A Single Case of Single-Port Access Laparoscopic Appendectomy During the Puerperium

Laparoscopic appendectomy is now widely practiced for the treatment of acute appendicitis. As result of increased demand for minimally invasive surgery, single-incision access was introduced and is being performed in various abdominal surgeries. Conventional laparoscopic appendectomy (LA) is gradually being performed in pregnant women. A 33-year-old woman was referred to our department at 39 weeks and 1 day of gestation due to abdominal pain. She was aware of her gastroepiploic pain even after the delivery. Though it was past 2 days, she was not recovering from right lower abdominal pain, so she was transferred to the Department of Gynecology at our hospital on the same day. Although an antibiotic was administered, the right abdominal pain did not improve, and she was referred to our department from the Department of Gynecology. We performed single-port LA (SP-LA). The total operation time was 63 minutes, and the estimated blood loss was 0 mL. She was discharged with no complications on postoperative day 7. We report our initial experience with single-port LA (SP-LA) using the glove technique for treatment of acute appendicitis in a postpartum woman. SP-LA using the glove technique was performed successfully during the puerperium without prolongation of operation time. This approach is less invasive, offers a much better cosmetic result than with conventional methods, and can be performed safely and at low cost.Key words: PLA (single-port laparoscopic appendectomy), PuerperiumThe advantages of laparoscopic appendectomy (LA) over open appendectomy (OA) are widely known and include decreased pain, shorter convalescence, and earlier return to work. Especially, LA is advantageous for treating acute appendicitis in pregnant women. Because the appendix of a pregnant woman is shifted from its normal position, OA may leave a larger operative scar than normal. In recent years, efforts of laparoscopic surgeons have resulted in a reduction in both the diameter of the access ports and the number of ports needed.¹ In addition, natural orifice transluminal endoscopic surgery (NOTES) is being developed as another form of minimally invasive surgery.² As a part of this process, the single-incision laparoscopic surgery (SILS) technique is presently being developed for various laparoscopic surgeries.³ SILS is a virtually scarless technique in which the single-port access site is hidden in the umbilicus. We think that the primary advantage of single-port laparoscopic appendectomy (SP-LA) is the superior cosmetic result compared with multi-port access LA. We report a very rare case in which SP-LA was performed to treat acute appendicitis during the puerperium. This approach is less invasive, offers a much better cosmetic result than with conventional methods, and can be performed safely and at low cost.     

Role of PKA signaling in D2 receptor-expressing neurons in the core of the nucleus accumbens in aversive learning

The nucleus accumbens (NAc) serves as a key neural substrate for aversive learning and consists of two distinct subpopulations of medium-sized spiny neurons (MSNs). The MSNs of the direct pathway (dMSNs) and the indirect pathway (iMSNs) predominantly express dopamine (DA) D1 and D2 receptors, respectively, and are positively and negatively modulated by DA transmitters via Gs- and Gi-coupled cAMP-dependent protein kinase A (PKA) signaling cascades, respectively. In this investigation, we addressed how intracellular PKA signaling is involved in aversive learning in a cell type-specific manner. When the transmission of either dMSNs or iMSNs was unilaterally blocked by pathway-specific expression of transmission-blocking tetanus toxin, infusion of PKA inhibitors into the intact side of the NAc core abolished passive avoidance learning toward an electric shock in the indirect pathway-blocked mice, but not in the direct pathway-blocked mice. We then examined temporal changes in PKA activity in dMSNs and iMSNs in behaving mice by monitoring Förster resonance energy transfer responses of the PKA biosensor with the aid of microendoscopy. PKA activity was increased in iMSNs and decreased in dMSNs in both aversive memory formation and retrieval. Importantly, the increased PKA activity in iMSNs disappeared when aversive memory was prevented by keeping mice in the conditioning apparatus. Furthermore, the increase in PKA activity in iMSNs by aversive stimuli reflected facilitation of aversive memory retention. These results indicate that PKA signaling in iMSNs plays a critical role in both aversive memory formation and retention.Aversive stimuli induce not only rapid avoidance behavior, but also memory formation to escape from uncomfortable environments, and thus strongly influence animal behavior (1–3). The mesolimbic dopaminergic (DA) system plays a critical role in both rapid aversive reaction and memory formation (3–5). The nucleus accumbens (NAc) receives DA inputs from the ventral tegmental area (VTA) and serves as a key neural substrate for the control of aversive learning (6–8). The NAc consists of two subpopulations of medium-sized spiny neurons (MSNs) (9–11). The MSNs of the direct pathway (dMSNs) send their axons to the substantia nigra pars reticulata (SNr) and VTA, and selectively express dopamine D1 receptors, whereas the MSNs of the indirect pathway (iMSNs) indirectly project to the SNr and VTA via the ventral pallidum (VP) and predominantly express D2 receptors (12, 13). D1 receptors stimulate the cAMP-dependent protein kinase A (PKA) signaling cascade via Gs and exhibit a low affinity for DA (14–16). Conversely, D2 receptors inhibit the cAMP-PKA cascade via Gi and show a high affinity for DA (14–16). Thus, these two distinct types of MSNs, constituting two parallel pathways, contribute to the dynamic modulation of neuronal cell excitability and synaptic plasticity in the NAc circuitry (14–16).Although accumulated evidence indicates that DA modulation of the NAc is critical for both reward-based and aversive reactions (3, 5, 6, 17), the response of DA neurons in the VTA to aversive stimuli is not uniform; that is, some DA neurons are stimulated in response to aversive stimuli, whereas most others react by transiently suppressing their firing (18–22). Recent optogenetic studies have revealed that not only activation of iMSNs, but also inactivation of the VTA neurons, which down-regulates DA levels in the NAc, evoke an aversive reaction and learning (23–26); however, how intracellular cAMP-PKA signaling is involved in the induction and retention of aversive memory in a cell type-dependent manner in the NAc circuit remains largely elusive.In the present investigation, we addressed this issue using two approaches. We first used asymmetric reversible neurotransmission blocking (aRNB) techniques (27, 28), in which either the direct or indirect pathway at one side of the NAc was selectively blocked by the pathway-specific expression of transmission-blocking tetanus toxin and the other intact side was manipulated by injection of PKA inhibitors. In the second approach, we examined temporal changes in PKA activities of these two pathways in the formation of aversive memory by monitoring Förster resonance energy transfer (FRET) responses of PKA selective for either dMSNs or iMSNs with the aid of in vivo microendoscopic analysis (29, 30). These two different approaches explicitly demonstrated that the activation of PKA in iMSNs plays a key role in both the formation and the retention of aversive memory.     

Membrane studies on rod-shaped red cells in hereditary elliptocytosis: least haemolysis and normal sodium influx with decreased membrane lipids

The clinical features of hereditary elliptocytosis were studied in 25 cases and compared with 20 normal individuals. Based on morphological features, these patients were classified into two groups: those with a rod-shaped type of elliptocytosis (nine cases), and those with a non-rod type (16 cases). Most of the cases with overt haemolysis were detected among cases of the non-rod type. Overt haemolysis typically tended to be accompanied by stomatocytic changes, which appear to be superimposed on elliptic transformation of the red cells. Sodium influx increased in eight of nine HE patients with overt haemolysis, but in none of the HE with rod-shaped red cells. Significant quantitative and qualitative differences in red cell membrane lipids were observed between the two types of HE. No spectrin abnormalities in domain composition, dimer-dimer association, and thermal stability were observed in 11 of the HE patients studied, including four cases with overt haemolysis.     

Aeromonas hydrophila septicemia with necrotizing myofascitis in a patient with hypoplastic leukemia

A 54-year-old male was admitted to Kawasaki Medical School Hospital with the complaint of fever. His diagnosis of hypoplastic leukemia had been made one year ago. After the admission, cecal mass with pain and high fever were noted. Four days later, he suddenly lost consciousness and died. Aeromonas hydrophila was isolated from blood cultures and also from the myofascitis specimen. Autopsy specimen of the iliopsoas muscle showed necrotizing myofascitis. The specimen obtained from the cecum showed submucosal hemorrhage with edema and these findings were compatible to ischemic colitis. This pathogen is widely distributed in nature, especially in water fields. Therefore, it would be advised to consider the Aeromonas hydrophila as one of the pathological organisms pathognomonic for the septicemia, when one may see febrile and gastrointestinal symptoms in a patient with hematological malignancies.     

The polymorphism linked to the human insulin gene: its lack of association with either IDDM or NIDDM in Japanese

Polymorphism of 5' portion of the human insulin gene was examined in 188 unrelated Japanese subjects (49 normal, 71 with IDDM, and 68 with NIDDM) using restriction endonuclease analysis. Restriction fragments were classified according to the insertion size: Class 1 (600 base pairs), Class 2 (1300 base pairs), and Class 3 (2000 base pairs). We found a very high frequency of Class 1 alleles (96.8%) and a low frequency of both Class 2 (0.8%) and Class 3 alleles (2.4%) and that approximately 94% of the genotypes were Class 1/Class 1 homozygote. In addition, there was no correlation of allelic or genotypic frequency with NIDDM or IDDM. We conclude that length polymorphism of the human insulin gene cannot be a useful marker for diabetes in Japanese.     

Cellular biological differences between human myeloma cell lines KMS-12-PE and KMS-12-BM established from a single patient

To clarify cellular biological varieties of myeloma cells, biological differences were analyzed between 2 human myeloma cell lines, KMS-12-PE and KMS-12-BM, derived from pleural effusion and bone marrow, respectively, of a single patient. Although both lines were considered to be derived from the same clone because both had the same chromosomal marker and immunoglobulin H rearrangement, several biological differences were noted. CD11a and CD20 were highly expressed in the KMS-12-BM line, whereas the KMS-12-PE line showed a higher expression of CD7 and CD95/Fas. Although growth was stimulated in KMS-12-BM by interleukin-6 and interferon-alpha, it was inhibited in KMS-12-PE. In addition, apoptosis inhibitors Bcl-2 and Bcl-X(L) were highly expressed in KMS-12-BM cells. Because KMS-12-PE was cultivated 2 months before KMS-12-BM, these differences might be related to their origin (pleural effusion and bone marrow) or the phases of disease progression. However, these biological differences may help clarify myeloma cell biology and lead to improvement in treatment for myeloma patients.     

<Emphasis Type="Italic">Agrobacterium tumefaciens</Emphasis>-mediated transformation of antifungal lipopeptide producing fungus <Emphasis Type="Italic">Coleophoma empetri</Emphasis> F-11899

The filamentous fungus Coleophoma empetri F-11899 produces an echinocandin-like compound FR901379, the original source for micafungin which is prescribed to treat deep-seated mycoses. Despite its industrial importance, no genetic information on C. empetri F-11899 is currently available. To characterize FR901379 biosynthetic genes by insertional mutagenesis and to improve the compound production genetically, Agrobacterium tumefaciens-mediated transformation (ATMT) was attempted to make genetic manipulation possible in this strain. The optimum conditions for ATMT of C. empetri were determined for the cell density of bacteria, time period of co-cultivation and types of filters in co-cultivation. Using the established ATMT method, the hygromycin B resistant gene was successfully transferred into the genome of C. empetri F-11899 and stably maintained even after a serial passage. Some of these results will be applicable for ATMT of various filamentous fungi.     

Characteristic features of the genotype and phenotype of hereditary spherocytosis in the Japanese population

Hereditary spherocytosis (HS) is the most common hemolytic anemia of congenital origin in the Japanese population. Among 844 cases of 520 kindred with congenital red cell membrane disorders studied at the Kawasaki Medical School in the last 25 years (1975-1999), 407 cases (48.2%) of 215 kindred had HS. Among the recent 60 kindred with HS, autosomal dominant (AD) transmission was proven in 19. The remaining 41 non-AD HS included 1) homozygous patients with autosomal recessive inheritance, 2) HS patients with de novo gene mutations, and 3) mild HS with AD inheritance. The extent of clinical severity in the non-AD HS cases was nearly identical to that in the AD cases. The incidence of membrane protein abnormalities in our 60 Japanese HS kindred was unique: there were lower ankyrin deficiencies (7%), moderate band 3 deficiencies (20%), and much higher protein 4.2 deficiencies (45%), with 28% of unknown etiology. The incidence of membrane protein deficiencies corresponded to that determined by gene analyses; i.e., mutations mostly in band 3 and/or in protein 4.2 genes and fewer ankyrin gene mutations. In the band 3 gene, 11 mutations pathognomonic for HS were identified (3 frameshift and 8 missense mutations). There were 5 mutations of the protein 4.2 gene (3 missense mutations, 1 nonsense mutation, and 1 splicing mutation) pathognomonic for HS. On the other hand, 2 missense mutations were detected in the ankyrin gene in this study. The genetic abnormalities in our HS patients correlated well with the phenotypic ultrastructural abnormalities of red cell membranes in situ. Ankyrin mutations (ankyrin Marburg and ankyrin Stuttgart with frameshift mutations) were associated mostly with a disrupted cytoskeletal network, and band 3 mutations (band 3 Kagoshima with frameshift mutation) typically demonstrated anomalies of intramembrane particles (IMPs). Protein 4.2 mutations (homozygotes of protein 4.2 Nippon) with complete protein 4.2 deficiency showed abnormalities of both the cytoskeletal network and IMPs.     

MHC class I-specific inhibitory receptors and their ligands structure diverse human NK-cell repertoires toward a balance of missing self-response

Variegated expression of 6 inhibitory HLA class I-specific receptors on primary NK cells was studied using high-dimension flow cytometry in 58 humans to understand the structure and function of NK-cell repertoires. Sixty-four subsets expressing all possible receptor com-binations were present in each repertoire, and the frequency of receptor-null cells varied among the donors. Enhancement in missing-self response between NK subsets varied substantially where subset responses were defined by donor KIR/HLA allotypes, reflecting the differences in interaction between inhibitory receptors and their ligands. This contrasted to the enhancement conferred by NKG2A, which was constant and of intermediate strength. We infer a mechanism that modulates frequencies of the NK subsets displaying diverse levels of missing-self response, a system that reduces the presence of KIR-expressing subsets that display either too strong or too weak a response and effectively replaces them with NKG2A-expressing cells in the repertoire. Through this high-resolution analysis of inhibitory receptor expression, 5 types of NK-cell repertoire were defined by their content of NKG2A(+)/NKG2A(-) cells, frequency of receptor-null cells, and degree of KIR receptor coexpression. The analyses provide new perspective on how personalized human NK-cell repertoires are structured.