Extrahepatic portal vein aneurysm in which the acute thrombogenic process triggered by trauma confirmed by abdominal ultrasonography: a case report

Extrahepatic portal vein aneurysm (PVA) is a rare condition in which the extrahepatic portal vein is partially dilated into a sac-like or spindle-like shape. Usually, patients are followed, but surgery is considered in cases of rupture, thrombus, or enlargement. We report a case of thrombus formation in an extrahepatic portal vein aneurysm following trauma that resulted in regression of the aneurysm and extrahepatic portal vein occlusion. Immediately after the trauma, ultrasonography showed moderately hyperechoic structures and comet signs along the vessel wall of the aneurysm and turbulent blood flow in the aneurysm, like in a whirlpool. There were floating point-like echogenic features, which were presumed to be microthrombi. In other words, the trauma might have triggered Virchow's triad: changes in the vessel wall, changes in blood properties, and blood stagnation. This is a valuable case in which ultrasonography imaging revealed interesting changes during the thrombus formation process inside an extrahepatic portal vein aneurysm. The aneurysm's size was reduced by thrombus-induced organization, but the main trunk of the portal vein became deficient in blood flow, resulting in extrahepatic portal vein occlusion. This case is suggestive of the mechanism of extrahepatic portal vein occlusion.

Successful Percutaneous Transhepatic Obliteration Plus Sengstaken-Blakemore Tube Combination Therapy for Recurrent Gastroesophageal Variceal Bleeding: A Case Report

We treated a case of gastroesophageal varices due to decompensated liver cirrhosis associated with Wilson's disease. The varicose veins penetrated the paraesophageal vein. We performed endoscopic variceal ligation (EVL) on the perforating vein and endoscopic injection sclerotherapy (EIS) distally. However, 5 days after treatment, the patient vomited blood. Esophagogastroduodenoscopy showed bleeding from the ulcer after EVL at the perforating vein. We performed EVL and stopped the bleeding. However, the next day, she vomited blood again and developed hemorrhagic shock. We were able to achieve hemostasis and save the patient's life with combination therapy consisting of percutaneous transhepatic obliteration and Sengstaken-Blakemore tube placement.

Features of patients who developed hepatocellular carcinoma after direct-acting antiviral treatment for hepatitis C Virus

Background

The features of hepatitis C virus patients with a sustained virologic response (SVR) who developed hepatocellular carcinoma (HCC) after direct-acting antiviral (DAA) therapy are unclear.

Methods

The study population included 1494 DAA-SVR patients without a history of HCC. The cumulative carcinogenesis rate after the end of treatment (EOT) and factors related to HCC were analyzed.

Results

Sixty (4.0%) patients developed HCC during a median observation period of 47.6 months. At four years, the cumulative carcinogenesis rate was 4.7%. A Cox proportional hazards analysis showed that age ≥73 years (hazard ratio [HR]: 2.148), male sex (HR: 3.060), hyaluronic acid (HA) ≥75 ng/mL (HR: 3.996), alpha-fetoprotein at EOT (EOT-AFP) ≥5.3 ng/mL (HR: 4.773), and albumin at EOT (EOT-Alb) <3.9 g/dL (HR: 2.305) were associated with HCC development. Especially, EOT-AFP ≥5.3 ng/mL was associated with HCC development after 3 years from EOT (HR: 6.237). Among patients who developed HCC, AFP did not increase in patients with EOT-AFP <5.3 ng/mL at the onset of HCC. Of these 5 factors, EOT-AFP ≥5.3 ng/mL was scored as 2 points; the others were scored as 1 point. The 4-year cumulative carcinogenesis rate for patients with total scores of 0–2, 3–4, and 5–6 points were 0.6%, 11.9%, and 27.1%, respectively (p<0.001).

Conclusions

EOT-AFP ≥5.3 ng/mL is useful for predicting HCC development after an SVR. However, AFP does not increase in patients with EOT-AFP <5.3 ng/mL at the onset of HCC. The combination of EOT-AFP, age, sex, HA, and EOT-Alb is important for predicting carcinogenesis.

[Pulse steroid therapy to treat liver injury with risk of liver failure due to immune-related adverse events:a case report]

A 75-year-old woman was diagnosed with clinical stage III lung cancer. The patient was treated with chemoradiotherapy and subsequent durvalumab, an anti-PD-L1 antibody immune checkpoint inhibitor (ICI). Liver dysfunction was observed 14 days after the start of durvalumab therapy (aspartate transaminase, 218U/l;alanine aminotransferase, 169U/l). This corresponded to a grade 3 adverse event according to the Common Terminology Criteria for Adverse Events. The second course of durvalumab was withheld. The patient was hospitalized 31 days after durvalumab therapy because of worsening liver dysfunction. Laboratory findings and imaging examinations suggested liver injury due to an immune-related adverse event (irAE). Liver biopsy performed 38 days after durvalumab therapy showed severe lymphocyte and plasma cell infiltration into the portal tract, focal necrosis in the hepatic lobules, and necrotic changes around the hepatic lobules. These findings were similar to those of autoimmune hepatitis (AIH). Immunohistochemical results revealed infiltration of CD3- and CD8-positive lymphocytes and mild infiltration of CD4-positive lymphocytes. Pathological findings in the liver tissue were consistent with an irAE. Jaundice worsened and the prothrombin time was prolonged, leading to a risk of progression to liver failure. Thus, pulse steroid therapy was performed with methylprednisolone (mPSL) starting at 0.8mg/kg. Liver dysfunction lessened and the mPSL dose was gradually reduced. Moreover, ICIs exert antitumor effects by inhibiting the immune checkpoint system but can cause irAEs in various organs. Liver injury is also relatively common. Liver tissue findings are similar to those in AIH, but immunostaining reveals the presence of numerous CD8-positive lymphocytes. Fewer CD4-positive lymphocytes exist in irAE-associated liver injury than in AIH. Medical departments must cooperate and effectively manage irAEs because ICIs are increasingly being used and can occur in organs throughout the body. In principle, irAEs are treated with steroids. Thus, high-dose steroids diminishing the therapeutic effect of ICIs is a concern, and it is important to control irAEs with low-dose steroids that are started earlier.

Two cases of liver cirrhosis with hyperammonemic encephalopathy caused by urease-producing bacteria in the urinary tract

Hyperammonemia is often experienced as a complication of liver cirrhosis, but it is not well known that hyperammonemic encephalopathy is induced by urease-splitting bacteria in the urinary tract. We report two cases of hyperammonemia in two women in their 80s with liver cirrhosis. Both cases were treated as hepatic encephalopathy with usual treatment, but there was no improvement. Urinalysis showed marked alkalinuria and urine culture showed urease-splitting bacteria, which were thought to be related to the pathology. After drainage of urine and administration of antimicrobials, the blood ammonia level decreased and the urine pH level normalized. The mechanism of this is that ammonia is produced by the degradation of urinary urea by urease-producing bacteria in the bladder, and in the presence of dysuria, it is absorbed into the blood circulation from the bladder venous plexus, leading to hyperammonemia.Urine findings should be confirmed when a patient with liver disease develops hyperammonemia or is unresponsive to conventional hepatic encephalopathy treatment.

Hypovascular tumors developed into hepatocellular carcinoma at a high rate despite the elimination of hepatitis C virus by direct-acting antivirals

BACKGROUND AND AIMS

Direct-acting antivirals (DAAs) against hepatitis C virus (HCV) exert high anti-HCV activity and are expected to show anti-inflammatory effects associated with HCV elimination. Furthermore, hepatocellular carcinoma (HCC) is known to dedifferentiate from hypovascular tumors, such as dysplastic nodules or well-differentiated HCC, to hypervascular tumors. We therefore explored whether or not DAAs can suppress the growth and hypervascularization of hypovascular tumors.

METHODS

We enrolled 481 patients with HCV genotype 1 infection who were treated with Daclatasvir and Asunaprevir therapy. Of these, 29 patients had 33 hypovascular tumors, which were confirmed by contrast-enhanced MRI or CT before therapy. We prospectively analyzed the cumulative incidence of HCC, i.e. the growth or hypervascularization of hypovascular tumors, and compared the HCC development rates between patients with hypovascular tumors and those without any tumors.

RESULTS

The mean size of the hypovascular tumors was 11.3 mm. Twenty seven of 29 patients who achieved an SVR had 31 nodules, 19 of 31 nodules (61.3%) showed tumor growth or hypervascularization, and 12 (38.7%) nodules showed no change or improvement. The cumulative incidence rates of tumor growth or hypervascularization were 19.4% at 1 year, 36.0% at 2 years, 56.6% at 3 years, and 65.3% at 4 years. Among the patients who achieved a sustained virologic response, the cumulative HCC development rates of patients with hypovascular tumors was significantly higher than in those without any tumors. A Cox proportional hazard analysis showed that a history of HCC therapy, the presence of a hypovascular tumor, and AFP >4.6 ng/mL at the end of treatment were independent risk factors for HCC development.

CONCLUSION

Hypovascular tumors developed into HCC at a high rate despite the elimination of HCV by DAAs. As patients with hypovascular tumors were shown to have a high risk of HCC development, they should undergo strict HCC surveillance.

Heparin affects the induction of regulatory T cells independent of anti-coagulant activity and suppresses allogeneic immune responses

Heparin is a widely used anti-coagulant that enhances anti-thrombin (AT) activity. However, heparin also suppresses immune and inflammatory responses in various rodent models and clinical trials, respectively. The mechanism by which heparin suppresses immune responses is unclear. The effect of heparin on regulatory T cells (T_regs ) in allogeneic immune responses was analysed using an acute graft-versus-host disease (aGVHD) mouse model and mixed lymphocyte reactions (MLRs). In-vitro culture systems were utilized to study the effects of heparin on T_regs . Heparin administration reduced mortality rates and increased the proportion of T_regs in the early post-transplantation period of aGVHD mice. In both murine and human MLRs, heparin increased T_regs and inhibited responder T cell proliferation. Heparin promoted functional CD4⁺ CD25⁺ forkhead box protein 3 (FoxP3)⁺ T_reg generation from naive CD4⁺ T cells, increased interleukin (IL)-2 production and enhanced the activation of pre-existing T_regs with IL-2. Heparin-induced T_reg increases were not associated with anti-coagulant activity through AT, but required negatively charged sulphation of heparin. Importantly, N-acetyl heparin, a chemically modified heparin without anti-coagulant activity, induced T_regs and decreased mortality in aGVHD mice. Our results indicate that heparin contributes to T_reg -mediated immunosuppression through IL-2 production and suggest that heparin derivatives may be useful for immunopathological control by efficient T_reg induction.

Viral and host factors are associated with retreatment failure in hepatitis C patients receiving all-oral direct antiviral therapy

AIM

Direct-acting antiviral (DAA) therapy for hepatitis C virus is associated with high sustained virologic response rates. However, patients for whom DAA therapy fails acquire resistance-associated substitutions (RASs). We therefore evaluated the efficacy of DAA retreatment and factors associated with retreatment failure.

METHODS

Non-structural 5A RASs were investigated at the start of DAA therapy and at treatment failure in 64 patients with hepatitis C virus genotype 1b for whom DAA combination therapy had failed. A total of 59 patients were introduced to DAA retreatment. The factors associated with retreatment failure were investigated.

RESULTS

A total of 20 of 43 (46.5%) daclatasvir + asunaprevir-treated patients with virologic failure had no RASs at baseline, and three (15%) acquired P32 deletion RASs. Four of seven sofosbuvir/ledipasvir-treated patients with virologic failure had more than two RASs of NS5A at baseline. The sustained virologic response rates on retreatment were as follows: sofosbuvir/ledipasvir, 81.8%; with elbasvir + grazoprevir, 0%; and glecaprevir/pibrentasvir, 87.5%. Patients for whom sofosbuvir/ledipasvir or elbasvir + grazoprevir failed achieved sustained virologic response with glecaprevir/pibrentasvir. Two of three patients for whom glecaprevir/pibrentasvir retreatment failed had Q24/L28/R30 and A92K RASs; the other had P32 deletion RAS at baseline. Interestingly, 10 of 11 patients with retreatment failure had the interleukin (IL)-28B single-nucleotide polymorphism (SNP) minor allele. A multivariate analysis showed that the IL28B SNP minor allele (P = 0.005, odds ratio 28.291) was an independent risk factor for retreatment failure.

CONCLUSIONS

In addition to viral factors (e.g. Q24, L28, R30, and A92 or P32 deletion RASs), host factors (e.g. IL28B SNP) are associated with DAA retreatment failure.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

The co-existence of NS5A and NS5B resistance-associated substitutions is associated with virologic failure in Hepatitis C Virus genotype 1 patients treated with sofosbuvir and ledipasvir

OBJECTIVE

The present study aimed to reveal the factors associated with virologic failure in sofosbuvir and ledipasvir (SOF/LDV)-treated patients, and identify baseline NS5A or NS5B resistance-associated substitutions (RASs).

METHODS

Four hundred ninety-three patients with Hepatitis C Virus (HCV) genotype 1b infection were treated with SOF/LDV; 31 had a history of interferon (IFN)-free treatment with daclatasvir and asunaprevir. The effect of baseline RASs on the response to SOF/LDV therapy was analyzed.

RESULTS

Overall, a sustained virologic response at 12 weeks (SVR12) was achieved in 476 patients (96.6%). The SVR12 rates in the patients with IFN-free treatment-naïve and retreatment were 97.6% and 80.6%, respectively. HCV elimination was not achieved in 17 patients, 11 (including 5 with IFN-free retreatment) of whom had virologic failure. Eight patients had coexisting NS5A RASs of Q24, L28 and/or R30, L31, or Y93 and one patient had coexisting NS5A RASs of P32L and A92K. Interestingly, 10 and 8 patients had NS5B A218S and C316N RAS respectively. According to a multivariate analysis, coexisting NS5A RASs, NS5A P32 RAS, NS5B A218 and/or C316 RASs, and γ-glutamyltranspeptidase were associated with virologic failure. In the naïve patients, all patients without NS5B A218 and/or C316 RAS achieved an SVR12. Notably, the SVR12 rates of patients with coexisting NS5A and NS5B RASs were significantly lower (83.3%).

CONCLUSIONS

Although SOF/LDV therapy resulted in a high SVR12 rate, coexisting NS5A and NS5B RASs were associated with virologic failure. These results might indicate that the coexisting baseline RASs influence the therapeutic effects of SOF/LDV.

Effects of pre-surgical nasoalveolar moulding on maxillary arch and nasal form in unilateral cleft lip and palate before lip surgery

OBJECTIVES

To investigate the effects of pre-surgical nasoalveolar moulding (PNAM) on the maxillary arch and nasal form in patients with unilateral cleft lip and palate (UCLP).

SETTING AND SAMPLE POPULATION

This is a retrospective case series study. The subjects were infants with complete UCLP who were treated with PNAM (n = 18) at Kagoshima University Medical and Dental Hospital (Japan) between 2006 and 2013.

MATERIAL AND METHODS

Maxillary dental casts and facial photographs were taken at the time of the first visit and immediately prior to lip surgery to evaluate the maxillary arch and nasal form changes. The dental casts were scanned with a laser scanner, and changes in the 3-Dimensional coordinates of anatomical landmarks and alveolar cleft width were analysed. Moreover, we investigated the correlation between the changes in the maxillary alveolar arch and nasal form.

RESULTS

Regarding the maxillary alveolar arch form, the anterior points of the major segment had moved significantly to the cleft side just prior to the time of lip repair, and the alveolar cleft width was significantly decreased. For nasal form, the inclination and displacement of the columella were significantly improved. The improvement of columella inclination was moderately correlated with the posterior movement of the anterior points of the major segment.

CONCLUSIONS

These findings indicate that PNAM for infants with UCLP enhanced symmetry in the maxillary alveolar arch and nasolabial form. In addition, the posterior movement of the anterior points of the maxillary alveolar arch was correlated with the improvement of columella deformation.

Detection of IgE autoantibodies to BP180 and BP230 and their relationship to clinical features in bullous pemphigoid

BACKGROUND

IgE autoantibodies are considered to be involved in the pathogenesis of bullous pemphigoid (BP), particularly inflammatory and erythematous phenotypes.

OBJECTIVES

To develop reliable enzyme-linked immunosorbent assays (ELISAs) for the detection of IgE autoantibodies to both BP180 and BP230 in BP sera, and to compare the ELISA results with clinical features.

METHODS

We used commercially available IgG ELISAs to develop IgE ELISAs for both BP180 and BP230. To determine the influence of excess amounts of IgG autoantibodies, all normal and BP sera were tested before and after IgG adsorption. The results of the IgE ELISAs were statistically compared with various ELISAs and various clinical parameters, including our own severity scores and BP phenotypes.

RESULTS

IgG adsorption generally showed no changes in sensitivity and specificity for IgE ELISAs, although slight cross-reactivity of anti-IgE secondary antibody to IgG and interference of excess amounts of IgG autoantibodies to IgE reactivity were suggested. IgE autoantibodies to BP180 were found in 21 of 36 BP sera and IgE autoantibodies to BP230 were found in 18 of 36 BP sera. The results of IgG and IgE ELISAs for both BP180 and BP230 were well correlated. IgG and IgE anti-BP180 antibodies correlated with disease activity but IgG and IgE anti-BP230 autoantibodies did not. IgE anti-BP230 autoantibodies correlated with nodular phenotype but not erythematous phenotype.

CONCLUSIONS

The results of this study indicated that IgE autoantibodies to both BP180 and BP230 are frequently detected in BP sera. IgE anti-BP180 autoantibodies seemed to be pathogenic, while an association between IgE autoantibodies and inflammatory BP phenotype was not indicated.

New resistance-associated substitutions and failure of dual oral therapy with daclatasvir and asunaprevir

BACKGROUND

Daclatasvir (DCV) and asunaprevir (ASV) combination therapy has been primarily used in patients without NS5A L31 or Y93 resistance-associated substitutions (RASs) before treatment. We examined the characteristics of patients without these baseline RASs who did not achieve hepatitis C virus eradication with DCV and ASV combination therapy and identified new baseline NS5A RASs that are closely associated with failure of combination therapy.

METHODS

Three hundred thirty-five patients with hepatitis C virus genotype 1 infection with no NS5A L31, NS5A Y93, and NS3 D168 RASs before DCV and ASV combination therapy and no history of protease inhibitor therapy were enrolled. All RASs were evaluated by direct sequencing.

RESULTS

Sustained virologic response at 12 weeks (SVR12) was achieved in 297 patients (89%). Patients with NS5A Q24, L28, and/or R30 RASs or concomitant NS5A F37 and Q54 RASs had a significantly lower SVR12 rate than patients without these RASs (70% vs 92%, p < 0.001 and 79% vs 92%, p = 0.002 respectively). Multivariate analysis showed that NS5A Q24, L28, and/or R30 RASs and concomitant NS5A F37 and Q54 RASs were significantly associated with virologic failure. The SVR12 rate in patients without NS5A Q24, L28, and/or R30 RASs and concomitant NS5A F37 and Q54 RASs was 96.2% (202/210).

CONCLUSIONS

In patients without NS5A L31 or Y93 RASs, the presence of NS5A Q24, L28, and/or R30 RASs and concomitant NS5A F37 and Q54 RASs at the baseline was associated with failure of DCV and ASV combination therapy. The coexistence of baseline RASs other than NS5A L31 and Y93 may affect the therapeutic effectiveness of DCV and ASV combination therapy.

A case of metachronous liver metastasis from neuroendocrine carcinoma of the stomach at 1 year and 10 months after endoscopic submucosal dissection

A 77-year-old man underwent endoscopic submucosal dissection (ESD) of a type 0-IIc tumor located in the cardiac part of the stomach. The pathological diagnosis of the tumor was poorly differentiated tubular adenocarcinoma with submucosal invasion depth;therefore, radical gastrectomy was also performed. After 1 year and 10 months, liver metastasis was detected because of which partial liver resection was performed. The pathological diagnosis of the tumor was neuroendocrine carcinoma (NEC). The pathology of the ESD specimen was re-examined, and a diagnosis of gastric NEC was made;furthermore, the liver tumor was regarded as metachronous metastasis. Despite the radical excision of the stage IA tumor, metastasis occurred. Chemotherapy with S-1 alone was successfully performed after the liver resection while considering the advanced age of the patient. Follow-up revealed no signs of recurrence at 1 year and 4 months after the treatment, indicating that the S-1 therapy may be considered for treating NEC in elderly and medically compromised patients owing to its mild side effects.

Detoxification mechanism of asbestos materials by microwave treatment

The detoxification mechanism of asbestos materials was investigated through simulations and experiments. The permittivities of pure CaO and Mg3Si4O12, as quasi-asbestos materials, were measured using the cavity perturbation method. The real and imaginary parts of the relative permittivity (ɛr' and ɛr″) of CaO are functions of temperature, and numerical simulations revealed the thermal distributions in an electromagnetic field with respect to both asbestos shape and material configuration based on permittivity. Optical microscopic observation revealed that the thickness of chrysotile fibers decreased as a result of CaO heating. The heating mechanism of asbestos materials has been determined using CaO phase, and the detoxification mechanism of asbestos materials was discussed based on the heating mechanism.

Th2 polarization enhanced by oral administration of higher doses of antigen

Although oral administration of a soluble proteinantigen can induce various immune responses, theeffect of the dosage of oral antigen on thepredominance of Th2-type cytokine and antibodyresponses has not been well clarified yet. In thepresent study, we fed T cell receptor (TCR) transgenic(tg) mice various amounts of chicken ovalbumin (0.1,5, and 250 mg) and examined the resulting immuneresponses to this antigen. In these TCR tg mice, theresponses of antigen-specific T cells were greatlyamplified concomitantly with significantantigen-specific cytokine secretion. We found that ahigh dose (250 mg) of antigen significantlyupregulated the serum antigen-specific IgG1 and IgAantibody responses in mice later intraperitoneallyinjected with antigen plus adjuvant. The miceadministered the same oral dose but not immunizedshowed upregulation of Th2-type IL-4 and IL-5secretion and downregulation of Th1-type IL-2 andIFN-gamma. This enhancement of Th2-type cytokineand antibody responses was more marked when largerdoses of antigen orally administered. These resultsdemonstrated that antigen feeding induces thedevelopment of T cells secreting Th2-type cytokines ina dose-dependent manner and that these T cells have ahelper function for the production of antibodies ofthe Th2-type isotypes. This experimental system shouldbe useful to screen foods and other substances thatcan modulate Th2-type responses relating to allergy.

Demonstration of reversed flow in segmental branches of the portal vein with hand-held color Doppler ultrasonography after hematopoietic stem cell transplantation

Hepatic veno-occlusive disease (VOD) is a severe complication of hematopoietic stem cell transplantation (SCT). When monitored with hand-held color Doppler ultrasonography during day -7 to +35 around SCT, reversed blood flow in the segmental branches of the portal vein was detected in nine of 56 patients who had undergone SCT. Three of nine patients had clinical evidence of VOD, but six patients did not fulfill the criteria for diagnosis of VOD initially. Two patients progressed to clinical VOD at a later date and the reversed portal flow disappeared with or without treatment for VOD in the other four patients. Monitoring for reversed portal flow with color Doppler ultrasonography may be a useful tool for the early diagnosis of VOD, and may improve prognosis by allowing early initiation of treatment.

Dietary D-psicose, a C-3 epimer of D-fructose, suppresses the activity of hepatic lipogenic enzymes in rats

D-Psicose (D-ribo-2-hexulose), a C-3 epimer of D-fructose, is present in small quantities in commercial carbohydrate complexes or agricultural products. Wistar male rats were fed experimental diets which consisted of 5% D-psicose, cellulose, D-fructose or D-glucose for 28 days. Abdominal adipose tissue weight was significantly lower (P < 0.05) in rats fed the D-psicose diet than in rats fed a D-fructose and D-glucose diets, even though the four dietary groups were offered the same amount throughout the experimental period. Fatty acid synthase and glucose 6-phosphate dehydrogenase activities in the liver were significantly lower (P < 0.05) in rats fed the D-psicose diet than in rats fed the D-fructose and D-glucose diets. However, lipoprotein lipase activities in the heart, soleus muscle and perirenal adipose tissue were the same. These results suggest that a supplement of D-psicose in the diet suppresses hepatic lipogenic enzyme activities. The lower abdominal fat accumulation in rats fed a D-psicose diet might result from lower lipogenesis in the liver.

Stereoselective pharmacokinetics and pharmacodynamics of disopyramide and its metabolite in rabbits

The extent to which interactions between enantiomers of disopyramide and between disopyramide and its metabolite, mono-N-dealkylated disopyramide (MND), contribute to stereoselectivity of the anti-arrhythmic effect has been investigated in rabbits by measuring the prolongation of the QUc interval. The plasma unbound fraction of disopyramide enantiomers was constant at a concentration range of 1.44-28.9 microM. An intravenous infusion study of the disopyramide enantiomer or racemate suggested that the S-enantiomer had a pharmacological effect, determined by linear regression analysis, approximately 3.3-times more potent than that of the R-enantiomer. Furthermore, the effect caused by racemic disopyramide was the sum of that elicited by both enantiomers individually. No significant difference was observed between the slope of linear regression analysis of intravenous infusion and that of intravenous bolus injection. Single intravenous bolus injection of MND did not affect the QUc intervals. In conclusion, the S-enantiomer of disopyramide was approximately 3.3-times more potent pharmacologically than the R-enantiomer. The relationship between plasma concentration of the disopyramide enantiomers and pharmacological effect was the sum of each enantiomer individually.

Colour Doppler ultrasonography of a segmental branch of the portal vein is useful for early diagnosis and monitoring of the therapeutic course of veno-occlusive disease after allogenic haematopoietic stem cell transplantation

We report two cases in which visualization of the segmental branch of the hepatic portal vein with the colour Doppler ultrasonography (US) technique was useful for the early diagnosis of veno-occlusive disease. The change in blood flow in the segmental branch of the portal vein occurred 5 and 6 d before the clinical criteria were fulfilled in the two cases. Reverse flow in the segmental branch began partially in the liver at first, and then spread to the whole liver several days later. All the US findings in both cases disappeared after thrombolytic therapy.

Alteration of regional cerebral metabolism in patients with cirrhosis in positron emission tomography

To evaluate the alteration of cerebral blood flow and oxygen metabolism in cirrhosis, we measured regional cerebral blood flow (rCBF), cerebral metabolic rate for oxygen (rCMRO2), and oxygen extraction fraction (rOEF) in twelve patients with cirrhosis (six with a history of hepatic encephalopathy and six without) and six age-matched controls using positron emission tomography. Regional CBF in whole brain was not different in cirrhotic patients from that in controls. In six cirrhotic patients with a history of hepatic encephalopathy, rCMRO2 was significantly lower in the frontal, temporal, parietal and occipital cortices, hippocampus, thalamus, cerebellum and brain stem, than that in each region of controls. On the other hand, rCMRO2 in six cirrhotic patients without a history of hepatic encephalopathy did not differ from the controls in all regions except for the frontal cortex. Regional OEF in cirrhotic patients without a history of hepatic encephalopathy was higher in the hippocampus and striatum than that in each region of controls. Among twelve cirrhotic patients, rCMRO2 in the occipital cortex and striatum correlated directly with plasma leucine levels, and rCMRO2 in the striatum directly correlated with plasma valine levels. Regional CMRO2 in the frontal cortex, temporal cortex, parietal cortex, white matter as well as brain stem correlated inversely with plasma phenylalanine levels, and rCMRO2 in the occipital cortex correlated inversely with plasma tyrosine levels. Brain oxygen metabolism is impaired in cirrhotic patients with a history of hepatic encephalopathy, but preserved in those without a history or in the early stage of cirrhosis. Reduced oxygen metabolism is related with altered amino acid metabolism.

Stereoselective pharmacokinetics and pharmacodynamics of verapamil and norverapamil in rabbits

We have estimated the pharmacokinetic and pharmacodynamic interactions of verapamil (VP) enantiomers and also the interaction between VP and its metabolite, norverapamil (NVP). ECGs of conscious rabbits were studied to determine the pharmacokinetics of VP enantiomers and racemic NVP in relation to their prolongation effect on PR intervals, which were used as an index of VP's antiarrhythmic effect. Plasma free fractions of VP enantiomers showed constant values at concentrations ranging from 0.022 to 1.10 microm. There were no interactions between enantiomers or between VP and NVP. The pharmacological effect of the S-enantiomer (S-VP), which was determined by linear regression analysis, showed it was about 20 times more potent than that of the R-enantiomer (R-VP). The effect of racemic VP was the simple sum of those elicited by both enantiomers. These relationships were not significantly different between intravenous infusion and bolus injection. Simultaneous intravenous infusion of NVP had no influence on the PR intervals. In conclusion, we demonstrated that the relationship between plasma unbound concentration of VP enantiomers and their pharmacological effect was the simple sum of two enantiomers.

[No relation between angiotensin-converting enzyme (ACE) inhibitor-induced cough and ACE gene polymorphism, plasma bradykinin, substance P and ACE inhibitor concentration in Japanese patients]

Persistent dry cough is well known as the most common side-effect of angiotensin-converting enzyme (ACE) inhibitors. We examined the relationship between a cough and ACE gene polymorphism, plasma bradykinin (BK), substance P (SP) and ACE inhibitor concentrations in patients with hypertension or chronic nephritis. First, ACE genotyping was carried out in 96 patients, 42 with coughs and 54 without coughs, which had been treated with various kinds of ACE inhibitors. However, no significant difference in the ACE genotypes was observed between the two groups. Second, the plasma concentrations of BK, SP and ACE inhibitor were measured in 12 patients, which were treated with trandolapril at a daily dose of 1 mg for 4-33 weeks. In 3 patients, the cough was induced during the trandolapril therapy, while it was induced not in 9 patients. The plasma levels of BK and SP did not significantly change after trandolapril administration in the patients with and without coughs. Between the two groups, there were no significant differences in the plasma levels of BK and SP either before or after the trandolapril therapy. Also the plasma concentrations of trandolapril and trandolaprilat, the active metabolite of trandolapril, did not significantly differ between the two groups. These results suggest that there is no significant relationship between the ACE inhibitor-induced cough and ACE gene polymorphism, plasma BK, SP and ACE inhibitor concentrations in patients with hypertension or chronic nephritis.

Autoimmune cholangiopathy associated with rheumatoid arthritis

We herein describe a patient with autoimmune cholangiopathy complicated with rheumatoid arthritis. A 58-year-old female was admitted to our hospital due to complications of arthralgia in her fingers, shoulders, elbows, knees and ankles. She presented with abnormally elevated levels of transaminases, alkaline phosphatase and was also negative for hepatitis B virus, hepatitis C virus and the serum mitochondrial antibody test, but had high titers of serum antinuclear antibody, rheumatoid factor and rheumatoid arthritis hemagglutination. A liver biopsy specimen showed chronic non-suppurative destructive cholangitis. She was thus diagnosed to have autoimmune cholangiopathy and rheumatoid arthritis. She began treatment with prednisolone 40 mg per day. After 20 days of steroid therapy, her hepatic function tests improved and the arthralgia symptoms disappeared. This is, to our knowledge, the first case of autoimmune cholangiopathy associated with rheumatoid arthritis, in which both symptoms improved with steroid therapy.

14-3-3zeta is an effector of tau protein phosphorylation

Neurofibrillary tangles associated with Alzheimer's disease are composed mainly of paired helical filaments that are formed by the aggregation of abnormally phosphorylated microtubule-associated protein tau. 14-3-3, a highly conserved protein family that exists as seven isoforms and regulates diverse cellular processes is present in neurofibrillary tangles (Layfield, R., Fergusson, J., Aitken, A., Lowe, J., Landon, M., Mayer, R. J. (1996) Neurosci. Lett. 209, 57-60). The role of 14-3-3 in Alzheimer's disease pathogenesis is not known. In this study, we found that the 14-3-3zeta isoform is associated with tau in brain extract and profoundly stimulates cAMP-dependent protein kinase catalyzed in vitro phosphorylation on Ser(262)/Ser(356) located within the microtubule-binding region of tau. 14-3-3zeta binds to both phosphorylated and nonphosphorylated tau, and the binding site is located within the microtubule-binding region of tau. From brain extract, 14-3-3zeta co-purifies with microtubules, and tubulin blocks 14-3-3zeta-tau binding. Among four 14-3-3 isoforms tested, beta and zeta but not gamma and epsilon associate with tau. Our data suggest that 14-3-3zeta is a tau protein effector and may be involved in the abnormal tau phosphorylation occurring during Alzheimer's disease ontogeny.

Effect of cationic liposomes on intracellular trafficking and efficacy of antisense oligonucleotides in mouse peritoneal macrophages

We have investigated the intracellular fate and antisense effect of oligonucleotide/cationic liposome complexes using phosphorothioate oligonucleotides (S-Oligo) targeted to inducible nitric oxide synthase in mouse peritoneal macrophages. Confocal laser microscopic analysis revealed that, after application of fluorescein isothiocyanate (FITC)-labeled S-Oligo alone, the intracellular localization of fluorescence exhibited a punctate pattern in the cytoplasm, suggesting that the oligonucleotides were mainly confined to the endosomal and/or lysosomal compartments. In the case of complexation with Lipofectin and DMRIE-C liposomes, cellular uptake of FITC-S-Oligo was not greatly enhanced and the fluorescence localization in the cells was similar to that of FITC-S-Oligo alone. LipofectAMINE slightly enhanced cellular uptake of FITC-S-Oligo; however, the intracellular localization profile of FITC-S-Oligo remained largely unchanged. The antisense effect was slightly enhanced by LipofectAMINE under only very limited experimental conditions. It was concluded that cationic liposomes are not a potential carrier for S-Oligo in peritoneal macrophages because of their inability to promote the release of S-Oligo from the endosomal compartments to the cytosol over a non-toxic concentration range.

Serum IgE response to orally ingested antigen: a novel IgE response model with allergen-specific T-cell receptor transgenic mice

BACKGROUND

The mechanism by which orally ingested allergens elicit an IgE response remains unclear because there are few animal models available for investigation of this response.

OBJECTIVE

We tried to develop a murine model suitable for investigation of the IgE response to orally ingested allergens, which would allow us to identify T cells that could promote IgE production.

METHODS

Ovalbumin (OVA)-specific T-cell receptor transgenic mice were fed a diet containing OVA, and both the serum antibody response and cytokine production by splenocytes were examined.

RESULTS

Oral administration of OVA to transgenic mice led to an increase in the levels of both antigen-specific IgE and total IgE in the sera. Subsequent intravenous challenge of OVA-fed transgenic mice with OVA resulted in anaphylactic shock. Analysis of cytokine production by splenocytes revealed that high IL-4-producing T cells appeared in the spleen 1 week after the start of feeding the OVA diet. T cells from these mice were found to promote IgE secretion by BALB/c B cells in vitro. This helper activity and the levels of IL-4 secretion were diminished after long-term feeding. These findings suggest the possibility that the orally ingested antigen elicited a response by a subpopulation of T cells that produce high levels of T(H2)-type cytokines and that promote IgE secretion, and these same T cells were tolerized by the orally ingested antigen.

CONCLUSION

This experimental model with transgenic mice may be a useful tool for further studies of the cellular and molecular mechanisms of the T-cell and IgE responses to orally ingested antigens.

Effect of cimetidine and probenecid on pilsicainide renal clearance in humans

OBJECTIVE

To investigate the effect of cimetidine and probenecid on the renal clearance of pilsicainide in healthy subjects.

METHODS

Nine healthy men (age range, 21 to 38 years) were given oral doses of 50 mg pilsicainide hydrochloride alone, with coadministration of 800 mg oral cimetidine, or with coadministration of 1,500 mg oral probenecid on three occasions in a Latin-square order. Urine and venous blood samples were collected on a timely basis. The concentration of pilsicainide in plasma and urine were determined by an HPLC method.

RESULTS

Concomitant administration of cimetidine significantly increased the area under the plasma concentration-time curve of pilsicainide by a mean of 33%, prolonged elimination half-life by a mean of 24% (from 5 to 6.2 hours), reduced apparent oral clearance by a mean of 26% (from 14.7 +/- 0.1 to 10.8 +/- 0.8 L/h) and reduced renal clearance by a mean of 28% (from 196.8 +/- 53.9 to 141.8 +/- 25.9 mL/min). The net renal clearance by tubular secretion was significantly reduced by a mean value of 38%, from 151.4 +/- 62.9 to 93.0 +/- 31.1 mL/min. Coadministration of probenecid did not show any changes in plasma concentrations of pilsicainide, pharmacokinetics, or the net renal clearance by tubular secretion of pilsicainide.

CONCLUSIONS

Pilsicainide appeared to be secreted by the active transport system for organic bases in the proximal tubule, and the excretion of pilsicainide was inhibited by cimetidine.

Hepatocellular carcinoma with metastasis to the rib complicated by hemothorax. An autopsy case

A 64-year old man was admitted to our hospital with multiple hepatocellular carcinoma (HCC) lesions in the liver, lung and bone. Three weeks after admission, the patient became complicated with right upper chest pain. A chest radiograph showed a marked increase in right pleural effusion. Thoracentesis demonstrated a hemothorax. Despite treatment with a continuous pleural tap and blood transfusions, the patient's clinical status worsened and he developed severe dyspnea. His right pleural effusion might be considered to be caused by a rupture of the HCC metastasis in the right 2nd rib. The patient died due to respiratory and hepatic failure 26 hours after his occurring the pleural effusion. An autopsy revealed moderately differentiated HCC in the liver, lung and bone. The HCC metastasis of the right 2nd rib was found to have torn the nearby pleura. We described a rare case in which hemothorax was caused by a ruptured rib-based HCC.

Ruptured duodenal varices: an autopsy case report

Bleeding from duodenal varices is a rare and life-threatening complication of cirrhosis. The diagnosis and management of this disease remains problematic. We herein report an autopsy case of a patient who suffered from recurrent bleeding from duodenal varices. A 48 year-old man with cirrhosis presented with upper gastrointestinal bleeding. He had three episodes of massive melena during the 6 months prior to admission. However, the source of bleeding was not known. Emergent endoscopy revealed jet bleeding from varices in the second to third portion of the duodenum. Endoscopic ethanol injection sclerotherapy was attempted but rebleeding occurred and the patient died.

Characterization of plasmid DNA binding and uptake by peritoneal macrophages from class A scavenger receptor knockout mice

PURPOSE

Plasmid DNA (pDNA) has become an important class of macromolecular agent suitable for non-viral gene therapy as well as DNA vaccination. Our recent study has suggested that pDNA is taken up by mouse peritoneal macrophages via a specific mechanism mediated by a receptor similar to the scavenger receptor (SR). This study was designed to further characterize the pDNA uptake by macrophages in order to elucidate the mechanism.

METHODS

The binding and uptake of pDNA labeled with 32P or a fluorescent marker were studied in vitro using cultured Chinese hamster ovary (CHO) cells expressing the class A scavenger receptor (SRA) and peritoneal macrophages from SRA-knockout mice.

RESULTS

pDNA binding and uptake by CHO(SRA) cells were minimal and almost identical to that by wild-type CHO cells. Macrophages from the knockout mice showed pronounced pDNA binding and uptake as did the control macrophages. In both types of macrophage, pDNA binding was significantly inhibited by cold pDNA, polyinosinic acid and dextran sulfate but not by polycytidylic acid or Ac-LDL. These results provide direct evidence that SRA is not responsible for the significant binding and subsequent uptake of pDNA by mouse peritoneal macrophages. Further binding experiments revealed that, in addition to polyinosinic acid and dextran sulfate, heparin was a potent inhibitor among a variety of polyanionic compounds such as polynucleotides, anionic polysaccharides and modified proteins including Ox-LDL.

CONCLUSIONS

The present study suggest that pDNA binding and uptake by mouse peritoneal macrophages are mediated by a specific mechanism to some defined polyanions not by scavenger receptors. The finding would be an important basis for further studies to elucidate the mechanism(s) of pDNA uptake by macrophages.

Quantitative determination of disopyramide, verapamil and flecainide enantiomers in rat plasma and tissues by high-performance liquid chromatography

Enantiomers of disopyramide (DP), flecainide (FLC) and verapamil (VP) were extracted from rat plasma and tissues (brain, lung, heart, liver, kidney and muscle), followed by quantitative determination using enantioselective high-performance liquid chromatography with chiral stationary-phase columns. The recoveries of S-(+)- and R-(-)-DP from tissues were higher than 69%, and the within- and between-day coefficients of variation were very low (0.5 - 5.7%). The lower limits of detection in each tissue were less than 289 ng/g tissue. The recoveries of S-(+)- and R-(-)-FLC from tissues were higher than 88%, and the within- and between-day coefficients of variation were 1.2-6.0%. The lower limits of detection in each tissue were less than 37 ng/g tissue. The recoveries of S-(-)- and R-(+)-VP from tissues were higher than 80%, and the within- and between-day coefficients of variation were 0.5-6.2%. The lower limits of detection in each tissue were less than 51 ng/g tissue. The analytical methods established in this study will be suitable for determining the concentrations of the enantiomers of these anti-arrhythmic agents in rat plasma and tissues.

Involvement of specific mechanism in plasmid DNA uptake by mouse peritoneal macrophages

The binding and uptake of plasmid DNA encoding luciferase reporter gene (pCMV-Luc) were studied in vitro using cultured mouse peritoneal macrophages. A significant and time-dependent cellular association of [32P]pCMV-Luc with resident macrophages was observed at 37 degrees C and this decreased at 4 degrees C. The binding at 4 degrees C was saturable and a Scatchard plot gave a maximum binding capacity of 0.81 microgram/mg-protein and a dissociation constant of 0.30 microgram/ml. The binding of [32P]-pCMV-Luc was inhibited by polyinosinic acid, dextran sulfate and salmon sperm DNA, but not by polycytidylic acid, dextran and EDTA. A confocal microscopic study demonstrated that fluorescein-labeled pCMV-Luc was internalized at 37 degrees C while only cell surface binding occurred at 4 degrees C. No significant luciferase gene expression was obtained after incubation with a high concentration (100 micrograms/ml) of pCMV-Luc. These data suggest that plasmid DNA is taken up by macrophages via a mechanism mediated by a receptor like the macrophage scavenger receptor.

Recurring encephalopathy abolished by gastrorenal shunt ligation in a diabetic hemodialysis patient

A 57-year-old man was admitted to our hospital for hepatic encephalopathy. He previously had undergone a partial gastrectomy for gastric ulcer, and also had been on maintenance hemodialysis because of diabetic nephropathy. Despite treatment with branched-chain amino acids and lactulose, encephalopathy occurred repeatedly. The findings of his laboratory examinations, computed tomography, and liver biopsy were not suggestive of chronic liver damage. Angiography revealed a portal-systemic shunt from the superior mesenteric vein via the left gastric vein to the left renal vein. A ligation of the gastrorenal shunt was performed. After the shunt ligation, hepatic encephalopathy no longer recurred, and no medication was required to prevent it. The insulin requirements also decreased, the plasma ammonia concentration then decreased, and serum concentration of several amino acids related to the ammonia metabolism also decreased. The molar ratio of branched-chain amino acids to aromatic amino acids increased. The ligation of the portal-systemic shunt was thus considered to be the key to the successful treatment of hepatic encephalopathy in this unusual case.

A rare case of hepatic injury associated with ovarian hyperstimulation syndrome

A 26-year-old married woman was admitted to our hospital because of massive ascites and hepatic injury. The patient had been treated with human menopausal gonadotropin and clomiphene citrate to prevent recurrence of spontaneous abortions. About 1 month later, she developed upper abdominal pain and noticed dark urine. On admission, she had elevated concentrations of serum transaminases with an asparate aminotransferase of 127 IU/L and alanine aminotransferase of 194 IU/L. An abdominal ultrasound showed massive ascites. Her serum concentration of estradiol was high at 12,100 pg/mL, which was much greater than the value of early stage of pregnancy (2,279-7,353 pg/mL). She was thus diagnosed as having ovarian hyperstimulation syndrome. Following a period of bed rest, her liver function normalized and the ascites disappeared. Based on the above findings, the patient was considered to have suffered from ovarian hyperstimulation syndrome, complicated by hepatic injury.

[Thyroid function in patients with Yusho: 28 year follow-up study]

To evaluate chronic effect of polychlorinated biphenyl (PCB) on thyroid functions, thyroid hormone levels and thyroidal autoantibodies were studied in 81 patients with Yusho in 1996. Serum level of thyroid stimulating hormone (TSH) was elevated in 7 cases (8.6%). All of them showed normal triiodothyronine (T3), thyroxine (T4) and free T4 levels, and regarded as latent hypothyroidism. There were no significant correlations between blood PCB concentrations and TSH levels, T2 levels, T4 levels or free T4 levels. Thyroglobulin antibodies were detected in 8 cases (19.5%) of 41 Yusho patients with high PBC concentration (higher than 3.0 ppb), and in only one case (2.5%) of 40 patients with low PBC concentration (lower than 2.9 ppb). We conclude that thyroglobulin antibody in patients with Yusho is not frequent and it may be associated with blood PCB concentration.

No effect of high-protein food on the stereoselective bioavailability and pharmacokinetics of verapamil

The effects of high-protein food on the bioavailability of both the racemate and individual enantiomers of verapamil were investigated in 12 healthy volunteers using a randomized crossover design. Food had no effect on any parameter of bioavailability for both the racemate and the individual enantiomers of verapamil except time to maximum concentration (tmax), which was significantly prolonged after food intake. The pharmacokinetics of the enantiomers of norverapamil were not significantly changed by food intake. These results suggest that high-protein food does not alter the pharmacokinetics and bioavailability of either the racemate or the individual enantiomers of verapamil. Therefore, the clinical efficacy of verapamil is not related to food intake, except for a slight prolongation in the time to onset of the pharmacologic effects. The present data can be applied to the high-protein content meal intake.

[Fucosyltransferase producing sialyl Le(a) and sialyl Le(x) carbohydrate antigen in gastrointestinal cancer]

Sialyl Lea and sialyl Lex are cancer-associated carbohydrate antigens. The biosynthesis of these antigens is completed by fucosyltransferases. We measured the activity of alpha 1-->4 fucosyltransferase (sialyl Lea synthase) and alpha 1-->3 fucosyltransferase (sialyl Lex synthase) in gastrointestinal cancer tissues. alpha 1-->4 fucosyltransferase activity was similarly detected in most normal or malignant tissues. alpha 1-->3 fucosyltransferase activity in gastric cancer was higher than in the normal mucosa. In colonic cancer, although the enhanced expression of sialyl Lex was observed in 86% of cases, the elevated activity of alpha 1-->3 fucosyltransferase was observed in only 58%. In conclusion, the expression of sialyl Lea and sialyl Lex antigens in the stomach and colon was not controlled solely by fucosyltransferases.

Fucosyltransferase-producing sialyl Le(a) and sialyl Le(x) carbohydrate antigen in benign and malignant gastrointestinal mucosa

BACKGROUND

Sialyl Le(a) antigen and sialyl Le(x) antigen are cancer-associated carbohydrate antigens. Previous immunohistologic and immunochemical studies have shown that these antigens are preferentially expressed in gastric cancer and colonic cancer and that they possibly are related to the metastatic potential of the cancer cells. The biosynthesis of these antigens is completed by fucosyltransferases, but it has not been reported how fucosyltransferases control the expression of these carbohydrate antigens concerning the invasive potential of the cancer.

METHODS

The authors established an assay system for measuring the activity of alpha 1-->4 fucosyltransferase (sialyl Le(a) synthase) and alpha 1-->3 fucosyltransferase (sialyl Le(x) synthase) with a high-pressure liquid chromatography system (HPLC). The activity was measured in various parts of normal and cancerous gastric and colonic tissue and compared with the expression of sialyl Le(a), sialyl Le(x), Le(a), and Le(x) antigens determined in a solid-phase enzyme-linked immunosolvent assay (EIA).

RESULTS

Sialyl Le(a) synthase was detected in most normal or malignant mucosa of gastric and colonic tissues, regardless of anatomic locations. Sialyl Le(x) synthase activity generally was low in the normal gastric mucosa, whereas the activity was higher in 77% (7 of 9) of gastric cancer tissues than in corresponding normal tissues with enhanced expression of sialyl Le(x) antigen in most patients (5 of 7). In the large intestine, the activity of sialyl Le(a) synthase and sialyl Le(x) synthase was correlated. Although enhanced expression of sialyl Le(x) in colonic cancer was observed in 86% (12 of 14) of all patients, concomitant higher sialyl Le(x) synthase activity than that in normal tissue was observed in only 58% (7 of 12) of patients.

CONCLUSIONS

The expression of sialyl Le(a) and sialyl Le(x) antigens in the stomach and the colon was not controlled solely by fucosyltransferases but by a more complicated system involving other glycosyltransferases.

[Surgical treatment of primary cardiac tumors]

Thirty-four cases of primary cardiac tumors, consisted of 11 men and 23 women, aged between 26 and 80 years have been operated on in our institution. A total of 30 myxomas and four malignant tumors were resected. The clinical presentations included congestive heart failure in 25 patients, tachyarrhythmia in 6, chest pain in 4, and embolism in 10. All 30 myxoma lesions were completely resected, although none of the malignant tumors could be resected completely because of invasion of the tumor to the surrounding tissues. Four patients with malignant tumors died of tumor recurrence within 9 months after operation. Histological diagnosis was rhabdomyosarcoma in two patients, round cell sarcoma in one and malignant fibrous histiocytoma in one. All patients with myxoma survived operation. Follow-up was completed in 28 patients (range 1 month to 15 years, mean 5.5 years): Twenty-four were in New York Heart Association Class I, and the remaining two in Class II. Actuarial survival rate was 89% at 15 years after operation. No recurrent myxoma have been identified clinically or by echocardiography. For malignant primary tumors, more effective adjuvant therapy with aggressive resection will be inevitable to improve long-term prognosis.

[Surgical repair of total anomalous pulmonary venous drainage--four adult cases of successful operation]

We have experienced four adult cases of total anomalous pulmonary venous drainage (TAPVD). They were three females and one male, age between 18-51 with a mean of 33.8. In Darling's classification, they constituted of three cases of type Ia and one type IV. Cardiac catheterization revealed 1.71-5.93 with a mean of 3.92 in Qp/Qs and 0.34-0.49 with a mean of 0.38 in Pp/Ps. The pulmonary to systemic resistance ratio (Rp/Rs) was then calculated as 0.02-0.15 with a mean of 0.09. All cases showed short route type of drainage vein in pulmonary arteriography. None of them had stenosis or obstruction in the drainage veins. The operation was composed of anastomosis between the left atrium and the common pulmonary vein, closure of the atrial septal defect (ASD), and ligation of the drainage vein. Gersony-Malm's method was adopted in two cases and the posterior approach in two cases in anastomoses between the left atrium and the common pulmonary vein. Intraatrial approach combined with posterior approach was tried in a case with small left atrium. The mean size of ASD was 43 mm (35-55 mm) in diameter. Patch closure was performed in three cases. Important factors in survival for adult TAPVD are large ASD and short route type drainage vein without stenosis. All of four cases had good results. The operation method is variable and an easier approach must be adopted.

Acetylation polymorphism of caffeine in a Japanese population

The frequency distribution of N-acetylation of caffeine was determined in 140 unrelated healthy Japanese subjects by measuring the amount of two main metabolites of caffeine, 5-acetylamino-6-formyl-amino-3-methyluracil (AFMU) and 1-methylxanthine (1X), in urine after an oral dose of caffeine. N-Acetylation capacity for caffeine appeared to be polymorphic: 15 subjects (10.7%) were phenotyped as slow acetylators, whereas 125 subjects (89.3%) were phenotyped as rapid ones. The urinary molar excretion ratio of AFMU (AFMU/1X) in 2 hours-urine samples ranged from 0.03 (slow acetylators) to 2.66 (rapid acetylators). The frequency of slow acetylators in this study was similar to that reported previously for the isoniazid and dapsone polymorphism in Japanese populations.

Diurnal effect on caffeine clearance

Caffeine (300 mg) was given orally to nine healthy subjects at 10:00 AM (day trial) or at 10:00 PM (night trial) using a crossover design. Saliva was obtained at 0.5, 1, 1.5, 2, 3, 4, 6, and 8 hours after administration of caffeine. Urine was collected for 8 hours after caffeine dosing. Caffeine clearances in saliva during the day trial were not different from those in the night trial. No significant difference was observed in urinary molar ratios of metabolites (AFMU + 1X + 1U/17U) between the two trials. These data suggest that caffeine clearances in saliva do not vary with its administration time. Since caffeine clearances in plasma are reflected in the urinary ratios of caffeine metabolites, its clearance in plasma might also not be altered by the time of dosing.

Phenytoin partially antagonized L-type Ca2+ current in glucagon-secreting tumor cells (ITC-1)

Transmembrane Ca2+ currents were investigated by means of a whole-cell clamp technique in a hamster glucagon-secreting tumor cell line (ITC-1). Two types of Ca2+ current were identified in ITC-1 cells. The low-threshold and transient (T-type) current became detectable above the potential level around -60 mV and decayed rapidly with an inactivation time constant of 95 ms (at -40 mV and 23 degrees C), while the high-threshold and long-lasting (L-type) one was activated by depolarization more positive to -30 mV with non-inactivating kinetics. The voltage dependence and kinetics of these currents were identical to those reported in guinea-pig pancreatic alpha 2 cells. Both currents were augmented by equimolar substitution of Ca2+ with Ba2+ and completely abolished by adding 1 microM La3+. Phenytoin, a well known anti-epileptic drug and a postulated T-type specific Ca2+ current antagonist, surprisingly blocked the L-type current without affecting the T-type current in ITC-1 cells. While phenytoin antagonized the L-type Ba2+ current selectively, 60% of the current remained even in supramaximal concentration range over 500 microM. The residual component of the L-type current was completely abolished by adding nifedipine.

Surgical treatment of abdominal aortic aneurysm in the high-risk patient

In an attempt to define the preoperative risk factors that predictably influence mortality after aneurysmectomy, this study reviews the surgical management of abdominal aortic aneurysms in a series of 110 consecutive patients who underwent elective resection. The preoperative risks to be added to the present study included pulmonary insufficiency, renal dysfunction, advanced age of over 80 years, ischemic heart disease, and associated other diseases such as thoracic aneurysms, atherosclerosis of the limbs and malignant tumors. Forty-six patients had one of these risk factors (one-risk group), 17 had two (two-risk group), and 9 had three (three-risk group). The operative mortality rates were 4.2 per cent for the high-risk patients and 0 per cent for the patients at no risk. As the number of risk factors increased, aneurysm repair was associated with an increased operative mortality; being 2.2 per cent in the one-risk group, 5.9 per cent in the two-risk group and 11.1 per cent in the three-risk group. The common risk factor in patients who died after aneurysmectomy was pulmonary insufficiency which induced prolonged periods of assisted ventilation. Thus, the optimal management of high-risk patients, particularly those with pulmonary insufficiency, may reduce the mortality after aneurysmectomy.