Rationale, design and baseline characteristics of the effect of canagliflozin in patients with type 2 diabetes and microalbuminuria in the Japanese population: The CANPIONE study

AIM

To evaluate the effect of canagliflozin, a sodium-glucose co-transporter-2 (SGLT2) inhibitor, on albuminuria and the decline of estimated glomerular filtration rate (eGFR) in participants with type 2 diabetes and microalbuminuria.

METHODS

The CANPIONE study is a multicentre, randomized, parallel-group and open-labelled study consisting of a unique 24-week preintervention period, during which the rate of eGFR decline before intervention is estimated, followed by a 52-week intervention and a 4-week washout period. Participants with a geometric mean urinary albumin-to-creatinine ratio (UACR) of 50 and higher and less than 300 mg/g in two consecutive first-morning voids at two different time points, and an eGFR of 45 ml/min/1.73m² or higher, are randomly assigned to receive canagliflozin 100 mg daily or to continue guideline-recommended treatment, except for SGLT2 inhibitors. The first primary outcome is the change in UACR, and the second primary outcome is the change in eGFR slope.

RESULTS

A total of 258 participants were screened and 98 were randomized at 21 sites in Japan from August 2018 to May 2021. The mean baseline age was 61.4 years and 25.8% were female. The mean HbA1c was 7.9%, mean eGFR was 74.1 ml/min/1.73m² and median UACR was 104.2 mg/g.

CONCLUSIONS

The CANPIONE study will determine whether the SGLT2 inhibitor canagliflozin can reduce albuminuria and slow eGFR decline in participants with type 2 diabetes and microalbuminuria.

Protein tyrosine phosphatase receptor type Q in cerebrospinal fluid reflects ependymal cell dysfunction and is a potential biomarker for adult chronic hydrocephalus

BACKGROUND AND PURPOSE

Protein tyrosine phosphatase receptor type Q (PTPRQ) was extracted from the cerebrospinal fluid (CSF) of patients with probable idiopathic normal-pressure hydrocephalus (iNPH) by proteome analysis. We aimed to assess the feasibility of using CSF PTPRQ concentrations for the additional diagnostic criterion of iNPH in Japanese and Finnish populations.

METHODS

We compared PTPRQ concentrations among patients with probable iNPH and neurologically healthy individuals (normal control [NC] group), patients with normal-pressure hydrocephalus (NPH) of acquired and congenital/developmental aetiologies, patients with Alzheimer's disease and patients with Parkinson's disease in a Japanese analysis cohort. A corresponding iNPH group and NC group in a Finnish cohort was used for validation. Patients in the Finnish cohort who underwent biopsy were classified into two groups based on amyloid and/or tau deposition. We measured PTPRQ expression levels in autopsied brain specimens of iNPH patients and the NC group.

RESULTS

Cerebrospinal fluid PTPRQ concentrations in the patients with NPH of idiopathic, acquired and congenital/developmental aetiologies were significantly higher than those in the NC group and those with Parkinson's disease, but iNPH showed no significant differences when compared with those in the Alzheimer's disease group. For the patients with iNPH, the area under the receiver-operating characteristic curve was 0.860 in the Japanese iNPH and 0.849 in the Finnish iNPH cohorts. Immunostaining and in situ hybridization revealed PTPRQ expression in the ependymal cells and choroid plexus. It is highly possible that the elevated PTPRQ levels in the CSF are related to ependymal dysfunction from ventricular expansion.

CONCLUSIONS

Cerebrospinal fluid PTPRQ levels indicated the validity of this assay for auxiliary diagnosis of adult chronic hydrocephalus.

Cardiac tamponade due to systemic lupus erythematosus in patient with Prader-Willi syndrome after growth hormone therapy

We present a 16-year old girl with Prader-Willi syndrome who developed cardiac tamponade as an initial finding of systemic lupus erythematosus. Until one year prior to this episode, she had received growth hormone treatment for nine years. The association among Prader-Willi syndrome, growth hormone treatment and systemic lupus erythematosus is discussed. Lupus (2007) 16, 447—449.

Differentiation of Friend virus-induced leukemia cells

A long-term cultured Friend leukemia cell is able to differentiate along the erythrocytic series following treatment with some substances and that can be demonstrated by a conjugated erythrocyte membrane-specific antibody technique. Differentiation is induced by inhibition of DNA synthesis and by dimethylsulfoxide (DMSO), erythropoietin (EP) and Vitamin B12 (B12), and other agents. The effective substances were divided into 2 groups by the mode of differentiation of Friend cells. A differentiated state continues for several days when cells are re-cultured in the medium without substances. The decreased tumorigenecity of differentiated cells is proved by back transplantation to mice.

Representation of older patients in clinical trials for drug approval in Japan

To examine how target patients seen in clinical practice are represented in clinical trials for approved drugs in Japan, we compared the age distribution of older patients enrolled in confirmatory clinical trials for regulatory approval with that of the estimated actual patient population. Drugs for 6 chronic conditions common among older patients (diabetes mellitus, hypertension, rheumatoid arthritis, non-small cell lung cancer, depression and Alzheimer's disease) launched by 2012 in Japan were selected. The disparity in age distribution between patients in trials and patients seen in clinical practice varied depending on the disease, but older patients, especially those aged 75 or older, were generally underrepresented in clinical trials for regulatory approval in Japan. Under-representation of older patients in hypertension trials was particularly marked compared to other conditions, despite the similarity in age distribution of patients seen in clinical practice. One factor causing this disparity may be an upper age limit in clinical trial protocols. More effort is needed to properly characterize the benefits and risks of drugs for older patients. This should include the active enrollment of older patients in clinical trials, the establishment of better assessment tools such as pharmacometric approaches, and the appropriate planning and conducting of post-marketing surveys and studies.

Human PTRF mutations cause secondary deficiency of caveolins resulting in muscular dystrophy with generalized lipodystrophy

Caveolae are invaginations of the plasma membrane involved in many cellular processes, including clathrin-independent endocytosis, cholesterol transport, and signal transduction. They are characterized by the presence of caveolin proteins. Mutations that cause deficiency in caveolin-3, which is expressed exclusively in skeletal and cardiac muscle, have been linked to muscular dystrophy. Polymerase I and transcript release factor (PTRF; also known as cavin) is a caveolar-associated protein suggested to play an essential role in the formation of caveolae and the stabilization of caveolins. Here, we identified PTRF mutations in 5 nonconsanguineous patients who presented with both generalized lipodystrophy and muscular dystrophy. Muscle hypertrophy, muscle mounding, mild metabolic complications, and elevated serum creatine kinase levels were observed in these patients. Skeletal muscle biopsies revealed chronic dystrophic changes, deficiency and mislocalization of all 3 caveolin family members, and reduction of caveolae structure. We generated expression constructs recapitulating the human mutations; upon overexpression in myoblasts, these mutations resulted in PTRF mislocalization and disrupted physical interaction with caveolins. Our data confirm that PTRF is essential for formation of caveolae and proper localization of caveolins in human cells and suggest that clinical features observed in the patients with PTRF mutations are associated with a secondary deficiency of caveolins.

Immunomodulatory Effects of Polysaccharides Produced by Lactobacillus delbrueckii ssp. bulgaricus OLL1073R-1

The extracellular polysaccharides (EPS) produced by lactic acid bacteria (LAB) are associated with the rheology, texture, and mouthfeel of fermented milk products, including yogurt. This study investigated the immunomodulatory effects of EPS purified from the culture supernatant of Lactobacillus delbrueckii ssp. bulgaricus (L. bulgaricus) OLL1073R-1. The crude EPS were prepared from the culture supernatant of L. bulgaricus OLL1073R-1 by standard chromatographic methods, and were fractionated into neutral EPS and acidic EPS (APS). Acidic EPS were further fractionated into high molecular weight APS (H-APS) and low molecular weight APS (L-APS). High molecular weight APS were shown to be phosphopolysaccharides containing D-glucose, D-galactose, and phosphorus. Stimulation of mouse splenocytes by H-APS significantly increased interferon-gamma production, and, moreover, orally administered H-APS augmented natural killer cell activity. Oral administration of yogurt fermented with L. bulgaricus OLL1073R-1 and Streptococcus thermophilus OLS3059 to mice showed a similar level of immunomodulation as H-APS. However, these effects were not detected following administration of yogurt fermented with the starter combination of L. bulgaricus OLL1256 and S. thermophilus OLS3295. We conclude from these findings that yogurt fermented with L. bulgaricus OLL1073R-1, containing immunostimulative EPS, would have an immunomodulatory effect on the human body.

Case control study of hormone replacement therapy (HRT) and breast cancer in Japanese women

10012

Background: Some prospective studies in US and UK (represented by Women’s Health Initiative and Million Women Study) show that HRT use may increase the risk of breast cancer. However, it is unclear whether or not this perspective is applicable to Japanese women, due to several factors such as the difference in incidence of breast cancer, difference in HRT prevalence, which are to be concerned in this study. To investigate the relationship between HRT use and breast cancer, a case-control study was conducted in Japan. Methods: We sent self-administered questionnaire to 4,500 cases who have a previous history of confirmed histological breast cancer and 4,500 controls who were selected according to the inclusion criteria. All the subjects were between age 45 and 69 at the time of enrollment. Among these subjects, 3,434 in case group and 2,427 in control group sent back their questionnaire (total 5,861). The datacenter was run in Kitasato Univ. and the statistical analysis was performed using SAS (version 9.1). Control was selected by considering the screening record for GI disease and respiratory disorders, with no previous history of breast cancer, gynecological and hormonal disease at the time of screening. We asked about past history of exposure to the factors supposed to be breast cancer-causing; previous or current use of HRT, age at diagnosis, academic background, BMI, lifestyle habits, age of menarche, birth history, history of breast feeding, family history, use of contraceptive agents and menopausal status. Results: As the main analysis result, 164 (5.0%) out of 3,316 cases and 253 (7.4%) out of 2355 controls had used HRT (Odds ratio 0.432 [95% CI 0.352–0.530]. Conclusions: The result of this study shows that HRT users were less likely to develop breast cancer than never users. However, in this study, there was a difference in the observation period for the past use of HRT between cases and controls. Considering the transition of HRT prevalence in Japan, there may be a possibility that this difference can be a cause of a serious bias for the main analysis result. Further sensitivity analyses are needed to evaluate the robustness of the findings and this point is under consideration.

No significant financial relationships to disclose.

Gastric ciliated metaplasia. A study of 3406 gastrectomy specimens from dwellers of the Atlantic and the Pacific basins

BACKGROUND

Ciliated cells in gastrectomies from patients dwelling in the Pacific and Atlantic basins have been reported previously.

AIM

To compare all the results in an attempt to explain the findings.

METHODS

Sections from 3406 gastrectomies were reviewed: 1966 and 1440 from the Atlantic and Pacific basins, respectively. Ciliated cells and intestinal metaplasia (IM) were recorded; IM was classified into focal or extensive IM. The total number of sections/gastrectomy was noted.

RESULTS

In the Atlantic basin, 5% of specimens had ciliated metaplasia (CM); it was more frequent in intestinal carcinoma (IC; 9%) than diffuse carcinoma (DC; 3%) or miscellaneous gastric diseases (MGD; 3%). In the Pacific basin, the frequency of specimens with CM was 29%: it was more frequent in IC (43%) than in DC (16%) or MGD (10%). The difference between the frequency of CM in specimens with IC or with DC/MGD in the Atlantic and the Pacific basins was significant (p < or = 0.05). The presence of CM was influenced by age and the extent of IM in both basins, but not by sex or the number of sections investigated.

CONCLUSIONS

CM-apparently an independent microscopic marker-was significantly higher in the Pacific than in the Atlantic basin. Environmental carcinogens involved in the evolution of IM and IC seem to be implicated in gastric ciliogenesis. Carcinogens that differ in nature and/or in strength in both basins might activate the latent natural genes encoding ciliated processes in gastric cells in patients subsequently developing gastric carcinoma, more notably of intestinal type.

Extended intestinal metaplasia. A survey of 1392 gastrectomies from dwellers of the Pacific basin

BACKGROUND

To assess the extent of gastric intestinal metaplasia (IM) in gastrectomy specimens in populations of the Pacific basin having different incidence of gastric carcinoma.

MATERIALS AND METHODS

One thousand three hundred and nine-two gastrectomies were investigated: 1088 had a gastric carcinoma and 304 miscellaneous gastric diseases. Twenty-one thousand three hundred and fourteen histological sections were reviewed under low-power (4X). IM was either spotty (SIM) or extended (EIM= encompassing one or more entire low-power fields/section). Widespread IM (WIM) was regarded as EIM if present in > or =5 histological sections.

RESULTS AND CONCLUSION

The percent of gastrectomies harboring a carcinoma increased significantly with increasing age more notably in those with diffuse carcinomas (DC) than in those with intestinal carcinomas (IC). The percent of gastrectomies with EIM was significantly higher in specimens with IC than with DC, particularly among elderly patients, and in specimens from countries with a high cancer incidence. The percent of gastrectomies with WIM was higher in specimens having IC than in those having DC. Migration per se did not influence the frequency of specimens with EIM in elderly Japanese patients: Japanese migrants to Hawaii had a similarly high frequency of EIM as those dwelling in Japan. Japanese patients with a gastric carcinoma showed atypical mitoses in areas with EIM far from the tumor, suggesting that cellular mutation(s) play a role in the evolution of EIM towards gastric dysplasia and carcinoma in that ethnic group. The drawback of gastric biopsies in assessing the extent of gastric intestinal metaplasia and, thereby, estimating possible cancer risk in long-term studies has been stressed.

Adrenergic mediation of TNF alpha-stimulated ICAM-1 expression on human brain microvascular endothelial cells

Adrenergic innervation derived from locus ceruleus has been implicated in regulating BBB permeability and inflammatory responses associated with neurological disorders. This report demonstrates that adrenergic agents attenuate the tumor necrosis factor-alpha (TNF alpha)-induced expression of intercellular adhesion molecule-1 (ICAM-1) on cerebral microvascular endothelial cells (HBMEC) derived from human brains. HBMEC were incubated with isoproterenol (1-10 microM) alone or in the presence of propranolol (10 microM) for 30 min followed by the addition of various concentrations of TNF alpha. ICAM-1 expression on cultured HBMEC was dose-dependently upregulated by TNF alpha. Incubation with isoproterenol significantly reduced levels of ICAM-1 expression indicating the possible involvement of adrenergic agents on ICAM-1 expression. Treatment with propranolol (beta 1/beta 2-adrenergic antagonist) and butoxamine (beta 2-adrenergic antagonist), but not atenolol (beta 1-adrenergic antagonist) reversed this inhibitory effect. Isoproterenol also dose-dependently stimulated cAMP production (assayed by RIA) by HBMEC; propranolol treatment abolished this effect. These data show that the beta 2-adrenergic receptor/cAMP pathway may be partly involved in TNF alpha-stimulated ICAM-1 expression and indicate the possible involvement of adrenergic mediation of capillary function including BBB integrity.

Atypical osteosarcomas in Werner Syndrome (adult progeria)

Werner syndrome (WS), adult progeria, is more common in Japan than elsewhere. It predisposes to osteosarcoma (OS) and five other rare tumors. To determine if and how OS is atypical in this genetic disorder, we studied the characteristics of ten Japanese cases with respect to clinical features, pathology, and radiographs, and compared them with a hospital series of 36 skeletal OS with the same atypical age-range, 35 - 57 years. The anatomic sites were also atypical: seven ankle / foot, two radius and one patella compared with only one at the ankle in the hospital series. The osteoblastic cell-type was about equally frequent in both series, but, among others than the three major subtypes, there was only one in WS as compared with 14 (39%) in the hospital series. The types of mutations were sought in five WS cases with OS. One showed no mutation at any of the ten known loci for Japanese, two were of type 4 / 4 and two of type 6 / 6. The mutations 4 and 6 have been found in 66% of alleles of WS cases in Japan. The increased frequency and unusual age and site distributions of OS in WS may be due to increased susceptibility, related to later-life leg ulcers, and weight-bearing on spindly ankles weakened by severe loss of lower limb subcutaneous tissue.

Effect of shear stress on platelet adhesion to expanded polytetrafluoroethylene, a silicone sheet, and an endothelial cell monolayer

We visualized in real-time platelets adhering to the surface of three representative biomaterials, by using an apparatus consisting of a modified cone and plate rheometer combined with an upright epifluorescence microscope under two shear flows (0.1 and 5.0 dyne/cm2). The materials were expanded polytetrafluoroethylene (ePTFE), silicone sheet, and a monolayer of bovine endothelial cells (ECs) formed on glass, all of which are opaque materials used for artificial blood vessels and medical devices. According to quantitative analysis, the monolayer of ECs formed on glass had better blood compatibility than did either the ePTFE or the silicone sheet under shear flow conditions. Under a shear flow condition of 0.1 dyne/cm2, platelet adhesion was silicone sheet > ePTFE. In contrast, under a shear flow condition of 5.0 dyne/cm2, ePTFE > silicone sheet. These results indicate that the intensity of shear stress could modify the order of hemocompatibility of the materials. Therefore, direct observation of platelet adhesion under shear flow conditions is indispensable for testing and screening biomaterials and for providing a precise quantitative evaluation of platelet adhesion.

Endothelin receptor antagonist preserves microvascular perfusion and reduces ischemic brain damage following permanent focal ischemia

Synthesis and release of the potent vasoconstrictor peptide endothelin-1 (ET-1) increases following cerebral ischemia and has previously been shown to mediate the delayed hypoperfusion associated with transient global ischemia. In this study we assessed the impact of ET-1 on perfusion and infarct volume in a focal model of cerebral ischemia by use of the selective ET(A) receptor antagonist Ro 61-1790 (affinity for ET(A) receptor 1000 fold greater than ETB receptor). Control rats subjected to permanent middle cerebral artery occlusion (MCAO) showed extensive reductions in microvascular perfusion 4 h post-MCAO that were significantly attenuated by Ro 61-1790 pretreatment (10 mg/kg, i.v.). Ro 61-1790 concomitantly and significantly reduced the ischemic lesion volume in the same animals. This effect was maintained 24 h post-MCAO providing that the animals received additional i.v. injections of 5 mg/kg Ro 61-1790 at 5 h and 8 h after MCAO. These findings demonstrate that ET(A) receptor antagonism partially preserves tissue perfusion following focal ischemia and that this effect is associated with significant neuroprotection. The results also support the hypothesis that vasoactive mediators, and ET-1 in particular, are important contributors to the pathogenesis of cerebral ischemic injury.

Disappearance of wheezing during epidural lidocaine anesthesia in a patient with bronchial asthma

BACKGROUND AND OBJECTIVES

Local anesthetics in blood absorbed from the epidural space attenuate bronchial hyperreactivity to chemical stimuli. However, it is not documented whether local anesthetics at clinically relevant concentrations improve active wheezing in patients with bronchial asthma.

CASE REPORT

We managed a 60-year-old man with bronchial asthma and active wheezing under continuous epidural anesthesia using plain lidocaine. The wheezing gradually diminished 20 minutes after the epidural injection of 13 mL 2% lidocaine and completely disappeared over 155 minutes during continuous epidural injection of 2% lidocaine (6 mL/h). The plasma concentrations of lidocaine in arterial blood during the epidural anesthesia ranged from 2.5 to 3.9 microg/mL. Wheezing reappeared 55 minutes after termination of the continuous epidural injection of lidocaine. The plasma concentration of lidocaine at this time was 1.9 microg/mL.

CONCLUSIONS

At clinically relevant concentrations, lidocaine in the blood absorbed from the epidural space may improve bronchospasm in patients with bronchial asthma.

The cancer problem--carcinogenesis and prevention from the viewpoint of the natural history of cancer

Cancer is mostly environmental in origin and therefore is theoretically preventable by control of environmental conditions. From the viewpoint of the natural history of cancer, the multi-step nature of neoplasia and the generally long latent period are stressed. The molecular biology of cancer tells us that neoplasia is a disease of the genes, with each tumor having its own series of gene alterations. Numerous carcinogens, mutagens and others, have been identified, and we are now in a good position to promote cancer prevention. The aim is to postpone clinical manifestation of latent cancer to an older age, and has two aspects: one is elimination of carcinogens from the environment and the other is active efforts to improve the lifestyle and develop effective chemopreventive agents. For understanding of prevention, elucidation of molecular mechanisms of interactions between genes and environmental or dietary compounds for each cancer is essential.

Real time observation of platelet adhesion to opaque biomaterial surfaces under shear flow conditions

We developed a new system which enables direct observation of platelet adhesion on opaque biomaterials under shear flow conditions, by combining a thin quartz cone which produces laminar shear flows, with an upright epifluorescence microscope which visualizes stained platelets through the rotating cone. This is the first report on the observation of platelets adhered to opaque biomaterials in real time under shear flow conditions. The direct observation of platelet adhesion to expanded polytetrafluoroethylene (ePTFE) as an opaque biomaterial revealed that the kinetics of platelet adhesion to ePTFE depended greatly on shear stresses, showing that the shear stress of 5.0 dyne/cm2 induced higher adhesiveness of platelets to ePTFE than that of either 0.1 or 15 dyne/cm2. The observation also showed a difference in platelet adhesiveness among ePTFEs with different fibril lengths--0, 3.2, 18, and 35 microm--indicating that ePTFEs with shorter fibril length had lower adhesiveness of platelets under a shear stress of 5.0 dyne/cm2. It is indispensable for analyzing the phenomena of platelet adhesion to opaque biomaterials to observe in real-time rolling, adhesion, and detachment of platelets under shear stresses without disturbing shear flow conditions. The results showed that the mechanical and optical design of the system could serve this purpose.

Unusual features of thyroid carcinomas in Japanese patients with Werner syndrome and possible genotype-phenotype relations to cell type and race

BACKGROUND

Werner syndrome (WS), an autosomal recessive disease characterized by premature aging, has a high frequency of association with six rare neoplasms in Japanese patients, and only four of these neoplasms also occur excessively in whites. Several differ from what is usual in their epidemiology and/or histology. Described in this article are peculiarities in the occurrences of follicular and papillary thyroid carcinomas among Japanese patients and the possible genotype-phenotype relations pertaining to cell types and the absence of excess thyroid carcinoma occurrence in whites with WS.

METHODS

Epidemiologic features of 23 histologically diagnosed thyroid carcinomas from a series of 150 cancers in 845 Japanese patients with WS were compared with those of 19,446 tumors in a Japanese national registry of thyroid carcinomas from 1977-1991. Germline mutations had been determined by molecular studies of peripheral blood.

RESULTS

The average age of patients with thyroid carcinoma was 39 years for those with WS and 49 years for the registry patients. The female-to-male ratios were 2.3:1 and 6.6:1, respectively. The rates of occurrence of papillary, follicular, and anaplastic carcinomas were 35%, 48%, and 13% for Japanese patients with WS and 78%, 14%, and 2% in the general Japanese population. All four cases of follicular carcinoma had germline mutations of the WS gene in the C-terminal region, and the germline mutation for the only papillary carcinoma was in the N-terminal region.

CONCLUSIONS

This study suggests two possible WS genotype-phenotype relations. One concerns thyroid carcinoma histology; the other concerns frequent mutations that occur in the C-terminal region in Japanese patients, but not in white patients, with WS. These may account for the excess thyroid carcinoma occurrence among Japanese.

[Anesthetic management of a morbidly obese patient with intestinal obstruction]

We managed a morbidly obese patient [body weight 150 kg, body height 157 cm (body mass index, 61 kg.m-2)] with intestinal obstruction due to incarcerated postoperative ventral hernia. The trachea was intubated while applying cricoid pressure. The SpO2 decreased rapidly down to 30% during intubation, but increased to 100% after ventilation with oxygen. Potential problems in the anesthetic management of morbidly obese patients for emergency surgery are discussed.

The long-term results of ankle joint synovectomy for rheumatoid arthritis

The clinical and radiological results of synovectomy for rheumatoid arthritis in the ankle joint were investigated in 20 ankles of 15 patients. The average follow-up period after synovectomy was 15 years, ranging from 10 to 25 years. The clinical evaluation at the time of follow-up, found that only two ankles showed recurrence of synovitis, and no patient complained of severe ankle pain disturbing the activities of daily life. During the period between the synovectomy and our investigation, no patients required further surgical procedures for their ankle joints. The radiological evaluation found that in approximately two-thirds of the cases, deterioration of the radiological grade, evaluated with Larsen's criteria, had continued after synovectomy. There was no considerable radiological deterioration in the less-erosive subset patients, classified according to Ochi's criteria (1). In the unilateral synovectomized cases, using the non-operated ankles as the natural-course control, osteoarthritic changes were predominant in the operated ankle joint, and the non-operated ankle demonstrated inflammatory disease changes. These results indicate that: (1) synovectomy for a rheumatoid ankle is still a preferred treatment, lessening the clinical symptom of persistent, marked synovial proliferation resistant to medical treatment. (2) Radiological deterioration continues after synovectomy in many cases. However, a radiogram demonstrates predominant osteoarthritic destruction, which indicates the natural course of rheumatoid destruction in the operated site could be altered by synovectomy.

Excess of rare cancers in Werner syndrome (adult progeria)

The association between genetic disorders and diverse cancers has provided clues for laboratory research into carcinogenesis. Such an opportunity now arises from studies of cancer in Werner syndrome (WRN). Soft-tissue sarcoma (STS) and benign meningioma have been associated with WRN, an autosomal recessive disorder characterized by premature aging, more commonly reported in Japan than elsewhere, in part because of inbreeding. In the literature we found 124 case-reports of neoplasia and WRN from Japan and 34 from outside Japan, 1939-August, 1995. They reveal a greater diversity of neoplasia in WRN than was previously known. In Japanese, there were 127 cancers, 14 benign meningioma, and 5 myeloid disorders, as compared with 30, 7 and 2 respectively in non-Japanese. The ratio of epithelial to non-epithelial cancers was about 1:1 for Japanese and for non-Japanese instead of the usual 10:1. Both series had excess of STS, osteosarcoma, myeloid disorders, and benign meningioma. In addition, the Japanese had an excess of thyroid cancer (20 versus 2 cases in non-Japanese) and melanoma (21 versus 3 cases), including 5 intranasal and 13 of the feet. STS, osteosarcoma, melanoma, and thyroid carcinoma accounted for 57% of all cancer in WRN as compared with 2% expected based on the Osaka population at 25-64 years of age. Multiple tumors were reported in 19 Japanese and 5 non-Japanese. In Japan, nine first-degree relatives had WRN and cancer, six of whom were concordant as to site and/or cell type. The WRN gene has been mapped to chromosome 8p. The high frequency of thyroid cancer and melanoma in Japanese, not found in Caucasians, may be related to a report of linkage disequilibrium with the WRN gene in Japanese but not in Caucasians and to haplotype differences within and between the two races, suggesting multiple independent mutations.

[Factors affecting continuation of home medical care--based on the relationship between patient and caregiver status]

In recent years it has gradually become possible to have some control over the medical condition of the end-stage cancer patient. However, there are various problems involved in the continuation of home care. In order to clarify how the mutual relationship between patient and caregiver effects the continuation of home care, we conducted a study on 28 end-stage cancer patients who made the transition from our hospital to home care by means of our HOme Care Service. Using the Kaneda Assessment Score, we obtained information from patients' charts, added reasons for rehospitalizations and analyzed the data. The results showed that the group of patients who remained on home care, despite the fact that their condition was significantly poorer than that of the group who discontinued home care, showed a significantly higher proportion of "wishing to be cared for at home to the last," in the view of the caregiver, a joint commitment of the caregiver together with the family, and a suitable response to changes in the patient. As a direction for forthcoming support in this area, there is a need for sufficient assessment in order to evaluate the balance between caregiver and family. It was suggested that guidance in each case and the use of community resources will be very important.

[The effectiveness of discharge planning (DSP) in home care--comparison of conditions of cancer patient shifted to home treatment before and after DSP introduction]

We developed a discharge planning (DSP) procedure as a method to assess the family and cancer patient situation when making the shift to home care, and we herewith report its significance. DSP is intended to sustain the patient's quality of life (QOL) and improve it; for a smooth transition to treatment at home, the family and patient situation must be assessed from various perspectives. The prospective illness conditions, needed medical treatment and care should be appropriately planned, with due recognition of the roles to be played and the requisite pooling of professional information in order to handle emergencies and the like when such arise. In the present study, in order to clarify issues dealing with DSP effectiveness, we compared 34 patients on home care, 17 before DSP and 17 thereafter. The results indicated that following the introduction of DSP, the home care increased for patients with gastroenterological problems such as pain, general debilitation, poor appetite, constipation, diarrhea and the like and those impulsiveness, vomiting and mental symptoms overlapping. With the proper assessment at the time of the transition to home care, this care could be continued. Moreover, with patient satisfaction, there was the need for assessment over the course in order to evaluate treatment and care. In the days to come, there is the need to improve this approach with a scoring system in the evaluation.

High K-ras mutation rates in goblet-cell-type adenocarcinomas of the lungs

Adenocarcinomas of the lungs show a variable histology. We have subclassified such lesions into five cell types: hobnail, columnar, polygonal, mixed and goblet cell types, and investigated their relationships with K-ras mutations. Codons 12, 13 and 61 of the K-ras gene in 120 surgically resected pulmonary adenocarcinomas were examined by the mutation-allele-specific amplification method. Point mutations were observed in 10% of the adenocarcinomas limited to K-ras codon 12 and the commonest base substitution (nine cases) was a G to T transversion. Of the five types, goblet cell lesions demonstrated the highest mutation index, which at 100% (6/6) was significantly different from that of all other cell types. No relationship between K-ras mutation and cigarette smoking was observed. From these findings, it appears that development of goblet-cell-type adenocarcinomas of the lung may involve different carcinogenic mechanisms from adenocarcinomas of other subtypes.

Frequent development of pancreatic carcinomas in the Rana nigromaculata group

In 1979, 2 species of pond frogs (Rana nigromaculata and Rana plancyi plancyi) were imported from China, and hybrids were made between these and Japanese, Korean, and Taiwanese pond frogs (R. nigromaculata, Rana plancyi fukienensis and Rana brevipoda) that had been kept for a number of years in the Laboratory for Amphibian Biology of Hiroshima University. From 1982, development of tumors, especially in the peritoneal cavity, was noticed frequently in the hybrids and also later, although rarely, in the Japanese pond frogs. Such tumors had never previously been observed among pond frogs in the laboratory. Histological and immunohistochemical studies identified the i.p. tumors to be pancreatic carcinomas with occasional production of insulin and/or somatostatin. Ultrastructural investigation revealed both endocrine and exocrine secretion granules together with C-type retrovirus particles in the carcinoma cells. Other tumors included a retroperitoneal rhabdomyosarcoma, liver adenomas, and an unclassifiable mesenchymal tumor of the foot pad.

[Endoscopic placement of self-expandable metallic stents (Wallstent) for malignant biliary stenosis, with special reference to preventive endoscopic nasal bile drainage against acute obstruction after stenting]

From December 1993 to December 1994, we inserted 14 biliary endoprostheses (Wallstent) endoscopically in 12 consecutive patients (5 men and 7 women; 55-91 years [mean 69.8 years] of age) with malignant biliary stenosis. Successful placement of Wallstent was achieved in all 12 patients. Procedure related death was encountered in one patient (8.3%) who was complicated with emphysematous cholecystitis, combined with a slipping migration of the stent. In 11 of the 12 patients, serum bilirubin levels reduced to less than 2.0 mg/dl. Acute obstruction, which was defined as the obstruction of the stent within 24 hours after the stent placement, occurred in 2 patients (16.7%). Endoscopic nasal bile drainage (ENBD) following stent placement was performed in 4 patients and acute obstruction was not developed in these cases. After endoprosthesis 8 patients were discharged with 6-47 hospital days and the average hospitalized period excluding a case with cerebral infarction was 12.7 days. Excluding one procedure related death, 6 patients died of primary malignancy 39-189 days (average 90.7 days) after endoprosthesis and in 2 cases recurrence of jaundice was observed. The other 4 patients have been alive for 60-174 days (average 102.5 days) without jaundice. The survival rate of the all patients was 64% for 3 months and 32% for 6 months, respectively. In conclusion, we suggested that the endoscopic Wallstent placement would contribute to the improvement of the quality of life for patients with malignant biliary stenosis. However, acute obstruction may be developed in some cases. For the purpose of managing acute obstruction, we recommend ENBD for a few days following the placement of a Wallstent.

[The relationship between genotypes of HLA-DRB1 alleles and progression of bony destruction changes of rheumatoid arthritis]

The relationship between genotypes of HLA-DRB 1 alleles and the progression of bone destruction of RA patients was assessed. The genotypes of the HLA-DRB 1 alleles were determined in 329 Japanese patients with seropositive RNA by polymerase chain reaction and allele-specific oligonucleotide probe techniques. We regarded HLA-DRB 1* 0101, 0401, 0404, 0405, 1001 and 1402 as susceptible alleles of RA and classified the patients into three groups. The s/s group consisted of those with susceptible factors in both of the HLA-DRB 1 alleles. The s/n group was made up of those having one susceptible factor and one non-susceptible factor. The n/n group consisted of those possessing two non-susceptible factors. The grading of radiographic change that was evaluated by Larsen's criteria compared with the genotyped results. In the result, the median years taken to development to grade III, IV and V were significantly shorter in the s/s groups compared with that in the s/n and n/n groups. Thus, genotyping of HLA-DRB 1 can be a useful prognostic market in the progression of bone destruction of RA.

Rheumatoid-susceptible alleles of HLA-DRB1 are genetically recessive to non-susceptible alleles in the progression of bone destruction in the wrists and fingers of patients with RA

OBJECTIVE

To assess the relationship between HLA-DRB1 genotypes and the progression of bone destruction in Japanese patients with RA.

METHODS

The HLA-DRB1 alleles were determined by polymerase chain reaction and allele specific oligonucleotide probe techniques in 160 Japanese patients with RA. HLA-DR 0101, 0401, 0404, 0405, 1001 and 1402 were regarded as susceptible alleles of RA according to previous reports. Patients were classified into three groups (S/S, S/N and N/N group), based on the possession of two, one or no susceptible factor. The grading of radio-graphic changes in the wrists and fingers were evaluated by Larsen's criteria. The radiographic grades were first compared with the results of genotyping in the 160 cross sectional cases. A retrospective study was then conducted on a subgroup consisting of 57 cases taken from the 160 cases used for the cross sectional study.

RESULTS

In the scatter diagram of the 160 cross sectional cases expressing the relationship between the stage of bone destruction and duration of RA, the regression line and the 95% confidence intervals separated the S/S group from the S/N and N/N groups in the early phase of development of bone destruction. In the retrospective study on the 57 cases the median years taken to development to stage V in the wrists after the onset of symptoms were 13.1 in the patients in the S/S group, 22.7 in the S/N group and 23.0 in the N/N group. The difference observed between the S/S and S/N group, and between the S/S and N/N group were statistically significant (p < 0.01), but that between the S/N and N/N groups was not. Thus the bone destruction in the wrists and fingers progressed more rapidly in the S/S group than in the S/N and N/N groups; and the rheumatoid susceptible alleles of HLA-DRB1 can be considered to be genetically recessive to the non-susceptible alleles in the progression of bone destructions in the wrists and fingers.

CONCLUSION

Genotyping of HLA-DRB1 can be a useful prognostic marker in the early phase of RA.

Characteristics of chromate workers' cancers, chromium lung deposition and precancerous bronchial lesions: an autopsy study

The characteristics of lung cancers induced by inhaled chromate were studied in 13 consecutive autopsies on male ex-chromate workers. In addition to histopathology, we examined: (1) the relationship between the occurrence of lung cancer and the amount of chromium (Cr) deposited in the lung as determined by atomic absorptiometry and (2) the chronological changes in five precancerous lung lesions followed by bronchoscopy till death. Twenty-one cancers were identified, including 16 lung tumours observed either during follow-up or at autopsy. Of these 16 tumours, 13 were found in six subjects, implying a high frequency of multiple cancers. Eleven (69%) out of the 16 tumours were of squamous cell type (including carcinoma in situ), this being twice as frequent as in age-matched controls. A further characteristic was predominance in the central part of lung (69%). The lung Cr burden was very much higher [40-15,800 micrograms g-1 (dry)] in patients with lung tumours than in those without (8-28 micrograms g-1). Five of the precancerous lesions followed by bronchoscopy originated at bronchial bifurcations. Four of these cases showed a return to normal histology at autopsy even without therapy, and the other did not progress.

"Hot spots" of chromium accumulation at bifurcations of chromate workers' bronchi

To investigate the mechanisms underlying respiratory tract carcinogenesis in chromate workers, we measured the concentration of chromium in samples of tissues from 50 bronchial bifurcations and other bronchial tissue obtained at autopsy, or during surgical procedures, from 9 exchromate workers known to be at risk of developing lung cancer. The mean duration of exposure was 21 years and the average time between cessation of exposure and death/surgery was 15 years. The area of the tissue samples was measured by image analysis and the chromium concentration determined by neutron activation analysis. Chromium concentrations ranged from 0.04 to 39 x 10(-10) g/microns tissue thickness/mm2 and in 80% of the cases the concentrations were greater at bifurcations than in neighboring epithelial tissue. The mean concentration ratios between bifurcations and adjacent areas were 1.5 (n = 1) in the trachea, 3.0 (n = 9) in the main bronchi, 3.6 (n = 22) in lobar bronchi, and 10.9 (n = 3) in subsegmental bronchi. Our results demonstrated long-term retention of chromium in the bronchial walls of chromate workers and also that chromium concentrations were higher at airway bifurcations than elsewhere, thus providing solid evidence for a deposition "hot spot" concept.

Epstein-Barr-virus-associated medullary carcinomas with lymphoid infiltration of the stomach

The association of Epstein-Barr virus (EBV) with gastric medullary carcinoma with lymphoid infiltration (GMCL) was investigated. The presence of GMCL exhibited a 2/1 male-to-female ratio and a 1/2 early-to-advanced cancer ratio, predominantly located in the cardia and corpus of the stomach (90%). The presence of EBV DNA could be proven in 28 out of 30 GMCL cases (93%) by the polymerase chain reaction method, and in 27 cases (90%) latent infection of EBV strictly limited to cancer cells was identified by in situ hybridization with RNA using an EBV-associated small RNAs (EBERs) probe. No histopathological difference was noted between EBERs-positive and -negative groups. Monoclonal EBV infection, identified by the length of lymphocyte-determined membrane antigen variable tandem repeats, was suggested in 19 out of 27 EBERs-positive cases (70.3%). However, only one case showed a positive reaction for anti-(latent membrane protein)-1 antibody, and none of the EBERs-positive cases bound anti-EBNA-2 antibodies, the respective antigens being considered oncoproteins directly linked with EBV-related B cell lymphomagenesis. In conclusion, while EBV is clearly present at extremely high incidence in GMCL, having characteristics biological features, a role for EBV in tumorigenesis of such lesions remains uncertain.

[The effect of the odour of mother's milk and orange on the spectral power of EEG in infants]

Few studies have been found on the EEG responses to odours in infants. Most of the studies done regarding infants up until now have focused only on the psychological and behavioral reaction of infants to odours. The purpose of the present study is to investigate whether or not relative differences in EEG response are seen before and during the odour presentation of mother's milk and orange in infants, and if they do respond to these odours, are there any differences in the EEG responses? EEG responses to these two odours were studied in 11 healthy mixed fed infants aged from 3.3 to 4.2 months during sleep. Changes in the sleep stage 2 and slow wave sleep EEG's were analyzed by the fast Fourier transformation method. While the mother's milk was presented, a significant decrease in the amplitude of EEG was observed in the delta and theta bands in the bilateral frontal and central regions of the brain, but on orange odour presentation, an increase of delta bands was seen in the central and right parietal regions. Detailed statistical analysis (ANOVA) revealed that the EEG responses to the two odours were significantly different from each other in the delta and theta bands. The present results suggest that these two odours seem to cause a different psychophysiological change in infants.

Ribosome-binding protein p34 is a member of the leucine-rich-repeat-protein superfamily

Protein p34 is a non-glycosylated membrane protein characteristic of rough microsomes and is believed to play a role in the ribosome-membrane association. In the present study we isolated cDNA encoding p34 from a rat liver cDNA library and determined its complete amino acid sequence. p34 mRNA is 3.2 kb long and encodes a polypeptide of 307 amino acids with a molecular mass of about 34.9 kDa. Primary sequence analysis, coupled with biochemical studies on the topology, suggested that p34 is a type II signal-anchor protein; it is composed of a large cytoplasmic domain, a membrane-spanning segment and a 38-amino-acid-long luminally disposed C-terminus. The cytoplasmic domain of p34 has several noteworthy structural features, including a region of 4.5 tandem repeats of 23-24 amino acids. The repeated motif shows structural similarity to the leucine-rich repeat which is found in a variety of proteins widely distributed among eukaryotic cells and which potentially functions in mediating protein-protein interactions. The cytoplasmic domain also contains a characteristic hydrophilic region with abundant charged amino acids. These structural regions may be important for the observed ribosome-binding activity of the p34 protein.