Presentation of oropharyngeal dysphagia and rehabilitative intervention following esophagectomy: a systematic review

No study has systematically reviewed the evidence on presentation of oropharyngeal dysphagia and swallowing rehabilitation following esophagectomy. The purposes of this systematic review are to 1) qualitatively synthesize the current findings on oropharyngeal swallowing abnormalities identified by instrumental swallowing evaluations, 2) describe the reported health-related outcomes in relation to swallowing abnormality following esophagectomy, and 3) examine the efficacy of reported rehabilitative interventions for oropharyngeal dysphagia in patients who underwent esophagectomy. Publications were searched using five electronic databases. No language or publication date restrictions were imposed. Two authors performed a blind review for published or unpublished studies that reported swallowing biomechanics and dysphagic symptoms using instrumental evaluation of swallowing, specifically the videofluoroscopic swallowing study and fiberoptic endoscopic evaluation of swallowing, and/or health-related outcomes in relation to swallowing abnormalities, and/or therapeutic interventions for oropharyngeal dysphagia following esophagectomy. Twelve studies out of 2,193 studies including 458 patients met the inclusion criteria. Reported abnormal swallowing biomechanics included vocal fold immobility, delayed onset of swallowing, reduced hyolaryngeal elevation, and reduced opening of the upper esophageal sphincter. Aspiration (0-81%) and pharyngeal residue (22-100%) were prevalent. Those abnormal swallowing biomechanics and swallowing symptoms were commonly reported following both transhiatal and transthoracic esophagectomy. Pneumonia presented in 5-25% of the study patients. One quasi-experimental study examined the effectiveness of swallowing exercises for postoperative oropharyngeal dysphagia; three case series reported a benefit of the chin-tuck maneuver in reducing aspiration and residue. This review revealed distinct swallowing impairments and increased pneumonia risks following esophagectomy. This review also found that evidence on the efficacy of therapeutic interventions was limited. Future studies are warranted to develop effective rehabilitative interventions for postesophagectomy patients with oropharyngeal dysphagia.

Evaluation of a follow-up program for mild traumatic brain injury in schoolchildren

INTRODUCTION

Mild traumatic brain injury is a common condition in childhood. Although classified as mild, post-concussive symptoms may persist and interfere with daily activities. Because no established guidelines exist with respect to follow-up medical care for these children, there may be a delay in receiving appropriate care. We developed a follow up program to screen for persistent symptoms and if necessary, refer patients for further medical assistance.

METHODS

From July 2010 until December 2013, eligible children aged 4-18 years who presented after sustaining a mild traumatic brain injury were included. All patients received a phone call after 6 weeks. After a period of 3 months, both their schoolteacher and parents were asked to complete in a questionnaire. The results were discussed monthly by a multidisciplinary team.

RESULTS

A total of 305 children were enrolled in our follow-up program. Headache was the most common acute symptom upon presentation (63%). Overall, 19% of all patients had problems, either at 6 weeks or 3 months. 14% of these patients were referred for special care. Most common persistent post-concussive symptoms were headache (32%), cognitive problems (23%) and behavioural problems (16%). After a period of two years, a review of patient charts revealed that all of the problems were resolved.

CONCLUSION

One fifth of the children exhibit post-concussive symptoms after mild traumatic brain injury. Education of patients and caregivers and a follow up visit if needed applied appropriate care at an early stage to minimise physical and mental problems.

Generation of camelid VHH bispecific constructs via in-cell intein-mediated protein trans-splicing

Production of various combinations of bispecific variable domain of heavy chain of heavy chain-only antibody (VHH) constructs to evaluate their therapeutic potential usually requires several gene-engineering steps. Here, we present an alternative method of creating bispecific VHH constructs in vivo through protein trans-splicing (PTS) reaction; this method may reduce the number of gene manipulation steps required. As a proof-of-concept, we constructed a bispecific antibody (bsAb) containing an anti-epidermal growth factor receptor VHH and anti-green fluorescent protein VHH, and we evaluated and confirmed its bispecificity. We also tested antibody labeling by fluorescent protein tagging using the PTS reaction. Compared with the conventional gene construction method, bsAb construction via PTS is a promising alternative approach for generating multiple bsAb combinations.

The psychometric characteristics of an assessment instrument for perceived harmfulness in adolescents with musculoskeletal pain (PHODA-youth)

BACKGROUND

Cognitive-behavioural models of chronic pain predict that dysfunctional assumptions about harmfulness of activities may maintain pain-related fear and disability. To assess perceived harmfulness in adolescents, the Photograph Series of Daily Activities for youth (PHODA-youth) was developed. Information concerning its methodological quality is currently lacking.

OBJECTIVE

To investigate psychometric characteristics (factor structure, test-retest reliability, construct validity) and feasibility of the PHODA-youth in adolescents with chronic musculoskeletal pain.

STUDY DESIGN

Test-retest design.

STUDY POPULATION

Adolescents aged 13-21 years with chronic nonspecific musculoskeletal pain.

METHODS

Participants filled in an electronic version of the PHODA-youth including 89 items twice with a 4-week interval. The instrument's factor structure was determined by a factor analysis. Construct validity was studied with criterion variables: catastrophizing (Pain Catastrophizing Scale for Children), pain intensity (visual analogue scale), depression (Children's Depression Inventory) and pain-related disability (Functional Disability Inventory) using regression analysis. Test-retest reliability was evaluated based on the Pearson correlation coefficient. Feasibility was studied with self-constructed questions.

RESULTS

Seventy-one adolescents participated. Results show a three-factor structure for the PHODA-youth including 51 items with subscales labelled as: 'activities of daily life', 'intensive physical activities' and 'social activities'. Total and subscale scores showed a high internal consistency. Its test-retest reliability was good (r = 0.94) and its construct validity is supported by the finding that both catastrophizing (β = 0.25; p = 0.02) and disability (β = 0.71; p < 0.001) were uniquely related to the PHODA-youth. In addition, feasibility appeared adequate.

CONCLUSION

The findings support the PHODA-youth as a valid and reliable measure of the perceived harmfulness of activities in adolescents with musculoskeletal pain.

Effect of rehabilitation on mortality of patients with Guillain-Barre Syndrome: a propensity-matched analysis using nationwide database

BACKGROUND

Rehabilitation for patients with Guillain-Barre Syndrome (GBS) is recommended as it improves the outcome of neurological deficits. Few studies focused on the effect of rehabilitation on mortality of the patients.

AIM

To investigate the effect of rehabilitation on hospital mortality of patients with GBS using the Japanese Diagnosis Procedure Combination (DPC) nationwide administrative claims database.

DESIGN

A retrospective observational cohort study.

SETTING

Hospitals adopting the Japanese DPC system.

POPULATION

Patients hospitalized with a diagnosis of GBS between July 2007 and October 2011.

METHODS

Data analyzed included sex, age, Barthel index at admission, use of ventilation, immune therapy, and rehabilitation during hospitalization, comorbidity, hospital volume, type of hospital, and in-hospital death. One-to-one propensity score-matching was used to compare hospital mortality rates within 30- and 90-days after admission in rehabilitation and non-rehabilitation groups. The adjusted odds ratios of rehabilitation to hospital mortality were also estimated.

RESULTS

A total of 3835 patients were identified and analyzed. Patients with advancing age, lower Barthel index at admission, comorbidities, ventilation, or immune therapy were more likely to receive rehabilitation during hospitalization. Propensity-matched analysis of 926 pairs showed that the rehabilitation group had lower hospital mortality rates within both 30- and 90-days than the non-rehabilitation group. The adjusted odds ratios of rehabilitation to hospital mortality within 30- and 90-days were 0.14 and 0.23, respectively.

CONCLUSION

After matching patients' background, rehabilitation was associated with lower hospital mortality of patients with GBS.

CLINICAL REHABILITATION IMPACT

Rehabilitation treatment is essential for patients with GBS to improve their survival.

Self-monitoring has potential for home exercise programmes in patients with haemophilia

Haemophiliacs who have had to keep a physically inactive lifestyle due to bleeding during childhood are likely to have little motivation for exercise. The purpose of this study is to clarify the effectiveness of the self-monitoring of home exercise for haemophiliacs. A randomized controlled trial was conducted with intervention over 8 weeks at four hospitals in Japan. Subjects included 32 male outpatients aged 26-64 years without an inhibitor who were randomly allocated to a self-monitoring group and a control group. Individual exercise guidance with physical activity for improvement of their knee functions was given to both groups. The self-monitoring materials included an activity monitor and a feedback system so that the self-monitoring group could send feedback via the Internet and cellular phone. The self-monitoring was performed by checking exercise adherence and physical activity levels, bleeding history and injection of a coagulation factor. Both groups showed significant improvements in exercise adherence (P < 0.001) and physical function such as the strength of knee extension (P < 0.001), range of knee extension (P < 0.001), range of ankle dorsiflexion (P < 0.01), a modified Functional Reach (P < 0.05) and 10 metre gait time (P < 0.01). In particular, improvements in exercise adherence (P < 0.05), self-efficacy (P < 0.05), and strength of knee extension (P < 0.05) were significant in the self-monitoring group compared with those in the control group. No increase in bleeding frequency and pain scale was noted. The self-monitoring of home exercise for haemophilic patients is useful for the improvement of exercise adherence, self-efficacy and knee extension strength.

ACVR1 (587T>C) mutation in a variant form of fibrodysplasia ossificans progressiva: second report

Fibrodysplasia ossificans progressiva (FOP) is a rare, congenital disorder caused by heterozygous mutation of the bone morphogenetic protein type I receptor ACVR1. Various forms of atypical FOP have recently been identified, and a novel mutation, ACVR1 (587T>C), was reported in 2011. We report on the second patient worldwide with ACVR1 (587T>C) mutation. A 22-year-old Japanese male with no family history of heterotopic ossification did not show any malformation of the great toes and showed normal development from birth to the age of 17 years, when heterotopic ossification appeared in the lumbar area. The clinical symptoms were similar to those reported previously: the delayed onset with a slower and mild clinical course and little finger camptodactyly. Gene analysis revealed that the patient was heterozygous for ACVR1 (587T>C) mutation, the same one as reported in 2011, suggesting a correlation between the location of the mutation and the clinical symptoms. This second report of ACVR1 (587T>C) mutation worldwide is particularly meaningful in that it highlights the difference between clinical symptoms of the first reported patient with ACVR1 (587T>C) mutation and those of classic FOP.

Should isolated peritoneal carcinomatosis from colorectal cancer be sub-classified into stage IVB in era of modern chemotherapy?

BACKGROUND

According to the 7th edition of the TNM staging system, stage IV metastatic colorectal cancer (CRC) at the time of initial diagnosis is sub-classified into stage IVA or IVB disease. Peritoneal carcinomatosis (PC), considered to have a dismal prognosis, is exclusively sub-classified into stage IVB, even though other metastases to a sole organ are sub-classified into stage IVA, which is considered to be associated with better survival. This retrospective study was undertaken to investigate the overall survival in metastatic CRC patients, focusing on PC patients.

METHODS

We reviewed data on patients with metastatic CRC at initial diagnosis surgically treated between January 2006 and June 2011. A survival analysis was performed paying special attention to PC and sub-classifying patients with PC into three categories according to metastatic sites.

RESULTS

There were 69 stage IVA patients (IVA group) and 83 stage IVB. Among stage IVB patients, 20 had isolated PC (PC-I group), 28 had PC with one or more other sites of metastasis (PC-II group), and 35 had at least 2 metastatic without peritoneal involvement (NPC group). Of 152 stage IV patients, 132 (87 %) underwent resection of the primary tumor and 19 (12 %) underwent radical resection of metastatic disease with microscopic free margins (R0 resection) including 5/20 (25 %) patients in the PC1 group. A total of 139 patients received oxaliplatin-based chemotherapy in a palliative (n = 125), neoadjuvant (n = 3), or adjuvant setting after R0 resection (n = 11). Compared with 36.6 months in the PC-I group, median survival was 32.5 months (P = 0.48) in the IVA group, 14.7 months (P = 0.07) in the PC-II group, and 12.9 months (P < 0.01) in the NPC group.

CONCLUSIONS

The sub-classification of isolated PC into stage IVA instead of IVB might be more appropriate in the era of modern chemotherapy. Further investigation is warranted.

Impact of hepatic lymph node metastasis on survival of patients with synchronous resectable or unresectable liver metastases of colorectal cancer

BACKGROUND

The goals of this retrospective study were to comprehensively evaluate the impact of hepatic lymph node (HLN) involvement on survival in patients with synchronous resectable or unresectable liver metastases from colorectal cancer and to highlight how to deal with such cases in the light of recent advances in chemotherapy.

METHODS

The impact of HLN involvement on survival, along with various clinical, pathological, and therapeutic factors, was retrospectively evaluated in 61 patients with synchronous liver metastases from colorectal cancer (resectable, 26; unresectable, 35), undergoing resection of the primary tumor and histopathological evaluation between July 2000 and April 2008.

RESULTS

The proportion with HLN metastasis was 11.5 % in resectable cases and 28.6 % in unresectable cases. On multivariate analysis using the Cox proportional hazards model, HLN metastasis (P < 0.001), along with non-resection of hepatic lesions (P < 0.001), larger metastatic tumor volume (P < 0.001), non-use of oxaliplatin-based chemotherapy (P < 0.001), involvement of 4 or more regional lymph nodes (P < 0.001), and excessive lymphatic invasion (P = 0.02), was identified as an independent risk factor for shorter survival.

CONCLUSIONS

To establish a new therapeutic strategy for synchronous liver metastasis of colorectal cancer, the HLNs should be examined histologically in patients undergoing resection of their primary colon and rectal cancer.

Predicting delayed pressure ulcer healing using thermography: a prospective cohort study

OBJECTIVE

To investigate whether thermography can be used to detect latent inflammation in pressure ulcers and predict pressure ulcer prognosis in a clinical setting.

METHOD

For this cohort study, we recruited 35 patients with stage II-IV pressure ulcers on the torso, who underwent thermographic assessment on discovery of their pressure ulcer. The patients were followed up for at least 3 weeks. Thermography was performed immediately after dressing removal. Pressure ulcers were classified into two groups depending on whether or not the wound site temperature was lower or higher than the periwound skin: the low temperature group and the high temperature group respectively. A generalised estimation equation was used to estimate the relative risk of delayed healing of pressure ulcers, comparing wounds with high temperatures and low temperatures.

RESULTS

Of the 35 patients, 21 had 'low temperature' wounds and 14 had 'high temperature' wounds at baseline. Two patients in the high temperature group presented with overt infection, and were excluded from further analysis. Twenty-two pressure ulcers were considered to heal 'normally' (that is, the wound area reduced by 30% or more within 3 weeks) and 16 did not heal. The baseline DESIGN score (a measure of gross wound status) did not differ in any subscales between the high and low temperature groups. The relative risk for delayed healing in high temperature cases was 2.25 (95% confidence intervals; 1.13-4.47, p=0.021). Sensitivity was 0.56, specificity was 0.82, positive predictive value was 0.75, and negative predictive value was 0.67.

CONCLUSION

Our results indicate that using thermography to classify pressure ulcers according to temperature could be a useful predictor of healing at 3 weeks, even though wound appearances may not differ at the point of thermographical assessment. The higher temperature in the wound site, when compared with periwound skin, may imply the presence of critical colonisation, or other factors which disturb the wound healing.

Resection of stage 0/I colon cancer via a circumferential periumbilical skin incision: relevance to single-incision laparoscopic surgery

BACKGROUND

We have been performing curative resection of colon cancer via a minilaparotomy without utilizing any laparoscopic instruments as an alternative to laparoscopic-assisted approach. Based on our experiences and improved surgical techniques, we have devised a new method for performing resection of stage 0/I colon cancer via a circumferential periumbilical skin incision that is associated with better cosmesis than standard minilaparotomy.

METHODS

The short- and long-term results of curative colectomy via a circumferential periumbilical skin incision without utilizing any laparoscopic instruments performed in selected patients with stage 0/I colon cancer between October 2003 and July 2004 were analyzed.

RESULTS

There were 8 men and 2 women with a median age of 66.5 years (range 61-77 years). Their median body mass index was 22.4 kg/m(2) (range 21.1-27.7 kg/m(2)). Pathological stage according the TNM classification was stage 0 in 4 patients and stage I in 6 patients. Median operative time was 160.5 min (range 135-203 min), and median blood loss was 60 ml (range 5-330 ml). Postoperative complications consisted of seroma in two patients and small bowel obstruction in one patient. After a median follow-up period of 5.7 years, there were no recurrences or wound complications.

CONCLUSION

Curative colectomy via a circumferential periumbilical skin incision seems oncologically safe, yields satisfactory cosmetic results, and may provide an alternative to single-incision laparoscopic surgery in selected patients with colon cancer.

Novel and recurrent TRPV4 mutations and their association with distinct phenotypes within the TRPV4 dysplasia family

BACKGROUND

Mutations in TRPV4, a gene that encodes a Ca(2+) permeable non-selective cation channel, have recently been found in a spectrum of skeletal dysplasias that includes brachyolmia, spondylometaphyseal dysplasia, Kozlowski type (SMDK) and metatropic dysplasia (MD). Only a total of seven missense mutations were detected, however. The full spectrum of TRPV4 mutations and their phenotypes remained unclear.

OBJECTIVES AND METHODS

To examine TRPV4 mutation spectrum and phenotype-genotype association, we searched for TRPV4 mutations by PCR-direct sequencing from genomic DNA in 22 MD and 20 SMDK probands.

RESULTS

TRPV4 mutations were found in all but one MD subject. In total, 19 different heterozygous mutations were identified in 41 subjects; two were recurrent and 17 were novel. In MD, a recurrent P799L mutation was identified in nine subjects, as well as 10 novel mutations including F471del, the first deletion mutation of TRPV4. In SMDK, a recurrent R594H mutation was identified in 12 subjects and seven novel mutations. An association between the position of mutations and the disease phenotype was also observed. Thus, P799 in exon 15 is a hot codon for MD mutations, as four different amino acid substitutions have been observed at this codon; while R594 in exon 11 is a hotspot for SMDK mutations.

CONCLUSION

The TRPV4 mutation spectrum in MD and SMDK, which showed genotype-phenotype correlation and potential functional significance of mutations that are non-randomly distributed over the gene, was presented in this study. The results would help diagnostic laboratories establish efficient screening strategies for genetic diagnosis of the TRPV4 dysplasia family diseases.

Curative colectomy via minilaparotomy approach without utilizing specific instruments

BACKGROUND

This study evaluated the need for specific instruments when performing a curative resection of colon cancer via a minilaparotomy approach, which has been reported to be a minimally invasive alternative to a laparoscopic approach.

METHODS

The feasibility, safety, and early oncological outcome were compared among 73 patients (first group), in whom a curative resection of colon cancer was performed via a minilaparotomy (skin incision < or =7 cm) utilizing specific instruments (North-bridge retractor system) between September 2002 and March 2005, and 94 patients (second group), in whom a similar procedure was performed without utilizing specific instruments between April 2005 and October 2007.

RESULTS

The two groups did not differ significantly in terms of age, sex, body mass index, site of tumor, level of lymph node dissection, blood loss, UICC stage, number of harvested lymph nodes, incidence of postoperative complications, length of postoperative hospital days, or overall survival, although the frequency of prior abdominal surgery was higher (38.3 vs. 21.9%; P = 0.03) and the median operating time required for a standard lymph node dissection was shorter (120 vs. 135 min; P = 0.03) in the second group.

CONCLUSION

With improved techniques and experience, specific instruments are not necessary for the performance of a curative colectomy via a minilaparotomy approach.

Towards integrated paediatric services in the Netherlands: a survey of views and policies on collaboration in the care for children with cerebral palsy

AIM

Worldwide, family-centred and co-ordinated care are seen as the two most desirable and effective methods of paediatric care delivery. This study outlines current views on how team collaboration comprising professionals in paediatric rehabilitation and special education and the parents of children with disabilities should be organized, and analyses the policies of five paediatric rehabilitation settings associated with the care of 44 children with cerebral palsy (CP) in the Netherlands.

METHODS

For an overview of current ideas on collaboration, written statements of professional associations in Dutch paediatric rehabilitation were examined. The policy statements of the five participating settings were derived from their institutional files. Documents detailing the collaborative arrangements involving the various professionals and parents were evaluated at the institutional level and at the child level. Involvement of the stakeholders was analysed based on team conferences.

RESULTS

Also in the Netherlands collaboration between rehabilitation and education professionals and parents is endorsed as the key principle in paediatric rehabilitation, with at its core the team conference in which the various priorities and goals are formulated and integrated into a personalized treatment plan. As to their collaborative approaches between rehabilitation centre and school, the five paediatric settings rarely differed, but at the child level approaches varied. Teams were large (averaging 10.5 members), and all three stakeholder groups were represented, but involvement differed per setting, as did the roles and contributions of the individual team members.

CONCLUSION

Collaboration between rehabilitation and education professionals and parents is supported and encouraged nationwide. Views on collaboration have been formulated, and general guidelines on family-centred and co-ordinated care are available. Yet, collaborative practices in Dutch paediatric care are still developing. Protocols that carefully delineate the commitments to collaborate and that translate the policies into practical, detailed guidelines are needed, as they are a prerequisite for successful teamwork.

Phase I/II study of S-1 combined with paclitaxel in patients with unresectable and/or recurrent advanced gastric cancer

Both paclitaxel and S-1 are effective against gastric cancer, but the optimal regimen for combined chemotherapy with these drugs remains unclear. This phase I/II study was designed to determine the maximum tolerated dose (MTD), recommended dose (RD), dose-limiting toxicity (DLT), and objective response rate of paclitaxel in combination with S-1. S-1 was administered orally at a fixed dose of 80 mg m-2 day-1 from days 1 to 14 of a 28-day cycle. Paclitaxel was given intravenously on days 1, 8, and 15, starting with a dose of 40 mg m-2 day-1. The dose was increased in a stepwise manner to 70 mg m-2. Treatment was repeated every 4 weeks unless disease progression was confirmed. In the phase I portion, 17 patients were enrolled. The MTD of paclitaxel was estimated to be 70 mg m-2 because 40% of the patients given this dose level (two of five) had DLT. The RD was determined to be 60 mg m-2. In the phase II portion, 24 patients, including five with assessable disease who received the RD in the phase I portion, were evaluated. The median number of treatment courses was six (range: 1-17). The incidence of the worst-grade toxicity in patients given the RD was 28 and 8%, respectively. All toxic effects were manageable. The response rate was 54.1%, and the median survival time was 15.5 months. Our phase I/II trial showed that S-1 combined with paclitaxel is effective and well tolerated in patients with advanced gastric cancer.

The technique of laparoscopically assisted total gastrectomy with jejunal interposition for early gastric cancer

BACKGROUND

In recent years, laparoscopic gastrectomy has been applied to the treatment of gastric cancer in Japan. However, there are few reports of laparoscopic or laparoscopically assisted total gastrectomy in the treatment of gastric cancer because of the difficulty of the surgical technique. Laparoscopically assisted total gastrectomies with jejunal interpositions were performed on four patients with early gastric cancer located in the upper portion of the stomach.

METHODS

Four surgical ports were inserted into the abdomen. The stomach was lifted to the abdominal wall using newly developed retraction tubes. Gastric arteries were divided using ultrasonically activated coagulating shears and ligated with ligation forceps. Following these steps, a total gastrectomy reconstruction was performed by jejunal interposition through a small transverse laparotomy. An esophagojejunostomy and a jejunoduodenostomy were made with circular staplers.

RESULTS

The mean operating time and blood loss were 246 min and 236 ml, respectively. The operations were performed without serious complications. All patients were pain free and ambulatory after the laparoscopically assisted total gastrectomy, and the mean postoperative hospital stay was 16 days.

CONCLUSION

We successfully performed laparoscopically assisted total gastrectomies in a relatively short period of time. When patients are carefully selected, the laparoscopic procedure can be curative and minimally invasive as a treatment for early gastric cancer.

Identification of sequence polymorphisms of the COMP (cartilage oligomeric matrix protein) gene and association study in osteoarthrosis of the knee and hip joints

Osteoarthrosis (OA) is a common cause of musculoskeletal disability characterized by late-onset degeneration of articular cartilage. Although several candidate genes have been reported, susceptibility genes for OA remain to be determined. Hereditary osteochondral dysplasias produce severe, early-onset OA and hence are models for common idiopathic OA. Among them are pseudoachondroplasia and multiple epiphyseal dysplasia, both of which are caused by mutations in the cartilage oligomeric matrix protein (COMP) gene. Therefore, COMP may be a susceptibility gene for OA. We screened for polymorphisms by direct sequencing of all exons of the COMP gene with their flanking intron sequences and the promoter region. We identified 16 polymorphisms, of which 12 were novel. Using six polymorphisms spanning the entire COMP gene, we examined the association of COMP in Japanese patients with OA of the knee and hip joints. Genotype and allele frequencies of the polymorphisms were not significantly different between OA and control groups, and there was no significant difference in haplotypes. These results do not support an association between COMP and OA in the Japanese population.

Cleft palate in spondyloepiphyseal dysplasia congenita: case reports

Cleft palate is one of the common features of spondyloepiphyseal dysplasia congenita (SEDC). However, there are few clinical data about cleft palate in SEDC. We report four patients with cleft palate and SEDC including two with overt cleft palate and two with submucous cleft palate. Our results suggested that SEDC associated with cleft palate should be treated in the same way as solitary cleft palate, and submucous cleft palate may be more common in patients with SEDC than previously appreciated.

Novel mutation in exon 18 of the cartilage oligomeric matrix protein gene causes a severe pseudoachondroplasia

Pseudoachondroplasia (PSACH) is a common skeletal dysplasia characterized by disproportionate short stature, early-onset osteoarthrosis, and dysplasia of the spine, epiphysis, and metaphysis. Multiple epiphyseal dysplasia (MED) is a similar but less severe disorder characterized by dysplasia of the epiphysis. Both disorders are caused by mutations in the cartilage oligomeric matrix protein (COMP) gene. COMP mutations cluster in a region of the gene that encodes calmodulin-like repeats (CLRs) and correlate closely with disease severity. Typically, mutations in exon 13 that composes the seventh CLR produce severe PSACH phenotypes, whereas mutations found elsewhere in the gene produce mild PSACH or MED phenotypes. We have identified a PSACH patient carrying a novel mutation in exon 18 of COMP that composes the C-terminal globular domain. This mutation produced a severe PSACH phenotype with marked short stature and deformities of the spine and extremities. Our results extend the range of disease-causing mutations within the COMP gene and demonstrate the importance of the additional domain of COMP protein in its in vivo function.

Pyloric relaxation regulated via intramural neural pathway of the antrum

Current information about pyloric relaxation is not sufficient. For this reason, our study aimed at measuring pyloric relaxation correctly and determining the role of the intrinsic and extrinsic neural pathway in pyloric relaxation. Five groups of dogs were used: five dogs had an intact gastrointestinal tract (control group); five dogs had transection and reanastomosis of the antrum 3 cm proximal to the pylorus (antral transection group); five dogs had extrinsic pyloric denervation (denervation group); five dogs had transection and reanastomosis of the antrum with extrinsic pyloric ring denervation (transection with denervation group); and five dogs had truncal vagotomy (vagotomy group). Gastropyloroduodenal motility was recorded by a strain-gauge force transducer in conscious dogs. In the control and denervation groups, pyloric relaxation was observed only during phase III of the interdigestive migrating motor complex. In the antral transection, transection with denervation, and vagotomy groups, pyloric relaxation was not observed in either the interdigestive or the postprandial state. The frequency of pyloric contractions increased in these groups in comparison with the control group. In conclusion, the results suggest that pyloric relaxation occurred during phase III to expel undigested particles from the stomach and that descending antral intramural pathways play an important role in the control of pyloric relaxation.

Barostat examination of proximal site of the anastomosis in patients with rectal cancer after low anterior resection

Patients who have undergone low anterior resection (LAR) of the rectum for cancer show symptoms of urgency and frequency of defecation after meals. The cause of these symptoms is unclear. It was hypothesized that the functional disorder of the proximal site of the anastomosis after low anterior resection of the rectum often leads to the symptoms and that the 5-HT3 receptor antagonist reduces postprandial colonic contractions. The aim of this study was to assess colon contractions of the proximal site of the anastomosis and the effects of the 5-HT3 receptor antagonist on the contractions. We evaluated 37 patients who had undergone LARs, 17 with high stool frequency (more than four times per day) and 20 with normal stool frequency. In the first part of the study, basal tone, compliance of the proximal site of the anastomosis, and response to a meal (300 kcal) were recorded with a barostat in all patients. In the second part of the study the effects of the 5-HT3 receptor antagonist on contractions of the proximal site of the anastomosis after ingesting a meal was evaluated. Seven healthy controls were also studied for descending colonic tone with a barostat after a meal. Basal barostat balloon volumes showed only small variations in the two post-LAR groups. Compliance of the proximal site of the anastomosis was similar in the two groups. Meal ingestion stimulated contractions of the proximal site of the anastomosis. In patients with high stool frequency the proximal site of the anastomosis contracted earlier than in those with normal stool frequency after a meal. The descending colonic tone of healthy controls did not change after a meal. The 5-HT3 receptor antagonist inhibited postprandial contractions of the proximal site of the anastomosis after LAR. These observations lend support to the idea that gastrocolonic reflex increases in patients who have undergone LAR, leading to high stool frequency. Furthermore, the 5-HT3 receptor antagonist may alleviate the symptoms of urgency and the frequency of defecation.

Magnetic resonance imaging findings and treatment outcome in late-onset tibia vara

Several retrospective studies have shown the usefulness of magnetic resonance imaging (MRI) in the evaluation of tibia vara. With respect to the late-onset type, however, there have been no English-language reports on MRI findings. In this article, the authors report on the MRI features of three patients with late-onset tibia vara, the results of treatment that was chosen on the basis of the findings, and the histologic characteristics of the disease. Fat-suppressed MRI revealed partial closure of the tibial physis in one patient and near-closure in another patient. They underwent osteotomy with resection of the bone bridge and have shown no evidence of recurrence. In the third patient, only irregularity of the physis was found on MRI, and she was treated conservatively. Her varus deformity subsequently improved, although it persisted. Histologic examination revealed disorganization and misalignment of the physeal zone and transverse alignment of the trabeculae. The patient with a bony bridge also had discrete ossification centers in the physeal zone.

Obstruction due to persimmon bezoars: computed tomography detection

BACKGROUND/AIMS

Small-bowel obstructions caused by persimmon bezoars are uncommon, and the diagnosis is difficult before operation. The aim of this study was to present computed tomography findings of persimmon bezoars in the small bowel.

METHODOLOGY

We reviewed 3 cases diagnosed with small-bowel obstruction caused by persimmon bezoars between April 1997 and March 1999 at Chikamori Hospital.

RESULTS

The cause of the small-bowel obstruction was bezoars in the 3 patients. Abdominal computed tomography performed before operation revealed a well-defined, intraluminal inhomogeneous mottled mass containing gas bubbles.

CONCLUSIONS

Computed tomography is useful for diagnosing obstructed small-bowel persimmon bezoars.

Effect of duodenectomy on gastric motility and gastric hormones in dogs

OBJECTIVE

To test the hypothesis that the duodenum is required to coordinate interdigestive insulin secretion with gastrointestinal motility and to determine whether duodenectomy alters the interdigestive cycles of plasma motilin and insulin levels and their relations to insulin secretion and motility.

METHODS

Adult mongrel dogs were chronically implanted with force transducers in the stomach, duodenum, and upper jejunum to monitor contractile activity. Eight healthy mongrel dogs were divided into control and duodenectomized dogs. Insulin secretion, gastrointestinal motility, and plasma concentrations of motilin during the interdigestive period were measured in normal and duodenectomized dogs.

RESULTS

After duodenectomy, no obvious phase III contractions were seen in the gastric antrum, but migrating phase III contractions were seen in the upper jejunum. The plasma motilin concentration did not fluctuate as it does in normal dogs, and remained low. After duodenectomy, insulin secretory cycles were not coordinated with either cycles of interdigestive motility or the plasma concentration of motilin. Exogenous motilin administration stimulated endogenous insulin release significantly compared with saline-treated controls. The contractile response of the stomach to exogenous motilin after duodenectomy was similar to that of intact dogs.

CONCLUSIONS

Duodenectomy disrupts the relation between cycles of both interdigestive gastrointestinal motility and insulin secretion. These effects of duodenectomy may be attributable to interruption of the duodenopancreatic neural connections, hormonal abnormalities, or loss of vagus-sensitive humoral factors. The duodenum, which stores motilin, seems to play an important role in the relations between gastric migrating motor complexes and the concomitant increase of insulin secretion in fasted dogs. The mechanism responsible for the effect of motilin in both duodenectomized and normal dogs may involve a cholinergic pathway.

Expression of telomerase reverse transcriptase and telomere elongation during sexual maturation in Paramecium caudatum

Paramecium caudatum has a sexually immature period that lasts for about 60 fissions. To examine the possibility that telomere length is one of the determining factors of the duration of immaturity, we cloned the telomerase reverse transcriptase (TERT) gene from P. caudatum, and analyzed its expression levels at mRNA, telomerase activity, and telomere length during the course of clonal division. Paramecium TERT (Pc_TERT) cDNA encodes a basic protein of 107 kDa that harbors conserved RT motifs, T motif, CP motif, and N motif. Pc_TERT mRNA is expressed at very low levels only detectable by RT-PCR, but constitutively, during immature and mature periods, exhibiting abundant telomerase activity. No clear phase shift in Pc_TERT expression, telomerase activity, or telomere length was observed at the point of maturation in P. caudatum. Instead, the telomere elongates successively as cells divide in P. caudatum, although a close species, P. tetraurelia, was reported to keep the length constant. We discuss possible mechanisms for the expression of sexual activity associated with telomere length in P. caudatum.

Mutation frequencies of EXT1 and EXT2 in 43 Japanese families with hereditary multiple exostoses

Hereditary multiple exostoses (EXT) is an autosomal dominant bone disease characterized by the formation of cartilage-capped prominences. EXT is genetically heterogeneous with at least four chromosomal loci. Among the four loci, the exostosis type 1 gene (EXT1) and type 2 gene (EXT2) have been cloned. Previous studies have shown that disease-type-specific frequency of mutations is different among various ethnic populations. To determine those frequencies in the Japanese, we conducted a large-scale mutation screening on both genes. In 23 of 43 Japanese families examined, we found 21 different mutations, of which 18 are novel. Seventeen (40%) of the 23 families had a mutation in EXT1 and six (14%) had a mutation in EXT2, suggesting that the former mutations are more frequent than the latter in Japanese EXT families. Of the 17 families with EXT1 mutations, 13 had those causing premature termination of the EXT1 protein and four showed missense mutations, whereas five of the six families with EXT2 mutations had those causing premature termination and one showed missense mutation. Interestingly, all four EXT1 missense mutations occurred in an arginine residue at codon 340 (R340) that is known as a critical site for expression of heparan sulfate glycosaminoglycans, suggesting that the region encompassing the arginine residue may play an important role in the function of the EXT1 protein. These results expand our knowledge of the ethnic difference of EXT and the structure-function relationship of the EXT genes.

Spondylar dysplasia in type X collagenopathy

BACKGROUND

The type X collagen gene (COL10A1) is currently known as the disease-causing gene of metaphyseal dysplasia type Schmid (MDS), whereas a mutation of COL10A1 has been reported to cosegregate with a disease phenotype of mild spondylometaphyseal dysplasia (SMD) in a Japanese family.

OBJECTIVE

To elucidate whether or not spondylar dysplasia is common in patients with mutations of COL10A1.

MATERIALS AND METHODS

We re-evaluated the radiological manifestations in six patients with mutations of COL10A1, who had been previously reported as having MDS.

RESULTS

Two of six patients showed mild platyspondyly in infancy and early childhood. In both patients, the spondylar dysplasia tended to normalize with age, but mild alterations of the vertebral bodies persisted, even into late childhood. The other radiological manifestations of both patients were identical to those of MDS.

CONCLUSION

Our observation suggests that mild spondylar dysplasia may not be uncommon in MDS.

A search for calcium, magnesium and zinc levels in fingernails of 135 patients with osteogenesis imperfecta

Calcium (Ca), magnesium (Mg) and zinc (Zn) levels of fingernails were measured in 135 patients with osteogenesis imperfecta (OI) and compared with the sex- and age-matched healthy controls. Zinc levels in OI nails were significantly higher than that in normal subjects, but in cases and controls Ca and Mg levels were not significantly different. The ratios of Ca/Zn and Mg/Zn in OI nails differed significantly from those in controls, but a similar Ca/Mg ratio was found in nails of both groups. These results suggest that Zn levels in fingernails may reflect abnormal Zn metabolism in OI. To determine Zn metabolism changes in OI, further studies are needed.

Laparoscopically assisted total or distal gastrectomy with lymph node dissection for early gastric cancer

BACKGROUND

A secure lymphadenectomy in a laparoscopically assisted gastrectomy performed for gastric cancer is required because of the high prevalence of lymph node metastasis. A surgical technique for laparoscopic gastrectomy with lymph node dissection and reconstruction using a conventional circular stapler is reported.

METHODS

Forty-nine laparoscopically assisted gastrectomies with lymphadenectomy (47 distal and two total gastrectomies) were performed using devices for retraction of the stomach and laparoscopic ligation of arteries, which were developed to ensure secure dissection of lymph nodes. Reconstruction by Billroth I or intestinal interposition using a conventional circular stapler was performed through a small incision through which the specimen was removed. When submucosal invasion was suspected (n = 16), the lymph nodes along with the common hepatic artery were also dissected through the same incision.

RESULTS

The operations were performed without serious complication. None was converted to laparotomy, and there were no deaths. Metastatic lymph nodes were seen in perigastric nodes and nodes along the left gastric artery in five cases. In five of the 49 patients the macroscopic diagnosis of depth of invasion was underestimated.

CONCLUSION

A technique of laparoscopic gastrectomy with lymph node dissection for early invasive gastric cancer is described. A definitive answer concerning the appropriate level of lymph node dissection and the role of laparoscopic gastrectomy in the treatment of more advanced gastric cancer remains to be defined.

Prostaglandin E2 stimulates motilin release via a cholinergic muscarinic pathway in the dog

Prostaglandins are well known to be widely distributed in mammalian gastrointestinal tissues and to play a role in the regulation of gastrointestinal hormones and contractions. The present study was undertaken to determine whether prostaglandins have an effect on the endogenous release of motilin in the dog. In six conscious dogs, gastrointestinal contractions were monitored by means of chronically implanted force transducers. Prostaglandin E2 (PGE2; 3, 10, 30 microgram kg-1) was given intravenously during the interdigestive phase I period with or without a muscarinic or nicotinic receptor antagonist. Blood samples were collected from 10 min before, to 30 min after, prostaglandin injection. Indomethacin (5 mg kg-1) was given intravenously to investigate the effect of endogenous prostaglandins on motilin release. PGE2 significantly stimulated motilin release but not gastric contractions. Atropine, but not hexamethonium, blocked PGE2-induced motilin release. Motilin release in response to PGE2 was significantly increased by pretreatment with hexamethonium. Indomethacin inhibited the cyclic release of motilin and gastric phase III contractions. We conclude that PGE2 appears to stimulate motilin release via cholinergic muscarinic pathways, and nicotinic receptors modulate this reaction. PGE2 may be involved in part in the regulation of the cyclic release of motilin and the occurrence of gastric phase III.

Laparoscopic Nissen fundoplication using laparosonic coagulating shears: report of a case

A 64-year-old man was admitted to Gunma University Hospital because of gastroesophageal reflux disease and hiatus hernia. Endoscopic examination showed a linear ulcer and mucosal redness in the lower esophagus. Gastrointestinal contrast study revealed a large esophageal hiatal sliding hernia. Laparoscopic Nissen fundoplication was then performed. Short gastric vessels were divided and lesser omentum was ablated with laparosonic coagulating shears, and the fundus of the stomach was used to construct the wrap around the esophagus. Three hundred and sixty degree fundoplication was undertaken using four sutures to secure the wrap. The patient is well and is currently free from reflux symptoms. Laparoscopic Nissen fundoplication is effective in the control of gastroesophageal reflux in the patient with hiatus hernia. This case report demonstrates that the use of laparosonic coagulating shears is effective for the division of the short gastric vessels.

Mutations in the N-terminal globular domain of the type X collagen gene (COL10A1) in patients with Schmid metaphyseal chondrodysplasia

Schmid metaphyseal chondrodysplasia (SMCD) is a relatively common, heritable osteochondrodysplasia characterized by short-limbed short stature with normal facies, and generalized metaphyseal dysplasias of the long and short tubular bones. Several mutations of the type X collagen gene (COL10A1) have been reported in patients with SMCD, all in the C-terminal globular domain. To address whether mutations in other domains can cause SMCD, we examined the coding region of the COL10A1 gene in DNA samples from six Japanese families affected with SMCD, by direct sequencing. We detected novel mutations in three unrelated SMCD patients; one was a one-base deletion in the C-terminal globular domain and others were de novo missense mutations in the N-terminal globular domain. All three cases revealed a typical clinical phenotype for SMCD. Thus, we have demonstrated that mutations of COL10A1 in regions other than the C-terminal globular domain can cause SMCD, and the results suggest that the N-terminal globular domain also plays an important role in formation of type X collagen.

Molecular cloning and functional analysis of apoxin I, a snake venom-derived apoptosis-inducing factor with L-amino acid oxidase activity

We previously purified apoxin I, an apoptosis-inducing factor with L-amino acid oxidase (LAO) activity, from Western diamondback rattlesnake venom. To determine the primary structure of apoxin I, we cloned its cDNA. The amino acid sequence showed that apoxin I has an FAD binding domain and shares homology with L-amino acid oxidase (LAO) from Neurospora crassa, human monoamine oxidase B, and mouse interleukin 4-induced F1G1 protein. The full-length apoxin I has an N-terminal signal sequence that is processed in mature apoxin I in venom. When the apoxin I gene was transfected into human 293T cells, the recombinant protein was expressed in the cells, and a significant amount of apoxin I was secreted into the medium. The secreted recombinant apoxin I protein showed LAO and apoptosis-inducing activity, but the recombinant protein in the cells did not, suggesting that maturation and secretion of the apoxin I protein is needed for its activity. Treating the transfected cells with tunicamycin inhibited the secretion and LAO activity of the recombinant apoxin I. In addition, deleting the amino-terminal region flanking the signal sequence, the FAD-binding domain and the carboxy-terminal region abolished the secretion and LAO activity of the recombinant proteins. These results indicate that in order for apoxin I to become active, these regions and posttranslational modification, such as N-glycosylation, are required.

Cytotoxic alkaloids of Pachysandra terminalis

Four steroidal alkaloids, epipachysamines B (1) and E (2), pachystermine A (3) and pachysamine E (4), were isolated as cytotoxic principles from the MeOH extract of the stems of Pachysandra terminalis SIEB. et ZUCC. (Buxaceae). These alkaloids showed cytotoxic activity against P388 and P388/ADR leukemia cells in vitro. Three of the alkaloids (1-3) were previously isolated from this plant material, and this is the first report of their cytotoxic activity. Pachysamine E (4) is a new alkaloid.

Swelling of the dorsum of the hand and/or foot can be a first sign of Maffucci syndrome

The cardinal feature of Maffucci syndrome is the coexistence of enchondromatosis and vascular anomalies. The patients are usually normal at birth, the disease becoming evident at any time up to puberty. Association of soft-tissue swelling has been described in this syndrome but has not been listed as a sign or symptom. We report three cases in which the initial sign was diffuse swelling of the dorsum of the hand and/or foot. This was noticed at birth in cases 1 (girl) and 3 (girl) and at the age of 1 month in case 2 (boy), who otherwise appeared normal except for case 3 who had a rectovestibular fistula. The pathology of the swollen soft tissue was adipose tissue associated with various degrees of thickened and fibrotic septum containing dilated lymphatic channels. These dilated channels within the septum were so subtle that they were initially overlooked in cases 1 and 2. Awareness that swelling of the dorsum of the hand or foot can be the sole sign and symptom of Maffucci syndrome before the typical indications become evident helps the physician establish an early diagnosis of this condition.

Postprandial normal saline intake delays gastric emptying of solids in conscious dogs: partial involvement of CCK in its mechanism

Although it is known that a caloric liquid meal given after food intake delays solid gastric emptying, the effect of a noncaloric liquid is not known. The aims of this study were to determine the effect of normal saline given at 3 hr after feeding on gastric antral motor activity and gastric emptying and to evaluate the role of endogenous cholecystokinin in the changes in gastric function induced by postprandial saline intake in conscious dogs. Two cannulas were implanted in each of five mongrel dogs for infusion of phenolsulfonphthalein into the proximal duodenum and for aspiration of luminal samples from the distal duodenum. Gastric contractile and emptying activity were measured by the force transducer method and a freeze-drying method newly developed by our group, respectively. Postprandial pancreaticobiliary secretion was assessed from amylase and bile acid outputs into the duodenum. One hundred grams of freeze-dried dog food was given as a solid meal after mixing it with 100 ml of normal saline. The dogs were given 100 ml of normal saline per os at 3 hr after feeding. In another study, intravenous administration of devazepide, a specific cholecystokinin-A receptor antagonist, at a dose of 0.1 mg/kg/hr was begun 15 min before postprandial saline intake and continued for 1 hr. Gastric antral motility was significantly (P < 0.01) inhibited for 30 min after the dogs had drunk saline at 3 hr after feeding. The mean fractional emptying rate of gastric solids in percentage per 30 min after postprandial saline intake was significantly (P < 0.05) slower than that in the control study without saline intake at 3 hr after feeding. Amylase output into the duodenum after postprandial saline intake showed a gradual increase lasting for about 1 hr, whereas that of bile acid increased transiently but markedly 15 min after saline intake, in comparison with the control study. Pretreatment with devazepide partially ameliorated the suppression of gastric antral motility. Postprandial intake of saline inhibited gastric motor activity and delayed solid gastric emptying, whereas it increased the outputs of amylase and bile acid. Endogenous cholecystokinin may be partially involved in these phenomena caused by saline intake at 3 hr after feeding.