Efficacy of "Awake ECMO" for critical respiratory failure after pediatric open-heart surgery.

A 4-year-old boy with atrioventricular discordance, double-outlet right ventricle, pulmonary stenosis, and mitral regurgitation, was undergoing anatomical repair consisting of Senning, Rastelli, Damus-Kaye-Stansel procedures, and a mitral valve repair, complained of post-operative excessive airway tract secretion, which ultimately developed into acute respiratory distress syndrome (ARDS) 28 days after the operation. The cause of the ARDS was thought to be frequent manual positive pressure recruitment and prolonged inhalation of pure oxygen. At 45 days after the operation, hypercapnia and respiratory acidosis turned out to be irreversible, and therefore, veno-arterial extracorporeal membrane oxygenation (ECMO) was established utilizing the Endumo(®)4000 system. Pulmonic interstitial inflammation gradually improved while resting the lung under ECMO support; however, effective ventilation volume decreased critically because a massive pulmonary hemorrhage occurred at 2 and 9 days after the initiation of ECMO. To maximize the effectiveness of respiratory physical therapy, "Awake ECMO" was started and tidal volume dramatically increased with a regained cough reflex. Five days later, he was successfully weaned off from ECMO, and discharged 7 months after the operation without any neurological and physiological sequelae.

Suspected cold agglutination during mild hypothermic pediatric open heart surgery: a report of two cases.

Cold agglutination was suspected in 2 pediatric open heart surgery cases during mild hypothermic cardiopulmonary bypass. The first patient was a 2-year-old boy with secundum atrial septal defect. Fifteen minutes after the initiation of mild hypothermic cardiopulmonary bypass, the inlet pressure of oxygenator suddenly elevated from 250 to over 500 mmHg, whereas outlet pressure was maintained. The blood flow rate decreased from 140 to 85 ml/kg/min. At that time, the arterial blood temperature was less than 32°C. Cold agglutinin was highly suspected, so patient was immediately warmed, and the inlet pressure of oxygenator decreased to 250 mmHg when the arterial blood temperature reached to 36°C. Second patient was a 3-year-old boy with secondary developed subvalvular pulmonary stenosis after the repair of double chambered right ventricle at 10 months of his age. Eighteen minutes after the initiation of mild hypothermic cardiopulmonary bypass, the inflow pressure suddenly elevated to 500 mmHg and transmission flow decreased to 55 ml/kg/min. Twenty-three minutes after warming, the pressure fell to a normal level and transmission flow was recovered. The operation continued with normo-thermic cardiopulmonary bypass and crystalloid cardioplegia. Both cases had no postoperative complications related to cold agglutinin such as myocardial infarction, cerebral infarction, or renal insufficiency.

Retrospective study of 100 autotransplanted teeth with complete root formation and subsequent orthodontic treatment.

INTRODUCTION: Autotransplantation has become a major therapeutic option for replacing missing teeth in adult orthodontic patients. However, little systematic information is available about the long-term stability of autotransplanted teeth with complete root formation after the application of an orthodontic force. The objective of this study was to investigate the outcomes of autotransplanted teeth with complete root formation that underwent orthodontic treatment. METHODS: One hundred teeth, autotransplanted in 89 patients, were examined over a mean observation period of 5.8 years. Orthodontic force was applied with nickel-titanium wires 4 to 8 weeks after autotransplantation. Root resorption, ankylosis, mobility, pocket depth, and inflammation at the recipient site were investigated clinically and with radiographs. RESULTS: The survival rate of the autotransplanted teeth was 93.0%. Abnormal findings were found in 29 teeth, including 7 lost teeth, for a success rate of 71.0%. Donor tooth type and occlusal condition of the donor tooth before transplantation were associated with abnormal findings. CONCLUSIONS: The early application of orthodontic force may increase the success rate of autotransplanted teeth, and the type and presurgical occlusal condition of donor teeth affect the success rate.

Comprehensive treatment approach for bilateral cleft lip and palate in an adult with premaxillary osteotomy, tooth autotransplantation, and 2-jaw surgery.

We report the successful treatment of a woman aged 25 years 3 months with bilateral cleft lip and palate. She had a protruded premaxilla, collapsed posterior segments, wide alveolar defects with oronasal fistulae, a congenital missing tooth, and severe facial asymmetry with a transverse occlusal cant. The comprehensive treatment approach included (1) premaxillary osteotomy combined with alveolar bone grafting to reposition the premaxilla and minimize the wide alveolar defects, (2) autotransplantation of a tooth with complete root formation to the grafted bone region to restore the missing tooth without a prosthesis such as a dental implant or bridge, and (3) 2-jaw surgery to improve facial asymmetry. The premaxillary osteotomy was managed orthodontically, in combination with bone grafting. The results suggest that surgical orthodontic treatment with tooth autotransplantation might be useful to improve the occlusion and facial esthetics without prosthetics.

Milk fat globule epidermal growth factor 8 serves a novel biomarker of opisthorchiasis-associated cholangiocarcinoma.

Milk fat globule epidermal growth factor 8 (MFG-E8) is a pleiotropic secreted glycoprotein to play roles in mediating immune tolerance and homeostasis maintenance and enhancing angiogenesis. To evaluate its value as a biomarker in opisthorchiasis-associated cholangiocarcinoma (CCA), the present study investigated MFG-E8 expression kinetics during the tumorigenesis in Opisthorchis viverrini infection-induced CCA, and demonstrated its expression in the tumor tissues of CCA patients and its serum level among them. During the tumorigenesis of CCA, MFG-E8 expression was increased in a time-dependent manner with the pathological processes. Absolutely higher expression of MFG-E8 messenger RNA was detected in the tumor tissues from CCA patients, compared with those in adjacent tissues. Immunobiochemical analysis showed that more than 90% CCA cases were positive and the positive reaction located in the membrane and cytoplasm of the tumor cells. Moreover, the average serum level in the CCA patients was significantly higher than that in healthy individuals and those with O. viverrini infection or other parasitosis. Correlation analysis of MFG-E8 expression with CCA clinicopathology revealed that a high expression of MFG-E8 protein was significantly bound with a poor differentiation, pathological advanced stage, and metastasis of CCA. The multivariation analysis indicated that MFG-E8 was an independent prognostic factor. In addition, short hairpin RNA-mediated MFG-E8 knockdown in CCA cell line obviously suppressed the cell proliferation. Our results strongly suggested that MFG-E8 is a promising biomarker for the diagnosis, prognosis, and therapy target of opisthorchiasis-associated CCA.

Effect of nematode Trichinella infection on glucose tolerance and status of macrophage in obese mice.

We investigated the effect of Trichinella infection on glucose tolerance and (pro- or anti-inflammatory) macrophage status in adipose tissue. Ob/ob mice and high fat-fed mice (obesity model) and C57/BL mice (control mice) were orally infected with (infected group) or without (uninfected group) 400 Trichinella per mouse. Four weeks later, the mice were subjected to investigation, which showed that fasting plasma glucose levels decreased in the infected group of C57/BL and ob/ob mice. Glucose tolerance, evaluated with intraperitoneal GTT, improved in the infected group of ob/ob mice and high fat-fed mice compared with the uninfected groups. Additional assay included anti-inflammatory macrophage (M2) markers and pro-inflammatory macrophage (M1) markers, with the aim to explore the effect of Trichinella infection on adipose tissue inflammation, since our previous study identified anti-inflammatory substances in secreted proteins by Trichinella. The result showed that mRNA levels of M2 markers, such as CD206, arginase and IL-10, increased, whereas M1 markers, such as CD11c, iNOS and IL-6, decreased in the stromal vascular fraction (SVF) isolated from epididymal fat in ob/ob mice. Residential macrophages obtained from the peritoneal lavage exhibited lower M1 markers and higher M2 markers levels in the infected group than in the uninfected group. Trichinella infection increases the ratio of M2/M1 systemically, which results in an improvement in pro-inflammatory state in adipose tissue and amelioration of glucose tolerance in obese mice.

Dehydroepiandrosterone reduces preadipocyte proliferation via androgen receptor.

Several studies have suggested that both testosterone and dehydroepiandrosterone (DHEA) have weight-reducing and antidiabetic effects, especially in rodent studies; however, the precise mechanism of their action remains unclear. Here, we investigated the effect of DHEA on cell growth in adipose tissue. The appearance of senescence-associated ß-galactosidase in stromal vascular fraction (SVF) isolated from Otsuka Long-Evans Tokushima fatty rats, an animal model of inherent obese type 2 diabetes, was prevented by DHEA administration. Next, the effects of DHEA and testosterone were compared in vivo and in vitro to evaluate whether these hormones influence cell growth in adipose tissue. Both DHEA and testosterone reduced body weight and epididymal fat weight equivalently when administered for 4 wk. To assess the effect of DHEA and testosterone on cell growth in adipose tissue, 5-bromo-2'-deoxyuridine (BrdU) uptake by SVF was measured. Quantification analysis of BrdU uptake by examining DNA isolated from each SVF revealed that treatment with DHEA and testosterone reduced cell replication. These results indicated that DHEA- and testosterone-induced decreased adiposity was associated with reduced SVF growth. Incubation with DHEA and testosterone equally decreased BrdU uptake by 3T3-L1 preadipocytes. Pretreatment with the androgen receptor (AR) inhibitor flutamide, but not the estrogen receptor inhibitor fulvestrant, abolished these effects. Knockdown of AR with siRNA also inhibited DHEA-induced decreases in BrdU uptake. These results suggest that DHEA-induced growth suppression of preadipocytes is mediated via AR. Therefore, both DHEA and testosterone similarly decrease adipocyte growth possibly via a common mechanism.

Alteration of galectin-1 during tumorigenesis of Opisthorchis viverrini infection-induced cholangiocarcinoma and its correlation with clinicopathology.

Galectin-1 is a beta-galactoside-binding lectin to function in cell adhesion, proliferation, differentiation, and might be involved in tumor progression and metastasis. In the present study, the expression kinetics of galectin-1 during the tumorigenesis of a parasite Opisthorchis viverrini infection-induced cholangiocarcinoma (CCA) was investigated in model animal hamsters, and the expression was confirmed in human CCA cases. It was found that galectin-1 was overexpressed at mRNA and protein levels with the tumor progression. The mRNA expression was elevated in very early stage during tumorigenesis and the increase was time dependent. Galectin-1 protein expression profiles indicated that the increased expression was mainly located in the epithelium of extensively proliferated and hyperplasia small bile ducts at early stage of CCA development in model animal and mainly in the extensive tumor stroma tissues in both model animals and human CCA cases at later stage. The analysis of correlation of the overexpression with clinicopathology in human cases suggested that high expression of galectin-1 was associated with advanced stage and metastasis and with shorter cumulative overall survival of the patients. Multivariate Cox regression analysis revealed that galectin-1 expression was of independent prognostic significance for CCA. Our results suggest that galectin-1 is likely involved in the tumorigenesis and expected to serve as a tumor stroma marker in diagnosis and prediction of metastasis and poor prognosis of the opisthorchiasis-associated CCA.

Candidate genes involving in tumorigenesis of cholangiocarcinoma induced by Opisthorchis viverrini infection.

Opisthorchiasis-associated cholangiocarcinoma (CCA) is one of main public health problems in Opisthorchis viverrini endemic areas. Although the definite relationship between prevalence of CCA and the parasite infection has been demonstrated, the molecular mechanism of tumorigenesis is still unknown. In the present study, by using animal model of opisthorchiasis-associated CCA, a kinetic analysis of cDNA microarray was performed to screen the candidate genes that involve in the development of opisthorchiasis-associated CCA. Microarray analysis revealed that the expressions of 131 genes were up-regulated during the development of CCA, including the genes relative to cell proliferation, differentiation and transformation, cell growth and cycle regulation, apoptosis, DNA repair, and cytoskeletal structure. The expressions of 145 genes were down-regulated, including the genes relative to metabolic enzymes, tumor suppressor, apoptosis, and oxidative response and oxidation reduction. The present study listed up the candidate genes involving tumorigenesis, provided molecular information on the development of opisthorchiasis-associated CCA and the potential biomarkers for diagnosis and therapy, and suggested that the increased expression of cell differentiation, proliferation, transformation-related genes, and decreased expression of metabolic enzymes may play important roles in the tumorigenesis of CCA.

Trial of integrated laboratory practice.

In most laboratory practices for students in medical schools, a laboratory guidebook is given to the students, in which the procedures are precisely described. The students merely follow the guidebook without thinking deeply, which spoils the students and does not entice them to think creatively. Problem-based learning (PBL) could be one means for the students themselves to actively learn, find problems, and resolve them. Such a learning attitude nurtures medical students with lifelong learning as healthcare professionals. We merged PBL and laboratory practices to promote deep thinking habits and developed an integrated laboratory practice. We gave a case sheet to groups of students from several schools. The students raised hypotheses after vivid discussion, designed experimental protocols, and performed the experiments. If the results did not support or disproved the hypothesis, the students set up another hypothesis followed by experiments, lasting for 4 or 5 consecutive days. These procedures are quite similar to those of professional researchers. The main impact achieved was the fact that the students developed the experimental design by themselves, for the first time in their college lives. All students enjoyed the laboratory practice, which they had never experienced before. This is an antidote to the guidebook-navigated traditional laboratory practice, which disappoints many students. As educators in basic medical sciences stand on the edge in terms of educating the next generation, there is a need to provide a strong foundation for medical students to design and perform scientific experiments. The integrated laboratory practice may provide the solution.

Infection of non-encapsulated species of Trichinella ameliorates experimental autoimmune encephalomyelitis involving suppression of Th17 and Th1 response.

Epidemiological and experimental studies have indicated that helminth infections can ameliorate autoimmune diseases. The present study investigated the amelioration effect of the Trichinella pseudospiralis infection on experimental autoimmune encephalomyelitis (EAE), a T-cell-mediated autoimmune disease of central nervous system (CNS), and expression kinetics of Th17 and Th1 cytokine which play a crucial role in the pathogenesis of EAE. The results indicated that the infection of helminth T. pseudospiralis obviously ameliorated clinical severity and greatly delayed the onset of EAE induced by myelin oligodendrocyte glycoprotein (MOG) immunization. Infection caused much lesser inflammatory infiltration and demyilination in the CNS of infected EAE mice than uninfected EAE mice. The reduced infiltration was also suggested by the expressions of the inflammation cytokines, IL-17, IL-6, IL-1ß, IFN-γ, and TNF-α, which were high in the spinal cords of the uninfected EAE mice, but was nearly normal or low in the infected EAE mice. The increased production of MOG-induced IL-17 and IFN-γ and the expression of IL-6, IL-1ß, TGF-ß in splenocytes after restimulation with MOG was inhibited in the infected EAE mice. On the other hand, the greatly induced Th2 response was observed in the splenocytes of the infected EAE mice. The present study showed that T. pseudospiralis infection can suppresses EAE by reducing the inflammatory infiltration in CNS, likely associated with the suppression of Th17 and Th1 responses by the infection.

Human trichinosis after consumption of soft-shelled turtles, Taiwan.

In 2008, an outbreak of human trichinosis associated with ingestion of raw soft-shelled turtles was identified and investigated in Taiwan. The data suggested that patients were likely infected with Trichinella papuae.

Effects of phorbol ester-sensitive PKC (c/nPKC) activation on the production of adiponectin in 3T3-L1 adipocytes.

PPARgamma plays a key role in adipocyte specific gene expression. In this study, we assessed the effects of phorbol ester (TPA)-sensitive PKC (c/nPKC) activation on the expression of adipocyte specific genes and inflammation related genes. Treatment with both TPA and TNFalpha decreased mRNA levels of PPARgamma, aP2, LPL and adiponectin. TNFalpha, but not TPA, increased IL-6 and MCP-1 mRNA levels, Next, we investigated the effects of ligands which activate c/nPKC. Insulin and angiotensin II (AII), but not high glucose, reduced PPARgamma, aP2 and adiponectin mRNA levels. AII-induced suppression of these genes was restored in the presence of Go6976, a specific c/nPKC inhibitor, and candesartan, an AII receptor blocker. The effect of reduced insulin was prevented by Go6976 and LY294002, a specific PI 3-kinase inhibitors. Our results indicate that activation of c/nPKC could debilitate and/or might deteriorate insulin sensitivity in vivo, through the reduction of PPARgamma and adiponectin expression in adipocyte.

Alterations of gene expression of RB pathway in Opisthorchis viverrini infection-induced cholangiocarcinoma.

Opisthorchiasis has the significant relationship with the high prevalence of cholangiocarcinoma (CCA; a bile duct cancer) in the endemic areas in Southeast Asia. To reveal the molecular mechanism of the tumorigenesis induced by Opisthorchis viverrini infection, the present study investigated the kinetic expression of RB pathway genes, including RB1, p16(INK4), cyclin D1, and CDK4, during the development of opisthorchiasis-associated CCA in hamster model. The results of quantitative real-time polymerase chain reaction indicated that the expressions of RB1 and p16(INK4) were down-regulated during the development of CCA induced by infection plus N-nitrosodimethylamine treatment in a time-dependent manner. On the other hand, the expressions of cyclin D1 and CDK4 were up-regulated. The expression kinetics was corresponding to the pathological progression of the opisthorchiasis-associated CCA, revealed by histopathological observation. Moreover, the analysis of the expression of these genes in human opisthorchiasis-associated CCA cases showed the decreased expression of RB1 and p16(INK4) in 50% and 82.7% cases and overexpression of cyclin D1 and CDK4 in half cases, respectively. The results suggested that RB pathway is likely involved in the tumorigenesis of opisthorchiasis-induced CCA and proposed the potential application of some of these genes as biomarkers in predispose and molecular therapy of the parasite-associated cancer.

Candidate genes responsible for common and different pathology of infected muscle tissues between Trichinella spiralis and T. pseudospiralis infection.

The gene expression profiles were compared between Trichinella spiralis- and T. pseudospiralis-infected muscle tissues by means of a cDNA microarray. Out of 30,000 genes, the expressions of 55 genes were up-regulated in both T. spiralis and T. pseudospiralis infections, 24 genes were down-regulated in both Trichinella infections, 30 genes were up-regulated only in T. spiralis infection, 23 genes were down-regulated only in T. spiralis infection, 25 genes were up-regulated only in T. pseudospiralis infection, and 21 genes were down-regulated only in T. pseudospiralis infection. Many of these differentially expressed genes were associated with satellite cell activation and proliferation (paired box gene 7, Pax7; Pax3; desmin; M-cadherin), myogenesis and muscle development (eyes absent 2 homolog, Eya2; myocyte enhancer factor 2C, MEF2C; pre B-cell leukemia transcription factor 1, Pbx1; chordin-like 2, Chrdl2), cell differentiation (galectin 1; insulin like growth factors, IGFs; c-ski; msh-like 1, Msx1; Numb), cell proliferation and cycle regulation (retinoblastoma 1, Rb1; granulin; p21, CDK4, cyclin A2), and apoptosis (tumor necrosis factor receptor 1, TNF-R1; programmed cell death protein 11, Pdcd11; Pdcd1; nuclear protein 1, Nuprl; clusterin, CLU). The differential expression of 17 genes was validated by quantitative real time PCR and 15 genes showed identical results with the microarray analysis. The present study listed the candidate genes that were commonly and differentially expressed between T. spiralis and/or T. pseudospiralis infection, thus suggesting that these genes need to be further investigated to reveal the mechanism of the common and/or different pathological changes induced by the two species Trichinella.

Problem-based learning and task-based learning: a practical synthesis.

The author of this article attended the International PBL Workshop in Kaohsiung Medical University in 2007 as an international tutor. Based on his personal experiences in the workshop and at his own medical school, he finds there are frequent problems in PBL programs related to the difficulty in providing expert tutors. Students in PBL tutorials may fear they are unable to get sufficient guidance from tutors in terms of learning the issues they should research; moreover, PBL case writers fear their cases are less effective, because non-expert tutors may misdirect students in the step 1 tutorial discussion. The author proposes that combining standard problem-based learning (PBL) methods with elements of task-based learning (TBL) can be effective at addressing both of these problems. The TBL method he proposes involves providing students with an additional sheet at the end of PBL tutorials. This sheet is written by the case writer and details key learning issues, questions and perspectives the students should investigate during their research process. This reduces the need to have expert tutors who know the full range of facts about the case, and leaves students feeling supported and less concerned they will miss important learning issues.

Early experience with low-prime (99 ml) extracorporeal membrane oxygenation support in children.

Quick setup is mandatory for cardiopulmonary resuscitation using an extracorporeal membrane oxygenation (ECMO) assist device. Our conventional ECMO circuit for pediatric patients consists of a centrifugal pump (CX-HP) and membrane oxygenator (CX10H). Because of the large priming volume (260 ml), the circuit had to be primed with donor blood and required 30 minutes for setup. We started to use a low-prime ECMO with small centrifugal pump (HPM-15) and membrane oxygenator (MENOX Alpha Cube) for induction of ECMO beginning in 2000. The priming volume of this low-prime circuit is only 99 ml. The circuit can be primed without donor blood, even in the small patient, and requires only 10 minutes to set up. We review our experiences with cardiopulmonary resuscitation for sudden cardiopulmonary collapse in pediatric patients, including postcardiotomy patients. From 1997 to 2000, 23 patients underwent ECMO support with a conventional circuit (group A). From 2000 to 2004, we used low-prime circuit for induction of ECMO in 12 patients (group B). After the induction of ECMO with low-prime circuit, ECMO was converted to conventional heparin-bonded circuit for the longer support. The results suggested that the quick induction of ECMO with low-prime circuit has significant advantages in cardiopulmonary support in pediatric patients.

Practical methods for collecting Trichinella parasites and their excretory-secretory products.

Trichinella is a unique nematode. Its developmental stages include adult worms, newborn larvae, and muscle larvae. Besides humans, the parasite also infects many kinds of animals, including mice. Mice are widely used as an animal model in the research fields of immunology, cell biology, and host-parasite relationships of trichinellosis. The different developmental stages of Trichinella share similar, but unique characteristics. Therefore, it is important to collect different sources of Trichinella-derived materials for research with appropriate methods. In the present study, we introduce methods to collect Trichinella at different stages as well as their ES products. By optimizing the concentration of artificial gastric juice, volume of medium, and time of incubation for ES collection in vitro, muscle larvae, adult worms, and newborn larvae were collected with less contamination by host materials, and the ES products collected were confirmed to be originally antigenic and biologically active. The DNA, RNA, and proteins isolated from the parasites collected were confirmed to be applicable to analyses, including PCR, real-time PCR, Western blotting, and stimulators of cell cultures (macrophages, splenocytes, and tumor cells). The present study compiled protocols to collect materials from Trichinella and provides a reference for research on Trichinella.

The expression of B7-H1 on keratinocytes in chronic inflammatory mucocutaneous disease and its regulatory role.

PD-1 and its ligands, B7-H1/PD-L1 and B7-DC/PD-L2, have been identified recently as CD28-B7 family molecules that are implicated in immune regulation. Lichen planus (LP) is a T cell-mediated chronic inflammatory mucocutaneous disease. We investigated the expression and function of PD-1 and its two ligands in LP. Immunohistochemical examination revealed the abundant expression of PD-1 and B7-H1 in infiltrating T cells and macrophages, and lower-level expression of B7-DC on macrophages in the subepithelium. Interestingly, substantial expression of B7-H1 on keratinocytes (KCs) was found close to the numerous T cell infiltrates in the subepithelium. Unstimulated cultured KCs expressed both B7-H1 and B7-DC, and their expression was upregulated by proinflammatory cytokines, particularly IFN-gamma. The T-cell proliferative responses and IFN-gamma production that were induced by IFN-gamma-treated KCs were augmented preferentially by anti-B7-H1 mAb, but not by anti-B7-DC mAb. These results indicate the regulatory role of B7-H1 on KCs in the interactions with T cells. Our results suggest that the induction of B7-H1 on KCs may play an important role in tolerance induction in the inflamed oral mucosa and skin.