Early-life adversity, epigenetics, and visceral hypersensitivity.

Abdominal pain is associated with many gastrointestinal dysfunctions, such as irritable bowel syndrome (IBS), functional dyspepsia, and inflammatory bowel disease (IBD). Visceral hypersensitivity is a key reason for development of abdominal pain that presents in these gastrointestinal disorders/diseases. The pathogenesis of visceral hypersensitivity is complex and still far from being fully understood. In animal studies, visceral hypersensitivity has been linked to several early-life adverse (ELA) events. In humans, IBD, functional dyspepsia, and IBS can have adult onset, though the adverse events that lead to visceral hypersensitivity are largely uncharacterized. In this issue of the journal, Aguirre et al. report the interesting finding that epigenetics underlies the effects of ELA events on visceral hypersensitivity. This mini-review examines models of ELA events leading to visceral hypersensitivity and the potential role of epigenetics, as reported by Aguirre et al. and others.

Predictors of the response to treatment in acute lupus hemophagocytic syndrome.

OBJECTIVE: The objective of this paper is to identify predictors for the response to treatment of acute lupus hemophagocytic syndrome (ALHS). METHODS: We reviewed seven cases with ALHS admitted to our hospital and published ALHS cases identified in the 2001-2014 Medline database, and then conducted univariate and multivariate analyses to identify predictors for the response to treatment. RESULTS: Review of our cases showed a significant and negative correlation between serum ferritin and anti-DNA antibody (p = 0.0025). All three patients treated with cyclosporine A (CsA) were considered responders despite high serum ferritin and corticosteroid resistance. We also reviewed 93 patients with ALHS identified in 46 articles. Multiple logistic regression analysis identified C-reactive protein (CRP) (OR 0.83, p = 0.042) and hemoglobin (OR 1.53, p = 0.026) measured at diagnosis of ALHS as significant predictors of the response to corticosteroid monotherapy. Moreover, among 32 patients treated with CsA, serum ferritin was significantly higher in CsA responders (12163 ± 16864 µg/l, n = 22) than in non-responders (3456 ± 6267/µg/l, p = 0.020, n = 10). Leukocyte count was significantly lower in the CsA responders (1940.0 ± 972.3/µl) than in the non-responders (3253 ± 2198/µl, p = 0.034). CONCLUSION: Low CRP and high hemoglobin can predict a positive response to corticosteroid monotherapy while high serum ferritin and low leukocyte count can predict a positive response to CsA in patients with ALHS and therefore, when corticosteroid monotherapy is not effective in such cases, CsA could be the first choice of an additional immunosuppressive agent.

A survival case of severe liver failure caused by acetylsalicylic acid that was treated with living donor liver transplantation.

BACKGROUND: Severe liver dysfunction caused by acetylsalicylic acid (ASA) is quite rare. The purpose is to describe a patient with severe liver dysfunction due to excessive intake of ASA in a suicide attempt, who was successfully treated with living donor liver transplantation (LDLT). DESCRIPTION OF CASE: We report a 20-year-old woman who took 66 g of ASA in a suicide attempt. She was admitted to our hospital and received forced alkaline diuresis. However, her liver and renal functions worsened after admission. On the 6th day after intake of ASA, she was transferred to the intensive care unit, and plasma exchange (PE) and continuous hemodiafiltration were performed. Since her liver function did not recover despite repeated PE, she was transferred to another hospital for LDLT on the 8th day. She underwent LDLT with a portion of the liver donated from her mother on the 11(th) day. After the operation, her renal dysfunction continued. Her renal parameters gradually improved, and she was discharged on the 44th post-operative day without renal dysfunction. CONCLUSION: PE is effective in removing ASA from blood. Liver transplantation is the only effective treatment if liver function does not recover in spite of repeated PE.

Septic shock caused by Klebsiella oxytoca: An autopsy case and a survival case with driving Extracorporeal Membrane Oxygenation.

We report two cases of Klebsiella oxytoca bacteremia. Case 1 was a 56-year-old man who was transferred to our hospital by ambulance due to diarrhea and general fatigue. On arrival, he was clearly conscious. However he was in septic shock. We injected broad spectrum antibacterial agents and started intensive care. Though intensive care included continuous hemodiafiltration (CHDF), he died 22 hours after admission. Case 2 was a 69-year-old man with a history of gastrectomy for gastric cancer. He had been admitted to a previous hospital due to ileus. His ileus tube was removed on the eighth day, and he then developed a fever of 38 ºC on the following day. He went into shock and became unconscious; he was therefore transferred to our hospital. We diagnosed septic shock and disseminated intravascular coagulation (DIC). We injected broad spectrum antibacterial agents, and recombinant thrombomodulin alpha (rTM). Although he was started in intensive care, his hemodynamics were unstable on the day following admission. Extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pumping (IABP) were started to maintain his hemodynamics. His condition gradually improved, and he was transferred to the previous hospital for rehabilitation on the 28(th) day. ECMO for septic shock in adults is unusual; however ECMO can be introduced even in patients with severe sepsis under careful monitoring. The new anti-DIC agent rTM is useful for safe driving of ECMO in patients with DIC.

Enhanced Needle Visualization: advantages and indications of an ultrasound software package.

The ultrasound software package Enhanced Needle Visualization (ENV) has been reported to provide improved ultrasound imaging of needles even at steep insertion angles. ENV has three settings: shallow, medium and steep. However, the angles are unknown. We examined the advantages and indications of ENV in an in vitro study. A 22-gauge needle was inserted into pork meat using the in-plane technique. The needle was positioned at zero, 30, 45 and 60 degree angles, and 1, 2, 3 and 4 cm in-depth from the probe. The ultrasound visibility in each ENV setting was objectively evaluated and graded as 'not visible', 'poor', 'visible', 'good' and 'excellent' in ascending order. At zero degrees we found no advantage of ENV. At 30 degrees, the needle exhibited better visibility with 'good' or above grade in the shallow setting at all depths and in the medium setting at depths of 1, 2 and 3 cm than in the off position. At 45 degrees, needle visibility significantly increased from 'not visible' in the off position to 'visible' or above in the steep settings at depths of 1, 2 and 3 cm. At 60 degrees the objective visibility was 'not visible' in the off position and significantly increased to 'poor' in the steep setting. We recommend selecting the shallow setting for needles with an insertion angle of 30 degrees and the steep setting for 45 degrees within the advantageous area. This technique may allow safer ultrasound procedures for various unprecedented approaches.

Activation of JNK and high expression level of CD133 predict a poor response to sorafenib in hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) ranks as the third leading cause of cancer deaths worldwide. While sorafenib, a multikinase inhibitor targeting the Raf/extracellular signal-regulated protein kinase (ERK) pathway, has been shown recently to provide a survival advantage to patients with advanced HCC, a predictive biomarker has not been developed. We studied whether c-Jun N-terminal kinase (JNK), which promotes liver carcinogenesis in mice, affects therapeutic response to sorafenib in HCC patients. METHODS: We collected pathological specimens from 39 patients with advanced HCC before starting sorafenib treatment, and measured JNK activity in HCCs. RESULTS: In patients treated with sorafenib, the expression of phospho-c-Jun in HCC, as a read out of JNK activity, was significantly higher (P<0.001) in the non-responder group than in the responder group. c-Jun N-terminal kinase activation in HCC was associated with a decreased time to progression and a poor overall survival (P=0.0028 and P=0.0008, respectively). CONCLUSION: In addition, JNK activity was significantly correlated with CD133 expression level. Correspondingly, high expression level of CD133 was linked to a poor response to sorafenib. Furthermore, D-JNKi, a specific JNK inhibitor, reduced the growth of xenografted CD133(+) cells in athymic mice. In conclusion, JNK activation was positively correlated with CD133 expression level and inversely correlated with the therapeutic response to sorafenib, suggesting that JNK activity may be considered as a new predictive biomarker for response to sorafenib treatment.

Heat shock protein 47 (HSP47) antisense oligonucleotides reduce cardiac remodeling and improve cardiac function in a rat model of myocardial infarction.

BACKGROUND: Cardiac remodeling after acute myocardial infarction is regulated by components of the extracellular matrix. The 47 kD heat shock protein 47 (HSP47) is a collagen-specific molecular chaperone that plays a major role during procollagen processing and/or secretion. OBJECTIVE: The purpose of the study was to determine whether HSP47 inhibition can mitigate ligated left anterior descending (LAD) coronary artery-induced myocardial infarction in rats. METHODS: Rats were randomly divided into four experimental groups and subjected to the following treatments: 1) intravenous (IV) administration of saline; 2) ligation of the LAD coronary artery; 3) ligation of the LAD coronary artery + IV administration of HSP47 antisense oligonucleotides; or 4) IV administration of HSP47 antisense oligonucleotides. We investigated cardiac histopathology, performed immunoblot and immunohistochemical analyses, and examined cardiac function. RESULTS: Rats with ligated LAD coronary artery experienced upregulation of HSP47 expression, remodeling of the left ventricle, and cardiac dysfunction. In contrast, rats with ligated LAD coronary artery treated with HSP47 antisense oligonucleotides had significantly reduced HSP47 expression, cardiac remodeling, and improved cardiac function. Intravenous (IV) administration of HSP47 antisense oligonucleotides alone had no effect on cardiac morphology. CONCLUSION: The data strongly support the idea that changes in the extracellular matrix and its components are important determinants of cardiac remodeling after myocardial infarction.

Processing of CD109 by furin and its role in the regulation of TGF-beta signaling.

CD109 is a glycosylphosphatidylinositol (GPI)-anchored glycoprotein, whose expression is upregulated in squamous cell carcinomas of the lung, esophagus, uterus and oral cavity. CD109 negatively regulates transforming growth factor (TGF)-beta signaling in keratinocytes by directly modulating receptor activity. In this study, we further characterized CD109 regulation of TGF-beta signaling and cell proliferation. We found that CD109 is produced as a 205 kDa glycoprotein, which is then processed in the Golgi apparatus into 180 kDa and 25 kDa proteins by furin (furinase). 180 kDa CD109 associated with GPI-anchored 25 kDa CD109 on the cell surface and was also secreted into the culture medium. To investigate whether furinase cleavage of CD109 is necessary for its biological activity, we mutated arginine 1273 in the CD109 furinase cleavage motif (amino acid 1270-RRRR-1273) to serine (R1273S). Interestingly, CD109 R1273S neither significantly impaired TGF-beta signaling nor affected TGF-beta-mediated suppression of cell growth, although it was expressed on the cell surface as a 205 kDa protein. Consistent with this finding, the 180 kDa and 25 kDa CD109 complex, but not CD109 R1273S, associated with the type I TGF-beta receptor. These findings indicate that processing of CD109 into 180 kDa and 25 kDa proteins by furin, followed by complex formation with the type I TGF-beta receptor is required for the regulation of TGF-beta signaling in cancer cells and keratinocytes.

Evaluation of out-in skin transparency using a colorimeter and food dye in patients with atopic dermatitis.

BACKGROUND: Atopic dermatitis is a disease of skin barrier dysfunction and outside stimuli can cross the skin barrier. OBJECTIVES: To examine a new method for evaluating the outside to inside skin transparency with a colorimeter and yellow dyes. METHODS: In study 1, a total of 28 volunteer subjects (24 normal and four with atopic dermatitis) participated. After provocation with yellow dye, the skin colour of all the subjects was measured using a colorimeter. The skin transparency index was calculated by the changes of the skin colour to yellow. Other variables of skin function, including transepidermal water loss (TEWL) and stratum corneum hydration, were also measured. In study 2, the skin transparency index was evaluated for a cohort of 38 patients with atopic dermatitis, 27 subjects with dry skin and 29 healthy controls. RESULTS: In study 1, the measurement of skin colour (b*) using tartrazine showed good results. There was a significant relationship between the skin transparency index with tartrazine and the atopic dermatitis score (P = 0.014). No other measurements of skin function, including the TEWL, were correlated. In study 2, the skin transparency index score obtained with tartrazine in the patients with atopic dermatitis was significantly higher than that of the controls and those with dry skin (P < 0.001 and P = 0.022, respectively). However, the TEWL in patients with atopic dermatitis was not significantly higher than that of patients with dry skin and the TEWL in subjects with dry skin was not higher than that of the controls. CONCLUSIONS: This method, which used a colorimeter and food dye, is noninvasive, safe and reliable for the evaluation of out-in skin transparency and can demonstrate the characteristic dysfunction in the skin barrier in patients with atopic dermatitis.

Neutrophil elastase inhibitor (sivelestat) reduces the levels of inflammatory mediators by inhibiting NF-kB.

OBJECTIVE: Sivelestat sodium hydrate (sivelestat) is a specific synthetic inhibitor of neutrophil elastase (NE). Various studies suggest that sivelestat treatment reduces inflammation. In this study, we tested the hypothesis that sivelestat acts as an inhibitor of inflammatory mediators and prevents nuclear factor-kB (NF-kB) activation. METHODS: In the presence and absence of sivelestat, the mouse macrophage cell line RAW 264.7 was stimulated with lipopolysaccharide (LPS) and the levels of inflammatory mediators (TNF-alpha, IL-6 and high mobility group box 1 (HMGB1)) and nitrite in the cell supernatant were measured, along with inducible nitric oxide synthase (iNOS) expression. RESULTS: While LPS administration increased the secretion of inflammatory mediators and nitric oxide (NO), sivelestat decreased the secretion of these mediators. Cell signaling studies demonstrated that sivelestat decreased NF-kB activation by inhibiting IkB phosphorylation. CONCLUSION: Sivelestat may inhibit the various inflammatory mediators through NF-kB inhibition.

Evaluation of the therapeutic results of epiduroscopic adhesiolysis for failed back surgery syndrome.

BACKGROUND: No data for patients with failed back surgery syndrome (FBSS) based on the location of adhesions separated by epiduroscopic adhesiolysis have been reported. METHODS: We performed epiduroscopic adhesiolysis on 28 FBSS patients to examine the impact of differences in the locations of the separated regions on the treatment results. We performed fluoroscopic imaging through the sacral hiatus to assess the condition of adhesions in the epidural space during the post-adhesiolysis observation period. RESULTS: In patients in whom only the epidural space was separated by adhesiolysis, there was a significant improvement in the Roland-Morris disability questionnaire (RDQ) score until 12 weeks after adhesiolysis, but the score gradually returned to the preoperative value thereafter. Among patients in whom the nerve root responsible for radicular pain was separated, there was a long-term improvement in the RDQ, Oswestry disability index 2.0 (ODI), and Japanese Orthopedic Association Assessment of Treatment (JOA) scores. Among patients in whom both the epidural space and the nerve root responsible for pain were separated, there was a 12 week improvement in the RDQ score and 24 week improvements in the ODI and JOA scores. CONCLUSIONS: Progressive epidural imaging after adhesiolysis suggested that pain was caused by re-adhesion around the nerve root. Since re-adhesion of the nerve root required some time, the effect of adhesiolysis was maintained for extended periods in these cases. We suggest that epiduroscopic adhesiolysis is an effective therapy for FBSS patients, and that adhesiolysis of the nerve root may exhibit the long-term (24 weeks) efficacy in patients with pain.

Follow-up of Large Aneurysms Treated with Coil Embolization at an Acute Stage in Patients with Poor-Grade Subarachnoid Hemorrhage.

SUMMARY: This study evaluated the clinical and angiographic outcome of large aneurysms treated with coil embolization at an acute stage in patients with poor-grade subarachnoid hemorrhage (SAH). Between July 1, 2001 and June 30, 2004, eight consecutive WFNS grade 5 patients with large aneurysms (15~23 mm) were treated with endovascular coil embolization within two days and followed for at least 30 months. There were three middle cerebral and five internal carotid artery aneurysms. No patients were treated by craniotomy and none survived without treatment. Two patients died of primary brain damage or cerebral vasospasm within one month. One patient died of pneumonia at 24 months. Four patients were alive with good recovery or moderate disability at the time of final follow-up (30~66 months). Angiography immediately after the procedure showed complete occlusion in three, neck remnant in four, and body filling in one patient. No complication was seen related to the procedure. Three aneurysms that were initially neck remnant developed body filling due to coil compaction. Two were re-treated with coils at six and 12 months and resulted in neck remnant. One patient refused re-treatment and died of re-bleeding. Endovascular coil embolization can be selected at an acute stage for the treatment of aneurysms in patients with poor-grade SAH without intraparenchymal hematoma even if the aneur-ysm is large. Serial follow up by MRA/angiography is necessary for at least 12 months.

Comparison of effects of total enteral versus total parenteral nutrition on ischemia/reperfusion-induced heart injury in rats.

BACKGROUND: The long-term effect of nutrition on cardiac function remains to be elucidated. One possible link is the newly discovered gastric hormone ghrelin, which has been reported to be cardioprotective. AIM: The present study examined whether total enteral nutrition (TEN) and total parenteral nutrition (TPN) differ in their modulation of ghrelin production and their effects on cardiac function after ischemia/reperfusion injury. METHODS: Rats received isocaloric parenteral or enteral nutrition through implanted vascular catheters or gastrostomy tubes. TEN was administered in a conventional (TEN-C) or immunonutrition (TEN-I) form. After 7 days, serum ghrelin levels were determined by enzyme-linked immunosorbent assays and myocardial function was assessed using the Langendorff isolated heart technique. RESULTS: TEN-I animals had significantly higher plasma ghrelin levels than the other groups. After ischemia/reperfusion injury, left ventricular developed pressure decreased in animals receiving TPN when compared to animals receiving TEN-I. Animals receiving TPN also had significant reductions in their maximal rates of increase and decrease in left ventricular pressure when compared to animals receiving TEN-I (unpaired t test, p < 0.05). CONCLUSION: TEN-I increases serum levels of ghrelin, which protects cardiac function after ischemic/reperfusion injury. Because TEN-I more effectively protects cardiac function, we recommend it for long-term nutritional support.

Combination therapy with PEG-IFN-alpha and 5-FU inhibits HepG2 tumour cell growth in nude mice by apoptosis of p53.

When the tumour suppressor p53 is activated by DNA damage, it stimulates the transcription of its target genes, which then induce cell cycle arrest or apoptosis. Here, we examined the role p53 plays in the antitumour effect of combination treatment with pegylated interferon (PEG-IFN)-alpha and 5-fluorouracil (5-FU), which has been shown to effectively treat advanced hepatocellular carcinoma (HCC). Nude mice were injected subcutaneously with cultured HepG2 cells, in which p53 is functional. They were treated a week later with PEG-IFN and/or 5-FU for 7 weeks, after which we measured and examined their tumours. Combination groups showed significantly lower tumour volumes and higher tumour cell apoptosis than the other groups. Combination treatment and PEG-IFN monotherapy also significantly elevated the p53 protein and mRNA levels in the tumour but only combination treatment increased the degree of p53 phosphorylation at serine46 and induced p53-regulated apoptosis-inducing protein 1 (p53AIP1) expression. The antitumour effects of combination treatment is due in part to the elevation by PEG-IFN of p53 protein and mRNA expression and in part to the DNA damage that is generated by 5-FU, which induces p53 serine46 phosphorylation, which in turn upregulates p53AIP1 expression.

Changes in cell culture temperature alter release of inflammatory mediators in murine macrophagic RAW264.7 cells.

OBJECTIVES: To examine whether moderate changes in cell culture temperature influence the production of various cytokines and associated mediators of inflammation. METHODS: We performed lipopolysaccharide (LPS) stimulation of the murine macrophagic RAW264.7 cell line under hyperthermic (40 degrees C), normothermic (37 degrees C) and hypothermic (34 degrees C) conditions. We then measured the levels of heat shock protein 70 (HSP70), heat shock factor protein (HSF) and nuclear factor-kB (NF-kB) dimers (p50 and p65) in the cells, and the levels of high mobility group box 1 (HMGB1) and the cytokines tumor necrosis factor-alpha (TNF-alpha), interleukin 1beta (IL-1beta) and interleukin 6 (IL-6) in the culture supernatants. RESULTS: Levels of HMGB1, IL-1beta, IL-6, and TNF-alpha, as well as NF-kB dimers (p50 and p65), were all reduced following LPS stimulation at 40 degrees C and 34 degrees C compared with those at 37 degrees C. Levels of HSP70 and HSF increased at 40 degrees C and 34 degrees C. CONCLUSIONS: The application of moderate hyperthermia and hypothermia after LPS-induced cell activation attenuated the inflammatory response and reduced the likelihood of cell damage. These findings suggest that moderate temperature changes modulate the inflammatory response and could be a useful therapy against sepsis.

Short-term complications of retrograde transvenous obliteration of gastric varices in patients with portal hypertension: effects of obliteration of major portosystemic shunts.

The type, incidence, and severity of complications of balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices should be precisely estimated. Complications were evaluated in 38 patients who had fundic gastric varices and 43 B-RTO procedures during injection of ethanolamine oleate (phase 1), within 4 h after injection (phase 2), 24 h after injection (phase 3), and from 24 h to 10 days after injection (phase 4). Endoscopic evaluation at 8 weeks showed resolution of gastric varices in 35 of 38 patients (92%) and smaller varices in the remaining three (8%). B-RTO caused transient hypertension in 35% of patients, hemoglobinuria in 49%, and fever in 33% during phases 1, 2, and 3, respectively. Pleural effusion, pulmonary infarction, ascites, gastric ulcers with unique appearance, localized mosaic-like change of gastric mucosa, and hemorrhagic portal hypertensive gastropathy were noted in phase 4. There were no fatalities. Lactate dehydrogenase, aspartate aminotransferase, and bilirubin increased on day 1. Each datum was retrieved within 7 days. The severity of lactate dehydrogenase elevation correlated significantly with the volume of infused ethanolamine oleate. Thus, B-RTO is a safe and effective management of fundic varices. However, short-term hemodynamic change after B-RTO may cause gastric mucosal damage. Pulmonary infarction and pleural effusion are potential complications.