EDPS of Clinical Case Record and Scientific Document in the Industry Post-Marketing Surveillance of Drugs

In order to meet the multifarious needs for drug information and to cope with the post-marketing surveillance of drugs adequately, an on-line drug information network, which is composed of two data bases, clinical case record data base and literature data base, has been developed. Primary considerations in designing these systems were input of clean data, accurate input, insuring that no ADRs are overlooked, accumulation of the latest data, saving manpower required for processing, and processing large quantities of data. This system is also designed to input and to output in Japanese character.

Impact of immunoreactive substances contained in apheresis platelet concentrate on postoperative respiratory function in surgical patients receiving platelet transfusion: a prospective cohort study

OBJECTIVES

To construct an alternative policy for the donor selection of platelet concentrate (PC), a clinical study exploring the features of lung injury following PC administration is needed.

BACKGROUND

Although a male-donor-only policy for plasma products appears to have efficiently reduced transfusion-related acute lung injury (TRALI), this policy may not be applied to PC because of supply shortages.

METHODS AND MATERIALS

We prospectively examined pulmonary function after the transfusion of PC in informed surgical patients treated at a tertiary university hospital in Japan. The contributions of immunoreactive substances contained in the PC to respiratory function after PC transfusion was then statistically examined.

RESULTS

Eighty-six patients (56 men, 30 women) were enrolled in the analysis. Fifty-four cases experienced respiratory failure (PaO2 /FiO2 <300 mmHg) after transfusion. Five cases were diagnosed as possible TRALI based on permeability pulmonary oedema, while 23 cases were diagnosed as transfusion-associated circulatory overload (TACO) based on chest radiograph findings. A multivariate logistic regression analysis identified the presence of anti-granulocyte antibody as a significant predictor of possible TRALI [P = 0.023; odds ratio (OR), 13.0; 95% confidence interval (CI), 1.4-118.3]. Meanwhile, anti-leukocyte antibody class II was identified as a significant independent predictor of TACO (P = 0.010; OR, 18.4; 95% CI, 2.0-170.1).

CONCLUSIONS

Our data suggest that antibodies contained in PC may contribute to the deterioration of respiratory function after PC transfusion, although the diagnoses of TACO and TRALI may have overlapped among the patients with pulmonary distress in this cohort.

Pancreatic granular cell tumor combined with carcinoma in situ

A 58-year-old man was treated for a granular cell tumor (GCT) of the pancreas; a very rarely occurring tumor. The patient, who had been followed for 6 years due to alcoholic hepatitis, chronic pancreatitis and elevated carcinoembryonic antigen (CEA) levels from smoking, was admitted to our hospital for evaluation of back pain, diarrhea and constipation. The patient was diagnosed as having pancreatic head cancer using clinical imaging studies, and a pylorus-preserving pancreatico-duodenectomy was done. In the resected specimen, a white tumor measuring 13 mm in diameter was observed at the pancreatic head, and there was marked fibrous change surrounding the tumor. The microscopic appearance of the pancreas showed atrophy of acinar cells, fibrosis, and dilatation of the main pancreatic duct (MPD). Within the tumor were oval cells with low-grade atypia and an increased number of diffuse eosinophilic granules. Neither mitosis nor invasive findings were observed. Periodic acid-Schiff staining and immunohistochemical staining for the S-100 protein were positive, thus the tumor was diagnosed as a benign GCT. In addition, carcinoma in situ was found at the dilated MPD. Therefore, this patient was diagnosed as having GCT with carcinoma in situ of the pancreas. To the best of our knowledge, this is only the fourth case of GCT of the pancreas to be reported.

Multiple minute carcinoids in type A gastritis: attempt at 3-D reconstruction

In type A gastritis, the numbers of endocrine cell micronests (ECM) and carcinoids increase through the trophic action of gastrin. This study examined the characteristics and growth of carcinoids in type A gastritis. A total of 395 lesions in five surgically removed stomachs with type A gastritis were investigated, in terms of number, size, distribution and histological appearance, to clarify the tumorigenesis and progression of carcinoids. 3-D reconstruction using serial paraffin sections was used to study carcinoid progression. Our findings suggest that in type A gastritis, carcinoids arise in areas where minute carcinoids are present at a high density. They also suggest that early stage carcinoids not only become large expansively, but also develop in a very complex manner, by maintaining contact with surrounding minute carcinoids.

Cloning of hypoxia-inducible factor 1alpha cDNA from chick embryonic ventricular myocytes

Hypoxia-inducible factor 1 (HIF-1) is composed of HIF-1alpha and arylhydrocarbon nuclear receptor translocator (ARNT), which belong to the basic-helix-loop-helix-Per/ARNT/Sim (bHLH-PAS) family of transcription factors. HIF plays key roles in oxygen homeostasis and embryonic cardiovascular development. In this study, we have cloned cDNAs encoding the chick HIF-1alpha from cultured embryonic ventricular myocytes (CEVM) and then examined its expression in various embryonic tissues. The deduced amino acid sequence of the chick HIF-1alpha cDNA showed 79% identity with that of the human HIF-1alpha cDNA. In contrast, sequence homology between the chick HIF-1alpha and endothelial PAS protein 1 (EPAS1), another member of the bHLH-PAS proteins, was only low (49%). HIF-1alpha mRNA was expressed abundantly in CEVM, but scarcely in the liver, which was quite different from expression pattern of EPAS1 mRNA. These data suggest that HIF-1alpha may be involved in embryonic cardiovascular development. HIF-1alpha and EPAS1 may play distinct roles during developmental stages.

Survey of residual tetracyclines in kidneys of diseased animals in Aichi Prefecture, Japan (1985-1997)

A survey was conducted to determine the incidence of tetracycline antibiotic (TCAs) residues in the kidneys of slaughtered animals that did not pass inspection for human consumption by the Japanese Food Sanitation Law and the Meat Inspection Law at the slaughterhouses in Aichi Prefecture, Japan, from April 1985 to March 1998. The kidneys were analyzed by the AOAC Official Method 995.09. Among 424 animals (147 cattle and 277 pigs), 131 (30.9%) were contaminated with TCAs, including 69 (16.3%) with chlortetracycline (CTC), 61 (14.4%) with oxytetracycline (OTC), 3 (0.7%) with tetracycline (TC), and 1 (0.2%) with doxycycline (DC). One sample (cattle kidney) was contaminated with both OTC and DC. The frequencies of OTC and TC residues were significantly higher (p < 0.05) in cattle than in pigs, whereas, the frequency of CTC was significantly higher (p < 0.01) in pigs. Pig kidney samples collected in 1991-1997 had significantly higher incidences of TCAs and CTC (p < 0.01) residues than those in 1985-1986.

Characterization and chromosomal distribution of a novel satellite DNA sequence of Japanese quail (Coturnix coturnix japonica)

A novel satellite DNA sequence of Japanese quail (Coturnix coturnix japonica) was isolated from genomic DNA digested with restriction endonuclease, Bg/II. Sequence analysis of three different-size clones revealed the presence of a tandem array of a GC-rich 41 bp repeated element. This sequence was localized by fluorescence in situ hybridization (FISH) primarily to microchromosomes of Japanese quail (2n = 78); approximately 50 of the 66 microchromosomes showed positive signals, although hybridization signals were also detected on chromosomes 4 and W. This satellite DNA did not cross-hybridize with genomic DNA of chicken (Gallus gallus) and Chinese painted quail (Excalfactoria chinensis) under moderately stringent conditions, suggesting that this class of repetitive DNA sequences was species specific and fairly divergent in Galliformes species.

Gastric carcinoma presenting with extensive extraluminal growth: report of a case

We report a 48-year-old-man with gastric carcinoma presenting with an unusual extraluminal growth. The patient underwent a barium meal examination and gastrofiberscopy because of progressive anemia over 6 months. These examinations revealed a Borrmann type 3 advanced gastric carcinoma of the greater curvature of the antrum. Biopsies showed moderately differentiated tubular adenocarcinoma. The intraoperative findings showed gastric carcinoma associated with extensive extraluminal invasion into the adjacent organs, i.e., the transverse colon and mesocolon. A palliative distal gastrectomy with a partial resection of the transverse colon was performed because of peritoneal dissemination found in the mesocolon and rectovesical pouch. A histological examination of the specimen confirmed adenocarcinoma which had massively infiltrated the transverse colon and mesocolon. His postoperative course was uneventful. However, he died of peritonitis carcinomatosa 9 months later.

[A case of gastric cancer with multiple liver metastasis responding to combined chemotherapy with low-dose cisplatin and 5-fluorouracil]

A 68-year-old man who had Borrmann type 4 gastric cancer with multiple liver metastases was admitted to our hospital on October 20, 1998. He was considered nonresectable and placed on neoadjuvant chemotherapy consisting of low-dose CDDP and 5-FU. After 9 weeks of administration, the liver metastases had disappeared on abdominal computed tomography, but the primary lesion had progressed. On May 12, 1999, a total gastrectomy with a partial resection of the transverse colon and resectional biopsy of a white nodule of the liver were performed. This was a non-curative operation because of the peritoneal dissemination. A histopathological examination of the liver nodule revealed that the cancer cells had disappeared. The patient had an uneventful postoperative course and 4 weeks of chemotherapy were added. He remains alive with no symptoms or re-growth of the liver metastatic tumor 4 months after the surgery.

Lipopolysaccharide augments expression and secretion of vascular endothelial growth factor in rat ventricular myocytes

Vascular endothelial growth factor (VEGF), also known as vascular permeability factor, is highly expressed in the myocardium under various stimuli including hypoxia and ischemia. On the other hand, lipopolysaccharide (LPS) causes systemic inflammatory response syndrome (SIRS), which consists of systemic pathophysiological changes related to vascular hyperpermeability. To test the hypothesis that VEGF is one of the important mediators of SIRS, we examined effects of LPS on the VEGF expression and secretion in cultured neonatal rat ventricular myocytes. LPS (10 microg/ml) rapidly (within 1 h) augmented the levels of VEGF mRNA in these cells. Pharmacological inhibition of nucleic factor-kappaB or tyrosine kinases did not affect the LPS-induced augmentation of VEGF mRNA expression, while these treatments markedly suppressed the up-regulation of inducible nitric oxide synthase (iNOS) expression by LPS. The VEGF concentrations in the conditioned media were also significantly increased by the LPS treatment of 6 h. In conclusion, LPS augments VEGF expression and secretion in rat ventricular myocytes, suggesting that VEGF may be involved in pathogenesis of SIRS. LPS may induce VEGF mRNA through the signaling pathways that are distinct from those responsible for the iNOS induction.

Laboratory diagnosis of toxigenic Clostridium difficile by polymerase chain reaction: presence of toxin genes and their stable expression in toxigenic isolates from Japanese individuals

Clostridium difficile causes pseudomembranous colitis and antibiotic-associated diarrhea. The definitive diagnosis of C. difficile infection is finally accomplished by the isolation of toxigenic C. difficile. However, only a small number of Japanese clinical laboratories are able to reach a definitive diagnosis of C. difficile infection, probably because simple reliable assays for toxins in the isolates are not available. In this study, we examined the compatibility of a polymerase chain reaction (PCR) assay and tissue culture assay to identify toxigenic C. difficile, in toxigenic and nontoxigenic C. difficile isolates from Japanese patients and healthy carriers. The specificity of PCR primers was demonstrated by restriction endonuclease digestion and seminested PCR in C. difficile VPI 10463 strain. No PCR product was amplified in the eight other clostridial species used to check the specificity of the PCR assay. The detection limit was 10(3) cells. Both toxin A and toxin B genes (the genes encoding the major virulence factors of C. difficile) were detected in 58 toxigenic C. difficile isolates, which showed a wide range of cytotoxic activity in tissue culture assays. Neither of the toxin genes was carried by 40 nontoxigenic strains of C. difficile. The results of this study strongly suggest that a definitive diagnosis of C. difficile infection can be accomplished by PCR detection of the toxin genes rather than by tissue culture assay of isolates.

Effect of arginine on toxin production by Clostridium difficile in defined medium

Twenty strains of Clostridium difficile were examined for the effect of arginine on toxin production in a defined medium. In three strains, the production of toxins A and B was greatly enhanced in the absence of arginine. These strains showed distinctively poorer growth in the absence of arginine in comparison with the remaining 17 strains, indicating that the presence of arginine is required for good growth among the three strains. From the present results, test strains were divided into two groups: a group in which arginine insufficiency caused distinctly poor growth and enhanced toxin production, and another group in which there was neither distinctly poor growth nor enhanced toxin production. The phenomenon is discussed in relation to the biosynthesis and catabolism of arginine.

[Interdural dermoid cyst of the cavernous sinus presenting with oculomotor palsy: case report]

A 19-year-old female was admitted to our hospital because of diplopia. Neurological examination showed slight anisocoria (right > left), disturbance of ocular movement in upward, downward and medial directions on the right side, and diplopia on upward gaze. Computed tomography (CT) scan demonstrated a well-demarcated cystic lesion in the right parasellar region. The lesion showed non-homogeneous low intensity with a high intensity margin on T1-weighted imaging and high intensity with a low intensity margin on T2-weighted imaging in magnetic resonance image (MRI). The lesion showed enhancement by contrast media on neither CT nor MRI. Cerebral angiography revealed no tumor stains. The lesion was approached via right fronto-temporal craniotomy. The right optic nerve, oculomotor nerve and internal carotid artery were compressed medially by the tumor. The tumor contents appeared to be flaky and greasy containing motor-oil-like fluid, mineralized body, and a few hairs. The tumor was attached to the lateral wall of the right cavernous sinus (inner membranous layer), but was totally resected with careful microscopic dissection. The histopathological examination confirmed the diagnosis of dermoid cyst. The patient's complaint of diplopia showed gradual improvement postoperatively. Supratentorial intracranial dermoid cyst is a rare congenital tumor and, to our knowledge, only one case arising within the lateral wall of the cavernous sinus and presenting oculomotor palsy has been reported. Total removal is ideal and may be possible even when the tumor arises from the lateral wall of the cavernous sinus.

A case of Sjögren's syndrome with valvular diseases

The case of a 61 year old woman with Sjögren's syndrome with aortic and mitral stenosis is reported. She suffered from rheumatic fever at a young age. Physical and echocardiographic examinations showed findings of mitral and aortic valve stenosis. In addition, she had experienced xerostomia, a gritty sensation in the eyes and Raynaud's phenomenon. Blood examination showed hypergammaglobulinemia, positive rheumatoid factor, antinuclear and anti-Ro (SS-A) antibodies. The diagnosis of Sjögren's syndrome was confirmed by sialography and biopsy of the labial salivary gland. The combination of valvular disease and Sjögren's syndrome is rare and the etiological correlation is discussed.

Selection of scientific periodicals to monitor drug safety information using Excerpta Medica and Japicdoc in the post marketing surveillance of drugs

In order to select important journals to be monitored for efficient collection of literature information on drug safety, a retrospective search was made of the safety information in the Excerpta Medica (EM) database between 1979 and 1981. The search provided 54,005 references to drug safety, which were found in a total of 2,536 journals. Fifty percent of the references appeared in only 148 journals, or 6% of all journals surveyed. A similar search, carried out using the Japicdoc (JD) database, provided 9,268 references in 172 journals. To cover all the necessary information appearing in overseas journals, however, a retrospective search of a bibliographic database is required as a cost-effective means to improve the comprehensiveness of the collection of information. In domestic journals, because JD includes fewer journals than EM, all of the 172 journals can be monitored for the collection of drug safety information.

A case of bacteremia and disseminated intravascular coagulation after the conduit procedure for tetralogy of Fallot with pulmonary atresia

A case undergoing conduit procedure for tetralogy of Fallot with pulmonary atresia was complicated postoperatively by bacteremia due to non-fermentative Gram-negative rods and by disseminated intravascular coagulation. He was able to be cured without any sequela. The patient was a 16-year-old male, who had undergone Blalock-Taussig anastomosis in his infancy. The present operation was carried out as follows: ventricular septal defect was closed with a Teflon-patch and discontinuity between the right ventricle and the pulmonary artery was corrected using a Hancock's valved conduit. Two weeks after the operation, pleural effusion in the right chest cavity was shown by a chest X-ray film. On the 32nd postoperative day, high fever with chills occurred, and subsequently developed pulmonary edema, shock and hemorrhagic tendencies with petechia. Pseudomonas aeruginosa, Flavobacterium and Alcaligenes faecalis were detected by the culture of pleural effusion. The platelet count decreased to about 10,000/microliters. Carbenicillin, tobramycin and minocycline were administered for the infection, and heparin and aprotinin were used for disseminated intravascular coagulation. By these treatments for about 6 months, the patient became well and was discharged without any sequela.

Demonstration of two different types of non-A, non-B hepatitis by reinjection and cross-challenge studies in chimpanzees

Utilizing immune electron microscopy, viruslike particles were identified in the serums of three apparently healthy, HBsAg-negative blood donors. The serum from one of the donors, when injected into two susceptible chimpanzees, induced non-A, non-B hepatitis with an increase in SGPT level and pathological changes in the liver compatible with acute hepatitis but none of the cytoplasmic ultrastructures previously noted by electron microscopy in non-A, non-B hepatitis. These two chimps did not contract hepatitis when the same inoculum was given again 17 wk after the first injection. When they were subsequently challenged, however, by a chimp inoculum containing viruslike particles known to induce non-A, non-B hepatitis with cytoplasmic tubular ultrastructures, they developed high SGPT levels and these characteristic ultrastructures in their hepatocytes. A third chimp was initially injected with the chimp inoculum containing viruslike particles known to induce hepatitis with tubular ultrastructures, reinjected with the same agent, and then challenged by the human serum containing viruslike particles capable of inducing non-A, non-B hepatitis without tubular ultrastructures. He developed biochemical and pathological evidence of acute hepatitis after the first and the third, but not after the second inoculations. There are at least two kinds of viruslike particles which are associated with infectivity for two different types of non-A, non-B hepatitis; these have been tentatively designated NANB-1 and NANB-2.

Viruslike particles in a plasma fraction (fibrinogen) and in the circulation of apparently healthy blood donors capable of inducing non-A/non-B hepatitis in humans and chimpanzees

Two patients who had received a fibrinogen preparation contracted hepatitis of non-A/non-B etiology 3 and 8 wk after the injection. A chimpanzee inoculated with the same preparation developed hepatitis 11 wk later, with an increase in SGPT and a liver pathology compatible with acute viral hepatitis. His preacute serum containing the presumptive etiologic agent induced hepatitis in another chimpanzee. Electron microscopic observation of the liver of these chimpanzees biopsied during preacute and acute stages revealed peculiar tubular structures composed of two unit membranes with electron-opaque material in between. Using the serum obtained from infected chimpanzees at convalescence as an antibody reagent, viruslike particles were identified in the fibrinogen preparation by immune electron microscopy. When the serum of 100 apparently healthy blood donors with SGPT value of 80 Karmen units/ml or higher was tested for viruslike particles, eight were found to be positive. Furthermore, one of these sera, when a 5-ml amount was injected into each of two chimpanzees, induced hepatitis with viruslike particles in the circulation and characteristic tubular changes in the liver. On the basis of the results obtained, the viruslike particles in the fibrinogen preparation, as well as in the circulation of apparently healthy donors, were capable of inducing hepatitis of non-A/non-B category with a liver pathology characterized by tubular structures. The detection of non-A/non-B viral particles, especially when refined to routine laboratory tests, may open the way for the specific diagnosis, exclusion of contaminated blood from transfusion, and eventual prophylaxis by vaccination.

A receptor for polymerized human and chimpanzee albumins on hepatitis B virus particles co-occurring with HBeAg

A receptor for polymerized human serum albumin was demonstrated on Dane particles as well as on 20-nm hepatitis B surface antigen particles, isolated from asymptomatic carriers of hepatitis B virus who were positive for HBeAg. In contrast, such receptor was not born by 20-nm hepatitis B surface antigen particles obtained from carriers positive for antibody to HBeAg. Hepatitis B surface antigen particles with the receptor were heavier than those without, and when treated with pronase, they became lighter and lost the receptor. The receptor is responsible for the agglutination of erythrocytes coated with polymerized human serum albumin by the serum of patients with Type B hepatitis and asymptomatic carriers, which have been attributed to autoantibodies directed to denatured albumin molecules. When albumin fractions of chimpanzees were polymerized with glutaraldehyde, they also bound with the receptor on hepatitis B surface antigen. Polymerized albumin fractions of all the other experimental animals without susceptibility to hepatitis B virus, however, failed to bind with the receptor. These results seem to suggest a possible role of the receptor on Dane particles (presently accepted hepatitis B virions) for polymerized albumin molecules in infecting hepatocytes both in humans and chimpanzees.

Changes in some marker enzyme activities of liver plasma membranes during regeneration after partial hepatectomy in rats

Liver plasma membranes were isolated from regenerating rat livers between 20 h and 10 days after partial hepatectomy in order to study the effect of partial hepatectomy on some membrane enzyme activities. Mg2+-ATPase (EC 3.6.1.4) activity, but not (Na+ + K+)-ATPase activity, decreased slightly at 2 days, whereas leucyl beta-naphthylamidase (EC3.4.1.1) and 5'-nucleotidase (EC3.1.3.5) activities increased considerably at 1-2 and 3-5 days, respectively. These changes were not parallel to a sharp increase in mitotic activity of liver cells which occurred at 36 h.