Robot-assisted laparoscopic partial gastrectomy combined with endoscopy for gastrointestinal stromal tumors with intraluminal growth: a report of two cases.

In cases of gastrointestinal stromal tumor (GIST) with intraluminal growth, determining the minimal resection line is difficult; however, the combined use of endoscopy can overcome this limitation. We performed robot-assisted partial gastrectomy with endoscopy for two cases of internally developed GISTs located on the posterior wall near the esophagogastric junction (EGJ). We confirmed the tumor location and determined minimal surgical margins using endoscopy. The double bipolar method (DBM), which is performed with Maryland bipolar forceps in the right hand and fenestrated bipolar forceps in the left hand, was used to reduce residual gastric damage and prevent tumor damage. The characteristics of robot-assisted surgery made it easier to precisely perform anastomosis of the upper part of the stomach, as compared with laparoscopic surgery, thus minimizing gastric deformity. Both patients were discharged without postoperative complications. In conclusion, robot-assisted partial gastrectomy using the DBM may represent a viable treatment option for gastric submucosal tumors close to the EGJ.

CpG ODN (K3)-toll-like receptor 9 agonist-induces Th1-type immune response and enhances cytotoxic activity in advanced lung cancer patients: a phase I study.

BACKGROUND: Cytosine-phosphate-guanine oligodeoxynucleotide (CpG ODN) (K3)-a novel synthetic single-stranded DNA immune adjuvant for cancer immunotherapy-induces a potential Th1-type immune response against cancer cells. We conducted a phase I study of CpG ODN (K3) in patients with lung cancer to assess its safety and patients' immune responses. METHODS: The primary endpoint was the proportion of dose-limiting toxicities (DLTs) at each dose level. Secondary endpoints included safety profile, an immune response, including dynamic changes in immune cell and cytokine production, and progression-free survival (PFS). In a 3 + 3 dose-escalation design, the dosage levels for CpG ODN (K3) were 5 or 10 mg/body via subcutaneous injection and 0.2 mg/kg via intravenous administration on days 1, 8, 15, and 29. RESULTS: Nine patients (eight non-small-cell lung cancer; one small-cell lung cancer) were enrolled. We found no DLTs at any dose level and observed no serious treatment-related adverse events. The median observation period after registration was 55 days (range: 46-181 days). Serum IFN-α2 levels, but not inflammatory cytokines, increased in six patients after the third administration of CpG ODN (K3) (mean value: from 2.67 pg/mL to 3.61 pg/mL after 24 hours). Serum IFN-γ (mean value, from 9.07 pg/mL to 12.7 pg/m after 24 hours) and CXCL10 levels (mean value, from 351 pg/mL to 676 pg/mL after 24 hours) also increased in eight patients after the third administration. During the treatment course, the percentage of T-bet-expressing CD8+ T cells gradually increased (mean, 49.8% at baseline and 59.1% at day 29, p = 0.0273). Interestingly, both T-bet-expressing effector memory (mean, 52.7% at baseline and 63.7% at day 29, p = 0.0195) and terminally differentiated effector memory (mean, 82.3% at baseline and 90.0% at day 29, p = 0.0039) CD8+ T cells significantly increased. The median PFS was 398 days. CONCLUSIONS: This is the first clinical study showing that CpG ODN (K3) activated innate immunity and elicited Th1-type adaptive immune response and cytotoxic activity in cancer patients. CpG ODN (K3) was well tolerated at the dose settings tested, although the maximum tolerated dose was not determined. TRIAL REGISTRATION: UMIN-CTR number 000023276. Registered 1 September 2016, https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000026649.

Effects of a False Window on the Change of Cognitive Function in Patients Admitted to a Neurological Ward.

False windows can display a variety of outdoor scenery in rooms without real windows. We aimed to assess the effects of three different hospital beds on the change in the frontal assessment battery scores in patients aged ≥ 20-year-old admitted in our neurological ward. We included 24 patients on the window side, 12 patients on the aisle side with a false window, and 12 patients on the aisle side without a false window. There were no statistical differences in the change of cognitive function among the three hospital beds. Only the length of hospital stay was a significant associated factor.

Relationship between tongue pressure and dysphagia diet in patients with acute stroke.

A dysphagia diet is important for patients with stroke to help manage their nutritional state and prevent aspiration pneumonia. Tongue pressure measurement is a simple, non-invasive, and objective method for diagnosing dysphagia. We hypothesized that tongue pressure may be useful in making a choice of diet for patients with acute stroke. Using balloon-type equipment, tongue pressure was measured in 80 patients with acute stroke. On admission, a multidisciplinary swallowing team including doctors, nurses, speech therapists, and management dietitians evaluated and decided on the possibility of oral intake and diet form; the tongue pressure was unknown to the team. Diet form was defined and classified as dysphagia diet Codes 0 to 4 and normal form (Code 5 in this study) according to the 2013 Japanese Dysphagia Diet Criteria. In multivariate analysis, only tongue pressure was significantly associated with the dysphagia diet form (p<0.001). Receiver operating characteristic analyses revealed that the optimal cutoff tongue pressure for predicting diet Codes 1, 2, 3, 4, and 5 was 3.6 (p<0.001, area under the curve [AUC] = 0.997), 9.6 (p<0.001, AUC = 0.973), 12.8 (p<0.001, AUC = 0.963), 16.5 (p<0.001, AUC = 0.979), and 17.3 kPa (p<0.001, AUC = 0.982), respectively. Tongue pressure is one of the sensitive indicators for choosing dysphagia diet forms in patients with acute stroke. A combination of simple modalities will increase the accuracy of the swallowing assessment and choice of the diet form.

Real-Time Monitoring of Key Gene Products Involved in Rice Photoperiodic Flowering.

Flowering is an important biological process through which plants determine the timing of reproduction. In rice, florigen mRNA is induced more strongly when the day length is shorter than the critical day length through recognition of 30-min differences in the photoperiod. Grain number, plant height, and heading date 7 (Ghd7), which encodes a CCT-domain protein unique to monocots, has been identified as a key floral repressor in rice, and Heading date 1 (Hd1), a rice ortholog of the Arabidopsis floral activator CONSTANS (CO), is another key floral regulator gene. The Hd1 gene product has been shown to interact with the Ghd7 gene product to form a strong floral repressor complex under long-day conditions. However, the mRNA dynamics of these genes cannot explain the day-length responses of their downstream genes. Thus, a real-time monitoring system of these key gene products is needed to elucidate the molecular mechanisms underlying accurate photoperiod recognition in rice. Here, we developed a monitoring system using luciferase (LUC) fusion protein lines derived from the Ghd7-LUC and Hd1-LUC genes. We successfully obtained a functionally complemented gene-targeted line for Ghd7-LUC. Using this system, we found that the Ghd7-LUC protein begins to accumulate rapidly after dawn and reaches its peak more rapidly under a short-day condition than under a long-day condition. Our system provides a powerful tool for revealing the accurate time-keeping regulation system incorporating these key gene products involved in rice photoperiodic flowering.

Binding and Structural Properties of DNA Aptamers with VEGF-A-Mimic Activity.

Vascular endothelial growth factors (VEGFs) are hypoxia-inducible secreted proteins to promote angiogenesis, in which VEGF-A is an important molecule that binds and activates VEGF receptor-1 (VEGFR-1) and VEGFR-2. In this study, two DNA aptamers, Apt01 and Apt02, were successfully isolated by alternating consecutive systematic evolution of ligands by exponential enrichment (SELEX) against VEGFR-1 and -2 using deep sequencing analysis in an early selection round. Their binding affinities for VEGFR-2 were lower than that of VEGFR-1, which is similar to that of VEGF-A. Structural analyses with the measurements of circular dichroism spectra and ultraviolet melting curve showed that Apt01 possessed the stem-loop structure in the molecule, whereas Apt02 formed G-quadruplex structures. In addition, Apt02 accelerated a tube formation of human umbilical vein endothelial cells faster than Apt01, which was affected by difference of binding affinity and nuclease resistance due to G-quadruplex structures. These results demonstrated that Apt02 might have a potential to function as an alternative to VEGF-A.

Screening of DNA Signaling Aptamer from Multiple Candidates Obtained from SELEX with Next-generation Sequencing.

Here, we demonstrated a strategy for developing signaling aptamers, based on screening of signaling aptamers from multiple aptamer candidates obtained by SELEX with next generation sequencing. Among aptamer candidates labelled by 6-carboxyfluorescein and quencher at both end termini, there is the possibility of discovering a potent signaling aptamer. In this study, we discovered DNA signaling aptamers against VEGFR-1. This strategy has the potential for signaling aptamer discovery without the extremely laborious task of optimization of oligodeoxynucleotide modifications.

[Resection of an Advanced Rectal Gastrointestinal Stromal Tumor Following Neoadjuvant Chemotherapy].

A 66-year-old man was referred to our hospital after being diagnosed with a pelvic tumor. A subsequent transperineal biopsy revealed spindle cells with CD34·c-kit(+). An enhanced computed tomography scan showed a giant rectal-derived tumor in the pelvis. The tumor was pressing on the urinary bladder and the prostate, and appeared to invade the posterior wall ofthese organs. The patient was diagnosed with rectal GIST, and neoadjuvant therapy with 400mg/day imatinib was initiated. Three months later, the tumor reduction rate was at 33.6%, and surgery was performed. The operative method applied was pelvic exenteration and ileal conduit, for local R0 resection. The patient has remained recurrence free for 2.5 years since the surgery.

Proposed criterion for distinguishing ABO mosaics from ABO chimeras using flow cytometric analysis.

Differentiation of ABO mosaics from chimeras is performed using flow cytometry (FCM) analysis. Although mosaics and chimeras have been distinguished by presence or absence of clear resolution using FCM analysis, the lack of quantitative metrics and definitive criteria for this differentiation has made some cases difficult to differentiate. In this study, therefore, we attempted to establish a definitive and quantitative criterion for this differentiation. When FCM histogram gates for group "A" or "B" antigen-negative and -positive red blood cells (RBCs) were set such that group O RBCs were classified as 99 percent negative and group A or B RBCs as 99 percent positive, the percentages of RBCs in the middle region of six chimeras and 23 mosaics (12 A mosaics and 11 B mosaics) were 0.1-0.6 percent and 7.0-19.0 percent, respectively. This results suggested that ABO mosaics and chimeras can be unambiguously differentiated when the cutoff point of the intermediate region is set to 1 percent.

Defining the Jr(a-) phenotype in the Japanese population.

BACKGROUND: The Jr(a-) phenotype is rare in European and North American populations but is not so rare in Japanese and other Asian populations. Recently, two groups have established the connection between the Jr(a-) phenotype and the ATP-binding cassette, member G2 (ABCG2) gene and concluded that ABCG2-null alleles encode the Jr(a-) phenotype. In Japanese Red Cross Blood Centers, the Jr(a-) phenotype is found with a prevalence of 0.05% among blood donors, and we applied DNA-based genotyping to investigate the molecular basis of the Jr(a-) phenotype in Japan, in addition to serologic typing. STUDY DESIGN AND METHODS: Purified genomic DNA extracts of Japanese donor samples [500 Jr(a+) and 85 Jr(a-) phenotypes] were amplified using specific amplification primers for the c.376C>T mutation, which is the most common mutation in the Asian JRnull allele. Polymerase chain reaction products were examined by high-resolution melt techniques and DNA sequence analyses. RESULTS: Seventy-nine of 85 Jr(a-) samples were homozygous for the single-nucleotide polymorphism c.376C>T (Gln126Stop) change. In other samples, two novel null alleles were detected: c.2T>C and c.421C>A: c.1515delC. CONCLUSION: In this study, more than 90% of the Japanese Jr(a-) phenotypes had c.376C>T (Gln126Stop) nucleotide change. In the other Jr(a-), a new mutation (c.2T>C) in the start codon encoding Thr instead of Met, c.1515delC encoding Ala505AlafsStop and heterozygous for c.337C/T and c.736C/T were detected. DNA-based genotyping is accurate and useful for Jr(a-) donor typing.

Adhesion molecule CADM1 contributes to gap junctional communication among pancreatic islet α-cells and prevents their excessive secretion of glucagon.

Cell adhesion molecule-1 (CADM1) is a recently identified adhesion molecule of pancreatic islet α-cells that mediates nerve-α-cell interactions via trans-homophilic binding and serves anatomical units for the autonomic control of glucagon secretion. CADM1 also mediates attachment between adjacent α-cells. Since gap junctional intercellular communication (GJIC) among islet cells is essential for islet hormone secretion, we examined whether CADM1 promotes GJIC among α-cells and subsequently participates in glucagon secretion regulation. Dye transfer assays using αTC6 mouse α-cells, which endogenously express CADM1, supported this possibility; efficient cell-to-cell spread of gap junction-permeable dye was detected in clusters of αTC6 cells transfected with nonspecific, but not with CADM1-targeting, siRNA. Immunocytochemical analysis of connexin 36, a major component of the gap junction among αTC6 cells, revealed that it was localized exclusively to the cell membrane in CADM1-non-targeted αTC6 cells, but diffusely to the cytoplasm in CADM1-targeted cells. Next, we incubated CADM1-targeted and non-targeted αTC6 cells in a medium containing 1 mM glucose and 200 mM arginine for 30 min to induce glucagon secretion, and found that the targeted cells secreted three times more glucagon than did the non-targeted. We conducted similar experiments using pancreatic islets that were freshly isolated from wild-type and CADM1-knockout mice, and expressed glucagon secretion as ratios relative to baseline values. The increase in ratio was larger in CADM1-knockout islets than in wild-type islets. These results suggest that CADM1 may serve as a volume limiter of glucagon secretion by sustaining α-cell attachment necessary for efficient GJIC.

Influenza vaccination of schoolchildren and influenza outbreaks in a school.

BACKGROUND: The objective of this retrospective descriptive study was to determine whether the universal influenza vaccination for schoolchildren was effective in controlling influenza outbreaks in a school. A universal vaccination program for schoolchildren was started in Japan in the 1960s, but the government abandoned the program in 1994 because of lack of evidence that the program was effective in preventing influenza in schoolchildren. METHODS: Influenza vaccine coverage rates, total numbers of class cancellation days, and absentee rates were reviewed in a single elementary school during the 24-year period during 1984-2007. RESULTS: The mean number of class cancellation days and the mean absentee rate in the compulsory vaccination period (1984-1987; mean vaccine coverage rate, 96.5%) were 1.3 days and 2.5%, respectively, and they increased to 8.3 days and 3.2% during the quasi-compulsory vaccination period (1988-1994; vaccine coverage, 66.4%). In the no-vaccination period (1995-1999; vaccine coverage, 2.4%), they were 20.5 days and 4.3%, respectively, and in the voluntary vaccination period (2000-2007; vaccine coverage, 38.9-78.6%), they were 7.0-9.3 days and 3.8%-3.9%. When minor epidemics were excluded, there was a significant inverse correlation between the vaccine coverage rates and both the number of class cancellation days and absentee rates. CONCLUSIONS: The universal influenza vaccination for schoolchildren was effective in reducing the number of class cancellation days and absenteeism in the school.

Comparison of clinical effectiveness between surgical and endovascular treatment for thrombotic obstruction in hemodialysis access.

PURPOSE: Endovascular treatment (ET) is widely used for thrombotic complications of vascular access (VA) for hemodialysis. We evaluated the effectiveness of both ET and surgical interventions for thrombotic complications. METHODS: We studied 533 patients who underwent surgical procedures (a total of 879 procedures) and 54 patients who received ET (a total of 156 procedures) for VA obstruction (endovascular group; group 1). The 533 patients who underwent surgical procedures were further divided into two groups: the surgical balloon-angioplasty group (the thrombus was surgically removed and the stenotic lesions were dilated by balloon angioplasty; 189 procedures; group 2) and the surgical repair group (the stenotic lesions were bypassed with additional graft diversion or creation of a new access; 690 procedures; group 3). The three groups were evaluated for VA patency. RESULTS: Using the Kaplan-Meier method, the 2-yr patency for groups 1, 2, and 3 were 11.1%, 11.5%, and 34.0% (p<0.0001). The 2-yr patency rates in patients in whom arteriovenous grafts were used were 5.9% (group 1), 9.2% (group 2), and 22.8% (group 3) (p<0.0001), whereas in patients with arteriovenous fistulae they were 33.7% (group 1), 35.7% (group 2), and 59.8% (group 3) (p=0.0005). CONCLUSIONS: A surgical approach may cause difficulty in creating a new VA, because useful access vessels are limited. Our results indicate surgical balloon-angioplasty and ET provide the same patency. ET is less invasive and can be repeated, which makes it beneficial for the patients. We concluded ET could be considered as the first-line treatment for thrombotic complications.

CXC chemokine receptor 4 expressed in T cells plays an important role in the development of collagen-induced arthritis.

INTRODUCTION: Chemokines and their receptors are potential therapeutic targets in rheumatoid arthritis (RA). Among these, several studies suggested the involvement of CXC chemokine 4 (CXCR4) and its ligand CXC ligand 12 (SDF-1) in RA pathogenesis. However, the role of these molecules in T-cell function is not known completely because of embryonic lethality of Cxcr4- and Cxcl12-deficient mice. In this report, we generated T cell-specific Cxcr4-deficient mice and showed that the CXCR4 in T cells is important for the development of collagen-induced arthritis (CIA). METHODS: T cell-specific Cxcr4-deficient mice were generated by using the Cre-loxP system. Mice harboring loxP sites flanking exon 2 of the Cxcr4gene (Cxcr4flox/flox) were generated by homologous recombination and crossed with Cre transgenic mice expressing Cre recombinase under the control of Lck promoter (Cxcr4+/+/Lck-Cremice) to generate T cell-specific Cxcr4-deficient mice (Cxcr4flox/flox/Lck-Cre mice). CIA was induced by immunization with chicken type II collagen and Complete Freund's Adjuvant (CFA). RESULTS: The incidence, but not the severity, of CIA was significantly reduced in Cxcr4flox/flox/Lck-Cre mice compared with Cxcr4+/+/Lck-Cre mice. We found that the expression of CXCR4 was enhanced in activated T cells, and the migration of Cxcr4-deficient T cells toward SDF-1 was severely impaired. However, antibody production, cellular proliferative response, and cytokine production on treatment with type II collagen (IIC) were normal in these knockout mice, suggesting that CXCR4 is not involved in T-helper functions. Interestingly, the proportion of CXCR4-expressing T cells was much increased in affected joints compared with that in draining lymph nodes in CIA-induced mice, and distribution of Cxcr4flox/flox/Lck-Cre mouse-derived T cells into affected joints was suppressed compared with that in Cxcr4+/+/Lck-Cre T cells. CONCLUSIONS: These results indicate that CXCR4 expression in T cells is important for the development of CIA, by recruiting activated T cells toward inflammatory sites, and suggest that CXCR4 is a good target for the treatment of RA in humans.

Advantage of absorbable suture material for pulmonary artery ligation.

PURPOSE: The applicability of absorbable materials as ligatures of pulmonary vessels has not been described. The present study compares tissue reactions around sites of pulmonary arteries ligated with absorbable material (Vicryl) and with nonabsorbable material (silk). METHODS: Beagle dogs underwent thoracotomy and the pulmonary artery branches were ligated with silk or Vicryl under general anesthesia. The ligated arterial tissues were obtained at 4 and 8 weeks after thoracotomy and processed for pathological analysis. RESULTS: The arteries ligated using Vicryl or silk were clinically completely sealed at 4 weeks after ligation. More inflammation and granuloma were evident at tissues surrounding ligations made with silk than with Vicryl at 8 weeks. Hyperplasia of the arterial intima continued at 8 weeks after ligation with both Vicryl and silk sutures, although some hyperplasia similar to that in nonligated arterial intima appeared at 4 weeks after ligation. CONCLUSION: Less inflammation and granuloma are caused at arterial tissues around ligations accomplished with absorbable Vicryl than those done with nonabsorbable silk sutures, although both are equally effective. Absorbable sutures might be suitable for ligating pulmonary arteries.

Prognostic value of reduced left ventricular ejection fraction at start of hemodialysis therapy on cardiovascular and all-cause mortality in end-stage renal disease patients.

BACKGROUND AND OBJECTIVES: Cardiac failure is directly affected by left ventricular (LV) dysfunction, and particularly LV systolic dysfunction is strongly associated with survival in ESRD patients. The aim of this study was to determine the prognostic value of reduced LV ejection fraction (LVEF) measured at the time of initiation of hemodialysis (HD) in incident HD patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: 1254 consecutive ESRD patients who electively started HD therapy were screened by echocardiography within 1 month after its inception. They were divided into five groups according to LVEF levels with a decrease of 0.1 each and were followed up for up to 7 years. Survival was examined with the Kaplan-Meier method and compared using the log-rank test. RESULTS: Among the 1254 patients, LVEF levels ≥0.6, 0.5 to 0.6, 0.4 to 0.5, 0.3 to 0.4, and <0.3 were seen in 842 (67.1%), 247 (19.7%), 107 (8.5%), 41 (3.3%), and 17 (1.4%) patients, respectively. On Kaplan-Meier analysis, 7-year event-free rates from cardiovascular death were 84.2, 83.7, 73.6, 59.4, and 30.9% in order of groups with decreasing LVEF of 0.1 each, respectively. Seven-year event-free rates from all-cause death were 69.2, 61.7, 57.1, 45.9, and 23.1% in the respective groups. Even after adjustment for other risk factors, decreasing LVEF was a strong independent predictor for cardiovascular death. CONCLUSIONS: Reduced LVEF on starting HD therapy could stratify risk of cardiovascular and all-cause mortality in ESRD patients. Screening by echocardiography at start of HD therapy might be recommended to predict prognosis in patients with ESRD.

Aggressive statin therapy in multicenter and effectiveness for the reduction of intra-myocardial damage caused by non-ST elevation acute coronary syndrome: AMERICA study.

BACKGROUND: While preprocedural statin treatment for acute coronary syndrome (ACS) is widely regarded as beneficial, there has been no prospective randomized multicenter trial of patients with non-ST elevation ACS in the Japanese population to examine the efficacy of preprocedural aggressive statin use. The aim of this study was to confirm this effect by prospective randomized multicenter design. METHODS: Fifty patients who presented with non-ST elevation ACS were enrolled, and randomly assigned to aggressive statin administration before percutaneous coronary intervention (PCI). Troponin-T (TnT), creatine phosphokinase (CK), CK-myocardial band (CK-MB), high-sense C-reactive protein (hs-CRP), and brain natriuretic peptide (BNP) were measured at baseline and/ or after procedure. RESULTS: Three days after PCI, the statin group had significantly less CK elevation compared with the nonstatin group (84+/-17 IU/l versus 180+/-68 IU/l, respectively, p = 0.02). CK-MB elevation also tended to be lower in the statin group than in the nonstatin group (3.2+/-1.9 versus. 7.0+/-3.0, respectively, p = 0.07), as was BNP level (3.2+/-1.9 versus 7.0+/-3.0 pg/ml, respectively, p = 0.07). The change of serum LDL cholesterol was significantly correlated with CK (p = 0.01) and TnT (p = 0.02) at 1 day after PCI. CONCLUSIONS: Aggressive statin usage before PCI to Japanese patients with non-ST elevation ACS appears to reduce myocardial damage after procedure. The degree of serum lipid level reduction may reflect the vulnerability of atheromatous plaques that could cause cardiac damage after PCI.