Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

FRI0218 PREVALENCE, BURDEN OF DISEASE AND HEALTHCARE UTILIZATION AMONG PATIENTS WITH EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (EGPA) IN JAPAN 2005-2017

Background:

EGPA is a rare vasculitis condition with very limited data available from real-world settings on burden and health care utilization (HCU), particularly in Japan.

Objectives:

To estimate the prevalence (overall and age, gender stratified) and describe HCU and treatment patterns among Japanese EGPA patients.

Methods:

This was a retrospective descriptive cohort study using a large administrative claims database covering up to more than 5 million corporate employees and their dependents (JMDC claim database) in Japan. Annual prevalence from 2005-2017 was estimated using two EGPA case definitions: a) patients with ≥1 ICD-10 code (2003 version) for EGPA (M30.1), b) patients with ≥2 ICD-10 codes for EGPA (M30.1) during the year in which prevalence was calculated. Among newly identified EGPA patients with no EGPA code in at least 12 months before, clinical burden, comorbidities, after hour visiting (AHV), all cause hospitalization, and treatment with drugs, including oral corticosteroid (OCS) use was described. OCS dose was expressed as prednisone equivalent.

Results:

The total number of newly identified patients in 2006-2016 was 45 persons and the mean (SD) age was 42.3 years (SD 14.7 years). The prevalence (per 1,000,000 patients) of EGPA with case definition a) in Japan in 2017 was estimated to be 38.0. The stratified prevalence (per 1,000,000) by age was: 2.3 in the group aged <18 years, 34.0 in those aged 18-50 years, and 91.1 in those aged ≥50 years, respectively. The prevalence in females (50.0) was approximately 1.7-fold higher than that in male (28.7). The prevalence, including stratified results, with definition b) was similar to that with definition a). In the newly identified patients, 60% of patients had at least one hospitalization and 55.6% had AHV, in the year after the first observed EGPA code during the study period. Following index date, new patients were treated: 77.8% with OCS, 11.1% with Azathioprine, 8.9% with intravenous immunoglobulin, 6.7% with Cyclophosphamide, 4.4% with Methotrexate, and 2.2% with Rituximab (non mutually exclusive). The mean (SD) maximum recorded daily dose of OCS in the 12 months follow up period was 53.5 (39.9) mg in new patients. The average dose (SD) of OCS in first month and last month in new patients was 39.1 (29.0) and 9.8 mg (4.8), respectively. Among those with at least a 14-day supply of OCS, 73.1% could be classified as adherent (≥80%) based on their 1-year proportion of days covered. 6.7% of EGPA patients experienced a potentially worsening with an increase of ≥10 mg daily OCS dose prescription following a previous prescription of <10mg.

Conclusion:

Analysis of the burden of disease and the use of medical resources in newly identified EGPA patients revealed that EGPA patients require hospitalizations and AHV, in addition to exposure to high doses of OCS. The appropriate medication for the treatment of EGPA to reduce burden on patients may need consider the pathophysiological state of EGPA patients.

Disclosure of Interests:

KEN-EI SADA Speakers bureau: I received speaker’s fee from GSK and Astra Zeneca K.K., Yoshiki Kojo Shareholder of: GSK, Employee of: GSK, Jolyon Fairburn-Beech Shareholder of: GSK, Employee of: GSK, Keiko Sato Shareholder of: GSK, Employee of: GSK, Etsuko Hayashi Shareholder of: GSK, Employee of: GSK, Shoko Akiyama Shareholder of: GSK, Employee of: GSK, melissa van-dyke Shareholder of: GSK, Employee of: GSK

FRI0179 A STUDY ON THE ACHIEVEMENT OF LUPUS LOW DISEASE ACTIVITY STATE AND QUALITY OF LIFE IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: FROM THE JUNTENDO UNIVERSITY SLE PROSPECTIVE REGISTRY STUDY

Background:

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease of unknown etiology that affects mostly young women. Multiorgan complications and prolonged treatment significantly cause physical and mental stress in patients. Improving patients’ quality of life (QOL) in SLE treatment is essential. We examined the treatment effects on disease activity and QOL of SLE patients.

Objectives:

In recent years, lupus low disease activity state (LLDAS) has been proposed as a treatment target for SLE. Patients who achieve LLDAS have a low recurrence rate for lupus and a low risk of serious complications (1). The aim of this study is to investigate whether achieving LLDAS reduces not only recurrence rate and complications of SLE but also improves patients’ QOL.

Methods:

A total of 104 SLE patients were enrolled in our prospective SLE registry study (Juntendo, Multi-center, Prospective cohort for investigation of clinical course and outcome in SLE: JUMP) conducted at our institution. SLE was diagnosed using the American College of Rheumatology (ACR) 1982 criteria (revised in 1997). QOL was evaluated using the standard version of the 36-item short form health survey version 2 (SF36v2). Participants were divided into the LLDAS achievement and non-achievement groups, and the characteristics of each group including results of SF36v2 were examined.

Results:

This study included 104 SLE patients, 94 female and 10 male, and the average age and disease duration were 46.4±13.8 and 14.5±11.3 years, respectively. The average corticosteroid dose was 8.0±17.4 mg/day in terms of prednisolone, and anti-dsDNA antibody titer was 16.8±38.5 IU/ml. Of the 104 patients, 57 achieved LLDAS. The subscale’s standard scoring using SF36v2 for role physical (RP) was 78.9±24.0 and 64.6±27.6 (P<0.01), general health (GH) was 50.0±17.0 and 42.0±19.3 (P<0.05), vitality (VT) was 55.8±15.8 and 38.0±24.1 (P<0.01), social functioning (SF) was 82.0±20.7 and 66.5±26.3 (P<0.01), role emotional (RE) was 89.0±16.1 and 73.4±28.1 (P<0.01), and mental health (MH) was 72.4±15.9 and 58.3±21.8 (P<0.01) in the LLDAS achievement and non-achievement groups, respectively. Furthermore, scoring based on the national standard value in the LLDAS achievement group showed that two categories were >50. However, in the LLDAS non-achievement group, all categories were <50. In particular, RP, GH, VT, SF, RE, and MH of the LLDAS achievement group had significantly higher scores than the LLDAS non-achievement group (RP and GH: p<0.05 and VT, SF, RE and MH: p<0.01).

Conclusion:

Results of examining the association between LLDAS and QOL using SF36v2 in SLE patients showed that patients who achieved LLDAS had significantly better standard statistical scores in many subscale categories. Thus, LLDAS achievement as a treatment target for SLE patients greatly contributes to improving patients’ QOL.

References:

[1]Franklyn K, et al. Definition and initial validation of a Lupus Low Disease Activity State (LLDAS).Ann Rheum Dis. 2016 Sep;75(9):1615-21.

Disclosure of Interests:

None declared

Reappraisal of classification of distal cholangiocarcinoma based on tumour depth

Background

In the eighth edition of the AJCC cancer staging classification, the T system for distal cholangiocarcinoma (DCC) has been revised from a layer-based to a depth-based approach. The aim of this study was to propose an optimal T classification using a measured depth in resectable DCC.

Methods

Patients who underwent pancreatoduodenectomy for DCC at 32 hospitals between 2001 and 2010 were included. The distance between the level of the naive bile duct and the deepest cancer cells was measured as depth of invasion (DOI). Invasive cancer foci were measured as invasive tumour thickness (ITT). Log rank χ2 scores were used to determine the cut-off points, and concordance index (C-index) to assess the survival discrimination of each T system.

Results

Among 404 patients, DOI was measurable in 182 (45·0 per cent) and ITT was measurable in all patients, with median values of 2·3 and 5·6 mm respectively. ITT showed a positive correlation with DOI (rs = 0·854, P &lt; 0·001), and the cut-off points for prognosis were 1, 5 and 10 mm. Median survival time was shorter with increased ITT: 12·4 years for ITT below 1 mm, 5·2 years for ITT at least 1 mm but less than 5 mm, 3·0 years for ITT at least 5 mm but less than 10 mm, and 1·5 years for ITT 10 mm or more (P &lt; 0·001). This classification exhibited more favourable prognostic discrimination than the T systems of the seventh and eighth editions of the AJCC (C-index 0·646, 0·622 and 0·624 respectively).

Conclusion

ITT is an accurate approach for depth assessment in DCC. The four-tier ITT classification with cut-off points of 1, 5 and 10 mm seems to be a better T system than those in the seventh and eighth editions of the AJCC classification.

Pancreatoduodenectomy with portal vein resection for distal cholangiocarcinoma

BACKGROUND

Little is known about the value of portal vein (PV) resection in distal cholangiocarcinoma. The aim of this study was to evaluate the clinical significance of PV resection in distal cholangiocarcinoma.

METHODS

Patients who underwent pancreatoduodenectomy (PD) for distal cholangiocarcinoma between 2001 and 2010 at one of 31 hospitals in Japan were reviewed retrospectively with special attention to PV resection. Short- and long-term outcomes were evaluated.

RESULTS

In the study interval, 453 consecutive patients with distal cholangiocarcinoma underwent PD, of whom 31 (6·8 per cent) had combined PV resection. The duration of surgery (510 versus 427 min; P = 0·005) and incidence of blood transfusion (48 versus 30·7 per cent; P = 0·042) were greater in patients who had PV resection than in those who did not. Postoperative morbidity and mortality were no different in the two groups. Several indices of tumour progression, including high T classification, lymphatic invasion, perineural invasion, pancreatic invasion and lymph node metastasis, were more common in patients who had PV resection. Consequently, the incidence of R1/2 resection was higher in this group (32 versus 11·8 per cent; P = 0·004). Survival among the 31 patients with PV resection was worse than that for the 422 patients without PV resection (15 versus 42·4 per cent at 5 years; P < 0·001). Multivariable analyses revealed that age, blood loss, histological grade, perineural invasion, pancreatic invasion, lymph node metastasis and surgical margin were independent risk factors for overall survival. PV resection was not an independent risk factor.

CONCLUSION

PV invasion in distal cholangiocarcinoma is associated with locally advanced disease and several negative prognostic factors. Survival for patients who have PV resection is poor even after curative resection.

Post-treatment levels of α-fetoprotein predict incidence of hepatocellular carcinoma after interferon therapy

BACKGROUND & AIMS

In patients with chronic hepatitis C virus (HCV) infection, lack of sustained virologic response (SVR) 24 weeks after the end of interferon therapy is a significant risk factor for hepatocellular carcinoma (HCC). Although many pretreatment factors are known to affect HCC incidence, less is known about post-treatment factors-many change during the course of interferon therapy.

METHODS

We performed a prospective study, collecting data from 2659 patients with chronic hepatitis C without a history of HCC who had been treated with pegylated interferon (Peg-IFN) plus ribavirin from 2002 through 2008 at hospitals in Japan. Biopsy specimens were collected before treatment; all patients received Peg-IFN plus ribavirin for 48 to 72 weeks (HCV genotype 1) or 24 weeks (HCV genotype 2). Hematologic, biochemical, and virologic data were collected every 4 weeks during treatment and every 6 months after treatment. HCC was diagnosed based on angiography, computed tomography, and/or magnetic resonance imaging findings.

RESULTS

HCC developed in 104 patients during a mean observation period of 40 months. Older age, male sex, lower platelet counts and higher levels of α-fetoprotein at baseline, and lack of an SVR were significant risk factors for HCC. The cumulative incidence of HCC was significantly lower in patients without SVRs who relapsed than those with no response to treatment. Levels of α-fetoprotein 24 weeks after the end of treatment (AFP24) were significantly lower than levels of α-fetoprotein at baseline in patients with SVRs and those who relapsed, but not in nonresponders. Post-treatment risk factors for HCC among patients with SVRs included higher AFP24 level and older age; among those without SVRs, risk factors included higher AFP24 level, integrated level of alanine aminotransferase, older age, and male sex. AFP24 (≥10 ng/mL, 10-5 ng/mL, and then <5 ng/mL) was a better predictor of HCC incidence than pretreatment level of AFP among patients with and without SVRs.

CONCLUSIONS

In patients with chronic HCV infection, levels of α-fetoprotein decrease during interferon therapy. High post-treatment levels of α-fetoprotein predict HCC, regardless of whether patients achieve an SVR. University Hospital Medical Information Network Clinical Trials Registry: C000000196, C000000197.

Reducing Peg-IFN doses causes later virologic response or no response in HCV genotype 1 patients treated with Peg-IFN alfa-2b plus ribavirin

BACKGROUND

The timing to the first undetectable hepatitis C virus (HCV) RNA level is strongly associated with sustained virologic response in pegylated interferon (Peg-IFN) plus ribavirin combination therapy for patients with chronic hepatitis C (CH-C) with genotype 1. This study was conducted to clarify the impact of drug exposure to Peg-IFN on the timing of HCV RNA negativity in Peg-IFN plus ribavirin combination therapy for CH-C patients with genotype 1.

METHODS

A total of 1409 patients treated with Peg-IFN alfa-2b plus ribavirin were enrolled and classified into four categories according to the Peg-IFN dosage. Furthermore, 100 patients were extracted from each Peg-IFN dosage category to adjust for characteristic factors, using the propensity score method.

RESULTS

Peg-IFN exposure was dose-dependently associated with the timing of HCV RNA negativity (p ≤ 0.001). The HCV RNA negative rate at week 4 decreased from 12% with a Peg-IFN dose of >1.5 μg/kg/week to 1-3% with a dose of <1.5 μg/kg/week (p ≤ 0.001), and at week 12 the rate had decreased from 44% with a dose of ≥1.2 μg/kg/week to 18% with a dose of <1.2 μg/kg/week (p = 0.001). Treatment failure (patients without a 1-log decrease of HCV RNA at week 4 or a 2-log decrease of HCV RNA at week 12, or positive at week 24) was found in 54-66% of patients given <1.2 μg/kg/week (p ≤ 0.001), and these patients accounted for 64% of the non-responders.

CONCLUSIONS

The timing of HCV RNA negativity depends significantly on the Peg-IFN dose. Reducing the Peg-IFN dose can induce a later virologic response or non-response in HCV genotype 1 patients treated with Peg-IFN plus ribavirin.

Can locoregional treatment of the primary tumor improve outcomes for women with stage IV breast cancer at diagnosis?

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Background: To determine whether locoregional treatment (LRT) of the primary tumor improves outcomes in patients with stage IV breast cancer at diagnosis.

Methods: The study cohort comprised 733 women referred from 1996 to 2005 to a population-based cancer institution with clinical or pathologic M1 breast cancer at diagnosis. Patient, tumor, and treatment characteristics were compared between women who were treated with (n=378) and without LRT (n=355) of the primary tumor. Five-year Kaplan-Meier overall survival (OS) and locoregional progression-free survival (LRPFS) were compared between groups. Multivariable analysis to control for potential confounding factors was performed using Cox regression modeling.

Results: LRT consisted of surgery alone in 67%, radiotherapy alone in 22%, and both in 11% of patients. LRT use was significantly associated with age <50 years, ECOG performance status 0-1, T1-2 tumors, and N0-1 disease, (all p<0.05). Subjects with less metastatic disease burden and those asymptomatic from the M1 disease were more likely to undergo LRT (p<0.001). Systemic therapy was used in 92% and 85% of patients treated with vs. without LRT, respectively. Five-year OS rates in the LRT and no LRT cohorts were 21% vs 14% (p<0.001). The 5-year LRPFS rates were 72% vs 46% (p<0.001). Among 378 patients who underwent LRT, 5-year OS rates were higher in patients with age <50, ECOG 0-1, ER positive disease, clear surgical margins, single M1 subsite, bone only metastases, and 1-3 metastatic lesions (all p<0.003). Type of LRT (surgery vs radiotherapy vs both) and type of surgery (lumpectomy vs mastectomy) were not associated with 5-year OS (all p>0.05). On multivariable analysis, LRT was associated with improved OS (hazard ratio 0.78, 95% confidence interval 0.64-0.94, p=0.009).

Conclusions: LRT of the primary disease was associated with improved survival in women with stage IV breast cancer at diagnosis. Among subjects treated with LRT, the most favorable survival rates were observed in patients with young age, good performance status, ER-positive disease, clear resection margins and in those with distant disease limited to one subsite, bone only, or fewer than 4 metastatic lesions.

The efficacy of extended treatment with pegylated interferon plus ribavirin in patients with HCV genotype 1 and slow virologic response in Japan

BACKGROUND

Which patients with hepatitis C virus (HCV) genotype 1 can benefit from extended treatment with pegylated interferon (Peg-IFN) plus ribavirin is unknown, although the overall sustained virologic response (SVR) rate has been shown to improve in patients with a late virologic response (LVR), defined as detectable serum HCV RNA at week 12 and undetectable at week 24.

METHODS

Among 1163 chronic hepatitis C patients with genotype 1 treated with Peg-IFN plus ribavirin combination therapy, 213 patients with an LVR were examined in this study. In addition, we selected 81 patients of matched sex and age from each of the 48- and 72-week treatment groups, using the propensity score, to compare the efficacy of the two treatment durations.

RESULTS

With 72-week treatment, the timing of HCV RNA disappearance and the hemoglobin level at baseline showed a strong correlation with the SVR on multivariate analysis. Earlier HCV RNA disappearance was associated with a better SVR rate, regardless of the ribavirin dose (HCV RNA disappearance at week 16, 74%; at week 20, 52%; and at week 24, 31%, p = 0.01). The SVR rate with 72-week treatment was higher than that with 48-week treatment, irrespective of age, sex, or the platelet value, and, especially in aged patients (≥65 years old), the SVR rate increased markedly with 72-week treatment (48 weeks, 25% vs. 72 weeks, 56%; p < 0.05).

CONCLUSIONS

An earlier response predicts a higher SVR rate in patients with an LVR given 72-week treatment. Extended treatment with Peg-IFN plus ribavirin for patients with an LVR improved the treatment efficacy, even for aged patients.

[A case of recurrent colon cancer with angina pectoris and interstitial pneumonia during cetuximab therapy with death by carcinomatous lymphangiosis]

The case was a man in his 60s with no past history of heart and lung. Chest tightness was felt during the first course of cetuximab therapy for recurrent colon cancer. He was diagnosed as having vasospastic angina, and administration of vasodilatation agents was done. After the therapy, no chest pain attack was seen. Chemotherapy was continued. After 3 courses, fever elevation, chest tightness and dyspnea were seen. Chest X-ray and CT revealed diffuse interstitial pneumonia in bilateral lung. Although steroid pulse therapy and intensive therapy with mandatory ventilation were performed, he died of respiratory failure. Pathological findings of autopsy revealed remarkable metastasis of cancer cells to the bilateral lungs accompanied chiefly with carcinomatous lymphangiosis. Furthermore, acute and subacute interstitial pneumonia with diffuse alveolar damage were seen in the background of the lungs. Cardiopulmonary disorder as well as skin disorder should be considered as possible adverse events of cetuximab therapy.

Factors affecting efficacy in patients with genotype 2 chronic hepatitis C treated by pegylated interferon alpha-2b and ribavirin: reducing drug doses has no impact on rapid and sustained virological responses

Reducing the dose of drug affects treatment efficacy in pegylated interferon (Peg-IFN) and ribavirin combination therapy for patients with hepatitis C virus (HCV) genotype 1. The aim of this study was to investigate the impact of drug exposure, as well as the baseline factors and the virological response on the treatment efficacy for genotype 2 patients. Two-hundred and fifty patients with genotype 2 HCV who were to undergo combination therapy for 24 weeks were included in the study, and 213 completed the treatment. Significantly more patients who achieved a rapid virological response (RVR), defined as HCV RNA negativity at week 4, achieved a sustained virological response (SVR) (92%, 122/133) compared with patients who failed to achieve RVR (48%, 38/80) (P < 0.0001). Multivariate logistic-regression analysis showed that only platelet counts [odds ratio (OR), 1.68; confidence interval (CI), 1.002-1.139] and RVR (OR, 11.251; CI, 5.184-24.419) were independently associated with SVR, with no correlation being found for the mean dose of Peg-IFN and ribavirin for RVR and SVR. Furthermore, in the stratification analysis of the timing of viral clearance, neither mean dose of Peg-IFN (P = 0.795) nor ribavirin (P = 0.649) affected SVR in each group. Among the patients with RVR, the lowest dose group of Peg-IFN (0.77 +/- 0.10 microg/kg/week) and ribavirin (6.9 +/- 0.90 mg/kg/day) showed 100% and 94% of SVR. Hence, RVR served as an important treatment predictor, and drug exposure had no impact on both SVR and RVR in combination therapy for genotype 2 patients.

Genetic control of the B cell response to LPS: opposing effects in peritoneal versus splenic B cell populations

Lipopolysaccharide (LPS) from gram-negative bacteria activates B cells, enabling them to proliferate and differentiate into plasma cells. This response is critically dependent on the expression of TLR4; but other genes, such as RP105 and MHC class II, have also been shown to contribute to B cell LPS response. Here, we have evaluated the role of genetic control of the B cell response to LPS at the single cell level. We compared the response to LPS of peritoneal cavity (PEC) and splenic B cells on the BALB/c genetic background (LPS-low responder) to those on the C57BL/6J background (LPS-high responder) and their F1 progeny (CB6F1). Both PEC and splenic B cells from B6 exhibited 100% clonal growth in the presence of LPS; whereas, BALB/c PEC and splenic B cells achieved only 50% and 23% clonal growth, respectively. Adding CpG to the LPS stimulus pushed PEC B cell clonal growth in the low responder strain BALB/c up to 90%, showing that the nonresponse to LPS is a specific effect. Surprisingly, PEC B cells on the F1 background behaved as high responders, while splenic B cells behaved as low responders to LPS. The data presented here reveals a previous unsuspected behavior in the genetic control of the B cell response to LPS with an opposing impact in splenic versus peritoneal cavity B cells. These results suggest the existence of an, as yet, unidentified genetic factor exclusively expressed by coelomic B cells that contributes to the control of the LPS signaling pathway in the B lymphocyte.

[A case of neuroendocrine carcinoma which originated in duodenal bulb]

A 95-year-old woman who presented with ischemic heart disease was admitted due to a sensation of chest compression. Endoscopy was performed due to anemia which showed an irregular ulcerative lesion in the duodenal bulb which a biopsy revealed to be high-grade neuroendocrine carcinoma. Distant metastasis was found and the patient died from the original disease 3 months after the first medical examination. The result of autopsy was neuroendocrine carcinoma of duodenum and invasion and metastases to multiple organs. We report a case of neuroendocrine carcinoma originating from the duodenum excluding the papilla which is extremely rare in Japan.

Factors contributing to antiviral effect of adefovir dipivoxil therapy added to ongoing lamivudine treatment in patients with lamivudine-resistant chronic hepatitis B

PURPOSE

The antiviral effect of adefovir dipivoxil (ADV) added to ongoing lamivudine (LAM) treatment for LAM-resistant chronic hepatitis B (CHB) differs among patients. We investigated clinical factors affecting the response to ADV therapy in LAM-resistant CHB.

METHODS

The subjects were 75 LAM-resistant CHB patients treated with ADV in addition to LAM. Virological response (VR) was defined as HBV DNA clearance (<2.6 logcopies/ml) at 12 months after the start of ADV therapy. Clinical factors contributing to VR were examined by univariate and multivariate analyses.

RESULTS

Lower HBV DNA at baseline and negative hepatitis B e antigen (HBeAg) were significant factors affecting VR in univariate analysis. In multivariate analysis, lower HBV DNA at baseline (P = 0.005), negative HBeAg (P = 0.009), and higher ALT (P = 0.036) were significant independent factors contributing to VR. In HBeAg-positive patients, HBV DNA clearance was more frequently observed during ADV therapy in patients with baseline HBV DNA < or = 7.0 logcopies/ml than in those with baseline HBV DNA >7.0 logcopies/ml. By contrast, the link of lower HBV DNA at baseline to better therapeutic response was not evident in HBeAg-negative patients.

CONCLUSION

In ADV therapy added to ongoing LAM treatment for LAM-resistant CHB, lower baseline HBV DNA and negative HBeAg contributed to a better antiviral effect. Addition of ADV should be done promptly before marked increase in HBV DNA, especially in CHB patients showing LAM resistance positive for HBeAg.

Pegylated interferon alpha-2b (Peg-IFN alpha-2b) affects early virologic response dose-dependently in patients with chronic hepatitis C genotype 1 during treatment with Peg-IFN alpha-2b plus ribavirin

Chronic hepatitis C (CH-C) genotype 1 patients who achieved early virologic response have a high probability of sustained virologic response (SVR) following pegylated interferon (Peg-IFN) plus ribavirin therapy. This study was conducted to evaluate how reducing drug doses affects complete early virologic response (c-EVR) defined as hepatitis C virus (HCV) RNA negativity at week 12. Nine hundred eighty-four patients with CH-C genotype 1 were enrolled. Drug doses were evaluated independently on a body weight base from doses actually taken. From multivariate analysis, the mean dose of Peg-IFN alpha-2b during the first 12 weeks was the independent factor for c-EVR (P = 0.02), not ribavirin. The c-EVR rate was 55% in patients receiving > or = 1.2 microg/kg/week of Peg-IFN, and declined to 38% at 0.9-1.2 microg/kg/week, and 22% in patients given <0.9 microg/kg/week (P < 0.0001). Even with stratified analysis according to ribavirin dose, the dose-dependent effect of Peg-IFN on c-EVR was observed, and similar c-EVR rates were obtained if the dose categories of Peg-IFN were the same. Furthermore, the mean dose of Peg-IFN during the first 12 weeks affected HCV RNA negativity at week 24 (P < 0.0001) and SVR (P < 0.0001) in a dose-dependent manner. Our results suggest that Peg-IFN was dose-dependently correlated with c-EVR, independently of ribavirin dose. Thus, maintaining the Peg-IFN dose as high as possible during the first 12 weeks can yield HCV RNA negativity and higher c-EVR rates, leading to better SVR rates in patients with CH-C genotype 1.

Interobserver agreement in endoscopic evaluation of reflux esophagitis using a modified Los Angeles classification incorporating grades N and M: a validation study in a cohort of Japanese endoscopists

The Los Angeles classification system is the most widely employed criteria associated with the greatest interobserver agreement among endoscopists. In Japan, the Los Angeles classification system has been modified (modified LA system) to include minimal changes as a distinct grade of reflux esophagitis, rather than as auxiliary findings. This adds a further grading M defined as minimal changes to the mucosa, such as erythema and/or whitish turbidity. The modified LA system has come to be used widely in Japan. However, there have been few reports to date that have evaluated the interobserver agreement in diagnosis when using the modified LA classification system incorporating these minimal changes as an additional grade. A total of 100 endoscopists from university hospitals and community hospitals, as well as private practices in the Osaka-Kobe area participated in the study. A total of 30 video clips of 30-40 seconds duration, mostly showing the esophagocardiac junction, were created and shown to 100 endoscopists using a video projector. The participating endoscopists completed a questionnaire regarding their clinical experience and rated the reflux esophagitis as shown in the video clips using the modified LA classification system. Agreement was assessed employing kappa (kappa) statistics for multiple raters. The kappa-value for all 91 endoscopists was 0.094, with a standard error of 0.002, indicating poor interobserver agreement. The endoscopists showed the best agreement on diagnosing grade A esophagitis (0.167), and the poorest agreement when diagnosing grade M esophagitis (0.033). The kappa-values for the diagnoses of grades N, M, and A esophagitis on identical video pairs were 0.275-0.315, with a standard error of 0.083-0.091, indicating fair intraobserver reproducibility among the endoscopists. The study results consistently indicate poor agreement regarding diagnoses as well as fair reproducibility of these diagnoses by endoscopists using the modified LA classification system, regardless of age, type of practice, past endoscopic experience, or current workload. However, grade M reflux esophagitis may not necessarily be irrelevant, as it may suggest an early form of reflux disease or an entirely new form of reflux esophagitis. Further research is required to elucidate the pathophysiological basis of minimal change esophagitis.

Triple therapy of initial high-dose interferon with ribavirin and amantadine for patients with chronic hepatitis C

AIMS

We previously reported the potential effect of combination therapy of an initial high-dose interferon (IFN) and amantadine on the eradication of HCV-RNA in patients with chronic hepatitis C. The additive effects of amantadine on interferon and ribavirin combination therapy remain controversial. In this study we investigated the efficacy of initial high-dose IFN with ribavirin and amantadine on the virological response in patients with chronic hepatitis C with a high viral load of genotype 1b.

METHODS

Twenty-two patients with high viral loads of genotype 1b hepatitis C virus were enrolled in this pilot study. Patients were administered IFN-beta for four weeks and then IFN-alpha2b for 22 weeks with daily oral administration of ribavirin and amantadine.

RESULTS

A sustained virological response (SVR) was shown in 31.8% (seven of 22 patients). With the naïve patients, the SVR rate was 21.4% (three of 14 patients). In patients who could not eradicate HCV-RNA by previous IFN monotherapy, the SVR rate was 50% (four of eight patients).

CONCLUSION

Triple therapy with an initial high dose of IFN with ribavirin and amantadine may be effective, especially for chronic hepatitis C IFN-retreatment patients with a high viral load of genotype 1b.

Vacuum ultraviolet spectroscopy of Ce(3+)-doped SrMgF(4) with superlattice structure

X-ray diffraction of Ce(3+)-doped SrMgF(4) (SMF:Ce) crystals shows a superlattice structure, reflecting the distribution of Ce(3+) polyhedra centres observed in optical experiments. Optical absorption bands and fluorescence bands from the Ce(3+) polyhedra centres overlap in the vacuum ultraviolet (VUV) and ultraviolet (UV) regions, respectively, so that wide pumping and tuning ranges are expected for laser operation. The SMF:Ce crystals, as well as the isomorphous BaMgF(4), are candidates for a tunable laser gain material with nonlinear properties. The optical absorption, excitation, and fluorescence bands observed in the SMF:Ce crystals at low temperatures are ascribed to five distinct fluorescent centres. Three centres have well-known Ce(3+) optical characters, for example, fluorescence with double peaks separated by 2000 cm(-1) and five resolved absorption/excitation bands. These centres are assigned to Ce(3+)-polyhedra classified by weak and strong crystal fields as a consequence of the superlattice structure. The other two fluorescence bands observed in the visible region have 1.5-2 times larger linewidths than those of the former three bands. These bands are interpreted as optical transitions from complexes consisting of Ce(3+) and one or two electrons trapped at a vacancy of the nearest neighbour F(-) ligand ions.

Identification of AFLP markers linked to a resistance gene against pine needle gall midge in Japanese black pine

Bulked segregant and AFLP analyses of two mapping populations (R17 x S6 and R17 x S1) were used to identify markers linked to Rpgm, the only known gene responsible for resistance to pine needle gall midge in Pinus thunbergii Parl. Rpgm was found to be bracketed by ACCC/CCTTT(190) on one side at a distance of 6.6 cM and ACGT/CCCGC(250) at 15.3 cM on the other side. The segregation of these markers was analyzed in two other families in order to determine their phase and transferability. One of the two additional resistant parents carried ACCC/CCTTT(190) in the homozygous state while the marker was in coupling (plus marker allele linked with an R allele) in a resistant parent, R17. The marker ACGT/CCCGC(250) was in a repulsion phase in R17 and was not detected in the other two resistant pine trees. Out of four AFLP markers identified, only ACGT/CCAAT(290) was transferable in all resistant trees tested, although its phase was opposite for different trees. These results indicate that in applying those markers to select resistant trees, the phase state of the markers in each resistant tree with respect to Rpgm needs to be considered.

Identification of AFLP markers linked to a resistance gene against pine needle gall midge in Japanese black pine

Bulked segregant and AFLP analyses of two mapping populations (R17 x S6 and R17 x S1) were used to identify markers linked to Rpgm, the only known gene responsible for resistance to pine needle gall midge in Pinus thunbergii Parl. Rpgm was found to be bracketed by ACCC/CCTTT(190) on one side at a distance of 6.6 cM and ACGT/CCCGC(250) at 15.3 cM on the other side. The segregation of these markers was analyzed in two other families in order to determine their phase and transferability. One of the two additional resistant parents carried ACCC/CCTTT(190) in the homozygous state while the marker was in coupling (plus marker allele linked with an R allele) in a resistant parent, R17. The marker ACGT/CCCGC(250) was in a repulsion phase in R17 and was not detected in the other two resistant pine trees. Out of four AFLP markers identified, only ACGT/CCAAT(290) was transferable in all resistant trees tested, although its phase was opposite for different trees. These results indicate that in applying those markers to select resistant trees, the phase state of the markers in each resistant tree with respect to Rpgm needs to be considered.

Evidence for the involvement of the optic nerve as a migration route for larvae in ocular toxocariasis of Mongolian gerbils

Although Toxocara canis, an important pathogen of ocular disease, tends to migrate to the eye, the precise migratory route has yet to be determined experimentally. Mongolian gerbils, Meriones unguiculatus, known as a useful animal model for human toxocariasis, were used to investigate the migration route toward the eyes. Infective larvae of T. canis were directly inoculated into the intracranial region. Haemorrhagic lesions or larvae were observed in 56.3% of cases. Histopathologically, a larva was observed in the optic nerve of gerbils 6 days after inoculation, and two larvae were found in the optic chiasma in the gerbils having a haemorrhage in the retina 9 days after inoculation. These results indicate that T. canis migrates from the brain to the eye through the optic nerve. Considering these data and previous studies showing that the ocular changes appear as early as 3 days of infection in the oral-administrated gerbils, there are two phases in the migration to the retina: a haematogenous early phase and an optic nerve route late phase.

Diffuse retinochoroiditis due to Baylisascaris procyonis in Monglian gerbils

Baylisascaris procyonis, raccoon roundworm, causes a severe retinal lesion in humans. The lesion is termed as diffuse unilateral subacute neuroretinitis (DUSN). To understand the pathogenesis of B. procyonis in gerbils, we inoculated 17 embryonated eggs/g body weight of B. procyonis into 15 male Mongolian gerbils, Merionis ungiculatus, and monitored their fundi with an ophthalmoscope. Six of 15 gerbils (40%) showed severe retinitis with a sinuous track due to larval movement. The lesions extended across nearly half of the affected fundi. Histopathological examination revealed perivasculitis in the optic disk region, inflammatory proliferation of the pigment cells, and vitreitis in most cases. These findings were similar to those in human cases of DUSN, suggesting that gerbils might be a useful model for understanding the pathogenesis of B. procyonis infection in humans.

Effects of 12 months of exercise training on salivary secretory IgA levels in elderly subjects

BACKGROUND

The immune system declines in efficiency with advancing age, making the elderly less resistant to pathogenic microorganisms. Upper respiratory tract infection (URTI) is a common illness. Recent studies have shown that suppression of secretory immunoglobulin A (SIgA) is associated with increased incidence of URTI.

OBJECTIVE

To assess the effect of exercise on salivary SIgA in elderly subjects.

METHODS

Forty five elderly subjects (18 men, 27 women; mean (SD) age 64.9 (8.4) years) performed both 60 minute resistance and 60 minute moderate endurance training a week for 12 months. Saliva samples were obtained before training, and at four and 12 months during the training period. Salivary SIgA concentrations were measured by enzyme linked immunosorbent assay, and the SIgA secretion rate was calculated.

RESULTS

SIgA concentrations before training, and at four and 12 months during training were 24.7 (14.4), 27.2 (14.2), and 33.8 (18.5) micro g/ml respectively. SIgA secretion rates were 29.5 (26.0), 33.8 (27.2) and 46.5 (35.1) micro g/min respectively. The results indicate that both the concentration and secretion rate of SIgA significantly (p<0.01) increased during 12 months of exercise in these elderly subjects.

CONCLUSION

Regular moderate exercise seems to enhance mucosal immune function in elderly subjects.

[Castleman lymphoma originated from the posterior mediastinum resected thoracoscopically: report of a case]

We report thoracoscopic resection of Castleman lymphoma originated from the posterior mediastinum. The patient was a 19-year-old woman, who was pointed out to show an abnormal shadow in the left upper lung in the chest X-ray photograph. It was diagnosed as a blood-rich posterior mediastinal tumor by dynamic MRI, and thoracoscopic surgery was performed. The tumor was adjacent to the vertebral body of the fourth thoracic vertebra. Although operation involved 2 hours and 40 minutes and 670 ml of bleeding due to a strong adhesion between the tumor and the intercostal muscle and considerable bleeding from the tumor itself, it was successfully removed under thoracoscopy. The tumor was elastic and hard, and 50 x 45 x 25 mm in size. The histopathological diagnosis was a Castleman lymphoma, hyaline vascular type. The postoperative course was satisfactory, and the patient was discharged from the hospital on the 7th postoperative day. Castleman lymphoma originated from the posterior mediastinum tends to bleed considerably during its resection. If a blood-rich posterior mediastinal tumor was found preoperatively, thoracoscopic operation must be advanced carefully keeping this disease in mind.

[Cases of death after surgery for pathologic stage I non-small cell lung cancer]

We clinically examined cases of death from pathologic stage I non-small cell lung cancer with the aim of improving the 5-year survival rate after surgery for this condition. The subjects were 70 patients with p-stage IA (20 cases of death) and 59 patients with p-stage IB (26 cases of death) from among those who underwent surgery for p-stage I non-small cell lung cancer between 1986 and 2000. 1) Of 30 patients who died from p-stage I lung cancer, 20 had distant metastases and 10 had recurrence in the thoracic cavity. Of 16 patients who died from other diseases, 5 had respiratory organ disease, 5 had cancers of other organs and 6 had circulatory organ disease. 2) Of 30 patients who died from p-stage I lung cancer, 20 (66.7%) had distant metastases, with lung metastasis occurring most frequently, in 10 of them (33.3%). The most common cause of death of patients with p-stage IB lung cancer was recurrence in the thoracic cavity. 3) The mean durations of survival (mean +/- standard deviation) after surgery for lung cancer of the patients who died from p-stage I lung cancer (30 patients) were 36.3 +/- 22.2 months for the 20 patients with distant metastases and 26.2 +/- 14.3 months for the 10 patients with recurrence in the thoracic cavity, the difference between groups was 10 months, but was not significant. 4) The 5-year survival rate in 45 patients who underwent p-stage IA mediastinal lymph node dissection was 83.1% whereas that in 25 patients without p-stage IB mediastinal lymph node dissection was 50.9% showing a significant difference of 32.2% (p < 0.01). 5) The patients in p-stage IA who died from other diseases were all men (10 patients). The mean durations of survival after surgery for lung cancer in the patients who died from other diseases were 35.2 +/- 19.0 months in the patients with respiratory organ disease, 37.0 +/- 23.9 months in those with cancers of other organs and 60 +/- 19.1 months in those with circulatory organ disease. 6) The 5-year survival rate after surgery in all cases of death was 76% in the patients in p-stage IA and 61.4% in those in p-stage IB. The 5-year survival rates in the patients excluding those who died from other diseases were 85% in the patients in p-stage IA (60 patients) and 60.3% in those in p-stage IB (53 patients) (p < 0.01). 7) To improve the 5-year survival rate in the patients with p-stage IA lung cancer, it is necessary to prevent death from other diseases in men. It is still possible to improve the 5-year survival rate in the patients with p-stage IB lung cancer by raising the accuracy of mediastinal lymph node dissection during surgery.

Disruption of Xpg increases spontaneous mutation frequency, particularly A:T to C:G transversion

Cells isolated from Xpg (the mouse counterpart of XPG)-disrupted mice underwent premature senescence and showed early onset of immortalization, suggesting that Xpg might be involved in genetic stability. Recent studies showed that human XPG, in addition to its function in the nucleotide excision repair (NER), was involved in the repair of oxidative base damages such as thymine glycol (Tg) and 8-oxo-guanine (8-oxoG), and this may explain the genetic instability observed in Xpg-deficient cells. To clarify this point, we determined spontaneous mutation frequencies and the type of spontaneous base substitution mutations in cells obtained from normal and Xpg-deficient mice using the supF shuttle vector (pNY200) for mutation assay. The spontaneous mutation frequency of the supF gene in pNY200 propagated in the Xpg-deficient cells was about three times higher than that in normal cells, indicating the importance of Xpg in reducing the frequency of spontaneous mutations. The frequency of spontaneous base substitution mutations at A:T sites, particularly that of the A:T to C:G transversion, increased markedly in the Xpg-deficient cells.

The intratumoral expression of vascular endothelial growth factor and interleukin-8 associated with angiogenesis in nonsmall cell lung carcinoma patients

BACKGROUND

Angiogenesis has important effects on tumor growth and metastasis. It is regulated by a variety of angiogenic and angiostatic factors.

METHODS

To evaluate the effects of tumor cell-derived angiogenic factors, we performed an immunohistochemic study to evaluate the intratumoral expression of vascular endothelial growth factor (VEGF) and interleukin-8 (IL-8) in relation to intratumoral microvessel density (IMD) in tumors from 104 nonsmall cell lung carcinoma (NSCLC)patients.

RESULTS

Fifty-four carcinomas were VEGF-positive, 47 carcinomas were IL-8-positive, and 53 carcinomas were hypervascular tumors. There was no significant correlation between the percentages of positive VEGF-staining and positive IL-8-staining in NSCLCs (rho = 0.174, P = 0.080). The IMD of VEGF-positive carcinomas was significantly greater than that of VEGF-negative carcinomas (P = 0.023). In addition, the IMD of IL-8-positive carcinomas was significantly greater than that of IL-8-negative carcinomas (P =0.013). The overall survival rate of patients with hypervascular tumors was significantly lower than that of patients with hypovascular tumors (41.0% versus 67.0%, P = 0.004). Cox proportional-hazards regression model also demonstrated that angiogenesis was one of the significant factors in predicting the survival of NSCLC patients (relative risk = 1.944, P = 0.041).

CONCLUSIONS

Intratumoral expression of VEGF and IL-8 was associated with angiogenesis in NSCLCs. Tumor angiogenesis significantly affected the prognosis of NSCLC patients.

Expression profiling of sulfotransferases in human cell lines derived from extra-hepatic tissues

To explore the physiological roles of sulfotransferases (SULTs) in extra-hepatic tissues, we examined the expression of eight SULT genes by reverse transcription (RT)-PCR in human cell lines that were established from various tissues. Expression levels of SULTs were low in neural cell lines such as NB-1 and GI-1, and high in epithelial cell lines, such as Caco-2 and BeWo. SULT1C2 expression was abundant in all cell types, whereas that of SULT1E1, SULTIBI or SULT2B1 was restricted to a specific cell type. SULT1C1, which can catalyze the sulfation of N-hydroxy-2-acetylaminofluorene, was expressed in Caco-2, BeWo and KB562. Induction of differentiation did not generally affect SULT expression, although that of SULT1C2 was reduced after differentiation of the neuroblastoma cell line, NB-1, was induced. The profile of SULT expression in the culture cells obtained here gives clues to understanding the physiological roles of SULT enzymes in extra-hepatic tissues or organs.

Further studies on the site-specific protein modification by microbial transglutaminase

A guinea pig liver transglutaminase (G-TGase)-mediated procedure for the site-specific modification of chimeric proteins was recently reported. Here, an alternative method with advantages over the recent approach is described. This protocol utilizes a microbial transglutaminase (M-TGase) instead of the G-TGase as the catalyst. M-TGase, which has rather broad structural requirements as compared to the G-TGase, tends to catalyze an acyl transfer reaction between the gamma-carboxamide group of a intact protein-bound glutamine residue and various primary amines. To demonstrate the applicability of the M-TGase-catalyzed protein modification in a drug delivery system, we have utilized recombinant human interleukin 2 (rhIL-2) as the target protein and two synthetic alkylamine derivatives of poly(ethyleneglycol) (PEG12; MW 12 kDa) and galactose-terminated triantennary glycosides ((Gal)(3))) as the modifiers. For the M-TGase-catalyzed reaction with PEG12 and (Gal)(3), 1 mol of alkylamine was incorporated per mole of rhIL-2, respectively. Peptide mapping of (Gal)(3)-modified rhIL-2 ((Gal)(3)-rhIL-2) by liquid chromatography-electrospray ionization mass spectrometry (LC-ESI/MS) suggested that the Gln74 residue in rhIL-2 was site specifically modified with (Gal)(3). The PEG12-rhIL-2 and (Gal)(3)-rhIL-2 conjugates retained full bioactivity relative to the unmodified rhIL-2. In pharmacokinetic studies, PEG12-rhIL-2 was eliminated more slowly from the circulation than rhIL-2, whereas (Gal)(3)-rhIL-2 accumulated in the liver via hepatic asialoglycoprotein receptor binding. The results of this study expand the applicability of the TGase-catalyzed methodology for the preparation of protein conjugates for clinical use.

Establishment and characterization of chondrocyte cell lines from the costal cartilage of SV40 large T antigen transgenic mice

Complete understanding of the physiology and pathology of the cartilage is essential to establish treatments for a variety of cartilage disorders and defects such as rheumatoid arthritis, congenital malformations, and tumors of cartilage. Although synthetic materials have been used in many cases, they possess inherent problems including wear of the materials and low mechanical strength. Autograft has been considered very effective to overcome these problems. However, the limitation of the transplant volume is a major problem in autograft to be overcome. The costal cartilage is the most serious candidate for donor site transplantation, since it is the largest permanent hyaline cartilage in the body. To investigate the possibility using the costal cartilage as a transplant source, we have established and characterized three mouse chondrocyte cell lines (MCC-2, MCC-5, and MCC-35) derived from the costal cartilage of 8-week-old male SV40 large T-antigen transgenic mice. At confluence, all the cell lines formed nodules that could be positively stained with alcian blue (pH 2.5). The size of nodules gradually increased during culturing time. After 2 and 6 weeks of culture, RT-PCR analysis demonstrated that all three cell lines expressed mRNA from the cartilage-specific genes for type II collagen, type XI collagen, aggrecan, and link protein. Furthermore, type X collagen expression was detected in MCC-5 and MCC-35 but not in MCC-2. Any phenotypic changes were not observed over 31 cell divisions. Immunocytochemistry showed further that MCC-2, MCC-5, and MCC-35 produced cartilage-specific proteins type II collagen and type XI collagen, while in addition MCC-5 and MCC-35 produced type X collagen. Treatment with 1alpha, 25-dihydroxyvitamin D(3) inhibited cell proliferation and differentiation of the three cell lines in a dose-dependent manner. These phenotypic characteristics have been found consistent with chondrocyte cell lines established from cartilage tissues other than costal cartilage. In conclusion, costal cartilage shows phenotypic similarities to other cartilages, i.e., articular cartilage and embryonic limbs, suggesting that costal cartilage may be very useful as the donor transplantation site for the treatment of cartilage disorders. Furthermore, the cell lines established in this study are also beneficial in basic research of cartilage physiology and pathology.

[A case of sarcoidosis with simultaneous involvement of the lower brainstem and the whole cervical cord and the extraocular muscles]

We report a 63-year-old woman with sarcoidosis which involved the spinal cord, lower brainstem and extraocular muscules simultaneously. In this patient, uveitis developed in 1991 and the skin lesion in 1992. A biopsy of the skin lesion showed changes consistent with sarcoidosis. The ocular and dermal symptoms improved with oral corticosteroid. In October 1997, she noted the left blepharoptosis and numbness of the hands. The MRI showed diffuse swelling of the lower brainstem and the cervical and upper thoracic cord. These lesions showed high intensity signal on T2WI and low intensity signal on T1WI. T1WI with contrast enhancement revealed localized enhancement within the spinal lesion at the C4/5 level. The ocular MRI showed swelling of the left superior rectus muscle and upper levator palpebral muscle. The steroid pulse therapy and subsequent oral administration of prednisolone markedly improved the clinical symptoms. MRI after treatment showed marked improvement of both the spinal cord and ocular muscle lesions. To our knowledge, the simultaneous occurrence of myelopathy and symptomatic extraocular musculopathy in the condition has not been reported previously.

Seasonal changes in sleep and behavioral problems in a pubescent case with autism

This study reports on the seasonal changes in sleep problems and behavioral problems in a pubescent case with autism. His care diary, kept for 1 year, showed seasonal changes of sleep and behavioral problems, and that his behavioral problems preceded his sleep problems.

[A case with lung metastasis of osteosarcoma occurred 21 years after the operation of osteosarcoma on left tibia]

The patient was a 38-years-old woman. A chest X-ray film demonstrated the presence of an abnormal lesion. Her past history included osteosarcoma on the left tibia for which she received amputation of the left inferior limb at 17 years of age without any relapse thereafter. Considering that the patient might have lung metastasis of osteosarcoma on the basis of lung biopsy performed under CT guide, and then a tumor was removed under the thoracoscope. The tumor, 2.8 x 2.2 x 2.1 cm in size, was located right under the pleura at left S10 with its inside being filled up with fragile necrotic tissues. When compared pathohistologically with the primary lesion of osteosarcoma which had occurred 21 years before, the lung tumor was almost identical in terms of the tumor cell morphology but had a higher cell density without evidence of osteoid formation. The diagnosis of lung metastasis of osteosarcoma was established on the basis of the clinical course and the immunohistochemical staining. It is extremely rare case that osteosarcoma recurs in the form of lung metastasis 21 years after the operation of primary lesion. We report this case as a valuable one to identify the prognosis of osteosarcoma and the development mechanism of lung metastasis.

E-cadherin expression associated with differentiation and prognosis in patients with non-small cell lung cancer

BACKGROUND

E-Cadherin plays a major role in maintaining the intercellular junctions in epithelial tissues. The reduction of E-cadherin expression in cancer cells may be associated with tumor differentiation, metastasis, and a poor prognosis.

METHODS

Immunohistochemistry for E-cadherin expression was performed on 109 tumors from patients with non-small cell lung cancer who underwent operations.

RESULTS

With respect to membranous immunostaining, 57 carcinomas were E-cadherin-positive, 39 carcinomas E-cadherin-reduced, and 13 carcinomas E-cadherin-negative. The percentage of poorly differentiated tumors in the impaired E-cadherin expression group was significantly higher than that in the E-cadherin-positive group (p = 0.005). Furthermore, the frequency of lymph node metastases in tumors with impaired E-cadherin expression was significantly higher than that in the E-cadherin-positive tumors (p = 0.011). A Cox regression analysis revealed that E-cadherin expression was a significant factor in the prediction of survival for patients with non-small cell lung cancer (p = 0.002).

CONCLUSIONS

E-Cadherin expression was associated with tumor differentiation, lymph node metastasis, and prognosis in patients with non-small cell lung cancer.

[Lobectomy of two or more lobes in patients with lung cancer]

We clinically examined patients who had undergone resection of two or more lobes for lung cancer. The subjects were 50 patients (25 who underwent pneumonectomy and 25 bilobectomy) who underwent lobectomy of two or more lobes from among those with primary non-small cell lung cancers in our hospital between 1975 and 1999; these individuals were assigned to Group A, and compared with 166 patients with lobectomy in Group B. The five-year survival rate was 27.7% in Group A, which differed significantly from the rate of 55.6% in Group B (p < 0.01, Kaplan-Meier method with log-rank test). The percentage of Stage I patients was 34% (17 patients) in Group A and 60.2% (100 patients) in Group B: this difference was significant (chi 2 test, p < 0.01). There were more patients with advanced cancer in Group A than in Group B. However, the five-year survival rates of Stage I patients were 52.4% in Group A and 77.6% in Group B, and significantly different (p < 0.05). In a comparison with respect to histological type, the five-year survival rates also differed significantly between Group A and B (p < 0.01 for adenocarcinoma, p < 0.05 for squamous cell carcinoma, with higher values in Group B for both). Resection of two or more lobes was indicated based on infiltration of the main tumor into adjacent lobes in 19 patients (38%), infiltration of lymph node metastasis into a bronchus or pulmonary artery in 14 (28%), direct infiltration of the main tumor into a bronchus in 10 (20%), and for other reasons in 7 (14%). The five-year survival rates for these groups were 15.8, 22.1, 54 and 42.9%, respectively. There was a significant difference between the patients with infiltration of cancer into adjacent lobes and those with direct infiltration into a bronchus (p < 0.05). The prognosis of patients with resection of two or more lobes was poorer than that of patients with lobectomy even in Stage I. In particular, infiltration of cancer into adjacent lobes accompanied lymph node metastasis in more than 50% in cases, and appeared to suggest a poor prognosis.

Expression of telomerase components in oral keratinocytes and squamous cell carcinomas

Telomerase activity was measured using a telomeric repeat amplification protocol (TRAP), and expressions of the telomerase components, telomerase associated protein 1 (hTEP1), human telomerase RNA component (hTR), and human telomerase reverse transcriptase (hTERT) were measured by reverse transcriptase-polymerase chain reaction (RT-PCR) in cultured normal oral keratinocytes and oral squamous cell carcinoma (SCC) cells. Telomerase localization was analyzed by in situ hybridization (ISH) in normal, precancerous and cancerous oral tissues. There was a strong correlation of telomerase activity with the expression levels of hTERT but not with hTEP1 or hTR mRNA in the cultured cells. Not only hTEP1 and hTR but also hTERT expression were detected in the basal cells of normal oral mucosa, and the cells expressing these mRNAs were also seen in the upper layer of leukoplakia of gingiva, and a heterogeneous pattern of expression was observed in the oral SCC tissues. These results indicate that there are at least two steps in the increase of telomerase activity during carcinogenesis in oral squamous cells; a change in distribution of cells expressing these telomerase components and the over-expression of hTERT gene in individual cells.

Reverse correlation of E-cadherin and snail expression in oral squamous cell carcinoma cells in vitro

The loss of E-cadherin expression has been shown to correlate to the invasion and metastasis of many types of carcinomas. We established E-cadherin positive (HOC719-PE) and negative (HOC719-NE) clones from an oral squamous cell carcinoma (SCC). HOC719-PE cells showed epithelial morphology with E-cadherin expression in the cell membrane, whereas HOC719-NE cells demonstrated fibroblastic morphology without E-cadherin expression. In invasion assay and three dimensional culture, HOC719-NE showed much higher invasive ability than HOC719-PE cells. These cells expressed similar levels of mRNAs for alpha- and beta-catenin. However, HOC719-NE cells, but not HOC719-PE cells, showed strong expression of snail, a transcription factor implicated in the differentiation of epithelial cells into mesenchymal phenotype. This reverse expression of snail and E-cadherin was further observed in other SCC cells including HOC313, and TSU cells that we previously reported to show no expression of E-cadherin protein. These results indicated that the expression of snail has a key role for the acquisition of more invasive and metastatic phenotypes of SCC and the clones we reported here will be useful tools for understanding the mechanism of the transition from epithelial to mesenchymal SCC cells.

[A case of G-CSF-producing large cell carcinoma of the lung with gastric metastasis]

We report a rare surgically-treated case of G-CSF-producing large cell carcinoma of the lung with gastric metastasis. A 65-year-old male was admitted to our hospital because of fever, anemia and epigastralgia. Chest X-ray examination and CT scanning revealed a round mass shadow (8 cm) in contact with the chest wall in the right upper lung field and metastasis to the mediastinal lymph nodes. Laboratory examination showed a WBC of 16,800/mm3, CRP of 11.6 mg/dl, and a serum G-CSF of 90 pg/ml. Upper gastrointestinal series and gastroscopy showed an ulcerating submucosal tumorous lesion in the pyloric antrum. The lung carcinoma was treated by right upper lobectomy with chest wall resection. After 1 month, gastrectomy was performed. After the operation, the WBC normalized, and the CRP and serum G-CSF levels decreased. Histopathological examination demonstrated a poorly differentiated large cell carcinoma in the lung and a metastatic lesion in the stomach. Immunohistochemical staining with anti-G-CSF mono-clonal antibody showed negative results in the lung but positive results in the stomach. He was discharged 3 weeks after gastrectomy but died of aggravation of the general condition associated with local recurrence in the chest wall 2 months after discharge.

Transglutaminase-mediated dual and site-specific incorporation of poly(ethylene glycol) derivatives into a chimeric interleukin-2

To expand the applications of poly(ethylene glycol) (PEG)-protein conjugates for clinical use, we have developed a novel method for dual and site-specific incorporations of PEG derivatives into proteins using a substrate peptide (AQQIVM, named TG2) and transglutaminase (TGase). In our previous studies, TG2 was shown to be a special peptide with two adjacent Gln substrates for guinea pig liver transglutaminase (G-TGase). We have now constructed a chimeric protein (named rTG2-IL-2) of human interleukin-2 (IL-2), in which TG2 was fused to the N-terminus of IL-2. For the G-TGase-catalyzed reaction, rTG2-IL-2 was dually and site-specifically modified with alkylamine derivatives of PEG (PEG10, average M(r) 10 kDa) at both the Gln2 and Gln3 residues in the appended tag. To demonstrate the effectiveness of the G-TGase-catalyzed PEG-incorporation, we have compared the characteristics and the biological properties of PEG10-rTG2-IL-2 species with two PEG10 molecules attached to rTG2-IL-2 [(PEG10)(2)-rTG2-IL-2] with that of (PEG10)(2)-rhIL-2(R), in which PEG10 was randomly incorporated into rhIL-2 by a general procedure using a N-hydroxysuccinimidyl ester of PEG (PEG10-COOSu) (M(r) 10 kDa). (PEG10)(2)-rTG2-IL-2 was found to be superior in its in vitro bioactivities and equivalent in its pharmacokinetic profiles to (PEG10)(2)-rhIL-2(R). Unlike most previous methods, this approach can place dual PEG chains at designed sites on chimeric proteins without decreasing their bioactivities. Thus, TGase-catalyzed PEG-incorporation would improve the therapeutic utility of PEG-protein conjugates.

Search for a W' boson via the decay mode W'-->munumu in 1.8 TeV pp collisions

We report the results of a search for a W' boson produced in pp collisions at a center-of-mass energy of 1.8 TeV using a 107 pb-1 data sample recorded by the Collider Detector at Fermilab. We consider the decay channel W'-->&munumu and search for anomalous production of high transverse mass munumu lepton pairs. We observe no excess of events above background and set limits on the rate of W' boson production and decay relative to standard model W boson production and decay using a fit of the transverse mass distribution observed. If we assume standard model strength couplings of the W' boson to quark and lepton pairs, we exclude a W' boson with invariant mass less than 660 GeV/c2 at 95% confidence level.