Correction of CAPD Catheter Displacement Using Gastric Biopsy Forceps: The Push-Pull Method

We corrected malpositioned continuous ambulatory peritoneal dialysis catheters in six patients using a new technique named the “push-pull method”. A gastric biopsy forceps was advanced through the catheter to near its tip. After manipulating the tip of the forceps through the abdominal wall, the forceps was opened and pulled out slowly. Repeated insertion and removal of the forceps induced the catheter to return to the pelvic cavity. This push-pull method was successful for Swan neck straight (n=2) and coiled (n=4) catheters in all patients. The time required for the procedure was only 5–10 minutes and there were no complications.

Note: application of UF-4 emulsion films to detect low-energy ions from plasmas produced by laser ablation

Detection of low-energy ions via Thomson parabola mass analyzer in the absence of any additional electrical systems is examined. Numerous low-energy ions were recorded on UF-4 solid state emulsion films. Kinetic energies between 1 and 4 keV of ions generated by YAG laser focused on Al and Ti targets were obtained using Thomson parabola measurements. Characteristics of ion tracks on the UF-4 detector are discussed in terms of pressure ranges of vacuum chamber. Moreover, differences in charges of ions between this study and previous spectroscopic measurements are discussed.

D-penicillamine-induced glomerulonephritis with crescent formation: Remission following drug discontinuation

We report a 71-year-old female who presented with rheumatoid arthritis complicated by proteinuria. She had been receiving D-penicillamine (D-Pc) for two years prior to presentation. A urinalysis showed proteinuria and hematuria which disappeared within 3 months after D-Pc was stopped. The renal histological findings showed focal proliferative glomerulonephritis with crescent formation. A total of 10 cases of D-Pc-induced glomerulonephritis with crescent formation without alveolar hemorrhage have previously been reported in the literature. To the best of our knowledge, this is the first case report in which the patient did not require any treatment.

Serum undercarboxylated osteocalcin level increases with 48 weeks of teriparatide treatment in pre-treated elderly rheumatoid arthritis patients who use anti-resorptive drugs

AIM

The serum undercarboxylated osteocalcin (ucOC) level, a biochemical bone marker of vitamin K insufficiency, is often affected by anti-osteoporosis drugs. There have been no reports regarding the relationship between ucOC and teriparatide.

SUBJECTS AND METHODS

We conducted a prospective observational study of 26 female rheumatoid arthritis (RA) patients. The patients were divided into 3 groups: those who underwent a direct switch from anti-resorptive drugs to teriparatide (12 cases), those who started teriparatide without pre-treatment (5 cases), and the control patients (9 cases). The median age (interquartile range) of the patients in each group was 75 (67-77), 82 (78-84), and 69 (62-80) yr, respectively. All patients, except controls, received 48-week treatments of teriparatide. We analyzed the median 48-week changes from baseline of the serum ucOC levels with the Steel-Dwass method.

RESULTS

The median change from baseline in the direct switch group was higher than that in other groups (p<0.05).

CONCLUSIONS

The serum ucOC levels increased with treatment of teriparatide in elderly RA patients, especially when the patients received pre-treatment.

Post-menopausal women with rheumatoid arthritis who are treated with raloxifene or alendronate or glucocorticoids have lower serum undercarboxylated osteocalcin levels

BACKGROUND

Serum undercarboxylated osteocalcin (ucOC) is a biochemical bone marker of vitamin K insufficiency. It had been reported that bone resorption inhibitors tend to decrease the serum ucOC level in patients with primary osteoporosis. In rheumatoid arthritis (RA) patients, these results have never been reported.

AIM

We investigated risk factors which could change serum ucOC level in post-menopausal women with RA (no.=100).

SUBJECTS AND METHODS

Twenty patients received no bone resorption inhibitor (control), 30 received raloxifene (RLX), while 50 received alendronate (ALN). This cross-sectional study was limited to patients with low RA disease activity (Disease Activity Score-28 ≤3.2). We measured serum ucOC, and the data were analyzed by multivariable analysis, including ucOC and the other variables.

RESULTS

Scheffe's F test demonstrated a significant difference in serum ucOC levels between controls and the RLX group (p<0.01), and between controls and the ALN group (p<0.01). Serum ucOC levels were low in both treated groups. An adjusted multivariate analysis was performed for the variables: bone resorption inhibitor use, serum alkaline phosphatase, glucocorticoid dose, age, estimated glomerular filtration rate and matrix metalloproteinase 3. As a result, serum ucOC inversely correlated with bone resorption inhibitor use (p<0.01) and oral glucocorticoid dose (p<0.01), which were independent risk factors of lowering ucOC.

CONCLUSIONS

Bone resorption inhibitors and glucocorticoids were independent risk factors for lowering serum ucOC levels in post-menopausal RA patients.

Herpes simplex virus infection in adult patients after unrelated cord blood transplantation: a single-institute experience in Japan

Herpes simplex virus (HSV) infection in adult patients who underwent cord blood transplantation (CBT) from unrelated donors was studied. None of nine HSV-seronegative patients developed HSV disease after CBT. Of 28 HSV-seropositive patients, seven (25%) developed HSV disease at a median of 92 days after CBT (range, 52-239 days). The cumulative incidence of HSV disease in HSV-seropositive patients was 27% at 12 months after CBT. The manifestations of HSV disease included gingivostomatitis (three patients), herpes labialis (two patients), localized herpes facialis of the nose (one patient), and disseminated eczema herpeticum (one patient). HSV disease recurred in two patients as gingivostomatitis and disseminated eczema herpeticum. All the patients responded to antiviral therapy. The presence of grade II-IV acute graft-versus-host disease (GVHD) was significantly associated with a higher rate of HSV disease after CBT (51 vs 8%, P=0.015). These results suggest that the recovery of HSV-specific immune responses is delayed in patients who develop grade II-IV acute GVHD after CBT.

Relative serum amyloid A (SAA) values: the influence of SAA1 genotypes and corticosteroid treatment in Japanese patients with rheumatoid arthritis

OBJECTIVES

(1) To determine whether serum concentration of serum amyloid A (SAA) protein is influenced by the SAA1 allele in Japanese patients with rheumatoid arthritis (RA) as previously shown in a healthy control group; and (2) to analyse what factors, based on such an allelic bias, influence the relative SAA values of those patients.

METHODS

SAA and C reactive protein (CRP) concentrations together with SAA1 genotypes were determined in 316 Japanese patients with RA. The relative SAA values were evaluated as an SAA/CRP ratio.

RESULTS

Comparison of the three SAA1 homozygote groups showed that the SAA/CRP ratio was highest in the 1.5/1.5 group (mean 9.0, p<0.01 v the other two homozygote groups) followed by the 1.3/1.3 group (mean 7.2, NS v the 1.1/1.1 group) and the 1.1/1.1 group (mean 4.0). The SAA/CRP ratio was significantly higher in patients receiving corticosteroids regardless of the presence of allele 1.5. No clear differences in the ratio between patients with or without amyloidosis were found.

CONCLUSION

The SAA1.5 allele and corticosteroid treatment had a positive influence on SAA concentrations in serum. These findings are important when evaluating SAA concentration in inflammatory diseases and when considering the cause or treatment of amyloidosis.

Correction of CAPD catheter displacement using gastric biopsy forceps: the push-pull method

We corrected malpositioned continuous ambulatory peritoneal dialysis catheters in six patients using a new technique named the "push-pull method". A gastric biopsy forceps was advanced through the catheter to near its tip. After manipulating the tip of the forceps through the abdominal wall, the forceps was opened and pulled out slowly. Repeated insertion and removal of the forceps induced the catheter to return to the pelvic cavity. This push-pull method was successful for Swan neck straight (n=2) and coiled (n=4) catheters in all patients. The time required for the procedure was only 5-10 minutes and there were no complications.

[Serum amyloid A (SAA) 1, SAA 2 and apolipoprotein E isotype frequencies in rheumatoid arthritis patients with AA amyloidosis]

OBJECTIVES

To examine the relationship between polymorphism of serum amyloid A (SAA) 1, SAA 2 and Apolipoprotein E (Apo E) and susceptibility to AA amyloidosis (AA) in rheumatoid arthritis (RA).

METHODS

We compared the frequencies of SAA 1 alleles (alpha, beta, gamma), SAA 2 alleles (alpha, beta) and apo E alleles (epsilon 2, epsilon 3, epsilon 4) in AA-positive RA with those in AA-negative RA. Each isotype was analyzed by the following method: SAA 1 and SAA 2 by PCR-RFLP and Apo E by Western blotting method. Blood samples were obtained from 50 AA-positive RA patients with SAA 1 isotype, 50 AA-negative RA patients with SAA 1 isotype, 27 AA-positive RA patients with SAA 2 isotype, and 26 AA-negative RA patients with SAA 2 isotype, respectively. Likewise, Apo E isotype was determined by withdrawing blood samples from 61 AA-positive RA cases and 51 AA-negative RA cases.

RESULTS

In AA-positive RA, each frequency of three different alleles of SAA 1, i.e., alpha, beta and gamma was 15%, 32% and 53%, while it was 32%, 28% and 40% in AA-negative RA. The allelic distribution between AA-positive RA group and AA-negative RA group was significantly different (P = 0.00163) with a lower frequency of alpha allele and a higher gamma allele frequency observed in AA-positive RA group. The frequency of each SAA 2 alleles (alpha & beta) was almost identical: 88.9% and 11.1% in AA-positive RA versus 90.4% and 9.6% in AA-negative RA with p value of 0.8007. Each frequency of three different Apo E alleles (epsilon 2, epsilon 3 & epsilon 4) was 4.9%, 85.2% and 9.8% in AA-positive RA, while in AA-negative RA it was 7.8%, 86.3% and 5.9%, respectively. The AA-positive RA group showed a slightly higher prevalence of epsilon 4 allele than the AA-negative RA group, yet the difference did not reach statistical significance (P = 0.3969).

CONCLUSIONS

These results suggest the possibilities that SAA 1 alpha may be working protectively against and SAA 1 gamma provocatively for the development of AA amyloidosis in RA. However, there was no significant association between SAA 2 isotype patterns and the development of AA amyloidosis in RA. Furthermore, there was no discernible association between AA amyloidosis in RA and Apo E 4 isotype.

Neuroprotective action of a novel compound--M50463--in primary cultured neurons

The neuroprotective effects of a novel synthetic compound, M50463, have been determined by using embryonic rat neocortical neurons in various culture conditions. M50463 was initially characterized as a potent specific ligand for a voltage-dependent sodium channel by radioligand binding studies. In fact, M50463 inhibited neuronal cell death induced by veratrine and inhibited an increase of the intracellular calcium level in neurons evoked by veratrine. In addition to such expected effects, M50463 had the ability to prevent glutamate neurotoxicity, to promote the neuronal survival in serum-deprived medium and to prevent nitric oxide-induced neurotoxicity. These results suggested that M50463 is not a simple sodium channel blocker, but a neuroprotective agent which has some crucial mechanism of action on neuronal death occurring in various situations, and it is a novel, innovative candidate for neuroprotective therapy for various neurodegenerative disorders.

Identification of the gene loci that predispose to rheumatoid arthritis

We have searched the human genome for genes that predispose to rheumatoid arthritis (RA) using fluorescence-based microsatellite marker analysis and affected sib-pair linkage study. A panel of 41 Japanese families, each with at least two affected siblings, was typed for genome-wide 358 polymorphic microsatellite marker loci. Markers were amplified by the PCR using fluorescence-tagged primers and sized based on the difference of CA repeats on DNA. Linkage analysis was made using maximum lod score (MLS). The MLS for D1S214 and D8S556 was 3.27 and 3.33, while the MLS for the HLA-DRB1 region was <3.0. According to detailed analysis by single-point analysis using MAPMAKER/SIBS, the MLS for D1S253 and D1S214 was 3.77 and 3.58. The MLS by multipoint analysis was 6.13 for D1S253. The MLS for D8S556 by single-point analysis was 4.20. The MLS for DXS1232 was 2.35 by single-point analysis, whereas the MLS for the region 2 cM right to DXS1232 and the region between DXS1227 and DXS1200 was 3.03 and 2.93 by multi-point analysis. Three principal chromosome regions of linkage, D1S253/214, D8S556 and DXS1232, have been identified which we call RA1, RA2 and RA3 for RA disease loci.

Decreased serum apolipoprotein AII/AI ratio in systemic amyloidosis

OBJECTIVE

To investigate if serum apolipoprotein A-I and A-II (apoAI and apAII) concentrations change in subjects with systemic amyloidosis secondary to underlying disorders.

METHODS

Serum concentrations of apoAI and apoAII were measured in 21 multiple myeloma patients, including eight with amyloidosis; 95 rheumatoid arthritis patients, including 45 with amyloidosis; and 73 haemodialysis patients, including 32 with amyloidosis.

RESULTS

ApoAII values tended to be reduced in subjects with amyloidosis in each group, but could not effectively distinguish amyloidosis. However, apoAII/AI ratios were significantly lower in subjects with amyloidosis in all groups. The ratio of 0.2 had diagnostic sensitivity and specificity for amyloidosis; 50% and 100%, respectively, in multiple myeloma; 80% and 78%, respectively, in rheumatoid arthritis; and 46% and 90%, respectively, in patients requiring long term haemodialysis.

CONCLUSION

The apoAII/AI ratio can be a useful biochemical marker of suspect amyloidosis in patients with underlying diseases, especially those with rheumatoid arthritis.

Dose escalation induces tolerance to side-effects of erythropoietin in a patient with dialysis anaemia: case report

A 51-year-old woman began haemodialysis for chronic renal failure in February 1981. Symptomatic anaemia required treatment with recombinant human erythropoietin (rHuEPO) in February 1990 (3000 IU, twice weekly, intravenously). She developed influenza-like symptoms and treatment was withdrawn. In June 1994 rHuEPO was resumed at a very low dose of 100 IU subcutaneously three times weekly, and was increased gradually to 500 IU, without inducing any side-effects. At this dose the haematocrit was maintained at 22.0-25.0% and the symptoms of anaemia improved. In patients like ours, with influenza-like symptoms caused by rHuEPO therapy, dose escalation starting from an ultra-low dose may be effective in avoiding side-effects.

Mixed Micellar Properties of Nonionic Saccharide and Anionic Fluorocarbon Surfactants in Aqueous Solution

Mixed micellar properties of nonionic saccharides (n-decyllactobionamide, C10Glu2; n-dodecyllactobionamide, C12Glu2) and anionic fluorocarbon surfactants (lithium perfluorooctanesulfonate, LiFOS) in aqueous solutions have been studied by means of surface tensiometry, NMR, and light scattering. The interaction parameters estimated from the modified regular solution theory are -5.0 for the C10Glu2/LiFOS system and -0.2 for the C12Glu2/LiFOS system. This difference could be due to the interaction of the surfactant tails. The average aggregation number is almost identical over a wide mole fraction of C12Glu2 for the C12Glu2/LiFOS system, while it shows a minimum at a C10Glu2 mole fraction of 0.4 for the C10Glu2/LiFOS system. It is also found from NMR measurements that the segmental motions of surfactants in the mixed micelles of C12Glu2 and LiFOS are not restricted, whereas they are restricted at a C10Glu2 mole fraction of 0.4 for the C10Glu2/LiFOS system. These motional changes as well as micellar composition reflect the solubilization of decafluorobiphenyl in the mixed micelles. Copyright 1998 Academic Press. Copyright 1998Academic Press

Detection of interstitial pneumonitis in patients with rheumatoid arthritis by measuring circulating levels of KL-6, a human MUC1 mucin

In rheumatoid arthritis (RA), interstitial-pneumonitis is one of the major extraarticular complications that worsens a patient's prognosis. KL-6, a human MUC1 mucin, has been reported to be a sensitive serum marker for activity of interstitial pneumonitis. We investigated the clinical significance of serum KL-6 level in patients with RA. Serum levels of KL-6 and RA-associated inflammatory markers were evaluated in 177 RA patients. The diagnosis of active interstitial pneumonitis was made by clinical symptoms, pulmonary function tests, chest X-ray film, and high resolution CT. Serum KL-6 was increased in 8 of 9 (88.9%) RA patients with active interstitial pneumonitis but in only 1 of 168 (0.6%) RA patients without active interstitial pneumonitis. No significant correlation was found between KL-6 level and conventional clinical parameters. In RA, abnormal elevation of serum KL-6 strongly indicates the complication of active interstitial pneumonitis.

Intractable diarrhoea associated with secondary amyloidosis in rheumatoid arthritis

OBJECTIVE

To examine the clinical characteristics of intractable diarrhoea associated with secondary amyloidosis in rheumatoid arthritis (RA).

METHODS

Of 179 RA patients with biopsy confirmed secondary amyloidosis, 24 cases (23 women and one man) with intractable diarrhoea lasting for more than one month were retrospectively evaluated.

RESULTS

The mean (SD) duration of diarrhoea was 87 (64) days. Prodromal symptoms of gastrointestinal dysfunction (n = 21) and impaired peristalsis (n = 16) were observed. Laboratory data showed hypoproteinaemia (4.7 (0.85) g/dl) caused by malabsorption or protein loss and high values of C reactive protein (17.0 (9.3) mg/dl). Recurrence of intractable diarrhoea (n = 4) and transition from intractable diarrhoea to other gastrointestinal problems of amyloidosis (ischaemic colitis (n = 2) and intestinal pseudo-obstruction (n = 4)) were observed. In 19 patients (25 episodes) the duration of intravenous hyperalimentation at remission (18 episodes) was 68 (52) days. Corticosteroid pulse therapy was administered to 10 patients (11 times) and the time elapsed from the end of corticosteroid pulse therapy to the end of diarrhoea was 18 (14) days. One and five year survival rates after the onset of intractable diarrhoea were 73.4% and 38.9%. Seven of 13 patients (54%) had died as a result of infectious diseases.

CONCLUSION

Intractable diarrhoea associated with secondary amyloidosis in RA is a serious clinical entity and the prognosis is poor. Although it is assumed that intravenous hyperalimentation treatment and corticosteroid pulse therapy are favourable regimens for intractable diarrhoea, the patients should be monitored for possible infectious complications.

[Incidence of cancer among Japanese patients with rheumatoid arthritis]

Most follow-up studies of patients with rheumatoid arthritis demonstrate no increase in the incidence of cancer apart from approximate doubling of the incidence of lymphoproliferative malignancies. A consecutive series of 1832 Japanese patients with rheumatoid arthritis seen at the center was studied to determine their cancer morbidity. Overall, 35 cancers were diagnosed in the series from 1982 through 1995 and were not significantly in excess of the expected number. No association was found between rheumatoid arthritis and subsequent development of cancer at any site, either.

[Clinical characteristics and genetic background of secondary amyloidosis associated with rheumatoid arthritis in Japanese]

In order to examine the clinical characteristics and genetic background of secondary amyloidosis associated with rheumatoid arthritis, we analyzed clinical features and HLA typing of 85 patients in a multicenter study. Eighty-five patients with secondary amyloidosis associated RA were studied. The diagnosis of secondary amyloidosis were made on histological findings by biopsy or autopsy. The most common biopsy site was gastrointestinal tract (79.5%). Clinical symptom and the frequency at the time of diagnosis were; diarrhea (35 cases), abdominal pain (22 cases) and vomiting and nausea (16 cases). Abnormalities and the frequency in a laboratory test included proteinuria (49 cases), increased serum creatinine (32 cases), anemia (30 cases) and hematuria (15 cases). Twenty-eight patients were dead and 57 patients were alive at the time of the study. The average duration between diagnosis of amyloidosis and death was 19.4 +/- 18.5 (SD) months among the dead patients. The average duration after diagnosis of amyloidosis was 24.2 +/- 19.5 (SD) months in surviving patients. The causes of death were renal failure complicated with heart failure (6 patients), heart failure alone (3 patients) and renal failure alone (2 patients). Fifty-nine patients in the control group who were negative to amyloid deposition on biopsies at more than one site in the gastrointestinal tract, were clinically compared with patients in the amyloidosis group. No difference were noted in the age of RA occurrence and the stage between the two groups. As to the class, however, the number of patients with severe functional disorder (class 3 or severe) was larger in the amyloidosis group. There were no significant difference between the two groups in Lansbury's activity index. On hematology, biochemistry and urinalysis, the incidences of increased white blood cell count, anemia, increased platelet count, increased serum creatinine, hypoproteinemia, hypoalbuminemia, increased IgA, and increased urine and blood BMG were statistically significantly higher in the amyloidosis group than in the control group. HLA-A, -B, -C, and DR-locus antigens were compared in the 53 patients in the amyloidosis group and in the 59 subjects in the control group. There were no significant differences in frequency of HLA-A, and -B antigens between two groups. Frequency of CW7 antigen was significantly decreased in the amyloidosis group (13.2%) than in the control group (39.0%). Frequency of DR1 antigen was decreased in the amyloidosis group (3.8%) than in the control group (22.0%), although the difference was not significant. These findings suggest the possible involvement of genetic factors in the occurrence of amyloidosis. It is suggested that the occurrence of amyloidosis is suppressed by some genes which are linked with CW7 antigen.

Secondary amyloidosis in patients with rheumatoid arthritis: diagnostic and prognostic value of gastroduodenal biopsy

Upper gastrointestinal endoscopy was performed in patients with rheumatoid arthritis (RA) during the period 1989-1991, and biopsy specimens were obtained from the stomach and from the duodenum for examining amyloid deposits. Among 407 patients, gastrointestinal amyloidosis was confirmed in 54 (13.3%). Twenty-two patients were regarded as having slight amyloid deposits, while 32 patients were categorized as having marked amyloid deposits. The incidence of clinical manifestations suggestive of systemic amyloidosis was more frequent in the marked deposits group than in the slight deposits group (47% vs 14%, P<0.05). Among the patients who died of manifestations associated with amyloidosis, the survival period following endoscopy was shorter in the marked deposits group than in the slight deposits group. These findings suggest that gastroduodenal biopsies may be useful for diagnosing secondary amyloidosis and that the degree of amyloid deposits seems to be correlated with the clinical manifestations of RA.

[Effects of ethyl all-cis-5,8,11,14,17-icosapentaenoate on low density lipoprotein in rabbits]

The hypolipidemic effects of ethyl all-cis-5,8,11,14,17-icosapentaenoate (EPA-E) on cholesterol diet-fed rabbits were studied. EPA-E (300 mg/kg, p.o. x 4 weeks) decreased total cholesterols in the lipoprotein fractions of very low-density lipoprotein and intermediate lipoprotein+low-density lipoprotein (LDL), but not in high-density lipoprotein. Furthermore, the properties of LDL were investigated in rabbits given EPA-E (300 mg/kg, p.o. x 2 weeks). EPA-E had no influence on the lipid composition in LDL, and the cholesterol accumulation into macrophages was not increased by the incubation with EPA-E-treated LDL. However, the omega 3 polyunsaturated fatty acids contents of LDL were increased by the administration of EPA-E. EPA-E-treated LDL was also studied on the binding to the hepatic membranes. The binding of EPA-E-treated LDL to the hepatic membranes was higher than that of ordinary LDL. These results suggest that EPA-E causes a modification of LDL, such that EPA-E has an enhancing effect on the hepatic uptake of LDL. These effects may contribute to the hypolipidemic action of EPA-E.

[Pneumocystis carinii pneumonia associated with low dose methotrexate treatment for malignant rheumatoid arthritis]

Low dose pulse methotrexate (MTX) has become a widely used therapy for rheumatoid arthritis (RA) because of its good response rate profile. With the increased use of MTX, reports of opportunistic infections associated with MTX therapy have appeared. Fourteen cases of pneumocystis carinii (PC) pneumonia in patients receiving low dose MTX have been previously reported. Yet, no case of PC pneumonia associated with low dose MTX has so far been reported in Japan. We report the first case in Japan of PC pneumonia occurring in a patient with rheumatoid vasculitis who was receiving low dose MTX. A 70-year old woman with 13 year history of RA presented with 3-day history of rapidly aggravating dyspnea, dry cough and fever. She had been receiving MTX 7.5 mg/week for 2.5 months because of her vasculitis symptoms. She had also been receiving prednisolone 7.5 mg/day which had been successfully tapered from an initial dose of 15 mg/day. At the time of her presentation with respiratory symptoms, all of her vasculitis symptoms had been alleviated. A chest radiograph revealed diffuse interstitial shadowing bilaterally and bilateral hilar and right lower lung field infiltrates. Her arterial blood gas showed severe hypoxemia (PaO2 27.7 torr). Polymerase chain reaction assay of bronchoalveolar lavage fluid showed PC. Although the patient required ventilatory support for 9 days, she was successfully treated with trimethoprime-sulphamethoxazole and methylprednisolone pulse therapy. Eight months later, the patient was well with no evidence of vasculitis or respiratory symptoms.

[Sleep apnea syndrome in rheumatoid arthritis (RA) patients complicated with cervical and temporomandibular lesions]

All-night polysomnographic studies were performed on ten patients (all female) with rheumatoid arthritis complicated with temporomandibular joint destruction and cervical lesions. The mean age of these subjects was 67.5 yrs, ranging from 48-81 yr. They all had some morphologic abnormalities of cervical spines and/or temporomandibular joints. Sleep study revealed that all of them had sleep apnea; five of them were of obstructive type (obstructive group) while the remaining showed central type of sleep apnea (central group) predominantly. There were no statistically significant differences of the levels of apnea index, mean-nadir SO2 and the lowest SO2 between the obstructive group and the central group. No detectable differences of cephalographic measurements and MRI findings existed between the two groups either. In one patient, nasal-CPAP converted central apnea to normal breathing dramatically. Our observations indicate that the cause of central apnea in RA patients with temporomandibular lesions is collapse of upper airway, inducing inhibitory inputs from the mechanoreceptors in that region.

[Amyloidosis in rheumatoid arthritis--clinical study of 124 histologically proven cases]

The diagnosis of secondary amyloidosis due to rheumatoid arthritis (RA) was confirmed by positive tissue staining using Congo-red and antiserum to amyloid A protein. Biopsied specimens were obtained mainly from gastro-intestinal tracts; small salivary glands of the lips as well as abdominal adipose tissues were also studied in a small number. The results were as follows: 1. Gastro-intestinal fiberscopies and biopsies were performed on 789 RA patients for the purpose of routine screening and follow-up for amyloidosis. Seventy-seven cases (10.5%) turned out positive for amyloid. Among the biopsied specimens taken from three different sites, the proportion of amyloid-positivity was 68.9% for gastric antrum, 76.5% for duodenal cap and 88.6% for the second portion of the duodenum, suggesting the higher sensitivity and efficacy of duodenal biopsy in studying secondary amyloidosis in RA. 2. 124 patients of RA complicated with secondary amyloidosis were studied clinically with special reference to its clinical characteristics and prognosis. (1) The mean duration of RA at diagnosis of amyloidosis was 15.4 years and all patients but two were in stage III or IV (Steinbrocker). (2) Gastro-intestinal symptoms were present in 58.1% of the cases, abnormal renal signs in 58.9%, cardiac symptoms in 39.5%, respectively. All of these findings had a significant association with poorer prognosis in secondary amyloidosis due to RA. (3) The 4-year survival rate of all the cases was 57.8%, while the 3-year survival rate for the group without symptoms and signs about amyloidosis was 100%. (4) The causes of death in 36 cases were renal failure (14 cases), infection (13 cases), cerebral bleeding (2 cases), myocardial infarction (1 case), pulmonary infarction (1 case), suicide (1 case) and unknown (4 cases). Patients with intractable diarrhea were mostly susceptible to the ensuing fatal bacterial infection.

[Two cases of acute progressive interstitial pneumonia associated with dermatomyositis--clinical features and immunological disorders]

Some patients of dermatomyositis (DM) with interstitial pneumonia (IP) have common clinical features. Clinical features of these patients are acute onset, very poor prognosis and that patients have fever, arthritis, typical skin rash, mild myositis and show low ratio of CPK/LDH, low incidence of antinuclear antibody (ANA) appearance, low inflammatory signs. We experienced two cases of this category of DM with IP and examined immunological aspects. Case 1. A 52-year-old woman was admitted in June 1, 1990 with a one-month history of arthralgia and a ten-days history of fever, skin rash, myalgia and dyspnea on exertion. On examination she had Gottron's papules on her fingers, erythema on back, bilateral elbows and legs, proximal muscle weakness and arthritis. Fine crackles were audible in the lower lung fields. Laboratory data included CPK 200 IU/l, ALD 3.2 IU/l, LDH 805 IU/l. Analysis of bronchoalveolar lavage fluid (BALF) revealed increased cellularity with lymphocytosis. She was treated with oral corticosteroid (CS), pulse CS, cyclosporin A. Inspite of these therapies, she died of progressive respiratory insufficiency in July 10, 1990. Case 2. A 23-year-old woman was admitted in April 1, 1991, with a two-month history of arthralgia and a one-month history of fever, skin rash, stomatitis, alopecia. On examination she had Gottron's papules on her fingers, erythema on malar, bilateral elbows and legs, arthritis and stomatitis. Laboratory data included CPK 97 IU/l, ALD 8.5 IU/l, LDH 779 IU/l. She began experiencing dry cough and dyspnea on exertion in May 1991. Analysis of BALF revealed increased cellularity with lymphocytosis. She was treated with oral corticosteroid(CS), pulse CS, pulse cyclophosphamide.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bronchoalveolar lavage fluid analysis in rheumatoid arthritis]

In order to clarify the pulmonary involvement in rheumatoid arthritis (RA), bronchoalveolar lavage (BAL) was performed in 52 RA patients, in conjunction with pulmonary function test (PFT) and high-resolution CT (HRCT) of the chest. The results were as follows: 1. Out of nine RA patients with no evidence of lung involvement on HRCT, six (66.7%) showed abnormal differentials of the cells obtained through BAL. 2. RA patients with advanced interstitial lung disease on HRCT had significantly higher BAL fluid (BALF) cellular concentrations, increased percentage of BALF neutrophils and decreased BALF CD 4/CD 8 ratio, as compared with those with no or mild lung involvement. 3. In the non-smoking RA patients who also demonstrated no obstructive patterns on PFT, positive correlations were observed between %VC and the BALF CD4/CD 8 ratio (R = 0.481) as well as the BALF CD4+Leu8- (helper T) cell ratio (R = 0.497). On the other hand, a negative correlation was detected between %VC and the BALF CD8+CD11b- (cytotoxic T) cell ratio (R = -0.533). 4. In those with the increased percentage of BALF eosinophils and/or with increased BALF CD4/CD8 ratio, V25/Ht was depressed significantly, as compared with other patients. Likewise, those with severely depressed value of V25/Ht tended to have significantly elevated BALF CD4/CD8 ratio, as compared with other patients with normal V25/Ht value. Thus, through these detailed studies of BAL cellular differentials and BALF lymphocyte subsets, the diversity of pulmonary involvement was well demonstrated in RA.

Relationship between chromosomal alpha-specific suppressors of sir4-11 and polymorphism of the HMRa-bearing fragment

In the course of studying sir4-11 which is responsible for the non-mating phenotype of asd-homothallism of Saccharomyces cerevisiae, we detected chromosomal alpha-specific suppressors of it. By examining the mating-type cassette constitution of two strains and the spore-clones derived from a diploid culture formed by a mass mating between these strains, we obtained the following results; (1) the HMRa-bearing HindIII-Bg/II restriction fragment was dimorphic, as judged by size, within each tetrad, (2) while one form was common to all tetrads, the other varied among tetrads, (3) spore-clones with the alpha-specific suppressor of sir4-11 had the variant forms while those without had the common form, and (4) while the two parents had the common form, each independent diploid clone had the common form plus a variant form. From these results, we conclude that the mating of cells in certain combinations induces a change of DNA structure at or near HMRa in a mating-pair specific manner and that the change makes HMRa non-derepressible or non-functional when derepressed.

[Clinical study of rheumatoid interstitial lung disease evaluated by high resolution CT]

High resolution computed tomographic (HRCT) scans were obtained in 215 patients with rheumatoid arthritis to assess pulmonary fibrosis (PF). We classified the HRCT appearances as five-point scale (0-4) based on the degrees of PF. The results were as follows: 1. We found 117 cases (54.4%) of PF on HRCT. 2. Patients with PF (grade 1-4) showed significantly increased leucocyte cell counts and significantly worsened pulmonary function test than patients without PF (grade 0). 3. Patients with advanced articular involvement had significantly higher prevalence of PF than others without them. 4. Patients who were previously or currently receiving gold sodium thiomalate (GST) injection or administration of methotrexate had higher prevalence of PF than others. However, patients who were receiving long term GST therapy (1 year long or sigma 1000 mg) had slightly lower prevalence of PF than others. This finding suggests that dose-dependent lung injury is not related to GST therapy. 5. Patients with advanced PF (grade 3, 4) had high prevalence of male sex, smoker, extraarticular manifestation.

[Cricoarytenoid joint involvement in rheumatoid arthritis]

The cricoarytenoid (CA) joint, which controls the vocal cords, is diarthrodial; it is composed of two cartilages with a ligamentous capsule lined by synovial membrane. It has been known that inflammation of CA joint occurs sometimes in patients with rheumatoid arthritis (RA). Yet, so far, no detailed full-report on this subject has ever been made in this country. Here we report four RA cases with CA joint ankylosis or abduction disturbance due to progression of CA arthritis. Episodes of inspiratory dyspnea were observed in all cases and tracheostomy was performed in case 1 and case 2. Further surgical intervention i.e., tracheoplasty was necessary in case 2. Case 3 and case 4 have been followed conservatively thus far. Clinical surgical interventions were necessitated mainly with joint replacement, 3) there exists severe destruction of cervical spines as well as temporomandibular joints. Rheumatologist must be fully aware of how urgent this clinical entity is and not miss-diagnose+ these patients.

[A case of rheumatoid arthritis complicated with auranofin-induced acute interstitial pneumonitis]

A case of auranofin(AF)-induced acute interstitial pneumonitis in a patient with rheumatoid arthritis (RA) is reported and possible mechanism of the incidence is discussed. A 57 year-old woman with a history of RA starting in early April 1989, had been prescribed AF for seven days prior to her referral to this hospital. Because of the severity of her polyarthritis, AF was discontinued; therapy with gold sodium thiomalate (GST) instead was started on 23 June 1989. The patient responded quite favorably. At a total cumulative dose of 160mg of GST, however, she developed generalized exfoliative dermatitis and the drug was discontinued. On 29 Sept. 1989 when her skin lesions cleared up completely, she was put on AF again. Six days after resumption of AF therapy, she developed fever. Nonproductive cough and dyspnea on exertion was observed within the following three days. The chest X-ray film revealed diffuse reticular-linear infiltrates more prominently in both upper lobes. Arterial blood gas studies showed hypoxemia and a restrictive ventilatory defect was demonstrated by pulmonary function studies. AF was stopped. High dose pulse iv corticosteroid(CS) therapy combined with oral CS was instituted. Immediate improvement of both subjective and objective findings was observed. By using the patient's peripheral blood lymphocytes, delayed lymphocyte stimulation test(DLST) against the probable causative agents was performed before the bolus CS therapy. Stimulation Index(shown in percentage) was markedly elevated in AF(724%) as compared with GST(163%). The fiberoptic bronchoscopy with bronchoalveolar lavage(BAL) was performed. Analysis of BAL fluid revealed increased cellularity (9 x 10(5)/ml) with marked lymphocytosis of 79%.(ABSTRACT TRUNCATED AT 250 WORDS)

"Alternative self-diploidization" or "ASD" homothallism in Saccharomyces cerevisiae: isolation of a mutant, nuclear-cytoplasmic interaction and endomitotic diploidization

A mutant of Saccharomyces cerevisiae representing a novel life cycle, named "alternative self-diploidization" or "ASD" homothallism, was obtained fortuitously. In this life cycle, MAT alpha (or MATa) haplophase and MAT alpha/MAT alpha (or MATa/MATa) diplophase alternate. Germinated cells are haploid and mating. They soon become nonmating and sporogenous as they vegetatively grow. They sooner or later diploidize presumably via endomitosis. The diploid cells haploidize via normal meiosis. A single recessive nuclear mutation, named asd 1-1, is responsible for "ASD" homothallism. In the rho 0 cytoplasm, asd 1-1 cells mate even if at a low efficiency and fail to diploidize. Since pet mutations do not have such effects, we conclude that a certain mitochondrial function other than respiration is required for manifestation of "ASD" homothallism. That is, "ASD" homothallism is the result of some sort of nuclear-cytoplasmic interaction.

A simple method for efficiently establishing 8-azaguanine-resistant mutant human leukemia and myeloma cell lines

A simple and convenient method for efficiently establishing 8-azaguanine-resistant mutant leukemia and myeloma cell lines (for example, the T cell lines Jurkat and CCRF-CEM, human myeloid/macrophage-like cell lines HL60 and U937, Burkitt lymphoma line Raji and the human myeloma line RPMI 8226), is described. The method relies on culturing the cell lines in RPMI 1640 medium containing 8-azaguanine and supplemented with 15% heat-inactivated fetal calf serum and large amounts of amino acids and vitamins, and removes the necessity for pretreatment with mutagenic reagents such as ethyl methylsulfonate or X-irradiation. The possibility of obtaining mutant cell lines using the method described here is about 15 times greater than using media without high levels of amino acids and vitamins. Hybridomas produced between mitogen-activated human peripheral blood lymphocytes and an 8-azaguanine-resistant Jurkat mutant cell line (established by this method) were shown to produce soluble T cell-derived macrophage activating factor (MAF)-like material.

[Surgical treatment of congenital muscular torticollis--long term follow-up study of total resection procedure (Mikulicz) and histological examination of resected sternomastoid muscles (author's transl]

Total resection procedure (Mikulicz) was performed in 27 patients under 10 years of age with typical congenital muscular torticollis. Postoperative clinical assessment was carried out in 20 of these 27 patients. Resected sternomastoid muscles were studied histologically in 14 other patients. The operative procedures and histological findings were compared in a discussion of the relative values of conservative and operative treatment. Neck contracture due to torticollis improved immediately after operation and no recidivations followed. Skeletal deformity of the face and spinal column completely subsided within two or three years after the operation. Plagiocephaly remained and seemed not to be directly related to the torticollis. There were no patients with scar formation such as disfiguration or keratosis. Subcutaneous adhesion probably of the platysma with the deeper layer was palpable in three patients, but did not affect the clinical course. Accessory nerve injury during operation occurred in one patients, causing slight weakness of the trapezius muscle. On the other hand, disappearance of the sternomastoid muscle relief was cosmetically acceptable subjectively and objectively. The resected sternomastoid muscle in 14 patients with typical congenital muscular torticollis were studied histologically in specimens sectioned longitudinally. Hematoxylin-eosin, Masson's and van Gieson's stains were used and the distribution of the fibrosis throughout the muscles was examined. Fibrous changes were detected in almost the whole length and breadth. The changes were similar in all operated patients, although the ages were different. The findings by naked eye examination were usually less than those by histological examination. This follow-up study confirmed that total resection procedure gives good clinical results of congenital muscular torticollis. Histological studies suggested the need for removal of the fibrous changes involving the whole muscular tissue, as such changes can lead to recidivations.