[Providing Opportunities for Close Examination of Lynch Syndrome after Microsatellite Instability Testing in a Hospital Setting]

Microsatellite instability(MSI)testing is performed in cancer patients to determine the indication for chemotherapy with immune checkpoint inhibitors. We report on our scheme to ensure that Lynch syndrome patients are offered the opportunity for genetic counseling and genetic testing. Two hundred and eight cancer patients(107 males and 101 females, 20- 87 years, mean 63.3 years)underwent MSI testing at our hospital between February 2019 and November 2021. From February 2019 to December 2020, the MSI testing was performed with a consent document that included a commentary on Lynch syndrome, and the results were explained only by the attending cancer doctors. Eleven(8.6%)of the 136 cases had MSI-high, but none of them led to a visit to the genetic medicine department. The Genome Center in our hospital, which was operational from April 2020, undertook information sharing by multiple professions and established a system to provide appropriate support to cancer doctors. Consecutively, 72 MSI tests were performed between January and November 2021, and 2 patients(2.8%)with MSI-high(1 with endometrial cancer and 1 with colorectal cancer)were referred to the Department of Clinical Genetics for genetic counseling. Through genetic testing, both were diagnosed with Lynch syndrome, and information on future surveillance and health care for blood relatives was provided.

[Antibody production capacity after COVID-19 vaccination in immune-mediated neuromuscular diseases under immunotherapy]

The post-vaccination antibody response in patients with immune-mediated neuromuscular diseases under immuno-suppressive therapy has not been sufficiently verified. The Japanese Society of Neurology has stated that coronavirus disease 2019 (COVID-19) vaccination should be given priority in patients with immunotherapy-associated neuromuscular diseases; however, data on antibody production to a novel mRNA vaccine are scarce in these patients. In this study, we aimed to measure residual antibody titers after the second dose and produced antibodies after the third dose of SARS-CoV-2 mRNA vaccine in 25 patients with neuromuscular diseases under immuno-suppressive therapy (disease group). We compared the disease group antibody titers with those of 829 healthy employees in our hospital (control group). The disease group included 17 patients with myasthenia gravis, 4 with multiple sclerosis, 3 with inflammatory muscle disease, and 1 with chronic inflammatory demyelinating polyneuropathies. Seven cases of the disease group showed negative antibody levels (<15.0 s/co) before the third vaccination, and antibody titers in the positive cases ranged from 16.9 to 4,589.0 s/co. Three of the seven antibody-negative cases turned positive after the third vaccination, and all but one of the antibody-positive cases showed a booster effect, with antibody titers after the third dose ranging from 245.1 to 85,374.0 s/co (1.0 to 885.0 times higher than those before vaccination). Although the immune response in the disease group was modest compared to the control group, in which antibody titers after the third vaccination ranged from 67.8 to 150,000 s/co (0.9 to 5,402.1 times higher than those before vaccination), the result indicated that a constant immune response was achieved under immuno-suppressive therapy. Even in the control group, three participants tested negative for residual antibody before the third inoculation, and four of the antibody-positive participants (27.7-24,054.0 s/co) lacked a booster effect after the third vaccination.

Analysis of the predictive factors for a critical illness of COVID-19 during treatment － relationship between serum zinc level and critical illness of COVID-19

OBJECTIVES

Because most severely ill patients with COVID-19 in our hospital showed zinc deficiency, we aimed to examine the relationship between the patient's serum zinc level and severe cases of COVID-19.

METHODS

Serum zinc <70 μg/dL was defined as the criterion for hypozincemia, and patients continuously with serum zinc <70 μg/dL were classified in the hypozincemia cohort. To evaluate whether hypozincemia could be a predictive factor for a critical illness of COVID-19, we performed a multivariate analysis by employing logistic regression analysis.

RESULTS

Prolonged hypozincemia was found to be a risk factor for a severe case of COVID-19. In evaluating the relationship between the serum zinc level and severity of patients with COVID-19 by multivariate logistic regression analysis, critical illness can be predicted through the sensitivity and false specificity of a ROC curve with an error rate of 10.3% and AUC of 94.2% by only two factors: serum zinc value (P = 0.020) and LDH value (P = 0.026).

CONCLUSIONS

Proper management of the prediction results in this study can contribute to establishing and maintaining a safe medical system, taking the arrival of the second wave, and the spread of COVID-19 in the future into consideration.

88 Severe tricuspid regurgitation due to papillary muscle rupture: A rare complication of anterior myocardial infarction and ventricular septal perforation

INTRODUCTION

Papillary muscle rupture (PMR) of the mitral valve is a fatal complication of acute myocardial infarction (MI). As a complication of anterior MI, PMR of the tricuspid valve is extremely rare. We experienced a case of acute anterior MI complicated with tricuspid PMR and ventricular septal perforation (VSP).

REPORT

An 85-year-old woman was admitted with general fatigue and appetite loss. Her consciousness was alert, but she was pale, and had cold extremities. Her blood pressure was 74/62 mmHg, and pulse was 99/min. There was no leg edema. Pan systolic regurgitant murmur (Levine III/VI) was audible at the lower left sternal border. Her oxygen saturation was 86% under room air. Electrocardiogram revealed ST segment elevation and QS pattern in V1 to V3. Transthoracic echocardiography revealed dyskinesis of the apical anterior septum, VSP with bidirectional shunt, and severe pulmonary hypertension. Left ventricular ejection fraction was preserved (58%). The anterior tricuspid leaflet was flail due to PMR, resulting in severe tricuspid regurgitation and right ventricular dilatation. Coronary angiography revealed a single vessel disease of the left anterior descending artery (LAD). We recommended surgical treatment, and transferred her to another hospital.

DISCUSSION

Common causes of tricuspid PMR are infective endocarditis and chest trauma. Right ventricular infarction, usually caused by right coronary artery (RCA) occlusion, may cause tricuspid PMR. In our case, however, tricuspid PMR was complicated with anterior MI. The tricuspid anterior, posterior, and septal leaflets are attached to anterolateral RV wall, inferior septum, and infundibular septum, respectively, via papillary muscles. Right ventricular branches and septal branches of the RCA usually supply these papillary muscles. Anterior leaflet PMR in this case was possibly due to anomalous blood supply of anterolateral RV wall by the right ventricular branches of the LAD. Right ventricular overload due to large VSP shunt elevated RV diastolic pressure and right atrial pressure, and might worsen ischemia of the RV wall.

Abstract 88 Figure. severe TR & shunt flow through VSP

Nocturnal blood glucose and IGFBP-1 changes in type 1 diabetes: Differences in the dawn phenomenon between insulin regimens

OBJECTIVE

Insulin-like growth factor binding protein-1 (IGFBP-1) is known to regulate the bioavailability of insulin-like growth factor (IGF) and the levels of IGFBP-1 are increased in the morning in patients with type 1 diabetes mellitus. We investigated the nocturnal fluctuations of glucose, IGFBP-1, and free IGF-1 levels with three insulin regimens.

RESEARCH DESIGN AND METHODS

Forty-eight type 1 diabetes patients were divided into three groups according to their basal insulin therapy (continuous subcutaneous insulin infusion [CSII], insulin glargine, NPH insulin). Blood samples were obtained every 2 h between 2 300 h and 0700 h to measure plasma glucose, IGFBP-1 and free IGF-1 levels.

RESULTS

The dawn phenomenon was more frequent with NPH (62.1%) than with glargine (16.6%, p<0.05) and CSII (14.3%, p<0.05). In the NPH group, the serum IGFBP-1 levels were markedly increased from 21.0+/-3.6 ng/ml at 2 300 h to 200.3+/-21.8 ng/ml at 0700 h and free IGF-1 levels were inversely decreased; these changes were partially suppressed in the CSII and glargine groups.

CONCLUSIONS

The use of insulin regimens that provide sufficient insulin levels in the early morning can suppress the dawn phenomenon, leading to improved glycemic control. The increase in circulating IGFBP-1 in the morning, as a result of waning of insulin action, lowers free IGF-1 levels and may cause insulin resistance.

Hyperbaric oxygenation therapy for simple adhesive postoperative intestinal obstruction in children: comparison of the use of a short tube versus a long tube

We hypothesized that hyperbaric oxygenation (HBO) combined with a long tube (LT) [HBO + LT] would be more effective than HBO combined with a short tube (ST) [HBO + ST] for simple adhesive postoperative intestinal obstruction (APIO) in children, assuming that there is synergism between HBO and LT. The objective of this study was to determine retrospectively the effect of HBO + LT compared to HBO + ST for simple APIO in children. Seventy-three patients were diagnosed with simple APIO, and 51 of these patients were treated with HBO + LT during 104 HBO sessions, while 22 were treated with HBO + ST during 34 HBO sessions. HBO was performed at a pressure of 2 atmospheres for 60 minutes once daily. The recovery rates after HBO therapy were 87.5 % for the HBO + LT group and 82.4 % for the HBO + ST group (p = 0.4496). HBO was performed 5 +/- 3 (range 1 to 15) times for the HBO + LT group and 4 +/- 2 (range 1 to 8) times for the HBO + ST group (p = 0.9847) for ultimate recovery from simple APIO. The recovery rate after HBO therapy of up to 6 sessions was 78.2 % for HBO + LT and 92.1 % for HBO + ST (p = 0.0360) among the cases that recovered ultimately. The effect of HBO + LT did not significantly differ from that of HBO + ST, but the insertion of an LT is more intricate and the cost is higher than that of an ST. Therefore, we conclude that the use of an LT is not necessarily required for HBO therapy for simple APIO.

Multicystic dysplastic kidney detected by prenatal ultrasonography: natural history and conservative management

Conservative management of multicystic dysplastic kidney (MCDK) without nephrectomy has recently been advocated. The purpose of this study was to determine the clinical course of conservatively managed unilateral MCDK detected prenatally. Between 1991 and 2001, ten children (three boys and seven girls) with unilateral MCDK detected by prenatal ultrasonography (US) were prospectively followed at our institution. At birth, US confirmed the prenatal findings in all cases. All patients underwent voiding cystourethrography, intravenous pyelography, and radionuclide scans. Postnatal follow-up US examinations were performed every 3 months until patients were 5 years old and annually from then forward. The mean age at diagnosis during the prenatal period was 29 weeks of gestation (range 21-38 weeks). Median follow-up time was 42 months (range 17-125 months). Follow-up US was performed in eight children; three (38%) showed partial resolution, three (38%) complete resolution, and two (24%) no change in cyst size. The mean age at complete resolution of the lesion was 23 months (range 9-33 months). No children developed hypertension or tumors, and all maintained normal growth. In the present study, the natural history of MCDK was benign, and serial US monitoring showed that the affected kidneys frequently showed resolution with time. The results of this study support the conclusion that a nonsurgical approach for patients with MCDK is advisable.

Degradation of microcystin by biofilm in practical treatment facility

Potential for degradation of microcystin by biofilm was examined by some batch experiments using biofilm scraped from practical biological treatment facility combined with conventional treatment processes. The viable cells of Microcystis viridis, which produced microcystin LR, RR and YR were degraded at 6 to 10 days by the addition of biofilm. Biofilm collected in summer season had especially higher potential for degradation of Microcystis with complete degradation at 6 days. In all seasons, Monas spp. grew remarkably, accompanied with the higher decrease of the viable cells of Microcystis and the micro-animals were considered as a main predator for Microcystis cells. Intracellular microcystin LR, RR, YR were degraded simultaneously with high reduction of Microcystis cells. Dissolved microcystin LR of 1,000 microg l(-1) was effectively degraded by indigenous aquatic bacteria on biofilm during 5 days, the degradability became higher with the increase in the concentration of microcystin LR. From the results of our research, it was clarified that the aggregated microorganisms consisting of biofilm had high potential for degradation of intracellular and dissolved microcystin.

Ultrasonographic features of normalization of the pylorus after pyloromyotomy for hypertrophic pyloric stenosis

PURPOSE

The purpose of this study was to describe the time course, early postoperative changes, and morphologic features of normalization of the pylorus after pyloromyotomy for hypertrophic pyloric stenosis.

METHODS

The subjects were 17 infants (9 boys, 8 girls) who underwent umbilical incision Ramstedt pyloromyotomy. The pyloric muscle mass was measured immediately before the operation and then at intervals from 3 days to 6 months after the operation using a 7.5-MHz ultrasound probe.

RESULTS

In longitudinal section, the dorsal part of the pyloric muscle thickened transiently and then thinned to normal values by 5 months after the operation. It was 5.1 +/- 0.8 mm (mean +/- SD) preoperatively, increased to 6.0 +/- 0.3 mm by day 3 after the operation (P <.05), and thinned to 2.8 +/- 0.2 mm by 5 months after the operation. Concomitantly, the length of the pylorus gradually decreased (from 20.1 +/- 2.9 mm preoperatively to 16.9 +/- 2.7 mm by 3 days postoperatively [P <.05] and to less than 15 mm, by 4 months). In transverse section, the muscle normalized as in the longitudinal section. At the site of the incision it was 4.3 +/- 0.4 mm thick preoperatively, thickened to 4.6 +/- 0.4 mm by 3 days after the operation (P <.05), thinned to 2.1 +/- 0.9 mm by 7 days (P <.05), and then increased slightly, but always was less than 3.0 mm. Morphologically, in transverse section, the incised area looked like a wedge by 3 days after the operation.

CONCLUSIONS

After pyloromyotomy for hypertrophic pyloric stenosis, there is an early transient increase in muscle thickness within the first few postoperative days followed by a slow decrease that reaches normal thickness (<3 mm) by 5 months. This decrease in thickness is accompanied by a gradual decrease in length to 75% of the preoperative value by 5 months. The morphologic features in this normalization are first a wedge (day 3), then a flat tire (days 7 and 14), and finally an elongated ring (5 months). J Pediatr Surg 36:582-586.

Inhibition of the human chemokine receptor CXCR4 by antisense phosphorothioate oligodeoxyribonucleotides

The CXC chemokine receptor CXCR4/fusion, a major coreceptor for the T-cell line T-tropic (X4) HIV-1 virus, plays a critical role in T-tropic virus fusion and entry into permissive cells. In the present study, we describe the effects of an antisense phosphorothioate oligodeoxyribonucleotide (anti-S-ODN) on the inhibition of CXCR4 gene expression in X4 HIV-1 infected HeLa-CD4 cells, to find more efficacious therapeutic possibilities for human immunodeficiency virus type 1 (HIV-1) infection. The naked antisense phosphorothioate oligodeoxyribonucleotide (anti-S-ODN-1), containing the AUG initiation codon at the center of the oligodeoxyribonucleotide, showed a slightly higher inhibitory effect on HIV-1 gag p24 production among all sequences tested. We also examined the concomitant use of a basic peptide transfection reagent, nucleosomal histone proteins (RNP), for the delivery of the anti-S-ODN-1. The anti-S-ODN-1 encapsulated with RNP had higher inhibitory effects on p24 products than the naked anti-S-ODN-1. When the anti-S-ODN-1 encapsulated with RNP was incubated with HeLa-CD4 cells, the surface levels of this chemokine receptor showed high suppression, indicating sequence-specific inhibition. The activities of unmodified oligodeoxyribonucleotide are effectively enhanced by using a basic peptide, RNP.

Genes for phytochrome A in horseradish: isolation of cDNAs and analysis of expression during light-induced formation of adventitious shoots from hairy roots

 Three cDNAs for phytochrome A (phyA), designated ArPHYA1, ArPHYA2 and ArPHYA3, respectively, were isolated from a cDNA library prepared from proximal parts of the hairy roots of horseradish (Armoracia rusticana). The level of phyA was higher in those parts than in any other parts of hairy roots. The amino acid sequences deduced from the cDNAs were quite similar, with stronger homology to the product of PHYA of Arabidopsis thaliana than to products of genes for phytochromes of many other plant species. Levels of transcripts in roots and tubers were higher than those in leaves and petioles. The levels in hairy roots were highest at the proximal ends and increased with increased duration of culture in darkness. Furthermore, the levels in proximal parts decreased by 25-50% after light irradiation. The elevated levels of transcripts of PHYA genes at the proximal ends of hairy roots are discussed with reference to the light-induced formation of adventitious shoots.

Characterization of whole-cell currents elicited by mechanical stimulation of Xenopus oocytes

Whole-cell mechanosensitive current (I(ms)) in Xenopus oocytes was studied using the two-electrode voltage-clamp technique. I(ms) was evoked by mechanically pressing the oocyte surface with a glass micropipette. The current was found to depend on the amplitude of the stimulus, showed a time-dependent decay, and turned off immediately after the stimulus was removed. The current-voltage relationship for the peak current exhibited inward and outward rectification at negative and positive potentials, respectively, while that for the sustained current exhibited only inward rectification. I(ms) was significantly suppressed by 30 microM Gd3+. One millimolar amiloride also significantly suppressed the inward I(ms) at negative potentials, but not the outward one at positive potentials. Replacing extracellular Na+ with K+ did not change the current-voltage relationship, whereas replacing extracellular Na+ with choline+ or tetraethylammonium+ significantly decreased the inward I(ms). The outward rectifier at positive potentials was abolished by replacing extracellular Cl- with gluconate-, by intracellular injection of 1,2-bis (2-aminophenoxy) ethane-N,N,N',N'-tetraacetic acid (BAPTA), by extracellular application of anthracene-9-carboxylic acid, and by replacing extracellular Ca2+ with Mg2+. These results suggest that mechanical stimulation activates stretch-activated cation channels and Ca2+-activated Cl- channels, the latter being secondarily activated by an increase in intracellular Ca2+ concentration by Ca2+ influx through stretch-activated cation channels.

Hemodynamic and thermal responses to a 30-minute constant-workload aerobic exercise in middle- or old-aged patients with cardiovascular diseases

The aim of the present investigation was to compare the hemodynamic and thermal responses to a 30-min aerobic exercise between middle- or old-aged patients with normal left ventricular function and those with left ventricular dysfunction. Constant-load sitting ergometer exercise of approximately 90% of the subject's oxygen uptake (VO2) at the anaerobic threshold for 30 min was conducted in 21 patients with left ventricular dysfunction (61+/-10 years, left ventricular ejection fraction (LVEF) 35+/-7%) and 24 patients with normal left ventricular function (59+/-9 years, LVEF 71+/-7%). Heart rate (HR), blood pressure, deep temperatures in the forehead and thigh, and forearm skin blood flow (SkBF) were measured every minute, and cardiac output (CO) and stroke volume (SV) were determined every 10 min with the dye-dilution technique during the exercise. Patients of both groups exhibited a progressive elevation in each temperature and an increase in SkBF during the exercise. Although the VO2 and CO remained stable, almost the same magnitude of decrease in SV as increase in HR was seen after the 10th min of exercise in both groups. The magnitude of the decrease in SV was greater in old-aged than middle-aged patients with left ventricular dysfunction. Thus, the downward drift in SV during a 30-min constant-load aerobic exercise might not be influenced by left ventricular function, but intensified by aging in patients with left ventricular dysfunction.

[Study of transforming growth factor-alpha expression in duodenal ulcer]

Various growth factors were also reported to promote healing of peptic ulcer. We have used a monoclonal antibody in conjunction with a standard immunohistochemical technique to characterize the expression of transforming growth factor-alpha (TGF-alpha) in duodenal ulcer. TGF-alpha immunoreactivity is found in Brunner's gland, also in immature gland and in duodenal epitheliums, but not in gastric metaplasia of the duodenum. TGF-alpha expression of healing and scar stage was higher than that of active stage. The presence or absence of Helicobacter pylori infection did not affect the expression of TGF-alpha in duodenal ulcer.

Effects of okadaic acid on rat colon

Effects of okadaic acid (OA) on mucosal damage were examined in rat colon. OA was sprinkled on rat colon mucosa under observation with an electronic-endoscopic system, and OA was also applied to the in vivo microscopic field. The OA-induced changes in transepithelial conductance (Gt) were measured by the Ussing voltage clamp technique. By endoscopic observation, the luminal sprinkling of OA (60 nmol/kg) evoked transient microthrombi in the submucosal venule, which was followed by mucosal edema. Histological study after endoscopic observation showed submucosal fluid retention, suggesting an increase of vascular permeability. The microthrombi were also detected by in vivo microscopy. By electrophysiological study after endoscopic observation with and without OA addition, the basal Gt values were 54+/-6.2 and 36.2+/-4.2 mS/cm2, respectively (P < 0.01). Furthermore in control rats, the serosal addition of OA evoked an increase in Gt in a concentration-dependent manner without increasing lactate dehydrogenase release. 2,4,6-Triaminopyrimidinium inhibited OA-induced Gt change by 60%. These results indicate that OA evokes an increase in paracellular permeability of epithelium. We conclude that the developed microthrombi are the first key event of OA-induced mucosal damage, followed by an increase in permeability in the submucosal venule and in the paracellular pathway of the epithelium.

[The significance of 123I-BMIPP myocardial SPECT on the evaluation of angina pectoris]

Some patients of ischemic heart disease have low uptake in 123I-labeled beta methyl-iodophenyl penta-decanoic acid (BMIPP) SPECT in spite of normal uptake in thallium-201 (Tl) SPECT. To investigate their clinical significance, we performed both T1 and BMIPP myocardial SPECT in 26 cases with stable angina (n = 16) and unstable angina (n = 10), and compared with clinical backgrounds electrocardiogram (ECG) and left ventriculography (LVG). In 11 patients of them, the uptake of BMIPP was moderately reduced. We divided 26 cases into two groups according to uptake of BMIPP (normal/reduced). The two groups had no differences in length of angina attack and duration of disease, but they had a significant difference in the abnormality of either ECG or LVG. Three to six months after PTCA, we examined LVG in 18 cases, 12 of 16 cases with the abnormality of LVG showed the improvement of wall motion. We concluded the reduced uptake of BMIPP with normal uptake of Tl was related to more severe ischemia in cases with unstable angina.

Hypertrophic cardiomyopathy with apical left ventricular aneurysm

We report a case of hypertrophic cardiomyopathy (HCM) with apical left ventricular aneurysm, which is difficult to review because cases are so rare. A 54-year-old Japanese man was first found to have an electrocardiographic abnormality (T-wave inversion at rest) 19 years ago, and non-obstructive apical HCM without identifiable cause was diagnosed by echocardiography, left ventriculography, and clinical findings. After 19 years, he was admitted because of repeated episodes of palpitation and chest oppression at rest. Widespread left ventricular hypertrophy from the anteroseptal wall to the apex with an apical left ventricular aneurysm was detected by echocardiography, left ventriculography, and cardiac magnetic resonance imaging. Histologic examination of the hypertrophic apical myocardium surrounding the aneurysm showed that the myocardial tissue had been extensively replaced by fibrous tissue containing hypertrophic myocardial fibers, and uptakes of [123I]-metaiodobenzyl guanidine (MIBG) and [123I-] beta-methyliodophenyl pentadecanoic acid (BMIPP) in single-photon emission photography images were reduced despite high myocardial perfusion. On the other hand, histologic examination of the hypertrophic anterior wall revealed myocardial hypertrophy with disorganization; myocardial perfusion and the uptakes of MIBG and BMIPP were preserved. Abnormalities of myocardial fatty acid metabolism and sympathetic neuron activity with preserved perfusion flow and histologic changes such as fibrosis in the apical wall are indicative of apical myocardial injury or ischemia (infarction) without coronary artery stenosis; apical aneurysm may have occurred in severe apical HCM with cavity obliteration up to the midventricular level.

Arabidopsis thaliana ECP63 encoding a LEA protein is located in chromosome 4

DCECP63 is a carrot embryogenic cell protein. To perform its genetic analysis, we isolated an Arabidopsis thaliana (At) ECP63 cDNA. The cDNA encoded a polypeptide of 449 amino acids (aa). Its deduced aa sequence showed extensive similarity with DCECP63, DCDC8 and BPBP8 which are embryonic proteins isolated from carrot and birch, respectively. The aa sequence contained eight well-conserved tyrosine phosphorylation sites and 16 repeats of 11 aa. Southern analysis showed that the AtECP63 gene might belong to a small multigene family. The AtECP63 transcripts accumulated specifically in mature seeds, and exogenous abscisic acid (ABA) induced its expression in immature siliques, but not in vegetative tissues. These results suggested that the AtECP63 gene encoding a putative phosphotyrosine protein belonging to late embryogenesis abundant (LEA) protein in group 3 might be involved in maturation and desiccation tolerance of seeds. Restriction fragment length polymorphism (RFLP) and cleaved amplified polymorphic sequence (CAPS) mapping showed that AtECP63 gene was present in the South part of chromosome 4.

[A case of hemolytic uremic syndrome associated with circulating anticoagulant]

A previously well 66-year-old woman was admitted to our hospital because of severe abdominal pain, oliguria, jaundice and hemoglobinuria. At admission, the following values were obtained: red blood cell count 261 x 10(4)/mm3, serum creatinine 2.8mg/100ml, total bilirubin 8.0mg/ml, indirect bilirubin 5.7mg/100ml, LDH 13886 WU, negative direct and indirect Coomb's test and peripheral blood smear showing schistocytosis. She was diagnosed as hemolytic uremic syndrome and was successfully treated with plasma infusion, plasma exchange and hemodialysis. The results of the tests for verotoxin titer of E. coli O157: H7 and circulating anticoagulant were positive. The test result for anticoagulant eventually became negative during her clinical course. In this case, circulating anticoagulant might have contributed to the pathogenesis of hemolytic uremic syndrome.

Effects of light and growth regulators on adventitious bud formation in horseradish (Armoracia rusticana)

To clarify that the presence of Ri T-DNA genes are not prerequisite for the light-induced bud formation in horseradish (Armoracia rusticana) hairy roots, leaf and root segments of nontransformed horseradish plants were used as explants. Bud formation from nontransformed tissues was observed in hormone-free medium under 16 h daylight conditions, but not under continuous darkness. To investigate the effects of growth regulators on bud formation, leaf and root explants were treated with auxin (1-naphthaleneacetic acid; NAA) and / or cytokinin (6-benzyl-aminopurine; BA). The most effective treatment in the dark to stimulate bud formation was BA at 1 mg·1(-1). These results show that adventitious bud formation in horseradish can be induced by light and growth regulators, and especially cytokinin, may be involved in bud formation, irrespective of whether the tissues were transformed with Ri T-DNA.

Effects of L- and DL-carnitine on patients with impaired exercise tolerance

We designed this study to determine whether orally administered L- and DL-carnitine can improve exercise tolerance in a group of patients with exercise intolerance. Nineteen patients with cardiac disease were randomly divided into 2 groups, an L-carnitine treatment group (n = 9) and a DL-carnitine treatment group (n = 10). Eight additional age-matched patients served as an untreated control group. Subjects in both carnitine treatment groups underwent cardiopulmonary exercise testing on a cycle ergometer in order to determine peak exercise time, peak oxygen uptake (VO2), lactate threshold (LT) and ventilatory threshold (VT) before and after the oral administration of 900 mg/day of L- or DL-carnitine for 2 weeks. Basal values of peak exercise time, peak VO2, LT and VT did not differ significantly among the 3 groups. Peak exercise time and peak VO2 tended to be increased in the L-carnitine treatment group, and tended to be decreased in the DL-carnitine treatment group. Both LT and VT (ml/kg/min) were significantly improved (LT: from 9.7 +/- 0.6 to 10.8 +/- 1.0, p < 0.05; VT: from 9.8 +/- 0.8 to 11.8 +/- 1.9, p < 0.02) by the administration of L-carnitine, while LT was significantly decreased (from 11.0 +/- 2.0 to 9.6 +/- 1.2, p < 0.05) and VT tended to be decreased by the administration of DL-carnitine (from 11.6 +/- 2.0 to 10.8 +/- 2.4). In the untreated control group, no significant changes were observed in the values of exercise tolerance between the 2 series of exercise testings. In neither group did carnitine modify hemodynamic parameters at rest or during exercise. In conclusion, this study demonstrated that L-carnitine increases and DL-carnitine decreases exercise tolerance in patients with impaired exercise tolerance.

[Acute progressive polyneuropathy in a patient with Waldenström macroglobulinemia]

A case of Waldenström's macroglobulinemia (WM) (IgM-kappa type) associated with acute-onset demyelinating peripheral neuropathy is reported. A 49-year-old woman was admitted to our hospital because of general fatigue and recurrent syncope attacks. She was treated with vincristine, cyclophosphamide, epirubicin and prednisolone. By 10th hospital day, her clinical condition improved and serum viscosity was reduced. However, on the 21st hospital day, she suffered from rapidly progressive writing and gait disturbance. Neurological examination showed muscular atrophy and weakness in the distal part of four extremities. Deep tendon reflexes were diminished. There was no sensory deficit. Cerebrospinal fluid was normal. Anti-myelin associated glycoprotein activity of her serum was negative. Both motor and sensory nerve conduction velocities were markedly decreased. Biopsy of sural nerve revealed marked demyelination and onion bulb formation. There was IgM deposition on myelin sheath. Minimal axonal changes excluded the possibility of vincristine neuropathy. Plasmapheresis improved her symptoms, but nerve conduction velocities remained unchanged. Polyneuropathy associated with WM is usually gradual onset and sensory dominant. In this case, associated neuropathy was acute onset, progressive and motor dominant. This type of neuropathy in patients with WM is very rare.

[Histopathology of corneal plaque in vernal keratoconjunctivitis]

The author reported 2 cases of vernal keratoconjunctivitis with corneal plaque showing a white board-like appearance. Conventional medications were not effective in both cases and during the course of the disease corneal ulcer developed followed by formation of corneal plaque. After the plaque spontaneously peeled off, or were surgically removed, the ulcers of both cases healed. The histological specimens from the 2 cases were examined by light and electron microscopy. The plaques showed lamellae-like structures, and formed alternate accumulation of hyaline-like material and another amorphous material. No cell components, such as corneal epithelial cells, keratocytes, or fibroblasts, were found either on the surface of and within the plaques. The corneal epithelial cells and/or eosinophils, however, were found at the edge of the plaque. These findings may suggest that these corneal plaques were formed by repeated episodes of deposition and that corneal epithelial cells and eosinophils may have been involved.

Glomerulonephritis with various crystalline deposits

A 60-year-old Japanese male was admitted with nephrotic syndrome complaining of facial and pedal edema. Renal biopsy revealed mesangial and endocapillary proliferation with massive mesangial and subendothelial deposits. Deposits of IgA, IgG, IgM, C3 and fibrinogen were identified by immunofluorescence technique in both mesangial and subendothelial areas. Deposits of kappa and lambda light chains were also recognized in similar patterns. Electron microscopy revealed crystalline structures of various appearance in these deposits. A large deposit consisted of various small triangular, quadrilateral and polygonal shapes of deposits with crystalline structures. These crystalline structures exhibited lattice or parallel lamellar lines with different periodic distances. Although a disease producing paraproteinemia was suspected, no immunoglobulin disorder or light chain abnormality could be detected on clinical and laboratory examinations. On the second biopsy, a faint reaction for cryoglobulin was recognized. However, the crystalline deposits observed in this case were absolutely different from the tubular structures seen in cryoglobulinemic nephropathy. This was a very rare and unclassified case.

Light requirement for shoot regeneration in horseradish hairy roots

Hairy roots of horseradish (Armoracia rusticana) were induced by inoculation with Agrobacterium rhizogenes harboring Ri plasmid and cultured on phytohormone-free Murashige and Skoog medium after eliminating the bacteria. Hairy roots grew vigorously and sometimes formed yellowish calli under dark conditions. On the other hand, growth of hairy roots stopped after several weeks of culture with light, then shoots were regenerated. Frequency of shoot formation from hairy roots increased as the culture period in light lengthened and the light intensity increased. The shoot regeneration was induced by treatment with white or red light, but not with far-red light. Shoot regeneration by red light was inhibited by following treatment with far-red light. Red and far-red light reversibly affected shoot regeneration. Excised roots of nontransformed plants grew quite slowly on phytohormone-free Murashige and Skoog medium and occasionally formed shoots under white light conditions.

Perfusion and mechanical analysis with technetium-99m 2-methoxy-isobutyl-isonitrile in a case of dilated cardiomyopathy

With technetium-99m 2-methoxy-isobutyl-isonitrile (99mTc-MIBI), regional wall thickening in a patient with dilated cardiomyopathy was analyzed by the first component Fourier method. The regional wall thickening was compared with thallium-201 and 99mTc-MIBI SPECT imaging. Thallium-201 SPECT images showed mildly reduced perfusion in the posterior wall and redistribution in the septum, whereas 99mTc-MIBI images showed heterogeneous accumulation around the left ventricular circumference. By means of phase analysis, diffusely decreased wall thickening and discontinuity of percent wall thickening in neighboring segments were observed throughout the left ventricle. Regional wall motion and wall thickening correlated roughly. However, discrepancies between the mechanical function and myocardial perfusion, and discrepancies in regional myocardial perfusion between thallium-201 and 99mTc-MIBI were observed.

An electron microscopic study of glomeruli in Japanese patients with non-insulin dependent diabetes mellitus

Renal biopsy specimens of 29 Japanese non-insulin dependent diabetes mellitus (NIDDM) patients were examined by quantitative electron microscopic morphometry. In NIDDM the relative increase of percent total mesangium and mesangial capillary surface density (S/Vb) and the relative decrease of peripheral capillary surface density (S/Va) were compared with disease controls. However, mesangial-GBM-epithelial surface density (S/Vc) was not different between both groups. These results suggest that the increased mesangial matrix expands directly towards the capillary lumen as well as along the inner surface of GBM, and narrows the capillary lumen and filtration surface. The duration of diabetes mellitus (DM) did not correlate with all morphological parameters. The mesangial expansion correlated with urinary protein excretion and decreased creatinine clearance (CCr). GBM thickening correlated with proteinuria, but not with CCr. The degree of these morphological changes could be the indicators of hypertension of NIDDM patients. Areas of thin GBM were occasionally noticed in glomeruli which revealed thick GBM extensively, although the mechanism of GBM thinning is not known at the present time.

[Initial experience using a new type extracorporeal lithotripter with an anti-miss-shot control device]

The results of clinical trial using a TOSHIBA piezolectric extracorporeal lithotripter are presented. The advantages of this machine are the installation of an anti-miss-shot control device (AMCD) to prevent miss-shots to the renal tissue and the improved ultrasound stone localization by an over-head type applicator. AMCD functions so that shock waves are generated only when the stone is in the focal region. Forty patients with urinary tract stone were treated by this machine from October 1989 to March 1990 at the Department of Urology, Tohoku University School of Medicine. Almost all patients could be treated with an analgesic only. The X-ray film obtained three months after ESWL treatment showed that 23 cases (57.5%) were stone-free and 10 cases (25.0%) had stone fragments of less than 4 mm. The successful rate of ESWL using this machine was 82.5%, the result was better than that using other piezolectric machines. No serious complication was observed, except mild hematuria in all cases. Milder postoperative hematuria suggested the decrease of renal tissue injury. It is concluded that the treatment with this machine is safe and seems to be more favorable than the conventional ones.

[A case of adenoid cystic carcinoma of the esophagus]

A 64-year-old male admitted with feeling of a foreign body at the esophagus in swallowing. Esophageal radiologic findings showed a serrated type shadow defect 6 cm in diameter at the middle thoracic esophagus. Endoscopic findings revealed a elevated type tumor at a site 32 cm from the incisor dentition. The biopsy specimens showed squamous cell carcinoma. The operation was performed with right thoracotomy, subesophagotomy, and reconstruction of gastric tube via substernum. Macroscopically, a elevated type tumor of 5.5 x 4.0 x 2.0 cm covered by normal esophageal mucosa at the periphery was recognized. Histologically, most of the tumor was adenoid cystic carcinoma differentiating to squamous cell carcinoma in the epithelium. Immunohistological stain of actin, S-100 protein indicated that the tumor may have originated from an esophageal gland. Histologic stage was mp, ly(-), v(-), n(-), stage I. Surgical curability was CIII. Postoperative irradiation for prevention of recurrence has been conducted. The patient survives without tumor at present 4 months later.

[A case of miliary tuberculosis with cutaneous lesion]

Miliary tuberculosis associated with cutaneous lesion has been rarely reported. We report a case of miliary tuberculosis in whom the cutaneous lesion was confirmed as tuberculosis by skin biopsy and bacterial examination. A 46-year-old man was admitted because of cough, fever, sore throat and abnormal shadow on the chest X-ray. Physical examination revealed an emaciated man with two ulcerous lesions overlying yellowed crust on the chest wall and fine crackles on the left side of the lung. Laboratory workup revealed a white blood cell count of 10,000 with 15% lymphocytes and positive CRP. Chest X-ray film showed the infiltration with cavity formation in left upper lung field and nodular dissemination. His tuberculin reaction was negative on admission. Sputum, urine and secrete from cutaneous lesion were positive for the acid-fast bacilli and the culture grew Mycobacterium tuberculosis. Examination of the skin biopsy specimen and bone marrow aspiration showed Langhans giant cells around necrotic lesion; therefore the diagnosis of miliary tuberculosis was made. After an initiation of antituberculosis therapy with combined regimen composed of streptomycin (SM), isoniazid (INH), ethambutol (EB) and rifampicin (RFP), this patient improved significantly. Although the case report of miliary tuberculosis tends to increase recently, the report of cutaneous lesion is relatively rare in association with miliary tuberculosis. We discussed this subject with reference to the literatures.

[Sympathetic innervation in the larynx of cats]

The site of origins, peripheral courses and intramucosal distribution of the sympathetic post-ganglionic nerve fibers supplying to the larynx were investigated by means of wheat germ agglutinin-horseradish peroxidase (WGA-HRP) and Falck-Hillarp method in 51 cats. The cervical sympathetic ganglia which send the postganglionic fibers to the larynx were the superior cervical ganglion (SCG), middle cervical ganglion (MCG), and stellate ganglion (SG). Location of MCG was at the bifurcation of the cervical sympathetic trunk, rostrally to the point of its crossing with the subclavian artery. After WGA-HRP injection, labeled sympathetic nerve fibers were observed mainly in the wall of the blood vessels and around the laryngeal glands of the posterior and caudal parts of the larynx. Labeled fibers originated from SCG were seen in the mucosa of the arytenoid region and posterior glottis ipsilaterally. Both the internal and external branches of the superior and inferior laryngeal nerves contained the postganglionic fibers from SCG. Labeled nerve fibers from MCG were recognized in the ipsilateral mucosa of the glottis and subglottis and were also contained in the internal and external branches of the superior and the inferior laryngeal nerves. Labeled sympathetic nerve fibers from SG appeared in the mucosa caudal to the first tracheal ring. The pattern of distribution of labeled sympathetic nerve fibers revealed by WGA-HRP technique coincided with that of the noradrenergic fibers stained by Falck-Hillarp method.

[Evaluation of pre-radiotherapy staging laparotomy in cancer of the uterine cervix]

Staging laparotomy prior to radiotherapy was performed in 70 patients with cervix cancer. Biopsy proven para-aortic lymph node metastases were found in 16(22.9%) patients. Pelvic lymph node metastases were estimated by palpation at laparotomy and 36(51.4%) patients were thought to be positive. Other laparotomy findings were: invasion to the bladder muscle in 14, cul-de-sac metastasis in 10, adnexal metastasis in 2, other intrapelvic metastasis in 3, and positive peritoneal cytology in 9. At laparotomy several hemostatic clips were put on the serosal surfaces of the uterine wall in order to visualize the uterine contour in the localization X-ray films. By this method, six patients were proved to have uterine perforation at the time of small source insertion. Five-year survival rates for each clinical stage were: Stage I, 60%; II, 35.7%; III, 56.8%; and IV 0%. It seems that stage II is worse than stage III, but statistical differences were not found among stages I, II, and III. Three patients with para-aortic metastasis survived for more than four years. Late radiation complications occurred in 25(35.7%) of the patients. This complication rate was statistically higher than that of the patients who had not undergone staging laparotomy (21.1%).

[The serum and tissue concentrations of tegafur, 5-fluorouracil and uracil in patients with gastric and colorectal cancers after oral administration of UFT]

Fifteen patients with stomach cancer and colorectal cancer were orally administered 600 mg of UFT before operation and the concentration of tegafur, 5-fluorouracil (5-FU) and uracil in the tissues and serum were measured by chemical assay. The mean 5-FU levels in tumor and lymph node were higher than those in normal tissues and were maintained in tumor for long time. Uracil level in tumor tissue was higher than in normal tissue with or without administration of UFT. Positive correlation between the concentration of uracil and 5-FU in the colorectal tumor with the correlation coefficient of 0.87 (p less than 0.01) was obtained.