Relationship Between Intraoperative Bispectral Index and Consciousness Recovery in Patients With Hepatic Encephalopathy Undergoing Liver Transplant: A Retrospective Analysis.

BACKGROUND: Although liver transplant (LT) improves liver function and restores symptoms of hepatic encephalopathy (HE), there is no index to predict the recovery of consciousness in patients with HE during LT. In this study, we evaluated the relationship between intraoperative bispectral index (BIS) values and the recovery of consciousness in patients with HE who were undergoing LT. METHODS: Patients with HE who underwent LT from June 2011 to December 2017 at our institution were enrolled. A total of 64 patients were enrolled, and, using the West Haven Criteria, they were divided into 2 groups: nonsevere HE group (n = 26), grades 1 to 2 HE; and severe HE group (n = 38), grades 3 to 4 HE. Grade of HE, intraoperative BIS, minimum alveolar concentration values, postoperative Glasgow Coma Scale (GCS) score, and the time to recover consciousness were compared. RESULTS: The severe HE group showed lower BIS after anesthetic induction compared with the nonsevere HE group (P = .005). In the severe HE group, intraoperative BIS gradient (the difference between values measured 4 hours after reperfusion and immediately after anesthesia induction) was significantly larger than in the nonsevere HE group (P = .001). Time to recovery of consciousness was prolonged in the severe HE group (P = .002). Model for End-Stage Liver Disease (MELD) score and the GCS score at 24 hours after LT were associated with delayed recovery of consciousness (MELD score: hazard ratio, 1.103; 95% CI, 1.002-1.214; P = .046; GCS score at 24 hours after LT: hazard ratio, 0.688; 95% CI, 0.566-0.835; P < .001). CONCLUSIONS: Our study indicated that BIS values immediately after anesthesia induction were significantly lower in patients with severe HE. However, it did not show a significant relationship with the time to recovery of consciousness after LT. Multivariate analysis demonstrated that MELD score and GCS score at 24 hours after LT were associated with the time to recovery of consciousness.

Peeled volume models of a whole body to enhance comprehension of anthropological bone landmarks.

BACKGROUND: In physical anthropology, bone landmarks are palpated in living humans for the identification of corresponding skin landmarks and exact biometry. The purpose of this study is to help comprehend the locations and depths of representative bone landmarks all over the body. MATERIALS AND METHODS: The sectioned images of a male cadaver's whole body were used to build a volume model, which was continuously peeled at 1 mm thicknesses to disclose 27 selected landmarks in the anterior, lateral, or posterior views. RESULTS: The captured views of peeled volume models along with the labels of the bone landmarks were loaded to browsing software that was distributed for free. The browsing software containing the peeled volume models will enhance convenient studying of the bone landmarks. CONCLUSIONS: With the knowledge of bone landmarks, investigators would be able to attain more accurate measurements between skin landmarks.

The relationship between clinical characteristics including presence of exposed lesions and health-related quality of life (HRQoL) in patients with psoriasis: analysis from the nationwide epidemiologic study for psoriasis in Korea (EPI-PSODE study).

BACKGROUND: Psychological aspect and quality of life should be considered in treating patients with psoriasis. OBJECTIVE: We sought to ascertain which clinical characteristics including presence of exposed lesions are associated with impairment of health-related quality of life (HRQoL) in patients with psoriasis. METHODS: The EPI-PSODE study was a nationwide, multicenter, cross-sectional study conducted in Korea that included 1260 adult patients with psoriasis. In addition to clinical characteristics including presence of exposed lesions, data were collected using the Psoriatic Arthritis (PsA) Screening and Evaluation (PASE), Dermatology Life Quality Index (DLQI), MOS 36-Item Short-Form Health Survey (SF-36), Work Productivity and Activity Impairment Questionnaire Psoriasis (WPAI: PSO) and Medication Satisfaction Questionnaire (MSQ). RESULTS: Patients with a DLQI score > 5 (n = 990) were younger, had an earlier onset of psoriasis, scored higher on the Psoriasis Area and Severity Index (PASI), had higher body surface area (BSA) and had higher PASE scores than patients with DLQI ≤ 5 (n = 266). The group of patients with exposed lesions (n = 871) were younger and male predominance, earlier onset of psoriasis, longer disease duration, higher PASI/BSA score and a higher proportion with drinking and smoking history each than the group of patients without exposed lesions (n = 389). Presence of exposed lesions negatively influenced DLQI, 36-Item Short-Form Health Survey (SF-36) (mental component), presenteeism, total work productivity impairment and total activity impairment in the WPAI: PSO. In multiple regression model, PASI score was the only variable which was significantly associated with all HRQoL measures. Presence of exposed lesions was a significant factor affecting DLQI and SF-36 (mental). CONCLUSION: The presence of exposed lesions has a negative impact on quality of life, mental health and work productivity. Therefore, effective treatments are particularly needed for psoriasis patients with exposed lesions.

Ischemic Preconditioning Produces Comparable Protection Against Hepatic Ischemia/Reperfusion Injury Under Isoflurane and Sevoflurane Anesthesia in Rats.

BACKGROUND: Various volatile anesthetics and ischemic preconditioning (IP) have been demonstrated to exert protective effect against ischemia/reperfusion (I/R) injury in liver. We aimed to determine whether application of IP under isoflurane and sevoflurane anesthesia would confer protection against hepatic I/R injury in rats. METHODS: Thirty-eight rats weighing 270 to 300 grams were randomly divided into 2 groups: isoflurane (1.5%) and sevoflurane (2.5%) anesthesia groups. Each group was subdivided into sham (n = 3), non-IP (n = 8; 45 minutes of hepatic ischemia), and IP (n = 8, IP consisting of 10-minute ischemia plus 15-minute reperfusion before prolonged ischemia) groups. The degree of hepatic injury and expressions of B-cell lymphoma 2 (Bcl-2) and caspase 3 were compared at 2 hours after reperfusion. RESULTS: Hepatic ischemia induced significant degree of I/R injuries in both isoflurane and sevoflurane non-IP groups. In both anesthetic groups, introduction of IP dramatically attenuated I/R injuries as marked by significantly lower aspartate aminotransferase and aminotransferase levels and better histologic grades compared with corresponding non-IP groups. There were 2.3- and 1.7-fold increases in Bcl-2 mRNA levels in isoflurane and sevoflurane IP groups, respectively, compared with corresponding non-IP groups (both P < .05). Caspase 3 level was significantly high in the isoflurane non-IP group compared with the sham group; however, there were no differences among the sevoflurane groups. CONCLUSIONS: The degree of hepatic I/R injury was significantly high in both isoflurane and sevoflurane groups in rats. However, application of IP significantly protected against I/R injury in both volatile anesthetic groups to similar degrees, and upregulation of Bcl-2 might be an important mechanism.

Two-year experience of using the measles, mumps and rubella vaccine as intralesional immunotherapy for warts.

BACKGROUND: The currently available treatments for warts, including cryosurgery, laser surgery, electrosurgery, and topical keratolytic applications, are often very painful and can induce disfiguring scars. Recently, intralesional immunotherapy with skin test antigens and vaccines has been shown to be effective in the management of warts. AIMS: To evaluate the efficacy of a new intralesional immunotherapy for warts, using the measles, mumps and rubella (MMR) vaccine. METHODS: A retrospective study was performed, and we enrolled 136 patients with various types of warts into the study, which was for a duration of 2 years. Patients were treated for a total of six times at 2-week intervals. The treatment response was classified as one of three levels, based on reduction in the size and number of warts, and patients with complete response (CR) were checked for recurrence. Clinical evaluations were carried out using photographs and medical records. RESULTS: Over half (51.5%) of patients experienced > 50% reduction in the size and number of warts, and 46.7% who had distant warts (in different locations) showed good response. Common warts showed significantly higher treatment response than other types of warts (P < 0.05). However, other clinical variables did not have any effect on efficacy. Almost all the patients reported mild pain during the injection, but other side effects were rarely observed. Only 5.6% of patients who experienced CR had recurrence of warts after 6 months. CONCLUSIONS: We suggest that intralesional immunotherapy with MMR vaccine is a tolerable and effective method for patients who are sensitive to pain, concerned about side effects, or have common warts. Treatment response is improved by increasing the number of injections.

Comparison of desflurane and sevoflurane anaesthesia in relation to the risk of vagally mediated reflex bradycardia during gastrectomy.

OBJECTIVE: This study compared the risk of clinically significant reflex bradycardia during anaesthesia with sevoflurane or desflurane in patients undergoing gastrectomy. METHODS: In this randomized prospective study, 100 patients undergoing gastrectomy were assigned to receive sevoflurane (n=50) or desflurane (n=50) anaesthesia. No anticholinergic prophylaxis was administered. Symptomatic reflex bradycardia was defined as a sudden decrease in heart rate to <50 beats/min, or a decrease to 50-59 beats/min if associated with a systolic arterial pressure of 70 mmHg in response to surgical manoeuvres. If reflex bradycardia developed, atropine or ephedrine were administered according to a predefined treatment protocol. RESULTS: Data from 85 patients were available for analysis. The proportion of patients with symptomatic reflex bradycardia in the sevoflurane and desflurane groups was similar (69.0% versus 55.8%, respectively) and both groups required a similar amount of atropine and/or ephedrine. CONCLUSIONS: Clinically significant reflex bradycardia occurred with a relatively high frequency during gastrectomy. Although desflurane is associated with sympathetic activation, it did not provide a protective effect against vagally mediated reflex bradycardia during gastrectomy compared with sevoflurane.

Clinical predictors of apnoea-hypopnoea during propofol sedation in patients undergoing spinal anaesthesia.

This study assessed the relationship between the occurrence of apnoea-hypopnoea during propofol sedation for spinal anaesthesia and two different predictive tests of sleep apnoea: the STOP-Bang score (snoring while sleeping, daytime tiredness, observed breathing stoppages, high blood pressure-body mass index, age, neck circumference, gender); and the obstructive sleep apnoea (OSA) score. Thirty-four middle-aged men not diagnosed with obstructive sleep apnoea received propofol infusions adjusted to produce a bispectral index of 70-75. ApnoeaLink(TM) was used to estimate the incidence of apnoea-hypopnoea. The median (IQR [range]) apnoea-hypopnoea index was 17 (8-24 [0-70]) events.h(-1) and correlated weakly with the STOP-Bang score (p = 0.022, r = 0.423) and moderately with the OSA score (p < 0.001, r = 0.693). Severe apnoea-hypopnoea developed more frequently in patients with a higher OSA score (34.5% vs 0%) or higher STOP-Bang score (27.6% vs 6.9%). Both assessment tools have some predictive value for the occurrence of apnoea-hypopnoea during propofol sedation in patients undergoing spinal anaesthesia.

The influence of patient position on withdrawal force of thoracic epidural catheters.

We investigated the forces required to remove thoracic epidural catheters to determine the effect of patient position on removal. Eighty-four patients undergoing open thoracotomy and thoracic patient-controlled epidural analgesia were enrolled. Catheterisation was performed under fluoroscopic guidance before surgery, and the patients were allocated to one of three position groups for removal: prone; sitting; and lateral. On the third postoperative day, the peak tension during withdrawal in the assigned position was measured. No differences in mean (SD) forces were found between groups: prone 1.61 (0.39) N, supine 1.62 (0.61) N and lateral 1.36 (0.56) N (p = 0.140). The withdrawal forces required to remove thoracic epidural catheters were not affected by the position. Thus, the position for removal can be determined by patient's choice and clinical judgement.

Clinical characteristics and risk of melanoma development from giant congenital melanocytic naevi in Korea: a nationwide retrospective study.

BACKGROUND: Giant congenital melanocytic naevi (GCMN) are known risk factors for the development of melanoma. However, melanoma risk among Asians is rarely evaluated. OBJECTIVES: To evaluate the clinical characteristics and risk of melanoma development from GCMN in Koreans, we performed a nationwide retrospective cohort study in Korea. GCMN were defined as those comprising ≥5% body surface area in children or measuring ≥20cm in adults. METHODS: In total, 131 patients with GCMN were enrolled, with a mean age of 10·3years (range: birth-70years). RESULTS: The posterior trunk was the most common site (67, 51·1%), followed by lateral trunk, anterior trunk, legs, both anterior and posterior trunk, buttocks, and arms. Satellite naevi were present in 69 cases (52·7%), and axial areas were more commonly involved in patients with satellite naevi than in those without satellite lesions. Atypical features such as rete ridge elongation and bridges were seen, and, among these, pagetoid spread and ballooning cell changes were more common in patients <4years old. Proliferative nodules were found in three cases. Melanomas had developed in three of 131 patients (2·3%; a 6-year-old girl, a 14-year-old girl and a 70-year-old man), and the incidence rate was 990 per 100000 person-years. Melanomas in these three patients consisted of two cutaneous melanomas and one extracutaneous meningeal melanoma. CONCLUSIONS: We should be aware of melanoma development from GCMN, and lifelong follow-up is required due to the risk of melanoma arising in GCMN.

Anatomical analysis of computed tomography images for determining the optimal oblique fluoroscope angle for percutaneous coeliac plexus block.

This retrospective study used abdominal computed tomography (CT) scan images to determine the optimal safe oblique angle for fluoroscopy in fluoroscope-assisted coeliac plexus block (CPB). Abdominal CT scans from 131 patients were included in the study: 42 patients with cancer of the pancreas head, 45 with cancer of the pancreas body and tail and 44 with chronic pancreatitis. The oblique angle and entry distance from the midline were measured at the T12 and L1 levels, and the safe angle range that avoided puncture of the organs was also measured. The optimal angle varied between the T12 and L1 levels, and between the right and left sides at the T12 level. There was no difference in the oblique angle between the patient groups. The optimal oblique angle for fluoroscopy was determined to be 17° for right T12, 18° for left T12, and 19° for both left and right L1.

Bronchial artery embolisation for the management of haemoptysis in patients with pulmonary tuberculosis.

OBJECTIVES: To evaluate immediate and long-term outcomes of bronchial artery embolisation (BAE) for the treatment of haemoptysis in patients with pulmonary tuberculosis (TB), and to clarify factors that influence recurrence. DESIGN: Of 398 patients with haemoptysis who underwent BAE between January 2004 and June 2009, 169 were retrospectively reviewed. All of the patients had either a history of pulmonary TB or a current diagnosis of TB. Follow-up ranged from 1 day to 66 months. RESULTS: Haemoptysis was stopped or markedly decreased, with subsequent clinical improvement, in 163 patients (96.4%); in 50 patients symptoms recurred during the follow-up period. Disease activity, aortography and mycetoma showed a statistically significant correlation with recurrence rate. Cumulative non-recurrence rates were 76.1% for 12 months and 51.4% for 40 months. The median non-recurrence time was 41.2 months. Disease activity and mycetoma showed a statistically significant correlation with early recurrence. Only one major complication was observed. CONCLUSIONS: BAE is a safe and effective treatment option for the control of haemoptysis in TB patients. Disease activity and mycetoma both correlate with higher recurrence rate and early time of recurrence.

Changes in pulmonary artery pressures during ethanol sclerotherapy for arteriovenous malformations: identifying the most vulnerable period.

AIM: To evaluate the changes in pulmonary artery pressure (PAP) during ethanol embolization and to identify the most vulnerable period associated with cardiovascular collapse in patients with arteriovenous malformations (AVMs). MATERIALS AND METHODS: Twenty-three patients (30 sessions) with AVMs were enrolled. PAP was measured at the following times: baseline (T(baseline)); immediately before (T(pre)), and after (T(post)) bolus injection of absolute ethanol; at the time of maximum mean PAP value during a session (T(highest-ethanol)); 10 min after final injection (T(final)); after restoration of spontaneous breathing (T(resp)); at extubation (T(extubation)); 30 min after extubation (T(extubation-30)(min)); and at the time of maximum mean PAP after patient resumed spontaneous respiration (T(highest-resp)). Nitroglycerin was infused (range 0.5-3 µg/kg/min) in all patients to attenuate the effect of ethanol on pulmonary vasoconstriction. RESULTS: The PAPs of T(highest-ethanol), T(resp), T(extubation), and T(highest-resp) were significantly higher than the corresponding values for T(baseline) and T(final) (all p<0.05). The systolic and mean PAPs of T(highest-resp) were significantly higher than those at T(highest-ethanol) (both p<0.05). In 24 sessions (80%), the highest mean PAP was detected during the recovery period. CONCLUSION: The greatest rise in PAP was noted during the recovery period in patients undergoing ethanol embolotherapy. Therefore, PAP monitoring and nitroglycerin infusions are recommended during the recovery period because early detection of an increase in PAP and prompt management may prevent detrimental complications.

Neck circumference to thyromental distance ratio: a new predictor of difficult intubation in obese patients.

BACKGROUND: This study was performed to assess whether intubation is more difficult in obese patients and to assess the ability of a new index: the ratio of the neck circumference to thyromental distance (NC/TM), to predict difficult intubation in obese patients. METHODS: The incidence of difficult tracheal intubation in 123 obese (BMI≥27.5 kg m(-2)) and 125 non-obese patients was compared. Difficult intubation was determined using the intubation difficulty scale (IDS≥5). The NC/TM ratio was calculated and its ability to predict difficult intubation in obese patients was compared with that of established predictors including high BMI, the Mallampati score, the Wilson score, NC, width of mouth opening, sternomental distance, TM, and a previous history of difficult intubation. RESULTS: Difficult intubation was more frequent in obese patients than in non-obese patients (13.8% vs 4.8%; P=0.016). Multivariate analysis revealed that the Mallampati score, the Wilson score, and NC/TM independently predicted difficult intubation in obese patients. Among these three indices, NC/TM showed the highest sensitivity and a negative predictive value, and largest area under the curve on an ROC curve. CONCLUSIONS: Difficult intubation was more common in obese patients and the NC/TM was a better method for predicting difficult intubation than other established indices.

Greater hemodynamic instability with histidine-tryptophan-ketoglutarate solution than University of Wisconsin solution during the reperfusion period in living donor liver transplantation.

OBJECTIVE: University of Wisconsin (UW) and histidine-tryptophan-ketoglutarate (HTK) solutions are the 2 most commonly used liver preservation solutions. The aim of this study was to compare cardiovascular stability, acid-base status, and potassium concentrations between patients who received grafts preserved in either UW or HTK solution in orthotopic liver transplantation (OLT). PATIENTS AND METHODS: In this retrospective study, 87 patients who underwent living donor OLT were divided into 2 groups: UW (n = 28) and HTK (n = 59). Group HTK was subdivided into group NF-HTK (n = 31; nonflushed before reperfusion) and group F-HTK (n = 28; flushed before reperfusion). We determined mean arterial pressure (MAP) and heart rate every minute for 5 minutes after reperfusion and the maximum change in these values and incidence of postreperfusion syndrome (PRS). Body temperature, cardiovascular and acid-base parameters, as well as potassium concentrations were compared at 5 minutes before and 5 and 30 minutes after reperfusion. RESULTS: The maximum decreases in MAP within 5 minutes after reperfusion were significantly greater in both the NF-HTK and the F-HTK groups. The rate of PRS was significantly greater in the NF-HTK compared with the UW group. Flushing with HTK solution decreased the rate of PRS; there was no significant difference between the F-HTK and UW groups. All serial changes in body temperature, cardiovascular and acid-base parameters, as well as potassium concentrations were similar among the 3 groups. CONCLUSIONS: The incidence of PRS was greater using HTK compared with UW solution during the reperfusion period. Therefore, careful hemodynamic management is advised when using HTK solution.

The paraoxonase gene polymorphism in stroke patients and lipid profile.

OBJECTIVES: The paraoxonase (PON) gene can reduce the risk of developing atherosclerosis. We investigated the associations between PON polymorphisms and ischemic stroke. We also investigated the associations between PON polymorphisms and lipid profile in stroke patients. METHODS: A total of 350 patients with ischemic stroke and 242 control subjects in Korean population were genotyped for the PON1M55 L, PON1Q192R, PON2A148 G and PON2S311C polymorphisms using melting point analysis with LightCycler real-time polymerase chain reaction (PCR) technology. RESULTS: There were no significant differences in genotype and allele distribution of the PON polymorphisms between the ischemic stroke patients and control subjects. The concentration of total homocysteine was significantly different in the PON1M55 L polymorphism (P = 0.047), and the apolipoprotein (Apo)B concentration was significantly different in the PON1Q192R polymorphism (P = 0.02) in stroke patients. The concentrations of low-density lipoprotein (LDL) cholesterol and ApoB were significantly different between the PON2A148 G (P = 0.011, P = 0.000, respectively) and PON2S311C polymorphisms (P = 0.046, P = 0.003, respectively) in stroke patients. CONCLUSIONS: This study did not provide association between PON gene polymorphisms and ischemic stroke. However, it confirmed that the PON1L55 L allele is associated with plasma concentration of total homocysteine and that the PON2G148 G and PON2S311S allele is associated with plasma concentrations of LDL cholesterol and ApoB.

Comparison of femoral arterial blood pressure with radial arterial blood pressure and noninvasive upper arm blood pressure in the reperfusion period during liver transplantation.

PURPOSE: The reperfusion period during liver transplantation is hemodynamically unstable. Accurate blood pressure measurements are the mainstay for the efficient management of abrupt cardiovascular changes. We sought to compare femoral arterial blood pressure (FABP) with radial arterial blood pressure (RABP) and noninvasive upper arm blood pressure (NIBP) in the reperfusion period. METHODS: Thirty-six adult living donor liver recipients were enrolled in this prospective study. Blood pressures in 3 locations were simultaneously recorded from 1 minute before reperfusion to 15 minutes after reperfusion. We evaluated agreements between FABP and RABP and between FABP and NIBP using intraclass correlation coefficients. Also, we investigated the rates of postreperfusion syndrome (PRS) based on the measurements from 3 locations. RESULTS: After reperfusion, the mean and diastolic RABP agreed more with the corresponding FABP than NIBP. However, systolic NIBP showed high agreement with FABP from 3 to 10 minutes after reperfusion in contrast with the moderate agreement between systolic RABP with FABP, and systolic values of NIBP than RABP were closer to FABP. The rates of PRS based on FABP, RABP, and NIBP measurements were 50.0% (18/36), 80.6% (29/36), and 50.0% (18/36), respectively. CONCLUSIONS: We believe that NIBP in addition to RABP may be considered to be a reliable alternative when FABP is not available to evaluate hemodynamic instability in the reperfusion period during liver transplantation.

Genetic selection of sox1GFP-expressing neural precursors removes residual tumorigenic pluripotent stem cells and attenuates tumor formation after transplantation.

Because of their ability to proliferate and to differentiate into diverse cell types, embryonic stem (ES) cells are a potential source of cells for transplantation therapy of various diseases, including Parkinson's disease. A critical issue for this potential therapy is the elimination of undifferentiated cells that, even in low numbers, could result in teratoma formation in the host brain. We hypothesize that an efficient solution would consist of purifying the desired cell types, such as neural precursors, prior to transplantation. To test this hypothesis, we differentiated sox1-green fluorescent protein (GFP) knock-in ES cells in vitro, purified neural precursor cells by fluorescence-activated cell sorting (FACS), and characterized the purified cells in vitro as well as in vivo. Immunocytofluorescence and RT-PCR analyses showed that this genetic purification procedure efficiently removed undifferentiated pluripotent stem cells. Furthermore, when differentiated into mature neurons in vitro, the purified GFP+ cell population generated enriched neuronal populations, whereas the GFP- population generated much fewer neurons. When treated with dopaminergic inducing signals such as sonic hedgehog (SHH) and fibroblast growth factor-8 (FGF8), FACS-purified neural precursor cells responded to these molecules and generated dopaminergic neurons as well as other neural subtypes. When transplanted, the GFP+ cell population generated well contained grafts containing dopaminergic neurons, whereas the GFP- population generated significantly larger grafts (about 20-fold) and frequent tumor-related deaths in the transplanted animals. Taken together, our results demonstrate that genetic purification of neural precursor cells using FACS isolation can effectively remove unwanted proliferating cell types and avoid tumor formation after transplantation.

The homeodomain transcription factor Pitx3 facilitates differentiation of mouse embryonic stem cells into AHD2-expressing dopaminergic neurons.

The A9 dopaminergic (DA) neuronal group projecting to the dorsal striatum is the most vulnerable in Parkinson's disease (PD). We genetically engineered mouse embryonic stem (ES) cells to express the transcription factors Nurr1 or Pitx3. After in vitro differentiation of Pitx3-expressing ES cells, the proportion of DA neurons expressing aldehyde dehydrogenase 2 (AHD2) increased, while the total number of DA neurons remained the same. The highest levels of AHD2 expression were observed in mouse A9 DA neurons projecting to the dorsal striatum. Furthermore, real-time PCR analyses of in vitro differentiated Pitx3-expressing ES cells revealed that genes highly expressed in A9 DA neurons were up-regulated. When transplanted into the mouse striatum, Pitx3-expressing cells generated an increased proportion of AHD2-expressing DA neurons. Contrastingly, in Nurr1-expressing ES cells, increases of all midbrain DA markers were observed, resulting in a higher total number of DA neurons in vitro and in vivo, whereas the proportion of AHD2-expressing DA neurons was not changed. Our data, using gain-of-function analysis of ES cells, suggest that Pitx3 may be important for specification and/or maintenance of A9-like neuronal properties, while Nurr1 influences overall midbrain DA specification. These findings may be important for modifying ES cells to generate an optimal cell source for transplantation therapy of PD.