Telemedicine for Pregnant Women on a Japanese Remote Island: A Two-year Report

Introduction

Remote antenatal checkups were conducted on the northernmost island of Japan to reduce the burden of hospital visits among pregnant women. This study aims to investigate the effectiveness and safety of remote antenatal checkups for pregnant women living on a remote island.

Methods

This observational study included singleton pregnancies on Rebun Island between October 2020 and September 2022. General surgeons conducted medical interviews and performed fetal sonography using an obstetrician videoconference system at the main central hospital. The primary outcomes were the degrees of physical, mental, and economic burdens of hospital visits and the levels of anxiety and satisfaction with remote antenatal checkups as assessed using a questionnaire survey. Moreover, we investigated the incidence of adverse perinatal events, including maternal death, fetal death, neonatal death, severe neonatal neurological disorders, and other obstetric complications.

Results

This study included 16 out of 22 pregnant women from Rebun Island who visited the central hospital. No adverse perinatal events occurred as a result of the remote antenatal checkups. One pregnant woman had gestational diabetes, whereas the others had no obstetric complications. The participants underwent a median of two remote antenatal checkups. According to a questionnaire survey, 90.0%, 80.0%, and 70.0% of the pregnant women perceived improvements in their physical, mental, and economic burdens, respectively. Although 70.0% of the participants experienced anxiety regarding remote antenatal checkups before the introduction, all were satisfied after delivery.

Conclusions

Remote antenatal checkups effectively reduced the burden of hospital visits for pregnant women, who reported high levels of satisfaction. Furthermore, antenatal checkups were safely conducted on remote islands.

Nationwide trends in and regional factors associated with minimally invasive hysterectomy for benign indications in Japan

OBJECTIVE

To examine the prevalence trends of minimally invasive hysterectomy for benign indications in Japan and investigate regional disparities.

STUDY DESIGN

A retrospective cohort and ecological study using "The National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) Open Data".

SETTING

Nationwide Japan.

PATIENTS

Individuals who underwent hysterectomy for benign indications from 2014 to 2020.

INTERVENTIONS

Trend analysis of minimally invasive surgery (MIS) rates through laparoscopic hysterectomies (LH) and robotic-assisted laparoscopic hysterectomies (RA-LH) at the national and prefecture levels. Examination of regional factors contributing to the disparity in MIS implementation rates by second medical service area (SMSA).

RESULTS

The number of LH has increased from 16,016 in 2014 to 27,755 in 2020. The nationwide MIS hysterectomy rate increased from 29% in 2014 to 55% in 2020 (p less than 0.001). More than 50% of hysterectomies have been performed as MIS since 2019. There was an increasing trend in MIS rates in all age groups. All prefectures except one showed a significant upward trend (p less than 0.05) in the MIS rates, but MIS rates varied widely (23-84%). In a multivariable model, the MIS was more likely to be performed in the SMSAs in western Japan (p = 0.011), in the SMSAs where the number of laparoscopy-qualified gynecologists is 5-10 (p = 0.013), and 11 or higher (p less than 0.001).

CONCLUSIONS

This study reveals a shift towards minimally invasive surgery (MIS) in total hysterectomy procedures in Japan. However, significant disparities in the prevalence of MIS hysterectomy exist, potentially influenced by the number of laparoscopy-qualified gynecologists.

Nutritional assessment using stable isotope ratios of carbon and nitrogen in the scalp hair of geriatric patients who received enteral and parenteral nutrition formulas

BACKGROUND & AIMS

The δ¹³C and δ¹⁵N values in the scalp hair of geriatric patients in Japan who received the enteral or parenteral nutrition formula were measured to assess nutritional status.

METHODS

The relations among δ¹³C, δ¹⁵N, calorie intake, BMI, albumin concentration, total cholesterol (T-CHO) and geriatric nutritional risk index (GNRI) in the patients were investigated. Furthermore, the enrichment of δ¹³C and δ¹⁵N from the nutrients to the hair was investigated.

RESULTS

The δ¹³C values in the hair of patients who received enteral nutrition decreased with decreases in the calories received, while the δ¹⁵N values increased, suggesting malnutrition in some patients with a low calorie intake due to a negative nitrogen balance. The distribution of patients with a low calorie intake (below 20 kcal/kg/day) when δ¹³C was plotted against δ¹⁵N differed from that of control subjects, but the distribution of patients with a high calorie intake (above 20 kcal/kg/day) was similar to that of control subjects. No significant differences were observed in BMI, albumin concentration, T-CHO or GNRI between the low and high calorie groups. The enrichment of δ¹³C and δ¹⁵N from the enteral nutrients to the hair were inversely correlated with the δ¹³C and δ¹⁵N in the enteral nutrients. The enrichment levels of δ¹³C and δ¹⁵N tended to be higher and lower, respectively, in the high calorie group. On the other hand, the δ¹³C and δ¹⁵N values in the hair of patients who received parenteral nutrition were higher and lower than those in the control subjects and in the patients who received enteral nutrition, respectively, reflecting the higher δ¹³C and lower δ¹⁵N contents of the parenteral nutrients.

CONCLUSIONS

The δ¹³C and δ¹⁵N values in the hair of patients who received enteral nutrition may be effective indicators for evaluating the long-term nutritional status of geriatric patients. A calorie intake of 20 kcal/kg/day may be a cut-off value for malnutrition in Japanese geriatric patients receiving enteral nutrition. However, caution is necessary when dealing with patients switching from parental nutrition as parenteral nutrition resulted in different changes in δ¹³C and δ¹⁵N. The enrichment levels of δ¹³C and δ¹⁵N from the enteral nutrients to the hair may be inversely correlated with the δ¹³C and δ¹⁵N values of enteral nutrients and vary according to the calorie intake.

Decreased gene expression of insulin signaling genes in insulin sensitive tissues of obese cats

Type 2 diabetes mellitus (DM) animal models have provided ample opportunity for investigating pathogenesis, as well as to evaluate novel treatment and prevention options for the disease. Because the domestic cat shares a similar environment with humans, it is also confronted with many similar risk factors for diabetes, such as physical inactivity and obesity. Obesity is a significant risk factor for diabetes in cats, and as such, the domestic cat may serve as an ideal model for investigating obesity induced insulin resistance. This study determined changes in insulin signaling genes within insulin sensitive tissues of obese felines. Quantitative RT-PCR was performed to determine mRNA levels of three important insulin signaling genes which have been implicated with insulin resistance: insulin receptor substrate (IRS)-1, IRS-2, and phosphatidylinositol 3'-kinase (PI3-K) p85alpha. Obese cats had significantly lower IRS-2 and PI3-K p85alpha mRNA levels in liver and skeletal muscle as compared to control cats. This down regulation of insulin signaling genes in obese cats mirrors that of obese humans and rodents suffering from insulin resistance. Interestingly, preprandial blood tests indicated that our obese cats were no different from control cats with regards to glucose tolerance and insulin resistance, thus indicating that the obese cats used in our study had a moderate level of obesity. Therefore, insulin signaling gene alterations were occurring in insulin sensitive tissues of moderately obese felines before glucose intolerance was clinically evident. As such, the monitoring of key insulin signaling genes may have some important diagnostic value to determine the risk level and degree of obesity induced insulin resistance.

Unilateral hilar lymphadenopathy of sarcoidosis or sarcoid reaction compressing the trunk of the right pulmonary artery

A case of sarcoidosis or sarcoid reaction with a rare manifestation of unilateral lymphadenopathy compressing the trunk of the right pulmonary artery is presented. A 71-year-old woman was admitted for evaluation of a left hilar mass. Chest CT scans showed a mass invading the right pulmonary artery. A frozen section obtained following open lung biopsy showed lymph node tissue largely replaced by noncaseous granulomas indicating sarcoidosis or sarcoid reaction. Old uveitis was compatible with sarcoidosis, and no malignancy was evident. These findings suggested sarcoidosis, however, other evidence of sarcoidosis was not obtained.

Basal layer reactivity in hyperplastic and metaplastic lesions of the bronchi as studied by lectin histochemistry

The relationship between squamous metaplasia and squamous cell carcinoma of the bronchi has been the subject of controversy. We investigated basal cell hyperplasia, stratification, squamous metaplasia, and squamous cell carcinoma by means of lectin histochemistry with peanut agglutinin (PNA), Ulex europeus agglutinin-I, soybean agglutinin, and Dolichos biflorus agglutinin for all normal basal cells that are reactive. A basal layer stained with PNA was observed in basal cell hyperplasia, stratification, and squamous metaplasia, but this layer was not exhibited by squamous cell carcinoma. In hyperplasia and metaplasia, PNA staining was biased toward the lowest (basal) layer, whereas staining for the other lectins was more uniformly distributed across the layers. A PNA-positive basal layer may be important for the morphologic reversibility of the bronchial mucosa in hyperplastic and metaplastic lesions, and destruction of this layer may be associated with a progression from metaplasia to squamous cell carcinoma.

[ADOC regimen for unresectable advanced thymic cancer]

Between 1996 and 1998, we treated 6 patients with unresectable and advanced thymic cancer (stages IVa and IVb). All received 50 mg/m2 of cisplatin and 40 mg/m2 of doxorubicin intravenously (i.v.) on day 1,0.6 mg/m2 of vincristine i.v. on day 3, and 700 mg/m2 of cyclophosphamide i.v. on day 4; ADOC regimen, respectively at 3-4 week intervals. Four patients obtained a partial response (PR) after ADOC chemotherapy and the overall clinical response rate was 67%. No life-threatening side effects were noted. In 2 patients, cisplatin plus VP-16 chemotherapy failed to demonstrate any benefits prior to the ADOC regimen. Radiotherapy was initiated after the achievement of PR in the other 2 patients. ADOC chemotherapy appears to be an effective treatment for thymic cancer.

Proliferation of type II pneumocytes and alteration in their apical surface membrane antigenicity in pulmonary sarcoidosis

STUDY OBJECTIVE

To evaluate both the proliferation of type II pneumocytes in the alveolitis associated with pulmonary sarcoidosis and any alteration in their surface membrane antigenicity.

MATERIALS AND METHODS

We investigated 20 transbronchial lung biopsy (TBLB) specimens from 20 patients with pulmonary sarcoidosis, 7 TBLB specimens from 7 sarcoidosis patients without pulmonary involvement, and 19 normal lung specimens, using colloidal iron stain and immunostaining with anti-Thomsen-Friedenreich (TF) antigen and anti-surfactant protein-A monoclonal antibodies.

RESULTS

The density of type II pneumocytes was significantly higher in the pulmonary sarcoidosis specimens ([mean +/- SD] 11.1+/-3.7 per 1 mm alveolar septal length) than in the nonpulmonary sarcoidosis (7.8+/-1.3) or normal lung specimens (7.2+/-0.8). TF antigen was directly expressed on the apical surface of some type II pneumocytes in the pulmonary sarcoidosis specimens, but it was completely masked by sialic acids in the nonpulmonary sarcoidosis specimens and in the normal lung tissues.

CONCLUSIONS

In pulmonary sarcoidosis, type II pneumocytes proliferated and the antigenicity of the surface membrane was altered. It is suggested that these type II pneumocytes may be vulnerable to injury by natural anti-TF antibodies that are cytotoxic when present with complement. This damage may decrease alveolar surfactant and cause focal alveolar collapse proceeding to pulmonary fibrosis in some cases of pulmonary sarcoidosis.

Mycobacterium avium-intracellulare pulmonary infection in patients without known predisposing lung disease

We tried to characterize the clinical features and findings on chest high resolution computed tomography (HRCT) of patients with Mycobacterium avium-intracellulare (MAI) pulmonary infection without known predisposing lung disease and with no immunodeficiency. We also aimed to clarify the small airway and alveolar inflammation using bronchoalveolar lavage (BAL) from the affected regions. MAI infection was diagnosed in 53 patients from respiratory samples, including sputum and materials obtained using a fiberoptic bronchoscope. None had a predisposing lung disease or immunodeficiency, as assessed by medical history, routine laboratory data, and previously normal chest radiographs and/or CT scans. The mean age of the 53 patients was 60 +/- 11 years, and 48 were nonsmoking females. They had few respiratory symptoms, although 42% had chronic paranasal sinusitis. Chest HRCT findings showed centrilobular small nodules and ectasia of small bronchi and/or bronchioles located mainly in segment (S) 2, 3, 4, and 5. S1, which is usually affected by pulmonary tuberculosis, was completely free of these opacities. The BAL study revealed that the predominant cells were activated T lymphocytes and neutrophils. The CD4+/CD8+ ratio increased significantly. Bacteriology was negative for other bacteria and fungi. Although our patients did not present with distinct respiratory symptoms, the regions affected by MAI showed a chronic inflammation of mainly neutrophils and activated T lymphocytes. The presence of chronic sinusitis may be merely coincidental. However, its high prevalence and the finding of bronchiectasis in chest HRCT raise the question of whether silent bronchiectasis may be a predisposition.

Cardiac sarcoidosis mimicking hypertrophic cardiomyopathy: clinical utility of radionuclide imaging for differential diagnosis

A 62-year-old woman with skin sarcoidosis was admitted to our hospital to ascertain whether she had cardiac involvement. Although she displayed no cardiac signs or symptoms, the electrocardiogram showed first-degree atrioventricular block, right bundle branch block with left anterior fascicular block, and giant negative T waves in the V3 lead. Echocardiography revealed marked hypertrophy localized in the basal portion of the interventricular septum (IVS) without systolic dysfunction, mimicking hypertrophic cardiomyopathy (HCM). Exercise thallium-201 myocardial imaging revealed redistribution in the anteroseptal region. Both gallium-67 (67Ga) and technetium-99m pyrophosphate (99mTc-PYP) scintigraphy revealed abnormal uptake in the myocardium. These findings disappeared after 2 months of steroid treatment. Reports of cardiac sarcoidosis mimicking HCM are rare. However, hypertrophy in the basal portion of the IVS is an important sign of early cardiac involvement in sarcoidosis. 67Ga and 99mTc-PYP scintigraphy were useful and necessary to differentiate this type of cardiac sarcoidosis from HCM.

Spontaneous regression of primary mediastinal germ cell tumor

A case of primary mediastinal germ cell tumor, which demonstrated spontaneous regression, is presented. The serum human chorionic gonadotropin level was elevated on admission and then decreased to the normal range with decrease in the size of the anterior mediastinal mass. Thoracotomy was performed with artificial replacement by grafts between the bilateral brachiocephalic veins and the right atrium. Histological diagnosis of combined teratoma with seminoma was made. After subsequent chemotherapy, the patient has remained alive without recurrence for over 10 years.

Inflammatory cytokines in BAL fluid and pulmonary hemodynamics in high-altitude pulmonary edema

To evaluate the pathogenesis of high-altitude pulmonary edema (HAPE), we performed bronchoalveolar lavage (BAL) and pulmonary hemodynamic studies in seven patients with HAPE at its early stage. We measured cell counts, biochemical contents, and concentrations of pro-inflammatory cytokines including interleukin (IL)-1, IL-6, IL-8 and tumor necrosis factor (TNF)-alpha and of anti-inflammatory cytokines including IL-1 receptor antagonist (ra) and IL-10 in the BAL fluid (BALF). All patients showed increased counts for total cells, alveolar macrophages, neutrophils and lymphocytes, and markedly elevated concentrations of proteins, lactate dehydrogenase, IL-1beta, IL-6, IL-8, TNF-alpha and IL-1ra. The levels of IL-1alpha and IL-10 were not increased. Patients also showed pulmonary hypertension with normal wedge pressure. Both the driving pressure obtained as pulmonary arterial pressure minus wedge pressure and the PaO2 under room air were significantly correlated with the concentrations of IL-6 and TNF-alpha in the BALF. These findings suggest that the inflammatory cytokines play a role at the early stage of HAPE and might be related to pulmonary hypertension.

Protein kinase C mediates increase of Ca2+ sensitivity for contraction by cholinoceptor partial agonist in ileal longitudinal muscle of guinea pig

1. Experiments were designed to study the roles of protein kinase C in carbachol- and pilocarpine-induced contraction and the increase in cytosolic Ca2+ concentration ([Ca2+]i) in guinea pig ileal longitudinal muscle. 2. The protein kinase C inhibitors, GF 109203X (10 microM), calphostin C (10 microM) and H-7 (10 microM), reduced the maximum of the concentration response curve produced by pilocarpine more effectively than that produced by carbachol. 3. The slopes of the regression lines between [Ca2+]i and tension development for pilocarpine and carbachol in tissues treated with GF 109203X were significantly gentler than those for untreated tissues. 4. The protein kinase C alpha- and beta 1 selective inhibitor Goe 6976 (1 microM) decreased both [Ca2+]i and contraction, but did not affect the slopes of the regression lines for pilocarpine and carbachol. 5. These results suggest that protein kinase C (both n- and/or a-type) plays an important role in the increase of Ca2+ sensitivity of the contractile element, and that pilocarpine mainly activates the protein kinase C-dependent pathways for contractile mechanisms in guinea pig ileal longitudinal muscle.

Laminin alpha2 chain-null mutant mice by targeted disruption of the Lama2 gene: a new model of merosin (laminin 2)-deficient congenital muscular dystrophy

Using the gene targeting technique, we have generated a new mouse model of congenital muscular dystrophy (CMD), a null mutant for the laminin alpha2 chain. These homozygous mice, designated dy3Kldy3K, are characterized by growth retardation and severe muscular dystrophic symptoms and die by 5 weeks of age. Light microscopy revealed that muscle fiber degeneration in these mice begins no later than postnatal day 9. In degenerating muscles, considerable amounts of TUNEL positive nuclei were detected as well as DNA laddering, suggesting increased apoptotic cell death was involved in the process of muscle fiber degeneration.

Functional expression and germline transmission of a human chromosome fragment in chimaeric mice

Human chromosomes or chromosome fragments derived from normal fibroblasts were introduced into mouse embryonic stem (ES) cells via microcell-mediated chromosome transfer (MMCT) and viable chimaeric mice were produced from them. Transferred chromosomes were stably retained, and human genes, including immunoglobulin (Ig) kappa, heavy, lambda genes, were expressed in proper tissue-specific manner in adult chimaeric tissues. In the case of a human chromosome (hChr.) 2-derived fragment, it was found to be transmitted to the offspring through the germline. Our study demonstrates that MMCT allows for introduction of very large amounts of foreign genetic material into mice. This novel procedure will facilitate the functional analyses of human genomes in vivo.

Diffuse pulmonary amyloidosis with monoclonal IgG-kappa gammopathy

A 62-year-old female with diffuse pulmonary amyloidosis developed abnormal radiographic findings while under observation for hyperimmunoglobulinemia over a ten-year period. Serum immunoglobulin G (IgG) was elevated (4,620 mg/dl), and associated with monoclonal gammopathy (M protein) of the kappa type, but no evident abnormalities were apparent in bone marrow. Chest radiograph and computed tomography showed a diffuse reticulonodular shadow in the bilateral lung. Thoracoscopic lung biopsy specimen revealed depositions of amyloid in the bronchus and pulmonary vessel. We emphasize that diffuse pulmonary amyloidosis should be considered a possible diagnosis in the presence of monoclonal immunoglobulin.

Two cases of severe bronchiectasis successfully treated with a prolonged course of trimethoprim/sulfamethoxazole

Two patients with severe bronchiectasis, one patient without other disease and the other with hyper IgE syndrome, were successfully treated with long-term therapy with low doses of trimethoprim and sulfamethoxazole (TMP-SMZ). Recurrent respiratory infections with productive cough and high fever were resistant to various antibiotics and often disturbed the patients' activities in daily life. However, they showed marked improvement following TMP-SMZ therapy, which was started for methicillin-resistant Staphylococcus aureus (MRSA) infection. MRSA disappeared some months later, but Pseudomonas aeruginosa appeared again in the sputum. Both patients, however, have remained free from symptoms for over one year.

Direct determination of serum glycyrrhetic acid by a monoclonal antibody-based inhibition ELISA using ibuprofen for releasing serum albumin-bound glycyrrhetic acid

We found that ibuprofen (IBU) had a potential for releasing serum albumin-bound glycyrrhetic acid (GA). Based on this observation, IBU was used to pretreat samples for the determination of serum GA levels by an inhibition ELISA. This method, termed IBU method was evaluated by the recovery of GA from human serum albumin (HSA) or normal human serum (NHS) that contained the exogeneously added GA (37-1000 ng/ml). The mean recovery of GA from HSA and NHS samples treated with IBU were 104.7 and 105.2%, respectively, whereas those without IBU pretreatment were 2.8 and 10.7%, respectively. Comparison of IBU method and chloroform extraction method revealed that the GA content of serum samples pretreated by each method were almost the same. These results suggest that IBU method is useful as a serum processing procedure for the determination of serum GA levels by an inhibition ELISA.

[Clinical usefulness of trans-brachial angiography for abdominal diseases]

Trans-brachial angiography for abdominal disease has several advantages for the patient. For example, the patient can walk immediately following angiography and can return home or eat in the sitting position after examination. We performed trans-brachial angiography on 451 cases of abdominal disease from June 1992 to March 1995. The purpose of performing angiography in 215 of these cases was examination only, while that in the remaining 236 cases was embolization of liver tumor. Four hundred and five cases were used for the study of safety and accuracy, and the remaining 46 cases as well as another 51 cases of trans-femoral angiography were used for the study of technical difficulty. Based on these experience, we have concluded that trans-brachial angiography for abdominal disease is highly useful, safe and accurate, and can provide significant advantages for patients requiring abdominal angiography.

Cytokines in bronchoalveolar lavage fluid in patients with high altitude pulmonary oedema at moderate altitude in Japan

BACKGROUND

The precise mechanism of high altitude pulmonary oedema (HAPE) remains unclear. The purpose of this study was to evaluate the role of cytokines and P-selectin in the development of HAPE which occurred at moderate altitude in Japan.

METHODS

The following cellular and biochemical markers and chemotactic cytokines were measured in the bronchoalveolar (BAL) fluid from four patients with HAPE at 2857-3180 m in the Japanese Alps: total proteins, albumin, lactate dehydrogenase (LDH), and interleukin (IL)-1 alpha, IL-1 beta, IL-1 receptor antagonist (ra), IL-6, IL-8, IL-10, tumour necrosis factor (TNF)-alpha, and the soluble form of P-selectin.

RESULTS

At admission there were significant increases in the levels of total cells, especially macrophages and neutrophils, total protein, albumin and LDH when compared with 13 healthy individuals. Furthermore, the levels of IL-1 beta, IL-6, IL-8, and TNF-alpha were also considerably increased but returned quickly to the normal ranges or were not detected after recovery. The levels of IL-1 alpha, IL-10, and P-selectin did not change.

CONCLUSIONS

These results suggest that an inflammatory process almost identical with acute respiratory distress syndrome (ARDS) may occur in HAPE, but that these changes are transient and are not associated with any increase in P-selectin levels in the BAL fluid.

Bronchoalveolar lavage fluid findings in patients with chronic hepatitis C virus infection

BACKGROUND

Hepatitis C virus (HCV) infection has recently been incriminated as an aetiological agent in idiopathic pulmonary fibrosis. This study was performed to determine the cellularity and lymphocyte phenotypes of bronchoalveolar lavage (BAL) fluid in patients with chronic hepatitis C.

METHODS

BAL fluid and lavage lymphocyte subsets from 13 patients (10 men) with active chronic hepatitis C, diagnosed by sustained elevated serum glutamic pyruvic transaminase and typical histological findings in the liver, were analysed. Lavage findings in these patients were compared with those from 13 healthy volunteers (eight men) as controls.

RESULTS

There was no difference in total cell counts in lavage fluid between the two groups. Lavage lymphocyte and eosinophil numbers were increased in patients with chronic hepatitis C. Surface marker analysis of the lymphocyte populations showed increases in CD2, CD3, CD4, and HLA-DR. CD4/CD8 ratios were not different.

CONCLUSIONS

The numbers of lymphocytes and eosinophils in BAL fluid are increased in patients with chronic hepatitis C. These findings suggest that HCV infection may trigger alveolitis.

[Analysis of cells and proteins in bronchoalveolar lavage fluid]

We studied cells and proteins in bronchoalveolar lavage fluid examined at the First Department of Internal Medicine of Shinshu University Hospital between 1990 and 1994. The samples came from 21 healthy subjects and from 216 patients with various diseases. Lymphocyte counts were abnormally high in patients with bronchiolitis obliterans organizing pneumonia. Sjögren's syndrome, sarcoidosis and hypersensitivity pneumonitis. Neutrophil counts were very high in the patients with diffuse panbronchiolitis and in those with high-altitude pulmonary edema, and eosinophil counts were high in those with eosinophilic pneumonia. The CD4:CD8 ratio was significantly higher in the patients with stage I sarcoidosis than in the healthy subjects. The total protein concentration and the albumin concentration were significantly higher in the patients with eosinophilic pneumonia and in those with high-altitude pulmonary edema than in the healthy subjects, and these findings suggest that in those two conditions the permeability of the pulmonary microvasculature was abnormally high.

[Pulmonary malignant fibrous histiocytoma presenting as hemothorax]

A 39-year-old woman, who suffered from a sudden episode of severe left-sided back pain, was admitted to our hospital because of hemothorax. Chest CT scans revealed a mass extending from the left hilum to the posterior thoracic wall. The mass occluded the left pulmonary artery at the left main bronchus. Examination of a frozen section of a specimen obtained during a thoracotomy showed a sarcomatous tumor. A left pneumonectomy was then performed. Microscopic examination of a specimen revealed that the tumor was composed of spindle cells with cellular atypia and mitosis forming fascicles and storiform arrays. Malignant fibrous histiocytoma (storiform-pleomorphic pattern) was diagnosed. Chemotherapy was carried out six times during the year after surgery. No recurrence of the tumor has been seen during 20 months of follow-up.

[Two cases of primary Sjögren's syndrome with pulmonary involvement histopathological study of open-lung biopsy specimens]

We report two cases of primary Sjögren's syndrome with pulmonary involvement, in which open lung biopsies were done. The patient in the first case was a 58-year-old woman and the patient in the second case was a 54-year-old woman. Both patients were admitted to our hospital because of dry coughing and exertional dyspnea. Chest X-ray films and CT scans showed interstitial shadows in both cases and multiple bullae in the first case. Pulmonary-function tests showed decreased diffusing capacity, and examination of bronchoalveolar lavage fluid revealed increased percentages of lymphocytes. Open-lung biopsy specimens showed thickening of the alveolar septa and interstitial mononuclear cell infiltration, composed predominantly of lymphocytes, with lymphoid follicles in both cases, and peribronchiolar mononuclear cell infiltration in the first case. Therefore, the histopathological diagnosis was cellular interstitial pneumonia with lymphoid follicles. Both patients were treated with oral corticosteroids. Symptoms were relieved and laboratory findings improved.

Salt-sensitive hypertension in transgenic mice overexpressing Na(+)-proton exchanger

Essential hypertension is one of the most common diseases that exacerbate the risk of cardiovascular or cerebrovascular attacks. Although the etiology of essential hypertension remains unclear, recent investigations have revealed that an enhancement of Na(+)-proton (Na(+)-H+) exchange activity is a frequently observed ion transport abnormality in hypertensive patients and animal models. To test the hypothesis that increased Na(+)-H+ exchange causes hypertension, we produced transgenic mice overexpressing Na(+)-H+ exchanger and analyzed their Na+ metabolism and blood pressure. Urinary excretion of water and Na+ was significantly decreased in transgenic mice, and systolic blood pressure was elevated after salt loading. The impaired urinary excretion of Na+ suggested that the Na(+)-H+ exchanger overexpressed in the renal tubules increased reabsorption of Na+, which caused a blood pressure elevation by Na+ retention after excessive salt intake. Our results demonstrate that overexpression of Na(+)-H+ exchanger can be a genetic factor that interacts with excessive salt intake and causes salt-sensitive blood pressure elevation.

Invasive thymoma with hypogammaglobulinemia spreading within the bronchial lumen

A case of invasive thymoma with hypogammaglobulinemia showing endobronchial growth is presented. A 63-year-old man was admitted for evaluation of a left hilar mass. A biopsy specimen obtained from the intraluminal mass, which occluded the left upper division bronchus, was highly suggestive of thymoma. The laboratory tests were almost normal except for hypogammaglobulinemia. The tumor was resected with the left upper lobe. Most of the tumor invaded the left upper lobe, and grew into the bronchi. The case was diagnosed histologically as invasive thymoma spreading within the bronchial lumen.

[Clinicopathological study of 4 patients with idiopathic BOOP, interstitial type on chest X-ray]

We studied four patients with idiopathic Bronchiolitis Obliterans Organizing Pneumonia (BOOP) diagnosed by open lung biopsy. All of four presented with acute onset and a rapid course with progressive dyspnea. Their chest X-ray films showed ground-glass opacities with reduced volumes in the bilateral lower lobes. Their chest CT revealed marked increases in lung density with air bronchograms. Radiologically, it was difficult to distinguish these cases from patients with acute interstitial pneumonia. Histologically, in the uninflated specimens, the collapse of alveoli and alveolar spaces filled with foamy macrophages and proteinous exudates were observed. The organizing tissues were present predominantly in the alveolar ducts, but varied in extent among cases. We considered the reduced lung volumes on chest X-ray films and the marked increases in lung density on chest CT to reflect alveolar collapse. Proliferation of type II pneumocytes was remarkable in all cases, but reactivity to antisurfactant protein-A antibody staining was decreased in the collapsed alveoli. It was suggested that the alveolar collapse was caused, in part, by decreased pulmonary surfactant in addition to obstruction of the alveolar ducts. The rapid responses to of these patients corticosteroid therapy may be due to improvement of the alveolar collapse.

Monoclonal antibody-based enzyme-linked immunosorbent assay for glycyrrhizin and its aglycon, glycyrrhetic acid

Monoclonal antibodies (MoAbs) specific for glycyrrhetic acid (GA) were prepared and characterized. Obtained MoAbs (AGA-1, AGA-3, and AGA-6) reacted with GA dose-dependently, but not with glycyrrhizin (GL), carbenoxolone, and steroids. Next, an enzyme-linked immunosorbent assay (ELISA) system using AGA-1 was established. The standard curve showed good linearity between 0.01 and 1000 ng/ml of GA, and the detection limit was 5 pg/ml. Recovery, and intra- and interassay variations of this assay system was satisfactory. GL was also measurable quantitatively after acid-hydrolysis of the samples. The developed ELISA system would be useful to determine GL and GA in biological samples or drugs as an alternative method to high performance liquid chromatography (HPLC).

Phenthoate metabolites in human poisoning

Five metabolites were detected in the plasma and urine of a patient following ingestion of the organophosphate insecticide, phenthoate. Intact phenthoate was detected only in gastric lavage fluid. After methylation of acidic extracts of plasma and urine, phenthoate acid, demethyl phenthoate, demethyl phenthoate oxon acid, demethyl phenthoate S-isomer, and demethyl phenthoate acid S-isomer were identified with synthesized phenthoate analogues by gas chromatography and gas chromatograph-mass spectrometry. The main metabolites were phenthoate acid and demethyl phenthoate oxon acid. Although demethyl phenthoate oxon acid was a significant metabolite, no phenthoate oxon, phenthoate oxon acid or demethyl phenthoate oxon were detected. If the oxon was formed in the patient, it may have been rapidly degraded by carboxylesterase or glutathione transferase to demethyl phenthoate oxon acid.

[A case of rheumatoid arthritis with obstructive bronchiolitis appearing after D-penicillamine therapy]

A 56-year-old woman was diagnosed as having rheumatoid arthritis in 1983. She was treated with D-penicillamine in addition to non-steroid anti-inflammatory drugs from April 1990. In August she noticed shortness of breath on exertion. Chest X-ray films showed bilateral interstitial shadows, and chest CT revealed bilateral multiple wedge-shaped shadows extending distally. Blood gas analysis showed severe hypoxemia and pulmonary function tests demonstrated decreased %VC, FEV1.0% and diffusion capacity. Open lung biopsy specimens revealed infiltration of inflammatory cells and fibrotic change in the walls of bronchioles. She was diagnosed as having obstructive bronchiolitis. Corticosteroid therapy and discontinuation of D-penicillamine therapy stopped the progression of her symptoms, and she was discharged on corticosteroid maintenance treatment and home oxygen therapy.

Myogenin gene disruption results in perinatal lethality because of severe muscle defect

Myogenin is a member of the basic helix-loop-helix (bHLH) gene family and converts multipotential mesodermal cells to myoblasts. The four members of the myoD family show unique spatio-temporal expression patterns and therefore may have different functions during myogenesis. Here we inactivate the myogenin gene in order to understand its role in myogenesis. Homozygous mutations are lethal perinatally owing to the resulting major defects in skeletal muscle. The extent of disorganization of muscle tissue differs in three regions. In the latero-ventral body wall, most cells, including myogenic cells, disappear and there is rapid accretion of fluid. In the limbs, cells of the myogenic lineage exist, but they are severely disrupted, and some of them are mono-nucleate with properties of myoblasts. In contrast, there are many axial, intercostal and back muscle fibres to be seen, although fibres are mainly disorganized and Z-lines are not present in most myofibrils. These findings are evidence that myogenin is crucial for muscle development in utero and demonstrate that other members of the myogenic gene family cannot compensate for the defect.

Upstream region of the myogenin gene confers transcriptional activation in muscle cell lineages during mouse embryogenesis

Myogenin, one of the MyoD-related factors containing basic-helix-loop-helix motifs, is transcriptionally activated in skeletal muscle lineages in somites and limb buds during embryogenesis. In an attempt to understand regulatory mechanisms which govern transcriptional activation of the myogenin gene, transgenic mice bearing the lacZ gene driven by the upstream region of the myogenin gene were generated. Stereoscopic visualization of LacZ-positive cells of these transgenic mouse embryos revealed that the upstream region of the myogenin gene conferred its transcriptional activation in cells of the skeletal muscle lineages in somites, limb buds, and visceral arches. Moreover, transient LacZ expression in newly formed somites in addition to its strong activation in myotomal regions of mature somites with a rostro-caudal gradient raised the possibility that myogenin is transcriptionally activated in immature somites before myotome formation.

A stable cellular marker for the analysis of mouse chimeras: the bacterial chloramphenicol acetyltransferase gene driven by the human elongation factor 1 alpha promoter

We have developed a method of marking of mouse cells by means of transfection of a foreign gene. The transgene chosen here was the plasmid pEF321CAT which contains the bacterial chloramphenicol acetyl transferase (CAT) gene linked to the promoter region of the human polypeptide chain elongation factor 1 alpha (hEF1 alpha) gene. Evaluation of the plasmid pEF321CAT as a cellular marker for mouse cells involved intensive examination of a transgenic mouse carrying pEF321CAT. The CAT gene was expressed in all tissues examined, demonstrating that the hEF1 alpha promoter was active in a wide range of mouse cells. The plasmid itself did not exert any harmful effect on the normal development of mice, and the CAT activity was immunohistologically detectable on sectioned tissues by the use of anti-CAT serum. When the plasmid was transferred into embryonal carcinoma (EC) cells and embryonic stem (ES) cells, the CAT gene was also found to be expressed constantly irrespective of their differentiation. These results demonstrated that the plasmid pEF321CAT can be used as a reliable and feasible cellular marker that would distinguish unequivocally the cells of each of genotype in chimeric tissues.

The stem cells of a primordial germ cell-derived teratocarcinoma have the ability to form viable mouse chimeras

A euploid testicular teratocarcinoma line, STT-3, has been established from a tumor spontaneously occurring in the testis of a 129/Sv-ter male. Developmental ability of the STT-3 stem cells was tested by injecting these cells into mouse blastocysts. The frequency and the extent of chimerism were examined in mid-gestational fetuses and in live-born mice. STT-3 stem cells form viable chimeras at a high rate and differentiate into normal tissues. This is the first reported testicular teratocarcinoma-derived stem line with a proven capacity to form viable chimeric mice upon injection into the blastocysts.

Embryonic stem cell-mediated transfer and correct regulation of the chicken delta-crystallin gene in developing mouse embryos

To study regulation of delta-crystallin expression during ontogeny, we transferred the gene from chicken into developing mouse embryos by first transforming an embryonic stem (ES) cell line of mouse and then producing chimaeric embryos by combining them with normal mouse embryos. Using this technique, genes were transferred into a variety of developing mouse tissues with high efficiency. Two delta-crystallin gene constructs were used: the wild-type gene with 2200 bp of the 5′ flanking sequence, shown to be lens-specific in an assay using cultured mouse cells, and a mutant gene with 51 bp of the 5′ flanking sequence, lacking the sequence required for expression in lens cells. Five independent lines carrying the former and two lines carrying the latter were employed in producing chimaeras. In the chimaeric embryos having the wild-type gene, delta-crystallin was expressed in the lens and in specific regions of the primitive central nervous system (CNS) as is seen in embryonic expression in the chicken. In adult mouse chimaeras also, expression was restricted to the lens and the CNS, in the pyramidal neurones of the piriform cortex and the hippocampus. delta-crystallin expression in these tissues is due to proper transcriptional regulation, since no expression was observed when chimaeras were produced with the ES lines carrying the mutant gene. The experimental results reported here demonstrate the advantage of ES-cell-mediated gene transfer in the study of embryonic gene regulation, because a number of gene constructs and chromosomal sites can be analysed shortly after embryo manipulation without requiring gene transmission to the next generation.

Segmental wall motion abnormalities in dilated cardiomyopathy: hemodynamic characteristics and comparison with thallium-201 myocardial scintigraphy

This study assessed the hemodynamic characteristics of segmental wall motion abnormality of the left ventricle in patients with dilated cardiomyopathy (DCM) and its relation to the thallium-201 (TI-201) myocardial scintigraphy (MPI). Left ventriculograms and MPI in 23 patients were analyzed by the use of quantitative indexes of regional wall motion and TI-201 uptake based on a mean and a standard deviation of 13 normal subjects. Relative normokinesis in our definition was more frequently seen in the inferior wall than in the anterior wall (p less than 0.01). In contrast, severe asynergy was more often seen in the anterior wall than in the inferior wall (p less than 0.01). There were 11 patients who had relative normokinesis and asynergy together. By means of the index of wall motion, the DCM patients were divided into two groups, one with segmental wall motion abnormality (SWMA) and another with diffuse wall motion abnormality (DWMA). The DWMA group had higher left ventricular end-diastolic pressures (p less than 0.05) and the tendency of large left ventricular end-diastolic volumes than the SWMA group. There was a rough correlation (r = 0.58) between the quantitative indexes of TI-201 uptake and wall motion at the same region of the left ventricle. Thus, the nonuniformity of the left ventricular wall motion was recognized in the patients with DCM and more increased preload was shown in the patients with DWMA than in the group with SWMA. Further, the regional asynergy may be related to the localized fibrosis within the left ventricle in DCM, considering the result that the worse TI-201 uptake was roughly accompanied by the more severe asynergy.

[Functional reserve of the ischemic left ventricle with ventricular aneurysm to afterload stress: digital subtraction angiographic assessments]

Digital subtraction angiography (DSA) has been confirmed to be an accurate method for determining left ventricular function. It is a relatively non-invasive technique without inducing premature ventricular complexes. The response of left ventricular function to afterload stress was assessed using DSA for eight patients with old anterior myocardial infarction and ventricular aneurysm including that of the anterior wall (averaging 30.3 months after the acute episodes). Their ages ranged from 36 to 65 years and one patient was a woman. Prior to the investigation, we confirmed that a single DSA procedure did not alter left ventricular function in a pilot study of one patient (No. 8). After initial DSA in the basal state, methoxamine was infused intravenously (1 to 2 mg/min). When aortic systolic blood pressure increased by 30 to 50 mmHg, a second DSA was performed for each patient. Left ventricular volumes and ejection fractions were calculated by the area-length method, and regional wall motion was assessed by the visual method according to the AHA classification and the curvature radius of the apical ventricular aneurysm was calculated. Methoxamine induced neither acute heart failure nor angina pectoris in the present series. The heart rates decreased, and there were a significant increase in end-systolic volumes (p less than 0.05), end-systolic radii (p less than 0.05), and a significant decrease in ejection fractions (p less than 0.02) after methoxamine infusion. In 32 of 40 segments, regional wall motion was unchanged by methoxamine as assessed by the visual method; whereas, in the other eight, there was a deterioration.(ABSTRACT TRUNCATED AT 250 WORDS)