Both groups, F and UF, had similar resting values for CVP and FVR; thus the diminished gain in F subjects was not simply an artifact resulting from a shift of the set point along the baroreflex stimulus-response curve. We also found a linear relationship between baroreflex gain and total blood volume (r = 0.59, P less than 0.05). We conclude that the gain of this vascular reflex is attenuated in trained individuals and is related to cardiovascular adaptations, such as an increased blood volume, associated with exercise training.