Tumor cell enrichment by tissue suspension enables detection of mutations with low variant allele frequency and estimation of germline mutations

Targeted sequencing offers an opportunity to select specific drugs for cancer patients based on alterations in their genome. However, accurate sequencing cannot be performed in cancers harboring diffuse tumor cells because of low tumor content. We performed tumor cell enrichment using tissue suspension of formalin-fixed, paraffin-embedded (FFPE) tissue sections with low tumor cell content. The enriched fractions were used to efficiently identify mutations by sequencing a target panel of cancer-related genes. Tumor-enriched and residual fractions were isolated from FFPE tissue sections of intestinal and diffuse gastric cancers harboring diffuse tumor cells and DNA of suitable quality was isolated for next-generation sequencing. Sequencing of a target panel of cancer-related genes using the tumor-enriched fraction increased the number of detectable mutations and variant allele frequency. Furthermore, mutation analysis of DNA isolated from tumor-enriched and residual fractions allowed us to estimate germline mutations without a blood reference. This approach of tumor cell enrichment will not only enhance the success rate of target panel sequencing, but can also improve the accuracy of detection of somatic mutations in archived specimens.

Identification and characterization of primary cilia-positive salivary gland tumours exhibiting basaloid/myoepithelial differentiation

Primary cilia (PC) are non-motile, antenna-like structures on the cell surface. Many types of neoplasms exhibit PC loss, whereas in some neoplasms PC are retained and involved in tumourigenesis. To elucidate the PC status and characteristics of major salivary gland tumours (SGTs), we examined 100 major SGTs encompassing eight histopathological types by immunohistochemical analysis. PC were present in all (100%) of the pleomorphic adenomas (PAs), basal cell adenomas (BCAs), adenoid cystic carcinomas (AdCCs), and basal cell adenocarcinomas (BCAcs) examined, but absent in all (0%) of the Warthin tumours, salivary duct carcinomas, mucoepidermoid carcinomas, and acinic cell carcinomas examined. PC were also detected by electron-microscopic analysis using the NanoSuit method. It is worthy of note that the former category and latter category of tumours contained and did not contain a basaloid/myoepithelial differentiation component, respectively. The four types of PC-positive SGTs showed longer PC than normal and exhibited a characteristic distribution pattern of the PC in the ductal and basaloid/neoplastic myoepithelial components. Two PC-positive carcinomas (AdCC and BCAc) still possessed PC in their recurrent/metastatic sites. Interestingly, activation of the Hedgehog signalling pathway, shown by predominantly nuclear GLI1 expression, was significantly more frequently observed in PC-positive SGTs. Finally, we identified tau tubulin kinase 2 (TTBK2) as being possibly involved in the production of PC in SGTs. Taken together, our findings indicate that SGTs that exhibit basaloid/myoepithelial differentiation (PA, BCA, AdCC, and BCAc) are ciliated, and their PC exhibit tumour-specific characteristics, are involved in activation of the Hedgehog pathway, and are associated with TTBK2 upregulation, providing a significant and important link between SGT tumourigenesis and PC. © 2021 The Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Defective repair capacity of variant proteins of the DNA glycosylase NTHL1 for 5-hydroxyuracil, an oxidation product of cytosine

The NTHL1 gene encodes DNA glycosylase, which is involved in base excision repair, and biallelic mutations of this gene result in NTHL1-associated polyposis (NAP), a hereditary disease characterized by colorectal polyposis and multiple types of carcinomas. However, no proper functional characterization of variant NTHL1 proteins has been done so far. Herein, we report functional evaluation of variant NTHL1 proteins to aid in the accurate diagnosis of NAP. First, we investigated whether it would be appropriate to use 5-hydroxyuracil (5OHU), an oxidation product of cytosine, for the evaluation. In the supF forward mutation assay, 5OHU caused an increase of the mutation frequency in human cells, and the C→T mutation was predominant among the 5OHU-induced mutations. In addition, in DNA cleavage activity assay, 5OHU was excised by NTHL1 as well as four other DNA glycosylases (SMUG1, NEIL1, TDG, and UNG2). When human cells overexpressing the five DNA glycosylases were established, it was found that each of the five DNA glycosylases, including NTHL1, had the ability to suppress 5OHU-induced mutations. Based on the above results, we performed functional evaluation of eight NTHL1 variants using 5OHU-containing DNA substrate or shuttle plasmid. The DNA cleavage activity assay showed that the variants of NTHL1, Q90X, Y130X, R153X, and Q287X, but not R19Q, V179I, V217F, or G286S, showed defective repair activity for 5OHU and two other oxidatively damaged bases. Moreover, the supF forward mutation assay showed that the four truncated-type NTHL1 variants showed a reduced ability to suppress 5OHU-induced mutations in human cells. These results suggest that the NTHL1 variants Q90X, Y130X, R153X, and Q287X, but not R19Q, V179I, V217F, or G286S, were defective in 5OHU repair and the alleles encoding them were considered to be pathogenic for NAP.

WDR62 overexpression is associated with a poor prognosis in patients with lung adenocarcinoma

Human WDR62, which is localized in the cytoplasm including the centrosome, is known to be responsible for primary microcephaly; however, the role of WDR62 abnormality in cancers remains largely unknown. In this study, we aimed to reveal the pathological role of WDR62 abnormality in lung adenocarcinoma (LAC). We first examined the WDR62 mRNA expression level of LAC (n = 64) using a QRT-PCR analysis and found that WDR62 mRNA transcripts were significantly overexpressed in LAC (P = 0.0432, Wilcoxon matched pairs test). An immunohistochemical analysis for LAC (n = 237) showed that WDR62 proteins were also significantly overexpressed in LAC (P < 0.0001, Mann-Whitney U test). A Kaplan-Meier analysis demonstrated that patients with LAC who exhibit WDR62 overexpression have a short overall survival (P = 0.0378, log-rank test), and a multivariate analysis revealed that WDR62 overexpression was an independent predictor of a poor survival outcome among LAC patients (hazard ratio, 2.032; 95% confidence interval, 1.071-3.777; P = 0.0305). Next, we examined the functional effect of WDR62 overexpression on the lung cancer cell line H1299. WDR62-overexpressing lung cancer cells exhibited an increase in cell growth. Moreover, the concurrent overexpression of WDR62 and TPX2, a WDR62-interacting protein that is also overexpressed in LAC, induced centrosome amplification in the lung cells. Finally, we disclosed that the concurrent overexpression of WDR62 and TPX2 is common in diverse human cancers, using data from the Cancer Genome Atlas. These results suggested that WDR62 overexpression is associated with a poor prognosis in patients with LAC and leads to an increase in the malignant potential of lung cells.

Comparative study on the effectiveness of corticosteroid injections between trigger fingers with and without proximal interphalangeal joint flexion contracture

Trigger fingers with proximal interphalangeal joint flexion contracture are suggested to have a poorer response to corticosteroid injection than those without contracture, though this has not been proven scientifically. We compared the clinical response to corticosteroid injection between trigger fingers with and without proximal interphalangeal joint contracture, and investigated the influence of the injection on the A1 pulley and flexor digitorum tendons using ultrasonography. One month after injection, pain was significantly reduced in the no contracture group, and 56% of trigger fingers with proximal interphalangeal joint contracture resolved. Before injection, relative thickening of the A1 pulley and flexor digitorum tendons, and a partial hypoechoic lesion of the flexor digitorum superficialis tendon were observed in the contracture group. One month after injection, the thickening of the tendons and the A1 pulley was reduced, but the partial hypoechoic lesion was still observed in significant numbers. We have demonstrated that the presence of a proximal interphalangeal joint contracture was associated with a reduced clinical response to corticosteroid injection, and we suggest that the pathologic change in the flexor digitorum superficialis tendon, represented by the partial hypoechoic lesion, contributed to corticosteroid injection resistance.

LEVEL OF EVIDENCE

IV.

NEIL1 p.Gln282Stop variant is predominantly localized in the cytoplasm and exhibits reduced activity in suppressing mutations

Human NEIL1 protein is a DNA glycosylase known to be involved in the repair of oxidized DNA lesions. A c.C844T germline variant of the NEIL1 gene has recently been identified in the Japanese population, however, the p.Q282Stop-type protein produced from this variant gene has not yet been characterized. In this study to determine whether the NEIL1 c.C844T variant might be a defective allele, we investigated the subcellular localization of the p.Q282Stop-type protein and its ability to suppress the development of mutations in mammalian cells. In contrast to the nuclear localization of wild-type (WT) NEIL1, the p.Q282Stop-type protein tagged with GFP or FLAG was localized predominantly in the cytoplasm of human H1299 cells. Mutant forms of the putative nuclear localization signal (NLS, amino acid sequences 359 to 378) of NEIL1-GFP resulted in predominant cytoplasmic localization of the mutants, suggesting that the abnormal localization of p.Q282Stop-type NEIL1 may also be caused by a loss of the putative NLS in the protein. Next, V79 mammalian cell lines inducibly expressing WT NEIL1 or p.Q282Stop-type NEIL1 were established using the piggyBac transposon vector system, and the mutation frequency was compared between the cell lines by HPRT assay. The frequency of mutations induced by glucose oxidase, an oxidative stress inducer, was higher in the p.Q282Stop-type NEIL1-transposed cells than that in the WT NEIL1-transposed cells. Finally, the Cancer Genome Atlas (TCGA) data showed an increased number of somatic mutations in primary carcinomas containing a truncating NEIL1 mutation. These results suggest that p.Q282Stop-type NEIL1 is predominantly localized in the cytoplasm, possibly due to a loss of the NLS, and possesses a reduced ability to suppress the onset of mutations, both findings suggesting that NEIL1 c.C844T is a defective allele.

BSND and ATP6V1G3: Novel Immunohistochemical Markers for Chromophobe Renal Cell Carcinoma

Differentiating between chromophobe renal cell carcinoma (RCC) and other RCC subtypes can be problematic using routine light microscopy. This study aimed to identify novel immunohistochemical markers useful for a differential diagnosis between chromophobe RCC and other RCC subtypes. We selected 3 genes (including BSND and ATP6V1G3) that showed specific transcriptional expression in chromophobe RCC using expression data (n = 783) from The Cancer Genome Atlas (TCGA) database. A subsequent immunohistochemical examination of 186 RCCs obtained in our patient series resulted in a strong diffuse positivity of BSND and ATP6V1G3 proteins (both of which are involved in the regulation of membrane transport) in all the chromophobe RCC specimens (23/23 cases, 100%) but not in the clear cell RCC specimens (0/153 cases, 0%) or the papillary RCC specimens (0/10 cases, 0%). BSND and ATP6V1G3 protein expressions were also detected in renal oncocytoma (13/14 cases, 92.9%) and in the distal nephron, including the collecting duct, in the normal kidney. A computational analysis of TCGA data suggested that DNA methylation was involved in the differential expression pattern of both genes among RCC subtypes. Finally, an immunohistochemical analysis showed lung carcinomas were negative (0/85 cases, 0%) for the expression of both proteins. These results suggest that BSND and ATP6V1G3 are excellent novel immunohistochemical markers for differentiating between chromophobe RCC and other subtypes of RCC, including clear cell and papillary RCCs.

SASS6 overexpression is associated with mitotic chromosomal abnormalities and a poor prognosis in patients with colorectal cancer

Spindle assembly abnormal protein 6 homolog (SASS6) plays an important role in the regulation of centriole duplication. To date, the genetic alteration of SASS6 has not been reported in human cancers. In the present study, we examined whether SASS6 expression is abnormally regulated in colorectal cancers (CRCs). Increased SASS6 mRNA and protein expression levels were observed in 49 (60.5%) of the 81 primary CRCs and 11 (57.9%) of the 19 primary CRCs, respectively. Moreover, the upregulation of SASS6 mRNA expression was statistically significant (P=0.0410). Next, using DLD-1 colon cancer cells inducibly expressing SASS6, SASS6 overexpression was shown to induce centrosome amplification, mitotic abnormalities such as chromosomal misalignment and lagging chromosome, and chromosomal numerical changes. Furthermore, SASS6 overexpression was associated with anaphase bridge formation, a type of mitotic structural abnormality, in primary CRCs (P<0.01). SASS6 upregulation in colon cancer was also revealed in the Cancer Genome Atlas (TCGA) data and was shown to be an independent predictor of poor survival (multivariate analysis: hazard ratio, 2.805; 95% confidence interval, 1.244‑7.512; P=0.0112). Finally, further analysis of the TCGA data demonstrated SASS6 upregulation in a modest manner in 8 of 11 cancer types other than colon cancer, and SASS6 upregulation was found to be associated with a poor survival outcome in patients with kidney renal cell carcinoma and lung adenocarcinoma. Our present findings revealed that the upregulation of SASS6 expression is involved in the pathogenesis of CRC and is associated with a poor prognosis among patients with colon cancer. They also suggest that SASS6 upregulation is a genetic abnormality relatively common in human cancer.

A comparison of 3-D computed tomography versus 2-D radiography measurements of ulnar variance and ulnolunate distance during forearm rotation

Positive ulnar variance is associated with ulnar impaction syndrome and ulnar variance is reported to increase with pronation. However, radiographic measurement can be affected markedly by the incident angle of the X-ray beam. We performed three-dimensional (3-D) computed tomography measurements of ulnar variance and ulnolunate distance during forearm rotation and compared these with plain radiographic measurements in 15 healthy wrists. From supination to pronation, ulnar variance increased in all cases on the radiographs; mean ulnar variance increased significantly and mean ulnolunate distance decreased significantly. However on 3-D imaging, ulna variance decreased in 12 cases on moving into pronation and increased in three cases; neither the mean ulnar variance nor mean ulnolunate distance changed significantly. Our results suggest that the forearm position in which ulnar variance increased varies among individuals. This may explain why some patients with ulnar impaction syndrome complain of wrist pain exacerbated by forearm supination. It also suggests that standard radiographic assessments of ulnar variance are unreliable.

A novel cluster of mariner-like elements belonging to mellifera subfamily from spiders and insects: implications of recent horizontal transfer on the South-West Islands of Japan

Mariner-like elements (MLEs) have been isolated from various eukaryotic genomes and they are divided into 15 subfamilies, including main five subfamilies: mauritiana, cecropia, mellifera/capitata, irritans, and elegans/briggsae. In the present study, MLEs belonging to mellifera subfamily were isolated from various spiders and insects (Hymenoptera and Lepidoptera) inhabiting the South-West Islands of Japan and neighboring regions. MLEs isolated from 15 different species formed a distinct novel cluster in mellifera subfamily. MLEs obtained from three different species [i.e., the bee Amegilla senahai subflavescens (Amsmar1), the wasp Campsomeris sp. (Casmar1), and the swallowtail butterfly Pachliopta aristolochiae (Paamar1)] contained an intact open reading frame that encoded a putative transposase. These transposases exhibited high similarity of 97.9% among themselves. In case of Casmar1, the presence of an intact ORF was found in high frequencies (i.e., 11 out of 12 clones). In addition, these transposases also showed the presence of a terminal inverted repeat-binding motif, DD(34)D and two highly conserved amino acid motifs, (W/L)(I/L)PHQL and YSP(D/N)L(A/S)P. These two motifs differed from previously known motifs, WVPHEL and YSPDLAP. MLEs isolated from these three different species may have been inserted into their genomes by horizontal transfer. Furthermore, the presence of an intact ORF suggests that they are still active in habitats along these isolated islands.

Giant spin Hall effect induced by skew scattering from bismuth impurities inside thin film CuBi alloys

We demonstrate that a giant spin Hall effect (SHE) can be induced by introducing a small amount of Bi impurities in Cu. Our analysis, based on a new three-dimensional finite element treatment of spin transport, shows that the sign of the SHE induced by the Bi impurities is negative and its spin Hall (SH) angle amounts to -0.24. Such a negative large SH angle in CuBi alloys can be explained by applying the resonant scattering model proposed by Fert and Levy [Phys. Rev. Lett. 106, 157208 (2011)] to 6p impurities.

CLOCK gene T3111C polymorphism is associated with Japanese schizophrenics: a preliminary study

The CLOCK gene has attracted attention due to its influence on the circadian rhythm, as well as its impacts on the dopaminergic system. We conducted a preliminary study to examine whether the T3111C single nucleotide polymorphism of the CLOCK gene is associated with the development of schizophrenia by examining samples from schizophrenics (n=145) and normal controls (n=128). Both genotype and allele frequencies were significantly different between schizophrenics and controls (p=0.022, p=0.015, respectively). Schizophrenics had a significantly higher frequency of the C allele compared to controls (odds ratio 1.76, 95% CI 1.12-2.75). In particular, disorganized and residual type schizophrenics had significantly higher C allele frequencies than controls (p=0.004 and p=0.037, respectively). Our results suggest that the T3111C polymorphism of the CLOCK gene is associated with schizophrenia. It is important to explore the association between CLOCK and dopamine function, and to examine the impact of CLOCK on phenotypes such as symptoms and drug response in patients with schizophrenia.

[Surgical treatment for thoracoabdominal aortic aneurysm]

Spinal cord injury such as paraparesis and paraplegia remains one of the major concerns in surgery on the thoracoabdominal aortic aneurysm (TAAA). We utilize spinal cord protection including cerebrospinal fluid drainage (CSFD), adjuncts of aortic distal perfusion, reconstruction of the intercostal or lumbar arteries and deep hypothermia in TAAA repair. This report describes the results of surgical treatment for TAAA including postoperative neurological outcome. Between October 1999 and January 2004, 33 patients (mean age 66 years; range 26 to 81) underwent TAAA repair. Adamkiewicz artery could be detected using magnetic resonance angiography in 9 patients. CSFD was done in 20 patients. TAAA repair was achieved using adjuncts of aortic distal perfusion in 31 patients (partial cardiopulmonary bypass: 19, deep hypothermia: 9, left heart bypass: 3). We tried to reconstruct the intercostal or lumbar arteries which were located between Th8 and L2 as possible. Twenty-five patients underwent reconstruction of the intercostal or lumbar arteries. There were 6 hospital deaths. Postoperative spinal cord injury occurred in 4 patients (paraparesis: 1, paraplegia: 3). This clinical experience demonstrates that current technical strategies enable patients to undergo TAAA repair with acceptable early survival. However, despite aggressive spinal cord protection, few patients suffered from postoperative spinal cord injury. Future research should focus on spinal cord protection in patients with TAAA.

[Management for type A acute dissection]

From March 1998 to May 2002, we experienced 46 patients with type A acute dissection (AAD). Fifteen patients managed initially with conservative treatment because of intramular hematoma (IH, n = 10), broad cerebral infarction (n = 3), others (n = 2). One who diagnosed IH at admission progressed to AAD and underwent surgery. However his diagnosis of IH at admission was proved to be misdiagnosis retrospectively. In 8 of the remaining 9 patients, hematoma disappeared during the follow-up of 6 months to 1 year. In patients with broad cerebral infarction, 2 died early after admission and 1 discharged with hemiplegia. Thirty-two patients underwent surgery and 1 with preoperative broad cerebral infarction died 36 days after surgery. In the remaining 31 patients, 30 patients discharged ambulatory.

Retinal vascular findings and penile cavernosal artery blood flow

OBJECTIVE

To assess the correlation between retinal vascular findings and penile cavernosal arterial blood flow, as it is probable that systemic atherosclerotic vascular disease is important in male erectile dysfunction (ED), and being systemic, it might be possible to evaluate the extent of atherosclerosis from retinal vascular findings.

PATIENTS AND METHODS

The study included 75 patients with ED; any with a history of pelvic injury, pelvic surgery, or diabetes mellitus were excluded. All patients gave fully informed consent. Ocular fundus photographs were taken with an automatic-focus fundus camera under amydriatic conditions. Three ophthalmologists, unaware of the patients' detailed data, evaluated the photographs using Hyman's classification to evaluate retinal vascular findings. Blood flow in the penile cavernosal artery was measured with colour Doppler ultrasonography, and the peak systolic velocity used as a haemodynamic variable. Correlations among the peak systolic velocity, retinal vascular findings and vascular risk factors (including hypertension, age, cigarette smoking, and hyperlipidaemia) were investigated using multivariate analysis.

RESULTS

Of the 75 patients, 72 (96%) had both right and left retinal vascular images of sufficient quality for evaluation; 37 were classified as normal and 35 as Grade I, while no patient was Grade II. From a logistic regression multivariate analysis, the peak systolic velocity was the only significant factor correlating with retinal vascular findings, with an odds ratio of 3.34. In contrast, hypertension, age, cigarette smoking and hyperlipidaemia did not correlate significantly with the retinal vascular findings. Similarly, the retinal vascular finding was the only significant factor correlating with the peak systolic velocity of cavernosal blood flow (odds ratio 3.28) and again hypertension, age, cigarette smoking and hyperlipidaemia were not significant factors.

CONCLUSIONS

These findings support the assumption that penile erectile function is one of the diseases of atherosclerosis, and emerges nearly simultaneously with retinal vascular disease. It is possible to predict penile arterial conditions in patients with ED from their retinal vascular findings. Thus, amydriatic fundoscopy, a simple practical examination, may be helpful for primary physicians in diagnosing and treating ED.

A polymerase chain reaction-based method for cloning novel members of a gene family using a combination of degenerate and inhibitory primers

We have developed a novel method for cloning gene family members by using a polymerase chain reaction technique. The method is based on the amplification of a broad range of homologous genes in combination with the specific inhibition of already cloned genes. To accomplish this, we designed degenerate primers to highly conserved regions among the gene family members, and inhibitory primers to the divergent region at the 3'-margin of each degenerate primer. The 5'-end of the inhibitory primer, the 3'-end of which was aminated, had 3-4 bases overlapping the 3'-end of the degenerate primer. The potential of this method was demonstrated by the successful cloning of a novel member of the yeast MKC7/YAP3 gene family homologue from a filamentous fungus, Aspergillus oryzae, by inhibiting amplification of an already cloned homologue, opsB.

Association analysis of polymorphisms in the prepronociceptin gene and schizophrenia

The human prepronociceptin (ppNoc) gene is located on chromosome 8p21, and several linkage studies have suggested that the susceptibility locus for schizophrenia is present in this chromosomal region. We investigated genetic variations in the promoter and coding regions of the ppNoc gene to determine if there may be an association between naturally occurring mutations and the manifestation of schizophrenia. Association analyses for the variations found were conducted between 87 unrelated schizophrenic patients and 100 healthy controls. Polymorphisms were found at both the -503 locus (G/A) in the promoter region and the 353 locus (Ala118Gly) in exon 3. Additionally, rare variants were identified at the -261 locus (A/G) in the promoter region, the 515 locus (Gln172Arg) in exon 3, and the 561 locus (G/A) in the untranslated region of exon 3. A significant difference was observed in allele frequency at the 353 locus between controls and patients with continuous-course schizophrenia (P = 0.0237), and between patients with and without prominent negative symptoms (P = 0.0201). However, neither difference was significant after Bonferroni correction. In addition, there were no significant differences in genotype and allele frequencies at either the -503 or 353 locus between the control group and patients with schizophrenia. These results suggest that ppNoc gene polymorphisms have no association with schizophrenia.

Spring balance evaluation of the ischiocavernosus muscle

We studied the voluntary contractile activity of the ischiocavernosus muscle (ICM) in 21 sexually potent and 97 erectile dysfunction (ED) subjects using a spring balance. A strap was placed around the coronal grove of the glans penis and tensioned with the spring balance. Subjects were asked and encouraged to contract the ICM against the spring balance. We evaluated the length of stroke, duration of contraction, and maximum contractile force. The length of stroke, duration of contraction, and maximum contractile force showed statistically significant differences between potent and ED subjects. Diagnosed psychogenic ED and arteriogenic ED showed higher contractile activity than cavernous ED and neurogenic ED. Our results corresponded to those of previous studies that have urged consideration of the role of the ICM during the process of erection in animal experiments and in human electrophysiological studies. The spring balance evaluation is a useful, inexpensive method for evaluating the ICM.

Linked polymorphisms (-333G>T and -286A>G) in the promoter region of the CCK-A receptor gene may be associated with schizophrenia

Cholecystokinin A receptors (CCKAR) modulate CCK-stimulated dopamine release, and mutations in the CCKAR gene may predispose affected individuals to schizophrenia. Our previous study suggested that -286A>G polymorphism (previously named 201A>G) in the CCKAR gene promoter is associated with schizophrenia. In the present study, we carried out a further investigation of the promoter and intron 1 of the CCKAR gene. In addition to polymorphisms reported previously (-333G>T, -286A>G, -241G>A, 773A>T, and 779T>C), two novel polymorphisms (-388(GT)(8)>(GT)(9) and -85C>G) were identified. These polymorphisms were in a linkage disequilibrium. Association analyses between schizophrenic patients and controls revealed that the frequencies of the A allele and AA genotype at the -286 loci, as well as the frequency of the GG genotype at the -333 loci, were significantly higher in patients than in controls. Furthermore, patients with paranoid type schizophrenia, auditory hallucinations, or a positive family history had a significantly higher frequency of the -286A allele than the control group. The results supported our previous data, and suggest the possible involvement of the -333G>T and the -286A>G polymorphisms in the promoter region of the CCKAR gene in the predisposition to schizophrenia.

Feasibility of multi-slice computed tomography in the diagnosis of arteriogenic erectile dysfunction

OBJECTIVE

To compare computed tomography (CT) angiography (CTA) obtained by multi-slice CT (a new minimally invasive method) with the current standard of arterial imaging, digital subtraction angiography (DSA), in diagnosing arteriogenic erectile dysfunction (ED).

PATIENTS AND METHODS

Twenty-one patients with suspected arteriogenic ED underwent DSA and CTA after providing informed consent. Prostaglandin E1 was injected into the penile cavernosal body and then non-ionic contrast medium was rapidly infused into the antecubital vein. The DSA and CTA images were diagnosed as showing a normal or abnormal status by three reviewers independently. CTA was undertaken on an outpatient basis but DSA required hospitalization.

RESULTS

In the 42 internal pudendal arteries, DSA showed 28 normal and 14 impaired arteries; CTA showed 21 normal arteries and 21 occlusions. The CTA image correlated closely with the diagnosis of stenosis or occlusion in internal pudendal arteries, with a sensitivity of 93%, a specificity of 71% and an accuracy of 79%. In the cavernosal arteries, DSA depicted 14 normal and 28 impaired arteries; CTA showed seven normal arteries and 35 occlusions. The CTA image agreed closely with the diagnosis of stenosis or occlusion in cavernosal arteries, with a sensitivity of 96%, a specificity of 43% and an accuracy of 79%. Of the 42 inferior epigastric arteries, DSA could not depict 11 arteries but CTA showed all 42 inferior epigastric arteries.

CONCLUSIONS

CTA images correlated with DSA images; at present DSA is better than CTA in visualizing stenosis in fine arteries. However, CTA is less invasive and relatively inexpensive, and in future will probably provide even greater improvements in graphic quality. CTA would be an adequate replacement for DSA in evaluating internal pudendal arterial stenosis.

[Treatment of phimosis with betamethasone ointment in children]

OBJECTIVE

We evaluated the efficacy of betamethasone ointment in the treatment of childhood phimosis and determined the most effective concentration of betamethasone.

MATERIAL AND METHODS

Between August 1996 and May 2000, 69 patients (median age 3.0, range 0-12) presented to our department with severe phimosis (grade 4, Tsugaya's classification), and were enrolled in this study and treated with betamethasone ointment for 4 weeks. The ointment was applied on the narrowed preputial skin twice a day by parents. During the first week, parents were asked not to retract the foreskin. After this period, parents were encouraged to retract the foreskin gently and without intense tension. The concentration of betamethasone were 0.12%, 0.05% and 0.025%. If the patients become to be able to retract foreskin satisfactory, we consider the state as complete response. If he become to be able to retract to allow partial exposure of the glans, we consider the state as partial response. We compared the efficacy among each of the concentrations, and at 3 months after the end of the treatment, we also assessed the adverse effects and recurrence.

RESULTS

The overall success rate was 85.5%. Success rates with 0.12%, 0.05% and 0.025% ointment were 96.8%, 82.8% and 55.6%, respectively (p = 0.0001). The 0.12% ointment was most effective. Recurrence was observed in 3 patients (4.3%). No adverse effects were observed in any of the patients.

CONCLUSIONS

Treatment with betamethasone ointment is very effective, easy and safe. We recommend betamethasone ointment as the first treatment of choice for childhood phimosis.

Effect of radical retropubic prostatectomy on erectile function, evaluated before and after surgery using colour Doppler ultrasonography and nocturnal penile tumescence monitoring

OBJECTIVE

To assess the effect of radical retropubic prostatectomy on erectile function, by evaluating objectively patients' erectile function before and after surgery.

PATIENTS AND METHODS

The study comprised 126 patients with clinically localized prostate cancer who were scheduled to undergo radical retropubic prostatectomy. After giving informed consent for the study, 123 patients underwent intracavernosal injection tests, colour Doppler ultrasonography and nocturnal penile tumescence monitoring before and after surgery.

RESULTS

From the intracavernosal injection tests and nocturnal penile tumescence monitoring, 21 patients (17%) were evaluated as having normal erectile function before surgery. After radical retropubic prostatectomy, nine (43%) of these 21 potent men had preserved erectile function. In eight patients whose neurovascular bundles were preserved, five were potent after surgery. The cause of erectile function after surgery was a neurogenic disorder in seven and a related vascular disorder in five.

CONCLUSION

From objective tests of erectile function on patients scheduled to undergo radical prostatectomy, 17% had normal erectile function. However, even after nerve-sparing radical retropubic prostatectomy, the proportion retaining potency was unsatisfactory. Although a neurological disorder was the main cause of erectile dysfunction after surgery, vascular disorders were also important.

Polymorphism of the 5'-upstream region of the human SNAP-25 gene: an association analysis with schizophrenia

Recent studies have suggested that synaptic abnormalities may be part of the pathophysiology of schizophrenia. SNAP-25 (synaptosomal-associated protein of 25 kD) is one of the synaptic proteins responsible for presynaptic neurotransmission, axonal elongation and synaptogenesis. Genetic variation in the 5'-upstream region of the SNAP-25 gene was analyzed in 87 unrelated schizophrenic patients and 100 healthy controls. A novel polymorphic (TAAA)(n) tandem repeat was identified in the 5'-upstream region. There were no significant differences between the patient and the control groups in the distribution of repeat numbers of alleles or genotypes. In addition, no associations were found between the polymorphism for subtypes, longitudinal courses or positive family history of the patients. Our results suggest that polymorphisms in the 5'-upstream region of the SNAP-25 gene have no association with schizophrenia.

Polymorphisms in the promoter and coding regions of the synapsin III gene. A lack of association with schizophrenia

The human synapsin III gene, located on chromosome 22q12-13, has previously been reported to indicate a susceptibility for schizophrenia. Noval rare variants (Thr136Thr in exon 3, Pro468Ser, Glu525Gln and Pro534Leu in exon 12, and 1769 G/C in the untranslated region of exon 13) were found in addition to the polymorphic variant (-196 G/A in the promoter region). No significant differences in genotypic or allelic frequencies of the -196 G/A polymorphism were found between 87 unrelated schizophrenic patients and 100 healthy controls, even when the patients were diagnostically subdivided into subtypes and course specifiers. Furthermore, allelic frequencies of the GATG repeat in intron 1 were not significantly different between the patients and the controls. These results suggest that synapsin III gene polymorphisms are not associated with schizophrenia.

Apoptosis/differentiation-inducing effects of vitamin K2 on HL-60 cells: dichotomous nature of vitamin K2 in leukemia cells

We originally reported that vitamin K2 (VK2) analogs, including menaquinone 4 (MK4) but not vitamin K1, effectively induce apoptosis in various types of primary cultured leukemia cells and leukemia cell lines in vitro. It has also been reported by others that VK2 showed the differentiation-inducing activity in leukemia cell lines. To investigate the discrepancy between apoptosis- and differentiation-inductions of leukemia cells by VK2 treatment, we used bcl-2 gene transfected HL-60 cells (HL-60-bcl-2) which resulted in five-fold over-expression of BCL-2 protein, and then compared the effects of MK4 to the control HL-60-neo cells. Seventy-two hours of exposure to various concentrations of MK4 resulted in growth inhibition of these cells in a dose-dependent manner (0.1-50 microM), however, HL-60-bcl-2 was less sensitive against MK4. MK4 potently induced apoptosis of HL-60-neo cells along with the depolarization of mitochondrial membrane potential and caspase-3 activation. Notably, HL-60-bcl-2 was almost completely resistant to apoptosis induction in response to MK4, although cell growth inhibition was still observed. In spite of the abrogation of apoptosis induction, about 90% of HL-60-bcl-2 cells were arrested in the G0/G1 phase within 48 h of exposure to 10 microM of MK4 accompanied by up-modulation of p27KIP1 expression. Concomitantly, HL-60-bcl-2 cells underwent monocytic differentiation. These data suggest that VK2 also shows the differentiation inducing effects on leukemia cells which are resistant against VK2-inducing apoptosis. The dichotomous nature of VK2 against leukemia cells appears to have clinical benefits for the treatment of patients with leukemias and myelodysplastic syndromes.

Management of pancreatic arteriovenous malformation

Pancreatic arteriovenous malformations (AVM), while extremely rare, are frequently complicated by gastrointestinal bleeding. The elimination of pancreatic AVM is difficult once portal hypertension has developed. We describe herein a patient with congenital AVM of the pancreatic head presenting with recurrent episodes of melena, in whom pylorus-preserving pancreatoduodenectomy provided a means of definitive management. We also review the literature and focus on the diagnostic and therapeutic approaches. Angiography is always necessary to facilitate tactics of treatment, even if diagnosis has been established by non-invasive imaging modalities. To obtain complete regression, total extirpation of the affected organ, or at least the involved portion, should be performed before this disease leads to the lethal complications of gastrointestinal bleeding and portal hypertension. Transcatheter arterial embolization is the only alternative treatment for the control of hemorrhage.

MALT lymphoma originating in breast and uvula

A case of marginal zone B cell lymphoma of MALT type arising in the uvula and breast is reported. The patient, a 30-year-old woman who delivered a child and lactated in 1997, was suffering from Sjögren syndrome (SS). She was diagnosed with MALT lymphoma after a biopsy of the right breast and uvula. To investigate the relationship of the delivery, lactation and MALT lymphoma, we examined the immunohistochemical analysis of hormone receptors. As a result, lymphoid cells of the breast were stained with anti-progesterone receptor antibodies in the cytoplasm. Consequently, the MALT lymphoma of the uvula appeared to be associated with SS. Moreover, hormones such as progesterone may have influenced the breast involvement of MALT lymphoma in our case.

Synthesis and structure–activity relationships of potent and orally active sulfonamide ETB selective antagonists

The synthesis and structure activity relationships of a series of N-pyrimidinyl benzenesulfonamides as ETB selective antagonists are described. N-Isoxazolyl benzenesulfonamide 1a, previously reported, (1) was selected as a lead compound, and isosteric replacement of the isoxazole ring of 1a with a pyrimidine ring led to the discovery of the highly potent ETB selective antagonist 6e with oral bioavailability. Modification of the terminal aldehyde group at the 6-position of the pyrimidine ring was investigated, and malonate 15b and acylhydrazone 16f were found to be equipotent to aldehyde 6e. Compound 6e showed ETB antagonistic activity on in vivo evaluation.

Screening of ischemic heart disease with cavernous artery blood flow in erectile dysfunctional patients

Erection is a hemodynamic event and accordingly, erectile dysfunction (ED) is closely related with ischemic heart disease. We should confirm that the cardiac condition of the ED patient is safe enough to perform sexual intercourse prior to beginning treatment for ED. Asymptomatic ischemic heart disease cannot be diagnosed only in an interview, but it's difficult to perform cardiac exercise tests on all patients complaining of ED. Therefore, screening methods to evaluate patients who should undergo exercise tests are needed. Sixty patients with erectile dysfunction participated in this study. Physical examinations, interviews, and color Doppler examinations were conducted. Chest X-rays and electrocardiograms of all patients in the resting position were obtained, as were electrocardiograms following exercise. Echocardiograms, treadmill test results, thallium exercise scintigrams, and coronary angiograms were obtained as required for diagnosis. Two patients were excluded because they had obvious arteriogenic ED due to perineal injury. Fifty-eight patients underwent Doppler evaluations of their cavernous arteries and heart exercise tests. Fourteen patients (24.1%) were diagnosed with ischemic heart disease. Although six of them had already been diagnosed with ischemic heart disease, eight were newly diagnosed by the exercise tests. Cardiovascular risk factors such as advanced age, hyperlipidemia, diabetes mellitus, hypertension, smoking, and obesity were not sufficient predictive factors. The mean peak systolic velocity of the patients without ischemic heart disease was 34.6 cm/s vs 22.0 cm/s in those with ischemic heart disease. Only 3.7% of patients whose peak systolic velocity in the cavernous artery was equal to or exceeded 35 cm/s had ischemic heart disease. On the other hand, 41.9% of patients with peak systolic velocity of less than 35 cm/s had ischemic heart disease. The sensitivity of peak systolic velocity against ischemic heart disease was 92.9%, and specificity was 59.1%. In ED patients, incidences of complications involving symptomatic or asymptomatic ischemic heart disease were found to be high. The peak systolic velocity in the cavernous artery is thought to be a useful predictive factor of ischemic heart disease in ED patients. When a patient reveals a peak systolic velocity of less than 35 cm/s, he should undergo heart exercise tests prior to treatment of ED.

Impending rupture in an aortic arch aneurysm by Candida infection

A 68-year-old man was hospitalized with the complaints of left back pain and fever. He had a history of using steroids to treat uveitis for about thirty years. Computed tomography on the chest demonstrated an impending rupture in an aortic arch aneurysm, which was consequently surgically excised. Candida albicans was identified in the wall of the aneurysm, so fluconazole and itraconazole were administered. The patient was discharged at 120 days after surgery without recrudescence of the candida. To our knowledge, this is the fifteenth case of a successfully treated aneurysm caused by candida infection.

Glutathione S-transferase M1 gene deletion may be associated with susceptibility to certain forms of schizophrenia

Recent studies have revealed that GSTM1 and M2 of the mu-class glutathione S-transferases catalyze a glutathione conjugate of catechol o-quinones including dopachrome, noradrenochrome, and adrenochrome under physiological conditions. Reduced or negative levels of activity amongst these enzymes would lead to an excess of neurotoxic compounds of catecholamine o-quinones. A defect in the mechanisms responsible for this form of detoxification may contribute to the development of certain forms of schizophrenia. We have performed a case-control study to explore the association between schizophrenia and polymorphism of the GSTM1 gene. DNA samples were obtained from 87 unrelated patients with schizophrenia who met the DSM-IV criteria for schizophrenia and from 176 control subjects. Individuals of both groups were ethnically Japanese and were from the same district. GSTM1 polymorphism was determined using the polymerase chain reaction method. The frequency of the GSTM1*0 allele was significantly higher amongst the patients with schizophrenia compared to controls (P = 0.0075). Moreover, the incidence of the GSTM1*0 was significantly higher amongst the schizophrenic patients classified as disorganized type (P = 0.0008), relative to the control sample. Our findings suggest that the GSTM1*0 is associated with an increased susceptibility to schizophrenia, particularly disorganized type of the disease. It is therefore likely that the GSTM1 gene deletion constitutes to vulnerability for disease states of this kind, rather than being the direct cause of schizophrenic conditions.

DNA G+C content of the third codon position and codon usage biases of human genes

The human genome, as in other eukaryotes, has a wide heterogeneity in the DNA base composition. The evolutionary basis for this heterogeneity has been unknown. A previous study of the human genome (846 genes analyzed) has shown that, in the major range of the G+C content in the third codon position (0.25-0.75), biases from the Parity Rule 2 (PR2) among the synonymous codons of the four-codon amino acids are similar except in the highest G+C range (Sueoka, N., 1999. Translation-coupled violation of Parity Rule 2 in human genes is not the cause of heterogeneity of the DNA G+C content of third codon position. Gene 238, 53-58.). PR2 is an intra-strand rule where A=T and G=C are expected when there are no biases between the two complementary strands of DNA in mutation and selection rates (substitution rates). In this study, 14,026 human genes were analyzed. In addition, the third codon positions of two-codon amino acids were analyzed. New results show the following: (a) The G+C contents of the third codon position of human genes are scattered in the G+C range of 0.22-0.96 in the third codon position. (b) The PR2 biases are similar in the range of 0.25-0.75, whereas, in the high G+C range (0.75-0.96; 13% of the genes), the PR2-bias fingerprints are different from those of the major range. (c) Unlike the PR2 biases, the G+C contents of the third codon position for both four-codon and two-codon amino acids are all correlated almost perfectly with the G+C content of the third codon position over the total G+C ranges. These results support the notion that the directional mutation pressure, rather than the directional selection pressure, is mainly responsible for the heterogeneity of the G+C content of the third codon position.

Pharmacogenomics and schizophrenia

Although antipsychotic drugs are effective in alleviating schizophrenic symptoms, individual differences in patient response suggest that genetic components play a major role, and pharmacogenetic studies have indicated the possibility for a more individually based pharmacotherapy. The new field of pharmacogenomics, which focuses on genetic determinants of drug response at the level of the entire human genome, is important for development and prescription of safer and more effective individually tailored drugs. DNA microarray (DNA chip) analysis enables genome-wide scanning, using the high-density single nucleotide polymorphisms map. Pharmacogenomics will aid in understanding how genetics influence disease development and drug response, and contribute to discovery of new treatments. The rate of discovery of those polymorphisms will depend on the quality of the drug response phenotype. Prospective genotyping of schizophrenic patients for the many genes at the level of the drug target, drug metabolism, and disease pathways will contribute to individualized therapy matching the patient's unique genetic make-up with an optimally effective drug.

[Rapidly progressive fibrosis and increased CD68-positive cells in the bone marrow at the terminal stage of adult T-cell leukemia accompanied by polycythemia vera]

We report a case of adult T-cell leukemia (ATL) accompanied by polycythemia vera (PV) in which rapid development of myelofibrosis and clinical features of hemophagocytic syndrome (HPS) were observed at the terminal stage. The patient, a 53-year-old man who was born in Oita Prefecture, Japan, was diagnosed as having PV in 1996. He had undergone venesection but had not received any chemotherapy. In June 1997, he showed systemic lymphadenopathy with positivity for serum HTLV-1 antibody (x 10,240). Pathological findings and Southern blotting analysis for detection of monoclonal integration of HTLV-1 provirus DNA in a lymph node biopsy sample revealed that he also had acute-type ATL. Although several courses of chemotherapy were transiently effective, high fever, pancytopenia, increased serum LDH, hypoproteinemia and hyperferritinemia appeared, all of which were compatible with the clinical features of HPS. In addition, cytomegalovirus infection became evident. He died of multiple organ failure with rapid progression of myelofibrosis in May 1998. Detection of both increased CD68-positive histiocytes by immunohistochemistry and iron-stained phagocytic cells in marrow biopsy specimens appeared to be helpful for diagnosis of HPS in this patient, whose marrow showed myelofibrosis with hypocellularity.

[Ischemic heart disease in patients with erectile dysfunction]

BACKGROUND

Erection is an hemodynamic event and accordingly, erectile dysfunction is closely related with ischemic heart diseases. Sufficient study has yet to be made of this relation.

METHOD

Fifty-eight patients with erectile dysfunction participated in the present study. Intracavernous injection tests and color Doppler examination were conducted for assessment of erectile function. For patients with history of ischemic heart disease, we referred to their doctor for data from their examinations. For patients otherwise, chest X-rays and electrocardiograms in the resting position were obtained and also electrocardiograms following exercise. Echocardiograms, treadmill test results, thallium exercise scintigrams, and coronary angiograms were obtained as requires for diagnosis.

RESULTS

Eighteen patients (31.0%) were diagnosed as ischemic heart disease or at high risk. Although 6 of them had been already diagnosed with ischemic heart disease, 12 were newly diagnosed by the exercise tests. Among these 18 patients 16 had one or more significant risk factors for ischemic heart disease such as age, hyperlipidemia, and diabetes mellitus. 3.7% of patients whose peak systolic velocity in the cavernous artery was equal to or exceeded 35 cm/sec had ischemic heart disease or were at high risk. 54.8% of patients with peak systolic velocity of less than 35 cm/sec had ischemic heart disease or were at high risk.

CONCLUSIONS

In erectile dysfunctional patients, incidence of complications with symptomatic or asymptomatic ischemic heart disease was found to be high. Therefore, in patients with risk factors or low peak systolic velocity in the cavernous artery, exercise tests should be implemented prior to treatment of erectile dysfunction.

Decline in antibiotic enzyme activity of neutrophils is a prognostic factor for infections in patients with myelodysplastic syndrome

We used flow cytometry to measure the activities of cathepsin G and elastase. The activity of elastase in neutrophils from patients with myelodysplastic syndrome (MDS) was significantly lower than that in neutrophils from the control group (P<.001). Patients with low elastase activity were significantly susceptible to infection (P<. 05). Our study suggests that analyzing antibacterial enzymes is useful in evaluating the prognosis of patients with MDS.

Circulating and tumor-infiltrating gamma delta T Cells in patients with B-cell lymphomas

In order to analyze the involvement of gamma delta T cells in the immune surveillance against B cell lymphomas (BCL), we investigated the proportion of circulating gamma delta T cells in 52 BCL patients using two-color flow cytometry, together with tumor-infiltrating gamma delta T cells in 22 of those patients. We found that the proportion of tumor-infiltrating gamma delta T cells in BCL patients was not different from that of lymph node gamma delta T cells in reactive hyperplasia patients. However, a decreased percentage of circulating gamma delta T cells were observed in indolent lymphoma (IL) and limited aggressive lymphoma (AL) patients when compared with normal controls. In contrast, as a result of a histogram, advanced AL patients were divided into two subgroups: the patients with increased circulating gamma delta T cells and those without any increase. However, there was no difference in the clinical features of between the two AL subgroups.

Primary osteosarcoma of heart with severe congestive heart failure

We present a case report on a 54-year-old woman with extraskeletal osteosarcoma of the left atrium featuring severe congestive heart failure. We resected the tumor, which occupied the left atrium and had widely infiltrated the atrial wall, but the patients died of the tumor 9 months after surgery. This is to our knowledge the 32nd case of cardiac osteosarcoma ever reported.

Combination of granulocyte colony-stimulating factor and low-dose cytosine arabinoside further enhances myeloid differentiation in leukemia cells in vitro

We examined the differentiation-inducing effect on freshly isolated myeloid leukemia cells in liquid suspension culture by combined treatment with granulocyte colony-stimulating factor (G-CSF) plus low-dose cytosine arabinoside (Ara-C; 5-10 ng/ml) in 25 patients with acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) in leukemic transformation. Culture with G-CSF alone showed leukemic cell growth stimulation in 15 out of the 25 cases (60%) and induction of cell differentiation in 19 out of the 25 cases (76%), respectively. In 23 cases (92%), either growth stimulation and/or differentiation induction of leukemia cells was observed in response to G-CSF. This suggests that most myeloid leukemia cells are able to respond to G-CSF stimulation. In addition, treatment of cells with low-dose Ara-C alone resulted in the enhancement of myeloid specific antigens expression in 16 cases (64%). Treatment of leukemia cells with higher concentrations of Ara-C (over 50 ng/ml) alone resulted in cytocidal effects but not in the induction of differentiation. Furthermore, 15 cases (60%) showed pronounced myeloid differentiation of leukemia cells after combined exposure to G-CSF plus low-dose Ara-C as compared with cells treated with either G-CSF or Ara-C alone. The enhanced effect of differentiation induction by combining G-CSF plus low-dose Ara-C was also observed in a murine myeloid leukemia cell line WEHI-3B in vitro. These data suggest that treatment with G-CSF plus low-dose Ara-C is capable of inducing differentiation of leukemic cells in vitro, and also appears to be useful for the differentiation-based therapy of patients with AML and MDS.

Membranous glomerulonephritis with nephrotic syndrome associated with chronic lymphocytic leukemia

A 66-year-old woman was admitted to our hospital for evaluation of edema of the extremities. Laboratory findings suggested that she had nephrotic syndrome and chronic lymphocytic leukemia (CLL). Renal biopsy (with PAM staining) showed a spike formation in the capillary wall. Immunofluorescent staining revealed deposition of immunoglobulin G (IgG) and the third component of complement in the glomerular basement membrane. Electron microscopy showed fibrillary deposits in the subepithelium. These findings indicated membranous glomerulonephritis (MGN). In addition, focal segmental sclerosis and interstitial lymphocytic infiltration were observed in the renal biopsy specimen. In CLL patients nephrotic syndrome occurs rarely. Even if the complication occurs, MGN is not frequent. Both diseases are suspected to occur in association with each other, and immunologic abnormality contributes to their coexistence. Although administration of prednisolone and endoxan improved leukocytosis, proteinuria was not sufficiently improved with combination therapy.

Chronic lymphocytic leukemia complicated by plasmacytoma originating from different clones

In a woman with chronic lymphocytic leukemia (CLL), a plasmacytoma developed on the back region after four years. CLL cases complicated with plasmacytoma are rare. In the present case, the plasmacytoma showed kappa cytoplasmic immunoglobulin (Ig), and the CLL showed gamma lambda surface Ig. To reveal the clonal origin of CLL and plasmacytoma, we analyzed Ig gene rearrangements in the patient's peripheral blood and plasmacytoma. Ig gene DNA analysis confirmed the presence of different rearrangements in the heavy and light chain genes of CLL and plasmacytoma. These findings suggest that in this patient, the two B cell malignancies arose from expansion of two phenotypically and genotypically distinct clones.

Tardive dystonia provoked by concomitantly administered risperidone

Two cases of tardive dystonia are reported. The first case was an 18-year-old schizophrenic woman suffering from parkinsonism and hypotension induced by antipsychotic drugs. Risperidone (4 mg/day) was added to her drug regimen and after increasing the dosage to 6 mg/day, she began to exhibit retrocollis. The second case was a 61-year-old woman who had schizophrenia and tardive dyskinesia. After replacing chlorpromazine (75 mg/day) with risperidone (4 mg/day), she began to exhibit retrocollis. The retrocollis in both cases was considered to be tardive dystonia provoked by risperidone administered concomitantly with other antipsychotics. Risperidone is reported to produce few extrapyramidal symptoms, but these cases suggested that changing from other drugs to risperidone, or rapidly increasing risperidone dosage, may provoke tardive syndrome.

[Combined CABG and valve operation]

We presented 20 patients, who were underwent combined valve and coronary artery bypass surgery in our institute from September 1995 to December 1999. They were 13 male and 7 female, ages ranged from 54 to 79 (mean 67.5 years). Previous cardiac operation was done in 2 cases. The patients carried out a combination of CABG with aortic valve replacement (n = 9), mitral valve replacement (n = 4), mitral valve plasty (n = 6), double valve replacement (n = 1). Emergency operation was performed in 2 cases. The hospital mortality was 5%. One patient who was underwent mitral valve repair and CABG died due to severe heart failure 2 week post operatively. The perioperative complications were found in 2 patients, one was acute renal failure with HD, the other was cerebral infarction. There are no patient with perioperative myocardial infarction. The combined operation of valvular surgery and CABG for the patients with coexisting disease might be safety and reliable methods, even in older one.