The outcome of a multidisciplinary approach incorporating neoadjuvant chemoradiotherapy with S1 for resectable pancreatic ductal adenocarcinoma

Aim

This study was performed to evaluate the efficacy of a multidisciplinary approach incorporating neoadjuvant chemoradiotherapy with S1 (S1-NACRT) for resectable pancreatic ductal adenocarcinoma.

Methods

The medical records of 132 patients who received S1-NACRT for resectable pancreatic ductal adenocarcinoma from 2010 to 2019 were reviewed. The S1-NACRT regimen consisted of S1 at a dose of 80-120 mg/body/day together with 1.8 Gy of radiation in 28 fractions. The patients were re-evaluated 4 weeks after S1-NACRT completion, and a pancreatectomy was then considered.

Results

Adverse events of S1-NACRT ≥grade 3 occurred in 22.7% of the patients, and 1.5% discontinued therapy. Of the 112 patients who underwent a pancreatectomy, 109 underwent R0 resection. Adjuvant chemotherapy with relative dose intensity ≥50% was administered to 74.1% of the patients who underwent resection. The median overall survival of all patients was 47 months, and the median overall survival and recurrence-free survival of patients who underwent resection was 71 and 32 months, respectively. According to the multivariate analyses of prognostic factors for overall survival in patients who underwent resection, negative margin status (hazard ratio: 0.182; P = 0.006) and relative dose intensity of adjuvant chemotherapy ≥50% (hazard ratio 0.294; P < 0.001) were independent prognostic factors of overall survival.

Conclusions

A multidisciplinary approach incorporating S1-NACRT for resectable pancreatic ductal adenocarcinoma demonstrated acceptable tolerability and good local control and resulted in comparable survival benefits.

Abstract P3-05-17: The numbers of Foxp3 positive cells in simultaneous bilateral breast cancer

Background

Evasion of the immune system is one of the hallmarks of malignant tumors, and recently blocking of such evasion has been used in clinical practice for the treatment of some types of cancers. Recruitment of regulatory T cells (Tregs), which express the specific marker Foxp3, is an established mechanism of escaping from the immune system. In breast cancer, it has been reported that the number of Tregs differs widely among breast cancer subtypes, and that patients who have many Tregs around the tumor tend to have a poor prognosis. However, the factors that are important for the recruitment of Tregs are not well known. Thus, factors that depend on the host (e.g., age or comorbidity), on the tumor (e.g., subtype, grade, or stage), or on measurement error might be the cause of the observed differences in the number of Tregs. In this study, we investigated the numbers of Tregs in simultaneous bilateral breast cancer patients in order to determine the factors that influence the recruitment of Tregs, while excluding differences in individuals as much as possible.

Material and methods

Patients who had breast cancer in both breasts and who underwent simultaneous surgery between January 2005 and September 2015 at two institutions were enrolled in this study. Patients who underwent primary systemic therapy who were diagnosed with ductal carcinoma in situ, or who were stage IV were excluded. The average numbers of Foxp3-positive (Foxp3+cells) were determined from scores of five high-power fields (HPFs). The association between the difference in Foxp3+ cell number between each breast in a single individual and clinicopathological features was examined.

Results

Seventy patients were included in this study. Their ages ranged from 39-85 (median 54) years old. Ninety five percent of the tumors were invasive ductal carcinoma non-special type. Eighty eight (62.9%), 43 (30.7%), and 9 (6.4%) of the tumors were T1, T2, and ≥T3, respectively, and 102 (72.9%) of the tumors were node-negative. Regarding nuclear grade (NG), 104 (74.3%), 21 (22.1%), and 7 (5%) of the tumors were NG1, 2, and 3, respectively. As for subtype, 124 (88.6%), 9 (6.4%), and 7 (5%) were ER-positive and HER2-negative(ER+/HER2-), ER-positive or negative and HER2-negative(ER±/HER2+), and ER-negative and HER2-negative(ER-/HER2-), respectively. The numbers of Foxp3+ cells ranged from 0 to 39.8 (median 3.3)/HPF, and difference in Foxp3+ cell number between each breast in a single individual ranged from 0 to 34 (median 3.9)/HPF.

Differences in tumor size and node status in individuals did not impact on the number of Foxp3+ cells. However, the number of Foxp3+ cells in tumors that were NG3 (P=0.00098) or ER±/HER2+ or ER-/HER2- type (P=0.00586) were statistically significantly increased compared with tumors that were NG1/2 or ER+/HER2- type in the same host.

Furthermore, the difference of Foxp3+ cells between each tumor in a single individual were quite small regarding tumor size and node status in 53 patients who had similar NG and subtype tumors in both breasts.

Conclusions

The number of Foxp3+ cells showed no relationship with tumor size, or lymph node status in simultaneous bilateral breast cancer patients. High NG, ER±/HER2+ or ER-/HER2- type of the tumor were involved with enhancement of the recruitment of Tregs.

Citation Format: Goto R, Hirota Y, Aruga T, Horiguchi S, Tazawa S, Nakamura S, Takimoto M. The numbers of Foxp3 positive cells in simultaneous bilateral breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-05-17.

Diabetic striatopathy manifesting as severe consciousness disturbance with no involuntary movements

BACKGROUND

Diabetic striatopathy, one of the complications of diabetes mellitus, is characterized by involuntary movements, including hemichorea and hemiballismus, and the presence of hyperintense lesions on T1-weighted magnetic resonance imaging of the striatum.

CASE REPORT

We present a case of diabetic striatopathy manifesting as severe consciousness disturbance without chorea or ballismus. A 58-year-old man was admitted to our hospital in a state of unconsciousness. He was diagnosed with diabetic striatopathy as a result of extremely elevated blood glucose levels and typical magnetic resonance imaging findings in the left striatum, although involuntary movements were absent. He was treated with insulin, and his glucose levels were well maintained. His neuropsychiatric symptoms recovered, rather slowly but completely, after ~20 days.

CONCLUSION

This case indicates the diversity of striatal dysfunction induced by hyperglycaemia. For good prognosis of diabetic striatopathy, prompt diagnosis and appropriate treatments are important. Physicians should be aware that this disease can cause various neurological and psychiatric symptoms other than chorea or ballismus.

A low number of tumor infiltrating FOXP3-positive cells after primary systemic chemotherapy is correlated with favorable relapse-free survival in breast cancer patients

Abstract #5043

Background: Cancer cells induce proliferation and local accumulation of immunosuppressive cells such as FOXP3-positive cells which known as regulatory T cells (Tregs). Tregs prevent the maturation of dendritic cells and their capacity to present tumor antigens to cytotoxic T lymphocytes (CTLs) and leads to tumor-induced tolerance. Although cancer chemotherapy was usually considered as immunosuppressive, some chemotherapeutic agents have recently been shown to activate an anticancer immune response, which is involved in the curative effect of these treatments. Therefore, we hypothesized that number of tumor infiltrating FOXP3-positive cells during primary systemic chemotherapy is correlated with therapeutic results in breast cancer patients.&#x2028; Methods: To test the hypothesis, between September 2000 and January 2005, breast cancer patients treated with primary systemic chemotherapy (PSC) (n=93) were included in the study. Three cases were excluded because main tumors were resected before PSC and three cases of pathological complete reaction were excluded because they were hard to define “tumor infiltrating” Tregs. To compare the number of FOXP3 positive cells in the tumors before and after PST, both core-needle biopsy (CNB) and surgical resected specimens were stained with FOXP3 monoclonal antibody. Numbers of tumor infiltrating FOXP3-positive cells were counted in 3 and 5 randomly chosen high power fields (CNB and surgical specimens, respectively). A median cutoff of &gt;16.3 and &gt; 6.6 defined patients with high numbers of Tregs (CNB and surgical specimens, respectively). We also divided the patients into four groups (high numbers of FOXP3 positive cells in both CNB and surgical specimens; HH, low numbers in the both specimens; LL, high numbers in CNB and low in the surgical specimens; HL, and low in CNB and high in surgical specimens; LH). All patients were treated with anthracyclin containing therapy and 79.3 %( n=69) of them were added taxanes sequentially.&#x2028; Results: In the tumors after PST, numbers of Tregs were significantly higher in lymphvessel invasion positive tumors (P=0.01) and ER negative tumors (P=0.02) but there was no correlation between lymph node involvement and numbers of Tregs (P=0.8). As for the comparison of four groups, LL group shows the longest relapse-free (P=0.04) and overall survival (P=0.09) and HH group shows the shortest relapse-free and overall survival among four groups. Interestingly, HL group shows better outcome than HH group and LH group shows worse one than LL.&#x2028; Conclusions: These findings suggest that the control of Tregs in the tumor is important for the control of the disease and Tregs might be an important therapeutic target for breast cancer. Furthermore, it is suggested that some chemotherapeutic agents could be a potential inhibitor of the Tregs in tumor and show antitumor effects addition to their direct cytotoxicity against cancer cells.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5043.

Beneficial effects of leukotriene receptor antagonists in the prevention of cedar pollinosis in a community setting

BACKGROUND

In recent years, many countries have experienced an increase in the prevalence of allergic rhinitis. No effective approach is currently available to prevent the onset of symptoms in allergic individuals. Pranlukast, a leukotriene receptor antagonist with a good safety and efficacy record for the management of allergic inflammation, may be appropriate for early intervention in the management of pollinosis.

OBJECTIVE

To investigate the efficacy of pranlukast as an early intervention in the control of cedar pollinosis.

METHODS

In a double-blind comparative study, pranlukast (n = 102) or placebo (n = 91) was administered to cedar pollinosis patients immediately before the start of the dispersion season and continued for 4 weeks. Subsequently, pranlukast was administered to all patients for 2 weeks until the end of the cedar pollen dispersion season (mid-March). All patients were carefully monitored for severity of nasal symptoms, symptom scores, medication scores, symptom-medication scores, and quality of life (QOL).

RESULTS

Compared with placebo, therapy with pranlukast before and during the dispersion of cedar pollen in these patients significantly improved nasal symptoms (paroxysmal sneezing, rhinorrhea, and nasal congestion), symptom scores, and symptom-medication scores. The drug also significantly reduced deterioration of QOL, and improved nasal symptoms and QOL throughout the dispersion period.

CONCLUSION

Administering pranlukast immediately before the beginning of cedar pollen dispersion is effective in reducing symptoms of allergic rhinitis throughout the dispersion period.

Detection of natural killer T cells in the sinus mucosa from asthmatics with chronic sinusitis

BACKGROUND

Chronic sinusitis (CS) with asthma generally exhibits a high degree of sinus tissue eosinophilia and recurrence often occurs even after surgical therapy. However, the cause has not yet been fully clarified.

AIMS OF THE STUDY

To elucidate the pathogenesis of this refractory disease, we examined the infiltration of natural killer T (NKT) and type 1 helper T (Th1)/type 2 helper T (Th2) cells, and the cytokine expression in the sinus mucosa.

METHODS

Sinus mucosal specimens were obtained surgically from 16 CS patients with nasal polyps. The NKT cells, Th1/Th2 cells and the expression of IL-4, IL-5, IL-13 and IFN-gamma were examined by a polymerase chain reaction or flow cytometry. Nasal mucosal specimens from six other patients with allergic rhinitis (AR) were examined in a similar manner.

RESULTS

The NKT cells were detected to varying degrees in the sinus mucosa from asthmatic CS patients, but neither in the nonasthmatics nor in the nasal mucosa from the patients with AR. The Th2 cells and Th2 cytokines were expressed at significantly higher levels in the sinus mucosa from the CS patients with asthma in comparison to those without asthma. However, the Th1 cell infiltration and IFN-gamma expression were not different between these groups.

CONCLUSION

Natural killer T cells may, therefore, play important roles in the enhanced Th2 cytokine expression and increased infiltration of Th2 cells and eosinophils observed in the sinus mucosa from asthmatic CS patients through MHC-independent mechanisms.

Influence of viral infection on the development of nasal hypersensitivity

BACKGROUND

The underlying relationship between viral infections and allergic diseases of the upper respiratory tract has not been well clarified.

METHODS

In order to clarify the relationship between viral infection and nasal hypersensitivity, mice were sensitized with ovalbumin (OVA) and then infected intranasally with respiratory syncytial virus (RSV), after which their nasal sensitivity to histamine or antigen was examined.

RESULTS

Non-sensitized mice showed transient mild nasal hypersensitivity following nasal administration of histamine after intranasal RSV inoculation. In mice sensitized with OVA, RSV infection significantly exaggerated their nasal hypersensitivity to histamine and OVA. Treatment of these mice with a neurokinin (NK)-1/NK-2 receptor antagonist, but not with anti-IL-5 antibodies, reduced their hypersensitivity. The infiltration of nasal mucosa with eosinophils was temporarily associated with accelerated rate of RSV elimination in these animals.

CONCLUSION

RSV infection induced transient nasal hypersensitivity. Several mechanisms, including impairment of nasal epithelial cells are thought to mediate this effect. In allergen-sensitized mice, RSV inoculation strongly enhanced nasal hypersensitivity.

Association between intratumoral free and total VEGF, soluble VEGFR-1, VEGFR-2 and prognosis in breast cancer

Vascular endothelial growth factor (VEGF) receptors consist of three cell-membrane type receptors (VEGFR-1, VEGFR-2 and VEGFR-3), and soluble form of VEGFR-1 (sVEGFR-1), an intrinsic negative counterpart of the VEGF. In this study, we measured intratumoral protein levels of free and total VEGF, VEGFR-2 and sVEGFR-1 from 202 primary breast cancer tissues and examined their prognostic values. A significant inverse correlation was found between free or total VEGF and oestrogen receptor (ER) status (P=0.042 and 0.032, respectively). A univariate analysis showed that low sVEGFR-1 and high total VEGF were significantly associated with poor prognosis in disease-free survival (DFS) and overall survival (OS). The ratio of sVEGFR-1 to total VEGF was a strong prognostic indicator (DFS: P=0.008; OS: P=0.0002). A multivariate analysis confirmed the independent prognostic values of total VEGF and the ratio of sVEGFR-1 to total VEGF. In subgroup analysis, total VEGF was a significant prognostic indicator for ER-positive tumours but not for ER-negative tumours, whereas sVEGFR-1 was significant for ER-negative tumours but not for ER-positive tumours. In conclusion, the intratumoral sVEGFR-1 level, VEGF level and the ratio of sVEGFR-1 to total VEGF are potent prognostic indicators of primary breast cancer, and might be relevant to ER status.

Modulation of thymidine phosphorylase by neoadjuvant chemotherapy in primary breast cancer

The combination effect of docetaxel and capecitabine on tumour response rate and survival was demonstrated recently in metastatic breast cancer patients. This combination was based on an experimental hypothesis that taxane can increase tumour sensitivity to the effect of capecitabine through the upregulation of thymidine phosphorylase (TP), which is responsible for the metabolism of 5-fluorouracil (5-FU) and its derivatives, including capecitabine. To examine the alteration in TP expression before and after neoadjuvant chemotherapy, 92 patients with primary breast cancer (T2-4N0-1M0) were enrolled in this study; 14 were treated with adriamycin and cyclophosphamide (AC) or epirubicin and cyclophosphamide (EC); 58 with 5-FU, adriamycin, and cyclophosphamide (FAC) or 5-FU, epirubicin, and cyclophosphamide (FEC); and 20 with FEC followed by docetaxel/taxotere (TXT-containing regimen). Thymidine phosphorylase upregulation was seen in 54.4% and 32.6% of patients in tumour cells and stromal cells, respectively. Increases in TP expression were found only in the AC/EC and TXT-containing regimen groups. In conclusion, it was strongly suggested that unlike 5-FU-containing regimens, the taxane and AC combination therapies upregulate TP expression in primary breast cancer. Thymidine phosphorylase upregulation by several anticancer drugs implies the importance of individualised strategies for sensitisation of tumour tissues to 5-FU and its derivatives.

Contribution of Na+/Ca2+ exchanger to the regulation of myogenic tone in isolated rat small arteries

The contribution of the Na+/Ca2+ exchanger to the myogenic vascular tone was examined in rat isolated skeletal muscle small arteries (ASK) with pronounced myogenic tone and mesenteric small arteries (AMS) with little myogenic tone. Myogenic tone was assessed by the vascular inner diameter at transmural pressures of 40 and 100 mmHg. To depress the Na+/Ca2+ exchanger, the extracellular Na+ concentration ([Na+]o) was lowered from 143 to 1.2 mM by substituting choline-Cl for NaCl. The ASK developed significant myogenic tone and constricted further in low [Na+]o. Nifedipine (1 microM) reduced both myogenic tone and low [Na+]o-induced contraction. Because the membrane potential of ASK was not changed by low [Na+]o (-35 +/- 2 mV at 143 mM [Na+]o, -37 +/- 3 mV at 1.2 mM [Na+]o), depolarization-induced Ca2+ influx was not a cause of the low [Na+]o-induced contraction. The AMS did not develop significant myogenic tone. Although low [Na+]o also constricted AMS, the magnitude of constriction was significantly weaker than that in ASK (17 +/- 4 vs. 47 +/- 6%, P < 0.01, at 58 mM Na+). With Bay K 8644, AMS developed myogenic tone, and low [Na+]o-induced constriction was significantly increased. In conclusion, Na+/Ca2+ exchanger may play an important role in regulating myogenic tone, likely via mediating Ca2+-extrusion.

Expression and anticoagulant function of the endothelial cell protein C receptor (EPCR) in cancer cell lines

Induction of procoagulant factors in malignant cells is considered to be the major cause of coagulation disorders in cancer. Thrombomodulin (TM), a negative regulator of coagulation was also found to be expressed in cancer cells. We report here evidence for another anticoagulant, the endothelial cell protein C receptor (EPCR), in cancer cells. EPCR was detected in several cell lines derived from various types of cancer. Significant levels of protein C (PC) activation were detected only with cell lines expressed both EPCR and TM. Anti-EPCR monoclonal antibodies (mAbs) specifically inhibited the activation. Thus, EPCR function appears to be important for PC activation by cancer cells. In addition, we detected EPCR expression in tumor cells from breast cancer patients, with an extremely high frequency. EPCR function may contribute to progression or pathogenesis of some types of cancer, and may explain the complexity of coagulopathy in cancer patients.

Interaction between L-type Ca2+ channels and sarcoplasmic reticulum in the regulation of vascular tone in isolated rat small arteries

A dysfunction of the sarcoplasmic reticulum (SR) causes an increase in the myogenic tone of rat skeletal muscle small arteries (A(SK)), but not that of mesenteric small arteries (A(MS)). We hypothesized that the difference depends on the activity of voltage-dependent Ca2+ channels in these vessels. To test this, we measured the membrane potential of these vessels and examined ryanodine-induced constrictions by manipulating the activity of voltage-dependent Ca2+ channels. The isolated vessels were cannulated to control the transmural pressure. To assess the vascular tone, the inner diameter was measured with a video-digitizing system. The membrane potential of A(SK) was more depolarized between 20 to 100 mm Hg of transmural pressure. A(MS) was not constricted by the Ca2+ channel agonist Bay K 8644 (1 nM(-1) microM) alone, but substantially constricted in the presence of ryanodine (1 microM). Ryanodine also augmented the KCl (20 mM)-induced constriction. In A(SK), the Ca2+ channel blocker nisoldipine fully dilated the ryanodine-induced constriction: however, the ryanodine-induced constriction was less susceptible to nisoldipine than was the myogenic and phenylephrine-induced constriction caused mainly by increased Ca2+ influx. In conclusion, the contribution of the SR function to Ca2+ metabolism depends on the activity of dihydropyridine-sensitive Ca2+ channels. The dysfunction of SR by ryanodine may impair the Ca2+ extrusion rather than increase Ca2+ influx in rat small arteries.

Possible metabolic interaction between hexane and other solvents co-exposed at sub-occupational exposure limit levels

OBJECTIVE

To investigate whether metabolic interactions exist between hexane (HEX) and other solvents when co-exposed at the levels below occupational exposure limits.

METHODS

Workers, 219 men in ten workshops in total, volunteered to participate in the study. They were occupationally exposed to mixtures of HEX and one or more of toluene (TOL), ethyl acetate (EA) and acetone (ACE). Time-weighted average intensity of vapor exposures was monitored by diffusive personal sampling. 'Free'- and 'total'-2,5-hexanedione (HD) levels in the end-of-shift urine samples were determined by gas chromatography (GC) before and after acid hydrolysis of urine, respectively, and expressed as observed (HDob) or after correction for creatinine concentration (HDcr) or urine specific gravity (HDsg). Possible interaction was examined by multiple regression analysis (MRA), taking either free- or total-HD as a dependent variable, and the four solvent concentrations as independent variables.

RESULTS

In most cases, exposure intensity did not exceed the current occupational exposure limits even when additiveness was assumed. In addition that HEX was the most influential independent variable in all cases as expected, the MRA showed that, in cases of free-HD, ACE was also influential to HDob although weakly, but not to HDcr or HDsg. With regard to total-HD, ACE was weakly influential to HDob and HDsg, and EA also weakly to HDcr. The effect of ACE on free- or total-HD was not detected, however, when 22 men exposed only to HEX and ACE were subjected to the same analysis. Similarly, the effect of EA on total-HD was not observed among the remaining 197 men exposed to HEX, TOL and EA only.

CONCLUSIONS

When the exposures were below occupational exposure limits, the free-HD levels in urine after HEX exposure will not be modified by co-exposures to TOL, EA or ACE.

Primary chemically induced tumors induce profound immunosuppression concomitant with apoptosis and alterations in signal transduction in T cells and NK cells

Whereas transplantable tumors can be readily cured with immunotherapeutic approaches, similar therapies in cancer patients have been less effective. This difference may be explained by an immunosuppression resulting from the presence of a slowly growing primary tumor in the patient, whereas the immune system in a mouse with a rapidly proliferating transplantable tumor would be less affected. As a more appropriate model to the immune dysfunction in patients, slowly progressing primary tumors were induced by the carcinogen methylcholanthrene (MC) in mice. Their ability to induce immunosuppression in T cells and natural killer (NK) cells was compared to that of rapidly growing transplanted MC-induced tumors. The results demonstrate that mice bearing primary MC tumors had significantly diminished T-cell and NK-cell functions, impaired capacity to produce Th1 cytokines, and markedly reduced levels of the signal-transducing zeta chain in T cells and NK cells, similar to that described in cancer patients. Moreover, a substantial number of CD8+ T cells in mice with large primary MC tumors were undergoing apoptosis, correlating with alterations in CD4/CD8 ratios. In contrast, T cells and NK cells from mice bearing rapidly growing transplanted tumors were only marginally affected. These findings could explain the apparent discrepancy between the consistent findings of a diminished immune response and alterations in signal transduction in cancer patients as compared to the less reproducible observations in murine transplantable tumors. In addition, they could explain the differences in the high efficacy of immunotherapy in mice with transplantable tumors and the low therapeutic results in cancer patients.

Clinical features of paroxysmal positional vertigo presenting combined lesions

Benign paroxysmal positional vertigo (BPPV) is one of the common vestibular disorders. Canalolithiasis is thought to be a likely lesion. A canalith repositioning procedure (CRP by Epley) generally yields good resolution of vertigo and nystagmus. The authors confirmed the efficacy of this procedure on typical BPPV of the posterior semicircular canal type. We designed a new procedure for BPPV of the lateral canal type, which also yielded satisfactory results. BPPV sometimes presents a nystagmus pattern, which suggests multiple lesions. We have seen eight cases of BPPV showing nystagmus that combines both the posterior and the lateral canal types. Combined CRP was performed on these cases, which again gave good clinical results. Other BPPV cases were associated with central lesions. We must be aware that BPPV may involve multiple canals and may be associated with central lesions.

Peripheral hemodynamics evaluated by acceleration plethysmography in workers exposed to lead

To clarify the effect of lead exposure on peripheral hemodynamics, acceleration plethysmography (APG) was performed for 48 male subjects occupationally exposed to lead (exposure group) and 43 male subjects with no history of occupational exposure to lead (control group). In the exposure group, the blood lead concentration (Pb-B) was also measured. Each APG parameter was assessed by comparing measured data with the standard aging curves. A significant negative correlation was obtained between the parameter--b/a and Pb-B. The exposure group showed significantly lower values of parameters--b/a (p < 0.01) and d/a (p < 0.05) than the control group. The parameter--b/a in the exposure group dose-dependently decreased with increases in length of working career (duration of exposure to lead) and Pb-B. The parameter--b/a significantly (p < 0.05) decreased in subjects with working careers of 5 years or more and in subjects whose Pb-B was 40 micrograms/100 ml or more. These results suggest that lead exposure affects peripheral hemodynamics as evaluated by APG.

Endosaccular embolization for internal carotid artery aneurysms at the c3 portion

SUMMARY

Direct surgery for the aneurysms at the C3 portion of the internal carotid artery (ICA) requires relatively complicated procedures. We present three patients with this aneurysm who underwent endovascular embolization. The remodelling technique was utilized in two of these patients with unruptured aneurysms. Sufficient obliteration was achieved in every case. Endovascular embolization may be an important alternative for ICA C3 aneurysms.

Selective caries removal with air abrasion

The purpose of this study was to evaluate selective caries removal using an air-abrasive technique. Alumina powders, glass beads, crushed glass powders, and crushed powders of polycarbonate resin were applied to intact human enamel, dentin, and artificially demineralized dentin (caries-model dentin). Furthermore, the effect of the particle size of abrasives and air pressures on the abraded depths was examined. When alumina powders and glass beads were used, the abraded depths of enamel, dentin, and caries model increased as the particle size and air pressure increased. Alumina powders and crushed glass powders abraded intact enamel and dentin more than the caries-model dentin, whereas glass beads abraded the caries-model dentin more than the intact enamel and dentin. Only crushed powders of polycarbonate resin abraded the caries-model dentin without reducing intact enamel and dentin. With hard particles, such as alumina powders, glass beads, or crushed glass powders, selective caries removal by the air-abrasive technique appeared to be difficult to achieve, even if the particle size and the air pressure were changed. Crushed powders of polycarbonate resin that reduced only the caries-model dentin are harder than caries-model dentin, but softer than intact enamel and dentin. This study elucidated the possibility of selective carious dentin removal with the air-abrasive technique.

MERIT-9: a patient information exchange guideline using MML, HL7 and DICOM

To realize clinical data exchange between healthcare providers, there must be many standards in many layers. Terms and codes should be standardized, syntax to wrap the data must be mutually parsable, then transfer protocol or exchange media should be agreed. Among many standards for the syntax, HL7 and DICOM are most successful. However, everything could not be handled by HL7 solely. DICOM is good for radiology images, but, other clinical images are already handled by other 'lighter' data formats like JPEG, TIFF. So, it is not realistic to use only one standard for every area of clinical information. For description of medical records, especially for narrative information, an standard generalized mark-up language, document type definition (SGML DTD) for medical information, called MML (medical markup language) had been created in Japan. It is already implemented in more than ten healthcare providers. However, it is again not realistic to use MML solely for clinical information in various level of detail. Therefore, we proposed a guideline for use of available medical standards to facilitate clinical information exchange between healthcare providers. It is called MERIT-9 (Medical Records, Images, Texts, -Information Exchange). A typical use is HL7 messages, DICOM files, referred from an MML file in a patient record, as external entities. Both MML and MERIT-9 have been research projects of Japanese Ministry of Health and Welfare and the purpose is to facilitate clinical data exchanges. They are becoming to be used in technical specifications for new hospital information systems in Japan.

Types of organic solvents used in workplaces and work environment conditions with special references to reproducibility of work environment classification

A survey of solvent was conducted for 196 unit work areas in 95 plants in 1994 to 1996 in Hiroshima Prefecture, Japan. The survey had been repeated every 6 months (i.e., twice a year) during the 3-year period. Sampling and analysis of the solvent vapors were carried out after national protocols set by the regulation. Toluene was most frequently detected regardless of the type of solvent work (except for degreasing), whereas the second- and the third-most common solvents varied depending on the type of solvent works. Among chlorinated hydrocarbon solvents for degreasing, dichloromethane was most widely used. Solvent concentrations were generally low as none of the median concentrations exceeded corresponding Administrative Control Levels set by the regulation, either individually or even when the assumption of additiveness was applied. Among the 1176 cases analyzed, 80% of the unit work areas were evaluated as adequate (i.e., classified as Class I). Furthermore, about 57% stayed in Class I throughout the 3 years, suggesting that solvent exposure conditions were generally quite stable. In regulatory evaluation by classification, A-sampling was decisive in most cases, whereas the role of B-sampling was limited.

[A case of pituitary apoplexy: remarkable improvement of visual acuity and field by surgical intervention at the subchronic stage]

A case is reported of a pituitary apoplexy which shows remarkable improvement of visual acuity and field by transsphenoidal surgery performed 33 days after hemorrhage. Possible factors contributing to this excellent surgical outcome are speculated about as follows; atrophic brain (wide suprasellar cistern), destruction of the sella floor by the tumor (infrasellar/extracranial decompression), no vasospasm (pure intracapsular hemorrhage), no hypopituitarism, less invasive operation (transsphenoidal surgery), and so on. Transsphenoidal surgery is thought to be worth performing for pituitary apoplexy, even if timing for the operation is later than the acute stage and even if initial visual impairment is severe.

Diffusive sampling and biological monitoring of 2-bromopropane

The possibilities to apply personal ambient air monitoring by diffusive sampling and biological exposure monitoring by urinalysis for 2-bromopropane or its metabolites were explored. The abilities of carbon cloth to adsorb 2-bromopropane was examined by experimental vapor exposure followed by solvent extraction and FID-GC. Urine from factory workers and rats exposed to 2-bromopropane were analyzed for 2-bromopropane, acetone and isopropyl alcohol by FID-GC, and for bromide ion by ECD-GC after chemical methylation. Carbon cloth adsorbed 2-bromopropane in a manner linearly related to exposures up to 1500 mg/m3 and to 8 h. The adsorption could quantitatively detect a 15 min peak exposure at 3,000 mg/m3. In rat experiments, analyses of urine samples collected over a 4-h period after termination of a 4-h exposure to 2-bromopropane at 500, 1,000 or 1,500 mg/m3 showed that acetone and bromide ion were excreted dose-dependently. Essentially, no 2-bromopropane or isopropyl alcohol was detected. When the analytical methods were applied to urine samples from 5 male workers exposed to 2-bromopropane at a low level (3 mg/m3 as a geometric mean), acetone and bromide ion levels were within respective normal ranges in four cases, but were higher than the upper limits of the normal ranges in the fifth case of a foreman who probably had the highest exposure. Thus, diffusive sampling is applicable to monitor exposure to 2-bromopropane. Urinalysis for acetone and bromide ion in combination appears to be a promising selective tool for biological monitoring of occupational exposure to 2-bromopropane.

FMLP actions and its binding sites in isolated human coronary arteries

The chemoattractant f-Met-Leu-Phe (FMLP) can modulate human coronary arterial tone without the involvement of peripheral leukocytes. We investigated the actions of FMLP and its cellular mechanism in human coronary arteries isolated 2-3 h after death. A single dose of FMLP (0.01-10 microM) produced transient contraction (or, followed by relaxation) responses in most human coronary rings examined. These responses to FMLP were in large part mediated by the generation of cyclooxygenase products, mainly thromboxane A2 (TXA2) and prostaglandin I2 (PGI2). Radiolabeled N-formyl hexapeptide. 125I-f-Nle-Leu-Phe-Nle-Tyr-Lys bound densely to intimal and adventitial sites that accumulated macrophages (CD68-positive) with a Kd of 14-29 nM and, further, weakly to the media with a Kd of 2.4-3.6 microM. Several cell types including macrophages, endothelial cells and smooth muscle cells were positively immunostained for both TXA2 synthase and PGI2 synthase. However, there was no significant relation between the magnitude of the responses to FMLP and dense macrophage accumulation in the intimal plaques or the adventitia. A reverse transcription-polymerase chain reaction showed predominant expression of FMLP receptor homologues, FPRH1 and FPRH2 mRNA, in human coronary medial tissues relative to that in leukocytes. In conclusion. FMLP produced transient tension changes in human coronary arteries, mainly via the generation of TXA2 and PGI2. This effect of FMLP did not appear to be mediated by the activation of densely accumulated intimal and/or adventitial macrophages, but by the activation of unidentified medial tissue cells which might have functional FMLP receptor homologues.

Role of cytosolic Ca2+ and protein kinase C in developing myogenic contraction in isolated rat small arteries

Cytosolic Ca2+ and protein kinase C (PKC) may regulate the myogenic contraction of arterial myocytes. The role of these second messengers is examined in skeletal muscle small arteries, which have strong myogenic activity, and mesenteric small arteries, which have weak myogenic activity. The vessels were isolated and cannulated. The inner diameter was measured with a video-digitizing system. Cytosolic Ca2+ concentration was assessed by fura 2. Skeletal muscle small arteries dilated from 122 +/- 6 to 153 +/- 6 microm immediately after the transmural pressure change from 40 to 100 mmHg and constricted to 121 +/- 5 microm (myogenic contraction) with an increase in the 340/380 fluorescence ratio (by approximately 33%) in control vessels. Nifedipine abolished myogenic contraction and the increase in the fluorescence ratio. PKC inhibitors (H7 and staurosporine) abolished myogenic contraction but did not depress the increase in the fluorescence ratio. In mesenteric small arteries, myogenic contraction was insignificant in control vessels. A relatively low dose of PKC activator (4.4 +/- 1.4 nmol/l) elicited myogenic contraction, but a higher dose (21 +/- 6 nmol/l) depressed it. Thus the cytosolic Ca2+ increase and PKC activity may cooperatively act on the myogenic contraction of skeletal muscle small arteries. The activity of PKC should play an important role in myogenic contraction of rat small arteries.

Monitoring of occupational exposure to 1-butanol by diffusive sampling and urinalysis

OBJECTIVES

To investigate the possibility of applying diffusive air sampling and urinalysis (for mother compound and metabolites) to the monitoring of exposure of factory workers to 1-butanol.

METHODS

The performance of carbon cloth in adsorbing 1-butanol vapor in air was studied by experimental exposure of the cloth to 1-butanol at 50, 100, 200 or 400 ppm for up to 10 h. 1-Butanol in the exposed cloth was extracted with carbon disulfide and this was followed by gas-chromatographic (GC) analysis. Urine samples were collected from factory workers occupationally exposed to 1-butanol and from rats exposed experimentally to 1-butanol vapour (up to 200 ppm). The urine samples were analyzed by GC without any pretreatment, or after treatment with hydrochloric acid or hydrolase preparation.

RESULTS

The performance of the carbon cloth was such that it adsorbed 1-butanol in proportion to the concentration (up to 400 ppm) and the duration (up to 10 h) of exposure, and responded quantitatively to a 15-min exposure up to 400 ppm. The amount of 1-butanol (after enzymic or acid hydrolysis) in post-exposure urine samples from rats was proportional to the exposure intensity. The proportion of free 1-butanol in total 1-butanol (i.e., free+conjugated) in urine was higher after 100 or 200 ppm exposure (35-40%) than after 50 ppm exposure (about 8%). There was a significant increase in total 1-butanol concentration (but not in free 1-butanol) in shift-end urine samples of workers exposed to 1-butanol at concentrations up to 3 ppm.

CONCLUSIONS

Diffusive sampling with carbon cloth as an adsorbent can be applied to ambient air monitoring of exposure to 1-butanol. Urinalysis for 1-butanol after hydrolysis is sensitive enough to detect occupational 1-butanol vapour exposure at 3 ppm.

Toluene itself as the best urinary marker of toluene exposure

Head-space gas chromatography (GC) and high-performance liquid chromatography (HPLC) (with fluorescence detectors) methods were developed for toluene (TOL-U) and o-cresol (CR-U) in urine, respectively. In order to identify the most sensitive urinary indicator of occupational exposure to toluene vapor (TOL-A) among TOL-U, CR-U, and hippuric acid in urine (HA-U), the two methods together with an HPLC (with untraviolet detectors) method for determination of HA-U were applied in the analysis of end-of-shift urine samples from 115 solvent-exposed workers (exposed to toluene at 4 ppm as geometric mean). Regression analysis showed that TOL-U correlated with TOL-A with a significantly higher correlation coefficient than did HA-U or CR-U. With regard to the TOL-A concentrations at which the exposed subjects could be separated from the nonexposed by the analyte, TOL-U achieved separation at < 10 ppm TOL-A, whereas both HA-U and CR-U did so only when TOL-A was 30 ppm or even higher. The ratio of the analyte concentrations at 50 ppm TOL-A to those at 0 ppm TOL-A was also highest for TOL-U. Overall, the results suggest that TOL-U is a better marker of exposure to toluene vapor than HA-U or CR-U.

The role of extracellular cations in the development of myogenic contraction in isolated rat small arteries

The purpose of this study was to determine the roles of extracellular cations (Na+, Ca2+ and K+), membrane K+ channels and Na+/K+ ATPase in the development of myogenic contraction (transmural pressure-induced contraction) in isolated rat skeletal muscle and mesenteric small arteries. The vessels were pressurized under no-flow conditions in a tissue bath. Lumen diameter was measured with a videomicroscopic system. Myogenic contraction was evoked by increasing the lumen pressure from 40 to 100 mmHg. The vessels demonstrated myogenic contraction in low-Na+ (Na+ 1.18 mmol/L) physiological salt solution (PSS), and this was abolished by removing Ca2+ or by applying nifedipine or nisoldipine (10 mumol/L). Neither tetraethylammonium (TEA, 1 mmol/L), Ba2+ (10 mumol/L) nor glibenclamide (1 mumol/L) affected the magnitude of the myogenic contraction. K(+)-free PSS and ouabain (0.1 mmol/L) partially depressed myogenic contraction. In conclusion, myogenic contraction was triggered by a cellular process that requires extracellular Ca2+, but not Na+ or K+. This triggering process is not affected by TEA, Ba2+ or glibenclamide.

Early diagnosis and stage classification of vocal cord abductor paralysis in patients with multiple system atrophy

OBJECTIVES

Vocal cord abductor paralysis (VCAP) is a life threatening complication which may cause nocturnal sudden death in patients with multiple system atrophy. However, the early diagnosis of VCAP is often difficult to make on routine laryngoscopy performed during wakefulness, as stridor, which is the sole symptom of VCAP in the early stage, develops only during sleep. The aim was to investigate laryngeal dysfunction in patients with multiple system atrophy while awake and asleep.

METHODS

Seven patients with multiple system atrophy with nocturnal stridor and five control patients were studied. Vocal cord movement was analysed by laryngoscopy while the patients were awake and also during sleep induced by intravenous diazepam.

RESULTS

When awake, for the seven patients with multiple system atrophy normal movement of the vocal cords occurred in three, mild abduction restriction in three, and paradoxical movement in one. When asleep, however, all showed obvious paradoxical movement with high pitched inspiratory stridor. In controls, there were no differences in the vocal cord movement between wakefulness and sleep. From these findings, VCAP could be divided into four stages: stage 0 (normal) with normal vocal cord movement during both wakefulness and sleep, stage 1 (mild VCAP) with normal movement during wakefulness and paradoxical movement during sleep, stage 2 (moderately severe VCAP) with abduction restriction during wakefulness and paradoxical movement during sleep, and stage 3 (severe VCAP) with an almost midline position for the vocal cords during both wakefulness and sleep.

CONCLUSIONS

Laryngoscopy during sleep can disclose subclinical VCAP, making an early diagnosis of VCAP in patients with multiple system atrophy. Stage 2 of VCAP seems to be a suitable stage for tracheostomy in patients with multiple system atrophy.

Monitoring of exposure to methylpentanes by diffusive sampling and urine analysis for alcoholic metabolites

OBJECTIVES

To investigate the possibilities of personal ambient monitoring and biological monitoring for methylpentane isomers.

METHODS

The performance of activated carbon cloth to absorb 2- and 3-methylpentane was studied by experimental vapour exposure followed by solvent extraction and gas chromatography (GC). Urine from workers and rats exposed to 2- and 3-methylpentane was analysed by GC with or without acid or enzymatic hydrolysis.

RESULTS

Carbon cloth absorbed 2- and 3-methylpentane linearly to exposures up to eight hours and to 400 ppm, and was sensitive enough to detect a 15 minute peak of exposure. The two isomers were clearly separated from hexane on a DB-1 column. For analysis of the urine, enzymatic hydrolysis was superior to acid hydrolysis. Exposure of rats to methylpentane vapours showed that 2-methyl-2-pentanol and 3-methyl-2-pentanol were excreted in urine in proportion to the dose of 2-methylpentane and 3-methylpentane, respectively. 2-Methyl derivatives of 1-, 3-, and 4-propanol, 2-methylpentane-2,4-diol, and 3-methyl-2-pentanol were minor metabolites. Analysis of urine from the exposed workers showed that 2-methyl- and 3-methyl-2-pentanol are leading urinary metabolites after exposure to the corresponding methylpentane.

CONCLUSIONS

Diffusive sampling is applicable to monitor 2- and 3-methylpentane vapours as is the case for hexane vapour. 2-Methyl-2-pentanol and 3-methyl-2-pentanol will be markers of occupational exposure to 2-methylpentane and 3-methylpentane, respectively. Also, 2-methylpentane-2,4-diol might be a marker of exposure to 2-methylpentane.

Vocal cord abductor paralysis (VCAP) in Parkinson's disease: difference from VCAP in multiple system atrophy

Vocal cord abductor paralysis (VCAP) is rare in Parkinson's disease (PD), while it is frequent in multiple system atrophy (MSA). Although VCAP is a life-threatening complication it has not yet been clarified whether there is any difference in the mechanism of VCAP between PD and MSA. Examining 3 autopsy-proven PD patients who developed severe VCAP requiring tracheostomy, we found the following differences in the mechanism of VCAP between MSA and PD: (1) clinical and laryngofiberscopic examination showed that VCAP in PD was not exacerbated during sleep, unlike in MSA; (2) On histological examination of the intrinsic laryngeal muscles, the posterior cricoarytenoid muscle demonstrated no abnormalities in PD, while the muscle showed characteristic neurogenic atrophy in MSA. There seemed to be two types of VCAP, namely the nonparalytic type observed in PD, and the paralytic type observed in MSA. Severe dysphagia requiring tube-feeding was common among PD patients who presented with VCAP. Although the relationship between VCAP and dysphagia is unknown, one should be aware of the possibility of fatal VCAP in PD patients with severe dysphagia.

Effects of methanol on styrene metabolism among workers occupationally exposed at low concentrations

A survey was conducted in the second half of a work week on 39 male workers who were occupationally exposed to styrene in combination with methanol and methyl acetate during the production of plastic buttons. Time-weighted average exposure during an 8-h shift to styrene (Sty-A) and methyl acetate was monitored by carbon cloth-equipped personal samplers and to methanol by water-equipped ones. Urine samples were collected near the end of the shift and analyzed for mandelic (MA-U) and phenylglyoxylic acids (PhGA-U) by HPLC. Geometric mean styrene concentration was 12.4 ppm (micrograms/g) with the maximum of 46 ppm, whereas the values for methanol and methyl acetate in combination were 23.5 ppm and 229 ppm, respectively. The relationship of MA-U and PhGA-U with Sty-A was examined by linear regression analysis. The equations for the regression lines were compared with the results from a previous survey (Ikeda et al. 1983) in which workers were exposed only to styrene, and the methods employed were identical with that in the present study. The comparison showed no evidence to suggest that styrene metabolism is suppressed by coexposure to methanol and methyl acetate at low concentrations below the current occupational exposure limit of 200 ppm.

Urinary methylchloroform rather than urinary metabolites as an indicator of occupational exposure to methylchloroform

In order to compare methylchloroform (MC, or 1,1,1-trichloroethane) per se and its metabolites in urine as indicators of occupational exposure to this solvent, 50 male solvent workers were studied in the second half of a working week to evaluate the exposure-excretion relationship. The time-weighted average intensity of solvent exposure of individuals during an 8-h shift was monitored by personal diffusive sampling. Urine samples were collected near the end of the shift and were analyzed for MC and its metabolites [i.e., trichloroacetic acid (TCA), trichloroethanol (TCE) and total trichloro-compounds (TTC; the sum of TCA and TCE)] by head-space gas chromatography. MC per se, TCA, TCE, and TTC in urine correlated significantly (P < 0.01) with MC in ambient air, and among the four the correlation coefficient was highest for MC. The same result were obtained by multiple regression analysis in which ambient air MC was taken as the dependent variable and either the three indicators urinary MC, TCA, and TCE or the two indicators urinary MC and TTC were taken as independent variables. Taking the specificity and selectivity of the analyte as well as the simple and hazardous chemical-free procedure of analysis into consideration, it is concluded that MC is the analyte of choice as an indicator of occupational exposure to MC, when urine is selected as a specimen available by noninvasive sampling.

[Relationship between orthostatic dizziness and/or giddiness, and hypotension in young normal females--a survey of 301 subjects]

Orthostatic dysregulation (OD) generally implies a systemic condition indicating poor circulatory function resulting from autonomic imbalance. It frequently appears in younger individuals at or around puberty, and is predominant in females. It is also known that individuals with this condition experience orthostatic dizziness and/or giddiness, fainting on standing and other various non-specific, subjective symptoms. Three hundred and one young normal females ranging in age from 18 to 21 years were examined using the Schellong test and the OD questionnaire to investigate the relationship between orthostatic dizziness and hypotension. Orthostatic dizziness and/or giddiness was the most frequent symptom, noted in 171 of 301 young subjects (56.8%), regardless of whether or not the subjects were actually diagnosed as having OD based on the questionnaire. Both low systolic blood pressure (90 mmHg or loss) in the supine position and systolic pressure decrease (11 mmHg or more) in the standing position during the procedure for the Schellong test were significantly related to the occurrence of orthostatic dizziness and/or giddiness. It may be reasonable to conclude from the present study that orthostatic dizziness is even more commonly observed in young normal female subjects than expected and correlates more closely with both hypotension and systolic pressure decrease in the standing position than previously thought. Thus, in our opinion, this testing procedure introduced by Schellong can be useful, and is clinically applicable to the assessment of orthostatic dizziness and/or giddiness and OD, since this test has the advantage of being simple enough to carry out in clinical practice.

[High-resolution teleradiology system based on ISDN and small computer]

A high-speed, high-resolution teleradiology system based on the Integrated Services Digital Network (ISDN) is described. The LAN at Saku Central Hospital and the Radiological Department at Shinshu University Hospital (60 km) are interfaced to a Macintosh computer with an image digitizer, interactive display, and network interface. The transmission time for a digitized high-resolution radiographic image with 4.39 megabytes was 358 seconds using a 128 kbps (kilobit-per-second) channel (B1 + B2), and the mean transmission rate was 98.1 kbps. Teleradiology conference is also available using this system. Radiologists can observe the same high-resolution images on the CRT screen simultaneously at two different remote hospitals, indicating a point of interest on the image by means of a mouse cursor. Graphical data of interest to the radiologists are also transmitted and displayed on the CRT.

Toluene in blood as a marker of choice for low-level exposure to toluene

The validity of two new biological exposure markers of toluene in blood (TOL-B) and toluene in urine (TOL-U) was examined in comparison with that of the traditional marker of hippuric acid in urine (HA-U) in 294 male workers exposed to toluene in workroom air (TOL-A), mostly at low levels. The exposure was such that the geometric mean for toluene was 2.3 ppm with a maximum of 132 ppm; the workers were also exposed to other solvents such as hexane, ethyl acetate, styrene, and methanol, but at lower levels. The chance of cutaneous absorption was remote. Higher correlation with TOL-A and better sensitivity in separating the exposed workers from the nonexposed subjects were taken as selection criteria. When workers exposed to TOL-A at lower concentrations (< 50 ppm, < 10 ppm, < 2 ppm, etc.) were selected with correlation with TOL-A was examined, TOL-B showed the largest correlation coefficient which was significant even at TOL-A of < 1 ppm, whereas correlation of HA-U was no longer significant when TOL-A was < 10 ppm. TOL-U was between the two extremes. The sensitivities of TOL-B and TOL-U were comparable; HA-U showed the lowest sensitivity. Thus, it was concluded that TOL-B is the indicator of choice for detecting toluene exposure at low levels.