[Secondary leukemia after etoposide treatment involved MLL gene rearrangement]

The 11q23 chromosomal abnormality is frequently observed in infantile leukemia and secondary leukemia, and the translocation associated gene in infantile leukemia is called mixed-lineage leukemia (MLL) gene. A 50-year-old man was admitted because of left axillary lymphadenopathy and IBL like T cell lymphoma was diagnosed by lymph node biopsy. The patient responded to the LSG-9 protocol with complete remission. After 10 months he was readmitted because of fever and was diagnosed acute myeloblastic leukemia by bone marrow aspiration. Chromosome analysis revealed 11q23 abnormality, suggesting that the leukemia was induced by etoposide treatment. Southern blot analysis demonstrated DNA rearrangement in the MLL gene at 11q23. It was suggested that the breakpoint region of the MLL gene in secondary leukemia is the same as that of infantile leukemia.

Deformation of swollen erythrocytes provides a model of sickling-induced leak pathways, including a novel bromide-sensitive component

Deoxygenation-induced red blood cell (RBC) sickling probably activates multiple cation leak pathways. In an attempt to model this, we examined the net passive K efflux ("K leak") from normal and sickle RBCs undergoing elliptical deformation in hypotonic media (200 mOsmol/L). This hypotonic deformation activates two deformation-dependent K leak pathways that are not detectable during the balanced leak (Kefflux = Nainflux) resulting from deformation of RBCs in isotonic medium. These are (1) a calcium-dependent leak component and (2) a novel leak pathway that is inhibited by substitution of bromide (but not sulfamate) for chloride, which converts the unbalanced K leak (Kefflux > Nainflux) of hypotonic deformation to a residual balanced leak. This dramatic effect of hypotonic deformation is reversible, is detected in both normal and sickle RBCs, and is inhibited significantly by 4,4'-diisothiocyano-2,2'-stilbene disulfonate. Remarkably, bromide also inhibits by 55% the K leak resulting from authentic deoxygenation-induced RBC sickling and, thereby, blunts the imbalance of accompanying monovalent cation leaks. The unique effect of bromide is not readily explainable on the basis of known behaviors of known ion leak/transport pathways. The mechanical threshold for triggering K leak during hypotonic deformation is at applied shear stress of 164 dyne/cm2, a value similar to the abnormal susceptibility we previously found for oxygenated sickle RBCs during isotonic deformation. These data suggest that membrane stretch accompanying hypotonic deformation activates the same multiple leak pathways that contribute to net K leak during authentic RBC sickling, including a previously unknown bromide-sensitive leak.

Intravenous extended infusion of recombinant human soluble thrombomodulin prevented tissue factor-induced disseminated intravascular coagulation in rats

This study demonstrated that intravenous infusion of recombinant human soluble thrombomodulin (rhs-TM) could inhibit disseminated intravascular coagulation (DIC) caused by 4 hr infusion of tissue factor (TF) in rats. Extended infusion of TF reduced fibrinogen and platelet counts and elevated serum FDP level. Pretreatment and coinfusion of rhs-TM could block changes of these DIC-parameters without prolongation of APTT. Heparin, which is a potent anti-DIC drug, could also inhibit these changes with extra prolongation of APTT and PT. Thus, these results suggest thrombomodulin prevent DIC less bleeding tendency than heparin.

Electron microscopic and physicobiochemical studies on disorganization of the cytoskeletal network and integral protein (band 3) in red cells of band 4.2 deficiency with a mutation (codon 142: GCT-->ACT)

The role of band 4.2 deficiency in the pathogenesis of red cell membrane dysfunctions was studied in seven unrelated patients with complete band 4.2 deficiency with a point mutation (142 GCT-->ACT; 142 Ala-->Thr) on the cDNA of the band 4.2 gene. Two major types of abnormalities were detected in these patients; (A) abnormalities of the cytoskeletal network in the horizontal dimension, and (B) abnormalities of band 3 in the vertical dimension. Electron microscopy by the surface replica method and the quick-freeze deep-etching method demonstrated the markedly impaired cytoskeletal network (a disorganized cobblestone pattern, uneven distribution of junctional units, and the appearance of bulky aggregates after heat treatment). Ektacytometry showed a markedly decreased red cell deformability especially at 48 degrees C, although the cytoskeletal proteins themselves were essentially normal with normal mechanical stability of the Triton-shells. Electron microscopy by the freeze fracture method revealed a decreased number and a random distribution of intramembrane particles (IMPs) with a shift of the IMPs to a larger size. Fluorescence recovery after photobleaching studies on band 3 indicated the marked increase of its mobile fraction. The extractability of band 3 by Triton X in vitro was markedly enhanced, although the physico-biochemical properties of band 3 itself (the cleavage pattern of band 3 fragments, and the binding properties of band 3 to band 4.2 or ankyrin) were basically normal. These findings demonstrate that band 4.2 plays a crucial role in the maintenance of the normal structure and functions of both the cytoskeletal and integral proteins (band 3).

Effects of recombinant human soluble thrombomodulin (rhs-TM) on a rat model of disseminated intravascular coagulation with decreased levels of plasma antithrombin III

We reported that recombinant human soluble thrombomodulin (rhs-TM) is effective for disseminated intravascular coagulation (DIC) in vivo, in mice and rats. In the present work, we investigated the effects of decreased plasma antithrombin III (ATIII) levels on anticoagulant effects of rhs-TM, as compared to findings with heparin, of which effect is lowered by the decreased plasma ATIII levels in patients with DIC. Rat plasma ATIII levels decreased when we mixed plasma with anti-rat ATIII antibody and the potential of heparin to prolong APTT or PT was markedly diminished. The potential of rhs-TM to prolong APTT and PT was not affected. In rats injected with anti-rat ATIII antibody, plasma ATIII levels decreased immediately. When the rats were infused with tissue factor (TF), DIC was induced. At doses of rhs-TM and heparin which were equally effective at inhibiting the decrease in platelet count and fibrinogen level in control rats treated with TF, only rhs-TM remained effective in preventing DIC in rats with reduced ATIII levels. Heparin was not effective when administered to these rats with reduced ATIII levels. Therefore, rhs-TM effectively inhibits coagulation independent of ATIII levels, in contrast to heparin, which depends on the ATIII level.

Cleft lip mongolian spot: mongolian spot associated with cleft lip

BACKGROUND

Mongolian spots in the cleft area of cleft lip have been found in some Japanese children.

OBJECTIVE

Our purpose was to study the frequency of cleft lip mongolian spot in children with cleft lip of various severity.

METHODS

Sixty-six babies with unilateral cleft lip were divided into three groups: namely, those with microform cleft lip (10 subjects), incomplete cleft lip (30 subjects), and complete cleft lip (26 subjects). The incidence of cleft lip mongolian spot in the three groups was studied.

RESULTS

Thirty-six babies (55%) had a cleft lip mongolian spot. The mongolian spot was observed in no patients with microform cleft lip, in 18 patients (60%) with incomplete cleft lip, and in 18 patients (69%) with complete cleft lip.

CONCLUSION

Cleft lip mongolian spot appears in high incidence when the cleft goes beyond the vermilion border.

[Allogeneic cryopreserved marrow transplantation in a patient with chronic myelogenous leukemia]

A 45-year-old male with chronic myelogenous leukemia received cryopreserved allogeneic bone marrow from his HLA-identical sister. Bone marrow was harvested and cryopreserved prior to chemoradiotherapy since the donor had neurotic tendencies. The preconditioning regimen consisted of standard dosage of busulfan plus cyclophosphamide and total lymphoid irradiation (5Gy). A total of 3.1 x 10(7)/kg marrow mononuclear cells, containing 4.7 x 10(5) CD34+ cells/kg, and 8.0 x 10(6)/kg buffy coat cells collected from the donor at day 0 was infused. Marrow engraftment occurred by day 38 although hematological recovery was delayed and subsequent administration of GM-CSF, methylprednisolone and donor buffy coat cells were required. Mononuclear cells obtained from the patient's blood at day 28 had an inhibitory effect on CFU-GM formation of the donor's bone marrow mononuclear cells. We considered that this case suffered from a transient myelosuppression due to residual host cells after bone marrow transplantation.

"Turbo charging" the vertical rectus abdominis myocutaneous (turbo-VRAM) flap for reconstruction of extensive chest wall defects

We report our experience using "turbo charging" of the vertical rectus abdominis myocutaneous (turbo-VRAM) flap in 7 patients with extensive chest wall defects. The turbo-VRAM flap provides augmented blood supply with microvascular anastomosis between the inferior epigastric system and available vessels of the axillary, brachial or cervical vascular system. All patients in this study had uncomplicated recovery. In 3 patients, the skin paddle of the flap, which was designed as a fish shape, was effectively used to cover a wide defect. One patient required resection of some lower costal cartilages located near the superior epigastric vascular system in order to extend the rotation distance of the flap. These technical options have made the turbo-VRAM flap more versatile. The turbo-VRAM flap allows successful coverage of extensive chest wall defects, including defects of the axilla, upper arm, shoulder, or neck.

[Analysis of chronic graft-versus-host disease in patients after bone marrow transplantation from HLA-identical siblings]

The incidence of chronic GVHD, involved organs, and outcome were evaluated in 59 patients aged 15 years or more who survived for 2 months or more after HLA-matched bone marrow transplantation. The incidence of chronic GVHD was 65.3%. The incidence was not correlated with the age at the time of transplantation, underlying disease, or the method to prevent GVHD (group treated with MTX alone and CSP-treated group). Concerning the degree of organ involvement, the CSP-treated group more frequently showed slight involvement and, especially a significantly lower incidence of dryness of the eyeballs. According to organs, the oral cavity was most frequently involved (87%), followed in order by the liver (74%), skin (52%), and the eyes (30%). The oral cavity alone was involved in 6 patients, and the outcome was generally good. The outcome of multi-organ involvement of chronic GVHD was poor, and the major causes of death were interstitial pneumonia and sepsis. Even of patients who did not develop chronic GVHD, 25% showed dryness of the eyeballs and oral cavity. Biopsy and careful observation of the clinical course are needed for diagnosing GVHD.

Antithrombotic effect of recombinant human soluble thrombomodulin on endotoxin-induced disseminated intravascular coagulation in rats

Thrombomodulin (TM) is an endothelial cell membrane glycoprotein which neutralizes thrombin procoagulant activity and accelerates the thrombin-catalyzed activation of protein C. We expressed recombinant human soluble TM (rhs-TM) in Chinese hamster ovary cells and compared the effects of rhs-TM and heparin on endotoxin-induced experimental disseminated intravascular coagulation (DIC) in rats. Experimental DIC was induced by a continuous intravenous infusion of endotoxin for four hours. rhs-TM or heparin was infused simultaneously with endotoxin. Treatment with rhs-TM significantly reversed the endotoxin-induced changes in significantly reversed the endotoxin-induced changes in following parameters: platelet count, fibrinogen level and fibrinogen and fibrin degradation products. Furthermore, glomerular fibrin deposits elevated by endotoxin treatment were reduced by the rhs-TM administration. Heparin showed the similar effects to rhs-TM. Activated partial thromboplastin time (APTT) in rats receiving rhs-TM were slightly longer than APTT in endotoxin-treated rats, but rats receiving heparin had much more prolonged APTT. From these results, we concluded that rhs-TM may be useful for the clinical treatment of DIC while having only minor adverse effects on APTT.

[Treatment of aplastic anemia with antithymocyte globulin, Lymphoser Berna]

Twenty-four patients with aplastic anemia (19 severe: 5 moderate) were treated with combined immunosuppression consisting of antithymocyte globulin (ATG: Lymphoser Berna, Swiss Serum and Vaccine Institute Berne) and high-dose methylprednisolone. Danazol or meptiostane was administered concurrently for at least 3 months. Three batches of ATG were used, two were not absorbed with thrombocytes and one was absorbed with thrombocytes for the prevention of thrombocytopenia. Nine of 20 evaluable patient (45%) had sustained improvement in hematopoiesis within 3 months of treatment. Nine of 14 patients (64%) showed a response to ATG without thrombocyte absorption, on the other hand, none of 6 patients responded to ATG with thrombocyte absorption. By life table analysis, the 3 year probability of survival was 81 +/- 27% after the combined immunosuppressive therapy. These results indicated that ATG therapy was very effective in Japanese patients with aplastic anemia.

Double cross lip flaps for reconstruction of the lower lip

Squamous cell carcinoma of the lower lip is a common tumor. Of the many methods available for reconstructing lower lip defects after radical excision, we found double cross lip flaps from each lateral side of the upper lip philtrum rotated into the defect of the lower lip to be an effective method, not only functionally but also cosmetically. The main reason why satisfactory results were obtained by this procedure is that the anatomical structure (skin-orbicularis oris muscle-mucosa, vermilion) of the upper lip is very similar to that of the lower lip. Our experience is with double cross lip operations in the management of lower lip cancers are described.

Abdominoplasty in paraplegic patients

Obese paraplegics can suffer discomfort when they lie in a prone position and site in wheelchairs. Two paraplegic cases who underwent abdominoplasty to eliminate such complaints are presented, with satisfactory results.

Prefabricated flaps using tissue expanders: an experimental study in rats

The aim of this study was to determine if muscle vascularized pedicle flaps (MVP flaps) elevated in expanded tissue on the rat would survive to the same or greater area than flaps elevated in nonexpanded tissue. The animals were divided into three groups: group I (n = 10), with a tissue expander; group II (n = 10), with a tissue expander but not expanded; and group III (n = 10), with a thin silicone sheet (Biobrane). The mean surviving area of group I (96.6 +/- 3.6 percent) was statistically higher than that of group II (73.2 +/- 24.7 percent) (p < 0.05) and group III (59.5 +/- 25.1 percent) (p < 0.005). These experiments demonstrate that there is a larger area of flap survival in expanded muscle vascularized pedicle flaps than that found in nonexpanded flaps in rats. The mechanism of increased vascularity associated with tissue expansion is still unclear, but microangiography of flaps showed increased vascularity of the pedicle itself, especially in group I.

Pharmacokinetics of meropenem in experimentally burned rats

The pharmacokinetics of meropenem were investigated to examine its penetration into the skin of third degree burned rats. The rats were divided into two groups. One group acted as the control, and the other group had third degree burns induced by immersing their backs into 80 degrees C water for 20 seconds. The rats in each group were given 20 mg/kg of body weight of meropenem intravenously by one bolus injection seven days after burn inducement or depilation. In the non-burned control group, the maximum concentrations of meropenem in the serum and skin of 6.03 micrograms/ml and 0.12 microgram/g were respectively obtained 15 minutes after the injection and decreased very rapidly thereafter. In the burned rats, the maximum concentrations of meropenem in the serum, skin (eschar), and exudate fluid of 7.07 micrograms/ml, 1.44 micrograms/g and 5.99 micrograms/ml were respectively obtained 15 minutes after the injection and decreased very slowly. The penetration of meropenem into the burned skin was higher than that into the normal skin. These results suggest that meropenem is a very useful antibiotic in the treatment of burn infection.

Laserflowgraphy: a new visual blood flow meter utilizing a dynamic laser speckle effect

We developed a visual laser blood flow meter that is capable of providing two-dimensional color graphic representations of blood flow distribution for a given area by utilizing a dynamic laser speckle effect. The device is called the laserflowgraph. The principle and configuration of this flowmeter, comparison with the 133Xe clearance method, difference from thermography, and clinical uses of this flowmeter in flap monitoring are presented. Flow level of the laserflowgraph was significantly correlated with blood flow rate determined by 133Xe clearance in observations on the forearms of normal volunteers. The laserflowgraph reflected blood flow through the region between the skin surface and the deeper region of the papillary layer of the dermis. The laserflowgraph is a highly useful, practical, and reliable tool for assessing cutaneous blood flow and is expected to be applicable to various clinical fields.

Diphenylamine: an unusual antioxidant

Diphenylamine (DPA) has been utilized as an antioxidant in studies of lipid peroxidation. Using peroxidizing red blood cell (RBC) membranes, we find that DPA actually promotes lipid hydroperoxide (LOOH) formation and oxygen consumption while markedly inhibiting generation of thiobarbituric acid reactive substances (TBARS). As a consequence, DPA increases the prelytic RBC K leak that results from peroxidative stress and potentiates a known nonprelytic but LOOH-dependent K leak pathway in RBC. In contrast, DPA abolishes formation of cyclooxygenase-dependent conversion products of arachidonate. DPA is almost as efficient as BHT in inhibiting peroxyl radical mediated destruction of phycoerythrin fluorescence. Study of DPA analogues shows that the antioxidant effect of DPA lies in its secondary amine function. Presumably, this results in intermediate formation of a nitrogen-based radical so that redox cycling of this aromatic amine stimulates further peroxidation. This dramatically illustrates the hazard of relying solely on TBARS measurements for assessment of peroxidation.

Midface advancement by gradual distraction

Midface osteotomy was performed on 5 young adult sheep aged 10-12 months. In 4 animals midface advancement by gradual distraction was performed using an external device; one animal served as a control. The midface was advanced by 2 mm per day for 21 days. The amount of advancement was 36 mm in the nasofrontal area and 43 mm on the lateral aspect of the maxilla. After the period of active distraction the midface was maintained with external fixation for an additional 6 weeks to allow for ossification. Radiographs were obtained immediately postoperatively, after 21 days of distraction, and at the end of the 6 week fixation period. New bone formation in the distracted area was obvious radiographically, clinically and histologically. In conclusion, midface advancement by osteotomy and gradual distraction is possible in the sheep model and may offer controlled correction of deformity, obviating the need for the bone grafting.

Primary correction of the unilateral cleft lip nose

The details of surgical techniques for primary correction of the unilateral cleft lip nose and their results for 45 cases are reported. The technique employed an infracartilaginous incision on the affected side, thus allowing direct suturing of the alar cartilage onto the lateral cartilage. For the post-operative evaluation, the nasal form in both frontal and bottom views was scored for five items. In overall evaluation, the grades of "Good," "Fair," and "Poor" were derived from the total scores of five items. In the postoperative results (range of follow-up: 24 months to 84 months), 24 cases were rated "Good" (53.3%), 13 cases "Fair" (28.9%), and 8 cases "Poor" (17.8%). Thirty cases appear not to need secondary correction (66.6%). The technique is useful because the alar cartilages and lateral cartilages can be accurately sutured, and relatively stable results can be obtained.

Superiority of the fasciocutaneous flap in reconstruction of sacral pressure sores

The gluteal maximus muscle has been used in the treatment of sacral pressure sores since the 1970s. However, it is noted that the muscle portion of the transferred flap shows highly atrophic degeneration and the muscle itself is not suitable tissue for covering the pressure-bearing area. We have managed various fasciocutaneous flaps as the first choice for reconstruction of sacral pressure sores and obtained good results. The fasciocutaneous flap has an anatomical structure that resists physical stimulation or external pressure and an abundant blood supply via its fascial plexus. In addition, if we use a gluteal maximus myocutaneous flap at first, some fasciocutaneous flaps are compromised because of the design and blood supply. We suggest that the fasciocutaneous flap has the first priority and is superior to the gluteal maximus myocutaneous and muscle flaps in reconstruction of sacral pressure sores.

Silent mixed ganglioneuroma/pheochromocytoma which produces a vasoactive intestinal polypeptide

An unusual pheochromocytoma was incidentally discovered in a 48-year-old woman. The patient had a 3-year history of myasthenia gravis. At the time of examination in our hospital, the right adrenal tumor was incidentally discovered by ultrasonography of the abdomen. She had no history of headache, perspiration, palpitation or hypertension. Although blood catecholamine levels were within the normal limits, urinary secretion of catecholamine was elevated. Histologically, the tumor was diagnosed to be mixed ganglioneuroma/pheochromocytoma and histochemically confirmed to produce vasoactive intestinal polypeptide. Such a tumor is quite rare.

Detection, characterization, and bioavailability of membrane-associated iron in the intact sickle red cell

It is hypothesized that membrane-associated iron in the sickle red cell is of pathophysiologic importance, but the actual existence of such iron in the intact cell has been questioned. Using a strategy whereby membrane iron can be detected through its bioavailability for catalyzing peroxidation, we used phospholipid exchange protein to load membranes of intact erythrocytes (RBC) with approximately 2% phosphatidylethanolamine hydroperoxide (PEOOH) and monitored the development of peroxidation by-products during subsequent incubation. Normal RBC loaded with PEOOH developed very little peroxidation, but vitamin E-replete sickle RBC showed an exuberant peroxidation response that was not seen in cells loaded with control nonoxidized phosphatidylethanolamine. Ancillary studies of sickle RBC revealed that the catalytic iron included both heme iron and free iron located at the bilayer inner leaflet. Significantly, these studies also revealed that peroxidation after PEOOH loading is promoted by cellular dehydration and inhibited by hydration, thus identifying a dynamic interaction between hemoglobin (sickle >> normal) and membrane lipid. High-reticulocyte control RBC and sickle trait RBC behaved exactly like normal RBC, while HbCC RBC and RBC having membranes gilded with hemoglobin iron because of prior exposure to acetylphenylhydrazine showed an abnormal peroxidation response like that of sickle RBC. Indeed, the peroxidation response of RBC loaded with PEOOH paralleled amounts of iron measured on inside-out membranes prepared from them (r = 0.783, P < 0.01). These studies corroborate existence of membrane-associated heme and free iron in the intact sickle cell, and they document its bioavailability for participation in injurious peroxidative processes. That association of cytosolic sickle hemoglobin with membrane lipid is modulated by cell hydration status provides a mechanism that may help explain increased development of oxidative membrane lesions in abnormally dehydrated sickle RBC regardless of the mechanism underlying their formation.

Thrombospondin mediates adherence of CD36+ sickle reticulocytes to endothelial cells

Initiation of vasocclusion in sickle disease pathophysiology may involve abnormal red blood cell (RBC) adhesivity to endothelium, a phenomenon influenced by both RBC and plasma factors. Using human umbilical vein endothelial cells and a gravity sedimentation adherence assay, we have examined thrombospondin (TSP) as a plasma factor in this adhesive event. The already-abnormal adherence of sickle RBCs in buffer/albumin is significantly augmented (P < .001) by the addition of TSP, with half-maximal effect at about 0.3 microgram/mL. This effect is abolished by antibodies to either TSP or glycoprotein (GP) IV (CD36), as well as peptides RGDS and CSVTCG. The even greater adherence (P < .005) of sickle RBCs in autologous platelet-rich plasma (without added TSP) is dramatically inhibited by alpha CD36 antibodies (OKM5 and alpha GPIV) and significantly diminished by alpha TSP, by peptides RGDS and CSVTCG, and by two antibodies to the vitronectin receptor (7E3 and LM609). Studies of density-separated subpopulations and of RBC adhesion to immobilized proteins, as well as analysis of sickle RBCs using fluorescence-activated cell sorting and single cell microfluorometry, show that TSP responsiveness is a feature of the immature sickle "stress" reticulocytes, which carry CD36 (and not GPIIbIIIa-like receptors) as the TSP-receptive moiety. The endothelial cell's participation in this phenomenon appears to be more complex, and the data are consistent with the notion that it involves TSP interaction with other plasma proteins and/or multiple receptor structures. Other potential adhesogenic proteins (plasma von Willebrand factor, vitronectin, fibrinogen, and fibronectin) neither exhibited an affinity for reticulocytes nor supported increased sickle RBC adherence when added to buffer/albumin in these assay systems. In aggregate, our results indicate that TSP may be the major promoter of RBC adhesivity in plasma, and they suggest that therapeutic benefit might derive from interference with sickle reticulocyte CD36, as achieved by antibodies and CSVTCG in these studies.

Exaggerated cation leak from oxygenated sickle red blood cells during deformation: evidence for a unique leak pathway

An abnormal susceptibility of the sickle red blood cell (RBC) membrane to deformation could compromise its permeability barrier function and contribute to the exuberant cation leakiness occurring during the sickling phenomenon. We examined this hypothesis by subjecting RBCs at ambient oxygen tension to elliptical deformation, applying shear stress in a viscous medium under physiologic conditions. Compared with normal and high-reticulocyte control RBCs, sickle RBCs manifest an exaggerated K leak response to deformation. This leak is fully reversible, is both Cl and Ca independent, and at pHe 7.4 is fully balanced so that Kefflux equals Nainflux. This abnormal susceptibility is also evident in that the K leak in response to deformation occurs at an applied shear stress of only 141 dyne/cm2 for sickle RBCs, as compared to 204 dyne/cm2 for normal RBCs. Fresh sickle RBC membranes contain elevated amounts of lipid hydroperoxide, the presence of which is believed to provide the biochemical basis for enhanced deformation susceptibility. When examined at pHe 6.8, oxygenated sickle RBCs acquire an additional, unbalanced (Kefflux > Nainflux) component to the K leak increment specifically ascribable to deformation. Studies with inhibitors suggest that this additional component is not caused by a known leak pathway (eg, either K:Cl cotransport or the Gardos channel). This abnormal susceptibility of the sickle membrane to development of cation leakiness during deformation probably contributes to the exuberant cation leak taking place during RBC sickling.

Periodicity of episode occurrences in rapid cycling affective disorders

We analyzed the medical records of nine patients with severe rapid cycling affective disorders (RCAD), and determined the cycle of mania occurrences by calculating the period between two successive onsets of mania for each patient. Using the cycle as the index we devised a cycle-oriented diagram by dividing the observation period by the index cycle, and visually studied the mode of episode occurrences. In seven patients, the onset of mania generally followed the index cycle, but sometimes shifted from the day estimated by the index cycle. The shift seemed to be caused by a cycle other than the index cycle, which appeared temporarily in the course. The period between two successive onsets of mania was often several times longer than the index cycle length. In patients with RCAD, some sort of periodic rhythms may possibly control the course of episode occurrences on a continuing basis.

Umbilical endometriosis

A 41-year-old woman with umbilical endometriosis is presented. The umbilical lesion is repeatedly painful and there is a bloody discharge simultaneous with the menstrual period. Treatment of umbilical endometriosis is by excision. Hormonal therapy results in its incomplete regression. Umbilical endometriosis is a very rare disease, but should be considered in the differential diagnosis of umbilical tumors.

Phospholipid asymmetry during erythrocyte deformation: maintenance of the unit membrane

To assess the red blood cell (RBC) membrane's ability to maintain normal phospholipid orientation in the face of deforming stress, we examined RBC subjected to elliptical, tank-treading deformation. As determined by accessibility to phospholipase digestion and by labelling with fluorescamine, normal RBC are able to fully preserve their phospholipid asymmetry despite attaining over 96% of their maximal possible deformation. Phospholipid orientation is unchanged during deformation even for RBC that are ATP-depleted or vanadate-treated and for RBC that already have destabilized phospholipids due to treatment with t-butyl hydroperoxide. These data indicate that maintenance of phospholipid organization during marked deforming stress and tank-treading motion of the membrane is ascribable predominantly to the passive stabilizing effect of membrane proteins. This provides additional evidence for the concept of a unit membrane characterized by intimate associations between lipid and protein.

[Treatment of aplastic anemia with antilymphocyte globulin, high-dose methylprednisolone and androgen]

Twenty-seven patients with aplastic anemia (20 severe: 7 moderate) were treated with combined immunosuppression consisting of antilymphocyte globulin (ALG: Ahlbulin, Green Cross Co., Osaka, Japan) and high-dose methylprednisolone. Danazol or meptiostane was administered concurrently for at least 3 months. Ten of 27 patients had sustained improvement in hematopoiesis within 3 months of treatment. Three patients with hematological response had a recurrence of pancytopenia 12-36 months after the combined immunosuppressive therapy. Six patients died due to fungal pneumonia (2), hepatic failure (2), interstitial pneumonitis (1) and complication following allogeneic bone marrow transplantation (1). By life table analysis, the survival rate for all patients was 76 +/- 8% at 4 years, with 70 +/- 10% survival rate for patients with severe aplastic anemia and 100% for patients with moderate aplastic anemia. The factors predicting the good response to the therapy were a longer interval from diagnosis to the therapy and higher counts of platelet and reticulocyte at admission.

Clinical evaluation of cutaneous malignant melanoma with histologically involved lymph node metastases

Thirty-six cases of cutaneous malignant melanoma with histologically involved lymph nodes were studied during a 2-10 year study period, and the characteristics of the metastasized nodes and the associated prognosis were compared. The results were as follows: 1) the survival rate in cases with 3 or fewer (n = 16) metastasized nodes was significantly higher than in cases with 4 or more positive nodes (n = 20); 2) the survival rate in cases in which metastasized nodes were limited to one regional lymph node section (n = 12) was significantly higher than in cases where metastasis extended to two or more intra-regional sections of nodes (n = 24); 3) cases which had nodes measuring 3.00 cm or less (n = 25) had significantly higher survival rates than those with nodes of 3.01 cm or more (n = 11). Therefore, the results indicate that the number of metastasized lymph nodes, the extension into regional lymph node sections, and the size of the metastasized lymph node(s) can be considered as important prognostic factors for melanoma patients.

The extensibility in human skin: variation according to age and site

Normal skin extensibility in the living body of 94 healthy male subjects ranging in age from 3 months to 73 years was determined quantitatively with the Bio-Skin Tension Meter at 12 sites. In comparison with the age of 20-29 years, the skin extensibility, particularly in the age group of less than 2 years, was significantly high. However, no significant difference from the age groups of 12-14, 15-19, 30-49 and over 50 years was found at any site. Correlation by age was noted at the extremities, excluding the posterior upper arm and at the lower abdomen, with the extensibility of the group less than 1 year as the maximum value, decreasing gradually down to 3-5 or 6-8 years. At the cheek, shoulder, anterior chest, and posterior upper arm, however, no correlation with age was noted.

Lipid hydroperoxides permit deformation-dependent leak of monovalent cation from erythrocytes

Subtle peroxidative perturbation of normal red blood cells (RBC) using t-butylhydroperoxide creates a leak pathway for monovalent cations that is reversibly activated by cell deformation. To determine what factor promotes expression of this unique membrane defect, we have dissected "peroxidation" into components that can be evaluated separately by comparing K leak from suitably modified RBC during elliptical deformation and parallel control incubation. Selective introduction of phospholipid hydroperoxides into normal RBC membranes successfully induces a deformation-dependent leak pathway having the same phenomenology as that previously documented for cells treated with t-butylhydroperoxide itself (fully recoverable; calcium-independent; inhibited at lower pH; K efflux balanced by Na influx). This leak pathway occurs in the absence of detectable secondary peroxidative change and appears to reflect a direct influence of lipid hydroperoxide. Using micropipette examination of vesicular bilayers reconstituted from RBC lipid extracts, we find that lipid from peroxidized RBC exhibits only a slight tendency to be less cohesive than normal lipid, apparently precluding isolated lipid properties as an explanation for altered permeability barrier function. However, addition of a hydrophobic membrane-spanning peptide to these same lipids significantly diminishes bilayer cohesion, an effect that is exacerbated further by the presence of peroxidized lipid. These observations suggest that lipid hydroperoxide is a necessary, but perhaps not sufficient, factor for induction of this unique leak pathway. Our results may be relevant to the abnormal cation homeostasis of sickle RBC in which deformation of an oxidatively perturbed membrane occurs during the sickling phenomenon.

[Factors related to serum lipid levels in women of middle and old age--a community study]

Serum lipid levels of 168 women ranging in age from 30 to 69 were measured at a mass health screening in an urban community in Saitama prefecture. Degree of obesity, skinfold thickness and blood pressure were measured and the relation between these physical measurements to serum lipid levels was studied. The results are as follows: (1) Mean total cholesterol level, degree of obesity, systolic blood pressure and diastolic blood pressure increased linearly with advancing age. (2) Simple correlation analysis disclosed that the level of total cholesterol was positively correlated to age, degree of obesity, systolic blood pressure and triglyceride level. HDL-cholesterol level showed a significantly negative correlation to degree of obesity, skinfold thickness and triglyceride level. Degree of obesity was positively correlated to skinfold thickness, systolic blood pressure, diastolic blood pressure, total cholesterol and triglyceride level, but was negatively correlated to HDL-cholesterol. Systolic blood pressure had a positive correlation with age, degree of obesity, diastolic blood pressure, total cholesterol and triglyceride level. (3) Principal component analysis, when performed with the variables age, degree of obesity, skinfold thickness, systolic blood pressure, diastolic blood pressure, level of total cholesterol, triglyceride and HDL-cholesterol, showed that subjects could be divided into the group having obesity with low HDL-cholesterol (first principal component), the hypertensive group (second principal component), and the group having hyperlipidemia with advancing age (third principal component). (4) Multiple regression analysis was also carried out, taking HDL-cholesterol level as the dependent variable, and age, degree of obesity, systolic blood pressure, total cholesterol and triglyceride level as independent variables. Degree of obesity and triglyceride level were negatively related to HDL-cholesterol.

Tracheoesophageal anastomosis for intractable aspiration pneumonia

Permanent tracheostomy and tracheoesophageal anastomosis were performed as a means of surgical intervention for the treatment of intractable aspiration pneumonia. Conventional methods of tracheoesophageal anastomosis have entailed various problems. The improved method devised by us uses the special histological features and enables safe and reliable anastomosis. By this method, the tracheal perichondrium is retained and the strength of the anastomosed portion of the trachea is maintained, the failure of sutures due to tension on the anastomotic site being prevented. Also, reanastomosis can be performed after the cure of primary disease.

Surgical method for treatment of syndactyly with osseous fusion of the distal phalanges

For the interdigital space plasty to correct a syndactyly with fusion of the distal phalanges, we adopted a new operative procedure, covering the exposed distal bone with local rectangular flaps designed transversely on both dorsal and volar surfaces. A full-thickness skin graft from the groin region covers the remaining raw surface. The procedure was performed in six patients, and the flaps measured 6 mm (width) x 12 to 16 mm (length) in four patients, 5 x 15 mm in one patient, and 5 x 18 mm in one patient. Partial necrosis was observed in only one patient, in whom a narrow flap of 5 x 18 mm was used. In the other five patients, however, the results were satisfactory on both external appearance and function during the follow-up period of 3 to 6 years.

Pharmacological profile of a potential anxiolytic: AP159, a new benzothieno-pyridine derivative

AP159 [N-cyclohexyl-1,2,3,4-tetrahydrobenzo(b)thieno(2,3c)pyridine]-3- carboamide,hydrochloride) showed clear anti-conflict activity in rats in the absence of effects on muscle relaxation, potentiation of anesthesia (in mice) or anticonvulsant activity (in mice). This anti-conflict effect was antagonized by treatment with Ro15-1788. By contrast with the deficits produced by diazepam, AP159 did not impair passive avoidance. The latter drug also improved scopolamine-induced amnesia in the same task. AP159 did not inhibit 3H-flunitrazepam binding, but potently inhibited 3H-8OH-DPAT binding. This compound increased serotonin and 5HIAA content of the midbrain raphe nuclei and of the amygdala centralis. AP159 has been shown to be a novel non-BZP anxiolytic agent with no side effects in laboratory animals; it could be a clinically effective anxiolytic agent.

Potent anticonflict activity and lessening of memory impairment with a series of novel [1]benzothieno[2,3-c]pyridines and 1,2,3,4-tetrahydro[1]benzothieno[2,3-c]pyridines

[1]Benzothieno[2,3-c]pyridines (10a-c, 11, 12a-t, and 13a,b) and 1,2,3,4-tetrahydro[1]benzothieno[2,3-c]pyridines (3a-c, 7, 8a-c, and 9) were synthesized. The compounds are bioisosteres of beta-carbolines and 1,2,3,4-tetrahydro-beta-carbolines where the indole nitrogen is replaced by sulfur. Their pharmacological activity was evaluated in a water lick conflict test in rats and a passive avoidance test in mice. In the 1,2,3,4-tetrahydro[1]benzothieno[2,3-c]pyridine series, the presence of ethyl ester (3b) or cyclohexyl carboxamide (7) groups at C-3 conferred good anticonflict activity and lessening of memory impairment, while N-acylation of 3b abolished activity. In the [1]benzothieno(2,3-c]pyridine series, the aminoethyl carboxamide (12a) group at C-3 also conferred activity, but other amides studied were not active. The most potent compounds (3b, 7, and 12a) were also administered orally and had potent anticonflict and antiscopolamine amnesia-reversal activity. These compounds did not bind to the BZP receptor in spite of having structures similar to those of beta-carbolines. Compound 7 bound strongly to 5-HT1A receptors and would be expected to be a novel anxiolytic.

Adult T-cell leukemia/lymphoma of the tongue

A case of posterior tongue lymphoma associated with adult T-cell leukemia (ATL) that occurred as a lesion in the lingual dorsal portion is reported in a 64-year-old woman. Initially, a diagnosis of Hodgkin's lymphoma was considered as no findings associated with ATL except lymphadenopathy and serum anti-ATLA antibodies were present. Combined radiotherapy and chemotherapy were administered with favorable results; however, 4 months later, Pneumocystis carinii pneumonia developed, and 2 months later, generalized lymphadenopathy and hypercalcemia evolved. At this time, a diagnosis of ATL was made. The patient died of renal dysfunction 6 months after the initial presentation. In suspected cases of ATL and malignant diseases of T-cell lineage, namely, malignant lymphoma and mycosis fungoides, the presence of HTLV-1 infection should be confirmed by testing for anti-ATLA antibodies.

[Ectopic production of amylase by a non-producing type of multiple myeloma]

The patient was a 64-year-old woman who was admitted to our hospital because of lumbago. A diagnosis of multiple myeloma (non-producing type) was made, based on (1) the presence of multiple osteolytic lesions, (2) hypercellular marrow with 64.2% plasmacytoid malignant cells, (3) no monoclonal gamma-globulin was detected in the serum and urine, and (4) abnormal monoclonal gamma-globulin was also not detected in the cytoplasm and membranes of these malignant cells. After several courses of chemotherapy, a pleural effusion infiltrated by myeloma cells developed and the patient's serum contained a markedly increased amylase activity of salivary-type. Amylase activity was also detected in vitro in the supernatant of cultured myeloma cells established from the patient's pleural effusion. The presence of alpha-amylase in the myeloma cells, which were derived from pleural effusion, was demonstrated immuno-histochemically. These observations indicates that amylase was ectopically produced by these myeloma cells. Interestingly, 14 out of 20 metaphases in the cells derived from pleural effusion showed translocation of 1p22 near the region of 1p21, where the amylase gene was assigned.

Cytomegalovirus-induced gastritis in a bone marrow transplant patient

Cytomegalovirus (CMV)-induced interstitial pneumonitis is a well-known lethal complication in bone marrow recipients. CMV is also known to cause gastroenteritis. We report the first case of a bone marrow recipient who developed CMV-induced gastritis which is verified both histologically and virologically. The gastritis preceded the interstitial pneumonitis which was detected in an early stage and was successfully treated. We propose that bone marrow recipients who show signs and symptoms of gastritis undergo an endoscopic examination, and that biopsied specimens should be scrutinized for CMV by both histological examination and culture investigation.

No beneficial effect of splenectomy in hereditary high red cell membrane phosphatidylcholine hemolytic anemia: clinical and membrane studies of 20 patients

The clinical features and red cell membrane characteristics of 20 patients with hereditary high red cell membrane phosphatidylcholine hemolytic anemia (HPCHA) were studied in relation to the effect of splenectomy. After splenectomy, anemia worsened and the extent of increased hemolysis in these patients was unchanged, indicating a contraindication for splenectomy. Concomitant with these results in clinical hematology, marked stomatocytic changes, increased red cell phosphatidylcholine content, and enhanced sodium transport, which were observed before splenectomy, were not improved by splenectomy.

beta-CCM inhibits muricide induced by olfactory bulbectomy in rats

Intravenous administration of beta-CCM (methyl-beta-carboline-3-carboxylate) at doses ranging from 0.3 to 10 mg/kg dose-dependently inhibited muricide in olfactory bulbectomized rats. beta-CCM elicited a decrease of locomotor activity at doses ranging from 0.3 to 3 mg/kg, and it impaired rotarod performance at doses of 1 and 3 mg/kg. The inhibition of muricide induced by beta-CCM was antagonized by intraperitoneal administration of Ro15-1788 at 10 mg/kg or diazepam at 3 mg/kg. However, the hypolocomotor activity and impairment of rotarod performance induced by beta-CCM were not antagonized by diazepam at 3 mg/kg. These results indicated that beta-CCM exerts an inhibitory effect on muricide through benzodiazepine receptors and this inhibitory effect was not solely caused by its sedative or motor incordinating activity at the dose ranges used in this study.

[A case of malignant neuroepithelioma in the retroperitoneum]

Reported is a case of a malignant neuroepithelioma in the retroperitoneum. The patient was a 37-year-old male suffering from lumbago and edema of the lower extremities. After ultrasonography and a CT scan, a diagnosis of a retroperitoneal tumor was made and a surgical resection of the tumor was performed in October, 1985. The subsequent pathological diagnosis was malignant neuroepithelioma which showed epithelioid cell clusters that stained positively to NSE. Eleven months later, metastatic tumors were seen present in the lungs and the liver though they regressed markedly after adjuvant chemotherapy with ADM, CPM, and VCR. Forty-one months after his first operation, the patient continues to work. In this case, adjuvant chemotherapy has proved effective.

Ultrastructural and immunoelectron microscopic studies on infiltrating mononuclear cells in lymphocytic submandibulitis in NOD mice

The ultrastructural relations of the infiltrating mononuclear cells to the parenchymal tissues were studied in the submandibular gland of the female non-obese diabetic (NOD) mouse. In addition, the phenotype of mononuclear cells infiltrating the submandibular gland has been determined by light and electron microscopy by using monoclonal antibodies against T-cell subsets (Thy1.2, Lyt1, Lyt2). Ultrastructurally, lymphoid cells were frequently observed around and in the acini and ducts. Some of the lymphoid cells observed in the acini and ducts were irregular in shape and sometimes sent spike-like projections into acinar and ductal cells. Immunohistochemical study demonstrated that Thy1.2+ cells were predominant among the infiltrating cells, and the majority of these infiltrating T-cells were composed of Lyt1+ cells with a small proportion of Lyt2+ cells. By immunoelectron microscopy, lymphocytes carrying Thy1.2, Lyt1 or Lyt2 antigen were identified, as is demonstrated by an electron-dense reaction product on the entire cell surface, and these immunopositive cells were frequently observed around and in the acini and ducts. Some of the Thy1.2+, Lyt1+ or Lyt2+ cells observed in the acini and ducts demonstrated a close contact with acinar and ductal cells and both Lyt1+ and Lyt2+ cells sent spike-like projections into them. Occasionally, a partial degeneration of acinar cell adjacent to the invading lymphocytes was observed. These observations suggest that T-lymphocytes are involved in the direct destruction of acinar and ductal cells in the NOD mouse submandibular glands.

Two human myeloma cell lines, amylase-producing KMS-12-PE and amylase-non-producing KMS-12-BM, were established from a patient, having the same chromosome marker, t(11;14)(q13;q32)

Two human myeloma cell lines, KMS-12-PE and KMS-12-BM, were established from a 64-year-old woman with a non-producing type of multiple myeloma. The KMS-12-PE line originated from the pleural effusion and the KMS-12-BM from the bone marrow. These two lines showed the same chromosome marker, t(11:14)(q13:q32). However, their phenotypes of surface markers differed from each other. KMS-12-BM cells were positive to CD20, CD38 and PCA-1. showing the plasmacytoid (immature plasma cell) stage of B-cell differentiation, while KMS-12-PE cells were positive to CD38 and PCA-1, but not to CD20, indicating the terminal differentiated stage of B-cells. As seen in the pleural effusion of the patient. KMS-12-PE cells ectopically produced a salivary type of amylase, but KMS-12-BM cells did not. Interestingly, the chromosome abnormality of del(1)(p22----pter) near the region of 1p21, where the amylase gene was assigned, was noticed in as many as 76% of KMS-12-PE cells.

[Evaluation of endoscopic local injection of hypertonic saline- epinephrine solution and surgical treatment on hemorrhagic gastroduodenal ulcer]

For the purpose of arresting hemorrhage from gastric and duodenal ulcer we developed a method of endoscopic local injection of hypertonic saline-epinephrine solution (HSE), consisting of 625mEq/L or 1,250mEq/L sodium chloride with 0.05mg/ml epinephrine. During the period between October 1978 and March 1988, a total 246 patients with peptic ulcers underwent treatment for hemostasis by this method. According to our criteria for the assessment of the hemostatic effect, 231(93.9%) of 246 cases achieved permanent hemostasis, 7(2.8%) achieved temporary hemostasis, and no effect was noted 8 cases (3.3%). From June 1975 to March 1988, a total 366 cases with gastric and duodenal ulcers were operated on at our hospital. By applying endoscopic local injection of HSE, the rate of emergency operation for patients with bleeding peptic ulcers was significantly reduced from 13.4%(22/164) to 1.5%(3/202). From these results, we consider that endoscopic local injection of HSE is valuable for hemorrhage from gastric and duodenal ulcer.

[The inhibitory effect on passive cutaneous anaphylaxis in guinea pigs of oral administration of Corynebacterium (Rhodococcus) equi]

We studied the inhibitory effect on the PCA reaction of BSA-rabbit anti-BSA (BSA-anti-BSA) system in CP-sensitized and CP-unsensitized guinea pigs by the oral administration of C. equi. Strain Ko-85 (Ko-85) cells. The results were as follows: 1) Guinea pigs were sensitized by intraperitoneal injection with the CP. Nine days later, the animals were administered with an oral dose of 80 mg (W.W.) of Ko-85 cells. The animals were submitted daily to PCA reaction tests using BSA and rabbit anti-BSA serum. The inhibition of PCA reaction of BSA-anti-BSA system in CP-sensitized guinea pigs was shown from 4th day to 10th day after administration of Ko-85 cells. The PCA reaction of 9th day was recognized strong inhibition by the oral administration of Ko-85 cells. 2) CP-unsensitized guinea pigs were given an oral dose of 80 mg of Ko-85 cells, and the animals were submitted every other day to PCA reaction tests of the BSA-anti-BSA system. PCA elicited in these animals on the 9th, 15th and 17th days Ko-85 administration were inhibited compared with those in the control animals (which were not given an oral dose of Ko-85 cells). The strongest inhibition was shown in animals challenged on the 15th day after Ko-85 administration. The inhibitory effect of PCA reaction of BSA-anti-BSA system by the oral administration of an oral dose 80 mg (W.W.) of Ko-85 cells was recognized in CP-sensitized and CP-unsensitized guinea pigs.

[advantages and disadvantages of three regional lymph node dissection of thoracic esophageal carcinoma and the lymph node dissection by thoraco-abdomino-midsternal approach]

The 117 cases of two regional (thoraco-abdominal) lymph node dissection were compared to the 56 cases of three regional (with neck area in addition) lymph node dissection for esophageal carcinoma. As for operative death and postoperative complications, there were no difference between these two groups. The prognosis of three regional dissecting group was better than that of two regional dissecting group concerning about the cases that lymph node metastases were less than 1 or 2, the depth of invasion was limited to just near adventitia (a1) and the locations were in upper or midthoracic esophagus. But also the rate of postoperative recurrence to the neck and uppermediastinal lymph nodes were high in spite of three regional dissection. Putting together with all cases, significant improvement of prognosis were not obtained in the three regional group compared to two regional group. So we thought the usual three regional lymph node dissection might not be sufficient. Recently we added midsternotomy and made the lymph node dissection in neck-thoracic junction more complete. This procedure did not make the operative death and postoperative complications increase and the improvement of prognosis was expected by it.