Effects of cilostazol on cerebral blood flow, P300, and serum lipid levels in the chronic stage of cerebral infarction

The effects of cilostazol (Pletaal, Otsuka Pharmaceutical Co., Tokyo, Japan) on cerebral blood flow, P300 event-related potentials, and serum lipid levels were examined in patients in the chronic stage of cerebral infarction. This study included 20 patients (13 men and 7 women, mean age 67 +/- 11 years) with cerebral infarction who had taken ticlopidine (100 mg orally, twice a day). Quantitative cerebral blood flow measurements by Patlak plot analysis, ultrasound examinations of the common carotid arteries, and measurements of P300 event-related potentials and serum lipid levels were performed. Ticlopidine was then replaced with cilostazol (100 mg orally, twice a day) while other medications remained unchanged. The same examinations were performed again 3 months later. After replacement of ticlopidine with cilostazol, cerebral blood flow significantly increased in the frontal white matter, temporal cortex, and occipital cortex compared with cerebral blood flow before replacement with cilostazol. Ultrasonograms of the common carotid arteries showed no significant differences in intima-media thickness before and after replacement. However, peak systolic velocity, time-averaged peak velocity, and volume flow all significantly increased after replacement. Blood flow in the frontal white matter showed a significant negative correlation with P300 latency before and after replacement of ticlopidine with cilostazol. And P300 latency improved significantly after replacement with cilostazol. Regarding lipid levels, total cholesterol, triglycerides, and remnant-like particles-cholesterol all decreased significantly after replacement with cilostazol. Cilostazol, an inhibitor of platelet aggregation, was thus concluded to be effective in improving cerebral blood flow, cerebral function, and serum lipid levels in patients in the chronic stage of cerebral infarction.

Long-term clinical outcomes and therapeutic benefits of triamcinolone-assisted pars plana vitrectomy for proliferative vitreoretinopathy: a case study

PURPOSE

To investigate intraoperative visibility and long-term clinical outcome following triamcinolone acetonide (TA)-assisted pars plana vitrectomy (PPV) for proliferative vitreoretinopathy (PVR).

METHODS

A retrospective interventional noncomparative clinical study was carried out on 21 eyes from 21 patients with more than grade C2 PVR, all of whom underwent TA-assisted PPV. Two of the specimens were observed with an electron microscope. After treatment, outcome measures, including changes in best-corrected visual acuity (BCVA), intraocular pressure (IOP) elevation, corneal pathology, and occurrence of endophthalmitis, were recorded. Patient follow-up time was >36 months (mean +/-standard deviation = 47.3 +/- 6.7 months).

RESULTS

TA improved the intraoperative visualization of the epiretinal membrane (ERM), allowing it to be easily removed together with the partially internal limiting membrane (ILM) using micro forceps. The excised tissue consisted of proliferative cells and an extracellular matrix underlying the ILM. After the operation, 71.4% of the eyes had improved BCVA. Three of the eyes showed sustained IOP elevation (14.3%); two of these cases were controlled by the administration of eyedrops, while the third required filtering surgery. In two cases, an absorption delay of the TA granule on the retinal surface was observed. One eye developed corneal stromal opacity. No other severe complications occurred during the observation period.

CONCLUSIONS

TA-assisted PPV offers improved visualization during the surgical management of PVR, and allows surgeons to excise the ERM safely and effectively without the risk of serious complications.

[Surgical technique of displacement and retraction of the heart with a pigtail shaped hook and Tentacles Heart Positioner]

We describe a novel heart retracting system with Tentacles Heart Positioner (Sumitomo Bakelite, Tokyo) during off-pump coronary artery bypass grafting (OPCAB). The heart retracting system is composed of a pigtail shaped hook attached to a flexible Universal Stabilizer Arm (Estech, Minneapolis). After Tentacles suction device is applied on the surface of the heart, the retracting system is fixed on the sternal retracter so that the hook can hang and support the retracting tubes of the sucker. By regulating the shape of the Universal Stabilizer Arm and the position of the hook, the retracting system can lift the heart sufficiently and maintain the optimal position of the heart during OPCAB procedure. Together with Tentacles Heart Positioner, the heart retracting system provides excellent exposure of target coronary arteries with minimal effect on hemodynamics.

A phase II study to establish a referential arm for treatment of gastric cancer patients with intraperitoneal micrometastases

15002

Background: Gastric cancer patients with free cancer cells in the peritoneal cavity as detected by cytologic examination of the peritoneal washes (CY1) are known to have dismal prognosis. In vivo studies by the authors suggest prognostic impact of early postoperative treatment with S-1 (Nakanishi H, et al. Cancer Sci 2003;94:112–8) . No standard treatment for this population has been proposed to date. Methods: A phase II study was conducted to evaluate the efficacy of S-1, a new oral fluoropyrimidine, given postoperatively to patients with CY1 disease. Eligibility criteria included histologically confirmed adenocarcinoma of the stomach without distant metastasis (peritoneal seeding allowed if completely resected), curatively resected with negative margins, <80 years of age with adequate organ functions and preoperative PS of 0∼2, and written informed consent. The primary endpoint was 2-year survival rate and secondary endpoints were time to treatment failure and safety. By referring to the historical control (2-year survival rate: 13.3%, 90% CI 3.1∼23.5%), the target 2- year survival rate was set at 36 % with estimated 90% CI>23.5%, and the sample size was calculated as 50. Results: Forty eight patients were accrued before the study was closed, and one patients was found to be ineligible (negative for the cytologic examination). Of 47 patients, 32 were men. Median age was 66 years (range: 39∼79 years). Serosal invasion was confirmed in 44 patients (94%) and node metastasis in 42 (89%). Seven patients had macroscopic but resectable peritoneal deposits. D2 dissection was encouraged and performed in 33 patients (70%). To date, median survival time was 21.7 months with 2-year survival rate of 43.5%. One patient died of ischemic heart disease 5 days after the initiation of treatment, and treatment for 7 other patients was discontinued due to toxicity. Time to treatment failure was 9.8 months and progression-free survival was 12.9 months. The most frequent >G3 toxicity was neutropenia (n=6), followed by anorexia/nausea (n=4). Conclusions: Although further period of observation is required, postoperative S-1 is likely to overwhelm the survival data obtained in the pre-S-1 era. Toxicity was manageable and 80% of the patients tolerated the treatment.

No significant financial relationships to disclose.

Molecular basis for sensitivity and acquired resistance to gefitinib in HER2-overexpressing human gastric cancer cell lines derived from liver metastasis

Gastric cancer metastasised to the liver was found to overexpress HER2 at a significantly higher incidence than primary gastric cancers. The purpose of the present study was to investigate the possibility of molecular therapy targeting HER2 overexpression in gastric cancer liver metastasis. We developed three new HER2-overexpressing gastric cancer cell lines (GLM-1, GLM-2, GLM-4) without epidermal growth factor receptor (EGFR) mutations derived from such liver metastasis, two of which had HER2 gene amplifications. All these GLM series of cell lines were highly sensitive to gefitinib in vitro, a specific inhibitor of EGFR tyrosine kinase (Iressa) rather than anti-HER2 antibody trastuzumab (Herceptin), whereas most of the HER2 low-expressing counterparts were not. In these HER2-overexpressing GLM series, protein kinase B (Akt), but not extracellular signal-regulated kinase 1/2 (ERK1/2), was constitutively phosphorylated, and gefitinib efficiently inhibited this Akt phosphorylation, induced strong apoptosis in vitro and exhibited antitumour activity in tumour xenografts in nude mice. This gefitinib-mediated antitumour effect in xenograft was significantly potentiated by trastuzumab treatment. On the other hand, gefitinib-resistant cells (GLM-1R) exhibited increased EGFR expression, followed by constitutive activation of mitogen-activated protein kinase (MAPK) pathway. These results suggest that the antitumour effect of gefitinib is due to the effective inhibition of HER2-driven constitutive activation of phosphatidylinositol-3-kinase (PI3K)/Akt pathway, and that the acquired resistance to gefitinib is due to the constitutive activation of Ras/MAPK pathway in compensation for PI3K/Akt pathway. Gastric cancer liver metastasis with HER2 overexpression would be a potential molecular target for gefitinib and trastuzumab.

beta-Thromboglobulin and 11-dehydrothromboxane B in tension-type headache

Platelet factor 4, beta-thromboglobulin, thromboxane B2, and 11-dehydrothromboxane B2 were investigated in tension-type headache. Ten cases of episodic tension-type headache (mean age 42.5 years), 10 cases of chronic tension-type headache (mean age 45.3 years), and 10 age-matched healthy controls were studied. The platelet factor 4, beta-thromboglobulin, thromboxane B2 and 11-dehydrothromboxane B2 concentrations in the plasma were significantly higher in the episodic tension-type headache group than in the chronic tension-type headache and healthy control groups. Platelets may be involved in episodic tension-type headache.

Phase II study of weekly paclitaxel as a second line chemotherapy for metastatic/recurrent gastric carcinoma

14059

Background: There is currently no standard treatment for gastric carcinoma patients (pts) who failed initial chemotherapy. Since performance status of these pts deteriorates rapidly, moderate and dose-fractionated single agent regimens have been preferred in Japan in the second line setting. Weekly paclitaxel, one of commonly used regimens in this setting, was explored for the first time in a formal phase II study. Methods: Pts with histologically confirmed gastric carcinoma who had unresectable or recurrent disease with ≥1 measurable lesions per RECIST were eligible. Other eligibility criteria included confirmed progressive disease (PD) per RECIST during a front line chemotherapy, PS ≤2, adequate liver, kidney, and marrow functions, no active gastrointestinal bleeding, and written informed consent. Patients received 80 mg/m2 of paclitaxel weekly for 3 successive weeks with one week of rest. The cycle was repeated until objective disease progression or drug intolerance. Results: 35 pts were enrolled: 29 men and 6 women, age 62 (48∼74), 6 unresectable and 29 recurrent cancers, 13 with poorly differentiated phenotype and 20 with differentiated type, 22 PS0, 8 PS1, and 6 PS2. All front line treatments involved oral fluoropyrimidines and had been S-1 in 29, S-1/CDDP in 5, S-1/CPT-11 in one, and UFT in one patient. One pt declined to continue the treatment due to a Grade 2 taste disturbance after a single dose of paclitaxel, and 34 other pts were evaluable for response. Partial response was observed in 6 pts (response rate 17.6%). Median time to progression was 97 days and median survival time was 214 days (467 days among 22 PS0 patients). The incidence of ≥Grade 3 adverse events were as follows: neutropenia in 7 pts, leucopenia in 5, anemia in 4, anorexia in 4, neurological disorder, nausea, diarrhea, asthenia, and dyspnea in one. Conclusions: Activity of weekly paclitaxel was modest for pts with fluoropyrimidine-refractory gastric carcinoma, but median survival time was satisfactory, with a mild toxicity profile. Further phase II study under less strict eligibility criteria (e.g. inclusion of patients with elevated tumor markers or subjective evidence of clinical deterioration during the front line therapy as the sole indication of disease progression) is underway.

No significant financial relationships to disclose.

Prospective validation of quantitative CEA mRNA detection in peritoneal washes in gastric carcinoma patients

Prediction of peritoneal relapse is extremely important for gastric cancer patients after curative surgery. The present study prospectively validates the prognostic ability of quantifying carcinoembryonic antigen (CEA) mRNA in peritoneal washes by real-time reverse transcriptase-polymerase chain reaction. Based on a retrospective study of 197 curatively resected gastric cancer patients (training set), we determined a cutoff value of CEA mRNA using receiver-operating characteristic curve. We used this cutoff value to validate the risk of peritoneal recurrence in a new cohort of 86 gastric cancer patients (validation set) between July 2000 and December 2002 in a prospective study. During the median 30 months of postoperative surveillance, 20 of the 86 patients died, and 13 of the 20 developed peritoneal metastases. Peritoneal recurrence-free survival as well as overall survival was significantly worse in patients with positive CEA mRNA (P<0.0001). Multivariate analysis with the Cox proportional hazards model showed that positive CEA mRNA was a significant independent risk factor with both survival (P=0.0130) and peritoneal recurrence-free survival (P=0.0006) as end points. These results indicate that quantitation of CEA mRNA in peritoneal washes is a reliable prognostic indicator of peritoneal recurrence in the clinical setting.

[Off-pump coronary artery bypass grafting using graft to coronary shunt for acute coronary syndrome]

We developed graft to coronary shunt during off-pump anastomosis. Proximal anastomosis of saphenous vein graft (SVG) was done formerly, and vinyl chloride tube, 5 cm long and 2 mm in diameter, was inserted into SVG. Another end was inserted into coronary artery, and continuous suture around the tube was performed before removing the tube. This technique is fit to use for the anastomosis between SVG and #3. Because the tube is easily inserted into those parts without injury of intima, and distal right coronary artery needs enough blood supply. After the revascularization of left anterior descending artery and #3, the heart can be displaced to expose circumflex artery. We adopted this technique to 3 patients with acute coronary syndrome (ACS). Though this technique is not adopted for the patients having stenosis on #4, we conclude that SVG to coronary shunt could be a important part of the strategies of off-pump coronary artery bypass grafting (OPCAB) for ACS patients.

[Pulmonary embolectomy followed by lobectomy to treat for massive endobronchial bleeding; report of a case]

We describe a case of successful pulmonary embolectomy that required lobectomy to treat for endobronchial bleeding. Sixty-nine-year-old female got into shock required CPR during rehabilitation after replacement of femur head. Her enhanced computed tomography (CT) showed massive embolism in pulmonary artery. Emergency embolectomy was performed under cardiopulmonary bypass (CPB). A videoscope was employed to see inside the pulmonary artery. At the end of the CPB, endobronchial bleeding occurred. The right bronchus was occluded by balloon and CPB was weaned. The right lower lobectomy was done on the next day. She had got pyothorax by methicillin-resistant Staphylococcus aureus (MRSA), and has recovered after intravenous administration of antibiotics and continuous wash out of pleural space by saline containing 0.02% povidon-iodine. Postoperative scan showed no defects of blood flow and ventilation except resected lobe.

Hereditary paroxysmal ataxia with mental retardation: a clinicopathological study in relation to episodic ataxia type 2

A case of hereditary acetazolamide-responsive paroxysmal ataxia with mild mental retardation in an autopsied Japanese man is described. His ataxic attacks had occurred for approximately 65 years since the age of 6. One of his daughters had severe mental retardation and epilepsy, and the other had paroxysmal ataxic attacks and mild mental retardation. Analysis of the subject's CACNA1A gene and that in his daughter revealed neither mutations nor CAG expansion. Neuropathologically, cortical degeneration consisting of the marked loss of Purkinje and granule cells was found exclusively in the cerebellar vermis. This was consistent with findings at autopsy for cases reported as spinocerebellar ataxia 6. In addition, there were minor anomalies, such as hypoplastic cerebellum and brainstem, heterotopic Purkinje cells, and cortical microdysgenesis of the temporal lobe. It is considered that the cerebellar cortical degeneration and the minor malformations found in the brain are closely related to one another, rather than having occurred independently.

An effective iodide formulation for killing Bacillus and Geobacillus spores over a wide temperature range

AIMS

To develop a sporicidal reagent which shows potent activity against bacterial spores not only at ambient temperatures but also at low temperatures.

METHODS AND RESULTS

Suspension tests on spores of Bacillus and Geobacillus were conducted with the reagent based on a previously reported agent (N. Kida, Y. Mochizuki and F. Taguchi, Microbiology and Immunology 2003; 47: 279-283). The modified reagent (tentatively designated as the KMT reagent) was composed of 50 mmol l(-1) EDTA-2Na, 50 mmol l(-1) ferric chloride hexahydrate (FeCl(3).6H(2)O), 50 mmol l(-1) potassium iodide (KI) and 50% ethanol in 0.85% NaCl solution at pH 0.3. The KMT reagent showed significant sporicidal activity against three species of Bacillus and Geobacillus spores over a wide range of temperature. The KMT reagent had many practical advantages, i.e. activity was much less affected by organic substances than was sodium hypochlorite, it did not generate any harmful gas and it was stable for a long period at ambient temperatures. The mechanism(s) of sporicidal activity of the KMT reagent was considered to be based on active iodine species penetrating the spores with enhanced permeability of the spore cortex by a synergistic effect of acid, ethanol and generated active oxygen.

CONCLUSIONS

The data suggest that the KMT reagent shows potent sporicidal activity over a wide range temperatures and possesses many advantages for practical applications.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results indicate development of a highly applicable sporicidal reagent against Bacillus and Geobacillus spores.

[Pulmonary thromboendarterectomy for an elderly patient]

We describe a case of successful pulmonary thromboendarterectomy for an elderly patient. A 75-year-old female suffered from severe dyspnea in spite of administration of pulmonary vascular dilators and anticoagulants. Her pulmonary vascular resistance was 545 dyn x sec x cm(-5) and, her pulmonary angiogram and perfusion scan revealed that almost all branches of her right pulmonary artery were occluded. Pulmonary thromboendarterectomy was performed under cardiopulmonary bypass. A videoscope was employed to see inside of the pulmonary artery. Flexible aspirator chip was used to peed abnormal intima easily. A non-invasive intracranial oxygen saturation monitor was used for secure circulatory arrest. The duration of cardiopulmonary bypass was 101 minutes and minimum body temperature was 24.5 degrees C. Her symptoms improved markedly after operation, and she went back to the ordinary life. Pulmonary thromboendarterectomy was useful even for elderly patients under some modifications of the operative procedures.

Transient elevation of serum bilirubin (a heme oxygenase-1 metabolite) level in hemorrhagic stroke: bilirubin is a marker of oxidant stress

Bilirubin (Bil) is the end product of heme catabolism. The production of Bil reflects heme oxygenase-1 expression in response to oxidative stress in various diseases. To assess the role of Bil as a marker of oxidative stress in cases of brain damage, we measured serum Bil concentrations in patients with hemorrhagic stroke. Serum levels of total Bil were measured in 20 subarachnoid hemorrhage patients with symptomatic vasospasms and in 23 patients with intracerebral hemorrhage; concentrations were measured every day for 14 consecutive days. Serum Bil levels were significantly elevated in the early phases in both groups. Moreover, transient elevation was observed on the day prior to the observation of clinical manifestations of symptomatic vasospasm after SAH. Bil, known to be a powerful antioxidant, was induced after hemorrhagic stroke, reflecting the intensity of oxidative stress. Plasma Bil concentrations might serve as a useful marker of oxidative stress in hemorrhagic stroke patients.

A pitfall of the diagnostic process of differentiating bile peritonitis from acute appendicitis

BACKGROUND/AIMS

We often encounter patients with bile peritonitis expressing right hypogastralgia who have been easily misdiagnosed as acute appendicitis. The aim of this study is to clarify why patients with bile peritonitis express right hypogastralgia and to recommend a way in which to prevent misdiagnosis of patients with bile peritonitis with right hypogastralgia as acute appendicitis.

METHODOLOGY

Subjects were 12 patients with bile peritonitis who underwent laparotomy in Yokohama City Nambu Hospital or Critical Care and Emergency Center of Yokohama Citizen Medical Center Hospital. The spread of bile and inflammatory peritoneal fluid confirmed during laparotomy was compared with the preoperative abdominal findings.

RESULTS

Five of the 12 cases (42%) showed signs of peritoneal irritation only in the epigastric and right hypochondral region; 6 (50%) in the right lateral and hypogastric region; and 1 (8%) in the diffuse abdomen. Four of the 12 cases (33%) showed widespread inflammation and accumulation of fluid in the whole peritoneal cavity (generalized peritonitis). Five cases (42%) showed limited peritoneal inflammation with green coating, leaked bile, and accumulation of inflammatory fluid within the hepatoduodenal ligament, Morison's pouch, right paracolic gutter, and right ileac pouch. Three of these 5 cases and 3 of the 4 generalized peritonitis cases showed signs of peritoneal irritation in the right hypogastric region. US of these cases showed signs of cholecystitis. Three of the 6 cases underwent emergency operation by right hypogastric incision under the diagnosis of acute appendicitis. One of these 3 cases underwent neither US nor CT; the second of these cases showed ileocecal inflammation by US but did not undergo CT; and the last of these cases expressed peritoneal irritation most strongly in the right hypogastric quadrant despite of signs of cholecystitis by US and CT.

CONCLUSIONS

If patients who complain of right hypogastralgia like acute appendicitis also complain of right epigastralgia or right hypochondralgia, we should suspect biliary peritonitis due to gangrenous or perforated cholecystitis and should perform upper abdominal scanning, especially around the gallbladder, by US and CT.

Acute aortic thrombosis and renal infarction in acute cocaine intoxication: a case report and review of literature

Emergency room visits related to cocaine use have been increasing over the past 10 years, with the cost of cocaine-related hospitalization now more than 80 million dollars per year. Well-recognized and common complications associated with cocaine use include hypertension, cardiac ischemia, cerebrovascular accidents and rhabdomyolysis. Renal infarction is uncommon, while aortic involvement is even less documented in literature. We present the first report of a case of renal infarction and aortic thrombus in a patient who used nasal cocaine. This case suggests that aortic pathology should be considered in patients presenting with renal infarction related to cocaine use.

A rare case of a facial-nerve neurofibroma in the parotid gland

The incidence of solitary neurofibroma of the facial nerve originating in the parotid region is extremely low. We report a case of a solitary neurofibroma in a 30-year-old male, who initially presented with a parotid mass without facial paresis or paralysis. A chain of small nodules had been palpable in the right parotid region for the previous 2-3 years. MRI and CT scans revealed several small ovoid lesions extending from the frontal margin of the parotid gland to the retromandibular region. The lesions were surgically removed. The main trunk of the facial nerve was adherent to the dorsal side of the largest nodule; however, this mass was resected atraumatically. Histopathological examination indicated neurofibroma. The incidence, presentation, diagnosis and surgical treatment of intraparotid neurofibroma are discussed and compared with those of Schwannoma.

Changes in the response of neutrophils to endotoxin priming following major abdominal surgery

Endotoxin (ETX) primes polymorphonuclear cells (PMNs) for the subsequent release of reactive oxygen species (ROS) in response to various stimulants such as phorbol myristate acetate (PMA). Although PMNs contribute to oxidative stress after stimulation by standard stimulants and after priming by many humoral factors, it is unknown whether the PMNs from patients at different postoperative times exhibit the same response to the same standard stimulant. We examined the response of PMA-induced production of ROS from PMNs at various intervals after major abdominal surgery in response to ETX priming. This study was a prospective clinical and laboratory study conducted over a 7-day period that involved 25 patients who were referred for elective major abdominal surgery (8 for gastric cancer, 9 for colonic cancer, 8 for rectal cancer). Blood was sampled on the day before operation and on postoperative days (PODs) 1, 3, and 7. For each sample we measured luminol-dependent chemiluminescence (CL), the time to peak counts (Tmax) of PMNs stimulated by PMA, and the serum ETX level. We studied the correlation between CL and ETX in samples from PODs 1 and 3. We also studied the CL of PMNs on PODs 1 and 3 preincubated (primed) with various concentrations of ETX (0, 20, 40, 60, and 100 pg/ml). We found that CL decreased on POD 1 compared with the preoperative level (p <0.05) because of the decreased Tmax. The level of CL per 1 ml of whole blood, however, was higher on PODs 1 and 3 than preoperatively. During this time, leukocytosis should compensate for the impaired production of ROS by an individual PMN. The serum ETX level was increased on POD 1 (p <0.05). There was a negative correlation between CL and ETX on POD 1 (correlation coefficient ?0.62, p < 0.01) and a positive correlation on POD 3 (0.61, p <0.01). CL on POD 3 was accelerated by ETX priming, but the CL on POD 1 was depressed by the priming using a low concentration of ETX. The mode of the response of PMNs to ETX priming differed between PODs 1 and 3. On POD 1 the responses of PMNs to environmental stimulants is suppressed, but by POD 3 these responses had increased.

Signals via FGF receptor 2 regulate migration of endothelial cells

Fibroblast growth factors (FGFs) stimulate angiogenesis, of which signals are transduced via FGF receptor (FGFR) tyrosine kinases. Although FGFR1 is a major receptor in endothelial cells, FGFR2 is frequently detectable in endothelial cells. We have previously demonstrated that the intracellular domain of FGFR1 sufficiently transduced signals leading to proliferation, migration, urokinase secretion, and tube formation. However, little is known about the roles of signaling via FGFR2 alone in endothelial cells. Murine brain capillary endothelial cells, denoted IBE cells, express small amounts of IIIc FGFR2, which is not activated by keratinocyte growth factor (KGF). We then transfected the IIIb FGFR2 in these cells. Three stable cell lines expressing IIIb FGFR2 demonstrated chemotaxis toward KGF, but never proliferated, secreted urokinase, or formed tube-like structure by KGF treatment. Weak but sustained activation of mitogen-activated protein kinase (MAPK) was observed in these cells. Chemotaxis toward KGF was significantly attenuated by treatment with PD98059. This is the first demonstration that signaling solely via FGFR2 in endothelial cells only contributes to motility through MAPK.

Cutaneous polyarteritis nodosa: therapy and clinical course in four cases

Cutaneous polyarteritis nodosa (PN) has a benign and chronic course; relapses are frequently associated with steroid dependence. We have observed four cases of cutaneous PN in the past 15 years and followed up two of the four cases long-term for 13 and 10 years after diagnosis. There has been a marked contrast in the clinical courses of these two cases: one case has shown a complete remission for 12.5 years without treatment during the most recent 11 years; the other case had four relapses and has never experienced cessation of treatment. The only difference between the two cases was careful therapy with adequate prednisolone in the long-term remission case. The other two cases clinically showed erythema nodosum-like features, and they had antecedent sore throats and embedded chronic tonsillitis; one was associated with presumed streptococcal infection. These two cases may simply be an accelerated process of post-streptococcal erythema nodosum rather than typical cutaneous PN. We performed tonsillectomies as adjuvant therapy in these two cases. No relapse of the disease has been observed in these two cases, and the tonsillectomy allowed us to taper the dose of steroids, resulting in discontinuation of the treatment in one of the two cases. The duration of the remission as well as the adjuvant therapy was variable in each of our cutaneous PN cases. Tonsillectomy can be recommended as an adjuvant to steroids for PN cases with chronic tonsillitis and/or streptococcal infection.

Expression of carbamoylphosphate synthetase I and glutamine synthetase in hepatic organoids reconstructed by rat small hepatocytes and hepatic nonparenchymal cells

The objective of this study was to investigate the expression of carbamoylphosphate synthetase I (CPS) and glutamine synthetase (GS) in small hepatocyte colonies and whether the heterogeneous expression of the enzymes could be induced during the maturation of small hepatocytes. Small hepatocytes isolated from an adult rat liver were cultured and proliferated to form colonies. The expression of CPS and GS was examined using immunocytochemistry and immunoblotting. In this culture more than 99% of morphologically hepatic cells were positive for CPS and all small hepatocytes were negative for GS at day 5. CPS-positive cells dramatically decreased with time in culture, whereas GS-positive ones appeared and their number increased in the colonies. Two to 3 weeks after plating, colonies with rising and piled-up cells appeared and the number of such colonies reached about 25% of all colonies at day 30. In most rising and piled-up cells in colonies both proteins were strongly expressed, whereas many small hepatocytes in monolayer colonies did not express either protein. When small hepatocytes in monolayer colonies were overlayed with Matrigel, the cells gradually piled up and both CPS and GS proteins were dramatically induced. The expression of CPS and GS in small hepatocytes may interact with the extracellular matrix because the rising and piled-up cells appear to be induced by the extracellular matrix produced by hepatic nonparenchymal cells.

Recent trend of increase in proportion of low birthweight infants in Japan

BACKGROUND

The proportion of low birthweight babies (LBW: 1500-2499 g) in Japan decreased steadily from 1950 to the 1970s. However, since then it has started to increase consistently, the reason for which has not been discussed in detail.

METHODS

Trends of birthweight and the two known factors for low birthweight (maternal smoking, and pre-pregnancy weight) were analysed with vital statistics, national nutritional and smoking prevalence survey data.

RESULTS

Increase in term LBW due to intrauterine growth retardation, is the major risk factor for the overall increase since the 1970s. The increase of smoking prevalence in women in their thirties started in the 1970s, while that for women in their twenties started in the 1960s. The decrease of body mass index for women in their thirties also began in the 1970s, while that for women in their twenties began in the 1960s. The ratio of delivery to mothers in their thirties to mothers in their twenties has increased more than threefold compared to the late 1970s.

CONCLUSIONS

Since the 1970s increase in smoking prevalence and decrease in body mass index in young women, especially those in their thirties, appeared to be the major factors involved in the increase in LBW babies.

Relation between smoking prevalence and various social factors in Japan

Although the smoking prevalence among women is significantly low compared to that among men in Japan, the prevalence in young Japanese women has been steadily increasing recently. The relationship between the prevalence of smoking among the general population and various social factors was investigated with a special emphasis regarding the influence of household size on the smoking prevalence of young Japanese women. Thirty-one thousand and six hundreds twenty-seven subjects of 20 years and older were randomly selected from the general population of Japan. The Ministry of Health and Welfare, Japan planned and conducted the survey. Subjects were divided into male and female, and smoking prevalence was investigated in terms of age, place of residence, occupation and household size factors. Statistical analyses were performed using chi-square test and multiple logistic regression. Multiple logistic regression analyses suggested that for men there was a strong relationship between becoming a smoker and living in a municipality with a smaller population, and that for women who were living in a municipality with a larger population. For women, as the size of a household increased from living alone to a two- or three-generation household, the tendency to becoming a smoker decreased, but this tendency was not observed among men. As to reasons for quitting smoking, more women than men living in two- and three-generation households gave "family's advice" as a major reason (p < 0.01). The steady replacement of the traditional three-generation household by smaller households in Japan may lead to an increase in the number of young women who smoke.

Repair of articular cartilage on the surface of heat-treated bone by transplantation of cultured chondrocytes

The present study addresses clinical problems associated with the degeneration of articular cartilage, which occurs when heat-treated bone with articular cartilage is used for re-implantation after resection of malignant bone tumors adjacent to the joints. We therefore evaluated the effect of transplantation of chondrocytes embedded in collagen gel on the surface of heat-treated bone. A cylindrical complex of bone and articular cartilage 6 mm in diameter was resected from rabbits' patellar grooves and treated in saline at 60 degrees C for 30 min. In Group A, articular cartilage was resected from the complex and the remaining bone was returned to the patellar groove. Then, autologous chondrocytes cultured in collagen gel were transplanted and covered with periosteum. As controls, the original complex of heat-treated bone and articular cartilage (Group B) and heat-treated bone directly covered with periosteum (Group C) was returned to the patellar groove. In Group A, histological study showed that round cells were mainly observed and the matrix was well stained with Safranin O in the repair tissue after 24 weeks. The repair tissue was as thick as the adjacent normal cartilage. Immunohistological study detected type-II collagen and chondroitin-6-sulphate (3B3+) in the matrix of the repair tissue, but not type-I collagen. The repair tissue was consequently cartilaginous in Group A. The repair tissue was not cartilaginous or was degenerative in the control groups. We believe that this modality of heat-treated joints will contribute to limb salvage reconstruction after resection of malignant bone tumors adjacent to the joints.

Profiles of maternally expressed genes in fertilized eggs of Ciona intestinalis

A set of 1,378 expressed sequence tags (ESTs), both the 5'-most and 3'-most ends, derived from Ciona intestinalis fertilized eggs was categorized into 1,003 independent clusters. When compared with sequences in databases, 452 of the clusters showed significant matches with reported proteins, while 190 showed matches with putative proteins for which there is not enough information to categorize their function, and 361 had no significant similarities to known proteins. Sequence similarity analyses of the 452 clusters in relation to the biological function as well as the structure of the message population at this stage demonstrated that 362 of them have functions that many kinds of cells use, 65 are associated with cell-cell communication, including a candidate cDNA for sonic hedgehog, and 25 are transcription factors. Sequence prevalence distribution analysis demonstrated that the great majority (78%) of the mRNAs are rare mRNAs or are represented by a single clone/cluster. All of the 1,003 clusters were subjected to whole-mount in situ hybridization to analyze the distribution of the maternal mRNAs in fertilized eggs, and a total of 329 genes showed localized distribution of the mRNAs: 16 showed cortical localization, 12 showed mitochondrial-like distribution, 99 crescent-like distribution, 63 partial localization, and 139 weak localization. When the distribution pattern of all the maternally expressed mRNAs was examined in the 8-cell stage embryos, it became evident that 248 genes which have localized mRNA patterns at the fertilized egg stage lose their localized distribution by the 8-cell stage. In contrast, 13 genes newly gain a localized pattern by the 8-cell stage. In addition, a total of 39 genes showed distinct in situ signals in the nucleus of blastomeres of the 8-cell stage embryo, suggesting early zygotic expression of these genes by this stage. These results suggest that complicated cytoplasmic movements are associated with the characteristic distribution of maternal mRNAs, which in turn support proper embryonic axis formation and establishment of the genetic network for embryonic cell specification.

[A case of bilateral synchronous renal cell carcinoma treated with left partial nephrectomy and laparoscopic right nephrectomy]

We describe a case of bilateral synchronous renal cell carcinoma. A 70-year-old female was admitted to our department because of further examination for bilateral renal masses. Computed tomographic scanning and ultrasound examinations revealed bilateral solid enhanced renal masses, and bilateral renal cell carcinomas were suspected. First, partial left nephrectomy was performed. On the 21th day after the first operation, we confirmed the recovery of the left kidney, and performed right nephrectomy laparoscopically. The histopathological diagnosis revealed bilateral renal cell carcinomas. The patient is alive with no metastatic lesions and no recurrence at 16 months after the operations.

The anaphase inhibitor Pds1 binds to the APC/C-associated protein Cdc20 in a destruction box-dependent manner

An essential aspect of progression through mitosis is the sequential degradation of key mitotic regulators in a process that is mediated by the anaphase promoting complex/cyclosome (APC/C) ubiquitin ligase [1]. In mitotic cells, two forms of the APC/C exist, APC/C(Cdc20) and APC/C(Cdh1), which differ in their associated WD-repeat proteins (Cdc20 and Cdh1, respectively), time of activation, and substrate specificity [2, 3]. How the WD-repeat proteins contribute to APC/C's activation and substrate specificity is not clear. Many APC/C substrates contain a destruction box element that is necessary for their ubiquitination [4-6]. One such APC/C substrate, the budding yeast anaphase inhibitor Pds1 (securin), is degraded prior to anaphase initiation in a destruction box and APC/C(Cdc20)-dependent manner [3, 7]. Here we find that Pds1 interacts directly with Cdc20 and that this interaction requires Pds1's destruction box. Our results suggest that Cdc20 provides a link between the substrate and the core APC/C and that the destruction box is essential for efficient Cdc20-substrate interaction. We also find that Pds1 does not interact with Cdh1. Finally, the effect of spindle assembly checkpoint activation, known to inhibit APC/C function [8], on the Pds1-Cdc20 interaction is examined.

Correlations between P300 components and regional cerebral blood flows

To evaluate the diagnostic importance of event-related potential P300, the correlation between P300 and regional cerebral blood flow (rCBF) was investigated in various brain regions in patients with multiple cerebral infarction (16 cases), chronic alcoholism (11 cases) and Alzheimer's disease (5 cases) and in seven healthy people. Cognitive function was also evaluated by mini-mental state examination. P300 latency and rCBF was measured by recording of evoked potentials using an oddball paradigm and stable xenon computed tomographic scanning, respectively. A significant (P<0.05) negative correlation between P300 and rCBF was observed in the thalamus in patients with multiple cerebral infarction and chronic alcoholism. In addition, a significant (P<0.01) negative correlation between P300 latency and the mini-mental state examination score and positive correlation between rCBF in the thalamus and the mini-mental state examination score were observed. These findings suggest that P300 latency is associated with rCBF in the thalamus and cognitive function.

[A case of breast cancer with bone marrow and liver metastases responding completely to low-dose weekly paclitaxel combined with toremifene]

A 36-year-old woman was admitted to our hospital because of general malaise in October 1999. She was diagnosed with bilateral breast cancer with bone marrow and liver metastases. Low-dose weekly paclitaxel (60 mg/body/week) combined with toremifene (120 mg/day) was started in December 1999. Myelofunction was recovered after 2 weeks of chemotherapy (CT), and the primary tumors and cervical/axillary lymphadenopathy disappeared after 4 weeks of CT. Bone marrow and liver metastases was no longer detected after 16 weeks of CT, and the case was evaluated as a complete response (CR). The same therapy has been performed for eight months and no evidence of recurrence has been observed.

Vascular endothelial growth factor C promotes human gastric carcinoma lymph node metastasis in mice

Vascular endothelial growth factor (VEGF)-C, one of several members of the VEGF family, is a relatively specific lymphangiogenic growth factor. VEGF receptor (VEGFR)-3 (or Flt4) is a VEGF-C receptor with expression restricted to lymphatic endothelial cells. Since the mechanisms by which carcinoma cells metastasize to lymph nodes remain unclear, we constructed a VEGF-C transfectant (AZ-VEGF-C) from the AZ521 human gastric carcinoma cell line, which ordinarily shows little nodal metastatic potential and little VEGF-C expression. We orthotopically implanted transfected tumor cells into the stomachs of nude mice. The number of mice developing lymph node metastases and the number of lymph node metastases per mouse with nodal metastases were higher than with implants of mock-transfected control cells. Specifically, percentages of mice with lymph node metastases were 95.5% (21/22) for AZ-VEGF-C and 29.4% (5/17) for controls (P<0.01), while mean numbers of involved lymph nodes were 3.76 for AZ-VEGF-C and 1.00 for controls (P<0.01). No difference was found between AZ-VEGF-C and controls regarding cell growth and chemotactic responses in vitro, or in volumes of tumors arising from implanted cells. When we performed immunohistochemical staining for VEGFR-3 in these tumors to investigate lymphangiogenesis by VEGF-C, the number of vessels stained for VEGFR-3 in tumors and surrounding tissues was higher for AZ-VEGF-C than for controls. VEGFR-3-positive vessels occupied 14.9/1000 of microscopically examined areas for AZ-VEGF-C, but only 1.30/1000 for controls (P<0.001). Our results suggest that VEGF-C is a specific lymphangiogenic growth factor with an important role in lymph node metastasis.

Inhibition of FGF-2-mediated chemotaxis of murine brain capillary endothelial cells by cyclic RGDfV peptide through blocking the redistribution of c-Src into focal adhesions

The alpha(v)beta(3) integrin is essential for fibroblast growth factor (FGF)-induced angiogenesis in vivo. However, the role of this integrin in FGF-2-mediated cellular responses by cultured endothelial cells is largely unknown. Cyclic RGDfV (cRGDfV) peptide is widely used to inhibit the binding of alpha(v)beta(3) integrin to vitronectin. To investigate the role of this integrin in FGF-2-mediated cellular responses, we used immortalized murine brain capillary endothelial cells, denoted IBE cells. Because IBE cells proliferate and migrate in response to FGF-2-treatment, when cultured on fibronectin-coated surface, we first examined the inhibitory activity of this peptide on the binding of alpha(v)beta(3) integrin to fibronectin as well as vitronectin. Solid phase binding assay revealed that cRGDfV peptide strongly inhibited the binding of purified alpha(v)beta(3) integrin to vitonectin- and fibronectin-coated plastic surfaces at a concentration of 50 microM. cRGDfV peptide at 50 microM inhibited spreading as well as adhesion of IBE cells on vitronectin-coated plastic surface but not on fibronectin. On fibronectin-coated substrata, cRGDfV at 50 microM attenuated FGF-2-mediated chemotaxis, but not FGF-2-induced proliferation, of IBE cells. We have previously demonstrated that mitogen-activated protein kinase (MAPK) activation within focal adhesions through c-Src activity was involved in FGF-2-induced chemotaxis of IBE cells. Treatment of cells with cRGDfV peptide was associated with reduced c-Src activity without tyrosine dephosphorylation. Immunofluorescent staining showed that cRGDfV inhibited redistribution of c-Src into focal adhesions. MAPK activation by FGF-2 within focal adhesions was also attenuated in the presence of cRGDfV peptide. Our results indicated that cRGDfV peptide inhibited redistribution of c-Src into focal adhesions, leading to impaired MAPK activation within focal adhesions and motility in FGF-2-treated endothelial cells.

L-histidine but not D-histidine attenuates brain edema following cryogenic injury in rats

Oxygen free radicals have been implicated in the genesis of traumatic brain injury and brain edema (BE). Recent studies have suggested that hydroxyl radical can initiate lipid peroxidation, thus producing lipid-free radicals that may become important sources of singlet oxygen. L-histidine, a singlet oxygen scavenger, potentially can be used to treat BE. In this study we investigated the effects of L-histidine and D-histidine on BE following cryogenic injury in rats. Male Wistar rats were anaesthetized with chloral hydrate. Vasogenic BE was produced by a cortical freezing lesion. Generation of singlet oxygen from photoactivation of rose bengal was studied by electron spin resonance (ESR). Animals were separated into four groups: sham rats (n = 5), saline-treated rats (n = 10), L-histidine treated rats (n = 6) and D-histidine treated rats (n = 7). Each agent (100 mg/kg) was administered intravenously at 30 minutes before lesion production. Animals were sacrificed at 24 hours after lesion production and the brain water content was determined by the dry-wet weight method. L-histidine had no effect on rectal and brain temperature. Election Spin Resonance studies demonstrated that L-histidine is a singlet oxygen scavenger. L-histidine but not D-histidine significantly attenuated BE following cryogenic injury (p < 0.05). In conclusion, L-histidine is useful in the treatment of traumatic BE.

Protective effect of a novel vitamin E derivative on experimental traumatic brain edema in rats--preliminary study

Oxygen free radicals have been proposed to be one of the major mechanisms of secondary brain damage in traumatic brain injury. Protective effect by vitamin E against oxidative damage has attracted much attention. Recent studies have demonstrated a novel vitamin E derivative, 2-(alpha-D-glucopyranosyl)methyl-2,5,7,8-tetramethylchroman-6-ol (TMG), has excellent water-solubility and antioxidant activity. The purpose of this study was to investigate protective effects of TMG on experimental traumatic brain edema (BE). Male Wistar rats were anaesthetized with chloral hydrate. Traumatic BE was produced by a cortical freezing lesion. Animals were separated into three groups: saline-treated rats (n = 4), TMG-treated (4 mg/kg) rats (n = 7) and TMG-treated (40 mg/kg) rats (n = 8). Saline or TMG was administered intravenously before lesion production. Animals were sacrificed at 6 hours after lesion production and the brain water content was determined by the dry-wet weight method. Half-life of TMG after intravenous administration of TMG was also investigated. The half life of TMG was approximately 5 minutes. TMG (40 mg/kg) significantly attenuated BE following cryogenic brain injury (p < 0.01). In conclusion, this preliminary study has demonstrated that a novel vitamin E derivative might be promising in the treatment of traumatic BE.

Gene expression profiles in Ciona intestinalis tailbud embryos

A set of 3423 expressed sequence tags derived from the Ciona intestinalis tailbud embryos was categorized into 1213 independent clusters. When compared with DNA Data Bank of Japan database, 502 clusters of them showed significant matches to reported proteins with distinct function, whereas 184 lacked sufficient information to be categorized (including reported proteins with undefined function) and 527 had no significant similarities to known proteins. Sequence similarity analyses of the 502 clusters in relation to the biosynthetic function, as well as the structure of the message population at this stage, demonstrated that 390 of them were associated with functions that many kinds of cells use, 85 with cell-cell communication and 27 with transcription factors and other gene regulatory proteins. All of the 1213 clusters were subjected to whole-mount in situ hybridization to analyze the gene expression profiles at this stage. A total of 387 clusters showed expression specific to a certain tissue or organ; 149 showed epidermis-specific expression; 34 were specific to the nervous system; 29 to endoderm; 112 to mesenchyme; 32 to notochord; and 31 to muscle. Many genes were also specifically expressed in multiple tissues. The study also highlighted characteristic gene expression profiles dependent on the tissues. In addition, several genes showed intriguing expression patterns that have not been reported previously; for example, four genes were expressed specifically in the nerve cord cells and one gene was expressed only in the posterior part of muscle cells.

This study provides molecular markers for each of the tissues and/or organs that constitutes the Ciona tailbud embryo. The sequence information will also be used for further genome scientific approach to explore molecular mechanisms involved in the formation of one of the most primitive chordate body plans.

[The validity of repeated mail surveys concerning smoking habits for Japanese physicians]

PURPOSE

A cross-sectional study of smoking prevalence among medical doctors was performed using questionnaires. Mailing four times proved essential in order to obtain a reasonable number of responses from the subjects. The objective of the present study was to analyze the smoking characteristics of the subjects who returned the questionnaires after the second to fourth mailings.

METHODS

A set of an anonymous questionnaire and a letter from the President of the Japan Medical Association (JMA) requesting cooperation was mailed with a return envelope with the subject's name and address written to 3,000 male and 1,500 female doctors randomly selected from the roster membership of the JMA. The survey was conducted between February and June 2000.

RESULTS

The collection rate after the first mailing was 66%, while the subtotal collection rate for the second through fourth mailings was 21%, bringing the grand-total to 87%. The total prevalence of smoking among the subjects who had sent back the questionnaire on the second to fourth mailings was approximately 1.5 times higher than for those who had sent back the questionnaire after the initial mailing for both male and female subjects. As to other characteristics of the subjects who only responded after the second to fourth mailings were: working in hospitals (odds ratios; male: 1.39, female: 1.47), not giving smoking cessation guidance (odds ratio; male: 0.58), and not recognizing the idea that doctors should not smoke (odds ratio; female: 0.67).

CONCLUSIONS

The results suggested that for future surveys on smoking to be conducted in academic institutions or work-places, efforts to obtain responses from those who do not answer the first attempt should take into consideration these points.

Corticotroph cell adenoma without typical manifestations of Cushing's disease presenting with cavernous sinus syndrome following pituitary apoplexy

This report presents a unique case of corticotroph cell adenoma in a 30-year-old man without acromegaly or features typical of Cushing's disease, who developed cavernous sinus syndrome following pituitary apoplexy. Magnetic resonance imaging revealed a large intrasellar/suprasellar mass with pituitary hemorrhage and extension of a hematoma to the anterior base of the skull. Urgent transnasal pituitary surgery revealed an acidophilic pituitary adenoma, with immunoreactivity for ACTH and GH and expression of proopiomelanocortin (POMC) and GH messenger ribonucleic acid (mRNA) demonstrated by in situ hybridization. To our knowledge, a silent corticotroph cell adenoma with GH production has never been reported. This type of adenoma may potentially enlarge and develop tumoral hemorrhage because it is free of endocrinological symptoms.

Maintenance of connexin 32 and 26 expression in primary cultured rat hepatocytes treated with 3-acetylpyridine

BACKGROUND AND AIM

We recently reported that primary rat hepatocytes treated with 3-acetylpyridine (3-AP), an analog of nicotinic acid, could maintain hepatic differentiated functions such as albumin, tryptophan 2,3-dioxygenase, and connexin 32 (Cx32) mRNA expressions for more than a week. In the present experiment, we investigated the expression of not only Cx32, but also Cx26 in cells treated with 10 mmol/L 3-AP in detail.

METHODS

We examined the expression of Cx32 and Cx26 in primary rat hepatocytes by using the methods of immunocytochemistry, immunoelectron microscopy, northern blotting, and dye-transfer.

RESULTS

The hepatocytes treated with 3-AP were polygonal with a large cytoplasm from day 3, and were maintained for approximately 2 weeks, whereas the cells without 3-AP began to die from day 4. Immunocytochemically in the cells with 3-AP, many Cx32- and Cx26-positive spots were observed between most adjacent cells, and the intensity of positive spots increased with time in culture, whereas in the cells without 3-AP, Cx32- and Cx26-positive spots disappeared at day 4. Furthermore, most Cx26-positive spots were colocalized with Cx32-positive ones. The amounts of Cx32 and Cx26 mRNA transcripts in the cells with 3-AP at day 14 were more than 80% and approximately 30% of those of Cx32 and Cx26 mRNA transcripts in the cells at day 1, respectively. Gap junctional intercellular communication was maintained in the cells treated with 3-AP at day 8, although it was lost in the cells without 3-AP.

CONCLUSION

Thus, the addition of 10 mmol/L 3-AP to the medium enhanced the maintenance of Cx32 and Cx26 expression, which is one of the hepatic differentiated functions, in primary rat hepatocytes for a long time.

Identification and characterization of a sac domain-containing phosphoinositide 5-phosphatase

We have characterized a novel Sac domain-containing inositol phosphatase, hSac2. It was ubiquitously expressed but especially abundant in the brain, heart, skeletal muscle, and kidney. Unlike other Sac domain-containing proteins, hSac2 protein exhibited 5-phosphatase activity specific for phosphatidylinositol 4,5-bisphosphate and phosphatidylinositol 3,4,5-trisphosphate. This is the first time that the Sac domain has been reported to possess 5-phosphatase activity. Its 5-phosphatase activity for phosphatidylinositol 4,5-bisphosphate (K(m) = 14.3 microm) was comparable with those of Type II 5-phosphatases. These results imply that hSac2 functions as an inositol polyphosphate 5-phosphatase.

[A case of Mycobacterium intracellulare lung disease occurred in a middle-aged man who complained hemoptysis with normal chest roentogenogram]

A 45-year-old man visited our clinic because of intermittent bloody sputum. The chest roentogenogram was normal, but the high-resolution computed tomography (HRCT) showed very small nodules and bronchiolitis adjacent to pleura in the upper right lung field. The bronchoscopic examination revealed blood-streaked bronchial secretion in the right upper lobe bronchus, and the cultures of the sputa and the bronchial washing specimen showed acid-fast bacilli identified as Mycobacterium intracellulare by DNA-DNA hybridization (DDH) method. This case was diagnosed as Mycobacterium intracellulare lung disease. The patient received isoniazid, levofloxacin, and clarithromycin for three years without clinical and bacteriological improvement. His hemoptysis and the number of colonies recovered from sputum cultures decreased without any medication later. The serial chest roentogenograms and HRCTs have showed no changes for 6 years after the diagnosis. This case may show some clues to elucidate the mechanism of the onset of Mycobacterium intracellulare lung disease without predisposing conditions.

[Severe Klebsiella pneumonia improved by endotoxin adsorption and continuous hemodiafiltration]

A 57-year-old man who had past history of alcoholic hepatitis was admitted to our hospital because of fever, general malaise and dyspnea. Chest X-ray films and computed tomographic scans disclosed lobar pneumonia of the right upper lobe. Laboratory tests showed hypoxemia and renal dysfunction. Artificial ventilation, endotoxin adsorption (PMX) and continuous hemodiafiltration (CHDF) were started on the day after admission because of the appearance of progressive renal failure, hypotension and disturbance of consciousness. A diagnosis of septic multiple organ failure was made on the basis of a blood and sputum culture that revealed a K. pneumoniae infection. After the initiation of intensive therapy, the patient's general condition improved and artificial ventilation, PMX and CHDF were withdrawn. However, MRSA was isolated from sputum specimens and a lung abscess developed. In spite of vancomycin administration, the effect was limited. The patient underwent a right upper lobectomy and was discharged. The prognosis of bacteremic K. pneumoniae pneumonia in alcoholics is reported to be very poor. In our case, it is suggested that PMX and CHDF contributed to the improvement of the clinical course.

Smoking prevalence and attitudes toward smoking among Japanese physicians

CONTEXT

The World Health Organization has advocated that physicians should not smoke cigarettes and surveys on this issue should be conducted among medical professionals. However, no nationally representative surveys of smoking among physicians in Japan have been reported.

OBJECTIVES

To estimate the nationwide prevalence of smoking and determine the attitudes toward smoking among Japanese physicians.

DESIGN, SETTING, AND PARTICIPANTS

Descriptive study in which anonymous questionnaires were mailed to 4500 randomly selected physician members of the Japan Medical Association in the year 2000, which represents 63% of all Japanese physicians; 3771 (84%) respondents were included in the analysis.

MAIN OUTCOME MEASURES

Smoking prevalence among physicians, history of smoking, and attitudes toward smoking.

RESULTS

The prevalence of cigarette smoking among physicians was 27.1% for men and 6.8% for women, about half the age-adjusted prevalences among the general Japanese population. Smoking prevalence was higher among male physicians in Japan than those in the United States (3%-10%) and the United Kingdom (4%-5%). Smoking prevalence differed by age, with the highest prevalence among male past smokers aged 70 years or older (51.8%; 95% confidence interval [CI], 47.4%-56.2%). Among male current smokers, the highest rates were for those aged 40 to 49 years (31%; 95% CI, 27.5%-34.5%); rates for female past smokers were highest among those aged 50 to 59 years (10.7%; 95% CI, 6.6%-14.8%) and for female current smokers were highest among those aged 70 years or older (8.2%; 95% CI, 4.8%-11.6%). Nonsmoking physicians had more unfavorable views toward smoking and were more active in encouraging patients not to smoke than those physicians who smoked.

CONCLUSION

Smoking cessation programs should be introduced among Japanese physicians to reduce the number of smoking physicians. Also, a continuing education program should be instituted to motivate physicians about their role in society.

[Pulmonary nocardiosis associated with nephrotic syndrome]

A 70-year-old man treated for 6 months with prednisolone for nephrotic syndrome, was referred to our pulmonary division because of a nodule in the right lower lung field. Nocardia asteroides was isolated from the culture of the percutaneous lung aspiration, and the case was diagnosed as pulmonary nocardiosis. The lesion disappeared after 2 months of therapy with sulfamethoxazole/trimethoprim (1,600 mg/320 mg once a day). Though it had been given prophylactically (800 mg/160 mg twice a week) for the prevention of pneumocystis carinii pneumonitis.

[A case of mucoid impaction of bronchi (MIB) due to Schizophyllum commune]

A 51-year-old woman was admitted because of a productive cough. Atelectasis of the left upper lobe and eosinophilia were noted. The atelectasis was resolved after bronchoscopic removal of the mucous plug. Pathologically, it consisted of eosinophil accumulation with hyphae. Cultures of sputum samples revealed Schizophyllum commune. We diagnosed this case as mucoid impaction of bronchi due to S. commune. Eight months later, a productive cough developed again. Chest radiography showed atelectasis of the right middle lobe. Cultures of bronchial washings yielded S. commune and Aspergillus niger. The atelectasis was resolved by four months of administration of itraconazole (200 mg daily).