Safety of hernia sac resection in inguinal herniorrhaphy for patients on peritoneal dialysis: a case series.

Peritoneal dialysis (PD) is a risk factor for inguinal hernia, and herniorrhaphy on PD might be complicated by PD fluid.Although sac resection should contribute to preventing indirect hernia recurrence, the safety on PD has not beendescribed. This case series describes the detailed surgical procedures and long-term outcomes of 16 cases ofinguinal herniorrhaphy on PD. Results are shown as median (range). The age was 67.5 (53-83) years. Beginning atthe 6th case, we omitted interim hemodialysis and performed the Lichtenstein procedure. We performed sac excisionin the 14 patients. No complication related to PD was found. The follow-up period was 41.5 (4-124) months. Norecurrence occurred. They could continue PD for 21.5 (4-103) months after surgery. The total PD duration was 38.5(18-152) months. In conclusion, inguinal herniorrhaphy with sac resection may not compromise safety even forpatients on PD and achieve the expected PD duration without recurrence.

Oncogenic K-RasG12V cannot overcome proliferation failure caused by loss of Ppp6c in mouse embryonic fibroblasts.

Protein phosphatase 6 is a Ser/Thr protein phosphatase and its catalytic subunit is Ppp6c. Ppp6c is thought to be indispensable for proper growth of normal cells. On the other hand, loss of Ppp6c accelerates growth of oncogenic Ras-expressing cells. Although it has been studied in multiple contexts, the role(s) of Ppp6c in cell proliferation remains controversial. It is unclear how oncogenic K-Ras overcomes cell proliferation failure induced by Ppp6c deficiency; therefore, in this study, we attempted to shed light on how oncogenic K-Ras modulates tumor cell growth. Contrary to our expectations, loss of Ppp6c decreased proliferation, anchorage-independent growth in soft agar, and tumor formation of oncogenic Ras-expressing mouse embryonic fibroblasts (MEFs). These findings show that oncogenic K-RasG12V cannot overcome proliferation failure caused by loss of Ppp6c in MEFs.

Comparison of Safety and Efficacy between Laparoscopic Ventral Rectopexy and Delorme's Procedure for External Rectal Prolapse in Nonagenarians.

Objectives: This study evaluates the safety and efficacy of laparoscopic ventral rectopexy (LVR) in nonagenarian patients with external rectal prolapse (ERP) compared to Delorme's procedure. Methods: We conducted a retrospective analysis of prospectively collected data, including nonagenarian patients who underwent either LVR or Delorme's procedure, comparing outcomes such as morbidity, length of hospital stay (LOS), and recurrence rates. Results: Between September 2009 and August 2023, 22 patients (median age 91, range 90-94 years) underwent LVR, while 12 patients (median age 91, range 90-96 years) received Delorme's procedure. Baseline characteristics, including sex ratio, parity, American Society of Anesthesiology grade, and Body Mass Index, did not significantly differ between the groups. LVR had a significantly longer operating time but lower blood loss than Delorme's procedure. Postoperative LOS was significantly shorter for LVR patients (median 1, range 1-3 days) compared to Delorme's procedure patients (median 2.5, range 1-13 days; P = 0.001). Notably, no significant morbidity occurred in the LVR group, while one case of delirium and another of solitary rectal ulcer syndrome were observed in the Delorme's procedure group. Recurrence rates were lower in the LVR group, with no recurrences during a median follow-up of 23 months (range 1-65 months), compared to one recurrence at 2 months during a median follow-up of 34 months (range 1-96 months) in the Delorme's procedure group. Conclusions: LVR is a safe and effective surgical option for nonagenarian ERP patients, showing favorable outcomes in terms of morbidity, LOS, and recurrence rates compared to Delorme's procedure.

A Case of Pediatric Breast Abscess Caused by Rarely Observed Bacteria in a Three-Year-Old Boy With an Inverted Nipple: Peptoniphilus harei, Actinotignum sanguinis, and Porphyromonas somerae.

Mastitis and breast abscesses are most common in lactating women but can also be observed in non-lactating women, adolescent girls, and neonates. However, breast abscesses are extremely rare in young boys. Herein, we report the case of a three-year-old boy with a swollen and painful right nipple, later diagnosed with a breast abscess. In this case, we suspected that the patient's inverted nipple was the possible site of the infection. To our best knowledge, this is the first case report of breast abscess in a young boy after the neonatal period. Although Staphylococcus aureus is the most common pathogen, our patient showed three rare bacteria, namely, Peptoniphilus harei, Actinotignum sanguinis, and Porphyromonas somerae, in the culture of the aspirated pus. Furthermore, this case study is the first report of a breast abscess caused by Porphyromonas somerae.

Laparoscopic or transanal repair of rectocele? Comparison of a reduction in rectocele size.

PURPOSE: This study aimed to compare the reduction in rectocele size after laparoscopic ventral rectopexy (LVR) with that after transanal repair (TAR). METHODS: Forty-six patients with rectocele who underwent LVR and 45 patients with rectocele who received TAR between February 2012 and December 2022 were included. This was a retrospective analysis of prospectively collected data. All patients had clinical evidence of a symptomatic rectocele. Bowel function was evaluated using the constipation scoring system (CSS) and fecal incontinence severity index (FISI). Substantial symptom improvement was defined as at least a 50% reduction in the CSS or FISI scores. Evacuation proctography was performed before surgery and 6 months postoperatively. RESULTS: Constipation was substantially improved in 40-70% of the LVR patients and 70-90% of the TAR patients over 5 years. Fecal incontinence was markedly improved in 60-90% of the LVR patients across 5 years and in 75% of the TAR patients at 1 year. Postoperative proctography showed a reduction in rectocele size in the LVR patients (30 [20-59] mm preoperatively vs. 11 [0-44] mm postoperatively, P < 0.0001) and TAR patients (33 [20-55] mm preoperatively vs. 8 [0-27] mm postoperatively, P < 0.0001). The reduction rate of rectocele size in the LVR patients was significantly lower than that in the TAR patients (63 [3-100] % vs. 79 [45-100] %, P = 0.047). CONCLUSION: The reduction in rectocele size was lower in the patients who underwent LVR than in those who received TAR.

Mechanism of cystogenesis by Cd79a-driven, conditional mTOR activation in developing mouse nephrons.

Polycystic kidney disease (PKD) is a common genetic disorder arising from developmental and postnatal processes. Defects in primary cilia and their signaling (eg, mTOR) underlie the pathogenesis. However, how mTOR regulates tubular integrity remains unclear. The paucity of faithful models has limited our understanding of pathogenesis and, therefore, the refinement of therapeutic targets. To understand the role of mTOR in early cystogenesis, we studied an in-house mouse model, Cd79a-Cre;Tsc1ff. (Cd79a-Tsc1 KO hereafter), recapitulating human autosomal-dominant PKD histology. Cre-mediated Tsc1 depletion driven by the promoter for Cd79a, a known B-cell receptor, activated mTORC1 exclusively along the distal nephron from embryonic day 16 onward. Cysts appeared in the distal nephron at 1 weeks of age and mice developed definite PKD by 4 weeks. Cd79a-Tsc1 KO tubule cells proliferated at a rate comparable to controls after birth but continued to divide even after postnatal day 14 when tubulogenesis is normally completed. Apoptosis occurred only after 9 weeks. During postnatal days 7-11, pre-cystic Cd79a-Tsc1 KO tubule cells showed cilia elongation, aberrant cell intercalation, and mitotic division, suggesting that defective cell planar polarity (PCP) may underlie cystogenesis. mTORC1 was activated in a portion of cyst-lining cells and occasionally even when Tsc1 was not depleted, implying a non-autonomous mechanism. Our results indicate that mTORC1 overactivation in developing distal tubules impairs their postnatal narrowing by disrupting morphogenesis, which orients an actively proliferating cell toward the elongating axis. The interplay between mTOR and cilium signaling, which coordinate cell proliferation with PCP, may be essential for cystogenesis.

Arf1 facilitates mast cell proliferation via the mTORC1 pathway.

Mast cells are one of major players in allergic responses. Mast cell activation via the high affinity IgE receptor (FcεRI) causes degranulation and release of de novo synthesized proinflammatory cytokines in a process that involves vesicle trafficking. Considering that the GTPase ADP-ribosylation factor 1 (Arf1) orchestrates and maintains membrane traffic and organelle structure, it seems likely that Arf1 contributes to mast cell activation. Actually, it has been reported that pharmaceutical blockade of the Arf1 pathway suppresses cytokine secretion and mast cell degranulation. However, physiological roles of Arf1 in mast cells remain elusive. Here, by using a genetic approach, we demonstrate that Arf1 is required for optimal mTORC1 activation upon IL-3 and facilitates mast cell proliferation. On the other hand, contrary to our expectation, Arf1-deficiency had little impact on FcεRI-induced degranulation nor cytokine secretion. Our findings reveal an unexpected role of Arf1 in mast cell expansion and its potential as a therapeutic target in the mast cell proliferative disorders.

Changes in tendon length and excursion following extensor tendon grafting at the distal radioulnar joint.

LEVEL OF EVIDENCE: IV.

Intra-vitreal gas injection and supine positioning for hypotony post-intrascleral intraocular lens fixation.

PURPOSE: This study aimed to report a case of intravitreal gas injection in the supine position for hypotony after intrascleral intraocular lens (IOL) fixation in a patient with Vogt-Koyanagi-Harada (VKH) disease. OBSERVATIONS: A 72-year-old Japanese female patient presented with blurred vision in her right eye. Both eyes exhibited a sunset glow fundus due to VKH disease. The right IOL was dislocated; therefore, IOL fixation was performed. The patient's hypotony and choroidal effusion persisted postoperatively and her intraocular pressure (IOP) remained 2-4 mmHg despite the performance of two steroid courses. C3F8 (perfluoro pane gas) was injected into the vitreous cavity on postoperative day 35. The patient was instructed to assume a supine position on the third day after injection. At 6 days post-injection, her IOP began to rise; her IOP remained within the normal range until 1 year later. CONCLUSIONS AND IMPORTANCE: This is the first report of successful intravitreal gas injection in a supinated patient with VKH disease to treat postoperative hypotony.

Predictive Factors for Recurrence of External Rectal Prolapse after Laparoscopic Ventral Rectopexy.

OBJECTIVES: This study aimed to evaluate factors that contribute to the recurrence of external rectal prolapse (ERP) following laparoscopic ventral rectopexy (LVR). METHODS: All patients who underwent LVR using synthetic meshes between 2011 and 2018 were prospectively included. A standard questionnaire including the Fecal Incontinence Severity Index (FISI) and Constipation Scoring System (CSS) was administered preoperatively and postoperatively. Defecography was performed 6 months postoperatively. Univariate and backward stepwise multivariate Cox analysis was performed to determine the prognostic factors of recurrence. RESULTS: In total, 132 patients with a median follow-up of 46 months were included. The overall recurrence rate was 6.8% (n = 9), as confirmed by defecography at 6 months in six of the patients. None of the patients developed mesh erosion. FISI and CSS scores were significantly reduced at 3 months and remained significantly reduced for 3 years. Multivariate analyses revealed that the predictors of recurrence included male sex (hazards ratio, 11.3; 95% confidence interval, 3.0-43.0) and age >80 years (hazards ratio, 10.7; 95% confidence interval, 1.3-86.3). Eight patients with recurrence underwent surgery via Delorme's procedure (n = 7) and posterior rectopexy (n = 1). Two patients with new-onset rectoanal intussusception and one with uncorrected sigmoidocoele underwent repeat LVR. CONCLUSIONS: LVR is effective in treating ERP with low morbidity and low recurrence. Male patients and patients older than 80 years are at increased risk of recurrence. Hence, the LVR technique should be modified or coupled with other perineal procedures when treating ERP, especially in male patients.

Intravenous injection of cyclophilin A realizes the transient and reversible opening of barrier of neural vasculature through basigin in endothelial cells.

Neural vasculature forms the blood-brain barrier against the delivery of systemically administered therapeutic drugs into parenchyma of neural tissues. Therefore, procedures to open the blood-brain barrier with minimal damage to tissues would lead to the great progress in therapeutic strategy for intractable neural diseases. In this study, through analyses with mouse in vitro brain microvascular endothelial cells and in vivo neural vasculature, we demonstrate that the administration of cyclophilin A (CypA), a ligand of basigin which is expressed in barrier-forming endothelial cells, realizes the artificial opening of blood-brain barrier. Monolayers of endothelial cells lost their barrier properties through the disappearance of claudin-5, an integral tight junction molecule, from cell membranes in a transient and reversible manner. Furthermore, the intravenous injection of a single dose of CypA into mice resulted in the opening of blood-brain barrier for a certain period which enabled the enhanced delivery of systemically administered doxorubicin into the parenchyma of neural tissues. These findings that the pre-injection of a single dose of CypA realizes an artificial, transient as well as reversible opening of blood-brain barrier are considered to be a great step toward the establishment of therapeutic protocols to overcome the intractability of neural diseases.

Comparison of Surgical Outcomes Between Ab Interno Suture Trabeculotomy and Ab Externo Metal Trabeculotomy in Adult Patients with Glaucoma.

PURPOSE: To compare the outcomes of ab interno suture trabeculotomy (AbI-TLO) and ab externo metal trabeculotomy (AbE-TLO) in adult patients with glaucoma aged over 40 years. PATIENTS AND METHODS: A retrospective chart review was conducted, including adult patients with glaucoma who underwent AbI-TLO or AbE-TLO between January 2015 and June 2019. A single surgeon (YO) performed all the operations. Eighty-one patients (81 eyes) were included in this study. Surgical success was defined as a postoperative intraocular pressure (IOP) of ≤18 mmHg and an IOP reduction of ≥20% from the preoperative IOP, without requiring additional glaucoma surgery. Success rates were assessed using Kaplan-Meier survival curves and log-rank (Mantel-Cox) tests, while risk factors were analyzed using the Cox proportional hazards model. RESULTS: Forty-nine patients who underwent AbI-TLO and 32 patients who underwent AbE-TLO were studied; the preoperative IOPs were 27.9 ± 7.3 (mean ± standard deviation) mmHg and 25.6 ± 8.1 mmHg in the AbI-TLO and AbE-TLO groups, respectively (p=0.217). The 12-month postoperative IOPs were 15.8 ± 4.0 mmHg and 16.3 ± 4.2 mmHg in the AbI-TLO and AbE-TLO groups, respectively (p=0.724). The surgical success rates at 12 months were 77.6% and 62.5% in the AbI-TLO and AbE-TLO groups, respectively (p=0.144). Postoperative hyphema with level formation and ocular hypertension over 30 mmHg were observed in 22.4% and 26.5% of patients in the AbI-TLO group and 18.8% and 12.5% of those in the AbE-TLO group, respectively. Stepwise multivariate Cox regression analysis showed that a longer axial length was a risk factor for surgical failure (hazard ratio: 2.030; p=0.042). CONCLUSION: AbI-TLO and AbE-TLO had similar surgical outcomes and postoperative complications. A longer axial length was associated with an insufficient IOP reduction.

New Approach to Drug Discovery of a Safe Mitochondrial Uncoupler: OPC-163493.

We serendipitously found a mitochondrial uncoupler (mUncoupler), compound 1, in the process of screening for inhibitors of a gene product related to calorie restriction (CR) and longevity. Compound 1 has a unique 4-cyano-1,2,3-triazole structure which is different from any known mUncoupler and ameliorated HbA1c in Zucker diabetic fatty (ZDF) rats. However, its administration at high doses was not tolerated in an acute toxicity test in rats. We therefore tried to optimize cyanotriazole compound 1 and convert it into an agent that could be safely administered to patients with diabetes mellitus (DM) or metabolic disorders. Considering pharmacokinetic (PK) profiles, especially organ distribution targeting the liver and avoiding the brain, as well as acute toxicities and pharmacological effects of the derivatives, various conversions and substitutions at the 5-position on the cyanotriazole ring were carried out. These optimizing processes improved PK profiles and effectiveness, and acute toxicities became negligible even at high doses. We finally succeeded in developing an optimized compound, OPC-163493, as a liver-localized/targeted mUncoupler.

PC3-Secreted Microprotein Is Expressed in Glioblastoma Stem-Like Cells and Human Glioma Tissues.

Glioblastoma multiforme (GBM) is the most prevalent malignant primary brain tumor with a high recurrence rate. Despite multimodal therapy including surgical resection, chemotherapy, and radiotherapy, the median survival time after the initial diagnosis of GBM is approximately 14 months. Since cancer stem cells (CSCs) are considered the leading cause of cancer recurrence, glioblastoma stem cell-targeted therapy is a promising strategy for the treatment of GBM. However, because CSC heterogeneity has been implicated in the difficulties of CSC-target therapy, more in-depth knowledge of CSC biology is still required to develop novel therapies. In this study, we established single cell-derived tumorspheres from human glioblastoma U87MG cells. One of these tumorspheres, P4E8 clone, showed CSC-like phenotypes, such as self-renewal capacity, expression of CSC markers, resistance to anti-cancer agents, and in vivo tumorigenicity. Therefore, we used P4E8 cells as a cell-based model of glioblastoma stem cells (GSCs). Gene expression analysis using microarray indicated that the most highly expressed genes in P4E8 cells compared to the parental U87MG were PC3-secreted microprotein (MSMP). Furthermore, MSMP was expressed in patient-derived GSCs and human glioma tissues at the protein level, implying that MSMP might contribute to glioma development and progression.

Arf1 and Arf6 Synergistically Maintain Survival of T Cells during Activation.

ADP-ribosylation factor (Arf) family consisting of six family members, Arf1-Arf6, belongs to Ras superfamily and orchestrates vesicle trafficking under the control of guanine nucleotide exchange factors (GEFs) and GTPase-activating proteins. It is well established that brefeldin A, a potent inhibitor of ArfGEFs, blocks cytokine secretion from activated T cells, suggesting that the Arf pathway plays important roles in T cell functions. In this study, because Arf1 and Arf6 are the best-characterized members among Arf family, we established T lineage-specific Arf1-deficient, Arf6-deficient, and Arf1/6 double-deficient mice to understand physiological roles of the Arf pathway in the immune system. Contrary to our expectation, Arf deficiency had little or no impact on cytokine secretion from the activated T cells. In contrast, the lack of both Arf1 and Arf6, but neither Arf1 nor Arf6 deficiency alone, rendered naive T cells susceptible to apoptosis upon TCR stimulation because of imbalanced expression of Bcl-2 family members. We further demonstrate that Arf1/6 deficiency in T cells alleviates autoimmune diseases like colitis and experimental autoimmune encephalomyelitis, whereas Ab response under Th2-polarizing conditions is seemingly normal. Our findings reveal an unexpected role for the Arf pathway in the survival of T cells during TCR-induced activation and its potential as a therapeutic target in the autoimmune diseases.

Subarachnoid hemorrhage-negative Terson syndrome after intracranial artery treatment with a flow diverter device.

PURPOSE: To report a case of subarachnoid hemorrhage-negative Terson syndrome following intracranial artery treatment with flow diverter stents. OBSERVATIONS: A 40-year-old Asian woman presented with floaters in her right eye after treatment of an intracranial aneurysm with flow diverter stents. Vitreous hemorrhage and sub-inner limiting membrane (sub-ILM) hemorrhage were present in her right eye. On fluorescein angiography, contrast perfusion and vascular occlusion were not noted. Magnetic resonance imaging (MRI) did not show any evidence of subarachnoid hemorrhage (SAH). We hypothesize that the bleeding was due to Terson syndrome associated with intracranial treatment with the flow diverter stents. During follow-up, the vitreous hemorrhage and sub-ILM hemorrhage disappeared, and the floaters in her vision improved. CONCLUSIONS AND IMPORTANCE: This is the first reported case of vitreous hemorrhage and sub-ILM hemorrhage that should be considered to be Terson syndrome, after flow diverter stents treatment in the absence of SAH.

Usefulness of Machine Learning-Based Gut Microbiome Analysis for Identifying Patients with Irritable Bowels Syndrome.

Irritable bowel syndrome (IBS) is diagnosed by subjective clinical symptoms. We aimed to establish an objective IBS prediction model based on gut microbiome analyses employing machine learning. We collected fecal samples and clinical data from 85 adult patients who met the Rome III criteria for IBS, as well as from 26 healthy controls. The fecal gut microbiome profiles were analyzed by 16S ribosomal RNA sequencing, and the determination of short-chain fatty acids was performed by gas chromatography-mass spectrometry. The IBS prediction model based on gut microbiome data after machine learning was validated for its consistency for clinical diagnosis. The fecal microbiome alpha-diversity indices were significantly smaller in the IBS group than in the healthy controls. The amount of propionic acid and the difference between butyric acid and valerate were significantly higher in the IBS group than in the healthy controls (p < 0.05). Using LASSO logistic regression, we extracted a featured group of bacteria to distinguish IBS patients from healthy controls. Using the data for these featured bacteria, we established a prediction model for identifying IBS patients by machine learning (sensitivity >80%; specificity >90%). Gut microbiome analysis using machine learning is useful for identifying patients with IBS.

Midterm functional outcome after laparoscopic ventral rectopexy for external rectal prolapse.

INTRODUCTION: Although long-term crude outcomes of laparoscopic ventral rectopexy for external rectal prolapse (ERP) have been documented, repetitive functional and quality of life (QOL) assessments are scarce. This study assessed midterm annual functional results and QOL after laparoscopic ventral rectopexy for ERP. METHODS: This study consisted of 58 patients and was a retrospective analysis of prospectively collected data. The Fecal Incontinence Severity Index, the Constipation Scoring System, and QOL instruments (ie 36-item Short-Form Health Survey and Fecal Incontinence Quality of Life scale) were administered before and after operation. RESULTS: There was no mortality or major morbidity. After a median follow-up of 49 months (6-92 months), recurrence of ERP was noted in one patient (2%). There were no mesh-related complications. The median Fecal Incontinence Severity Index score was significantly reduced at 3 months (34 [10-61] vs 12 [0-50], P < 0.0001) and remained significantly reduced for 5 years. The median Constipation Scoring System score was significantly reduced at 3 months (14 [9-20] vs 7 [0-16], P < 0.0001) and remained significantly reduced for 4 years. No patients developed new-onset constipation. All of the Fecal Incontinence Quality of Life scales significantly improved overtime for 4 years. All of the 36-item Short-Form Health Survey scales were significantly improved at 3 and 6 months, but none of the scales significantly improved after 2 years. CONCLUSION: Laparoscopic ventral rectopexy for ERP was associated with low morbidity, low recurrence, and a midterm improvement in function and fecal incontinence-specific QOL.

Successful Treatment of Pediatric Posttraumatic Tibiofibular Synostosis by Resection and Peroneal Artery Perforator Adipofascial Flap: A Case Report.

CASE: Pediatric posttraumatic tibiofibular synostosis (PPTFS) is a rare postfracture complication that often leads to growth abnormalities. There are very few reports demonstrating the long-term efficacy of surgical treatment. An 11-year-old boy with PPTFS displayed progressive prominence of the fibular head and shortening of the lateral malleolus subsequent to a fracture suffered at the age of 5 years. He was treated by synostosis resection and a peroneal artery perforator adipofascial flap. Eight years postoperatively, the synostosis had not recurred, and his earlier growth abnormalities were nearly normal. CONCLUSIONS: Peroneal artery perforator adipofascial flap is effective for pregrowth spurt PPTFS.