Spatial and temporal expression patterns of the cyclin-dependent kinase (CDK) inhibitors p27Kip1 and p57Kip2 during mouse development

The cyclin-dependent kinase (CDK) inhibitors p27Kip1 and p57Kip2 are thought to regulate progression of the cell cycle. We have previously shown that the phenotypes of p27-/- mice are substantially different from those of p57-/- mice, suggesting that spatial and temporal expression patterns of p27Kip1 and p57Kip2 might be distinct. In this study, the roles of p27Kip1 and p57Kip2 in development were examined by characterizing their expression patterns during mouse embryogenesis by immunohistochemical analysis. Whereas certain organs and tissues (brain, lens, ganglion, lung, heart, liver, skin and kidney) expressed both proteins, others expressed only p27Kip1 (thymus, spleen, retina, testis and ovary) or only p57Kip2 (gut, palate, pancreas, cartilage and skeletal muscle). In addition, some organs expressed both p27Kip1 and p57Kip2 but showed mutually exclusive patterns of distribution among tissues. Thus, in the adrenal gland, p57Kip2 was expressed in the cortex but not in the medulla, whereas p27Kip1 was expressed in the medulla but not in the cortex. Whereas the expression of p57Kip2 in most tissues was restricted to embryogenesis, expression of p27Kip1 in many tissues was maintained in adult animals. Double-label immunofluorescence staining with either anti-p27Kip1 or anti-p57Kip2 and anti-BrdU revealed that the expression of p27Kip1 and p57Kip2 was inversely correlated with cell proliferation, suggesting that p27Kip1 and p57Kip2 are expressed exclusively in postmitotic cells. These complex spatial and temporal patterns of expression are consistent with the phenotypes of mice deficient in p27Kip1 or p57Kip2, and they suggest that these proteins might play important roles in tissue development.

Nafamostat mesilate treatment during open heart operation in immune thrombocytopenic purpura

A 58-year old woman with idiopathic thrombocytopenic purpura underwent mitral and aortic valve replacements and tricuspid annuloplasty. Preoperative therapeutic interventions including prednisone and immunoglobulin were successful in elevating the platelet count to 93,000/ mm2. Furthermore, we used nafamostat mesilate for coagulopathy prophylaxis during cardiopulmonary bypass. Postoperative bleeding was average and clinical course was uneventful. The perioperative management for patients with idiopathic thrombocytopenic purpura requiring cardiac operation is reviewed.

Aberrant cell cycle checkpoint function and early embryonic death in Chk1(-/-) mice

The recent discovery of checkpoint kinases has suggested the conservation of checkpoint mechanisms between yeast and mammals. In yeast, the protein kinase Chk1 is thought to mediate signaling associated with the DNA damage checkpoint of the cell cycle. However, the function of Chk1 in mammals has remained unknown. Targeted disruption of Chk1 in mice showed that Chk1(-/-) embryos exhibit gross morphologic abnormalities in nuclei as early as the blastocyst stage. In culture, Chk1(-/-) blastocysts showed a severe defect in outgrowth of the inner cell mass and died of apoptosis. DNA replication block and DNA damage failed to arrest the cell cycle before initiation of mitosis in Chk1(-/-) embryos. These results may indicate that Chk1 is indispensable for cell proliferation and survival through maintaining the G(2) checkpoint in mammals.

Targeted disruption of Skp2 results in accumulation of cyclin E and p27(Kip1), polyploidy and centrosome overduplication

The ubiquitin-proteasome pathway plays an important role in control of the abundance of cell cycle regulators. Mice lacking Skp2, an F-box protein and substrate recognition component of an Skp1-Cullin-F-box protein (SCF) ubiquitin ligase, were generated. Although Skp2(-/-) animals are viable, cells in the mutant mice contain markedly enlarged nuclei with polyploidy and multiple centrosomes, and show a reduced growth rate and increased apoptosis. Skp2(-/-) cells also exhibit increased accumulation of both cyclin E and p27(Kip1). The elimination of cyclin E during S and G(2) phases is impaired in Skp2(-/-) cells, resulting in loss of cyclin E periodicity. Biochemical studies showed that Skp2 interacts specifically with cyclin E and thereby promotes its ubiquitylation and degradation both in vivo and in vitro. These results suggest that specific degradation of cyclin E and p27(Kip1) is mediated by the SCF(Skp2) ubiquitin ligase complex, and that Skp2 may control chromosome replication and centrosome duplication by determining the abundance of cell cycle regulators.

Clinicopathological features in misdiagnosed pancreatic carcinoma

BACKGROUND/AIMS

There is more potential for misclassification of adenocarcinoma of the pancreas than for many other cancers because of the difficulty of accurate diagnosis.

METHODOLOGY

We analyzed the clinicopathological features of 105 patients who were suspected of having unresectable adenocarcinoma of the pancreas on their 1st visit to our outpatient clinic.

RESULTS

Ten of 105 patients (10%) had been misdiagnosed as having pancreatic carcinoma. The final diagnoses were made mainly using dynamic computed tomography (CT) and/or histologic examination. The incidence of weight loss (> or = 7% of total-body weight, within 6 months before diagnosis) in the misdiagnosed patients was significantly lower than that in pancreatic carcinoma patients (30% vs. 67%, p=0.02). Serum CA19-9 abnormality (> 100 U/ml) was observed less frequently in the misdiagnosed patients than in the patients with pancreatic carcinoma (40% vs. 77%, p=0.01). The detection of a dilated main pancreatic duct and/or pancreatic mass by imaging modalities was less frequent in the misdiagnosed patients (p<0.01).

CONCLUSIONS

Dynamic CT and/or histologic examination may be essential when making a definite diagnosis of advanced pancreatic carcinoma. In addition, weight loss, serum CA19-9 abnormality, detection of a dilated main pancreatic duct and/or pancreatic mass may also be useful in making a differential diagnosis of this disease.

Site-directed mutagenesis and steady-state kinetic analysis of mutant enzymes of human adenylate kinase

Site-directed mutagenesis of human adenylate kinase (AK) was carried out on residues His36, Lys55, and the C-terminal segment (Val182, V186, and Leu193). Five mutants [(H36T, K55G, V182G, V186S, and L193Stop (deletion of residues 193-194)] were generated and analyzed by steady-state kinetics. H36T, K55G, and L193Stop mutants showed an increase of K(m) values (19.8-, 19.7-, and 11.3-fold) for AMP2- compared to that for the wild-type enzyme, and these residues appeared to interact with AMP2-. V182G showed an increased K(m) value (7.4-fold) for MgATP2-. Therefore, V182 may be essential for interaction with MgATP2-. V186S increased the K(m) value (7.0- and 7.5-fold) for MgATP2- and AMP2-. V186 may thus interact with both substrates. The C-terminal domain of AK appears to be essential for MgATP2- and AMP2- binding.

[A survey of opioid use in preanesthetic medication]

A mailing survey was carried out to assess the current practice of sedative premedication in anesthesia. Questionnaires were sent by mail to 77 university hospitals. We especially evaluated use of opioids for premedication. Sixty-one percent (n = 47) of the hospitals answered these questionnaires and 31 percent (n = 15) of them were using opioids for the preanesthetic medication. Pethidine was used most frequently for premedication of all opioids, and morphine was often used for the premedication before cardiac surgery. All opioids were administrated intramusculary both in adults and children.

Transarterial chemotherapy with zinostatin stimalamer for hepatocellular carcinoma

Zinostatin stimalamer (SMANCS) is a lipophilic intra-arterial chemotherapeutic agent for hepatocellular carcinoma (HCC). Thirty HCC patients underwent transcatheter arterial injection of 4 mg SMANCS-lipiodol emulsion. Their responses were evaluated by computed tomography 1 month after treatment. Complete response (CR) was defined as disappearance or 100% necrosis of all tumors. Partial response (PR) was defined as > or = 50% reduction and/or > or = 50% necrosis. We regarded the lipiodol accumulation in tumors as being necrotic. CR and PR were observed in 8 patients (27%) and 4 patients (13%), respectively, and the overall response rate (CR + PR/all patients) was 40% (12/30). Of 12 patients whose serum alpha-fetoprotein levels had been more than 200 ng/ml before treatment, 5 patients (42%) showed more than 50% reduction in this level within 1 month after treatment. Toxicity was quite acceptable, although grade 4 toxicity (WHO) was observed as liver dysfunction in 1 patient. Transarterial chemotherapy with SMANCS, which is well tolerated, appears to have moderate antitumor effect in patients with HCC.

[The effects of midazolam on the memory of pain]

The purpose of this study was to evaluate the effects of low dose midazolam (MZ) on memories of spinal puncture. The low doses of MZ were administered to 70 patients (ASA 1-2), of whom 37 patients were premedicated with atropine sulfate 0.5 mg and pethidine hydrochloride i.m. (group P), and 33 patients received no premedication (group N). Double blind randomized trials were conducted with the doses of MZ (0, 0.03, 0.06 mg.kg-1), and MZ was administered i.v. to the patients just prior to spinal puncture. Subjective evaluation of pain was performed with pain score (PS) on postoperative phase, and objective evaluation of pain was performed with the reaction of spinal puncture. Short term memory was impaired mainly after administration of MZ. However, subjective memory of pain almost disappeared, but objective evaluation was not so good. We conclude that MZ induces impairment to recall of pain. However, it might maintain the response to the pain.

[Anesthesia in two patients with essential thrombocythemia]

Case 1. The patient was a 69-year-old man with essential thrombocythemia (ET), who underwent urgent laparotomy. On admission he was dehydrated and the platelet count was more than 160 x 10(4).microliter-1, with hematocrit of 50%. Anesthesia was induced with ketamine i.v. and maintained with nitrous oxide and sevoflurane in oxygen. Postoperative care included the administration of gabexate mesilate (GM) which is an antiplatelet agent. Case 2. An 84-year-old woman with ET was diagnosed as gastric cancer and elective gastrectomy was scheduled. The platelet count was more than 100 x 10(4).microliter-1. The patient was anesthetized with nitrous oxide and oxygen supplemented with fentanyl and mepivacaine via epidural catheter. Intravenous infusion of GM was performed at a rate of 1 mg.kg-1.hr-1 during surgery. PF-4 and beta-TG were measured. These are platelet releasing factors. The level of PF-4 decreased to normal level during this procedure. In conclusions, it will be important to use GM during anesthesia in order to avoid the complications such as myocardial or pulmonary infarction caused by thrombocythemia.

Predictive factors for tumor response to systemic chemotherapy in patients with hepatocellular carcinoma

Chemotherapy is of limited value in the treatment of hepatocellular carcinoma (HCC), since there are no established chemotherapeutic regimens proven to be effective. The aim of the present study was to determine predictive factors for tumor response to systemic chemotherapy in HCC patients. The relationship between patients' characteristics and tumor response was examined in 147 previously untreated HCC patients receiving systemic chemotherapy. Ten patients showed partial response (PR) and none showed complete response (CR). The response rate for all single anticancer agents was less than 10% and the overall response rate was 6.8%. The response rate in patients with unilateral HCC was significantly higher than in those with bilateral HCC. However, there were no responders among patients with a performance status of 2-3, ascites, a tumor occupying more than 50% of the entire liver, tumor thrombus in the main portal trunk or a serum bilirubin level of more than 2.0 mg/dl. There was a close relationship between patients' characteristics and tumor response. It is concluded that patients with fairly advanced HCC and/or poor hepatic reserve should not be given systemic chemotherapy.

Hepatocellular carcinoma with gastrointestinal hemorrhage caused by direct tumor invasion to the duodenum

Gastrointestinal hemorrhage from hepatocellular carcinoma invading the duodenum is very rare. A 60-year-old man with multiple hepatocellular carcinoma was admitted to our hospital because of massive melena and hematemesis. We succeeded in hemostasis of an esophageal variceal rupture by endoscopic varicial ligation. The duodenum could not be observed endoscopically due to extramural compression to the stomach from the liver tumor. Massive gastrointestinal hemorrhage occurred again and the patient died of hepatic failure. The postmortem examination revealed that the liver tumor had invaded the second portion of the duodenum and perforated into the lumen.

[The use of low dose midazolam for the management of spinal anesthesia]

The purpose of this study was to evaluate the effects of low dose midazolam (MZ) on memories and ease of management of spinal anesthesia. The low doses of MZ were administered to 70 patients (ASA 1-2), of whom 37 patients were premedicated with atropine sulfate 0.5 mg and pethidine hydrochloride (group P), with 33 patients receiving no premedication (group N). Double blind randomized trials were conducted with the doses of MZ (0, 0.03, 0.06 mg.kg-1), and MZ was administered i.v. to patients just prior to spinal puncture. The short-term and long-term memories were impaired after administration of MZ in both groups. We conclude that MZ appears to be a suitable replacement for other benzodiazepines for relieving anxiety of patients during surgery.

Protracted 5-fluorouracil infusion with concurrent radiotherapy as a treatment for locally advanced pancreatic carcinoma

BACKGROUND

Radiotherapy plus bolus 5-fluorouracil (5-FU) is generally accepted as the standard treatment for locally advanced pancreatic carcinoma. To intensify the antitumor effect of chemotherapy, the authors administered protracted 5-FU infusion with concurrent radiotherapy. The aim of this study was to determine the feasibility and effectiveness of this combined therapy.

METHODS

Twenty patients, all of whom had histologically confirmed exocrine pancreatic carcinoma that was nonresectable but confined to the pancreatic region, were enrolled in a Phase II trial of protracted 5-fluorouracil infusion (200 mg/m2/day) with concurrent radiotherapy (50.4 gray in 28 fractions over 5.5 weeks). Chemotherapy began on the first day of radiation and continued through the entire radiation course. Thereafter, weekly infusions (500 mg/m2) were administered until disease progression.

RESULTS

Of the 20 patients, 17 (85%) completed the scheduled course of chemoradiotherapy. Grade 3 or worse toxicity, graded according to World Health Organization criteria, was observed in 4 patients (20%). Two patients (10%) achieved partial response, and disease remained stable in 16 patients (80%). After the completion of combined therapy, serum CA 19-9 levels were reduced by more than 50% in 10 of 12 patients (83%) who had pretreatment CA 19-9 levels of 100 U/mL or greater. The median progression free survival and 1-year progression free survival rate were 4.9 months and 29.5%, respectively. The median overall survival and 1-year overall survival rate were 10.3 months and 41.8%, respectively.

CONCLUSIONS

This treatment showed moderate activity against locally advanced pancreatic carcinoma and was accompanied by an acceptable toxicity level.

Prognosis of hepatocellular carcinoma patients with extrahepatic metastases

BACKGROUND/AIMS

There is no effective treatment for hepatocellular carcinoma (HCC) with extrahepatic metastases. This study investigated the survival and causes of death in HCC patients with extrahepatic metastases.

MATERIALS AND METHODS

We retrospectively analyzed 34 HCC patients with extrahepatic metastases who received systemic chemotherapy without other anticancer treatment except prior hepatectomy. We classified causes of death as cancer death and death from other causes, and subclassified cancer deaths into hepatic cause, extrahepatic cause and cachectic cause. Each cause of death was analyzed in the two subgroups comprised of 10 patients with bone metastases alone and 22 patients with metastatic lesions in sites other than bone.

RESULTS

Thirty-two of the 34 patients had died at the time of analysis. The median survival time and the 1-year survival rate were 4.6 mo and 20.3%, respectively. Incidence of hepatic cause, extrahepatic cause, cachectic cause and death from other causes were 21 (66%), 7 (22%), 2 (6%) and 2 (6%), respectively. In the subgroup of 10 patients with bone metastases alone, nine (90%) died from hepatic causes, but none died from extrahepatic causes. In the group of 22 patients with metastatic lesions in sites other than bone, 7 (32%) patients died from extrahepatic causes.

CONCLUSION

The causes of death in HCC patients with extrahepatic metastases depended on metastatic site at the time of diagnosis. The results of this study may be useful in the design and analysis of future clinical trials of the HCC therapy.

Clinical response to systemic combined chemotherapy with 5-fluorouracil and cisplatin (FP therapy) in patients with advanced pancreatic cancer

Pancreatic cancer shows high mortality and has a poor prognosis. Although the rate of response to all chemotherapeutic regimens is low, some patients have shown improvement of their symptoms after chemotherapy and/or radiotherapy without obvious tumor regression. We assessed the clinical benefit of systemic combined chemotherapy with 5-fluorouracil and cisplatin (FP therapy) in 21 patients with advanced cancer of the pancreas. The clinical response to FP therapy was evaluated using two parameters: pain (intensity of pain and consumption of morphine) and performance status. A patient was considered to be a clinical responder if one of two parameters was positive and the other was positive or stable. Four patients (19%) responded. Two of the responders achieved partial response according to the objective tumor response, and the remaining two showed no change. The survival period in responders was significant longer than in the other patients. The clinical response may be one parameter for evaluating the results of treatment for pancreatic cancer, and the longer survival period of the clinical responders in this study supports this notion.

The prognosis of patients with hepatocellular carcinoma of multicentric origin

BACKGROUND/AIMS

The characteristics of patients with multicentric hepatocellular carcinoma (HCC) differ from those of patients with intrahepatic metastatic HCC. However, there are few reports regarding the long-term results in patients with HCC of multicentric occurrence. The purpose of this study was to clarify the prognosis of a group of patients with multicentric HCCs.

MATERIALS AND METHODS

We evaluated the outcome in 28 patients with multiple hepatocellular carcinoma (HCC) suggestive of multicentric occurrence, all of whom underwent hepatic resection. The disease-free survival, recurrence pattern and survival were analyzed in the two subgroups of 12 patients with single advanced HCC (AdHCC) nodule and an early HCC (eHCC) or early advanced HCC (eAdHCC) nodule [Group A] and 16 patients with two AdHCC lesions [Group B]. These data were also compared with those of 58 patients with solitary AdHCC [Group C].

RESULTS

Both the disease-free survival and survival periods for Groups A and C were significantly longer than those for Group B, while no significant difference was seen between Group A and C. No significant differences among the three groups were recognized in the incidence of various types of recurrence pattern.

CONCLUSIONS

The long-term results in patients with multicentric HCC apparently vary depending on the pathological condition at the time of operation. Among patients with multicentric HCC, those with AdHCC combined with an eHCC or eAdHCC are likely to show improved prognosis as a result of hepatic resection.

Predictive factors for recurrence after percutaneous ethanol injection for solitary hepatocellular carcinoma

BACKGROUND/AIMS

Intrahepatic recurrence frequently occurs in patients with hepatocellular carcinoma (HCC) even after successful percutaneous ethanol injection (PEI). This study investigated factors predicting recurrence after PEI for solitary HCC.

MATERIALS AND METHODS

The subjects were 31 patients with solitary HCC (10-29 mm) who received successful PEI. We investigated the relationship of pretreatment clinicopathological variables to recurrence-free survival including: age, gender, alcohol abuse, tumor size, tumor staining, tumor differentiation, serum alpha-fetoprotein (AFP) level, associated liver disease, and Child-Pugh classification. Differences in recurrence-free survival among subgroups classified by each factor were evaluated using log-rank tests.

RESULTS

Median recurrence-free survival time, 1 and 2 years recurrence-free survival rates of all 31 patients were 1.57 years, 72.2% and 45.4%, respectively. Among the 9 variables evaluated, serum AFP level of 20 ng/ml or less (p < 0.005) and absence of cirrhosis (p = 0.025) were factors favoring longer recurrence-free survival significantly.

CONCLUSION

These results indicate that HCC patients with higher serum AFP level or coexistent cirrhosis should be followed more closely even after successful PEI.

[The use of low dose midazolam for the management of spinal anesthesia]

The present study was designed to evaluate the effects of low dose midazolam (MZ) on memories and ease of management of spinal anesthesia. MZ was administered to 103 patients (ASA 1-2), of whom 50 patients were premedicated with atropine sulfate 0.5mg and pethidine hydrochloride (group P), with 53 patients receiving no premedication (group nP). A double blind randomized trial was conducted with the dose of MZ (0, 0.01, 0.02, 0.04, 0.08 mg.kg-1), and MZ was administered i.v. to patients just prior to spinal puncture. The short-term and long-term memories were impaired after administration of MZ in both groups. But the recovery from impairment of memories was more rapid in the short-term memory than in the long-term memory, suggesting that MZ impairs mainly the acquisition of memories. A dose-dependent decrease in SpO2 was observed in group P. We conclude that MZ is a useful drug to relieve anxiety of patients during surgery, but it accompanies the risk of respiratory depression.

Construction of the plasmid PMEX8-HAK1 and random site-directed mutagenesis of human cytosolic adenylate kinase

The pMEX8-hAK1 vector was devised from the pAK plasmid (Kim J. H. et al., 1989, Protein Engineering 5, 379-386), which could directly express human adenylate kinase proteins without recombination and its single strand DNA could be withdrawn with helper phage for random site-directed mutagenesis. The conserved key residues at Lys21, Lys27, and Thr39 were engineered to obtain mutants for kinetic analysis. Three mutants were obtained as K21P, K27R, and T39S, their specific activities were strikingly reduced compared to those of wild type adenylate kinase. This pMEX8-hAK1 will be a powerful tool for site-directed mutagenesis to detect the substrate-enzyme interaction for human adenylate kinase including various other enzymes.

[The use of a laryngeal mask in a newborn infant with Nager acrofacial dysostosis]

A newborn female infant born at 41 week gestation with Nager acrofacial dysostosis had no congenital abnormalities in her parents and closed relatives. Her mother had uncomplicated pregnancy and normal delivery. Endotracheal intubation was attempted, because she developed apnea on her delivery, but it was not successful. She was transported immediately to our university hospital with mask ventilation. A laryngeal mask was placed after several trials of intubation, and ventilation was carried out successfully. We consider that the use of a laryngeal mask is one of the best ways in a case of difficult intubation.

[Severe theophylline toxicity in a pregnant asthmatic patient]

A 32 year old pregnant woman who had taken large doses of theophylline for asthmatic attack was brought to our emergency medical center with convulsion and respiratory disturbance. Serum theophylline concentration was 52 micrograms.dl-1 on admission. We intubated the patient to control convulsion and respiration and performed cesarean section. Serum theophylline concentration of the newborn was almost at the same level as that of her mother. Baby was placed on ventilator for several days and discharged without trouble. We must consider the pregnancy as a major risk factor of theophylline toxicity.