Identification and Modification of Porphyromonas gingivalis Cysteine Protease, Gingipain, Ideal for Screening Periodontitis.

Chronic periodontitis is an inflammatory disease caused by the formation of oral microbial biofilms. Periodontitis is associated with general health and not only oral diseases. Porphyromonas gingivalis is a well-known keystone pathogen for periodontitis and is associated with several systemic diseases, such as diabetes mellitus and Alzheimer's disease. We previously developed a system for screening periodontitis using P. gingivalis-specific serum immunoglobulin G (IgG) in an enzyme-linked immunosorbent assay with a sensitivity of 0.774 and a specificity of 0.586 and an area under the receiver operating characteristic curve of 0.708. However, the antigens elicited non-specific responses, since they were obtained from whole extracts of sonicated cultured bacteria. The purpose of this study was to identify antigens ideal for a sensitive and specific serum test. We identified the specific antigens using immunoaffinity columns immobilized with IgG antibodies from periodontitis patients. Liquid chromatography-tandem mass spectrometry identified 29 antigens from the elutes. Recombinant proteins for these candidates were synthesized using the wheat germ cell-free translation system and screened by dot blot analysis with serum from the columns. Three of the 16 candidates that reacted showed strongest affinities upon dot blot analysis; they included outer membrane protein 28, cysteine proteases, lysine gingipain Kgp, and arginine gingipain RgpA. Outer membrane protein 28 was not suitable for screening P. gingivalis infection because of its high false-negative rates. Kgp and RgpA were unstable antigens since they underwent self-digestion. They were made stable by substituting the active cysteine residues in Kgp and RgpA with alanine using site-directed mutagenesis. Using the modified antigens, we demonstrated that the patient serum IgG level against RgpA was the highest among all the antigens expressed in P. gingivalis. Moreover, the N-terminus of recombinant RgpA was excellent in differentiating between diseased and non-diseased states (with sensitivity of 0.85, specificity of 0.9, and area under the curve of 0.915). Although dot blot analysis was the only experiment used, the N-terminus of RgpA is an excellent antigen to immunologically test for P. gingivalis infection, especially for estimating the risks for periodontitis-associated systemic diseases. In conclusion, we have developed a P. gingivalis antigen for screening periodontitis.

Usefulness of Oral Xa Inhibitor for Management of Ischemic Stroke Associated with Thrombosis in the Pulmonary Vein Stump after Lung Resection.

OBJECTIVES: Brain infarction is a critical complication after lung resection using video-assisted thoracoscopic surgery. Recent reports have described its association with thrombosis in the pulmonary vein (PV) stump. However, the optimal management of this complication remains controversial. We describe serial 3 cases of brain infarctions associated with thrombosis in the PV stumps, which were successfully treated with the oral Xa inhibitor rivaroxaban. METHODS AND RESULTS: We retrospectively reviewed medical records of 3 patients. The first case was a 72-year-old man who underwent left upper lobectomy for treatment of lung adenocarcinoma. The second case was a 55-year-old man who underwent right lower segmentectomy for treatment of metastatic tumor from Barrett's esophageal carcinoma. The third case was a 73-year-old man who underwent left upper lobectomy for treatment of metastatic tumor from colon adenocarcinoma. In the first case, a large cerebellar infarction was developed and a decompressive craniotomy was performed on postoperative day 4. In the second and the third case, cerebral infarctions in the territories of right middle cerebral arteries occurred on postoperative day 2. In all cases, contrast-enhanced computed tomography demonstrated the thrombi in the stumps of the PVs. They were treated with oral administration of rivaroxaban without adverse effect, and the thrombi in the PVs disappeared within 1 month. DISCUSSION: Blood flow stasis in the long PV stump after lung resection might contribute to thrombosis development. Oral Xa inhibitor rivaroxaban appeared to be safe and useful for the management of ischemic stroke associated with PV thrombosis after lung resection.

Free testosterone concentration is inversely associated with markers of liver fibrosis in men with type 2 diabetes mellitus.

The association between serum testosterone level and liver fibrosis in patients with non-alcoholic fatty liver disease is unclear. To clarify this association, we investigated the relationship between serum free testosterone concentration and markers of liver fibrosis in men with type 2 diabetes mellitus but no obvious features of alcohol consumption. This retrospective observational cross-sectional study enrolled 248 men with type 2 diabetes mellitus. The FIB-4 index was measured as a marker of liver fibrosis, and multiple linear regression analysis was performed to examine its association with serum free testosterone concentration. In addition, the 7S domain of type IV collagen (IV-7S) was examined in 140 of the 248 patients. The mean free testosterone concentration was 10.6 ± 6.8 pg/mL and the means of the FIB-4 index and IV-7S were 1.64 ± 1.19 and 4.02 ± 1.11 ng/mL, respectively. After adjusting for all relevant variables, serum free testosterone concentrations were inversely associated with both the FIB-4 index and IV-7S (ß; -0.28, P < 0.0001, and ß; -0.28, P = 0.002, respectively). Measuring serum free testosterone concentrations in men with type 2 diabetes mellitus may help to predict progression to advanced liver disease. Identifying patients at risk may help to prevent the development of cirrhosis and hepatocellular carcinoma.

Successful video-assisted thoracoscopic surgery in prone position in patients with esophageal cancer and aberrant right subclavian artery: report of three cases.

BACKGROUND: An aberrant right subclavian artery (ARSA) with an associated nonrecurrent right inferior laryngeal nerve (NRILN) is a relatively rare anomaly that occurs at a frequency of 0.3 to 2.0% of the general population. NRILN has been mainly documented in the head and neck region; it has been rarely described in patients with esophageal cancer, especially those undergoing thoracoscopic surgery. Video-assisted thoracoscopic surgery for esophageal cancer (VATS-E) is becoming more widespread as a reliable minimally invasive surgical procedure associated with reduced perioperative complications. CASE PRESENTATION: Herein, we report three cases of esophageal cancer with ARSA and NRILN which underwent successful VATS-E. Case 1, a 53-year-old male who had early stage esophageal cancer was performed VATS-E. Upper gastrointestinal (GI) series showed "Bayonet sign" (T1aN0M0, pStageIA in UICC). Case 2, a 75-year-old male who had advanced esophageal cancer was performed neoadjuvant chemotherapy and following VATS-E. This case had right thoracic duct and "Bayonet sign" on upper GI series (T1bN2M0, pStage IIIA in UICC). Case3, a 72-year-old male who had advanced esophageal cancer was performed neoadjuvant chemotherapy and following VATS-E (T3N2M0, pStageIIIB in UICC). All of these three cases were performed VATS-E and discharged without any complication. CONCLUSION: VATS-E in the prone position is a feasible procedure that can reduce the risk of complications with an enlarged and clear view, and knowledge of this type of anomaly is very important for surgeons who perform esophagectomy.

Multicenter phase II study of an oral care program for patients with head and neck cancer receiving chemoradiotherapy.

PURPOSE: This multicenter phase II trial assessed the clinical benefit of a multidisciplinary oral care program in reducing the incidence of severe chemoradiotherapy-induced oral mucositis (OM). METHODS: Patients with head and neck cancer (HNC) who were scheduled to receive definitive or postoperative chemoradiotherapy were enrolled. The oral care program included routine oral screening by dentists and a leaflet containing instructions regarding oral care, nutrition, and lifestyle. Oral hygiene and oral care were evaluated continuously during and after the course of chemoradiotherapy. The primary endpoint was the incidence of grade ≥3 OM assessed by certified medical staff according to the Common Terminology Criteria of Adverse Events version 3.0. RESULTS: From April 2012 to December 2013, 120 patients with HNC were enrolled. Sixty-four patients (53.3 %) developed grade ≥3 OM (i.e., functional/symptomatic). The incidence of grade ≤1 OM at 2 and 4 weeks after radiotherapy completion was 34.2 and 67.6 %, respectively. Clinical examination revealed that 51 patients (42.5 %) developed grade ≥3 OM during chemoradiotherapy. The incidence of grade ≤1 OM at 2 and 4 weeks after radiotherapy completion was 54.7 and 89.2 %, respectively. The incidences of grade 3 infection and pneumonitis throughout chemoradiotherapy were <5 %. Only 6.7 % of patients had unplanned breaks in radiotherapy, and 99.2 % completed treatment. CONCLUSIONS: A systematic oral care program alone is insufficient to decrease the incidence of severe OM in patients with HNC being treated with chemoradiotherapy. However, systematic oral care programs may indirectly improve treatment compliance by decreasing infection risk. TRIAL REGISTRATION NUMBER: UMIN000006660.

A 10-year experience of totally extraperitoneal endoscopic repair for adult inguinal hernia.

PURPOSE: Laparoscopic surgery is fast becoming the treatment of choice for inguinal hernia. By reviewing our 10-year experience of performing totally extraperitoneal repair (TEP), we sought to establish its clinical significance in the treatment of adult inguinal hernia. METHODS: We reviewed retrospectively the clinical records of patients who underwent TEP for adult inguinal hernia between January 2003 and December 2012. RESULTS: None of the 303 patients with adult primary or recurrent inguinal hernia in our study needed TEP converted to other procedures or suffered serious complications during the procedure. A significant difference was noted in the operation time between direct (n = 32) vs indirect (n = 128) hernias in the primary unilateral inguinal hernia group (91 ± 27 vs 80 ± 32 min, p = 0.033) and between direct/direct (n = 31) vs indirect/indirect (n = 24) hernias (136 ± 58 vs 89 ± 24 min, p = 0.01) in the primary bilateral inguinal hernia group. The only postoperative complications recorded were four cases of hernia recurrence (1.3 %) and one case of chronic pain (0.3 %). CONCLUSIONS: The results obtained for TEP over 10 years support this as a promising procedure for the treatment of adult inguinal hernia.

Primary carcinoid tumor in a retroperitoneal mature teratoma: report of a case.

Primary retroperitoneal teratoma in an adult is rare, as is the occurrence of a malignant tumor within a mature teratoma, known as "malignant transformation". A 24-year-old woman was admitted to our hospital for investigation of an abdominal mass. Computed tomography and magnetic resonance imaging revealed a multilocular mass in the right upper abdomen. The tumor consisted of fat, soft tissue, and bone, with a slightly enhanced solid component. The tumor was diagnosed preoperatively as a retroperitoneal mature teratoma with an immature component, and excised. Histologically, it was composed mainly of mature fat, soft tissue, and bone, accompanied by a solid component of prostate-like tissue. In addition, a latent carcinoid tumor was recognized in the middle of the tumor. The tumor was finally diagnosed as a primary carcinoid tumor within the retroperitoneal mature teratoma. The patient has been followed-up for 24 months since her operation without any evidence of recurrence. We report this case to highlight the possibility of malignant transformation in adult retroperitoneal teratoma, even when the preoperative diagnosis is benign mature teratoma.

Protective effects of polysaccharides and polyhydric alcohols in a dry mouth model in cultured cells.

PURPOSE: The goal of the study was to investigate the effects of 21 polysaccharides and 12 polyhydric alcohols on inhibition of dryness in oral mucosal epithelial cells in vitro. All the tested compounds are currently used in oral products. METHODS: Human gingival epithelial Ca9-22 cells were incubated in 96-well plates until the cells reached confluence. After removal of the culture medium, the cells were incubated with a solution containing one of 21 polysaccharides (seven semisynthetic and 14 natural polysaccharides) or 12 polyhydric alcohols for 15 min (short-term treatment). After removal of the sample solution, the cells were dried at 25°C and 30% humidity, and cell viability was measured to determine the effect of each compound on prevention of cell death due to drying. The effects of the polyhydric alcohols were also examined for 3 days (long-term treatment). RESULTS: The semisynthetic polysaccharides ethylcellulose (EC), methylcellulose (MC), and hydroxypropylmethylcellulose (HPMC) and the natural polysaccharides xanthan and gellan gum significantly inhibited cell death due to drying. Hydroxypropylcellulose increased cell death under these conditions. Of the polyhydric alcohols, long-term treatment with glycosyltrehalose significantly inhibited cell death due to drying, but short-term treatment with glycosyltrehalose did not do so. Long-term treatment had an effect on cell proliferation that appeared to differ from the effect of short-term treatment. CONCLUSIONS: Short-term treatment with EC, MC, HPMC, xanthan gum, and gellan gum and long-term treatment with glycosyltrehalose showed significant inhibition of cell death due to drying. These materials might have protective effects against dry mouth.

[A case of gastrointestinal stromal tumor of the stomach which rapidly increased in size over the period of three years].

The patient was a 75-year-old woman. Esophagogastroduodenoscopy revealed a submucosal tumor 2 cm in size on the anterior wall of the cardiac part of the stomach. Three years later, she visited at our hospital with the chief complaints of tarry stool and dizziness. Proximal gastrectomy was performed, because endoscopically the tumor increased to 7cm in size with ulceration and it was considered to be malignant. Pathological examination was high-risk gastrointestinal stromal tumor. In this case, the submucosal tumor increased by 3.5 times. GIST is needed to be observed carefully and be treated in the appropriate time.