Mortality from coronary heart disease and cerebrovascular disease and associated risk factors in diabetic patients in Osaka District, Japan

Mortality from coronary heart disease (CHD) and cerebrovascular disease (CVD), as well as associated risk factors, were examined. The subjects studied were 1939 non-insulin-dependent diabetic (NIDDM) patients and 503 deaths were observed during a mean follow-up period of 9.4 years. Of these deaths, 62 were CHD deaths and 84 were CVD deaths. The mortality rates per 1000 person-years from CHD were 3.95 for males and 2.57 for females and those from CVD were 5.12 and 3.86 for males and females, respectively, showing a higher mortality for males and an increasing trend with age. The baseline factors associated with CHD mortality were age at entry into the study, hypertension, ischemic ECG changes, serum cholesterol level, diabetic retinopathy and albuminuria, while those associated with CVD were age at entry, hypertension, ischemic ECG changes, diabetic retinopathy, albuminuria and therapeutic regimen, all of which were found to be significant by univariate analysis. The relationships were further analyzed by the multiple logistic method. In addition, the baseline characteristics of the patients who died of CHD and CVD were compared with those of patients who died from other causes. The baseline characteristics in cases of deaths from CHD and CVD were significantly different from those of deaths from other causes in terms of obesity, ischemic ECG changes, serum cholesterol level and serum triglycerides level for deaths from CHD and in terms of age at onset, age at death and hypertension for deaths from CVD.

Relationship between the anchor structure of the galactosyl ligand for liposome modification and accumulation in the liver

Liposomes which have been modified with (8-hexadecanoylamido-3,6-dioxaoctyl)-beta-D-galactose (Gal-t-pa), a straight chain palmitoyl derivative, and are composed of dipalmitoylphosphatidylcholine (DPPC), cholesterol (CH), and dicetyl phosphate (DCP) at a ratio of 10:10:1, showed the same accumulation in the liver as the control liposome. Also, liposomes which have been modified with [8-(2-hexadecyloctadecanoylamido)-3,6-dioxaoctyl]-beta-D-gal actoside (Gal-t-psa) showed remarkable accumulation in the liver. The accumulation of liposomes modified with galactose derivatives in the rat liver differed markedly according to the anchor structure. To clarify the cause of this finding, we produced [3H]inulin entrapped [14C]Gal-t-pa modified double label liposomes and evaluated changes in their rat plasma concentration, distribution in the organs, and the in vitro interaction with rat plasma. [14C]Gal-t-pa on the liposome surface bound to serum albumin and was released, resulting in no accumulation in the liver. In addition, sialic acid palmitoyl derivatives and glucuronic acid palmitoyl derivatives behaved similarly. As with the galactose derivatives, they also bound to serum albumin, being released from liposomes. These results suggest that adequate attention should be paid to the anchor structure of the ligand, in order to incorporate a recognition element into liposomes for transport to cells.

[Aortic root replacement in twin Marfan patients]

We have performed aortic root replacement in twin Marfan patients. They were male and aged 33 years at the times of the operations. One had pneumonia but the other had no complaints. Echocardiography showed geometries typical of annuloaortic ectasia (aortic diameters of 6.4 and 6.8 cm) and a moderate degree of aortic insufficiency. Aortic roots were replaced utilizing composite valve graft and the coronary orifices were reimplanted with Carrel's patch technique. The operations were carried out at almost the same time. The patients had a satisfactory postoperative course. Because of the potential for late dissection or aneurysm in other areas of the aorta, they should have regular follow-up examinations by MRI and CT indefinitely.

Assessment of immunoassays for insulin in diagnostic tests for insulinoma

An immunoassay for insulin using a monoclonal insulin-specific antibody has been marketed in Japan for 2 years. This new assay may yield different plasma insulin (IRI) values from those obtained by the conventional immunoassay because of its high specificity. In this study, we compared IRI values obtained by three different immunoassays, assays P, M1 and M2, the last two of which involved monoclonal antibodies. For normal subjects, similar IRI values were obtained from all three assays. In patients with insulinoma, IRI values from assay M1 were 7-63% of those from assay P. Assays M1 and M2 gave similar values. Proinsulin interfered with assay P but not with assays M1 or M2. Differences between the IRI(P) value and the IRI(M1) or IRI(M2) value were correlated with the concentration of proinsulin (r = 0.98). The IRI(P) value appears therefore to represent the sum of levels of insulin and proinsulin. We conclude, therefore, that an immunoassay with broad specificity (i.e. assay P) is better for screening for hyper-(pro)insulinemia. Immunoassays with narrow specificity (i.e. assays M1 and M2) may have benefits in some tests aimed at tumor localization.

[Two cases of surgically treated malignant primary tumors originated from the pulmonary artery]

Two surgically treated cases of malignant tumors which originated inside of the pulmonary artery were reported. A 62-year-old female with an undifferentiated sarcoma and a 24-year-old male with a malignant fibrous histiocytoma were successively operated on in two months for the release of their chief complaints of exertional dyspnea. In the first case the tumor was resected completely, although partially resected in the second case. Preoperatively, noninvasive examinations including the echocardiography, the computed tomography and the magnetic resonance imaging confirmed the presence of these tumors in the main pulmonary arteries in both cases and also the invasion to the vessel wall with the growth to the pericardial cavity in the second case. Both patients are doing well and has been followed up at the out-patient department 22 and 20 months after surgery, respectively.

[A case of left ventricular-right atrial communication complicated with aortic regurgitation caused by active infective endocarditis]

A 63-year-old man with cough and shortness of breath was diagnosed to have active infective endocarditis resulting in acute pulmonary edema with aortic regurgitation caused by a huge vegetation on the noncoronary cusp and left ventricular-right atrial (LV-RA) communication which were demonstrated by the echocardiogram and color doppler method. The LV-RA communication located at the atrioventricular portion of the membranous septum was closed with GoreTex patch through the right atrium combined with the aortic valve replacement with a bileaflet mechanical valve in emergency. The bacteriological studies demonstrated staphylococcus epidermidis. The postoperative course was uneventful and the patient is now on regular duty two years after surgery.

Intracranial malignant fibrous histiocytoma: characterization of GFAP-positive cells in the tumor

A case of malignant fibrous histiocytoma (MFH) arising in the cerebellopontine angle of a 57-year-old woman was reported. The immunohistochemical and electron microscopic findings indicated distinct fibrohistiocytic nature and myofibroblastic differentiation of this peculiar tumor. Immunohistochemistry disclosed that the tumor cells expressed monocyte/macrophage markers including CD-68, MAC 387, and alpha-1-antichymotrypsin. In addition, the neoplasm contained scattered glial fibrillary acidic protein (GFAP)-positive cells which made small nests in some areas. These GFAP-positive cells had bundles of densely packed intermediate filaments and scanty organellae in the cytoplasm, as demonstrated by an immunostained-semithin and serial-ultrathin section method. By immunostaining of MIB-1 and GFAP, and silver nucleolar organizer region (AgNOR) impregnation on serial sections, the GFAP-positive cells were not labeled by MIB-1 and their AgNOR counts averaged 1.13/nucleus. Thus, these GFAP-positive cells seem to have lower proliferating activity than neoplastic astrocytes. It is concluded that they may be nonneoplastic astrocytic cells involved by MFH.

Mortality and causes of death in patients with diabetes mellitus in Japan

Although the mortality rate of diabetes mellitus in Japan is much lower than the rates in Western countries, an increasing trend has been evident over the last 40 years as a whole. However, the trend shows variations with age; there is an apparent decreasing trend in subjects of 0-35 years of age at death, while there is a remarkable increasing trend in subjects of 75 years of age and over. It appears that the increase in diabetes mortality is largely due to an elevation in the mortality rate in aged subjects and an increase in the size of the aged population in this country. A population-based study of causes of death, carried out in Osaka Prefecture for the period 1960-1989, indicates a remarkable increase in the age at death and significant changes in the causes of death of diabetic patients. Diseases of the circulatory system were found to be the major causes of death other than diabetes, and, among them, a rapid increase in the frequency of disease of the heart was observed. As a cause of death, tuberculosis decreased sharply, while malignant neoplasms, ischemic heart disease, and pneumonia and bronchitis increased during the same period. Among malignant neoplasms, an increase in neoplasm of the liver was marked.

Pheophorbide a, a potent endothelin receptor antagonist for both ETA and ETB subtypes

Many crude drugs were screened for their capacity to inhibit the binding of endothelin-1 (ET-1) to ET receptors; several crude drugs showed significant binding inhibitory activity. Pheophorbide a (1), a potent non-peptide ET receptor antagonist, was isolated from Altemisiae capillaris Flos ("Inchinko" in Japanese), which has been utilized as a remedy for hepatitis in Oriental medicine. In receptor binding experiments, compound 1 inhibited ET-1 binding specifically to both the ETA receptor (ETAR) and ETB receptor (ETBR), with IC50 values of 8.0 x 10(-8) and 2.1 x 10(-7) M, respectively. Thus, compound 1 is an ET-1 binding inhibitor; however, it exhibited no affinity for the other receptors of angiotensin II and atrial natriuretic peptide. We also evaluated the inhibitory activity of porphyrin compounds, and found that some exhibited moderate activity.

[The role of platelet in the etiology of Binswanger's disease]

White matter changes, which are noted in Binswanger's disease and which may be due to ischemia, have previously been explained mainly on the basis of the hemodynamic mechanism. To elucidate the etiopathophysiology of Binswanger's disease from the hemorheology viewpoint, platelet activation in the cerebral circulation was studied in 30 patients with Binswanger's disease, who satisfied the diagnostic criteria of Binswanger's disease proposed by Bennett et al. Plasma beta-thromboglobulin concentration gradients (delta BTG) between the jugular vein and the antecubital vein, as indicators of platelet activation in the cerebral circulation, were determined in these patients (Binswanger's disease group) compared with those of different stroke subtypes groups (lacunar, atherothrombotic, cardioembolic) in the chronic phase and 25 patients with various diseases other than stroke (non-stroke group). Among these groups, the elevation of delta BTG levels in the Binswanger's disease group (4.55 +/- 6.95) were so frequent and prominent that differences were significant, especially in comparison to those of the cardioembolic group, and the non-stroke group. The enhanced platelet activation in the cerebral circulation observed in Binswanger's disease indicated not only the widespread development of underlying vascular lesions, but also accelerated release reaction of vasoactive substances from platelets into the blood stream, which could biochemically injure the vascular wall and neurons downstream, resulting in Binswanger's disease.

A case of Pick's disease with unusual neuronal inclusions

An autopsy case of unusual Pick's disease in a 61-year-old male is described. Findings included severe atrophy of the frontal and temporal lobes, pyramidal tracts and basal ganglia accompanied by numerous intraneuronal argyrophilic hyaline inclusions. His neurological symptoms were constantly progressive during the 12-year course, characterized by akinesia and emotional incontinence. The inclusions were round, well-demarcated, slightly eosinophilic and intensely argyrophilic bodies in the perikarya, and distributed mainly in the subiculum and Sommer's sector of the hippocampus, amygdala and affected gyri. Immunocytochemically, they contain antigenic determinants of both phosphorylated and nonphosphorylated neurofilaments, but were negative for ubiquitin. Ultrastructurally, they were composed primarily of skeins of neurofilaments intermingled with cell organelles. Tubular profiles studded with granular substances, previously reported as a feature of the generalized variant of Pick's disease, and Hirano body-like lattice structures were occasionally observed in the inclusions. This case represents a slowly progressive neurodegenerative disorder characterized by fronto-temporal lobar atrophy and might by categorized as a variant of Pick's disease. However, some unusual properties of neuronal inclusions may suggest a different pathogenesis from that in classical Pick's disease.

Transplantation of allogeneic peripheral blood stem cells after myeloablative treatment of a patient in blastic crisis of chronic myelocytic leukemia

A 48-year-old man in blastic crisis of chronic myelocytic leukemia received a transplant of allogeneic peripheral blood stem cells. The donor was his HLA-identical sister, who refused to donate bone marrow cells, but agreed to donate peripheral blood stem cells. The patient received standard transplant conditioning with cyclophosphamide (120 mg/kg) and busulfan (16 mg/kg). Peripheral blood stem cells were mobilized with granulocyte colony stimulating factor and collected by apheresis. After transplantation, the white blood cell count and the result of microscopic analysis of the bone marrow became normal, and the leukocyte karyotype became 46XX. DNA fingerprinting showed complete chimerism. Graft-versus-host disease was suppressed with cyclosporine and methyl-prednisolone. The patient died of recurrence of leukemia on day 102+.

[Induction of anti-cancer cells and systemic immune response in hepatocellular carcinoma by OK-432]

We examined whether anti-cancer cells are induced in vivo in hepatocellular carcinoma (HCC) by OK-432. Ten patients with HCC were randomly divided into two groups. The group I patient (n = 5) served as the control. In group II (n = 5), OK-432 was preoperatively administered via the hepatic artery. Tumor infiltrating lymphocytes (TILs) were collected from resected tumors. Cytotoxicity of TILs against K562 cells and Raji cells was studied with phenotypic analysis by flow cytometry. Freshly isolated TILs, whether or not treated with OK-432, showed low cytotoxicity. When TILs were co-cultured with recombinant interleukin-2 (rIL-2), the cytotoxicity was significantly activated in the OK-432 treated group, whereas untreated TILs showed no activation. The natural killer (NK) activity and the lymphokine-activated killer (LAK) activity were depressed in group I after hepatic resection, but patients in group II had no depression. Our data indicate that LAK precursor cells are induced in TILs and the prevention of post-operative immune suppression is made possible by OK-432.

Inhibition of tumor necrosis factor-alpha and -beta secretion by lymphokine activated killer cells by transforming growth factor-beta

Transforming growth factor-beta (TGF-beta) has a variety of immunosuppressive properties. We investigated the effect of TGF-beta secreted by glioblastoma (T98G) cells on the secretion of tumor necrosis factor-alpha and -beta (TNFs) by lymphokine activated killer (LAK) cells stimulated with tumor cells. The supernatant from T98G cells was preincubated with anti-TGF-beta 1 and -beta 2 neutralizing antibodies or untreated, and added to a coculture of LAK and Daudi cells. The neutralizing antibodies were added to LAK/Daudi and LAK culture, and natural human TGF-beta 1 and recombinant human TGF-beta 2 were also added to the LAK/Daudi culture. LAK cells were also cultured with T98G cells, of which the supernatant contained both active and latent forms of TGF-beta 1 and TGF-beta 2, and the neutralizing antibodies were added to the coculture. TNFs activity in the supernatants from LAK/Daudi cultures was examined by a specific bioassay. Addition of the supernatant from T98G cells to LAK/Daudi culture resulted in the inhibition of TNFs secretion by LAK cells. The inhibition was abrogated by the pretreatment of the supernatants with the anti-TGF-beta antibodies. Addition of TGF-beta 1 and TGF-beta 2 to LAK/Daudi culture inhibited TNFs secretion by LAK cells in a dose-dependent manner. Addition of anti-TGF-beta antibodies to LAK culture resulted in an increase of TNFs secretion. These results suggest that, if tumor cells have the capacity to convert TGF-beta from a latent to an active form, the active TGF-beta suppresses TNFs secretion by LAK cells stimulated with the tumor cells, and that TGF-beta secreted and activated by glioblastoma cells suppresses the propagation of immune reaction by inhibiting TNFs secretion by activated lymphocytes adjacent to tumor cells.

Krabbe's disease with giant lamellar bodies in Purkinje cells

An autopsy case of Krabbe's disease in a child aged 6 years 7 months 1s reported. Histologically, globoid cells, loss of myelin, oligodendroglia and axons, and marked gliosis were observed in the white matter. In addition, there was severe neuronal loss in the thalamus, pontine nucleus, dentate nucleus and olivary nuclei. The cerebellar cortex showed extensive loss of granular cells and moderate loss of Purkinje cells. There were numerous eosinophilic inclusion bodies, ranging from 2 to 15 microns in diameter, in the dendrites of Purkinje cells. The ultrastructural findings for the inclusion bodies were consistent with those of giant lamellar bodies. In addition, smaller lamellar bodies were frequently observed in the perikarya and dendrites. Although loss of granular cells was more prominent in the hemispheres than in the vermis, the inclusion bodies were observed in hemispheres but were infrequently observed in the vermis. They were found in degenerated Purkinje cells which had lost afferent fibers. It is considered that these giant lamellar body inclusions are an unusual type of degenerative structure specific to Purkinje cells.

Evolution of antigen drift/switching: continuously evading pathogens

Following infection to a host, some pathogens repeatedly alter their antigen expression, and thereby escape the immune defense (antigen drift/switching). This paper examines the evolutionarily stable mutation rate of pathogens which maximizes the stationary pathogen density in a host. Assumptions are: (i) most mutations are deleterious but a minor fraction, p, of mutations can contribute to the alternation of antigenic property of the pathogen; and. (ii) potential antigen types can be indexed in a one-dimensional lattice (the stepping-stone model). The model reveals that: (a) if the mutation rate is higher than a threshold mu(c) = R0/(1-p), where R0 is the per capita growth rate of pathogen before the immune system is activated, pathogens cannot maintain themselves because too many progeny are lost by lethal mutations; (b) if the mutation rate lies between zero and mu(c), the system converges to a traveling wave of antigen variants with a constant wave speed; (c) the evolutionarily stable mutation rate microESS is unexpectedly high: more than 0.25 per genome per replication even if most mutations are lethal. Hence more than a fourth of progeny are born defective in the evolutionarily stable state; (d) the microESS is even higher if multiple infections by pathogens are common. The paper also studies the evolutionarily stable mutation rate if every mutant antigen belongs to a different type (the infinite allele model), and the evolution of antigen switching between a finite number of antigen variants stored in the pathogen genome.

Changes in causes of death in diabetic patients based on death certificates during a 30-year period in Osaka District, Japan, with special reference to cancer mortality

As reported previously, we have conducted studies on causes of death among diabetic patients during the 25-year period, from 1960 to 1984, in Osaka District, Japan. We have now added the most recent 5-year data, for 1985-1989, and analyzed changes in causes of death during the entire 30-year period as a whole. The subjects studied were those for whom a total of 32,222 death certificates had been filed in Osaka Prefecture, from 1960 to 1989, with diabetes mentioned either as the underlying cause or as a contributory condition. The relative number of death certificates mentioning diabetes as the underlying cause, which had been decreasing during the 25-year study period, showed a further decrease, reaching the lowest value, 33.4%, for the period 1985-1989. The mean age at death exceeded 70 years for all causes of death, showing a continuous increasing trend. An increase in disease of the heart and a decrease in cerebrovascular disease were observed, making the difference between the two causes greater since 1980-1984. Malignant neoplasms, ischemic heart disease, and pneumonia and bronchitis also showed steady increases. The O/E ratios (ratio of observed/expected number of deaths) for cirrhosis of the liver and tuberculosis were markedly increased, while that for malignant neoplasms was only about 0.5, suggesting extreme underestimation of the number of diabetic cases with cancer. Among malignant neoplasms, an increasing trend in liver cancer was remarkable and was associated with a relatively high O/E ratio.

[Surgical treatment and long-term results of congenital heart disease in adults: early and late follow-up studies in 231 cases]

In a past one decade from January 1981 to August 1991, 231 patients over 18 years old with congenital heart disease (CHD) including 65 patients with cyanotic (C) and 166 with acyanotic (AC) diseases, were surgically treated. There were one operative death (0.6 percent mortality) and three late deaths (1.9%) in 166 patients with AC diseases, whereas there were four operative (6.1%), and four late deaths (6.1%) in 65 patients with C. These patients were followed for 3 to 124 months (the mean of 46.4 +/- 11.9) after the operation. Compared with group AC, group C showed a high rate of early postoperative deaths or late deaths. Group AC comprised patients in their forties (95 patients with ASD and 15 with PDA) and those in their thirties (26 with VSD and 13 with ECD) at the operation. On the contrary, except 5 patients with Ebstein disease, a mean age of patients of group C at the operation lay in their twenties. Surgical outcomes for adult patients of group C still pose much problems compared with AC group in terms of decreased heart function, development of collateral circulatory pathway, and impaired hepatic and renal functions by long lasting hypoxemia. In group C decreased heart function or association of abscess of the brain might be the main cause of postoperative LOS. These findings indicate that early diagnosis, recent advanced operative procedure and appropriate postoperative care can provide symptomatic remission for even adult patients with severe CHD with a low mortality.

[Morphometric study of age-related changes of the spinal cord]

The relation of aging to the length of the spinal cord and to the cross-sectional area at the levels of C6 and L3 of the spinal cord was studied in 140 autopsy cases who between the age of 47 to 105 without spinal cord lesions. In addition the effect of being bed-ridden on the spinal cord was studied in 11 of 140 cases. As pathological controls, we referred to 40 autopsy cases with compression change of the cervical cord. The length of the spinal cord had no correlation with aging but had a significant positive correlation with the height of the subject. A significant decrease in the cross-sectional area of the spinal cord was observed after the age of 80, in particular at C6. However, the extent of the decrease was not as serious as that of pathological control cases. Decrease of cross-sectional area was associated with that of white matter area. In addition, effect of being bed-ridden on the spinal cord was reflected in a significant decrease of the grey matter of the lumbar cord.

[Swallowing disorders after esophagectomy in thoracic esophageal cancer]

Postoperative swallowing disorders have been studied in 17 consecutive esophageal cancer patients who had undergone an esophagectomy with a lymph node dissection and a cervical anastomosis via the posterior mediastinal route. The patients were divided into two groups: those manifesting postoperative abnormal aspiration episodes (aspiration group: 6 cases), and those without such episodes (non-aspiration group: 11 cases). Pharyngoesophageal manometry and scintigraphic measurement of the oropharyngeal transit of a liquid bolus was done on 14th postoperative day and at hospital discharge. In contrast to the non-aspiration group, the aspiration group initially showed a lower mean pharyngeal contraction pressure and an uncoordinated deglutive response of the upper esophageal sphincter (UES) as well as frequent incomplete UES relaxation. However, the second examination revealed recovery of the mean pharyngeal contraction pressure, less frequent, uncoordinated UES responses in 2 cases and complete UES relaxation in the other cases, and shortened transit times. Based on these results, it thus was concluded that weak pharyngeal contraction with a UES dysfunction in postoperative patients appears to elongate the pharyngeal passage time of foods and induce episodes of abnormal aspiration.

Syntheses of novel galactosyl ligands for liposomes and their accumulation in the rat liver

The effects of liposomes, bearing galactosyl ligands on their surface, on their clearance from circulation and on tissue distribution were studied in rats. The ligands were obtained through coupling 2,3,4,6-tetraacetyl-(2-[2-(2-aminoethoxy)ethoxy]ethyl)-beta- D-galactoside p-toluenesulfonate with hydrophobic anchors, followed by deprotection. We introduced mid-chain or long, branched or non-branched alipathic chains, and cholesterol as anchors. Among various anchors tested, that with a dihexadecyl branch caused the greatest accumulation of liposomes in the liver. On the other hand, liposome bearing these ligands were aggregated by Ricinus communis agglutin. This showed that these ligands were similarly incorporated to liposomes. These results show the importance of the balance between lipophilicity and the structure of ligands.