Clinical characteristics and survival outcomes of elderly patients with de novo metastatic germ cell tumors

OBJECTIVES

To determine the outcomes for elderly patients with de novo metastatic germ cell tumors and the influence of patient age on adherence to standard chemotherapy.

METHODS

A total of 150 patients who were initially diagnosed with metastatic germ cell tumors and treated at our institution between 2007 and 2021 were included. Patients were classified according to three age groups: aged <40, 40-49, and ≥50 years. Clinicopathological features, adherence to standard first-line chemotherapy, overall survival, and disease-free survival were compared between these groups. We also analyzed the outcomes of patients who received low-intensity induction chemotherapy due to adverse events and/or comorbidities.

RESULTS

There was no significant difference in any of the survival outcomes and in the rate of adherence to standard first-line chemotherapy between the three age groups, although elderly patients with intermediate/poor prognosis group tended to receive less-intense chemotherapies. The rate of febrile neutropenia as a chemotherapy-related adverse event was significantly higher in patients aged ≥50 years. No statistical significance in survival outcomes was detected between the group of patients who received relatively low-intensity induction chemotherapy and those who received adequately intensive planned chemotherapy.

CONCLUSIONS

The adherence rate of standard fist-line chemotherapy of elderly patients is almost comparable to that of younger patients, although some adverse events should be carefully managed. Even elderly patients with metastatic germ cell tumors can aim for equivalently good survival outcome like younger populations, with effort to adhere to standard chemotherapy.

Significant reduction in burden of metastatic disease by intermittent docetaxel therapy in a patient with castration-resistant prostate cancer

Intermittent docetaxel therapy (IDT) is rarely used nowadays as a treatment option for men with metastatic castration-resistant prostate cancer (mCRPC) because of the widespread availability of androgen receptor axis-targeted therapy, which is less toxic. Therefore, there is limited information available on whether IDT has a clinical benefit in the treatment of men with mCRPC. This report describes the case of a 66-year-old man with a diagnosis of cT2N1M0 prostate cancer who underwent neoadjuvant combined androgen blockade and whole-pelvis radiation therapy. However, the tumor had progressed to mCRPC with metastasis to the bladder and a left pelvic lymph node within 2 years. Docetaxel had been administered as first-line chemotherapy, and the patient achieved a complete response in terms of the bladder metastasis. Docetaxel was stopped after 15 cycles. When a durable response had been maintained for more than 2 years, during which only androgen deprivation therapy was administered, the patient was switched to observation only. However, his prostate-specific antigen level gradually increased. Abiraterone was started as second-line therapy, during which there was a rapid increase in the PSA level. Computed tomography revealed further enlargement of the left pelvic lymph node, bladder metastasis, metastasis to the left common iliac lymph nodes, and several disseminated nodules around the bladder. Docetaxel was reintroduced as IDT for third-line therapy, and a complete response was achieved for all metastases, with the exception of the metastasis in the left pelvic lymph node. Thus far, the patient has survived for more than 7 years after starting docetaxel as first-line therapy for mCRPC. IDT is potentially useful in a subgroup of patients with mCRPC and could achieve long-term survival. Comprehensive genomic profiling may help physicians to select patients with mCRPC who are more likely to benefit from docetaxel than other systemic therapy.

Brainstem Neural Circuits Triggering Vertical Saccades and Fixation

Neurons in the nucleus raphe interpositus have tonic activity that suppresses saccadic burst neurons (BNs) during eye fixations, and that is inhibited before and during saccades in all directions (omnipause neurons, OPNs). We have previously demonstrated via intracellular recording and anatomical staining in anesthetized cats of both sexes that OPNs are inhibited by BNs in the medullary reticular formation (horizontal inhibitory BNs, IBNs). These horizontal IBNs receive monosynaptic input from the caudal horizontal saccade area of the superior colliculus (SC), and then produce monosynaptic inhibition in OPNs, providing a mechanism to trigger saccades. However, it is well known that the neural circuits driving horizontal components of saccades are independent from the circuits driving vertical components. Thus, our previous results are unable to explain how purely vertical saccades are triggered. Here, we again apply intracellular recording to show that a disynaptic vertical IBN circuit exists, analogous to the horizontal circuit. Specifically, we show that stimulation of the SC rostral vertical saccade area produces disynaptic inhibition in OPNs, which is not abolished by midline section between the horizontal IBNs. This excludes the possibility that horizontal IBNs could be responsible for the OPN inhibition during vertical saccades. We then show that vertical IBNs in the interstitial nucleus of Cajal, which receive monosynaptic input from rostral SC, are responsible for the disynaptic inhibition of OPNs. These results indicate that a similarly functioning SC-IBN-OPN circuit exists for both the horizontal and vertical oculomotor pathways. These two IBN-mediated circuits are capable of triggering saccades in any direction.Significance Statement Saccades shift gaze to objects of interest, moving their image to the central retina, where it is maintained for detailed examination (fixation). During fixation, high gain saccade burst neurons (BNs) are tonically inhibited by omnipause neurons (OPNs). Our previous study showed that medullary horizontal inhibitory BNs (IBNs) activated from the caudal superior colliculus (SC) inhibit tonically active OPNs in order to initiate horizontal saccades. The present study addresses the source of OPN inhibition for vertical saccades. We find that OPNs monosynaptically inhibit vertical IBNs in the interstitial nucleus of Cajal during fixation. Those same vertical IBNs are activated by the rostral SC, and inhibit OPN activity to initiate vertical saccades.

[A Survey on the Concomitant Use of Drugs with Enzalutamide in Medical Practice-The Effects and Resultant Decrease in Efficacy]

PURPOSE

Enzalutamide is a potent inducer of cytochrome P450 substrates. Hence, it induces major metabolizing enzyme effects in some of the concomitant drugs, raising the possibility of decreased efficacy. We investigated the actual status of drugs for which precautions for co-administration are indicated during concomitant use with enzalutamide.

METHODS

We retrospectively investigated the duration of enzalutamide use, concomitant medications, laboratory values, and events using the medical records of patients prescribed enzalutamide for castration-resistant prostate cancer at the National Cancer Center Hospital from May 2014 to May 2017.

RESULTS

The median age of the 107 studied patients was 74 years[range: 53-93], median duration of enzalutamide prescriptions was 120 days[range: 14-1,008], and the median number of concomitant medications(components)was 6[range: 0-16]. Sixty nine patients(64%)were taking drugs that could be affected by enzyme induction. The medications listed in the concomitant use section of the package insert were warfarin(3 patients) and omeprazole(2 patients). In this study, 4 patients(except for 1 on warfarin)were taking other drugs that could be affected by enzyme induction. Events considered to possibly reduce their efficacy during concomitant use with enzalutamide were elevated blood pressure and blood clots.

CONCLUSIONS

When enzalutamide is used in combination with other drugs, there exists the possibility that the effect of concomitant medications may be weakened by enzyme induction.

Massive calcification around large joints in a patient subsequently diagnosed with adult-onset hypophosphatasia

We report a 64-year-old Japanese woman with a history of progressive loss of motor function and painful swelling of large joints. At the age of 54, profound calcification appeared around the shoulder and hip joints, which did not heal after repeated surgical resections. Iliac bone biopsy revealed osteomalacic changes. Laboratory data showed low serum alkaline phosphatase (ALP) activity and a high urine phosphoethanolamine (PEA) concentration with normal serum calcium, phosphate, and fibroblast growth factor 23 (FGF23) levels. Subsequent genetic analysis of the ALPL gene confirmed the diagnosis of hypophosphatasia (HPP) with the identification of a heterozygous single nucleotide deletion, c.1559delT (p.Leu520ArgfsX86). We started a mineral-targeted enzyme replacement therapy, asfotase alfa (AA), to treat the patient's musculoskeletal symptoms. A follow-up bone biopsy after 12 months of AA treatment showed improvement of osteomalacia. Calcified deposits around the large joints were unchanged radiographically. To our knowledge, this is the first report of a patient with an adult-onset HPP who presented with profound calcification around multiple joints. Nonspecific clinical signs and symptoms in patients with adult-onset HPP often result in delayed diagnosis or misdiagnosis. We propose that bone biopsy and genetic analysis should be considered along with laboratory analysis for all patients with ectopic calcification around joints of unknown etiology for accurate diagnosis and better treatment.

Impact of low-dose or under-dose direct oral anticoagulant on coagulation and fibrinolytic markers in patients with atrial fibrillation

Background

Atrial fibrillation (AF) is known to increase the risks of cerebral and systemic embolism. Apart from vitamin K antagonists, edoxaban, a direct oral anticoagulant (DOAC), has been approved for oral anticoagulation in patients with non-valvular AF. On the other hand, DOACs are sometimes prescribed at off-label under-doses for patients who have undergone ablation for AF. Prothrombin fragment F1+2 is an activation peptide released from prothrombin during thrombin formation. The purpose of this study is to compare the effects of DOAC doses on coagulation and fibrinolytic markers.

Methods and results

A total of 88 patients with AF (age: 68±11 years, male:45%, paroxysmal AF n=49, persistent AF n=39) were recruited. All patients were received edoxaban (60mg or 30mg) once a day. For the purpose of the study, patients were divided into three groups according to whether they had been treated before the ablation procedure under an appropriate standard dose group (n=30 [34.1%]), appropriate low-dose group (n=35 [39.8%]), or off-label under-dose group (n=23 [26.1%]). We examined the coagulation and fibrinolytic markers, and echocardiographic parameters before ablation. All patients were followed up for 12 months after AF ablation. Creatinine clearance was significantly higher in appropriate standard-dose group than in appropriate low-dose or off-label under-dose group (101.1±38.4, 57.1±15.9 and 73.2±14.6 mL/min, respectively; P&lt;0.001). There were no significant baseline differences in AF type, history of stroke/transient ischemic attack (TIA), plasma B-type natriuretic peptide, protein C, fibrinogen, D-dimer level, left ventricular ejection fraction or left atrium dimension among the three groups. Prothrombin fragment F1+2 level was significantly lower in the appropriate standard-dose group than the appropriate low-dose and off-label under-dose groups (105.9±29.4, 142.6±41.3 and 142.8±84.9 pmol/L, respectively; P=0.011, Figure). One patient in the appropriate low-dose group had a TIA and 1 patient in the off-label under-dose group had a bleeding event during the follow up period after ablation.

Conclusion

Our results suggest that an appropriate standard dose of edoxaban is needed to suppress hypercoagulability in patients with AF.

Funding Acknowledgement

Type of funding sources: None. Prothrombin fragment F1+2 level

Prognostic implication of staging of seminal vesicle invasion in patients with prostatic adenocarcinoma after prostatectomy

OBJECTIVES

To evaluate whether the extent of seminal vesicle invasion of prostatic adenocarcinoma can stratify the risk of biochemical recurrence after radical prostatectomy.

METHODS

We carried out radical prostatectomy for 1309 patients with prostatic adenocarcinoma between 2006 and 2019; 135 (10.3%) patients had seminal vesicle invasion. After excluding patients with neo-/adjuvant therapy, we reviewed 105 patients. We analyzed the correlation of the extent of seminal vesicle invasion and biochemical recurrence-free survival after prostatectomy and adjusted by various clinicopathological factors in multivariate analyses. Seminal vesicle invasion was stratified into three groups; the proximal part from the base was defined as level 1, followed by level 2 and the distal part as level 3.

RESULTS

Among the 105 patients, 30 (29%), 54 (51%) and 21 patients (20%) had seminal vesicle invasion at levels 1, 2 and 3, respectively. Median times to biochemical recurrence were 110, 67 and 12 months in patients with levels 1, 2 and 3, respectively (P = 0.002). The extent of seminal vesicle invasion was the independent risk factor for biochemical recurrence in univariate (level 3 vs 1, P = 0.001; level 3 vs 2, P = 0.015) and multivariate analyses (level 3 vs 1, P = 0.025; level 3 vs 2, P = 0.030).

CONCLUSIONS

The extent of seminal vesicle invasion might be a significant predictor of biochemical recurrence in prostate cancer patients undergoing radical prostatectomy.

Treatment results of radiotherapy to both the prostate and metastatic sites in patients with bone metastatic prostate cancer

Although systemic therapy is the standard treatment for metastatic prostate cancer, a randomized controlled trial showed radiotherapy to the prostate improved overall survival of metastatic prostate cancer patients with the low metastatic burden. Additionally, a randomized phase II trial showed that metastasis-directed therapy for oligo-recurrent prostate cancer improved androgen-deprivation therapy (ADT)-free survival. Therefore, administering radiotherapy to both prostate and metastatic regions might result in better outcomes. Thus, we report the treatment results of radiotherapy to both prostate and metastatic regions. Our institutional database was searched for patients who received radiotherapy to the prostate and metastatic regions. We summarized patient characteristics and treatment efficacy and performed statistical analysis to find possible prognostic factors. A total of 35 patients were included in this study. The median age was 66 years, and the median initial prostate-specific antigen (PSA) level was 32 ng/ml. The Gleason score was 7 in 10 patients, 8 in 13 patients, and 9 in 12 patients. The median radiotherapy dose was 72 Gy to the prostate and 50 Gy to the metastatic bone region. The 8-year overall survival, cause-specific survival, progression-free survival, and freedom from biochemical failure rate were 81, 85, 53, and 57%. Among the 35 patients, 12 were disease-free even after ADT was discontinued. In selected patients with metastatic prostate cancer, ADT and radiotherapy to the prostate and metastatic sites were effective. Patients with good response to ADT may benefit from radiotherapy to both prostate and metastatic regions.

Clinical outcomes of definitive whole pelvic radiotherapy for clinical lymph node metastatic prostate cancer

Background

In this study, we aim to present the clinical outcomes of radiotherapy (RT) in clinical pelvic lymph node‐positive prostate cancer (cN1) patients. We also analyze the prognostic factors with focus on RT dose escalation to metastatic lymph nodes (LN).

Methods

We retrospectively analyzed the data from cN1 patients who were treated with definitive RT and androgen deprivation therapy (ADT) between June 2004 and February 2016. All patients received localized irradiation to the prostate region and whole pelvis irradiation. Some patients received intensity‐modulated radiation therapy with RT dose escalation to metastatic LN. Univariate analyses using log‐rank test were performed to find prognostic factors between patient subgroups.

Results

Fifty‐one consecutive patients were identified. The median follow‐up period for all patients was 88 (range 20‐157) months. Primary Gleason pattern and LN RT dose were statistically significant prognostic factors for relapse‐free survival (RFS) and distant metastasis‐free survival (DMFS). Especially, RT dose escalation (60 Gy or more) to metastatic LN significantly improved RFS and DMFS compared with standard dose RT (4‐year RFS 90.6% vs 82.1%, 7‐year RFS 90.6% vs 58.0%, P = .015; 4‐year DMFS 90.6% vs 82.1%, 7‐year DMFS 90.6% vs 62.8%, P = .023). The following factors were all statistically significant for biochemical relapse‐free survival (BRFS): T stage, LN RT dose, local RT dose, and ADT duration period. Any significantly different toxicity was not seen for each LN or local RT dose except for the incident rate of grade 2 or more acute urinary retention, which was significantly higher in the higher LN RT dose (60 Gy or more) group by the Chi‐square test.

Conclusions

RT dose escalation to metastatic LN in cN1 patients improves BRFS, RFS, and DMFS at 4 and 7 years, without increasing severe adverse events.

P321A single factor related to left atrial pressure overload is useful for prognosis in elderly patients with heart failure with preserved ejection fraction: PURSUIT HFpEF study

Background

E/e' and the ratio of diastolic elastance (Ed)/arterial elastance (Ea) = (E/e')/(0.9 × systolic blood pressure), indices of left atrial (LA) pressure overload, are elevated in elderly women with heart failure with preserved ejection fraction (HFpEF). The severity of diastolic dysfunction is assessed by a combination of several indices of LA volume and pressure overload. However, which overload is more important as a single factor for the prognosis of these patients remains undefined.

Methods

We enrolled patients with HFpEF showing sinus rhythm (n=145; left ventricular ejection fraction >50%; men/women, 56/89; mean age, 80.5 years). Blood examination and transthoracic echocardiography were performed before discharge. All-cause mortality and admission for cardiac events were evaluated after more than 1 year (mean, 370 days).

Results

The all-cause mortality rate was 11% (16/145). There were significant differences in age (p=0.005), serum N-terminal pro-brain natriuretic peptide (NT-proBNP) level (p<0.001), LA volume index (p=0.018), E/e' (p=0.022), and Ed/Ea (p=0.016) between patients with and without all-cause mortality. When cutoff points for mortality by receiver operating characteristic curve analysis were examined, the area under the curve in LA volume index (0.564) was slightly smaller than that in age (0.734), NT-proBNP level (0.732), E/e' (0.695), and Ed/Ea (0.709). Kaplan-Meier survival analysis clearly showed that age >85 years (p<0.001), NT-proBNP level >888 pg/mL (p=0.003), E/e' >14.4 (p=0.020), and Ed/Ea >0.153 (p<0.001) were determinant factors for mortality. Cox hazard ratios were also significant in these indices (p=0.002, p=0.012, p=0.028, and p=0.001, respectively). In the case of all-cause mortality or admission for cardiac events, the results were nearly similar as those in the case of all-cause mortality. Ed/Ea exhibited a larger Cox hazard ratio for prognosis than E/e' in the multivariate analysis.

Conclusions

LA pressure overload compared to volume overload was a useful marker for prognosis in elderly patients with HFpEF. As a single index for LA pressure overload in noninvasive echocardiographic findings, Ed/Ea may be more suitable than E/e'.

P3395Arrival time at hyperemia of below the ankle as a determinant factor for limb salvage: evaluation by 2 dimension perfusion angiography

Background

In patients with critical limb ischemia, it is desirable to obtain enough skin perfusion pressure (SPP) levels through revascularization. 2D-perfusion angiography is an emerging technology for the quantification of tissue perfusion consisted of 6 parameters calculated by time-density curve of digital subtraction angiography (DSA).

Purpose

We evaluated the feasibility of 2D-perfusion angiography for below the knee (BTK) endovascular therapy (EVT). We aimed to clarify which angiographical parameters of lower limb are related to SPP after EVT.

Methods

Consecutive 33 limbs (mean age 74.5 years, men 55%), which successfully underwent EVT for isolated BTK lesions, were enrolled in this study. We excluded Rutherford 6 limbs with severe gangrene or tissue loss, consequently 26 limbs were Rutherford 4 or 5 critical limb ischemia. We treated total 47 lesions, including 26 chronic total occlusive lesions. 5Fr guiding sheath was advanced to popliteal artery. DSA images were obtained by mechanical contrast infusion. We quantified indexed blood flow on below the ankle area by using 2D-perfusion angiography, and examined 6 parameters [arrival time (AT), time to peak (TTP), wash-in rate, width, area under the curve and mean transit time (MTT)] from acquired DSA. Hyperemia was induced by 20mg papaverine intra-arterial infusion through the guiding sheath.

Results

The parameters except wash-in rate were significantly shortened after hyperemia induced by intra-arterial papaverine infusion below the ankle region. Dorsal and plantar SPP were significantly correlated with hyperemic AT, hyperemic wash-in rate and AT ratio (hyperemic/rest) of lower ankle regions after EVT. However, only AT ratio was independently associated with dorsal SPP in multivariate analysis (P=0.032). A receiver operating characteristic curve showed hyperemic AT <4.5 seconds and AT ratio <0.49 predicted to obtain SPP levels >50 mmHg after EVT with the area under the curve of 0.71 (95% confidence interval, 0.52–0.90) and 0.73 (95% confidence interval, 0.55–0.90), respectively.

Representative Case of 2D-perfusion

Conclusion

Hyperemic AT <4.5 seconds and AT ratio <0.49 of lower ankle regions may be essential to obtain the sufficient levels of SPP for limb salvage after BTK intervention. 2D perfusion angiography technique at hyperemic condition is feasible and has the potential to monitor lower limb tissue perfusion through EVT and to optimize the interventional treatment.

Giant multilocular prostatic cystadenoma

BACKGROUND

The giant multilocular prostatic cystadenoma is a very rare benign tumor of the prostate gland. It is composed of predominantly cystic enlarged prostatic glands in a fibrous stroma and spreads extensively into the pelvis. Because of the large size at the time of diagnosis, it is not always possible to determine the exact point of origin for these multilocular cystic neoplasms. Thus, diagnosis before histological examination of a surgical specimen is often difficult. Here, we present a case involving one of the largest giant multilocular prostatic cystadenomas reported in the literature and discuss preoperative diagnoses and appropriate surgical approaches for this rare retroperitoneal tumor.

CASE PRESENTATION

A 50-year-old man presented with a 2-year history of abdominal distension and lower urinary symptoms. Enhanced CT showed a large retroperitoneal mass with multiple septations in the pelvis and lower abdomen, measuring 30 cm in size, surrounding the rectum and displacing the bladder, prostate, and seminal vesicle to the right anterior side. MRI showed multiple cysts with a simple fluid appearance on T2-weighted images and enhanced solid components on gadolinium-enhanced fat-saturated T1-weighted images, suggesting the retroperitoneal mass as leiomyoma with cystic degeneration or perivascular epithelioid cell tumor. Biopsy of the mass showed a spindle cell tumor with focal smooth muscle differentiation. Differential diagnosis comprising leiomyoma, low-grade leiomyosarcoma, and perivascular epithelioid cell tumor was made. Complete resection of the tumor with low anterior resection of the rectum was performed. The tumor was solid with multilocular cavities containing blackish-brown fluid and measured 33 × 23 × 10 cm. Histologically, the tumor was composed of variously sized dilated glandular structures lined by prostatic epithelia surrounded by fibromuscular stroma. The prostatic nature of the lesions was confirmed by immunohistochemical staining of the epithelium for prostate-specific antigen. Thus, pathological diagnosis was a giant multilocular prostatic cystadenoma.

CONCLUSIONS

We present our experiences with one of the largest giant multilocular prostatic cystadenomas. When a retroperitoneal huge lesion with locular cavities fills the pelvis in a male patient, the possibility of giant multilocular prostatic cystadenoma should be considered before planning for retroperitoneal tumor treatment.

Risk factors for severe neutropenia induced by combination therapy of S-1 and cisplatin in patients with advanced/recurrent gastric cancer

S-1 and cisplatin therapy (SP therapy) is widely used as the first-line of advanced/recurrent gastric cancer. However, severe neutropenia is often observed (40%) during this therapy. Therefore, the risk management of neutropenia is important. From September 2014 to April 2017, we investigated 76 patients who underwent SP therapy as primary treatment for advanced/recurrent gastric cancer at Ogaki Municipal Hospital. Risk factors for grade 3/4 neutropenia were examined by univariate and multivariate analyses. In SP therapy, 19 patients (25%) experienced grade 3/4 neutropenia. The results of multivariate analysis of factors with p <0.05 in the univariate analysis indicated that less than 10.6 g/dL of the haemoglobin value before the course at the lowest neutrophil count (odds ratio: 7.900; 95% CI: 1.280-48.60; p = 0.026), more than six courses of the total course (odds ratio: 9.13; 95% CI: 2.13-39.1; p = 0.003), and less than 3140 m2 neutrophil counts (odds ratio: 5.33; 95% CI: 1.47-19.3; p = 0.011) before chemotherapy were risk factors of grade 3/4 neutropenia. A low haemoglobin value before the course at the lowest neutrophil count was revealed as a risk factor causing severe neutropenia in SP therapy.

Nodule Size After Chemotherapy and Primary-Tumor Teratoma Components Predict Malignancy of Residual Pulmonary Nodules in Metastatic Nonseminomatous Germ Cell Tumor

BACKGROUND

The treatment goal for visceral metastatic nonseminomatous germ cell tumor (NSGCT) is to remove any residual teratoma or viable NSGCT after chemotherapy. However, this provides no therapeutic benefit to patients whose metastases necrotize on their own. This study therefore analyzed NSGCTs with pulmonary metastases to determine preoperative factors that predict necrosis and could help identify patients who might be treated with monitoring rather than surgery.

METHODS

The study retrospectively analyzed 41 patients (135 metastatic pulmonary nodules) treated from 1997 to 2016 for NSGCT who showed tumor marker normalization after chemotherapy. Relationships between clinicopathologic characteristics and necrosis in resected pulmonary specimens were analyzed.

RESULTS

Receiver operating characteristic analysis of the pulmonary nodules showed 9 mm to be the optimal cutoff length for predicting necrosis. The logistic regression model showed that absence of teratoma components in the primary tumor and all pulmonary nodules shorter than 10 mm after chemotherapy both were independent predictors of pathologic necrosis in pulmonary specimens. No patients experienced late recurrence (i.e., > 2 years afterward).

CONCLUSIONS

The presence of teratoma components in primary tumors and nodular size after chemotherapy predict the pathology of residual pulmonary nodules. Patients whose residual nodules all are shorter than 10 mm and who have no primary-tumor teratoma components might be candidates for careful monitoring before pulmonary resection.

Tolerability and Efficacy of Neoadjuvant Chemotherapy with a Tri-Weekly Interval Methotrexate, Doxorubicin, Vinblastine, and Cisplatin Regimen for Patients with Locally Advanced Bladder Cancer

Objective

Compared with standard treatment, a modified tri-weekly MVAC (methotrexate, doxorubicin, vinblastine, and cisplatin) treatment regimen with a high cisplatin dose intensity shows good efficacy and lower toxicity. Thus, we retrospectively investigated the tolerability and efficacy of a modified tri-weekly MVAC neoadjuvant regimen.

Methods

We analyzed 25 patients with locally advanced bladder cancer medicated by a modified tri-weekly MVAC neoadjuvant regimen that omits treatment on days 15 and 22. The efficacy and tolerability were assessed retrospectively.

Results

The numbers of patients in clinical stages 2, 3, and 4 were 13 (52.0%), 1 (4.0%), and 11 (44.0%), respectively. Surgery could be performed on all patients. Five patients (20.0%) had no cancer remaining in their surgical specimens. Remaining non-muscle-invasive cancer without metastasis was observed in 7 patients (28.0%), and the total downstaging rate was 44.0%. The 5-year overall and relapse-free survival rates were 79.0 and 75.0%, respectively. The overall relative dose intensity was 0.90. Serious hematologic toxicities rated grade 3 or greater were leukopenia in 6 patients (24.0%) and anemia in 1 patient (4.0%).

Conclusions

Sufficient efficacy and tolerability of a modified tri-weekly MVAC neoadjuvant regimen were suggested. Thus, tri-weekly modified MVAC may be an option for neoadjuvant chemotherapy of advanced bladder cancer.

Outcomes of active surveillance of clinical stage I non-seminomatous germ cell tumors: sub-analysis of the multi-institutional nationwide case series of the Japanese Urological Association

Objective

To evaluate the survival rate and risk factors of distant metastasis in stage I non-seminomatous germ cell tumor (NSGCT) cases without adjuvant treatments.

Methods

A national testicular cancer survey of cases newly diagnosed in 2005 and 2008 was conducted by the Japanese Urological Association in 2011. In 159 stage I NSGCT cases, 132 were followed by active surveillance after high orchiectomy. Their recurrence-free survival rate (RFS) was compared with 27 cases that received adjuvant treatments, and clinical and pathological parameters were explored to identify significant risk factors of recurrence.

Results

Within a median follow-up period of 30.3 months (range: 0.3-65.6 months), 16 (12.1%) of the 132 surveillance cases relapsed at 2.8-51.2 months after high orchiectomy (median: 8.35 months). The 2-year RFS rate was 90%. Eleven (68.8%) cases relapsed within 1 year, and five (31.3%) cases relapsed in 3 years or more. Half (50%) of the recurrences were detected by imaging studies alone, 37.5% by imaging combined with tumor markers, and 12.5% by tumor marker elevation alone. The only significant risk factor of recurrence was the existence of embryonal carcinoma elements in the primary testicular tumor (P = 0.0068). There was no significant difference in RFS between cases with active surveillance and adjuvant treatments.

Conclusions

The present report is the first large scale study of clinical stage I NSGCTs in Japan. Active surveillance appears to be an effective treatment option for patients with clinical stage I NSGCTs.

Evaluation of antimicrobial stewardship (AS) for appropriate use of antimicrobial agents

We implemented an antimicrobial stewardship (AS) program whereby pharmacists sought appropriate use of antimicrobial agents in January 2012. At that time, we targeted anti-methicillin-resistant Staphylococcus aureus (MRSA) agents and carbapenems; however, in January 2014, we added tazobactam/piperacillin (TAZ/PIPC). We evaluated outcomes using multilateral analyses. The average one-day dosage of carbapenems increased; however, the duration of administration and number of recipient patients decreased significantly (P < 0.01). Moreover, the percentage of patients receiving meropenem (MEPM), for whom the time above minimal inhibitory concentration (MIC) was 40% or higher increased (P < 0.01). In contrast, patient utilization of TAZ/PIPC increased significantly after targeting of carbapenems as specific antibacterial agents. However, after TAZ/PIPC was targeted as a specific antibacterial agent, the number of TAZ/PIPC administrations decreased significantly (P < 0.01). The duration of hospitalization and mortality rate in patients receiving specific antibacterial agents significantly decreased after implementation of the AS program (P < 0.01). In conclusion, pharmacist's interventions to provide AS and patient follow-up reduced improper use and promoted proper administration of antibacterial agents. Furthermore, AS was effective in improving patient prognoses and suppressing drug-resistant strains, as well as promoting effective treatment.

Antibacterial therapy of aspiration pneumonia in patients with methicillin-resistant Staphylococcus aureus-positive sputum: identification of risk factors

Inappropriate antimicrobial treatment could adversely affect the recovery of patients with aspiration pneumonia. We attempted to identify inappropriate antibacterial treatment and to determine the standard use of anti-methicillin-resistant Staphylococcus aureus (MRSA) drugs in aspiration pneumonia patients with MRSA-positive in sputum. Aspiration pneumonia patients with MRSA-positive sputum treated between January 2013 and May 2013 were included in this study to determine the risk factors for death during hospitalization. The relationship between anti-MRSA medicine use and death during hospitalization was also investigated. More than 10⁷ MRSA colony-forming units in sputum culture, creatinine clearance of less than 30 mL/min, and quinolone use were found to be risk factors for death during hospitalization. The death rate during hospitalization was significantly lower in cases a Geckler classification of 4 or 5 when anti-MRSA treatment was initiated soon after the culture was obtained. Therefore, we concluded that the use of quinolones as antibacterial treatment in aspiration pneumonia patients with MRSA-positive sputum should be avoided and that anti-MRSA treatment should be started in cases with good quality sputum cultures.

Input-output organization of inhibitory neurons in the interstitial nucleus of Cajal projecting to the contralateral trochlear and oculomotor nucleus

Neurons in the interstitial nucleus of Cajal (INC) that are known to be involved in eye and head movements are excitatory. We investigated the input-output organization of inhibitory INC neurons involved in controlling vertical saccades. Intracellular recordings were made in INC neurons activated antidromically by stimulation of the contralateral trochlear or oculomotor nucleus, and their synaptic input properties from the superior colliculi (SCs) and the contralateral INC were analyzed in anesthetized cats. Many INC neurons projected to the contralateral trochlear nucleus, Forel's field H, INC, and oculomotor nucleus, and mainly received monosynaptic excitation followed by disynaptic inhibition from the ipsi- and contralateral SCs. After sectioning the commissural connections between the SCs, these neurons received monosynaptic excitation from the ipsilateral medial SC and disynaptic inhibition via the INC from the contralateral lateral SC. Another group of INC neurons were antidromically activated from the contralateral oculomotor nucleus, INC and Forel's field H, but not from the trochlear nucleus, and received monosynaptic excitation from the ipsilateral lateral SC and disynaptic inhibition from the contralateral medial SC. The former group was considered to inhibit contralateral trochlear and inferior rectus motoneurons in upward saccades, whereas the latter was considered to inhibit contralateral superior rectus and inferior oblique motoneurons in downward saccades. The mutual inhibition existed between these two groups of INC neurons for upward saccades on one side and downward saccades on the other. This pattern of input-output organization of inhibitory INC neurons suggests that the basic neural circuits for horizontal and vertical saccades are similar.

Outcome measurement of extensive implementation of antimicrobial stewardship in patients receiving intravenous antibiotics in a Japanese university hospital

BACKGROUND

Antimicrobial stewardship has not always prevailed in a wide variety of medical institutions in Japan.

METHODS

The infection control team was involved in the review of individual use of antibiotics in all inpatients (6348 and 6507 patients/year during the first and second annual interventions, respectively) receiving intravenous antibiotics, according to the published guidelines, consultation with physicians before prescription of antimicrobial agents and organisation of education programme on infection control for all medical staff. The outcomes of extensive implementation of antimicrobial stewardship were evaluated from the standpoint of antimicrobial use density, treatment duration, duration of hospital stay, occurrence of antimicrobial-resistant bacteria and medical expenses.

RESULTS

Prolonged use of antibiotics over 2 weeks was significantly reduced after active implementation of antimicrobial stewardship (2.9% vs. 5.2%, p < 0.001). Significant reduction in the antimicrobial consumption was observed in the second-generation cephalosporins (p = 0.03), carbapenems (p = 0.003), aminoglycosides (p < 0.001), leading to a reduction in the cost of antibiotics by 11.7%. The appearance of methicillin-resistant Staphylococcus aureus and the proportion of Serratia marcescens to Gram-negative bacteria decreased significantly from 47.6% to 39.5% (p = 0.026) and from 3.7% to 2.0% (p = 0.026), respectively. Moreover, the mean hospital stay was shortened by 2.9 days after active implementation of antimicrobial stewardship.

CONCLUSION

Extensive implementation of antimicrobial stewardship led to a decrease in the inappropriate use of antibiotics, saving in medical expenses, reduction in the development of antimicrobial resistance and shortening of hospital stay.

Topographic organization of excitatory and inhibitory commissural connections in the superior colliculi and their functional roles in saccade generation

Our electrophysiological study showed that there are topographic connections between excitatory and inhibitory commissural neurons (CNs) in one superior colliculus (SC) and tectoreticular neurons (TRNs) in the opposite SC. To obtain morphological evidence for these topographic commissural connections between the SCs, tracers were injected into various parts of the SC, the inhibitory burst neuron (IBN) area and Forel's field H (FFH), in the cat. Retrogradely labeled CNs were classified into three types according to their somatic areas and identified as GABA-positive or -negative immunohistochemically. Caudal SC injections labeled small GABA-positive CNs (<200 μm(2)) in the deep layers of the opposite rostral SC. Rostral SC injections mainly labeled medium-sized GABA-negative CNs (200-700 μm(2)) in the upper intermediate layer of the opposite rostral SC and small GABA-positive CNs in its deeper layers. Lateral SC injections labeled small GABA-positive CNs in the opposite medial SC and mainly medium-sized GABA-negative CNs in its lateral part. Medial SC injections labeled small GABA-positive CNs in the lateral SC and medium-sized GABA-negative CNs in the medial SC. In comparison, TRNs projecting to the FFH or IBN region were large (>700 μm(2)) and medium-sized. Many of the medium-sized GABA-negative CNs were TRNs projecting to the FFH. These results indicate that mirror-symmetric excitatory pathways link medial to medial (upper field) and lateral to lateral (lower field) parts of the SCs, whereas upper and lower field representations are linked by reciprocal inhibitory pathways in the tectal commissure. These connections presumably play important roles in conjugate upward and downward vertical saccades.

Commissural mirror-symmetric excitation and reciprocal inhibition between the two superior colliculi and their roles in vertical and horizontal eye movements

The functional roles of commissural excitation and inhibition between the two superior colliculi (SCs) are not yet well understood. We previously showed the existence of strong excitatory commissural connections between the rostral SCs, although commissural connections had been considered to be mainly inhibitory. In this study, by recording intracellular potentials, we examined the topographical distribution of commissural monosynaptic excitation and inhibition from the contralateral medial and lateral SC to tectoreticular neurons (TRNs) in the medial or lateral SC of anesthetized cats. About 85% of TRNs examined projected to both the ipsilateral Forel's field H and the contralateral inhibitory burst neuron region where the respective premotor neurons for vertical and horizontal saccades reside. Medial TRNs received strong commissural excitation from the medial part of the opposite SC, whereas lateral TRNs received excitation mainly from its lateral part. Injection of wheat germ agglutinin-horseradish peroxidase into the lateral or medial SC retrogradely labeled many larger neurons in the lateral or medial part of the contralateral SC, respectively. These results indicated that excitatory commissural connections exist between the medial and medial parts and between the lateral and lateral parts of the rostral SCs. These may play an important role in reinforcing the conjugacy of upward and downward saccades, respectively. In contrast, medial SC projections to lateral SC TRNs and lateral SC projections to medial TRNs mainly produce strong inhibition. This shows that regions representing upward saccades inhibit contralateral regions representing downward saccades and vice versa.

Association of KLK5 overexpression with invasiveness of urinary bladder carcinoma cells

Array-based comparative genomic hybridization (array-CGH) has powerful potential for high-throughput identification of genetic aberrations in cell genomes. We identified high-level amplification of kallikrein (KLK) genes, which are mapped to 19q13.3 and belong to the serine protease family, in the course of a program to screen a panel of urinary bladder carcinoma cell lines for genomic copy number aberrations using our in-house CGH-array. Expression levels of KLK5, -6, -8 and -9 were significantly increased in three cell lines with copy number gains of these KLK genes. Knockdown of these KLK transcripts by specific small interfering RNA significantly inhibited the invasion of a bladder carcinoma cell line through Matrigel in vitro. Reverse transcription-polymerase chain reaction analysis of 42 primary bladder tumor samples showed that increased expression of KLK5 was frequently observed in invasive tumors (pT2-pT4) (14.3%, 6/42) compared with superficial tumors (pTa, pT1) (0%, 0/42; P = 0.0052), and expression levels of KLK5, -6, -8 and -9 mRNA were higher in invasive tumors than in superficial tumors (P < 0.0001, P = 0.0043, P = 0.0790 and P = 0.0037, respectively). These observations indicate that KLK5, -6, -8 and -9 may be the most likely targets of the 19q13.3 amplification, and may play a crucial role in promoting cancer-cell invasion in bladder tumor.

Commissural excitation and inhibition by the superior colliculus in tectoreticular neurons projecting to omnipause neuron and inhibitory burst neuron regions

Previous electrophysiological studies have shown that the commissural connections between the two superior colliculi are mainly inhibitory with fewer excitatory connections. However, the functional roles of the commissural connections are not well understood, so we sought to clarify the physiology of tectal commissural excitation and inhibition of tectoreticular neurons (TRNs) in the "fixation " and "saccade " zones of the superior colliculus (SC). By recording intracellular potentials, we identified TRNs by their antidromic responses to stimulation of the omnipause neuron (OPN) and inhibitory burst neuron (IBN) regions and analyzed the effects of stimulation of the contralateral SC on these TRNs in anesthetized cats. TRNs in the caudal SC (saccade neurons) projected to the IBN region, and received mono- or disynaptic inhibition from the entire rostrocaudal extent of the contralateral SC. In contrast, TRNs in the rostral SC projected to the OPN or IBN region and received monosynaptic excitation from the most rostral level of the contralateral SC, and mono- or disynaptic inhibition from its entire rostrocaudal extent. Among the rostral TRNs with commissural excitation, IBN-projecting TRNs also projected to Forel's field H (vertical gaze center), suggesting that they were most likely saccade neurons related to vertical saccades. In contrast, TRNs projecting only to the OPN region were most likely fixation neurons. Most putative inhibitory neurons in the rostral SC had multiple axon branches throughout the rostrocaudal extent of the contralateral SC, whereas excitatory commissural neurons, most of which were rostral TRNs, distributed terminals to a discrete region in the rostral SC.

Physiological Characterization of Synaptic Inputs to Inhibitory Burst Neurons From the Rostral and Caudal Superior Colliculus

The caudal superior colliculus (SC) contains movement neurons that fire during saccades and the rostral SC contains fixation neurons that fire during visual fixation, suggesting potentially different functions for these 2 regions. To study whether these areas might have different projections, we characterized synaptic inputs from the rostral and caudal SC to inhibitory burst neurons (IBNs) in anesthetized cats. We recorded intracellular potentials from neurons in the IBN region and identified them as IBNs based on their antidromic activation from the contralateral abducens nucleus and short-latency excitation from the contralateral caudal SC and/or single-cell morphology. IBNs received disynaptic inhibition from the ipsilateral caudal SC and disynaptic inhibition from the rostral SC on both sides. Stimulation of the contralateral IBN region evoked monosynaptic inhibition in IBNs, which was enhanced by preconditioning stimulation of the ipsilateral caudal SC. A midline section between the IBN regions eliminated inhibition from the ipsilateral caudal SC, but inhibition from the rostral SC remained unaffected, indicating that the latter inhibition was mediated by inhibitory interneurons other than IBNs. A transverse section of the brain stem rostral to the pause neuron (PN) region eliminated inhibition from the rostral SC, suggesting that this inhibition is mediated by PNs. These results indicate that the most rostral SC inhibits bilateral IBNs, most likely via PNs, and the more caudal SC exerts monosynaptic excitation on contralateral IBNs and antagonistic inhibition on ipsilateral IBNs via contralateral IBNs. The most rostral SC may play roles in maintaining fixation by inhibition of burst neurons and facilitating saccadic initiation by releasing their inhibition.

Vestibular projection to the periarcuate cortex in the monkey

Vestibular inputs to the cerebral cortex are important for spatial orientation, body equilibrium, and head and eye movements. We examined vestibular input to the periarcuate cortex in the Japanese monkey by analyzing laminar field potentials evoked by electrical stimulation of the vestibular nerve. Laminar field potential analysis in the depths of the cerebral cortex showed that vestibular-evoked potentials consisted of early-positive and late-negative potentials and early-negative and late-positive potentials in the superficial and deep layers of the periarcuate cortex, respectively, with latencies of 4.8-6.3 ms, suggesting that these potentials were directly conveyed to the cortex through the thalamus. These potentials were distributed continuously in the fundus, dorsal and ventral banks of the spur and the bottom of the junctional part of the arcuate sulcus and spur. This vestibular-projecting area overlapped the cortical distribution of corticovestibular neurons that were retrogradely labeled by tracer injection into the vestibular nuclei (previously reported area 6 pa), and also the distribution of smooth pursuit-related neurons recorded in the periarcuate cortex including area 8 in a trained monkey. These results are discussed in relation to the function of vestibular information in control of smooth pursuit and efferents of the smooth pursuit-related frontal eye field.

Extracellular carbohydrate-signal triggering camp-dependent protein kinase-dependent neuronal actin-reorganization

Cell surface glycoconjugates are thought to mediate cell-cell recognition and to play roles in neuronal development and functions. We demonstrated here that exposure of neuronal cells to nanomolar levels of glyco-chains with an N-acetylgalactosamine (GalNAc) residue at the non-reducing termini (GalNAc-S) such as GalNAcbeta4(Neu5Acalpha3)Galbeta4GlcCer (GM2) ganglioside, its oligosaccharide portion, GalNAcbeta4Galbeta4GlcCer (Gg(3)) Cer, GalNAcalpha3GalNAcbeta3Galalpha4Galbeta4GlcCer (Gb(5)) Cer (Forssman hapten) and alpha1-4 linked oligomers of GalNAc, induced a rapid and transient activation of cAMP-dependent protein kinase (PKA) in subplasmalemma. The treatment was accompanied by peripheral actin polymerization and filopodia formation in NG108-15 cells and primary cultured hippocampal neurons, but not in glial cells. A cAMP-dependent protein kinase (PKA) selective inhibitor and an adenylate cyclase inhibitor blocked both PKA activation and the subsequent filopodia formation. A small GTPase cdc42 was a potential downstream target of GalNAc-S-activated PKA. These results suggest that extracellular GalNAc-S serve as potential regulators of the filopodia formation in neuronal cells by triggering the activation of PKA followed by cdc42 up-regulation via a cell surface receptor-like component. Filopodia formation induced by GalNAc-S may have a physiological relevance because long-term exposure to GalNAc-S enhanced F-actin-rich dendrite generation of primary cultured hippocampal neurons, and PKA-dependent dendritic outgrowth and branch formation of primary cultured cerebellar Purkinje neurons, in which actin isoforms were localized to motile structures in dendrites. These findings provide evidence for a novel GalNAc/PKA-signaling cascade in regulating some neuronal maturation.

The entire trajectories of single olivocerebellar axons in the cerebellar cortex and their contribution to Cerebellar compartmentalization

The functional partitioning of the cerebellar cortex depends on the projection patterns of its afferent and efferent neurons. However, the entire morphology of individual projection neurons has been demonstrated in only a few classes of neurons in the vertebrate CNS. To investigate the contribution of the projection pattern of individual olivocerebellar axons to the cerebellar functional compartmentalization, we labeled individual olivocerebellar axons, which terminate in the cerebellar cortex as climbing fibers, with biotinylated dextran amine injected into the inferior olive in the rat, and completely reconstructed the entire trajectories of 34 olivocerebellar axons from serial sections of the cerebellum and medulla. Single axons had seven climbing fibers on average, which terminated at similar distances from the midline in a single or in multiple lobules. Cortical projection areas of adjacent olivary neurons were clustered as narrow but separate longitudinal segments and often innervated by collaterals of single neurons. Comparison of the cerebellar distribution of olivocerebellar axons arising from different sites within a single olivary subnucleus indicated that slightly distant neurons projected to complementary sets of such segments in a single longitudinal band. Several of these longitudinal bands formed a so-called parasagittal zone innervated by a subnucleus of the inferior olive. Single olivocerebellar axons projected rostrocaudally to segments within a single band but did not project mediolaterally to multiple bands. These results suggest fine substructural organization in the cerebellar compartmentalization that may represent functional units.

Sites and temporal changes of gangliosides GM1/GM2 storage in the Niemann-Pick disease type C mouse brain

Niemann-Pick disease type C (NPC) is a progressive neurodegenerative disorder with characteristic storage of glycolipids in the brain. This study investigated cellular origin and temporal changes of monosialoganglioside storage in the Balb/c npc(nih) mouse brain by immunohistochemistry. Anti-GM1 gave positive staining of the hippocampus, thalamus, cerebellar molecular and Purkinje cell layers in the 3-week old NPC mouse brain and in general, the staining progressively diminished in an age-dependent manner. Anti-GM2 gave positive staining of the hippocampus, thalamus, cerebellar granule cell layer and brainstem nuclei in the 3-week old NPC mouse brain. In contrast to GM1, GM2 staining in these regions, except for the hippocampus, progressively augmented in an age-dependent manner. Double labeling experiments with antibodies against glial fibrillary acidic protein and lysozyme showed localization of GM1 and GM2 in reactive astrocytes and macrophages, respectively. Thus in the NPC mouse brain, GM1 accumulated primarily in neurons and astrocytes whereas GM2 accumulated primarily in neurons and macrophages. Temporal profiles of storage were different from each other and depended on the cell type, presumably reflecting both developmental changes and progression of the disease process. We also investigated subcellular sites of storage in primary-cultured Purkinje cells from the neonatal NPC mouse by immunocytochemistry. In NPC Purkinje cells, GM1 accumulated both in the cytoplasm and dendrites whereas GM2 showed punctuate accumulation in perinuclear vesicles. Thus, subcellular sites of storage were also different between GM1 and GM2 in NPC neurons.

Thalamic terminal morphology and distribution of single corticothalamic axons originating from layers 5 and 6 of the cat motor cortex

We investigated the axonal morphology of single corticothalamic (CT) neurons of the motor cortex (Mx) in the cat thalamus, using a neuronal tracer, biotinylated dextran amine (BDA). After localized injection of BDA into the Mx, labeled CT axons were found ipsilaterally in the thalamic reticular nucleus (TRN), the ventroanterior-ventrolateral complex (VA-VL), the central lateral nucleus (CL), the central medial nucleus, and the centromedian nucleus, but with the primary focus in the VA-VL. The terminals in the VA-VL formed a large laminar cluster, which extended approximately in parallel with the internal medullary lamina. The laminar organization mirrored morphologic features of single CT axons. We reconstructed the trajectories of 25 single CT axons that arose from layer V (16 axons) or layer VI (9 axons) and terminated in the VA-VL. Terminals of single CT axons that originated from both layer V and layer VI were confined within a laminar structure about 700 microm thick, suggesting the existence of laminar input organization in the VA-VL. Otherwise, the two groups of the CT axons showed contrasting features. All of the CT axons derived from layer VI gave rise to a few short collaterals to the TRN and then formed extensive arborization with numerous small, drumstick-like terminals in the VA-VL. On the other hand, the CT axons arising from layer V gave rise to collaterals whose main axons descended into the cerebral peduncle. Each collateral projected to the VA-VL or CL without projection to the TRN and formed a few small clusters of giant terminals. The two groups of CT neurons in the same cortical column had convergent rather than segregated termination in the VA-VL. However, the terminals of layer VI CT neurons were distributed diffusely and widely in the VA-VL, whereas the terminals of layer V CT neurons were much more focused and surrounded by the terminals of the former group. These contrasting features of the two types of CT projections appear to represent their different functional roles in the generation of motor commands and control of movements in the Mx.

Progressive neuronal loss in the ventral posterior lateral and medial nuclei of thalamus in Niemann-Pick disease type C mouse brain

Niemann-Pick disease type C (NP-C) disease is a progressive and fatal neurological disorder characterized by accumulation of cholesterol and glycosphingolipids in peripheral tissues and that of glycosphingolipids in the brain. A C57BL/KsJ-npc1(spm) mutant strain is a genetically authentic model of NP-C. This study investigated neuronal cell loss and lipid accumulation in the npc1(spm) mouse brain. Nissl-staining revealed abundant swollen neurons in the neocortex, piriform cortex, hippocampus and basal ganglia at 3-4 wk of age. In addition to loss of the Purkinje cells, we found a conspicuous cell loss in the ventral posterial lateral (VPL) and medial (VPM) nuclei of thalamus, which became apparent after 4-5 wk. Biochemical analyses revealed no increase of cholesterol in the lipid extracts whereas a substantial accumulation of cholesterol was detectable in most of the large neurons by filipin staining in the brain of homozygous mice. In contrast to the diffuse staining pattern in normal brains, the neuropils of the neurons in the brain of homozygous mice were stained in a punctate pattern. The ubiquitous accumulation excludes a direct role of cholesterol in the progressive neuronal loss in the Purkinje cell layer and in the VPL and VPM of the thalamus.

Spontaneous neoplastic lesions in aged Sprague-Dawley rats

Neoplastic lesions were observed in untreated aged Sprague Dawley (SD) rats throughout their lifespan starting at 5 weeks. Their mean survival times were 89 to 105 weeks of age. The total tumor incidences were 70 to 76.7% and 87 to 95.8% in males and females, respectively. The common neoplasmas were pituitary adenoma and adrenal pheochromocytoma in both sexes, testicular Leydig cell tumor in males and mammary gland tumors, thyroidal C-cell adenoma and uterine stromal polyp in females.

The entire trajectory of single climbing and mossy fibers in the cerebellar nuclei and cortex

The present study has revealed that OC axons gave rise to a number of thin collaterals. Due to the abundance of these non-CF thin collaterals, it seems better to make a distinction between the terms CFs and OC axons, as was done in the present paper. The present findings on the innervation of PC dendrites by CFs are basically similar to those in previous reports (Ramón y Cajal, 1911; Palay and Chan-Palay, 1974). The number of swellings on a single CF in the present study (n = 250) is comparable to a previously measured value in the rat (n = 288; Rossi et al., 1993) and larger than a value in the frog (n = about 100 beads; Llinás et al., 1969). The average number of CFs per OC axon in this study was close to the number (n = about 7) inferred in the rat by counting the total number of IO neurons and PCs (Schild, 1970). Contact of interneurons by some swellings of CFs in the molecular layer was emphasized by Scheibel and Scheibel (1954) in their study with Golgi staining. Despite the contact of CF terminals on interneurons, the formation of a synaptic structure between them has been excluded in an electron-microscopic study (Hámori and Szentàothai, 1980). On the other hand, electrophysiological studies have demonstrated a weak excitatory effect of CFs on some interneurons (Eccles et al., 1966). Terminals in the granular layer were originated either from thin collaterals of OC axons or from retrograde collaterals of CF terminal arborizations. The former was the main source of swellings in the granular layer. The morphology of the thin collaterals in the present study was consistent with "globose varicosities connected by a fine thread" as described in Golgi preparations and electron micrograms (Chan-Palay and Palay, 1971). Swellings of thin collaterals (about 1.7% of the total number of swellings per OC axon) were most abundant in the upper portion of the granular layer just underneath the PC layer, in which Golgi cells are usually located. Furthermore, some of these swellings were observed to touch presumed Golgi cells in the present study, which is consistent with electron-microscopic findings on the innervation of somata of Golgi cells by thin collaterals (Hámori and Szentàothai, 1980; Chan-Palay and Palay, 1971). Inferior olive stimulation has been shown electrophysiologically to have a weak direct excitatory effect on Golgi cells (Eccles et al., 1966). Ninety-one percent of the OC axons examined had nuclear collaterals; since the possibility of insufficient staining could not be excluded, this percentage may be an underestimation. The ratio of swellings in the cerebellar nuclei versus those of CF terminal arborizations was about 0.036 in individual OC axons in the present study. However, since the volume of the cerebellar nuclei is much smaller than that of the cerebellar cortex, and significant convergence of input from OC axons to cerebellar nucleus neurons is present (Sugihara et al., 1996), cerebellar nucleus projection of OC fibers can still be functionally important. Some swellings seemed to make contact with the soma and the proximal portions of dendrites of large neurons in the present study, which is consistent with the steep rising phase of postsynaptic excitatory potentials in cerebellar nucleus neurons following IO stimulation (Kitai et al., 1977; Shinoda et al., 1987). Although intracellular potentials were presumably recorded only from large output neurons in the cerebellar nuclei, the present study suggested that small neurons were also innervated by OC axons. The present study revealed that virtually all reconstructed LRN axons projected not only to the Cx as mossy fibers, but also to the DCN including the VN by their axon collaterals. None of the LRN neurons specifically projected to the DCN without projecting to the Cx, namely all axon terminals of LRN neurons in the DCN and VN belonged to axon collaterals of mossy fibers projecting to the Cx. (ABSTRACT TRUNCATED)

Helicobacter pylori-negative peptic ulcer in Japan: which contributes most to peptic ulcer development, Helicobacter pylori, NSAIDS or stress?

Of 302 patients with peptic ulcer, 11 (3.6%) proved negative for Helicobacter pylori: 9 with gastric ulcer (GU) and 2 with duodenal ulcer (DU). Among these 11 H. pylori-negative patients with ulcers, two with GU were using non-steroidal anti-inflammatory drugs (NSAIDs) and one with GU was using a corticosteroid. The Hanshin-Awaji earthquake induced life-event stress that not only triggered but exacerbated GU, particularly in the elderly, resulting in a higher GU/DU ratio than the corresponding period of the previous year (3.07 vs. 1.88) in the devastated area. Furthermore, the seroprevalence of the infection and the odds ratio from the case-control study were similar to or even higher than that reported previously in patients with GUs unrelated to the earthquake. H. pylori and the use of NSAIDs are the major independent risk factors for peptic ulcers, although, H. pylori infection plays some role in the development of peptic ulcers under stressful conditions.

Isolation and characterization of a new denitrifying spirillum capable of anaerobic degradation of phenol

Two kinds of phenol-degrading denitrifying bacteria, Azoarcus sp. strain CC-11 and spiral bacterial strain CC-26, were isolated from the same enrichment culture after 1 and 3 years of incubation, respectively. Both strains required ferrous ions for growth, but strain CC-26 grew better than strain CC-11 grew under iron-limited conditions, which may have resulted in the observed change in the phenol-degrading bacteria during the enrichment process. Strain CC-26 grew on phenol, benzoate, and other aromatic compounds under denitrifying conditions. Phylogenetic analysis of 16S ribosomal DNA sequences revealed that this strain is most closely related to a Magnetospirillum sp., a member of the alpha subclass of the class Proteobacteria, and is the first strain of a denitrifying aromatic compound-degrading bacterium belonging to this group. Unlike previously described Magnetospirillum strains, however, this strain did not exhibit magnetotaxis. It grew on phenol only under denitrifying conditions. Other substrates, such as acetate, supported aerobic growth, and the strain exhibited microaerophilic features.