A case of multiple hepatocellular carcinoma experiencing complete responses to sorafenib and atezolizumab-bevacizumab and developing severe, refractory venous congestive cutaneous ulcers on either regimen

A man in his eighties presented with a history of bilateral leg congestive phlebitis, and multiple hepatocellular carcinoma (HCC) treated with sorafenib. When the dose was increased to 400 mg, ulcers appeared under both knees, which worsened, and the drug was discontinued 2 months after administration. However, the ulcers to 30 mm in diameter, requiring debridement and antibiotics. The HCC showed a complete response (CR) based on modified-RECIST criteria; however, after several rounds of locoregional therapy for recurrence, multiple HCCs and metastatic lesions in the Morrison's fossa were detected. Therefore, atezolizumab 1200 mg-bevacizumab 900 mg was started. After the first course, the patient complained of pain below both knees, and when the second course was administered, leg ulcers re-appeared and rapidly worsened. The ulcers were circular and multiple and progressed to deep digging, leading to tendon exposure. Bevacizumab-induced congestive venous ulcer was diagnosed, requiring skin grafts to heal. HCC then showed a CR based on m-RECIST criteria. Initially, the cause of the ulcer was thought to be immune-related adverse effects due to atezolizumab, but experience with sorafenib led us to conclude that the cause was stagnant venous ulcers due to vascular endothelial growth factor receptor inhibitor, which inhibited angiogenesis.

Volume-Outcome Relationship in Cancer Survival Rates: Analysis of a Regional Population-Based Cancer Registry in Japan

BACKGROUND

There is limited data on the relationship between hospital volumes and outcomes with respect to cancer survival in Japan. The primary objective of this study was to evaluate the effect of hospital volume on cancer survival rate using a population-based cohort database.

METHODS

Using the Kanagawa cancer registry, propensity score matching was employed to create a dataset for each cancer type by selecting 1:1 matches for cases from high- and other-volume hospitals. The 5-year survival rate was estimated and the hazard ratio (HR) for hospital volume was calculated using a Cox proportional hazard model. Additional analyses were performed limited to cancer patients who underwent surgical operation, chemotherapy, and other treatments in each tumor stage and at the time of diagnosis.

RESULTS

The number of cases with complete data, defined as common cancers (prostate, kidney, bladder, esophagus, stomach, liver, pancreas, colon, breast, and lung), was 181,039. Adjusted HR differed significantly among hospital volume categories for the most common cancers except bladder, and the trends varied according to cancer type. The HR ranged from 0.76 (95%CI, 0.74-0.79) for stomach cancer to 0.85 (0.81-0.90) for colon cancer.

CONCLUSIONS

This study revealed that a relationship may exist between hospital volume and cancer survival in Japan.

Contribution of chemotherapy to improved prognosis in stage 4 gastric cancer: trend analysis of a regional population-based cancer registry in Japan

OBJECTIVES

Little is known about time trends in the prognosis of gastric cancer (GC), since the introduction of new chemotherapeutic agents. This study aimed to analyze how the increased number of available chemotherapeutic options affected the prognosis of GC and which patient types benefited within in a large population.

METHODS

From a population-based cancer registry in Japan, 35,751 cases of GC were identified. Of these, 8214 cases were stage 4. The time trend for 3-year survival in stage 4 GC according to patient characteristics (age and tumor location) was estimated in relation to the introduction of new anticancer drugs. Multiple imputation was performed for sensitivity analysis to strengthen the missing data. In addition, we estimated the 5-year survival rate for distal-GC (DGC) and proximal-GC (PGC), and the hazard ratio (HR) was estimated by Cox proportional hazard model.

RESULTS

Improvement of overall survival was accelerated in stage 4 cases over time. The prognosis was improved from 11.4% to 13.2%, subsequent to the approval of several oncologic drugs since 2009. Younger patients were more likely to have improved survival rates in response to the increase in chemotherapy options (< 60-year-old, 5.4%: 60-70, 2.2%; 70-80, 0.3%) from 2007 to 2015. The HR for DGC vs. PGC was 1.11 (95% CI 1.08-1.15), and PGC showed a higher rate of improved outcomes (2.4% vs. 0.6%).

CONCLUSIONS

This analysis showed that improvement in the GC survival rate was accelerated by the introduction of new chemotherapeutic strategies and it was most evident among younger patients and in patients with PGC.

Giant magneto-optical responses in magnetic Weyl semimetal Co3Sn2S2

The Weyl semimetal (WSM), which hosts pairs of Weyl points and accompanying Berry curvature in momentum space near Fermi level, is expected to exhibit novel electromagnetic phenomena. Although the large optical/electronic responses such as nonlinear optical effects and intrinsic anomalous Hall effect (AHE) have recently been demonstrated indeed, the conclusive evidence for their topological origins has remained elusive. Here, we report the gigantic magneto-optical (MO) response arising from the topological electronic structure with intense Berry curvature in magnetic WSM Co₃Sn₂S₂. The low-energy MO spectroscopy and the first-principles calculation reveal that the interband transitions on the nodal rings connected to the Weyl points show the resonance of the optical Hall conductivity and give rise to the giant intrinsic AHE in dc limit. The terahertz Faraday and infrared Kerr rotations are found to be remarkably enhanced by these resonances with topological electronic structures, demonstrating the novel low-energy optical response inherent to the magnetic WSM.

Manufacturing Industry Cancer Risk in Japan: A Multicenter Hospital-Based Case Control Study

Background:

It is well known that specific occupations can cause harm in developing malignant neoplasms. Chemical exposure is particularly high in the manufacturing industry and workers in this sector may face a higher occupational risk for cancer. We aimed to estimate inequalities in the risk of cancers related to occupational chemical exposure in various manufacturing categories.

Methods:

Using nationwide clinical inpatient data (1984−2017) in Japan, we undertook a multicenter, case-control study with regard to risks of developing cancers among various manufacturing industry categories. Using the food manufacturing industry as the reference group, odds ratios and 95% confidence intervals for each industry were estimated by conditional logistic regression, adjusted for sex, age, admission period, and the admitting hospital. Medical record summaries accounting for 89% of industrial categories with high odds ratios were collected to confirm diagnoses made on the basis of histology. We estimated industrial hazards based on the Pollutant Release and Transfer Register.

Results:

A reduced risk for some of common cancers was observed among lumber and wood products industries. Leather tanning, leather products and fur tended to show a higher risk: 2.36 (95% CI 1.15−4.83) for pancreatic cancer, 2.85 (95% CI 1.26−6.47) for liver cancer and 2.00 (95% CI 1.01–3.99) for lung cancer. For the electronics category, observations of high risk ranged from 2.09 (95%CI 1.18–3.70) for ureter cancer, to 2.49 (95% CI 1.79–3.55) for kidney cancer.

Conclusions:

This study revealed industry risk inequalities in manufacturing categories were present with regard to the risk of common cancers in Japan.

A case of primary hepatic mixed neuroendocrine-non-neuroendocrine tumor (MiNEN) associated with gallbladder carcinosarcoma

A woman in her seventies visited our hospital because of abdominal pain. Multiple hepatic tumors were detected and a liver biopsy revealed mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN), which was composed of cholangiocellular carcinoma and neuroendocrine tumor (NET). Diagnostic imaging ruled out primary malignancies other than the liver and identified that the tumor originated from the liver. Because a predominant and aggressive part of the tumor was considered to be cholangiocellular carcinoma, gemcitabine and S-1 were used as first-line treatment. After the treatment, octreotide acetate was administered for the NET component, followed by transcatheter arterial embolization. Subsequently, her gallbladder (GB) rapidly swelled with biliary tract obstruction, and cholecystectomy revealed carcinosarcoma of the GB. She is still undergoing treatment at 44 months after diagnosis. Herein we report this case of primary hepatic MiNEN consisting of cholangiocarcinoma and NET, followed by GB carcinosarcoma. This is the first case illustrating that a multidisciplinary treatment approach for MiNEN accompanied with carcinosarcoma, involving assessment and treatment targeting the most aggressive component, can result in a long survival time.

The Prognosis of Hepatocellular Carcinoma Treated with Sorafenib in Combination with TACE

OBJECTIVE

Sorafenib have been shown to be effective in the treatment of advanced HCC and has been standard therapy since its release in Japan in 2009 (Llovet et al., 2008; Cheng et al., 2009). However, due to a low response rate, more aggressive combination treatment has been utilized as a multimodal strategy. The present study aimed to determine the efficacy of sorafenib alone and in combination with transarterial chemoembolization (TACE) for the treatment of advanced HCC.

METHODS

All patients with unresectable advanced HCC who were prescribed sorafenib at Kanto Rosai Hospital were included in the study. Five-year overall survival (OS) rates were estimated for patients treated with sorafenib alone or in combination with TACE. Multivariate and univariate regression analyses were performed to identify factors affecting OS. Analysis using propensity score matching and inverse-probability weights were also performed.

RESULTS

A total of 46 patients were treated with sorafenib up to June 2018. The total sorafenib dose administered was higher in the TACE combination group (70900 mg vs. 24000 mg vs. with sorafenib alone), although the relative dose intensity was lower (11.7% vs. 17.6%, respectively). The 5-year survival prognosis estimated using the Kaplan-Meier method was longer in patients treated with sorafenib in combination with TACE versus sorafenib alone (36.3% vs. 7.7%). Combination with TACE was the only factor associated with improved OS in both univariate and multivariate analysis. Among cases matched by propensity scores the hazard rate for combination with TACE was 0.067 (95% CI 0.091-1.128).

CONCLUSION

With an array of therapeutic options currently available, it is important to determine the efficacy of different multimodal strategies, such as sorafenib combined TACE, for patients with unresectable HCC.

Risk of cancer and longest-held occupations in Japanese workers: A multicenter hospital-based case-control study

Objectives

Little is known about the risk of developing various cancers according to occupation and occupational physical activity.

Methods

Using nationwide clinical inpatient data (1984‐2017) in Japan, we undertook a multicentered, matched case‐control study with regard to the risk of developing various cancers according to occupation and using patients admitted with fractures as controls. Using standardized national occupation and industrial classifications, we first identified the longest‐held job for each patient. Using sales workers as the reference group, odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by conditional logistic regression, adjusted for age, admission period, and the admitting hospital, with smoking, alcohol consumption, and lifestyle diseases as covariates. The risk of high and low occupational physical activity was also estimated.

Results

Across all occupations, a reduced risk for all common cancers among males was observed among those occupations associated with high physical activities, such as agriculture. People in these occupations tended to show a lower risk for most cancers, including, for example, prostate cancer (OR 0.58, 95% CI 0.45‐0.75) and lung cancer (OR 0.63, 95% CI 0.51‐0.76). For females, the breast cancer risk was low in women engaged in agriculture (OR 0.58, 95% CI 0.45‐0.75) and in those occupations with high levels of occupational physical activity (OR 0.58, 95% CI 0.52‐0.66).

Conclusions

This study revealed differences in cancer risk among diverse occupations in Japan. Specifically, those occupations associated with high levels of physical activity may be associated with a decreased risk of cancer.

Cholangiocarcinoma Prognosis Varies over Time Depending on Tumor Site and Pathology

BACKGROUND

Cholangiocarcinoma is a relatively rare cancer that is difficult to diagnose and has a poor prognosis. Currently, knowledge concerning its etiology, tumor localization, and pathological features remains limited. The present study aimed to clarify the clinico-epidemiologic nature of cholangiocarcinoma with its clinical subtypes using the largest regional cancer registry in Japan.

METHODS

Using a regional cancer registry in Kanagawa prefecture, Japan, we estimated three-year and five-year survival rates of cholangiocarcinoma patients, who were classified into two groups: intrahepatic (i-CCA) and extrahepatic cholangiocarcinoma (e-CCA) cases. The hazard ratio for each subtype, including pathological tissue type and tumor site, was calculated.

RESULTS

During the period from 1976 to 2013, 14,287 cases of cholangiocarcinoma were identified. The prognosis markedly improved after 2006, when a new type of chemotherapy for cholangiocarcinoma was introduced in Japan. Patients with i-CCA were more likely to be younger, and less likely to undergo surgery than those with e-CCA. The prognosis of cases with i-CCA was poor compared to that of patients with e-CCA.

CONCLUSION

In Japan, i-CCA was more likely to develop in younger people and to have a poor prognosis. The prognosis of both i-CCA and e-CCA cases markedly improved after 2006. The present study describes clinico-epidemiological features of cholangiocarcinoma that may be useful for determining therapeutic strategies for this disease.

Occupational class and male cancer incidence: Nationwide, multicenter, hospital-based case-control study in Japan

Little is known about socioeconomic inequalities in male cancer incidence in nonwestern settings. Using the nationwide clinical and occupational inpatient data (1984‐2016) in Japan, we performed a multicentered, matched case–control study with 214 123 male cancer cases and 1 026 247 inpatient controls. Based on the standardized national classifications, we grouped patients’ longest‐held occupational class (blue‐collar, service, professional, manager), cross‐classified by industrial cluster (blue‐collar, service, white‐collar). Using blue‐collar workers in blue‐collar industries as the referent group, odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by conditional logistic regression with multiple imputation, matched for age, admission date, and admitting hospital. Smoking and alcohol consumption were additionally adjusted. Across all industries, a reduced risk with higher occupational class (professionals and managers) was observed for stomach and lung cancer. Even after controlling for smoking and alcohol consumption, the reduced odds persisted: OR of managers in white‐collar industries was 0.80 (95% CI 0.72‐0.90) for stomach cancer, and OR of managers in white‐collar industries was 0.66 (95% CI 0.55‐0.79) for lung cancer. In white‐collar industries, higher occupational class men tended to have lower a reduced risk for most common types of cancer, with the exception of professionals who showed an excess risk for prostate cancer. We documented socioeconomic inequalities in male cancer incidence in Japan, which could not be explained by smoking and alcohol consumption.

Association between Sarcopenia and Overactive Bladder in Elderly Diabetic Patients

OBJECTIVES

To determine the association between sarcopenia and overactive bladder (OAB) in elderly diabetic patients using the Japanese version of SARC-F called SARC-F-J.

DESIGN

Cross-sectional study.

SETTINGS AND PARTICIPANTS

The study included 329 elderly diabetic patients (aged ≥65 years) who regularly visited the outpatient clinic at Community hospital in Japan.

MEASUREMENTS

The condition of OAB was evaluated using the OAM symptom score, which involves a self-administered questionnaire, and sarcopenia was evaluated using the self-administered SARC-F-J questionnaire comprising five items. The odds ratio for OAB due to sarcopenia was calculated using multiple logistic regression analysis, with OAB as the dependent variable and sarcopenia as the explanatory variable.

RESULTS

A total of 329 patients (186 males, 143 females) were included for analysis in the present study. Of these patients, 22.9% had sarcopenia and 18.7% had OAB. After adjusting the variables, the odds ratio for OAB due to sarcopenia was 4.46 (95% confidence interval [CI], 1.14-17.36, P = 0.031) and 2.09 (95% CI, 0.52-8.26, P = 0.293) for males and females, respectively.

CONCLUSION

This study found that sarcopenia was significantly associated with OAB in elderly diabetic male patients based on SARC-F-J. Moreover, the possibility of the development of OAB should be considered during the medical examinations of elderly diabetic male patients with sarcopenia.

Efficacy of ledipasvir/sofosbuvir with or without ribavirin for 12 weeks in genotype 1b HCV patients previously treated with a nonstructural protein 5A inhibitor-containing regimen

AIM

The therapeutic benefit of adding ribavirin (RBV) to 12 weeks of ledipasvir/sofosbuvir (LDV/SOF) for patients who experienced failure of a previous nonstructural protein (NS) 5A inhibitor-containing regimen is unclear.

METHODS

A total of 29 genotype 1b HCV patients who had failed prior daclatasvir (DCV) plus asunaprevir (ASV) treatment were retreated for 12 weeks of LDV/SOF, with or without RBV. Antiviral efficacy and predictive factors associating with a sustained virological response at 24 weeks (SVR24) were evaluated retrospectively.

RESULTS

SVR24 was achieved in 67% (10/15) of patients who received LDV/SOF with, and 64% (9/14) without, RBV. The SVR24 rates were 80% in patients with, and 58% without, mild fibrosis (FIB-4 < 3.25). The SVR24 rate was lower with unfavorable IL28B rs8099917 SNP genotypes; specifically, the TT, TG and GG had SVR24 rates of 78%, 50% and 40%. The SVR24 rate was lower with a poor response to prior DCV plus ASV, where relapse, viral breakthrough and no response had SVR24 rates 71%, 58% and 0%. The SVR24 rate was lower with the number of NS5A resistance-associated substitutions (RAS), where 2, 3, 4 and 5 RAS had SVR24 rates of 78%, 67%, 50% and 0%. A patient with an NS5A-P32 deletion, which shows resistance to next-generation NS5A inhibitors, was retreated with LDV/SOF with RBV and achieved SVR24.

CONCLUSIONS

The addition of RBV to 12 weeks of LDV/SOF has little therapeutic benefit when retreating patients in whom a prior NS5A inhibitor-containing regimen had failed.

Occupational inequalities in female cancer incidence in Japan: Hospital-based matched case-control study with occupational class

BACKGROUND

Socioeconomic inequalities in female cancer incidence have previously been undocumented in Japan.

METHODS

Using a nationwide inpatient dataset (1984-2016) in Japan, we identified 143,806 female cancer cases and 703,157 controls matched for sex, age, admission date, and admitting hospital, and performed a hospital-based matched case-control study. Based on standardized national classification, we categorized patients' socioeconomic status (SES) by occupational class (blue-collar, service, professional, manager), cross-classified by industry sector (blue-collar, service, white-collar). Using blue-collar workers in blue-collar industries as the reference group, we estimated the odds ratio (OR) for each cancer incidence using conditional logistic regression with multiple imputation, adjusted for major modifiable risk factors (smoking, alcohol consumption).

RESULTS

We identified lower risks among higher-SES women for common and overall cancers: e.g., ORs for managers in blue-collar industries were 0.67 (95% confidence interval [CI], 0.46-0.98) for stomach cancer and 0.40 (95% CI, 0.19-0.86) for lung cancer. Higher risks with higher SES were evident for breast cancer: the OR for professionals in service industries was 1.60 (95% CI, 1.29-1.98). With some cancers, homemakers showed a similar trend to subjects with higher SES; however, the magnitude of the OR was weaker than those with higher SES.

CONCLUSIONS

Even after controlling for major modifiable risk factors, socioeconomic inequalities were evident for female cancer incidence in Japan.

Primary Hepatic Lymphoma Complicated by a Hepatic Inflammatory Pseudotumor and Tumor-Forming Pancreatitis

BACKGROUND

Hepatic inflammatory pseudotumor (IPT) is considered to be benign in biological behavior, and its malignant transformation is extremely rare. There has only been one published case of primary hepatic lymphoma complicated by hepatic IPT.

CASE PRESENTATION

A 73-year-old man presented with obstructive jaundice and a pancreatic head mass. Histology of the mass revealed chronic pancreatitis with lymphoid follicle formation, leading to a diagnosis of a suspicion of follicular pancreatitis. After a choledochojejunostomy, a hepatic tumor was detected, and a biopsy revealed lymphoplasmacytic infiltration. Immunohistochemistry confirmed the polyclonal nature of lymphoplasma cells, indicative of an IPT. The hepatic tumor disappeared during follow-up, but the patient exhibited a high fever related to tumor recurrence. A biopsy revealed the co-existence of a diffuse large B-cell lymphoma and an IPT. IgG4-related disease was excluded because storiform fibrosis, obliterative phlebitis, and a significant increase in IgG4-immunoreactive cells were absent in all investigated tissues. The tumor completely disappeared after chemotherapy.

CONCLUSION

Careful observation is necessary in this kind of situation because the presence of a hepatic IPT may represent an increased risk of malignant transformation.

Efficacy of direct-acting antiviral treatment for chronic hepatitis C: A single hospital experience

AIM

To evaluate the efficacy of direct-acting antivirals (DAAs) in Kanto Rosai Hospital.

METHODS

All patients with hepatitis C virus (HCV) who underwent DAA prescription were enrolled in this study. The present study was a single center retrospective analysis using patients infected with HCV genotype 1 or 2. Resistance analysis was performed by using direct sequencing and cycleave PCR in genotype 1 patients treated with interferon (IFN)-free DAA. The primary endpoint was sustained virologic response at 12 wk after therapy (SVR12).

RESULTS

A total of 117 patients participated in the study, including 135 with genotype 1 and 42 with genotype 2. Of the 135 patients with genotype 1, 16 received protease inhibitor + IFN + ribavirin and all achieved SVR. Of the 119 patients who received IFN-free DAA (in different combinations), 102 achieved SVR and 9 failed (7/9 were on daclatasvir/asunaprevir and 2/9 on ledipasvir/sofosbuvir). Efficacy analysis was done only for 43 patients who received daclatasvir/asunaprevir. From this analysis, Y93 resistance-associated substitutions were significantly correlated with SVR.

CONCLUSION

The SVR rate was 98% for genotype 1 and 100% for genotype 2. However, caution is needed for HCV NS5A resistance-associated substitutions that are selected by HCV NS5A inhibitors because cerebrovascular adverse events are induced by some DAA drugs.

The Effect of New Therapeutic and Diagnostic Agents on the Prognosis of Hepatocellular Carcinoma in Japan – An Analysis of Data from the Kanagawa Cancer Registry

Objective: Notable advances in diagnostic imaging modalities and therapeutic agents have contributed to improvement in the prognosis of hepatocellular carcinoma (HCC) over the past decade. However, knowledge concerning their epidemiological contribution remains limited. The present study investigated the effect of emerging diagnostic and therapeutic agents on HCC prognosis, using the largest regional cancer registry in Japan. Methods: Using data from the Kanagawa Cancer Registry, the five-year survival rate of patients with liver cancer was estimated according to the International Statistical Classification of Diseases and Related Health Problems (10th Edition). Result: A total of 40,276 cases of HCC (from 1976 to 2013) were identified. The prognosis markedly improved after the introduction of new devices into the diagnosis and treatment of HCC (p<0.01). The trend of survival rate varied significantly between institutions with many registered patients (high-volume centers) (p<0.01). Conclusion: The five-year survival rate of patients with HCC in Kanagawa has markedly improved in recent years. This improvement in survival may be attributed to the advances in surveillance and intervention for the treatment of HCC.

Hypnotics Use and Falls in Hospital Inpatients Stratified by Age

<p><strong>BACKGROUND:</strong> Little is known about the association between hypnotics use and falls among inpatients in young and middle-aged populations. We aimed to determine whether the use of hypnotics elevated the fall risk in adult inpatients aged 20 and above.</p><p><strong>METHODS:</strong> Patients admitted to the Kanto Rosai Hospital, Kanagawa, Japan, between April 1, 2013 and January 31, 2014 were followed up until discharge. We estimated the incidence rate ratio (IRR) and 95% confidence intervals (CI) of falls for the use of hypnotic drugs with a Poisson regression model, adjusted for sex, age, activities of daily living, and comorbidities.</p><p><strong>RESULTS:</strong> For the 6,949 inpatients whose medical records were examined, the incidence of falls was significantly higher in hypnotics’ users than in non-users. The IRR was 1.52 (95% CI, 1.10-2.11). When stratified by age, the risk of hypnotics use in the patients aged 65 and above was statistically elevated (IRR, 1.48; 95% CI, 1.02-2.13); the risk in the patients aged 25-64 was elevated but not significant (IRR, 1.33; 95% CI, 0.63-2.81).</p><p><strong>CONCLUSION:</strong> Usage of hypnotics elevated fall risk in the older inpatients, though this association was not significant in the young and middle-aged inpatients. Further studies are needed.</p>

A new index of abdominal obesity which effectively predicts risk of colon tumor development in female Japanese

BACKGROUND

A relation between abdominal obesity and colorectal tumor development has been reported repeatedly, and is believed to be more remarkable in man than in women. However, the details vary depending on scientific reports. This may be due at least partly to the selected surface anthropometric index in addition to the influence of gender and ethnic groups. To cope with this, we considered a new index of abdominal obesity and evaluated its risk prediction potential.

MATERIALS AND METHODS

Six hundred ninety five Japanese (262 women and 433 men) who had a colonoscopy were studied. The new index was named as waist circumference to height index (WHI) and was calculated by the formula of waist circumference (cm)/height (m)/height (m). Biochemical and lifestyle factors were investigated preceding the colonoscopy. Statistical analysis was performed using SPSS for Windows.

RESULTS

Increase of WHI was associated with altered metabolism of carbohydrate and lipid in both women and men. WHI was positively related with the development of colon tumor of women, while not with that of men. Logistic regression analysis performed for stratified age groups (45-54, 55-64 and 65-74 years) showed that WHI significantly increased odds ratio to 1.31 (CI 1.05-1.64 p=0.01) in women of 55-65 years. In contrast, in men this index WHI reduced the odds ratio insignificantly, while low density lipoprotein and triglyceride significantly increased the odds ratio to 1.01 (CI 1.00-1.03 p=0.02) in the 55-65 year group and to 1.02 (CI 1.00-1.03 p=0.02) in the 45-55 year group.

CONCLUSIONS

In Japanese the risk factors for colon tumor development are different between women and men. WHI is a simple and efficient predictor of colon tumor risk in Japanese women and may be used to select those who should have colonoscopy.

Two cases of food additive-induced severe liver damage associated with positive results on lymphocyte stimulation test and for antinuclear antibodies

Two cases of severe liver injury and positive result for antinuclear antibodies induced by food additives are reported. The first patient reported long-term intake of Mabo Ramen(®) noodle soup, nutritional supplements, and over-the-counter drugs. Total bilirubin, aspartate aminotransferase, and alanine aminotransferase were 9.6 mg/dL, 1,048, and 1,574 IU/L, respectively. Antinuclear antibody was 80×. The drug-induced lymphocyte stimulation test (DLST) was positive for Mabo Ramen(®) and its additives such as Xanthan gum, guar gum, and Doubanjiang. Histologic examination of a liver biopsy specimen showed lymphocyte infiltration and necrosis. The autoimmune hepatitis score was 3. The second patient reported intake of dietary supplements, including Bimore C(®) and Chokora BB(®). Laboratory tests revealed that total bilirubin was 9.8 mg/dL, aspartate aminotransferase was 1,130 IU/L, and alanine aminotransferase was 1,094 IU/L. Antinuclear antibody was 320×. Co-existing pancreatic damage was confirmed by the findings on abdominal CT and elevation of serum lipase, span-1, and DUPAN-2. DLSTs were positive for both supplements. These two supplements contained additives such as titanium oxide, magnesium stearate, and hydroxypropylcellulose. DLSTs for all three additives were positive. Histologic examination revealed periportal necrosis and lymphocyte infiltration of lobular and portal areas. These two cases demonstrate that repeating DLSTs is useful for identifying causative constituents in foods and supplements.

Neuron-immune interactions in the sensitized thalamus induced by mustard oil application to rat molar pulp

We have reported that mustard oil application to the rat dental pulp induces neuronal activation in the thalamus. To address the mechanisms involved in the thalamic changes, we performed neuronal responsiveness recording, immunohistochemistry, and molecular biological analysis. After mustard oil application, neuronal responsiveness was increased in the mediodorsal nucleus. When MK801 (an N-methyl-D-aspartate receptor antagonist) was applied to the mediodorsal nucleus, the enhanced responsiveness was decreased. N-methyl-D-aspartate receptor 2D, glial fibrillary acidic protein, and antigen-presenting cell-related gene mRNAs in the contralateral thalamus were up-regulated at 10 minutes after mustard oil application, but were down-regulated within 10 minutes after the antagonist application. OX6-expressing microglia and glial fibrillary acidic protein-expressing astrocytes did not increase until 60 minutes after mustard oil application. These results suggested that the thalamic neurons play some roles in regulating the glial cell activation in the mediodorsal nucleus via N-methyl-D-aspartate receptor 2D during pulp inflammation-induced central sensitization.

A CONTRIBUTION TO THE ETIOLOGY AND PATHOLOGY OF RAT-BITE FEVER

Of the two postmortem examinations on rat-bite fever previously reported, the patient of Miura and Toriyama, a woman, aged 32 years, died on the 70th day after the onset of the disease. Anatomically there were no marked changes. Histological examinations were not made. Macroscopically, the following findings are reported: increase of cerebrospinal fluid, hyperemia of the meninges, inflammatory edema of the lungs, cloudy swelling of the liver, etc. The other, Blake's case, was a woman of 67, who died 1 month after the bite of a rat. The anatomical findings were acute ulcerative endocarditis, subacute myocarditis, interstitial hepatitis, glomerular and interstitial nephritis. The suprarenals contained a large amount of perivascular fluid. There were infarcts in the spleen and kidney. In general, the organs were hyperemic; the lung showed hemorrhages and edema, Histologically, Blake found marked degeneration, necrosis, and infiltration in the cardiac muscles, infiltration of polynuclear cells, and increase in the interstices of the liver, also marked polynuclear infiltration of the shrunken kidney.

Clinico-epidemiologic study of the metabolic syndrome and lifestyle factors associated with the risk of colon adenoma and adenocarcinoma

BACKGROUND

The numbers of patients with colorectal cancer and associated deaths have been increasing in Japan, probably due to rapid lifestyle changes. Prevention is clearly important and the present study aimed to clarify risk factors and to promote colon cancer screening.

METHODS

We investigated lifestyle factors, biochemical data, and pathological features of 727 individuals who underwent colonoscopy. Data were subjected to statistical analysis using SPSS software.

RESULTS

Low-grade adenoma was more frequent among the elderly and in men. All of the men and 87.5% of the women with high-grade adenoma or adenocarcinoma were aged≥45 and≥50 years, respectively. In women, a larger waist circumference (=80 cm) increased the odds ratio for colon adenoma or adenocarcinoma (colon tumors) by 1.033 (95% confidence index (CI), 1.001-1.066; p=0.040). Metabolic syndrome significantly increased the odds ratio of colon tumors in men, but not in women. Cigarette smoking, drinking alcohol, and increased physical activity were significant risk factors for colon tumors in men, with odds ratios of 1.001 (95% CI, 1.000-1.002; p=0.001), 1.001 (95% CI, 1.000-1.003; p=0.047), and 1.406 (95% CI 1.038-1.904; p=0.028), respectively.

CONCLUSIONS

Colon tumors have a high prevalence in the elderly. A larger waist circumference in women and metabolic syndrome in both men and women elevate the risk of colon tumors. In addition, smoking, drinking, and excessive physical activity are risk factors for adenoma and adenocarcinoma in men. For early detection of colorectal cancer, men older than 45 years and women older than 50 years with these risk factors are recommended to undergo colonoscopy.

Activation of p38 mitogen-activated protein kinase is required for in vivo brain-derived neurotrophic factor production in the rat hippocampus

Several lines of evidence strongly suggest that brain-derived neurotrophic factor (BDNF) is associated with the formation, storage and recall of memory in the hippocampus and that it is important to maintain a considerable level of hippocampal BDNF in order to keep normal functions. BDNF can be synthesized in an activity-dependent manner. In fact, kainic acid or AMPA enhances BDNF levels in hippocampal granule neurons. However, the mechanisms of BDNF production are largely unclear. Recently, we have found that riluzole, which blocks voltage-gated sodium channels and thereby reduces glutamate release, actually strengthens immunoreactivity of BDNF in hippocampal granule neurons of rats. Therefore, we examined the riluzole-activated signaling pathways for BDNF production. Riluzole increased levels of phospho-p38 mitogen-activated protein kinase (p38 MAPK), as well as BDNF levels. Inhibition of p38 MAPK by SB203580 reduced riluzole effects, while activation of p38 MAPK by anisomycin increased levels of BDNF, suggesting that p38 MAPK can mediate BDNF production. Riluzole-induced elevation of phospho-activating transcription factor-2, a transcription factor downstream of p38 MAPK, was also observed. A blocker of N-type voltage-gated calcium channels reduced the effects of riluzole on BDNF production and p38 MAPK activation. We also examined a possible involvement of the adenosine A1 receptor in BDNF production because riluzole can influence ecto-nucleotide levels. An A1 receptor agonist inhibited riluzole-induced elevation of BDNF levels, whereas an antagonist not only increased levels of BDNF and active p38 MAPK but also augmented riluzole effects. These results indicate that, in the rat hippocampus, there is an in vivo signaling pathway for BDNF synthesis mediated by p38 MAPK, and that N-type voltage-gated calcium channels and/or adenosine A1 receptors contribute to p38 MAPK activation.

Antigen-presenting cells in human radicular granulomas

Substantial numbers of dendritic cells have been detected in radicular granulomas. To test the hypothesis that local antigen presentation from dendritic cells to T-cells is involved critically in immunological responses within radicular granulomas, we compared characteristics of dendritic cells and macrophages by morphological and biological analyses. Under light microscopy, HLA-DR+ and CD68+ cells showed diverse profiles, including dendritic-shaped cells. Transmission electron microscopy revealed that HLA-DR+ dendritic cells, with long cytoplasmic processes and lacking distinct phagosomes, were concentrated in the lymphocyte-rich area. HLA-DR alpha-chain, CD83, and CD86 mRNAs from HLA-DR+ dendritic cells, and CD28 mRNA from CD28+ T-cells were up-regulated in lymphocyte-rich area. Scanning electron microscopy demonstrated that the density of gold particles on dendritic cells was higher than that on HLA-DR+ macrophages. These results suggest that dendritic cells in radicular granulomas are associated with local defense reactions as stronger antigen-presenting cells, as compared with macrophages.

CD30+ large cell transformation of mycosis fungoides after psoralen plus ultraviolet A photochemotherapy

Psoralen plus ultraviolet A (PUVA) photochemotherapy is widely used for the therapy of mycosis fungoides (MF). Clinical progression of MF is often associated with an increase in the size of tumour cells known as transformation. We report two patients with CD30+ large cell transformation that appeared after low-dose PUVA therapy for MF. Clinical data, histopathology, immunohistopathology and T-cell receptor gene rearrangement were studied. Nodules consisted of atypical large cells that expressed CD30. Monoclonal rearrangement of T-cell receptors was observed in one case. Low-dose PUVA therapy may be associated with CD30+ large cell transformation in patients with MF.

Idiopathic acquired generalized anhidrosis due to occlusion of proximal coiled ducts

Idiopathic acquired generalized anhidrosis is a very rare disease of unknown pathogenesis. We report a 25-year-old man with acquired generalized anhidrosis due to occlusion of the coiled ducts. He did not have sweat secretion over the entire surface of the body, including the palms and soles. Sweat-inducing stimuli provoked tingling pain on the skin. Pilocarpine iontophoresis on the forearm did not induce sweat secretion. Neurological examination did not reveal any abnormality in the central or peripheral nervous system. Skin biopsy showed that the coiled ducts were occluded by an amorphous eosinophilic substance. This amorphous eosinophilic substance was positive with periodic acid-Schiff (PAS) staining and was resistant to digestion by diastase. Electron microscopy demonstrated that the coiled ducts were completely occluded by an amorphous substance. The substance occluding the coiled ducts contained fibrous structures. These findings suggested that the acquired generalized anhidrosis in this patient was caused by occlusion of the coiled ducts by a PAS-positive substance probably derived from dark cell granules.

Curative treatment of central hemangioma in the mandible by direct puncture and embolisation with n-butyl-cyanoacrylate (NBCA)

Management of central hemangioma in the mandible is difficult because of the abundant vascular network in this region. One of the most common signs of these patients, especially in the mixed dentition period, is hypermobility of the teeth with spontaneous hemorrhage from the surrounding gingival sulcus. Various therapeutic modalities have been considered, but surgery is the most frequently used. In cases of a large extensive lesion, however, intralesional injections of sclerosing agents have often been successful. A case of central hemangioma of the mandible with arteriovenous malformations in a 10-year-old girl is reported. She was treated with direct injection of an embolic material, n-butyl-cyanoacrylate, which brought satisfactory results. Preoperative embolisation of feeder vessels with Gelfoam and Avitene soaked in thrombin together with this direct injection is a safe treatment modality that is as effective as surgery.

An enzymatic cycling method for the measurement of myo-inositol in biological samples

INTRODUCTION

A sensitive and simple enzymatic cycling method is described for the quantitation of myo-inositol in biological samples.

METHODS

The method involves the use of a sensitive and simple enzymatic cycling method is described for the quantitation of myo-inositol in biological samples. The method involves use of thio-NAD(+), NADH and thermostable myo-inositol dehydrogenase (IDH; EC. 1.1.1.18) and measurement of the increase in absorbance at 405 nm of thio-NADH at 37 degrees C.

RESULTS

The calibration curve for myo-inositol was linear (r=1.00) between 10 and 400 micromol/l. Analytical recoveries of exogenous myo-inositol added to serum and urine were 100-105% and 98-103%, respectively. Within-run and between-run coefficient of variation (CV) were 0.6-2.1% and 1.1-3.0%, respectively. This method was free from interference by hemoglobin, bilirubin, ascorbate, chyle, various sugars, sugar alcohol and myo-inositol phosphates. With the use of myo-inositol as a standard solution, the serum myo-inositol concentration (mean+/-SD) was significantly greater in patients with diabetes mellitus (DM) without nephropathy (73.0+/-13.8 micromol/l, n=7) than in healthy individuals without DM (61.0+/-12.4 micromol/l, n=20). The urinary myo-inositol concentration was also significantly greater in patients with DM without nephropathy (793.3+/-870.3 micromol/l, n=7) than in healthy individuals without DM (76.0+/-63.0 micromol/l, n=13).

CONCLUSIONS

This new method is simple, sensitive and enables quantitative analysis of myo-inositol.

Terminal deoxynucleotidyltransferase is negatively regulated by direct interaction with proliferating cell nuclear antigen

BACKGROUND

The repertoires of Ig and TcR are generated by a combinatorial rearrangement of variable (V), diversity (D), and joining (J) segments (V(D)J recombination) in B- and T-cells. Terminal deoxynucleotidyltransferase (TdT) adds extra nucleotides (N nucleotides) at the junctions of the gene segments to enhance the Ig and TcR genes diversity. Using an anti-TdT antibody column, TdT has been purified as a member of a megadalton protein complex from rat thymus. The N region would be synthesized with the large protein complex.

RESULTS

The cDNAs for proliferating cell nuclear antigen (PCNA) were isolated by yeast two-hybrid screening as the gene products which directly interacted with TdT. The interaction between PCNA and TdT was confirmed by co-immunoprecipitation, both in vitro and in vivo. TdT binds directly to a PCNA trimer, as shown by gel filtration. TdT interacts with PCNA in its DNA polymerization domain (DPD), but not in its BRCA-1 C-terminal (BRCT) domain. TdT activity was reduced to 17% of the maximum value by TdT/PCNA complex formation.

CONCLUSION

TdT interacts directly with PCNA through its DPD. A functional consequence of this interaction is the negative regulation of TdT activity. These findings suggest that TdT catalyses the addition of N nucleotides under the negative control of PCNA during V(D)J recombination.

Terminal deoxynucleotidyltransferase directly interacts with a novel nuclear protein that is homologous to p65

BACKGROUND

Terminal deoxynucleotidyltransferase (TdT) is a DNA polymerase that enhances Ig and TcR gene diversity in the N region in B- and T-cells. TdT is found as a member of a large protein complex in the lysate of the thymocytes. To elucidate the molecular mechanism of the synthesis of the N region, we first attempted to isolate the genes with products that are interacting directly with TdT.

RESULTS

Using a yeast two-hybrid system, we isolated a cDNA clone encoding a novel nuclear protein that interacts with TdT. This protein was designated as TdT interacting factor 1 (TdIF1). TdIF1 has a high degree of homology to the transcription factor p65, which belongs to the nuclear receptor superfamily. TdIF1 contains HMG-I and HMG-Y DNA binding domains (AT-hooks) and can bind to single- and double-stranded DNA. TdT and TdIF1 were co-eluted at position 232 kDa by gel filtration of MOLT4 lysate. TdIF1 can enhance TdT activity fourfold in vitro assay system using oligo(dT)16 as primers.

CONCLUSIONS

TdIF1 binds directly to TdT, both in vitro and in vivo. TdIF1 and TdT exist as the members of a 232 kDa protein complex. TdIF1 can enhance TdT activity maximum fourfold in vitro assay system, suggesting that it positively regulates the synthesis of the N region during V(D)J recombination in the Ig and TcR genes.

Structure-sweetness relationship in thaumatin: importance of lysine residues

To clarify the structural basis for the sweetness of thaumatin I, lysine-modified derivatives and carboxyl-group-modified derivatives were prepared by chemical modification followed by chromatographic purification. The sweetness of derivatives was evaluated by sensory analysis. Phosphopyridoxylation of lysine residues Lys78, Lys97, Lys106, Lys137 and Lys187 markedly reduced sweetness. The intensity of sweetness was returned to that of native thaumatin by dephosphorylation of these phosphopyridoxylated lysine residues except Lys106. Pyridoxamine modification of the carboxyl group of Asp21, Glu42, Asp60, Asp129 or Ala207 (C-terminal) did not markedly change sweetness. Analysis by far-UV circular dichroism spectroscopy indicated that the secondary structure of all derivatives remained unchanged, suggesting that the loss of sweetness was not a result of major disruption in protein structure. The five lysine residues, modification of which affected sweetness, are separate and spread over a broad surface region on one side of the thaumatin I molecule. These lysine residues exist in thaumatin, but not in non-sweet thaumatin-like proteins, suggesting that these lysine residues are required for sweetness. These lysine residues may play an important role in sweetness through a multipoint interaction with a putative thaumatin receptor.

Sweetness of sweet protein thaumatin is more thermoresistant under acid conditions than under neutral or alkaline conditions

Thermostability of thaumatin and mechanisms of thermoinactivation were examined at 80 degrees C in the pH range from 2 to 10. The sweetness of thaumatin disappeared on heating at pH above 7 for 15 min, but the sweetness remained even after heating at 80 degrees C for 4 h at pH 2. This indicated that the sweet protein thaumatin is more thermoresistant under acid conditions than under neutral or alkaline conditions. Prolonged heating of thaumatin under acid conditions slowly reduced sweetness, and produced a heterogeneous population of molecules, all of which was soluble and monomeric. The resultant molecules were clearly distinct from those generated by heating at pH above 7. Hydrolysis of peptide bonds and other irreversible chemical reactions slowly took place in the molecule heated under acid conditions, and it would be, in part, a cause of thermoinactivation of thaumatin under acid conditions. The thermostability of thaumatin and the mechanism of thermoinactivation were largely dependent on pH.