Determination of a new immunosuppressant, mycophenolate mofetil, and its active metabolite, mycophenolic acid, in rat and human body fluids by high-performance liquid chromatography

Mycophenolate mofetil, a new immunosuppressant, is a morpholinoethyl ester of mycophenolic acid. A new selective, sensitive and simple high-performance liquid chromatographic method was developed for the determination of mycophenolic acid and mycophenolate mofetil in biological samples. The preparation of samples was based on liquid-liquid extraction. The compounds were separated on a CN column using acetonitrile-0.01 M phosphate buffer (1:4, v/v) as the mobile phase. UV detection was used at wavelengths 215 and 304 nm. The detection limit was 5 ng per injection volume. This method enabled pharmacokinetic and pharmacodynamic studies in humans and rats.

A novel form of self tolerance dictated in the thymus of transgenic mice with autoreactive TCR alpha and beta chain genes

Transgenic (TG) mice with TCR alpha and beta chain genes from a CD4-dependent auto-I-Ak reactive T cell clone were generated. H-2k TG mice had a large number of thymic and splenic CD4 T cells expressing the autoreactive TCR without manifestation of autoimmunity. The cells were not anergic, as they could respond to autologous antigen presenting cells and anti-TCR antibodies in vitro to proliferate and to produce interleukins. Various degrees of down-regulation of CD2 and CD44 was observed in TG mice, indicating the presence of a defective co-stimulatory process in TG T cells. These features indicate that the self tolerance in autoreactive TCR TG mice is due not to clonal deletion and anergy but to a novel mechanism where T cells cannot sufficiently respond to normally existing self ligand in vivo. That such an in vivo unresponsiveness of autoreactive T cells is dictated in the thymus during CD4 T cell differentiation atypical form of positive selection of autoreactive T cells was suggested by the abnormal surface expression of CD69 and HSA.

Double switch operation in cardiac anomalies with atrioventricular and ventriculoarterial discordance

Since June 1987, 10 of 19 consecutive patients with atrioventricular and ventriculoarterial discordance (average age 4 +/- 2 years) had undergone a double switch operation with the morphologically left ventricle used as a systemic ventricle. There were two combinations of procedures. Atrial switch combined with arterial switch was used in two patients who had a normal pulmonary valve. Atrial switch combined with ventriculoarterial switch by Rastelli's procedure was used in eight patients with pulmonary stenosis or atresia and a large ventricular septal defect. One early death and two late deaths have occurred in a postoperative follow-up period of up to 4 years. Subsequent problems were mainly related to the results of atrial switch procedures in patients who had a small atrium because of low pulmonary flow, especially in patients with apicocaval juxtaposition. Our experience suggested that the double switch operation would open a new era of definitive surgical treatment in half of the patients with atrioventricular and ventriculoarterial discordance.

[Subaortic stenosis in coarctation or interruption of the aorta--changes of left ventricular outflow tract dimension after aortic arch repair and pulmonary artery banding]

Left ventricular outflow tract (LVOT) dimension was measured in seven patients with coarctation (CoA) or interruption (IAA) of the aorta before and after aortic arch repair and pulmonary artery banding. The age of patients ranged 3 to 69 (mean 16) days, the weight 3.0 to 3.9 (mean 3.4) kg. Associated cardiac anomalies were VSD in 6, MA and DORV in 1. In five patients compared by ultrasound, preoperative LVOT dimension ranged from 3.5 to 5.0 (mean 4.4) mm with the ratio to the normal aortic valve dimension (n-AVD; 16.6 x BSA0.6) from 54 to 82 (mean 69)%. Postoperative dimension increased 5.0 to 7.4 (mean 5.7) mm and the ratio to the n-AVD increased 65 to 89 (mean 80)%. In three patients compared by LV graphy, preoperative LVOT dimension ranged from 4.0 to 4.5 (4.2) mm and the ratio ranged from 61 to 72 (68)%. Postoperative dimension increased from 4.5 to 6.7 (5.3) mm, and 74 to 80 (78)% to n-AVD after operation. Postoperative pressure gradients between LV and ascending aorta in each patient were 1 to 9 (mean 6) mmHg. In any patients, LVOT obstruction did not advance after aortic arch repair and pulmonary artery banding.

Effective cases of transcatheter arterioportal chemoembolization with high-dose iodized oil for hepatocellular carcinoma

By administering an excessive amount of iodized oil via the hepatic artery, anticancer drugs in the iodized oil flow into the portal vein through the arterioportal communication. This phenomenon permits chemotherapy against extracapsular infiltration by a hepatocellular carcinoma (HCC) nourished by the portal blood flow. From May 1983 through July 1992, 240 cases of HCC underwent transcatheter arterioportal chemoembolization (TAPCE) with more than 5 ml of iodized oil (mean, 15 ml) in our hospital. In all, 32 patients survived for more than 3 years, and the factors favoring the efficacy of TAPCE therapy were investigated. Doxorubicin (mean, 46 mg) was given to 31 patients and 20 mg mitomycin C was given to 1 patient. The patients included one Stage 1 case, 13 Stage 2 cases, 17 Stage 3 cases, and one Stage 4 case. The mean tumor size was 5.0 cm, and portal invasion was suggested in 8 cases by angiography. The tumors were divided into 5 types: 13 cases of the single nodular type (SN), 7 cases of the single nodular type with proliferation (SN-P), 3 cases of the multinodular fused type (MN-F), 5 cases of the multinodular type (MN), and 4 cases of the massive type. A complication of liver dysfunction was detected in 14 cases, and half of them were Child's class C. In all, 7 patients underwent hepatectomy and 6 received percutaneous ethanol injection after TAPCE. The treated area of TAPCE was classified as segmental, lobar, or total. Segmental and lobar administration of TAPCE yielded statistically effective results, and their tumor response rate was 86%. All of the MN-F and massive types showed a good tumor response. The incidence of intrahepatic distant metastasis was higher in the localized TAPCE group than in the total TAPCE group. Segmental and lobar TAPCE should be applied for localized infiltrating HCCs, even in cases associated with liver cirrhosis, but these methods have a limited capacity to prevent distant intrahepatic metastasis.

[Clinical evaluation of endoscopic variceal ligation (EVL)]

From August 1992 through February 1993, we treated 21 patients with endoscopic variceal ligation (EVL). Two patients had a history of the esophageal variceal bleeding, but 19 patients did not have bleeding episodes. To evaluate preventive effect of bleeding, we selected the patients who had grade F2 or red color sign positive varices. We repeated EVL until varices improved into grade F0 or F1 and red color sign negative. The therapeutic goal was sometimes changed according to patient's general condition. No additional therapy was performed to eradicate varices, such as endoscopic injection sclerotherapy. As a result of our therapy, eradication rate was 73.7% and period of hospitalization were 25 +/- 11 days. No major complications were found during and after EVL. EVL affected neither liver function test nor size of gastric varices. Recurrent varices with red color sign were found in 4 patients, but easily controlled by retreatment with EVL. EVL seems to be convenient and effective therapy in our short-term study, and useful for preventive therapy of the esophageal variceal bleeding.

Comparative analysis of p53 and c-myc expression and cell proliferation in human hepatocellular carcinomas--an enhanced immunohistochemical approach

Expression of p53 and c-myc was investigated and compared with cell proliferative activity in a series of 40 hepatocellular carcinomas (HCC), by means of enhanced immunohistochemistry. p53 expression was demonstrated in 5 out of 40 HCC (12.5%) with the incidence increasing in 5 out of 40 HCC (12.5%) with the incidence increasing in proportion to the histological grading of malignancy: thus, 0% of well-differentiated, 6.9% of moderately differentiated and 33.3% of poorly differentiated lesions were positive. The proliferating-cell nuclear antigen (PCNA) labeling index also showed a statistically significant increase with this grading. Distribution patterns of PCNA-positive cell were divided into four types: scatter, marginal, mosaic and diffuse. Four HCC cases, predominantly of the poorly differentiated type, exhibited the diffuse pattern. Generally, p53 overexpression corresponded well with PCNA positivity. In contrast, there was no correlation between c-myc overexpression, found in 19 out of 40 HCC (47.5%), and histological grading of HCC or PCNA labeling index. The distribution pattern of c-myc-positive HCC cells was also different from that of PCNA and p53. Our results suggest that p53 overexpression closely relates to proliferation of HCC cells. Furthermore, there may be a consistent difference in regulatory mechanisms between p53 and c-myc expression in multistep hepatocarcinogenesis.

Computerized EEG and brain imaging studies in untreated schizophrenic patients: a report of seven cases

We undertook routine EEG, Z-map, CT and PET scans in seven acute untreated schizophrenics. Routine EEGs showed slower activity in only one case. However, the Z-map showed slower activity in all the cases. CT demonstrated brain atrophy in three of the cases, and PET revealed hypofrontality in two, right hypoparietality in four, and both conditions in one case. There was no relation between CT and PET or the Z-map. However, a significant increase in alpha 1 activity was demonstrated on the Z-map in cases who were found to be the parietal type on PET; this was not conspicuous in the frontal type on PET. Moreover, in three of the patients, the Z-map findings were similar to the lesion indicated on PET.

Bone mineral density of the radius in patients with ossification of the cervical posterior longitudinal ligament. A longitudinal study

Radial bone mineral density (BMD) in the distal one sixth and distal one third of the left radius was measured by single-photon absorptiometry (SPA) in patients with ossification of the cervical posterior longitudinal ligament (OPLL). Twenty-three OPLL patients (15 men and 8 women) with mean initial age of 60.1 years were studied longitudinally for mean follow-up period of 3.9 years. Based on roentgenologic findings, the patients were divided into two groups, those with advancing OPLL and those with non-advancing OPLL. The final value of distal 1/6th BMD in the advancing group was significantly lower than its initial value, but no change of the value of the distal 1/3rd BMD was observed in either group. The final value of distal 1/6th BMD/distal 1/3rd BMD ratio in the advancing group was significantly decreased compared with its initial value. These results suggest that, in the advancing OPLL group, trabecular bone mass decreased while cortical bone mass remained unchanged.

Significance of glomerular deposition of plasmin-alpha 2-plasmin inhibitor complexes in various glomerulopathies

To elucidate the relationship between glomerular deposition of plasmin-alpha 2-plasmin inhibitor complexes (PIC) and renal lesions or dysfunction, 25 patients with various glomerulopathies and various degrees of renal injuries were examined. Glomerular PIC deposition was found in eight patients (group A), and other 17 patients showed no deposition (group B). PIC was found mainly in the mesangium and along the capillary loops. Group A showed significantly more severe hematuria (p < 0.05) than group B. Group A showed a significant decrease in glomerular filtration rate (GFR; p < 0.05): the mean values being 60.8 +/- 39 in group A and 94.5 +/- 32 ml/min in group B. Group A showed a significant decrease in the phenolsulfonphthalein excretion test (p < 0.05). There was no significant difference in the mean values of plasma PIC, D-dimer, and thrombin-antithrombin III complexes (TAT) between two groups. Histologically, group A showed a significantly high incidence of adhesion (p < 0.05), crescentic formation (p < 0.05), endothelial swelling and/or detachment (p < 0.01), tubulointerstitial changes (p < 0.01), and glomerular deposition of platelet factor 4 (p < 0.01). The present study demonstrates that glomerular PIC deposition reflects the existence of activation of coagulation and fibrinolysis within the glomeruli and suggests that glomerular PIC deposition plays a part in the progression of renal injuries in various glomerulopathies.

Direct identification of lung cancer cells producing granulocyte colony stimulating factor with monoclonal anti-G-CSF antibodies

This is a case report of an 82-year-old man with squamous cell lung cancer which produced G-CSF. The leukocyte cell count was elevated to 94,400/mm3. The serum G-CSF concentration was also elevated to 351 pg/ml. This is the first report to demonstrate, by application of immunohistochemical staining techniques directly to tumor tissue obtained at autopsy, squamous carcinoma cells which produce G-CSF. The tumor cells were stained with monoclonal anti-G-CSF antibodies.

Clinico-pathological studies of Amyloid-P component in human glomerulopathies

Renal tissues from 171 patients with different glomerulopathies and 6 normal controls were examined by an immunofluorescent technique. Specimens were stained in particular with anti-Amyloid P (AP) antisera, and were also stained for immunoglobulins and complement. The intensity and distribution pattern of AP staining were studied. The AP staining revealed a faint/linear pattern in normal controls, and was granular and linear in pathological specimens. The distribution of AP was found to be mesangial, capillary and mesangiocapillary. According to the degree of AP intensity, the patients were divided into two groups: group I (56 patients) exhibiting a faint intensity as seen in the normal controls, and group II (115 patients) with a strong intensity. The histological findings and laboratory data were compared between the two groups as well as among patients with different diseases. The incidence of sclerotic lesions and the amount of proteinuria were significantly higher in group II than in group I. Increased amounts of AP deposition in different glomerular diseases thus appear to be related to a diminished renal function or glomerular damage.

Chronic parathyroid hormone administration reverses the antihypertensive effect of calcium loading in young spontaneously hypertensive rats

To investigate the role of parathyroid hormone (PTH) in the development of hypertension, the long-term administration of human PTH (hPTH) was performed in 7-week-old male spontaneously hypertensive rats maintained on a standard calcium diet (1.1% calcium) or a high calcium diet (2.8% calcium). The hPTH was infused subcutaneously at 0.9 U/h over 2 weeks using a minipump. Two weeks after minipump implantation, rat PTH (rPTH) and 1,25-dihydroxy vitamin D (1,25-D) levels were measured and the pressor response to norepinephrine (NE) was examined. Calcium loading both attenuated the development of hypertension and reduced the pressor response to norepinephrine. Chronic hPTH administration accelerated the development of hypertension and increased the pressor response to norepinephrine in rats fed a high calcium diet, but did not affect either parameter in rats fed a standard calcium diet. The serum concentrations of rat PTH and 1,25-D were significantly lower in rats fed a high calcium diet than in those fed a standard calcium diet (rat PTH: 351 +/- 16 v 430 +/- 1 pmol/L; 1,25-D: 125 +/- 19 v 206 +/- 31 pg/mL). Chronic administration of hPTH increased the serum 1,25-D concentration in rats fed a high calcium diet (186 +/- 35 pg/mL), but did not affect that of rats fed a standard calcium diet (165 +/- 16 pg/mL). It is concluded that PTH prevented the antihypertensive effect of calcium loading in young SHR, perhaps by enhancing blood pressure reactivity through causing an increase of 1,25-D.

[A case of dextrocardia concomitant with tetralogy of Fallot, patent ductus arteriosus and bronchiectasia]

We report a case of dextrocardia concomitant with tetralogy of Fallot (TOF), patent ductus arteriosus (PDA), bronchiectasia, and pulmonary tuberculosis. A 24-years-old man without surgical operation for TOF, whose diagnosis had been made at infancy, was admitted to the Osaka City University Hospital because of massive hemoptysis. The diagnosis of pulmonary tuberculosis was made. He received anti-tuberculotic drugs and bronchial arterial embolization improved his symptoms. A case of mirror-image dextrocardia concomitant with TOF, PDA, and bronchiectasia, as seen in our case, has a low incidence rate, and, moreover, such a case concomitant with pulmonary tuberculosis is rarer still.

Negative selection of thymus-dependent CD4+8+ intestinal intraepithelial lymphocytes by internal superantigens

CD4 and CD8 double-positive (DP) T cells were transiently found in the Peyer's patch of mice 2 to 3 weeks after birth and preceded the appearance of DP intestinal intraepithelial lymphocytes (iIEL). DP iIEL were detected in euthymic-specific pathogen-free mice, but not in athymic and germ-free mice. The pattern of V beta genes expressed on these DP iIEL was similar to that of CD4 single-positive peripheral T cells, which reflected the negative selection by internal superantigens, M1s, and I-E. CD8 SP T cells did not receive such a strict negative selection with these antigens. DP iIEL expressed a high density of T cell receptor alpha beta and CD3 and responded to immobilized anti-CD3 to undergo blastogenesis and de novo IL2 receptor expression. These results indicate that DP iIEL are mature thymus-dependent T cells immigrated to intraepithelial space via the Peyer's patch in response to intestinal antigenic stimulation.

[A case report of successfully corrected 26 days old infant of tetralogy of Fallot with absent pulmonary valve]

A female infant weighing 2.4 kg had respiratory distress at birth. She became dyspneic and hypercapnic and required intubation with assisted ventilation 11 days after birth. Because cardiac failure and respiratory failure did not improve, she underwent total correction at 26 days old, which consisted of VSD closure, right ventricular outflow tract reconstruction with valved porcine pericardial roll (VPR) and plication of both pulmonary arteries. She was weaned from the ventilator 11 days after operation and discharged at 12 weeks of age. One year later, reoperation was successfully performed for the replacement of the stenotic VPR with a transannular patch.

[Surgical management of tetralogy of Fallot with absent pulmonary valve in infancy]

Between November, 1987 and May, 1990, definitive operation was performed in 7 infants for tetralogy of Fallot with absent pulmonary valve. Preoperative respiratory failure was serious in 5 patients and semi-emergency operation was done. Surgical procedure consisted of closure of ventricular septal defect, reconstruction of right ventricular outflow tract using heterograft valved pericardial roll and plication of aneurysmally dilated pulmonary artery with or without pulmonary artery suspension in 5 infants with severe respiratory distress and heart failure, operated on 26 days to 5 months of age. In the other two less symptomatic infants, operated on at 13 months of age, reconstruction of right ventricular outflow tract was performed by transannular bovine pericardial patch with monocusp. There were no operative death and six infants are doing well 6 months to 3 years postoperatively, but one patient died of prolonged respiratory infection and respiratory failure one year after operation. Postoperative pulmonary arteriogram revealed a 42 to 61 (mean 54) percent reduction in right and left pulmonary artery size in 3 patients who underwent extensive plication of pulmonary artery. We suggest that definitive plication with or without suspension of pulmonary artery, together with closure of ventricular septal defect and reconstruction of right ventricular outflow tract is supposed to eliminate air way obstruction.

Drug-resistant Staphylococcus aureus contamination in the ward environment

A total of 282 strains of Staphylococcus were isolated from University Hospital ward environment from April 1991 to January 1992 and drug-susceptibility tests were performed. The main isolates were 84 strains of S. epidermidis (30%), 65 strains of S. aureus (23%), and 58 strains of S. haemolyticus (21%). One hundred and thirty-six strains of all staphylococci (48%) and 13 of 65 strains of S. aureus (20%) were methicillin (DMPPC)-resistant. The DMPPC-resistant strains of S. aureus were multiple drug-resistant to three to seven antibiotics; ampicillin. cephaloridine, cephametazole, tetracycline, erythromycin, gentamicin, and methicillin, while the DMPPC-susceptible strains were resistant to less than two drugs. These results indicate that this routine testing, along with testing of the anterior nares of the medical staff, is necessary to prevent nosocomial transmission.

[A case of general paresis with marked improvement of cerebral blood flow after antiluetic therapy--case report]

Although the incidence of neurosyphilis has declined dramatically after the World War II because of the development of antibiotics, it is recently increasing a little bit. There has been few reports on the neuroimaging of general paresis. We studied a fresh case of general paresis by X-ray CT (XCT), MRI and PET scans, and report the changes of neuroimages before and after the therapy. A 38-year-old man was admitted with disorientation, thought disorder and personality change. He also had insomnia and megalomania. There were neither obvious neurological signs nor particular changes of the XCT scan abnormalities on admission. His clinical symptoms were gradually worsened within three months, when the XCT and MRI scans showed moderate brain atrophy especially in the frontal and temporal lobes with mild dilatation of the lateral ventricles. In the PET study, the cerebral blood flow was decreased in the entire brain, especially in the frontal lobes, although the thalamus and the basal ganglia had normal levels. By immunological procedures and the cerebrospinal fluid (CSF) studies, the diagnosis of general paresis was made. He was treated with penicillin G and other antibiotics. In one year after his first therapy, many symptoms vanished. Although the cerebral atrophy was a little advanced, the cerebral blood flow was dramatically increased. As far as we know, this is the first PET study of general paresis before and after penicillin treatments.

High-density-lipoprotein metabolism during a very-low-calorie diet

We examined the changes in high-density-lipoprotein (HDL) metabolism in eight female obese patients undergoing a very-low-calorie diet (VLCD). In the first half of the study, HDL cholesterol (HDL-C), apolipoprotein A-I (apo A-I), and apo A-II showed a parallel decrease. Although lipoprotein lipase (LPL) and hepatic lipase (HTGL) did not change, lecithin: cholesterol acyltransferase (LCAT) decreased. In the latter half of the protocol, HDL-C and apo A-I increased whereas apo A-II decreased, resulting in increased apo A-I-A-II ratios. There was no change in LPL, HTGL, or LCAT. LCAT and apolipoprotein composition may be important in HDL-C changes after VLCD.