Rearrangement of the rheumatoid factor-related germline gene Vg and bcl-2 expression in lymphoproliferative disorders in patients with Sjögren's syndrome

Of 250 patients with Sjögren's syndrome (SS) (190 with 1 degree SS and 60 with 2 degrees SS), 60 patients demonstrated lymphoproliferative disorders (LPD): 41 patients had monoclonal gammopathy (MG), 4 had pseudolymphoma, 3 had in situ monoclonal lymphoproliferation, and 12 had malignant lymphoma. Rearrangement of the rheumatoid factor (RF)-related germline gene Vg (associated with the monoclonal RF SF18/2) was demonstrated in 24 of 50 genomic DNAs from the peripheral blood leukocytes of SS patients. It was found in none of 20 DNAs from normal subjects. This suggests an almost 50% incidence of a germline Ig gene rearrangement in SS patients without clinical MG. Lymphocytes composing the lymphoepithelial lesion (LEL) in the major salivary glands of SS patients expressed the oncogene bcl-2 protein in 4 out of 6 patients. The progression of SS from benign to malignant lymphoproliferation may be related to suppression of apoptotic death by bcl-2. These findings suggest that (i) RF clones are activated in SS with little or no somatic mutation resulting in monoclonal proliferation and (ii) the LEL in the salivary gland is one site for monoclonal B cell proliferation and emerging malignant lymphoma.

Effect of altering cerebrospinal fluid pressure on spinal cord blood flow

Removal of cerebrospinal fluid (CSF) has been proposed as a means of protecting the spinal cord against ischemic injury during thoracoabdominal aneurysm operations. We investigated the effect of altering CSF pressure (CSFP) on lumbar spinal cord blood flow (SCBF) in an experiment using dogs. The SCBF was measured before and after withdrawal of CSF in settings with and without thoracic aortic clamping. Furthermore, SCBF was measured at the basal state and after elevation of CSFP to 20 mm Hg and to 40 mm Hg. The SCBF did not change significantly before and after removal of CSF in settings both with and without thoracic aortic clamping. Elevation of CSFP significantly reduced SCBF. Elevation of CSFP reduces SCBF, but lowering CSFP per se does not increase SCBF whether the thoracic aorta is occluded or not. This supports the notion that removal of CSF offers spinal cord protection only when CSFP is abnormally elevated.

[Antigen-induced pulmonary arterial responses in the isolated perfused lung of sensitized rabbits]

To investigate whether blood components, such as complements, antibody, platelets and leukocytes, can play important roles in increasing pulmonary arterial and airway pressures after antigen challenge in sensitized rabbits, we measured the time course of pulmonary arterial pressure, airway pressure and lung weight gain after antigen challenge in isolated perfused rabbit lungs. Nineteen rabbits were divided into 3 groups; S group (n = 9), which was sensitized rabbit lung with antigen added into perfusate; NS group (n = 5), which was nonsensitized rabbit lung with antigen added into perfusate; S+R group (n = 5), which was sensitized rabbit lung with autologous erythrocytes added into perfusate. Although agglutinin titer in sensitized rabbits was more than 1: 10,000, that in the perfusate was less than 1:16. Pulmonary arterial and airway pressures significantly increased after antigen challenge in S group, while those in NS and S+R groups did not show any change. Also there were no significant changes in pulmonary arterial and airway pressures and lung weight gain in nonsensitized rabbit lungs of the same agglutinin titer as S group. Lung weight gain in S group was 2-4 times higher than that in S+R group after antigen challenge. We conclude that blood components, such as complements, antibody, platelets and leukocytes, do not play important roles on antigen induced pulmonary responses in sensitized rabbit lungs.

In vivo, in vitro correlation of acetylcholine airway responsiveness in sensitized guinea pigs. The role of modified epithelial functions

Many attempts have failed to correlate in vivo airway responsiveness with in vitro airway smooth muscle functions. We have reexamined this relation by taking account of airway epithelial functions in guinea pigs sensitized with inhaled ovalbumin (OA). In vivo responses were assessed by the provocative concentration of acetylcholine (ACh) required to double the airway opening pressure (PC200) under mechanical ventilation. In vitro responses were measured in a perfused whole-tracheal preparation. The negative logarithm of the molar concentration of ACh required to produce a 10% reduction in diameter was calculated both for epithelial-side stimulation (PC10(in)) and for serosal-side stimulation (PC10(out)). OA-sensitized guinea pigs showed significantly smaller log PC200 than control animals (0.51 +/- 0.07 and 0.81 +/- 0.10, respectively, p < 0.01). In in vitro study, there were variable differences in PC10(in) and PC10(out) in each animal. The difference in sensitivity between epithelial- and serosal-side stimulation (PC10(in-out)) showed a significant correlation in PC10(in) (r = 0.82, n = 9, p < 0.01) but not to PC10(out) (r = 0.39, p > 0.1), indicating that the variation in PC10(in-out) resulted from the changes in PC10(in). For in vivo-in vitro correlation, log PC200 correlated significantly with PC10(in) (r = 0.68, n = 9, p < 0.05) but not with PC10(out) (r = 0.18, p > 0.1). These results indicate that the sensitization by inhalation of OA produces increased airway responsiveness to ACh in vivo and that this airway responsiveness may be related, at least in part, to the altered airway epithelial functions.

[Successful VEP-IFN-alpha therapy in a case of non-secretory plasma cell leukemia (BJ-kappa type)]

Plasma cell leukemia is a rare disorder with poor prognosis. We present a case of non-secretory primary plasma cell leukemia (Bence-Jones kappa type), which was treated successfully by VEP-IFN-alpha therapy. A 82-year old man was admitted to Kanazawa Medical University in May 1991, because of emaciation and dehydration. Clinical findings showed decreased level of gamma-globulin (IgG, IgA and IgM were all decreased markedly), hypercalcemia, renal dysfunction and increased serum beta-2 microglobulin. The peripheral blood leukocyte count was 30,100/microliters with 64% plasma cells, and 80.4% plasma cells were also observed in the bone marrow. Only light chain-kappa was detected in plasma cells by an immunohistochemical staining method, but immunoelectrophoresis showed no M-bow either in serum or urine. Electron microscopy revealed typical plasma cells with prominently developed rough endoplasmic reticulum. From these results, the diagnosis of non-secretory primary plasma cell leukemia was established. He was treated with VEP-IFN-alpha regimen, and plasma cells decreased markedly in both peripheral blood and bone marrow. Serum immunoglobulin recovered to within the normal range. After 6 courses of VEP-IFN-alpha, complete remission was achieved and the remission was maintained until he died of an unrelated event, bronchial obstruction due to misswallowing, in April 1992.

Effect of daily subcutaneous administration of recombinant erythropoietin on chronic anemia in rheumatoid arthritis

Mean (+/- SD) serum erythropoietin (EPO) levels were 18.6 +/- 5.6 mU/ml in 180 normal Japanese subjects. Serum EPO levels were elevated with a negative correlation on a log scale (r = -0.864, P < 0.005) to hematocrit (Ht) values in anemic patients not associated with rheumatoid arthritis (RA) or chronic renal failure (CRF). Serum EPO levels in patients with RA (31.6 +/- 16.4 mU/ml) were relatively lower than those in normal subjects and anemic patients without RA or CRF when matched for comparative Ht values. Seven anemic patients with RA were treated by daily subcutaneous (sc) injection of recombinant EPO (rEPO, 500-1,000 U/day) for 4 weeks. The patients had initial Ht values of 25.1% or less and maintained stable clinical status. The treatment with rEPO raised serum EPO levels (53.8 +/- 15.2 mU/ml, P < 0.05), which resulted in an increase in Ht values (more than 3%) in 6 out of 7 patients with RA. The mean (+/- SD) Ht values at the end of the treatment with rEPO (500-1,000 U/day) were greater than those before the treatment in the 7 patients with RA (28.5 +/- 4.6 vs. 22.7 +/- 2.5%, P < 0.05). These findings suggest that chronic anemia associated with RA may be corrected by daily sc injection of a small dose of rEPO.

Induction of ovulation by endothelin-3 in rats

Endothelins vary in their biological activity. We therefore examined the effects of endothelin-3 (ET-3) on ovulation and secretion of LH, FSH and prolactin in rats in which naturally occurring ovulation was blocked by the administration of sodium pentobarbital (40 mg/kg, i.p.) prior to the critical period (1330 h) on the day of pro-oestrus. ET-3 (10 nmol/kg) was given via the jugular vein under pentobarbital anaesthesia from 1600 to 1800 h on the day of pro-oestrous and induced ovulation in all rats whether given by venous injection or by infusion but the number of ova in rats injected with ET-3 was less than that in normally cycling control rats. Infusion of ET-3 stimulated the secretion of LH but caused a lower than expected rate of secretion of FSH. It would therefore appear that ET-3 causes release of the total amount of LH that is required for induction of ovulation. Our findings strongly suggest that ET-3 has a physiologically significant role in the regulation of anterior pituitary hormone secretion.

Sweet's syndrome during therapy with granulocyte colony-stimulating factor in a patient with aplastic anaemia

A patient with aplastic anaemia developed Sweet's syndrome (a febrile neutrophilic dermatosis) during granulocyte colony-stimulating factor (G-CSF) therapy. Three repeated episodes of appearance and disappearance of erythematous nodules after administration and withdrawal of G-CSF confirmed that G-CSF induced Sweet's syndrome in the patient. Sweet's syndrome has been reported in patients with myelodysplastic syndrome and acute leukemia, but not in patients with aplastic anaemia. This is the first report of a patient with aplastic anaemia who developed G-CSF-induced Sweet's syndrome.

[Prostaglandin E1 does not inhibit production of TNF and IL-1 by mononuclear cells after head-neck surgery]

We studied whether human blood mononuclear cells could produce tumor necrosis factor (TNF) and interleukin 1 (IL-1) by surgical stimuli, and if so, prostaglandin E1 (PGE1) could inhibit their increases before and following operation in patients undergoing head-neck surgery. The patients were randomly allocated into 2 groups; no PGE1 infusion group (control group, n = 6) and PGE1 infusion group (PGE1 group, n = 6). PGE1 group was infused intravenously with PGE1 at a rate of 30 ng.kg-1 x min-1 during surgery and at a rate of 10-30 ng.kg-1 x min-1 after surgery. Peripheral blood was withdrawn into heparinized syringes from these patients immediately before surgery and on the 1st postoperative day. Production of TNF on the 1st postoperative day increased 1.5 fold in control group and 1.4 fold in PGE1 group compared with those before surgery. Production of IL-1 on the 1st postoperative day increased 1.7 fold in control group and 1.1 fold in PGE1 group compared with those before surgery. Also, there were no significant differences between 2 groups in both productions of TNF and IL-1. These data indicate that human blood mononuclear cells would produce TNF and IL-1 by surgical stimuli and PGE1 could inhibit their production by surgical stimuli. It also provides evidence that PGE1 does not inhibit the body's defense response to surgical stimuli.

Gamma-interferon modifies guinea pig airway functions in vitro

Cytokines produced by T-lymphocytes may have significant roles in the airway inflammation seen in bronchial asthma. Gamma interferon (IFN-gamma), a T-cell derived cytokine, is known to modify functions of both immune and non-immune cells. In this study, we investigated whether IFN-gamma can modify guinea pig airway functions in vitro. The isometric tension of guinea pig airway strips was measured in a tissue bath filled with Krebs-Henseleit solution. Contracting responses to carbachol and KCl, and the relaxing response to isoproterenol (ISO) were examined. Effects of IFN-gamma were examined by comparing responses of the strips incubated with or without IFN-gamma (1000 U.ml-1; 25,000 U.ml-1). Contracting responses to carbachol and KCl were not affected by the incubation with IFN-gamma other than slight increased in maximum contraction by carbachol after 5 hours incubation with 25,000 U.ml-1 of IFN-gamma. Both 1 and 5 h incubation of strips with 25,000 U.ml-1 IFN-gamma significantly increased the sensitivity to ISO (p < 0.01 and p < 0.05, respectively) without affecting maximum relaxation. The effect of IFN-gamma on ISO relaxation was abolished by the denudation of airway epithelium from strips, indomethacin (2 microM), and cycloheximide (70 microM) but not by N omega-nitro-L-arginine methyl ester (30 microM). In addition, heat-inactivated IFN-gamma and bacterial endotoxin (LPS, 0.625 pg.ml-1) had no effect on ISO relaxation. These results suggest that IFN-gamma is able to modify airway smooth muscle response to beta-adrenergic agonist by inducing release of prostanoids from airway epithelium.

Clinical characteristics of idiopathic interstitial pneumonia (IIP) with bullae

Multiple bullae have often been observed in the lungs of patients with idiopathic interstitial pneumonia (IIP). The etiology of bullae has been considered to be distinct from that of interstitial pneumonia and honeycomb lesions seen in IIP. The incidence of bullae was evaluated in 27 IIP patients (male; 23 cases, female; 4 cases) and clinical factors which are related to the development of bulla were analyzed. Of the 27 patients, 16 (59%) had bullae. All 16 were male smokers, and had higher smoking indices (p < 0.01) than patients without bullae. Eleven of the 16 IIP patients with bullae had clubbed fingers (69%, p < 0.05). Roentgenologically, cysts (75%, p < 0.05), low attenuation area (56%, p = 0.06), and honeycomb appearance (94%, p = 0.07) were observed more often in IIP patients with bullae. These results suggest that smoking habits may have a close relationship to the development of bullae seen in patients with IIP.

[Bronchial asthma--airway inflammation and asthma--role of airway epithelium]

The importance of airway inflammation in the pathophysiology of bronchial asthma has been recognized recently. This inflammation is organized by the interaction between inflammatory cells and the cells which compose airway structures. We studied the role of airway epithelium in airway hyperresponsiveness and airway inflammation, which are the major characteristics of bronchial asthma, and demonstrated a close relationship between them. On the bases of these data and the data reported by many other researchers, and from the point of view of airway inflammation, we discussed the possible roles of airway epithelium in bronchial asthma.

Flavin-photosensitized monomerization of dimethylthymine cyclobutane dimer in the presence of magnesium perchlorate

We have investigated the photosensitized monomerization of the cis,syn-cyclobutane dimer of 1,3-dimethylthymine using riboflavin tetraacetate and a 5-deazaflavin derivative as photosensitizer. Although little monomerization of the dimer is induced by photoexcitation of the flavins in the absence of any additives, the flavins can function as an efficient photosensitizer in the presence of magnesium perchlorate. Mechanistic studies involving spectroscopic, quantum-yield and flash-photolysis measurements demonstrated that the photosensitized monomerization exclusively proceeds through electron transfer from the dimer to the triplet flavins complexed with Mg2+. The effects of magnesium perchlorate are compared with those on the chloranil-photosensitized monomerization and also with the effects of HClO4 on the flavin-photosensitized reaction.

[Effects of DbcAMP on tumor necrosis factor and interleukin-1 production in human monocytes]

Recent reports have shown that dibutyryl cAMP (DbcAMP) blocks endotoxin-induced lung injury. To determine whether DbcAMP suppresses the production of tumor necrosis factor (TNF) and interleukin-1 (IL-1) in human monocytes, we measured the levels of TNF and IL-1 in response to E. Coli lipopolysaccharide (40 micrograms.ml-1) in vitro. We now show that DbcAMP suppressed dose-dependently the production of TNF in human monocytes, and DbcAMP totally suppressed it at the dose above 5 x 10(-4) M. However, DbcAMP did not suppress the production of IL-1 even at the dose of 5 x 10(-3) M in human monocytes. These data suggest that the productive mechanism of IL-1 may be different from that of TNF. Further, suppression of TNF by DbcAMP may contribute to the beneficial effects in animal models of septic shock or lung injury and this may have clinical implications.

[A case of bronchial artery aneurysm communicating with pulmonary artery]

A 48-year-old man was admitted to our hospital because of an abnormal shadow on the chest rentogenogram detected by the regular health screening. A tumorous shadow about 10 mm in diameter existed in the right lower lobe on chest X-ray film. It was suggested that the tumor was receiving blood flow from the aortic system by IVDSA and dynamic CT, right bronchial angiogram demonstrated a dilatation and aneurysm formation associated with anastomosis of the pulmonary artery. Aneurysmectomy and right bronchial arterial ligation were performed, and no other complication was observed. Bronchial artery aneurysm is a rare disease, and 25 cases have been previously reported in the literature in Japan.

What factors are involved in the knowledge necessary for the self-management of diabetic patients?

The aim of this study is to obtain data for improving a training program for patients with diabetes mellitus. One hundred eighty-seven patients with non-insulin dependent diabetes mellitus were tested with 20 questions about their knowledge for self-management of diabetes mellitus. Then to draw out factors in their personal backgrounds relating to their correct answers, multiple regression analyses were conducted. As a result, four factors showed significant differences in the following order: Educational careers > ages > duration of disease > socioeconomic strata. The results of the present study have shown for the first time, that these four factors closely concern patients to acquire the necessary knowledge for their self-management of the disease. In addition, this study has raised some fundamental problems regarding the training program for patients: how education should be given to patients.

[A case of Sjögren's syndrome at the age of 91 with a lymphoepithelial lesion]

A 91 year old woman with Sjögren's syndrome who developed a lymphoepithelial lesion and showed an active state of the disease is described. Since June, 1990, the patient had been complaining of dry eyes and mouth and a left submandibular tumor (1.0 x 1.5 cm in diameter). A biopsy of the tumor revealed lymphoepithelial lesions in the salivary gland. Mild anemia (Hb 9.6 g/dl) and an elevated erythrocyte sedimentation rate (80 mm/hr) were noted. The gamma-globulin level was 2.7 g/dl, IgG 2789 mg/dl, IgA 469 mg/dl, RAHA x80, antinuclear antibody x20, anti-SS-A x256, thyroid test x400 and microsome test x102400. The Schirmer's test showed decreased tear secretion (Lt. 3mm, Rt. 9mm) and keratoconjunctivitis sicca were noticed by an ophthalmologist. Salivary scintigraphy revealed decreased uptake and slow excretion of the isotope (grade II). A biopsy of a minor salivary gland showed periductal lymphocytic infiltration and acinar cell destruction. Immunohistochemical analyses revealed the cross-reactive idiotype of a monoclonal rheumatoid factor which is associated with a patient with Sjögren's syndrome, in the infiltrating lymphocytes and plasma cells of the minor salivary glands, but not in the lymphoepithelial lesions of the left submandibular gland. This was a rare case concerning a 91-year old patient with Sjögren's syndrome who developed a lymphoepithelial lesion and showed high activity in the serum and gives us valuable information on the relationship between aging and autoimmunity.

High-dose 15-deoxyspergualin monotherapy surpasses methylprednisolone in its therapeutic effect on advanced lupus nephritis in New Zealand black/white F1 hybrid mice, and low-dose combination may be synergistic

To compare the therapeutic effect of 15-deoxyspergualin with that of methylprednisolone on advanced lupus nephropathy of New Zealand black/white F1 hybrid (B/W) mice, and also to study the possible synergistic effect of both drugs, B/W mice were heminephrectomized at 32 weeks of age, and were divided into six groups. Each group of mice was treated with 50 microliters phosphate-buffered saline (PBS), 3 mg/kg methylprednisolone, 20 mg methylprednisolone, 0.6 mg DSP, 6 mg DSP, or with 3 mg methylprednisolone plus 0.6 mg DSP, s.c., four times per week for 8 weeks. Urine and blood samples (by tail vein venipuncture), as well as renal tissue specimens, were taken at 32 and 40 weeks of age. The degree of proteinuria, and serum anti-DNA activity (by ELISA) were determined. Renal specimens were evaluated with light- and immunofluorescence (C3)-microscopy, the degree of pathological changes being semi-quantitated and expressed as total light-microscopy (LM) and immunofluorescence (IF) scores. The survival rate at 40 weeks of age was significantly elevated in 0.6 mg DSP, 6 mg DSP, and methylprednisolone + DSP groups of mice compared with the control group. The appearance rate of significant post-treatment proteinuria was comparable among all groups. The difference (post-treatment titre--pretreatment titre) of serum anti-DNA activity in the 6 mg DSP and methylprednisolone + DSP groups were significantly less, while that of the 3 mg methylprednisolone group was greater compared with the control level. As for the total LM score, the levels significantly decreased in the 6 mg DSP, methylprednisolone + DSP and 3 mg methylprednisolone groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of Cushing's disease associated with a non-functioning adrenal tumor]

A 52-year-old woman was admitted to our hospital for further examination of central obesity, hypertension and hirsutism suggesting Cushing's syndrome. Hirsutism had been remarkable for two years, and muscle weakness of the lower extremities gradually developed during the past year. CT scan revealed a tumor in the left adrenal gland which was 1 cm in diameter, round, well-circumscribed, homogeneous and not enhanced. Endocrine data disclosed increased urinary 17-OHCS (11.5-16.4 mg/day) and elevated plasma ACTH (125 pg/ml) and cortisol (19 micrograms/dl) with a lack of diurnal rhythm. Administration of the single-dose dexamethasone (1mg) did not suppress plasma cortisol. However, consecutive administration of either 2mg or 8mg of dexamethasone for 2 days suppressed both plasma cortisol and urinary 17-OHCS. Administration of metyrapone raised both urinary 17-OHCS and plasma ACTH levels. Rapid ACTH test resulted in a hyperresponse of plasma cortisol. CRF injection raised plasma ACTH and cortisol. Bilateral adrenal glands were well demonstrated by 19-iodocholesterol (I-131) scintigraphy during the administration of dexamethasone. MRI with Gd-contrast revealed a microadenoma in the sella turcica. With the diagnosis of Cushing's disease, the microadenoma was removed by the transsphenoidal approach and adrenal function was normalized. However, the left adrenal tumor remained on CT scan but was not demonstrated by scintigraphy. These findings indicate that this is a very rare case of Cushing's disease which was associated with an unilateral non-functioning adrenal tumor.

[Functional evaluation of possible cytokine receptors on airway smooth muscle: modification of airway smooth muscle responses by cytokines]

Recently, the role of activated T-cell derived cytokines in the pathophysiology of asthma has been recognized. In this study, we evaluated the effects of interleukin-2 (IL-2) and gamma interferon (IFN-gamma) on contractile and relaxing responses of guinea-pig tracheal strips in isometric tension measurement system. IL-2 enhanced carbachol (Carb)- and KCl-induced contraction, and attenuated isoproterenol (Iso)-induced relaxation. IFN-gamma had little effect on Carb and KCl contraction, but enhanced Iso relaxation. These effects of cytokines were abolished by denuding epithelium from tracheal strips. These results suggest that IL-2 and IFN-gamma are able to affect functions of non-immune cells in the airway, and that the airway epithelium has some role in the effects of cytokines on airway responses.

Radiotherapy resolves leukemic involvement of the optic nerves

A 40-year-old woman with acute lymphoblastic leukemia had a visual disturbance OD. The optic disc was slightly swollen in the right fundus, and blast cells in the cerebrospinal fluid were found. Radiotherapy to the brain and orbit resolved these findings. Five months later, visual acuity decreased OS. Radiotherapy also was effective in treating the leukemic involvement of the optic nerve.

[Clinical use of serum erythropoietin determination by the recombigen EPO RIA kit]

Serum erythropoietin (EPO) levels were determined by the recombigen EPO RIA kit (DPC) in normal subjects and patients with renal dysfunction, diabetes mellitus, hypothyroidism and a variety of hematological disorders. Mean (+/- SD) serum EPO levels were 18.6 +/- 5.6 mU/ml in 180 normal subjects and no sex difference was obtained. Serum EPO levels in older subjects were slightly greater than those in younger subjects. There was a negative correlation between serum EPO levels and Ht values in anemic patients with normal renal function, whereas serum EPO levels were within the normal range in anemic patients with renal disorders, suggesting that serum EPO levels were relatively low in patients with chronic renal failure. Serum EPO levels were rather increased in patients with diabetes mellitus and hypothyroidism. High serum EPO levels were obtained in patients with a variety of hematological disorders such as acute leukemia, multiple myeloma, myelodysplasia syndrome, aplastic anemia and pure red cell aplasia. In a patient with pure red cell aplasia treated with glucocorticoids, serum EPO levels were lowered before anemia was recovered and reticulocytes were increased. These findings indicate that measurement of serum EPO levels are useful for not only differential diagnosis of anemia but also clinical evaluation of the treatment.

[A case of unknown origin cancer of the mediastinal lymph node]

We encountered an unusual case with a sole cancer focus at the mediastinal lymph node. The patient was a 44-year-old man who visited our department with a chief complaint of chest pain. Subsequent chest X-ray and CT revealed an enlargement of a mediastinal lymph node. The excised lymph node measured 6.8 x 5.5 x 4.0 cm and weighed 51 g. It showed metastasis of poorly differentiated adenocarcinoma. In spite of a thorough systemic examination, no primary foci were detected. Lymph node tumors of the mediastinum or hilar region with unknown primary foci are extremely rare (there have been only 2 reported cases of lesions found at the hilar lymph node with unknown primary focus). There have been no reports on cancerous foci limited to the mediastinal lymph nodes. The patient has been under chemotherapy and radiotherapy during the past 3 years following surgery. He shows no signs of recurrence. It is a very unusual case. A possible classification of T0N2M0 has been considered.

[A case of type 1 diabetes mellitus with hypothalamic amenorrhea: successful pregnancy following subcutaneous pulsatile administration of LHRH]

A 27-year-old woman with type 1 diabetes mellitus was admitted to the Shimane Medical University Hospital because of secondary amenorrhea. She had been treated with insulin since July, 1986. Fasting plasma glucose and HbA1c levels were controlled within normal limits. However, body weight gradually decreased and amenorrhea started in 1988. Physical examination revealed emaciation with BMI of 17.3. Basal levels of plasma T3, somatomedin C, LH, FSH and estradiol levels were low, whereas HGH levels were slightly elevated. Plasma LH markedly increased in response to LHRH administration. She was diagnosed as having weight loss-related hypothalamic amenorrhea. Induction of ovulation was not obtained with clomiphene citrate. Treatment with subcutaneous pulsatile administration of LHRH (20 micrograms every 120 min) resulted in an increase in plasma levels of LH, FSH and estradiol, which was accompanied by ovulation and corpus luteum formation. Further treatment with pulsatile LHRH administration was followed by conception. Two gestational sacs were detected by ultrasonography. One of them was absorbed at the early stage of pregnancy. She was delivered of one healthy female infant without complications. These findings suggest that it is important not only to control plasma glucose levels but to keep the appropriate weight and support the psychological aspects of the subject in the treatment of diabetes mellitus. Subcutaneous pulsatile LHRH therapy may be effective for the induction of ovulation in clomiphene-resistant hypothalamic amenorrhea; however, it will be necessary to solve the problem of dosage and the interval of LHRH administration in the future.

Effect of 15-deoxyspergualin on lupus nephropathy in New Zealand black/white F1 mice

Fourteen-week-old female New Zealand B/W F1 mice were treated subcutaneously with 15-deoxyspergualin (DSP) at 0.3 mg-6.0 mg/kg body weight, 4 times/week. They were sacrificed at 36 weeks of age to determine the minimal effective dose as well as the lowest maximally effective dose without toxicity of DSP required to suppress the development of nephropathy. The life span of the animals was significantly prolonged with 0.6 mg/kg or more DSP. Additionally, glomerular (immuno)histological improvement of the kidney at 36 weeks was observed with 0.6 mg/kg DSP, although a higher dose was required to lower serum anti-DNA activity or to decrease proteinuria. In addition, DSP produced a decrease of L3T4+ splenocytes without affecting the number of Lyt 2+ cells, while the level of IL-2 generated in vitro was somewhat elevated. It may be concluded that DSP has a therapeutic range within an order of ten, but its exact mechanism of immunosuppression remains to be determined.

Degradation and distribution of brain natriuretic peptide in porcine tissues

Brain natriuretic peptide (BNP) is a novel peptide that has actions similar to atrial natriuretic peptide (ANP). The present study investigated BNP localization in the heart, ANP and BNP contents in several organs, and ANP and BNP clearance through these organs. In the morphological study, it was shown that porcine BNP-like immunoreactivity was mainly distributed in the granules of the atrium. The content of porcine BNP-like immunoreactivity in the atrium was extremely high, about 100-fold greater than in the ventricle. From the determination of porcine BNP and ANP contents of such organs as the heart, kidney and liver and also plasma, it was shown that porcine BNP concentration was approximately one order of magnitude lower than that of ANP, and clearance rates of ANP and porcine BNP from these organs were similar and not significantly different between the organs. These results suggest that the modes of secretion and degradation of porcine BNP are not the same as those of ANP.

[Effect of almitrine in acute canine lung injury induced by paraquat]

The effects of intravenously administered almitrine (0.3 or 1.0 micrograms/kg/min, for 30 min) on hemodynamics and pulmonary gas exchange were assessed in eight dogs with acute lung injury induced by paraquat under controlled ventilation. Arterial blood gases, pulmonary and systemic hemodynamics, and ventilation-perfusion distribution (VA/Q) using the multiple inert gas elimination technique were examined before (control) and during infusion of almitrine. Almitrine produced significant increases in mean pulmonary arterial pressure from 17.4 +/- 3.3 (control, mean +/- SD) to 20.4 +/- 1.5 mmHg (1.0 micrograms/kg/min), and in total pulmonary vascular resistance. There was no change in other hemodynamic parameters, arterial gas tensions, or VA/Q distribution. These results indicate that almitrine causes pulmonary vasoconstriction without changing ventilation-perfusion distribution in dogs with paraquat-induced lung injury.

[Effects of ulinastatin on granulocyte elastase and fibronectin in patients undergoing cardiopulmonary bypass]

We investigated the effects of ulinastatin on the increase of granulocyte elastase (GEL) and the decrease of fibronectin (FN) after cardiopulmonary bypass (CPB) in 30 patients undergoing cardiopulmonary bypass. Ulinastatin 300,000 units were given immediately after the induction of anesthesia (U1) or during CPB (U2). GEL increased by 20 times after CPB. GEL was lower in U2 than those in other groups. FN increased by 7-13% after CPB in U1 but decreased in other groups. FN decreased by 21-13% on the first postoperative day in three groups. There was a close relationship between CPB time and increase of GEL in the control group (no ulinastatin given) (y = 18.5 x -833, r = 0.751), between CPB time and increase of FN in U1 (y = 1.4 x -163.4, r = 0.683) or increases of GEL and FN in the control group (y = 0.068 x -202.6, r = 0.812). From these results, we recommend that ulinastatin should be given after the induction of anesthesia and during CPB, to keep a favorable host defense function after CPB.

[A case of adult T-cell leukemia (ATL) complicated with multiple nocardial abscesses]

A 45-year-old woman was admitted to our hospital with complaints of fever and lumbago. She was treated for adult T-cell leukemia and thrombocytopenia with 20 mg/day of prednisolone. CT scan showed multiple abscesses in right peri-kidney, right iliopsoas muscle, left subcutaneous region in the abdominal wall and the brain. Left subcutaneous abscess was drained. Gram-positive organisms consisting of filaments were found, and Nocardia farcinica was grown in cultures. After two months of chemotherapy (FMOX, MINO and AMK), all abscesses except one in the brain disappeared. Cerebral abscess was cured fifty days after the start of the treatment with oral administration of Sulfamethoxazole-trimethoprim (SMX/TMP). The mortality of Nocardial cerebral abscess is high. This patient is a very rare case in which multiple Nocardial abscesses including brain abscess was cured by chemotherapy.

[Effects of local anesthetics upon human natural killer cytotoxicity in vitro]

Effects of 3 local anesthetics, bupivacaine, mepivacaine and lidocaine, upon natural killer cytotoxicity were studied in vitro. Mononuclear cell layer was recovered by Ficoll-Paque sedimentation from heparinized venous blood obtained prior to the induction of anesthesia. The mononuclear cells were divided into three groups: control group was incubated in medium only: low concentration group incubated in medium with 2.0 micrograms.ml-1 of mepivacaine (n = 20) or lidocaine (n = 20), or 0.5 micrograms.ml-1 of bupivacaine (n = 21); high concentration group in medium with 20 micrograms.ml-1 of mepivacaine or lidocaine, or 5 micrograms.ml-1 of bupivacaine. These three groups were incubated simultaneously in humidified atmosphere with 5% CO2 in incubator for 2 hours. NK cell cytotoxicity was determined in a chromium release assay against K 562 cell as a target cell. An effector to target cell ratio of 40:1 was used. Comparison among 3 local anesthetics showed no significant difference at high concentration, but a significant difference at low concentration. This was due to the differences between bupivacaine and lidocaine. Neither bupivacaine nor mepivacaine inhibited % NK cytotoxicity at both low and high concentrations compared with control. Lidocaine significantly inhibited % NK cytotoxicity at low concentration, but did not inhibit at high concentration compared with control. We concluded that neither bupivacaine nor mepivacaine inhibited % NK cytotoxicity at concentration of clinical dose compared with control in vitro, but lidocaine inhibited % NK cytotoxicity at a concentration of 2.0 micrograms.ml-1 compared with control.

[General anesthesia and surgery inhibited natural killer cell cytotoxicity in patients with cancer or benign disease undergoing upper abdominal surgery]

In this study, effect of enflurane anesthesia combined with epidural analgesia on natural killer cell cytotoxicity (NKCC) was investigated in 20 patients. Patients were divided into two groups: the first group with adenocarcinoma of stomach (Group 1); the second with cholecystolithiasis (Group 2). Four samples were taken; 1) on arrival at operating room; 2) during anesthesia and 1 hour after skin incision; 3) on 1st postoperative day; and 4) on 4th or 5th postoperative day. NKCC was determined with a chromium release assay against K 562 cell. NKCC was already significantly higher before induction in Group 1 compared with Group 2 and normal value. In Group 1, NKCC decreased significantly compared with baseline during operation, but in group 2 NKCC was unchanged during operation. NKCC in group 2 was inhibited significantly less than Group 1 during 5 postoperative days, while NKCC was significantly inhibited postoperatively in both groups compared with the baseline. We conclude that enflurane anesthesia combined with epidural analgesia and surgery did not decrease NKCC below normal value during operation, but it was significantly inhibited during 5 postoperative days in both groups. There were differences in responses to stress of anesthesia and surgery between patients with and without cancer.

[Studies on right ventricular performance in surgical treatment for primary lung cancer--especially in changes of right ventricular ejection fraction in acute phase]

In surgical treatment for lung cancer, increase of right ventricular afterload associated with decrease of pulmonary vascular bed after lung resection is serious problem in acute phase. Intensive care is necessary for the patients having major surgery, especially in aged. Until now, we have studied on pre and post operative extravascular lung water (EVLW) in addition to measurement of conventional hemodynamic changes on right ventricular afterload. And then, we have discussed when we should start to care intensively for degradation of compensatory hyperdynamic change. According to percent exchanges (delta %) between pre and post operative measurement, we established following criterion 1) delta %HR greater than 150% 2) delta SVI less than 60% 3) delta % PARI greater than 200% 4) observed postoperative EVLW greater than predicted postoperative EVLW. Furthermore, we investigated the correlation with these criterion and RVEF in 14 patients using a rapid computerized thermodilution method on right cardiac function in acute phase. We found that 1) changes of RVEF seem to depend on endsystolic volume 2) RVEF decreased just after operation and then slowly increased until 48 hours 3) PARI elevated to 194 +/- 117% in average at 6 to 24 hours showing significant inversed linear correlation to changes of RVEF (R = -0.54). The patients having prolonged elevation of PARI showed degradation of cardiac output and RVEF. RVSWI showed compensative acceleration gradually with increased right ventricular afterload.(ABSTRACT TRUNCATED AT 250 WORDS)

Spectral and waveform characteristics of fine and coarse crackles

Two acoustically different types of lung crackles, fine and coarse, occur in different pathophysiological conditions. To differentiate these crackles from objective characteristics of frequency information, crackles were recorded from 16 patients with pulmonary fibrosis judged clinically to have "fine" crackles and from 10 with chronic bronchitis who had mainly "coarse" crackles. Time expanded waveforms (1/4 cycle duration, initial deflection width, two cycle duration, and 9/4 cycle duration; duration of the first 1/4, 2/4, 8/4, and 9/4 cycles of crackle waveforms) were examined and fast Fourier transform analysis (peak and maximum frequencies) was performed. All waveform measurements for fine crackles were significantly smaller than those for coarse crackles. Peak and maximum frequencies for fine crackles were significantly higher than those for coarse crackles. Although there was some overlap in these values for individual crackles between the two groups when average values of these measurements were calculated for each patient, there was no overlap between fine and coarse crackles and the two groups could be clearly separated. Log peak frequency and log maximum frequency correlated better with 9/4 cycle duration (r = 0.85, 0.84) and two cycle duration (r = 0.87, 0.86) than with 1/4 cycle duration (r = 0.66, 0.77) or initial deflection width (r = 0.67, 0.79). Early and late segments of crackles have different characteristics, probably related to the origin of the sound and the resonance of the lung respectively. These results suggest that spectral and waveform characteristics may help to improve the accuracy of pulmonary auscultation and increase knowledge of how crackles are generated.

[Simplified prediction of postoperative lung function by plain chest roentgenogram in patients with primary lung cancer--in correlation to postoperative respiratory complications]

For the purpose of simplification of prediction of postoperative lung function, we studied to predict lung function by analizing the frontal and lateral view of chest plain roentgenogram and investigate the correlation to respiratory complication on 111 patients with lung cancer. According to TNM classification of lung cancer, prediction was performed as follows. Predicted postoperative lung function = [(42-number of resected subsegments)/(42-number of occupied subsegments)] x preoperative VC or FEV1.0. In this formula, 42 was the number of functioning subsegments of whole lung (right: 22, left: 20), and then preoperative occupied subsegments was ordered by T factor, where T1 lesion in lung field was prescribed as 1 subsegment and T2 was more than 2 subsegments respectively in plain chest roentgenogram. And also, on the patients having hilar lesions, it was required to calculate the number of subsegments in atelectasis, peripheral obstructive pneumonia and/or partial emphysematous change due to intrabronchial lesions. There was uniformly positive correlations in VC (R = 0.7949) and FEV1.0 (R = 0.8235) of the patients studied respectively. The patients having pneumonectomy showed tendency of over estimation, on the other hand, the patients having resection of a few segments showed under estimation. To predict the postoperative respiratory condition, we calculated the predicted post-operative %VC and %FEV1.0 for predicted preoperative normal VC and FEV1.0. Above the al, we tried to investigate the correlation with predicted postoperative %VC, %FEV1.0 and postoperative respiratory complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma free triiodothyronine response to thyrotropin-releasing hormone to predict the remission of Graves' disease treated with antithyroid drugs

The responses of both plasma TSH and free T3 (FT3) to TRH were examined in 31 patients with Graves' disease who were euthyroid after treatment with antithyroid drugs, 6 patients with primary hypothyroidism, and 14 control subjects. TSH was measured 0, 15, 30, 60, 90, and 120 min and FT3 was measured 0, 30, 60, 90, 120, 150, and 180 min after TRH injection (500 microgram, iv). The increment in FT3 above the basal level (delta FT3) in normal controls ranged from 1.2-3.7 pmol/L, with a mean +/- SD of 2.2 +/- 0.8 pmol/L. The mean (+/- SD) delta FT3 in patients with primary hypothyroidism was 0.3 +/- 0.2 pmol/L. After the TRH test, antithyroid drugs were stopped in patients with Graves' disease. Nine of 31 Graves' patients relapsed within 6 months after the TRH test. The other 22 patients with Graves' disease were followed while in remission during the observation period of up to 48 months. The mean (+/- SD) delta FT3 were significantly lower in 9 Graves' patients who relapsed than in those who achieved remission (0.5 +/- 0.3 vs. 2.6 +/- 1.1 pmol/L; P less than 0.01). Eight of 9 Graves' patients who relapsed showed lower delta FT3 values than the lowest value (1.1 pmol/L) in 22 Graves' patients in remission. Although the mean increment of TSH above the basal level (delta TSH) was also significantly different between the Graves' patients who relapsed and those in remission (1.4 vs. 12.3 mU/L; P less than 0.01), there was considerable overlap between the 2 groups. These findings suggest that delta FT3 reflects the endocrinological recovery of the pituitary-thyroid axis and is a beneficial indicator for the termination of antithyroid drugs in Graves' disease.

Prolongation of the kidney preservation period by simple cold storage up to 72 hours by human atrial natriuretic peptide

To prolong the preservation period of donor kidneys, we tried to evaluate the effect of human atrial natriuretic peptide (hANP), which has vasodilator, natriuretic, and GFR-increasing effects. Autotransplantations were successful in 6 of 8 hANP-treated cases, but only one of 7 untreated cases (P less than 0.05) was successful. When removed kidneys were perfused prior to preservation, the gravity perfusion time was shorter in hANP-treated kidneys, resulting in rapid cooling. Renal biopsy 1 hr after transplantation revealed normal histology in the hANP-treated kidneys while a remarkable capillary collapse occurred in controls. A hANP-like immunoreactivity contents of biopsied tissue in the hANP-treated kidneys showed a higher value than in the controls, and cyclic GMP contents were also higher in the hANP-treated kidneys. Microangiography showed complete clarity, down to the peripheral vessels, in the hANP-treated kidneys, but not in the controls. Thus, the present study suggests that hANP is useful for prolonging the preservation time of donor kidneys.

[A prospective study of lung cancer in cases of idiopathic interstitial pneumonia (IIP)]

The incidence of lung cancer in 45 patients (37 males and 8 females), who were originally diagnosed as having idiopathic interstitial pneumonia (IIP), was studied prospectively by following them 4 to 10 years. As controls, sex-, age-, and smoking history matched patients with chronic obstructive lung disease (COLD) were also surveyed for the same follow up period. In addition, the differences in clinical findings between those with and without lung cancer were examined. Eight out of 45 patients with IIP (18%) developed lung cancer (adenocarcinoma; 4, small cell carcinoma; 3, squamous cell carcinoma; 2, including one double cancer). All lung cancer patients were male smokers. Looking only at males, 8 out of 37 patients with IIP (21.6%) developed lung cancer. This incidence was significantly higher than that of the male COLD group (2.2%, less than 0.01). In clinical findings, IIP patients with lung cancer had the characteristics of the chronic type of IIP (lack of volume loss on chest radiographic milder dyspnea, not on steroid treatment) when compared with those who did not develop lung cancer.

[Studies on increased sputum after bronchoplastic surgery for lung cancer in correlation with hemodynamics and extravascular lung water]

In surgical treatment for lung cancer, large amount of intrabronchial sputum and secretion was occasionally encountered in patients, especially underwent bronchoplastic surgery. It has been discussed as causes which was affected from transection of pulmonary branches of vagal nerve and bronchial arteries. So we have measured pre- and postoperative hemodynamics and extravascular lung water (EVLW) at the bedside, as to investigate the correlation with formyl sputum and increase of right ventricular afterload which was presumed by lung resection and bronchoplasty. Respiratory complication was classified by the incidence of forced bronchial toilet in acute phase. Seven patients were investigated. Three of seven showed white sputum which was difficult to excrete. EVLW was 9.91 +/- 2.12 ml/kg in average before operation and then showed a tendency to increase within 102 +/- 29% of percent exchange (delta %) between pre- and postoperation. As to comparison of delta % of EVLW in acute period, the patients underwent bronchoplastic surgery showed a tendency to increase rather than the patients underwent lobectomy. According to former studies, we found the uniform correlation R = 0.7075 between observed EVLW and predicted postoperative EVLW estimated by prediction of residual functioning lung volume before operation. And also, the patients showing postoperative EVLW more than predicted EVLW before operation had a tendency to increase amount of sputum. Furthermore, concerning hemodynamic changes, pulmonary arterial resistance index (PARI) elevated to 196 +/- 165% (83-515%) in average associated with increased right ventricular stroke work index (RVSWI) as a result of compensatory changes for increased right cardiac afterload.(ABSTRACT TRUNCATED AT 250 WORDS)

Toxicological and immunological evaluation of the immunosuppressant 15-deoxyspergualin in BALB/c mice: an in vivo and in vitro study

The toxicological aspects as well as the immunosuppressive mechanism of 15-deoxyspergualin (DSP) were studied using BALB/c mice. Five-week-old animals were subcutaneously given phosphate-buffered saline (PBS; Group 1) or DSP at 0.5 (Group 2) to 5.0 mg (Group 4) per kg body weight daily for 1 to 3 months. They were sacrificed to obtain blood for hematology and liver function studies. The spleen, taken simultaneously, was histologically examined, the T cell surface markers of splenocytes were flow cytometrically measured, and their interleukin 2 (IL-2) production induced in vitro by Enterotoxin A (Ent A) was assayed using CTLL cells. Additionally, the in vitro effect of DSP on IL-2 generation and plaque forming cell (PFC) production was studied using splenocytes of non-treated mice. During the 3 months of treatment, the body weight slowly increased in Groups 1 and 2, while the body weight of the 2.5-mg DSP mouse group (Group 3) was significantly lower on days 28 and 56 of treatment compared with Group 1 of the same age (P less than 0.05). The administration of DSP at 5.0 mg/kg (Group 4) caused marked reduction in body weight of the animals. They were sacrificed on day 28 because of their worsening general condition. WBC and RBC counts decreased in Group 3 on days 57 and 93, and the platelet number increased on day 57. A liver function test was not affected by DSP treatment except for an elevated SGOT in Group 4.(ABSTRACT TRUNCATED AT 250 WORDS)

[Management of pain after thoracotomy: experience of intercostal nerve block with alcohol during operation]

Post-thoracotomy wound pain in 11 patients who underwent thoracic operation was controlled by intercostal nerve block with alcohol and thoracic epidural anesthesia. The intercostal nerve block was performed just before the closure of the thoracotomy wound. Epidural anesthesia was employed from the 1st to 5th post operative day. This method alleviated post-thoracotomy pain and obviated postoperative pulmonary complication in all patients in early post operative periods. In late post operative periods after discharge, intercostal nerve block could maintain excellent analgesia in 9 of 11 patients, only 2 patients required analgesic drugs or re-block of the intercostal nerve. Thus, intercostal nerve block with alcohol is an effective and simple option to control recalcitrant post-thoracotomy wound pain in thoracic surgery.

Host immunosuppression following orthotopic bowel allotransplantation in rats using low-dose cyclosporine

This study shows that Le rats bearing total bowel allografts treated with CyA (5 mg/kg for 14 days) demonstrated within one month immunological unresponsiveness to donor and third-party alloantigens as determined by MLR responses. Assays performed in long-term survivors (greater than 100 days) showed a continued depressed MLR response to antigen-specific (BN) alloantigens. The response to third-party (ACI) alloantigens was not significantly depressed. After the long-term bowel recipients rejected donor skin grafts, the MLR responses were increased over control, but the transplanted bowel remained intact.

[Effect of endotoxin on plasma angiotensin-converting enzyme in dogs]

We calculated angiotensin converting enzyme (ACE) index (ACE/CO) to exclude the influence of pulmonary perfusion and investigated the relationship among ACE, ACE index, hemodynamic changes in 6 endotoxin dogs. Systemic arterial pressure and cardiac output (CO) decreased significantly after 3 mg.kg-1 of endotoxin administration, but neither pulmonary arterial pressure nor pulmonary arterial wedge pressure changed. Lung wet/dry ratio was higher. Although endotoxin administration caused the pulmonary capillary endothelial damage in this experiment, plasma ACE showed a nonsignificant increase. The main reason may be related to the reduction of surface area of pulmonary capillary endothelial cells caused by the decrease in cardiac output. The increased ACE index lasted for 15 to 90 min and began to return to baseline at 120 min after endotoxin administration. We conclude that ACE index is more useful than plasma ACE as an early marker of the pulmonary capillary endothelial damage induced by endotoxin.