Short-term outcomes of a multicentre randomized clinical trial comparing laparoscopic pylorus-preserving gastrectomy with laparoscopic distal gastrectomy for gastric cancer (the KLASS-04 trial).

BACKGROUND: There remain concerns about the safety and functional benefit of laparoscopic pylorus-preserving gastrectomy (LPPG) compared with laparoscopic distal gastrectomy (LDG). This study evaluated short-term outcomes of a randomized clinical trial (RCT) comparing LPPG with LDG for gastric cancer. METHODS: The Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS)-04 trial was an investigator-initiated, open-label, parallel-assigned, superiority, multicentre RCT in Korea. Patients with cT1N0M0 cancer located in the middle third of the stomach at least 5 cm from the pylorus were randomized to undergo LPPG or LDG. Participants, care givers and those assessing the outcomes were not blinded to group assignment. Outcomes were 30-day postoperative morbidity rate and death at 90 days. RESULTS: Some 256 patients from nine institutions were randomized (LPPG 129 patients, LDG 127 patients) between July 2015 and July 2017 and outcomes for 253 patients were analysed. Postoperative complications within 30 days were seen in 19.3 and 15.5 per cent in the LPPG and LDG groups respectively (P = 0·419). Postoperative pyloric stenosis was observed in nine (7.2 per cent) and two (1·5 per cent) patients in the LPPG and LDG groups (P = 0·026) respectively. In multivariable analysis higher BMI was a risk factor for postoperative complications (odds ratio 1·17, 95 per cent c.i. 1·04 to 1·32; P = 0·011). Death at 90 days was zero in both groups. CONCLUSION: Postoperative complications and mortality was comparable in patients undergoing LPPG and LDG. Registration number: NCT02595086 (http://www.clinicaltrials.gov).

Prevalence and risk factors of chronic rhinosinusitis in South Korea according to diagnostic criteria.

BACKGROUND: We aimed to compare the prevalence and risk factors of chronic rhinosinusitis (CRS) using two different diagnostic criteria with the same statistical data from the Korean National Health and Nutrition Examination Survey in 2009. METHODS: Symptom-based CRS was defined as CRS diagnosed by questionnaires related to nasal symptoms. Endoscopy-based CRS was defined based on endoscopic findings and nasal symptoms of symptom-based CRS. RESULTS: The overall prevalence of CRS based on the different diagnostic criteria was as follows: symptom-based CRS was 10.78% (797 of 7,394) and endoscopy-based CRS was 1.20% (88 of 7,343). Comparing symptom-based CRS to endoscopy-based CRS showed slight agreement (kappa = 0.183 (0.150-0.216, 95% confidence interval)). Allergic rhinitis was identified as a common risk factor for CRS based on the two diagnostic criteria. CONCLUSIONS: The prevalence and risk factors of CRS were quite different from each other according to the different criteria, even in the same population. Therefore, it would be important to consider what specific diagnostic criteria have been adopted in the studies comparing the prevalence of CRS.

Improving pre-operative planning for complex total hip replacement with a Rapid Prototype model enabling surgical simulation.

Pre-operative planning for total hip replacement (THR) is challenging in hips with severe acetabular deformities, including those with a hypoplastic acetabulum or severe defects and in the presence of arthrodesis or ankylosis. We evaluated whether a Rapid Prototype (RP) model, which is a life-sized reproduction based on three-dimensional CT scans, can determine the feasibility of THR and provide information about the size and position of the acetabular component in severe acetabular deformities. THR was planned using an RP model in 21 complex hips in five men (five hips) and 16 women (16 hips) with a mean age of 47.7 years (24 to 70) at operation. An acetabular component was implanted successfully and THR completed in all hips. The acetabular component used was within 2 mm of the predicted size in 17 hips (80.9%). All of the acetabular components and femoral stems had radiological evidence of bone ingrowth and stability at the final follow-up, without any detectable wear or peri-prosthetic osteolysis. The RP model allowed a simulated procedure pre-operatively and was helpful in determining the feasibility of THR pre-operatively, and to decide on implant type, size and position in complex THRs.

Stomach hanging technique using gauze during laparoscopic gastrectomy.

INTRODUCTION: Lifting the stomach using laparoscopic instruments during laparoscopic gastrectomy is difficult and increases the risk of crushing the tumor. In this study, we present a stomach hanging technique using gauze pieces that reduces the risk to the tumor. MATERIALS AND SURGICAL TECHNIQUE: After a partial omentectomy and the opening of the lesser sac, the antrum was wrapped with a 15-20-cm gauze piece. Next, a straight needle with 2-0 monofilament suture material pierced the abdominal cavity through the right subcostal area on the mid-clavicular line, and the gauze was then sutured twice in a figure of eight manner. The needle was removed percutaneously through the right middle quadrant of the abdomen. Another suture was applied to wrap the left side of the stomach. The stomach was easily lifted and positioned by pulling the four suture strings in different directions. After the suture materials were fastened to the abdominal wall using hemostat forceps, the surgical field was sufficiently exposed, facilitating lymph node dissection on the superior surface of the pancreas. This method freed the assistant from holding the stomach and enabled this individual to assist the operation in other ways. DISCUSSION: This stomach lifting technique using gauze is a good option for exposing the surgical field, enables the assistant to perform other tasks, and reduces the risk of crushing the tumor during laparoscopic gastrectomy.

Reliability and validity of measuring version of the acetabular component.

A variety of radiological methods of measuring version of the acetabular component after total hip replacement (THR) have been described. The aim of this study was to evaluate the reliability and validity of six methods (those of Lewinnek; Widmer; Hassan et al; Ackland, Bourne and Uhthoff; Liaw et al; and Woo and Morrey) that are currently in use. In 36 consecutive patients who underwent THR, version of the acetabular component was measured by three independent examiners on plain radiographs using these six methods and compared with measurements using CT scans. The intra- and interobserver reliabilities of each measurement were estimated. All measurements on both radiographs and CT scans had excellent intra- and interobserver reliability and the results from each of the six methods correlated well with the CT measurements. However, measurements made using the methods of Widmer and of Ackland, Bourne and Uhthoff were significantly different from the CT measurements (both p < 0.001), whereas measurements made using the remaining four methods were similar to the CT measurements. With regard to reliability and convergent validity, we recommend the use of the methods described by Lewinnek, Hassan et al, Liaw et al and Woo and Morrey for measurement of version of the acetabular component.

The effects of mesenchymal stem cells injected via different routes on modified IL-12-mediated antitumor activity.

Owing to its tumor tropism and prolonged transgene expression, mesenchymal stem cell (MSC) has been considered as an ideal delivery vehicle for cancer gene therapies or therapeutic vaccines. In this study, we demonstrated that intratumoral (i.t.) injection of MSCs expressing modified interleukin-12 (MSCs/IL-12M) exhibited stronger tumor-specific T-cell responses and antitumor effects as well as more sustained expressions of IL-12 and interferon (IFN)-γ in both sera and tumor sites than did IL-12M-expressing adenovirus (rAd/IL-12M) in mice bearing both solid and metastatic tumors. Subcutaneous (s.c.) injection of MSCs/IL-12M at contralateral site of tumor exhibited similar levels of serum IL-12 and IFN-γ as i.t. injection, but much weaker antitumor effects in both B16F10 melanoma and TC-1 cervical cancer models than i.t. injection. Although intravenous (i.v.) injection elicited earlier peak serum levels of cytokines, it induced weaker tumor-specific T-cell responses and antitumor effects than i.t. injection, indicating that serum cytokine levels are not surrogate indicators of antitumor effects. Taken together, these results indicated that MSC is more efficient than adenovirus as a cytokine gene delivery vehicle and that i.t. injection of MSCs/IL-12M is the best approach to induce strong tumor-specific T-cell responses that correlate with anti-metastatic effects as well as inhibition of solid tumor growth, although MSCs themselves have an ability to migrate into the tumor site. In addition, MSCs/IL-12M embedded in Matrigel (MSCs/IL-12M/Matrigel) exhibited significant antitumor effects even in immunodeficient mice such as SCID and BNX mice lacking T, B and natural killer (NK) cells, but not in IFN-γ knockout mice. Our findings provide an optimal approach for designing an efficient clinical protocol of MSC-based cytokine gene therapy to induce strong tumor-specific T-cell responses and therapeutic anticancer efficacy.

Mhc class I haplotypes associated with survival time in simian immunodeficiency virus (SIV)-infected rhesus macaques.

In both human immunodeficiency virus-infected humans and simian immunodeficiency virus (SIV)-infected macaques, genes encoded in the major histocompatibility complex (MHC) class I region are important determinants of disease progression. However, compared to the human human lymphocyte antigen complex, the macaque MHC region encodes many more class I genes. Macaques with the same immunodominant class I genes express additional Mhc genes with the potential to influence the disease course. We therefore assessed the association between of the Mhc class I haplotypes, rather than single gene variants, and survival time in SIV-infected rhesus macaques (Macaca mulatta). DNA sequence analysis and Mhc genotyping of 245 pedigreed monkeys identified 17 Mhc class I haplotypes that constitute 10 major genotypes. Among 81 vaccination-naive, SIV-infected macaques, 71 monkeys carried at least one Mhc class I haplotype encoding only MHC antigens that were incapable of inducing an effective anti-SIV cytotoxic T lymphocytes response. Study of these macaques enabled us to relate individual Mhc class I haplotypes to slow, medium and rapid disease progression. In a post hoc analysis, classification according to disease progression was found to explain at least 48% of the observed variation of survival time.

Electroconvulsive shock reduces inositol trisphosphate receptor1 mRNA in rat brain.

We studied the expression pattern of the inositol 1,4,5-trisphosphate receptor1 (InsP3R1) mRNA after a single electroconvulsive shock (ECS) in the rat brain by in situ hybridization. The expression was significantly decreased in the dentate gyrus and the CA1 area of the hippocampal formation 3 to 24 h after ECS. While the downregulation of InsP3R1 by accelerated protein degradation has been reported, our results indicate that the downregulation of InsP3R1 occurs at the mRNA level. This finding, along with our previous report on the InsP3 3-kinase(A), suggests that ECS regulates the phosphoinositide mediated signaling, which might be related to the therapeutic mechanism of ECS.

Enhancement of VP1-specific immune responses and protection against EMCV-K challenge by co-delivery of IL-12 DNA with VP1 DNA vaccine.

It has been reported that co-delivery of IL-12 DNA with a DNA vaccine further enhances antigen (Ag)-specific protective immunity in pathogenic challenge models. However, the enhancing effects of antibody by IL-12 have been controversial. To clarify this issue, we constructed an IL-12 expression vector, co-immunized IL-12 DNA with an encephalomyocarditis virus (EMCV)-D VP1 plasmid vaccine, and then evaluated immune modulatory effects and protection against lethal EMCV-K challenge. We observed that VP1-specific IgG production, as well as seroconversion rates, were significantly enhanced by IL-12 co-injection, indicating that IL-12 can enhance antibody responses in this model system. In particular, co-injection with VP1 plus IL-12 DNA into the same leg enhanced systemic Ag-specific IgG production to a significantly greater extent than either the separate leg injection of VP1 and IL-12 DNA or VP1 DNA vaccine alone. This suggests that local co-expression of IL-12 along with antigens is more important for enhanced antibody production. Furthermore, IgG2a isotype was significantly enhanced by IL-12 DNA co-injection, indicating a Th1 bias. In addition, co-delivery of IL-12 DNA was demonstrated to enhance VP1-specific Th cell proliferative responses. When animals were challenged with a lethal dose of EMCV-K, IL-12 DNA-co-immunized animals exhibited enhanced survival, as compared to VP1 DNA vaccine alone. These studies suggest that IL-12 plays an important role in increasing Ag-specific Th1 type antibody and cellular responses, resulting in enhanced protection against lethal EMCV-K challenge.

Characterization of chromosomal aberrations in human gastric carcinoma cell lines using chromosome painting.

Using chromosome painting, a study of chromosomal abnormalities was performed in six gastric carcinoma cell lines (SNU-484, 601, 620, 638, 668, 719) from Korean patients. Each carcinoma cell line had unique modal karyotypic characteristics and showed a variable number of numerical and structural clonal cytogenetic aberrations. SNU-484, SNU-620, and SNU-668 had near-triploidy; SNU-601, SNU-638, and SNU-719 had near-diploidy. The origins of the marker chromosomes of these cell lines were identified by fluorescence in situ hybridization with constructed painting probes. In all of six cell lines, rearrangement of chromosome 17 resulting in partial deletion of 17p (and/or partial duplication of 17q) was found. The most frequent marker was a partial gain of chromosome 7 with the breakpoints on 7q22 and 7q31. The nonrandom rearrangements of chromosomes were also determined on 1q32, 5q11-q22, 8q, 14q22, 14q34, and 15q15; suggesting that they may be the candidate regions for the isolation of the genes related to gastric cancer.

Enhancement of immunoglobulin G2a and cytotoxic T-lymphocyte responses by a booster immunization with recombinant hepatitis C virus E2 protein in E2 DNA-primed mice.

The induction of strong cytotoxic T-lymphocyte (CTL) and humoral responses appear to be essential for the elimination of persistently infecting viruses, such as hepatitis C virus (HCV). Here, we tested several vaccine regimens and demonstrate that a combined vaccine regimen, consisting of HCV E2 DNA priming and boosting with recombinant E2 protein, induces the strongest immune responses to HCV E2 protein. This combined vaccine regimen augments E2-specific immunoglobulin G2a (IgG2a) and CD8(+) CTL responses to a greater extent than immunizations with recombinant E2 protein and E2 DNA alone, respectively. In addition, the data showed that a protein boost following one DNA priming was also effective, but much less so than those following two DNA primings. These data indicate that sufficient DNA priming is essential for the enhancement of DNA encoded antigen-specific immunity by a booster immunization with recombinant E2 protein. Furthermore, the enhanced CD8(+) CTL and IgG2a responses induced by our combined vaccine regimens are closely associated with the protection of BALB/c mice from challenge with modified CT26 tumor cells expressing HCV E2 protein. Together, our results provide important implications for vaccine development for many pathogens, including HCV, which require strong antibody and CTL responses.

Magnetic resonance image-based cerebellar volumetry in healthy Korean adults.

The effects of age and gender on cerebellar size have not been established yet. To understand these effects, the area of cerebellar vermis and the volume of cerebellum were measured using serial magnetic resonance images of 124 Korean adults free of neurologic symptoms and signs. Cerebellar volume of male was significantly larger than that of female, although the size of vermis did not show significant gender difference. Correlation analysis revealed that cerebellar volume was not affected by aging. Regressional analysis demonstrated that female vermis had a tendency to shrink after age of 50, whereas male vermis and total cerebellar volume in both sexes were not altered with aging. The different response of vermis with aging and maintenance of cerebellum volume need to be more explored.

Morphologic investigation of rolling mouse Nagoya (tg(rol)/tg(rol)) cerebellar Purkinje cells: an ataxic mutant, revisited.

Rolling mouse Nagoya (rolling: tg(rol)) is a neurologic mutant mouse exhibiting severe ataxia. Two alleles of the rolling mutation, tottering (tg) and leaner(tg(la)), have been identified as mutations in the voltage-dependent calcium channel alpha1A subunit. No specific light and electron microscopic findings have been reported for the rolling mouse cerebellum except a decreased number of granule cells, while altered Purkinje cell/parallel fiber synapses have been observed in tottering and leaner cerebella. Rolling mouse cerebella were analyzed using anti-calbindin-D immunohistochemistry and transmission electron microscopy to investigate Purkinje cell morphology and synaptic contacts between Purkinje cell dendritic spines and parallel fiber varicosities. Multiple Purkinje cell dendritic spines synapsing with single parallel fiber varicosities were frequently observed in rolling cerebella. The correlation between the presence of altered Purkinje cell synapses and ataxia in rolling mice warrants further investigation.

DNA inoculations with HIV-1 recombinant genomes that express cytokine genes enhance HIV-1 specific immune responses.

Vaccination with HIV-1 DNA sequences induce both humoral and cellular immune responses in experimental animals. However, these responses are relatively weak and are often only transient in their nature. In order to enhance the level of HIV-1 specific immunity, we have engineered HIV-1 DNA constructs which contained various cytokine genes such as interleukin-2 (IL-2), granulocyte-macrophage colony stimulating factor (GM-CSF) and interferon-gamma (IFN-gamma) gene. These constructs have deleted the tat and nmf genes of HIV-1 to eliminate their immunosuppressive effects. Immunizations with these recombinant constructs elicited moderate proliferative T cell responses but poor antibody responses in rats. However, inoculations of HIV-1 DNA that contained the GM-CSF or the IL-2 gene significantly enhanced humoral and proliferative T cell responses, respectively. Thus, recombinant HIV-1 genomes such as those described here may increase the efficacy of DNA vaccination.

MK-801, a non-competitive NMDA receptor antagonist, prevents postischemic decrease of inositol 1,4,5-trisphosphate receptor mRNA expression in mongolian gerbil brain.

Changes of inositol 1,4,5-trisphosphate receptor (IP3R) mRNA expression after transient brain ischemia and the effect of MK-801, a non-competitive N-methyl-D-aspartic acid (NMDA) receptor antagonist, on the IP3R mRNA expression was studied in mongolian gerbil brain by in situ hybridization. Transient ischemia was induced by ligating left common carotid artery for 10 min, and the animals were allowed recovery from 15 min to 24 h. MK-801 was introduced intraperitoneally 30 min before ischemia. IP3R mRNA expression was decreased in dentate gyrus and hippocampus from 90 min until 24 h after ischemia. MK-801 pretreatment prevented the change of IP3R mRNA expression after ischemia. These results suggest that IP3R mRNA expression in ischemia may be related with NMDA receptor.

Protective immunity against heterologous challenge with encephalomyocarditis virus by VP1 DNA vaccination: effect of coinjection with a granulocyte-macrophage colony stimulating factor gene.

For DNA vaccination studies, recombinant VP1 protein of encephalomyocarditis virus (EMCV) was produced from Escherichia coli, and eukaryotic VP1 expression vector, pCT-Gs-VP1, was generated and used as a DNA vaccine. Mice were immunized intramuscularly (i.m.) with pCT-Gs-VP1 in the presence or absence of plasmid DNA expressing granulocyte-macrophage colony stimulating factor (GM-CSF), and were subsequently analyzed for their anti-VP1 immune responses with recombinant VP1 in ELISA. Immunization of mice with pCT-Gs-VP1 resulted in VP1-specific immune response and 43% protection from subsequent lethal heterologous challenge of EMCV. Coinjection of mice with pCT-Gs-VP1 and plasmid DNA encoding GM-CSF was shown to increase the seroconversion rate of the immunized mice with a single DNA injection, and enhanced to a higher degree VP1-specific immunity, which appeared to result in better protection (about 80%) from lethal virus challenge. Thus, our results provide evidence for the potential use of GM-CSF to induce better immune response and resistance against viral infection in DNA vaccination.

Comparison of various expression plasmids for the induction of immune response by DNA immunization.

Intramuscular injection of plasmid DNA is an efficient method to introduce a foreign gene into a live animal. We investigated several factors affecting the gene transfer efficiency and the following immune response by intramuscular injection of plasmid DNA. When the strength of several highly efficient viral promoters was compared in muscle by using the chloramphenicol acetyltransferase (CAT) gene as an indicator, cytomegalovirus (CMV) immediate early promoter was found to be stronger than any other viral promoters including Rous sarcoma virus (RSV), murine leukemia virus (SL3-3) and simian virus 40 (SV40) early promoters. Inclusion of adenovirus tripartite leader (TPL) sequences and a synthetic intron in the 5' untranslated region of mRNA moderately stimulated the CAT expression. On the other hand, the expression of encephalomyocarditis virus (EMCV) VP1 gene was greatly enhanced by the TPL sequences and an intron. The level of humoral immune response by intramuscular injection of various VP1 expression plasmids was compared. The seroconversion rate was highly dependent on the strength of the expression vector. However, the ratio of IgG1 and IgG2a immune response was not significantly variable depending on the strength of the expression vector. Also, the efficiency of the sindbis virus-based DNA vector was examined for the gene expression and immune response. Although a high level of CAT expression was obtained in muscle by using this system, VP1 was not produced as much as the conventional expression vectors. Furthermore, little humoral immune response was elicited by intramuscular injection of VP1-expressing sindbis vector, suggesting that this system was not superior to the conventional vector for DNA immunization.

Chromosomal localization and neural distribution of voltage dependent calcium channel beta 3 subunit gene.

Voltage dependent calcium channel (VDCC) mediates the influx of free calcium ions that acts as a signal transducer. The beta 3 subunit of the VDCC regulates the activation (opening) and inactivation (closing) kinetics through phosphorylation/dephosphorylation. We isolated a genomic clone of the human VDCC beta 3 subunit from a human genomic DNA library using VDCC beta 3 cDNA as a probe. We localized VDCC beta 3 with this genomic DNA on the chromosome by fluorescent in situ hybridization, and the distribution of VDCC beta 3 in the nervous system was investigated in rats by in situ hybridization histochemistry with rat VDCC beta 3 cDNA. The gene for the VDCC beta 3 was specifically localized on human chromosome 12q13. The mRNA for the VDCC beta 3 was predominantly expressed in the nervous system. In the brain, a strong expression of VDCC beta 3 mRNA was found in the medial habenular nucleus, a high level of expression was observed in the olfactory bulb and cerebellum, and a relatively high level of VDCC beta 3 mRNA was localized in the cerebral cortex, caudate-putamen and hippocampal formation. Interestingly, this distribution pattern is very similar to that of the rbE-II, mid-low VDCC 1 subunit, and it is suspected that VDCC beta 3 and rbE-II may function together as a pair.

Integrated delivery networks. A system for the future. Genesys Health System designs and builds a patient-focused care delivery network.

St. Joseph Hospital, Flint, MI, formed Genesys Health System in 1981, affiliating with five area hospitals and a number of other healthcare organizations. In 1983 the system closed one of the hospitals. Genesys Health System's vision is described as a three-legged stool, with the integrated delivery system as the seat. That system balances on three legs: a strong primary and specialty care physician network; a financing, or insuring, mechanism; and a revolutionary hospital and delivery system with a full continuum of services across a range of institutional and home settings. Genesys has two physician joint ventures that will eventually become one as Genesys member hospitals' medical staffs merge. Member physicians are already linked by a common computer system and risk-sharing mechanisms. The physician-Genesys joint ventures have contractual arrangements with various managed care organizations. The system serves more than 50,000 persons enrolled with HealthPlus of Michigan and virtually all the 10,000 enrolled patients of Blue Care Network, the Blue Cross health maintenance organization. After evaluating the community's needs, Genesys Health System decided to build a new hospital; 439-bed Genesys Regional Medical Center at Health Park is scheduled to open in 1997. The new hospital will be the first in the United States to be designed and built using patient-focused care concepts.

Hemodynamic responses to passive body tilts.

To investigate the relationship between the effects of gravity and hemodynamic responses to body tilts in the early steady-state, twelve healthy young adult males were passively tilted from the supine control position (SCP) to the 15 degrees, 30 degrees and 60 degrees head-up position (HU), and then the -15 degrees and -30 degrees head-down position (HD). Cardiac output (Q), stroke volume (SV), acceleration index (ACI) of the heart, thoracic fluid volume (TFV), blood pressure (BP), heart rate (HR), total peripheral vascular resistance (TPR) and ECG were measured. In the postural changes from SCP to the 15 degrees, 30 degrees and 60 degrees HU, the SV gradually decreased and the Q also decreased. The HR and TPR gradually increased. On the contrary, in the -15 degrees and -30 degrees HD, the SV increased and the Q increased and the HR and TPR decreased. The ACI increased in the HD, but decreased in the HU. The mean BP increased in the HU, but decreased in the HD. The TFV increased in the HD, and decreased in the HU. The average QRS vector was 56.1 degrees on the SCP and it increased in the HU, but decreased in the HD. In conclusion, the changes of hemodynamic parameters except in BP were linearly related to the sine of the tilt angle in regardless of HU or HD.