Efficacy and safety of anti-CD20 antibody rituximab for patients with refractory systemic lupus erythematosus.

Objective We examined the efficacy and safety of rituximab in patients with refractory systemic lupus erythematosus (SLE). Methods The study enrolled 63 SLE patients who were treated with rituximab between 2002 and 2015. The participants underwent a battery of tests before treatment and at one year. Treatment ranged from two to four times at 500 or 1000 mg. Results Baseline characteristics were males:females = 6:57, age 33.9 years, and disease duration 87.2 months. The primary endpoint: The rate of major clinical response (MCR) was 60% while the partial clinical response (PCR) was 25%. Thirty of 36 (83%) patients with lupus nephritis (WHO II: 2, III: 5, IV: 22, V: 4, IV+V: 2, not assessed: 1) and 22 of 24 patients (92%) with neuropsychiatric SLE, who could be followed at one year, showed changes from BILAG A or B score to C or D score at one year. Multivariate analysis identified high anti-dsDNA antibody and shorter disease duration as significant determinants of MCR at one year. Repeat examination was conducted at five years. Primary failure was recorded in 8.8% and secondary failure in 32.4% (time to relapse: 24.4 months). Rituximab was well tolerated although 65 adverse events, mostly infections, were recorded within one year. Conclusion Rituximab is potentially efficacious for the treatment of patients with refractory SLE.

Outcomes after open surgery and endovascular aneurysm repair for abdominal aortic aneurysm in patients with massive neck atheroma.

OBJECTIVE: We retrospectively analysed surgically treated abdominal aortic aneurysm (AAA) in patients with massive atheroma in the aneurysmal neck and compared the outcomes of endovascular aneurysm repair (EVAR) and open surgery (OS) to determine an appropriate strategy for massive neck atheroma cases. METHODS: A retrospective study was performed in 326 consecutive patients who underwent EVAR and in 247 patients who underwent OS. We defined massive neck atheromas if the following characteristics were observed: (1) thickness ≥ 5 mm; (2) the circumference of the infrarenal aorta ≥ 75%; and (3) length ≥ 5 mm. Twenty-eight patients (8.5%) in the EVAR group and 22 (8.9%) in the OS group met these criteria. We modified the previously published reporting standards on the basis of the selection of systemic and embolisation-related complications. RESULTS: Patients in the EVAR group had less intra-operative blood loss, shorter operation time, and shorter hospital stays after the operation (P < 0.01). No perioperative deaths were observed in either group. Major complications were categorised as early (in-hospital) or late (outpatient, within 6 months). Five and three patients in the OS and EVAR groups had early complications, but the difference was not statistically significant. In contrast, 7 patients in the EVAR group had late complications, compared to no patients in the OS group (P = 0.01). Kaplan-Meier analysis revealed a significantly higher survival rate in the OS group (P = 0.011). Two of the 4 patients with suprarenal clamping developed major complications. Mild eosinophilia was observed in 10 patients in the EVAR group. Proteinuria occurred or worsened in 5 EVAR patients and 1 OS patient. CONCLUSION: Compared to OS patients, EVAR patients with massive neck atheroma tend to develop late-phase complications possibly related to cholesterol crystal embolisation. The clinical features of massive neck atheroma patients receiving EVAR should be carefully monitored even after hospital discharge.

Middle-term results of endovascular aneurysm repair in Japan: does intraoperative endovascular management against the hostile aneurysmal neck prevent the proximal type I endoleak?

AIM: Endovascular aneurysm repair (EVAR) was first approved in Japan in 2007. In order to avoid the learning curve generally seen in the initial stages of implementation, we have aimed for procedural perfection. As the proximal type I endoleak (EL) is associated with a higher risk of late conversion and rupture, so we have treated the intraoperative type I EL scrupulously. The hostile neck, which is known to be a risk for perigraft leakage, is the focus of this study. We showed both the middle-term results of EVAR in our country and the possible necessity of intraoperative management for the hostile neck. METHODS: From a consecutive series of 134 patients who underwent EVAR of abdominal aortic aneurysms, 129 cases in which contrast agent was used intraoperatively were selected. All cases had at least 12-month follow-up postoperatively (12-40 months). Of the 129 selected cases, 49 cases (37%) that did not fulfill the commercially recommended criteria of the aneurysmal neck (length <15 mm and angle >60° of the aneurysm or >45° of the suprarenal aorta) were assigned to the off-label group. The other 80 cases were assigned to the on-label group. We carefully observed the completion angiography and when we found or suspected a type I EL, we performed a re-touch up, changed to a non-compliant balloon, and used a supportive device, such as a PalmazTM stent or aortic cuffs, in sequence. RESULTS: No postoperative type I ELs were detected within the follow-up period. Intraoperative type I ELs were detected more frequently in the off-label group (51%) than the on-label group (20%) (P<0.01). The rate of type I EL in the off-label group in terms of the neck length criteria (11/14 cases) was higher than that in the on-label group (30/115 cases) (P<0.01). In terms of the neck angle, patients in the off-label group had a greater tendency to develop the type I EL than those in the on-label group (18/42 vs. 23/87 cases) (P=0.06). CONCLUSION: Off-label usage regarding aneurysmal neck length and angle tends to be incomplete without additional procedures. Conversely, various techniques, including non-compliant balloon usage and aortic stenting or cuffs, produce good results for the intraoperative type I EL. We found a relationship between the neck condition and the intraoperative type I EL, and showed the importance of strictly obeying our simple algorithm against the proximal type I EL.

Nuclear factor kappa B plays a pivotal role in polyinosinic-polycytidylic acid-induced expression of human ß-defensin 2 in intestinal epithelial cells.

Intestinal epithelial cells (IECs) play an important role in protecting the intestinal surface from invading pathogens by producing effector molecules. IECs are one of the major sources of human beta-defensin 2 (hBD-2), and can produce it in response to a variety of stimuli. Although IECs express Toll-like receptor 3 (TLR-3) and can respond to its ligand, double-stranded RNA (dsRNA), hBD-2 expression in response to dsRNA has not been elucidated. In the present study, using an artificial analogue of dsRNA, polyinosinic-polycytidylic acid (poly I:C), we investigated whether the human IEC line, HT-29, can produce hBD-2 in response to poly I:C. HT-29 cells can express hBD-2 mRNA only when stimulated with poly I:C. The induction of hBD-2 mRNA expression was observed at 3 h after stimulation and peaked at 12 h of post-stimulation. Pre-incubation of the cells with nuclear factor kappa B (NF-κB)-specific inhibitor, l-1-4'-tosylamino-phenylethyl-chloromethyl ketone (TPCK) and isohelenine abolished the expression of hBD-2. Detection of the poly I:C signal by TLR-3 on the surface of HT-29 cells was revealed by pre-incubating the cells with anti-TLR-3 antibody. The 5'-regulatory region of the hBD-2 gene contains two NF-κB binding sites. A luciferase assay revealed the importance of the proximal NF-κB binding site for poly I:C-induced expression of hBD-2. Among NF-κB subunits, p65 and p50 were activated by poly I:C stimulation and accumulated in the nucleus. Activation of the p65 subunit was investigated further by determining its phosphorylation status, which revealed that poly I:C stimulation resulted in prolonged phosphorylation of p65. These results indicate clearly that NF-κB plays an indispensable role in poly I:C induced hBD-2 expression in HT-29 cells.

A retrospective study of intravascular ultrasound use in patients undergoing endovascular aneurysm repair: its usefulness and a description of the procedure.

OBJECTIVES: To verify the usefulness and limitation of intravascular ultrasound (IVUS) in endovascular aneurysm repair (EVAR). METHODS: A total of 112 consecutive patients, who underwent EVAR to treat abdominal aortic aneurysms, were examined retrospectively. Of these, 33 patients were assigned to the IVUS group because of renal failure, a suspected allergy to contrast agents or anatomical difficulties; the remaining 79 patients were assigned to the non-IVUS group. RESULTS: Patients in the IVUS group required fewer intra-arterial contrast agents (IACAs) than those in the non-IVUS group (67±34ml vs. 123±50ml; p<0.01). Blood loss and operation time were comparable between the two groups. No patients died within 30 days of the operation. Three major renal complications occurred in the non-IVUS group. Renal deterioration evaluated by chronic kidney disease (CKD) stage was found to a greater extent in the non-IVUS group. CONCLUSIONS: IVUS is a powerful auxiliary method in EVAR for reducing the required volume of contrast agents. The combination of IVUS and IACA usage showed good overall performance; thus, we propose the routine use of IVUS in EVAR procedures.

Winter lipid depletion of juvenile walleye pollock Theragra chalcogramma in the Doto area, northern Japan.

Seasonal variation in body size and nutritional condition of juvenile walleye pollock Theragra chalcogramma was examined to elucidate the mechanism underlying their first-winter survival on the continental shelf of the Doto area, northern Japan, based on monthly samples collected over 2 years. Stored lipid mass was highest during autumn, but 93% (2004) and 80% (2005) of lipids were exhausted by the onset of winter. Lipid levels in the winter of 2004 remained low (7-14% of the autumnal maximum), and there was reduced growth rate until the spring, whereas in 2005 lipid levels were higher and more variable (10-46% of the maximum) and some growth occurred. An analysis of the allometric relationships between body size and stored energy showed that larger individuals accumulated disproportionately more energy in the autumn, but the advantage disappeared prior to the winter. In January 2004, stored lipid energy was low throughout the Doto continental shelf relative to the continental slope area. These results suggest that winter feeding opportunities on the shelf are severely limited but not completely absent. Previous studies have shown that winter temperatures on the shelf are lower than those in the slope area. It is possible that juvenile T. chalcogramma survive winter on the shelf without a high level of pre-winter lipid storage because the occasional feeding in the cold shelf water benefits energy conservation.

Tumour necrosis factor-alpha-mediated human polymeric immunoglobulin receptor expression is regulated by both mitogen-activated protein kinase and phosphatidylinositol-3-kinase in HT-29 cell line.

Human polymeric immunoglobulin receptor (pIgR) is present on the surface of glandular epithelium, and it plays a crucial role in the mucosal immune defence. pIgR expression in HT-29 cells is up-regulated by one of the proinflammatory cytokines, tumour necrosis factor (TNF)-alpha. However, the mechanism used by the TNF-alpha-mediated signalling pathway has not been examined exclusively. To elucidate this mechanism in detail, HT-29 cells were cotreated with TNF-alpha and mitogen-activated protein kinase kinase (MAPKK, also called MEK1) inhibitor, PD98059, and the amount of free secretory component (SC) secreted into the culture medium was measured. The amount of free SC stimulated by TNF-alpha was increased by addition of PD98059. This up-regulation occurred at the transcriptional level. The amount of SC was also up-regulated by addition of TNF-alpha with U0126, an inhibitor of MEK1 and MEK2. Nuclear factor (NF)-kappaB activity and NF-kappaB binding to the kappaB2 site localized upstream of the pIgR gene did not change after coincubation of HT-29 cells with TNF-alpha and PD98059. The expression level of pIgR by TNF-alpha was decreased by LY294002, an inhibitor of phosphatidylinositol-3-kinase (PI3K), at the transcriptional level. Extracellular signal-regulated kinase (ERK)1/2 phosphorylation and NF-kappaB binding to the kappaB2 site were not affected by LY294002 treatment. These data suggest that TNF-alpha-mediated pIgR expression is negatively regulated by ERK pathway, which is independent of NF-kappaB. In addition, decrease of SC production by Ly294002 suggests that the presence of PI3K mediated regulation of SC production.

Dietary fructooligosaccharides up-regulate immunoglobulin A response and polymeric immunoglobulin receptor expression in intestines of infant mice.

We examined whether or not dietary fructooligosaccharides (FOS) in infancy can have a beneficial effect on the mucosal immune system. Newborn BALB/c mice, accompanied by their dams until 21 days of age, were fed either a control diet based on casein [FOS- diet group] or a FOS- diet supplemented with 5% (w/w) FOS [FOS+ diet group]. Total IgA levels in tissue extracts from the intestines of mice in the FOS+ diet group at 38 days of age were about twofold higher (P < 0.05) than those in the FOS- diet group in the jejunum, ileum and colon. Ileal and colonic polymeric immunoglobulin receptor (pIgR) expression in the FOS+ diet group at 36 days of age was 1.5-fold higher than in the FOS- diet group (P < 0.05). Consistent with these results, the ileal IgA secretion rate of the FOS+ diet group at 37 days of age was twofold higher than that of the FOS- diet group (P < 0.05). Moreover, the percentage of B220(+)IgA+ cells in Peyer's patches (PP) was significantly higher in the FOS+ diet group than in the FOS- diet group (6.2%versus 4.3%, P < 0.05), suggesting that isotype switching from IgM to IgA in PP B cells might be enhanced in vivo. Taken together, our findings suggest that dietary FOS increases the intestinal IgA response and pIgR expression in the small intestine as well as the colon in infant mice.

Deduced primary structure of two forms of vitellogenin in Japanese common goby (Acanthogobius flavimanus).

Complete nucleotide sequences of two forms of vitellogenin (Vg) cDNA in Japanese common goby were determined from a liver cDNA library of E(2)-treated male fish. These two Vg cDNAs contained complete open reading frames encoding 1664 and 1238 amino acid residues including signal peptides, respectively. From comparison of the deduced amino acid sequences of both Vgs and the partial amino acid sequences of the yolk proteins, the longer sequence was concluded to be cDNA of the Vg-530 and the shorter one was that of the Vg-320 of the Japanese common goby which were reported in our previous paper. The deduced sequence of Vg-530 without signal peptide was arranged by lipovitellin heavy-chain (LvH), phosvitin (Pv), lipovitellin light-chain (LvL), and beta'-component beta'-c) domains from the N-terminus, and showed a range of 40-45% sequence identity to those of other fish. Furthermore, the deduced sequence of Vg-320 showed no obvious Pv domain, has a shortened C-terminal coding region after the LvH domain, and showed a close similarity to the phosvitin-less Vg of zebrafish. Moreover, biochemical analysis of the yolk proteins verified that Vg-530 cleaves into the Lv-Pv complex (molecular mass: 470 kDa) and beta'-c (33 kDa), while Vg-320 showed no change when incorporated into oocytes. The present study demonstrated the existence of the two different forms of Vgs at both the cDNA and protein level, and showed molecular alteration of the two Vgs during vitellogenesis. Two Vg sequence data will aid in designing nucleotide probes for detecting Vg gene expressions as a biomarker of environmental estrogens.

Retinoic acid enhances the gene expression of human polymeric immunoglobulin receptor (pIgR) by TNF-alpha.

In this study, the detailed mechanisms for the effects of vitamin A on the expression of polymeric immunoglobulin receptor (pIgR) were examined. Expression of the pIgR by tumour necrosis factor (TNF-alpha) was enhanced by the addition of all-trans retinoic acid (ATRA) or 9-cis retinoic acid (9CRA). This enhancement was mediated mainly by RARalpha, and regulated at the transcriptional level. Transcription factor nuclear factor-kappaB (NF-kappaB) binding and activation were not influenced by addition of ATRA. These data imply that RA, in combination with TNF-alpha, could up-regulate the expression of pIgR. In addition, we hypothesize that up-regulation of pIgR by RA is controlled through the RAR-dependent signalling pathway and that it plays a role in enhancement of mucosal immunity.

Release of non-glycosylated polymeric immunoglobulin receptor protein.

Using a recombinant vaccinia virus containing the T7 RNA polymerase, we have established a system for the transient expression of human polymeric immunoglobulin receptor (pIgR) in baby hamster kidney cells, a baby hamster-derived fibroblastic cell line. This transfection system resulted in the successful expression of pIgR in these cells, and Western blot analysis showed that human pIgR was expressed as two different molecular weight forms of 92 and 107 kDa. Treatment with endoglycosidase H showed that the difference between these two forms was due to the glycosylation status of the protein. In order to examine the functional role of glycosylation, we treated the transfected cells with tunicamycin, which prevents a core glycosylation step in the endoplasmic reticulum. Non-glycosylated pIgR was released into the culture medium of the transfected cells, albeit with extremely low efficiency. Taking these results together, we conclude that the glycosylation of pIgR may play a positive role in the efficient transport or release of free pIgR.

Serial change in the atrial transport function after the radial incision approach.

BACKGROUND: The left atrial transport function recovers slowly over several months after the maze procedure (Maze), but remains at a low level even during the long-term postoperative period. Because the Maze leaves an insufficient left atrial transport function, patients may still be prone to thromboembolism after the Maze. The radial incision approach (Radial) has been shown to preserve greater atrial transport function than does the Maze in the early postoperative period. METHODS: To examine the serial change in the atrial transport function after the Radial, out of 32 patients who underwent the Radial, 15 patients were assessed by transthoracic Doppler echocardiography 1, 3, 6, and 12 months after surgery. The atrial filling fraction and peak A/E velocity ratio were determined from the flow-velocity spectra across the mitral and tricuspid valves. The incidence of thromboembolic events was examined in 21 patients who were followed for more than 3 months after the Radial. The data were compared with data obtained from 13 patients after (41 +/- 6 months) the Maze III procedure. RESULTS: The left atrial transport function after the Radial increased within 3 months to a significantly greater level than did that after the Maze in the longterm. The atrial filling fraction was 28.2% +/- 7.9% at 3 months after the Radial and 15.1% +/- 4.0% at 41 months after the Maze (p < 0.01). The peak A/E ratio was 0.52 +/- 0.18 at 3 months after the Radial and 0.25 +/- 0.07 at 41 months after the Maze (p < 0.01). This increased atrial transport function was maintained for an extended period after the Radial. There were no thromboembolic events in any of the patients after the Radial or Maze, irrespective of postoperative anticoagulant therapy. CONCLUSIONS: The Radial approach prevents thromboembolism by restoring sufficient atrial transport function more effectively and faster than does the Maze.

Apolipoprotein E4 stimulates cAMP response element-binding protein transcriptional activity through the extracellular signal-regulated kinase pathway.

Inheritance of the epsilon4 allele of the apolipoprotein E gene (APOE4) is a major risk factor for the development of Alzheimer's disease (AD). Although the association between APOE4 and AD is well documented, the mechanism by which apolipoprotein E exerts an isoform-specific effect on neurons in disease is unknown. In this report, we demonstrate that apoE4 stimulates the transcriptional activity of cAMP-response element-binding protein (CREB) by activating the extracellular signal-regulated kinase (ERK) cascade in rat primary hippocampal neurons. In contrast, apoE3 was unable to stimulate CREB transcriptional activity and unable to activate the ERK pathway. Elevation of intracellular Ca(2+) levels are also involved because treatment with receptor-associated protein, nifedipine, MK801, removal of Ca(2+) from the medium and dantrolene all served to inhibit calcium elevation and attenuate the activation of CREB. Treatment with an apoE peptide was also found to facilitate transcription of the CREB-dependent genes, c-fos and Bcl-2. In contrast to treatment with apoE3, our findings suggest apoE4 and apoE-peptide induce a novel signaling pathway.

Activated cAMP-response element-binding protein regulates neuronal expression of presenilin-1.

Upon binding to the cAMP-response element of a gene's promoter, the transcription factor known as cAMP-response element-binding protein (CREB) facilitates transcription of many different neuronal genes including those involved with synaptic function. Based on our previous reports of gene structure (GenBank accession number AF029701 ), we now demonstrate that activated CREB binds to the proximal promoter of the human presenilin-1 (PS-1) gene to activate PS-1 transcription in rat and in human neuronal cells. Specific stimulation of the N-methyl-d-aspartate subtype of neuronal glutamate receptors activates CREB and results in increased PS-1 expression. Similarly, treatment with brain-derived neurotrophic factor activates CREB and increases PS-1 expression in a dose-dependent fashion. By using adenovirus vectors expressing dominant negative forms of CREB, we were able to show that induction of PS-1 expression requires the activation of CREB. Conversely, constitutive expression of mitogen-activated protein kinase/extracellular signal-regulated kinase (MEK) results in activation of CREB and increased PS-1 expression that can be blocked by the addition of selective MEK inhibitors. Our findings suggest a hypothesis where stimulation of N-methyl-d-aspartate receptors signals CREB activation to enhance PS-1 gene product expression that contributes to normal neuronal functions.

Is median sternotomy invasive? A comparison between minimally invasive direct coronary artery bypass and off-pump bypass.

Although minimally invasive direct coronary artery bypass (MIDCAB) eliminates the need for median sternotomy and cardiopulmonary bypass, its indications are limited. Conversely, coronary artery bypass without cardiopulmonary bypass (off-pump bypass) enables complete surgical revascularization under an optimal surgical field established by median sternotomy, even if patients have multivessel disease. The present study was designed to determine the invasiveness of median sternotomy by comparing 11 patients who underwent MIDCAB and 5 who underwent off-pump bypass between May 1997 and April 1998. There were no significant differences between the MIDCAB group and the off-pump group in age, being 57 +/- 11 vs 66 +/- 8 years old, the operative time, being 321 +/- 149 vs 441 +/- 205 min, the number of grafts, being 1.0 vs 1.4/patient, peak creatine kinase (CK) values, being 662 +/- 436 vs 609 +/- 56 IU/l, the peak CK-muscle-brain values, being 12 +/- 9 vs 16 +/- 5 IU/l, and the postoperative blood loss, being 369 +/- 198 vs 541 +/- 204 ml. Although there was no significant difference in peak C-reactive protein, at 17 +/- 5 vs 20 +/- 2 mg/dl, the periods declining within the normal ranges were shorter in the MIDCAB group than in the off-pump group, at 7 +/- 1 vs 15 +/- 2 days (P > 0.01). The hospital stay was almost the same in both groups, at 16 +/- 8 vs 26 +/- 14 days. These findings suggest that off-pump bypass is more invasive than MIDCAB, which may be attributed to the median sternotomy.

Importance of preoperative marking for minithoracotomy and for internal thoracic artery harvesting in minimally invasive direct coronary artery bypass grafting.

Minimally invasive direct coronary artery bypass has the potential to cause an anastomotic failure because of a limited exposure of the operative field and the difficulty of internal thoracic artery harvesting. In the present study, the importance of preoperative marking for an accurate minithoracotomy location and a successful internal thoracic artery harvest was assessed. A paperclip was placed on the left nipple and a chest X-ray was performed in the supine position. By aligning the position of the paperclip to the location of the left anterior descending coronary artery from a coronary arteriogram frontal view, the intercostal space for the minithoracotomy was thus determined. Marking the incisional intercostal space during preoperative left internal thoracic arteriography revealed the number and location of the internal thoracic artery branches at the beginning of the harvest. This preoperative marking technique allowed for a more adequate exposure of the operative field and an easier internal thoracic artery harvest which therefore contributed to an improvement in the operative results.

Role of nuclear factor-kappaB in the expression by tumor necrosis factor-alpha of the human polymeric immunoglobulin receptor (plgR) gene.

We analyzed the mechanism of human polymeric immunoglobulin receptor (pIgR) gene upregulation by tumor necrosis factor (TNF)-alpha. Northern blot analysis showed that the expression of pIgR mRNA was enhanced by TNF-alpha stimulation. This activation was completely inhibited by RNA polymerase or protein synthesis inhibitors, suggesting that the regulation of pIgR gene expression depends on de novo RNA and protein synthesis. Furthermore, the stimulation of pIgR mRNA by TNF-alpha was decreased by pyrrolidinedithiocarbamate and L-1-4'-tosylamino-phenylethyl-chloromethyl ketone, which are known nuclear factor (NF)-kappaB inhibitors. For further analysis of gene regulation, we cloned and sequenced the 1.5-kb 5'-flanking region of the pIgR gene. In the upstream region, we found two NF-kappaB-binding motifs (named kappaB1 and kappaB2 from the 5' region). An electrophoretic mobility shift assay indicated that two components of the NF-kappaB/Re1 family, p50 and p65, bound with higher affinity to the KB2 element than to the kappaB1 element. We also analyzed plgR gene expression using reporter plasmids expressing the firefly luciferase gene. Stimulation by TNF-alpha significantly activated the pIgR gene promoter, as a 775-bp upstream region of the pIgR gene increased luciferase gene expression in cells treated with TNF-alpha. The activation of promoter activity by TNF-alpha was abolished when a mutation was inserted into kappaB1 or kappaB2. These data indicated that pIgR gene expression induced by TNF-alpha is transcriptionally regulated via activation of NF-kappaB. In addition, there is a possibility that another factor may act in concert with NF-kappaB.

Spontaneous closure of a large tracheal fistula due to descending necrotizing mediastinitis.

We present a case of a 77-year-old man who had a large tracheal fistula due to descending necrotizing mediastinitis. He underwent long-term care with a respirator after mediastinal drainage operations. The fistula was covered spontaneously with the anterior wall of the esophagus 1.5 months postoperatively.