Dose-dependent incidence of agranulocytosis in patients treated with methimazole and propylthiouracil

Agranulocytosis is a serious adverse effect of methimazole (MMI) and propylthiouracil (PTU), and although there have been reports suggesting a dose-dependent incidence in relation to both drugs, the evidence has not been conclusive. The objective of our study was to determine whether the incidences of agranulocytosis induced by MMI and PTU exhibit dose-dependency. The subjects were 27,784 patients with untreated Graves' disease, 22,993 of whom were on an antithyroid drug treatment regimen for more than 90 days. Within this subset, 18,259 patients had been treated with MMI, and 4,734 had been treated with PTU. The incidence of agranulocytosis according to dose in the MMI group was 0.13% at 10 mg/day, 0.20% at 15 mg/day, 0.32% at 20 mg/day, and 0.47% at 30 mg/day, revealing a significant dose-dependent increase. In the PTU group, there were 0 cases of agranulocytosis at doses of 125 mg/day and below, 0.33% at 150 mg/day, 0.31% at 200 mg/day, and 0.81% at 300 mg/day, also revealing a significant dose-dependent increase. The incidence of agranulocytosis at MMI 15 mg and PTU 300 mg, i.e., at the same potency in terms of hormone synthesis inhibition, was 0.20% and 0.81%, respectively, and significantly higher in the PTU group. Our findings confirm a dose-dependent increase in the incidence of agranulocytosis with both drugs, but that at comparable thyroid hormone synthesis inhibitory doses PTU has a considerably higher propensity to induce agranulocytosis than MMI does.

An Evaluation of the Efficacy of Machine Learning in Predicting Thyrotoxicosis and Hypothyroidism: A Comparative Assessment of Biochemical Test Parameters Used in Different Health Checkups

Objective This study assessed the efficacy of machine learning in predicting thyrotoxicosis and hypothyroidism [thyroid-stimulating hormone (TSH) >10.0 mIU/L] by leveraging age and sex as variables and integrating biochemical test parameters used by the Japan Society of Health Evaluation and Promotion (JHEP) and the Japan Society of Ningen Dock (JND). Subjects and Methods Our study included 20,653 untreated patients with Graves' disease, 3,435 untreated patients with painless thyroiditis, 4,266 healthy individuals, and 18,937 untreated patients with Hashimoto's thyroiditis. Machine learning was conducted using Prediction One on three distinct datasets: the Ito dataset (age, sex, and 30 blood tests and biochemical test data), the JHEP dataset (age, sex, and TP, T-Bil, AST, ALT, γGTP, ALP, CRE, UA, and T-Cho test data), and the JND dataset (age, sex, and AST, ALT, γGTP, CRE, and UA test data). Results The results for distinguishing thyrotoxicosis patients from the healthy control group showed that the JHEP dataset yielded substantial discriminative capacity with an area under the curve (AUC) of 0.966, sensitivity of 92.2%, specificity of 89.1%, and accuracy of 91.7%. The JND dataset displayed similar robustness, with an AUC of 0.948, sensitivity of 92.0%, specificity of 81.3%, and accuracy of 90.4%. Differentiating hypothyroid patients from the healthy control group yielded similarly robust performances, with the JHEP dataset yielding AUC, sensitivity, specificity, and accuracy values of 0.864, 84.2%, 72.1%, and 77.4%, respectively, and the JND dataset yielding values of 0.840, 83.2%, 67.2%, and 74.3%, respectively. Conclusions Machine learning is a potent screening tool for thyrotoxicosis and hypothyroidism.

Incidence and risk factors for Graves' orbitopathy in patients who underwent anti-inflammatory and immunosuppressive treatment during medical treatment for Graves' disease: investigation of 1,553 cases with newly diagnosed Graves' disease and proposal of a predictive score

Appropriate administration of anti-inflammatory and immunosuppressive treatment (AIIST) is important for patients with Graves' orbitopathy (GO). This study aimed to clarify the incidence and risk factors for GO treated with AIIST and propose a predictive score, among newly diagnosed Graves' disease (GD) patients in Japan. A total of 1,553 GD patients who were newly diagnosed during the year 2011 were investigated. AIIST included local and/or systemic glucocorticoid administration and retrobulbar irradiation. A multivariable Cox proportional hazards model was used to investigate the risk factors for GO underwent AIIST during medical treatment, including at diagnosis, of GD. Then, a GO score was created by summing each point assigned to risk factors based on their coefficient obtained in the Cox model. AIIST was administered to 107 patients (6.9%). The risk factors and hazard ratios for GO underwent AIIST were: age (per 10 years), 1.32 (95% confidence interval: 1.16-1.50), p < 0.0001; TSH binding inhibitory immunoglobulin (TBII) (per 10 IU/L), 1.33 (1.15-1.54), p = 0.0001; and thyroglobulin antibody (TgAb) negativity, 2.98 (1.96-4.59), p < 0.0001. The GO score, ranging from 0 to 8 points, showed moderate performance (area under the curve: 0.71, cut-off value: 5 points, sensitivity: 0.76, specificity: 0.59, positive predictive value: 0.12, negative predictive value: 0.97). AIIST was performed for patients with active manifestations of GO in 6.9% of newly diagnosed GD patients. The risk factors for GO underwent AIIST were higher age, higher TBII, and TgAb negativity. The GO score based on these factors may be useful in managing GO.

Incidence of and Risk Factors for Neonatal Hypothyroidism Among Women with Graves' Disease Treated with Antithyroid Drugs Until Delivery

Background: The incidence of neonatal hypothyroidism among newborns born to mothers with Graves' disease (GD) who continued antithyroid drug (ATD) treatment until delivery has never been reported. Objective: Our primary objective was to investigate the incidence of neonatal hypothyroidism among newborns born to mothers with GD who were treated with ATD until delivery. Our secondary objective was to identify the cutoff ATD daily doses for neonatal hypothyroidism risk, based on maternal thyrotropin (TSH) receptor antibody (TRAb) levels. Methods: We conducted a retrospective cohort study. We included 305 pregnant women with GD who were treated with an ATD until delivery (63 treated with methimazole [MMI] and 242 treated with propylthiouracil [PTU]). Umbilical cord TSH, free thyroxine (fT4), and TRAb levels were measured at delivery, and we investigated the respective relationships between neonatal hypothyroidism at delivery and maternal fT4 levels, TRAb levels, and daily ATD doses during pregnancy. Neonatal hypothyroidism was diagnosed when the umbilical cord fT4 level was below the lower limit of the reference range. Results: The incidence of neonatal hypothyroidism at delivery was 19.0% ([confidence interval, CI, 11.2-30.4]; 12/63) in the MMI group and 12.8% ([CI, 9.2-17.6]; 31/242) in the PTU group. Neonatal goiter was observed in one neonate in the PTU group, and two infants in the PTU group required levothyroxine treatment. The daily ATD dose in the third trimester was the strongest predictor of neonatal hypothyroidism at delivery; the cutoff MMI dose was 10 mg/day, and the cutoff PTU dose was 150 mg/day. When the maternal TRAb level in the third trimester was above three times the upper limit of the normal range, the cutoff MMI dose was 20 mg/day, and the cutoff PTU dose was 150 mg/day. Conclusions: Maternal fT4 and TRAb levels were higher in the neonatal hypothyroid group, which suggested prolonged GD activity. Careful follow-up is necessary when maternal GD remains active and the ATD dose to control maternal thyrotoxicosis cannot be reduced.

Empagliflozin versus sitagliptin for ameliorating intrahepatic lipid content and tissue-specific insulin sensitivity in patients with early-stage type 2 diabetes with non-alcoholic fatty liver disease: A prospective randomized study

AIM

To compare the effects of sodium-glucose co-transporter-2 (SGLT2) inhibitors and dipeptidyl peptidase-4 inhibitors on ectopic fat accumulation and tissue-specific insulin sensitivity.

MATERIALS AND METHODS

This randomized controlled trial enrolled 44 patients with type 2 diabetes (T2D) and non-alcoholic fatty liver disease (NAFLD). They were randomly assigned to receive either empagliflozin 10 mg/day or sitagliptin 100 mg/day for 12 weeks. The primary endpoint was the change in intrahepatic lipid content (IHL) measured using proton magnetic resonance spectroscopy (¹ H-MRS). The secondary endpoints included intramuscular and extramuscular lipid content seen in ¹ H-MRS, body composition seen through dual-energy X-ray absorptiometry and tissue-specific insulin sensitivity shown through hyperinsulinaemic-euglycaemic clamp using stable isotopic glucose. Liver biopsy samples were pathologically evaluated at baseline.

RESULTS

At baseline, the mean duration of diabetes, HbA1c level and IHL were 3.7 years, 7.2% and 20.9%, respectively. The median NAFLD activity score was 3.0. IHL was significantly more decreased in the empagliflozin group than that in the sitagliptin group (between-group difference was -5.2% ± 1.1% and -1.9% ± 1.2%, respectively, (95% confidence interval); -3.3 (-6.5, -0.1), P = .044). However, there were no significant between-group differences in the change of insulin sensitivity in the liver, muscle or adipose tissues. Interestingly, hepatic insulin sensitivity was significantly increased only in the empagliflozin group and was significantly negatively associated with the change in IHL.

CONCLUSIONS

Empagliflozin significantly improves hepatic steatosis compared with sitagliptin, and this may protect against subsequent hepatic insulin resistance. Early administration of SGLT2 inhibitors is preferable for T2D patients with NAFLD.

A prospective randomized study comparing effects of empagliflozin to sitagliptin on cardiac fat accumulation, cardiac function, and cardiac metabolism in patients with early-stage type 2 diabetes: the ASSET study

Background

While the cardioprotective benefits of sodium-glucose cotransporter-2 (SGLT2) inhibitors have been established in patients with cardiovascular disease (CVD), their advantages over other anti-diabetic drugs at earlier stages remain unclear. We compared the cardioprotective effects of empagliflozin, an SGLT2 inhibitor, with those of sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor, focusing on cardiac fat accumulation, cardiac function, and cardiac metabolism in patients with early-stage type 2 diabetes mellitus (T2DM) without CVD complications.

Methods

This was a prospective, randomized, open-label, blinded-endpoint, parallel-group trial that enrolled 44 Japanese patients with T2DM. The patients were randomized for 12-week administration of empagliflozin or sitagliptin. Pericardial fat accumulation and myocardial triglyceride content were evaluated by magnetic resonance imaging and proton magnetic resonance spectroscopy, respectively. Echocardiography, ¹²³I-β-methyl-iodophenyl pentadecanoic acid myocardial scintigraphy, and laboratory tests were performed at baseline and after the 12-week treatment period.

Results

The patients were middle-aged (50.3 ± 10.7 years, mean ± standard deviation) and overweight (body mass index 29.3 ± 4.9 kg/m²). They had a short diabetes duration (3.5 ± 3.2 years), HbA1c levels of 7.1 ± 0.8%, and preserved cardiac function (ejection fraction 73.8 ± 5.0%) with no vascular complications, except for one baseline case each of diabetic nephropathy and peripheral arterial disease. After the 12-week treatment, no differences from baseline were observed between the two groups regarding changes in pericardial, epicardial, and paracardial fat content; myocardial triglyceride content; cardiac function and mass; and cardiac fatty acid metabolism. However, considering cardiometabolic biomarkers, high-density lipoprotein cholesterol and ketone bodies, including β-hydroxybutyric acid, were significantly increased, whereas uric acid, plasma glucose, plasma insulin, and homeostasis model assessment of insulin resistance were significantly lower in the empagliflozin group than in the sitagliptin group (p < 0.05).

Conclusions

Although the effects on cardiac fat and function were not statistically different between the two groups, empagliflozin exhibited superior effects on cardiometabolic biomarkers, such as uric acid, high-density lipoprotein cholesterol, ketone bodies, and insulin sensitivity. Therefore, when considering the primary preventive strategies for CVD, early supplementation with SGLT2 inhibitors may be more beneficial than DPP-4 inhibitors, even in patients with early-stage T2DM without current CVD complications.

Clinical Trial Registration: UMIN000026340; registered on February 28, 2017. https://upload.umin.ac.jp/cgi-open-bin/icdr_e/ctr_view.cgi?recptno=R000030257

Rationale, Design for the ASSET Study: A Prospective Randomized Study Comparing Empagliflozin's Effect to Sitagliptin on Cardiac Fat Accumulation/Function in Patients with Type 2 Diabetes

INTRODUCTION

Ectopic fat accumulation has been found to play a pathophysiological role in insulin resistance, type 2 diabetes (T2DM), and coronary artery diseases. Findings from a number of previous studies suggest that sodium glucose cotransporter 2 (SGLT2) inhibitors reduce lipid accumulation, including myocardial and pericardial fat, while dipeptidyl peptidase 4 (DPP4) inhibitors suppress ectopic lipid accumulation and improve cardiac function. However, a clinical study that precisely explains and compares the efficacy of SGLT2 inhibitors and DPP4 inhibitors on cardiac fat accumulation has not been performed. Moreover, the association between cardiac fat accumulation and cardiac function or metabolic changes, such as tissue-specific insulin resistance, remains unclear. It is our intention to conduct the first study to assess the effects of empagliflozin compared to sitagliptin in reducing ectopic fat accumulation, specifically pericardial fat, and its association with improvement in cardiac function and tissue-specific insulin sensitivity.

METHODS

We have designed a prospective, randomized open-label, and blinded-endpoint study with the intention to enroll 44 Japanese patients with T2DM. The patients are to be divided them into two groups, an empagliflozin group and an sitagliptin group, with the former to be supplemented with empagliflozin 10 mg and the latter to be supplemented with sitagliptin 100 mg, both groups for 12 weeks. The primary endpoint of the study is the change in the amount of pericardial fat. The secondary endpoints are the changes in the amount of intracellular fat in the myocardium, cardiac function, tissue-specific insulin sensitivity, fatty acid metabolism in myocardial tissue, assessed by parameters of iodine-123-β-methyl-iodophenyl pentadecanoic acid myocardial scintigraphy, blood and urine biomarkers, and lifestyle evaluation.

PLANNED OUTCOMES

The results of this study will be available in 2020. The aim of this study is to provide an effective treatment strategy for patients with T2DM by considering cardiac fat accumulation, cardiac function, and insulin resistance.

FUNDING

Boehringer Ingelheim & Eli Lilly and Company Diabetes Alliance.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trial Registry: UMIN000026340.

Differential effects of acetaminophen pretreatment on hepatic aflatoxin B(1)-DNA binding, cellular proliferation, and aflatoxin B1-induced hepatic foci in rats and hamsters

Effects of acetaminophen (AAP) pretreatment on hepatic aflatoxin B1 (AFB(1))-DNA binding, cellular proliferation, and AFB(1)-induced glutathione S-transferase placental form (GST-P) positive hepatocytes and foci have been examined in young male rats and hamsters. Intraperitoneal (i.p.) dosing of 600mg AAP 3h before AFB(1) i.p. injection showed three-fold more AFB(1)-DNA binding in hamsters and 40% less binding in rats. Cell proliferation analyzed by bromodeoxyuridine incorporation was not significant (0.4-0.6%) 24-96h after AAP (600mg) treatment of rats; however, proliferation was stimulated and was maximum (11%) in hamsters at 72h after AAP treatment. Dosing of rats with AFB(1) alone at 0.5 or 2.5mg level gave an appreciable number of GST-P positive minifoci (two to nine cells) with a few foci larger than 100 microm; pretreatment with AAP (300 or 600mg) 48h before 0.5 or 2.5mg AFB(1) had no effect on the number and focal area of foci. In hamsters, 1 or 2mg AFB(1) alone yielded GST-P positive hepatocytes without any minifoci. Pretreatment with AAP (600mg) 48 or 72h before 1 or 2mg AFB(1) produced increases in both GST-P positive hepatocytes and minifoci. Thus, marked changes are observed after AAP pretreatment in hamsters compared to rats.

Malignant gastrointestinal stromal tumor showing remarkable whorl formations

A case of malignant gastrointestinal stromal tumor (GIST) is reported. Histologically, spindle cell proliferation with remarkable whorl formations was predominant in the tumor. Immunohistochemically, the tumor cells were diffusely positive for CD117 (c-Kit) and vimentin and partially positive for CD34. Ultrastructurally, the desmosome-like structures and interdigitations occurred much more frequently in the areas with whorl formations. These organelles were considered to be closely associated with the whorl formations. Various kinds of cellular arrangements are revealed in GISTs, but remarkable whorl formations, such as in our case, are a rare variant pattern. Herein, we discuss the histopathologic differences between this and other tumors showing whorl formations and describe the meaning of this unique arrangement. GISTs are thought to be immature tumors, and, therefore, variations in histopathologic findings are recognized. Finally, the ultrastructural study of GISTs is useful for understanding the mechanisms forming whorl formations and the differentiation or pathogenesis of GISTs.

Histochemical study of human cremaster in varicocele patients

Despite the cremaster's important role in thermoregulation, few morphological and biochemical studies of this muscle in humans have been reported, probably due to limitation of sampling. To gain further insight into the pathology of varicocele, the authors studied the histochemical changes of the cremaster from patients with varicocele. Cremaster was obtained from patients with male infertility and varicocele, grades 1-3. The samples were studied using routine histochemical stains. Fiber size variability and type I predominance were observed in all varicocele cases regardless of the grade, and also in control specimens. Muscle from patients with grades 2 and 3 varicocele showed small group atrophy. It would appear that the hemostasis associated with local tissue edema and hypoxemia may lead to nerve damage and denervation of the cremaster. If denervation of the cremaster persists despite the correction of varicocele, thermoregulation would remain disrupted.

Relationship between the states of spinal impact injuries and magnetically evoked EMGs in rats

The relationship between the states of spinal impact injuries and magnetically evoked electromyograms (EMGs) were studied in rats. Impact injuries to the spinal cord were induced at a depth of 0.25-2.0 mm by insertion of a cylinder tip measuring 2 mm in diameter into the lumbar vertebrae L1-L2. Magnetically induced electromyograms for the brain and lumbar vertebrae L4-L5 were recorded from the tibialis anticus and the gastrocnemius muscles. H-reflex was not induced by the spinal cord injury (SCI) at a depth of 0.25 mm, although motor evoked potential (MEP) was observed. Continuous waves following the M-response were observed in the SCI at a depth of 0.25 mm. Elevation of the threshold, reduction of its latency and decrease in amplitude of the M-responses were observed at an injury depth of 0.5 mm or deeper. With SCI magnitude from mild (0.5 mm depth) to severe (1.0 mm depth), the amplitudes of the M-response were decreased, and the latency of the M-response was shorter than that of the control. The F-response was accelerated in severe SCI. Our results indicated that there was a relationship between extensive injury legions and the H-reflex F- and M-responses in magnetically evoked EMGs. Magnetically evoked EMGs are useful for monitoring the states of SCI.

Changes in spinal cord function caused by injuries at different levels of the lumbar spinal cord

We examined the impact of spinal cord injury to a depth of 0.5 mm at L1-L2 (upper lumbar cord injury) and in L6-S1 (lower cord injury) in Wistar rats. Upper lumbar cord injury resulted in the disappearance of the motor evoked potential (MEP) of the gastrocnemius muscle during transcranial magnetic stimulation, while the threshold was decreased in rats with lower cord injury. During magnetic stimulation of L4-L5, the M-response threshold was decreased in rats with upper lumbar cord injury, while the amplitude was increased. In lower cord injury, the pattern of H-response recruitment curves differed from that in controls. Our results indicated that MEP and the spinal reflex are influenced not only by upper lumbar cord injury but also by lower cord injury.

Sensorimotor polyneuropathy associated with chronic lymphocytic leukemia, IgM antigangliosides antibody and human T-cell leukemia virus I infection

A 65-year-old man presented with a sensorimotor polyneuropathy associated with B-cell chronic lymphocytic leukemia (CLL) and immunoglobulin M (IgM) antibody to various gangliosides. Electrophysiological studies denoted significant abnormalities of motor and sensory nerve conduction. Although the pathology of sural nerve biopsy looked minimally affected, immunohistochemical studies showed specific binding of IgM to the human peripheral nerve. Our patient also had high titer of antibody to human T-cell leukemia virus I (HTLV-I) in both serum and cerebrospinal fluid (CSF), which might activate B-cell-mediated immunity and facilitate the production of IgM antibody. The other unique feature is the reactivity of antibody to gangliosides. The patient had IgM antibody reactivities to gangliosides with disialosyl residue such as GT1b, GQ1b and GD3, but not to GD1b. IgM antibody to gangliosides with disialosyl residue has been reported in ataxic symptoms, but our patient failed to demonstrate ataxia. Without reactivity to GD1b, sensory ataxic neuropathy might not develop even in the presence of antibody reactive to other gangliosides with disialosyl residue.

[A case of glomangioma of the stomach]

Glomus tumor of the stomach is still a rare disease. In Japan, till now, only 78 cases have been reported as far as we look over the literatures. We report a case of glomangioma of the stomach. The patient is a 44-years old female who underwent a medical examination and pointed out a gastric submucosal tumor, but she had no symptoms and admitted for operation. The endoscopical finding was a submucosal tumor as large as 4 cm, and the result of biopsy was chronic atrophic gastritis. So typical gastrectomy was performed without a definite diagnosis. In the cross section, the tumor was clearly bounded gastric mucosa by a white membrane, and the center of the tumor was spongy. By patho-histological and electro-microscopic study, we diagnosed that the tumor was glomangioma in the classification of Weiss & Enzinger. The patient was getting on well after the operation and left the hospital on the 29th day.

Simple and reproducible model of rat spinal cord injury induced by a controlled cortical impact device

Consistently reproducible experimental trauma was inflicted on the rat spinal cord (L3-L4) employing a controlled cortical impact device. The spinal cord was injured with one of three sizes of chips; thick (3 mm diameter), medium (2 mm diameter), thin (1 mm diameter). Each chip was applied at 1, 2 and 3 mm deformation depths. The correlations of the magnitude of the primary trauma were examined histopathologically. It was found that the extent and intensity of the trauma could be changed by altering the depth of deformation and the chip diameter at a fixed velocity of 4.6 m per sec. The injury caused by the 2 mm diameter chip at 0.5 mm-deformation damaged one to two segments of the perifocal spinal cord. In the surviving animals, the histological changes could be classified as primary, secondary, and late phase changes, and finally the lesion became a cavity. This study reports the application of a controlled cortical impact device to morphological research on a spinal cord injury. We found that the injury by the 2 mm chip at 0.5 mm deformation was the most advantageous and reproducible model for further investigations.

[An experience of treatment of double positive myeloperoxidase-antineutrophil cytoplasmic antibodies (MPO-ANCA) and anti-glomerular basement membrane antibodies in Goodpasture's syndrome onset of crescentic glomerulonephritis]

A 68-year-old woman was admitted to Kinki University Hospital because of progressive renal failure. She had been well until two months before admission. Laboratory data were as follows: serum creatinine 4.1 mg/dl, BUN 69 mg/dl, MPO-ANCA 33 EU, anti-glomerular basement membrane antibodies (AGBMA) 118 U. Histological findings showed cellular and fibrocellular crescents in many glomeruli. Therefore, we diagnosed rapidly progressive glomerulonephritis (RPGN) due to MPO-ANCA and anti-GBM associated renal disease. The patient was started on prednisolone and double filtration plasmapheresis (DFPP) therapy. Subsequently, the values of MPO-ANCA and AGBMA decreased. However, the patient's condition suddenly worsened and she died of interstitial pneumonia. Autopsy examination revealed crescentic glomerulonephritis and alveolar hemorrhage with linear deposition of IgG along the glomerular and alveolar capillary walls by immunofluorescence studies. We considered this to be a rare case of Goodpasture's syndrome associated with not only anti-GBM antibodies, but also MPO-ANCA.

Magnetically induced motor evoked potentials and H-reflex during nembutal and ketamine anesthesia administration in rats

The effects of nembutal and ketamine anesthesia on motor evoked potentials (MEPs) and spinal segment reflex (H-response, F and M waves) were investigated in rats by magnetic stimulation. These potentials were generated by magnetic stimulation of the motor cortex and the spinal cord (L4-L5). After application of nembutal, MEP and H-response decreased in amplitude, eventually disappearing. The amplitudes of F and M waves increased and persisted at the increased levels during anesthesia. The latencies of F and M waves were constant before and after anesthesia. Following ketamine administration, the threshold, latency and amplitude of the magnetically induced MEPs, and M, F and H responses were not influenced systematically. The results suggested that MEPs and H-response depression and/or disappearance due to synaptic site suppression after nembutal anesthesia, and the increase and persistence of increased F and M waves amplitudes were all due to the increasing motoneuron excitability, whereas ketamine did not affect synaptic sites subjected to magnetic stimulation.

[The immunoreactivity studies of the idiopathic inflammatory myopathy over the past three years in our laboratory]

Biopsied skeletal muscles from patients with inflammatory myopathy (6 cases of polymyositis (PM), 2 cases of dermatomyositis (DM), 5 cases of collagen disease with polymyositis and a case of allergic granulomatous angitis) were examined by comparing immunostained infiltrated cells at perivascular, perimysial and the endomysial sites as well as examining the histochemical findings on serial frozen sections from cases examined by our laboratory over the past three years. CD68 was used for macrophage, L26 for B lymphocytes, CD4 and CD8 for T lymphocytes. Expression of HLA-ABC was examined for Class I antigen and HLA-DR for Class II antigen on the muscle fibers. Many macrophages and CD8-positive T lymphocytes had infiltrated the endomysium in PM. Many CD4-positive T lymphocytes and L26-positive B lymphocytes had infiltrated perivascular sites in DM. These results were almost the same as those in many other reports. HLA-ABC was positive on the muscle sarcolemma in all cases. However, the expression of HLA-DR was not identical in all cases. It is useful to determine the diagnosis and consider a pathogenesis of inflammatory muscle diseases to analyze the infiltrated cells and the site of infiltration even in case showing few of infiltrating cells and necrotic fibers.

Nemaline bodies of skeletal muscle fibers of the neck in a case of pharyngeal cancer

Nemaline bodies were found in the regenerating muscle fibers of the neck of a 74-year-old Japanese male with pharyngeal cancer. Histologically, the nemaline bodies were needle-shaped structures and hematoxophilic with phosphotungstic acid-hematoxylin stain. Electron microscopic examination suggested that they arise as extensions of the Z bands. Although nemaline bodies occur in a variety of pathological conditions other than nemaline myopathy, their occurrence in regenerating skeletal muscle fibers invaded by cancer has not been reported previously. The pathogenesis of the nemaline body formation in the present case is discussed.

Potentiation of aflatoxin B1-induced hepatocarcinogenesis in the rat by pretreatment with buthionine sulfoximine

A single i.p. dose of aflatoxin B1 (AFB1) (1.0 and 2.0 mg/kg body wt)-induced hepatocarcinogenesis with phenobarbital as a promoter has been examined in young male Fischer rats. Immunohistochemical method has been employed to detect AFB1-induced glutathione S-transferase placental form (GST-P)-positive hepatic foci observed from 3 week and 10 week to 40-48 week periods. With 2.0 mg AFB1 dosing, the number, area and volume occupied by GST-P-positive hepatic foci increased significantly and progressively from 3 week, 10 week and 48 week periods. In long term studies (40-48 weeks), 1.0 mg and 2.0 mg AFB1 dose levels yielded linear response in area and volume occupied by AFB1-induced hepatic foci. Pretreatment of rats with L-buthionine sulfoximine (BSO), a GSH depleter, at a dose of 4 mmol/kg body wt 4 and 2 h before 1.0 or 2.0 mg AFB1 treatment enhanced the number, area and volume of GST-P-positive hepatic foci, increases being the largest at shorter time periods (3 and 10 weeks) compared to longer time periods (40 and 48 weeks). This report appears to be the first example of an enhanced chemical induced hepatocarcinogenesis in a long term study in any experimental animals species by a GSH depleting agent.

Ciliary neurotrophic factor immunoreactivity in rat intramuscular nerve during reinnervation through a silicone tube after severing of the rat sciatic nerve

The immunoreactivity of ciliary neurotrophic factor (CNTF) and S100 was studied in the degenerating and regenerating intramuscular nerves after the sciatic nerve was severed. The sciatic nerves of male Wistar rats were transected at the midpoint of the thigh, and silicone tubing was used to obtain effective reinnervation. The strong immunoreactivity of CNTF and S100 was observed in the Schwann cell cytoplasm of intramuscular nerves (IMN) and at the neuromuscular junction (NMJ) on the control sections. The CNTF immunoreactivity gradually became weak and indistinct in the Schwann cell cytoplasm after the operation. However, it was recognized again in the IMN at 4 weeks after the operation. On the other hand, the S100 immunoreactivity was continuously observed except at the NMJ through the denervating and reinnervating period. At 12 weeks after the operation, the strong immunoreactivity of both CNTF and S100 was observed again. These findings suggest that the amount of CNTF protein decreased in Schwann cells of the IMN and NMJ during the denervating period and increased during the reinnervating period in proportion to the number of remyelinated Schwann cells after severing of the sciatic nerve. They also suggest that CNTF was more highly correlated than the S100 protein with the reinnervation activity of Schwann cells.

[Psychosocial support to improve quality of life (QOL) in home terminal carcinoma patients]

There are numerous psychosocial problems with home care for terminal cancer patients. We studied one case from the viewpoint of providing support for cancer patients and their families. Psychosocial problems are important for the life of cancer patients and their families. The cancer diagnosis and the terminal stage have different levels of psychosocial concerns. We must consider effective intervention with such psychosocial support. (1) The team delivery of health care in oncology is more crucial than ever. (2) Social work plays a key role. (3) We should strive to understand the roles of other members of teams. (4) Members of a support team should take turns in providing care according to the psychosocial conditions of the patients. (5) Sympathy and a broad social outlook are required of medical staff members.

[Assistance to enhance the use of home helper services for the cancer patient]

For the end-stage cancer patient to live at home with his or her quality of life (QOL) sustained, Home Helper Services are considered effective. In fact, however, many do not avail themselves of such services. Since the disease situation is apt to change dramatically, it is difficult to predict the length of time of care at home, and the patient's family does not tend to utilize such services unless the patient is completely bedridden. Short-term use or the difficulty or rapid response of such services has been among the reasons given of this. Given this background, there appears to be a need for suitable assessment in dealing quickly with possible disabilities which might occur and a number of occupations. Also, when considering home medical care for the cancer patient, an administrative system capable of a rapid response when problems of this kind occur is indispensable. Working on the administration to fulfill this need is also the task of the professionals in this field.

Effect of cell proliferation on initiation of aflatoxin B1-induced enzyme altered hepatic foci in rats and hamsters

Rat is susceptible whereas hamster is resistant to aflatoxin B1 (AFB1) hepatocarcinogenesis. Effect of cell proliferation on AFB1-induced glutathione S-transferase placental form (GST-P) positive foci has been examined in these two species after a single i.p. dose of AFB1 and phenobarbital (PB) as a promoter in a 3 week period. Bromodeoxyuridine incorporation as a measure of cell proliferation and GST-P hepatic foci were analyzed by immunohistochemical methods. Hepatic cell proliferation was maximum at 24 h after either partial hepatectomy (PH) or CCl4 (4 mmol/kg) pretreatment of rats whereas cell proliferation was maximum at 48 h after PH or CCl4 (1 mmol/kg) treatment of hamsters. Enhanced number of GST-P positive hepatic minifoci (two to nine cells) and foci (>100 microns) and focal area were observed in rats with either AFB1 (0.5 mg/kg) given 24 h after PH or AFB1 (0.5 or 2.5 mg/kg) given 48 h after CCl4 dosing. In hamsters, 1 or 2 mg AFB1 treatment produced only GST-P positive single hepatocytes without presence of any minifoci whereas 3 or 6 mg AFB1 produced minifoci consisting only of doublets. Pretreatment with CCl4 48 or 72 h before 1 mg AFB1 dose level increased GST-P positive single cells and minifoci several fold. PH 24 or 48 h before 1 or 2 mg AFB1 dose level increased minifoci. However, increase in minifoci was higher in PH hamsters at 48 h compared with those at 24 h. These results indicate that even though maximum initiation occurs in both speices when AFB1 is administered at the peak of DNA synthesis, rats are more responsive than hamsters to cellular proliferation in the initiation phase of AFB1-induced hepatocarcinogenesis.

[Support system for long-term morphine administration to terminal cancer patients at home--verification from three patients at home with terminal cancer]

The nursing department at the Saitama Prefectural Cancer Center established a Nursing Consultation Section in April 1993 and a Visiting Nursing Program in May 1993 with the purpose of supporting cancer patients who desired home care. From these dates through March 1994, 1,021 patients were instructed in home care methods and visiting nursing was provided in 98 cases. Of these, three patients with terminal cancer received long-term ameliorative treatment using orally administered morphine and were able to maintain satisfactory QOL through their terminal periods. The results are reported herein.

Effect of glutathione levels on aflatoxin B1-DNA binding in livers and kidneys of male rats and hamsters pretreated with buthionine sulfoximine and dimethylmaleate

The effects of pretreatment of buthionine sulfoximine (BSO) alone or in combination with diethylmaleate (DEM) on glutathione (GSH) levels and aflatoxin B1 (AFB1)-DNA binding have been examined in livers and kidneys of young male Fischer rats and Syrian golden hamsters 2 h after an intraperitoneal injection of [3H]AFB1 (0.4 mg/kg body wt.). Animals were treated with BSO (4 mmol/kg body wt.) alone at 4 h and 2 h or with DEM (3 mmol/kg body wt.) at 4 h and BSO at 2 h before AFB1 injection. Hepatic AFB1-DNA binding was about 29.0 and 6.0 pmol/mg DNA in rats and hamsters, respectively. In rats, BSO increased AFB1-DNA binding by about 40% with a drop in GSH by 70%. Treatment with DEM-BSO increased AFB1-DNA binding by about 80% with a concomitant drop in GSH in both species. In hamsters, BSO increased AFB1-DNA binding by only 10% with a 50% drop in GSH. The kidneys of both species have lower GSH levels and AFB1-DNA binding than their respective liver tissues. The effect of BSO alone or in combination with DEM on both GSH levels and AFB1-DNA binding are comparable even though BSO alone is less effective in both species. The role of modulation of GSH levels on AFB1-DNA binding and hence biological effects of AFB1 in these two species is discussed.

Neurotrophic factor-like effect of FPF1070 on septal cholinergic neurons after transections of fimbria-fornix in the rat brain

FPF1070 is an aqueous protein-free solution, which consists of 85% free amino acids and 15% small peptides. Our previous study showed a potent neurotrophic factor-like activity in cultured embryonic cells of dorsal root ganglia. The present study investigated whether FPF1070 regenerated the cholinergic cells in the medial septal nucleus after axonal transections by cutting the fimbria-fornix. Fimbrial transection reduced the number of septal cholinergic cells by 30 +/- 3.6%, compared with the number on contralateral sides at 4 weeks. Intraperitoneal injections of FPF1070 caused 49.9 +/- 6.3% of the cholinergic neurons to survive. Furthermore, the cell sizes of the cholinergic neurons were significantly different: 16.4 +/- 4.2 microns, 14.3 +/- 3.8 microns in FPF1070 treatment and vehicle treatment, respectively. These results indicated that FPF1070 prevents the degeneration and atrophy of impaired cholinergic neurons by systemic administration.

Monoclonal antibody to rat brain actin antigenically enhanced with HVJ (Sendai virus) M protein

Monoclonal antibody to rat brain actin was easily produced using HVJ (Sendai Virus) M protein to enhance the antigenicity of the actin. This monoclonal antibody was determined to be IgM with a kappa light chain. By immunoblot analysis the antibody was also shown to react with rat brain actin but not with HVJ M protein on nitrocellulose sheets. Utilizing the antibody, neuronal cytoplasm in the cerebral cortex, the anterior and posterior horns in the spinal cord, the spinal ganglion and astrocytes showed positive immunohistochemical staining by light microscopy. However, Purkinje cells showed variable staining, some staining intensely, while others were negative. All of neurons in specific anatomical locations showed always positive staining but variable intensities. Vascular walls were stained only faintly. By electron microscopy, neuronal cytoplasm showed diffuse positive staining. Other areas showed a positive reaction, including dendrites, the postsynaptic densities, and a few capillary endothelial cells and arterial smooth muscle cells. The results suggest that the HVJ M protein was effective for producing monoclonal antibody to brain actin, and that the antibody could be utilized for the immunohistochemical study of neuronal elements in both normal and pathological conditions.

Immunohistochemical change of actin in experimental myocardial ischemia. Its usefulness to detect very early myocardial damages

Pathomorphological diagnosis of acute myocardial infarction has many problems in human autopsy materials less than 4 to 6 hours after clinical onset and in rats 2 to 3 hours after experimental coronary occlusion. Since immunohistochemical reaction depends on the antigen determinant site of the material, changes in the reaction may reflect alterations at the molecular level in myocardial fibers. With this consideration in mind, the effectiveness of diagnosing infarction at the earliest (possible) stage, and the changes of actin filaments were investigated through experiments, using immunohistochemical methods involving anti-actin antibodies produced from chicken gizzards in our laboratory. The left coronary arteries of rats were ligated to produce ischemia. Dehydrogenases were shown to be still present by triphenyltetrazolium chloride (TTC) reaction, but the anti-actin antibody reaction had disappeared in areas corresponding to the ischemic sites. However, on electron microscopic examination of these sites, actin fibers were clearly revealed. In the case of ischemia lasting for more than 6 hours, the anti-actin antibody reaction had disappeared, corresponding to the disappearance of the TTC reaction. At this stage, myocardial actin fibers were revealed by electron microscopic examination. These results indicate that ischemia induces some type of biochemical degeneration at the molecular level of myocardial actin, most likely the change of actin polymerization. Moreover, they show that the anti-actin antibody technique is capable of detecting such very early degenerative and ischemic changes proving itself to be better suited for determining the range and degree of early infarction.

Immunohistochemical reaction of myocardial fibers with actin antiserum in autopsy cases of myocardial infarction

The purpose of this study was to determine the immunoreactivity of myocardial actin filaments with actin antiserum and to examine the significance of its application to diseased human cardiac muscle. The actin was extracted and purified from chicken gizzards. Anti-actin rabbit serum was prepared and purified by affinity chromatography and defined by an immunoblotting test. Using the avidin-biotin-peroxidase complex (ABC) method, the actin antiserum was applied to paraffin sections prepared from hearts taken from routine autopsies of patients who had died of myocardial infarction. Reactivity was shown to be completely lost, not only in necrotized fibers, but also in non-specific degenerative fibers which could be identified by their eosinophilic cytoplasm with pyknotic nuclei, and clearly remaining and/or diminished cross-striations stained with hematoxylin-eosin. In contrast, hypertrophic myocardial fibers adjacent to granulation or scar tissue and those adjacent to infarcted foci exhibited a more intense reaction. These results indicated that the immunohistochemical reaction of actin filaments can be used for the easy detection of very mild degrees of degeneration of cardial muscle fibers, and for hypertrophic fibers adjacent to diseased foci. Studies of the immunoreactivity of actin protein suggestive of alteration at the molecular level might yield morphological clues regarding the nature of functional activity in the contraction of cardiac fibers.

Lectin (UEA-1) reaction of capillary endothelium with reference to permeability in autopsied cases of cerebral infarction

The relationship between endothelial reactivity to Ulex europaeus agglutinin-1 (UEA-1) and the permeability of the vascular wall in human autopsied cases of cerebral infarction was studied. Sections from the cerebral cortex were reacted with horseradish peroxidase UEA-1 to demonstrate the surface membrane of endothelial cells. Albumin in the neuropil of sections was demonstrated for the estimation of increased vascular permeability. The results showed that endothelial reactivity to UEA-1 was reduced in cases where death had occurred 3 to 5 days after onset of cerebral infarction. Reactivity was also diminished in cases where death had occurred after 13 and 25 days; these cases showed fresh ischemic lesions caused by re-attacks of infarction. Albumin extravasation into the neuropil was demonstrated in these intermediate cases. Chronic cases, dying after more than 52 days, showed no reduction of endothelial reactivity to UEA-1 and no albumin extravasation was proved. It was concluded that UEA-1 can be employed as a useful morphological marker for evaluation of endothelial function and vascular permeability.

A morphological study on the effects of collagen gel matrix on regeneration of severed rat sciatic nerve in silicone tubes

The present study is a chronological morphological examination on the effects of collagen gel matrix on regeneration of severed sciatic nerves. The nerves (5 mm length) were resected, and both the distal and proximal stumps were inserted into a silicone tube with 5 mm gap in between. In the test side, the gap in the tube was then injected with liquid collagen which gels in the tissue when reconstructed with a certain buffer solution. The gap space in the tube of the control side was left empty. In a chronological examination of the tissue in the tube, considerably more rapid growth of sprouting axons toward the distal stump in the test side was revealed in comparison with the control side. The cells, including both fibroblasts and larger Schwann cells, were less in number. More orderly directions were observed in the collagen matrix than in the control tube. The result indicates that regeneration of the peripheral nerves in the silicone tube can be improved, by using appropriate exogenous fine materials, collagen matrix.

Experimental study of WGA binding on the endothelial cell surface in cerebral ischemia

The relationship between the saccharide chain on the endothelial cell surface and the permeability of intracerebral blood vessels has been studied. In the present study, wheat germ agglutinin (WGA) was perfused into capillaries in the area postrema of the normal Mongolian gerbil, where the blood brain barrier (BBB) is known to lack, and into intracerebral blood vessels, the BBB of which had been destroyed by experimentally induced brain ischemia. The light microscopic features of the sections from WGA-perfused brain tissues of the normal gerbil revealed that most of the blood vessels, including capillaries in the brain parenchyma, showed positive findings (the reaction induced a very distinct staining of the vascular wall) from which the course and structure of the fine vessels could be determined. The reaction to WGA on the diaphragma fenestra (DF) in capillaries in the area postrema was relatively weak, and DF without the reaction were occasionally revealed by electron microscopy. The gerbil, in which cerebral ischemia had been induced, also showed partial defect of the reaction with WGA on the luminal side of the endothelial cells. The results of the present experiment suggest some degree of correlation between the saccharide chains, including the specific monosaccharide of WGA, on the endothelial cell surface and permeability. It was considered that lectin can be used as an index for morphological observations, suggesting an alteration in function of the endothelial cell membrane. In addition, the perfusion method in this experiment suggested the possibility of distinguishing pinocytotic vesicles from pits of cell membranes.

Neuronal changes of hypokalemic myopathy. A light- and electron-microscopic study on muscle biopsy

Hypokalemic myopathy has been observed in various clinical conditions. There are many studies of the pathomorphological changes of muscle fibers but alterations in intramuscular nerves and motor end-plates are seldom mentioned. The present authors observed biopsied muscle from a 51-year-old housewife who had suffered from gradually increasing muscle weakness. Laboratory examinations revealed a severe hypokalemia of 1.5 mEq/1, 18304 U/1 of CPK, 1300 U/1 of LDH, 343 U/1 of SGOT and 297 IU/1 of adolase. Light-microscopic examination showed changes previously described, including twin-peaked distribution in the histogram of type I, IIA and IIB fibers, ballooning and thickening of terminal axon, and 2 or 3 end-plates closely spaced along the length of muscle fibers. The electron-microscopic examination revealed empty folds of basement membrane in end-plate regions, reduced secondary synaptic clefts, interposition of Schwann cell processes between nerve ending and primary synaptic cleft, and an increase of disarranged microtubules and neurofilaments in terminal axons. The findings suggest that severe hypokalemia primarily produces structural alterations of intramuscular peripheral nerves and motor end-plates as well as of muscle fibers.