Partial splenic embolization for the treatment of chronic idiopathic thrombocytopenic purpura

OBJECTIVE

The purpose of this study was to assess the effectiveness of partial splenic embolization in the treatment of chronic idiopathic thrombocytopenic purpura.

SUBJECTS AND METHODS

Twenty-six patients with chronic idiopathic thrombocytopenic purpura underwent partial splenic embolization and were followed up for 6-61 months. The condition was refractory to steroids in 20 of 26 patients. The other six patients, in whom a response to steroids was shown, could not be withdrawn from steroid therapy because their platelet counts decreased with any decrease in steroid dose. Five of 26 patients underwent splenectomy after partial splenic embolization, and the other patients were followed up without medical treatment until platelet counts decreased below 3 x 10(10)/l. The therapeutic effect of partial splenic embolization was defined on the basis of the platelet count at the last follow-up after partial splenic embolization: complete response, greater than 10 x 10(10)/l; partial response, 5 x 10(10)/l to 10 x 10(10)/l; and no response, less than 5 x 10(10)/l without medication.

RESULTS

Partial splenic embolization brought a complete response in seven (33%) of 21 patients, a partial response in eight (38%), and no response in six (29%). In four of five patients, who later underwent splenectomy, response to partial splenic embolization was coincident with the response to splenectomy. No serious complications occurred, but minor complications such as abdominal pain, fever, and nausea were observed in most patients.

CONCLUSION

This study suggests that partial splenic embolization might be useful as an alternative to splenectomy in the treatment of chronic idiopathic thrombocytopenic purpura.

[Transjugular intrahepatic portosystemic shunt--early experience in eleven liver cirrhosis patients]

Eleven liver cirrhosis patients with variceal bleeding and/or ascites were treated by transjugular intrahepatic portosystemic shunt. Four of the patients were combined with hepatoma, and 2 had portal thrombosis. Ten of the patients were successfully achieved TIPS, but one patient who had portal thrombosis was failed because of portal vein occlusion; success rate of 90%. An average decrease of 14mmHg in portal vein pressure was measured in the 10 patients. All of the successful patients including 4 with hepatoma were observed the disappeared or diminished varices and ascites without technical complication. Mild encephalopathy was encountered in 2 patients but who responded well to medical therapy. Three dimension MRA before TIPS was helpful for understanding the anatomical relationship between portal vein and hepatic vein. It is concluded that TIPS is an effective and safe treatment, indicating for the patients who have uncontrollable variceal bleeding and/or ascites even with hepatoma.

Invasive growth patterns of hepatic hilar ductal carcinoma. A histologic analysis of 18 surgical cases

BACKGROUND

Postoperative recurrence of hepatic hilar ductal carcinoma usually occurs in a localized region around the surgical margin, such as the bile duct. This study was aimed at assessing the invasive patterns of the hepatic hilar ductal carcinoma by histologically examining surgical specimens obtained by extended liver resection, especially the involvement of intrahepatic duct.

METHODS

Eighteen resected specimens of hepatic hilar ductal carcinoma were histologically investigated. Multiple sections vertical to the extrahepatic and intrahepatic bile duct were made at a 5-mm interval. The extension of carcinoma was evaluated on each of three layers (mucosal, extramucosal-intramural, and extramural), and routes of the invasion were examined.

RESULTS

Extramucosal extent toward the hepatic side was observed in 14 patients (77.8%) and that toward the duodenal side in 8 patients (44.4%) (P < 0.05). The distance of extramucosal tumor extent was also significantly longer (P < 0.05) in the hepatic side than in the duodenal side. Histologic tumor margin was usually identified in the extramural layer. Two patients had discontinuous extramucosal invasion. The lymphatic invasions were observed most frequently, followed by perineural invasion, and venous invasion was rare. In the extramucosal invasion of the liver, the left dominant carcinomas had extended toward the left, whereas those right dominant had extended toward the right (P < 0.05). Well differentiated differentiated tubular adenocarcinomas extended to the liver more extensively than moderately and poorly differentiated ones, but not significantly.

CONCLUSIONS

The authors examined the extramucosal invasion of hepatic hilar ductal carcinoma. This invasion extended more frequently and further to the hepatic side than to the duodenal side, usually by the route of the extramural layer.

Involvement of interferon-gamma and macrophage colony-stimulating factor in pathogenesis of haemophagocytic lymphohistiocytosis in adults

We investigated the role of monocyte/macrophage-activating cytokines in pathogenesis of haemophagocytic lymphohistiocytosis (HLH) in 21 adult patients. Sera from patients with active HLH contained extremely high levels of macrophage colony-stimulating factor (M-CSF) and of interferon-gamma (IFN-gamma). These levels returned to almost normal during remission. Neither interleukin-4 nor granulocyte/macrophage colony-stimulating factor could be detected. Active HLH sera also contained high concentrations of inflammatory monokines, such as interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNF-alpha). Serum concentrations of soluble CD8 and soluble interleukin-2 receptor were extremely high during active HLH, and returned to virtually normal levels during remission. Circulating CD2+ T-cells obtained from patients with active HLH spontaneously secreted M-CSF and IFN-gamma in vitro, whereas circulating monocytes did not produce detectable levels of both M-CSF and IFN-gamma, but produced high levels of IL-6 and TNF-alpha. These findings suggest that IFN-gamma and M-CSF at least partly from T-cells, such as CD8+ T-cells, might contribute to activation of monocytes or histiocytes, resulting in the up-regulated monokine production and haemophagocytosis in HLH.

Persistence of respiratory syncytial virus genome and protein after acute bronchiolitis in guinea pigs

Children with acute respiratory syncytial virus (RSV) bronchiolitis often develop sequelae of recurrent wheezing and asthma. To determine whether RSV persists within the lung after resolution of acute bronchiolitis, we examined the lungs of guinea pigs 60 days after intranasal inoculation with either human RSV (n = 10) or uninfected cell culture supernatant (n = 11). Evidence of viral persistence within the lung was determined by viral culture to test for replicating virus, immunohistochemistry to test for viral protein, and the reverse transcriptase-polymerase chain reaction (RT-PCR) to test for viral genomic RNA. Lungs were also examined histologically for evidence of bronchiolar inflammation or increased numbers of mast cells in the airway walls. All viral cultures were negative; however, there was positive immunohistochemical staining of occasional alveolar macrophages in six of ten RSV-inoculated guinea pigs while RT-PCR was positive in seven of ten RSV-inoculated animals. The six guinea pigs with evidence of RSV by immunohistochemistry and RT-PCR showed excess bronchiolar polymorphonuclear cell infiltrates (p < 0.005) but no increase in the number of airway wall mast cells. These results show that RSV protein and genomic RNA can persist in the lungs of experimentally inoculated guinea pigs for at least 60 days after infection and that persistence of the virus within alveolar macrophages might contribute to the pathogenesis of chronic bronchiolar inflammation.

Platelet-derived growth factor and its receptor in lungs from patients with asthma and chronic airflow obstruction

The airway walls of patients who have asthma or chronic obstructive pulmonary disease (COPD) are thickened by an increase in the amount of smooth muscle and connective tissue. Platelet-derived growth factor (PDGF) is a candidate cytokine for this increase because it can produce smooth muscle proliferation in vitro. The present study was designed to examine the expression of PDGF and its receptor (PDGFR) in lungs from six asthmatics, six patients with COPD, and six patients with normal lung function. PDGF was immunolocalized to tissue macrophages, but the number of PDGF-positive cells was similar in all three groups. PDGFR-beta was rarely expressed on interstitial cells, and, occasionally, on bronchial epithelium. Northern blotting, performed on tissue from the same groups, showed a positive correlation of PDGF(B) with PDGFR-beta mRNA level (r = 0.74, P < 0.001) and a higher abundance of PDGF(B) and PDGFR-beta mRNA in the asthmatics vs. the COPD (P < 0.05). We conclude that PDGF and its receptor are expressed in human lungs but do not correlate closely with the structural changes in diseased airways.

[A clinical study of the left ventricular wall motion after coronary artery bypass grafting using right gastroepiploic artery]

From 1989 to 1993 we performed coronary artery bypass grafting (CABG) using only arterial grafts in 135 cases. Both pre- and post-operative left ventriculography (LV graphy) were evaluated in 115 cases (282 branches). In accordance with the American Heart Association (AHA) classification, the left ventricular (LV) wall was divided into seven segments and the LV regional wall motion was assessed as per five grade. The rate of improvement (%) was defined as follows: (number that showed improvement of regional LV wall motion on post-operative LVgraphy/number that showed decreased regional LV wall motion on pre-operative LVgraphy) x 100. Examination was made separately regarding cases of ischemia (193 branches) and infarction (89 branches). For ischemic cases, the rate of improvement using left internal thoracic artery (LITA), right internal thoracic artery (RITA) and right gastroepiploic artery (RGEA) was 55.0% (11/20), 63.2% (12/19) and 75.0% (12/16) respectively. For infarction cases, the rate of improvement using LITA, RITA and RGEA was 42.1% (8/19), 55.6% (5/9) and 52.9% (18/34) respectively. Among these three groups no significant differences were noted. As a result, RGEA is thought to have usefulness equivalent to LITA and RITA.

Association of thrombosis-inducing activity (TIA) with fatal hypercoagulable complications in patients with lung cancer

We previously reported that thrombosis-inducing activity (TIA) is present in plasma from patients with advanced lung cancer. Of 73 patients with non-small cell lung cancer, stages IIIb and IV, 41 (56 percent) had such activity in plasma. The median survival time was significantly shorter in the TIA-positive vs the TIA-negative group. When 34 of those 73 patients who had died at Kyushu University Hospital were evaluated for the incidence of disseminated intravascular coagulation (DIC) and adult respiratory distress syndrome (ARDS), they were significantly higher in the TIA positive group (p < 0.05). The DIC occurred in 7 of 20 patients positive for TIA and 5 died of ARDS. In contrast, in the 14 TIA-negative subjects, only 1 patients experienced DIC and none died of ARDS. Peripheral platelet counts, which had been rather elevated on the day of hospital admission, were below normal within 1 week of death in 40 percent of the 20 patients who were positive for TIA. These observations suggest that TIA may be responsible at least in part for the increased activity of the coagulation system and the high incidence of DIC and ARDS in patients with advanced lung cancer.

[Therapeutic effect of mineralocorticoid in patients with hyponatremia of central origin]

Patients with hyponatremia of central origin were treated with a mineralocorticoid, and the pathogenetic mechanism of the hyponatremia was assessed based on the therapeutic effect obtained. The subjects were 14 patients (6 with subarachnoid hemorrhage, 3 with hypertensive intracerebral hemorrhage, 2 with cerebral infarct and 3 with head injury) who developed hyponatremia, as a complication during their hospital stay for their intracranial lesions from April to December 1992. Patients with serum Na levels below 135 mEq/l for more than 2 days with no other discernible etiology were defined as having hyponatremia of central origin. The mineralocorticoid used was fludrocortisone acetate, and as a rule administration was started the day after the onset of hyponatremia. When improvements occurred within 3 days, in 3 to 7 days, or 8 days or more efficacy was rated "excellent", "good" or "poor", respectively. The mean interval until the onset of hyponatremia was 10.4 days, its mean duration was 5.7 days, and the mean minimum serum sodium level was 129.5 mEq/l. The dose of fludrocortisone administration was 0.1 mg/day except for one patient who was treated with 0.3 mg/day. The mean period of administration was 3.7 days (range: 3 to 6 days), and the route was via a stomach tube in 5 cases and oral in 9 cases. The therapeutic effect was excellent in 9 cases, good in 3 cases and poor in 2 cases, the efficacy rate being 86%. None of the patients manifested side effects. Plasma atrial natriuretic peptide levels were above 100 pg/ml in 2 patients and 50-100 pg/ml in 8 patients and neither of the former 2 patients exhibited "excellent" efficacy.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional regions of ornithine decarboxylase antizyme

Degradation of ornithine decarboxylase, a key enzyme in polyamine biosynthesis, is accelerated by the binding of antizyme, an ornithine decarboxylase inhibitory protein induced by polyamines. In the present study, we examined the effects of a series of deletion mutants of rat antizyme. The results indicated that two regions of antizyme, one internal (amino acids 122-144) and the other near the C-terminus (amino acids 211-218) are necessary for its binding to ornithine decarboxylase and inhibition of its activity, and an additional internal region (amino acids 88-118, especially 113-118) is necessary for its destabilization.

[A case of congenital protein C deficiency with pulmonary thromboembolism]

A 47-year-old woman, with a history of recurrent venous thrombosis in her lower limbs (1988 and June, 1992), was admitted because of pulmonary thromboembolism in the right middle lung lobe. She was given anti-coagulant therapy with warfarin. The consolidation in the right middle lobe disappeared within two months. Hematological examinations concerning the coagulation and fibrinolytic system showed a significant decrease in both the serum concentration and the activity of protein C, a vitamin K-dependent hepatic protein which acts as an anticoagulant by shutting off fibrin formation and stimulating fibrinolysis. Since a sister of the patient also has a history of venous thrombosis, several members of her family were tested for protein C deficiency. The familial study revealed that her sister and mother had both a decreased concentration and depressed activity of protein C, indicating that this is a case of congenital protein C deficiency. Warfarin therapy has been continued to reduce the prothrombin time to 70% of the normal control level, resulting in no further episodes of thrombosis.

[Detection of anti-neutrophil antibodies by enzyme linked immunosorbent assay--comparison of results obtained by ELISA with those by leukocyte agglutination test and granulocyte cytotoxicity test]

We examined anti-neutrophil antibodies in 12 patients with various disorders using enzyme-linked immunosorbent assay (ELISA), and the results obtained by ELISA were compared with those obtained by leukocyte agglutination test (LAT) and granulocyte cytotoxicity test (GCT). IgG anti-neutrophil antibody was positive in 7 of 12 patients, and IgM type antibody was positive in 6 patients. There was a significant correlation between IgG and IgM anti-neutrophil antibodies. The results obtained by ELISA were not in accord with those obtained by LAT or GCT. In addition, we examined anti-neutrophil antibodies in serially collected serum samples from two patients with immune neutropenia. The results obtained by ELISA correlated with their neutrophil counts, suggesting that anti-neutrophil antibodies detected by ELISA have pathological relevance.

Effects of macrophage colony-stimulating factor (M-CSF) on the development, differentiation, and maturation of marginal metallophilic macrophages and marginal zone macrophages in the spleen of osteopetrosis (op) mutant mice lacking functional M-CSF activity

Immunohistochemical techniques using an anti-mouse panmacrophage monoclonal antibody and anti-mouse monoclonal antibodies specific for marginal metallophilic macrophages or marginal zone macrophages were used to detect red pulp macrophages, marginal metallophilic macrophages, and marginal zone macrophages in the spleen of op/op mice. In the mutant mice, the red pulp macrophages were reduced to about 60% of those in the normal littermates and the marginal metallophilic macrophages and marginal zone macrophages were absent. After administration of recombinant human macrophage colony-stimulating factor (rhM-CSF), numbers of red pulp macrophages increased rapidly, reaching levels found in normal littermates 1 week later. In contrast, the marginal metallophilic macrophages as well as the marginal zone macrophages appeared slowly after rhM-CSF administration and their numbers were less than half of the baseline level of normal littermates even at 12 weeks of administration. The distribution of marginal metallophilic macrophages and marginal zone macrophages appearing after M-CSF administration was irregular in the spleen of the op/op mice. These splenic macrophage subpopulations differed in their responses to rhM-CSF, suggesting that distinct mechanisms may be involved in their development and differentiation. The splenic red pulp macrophages present in unmanipulated op/op mice are an M-CSF-independent macrophage population. Although the marginal metallophilic macrophages and marginal zone macrophages are thought to be M-CSF-dependent, their development and differentiation appear to be influenced by locally produced M-CSF or other cytokines.

Interindividual difference in expression of human Ah receptor and related P450 genes

The genomic clones of human aryl hydrocarbon receptor (Ahr) and Ahr nuclear translocator (Arnt) were isolated, and the structures of exon-intron junctions of these genes were partially determined. Based on the sequence information, a quantitative RT-PCR analysis was developed, and the expression of these genes was studied in various human tissues. mRNAs for Ahr and Arnt were widely expressed in human tissues and abundantly in lung. Individual difference in expression levels of Ahr and Arnt mRNA was observed in liver, lung and blood. In order to examine whether expression levels of Ahr and Arnt were associated with those of CYP1A1, we studied the expression of these mRNAs in blood among 20 healthy subjects, taking account of individuals' cigarette smoking habits. We found that the expression levels of CYP1A1 appeared to associate with those of Ahr and Arnt mRNAs (P < 0.06), and also that the expression of Ahr and Arnt was influenced by cigarette smoking. The expression of human Ahr and Arnt is reported here for the first time, providing a quantitative RT-PCR analysis as a useful tool for further studies.

Heat shock protein produced by Helicobacter pylori

The cells of Helicobacter pylori were suspended in the medium containing 35S-methionine. After a heat shock of the cells at 42 C for 5, 10, and 30 min, the production of proteins was analyzed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and autoradiography. Out of many proteins produced by the cells, only 66 kDa protein production was dramatically increased by heat treatment. The N-terminal amino acid sequence of 66 kDa protein was quite similar to that of 62 kDa and 54 kDa proteins previously suggested as heat shock protein (HSP) of H. pylori based on the reaction with polyclonal and monoclonal antibodies against HSP 60 family proteins produced by other bacteria. Therefore, it was concluded that H. pylori produces the 66 kDa protein as its major heat shock protein which belongs to HSP 60 family.

Patient with unusual Hutchinson-Gilford syndrome (progeria)

A patient with unusual Hutchinson-Gilford syndrome (progeria) is reported. This 7-year-old boy had all the characteristics of progeria, except for coxa valga and the "horse-riding" stance. A previous cerebral infarction was detected in the right putamen on cranial magnetic resonance imaging. During treadmill exercise test electrocardiography, ST depression suggested the existence of arteriosclerotic lesions. Skin fibroblast culture exhibited 76% DNA-repair capacity compared to normal. He has not manifested endocrinologic abnormalities. From these findings it is concluded that this patient has an incomplete case of Hutchinson-Gilford syndrome and that a correlation may exist between the clinical features and the degree of DNA-repair capacity.

Amphibian allantoinase. Molecular cloning, tissue distribution, and functional expression

The chain of enzymes necessary to convert uric acid to its metabolic products urea and glyoxylic acid in vertebrates is truncated through the successive loss of allantoicase, allantoinase, and urate oxidase during phylogenetic evolution. Previous studies have assigned the localization of both urate oxidase and allantinase to the peroxisome in the amphibian liver. This study reports the cloning of a cDNA encoding bullfrog (Rana catesbeiana) allantoinase, an enzyme that converts allantoin to allantoic acid. The cDNA is 2112 base pairs in length containing a 1449-base pair open reading frame which corresponds to a 483-residue protein (53,296 Da). Structural analysis of the deduced protein suggested two potential transmembrane segments and the presence of a putative mitochondrial localization sequence in the amino terminus. Immunocytochemical analysis revealed that allantoinase is localized to mitochondria and not to peroxisomes. On Northern blotting, a single mRNA species was detected in the liver and kidney of frog but not in other tissues; this distribution was confirmed by immunoblotting. The hepatic- and renal-specific expression of allantoinase coincides with the distribution of urate oxidase in these tissues in the frog. The allantoinase expressed in Saccharomyces cerevisiae and in Spodoptera frugiperda (Sf9) insect cells exhibits catalytic activity and is antigenically identical to the native frog enzyme.

Magic-angle spinning nuclear magnetic resonance of half-integer quadrupole nuclei: effect of spin-locking efficiency on powder lineshapes

23Na spin-lock magic-angle spinning (MAS) and cross-polarization (CP) MAS nuclear magnetic resonance (NMR) spectra have been traced for sodium-containing compounds such as Na2SnO3.3H2O, Na2TeO4.2H2O, Na2SiO3.9H2O and NaBO2.2H2O whose asymmetric factors in quadrupole interaction are 0.00, 0.37, 0.63 and 0.80, respectively. The lineshapes in the spin-lock/MAS and CP/MAS NMR spectra are different from those in the spectra measured with the single-pulse sequence (SP) combined with 1H dipolar decoupling (DD). In other words, the former lineshapes are distorted from the theoretical ones broadened by the second-order quadrupole interaction. The lineshapes are distorted during the spin-locking period, since the spin-locking efficiency depends on the crystallite orientation in a powder sample. We have discussed the distortion on theoretical bases and simulated the observed spectra.