Drugs against metabolic diseases as potential senotherapeutics for aging-related respiratory diseases

Recent advances in aging research have provided novel insights for the development of senotherapy, which utilizes cellular senescence as a therapeutic target. Cellular senescence is involved in the pathogenesis of various chronic diseases, including metabolic and respiratory diseases. Senotherapy is a potential therapeutic strategy for aging-related pathologies. Senotherapy can be classified into senolytics (induce cell death in senescent cells) and senomorphics (ameliorate the adverse effects of senescent cells represented by the senescence-associated secretory phenotype). Although the precise mechanism has not been elucidated, various drugs against metabolic diseases may function as senotherapeutics, which has piqued the interest of the scientific community. Cellular senescence is involved in the pathogenesis of chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF), which are aging-related respiratory diseases. Large-scale observational studies have reported that several drugs, such as metformin and statins, may ameliorate the progression of COPD and IPF. Recent studies have reported that drugs against metabolic diseases may exert a pharmacological effect on aging-related respiratory diseases that can be different from their original effect on metabolic diseases. However, high non-physiological concentrations are needed to determine the efficacy of these drugs under experimental conditions. Inhalation therapy may increase the local concentration of drugs in the lungs without exerting systemic adverse effects. Thus, the clinical application of drugs against metabolic diseases, especially through an inhalation treatment modality, can be a novel therapeutic approach for aging-related respiratory diseases. This review summarizes and discusses accumulating evidence on the mechanisms of aging, as well as on cellular senescence and senotherapeutics, including drugs against metabolic diseases. We propose a developmental strategy for a senotherapeutic approach for aging-related respiratory diseases with a special focus on COPD and IPF.

Involvement of Parkin-mediated mitophagy in the pathogenesis of chronic obstructive pulmonary disease-related sarcopenia

BACKGROUND

Sarcopenia is characterized by the loss of skeletal muscle mass and strength and is associated with poor prognosis in patients with chronic obstructive pulmonary disease (COPD). Cigarette smoke (CS) exposure, a major cause for COPD, induces mitochondrial damage, which has been implicated in sarcopenia pathogenesis. The current study sought to examine the involvement of insufficient Parkin-mediated mitophagy, a mitochondrion-selective autophagy, in the mechanisms by which dysfunctional mitochondria accumulate with excessive reactive oxygen species (ROS) production in the development of COPD-related sarcopenia.

METHODS

The involvement of Parkin-mediated mitophagy was examined using in vitro models of myotube formation, in vivo CS-exposure model using Parkin^-/- mice, and human muscle samples from patients with COPD-related sarcopenia.

RESULTS

Cigarette smoke extract (CSE) induced myotube atrophy with concomitant 30% reduction in Parkin expression levels (P < 0.05). Parkin-mediated mitophagy regulated myotube atrophy by modulating mitochondrial damage and mitochondrial ROS production. Increased mitochondrial ROS was responsible for myotube atrophy by activating Muscle Ring Finger 1 (MuRF-1)-mediated myosin heavy chain (MHC) degradation. Parkin^-/- mice with prolonged CS exposure showed enhanced limb muscle atrophy with a 31.7% reduction in limb muscle weights (P < 0.01) and 2.3 times greater MuRF-1 expression (P < 0.01) compared with wild-type mice with concomitant accumulation of damaged mitochondria and oxidative modifications in 4HNE expression. Patients with COPD-related sarcopenia exhibited significantly reduced Parkin but increased MuRF-1 protein levels (35% lower and 2.5 times greater protein levels compared with control patients, P < 0.01 and P < 0.05, respectively) and damaged mitochondria accumulation demonstrated in muscles. Electric pulse stimulation-induced muscle contraction prevented CSE-induced MHC reduction by maintaining Parkin levels in myotubes.

CONCLUSIONS

Taken together, COPD-related sarcopenia can be attributed to insufficient Parkin-mediated mitophagy and increased mitochondrial ROS causing enhanced muscle atrophy through MuRF-1 activation, which may be at least partly preventable through optimal physical exercise.

Refractory Hemoptysis Caused by Severe Pulmonary Vein Stenosis after Multiple Catheter Ablations

We herein report a 48-year-old man with a history of chronic atrial fibrillation (AF) and repeated hemoptysis after radiofrequency ablation. Contrast tomography showed soft tissue thickening of the left hilar region and left pulmonary vein stenosis. We performed bronchial artery embolization, but the hemoptysis did not disappear, and AF was not controlled. We performed left lung lobectomy and maze procedures since we considered surgical removal necessary as radical treatment. After the surgery, hemoptysis and atrial fibrillation did not recur. Refractory hemoptysis after catheter ablation is rare, but occasionally occurs in patients with severe pulmonary vein stenosis.

Allergic bronchopulmonary aspergillosis in a patient with ankylosing spondylitis treated with adalimumab

We herein report a case of allergic bronchopulmonary aspergillosis (ABPA) that occurred in a man treated with adalimumab for ankylosing spondylitis (AS). A 69-year-old man with a history of ankylosing spondylitis treated by adalimumab, an anti-tumour necrosis factor-α (TNF-α) antibody, developed cough and wheezing. Chest computed tomography showed obstruction of dilated left upper lobe bronchus by high attenuation mucus as well as central bronchiectasis. Both Aspergillus-specific immunoglobulin E (IgE) and Aspergillus precipitating antibody were positive and Aspergillus fumigatus was detected in a sputum culture. According to the new diagnostic criteria, the patient was diagnosed with ABPA. His condition rapidly improved after the withdrawal of adalimumab and initiation of prednisolone and itraconazole. Anti-TNF-α antibody might cause ABPA through both aggravation of the host's T-helper 2 immunological response and anti-fungal response.

Cost-effectiveness of bronchial thermoplasty for severe asthmatic patients in Japan

Bronchial thermoplasty (BT) is an interventional endoscopic treatment for severe bronchial asthma. Some studies have shown the clinical efficacy of this intervention, but its cost-effectiveness is unclear. The aim of this study was to evaluate the cost-effectiveness of BT. We collected data from the medical records of 16 Japanese patients who were treated with BT between February 2015 and April 2017, and compared asthma-related medical expenses between the year preceding and the year following BT. Four patients were Global Initiative for Asthma (GINA) treatment step 4, and 12 were step 5. In 8 patients who had a successful response to BT, the annual asthma-related medical expenses decreased because of a reduction in hospitalization and emergency outpatient visits due to asthma attacks, and termination of the use of biologics. Most patients in the non-responder group had increased asthma-related medical costs postoperatively. The main reason for the increase in medical costs was the add-on treatment of biologics. BT was cost-effective in the responder group. If its effects continue for more than 10 years, BT will be a cost-effective treatment. Medical costs will be reduced if those who respond to BT can be identified prior to commencement of treatment.

Impact of emphysema on sputum culture conversion in male patients with pulmonary tuberculosis: a retrospective analysis

Background

Although cigarette smoking may have a negative impact on the clinical outcome of pulmonary tuberculosis (PTB), few studies have investigated the impact of smoking-associated lung diseases. Emphysema is a major pathological finding of smoking-related lung damage. We aimed to clarify the effect of emphysema on sputum culture conversion rate for Mycobacterium tuberculosis (MTB).

Methods

We retrospectively studied 79 male patients with PTB confirmed by acid-fast bacillus smear and culture at Jikei University Daisan Hospital between January 2015 and December 2018. We investigated the sputum culture conversion rates for MTB after starting standard anti-TB treatment in patients with or without emphysema. Emphysema was defined as Goddard score ≥ 1 based on low attenuation area < − 950 Hounsfield Unit (HU) using computed tomography (CT). We also evaluated the effect on PTB-related CT findings prior to anti-TB treatment.

Results

Mycobacterial median time to culture conversion (TCC) in 38 PTB patients with emphysema was 52.0 days [interquartile range (IQR) 29.0–66.0 days], which was significantly delayed compared with that in 41 patients without emphysema (28.0 days, IQR 14.0–42.0 days) (p < 0.001, log-rank test). Multivariate Cox proportional hazards analysis showed that the following were associated with delayed TCC: emphysema [hazard ratio (HR): 2.43; 95% confidence interval (CI): 1.18–4.97; p = 0.015), cavities (HR: 2.15; 95% CI: 1.83–3.89; p = 0.012) and baseline time to TB detection within 2 weeks (HR: 2.95; 95% CI: 1.64–5.31; p < 0.0001). Cavities and consolidation were more often identified by CT in PTB patients with than without emphysema (71.05% vs 43.90%; p = 0.015, and 84.21% vs 60.98%; p = 0.021, respectively).

Conclusions

This study suggests that emphysema poses an increased risk of delayed TCC in PTB. Emphysema detection by CT might be a useful method for prediction of the duration of PTB treatment required for sputum negative conversion.

Clinical utility of thoracoscopy in elderly tuberculous pleurisy patients under local anesthesia

INTRODUCTION

Diagnosing tuberculous pleurisy is important in Japan because it currently has a moderate tuberculosis prevalence. However, physicians often have difficulty making a diagnosis. It was reported that thoracoscopy under local anesthesia is useful for the diagnosis of tuberculous pleurisy, but there are no reports focusing on elderly patients.

METHODS

In this study, the usefulness of thoracoscopy under local anesthesia was evaluated in elderly patients. Among 170 patients who underwent thoracoscopy under local anesthesia at our hospital during 11 years from January 2008 to December 2018, those aged 75 years or older (n = 75) were investigated retrospectively.

RESULTS

A total of 55 patients underwent thoracoscopy under local anesthesia for detailed examination of pleural effusion of unknown cause. Of these, 18 were diagnosed as tuberculous pleurisy. The median age was 82 years (range: 75-92 years). The diagnosis of tuberculous pleurisy was made in 11 patients in whom Mycobacterium tuberculosis was detected and in four patients whose pathological findings indicated epithelioid granuloma accompanied by caseous necrosis. Clinical diagnosis was made in the remaining three patients based on thoracoscopic findings of the pleural cavity and a high level of adenosine deaminase in pleural fluid. No serious complications attributable to the examination were observed in any patient.

CONCLUSIONS

Thoracoscopy under local anesthesia was useful for the diagnosis of tuberculous pleurisy in elderly patients, with useful information being also obtained for the treatment of tuberculosis.

Three different CT and FGD PET/CT findings of pulmonary involvement in methotrexate-associated lymphoproliferative disease

Lymphoproliferative disease (LPD) is one of the complications of methotrexate (MTX) therapy. In MTX-associated LPD (MTX-LPD), LPD lesions limited to the lungs are rare and show various types of opacity. A 75-year-old woman with rheumatoid arthritis (RA) presented with myalgia. She had been taking MTX for 11 years. Chest computed tomography (CT) scans showed a nodule in the left lower lobe that had grown significantly and a new nodule in the right lower lobe. 18F-fluorodeoxyglucose (FDG)/positron emission tomography (PET)/CT revealed significant FDG uptake in these nodules. Transbronchial biopsy specimen showed diffusely distributed CD20-positive lymphoid cells, and we made a diagnosis of MTX-LPD. All lung lesions disappeared within months after the immediate discontinuation of MTX. We also had two other patients with MTX-LPD lung lesions that had high FDG uptake. FDG PET/CT might be a useful diagnostic tool as it may reflect disease progression and help identify separate lesions.

A case of recurrent hemoptysis caused by pulmonary actinomycosis diagnosed using transbronchial lung biopsy after bronchial artery embolism and a brief review of the literature

A 60-year-old man was admitted to our hospital because of massive hemoptysis with acute respiratory failure. Since six months ago, he noticed gradual worsening of hemoptysis and was transferred to our hospital. Chest computed tomography showed a nodular lesion with cavitation in the left upper lobe and surrounding ground-glass opacification. Initially, a hemostatic agent was administered, but we eventually performed bronchial artery embolization (BAE) by ourselves due to persistent hemoptysis. After achieving good hemostasis with BAE bronchoscopy was performed, which gave a diagnosis of pulmonary actinomycosis on histopathologic examination of the transbronchial biopsy specimen without the need for lung resection.

A case of Aspergillus and Nocardia infections after bronchial thermoplasty

Bronchial thermoplasty (BT) is a bronchoscopic treatment for severe asthma. A 35-year-old woman with uncontrolled severe asthma despite maximal pharmacological treatment underwent BT and started coughing after the first procedure. One month later, during the second BT procedure, there were white ulcerous lesions on the right B9 bronchus. Culture of the bronchial brushing specimen showed Aspergillus fumigatus, for which voriconazole was started for treatment. On the third BT procedure, endobronchial mucus sampling demonstrated Nocardia spp., for which trimethoprim-sulfamethoxazole was given for three months. Seven months after the third BT procedure, no particular endobronchial lesions were found, and no abnormal pathogens were obtained by culture. The resulting bronchial infection in this case may be attributed to the use of systemic steroids, which rendered the patient immunocompromised, and to tissue fragility that was caused by the thermal energy from the BT procedure. Culture of endobronchial mucus should be considered during BT.

Effectiveness of clarithromycin in patients with yellow nail syndrome

BACKGROUND

Yellow nail syndrome (YNS) is a rare disease characterized by the triad of thickened, slow-growing yellow nails, lymphedema, and chronic respiratory manifestations. The cause of YNS is not known; however, it is suggested to be due to a congenital lymph abnormality. Since YNS is accompanied by chronic bronchial infection in more than half of patients, we hypothesized that treatment with clarithromycin (CAM) could be effective. We therefore evaluated the effectiveness of CAM against nail discoloration and respiratory manifestation in patients with YNS.

METHODS

We conducted an observational study involving 5 patients with YNS who were treated at our institution between January 2005 and January 2016. CAM was prescribed for every patient. Patient demographic information, comorbidities, medications, chest radiographs, and clinical data such as nail color were extracted to evaluate clinical outcome.

RESULTS

Mean patient age was 71.6 years, and 2 patients (40%) were male. Four patients had sinusitis, and 2 had rheumatoid arthritis. Regarding respiratory manifestations, 4 patients had sinobronchial syndrome and 2 had pleural effusion. Nail discoloration improved in every patient after CAM treatment. Four patients also experienced improvement in their respiratory manifestations.

CONCLUSIONS

In patients with YNS, the anti-inflammatory activity of macrolides might improve their systemic inflammation. This improvement could help to reduce lymphedema and promote nail growth.

TRIAL REGISTRATION

Ethical approval was provided by the institutional review board of the National Center of Global Health and Medicine (NCGM-G-002143-00), in January 2017. This study is retrospectively registered for UMIN Clinical Trial Registry ( UMIN000028514 ) in August 4th, 2017.

Epidemiology of CTX-M-type extended-spectrum β-lactamase-producing Escherichia coli among older adults

To identify independent predictors for isolation of CTX-M-type extended-spectrum β-lactamase-producing Escherichia coli (CTX-M E coli) in older adults (>65 years old), 87 cases with CTX-M E coli isolation were compared with matched controls without E coli isolation. Institutionalized residence, multiple comorbidities, and urinary catheter were independent predictors of CTX-M E coli among older adults.

Femoral head deformity and severity of acetabular dysplasia of the hip

Patients with acetabular dysplasia commonly undergo peri-acetabular osteotomy after skeletal maturity to reduce the risk of the late development of osteoarthritis. Several studies have suggested that deformity of the femoral head influences the long-term outcome. We radiologically examined 224 hips in 112 patients with acetabular dysplasia and early-stage osteoarthritis. There were 103 women and nine men with a mean age of 37.6 years (18 to 49). A total of 201 hips were placed in the acetabular dysplasia group and 23 in a normal group. The centre–edge angle and acetabular head index were significantly smaller (both p < 0.001), and the acetabular angle, acetabular roof angle and roundness index were significantly greater in the acetabular dysplasia group than those in the normal group (all p < 0.001). There were significant correlations between the roundness index and other parameters. Femoral head shape may be influenced by the severity of the acetabular dysplasia.

Cite this article: Bone Joint J 2013;95-B:1192–6.

COL2A1 Mutation in Spondylometaphyseal Dysplasia Algerian Type

Spondylometaphyseal dysplasia Algerian type (SMD-A) is an autosomal dominant disorder that was first reported in an Algerian family by Kozlowski et al. [Pediatr Radiol 1988;18:221-226]. Kozlowski's group reported a sporadic case in a 12-year-old Polish boy. They proposed SMD-A as a distinctive skeletal dysplasia and also suggested that a case of SMD reported by Schmidt et al. [J Pediatr 1963;63:106-112] might have had the same disorder. Afterwards, however, no additional report has emerged to date. In addition, the question whether SMD-A belongs to type II collagenopathy (a group of disorders due to a heterozygous mutation of COL2A1) has been continuously under debate. Here we report a 7-year-old Japanese boy with a heterozygous missense mutation in COL2A1, 2582G>T (Gly861Val), whose phenotype matched that of SMD-A. Our observation supports the hypothesis that SMD-A is a variant of type II collagenopathy.

Telecytology in Hokkaido Island, Japan: results of primary telecytodiagnosis of routine cases

In 1997, an Internet-based static image telepathology system was built at Sapporo National Hospital, Japan. We can exchange high-resolution microscopical images through a file transfer protocol server and discuss cytological findings and diagnosis on an electronic mailing list. We applied the system to primary telecytodiagnosis. From May 1997 to April 1999 we have made diagnoses of 614 daily cases only by looking at the video monitor images transmitted from the cytotechnologist of Wakkanai Municipal Hospital 300 km distant from Sapporo. The concordance between telecytodiagnosis and glass slide diagnosis was 88.6%. Kappa statistics for cervical smears was 0.919 and that for specimens other than uterine cervix was 0.810. The accuracy of telecytodiagnosis was 91.4%, and was not substantially different from that of the conventional mail-based cytology in a previous year. We had five cases with a severely inappropriate diagnosis in telecytology, all of which however were quickly corrected by follow-up histological or cytological specimens. With the use of an electronic mailing list the participants had quick and sufficient discussions. We conclude that telecytology is very useful for primary cytodiagnosis in regional medicine and that it may raise the accuracy of cytodiagnosis in future, if we make consistent efforts to reflect the benefits of telecytology in daily practices. This is the first report of clinical results of telecytology from Japan.

Are DNA ploidy and epidermal growth factor receptor prognostic factors for untreated ovarian cancer? A prospective study

To identify prognostic factors for untreated ovarian cancer, DNA ploidy, proliferative index (P.I.) and epidermal growth factor receptor (EGFR) expression were analyzed in a prospective series of 40 patients with ovarian cancer and 7 patients with borderline malignant ovarian tumor followed up for 5 years or more (median, 77 months). The frequency of aneuploid cells was 53.8% (21/39) in ovarian cancer and 14.3% (1/7) in borderline malignancy. There was no significant association between DNA ploidy and the clinicopathologic findings, in which aneuploid ovarian cancer was more common among advanced tumors. The S-phase fraction and P.I. value were higher in the patients with aneuploid tumors (p = 0.076). EGFR expression was detected in 76.9% (30/39) of ovarian cancers and 42.9% (3/7) of borderline malignant ovarian tumors, and the mean EGFR level was 5.8 +/- 12.1 (range: 0-49.5) and 28.3 +/- 71.1 (range: 0-189.4) fmol/mg protein, respectively. There was no correlation between EGFR expression and DNA ploidy, P.I., and clinicopathologic findings analyzed. The 5-year survival rate in patients with aneuploid tumors was significantly worse in patients with ovarian cancer (p = 0.0165, log-rank test). No significant relationship was shown between P.I., EGFR expression, and 5-year survival. Cox multivariate analysis showed that DNA ploidy, P.I., and EGFR expression are not associated with the risk of death (p = 0.5917, p = 0.9924, and p = 0.6840, respectively), although clinical stage shows a significant relationship (p = 0.0027). Our data showed that DNA ploidy is significantly related to the prognosis by univariate analysis, but DNA ploidy, P.I., and EGFR expression were not independent prognostic factors for the untreated ovarian cancer.

Hypothalamic-pituitary-thyroidal dysfunctions in anorexia nervosa

There are clinical similarities between anorexia nervosa and hypothyroidism. Circulating levels of T4 and particularly T3 have been reported to be low in this eating disorder. Previous reports have, however, shown normal basal levels of serum TSH with normal or delayed responses to TRH. To assess thyroid function and the hypothalamic-pituitary axis in 21 women with anorexia nervosa, serum levels of free and total thyroid hormones, binding proteins, and TSH employing an extremely sensitive assay (detection limit = 0.02 microU/ml) were measured. Serum T4, free T4, T3, free T3, TSH, TBG and TBPA concentrations were significantly lower and rT3 levels were significantly higher in anorexia nervosa patients than in normal controls. A delayed TSH response to TRH was noted in 66% of patients, hyporesponsiveness was seen in another 24%, and a normal response in only 10%. In 10 anorexia nervosa patients studied after weight gain, T4, T3, free T3, TSH, TBG and TBPA were significantly increased, and rT3 was significantly decreased. No change in mean free T4 levels with weight gain was noted. Other parameters of hypothalamic dysfunction in anorexia nervosa have been reported and the present data suggest that apparent hypothalamic hypothyroidism occurs perhaps as an adaptation to prolonged starvation.

Effect of psychological stress on human growth hormone response to thyrotropin-releasing hormone in normal controls

Human growth hormone (hGH) responses to thyrotropin-releasing hormone (TRH) were investigated in normal subjects under psychological stress. Fifteen subjects (4 men and 11 women), whose ages ranged from 19 to 22 years, were studied. The mirror-drawing test (MDT) was performed to induce psychological stress. Plasma hGH and prolactin (PRL) were determined serially before, during and after the following tests: TRH alone (500 micrograms synthetic TRH i.v. bolus), MDT alone, and TRH with MDT. The changes in hGH concentrations with MDT alone were not significant. The hGH response to TRH alone also showed no remarkable change; however, hGH responses to TRH combined with MDT were significantly higher than the responses to TRH alone. PRL did not respond with MDT alone but responded significantly with the other two tests. Thus there was a divergence in hGH and PRL secretion to TRH and psychological stress. Significant increases in hGH secretion were observed only when TRH and psychological stress were combined as stimuli.

Paradoxical responses of plasma cortisol, adrenocorticotropic hormone and growth hormone to thyrotropin-releasing hormone and luteinizing-hormone-releasing hormone in anorexia nervosa patients

Abnormalities of hypothalamic-pituitary function in patients with anorexia nervosa (AN) have been reported previously. Since atypical responses to thyrotropin-releasing hormone (TRH) and luteinizing-hormone-releasing hormone (LHRH) have been observed in other disease states, hormonal responses to these hypothalamic peptides in 60 otherwise unstressed young women with anorexia nervosa were studied. Sixteen patients demonstrated a growth hormone (GH) response to TRH and 10 showed an increase in GH after LHRH. Five patients had an increase in cortisol after TRH, 2 of whom showed GH response, and 2 patients demonstrated a cortisol response to LHRH, 1 of whom had a GH response. Variable TSH responses to TRH were observed in the study but there was no correlation with the occurrence of GH or cortisol responses. GH responses to TRH and LHRH were typically not seen in the same patients, nor were they predictive of a cortisol response to the same stimulus. These data add to the evidence for an abnormal hypothalamic-pituitary regulation in AN.

[The linkage of the major histocompatibility complex to autoimmune thyroid diseases]

To investigate the association between human leukocyte antigen (HLA) and development of autoimmune thyroid diseases such as Graves' disease (GD), Hashimoto's thyroiditis (HT), and Graves' disease patients with undetectable TSH-binding inhibitor immunoglobulin (TBII-negative GD), HLA typing was done. 1. We previously reported increased frequencies of HLA-A2 and DPB1*0501 in TBII-positive GD patients, 2. significantly increased frequencies of HLA-A2 and DPB4*0101 in patients with HT, 3. more TBII-negative GD patients having both HLA-B46 and DPB1*0202 than those having each allele alone, suggesting that these 2 alleles may play a synergistic role in controlling the susceptibility to TBII-negative GD, and 4. contrarily that the frequencies of DQA1*0102 in HT patients and of DQB1*0501 in GD patients were significantly decreased, suggesting that DQA1*0102 and DQB1*0501 might confer resistance to the development of HT and GD.

[A clinical application of laser scanning cytometer--the significance in the cytology as an additional diagnostic technique]

Laser scanning cytometer (LSC) is a new machine similar to flow cytometer but with advantages for certain clinical and research applications. LSC is a microscope based and measures cells on a slide with the position of each cell on the slide. This new technique of LSC can be utilized on extremely small specimens and enables direct correlation of all of the measured fluorescent parameters with light microscopic cytologic morphology. To date, LSC has been successfully used to perform DNA content analysis of numerous specimen types and automated analysis of fluorescence in situ hybridization specimens. In this report, we describe characteristics of LSC comparison with flow cytometry and a clinical application of LSC focused on DNA content analysis in clinical specimens with pulmonary disorders. LSC provides a number of benefits that may make it more suitable for clinical laboratories than FCM.

Sensitive determination of melatonin by precolumn derivatization and reversed-phase high-performance liquid chromatography

A sensitive determination method for melatonin was developed. Melatonin was derivatized under alkaline conditions in the presence of hydrogen peroxide. The resultant fluorophore was excited at 247 nm and the emission wavelength was 384 nm. The Stokes shift was 137 nm, which was longer than that of melatonin itself (lambda ex 280 nm, lambda em 330 nm). The melatonin derivative was separated by reversed-phase HPLC in about 15 min and the calibration curve was linear from 500 amol to 5 pmol (r > 0.999) with the detection limit of 500 amol (S/N = 5). The sensitivity of this method was about ten times higher than that of previous methods. Both the day-to-day precision and within-day precision were about 5%, and the derivative of melatonin in the aqueous solution was stable for more than 10 days. This method was successfully applied to the determination of melatonin in rat pineal gland.

Iodine-induced hypothyroidism as a result of excessive intake of confectionery made with tangle weed, Kombu, used as a low calorie food during a bulimic period in a patient with anorexia nervosa

A 20-year-old Japanese female anorectic patient developed primary hypothyroidism associated with generalized edema because of excessive daily intake (40 to 50 g) of confectionery made with tangle weed, Kombu, which she substituted to food during bulimic periods; TSH 60.35 mcU/ml, free T3 1.19 pg/ml, and free T4 0.48 ng/dl, and her weight increased by 12 kg to 45 kg over 4 months. After withdrawal of Kombu her thyroid function returned to normal, and her weight decreased by 7 kg to 38 kg along with disappearance of edema. In conclusion, the physician noticed that susceptible anorectic patients may sometime develop hypothyroidism or hyperthyroidism because of excessive iodine intake of sea-weed confectionery as a substitute of high calorie cakes during bulimic period.

[Clinical characteristics and linkage analysis of autosomal recessive form of juvenile parkinsonism(AR-JP)]

We present the clinical characteristics of autosomal recessive form of juvenile parkinsonism(AR-JP) (MIM 600116) and the result of the linkage analysis using 11 markers on the long arm of chromosome 6. We examined 25 patients of 13 Japanese AR-JP families. They showed female predominance, mean age at onset at 24.4 +/- 10.3 years, slow progression, good response to levodopa and frequent occurrence of wearing-off phenomenon and dopa-induced dyskinesia. Compared to Parkinson's disease(PD), the parkinsonian triad(tremor, rigidity and bradykinesia) were mild, but dystonic posture, postural instability and hyperreflexia were more prominent compared to PD. By the linkage analysis, we obtained a strong evidence for linkage of the AR-JP gene to a 17 cM region of chromosome 6q25.2-27 including the Mn-superoxide dismutase gene(SOD2) with a maximal cumulative multipoint lod score of 9.44 at 0.9 cM telomeric to D6S253.

mtDNA polymorphism in East Asian Populations, with special reference to the peopling of Japan

Nucleotide sequences of the major noncoding (D-loop) region of human mtDNA from five East Asian populations including mainland Japanese, Ainu, Ryukyuans, Koreans, and Chinese were analyzed. On the basis of a comparison of 482-bp sequences in 293 East Asians, 207 different sequence types were observed. Of these, 189 were unique to their respective populations, whereas 18 were shared between two or three populations. Among the shared types, eight were found in common between the mainland Japanese and Koreans, which is the largest number in the comparison. The intergenic COII/tRNA(Lys) 9-bp deletion was observed in every East Asian population with varying frequencies. The D-loop sequence variation suggests that the deletion event occurred only once in the ancestry of East Asians. Phylogenetic analysis revealed that East Asian lineages were classified into at least 18 monophyletic clusters, though lineages from the five populations were completely intermingled in the phylogenetic tree. However, we assigned 14 of the 18 clusters for their specificity on the basis of the population from which the maximum number of individuals in each cluster was derived. Of note is the finding that 50% of the mainland Japanese had continental specificity in which Chinese or Koreans were dominant, while < 20% of either Ryukyuans or Ainu possessed continental specificity. Phylogenetic analysis of the entire human population revealed the closest genetic affinity between the mainland Japanese and Koreans. Thus, the results of this study are compatible with the hybridization model on the origin of modern Japanese. It is suggested that approximately 65% of the gene pool in mainland Japanese was derived from the continental gene flow after the Yayoi Age.

Association between the DRB1*08032 histocompatibility antigen and methimazole-induced agranulocytosis in Japanese patients with Graves disease

OBJECTIVE

To determine the association between HLA class II genes and methimazole-induced agranulocytosis in patients with Graves disease.

DESIGN

Case-control study.

SETTING

Kuma Hospital, which specializes in thyroid diseases, in Kobe, Japan.

SUBJECTS

24 patients with Graves disease who had methimazole-induced agranulocytosis diagnosed by peripheral granulocyte counts of less than 0.5 x 10(9)/L, and 68 patients with Graves disease treated with methimazole, who were free from agranulocytosis. Controls were 525 healthy, unrelated Japanese student volunteers at Kyushu University in Japan.

MEASUREMENTS

All HLA class II genes were analyzed for polymorphisms at the DNA level by using the polymerase chain reaction sequence-specific oligonucleotide probes method. The allele frequencies in the agranulocytotic Graves disease group were compared with those in the nonagranulocytotic Graves disease and control groups.

RESULTS

A strong positive association was seen in DRB1*08032 between the agranulocytotic group and both the control and nonagranulocytotic Graves disease groups.

CONCLUSION

The HLA DRB1*08032 allele was strongly associated with susceptibility to methimazole-induced agranulocytosis, suggesting that cellular autoimmunity may be involved in its development.

[A 83 year-old woman with dementia, gait disturbance, and convulsion]

We report a 83 year-old woman with dementia. She was apparently well until December of 1993 when she was 81-year-old. At that time, she was operated or her cataract. Her post operative course was uneventful, however, shortly after her operation, she had an onset of memory loss and abnormal behavior. She showed a fluctuating course in her mental disturbance. In 1995, her dementia worsened with nocturnal agitation. She was admitted to our service on June 12, 1995. She was alert and her blood pressure was 140/100 mmHg. She showed recent memory loss and disorientation to time. Motor wise, she was unable to stand unsupported. Her gait with support showed small steps and a wide base. She was bradykinetic and ataxic in her finger-to-nose and heel-to-knee test, however, no rigidity or tremor was noted. Her MRI showed T2-high signal lesions in both medial thalamic areas, in the right occipital lobe, and in the bilateral cerebral white matters as well as in the basal ganglia. She was discharged for out-patient follow up on July 3, 1995. Four days after the discharge, she showed declining responses to stimuli and she developed dyspnea on July 14, 1995. She was admitted again on the same day. Her body temperature was 38.5 degrees C and moist rales were heard in the left lung field. She appeared drowsy and no verbal response was obtained; no apparent motor palsy was noted. Blood count showed leukocytosis (14,300/ml). Blood gas analysis under 61 of oxygen inhalation through a mask was as follows: pH 7.460, PCO2 39.6 mmHg, PO2 67 mmHg, and HCO3-28.5 mEq/l. Two days after admission, she developed a convulsion in her left arm and she became unconscious. Her EEG showed periodically recurring lateralized epileptic discharges on the right fronto-central areas. Her subsequent course was complicated by status epilepticus and respiratory distress. She died on July 26, 1995. She was discussed in a neurological CPC. The chief discussant arrived at a conclusion that she suffered from multi-infarct dementia. Bilateral thalamic infarctions were considered to have played a significant role in her dementia. Post-mortem examination revealed subcortical leukoencephalopathy of Binswanger's type and cerebral infarctions in the thalamic and basal ganglia regions and in the right occipital lobe. In addition, she showed isolated angitis of the central nervous system involving mainly in the small arteries located in the superficial areas of the brain and the spinal cord. This patient was interesting in that despite relatively mild leukoaraiosis in MRI, post-mortem examination revealed profound pathologic changes in the subcortical white matters. In addition, she showed the isolated angitis of the CNS. The cause and the clinical correlates of her angitis were unclear.

Graves'disease after the onset of panic disorder

BACKGROUND

It is still unknown whether anxiety disorders observed in Graves' disease are a consequence of increased thyroid hormone levels or precede the onset of Graves' disease.

METHODS

Two case reports are described.

RESULTS

In 2 patients Graves' disease occurred in the setting of previously established euthyroid panic disorder. The interval between the onset of panic disorder and that of hyperthyroidism was 4 and 5 years, respectively. Antithyroid drug treatment reduced psychiatric symptoms, but only to a partial degree.

CONCLUSION

The findings indicate that panic disorder may not only be a consequence of Graves' disease but may precede its onset and potentially predispose to its development.

The correlation between papillary thyroid carcinoma and lymphocytic infiltration in the thyroid gland

Ninety-five patients with papillary thyroid carcinoma (PTC) who received primary surgical treatment in 1983 at Kuma Hospital and were followed until 1992 were the subjects of this study. Initial therapy was tumor resection for 5 patients, lobectomy for 23 patients, total thyroidectomy with unilateral modified neck dissection for 60 patients, and total thyroidectomy with bilateral modified neck dissection for 7 patients. Clinical stage at diagnosis was as follows. Class I included 28 patients with intrathyroidal disease, class II included 60 patients with positive cervical lymph nodes, and class II included 7 patients with tumor invasion into tissue outside of the thyroid gland. Recurrence of the tumor was evaluated according to lymphocytic infiltration in the thyroid gland. Group A consisted of 36 patients with PTC associated with lymphocytic infiltration, 26 with infiltration surrounding the tumor, 3 with infiltration inside of the tumor, and 7 with both. Group B consisted of the remaining 59 patients with PTC with no lymphocytic infiltration. There were no differences in age, sex, initial tumor size, or initial treatment between groups A and B. Antithyroglobulin antibody and/or antimicrosomal antibody were positive in 16 patients from group A and 4 patients from group B (P < 0.001). Class I included 14 patients from each group, class II included 22 patients from group A and 38 patients from group B, and class III included 7 patients, all from group B. Recurrence of the tumor was found in only 1 group A patient (2.8%), but in 11 patients of group B (18.6%). The percentage of patients free from recurrence over the 10 yr of follow-up in group A was significantly higher than that in group B (by Cox-Mantel test, P < 0.01). The time between initial treatment and recurrence was 2-10 yr. In comparing the clinical stage at the time of initial treatment, recurrence was found in 1 class II patient from group A (4.5%) and in 1 class I (7.1%), 6 class II (15.8%), and 4 class III (57.1%) patients from group B. No patients died during the 10 yr of follow-up. In conclusion, 1) lymphocytic infiltration surrounding the tumor or inside the tumor in PTC might be of use as a means for predicting a favorable prognosis; and 2) class II or class III patients with no lymphocytic infiltration had a high rate of recurrence.

Clinical evaluation of human granulocyte colony-stimulating factor in chemotherapy for ovarian cancer

The clinical evaluation of human granulocyte colony-stimulating factor (G-CSF) in 38 patients treated with chemotherapy for ovarian cancer stage III was investigated among 3 groups. G-CSF was not given in group A (19 courses), was administered from day 5 of chemotherapy in group B (53 courses), and was given when the WBC count decreased to below 2,000/mm3 in group C (29 courses). The time to nadir was significantly shorter in group B compared with groups A and C and revealed 10 days for the WBC count and 11 days for the neutrophil count (p <0.01), with mean nadir values of 2,896/mm3 and 982/mm3 respectively, and so the count of WBC and neutrophil have been kept during the course. The effect of G-CSF was not modified by age, body weight or the number of chemotherapy courses in groups B and C. These results demonstrate that early treatment with G-CSF may allow increased intensity of chemotherapy by using greater doses or by shortening of the interval between cycles.

A study of untreated Graves' patients with undetectable TSH binding inhibitor immunoglobulins and the effect of anti-thyroid drugs

OBJECTIVE

We previously reported the clinical characteristics of Graves' disease with undetectable TSH binding inhibitor immunoglobulins (TBII) at first visit, but a study of the prognosis of untreated TBII negative patients with anti-thyroid drug medication has never been undertaken. The aim of this paper is to study the difference between negative and positive TBII Graves' disease in relation to the effect of anti-thyroid drug treatment.

PATIENTS

From January 1986 to April 1991, 1545 patients with untreated Graves' disease were referred to Kuma Hospital, Kobe, Japan. Of these, 94 TRAb negative patients were identified. Another 83 TRAb positive patients were randomly selected from the other Graves' disease patients and served as a comparison group. Fifty-six of the 94 patients in the TBII negative group and 52 of the 83 patients in the TBII positive group completed treatment with methimazole only.

MEASUREMENTS

The trial was conducted as a retrospective study with a maximum treatment period of 36 months and a follow-up period of a further 12 months. From the original pool of patients, we classified 56 TBII negative patients into two groups according to the clinical course taken; Group A in whom TBII remained undetectable throughout methimazole treatment (9 men and 34 women, age 37.2 +/- 2.2 years), and Group B who became TBII positive (4 men and 9 women, 31.2 +/- 4.4 years). Fifty-two TBII positive patients served as the comparison Group C (8 men and 44 women, age 38.1 +/- 2.0 years).

RESULTS

Serum free T4 and free T3 levels in groups A and B were significantly lower before treatment than those of Group C (P < 0.001). The thyroid volumes of Group A and B patients were significantly smaller than those of Group C (P < 0.01). The level of TBII in Groups A and B was significantly lower than that in Group C (8.3 +/- 0.7 and 8.8 +/- 1.1 vs 57.0 +/- 2.8%, respectively, P < 0.001). The level of thyroid stimulating antibody (TSAb) in Groups A and B was significantly lower than that in Group C (478 +/- 71.0 and 761 +/- 140.3 vs 2143 +/- 280%, respectively, P < 0.01), and there were no significant differences in TSAb activities between Groups A and B. The remission rates in Groups A, B and C were 77.4, 36.4 and 36.5%, respectively. These data indicate that Group A has a good prognosis, but Group B has the same prognosis as Group C.

CONCLUSION

We conclude that patients in whom TSH binding inhibitor immunoglobulins remained negative have a much better prognosis than TSH binding inhibitor immunoglobulins positive patients or those who become TSH binding inhibitor immunoglobulins positive, having been initially negative.

Lack of effect of thyroxine administration on elevated thyroid stimulating hormone receptor antibody levels in treated Graves' disease patients

Increased levels of antibodies to TSH receptors are thought to be a major cause of active Graves' disease or recurrence following therapy. It was recently reported that T4 administration during antithyroid drug treatment for Graves' disease resulted in a significant decrease of TSH receptor antibodies compared to drug therapy alone. It is known that these antibodies may remain elevated long after patients become euthyroid, so a large number of patients whose antibodies remained significantly elevated after 1 year of methimazole therapy were evaluated in the study. A total of 330 Graves' disease patients were treated with methimazole for 1 year. TSH receptor antibody titers remained persistently elevated in 195 patients. Thirty-five randomly selected patients were continued on maintenance doses of methimazole for a second year, and 160 patients were treated with a combination of methimazole and thyroxine for a second year. T4 doses needed ranged from 75-100 micrograms/day to maintain serum-free T4 and free T3 within the normal range. After 6 months of combined therapy, 35 patients were found to have suppressed serum TSH levels. The patients were divided after 18 months into three groups: A, B, and C. Group C, consisting of 35 randomly selected patients (8 males and 27 females) whose ages ranged from 12-62 years and who had been maintained on methimazole alone, served as controls. Group B, whose serum TSH levels were suppressed after 6 months of combined therapy, consisted of 9 males and 26 females whose ages were 15-66 years. Group A, 35 randomly selected patients with normal serum TSH levels after methimazole and thyroxine therapy for 6 months, consisted of 8 males and 27 females whose ages were 10-63 years. TSH receptor antibody titers gradually decreased in all three groups with drug therapy, and there was no significant difference in the titers at corresponding times, i.e. 0, 1.0, 1.5, and 2.0 years. After treatment for 2.0 years, all patients of the three groups were followed for a further 12 months. Rates of recurrence among the above three groups were not significantly different during the observation period. In the present study, T4 administration in combination with antithyroidal drugs had no effect on levels of antibodies to TSH receptors and no effect on rates of recurrence. The reason for the discrepant results in the present study from previous reports is not known.

[A 55-year-old man with prostate cancer, papilledema, and multiple cranial nerve palsies]

We report a 55-year-old man with papilledema and multiple cranial nerve palsies. He was well until 52 years of age when there was an onset of progressive difficulty in initiating urination; he visited the urology service of our hospital where a diagnosis of prostate cancer was made; the cancer was invading the bladder and was metastasizing to lymph nodes and bones. He was treated with oochiectomy and estrogen preparations with some improvement in his symptoms. Two years later, he developed difficulty in urination again, and transurethral resection of the tumor was performed in 1991. In December 1991, he noted tingling and numb sensation in his left face, which had become progressive worse within the next one month, and he developed blepharoptosis and deafness all on the left side. He was admitted to the urology service on February 4, 1992, and a neurological consultation was asked. On physical examination, general findings were unremarkable, except for lymph node enlargements of about 0.5 to 1.0 mm in size in cervical and inguinal regions. On neurologic examination, he was alert with normal mental activities; higher cerebral functions were intact. He had normal vision and visual fields, however, papilledema was present bilaterally; pupils and light reactions were normal. Extraocular muscles were intact on the right side, however, moderate restriction was noted in the left eye in that all the extraocular muscles except for the medial rectus were weak; blepharoptosis was noted on the left; no nystagmus was present. The sensation was diminished in the left face, and left facial paresis of the peripheral type was also noted; the taste sensation was also diminished in the left anterior two thirds of the tongue. He had sensorineural deafness on the left side. The other cranial nerves appeared intact. He walked normally; no weakness or muscle atrophy was noted; muscle tone was normal and no ataxia was observed. Deep reflexes were normally elicited and symmetric; the plantar response was flexor. No meningeal signs were present. Laboratory examination revealed following abnormalities: Hb 7.1 g/dl, platelet 47,000/cmm, WBC3,800/cmm, LDH 950IU/l, PAP232ng/ml (normal less than 1.6), PA2.631ng/ml (normal less than 7.4); a small amount of effusion was noted in the left pleural cavity; cytological examination of the fluid was class V. A cranial CT scan as well as MRI were entirely normal, as was the spinal tap. He was treated with glycerol, however, there was progressive increase in the pleural effusion, and he developed dyspnea; moist rale had become audible in the end of February.(ABSTRACT TRUNCATED AT 400 WORDS)

Insulin response to intravenous glucose in patients with anorexia nervosa showing low insulin response to oral glucose

To investigate the cause of a low insulin secretory response to an oral glucose tolerance test (OGTT) in patients with anorexia nervosa (AN), we performed iv glucose tolerance tests (IVGTT) before and after treatment in 36 anorectic patients who showed low insulin secretion in response to the OGTT. These patients were subdivided into 3 groups by glucose tolerance curves during the OGTT: normal type, blood glucose level peaking 60 min or earlier after oral glucose ingestion; delayed type, blood glucose level peaking 90 min or later after oral glucose; and flat type, peak blood glucose level of 5.56 mmol/L or less after oral glucose. The results showed that the normal and flat type groups had normal glucose and insulin responses to iv glucose. In the delayed type group, in which the longest duration of AN before therapy was found, initial insulin secretion was decreased in response to both oral and iv glucose, indicating diminished pancreatic beta-cell function. After weight gain, this parameter improved significantly in both tests. The rate of glucose disappearance for the IVGTT was lower both before and after weight gain in this subgroup compared to that in normal controls, suggesting insulin resistance. In conclusion, the low insulin response to oral glucose seen in the flat type group may be due to the disturbance of gastrointestinal factors, such as motility. In contrast, the observations suggest that the delayed type group has beta-cell failure corrected by weight gain and has insulin resistance requiring a longer recovery time; these abnormalities are related to the duration of AN.

Severe depression associated with ACTH, PRL, and GH deficiency: a case report

A 68-year-old man was hospitalized in August, 1990 with general malaise, loss of energy, poor appetite and severe depression. He had experienced depressed moods, markedly diminished interest, feelings of worthlessness, diminished ability to think, general malaise and muscle weakness beginning in November, 1989. He was treated for depression at another hospital until his emergent admission to our hospital because of difficulty in walking. Laboratory studies disclosed hyponatremia, low plasma ACTH level (4.2 pmol/L), and a low cortisol level (27.6 nmol/L). Rapid ACTH test elicited an increase in serum cortisol from 75.6 nmol/L to 361.2 nmol/L at 30 min. Ovine corticotropin releasing hormone (CRH) did not stimulate secretion of either ACTH or cortisol. Human growth hormone releasing hormone (GRH) together with thyrotropin releasing hormone (TRH) elicited a normal response of TSH and low responses of GH and PRL. The patient's serum autoantibodies to anterior pituitary cell membranes using GH3 rat pituitary cells and AtT-20 mouse pituitary cells were positive. On the basis of these data, the diagnosis of selective ACTH, GH and PRL deficiency was made and thought to have been caused by lymphocytic adenohypophysitis. Following cortisol replacement therapy, he quickly regained his appetite and was restored to a normal mental state of being.

[A 52-year-old man with sensory aphasia and multiple intracranial masses]

We report a 52-year-old-man who developed aphasia, apraxia and agnosia. He was well until December of 1991 when he noted an onset of skin scaling in the extensor sides of his elbow joints; he was admitted to the dermatology service of our hospital and was diagnosed as having pemphigoid. Treatment with PDN 30 to 60 mg/day and azathioprine 50-100 mg was started. While in the hospital there was a insidious onset of right tinnitus and tingling sensation in his right leg in the middle of March, 1991. During next one week, his family noted that the patient responded incoherently in his speech once in a while. Neurological consult was requested on April 2, 1991. On neurologic examination, he was alert but incoherent in his speech. His spontaneous speech was reduced but it was fluent. However, he had a difficulty in understanding spoken as well as written language. Naming and repetition were also impaired, and he appeared to have Wernicke's aphasia. Ideational apraxia, ideomotor apraxia, constructional apraxia, left-right disorientation, finger agnosia, and body agnosia were noted as well, but he did not have dressing apraxia or spatial disorientation. Right homonymous hemianopsia was present, but any other cranial nerves were not disturbed. He had no weakness or ataxia; gait was normal. Deep reflexes were normal and symmetric. Sensations were intact. Complete blood counts and routine blood chemistries were normal. The lung was clear. Opening pressure at spinal tap of CSF was under a normal pressure; CSF contained 6 lymphocytes/microliters and 78mg/dl of protein; a cytological study showed no malignant cells.(ABSTRACT TRUNCATED AT 250 WORDS)

[A 85-year-old right-handed woman with aphasia and left hemiparesis]

We report a 85-year-old woman who developed speech disturbance and left hemiparesis. She had a gradual onset of gait disturbance 3 years prior to the present admission. Five days before admission, she started to pace up and down in her house; she did not want to take food on the following day, and she developed fever of 39 degrees C; it was also noted that she became mute. On the next day, she developed left hemiparesis; she was still mute but was able to communicate by hand writing to some extent. She was admitted to our service on February 24, 1992. On admission, she was alert but mute; her body temperature was 37.1 degrees C, and her BP 110/70 mmHg. The lungs were clear and general physical examination was unremarkable. Neurologic examination revealed that she did not utter even a word. She was unable to understand examiner's simple questions; communication by hand writing was also difficult, but she could draw her name and a circle; repetition was also impaired. Examination of other higher cerebral functions such as praxis and gnosis was impossible. Her optic fundi were unremarkable; no anisocoria was noted; extraocular muscles appeared intact, and the vestibulo-ocular reflex was normally elicited. The nasolabial fold was shallower on the left; the tongue showed a slight deviation to the left. She had near complete spastic left hemiplegia; deep tendon reflexes were increased bilaterally.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunological findings and thyroid function of untreated Graves' disease patients with undetectable TSH-binding inhibitor immunoglobulin

OBJECTIVE

TSH-binding inhibitory immunoglobulin (TBII) is undetectable in about 10% of untreated Graves' disease patients, but the clinical characteristics and immunological significance of this finding are unknown. In this study we evaluated the clinical characteristics of TBII negative Graves' disease.

PATIENTS

We examined TBII in 1048 untreated patients at Kuma hospital from 1986 to 1990 and found 69 TBII undetectable patients (12 men and 57 women, mean age +/- SEM 35 +/- 2 years, group A).

MEASUREMENTS

We compared the clinical characteristics and immunological findings of group A with 57 untreated TBII detectable Graves' patients who were selected randomly (11 men and 46 women, mean age +/- SEM 40 +/- 2 years, group B). T4, TSH, FT4, FT3, 123I thyroid uptake, TBII, thyroid stimulating antibodies (TSAb) and the volume of the thyroid using ultrasonography were measured at the first visit.

RESULTS

Serum T4, FT4 and FT3 levels in group A were significantly lower than those in group B (P < 0.001). The values of TSAb in group A were significantly lower than those in group B (593 +/- 67 (mean +/- SE) vs 2143 +/- 280%, respectively, P < 0.001). The 123I thyroid uptake in group A was significantly lower than that in group B (53.1 +/- 1.1 vs 61.4 +/- 1.4%, respectively, P < 0.01). The thyroid volume in group A was significantly smaller than that in group B (39.1 +/- 3.0 vs 51.3 +/- 3.3 ml, respectively, P < 0.01). TSAb was undetectable in about 10% (6) of the TBII negative untreated Graves' patients at their first visit.

CONCLUSION

In the present study, untreated TBII negative patients with Graves' disease were characterized by mild elevation of thyroid hormones, mildly elevated 123I uptake, weak TSAb activities and small goitres. The finding of both TBII and TSAb negative titres in untreated Graves' disease patients was also confirmed.

Resistance to autoimmune thyroid disease is associated with HLA-DQ

Genotypes of DQA1 and DQB1 genes were determined by polymerase chain reaction followed by dot blot hybridization with sequence-specific oligonucleotide probes in 105 patients with goitrous autoimmune thyroiditis (Hashimoto's thyroiditis) and in 67 patients with Graves' disease to investigate whether specific DQ alleles were associated with susceptibility or resistance to autoimmune thyroid diseases. Hashimoto's thyroiditis was found to be negatively associated with DQA1*0102 and DQB1*0602 whereas Graves' disease showed a negative association with DQB1*0501. No strongly positive association with a specific DQ allele was found in either disease. These results suggest that the HLA-DQ gene may be a genetic marker for resistance to autoimmune thyroid diseases.

Treatment of methimazole-induced agranulocytosis using recombinant human granulocyte colony-stimulating factor (rhG-CSF)

Agranulocytosis, although extremely infrequent, is a serious complication of antithyroidal drug therapy in patients with hyperthyroidism. Presently, there is no specific therapy for this life-threatening complication, and recovery time is highly variable. Recently, recombinant human granulocyte colony-stimulating factor (rhG-CSF) was reported to be effective in shortening the recovery time of the neutropenia in patients undergoing chemotherapy. The present study was undertaken to determine the efficacy of rhG-CSF administration in patients with methimazole-induced (MMI) agranulocytosis. Thirty-four patients (7 males and 27 females, ages 16-68 yr) with MMI agranulocytosis were divided into 3 groups: group A (n = 11) was treated with antibiotics only; group B (n = 11) received antibiotics and dexamethasone, 8 mg/day; and group C (n = 12) was treated with antibiotics and im injections of rhG-CSF, 75 micrograms/day. Patients in groups A and B were studied retrospectively. When rhG-CSF became available, patients in group C were studied prospectively. Bone marrow sternal punctures were performed in all group C patients who were then divided into 2 subgroups according to the granulocyte to erythrocyte count ratio (G:E). Group C1 (n = 6) had a G:E ratio of less than 0.5, and group C2 (n = 6) had a ratio of more than or equal to 0.5. Recovery time in all groups was defined as the number of days required for the peripheral granulocyte count to be greater than 1.0 x 10(9)/L. There was no significant difference in recovery time between groups A and B: 10.1 +/- 2.2 and 12.3 +/- 1.9 days (mean +/- SE), respectively. P was not significant; the administration of dexamethasone proved to be ineffective in shortening the time for recovery from peripheral granulocytes. On the other hand, recovery time was significantly shorter in group C (6.8 +/- 1.2 days mean +/- SE) compared with groups A and B (P < 0.05). Group C2 recovered in 2.2 +/- 0.6 days whereas group C1 took much longer, 9.8 +/- 1.3 days (P < 0.001). There was a direct correlation between the G:E ratio and the peripheral leucocyte count, r = 0.806, P < 0.01. Furthermore, rhG-CSF significantly shortened recovery time when the peripheral granulocyte count was greater than 0.1 x 10(9)/L (group C2) compared with patients whose counts were less than 0.1 x 10(9)/L (group C1), 2.2 +/- 0.4 vs. 8.6 +/- 1.3 days, respectively (P < 0.001). These data indicate that administration of steroids is ineffective in shortening the duration of recovery in patients with MMI agranulocytosis.(ABSTRACT TRUNCATED AT 400 WORDS)

Vascular responses to angiotensin II in anorexia nervosa

Anorexia nervosa (AN) patients have a tendency to develop renin-angiotensin-aldosterone (RAA) abnormalities caused by abnormal behaviors expressed over long periods of time. Short-term dietary sodium intake is a known modulator of blood pressure response to infused angiotensin II (A II) in normal subjects. Therefore AN patients and normal gender-matched and age-matched controls were studied for vascular responses to exogenous A II. Untreated AN patients needed significantly greater quantities of exogenous A II to raise diastolic blood pressure (DBP) to over 20 mmHg for 30 min compared with controls (12.1 +/- 0.47 versus 7.6 +/- 0.69 ng/kg/min, p < 0.01). The amount of A II required to raise DBP to over 20 mmHg in AN patients in tests before and after completion of treatment (4.2 +/- 0.33 months later) was significantly different (12.1 +/- 0.47 versus 8.1 +/- 0.25 ng/kg/min, p < 0.01). There was no significant difference between AN patients following treatment and controls. Our results indicate that it requires long time before decreased A II responsiveness caused by chronic sodium depletion normalizes in AN patients.