A 52-week randomized controlled trial of ipragliflozin or sitagliptin in type 2 diabetes combined with metformin: The N-ISM study

AIM

To compare the long-term efficacy of sodium-glucose co-transporter-2 inhibitors and dipeptidyl peptidase-4 inhibitors as second-line drugs after metformin for patients not at high risk of atherosclerotic cardiovascular disease (ASCVD).

MATERIALS AND METHODS

In a 52-week randomized open-label trial, we compared ipragliflozin and sitagliptin in Japanese patients diagnosed with type 2 diabetes, without prior ASCVD and treated with metformin. The primary endpoint was a glycated haemoglobin (HbA1c) reduction of ≥0.5% (5.5 mmol/mol) without weight gain at 52 weeks.

RESULTS

Of a total of 111 patients (mean age 59.2 years, mean body mass index [BMI] 26.6 kg/m² , 61.3% men), 54 patients received ipragliflozin and 57 received sitagliptin. After 52 weeks, achievement of the primary endpoint was not significantly different (37.0% and 40.3%; P = 0.72). HbA1c reduction rate at 24 weeks was greater for sitagliptin (56.1%) than for ipragliflozin (31.5%; P = 0.01). From 24 to 52 weeks, the HbA1c reduction with sitagliptin was attenuated, with no significant difference in HbA1c reduction after 52 weeks between sitagliptin (54.4%) and ipragliflozin (38.9%; P = 0.10). Improvements in BMI, C-peptide and high-density lipoprotein cholesterol were greater with ipragliflozin than with sitagliptin. Adverse events occurred in 17 patients with ipragliflozin and in 10 patients with sitagliptin (P = 0.11).

CONCLUSION

The HbA1c-lowering effect at 24 weeks was greater with sitagliptin than with ipragliflozin, but with no difference in efficacy related to HbA1c and body weight at 52 weeks. However, some ASCVD risk factors improved with ipragliflozin.

Type 1 diabetes mellitus and isolated adrenocorticotropin deficiency manifested by parkinsonism: a case report and literature review

A 67-year-old woman developed isolated adrenocorticotropin deficiency (IAD), which manifested as lethargy, a 20-kg body weight loss, hypoglycemia, and parkinsonism, and began corticosteroid replacement. Her symptoms resolved rapidly, and her weight returned to normal within six months. However, she then developed slowly progressive type 1 diabetes mellitus (T1D) with co-existing Hashimoto thyroiditis, and commenced insulin therapy. To our knowledge, this is the first reported case of parkinsonism associated with IAD. In addition, because diabetes mellitus, including T1D, could be latent in patients with untreated IAD, careful assessment of glucose metabolism is needed after commencing corticosteroid replacement until weight regain is achieved.

Effect of the 2004 Mid-Niigata Prefecture Earthquake on Home Blood Pressure Measurement in the Morning in Type 2 Diabetic Patients

A major earthquake struck the Niigata Prefecture, Japan, on October 23, 2004. This study investigated the effect of the earthquake on morning home blood pressure (MHBP) measurements, as well as clinic blood pressure (CBP) and associated complications, in 222 type 2 diabetic patients who measured MHBP and CBP before the earthquake. Physical and laboratory examinations were assessed at every three months. Each patient completed a questionnaire on MHBP measurement, Japanese intensity grade (JIS), patient's lifestyle and psychological impact using posttraumatic stress disorder (PTSD) symptom score. Median JIS showed all patients lived in areas affected by strong aftershocks. Most patients stayed in their own houses, while one-third of patients sought refuge in other houses. No new clinical manifestations of disease were noted. Median PTSD score was low. Patients in public refuge houses had daytime blood pressure, but MHBP was not measured. In the first month, the number of patients who continued MHBP measurements decreased to 27% of pre-shock level. Many patients were unable to measure MHBP for several reasons, including losing MHBP equipment, having equipment destroyed, or suffering from anxiety due to the extensive devastation. Mean systolic MHBP and median urinary albumin excretion rate (UAER) increased significantly within three months and returned to pre-earthquake level at six months. On multiple regression analysis, increased systolic and diastolic MHBPs were significantly associated with UAER elevation. In type 2 diabetic patients following an earthquake, it is important to develop a device of MHBP measurement for maintaining control of MHBP to prevent vascular complications.

A case of preclinical Cushing's syndrome associated with diurnal rhythms of ACTH and cortisol in blood: correlation with histological findings

We describe a case of adrenocortical adenoma with preclinical Cushing's syndrome demonstrating diurnal rhythms of ACTH and cortisol in blood. A 50-year-old man was admitted to the hospital for the evaluation of incidental right adrenal mass with hyperglycemia and hypertension. On admission, there were no signs of clinical manifestation of hypercortisolism. The basal levels of cortisol (9.3 microg/dl) and ACTH (9.4 pg/ml) at 0800 h were not elevated and these diurnal rhythms were maintained. One or 8 mg of dexamethasone given orally overnight suppressed the plasma ACTH but not serum cortisol. Ultrasonogram, CT and scintiscan of (131)I adosterol all demonstrated an enlarged adrenal mass in the right adrenal gland. The right adrenal gland was subsequently resected by laparoscopic surgery. Histopathological findings of resected adrenal tumor were consistent with adrenocortical adenoma. Adjacent non-neoplastic adrenal tissue demonstrated adrenocortical atrophy but DHEA-sulfotransferase immunoreactivity in the zona reticularis was detected.

Effect of the 2004 mid niigata prefecture earthquake on patients with endocrine disorders

A major earthquake (Richter scale magnitude 6.8) struck the Chuetsu district of Niigata Prefecture, Japan, a rural area with mountain villages, on October 23, 2004. Strong aftershocks (Grade 5-6 on the Japanese intensity scale, JIS) continued for 2 months. We analyzed the earthquake's impact on 229 patients with various endocrine disorders [6 central diabetes insipidus (CDI), 16 adrenal insufficiency (AI) including 5 panhypopituitarism, 10 ACTH isolated deficiency and 1 Addison's disease, 145 Graves' disease and 62 Hashimoto's disease]. The status of patients with CDI or AI was not adversely affected by the earthquake. Twenty-eight (19%) patients with Graves' disease developed more severe hyperthyroidism; the incidence of developing more severe hyperthyroidism increased with greater degrees of hyperthyroidism. Three (5%) patients with Hashimoto's disease developed increased TSH concentrations. Most patients stayed in their own houses following the first shock. The median PTSD total score for all patients was low. However, the PTSD total score in patients with CDI or Hashimoto's disease was significantly higher than in other patients, while the subscore of mental status in patients with AI was significantly much lower than in other patients. In patients with Hashimoto's disease, patients whose hypothyroidism worsened had higher total and environmental effects score than patients whose hypothyroidism remained stable. Comparing patients whose hyperthyroidism became more severe to those in whom it remained stable, as well as on multiple logistic regression analysis, serum TRAb was found to be a risk factor for developing more severe hyperthyroidism. In conclusion, our findings indicate that Graves' disease patients need to maintain their euthyroid state with a low serum TRAb titer to prevent the development of further thyroid dysfunction after an earthquake, and that all patients should continue to take their medication, since it is likely that their lives will be interrupted by environmental effects owing to earthquake-shock, especially patients with CDI or Hashimoto's disease. Due to the risk of medical facility closure during a disaster, all patients should always have a note or copy of their medical records, including medical history and medications used, to avoid relying on patients remembering their drug names and doses. Furthermore, appropriate information should be provided by all means possible, including the mass media, to affected individuals, particularly those with AI, to decrease the occurrence of adverse consequences.

Risk factors for severe coronary artery disease - a case-control study of patients who have undergone coronary artery bypass grafting

To investigate risk factors for coronary artery disease (CAD), we analyzed the clinical parameters of patients with a coronary artery bypass graft (CABG) in a case-control study. Eighty-eight patients (75 males and 13 females) who underwent CABG surgery between 2001 and 2002 were compared with age- and sex-matched healthy controls randomly chosen from the registry of Kobari Health Care Center. Wilcoxon's signed rank test and McNemar's test were used for pairwise comparisons. Multivariate logistic regression analysis was used to identify significant risk factors for CABG. Significant differences between the patients and controls were observed in HDL-C (p < 0.001), HbA(1c) (p < 0.001), Brinkman Index (BI; p < 0.001), body mass index (BMI; p = 0.002), and systolic blood pressure (SBP; p = 0.013). Subjects with an abnormal BMI, HbA(1c), or HDL-C or high BI value made up a significantly higher proportion of the patients who underwent CABG, compared to their age- and sex-matched controls. Multivariate logistic regression analysis identified high levels of HbA(1c), low levels of HDL-C, and high scores on the BI as significant risk factors for needing a CABG. These results demonstrate that, despite the modification of laboratory determinations by antecedent treatment, HDL-C, HbA(1c), BI, BMI, and SBP are significant indicators of risk for CAD.

The bedtime administration of doxazosin controls morning hypertension and albuminuria in patients with type-2 diabetes: evaluation using home-based blood pressure measurements

The control of high blood pressure (BP) after awakening in the morning (morning hypertension) as determined by home BP (HBP), as well as BP control throughout the day, may prevent diabetic vascular complications. We examined the effect of an alpha-adrenergic blocker (doxazosin) on BP measurements taken by HBP after awakening and during clinic visits (CBP) in 50 patients with type-2 diabetes and morning hypertension. We evaluated the urinary albumin excretion rate as an indicator of nephropathy. Doxazosin was taken orally once at bedtime for 1 to 3 months. The mean (+/- SD) dose was 2.9 +/- 2.1 mg/day (1 to 8 mg/day). The BP was measured monthly at the clinic during the day and at home after awakening in the morning. In this short-term trial (2.8 +/- 0.4 months), the systolic HBP decreased significantly from 164 +/- 17 mmHg before treatment to 146 +/- 19 mmHg after treatment, and the diastolic HBP decreased significantly from 85 +/- 14 mmHg before treatment to 80 +/- 9 mmHg after treatment. The systolic, but not the diastolic CBP, decreased significantly after treatment. There was no significant difference in the systolic or diastolic values between the HBP and the CBP after treatment. The percentage change in the systolic HBP after treatment was three times greater than for the systolic CBP. The median (interquartile) urinary albumin excretion rate decreased significantly (P < 0.001) from 62 (25-203) mg/g creatinine before treatment to 19 (9-76) mg/g creatinine after treatment. On multiple regression analysis, the decrease in the systolic HBP with treatment positively correlated with the reduction in urinary excretion of albumin. The control of morning hypertension reduced the albuminuria found in both untreated and treated hypertensive patients with type-2 diabetes. Bedtime administration of doxazosin appears to be safe and effective in reducing morning hypertension as measured by HBP. This finding also demonstrates that HBP taken in the morning has a stronger predictive power for the albuminuria level than does CBP.

Lipoprotein lipase (LPL) mass in preheparin serum reflects insulin sensitivity

Lipoprotein lipase (LPL) is one of the enzymes regulated by insulin and its plasma activity reflects insulin sensitivity. Although intravenous heparin injection is required to measure LPL activity, we can detect LPL mass in preheparin serum (Pr-LPL mass) by immunoassay. In this study, we examined whether Pr-LPL mass reflects insulin sensitivity. We measured Pr-LPL mass, insulin sensitivity (Si), and acute insulin release in response to a glucose bolus (AIRg) in subjects with normal glucose tolerance (NGT; n = 23), impaired glucose tolerance (IGT; n = 10), and Type II diabetes mellitus (DM; n = 48). Si and AIRg were determined by minimal model analysis. We also compared Pr-LPL mass with the homeostasis model assessment of insulin resistance (HOMA-R) and the urinary excretion of C-peptide (urine CPR). We found that Pr-LPL mass correlated significantly with Si ( r = 0.354, P < 0.01) in all the subjects. This correlation was still significant in the NGT group (P < 0.472, P < 0.05), DM group (r = 0.311, P < 0.01), and DM group with a fasting plasma glucose >150 mg/dl ( n = 20, r = 0.459. P < 0.05). Moreover, Pr-LPL mass correlated negatively with HOMA-R (r = -0.272. P < 0.05) and fasting IRI (r = -0.256, P < 0.05). By contrast, Pr-LPL mass was not correlated with either urine CPR or logAIRg that reflect the ability to secrete insulin. In conclusion, Pr-LPL mass reflects insulin sensitivity. We speculate that Pr-LPL mass might be used to assess insulin sensitivity not only in the general population but also in advanced diabetic patients.

A rare case of Graves' disease during regular hemodialysis

We report a case of Graves' disease in a patient on regular hemodialysis. The patient also suffered from Wolff-Parkinson-White (WPW) syndrome and paroxysmal atrial fibrillation, which may both have been manifestations of the Graves' disease because of the increased oxygen demand. To our knowledge, this is the first case to illustrate the usefulness of the antithyroid agent propylthiouracil for Graves' disease complicated by endstage renal disease (ESRD) and WPW syndrome.

Genotype Gly/Gly of the Arg16Gly polymorphism of the beta2-adrenergic receptor is associated with elevated fasting serum insulin concentrations, but not with acute insulin response to glucose, in type 2 diabetic patients

The beta(2)-adrenergic receptor (B2AR) is expressed in pancreatic beta-cells and modulates insulin secretion. The purpose of the present study was to evaluate the influence of the Arg16Gly variant allele of B2AR on insulin secretion in patients with type 2 diabetes. We used minimal model analysis of the frequently sampled insulin-modified intravenous glucose tolerance test (FSIGT) and polymerase chain reaction (PCR)-restriction fragment length polymorphism to examine differences of insulin secretion and insulin resistance among three genotypes. There were no significant differences in baseline clinical characteristics, HbA1c, uric acid, CRP or lipid profiles among the three groups. The Gly/Gly group had significantly higher levels of fasting insulin (38.2+/-4.7 pmol/l versus 23.6+/-3.5 pmol/l) and homeostasis model assessment of insulin resistance (HOMA-R) (1.90+/-0.19 versus 1.32+/-0.24), compared with the Arg/Arg group, but there were no significant differences in acute insulin response to glucose (AIRg) bolus, insulin sensitivity (Si), or glucose effectiveness (Sg) among the three genotypes. Several reports have speculated that the Gly16 allele of B2AR exhibits agonist-promoted downregulation, but our findings, elevated fasting insulin concentrations, and previous clinical studies of blood pressure and lypolysis are controversial. The direct mechanism by which the Gly16 allele of B2AR may influence insulin secretion of pancreatic beta-cells is unknown. Further studies of the expression of the allelic receptor in islet cells may help to resolve the role of B2AR in insulin secretion. However, increased sensitivity to catecholamine-induced lipolysis of the Gly allele promotes higher free fatty acids concentrations in the portal system, which could enhance the higher levels of fasting insulin.

Brain-derived neurotrophic factor modulates glucagon secretion from pancreatic alpha cells: its contribution to glucose metabolism

AIM

Brain-derived neurotrophic factor (BDNF) reduces plasma glucose levels in obese db/db diabetic mice and is speculated to produce its effects via the hypothalamus, the regulatory centre of satiety and the autonomic nervous system. The potential effect of BDNF directly on peripheral endocrine organs, however, remains to be clarified. Here we report the effects of BDNF on hormonal secretion from pancreatic islets of Langerhans using their isolated culture.

METHODS AND RESULTS

In an immunohistochemical study, mouse pancreatic alpha cells were stained specifically with the anti-TrkB (a specific receptor for BDNF) antibody. After 7 days culture of isolated islets of the normal mouse pancreas, 10 ng/ml BDNF decreased the secretion of glucagon per 6 h significantly less than that of the control (p = 0.016). In contrast, there were no significant changes in insulin secretion or glucagon and insulin contents in the islets cultured under the same conditions. In vivo administration of BDNF (10 mg/kg/day) to normal mice for 7 days significantly decreased their food consumption (p < 0.05). The fasting plasma glucose levels were decreased on day 7 compared with day 1 more significantly in BDNF-treated mice (p = 0.043) than in pair-fed control mice (p = 0.14). In newborn BDNF-knockout mice, fasting plasma glucose levels increased in the order of homozygote, heterozygote and wild type (p = 0.033). No apparent immunohistochemical abnormality was observed for pancreatic glucagon in the BDNF-knockout mice.

CONCLUSION

These data suggest that BDNF affects glucose metabolism not only with its anorectic effect but also with modulated glucagon secretion from pancreatic alpha cells.

Renoprotective effects of low-dose valsartan in type 2 diabetic patients with diabetic nephropathy

It is unknown whether the angiotensin receptor antagonist valsartan exerts a renoprotective effect on patients with type 2 diabetes and diabetic nephropathy independent of its hypotensive effects. Forty patients with type 2 diabetes participated in this study. All patients received valsartan 40 mg, a dose with no clinical effect on blood pressure levels. Blood pressure, urinary albumin excretion (UAE), and creatinine clearance were determined at baseline and at the end of the 6-month treatment period. Antihypertensive and/or antidiabetic drugs, including insulin, were permitted throughout the study. After 6 months of valsartan therapy, mean UAE decreased from 86.8 +/- 196 to 46.9 +/- 97 microg/min (n = 37). In addition, a significant decrease was observed in the UAE of the subgroup of patients displaying diabetic nephropathy (UAE > 20 microg/min, n = 14), from 219.4 +/- 275 to 102.7 +/- 141 microg/min, (P < 0.01). Changes in UAE for valsartan correlated significantly with UAE at baseline (r = -0.935, P < 0.0001). Serum creatinine levels and creatinine clearance remained stable before and after treatment with valsartan. No significant differences were observed between pre- and post-treatment body mass index, glycosylated hemoglobin, or systolic and diastolic blood pressure. In type 2 diabetic patients with diabetic nephropathy, 6 months of treatment with low dose valsartan, an angiotensin-II receptor antagonist, thus reduced UAE with no reduction in systemic blood pressure. The drug may be safely administered in this subset of type 2 diabetic patients. The long-term benefits in terms of risk reduction must still be evaluated in further trials.

Malignant melanoma of mandibular gingiva; the usefulness of fat-saturated MRI

Case report of a histologically validated malignant melanoma affecting the mandibular molar gingiva in a 31-year-old woman. Tumour was evaluated by magnetic resonance (MR) imaging at 1.5-T, spin-echo 3 mm slice thickness with T1-weighted and fat-saturated T1-weighted images. The fat-saturated T1-weighted images demonstrated the lesion more clearly than conventional T1-weighted images.

Osteogenic sarcoma of the prostate

A 76-year-old man was treated with bilateral orchiectomy, estramustine phosphate and pelvic irradiation for prostate cancer. Osteogenic sarcoma of the prostate developed 18 months after the treatment. Postmortem examination revealed that the tumor was 8 cm in diameter and had infiltrated into the bladder and rectal walls and had resulted in peritoneal dissemination. There was no distant metastasis. Macroscopically, the tumor was ashen, firm and relatively homogenous and diffusely spread. Histologically, it was composed of spindle and pleomorphic cells, which were making osteoid with calcification. There was no ordinary tubular formation as shown in adenocarcinoma of the prostate. No positive immunostaining for prostate-specific antigen, epithelial membrane antigen and cytokeratin (AE-1, AE-3) were confirmed. Positive immunostaining for nonepithelial marker vimentin was confirmed. The ultimate diagnosis was osteogenic sarcoma of the prostate.

Parapelvic neurofibroma of the kidney

We report the first case of neurofibroma causing obstruction by external compression of the upper renal pelvis. A 33-year-old woman reported a 1-year history of dull lumbar pain on the right side. A right renal parapelvic cyst was suspected. The patient underwent retroperitoneoscopic exploration. The right renal parapelvic lesion was identified as a soft tissue tumor. The tumor was removed with a retroperitoneoscopic procedure. Histopathological findings revealed neurofibroma.

Calcitonin-producing pancreatic somatostatinoma: report of a case

A 59-year-old woman was hospitalized due to a 1-year history of diarrhea and weight loss. Echography and computed tomography of the abdomen revealed a 10 x 7 cm solid mass in the tail of the pancreas and gallstones, while selective celiac angiography revealed the presence of a hypervascular mass. High levels of somatostatin and calcitonin were detected in the plasma, 70 pg/ml (normal range <28 pg/ml) and 5550 pg/ml (normal range 37 +/- 8 pg/ml), respectively. This tumor was thus removed by means of a distal pancreatectomy and a splenectomy. After the pancreatic tumor was removed, the elevated levels of plasma somatostatin and calcitonin returned to the normal ranges, and the persistent diarrhea also dramatically disappeared. A postoperative immunohistochemical study showed the tumor cells to be diffusely positive for somatostatin and calcitonin. These results clearly indicate this patient to be a case of calcitonin-producing pancreatic somatostatinoma.

[Bronchial hypersensitivity and development of bronchial asthma in children with atopic dermatitis]

Using histamine inhalation tests, we followed changes in bronchial hypersensitivity in 48 children with atopic dermatitis (AD) who were nonasthmatic on their initial visit. Twenty-three of these subjects became asthmatic during the follow-up period. The respiratory thresholds to histamine RT-Hist) of children with AD were widely distributed, ranging from 156 to more than 5000 micrograms/ml. There was a statistical difference in RT-Hist, as those who became asthmatic showed lower levels (< or = 625 micrograms/ml) at 2-6 yr of age. The percentage of peripheral eosinophil counts and IgE level was significantly elevated in those who became asthmatic. Subjects who developed asthma were more likely to have had positive D.p. RAST when they were less than 2 yr of age. The development of asthma in children with AD showed no significant relationship with family history of bronchial asthma.

[Bronchial hypersensitivity to histamine in asthmatic children longitudinal study from first visit to remitted state]

In order to examine the changes in bronchial hypersensitivity, histamine inhalation tests were evaluated in 27 asthmatic children who remitted. The respiratory threshold to histamine (RT-Hist) 2-3 yrs after remission was higher than in the initial test, in their worst periods of the asthma and just before remission (p < 0.001, p < 0.001, p < 0.005, respectively). Eleven subjects (40.7%), showed no improvement of bronchial hypersensitivity 2-3 yrs after remission (RT-Hist was 1250 micrograms/ml or lower). In this group, the asthma score per year two and three years before symptom-free state was higher than in the group with improved bronchial hypersensitivity (p < 0.05). There was no significant difference between % fall of FEV1.0 in RT-Hist in the worst periods of the asthma and 2-3 yrs after remission. FEV1.0/VCP, %V50, %V25 and V25/Ht 2-3 yrs after remission were higher than those in the worst periods of the asthma.

Cystic lymphangioma and plunging ranula treated by OK-432 therapy: a report of two cases

Among head and neck angiotumors, cystic lymphangioma occurs in infancy in most cases and it is rare in adulthood. Plunging ranula is one of the diseases which need to be distinguished from lymphangioma, though operation is the first choice therapy for both of these. In the present study, we report on 2 cases in whom we conducted intralesional injection of OK-432 for cervical lymphangioma and ranula found in 20 and 35 year-old female patients. We obtained excellent improvement. First of all, we punctured the tumors and sucked out the liquid content as much as possible, and then used OK-432 in the same volumes to those drawn out. No swelling was observed in either patient after 1 month, and cysts disappeared in CT 4 and 12 months after injection, respectively; at present, the prognosis is satisfactory, without recurrence. The intralesional injection of OK-432 is considered an effective method, as the speed of complete disappearance by this therapy is high. Cosmetically it is superb, leaving no lesions in the skin of the injection site.

The effect of uvulonodular lesions on horizontal optokinetic nystagmus and optokinetic after-nystagmus in cats

The effect of uvulonodular lesions on horizontal optokinetic nystagmus (OKN) and optokinetic after-nystagmus (OKAN) was investigated in alert cats. A lesion in each of 6 cats was made by suction-ablation under anesthesia. In the 3 cats with only a uvular lesion, both the initial slow phase velocity and the time constant of OKAN were unchanged. In the remaining 3 cats whose lesions included the nodulus as well as the uvula, the time constant of OKAN was markedly prolonged, but the initial slow phase velocity of OKAN was not affected. The postoperative average time constant of OKAN increased from the normal value of 9 s to about 40 s. In contrast, OKN parameters (the steady-state velocity and the rising time constant) were not affected by uvular or uvulonodular lesions. These results strongly suggest that the nodulus is involved in the velocity storage mechanism and might control the discharge characteristics of the velocity storage integrator.

Facial nerve enhancement in Gd-MRI in patients with Bell's palsy

The diagnostic value of a contrast enhanced MRI in patients with Bell's palsy was investigated. It was a characteristic finding that the internal acoustic meatal segment of the facial nerve was enhanced only on the affected side. The signal intensity ratio of the geniculate ganglion and the tympanic segment was significantly higher on the affected side than on the normal side. The severity of the facial palsy and the results of physiological examinations showed no relation to the results of MRI scans. Gd enhanced MRI thus appears to provide some useful findings for estimating the affected region of Bell's palsy, whereas it is not considered to be valuable in the diagnosis of severity.

Splenic hemangiosarcoma with sinus endothelial differentiation

A case of primary splenic hemangiosarcoma where the tumors entirely replaced the spleen is reported. Histologically, the splenic tumors consisted of two major components: (i) solid and nodular areas, in which spindle cells (SC) were arranged in interlacing fascicles; and (ii) vasoformative areas, in which vascular lining cells (VC) closely resembled normal splenic sinus endothelial cells (SSEC) in shape. Both SC and VC were immunoreactive with the markers of vascular endothelial cells (EC) including SSEC, JC70, von Willebrand factor, OKM5, vimentin MAb and Ulex europaeus-1 lectin. The tumor cells were positive for OKM5 MAb as well as normal SSEC and sheathed arterial EC, but other vascular EC in normal spleen were negative. Enzyme-histochemically, the tumor cells and normal SSEC revealed naphthol AS-D acetate esterase activity but no reaction for ALPase, whereas normal vascular EC other than SSEC in the spleen were positive for the latter but negative for the former. These studies revealed that the tumor cells expressed the same phenotype as normal SSEC. To the present author's knowledge this is the first report demonstrating sinus endothelial differentiation of splenic hemangiosarcoma, enzyme- and immuno-histochemically.

[Efficacy of continuous isoproterenol inhalation therapy for severe asthma attacks in younger children]

The aim of this study was to evaluate the efficacy of continuous isoproterenol inhalation therapy for severe asthma attacks in younger children, compared with its efficacy in older children. We used l-body isoproterenol (Proternol L) in 31 children with 42 episodes of severe attacks. They were divided into two group according to age: 20 cases under 6 years old (Group A), and 22 cases over 7 years old (Group B). All of the patients except for one in Group B, eventually improved with this therapy. Wood's clinical scores for Group A were significantly higher than those for group B (p < 0.01). In 22 cases whose scores were 5-6, their SpO2 values at the onset of this therapy were 90.8 +/- 3.17 in group A and 92.4 +/- 3.82% in group B. The improvement time of group A (13.6 +/- 16.2 hours) was significantly longer than that of group B (2.5 +/- 5.66, p < 0.01). The nebulized isoproternol doses for group A were 0.47 +/- 0.168 and for group B 0.26 +/- 0.096 mg/kg/saline 500 ml. The dose for group A was significantly higher than that for group B (p < 0.01). We concluded that continuous isoproterenol inhalation therapy was effective even in younger children. But the degree of efficacy was slightly lower in younger children, although they inhaled higher doses of isoproterenal than older children.

[Efficacy of early use of continuous isoproterenol inhalation therapy for severe asthma attacks in children]

The aim of this study was to evaluate the efficacy and safety of continuous isoproterenol inhalation therapy for asthma attacks in children. We used l-body isoproterenol (Proternol L) in 22 children with 32 episodes of severe attacks. One of them did not respond to this therapy, and two had complications (atelectasis and pneumothorax). Twenty-nine cases were divided into three subgroups according to their clinical scores; A) scores less than or equal to 4, which meant that they were in the early stage of severe attack (n = 9), B) scores 5-6, which meant impending respiratory failure (n = 17), C) scores greater than or equal to 7, which meant respiratory failure (n = 3). The values of SpO2 at the start of this therapy were 94.8, 91.5, 82.0%, respectively. The more severe their attacks were, the lower their SpO2 levels were. The periods until their scores became zero were 0.78, 6.3, 17.2 hours, respectively. There were significant differences between each period respectively (p less than 0.001, p less than 0.01). Heart rates decreased when their symptoms improved, and other adverse effects were not detected. These results suggest that this therapy is effective and safe for children with severe asthma attacks, especially in the early stage.

Re-evaluation of hydatidiform mole by DNA fingerprint method: the discrepancy in the diagnoses by pathological finding and the DNA fingerprint method

Ten cases of hydatidiform mole (HM) were analysed by the DNA fingerprint method. DNA samples were prepared from HM tissue of HM and maternal and paternal bloods, followed by digestion with HaeIII restriction endonuclease, applied to agarose gel, and then transferred to a nitrocellulose filter. The filter was hybridized using mini-satellite DNA as a probe. A case of partial HM diagnosed by histological findings was revealed to be complete HM using DNA fingerprinting. The case was suggested to be a twin pregnancy with a cHM and an abortion, because the DNA fingerprint of hydropic tissue showed a paternal pattern and that of the non-hydropic tissue did not show such a pattern. DNA fingerprinting was considered to be useful in distinguishing complete HM from partial HM.

Effect of uvulonodular lesions on optokinetic nystagmus and optokinetic after-nystagmus in cats

To investigate the effect of uvulonodular lesions on horizontal optokinetic nystagmus (OKN) and optokinetic after-nystagmus (OKAN), 6 cats were tested before and after lesions made by ablation under anesthesia. In the 3 cats with only uvular lesion, the initial slow phase velocity and the time constant of OKAN were unchanged. In the remaining three cats whose lesions included not only the uvula but also the nodulus, the time constant of OKAN was markedly prolonged, and the initial OKAN velocity was not affected. The postoperative average time constant of OKAN increased from normal value of 9 s to about 40 s. In contrast, OKN was unchanged in all of the 6 animals. These findings indicate that the nodulus may contribute to the discharge characteristics of the velocity storage integrator.

Discrepancy in the diagnoses of hydatidiform mole by macroscopic and microscopic findings and the deoxyribonucleic acid fingerprint method

Ten cases of hydatidiform mole were analyzed by the deoxyribonucleic acid fingerprint method. Deoxyribonucleic acid samples were prepared from hydatidiform mole tissue of hydatidiform mole and maternal and paternal blood. A case of partial hydatidiform mole diagnosed by histologic findings was revealed to be complete hydatidiform mole by deoxyribonucleic acid fingerprinting.

Sialates and negative charge on the surface of syncytiotrophoblastic cells of full-term placentae in toxemic patients

In the syncytiotrophoblastic surface of the toxemic full-term placentae, the sialates and their consequent negative charging were studied by both electron microscopic histochemistry (Ferritin method) and Western blot analysis. Evidence is presented showing (1) that the reactions with both the ferritin labelled Limulus Polyphemus Agglutinin (LPA-ferritin), specific to sialates, and the cationized ferritin, specific to a negative charge, decrease in the specimens of toxemic placentae, (2) that the density of sialates in placentae of severe gestational proteinuria or/and hypertension is statistically lower than that of severe gestational edema, and (3) that there is no difference between the blotted bands in normal placentae and toxemic ones regardless of the severity of the toxemia. These results indicate that the reduction of the surface negative charging is demonstrated in toxemic syncytiotrophoblasts and appears to be secondary to the decrease in the amount of sialate.

46,XY pure gonadal dysgenesis with gonadoblastoma

A case of gonadoblastoma on one side in streak gonads in a phenotypic female with chromosomal 46,XY pattern is described. The histopathological resemblance between gonadoblastoma and sex cord tumor with annular tubules is discussed. The high serum testosterone level, being unrelated to the administration of human chorionic gonadotropin is valuable for the diagnosis of gonadoblastoma in an individual with dysgenetic gonads. Gonadoblastoma is frequently very small in size and is located in ectopic regions, so that laparotomy with biopsy has been stressed. The hormonal supplement for a postgonadectomized girl is also discussed.

Malignant paraganglioma of the organ of Zuckerkandl. Initially diagnosed as renal cell carcinoma by biopsy of a right humeral fracture lesion

Malignant paraganglioma of the organ of Zuckerkandl (malignant POZ) in a 38-year-old woman is reported. Ten months before her death, the patient suffered from right shoulder pain. By biopsy of a pathological right humeral fracture, a histological diagnosis of metastatic renal cell carcinoma was initially made. However, autopsy revealed a left retroperitoneal tumor, which was diagnosed as malignant POZ. Upon immunohistochemical examination, tumor cells showed definite positivity for neuronspecific enolase (NSE) and chromogranins, and neurosecretory granules were found electron microscopically. The skeletal system is the most common site for distant metastases of malignant POZ. We were unable to find any previous reports of malignant POZ which were first manifested as humeral metastases, as in the present case. As paraganglioma might be histologically confused with a large variety of neoplasms (e.g. renal cell carcinoma), differential diagnosis of this condition is discussed.

Role of the nucleus of the optic tract of monkeys in optokinetic nystagmus and optokinetic after-nystagmus

A previous experiment disclosed that unilateral lesions of the nucleus of the optic tract (NOT) in the fascicularis monkey resulted in selective loss of optokinetic nystagmus (OKN) towards the lesioned side. This may suggest that the NOT in monkeys, as in non-primates, represents the first relay station in the basic horizontal optokinetic path. This monkey, however, did not show a rapid rise in OKN velocity in response to steps in stimulus velocity. In the present experiments, effects of NOT lesions upon both the rapid and the slow rise of OKN as well as optokinetic after-nystagmus (OKAN) were examined in 6 fuscata monkeys. In 3 with total NOT lesions of 6 monkeys, none of the slow rise OKN or OKAN slow phase velocity were produced towards the lesioned side. In one of the remaining 3 monkeys with partial NOT lesions, a slow rise OKN and OKAN slow phase velocity were selectively reduced towards the lesioned side. In 2 of these 4 monkeys whose lesions were localized in the lateral portions of the pretectum, rapid rise in OKN velocity remained unchanged, whereas in the remaining two whose lesions were large enough to extend into the medial portions of the pretectum near the nucleus of the posterior commissure, rapid rise in OKN velocity was reduced. In the remaining 2 monkeys whose NOT was only superficially damaged, all components of OKN were normal. Other visually induced eye movements were normal. In all monkeys except for one who had marked spontaneous nystagmus, the peak velocity of vestibular nystagmus was not affected after NOT lesions. These findings indicate that the dynamics of the charge of the velocity storage mechanism is separately influenced by NOT lesions: OKN and OKAN are abolished, but vestibular nystagmus remains unaffected.

Trophoblastic embolism in sudden maternal death

Trophoblastic embolism (TE) was shown in three out of eight maternal autopsy cases. The trophoblasts of TE were easily identified by the immunocytochemical method with antisera to placental antigen (PA) and human placental lactogen (HPL). Two types of TE were differentiated in the morphology of trophoblasts: One was formed of whole trophoblastic cells (TE-Type I) and the other was composed of amorphous trophoblastic fragments (TE-Type II). The TE-Type II was confirmed in the central nervous system (trophoblastic emboli in brain) and appeared to be the sudden maternal death cause.

Immunohistochemical localization of placental proteins and tumor-associated antigens in endometrial cancer and endometrial hyperplasia

As to endometrial cancer and endometrial hyperplasia, this study represents the localizations of the placental proteins and the tumor-associated antigens by both immunohistochemical light microscopy (ILM) and immunoelectron microscopy (IEM). The reagents examined include human placental lactogen (HPL), placental alkaline phosphatase (PAP), pregnancy-associated plasma protein A (PAPP-A), pregnancy-specific beta 1-glycoprotein (SP1), alpha 1-anti-trypsin (alpha-AT), and tissue polypeptide antigen (TPA). The tumor cells stained for HPL are localized and the SP1-positive cancer cells are almost entirely restricted to an infiltrating front. alpha-AT is shown in both tumor cells with marked cellular atypism and ones in deeply infiltrating foci. The immunoreactive frequency for the above six reagents in endometrial cancer is higher than that in endometrial hyperplasia. In endometrial cancer, the high frequency of an immunoreaction is confirmed in TPA (p less than 0.05). The combined stainings, i.e. either for TPA and SP1 or for TPA and PAPP-A, are efficient immunohistochemical screening methods to use in diagnosing endometrial cancer in the biopsied specimens (p less than 0.05).

Electronystagmographic assessment of cerebellar lesions

Remarkable progress has been achieved in the neurophysiological study of the cerebellum. Based on these neurophysiological data, electronystagmographic (ENG) assessment of cerebellar lesions was made to ascertain to what extent cerebellar lesions could be diagnosed. In 13 patients out of 17 whose lesions were mainly localized on one side through CT, cerebellar lesions could be diagnosed by electronystagmographic findings. In the 1 patient with amyotrophic lateral sclerosis of the remaining 4, asymptomatic cerebellar infarction was detected unexpectedly through CT. In the remaining 3 patients, differential diagnosis from brainstem lesions was difficult to evaluate on the basis of ENG findings. In 13 patients showing cerebellar signs and symptoms, pursuit eye movements, optokinetic nystagmus (OKN), and fixation-suppression of caloric nystagmus were impaired on both sides, suggesting large mass effects upon the bilateral brainstem. However, either rebound nystagmus or opposing positioning nystagmus characteristic of cerebellar lesions was detected in 13 patients (81%). The same was true in patients with bilateral cerebellar lesions. ENG test, however, could not detect any patients who showed neither cerebellar signs nor symptoms. Further investigations are needed to supplement the gap between basic and clinical research.

[Clinical significances of tissue polypeptide antigen in patients with gynecological malignancies]

Recently, tissue polypeptide antigen (TPA) has become of general interest as one of the new tumor-related antigens. In this study, TPA was measured mainly in patients with various gynecological malignancies by radioimmunoassay, and serum TPA levels above 110u/l were considered pathological. The serum TPA level in normal women was 66 +/- 21 u/l (mean +/- S.D.) and the positive rate was 0 percent. Serum TPA levels in patients with cervical cancer, endometrial cancer, ovarian cancer and uterine sarcoma (181 +/- 262, 117 +/- 49, 217 +/- 215, 142 +/- 49u/l) and positive rates (55, 40, 53, 75 percent) were significantly higher than those in normal women. Serum TPA levels in patients with advanced or recurrent diseases had a tendency to show highly positive. In all of 13 patients with positive TPA, serum TPA levels were significantly reduced and turned negative after the appropriate treatments. However, among our follow-up patients, serum TPA levels were often positive even when there was no clinical evidence of recurrence. Conclusion; serum TPA measurement could be a useful subordinate tumor marker in many patients with gynecological malignancies, even though careful judgement is necessary to interpret positive TPA.

Immuno-histological localization of tissue polypeptide antigen (TPA) in gynecological malignancies

The presence of Tissue Polypeptide Antigen (TPA) was demonstrated by immunohistochemical techniques in various specimens of gynecological malignancies as well as uterine precancerous lesions and trophoblastic disease. In 82 cases, the overall positive rate for staining was 49%. The relationship between the histological progress of malignancy and the positive rate for TPA was not confirmed, nor was the positive rate directly proportional to the histological typings. A serum TPA level of 160 U/l was considered to be the critical level of immunohistological positivity.

[A clinicopathological study of 11 patients with Paget's disease of the vulva]

A clinicopathological analysis of 11 patients with Paget's disease of the vulva was reported. A close association of this disease with cancer was strongly suggested in the histological examination. Nine of 11 patients had wide primary lesion; 4 patients had coexisting undifferentiated carcinoma (one patient with in situ sweat gland carcinoma) and one patient had squamous cell carcinoma in other lesion of the vulva. Five patients had downward growth of the tumor from the epidermis proper. There were, thus, only two patients who had Paget's cells confined within the epidermis. Three patients died of generalized metastasis of carcinoma and two patients had vulvar recurrence. The results of staining for PAS, PAS diastase resistant reaction, alcian blue, mucicarmin and carcinoembryonic antigen (CEA) were all positive in specimens with similar stainings to coexisting undifferentiated carcinoma of the vulva and metastasized lesions. CEA staining was positive in cytoplasm of Paget's cells and basal cells widely in the epidermis. It could be considered that the Paget's cells of the vulva originated multifocally from primitive stratum germinativum, which gave rise to the surface epithelium as well as all of the dermal appendages.

[Effect, toxicity and tissue concentration in the clinical use of cis-diamminedichloroplatinum (II)]

The tissue cis-diamminedichloroplatinum (II) (CDDP) concentration was measured in autopsies treated with CDDP therapy for gynecological malignancies. These cases consisted of 10 of ovarian tumor and one of choriocarcinoma. Total CDDP doses administered were from 55mg to 560mg and among them three cases were treated with more than 500mg (525mg, 555mg in ovarian cancer and 560mg in choriocarcinoma). We found moderate renal impairment with this drug by serum functional test and histopathology, although these changes did not correspond with the total doses. In liver, kidney and residual tumor measured for CDDP, the tissue concentration was highest in liver. When total doses administered were compared with the tissue concentration in liver, kidney, residual tumor and the decrease in creatinine clearance value, there were statistically significant differences only in residual tumor at p less than 0.01.