Treatment of acute myeloblastic leukaemia in a patient with Bombay blood type: a case report

A 62-year-old female was admitted to our hospital with suspected acute leukaemia and after investigation we diagnosed acute myeloblastic leukaemia (AML-M1). The patient's blood type was found to be the very rare Bombay type and surveillance of her relatives showed the same blood type in her male cousin on her mother's side. Alongside chemotherapy the patient received 4000 ml of frozen Bombay-type red cells, 1400 ml of concentrated red cells in manitol adenine phosphate solutions and 360 units of type O concentrated platelets without marked effects. The anti-H antibody was initially at 128 dilution but for unknown reasons increased to 2048 dilution after remission of AML-M1. About 3 months after hospitalization the patient died of Cryptococcus neoformans pneumonia despite strict precautions against infection. Although AML-M1 is a common adult leukaemia and is chemosensitive to anti-leukaemic drugs, neither AML-M1 in a patient with Bombay-type red cells nor its treatment with chemotherapy and transfusion with type Oh frozen red cells have previously been reported.

A practical quick staining method using hydrochloric acid-fast metachromatic dye for megakaryocytes

A specific stain using violet polymethine dye (VPM stain) for megakaryocytes was first developed by Kass (1995). We have modified this method for practical use in bone marrow specimens. The modified VPM stain labels megakaryocytes very well, while other marrow cells are poorly colorized. This staining procedure was more stable, and its color intensity was finer and clearer than the original. Using this stain, morphologic classification of megakaryocytes in bone marrow specimens from 11 normal and 8 myelodysplastic syndrome (MDS) patients was performed. Many megakaryocytes observed in MDS patients were juvenile compared with normal subjects according to their morphology. Blasts from acute megakaryoblastic leukemia (M7) and from a megakaryoblastic cell line (Mo7e) were also clearly stained with our method. This staining method is practical and very useful for rapid identification of megakaryocyte distribution and morphology.

Development and testing of radionuclide transport models for fractured rock: examples from the Nagra/JNC Radionuclide Migration Programme in the Grimsel Test Site, Switzerland

The joint Swiss National Co-operative for the Disposal of Radioactive Waste (Nagra)/Japan Nuclear Cycle Development Institute (JNC) Radionuclide Migration Programme has now been on-going for over a decade in Nagra's Grimsel Test Site (GTS). The main aim of the programme has been the direct testing of radionuclide transport models in as realistic manner as possible. Although it will never be possible to fully test these models due to the large time and distance scales involved, tests of the model assumptions in scaled down but otherwise realistic conditions will contribute to developing confidence in the predictive power of the models. In this paper, the Nagra/JNC approach is highlighted with examples from a large programme of field, laboratory and natural analogue studies based around the GTS. The successes and failures are discussed as in the general approach to the thorough testing of predictive transport codes which will be used in repository performance assessment (PA). Some of the work is still on-going and this represents the first presentation of a unique set of results and conclusions.

The CAG regimen (low-dose cytarabine, aclarubicin hydrochloride and granulocyte colony-stimulating factor) for the treatment of elderly acute myelomonocytic leukaemia: a case study

Elderly patients with acute myelomonocytic leukaemia (AMMoL) frequently have a poor quality of life after induction of remission using high-intensity treatment; we seek a more appropriate regimen for such patients. An 86-year-old man was hospitalized with a diagnosis of AMMoL (FAB classification M4), of abnormal karyotype, and complications of diabetes mellitus and complete right bundle branch block. He was treated with CAG therapy (cytarabine 10 mg/m2 subcutaneously every 12 h for 14 consecutive days; aclarubicin hydrochloride 10 mg/m2 per day, bolus intravenously for 4 consecutive days; granulocyte colony-stimulating factor 100 microg/day, subcutaneous injection for 14 consecutive days) every 3 months. White blood cell counts were at their lowest (around 600 - 800/microl) 12 days after the end of therapy, but returned to about 2000 - 2300/microl 30 days after stopping therapy. No symptoms of drug-related toxicity, except slight nausea, were found. Complete remission with a good quality of life was induced and lasted over 2 years suggesting that CAG therapy might prove effective in elderly patients with AMMoL.

Chronic cyclosporin-induced nephropathy

AIMS

There is still no consensus about the prognostic influence of chronic nephropathy induced by low-dose maintenance therapy with cyclosporin. Our aim was to investigate the prognostic effect of cyclosporin nephropathy in Japanese renal transplant recipients.

MATERIAL

We retrospectively investigated the clinical records of 1,323 kidney transplant recipients who received cyclosporin at 65 institutions in Japan from 1982 to 1991.

METHOD

Renal biopsy was performed in 461 patients.

RESULTS

At 5 years and 9 years after transplantation, the patients who had cyclosporin nephropathy associated with immunological rejection, glomerulonephritis, or both showed a significantly worse prognosis than those with cyclosporin nephropathy alone (p < 0.01). There was no significant difference in the loss of renal function at 9 years after transplantation between patients showing no abnormalities and patients with cyclosporin nephropathy alone. Even when cyclosporin nephropathy was absent, the long-term prognosis was unfavorable in recipients with immunological rejection or glomerulonephritis.

CONCLUSIONS

These results suggest that cyclosporin nephropathy does not influence the prognosis of renal transplantation in patients on low-dose maintenance therapy with cyclosporin.

Evolution of heteromorphic sex chromosomes in the order Aulopiformes

The fish order Aulopiformes contains both synchronously hermaphroditic and gonochoristic species. From the cytogenetic viewpoint, few reports show that gonochoristic Aulopiformes have heteromorphic sex chromosomes. Because fish in this order give us a unique opportunity to elucidate the evolution of sex chromosomes, it is important to examine a phylogenetic relationship in Aulopiformes by both molecular evolutionary and cytogenetic methods. Thus, we conducted molecular phylogenetic and cytogenetic studies of six Aulopiform species. Our results suggested that hermaphroditic species were evolutionarily derived from gonochoristic species. It follows that the hermaphroditic species might have lost the heteromorphic sex chromosomes during evolution. Here, we suggest a possibility that heteromorphic sex chromosomes can disappear from the genome, even if they have appeared once in evolution. Taking into account Ohno's hypothesis that heteromorphic sex chromosomes might have emerged from autosomes, we propose the hypothesis that heteromorphic sex chromosomes may have undergone repeated events of appearance and disappearance during the course of fish evolution.

[Continuous nursing of incurable patients at home--the case of a patient with Parkinson's disease]

At the Department of Neurology and Internal Medicine at our hospital, there are 22 outpatients who are nursed at home. Their diseases are Parkinson's disease, spinal cerebellar degeneration, dementia and other diseases. The problem is how we should care for and support these patients in the future, now that the official Care Insurance System has started. We discuss how we could support such patients, through the case of a patient suffering from Parkinson's disease. The patient was a 69-year-old female. In 1991, she developed Parkinson's disease, accompanied with trembling in her right upper limb. Her condition was controlled at our hospital. Is April 1999, she lost strength in her right thigh without any previous notice, so she was hospitalized for treatment. For a period, she became aggressive from hallucinations and delusions and she had to be taken care of all day. Her only daughter lived apart and her 72-year-old husband was also suffering from Parkinson's disease. In spite of such conditions, she hoped to receive home care and her husband accepted that. We asked what they would want us to do. We had meetings together with the staff of the local administration, doctors, nurses, and pharmacists. The report from our hospital staff says, "It may be difficult for only her family to support her. She needs other supporting systems." She came to our hospital twice a month. We made an effort to understand her condition with the help of the report of a visiting nurse. However, her illusions and delusions made it difficult even to utilize the short-stay. Her husband sometimes uses violence and says. "I can't stand this any more--her unrest, micturition at night and refusal to eat." Nevertheless, she continues to say "I want to stay at home." They have had considerable trouble. The following are necessary for home care of some patients. 1. Understanding what a patient and her family want to do. Cooperating with the staff of the administration, in consideration of the Care Insurance System. 2. Studying with incurable neurology patients using pamphlets or other materials and supporting them, 3. Discussing how to act in concert with patients at home and outpatients at the hospital involving a risk without MSW.

[Clinical cases of acquired coagulation inhibitors]

The acquired coagulation factor inhibitors are classified into alloantibodies, which appear in association with supplementary treatment for congenital coagulation factor deficiency, and autoantibodies, which are spontaneously produced. We report here 2 cases of acquired factor VIII inhibitor and 1 case of factor V inhibitor. Case 1: A 52-year-old woman noted swelling of the right parotid region in March 1988. Though contrast examination was scheduled, she was admitted for detailed examination due to a markedly prolonged coagulation time. An APTT correction test suggested that decreased factor VIII activity was due to the presence of an inhibitor. Since antinuclear antibody and SS-A antibody were positive and infiltration by lymphocytes in the salivary gland acini in a lip biopsy specimen was detected, Sjögren's syndrome was diagnosed. Case 2: A 33-year-old woman had normal delivery of her second child in February 1998. In June 1998, she suffered slight contusion in the left lower limb. The affected site became swollen and painful, making walking difficult. Since both upper limbs became markedly swollen after 1 week, she visited our hospital. Prolonged APTT and a marked decrease in factor VIII activity were observed. Factor VIII inhibitor titer was high at 19 Bethesda units. Case 3: A 64-year-old man had had asymptomatic macroscopic hematuria since the beginning of August 1998 but was placed under observation since no abnormal findings were observed on various imaging tests. However, he was admitted to Osaka City General Medical Center because of vesicular tamponade. Factor V activity was markedly decreased to 1.0%. PT correction test suggested that decreased factor V activity was due to the presence of an inhibitor. The underlying disease could not be determined in this case. In patients with acquired coagulation inhibitors, bleeding symptoms are reported to be mild in many cases, and severe bleeding is rare. However, cases of death without severe bleeding or underlying disease have also been reported, indicating that the prompt diagnosis and treatment of this condition are necessary.

Isolated factor VII deficiency diagnosed after a life-threatening brain haemorrhage

A 65-year-old man was admitted to another hospital with a life-threatening brain haemorrhage, and laboratory examinations on admission revealed prolonged prothrombin time with normal activated partial thromboplastin time. To establish the cause of his abnormal coagulation, he was referred to our clinic. Neither the patient nor his family had any previous history of bleeding symptoms. His liver function was within normal limits but coagulation tests showed increased plasma activities of factors II, VIII, IX, X, with reduced activities of factors V and VII. The activity of factor VII was less than 2% but no inhibitor of factor VII was detected in the plasma. We concluded that the patient had a rare congenital isolated factor VII deficiency although he had not shown earlier bleeding problems, presumably because of compensation for the factor VII deficiency by enhanced activities of components of the extrinsic coagulation pathway, factors II, VIII, IX and X.

Membrane integration of the second transmembrane segment of band 3 requires a closely apposed preceding signal-anchor sequence

We have investigated the topogenic rules of multispanning membrane proteins using erythrocyte band 3. Here, the fine structural requirements for the correct disposition of its second transmembrane segment (TM2) were assessed. We made fusion proteins where TM1 and the loop sequence preceding TM2 were changed and fused to prolactin. They were expressed in a cell-free system supplemented with rough microsomal membrane, and their topologies on the membrane were assessed by protease sensitivity and N-glycosylation. TM1 was demonstrated to be a signal-anchor sequence that mediates translocation of the downstream portion, and thus TM2 should be responsible to halt the translocation to acquire TM topology. When the loop between TM1 and TM2 was elongated, however, TM2 was readily translocated through the membrane and not integrated. For the membrane integration of TM2, TM2 must be in close proximity to TM1. The TM1 can be replaced with another signal-anchor sequence with a long hydrophobic segment but not with a signal sequence with shorter hydrophobic stretch. The length of the hydrophobic segment affected final topology of TM2. We concluded that the two TM segments work synergistically within the translocon to acquire the correct topology and that the length of the preceding signal sequence is critical for stable transmembrane assembly of TM2. We propose that direct interaction among the TM segments is one of the critical factors for the transmembrane topogenesis of multispanning membrane proteins.

[Acquired immunodeficiency syndrome-associated progressive multifocal leukoencephalopathy treated with highly active anti-retroviral therapy]

We reported a patient with acquired immunodeficiency syndrome (AIDS)-associated progressive multifocal leukoencephalopathy (AIDS-PML), whose condition improved after highly active anti-retroviral therapy (HAART). A 70-year-old man was admitted to our hospital because of worsening left hemiplegia and disturbance of consciousness. During the past 30 years, he frequently traveled to the United States and southeast Asia. On neurological examination, he was somnolent and left hemiplegia with severe rigospasticity was present. The deep tendon reflexes showed hyper-reflexes with extensor plantar responses. Laboratory studies showed pancytopenia and positive HIV-1 antibodies. The CD4 cell count was 38/mm3 and his HIV viral RNA load in the blood was 9,500 copies/ml. T2-weighted magnetic resonance imaging (MRI) of the brain revealed asymmetrical high intensity white matter lesions in the right fronto-parietal, and left frontal regions and in the cerebellar hemisphere. The cerebrospinal fluid (CSF) protein elevated to 91 mg/dl with a normal cell count. The diagnosis of PML was confirmed by the detection of JC virus DNA in the CSF using a nested polymerase chain reaction assay. Three weeks after starting HAART with zidovudine, lamivudine, and indinavir, he was able to respond to simple commands. Two months later, the HIV viral RNA load decreased to less than 400 copies/mm3, and no JC virus DNA was detected in the CSF, with an increase of the CD4 cell count to 285/mm3 in the blood. A follow-up MRI of the brain showed a reduction in the cerebellar and cerebral white matter lesions. The recovering immune function by decreasing of the HIV load after HAART might suppress JC virus replication. It was suggested that HAART would become a beneficial treatment for patients with AIDS-PML.

Fas-mediated cytotoxicity by gammadelta T cells during acute rejection in xenotransplantation of spheroidal aggregate-cultured hepatocytes

Xenogeneic transplantation has recently become a subject of interest for the transplantation community due to the current organ shortage, which could be partially or even totally solved by the development of this strategy. However, xenogenetic rejection remains a formidable barrier preventing such use in a clinical setting. The spheroidal aggregate-cultured hepatocytes of WKA rats were injected into the spleen of C3H mice, and quantitative assessment of transplanted xenogeneic hepatocytes using 99mTc-GSA demonstrated that hepatocytes decreased dramatically 2 days after transplantation (day 2) and few viable hepatocytes in spheroids were detected on day 3. The NK activity significantly increased on day 1, and gammadelta receptor/FasL-expressing T cells appeared on day 2. These results suggested that xenogeneic cytotoxicity consisted of gammadelta T cells through the Fas/Fas ligand system, as well as non-T-cell-mediated cellular response, in the MHC-unrestricted pathway in this intrasplenically transplanted xenogeneic hepatocyte model.

The significance of serum homocysteine levels in diabetic patients on haemodialysis

BACKGROUND

Atherosclerotic diseases are the major cause of mortality and morbidity in patients on haemodialysis (HD). Furthermore, the prognosis of diabetic patients on HD is especially poor due to atherosclerotic complications. Because homocysteine (Hcy), a sulfur-containing amino acid, is emerging as an important risk factor for atherosclerosis in patients with end-stage renal disease, we examined the significance of serum Hcy levels in diabetic patients on HD.

METHODS

We measured total serum Hcy levels (tHcy) in 31 patients with diabetes mellitus on HD (DM group) and 37 non-diabetic patients on HD (N group), adjusting for age and HD duration. Linear regression analysis was used to assess the correlation of multiple variables to tHcy.

RESULTS

The proportion of atherosclerotic disease in the DM group was significantly higher than in the N group. However, serum tHcy, serum creatinine and per cent creatinine generation rate in the DM group were significantly lower than in the N group. In the DM group, serum tHcy was positively correlated with creatinine, albumin and per cent creatinine generation rate, respectively. This was not the case in the N group.

CONCLUSIONS

The demethylation pathway in methionine metabolism in the liver, which is linked directly to the creatinine generation system, may be disturbed in diabetic patients on HD. This may be the reason why serum tHcy and creatinine in diabetic patients on HD are lower than in non-diabetic patients on HD. Therefore, it is necessary to consider the possibility of an altered relation between serum tHcy and vessel disease when evaluating the atherogenic risk in diabetic patients on HD.

Neutrophil activation in immunoadsorption

Immunoadsorption therapy (IAT) is used in the treatment of autoimmune diseases. Although IAT has been reported to modify humoral immunity by inducing chemokines and activating complements, much remains unknown about the biological effects of IAT on cellular components in peripheral blood. To define the influence of IAT on leukocytes, we determined leukocyte L-selectin (CD62L) and Mac-1 (CD11b) as parameters for activation of leukocytes in peripheral blood during IAT. Peripheral leukocyte L-selectin and Mac-1 were determined continuously by flow cytometry in 6 patients with neuroimmunological disorders in whom IAT was conducted using a Plasma Flow OP-05 (Asahi Medical Corp., Tokyo, Japan) as a plasma separator and Immusorba TR-350 (Asahi Medical Corp., Tokyo, Japan) as an adsorption column. Expression of neutrophils (PMN) L-selectin was decreased 30 min after starting IAT, with the decreases particularly marked at the end of IAT, while expression of mononuclear cells (MNC) L-selectin slightly increased during IAT. Expression of PMN Mac-1 was markedly increased at the end of IAT, whereas expression of MNC Mac-1 did not change during IAT. Leukocyte counts decreased 30 min after starting IAT, and then increased to the initial level or higher in parallel with L-selectin downregulation and Mac-1 upregulation on PMN. L-selectin downregulation and Mac-1 upregulation on PMN suggested that activation of PMN associated with changes in peripheral leukocyte counts occurred during IAT and might play some role in modulating the human circulating blood and immune systems.

The natural history and prognostic factors in patients with cirrhosis and gastric fundal varices without prior bleeding

Objectives and methods: The prognostic factors have not yet been fully evaluated in patients with cirrhosis and gastric fundal varices (FV). We investigated the natural history of 145 patients with cirrhosis and FV with no history of bleeding. Various possible prognostic factors, which include clinical, biochemical, and endoscopical variables, were analyzed using Cox's proportional hazard model. Results: Among the 145 patients with cirrhosis and FV, there were 76 patients in class A, 45 in class B and 24 class C according to Child's classification. Sixty-five patients had concomitant hepatocellular carcinoma at the time of enrollment. Seventy deaths and 34 episodes of the hemorrhage from FV occurred during the mean follow-up period of 26.4 months. The cumulative survival rates at 1, 3, and 5 years were 75, 53 and 34%, respectively. The cause of death was related to gastrointestinal hemorrhage in 18 patients (15 deaths were related to FV hemorrhage), hepatic failure in 22, hepatocellular carcinoma in 22, and other causes in eight patients. In patients with small-, medium-, and large-sized FV, the deaths related to FV hemorrhage were 4, 21 and 54%, respectively. Overall, the death related to FV hemorrhage was 21%. A multiple regression analysis using Cox's model showed hemorrhage from FV, the presence of hepatocellular carcinoma and poor Child's status were all highly significant prognostic factors. Conclusion: The natural history of the patients with cirrhosis and FV was adversely modified by the hemorrhage from FV, concomitant hepatocellular carcinoma and poor hepatic functional reserve. Since the number of deaths related to FV hemorrhage was great in patients with large-sized FV, it is important to identify high-risk large FV and its prophylactic obliteration. Further studies are needed to elucidate the efficacy of prophylactic obliteration of large-sized FV.

The incidence of reflux oesophagitis after cure of Helicobacter pylori in a Japanese population

AIM

To investigate the incidence of reflux oesophagitis after antibacterial therapy for Helicobacter pylori infection in our patient population.

METHODS

Subjects were 451 H. pylori-infected patients (primary symptom: peptic ulcer disease in 347, nonulcer dyspepsia in 100, and reflux oesophagitis in four): 11 of these patients had reflux oesophagitis on study entry. H. pylori infection was treated by a proton pump inhibitor/amoxycillin-clarithromycin regimen for either 7 or 14 days. Each patient was examined by endoscopy before treatment and more than 6 months after treatment to compare oesophageal findings. In addition, 227 patients were interviewed regarding reflux symptoms, using symptom questionnaires, before and more than 6 months after treatment.

RESULTS

Among 440 patients who did not have reflux oesophagitis prior to antibacterial treatment (340 peptic ulcer patients and 100 nonulcer dyspepsia patients), 23 patients whose infection was eradicated developed reflux oesophagitis (5.4%). The 11 patients who had reflux oesophagitis prior to treatment were all successfully cured of infection. Six of these patients showed no change in their oesophagitis, while the condition improved in three and worsened in two. Symptom scores improved in 34 of the 36 patients who reported reflux symptoms. Among 19 patients who showed persistent infection, only one developed reflux oesophagitis (5.2%), while none complained of newly developed symptoms following treatment.

CONCLUSIONS

Development of reflux oesophagitis after treatment of H. pylori infection was observed in a Japanese population. However, the incidence of this condition was comparable between those with persistent H. pylori infection and those in whom the infection was eradicated.

Evidence for regulation of NF-kappaB by poly(ADP-ribose) polymerase

The DNA-binding activity of NF-kappaB in nuclear extracts of poly(ADP-ribose) polymerase (PARP)-defective mutant L1210 cell clones was markedly increased and was inversely correlated with the PARP content in these cells. The DNA-binding activity of NF-kappaB in a clone with the lowest PARP content (Cl-3527, contained 6% of PARP of wild type cells) was about 35-fold of that of the wild-type cells, whereas the change in the DNA-binding activity of AP-1 and SP-1 in the mutant was relatively small or not so significant. Transfection of a PARP-expressing plasmid to the mutant cells decreased the abnormally high levels of NF-kappaB complexes, especially p50/p65(Rel A) complex, to near the normal level. Moreover, poly(ADP-ribosyl)ation of nuclear extracts in vitro suppressed the ability of NF-kappaB to form a complex with its specific DNA probe by approx. 80%. Further analysis with purified recombinant NF-kappaB proteins revealed that both rp50 and rMBP-p65 (Rel A) proteins, but not rGST-IkappaB, could be poly(ADP-ribosyl)ated in vitro and that the modification resulted in a marked decrease in the DNA-binding activity of rMBP-p65, whereas a slight activation was observed in rp50. Poly(ADP-ribosyl)ated p65/NF-kappaB was detected in the cytosol of wild type L1210 cells by immunoblotting with anti-poly(ADP-ribose) and anti-p65 antibodies. Taken together, these results strongly suggest that PARP is involved in the regulation of NF-kappaB through the protein modification.