Learning curve analysis of multiport robot-assisted hysterectomy.

PURPOSE: The purpose of this study was to evaluate the surgical outcomes and learning curve of multiport robot-assisted hysterectomy. METHODS: Eighty-eight patients were identified who underwent multiport robot-assisted surgery for hysterectomy. A retrospective analysis was performed. The cumulative summation technique (CUSUM) was used to investigate the learning curve in surgical proficiency by analyzing total operative, docking, and console times. RESULTS: The patients' median age was 51 years. In addition, the median operative time was 120.5 min (range 56-344 min). The most common indication for surgery was myoma (33.0%). The median estimated blood loss was 30 mL (range 5-200 mL). There was no conversion to laparoscopic or open surgery. No transfusion was required, and only one complication including umbilical incisional hernia was reported. A tendency of decline in total operative time following the first 23 cases was found. The CUSUM graph for total operative time indicated the generation of three distinct performance phases: learning (n = 23), competence (n = 36), and mastery (n = 29). The median docking time was 3 min (range 1-10 min) and median console time was 70 min (range 24-298 min). CONCLUSION: The multiport robot-assisted surgery is an easy and safe procedure with minimal postoperative complications and can be quickly learned. The learning curve was 23 cases to significantly decrease the operative time.

Ultrasonographic ovarian mass scoring system for predicting malignancy in pregnant women with ovarian mass.

During routine antenatal ultrasound examinations, an ovarian mass can be found incidentally. In clinical practice, the differential diagnosis between benign and malignant ovarian masses is essential for planning further management. Ultrasound imaging has become the most popular diagnostic tool during pregnancy, with the recent development of ultrasonography. In non-pregnant women, several methods have been used to predict malignant ovarian masses before surgery. The International Ovarian Tumor Analysis (IOTA) group reported several scoring systems, such as the IOTA simple rules, IOTA logistic regression models, and IOTA assessment of different NEoplasias in the adneXa. Other researchers have also evaluated the malignancy of ovarian masses before surgery using scoring systems such as the Sassone score, pelvic mass score, DePriest score, Lerner score, and Ovarian-Adnexal Reporting and Data System. These researchers suggested specific features of ovarian masses that can be used for differential diagnosis, including size, proportion of solid tissue, papillary projections, inner wall structure, locules, wall thickness, septa, echogenicity, acoustic shadows, and presence of ascites. Although these factors can also be measured in pregnant women using ultrasound, only a few studies have applied ovarian scoring systems in pregnant women. In this article, we reviewed various scoring systems for predicting malignant tumors of the ovary and determined whether they can be applied to pregnant women.

Effects of Preoperative Autologous Blood Donation in Patients Undergoing Minimally Invasive Cardiac Surgery.

BACKGROUND: Preoperative autologous blood donation (PABD) is a conservation strategy for reducing allogenic blood transfusion (ABT) during minimally invasive cardiac surgery (MICS). We aimed to evaluate the effects of PABD on the frequency of ABT and clinical outcomes in patients undergoing MICS. METHODS: We enrolled 113 patients (47.8±13.1 years, 50 men) undergoing MICS without preoperative anemia (hemoglobin >11 g/dL) between 2014 and 2017. Of these patients, 69 (the PABD group) donated autologous blood preoperatively and were compared to the non-PABD group (n=44). We analyzed the frequency of perioperative ABT and clinical outcomes. RESULTS: Baseline characteristics did not significantly differ between groups, although preoperative hemoglobin levels were lower in the PABD group. All operations were performed using a minimally invasive approach. Patients' surgical profiles were similar. There were no cases of mortality or significant differences in early postoperative outcomes. During the early postoperative period, hemoglobin levels were higher in the PABD group. No significant difference was found in the frequency of ABT. CONCLUSION: Although the PABD group had higher postoperative hemoglobin levels, there was no clear clinical benefit in the early postoperative period, despite a great deal of effort and additional cost. Additional PABD in the setting of strict policies for blood conservation was ineffective in reducing ABT for young and relatively healthy patients who underwent MICS.

Incidence and Distribution of Cerebral Embolism After Cardiac Surgery According to the Systemic Perfusion Strategy　- A Diffusion-Weighted Magnetic Resonance Imaging Study.

BACKGROUND: Stroke is a major concern in minimally invasive cardiac surgery, so we investigated the incidence and risk factors of cerebral embolism according to the systemic perfusion strategy under thorough imaging assessment.Methods and Results:Between November 2011 and May 2015, 315 cardiac surgery patients who underwent preoperative computed tomography angiography (CTA) as a routine evaluation were enrolled. The incidence and distribution of cerebral embolism were analyzed with routine postoperative brain diffusion-weighted magnetic resonance imaging (DW-MRI) examination. Anterograde perfusion was used in 103 patients (group A), and retrograde perfusion was performed in 212 patients (group R). Operative deaths, incidence of clinical stroke (group A: 0%, group R: 0.5%, P=0.77), and rate of cerebral embolism (group A: 35.9%, group R: 26.4%, P=0.08) were comparable. The median number of new embolic lesions detected by MRI per patient (group A: 2, group R: 2, P=0.16), maximal diameter of the lesion (group A: 6.5 mm, group R: 6.0 mm, P=0.97), and anatomic distribution of the lesion were similar between groups. In the multivariate analysis, hypertension, emergency status, atherosclerosis grade 3 or 4 (intimal thickening >4 mm), and cardiopulmonary bypass time were independent risk factors for postoperative cerebral embolism, but retrograde perfusion was not. CONCLUSIONS: According to the results of postoperative DW-MRI, retrograde perfusion itself might not increase the incidence of postoperative cerebral embolism in properly selected cardiac surgery patients undergoing routine preoperative CTA examination.

Frameshift Mutations in the Mononucleotide Repeats of TAF1 and TAF1L Genes in Gastric and Colorectal Cancers with Regional Heterogeneity.

Initiation of transcription by RNA polymerase II requires TATA-box-binding protein (TBP)-associated factors (TAFs). TAF1 is a major scaffold by which TBP and TAFs interact in the basal transcription factor. TAF1L is a TAF1 homologue with 95 % amino acid identity with TAF1. TAF1 is involved in apoptosis induction and cell cycle regulation, but roles of TAF1 and TAF1L in tumorigenesis remain unknown. The aim of this study was to explore whether TAF1 and TAF1L genes were mutated in gastric (GC) and colorectal cancers (CRC). In a public database, we found that TAF1 and TAF1L genes had mononucleotide repeats in the coding sequences that might be mutation targets in the cancers with microsatellite instability (MSI). We analyzed the mutations in 79 GC and 124 CRC by single-strand conformation polymorphism analysis and DNA sequencing. In the present study, we found TAF1 frameshift mutations (3.8 % of CRC with MSI-H) and TAF1L frameshift mutations (2.9 % of GC and 3.8 % of CRC with MSI-H). These mutations were not found in stable MSI/low MSI (MSS/MSI-L) (0/90). In addition, we analyzed intratumoral heterogeneity (ITH) of TAF1 and TAF1L frameshift mutations in 16 CRC and found that two and one CRC harbored regional ITH of TAF1 and TAF1L frameshift mutations, respectively. Our data indicate that TAF1 and TAF1L genes harbored not only somatic mutations but also mutational ITH, which together might play a role in tumorigenesis of GC and CRC with MSI-H. Our results also suggest that ultra-regional mutation analysis is required for a comprehensive evaluation of mutation status in these tumors.

Critical roles of Cyclin D1 in mouse embryonic fibroblast cell reprogramming.

Although pluripotent stem cells hold great promise in the fields of human disease modeling and regenerative medicine, the molecular basis of Oct-4, Sox2, Klf4, and c-Myc (OSKM)-induced cellular reprogramming remains unclear. To investigate the molecular mechanisms involved in cellular reprogramming, we studied the immediate effects of expression of the OSKM reprogramming factors on mouse embryonic fibroblasts (MEFs) in this study. Induction of the OSKM reprogramming factors significantly altered primary MEF growth properties. Although MEFs not expressing the reprogramming factors underwent replicative senescence within 9-12 days in culture, MEFs expressing the four reprogramming factors proliferated continuously throughout the duration of the experiment, suggesting that the expression of the OSKM reprogramming factors inhibits or delays replicative senescence. Cell cycle progression by the reprogramming factors was accompanied by the accumulation of Cyclin D1 through the early stages of reprogramming in MEFs, leading us to hypothesize that it might play a positive role in cellular reprogramming. Consistent with this hypothesis, forced Cyclin D1 expression enhanced reprogramming if administered concomitant with expression of the OSKM reprogramming factors. Most importantly, unlike wild-type MEFs expressing reprogramming factors, the number of emerging alkaline phosphatase-positive cyclin D1-null colonies was significantly reduced and cyclin D1-null MEFs were unable to initiate mesenchymal-to-epithelial transition. Our studies demonstrate that cyclin D1 is an essential gene in the reprogramming process and that activation of cyclin D1 by reprogramming factors is an important process for somatic cell reprogramming.

Frameshift mutations of TAF1C gene, a core component for transcription by RNA polymerase I, and its regional heterogeneity in gastric and colorectal cancers.

Initiation of transcription for ribosomal RNA (rRNA) by RNA polymerase I requires TATA-binding protein (TBP) and TBP-associated factors (TAF1A, TAF1B and TAF1C). p53 tumour suppressor inhibits rRNA transcription by blocking TAF1C-UBF interaction, but alterations of TAF1C itself in tumorigenesis remain unknown. The aim of this study was to explore whether TAF1C gene was mutated in gastric (GC) and colorectal cancers (CRC).In a public database, we found that TAF1C gene had a mononucleotide repeat (C8) in the coding sequences that might be a mutation target in the cancers with microsatellite instability (MSI). We analysed 79 GC and 124 CRC by single-strand conformation polymorphism and DNA sequencing analyses. In this study, we found TAF1C frameshift mutations (8.8% of GC and 10.1% of CRC with MSI-H), which were not found in stable MSI/low MSI (MSS/MSI-L) (0/90). In addition, we analysed intratumoural heterogeneity (ITH) of TAF1C frameshift mutations in 16 CRC and found that three CRC (18.8%) harboured regional ITH of the TAF1C frameshift mutations. Our results indicate that TAF1C gene harboured not only somatic frameshift mutations but also the mutational ITH, which together might play a role in tumourigenesis of GC and CRC. Our data also suggest that multi-regional mutation analysis is needed for a better evaluation of the mutation status in CRC.

Frameshift mutations of MUC15 gene in gastric and its regional heterogeneity in gastric and colorectal cancers.

Mucins are important in tumorigenesis and expressional alterations of mucins are common in human cancers. A membrane-bound mucin MUC15 and secreted mucins MUC4 and MUC7 are known to involve in tumorigenesis, but their mutation status in cancers remains unknown. Aim of this study was to explore whether MUC4, MUC7 and MUC15 genes are mutated and expressionally altered in gastric (GC) and colorectal cancers (CRC). In a public database, we found that MUC15 and MUC7 genes had mononucleotide repeats in the coding sequences that might be mutation targets in the cancers with microsatellite instability (MSI). We analyzed the mutations in 90 GC and 141 CRC (high MSI (MSI-H) or stable MSI/low MSI (MSS/MSI-L)) by single-strand conformation polymorphism analysis and DNA sequencing. In the present study, we found MUC15 frameshift mutations (14.7% of GC and 15.2% of CRC with MSI-H), MUC 7 frameshift mutations (2.9% of GC with MSI-H) and MUC4 frameshift mutations (8.8% of GC and 3.8% of CRC with MSI-H). These mutations were not found in in MSS/MSI-L (0/118). Additionally, we analyzed intratumoral heterogeneity (ITH) of MUC15 mutation in 16 CRC and found that seven CRC (43.8%) harbored regional ITH of MUC15. We also analyzed MUC15 expression in GC and CRC by immunohistochemistry. Negative MUC15 expression was identified in 15-41% of the GC and CRC irrespective of MSI status. Of note, the negative expression was more common in those with MUC15 mutations. We identified alterations of MUC genes at various levels (frameshift mutations, genetic ITH and expression loss), which together might play a role in tumorigenesis of GC and CRC with MSI-H. Our data suggest that mutation analysis in multiple regions is needed for a better evaluation of mutation status in CRC with MSI-H.

Somatic mutations of amino acid metabolism-related genes in gastric and colorectal cancers and their regional heterogeneity--a short report.

BACKGROUND: Metabolic reprogramming is an emerging topic in cancer research. However, genetic alterations in genes encoding enzymes involved in amino acid metabolism are largely unknown. The aim of this study was to explore whether genes known to be involved in amino acid metabolism are mutated in gastric cancer (GC) and/or colorectal cancer (CRC). METHODS: Through a public database search, we found that a number of genes known to be involved in amino acid metabolism, i.e., AGXT, ALDH2, APIP, MTR, DNMT1, ASH1L, ASPA, CAD, DDC, GCDH, DLD, LAP3, MCEE and MUT, harbor mononucleotide repeats that may serve as mutation targets in cancers exhibiting microsatellite instability (MSI). We assessed these genes for the presence of the mutations in 79 GCs and 124 CRCs using single-strand conformation polymorphism (SSCP) and direct sequencing analyses. RESULTS: Using SSCP in conjunction with DNA sequencing we detected frameshift mutations in AGXT (17 cases), ALDH2 (3 cases), APIP (4 cases), MTR (5 cases), DNMT1 (1 case), ASH1L (1 case), ASPA (2 cases), CAD (2 cases), DDC (1 case), GCDH (3 cases), DLD (1 case), LAP3 (1 case), MCEE (5 cases) and MUT (1 case). These mutations were exclusively detected in MSI-high (MSI-H), and not in MSI-low or MSI-stable (MSI-L/MSS) cases. In addition, we analyzed 16 CRCs for the presence of intra-tumor heterogeneity (ITH) and found that two CRCs harbored regional ITH for GCDH frameshift mutations. CONCLUSIONS: Our data indicate that genes known to be involved in amino acid metabolism recurrently acquire somatic mutations in MSH-H GCs and MSH-H CRCs and that, in addition, mutation ITH does occur in at least some of these tumors. Together, these data suggest that metabolic reprogramming may play a role in the etiology of MSI-H GCs and CRCs. Our data also suggest that ultra-regional mutation analysis is required for a more comprehensive evaluation of the mutation status in these tumors.

Frameshift mutation of a histone methylation-related gene SETD1B and its regional heterogeneity in gastric and colorectal cancers with high microsatellite instability.

Histone methyltransferase (HMT), which catalyzes a histone methylation, is frequently altered in cancers at mutation and expression levels. The aims of this study were to explore whether SETD1B, SETDB2, and SETD2, SET domain-containing HMT genes, are mutated and expressionally altered in gastric (GC) and colorectal cancers (CRC). In a public database, we found that SETD1B, SETDB2, and SETD2 had mononucleotide repeats in coding sequences that might be mutation targets in cancers with microsatellite instability (MSI). We analyzed the mutations in 76 GCs and 93 CRCs and found SETD1B (38.7% of GC and 35.6% of CRC with high MSI [MSI-H]), SETDB2 (11.1% of CRC with MSI-H), and SETD2 frameshift mutations (6.7% of CRC with MSI-H). These mutations were not found in stable MSI/low MSI. In addition, we analyzed intratumoral heterogeneity (ITH) of SETD1B mutation in 6 CRCs and found that 2 CRCs harbored regional ITH of SETD1B. We also analyzed SETD1B expression in GC and CRC by immunohistochemistry. Loss of SETD1B expression was identified in 15% to 55% of the GC and CRC with respect to the MSI status. Of note, the loss of expression was more common in those with SETD1B mutations than those with wild-type SETD1B. We identified alterations of SET domain-containing HMT at various levels (frameshift mutations, genetic ITH, and expression loss), which together might play a role in tumorigenesis of GC and CRC with MSI-H. Our data suggest that mutation analysis in multiple regions is needed for a better evaluation of mutation status in CRC with MSI-H.

The reprogramming factor nuclear receptor subfamily 5, group A, member 2 cannot replace octamer-binding transcription factor 4 function in the self-renewal of embryonic stem cells.

Although octamer-binding transcription factor 4 (Oct-4) is one of the most intensively studied factors in mammalian development, no cellular genes capable of replacing Oct-4 function in embryonic stem (ES) cells have been found. Recent data show that nuclear receptor subfamily 5, group A, member 2 (Nr5a2) is able to replace Oct-4 function in the reprogramming process; however, it is unclear whether Nr5a2 can replace Oct-4 function in ES cells. In this study, the ability of Nr5a2 to maintain self-renewal and pluripotency in ES cells was investigated. Nr5a2 localized to the nucleus in ES cells, similarly to Oct-4. However, expression of Nr5a2 failed to rescue the stem cell phenotype or to maintain the self-renewal ability of ES cells. Furthermore, as compared with Oct-4-expressing ES cells, Nr5a2-expressing ES cells showed a reduced number of cells in S-phase, did not expand normally, and did not remain in an undifferentiated state. Ectopic expression of Nr5a2 in ES cells was not able to activate transcription of ES cell-specific genes, and gene expression profiling demonstrated differences between Nr5a2-expressing and Oct-4-expressing ES cells. In addition, Nr5a2-expressing ES cells were not able to form teratomas in nude mice. Taken together, these results strongly suggest that the gene regulation properties of Nr5a2 and Oct-4 and their abilities to confer self-renewal and pluripotency of ES cells differ. The present study provides strong evidence that Nr5a2 cannot replace Oct-4 function in ES cells.

Docosahexaenoic acid induces autophagy through p53/AMPK/mTOR signaling and promotes apoptosis in human cancer cells harboring wild-type p53.

Docosahexaenoic acid (DHA) has been reported to induce tumor cell death by apoptosis. However, little is known about the effects of DHA on autophagy, another complex well-programmed process characterized by the sequestration of cytoplasmic material within autophagosomes. Here, we show that DHA increased both the level of microtubule-associated protein light-chain 3 and the number of autophagic vacuoles without impairing autophagic vesicle turnover, indicating that DHA induces not only apoptosis but also autophagy. We also observed that DHA-induced autophagy was accompanied by p53 loss. Inhibition of p53 increased DHA-induced autophagy and prevention of p53 degradation significantly led to the attenuation of DHA-induced autophagy, suggesting that DHA-induced autophagy is mediated by p53. Further experiments showed that the mechanism of DHA-induced autophagy associated with p53 attenuation involved an increase in the active form of AMP-activated protein kinase and a decrease in the activity of mammalian target of rapamycin. In addition, compelling evidence for the interplay between autophagy and apoptosis induced by DHA is supported by the findings that autophagy inhibition suppressed apoptosis and further autophagy induction enhanced apoptosis in response to DHA treatment. Overall, our results demonstrate that autophagy contributes to the cytotoxicity of DHA in cancer cells harboring wild-type p53.

Apigenin inhibits the production of NO and PGE2 in microglia and inhibits neuronal cell death in a middle cerebral artery occlusion-induced focal ischemia mice model.

Flavonoids have been intensively studied on their pharmacological activities such as anti-cancer, anti-oxidant and anti-inflammation. However, little is known about their neuroprotective effects. Recent studies suggest that inflammation mediated by microglia may play a role in neurodegenerative diseases. In this study, we evaluated the anti-inflammatory effect of various flavonoid compounds by using BV-2, a murine microglia cell line. Of the compounds that were evaluated, apigenin inhibited the production of nitric oxide and prostaglandin E(2) by suppressing the expression of inducible nitric oxide synthase and cyclooxygenase-2 protein, respectively. Moreover, apigenin suppressed p38 mitogen-activated protein kinase (MAPK), c-Jun N-terminal kinase (JNK) phosphorylation without affecting the activity of extracellular signal-regulated kinase (ERK). Apigenin was also found to protect neuronal cells from injury in middle cerebral artery occlusion.

Effects of Anemarrhena asphodeloides on focal ischemic brain injury induced by middle cerebral artery occlusion in rats.

The preventive effect of Anemarrhena asphodeloides Bunge (Liliaceae), a traditional Chinese medicine, on ischemia-reperfusion-induced brain injury was evaluated in the rat brain. Ischemia was induced by intraluminal occlusion of the right middle cerebral artery for 2 h and reperfusion was continued for 22 h. Water extract of Anemarrhena asphodeloides (WEAA) was orally administered promptly prior to and 2 h after reperfusion. Total infarct volume and edema in the ipsilateral hemispheres of ischemia-reperfusion rats were significantly reduced by treatment with WEAA in a dose-dependent manner (p<0.05). The therapeutic time window of WEAA was 3 h in this ischemia-reperfusion rat model. WEAA also significantly inhibited increased neutrophil infiltration of ischemic brain tissue as estimated by myeloperoxidase (MPO) activity and immunohistochemical analysis. MPO-positive cells were markedly reduced by WEAA administration in striatal and cortical areas. These findings suggest that WEAA plays a crucial protective role in ischemia-induced brain injury, and suggest that WEAA could serve as a lead medicinal herb for the development of neuroprotective agents following transient focal ischemic brain injury.

Anxiolytic effects of the aqueous extract of Uncaria rhynchophylla.

The purpose of this study was to characterize the putative anxiolytic-like effects of the aqueous extract of hooks with stem of Uncaria rhynchophylla using the elevated plus maze (EPM) and the hole-board apparatus in rats and mice. Control rats were treated with an equal volume of saline, and positive control rats with buspirone (1 mg/kg). Single or repeated treatments of the aqueous extract of Uncaria rhynchophylla (200 mg/kg/day, p.o.) for 7 days significantly increased the time-spent and entries into open arms of the EPM, and reduced the time-spent and entries into the closed arms versus saline controls (P<0.05). However, no changes in spontaneous locomotor activity or myorelaxant effects were observed versus saline controls. In the hole-board test, repeated treatment with the aqueous extract of Uncaria rhynchophylla (100 or 200 mg/kg/day, p.o.) significantly increased the number of head-dips (P<0.05). In addition, the anxiolytic-like effects of Uncaria rhynchophylla extract as assessed using the EPM test were abolished by WAY 100635 (0.3 mg/kg, i.p.), a 5-HT(1A) receptor antagonist. These results suggest that Uncaria rhynchophylla is an effective anxiolytic agent, and acts via the serotonergic nervous system.

Anxiolytic-like effects of Gastrodia elata and its phenolic constituents in mice.

The purpose of this study was to characterize the putative anxiolytic-like effects of the aqueous extract of the rhizome of Gastrodia elata along with its phenolic constituents, 4-hydroxybenzyl alcohol (HA) and 4-hyroxybenzaldehyde (HD), using an elevated plus maze (EPM) in mice. The mice were administered either the aqueous G. elata extract orally or received an intraperitoneal injection of the phenolic constituents, 1 h before the behavioral evaluation in the EPM. A single treatment of the aqueous G. elata extract significantly increased the percentage of time spent and arm entries into the open arms of the EPM versus the saline controls. Among the phenolic constituents of G. elata, HA and HD significantly increased the percentage of time spent and arm entries into the open arms of the EPM versus saline controls (p<0.05). Moreover, there were no changes in the locomotor activity and myorelaxant effects in any group compared with the saline controls. In addition, the anxiolytic-like effects of G. elata extract were blocked by both WAY 100635 (0.3 mg/kg, i.p.), a 5-HT(1A) receptor antagonist, and flumazenil (10 mg/kg, i.p.), a GABA(A) receptor antagonist. The anxiolytic-like effects of HA were inhibited by WAY 100635 and the effects of HD were antagonized by flumazenil. These results indicate that G. elata is an effective anxiolytic agent, and suggests that the anxiolytic-like effects of G. elata via the serotonergic nervous system depends on HA and those effects of G. elata via the GABAergic nervous system depends on HD.

Enhancement of neuroprotection of mulberry leaves (Morus alba L.) prepared by the anaerobic treatment against ischemic damage.

Several neurological disorders such as Alzheimer's and Parkinson's diseases have been attributed to gamma-aminobutyric acid (GABA) depletion in the brain. In order to provide a pharmacological basis for the neuroprotective actions of the enhanced accumulation of GABA in mulberry leaves (ML) against cerebral ischemia in vitro and in vivo, a process was developed to enhance the accumulation of GABA in mulberry leaves (GAML) as a result of the various anaerobic treatments. The GABA concentrations were changed by N(2) gas purging, the reaction temperature, reaction time, pH and the leaf size. GABA enhanced the potential of neuroprotection in the PC12 cells damaged by H(2)O(2)-induced oxidation. GAML reduced the cytotoxicity in the PC12 cells against oxygen glucose deprivation-induced cerebral ischemic condition. The neuroprotective effect of GAML was further demonstrated in vivo using middle cerebral artery occlusion brain injury model. GAML significantly decreased the infarct volume of the brain compared with than control group. Overall, these results suggest that the anaerobic treatment of ML makes GAML enhance the neuroprotection effect against in vivo cerebral ischemia such as in vitro.