Copper deficiency with pancytopenia during total parenteral nutrition

Anemia and neutropenia are commonly observed hematologic changes in patients with copper (Cu) deficiency, but thrombocytopenia is rarely found. A-69-year-old patient with postoperative small-bowel obstruction underwent laparotomy three times. Because of persistent obstruction, nasoduodenal suction was continued and total parenteral nutrition was instituted. Fifteen months after the initiation of total parenteral nutrition, the patient gradually developed pancytopenia (red blood cell count 222 x 10(4)/mm3, neutrophil count 1254/mm3, and platelet count 9.2 x 10(4)/mm3). The serum Cu level was 10 micrograms/dL and the serum ceruloplasmin level was less than 5 mg/dL. After 2 weeks of Cu supplementation in a daily dose of 20 mumol, the serum Cu level increased to 81 micrograms/dL and the serum ceruloplasmin level to 20 mg/dL. Hematologic values showed a dramatic response: red blood cell count increased to 362 x 10(4)/mm3, neutrophil count to 4819/mm3, and platelet count to 22.1 x 10(4)/mm3. The improvement of pancytopenia could be attributed to Cu supplementation. This is the first case report of Cu deficiency with pancytopenia during total parenteral nutrition.

Intestinal failure - its nature, pathophysiology and treatment

The existence of 'intestinal failure' was proposed. This pathologic condition may occur in two distinct forms, ie short bowel syndrome marked by a gross reduction in functioning gut mass and impaired intestinal function (impairment of motility and extensive parenchymatous disorders). This has been newly recognized as a complex independent entity on account of an increasing number of patients that now survive thanks to the recent progress in nutritional management, especially total parenteral nutrition (TPN). In view of many unresolved clinical questions regarding long-term TPN and loss of gut mass, it is hoped that future research efforts will be directed towards settlement of these issues and how to surmount difficulties in bowel transplantation.

Abnormal glutathione metabolism and increased cytotoxicity caused by H2O2 in human umbilical vein endothelial cells cultured in high glucose medium

To determine whether increased oxidative stress in diabetes mellitus is due to an impaired free-radical scavenger function in endothelial cells, GSH-dependent H2O2 degradation in human umbilical vein endothelial cells was studied. The GSH-dependent, NaN3-uninhibitable H2O2-degradation in endothelial cells was reduced by 48% (p < 0.001) when the cells were exposed to 33 mmol/l D-glucose vs 5.5 mmol/l D-glucose. This impairment was dependent not only on the D-glucose concentration in the medium but also on D-glucose specific metabolism, since neither 27.5 mmol/l L-glucose nor 27.5 mmol/l D-raffinose had any effect on the peroxide degradation activity. Activation of the glutathione redox cycle by H2O2 in cells exposed to high glucose concentrations was attenuated as compared with 5.5 mmol/l D-glucose because of: 1) a 42% decrease (p < 0.001) in intracellular NADPH content, and 2) a 34% reduction (p < 0.01) in glutathione release into the media. This results in an accumulation of GSSG in the cells following exposure to H2O2. Both H2O2-evoked 51Cr-release and H2O2-induced endothelial cell damage were significantly (p < 0.01) greater in the 33 mmol/l D-glucose group than in the 5.5 mmol/l D-glucose group. These results indicate that the abnormal glutathione redox cycle observed in endothelial cells is induced by high glucose concentrations in the medium, resulting in an impairment of reduced GSH-dependent H2O2-degradation. These abnormalities may associate with the increased cellular damage following an exogenous exposure to H2O2.

Novel exon 1 of the aromatase gene specific for aromatase transcripts in human brain

Aromatase in the brain is supposed to participate in sexual differentiation of the brain. The presence of a brain-specific exon 1 and promoter in the human aromatase gene was examined in the 5' regions of aromatase cDNAs isolated from the amygdala and hypothalamus areas. The DNA sequences of all the isolated clones were different in the 5' regions encoded by exon 1 from those encoded by any alternative exons 1 of human aromatase gene. This unique sequence was also found in the clones isolated from a human genomic library and indicated to be that of a new exon 1. It involved putative TATA and CAAT boxes, Ad4 sequence, and the androgen responsive element in the promoter region. Reverse transcriptase-polymerase chain reaction analysis of mRNAs in various tissues revealed that expression of this unique species of aromatase mRNA is specific for the brain, in particular in the fetal brain. These show that the aromatase gene in the human brain is expressed by means of the brain-specific exon 1 and promoter, and may be responsible for sexual differentiation of the brain in the fetal period.

[A case underwent separate operation for AAE, AR and TAA using elephant trunk method]

A 20-year-old man with Marfan syndrome was recommended emergency operation for impending rupture of TAA. Because he was in the state of acute heart failure due to coexisting AAE and AR, so the simultaneous operations for AAE, AR and TAA were needed. He underwent Bentall, arch replacement and elephant trunk operation utilizing separate extracorporeal circulation and circulatory arrest. Chest CT, taken after 5 months postoperatively, revealed only a small amount of thrombus in TAA. Anticoagulation therapy stood in the way of aneurysmal thrombo-exclusion. The second operation, grafting of descending thoracic aorta, was performed 6 months later and elephant trunk made the second operation easier. Now 12 months passed after the second operation, he is in good health.

Total cystectomy after intravesical bacillus Calmette-Guérin (Tokyo strain) therapy for superficial bladder cancer: experience in Japan

To clarify which patients might most require total cystectomy after intravesical bacillus Calmette-Guérin (BCG) therapy, we reviewed data for 111 individuals with superficial bladder cancer. Of the 111 patients, 73 received the BCG treatment for prophylaxis of intravesical recurrence after transurethral resection (group 1), 24 therapeutically for Ta or T1 tumours (group 2), and 14 for eradicating carcinomas in situ (CIS, group 3). Although the BCG therapy significantly reduced frequencies of recurrence in group 1, 27 patients (37%) did develop tumours again. Tumours disappeared in 18 of 24 patients (75%) in group 2, and in 11 of 14 (79%) in group 3. The rate of disease progression was 6% for all 111 patients: 3% (2/73) for group 1, 17% (4/24) for group 2, and 7% (1/14) for group 3. A total of 16 of the 111 patients (14%) underwent total cystectomy, the respective figures being 7% in group 1, 29% in group 2, and 29% in group 3. Indications for total cystectomy were progression in 7, recurrent multiple tumours in 5, persistent CIS in 2, a contracted bladder in 1, and occurrence of bilateral renal pelvic cancer in 1. Thus, 4 of 6 patients (67%) who had tumours unresponsive to BCG therapy in group 2 demonstrated progression and necessitated total cystectomy. Because tumours persisting after BCG therapy are frequently of the muscle-invasive type, such cases should be regarded as candidates for immediate total cystectomy.

Distribution of alpha 2HS glycoprotein in pathological human dentins

The concentration and distribution of alpha 2HS glycoprotein in teeth from patients with heritable dentin disorders were examined utilizing immunological techniques. ELISA for the quantitative determination showed lower concentrations of alpha 2HS glycoprotein in dentins of patients with heritable disorders than in the control; some cases contained very low and others intermediate concentrations. Immunohistochemical findings indicated that the concentration of this protein was correlated to the regularity of the dentinal tubules. This result suggests that alpha 2HS glycoprotein is incorporated into dentin in concomitance with the development of the dentinal tubule, especially with the deposition of peritubular dentin. Incorporation of this protein into dentin is thought to involve the function of odontoblasts.

Stereocontrol in Diels-Alder cycloaddition to unsaturated sugars: reactivities of cis-dienophiles with cyclopentadiene

Cycloaddition of cyclopentadiene with a D-arabinose-derived cis-dienophile, methyl (Z)-4,5,6,7-tetra-O-acetyl-2,3-dideoxy-D-arabino-hept-2-enonate (2), under thermal conditions gave essentially a single norbornene adduct, isolated crystalline in 81% yield and identified by NMR spectroscopy and X-ray crystallography as methyl (5R,6S)-6-endo-(1,2,3,4-tetra-O-acetyl-D-arabino-tetritol-1-yl)bic yclo [2.2.1]-hept-2-ene-5-endo-carboxylate (3). The diene adds exclusively from the si-face of the dienophile and give only the endo product. The same sequence starting from L-arabinose gave the enantiomer (7) of 3. In contrast, a related cis-dienophile (9) having a butenolide ring reacts with cyclopentadiene from the opposite (re) face giving mainly the endo adduct (5S,6R)-6-endo-(2,3,4-tri-O-acetyl)-D-arabino-tetritol-1-yl)bicycl o [2.2.1]hept-2-ene-5-endo-carboxylic acid 1,4-lactone (10), isolated crystalline in 70% yield, whose structure was again established by NMR spectroscopy, and firmly consolidated by X-ray crystallography. The minor (11%) product was the exo(5S,6R) isomer 11. A cis-enonate 14, analogous to 2 but deoxygenated at the allylic position, showed negligible diastereofacial selectivity and reacted with cyclopentadiene to give a mixture of all four possible adducts. A 6-membered ring dienophile 16 was also subjected to the same cycloaddition for comparison with the butenolide 9; it gave principally the two endo products 17 and 19 in 31 and 38% yields, respectively, accompanied by 12% of a mixture of the two exo products (18 and 20). The quantitative distribution of cycloaddition products as a function of dienophile stereochemistry is discussed. The high degree of asymmetric induction observed, especially with the readily accessible dienophiles 2 and 7, provides a valuable route of access to enantiomerically pure tetra-C-substituted cycloalkanes.

Tissue-specific expression of the human aromatase cytochrome P-450 gene by alternative use of multiple exons 1 and promoters, and switching of tissue-specific exons 1 in carcinogenesis

Extensive screening of aromatase cDNA was carried out in cDNA libraries from various human tissues. The DNA sequences of all the isolated cDNA clones were identical in the region encoded by exons 2-10 of the aromatase gene. However, tissue-specific sequences, which were classified into four groups, were observed in the 5' portions of the clones corresponding to the region encoded by exon 1. All of them were also found in clones isolated from a human genomic library and mapped between exons 1 and 2 of the human aromatase gene reported previously, suggesting the presence of multiple exons 1 and promoters in the gene. Reverse transcription-PCR analyses of aromatase mRNAs in various tissues revealed that aromatase transcripts are tissue-specifically spliced by alternative use of multiple exons 1, although minor forms of the transcripts were also present in each tissue. Aromatase mRNA is spliced from 10 exons in most tissues, but from 9 exons in the prostate and from 10 or 11 exons in the placenta. This suggests that tissue-specific regulation of the aromatase gene in various tissues may be explained by alternative use of multiple exons 1 flanked with tissue-specific promoters. The alternative use of multiple exons 1 for liver transcripts was found to change developmentally. Furthermore, switch from an adipose-specific exon 1 to another type of exon 1 was observed in aromatase transcripts of adipose tissues of three of five breast cancer patients.

[Staging pelvic lymphadenectomy for prostatic carcinoma]

Forty-two prostatic carcinoma patients with clinical stage A2, B or C underwent pelvic lymphadenectomy (limited node dissection) as a staging operation. The relationships among the presence of lymph node metastasis, tumor marker levels and histological findings of primary lesions were examined in 42 patients. Pelvic lymph node metastasis was noted in 18 (43%) of the 42 patients. The incidence of lymph node metastasis tended to be correlated with differentiation and Gleason's primary lesion sum. The preoperative PSA and PAP levels were significantly elevated in patients with positive lymph nodes for carcinoma than in those with negative lymph node for carcinoma. Patients with higher serum PSA (> or = 20 ng/ml) and PAP (> or = 10 ng/ml) levels were more frequently associated with lymph node metastasis. Thus, when serum PSA and PAP were markedly elevated before treatment in patients with prostatic carcinoma, they should be considered to have a potential of pelvic lymph node metastasis. Pelvic lymph node metastasis was observed in some cases even without high tumor marker levels, particularly those with poorly differentiated carcinoma.

[Antibiotic prophylaxis for transurethral resection of the prostate--comparison of oral administration therapy with intravenous administration therapy]

To compare the prophylactic effect of oral and intravenous antibiotics against postoperative fever and urinary tract infection (UTI) after transurethral resection of the prostate (TUR-P), we conducted a multi-center prospective randomized study. The incidence of pyrexia over 38 degrees C was defined as the primary endpoint. One hundred and fifty patients with sterile urine before TUR-P were entered into this study. The patients were allocated randomly into the two arms; arm A cefotiam 4 g a day for 7 days, arm B tosufloxacin 300 mg a day for 7 days, based on the stratification into the 4 groups determined with/without preoperative indwelling catheters and with/without the history of preoperative UTI. Of these patients, 143 were eligible. We divided 124 patients without preoperative UTI and without indwelling catheters as the "low risk group", and the other 19 patients with preoperative UTI and/or with indwelling catheters as the "high risk group". In the low risk group, 9 patients out of 63 (14.3%) in arm A and 6 out of 61 (9.8%) in arm B had pyrexia during 7 postoperative days. The incidence of fever in arm B was 4.4% less than that in arm A and the 95% confidence limit was from -7% to 16%. In the high risk group, 4 out of 11 (36.4%) patients in arm A and none of 8 in arm B had fever but the difference was not significant. The incidence of post operative UTI in the low risk group on the 4 to 5, 9 to 12, 23 to 26 and 37 to 40 postoperative days was 8.3, 16.4, 25.0 and 23.9% in arm A and 6.7, 16.7, 29.6 and 36.7% in arm B, respectively. The prophylactic effect of oral administration of tosufloxacin is equivalent to that of the intravenous administration of cefotiam. The use of oral antibiotics is beneficial to reducing the cost of medication.

[Clinical study of 8 cases of spontaneous esophageal rupture]

Among 8 patients with spontaneous esophageal rupture, mean age was 46.5 years, and there was only one female. Vomiting after drinking was the main cause of onset. In 4 patients who underwent drainage of the thoracic cavity or initial treatment by surgery within 24 hrs after onset, closure after layer-layer suture of the site of rupture was made in two patients in whom definitive diagnosis was obtained at the first medical examination and early discharge was possible. A definitive diagnosis was obtained after drainage of the thoracic cavity in the other two patients, and esophagectomy without thoracotomy was performed on the 55th day after onset in one and the other patient received only conservative treatment without surgery, both patients were discharged. Of 4 patients who underwent treatment after 24 hrs, two patients who recovered included one who received only conservative treatment and another who underwent closure by suture of the site of rupture and covering with a pedicled omental flap 12 days after onset. The other two patients died of MOF after operation. We propose the following guidelines for treatment of this condition; In patients in whom surgical treatment is possible within 24 hrs after onset, closure by layer-layer suture of the site of rupture may be indicated. In cases in which more than 24 hrs has elapsed after rupture spontaneous closure sometimes can be expected in patients with a rupture would less than 2 cm. In patients accompanied with progressing mediastinitis or pyothorax with drainage procedure surgical treatment is indicated.(ABSTRACT TRUNCATED AT 250 WORDS)

Molecular cloning of a cDNA encoding human histidase

We isolated overlapping cDNA clones encoding human histidase (histidine ammonia-lyase) from a human lambda gt10 library. The cDNA predicted a 657 amino acid protein of 72,651 Da. The human histadase amino acid sequence was 93% conserved with both rat and mouse histidase sequences, including four N-glycosylation consensus sites.

Differential effect of host microenvironment and systemic humoral factors on the implantation and the growth rate of metastatic tumor in parabiotic mice constructed between young and old mice

B16 melanoma cells were injected into the tail vein of young mice, old mice and parabiotic mice constructed between young and old mice, and the number and shape of pulmonary metastases were compared among three experimental groups. In unpaired mice, the number of metastatic colonies in the lungs was 10-fold larger in young than in old mice. In parabiotic mice, the number in young mice was almost comparable with that of unpaired young mice, but the number in old mice approached the level of young mice. Metastatic colonies on the pulmonary surface of young mice were mostly nodular in shape, while those of old mice were flat in shape. The shape of colonies reflecting the tumor growth rate did not change in parabiotic old mice in spite of an increase in number. In young parabiotic mice, the large and intermediate colonies decreased with a concomitant increase of small ones as compared with unpaired young mice. These results suggest that the implantation of metastatic colonies in the lung is mainly dependent on systemic humoral factors and their growth is mainly dependent on the host local factors in the microenvironment, and distinct age changes of both factors greatly influence the metastatic mode of tumors, respectively.

Effect of medium pH on glutathione redox cycle in cultured human umbilical vein endothelial cells

Impairments of the glutathione redox cycle in cultured endothelial cells under acidic pH conditions were measured. Glutathione-dependent H2O2-degrading activities decreased by 20% (P < .01) at pH 6 and by 51% (P < .01) at pH 4 compared with activities at pH 7.4 1 hour after a change with fresh medium. Intracellular reduced glutathione (GSH) content increased by 85% (P < .01) following the change with pH 7.4 medium. Such increases in GSH content were impaired after exposure to acidic medium. After exposure to 500 mumol/LH2O2, intracellular GSH content decreased by 61% compared with the level obtained in the absence of H2O2 at pH 7.4 (P < .01). Compared with the level at pH 7.4, the H2O2-induced decrease in intracellular GSH content was 32% lower (P < .01) at pH 6 and did not change at all at pH 4. After exposure to 500 mumol/L H2O2, the intracellular oxidized glutathione (GSSG) content increased by 160% at pH 7.4 (P < .01), 370% at pH 6 (P < .01), and 90% at pH 4 compared with treatment without H2O2, respectively. After exposure to 500 mumol/L H2O2, the release of GSSG from cells at pH 6 decreased by 38% compared with the value found at pH 7.4 (P < .05), and the release at pH 4 completely disappeared. Both glutathione peroxidase (GPO) and glutathione reductase activities decreased as a function of a decrease in pH from 7.4 to 4.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clock drawing task as screening for cognitive impairment in the elderly population]

This study compared the "Clock-Drawing Task" to the Mini-Mental State Test (MMST) in 834 elderly persons. A cut-off score of 20 or less on the MMST was used to determine cognitive impairment. The "Clock drawing Task" was score of 20 or less on the MMST was used to determine cognitive impairment. The "Clock drawing Task" was scored by three components; frame, numbers, and two hands. Using a criterion of completion on two or more of the three components, the sensitivity, specificity, and correct identification of the diagnosis of cognitive impairment of "Clock Drawing Task" were 89%, 65% and 83% respectively. "Clock Drawing" appears to be a practical test which can be useful for clinicians as a screening for cognitive impairment in old age.

Microsequence analysis of the N-terminally blocked proteins immobilized on polyvinylidene difluoride membrane by western blotting

A technique has been developed for efficient deblocking and subsequent microsequencing of N-terminally blocked proteins immobilized on a polyvinylidene difluoride (PVDF) membrane at the picomole levels. In this technique, proteins were first separated by polyacrylamide gel electrophoresis and then transferred onto a PVDF membrane by Western blotting. The electroblotted proteins with N-terminal acetylserine or acetylthreonine could be deblocked on-membrane by treatment with trifluoroacetic acid vapor and sequenced by a gas-phase protein sequencer. Similarly, N-formylated proteins could be deblocked on-membrane in HC1 solution and then directly sequenced from the N-terminal amino acid. Proteins with N-terminal pyroglutamic acid were enzymatically deblocked by in situ pyroglutamyl peptidase digestion, and N-acetylated proteins were also enzymatically deblocked with acylamino acid-releasing enzyme (AARE) after on-membrane digestion with trypsin to generate the N-terminal peptide fragment. This tryptic digestion was required since AARE can remove the acetylamino acid only from a short peptide. Based on these four deblocking methods, we present a strategy for sequential deblocking and subsequent N-terminal sequence analysis of N-blocked protein immobilized on PVDF membrane.

Effects of changes in gonadal hormones on the amount of aromatase messenger RNA in mouse brain diencephalon

Aromatase in brain is known to play a crucial role in development and maintenance of androgen dependent sexual behavior of males. Biochemical studies have shown that the aromatase activity in brain is influenced by androgen. In this study, we measured the aromatase mRNA content of mouse brain quantitatively to gain a deeper insight into this phenomenon. We found that in the diencephalic area it is sexually dimorphic, as reported for aromatase activity. The amount of aromatase mRNA in this area in males was 150% higher than that in females and decreased to the level in females after castration. The content of aromatase mRNA in castrated males was elevated by 2-fold by injection of testosterone and restored to the level observed in intact males. Injection of testosterone also affected the level of aromatase mRNA in normal mice of both sexes, though to lesser extent. On the contrary, injection of estrogen decreased the amount of aromatase mRNA in gonadectomized mice of both sexes. These results show that transcriptional control of the aromatase gene is involved in the mechanism of testosterone to affect sexual behavior.

Elevated complement activities of sera from patients with high density lipoprotein deficiency (Tangier disease): the presence of normal level of clusterin and the possible implication in the atherosclerosis

Clusterin (apolipoprotein J, SP-40,40), as well as apolipoprotein A-I (apo A-I) and apolipoprotein A-II (apo A-II), are apolipoprotein components of high density lipoprotein (HDL), but not of low density lipoprotein. In spite of the deficiencies of apo A-I, apo A-II and HDL in the sera of patients with Tangier disease, clusterin was found in them at normal level. While clusterin was present as the component of HDL with apo A-I in sera of normal donors, it was present as a protein which did not form a complex in sera of Tangier patients. SC5b-9 made from the sera of Tangier patients contained normal amounts of clusterin and was deficient in apo A-I, indicating that clusterin could be incorporated into the SC5b-9 complex without apo A-I. The complement activities of the sera of the patients were higher than those of normal donors. These results may be explained by the deficiencies of apo A-I, apo A-II and HDL in the patients, because they were suggested to be the inhibitors of the reactive haemolysis of complement. The elevated complement activities of the patients might be related to the severe atherosclerotic lesions in Tangier disease.

[A case report of redo Fontan operation]

A 21-year-old man, who had undergone Fontan operation for tricuspid atresia type 1b using 21 mm Hancock valved conduit 15 years ago, had right sided heart failure when his heart rhythm turned to atrial fibrillation. On cardiac catheterization, pressure data revealed that trans valved conduit pressure gradient reached to 5.2 mmHg. Chest CT and right atrial angiography showed right atrial wall thrombus. Right upper lobe perfusion defect was detected by lung perfusion scintigraphy. Then he was recommended redo Fontan operation. He underwent resection of stenosed valved conduit, right atrial thrombectomy and reconstruction of new route between right atrium and pulmonary artery with bovine pericardium. He tolerated well that operation and now 3 months passed, he resumed fairly vigorous physical activity.