Minimum standards of clinical practice for physical therapists working in intensive care units in Japan.

OBJECTIVE: Early mobilization and rehabilitation has become common and expectations for physical therapists working in intensive care units have increased in Japan. The objective of this study was to establish consensus-based minimum clinical practice standards for physical therapists working in intensive care units in Japan. It also aimed to make an international comparison of minimum clinical practice standards in this area. METHODS: In total, 54 experienced physical therapists gave informed consent and participated in this study. A modified Delphi method with questionnaires was used over three rounds. Participants rated 272 items as "essential/unknown/non-essential". Consensus was considered to be reached on items that over 70% of physical therapists rated as "essential" to clinical practice in the intensive care unit. RESULTS: Of the 272 items in the first round, 188 were deemed essential. In round 2, 11 of the 62 items that failed to reach consensus in round 1 were additionally deemed essential. No item was added to the "essential" consensus in round 3. In total, 199 items were therefore deemed essential as a minimum standard of clinical practice. Participants agreed that 42 items were not essential and failed to reach agreement on 31 others. Identified 199 items were different from those in the UK and Australia due to national laws, cultural and historical backgrounds. CONCLUSIONS: This is the first study to develop a consensus-based minimum clinical practice standard for physical therapists working in intensive care units in Japan.

Impact of a Rehabilitation Protocol and a Dedicated Therapist in the Intensive Care Unit on Physical Function and Activities of Daily Living.

OBJECTIVES: The goal of this study was to determine the effects of an intensive care unit (ICU) rehabilitation protocol with dedicated therapists on the physical function and activities of daily living (ADL) of patients on discharge from the ICU. METHODS: This retrospective study included patients who started rehabilitation during their ICU stay. Patients were divided into three groups: the Usual Care group (before the introduction of the rehabilitation protocol), the Protocol group (after the introduction of the rehabilitation protocol), and the PT + Protocol group (with a dedicated therapist in addition to the rehabilitation protocol). The standard interventions in the Protocol group and the PT + Protocol group were set according to the protocol based on the level of consciousness and strength of each individual patient. Patients' age, APACHE II score, length of ICU stay, length of hospital stay, and the Functional Status Score for the ICU (FSS-ICU) and Medical Research Council score (MRC score) on discharge from the ICU were compared among the three groups. RESULTS: There were no significant differences among the three groups in age and APACHE II score. The MRC and FSS-ICU scores were significantly higher in the PT + Protocol and Protocol groups than in the Usual Care group. Furthermore, the lengths of ICU stay and hospital stay were lower in the PT + Protocol group than in the Usual Care group. CONCLUSIONS: Introduction of the rehabilitation protocol improved the limb strength and ADL of patients. Moreover, the presence of dedicated therapists in addition to the protocol reduced the lengths of ICU and hospital stays.

Glycomics of a novel type-2 N-acetyllactosamine-specific lectin purified from the feather star, Oxycomanthus japonicus (Pelmatozoa: Crinoidea).

A lectin - designated OXYL for the purposes of this study that strongly recognizes complex-type oligosaccharides of serum glycoproteins - was purified from a crinoid, the feather star Oxycomanthus japonicus, the most basal group among extant echinoderms. OXYL was purified through a combination of anion-exchange and affinity chromatography using Q-sepharose and fetuin-sepharose gel, respectively. Lectin was determined to be a 14-kDa polypeptide by sodium dodecyl sulphate-polyacrylamide gel electrophoresis under reducing conditions. However, 14-kDa and 28-kDa bands appeared in the same proportion under non-reducing conditions. Gel permeation chromatography showed a 54-kDa peak, suggesting that lectin consists of four 14-kDa subunits. Divalent cations were not indicated, and stable haemagglutination activity was demonstrated at pH 4-12 and temperatures below 60°C. Surface plasmon resonance analysis of OXYL against fetuin showed k(ass) and k(diss) values of 1.4×10(-6)M(-1)s(-1) and 3.1×10(-3)s(-1), respectively, indicating that it has a strong binding affinity to the glycoprotein as lectin. Frontal affinity chromatography using 25 types of prydylamine-conjugated glycans indicated that OXYL specifically recognizes multi-antennary complex-type oligosaccharides containing type-2 N-acetyllactosamines (Galß1-4GlcNAc) if α2-3-linked sialic acid is linked at the non-reducing terminal. However, type-1 N-acetyllactosamine (Galß1-3GlcNAc) chains and α2-6-linked sialic acids were never recognized by OXYL. This profiling study showed that OXYL essentially recognizes ß1-4-linkage at C-1 position and free OH group at C-6 position of Gal in addition to the conservation of N-acetyl groups at C-2 position and free OH groups at C-3 position of GlcNAc in N-acetyllactosamine. This is the first report on glycomics on a lectin purified from an echinoderm belonging to the subphylum Pelmatozoa.

Glycan-binding profile and cell adhesion activity of American bullfrog (Rana catesbeiana) oocyte galectin-1.

The glycan-binding profile of a beta-galactoside-binding 15 kDa lectin (Galectin-1) purified from the oocytes of the American bullfrog, Rana catesbeiana, was studied using 61 pyridyl-aminated oligosaccharides by frontal affinity chromatography. Human blood type-A-hexasaccharide (GalNAcalpha1-3(Fucalpha1-2)Galbeta;1-4GlcNAcbeta1-4Galbeta1-4Glc) was found to exhibit the strongest ligand binding to the galectin while Forssman antigen (GalNAcalpha1-3GalNAcbeta1-3Galalpha1-4Galbeta1-4Glc) and type-A-tetrasaccharide (GalNAcalpha1-3(Fucalpha1-2)Galbeta1-4GlcNAcbeta1-4Glc) were also extensively recognized. The kinetics of affinity of galectin-1 to type-A oligosaccharide was analysed by surface plasmon resonance using neoglycoprotein with type-A oligosaccharides. R. catesbeiana oocyte galectin adhered to human rhabdomyosarcoma cells dose dependently and the activity was specifically cancelled by the neoglycoprotein. It was concluded that galectin-1 from R. catesbeiana oocytes possesses different and rare glycan-binding properties from typical members in galectin family.

Optimal extent of lymph node dissection for T1 gastric cancer, with special reference to the distribution of micrometastasis, and accuracy of preoperative diagnosis for wall invasion.

BACKGROUND/AIMS: Preoperative diagnosis for wall invasion and lymph node metastasis is sometimes difficult in T1 gastric cancer. Optimum dissection extent of lymph nodes for T1 gastric cancer was studied from the aspect of subclassification of wall invasion and lymph node metastasis including micrometastasis. METHODOLOGY: 184 patients with cT1 or pT1 gastric cancer were studied. The grade of clinical wall invasion (cT) and clinical lymph node status (cN) were diagnosed by endoscopy and computed tomography or intraoperative findings. Lymph node metastasis (pN) was studied by hematoxylin and eosin staining and immunohistochemistry (IHC). RESULTS: In 79 cM tumors, 60 (75.9%) were diagnosed as pM. In 88 cSM tumors, 42 (47.7%) were diagnosed as pSM. In 94 pM gastric cancers, micrometastases were found in two patients (2.1%) and in N1 stations. Two (1.9%) of 70 pSM cancers had micrometastasis in No. 7, 8a and 12a stations. Lymph node metastasis (pN) correlated significantly with the depth of tumor invasion, lymphatic invasion and venous invasion. Regarding the pN2 stations, one (1.1%) of 94 pM tumors had lymph node metastasis in No.7 station, and 9 (12.9%) of 70 pSM tumors had nodal involvement in No.7, 8a, 11p, 12a and 14v stations. All eight pN+/cM tumors were diagnosed as nN0 and four (1.4%) of 23 pN+/cSM tumors were correctly diagnosed as pN+. In contrast, 8 (9.9%) of 81 cN0/cM tumors and 19 (24.1%) of 79 cN0/cSM tumors had histological lymph node metastasis (pN+). CONCLUSIONS: Accuracy of the clinical diagnosis of lymph node metastasis is very low. Accordingly, prophylactic lymph node dissection is recommended even for cT1 and cN0 tumors. For cN0/cM cancer, D1+No.7 is recommended. D1+No.7, 8a, 9, 11p is recommended for cSM cancer, located in U or M region and additional dissection of No. 14v is recommended for cSM cancer located in L region.

Treatment results of adenocarcinoma of the gastroesophageal junction.

BACKGROUND/AIMS: In the treatment of cardiac cancer, the selection of surgical procedures is controversial. METHODOLOGY: In this study 297 resectable adenocarcinomas arising around the GE junction, that had their center within 5cm oral and aboral of the anatomical GE junction, were analyzed. They were subdivided into those with the tumor center located more than 1cm above the GE junction (Type 1, N = 7), those with the tumor center located within 1cm oral and 2cm aboral of the GE junction (Type 2) and those with the tumor center 2cm below the junction (Type 3). Type 2 and 3 are subdivided into four groups as Type 2A (N = 47), 2B (N = 18), 3A (N = 37) and 3B (N = 188). Type 2A and 3A have esophageal invasion and Type 2B and 3B have no esophageal invasion. Thoraco-abdominal approach and transhiatal resection were done in 65 and 35 patients. Left and right thoracotomies were performed in 60 and 5 patients, respectively. RESULTS: Esophageal invasion distance of 83 among 84 Type 2A and 3A tumors limited within 5cm from the GE junction. The maximum esophageal length by transhiatal approach was 6cm. Postoperative mortality rates after transhiatal approach and thoracotomy were 0% and 5.8%, respectively. One patient of Type 2A with No110 involvement survived longer than 5 years. No patients with Type 2A and 3A had recurrence in the upper mediastinal nodes after transhiatal approach and left thoracotomy. Mediastinal node involvement was found in 3 of 7 Type 1 tumors. Cox regression analyses revealed that the esophageal invasion distance (< 3cm vs. > 3cm), lymph node status (N0 vs. N2) and extent of lymph node dissection (D1 vs. D2) are the independent prognostic factors. CONCLUSION: Dissection of the lower thoracic paraesophageal nodes is recommended if the esophageal invasion longer than 1cm. Almost all Type 2A and 3A tumors can be treated by transhiatal approach without positive esophageal margin under a routine use of intraoperative frozen section. Right thoracotomy and the dissection of the upper mediastinal nodes are recommended for Type 1 tumor. Cardiac resection with D2 dissection is indicated for Type 1 and T1 tumors of Type 2. Total gastrectomy +D2 dissection is recommended for T2-3 tumors of Type 2 and T1-4 tumors of Type 3. Treatment should be selected according to the proposed classification.

Cooperative interaction between hepatocyte nuclear factor 4 alpha and GATA transcription factors regulates ATP-binding cassette sterol transporters ABCG5 and ABCG8.

Cholesterol homeostasis is maintained by coordinate regulation of cholesterol synthesis and its conversion to bile acids in the liver. The excretion of cholesterol from liver and intestine is regulated by ATP-binding cassette half-transporters ABCG5 and ABCG8. The genes for these two proteins are closely linked and divergently transcribed from a common intergenic promoter region. Here, we identified a binding site for hepatocyte nuclear factor 4alpha (HNF4alpha) in the ABCG5/ABCG8 intergenic promoter, through which HNF4alpha strongly activated the expression of a reporter gene in both directions. The HNF4alpha-responsive element is flanked by two conserved GATA boxes that were also required for stimulation by HNF4alpha. GATA4 and GATA6 bind to the GATA boxes, coexpression of GATA4 and HNF4alpha leads to a striking synergistic activation of both the ABCG5 and the ABCG8 promoters, and binding sites for HNF4alpha and GATA were essential for maximal synergism. We also show that HNF4alpha, GATA4, and GATA6 colocalize in the nuclei of HepG2 cells and that a physical interaction between HNF4alpha and GATA4 is critical for the synergistic response. This is the first demonstration that HNF4alpha acts synergistically with GATA factors to activate gene expression in a bidirectional fashion.

SOX6 attenuates glucose-stimulated insulin secretion by repressing PDX1 transcriptional activity and is down-regulated in hyperinsulinemic obese mice.

In obesity-related insulin resistance, pancreatic islets compensate for insulin resistance by increasing secretory capacity. Here, we report the identification of sex-determining region Y-box 6 (SOX6), a member of the high mobility group box superfamily of transcription factors, as a co-repressor for pancreatic-duodenal homeobox factor-1 (PDX1). SOX6 mRNA levels were profoundly reduced by both a long term high fat feeding protocol in normal mice and in genetically obese ob/ob mice on a normal chow diet. Interestingly, we show that SOX6 is expressed in adult pancreatic insulin-producing beta-cells and that overexpression of SOX6 decreased glucose-stimulated insulin secretion, which was accompanied by decreased ATP/ADP ratio, Ca(2+) mobilization, proinsulin content, and insulin gene expression. In a complementary fashion, depletion of SOX6 by small interfering RNAs augmented glucose-stimulated insulin secretion in insulinoma mouse MIN6 and rat INS-1E cells. These effects can be explained by our mechanistic studies that show SOX6 acts to suppress PDX1 stimulation of the insulin II promoter through a direct protein/protein interaction. Furthermore, SOX6 retroviral expression decreased acetylation of histones H3 and H4 in chromatin from the promoter for the insulin II gene, suggesting that SOX6 may decrease PDX1 stimulation through changes in chromatin structure at specific promoters. These results suggest that perturbations in transcriptional regulation that are coordinated through SOX6 and PDX1 in beta-cells may contribute to the beta-cell adaptation in obesity-related insulin resistance.

Evaluation of carcinoembryonic antigen mRNA in living, necrotic, and apoptotic gastric cancer cells by reverse transcriptase-polymerase chain reaction.

PURPOSE: Positive mRNA expression of carcinoembryonic antigen (CEA) is often found in histologically negative lymph nodes, even in early gastric cancer. Therefore, we examined the differences in mRNA expression in MKN45 gastric cancer cells obtained under various cell conditions, namely, living cells, necrosis, and apoptosis, and assessed the possibility of detecting micrometastasis from these results. METHODS: MKN45 cells were cultured with low-dose anticancer drugs (5-fluorouracil (5FU) + cisplatin (CDDP)) or cytokines (tumor necrosis factor alpha (TNFAlpha) + interferon gamma (INFGamma)) to induce apoptosis, or subjected to freezing-thawing to induce necrosis. All the treated cells were stained with propidium iodide and Hoechst and the numbers of living, apoptotic, and necrotic cells were counted. CEA mRNA expression was examined by reverse transcriptase-polymerase chain reaction (RT-PCR) and DNA fragmentation was confirmed. RESULTS: mRNA expression of CEA and CEA/glyceraldehyde-3-phosphate dehydrogenase (GAPDH) tended to decrease as the apoptotic index (AI) increased in the 5FU + CDDP group. On the other hand, almost no change was seen, even when the AI increased, in the TNFAlpha + IFNGamma group. mRNA expression in the necrotic cells was the almost same as that in the living cells. CONCLUSION: Positive CEA mRNA expression by RT-PCR could suggest the existence of living cancer cells.