Comparison of SGLT2 inhibitors vs. DPP4 inhibitors for patients with metabolic dysfunction associated fatty liver disease and diabetes mellitus

PURPOSE

This study aimed to examine the potential benefit of sodium-glucose cotransporter 2 (SGLT2) inhibitors for patients with metabolic dysfunction-associated fatty liver disease (MAFLD) and diabetes mellitus (DM) using a real-world database.

METHODS

We analyzed individuals with MAFLD and DM newly initiated on SGLT2 or dipeptidyl peptidase 4 (DPP4) inhibitors from a large-scale administrative claims database. The primary outcome was the change in the fatty liver index (FLI) assessed using a linear mixed-effects model from the initiation of SGLT2 or DPP4 inhibitors. A propensity score-matching algorithm was used to compare the change in FLI among SGLT2 and DPP4 inhibitors.

RESULTS

After propensity score matching, 6547 well-balanced pairs of SGLT2 and 6547 DPP4 inhibitor users were created. SGLT2 inhibitor use was associated with a greater decline in FLI than DPP4 inhibitor use (difference at 1-year measurement, - 3.8 [95% CI - 4.7 to - 3.0]). The advantage of SGLT2 inhibitor use over DPP4 inhibitor use for improvement in FLI was consistent across subgroups. The relationship between SGLT2 inhibitors and amelioration of FLI was comparable between individual SGLT2 inhibitors.

CONCLUSIONS

Our analysis using large-scale real-world data demonstrated the potential advantage of SGLT2 inhibitors over DPP4 inhibitors in patients with MAFLD and DM.

Visible luminescent lanthanide ions and a large π-conjugated ligand system shake hands

The novel photophysics induced by the combination of visible luminescent europium(iii) ions and large π-conjugated systems are described.

Expression of thep63and Notch Signaling Systems in Rat Testes During Postnatal Development: Comparison With Their Expression Levels in the Epididymis and Vas Deferens

The role of tubular structures that contribute to the passage of spermatozoa is not solely passive; these structures actively contribute to their own functions, although these tubules and ducts are contiguous and collaborate in the development of the male gamete along their lengths. The testis has the specific function to generate spermatozoa and spermatozoa undergo numerous changes as they pass through the epididymis. A member of the p53 family of genes, p63, is highly expressed in the basal layers of epithelial tissues and plays a key role in maintaining their cell populations, whereas Notch 1 and its ligand Jagged 2 have an important role in the differentiation of germ cells and Jagged 2 is up-regulated by TAp63, one of the p63 isoforms, which transactivates p53 target genes and induces apoptosis. Although the presence of p63 in most epithelia is established, the role of p63 and its possible relationship with the Notch system in the seminiferous epithelium have not been examined. Therefore, we investigated the expression of p63, Jagged 2, and Notch 1 in the testis during postnatal development in comparison with their expression levels in the vaso-epididymal epithelium. In the testis, the expression of TAp63 mRNA increased at day 14 after birth and the expressions of Jagged 2 and Notch 1 mRNA increased at day 16 after birth, suggesting that TAp63-mediated Jagged 2 induction activates the Notch signaling system. On the other hand, the strong signal of DeltaNp63 mRNA was already recognized in the vas deferens at day 0 after birth and advanced chronologically along the duct to the caput epididymis and p63 protein was expressed in basal cells in their epithelium, whereas the mRNAs of Jagged 2 and Notch 1 were maintained at a low level. Consequently, examination of our data raises the probability that TAp63 has an important role for maintenance of germ cell numbers, triggering or balancing the development, differentiation, and apoptosis of germ cells in the testis, which is completely different from the role of DeltaNp63 in other epithelial tissues.

Current-voltage characteristics of high resistivity CdTe

Current-voltage characteristics of high resistivity CdTe, with consideration to Schottky barrier height at the contact and defect levels in the band gap were investigated by experimental and numerical simulation methods. From the electron injection investigation, the density of electron traps corresponded to the doped Cl concentration in the crystal. Numerical simulation of current-voltage characteristics was made based on Schockley Read Hall (SRH) statistics. In the low bias region, calculated characteristics were in fairly close agreement with the experimental results for Pt/CdTe/Pt diode. The electric field was not uniform along the biased direction and an almost neutral region was present in the vicinity of anode contact even when the bias was applied.

Pre-transplant imatinib-based therapy improves the outcome of allogeneic hematopoietic stem cell transplantation for BCR-ABL-positive acute lymphoblastic leukemia

A high complete remission (CR) rate has been reported in newly diagnosed Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL) following imatinib-based therapy. However, the overall effect of imatinib on the outcomes of allogeneic hematopoietic stem cell transplantation (allo-HSCT) is undetermined. Between 2002 and 2005, 100 newly diagnosed adult patients with Ph+ALL were registered to a phase II study of imatinib-combined chemotherapy (Japan Adult Leukemia Study Group Ph+ALL202 study) and 97 patients achieved CR. We compared clinical outcomes of 51 patients who received allo-HSCT in their first CR (imatinib cohort) with those of 122 historical control patients in the pre-imatinib era (pre-imatinib cohort). The probability of overall survival at 3 years after allo-HSCT was 65% (95% confidence interval (CI), 49-78%) for the imatinib cohort and 44% (95% CI, 35-52%) for the pre-imatinib cohort. Multivariate analysis confirmed that this difference was statistically significant (adjusted hazard ratio, 0.44, P=0.005). Favorable outcomes of the imatinib cohort were also observed for disease-free survival (P=0.007) and relapse (P=0.002), but not for non-relapse mortality (P=0.265). Imatinib-based therapy is a potentially useful strategy for newly diagnosed patients with Ph+ALL, not only providing them more chance to receive allo-HSCT, but also improving the outcome of allo-HSCT.

Improvement of oligoasthenozoospermia in epileptic patients on switching anti-epilepsy medication from sodium valproate to phenytoin

We present two cases of infertile male patients with oligoasthenozoospermia who were receiving anti-epilepsy medication. Complete reversal of the spermatic dysfunction followed by a successful conception was achieved after discontinuation of sodium valproate, suggesting that the drug was responsible for spermatic dysfunction in these individuals.

CMC-544 (inotuzumab ozogamicin), an anti-CD22 immuno-conjugate of calicheamicin, alters the levels of target molecules of malignant B-cells

We studied the effect of CMC-544, the calicheamicin-conjugated anti-CD22 monoclonal antibody, used alone and in combination with rituximab, analyzing the quantitative alteration of target molecules, that is, CD20, CD22, CD55 and CD59, in Daudi and Raji cells as well as in cells obtained from patients with B-cell malignancies (BCM). Antibody inducing direct antiproliferative and apoptotic effect, complement-dependent cytotoxicity (CDC) and antibody-dependent cellular cytotoxicity (ADCC) were tested separately. In Daudi and Raji cells, the CDC effect of rituximab significantly increased within 12 h following incubation with CMC-544. The levels of CD22 and CD55 were significantly reduced (P<0.001 in both cells) after incubation with CMC-544, but CD20 level remained constant or increased for 12 h. Similar results were obtained in cells from 12 patients with BCM. The antiproliferative and apoptotic effect of CMC-544 were greater than that of rituximab. The ADCC of rituximab was not enhanced by CMC-544. Thus, the combination of CMC-544 and rituximab increased the in vitro cytotoxic effect in BCM cells, and sequential administration for 12 h proceeded by CMC-544 was more effective. The reduction of CD55 and the preservation of CD20 after incubation with CMC-544 support the rationale for the combined use of CMC-544 and rituximab.

Dasatinib phase I/II study of patients with chronic myeloid leukemia (CML) resistant or intolerant to imatinib: Results of the CA180031 study in Japan

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Background: Dasatinib is a potent, orally active, multi-targeted kinase inhibitor of BCR-ABL and SRC family kinases. Studies outside Japan have shown dasatinib to be highly effective in overcoming resistance and intolerance to imatinib, inducing durable cytogenetic (CyR) and hematologic responses (HR) in this population. The maximum tolerated dose was not reached in the Phase-I trial outside Japan and a 70-mg BID dose was determined to provide the optimal benefit-risk profile. Methods: This Phase-I/-II study was designed to assess the safety and efficacy of dasatinib in Japanese patients with imatinib-resistant or -intolerant CML or Ph+ALL. In the 4-week Phase-I portion in patients with chronic-phase (CP) CML, three dose levels were evaluated: 50 mg, 70 mg, and 90 mg BID. The Phase-II portion is currently evaluating the CyR of dasatinib in patients with CP-CML at 24 weeks, and the HR rate in accelerated- (AP) or blast-phase (BP) CML and Ph+ ALL at 12 weeks. Results: As of December 2006, 17 eligible patients have been treated in Phase I. Six patients (4F, 2M; median age 43 y [range 27–56]) were treated with 50 mg BID and 1 dose-limiting toxicity (DLT) was observed (Grade 4 thrombocytopenia). Two patients experienced transient Grade 3 ALT elevations but as treatment was uninterrupted, these were not considered DLTs. Six patients (6M; median age 42 y [range 27–55]) were treated with 70 mg BID and again 1 DLT was observed (Grade 4 thrombocytopenia). No DLT has been observed among 4 patients (3M, 1F; median age 41 y [range 27–64]) at the 90-mg BID dose. Major CyRs have been achieved in all three cohorts in the Phase-I segment of the trial. Thirty six patients were enrolled and treated in the Phase-II part of the trial (12 CP-CML, 7 AP- CML, 4 BP-CML, and 13 Ph+ALL). Efficacy and safety data as well as the baseline BCR-ABL mutation data are currently being assessed and will be presented. Conclusions: Dasatinib can be safely administered at doses of up to 90 mg BID to Japanese patients with imatinib-resistant or -intolerant CP-CML.

No significant financial relationships to disclose.

[A pediatric case diagnosed as urachal cyst and vesicoureteral reflux by urinary tract infection: a case report]

A one-month-old girl was refereed to our department because of urinary tract infection. Ultrasonography showed grade III left hydronephrosis and cystic mass at the dome of the urinary bladder. Voiding cystourethrography revealed grade 4 vesicoureteral reflux associated with Hutch's diverticulum. In addition, magnetic resonance imaging revealed multiple cysts at the dome of the urinary bladder. The vesicoureteral reflux was repaired and the urachal cyst removed.

[A case of hypospadias with a dicentric Y chromosome]

An infant was referred to our department with complaint of abnormality of the external genitalia. Hypospadias and right inguinal hernia were detected and left testis was palpable, but right testis was not palpable. Chromosomal examination revealed 45, X/46, X, idic (Y) (q11.2). On ultrasonographic examination, uterus and ovary were not recognized. At one year of age, we performed operation of right inguinal hernia and right cryptorchism. During operation right spermatic cord and epididymis were detected, but right testis was not detected. At two years of age, urethroplasty was performed. After the operation closure of hypospadias fistulas was performed. Now the patient does not have fistulas and has good clinical progress.

Efficacy and safety of recombinant human soluble thrombomodulin (ART-123) in disseminated intravascular coagulation: results of a phase III, randomized, double-blind clinical trial

BACKGROUND

Soluble thrombomodulin is a promising therapeutic natural anticoagulant that is comparable to antithrombin, tissue factor pathway inhibitor and activated protein C.

OBJECTIVES

We conducted a multicenter, double-blind, randomized, parallel-group trial to compare the efficacy and safety of recombinant human soluble thrombomodulin (ART-123) to those of low-dose heparin for the treatment of disseminated intravascular coagulation (DIC) associated with hematologic malignancy or infection.

METHODS

DIC patients (n = 234) were assigned to receive ART-123 (0.06 mg kg(-1) for 30 min, once daily) or heparin sodium (8 U kg(-1) h(-1) for 24 h) for 6 days, using a double-dummy method. The primary efficacy endpoint was DIC resolution rate. The secondary endpoints included clinical course of bleeding symptoms and mortality rate at 28 days.

RESULTS

DIC was resolved in 66.1% of the ART-123 group, as compared with 49.9% of the heparin group [difference 16.2%; 95% confidence interval (CI) 3.3-29.1]. Patients in the ART-123 group also showed more marked improvement in clinical course of bleeding symptoms (P = 0.0271). The incidence of bleeding-related adverse events up to 7 days after the start of infusion was lower in the ART-123 group than in the heparin group (43.1% vs. 56.5%, P = 0.0487).

CONCLUSIONS

When compared with heparin therapy, ART-123 therapy more significantly improves DIC and alleviates bleeding symptoms in DIC patients.

Asthenospermia in hay fever patients improved by stopping treatment with histamine H1 receptor antagonists

We report two cases of asthenospermia, which appeared to be associated with exposure to histamine H1 receptor antagonists. A 44-year-old man and a 35-year-old man had continued the treatment with fexofenadine hydrochloride and cetirizine hydrochloride, respectively, under the diagnosis of hay fever. They and their wives had been examined as infertile couples. Infertility evaluations revealed no problems with their wives; the patients, however, were found to have a low sperm motility (<10%). On suspicion of adverse effects of the histamine H1 receptor antagonists, they stopped treatment with these drugs, which resulted in a complete reversal of spermatic dysfunction. Current information identifies the potential fertility hazards of histamine H1 receptor antagonists.

Bilateral renal angiomyolipoma coexistent with pulmonary lymphangioleiomyomatosis and tuberous sclerosis

A case of bilateral renal angiomyolipoma coexistent with pulmonary lymphangioleiomyomatosis and tuberous sclerosis was described, being in shock with massive hematuria. The left giant angiomyolipoma, filling the almost entire abdomen, was complicated with two large hump and moniliform aneurysms. This life-threatening hemorrhage was successfully treated by transcatheter arterial embolization; packing mechanically detachable coils into the aneurysms and embolization of trunk of the left renal artery. Lymphangioleiomyomatosis has been suggested to be an incomplete expression of tuberous sclerosis. Although coexisting renal and pulmonary involvement in tuberous sclerosis is rare, it is important to recognize lymphangioleiomyomatosis as a pulmonary involvement of angiomyolipoma with tuberous sclerosis.

[Comparison and outcome of prevalence of concurrent diseases in patients with urological malignant diseases]

We compared the prevalence of concurrent diseases (diabetes mellitus, hypertension, ischemic heart diseases and apoplexy) in patients with renal cell carcinoma, bladder carcinoma and prostatic carcinoma diagnosed in our department with that in all patients in our department analyzed using Mantel-Haenszel regression. In hypertension, there was a significantly high prevalence of patients with renal cell carcinoma (p < 0.05) in males and females, and prostatic carcinoma (p < 0.05). In diabetis mellitus, ischemic heart diseases and apoplexy, no apparent characteristic of prevalence was recognized. The close relationship between renal cell carcinoma, prostatic carcinoma and hypertension in this study corresponded with previous reports.

Role of volume and attenuation value histogram of urinary stone on noncontrast helical computed tomography as predictor of fragility by extracorporeal shock wave lithotripsy

OBJECTIVES

To test, for the first time, the predictive capability of the total stone volume (TSV) and the attenuation value histogram. Recently, the mean attenuation value (MAV) of urinary stones has been recognized as a predictor of fragility by extracorporeal shock wave lithotripsy. However, properties other than MAV, including the TSV and the heterogeneity of attenuation value histogram, may also be related to fragility.

METHODS

A total of 62 renal and proximal ureteral radiopaque stones treated with extracorporeal shock wave lithotripsy were included in this prospective study. Stones less than 5 mm or greater than 20 mm were excluded. Attenuation value histograms were graphed from the data from noncontrast helical computed tomography scans. The TSV, MAV, and hump existence (HE) on the histogram were also calculated. These parameters were compared between the treatment success and treatment failure groups.

RESULTS

Of the 62 stones, 6 were excluded, 39 were in the success group, and 17 in the failure group. Of the 56 stones, 16 had a hump and 40 did not on the attenuation value histograms. The TSV, MAV, and HE were significantly different statistically between the two groups (P <0.001), with an accuracy of 82.1%, 83.9%, and 91.1%, respectively. Also, HE was the only independent predictor of success or failure of extracorporeal shock wave lithotripsy on multivariate analysis (P = 0.0073).

CONCLUSIONS

Our results have suggested that TSV, MAV, and HE are good predictors of stone fragility. The treatment modality of the stone should be selected according to the HE, which is a practical, simple, and predictive index.

HtrA2 is up-regulated in the rat testis after experimental cryptorchidism

AIM

The aim of the present study was to elucidate the role of high temperature requirement A2 (HtrA2) in germ cell loss in the heat-stressed testis.

METHODS

We examined the expression of HtrA2, caspase-9 activity and proteolytic activity of HtrA2 in the rat testis, and their in vivo responses to experimental cryptorchid treatment.

RESULTS

Northern analysis revealed the expression of HtrA2 mRNA peaked at days 1 and 7 after cryptorchid treatment. While expression of HtrA2 mRNA was seen in the spermatogonium, spermatocytes and some spermatids in normal adult rat testis, experimental cryptorchidism treatment resulted in a marked increase in its signal intensity in spermatocytes and some spermatids, and the layers of spermatogonium and early primary spermatocytes became negative at days 1 and 7 after the treatment. However, the spermatogonium, Sertoli cells and interstitial cells appeared to have strong intensities at days 14, 28 and 56 after the treatment. Western analysis revealed the expression of HtrA2 protein peaked at day 2 coinciding with the increase of positive spermatogonium, the appearance of protein-positive interstitial cells, and day 28 coinciding with the reappearance of protein-positive interstitial cells. Caspase-9 activity peaked at day 2 and HtrA2 proteolytic activity peaked at day 28. Consequently, the first peak of HtrA2 mRNA expression was followed by the peak of caspase-9 activity and the second peak was followed by the peak of proteolytic activity; however, the second peak of mRNA expression had considerable chronological difference from that of the protein.

CONCLUSION

These findings suggest the probabilities that the heat stress results in germ cell death by a caspase-independent manner with the elevation of HtrA2 proteolytic activity, as well as a caspase-dependent manner with the elevation of caspase-9 activity.

[Primary leiomyosarcoma of the spermatic cord with an unusually indolent clinical course]

A 33-year-old man referred to our hospital with a painful swelling of the left scrotal content which had gradually enlarged during the past 4 years. Physical examination revealed a hard, irregular, nontender mass of 5x4 cm in the left scrotum. The mass was fixed to the left epididymis and spermatic cord. Local excision was performed and histologcal examination revealed leiomyosarcoma originating from the spermatic cord. Distant metastases were not observed. Because of the reportedly high propensity for local recurrence, we performed radical orchiectomy and adjuvant radiation. The patient has been alive for 13 months with no evidence of disease.

[Inflammatory myofibroblastic tumor of the renal pelvis]

Inflammatory myofibroblastic tumor (IMT) of the genitourinary tract is rare and has been classified into separate groups based on their anatomical site and postulated aetiology. Herein, we present a case of IMT of the renal pelvis. A 44-year-old man presented with gross hematuria. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) revealed a tumor of the left renal pelvis. Under the diagnosis of left renal pelvic tumor, he underwent left nephrectomy and ureterectomy. Microscopic examination revealed fascicular spindle cell proliferation in an oedematous myxoid background with an infiltrate of plasma cells. The spindle cells were strongly positive for smooth muscle actin (SMA) and vimentin, and negative for desmin and anaplastic lymphoma kinase (ALK). Diagnosis of the lesion was IMT of the renal pelvis.

Successful cure of dermatomyositis after treatment of nonseminomatous testicular cancer

Although the association between dermatomyositis and cancer is well recognized, there have been a limited number of reports of dermatomyositis associated with testicular cancer. We report the case of a 31-year-old man who was diagnosed with dermatomyositis. Because the patient's serum levels of alpha-fetoprotein and human chorionic gonadotropin beta subunit were elevated, the patient was referred to our department. Physical examination revealed an induration (2 cm x 2 cm) in the left testis and the patient was diagnosed with stage IIIB left testicular cancer. A left high orchidectomy was then performed, and pathological examination revealed embryonal carcinoma. The patient was started on a systemic chemotherapeutic (etoposide, ifosfamide and cisplatin; VIP) regimen. After the third chemotherapy session, metastases had completely disappeared, the serum levels of alpha-fetoprotein and human chorionic gonadotropin beta subunit had normalized and the dermatomyositis symptoms had improved. Cancer is known to be a trigger of dermatomyositis. This case illustrates the importance of palpation of the testes in young patients with dermatomyositis.

[Metastatic tumor of spermatic cord with elevation of serum human chorionic gonadotropin beta-subunit]

A 62-year-old man was presented with a firm mass in right scrotum. Serum LDH and AFP were within normal range, but hCG-beta was elevated (2.3 ng/ml). Under the diagnosis of right testicular tumor, he underwent right radical orchiectomy. The specimen was a spermatic cord tumor with poorly differentiated adenocarcinoma. hCG-beta was still elevated postoperatively and gastric fiber revealed adenocarcinoma of the stomach. Histochemical staining for hCG-beta was positive in both tumor of the spermatic cord and stomach. Finally the tumor was diagnosed as metastatic tumor of spermatic cord from gastric cancer, causing the elevation of hCG-beta.

[A stage-dependent follow-up strategy after radical cystectomy for bladder carcinoma]

With the aim of developing stage-dependent follow-up strategy after radical cystectomy for bladder carcinoma, the records of 111 patients with bladder carcinoma who underwent radical cystectomy during the period between 1986 and 2003, were reviewed for the date and site of recurrence. Intrapelvic recurrence developed in 3 out of 56 patients with pT1> or =, 1 of 22 with pT2 and 6 out of 33 with pT3< or = at a median of 34 (range 32-58), 28, 8 (4-51) months, respectively. Extrapelvic recurrence developed in 20 patients with pT1> or =, 4 with pT2 and 14 with pT3< or = at a median of 43 (20-66), 15.5 (13-20), 8 (2-46) months, respectively. Recurrence developed earlier and more frequently in patients with pT3< or = and pT2 than those with pT1> or =. A stage-specific approach to tumor surveillance after radical cystectomy for bladder carcinoma, taking into consideration the risk of recurrence, represents a new approach for efficiently detecting recurrence and reducing medical costs. Our results offer the possibility of a new stage-specific approach to tumor surveillance after radical cystectomy for bladder carcinoma, for efficiently detecting recurrence and reducing medical costs, taking into consideration the risk of recurrence.

New hammock hypothesis-based method for the treatment of stress urinary incontinence: the first 29 urethral supports with a small fascial patch

AIM

We have developed a new method requiring no manipulations of the retropubic passages, and carried out a retrospective study to assess the effectiveness, safety and early results of this new procedure in the treatment of female stress urinary incontinence.

METHODS

From January 2001 to September 2003, 29 patients underwent our new surgery for the treatment of SUI. A 3 x 2 cm vertical rectangle was harvested from the rectus fascia. A convex horizontal incision was made over the mid urethra and bladder neck. The retropubic space was entered to the urethropelvic ligament spreading toward the junctions between urethropelvic ligament and tendinous arc. One suture was made at the point lateral to the bladder neck. Another suture was made behind the pubic bone. These two sutures were sutured again and tied with the short side end of the harvested fascia. The same procedure was performed on the other side.

RESULTS

Of 29 patients, 26 (89.7%) were cured of stress urinary incontinence and 3 were improved. None of the patients had difficulty in voiding after the operation. Maximum flow rates were almost the same before and after surgery. None of the patients had any adverse events.

CONCLUSION

This procedure, which requires no manipulations of the retropubic passages, is safe and effective for the treatment of stress urinary incontinence.

Successful treatment of recurrent vesicourethral stricture after radical prostatectomy with holmium laser: report of three cases

We report three cases with severe anastomotic strictures, which recurred several times after radical prostatectomy despite repeated treatments of urethral dilation, internal urethrotomy and/or transurethral resection. All three cases were finally treated with holmium laser successfully without any intraoperative or postoperative complications after repeated failures of each treatment. There were two specific characteristics in these three cases: the early onset of the stricture and the pinhole opening located on the top (12-o'clock) of the stricture wall.

Expression and methylation status of the FHIT gene in acute myeloid leukemia and myelodysplastic syndrome

To clarify the role of fragile histidine triad (FHIT) in hematological malignancies, we examined the methylation status and the expression level of the FHIT gene in myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) cells in comparison with the methylation of the p15(INK4B) gene. The FHIT methylation was found in 13 of 94 (13.8%) AML and 22 of 40 (55.0%) MDS cases, but not in normal mononuclear cells (MNCs). Both the frequency and density of methylation increased in the advanced-stages MDS and the relapsed AML cases. Although FHIT and p15(INK4B) methylations were not correlated in MDS and AML, increased FHIT methylation at the relapse in AML was associated with p15(INK4B) methylation. The median expression level in AML was significantly higher than in normal MNCs, although the median expression level in those with methylation was significantly lower than in those without methylation. Furthermore, the methylation level at relapse was significantly higher than at diagnosis in AML. These results suggested that FHIT methylation was accumulated through the disease progression of MDS and AML, and the role of the FHIT gene as a tumor suppressor seemed different in AML and MDS.

Efficacy of gemtuzumab ozogamicin on ATRA- and arsenic-resistant acute promyelocytic leukemia (APL) cells

Acute promyelocytic leukemia (APL) cells express a considerable level of CD33, which is a target of gemtuzumab ozogamicin (GO), and a significantly lower level of P-glycoprotein (P-gp). In this study, we examined whether GO was effective on all-trans retinoic acid (ATRA)- or arsenic trioxide (ATO)-resistant APL cells. Cells used were an APL cell line in which P-gp was undetectable (NB4), ATRA-resistant NB4 (NB4/RA), NB4 and NB4/RA that had been transfected with MDR-1 cDNA (NB4/MDR and NB4/RA/MDR, respectively), ATO-resistant NB4 (NB4/As) and blast cells from eight patients with clinically ATRA-resistant APL including two patients with ATRA- and ATO-resistant APL. The efficacy of GO was analyzed by (3)H-thymidine incorporation, the dye exclusion test and cell cycle distribution. GO suppressed the growth of NB4, NB4/RA and NB4/As cells in a dose-dependent manner. GO increased the percentage of hypodiploid cells significantly in NB4, NB4/RA and NB4/As cells, and by a limited degree in NB4/MDR and NB4/RA/MDR cells. Similar results were obtained using blast cells from the patients with APL. GO is effective against ATRA- or ATO-resistant APL cells that do not express P-gp, and the mechanism of resistance to GO is not related to the mechanism of resistance to ATRA or ATO in APL cells. Leukemia (2005) 19, 1306-1311. doi:10.1038/sj.leu.2403807; published online 26 May 2005.

[A case of renal cell carcinoma associated with idiopathic thrombocytopenic purpura]

A 29-year-old woman was referred to another hospital with complaints of bruising and ecchymosis and thrombocytopenia (12,000/microl) was pointed out. After some examinations, the patient was diagnosed with idiopathic thrombocytopenic purpura and was started on steroid therapy. Then the patient consulted our hospital and computerized tomography revealed a left renal tumor 4 cm in diameter. Under the diagnosis of left renal neoplasm we performed left nephrectomy and splenectomy with preoperative high-dose intravenous gammaglobulin treatment. Pathological examination revealed clear cell carcinoma. After the operation, the platelet count increased gradually. We should consider bleeding tendency by thrombocytopenia and side effect of long-term steroid treatment when we perform operations on patients with idiopathic thrombocytopenic purpura.

[A case of spontaneous rupture of infectious renal cyst with difficulty in diagnosis]

A 27-year-old gravida was referred to an other hospital complaining of left lumbago and pyrexia, and she was diagnosed with acute pyelonephritis. Left lumbago increased and magnetic resonance imaging of abdomen demonstrated a low intensity area like hematoma around the left kidney. Then the patient was transported to our hospital under the diagnosis of high-risk graviditas. She was performed cesarean section. High-grade inflammation still continued after the operation and computerized tomography revealed the increase of high density area. We performed angiography of the left kidney for hemostasis, but the tumor in the left renal upper pole revealed hypovascularity. We started medication of imipenem/cilastatin sodium (IPM/CS). Inflammation and pyrexia did not improve until we changed antibiotics from IPM/CS to amikacin sulfate. Seven days after that high density area around the left kidney disappeared and a renal cyst was recognized by computerized tomography for the first time. Finally, the current case was diagnosed as spontaneous rupture of infectious renal cyst.

[Usefulness of an all-in-one clinical pathway for transurethral resection of prostate]

We evaluated the usefulness of our original all-in-one clinical pathway for transurethral resection of the prostate (TUR-P) on 86 consecutive patients. There were 27 consecutive patients treated before introduction of the clinical pathway (group 1). Twenty-nine consecutive patients were treated just after the introduction of the clinical pathway (group 2) and 30 consecutive patients were treated one year after the introduction of the clinical pathway (group 3). Our pathway includes all items such as vital sign charts and events charts. Although the hospitalization ranged from 5 days to 12 days after introduction of the clinical pathway, the average length of hospital stay was shortened by 2.6 days in group 3. Although the duration of the postoperative indwelling urethral catheter ranged from 2 days to 7 days in the groups 2 and 3, the average duration was approximately 4 days in group 3. Postoperative complications did not differ among the three groups. The medical insurance claims decreased with the introduction of the clinical pathway. Our all-in-one clinical pathway is considered to be a good tool for not only reduction of health care costs but also giving higher quality and better service to patients.

[Giant sarcomatoid carcinoma with spontaneous vesical rupture: a case report]

A 60-year-old woman has been on steroids under the diagnosis of polymyositis for 25 years. She was referred to our hospital complaining of asymptomatic macroscopic hematuria and lower abdominal pain. Physical examination revealed abdominal tenderness and rigidity. We suspected peritonitis because of free air image on the abdominal roentogenogram. The computed tomographic (CT) scan demonstrated an 8 cm solid mass in the bladder and defect of anterior wall of urinary bladder. Then we performed total cystectomy with cutaneous ureterostomy and partial resection of ileum as an emergency operation. Macroscopically, intra-peritoneal bladder rupture and severe adhesion of necrotic bladder dome wall to ileum were recognized and the tumor 8 cm in diameter existed in posterior wall of urinary bladder. Microscopic examination showed sarcomatoid carcinoma with spindle cell component and no invasion to ileum was recognized. Multiple lung, liver and bone metastasis appeared 6 months after the operation. She died of cancer 11 months after the operation.

[Vesicorectal fistula caused by pelvic metastasis of penile cancer: a case report]

A 65-year-old man was referred to our hospital complaining of glans induration. Tumor biopsy revealed squamous cell carcinoma. Although he was given radiation therapy and subcutaneous injection therapy of bleomycin, viable cancer cells remained. Then he was given combination chemotherapy of bleomycin and cisplatin, and paint therapy of bleomycin ointment. Local recurrence with a cauliflower-like tumor occurred five years after the chemotherapy. Then we performed total penectomy and reconstructive surgery of penis. Five years later, discharge of urine from anal appeared. Computerized tomography of pelvis demonstrated a mass 3 cm in diameter in the anterior portion of anal and cystogram demonstrated a vesicorectal fistula. We tried to perform fistulectomy, but foiled because of large fistula. Then we inserted a urethral catheter, which resulted in obstruction of fistula by its balloon, and we made a cystostomy for securing urinary tract. Pathological examination of tissue around the fistula revealed squamous cell carcinoma. His quality of life was improved, but his general condition became worse gradually and he died of cancer.

Asthenozoospermia: Possible association with long-term exposure to an anti-epileptic drug of carbamazepine

Little attention has been paid to infertility in men with epilepsy and little information exists about the mechanisms by which anti-epileptic drugs affect spermatogenesis or sperm function. We report a case of a male infertility patient with asthenozoospermia during long-term treatment with anti-epileptic drugs. A 29-year-old man had continued treatment with anti-epileptic drugs under the diagnosis of epilepsy for 13 years. He and his wife had been examined and treated as an infertile couple for 3 years. The patient was found to have no motile sperm with a normal sperm count, while taking a dose of 400 mg/day of carbamazepine. On suspicion of an adverse effect of carbamazepine, he was switched to phenytoin monotherapy. One month after that, sperm motility was vastly improved (65%) and they conceived a child 5 months after that. One must be cautious in extrapolating from a case report, but these findings strongly suggest a direct effect of carbamazepine on spermatic function.

[A case of hypogonadotrophic hypogonadism causing lumbar stress fracture]

A 57-year-old man was referred to our hospital for further evaluation on hypogonadotrophic hypogonadism causing a stress fracture of the 4th lumbar vertebrae. Azoospermia had been pointed out at the age 30, but hormonal evaluation had not been performed. Physical examination revealed an eunuchoidal body proportion, a stretched phallus length of 4 cm and bilateral scrotal testes of 6 ml. Hormonal evaluation demonstrated a testosterone level of 13 ng/dl (normal, 320 to 1,030 ng/dl), a luteinizing hormone of 0.2 mU/ml (normal, 1.8 to 9.2 mU/ml) and a follicular stimulating hormone of 1.0 mU/ml (normal, 1.6 to 10.7 mU/ml). Results of a stress test of gonadotrophin-releasing hormone was a low delay type. Computerized tomography showed no abnormality in the hypothalamic-pituitary region. The patient was treated with the substitution therapy of androgen. The therapy was discontinued 6 months later because of severe nipple pain. We should perform hormonal evaluation and other examinations for male infertility.

Nicorandil improves diabetes and rat islet beta-cell damage induced by streptozotocin in vivo and in vitro

OBJECTIVE

N-(2-hydroxyethyl)-nicotinamide nitrate (nicorandil) is a unique anti-anginal agent, reported to act as both an ATP-sensitive K(+) channel opener (PCO) and a nitric oxide donor. It also has an anti-oxidant action. We examined the effects of nicorandil on streptozotocin (STZ)-induced islet beta-cell damage both in vivo and in vitro.

DESIGN AND METHODS

STZ-induced diabetic Brown Norway rats (STZ-DM) were fed with nicorandil-containing chow from day 2 (STZ-DM-N48), 3 (STZ-DM-N72), and 4 (STZ-DM-N96) to day 30. Body weight, blood glucose, and plasma insulin were measured every week. For the in vitro assay, neonatal rat islet-rich cultures were performed and cells were treated with nicorandil from 1 h before to 2 h after exposure to STZ for 30 min. Insulin secretion from islet cells was assayed after an additional 24 h of culture. We also observed the effect of nicorandil on the generation of reactive oxygen species (ROS) from rat inslinoma cells (RINm5F).

RESULTS

Body weight loss and blood glucose levels of STZ-DM-N48 rats were significantly lower than those of STZ-DM rats. Immunohistochemical staining of insulin showed preservation of insulin-secreting islet beta-cells in STZ-DM-N48 rats. Nicorandil also dose-dependently recovered the insulin release from neonatal rat islet cells treated with STZ in in vitro experiments. Nicorandil did not act as a PCO on neonatal rat islet beta-cells or RINm5F cells, and did not show an inhibitory effect on poly(ADP-ribose) polymerase-1. However, the drug inhibited the production of ROS stimulated by high glucose (22.0 mmol/l) in RINm5F cells.

CONCLUSIONS

These results suggested that nicorandil improves diabetes and rat islet beta-cell damage induced by STZ in vivo and in vitro. It protects islet beta-cells, at least partly, via a radical scavenging effect.

[Extracorporeal shockwave lithotripsy in the treatment of distal ureteral stones larger than 10 mm in diameter]

Optimal treatment for distal ureteral stones remains controversial. During a period of 10 years, from December 1992 to December 2002, 103 distal ureteral stones larger than 10 mm in diameter were treated at our institution with extracorporeal shock wave lithotripsy (ESWL) using the Siemens Lithostar. Only 2 patients had a ureteral stent in place at the time of treatment. The overall stone-free rate was 98% with 1-12 session and 3-month stone-free rate was 95.1%. These data reveal that a high success rate was achieved in multisession ESWL. Therefore, ESWL is considered to be acceptable as first-line therapy for fragmentation of distal ureteral stones larger than 10 mm in diameter.

[Three cases of congenital penile curvature]

Congenital penile curvature is a rare disease. We experienced three cases of congenital penile curvature. Penile curvature was recognized in all cases from adolescence. Induration and cordee were not palpable in the penis of all cases. We performed modified Nesbit method in all cases. Penile curvature, however, recurred in 1 case.

Dual mutations in the AML1 and FLT3 genes are associated with leukemogenesis in acute myeloblastic leukemia of the M0 subtype

Point mutations of the transcription factor AML1 are associated with leukemogenesis in acute myeloblastic leukemia (AML). Internal tandem duplications (ITDs) in the juxtamembrane domain and mutations in the second tyrosine kinase domain of the Fms-like tyrosine kinase 3 (FLT3) gene represent the most frequent genetic alterations in AML. However, such mutations per se appear to be insufficient for leukemic transformation. To evaluate whether both AML1 and FLT3 mutations contribute to leukemogenesis, we analyzed mutations of these genes in AML M0 subtype in whom AML1 mutations were predominantly observed. Of 51 patients, eight showed a mutation in the Runt domain of the AML1 gene: one heterozygous missense mutation with normal function, five heterozygous frameshift mutations and two biallelic nonsense or frameshift mutations, resulting in haploinsufficiency or complete loss of the AML1 activities. On the other hand, a total of 10 of 49 patients examined had the FLT3 mutation. We detected the FLT3 mutation in five of eight (63%) patients with AML1 mutation, whereas five of 41 (12%) without AML1 mutation showed the FLT3 mutation (P=0.0055). These observations suggest that reduced AML1 activities predispose cells to the acquisition of the activating FLT3 mutation as a secondary event leading to full transformation in AML M0.

[Successful trans-stomal operation for multiple urinary stones occurring in the Indiana continent urinary diversion: a case report]

A total cystectomy with the Indiana continent diversion was performed on a 73-year-old man under the diagnosis of invasive bladder cancer in 1992. In 1994 there appeared a few urinary stones in his Indiana continent urinary diversion. Extracorporeal shock wave lithotripsy (ESWL) was successfully performed. In 1999 a few urinary stones recurred and ESWL was performed. Stones could not be discharged because of stricture of the efferent limb, although stones were crushed down into small pieces by repeated ESWL. The number and sizes of stones gradually increased. Dilatation of the stoma followed by a trans-stomal operation was performed and all of the stones except for one were extracted.

Role of COX inhibition in pathogenesis of NSAID-induced small intestinal damage

Nonsteroidal antiinflammatory drugs (NSAIDs) such as indomethacin decrease mucosal PGE(2) production by inhibiting cyclooxygenase (COX) activity and produce damage in the small intestine. The development of intestinal lesions as induced by indomethacin was accompanied by increases in intestinal motility, enterobacterial invasion, and myeloperoxidase (MPO) as well as inducible nitric oxide synthase (iNOS) activity, together with the up-regulation of COX-2 and iNOS mRNA expression. Neither the selective COX-1 inhibitor, SC-560, nor the selective COX-2 inhibitor, rofecoxib, alone caused intestinal damage, but their combined administration produced lesions. SC-560, but not rofecoxib, caused intestinal hypermotility, bacterial invasion and the expression of COX-2 as well as iNOS mRNAs, yet the iNOS and MPO activity was increased only when rofecoxib was administered together with SC-560. Although SC-560 inhibited the PG production, the level of PGE(2) was recovered, in a rofecoxib-dependent manner. The intestinal hypermotility response to indomethacin was prevented by both 16,16-dimethyl PGE(2) and atropine but not ampicillin, yet all these agents inhibited not only the bacterial invasion but also the expression of COX-2 as well as the iNOS activity in the intestinal mucosa following indomethacin treatment, resulting in preventing the intestinal lesions. These results suggest that inhibition of COX-1, despite causing intestinal hypermotility, bacterial invasion and iNOS expression, up-regulates the expression of COX-2, and the PGE(2) derived from COX-2 counteracts deleterious events caused by COX-1 inhibition and maintains the mucosal integrity. These sequences of events explain why intestinal damage occurs when both COX-1 and COX-2 are inhibited.

Cold-specific and light-stimulated expression of a wheat (Triticum aestivum L.) Cor gene Wcor15 encoding a chloroplast-targeted protein

Wcor15, a member of the wheat cold-responsive (Cor) gene family, has been isolated and characterized. The deduced polypeptide WCOR15 (MW=14.7 kDa) showed high homology to the previously identified wheat and barley COR proteins. Southern blot analysis using diploid, tetraploid and hexaploid wheat and diploid Aegilops species showed that the wheat and related wild genomes possessed multiple copies of Wcor15 homologues. Five copies were assigned to the homologous group 2 chromosomes by nulli-tetrasomic analysis. Northern blot analysis showed that expression of Wcor15 was specifically induced by low-temperature. Homologous transcripts accumulated in leaves, and light markedly increased their steady-state levels. Bombardment-mediated transient expression analysis of a chimeric CaMV 35S::Wcor15-GFP construct showed protein-targeting to epidermal guard cell chloroplasts in excised spiderwort leaves. A promoter of Wcor15 contained at least three CRT/DRE-like sequence motifs found in Arabidopsis Cor genes and induced the reporter GUS gene expression in leaves of transgenic tobacco plants under low-temperature and light conditions. These results suggest that the functional Cor gene system involving the CRT/DRE cis-element is conserved in both monocotyledonous and dicotyledonous plants.

Treatment of acute promyelocytic leukemia: strategy toward further increase of cure rate

Acute promyelocytic leukemia (APL) has become a curable disease by all-trans retinoic acid (ATRA)-based induction therapy followed by two or three courses of consolidation chemotherapy. Currently around 90% of newly diagnosed patients with APL achieve complete remission (CR) and over 70% of patients are curable. To further increase the CR and cure rates, detection and diagnosis of this disease at its early stage is very important, hopefully before the appearance of APL-associated coagulopathy. In induction therapy, concomitant chemotherapy is indispensable, except for patients with low initial leukocyte counts. Prophylactic use of intrathecal methotrexate and cytarabine should be done, particularly for patients with hyperleukocytosis. If patients relapse hematologically or even molecularly, arsenic trioxide will be the treatment of choice under careful electrocardiogram monitoring. Am80, liposomal ATRA, gemtuzumab ozogamicin or ATRA in combination with cytotoxic drugs may be used at this stage or later. Allogeneic SCT will be the treatment of choice after patients of age <50 years have relapsed, provided that they have HLA-identical family donors or DNA-identical unrelated donors.

The percentage of myeloperoxidase-positive blast cells is a strong independent prognostic factor in acute myeloid leukemia, even in the patients with normal karyotype

To examine whether the percentage of myeloperoxidase (MPO)-positive blast cells is useful as a prognostic factor for acute myeloid leukemia (AML), cytochemical analysis of MPO was performed in 491 patients who were registered to the Japan Adult Leukemia Study Group-AML92 study. Patients were divided into two using the percentage of MPO-positive blast (high [>or=50%] and low (<50%)). Complete remission rates were 85.4% in the former and 64.1% in the latter (P=0.001). The overall survival (OS) and the disease-free survival (DFS) were significantly better in the high MPO group (48.3 vs 18.7% for OS, and 36.3 vs 20.1% for DFS, P<0.001, respectively). Multivariate analysis showed that both karyotype and the percentage of MPO-positive blast cells were equally important prognostic factors. The high MPO group still showed a better survival even when restricted to the intermediate chromosomal risk group or the patients with normal karyotype (P<0.001). The OS of patients with normal karyotype in the high MPO group was almost equal with that of the favorable chromosomal risk group. The percentage of MPO-positive blast cells is a simple and highly significant prognostic factor for AML patients, and especially useful to stratify patients with normal karyotype.

[A case of spermatic cord tuberculosis]

A 47-year-old man visited our hospital with a complaint of a right intrascrotal mass. The results of a laboratory examination were unremarkable. An ultrasonographic examination of the right scrotum demonstrated a low echoic legion, 2.5 x 1.3 x 0.7 cm in diameter. A right spermatic cord tumor was diagnosed. Right high orchiectomy was performed. Microscopic examination showed a granulomatous lesion with Langhans large cells. Tuberculin skin test was strongly positive. From these findings we diagnosed the patient with tuberculosis in the spermatic cord.