Generation-Dependent Retention Rates and Reasons for Discontinuation of Molecular Targeted Therapies in Patients with Rheumatoid Arthritis: From FIRST Registry

INTRODUCTION

The study aimed to optimize medical care for elderly patients with rheumatoid arthritis (RA) by examining the 3-year continuation rate of different molecular targeted therapies across age groups in Japan, which has a significant elderly population.

METHODS

The study included patients with RA who started molecular targeted therapies between 2013 and 2019 and divided them into three age groups. The primary outcome was to assess the 3-year continuation rate of each drug and analyze reasons for treatment discontinuation using inverse probability of treatment weighting.

RESULTS

Among 2292 patients analyzed, tumor necrosis factor (TNF) inhibitors were most commonly used in those younger than 65 years of age (43.5%), while Janus kinase (JAK) inhibitors were also utilized (17.1%). In contrast, JAK inhibitors were less frequently used in patients aged 75 years and older (7.8%), with cytotoxic T lymphocyte antigen 4 immunoglobulin fusion proteins (CTLA4-Ig) being the most common (39.2%). JAK inhibitors and anti-interleukin-6 receptor (IL-6R) antibodies had higher continuation rates than other drugs in patients under 65 years (p < 0.001). For those aged 65-74 years, JAK inhibitors and CTLA4-Ig had higher continuation rates (p < 0.001), while among those aged 75 years and older, CTLA4-Ig and IL-6R antibodies had higher continuation rates (p < 0.001). Inadequate efficacy was the main reason for discontinuation in all age groups, while infection leading to discontinuation increased with age.

CONCLUSIONS

The study highlights the need to consider different age groups separately in elderly RA care. Among patients aged 75 years and older, abatacept and anti-IL-6R antibodies showed the highest continuation rates, suggesting their potential suitability and efficacy for this specific age cohort.

Biological/targeted synthetic DMARDs do not arrest bone loss in patients with rheumatoid arthritis: a multicenter prospective observational study

OBJECTIVE

To elucidate the differential effects of biological/target synthesized DMARDs (b/tsDMARDs) on bone metabolism in patients with rheumatoid arthritis (RA) in a real-world cohort.

METHODS

This was a multicentre prospective observational study of RA patients enrolled at the time of 1st b/tsDMARDs administration. Bone mineral density (BMD) and bone turnover markers (BTMs) were measured during the 52-week observation. The study was designed to enrol all eligible RA patients. The end-points were differences in changes in BMD according to b/tsDMARD type, and the correlation between BMD and BTMs.

RESULTS

A total of 1,164 patients were enrolled in this study. b/tsDMARDs improved RA disease activity from mean CDAI 25.5 at baseline to 4.5 at week 26. Patients not receiving anti-osteoporotic agents (anti-OP) at baseline with no history of fracture experienced a significant decrease in both femoral neck (F: mean 0.666-0.655 g/cm3) and radial (R: 0.518-0.514) BMD at week 26. Despite maintaining low CDAI levels during weeks 26-52 (5.3-4.4), there was a continued decline in BMD (F: 0.653, R: 0.509. Weeks 52). None of b/tsDMARDs type preserved BMD. Conversely, patients receiving anti-OP at baseline maintained stable BMD throughout the study (Weeks 0/26/52. F: 0.551/0.551/0.555, R: 0.415/0.416/0.415). Although BTMs were changed by b/tsDMARDs, the changes were unrelated to those in BMD.

CONCLUSION

Our study suggested the progression of osteoporosis in RA patients during b/tsDMARDs treatment without anti-OP. BTMs may not reflect BMD change. Regular monitoring of BMD in RA should be considered for early management of osteoporosis.

TGF-β3 in differentiation and function of Tph-like cells and its relevance to disease activity in patients with systemic lupus erythematosus

OBJECTIVES

T peripheral helper (Tph) cells have major roles in pathological processes in SLE. We sought to clarify the mechanisms of Tph cell differentiation and their relevance to clinical features in patients with SLE.

METHOD

Phenotypes and functions of Tph cell-related markers in human CD4+ T cells purified from volunteers or patients were analysed using flow cytometry and quantitative PCR. Renal biopsy specimens from patients with LN were probed by multicolour immunofluorescence staining.

RESULTS

Among multiple cytokines, transforming growth factor (TGF)-β3 characteristically induced programmed cell death protein 1 (PD-1)hi musculoaponeurotic fibrosarcoma (MAF)+, IL-21+IL-10+ Tph-like cells with a marked upregulation of related genes including PDCD-1, MAF, SOX4 and CXCL13. The induction of Tph-like cells by TGF-β3 was suppressed by the neutralization of TGF-β type II receptor (TGF-βR2). TGF-β3-induced Tph-like cells efficiently promoted the differentiation of class-switch memory B cells into plasmocytes, resulting in enhanced antibody production. The proportion of Tph cells in the peripheral blood was significantly increased in patients with SLE than in healthy volunteers in concordance with disease activity and severity of organ manifestations such as LN. TGF-β3 was strongly expressed on macrophages, which was associated with the accumulation of CD4+ C-X-C chemokine receptor (CXCR5)-PD-1+ Tph cells, in the renal tissue of patients with active LN.

CONCLUSION

The induction of Tph-like cells by TGF-β3 mainly produced from tissue macrophages plays a pivotal role in the pathological processes of active LN by enhancing B-cell differentiation in patients with SLE.

Nailfold microvascular abnormalities are associated with a higher prevalence of pulmonary arterial hypertension in patients with MCTD

OBJECTIVE

MCTD manifests with microvasculopathy and overlapping clinical features of SLE, SSc and idiopathic inflammatory myopathies (IIM). The aim of this study was to investigate the clinical significance of microvasculopathy in patients with MCTD using nailfold videocapillaroscopy (NVC).

METHODS

Fifty patients with newly diagnosed and untreated MCTD were enrolled in this multicentre, prospective and observational study. Clinical features and NVC findings were assessed at baseline and after 1 year post-intervention, along with disease controls [SLE (n = 40), SSc (n = 70) and IIM (n = 50)].

RESULTS

All MCTD patients presented Raynaud's phenomenon and were positive for anti-U1 RNP antibodies, and 22.0% (11/50) had pulmonary arterial hypertension (PAH). The prevalence of NVC scleroderma patterns in MCTD was 38.0%, which was lower than SSc (88.6%) but higher than SLE (10.0%). In addition, when we divided MCTD patients into two groups by presence or absence of NVC scleroderma patterns, we found a higher prevalence of PAH in patients with NVC scleroderma patterns. Namely, NVC scleroderma patterns were observed in all MCTD patients with PAH, and in 21.0% of those without PAH. After intensive immunosuppressive therapy, NVC scleroderma patterns disappeared in half of the MCTD patients but were not changed in SSc patients.

CONCLUSIONS

MCTD differed from SLE, SSc and IIM in terms of the prevalence and responsiveness of NVC scleroderma patterns to immunosuppressive therapy. Detection of nailfold microvascular abnormalities in MCTD could contribute to predicting PAH and help us to understand further aspects of the pathogenesis of MCTD.

Eosinophilic granulomatosis with polyangiitis exhibits T cell activation and IgG4 immune response in the tissue; comparison with IgG4-related disease

Objective

To study the pathophysiological differences of EGPA and IgG₄-related disease (RD) by clarifying their clinical, pathological and immunological features.

Methods

Clinical and pathological findings were compared in patients with EGPA and IgG₄-RD. Peripheral blood mononuclear cells were used for comprehensive flow cytometric analysis.

Results

An elevation of the IgG4 level was found in all EGPA cases, with the accompanying pathological findings of lymphocytic infiltration and fibrosis observed in 30.8% patients, and the elevation of IgG₄/IgG ratio in 61.5% patients. However, actual IgG₄ levels, as well as the degree of the infiltration of IgG₄-positive plasma cells, were still higher in patients with IgG₄-RD than patients with EGPA. Examination by ACR/EULAR classification criteria showed only 13.6% of the EGPA patients met entry criteria, while all of them met the exclusion criteria. In regard to the immunophenotyping, EGPA patients had increases in activated CD4 and CD8 T cells compared with the healthy controls. However, no such similar changes occurred in IgG₄-RD patients. On the other hand, both the EGPA and IgG₄-RD patient groups had correlated increased plasmablasts and Tfh. These results indicate the presence of two axes: namely, the activation of T cells and that of B cells. Both axes are present in EGPA, but the T cell activation axis was not observed in IgG₄-RD.

Conclusions

The elevation of serum IgG₄ as well as pathological IgG₄ infiltration are not specific. Meanwhile, EGPA and IgG4-RD differ in immunological phenotypes, indicating the possible importance of the predominant activation of T cells in the development of vasculitis.

Remission of Granulomatosis with Polyangiitis Only After Resection of a Pulmonary Nodule

Granulomatosis with polyangiitis (GPA) is characterized by necrotizing granulomatous lesions and is classified as ANCA-associated vasculitis (AAV). We herein report a case of GPA that was remitted by resection of a pulmonary lesion without immunosuppressive therapy. We detected activated neutrophils and neutrophil extracellular traps (NET) formation in resected lung tissue by immunofluorescence. Activated neutrophils and NETs might be involved in the pathophysiology of AAV and induce the vicious cycle of ANCAs and NETs. In cases of GPA with no other severe lesions, the reevaluation of the disease activity after diagnostic resection is crucial for considering the need for immunosuppressive therapy.

mTOR activation in CD8+ cells contributes to disease activity of rheumatoid arthritis and increases therapeutic response to TNF inhibitors

OBJECTIVE

This study aimed to understand the role of mTOR in CD8+ cells in the pathogenicity of rheumatoid arthritis (RA) and the changes after treatment with biologic drugs.

METHODS

Peripheral blood mononuclear cells (PBMCs) were isolated from 17 healthy controls and 86 patients with RA. Phosphorylation of mTOR (p-mTOR) and its clinical relevance were evaluated. The role of mTOR in CD8+ cells was also examined in vitro.

RESULTS

Patients with RA who had a moderate or high disease activity, were biologic-naïve, and were refractory to MTX were enrolled in this study. The p-mTOR levels in CD8+ cells were higher in patients with RA than in healthy controls, and they positively correlated with the disease activity in such patients. However, after one year of treatment with TNF inhibitors, the p-mTOR levels in CD8+ cells were suppressed and showed a positive correlation with the treatment response, which was not observed in the abatacept-treatment group. In vitro stimulation of CD8+ cells with anti-CD3 and anti-CD28 antibodies induced mTOR phosphorylation and increased the production of granzyme B, GNLY, TNF-α, and IFN-γ but decreased the production of granzyme K. However, on treatment with TNF inhibitors, p-mTOR levels in CD8+ cells and granzyme B production decreased, while granzyme K production increased. The production of GNLY and IFN-γ was not affected by the TNF inhibitors.

CONCLUSION

These results suggested that mTOR activation in CD8+ cells may be a novel evaluation marker for RA disease activity and a predictive marker of therapeutic response to TNF inhibitors.

An enhanced mitochondrial function through glutamine metabolism in plasmablast differentiation in systemic lupus erythematosus

OBJECTIVE

To evaluate the dysfunction of B cell metabolism and its involvement in SLE pathology.

METHODS

We assessed the expression of metabolic markers of B cells in the peripheral blood of healthy controls (HCs) and SLE patients by using flow cytometry. In vitro, peripheral B cells were isolated from HCs and SLE patients to investigate the metabolic regulation mechanisms involved in their differentiation.

RESULTS

The expression level of DiOc6 (mitochondrial membrane hyperpolarization) was higher in B cells from SLE patients than in HCs, and correlated to the percentage of plasmablasts in CD19+ cells and with SLEDAI, a disease activity score. Stimulation of CD19+ cells with the Toll-like receptor 9 (TLR9) ligand CpG and IFN-α enhanced glycolysis, oxidative phosphorylation (OXPHOS), DiOc6 expression, and plasmablast differentiation in vitro. In the absence of glutamine, both glycolysis and OXPHOS were reduced, and plasmablast differentiation was suppressed, whereas there was no change in the absence of glucose. As glutamine is an important nutrient for protein synthesis, we further investigated the effect of the glutaminase inhibitor BPTES, which inhibits glutamine degradation, on metabolic regulation. BPTES reduced DiOc6 expression, OXPHOS, reactive oxygen species (ROS) production, ATP production, plasmablast differentiation without affecting glycolysis. Metformin inhibited CpG- and IFN-α-induced glutamine uptake, mitochondrial functions and suppressed plasmablast differentiation.

CONCLUSIONS

Mitochondrial dysfunction in B cells is associated with plasmablast differentiation and disease activity in SLE. Enhanced mitochondrial functions mediated by glutamine metabolism are important for plasmablast differentiation, which may be a potential therapeutic target for SLE.

Pathological role of activated mTOR in CXCR3+ memory B cells of rheumatoid arthritis

OBJECTIVES

B cells play an important pathological role in rheumatoid arthritis (RA). In this study, we investigated the role of metabolic regulator mTOR in B cells and its relevance to the pathology of RA.

METHODS

Peripheral blood mononuclear cells were isolated from 31 normal subjects and 86 RA patients and the gated B cells were assessed for mTOR phosphorylation and chemokine receptor expression. In vitro studies on peripheral blood B cells isolated from the control and RA patients investigated the molecular mechanisms.

RESULTS

Higher concentrations of CXCL10 (CXCR3 ligands) and lower percentages of CXCR3+ memory B cells were present in the peripheral blood of RA patients relative to the control. RA patients with high CXCL10 concentrations had smaller percentage of CXCR3+ memory B cells and high disease activity. One-year treatment with TNF inhibitors increased the percentage of CXCR3+ memory B cells and reduced serum CXCL10 concentrations. mTOR phosphorylation in B cells was further enhanced in RA patients, compared to the control, and was selectively enhanced in CXCR3+ memory B cells. mTOR phosphorylation in CXCR3+ memory B cells correlated with disease activity. In vitro, mTOR phosphorylation in B cells enhanced IL-6 production and increased RANKL expression.

CONCLUSION

mTOR activation in CXCR3+ memory B cells of RA patients is associated with disease activity, mediated through IL-6 production and RANKL expression. The obtained results also suggest that TNF inhibitors mediate an impact on the association between CXCL10 and mTOR activated CXCR3+ memory B cells.

A case of eosinophilic granulomatosis with polyangiitis as a mimicker of IgG4-related disease

A 62-year-old woman was admitted to our hospital because of fever, renal dysfunction, eosinophilia, and the presence of MPO-ANCA. Based on the renal pathological examination which showed granuloma lesion with eosinophils and crescentic glomerulonephritis, eosinophilic granulomatosis with polyangiitis (EGPA) was diagnosed. On the other hand, laboratory examination showed elevated serum IgG4 levels and renal pathological examination showed marked lymphoplasmacytic infiltration and fibrosis surrounding nest "Bird's eye pattern," which were characteristic of IgG4-related kidney disease (IgG4-RKD). Because there are cases when EGPA has clinical features of IgG4-RKD, we should be careful about diagnoses of IgG4-RKD in patients with EGPA.

A case of bone destruction caused by chronic non-bacterial osteomyelitis (CNO) successfully repaired with a tumour necrosis factor-α (TNF-α) inhibitor, adalimumab

Chronic Non-bacterial Osteomyelitis (CNO) is an autoinflammatory bone disorder that causes non-bacterial and non-neoplastic osteomyelitis. CNO appeared to the long bone, clavicle, pelvis, and spine on children commonly. This time, we report a case with osteomyelitis of the mandible for the adult-onset. A 25-year-old woman presented pustulosis palmaris/pustular psoriasis after the extraction of the lower right tooth 1 year before hospitalisation. She felt pain and swelling of the right jaw and an antibiotic, NSAIDs, and glucocorticoids were ineffective. The cortical osteotomy of right mandibular bone was carried out 2 months before hospitalisation, but the symptom was not improved and she was admitted to our hospital. For pustular psoriasis with CNO, we treated her with adalimumab and the pain and swelling in her right jaw disappeared immediately. One and two years after the treatment, osteolytic and sclerotic bone lesion and osteomyelitis were improved in both Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). An anti-TNF-α antibody may be an effective therapy for CNO resistant to conventional treatment.

AN INTERNATIONAL COOPERATION BY USING AN ALL-ENCOMPASSING PASSIVE RADON MONITOR

The recently developed radon film-badge makes it possible to measure radon indoors, in soil, in water and/or in aqueous media (e.g. mud). As a result of its wide response linearity, this monitor has been successfully used to measure radon in-water with concentrations from 10 to ~10 000 Bq/L. By exploiting the unique characteristics of this badge, a mini-survey has been carried out by Health Canada in which radon in water was measured from 12 private wells, as well as in tap water originating from the Ottawa River. Due to the widespread interest of different laboratories in using these passive monitors, laboratories were provided with plastic films to construct their own badges by using in-house CR-39 detectors. Monitors were then irradiated by a known radon concentration at the National Institute of Radiation Metrology (ENEA)'s radon chamber and sent back to each laboratory for processing and counting. Even though these laboratories have been using different etching- and counting-procedures, the film-badge responses varied only within ~12%.

Modified repeated intracyclic clomiphene citrate therapy after conventional clomiphene therapy

PURPOSE OF INVESTIGATION

We compared modified repeated intracyclic clomiphene citrate therapy (RICCT) to gonadotropin therapy to determine whether this modified regimen was an effective alternative after conventional clomiphene therapy.

METHODS

Patients with ovulation disorder received treatment with modified RICCT and gonadotropin, and ovulation, pregnancy, total drug cost, and adverse effects were compared.

RESULTS

Among a total of 16 patients, 14 successfully ovulated after modified RICCT and 11 ovulated after gonadotropin therapy; two did not respond to either therapy. The total drug cost was US $36.3+/-17.9 for modified RICCT, which was significantly lower than the cost of gonadotropin therapy, US $213.9+/-100.4 (p=0.0001).

CONCLUSIONS

Because modified RICCT does not require the discomfort of daily injection and has excellent ovulation-inducing effects, it is a useful treatment after conventional clomiphene therapy.

Chromosome aberrations in peripheral blood lymphocytes of individuals living in high background radiation areas of Ramsar, Iran

In order to investigate the biological effects of exposure to low-dose radiation and to assess the dose-effect relationship in residents of high background radiation areas (HBRAs) of Ramsar, cytogenetic investigation of unstable-type aberrations was performed in 15 healthy elderly women in a HBRA of Ramsar, Talesh mahalle, and in 10 elderly women living in a nearby control area with normal background radiation. In total, 77,714 cells were analyzed; 48,819 cells in HBRA residents and 28,895 cells in controls. On average, 3,108 cells per subject were analyzed (range 1,475-5,007 cells). Significant differences were found in the frequency of dicentric plus centric rings in 100 cells (0.207 ± 0.103 vs. 0.047 ± 0.027, p < 0.0005), total chromosome-type aberrations per 100 cells (0.86 ± 0.44 vs. 0.23 ± 0.17, p < 0.0005), and chromatid-type aberrations per 100 cells (3.31 ± 2.01 vs. 1.66 ± 0.63, p = 0.01) by the Mann-Whitney U test between HBRA and the control, respectively. Using chromosomal aberrations as the main endpoint to assess the dose-effect relationship in residents of HBRAs in Ramsar, no positive correlation was found between the frequency of dicentric plus centric ring aberrations and the cumulative dose of the inhabitants estimated by direct individual dosimetry; however, obvious trends of increase with age appeared in the control group. Based on these results, individuals residing in HBRAs of Ramsar have an increased frequency of detectable abnormalities in unstable aberrations.

Chemically induced premature chromosome condensation in short-term cultured human peripheral lymphocytes: applications to biodosimetry

We describe here the chemical induction of premature condensed chromosomes in human peripheral lymphocytes after culture for 6 h. Many have attempted this induction without culture or with short-term culture, because this technique permits prompt cytogenetic biodosimetry of radiation accidents. Lymphocytes were separated from blood, incubated in the presence of phytohemagglutinin, ATP, and p34(cdc2)/cyclin B kinase, then treated with calyculin A during the last hour. The culture medium was supplemented with a lower concentration of fetal calf serum than conventionally used to minimize its possible interference with the effects of these drugs. We obtained, rarely, a suitable morphology of premature chromosome condensation in short-term cultured lymphocytes for conventional chromosome aberration analysis.

Investigation of new cytogenetic biomarkers specific to high-LET radiation usingin vivoandin vitroexposed human lymphocytes

PURPOSE

To find detectable cytogenetic biomarkers that can offer information about the radiation quality of in vivo exposure retrospectively.

MATERIALS AND METHODS

Chromosome-type aberrations of peripheral lymphocytes of uterine cancer patients that received internal gamma- and external X-ray therapy or carbon beam therapy and of victims severely exposed to neutrons and gamma-rays in a criticality accident that occurred in Tokai-mura, Japan were analysed. Data obtained from in vitro irradiation experiments using 60Co gamma-rays and 10 MeV neutrons were compared with the in vivo exposure data.

RESULTS

The ratio of acentric rings to dicentric chromosomes (termed RaD ratio) and that of excess fragments to dicentrics (termed EfD ratio) showed significant (p < 0.05) differences between the two groups of cancer patients, and these ratios for accidental victims were in between the values of the two groups of cancer patients. The in vitro studies using doses equivalent to 1 - 3 Gy of gamma-rays have confirmed that the EfD ratios were increased with the high LET (linear energy transfer) and RaD ratios decreased.

CONCLUSION

The present data show that the RaD and EfD ratios can be used as cytogenetic biomarkers of exposure to high-LET radiation at least within a few years of exposure.

Sister chromatid exchanges in ring chromosomes following X‐irradiation of human lymphocytes

PURPOSE

To examine whether X-rays induce sister chromatid exchanges (SCE).

MATERIALS AND METHODS

Peripheral lymphocytes irradiated in vitro or in vivo were cultured and treated with okadaic acid to generate premature chromosome condensation (PCC). When identical spreads were analysed using conventional Giemsa staining and pan-centromeric fluorescence in situ hybridization painting, ring chromosomes were observed.

RESULTS

In PCC preparations, cells in the late G(2) phase and late M phase were observed. In late M phase cells, 17-20% of ring chromosomes lacked one chromatid (single-chromatid ring), irrespective of dose. Both the distribution patterns of centromeres in rings and intercentromere distances in dicentric rings indicate that a considerable number of single-chromatid rings might be formed by SCE occurring in a chromosome-type ring, thereby joining strands of two rings, followed by a transformation into one ring. These single-chromatid rings were less stable in vivo than chromosome-type rings.

CONCLUSION

Single-chromatid rings visualized clearly using PCC techniques indicate SCE in the respective rings. Contrary to the conventional SCE-detecting technique, this approach does not require the use of bromodeoxyuridine, which itself leads to SCE. Some of the observed SCE might be secondary products resulting from the repair of radiation-induced DNA damage, while others may be spontaneous.

Repeated intracyclic clomiphene citrate therapy can be more effective than hMG therapy in inducing ovulation: case report

PURPOSE OF INVESTIGATION

When clomiphene citrate is ineffective in the treatment of anovulation, hMG administration is typically selected. However, high-dose hMG therapy is associated with a variety of adverse events. We describe the use of a modified clomiphene citrate regimen that was successful in increasing the effectiveness of ovulation induction.

CASE REPORT

A patient who did not initially respond to clomiphene citrate therapy required a total dose of 2400 IU hMG to prodeuce mature follicles. However, because of the physical and emotional burdens on the patient, and the possibility of multiple pregnancy and ovarian hyperstimulation syndrome, re-treatment with clomiphene citrate was then selected. Two courses of clomiphene citrate administered at a fixed interval during the same cycle safely induced ovulation. After initial induction of ovulation, her ovulatory failure improved and natural ovulation occurred.

CONCLUSIONS

Repeated intracycle clomiphene cirate therapy may be more effective than hMG therapy in inducing ovulation in some patients.

Removal of endocrine disrupting compounds during conventional wastewater treatment

There is evidence that aquatic organisms downstream of some sewage treatment works show endocrine disruption as a result of exposure to substances in the effluent. As a result, the Environment Agency of England and Wales, in collaboration with the UK Government and the water industry, has started an intensive programme to determine the fate and behaviour of endocrine disrupting compounds in sewage treatment works. Sampling sites for the endocrine disruption demonstration programme are located throughout England and Wales. This paper presents data from Nuneaton sewage treatment works (Warwickshire, England), a modem nitrifying activated sludge plant serving an equivalent population of 98,000 and one of the selected sites for the demonstration programme. Results for the 24-hour survey carried out in June 2006 in which manual grab samples were taken hourly show excellent removal of estrone, estradiol, nonyl-phenol and the nonylphenolethoxylates (3-5 EO units) at 97, 99, 94 and 98% respectively. They also show excellent removal (99%) of estrogenicity, measured by the YES bioassay. However the removal of ethynylestradiol was poor at only 3%. In November 2006, a further survey was carried out comprising grab samples taken at 4-hourly intervals across a continuous 7-day period. This monitoring confirmed the good removal of estrone and estradiol, at 97.8% and 96.3% respectively as well as an excellent reduction in estrogenicity (98.3%), but again showed poor removal of ethynylestradiol of 5.6%. There was evidence of a diurnal pattern for estrone and estradiol concentrations and to a lesser extent for ethynylestradiol in samples of crude sewage with works returns. Peak concentrations tended to occur at around midday.

Chemically induced premature chromosome condensation in human fibroblast cell lines: fundamental study for applications to the biodosimetry of local exposure

The premature chromosome condensation (PCC) of human peripheral lymphocytes treated with inhibitors of protein phosphatase has been demonstrated to be an excellent tool for the estimation of high-dose whole-body exposure. To develop a new biodosimetry for local exposure, the cytogenetical reaction of human fibroblast lines to PCC inducers was examined and compared with that of lymphocytes. The efficiency of the induction by calyculin A was greater than that by okadaic acid in both cell types. Calyculin A induced PCC in 5-Gy-irradiated and unirradiated samples at almost the same frequency in the lymphocytes, whereas the efficacy was considerably lower in irradiated fibroblasts than in unirradiated ones. Calcium ionophore enhanced the induction of PCC in irradiated fibroblasts, although PCC frequencies were still much lower than those in the lymphocytes. The frequency of ring chromosomes observed in 2- and 5-Gy-irradiated fibroblasts was too low to be used as a marker for cytogenetic dosimetry, and that of excess fragments, scored as the observed chromosome number minus 46, might be substituted. The frequency of excess fragments for 2-, 5-, and 10-Gy-irradiated fibroblasts was less than 0.75, about 1 and a few per cell, respectively, although these values changed with the culture period. The prospects and limitations of the application of PCC techniques to fibroblasts are discussed.

Dynamic analysis of chromosome aberrations in three victims of the Tokai-mura criticality accident

PURPOSE

To investigate the dynamics of chromosome aberrations in the blood cells of three workers severely exposed to neutrons and gamma-rays in a criticality accident that occurred in Tokai-mura, Japan, in 1999.

MATERIALS AND METHODS

The change with time of the frequency of' chromosome aberrations in the three patients was examined using a new analysis to score drug-induced prematurely condensed ring chromosomes (PCC-R) and a conventional meta-phase analysis.

RESULTS

The frequencies and cellular distributions of PCC-R, dicentrics and rings did not change significantly among the samples obtained at 9-48h after the accident while the first depletion of lymphocytes occurred. The distributions of these aberrations in the cells of two patients showed a slight overdispersion compared with a Poisson distribution reflecting neutron and non-uniform exposures. The dose response curve of rings paralleled that of dicentrics, but not PCC-R. The half-lives of PCC-R (8.5 months) and of rings (8.7 months) were shorter than that of dicentrics (13.5 months).

CONCLUSIONS

In the three patients of the Tokai-mura accident, lymphocytes in the circulating and extravascular pools had reached equilibrium at 9h, and highly damaged lymphocytes did not selectively move away from the circulatory system during the first rapid depletion of lymphocytes after exposure. Data on the in vivo half-life of PCC-R as well as dicentrics and rings obtained in the present study may be useful for retrospective dosimetry.

Cytogenetical dose estimation for 3 severely exposed patients in the JCO criticality accident in Tokai-mura

A dose estimation by chromosome analysis was performed on the 3 severely exposed patients in the Tokai-mura criticality accident. Drastically reduced lymphocyte counts suggested that the whole-body dose of radiation which they had been exposed to was unprecedentedly high. Because the number of lymphocytes in the white blood cells in two patients was very low, we could not culture and harvest cells by the conventional method. To collect the number of lymphocytes necessary for chromosome preparation, we processed blood samples by a modified method, called the high-yield chromosome preparation method. With this technique, we could culture and harvest cells, and then make air-dried chromosome slides. We applied a new dose-estimation method involving an artificially induced prematurely condensed ring chromosome, the PCC-ring method, to estimate an unusually high dose with a short time. The estimated doses by the PCC-ring method were in fairly good accordance with those by the conventional dicentric and ring chromosome (Dic+R) method. The biologically estimated dose was comparable with that estimated by a physical method. As far as we know, the estimated dose of the most severely exposed patient in the present study is the highest recorded among that chromosome analyses have been able to estimate in humans.

Improvement of accuracy of chromosome aberration analysis for biological radiation dosimetry

The frequency of chromosome aberrations in circulating lymphocytes is accepted as being the most reliable indicator of the absorbed dose of radiation. Researches done to improve the accuracy of cytogenetic analysis are described in this review. These include investigations of in vitro factors that affect the yield of radiation-induced aberrations and of in vivo factors that affect the chromosomal radiosensitivity of individuals. Improved chromosome-painting methods for accurate judgment of dicentrics and translocations are introduced. The practicality of these advanced cytogenetic techniques is shown by examinations of individuals exposed in the radiation accident at Tokaimura in 1999.

Effect of estradiol on radiation-induced chromosome aberrations in human lymphocytes

As a part of studies on physiological factors that affect radiosensitivity, we examined the in vitro effect of estradiol (E2) on the yield of radiation-induced chromosome aberrations in human peripheral lymphocytes. Lymphocytes were cultured for 3 days in the medium containing E2 at 0-100,000 ng/ml. On the second day, they were irradiated by X-rays at 3 Gy, and then 2% phytohemagglutinin and 0.05 microgram/ml colcemid were added to the medium. After further 48 h, mitotic indices and the yields of chromosome aberrations were examined at various E2 concentrations. E2 treatment at concentrations above 1000 ng/ml resulted in dose-related inhibition of mitosis. Repeated experiments showed that the yield of dicentrics plus centric rings in the culture containing E2 at 100 ng/ml was significantly higher than the yields at 0 ng/ml. Similarly, the yield of total chromosome breaks in the culture containing E2 at 100 ng/ml was significantly higher than that at 1 ng/ml. This study provides the direct evidence in human that radiosensitivity may vary in relation to hormonal conditions.

Allocyclic X chromosome visualized by drug-induced premature chromosome condensation

Calyculin A, an inhibitor of serine/threonine protein phosphatases, can induce premature chromosome condensation (PCC) in human peripheral lymphocytes. In female lymphocytes treated with calyculin, one highly condensed chromosome per nucleus was frequently observed at early to middle S phase. When these PCC spreads were hybridized with a whole chromosome-painting probe for the X chromosome, one large spot and a cluster of small spots were observed in a cell. Judging from the Giemsa stained image, the former seemed to have finished DNA replication, while the latter was in the process of replication. Because this large spot was seldom observed in male PCC spreads, it was considered an inactive X chromosome. The inconsistency of this observation with earlier reports that the inactive X chromosome replicates later than autosomes and the active homolog is discussed.

Easy biodosimetry for high-dose radiation exposures using drug-induced, prematurely condensed chromosomes

PURPOSE

To propose a practical method of biodosimetry for high-dose estimation.

MATERIALS AND METHODS

Okadaic acid in the range 100 nM to 500 nM was given for 1-6 h to cultured lymphocytes that had been exposed in the range of 0 Gy to 40 Gy. The frequency of the cells with prematurely condensed chromosomes (PCC) was compared with that of metaphases accumulated by 0.05 microg/ml colcemid. The dose-response relationship of the yield of prematurely condensed ring chromosomes (PCC rings) in the irradiated lymphocytes was examined.

RESULTS

The 0.05 microg/ml colcemid collected few metaphases when lymphocytes were irradiated to over 10 Gy. However, 500 nM okadaic acid produced a substantial number of analysable PCC in lymphocytes that had been exposed in the range of 0 Gy to 40 Gy. After 1 h of treatment, the 500 nM okadaic acid gave the most suitable chromosome morphology for the analysis. PCC rings were narrow, which facilitated their detection in Giemsa-stained preparations. The yield of PCC rings increased dose-dependently up to 20 Gy.

CONCLUSION

PCC rings are a more suitable indicator than dicentrics at high doses over 10 Gy. This technique requires no particular equipment or exceptional skill. After a serious radiation accident, it can be easily performed in a short time in most medical facilities to obtain dose information to assist physicians.

Phosphatase inhibitors and premature chromosome condensation in human peripheral lymphocytes at different cell-cycle phases

The cytogenetical reaction of human peripheral lymphocytes to okadaic acid and calyculin A was examined. Calyculin A could induce PCC about 20 times more effectively than okadaic acid. Their mechanisms of PCC induction were judged similar by their dose-dependent manner and chromosome morphology. Contrary to earlier studies suggesting that chemicals could not induce PCC in G1 cells where little cyclin B is present, the present study showed that calyculin A could induce PCC in lymphocytes not only at S and G2/M but also at the second G1 phase after PHA stimulation in vitro. PCC was induced slightly in lymphocytes both at G0 and the first in vitro G1 phase even when the calyculin A concentration increased one hundred fold. It was found that calcium ionophore A23187 increased frequencies of G0-PCC induced by calyculin A, although a further refinement is necessary to obtain a suitable morphology of G0-PCC for cytogenetic studies.

Visualization of clear echocardiographic images with near field noise reduction technique: experimental study and clinical experience

BACKGROUND

With transthoracic echocardiography, it is sometimes difficult to obtain a clear image of the apical portion of the heart because of noise near the transducer. To reduce this artifact, we have developed a new technique (near field noise reduction, NFNR) based on the digital filtering by using radiofrequency signals. This technique may be useful for the accurate measurement of the wall thickness of the myocardium in the near field. The objectives of these studies were (1) to determine the accuracy of this new technique for the measurement of wall thickness in the experimental study and (2) to determine whether the improvement in the image quality in the apical portion can be obtained in the clinical setting by using the NFNR technique.

EXPERIMENTAL STUDY

By using the NFNR technique, we measured wall thickness of three kinds of phantoms (wall thickness 9.0, 14.0, and 21.0 mm) moving at various velocities (5 to 80 mm/sec) in the water bath with artifact produced by a single probe. It was difficult to obtain clear echocardiographic images of the phantom and measure its wall thickness because of the artifact. By using the NFNR technique, on the other hand, the same phantom was clearly imaged. It was possible to measure the wall thickness of each phantom at each moving velocity with the NFNR technique. Mean differences between the echocardiographic measurement and actual value of wall thickness in each phantom model (9.0, 14.0, and 21.0 mm) were 0.04 +/- 0.58 mm, 0.09 +/- 0.58 mm, and -0.02 +/- 0.24 mm, respectively.

CLINICAL STUDY

We studied 25 initial patients in whom the near field was not clearly imaged in apical views by conventional echocardiography because of near field noise. Apical four-chamber or two-chamber views were obtained with and without the NFNR technique. Two observers independently graded endocardial visualization for the 50 segments by using a three-point scale (0 = endocardium not seen, 1 = seen in part but not all of the segment, 2 = endocardium seen along entire segment). The mean segment score in the imaging with the NFNR technique was significantly higher than that without the NFNR technique (observer 1: 1.8 +/- 0.7 vs 1.2 +/- 0.8, p < 0.01; observer 2: 1.6 +/- 0.7 vs 1.2 +/- 0.8, p < 0.01).

CONCLUSIONS

The newly developed NFNR technique provides clear echocardiographic images and accurate wall thickness measurement in the experimental model even when it is difficult to obtain clear images because of the artifact. This new technique will be useful in the reduction of near field noise in the clinical setting.

Non-fluorescent chromosome painting using the peroxidase/diaminobenzidine (DAB) reaction

PURPOSE

To develop and validate non-fluorescent chromosome painting for bright-field microscopy using the peroxidase/diaminobenzidine (DAB) reaction.

MATERIALS AND METHODS

Peripheral blood lymphocytes were taken from patients with uterine cancer who had received heavy-ion radiation therapy. Chromosome slides were treated with RNase and pepsin, denatured mildly, hybridized with a biotinylated DNA probe specific for whole-chromosome 4 and stained using the peroxidase/DAB reaction with an avidin-biotin amplification. The slides were analysed under a bright-field microscope and an atomic force microscope. The detection rate of chromosome aberrations by DAB painting was compared with that obtained by dual analysis of Giemsa staining and FISH painting.

RESULTS

When chromosomes 4 were painted, 11.5% of unstable aberrations were detected by DAB painting, while 10.8% of them were found by dual analysis of Giemsa staining and FISH painting.

CONCLUSION

A DAB painting method that can effectively detect rearranged aberrations was established. It has advantages over FISH painting: the preparations can be analysed by bright-field microscope, can be preserved permanently and are suitable for analysis by an automated system.

Pilomatricoma with a bullous appearance

A 15-year-old Japanese girl had an asymptomatic nodule on the right thigh of seven months' duration. The clinical appearance was similar to that of a bulla. There was a history of blunt trauma from dog scratch to the skin over the tumor shortly before tumor growth. Histopathological findings were consistent with pilomatricoma. In the overlying dermis, the collagen bundles were compressed to the tissue surrounding the tumor and the large space was seen. Around the tumor, some dilated endothelium-lined vascular channels were found, which were identified as lymphatic vessels.

Comparison of the yields of translocations and dicentrics measured using conventional Giemsa staining and chromosome painting

Inconsistent results have been reported regarding the yields of translocations and dicentrics measured using chromosome painting. This inconsistency may be due to mis-scoring of dicentrics as translocations because painting is unsuited to identify centromere positions. In the present study, chromosome aberrations exclusively in the first mitosis after irradiation were analyzed using human peripheral lymphocytes. When identical metaphases were analyzed by both painting and conventional Giemsa staining, which is the most reliable method to locate centromeres, equal frequencies of translocations and dicentrics were observed.

Involvement of human papillomavirus type 20 in epidermodysplasia verruciformis skin carcinogenesis

The involvement of human papillomavirus (HPV) in skin carcinogenesis in a patient with epidermodysplasia verruciformis was studied. This patient had disseminated pityriasis versicolor-like lesions, flat warts, and a malignant skin carcinoma. HPV types 3, 17, 20 (HPV-20), and 38 were isolated and molecularly cloned from the benign skin lesions of this patient. Of these HPVs, only HPV-20 was detected in the malignant skin carcinoma. Transcripts of HPV-20 were also expressed in the carcinoma. These findings suggest that HPV-20 was involved in the skin carcinogenesis in this patient.

Effects of colcemid concentration on chromosome aberration analysis in human lymphocytes

As a part of technical improvements of chromosome aberration analysis on human peripheral lymphocytes for biological radiation dosimetry, we examined the optimal conditions for the use of colcemid in chromosome preparation in order to obtain enough number of cells at metaphase in the first cell division. When treated with colcemid at concentrations below 0.01 microgram/ml from the beginning of culture, cultures harvested at 48 hours had low mitotic indices. Colcemid treatment at 0.025 to 0.05 microgram/ml during 48 hours resulted in high mitotic indices (8 to 15%) and almost of the mitotic cells remaining in the 1st cell division, suggesting that this range of colcemid concentration was appropriate for continuous treatment with colcemid. We further examined the effect of colcemid concentration on the quantitative consistency of the yields of radiation-induced chromosome aberration. Repeated experiments showed that the yield of dicentrics and centric rings in the culture having colcemid at 0.025 microgram/ml concentration were larger than that at 0.05 microgram/ml. These data indicate the importance of assuring the accuracy of colcemid concentration in the lymphocyte culture for cytogenetic radiation dosimetry.

Severe intractable common warts associated with human papillomavirus 2, 3 and 20

A 26-year-old male had had numerous common warts on the feet and hands since childhood. They had repeatedly undergone etretinate cryosurgery, always responding well to it. However, the warts reappeared. Human papillomavirus (HPV) 2, 3 and 20 were detected in the warts using Southern's blot hybridization technique with HPV DNA. Histologically, the warts showed swollen, clear keratinocytes with vacuolated degeneration not found in common warts. The findings are presented in this paper.

Types of human papillomavirus isolated from Japanese patients with epidermodysplasia verruciformis

Virological studies were performed on 12 patients with epidermodysplasia verruciformis (EV). Three types of lesions were observed: red plaques, pityriasis versicolor (PV)-like macules and plane warts. Human papillomavirus (HPV) 14, 20 and 21 were isolated from the plaques, HPV 3, 14 and 38 from flat warts and HPV 5, 12, 17, 20 and 38 from PV-like lesions. No clear relationship could be established between the different lesions and the types of HPV. Types 17 and 20 have been isolated most frequently from Japanese EV patients and HPV 5, frequently detected in other countries, is less common, whereas HPV 8 has not been isolated. Skin cancers occurred in six of the cases (50%) and all had benign lesions that were PV-like. At least one type of HPV 5, 17 or 20 could be isolated from these benign lesions and HPV 17 or 20 detected in the cancers. These three types of HPV in EV patients appear to be involved in the malignant transformation.

Epidemiologic aspects of epidermodysplasia verruciformis (L-L 1922) in Japan

A survey of epidermodysplasia verruciformis (EV), a skin disease caused by human papillomavirus (HPV), was made by means of a questionnaire sent to 92 university hospitals. Replies were obtained from 68 hospitals (74% recovery) reporting 66 patients. Fewer patients were reported from north-eastern Japan than from south-western Japan. Many EV patients were from families of consanguineous marriages (44%), showing a high incidence of intra-familial onset after consanguineous marriages. The complication of malignant tumors was observed in 36 of 62 cases (58%). Malignant tumors of the skin developed at an early age in EV patients. These cancers developed predominantly in exposed areas of the skin (72%). The time from onset of skin lesions to the onset of cancer seemed to be related to the nature of the lesions in EV patients. These findings suggest that the interaction of HPVs, ultraviolet rays and host factors is associated with the development of skin carcinomas.

[Familial occurrence of intracerebral cavernous angioma]

A case of familial occurrence of intracerebral cavernous angioma is reported. The patients were a mother and her eldest son, a 48-year-old woman and a 28-year-old man, respectively. The mother, a hypovascular mass in the right frontal lobe was excised surgically, and in the son a well demarcated mass in the left temporal lobe was extirpated. Pathological examination in each case revealed cavernous angioma. Familial occurrence of intracerebral cavernous angioma is extremely rare. In the literature, 8 cases of familial occurrence have been reported, including our case, and in three out of the 8 cases the lesions were histologically confirmed. To our knowledge, this is the first case in Japan in which the diagnosis was established by surgical specimen. Of 17 cases in 8 family lines, multiple occurrence was observed in 7 cases. The clinical manifestations of the disease appear mostly in a form of adult epilepsy or intracerebral hematoma, and rarely sudden death associated with intracerebral hematoma. At present, CT scanning is widely used for diagnosis of the disease, and the lesions are surgically curable if they are located at the accessible sites. Although there has been no evidence of genetic basis, it is interesting that there is familial occurrence. From this point of view, we should carefully check the family tree of such patients.

Human papillomavirus type 38 isolated from patients with epidermodysplasia verruciformis

A new type of human papillomavirus (HPV), HPV-38b, was isolated from patients with epidermodysplasia verruciformis and was molecularly cloned. This HPV was shown by hybridization experiments to have almost no sequence homology with other types of reported HPVs, but did show homology with HPV-38, which was recently isolated from a melanoma. A physical map and a rough genetic map of the organization of this HPV are presented.