Possible Roles of Carbohydrate Management and Cytokinin in the Process of Defoliation-Regrowth Cycles in Rice

Defoliation is an inevitable abiotic stress for forage and turf grasses because harvesting, grazing, and mowing are general processes for their production and management. Vegetative regrowth occurs upon defoliation, a crucial trait determining the productivity and persistence of these grasses. However, the information about the molecular regulation of this trait is limited because it is still challenging to perform molecular analyses in forage and turf grasses. Here, we used rice as a model to investigate vegetative regrowth upon defoliation at physiological and molecular levels. This study analyzed stubble and regrown leaves following periodic defoliation using two rice varieties with contrasting regrowth vigor. Vigorous regrowth was associated with maintained chlorophyll content and photosystem II performance; a restricted and promoted mRNA accumulation of sucrose synthase (SUS) I and III subfamilies, respectively; and reduced enzymatic activity of SUS. These results suggest that critical factors affecting vegetative regrowth upon defoliation are de novo carbohydrate synthesis by newly emerged leaves and proper carbohydrate management in leaves and stubble. Physiological and genetic analyses have demonstrated that the reduced sensitivity to and inhibited biosynthesis of cytokinin enhance regrowth vigor. Proper regulation of these metabolic and hormonal pathways identified in this study can lead to the development of new grass varieties with enhanced regrowth vigor following defoliation.

Role of modified Glasgow Prognostic Score in patients with achalasia who underwent laparoscopic Heller-myotomy with Dor-fundoplication

BACKGROUND

Systemic inflammatory response is significant prognostic indicator in patients with various diseases. The relationship between prognostic scoring systems based on the modified Glasgow Prognostic Score (mGPS) and achalasia in patients treated with laparoscopic Heller‑myotomy with Dor‑fundoplication (LHD) remains uninvestigated. This study aimed to examine the role of mGPS in patients with achalasia.

METHODS

457 patients with achalasia who underwent LHD as the primary surgery between September 2005 and December 2020 were included. We divided patients into the mGPS 0 and mGPS 1 or 2 groups and compared the patients' background, pathophysiology, symptoms, surgical outcomes, and postoperative course.

RESULTS

mGPS was 0 in 379 patients and 1 or 2 in 78 patients. Preoperative vomiting and pneumonia were more common in patients with mGPS of 1 or 2. There were no differences in surgical outcomes. Postoperative upper gastrointestinal endoscopy revealed that severe esophagitis was more frequently observed in patients with mGPS of 1 or 2 (P < 0.01). The clinical success was 91% and 99% in the mGPS 0 and mGPS 1 or 2 groups, respectively (P < 0.01).

CONCLUSIONS

Although severe reflux esophagitis was more common in patients with achalasia with a high mGPS, good clinical success was obtained regardless of the preoperative mGPS.

Tumor-infiltrating lymphocytes in patients undergoing esophagectomy following neoadjuvant DCF therapy

BACKGROUND

Accumulating evidence suggests that expression levels of tumor-infiltrating (TI) cells may play a prognostic role in patients with esophageal cancer who have undergone esophagectomy. However, its effect on patients undergoing neoadjuvant docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy followed by esophagectomy for esophageal squamous cell carcinoma (ESCC) remains unclear. Therefore, this study aimed to elucidate the prognostic impact of TI cells in patients who underwent esophagectomy following neoadjuvant DCF therapy.

METHODS

Overall, 81 patients with ESCC who underwent curative esophagectomy following neoadjuvant DCF therapy were included. The number of TI CD8+ cells was determined using light microscopy at ×400 in tumor invasive margins. Receiver operative characteristic curve was used to determine the cutoff values for mortality for continuous variables; the patients were separated into high and low TI CD8+ cell groups and their backgrounds and clinical outcomes were compared.

RESULTS

Overall and relapse-free survival were significantly worse in the TI CD8+-low group than that in the TI CD8+-high group (p < 0.01). Multivariate analysis revealed that positive ypN (hazard ratio [HR], 3.12; 95% confidence interval [CI], 1.08-9.02) and low TI CD8+ cell levels (HR, 2.77; 95% CI, 1.31-5.85) were independent prognostic factors for overall survival. Furthermore, positive venous invasion (HR, 2.63; 95% CI, 1.29-5.35) and low TI CD8+ cell levels (HR, 2.77; 95% CI, 1.70-5.46) were significant prognostic factors for relapse-free survival.

CONCLUSIONS

Low TI CD8+ cell level was a prominent prognostic factor for patients with ESCC undergoing neoadjuvant DCF therapy followed by esophagectomy.

Is it meaningful to add mesh reinforcement to laparoscopic fundoplication for esophageal hiatal hernias in the patients with high risk of hiatal hernia recurrence?

BACKGROUND

While laparoscopic fundoplication is a standard surgical procedure for patients with esophageal hiatal hernias, the postoperative recurrence of esophageal hiatal hernias is a problem for patients with giant hernias, elderly patients, or obese patients. Although there are some reports indicating that reinforcement with mesh is effective, there are differing opinions regarding the use thereof. The aim of this study is to investigate whether mesh reinforcement is effective for laparoscopic fundoplication in patients with esophageal hiatus hernias.

METHODS

The subjects included 280 patients who underwent laparoscopic fundoplication as the initial surgery for giant esophageal hiatal hernias, elderly patients aged 75 years or older, and obese patients with a BMI of 28 or higher, who were considered at risk of recurrent hiatal hernias based on the previous reports. Of the subject patients, 91 cases without mesh and 86 cases following the stabilization of mesh use were extracted to compare the postoperative course including the pathology, symptom scores, surgical outcome, and recurrence of esophageal hiatus hernias.

RESULTS

The preoperative conditions indicated that the degree of esophageal hiatal hernias was high in the mesh group (p = 0.0001), while the preoperative symptoms indicated that the score of heartburn was high in the non-mesh group (p = 0.0287). Although the surgical results indicated that the mesh group underwent a longer operation time (p < 0.0001) and a higher frequency of intraoperative complications (p = 0.037), the rate of recurrence of esophageal hiatal hernia was significantly low (p = 0.049), with the rate of postoperative reflux esophagitis also tending to be low (p = 0.083).

CONCLUSIONS

Mesh reinforcement in laparoscopic fundoplication for esophageal hiatal hernias contributes to preventing the recurrence of esophageal hiatal hernias when it comes to patient options based on these criteria.

The pathological conditions and surgical outcomes depending on the degree of hernia in the intra-thoracic stomach

BACKGROUND

In recent years, the number of patients requiring surgery for intra-thoracic stomach (ITS) has been increasing due to the effects of obesity and gibbus due to aging. The aim of this study is to assess the effects of the degree of hernia on the pathological conditions and surgical outcomes in ITS patients.

METHODS

ITS was defined as cases in which over 50% of the stomach had deviated into the mediastinum by esophagogastric fluoroscopy and/or computed tomography, with 65 patients who underwent laparoscopic surgery as the initial surgery included. We compared the pathological conditions and surgical outcomes by dividing the subjects into 3 groups: Group A: 50%- < 75%; Group B: 75%- < 100%; and Group C: 100% (upside-down stomach), depending on the degree of deviation into the mediastinum of the stomach.

RESULTS

The breakdown of patients was 33 in Group A, 21 in Group B, and 11 in Group C. Regarding the preoperative pathological conditions, Group C had a high body mass index (BMI) and a low score for factor V according to upper gastrointestinal endoscopy (p = 0.0109, p = 0.0062, respectively). While the surgical results indicated that the operation time was extended depending on the degree of hernia (p = 0.0051), there was no marked difference in other surgical outcomes or the postoperative course among the three groups, with a high degree of satisfaction.

CONCLUSIONS

In the case of ITS, although the operation time was extended depending on the degree of the hernia, the surgical outcomes were the same, and overall good results were obtained.

Is an objective evaluation essential for determining the therapeutic effect of laparoscopic surgery among patients with esophageal achalasia?

BACKGROUND

Despite a high degree of satisfaction with laparoscopic Heller-Dor surgery (LHD) for esophageal achalasia, some cases show no improvement in postoperative esophageal clearance. We investigated whether an objective evaluation is essential for determining the therapeutic effect of LHD.

METHODS

We investigated the difference in symptoms, regarding esophageal clearance, using timed barium esophagogram (TBE), in 306 esophageal achalasia patients with high postoperative satisfaction who underwent LHD. Furthermore, these patients were divided into two groups, in accordance with the difference in postoperative esophageal clearance, in order to compare the preoperative pathophysiology, symptoms, and surgical results.

RESULTS

Although the poor postoperative esophageal clearance group (117 cases, 38%) was mostly male and the ratio of Sigmoid type was high compared to the good postoperative esophageal clearance group (p = 0.046, p = 0.001, respectively); in patients with high surgical satisfaction, there was no difference in terms of preoperative symptom scores and surgical results. However, although the satisfaction level was high in the poor esophageal clearance group, the scores in terms of the postoperative dysphagia and vomiting were high (p = 0.0018 and p = 0.004, respectively). The AUC was 0.9842 upon ROC analysis regarding the presence or absence of clearance at 2 min following postoperative TBE and the postoperative feeling of difficulty swallowing score, with a cut-off value of 2 points (sensitivity: 88%, specificity: 100%) in cases with a high degree of surgical satisfaction.

CONCLUSION

The esophageal clearance ability can be predicted by subjective evaluation, based on the postoperative symptom scores; so, an objective evaluation is not essential in cases with high surgical satisfaction.

Risk factors for the occurrence of peptic esophagitis following laparoscopic Heller-Dor surgery for esophageal achalasia

Peptic esophagitis can occur as a complication of laparoscopic Heller-Dor surgery (LHD) among patients with esophageal achalasia. The goal of this study was to identify the characteristics of patients who have developed peptic esophagitis following LHD surgery along with the risk factors associated with the occurrence of peptic esophagitis. Among the 447 cases consisting of esophageal achalasia patients who underwent LHD as the primary surgery, we compared the patient background, pathophysiology, symptoms, and surgical outcomes according to whether or not peptic esophagitis occurred following surgery. We also attempted to use univariate and multivariate analyses to identify the risk factors for peptic esophagitis occurring following surgery. Esophagitis following surgery was confirmed in 67 cases (15.0%). With respect to the patient backgrounds for cases in which peptic esophagitis had occurred, a significantly higher number were male patients, with a significantly high occurrence of mucosal perforation during surgery in terms of surgical outcomes, along with a high occurrence of esophageal hiatal hernias in terms of postoperative course (P = 0.045, 0.041, and 0.022, respectively). However, there were no significant differences in terms of age, BMI, disease duration, preoperative symptoms, esophageal manometric findings, esophageal barium findings, and esophageal clearance. A multivariate analysis indicated independent risk factors for the occurrence of peptic esophagitis following LHD as being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias. Peptic esophagitis occurred following LHD in 15% of cases. Independent risk factors for the occurrence of peptic esophagitis following LHD included being male, the occurrence of mucosal perforation during surgery, and the occurrence of esophageal hiatal hernias following surgery.

Therapeutic effect of laparoscopic fundoplication for patients with GERD from the viewpoint of Lyon Consensus

BACKGROUND AND OBJECTIVES

The Lyon Consensus was conducted in 2017, leading to a revision of the diagnostic criteria of GERD. Conclusive GERD was defined as cases in which the distal esophageal acid exposure time (AET) is greater than 6% and there exists either peptic esophagitis, constriction, or long-segment Barrett's mucosa with a Los Angeles classification of grade C or D. Borderline GERD is defined as cases in which AET is between 4 and 6% and there exists peptic esophagitis with a Los Angeles classification of either grade A or B. All other cases were defined as Inconclusive GERD. We conducted a retrospective investigation of the treatment results of laparoscopic fundoplication (LF) for GERD according to the Lyon Consensus and evaluated whether or not it is an effective treatment predictor.

MATERIALS AND METHODS

From among the cases of primary LF conducted on patients with GERD-related illnesses at our university hospital from June 2008 to March 2020, the subjects included 215 individuals who underwent upper gastrointestinal endoscopy and 24 h multichannel intraluminal impedance pH (MII-pH) testing prior to surgery. We compared the pathophysiology of the Conclusive GERD Group (Group A), Borderline GERD Group (Group B), and Inconclusive GERD Group (Group C), and then investigated the treatment results of each group. We used AFP classification for pathophysiological evaluation. For the acid reflux evaluation, we conducted MII-pH measurements using Sleuth, manufactured by Sandhill. The postoperative evaluation period was set to 3 months following surgery. The data are expressed using median values, with a statistical significance defined as p < 0.05 using the Kruskal-Wallis, Mann-Whitney, Wilcoxon signed-rank, and Chi-squared tests.

RESULTS

Group A: 92 cases (43%, male 69 cases, age 57), Group B: 48 cases (22%, male 20 cases, age 52), and Group C: 75 cases (35%, male 69 cases, age 57). Regarding the patient backgrounds, while there were no significant differences in terms of gender or disease duration, those in Group A were significantly older than the other two groups, and there was a significant difference in Body Mass Index (BMI) between Group A and Group C. The results of each factor were: A factor (1 vs.1 vs. 1, p < 0.001), F factor (2 vs. 0 vs. 0, p < 0.001), and P factor (2 vs. 1 vs. 0, p < 0.001), with AET of 10.0 vs. 2.9 vs. 0.6, p < 0.001, and the disease had progressed more in Group A. There were also no differences in terms of surgical methods, hemorrhage volume, and intraoperative/postoperative complications; however, the use of mesh was higher and surgery duration was longer in Group A. There were obvious improvements in the A, F, and P factors and AET of each group following surgery (other than F and P of Group C, p < 0.001). The rate of recurrence was 15% in Group A, 8% in Group B, and 6% in Group C. It tended to be higher in Group A, but this was not statistically significant.

CONCLUSION

The classification of GERD pathophysiology based on the Lyon Consensus is satisfactory, with no significant differences in the rate of effect of LF. The Lyon Consensus is effective for ascertaining the severity and pathophysiology of GERD; however, we were unable to forecast the treatment results of LF.

Therapeutic effect of laparoscopic fundoplication for GERD-related disease in the elderly

BACKGROUND

It is anticipated that surgical treatment for gastro-esophageal reflux disease (GERD) in the elderly will increase. This time, using propensity score matching, we examined the results of laparoscopic fundoplication (LF) for GERD-related diseases in the elderly.

METHODS

Of 302 cases which underwent initial LF for GERD-related diseases during the period from June 2008 to February 2019, we classified them into elderly (65 years of age or older) and non-elderly groups (64 years of age or younger). 57 cases each were extracted upon performing propensity score matching regarding five factors including: gender; body mass index; esophageal hiatal hernia; extent of reflux esophagitis; and the use of mesh.

RESULTS

With regard to the preoperative disease status, the pH < 4 holding time was indicated as 2.8% (0.5-10.7%) in the elderly group and 3.4% (0.6-8.0%) in the non-elderly group, with no difference in terms of the illness period as well (p = 0.889 and p = 0.263, respectively). Although there was no difference in terms of the operative time (155 vs. 139 min, p = 0.092) and estimated blood loss (both ≒ 0 ml, p = 0.298), postoperative hospital stay was prolonged in the elderly group [7 (7-9) vs. 7 (7-7), p = 0.007]. On the other hand, esophageal hiatal hernia, reflux esophagitis, and acid reflux time in the esophagus were all improved following surgery in both groups (p < 0.001 in both groups).

CONCLUSION

The treatment results of LF for GERD-related diseases in the elderly were as good as those in the non-elderly, indicating possible safe implementation.

The patient characteristics of esophageal carcinoma following laparoscopic myotomy for esophageal achalasia

BACKGROUND

It is common knowledge that esophageal achalasia patients have a high risk of developing esophageal carcinoma. The present study assessed the characteristics of esophageal carcinoma patients following laparoscopic Heller-Dor surgery (LHD) for esophageal achalasia.

METHOD

Among 622 cases which were esophageal achalasia patients and underwent LHD as the primary surgery, we compared the patient background, pathophysiology, symptoms, and surgical outcomes according to whether or not esophageal carcinoma occurred following surgery.

RESULTS

Six cases (0.96%) of postoperative esophageal carcinoma were confirmed. The characteristics of the cases in which esophageal carcinoma occurred were older age, longer disease duration (p = 0.0362 and 0.0028, respectively), decreased sphincter pressure of the lower esophagus, a high rate of sigmoid esophagus, and a long esophagus lateral diameter (p = 0.0214, 0.001, and 0.0416, respectively). Moreover, no differences in surgical outcomes were confirmed and there were no differences in symptoms from before and following surgery.

CONCLUSION

The characteristics of esophageal carcinoma patients with achalasia following laparoscopic myotomy were an older age, longer disease duration, and greater progression of disease pathophysiology.

Effects of the preoperative IRP values on the pathophysiology of patients with esophageal achalasia and on the treatment outcome of laparoscopic Heller-Dor surgery

PURPOSE

One diagnostic criterion of esophageal achalasia is that the integrated relaxation pressure (IRP) measured by high-resolution manometry (HRM) is at least 15 mmHg. Moreover, while the standard surgical treatment for esophageal achalasia is laparoscopic Heller-Dor surgery (LHD), there have been insufficient investigations concerning the surgical outcomes from the perspective of the preoperative IRP value.

METHODS

We split 121 cases in which LHD was performed as an initial treatment on patients with esophageal achalasia, into two categories according to the IRP median value, and performed a comparative investigation of the surgical outcomes with regard to the preoperative pathophysiology and symptoms.

RESULTS

The IRP median value was 29.6 mmHg. The high IRP group consisted of younger individuals and low BMI (p = 0.004 and p = 0.0273, respectively), and the percentage of Chicago classification Type II and III was high (p = 0.029) and the regurgitation score in the preoperative symptoms was high (p = 0.0043). However, no differences in the surgical outcomes were confirmed.

CONCLUSION

In patients with esophageal achalasia, the degree of the preoperative IRP value affects the age, BMI, preoperative LESP, and preoperative regurgitation symptoms. However, there were no effects on the surgical outcomes, with the surgical outcomes being satisfactory, regardless of the IRP value.

Factors affecting the treatment outcomes of laparoscopic fundoplication for erosive reflux esophagitis: findings of esophageal pathological function tests

PURPOSE

To identify the factors that affect laparoscopic fundoplication (LF) treatment efficacy in patients with erosive gastroesophageal reflux disease (e-GERD) esophagitis, based on the findings of multichannel intraluminal impedance pH (MII-pH) and high-resolution manometry (HRM).

METHODS

The subjects were 102 patients with e-GERD diagnosed by endoscopy, who underwent LF as the initial surgery. To analyze the findings of MII-pH and HRM, the patients were divided into two groups: a cured group (CR), comprised of patients whose esophagitis was cured postoperatively; and a recurrence group (RE), comprised of patients who suffered recurrent esophagitis.

RESULTS

There were 96 patients in the CR group and 6 in the RE group. MII-pH indicated that the acid reflux time, the longest reflux time, and the number of refluxes longer than 5 min, were significantly higher in the RE group than in the CR group (p = 0.0028, p = 0.0008, p = 0.012, respectively). The HRM indicated that only the distal contractile integral (DCI) was significantly lower in the RE group (p = 0.0109).

CONCLUSION

The results of this study indicate that esophageal clearance may affect the treatment outcome of LF. Based on the findings of MII-pH, the longest reflux time and the number of refluxes longer than 5 min were important factors influencing the therapeutic effect, whereas based on the HRM, the DCI value was most important.

The evaluation of the dilation-degree classification of esophageal achalasia patients from the viewpoint of esophageal clearance

PURPOSE

To examine whether or not we could propose a more appropriate dilation-degree classification suitable for the pathological condition of patients with esophageal achalasia.

METHODS

In accordance with the current dilation-degree classification, the maximum dilated diameter was measured based on the esophageal barium swallow. The relationship between the pathophysiology and dilation-degree classification was examined. Furthermore, the current dilatation-degree classification from the viewpoint of esophageal clearance was evaluated to examine whether or not a more appropriate dilatation-degree classification could be proposed.

RESULTS

Because the clearance ratio tended to decrease at a maximum expansion diameter of 80 mm, when the maximum dilated diameter was divided into units of 10 mm, they were classified into two groups, with 80 mm as the boundary. As a result, the illness period was significantly prolonged (p = 0.0045) and the frequency of sigmoid type was high (p < 0.001) for lengths of ≥ 80 mm. With regard to the esophageal clearance rate, the clearance rate was significantly decreased in patients with a diameter of ≥ 80 mm at 5 min after taking barium (p = 0.0229).

CONCLUSIONS

From the viewpoint of esophageal clearance, classification into 2 groups with a boundary of 80 mm may reflect the pathological condition.

Comparison of Needlescopic and Conventional Laparoscopic Fundoplication for Gastroesophageal Reflux Disease-Related Diseases: A Propensity Score-Matched Analysis

Background: Recently, in pursuit of minimal invasion, needlescopic surgery (NS) using forceps thinner than the previous standard has garnered attention as a surgical approach to various diseases. Objective: We compared the outcomes of NS for gastroesophageal reflux disease (GERD)-related diseases with the conventional method using propensity score-matched analysis. Subjects and Methods: Among 205 of 328 cases who underwent laparoscopic fundoplication for the first time from June 2008 to December 2019, excluding 115 cases using mesh and 8 cases undergoing reduced port surgery, 25 subjects in the NS group and 25 subjects in the conventional group were extracted upon propensity score matching for six factors: age, gender, body mass index, degree of esophageal hiatal hernia, duration of intraesophageal acid reflux, and severity of reflux esophagitis. Results: The NS group used the Toupet method, whereas the conventional group used the Nissen method for 2 cases and the Toupet method for 23 cases. There were no significant differences between them (P = .490). Although the operative time (143 versus 112 minutes, P = .038) was longer in the NS group, there were no differences in the bleeding volume (nearly equal at 0 mL in both groups), laparotomy conversion rate, intraoperative complications, and postoperative complications (P = .588, P = 1.000, P = 1.000, P = 1.000, respectively). There was also no significant difference in recurrence: 2 cases in the conventional group (8%) and 1 case in the NS group (4%) (P = 1.000). Moreover, the degree of esophageal hiatal hernia, the severity of reflux esophagitis, and the duration of intraesophageal acid reflux all improved after the surgery in both groups (NS group: P = .001, P < .001, P = .002; conventional group: P = .007, P < .001, P = .003). Conclusions: The short-term outcomes of NS for GERD-related diseases were good, with a longer operative time but no difference in terms of safety or outcomes compared with the conventional method. This study was approved by the Institutional Review Board of the Jikei University School of Medicine [30-238 (9259)].

Degradation pathways of cyclic alkanes in Rhodococcus sp. NDKK48

The degradation pathways for cyclic alkanes (c-alkanes) in Rhodococcus sp. NDKK48 were investigated. Strain NDKK48 used dodecylcyclohexane as a sole carbon and energy source, and five metabolites in the dodecylcyclohexane degradation pathway were detected by gas-chromatography/mass spectra. The metabolites were identified as cyclohexanecarboxylic acid, cyclohexylacetic acid, 1-cyclohexene-1-acetic acid, 4-dodecylcyclohexanol, and 4-dodecylcyclohexanone. The strain degrades dodecylcyclohexane via a ring oxidation pathway and an alkyl side chain oxidation pathway. Cyclohexanecarboxylic acid was further oxidized to muconic acid via 1-cyclohexene-1-carboxylic acid and benzoic acid, and the muconic acid was finally used by strain NDKK48 for growth. Methylcyclohexane and cyclohexane were co-oxidized with hexadecane by strain NDKK48. Methylcyclohexane was degraded via a ring oxidation pathway, and the degradation pathway contained part of the Baeyer-Villiger oxidation for ring cleavage. Cyclohexane was also degraded by the same pathway as methylcyclohexane. Thus, strain NDKK48 has two pathways for the complete degradation of c-alkanes.

Differential screening-selected gene aberrative in neuroblastoma protein modulates inflammatory pain in the spinal dorsal horn

Differential screening-selected gene aberrative in neuroblastoma (DAN) belongs to a novel gene family that includes the Xenopus head-inducing factor, Cerberus and the dorsalizing factor, Gremlin. It has been suggested that members of this family control diverse processes in growth, development and the cell cycle.Here, we demonstrate that the DAN protein is produced in the small neurons of the dorsal root ganglion and is transported to the nerve terminals in the spinal dorsal horn in adult rats. Furthermore, intrathecal injection of an antibody to the DAN protein suppressed inflammatory pain caused by the introduction of complete Freund's adjuvant or carrageenan into the rat hindpaw. The amount of mRNA for DAN in dorsal root ganglion neurons and of its expressed protein in the spinal dorsal horn were both increased in inflammatory models.Together, these data suggest that the DAN protein may be a novel neuromodulator in primary nociceptive nerve fibers.

Gut transit time after ileal pouch-anal anastomosis using a radiopaque marker

PURPOSE

The aim of this study was to determine the contribution of gastrointestinal motility to bowel function and the pathogenesis of pouchitis after ileal pouch-anal anastomosis.

METHODS

Gastrointestinal transit time was assessed by a radiopaque marker technique in 32 patients with ulcerative colitis.

RESULTS

Small intestinal transit time and pouch emptying time were 4.1 +/- 2 hours and 4.1 +/- 2.5 hours, respectively. There was no significant difference in pouch emptying time between patients with and without pouchitis. When only patients with acute pouchitis that responded to metronidazole were analyzed, there was a trend toward a prolonged pouch emptying time compared with those without pouchitis (P = 0.095). Whole gut transit time was inversely correlated with 24-hour stool frequency in patients without pouchitis (r = -0.63, P < 0.005). In the analysis of regional transit time, only small intestinal transit time was inversely correlated with 24-hour stool frequency (r = -0.472, P < 0.05). Significant prolongation of small intestinal transit time was demonstrated in patients over a period of 41 months (the median time) after ileostomy closure compared with those whose pouches had been functioning for 6 to 41 months (5.4 +/- 1.7 hours vs. 3.1 +/- 1.3 hours, P < 0.005).

CONCLUSIONS

There was an association between small intestinal motility and bowel frequency. Further investigation is necessary in the pathogenesis of acute pouchitis regarding the relationship between delayed pouch emptying and subsequent development of mucosal inflammation.

Spinal N-acetyl-alpha-linked acidic dipeptidase (NAALADase) inhibition attenuates mechanical allodynia induced by paw carrageenan injection in the rat

N-Acetylated-alpha-linked acidic dipeptidase (NAALADase) hydrolyzes N-acetyl-aspartyl-glutamate (NAAG) to liberate N-acetyl-aspartate and glutamate. NAAG is a putative neurotransmitter and acts as a mixed agonist/antagonist on N-methyl-D-aspartate (NMDA) receptors and acts as an agonist on the metabotropic glutamate receptor 3 (mGluR3). In the present study, we examined the role of spinal NAALADase in the maintenance of mechanical allodynia induced by carrageenan injection, skin incision and mild thermal injury using 2-(phosphonomethyl)pentanedioic acid (2-PMPA), a specific NAALADase inhibitor, in rats. Mechanical allodynia was induced by injection of 2 mg carrageenan into the paw (carrageenan model), by creating a 1-cm longitudinal skin incision of the plantar aspect of the foot (post-operative model), or by application of thermal stimulation (52.5 degrees C) for 45 s to the hind paw (mild thermal injury model). 2-PMPA was administered intrathecally at the time when the maximum mechanical allodynia occurred. Mechanical allodynia was assessed by the measurement of mechanical threshold using von Frey filaments. The mechanical threshold was measured 5, 15, 30, 60 and 90 min after the drug administration. In the carrageenan model, 100 microg of 2-PMPA attenuated the level of mechanical allodynia. 2-PMPA had no effect on the level of mechanical allodynia in both the post-operative pain model and the mild thermal injury model. These data suggested that the inhibition of spinal NAALADase alleviated mechanical allodynia induced by paw carrageenan injection.

Antagonism of ORLI receptor produces an algesic effect in the rat formalin test

The authors investigated the role of endogenously released nociceptin (also known as orphanin FQ) spinal and supraspinal nociceptive transmission during the rat formalin test by examining the effect of intrathecal and intracerebroventricular injection of J-113397, a non-peptidyl ORL1 receptor selective antagonist. When J-113397 was injected intrathecally or intracerebroventricularly 10 min before the formalin injection, it enhanced the agitation behavior induced by paw formalin injection. This suggested that paw formalin injection induced nociceptin release in the spinal cord and the supraspinal brain sites, that this endogenously released nociceptin produced an analgesic effect and that J-113397 antagonized this analgesic effect of nociceptin and produced an algesic effect in the rat formalin test.

Inhibition of spinal N-acetylated-alpha-linked acidic dipeptidase produces an antinociceptive effect in the rat formalin test

N-acetyl-aspartyl-glutamate is a putative neurotransmitter and acts as a weak agonist at the N-methyl-D-aspartate receptor. N-acetyl-aspartyl-glutamate also acts as an agonist at the metabotropic glutamate receptor 3. N-acetyl-aspartyl-glutamate is hydrolyzed by N-acetylated-alpha-linked acidic dipeptidase to liberate N-acetyl-aspartate and glutamate. Recently, a specific inhibitor of N-acetylated-alpha-linked acidic dipeptidase, 2-(phosphonomethyl)pentanedioic acid, has been reported. In the present study, we examined the effect of i.t. administered 2-(phosphonomethyl)pentanedioic acid in the rat formalin test (a model of inflammatory pain) and the rat hot plate test. In the formalin test, drugs were administered 10min before (pre-treatment study) or 7min after (post-treatment study) the formalin injection. The paw formalin injection induces biphasic flinching (phase 1: 0-2min; phase 2: 10-60min) of the injected paw. In the pre-treatment study, i.t. administered 2-(phosphonomethyl)pentanedioic acid depressed both phases 1 and 2 flinching behavior in a dose-dependent manner but 2-(phosphonomethyl)pentanedioic acid had no effect on the flinching behavior in the post-treatment study. In the pre-treatment study, the potency of 2-(phosphonomethyl)pentanedioic acid in depressing the phase 2 response is greater than that in depressing the phase 1 response. Intrathecal injection of 2-(phosphonomethyl)pentanedioic acid had no effect in the hot plate test. We suggest that N-acetylated-alpha-linked acidic dipeptidase plays an important role in spinal nociceptive transmission and that inhibition of spinal N-acetylated-alpha-linked acidic dipeptidase produces an antinociceptive effect during the rat formalin test but not during the hot plate test.

Involvement of PACAP receptor in primary afferent fibre-evoked responses of ventral roots in the neonatal rat spinal cord

The role of PACAP receptor in nociceptive transmission was investigated in vitro using maxadilan, a PACAP receptor selective agonist and max.d.4, a PACAP receptor selective antagonist. Potentials, from a ventral root (L3 - L5) of an isolated spinal cord preparation or a spinal cord - saphenous nerve - skin preparation from 0 - 3-day-old rats, were recorded extracellularly. In the isolated spinal cord preparation, single shock stimulation of a dorsal root at C-fibre strength induced a slow depolarizing response lasting about 30 s (slow ventral root potential; slow VRP) in the ipsilateral ventral root of the same segment. Bath-application of max. d.4 (0.01 - 3 microM) inhibited the slow VRP in a concentration-dependent manner. In the spinal cord - saphenous nerve - skin preparation, application of capsaicin (0.1 microM) to the skin evoked a depolarization of the ventral root. This response was also depressed by max.d.4 (1 microM). Application of maxadilan evoked a long-lasting depolarization in a concentration-dependent manner in the spinal cord preparation. In the presence of max.d.4 (0.3 microM), the concentration response curve of maxadilan was shifted to the right. Reverse transcription-polymerase chain reaction (RT - PCR) experiments demonstrated the existence of PACAP receptor and VPAC(2) receptor in the neonatal rat spinal cord and [(125)I]-PACAP27 binding was displaced almost completely by maxadilan and max.d.4, but not by vasoactive intestinal peptide (VIP). These data indicate that PACAP receptor is dominantly distributed in the neonatal rat spinal cord. The present study suggests that PACAP receptor may play an excitatory role in nociceptive transmission in the neonatal rat spinal cord.

Primary leptomeningeal lymphoma

Primary leptomeningeal lymphoma is a rare disorder, and the neuroradiological characteristics or the complication of this rare disorder have not been well reported. We reported herein a patient with a primary leptomeningeal lymphoma who has complication with subdural hematoma. The patient complained of headache and vomiting. Neurological examination revealed progressive cranial nerve palsy. Cerebrospinal fluid examination disclosed monoclonal proliferation of atypical B-lymphocytes. Cranial computed tomographic scans showed a left frontal mass with convex form to the brain parenchyma. T1-weighted magnetic resonance (MR) images disclosed subacute subdural hematoma. However, proton-weighted MR images showed high signal intensity in subarachnoid space, which suggested leptomeningeal lymphoma. He underwent craniotomy, and the diagnosis of leptomeningeal lymphoma complicated with subdural hematoma was confirmed. Systemic examinations disclosed no lymphomatous lesions except for leptomeningus, and the diagnosis of primary leptomeningeal lymphoma was established. We suggested that subdural hematoma was associated with primary leptomeningeal lymphoma in this patient. Cerebrospinal fluid examination and proton-weighted MR imaging should be performed when progressive neurological abnormalities are found in patients with subdural hematoma.

Baicalin, the predominant flavone glucuronide of scutellariae radix, is absorbed from the rat gastrointestinal tract as the aglycone and restored to its original form

When baicalin was orally administered to conventional rats, it was detected in their plasma for 24 h after administration, but baicalein, the aglycone of baicalin, was not detected. However, when baicalin was given to germ-free rats, only a small amount of baicalin was detected in their plasma within 2 h after the administration, its AUC0-lim (the area under the concentration-time curve from 0 to last determination time) being 12.0% of that in conventional rats. Subsequently, a considerable amount (55.1 +/- 6.2%) of baicalin was recovered from the gastrointestinal tract even 4 h after administration. When baicalein was orally administered to conventional rats, however, baicalin appeared rapidly in their plasma at an AUC0-lim value similar to that obtained after oral administration of baicalin, despite the absence of baicalein in plasma. When intestinal absorption was evaluated by the rat jejunal loop method, baicalein was absorbed readily, but only traces of baicalin were absorbed. Moreover, in conventional rats a small amount (13.4 +/- 3.1%) of baicalin and an appreciable amount (21.9 +/- 3.4%) of baicalein were recovered from the gastrointestinal tract even 4 h after oral administration of baicalin, but only a small amount (3.93 +/- 1.43%) of baicalein was detected in the intestinal tract 1 h after administration of baicalein. Baicalin was transformed to baicalein readily by the rat gastric and caecal contents. When baicalin was administered orally to conventional rats, an appreciable amount of baicalein was recovered in their gastrointestinal tracts. Moreover, baicalein was efficiently conjugated to baicalin in rat intestinal and hepatic microsomes. These results indicate that baicalin itself is poorly absorbed from the rat gut, but is hydrolysed to baicalein by intestinal bacteria and then restored to its original form from the absorbed baicalein in the body.

A brief course of colon preparation with oral antibiotics

We carried out a prospective clinical trial of colon preparation with a regimen of oral antibiotics starting on the day before surgery. The patients were assigned to one of two groups consisting of either a mechanical preparation alone group (group 1, 45 cases) or a mechanical bowel preparation with oral antibiotics group (group 2, 38 cases). Group 2 received kanamycin and metronidazole three times on the day before surgery. Cefmetazole was administered for 3 consecutive days as prophylaxis in both groups. In a study using intraoperative mucosal swabs, the rates of group 2 patients with cultures yielding anaerobes or Gram-negative bacteria were significantly lower than those of group 1. There were no significant differences in the rates of patients with cultures yielding fungi or Gram-positive organisms. The positive culture rate in the peritoneal fluid of group 1 was also higher than that of group 2 (40%, 16%, P < 0.05). The surgical site infection rate was 18% in group 1 and 13% in group 2. Organisms isolated from the sites of postoperative infections were not identical with those from the peritoneal fluid. This relatively brief course preparation minimized the emergence of resistant strains. However, in spite of the colonic bacterial burden and the intraoperative inoculation in the patients with mechanical cleansing alone, their incidence of subsequent infections was comparable to that of patients who were administered oral antibiotics provided that the prophylactic antibiotic was administered for 3 days after surgery.

Anti-allodynic effects of oral COX-2 selective inhibitor on postoperative pain in the rat

PURPOSE

To examine the effect of a cyclooxygenase (COX)-2 inhibitor on the maintenance of mechanical allodynia induced by skin incision (an animal model of postoperative incident pain) in the rat. Also, to compare the effect of a COX-2 inhibitor with that of a nonselective COX-1 and COX-2 inhibitor and B2 receptor antagonist.

METHODS

A 1 cm longitudinal skin incision was made in the plantar aspect of the foot. JTE522 (1-100 mg x kg(-1)), a COX-2 inhibitor, indomethacin (1-30 mg x kg(-1)), a nonselective COX-1 and COX-2 inhibitor, or FR173657 (10 and 100 mg x kg(-1)), a bradykinin B2 receptor antagonist, was administered orally five minutes after the end of the surgery. The level of mechanical allodynia was assessed by measuring the frequency of foot withdrawal in response to the application of a 12.5 g on Frey filament at 2, 4, 6, 8 and 24 hr after the drug administration.

RESULTS

Oral administration of JTE522 or indomethacin attenuated the maximum response frequency in a dose-dependent manner at a dose between 1 and 30 mg x kg(-1) (P < 0.05). Oral FR 173657, (100 mg x kg(-1)), had no effect on the maximum response frequency.

CONCLUSION

These data indicated that a COX-2 inhibitor attenuated the level of mechanical allodynia in the rat model of postoperative pain.

Generation of pro-inflammatory and anti-inflammatory cytokines in the gut in zymosan-induced peritonitis

In major systemic inflammation such as severe peritonitis, various pro-inflammatory cytokines, such as TNF-alpha, IL-1 beta and IL-6, play important roles in the development of multiple organ dysfunction syndrome (MODS). The purpose of this study was to investigate the outflow of pro-inflammatory and anti-inflammatory cytokines from the efferent mesenteric lymphatic vessels under peritonitis. Mesenteric lymph samples were collected from adult male rats at 2, 4, 6, 8 and 10 hr after an intraperitoneal injection of zymosan at a dosage of 0.1 mg/g (non-lethal dose) or 0.5 mg/g (lethal dose). Blood samples were obtained at 10 hr after zymosan administration. The amounts of drained TNF-alpha and IL-6 in the lymph peaked at 2-4 hr and 4-8 hr after zymosan administration, respectively. The amounts of drained IL-10 in the lymph gradually increased until 10 hr. The amounts of drained TNF-alpha and IL-10 in the mesenteric lymph were significantly correlated with the dosage of zymosan. In conclusion, under intraperitoneal inflammation, pro-inflammatory cytokines (TNF-alpha and IL-6) increased in the mesenteric lymph and were drained into circulation. IL-10, one of the anti-inflammatory cytokines, also increased in the mesenteric lymph after several hours' delay and its increase was remarkable in several inflammations. These findings suggested that the gut might be one of the pro-inflammatory and anti-inflammatory cytokine-generating organs under peritonitis. The lymph-drained amounts of each cytokine under peritonitis are considered to differ with the time or severity of inflammation, which may cause different conditions in patients due to the imbalance of pro-inflammatory and anti-inflammatory cytokines.

The role of the spinal opioid receptor like1 receptor, the NK-1 receptor, and cyclooxygenase-2 in maintaining postoperative pain in the rat

Postoperative incident pain is not easily treated with opioids. Mechanical hyperalgesia induced by skin incision in rats is one of the animal models of postoperative incident pain. It is thought that mechanical hyperalgesia is maintained by the sensitization of spinal dorsal horn neurons. The NK-1 receptor, the opioid receptor like1 (ORL1) receptor, and cyclooxygenase (COX)-2 reportedly are involved in the development of spinal sensitization. In this study, we clarified the role of the NK-1 receptor, the ORL1 receptor, and COX-2 in the maintenance of mechanical hyperalgesia induced by skin incision. A 1-cm longitudinal incision was made through skin and fascia of the plantar aspect of the right foot in the rat. Four hours after the skin incision, significant mechanical hyperalgesia developed. An ORL1 receptor agonist (nociceptin), NK-1 receptor antagonists (CP-96,345 and FK888), and COX-2 inhibitors (NS398 and JTE522) were administered intrathecally 4 h after the skin incision. An ORL1 receptor agonist and NK-1 receptor antagonists, but not COX-2 inhibitors, significantly attenuated the level of mechanical hyperalgesia induced by the skin incision. These findings suggest that the spinal ORL1 receptor and the NK-1 receptor play an important role in maintaining the mechanical hyperalgesia induced by skin incision.

IMPLICATIONS

Intrathecal injection of an NK-1 receptor antagonist and an ORL1 receptor agonist may be effective for the treatment of postoperative incident pain.

Differential effects of intrathecally administered morphine and its interaction with cholecystokinin-B antagonist on thermal hyperalgesia following two models of experimental mononeuropathy in the rat

BACKGROUND

Cholecystokinin-B receptor activation has been reported to reduce morphine analgesia. Neuropathic pain is thought to be relatively refractory to opioids. One possible mechanisms for a reduced effect of morphine on neuropathic pain is the induction of cholecystokinin in the spinal cord by nerve injury. The authors evaluated the role of the spinal cholecystokinin-B receptor on morphine analgesia in two rat neuropathic pain models: chronic constriction injury and partial sciatic nerve injury.

METHODS

A chronic constriction injury is created by placing four loosely tied ligatures around the right sciatic nerve. A partial sciatic nerve injury was created by tight ligation of one third to one half of the right sciatic nerve. All drugs were injected intrathecally 7 and 11 days after the nerve injury. The effect of the drugs was reflected in the degree of paw withdrawal latency to thermal nociceptive stimulation. The paw withdrawal latencies of injured and uninjured paws were measured 5, 15, 30, and 60 min after the drugs were injected.

RESULTS

In the chronic constriction injury model, intrathecal morphine increased the paw withdrawal latencies of injured and uninjured paws. PD135158, a cholecystokinin-B receptor antagonist, potentiated the analgesic effect of morphine on injured and uninjured paws. In the partial sciatic nerve injury model, the effect of morphine on the injured paw was less potent than that on the uninjured paw, and PD135158 potentiated the morphine analgesia in the uninjured paw and had only a minor effect on the morphine analgesia in the injured paw.

CONCLUSIONS

The effectiveness of morphine for thermal hyperalgesia after nerve injury depends on the type of nerve injury. The role of the cholecystokinin-B receptor in morphine analgesia in thermal hyperalgesia after nerve injury also depends on the type of nerve injury.

The effectiveness of perineal rectosigmoidectomy for the treatment of rectal prolapse in elderly and high-risk patients

We report herein on the follow-up of ten consecutive patients who underwent perineal rectosigmoidectomy, and discuss the indications, surgical technique, and outcomes of this procedure. The median age of the patients was 79 years, with a range of 26 to 85 years, and eight patients had complicating medical conditions. Of five patients who underwent this procedure for a recurrent prolapse after another type of perineal procedure, four had previously undergone the Thiersch operation combined with the Gant-Miwa technique. The mean length of the excised rectum and sigmoid colon was 22.1 cm. Pain was minimal or absent in all patients and oral intake was commenced after 2 days. There were no mortalities, but anastomotic leakage occurred in one patient. The mean follow-up period was 3.5 years. Only one patient developed recurrent rectal prolapse 24 months after the operation. Of seven patients who underwent concomitant levatoroplasty for incontinence, five became fully continent within 3 weeks after the operation, while the remaining two improved after 2 months. We propose that perineal rectosigmoidectomy is indicated for patients who have suffered an early recurrence of prolapse after another transperineal repair; elderly or high-risk patients with incontinence; male patients; and patients with an incarcerated or gangrenous prolapsed rectal segment.

Nociceptin/orphanin FQ: role in nociceptive information processing

Recently, opioid receptor like1 (ORL1) receptor was identified. The ORL1 receptor is a G protein coupled receptor and the sequence of the ORL1 receptor is closely related to that of the opioid receptors. Nociceptin/orphanin FQ has been identified as a potent endogenous agonist of the ORL1 receptor and the sequence of nociceptin/orphanin FQ is closely related to that of dynorphin A. Nociceptin/orphanin FQis not active at the classical opioid receptors, such as mu, kappa and delta receptors. The distribution of prepronociceptin mRNA is distinct from that of the opioid peptide precursor. Mice lacking the ORL1 receptor showed no significant differences in nociceptive threshold compared with wild mice. The role of nociceptin/orphanin FQ on nociceptive transmission is unclear. Intracerebroventricular (i.c.v.) injection of nociceptin/orphanin FQ produced hyperalgesia and allodynia and antagonized morphine analgesia. On the other hand, intrathecal injection of low dose nociceptin/orphanin FQ produces allodynia, but high dose of nociceptin/orphanin FQ produces an analgesic effect. Although we do not fully understand the mechanisms that produce the difference between the effect of i.c.v. injection of nociceptin/orphanin FQ and that of intrathecal injection of nociceptin/orphanin FQ, we believe that spinal ORL1 receptor may be the next receptor which should be targeted by drugs designed for the treatment of pain.

Effect of nocistatin and its interaction with nociceptin/orphanin FQ on the rat formalin test

Nocistatin is a 17 amino acid peptide and is processed from prepronociceptin. Nocistatin does not bind to the nociceptin receptor, but nocistatin blocks allodynia induced by nociceptin/orphanin FQ. In this study, we examined the effect of intrathecal nocistatin and its interaction with nociceptin/orphanin FQ in the rat formalin test and the hot plate test. Intrathecal nocistatin attenuated the formalin induced phase 1, but not phase 2, flinching behavior. Coadministration of nocistatin with nociceptin/orphanin FQ did not block the analgesic effect of nociceptin/orphanin FQ. Nocistatin had no effect on the hot plate test. These data suggest that nocistatin produces analgesic effect in the formalin test, but not in the hot plate test, and that the mechanisms underlying the analgesic effect of nocistatin is complex.

COX-2 inhibitor prevents the development of hyperalgesia induced by intrathecal NMDA or AMPA

Cyclooxygenase (COX)-2 is constitutively expressed in the superficial dorsal horn of the spinal cord, but its role in the spinal cord is still unclear. We examined the effect of intrathecally administered NS398, a selective COX-2 inhibitor and indomethacin, an non-selective COX-1 and COX-2 inhibitor, on the development of thermal hyperalgesia induced by the activation of NMDA or AMPA receptors. Intrathecal injection of either NS398 or indomethacin equally blocked the development of thermal hyperalgesia induced by intrathecal injection of either NMDA or AMPA in a dose-dependent manner. These data suggest that COX-2 plays an important role in spinal thermal nociceptive transmission when neurons in the spinal cord are facilitated by NMDA or AMPA.

Prediction for the development of postoperative infections in the operation of esophageal cancer compared with gastric surgery

The purpose of this study was to assess the point at which the postoperative infection has occurred in order to decide upon the proper duration of prophylactic antibiotic use. Another goal of this study was to determine whether prediction for the development of postoperative infections in major surgery such as esophagectomy should be the same as that in routine gastroenterological surgery. Twenty-five patients who underwent transthoracic esophagectomy and 127 patients who underwent gastrectomy were studied. On the third day after gastric surgery, the body temperature of patients who developed an infection was higher than that of the patients who did not develop an infection. The relative changes in peripheral white blood count (WBC), and C-reactive protein (CRP) concentration on the third and fourth days were more predictive of the development of infection than the absolute values. Almost all patients with systemic inflammatory response syndrome (SIRS) on the third day after gastric surgery developed an infection. On the other hand, the incidence of SIRS in patients who did not develop an infection was high on both the third and fourth days after esophageal surgery. It was nearly impossible to predict who would develop an infection in esophageal surgery. The high incidence of postoperative infections, and their significant consequences justify planned successive postoperative antibiotic use in esophageal surgery.

Differential effects of intrathecally administered N- and P-type voltage-sensitive calcium channel blockers upon two models of experimental mononeuropathy in the rat

We investigated the effects of intrathecally administered N-type and P-type voltage-sensitive calcium channel (VSCC) blockers on the level of thermal hyperalgesia in two neuropathic pain models: the chronic constriction injury (CCI) model and the partial sciatic nerve injury (PSNI) model. N-type, but not P-type, VSCC blockers attenuated the level of thermal hyperalgesia induced by CCI in a dose-dependent manner. In the PSNI model, both N-type and P-type VSCC blockers had no effect on thermal hyperalgesia. This suggests that some types of neuropathic pain may be treatable with N-type VSCC blockers.

[A case of mitral valve prolapse diagnosed by transesophageal echocardiography during emergency laparotomy]

We described a case of severe mitral valve prolapse diagnosed and successfully managed with transesophageal echocardiography (TEE) during emergency laparotomy for obstructive ileus. As the nature of the surgical procedure and the condition of the patient did not allow us to spend time to perform full cardiac examination preoperatively, we decided to use intraoperative TEE for the determination of cardiac pathology and for the monitoring of ventricular function. We discussed the indication of TEE during noncardiac surgery in patients having cardiac complications. The anesthesiologists should be able to utilize TEE to make correct decision in the hemodynamic management, especially when the preoperative cardiac evaluation is insufficient or lacking.

Changes in cerebral blood flow and vasoreactivity in response to acetazolamide in patients with transient global amnesia

OBJECTIVE

Previous reports about changes in cerebral blood flow (CBF) in transient global amnesia disclosed decreased flow in some parts of the brain. However, CBF analyses in most reports were qualitative but not quantitative. The purpose of this study was to determine changes in CBF in transient global amnesia.

METHODS

The CBF was measured and the vasoreactive response to acetazolamide was evaluated in six patients with transient global amnesia using technetium-99m hexamethylpropylene amine oxime single-photon emission computed tomography (SPECT). The CBF was measured during an attack in two patients and soon after an attack in the other four. About one month later, CBF was re-evaluated in each patient.

RESULTS

Two patients examined during an attack and one patient examined five hours after an attack had increased blood flow in the occipital cortex and cerebellum. Three patients examined at six to 10 hours after an attack had decreased blood flow in the thalamus, cerebellum, or putamen. These abnormalities of blood flow almost disappeared in all patients one month after onset. The vasodilatory response to acetazolamide, which was evaluated initially using SPECT, was poor in areas of increased blood flow. By the second evaluation of CBF with acetazolamide, the vasodilatory response had returned to normal.

CONCLUSIONS

In a patient with transient global amnesia, CBF increased in the vertebrobasilar territory during the attack and decreased afterwards. The vasodilatory response to acetazolamide may be impaired in the parts of the brain with increased blood flow. It is suggested that transient global amnesia is distinct from migraine but may share the same underlying mechanism.

Health and welfare data on optical memory cards in Isehara city

An off-line network system of health and welfare for elderly people using optical memory cards has been established in Isehara city (Japan) since 1991. 2775 citizens have the cards and 24 offices have the terminals. It covers almost one third of people aged over 65 in Isehara city and almost all of the offices concerned with their health and welfare. About a half of holders use optical memory cards every time they visit these offices. The optical memory card holds data including basic data for health and welfare, health check data over 5 years, medical images with scripts and history of welfare services. All the data are used for medical care, health consultation and management of health and welfare services. A card can hold health and welfare data for a lifetime, and it is easy to expand the system. It has been a good experience for us, because the optical memory card system needs co-operation among citizens, medical association and local government, and the experience will help us to expand the system in the future.

[Analysis of patients with excellent motor recovery after large infarction in the middle cerebral artery territory including the cortex]

We reported 6 cases of excellent motor recovery after a large infarction in the middle cerebral artery territory including the cortex. All patients were men (aged 67 to 80); 4 had left hemiplegia and 2 had right hemiplegia. They had abrupt onset of focal neurologic symptoms and signs, suggesting embolic stroke. The consciousness level, according to the Japan coma scale, was grade II in 4 patients and normal in the other 2. Atrial fibrillation was present in 4 patients and premature atrial and ventricular contractions were seen in 1 each. Hypertension was present in 3 patients and diabetes mellitus in 1. The motor plegia gradually improved after 1 to 3 days and almost completely disappeared at 12 days after onset. All patients were eventually able to walk alone without any aids. However, aphasia persisted in 2 patients with left hemispheric damage and left unilateral spatial neglect in 3 patients with right hemispheric damage. A cerebral blood flow analysis by single photon emission computed tomography, using [123I] isopropyliodoamphetamine or technetium 99m hexamethylpropylenamine oxime, demonstrated increased blood flow in the frontal lobe cortex surrounding the infarcted region in 5 patients. These patients showed good recovery from motor deficit, even though, motor symptoms did not begin to improve until 1 to 3 days after onset of stroke. We suggest that there is a subgroup of stroke patients, whose severe motor deficit starts to improve even 3 days after onset of a large infarction in the middle cerebral artery territory including the cerebral cortex.

Regional medical information network using optical memory cards and integrated services for digital network

Since 1986, we have been developing a regional health and welfare system using optical memory cards. We have expanded the system and performed model experiments and evaluations this time. There are approximately 3000 card-holders and 23 card-reader terminals in use. They cover 50 percent of the medical facilities in the city of Isehara. Two medical clinics within neighboring cities have joined our project. Standard Deviation Index (SDI) has been introduced to standardize the numeric results of examinations. The terminals are connected with Integrated Services for Digital Network (ISDN) allowing remote access to the optical memory cards. This enhanced connectivity has allowed greater cooperation in delivering quality medical services.

Identification of bovine serum transferrin phenotypes by polyacrylamide gel isoelectric focusing (PAGIEF)

Each of four common homozygous bovine serum transferrins Tf A, Tf D1, Tf D2, and Tf E gave only two main bands in polyacrylamide gel isoelectric focusing (PAGIEF). This is considered to be due to the co-migration of the main components 2a and 3a with the main components 2b and 3b, respectively, in PAGIEF. Ten phenotypes, which are controlled by four alleles TfA, TfD1, TfD2, and TfE, were distinguishable from each other in PAGIEF.

[Noradrenaline synthesis by locus coeruleus neurons transplanted in rat frontal cortex--influence of denervation of intrinsic noradrenergic projection]

Locus coeruleus (LC) noradrenergic neurons obtained from rat embryo (embryonic day 17) was prepared as cell suspension, and this neuronal cell suspension was transplanted in the frontal cortex of adult rats. The recipient rats were divided into 2 groups to examine the influence of the elimination of the intrinsic noradrenergic projection to the cortex on the transplanted neurons: the first group of animals received electric LC lesion 1 week prior to the transplantation (pre-lesioned group), and the second group received LC lesion 5 weeks after the transplantation (post-lesioned group). The animals were sacrificed 8 weeks after the transplantation, and the noradrenaline (NA) content in the frontal cortex was measured. The NA content in the frontal cortex was also measured 3 or 8 weeks after the LC lesion in the rats received no transplantation (without-T group). The NA content in the frontal cortex was 249 +/- 69 ng/g tissue weight (mean +/- SD, n = 7) in the pre-lesioned group and 252 +/- 69 (n = 11) in the post-lesioned group, while the NA content in the without-T group remained as low as 61 +/- 44 (n = 5) 3 weeks or 51 +/- 14 (n = 9) 8 weeks after the LC lesion. The differences of the NA content between the without-T group and the other two groups were statistically significant respectively. These results suggested that, both in the pre- and post-lesioned groups, the transplanted neurons survived in the recipient animal and synthesized substantial amount of specific neurotransmitter or NA.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypoperfusion and vasoreactivity in the thalamus and cerebellum after stroke

BACKGROUND AND PURPOSE

Cerebellar hypoperfusion in the contralateral hemisphere after stroke is well studied and termed crossed cerebellar diaschisis. However, studies of hypoperfusion in the ipsilateral thalamus have been few. The purpose of this study was to investigate the prevalence of hypoperfusion and vasoreactivity to acetazolamide in the thalamus and cerebellum after stroke.

METHODS

We studied cerebral blood perfusion in the thalamus and cerebellum of 14 patients with unilateral cerebral infarction using [123I]isopropyliodoamphetamine single-photon emission computed tomography (123I-IMP SPECT). We also administered acetazolamide-stressed 123I-IMP SPECT to determine vasodilator capacity in these two areas. Regions of interest were drawn over the bilateral thalami and bilateral cerebellar cortices, and asymmetry indexes were obtained.

RESULTS

We found ipsilateral thalamic hypoperfusion in 12 (85.7%) and contralateral cerebellar hypoperfusion in 11 (78.6%) of 14 patients. Hypoperfusion was improved (p < 0.01 by the Wilcoxon signed rank test) in 11 (91.7%) of the 12 patients with ipsilateral thalamic hypoperfusion and in seven (63.6%) of the 11 patients with contralateral cerebellar hypoperfusion.

CONCLUSIONS

Hypoperfusion in the ipsilateral thalamus and contralateral cerebellum is common, and vasoreactivity to acetazolamide is preserved in both the thalamus and the cerebellum with hypoperfusion.

Hereditary motor and sensory neuropathy with calf muscle enlargement

We report three related patients with autosomal dominant hereditary motor and sensory neuropathy (HMSN). An unusual and characteristic feature was calf enlargement, caused by muscle fiber hypertrophy predominantly of type 1 fibers. None of the family members showed atrophy of the legs. Sural nerve pathology disclosed marked loss of myelinated fibers and numerous onion bulb formations. While cases of HMSN with calf muscle hypertrophy have been reported, the present pedigree was different from that in any of the previous cases in that no family member showed clinically apparent leg atrophy.

Studies on endogenous formation of N-nitroso compounds in the guinea pig supplemented with proline or thioproline and sodium nitrate

The endogenous formation of N-nitrosoproline (NPRO) and N-nitrosothioproline (NTPRO, N-nitrosothiazolidine-4-carboxylic acid) was studied by monitoring their excretion in the urine of guinea pigs given oral doses of 10 mg proline or thioproline after supplementation with 34 mg (0.4 mmol) sodium nitrate. In order to estimate the conversion of nitrate to nitrite, the animals were also supplemented with 3.5 mg (0.05 mmol) sodium nitrite instead of sodium nitrate. In animals fed commercial diets, the excretion of NPRO and NTPRO under supplementation with sodium nitrate was 2.0 micrograms and 28.7 micrograms/animal/day, respectively, whereas the excretion under supplementation with sodium nitrite was 0.7 micrograms and 13.3 micrograms/animal/day, respectively. The higher excretion of NTPRO than NPRO in each case shows that thioproline is more effective for nitrite trapping than proline. The animals supplemented with nitrate excreted more than twice the amounts of NPRO or NTPRO than those supplemented with nitrite. It is assumed, therefore, that more than 0.1 mmol nitrate is reduced to nitrite and takes part in the endogenous nitrosation of the guinea pig. When various concentrations of L-ascorbic acid (AsA), known to inhibit the formation of N-nitroso compounds, were also administered orally to animals immediately after supplementation with sodium nitrate, the NPRO excretion decreased with increasing AsA concentration. These data indicate that the guinea pig, which is unable to synthesize AsA as well as humans, may be an appropriate animal model for evaluation of the endogenous nitrosation ability of humans ingesting nitrate.

[Unilateral persistent hyperhidrosis after ischemic stroke]

A 64-year-old right hemiplegic woman, who had been treated for hypertension for 15 years, was admitted to our hospital. Neurologic examination on admission disclosed right hemiplegia and motor aphasia; however, ophthalmoparesis, pupillary abnormality, and blepharoptosis were not evident. Excessive sweating on the right side of the body, which was most marked on the face, was observed. Amount of sweating on the left side of the body was normal. Unilateral hyperhidrosis persisted for more than 2 months. MRI revealed hemorrhagic infarctions in the left basal ganglia, internal capsule, thalamus, hypothalamus, and medial part of the cerebral peduncle. 123I-IMP SPECT disclosed hypoperfusion in the left striatum, thalamus, occipital cortex, and right cerebellar hemisphere. Cerebral angiography revealed arteriosclerotic changes in the basilar artery, but that the left posterior cerebral artery and its branches were not occluded. Unilateral persistent hyperhidrosis is rare after ischemic stroke. Hypothalamic lesion was thought to be responsible for the hyperhidrosis in this patient. As the hypothalamus receives its blood supply from the posterior cerebral artery, unilateral persistent hyperhidrosis may be an important sign of cerebral infarction in the posterior cerebral artery region.

Visual attentional disturbance with unilateral lesions in the basal ganglia and deep white matter

To elucidate the role of the basal ganglia and deep white matter in the visual attention mechanism, a new visual attention task was carried out by 15 patients, 9 with left-side and 6 with right-side basal ganglia and/or deep white matter damage without visual field defects, and by 12 normal subjects. Their reaction times were recorded in response to a random visual stimulation by pushing a button with the hand ipsilateral to the side of the lesion. All the patients with damage to the right side of the brain had a longer reaction time in the left space than in the right or middle space. With conventional test, only one of them showed left unilateral spatial neglect. Seven of the 9 patients with a left lesion had a significantly longer reaction time in the right space than in the left. None had unilateral spatial neglect. Both the right and left brain-damaged groups showed longer reaction times in both spaces, compared to the normal groups. There was no significant difference in reaction time among the control subjects. These findings suggest that the basal ganglia and deep white matter in each hemisphere play some role in directing visual attentional factors into both spaces. Visual attentional disturbance was highly evident even with left-side brain damage, and this kind of disturbance is not usually revealed with the current tasks used for testing unilateral spatial neglect.