Learning curve of single-incision laparoscopic totally extraperitoneal repair (SILTEP) for inguinal hernia.

PURPOSE: Laparoscopic totally extraperitoneal hernia repair (TEP) is a widely used treatment for inguinal hernia. Single-incision laparoscopic TEP (SILTEP) has attracted the attention of several surgeons, given its superior cosmetic results and patient satisfaction, as well as comparable outcomes to multiport surgery. Nonetheless, no relevant studies have evaluated the learning curve (LC) of SILTEP in terms of both operation time (OT) and surgical failure. Therefore, we aimed to investigate the LC of SILTEP for inguinal hernia. METHODS: Medical records of 180 patients who underwent SILTEP performed by a single surgeon from a single institution between October 2012 and November 2017 were retrospectively reviewed. The LC was analyzed using the moving average method and cumulative sum control chart (CUSUM) for OT and surgical failure. Surgical failure was defined as the need for additional ports, open conversion, severe postoperative complications (Clavien-Dindo ≥ IIIa), and recurrence. Eight patients who underwent combined surgery or bilateral hernia repair were excluded from the OT analysis. RESULTS: From CUSUM graphs, the study period was divided into three phases: OT-phases 1 (1st-32nd), 2 (33rd-83rd), and 3 (84th-172nd) for OT and failure-phases 1 (1st-29th), 2 (30th-58th), and 3 (59th-180th) for surgical failure. Mean OTs were statistically different in the three OT phases (64.6 vs. 50.8 vs. 35.2 min; p < 0.001). Open conversion (31.0% vs. 0% vs. 2.5%) and additional port insertion (6.9% vs. 24.1% vs. 2.5%) stabilized consecutively at failure-phases 2 and 3 (p < 0.001). Surgical failure rates decreased to 5.7% by failure-phase 3 (37.9% vs. 24.1% vs. 5.7%; p < 0.001). CONCLUSION: For an experienced laparoscopic surgeon, we estimated that approximately 60 cases are needed to overcome the LC for SILTEP in terms of both reducing OT and achieving a surgical failure rate < 10%. Further proficiency could be achieved after approximately 85 SILTEP procedures with a stable OT of approximately 35 min.

Correction: Musashi RNA-binding protein 2 regulates estrogen receptor 1 function in breast cancer.

The original version of this article contained error in Figure 2e. In Figure 2e, the 6th colony image of T47D cells treated with shMSI2 was inadvertently replaced with a duplicate of 7th colony image. However, the conclusions reported in the manuscript are not affected by figure replacement. The authors regret that these errors were made and apologize for the confusion and inconvenience. The correct version of this figure panel appears in the Author Correction associated with this Article.

Priming with Toll-like receptor 3 agonist or interferon-gamma enhances the therapeutic effects of human mesenchymal stem cells in a murine model of atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is a chronic and relapsing inflammatory skin disease. Great efforts have been recently made to treat AD using mesenchymal stem cells (MSCs), which have immunomodulatory functions. However, the immunomodulatory effects of MSCs need to be enhanced for clinical application in the treatment of AD. OBJECTIVES: To evaluate and characterise the therapeutic effects of human Wharton's jelly-derived MSCs (WJ-MSCs) primed with the Toll-like receptor 3 agonist poly I:C or interferon-γ (IFN-γ) in a murine model of AD. METHODS: Mice were treated with Aspergillus fumigatus extract to induce AD and then subcutaneously injected with non-primed, poly I:C-primed or IFN-γ-primed WJ-MSCs. Clinical symptom scores, transepidermal water loss (TEWL), histological characteristics and cytokine levels were determined. Transcriptome profiling and pathway analyses of primed WJ-MSCs were conducted. RESULTS: The clinical symptom score and TEWL in skin lesions were reduced in mice administered non-primed and primed WJ-MSCs. Epidermal thickness and inflammatory cell infiltration in skin lesions were reduced more in mice administered primed WJ-MSCs than in mice administered non-primed WJ-MSCs. Secretion of interleukin-17 was significantly reduced in skin draining lymph nodes of mice administered primed WJ-MSCs. Genomics and bioinformatics analyses demonstrated the enrichment of certain pathways specifically in WJ-MSCs primed with poly I:C or IFN-γ. CONCLUSIONS: Priming with poly I:C- or IFN-γ improved the therapeutic effects of WJ-MSCs in a murine model of AD. This study suggests that priming with poly I:C or IFN-γ enhances the immunomodulatory functions of WJ-MSCs and can be used as a novel therapeutic approach for AD.

Correction: RCP induces Slug expression and cancer cell invasion by stabilizing ß1 integrin.

Following the publication of this article the authors noted that images were inadvertently duplicated in Fig. 1b. The corrected Fig. 1 can be found in the associated Correction. The conclusions of this paper are not affected. The authors sincerely apologize for this error. This error has not been corrected in the HTML or PDF of the original Article.

Musashi RNA-binding protein 2 regulates estrogen receptor 1 function in breast cancer.

Musashi RNA-binding protein 2 (MSI2) has important roles in human cancer. However, the regulatory mechanisms by which MSI2 alters breast cancer pathophysiology have not been clearly identified. Here we demonstrate that MSI2 directly regulates estrogen receptor 1 (ESR1), which is a well-known therapeutic target and has been shown to reflect clinical outcomes in breast cancer. Based on gene expression data analysis, we found that MSI2 expression was highly enriched in estrogen receptor (ER)-positive breast cancer and that MSI2 expression was significantly correlated with ESR1 expression, including expression of ESR1 downstream target genes. In addition, MSI2 levels were associated with clinical outcomes. MSI2 influenced breast cancer cell growth by altering ESR1 function. MSI2 alters ESR1 by binding specific sites in ESR1 RNA and by increasing ESR1 protein stability. Taken together, our findings identified a novel regulatory mechanism of MSI2 as an upstream regulator of ESR1 and revealed the clinical relevance of the RNA-binding protein MSI2 in breast cancer.

RCP induces Slug expression and cancer cell invasion by stabilizing ß1 integrin.

Rab coupling protein (RCP)-induced tumor cell migration has been implicated in tumor pathophysiology and patient outcomes. In the present study, we demonstrate that RCP stabilizes ß1 integrin leading to increased ß1 integrin levels and activation of a signaling cascade culminating in Slug induction, epithelial-to-mesenchymal transition and increased invasion. Ectopic expression of RCP induced Slug expression. Silencing ß1 integrin efficiently inhibited RCP-induced Slug expression and subsequent cancer cell invasion. Conversely, ectopic expression of ß1 integrin was sufficient to induce Slug expression. Pharmacological inhibition of integrin linked kinase (ILK), EGFR and NF-κB, as well as transfection of a dominant-negative mutant of Ras (RasN17), significantly inhibited RCP-induced Slug expression and cancer cell invasion. Strikingly, ectopic expression of RCP was sufficient to enhance metastasis of ovarian cancer cells to the lung. Collectively, we demonstrate a mechanism by which RCP promotes cancer cell aggressiveness through sequential ß1 integrin stabilization, activation of an ILK/EGFR/Ras/NF-κB signaling cascade and subsequent Slug expression.

MARCH5-mediated quality control on acetylated Mfn1 facilitates mitochondrial homeostasis and cell survival.

Mitochondrial dynamics and quality control have a central role in the maintenance of cellular integrity. Mitochondrial ubiquitin ligase membrane-associated RING-CH (MARCH5) regulates mitochondrial dynamics. Here, we show that mitochondrial adaptation to stress is driven by MARCH5-dependent quality control on acetylated Mfn1. Under mitochondrial stress conditions, levels of Mfn1 were elevated twofold and depletion of Mfn1 sensitized these cells to apoptotic death. Interestingly, overexpression of Mfn1 also promoted cell death in these cells, indicating that a fine tuning of Mfn1 levels is necessary for cell survival. MARCH5 binds Mfn1 and the MARCH5-dependent Mfn1 ubiquitylation was significantly elevated under mitochondrial stress conditions along with an increase in acetylated Mfn1. The acetylation-deficient K491R mutant of Mfn1 showed weak interaction with MARCH5 as well as reduced ubiquitylation. Neither was observed in the acetylation mimetic K491Q mutant. In addition, MARCH5-knockout mouse embryonic fibroblast and MARCH5(H43W)-expressing HeLa cells lacking ubiquitin ligase activity experienced rapid cell death upon mitochondrial stress. Taken together, a fine balance of Mfn1 levels is maintained by MARCH5-mediated quality control on acetylated Mfn1, which is crucial for cell survival under mitochondria stress conditions.

Periostin cooperates with mutant p53 to mediate invasion through the induction of STAT1 signaling in the esophageal tumor microenvironment.

Periostin (POSTN), a matricellular protein, has been reported to be important in supporting tumor cell dissemination. However, the molecular mechanisms underlying POSTN function within the tumor microenvironment are poorly understood. In this study, we observe that the inducible knockdown of POSTN decreases esophageal squamous cell carcinoma (ESCC) tumor growth in vivo and demonstrate that POSTN cooperates with a conformational missense p53 mutation to enhance invasion. Pathway analyses reveal that invasive esophageal cells expressing POSTN and p53(R175H) mutation display activation of signal transducer and activator of transcription 1 (STAT1) target genes, suggesting that the induction of STAT1 and STAT1-related genes could foster a permissive microenvironment that facilitates invasion of esophageal epithelial cells into the extracellular matrix. Genetic knockdown of STAT1 in transformed esophageal epithelial cells underscores the importance of STAT1 in promoting invasion. Furthermore, we find that STAT1 is activated in ESCC xenograft tumors, but this activation is attenuated with inducible knockdown of POSTN in ESCC tumors. Overall, these results highlight the novel molecular mechanisms supporting the capacity of POSTN in mediating tumor invasion during ESCC development and have implications of therapeutic strategies targeting the tumor microenvironment.

Clinical significance of enzymatic lysophosphatidylcholine (LPC) assay data in patients with sepsis.

Lysophosphatidylcholine (LPC) has been suggested to serve as a useful prognostic marker for sepsis. However, existing LPC assays are complicated, time-consuming, and of limited application in real clinical situations. Thus, we investigated the serum LPC levels in sepsis patients using an enzymatic assay and analyzed the correlations between the serum LPC concentration and clinical characteristics. We prospectively collected blood samples from suspected sepsis patients, commencing on day 1 of sepsis. We analyzed all samples using an enzymatic assay. Additionally, we analyzed the serum LPC concentrations in a control group of 21 healthy blood donors. A total of 105 patients who fulfilled the sepsis criteria were included. The mean serum LPC concentration was 43.49 ± 33.09 µmol/L in sepsis patients, which was much lower than that of 21 healthy controls (234.68 ± 30.33 µmol/L, p<0.001). Bacteremic sepsis was associated with a lower serum LPC concentration than non-bacteremic sepsis (34.8 ± 26.85 vs. 49.05 ± 35.63 µmol/L, p<0.05). No difference in serum LPC concentration was evident between survivors and non-survivors. The serum LPC concentration tended to decrease with the severity of sepsis. The day 1 serum LPC concentration was decreased in patients with sepsis, especially when bacteremia was present. However, the serum LPC level did not correlate with disease severity and did not predict mortality from sepsis.

Identification of oncogenic microRNA-17-92/ZBTB4/specificity protein axis in breast cancer.

The human POK family members are transcription factors with a POZ domain and zinc-fingers that act primarily as transcriptional repressors. Several members of this family are involved in oncogenesis and this prompted us to assess whether expression levels of individual POK family members are associated with clinical outcomes in cancer. We have observed that ZBTB4 (zinc-finger and BTB domain containing 4) is downregulated in breast cancer patients, and that its expression is significantly correlated with relapse-free survival. Further integrative analysis of mRNA and microRNA (miR) expression data from the NCI-60 cell lines revealed an inverse correlation between ZBTB4 and oncogenic miRs derived from the miR-17-92 cluster and its paralogs. The experimental results using MDA-MB-231 and MCF-7 human breast cancer cells confirm that miRNAs derived from these clusters, containing miR-17-5p, miR-20a, miR-106a, miR-106b and miR-93, negatively regulate ZBTB4 expression. Overexpression of ZBTB4 or restoration of ZBTB4 by using an antagomir inhibit growth and invasion of breast cancer cells, and this effect is due, in part, to ZBTB4-dependent repression of the specificity protein 1 (Sp1), Sp3 and Sp4 genes, and subsequent downregulation of several Sp-dependent oncogenes, in part, through competition between ZBTB4 and Sp transcription factors for GC-rich promoter sequences. These results confirm that ZBTB4 functions as a novel tumor-suppressor gene with prognostic significance for breast cancer survival, and the oncogenic miR-17-92/ZBTB4/Sp axis may be a potential therapeutic target.

Effects of stress on female rat sexual function.

This study was undertaken to investigate whether prolonged stress interferes with sexual behavior and changes biochemical and physiologic mechanisms. Experiments were repeated three times with different rats in each period. In all, 63 female Sprague-Dawley rats were employed, with 21 rats in each period, and the control group was maintained at room temperature with free access to food and water. The stress group was maintained under a scheduled stress condition for 10 days, and seven rats from the group were randomly selected and exposed to the control environment for 10 days as the recovery group. Sexual behavior, hormonal values, and neuronal and endothelial nitric oxide synthase (nNOS and eNOS) expressions of vaginal tissue were analyzed and compared. Serum testosterone levels were significantly elevated in the stress and recovery groups (P<0.05). Female rats in the stress group showed reduced receptivity to their male mates (P<0.05). Western blot analysis demonstrated that nNOS and eNOS expressions were significantly lower in the stress group (P<0.05) than in the other groups. We conclude that chronic physical stress modifies the sexual behavior of female rats through a mechanism believed to involve complex changes in sex hormones, endocrine factors, and neurotransmitters.

Effects of estrogen on nitric oxide synthase and histological composition in the rabbit clitoris and vagina.

We investigated the functional and histological changes after oophorectomy in the rabbit clitoris and vagina to determine the mechanism responsible for the development of arousal disorder in postmenopausal women. Twenty mature female New Zealand white rabbits were randomly divided into three groups: control; oophorectomy; and estrogen replacement after oophorectomy. We compared the nitric oxide synthase (NOS) activity and the degree of expression of neuronal (nNOS) and endothelial NOS (eNOS) using biochemical and Western blot analysis in clitoral and vaginal tissues. Histological change of smooth muscle and collagen contents in those tissues were also compared using Masson's trichrome staining. NOS activity and the expression of nNOS and eNOS were significantly increased in the oophorectomized group while there was a decrease to the level of the control group in the estrogen replacement group. Histological examination showed that oophorectomy induced a significant increase in collagen and decrease in muscle content in both clitoris and vagina, while the ratio of smooth muscle content was increased significantly after the estrogen replacement. Our results clearly demonstrate that estrogen deficiency induces compensatory NOS production which may be related to decreases in muscle to collagen ratio in female rabbit genital organs.

Non-Hodgkin's lymphoma & primary biliary cirrhosis with Sjögren's syndrome.

Sjögren's syndrome (SS) is an autoimmune disease characterized by a lymphocytic infiltration of the salivary and lacrimal glands leading to a progressive destruction of these glands due to the production of autoantibodies. This disorder is either isolated (primary SS) or associated with other systemic diseases (secondary SS). The occurrence of B-cell non-Hodgkin's lymphoma (NHL) represents the major complication in the evolution of SS patients. The risk of developing NHL, which is equivalent for both primary and secondary SS, was estimated to be 44 times greater than that observed in a comparable normal population. NHLs in SS patients occur preferentially in the salivary glands and in other mucosa-associated lymphoid tissues (MALT). However, it can also occur in the lymph nodes or bone marrow. We documented a case of low-grade B-cell lymphoma of MALT in the right eyelid and primary biliary cirrhosis (PBC) of a patient with SS. To the best of our knowledge, this is the first case reported in Korea.

Hemodynamic insult by vascular risk factors and pharmacologic erection in men with erectile dysfunction: Doppler sonography study.

To evaluate the penodynamic impact of known vascular risk factors in men with erectile dysfunction, we obtained thorough medical histories covering diabetes, hypertension, heart disease and hypercholesterolemia, alcohol ingestion, and smoking in 265 consecutive patients. We also measured their penile hemodynamic parameters by color duplex ultrasonography after intracavernous prostaglandin E1 injection. In patients with vascular risk factors there was a statistically significant decrease in the peak systolic velocity and increase in the end-diastolic velocity of the cavernosal artery (P < 0.01). Those men who had diabetes had higher average end-diastolic velocities and lower resistance indices (P < 0.01). Smoking and alcohol use also affected penile hemodynamics (P < 0.05). These data confirm that vascular risk factors do increase the likelihood of vasculogenic impotence and that diabetes plays a major role in veno-occlusive dysfunction in the penis.

Is obesity an underlying factor in erectile dysfunction?

OBJECTIVES: We conducted a study to evaluate the impact of obesity on erectile function in men with erectile dysfunction. METHODS: Three hundred and twenty-five consecutive patients with erectile dysfunction were evaluated. We classified the men into 2 groups according to body weight: <120% of the ideal body weight, and >/=120%. We compared several erectile capacities and the findings of penile duplex ultrasonography. RESULTS: There was a statistically significant decrease in the quality of residual erectile function in patients with obesity (penile rigidity grade 1.32 versus 1.62 in the nonobese patients). Obese patients also have an increased prevalence of vascular risk factors based on a review of the medical records and vascular impairment by duplex ultrasound study (43 and 62% in the obese patients versus 30 and 42% in the nonobese patients, respectively, p < 0.05). However, when we focused only on the patients without any vascular risk factors, no significant difference between the 2 groups was noted in the quality of residual erectile function and also the prevalence of penile vascular impairments (p > 0.05). CONCLUSIONS: These data demonstrate that obesity in itself does not seem to be an underlying factor, but does impose a risk to vasculogenic impotence by developing chronic vascular disease.

The impact of aging on penile hemodynamics in normal responders to pharmacological injection: a Doppler sonographic study.

PURPOSE: The change in arterial flow velocity with age in patients with a normal response to pharmacological injection was evaluated. MATERIALS AND METHODS: We studied 64 patients with erectile dysfunction who responded well to intracavernous injection of 10 micrograms. prostaglandin E1 with well sustained penile rigidity for longer than 1 hour and normal cavernous arterial flow velocities on color Doppler ultrasonography. The men were classified into 4 groups according to age younger than 30 years, and 30 to 39, 40 to 49 and 50 years old or older. Flow parameters were compared. RESULTS: The statistically significant decreasing tendency of peak systolic velocity with age was revealed by a simple regression test (p = 0.003). The greatest decrease was observed between patients in the third and fourth decades. When comparing the peak systolic velocity according to timing of measurement, the greatest velocities occurred at later measurements after the fifth decade, while in younger patients these values were reached earlier. CONCLUSIONS: These data demonstrate that cavernous arterial flow during pharmacological erection decreases and the response time of the cavernous artery or tissue to a vasoactive drug becomes longer with age.

Effects of chronic central administration of losartan on the cardiovascular and hormonal responses to hemorrhage in conscious rats.

Our objective was to assess the effects of chronic central angiotensin II (Ang II) blockade on the basal regulation of blood pressure, heart rate (HR), arginine vasopressin (AVP), renin, epinephrine (EPI), norepinephrine (NE) and on cardiovascular and hormonal responses to hemorrhage in conscious rats. Losartan (4 micrograms/h), or artificial cerebrospinal fluid (aCSF), was chronically infused into a lateral ventricle by using an osmotic minipump for 6 days at a rate of 1 microliter/h. Compared with aCSF controls, chronic losartan treatment significantly decreased the basal level of blood pressure (from 117 +/- 2.3 to 106 +/- 2.2 mmHg, P < 0.01) and increased the HR (from 357 +/- 3.7 to 410 +/- 6.6 beats/min, P < 0.01). Plasma renin concentration increased 3-fold (from 6.1 +/- 0.6 to 19.2 +/- 1.6 ng.ml(-1).h(-1), P < 0.01). Basal levels of AVP, EPI and NE were not different between two groups. Blood pressure immediately after hemorrhage and its compensatory recovery following hemorrhage was not different in both groups. Immediately after hemorrhage, however, in the losartan-treated rats, the HR was distinctly lower than that of aCSF controls, even at 10 min after hemorrhage. Hemorrhage produced a significant increase in the plasma concentrations of AVP, renin, EPI and NE. Chronic losartan treatment markedly augmented the AVP, renin and EPI responses to hemorrhage. These results strongly suggest that Ang II acting through AT1 receptors in the brain plays a significant physiological role in the regulation of basal blood pressure, HR and renin release. In addition, centrally acting Ang II may be one of the important mediators for cardiovascular regulations and hormone releases in response to hemorrhage.