Analysis of vasovagal syncope in the blood collection room in patients undergoing phlebotomy

Vasovagal syncope (VVS) is well-known to occur in patients undergoing phlebotomy, however, there have been no large-scale studies of the incidence of VVS in the blood collection room. The aim of our present retrospective study was to investigate the conditions of phlebotomy and determine the incidence/factors predisposing to the development of VVS. We investigated 677,956 phlebotomies performed in outpatients in the blood collection room, to explore factors predisposing to the development of VVS. Our analysis revealed an overall incidence of VVS of 0.004% and suggested that use of more than 5 blood collection tubes and a waiting time of more than 15 min were associated with a higher risk of VVS. The odds ratios of these factors were 8.10 (95% CI 3.76-17.50) and 3.69 (95% CI 0.87-15.60), respectively. This is the large-scale study to analyze factors of the development of VVS in the blood collection room, and according to our results, use of a large number of blood collection tubes and a prolonged waiting time for phlebotomy may be risk factors for the development of VVS.

Using Standardized Electronic Pathology and Surgery Data to Inform Clinical Quality Improvement and Health System Planning

Background: Practice variation in diagnosis and treatment exists between clinicians and jurisdictions across Canada. This variation can impact the quality of care that patients receive and patient outcomes. Knowledge of the scale and type of variation is the first step to developing action plans to improve consistency and enhance patient care. Aim: We aimed to establish a method by which to examine the magnitude of practice variation between clinicians and interjurisdictionally within the cancer system. We leveraged and derived evidence from discrete pathology data collected by five Canadian jurisdictions at the point of care to identify areas to improve quality of cancer care services and to direct patient care. Methods: Fifty pathologists, surgeons, and medical oncologists from 10 jurisdictions conferred to leverage literature and data standards (developed by the College of American Pathologists (CAP)) to create 48 descriptive and outcome indicators related to five cancers: breast, lung, colorectal, endometrial, and prostate cancer. Five jurisdictions collected and used data to generate the indicators. This baseline data were reviewed by 65 clinicians. Results: Interjurisdictional comparative baseline data analyses on 48 indicators showed clinical validity and relevance for use to direct downstream patient care. Data characterizing cancer type, stage, and grade distribution were consistently reported across geography and aligned with the evidence noted in the literature. The data also noted practice and performance variation across multiple cancer sites. For example, although the recommended guideline is to examine at least 12 lymph nodes in 90% of colorectal cancer patients, only one province met this target. Another example is Lynch syndrome testing, which may be important for patients with a diagnosis of colorectal or endometrial cancer depending on the age at diagnosis and family history. The data showed that 0%–70% of patients diagnosed with colorectal cancer prior to age 70 received testing for Lynch syndrome, and only 10%–40% of endometrial cancer cases were tested for markers of Lynch syndrome across the country. The value of these indicators is enormous to inform potential training opportunities and set standards of care at the local or broader clinical governance level so that consistent, high-quality care is delivered in accordance with evidence-based guidelines. Conclusion: Practice variation exists between clinicians and jurisdictions, and comparative pathology data can be used to create a cancer learning system. Four jurisdictions are now embarking on leveraging indicator data analysis to generate physician-level feedback reports and convening communities of practice with the goal of facilitating peer-to-peer conversations, and establishing benchmarks and targets to improve the quality of care, refine or develop clinical guidelines, and inform health system planning in Canada. These lessons can be applied in other cancer systems.

Disappearance of perihepatic lymph node enlargement after hepatitis C viral eradication with direct-acting antivirals

Perihepatic lymph node enlargement (PLNE) which has been shown to be negatively associated with hepatocellular carcinoma (HCC) occurrence is frequently observed in chronic liver disease; however, changes in the state of perihepatic lymph nodes after eradication of hepatitis C virus (HCV) have not been investigated yet. We aimed to evaluate this issue. We enrolled 472 patients with chronic HCV infection who achieved viral eradication with direct-acting antivirals (DAA). We investigated whether the status of perihepatic lymph nodes changed before and after HCV eradication (primary endpoint). We also evaluated the association between PLNE and clinical findings such as liver fibrosis or hepatocellular injury before HCV eradication (secondary endpoint). Perihepatic lymph node enlargement was detected in 164 of 472 (34.7%) patients before DAA treatment. Surprisingly, disappearance of PLNE was observed in 23.8% (39 patients) of all PLNE-positive patients after eradication of HCV. Disappearance of PLNE was not associated with baseline clinical parameters or changing rates of clinical findings before and after DAA treatment. At baseline, presence of PLNE was significantly associated with a lower serum HCV-RNA level (P = .03), a higher serum AST level (P = .004) and a higher ALT level (P < .001) after adjustment for sex and age. In conclusion, PLNEs became undetectable after DAA treatment in 23.8% of PLNE-positive patients. Further study with a longer follow-up period is needed to clarify the clinical importance of this phenomenon especially in relationship with the risk of HCC development.

Ultrasound evaluation of liver stiffness: accuracy of ultrasound imaging for the prediction of liver cirrhosis as evaluated using a liver stiffness measurement

BACKGROUND AND AIMS

Because of the low penetration rate of transient elastography (TE) or its limitations in patients with obesity, narrow intercostal spaces, or ascites, the physical appearance of the liver as visualized using ultrasonography (US) is still thought to provide important information for the prediction of liver fibrosis. We examined the accuracy of various US signs when assessing the presence of liver cirrhosis, compared with TE.

METHODS

We enrolled 189 patients who had undergone both conventional US and TE examinations. We then assessed the associations between US parameters of the liver (surface, edge, and parenchymal texture) or the US score (sum of each parameter score), and the presence of liver cirrhosis as determined based on a liver stiffness measurement (LSM) of >15.

RESULTS

A significant increase in the LSM was observed according to the liver surface score (P < 0.001), liver edge score (P < 0.001), parenchymal texture score (P < 0.001), and US score (P < 0.001). The areas under the curves (AUROC) for the prediction of an LSM >15 for the liver surface, liver edge, parenchymal texture, and the US score were 0.859, 0.768, 0.837, and 0.902, respectively. The AUROC of the US score was higher than that of the APRI score (0.823) or the FIB-4 index (0.804). Using an optimal cut-off value of 3.5, the sensitivity and specificity of the US score were 0.815 and 0.858, respectively.

CONCLUSIONS

The US score was clinically useful for the diagnosis of an LSM >15. The US score can be used as a substitute for TE data in patients with obesity, narrow intercostal spaces, or ascites or in hospitals where TE is unavailable.

Evaluation of human nonmercaptalbumin as a marker for oxidative stress and its association with various parameters in blood

Oxidative status of albumin was not a useful biomarker for oxidative stress in practical use due to time-consuming measuring method. We evaluated oxidized, human nonmercaptalbumin measured more quickly than ever by a novel method using anion-exchange HPLC. In 60 subjects taking a general health examination, mean serum human nonmercaptalbumin level was 25.1 ± 3.0% with no gender difference but positive correlation with age. There were no links between human nonmercaptalbumin and C-reactive protein, γ-glutamyltransferase or iron, reportedly associated with oxidative stress. Human nonmercaptalbumin correlated with systolic blood pressure, pulse pressure and body mass index among physical findings. Positive correlations were observed between human nonmercaptalbumin and AST, LDH, BUN, or creatinine, suggesting that oxidative stress may link with liver injury and renal function. Human nonmercaptalbumin correlated with uric acid in female but not in male, suggesting that higher uric acid levels may be associated with increased oxidative stress only in female. As another gender difference, white blood cell counts correlated with human nonmercaptalbumin in female, while the parameters for red blood cells correlated with human nonmercaptalbumin in male. In conclusion, serum human nonmercaptalbumin level in healthy subjects was approximately 25% as previously reported. Oxidative stress may be closely associated with hypertension, obesity, liver injury, renal function, and anemia.

Effect of CT digital image compression on detection of coronary artery calcification

Purpose: To test the effect of digital compression of CT images on the detection of small linear or spotted high attenuation lesions such as coronary artery calcification (CAC).

Material and Methods: Fifty cases with and 50 without CAC were randomly selected from a population that had undergone spiral CT of the thorax for screening lung cancer. CT image data were compressed using JPEG (Joint Photographic Experts Group) or wavelet algorithms at ratios of 10:1, 20:1 or 40:1. Five radiologists reviewed the uncompressed and compressed images on a cathode-ray-tube. Observer performance was evaluated with receiver operating characteristic analysis.

Results: CT images compressed at a ratio as high as 20:1 were acceptable for primary diagnosis of CAC. There was no significant difference in the detection accuracy for CAC between JPEG and wavelet algorithms at the compression ratios up to 20:1. CT images were more vulnerable to image blurring on the wavelet compression at relatively lower ratios, and "blocking" artifacts occurred on the JPEG compression at relatively higher ratios.

Conclusion: JPEG and wavelet algorithms allow compression of CT images without compromising their diagnostic value at ratios up to 20:1 in detecting small linear or spotted high attenuation lesions such as CAC, and there was no difference between the two algorithms in diagnostic accuracy.

Ultrasonography of Thymoma with Pathologic Correlation

Preoperative ultrasonograms of 11 surgically proved thymomas and ex vivo ultrasonograms of 3 resected specimens were compared with pathologic findings of resected specimens. Among 11 thymomas 7 appeared solid, 3 were solid with several cystic regions, and the remaining one was unilocular cystic in appearance. Cystic regions on ultrasonograms corresponded to cystic changes on pathologic specimens. Six malignant thymomas showed a typical lacy appearance on ultrasonograms, which corresponded to the lobulated configuration separated by fibrous septa shown on the pathologic specimens.

Detection of occult metastatic lymph nodes in the neck with gray-scale and power doppler us

Purpose: To determine the most accurate criterion for predicting malignancy of small cervical lymph nodes with gray-scale ultrasound (GSUS) and power Doppler ultrasound (PDUS).

Material and Methods: Findings of 69 pathologically verified cervical nodes (38 benign, 31 malignant) in 57 patients without wide echogenic hilum on GSUS that measured less than 10 mm in minimal axial diameter were prospectively studied. Minimal and maximal axial diameters, ratios of minimal to maximal axial diameters, and presence or absence of calcification or necrosis of the nodes were assessed. On PDUS, vascularity in the node was classified into 4 pattern groups. A logistic model was used to evaluate the significant factors for predicting malignancy.

Results: The logistic model revealed that the minimal axial diameter and vascularity patterns were the only significant factors for malignancy. Using the minimal axial diameter, a node larger than 8 mm showed the highest accuracy (73%) with 45% sensitivity and 93% specificity. Of the vascularity patterns, spotted or peripheral pattern had the highest accuracy (80%) with 61% sensitivity and 93% specificity. A combined criterion of the minimal axial diameter larger than 8 mm and spotted or peripheral pattern increased the accuracy to 82% and sensitivity to 77% but specificity decreased to 86%.

Conclusion: A combined criterion of minimal axial diameter and vascular patterns was most accurate for diagnosing occult metastatic lymph nodes in the neck.

Computed Tomography Reveals Atypical Localization of Benign Mediastinal Tumors

Computed tomographic appearances of 147 surgically proven mediastinal tumors (113 benign and 34 malignant lesions) were evaluated paying special attention to their localization or extension. Ten of the 113 benign lesions (9%) showed atypical or unique localization or extension, and were divided into three groups. In the first group, two lymphangiomas and one bronchogenic cyst spread over both the precardiovascular and the retrocardiovascular compartments, mimicking a malignant lesion. In the second group, the single cases of thymic hypertrophy, thymic cyst, schwannoma, and pericardial cyst were located atypically in the retrocardiovascular compartment. In the last group, two esophageal leiomyomas and one esophageal duplication showed upward and downward longitudinal extension beyond the azygos arch and the aortic arch.

Chest Imaging with Dual-Energy Subtraction Digital Tomosynthesis

Dual-energy subtraction digital tomosynthesis with pulsed X-ray and rapid kV switching was used to examine calcifications in pulmonary lesions. The digital tomosynthesis system used included a conventional fluororadiographic TV unit with linear tomographic capabilities, a high resolution videocamera, and an image processing unit. Low-voltage, high-voltage, and soft tissue subtracted or bone subtracted tomograms of any desired layer height were reconstructed from the image data acquired during a single tomographic swing. Calcifications, as well as their characteristics and distribution in pulmonary lesions, were clearly shown. The images also permitted discrimination of calcifications from dense fibrotic lesions. This technique was effective in demonstrating calcifications together with a solitary mass or disseminated nodules.

Effects of JPEG and wavelet compression of spiral low-dose CT images on detection of small lung cancers

Purpose: To compare the effect of compression of spiral low-dose CT images by the Joint Photographic Experts Group (JPEG) and wavelet algorithms on detection of small lung cancers.

Material and Methods: Low-dose spiral CT images of 104 individuals (52 with peripheral lung cancers smaller than 20 mm and 52 control subjects) were used. The original images were compressed using JPEG or wavelet algorithms at a ratio of 10:1 or 20:1. Five radiologists interpreted these images and evaluated the image quality on a high-resolution CRT monitor. Observer performance was studied by receiver operating characteristic (ROC) analysis.

Results: There was no significant difference in the detection of cancers measuring 6 to 15 mm in uncompressed images and in those compressed by either of the algorithms, although the quality of images compressed at 20:1 with the wavelet algorithm was somewhat inferior. A lower diagnostic accuracy was noted using images compressed by the JPEG or wavelet algorithms at 20:1 in detecting lung cancers measuring 6 to 10 mm and cancers measuring from 6 to 15 mm with ground-glass opacity.

Conclusion: Compression of low-dose CT images at a ratio of 10:1 using JPEG and wavelet algorithms does not compromise the detection rate of small lung cancers.

Digital Image Processing to Remove Blur from Linear Tomography of the Lung

We have studied digital image processing methods to reduce blur in linear tomography of the lung performed with the Fuji computed radiography (FCR) system. One-dimensional unsharp (blur) mask filtering in the direction of tomographic movement was found to be effective in reducing blur. The appearance of the processed tomograms varied depending largely on the properties of the unsharp mask filters applied. With regard to the spatial frequency response of the filter, a high mid-frequency response and a low low-frequency response of the tomographic image data was most effective in obtaining high image quality tomograms. When the standard 2-dimensional unsharp mask technique of the FCR system was additionally applied to the one-dimensional unsharp mask processed tomogram, the clarity of the tomogram was further enhanced. These observations may also be helpful when considering image processing to obtain diagnostically informative digital radiography.

Size of Normal Hilar Lymph Nodes Measured in Autopsy Specimens

The normal size of lymph nodes for each region of the hilum was determined by direct measurement of the short and long diameters of each node in the transverse plane of the node and the longitudinal diameter in the vertical plane of the node in 30 adult cadavers. The mean short transverse diameters ranged from 3.2 to 6.4 mm, the mean long transverse diameters ranged from 4.9 to 10.0 mm, and the mean longitudinal diameters ranged from 5.7 to 11.3 mm. The largest mean transverse diameters were found in the anterior upper lobe (AUL) and the inferior interlobar (IIL) regions. We noted a different maximum normal size for lymph nodes in each region of the hilum and determined the standard maximum normal short transverse diameters to be as follows: 12 mm for nodes in the right AUL and IIL regions, 10 mm for nodes in the right superior interlobar region and the left AUL and IIL regions, and 8 mm for nodes in other regions. Both the maximum normal long transverse diameters and the longitudinal diameters showed a wider variation, ranging from 18 to 10 mm and from 20 to 12 mm, respectively.

3D CT Angiography as a Pre-Embolization Study for Embolization of Cerebral Aneurysms

An image guide for aneurysm embolization based on three dimensional CT angiography is reported. Multiplanner reformation (MPR) can measure the neck and dome of the aneurysm accurately enough to select the first coils for aneurysms.

For neck evaluation, cut model and virtual endoscope are helpful because we can observe the neck from inside of dome or parent artery. Proximal arteries are visualized by 3D images and MPR if needed.

Using laser lithography, we can get a real model of aneurysm and parent artery through which we can insert microcatheters and coils. 3D CTA is a dependable modality for embolization of cerebral aneurysms.

[Management of massive transfusion - the role of the blood transfusion service]

Massive transfusion (hemorrhage) is defined as blood transfusion exceeding the circulatory blood volume within 24 hours. Here, we investigated cases of massive transfusion, defined as transfusion of more than 21 units of red blood cells within 24 hours, in our institution in the period from August 2005 to March 2013. Massive transfusion accounted for approximately 1% of all blood transfusions in our institution, and the majority were cardiac surgery cases (75%), with 80% of the cases receiving blood transfusion irtfhe operating theater. Brain-dead heart and liver transplantations were started in our hospital in 2006. Due to the revision of the Organ Transplantation Law in July 2010, brain-dead organ donations increased in Japan. Massive transfusion was required in approximately 47% of heart and 41% of liver transplants, with 44% of the transplants being conducted on holidays, and 47% at night. Therefore, the implementation of a 24-hour duty system for medical technologists, including holidays, is essential for the prompt testing and supply of blood products. For improvement of the safety of blood supply, a computer network system, connecting the blood control system of the blood transfusion service, the anesthetic system of the operating theater, and the hospital general medical system, was implemented in our hospital in March 2007. In the operating theater, anesthetists can request blood products, order new blood products, cross-check the provided blood products, and register their use, using this system. At the blood transfusion service, the blood products to be provided are cross- checked against the anesthetists' requests. Through this system, the anesthetists and blood transfusion service staff can check the list of blood products available for the surgical patient as well as those already transfused, on a real-time basis. For analysis of the improvements achieved, we compared the number of non-used blood units, i.e., the number of those provided minus the number of transfused units in the surgical theater, in the period after (2009-2012) and before (2005-2006) the implementation of this computer network system. In the period after its implementation, the number of non-used units decreased from 17.4 units to 7.5 units (P<0.001), leading us to conclude that this system helped avoid the excessive ordering of blood products by the anesthetists. (Review).

[Emergency drills and exercises to prepare the initial response and countermeasures for a disaster: an evacuation simulation for the hospital's outpatient blood collection room in the event of an earthquake]

In case of a disaster, the clinical laboratory's departmental staff is not only responsible for recovery efforts of routine work and the continuation of emergency tests, but also for protecting patients against both dangers and possible risks in the blood collecting room and physiology laboratory. For this reason, we decided to participate in an emergency drill, which focuses on the initial response to a disaster, specifically evacuation procedures and the cessation of phlebotomy operations. Since there were no existing manuals regarding disasters in our blood collection room, we first made a draft disaster plan. Additionally, since we were absolute beginners with regard to training and had inadequate knowledge of disaster countermeasures, we conducted theoretical simulations in advance. We decided to explain the evacuation details and had each participant in the exercise perform their own role in accordance with our scenario. Furthermore, we asked the participants to discuss the effectiveness of the training and seek out ways to improve our manuals. Although this was the first practice for the blood collection room, we were able to achieve our first goal by raising awareness of disaster prevention activities. The precautions against disaster that eliminate accidents require an immense amount of time and effort. Thus, it is necessary to continue training in order to increase the staffs awareness of disaster defense and to continue to improve our skills in the future.

[Introduction of preventive measures toward contact infection without affecting the efficiency of the outpatient blood collection]

At the University of Tokyo Hospital, an average of 956 venopunctures/day was performed for outpatients in the period between 2008 and 2011. At the outpatient clinic, the collection of blood without delay, and the prevention of contact infection, are always important matters to be addressed. For the prevention of infection, changing gloves, and wiping of tables and tourniquets with antiseptic cotton, for each patient has been performed since August 2010. Because the time required for each blood collection was prolonged about 19 sec., after the introduction of these preventive measures, we analyzed the factors which affected the waiting time at the blood collection room. The waiting time required for the blood collection between period of August and October, 2010, i.e., after the introduction of the preventive measures, was analyzed and compared with that between August and October, 2009, as the control. After the implementation of the preventive measures, the percentage of patients with waiting time of blood collection shorter than 10 min decreased from 73% to 58%. Thus, to improve the efficiency of blood collection and shorten the collection time, one collection booth was added, and the blood collection procedure was standardized. Also, the number of outpatients waiting for phlebotomy and the number of available phlebotomists are automatically transferred from the computer system for blood collection to the laboratory computer system, which, based on these data, displays an alert for the need of additional phlebotomists, when required. By the implementation of these measures, the percentage of patients with waiting time shorter than 10 min increased from 73% to 83%. From the present results, we considered that the preventive measures against contact infection could be successfully implemented, without affecting on the waiting time, and consequently, efficient management at the outpatient clinic could be achieved.

Nerve growth factor derived from bronchial epithelium after chronic mite antigen exposure contributes to airway hyperresponsiveness by inducing hyperinnervation, and is inhibited by in vivo siRNA

BACKGROUND

Bronchial asthma is a chronic allergic airway inflammatory disease. Neurotrophins, including nerve growth factor (NGF), play an important role in the pathogenesis of asthma. However, the effects of NGF derived from epithelium on airway hyperresponsiveness (AHR) after antigen sensitization/exposure remain uncertain.

OBJECTIVE

In this study, we examined the role of NGF on AHR after chronic antigen exposure and the effect of inhibiting NGF by in vivo siRNA on AHR exacerbation.

METHODS

We generated chronic mouse models of bronchial asthma using house-dust mite antigen (Dermatophagoides pteronyssinus; Dp). NGF concentrations in bronchoalveolar lavage fluid (BALF), lung histopathology, hyperresponsiveness, and related neuronal peptides and cytokines in supernatants of lung homogenates were determined.

RESULTS

NGF in BALF was increased in a dose- and time-dependent manner, and was expressed primarily in bronchial epithelium. Nerve fibres and substance P-positive fibres were detected in subepithelium of Dp-sensitized and challenged mice over 4 weeks of mite antigen exposure. AHR was positively correlated with NGF concentration and nerve fibre innervation. AHR, modulation of innervation, and increased substance P were inhibited by in vivo administration of siRNA that targeted NGF, although the inhibition of NGF did not affect allergic inflammation and subepithelial fibrosis.

CONCLUSION AND CLINICAL RELEVANCE

These findings suggest that NGF derived from bronchial and alveolar epithelium plays an important role in AHR after chronic exposure to mite antigen. NGF inhibition could potentially manage bronchial asthma, including AHR.

IκB kinase β inhibitor IMD-0354 suppresses airway remodelling in a Dermatophagoides pteronyssinus-sensitized mouse model of chronic asthma

BACKGROUND

Nuclear factor (NF)-κB is a transcription factor that regulates cytokine and chemokine production in various inflammatory diseases, including bronchial asthma. IκB kinase (IKK) β is important for NF-κB activation in inflammatory conditions, and is possibly related to airway remodelling. Thus, inhibition of the IKKβ-NF-κB pathway may be an ideal strategy for the management of airway remodelling.

OBJECTIVE

We examined the effects of a newly synthesized IKKβ inhibitor, IMD-0354, in a chronic allergen exposure model of bronchial asthma in mice.

METHODS

A chronic mouse model was generated by challenge with house dust mite antigen (Dermatophagoides pteronyssinus). IMD-0354 was administrated intraperitoneally in therapeutic groups. Lung histopathology, hyperresponsiveness and the concentrations of mediators and molecules in supernatants of lung homogenates were determined.

RESULTS

NF-κB activation was inhibited by prolonged periods of IMD-0354 administration. IMD-0354 reduced the numbers of bronchial eosinophils. IMD-0354 also inhibited the pathological features of airway remodelling, including goblet cell hyperplasia, subepithelial fibrosis, collagen deposition and smooth muscle hypertrophy. Inhibition of these structural changes by IMD-0354 was the result of the suppressing the production and activation of remodelling-related mediators, such as TGF-β, via inhibition of IKKβ. IMD-0354 inhibited IL-13 and IL-1β production, and it restored the production of IFN-γ. It also ameliorated airway hyperresponsiveness.

CONCLUSION

IKKβ plays crucial roles in airway inflammation and remodelling in a chronic mouse model of asthma. A specific IKKβ inhibitor, IMD-0354, may be therapeutically beneficial for treating airway inflammation and remodelling in chronic asthma.

Low Temperature Fabrication of (Ba, Sr)TiO3 Thin Films by ECR Plasma CVD

Physical and electrical properties are investigated for (Ba, Sr)TiO3 (BST) films prepared by electron cyclotron resonance (ECR) plasma chemical vapor deposition (CVD) at relatively low temperatures, between 450 °C and 500 °C. The crystallinity of BST, estimated by X-ray diffraction and from the grain size, is greatly improved when the temperature is raised from 450 °C to 500 °C. Also better crystallinity is obtained for films grown at a deposition rate of 1.1 nn/min than at 2.7 nm/min. The mass transport rates of metal organic sources under our deposition conditions are estimated. The BST film composition is precisely controlled using the results of the investigation on mass transport. At near stoichiometric composition, i.e., (Ba+Sr)/Ti=0.97, and Ba/(Ba+Sr)=0.4, the films grown at 500 °C are found to have the largest dielectric constant, measured using flat capacitors with Pt bottom electrodes. A dielectric constant of 160 is obtained for 27 nm thick films grown at 500 °C and at 1.1 nm/min, without post-deposition annealing. These films exhibit the smallest SiO2 equivalent thickness of 0.65 nm and a leakage current density of 4.6x10−7 A/cm2 at plus IV.

Blockade of Th1 chemokine receptors ameliorates pulmonary granulomatosis in mice

Sarcoidosis is a granulomatous disease of unknown aetiology. We identified immunological targets for the treatment of pulmonary granulomatosis using a murine model generated with Propionibacterium acnes. Sensitisation and challenge using heat-killed P. acnes and dendritic cells (DCs) were performed to produce pulmonary granulomatosis in C57BL/6 mice. Immunological analyses using ELISA as well as cDNA microarray analysis were used to search for cytokines or chemokines associated with the formation of granulomas in the lungs. Co-administration of P. acnes and DCs reproducibly induced the formation of pulmonary granulomas, which resembled sarcoid granulomas. The cDNA microarray assay demonstrated that the gene expression of CXCL9 and CXCL10, ligands for CXCR3, and of CCL4, a ligand for CCR5, was strongly upregulated during granulomatosis. ELISA confirmed that levels of CXCL9 and CXCL10 as well as T-helper (Th)1 cytokines and chemokines including tumour necrosis factor-α and interferon-γ were elevated in bronchoalveolar lavage fluid (BALF). The blockade of Th1 chemokine receptors using TAK-779, a dual blocker for CXCR3 and CCR5, led to reduced numbers of CXCR3+CD4+ and CCR5+CD4+ T-cells in BALF. Furthermore, administration of TAK-779 ameliorated the granulomatosis. The targeted inhibition of Th1 chemokines might be useful for inhibiting Th1-biased granulomatous diseases, including sarcoidosis.

Hepatocyte growth factor as inducer of gefitinib resistance in non-small cell lung cancer harboring EGFR activating mutations

e19034

Background: Non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR)-activating mutations (EGFRmu) responds favorably to the EGFR tyrosine kinase inhibitors (EGFR-TKIs), gefitinib or erlotinib. However, 25–30% of patients with EGFRmu show intrinsic resistance, and the responders invariably acquire resistance to EGFR-TKIs. Here, we examined the role of hepatocyte growth factor (HGF), a specific ligand of MET, in gefitinib resistance of NSCLC with EGFRmu. Methods: NSCLC cells, PC-9 and HCC827, with EGFRmu, but not T790M second mutation in EGFR or MET amplification, were used in this study. Sensitivity to gefitinib was determined by MTT assay. Phosphorylation of MET, EGFR, ERBB3, and the PI3K/Akt pathway were examined by Western blotting. HGF expression in 20 tumors from 16 NSCLC patients with EGFRmu who were treated with gefitinib was determined by immunohistochemistry. Results: HGF induced resistance to gefitinib by restoring Akt phosphorylation independently of ErbB3. Specific down-regulation of MET, but not ErbB3, reversed gefitinib resistance and Akt phosphorylation induced by HGF. Importantly, high levels of immunoreactivity for HGF were detected in cancer cells of 3 of 3 intrinsic resistant tumors and in one of 2 tumors with acquired resistance without T790M second mutation or MET amplification. Conclusions: The findings indicate that HGF-mediated MET activation is a novel mechanism of intrinsic and acquired gefitinib-resistance in NSCLC with EGFRmu. Therefore, inhibition of HGF-MET signaling may be considerable strategy for more successful treatment with EGFR-TKIs.

[Table: see text]

Protein biomarker analysis by mass spectrometry in patients with rheumatoid arthritis receiving anti-tumor necrosis factor-alpha antibody therapy

OBJECTIVE

To investigate the mechanism of action of anti-tumor necrosis factor-alpha (TNF-alpha) antibody in patients with rheumatoid arthritis (RA), we analyzed serum or plasma proteins by mass spectrometry system.

METHODS

Ten RA patients who received treatment with anti-TNF-alpha antibody were studied. Samples obtained before and after therapy were analyzed by a two-dimensional liquid chromatography tandem mass spectrometry (2D LC-MS/MS) system after pretreatment by a recently developed method to remove high molecular weight proteins.

RESULTS

Using this system, certain proteins were identified after treatment with anti-TNF-alpha antibody, including proteins related to the TNF-alpha-mediated pathway for nuclear factor kappa B (NF-kappaB) activation and/or to the metabolism (including regeneration) of articular cartilage.

CONCLUSION

Our mass spectrometry system appears to be useful for proteomic analysis. The efficacy of anti-TNF-alpha antibody therapy for RA may be related to various consequence of the inhibition of TNF-alpha activity.

CXCL9 and 11 in patients with pulmonary sarcoidosis: a role of alveolar macrophages

Interferon-inducible protein-10 (IP-10)/CXCL10, which is a ligand for CXC chemokine receptor 3 (CXCR3), is known to be involved in the pathogenesis of pulmonary sarcoidosis. However, the roles of monokine induced by interferon gamma (Mig)/CXCL9 and interferon-inducible T cell alpha chemoattractant (I-TAC)/CXCL11, which are also CXCR3 ligands, remain unclear. Mig/CXCL9, IP-10/CXCL10 and I-TAC/CXCL11 in both bronchoalveolar lavage fluid (BALF) and serum in patients with pulmonary sarcoidosis were measured by enzyme-linked immunosorbent assay (ELISA). The expression of these chemokines in alveolar macrophages was examined using ELISA, quantitative real-time polymerase chain reaction and immunostaining. In BALF, Mig/CXCL9 and IP-10/CXCL10 were significantly elevated in stage II sarcoidosis as compared with the levels in healthy volunteers. In serum, Mig/CXCL9 and I-TAC/CXCL11 were increased in stage II of the disease. The levels of all CXCR3 ligands in BALF were correlated with the numbers of both total and CD4(+) lymphocytes. Alveolar macrophages were stained positive for all CXCR3 ligands and produced increased amounts of these chemokines. Positive staining of the three chemokines was also observed in the epithelioid and giant cells in the sarcoid lungs. These findings suggest that Mig/CXCL9 and I-TAC/CXCL11 as well as IP-10/CXCL10 play important roles in the accumulation of Th1 lymphocytes in sarcoid lungs.

Quantitative RT-PCR analysing expression of gefitinib resistance related genes predicts clinical outcome of non-small cell lung cancer patients treated with gefitinib

7181

Background: Gefitinib, an inhibitor of epidermal growth factor receptor-tyrosine kinase, has shown favorable anti-tumor activity to a subset of patients with advanced non-small cell lung cancer (NSCLC). However, gefitinib failed to significantly prolong survival in comparison to placebo in unselected population. Consequently, selection of patients who will benefit from this treatment is clinically important. In the previous study, we identified gefitinib-resistance related genes (GRRGs) by cDNA microarray analyses and reported that the responsiveness of individual patients with NSCLC to gefitinib could be predicted by expression of GRRGs. The goal of this study is to establish clinically adoptive prediction system of clinical outcome of NSCLC patients treated by gefitinib. Methods: Tumors from 30 NSCLC patients treated daily with 250mg of gefitinib were evaluated for the expression of GRRGs by quantitative RT-PCR. Gefitinib response score (GRS) reflecting gene expression was calculated based on weighted vote method and this numerical scoring system was validated by leave-one-out approach and independent test cases. Results: The sensitivity of 15 learning cases (five partial response (PR) cases and 10 progressive disease (PD) cases) were predicted by leave-one-out cross validation with 93.3% (14/15) accuracy. This numerical scoring system correctly predicted responses to the drug in all of nine additional test cases (three PR cases and six PD cases). Notably, this system also could predict two stable disease (SD) cases who successfully controlled by gefitinib more than four months as responder. On the other hand, four patients who had been judged as SD but showed progression of the disease within three months were judged as non-responders. Moreover, gefitinib-treated patients with good signature had a statistically significant improvement in time to progression, and survival compared with patients with bad signature (13.0 vs 1.7 months, P < .0001; 27.7 vs 6.6 months, P = .0007, respectively). Conclusions: Our results suggest that clinical outcome of NSCLC patients treated with gefitinib could be predicted by expression levels of GRRGs determined by quantitative RT-PCR analyses.

No significant financial relationships to disclose.

Long-term follow-up of pulmonary function in bronchial asthma patients treated with pranlukast

Clinical studies have shown that pranlukast, a selective cysteinyl leukotriene antagonist, is effective for bronchial asthma. In the present paper, we retrospectively analyzed long-term asthma control by pranlukast treatment in patients treated with inhaled corticosteroids. We analyzed medical records and asthma diaries of 21 patients (9 males, 12 females) (52.1 +/- 3.5 years of age) with bronchial asthma who experienced increase of more than 10 L/min in peak expiratory flow in the first 4 weeks of treatment with pranlukast (450 mg/day) and were subsequently treated with pranlukast for more than 1 year. They all received inhaled corticosteroids (400-1600 microg/day of beclomethasone dipropionate or equivalent). We examined clinical control in terms of time course of self-monitored peak expiratory flow. During the analyzed period, the dose of inhaled corticosteroids was tapered in 4 patients, constant in 15 patients and increased in 2 patients. In 19 patients treated with unchanged or tapered dose of inhaled corticosteroids, improvement in the increase of mean PEF at 4-week treatment was maintained for 1 year. No difference in the add-on effect of pranlukast was observed in patients treated with less than 800 microg and more than or equal to 800 microg of inhaled corticosteroids. Four patients underwent reduction of inhaled corticosteroids in the analyzed period and PEF was well-maintained and even increased by pranlukast treatment. In 11 patients in whom data for 3 years were available, the improvement in PEF persisted for 3 years. Although the present investigation is a retrospective analysis, these data may suggest that pranlukast has no tachyphylaxis and its effect continues for more than 1 year.

Add-on effects of suplatast tosilate in bronchial asthma patients treated with inhaled corticosteroids

Th2 cytokines play an important role in the pathogenesis of asthma. In the present study, we investigated the effect of suplatast tosilate, a selective Th2 cytokine inhibitor, on asthma control, in terms of subjective symptoms and pulmonary function in patients treated with inhaled corticosteroids. Thirty-eight patients with bronchial asthma being treated with inhaled corticosteroids were given suplatast tosilate (100 mg three times daily) for 12 weeks, in a multicenter setting. During the study period, other medications were continued. Morning and evening peak expiratory flow, asthma symptoms, blood eosinophil count and serum IgE levels were monitored. Suplatast tosilate treatment was associated with a significant improvement in mean morning peak expiratory flow (from 295 L/min to 348 L/min, P < 0.01) and evening peak expiratory flow (from 313 L/min to 357 L/min, P < 0.01). The mean daily variation in peak expiratory flow was significantly reduced (from 11.6% to 7.3%, P < 0.01) by suplatast tosilate treatment. The greatest improvement in peak expiratory flow was observed in patients whose blood eosinophil counts were decreased by suplatast tosilate treatment. Treatment with suplatast tosilate improved pulmonary function in patients with bronchial asthma. Our results suggest the therapeutic effects observed may occur through suppression of eosinophilic inflammation.

Adenoviral interleukin-12 gene transduction into human bronchial epithelial cells: up-regulation of pro-inflammatory cytokines and its prevention by corticosteroids

BACKGROUND

One of the potential effects of IL-12 is to restore Th1/Th2 balance. Therefore, we investigated the possibility of developing a system for local delivery of IL-12 into the airways by examining protein expression in a human bronchial epithelial cell line (BEAS-2B) after adenoviral IL-12 gene transduction. The effects of dexamethasone on the gene-modified cells were also examined.

METHODS

Adenoviral vectors AxCAegfp and Ax1CIhp40ip35 were used to transduce enhanced green fluorescence protein and IL-12 genes, respectively, into BEAS-2B cells. Wild-type and IL-12 gene-transduced BEAS-2B cells were then incubated with or without dexamethasone, and concentrations of IL-12, IFN-gamma, IL-6, IL-8, granulocyte macrophage-colony stimulating factor and chemokines (TARC and RANTES) in the supernatant were measured by ELISA. IL-12 receptor expression was analysed by flow cytometry and RT-PCR.

RESULTS

The efficiency of transgene expression in BEAS-2B cells at a multiplicity of infection of 30 was approximately 80%. Gene-modified BEAS-2B cells produced biologically active IL-12, regardless of dexamethasone treatment. While IL-12 gene transduction led to increased production of IL-6 and IL-8 by BEAS-2B cells, expressions of these proteins were suppressed by dexamethasone. Addition of exogenous IL-12 failed to augment BEAS-2B cell IL-6 and IL-8 production, and IL-12 receptor expression by BEAS-2B cells was not detected.

CONCLUSIONS

Our findings suggest that adenoviral IL-12 gene transduction may be effective in inducing IL-12 expression in the airways, and could be a potential approach in the management of bronchial asthma.

Proliferation of type II pneumocytes in the lung biopsy specimens reflecting alveolar damage

Proliferation of type II pneumocytes may be the most sensitive pathological indicator of alveolitis, and the density of type II pneumocytes reflecting the severity of the recent alveolar damage. Twenty-nine patients were divided into three groups by the severity of ground-glass opacities on the CT scans; the severe (acute), the moderate (subacute) and the mild (chronic) groups. We compared the density of type II pneumocytes in the transbronchial lung biopsy specimens and cell analysis of bronchoalveolar lavage (BAL) fluid with the ground-glass opacities. Clinical and laboratory findings and BAL fluid analysis also corresponded well with this grouping. Type II pneumocytes were selectively stained with an antibody against Thomsen-Friedenreich and the density of the type II pneumocytes was expressed as the number per 1 mm alveolar septal length. The densities of the type II pneumocytes in the severe, the moderate, the mild, and the control groups were 21.2+/-1.1, 14.4+/-7.2, 11.0+/-3.3 and 7.5+/-0.9/mm, respectively. There were significant differences between the acute group and the other three groups, and between the control and chronic groups. The density of type II pneumocytes is a useful index for evaluating alveolar damage even in mild alveolitis.

Demethylation by 5-aza-2'-deoxycytidine (5-azadC) of p16INK4A gene results in downregulation of vascular endothelial growth factor expression in human lung cancer cell lines

Vascular endothelial growth factor (VEGF) plays a pivotal role in tumor progression via angiogenesis. Recently, gene transduction of wild-type p16INK4A, tumor suppressor gene, has been shown to result in downregulation of VEGF expression in p16INK4A-deleted glioma cells. Because expression of p16INK4A is regulated by methylation of the p16INK4A gene, we examined whether demethylation of the p16INK4A gene by 5-aza-2'-deoxycytidine (5-azadC) could cause the protein expression of VEGF as well as of p16INK4A in human lung cancer cells. For this, five different lung cancer cell lines with or without loss of p16 activity were used. H841 and Ma-10 cells had the methylated p16INK4A gene without expression of p16INK4A protein, whereas Ma-1 and H209 cells had the unmethylated p16INK4A gene with constitutive expression of p16INK4A protein. Neither the p16INK4A gene nor p16INK4A protein was detected in A549 cells. Treatment with 5-azadC caused demethylation of the p16INK4A gene with reexpression of p16INK4A protein in H841 and Ma-10 (methylated p16INK4A gene dominant) cell, but not in other cell lines such as Ma-1, H209 (unmethylated p16INK4A gene dominant), or A549 (p16INK4A gene deleted). In a parallel experiment, 5-azadC inhibited production of VEGF protein by H841 and Ma-10 cells, especially in the later hypermethylated cells, but not Ma-1, H209, or A549 cells. RT-PCR analysis showed that Ma-10 cells expressed VEGF isoforms 121, 165, and 189, all of which were inhibited by 5-azadC. These findings indicate that the methylation status of the p16INK4A gene plays an important role in the regulation of angiogenesis associated with progression of lung cancer, through regulation of VEGF expression.

Bone metastasis model with multiorgan dissemination of human small-cell lung cancer (SBC-5) cells in natural killer cell-depleted SCID mice

Lung cancer is commonly associated with multiorgan metastasis, and bone is a frequent metastatic site for lung cancer. Nevertheless, no bone metastasis model of lung cancer with multiorgan dissemination is available, which could provide opportunity to study the molecular pathogenesis. We examined the abilities of eight human lung cancer cell lines injected intravenously into natural killer (NK) cell-depleted SCID mice to generate metastatic nodules in bone and multiple organs, and explored the correlation of the parathyroid hormone-related protein (PTHrP) with the bone metastasis. Although all the small-cell carcinoma cell lines (SBC-5, SBC-3, SBC-3/ADM, H69, H69/VP) formed metastatic nodules in multiple organs (liver, kidney, and lymph nodes), only SBC-5 cells reproducibly developed bone metastases. Squamous cell carcinoma (RERF-LC-AI) cells metastasized mainly into the liver and kidneys, whereas adenocarcinoma (PC-14, A549) mainly produced colonies in the lungs. As assessed by X-ray photography, the osteolytic bone metastases produced by SBC-5 cells were detected as early as on day 28, and all recipient mice developed bone metastasis by day 35. The expression of PTHrP in eight cell lines was directly correlated with the formation of bone metastasis. No correlation was observed between the formation of bone metastasis and the expression of other metastasis-related cytokines (IL-1, IL-6, IL-8, IL-10, IL-11, TNF-alpha, VEGF, M-CSF). Consistent with the formation of bone metastasis by SBC-5 cells, the levels of PTHrP and calcium in the mouse serum were increased in a time-dependent manner, suggesting that PTHrP produced by human lung cancer may play a crucial role in the formation of bone metastasis and hypercalcemia. These findings indicate that a bone metastasis model of SBC-5 cells may be useful for clarifying the molecular aspects of the metastatic processes in different organ microenvironments and the development of therapeutic modalities for lung cancer patients with bone metastases.

MR imaging of primary malignant lymphoma in the larynx

We present MR findings in a patient with primary laryngeal lymphoma. The MR images showed a homogeneous mass in the right supraglottic larynx extending to the true vocal cord through the paraglottic space, of which signal intensity was intermediate both on T1- and T2-weighted images. The tumor was moderately enhanced and preserved mucosal layers were demonstrated as hyperintense bands on gadolinium-enhanced fat-suppressed T1-weighted images. Primary laryngeal lymphoma should be included in the differential diagnosis for a homogeneous solid mass in the supraglottic submucosal area.

Efficient generation of dendritic cells from alveolar and pleural macrophages as well as blood monocytes in patients with lung cancer

In this study, we investigated the generation of dendritic cells (DCs) from blood monocytes and mature macrophages from untreated primary lung cancer patients. Blood monocytes were separated by adherence from blood mononuclear cells (MNC) from ten lung cancer patients and ten control subjects, and cultured for 7 days in medium with granulocyte/macrophage colony-stimulating factor (GM-CSF) plus interleukin (IL-) 4. In all cases examined, DCs with typical characteristics were obtained even in lung cancer patients after 7 days culture with these cytokines, and there was no significant difference in phenotype and stimulatory activity in allogeneic lymphocyte proliferation between DCs derived from monocytes from lung cancer patients and those from control subjects. Next, we examined whether alveolar and pleural macrophages in malignant pleural effusion separated by magnetic beads could differentiate to immunostimulatory DCs. Conventional culture conditions with GM-CSF and IL-4 did not induce efficient numbers of DCs from mature macrophages, whereas the addition of tumor necrosis factor-alpha (TNF-alpha) to GM-CSF and IL-4 effectively contributed to generate DCs. These findings suggest that both mature macrophages and blood monocytes from lung cancer patients could differentiate to DCs, and might be a useful source of DCs for immunotherapy.

Increased CCR4 expression in active systemic lupus erythematosus

CC chemokine receptor (CCR)4 is selectively expressed on Th2-type T cells and has been shown to be responsible for Th2-dominant immune responses. In this study, we analyzed the expression of CCR4 in active systemic lupus erythematosus (SLE) patients by FACS analysis using anti-human CCR4 monoclonal antibody and determined the clinical relevance in this disease. Higher expression of CCR4 was found on peripheral blood CD4+ T lymphocytes of active SLE patients than was found with healthy controls and inactive SLE patients. The CCR4 expression significantly correlated with the SLE disease activity index (SLEDAI) scores. The expression was dramatically decreased after the corticosteroid therapy in parallel with a serum level of double-stranded DNA antibody and SLEDAI scores. Moreover, we found that serum levels of IL-10 were increased in active SLE patients and significantly correlated with the CCR4 expression. This study suggests that Th2 immune response is predominant in the active state of SLE, and CCR4 may have relevance in regard to the disease course in SLE patients.