[Adenocarcinoma in the Lung Detected Due to the Development of Perforative Peritonitis Caused by Small Intestinal Metastasis-A Case Report]

Previous studies have reported that perforations of the small intestine caused by metastatic tumors prior to the diagnosis of primary lung cancer are very rare. A 79-year-old man was admitted to our hospital with acute lower abdominal pain. Abdominal computed tomography revealed intraperitoneal free air around the bowel wall thickening in the small intestine. The patient was diagnosed with acute peritonitis caused by perforation of the small intestine, and an emergency operation was performed. Laparotomy revealed perforation in the jejunum without any palpable tumor in the abdomen. Partial resection of the jejunum revealed an ulcerating lesion at the perforation site. Histological examination indicated small intestinal metastasis secondary to lung adenocarcinoma. Positron emission tomography performed after discharge showed a small reticular opacity with intense accumulation of FDG in the left lung. The patient was diagnosed with perforation of the small intestine metastasis secondary to lung adenocarcinoma. The postoperative course was uneventful; the patient received chemotherapy, and is alive 6months after the operation.

P104 Prognostic value of Circulating Amino Acids (AAs) in Patients with Idiopathic Dilated Cardiomyopathy (DCM)

Methods

Consecutive 59 patients with DCM (M/F: 46/13, mean age: 59 years) were enrolled. We measured 25 kinds of plasma AA concentration, derivative of reactive oxygen metabolites (d-ROMs) as marker of oxidative stress, and washout rate of Tc-99m Sestamibi (WOR) as function of mitochondria and LVEF as LV function parameters. The occurrence of rehospitalization for cardiac events or cardiac death were followed during mean 1101 days (13-2626).

Results

Histidine, arginine and Fischer ratio (FR) showed a significant positive association with LVEF (p < 0.05). Threonine and asparagine showed a significant negative association with WOR (P < 0.05). Histidine and arginine showed a significant negative association with levels of d-ROMs (p < 0.05).Rehospitalization for cardiac events and cardiac death were recorded in 16 patients (27%) and 6 patients (10%), respectively. Kaplan-Meier curves analysis showed similar trend of rehospitalization in subjects with lower FR and those with higher values. However, cardiac death in subjects with lower FR was observed more frequently as compared to those with higher values (22.2% vs 5.3% p < 0.05).

ConclusionsThe plasma FR could be a novel prognostic biomarker in DCM patients.

[A Case of Trousseau Syndrome Complication during Chemotherapy for Advanced Gastric Cancer]

The pathological condition which causes cerebrovascular disease through hypercoagulability associated with malignant tumors is known as Trousseau syndrome. Here, we report the case of a patient with Trousseau syndrome which developed as a complication during chemotherapy for advanced gastric cancer. A 70-year-old woman with multiple lymph node metastases of gastric cancer underwent TS-1 plus CDDP chemotherapy before surgery. She had symptoms of left hemiparesis during the first course of chemotherapy. She was diagnosed with acute cerebralinfarction using brain MRI, and blood tests indicated hypercoagulability. Therefore, it was strongly suspected that she had Trousseau syndrome. A total of 2 courses of chemotherapy were administered, along with anticoagulation therapy with edoxaban. She exhibited improved paralysis and received a totalgastrectomy after chemotherapy. According to recent reports, more than 90% of patients with malignant tumors have hypercoagulability, and more than 50% of them have thromboembolisms. It is therefore essential to obtain early diagnosis and provide anticoagulation therapy for cerebral infarction, and to provide treatment against malignant diseases in patients with Trousseau syndrome.

P3648Plasma glutamate are increased in non-smoker patients with vasospastic angina pectoris and associated with plasma cystine and antioxidant capacity

Background

Endothelial dysfunction of the coronary arteries caused by oxidative stress plays an important role in the pathogenesis of vasospastic angina pectoris (VSAP). Glutamate, a non-essential amino acid, exerts endothelial dysfunction by oxidative stress production through N-methyl-D-aspartate receptor activation. Besides oxidative stress, decrease of antioxidant may be responsible for endothelial dysfunction. Glutathione (GSH), an important antioxidant, is synthesized from imported cystine through the cystine/glutamate antiporter system (XC-) in association with the export of glutamate. Glutamate also competitively inhibits cystine import into the endothelial cells through the XC-leading to GSH depletion. Thus the extracellular glutamate and cystine are crucial for the intracellular redox status. However, it remains unclear whether glutamate and/or cystine are implicated in the pathogenesis of VSAP. As smoking induces powerful oxidant stresses in the whole body, we investigated plasma glutamate, cystine, oxidative stress markers and antioxidant capacity in non-smoker patients with VSAP.

Methods and results

Sixty-two consecutive non-smoker patients suspected having VSAP were performed coronary angiograms (CAG). Forty-nine patients who did not show any significant coronary stenosis (<50%) were performed the intracoronary acetylcholine provocation test. Patients were categorized into the VSAP-positive group (n=27) and the VSAP-negative group (n=22) on the basis of test results. Blood samples were collected from the femoral sheath before the CAG. Plasma glutamate, cystine, nitrotyrosine (NT), reactive oxygen metabolites (d-ROMs) and biological antioxidant potential (BAP) were measured. The levels of plasma glutamate and cystine in the VSAP-positive group were significantly higher than those in the VSAP-negative group (59.8±25.7 vs 43.5±18.7 nmol/L, p=0.0054, and 35.3±14.2 nmol/L vs 25.2±9.1 nmol/L, p=0.0018, respectively). The levels of plasma glutamate showed significant and positive association with the levels of plasma cystine (r=0.40, p=0.005). There were no significant differences in the levels of NT and d-ROMs as oxidative stress markers, and BAP as an antioxidant capacity between the two groups, respectively. However, the levels of plasma glutamate showed significant and negative association with BAP values (r=−0.3, p=0.038).

Conclusions

Plasma levels of glutamate were increased in non-smoker patients with VSAP and positively associated with plasma cystine levels and negatively associated with antioxidant capacity, suggesting that plasma glutamate modulate plasma cystine levels and antioxidant capacity through the XC- inhibition, and could be a novel risk factor of VSAP.

[A Case That Was Complicated with Pulmonary Artery Thrombosis during Chemotherapy of the Regimen of CapeOX plus Bevacizumab against Recurrence of Colon Cancer]

An 80-year-old woman with peritoneal dissemination after laparoscopic right hemicolectomy for appendicular carcinoma (mucinous adenocarcinoma, pT4aN1M0, stage Ⅲa)underwent CapeOX plus bevacizumab chemotherapy. The patient achieved stable disease over 5 courses of the treatment. Subjective and objective symptoms were not observed; however, chest computed tomography findings revealed a thrombus in the pulmonary artery that was considered to be associated with bevacizumab. Chemotherapy was discontinued, and anticoagulation therapy was initiated with heparin and then switched to apixaban. The thrombus resolved with treatment, but the patient died following an increase in peritoneal dissemination. CapeOX plus bevacizumab is a recommended colon cancer treatment, and even though it is generally considered safe, the side effects of bevacizumab include relatively rare occurrences of gastrointestinal perforation or thrombosis. The frequency of pulmonary embolism associated with bevacizumab is approximately 0.1%, and fatalities have been reported. The possibility of asymptomatic thrombosis warrants regular monitoring of this serious side effect in patients receiving bevacizumab. Early detection and prompt antithrombotic treatment are necessary to ensure patient safety and continued disease management.

Nafamostat as Anticoagulant for Membrane Plasmapheresis in high Bleeding risk Patients

Nafamostat mesilate (NM), an ultrashort-acting multi-enzymatic inhibitor, is a useful anticoagulant in high bleeding risk patients needing hemodialysis. We applied NM as a membrane plasmapheresis (MP) anticoagulant in patients with high bleeding risk. Eleven patients, the majority with hepatic failure and active hemorrhagic foci or severe bleeding diathesis, could be treated with MP 22 times under anticoagulation by 20-40 mg/h/NM by continuous infusion without any trouble. Celite-activated coagulation time (CCT) at the plasma separator inlet and outlet was adequately prolonged during MP, but CCT in systemic blood showed no prolongation throughout the procedure, because NM was rapidly inactivated. There was no observable blood coagulation in the extracorporeal circuit including the plasma separator. No adverse reaction or exacerbation of hemorrhage was noted throughout the MP. NM thus appears to be a useful and safe anticoagulant not only for hemodialysis but also for MP in high bleeding risk patients.

[A Case of Orange-Induced Small Bowel Diverticular Obstruction Treated with Laparoscopically-Assisted Surgery]

We report a case of orange-induced small bowel diverticular obstruction treated with laparoscopically-assisted surgery. A 64-year-old man was seen at the hospitalbecause of abdominalpain and vomiting after dinner. Abdominalcomputed tomography( CT)showed a small intestinal ileus. We performed laparoscopically-assisted surgery on the same day for definitive diagnosis and treatment. The postoperative course was uneventful. The pathological diagnosis was orange-induced small boweldiverticul ar obstruction. Food-induced smallbowelobstruction is rare disease, but often requires surgery. Laparoscopic surgery is an effective option for surgery of food-induced smallbowel obstruction.

Functional status of the articularis genus muscle in individuals with knee osteoarthritis

OBJECTIVES

To clarify the functional status of the articularis genus muscle (AGM) in individuals with knee osteoarthritis (OA) and to analyze the muscle's relationship with knee OA.

METHODS

Fifty-two individuals with knee OA (mean age, 73.4 years), 50 elderly individuals without knee OA changes (mean age, 71.2 years) and 75 young individuals (mean age, 20.2 years) were observed the AGM using ultrasonography. The thickness of the AGM, the anteroposterior distance of the suprapatellar bursa, and moving distance of the muscle insertion were measured both at rest and during isometric contraction, and values during contraction were expressed as percentages of the values at rest (%Muscle-Increase, %Bursa-Increase).

RESULTS

Muscle thickness at rest, %Muscle-Increase, %Bursa-Increase, and moving distance of the muscle insertion were significantly lower and anteroposterior distance of the suprapatellar bursa was significantly higher in the OA group than in the controls (p<0.001, all). In the OA group, these values for the AGM were significantly correlated with knee range of motion, knee pain, and Kellgren and Lawrence grade.

CONCLUSIONS

Individuals with knee OA exhibited atrophic changes and dysfunctions of the AGM, and these were associated with symptoms. Atrophic changes and dysfunctions of the AGM may be specific changes associated with knee OA.

[A Case of a Laparoscopically Resected Gastrointestinal Stromal Tumor of the Stomach]

During treatment for sigmoid colon diverticulitis, a 72-year-old man underwent abdominal computed tomography, which revealed a gastric tumor that was approximately 40mm in diameter. He then underwent a detailed examination after the remission of diverticulitis. The gastric mucosa was found to be unremarkable on gastrointestinal endoscopy. On ultrasonic endoscopy, however, a hypoechoic mass of approximately 40mm in diameter was detected in the fourth layer of the gastric fornix and was believed to be a gastric submucosal tumor(SMT). The tumor was laparoscopically resected, and histological analysis of the tumor revealed a high-risk gastrointestinal stromal tumor(GIST, modified-Fletcher classification). In many cases, when subgastric SMTs are approximately 2-5 cm in diameter and are without obvious malignant findings on endoscopic or computed tomographic examinations, they are followed-up. However, some recent case reports describing treatments for high- or medium-risk groups of patients with small GISTs have been published. When a small submucosal gastric tumor is suspected to be GIST, we believe that laparoscopic surgery is a minimally invasive and effective method for the diagnosis and treatment of the tumor.

[A Giant Appendiceal Mucinous Neoplasm Treated with Laparoscopic Surgery]

We encountered a case of giant appendiceal mucinous neoplasm that was treated with laparoscopic surgery. The patient was a 77-year-old man with constipation. Lower endoscopy demonstrated a giant SMT-like tumor in the cecum, and abdominal computed tomography revealed a giant appendiceal mucinous neoplasm and nearby lymph nodes swelling. Hematological examination showed an elevated serum CEA level. We performed laparoscopic ileocecal resection for a definite diagnosis and treatment. The postoperative course was uneventful. The pathological diagnosis was low-grade appendicealmucinous neoplasm(LAMN). Laparoscopic surgery can be considered safe for the resection of appendicealmucinous neoplasm when it is performed with a carefulsurgicalapproach.

[A Giant Malignant Lymphoma of the Ileocecum Treated with Laparoscopic Surgery]

We experienced a case ofa giant malignant lymphoma ofthe ileocecum treated with laparoscopic surgery. A 78-year-old man presented with right flank pain. Lower endoscopy and abdominal computed tomography revealed a giant tumor in ileocecum. Biopsy results suggested malignant lymphoma or adenocarcinoma. We performed a laparoscopic ileocecal resection for definite diagnosis and treatment. The postoperative course was uneventful. The pathological diagnosis was malignant diffuse large B-cell lymphoma. The patient underwent chemotherapy and is being followed. Laparoscopic surgery can be considered useful to resect gastrointestinal malignant lymphoma.

Enhanced inhibitory effects of TBT chloride on the development of F1 rats

Neurotoxicity is one of the major effects of tributyltin (TBT). The effects on the next generation of F(1) rats exposed to TBT via the placenta and their dams' milk may be stronger than those on adults. Pregnant Wister rats were exposed to TBT at 0 and 125 ppm in their food. Half of the female F(1) rats in both groups were exposed to TBT at 125 ppm in their food from 9 to 15 weeks of age. Female F(1) rats were divided into the following groups: the control-control (CC) group, with no exposure; the TBT-control (TC) group, exposed to TBT via the placenta and their dams' milk; the control-TBT (CT) group, exposed to TBT via their food from 9 to 15 weeks of age; and the TBT-TBT (TT) group, exposed to TBT via the placenta, their dams' milk, and their food (n = 10/group). After administration, an open-field test and prepulse inhibition (PPI) test were performed at 15 weeks of age. The mean body weights of the TC and TT groups were significantly lower than that of the CC group from 9 to 15 weeks of age. The mean relative thymus weight of the TC and TT groups was significantly lower than that of the CC group. In the open-field test, a marked decrease in the total locomotion distance was observed in the TT group. The mean values in the TT and TC groups were significantly lower than that in the CC group. For the locomotion distance between 15 and 20 min, the mean values in the CT, TC, and TT groups were significantly lower than that in the CC group. The mean locomotor distance between 25 and 30 min in the TT group was significantly lower than that in the CC and TC groups. The mean values of instances of wall rearing in the TC, CT, and TT groups were significantly lower than that in the CC group. The mean value of face washing or body washing in the TT group was significantly lower than that in the CT group. There were no significant differences in indexes of the PPI test. Exposure to TBT via the placenta and their dams' milk inhibited the development of F(1) rats, which continued after weaning. Inhibition of the rats' activity induced by exposure to TBT via the placenta and their dams' milk and/or via their food was suggested. The effects were most evident in the TT group.

Increased apoptosis rate by hyperthermochemoradiotherapy for advanced rectal cancers

Apoptosis induced in cancer cells by ionizing radiation, hyperthermia, and 5-fluorouracil (5-FU), termed "hyperthermochemoradiotherapy" (HCR), has been well studied in vitro; however, the role of apoptosis in the tumocidal effect of HCR for primary rectal cancers has not yet been clarified. Therefore, we examined the relationship between the therapeutic effect and induction rate of histological apoptosis in 16 patients with rectal cancers after HCR. Numerous Tunel-positive apoptotic cells were found in the tumor tissue after HCR, but few were found in the tumors which had not received HCR. The histological therapeutic effect was closely correlated to the rate of apoptosis. Thus, we suggest that HCR induces a therapeutic effect mainly through apoptosis in human rectal cancers.

Interaction of the basic protrusion of Escherichia coli ribonuclease HI with its substrate

In order to determine the actual distance between the active site and the substrate binding site, termed the basic protrusion, of Escherichia coli ribonuclease HI, synthetic oligonucleotide duplexes with gradually extended overhangs were used, in which the enzymatic cleavage was restricted to a single site with 2'-O-methylnucleosides. The affinity of the enzyme for each substrate was determined by kinetic analysis. It was found that the affinity increased markedly when one nucleotide was attached to the 3' end of the DNA strand of the nine-base-pair hybrid duplex and then increased slightly as the DNA strand was extended further, whereas elongation of the strand in the other direction caused no change. When a mutant enzyme, in which three lysine residues in the basic protrusion were altered to alanine, was used, no increase in the kcat/K(m) value was observed. The results indicate that, for the productive binding, the axis from the 3' to the 5' end of the RNA strand of the substrate duplex must be oriented in agreement with the direction from the active site to the basic protrusion of the enzyme. The distance between the active site and the basic protrusion in the enzyme-substrate complex was shorter than that anticipated in modeling studies. A dynamic structure refinement, referred to as the normal mode analysis, was carried out in order to simulate the fluctuations of the basic protrusion.

Plasma bradykinin levels during hemodialysis with PAN DX and polysulfone membranes with and without concurrent ACE inhibitor

The effects of dialyzer membrane material and concurrent angiotensin converting enzyme (ACE) inhibitor on plasma bradykinin levels during hemodialysis were investigated by administration of 3 successive hemodialyses using a PAN DX membrane dialyzer and another 3 using a polysulfone membrane dialyzer with the order of the 2 sequences randomized, for 6 patients receiving concurrent treatment with ACE inhibitor and 6 others receiving no ACE inhibitor. With the PAN DX membrane dialyzer the plasma bradykinin concentration obtained from the dialyzer outlet was significantly higher than that from the inlet at 10 min, but not at 5 min after initiation of dialysis, whereas no significant difference between inlet and outlet bradykinin concentrations was observed at either time with the polysulfone membrane dialyzer. No significant difference was observed between the changes in plasma bradykinin concentration in cases involving concurrent ACE inhibitor and that in cases receiving no ACE inhibitor. The results suggest that the PAN DX membrane dialyzer stimulates bradykinin production, but also that its release of bradykinin is delayed, possibly because of adsorption and modified release of bradykinin by the PAN DX membrane, and that ACE inhibitor may have no significant effect on the change in plasma bradykinin levels.

Recognition of 2'-hydroxyl groups by Escherichia coli ribonuclease HI

In order to investigate the hydrogen-bonding interactions between Escherichia coli ribonuclease HI and the 2'-hydroxyl functions of the substrate, oligonucleotide duplexes containing 2'-amino-2'-deoxyuridine or 2'-fluoro-2'-deoxyuridine at a specific site were used, and their affinities for the enzyme were determined by kinetic analyses. The results indicate that the hydroxyl groups of the nucleoside 3'-adjacent to the cleaved phosphodiester linkage and the second nucleoside 5' to the cleaved phosphodiester act as both a proton donor and an acceptor and as a proton acceptor, respectively, in the enzyme-substrate complex. A molecular model was constructed using the interactions derived from the results.

Nerve regeneration in predegenerated basal lamina graft: the effect of duration of predegeneration on axonal extension

We used predegenerated acellular grafts to bridge proximal and distal stumps of transected nerves and studied how the duration of predegeneration might affect axonal regeneration. Predegenerated acellular grafts were prepared by transecting the tibial nerve of donor rats and, after a period of degeneration, freeze-thawing a 40-mm long segment of the distal stump. Five degeneration periods were used: 0 days (for fresh grafts), 3 days, 1 week, 4 weeks, and 8 weeks. Fresh cellular grafts not treated with freeze-thawing were also used for comparison. Each graft was then transplanted to an isogeneic recipient rat, in which it was used to bridge the proximal stump of the transected left tibial nerve and the distal stump of the transected right tibial nerve. Six weeks were allowed for the regeneration of axons in all grafts. The regeneration was then assessed by studying transverse sections of the grafts, to determine the maximum length that the axons had regenerated, and the packing density of axons (percentage of sampled areas occupied by axons). The results show that axons had grown to the maximum length in the 4-week predegenerated grafts, and had the highest packing density in the 1-week predegenerated grafts. Regeneration in the fresh acellular (0-day predegenerated) and 8-week predegenerated grafts, especially the latter, was poor. We examine the results with reference to time-dependent events of Wallerian degeneration and propose that there are beneficial effects of multiple factors on the grafts during the first 4 weeks of predegeneration, causing a slow but significant improvement in their capability to support axonal growth. The subsequent rapid deterioration of such capability may be related to structural changes in the extracellular scaffold.

Effect of dialysis membranes and ACE inhibitor on bradykinin levels during hemodialysis

The effects of dialyzer membrane material and concurrent angiotensin converting enzyme (ACE) inhibitor on plasma bradykinin levels during hemodialysis were investigated. Six patients treated with an ACE inhibitor and 6 other patients not receiving an ACE inhibitor underwent three consecutive hemodialysis sessions with an AN-69 dialyzer and three sessions with a polysulfone dialyzer. The sequence of dialyzers (AN-69 followed by polysulfone or the reverse) was determined randomly. With the AN-69 membrane dialyzer, the plasma bradykinin level at the dialyzer outlet was significantly greater than that at the dialyzer inlet at 5 min but not at 10 min after initiation of dialysis, whereas no significant difference between inlet and outlet bradykinin concentrations was observed at either time with the polysulfone membrane dialyzer. The changes in plasma bradykinin level in patients with concurrent ACE inhibitor did not differ from those found in patients without ACE inhibitor. These results indicate that the AN-69 membrane stimulates bradykinin production at the initial stage of hemodialysis in patients with as well as without concurrent ACE inhibitor. Further study is necessary to clarify the exact role of ACE inhibitor in elevation of bradykinin levels during hemodialysis.

Nafamostat as anti-coagulant for membrane plasmapheresis in high bleeding risk patients

Nafamostat mesilate (NM), an ultrashort-acting multi-enzymatic inhibitor, is a useful anti-coagulant in high bleeding risk patients needing hemodialysis. We applied NM as a membrane plasmapheresis (MP) anti-coagulant in patients with high bleeding risk. Eleven patients, the majority with hepatic failure and active hemorrhagic foci or severe bleeding diathesis, could be treated with MP 22 times under anti-coagulation by 20-40 mg/h/NM by continuous infusion without any trouble. Celite-activated coagulation time (CCT) at the plasma separator inlet and outlet was adequately prolonged during MP, but CCT in systemic blood showed no prolongation throughout the procedure, because NM was rapidly inactivated. There was no observable blood coagulation in the extracorporeal circuit including the plasma separator. No adverse reaction or exacerbation of hemorrhage was noted throughout the MP. NM thus appears to be a useful and safe anti-coagulant not only for hemodialysis but also for MP in high bleeding risk patients.

Yellow nail syndrome associated with chronic pericardial effusion

A 74-year-old man had typical yellow nail syndrome, associated with pericardial effusion and hyperimmunoglobulinemia (IgG 3,179 mg/dl, IgM 402 mg/dl). A search of the literature fails to reveal a previously reported case of yellow nail syndrome associated with pericardial effusion.

Estimation of circulating immune complexes following oral challenge with cow's milk in patients with IgA nephropathy

We recently reported on an experimentally induced model of IgA nephropathy in mice by long-term oral immunization under the reticuloendothelial dysfunction, which was found to be effectively inhibited by the administration of the antiallergic agent sodium cromoglycate (SCG). On the basis of these findings, we investigated the participation of food antigens in patients with IgA nephropathy. We studied 24 patients with IgA nephropathy, 11 patients with primary glomerulonephritis (PGN) except IgA nephropathy and 11 healthy controls. Serum levels of immunoglobulins (IgG, IgA, IgE) and circulating immune complexes containing IgG (IgG-CIC) or IgA (IgA-CIC) were measured in the fasting state and 30, 60, 120 or 180 min after oral challenging with cow's milk (400 ml). After the oral challenge IgA-CIC levels remained within the normal range in healthy controls and in patients with PGN, while 3 out of the 24 patients with IgA nephropathy showed a transient elevation and 2 cases showed a significant rise of IgA-CIC levels. The levels of IgG, IgA, IgE and IgG-CIC remained uninfluenced by the challenge test in all subjects. In addition, we carried out the same challenge test under SCG administration. These cases indicating an oral-challenge-induced IgA-CIC elevation demonstrated an inhibition of this elevation, and in 3 out 7 patients who showed hyper-IgA-CIC-emia before and after oral challenge IgA-CIC levels returned to the normal range through SCG administration. These results suggest that food antigens participate strongly in the pathogenesis of some patients with IgA nephropathy, and that SCG is an effective agent for such patients.