The use of angiotensin receptor blockers is associated with greater recovery of cardiac function than angiotensin-converting-enzyme inhibitors among patients with dilated cardiomyopathy

Background

We previously showed that angiotensin-converting-enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) were associated with heart failure with recovered ejection fraction (HFrecEF) in patients with dilated cardiomyopathy (DCM). However, the different effects of these drugs on cardiac reverse remodeling have not been fully elucidated. The aim of this study was to assess comparative effectiveness of ACEi versus ARB on recovery of left ventricular ejection fraction (LVEF) among patients with DCM.

Methods

We analyzed the clinical personal records of DCM, a national database of Japanese Ministry of Health, Labour and Welfare, from 2003 to 2014. Patients with LVEF <40% and on either ACEi or ARB were included. Eligible patients were divided into two groups according to the use of ACEi or ARB. A one-to-one propensity case-matched analysis was used. A propensity score was estimated by fitting a logistic-regression model which adjusted for age, sex, duration of HF, NYHA functional class (I-II vs. III-IV), systolic blood pressure, diastolic blood pressure, heart rate, atrial fibrillation, pacing, left bundle branch block, LVEF, hypertension, diabetes mellitus, hyperuricemia, chronic kidney disease, B-type natriuretic peptide (BNP), beta-blockers, mineralocorticoid receptor antagonists, loop diuretics, thiazides, digitalis, amiodarone, and oral inotropes. The primary outcome was defined as LVEF ≥40% at 3 years of follow-up.

Results

Out of 4,618 eligible patients, 2,238 patients received ACEi and 2,380 patients received ARB. Propensity score matching yielded 1,341 pairs. Mean age was 56.0 years and 2,041 (76.1%) was male. Mean LVEF was 27.6%, and median duration of HF was 1 year. The primary outcome was observed more frequently in ARB group than in ACEi group (59.8% vs. 54.1%; odds ratio [OR] 1.26; 95% confidence interval [CI] 1.08–1.47; P=0.003). The change in LVEF from baseline to 3 years of follow-up was greater in ARB group than in ACEi group (15.8±0.4 vs. 14.0±0.4%, P=0.002). In the ACEi group, 946 patients (70.6%) continued to receive ACEi at 3 years of follow-up, while 1,088 patients (81.3%) continued to receive ARB in the ARB group. Per-protocol analysis consistently showed that ARB increased the prevalence of HFrecEF (62.0% vs. 54.0%; OR 1.39; 95% CI 1.17–1.66; P<0.001). Subgroup analysis showed that ARB increased frequency of HFrecEF regardless systolic blood pressure, heart rate, LVEF, chronic kidney disease, and concomitant use of beta-blockers and mineralocorticoid receptor antagonists.

Conclusions

The use of ARB was associated with HFrecEF more frequently than ACEi among patients with DCM and reduced LVEF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Health Sciences Research Grants from the Japanese Ministry of Health, Labour and Welfare (Comprehensive Research on Cardiovascular Diseases)Japan Agency for Medical Research and Development (AMED) grant

The nationwide registry of hospitalized heart failure patients in Japan: Japanese Registry Of Acute Decompensated Heart Failure (JROADHF)

Background and aim

Heart failure (HF) is a growing healthcare problem worldwide. This study aimed to describe clinical characteristics and long-term outcomes of HF patients in Japan.

Methods and results

JROADHF (the Japanese Registry Of Acute Decompensated Heart Failure) is a retrospective, multicentre, nationwide observational database of 13,238 patients hospitalized due to HF in 128 hospitals randomly selected from Japanese Circulation Society (JCS)-certified teaching hospitals during 2013. At inclusion, demographic and clinical data were collected from medical records with linkage to a nationwide claim-based database, the Japanese Diagnosis Procedure Combination (DPC). Patients were followed up to 5 years after discharge at each participating site. Patients were old as the median age of 81 years and women were older (74.8±12.8 vs 81.6±11.1 y.o). Mean left ventricular ejection fraction (LVEF) was 47%, and 45% were HF with preserved ejection fraction of >50% (HFpEF). Causes of HF included ischemic in 27%, valvular in 19%, arrhythmia in 17%, and hypertensive in 16%. Median length of hospital stay was 18 days and in-hospital mortality was 7.7%. All-cause mortality during 1 and 4 years were 22.3% and 48.4%, respectively. Hospitalization rates due to HF within 1 and 4 years were as high as 30.5 and 48.4%, respectively.

Conclusions

Contemporary nationwide registry revealed that hospitalized HF patients were elder and had more HFpEF, and their prognosis was still poor compared to the data shown in prior registries.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical Research and Development (AMED) Practical Research Project for Life-Style related Diseases including Cardiovascular Diseases and Diabetes Mellitus

Use of direct oral anticoagulants is associated with better long-term outcomes in patients with atrial fibrillation and heart failure as compared with vitamin K antagonists

Background

Direct oral anticoagulants (DOACs) have been shown to be safe and effective in patients with atrial fibrillation (AF) as compared with warfarin, a vitamin K antagonist. However, the safety and efficacy of DOACs in patients with AF and heart failure (HF) have been unclear.

Purpose

The purpose of this study was to determine whether DOACs can improve long-term outcomes in patients with AF and HF as compared with warfarin.

Methods

We analyzed the JROADHF registry, which was a multicenter registry of patients hospitalized for the worsening HF in Japan. Baseline data were collected during the episode of index hospitalization from April 2013 to March 2014. Follow-up data were collected up to 4.5 years after the index hospitalization. Patients with AF and creatinine clearance ≥15 ml/min/1.73m2 were included. Valvular heart disease, congenital heart disease, and constrictive pericarditis were excluded. Eligible patients were divided into two groups according to the use of warfarin or DOACs. The primary outcome was defined as all-cause death. The secondary outcomes were defined as cardiovascular death, composite of all-cause death or cardiovascular hospitalization, and composite of stroke death or stroke related hospitalization. A one to one propensity case-matched analysis was used. Complete case analysis and multiple imputation analysis were also conducted as sensitivity analyses.

Results

Out of the 14,847 patients in this registry, 2,175 had AF, creatinine clearance ≥15 ml/min/1.73m2 and discharged alive. Propensity score matching yielded 475 pairs. In matching cohort, mean age was 76.5 years and 513 (54.0%) was male. Mean left ventricular ejection fraction was 48.6±16.4%. During a mean follow-up of 3.2 years, patients with DOACs had a lower incidence rate of all-cause death than those with warfarin (75.2 vs. 99.9 death per 1000 patient-years; rate ratio (RR) 0.75; 95% confidence interval [CI] 0.59–0.96; P=0.022). The incidence of cardiovascular death tended to be lower in DOAC group (30.9 vs. 43.1; incidence rate ratio 0.72; 95% CI 0.49–1.04; P=0.081). There were no significant differences in the incidence of composite of all cause death or cardiovascular hospitalization (252.3 vs. 269.4; RR 0.94; 95% CI 0.79–1.11; P=0.45) or composite of stroke death or stroke related hospitalization (13.1 vs. 16.7; RR 0.79; 95% CI 0.39–1.59; P=0.50). Cox regression model showed that DOAC was associated with lower mortality than warfarin (hazard ratio (HR) 0.75; 95% CI 0.59–0.96; P=0.023). Complete case analysis (HR 0.78; 95% CI 0.63–0.98; P=0.035) and multiple imputation analysis (HR 0.78; 95% CI 0.68–0.84; P<0.001) also showed the same results. A restricted cubic spline analysis demonstrated that the effectiveness of DOACs over warfarin waned with age, and DOACs were effective in patients younger than 80 years old.

Conclusion

Use of DOACs was associated with better long-term outcome in patients with HF as compared with warfarin.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical Research and Development

Artificial intelligence-based analysis of payment system data can predict one-year mortality of hospitalized patients with heart failure

Background

Individual risk stratification is fundamental in the care of heart failure (HF) patients. However, the prediction performance of risk scores, such as MAGGIC and SHFM, is not adequate and, more importantly, they need additional predictors including various biomarkers, imaging data, and environmental factors. Data from a case-mix payment system including diagnosis and procedures with outcomes can be used to develop the risk prediction models, allowing the use of big data for a more accurate prediction of mortality.

Purpose

This study aimed to develop artificial intelligence (AI) models for predicting 1-year mortality in patients hospitalized due to HF.

Methods

We analyzed the data from 10175 patients enrolled in the Japanese Registry Of Acute Decompensated Heart Failure (JROADHF). Candidate variables included the data obtained from a payment system introduced by the Japanese government, the Diagnosis Procedure Combination (DPC), which included each patient profile (age, sex, height, weight), principal diagnosis for hospitalization, comorbidities, procedures, length of hospital stay, and discharge status. They did not include clinical data available from patients such as vital status, laboratory data including bio-makers, electrocardiographic and echocardiographic data. The collected data were divided into the training set and the validation set (80%: 20%). With the training set, 5 AI models (logistic regression, random forest, support vector machine, neural network, and ensemble classifier) learned the one-year mortality results. AI models were evaluated by using the validation set with ROC analysis. The training and validation steps were repeated 10 times with different seed values to calculate the C-statistic of each model. We also identified the predictors for one-year prognosis acquired from the AI models.

Results

At 1-year of follow-up, a total of 1727 patients had died (17%). Among the machine learning models, the ensemble classifier showed the highest C-statistic of 0.76 (95% confidence interval: 0.75 to 0.77) for predicting mortality. Top predictors acquired from the random forest classifier was ADL (Barthel Index) at discharge, age, body mass index, and length of hospital stay.

Conclusion

By using AI-based analysis of a national case-mix payment system data, the present risk stratification model could predict the one-year mortality of hospitalized HF patients without any quantitative laboratory and physiological data. Furthermore, the present results could emphasize the advantage of this approach using the claim-based data that are routinely collected in a usual daily practice with no need to collect any additional information.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical Research and Development

Doublon-holon pairing mechanism via exchange interaction in two-dimensional cuprate Mott insulators

Coupling of charge and spin degrees of freedom is a critical feature of correlated electron oxides, as represented by the spin-related mechanism of a Cooper pair under high-T _c superconductivity. A doublon-holon pair generated on an antiferromagnetic spin background is also predicted to attract each other via the spin-spin interaction J, similar to a Cooper pair, while its evidence is difficult to obtain experimentally. Here, we investigate such an excitonic effect by electroreflectance spectroscopy using terahertz electric field pulses in undoped cuprates: Nd₂CuO₄, Sr₂CuO₂Cl₂, and La₂CuO₄. Analyses of the spectral changes of reflectivity under electric fields reveal that the splitting of odd-parity and even-parity excitons, a measure of doublon-holon binding energy, increases with J. This trend is reproduced by t-J-type model calculations, providing strong evidence of the spin-related doublon-holon pairing. Agreement with the calculations supports the s-wave symmetry of the doublon-holon pair in contrast to the d-wave Cooper pair in doped cuprates.

Point nodes persisting far beyond Tc in Bi2212

In contrast to a complex feature of antinodal state, suffering from competing orders, the pairing gap of cuprates is obtained in the nodal region, which therefore holds the key to the superconducting mechanism. One of the biggest question is whether the point nodal state as a hallmark of d-wave pairing collapses at T_c like the BCS-type superconductors, or it instead survives above T_c turning into the preformed pair state. A difficulty in this issue comes from the small magnitude of the nodal gap, which has been preventing experimentalists from solving it. Here we use a laser ARPES capable of ultrahigh-energy resolution, and detect the point nodes surviving far beyond T_c in Bi2212. By tracking the temperature evolution of spectra, we reveal that the superconductivity occurs when the pair-breaking rate is suppressed smaller than the single-particle scattering rate on cooling, which governs the value of T_c in cuprates.

The pairing gap of the high-T_c cuprates has been expected to close at the transition temperature, similarly to the case of conventional superconductors. Here the authors perform ARPES measurements on Bi2212, and reveal a point nodal gap formation beyond T_c, characterized in terms of three parameters.

Kondo resonance from p-wave hybridization in graphene

The p-wave hybridization in graphene present a distinct class of Kondo problem in pseudogap Fermi systems with bath density of states (DOS) ρ₀(ε) ∝ |ε|. The peculiar geometry of substitutional and hollow-site ad-atoms, and effectively the vacancies allow for a p-wave form of momentum dependence in the hybridization of the associated local orbital with the Dirac fermions of the graphene host which results in a different picture than the s-wave momentum independent hybridization. For the p-wave hybridization function, away from the Dirac point we find closed-form formulae for the Kondo temperature TK which in contrast to the s-wave case is non-zero for any value of hybridization strength V of the single impurity Anderson model (SIAM). At the Dirac point where the DOS vanishes, we find a conceivably small value of Vmin above which the Kondo screening takes place even in the presence of particle-hole symmetry. We also show that the non-Lorentzian line shape of the local spectrum arising from anomalous hybridization function leads to much larger TK in vacant graphene compared to a metallic host with similar bandwidth and SIAM parameters.

High-energy spin and charge excitations in electron-doped copper oxide superconductors

The evolution of electronic (spin and charge) excitations upon carrier doping is an extremely important issue in superconducting layered cuprates and the knowledge of its asymmetry between electron- and hole-dopings is still fragmentary. Here we combine X-ray and neutron inelastic scattering measurements to track the doping dependence of both spin and charge excitations in electron-doped materials. Copper L3 resonant inelastic X-ray scattering spectra show that magnetic excitations shift to higher energy upon doping. Their dispersion becomes steeper near the magnetic zone centre and they deeply mix with charge excitations, indicating that electrons acquire a highly itinerant character in the doped metallic state. Moreover, above the magnetic excitations, an additional dispersing feature is observed near the Γ-point, and we ascribe it to particle-hole charge excitations. These properties are in stark contrast with the more localized spin excitations (paramagnons) recently observed in hole-doped compounds even at high doping levels.

Quantum dynamics of a driven correlated system coupled to phonons

Nonequilibrium interplay between charge, spin, and lattice degrees of freedom on a square lattice is studied for a single charge carrier doped in the t-J-Holstein model. In the presence of a static electric field we calculate the quasistationary state. With increasing electron-phonon (e-ph) coupling the carrier mobility decreases; however, we find increased steady state current due to e-ph coupling in the regime of negative differential resistance. We explore the distribution of absorbed energy between the spin and the phonon subsystem. For model parameters as relevant for cuprates, the majority of the gained energy flows into the spin subsystem.

Modeling the antiferromagnetic phase in iron pnictides: weakly ordered state

We examine electronic states of antiferromagnetic phase in iron pnictides by mean-field calculations of the optical conductivity. We find that a five-band model exhibiting a small magnetic moment, inconsistent with the first-principles calculations, reproduces well the excitation spectra characterized by a multipeak structure emerging below the Néel temperature at low energy, together with an almost temperature-independent structure at high energy. Investigating the interlayer magnetoresistance for this model, we also predict its characteristic field dependence reflecting the Fermi surface.

Bipolaron in the t-J model coupled to longitudinal and transverse quantum lattice vibrations

We explore the influence of two different polarizations of quantum oxygen vibrations on the spacial symmetry of the bound magnetic bipolaron in the context of the t-J model by using exact diagonalization within a limited functional space. Linear as well as quadratic electron-phonon coupling to transverse polarization stabilize d-wave symmetry. The existence of a magnetic background is essential for the formation of a d-wave bipolaron state. With increasing linear electron-phonon coupling to longitudinal polarization the symmetry of a d-wave bipolaron state changes to a p wave. Bipolaron develops a large anisotropic effective mass.

Temperature and doping dependence of the high-energy kink in cuprates

It is shown that spectral functions within the extended t-J model, evaluated using the finite-temperature diagonalization of small clusters, exhibit the high-energy kink in single-particle dispersion consistent with recent angle-resolved photoemission results on hole-doped cuprates. The kink and waterfall-like features persist up to large doping and to temperatures beyond J; hence, the origin can be generally attributed to strong correlations and incoherent hole propagation at large binding energies. In contrast, our analysis predicts that electron-doped cuprates do not exhibit these phenomena in photoemission.

Late flare-up of nephrotic lupus nephritis transforming histological pattern and autoantibody reactions

A 15-year-old boy developed a nephrotic syndrome. At that time, autoantibodies related to systemic lupus erythematosus (SLE) had been persistently negative, even on repeated evaluation. C1q was normal, but C4, C3 and CH50 were low. Renal biopsy revealed membranous lupus nephritis (LN) based on the new classification of glomerulonephritis in SLE [Weenig et al. 2004]. We did not establish our diagnosis of SLE on the criteria of the American Rheumatism Association (ARA). The patient showed complete remission ofnephrotic syndrome treated with prednisolone and cyclophosphamide. Thereafter, he had no proteinuria and clinical evidence of SLE for 22 years. At the age of 37, however, he developed facial discoid eruption, proteinuria in the nephrotic range, hypocomplementemia and positive reaction to autoantibodies of SLE. Light microscopic findings of renal biopsy indicated mesangial LN, which showed "full-house" immunofluorescence and mesangial dense deposits associated with diffuse epithelial cell foot process effacement in electron microscopy. Steroid therapy was very effective. This case initially showed autoantibody-negative and hypocomplementemic LN with membranous type, and transformed to SLE with mesangial LN after a long interval.

Momentum dependence of charge excitations in the electron-doped superconductor Nd1.85 Ce0.15 CuO4: a resonant inelastic x-ray scattering study

We report a resonant inelastic x-ray scattering (RIXS) study of charge excitations in the electron-doped high-T(c) superconductor Nd1.85 Ce0.15 CuO4. The intraband and interband excitations across the Fermi energy are separated for the first time by tuning the experimental conditions properly to measure charge excitations at low energy. A dispersion relation with q-dependent width emerges clearly in the intraband excitation, while the intensity of the interband excitation is concentrated around 2 eV near the zone center. The experimental results are consistent with theoretical calculation of the RIXS spectra based on the Hubbard model.

Mott gap excitations in twin-free YBa2Cu3O7-delta (Tc=93 K) studied by resonant inelastic x-ray scattering

Mott gap excitations in the optimally doped high-T(c) superconductor YBa(2)Cu(3)O(7-delta) (T(c)=93 K) have been studied by the resonant inelastic x-ray scattering method. Anisotropic spectra in the ab plane are observed in a twin-free crystal. The excitation from the one-dimensional CuO chain is enhanced at 2 eV near the zone boundary of the b* direction, while the excitation from the CuO2 plane is broad at 1.5-4 eV and almost independent of the momentum transfer. Theoretical calculations based on the one-dimensional and two-dimensional Hubbard model reproduces the observed spectra when different values of the on-site Coulomb energy are assumed. The Mott gap of the CuO chain site is found to be much smaller than that of the CuO2 plane site.

Resonant two-magnon Raman scattering and photoexcited States in two-dimensional mott insulators

We investigate the resonant two-magnon Raman scattering in two-dimensional (2D) Mott insulators by using a half-filled 2D Hubbard model in the strong coupling limit. By performing numerical diagonalization calculations for small clusters, we find that the Raman intensity is enhanced when the incoming photon energy is not near the optical absorption edge but well above it, being consistent with experimental data. The absence of resonance near the gap edge is associated with the presence of background spins, while photoexcited states for resonance are found to be characterized by the charge degree of freedom. The resonance mechanism is different from those proposed previously.

Development of a cryopreservation procedure employing a freezer bag for pancreatic islets using a newly developed cryoprotectant

One of the most important requirements for success in clinical islet transplantation is the use of a large number of viable donor islets. To achieve this, the ability to cryopreserve islets and to establish an islet bank are critical. Previously, we developed a two-step cryopreservation procedure with freezing tubes utilizing low and high concentrations of dimethyl sulfoxide (DMSO) and using a fully automated cryomachine for human pancreatic islets and porcine islet-like cell clusters (ICCs). Based on these experiments, we developed a simple and efficient cryopreservation procedure of a freezer bag for isolated islets using a fully automated computer-controlled cryomachine with a newly developed cryoprotectant consisting of ethylene glycol (EG) instead of DMSO for decreasing injury of the islets by freezing. A 250 ml Cryocyte blood freezer bag and our newly developed cryoprotectant containing ethylene glycol (EG) were used in the freezing procedure. The islets were frozen by a fully automated computer-controlled cryomachine (GE 9,000) with our original program of slow cooling. Nucleation occurred at -8 degrees C, and the frozen islets were stored at -196 degrees C in a liquid nitrogen tank. The frozen-stored islets were subsequently rapidly thawed in a 37 degrees C water bath and cultured before viability testing. In vitro function, the stimulation index of insulin release during the static incubation test for rat islets cryopreserved in a freezer bag vs. nonfrozen islets as control, was 2.13 +/- 0.42 and 2.02 +/- 0.38 (94.8% compared with control), respectively (n = 5, p = NS). The islet recovery compared with the nonfrozen control group was 85% (n = 5) in insulin content. When 1000 rat islets cryopreserved in a freezer bag were transplanted into the renal capsule of diabetic athymic mice, all the mice became normoglycemic within 7 days from transplantation. Before nephrectomy, the intravenous glucose torelance test (IVGTT) was performed. The fractional decay constant of the glucose level (K value) of the frozen-thawed group was 0.42 +/- 0.06%/min. A histological study of renal subcapsular grafts demonstrated the morphological integrity of the islets. These results demonstrate the utility of our cryopreservation procedure of a freezer bag for isolated islets using a fully automated computer-controlled cryomachine with a newly developed cryoprotectant for the maintenance of viability and function of frozen-stored islets both in culture and after transplantation. Cryopreservation using freezer bags with the new cryoprotectant is an effective and simple method for making an islet bank for clinical trials of islet transplantation.

Large third-order optical nonlinearity of Cu-O chains investigated by third-harmonic generation spectroscopy

Spectra of the third-order nonlinear susceptibility chi((3)) have been investigated for one-dimensional Mott insulators, Sr(2)CuO(3) and Ca(2)CuO(3), by applying the third-harmonic generation (THG) spectroscopy on their single-crystalline thin films. The three-photon resonance to the lowest charge-transfer (CT) state with odd parity strongly enhances chi((3)), which is of the order of 10(-9) esu. The two-photon resonant structure unravels the even-CT state, located close to the odd-CT state. Two types of chi((3)) spectra obtained from THG and the electroreflectance measurements are explained based on the concept of spin-charge separation.

Electronic structure of mott insulators studied by inelastic X-ray scattering

The electronic structure of Mott insulators continues to be a major unsolved problem in physics despite more than 50 years of research. Well-developed momentum-resolved spectroscopies such as photoemission or neutron scattering cannot probe the full Mott gap. High-resolution resonant inelastic x-ray scattering revealed dispersive charge excitations across the Mott gap in a high-critical temperature parent cuprate (Ca(2)CuO(2)Cl(2)), shedding light on the anisotropy of the Mott gap. These charge excitations across the Mott gap can be described within the framework of the Hubbard model.

[Histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto's disease) accompanied by hemophagocytosis and salivary gland swelling in a patient with systemic lupus erythematosus]

After 2 years of steroid therapy that had effectively controlled her systemic lupus erythematosus, a 37-year-old woman presented with fever, erythema (face, upper chest), and low CH50. Increased oral steroid (prednisolone from 15 mg to 40 mg) and intravenous methylprednisolone (mPSL) (80 mg for 3 days) alleviated these symptoms except for the fever. Subsequently, the patient's fever worsened and leukocytopenia, abnormal liver function, lymphadenopathy (neck, axilla), and salivary gland swelling developed. Lymph node histology revealed features characteristic of Kikuchi-Fujimoto's disease (KFD). Laboratory examinations showed WBC 600/microliter, Hb 9.5 g/dl, platelets 90,000/microliter, GOT 766 IU/l, GPT 646 IU/l, LDH 4,228 IU/l, TG 1,622 mg/dl, and ferritin 6,330 ng/ml. Serum interferon gamma was also elevated (673 U/ml). Because a bone marrow smear revealed hemophagocytosis, mPSL pulse therapy (1 g for 3 days) was started for treatment of hemophagocytic syndrome. The fever promptly disappeared, and the patient's clinical symptoms resolved within 2 weeks. The abnormal laboratory data related to KFD and hemophagocytosis returned to normal within 4 weeks after the initiation of mPSL pulse therapy. We speculated that the hemophagocytosis and salivary gland involvement in this patient were also symptoms of KFD. This case indicated that corticosteroid pulse therapy is effective for KFD with serious clinical symptoms.

Stable integration of human immunodeficiency virus-based retroviral vectors into the chromosomes of nondividing cells

Human immunodeficiency virus type 1 (HIV-1)-based vectors are thought to be useful for gene transfer into nondividing cells. We examined whether HIV vectors can really integrate into the chromosomes of nondividing cells. CD4+HeLa cells arrested at the G2 or G1/S phase were incubated with the HIV vector pseudotyped with the HIV envelope. The transduction efficiency of the HIV vector in these nondividing cells was comparable to that in proliferating cells. Sequencing of the polymerase chain reaction-amplified fragments containing the junction sites showed that the HIV vector was stably integrated into the chromosomal DNA. It was also demonstrated that terminally differentiated human macrophages and nonproliferating NT neurons could be transduced by the HIV vector after adenovirus-mediated expression of CD4. These results suggest that the HIV vector may be useful not only for gene therapy of AIDS but also for a variety of gene therapy protocols targeting nondividing cells.

Human herpesvirus 7 infection of lymphoid and myeloid cell lines transduced with an adenovirus vector containing the CD4 gene

It has been reported recently that CD4 is a major component of the receptor for human herpesvirus 7 (HHV-7), which has been newly identified as a T-lymphotropic virus. To investigate further the role of CD4 in HHV-7 infection, we examined the susceptibility to HHV-7 infection of various CD4-negative or weakly positive cell lines into which the cDNA for CD4 was transferred using an adenovirus vector (Adex1CACD4). Of 13 cell lines transduced with Adex1CACD4, including T-lymphoid, B-lymphoid, monocytoid, and myeloid cell lines, one T-lymphoid cell line, one monocytoid cell line, and two cell lines established from the blast crisis of chronic myelogenous leukemia showed high susceptibility to HHV-7 infection. Taken together with the results of previous studies, these data suggest strongly that CD4 is a major component of the binding receptor for HHV-7. This study also shows that HHV-7 may be able to infect CD4-positive hematopoietic precursor cells as well as T lymphocytes.

Two-step gene transfer using an adenoviral vector carrying the CD4 gene and human immunodeficiency viral vectors

Human immunodeficiency virus-1 (HIV-1) belongs to the lentivirus subfamily of retroviruses and has several interesting features, including T cell tropism and the ability to infect nondividing cells. Replication-incompetent HIV vectors were developed and were shown to be capable of targeted gene transfer into CD4+T cells. This strict T cell tropism may be important for the development of gene therapy of acquired immunodeficiency syndrome (AIDS), but it hampers the use of the HIV vector for other gene transfer applications. To expand the host range of the HIV vector, we established the two-step gene transfer system, which allows us to transduce non-T cells stably. In the first step, the CD4 gene was introduced into target cells using a replication-defective adenoviral vector. Transient but high-level expression of CD4 molecules was detected in both adherent and floating cells. In the subsequent step, the cells were incubated with HIV vectors. Stable integration of the HIV vector was demonstrated in cells transduced with the adenoviral vector. These results indicate that transient expression of CD4 molecules by the adenoviral vector is sufficient to render non-T cells susceptible to HIV-mediated gene transfer. This two-step gene transfer strategy may be used as a general method to transduce various types of human cells stably including nondividing cells.

A distribution study of 11C platelet-activating factor (PAF) analogs in normal and tumor-bearing mice

As a preliminary study to image platelet-activating factor (PAF) receptors in vivo, comparative study of biodistribution between 1-O-hexadecy1-2-O-N, N-dimethylcarbamoyl-sn-glycero-3-phosphocholine [choline-methyl-11C](L-[11C]dimethylcarbamoyl-PAF) and nonspecific PAF analog, 3-O-hexadecyl-2-O-N,N-dimethylcarbamoyl-sn-glycero-1-phosphocholine [choline-methyl-11C](D-[11C]-dimethylcarbamoyl-PAF) was carried out in both normal and tumor-bearing mice. Higher accumulation of L-[11C]dimethylcarbamoyl-PAF than D-[11C]dimethylcarbamoyl-PAF was observed in normal mice spleen. The co-administration of PAF antagonists dose-dependently reduced the radioactivity level of the L-isomer only in the spleen. In mice bearing Ehrlich tumors and Sarcoma 180, more L-than the D-[11C]-isomer was accumulated in the tumor and spleen. We found that specific accumulation sites for L-[11C]dimethylcarbamoyl-PAF exist in the spleen and tumors than in other tissues. Moreover, the comparison of accumulation between L- and D-[11C] dimethylcarbamoyl-PAF would be a useful procedure for estimation of PAF receptors in vivo.

Meningiomas associated with peritumoural venous stasis: three types on cerebral angiogram

Many factors have been suggested as possible mechanisms for the development of peritumoural oedema in meningioma. Venous compression by the tumor is thought to be one factor, but reports presenting a direct relationship between venous compression and the formation of oedema are rare. We have recently observed 6 meningioma patients in whom venous stasis contributed to peritumoural oedema. The stasis was due to 1) compression of an adjacent cortical vein by the tumour with stasis at the site of compression and/or its distal portion, 2) compression of adjacent brain by the tumour with prolonged perfusion and delayed venous return (visualized as pial staining in the capillary and venous phases), and 3) presence of an early draining vein linked to a nearby cortical vein with stasis at its periphery. Venous compression and stasis seem to be related not only to the formation of peritumoral oedema but also to the occurrence of haemorrhagic infarction after the resection of meningiomas.

In vivo and in vitro models of medulloblastomas and other primitive neuroectodermal brain tumors of childhood

Recent advances in understanding the basic biology of the neoplastic cells that populate childhood primitive neuroectodermal tumors (PNET) of the central nervous system (CNS) underline several unique properties of these common pediatric brain neoplasms. For example, studies of posterior fossa cerebellar medulloblastomas (MB), a prototypical group of brain tumors that comprise the largest class of PNET, suggest that the molecular phenotype of subpopulations of neoplastic cells in MB partially recapitulates stages in the acquisition of the neuronal phenotype by normal developing human CNS progenitor cells. However, as reviewed here, it appears that the neoplastic cells in MB exhibit one or more molecular defects in the sequence of normal maturational events that enable CNS progenitor cells to exit the cell cycle, become committed to the neuronal lineage, and undergo terminal differentiation into fully mature, permanently postmitotic CNS neurons. Indeed, since PNET emerge almost exclusively in early childhood, the induction of PNET may result from genetic lesions that arise in developing CNS progenitor cells thereby preventing these neural precursors from executing normal programs of lineage commitment and differentiation in the CNS. Clarification of how lineage commitment and maturation in PNET comprised of neuron-like tumor cells deviate from normal CNS development may clarify how oncogenes and tumor suppressor genes exert their effects in a cell type specific manner at different stages in the normal maturation of CNS cells. Recently, a number of potentially effective in vitro and in vivo model systems of PNET have been developed. Since these model systems could facilitate efforts to elucidate mechanisms of neoplastic transformation and tumor progression in the CNS, we review the potential utility of several recently described in vitro (e.g., MB cell lines) and in vivo (e.g., transgenic mice) experimental systems as models of authentic childhood CNS neoplasms.

[Guidance of community mental health training for psychiatry residents]

Compared to other advanced countries, the field of mental health in Japan is characterized by a large hospitalized to general population ratio and a long mean hospitalization period. This is in large part attributable to the lack of appropriate housing as well as occupational recreational centers after discharge. At the same time the education of psychiatric medical staff has focused on the hospital environment, with little attention devoted to training at centers of community mental health. This hospital-dominant approach has been difficult to shed, and has persisted since the WHO report of Dr. Clark in 1968. Paralleling the introduction of the certified doctor system, at the Japanese Society of Psychiatry and Neurology recently, the manner of postgraduate training for psychiatrists and attempts to reform it were debated. In the midst of this debate, a consensus has emerged that study of community mental health is one of the minimum requirements to become a full-fledged psychiatrist. However, no adequate community mental health training programs have been established at any institution. At Nara Medical University hospitals, considerable weight has been placed on community mental health training, with such a training program designed and put into practice. In the present report, this training program is introduced and interim results reported, and the problems associated with community mental health training are discussed.

Family study of women showing development of antibody to human T-cell leukemia virus I and assessment of the risk of vertical transmission of the virus to their children

When pregnant women were tested for antibody to human T-cell leukemia virus-I, some were found to be positive although they had been negative during the previous pregnancy. In these women, HTLV-I infection was found from pedigree studies to have been acquired from their mothers rather than from their husbands. Furthermore, some of them had apparently remained HTLV-I antibody-negative for long periods after infection. When the breast-fed children of these women, in whom HTLV-I was acquired from their mothers but who were in an HTLV-I antibody-negative state, were also examined for evidence of HTLV-I infection, none was found.

Monoclonal antibodies to a rat nestin fusion protein recognize a 220-kDa polypeptide in subsets of fetal and adult human central nervous system neurons and in primitive neuroectodermal tumor cells

Nestin is the major intermediate filament protein of embryonic central nervous system (CNS) progenitor cells. To identify proteins involved in early stages of lineage commitment in the developing human CNS we generated monoclonal antibodies to a TrpE-rat nestin fusion protein. This resulted in a monoclonal antibody (designated NST11) that did not recognize authentic human nestin, but did recognize a novel neuron-specific human polypeptide expressed in a subset of embryonic and adult CNS neurons as well as in medulloblastomas. NST11 immunoreactivity was abundant in developing spinal cord motor neurons, but was extinguished in these neurons by 17 weeks gestation. NST11 also labeled Purkinje cells at 17 weeks gestation, but Purkinje cells continued to express the NST11 antigen throughout gestation as well as in the adult cerebellum, and NST11 immunoreactivity was more abundant in Purkinje cells than in any other human CNS neurons. No NST11 immunoreactivity was detected in cells of the adult human peripheral nervous system or in a variety of adult non-neural human tissues. Further, NST11 almost exclusively stained cerebellar medulloblastomas. In Western blots of immature and mature human cerebral and cerebellar extracts, NST11 did not bind human nestin, but did detect an immunoband with a molecular weight of 220 kd. A similar immunoband was detected in medulloblastoma-derived cell lines with a neuron-like phenotype. These findings suggest that the NST11 monoclonal antibody recognizes a novel protein expressed by a subpopulation of immature and mature human CNS neurons, medulloblastomas, and medulloblastoma-derived cell lines.

Medulloblastomas and related primitive neuroectodermal brain tumors of childhood recapitulate molecular milestones in the maturation of neuroblasts

We review here recent data that have brought into sharper focus a number of important biological properties of the neoplastic cells in childhood primitive neuroectodermal tumors (PNETs) of the central nervous system (CNS). Studies of this group of tumors, as exemplified by posterior fossa medulloblastomas (MBs), suggest that neoplastic cells in PNETs partially recapitulate stages in the maturation of normal human neuroblasts. These findings may contribute to the elucidation of the mechanisms involved in tumor initiation and progression because oncogenes and antioncogenes appear to exert their effects in a cell type-specific manner that also depends on the maturational state of a given cell. Currently, a large body of data suggests that populations of cells in PNETs (e.g., MBs) exhibit one or more molecular defects in the sequence of maturational events leading to the exit of stem cells or partially committed neuron-like precursors from the cell cycle, followed by their terminal differentiation into neurons. This, together with the orchestrated interactions of as yet unidentified oncogenes and antioncogenes in these PNET cells, may represent a cluster of molecular abnormalities that underly the emergence of the highly malignant phenotype that characterizes childhood PNETs.

Nestin expression in embryonic human neuroepithelium and in human neuroepithelial tumor cells

Nestin is a recently described member of the intermediate filament (IF) protein family that is especially abundant in neuroepithelial stem cells of the rat. The studies described here examine this class VI IF protein in the normal human developing central nervous system (CNS), human brain tumor-derived cell lines, and tissue samples of human CNS tumors. Human nestin exhibited biochemical and immunochemical properties similar to those of rat nestin. Further, as in the rat, nestin was detected immunohistochemically in several different types of immature human CNS cells, i.e. germinal matrix cells, neuroepithelial cells lining the central canal, radial glia and vascular cells. Nestin appeared in these cells at the earliest gestational age (i.e., 6 weeks) examined here and then it declined in all but the vascular cells at later embryonic stages. Nestin also was detected by immunocytochemistry in 6 of 7 primitive neuroectodermal tumor cell lines and in both of 2 malignant glioma cell lines examined. In these cell lines, nestin co-localized incompletely with bundles of IFs containing other IF proteins (i.e., vimentin, glial filament, neurofilament). Nestin was ubiquitous in a wide variety of brain tumors, but was most prominent in gliomas. The transient expression of nestin in primitive neuroepithelial cells at early stages of human embryogenesis and its abundance in neuroepithelial tumors suggest a role for nestin IFs in cellular events that precede the exit of embryonic CNS stem cells from the cell cycle and the commitment of the progeny of these stem cells to a specific lineage. The subsequent induction of different members of the IF protein family in phenotypically distinct CNS cells (i.e. neurons, glia) and the elimination of nestin from almost all differentiated CNS cells, imply that different classes of IFs subserve functions that are closely linked to the maturational state, as well as the lineage, of CNS cells.

Molecular milestones that signal axonal maturation and the commitment of human spinal cord precursor cells to the neuronal or glial phenotype in development

Insights into the programmatic induction of neuronal and glial genes during human embryogenesis have depended largely on extrapolations of data derived from experimental mammals. However, the assumptions upon which these extrapolations are based have not been rigorously tested. Indeed, practically no information is available even on the human counterparts of the relatively small subset of well-characterized, developmentally regulated neuron and glial specific genes of the mammalian CNS. Thus, the developmental programs upon which human neural embryogenesis are based remain largely undeciphered. We have addressed this problem in immunohistochemical studies conducted on 22 human fetal spinal cords with gestational ages (GAs) that ranged from 6 to 40 weeks by using monoclonal antibodies to several classes of neuron or glial specific polypeptides. These polypeptides included: representatives of four different types (Types I-IV) of intermediate filament proteins, i.e., vimentin filament protein (VFP), glial fibrillary acidic protein (GFAP), different phospho-isoforms of the high (NF-H), middle (NF-M), and low (NF-L) molecular weight (Mr) neurofilament (NF) subunits, both acidic and basic cytokeratin (CK) proteins; three different microtubule associated proteins (MAPs), i.e., MAP2, MAP5, and tau; two different synaptic or coated vesicle proteins, i.e., synaptophysin (SYP) and clathrin light chain B (LCb); an oligodendroglial specific protein, i.e., myelin basic protein (MBP); and a receptor for a CNS trophic factor, i.e., the nerve growth factor receptor (NGFR).(ABSTRACT TRUNCATED AT 400 WORDS)

[A case of hemangioblastoma with subarachnoid dissemination]

A case is reported in which a diffuse subarachnoid dissemination occurred after successful removal of a posterior fossa hemangioblastoma. The patient was a 51-year-old man who suffered from headache and gait disturbance, and who was admitted to our hospital on September 25, 1985. Neurological examination revealed trunkal ataxia and increased intracranial pressure. A CT scan with contrast media revealed a high-density lesion with surrounding low-density area in the posterior fossa. Right vertebral angiography demonstrated a round tumor stain behind the medulla oblongata, which was fed by the right posterior inferior cerebellar artery. The complete resection of the tumor was carried out. A biopsy specimen from the tumor showed a picture characteristic of hemangioblastoma. Fourteen months later the patient was readmitted due to the sudden onset of disturbance of consciousness. A CT scan revealed a large intracerebral hematoma in the right putaminal region. Right carotid angiography demonstrated two small tumor stains in the right temporal lobe. An emergency operation to extirpate the hematoma was performed. But the disturbance of consciousness did not improve, and the patient died. At necropsy a lot of small round tumors were recognized at the surface of the bilateral cerebral and cerebellar cortex. They were present in the subarachnoid space and partially invaded the cerebral and cerebellar parenchyma, extending through Virchow-Robin's space. There was no recurrence of the tumor at the site of the original operation. No doubt, a subarachnoid dissemination had occurred. However the histological findings of tumors were similar to the findings recorded in the first biopsy.

[The clinical usefulness of portal venous flow ratio by hepatic angiography with 99mTc-Sn colloid in chronic liver diseases: a comparison with histological finding]

The ratio of portal venous to hepatic blood flow was measured in chronic liver diseases by radionuclide angiography with 99mTc-Sn colloid and its clinical value was discussed. The ratio was proportionally decreased to the progression of the diseases (normal 74.5 +/- 7.3%, chronic hepatitis 58.8 +/- 9.2%, compensated liver cirrhosis 29.3 +/- 19.3%). In alcoholic liver diseases, the standard deviation of the ratio was large as 52.7 +/- 23.7%, and the low ratio in the early period of the disease increased within one or two months as the disease recovered. In comparison with the histological findings of the liver, the ratio in the alcoholic liver diseases was well correlated with the severity of liver fibrosis and liver cell swelling. In conclusion, this noninvasive and simple method is valuable in diagnosing the chronic liver disease, especially alcoholic liver diseases, and also in estimating its clinical course.

Drug-induced mononucleosis-like hepatic injury in a patient with systemic lupus erythematosus

A case of systemic lupus erythematosus (SLE) with mononucleosis-like hepatic injury was described. An emergent cesarean section was performed in a 25 yr-old house wife at 34 weeks gestation, followed by administration of several antibiotics. After the surgery she complained of high fever, hepatomegaly and dull right hypochondralgia, and mild liver dysfunction was also found. The liver biopsy showed prominent mononuclear cell infiltration in the sinusoids with minimum hepatocellular necrosis and mild triaditis, resembling hepatic lesion in infectious mononucleosis (mononucleosis-like injury). There were no clinical and serological features suggestive of infectious mononucleosis. This hepatic lesion was thought to be a manifestation of allergic reaction to drugs to which the lymphocyte stimulation test was found to be positive. Immunological abnormalities inherent in SLE might be related to occurrence of such allergic drug reaction.

[Glial fibrillary acidic protein and neurofilament protein in medulloblastoma]

Medulloblastoma is the most common primitive neuroectodermal tumor (PNET) with the potential to differentiate along glial or neuronal lines. Thirty cases of medulloblastoma were tested by the peroxidase-antiperoxidase (PAP) method with anti-GFAP serum (DAKO) and by the avidin-biotin peroxidase complex (ABC) method with 68kd subunit of anti-NF antibody. All the cases were classified into three subtypes based on these immunohistochemical findings and were analyzed in relation to clinico-pathological features. Fifteen of thirty medulloblastomas contained GFAP positive cells, seventeen showed cells reacting to NF. The reactions for both proteins were present in eight medulloblastomas (PNET-BD, bipotential differentiation). Seventeen medulloblastomas reacted to only one protein (PNET-MD, monopotential differentiation). No reaction for either was found in five cases (PNET-NOS, not otherwise specified). The two year survival rate was 12.5% for PNET-BD compared to 49.2% for PNET-MD and 53.3% for PNET-NOS. Nine variables, i.e. age, tumor stage, metastatic stage, operation, radiotherapy, chemotherapy, histology, GFAP and NF, were analyzed using Cox's proportional hazard model. This revealed that the significant factors were tumor stage (p = 0.0002), GFAP (p = 0.0008) and operation (p less than 0.05). In conclusion, GFAP is the most important histological factor for prognosis and medulloblastoma without glial differentiation has a much better prognosis than one with glial differentiation.