Completion pneumonectomy of the residual left lung to treat lung cancer in a patient with hemophilia A: report of a case

Hemophilia A is a sex-linked recessive hereditary disease that is relatively rare and the number of patients with this disorder who undergo major surgery is limited. Although replenishing coagulation factors can allow hemophiliac patients to undergo similar surgery to that performed for patients without hemophilia, there have been few reports on major surgery and none on the resection of lung cancer in patients with hemophilia A. We recently performed completion pneumonectomy of the left lung in a 70-year-old man with hemophilia A, for squamous cell carcinoma in the residual left lung. The administration of a recombinant DNA coagulation factor VIII preparation allowed this operation to be successfully carried out. This case serves to demonstrate that the recombinant DNA coagulation factor VIII preparation described may enable us to safely perform major surgery on hemophiliac patients, since there is no risk of viral infection or any other adverse effects, such as deterioration of immunocompetence or hemolysis, which are occasionally encountered with human plasma-derived preparations.

Lack of association between genetic polymorphism of CYP11B2 and hypertension in Japanese: the Suita Study

Aldosterone synthase (CYP11B2) is a key enzyme in the biosynthesis of aldosterone. Recently, a polymorphism in the 5'-flanking region of the CYP11B2 gene [T(-344)C] has been reported to be associated with blood pressure and plasma aldosterone levels. We investigated the association between this polymorphism and hypertension in a large population-based sample of 4,000 Japanese. The genotype distribution in hypertensive subjects (n=1,535) was compared to that in normotensive subjects (n=2,514). In subjects not receiving antihypertensive medication, the influence of the genotype on blood pressure values adjusted for clinical covariates was analyzed. All analyses were performed separately for men and women. The genotype distribution did not differ between hypertensive and normotensive subjects in either men (frequency of C allele: 30.3% vs. 31.4%, p=0.48) or women (31.5% vs. 31.7%, p=0.93). There were no significant differences in systolic blood pressure, diastolic blood pressure, or pulse pressure among the three genotypes in either men or women who had not received hypertensive medication. Our data suggest that the T(-344)C polymorphism of CYP11B2 is unlikely to influence blood pressure status in the Japanese population.

T+31C polymorphism of angiotensinogen gene and essential hypertension

A common variant at codon 235 of the angiotensinogen gene with methionine to threonine amino acid substitution (AGT M235T) has been reported as a genetic risk for essential hypertension. However, the frequency of AGT T235 was heterogeneous among races, and a positive association between AGT M235T and hypertension was not settled. To examine the association in a general population of Japanese (n=4013), we introduced the TaqMan polymerase chain reaction method and examined the relation between hypertension and T+31C polymorphism, which was in absolute linkage disequilibrium with AGT M235T. The C+31 allele of AGT was significantly associated with the positive family history of hypertension (FH) but not with the presence of hypertension or blood pressure. The subjects with CC tended to have hypertensive relatives, especially a hypertensive father or siblings, and its statistical significance was stronger in men. Adjustment of confounding factor did not alter the results of simple association study, suggesting that this positive association with FH is independent and significant. Our findings revealed that the TaqMan polymerase chain reaction method is a powerful tool for genetic association study with a large number of subjects and that AGT T+31C is significantly associated with paternal FH.

Impaired distribution of retinoic acid receptors in the hindgut-tailgut region of murine embryos with anorectal malformations

BACKGROUND/PURPOSE

Retinoid-mediated signal transduction plays a crucial role in the organogenesis of various organs. To investigate the pathogenesis of anorectal malformations (ARM), the authors studied the distribution pattern of retinoic acid receptors (RARs) in ARM murine embryos induced by overdose of all-trans retinoic acid (ATRA).

METHODS

Pregnant mice were gavage-fed 100 mg/kg of ATRA on the ninth gestational day (E9.0). Embryos were obtained between E11.0 and E14.0 and were fixed immediately in a 4% paraformaldehyde solution. Frozen sections were prepared for immunohistochemistry using antibodies specifically raised against RAR-alpha, RAR-beta, and RAR-gamma.

RESULTS

Over 98% of the embryos administered ATRA had ARM; rectoprostatic urethral and rectocloacal fistulas were the most frequent anomalies. The immunoreactivity of RAR-alpha was found equally in the epithelium of hindgut-tailgut in normal embryos on E11.5. However, it was absent in the hindgut in the treated embryos. The immunoreactivities of RAR-beta and RAR-gamma showed no difference in the distal hindgut.

CONCLUSIONS

Impaired distribution of RAR-alpha in the hindgut-tailgut on E11.5 resulted in the incomplete partitioning of the cloaca and the rectourethral or rectocloacal fistula on E14.0. These results suggest that overdose of ATRA affects the distal hindgut development by directly disrupting the retinoid-mediated signalling pathway.

Factors of biliary carcinogenesis in choledochal cysts

The long-term complications of choledochal cysts include malignant degeneration of the epithelial lining of the biliary tract. Possible factors leading to malignant degeneration were examined by measuring amylase levels in the biliary tract, intraoperative biliary manometry and a histopathological study. 27 patients, 1 to 13 years of age, with choledochal cysts, were studied over a 13-year period. Amylase levels in the bile of choledochal cysts and the gallbladder were measured. The pressure profile of the biliary tract was recorded as the probe was withdrawn from the sphincter of Oddi (SO) to the distal end of the common bile duct. Hyperplasia of the gallbladder mucosa and malignancy of the biliary tract were investigated. Patients with high levels of biliary amylase had higher pressure differences between the SO and the duodenum than those with low levels of biliary amylase. The incidence of mucosal hyperplasia of the gallbladder mucosa was significantly higher in the fusiform type than in the cystic type. Adenocarcinoma in a cystic choledochal dilatation was found in a 12-year-old girl with high amylase levels. The cause of regurgitation of pancreatic juice into the biliary system might be due to a high pressure difference between the SO and the duodenum in addition to the lack of sphincter function at the abnormal junction of the pancreaticobiliary ductal system. Early diagnosis and surgical treatment to prevent the regurgitation leading to hyperplasia and malignancy of the biliary tract are important for children with choledochal cysts.

Diminution of the AML1 transcription factor function causes differential effects on the fates of CD4 and CD8 single-positive T cells

In the thymic cortex, T lymphocytes are positively selected to survive and committed either to the CD4 single-positive (SP) or the CD8 SP lineage. The SP cells then pass through a step of maturation in the medulla and are delivered to peripheral lymphoid tissues. We examined the role of AML1, the gene encoding a transcription factor, in the above processes by using the transgenic mice expressing a dominant interfering form of AML1 as well as mice targeted heterozygously for AML1. One phenotypic change seen in the AML1-diminished mice was the reduction in the numbers of both CD4 SP and CD8 SP thymocytes, reflecting the partial impairment of the transition from the double-positive to SP stage. In addition, distinct from the above abnormality, perturbed were several aspects of SP cells, including the maturation of SP thymocytes, the recent thymic emigration, and the proliferative responsiveness of peripheral T cells to TCR stimulation. Interestingly, the AML1 diminution caused inhibitory and enhancing effects on the CD4 SP and CD8 SP cells, respectively. These differential effects are most likely related to the reduction in the peripheral CD4 SP/CD8 SP ratio observed in the AML1-diminished mice. The AML1 transcription factor thus maintains the homeostasis of each SP subset by functioning at the later stages of T lymphocyte differentiation.

Genetic mapping of quantitative trait loci influencing left ventricular mass in rats

High blood pressure is the leading cause of left ventricular hypertrophy (LVH); however, not all hypertensive patients develop LVH. Genetic factors are important in the development of LVH. With the use of F2 male rats from spontaneously hypertensive rats and Lewis rats, we performed a study to identify the quantitative trait loci (QTL) that influence left ventricular mass (LVM). Mean arterial pressure (MAP) was measured by the direct intra-arterial method in conscious animals, and LVM was determined at 24 wk of age. QTL analysis was done using 160 microsatellite markers for a genome-wide scan. Two loci that influenced body weight-adjusted LVM with logarithm of the odds scores >3.4 were found. One locus on chromosome 17 influenced LVM independently of MAP. Another locus on chromosome 7 influenced LVM and MAP. These findings indicate not only the existence of a gene on chromosome 7 that influences LVM in a manner dependent on blood pressure but also the existence of a gene on chromosome 17 that influences LVM independently of blood pressure.

Congenital anomalies in mice induced by etretinate

We report on the experimental induction of anorectal malformations (ARM) and other internal and external malformations in mouse fetuses induced by maternal administration of etretinate, a long-acting vitamin A analogue. The teratogen was administered to pregnant mice between the 7th and 10th gestational days (E7 and E10). The mice of the control group were given pure sesame oil on E9. We examined survival rates, crown-rump length, and the incidence of internal and external malformations, with particular attention to ARM, in each group. All mice in the E8 group exhibited rectovesical fistula, hydronephrosis, and spina bifida. All males and females in the E9 group given 60 mg/kg of etretinate developed rectoprostatic urethral fistula and rectocloacal fistula, respectively. The E10 group, given 60 mg/kg of etretinate displayed cleft palate (63.6%), forelimb malformation (68.2%), and a short club-shaped tail (100%). The fetuses had more severe types of ARM when etretinate had been administered on an earlier gestational day. The E9 group is a useful model for anorectal malformation, whereas the E8 group is a model for hydronephrosis and spina bifida.

Arteriovenous malformation of the penis in an infant

Arteriovenous malformations (AVMs) are common benign lesions in infancy, although they are rare in the genitourinary region. The authors report on a 2-year-old boy with a penile AVM. At presentation, there was venous dilatation and tortuosity of the prepuce without ulceration, which had been recognized at 1 year of age. Left internal iliac arteriography showed early venous filling leading to the diagnosis of AVM. Surgical excision was performed at age 2. The postoperative course was uneventful. At the 6-month follow-up, there was no evidence of recurrence. This is the first report of a penile AVM that was successfully treated by surgical excision.

Leisure-time physical activity and related lifestyle characteristics among middle-aged Japanese. Japan Lifestyle Monitoring Study Group

The present study describes leisure-time physical activity status and related lifestyle factors in middle-aged Japanese. Data were obtained from 1,893 (905 men, 988 women) participants aged 40-69 years who had either been selected from a public registry or who had visited a healthcare facility. Subjects responded to a self-administered questionnaire and were interviewed using an assessment method for leisure-time and on-the-job physical activity within the last 12 months by trained interviewers. According to the leisure-time physical activity score, men and urban residents tended to engage in more leisure-time physical activity than did women and rural residents, respectively. Leisure-time physical activity tended to be inversely associated with on-the-job physical activity in all cases aside from women in urban regions, and also to be associated with higher levels of education in rural regions. Subjects engaging in more leisure-time physical activity had higher odds ratios of certain lifestyle factors, indicating a healthy lifestyle that included a variety of foods in their diet and a subjective sense of wellness in both men and women, in addition to non-smoking and drinking milk in men. These results suggested that leisure-time physical activity is influenced by socio-environmental factors, and that it is accompanied by other healthy behavior.

Proliferation and cell death of embryonic primitive erythrocytes

Erythropoietin (EPO) is the principal regulator for the production of adult-type definitive erythrocytes (EryD). EPO not only stimulates both the proliferation and differentiation of EryD progenitors, but also maintains the viability of EryD progenitors. Compared to the abundant knowledge about the function of EPO in EryD production, the roles of EPO in the production of embryonic-type primitive erythrocytes (EryP) are less clear. The effects of EPO on EryP proliferation and differentiation were investigated using EryP purified from developing mouse embryos and the cells obtained from mouse embryonic stem cells using an in vitro differentiation induction. Immature EryP of both in vivo and in vitro origin responded to EPO stimulation and underwent apoptosis with EPO deprivation. In contrast, there were no significant differences between the cultures with and without EPO, when fully mature EryP were examined, that is, EryP lost its dependency on EPO stimulation with maturation. These results show that EPO functions as a survival factor for immature embryonic EryP as well as immature EryD progenitors.

Intermittent adjuvant chemo-immunotherapy after resection of non-small cell lung cancer with multilevel mediastinal lymph node metastasis

The prognosis of patients with multilevel mediastinal lymph node metastasis remains poor notwithstanding the progress in multimodal therapy in non-small cell lung cancer. We conducted a feasible study of intermittent adjuvant chemo-immunotherapy after surgery for patients with multilevel mediastinal lymph node metastasis of non-small cell lung cancer. Eleven patients with pathologically N2 or N3 lung cancer (10, adenocarcinomas; 1, squamous cell carcinoma) were enrolled. Five completely resected cases received systemic chemo-immunotherapy and six incompletely resected cases received local chemo-immunotherapy by an indwelling catheter in the thoracic cavity. Cisplatin-based and dose-dependent anti-cancer drugs were selected on the basis of sensitivity tests. Either adoptive immunotherapy with interleukin-2 and lymphokine-activated killer cell or combination of interferon gamma# and OK432 were administered after chemotherapy. This adjuvant therapy was performed every 2-3 months after surgery for 2 years. The 2-year survival rate for all cases were 72.7% and the 2-year disease-free survival were 36.4%. The 2-year survival rate for five completely resected cases and six incompletely resected cases was 80% and 66.7%, respectively. Combined intermittent chemo-immunotherapy after surgical resection of tumors may be a promising modality to improve the survival of patients with multilevel mediastinal lymph node metastasis in non-small cell lung cancer.

Mucosal cell proliferation activity of the gallbladder in children with anomalous arrangement of the pancreaticobiliary duct

Anomalous arrangement of the pancreaticobiliary duct (AAPBD) is an anatomical maljunction of the bile duct and the pancreatic duct that is frequently associated with gallbladder carcinoma. In patients with AAPBD, it has been postulated that pancreatic juice regurgitates into the biliary tree, and the mixture of refluxed pancreatic juice and stagnant bile juice acts as an irritant factor to the biliary tract epithelium, leading to chronic inflammation and metaplasia. Eventually these mucosal changes may progress to invasive carcinoma. We reviewed clinicopathologic studies on epithelial changes of the gallbladder in patients with AAPBD to clarify the implications relevant to carcinogenesis. Conventional histological studies have shown that the most characteristic change observed in the gallbladder of children with this anomaly was epithelial hyperplasia. Furthermore, the incidence of mucosal hyperplasia was significantly increased in the gallbladder of children in whom the pancreatic duct joined the common bile duct (P-C type) compared with the incidence in children in whom the common bile duct joined the pancreatic duct (C-P type). In addition, cell kinetic studies have demonstrated increased cellular proliferative activity of the gallbladder in children with AAPBD. Cell proliferative activity was significantly elevated in children with the P-C type of AAPBD compared with that in children with the C-P type of anomaly. In conclusion, AAPBD may yield increased cell proliferation in the gallbladder of patients with this anomaly in early childhood, resulting in epithelial hyperplasia. Although it remains unknown which agents are responsible for promoting the activation of cellular function, it seems that bile acids and refluxed pancreatic proteases are likely play a role in such promotion. Further investigations are needed to elucidate the mechanism of increased cellular function.

Ultrasonographic detection of intrauterine intussusception resulting in ileal atresia complicated by meconium peritonitis

A neonate with ileal atresia (IA) complicated by meconium peritonitis (MP) whose prenatal ultrasonography (US) detected an intrauterine intussusception (IUI) is reported. Fetal ascites, dilated bowel loops, and abdominal calcifications were identified on serial US from 25 weeks of gestation. Intestinal loops with high echogenecity and a "target-like" appearance suggestive of IUI were detected in the right lower quadrant. The 2,680-g male was delivered vaginally at term and underwent a laparotomy. Fibrous adhesions and small calcifications were scattered throughout the peritoneal cavity. IA (interrupted type) was confirmed 17.0 cm cranial to the ileocecal valve (ICV). An ileo-ileal intussusception was also found between 16.5 cm and 9.0 cm cranial to the ICV. Partial resection of the ileum and an ileo-ileal anastomosis was performed. The postoperative course was uneventful. In this case, the pathological process of IUI resulting in IA and MP was demonstrated sonographically by identifying the "target-like" appearance in the fetus.

A bleeding tendency as the first symptom of a choledochal cyst

We report an 8-month-old male presenting with gingival hemorrhages and nasal bleeding as the first symptom of a choledochal cyst (CC). On physical examination, there was a large cystic mass in the right upper abdominal quadrant. Laboratory studies on admission revealed moderate liver dysfunction and a bleeding tendency due to vitamin K deficiency. After administration of 5 mg vitamin K the bleeding tendency disappeared. At laparotomy, a large CC 5 cm in diameter was found and the liver showed moderate cholestasis. The sudden onset of a bleeding tendency in infants with congenital liver or biliary-tract disease may suggest not only biliary atresia, but also CC.

Variation of the factor VII gene and ischemic heart disease in Japanese subjects

BACKGROUND

Polymorphisms of the 5' region (5'FT), an intronic mutation (IVS7), and the 353Arg-Gln (R353Q) substitution of the factor VII gene have been reported to be associated with the plasma level of factor VII. Greater than normal levels of factor VII have also been reported to be associated with atherothrombotic events. However, the significance of factor VII gene polymorphism in the pathogenesis of ischemic heart diseases (IHD) has not been confirmed.

OBJECTIVE

To determine whether these three factor VII gene polymorphisms are associated with levels of factor VII in Japanese subjects, and whether these three polymorphisms of the factor VII gene are associated with the risk of myocardial infarction.

METHODS

We studied three polymorphisms of the factor VII gene, 5'FT, IVS7, and R353Q polymorphisms, for 493 Japanese subjects consisting of 285 subjects without clinical evidence of ischemic heart disease (non-IHD group) and 208 myocardial infarction patients (myocardial infarction group). We also assessed the plasma levels of factor VII antigen (FVIIag) in 103 subjects in the non-IHD group.

RESULTS

Multiple regression analysis revealed that the level of FVIIag was significantly associated with age, body mass index, cholesterol level and a polymorphism of the factor VII gene (5'FT). Logistic analysis of 493 subjects revealed that cholesterol level [P = 0.0036, odds ratio 1.010, 95% confidence interval (CI) 1.003-1.017], smoking (P = 0.0001, odds ratio 5.522, (95% CI 2.684-11.364) and diabetes mellitus (P = 0.0001, odds ratio 6.450, (95% CI 2.953-14.088) were risk factors for myocardial infarction. However, the three polymorphisms of factor VII gene were not associated with risk of myocardial infarction.

CONCLUSION

The polymorphisms of the factor VII gene influenced the levels of factor VII but were not significantly associated with risk of myocardial infarction in Japanese subjects.

Human prostacyclin synthase gene and hypertension : the Suita Study

BACKGROUND

Prostacyclin (prostaglandin I(2)) is a strong vasodilator that inhibits the growth of vascular smooth muscle cells and is also the most potent endogenous inhibitor of platelet aggregation. Therefore, it has been considered to play an important roles in cardiovascular disease. On the basis of the hypothesis that variations of the prostacyclin synthase gene may also play an important role in human cardiovascular disease, we performed a screening for variations in the human prostacyclin synthase gene.

METHODS AND RESULTS

We have detected a repeat polymorphism in the promoter region of the human prostacyclin synthase gene. The number of 9-bp (CCGCCAGCC) repeats in the promoter region, which encodes a tandem repeat of Sp1 transcriptional binding sites, varied between 3 and 7 in Japanese subjects. Luciferase reporter analysis indicated that the alleles of 3 and 4 repeats (R3 and R4, respectively) had less promoter activity in cultured human umbilical vein endothelial cells. We then investigated the possible association of this repeat polymorphism with blood pressure in a large population-based sample (the Suita Study), which consisted of 4971 Japanese participants. Multivariate models indicated that participants with the R3R3, R3R4, or R4R4 genotype (SS genotype, n=80) had significantly higher systolic pressure (P=0.0133) and pulse pressure (P=0.0005). The odds ratio of hypertension (140/90 mm Hg) for the SS genotype was 1.942 (95% confidence interval 3.20 to 1.19, P=0.0084).

CONCLUSIONS

Repeat polymorphism of the human prostacyclin synthase gene seems to be a risk factor for higher pulse pressure and is consequently a risk factor for systolic hypertension in the Japanese population.

Chromosomal mapping of quantitative trait loci that influence renal hemodynamic functions

BACKGROUND

Impaired renal hemodynamic function has been suspected to be responsible for hypertension in the spontaneously hypertensive rat (SHR).

METHODS AND RESULTS

We measured renal hemodynamic functions, including the glomerular filtration rate, renal plasma flow, and renal vascular resistance, in an F2 rat population derived from spontaneously hypertensive and Wistar-Kyoto (WKY) rats and performed a genome-wide screening to map quantitative trait loci that influence these functions to gain insight into the relationship between renal hemodynamic functions and blood pressure control. The D1 Mit7 locus was identified as a major locus that influenced renal hemodynamic functions, and we transferred the SHR chromosomal segment around the D1 Mit7 locus into the WKY strain. The congenic rats exhibited impaired renal hemodynamic functions. The systolic blood pressure of the congenic rats was significantly higher than that of age-matched WKY rats, but only at nighttime. No significant differences in systolic blood pressure during daytime or diastolic blood pressure were observed between the 2 strains.

CONCLUSIONS

We have identified a chromosome segment that influences renal hemodynamic function. The SHR chromosome segment around the D1 Mit7 locus had significant, but not dramatic, effects in increasing blood pressure in the WKY genetic background. However, further studies will be necessary to determine the significance of this locus in SHR hypertension.

Antenatal diagnosis of biliary atresia (noncorrectable cyst type): a case report

At 32 weeks of gestation a cystic mass was identified in the hepatic hilum of a fetus by maternal sonography. Laparotomy was performed at 39 days of life after a diagnosis of correctable type of biliary atresia (Type I). A cystically dilated extrahepatic duct, in which the proximal and distal sides of the common bile duct were occluded (Type III with cyst, noncorrectable type), was identified by operative cholangiography. A standard Kasai operation was performed, and 1 year after operation the patient was doing well and was jaundice-free. From this experience in routine maternal sonography, a cystic mass in the hepatic hilum may also suggest Type III biliary atresia with a cyst.

Mutational analysis of the RET proto-oncogene in a kindred with multiple endocrine neoplasia type 2A and Hirschsprung's disease

BACKGROUND/PURPOSE

Germline mutations of the RET proto-oncogene (RET; 10q11.2) have been reported in multiple endocrine neoplasia type 2A (MEN 2A) and Hirschsprung's disease. The authors investigated a Japanese kindred in which MEN 2A and Hirschsprung's disease frequently have been found.

METHODS

The pedigree consisted of 28 members (11 boys and 17 girls) spanning 4 generations, of whom, 8 were affected with MEN 2A or Hirschsprung's disease.

RESULTS

Direct sequence DNA analysis of the RET proto-oncogene showed a heterozygosity for a G to C transition at the second nucleotide of codon 620 (exon 10) in the patients, resulting in the replacement of cysteine by a serine residue in the affected Ret protein. This family added a novel RET missense mutation (C620S) predisposing to the association of MEN 2A and Hirschsprung's disease.

CONCLUSION

Detection of the mutated RET gene carriers may be used for genetic counseling of potential risk for Hirschsprung's disease as well as MEN 2A in the affected families.