Activity-dependent glassy cell mechanics Ⅰ: Mechanical properties measured with active microrheology

Active microrheology was conducted in living cells by applying an optical-trapping force to vigorously-fluctuating tracer beads with feedback-tracking technology. The complex shear modulus G(ω)=G'(ω)-iG″(ω) was measured in HeLa cells in an epithelial-like confluent monolayer. We found that G(ω)∝(-iω)^1/2 over a wide range of frequencies (1 Hz <ω/2π <10 kHz). Actin disruption and cell-cycle progression from G1 to S and G2 phases only had a limited effect on G(ω) in living cells. On the other hand, G(ω) was found to be dependent on cell metabolism; ATP-depleted cells showed an increased elastic modulus G'(ω) at low frequencies, giving rise to a constant plateau such that G(ω)=G₀+A(-iω)^1/2 . Both the plateau and the additional frequency dependency ∝(-iω)^1/2 of ATP-depleted cells are consistent with a rheological response typical of colloidal jamming. On the other hand, the plateau G₀ disappeared in ordinary metabolically active cells, implying that living cells fluidize their internal states such that they approach the critical jamming point.

Two cases of immunoglobulin G4-related disease diagnosed by transvaginal urethral needle biopsy

INTRODUCTION

Immunoglobulin G4-related disease is a systemic disease characterized by multifocal systemic involvement. We report two cases of women diagnosed with immunoglobulin G4-related disease in the urethra.

CASE PRESENTATION

Case 1: A 67-year-old woman presented with discomfort around her perineum. Magnetic resonance imaging revealed a well-defined mass around the urethra. She underwent an ultrasound-guided core needle biopsy of the mass. The pathologic specimen showed immunoglobulin G4 positive cells. Steroid therapy was initiated, causing improvement of symptoms, decreased serum immunoglobulin G4 levels, and shrinking of the mass. Case 2: An 89-year-old woman was accidentally diagnosed with renal pelvic wall thickening on computed tomography. The pathologic specimen captured by ultrasound-guided needle biopsy showed immunoglobulin G4 positive cells. She had no symptoms and received no medical treatment.

CONCLUSION

The frequency of urethral mass formation in female patients with immunoglobulin G4-related disease may also be high, and an echo-guided transvaginal urethral biopsy may be performed as a definitive diagnostic tool for immunoglobulin G4-related disease.

Surgical outcomes and learning curve of totally intracorporeal ileal conduit urinary diversion following laparoscopic radical cystectomy at a single institution

INTRODUCTION

Constant evaluation of the outcomes of laparoscopic intracorporeal urinary diversion is not yet established. This study aimed to describe surgical outcomes and learning curve of intracorporeal ileal conduit (ICIC) following laparoscopic radical cystectomy (LRC) at a single institution.

METHODS

From June 2012 to February 2018, 38 patients with bladder cancer underwent LRC with ileal conduit at our institution. Surgical outcomes were compared between ICIC (n = 30) and extracorporeal ileal conduit (ECIC) (n = 8). The learning curve during ICIC with regard to the operative time and complication rate was compared.

RESULTS

No significant differences in patient characteristics between the ICIC and ECIC groups were found. Comparison of outcomes between the ICIC and ECIC groups were as follows: median total operative time, 688 vs 713 minutes; urinary diversion time, 213 vs 192 minutes; and estimated blood loss, 450 vs 420 mL, respectively. The median time to walking and oral intake were similar in both groups. Rates of high-grade complications associated with urinary diversion (Clavien-Dindo grade ≥ III) were 3% in ICIC and 25% in ECIC. Although 25% of ECIC patients developed wound dehiscence (Clavien-Dindo grade IIIb), no patient in the ICIC group had postoperative wound infection. For the learning curve of ICIC (n = 30), urinary diversion time decreased significantly (27 minutes decrease per 10 cases, P = .02). Clavien-Dindo grade ≥ II complication did not occur after 20 cases.

CONCLUSIONS

LRC with ICIC could be performed safely with low incidence of severe wound infection compared with ECIC. The incidence and severity of complications also decreased with time.

Atypical oncologic failure after laparoscopic and robot-assisted radical cystectomy at a single institution

BACKGROUND

The incidence of atypical oncologic failure in patients with bladder cancer, including peritoneal carcinomatosis, and recurrences at the port site and soft tissue after laparoscopic and robot-assisted radical cystectomy are not well characterized.

METHODS

We retrospectively reviewed the records of 52, 51, and 12 patients who underwent open, laparoscopic, and robot-assisted radical cystectomy, respectively, for bladder cancer from 2007 to 2018 at our institution. We identified techniques associated with atypical oncologic failure.

RESULTS

The median follow-up period was 29 months. Among the 115 patients, 29 (25%) experienced oncological recurrences, and 7 (6%), 12 (10%), and 23 (20%) had atypical, local, and distant recurrences, respectively. The laparoscopic and robot-assisted radical cystectomy groups had significantly higher incidences of total atypical oncologic failure than the open radical cystectomy group (p = 0.013), including six, one, and two patients with peritoneal carcinomatosis, port site carcinomatosis, and soft tissue involvement, respectively. All 7 patients with atypical oncologic failure died of cancer; the median time from surgery to death was 9.3 months. All these patients were cT ≧ 3 and had grade 3 disease. In three patients (43%), the pathological tissue contained variants other than urothelial carcinoma. Five (71%) were among the initial twenty patients. Four patients (57%) had histories of intraoperative urine spillage or bladder perforation during transurethral resection.

CONCLUSIONS

Patients with cT ≧ 3 stage, with pathological variants other than urothelial carcinoma, and those undergoing procedures that lead to extravesical dissemination should avoid laparoscopic radical cystectomy when the procedures are first introduced.

A case report of fulminant cytokine release syndrome complicated by dermatomyositis after the combination therapy with immune checkpoint inhibitors

INTRODUCTION

Immune-related adverse events (ir-AEs) are increasingly becoming a concern, as immune checkpoint inhibitors (ICIs) are used more frequently. Herein, we present a case of fulminant cytokine release syndrome (CRS) complicated by dermatomyositis after the combination therapy with ICIs.

PATIENT CONCERNS

A 70-year-old male developed dermatomyositis during the course of treatment with two ICIs, nivolumab and ipilimumab. He was treated by steroid pulse therapy, but the effect was limited. Afterwards, he had acute-onset high fever, hypotension, respiratory failure, impaired consciousness, renal failure, and coagulation abnormality at the same time. C reactive protein (CRP), creatinine kinase (CK), D-dimer, and ferritin levels were considerably elevated: CRP, 24 mg/dL; CK, 40,500 U/L; D-dimer, 290 μg/mL; ferritin, 329,000 ng/mL.

DIAGNOSIS

CRS induced by ICI combination therapy.

INTERVENTIONS

Given that high fever and elevated CRP level indicated potential sepsis, an antibiotic was used until the confirmation of negative blood cultures. All the simultaneous acute symptoms were supposed to be CRS. He was admitted to the intensive care unit (ICU), and temporary intubation and hemodialysis were needed. Immunosuppressive therapy was reinforced by mycophenolate mofetil together with steroid, and plasma exchange was performed for the elimination of abnormal proteins.

OUTCOMES

The patient's clinical symptoms and laboratory parameters gradually improved and he was discharged from the ICU in a month.

CONCLUSION

Fulminant CRS can be induced by ICI combination therapy. As the initial symptoms of CRS resemble sepsis, it is important to consider CRS as a differential diagnosis and to initiate immunosuppressive therapy early when needed. In steroid-resistant cases, early introduction of other immunosuppressive therapy and plasma exchange can be effective.

Absence of asymptomatic unruptured renal artery pseudoaneurysm on contrast-enhanced computed tomography after robot-assisted partial nephrectomy without parenchymal renorrhaphy

Objective

To assess the incidence of asymptomatic unruptured renal artery pseudoaneurysm (RAP) on contrast-enhanced computed tomography (CE-CT) after robot-assisted partial nephrectomy (RAPN) without parenchymal renorrhaphy.

Methods

From May 2016 to December 2017, 78 patients underwent RAPN for renal tumors. Inner suture was performed in the opened collecting system or renal sinus, whereas parenchymal renorrhaphy was not. For hemostasis, the soft coagulation system was used, and absorbable hemostats were placed on the resection bed. CE-CT was carried out within 7 days after surgery. Data on these patients were prospectively collected. A single radiologist determined the diagnosis of RAP.

Results

Median (range) data were as follows: Patient age, 65 (19–82) years; radiographic tumor size, 30 (12–95) mm; operating time, 166 (102–294) min; warm ischemic time, 16 (7–67) min; and blood loss, 15 (0–4450) mL. One patient (1.6%) required a perioperative blood transfusion. No patient required conversion to open surgery or nephrectomy. CE-CT was carried out at median 6 (3–7) days after surgery. CE-CT showed no RAP development in all 61 patients. Urinary leakage was not observed. One patient had acute cholecystitis, a postoperative complication classified as Clavien-Dindo grade higher than 3, which was treated with cholecystectomy. Positive surgical margin was identified in four patients (6.6%).

Conclusion

RAPN using soft coagulation and absorbable hemostats without renorrhaphy appears to be feasible and safe. Our technique could eliminate the risk of RAP.

En bloc laparoscopic radical nephrectomy with inferior vena cava thrombectomy: A single-institution experience

OBJECTIVE

To report the outcomes of laparoscopic radical nephrectomy with inferior vena cava thrombectomy for right renal cell carcinoma at Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan.

METHOD

A retrospective review of the clinical records of five patients who underwent laparoscopic radical nephrectomy with inferior vena cava thrombectomy for right renal cell carcinoma between 2013 and 2017 was carried out. The surgical procedure included ligation and cutting of the right renal artery, followed by kidney mobilization. The left renal vein, and the caudal and cephalad sides of the inferior vena cava thrombus were clamped using laparoscopic vascular clamps, and the inferior vena cava was incised. The free kidney and tumor thrombus were placed en bloc in a retrieval bag. Subsequently, the inferior vena cava was laparoscopically closed using a continuous suture.

RESULTS

The median operative time, pneumoperitoneum time, blood loss and postoperative hospital stay were 316 min, 266 min, 400 mL and 7 days, respectively. The median clamp time was 28 min (range 13-105 min). One patient (20%) required a perioperative blood transfusion. The surgical margin was negative in all patients. Only one patient experienced a major complication (Clavien-Dindo grade ≥3), namely a postoperative hemorrhage requiring transarterial embolism.

CONCLUSION

En bloc laparoscopic radical nephrectomy with inferior vena cava thrombectomy is a challenging yet feasible procedure for experienced surgeons in carefully selected patients. Further studies of this surgical procedure are required for standardization and safe application.

Effect of miR-433-3p and miR-883b-5p on murine CYP 3A family enzymes in AML12 cells

Here we searched for microRNAs that could interact with cytochrome P450 (CYP) enzymes in silico, and then investigated their effects on Cyp gene expressions using the cultured mouse liver cell line AML12. Among the mouse Cyp3a genes, some miRNAs were found to interact with Cyp3a11, 13, 16, and 44 by the in silico analysis using the miRWalk2.0 database. In addition to this software, which included twelve miRNA target prediction algorithms, we also applied our in-house-developed Excel VBA algorithm to obtain predictions more efficiently. Finally, two miRNAs, miR-433-3p and miR-883b-5p, were extracted as candidates that interact with Cyp3a genes. To evaluate the effects of these miRNAs on Cyp3a gene expression, we first examined whether they actually interacted with the Cyp3a 3'-untranslated region (3'-UTR) using a luciferase assay system in AML12 cells. We then evaluated whether the expression of each miRNA affected the expression of Cyp3a mRNAs and their transcribed proteins. We found that the transiently expressed miRNAs significantly reduced the reporter activity of the Cyp3a 3'-UTR site in AML12 cells. In addition, the mRNA and protein expressions of the corresponding Cyp3as were significantly decreased in the miRNA-treated AML12 cells. Using cultured cells, we clearly demonstrated that miR-433-3p and miR-883b-5p, which were identified by in silico prediction, actually bind to Cyp3a mRNAs and regulate Cyp gene expressions.

Identification of patterns of factors preceding severe or life-threatening asthma exacerbations in a nationwide study

BACKGROUND

Reducing near-fatal asthma exacerbations is a critical problem in asthma management.

OBJECTIVES

To determine patterns of factors preceding asthma exacerbations in a real-world setting.

METHODS

In a nationwide prospective study of 190 patients who had experienced near-fatal asthma exacerbation, cluster analysis was performed using asthma symptoms over the 2-week period before admission.

RESULTS

Three distinct clusters of symptoms were defined employing the self-reporting of a visual analogue scale. Cluster A (42.1%): rapid worsening within 7.4 hours from moderate attack to admission, young to middle-aged patients with low Body mass index and tendency to depression who had stopped anti-asthma medications, smoked, and hypersensitive to environmental triggers and furred pets. Cluster B (40.0%): fairly rapid worsening within 48 hours, mostly middle-aged and older, relatively good inhaled corticosteroid (ICS) or ICS/long-acting beta-agonist (LABA) compliance, and low perception of dyspnea. Cluster C (17.9%): slow worsening over 10 days before admission, high perception of dyspnea, smokers, and chronic daily mild-moderate symptoms. There were no differences in overuse of short-acting beta-agonists, baseline asthma severity, or outcomes after admission for patients in these 3 clusters.

CONCLUSION

To reduce severe or life-threatening asthma exacerbation, personalized asthma management plans should be considered for each cluster. Improvement of ICS and ICS/LABA compliance and cessation of smoking are important in cluster A. To compensate for low perception of dyspnea, asthma monitoring of peak expiratory flow rate and/or exhaled nitric oxide would be useful for patients in cluster B. Avoidance of environmental triggers, increase usual therapy, or new anti-type 2 response-targeted therapies should be considered for cluster C.

Severe or life-threatening asthma exacerbation: patient heterogeneity identified by cluster analysis

BACKGROUND

Severe or life-threatening asthma exacerbation is one of the worst outcomes of asthma because of the risk of death. To date, few studies have explored the potential heterogeneity of this condition.

OBJECTIVES

To examine the clinical characteristics and heterogeneity of patients with severe or life-threatening asthma exacerbation.

METHODS

This was a multicentre, prospective study of patients with severe or life-threatening asthma exacerbation and pulse oxygen saturation < 90% who were admitted to 17 institutions across Japan. Cluster analysis was performed using variables from patient- and physician-orientated structured questionnaires.

RESULTS

Analysis of data from 175 patients with severe or life-threatening asthma exacerbation revealed five distinct clusters. Cluster 1 (n = 27) was younger-onset asthma with severe symptoms at baseline, including limitation of activities, a higher frequency of treatment with oral corticosteroids and short-acting beta-agonists, and a higher frequency of asthma hospitalizations in the past year. Cluster 2 (n = 35) was predominantly composed of elderly females, with the highest frequency of comorbid, chronic hyperplastic rhinosinusitis/nasal polyposis, and a long disease duration. Cluster 3 (n = 40) was allergic asthma without inhaled corticosteroid use at baseline. Patients in this cluster had a higher frequency of atopy, including allergic rhinitis and furred pet hypersensitivity, and a better prognosis during hospitalization compared with the other clusters. Cluster 4 (n = 34) was characterized by elderly males with concomitant chronic obstructive pulmonary disease (COPD). Although cluster 5 (n = 39) had very mild symptoms at baseline according to the patient questionnaires, 41% had previously been hospitalized for asthma.

CONCLUSIONS & CLINICAL RELEVANCE

This study demonstrated that significant heterogeneity exists among patients with severe or life-threatening asthma exacerbation. Differences were observed in the severity of asthma symptoms and use of inhaled corticosteroids at baseline, and the presence of comorbid COPD. These findings may contribute to a deeper understanding and better management of this patient population.

[Two Cases of Oncocytic Papillary Renal Cell Carcinoma]

Oncocytic papillary renal cell carcinoma isa variant of papillary renal cell carcinoma (PRCC). We herein report two cases treated with retroperitoneoscopic partial nephrectomy. Histologically, tumor cells of both cases exhibit round and regular nuclei with CK7 positive areas in the cytoplasm typical of TYPE1 PRCC and eosinophilic granular cytoplasm with E-cadherin positive areas in the cytoplasmic membrane, which indicates TYPE2 PRCC. Out of 46 cases reported in the literature, only one died of disease, which reveals its low malignant potential.

[Clinical Characteristics of Prostate Ductal Adenocarcinoma in Kyoto University Hospital]

Prostate ductal adenocarcinoma is a rare variant of prostate cancer and considered to be more aggressive than the common acinar type of adenocarcinoma. The appropriate treatment guideline for prostate ductal adenocarcinoma has not been established. The aim of the present study was to examine the clinical characteristics and the effectiveness of treatment for prostate ductal adenocarcinoma. From 2005 to 2012, 41 patients were diagnosed to have prostate ductal adenocarcinoma in Kyoto University Hospital. The mean±SD age was 68.6±7.0 years, and the median (range) initial serum PSA level was 9.3 (3.7-217) ng/ml. Among 17 patients who underwent radical prostatectomy, 10 (58.8%) had pT3 disease and 5 (29.4%) had biochemical recurrence during median follow-up of 22.9 months. Out of 19 patients treated with definitive EBRT with endocrine therapy, 2 patients (10.5%) experienced biochemical recurrence with median follow-up of 37.3 months. Five patients were treated with endocrine therapy alone, and 2 (40.0%) of them died of prostate ductal adenocarcinoma. In conclusion, patients with prostate ductal adenocarcinoma were more likely diagnosed as locally advanced diseases than those with prostate acinar adenocarcinoma. However, for patients without metastasis, either surgery or EBRT with endocrine therapy is effective with good prognosis.

Underweight body mass index is a risk factor of mortality in outpatients with nocturia in Japan

Background

Although nocturia has been reported to increase mortality in elderly individuals, the particular risk factors that are associated with this event are unclear. Therefore, we evaluated risk factors for death in outpatients with nocturia.

Methods

Between October 2002 and December 2009, 250 consecutive patients with nocturia were enrolled in two general hospitals in Japan. Among them, 193 patients were able to be followed for at least 1 year and up to 9 years (median 4.8 years) if the patients did not die. Mortality rates and risk factors were evaluated in the nocturic outpatients.

Results

Two- and 5-year survival of the nocturic outpatients was 94.6 % [95 % confidence interval (CI) = 92.2–97.1] and 82.6 % (95 % CI = 75.4–87.8), respectively. Higher Charlson Comorbidity Score, lower body mass index (BMI) and lower Physical Component Summary of Short Form-36 item scores were significantly correlated with mortality (p < 0.0001, p < 0.005 and p < 0.05, respectively) in multivariate analysis. The International Prostate Symptom Score, Pittsburgh Sleep Quality Index, Mental or Role/Social Component Summary of Short Form-36 item scores and Nocturnal Polyuria index were not significantly correlated with mortality. The mortality rate was significantly higher in subjects with an underweight BMI (<18.50) compared with a normal range (18.50–24.99) or overweight (≥25.00) BMI [p < 0.00005, hazard ratio (HR) = 5.84, 95 % CI = 2.03–16.8; p < 0.0005, HR = 5.92, 95 % CI = 1.94–18.0].

Conclusions

Additional attention is required for nocturic outpatients with not only a high Charlson Comorbidity Score but also an underweight BMI because of their high mortality. Large prospective studies are warranted to validate this finding and extend more.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1456-6) contains supplementary material, which is available to authorized users.

Bladder afferent hyperexcitability in bladder pain syndrome/interstitial cystitis

Bladder pain syndrome/interstitial cystitis is a disease with lower urinary tract symptoms, such as bladder pain and urinary frequency, which results in seriously impaired quality of life of patients. The extreme pain and urinary frequency are often difficult to treat. Although the etiology of bladder pain syndrome/interstitial cystitis is still not known, there is increasing evidence showing that afferent hyperexcitability as a result of neurogenic bladder inflammation and urothelial dysfunction is important to the pathophysiological basis of symptom development. Further investigation of the pathophysiology will lead to the effective treatment of patients with bladder pain syndrome/interstitial cystitis.

Laser-capture microdissection for analysis of cell type-specific gene expression of muscarinic receptor subtypes in the rat bladder with cyclophosphamide-induced cystitis

PURPOSE

This study examined whether the laser-capture microdissection (LCM) method can achieve separation of urothelial cells from detrusor cells or superficial urothelial cells from intermediate/basal urothelial cells, using α-smooth muscle actin (SMA) and cytokeratin 20 (CK20). In addition, we investigated the changes in expression of muscarinic receptors in laser-captured urothelial and detrusor cells in rats with chronic cystitis.

METHODS

Female SD rats were injected with cyclophosphamide (75 mg/kg) intraperitoneally at day 1, 4, 7 and 10 to induce chronic cystitis. Saline was injected in the same protocol for controls. Bladder specimens were cut at 8 μm thickness, fixed in 70% ethanol and lightly stained by hematoxylin and eosin, and then superficial urothelium, intermediate/basal urothelium and detrusor muscles were laser-captured separately. Real-time PCR was performed to examine expressions of α-SMA, CK20, muscarinic 2 receptors (M2R) and muscarinic 3 receptors (M3R).

RESULTS

The expression of α-SMA mRNA in detrusor muscle cells was 200 times higher than that in urothelial cells in controls. CK20 mRNA expression in apical urothelial cells was 55 times more than that in detrusor muscle and four times more than that in intermediate/basal urothelial cells. Expressions of M2R and M3R mRNA were increased in urothelial cells and decreased in detrusor muscles following chronic cystitis.

CONCLUSIONS

The LCM could be useful for tissue collection of detrusor muscle and different layers of urothelial cells with minimal contamination of other cell types, and cell type-specific changes in molecular expression could accurately be analyzed. Increased expression of urothelial MR might enhance urothelial-afferent interactions to induce bladder overactivity/pain conditions associated with bladder inflammation.

[Presurgical treatment of axitinib reduced operation risk by downsizing the vena cava tumor thrombus in advanced renal cell carcinomas: two case reports]

In cases of advanced renal cell carcinoma with inferior vena cava (IVC) thrombus, surgical resection of both tumor and thrombus contributes to the improvement of patient's prognosis, but the risk of perioperative complication is still high. We experienced two cases of advanced renal tumors with IVC tumor thrombus down-sized by presurgical treatment of axitinib. Axitinib treatment showed a marked tumor reduction effect without any severe adverse event. We could remove both tumor and thrombus without perioperative complications. In these two cases, downsizing of IVC thrombus enabled us to reduce the extent of the surgery.

[A case of late perirenal fat recurrence after partial nephrectomy for T1A renal cell carcinoma]

An 84-year-old man had undergone laparoscopic partial nephrectomy for right renal cell carcinoma (RCC), cT1aN0M0 in 2003. The histopathological diagnosis was clear cell carcinoma, grade 1, v (-), surgical margin negative, pT1a. Nine years and 10 months postoperatively, computed tomography scans demonstrated tumors on right renal fossa. As we could not detect other metastatic lesions, we diagnosed him with local recurrence of RCC and planned the surgery with curative intent. He underwent laparoscopic resection of retroperitoneal tumors. The histopathological diagnosis was clear cell carcinoma, grade 2 ＞ 3, v (-), surgical margin negative, and confirmed recurrence of RCC. In retrospective review of 176 cases of pT1a renal cell carcinoma with partial nephrectomy in our institute, 3 patients (1.7%) developed local recurrence and 2 patients (1.1%) developed late local recurrence.

[Urinary diversion in patients treated with pelvic irradiation: transverse colon conduit revisited]

In patients receiving pelvic irradiation for gynecological or genitourinary malignancies, urinary diversion is sometimes required for complete resection of malignancies or treatment of urological complications by irradiation. We report our attempts to promote healing and prevent complications by urinary diversion using a transverse colon conduit in cases in which urinary reconstruction was performed with irradiated lower abdominal organs such as small intestine or distal ureters. Between 2008 and 2012, 9 patients with pelvic irradiation received transverse colon conduit urinary diversion. Six patients received diversion for genitourinary complications, while 3 patients received complete resection of pelvic malignancies. Colostomy formation and lithotripsy of vesical stones were simultaneously performed in 4 cases. Wallace method was adopted for ureterointestinal anastomosis. There was no operative mortality. Although acute pyelonephritis, ileus, wound dehiscence and pelvic abscess formation were seen as postoperative complications, all but two improved without any additional procedure. Cases of pelvic abscess or wound dehiscence were treated by abscess drainage. In observation periods, no patients required urinary stent placement and none suffered from defecation problems. We think that transverse colon conduit can be a viable option for patients with pelvic irradiation history, affording them reasonable quality of life postoperatively.

[A case of successful living related renal transplantation in a patient with end-stage renal disease resulting from sarcoidosis]

We report a case in a 44-year-old man with known past history of sarcoidosis associated with uveitis that was first diagnosed when he was 20 years old. He developed renal dysfunction 6 years after the diagnosis of sarcoidosis. At that time, a renal biopsy revealed non-necrotizing granulomatous interstitial nephritis, typical findings of renal involvement of sarcoidosis. Despite corticosteroid therapy administered soon after the biopsy, the renal dysfunction gradually progressed to end-stage renal disease. The patient underwent kidney transplantation from a living donor and the renal graft has been functioning well with no evidence of recurrence 10 months postoperatively, and with a serum creatinine level between 1.2 and 1.5 mg/dl.

[Perioperative agranulocytosis induced by immunosuppressants in a renal graft recipient : a case report]

A 20-year-old man with end-stage renal disease was scheduled to have an ABO-incompatible living kidney transplantation donated by his mother. His complete blood count including differential white blood cell count was normal before preoperative immunosuppressive therapy including mycophenolate mofetil (MMF), tacrolimus (FK506), and prednisolone was started 3 weeks before the operation. The dosage of MMF was initially 2,000 mg/day, but was reduced to 500 mg/day due to diarrhea 10 days before the operation. He received rituximab 13 days before the operation. The neutrophil (Neu) count was 3,100/μl a day before the operation. Transplant surgery was finished without any complications. The Neu count was found to be 300/μl on the day and 80/μl the next day. Granulocyte colony-stimulating factor was administered daily. Then the Neu count increased to 9,100/μl on postoperative day (POD) 2, and was maintained within the normal range. MMF was re-started on POD 12. The dosage was 500 mg, and was increased to 1,000 mg on POD 21. On POD 30 the 12-hr blood concentration of MMF was 117.2 mg× hr/l, which was almost double the adequate target dose. Then the dosage was reduced to 500 mg. In this case MMF is the most suspected drug for drug-induced agranulocytosis. Although MMF-induced neutropenia is frequently observed in transplant recipients, it usually happens three months after transplantation or later. The present case is a rare case as it occurred on the day of transplantation. The pharmacokinetics of MMF varies with the individual. Although routine monitoring of blood concentration of MMF is not recommended, specific attention to prevent overdosage should be given particularly in a patient presenting possible adverse effects including diarrhea and depilation.

[Small cell carcinoma of the bladder]

We retrospectively reviewed the records of 11 patients with small cell carcinoma of the bladder, who were diagnosed at Kyoto University Hospital between June 1995 and November 2010. The median age was 79 years. Two patients had stage I disease, 4 had stage II disease, 2 had stage III disease, and 3 had stage IV disease. All 3 patients with stage IV disease had metastatic disease. They had very poor prognosis with a median survival of only 9.1 months (range 3.2-13.0 months). Of 8 patients without metastatic disease, 3 patients who had been treated with neoadjuvant chemotherapy followed by cystectomy had longterm survival. The median survival of these 3 patients was 85.5 months (range 38.0-102.8 months), and all of them are still alive without cancer. The median survival of the other 5 patients was 12.6 months (range 9. 9-33. 8 months). There were significant differences in survival between patients with neoadjuvant chemotherapy followed by cystectomy and with other treatments (p＝0.024). In conclusion, these results suggested that neoadjuvant chemotherapy followed by cystectomy could cure patients with small cell carcinoma of the bladder without metastatic disease.

Novel constant-pressure irrigation technique for the treatment of renal pelvic tumors after ipsilateral ureterectomy

We herein report a case of a renal pelvic tumor that developed in the residual left renal pelvis after right nephroureterectomy, left ureterectomy and total cystectomy in a patient with multiple urothelial tumors. The tumor was endoscopically ablated through a nephrostomy tract, and mitomycin C irrigation was carried out. We designed a novel constant-pressure irrigation system for effective and safe irrigation into the closed space of the renal pelvis. We created a hole in the urine bag tube, inserted a 5-Fr open-end ureteral catheter through the hole and kept the tip of the catheter at the end of the nephrostomy tube. The urine bag tube was placed 20 cm above the kidney level, and mitomycin C was continuously irrigated into the renal pelvis for 1 h. Six-weekly treatments were carried out, and tumor recurrence was not identified for 1 year.

[Risk factors for recurrence in pT3aN0M0 renal cell carcinoma according to 2009 TNM classification]

The TNM classification of renal cell carcinoma was updated in 2009. In this new classification system, T3a consists of tumors with renal vein involvement and tumors with fat invasion. To assess risk factors for recurrence, we retrospectively reviewed 89 patients with pT3aN0M0 renal cell carcinoma who underwent radical or partial nephrectomy between 1992 and 2011. Analyzed risk factors for recurrence were age, gender, tumor size, grade, v factor, infiltrative growth (INF), adjuvant interferon, surgical technic (radical or partial), clinical T classification, renal vein thrombus, and pathological fat invasion. The median follow-up was 52.2 months. Five-year recurrence-free survival rate was 69.0%. Within the pT3a subcategory, the five-year recurrence-free survival was 76.7% in patients with fat invasion only, 42.9% in patients with renal vein thrombus only, and 28.6% in patients with the two concomitant features. On univariate analysis, tumor size, grade, INF, clinical T classification, and renal vein thrombus were significantly associated with recurrence. On multivariate analysis, INF (p = 0.023, HR 3.927) was an independent risk factor for recurrence. In pT3aN0M0 renal cell carcinoma, INF significantly affects recurrence, and patients with both fat invasion and renal vein thrombus have worst prognosis.

[A case of prostate carcinosarcoma successfully treated with combined modality therapy]

A 58-year-old man was referred to our hospital with dysuria and elevation of prostate specific antigen (38.0 ng/ml). Prostate surface was smooth and elastic hard on digital rectal examination. Transrectal ultrasound (TRUS) indicated irregular boundary and low echoic area of the prostate. Prostate biopsy specimen included the components of adenocarcinoma (Gleason score 9) and sarcoma. The tumor had extended to the rectum and metastasized to bilateral obturator lymph nodes and right ischial bone (cT4N1M1b). We started hormone therapy for the adenocarcinoma component followed by total pelvic exenteration with colostomy and ileal conduit diversion for the sarcoma component. In addition, pelvic cavity and the bone metastasis were irradiated. The patient was free of recurrence at four and a half years after surgery.

[Pseudomyxoma peritonei arising from urachal carcinoma]

A 77-year-old man was diagnosed with urachal cyst, but had not been followed-up because of his severe dementia. He visited our department complaining of mucinuria. Ultrasonography showed a tumor with heterogeneous contents above the bladder. Mucinousfluid was found by cystoscopic examination. After the fluid was removed, a non-papillary tumor with mucin secretion was identified at the dome of the bladder. Computed tomography revealed that the peritoneal cavity was filled with a mucinous tumor. Peritonitis was suspected because of the existence of free air and abdominal rebound tenderness, and emergent surgery was performed. Bowel perforation was not found. Tumors could not be removed and the tissue biopsy was performed. It was pathologically diagnosed as pseudomyxoma peritonei arising from urachal carcinoma.

Myocardin and microRNA-1 modulate bladder activity through connexin 43 expression during post-natal development

Overactive bladder (OAB) is a pervasive clinical problem involving alterations in both neurogenic and myogenic activity. While there has been some progress in understanding neurogenic inputs to OAB, the mechanisms controlling myogenic bladder activity are unclear. We report the involvement of myocardin (MYOCD) and microRNA-1 (miR-1) in the regulation of connexin 43 (GJA1), a major gap junction in bladder smooth muscle, and the collective role of these molecules during post-natal bladder development. Wild-type (WT) mouse bladders showed normal development from early post-natal to adult including increases in bladder capacity and maintenance of normal sensitivity to cholinergic agents concurrent with down-regulation of MYOCD and several smooth muscle cell (SMC) contractile genes. Myocardin heterozygous-knockout mice exhibited reduced expression of Myocd mRNA and several SMC contractile genes concurrent with bladder SMC hypersensitivity that was mediated by gap junctions. In both cultured rat bladder SMC and in vivo bladders, MYOCD down-regulated GJA1 expression through miR-1 up-regulation. Interestingly, adult myocardin heterozygous-knockout mice showed normal increases in bladder and body weight but lower bladder capacity compared to WT mice. These results suggest that MYOCD down-regulates GJA1 expression via miR-1 up-regulation, thereby contributing to maintenance of normal sensitivity and development of bladder capacity.

[Experience of transobturator sling for iatrogenic male stress urinary incontinence]

We performed transobturator sling (TOS) surgery for iatrogenic stress urinary incontinence (SUI) in 7 men. Assessment with the International Consultation Society Incontinence Questionnaire Short Form revealed that complete continence, significant improvement, and no change of incontinent status were observed in two, three, and two patients, respectively, at one year after surgery. Of the three patients with significant improvement, two patients obtained a pad-free status. Both of the two patients without improvement had a past history of salvage radiation therapy for biochemical recurrence after radical prostatectomy before TOS surgery. The severity of SUI seems not to be associated with the outcome of TOS surgery. TOS surgery can be one of the surgical options for iatrogenic male SUI.

PTHrP is endogenous relaxant for spontaneous smooth muscle contraction in urinary bladder of female rat

Acute bladder distension causes various morphologic and functional changes, in part through altered gene expression. We aimed to investigate the physiologic role of PTHrP, which is up-regulated in an acute bladder distension model in female rats. In the control Empty group, bladders were kept empty for 6 hours, and in the Distension group, bladders were kept distended for 3 hours after an artificial storing-voiding cycle for 3 hours. In the Distention group bladder, up-regulation of transcripts was noted for 3 genes reported to be up-regulated by stretch in the cultured bladder smooth muscle cells in vitro. Further transcriptome analysis by microarray identified PTHrP as the 22nd highest gene up-regulated in Distension group bladder, among more than 27,000 genes. Localization of PTHrP and its functional receptor, PTH/PTHrP receptor 1 (PTH1R), were analyzed in the untreated rat bladders and cultured bladder cells using real-time RT-PCR and immunoblotting, which revealed that PTH1R and PTHrP were more predominantly expressed in smooth muscle than in urothelium. Exogenous PTHrP peptide (1-34) increased intracellular cAMP level in cultured bladder smooth muscle cells. In organ bath study using bladder strips, the PTHrP peptide caused a marked reduction in the amplitude of spontaneous contraction but caused only modest suppression for carbachol-induced contraction. In in vivo functional study by cystometrogram, the PTHrP peptide decreased voiding pressure and increased bladder compliance. Thus, PTHrP is a potent endogenous relaxant of bladder contraction, and autocrine or paracrine mechanism of the PTHrP-PTH1R axis is a physiologically relevant pathway functioning in the bladder.

A survey of the FAERS database concerning the adverse event profiles of α1-adrenoreceptor blockers for lower urinary tract symptoms

PURPOSE

Current guidelines recommend α1-adrenoreceptor blockers (A1Bs) for treating lower urinary tract symptoms suggestive of benign prostatic hyperplasia, but their adverse effects can be problematic. In this study, reports submitted to the US Food and Drug Administration Adverse Event Reporting System (FAERS) between 1997 and 2011 were reviewed to assess the safety profiles of A1Bs.

METHODS

After deleting duplicated submissions and revising arbitrary drug names, reports involving A1Bs for male patients were analyzed. Data mining algorisms were used for the quantitative detection of signals, where a signal represents an association between a drug and an adverse event or a drug-associated adverse event, including the proportional reporting ratio, reporting odds ratio, information component given by a Bayesian confidence propagation neural network, and empirical Bayes geometric mean.

RESULTS

The total number of reports used was 1,260,182. Signal scores suggested the associations of alfuzosin, doxazosin, tamsulosin, and terazosin with dizziness/vertigo, orthostatic hypotension, erectile dysfunction, ejaculation dysfunction (EjD), thirst/dry mouth, and constipation; however, reports on naftopidil, silodosin, and urapidil were not enough to compare with the other 4 A1Bs. Signal scores for EjD were higher for tamsulosin, and those for dizziness/vertigo were lower for doxazosin than for the other 3 drugs.

CONCLUSIONS

Tamsulosin-associated EjD, which was found in clinical studies, was reproduced in this analysis with markedly higher signal scores, and these results strongly suggest the necessity of well-organized clinical studies on A1B-associated adverse events.

Down-regulation of nerve growth factor expression in the bladder by antisense oligonucleotides as new treatment for overactive bladder

PURPOSE

Nerve growth factor over expression in the bladder has a role in overactive bladder symptoms via the mediation of functional changes in bladder afferent pathways. We studied whether blocking nerve growth factor over expression in bladder urothelium by a sequence specific gene silencing mechanism would suppress bladder overactivity and chemokine expression induced by acetic acid.

MATERIALS AND METHODS

Female Sprague-Dawley® rats anesthetized with isoflurane were instilled with 0.5 ml saline, scrambled or TYE™ 563 labeled antisense oligonucleotide targeting nerve growth factor (12 μM) alone or complexed with cationic liposomes for 30 minutes. The efficacy of nerve growth factor antisense treatments for acetic acid induced bladder overactivity was assessed by cystometry. Bladder nerve growth factor expression levels and cellular distribution were quantified by immunofluorescence staining and enzyme-linked immunosorbent assay. Effects on bladder chemokine expression were measured by Luminex® xMAP® analysis.

RESULTS

Liposomes were needed for bladder uptake of oligonucleotide, as seen by the absence of bright red TYE 563 fluorescence in rats instilled with oligonucleotide alone. At 24 hours after liposome-oligonucleotide treatment baseline bladder activity during saline infusion was indistinct in the sham and antisense treated groups with a mean ± SEM intercontraction interval of 348 ± 55 and 390 ± 120 seconds, respectively. Acetic acid induced bladder overactivity was shown by a decrease in the intercontraction interval to a mean of 33.2% ± 4.0% of baseline in sham treated rats. However, the reduction was blunted to a mean of 75.8% ± 3.4% of baseline in rats treated with liposomal antisense oligonucleotide (p <0.05). Acetic acid induced increased nerve growth factor in the urothelium of sham treated rats, which was decreased by antisense treatment, as shown by enzyme-linked immunosorbent assay and reduced nerve growth factor immunoreactivity in the urothelium. Increased nerve growth factor in bladder tissue was associated with sICAM-1, sE-selectin, CXCL-10 and 1, leptin, MCP-1 and vascular endothelial growth factor over expression, which was significantly decreased by nerve growth factor antisense treatment (p <0.01).

CONCLUSIONS

Acetic acid induced bladder overactivity is associated with nerve growth factor over expression in the urothelium and with chemokine up-regulation. Treatment with liposomal antisense suppresses bladder overactivity, and nerve growth factor and chemokine expression. Local suppression of nerve growth factor in the bladder could be an attractive approach for overactive bladder. It would avoid the systemic side effects that may be associated with nonspecific blockade of nerve growth factor expression.

Prevalence of postmicturition urinary incontinence in Japanese men: comparison with other types of incontinence

OBJECTIVE

To investigate the prevalence and correlates of postmicturition urinary incontinence in Japanese men, and to compare with those of other types of urinary incontinence.

METHODS

A total of 3224 male participants in a community-based survey were investigated. Three types of urinary incontinence were assessed; that is, postmicturition urinary incontinence, stress urinary incontinence and urge urinary incontinence. Age, body mass index, alcohol intake, cigarette smoking, and medical history of 18 diseases and conditions were the dependent variables for candidate correlates of the three types of incontinence.

RESULTS

Unlike stress urinary incontinence and urge urinary incontinence, the prevalence of postmicturition urinary incontinence was constant throughout all generations (6.5% for the 30 s, 6.6% for the 40 s, 6.0% for the 50 s, 6.3% for the 60 s and 5.1% for the 70 s). The independent correlates for postmicturition urinary incontinence were asthma (P < 0.001; odds ratio 3.01), prostatic disease (P < 0.001; odds ratio 2.38), rhinosinusitis (P = 0.001; odds ratio 1.92), low back pain (P = 0.003; odds ratio 1.58), sleeplessness (P = 0.013; odds ratio 1.86), depression (P = 0.024; odds ratio 3.41) and body mass index (P = 0.025; odds ratio 0.73).

CONCLUSIONS

Postmicturition urinary incontinence has different characteristics from those of stress urinary incontinence and urge urinary incontinence. Unlike stress urinary incontinence and urge urinary incontinence, postmicturition urinary incontinence is not age-dependent. Several diseases related to an allergic status, such as asthma and rhinosinusitis, are correlates for postmicturition urinary incontinence.

Regional differences in rat vaginal smooth muscle contractility and morphology

The objective of this study was to define the regional differences in rat vaginal smooth muscle contractility and morphology. We evaluated circumferential segments from the proximal, middle, and distal rat vagina (n = 21) in vitro. Contractile responses to carbachol, phenylephrine, potassium chloride, and electrical field stimulation (EFS) were measured. Immunohistochemical analyses were also performed. The dose-response curves for carbachol- and phenylephrine-dependent contractions were different in the distal (P = .05, P = .04) compared to the proximal/middle regions. Adjusted for region-dependent changes in contractility, the distal vagina generated lower force in response to carbachol and higher force in response to phenylephrine. There was less force with increasing EFS frequency in the distal (P = .03), compared to the proximal/middle regions. Cholinergic versus adrenergic nerves were more frequent in the proximal region (P = .03). In summary, the results indicate that functional and morphological differences in smooth muscle and nerve fibers of the distal versus proximal/middle regions of the vagina exist.

Serum lipid levels are positively associated with non-erosive reflux disease, but not with functional heartburn

BACKGROUND

Metabolic syndrome and obesity are known risk factors for gastro-esophageal reflux disease (GERD), especially for erosive esophagitis. Although non-erosive reflux disease (NERD) is probably associated with obesity or other metabolic syndrome, there is little direct evidence to support this assertion.

METHODS

Workers in Keio University who underwent a general health examination between September 2006 and August 2007 were enrolled. Reflux symptom questionnaires were administered and metabolic parameters were obtained. The severity of gastro-esophageal reflux (GER) was scored using a validated scale of videoesophagography.

KEY RESULTS

Two hundred and eighty-three subjects (243 men and 40 women; mean age 49.8 +/- 6.9 years) with no radiographic evidence of erosive esophagitis were enrolled. The severity of GER was worse among men than among women, whereas the severity of reflux symptoms was worse among women. The severity of GER was associated with age and serum triglyceride levels in men, and with the serum low-density lipoprotein cholesterol levels in women. The severity of reflux symptoms, however, was not associated with metabolic parameters. There were more women than men with reflux symptoms but without GER ('presumed' functional heartburn group), compared with subjects with neither GER nor reflux symptoms. In men, the presence of both reflux symptoms and GER ('presumed' NERD group) was associated with the serum triglyceride levels.

CONCLUSIONS & INFERENCES

While NERD is associated with serum lipid levels, functional heartburn is not. The prevalence of GER was greater among men; conversely, the prevalence of functional heartburn was greater among women.

Septins as diagnostic markers for a subset of human asthenozoospermia

PURPOSE

Septins are the major constituents of the annulus, a submembranous ring that separates the middle and principal pieces of spermatozoa. We previously reported its essential role in spermiogenesis and reproduction in mice. In the current study we investigated septin abnormality in infertile men.

MATERIALS AND METHODS

Semen samples from 108 infertile patients and 21 healthy volunteers were analyzed for sperm concentration and motility. Spermatozoa were immunostained for the 2 representative septin subunits SEPT4 and SEPT7. Peripheral blood DNA from 8 patients with asthenozoospermia who had defective SEPT4 and/or SEPT7 labeling in the annuli was analyzed by direct sequencing. Clinical information and a followup review of pregnancy were obtained retrospectively from medical records.

RESULTS

Specific antibodies for SEPT4 and SEPT7 consistently labeled the annuli in spermatozoa from the 21 healthy volunteers, while 14 of 108 samples (13%) from infertile patients showed defective labeling. In 33 patients with asthenozoospermia 10 samples (30%) demonstrated defective labeling for SEPT4 and/or SEPT7. We could not detect exon mutations in the SEPT4 gene by sequencing peripheral blood DNA from 8 patients with asthenozoospermia who had defective SEPT4 and/or SEPT7 labeling. During followup 8 of 14 patients (57%) with SEPT4 and/or SEPT7 labeling defects achieved successful pregnancies.

CONCLUSIONS

Annulus defects were found exclusively in infertile patients. Although their prognoses do not differ from those without annulus defects, annulus labeling by septin antibodies may serve as an index for classifying a subset of spermatogenesis defects and monitoring sperm quality.

Epigenetic silencing of prostaglandin E receptor 2 (PTGER2) is associated with progression of neuroblastomas

We previously identified a cluster of prostanoid receptor genes, prostaglandin D2 receptor (PTGDR) and prostaglandin E receptor 2 (PTGER2), as possible targets for DNA methylation in advanced types of neuroblastoma (NB) using bacterial artificial chromosome array-based methylated CpG island amplification method. Among them, in this study, we found that PTGER2 was frequently silenced in NB cell lines, especially in those with MYCN amplification, through epigenetic mechanisms. In NB cell lines, DNA methylation pattern within a part of CpG island was inversely correlated with PTGER2 expression, and histone H3 and H4 deacetylation and histone H3 lysine 9 methylation within the putative promoter region were more directly correlated with silencing of this gene. Methylation of PTGER2 was observed more frequently in advanced-type of primary NBs compared with early-stage tumors. Growth of NB cells lacking endogenous PTGER2 expression was inhibited by restoration of the gene product by transient and stable transfection. A PTGER2-selective agonist, butaprost, increased intracellular cyclic adenosine monophosphate (cAMP) level, inhibited cell growth and induced apoptosis of NB cells stably expressing exogenous PTGER2. 8-Bromo-cAMP also inhibited growth of NB cells lacking PTGER2 expression, but not cells expressing this gene. Taken together, it is suggested that NB cells may lose responsiveness to PTGER2-mediated growth inhibition/apoptosis through epigenetic silencing of PTGER2 and/or disruption of downstream cAMP-dependent pathway during the neuroblastomagenesis.

Genotyping of congenital adrenal hyperplasia due to 21-hydroxylase deficiency presenting as male infertility: case report and literature review

We describe here two infertile male patients who were referred to our hospital with azoospermia at the ages of 33 and 30 years, respectively. Hormonal examinations led to a diagnosis of congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency in both patients. Genotyping revealed that the patients had a homozygous I172N and a heterozygous compound I172N/IVS2-13A/C>G mutation, respectively. Glucocorticoid replacement therapy succeeded in improving the seminal status of one patient, but not the other. For the latter patient and his wife, a pregnancy was achieved by testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI) following genetic counseling. It is important to investigate genotyping and to classify patients on the basis of genotypic information in order to arrive at better treatment strategies for male infertility; especially in counseling of TESE-ICSI.