[Hansen's disease and nephropathy as its sequence]

Nephropathy as the sequences of Hansen's disease before and after the introduction of chemotherapy was compared referring to the report by Hayashi in 1943 and the summary of the autopsy reports from 1978 to 1981 at National Hansen's disease hospital Zenseien. Unlike the high rates of tuberculosis as the cause of death before the introduction of chemotherapy (41.3%) those thereafter decreased to be negligible. On the other hand the comparison of the rates of nephropathy with the same way as that of tuberculosis was impossible since the description about nephropathy by Hayashi was not sufficient to characterize each nephropathy since he included arteriolitis, glomerulonephritis and interstitial nephritis together in the term of nephritis. Death rate due to nephritis among Hansen's disease patients according to Hayashi at that time was 21.2% which was twice as many comparing to that in the other cases. According to the report about the cases of Zenseien those reported to have glomerulonephritis was 37.3% though those were not necessarily listed as the cause of death. Also the nephropathy including fibrinoid angitis with occasional microaneurysmal dilatation of afferent arteries, glomerulitis, sclerosis and stricture of efferent arteries likewise ischemic acute tubular necrosis possibly as the result of these angiopathy seemed to be present. These vascular changes partially resemble to that of microscopic periarteritis nodosa but seems to be common in the smaller arteries. In conclusion, unlike the case of tuberculosis the rate of nephritis including glomerulitis, arteriolitis and interstitial nephritis as Hayashi used as his criteria does not seem to have decreased. Therefore, the critical analysis of the nephropathy especially of that relating to the arteriolitis should be done to obtain the knowledge to suppress its occurrence.

Assessing the permeability of the gastrointestinal mucosa after oral administration of phenolsulfonphthalein

BACKGROUND/AIMS

In this study, the oral phenolsufonphthalein (PSP) absorption test as a simple and non-invasive method for the assessment of either the extent of the permeability of or damage to the gastrointestinal mucosa was evaluated.

METHODOLOGY

The permeability of the gastrointestinal mucosa of patients with liver cirrhosis and those who underwent gastrointestinal surgery was assessed by the oral administration of 30 mg of PSP and the measurement of its urinary recovery rate.

RESULTS

The urinary PSP excretion in patients with liver cirrhosis (n = 8; 28.8 +/- 6.0%) was significantly higher than that of patients who underwent vascular surgery (n = 8; 10.0 +/- 1.7%) (p < 0.01), which thus suggested an increased permeability of the gastrointestinal mucosa in patients with liver cirrhosis. The urinary PSP excretion rate in patients who underwent a total gastrectomy with Roux-en-Y reconstruction (n = 5) was 17.3 +/- 1.7% which was significantly higher than that observed in the control (p < 0.05), while the same rates in patients who underwent a partial gastrectomy (n = 10) or colectomy (n = 10) were 10.2 +/- 1.8% or 10.6 +/- 0.7%, respectively, which suggested that the intestinal mucosa is damaged by a total resection of the stomach.

CONCLUSIONS

The oral PSP absorption test, which is non-invasive, simple and inexpensive, is thus considered to be useful for assessing the degree of damage to or the permeability of the gastrointestinal mucosa under various conditions.

Biochemical evidence for the presence of NAP-22, a novel acidic calmodulin binding protein, in the synaptic vesicles of rat brain

NAP-22 is a neuronal tissue-enriched acidic protein which is expressed predominantly in rat brain. In the present study, we quantitated the amount of NAP-22 in a highly purified synaptic vesicle fraction. NAP-22 comprised 1.3 +/- 0.15% of the total protein in the fraction, and NAP-22 was located on the external surface of the synaptic vesicle membrane. The results suggest NAP-22 may be involved in the synaptic vesicle cycling.

Localization of 2',5'-oligoadenylate synthetase and the enhancement of its activity with recombinant interferon-alpha A/D in the mouse brain

Although the expression of 2',5'-oligoadenylate synthetase (2-5AS) is induced by interferon (IFN), low constitutive levels can be detected in animals that have not been treated with IFN. In order to clarify which cells express 2-5AS in the mouse brain, the distribution of this enzyme in the brains of both normal healthy mice and mice treated with recombinant human IFN-alpha A/D was studied by Western blotting and immunohistochemistry, using a specific monoclonal antibody. On the Western blots, the antibody to 42-kD 2-5AS reacted slightly with extracts from the telencephalon, cerebellum, diencephalon, and medulla oblongata of normal mouse brain. 42-kD 2-5AS was predominantly found in the ependymal cells and epithelium of the choroid plexus, and to a lesser degree in neurons and glial cells. Injection of recombinant human IFN-alpha A/D into the left lateral ventricle enhanced the activity of the enzyme in the telencephalon, cerebellum, diencephalon, and medulla oblongata, but did not change the immunohistochemical localization of the enzyme. Direct injection of the IFN into the cortex of the telencephalon enhanced the activity of 2-5AS in all parts of the brain and immunoreactivity was observed in the neurons and glial cells surrounding the injection site. These data indicate that 42-kD 2-5AS activity in the mouse brain is enhanced by the injection of recombinant human IFN-alpha A/D either into the left lateral ventricle or cortex of the telencephalon. Expression of 42-kD 2-5AS in ependymal cells and epithelium of the choroid plexus may prevent viral infections in the brain.

Serum carcinoembryonic antigen concentration doubling time correlates with tumor biology and life expectancy in patients with recurrent gastrointestinal carcinoma

OBJECTIVE

To determine if carcinoembryonic antigen (CEA) concentration doubling time (DT) can predict the course of disease and characterize tumor biology.

DESIGN

Retrospective case series of patients who exhibited a distinct increase in circulating CEA during disease recurrence in the routine postoperative follow-up.

SETTING

A tertiary general hospital.

PATIENTS

Twenty patients with recurrent gastric carcinoma and 17 patients with recurrent colorectal carcinoma.

INTERVENTION

The CEA DT was determined from semilogarithmic plots of CEA concentration time courses.

MAIN OUTCOME MEASUREMENTS

The quantitative analyses of the CEA DT as related to various host and tumor characteristics, modes of recurrence, and life expectancy.

RESULTS

The mean CEA DTs for gastric and colorectal carcinomas were 229 days and 86 days, respectively. Although there were no significant differences with regard to patient age, tumor size, gross appearance, and histological differentiation, women had shorter CEA DT than did men. Flow cytometric analysis showed that tumors with a higher proportion of cells in S phase (> or = 15%) had significantly shorter CEA DT than those with a lower S-phase fraction (< 15%). There was a significant correlation between the CEA DT and the length of survival after the initial CEA concentration increase in patients with recurrent gastric and colorectal carcinomas. In the multiple regression analysis of patients who had been treated with curative surgery and chemotherapy, CEA DT proved to be a major independent prognostic factor.

CONCLUSIONS

Carcinoembryonic antigen DT predicts life expectancy in patients with adenocarcinoma of the gastrointestinal tract. Differences in survival time are closely associated with variations in the biological aggressiveness of individual tumors.

Solitary and multiple pyogenic liver abscesses: characteristics of the patients and efficacy of percutaneous drainage

OBJECTIVES

Although percutaneous drainage has emerged as one of the first line of therapies for pyogenic liver abscesses, the presence of multiple abscesses may warrant surgical drainage, which remains controversial in the literature. We studied whether the multiplicity of the lesions influences the outcome of the treatment.

METHODS

Ultrasonography-guided percutaneous drainage was carried out in 48 patients with pyogenic liver abscesses. The abscesses were solitary in 38 patients and multiple (two to seven lesions) in 10 patients. Clinical characteristics and the efficacy of the treatment were compared between these two groups.

RESULTS

Biliary diseases and malignancies were more frequently observed in the solitary cases than multiple cases. A past history of surgery for cholelithiasis was seen exclusively in the multiple cases. E. coli was more frequently cultured from the abscesses in the multiple cases. Three of the multiple cases required more than a single catheter. All of the multiple cases and 36 of the 38 solitary cases were successfully treated. Two patients died of biliary peritonitis as a complication of the procedure, and three died of other underlining diseases.

CONCLUSION

Ultrasonography-guided percutaneous drainage is effective even in patients with multiple pyogenic liver abscesses by adding catheters to obtain sufficient drainage.

Identification of NAP-22 and GAP-43 (neuromodulin) as major protein components in a Triton insoluble low density fraction of rat brain

NAP-22 is a membrane-localized brain enriched acidic protein having a Ca(2+)-dependent calmodulin binding activity. Further fractionation of the NAP-22 containing membrane showed the localization of NAP-22 in a Triton insoluble fraction of low density. Besides NAP-22, this fraction was found to contain GAP-43 (neuromodulin), trimeric G proteins, and some GPI-anchored proteins such as Thy-1 and N-CAM-120. Presence of some protein tyrosine kinases, such as src and fyn, was also shown.

Relationship between hormone receptor levels and cell-kinetics in human colorectal cancer

BACKGROUND

This study was done to determine the potential role of sex steroid hormone receptors in the development of human colorectal cancer.

METHOD

Receptors for estrogen (ER) and progesterone(PgR) were investigated in surgical specimens from 22 patients with colorectal cancer, using enzyme immunoassay. These values were examined in relation to cell kinetics parameters determined by DNA flow cytometry.

RESULTS

ER and PgR were detected in 27% and 41%, respectively. There were no significant differences in the expression of ER or PgR according to the age, sex of the patients, tumor size, location, histological differentiation and lymph node metastasis. Although ER status appeared to be independent of DNA parameters, there were better correlations of PgR-negative tumors with increased hyperaneuploid levels. There were significantly higher values of heterogeneity index score in PgR-negative tumors compared with PgR-positive tumors. In the multiple regression analysis, PgR levels proved to be a major independent factor for changes in DNA index and heterogeneity index score.

CONCLUSION

The PgR status is a critical factor for determining the proliferative activity of colorectal cancer tissue and may play a biological role in regulating the growth of the tumor.

A comparison of open and laparoscopic cholecystectomy for patients with cirrhosis

To evaluate the benefits of performing laparoscopic cholecystectomy (LC) in patients with cirrhosis, data on 13 patients with liver cirrhosis who underwent cholecystectomy for gallstones between 1989 and 1995 were retrospectively collected from charts filed at Fukuoka City Hospital. These 13 patients were classified into two groups; one, comprised of 7 who underwent LC, and another, comprised of 6 who underwent open cholecystectomy (OC). No statistical differences were observed in the duration of surgery or the intraoperative blood loss between the two groups; however, the C-reactive protein (CRP) level in the serum was significantly higher in the OC group than in the LC group. LC was followed by a significantly earlier resumption of a normal diet (P < 0.05) and a shorter hospital stay (P < 0.05) in comparison to OC. All of the patients who underwent OC had an uneventful clinical course; however, one of the patients who underwent LC suffered from intractable ascites postoperatively. The difference in the cost of hospitalization between the two groups was not statistically significant. These findings suggest that the therapeutic significance of performing LC in patients with cirrhosis should be assessed after carefully evaluating all factors including mortality, morbidity, and cost-effectiveness. Thus, further controlled trials are necessary.

Distribution of immunoreactive 2',5'-oligoadenylate synthetase in mouse reproductive organs

Although 2', 5'-oligoadenylate synthetase (2-5AS) is an enzyme induced by inferferon (IFN) or viral infections and mediates one of the principal antiviral pathways turned on by IFN, low constitutive levels of the enzyme can be detected in various "normal" animals that have not been treated with IFN or virus. The distribution of this enzyme in the female and male reproductive organs of normal healthy mice was studied by Western blotting and by an immunohistochemical method, using a specific monoclonal antibody. On Western blotting, an antibody to 42-kD 2-5AS reacted with extracts from the ovary, oviduct, uterus, vagina, and placenta among the female reproductive organs, and testis, epididymis, and ductus deferens in the male. Immunohistochemically, the 2-5AS was localized on the following cells in the female reproductive organs: oocytes in the ovary; epithelium in the oviduct, uterus, and vagina; and trophoblasts in the placenta. Furthermore, the 2-5AS was localized on the epithelium and muscular layer in the ductus deferens and epithelium in the penis of the male mice, whereas the epithelium of the testis, epididymis, and seminal vesicle were stained faintly. It is well known that IFN is produced continuously in normal mice, so the 2-5AS in the tissues of normal mice is considered to be induced by such IFN produced under physiological conditions. Expression of the 2-5AS on the epithelium and trophoblasts in the reproductive organs may be responsible for the prevention of viral infections. However, the enzyme in oocytes may have some functions other than as an antiviral agent, since the enzyme was not detectable in embryos during early development.

Transcolonic approach for a stapled end-to-end colorectal anastomosis in low anterior resection

We designed the transcolonic approach for a stapled end-to-end colorectal anastomosis using a premium curved EEA in low anterior resection. The advantage of this repair is the elimination of transanal introduction of the stapler by a second assistant from below, which make the stapled anastomosis technically easier and safer. The fact that the anvil can be removed from the center shaft by pressing on the anvil release button allows the anvil to be released from anus, which theoretically prevents suture break down. This procedure can be considered for selected patients who have anal structure and where it is impossible to insert the instrument.

[Permanent paraplegia following epidural and general anesthesia: two case reports]

Case-1: A 72-year-old woman with no past neurological history was scheduled for a rectum resection under general combined with epidural anesthesia. An epidural catheter was introduced at T11-12 interspace without any difficulties. During the operation, she had hypotensive episode needing dopamine, but waked up from anesthesia without any event. When she became alert, she complained muscle weakness and loss of sensation in both lower extremities. On the day after surgery, she became quadriplegic and completely insensitive under Th4 level, but her MRI of the spine showed no abnormal findings. A month after the operation, her MRI showed diffuse spinal degeneration below C4 level and she had flaccid paralysis below Th1 with complete sensory loss below Th7 level. Case-2: A 62-year-old man with no past neurological history was scheduled for gastrectomy under general combined with epidural anesthesia. An epidural catheter was placed via T12-L1 without any difficulty. Operative course was uneventful and awakening from anesthesia was normal. He showed muscle weakness and hypesthesia of lower extremities two hours after the operation, and we stopped continuous injection of epidural anesthesia. His paralysis became worse but MRI of his spine showed no abnormality on the day after the operation. He became complete flaccid paralytic and had complete sensory loss below T7 level. The MRI examination two weeks after the operation showed degeneration below middle thoracic spinal cord. His neurologic symptoms have not improved for two years. The etiology of neurologic deficits of these two case is not obvious although the relation between epidural anesthesia and neurologic symptoms was most likely.

Comparative distribution of the serotypes of Enterococcus faecalis isolated from the urine of patients with urinary tract infections and the feces of healthy persons as determined by the slide agglutination reaction

In 1992, we reported a new scheme for identifying 21 distinct serovars of E. faecalis by the bacterial agglutination reaction. In this study we isolated strains of E. faecalis from the urine of patients with urinary tract infections and serotyped. We also serotyped strains of E. faecalis isolated from the faces of healthy persons. The results showed that serovars 2, 7, 1 and 3 were the major serotypes a distribution on strains of E. faecalis isolated from patients. Serovars 2, 1 and 13 were the major serotypes of the fecal strains isolated from healthy persons. Single serovars were typable of all strains of E. faecalis isolated from patients in 80.6% (395/496) and in 62.4% of the fecal strains. Examination of the hemolytic zone around colonies on horse/sheep blood agar plates showed that beta-hemolytic strains on horse blood agar plate isolated from patients had 36.1% for all isolated strains from patients and 8.3% for fecal strains isolated from healthy persons.

Surgical treatment for advanced gastric cancer

BACKGROUND/AIMS

We herein report on the clinicopathological factors related to the unresectability of far advanced gastric cancer and the prognostic effect of gastrectomy on these cases.

MATERIAL AND METHODS

There are four main prognostic factors for advanced gastric cancer including 1) peritoneal dissemination, 2) hepatic metastasis, 3) lymph node involvement and 4) invasion to adjacent organs.

RESULTS

The rate of unresectability was high in the cases demonstrating both histologically undifferentiated type cancer and cancers located in the lower third of the stomach. It was difficult to resect the main tumor based on an increase in the factors regulating the macroscopical stage. The rate of unresectability tended to be higher in cancers with peritoneal dissemination or invasion to adjacent organs. The pancreas was the most frequently invaded organ. accounting for the unresectability of the disease. The prognosis for cases with unresected gastric cancers was poor and all died within 2 years of the operation. In addition, the prognosis for cases with Stage IV gastric cancer, demonstrating either 1 or 2 factors, improved after gastrectomy while no such improvement was seen in cases with 3 or 4 factors.

CONCLUSIONS

To improve prognosis, gastrectomy should be performed when a patient has far advanced gastric cancer but only demonstrates 1 or 2 of the above 4 factors.

Host dependent variation of hepatitis C virus: phylogenetic analyses

Hepatitis C virus quasispecies in six patients from three families were separated by single strand conformation polymorphism analysis and by determination of nucleotide sequences of envelope regions containing the E1 gene segment and hypervariable region-1 of each quasispecies. Four of the six patients had multiple quasispecies. Phylogenetic analyses indicated that all quasispecies from one individual were highly homologous to each other. The homology was higher in the E1 gene segment than in hypervariable region-1. Furthermore, all quasispecies found in members of one family (husband and wife) were also highly homologous, suggesting direct intrafamilial transmission. The direction of hepatitis C virus variation in hypervariable region-1, however, seems to differ depending on the host in intrafamilial transmission.

Relationship between peritoneal collagen type IV concentrations and the presence of disseminated metastases in gastric cancer

OBJECTIVE

To predict disseminated microscopic foci or occult micrometastases in the peritoneal cavity in patients with gastric cancer.

DESIGN

Randomly selected patients with gastric cancer had peritoneal washings performed at the beginning of laparotomy.

PATIENTS

Thirty-nine patients with gastric carcinoma and 10 patients with other benign disease as a control group.

SETTING

Inpatients in a surgical department.

INTERVENTIONS

The concentration of collagen type IV in the irrigated peritoneal fluid was measured radioimmunologically. Intraoperative peritoneal cytologic examination and measurements of carcinoembryonic antigen (CEA) levels were also performed.

MAIN OUTCOME MEASUREMENTS

Results of the quantitative analyses of the collagen type IV concentrations as related to the clinicopathological characteristics and comparison of these results with regard to those of the peritoneal cytologic examination and CEA and collagen type IV levels.

RESULTS

There were eight patients with elevated collagen type IV concentrations. They had carcinomas with serosal invasion (pT3 and pT4) and metastatic spread (pN2, M1). Patients with clinically evident peritoneal disseminated metastases had significantly higher collagen type IV concentrations compared with those without metastases. The collagen type IV levels were more sensitive than peritoneal cytologic examination or CEA values in detecting disseminated metastases. There was an early peritoneal recurrence in the form of ovarian metastases in one patient with negative cytologic results and an elevated collagen type IV level. Linear regression analysis showed a statistically significant correlation between the collagen type IV and CEA levels.

CONCLUSION

Quantitative detection of abnormal collagen type IV levels may be useful for predicting the presence of disseminated metastases in patients with gastric cancer.

Clinicopathological features of lymph node metastasis in early gastric cancer

From 1979 through 1992, 482 cases with solitary early gastric cancer were resected in the Department of Surgery of the National Kyushu Medical Center Hospital. Among the 482 cases, the incidence of lymph node metastasis was 10.0% (48/482). The features of lymph node metastasis were studied while taking into account the combination of clinicopathological findings of the gastric cancer. Lymph node metastasis was rare in both the differentiated type mucosal cancers and submucosal cancers measuring 20 mm or smaller in size without depression. From these results, for early gastric cancer with the above-mentioned characteristics, either endoscopic therapy or local resection without lymph node dissection is considered to be sufficient treatment to obtain a favorable outcome.

Combination chemotherapy with methotrexate and 5-Fluorouracil and surgery for advanced gastric-cancer with liver and lymph-node metastases - a case-report

We report on a case of advanced gastric cancer with multiple liver metastasis and lymph node metastases in a 65-year-old Japanese man. He was treated with sequential intravenous administration of moderate-dose methotrexate 1 (MTX) and 5-fluorouracil (5-FU) preoperatively. After eleven cycles of the combination chemotherapy, the findings of liver and lymph node metastases diminished dramatically and the tumor could be resected for a potential cure, using a total gastrectomy and combined hepatectomy. The resected specimen revealed a slightly elevated lesion and a somewhat shallow ulceration due to chemotherapy. Histologically, there was an infiltration of poorly differentiated adenocarcinomas with medullary structure in the muscularis mucosae with fibrous change. The liver was metastasized, but there was no evidence-of lymph node metastasis. We believe that combination chemotherapy of MTX and 5-FU can be effective against gastric cancer.