Changes in Muscle Strength and Six-Minute Walk Distance Before and After Living Donor Liver Transplantation.

BACKGROUND: Impaired exercise capacity and muscle weakness are important characteristics of liver transplantation recipients. Perioperative rehabilitation has been introduced to promote early mobilization of patients and to prevent postoperative pulmonary complications. However, it is unknown how physical status recovers during the hospital stay after a liver transplant. The purpose of this study was to evaluate the changes in clinical indicators that represent the functional exercise capacity and muscle strength before and after living donor liver transplantation (LDLT). METHODS: We retrospectively reviewed 21 consecutive patients who underwent LDLT with perioperative rehabilitation from April 2014 to December 2015. Twelve patients who were tested for 6-minute walk distance, hand-grip strength, and isometric knee extensor muscle strength before and 4 weeks after LDLT were enrolled. RESULTS: At the preoperative baseline, the 6-minute walk distance significantly correlated with the Model for End-stage Liver Disease score and pulmonary functions (vital capacity, forced vital capacity, and forced expiratory volume in 1 second of predictive values). Comparisons between the preoperative and postoperative values revealed significant decreases in weight, Barthel Index, hand-grip strength, and isometric knee extensor muscle strength. Changes in hand-grip strength and isometric knee extensor muscle strength after LDLT correlated with the preoperative Model for End-stage Liver Disease score. CONCLUSIONS: Physical functional status had not been fully recovered 4 weeks after LDLT. Further investigation regarding developing a strategy for prevention of muscle atrophy before LDLT and recovery of physical fitness after LDLT would be helpful.

An Effective New Cryopreservation Procedure for Pancreatic Islets Using Hollow Fiber Vitrification.

The present study aimed at establishing a new cryopreservation method for mouse pancreatic islets by vitrification using hollow fibers as a container. A unique feature of the hollow fiber vitrification (HFV) method is that this method achieves stable vitrification using a minimum volume of cryoprotectant (CPA) solution, thereby ensuring high viability of the islets. The cytotoxicity, optimum composition, and concentration of the CPAs for vitrifying islets were examined. The viability, functional-integrity of vitrified islets were evaluated in comparison with those vitrified by conventional methods. Insulin secretion was measured in vitro by a static incubation assay and the metabolic functions was tested after transplantation into Streptozotocin-induced diabetic mice. The combination of 15% dimethyl sulfoxide+15% ethylene glycol resulted in the best CPA solution for the HFV of islets. HFV showed the highest viability in comparison to 2 vitrification methods, open pulled straws and vitrification with EDT324 solution. The vitrified islets stably expressed ß-cells markers NeuroD, Pancreatic and duodenal homeobox-1, and MafA. Transplantation of the vitrified islets achieved euglycemia of the host diabetic mice and response to an intraperitoneal glucose tolerance test to a similar extent as non-vitrified transplanted islets. The HFV method allows for efficient long-term cryopreservation of islets.

Advancing pig cloning technologies towards application in regenerative medicine.

Regenerative medicine is expected to make a significant contribution by development of novel therapeutic treatments for intractable diseases and for improving the quality of life of patients. Many advances in regenerative medicine, including basic and translational research, have been developed and tested in experimental animals; pigs have played an important role in various aspects of this work. The value of pigs as a model species is being enhanced by the generation of specially designed animals through cloning and genetic modifications, enabling more sophisticated research to be performed and thus accelerating the clinical application of regenerative medicine. This article reviews the significant aspects of the creation and application of cloned and genetically modified pigs in regenerative medicine research and considers the possible future directions of the technology. We also discuss the importance of reproductive biology as an interface between basic science and clinical medicine.

Single pancreatic beta cells co-express multiple islet hormone genes in mice.

AIMS/HYPOTHESIS: It is widely accepted that production of insulin, glucagon, somatostatin and pancreatic polypeptide in islet cells is specific to beta, alpha, delta and pancreatic polypeptide cells, respectively. We examined whether beta cells express other genes encoding islet hormones. METHODS: Nested RT-PCR was performed on single beta cells of transgenic mice with green fluorescent protein (GFP) driven by mouse insulin I promoter (MIP-GFP). RESULTS: Only 55% of adult beta cells expressed the insulin gene alone, while others expressed two or more islet hormone genes; 4% expressed all four hormone genes. In embryonic and neonatal cells, 60% to 80% of GFP(+) cells co-expressed pancreatic polypeptide and insulin genes in contrast to 29% in adult. To clarify cell fate, we conducted lineage tracing using rat insulin II promoter-cre mice crossed with reporter mice Gt(ROSA)26Sor-loxP-flanked STOP-cassette-GFP. All GFP(+) cells expressed insulin I and II genes, and showed similar heterogeneity of co-expression to that seen in MIP-GFP mice. Although we report expression of other hormone genes in a significant proportion of beta cells, our lineage tracing results demonstrate that after inducing InsII (also known as Ins2) expression, beta cell progenitors do not redifferentiate to non-beta cells. CONCLUSIONS/INTERPRETATION: This study shows co-expression of multiple hormone genes in beta cells of adult mice as well as in embryos and neonates. This finding could: (1) represent residual expression from beta cell precursors; (2) result from alternative developmental pathways for beta cells; or (3) denote the differentiation potential of these cells. It may be linked to functional heterogeneity. This heterogeneity in gene expression may provide a means to characterise the functional, cellular and developmental heterogeneity seen in beta cells.

Refractory hypotension during combined general and epidural anaesthesia in a patient on tricyclic antidepressants.

We report a case of refractory hypotension that occurred after epidural injection of local anaesthetic, in a patient who was receiving tricyclic antidepressant therapy and was under general anaesthesia. The patient failed to respond to repeated injections of appropriate doses of sympathomimetics, but did respond to high-dose catecholamine infusions. We suggest that epidural anaesthesia should be used with care when combined with general anaesthesia for patients on long-standing tricyclic antidepressant therapy. If refractory hypotension should occur in such patients, the use of direct-acting vasoconstrictors such as noradrenaline should be considered.

Colonisation on the tongue surface by respiratory pathogens in residents of a nursing home--a pilot study.

OBJECTIVE: The morbidity and mortality of the dependent elderly that result from aspiration pneumonia have been recognised as a major geriatric health problem. The tongue has an extremely large surface area and due to its papillary structure can retain considerable quantities of food, and thus can support and harbour a large bacterial population. The purpose of this study was to gain more information on the microflora of the tongue surface and to assess the existence of oral infectious pathogens potentially causing respiratory disease in nursing home residents. SUBJECTS AND METHODS: The tongue bacterial flora of 69 nursing home residents were examined to identify microorganisms by the culture method. RESULTS: Thirteen species of microorganisms were detected from the tongue in this study. In 41 of 69 subjects (59%), potential respiratory pathogens, had colonised the tongue surface. CONCLUSION: The results of the present study revealed that bacteria that commonly cause respiratory infection colonised the tongue of nursing home residents, suggesting that it may function as a reservoir of potential respiratory pathogens to facilitate colonisation on the oropharynx.

Evaluation of thermoreversible gelation polymer for regeneration of focal liver injury.

Liver injuries are often associated with complications including infection of the dead space, bleeding, leakage of bile and so on. We have recently developed a thermoreversible gelation polymer (TGP) which provides a good healing environment for wounds and possibly reduces complications. The purpose of this study was to evaluate whether adequate regeneration occurred with a liver defect by using TGP. The sol-gel transition of TGP is reversibly controlled by temperature; TGP is soluble below a lower critical solution temperature (LCST) of 22 degrees C, and becomes solid above the LCST. Soluble TGP can reach anywhere, and gelation of TGP occurs at the wound surface by body temperature to fill the wound/cavity. A section of median part of the left lobe comprising 3% (2 x 2 cm wide and 1 cm deep) of the liver was resected, and the Beagle dogs were assigned to three groups: 'resection alone group', 'resection + fibrin glue (FG) group' and 'resection + TGP group'. The resection alone group and the resection + FG group showed severe fibrosis at week 12, and a scarring was clearly visible. The resection + TGP group showed almost complete healing by week 4, with no adhesion and recession of the wound; the resection site was completely filled with TGP, liver-like capsule organoids emerged to cover the wound and neovascularization was observed within the organoids. Furthermore, the resected liver regenerated completely by week 12, TGP was replaced by hepatocytes, and the presence of hepatic lobules confirmed structural reorganization. The number of RCA-1-positive macrophages accumulating around the wound was significantly reduced in the resection + TGP group compared to the other two groups. In the early stage of liver resection and regeneration, TGP seemed to suppress the accumulation of macrophages and stellate cells. In the late stage, when massive inflammatory cell accumulation had subsided, TGP was degraded, that may contribute to avoid unnecessary inhibition of the liver regeneration process. Collectively, TGP may induce efficient regeneration by reducing the fibrosis and enhancing proliferation, even with a minor liver defect. Because TGP has good biocompatibility, it may become useful as an ideal biomaterial for the treatment of liver injuries.

Late infantile Hirschsprung disease-mental retardation syndrome with a 3-bp deletion in ZFHX1B.

A 48-year-old woman with late infantile onset mental retardation developed megacolon. Although the patient had no typical clinical features of Hirschsprung disease-mental retardation syndrome, a new 3-base pair deletion, eliminating an Asn, was identified in the responsible gene ZFHX1B. This suggests that screening for ZFHX1B mutations is warranted even in the absence of typical clinical features of the syndrome.

Late versus early surgical correction for congenital diaphragmatic hernia in newborn infants.

BACKGROUND: Congenital diaphragmatic hernia, although rare (1 per 2-4,000 births), is associated with high mortality and cost. Opinion regarding the timing of surgical repair has gradually shifted from emergent repair to a policy of stabilization using a variety of ventilatory strategies prior to operation. Whether delayed surgery is beneficial remains controversial. OBJECTIVES: To summarize the available data regarding whether surgical repair in the first 24 hours after birth rather than later than 24 hours of age improves survival to hospital discharge in infants with congenital diaphragmatic hernia who are symptomatic at or immediately after birth. SEARCH STRATEGY: Search of MEDLINE (1966-2002), EMBASE (1978-2002) and the Cochrane databases using the terms "congenital diaphragmatic hernia" and "surg*"; citations search, and contact with experts in the field to locate other published and unpublished studies. SELECTION CRITERIA: Studies were eligible for inclusion if they were randomized or quasi-randomized trials that addressed infants with CDH who were symptomatic at or shortly after birth, comparing early (<24 hours) vs late (>24 hours) surgical intervention, and evaluated mortality as the primary outcome. DATA COLLECTION AND ANALYSIS: Data were collected regarding study methods and outcomes including mortality, need for ECMO and duration of ventilation, both from the study reports and from personal communication with investigators. Analysis was performed in accordance with the standards of the Cochrane Neonatal Review Group. MAIN RESULTS: Two trials met the pre-specified inclusion criteria for this review. Both were small trials (total n<90) and neither showed any significant difference between groups in mortality. Meta-analysis was not performed because of significant clinical heterogeneity between the trials. REVIEWER'S CONCLUSIONS: There is no clear evidence which favors delayed (when stabilized) as compared with immediate (within 24 hours of birth) timing of surgical repair of congenital diaphragmatic hernia, but a substantial advantage to either one cannot be ruled out. A large, multicenter randomized trial would be needed to answer this question.

Relationship of the fistulas to the rectum and genitourinary tract in mouse fetuses with high anorectal malformations induced by all-trans retinoic acid.

Since high anorectal malformations with fistulae in human embryos and fetuses of successive developmental stages have not been reported, the embryologic relationship between the rectal fistula (RF) and the genitourinary tract (GUT) in high anorectal agenesis (ARA) remains to be elucidated. This study investigates the developmental relationship between the RF and the GUT in male and female fetuses with high ARA using our established model for high ARA with fistula in mice. Pregnant mice received all-trans retinoic acid suspended in corn oil (5 mg/ml) 100 mg/kg i.p. on day 9 of pregnancy. All fetuses were removed from the uterus on a single day from days 12 to 18 of pregnancy. The caudal regions were analyzed histologically with hematoxylin and eosin staining. All fetuses examined had high ARA with fistula. On day 12 of pregnancy, an anomalous communication was seen between the urogenital sinus (UGS) and the rectum. In the affected female fetuses, on day 14 of pregnancy the paramesonephric (müllerian) ducts and müllerian tubercle were located above the rectocloacal fistula (RCF), and on day 18 of pregnancy the uterovaginal canal was located between the cloaca and the RCF. In the male fetuses, on day 14 of pregnancy the junction between the mesonephric (wolffian) duct and the UGS was located away from the junction between the rectum and the UGS. On day 18 of pregnancy the ejaculatory duct was located between the urinary bladder and the rectourethral fistula. The results of our experiment clearly show the embryologic relationship between the RF and the GUT with high ARA. The anomalous communication between the UGS and the rectum may interfere with normal caudal migration along the dorsal wall of the UGS at the junction between the UGS and the mesonephric or paramesonephric duct.

Nonsense and frameshift mutations in ZFHX1B, encoding Smad-interacting protein 1, cause a complex developmental disorder with a great variety of clinical features.

Mutations in ZFHX1B, encoding Smad-interacting protein 1 (SIP1), have been recently reported to cause a form of Hirschsprung disease (HSCR). Patients with ZFHX1B deficiency typically show mental retardation, delayed motor development, epilepsy, microcephaly, distinct facial features, and/or congenital heart disease, in addition to the cardinal form of HSCR. To investigate the breadth of clinical variation, we studied DNA samples from six patients with clinical profiles quite similar to those described elsewhere for ZFHX1B deficiency, except that they did not have HSCR. The results showed the previously reported R695X mutation to be present in three cases, with three novel mutations-a 2-bp insertion (760insCA resulting in 254fs262X), a single-base deletion (270delG resulting in 91fs107X), and a 2-bp deletion (2178delTT resulting in 727fs754X)-newly identified in the other three. All mutations occurred in one allele and were de novo events. These results demonstrate that ZFHX1B deficiency is an autosomal dominant complex developmental disorder and that individuals with functional null mutations present with mental retardation, delayed motor development, epilepsy, and a wide spectrum of clinically heterogeneous features suggestive of neurocristopathies at the cephalic, cardiac, and vagal levels.

Extracorporeal membrane oxygenation for newborns with gastric rupture.

Extracorporeal membrane oxygenation (ECMO) has been recognized to be beneficial to overcome not only persistent pulmonary hypertension of the newborn, but also cardiopulmonary distress due to neonatal sepsis. However, few papers have reported on the efficacy of ECMO for surgical sepsis in neonates with underlying diseases. This paper reports our experience with ECMO in three newborns with gastric rupture, one of the most serious causes of surgical sepsis in the neonatal period. Over the past 12 years, 14 newborns had gastric rupture; 3 developed lethal cardiopulmonary distress that conservative strategies, including aggressive intensive care, failed to manage, and were selected for ECMO. The clinical data of these patients were retrospectively analyzed. The onset time and duration of ECMO varied from 23 to 143 h of age and 72 to 294 h, respectively. In case 3, complicated by massive intra-abdominal hemorrhage during ECMO, anticoagulants were changed from heparin alone to combined use with nafamostat mesilate, a thrombin inhibitor with a very short half-life. Ultrafiltration or hemodialysis was added in two cases to regulate massive volume overload associated with renal failure. Despite major hemorrhagic complications in two cases, all patients survived. Thus, ECMO may be beneficial in managing neonates with therapy-resistant gastric rupture.

Mutations in SIP1, encoding Smad interacting protein-1, cause a form of Hirschsprung disease.

Hirschsprung disease (HSCR) is sometimes associated with a set of characteristics including mental retardation, microcephaly, and distinct facial features, but the gene mutated in this condition has not yet been identified. Here we report that mutations in SIP1, encoding Smad interacting protein-1, cause disease in a series of cases. SIP1 is located in the deleted segment at 2q22 from a patient with a de novo t(2;13)(q22;q22) translocation. SIP1 seems to have crucial roles in normal embryonic neural and neural crest development.

Attitudes to oral care among caregivers in Japanese nursing homes.

OBJECTIVES: The purpose of this study is to investigate oral care practice and awareness of it among caregivers in Japanese nursing homes. METHODS: Caregivers were surveyed by means of a self-administered questionnaire designed to elicit the following information: awareness of oral care, its importance, the burden involved in oral care, and systematization of oral care. RESULTS: The results showed that most caregivers are adequately informed of the importance of oral care, but are inadequately educated in oral care and have little training in systematic oral care. CONCLUSION: The importance of providing appropriate and systematic oral care training must be stressed among caregivers along with the need to develop equipment to simplify and support oral care.

Lordosis of lumbar vertebrae in omphalocele: an important factor in regulating abdominal cavity capacity.

PURPOSE: Although it is well known that the tiny abdominal cavity associated with larger omphalocele enlarges rapidly after surgery, the responsible mechanism remains obscure. The authors have studied the curve of lumbar vertebrae and established a hypothesis in which lordosis of lumbar vertebrae plays a major role in changing the capacity of the abdominal cavity. METHODS: Fifty-three patients with intact omphalocele and 10 normal newborns as the control were studied. The size of omphalocele was determined from the mean value of the length and breadth of the sac. The curve of lumbar vertebrae (lordotic angle) was measured using Cobb's technique on the lateral radiograph serially taken in the supine position. RESULTS: The mean lordotic angle of 53 patients was 22.2 degrees (range, 0 to 65), which was significantly greater than 11.0 degrees of the control (P <.012). The individual lordotic angle before surgery was significantly correlated with the size of omphalocele (r = 0.668, P <.0001). In serial studies carried out in 15 patients with larger omphalocele, the mean lordotic angle was decreased significantly from 30.5 degrees to 20.0 degrees (P <.009) on the first postoperative day and returned to the control level within a few weeks. CONCLUSIONS: These results suggest that severe lumbar lordosis may well become an alternative factor to produce visceroabdominal disproportion observed before surgery, and its correction after surgery may well induce the abdominal cavity to rapidly enlarge. It may be speculated that the dehiscence of abdominal rectus muscles associated with omphalocele causes the tension of ventral muscles to decline, and, then, imbalance in tension between ventral (abdominal) and dorsal (back) muscles causes the lumbar lordosis to increase. Accordingly, at the staged procedure, the prosthetic sheet should be attached under moderate tension, and its plication should be carried out at regular intervals to maintain the tension of abdominal rectus muscles.

Late versus early surgical correction for congenital diaphragmatic hernia in newborn infants.

BACKGROUND: Congenital diaphragmatic hernia, although rare (1 per 2-4,000 births), is associated with high mortality and cost. Opinion regarding the timing of surgical repair has gradually shifted from emergent repair to a policy of stabilization using a variety of ventilatory strategies prior to operation. Whether delayed surgery is beneficial remains controversial. OBJECTIVES: To summarize the available data regarding whether surgical repair in the first 24 hours after birth rather than later than 24 hours of age improves survival to hospital discharge in infants with congenital diaphragmatic hernia who are symptomatic at or immediately after birth. SEARCH STRATEGY: Search of Medline (1966-1999), Embase (1978-1999) and the Cochrane databases using the terms "congenital diaphragmatic hernia" and "surg*"; citations search, and contact with experts in the field to locate other published and unpublished studies. SELECTION CRITERIA: Studies were eligible for inclusion if they were randomized or quasi-randomized trials that addressed infants with CDH who were symptomatic at or shortly after birth, comparing early (<24 hours) vs late (>24 hours) surgical intervention, and evaluated mortality as the primary outcome. DATA COLLECTION AND ANALYSIS: Data were collected regarding study methods and outcomes including mortality, need for ECMO and duration of ventilation, both from the study reports and from personal communication with investigators. Analysis was performed in accordance with the standards of the Cochrane Neonatal Review Group. MAIN RESULTS: Two trials met the pre-specified inclusion criteria for this review. Both were small trials (total n<90) and neither showed any significant difference between groups in mortality. Meta-analysis was not performed because of significant clinical heterogeneity between the trials. REVIEWER'S CONCLUSIONS: There is no clear support for either immediate (within 24 hours of birth) or delayed (until stabilized) repair of congenital diaphragmatic hernia, but a substantial advantage to either one cannot be ruled out. A large, multicenter randomized trial would be needed to answer this question.

Effect of swallowing training on swallowing disorders in Parkinson's disease.

The purpose of the present study was to determine whether swallowing training improves swallowing function in patients with Parkinson's disease. Ten patients (5 males, 5 females) who had symptoms of dysphagia and 12 healthy volunteers were studied. The initiation time of the swallowing reflex, the "premotor time" (PMT), was calculated from an electromyogram of the submental muscles before and after swallowing training. Patients with Parkinson's disease had a significantly longer PMT (p = 0.0014) than did healthy controls. There was no correlation between PMT and the duration of the disease (r = -0.146; p = 0.6867) or the patient's age (r = 0.602; p = 0.0653). After swallowing training, the patients' PMTs decreased significantly (p = 0.0051).

Secondary excision of choledochal cysts after previous cyst-enterostomies.

BACKGROUND/AIMS: Patients with a choledochal cyst previously treated by internal drainage should undergo secondary cyst excision. The results of such secondary excisions have not yet been reported. METHODOLOGY: Over a 27-year period, 121 patients underwent excision of a choledochal cyst at our hospitals. Of these, 14 patients underwent secondary cyst excision following internal drainage. These patients were compared retrospectively with the remaining 107 patients who underwent primary cyst excision. RESULTS: Blood loss and operative time were greater, and early and late post-operative complications were significantly more frequent in the secondary excision group. Wound infection (early complication), pancreatic stones (late complication), and hepatolithiasis (late complication) were significantly more common in the secondary excision group. Histologically, inflammation and biliary glands were more frequently seen in the resected bile ducts in the secondary excision group. CONCLUSIONS: The long-term results of secondary excision of choledochal cysts are worse than after primary excision. The frequent late complications may be related to the development of biliary glands as a consequence of cyst-enterostomy.

Selective expression of the large neutral amino acid transporter at the blood-brain barrier.

Amino acid supply in brain is regulated by the activity of the large neutral amino acid transporter (LAT) at the brain capillary endothelial cell, which forms the blood-brain barrier (BBB) in vivo. Bovine BBB poly(A)(+) RNA was isolated from 2.0 kg of fresh bovine brain and size fractionated on a sucrose density gradient, and a size-fractionated bovine BBB cDNA library in the pSPORT vector was prepared. The full-length cDNA encoding the bovine BBB LAT was isolated from this library, and the predicted amino acid sequence was 89-92% identical to the LAT1 isoform. The bovine BBB LAT1 mRNA produced a 10-fold enhancement in tryptophan transport into frog oocytes coinjected with bovine BBB LAT1 mRNA and the mRNA for 4F2hc, which encodes the heavy chain of the heterodimer. Tryptophan transport into the mRNA-injected oocytes was sodium independent and was specifically inhibited by other large neutral amino acids, and the K(m) of tryptophan transport was 31.5 +/- 5.5 microM. Northern blotting with the bovine BBB LAT1 cDNA showed that the LAT1 mRNA is 100-fold higher in isolated bovine brain capillaries compared with C6 rat glioma cells or rat brain, and the LAT1 mRNA was not detected in rat liver, heart, lung, or kidney. These studies show that the LAT1 transcript is selectively expressed at the BBB compared with other tissues, and the abundance of the LAT1 mRNA at the BBB is manyfold higher than that of transcripts such as the 4F2hc antigen, actin, or the Glut1 glucose transporter.