Nihon University Itabashi Hospital

PURPOSE S-1 is a standard postoperative adjuvant chemotherapy for patients with stage II or III gastric cancer in Asia. Neoadjuvant or perioperative strategies dominate in Western countries, and docetaxel has recently shown significant survival benefits when combined with other standard regimens in advanced cancer and perioperative settings. PATIENTS AND METHODS This randomized phase III study was designed to prove the superiority of postoperative S-1 plus docetaxel over S-1 alone for R0 resection of pathologic stage III gastric cancer. The sample size of 1,100 patients was necessary to detect a 7% increase in 3-year relapse-free survival as the primary end point (hazard ratio, 0.78; 2-sided α = .05; β = .2). RESULTS The second interim analysis was conducted when the number of events reached 216 among 915 enrolled patients (median follow-up, 12.5 months). Analysis demonstrated the superiority of S-1 plus docetaxel (66%) to S-1 (50%) for 3-year relapse-free survival (hazard ratio, 0.632; 99.99% CI, 0.400 to 0.998; stratified log-rank test, P < .001), and enrollment was terminated as recommended by the independent data and safety monitoring committee. Incidences of grade 3 or greater adverse events, particularly neutropenia and leukopenia, were higher in the S-1 plus docetaxel group, but all events were manageable. CONCLUSION Addition of docetaxel to S-1 is effective with few safety concerns in patients with stage III gastric cancer. The present findings may also be applicable in countries in which perioperative adjuvant chemotherapy or chemoradiation is not standard.

Phaeochromocytomas (PHEO) and paragangliomas are rare catecholamine-producing tumours. Although 10-30% of these tumours metastasise, histopathological criteria to discriminate malignant from benign tumours have not been established; therefore, reliable histopathological markers predicting metastasis are urgently required. A total of 163 tumours, including 40 metastatic tumours, collected by the Phaeochromocytoma Study Group in Japan (PHEO-J) were analysed using a system called grading system for adrenal phaeochromocytoma and paraganglioma (GAPP). The tumours were scored based on GAPP criteria as follows: histological pattern, cellularity, comedo-type necrosis, capsular/vascular invasion, Ki67 labelling index and catecholamine type. All tumours were scored from 0 to 10 points and were graded as one of the three types: well-differentiated (WD, 0-2 points), moderately differentiated (MD, 3-6 points) and poorly differentiated (PD, 7-10 points). GAPP scores of the non-metastatic and metastatic groups were 2.08±0.17 and 5.33±0.43 (mean±s.e.m., P<0.001) respectively. There was a significant negative correlation between the GAPP score and the interval until metastasis (r=-0.438, P<0.01). The mean number of years until metastasis after the initial operation was 5.5±2.6 years. The study included 111 WD, 35 MD and 17 PD types. The five-year survival of these groups was 100, 66.8 and 22.4% respectively. In addition, negative immunoreactivity for succinate dehydrogenase gene subunit B (SDHB) was observed in 13 (8%) MD or PD tumours and ten of the 13 (77%) had metastases. Our data indicate that a combination of GAPP classification and SDHB immunohistochemistry might be useful for the prediction of metastasis in these tumours.

The Institute of Medicine (IOM) released a new report, Strategies to Improve Survival from Cardiac Arrest: A Time to Act, on June 30, 2015. The new report presents a comprehensive system-wide approach for improving cardiac arrest (CA) survival throughout the USA1 with eight evidence-based recommendations. In this communication, we wish to highlight this new report and briefly describe differences in approaches to improving survival for CA patients between Japan and the USA. In the weeks following the report, many organizations like the American Heart Association (AHA), American Red Cross, foundations, and others, have amplified many of the recommendations. For example, the AHA has committed $5million of funding to support the recommendations.2 By way of background for Japanese readers, the IOM/National Academy of Medicine (NAM) is one of the most influential organizations in the promotion of new health care policy within the US. With a mission to “improve the health of the nation”, the IOM/NAM has been described by the New York Times as “The most esteemed and authoritative adviser on issues of health and medicine, and its reports can transform medical thinking around the world.” One of the most influential prior reports from the IOM is “To Err is Human”.3 As resuscitation experts, we have high hopes that this recently released IOM report will help elevate survival of CA both within the USA and globally because the system level recommendations call for tangible actions that could save thousands of lives. We particularly want to inform Japanese readers about the IOM report, and to provide a perspective from the Japan Resuscitation Council (JRC) and the Japanese Association of Acute Medicine (JAAM) in response to the recommendations. In addition, we highlight areas where the Japanese nation has been working actively (Table 1). Our most important message is to encourage everyone to read and consider the value of these recommendations. We agree that now is the “time to act”. 1. Establish a National Cardiac Arrest Registry: Because the USA does not have a national CA registry, as we have in Japan, the first recommendation addresses the need for this vital national data. The Japanese nation is proud of its existing national registry of out-of-hospital CA (OHCA) that was established in 2005 thanks to the broad support from the Japanese emergency medical system (EMS). According to the latest data,4 the 1-month survival rate of OHCA patients in 2013, whose arrest was witnessed, with presumed cardiac origin, and initially shockable rhythms, was 31.6%. Nichol et al.5 reported survival rates of shockable rhythms ranged from 7.7% to 39.9% in 10 communities in North America. These data tell us that Japan's overall survival rates are increasing significantly but have not yet achieved the maximum possible. The AHA has the aspirational goal to double survival rates2 in the USA by the year 2020. 2. Foster a Culture of Action through Public Awareness and Training: CA demands immediate responses from laypersons, to rapidly begin bystander cardio pulmonary resuscitation (CPR) and bystander use of an automated external defibrillator (AED).6, 7 The Fire and Disaster Management Agency has trained over 1.4 million people in more than 70,000 public training courses during the last two decades in Japan. The AHA is planning to increase the number of trained laypersons by 50%. Since Japan's adoption of AEDs by the public,8 training courses for AED plus CPR have been widespread. Over 500,000 AEDs have been placed throughout the country.9 3. Enhance the Capabilities and Performance of EMS Systems: Standardized training for EMS personnel promotes more rapid adoption of best practices and allows for better quality of CA care. Since Japanese CPR guidelines were released in 2010 by the JRC,10 progress in uniform adoption and quality assurance has been accelerated for all health care providers. 4. Set National Accreditation Standards Related to Cardiac Arrest for Hospitals and Health Care Systems: The AHA's BLS, Heart saver, and ACLS provider courses have contributed to improve quality control for the provision of CPR in health care systems for the last several decades in Japan. These efforts were enhanced in 2007 with the establishment of the Japanese Circulation Society's International Training Center, which was done in partnership with the AHA. The Japanese Circulation Society initiated CPR consensus for cardiologists in 2009.11 In the meantime, JAAM organized a new training course called Immediate Cardiac Life Support for non-cardiology residents and physicians. The course is typically attended by doctors, nurses, and EMS personnel working together in a local area so that it builds important personal relationships between team members. 5. Adopt Continuous Quality Improvement Programs: Quality improvement programs for CA need to include specific CA outcomes and process measures. However, Japan faces challenges similar to those faced in the USA because there are too few personnel available who have the responsibility, authority, and accountability to ensure quality measures and process improvements. Additional personnel are needed to be responsible for data entry, reporting of events, follow-up for outcomes, generating reports, and ongoing assessments of the quality of CPR. 6. Accelerate Research on Pathophysiology, New Therapies, and Translation of Science for Cardiac Arrest; 7. Accelerate Research on the Evaluation and Adoption of Cardiac Arrest Therapies: Japanese resuscitation investigators have published many key papers using the national database; these papers have provided new insights into social and environmental risk factors.6, 7, 12 However, the funding support for basic science and translational science is relatively small in the area of resuscitation science. Building a more robust infrastructure to support fundamental and basic science, discovering the fundamental mechanism of physiology that underlie CA, and development of new human therapies need substantial additional support in Japan. 7. Create a National Cardiac Arrest Collaborative: To accomplish all these tasks and to create a better national infrastructure for improving survival, the collaboration between the Japanese Ministry of Health in synergy and many other stakeholder organizations should be strengthened to advocate for these goals. Implementation of the IOM/NAM's eight recommendations will help advance collaborative efforts in resuscitation and serve to improve patient outcomes from CA globally. K.S. is currently working for Northwell Health System and previously had a visiting position at the University of Pennsylvania and the Children's Hospital of Philadelphia. K.S. has a patent royalty right of the device for metabolic measurement in resuscitation. K.N. and H.N. have no disclosures on potential conflict of interests. L.B.B. has employment/leadership/advisory appointments at Northwell Health System, Scientific Advisory Committee at Nihon Kohden, and previously served as the director of the Center for Resuscitation Science at the University of Pennsylvania. L.B.B. holds inventor's equity and royalties from Helar, a company started by the University of Pennsylvania. L.B.B. has a patent royalty right of hypothermia induction and reperfusion therapies and the device for metabolic measurement in resuscitation. L.B.B. received honoraria from Philips Medical Systems, NIH Data Safety Monitoring Board, NIH Resuscitation Outcomes Consortium, NIH K12 Training Grant and Nihon Kohden. L.B.B. is funded in his research as a principal investigator by NIH, NIH/NHLBI, Medtronic Foundation, Benechill, Zoll Medical, Philips Medical, and Nihon Kohden. None.

Assessing the prognosis before treatment for metastatic spine tumor is extremely important in therapy selection. Therefore, we review some prognostic scoring systems and their outcomes. Articles with combinations of two keywords among "metastatic spine tumor" and "prognosis", "score", "scoring system", "predicting", or "life expectancy" were searched for in PubMed. As a result, 236 articles were extracted. Those referring to representative scoring systems about predicting the survival of patients with metastatic spine tumors were used. The significance and limits of these scoring systems, and the future perspectives were described. Tokuhashi score, Tomita score, Baur score, Linden score, Rades score, and Katagiri score were introduced. They are all scoring systems prepared by combining factors that affect prognosis. The primary site of cancer and visceral metastasis were common factors in all of these scoring systems. Other factors selected to influence the prognosis varied. They were useful to roughly predict the survival period, such as, "more than one year or not" or "more than six months or not". In particular, they were utilized for decision-making about operative indications and avoidance of excessive medical treatment. Because the function depended on the survival period in the patients with metastatic spine tumor, it was also utilized in assessing functional prognosis. However, no scoring system had more than 90% consistency between the predicted and actual survival periods. Future perspectives should adopt more oncological viewpoints with adjustment of the process of treatment for metastatic spine tumor.

The recurrence rates of Hepatocellular carcinoma (HCC) are high, necessitating novel and effective adjuvant therapies. Therefore, we conducted a phase II study of glypican-3 (GPC3) peptide vaccine as an adjuvant therapy for HCC patients. Forty-one patients with initial HCC who had undergone surgery or radiofrequency ablation (RFA) were analyzed in this phase II, open-label, single-arm trial. Ten vaccinations were performed for 1 y after curative treatment. We also investigated case-control subjects, where selected patients treated surgically during the same period were analyzed. The expression of GPC3 in the available primary tumors was determined by immunohistochemical analysis. Six patients received RFA therapy while 35 received surgery. The recurrence rate tended to be lower in the 35 patients treated with surgery plus vaccination compared to 33 patients who underwent surgery alone (28.6% vs. 54.3% and 39.4% vs. 54.5% at 1 and 2 y, respectively; p = 0.346, 0.983). Twenty-five patients treated with surgery and vaccination had GPC3-positive tumors; the recurrence rate in this group was significantly lower compared to that in 21 GPC3-positive patients who received surgery only (24% vs. 48% and 52.4% vs. 61.9% at 1 and 2 y, respectively; p = 0.047, 0.387). The GPC3 peptide vaccine improved the 1-y recurrence rate in patients with GPC3-positive tumors. This study demonstrated that GPC3 expression by the primary tumor may be used as a biomarker in a putative larger randomized clinical trial to determine the efficacy of the GPC3-derived peptide vaccine.

BACKGROUND: During out-of-hospital cardiac arrest, it is unclear how long prehospital resuscitation efforts should be continued to maximize lives saved. METHODS AND RESULTS: Between 2005 and 2012, we enrolled 282 183 adult patients with bystander-witnessed out-of-hospital cardiac arrest from the All-Japan Utstein Registry. Prehospital resuscitation duration was calculated as the time interval from call receipt to return of spontaneous circulation in cases achieving prehospital return of spontaneous circulation or from call receipt to hospital arrival in cases not achieving prehospital return of spontaneous circulation. In each of 4 groups stratified by initial cardiac arrest rhythm (shockable versus nonshockable) and bystander resuscitation (presence versus absence), we calculated minimum prehospital resuscitation duration, defined as the length of resuscitation efforts in minutes required to achieve ≥99% sensitivity for the primary end point, favorable 30-day neurological outcome after out-of-hospital cardiac arrest. Prehospital resuscitation duration to achieve prehospital return of spontaneous circulation ranged from 1 to 60 minutes. Longer prehospital resuscitation duration reduced the likelihood of favorable neurological outcome (adjusted odds ratio, 0.84; 95% confidence interval, 0.838-0.844). Although the frequency of favorable neurological outcome was significantly different among the 4 groups, ranging from 20.0% (shockable/bystander resuscitation group) to 0.9% (nonshockable/bystander resuscitation group; P<0.001), minimum prehospital resuscitation duration did not differ widely among the 4 groups (40 minutes in the shockable/bystander resuscitation group and the shockable/no bystander resuscitation group, 44 minutes in the nonshockable/bystander resuscitation group, and 45 minutes in the nonshockable/no bystander resuscitation group). CONCLUSIONS: On the basis of time intervals from the shockable arrest groups, prehospital resuscitation efforts should be continued for at least 40 minutes in all adults with bystander-witnessed out-of-hospital cardiac arrest. CLINICAL TRIAL REGISTRATION: URL: http://www.umin.ac.jp/ctr/. Unique identifier: 000009918.

Current diagnostic criteria have limited clinical value for prediction of preeclampsia and fetal adverse outcomes. The prediction of short-term outcome in pregnant women with suspected preeclampsia study in Asia (PROGNOSIS Asia) was a prospective, multicenter study designed to investigate the value of the sFlt-1 (soluble fms-like tyrosine kinase 1)/PlGF (placental growth factor) ratio for predicting adverse outcomes in pregnant Asian women with suspected preeclampsia. Seven hundred sixty-four pregnant women at gestational week 20+0 days (18+0 days in Japan) to 36+6 days were enrolled at 25 sites in Asia. The primary objectives were to demonstrate the value of the sFlt-1/PlGF ratio for ruling out preeclampsia within 1 week and ruling in preeclampsia within 4 weeks. The value of the ratio for predicting fetal adverse outcomes was also assessed. Seven hundred patients were evaluable for primary end point analysis. The prevalence of preeclampsia was 14.4%. An sFlt-1/PlGF ratio of ≤38 had a negative predictive value of 98.6% (95% CI, 97.2%-99.4%) for ruling out preeclampsia within 1 week, with 76.5% sensitivity and 82.1% specificity. The positive predictive value of a ratio of >38 for ruling in preeclampsia within 4 weeks was 30.3% (95% CI, 23.0%-38.5%), with 62.0% sensitivity and 83.9% specificity. An sFlt-1/PlGF ratio of ≤38 had a negative predictive value of 98.9% (95% CI, 97.6%-99.6%) for ruling out fetal adverse outcomes within 1 week and a ratio of >38 had a positive predictive value of 53.5% (95% CI, 45.0%-61.8%) for ruling in fetal adverse outcomes within 4 weeks. The sFlt-1/PlGF ratio cutoff of 38 demonstrated clinical value for the short-term prediction of preeclampsia in Asian women with suspected preeclampsia, potentially helping to prevent unnecessary hospitalization and intervention.

The objective of this study was to investigate the effect of long‐term melatonin administration on plasma levels of triglycerides, insulin and leptin, and on the fatty‐acid metabolism of plasma and hepatic lipids in type 2 diabetic rats. Otsuka Long‐Evans Tokushima Fatty (OLETF) rats, an animal model of type 2 diabetes mellitus, were divided into two groups: one untreated (n=6), and one implanted with time‐releasing melatonin pellets (1.1 mg/day for 30 wk) under the abdominal skin (n=6). Age‐matched Long‐Evans Tokushima Otsuka (LETO) rats (n=6) were used as healthy controls. The untreated diabetic rats had the increased plasma levels of triglycerides, cholesterol, insulin and leptin at 35 wk, as compared with the healthy control rats (n=6). The diabetic rats also had augmented ratios of 20:3n‐6/20:4n‐6 fatty acids, owing to diminished activity of Δ ‐5 desaturase, an insulin‐permissive enzyme, in the liver. Melatonin administration to OLETF rats reduced the hypertriglyceridemia (−39%, P &lt; 0.05), hyperinsulinemia (−33%, P &lt; 0.01) and hyperleptinemia (–43%, P &lt; 0.01), and restored hepatic Δ ‐5 desaturase activity (148%, P &lt; 0.005). This resulted in a return to normal ratios of 20:3n‐6/20:4n‐6 fatty acids in plasma and hepatic lipids. There was a significant correlation ( r =0.64, P &lt; 0.005) between plasma levels of insulin and the ratios of 20:3n‐6/20:4n‐6 in plasma phospholipids of all rats in the three groups. Thus, subcutaneous implantation of a melatonin‐releasing pellet thus resulted in improved lipid metabolism in diabetic rats, probably through restored insulin resistance.ALP, alkaline phosphataseGOT, glutamic oxalacetic transaminaseGPT, glutamic pyruvic transaminaseHPLC, high performance liquid chromatographyLETO rats, Long‐Evans Tokushima Otsuka ratsMUFA, monounsaturated fatty acidOLETF rats, Otsuka Long‐Evans Tokushima Fatty ratsPUFA, polyunsaturated fatty acidVLDL, very low density lipoprotein

OBJECTIVES: Despite just a 4-year interval from the last version (2015) of the Clinical Practice Guidelines for Bladder Cancer, several dramatic paradigm shifts have occurred in the latest clinical practice regarding both the diagnosis and treatment of bladder cancer. Herein, we updated the 2019 version of the Clinical Practice Guidelines for Bladder Cancer under the instruction of the Japanese Urological Association. METHODS: We previously reported in a revision working position paper for Clinical Practice Guidelines for Bladder Cancer 2019 edition and described the methods of revision detail. RESULTS: The major points of change in the 2019 version are presented and explanations are given as follows: (i) introduction of the new reference assessment system; (ii) modification of the risk classification for non-muscle-invasive bladder cancer; (iii) addition of clinical questions for the new tumor-visible techniques in non-muscle-invasive bladder cancer; (iv) inclusion of minimally invasive surgeries for muscle-invasive bladder cancer and immune checkpoint inhibitors for locally advanced/metastatic muscle-invasive bladder cancer; (v) overview chapter of the histological variant of urothelial cancer and rare cancers of the bladder; and (vi) recommendation of follow up in non-muscle-invasive bladder cancer and muscle-invasive bladder cancer. CONCLUSIONS: Guidelines should be updated based on the current evidence and updates carried out without delay. The hope is that this guidelines will be assessed by many urologists and will be the cornerstone for the next revision.

Abstract Ubiquitin-specific protease 10 (USP10) is known to deubiquitylate its target proteins, mainly to enhance their stabilities. USP10 maintains p53 protein levels and controls epigenetic changes induced by the androgen receptor (AR). GTPase-activating protein-binding protein 2 (G3BP2), an androgen-responsive gene, is known as the main component of stress granules (SG) that interacts with USP10 in SGs. This study explores the roles of USP10 in prostate cancer progression in p53, G3BP2, and AR signaling. Using chromatin immunoprecipitation (ChIP) and sequence analysis, it was found that USP10 is transcriptionally induced with AR recruitment to an intronic region. Furthermore, USP10 regulates androgen-mediated signaling and cell growth. USP10 maintained G3BP2 protein stability by reducing polyubiquitylation. G3BP2-dependent growth activation and p53 nuclear export that reduced p53 signaling were repressed by USP10 knockdown. Clinically, USP10 was expressed primarily in the cytoplasm of prostate cancer tissues. High levels of USP10 expression were strongly correlated with high levels of AR, G3BP2, and p53 in the cytoplasm. High expression of USP10 was significantly associated with poor prognosis of patients with prostate cancer. Taken together, USP10 has a repressive effect on p53 signaling for cell growth by regulating G3BP2 expression. These findings highlight an important oncogenic aspect of USP10 through its modulation of the p53–G3BP2 complex and AR signaling in prostate cancer. Implications: These findings elucidate the oncogenic role of USP10 in prostate cancer through an increase in G3BP2 protein that inhibits p53 activity, in addition to the promotion of AR signaling. Mol Cancer Res; 16(5); 846–56. ©2018 AACR.

IgE and mast cells play a pivotal role in various allergic diseases, including asthma, allergic rhinitis, and urticaria. Treatment with omalizumab, a monoclonal anti-IgE antibody, has significantly improved control of these allergic diseases and introduced a new era for the management of severe allergic conditions. About 10 years of experience with omalizumab treatment for severe allergic asthma confirmed its effectiveness and safety, reducing symptoms, frequency of reliever use, and severe exacerbations in patients with intractable conditions. Omalizumab is particularly useful in childhood asthma, where atopic conditions often determine clinical courses of asthma. Recently, omalizumab is approved for the treatment of chronic spontaneous urticaria (CSU) with the fixed dose of 300 mg. Although the mechanisms underlying the actions of omalizumab in CSU are not fully clarified, nearly 90% of patients with CSU showed a complete or a partial response to omalizumab treatment. Furthermore, omalizumab is just approved for the treatment of severe Japanese cedar pollinosis (JC) based on the successful results of an add-on study of omalizumab for inadequately controlled severe pollinosis despite antihistamines and nasal corticosteroids. For proper use of omalizumab to treat severe JC, co-administration of antihistamines is necessary, while patients should meet the criteria including strong sensitization to Japanese cedar pollen (≥class 3) and poor control under standard treatment. In the management of severe allergic diseases using omalizumab, issues including cost and concerns about relapse after its discontinuation should be overcome. At the same time, possibilities for application to other intractable allergic diseases should be considered.

Pyrrole-imidazole (Py-Im) polyamides are nuclease-resistant novel compounds that inhibit gene expression by binding to the minor groove of DNA. A Py-Im polyamide that targets rat TGF-beta1 was designed as a gene-silencing agent for progressive renal diseases, and the distribution and the effects of this polyamide on renal injury were examined in Dahl-salt sensitive (Dahl-S) rats. For identification of transcription factor binding elements for activation of the rat TGF-beta1 gene, recombinant TGF-beta1 reporter plasmids were transfected into HEK-293 cells, and promoter activity was measured. Py-Im polyamide was designed to the activator protein-1 binding site of the rat TGF-beta1 promoter. This Py-Im polyamide showed strong, fast, and specific binding to the target DNA in gel mobility shift and Biacore assays. Py-Im polyamide significantly inhibited TGF-beta1 promoter activity and expression of TGF-beta1 mRNA and protein in rat mesangial cells. Intravenously administered fluorescein-labeled polyamide distributed to the kidney of rats. Py-Im polyamide significantly inhibited expression of TGF-beta1 mRNA and protein in the renal cortex of Dahl-S rats and reduced the increase in urinary protein and albumin in Dahl-S rats independent of changes in blood pressure. These results indicate that Py-Im polyamide that targets TGF-beta1 will be a novel gene-silencing agent for the TGF-beta1-associated diseases, including progressive renal diseases.

An impaired synthesis of nitric oxide (NO) by the vascular endothelium has been implicated in the pathogenesis of essential hypertension (EH). The possible association between a variable number of tandem repeats (VNTR) polymorphism in intron 4 of the endothelial constitutive NO synthase (ecNOS) gene and EH in Japanese subjects was investigated. A total of 123 individuals with EH and 120 normotensive control subjects were studied. The VNTR region of the ecNOS gene was amplified by the polymerase chain reaction to determine the number of repeats, and the allele frequencies were compared between the hypertensive and normotensive groups. Two alleles, containing four and five repeats, were identified. The overall distributions of allele frequencies differed significantly between the two groups, with the four-repeat allele more frequent in the EH group than in the normotensive group (P = .00027, odds ratio = 4.0). The four-repeat allele of the ecNOS gene was thus associated with EH and may be a genetic marker of this disease in Japanese subjects.

BACKGROUND: Speciation of arsenic trioxide (ATO) metabolites in clinical samples such as peripheral blood (PB) from acute promyelocytic leukemia (APL) patients has been conducted. However, speciation of arsenicals in bone marrow (BM) has not yet been performed. Profiles of arsenic speciation in plasma of BM were thus investigated and compared with those of PB plasma from a relapsed APL patient. The total arsenic concentrations in high molecular weight fraction (HMW-F) of BM and PB plasma were also determined. METHODS: Response assessment was evaluated by BM aspirate examination and fluorescence in situ hybridization analysis. The analyses of total arsenic concentrations and speciation were preformed by inductively coupled plasma mass spectrometry (ICP-MS), and high-performance liquid chromatography (HPLC)/ICP-MS, respectively. RESULTS: Response assessment showed that the patient achieved complete remission. The total arsenic concentrations in BM plasma increased with time during the consecutive administration. The PB plasma concentrations of methylated arsenic metabolites substantially increased after the start of administration, while those of inorganic arsenic were still kept at a low level, followed by substantially increase from day-14 after administration. The arsenic speciation profiles of PB plasma were very similar to those of BM plasma. Furthermore, the total arsenic concentrations of HMW-F in BM plasma were much higher than those in PB plasma. CONCLUSIONS: The behaviors of arsenic speciation suggested for the first time that arsenic speciation analysis of PB plasma could be predicative for BM speciation, and showed relatively higher efficiency of drug metabolism in the patient. These results may further provide not only significance of clinical application of ATO, but also a new insight into host defense mechanisms in APL patients undergoing ATO treatment, since HMW proteins-bound arsenic complex could be thought to protect BM from the attack of free arsenic species.

Abstract Background Large‐scale investigations on the use of oral anticoagulants including direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) have not included Japanese patients. Methods We established the multicenter SAKURA AF Registry to support prospective observational research on the status of anticoagulation treatment, especially with DOAC, for AF in Japan. We enrolled 3266 AF patients treated with warfarin ( n =1577) or any of 4 DOACs ( n =1689) from 63 institutions (2 cardiovascular centers, 13 affiliated hospitals or community hospitals, and 48 private clinics) in the Tokyo area. Results We conducted our first analysis of the registry data, and although we found equivalent mean age between the DOAC and warfarin users (71.8±9.5 vs. 72.3±9.4 years, p =0.2117), we found a slightly lower risk of stroke (CHADS 2 score of 0 or 1 [46.9% vs. 39.4%, p &lt;0.0001]) and significantly better creatinine clearance in DOAC users (70.4±27 vs. 65.6±25.7 mL/min, p &lt;0.0001). Importantly, we documented under‐dosing in 32% of warfarin users and inappropriate‐low‐dosing in 19.7–27.6% of DOAC users. Conclusions Our initial analysis of the SAKURA AF Registry data clarified the real‐world use of anticoagulants, which includes DOACs and warfarin in Japan. The DOAC users were at a lower risk for stroke than the warfarin users. In 20–30% of DOAC users, the dose was inappropriately reduced.

Molecule targeting therapy using somatostatin (SS) analogues has become a widely accepted modality to treat neuroendocrine tumors (NETs), particularly gastrointestinal (GI) and pancreatic endocrine tumors. On the other hand, little is known about the expression of somatostatin receptor (SSTR) subtypes in neuroendocrine carcinomas (NECs). We investigated the expression of SSTR subtypes (SSTR-1, 2A, 3, 4 and 5) using real-time reverse transcription polymerase chain reaction (RT-PCR) method and immunohistochemistry in 32 neuroendocrine neoplasms (9 NET G1, 2 NET G2, 18 NECs G3 and 3 mixed NEC G3) of various primary sites. Expression of more than two SSTR subtypes was detected in all neuroendocrine neoplasms examined. Expression of SSTR-2A mRNA was significantly higher than other subtypes. In addition, mRNA expression of SSTR-3 and SSTR-5 was significantly low or below the detection level except for gastroduodenal NET G1. No significant difference of the expression of SSTR subtypes was observed between the NET and NEC groups. The expression of protein and mRNA was generally well correlated. In conclusion, NECs would be a good candidate for molecule targeting therapy using SS analogues, and the expression of SSTR-2A can be useful as a biomarker of neuroendocrine differentiation. We have demonstrated that NEC G3 small cell type shows a different expression profile of SSTR subtypes compared with NET and NEC non-small cell type.

Helicobacter cinaedi has being recognized as an important human pathogen which causes bloodstream infections. Although the first case of bacteremia with this pathogen in Japan was reported in 2003, the true prevalence of H. cinaedi as a pathogen of bloodstream infections in this country is not yet known. Therefore, the aim of our study was to assess the incidence of bacteremia with H. cinaedi in Japan. We conducted a prospective, multicenter analysis in 13 hospitals during 6 months in Tokyo, Japan. Among positive blood cultures from 1 October 2003 to 31 March 2004, isolates suspected of being Helicobacter species were studied for further microbial identification. Identification of the organisms was based on their biochemical traits and the results of molecular analysis of their 16S rRNA gene sequences. A total of 16,743 blood culture samples were obtained during the study period, and 2,718 samples (17.7%) yielded positive culture results for coagulase-negative staphylococci. Among nine isolates suspected to be Helicobacter species, six isolates were finally identified as H. cinaedi. The positivity rate for H. cinaedi in blood culture was 0.06% of total blood samples and 0.22% of blood samples with any positive culture results. All patients with bacteremia with H. cinaedi were found to have no human immunodeficiency virus (HIV) infection, but many of them had complications with either malignancy, renal failure, or a history of surgical operation. Therefore, our results suggest that bacteremia with H. cinaedi is rare but can occur in compromised hosts other than those with HIV infection in Japan.

BACKGROUND: In hemodialysis (HD) patients, zinc depletion caused by inadequate intake, malabsorption, and removal by HD treatment leads to erythropoiesis-stimulating agent (ESA) hyporesponsiveness. This study investigated the effects of zinc supplementation in HD patients with zinc deficiency on changes in the erythropoietin responsiveness index (ERI). METHODS: Patients on HD with low serum zinc levels (<65 μg/dL) were randomly assigned to two groups: The polaprezinc group (who received daily polaprezinc, containing 34 mg/day of zinc) (n = 35) and the control group (no supplementation) (n = 35) for 12 months. All the 70 patients had been taking epoetin alpha as treatment for renal anemia. ERI was measured with the following equation: Weekly ESA dose (units)/dry weight (kg)/hemoglobin (g/dL). RESULTS: There were no significant changes in hemoglobin levels within groups or between the control and polaprezinc groups during the study period. Although reticulocyte counts were increased immediately after zinc supplementation, this change was transient. Serum zinc levels were significantly increased and serum copper levels were significantly decreased in the polaprezinc group after three months; this persisted throughout the study period. Although there was no significant change in the serum iron or transferrin saturation levels in the polaprezinc group during the study period, serum ferritin levels significantly decreased following polaprezinc treatment. Further, in the polaprezinc group, ESA dosage and ERI were significantly decreased at 10 months and nine months, respectively, as compared with the baseline value. Multiple stepwise regression analysis revealed that the change in the serum zinc level was an independent predictor of lowered ERI. CONCLUSIONS: Zinc supplementation reduces ERI in patients undergoing HD and may be a novel therapeutic strategy for patients with renal anemia and low serum zinc levels.

INTRODUCTION: The Berlin definition divides acute respiratory distress syndrome (ARDS) into three severity categories. The relationship between these categories and pulmonary microvascular permeability as well as extravascular lung water content, which is the hallmark of lung pathophysiology, remains to be elucidated. The aim of this study was to evaluate the relationship between extravascular lung water, pulmonary vascular permeability, and the severity categories as defined by the Berlin definition, and to confirm the associated predictive validity for severity. METHODS: The extravascular lung water index (EVLWi) and pulmonary vascular permeability index (PVPI) were measured using a transpulmonary thermodilution method for three consecutive days in 195 patients with an EVLWi of ≥10 mL/kg and who fulfilled the Berlin definition of ARDS. Collectively, these patients were seen at 23 ICUs. Using the Berlin definition, patients were classified into three categories: mild, moderate, and severe. RESULTS: Compared to patients with mild ARDS, patients with moderate and severe ARDS had higher acute physiology and chronic health evaluation II and sequential organ failure assessment scores on the day of enrollment. Patients with severe ARDS had higher EVLWi (mild, 16.1; moderate, 17.2; severe, 19.1; P <0.05) and PVPI (2.7; 3.0; 3.2; P <0.05). When categories were defined by the minimum PaO2/FIO2 ratio observed during the study period, the 28-day mortality rate increased with severity categories: moderate, odds ratio: 3.125 relative to mild; and severe, odds ratio: 4.167 relative to mild. On independent evaluation of 495 measurements from 195 patients over three days, negative and moderate correlations were observed between EVLWi and the PaO2/FIO2 ratio (r = -0.355, P<0.001) as well as between PVPI and the PaO2/FIO2 ratio (r = -0.345, P <0.001). ARDS severity was associated with an increase in EVLWi with the categories (mild, 14.7; moderate, 16.2; severe, 20.0; P <0.001) in all data sets. The value of PVPI followed the same pattern (2.6; 2.7; 3.5; P <0.001). CONCLUSIONS: Severity categories of ARDS described by the Berlin definition have good predictive validity and may be associated with increased extravascular lung water and pulmonary vascular permeability. TRIAL REGISTRATION: UMIN-CTR ID UMIN000003627.

The nuclear receptor ERRalpha (estrogen-related receptor alpha) is known to modulate the estrogen-signaling pathway, but the biological significance of ERRalpha in the prostate remains unclear. We investigated the expression of ERRalpha in human prostate tissues and cancer cell lines to evaluate the potential roles of the receptor in prostate cancer (PC). Western blot analysis of ERRalpha was performed in three cell lines of human PC (LNCaP, DU145 and PC-3). The expressions of ERRalpha in cancerous lesions (n = 106) and benign foci (n = 99) of 106 surgically obtained prostate specimens were evaluated by immunohistochemistry. The relationships between the ERRalpha expression and clinicopathological features were evaluated. Western blot analysis using the polyclonal anti-ERRalpha antibody detected a 52 kD band in all three PC cell lines. Positive immunostaining of ERRalpha in the nuclei was found in 73 (69%) cancerous and 47 (47.5%) benign epithelium, whereas the stromal tissues were negative for ERRalpha. The mean immunoreactivity score (IR score) of the cancerous lesions (3.5 +/- 2.6) was significantly higher than that of the benign foci (1.8 +/- 2.1) (p < 0.0001). The IR score of the cancerous lesions significantly correlated with the Gleason score (p = 0.0135). Univariate and multivariate hazard analyses revealed significant correlations between elevated ERRalpha expression and poor cancer-specific survival (p = 0.0141 and 0.0367, respectively). The enhanced expression of ERRalpha might play a role in the development of human PC and serve as a significant prognostic factor for the disease.