Multi-institutional study of all-trans-retinoic acid as a differentiation therapy of refractory acute promyelocytic leukemia. Leukaemia Study Group of the Ministry of Health and Welfare

We treated 70 acute promyelocytic leukemia (APL) patients with daily oral 45 mg/m2 all-trans-retinoic acid (ATRA) in two multi-institutional prospective studies. Of 64 evaluable patients, 21 were refractory to initial induction chemotherapy; 10 were refractory to salvage chemotherapy; 17, five, and four were in the first, second and, third relapse, respectively; and seven were previously untreated due to old age. In the first study with ATRA from China, 18 out of 22 (82%) evaluable patients achieved complete remission (CR). Initial peripheral leukemia cell counts were significantly less in the CR cases (p < 0.01); < 100/microliters in 17 out of 18 CR cases, and > or = 200/microliters in all failure cases. In the second study with ATRA from Hoffmann-La Roche, if initial leukemia cell counts were more than 200/microliters, chemotherapy was first given and then ATRA was started. Of 42 evaluable patients, 36 (86%) achieved CR. Morphological evidence of differentiation was noted in all CR cases. Patients achieving CR received standard consolidation and maintenance chemotherapies, and the 20-month predicted disease-free survival rate is 76% for cases achieving their first CR with ATRA. Toxicities attributable to ATRA were minimal and included cheilitis, xerosis, dermatitis, gastrointestinal disorders, bone pain, liver damage, and high serum triglyceridemia.

Prognostic significance of atrial fibrillation in dilated cardiomyopathy

We evaluated the relation of atrial rhythm to a clinical course of treatment in 147 patients diagnosed with dilated cardiomyopathy (DCM). Thirty-six of the patients (24%) had either transient (9 patients) or persistent (27 patients) atrial fibrillation (AF). Compared with DCM patients with sinus rhythm (SR), the AF patients did not differ in age, left ventricular (LV) dimension, fractional shortening, or hemodynamic parameters, but the AF patients had slightly larger left atria. After a mean follow-up of 3.8 +/- 2.9 years, the NYHA functional classifications in the AF patients improved in 20 of the 36 (56%), whereas those of the SR patients improved in only 30 (27%) (p < 0.01). The actuarial 5-year survival rate was significantly better for AF patients than for SR patients (93% versus 68%, p < 0.05). LV function remained unchanged in SR patients but improved significantly in AF patients, particularly in patients with transient AF and with "rate-controlled" AF (those with a mean heart rate of less than 90 beats/min). This study suggests that atrial fibrillation may result in significant LV dysfunction, which is reversible in some cases once the arrhythmia is controlled. Aggressive antiarrhythmic therapy should be considered for patients initially diagnosed with dilated cardiomyopathy and atrial fibrillation.

[Antiemetic efficacy of granisetron in the treatment of pediatric cancer--(1). Clinical evaluation of granisetron at a dose of 40 micrograms/kg]

Seventeen children with various types of cancer were studied on the effectiveness of antiemetic drug, granisetron, by a crossover randomized trial; receiving granisetron (40 micrograms/kg; n = 53) or conventional antiemetics, during intensive chemotherapy. In the patients given granisetron nausea and vomiting were well controlled (83.0%), compared with 33.3% of conventional (non granisetron) group. The mean number of vomiting episodes for each 6h-period over 24h after chemotherapy was reduced markedly in the patients given granisetron, compared with conventional therapy. One patient developed paraesthesia of the hand after injection of granisetron as the adverse effect, which recovered to normal spontaneously after 3 hrs. Our data indicated that antiemetic effect of granisetron was superior to conventional antiemetic drugs, both in terms of clinical effectiveness and usefulness.

The cytoplasmic domain of P-selectin is phosphorylated on serine and threonine residues

P-selectin is an adhesion receptor for leukocytes that is redistributed from secretory granule membranes to the surfaces of activated platelets and endothelial cells. The cytoplasmic domain of P-selectin contains two serines, two threonines, and one tyrosine that could potentially be phosphorylated. We found that P-selectin was phosphorylated in both platelets and endothelial cells and that phosphorylation rapidly increased after cell activation. Approximately 0.02, 0.05, and 0.08 mol of phosphate/mol of P-selectin were incorporated, respectively, into resting, thrombin-activated, and phorbol ester-activated platelets. Phosphorylation was completely inhibited by the protein kinase C inhibitors, staurosporine, H-7, and chelerythrine, and was enhanced by the phosphatase inhibitors, okadaic acid and calyculin-A. Phosphoamino acid analysis of 32P-labeled P-selectin showed that phosphorylation occurred predominantly on serine with lesser amounts on threonine. When expressed in transfected Chinese hamster ovary cells, P-selectin was also phosphorylated. Mutagenesis studies showed that Ser788 was the principal site of phosphorylation, with minor sites on the other serine and threonine residues of the cytoplasmic domain. Phosphorylation may regulate membrane trafficking or other functions of P-selectin.

[Liver metastases from breast cancer: survival and an attempt at cauterization and thermocoagulation therapy combined with selective intra-arterial infusion chemotherapy]

During the past thirteen years, 599 patients with primary breast cancer underwent surgery in our hospital. Nine of them died of liver metastases and the median survival time after detection of liver metastases was five months (range 1-32 months). Four are still alive with liver metastases. Based upon these results, we attempted intraoperative, ultrasound-guided cauterization and thermocoagulation for three patients to improve their prognosis and postoperatively treated them with hepatic arterial infusion chemotherapy. During surgery, a monopolar electrode was inserted with an ultrasonic guide. One round of cauterization lasted for 10 seconds at 100 W, and was repeated until the tissue around the tumor became hyperechoic. The antitumor effect of the therapy was assessed by histological examination of resected liver tissues. Tumor coagulation and necrosis were observed to be consistent with the cauterized area. On CT scanning, treated areas were shown to be of low density and homogeneous. Since this therapeutic approach acts directly on unresectable tumors and is safe, it seems to provide a useful means for intraoperative regional treatment of tumors.

Muscle contractile properties by surface electrodes compared with those by needle electrodes

We measured the contractile properties of the first dorsal interosseous muscle by surface electrodes and needle electrodes during submaximal voluntary contraction. Twenty-seven single motor units were recorded from 5 volunteers by surface electrodes, which were confirmed by subsequent needle electrode recordings. Twitch tension ranged from 0.6 to 10.0 g with a mean of 3.7 g based on an averaging method triggered by surface myoelectric signals, and the tension calculated from the needle myoelectric signals ranged from 0.8 to 11.7 g with a mean of 3.6 g. Rise time ranged from 33.9 to 81.6 msec with a mean of 49.4 msec for the surface electrode recordings, and from 33.0 to 73.2 msec with a mean of 50.8 msec for the needle electrode recordings. The obtained data of surface electrode recordings indicated a high correlation with that of the needle electrode recordings, r = 0.92 (P < 0.001) for twitch tension and r = 0.91 (P < 0.001) for rise time. We also found a positive correlation between threshold force and twitch tension (by surface electrodes: r = 0.71, P < 0.05; by needle electrodes: r = 0.77, P < 0.05). Our studies indicate that it is possible to record single motor units by non-invasive surface electrodes provided that the unit has a threshold force of less than 2 kg.

[Evaluation of subselective intraarterial infusion chemotherapy in far advanced gastric and colorectal cancer]

We investigated the usefulness of subselective intraarterial infusion chemotherapy in far advanced gastric and colorectal cancer. Among gastric and colorectal cancer cases undergoing surgery at our hospital for the past ten years, patients with and without palliative resection were studied. Forty gastric cancer patients and 29 colorectal cancer patients were treated by subselective intraarterial infusion chemotherapy. In gastric cancer cases without resection, a significantly longer survival was noted in patients undergoing this therapy with over 5 g of 5-FU than those treated with conventional chemotherapy. In gastric cancer patients with palliative resection and colorectal cancer patients, survival time was longer by intraarterial infusion with over 5 g of 5-FU, but not significant. Partial response was obtained in 5 cases of gastric cancer and 3 cases of colorectal cancer, and clinical symptoms were improved in 44% of the patients. The main complications of this therapy were myelosuppression and occlusion of the catheter, but none of them were serious. For the improved quality of life of cancer patients, subselective intraarterial infusion chemotherapy is considered a safe and useful form of treatment.

[Evaluation of colorectal hepatic metastases with combined modality therapy]

We treated synchronous hepatic metastases in colorectal cancers with combined modality therapy including hepatic resection, selective intra-arterial infusion chemotherapy, and thermocoagulation therapy using a microwave tissue coagulator and compared the value of such therapies. Synchronous hepatic metastases were noted in 563 patients with colorectal cancer who had undergone surgery in our department over the past ten years. Forty-four patients were studied. Six patients underwent hepatic resection only (group A). Another six were subjected to hepatic resection and the residual lesions were treated with selective intra-arterial infusions and thermocoagulation therapy (group B). Fourteen patients were treated with either selective or subselective intra-arterial infusions (group C). The remaining 18 patients were treated in other ways (group D). Cumulative survival, estimated by the Kaplan-Meier method, was compared. One- and three-year cumulative survival rates of patients were 100% and 74% in group A, 100% and 67% in group B, 62% and 0% in group C, and 38% and 5% in group D, respectively. H1 patients accounted for 83% in group A, 33% in group B, 7% in group C, and 22% in group D. The high rate of survival in group A was because of the greater number of H1 patients. One- and three-year survival rated among H2-H3 patients were 100% and 54% in group B, 62% and 0% in group C, and 35% and 14% in group D, respectively. Survival of H2-H3 patients was higher in group B than in group C or D.

[Mediastinal widening simulating relapse in a case of Hodgkin's disease]

The appearance of a mediastinal mass in a patient with Hodgkin's disease in remission frequently indicates recurrence. However, benign processes such as rebound hyperplasia of the thymus gland should be included in the differential diagnosis. The authors present a case in which an anterior mediastinal mass was revealed by a routine chest radiograph 3 months after completion of combined modality treatment with low-dose radiation and MOPP chemotherapy for cervical Hodgkin's disease, stage I, nodular sclerosis. As the patient was clinically well with no other laboratory evidence of disease, recurrence was considered unlikely. Benign thymic enlargement was strongly suspected on the basis of striking resolution of the mediastinal mass after treatment with a short course of oral prednisolone. Thymic rebound in our case occurred coincidentally with the restoration of normal immune functions after removal of the stress imposed by antineoplastic treatment. The patient has remained free of disease recurrence for more than 20 months after cessation of therapy. Awareness of the possible benign etiology of a mediastinal mass may avert a diagnostic surgical exploration and also unnecessary adjuvant therapy.

Early invasive colorectal carcinomas metastatic to the lymph node with attention to their nonpolypoid development

Clinicopathologic study of six cases of early invasive colorectal carcinoma metastatic to lymph node was performed in order to elucidate possible characteristics relating to the risk of metastasis, with particular attention to the growth pattern of the primary tumor. All of the cases had at least one of the well-known risk factors for lymph node metastasis, including moderately or poorly differentiated histologic characteristics, considerable degree of submucosal invasion, and lymphatic invasion. An interesting finding of the present study was the identification of a nonpolypoid growth pattern with no concomitant adenomatous tissue, which seemed to be different from that of "malignant polyps" of previously reported cases showing adenoma-carcinoma sequence. This unique growth feature was found in all of the cases. Therefore, in addition to the accepted risk factors, nonpolypoid growth pattern and absence of adenomatous component may be risk factors predictive of nodal metastasis in patients with early invasive colorectal carcinoma.

Development of a miniature intraventricular axial flow blood pump

A new intraventricular axial flow blood pump has been designed and developed as a totally implantable left ventricular assist device (LVAD). This pump consists of an impeller combined with a guide-vane, a tube housing, and a DC motor. The pump is introduced into the LV cavity through the LV apex, and the outlet cannula is passed antegrade across the aortic valve. Blood is withdrawn from the LV through the inlet ports at the pump base, and discharged to the ascending aorta. Our newly developed axial flow pump system has the following advantages: 1) it is a simple and compact system, 2) minimal blood stasis both in the device and the LV cavity, 3) minimal blood contacting surface of the pump, 4) easy accessibility with a less invasive surgical procedure, and 5) low cost. A pump flow > 5 L/min was obtained against 100 mmHg differential pressure in the mock circulatory system. The pump could produce a passive pulsatile flow effect with a beating heart more efficiently than other non-pulsatile pumps because of minimal pressure drop and inertia along the bypass tract. Anatomic fit studies using dissected hearts of dilated cardiomyopathy (DCM) cadavers showed that this pump could smoothly pass through the aortic valve without any interference with mitral valve function. Recently, a dynamic pressure groove bearing and a miniature lip seal have been developed. The dynamic pressure groove bearing has a simple structure and acts as a pressure resistant sealing mechanism.(ABSTRACT TRUNCATED AT 250 WORDS)

[CT findings of invaginated mesentery in adult intussusception]

The CT findings of invaginated mesentery in adult intussusception were analyzed in 12 patients (three patients with four small bowel intussusceptions and nine patients with nine large bowel intussusceptions). In all small bowel intussusceptions, the neck was located near the superior mesenteric artery and vein (SMA & SMV) and showed a medial opening, and the vessels in the neck showed a continuity to the left side of SMA & SMV. In most of the large bowel intussusceptions, the neck was located distant from SMA & SMV, and the vessels in the neck did not show continuity to SMA & SMV. The difference in CT findings between small and large bowel intussusception is attributed to the difference in mesenteric anatomy; the small bowel and its mesentery move freely in the peritoneal cavity, whereas the large bowel is partially fixed to the retroperitoneum.

Actin and myosin deposition around bile canaliculi: a predictor of clinical outcome in biliary atresia

The role of pathological changes of the intrahepatic bile canaliculi in determining postportoenterostomy bile drainage in biliary atresia (BA) patients remains unestablished. It is known that canalicular contraction contributes an active force for bile flow in normal ductal systems. This motility is controlled by the bile canalicular membrane-associated filaments (BCMF), particularly actin and myosin. Wedge resected specimens of liver from 13 patients with BA were studied using histopathological markers of BCMF in order to clarify the morphological and functional changes of bile canaliculi. Histopathological data were also compared with clinical outcomes after portoenterostomy. Patients who showed sufficient bile flow after the operation showed an almost normal shape and level of BCMF accumulation around bile canaliculi, whereas there was markedly increased BCMF volume in patients who did not exhibit bile flow after surgery. The clinical staining patterns of BCMF in BA patients appears closely related to clinical outcome. These findings suggest that BCMF plays an important role in determining the rate of postoperative bile flow in BA patients.

Involvement of membrane excitation failure in fatigue induced by intermittent submaximal voluntary contraction of the first dorsal interosseous muscle

Factors involving muscle fatigue were studied at intermittent isometric contraction of the first dorsal interosseous muscle (FDI). Subjects made repeated contraction of 6 s, 40% of maximal voluntary contraction (40% MVC) (= target force) followed by 4 s rest until the target force could no longer be maintained. Measurement of MVC, recording of M wave evoked from the relaxed muscle, force measurement during tetanic electrical stimulation and measurement of serum K+ concentration were performed every 2 min during the fatiguing exercise and after 10 min of recovery. The declining rate of MVC force was always smaller than that of the force generated by 50 Hz stimulation, suggesting that no central nervous system (CNS) failure was involved. The amplitude and the area of the M wave declined while the duration of the wave increased, accompanied by the rise in serum K+ concentration. After 10 min of recovery, all parameters except the MVC force were restored. Thus we concluded that the failure in muscle membrane excitation, as well as the failure in excitation/contraction coupling, is involved in the deteriorating force generating capacity of FDI during intermittent isometric contraction.

P-selectin is acylated with palmitic acid and stearic acid at cysteine 766 through a thioester linkage

We report that the adhesion receptor P-selectin can be metabolically labeled with [3H]palmitic acid in human platelets. Analysis of alkaline methanolysis products from labeled protein demonstrated that the radioactivity associated with P-selectin was covalently bound palmitic acid. [3H]Palmitic acid was cleaved by hydroxylamine treatment at neutral pH and by reducing agents, indicating that acylation occurred through a thioester linkage. Both stearic acid and palmitic acid were detected by gas chromatography-mass spectrometry analysis of alkaline hydrolysates of purified P-selectin. Deletion or mutation of Cys766 eliminated [3H] palmitic acid labeling of P-selectin in transfected COS-7 cells. We conclude that the cytoplasmic domain of P-selectin is acylated at Cys766 through a thioester bond. Fatty acid acylation may regulate intracellular trafficking or other functions of P-selectin.

Genesis of the Austin Flint murmur: relation to mitral inflow and aortic regurgitant flow dynamics

OBJECTIVES

This study was designed to elucidate the genesis of the Austin Flint murmur.

BACKGROUND

The Austin Flint murmur is an apical diastolic rumble associated with significant aortic regurgitation. The precise mechanism of the murmur remains unclear.

METHODS

The relation between the Austin Flint murmur and mitral inflow and aortic regurgitant flow dynamics was evaluated nonivasively in 13 patients with moderate to severe aortic regurgitation and 15 control subjects using phonocardiographic and pulsed and color-coded Doppler echocardiographic techniques. The severity of aortic regurgitation was determined by color-coded Doppler echocardiography on the basis of the maximal distance of the regurgitant signal.

RESULTS

The direction of aortic regurgitant flow was unrelated to the presence of the Austin Flint murmur. The severity of aortic regurgitation was greater in patients with than in those without this murmur. The peak mitral inflow velocity during early diastole (E) was significantly increased, and both peak mitral inflow velocity at atrial contraction (A) and the A/E ratio were significantly decreased in patients with the Austin Flint murmur compared with values in those without this murmur or in control subjects. However, the maximal amplitude of the Austin Flint murmur did not coincide temporally with the peak mitral inflow velocity. The murmur continued both after rapid mitral inflow had ended and during diastolic mitral regurgitation.

CONCLUSIONS

The increased velocity of early diastolic mitral inflow in patients with the Austin Flint murmur is due to aortic regurgitation, but rapid mitral inflow is not an essential requirement for production of the murmur. In some cases, the Austin Flint murmur may be generated by aortic regurgitant flow alone.

Hydronephrosis caused by a left renal vein in a patient with horseshoe kidney: a case report

We report a rare case of hydronephrosis secondary to ureteropelvic stenosis caused by a branch of the left renal vein in horseshoe kidney. We were unable to determine the etiology of hydronephrosis of the horseshoe kidney by means of radiological images. When radiological images fail to show any etiology of hydronephrosis in horseshoe kidney, the possibility of compression of the ureteropelvic junction by a branch of the renal vein should be borne in mind, and re-assessment of the venous phase of angiography and evaluation by coronal or sagittal images of MRI is recommended.

Current concept of the treatment of biliary atresia

Hepatic portoenterostomy (Kasai operation) for the patient with biliary atresia (BA) can restore the bile flow in approximately 80% of children operated on before 60 days of life [1]. However, in terms of long-term survival, according to a recent nationwide survey among the major pediatric centers in Japan, only 325 of 2013 patients had more than 10 years' survival, and only 157 patients (7.8%) remained jaundice-free with normal liver function [2]. About 20% of BA cases without jaundice are generally able to survive for long periods; and most of those patients have portal hypertension or abnormal liver function [3-5]. As the results of liver transplantation have improved, controversy has arisen over the optimal care of these children [4, 6, 7]. Some investigators have claimed that transplantation is the favored primary therapy for most patients with BA [8]. We are thus at a turning point concerning the primary therapy of BA, which makes it necessary to determine the exact indications for the Kasai portoenterostomy and the timing of liver transplantation. This paper describes our strategy for the optimal treatment of BA patients based on our 117 patients who have had various form of portoenterostomy.

[One family having 5 members with hypertrophic cardiomyopathy with similar pattern of left ventricular inflow and distribution of hypertrophy]

We examined, in one family, 5 cases of hypertrophic cardiomyopathy (HCM) with a similar pattern of left ventricular inflow (LVIF) and distribution of hypertrophy. Its clinical background and significance were discussed. Because a variety of morphologic expressions of HCM may be observed in the same family, distribution of left ventricular hypertrophy (LVH) varies in even first-degree relatives of the family. In all five cases in this study, however, LVH was localized between the anterior wall and the interventricular septum. On the other hand, typical pattern of LVIF in HCM is "decreased peak velocity and prolonged deceleration time of the early diastolic wave (E), and compensatory augmentation of the atrial contraction wave (A)". All of the five cases in this study had a pattern of three characteristic peaks of LVIF, which showed the mid-diastolic wave between the E and A waves. The above findings suggested that the myocardial characteristics of the five cases in this family were very similar, and could be important clues clarifying the mode of inheritance of HCM.

A patient with hepatocellular carcinoma who underwent resection of the primary lesion 10 years ago and resection of a giant adrenal metastasis 8 and a half years later

A 56-year-old male consulted us because of a palpable mass and pain of the left flank 8 and a half years after resection of hepatocellular carcinoma of the left lobe about 3 cm in diameter. Ultrasound examination of the abdomen demonstrated a tumor about 10 cm in diameter showing a mosaic of hyperechoic and hypoechoic areas on the upper pole of the left kidney. By angiography, the tumor was found to be supplied mainly by the inferior adrenal artery. PIVKA-II was increased. Adrenal metastasis of hepatocellular carcinoma was suspected, and adrenalectomy was carried out. No intrahepatic metastasis was noted. The tumor was histopathologically identified as a pseudo-glandular type of moderately differentiated hepatocellular carcinoma with a trabecular pattern similar to the primary lesion. In this patient, a resectable giant metastasis was observed only in the left adrenal gland and no intrahepatic metastasis was demonstrated 8 and a half years after resection of hepatocellular carcinoma. The patient has survived 10 years after the first operation. This case is considered to be important for evaluation of the treatment for distant metastasis of hepatocellular carcinoma.

Cholesterol ester in corpus luteum of rat observed by analytical color fluorescence electron microscopy

We used an analytical color fluorescence electron microscope to observe cathodoluminescence (CL) in the corpus luteum of rat. CL was emitted from lipid droplets and has a typical spectrum of two peaks at wavelengths of 320 and 430 nm. The intensity of CL at 320 nm (CL320) in the corpus luteum showed a regular change during an estrous cycle: it was very weak at the newly formed stage, gradually increased, reached the maximum at diestrus 2, and then began to diminish at proestrus except in the patches of degenerated cells. CL320 decreased during early stages of pregnancy or after prolonged treatment with 4-aminopyrazolo-pyrimidine; CL at 430 nm (CL430) remained clearly visible. CL320 showed a strong emission from degenerated luteal cells 10 days after hypophysectomy, but was diminished in cells rescued by injection of 50 IU pregnant mare's serum gonadotropin. In the luteal cells of luteinized ovary 2 hr after intravenous injection of 10 IU luteinizing hormone, CL was barely detected. CL320 in interstitial cells was also weak in the rats hypophysectomized and then treated with pregnant mare's serum gonadotropin, and in the 4-aminopyrazolo-pyrimidine-treated rats, although it has little change through a natural estrous cycle. The results are consistent with the assumption that the content of cholesterol ester is reflected by the intensity of CL320 emitted from the lipid droplets of rat luteal cells. The possibility was shown that the condition of steroidogenesis can be monitored through CL analysis by microscopy.

Application of tryptic condensation strategy for the synthesis of alpha-melanocyte stimulating hormone

The use of trypsin in 1,1,1,3,3,3-hexafluoro-2-propanol (HFIP) paired with N,N-dimethylformamide (DMF) has been proposed for the enzymatic condensation of peptides. The tryptic condensation strategy was applied to the synthesis of the 13-peptide, alpha-melanocyte stimulating hormone (alpha-MSH), which contains two susceptible points to trypsin, in a low-water-containing solvent system, 4% H2O in HFIP/DMF (1/1, v/v). The N-terminal 8-peptide segment (S1) ending with Arg and C-terminal 5-peptide with the side-chain protections at Lys and Trp (S2) were prepared by the stepwise coupling on p-nitrobenzophenone oxime resin and by a conventional method, respectively. Both segments were condensed by the aid of trypsin. The acid component was converted into the partially protected alpha-MSH at as high as 95% conversion determined by reversed-phase HPLC. When the side-chain of Lys at the 11-position was not protected, alpha-MSH was obtained only in 35% yield, and was contaminated with products of secondary hydrolysis. Although the Lys11-Pro12 sequence was very poorly susceptible to trypsin, the side-chain of Lys had to be protected in order to be inert to trypsin under the synthetic conditions. HFIP is demonstrated as a good solvent with DMF to allow the efficient tryptic condensation of peptides. The strategy increased the value of the enzymatic condensation as practical method by avoidance of secondary hydrolysis, high dissolution of peptides and retention of activity of enzyme.