A multi-center, prospective, clinical study to evaluate the anti-reflux efficacy of laparoscopic double-flap technique (lD-FLAP Study)

Background

Double-flap technique (DFT) is a reconstruction procedure after proximal gastrectomy (PG). We previously reported a multi-center, retrospective study in which the incidence of reflux esophagitis (RE) (Los Angeles Classification ≥Grade B [LA-B]) 1 year after surgery was 6.0%. There have been many reports, but all of them were retrospective. Thus, a multi-center, prospective study was conducted.

Methods

Laparoscopic PG + DFT was performed for cT1N0 upper gastric cancer patients. The primary endpoint was the incidence of RE (≥LA-B) 1 year after surgery. The planned sample size was 40, based on an estimated incidence of 6.0% and an upper threshold of 20%.

Results

Forty patients were recruited, and 39, excluding one with conversion to total gastrectomy, received protocol treatment. Anastomotic leakage (Clavien-Dindo ≥Grade III) was observed in one patient (2.6%). In 38 patients, excluding one case of postoperative mortality, RE (≥LA-B) was observed in two patients (5.3%) 1 year after surgery, and the upper limit of the 95% confidence interval was 17.3%, lower than the 20% threshold. Anastomotic stricture requiring dilatation was observed in two patients (5.3%). One year after surgery, body weight change was 88.9 ± 7.0%, and PNI <40 and CONUT ≥5, indicating malnutrition, were observed in only one patient (2.6%) each. In the quality of life survey using the PGSAS-45 questionnaire, the esophageal reflux subscale score was 1.4 ± 0.6, significantly better than the public data (2.0 ± 1.0; p = 0.001).

Conclusion

Laparoscopic DFT showed anti-reflux efficacy. Taken together with the acceptable incidence of anastomotic stricture, DFT can be an option for reconstruction procedure after PG.

Prognostic nutritional index is a prognostic factor for patients with gastric cancer and esophagogastric junction cancer undergoing proximal gastrectomy with esophagogastrostomy by the double-flap technique: A secondary analysis of the rD-FLAP study

PURPOSE

Although proximal gastrectomy (PG) is commonly used in patients with upper gastric cancer (GC) and esophagogastric junction (EGJ) cancer, long-term prognostic factors in these patients are poorly understood. The double-flap technique (DFT) is an esophagogastrostomy with anti-reflux mechanism after PG; we previously conducted a multicenter retrospective study (rD-FLAP) to evaluate the short-term outcomes of DFT reconstruction. Here, we evaluated the long-term prognostic factors in patients with upper GC and EGJ cancer.

METHODS

The study was conducted as a secondary analysis of the rD-FLAP Study, which enrolled patients who underwent PG with DFT reconstruction, irrespective of disease type, between January 1996 and December 2015.

RESULTS

A total of 509 GC and EGJ cancer patients were enrolled. Univariate and multivariate analyses of overall survival demonstrated that a preoperative prognostic nutritional index (PNI) < 45 (p < 0.001, hazard ratio [HR]: 3.59, 95% confidential interval [CI]: 1.93-6.67) was an independent poor prognostic factor alongside pathological T factor ([pT] ≥2) (p = 0.010, HR: 2.29, 95% CI: 1.22-4.30) and pathological N factor ([pN] ≥1) (p = 0.001, HR: 3.27, 95% CI: 1.66-6.46). In patients with preoperative PNI ≥45, PNI change (<90%) at 1-year follow-up (p = 0.019, HR: 2.54, 95%CI: 1.16-5.54) was an independent poor prognostic factor, for which operation time (≥300 min) and blood loss (≥200 mL) were independent risk factors. No independent prognostic factors were identified in patients with preoperative PNI <45.

CONCLUSIONS

PNI is a prognostic factor in upper GC and EGJ cancer patients. Preoperative nutritional enhancement and postoperative nutritional maintenance are important for prognostic improvement in these patients.

Incidence of Metachronous Remnant Gastric Cancer after Proximal Gastrectomy with the Double-flap Technique (rD-FLAP-rGC Study): A Multicenter, Retrospective Study

BACKGROUND

Although proximal gastrectomy (PG) with the double-flap technique (DFT) is a function-preserving surgery that prevents esophagogastric reflux, there is a risk of developing metachronous remnant gastric cancer (MRGC). Moreover, details of MRGC and appropriate postoperative follow-up after PG with DFT are unclear.

METHODS

We reviewed the medical records of 471 patients who underwent PG with DFT for cancer in a preceding, multicenter, retrospective study (rD-FLAP Study). We investigated the incidence of MRGC, frequency of follow-up endoscopy, and eradication of Helicobacter pylori (H. pylori) infection.

RESULTS

MRGC was diagnosed in 42 (8.9%) of the 471 patients, and 56 lesions of MRGC were observed. The cumulative 5- and 10-year incidence rates were 5.7 and 11.4%, respectively. There was no clinicopathological difference at the time of primary PG between patients with and without MRGC. Curative resection for MRGC was performed for 49 (88%) lesions. All patients with a 1-year, follow-up, endoscopy interval were diagnosed with early-stage MRGC, and none of them died due to MRGC. Overall and disease-specific survival rates did not significantly differ between patients with and without MRGC. The incidence rate of MRGC in the eradicated group after PG was 10.8% and that in the uneradicated group was 19.6%, which was significantly higher than that in patients without H. pylori infection at primary PG (7.6%) (p = 0.049).

CONCLUSIONS

The incidence rate of MRGC after PG with DFT was 8.9%. Early detection of MRGC with annual endoscopy provides survival benefits. Eradicating H. pylori infection can reduce the incidence of MRGC.

Successful intragastric suture repair using endoscopy for refractory ischemic stomach perforation: A case report

INTRODUCTION

Ischemic stomach perforation and bleeding are major complications after distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for locally advanced pancreatic cancer. Although there are some treatment options for ischemic gastric events, we need to discuss the optimal treatment based on the patient's general condition and history.

CASE PRESENTATION

A 76-year-old woman with advanced pancreatic cancer underwent DP-CAR with the reconstruction of the common hepatic artery-celiac artery. She presented with a high fever and melena at 13 days and twenty-nine days after the operation, respectively. Contrast-enhanced computed tomography (CECT) demonstrated ischemic stomach perforation, which was localized. Although nonsurgical treatments, including endoscopic clipping and proton-pump inhibitor administration, were attempted, her symptoms were not relieved. Therefore, we performed intragastric suture repair using oral endoscopy (ISE) for gastric perforation. Although she presented with surgical site infection and a catheter-related blood stream infection after ISE, she was discharged 140 days after the first operation.

CLINICAL DISCUSSION

Ischemic gastric events following DP-CAR can be treated with non-surgical and surgical approaches. In this case, non-surgical management could not improve the patient's gastric complications, and she had to undergo surgery. Given the patient's condition, ISE was an indication for this complication and was, thus, performed among surgical procedures, resulting in the alleviation of the complication. Using ISE may provide safe and less invasive surgery.

CONCLUSION

This is the first case of ISE for use in refractory ischemic stomach perforation following DP-CAR. ISE can be a useful and minimally invasive surgical procedure.

Rapid recurrence of spindle cell type undifferentiated carcinoma early after radical surgery in a bile duct cancer patient - A case report

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An undifferentiated, spindle cell type cholangiocarcinoma (USCC) is extremely rare.

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USCC possesses a high metastatic potential.

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Upfront surgery for USCC was not feasible.

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USCC may be the induction of multidisciplinary treatment.

Introduction

Spindle cell type undifferentiated carcinoma of the extrahepatic bile duct is extremely rare and has a poor prognosis. However, its pathology is not fully known, yet.

Case presentation

76-year-old man with abdominal pain and dark-colored urine was referred to our department. Contrast-enhanced computed tomography showed an enhanced tumor at the junction of the cystic duct and direct invasion of the portal vein. He was diagnosed as having resectable biliary cancer and underwent a subtotal stomach-preserving pancreaticoduodenectomy with a reconstruction of the portal vein. Histopathological findings demonstrated undifferentiated spindle cell carcinoma. Forty-two days post-surgery, he presented with peritoneal dissemination and local recurrence with ascites, and died sixty-five days after his operation.

Clinical discussion

Spindle cell type undifferentiated carcinoma has highly metastatic potentials and also easily invade adjacent organs. Therefore, the prognosis of an undifferentiated, spindle cell type cholangiocarcinoma was poor. Although only surgery ensures cure, multidisciplinary treatment, including chemotherapy and radiotherapy is required.

Conclusion

Although surgery for spindle cell type undifferentiated carcinoma may provide a cure, we must consider the induction of multidisciplinary treatment.

Effectiveness of gallium scintigraphy in diagnosing a spontaneous giant chronic expanding hematoma of the adrenal gland: A case report

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A chronic expanding hematoma of the adrenal gland is extremely rare.

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Chronic expanding hematomas mimic sarcomatous lesions.

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Gallium scintigraphy may help the differential diagnosis between chronic expanding hematomas and sarcomatous lesions.

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Complete resection of chronic expanding hematomas is the gold standard.

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Preoperative arterial embolization may reduce intraoperative bleeding on complete tumor removal.

Introduction

A chronic expanding hematoma in the retroperitoneal space is a rare disease with poorly understood pathology, and preoperative diagnosis of such hematomas using conventional methods is sometimes difficult.

Presentation of case

A 68-year-old man with a history of slowly progressive abdominal distention was referred to our department for further evaluation. Contrast-enhanced CT revealed a large retroperitoneal tumor of the adrenal gland. MRI revealed that the tumor was iso-intense to hyperintense on T2-weighted imaging, with heterogeneous signal intensity on T1-weighted imaging without fat components. Angiography of the left adrenal artery confirmed many extravasations into the tumor. However, gallium scintigraphy showed no accumulation in the tumor. These findings were suggestive of a chronic expanding hematoma of left adrenal gland. This patient underwent complete tumor resection. Postoperative histopathological findings revealed a chronic expanding hematoma.

Discussion

Chronic expanding hematomas are slowly expanding, space-occupying masses as a result of trauma, surgery, or bleeding disorders. Chronic expanding hematomas mimic malignant tumors such as sarcomatous lesions. Although CT and MRI are used to obtain the diagnosis, the diagnosis is sometimes difficult. Gallium scintigraphs play a pivotal role in the differential diagnosis between them.

Conclusion

Gallium scintigraphs, magnetic resonance imaging and computed tomography, are useful tools to differentiate chronic expanding hematomas from sarcomatous lesions.

Multicenter retrospective study to evaluate the efficacy and safety of the double-flap technique as antireflux esophagogastrostomy after proximal gastrectomy (rD-FLAP Study)

AIM

As a result of the difficulty in effective prevention of gastroesophageal reflux, no standard reconstruction procedure after proximal gastrectomy (PG) has yet been established. The double-flap technique (DFT), or Kamikawa procedure, is an antireflux reconstruction procedure in esophagogastrostomy. The efficacy of DFT has recently been reported in several studies. However, these were all single-center studies with a limited number of cases.

METHODS

We conducted a multicenter retrospective study in which patients who underwent DFT, irrespective of disease type and reconstruction approach, at each participating institution between 1996 and 2015 were registered. Primary endpoint was incidence of reflux esophagitis at 1-year after surgery, and secondary endpoint was incidence of anastomosis-related complications.

RESULTS

Of 546 patients who were eligible for this study, 464 patients who had endoscopic examination at 1-year follow up were evaluated for reflux esophagitis. Incidence of reflux esophagitis of all grades was 10.6% and that of grade B or higher was 6.0%. Male gender and anastomosis located in the mediastinum/intra-thorax were independent risk factors for grade B or higher reflux esophagitis (odds ratio [OR]: 4.21, 95% confidence interval [CI]: 1.44-10.9, P = 0.0109). Total incidence of anastomosis-related complications was 7.2%, including leakage in 1.5%, strictures in 5.5% and bleeding in 0.6% of cases. Laparoscopic reconstruction was the only independent risk factor for anastomosis-related complications (OR: 3.93, 95% CI: 1.93-7.80, P = 0.0003).

CONCLUSION

Double-flap technique might be a feasible option after PG for effective prevention of reflux, although anastomotic stricture is a complication that must be well-prepared for.

Composite neuroendocrine carcinoma and squamous cell carcinoma with regional lymph node metastasis: a case report

Background

Neuroendocrine cell carcinoma is a rare variant of esophageal carcinoma. The characteristic clinical features and diagnosis of superficial neuroendocrine cell carcinoma remain to be established. We report a rare case of superficial coexistence of neuroendocrine cell carcinoma with squamous cell carcinoma treated by endoscopic submucosal dissection, and regional lymph node metastasis was detected after additional surgical treatment.

Case presentation

A 77-year-old Japanese man with esophageal squamous cell carcinoma received endoscopic submucosal dissection in en-bloc resection. Histopathological findings showed that lymphovascular invasion by the neuroendocrine cell carcinoma component occurred in the deep part of the muscularis mucosa. Regional lymph node metastasis was identified after additional surgical treatment. After surgical treatment, our patient received chemotherapy consisting of etoposide and carboplatin for 3 months. He is alive and shows no sign of disease recurrence 12 months after surgery.

Conclusions

This case report highlights the fact that even if neuroendocrine cell carcinoma is small and limited to superficial, the tumor has the potential for metastasis if lymphovascular invasion by the neuroendocrine cell carcinoma component occurs. In addition, this case indicates the necessity of close follow-up of small neuroendocrine cell carcinoma after treatment.

Enteral supplementation with glutamine, fiber, and oligosaccharide modulates incretin and glucagon-like peptide-2 secretion

Aims/Introduction

A dietary supplementation product enriched with glutamine, dietary fiber and oligosaccharide (GFO) is widely applied for enteral nutrition support in Japan. The aim of the present study was to evaluate the effects of GFO ingestion on secretion of incretins, gastric inhibitory polypeptide (GIP) and glucagon-like peptide-1 (GLP-1), and glucagon-like peptide-2 (GLP-2).

Materials and Methods

We carried out a cross-over study involving 20 healthy Japanese volunteers. The participants received GFO or 17 g of glucose, the equivalent carbohydrate in GFO as the control. Plasma glucose, serum insulin, and plasma total GIP, total GLP-1 and total GLP-2 levels during GFO or glucose loading were determined.

Results

GFO loading produced significantly higher plasma GLP-1 levels at 30 min and 60 min, area under the curve-GLP-1 value, and area under the curve-GLP-2 value after administration compared with those by glucose loading. In contrast, plasma GIP levels at both 30 and 60 min, and area under the curve-GIP value after glucose loading were significantly higher than those after GFO loading.

Conclusions

These results show that GFO ingestion stimulates GLP-1 and GLP-2 secretion, and reduces GIP secretion compared with glucose ingestion. Therefore, GFO could have an intestinotrophic effect as well as an ameliorating effect on metabolic disorders through modification of release of gut hormones.

Effects of glucose and meal ingestion on incretin secretion in Japanese subjects with normal glucose tolerance

Aims/Introduction:  Gastric inhibitory polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) are the major incretins; their secretion after various nutrient loads are well-evaluated in Caucasians. However, little is known of the relationship between incretin secretion and differing nutritional loading in Japanese subjects. In the present study, we evaluated GIP and GLP-1 secretion in Japanese subjects with normal glucose tolerance (NGT) after glucose loading (75 g glucose and 17 g glucose) and meal ingestion.

MATERIALS AND METHODS

  A total of 10 Japanese NGT subjects participated in 75 g oral glucose tolerance test (OGTT), 17 g OGTT and meal tolerance test (MTT). Plasma glucose (PG), serum insulin (IRI), serum C-peptide (CPR), plasma total GIP, and plasma total GLP-1 levels during OGTT and MTT were determined.

RESULTS

  Area under the curve (AUC)-GIP was increased in proportion to the amount of glucose, and was highest in MTT, showing that GIP secretion is also stimulated by nutrients other than glucose, such as lipid. In contrast, although the larger glucose load tended to induce a larger GLP-1 release, AUC-GLP-1 was not significantly different among the three loading tests (75 g OGTT, 17 g OGTT, MTT) irrespective of the kind or amount of nutrition load.

CONCLUSIONS

  Our results suggest that nutritional composition might have a greater effect on GIP secretion than that on GLP-1 secretion in Japanese NGT subjects. (J Diabetes Invest, doi: 10.1111/j.2040-1124.2011.00143.x, 2012).

Plasma gastric inhibitory polypeptide and glucagon-like peptide-1 levels after glucose loading are associated with different factors in Japanese subjects

Aims/Introduction:  Gastric inhibitory polypeptide (GIP) and glucagon‐like peptide‐1 (GLP‐1) are major incretins that potentiate insulin secretion from pancreatic β‐cells. The factors responsible for incretin secretion have been reported in Caucasian subjects, but have not been thoroughly evaluated in Japanese subjects. We evaluated the factors associated with incretin secretion during oral glucose tolerance test (OGTT) in Japanese subjects with normal glucose tolerance (NGT).

Materials and Methods:  We measured plasma GIP and GLP‐1 levels during OGTT in 17 Japanese NGT subjects and evaluated the factors associated with GIP and GLP‐1 secretion using simple and multiple regression analyses.

Results:  GIP secretion (AUC‐GIP) was positively associated with body mass index (P < 0.05), and area under the curve (AUC) of C‐peptide (P < 0.05) and glucagon (P < 0.01), whereas GLP‐1 secretion (AUC‐GLP‐1) was negatively associated with AUC of plasma glucose (P < 0.05). The insulinogenic index was most strongly associated with GIP secretion (P < 0.05); homeostasis model assessment β‐cell was the most the strongly associated factor in GLP‐1 secretion (P < 0.05) among the four indices of insulin secretion and insulin sensitivity.

Conclusions:  Several distinct factors might be associated with GIP and GLP‐1 secretion during OGTT in Japanese subjects. (J Diabetes Invest, doi: 10.1111/j.2040‐1124.2010.00078.x, 2011)

A hospital-based cross-sectional study to develop an estimation formula for 2-h post-challenge plasma glucose for screening impaired glucose tolerance

AIMS

To create and validate an estimation formula for 2-h post-challenge plasma glucose (2-hPG) as an alternative to oral glucose tolerance test (OGTT) for impaired glucose tolerance (IGT) screening.

METHODS

380 Japanese subjects (57.6% males, aged 58.5 (14.0); mean (SD) years) undergoing OGTT were included in this hospital-based cross-sectional study mainly at Kyoto University Hospital between 2000 and 2011. We determined the main predictive variables of 2-hPG from clinical variables and separated the subjects randomly into two groups: a derivation group to construct an estimation formula of 2-hPG on the basis of predictive variables and a validation group to evaluate the accuracy of the formula.

RESULTS

Fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) were highly correlated with 2-hPG measured by OGTT. Multiple linear regression analysis showed that estimated 2-hPG (e2-hPG) was calculated by the formula: e2-hPG = 1.66 × FPG (mmol/l) + 1.63 × HbA1c (%)-10.11 (R(2), coefficient of determination=60.2%). When the cut-off value was set to the diagnostic criteria of IGT, 7.8 mmol/l of e2-hPG, sensitivity, specificity, and negative predictive value (NPV) were 83.3%, 44.1%, and 74.3%, respectively. When the cut-off value was set lower (7.2 mmol/l), these values were 94.4%, 30.5%, and 85.7%, respectively. The area under the receiver operating characteristic (ROC) curve was 0.68.

CONCLUSIONS

This high-sensitive estimation formula may be a useful alternative to OGTT for IGT screening. For the levels ≤ 7.2 mmol/l, this formula may also be useful in cross-sectional study to identify people whose glucose tolerance is normal.

[A case of pathologically complete response of esophageal carcinoma treated with low-dose 5-FU/CDDP as neoadjuvant chemotherapy]

The patient was a 75-year-old woman with advanced esophageal cancer and lymph-node swelling in the mediastinum(cStage RR). We administered preoperative chemotherapy(5-FU 500mg/body×10, CDDP 10mg/body×10). She received the two courses without showing any serious side effects. The primary tumor revealed remarkable improvement, but the rigidity of the esophagus wall and swelling of the lymph nodes were not resolved, and images showed that the patient exhibited a partial response to the treatment. Radical resection of the esophageal carcinoma was performed. Pathological examination of the resected specimens revealed no malignant cells in the esophagus, no metastasis of the lymph node, and the response evaluation was grade 3. The patient showed no recurrence 4 years and eleven months after the operation. In lonclusion, this rare case of esophageal carcinoma showed a pathologically complete response when treated with low-dose 5-FU/CDDP as neoadjuvant chemotherapy.

[A case of gastric cancer with rhabdoid features showing better prognosis through S-1/CDDP chemotherapy]

Although gastric cancers(GCs)with rhabdoid features are rare, they are known to show a poorer prognosis compared with conventional GCs. Indeed, more than half of reported GCs with rhabdoid features died within 6 months after receiving any kind of initial treatment. Obviously, no effective chemotherapy has been reported. In this study, we present a case of GC with rhabdoid features which showed a better response to a chemotherapy, S-1/CDDP, and lived for over 12 months after the initial chemotherapy. A 75-year-old man was seen in our hospital for epigastralgia. Detailed examinations revealed that he had GC at Stage IV. Consequently, he underwent S-1/CDDP treatment. This treatment produced a good response for 6 months, minimizing the size of the primary tumor and eradicating distant metastases. Re-growth of the primary tumor without uprising distant metastasis was confirmed 8 months after the initialS -1/CDDP treatment, and the patient went through a gastrectomy for curative care. After surgery, a precise pathological examination revealed that the primary tumor possessed a poorly differentiated adenocarcinoma that contained tumor cells with typical rhabdoid features. In the end, the patient died of liver metastasis 13 months after the initial S-1/CDDP chemotherapy.

[In-vitro evaluation of cinnarizine as a competing agent to beta-cyclodextrin inclusion complexes: effect of cinnarizine on the membrane permeation rate of progesterone from its beta-cyclodextrin inclusion complex]

The use of competing agents is considered a powerful tool for the development of a drug-delivery system with drug/cyclodextrin inclusion complexes. However, there are very few studies examining this issue. To explain this phenomenon, it was thought that a competing agent with a sufficiently high stability constant had not yet been reported. In this study, cinnarizine (CN), which has a high stability constant with beta-cyclodextrin (beta-CD) and unique solubility characteristics, was selected, and its ability as a competing agent was examined in a membrane permeability study. The permeability study showed that the permeation rates of the drugs flurbiprofen, progesterone, and spironolactone decreased with their stability constants with the addition of beta-CD. In one of the drugs, progesterone (Pro), the decrease was restored by the addition of CN. The amount of CN added was a 1:1 molar ratio to the amount of Pro. However, no similar action was induced with the addition of DL-phenylalanine (Phe) in the permeation study at the 1:5 (Pro:Phe) molar ratio. These finding indicate that CN acts as a competing agent, and its action is much stronger than that of Phe.

Stability of spironolactone in rat plasma: strict temperature control of blood and plasma samples is required in rat pharmacokinetic studies

The stability of spironolactone (SPN) in rat plasma was studied and its degradation was found to be an apparent first-order reaction. The apparent first-order rate constants (k(obs)) at 37, 23.5 and 0 degrees C were 3.543+/-0.261 (h-1, mean+/-S.D., n=3), 6.278+/-0.045 (x10(-1) h-1), and 7.336+/-0.843 (x10(-2) h-1), respectively. The half-lives were 0.20 h, 1.10 h, and 9.53 h. The degradation rate of SPN in rat plasma was markedly decreased when NaF, an esterase inhibitor, was added to the plasma, and the degradation was catalyzed by esterase in the plasma. These results indicated that not only plasma but also blood and serum samples in rat pharmacokinetic studies should be cooled to 0 degrees C, the temperature maintained, and treated as soon as possible. In pharmacokinetic studies reported previously, the temperature control of plasma, blood, and serum samples was not described. The pharmacokinetic study in rats after intravenous administration of SPN at 20 mg/kg was performed with strict temperature control of plasma and blood samples. The AUC, MRT, CL and Vd(ss) values (mean+/-S.E. of 4 rats) for SPN were 4100.8+/-212.9 ng h/ml, 0.29+/-0.01 h, 4915.7+/-248.0 ml/h/kg, and 1435.4+/-48.4 ml/kg, respectively. The AUC value was much larger than that previously reported. The AUC, MRT, Cmax and Tmax values (mean+/-S.E. of 4 rats) of canrenone, an active metabolite of SPN, after the administration of SPN were 4196.1+/-787.5 ng h/ml, 1.99+/-0.13 h, 1546.3+/-436.4 ng/ml and 1.0+/-0.0 h, respectively. This AUC value was almost identical to the value previously reported.

Ureteral metastasis from appendiceal cancer: report of a case

We report a case of primary appendiceal cancer that metastasized to the ureter. The patient was a 51-year-old woman who complained of persistent left back pain and right lower abdominal pain. After a detailed examination she was diagnosed to have cancer of the appendix, multiple liver metastases, and left hydronephrosis. Since an obstruction of the ileocecum was obvious, she underwent an ileocecal resection and a resection of the spindle-shaped tumor invading the left ureter. Lymph node metastases were found at the root of the superior mesenteric artery. The spindle-shaped tumor was considered to be due to invasion of the appendiceal cancer to the left ureter. The patient died 5 months postoperatively.

Evaluation of the bioavailability of flurbiprofen and its β-cyclodextrin inclusion complex in four different doses upon oral administration to rats

The dissolution profiles of flurbiprofen (Flu) and its beta-cyclodextrin inclusion complex (Flu/beta-CD) in buffer solutions at various pH values were examined. The percent dissolved at 15 min for Flu and Flu/beta-CD was almost 100% at pH 6.8 and 8.0 but the dissolution rate of Flu was extremely reduced at pH 1.2 and 4.0. In these lower pH conditions, Flu/beta-CD improved the dissolution rate of Flu. The percent dissolved at 1 h for Flu/beta-CD at pH 1.2 and 4.0 were 33.4 and 41.3%, respectively, and about 10 times larger than those for Flu. The oral bioavailability of Flu from Flu or Flu/beta-CD at doses of 1, 3, 10, and 30 mg/kg (as Flu) was examined in rats. An apparent linear relationship between doses and C(max) and AUC was observed after administration of Flu and Flu/beta-CD. The Flu C(max) and AUC values at 30 mg/kg, however, were much lower than would have been predicted from doses of 1-10 mg/kg. Those of Flu/beta-CD were also lower than the predicted values, but the gap was quite small. The results suggest that the absorption of Flu in rats was saturated at 10 mg/kg, and that the enhanced dissolution rate of Flu/beta-CD increased the saturation dose to 30 mg/kg.

Ciliated foregut cyst of the gallbladder: report of a case

We report the rare case of a gallbladder cyst arising from the foregut remnants. A 36-year-old woman was referred to our hospital after screening ultrasonography (US) detected a tumor in the gallbladder. On admission, she was well and her blood analyses were all normal. US showed a cystic mass with internal high-echoic lesions, and computed tomography (CT) demonstrated a protruding tumor with slight enhancement in the gallbladder. Angiography provided no additional information; however, sequential CT-arteriography (CTA) clearly demonstrated that this tumor was a cystic lesion. Surgical exploration was performed, first because of the difficulty in establishing a definite diagnosis, and also because the patient wanted the tumor removed. The resected specimen contained a unilocular cystic tumor that looked like a submucosal tumor. Histologically, the wall of the cyst was lined by ciliated stratified columnar epithelium with interspersed goblet cells and underlying smooth muscle fibers. The mass was finally diagnosed as a congenital ciliated foregut cyst of the gallbladder. Cysts of the gallbladder are uncommon and the majority are acquired. To our knowledge, this represents only the fourth report of a ciliated foregut cyst of the gallbladder in the literature. Although rare, an awareness of this entity could allow a preoperative diagnosis to be made, whereby surgical exploration may be avoided. CT-A is a very useful diagnostic tool, especially when the nature of the tumor presents a difficult differential diagnosis.

A gastric duplication cyst with an aberrant pancreatic ductal system: report of a case

We report an extremely rare case of a gastric duplication cyst together with an aberrant pancreatic ductal system, which communicated with the stomach rather than the pancreatic ductal system with no evidence of pancreatitis. A 46-year-old woman developed severe abdominal pain after a 10-year history of occasional mild abdominal pain. Upper gastrointestinal barium radiography showed a rigidity of the stomach wall, and gastroscopy revealed a fistula orifice at a greater curvature of the gastric body. Subsequent endoscopic suction of mucous secretion from within the fistula provided immediate pain relief. Abdominal computed tomography and ultrasonography showed a cystic mass contiguous with the stomach wall. Surgical exploration revealed an uncommon anomaly of a gastric duplication cyst with the aberrant pancreatic lobe. The patient made an uneventful recovery and remains well 4 years after surgery. We also herein review ten other similar cases of this uncommon congenital anomaly reported in the literature.

Nitric oxide donating compounds inhibit HCl-induced gastric mucosal lesions mainly via prostaglandin

Prostaglandin (PG) and nitric oxide (NO) have been known to inhibit the lesion formation induced by necrotic agents. However, no clear correlation between PG and NO has been shown in the gastroprotective action against necrotic agent-induced gastric mucosal lesions in rats. Thus, the present study was performed to clarify this correlation. Gastric mucosal lesions were induced by the oral administration of 0.6 M HCl in rats. 16,16-Dimethyl PGE2 (0.3-3 microg/kg, p.o.; dim-PGE2), sodium nitrite (0.3 and 1 mg/kg, s.c.) and sodium nitroprusside (30 and 100 microg/kg, i.v.; SNP) dose-dependently inhibited the lesion formation. Orally administered sodium nitrite or SNP (3 mg/kg) also significantly inhibited the lesion formation. The gastroprotective action by dim-PGE2 was not affected by the pre-treatment with N(G)-nitro-L-arginine methylester (10 mg/kg, i.v.). The gastroprotective effect by sodium nitrite or SNP was markedly attenuated by the pre-treatment with indomethacin (10 mg/kg, s.c.). These findings suggest that NO donating compounds inhibit the HCl-induced mucosal lesions mainly through prostaglandin, but dim-PGE2 directly inhibits the lesions without involvement of NO in rats.

Endovascular stent grafting for the treatment of blunt thoracic aortic injury

OBJECTIVE

Recent advances of endovascular stent-grafting (ESG) provide a new therapeutic option with minimum surgical damage for blunt aortic injury (BAI) during its acute phase. To clarify the effectiveness of ESG for BAI, a prospective clinical study at a university hospital was conducted.

METHODS

All patients with blunt thoracic injury underwent thoracic contrast-enhanced computed tomographic (CT) scan. Six patients age 48.8 +/- 19.8 years, with Injury Severity Scores of 35.8 +/- 8.1, and with BAI were treated according to our protocol. The stent-graft covered by woven Dacron was placed at the injury site. Endoleakage was then checked by aortography and CT scan was again performed once a day on days 7 through 14.

RESULTS

All patients had injury of the aortic isthmus. ESG placement was performed within 8 hours after injury except in one (48 hours). The operating time was 159.5 +/- 21.1 minutes and bleeding volume was 105 +/- 26.6 mL. No endoleakage was found. Repeat CT scan revealed disappearance of hematoma. All patients except one had an event-free clinical course. One patient died because of rupture of the ascending aorta on day 6; however, autopsy revealed evidence of the healing process at the injury site sealed by ESG.

CONCLUSION

An ESG is a valid therapeutic option with minimal surgical invasion for patients with acute-phase aortic injury.

Involvement of nitric oxide from nerves on diarrhea induced by castor oil in rats

Nitric oxide (NO) is involved in the mechanism of castor oil-induced diarrhea. This study was performed to elucidate the source of NO. Diarrhea was induced by oral administration of castor oil in rats. Diarrhea was significantly inhibited by the pre-treatment with a relatively selective nerve NO synthase inhibitor, 7-nitroindazole. This effect was attenuated by the treatment with L-arginine. Capsaicin-sensitive afferent nerve degeneration did not affect the diarrhea. N(G)-Nitro-L-arginine methylester significantly inhibited diarrhea even in capsaicin-pretreated rats. These data suggest, at least in part, the involvement of NO from nerves on the diarrhea induced by castor oil in rats.

Type IIa early gastric cancer with proliferation of xanthoma cells

We report a type IIa early gastric cancer associated with xanthoma cell proliferation in a 61-year-old man. The patient was admitted to our hospital because of a gastric polyp detected at a medical checkup. An irregular protruding lesion with xanthoma cell proliferation was detected endoscopically. Histological examination showed a well differentiated tubular adenocarcinoma in the mucosa associated with xanthoma cell proliferation. The distribution of the xanthoma cells in the stroma corresponded closely with that of the cancer cells. Neither atypism nor mitotic figures were recognized in the xanthoma cells. In an immunohistochemical study, almost all the xanthoma cells were stained positive for alpha 1-antitrypsin, while relatively few exhibited positive S-100 protein staining. Specific monocyte chemotactic and activating factor immunoreactivity was present only in the xanthoma cells, and not in the cancer cells. On the basis of these findings, it was speculated that the gastric cancer cells may have caused the xanthoma cell proliferation via an autocrine mechanism i.e., by a chemical mediator acting in a paracrine or juxtacrine manner.

Partial adenine phosphoribosyltransferase deficiency detected by ureterolithiasis

A 30-year-old woman was admitted to our hospital because of recurrent ureterolithiasis. She was suspected of having adenine phosphoribosyltransferase (APRT) deficiency based on the presence of 2,8-dihydroxyadenine (DHA) crystals in her urinary sediment, infrared spectrophotometric analysis of the excreted stone, and then the definitive diagnosis by gene analysis. A pedigree study indicated only a slight possibility of this disease in the family. From these results, we consider that urinary sediment and stone analysis should be used for screening while gene analysis should be employed for definitive diagnosis of APRT deficiency, so that the complications of this condition can be prevented.

[Involvement of nitric oxide, which was synthesized by constitutive nitric oxide synthase, and prostaglandin on diarrhea induced by castor oil in rats]

To clarify the mechanism of castor oil-induced diarrhea, this study was performed by using rats in relation to nitric oxide (NO) and prostaglandin (PG). Castor oil induced diarrhea in all rats within 3 hr in the control group. The pretreatment of NG-nitro-L-arginine methyl ester prevented the diarrhea, and this effect was attenuated by the combined treatment of L-arginine. Amino-guanidine inhibiting inducible NO synthase had no effect on the diarrhea, but dexamethasone, an inhibitor of both inducible NO synthase and phospholipase A2 that synthesizes PGs, significantly prevented it. Indomethacin, an inhibitor of cyclooxygenase that synthesizes PGs, also significantly prevented diarrhea. Therefore, the mechanism of the preventive effect by dexamethazone on diarrhea was suggested to be the inhibition of PGs generation. From the above results, it became clear that PG and NO, especially that synthesized by constitutive NO synthase, are involved in the mechanism of diarrhea induction by castor oil in rats.

Cloning and chromosomal localization of a gene (GPR18) encoding a novel seven transmembrane receptor highly expressed in spleen and testis

Using the techniques of relaxed stringency polymerase chain reaction and genomic library screening, we have isolated homologous canine and human genes that encode a novel putative seven transmembrane G-protein-linked receptor. The gene encodes an open reading frame (ORF) of 993 bp. The sequences of the canine and human ORFs are highly conserved, sharing 89% nucleotide identity and 92% amino acid similarity between the two species. Northern blot analysis demonstrates that mRNA transcripts of the gene are abundantly expressed in testis and spleen with a lesser degree of expression observed in several other tissues associated with endocrine and immunologic/hematologic function. The gene, designated GPR18, was localized to human chromosome 13q32 using fluorescence in situ hybridization.

Canine H(+)-K(+)-ATPase alpha-subunit gene promoter: studies with canine parietal cells in primary culture

H(+)-K(+)-adenosinetriphosphatase (H(+)-K(+)-ATPase) is the principal enzyme responsible for the process of gastric acid secretion. This enzyme is expressed in a cell-type-specific manner in gastric parietal cells. To explore the mechanisms regulating its expression, we transfected differentiated canine parietal cells in primary culture with H(+)-K(+)-ATPase-luciferase reporter genes and assessed transcriptional activities. Deletional analysis of the 5'-flanking region of this gene demonstrated a remarkable increment in transcriptional activity associated with a segment between bases -54 to -45 (5' GCTCCGCCTC 3') relative to the transcriptional initiation site. Gel shift assays with competition and supershift analysis demonstrated that this segment is specifically bound by the transcription factor Sp1. A point mutation, eliminating Sp1 binding, diminished basal transcriptional activity by 80%, indicating that this Sp1 binding site is important for constitutive transcriptional activity. Although these studies indicate that Sp1 is required to maintain a high concentration of the H(+)-K(+)-ATPase gene in the parietal cell, its cell-type-specific expression must rely on other elements because Sp1 is a ubiquitously expressed transcription factor.

Acute gastric anisakiasis: 28 cases during the last 10 years

Anisakiasis is a disease which occurs following eating raw fish infected with anisakis larvae. Many cases have been reported from Japan and from other countries with increasing opportunities of eating raw fish such as "sushi" and "sashimi." We have reviewed 28 patients with acute gastric anisakiasis during the last 10 years from November 1984 to October 1994. This disease has rarely been detected in persons over 60 years of age and in patients with gastric surgery. Therefore it is postulated that gastric acid secretion influences the activities of anisakis larvae. An alkaline gastric pH could interfere with the toxicity of anisakis larvae.

[Emergency coronary artery bypass grafting (CABG) in a case of coronary occlusion secondary to long segmental dissection of left anterior descending artery after percutaneous transluminal coronary angioplasty (PTCA)]

A 60-year-old man with unstable angina underwent PTCA at left anterior descending artery (LAD) #6, which had stenosis of 90%. Subsequently, a long segmental dissection formed from #6 to #7 and the patients was scheduled for CABG. On the day before the expected date of CABG, he had an angina attack and a 12 lead electrocardiogram (ECG) showed ST segment and T wave elevation in V1-3. Coronary angiograms revealed 99% stenosis in LAD #6 and immediately rePTCA was performed at the site. RePTCA improved the stenosis to 50%, but ECG showed an inverted T wave in V3,4 and emergency CABG was performed, with the saphenous vein at LAD #8 and high lateral artery. Some authors have stated that CABG is not useful for long segmental coronary dissection, but we conclude that CABG should be definitely considered in such a case, because this procedure resolves pressure gradients at before-and-after entry and the bypass grafts will be never occluded whenever anastomosis (intima-adventitia-graft) is performed.

Analysis of the structural features of the C-terminus of GLUT1 that are required for transport catalytic activity

C-terminally truncated and mutated forms of GLUT1 have been constructed to determine the minimum structure at the C-terminus required for glucose transport activity and ligand binding at the outer and inner binding sites. Four truncated mutants have been constructed (CTD24 to CTD27) in which 24 to 27 amino acids are deleted. In addition, point substitutions of R468-->L, F467-->L and G466-->E have been produced. Chinese hamster ovary clones which were transfected with these mutant GLUT1s were shown, by Western blotting and cell-surface carbohydrate labelling, to have expression levels which were comparable with the wild-type clone. Wild-type levels of 2-deoxy-D-glucose transport activity were retained only in the clone transfected with the construct in which 24 amino acids were deleted (CTD24). The CTD25, CTD26 and CTD27 clones showed markedly reduced transport activity. From a kinetic comparison of the CTD24 and CTD26 clones it was found that the reduced transport was mainly associated with a reduced Vmax. value for 2-deoxy-D-glucose uptake but with a slight lowering of the Km. These data establish that the 24 amino acids at the C-terminus of GLUT1 are not required for the transport catalysis. However, the point mutations of F467L and G466E (26 and 27 residues from the C-terminus) did not significantly perturb the kinetics of 2-deoxy-D-glucose transport. The substitution of R468L produced a slight, but significant, lowering of the Km. The ability of the truncated GLUt1s to bind the exofacial ligand, 2-N-4-(1-zai-2,2,2-trifluoroethyl)benzoyl-1,3-bis-(D-mannos- 4-yl-oxy) -2-propylamine (ATB-BMPA), and the endofacial ligand, cytochalasin B, were assessed by photolabelling procedures. The ability to bind ATB-BMPA was retained only in the CTD24 truncated mutant and was reduced to levels comparable with those of the non-transfected clone in the other mutant clones. Cytochalasin B labelling was unimpaired in all four mutated GLUT1s. These data establish that a minimum structure at the C-terminus of GLUT1, which is required for the conformational change to expose the exofacial site, includes amino acids at positions Phe-467 and Arg-468; however, these amino acids are not individually essential.

Epidermal growth factor induces H+,K+-ATPase alpha-subunit gene expression through an element homologous to the 3' half-site of the c-fos serum response element

Epidermal growth factor (EGF) acutely inhibits acid secretion; however, prolonged administration of EGF has been reported to increase acid production. We undertook these studies to examine whether the physiological effects of EGF on acid secretion are mediated by regulation of gastric H+,K+-ATPase, the principle enzyme responsible for acid secretion. EGF in concentrations equivalent to those in plasma increased H+,K(+)-ATPase alpha-subunit mRNA levels. Using H+,K(+)-ATPase-luciferase constructs transfected into primary cultured parietal cells, a significant step up in EGF inducibility was observed between bases -162 and -156 (5'-GACATGG-3') relative to the cap site. This EGF response element (ERE) conferred EGF inducibility when linked to homologous and heterologous promoters. The ERE is homologous to the 3' half-site of the c-fos serum response element to which rNFIL-6, rE12, and SRE-ZBP bind. Electrophoretic mobility shift assays using an ERE probe and parietal cell nuclear extracts revealed a specific DNA-protein complex, the formation of which was changed by neither E12 and NFIL-6 consensus oligonucleotides nor antibodies for NFIL-6, SRE-ZBP, and E12. Our studies indicate that EGF induces gastric H+,K(+)-ATPase alpha-subunit gene expression via an interaction between a specific ERE and a novel transcriptional factor and that this may be a physiologic mechanism by which EGF regulates acid secretion.

Glycine-extended progastrin processing intermediates induce H+,K(+)-ATPase alpha-subunit gene expression through a novel receptor

Biologically active amidated gastrin is synthesized by carboxyl-terminal alpha-amidation of a glycine-extended progastrin post-translational processing intermediate (G-Gly). Although plasma levels of G-Gly are equivalent to those of gastrin, G-Gly has essentially no acute effect on gastric acid secretion. However, we have observed that inhibition of gastrin amidation leads to increased plasma concentrations of G-Gly and enhanced gastric acid secretion. We hypothesized, therefore, that G-Gly might have a chronic effect to increase H+,K(+)-ATPase expression in gastric parietal cells. In the present studies, we observed that a 2-day preincubation with G-Gly significantly enhanced histamine-stimulated [14C]aminopyrine uptake by isolated canine gastric parietal cells but acutely administered G-Gly had no effect. On Northern blot analysis, both G-Gly and gastrin dose-dependently increased H+,K(+)-ATPase alpha-subunit gene expression with maximal induction (225 +/- 35 and 170 +/- 29% of basal, mean +/- S.E.) achieved at concentrations of 10(-9) M G-Gly and 10(-8) M gastrin, respectively. Using an H+,K(+)-ATPase alpha-subunit gene-luciferase chimeric reporter construct transfected into primary cultured parietal cells, we observed that both G-Gly and gastrin increased luciferase activity in a manner similar to that obtained by Northern blot analysis. L365,260, a specific gastrin/CCKB receptor antagonist, completely reversed the stimulation of luciferase activity induced by gastrin but had no effect on G-Gly-stimulated activity. Gastrin increased [Ca2+]i, although G-Gly did not, however, genistein (a tyrosine kinase inhibitor) significantly reduced induction of luciferase activity by both G-Gly and gastrin. Specific binding of 125I-Leu15-G2-17-Gly to gastric parietal cells was dose-dependently displaced by G2-17-Gly but not by gastrin nor L365,260. Gastrin peptides truncated at the carboxyl- (G1-13) and amino terminus (G5-17-Gly) both induced H+,K(+)-ATPase alpha-subunit gene expression and inhibited 125I-Leu15-G2-17-Gly binding, but were less potent than G2-17-Gly. These data indicate that G-Gly may have a functional role in potentiating gastric acid secretagogue action via enhanced expression of the gene responsible for H+ generation through action at a novel receptor that can be distinguished from the gastrin/CCKB receptor. Thus, both the substrate and product of the terminal progastrin processing reaction appear to have complementary functions in regulation of gastric acid secretion.

delta-Aminolevulinic acid dehydratase deficiency porphyria (ADP) with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in a 69-year-old woman

delta-Aminolevulinic acid dehydratase deficiency porphyria (ALAD porphyria, ADP) with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in a 69-year-old woman is reported. The patient was admitted to our hospital complaining of slight cough with low-grade fever, and treated with piperacillin sodium, resulting in complete resolution of the symptoms, following a diagnosis of bronchopneumonia. Thereafter, however, she began to complain of vomiting, abdominal pain, facial numbness and paresis of the extremities with gait disturbance, and became comatose with hyponatremia (serum Na concentration 119 mEq/L) in a few days. Laboratory tests revealed an antidiuretic hormone (ADH) level of 13.5 pg/mL, plasma osmolality 218 mOsm/KgH2O, urinary osmolality 429 mOsm/KgH20, urinary Na concentration > 20 mEq/L, and no abnormalities of thyroid, adrenal or renal function. Neither edema nor dehydration was evident. These data indicated the presence of SIADH. No abnormalities suggestive of malignant or infectious diseases such as lung cancer, pneumonia and Guillain-Barré syndrome were evident from laboratory and roentgenographic findings. As the cause of SIADH, therefore, porphyria was suspected. Metabolites and activities of enzymes in the heme biosynthetic pathway were examined, and very low activity of delta-aminolevulinic acid dehydratase (ALA-D) (0.14 mumol PBG/mL RBC/h) was found. The patient was neither an alcoholic nor a heavy smoker, and she had no past history of heavy metal intoxication, photosensitivity or tyrosinemia. On the basis of these data and clinical features, she was diagnosed as having ADP. We consider this to be the first case of ADP reported in Japan.

Substitution of tyrosine 293 of GLUT1 locks the transporter into an outward facing conformation

Tyrosines 292 and 293 in the mammalian glucose transporter GLUT1 have been substituted by either isoleucine or phenylalanine. Chinese hamster ovary clones that were transfected with Tyr-292-->Ile, Tyr-292-->Phe, Tyr-293-->Ile, and Tyr-293-->Phe constructs of GLUT1 were shown, by Western blotting and cell surface carbohydrate labeling, to have expression levels that were comparable with the wild type. The Vmax for 2-deoxy-D-glucose transport was markedly reduced only as a result of the Tyr-293-->Ile mutation. The ability of the Tyr-293-->Ile mutated GLUT1 to bind the exofacial ligand 2-N-4-(1-azi-2,2,2-trifluoroethyl)benzoyl-1,3-bis-(D-mannos- 4-yloxy)-2- propylamine (ATB-BMPA) and the endofacial ligand cytochalasin B were assessed by photolabeling procedures. The ability to bind the bis-mannose compound was unimpaired, whereas the ability to bind cytochalasin B was totally abolished, and the level of labeling was lower than in the nontransfected clone. Affinities of the wild-type and Tyr-293-->Ile GLUT1 for D-glucose, the exofacial ligands (ATB-BMPA and 4,6-O-ethylidene-D-glucose), and the endofacial ligand (cytochalasin B) were assessed by the ability of these agents to displace the radioactive ATB-BMPA photolabel. These data indicated that the Tyr-293-->Ile substitution produced no change in the affinity for D-glucose, a relatively small enhancement in the affinity for exofacial ligands, but a large approximately 300-fold reduction in affinity for cytochalasin B, suggesting that the mutated GLUT1 is locked in an outward facing conformation. The observation that the Tyr-293-->Ile mutant transporter can bind nontransported C4 and C6 substituted hexose analogues but cannot catalyze transport is interpreted as indicating that Tyr-293 is involved in closing the exofacial site around C4 and C6 of D-glucose in the transport catalysis process.

Substitution at Pro385 of GLUT1 perturbs the glucose transport function by reducing conformational flexibility

The mammalian glucose transporter, GLUT1, is capable of alternating between two conformations which expose either an outward- or inward-facing ligand binding site. The possibility that these conformational changes are related to the presence of prolines and glycines in transmembrane region 10 was investigated by site-directed mutagenesis. Chinese hamster ovary clones which were transfected with Pro385-->Ile and Pro385-->glycine mutations of GLUT1 were shown, by Western blotting and cell surface carbohydrate labelling, to have expression levels which were comparable with the wild type. The transport activity was markedly reduced as a result of the Pro385-->isoleucine but not in the Pro385-->glycine mutation. The loss of transport activity in the Pro385-->isoleucine clone was associated with loss of labeling by the exofacial photoaffinity ligand, 2-N-4-(1-azi-2,2,2-trifluoroethyl)benzoyl-1,3-bis(D-mannos-4 -yloxy)-2- propylamine (ATB-BMPA), but there was no loss in labeling by the inside site-directed ligand cytochalasin B. These results suggest that the transporter cannot adopt the outward-directed conformation in the Pro385-->isoleucine clone. By contrast, the glycine substitution for proline at this position resulted in a retention of the ligand binding properties at both inside and outside sites. We suggest a putative mode of operation of the transporter which involves conformational flexibility about the prolines in transmembrane segment 10 such that helices 11 and 12 can alternately either pack against the outside (ATB-BMPA binding) site in helices 7, 8, and 9 or against the inner (cytochalasin B binding) site at the base of transmembrane segment 10.

Site-directed mutagenesis of GLUT1 in helix 7 residue 282 results in perturbation of exofacial ligand binding

The structure-function relationship of the HepG2/erythrocyte-type glucose transporter (GLUT1) has been studied by in vitro site-directed mutagenesis. Chinese hamster ovary clones in which glucose transporters were transfected were shown by Western blotting with a GLUT1 anti-COOH-terminal peptide antibody to have expression levels of Gln282----Leu, Asn288----Ile, and Asn317----Ile mutations that were comparable with the wild type. All three mutant GLUT1 clones had high 2-deoxy-D-glucose transport activity compared with a nontransfected clone, suggesting that these residues are not absolutely required for the transport function. We have examined the possibility that the inner and outer portions of the transport pathway are structurally separate by measuring the interaction of the mutant transporters with the inside site-specific ligand cytochalasin B and the outside site-specific ligand 2-N-4-(1-azi-2,2,2-trifluoroethyl)benzoyl-1,3-bis(D-mannos-4 -yloxy)-2- propylamine (ATB-BMPA). All three mutant GLUT1 clones showed high levels of cytochalasin B labeling, and the N288I and N317I mutants showed high levels of ATB-BMPA labeling. In contrast to the transport and cytochalasin B labeling results, the transmembrane helix 7 Gln282----Leu mutant was labeled by ATB-BMPA to a level that was only 5% of the level observed in the wild type. We have confirmed that this mutant was defective in the outer site by comparing the inhibition of wild-type and mutant 2-deoxy-D-glucose transport by the outside site-specific ligand 4,6-O-ethylidene-D-glucose. 4,6-O-Ethylidene-D-glucose inhibited wild-type transport with a Ki of approximately 12 mM, but this was increased to greater than 120 mM in the Gln282----Leu mutant. Thus, of the 3 residues mutated in this study, only glutamine 282 substitution causes a major perturbation in function, and this is a specific and striking reduction in the affinity for the outside site-specific ligands ATB-BMPA and 4,6-O-ethylidene-D-glucose.

[Management of cesarean section under replacement therapy with factor VIII concentrates in a pregnant case with congenital combined deficiency of factor V and factor VIII]

The congenital combined deficiency of Factor V and Factor VIII, a rare bleeding disorder, was identified in a 25-year-old woman. She was admitted to our hospital with a complaint of genital bleeding. Her prothrombin time and activated partial thromboplastin time were prolonged. She had low levels of Factor V coagulant activity (F. V:C) 14%, and Factor VIII coagulant activity (F. VIII:C), 12%, and normal levels of von Willebrand factor antigen (vWF:Ag), ristocetin cofactor (Rcof) and Protein C antigen. Her Protein C inhibitor level was slightly low. Her Rcof, vWF:Ag and F. VIII:C were elevated following administration of 1-deamino-8-D-arginine-vasopressin (DDAVP), but her F. V:C remained unchanged. Four years later, her F. VIII:C rose to 70% during the course of her pregnancy, but her F. V:C value remained low. It was expected that the vaginal delivery would be possible at the termination of pregnancy. Premature rupture of the membranes and an anomaly of rotation appeared in the course of delivery, however, and cesarean section was accomplished without excess bleeding under replacement therapy with Factor VIII concentrates. These findings suggested that DDAVP and Factor VIII concentrates were useful for management of her delivery. However the mechanisms of the rise of plasma F. VIII:C during pregnancy in a case with congenital combined deficiency of Factor V and Factor VIII are unclear.

Polymorphism in exon 4a of the human GLUT4/ muscle-fat facilitative glucose transporter gene detected by SSCP

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[Phosphoenolpyruvate:carbohydrate phosphotransferase systems in Enterococcus faecalis]

A wild-type strain of Enterococcus faecalis and its mutants resistant to 2-deoxy-D-glucose (2DG) were examined for the presence of phosphoenolpyruvate:carbohydrate phosphotransferase systems (PTSs) with 12 carbohydrates, which were utilized by the organism, as the substrates. The wild-type strain possessed a constitutive mannose-PTS, which was reactive with glucose, mannose, glucosamine, 2DG and fructose. This activity was absent in the mutants. No independent glucose- or fructose-PTS was found in the mannose-PTS-defective mutants. The mutants, however, showed a low level of a constitutive PTS activity with maltose, suggesting the existence of an independent maltose-PTS in the organism. Both wild-type and mutant strains possessed inducible lactose-, mannitol-, and trehalose-PTSs. Lactose-PTS was induced by either lactose or galactose in the parent, but only by lactose in the mutants. The lactose-PTS was not reactive with galactose, and no separate galactose-PTS was present. These observations suggest that the inducer for lactose-PTS, probably being galactose 6-phosphate, may not be formed from galactose in the organism when the constitutive mannose-PTS is lost by mutation.

[A neuron-specific enolase (NSE) positive leiomyosarcoma]

A 40-year-old woman with multiple skin tumors was admitted to our hospital on September 5, 1989. Extensive studies by means of light and electron-microscopic examination and immunohistochemical analysis revealed a neuron-specific enolase (NSE) positive leiomyosarcoma. The level of her elevated serum NSE decreased after receiving her initial chemotherapy, but after the fourth session of chemotherapy, the NSE began to elevate again and she died on December 25, 1989. NSE appears to be a useful marker for determining if the neuronal and neuroendocrine cells are normal. This rare case, however, seems to demonstrate that abnormal, nonneuronal cells like a sarcoma also open metabolic pathways to synthesize NSE.

[B-chronic lymphocytic leukemia/prolymphocytic leukemia (CLL/PL)--a case report]

A 48-year-old male was admitted to our hospital on April 20, 1989 because of general fatigue and abdominal fullness. Physical examination showed hepatomegaly, massive splenomegaly, and systemic lymphadenopathy. Hematological findings revealed WBC 73,000/microliters, RBC 289 x 10(4)/microliters, Hb 8.0g/dl, and platelet 9.1 x 10(4)/microliters. WBC differential count demonstrated a mixture of 63% matured small lymphocytes and 32% prolymphocytoid cells. Bone marrow aspiration was unsuccessful with a dry tap. Surface marker analysis of peripheral blood lymphoid cells disclosed that they were positive for anti-HLA-DR, CD 5, CD 19, CD 20, CD 21, CD 25, Sm-IgM, Sm-IgD, and Sm-K. He was diagnosed as B-CLL/PL, and treated with VEPA with partial remission. CLL/PL which was advocated by Melo in 1986 is regarded as a distinct clinical entity intermediate between CLL and PLL in clinical and laboratory features. Our case is interesting with regard to good response to combination chemotherapy, though most cases of CLL/PL have a resistance to standard chemotherapy.

Effect of fish oil and safflower oil in common Japanese diet on human plasma fatty acid composition

The influence of fish oil and safflower oil contained in the common Japanese diet as the main dietary polyunsaturated fatty acid source on plasma fatty acids in ten female student volunteers (21-22 years old) was investigated. The subjects were divided into two groups and fed the experimental diets for five days. The total daily fat intake in the fish diet and safflower oil diet was 54.4 g and 56.2 g, respectively, and the fat derived from fish and safflower oil was 16 g and 23 g, respectively. The proportion of linoleic acid was reduced in the plasma of subjects fed the fish diet and increased in the plasma of subjects fed the safflower oil diet. The plasma levels of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were significantly elevated in the fish diet group. The ratio of EPA/arachidonic acid (AA) was higher, and those of n-6/n-3 and n-9/n-3 were lower in the plasma of subjects fed the fish diet when compared to the results obtained from plasma of subjects fed the safflower oil diet. From these results, it seems likely that fish oil in the common Japanese diet is a favorable source of plasma EPA and DHA even in such short term supplementation and with such a small amount of daily consumption.

[Tissue culture course of a human hepatoma cell line]

A cell line, HuH-33 was cultured in vitro from a patient with hepatocellular carcinoma. This cell line has been in continuous culture over 12 month period with slow growth potential. HuH-33 was composed spindle-or polygonal-shaped cells as a major population. Chromosome number of the cells were widely distributed even in the primary culture. HuH-33 was transplantable into nude mice and secreted alpha-fetoprotein, albumin, beta 2 microglobulin, ferritin and tissue polypeptide antigen.