Continuous function of 80 primary renal allografts for 30-47 years with maintenance prednisone and azathioprine/mycophenolate mofetil therapy: A clinical mosaic of long-term successes

Eighty primary renal allograft recipients, 61 living-related and 19 deceased donor, transplanted from 1963 through 1984 had continuous graft function for 30-47 years. They were treated with three different early immunosuppression programs (1963-1970: thymectomy, splenectomy, high oral prednisone; 1971-1979: divided-dose intravenous methylprednisolone; and 1980-1984: antilymphocyte globulin) each with maintenance prednisone and azathioprine, and no calcineurin inhibitor. Long-term treatment often included the anti-platelet medication, dipyridamole. Although both recipient and donor ages were young (27.2 ± 9.5 and 33.1 ± 12.0 years, respectively), six recipients with a parent donor had >40-year success. At 35 years, death-censored graft survival was 85.3% and death with a functioning graft 84.2%; overall graft survival was 69.5% (Kaplan-Meier estimate). Biopsy-documented early acute cellular and highly probable antibody-mediated rejections were reversed with divided-dose intravenous methylprednisolone. Complications are detailed in an integrated timeline. Hypogammaglobulinemia identified after 20 years doubled the infection rate. An association between a monoclonal gammopathy of undetermined significance and non-plasma-cell malignancies was identified. Twenty-seven azathioprine-treated patients tested after 37 years had extremely low levels of T1/T2 B lymphocytes representing a "low immunosuppression state of allograft acceptance (LISAA)". The lifetime achievements of these patients following a single renal allograft and low-dose maintenance immunosuppression are remarkable. Their success evolved as a clinical mosaic.

Isolation of a thermotolerant bacterium producing medium-chain-length polyhydroxyalkanoate

AIMS

The aim of this study was to isolate a thermotolerant micro-organism that produces polyhydroxyalkanoates (PHAs) composed of medium-chain-length (mcl) HA units from a biodiesel fuel (BDF) by-product as a carbon source.

METHODS AND RESULTS

We successfully isolated a thermotolerant micro-organism, strain SG4502, capable to accumulate mcl-PHA from a BDF by-product as a carbon source at a cultivation temperature of 45°C. The strain could also produce mcl-PHA from acetate, octanoate and dodecanoate as sole carbon sources at cultivation temperatures up to 55°C. Taxonomic studies and 16S rRNA gene sequence analysis revealed that strain SG4502 was phylogenetically affiliated with species of the genus Pseudomonas. This study is the first report of PHA synthesis by a thermotolerant Pseudomonas.

CONCLUSIONS

A novel thermotolerant bacterium capable to accumulate mcl-PHA from a BDF by-product was successfully isolated.

SIGNIFICANCE AND IMPACT OF THE STUDY

A major issue regarding industrial production of microbial PHAs is their much higher production cost compared with conventional petrochemical-based plastic materials. Especially significant are the cost of a fermentative substrate and the running cost to maintain a temperature suitable for microbial growth. Thus, strain SG4502, isolated in this study, which assimilates BDF by-product and produces PHA at high temperature, would be very useful for practical application in industry.

Quantification of hepatitis C virus in patients treated with peginterferon-alfa 2a plus ribavirin treatment by COBAS TaqMan HCV test

Extremely low levels of serum hepatitis C virus (HCV) RNA can be detected by COBAS TaqMan HCV test. To investigate whether the COBAS TaqMan HCV test is useful for measuring rapid virological response (RVR) and early virological response (EVR) to predict sustained virological response (SVR), we compared the virological response to PEG-IFN-alfa 2a plus RBV in 76 patients infected with HCV genotype 1 when undetectable HCV RNA by the COBAS TaqMan HCV test was used, with those when below 1.7 log IU/mL HCV RNA by COBAS TaqMan HCV test was used, which corresponded to the use of traditional methods. Among the 76 patients, 28 (36.8%) had SVR, 13 (17.1%) relapsed, 19 (25.0%) did not respond, and 16 (21.0%) discontinued the treatment due to side effects. The positive predictive values for SVR based on undetectable HCV RNA by COBAS TaqMan HCV test at 24 weeks after the end of treatment [10/10 (100%) at week 4, 21/23 (91.3%) at week 8 and 26/33 (78.7%) at week 12] were superior to those based on <1.7 log IU/mL HCV RNA [17/19 (89.4%) at week 4, 27/38 (71.0%) at week 8, and 27/43 (62.7%) at week 12]. The negative predictive values for SVR based on <1.7 log IU/mL HCV RNA by COBAS TaqMan HCV test [46/57 (80.7%) at week 4, 37/38 (97.3%) at week 8, and 32/33 (96.9%) at week 12] were superior to those based on undetectable HCV RNA [48/66 (72.7%) at week 4, 46/53 (86.7%) at week 8, and 41/43 (95.3%) at week 12]. The utilization of both undetectable RNA and <1.7 log IU/mL HCV RNA by COBAS TaqMan HCV test is useful and could predict SVR and non-SVR patients with greater accuracy.

[Application of the lower partial sternotomy approach to patients who may need tracheostomy in the early period after cardiac surgery]

Recent good results of cardiovascular surgery have led to expansion of its indication to elderly patients and patients with serious complications. Such patients may have serious respiratory complications after cardiac surgery and need to undergo tracheostomy relatively early in the postoperative period. Although the full sternotomy approach is the standard in almost all cardiac surgeries, superficial and deep sternal infections are rather common after early tracheostomy in full sternotomy patients. The lower partial sternotomy approach is a safer and more useful procedure in patients who will need tracheostomy in the early period after cardiac surgery. We report on 2 patients who were successfully tracheostomized within a week after cardiac surgery, with a review of the literature.

Hepatitis A virus (HAV) proteinase 3C inhibits HAV IRES-dependent translation and cleaves the polypyrimidine tract-binding protein

Hepatitis A virus (HAV) infection is still an important issue worldwide. A distinct set of viruses encode proteins that enhance viral cap-independent translation initiation driven by an internal ribosome entry site (IRES) and suppress cap-dependent host translation. Unlike cytolytic picornaviruses, replication of HAV does not cause host cell shut off, and it has been questioned whether HAV proteins interfere with its own and/or host translation. HAV proteins were coexpressed in Huh-7 cells with reporter genes whose translation was initiated by either cap-dependent or cap-independent mechanisms. Among the proteins tested, HAV proteinase 3C suppressed viral IRES-dependent translation. Furthermore, 3C cleaved the polypyrimidine tract-binding protein (PTB) whose interaction with the HAV IRES had been demonstrated previously. The combined results suggest that 3C-mediated cleavage of PTB might be involved in down-regulation of viral translation to give way to subsequent viral genome replication.

Indications for the use of endoscopic mucosal resection for early gastric cancer in Japan: a comparative study with endoscopic submucosal dissection

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) has been reported to produce excellent treatment results for early gastric cancer. In terms of lesions that previously met the criteria for endoscopic mucosal resection (EMR), there is now controversy about which of the two methods is superior, and whether the two methods are comparable.

PATIENTS AND METHODS

A total of 177 patients (202 lesions) with early gastric cancer who met the guidelines for EMR and who underwent either EMR or ESD were studied. The rates of en bloc resection, complete resection, local recurrence, and complications were compared between EMR and ESD.

RESULTS

The overall en bloc and complete resection rates were lower in patients undergoing EMR than in those undergoing ESD (en bloc: 53.8 % vs. 94.3 %, P < 0.001; complete: 37.5 % vs. 92.6 %, P < 0.001). The overall 5-year recurrence-free rate was lower in the EMR group than in the ESD group (82.5 % vs. 100 %; P < 0.001). However, with regard to the tumor size, the two groups did not differ in en bloc ( P = 1.0) or complete resection rate ( P = 0.8) for tumors < or = 5 mm and in 5-year recurrence-free rate ( P = 0.19) for tumors < or = 10 mm. The mean time required for resection was longer for ESD than for EMR ( P < 0.001). Perforation and bleeding requiring blood transfusion occurred in a small percentage in the ESD group, but in none in the EMR group.

CONCLUSION

In this study, EMR was comparable to ESD for the millimeter-sized lesions. We suggest that such small lesions might be well suited to treatment with EMR.

First Report of Leaf Rust of Blueberry Caused by Pucciniastrum vaccinii in Hawaii

Blueberries (Vaccinium corymbosum L.) are a potential high-value, niche market crop for Hawaii. In May of 2007, rust-like symptoms were observed on multiple blueberry plants in a private nursery in Waimea, HI. In September of 2007, a similar leaf rust was observed on one bush of V. corymbosum cv. Sharpblue in the corner of a 36.6 × 9.1-m experimental plot at Mealani Research Station in Waimea. Within a month, rust was observed throughout the plot on 'Biloxi', 'Emerald', 'Jewel', 'Misty', 'Sapphire', and 'Sharpblue'. Preliminary field observations suggest that 'Sharpblue' and 'Sapphire' are highly susceptible to the rust and 'Biloxi' shows some tolerance. Leaf lesions began as approximately 1-mm² chlorotic flecks that expanded and developed into reddish brown, necrotic spots with a chlorotic halo. New lesions and uredinia kept appearing over the course of 4 months. Defoliation occurred on plants where infection was severe. Yellowish orange pustules containing urediniospores first appeared on the abaxial side of older leaves and later appeared on new leaves. Urediniospores were elliptical to obovate (19.4 to 24.8 × 15.2 to 19.8 μm) with a thick, slightly roughened wall and a well-developed pore. Urediniospore morphology and dimensions were consistent with the description of Pucciniastrum vaccinii (G. Wint.) (1). A pathogenicity test was conducted with two 18-month-old 'Sharpblue' plants. Fully expanded leaves were sprayed with freshly collected urediniospores (3.8 × 10⁵ spores per ml) suspended in a 0.05% solution of Tween 20 in water. The control plant was sprayed with sterile distilled water (SDW). Plants were covered with plastic bags for 48 h and held in a growth chamber at 20 to 22°C under continuous fluorescent lighting. The plastic bags were then removed and the plants were maintained in the growth chamber. Yellowish orange pustules that were identical to the original symptoms developed on 100% of inoculated leaves after 10 days. The plant inoculated with SDW remained symptomless. While leaf rust caused by P. vaccinii has been reported on Ohelo berry (V. reticulatum) (2), it has not been reported on V. corymbosum in Hawaii. To our knowledge, this is the first report of P. vaccinii on blueberry plants in Hawaii. This rust disease may pose a threat to the potential blueberry industry in Hawaii. References: (1) P. R. Bristow and A. W. Stretch. Page 20 in: Compendium of Blueberry and Cranberry Diseases. F. L. Caruso and D. C. Ramsdell, eds. The American Phytopathological Society, St. Paul, MN, 1995. (2) D. F. Farr et al. Fungal Databases. Systematic Botany and Mycology Laboratory. Online publication. ARS, USDA, 2008.

Obstructed Coarctation in a Right Aortic Arch in an Adult Female

Coarctation of a right aortic arch is rare congenital anomaly. We report a rare case of a 24-year-old female with coarctation of the right aortic arch with aberrant left subclavian artery between the right common carotid and right subclavian arteries. The coarctation progressed into complete obstruction as the interruption of the aorta in adulthood. To prevent cerebral complications and progression to heart failure, surgical procedure was selected. Extraanatomical bypass grafting between the ascending and descending aorta was successfully performed using cardiopulmonary bypass. Some patients diagnosed with interruption of the aortic arch in adulthood might be displaying progression of undiagnosed coarctation, as our in case. Three-dimensional computed tomography was useful to detect the obstructive lesion and to determine the surgical approach and methods.

Williams syndrome associated with complete atrioventricular septal defect

Williams syndrome is a genetic disorder associated with characteristic facies, supravalvar aortic stenosis, peripheral pulmonary stenosis, mental retardation, hypertension, premature aging of skin, and congenital cardiac defects. Many cardiac defects such as bicuspid aortic valve, mitral valve regurgitation, coarctation of the aorta, and ventricular or atrial septal defects are linked to the syndrome. Complete atrioventricular septal defect has rarely been associated with Williams syndrome and only one necropsy case has been reported in the literature. The long term follow up of Williams syndrome associated with complete atrioventricular septal defect is reported. During a 10 year follow up period, the pressure gradient in the ascending aorta did not increase despite narrowing of the ascending aorta as identified on an aortogram.

A new generic column switching system for quantitation in cassette dosing using LC/MS/MS

Cassette dosing is a method in which multiple drugs are administered to a single animal at the same time, and the plasma concentrations of the individual compounds are simultaneously determined. This method enables high-throughput rapid screening for pharmacokinetic assessment of new drug candidates. An available gradient method was modified for cassette dosing analysis to attain the advantages of high sensitivity and applicability to a wide range of compounds. However, two problems arose; (1). the time-consuming optimization of mobile phases for each compound group, which limited applicability and (2). the remarkable suppression of ionization by polyethyleneglycol, which is commonly used in intravenous administration. To resolve these problems, a new column switching method was established to attain wider applicability and avoid the ionization suppression. This column switching system is very simple because the trap column and the analytical column are specified and the mobile phase is selected from only two species. Method optimization requires only the selection of the mobile phase and takes only a few hours. About 200 compounds, which were administered as about 50 cassettes, were analyzed using this column switching system. Assay validation of one cassette was carried out, and good accuracy and precision were obtained. About 90% of the compounds could be determined within 20% bias. These results showed that this new column switching system for cassette dosing is accurate enough for the screening of drug candidates and offers wide applicability for various compounds. This system was shown to be very useful for the determination of cassette dosing samples, containing multiple compounds.

hTR repressor-related gene on human chromosome 10p15.1

Somatic cells express genes that suppress telomerase activity and these genes may be inactivated in tumour cells. We postulated that cancer cells acquire immortality by activation of telomerase by the loss of such a gene. We have reported recently that a telomerase repressor gene may be located on 10p15.1 by deletion mapping using microcell-mediated chromosome transfer (MMCT), radiated microcell fusion (RMF), fluorescent in situ hybridization (FISH) and STS analysis. To independently confirm this result, we correlated expression of RNA component of telomerase (hTR) as a marker of telomerase expression by in situ hybridization with allelic loss in pulmonary carcinoid tumours. Unlike most malignant tumours, pulmonary carcinoids (which are low-grade malignant tumours) are heterogeneous for telomerase expression. Loss of 5 closely spaced polymorphic markers on 10p15.1, especially D10S1728, were highly correlated with hTR expression. In an additional experiment, 10p15.1 showed higher and more significant correlation than any region of 3p where it has been predicted as another chromosomal location of telomerase repressor with allelic loss of the region. Our findings strongly suggest that 10p15.1 harbours a gene involved in repression of telomerase RNA component in human somatic cells and each putative repressor (on 3p and 10p) may act independently.

Surgical treatment of pacemaker induced left innominate vein occlusion using a spiral vein graft

Superior vena cava syndrome due to transvenous pacing leads is an uncommon but potentially life-threatening complication. This case involves a 54-year-old man who developed left innominate vein occlusion due to a pacemaker lead. This complication induced a progressive swelling on the left side of his face, neck, arm, and upper chest. The left innominate vein occlusion was surgically treated using a composite spiral saphenous vein graft. Postoperatively, the patient has received anticoagulation therapy with warfarin to prevent thrombosis and, thereby, the long-term patency of the graft. He has undergone follow-up on a regular outpatient basis without showing any recurrence of clinical symptoms.

Disseminated cholesterol embolism after coronary artery bypass grafting

Blue toe syndrome caused by cholesterol emboli is a relatively benign disease. However, disseminated cholesterol embolism is a life-threatening condition. We describe here the case of a 71-year-old female admitted because of anterior chest pain and intermittent claudication. Following cardiac catheterization, warfarin potassium was administered. However, the patient's toes soon darkened bilaterally, and BUN and creatinine levels increased from the normal value. Skin discoloration and renal failure were improved after stopping warfarin potassium administration. The patient underwent coronary artery bypass grafting and left femoropopliteal bypass. Cerebral infarction and renal failure occurred postoperatively due to disseminated cholesterol embolism. The patient died from renal failure on the 16th postoperative day without regaining consciousness following surgery. For high risk patients, interventional procedures to the ascending aorta must be avoided. When CABG cannot be avoided for coronary revascularization, off-pump bypass and use of arterial grafts are recommended.

Pyrrolidine inhibitors of human cytosolic phospholipase A2. Part 2: synthesis of potent and crystallized 4-triphenylmethylthio derivative 'pyrrophenone'

We synthesized a potent and crystallized human cytosolic phospholipase A2alpha inhibitor, pyrrophenone (6) which inhibits the isolated enzyme with an IC50 value of 4.2 nM. Pyrrophenone shows potent inhibition of arachidonic acid release, prostaglandin E2, thromboxane B2, and leukotriene B4 formation in human whole blood. The magnitudes of prostaglandin E2 and thromboxane B2 inhibition are the same as those of indomethacin.

A case of Standford type B aortic dissection involving a right-sided aortic arch with mirror-image branching and right-sided descending aorta

Isolated right aortic arch with mirror-image branching is a rare congenital anomaly. To date, no case has been reported for aortic dissection involving a right aortic arch with mirror-image branching. We report here on a case involving a 58-year-old man in whom expanding type B aortic dissection was demonstrated in the right aortic arch with mirror-image branching and a right descending aorta. The patient was successfully treated by interposition of a prosthetic graft via a right posterolateral thoracotomy approach. We also reviewed the literature.

Age of onset, not type of onset, affects the positivity and evanescence of IA-2 antibody

Autoantibody against IA-2 (IA-2A) was found to be discordant with autoantibody against glutamic acid decarboxylase (GADA) with respect to both positivity and titer in Japanese, the same as in Caucasians. In this study, 247 type 1 diabetic patients were tested in order to clarify how the type of onset, age of onset, and duration of diabetes affect the frequency and evanescence of IA-2A. Among the young onset patients, the frequency of IA-2A was higher (52.2%), but evanescent (54.5, 66.7 and 36.7% in the insulin therapy duration < or =1, 2-5 years, and > or =6 years groups, respectively), whereas among adult onset patients, the frequency was lower (19.3%) but persistent (19.6, 13.3 and 23.5%, respectively). In addition, in the follow-up study, two of three IA-2A-positive young onset patients converted to negative in only three years, while all five adult onset patients remained positive for over 5 years. Among the adult onset patients, IA-2A frequency was similar in the slowly progressive type and the abrupt onset type. In view of the above findings, IA-2A positivity and evanescence in type 1 diabetic patients appear to be affected by age of onset, not type of onset.

Solid-pseudopapillary tumor of the pancreas: immunohistochemical localization of neuroendocrine markers and CD10

To clarify the neuroendocrine differentiation and CD10 expression in solid-pseudopapillary tumors (SPTs) of the pancreas, we performed immunohistochemical analysis in 19 such tumors, including one solid-pseudopapillary carcinoma (SPC), along with 20 pancreatic neuroendocrine tumors (PNTs), six acinar cell carcinomas (ACCs), and one pancreatoblastoma (PB). We used antisera directed against CD56, synaptophysin, protein gene product 9.5, the alpha-subunit of Go protein, chromogranin A, CD10, trypsin, chymotrypsin, various cytokeratins (CKs), CA19-9, vimentin, and alpha-1-antitrypsin (AAT). All SPTs exhibited immunoreactivity for CD56 and CD10, and 15 expressed other neuroendocrine markers focally with the exception of chromogranin A. Frequent clustering of synaptophysin-positive cells was noted. Two cases contained a peculiar nodule that cytomorphologically and immunohistochemically resembled PNT. CD10-positive cells were scarce in one SPC. PNTs were CD56-positive, but often with faint intensity, and staining for other neuroendocrine markers, including chromogranin A, was diffusely positive. CD10 was detected, mostly in a focal pattern, in five PNTs. Pan-CK, CK8, CK18, and CK19 were more frequently demonstrated in PNT than SPT. Vimentin and AAT were often identified in PNT as well and were not specific for SPT. ACCs were CD56-negative, with the exception of one case designated as a mixed acinar-endocrine carcinoma. PB was focally positive for CD56 at the periphery of the tumor nests. Four ACCs and one PB exhibited focal CD10 reactivity. This study demonstrated the unique immunohistochemical features of SPT. Our results also suggest that SPT exhibits, at least focally, neuroendocrine differentiation, and that these neuroendocrine markers and CD10 are diagnostically useful.

Intraoperative radiotherapy and bypass surgery for unresectable pancreatic cancer

BACKGROUND/AIMS

Conflicting results have been reported concerning the usefulness of radiotherapy for unresectable pancreatic cancer. We evaluated the clinical efficacy of intraoperative radiotherapy and/or external beam radiotherapy in combination with bypass surgery.

METHODOLOGY

Twenty-six patients with unresectable pancreatic cancer (16 in Stage II-III and 10 in Stage IV) were treated with intraoperative radiotherapy plus external beam radiotherapy (16 patients) or intraoperative radiotherapy alone (10 patients). The dose of intraoperative radiotherapy was either 25 or 30 Gy and the external beam radiotherapy dose was 31-60 Gy. The feasibility and clinical outcome were analyzed.

RESULTS

The median survival time for Stage II-III and Stage IV were 11.5 and 6.5 months, respectively. The difference between Stage II-III and Stage IV in survival patterns was statistically significant (P < 0.05). For Stage II-III patients, the survival curves between the groups of intraoperative radiotherapy plus external beam radiotherapy and intraoperative radiotherapy alone were not significantly different, and only performance status was a significant factor in the prognosis (P < 0.05). Gastrointestinal bleeding was noted in 8%, but did not occur in the patients treated with an external beam radiotherapy dose less than 50 Gy. Palliative radiation was successfully performed to relieve pain, jaundice and appetite-loss and to shorten the hospital stay.

CONCLUSIONS

The combination therapy with intraoperative radiotherapy and bypass surgery is considered to be tolerable and effective for unresectable pancreatic cancer, and also may improve the quality of life of the patients.

Epithelioid trophoblastic tumor: morphological and immunohistochemical study of three lung lesions

Epithelioid trophoblastic tumor (ETT) is a term proposed for an unusual variant of trophoblastic tumor that is closely related to choriocarcinoma but shows monomorphic growth of highly atypical trophoblastic cells instead of the typical dimorphic pattern of choriocarcinoma. We report here 3 cases of ETT, all of which were lung lesions probably originating from uterine trophoblastic disease. The antecedent pregnancies of the 3 cases were hydatidiform mole, invasive mole, and term pregnancy, respectively. The tumors were composed of highly atypical mononucleate cells, which mainly involved alveolar spaces, forming nests with central eosinophilic necrosis. Multinucleate giant cells were found within the nests, but they were fewer in number than in typical choriocarcinoma. The tumors were not associated with extensive hemorrhage or necrosis, except for 1 case, in which the ETT was combined with typical dimorphic choriocarcinoma. Immunohistochemically, multinucleate giant cells and occasional mononucleate tumor cells showed positivity for human chorionic gonadotropin. Staining for human placental lactogen was positive in rare multinucleate giant cells, and in 1 case, tumor cells showed diffuse positivity for placental alkaline phosphatase. Because ETT has a remarkably epithelioid appearance in cytological and architectural features, differentiation from the epithelial malignancies is problematic. Trophoblastic markers are frequently expressed in nontrophoblastic tumors, and reactivity for those markers alone is not sufficient for exclusion of other tumors. Rather, evidence of ETT comes from a combination of morphological features, immunohistochemical study, and clinical history.

[Moderate aplastic anemia associated with Crohn's disease during antithymocyte globulin treatment]

A 53-year-old woman with moderate aplastic anemia (AA) was treated with antithymocyte globulin (ATG). However, on the 4th day of treatment, ATG was discontinued because of bloody vomiting and melena. The patient improved with conservative treatment but complained of abdominal pain when the prednisolone (PSL) dose was decreased. Crohn's disease was finally diagnosed on the basis of upper and lower gastrointestinal X-ray studies. The patient responded well to ATG with hematologic improvement, and maintained remission with low-dose PSL and nutritional support. Drug-induced AA may occur during treatment for Crohn's diseases. The association of AA and Crohn's disease is rare, and to our knowledge, has not yet been reported in the literature. We discussed the pathogenesis of Crohn's disease during immunotherapy for AA.

Refractoriness to platelet transfusion following double valve replacement in an ITP patient who had undergone splenectomy

Reports of patients with idiopathic thrombocytopenic purpura (ITP) undergoing cardiac surgery are rare, and almost all of the reported cases required platelet transfusion. ITP patients, especially those having a history of splenectomy or a history of heavy bleeding, may have to undergo multiple platelet transfusions. Such transfusions may induce alloimmunization against the human leukocyte antigen (HLA) and result in refractoriness to subsequent platelet transfusions. We report a case of a 63-year-old female with ITP, with a history of splenectomy and multiple platelet transfusions, who underwent aortic and mitral valve replacement. Although corticosteroid administration, high-dose immunoglobulin therapy, and repeated platelet transfusion led to a temporary increase in platelet count and successful hemostasis, refractoriness to platelet transfusion occurred postoperatively because of the presence of the anti-HLA antibody. In addition, the patient showed complications of pyothorax. Corticosteroids might have exerted an inhibitory influence on the occurrence of pyothorax.

High-titer autoantibodies against glutamic acid decarboxylase plus autoantibodies against insulin and IA-2 predicts insulin requirement in adult diabetic patients

Antibodies against glutamic acid decarboxylase (GADA) is known to be a good predictive marker for insulin-dependency among adult diabetic patients. However, since not all of the GADA-positive patients will develop insulin requirement, we investigated whether other markers, that is, antibodies against IA-2 (IA-2A), insulin autoantibodies (IAA) and HLA class II type, would affect its predictive value for insulin requirement. Adult diabetic patients in the non-insulin-requiring stage were screened for GADA and registered in the study if positive. At the end of the follow-up period, 15 of the 43 GADA-positive patients required insulin. Among GADA-positive patients, the GADA titers of the insulin-requiring patients were significantly higher (199 U vs. 5.8 U, P<0.001) and high-titer GADA was more frequently detected among insulin-requiring patients (80%vs. 11%, P<0.0001). IAA was more frequently detected in insulin-requiring patients (40%vs. 0%, P<0.001), and IA-2A was detected only among insulin-requiring patients. Combinations of these three antibodies (GADA with either IAA or IA-2A) had 100% positive predictive value. In conclusion, the GADA test is a good screening test for predicting insulin requirement in adult diabetic patients and both the IAA and IA-2A tests are useful second line tests.

Novel TSC2 mutation in a patient with pulmonary tuberous sclerosis: lack of loss of heterozygosity in a lung cyst

A Japanese patient with tuberous sclerosis (TSC), who manifested with multiple lung cysts and pneumothorax, is described. All exons of two TSC genes, TSC1 and TSC2, in peripheral blood leukocytes from the patient were analyzed by polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP). A novel T-to-G transition was found in exon 19 of TSC2 at nucleotide position 2168. This mutation caused an amino acid change, L717R. There was no such mutation in any other family members or in 100 normal Japanese. An automated sequencer-assisted quantitative analysis of normal and mutated SSCP-bands revealed no loss of heterozygosity (LOH) in the lung cyst tissue of the patient.

Post-sternotomy mediastinitis following coronary bypass grafting treated by supra-sternal omental transfer without sternal closure

Sternal infections and mediastinitis following coronary bypass grafting are rare, but the treatment for infection remains difficult and the mortality of these complications is reported high. We reviewed our experiences in treating two patients in whom post-sternotomy mediastinitis had developed after coronary bypass grafting. Sternal infections and mediastinitis were treated with debridement of the infected sternum, supra-sternal omental transfer with an open sternal technique, and a primary skin closure.

Promotion of chlamydoconidium formation in Candida albicans by corn meal broth incubation

Chlamydoconidium formation can be used as a tool for the identification of Candida albicans. While chlamydoconidia are known to be inducible on corn meal agar, this report demonstrates that testing in liquid media supplemented with milk or serum enhances chlamydoconidium formation and the formation of complex mycelial clusters.

[The left ventriculectomy (Batista procedure) in a patient of the dilated cardiomyopathy: a report of the first successful case in Japan]

We presented a case of 18-year-old male with dilated cardiomyopathy undergoing surgical left ventricular volume reduction (Batista procedure). He seemed to be the first successful survivor after the procedure in Japan. In the follow up study, cardiac function and clinical status of the patient have been moderately improved. Batista procedure seems to be an attractive choice to treat end-stage heart failure in Japan where the option of treatment for this particular situation is limited.

Effect of insulin therapy on body fat distribution in NIDDM patients with secondary sulfonylurea failure: a preliminary report

OBJECTIVE

To clarify the influence of insulin therapy on body weight and fat distribution, we compared these parameters in five non-insulin dependent diabetes mellitus (NIDDM) patients, with secondary sulfonylurea failure, before and after insulin therapy. Body weight increased significantly after instituting insulin treatment. However, the visceral to subcutaneous fat (V/S) ratio decreased significantly due to a marked increase in S-fat without a change in V-fat. Insulin therapy necessitated by sulfonylurea failure does not appear to accelerate the atherogenic process in NIDDM patients as there is no increase in visceral fat.

Single lead atrial synchronous ventricular pacing in Japanese patients with complete atrioventricular block

The purpose of this study was to review our experience with atrial synchronous ventricular pacing devices (THERA VDD pacing systems, Medtronic, Inc., U.S.A.) using single atrioventricular leads in Japanese patients with complete atrioventricular block and normal sinus function. Twenty patients with a mean age of 55 +/- 13 years underwent implantation of VDD pacemakers. At implantation the amplitude of atrial signals in the supine position during normal breathing, which was measured directly using an external pacing system analyzer, ranged from 1.8 to 5.8 mV with a mean amplitude of 3.4 +/- 1.4 mV. Atrial amplitudes did not change during deep breathing (3.3 +/- 1.1 mV) or in the semi-Fowler position (3.4 +/- 1.6 mV). Atrial oversensing or undersensing was not observed in any of the patients. During a follow-up period, the percentage of atrial synchronization was >95% in 19 patients, and none of the patients had pacemaker related tachycardia or pacemaker related complications. These results were promising enough to warrant the extension of the clinical use of the VDD pacemaker.

Effect of allergen immunotherapy on nasal responses in guinea-pigs with allergic rhinitis

METHODS

We have investigated the effects of allergen immunotherapy on the nasal responses in the guinea-pigs with allergic rhinitis. Thirty-three male Hartley guinea-pigs with allergic rhinitis were divided into three groups; those receiving intradermal injection of saline (Group 1) or 0.1% ovalbumin (Group 2) 6 days after the last intranasal sensitization, and those injected with 0.1% ovalbumin intradermally once daily for 6 consecutive days from the next day after the last intranasal sensitization (Group 3).

RESULTS

The dye leakage and histamine content into the nasal lavage significantly decreased at 30 min after antigen challenge in Group 3, compared with Group 1 or 2. We also observed the change of mast cell numbers in superficial nasal mucosa, lamina propria and injected dorsal skin. The number of mast cells in superficial nasal mucosa significantly decreased in Group 3 compared with Group 1 or 2, but not those in nasal lamina propria or dorsal skin.

CONCLUSIONS

These results suggest that the improvements of nasal responses such as dye leakage and histamine content may be caused by the decrease of mast cell numbers in the superficial mucosal layer after the specific immunotherapy, which may be developing tolerance and one of the mechanisms underlying the beneficial effect of immunotherapy.

Evaluation of nasal passage patency after antigen and histamine challenge in guinea pigs by acoustic rhinometry

We investigated the effects of antigen and histamine on the nasal passage patency in guinea pigs with or without nasal allergy. The change of nasal patency was measured by acoustic rhinometry and nasal airway resistance. Acoustic reflections have been used in adult humans to determine nasal cavity dimensions in terms of cross-sectional areas as a function of the distance from the nostril. In order to measure nasal cavity dimensions in guinea pigs, we modified equipment for use in humans by decreasing sound tube dimensions, increasing sampling frequency, and applying a special nosepiece. The percent change of volume, minimum cross-sectional area, and nasal airway resistance showed the largest changes at 10 minutes after antigen challenge in sensitized guinea pigs. There was a significant correlation between the individual percent change of nasal airway resistance and volume or minimum cross-sectional area. Histamine, 10(2) to 10(5) micrograms/mL, caused a dose-dependent reduction in percent change of volume in the challenged side of nonsensitized guinea pigs, but not in the opposite side. These results indicate that the noninvasive acoustic reflections technique is useful in small experimental animals, especially to assess the effect of nasal cavity dimensions after the challenge of antigen or nonspecific stimuli.

[Intracranial hypertension in a patient with acute promyelocytic leukemia treated with all-trans retinoic acid]

A 21-year-old Japanese woman was referred to our hospital because of severe anemia and thrombocytopenia. Bone marrow aspiration showed a hypercellular marrow with 91.5% promyelocytes. Cytochemical study and surface marker a diagnosis of acute promyelocytic leukemia. Because leukocyte count elevated, she was treated with all-trans retinoic acid (ATRA) after conventional chemotherapy. After 11 days of ATRA therapy, the patient started to develop severe headache, nausea and diplopia. Ophthalmologic examination revealed bilateral papilledema. Computed tomography and magnetic resonance imaging of the head showed no intracranial lesion. ATRA was discontinued because it was suspected to cause intracranial hypertension. Her symptoms were relieved and patilledema improved gradually. ATRA is safe and well-tolerated, if the retinoic acid syndrome can be prevented or managed. As the tolerable dose of ATRA in adults is higher than that in children, the side effects tend to occur in children. In Japan, only two childhood cases of intracranial hypertension during ATRA therapy have been reported. We must remember the possibility of intracranial hypertension during ATRA therapy, even in adults.

Two-directional aortic annular enlargement for aortic valve replacement in the small aortic annulus

We have encountered 3 patients with a small aortic annulus for whom the conventional posterior enlargement alone was not extensive enough to implant an artificial valve of acceptable size. Therefore, we performed two-directional enlargement, which is a combination of posterior and anterior enlargement. First, the posterior enlargement was done, and then an additional aortotomy was made anteriorly and extended to the ventricular septum. The aortic annulus was enlarged by 68% after the two-directional enlargement. At a follow-up of 31 months, the patients' functional status was New York Heart Association class I.

Effects of aminoguanidine on serum advanced glycation endproducts, urinary albilmin excretion, mesangial expansion, and glomerular basement membrane thickening in Otsuka Long-Evans Tokushima fatty rats

This study evaluated the effects of treatment with an inhibitor of advanced glycation endproducts, aminoguanidine, on the development of albuminuria, mesangial expansion and glomerular basement membrane (GBM) thickening in Otsuka Long-Evans Tokushima Fatty (OLETF) rats, which we found to be an excellent model of non insulin-dependent diabetes mellitus (NIDDM), for its very close similarity to human NIDDM. OLETF rats were randomized into a non-treatment diabetic group (D-group, n = 5) and an aminoguanidine-treated group (AG-group, n = 5). The AG-group was given 100 mg/dl aminoguanidine HCl in free drinking water. Treatment was started at 16 weeks of age. We measured body weight, plasma glucose, total cholesterol, triglycerides and the urinary albumin excretion (UAE) rate before and after treatment at regular intervals. At 56 weeks of age, we measured serum advanced glycation endproducts (AGE), mesangial expansion and glomerular basement membrane. There were no significant differences in pre-treatment body weight, plasma glucose and UAE between the D-group and the AG-group. Likewise, after treatment there were no significant differences in body weight, plasma glucose, total cholesterol, triglycerides and immunoreactive insulin. Significant differences were, however, noted in serum AGE (63.2 +/- 3.5 and 51.8 +/- 3.0 U AGE/ml, P < 0.05), UAE (203.6 +/- 37.7 and 89.8 +/- 18.6 mg/day, P < 0.05), fractional mesangial volume (21.3 +/- 1.7 and 16.7 +/- 0.8%, P < 0.05) and GBM thickness (453 +/- 17 and 366 +/- 50 nm, P < 0.05) between the D-group and the AG-group. Our results suggest that aminoguanidine inhibits the AGE formation and the development of diabetic nephropathy in OLETF rats.