Accuracy, criteria, and clinical significance of visual assessment on diffusion-weighted imaging and apparent diffusion coefficient quantification for diagnosing acute appendicitis

PURPOSE

To assess the accuracy, criteria, and clinical significance of diffusion-weighted imaging (DWI) signal intensity and apparent diffusion coefficient (ADC) quantification for diagnosing acute appendicitis.

METHODS

Fifty-one patients with right lower abdominal pain [uncomplicated appendicitis (n = 25), complicated appendicitis (n = 10), and non-appendicitis (n = 16)] who underwent MR examination were enrolled in this retrospective study. Two radiologists independently measured appendiceal diameter and wall thickness. They assessed whether a wall defect, an abscess, extraluminal air, or an appendicolith was present on axial T2WI; evaluated intensity on DWI using a 5-point scale; and determined the ADC values of the appendix and peri-appendiceal tissue. Statistical analysis was performed to assess imaging findings for the diagnosis of appendicitis and complicated appendicitis. Cut-off values were determined using receiver operating characteristic analysis.

RESULTS

For diagnosing acute appendicitis, the accuracy improved from 78.4% using only T2WI to 86.3% using combined T2WI and DWI for reader 1 and from 82.4 to 86.3% for reader 2. For the appendix, the cut-off ADC values that diagnosed appendicitis were 1.41 × 10^-3 and 1.26 × 10^-3 mm²/s with accuracies of 78.4% and 76.5%, respectively. For the peri-appendiceal tissue, these values of 1.03 × 10^-3 and 0.91 × 10^-3 mm²/s differentiated between uncomplicated and complicated appendicitis with an accuracy of 97.1%.

CONCLUSIONS

Combined DWI and T2WI provided high accuracy for diagnosing appendicitis. The inflamed appendix had lower ADC value than the normal appendix. The peri-appendiceal tissue presenting low ADC value was a notable finding of complicated appendicitis.

A prospective phase II study of combined androgen blockade in patients with androgen receptor-positive metastatic or locally advanced unresectable salivary gland carcinoma

Background

There is no standard first-line chemotherapy for recurrent/metastatic (RM) or unresectable locally advanced (LA) salivary gland carcinoma (SGC).

Patients and methods

We conducted a single institution, open-label, single arm, phase II trial of combined androgen blockade (CAB) for androgen receptor (AR)-positive SGC. Leuprorelin acetate was administered subcutaneously at a dose of 3.75 mg every 4 weeks. Bicalutamide was administered orally at a daily dose of 80 mg. Patients were treated until progressive disease or unacceptable toxicities.

Results

Thirty-six eligible patients were enrolled. Thirty-three patients had RM disease and three patients had LA disease. The pathological diagnoses were salivary duct carcinoma (34 patients, 94%) and adenocarcinoma, NOS (two patients, 6%). The best overall response rate was 41.7% [n = 15, 95% confidence interval (CI), 25.5%-59.2%], the clinical benefit rate was 75.0% (n = 27, 95% CI, 57.8%-87.9%). The median progression-free survival was 8.8 months (95% CI, 6.3-12.3 months) and the median overall survival was 30.5 months (95% CI, 16.8 months to not reached). Additional analyses between treatment outcomes and clinicopathological factors or biomarkers including AR positivity, human epidermal growth factor receptor 2 status, and its complex downstream signaling pathway gene mutations showed no statistically significant differences. Elevated grade 3 liver transaminases and increased serum creatinine were reported in two patients, respectively. Discontinuation of leuprorelin acetate or bicalutamide due to adverse event occurred in one patient.

Conclusion

This study suggests that CAB has equivalent efficacy and less toxicity for patients with AR-positive RM or unresectable LA SGC compared with conventional chemotherapy, which warrants further study.

Clinical Trial Registration

UMIN-CTR (http://www.umin.ac.jp/ctr/index-j.htm), identification number: UMIN000005703.

Factors affecting pancreatic hyperamylasemia in patients undergoing peroral single-balloon enteroscopy

BACKGROUND AND AIM

Acute pancreatitis following balloon-assisted enteroscopy is a rare but serious complication. The causative mechanism is uncertain and prevention strategies are not established. We conducted a retrospective study to clarify the risk factors for pancreatic hyperamylasemia.

METHODS

Eighty-four patients undergoing peroral single-balloon enteroscopy (SBE) were enrolled in this study. Serum pancreatic and salivary amylase levels were measured 2 h after endoscopic examination.

RESULTS

We experienced three patients with post-SBE pancreatitis. Factors predicting pancreatic hyperamylasemia were: (i) elderly patients; (ii) deeper insertion; and (iii) clockwise insertion. In contrast, younger age at examination was a significant factor observed in salivary hyperamylasemia.

CONCLUSIONS

It is important to measure pancreatic amylase and not total amylase after SBE. When carrying out peroral SBE, the distance of insertion should be reduced especially if the scope traces a clockwise loop or the subject is elderly.

[A case report: feasible treatment of adalimumab for Crohn disease during pregnancy]

A 33-year-old woman with Crohn disease complained of diarrhea and hematochezia from the fifth week of her third pregnancy and was hospitalized. Because her CDAI indicated 307.1 points and colonoscopy showed multiple longitudinal ulcers in the distal colon, adalimumab therapy was initiated. The CDAI had decreased to 160.0 points and the colonic ulcers improved by 22 days after beginning the administration of adalimumab. Although adalimumab therapy was continued every 2 weeks during the third trimester, fetus growth was not affected and the woman delivered a healthy child. Adalimumab should be considered as one treatment for Crohn disease during pregnancy.

[A case of anesthetic management using levobupivacaine in epidural anesthesia combined with general anesthesia for thymectomy with thoracoscopy for generalized type myasthenia gravis]

Combined epidural and general anesthesia has become a standard anesthetic method for thymectomy. We employed levobupivacaine for epidural anesthesia combined with general anesthesia using remifentanil and sevoflurane for thymectomy with thoracoscopy for generalized type of myasthenia gravis. After decreasing the high level of antibodies to acethylcholine receptor by plasmapheresis, we could perform a stable and successful anesthetic management without the use of any muscle relaxants for the thymectomy. And a myasthenic crisis did not occur after the procedure. We concluded that levobupivacaine would be one of the appropriate options in epidural anesthesia for thymectomy for myasthenia gravis.

Multicenter study of plasma diafiltration in patients with acute liver failure

Plasma diafiltration (PDF) is a blood purification therapy in which simple plasma exchange (PE) is performed using a selective membrane plasma separator while the dialysate flows outside the hollow fibers. A prospective, multicenter study was undertaken to evaluate the changes in bilirubin, IL-18, and cystatin C, as well as the 28-day and 90-day survival rates, with the use of PDF according to the level of severity as measured by the Model for End-Stage Liver Disease (MELD) score. Twenty-one patients with liver failure were studied: 10 patients had fulminant hepatitis and PDF therapies were performed 28 times; 11 had acute liver failure with the therapy performed 96 times. Levels of total bilirubin, IL-18, and cystatin C decreased significantly after treatment. The 28-day survival rate was 70.0% and that at 90 days was 16.7%. According to the severity of the MELD score, each of the results compared well with the use of Molecular Adsorbent Recirculating System or Prometheus therapy. In conclusion, PDF appears to be one of the most useful blood purification therapies for use in cases of acute liver failure in terms of medical economics and the removal of water-soluble and albumin-bound toxins.

Impact of plasma exchange on pharmacokinetic disposition of micafungin

Change in the pharmacokinetic disposition of an antifungal agent micafungin (MCFG) by 8-hour plasma exchange (PE) with 3200 mL replacement was examined in a stem cell transplant recipient. On pharmacokinetic analysis of the time course of the serum concentrations of MCFG, it was determined that PE shortened the elimination half-life of MCFG from 16.5 hours to 6.3 hours. Total clearance (CL(tot)) was increased from 0.366 L/h to 0.932 L/h by PE. PE-dependent clearance (CL(pe)) accounted for approximately two-thirds of CL(tot), and PE was found to contribute to the removal of nearly 40% of the total body store of MCFG. It was confirmed that a significant amount of MCFG was excluded into apheresed plasma waste. In addition, adsorption of MCFG onto plasma-separating membrane was strongly suggested, because the CL(pe) exceeded the rate of plasma apheresis and MCFG concentrations in apheresed plasma were lower than those in circulating blood collected at the same time. The marked elimination of MCFG during PE can be explained by its low volume of distribution and high affinity for serum proteins. Judging from these findings as well as those of other reports, MCFG can be considered one of the drugs most susceptible to removal by PE. Our findings suggest that an increment in the regular dose of MCFG would be required at the next administration after PE.

Pneumatosis coli with ulcerative colitis as a rare complication of colonoscopy

Pneumatosis coli is a relatively rare condition characterized by the presence of gas in the submucosa or subserosa involving mainly the large intestine and, occasionally, the mesenteric attachments. We experienced two cases of pneumatosis coli with ulcerative colitis after colonoscopy that had different clinical courses. Case 1 showed submucosal pneumatosis coli and portal venous air. The air was resolved 30 h later. Case 2 showed subserosal pneumatosis coli and retropneumoperitoneum. The air was eliminated after 3 weeks. The clinical features of pneumatosis coli may depend on the intramural region of the air. Cases 1 and 2 had different air localization, that is, submucosal and subserosal air, and this seems to reflect the differences in the complications. In Case 1 the air expanded to the portal vein, and took only a short time to resolve. In Case 2, however, the air leaked to the retroperitoneal space and took a long time to resolve. In summary, pneumatosis coli as a complication of colonoscopy presented different features depending on the air location. To our knowledge, this is the first report to reveal the difference of air localization and the complications associated with pneumatosis coli after colonoscopy.

Bone metastasis and poor performance status are prognostic factors for survival of carcinoma of unknown primary site in patients treated with systematic chemotherapy

BACKGROUND

Cancer of unknown primary site (CUP) generally has a poor prognosis, and there is no established standard therapy. There have been no reports of a prognostic model for CUP patients treated with a single regimen of systemic chemotherapy.

METHODS

Univariate and multivariate prognostic factor analysis for overall survival (OS) were conducted retrospectively in 58 consecutive CUP patients treated with carboplatin plus paclitaxel (Taxol) therapy as a first-line treatment.

RESULTS

Univariate prognostic factor analysis revealed baseline performance status (PS) of two or more, low serum albumin level, pleural effusion, bone metastasis, and liver metastasis as adverse prognostic factors. Cox proportional hazards analysis showed that poor PS and bone metastasis had the most powerful adverse impact on survival. We developed a prognostic model using those two variables-a good-risk group (PS 0-1 without bone metastasis) and a poor-risk group (PS > or =2 or bone metastasis). The poor-risk group showed significantly poorer OS than the good-risk group (1 year OS 36.8% versus 67.1%, P = 0.0003).

CONCLUSIONS

Poor PS and bone metastasis were identified as independent adverse prognostic factors in CUP. A simple prognostic model was developed and seems useful for decision making as to whether chemotherapy is indicated for CUP patients.

A surviving case of mitochondrial cardiomyopathy diagnosed from the symptoms of multiple organ dysfunction syndrome

A 49-year-old female cardiomyopathic patient with heart, hepatic, and renal failure and lactic acidosis was transferred to the intensive care unit without a unifying diagnosis. She was of short stature (145 cm tall), had difficulty in hearing, a past history of complete atrioventricular block, and had received a permanent pacemaker. She had been diagnosed and treated as dilated cardiomyopathy by her primary doctor. Treatment in the intensive care unit for 21 days including plasma exchange, continuous hemodiafiltration, artificial ventilation, and administration of catecholamine, carperitide, and a large amount of coenzyme Q10 (210 mg/day) improved the symptoms. Genetic analysis using mitochondrial DNA from leukocytes and sternocleidomastoid muscle revealed a 3243A>G mutation in the mitochondrial tRNA(Leu (UUR)) gene, which is related to mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS). The patient recovered through intensive care and could be discharged from hospital without any sequelae. This case was mitochondrial cardiomyopathy diagnosed from the symptoms of multiple organ dysfunction syndrome. Cardiomyopathy due to the mutation of mitochondrial DNA is not a common disease. However, it should be considered as a possible cause of heart failure.

A case of severe acute pancreatitis treated with CTR-001 direct hemoperfusion for cytokine apheresis

Severe acute pancreatitis is a clinical entity that can develop into multiple organ failure (MOF), and still has a poor prognosis. It is generally agreed that excessive humoral mediators such as pro-inflammatory cytokines play important roles in the pathogenesis of organ failure in patients with severe acute pancreatitis (SAP). Furthermore, it has been reported that continuous hemodiafiltration (CHDF) can remove the excess humoral mediators during the hypercytokinemic state of systemic inflammatory response syndrome (SIRS). We experienced a case of severe acute pancreatitis induced by alcohol abuse, on whom we performed cytokine apheresis. The patient was a 46 year-old male. He received 14 cytokine apheresis procedures, for about 4 hours in each session, using a CTR-001 direct hemoperfusion (DHP) cartridge. His serum levels of pro-inflammatory cytokines such as interleukin-6 (IL-6; 1649.1+/-667.1-1257.1+/-489.4 pg/mL, P=0.013) decreased significantly after the CTR-001 procedures. However tumor necrosis factor-alpha (TNF-alpha) (26.2+/-1.7-24.3+/-1.9 pg/mL, P=0.087), IL-1beta (6.1+/-2.9-3.49+/-1.1 pg/mL, P=0.477), IL-8 (192.5+/-33.4-229.5+/-51.8 pg/mL, P=0.754) and IL-10 (14.4+/-2.7-14.0+/-1.9 pg/mL, P=0.726) did not decrease statistically. Therefore, we conclude that in this case, cytokine apheresis using a CTR-001 cartridge was effective for reducing the pro-inflammatory cytokines during severe acute pancreatitis.

Unusual hypersensitivity to warfarin in a critically ill patient

A patient was admitted to the intensive care unit because of respiratory failure, and warfarin therapy was started at 2 mg/day for the treatment of pulmonary embolism, together with other medications. Despite the low dosage of warfarin, international normalized ratio (INR) was markedly elevated from 1.15 to 11.28 for only 4 days, and bleeding symptoms concurrently developed. Vitamin K2 was infused along with discontinuation of warfarin. One day later, the INR was found to have decreased, and bleeding was also improved. An objective causality assessment indicated a probable relationship between clotting abnormality and warfarin administration, although the degree of elevation of the INR was unusual in the light of the daily warfarin dose and duration of its exposure. Based on the clinical status of the patient, it was suspected that several conditions contributed to the abnormal hypersensitivity to warfarin. Contributory factors probably included pharmacokinetic interactions with co-administrated drugs, vitamin K deficiency caused by decreased dietary intake, reduced gut bacterial production, impaired intestinal absorption and hepatic synthetic capacity, and increased consumption of clotting factors. In view of our experience in the present case, it should be stressed that close monitoring of coagulation capacity is necessary in critically ill patients in order to avoid fatal haemorrhage after initiating warfarin therapy regardless of the dosage.

Cross-sectional imaging in Crohn disease

The role of cross-sectional imaging in the diagnosis of Crohn disease has expanded with recent technologic advances in computed tomography (CT) and magnetic resonance (MR) imaging that allow rapid acquisition of high-resolution images of the intestines. To acquire images of diagnostic quality, administration of a fairly large amount of intraluminal contrast agent prior to examination and scanning with intravenous contrast material injection are necessary. Both CT and MR imaging are reported to have a sensitivity of over 95% for the detection of Crohn disease; however, they may not allow early diagnosis. Colonoscopy and conventional enteroclysis studies are indicated for patients with early-stage disease. At more advanced stages, CT and MR imaging can help identify and characterize pathologically altered bowel segments as well as extraluminal lesions (eg, fistulas, abscesses, fibrofatty proliferation, increased vascularity of the vasa recta, mesenteric lymphadenopathy). These modalities can also clearly depict inflammatory lesion activity and conditions that require elective gastrointestinal surgery, thereby aiding in treatment planning. In the clinical setting, CT is currently the imaging modality of choice at most institutions; however, it is expected that MR imaging will soon play a comparable role. CT or MR imaging should be included in a comprehensive evaluation of patients with Crohn disease, along with conventional imaging and clinical and laboratory tests.

Inflixmab as a possible treatment for the hemorrhagic type of Crohn's disease

Acute lower gastrointestinal bleeding is a rare complication of Crohn's disease (CD). Although anti-tumor necrosis factor-alpha (TNF-alpha, infliximab) therapy has been established for patients with inflammatory and fistulous CD, there has been little evidence on whether infliximab is effective for the hemorrhagic type of CD. We report a case of a 31-year-old man with CD who had recurrent sudden-onset bloody stool. After a second surgery, he visited our hospital because of bloody stool. Infusion of infliximab stopped the bleeding and promoted the healing of ulcers in the ileum and ileocolon anastomosis. We suggest that infliximab therapy should be tried to stop acute gastrointestinal bleeding in CD before there is a surgical emergency.

Pro-inflammatory cytokine-induced matrix metalloproteinase-1 (MMP-1) secretion in human pancreatic periacinar myofibroblasts

Matrix metalloproteinases (MMPs) are the proteases involved in the degradation of the extracellular matrix. MMP-1 is thought to be one of the key enzymes in fibrolysis, a process closely related to tissue remodeling. In the present study, we investigated MMP-1 secretion from human pancreatic periacinar myofibroblasts in response to pro-inflammatory cytokines IL-1beta and TNF-alpha. We also attempted to clarify the intracellular signaling pathways mediating the cytokine-induced MMP-1 secretion. MMP-1 secretion was measured by an enzyme-linked immunosorbent assay. MMP-1 molecules were analyzed by Western blotting. MMP-1 mRNA expression was evaluated by Northern blotting. IL-1l and TNF-alpha stimulated the MMP-1 secretion in a dose- and time-dependent manner. Ninety percent of MMP-1 was secreted as inactive form (pro-MMP-1). The effects of IL-1beta and TNF-alpha were significantly inhibited by PD98059 MEK/ERK inhibitor). In contrast, SB203580 (p38 MAPK inhibitor), GF109203X (PKC inhibitor), and PDTC (NF-kappaB inhibitor) did not alter the MMP-1 secretion induced by IL-1beta and TNF-alpha. These effects were also observed at them RNA level. In conclusion, in human pancreatic periacinar myofibroblasts, MMP-1 secretion was regulated by the pro-inflammatory cytokines via the MEK/ERK cascade. Thus, human pancreatic periacinar myofibroblasts may play an important role in the remodeling of damaged pancreatic tissue in chronic pancreatitis via MMP-1 secretion.

Supplement of a chitosan and ascorbic acid mixture for Crohn's disease: a pilot study

OBJECTIVE

Although the pathogenesis of Crohn's disease remains unclear, dietary fat is thought to exacerbate intestinal inflammation. Chitosan is a water-insoluble dietary fiber, and a chitosan and ascorbic acid mixture has been shown in rats to increase fecal fat excretion without affecting protein digestibility. However, it remains unclear whether a chitosan and ascorbic acid mixture is safe and effective for patients with Crohn's disease. We designed a pilot trial to investigate the tolerability and amount of fat excretion after the oral administration of a chitosan and ascorbic mixture for inactive Crohn's disease.

METHODS

Eleven outpatients were given seven tablets daily of a chitosan and ascorbic mixture (chitosan was given at 1.05 g/d) for 8 wk. Patients did not interrupt their respective therapies for Crohn's disease.

RESULTS

The bowel movements of most patients increased slightly during the study. Nutritional and inflammatory markers in patients did not differ before and after treatment. The chitosan and ascorbic acid mixture significantly increased the fat concentration in the feces during treatment.

CONCLUSIONS

These results indicated that oral administration of a chitosan and ascorbic acid mixture in patients with Crohn's disease is tolerable and increases fecal fat excretion without affecting disease activity.

Dose-finding phase I study of simultaneous weekly infusion with doxorubicin and docetaxel in patients with advanced breast cancer

BACKGROUND

Combination therapy with doxorubicin (DOX) and docetaxel (DOC), given 3 weeks apart, is one of the standard regimens used for treating metastatic breast cancer, but it frequently generates febrile neutropenia. To find a safer regimen with less myelotoxicity and the appropriate dose intensity, we conducted a phase I study of simultaneous weekly infusion with DOX and DOC.

METHODS

Twenty-five patients with advanced breast cancer were treated with an intravenous push-injection of DOX that was immediately followed by a 1-h infusion of DOC. This was repeated every week for at least 6 weeks. The premedication employed was three 4-mg doses of dexamethasone every week. Patients were divided into four groups for which the doses of DOX and DOC were escalated in 5-mg/m2 increments.

RESULTS

In the 18 patients who were treated with DOX 15 or 20 mg/m2 and DOC 25 mg/m2, or lower, the regimen was found to be tolerable, without febrile episodes. The regimen with 20 mg/m2 of DOX and 30 mg/m2 of DOC was the maximum tolerated dose. Other indications of grade 3 toxicity included asthenia in 4% of patients, anorexia in 8%, and vomiting in 8%. Of the 25 patients, 14 had a partial response. The overall response rate was 56% (95% confidence interval [CI], 35% to 77%). The recommended dose for further trial was 20 mg/m2 of DOX and 25 mg/m2 of DOC.

CONCLUSION

Simultaneous weekly infusion with DOX and DOC was feasible, with modest neutropenia and preserved dose intensity. This regimen may be helpful in the management of patients with advanced breast cancer.

Epithelial expression of caveolin-2, but not caveolin-1, is enhanced in the inflamed mucosa of patients with ulcerative colitis

Caveolae are vesicular invaginations of the plasma membrane that act as a scaffold of the assembly of many classes of signaling molecules. Caveolins are the principal structural component of caveolae membranes, and three distinct forms of caveolins have been identified: caveolin-1, caveolin-2, and caveolin-3. In this study, we evaluated the changes in the caveolin-1 and caveolin-2 expression in the inflamed mucosa of patients with IBD. Tissue samples were obtained endoscopically from patients with ulcerative colitis (UC) (n = 18), Crohn's disease (n = 10) and ischemic colitis (n = 8). Normal colorectal tissues were also obtained (n = 15). The caveolin expression was evaluated by standard immunohistochemical procedure. In normal colonic mucosa, caveolin-1 expression was detected in the smooth-muscle cells of the muscularis mucosae and the endothelial cells, but caveolin-2 expression was not detected. In the inflamed mucosa of patients with active UC, caveolin-2 expression was clearly detectable as small scattered foci on the luminal surfaces of epithelial cells, but caveolin-1 expression was similar to that in normal mucosa. Caveolin-2 expression increased in accordance with the disease activity of UC. This enhanced caveolin-2 expression was not detected in active Crohn's disease or ischemic colitis. In conclusion, we demonstrated that the epithelial expression of caveolin-2 is markedly enhanced in the inflamed mucosa of patients with UC. It is likely that the enhanced caveolin-2 expression in patients with UC was associated with the altered signal transductions in the intestinal epithelial cells. Furthermore, our results suggest that there are differences in the phenotypic features of epithelial cells between UC and Crohn's disease.

Chemotherapy with irinotecan (CPT-11), a topoisomerase-I inhibitor, for refractory and relapsed non-Hodgkin's lymphoma

Irinotecan hydrochloride (CPT-11), a DNA topoisomerase-I inhibitor, is now widely used in the treatment of various solid tumors, including colorectal, gastric, breast, lung, and ovarian cancer. Despite the good response shown in the late phase-II study, CPT-11 was not often employed in the treatment of malignant lymphoma, mainly because of severe leukopenia and diarrhea caused by the recommended schedule: 40 mg/m2 of CPT-11 on days 1 to 3, 8 to 10, 15 to 17, then discontinued for at least 2 weeks. In clinical use, administration of CPT-11 had to be ceased on days 15 to 17 in almost all cases, and on days 8 to 10 in a considerable number of patients. Subsequently, a lower dose schedule (less than 40 mg/m2) was developed. Our phase II trial employing a reduced dose of CPT-11 on days 1 and 2, plus ADM on day 3 with 3-week interval in patients with refractory and relapsed NHL showed a fairly good response of relapsed B-cell lymphoma and a substantial response of T-cell lymphoma with acceptable toxicity. The combination of a topoisomerase-I inhibitor (CPT-11) and a topoisomerase-II inhibitor is an interesting concept for the treatment of NHL. Another phase II trial in combination with CPT-11 and other anti-cancer drugs, particularly cisplatin or topoisomerase-II inhibitors, is warranted. A superior salvage chemotherapy regimen could be found in the future by investigating combinations of low-dose CPT-11 and cisplatin or topoisomerase-II inhibitors.

Effects of synthetic serine protease inhibitors on proliferation and collagen synthesis of human pancreatic periacinar fibroblast-like cells

Protease inhibitors are currently used as therapeutic agents for chronic pancreatitis in Japan. We previously reported that human pancreatic periacinar fibroblast-like cells (hPFCs) could be cultured from isolated pancreatic acini, and those are thought to play a crucial role in pancreatic fibrosis correlating with platelet-derived growth factor (PDGF) and transforming growth factor beta1 (TGF-beta1) (Pancreas 1997;14: 373-82). The present study was designed to examine the effects of synthetic serine protease inhibitors (FOY-007 and FOY-305) on proliferation and collagen synthesis of hPFCs under cytokine stimulation. The cell proliferation and collagen synthesis were evaluated using assays of [3H]-thymidine incorporation and procollagen type I c-terminal peptide (PIP), and [14C]-proline incorporation to de novo synthesized collagen, respectively. The cell proliferation stimulated by PDGF was inhibited by the application of FOY-007 dose dependently (1-100 microM) and FOY-305 at 100 microM. FOY-007 attenuated the collagen synthesis and PIP production stimulated by TGF-beta1 dose dependently, but FOY-305 inhibited only PIP production. Both protease inhibitors demonstrated no effect on the proliferation and collagen synthesis of hPFCs when they were not stimulated by PDGF or TGF-beta1. Thus, serine protease inhibitors act on hPFCs to diminish the effects of PDGF on proliferation and the effects of TGF-beta1 on collagen synthesis.

Orexinergic innervation of POMC-containing neurons in the rat arcuate nucleus

A pre-embedding double immunostaining technique was used to study the synaptic relationships between orexin-like immunoreactive axon terminals and preopiomelanocortin (POMC)-like immunoreactive neurons in the rat arcuate nucleus. Most of the synapses were axo-dendritic, while some axo-somatic synapses were also found. Both the axo-somatic and axodendritic synapses were symmetrical. In some cases the presynaptic orexin-like immunoreactive axon terminals contained a few large dense-cored vesicles. The results suggest that the orexinergic axon terminals in the arcuate nucleus may play an important role in the regulation of food intake via synapses through POMC neurons.

[Oral cancer chemotherapy in the clinic]

The present status of oral chemotherapeutic agents and the treatment of cancer were reviewed. Twenty anticancer agents are commercially available in Japan excluding hormonal and BRM agents. Cancers for the outpatient chemotherapy are limited because useful drugs are few for such circumstances. Now new potent agents such as S-1, capecitabine and molecular targeting are available. This kind of chemotherapy is needed for growing number of elderly patients for QOL and medical cost.

Cytokine regulation of chemokine (IL-8, MCP-1, and RANTES) gene expression in human pancreatic periacinar myofibroblasts

BACKGROUND & AIMS

We have previously isolated and characterized human pancreatic periacinar myofibroblasts. In this study, to define the role of these cells in the pathogenesis of acute pancreatitis, we investigated chemokine expression in them.

METHODS

Secretion of chemokines (interleukin [IL]-8, monocyte chemoattractant protein [MCP]-1, RANTES, and MIP [macrophage inflammatory protein]-1alpha) was evaluated by ELISA, Northern blotting, and nuclear run-on assays. The activation of NF-kappaB and NF-IL6 was assessed by an electrophoretic gel mobility shift assay.

RESULTS

IL-8 and MCP-1 secretion was rapidly induced by both IL-1beta and tumor necrosis factor (TNF)-alpha. RANTES secretion was induced more slowly and was induced mainly by TNF-alpha. However, MIP-1alpha secretion was not induced by any stimuli. These responses were also observed at the messenger RNA level, and they were accompanied by an increase in transcriptional rate. The increase in transcriptional activation of chemokine genes correlated with the NF-kappaB and NF-IL6 activation. Furthermore, a blockade of NF-kappaB activation by PDTC and TPCK markedly reduced the IL-1beta- or TNF-alpha-induced chemokine gene expression.

CONCLUSIONS

Chemokine secretion is differentially regulated in pancreatic periacinar myofibroblasts, suggesting a role for these cells in mediating the infiltration and accumulation of inflammatory cells in the pancreas.

Combination chemotherapy with irinotecan and adriamycin for refractory and relapsed non-Hodgkin's lymphoma

Twenty-five patients with relapsed or refractory non-Hodgkin's lymphoma were treated by combination chemotherapy with irinotecan hydrochloride (CPT-11) and adriamycin (ADM): CPT-11, 25 mg/m2 on days 1 and 2; ADM, 40 mg/m2 on day 3. Nine (36%) of twenty-five patients achieved CR. Fairly good responses were seen in relapsed B-cell lymphomas (4 of 8 in diffuse large B-cell lymphoma and 2 of 2 in follicular lymphoma grade 1), and substantial responses in T-cell lymphomas (1 of 4 in peripheral T-cell lymphoma and 2 of 7 in adult T-cell leukemia/lymphoma). Leukopenia was frequent but tolerable, and diarrhea minimal. Combination chemotherapy with a reduced dose CPT-11 and ADM was useful in the treatment of relapsed non-Hodgkin's lymphoma.

[Improvement of quality of life (QOL) and life prolongation by CPT-11 + adriamycin (ADM) therapy: report of 4 cases of non-Hodgkin's lymphoma refractory to conventional chemotherapies]

CPT-11 + ADM therapy (CPT-11 40 mg/body x 2 days; Day 1 & 2, combined with ADM 20 to 60 mg/body x 1 day; Day 3) was given to four patients with relapsed and advanced non-Hodgkin's lymphoma, which was refractory to conventional chemotherapies. The symptoms of the patients at the beginning of CPT-11 + ADM therapy were fever (in two cases), dyspnea due to pleural effusion (in two), severe backache (in one), and jaundice with splenomegaly (in one). Their Karnofsky performance scales were 20 or 30%. Soon after the initiation of CPT-11 + ADM therapy, their clinical conditions improved dramatically, and they obtained a partial remission lasting 3.5 to 9 months. During the period of controlling lymphomas by this therapy, all patients had some time at home for 2 to 8 months. The adverse effects were vomiting, diarrhea, neutropenia and thrombocytopenia, but no lethal infection or hemorrhage was seen. We conclude that CPT-11 + ADM therapy is very useful for improvement of QOL and life prolongation of patients with non-Hodgkin's lymphoma, which is refractory to conventional chemotherapies and is even disseminated.

A blockade of complement activation prevents rapid intestinal ischaemia-reperfusion injury by modulating mucosal mast cell degranulation in rats

We attempted to define the putative role of complement activation in association with mucosal mast cell (MMC) degranulation in the pathogenesis of rapid intestinal ischaemia-reperfusion (I/R) injury. We prepared complement activity-depleted rats by the administration of the anti-complement agent K-76COOH and the serine-protease inhibitor FUT-175. Autoperfused segments of the jejunum were exposed to 60 min of ischaemia, followed by reperfusion for various time periods, and the epithelial permeability was assessed by the 51Cr-EDTA clearance rate. The number of MMC was immunohistochemically assessed. In control rats, the maximal increase in mucosal permeability was achieved by 30-45 min of reperfusion. This increase was significantly attenuated by the administration of either K-76COONa alone or in combination with FUT-175. In contrast, the administration of carboxypeptidase inhibitor (CPI), which prevents the inactivation of complement-derived anaphylatoxins such as C5a, significantly enhanced the increase in I/R-induced mucosal permeability. These findings were confirmed morphologically by light microscopy and scanning electron microscopy. In addition, the I/R-induced mucosal injury was accompanied by a marked decrease in the number of MMC, and administration of K-76COOH significantly inhibited this change. These results indicate that complement activation and the generation of complement-derived anaphylatoxins are key events in I/R-induced mucosal injury. It is likely that intestinal I/R-induced mucosal injury may be partially mediated by MMC activation associated with the complement activation.

Reduced tumorigenicity of human gastric carcinoma cells engineered to produce IL-2 in SCID mice reconstituted with peripheral blood cells from cancer patients

We have examined the validity of a humanized immune system with an animal model to assess cytokine gene therapy for cancer patients. For that purpose, we prepared hematologically-reconstituted severe combined immunodeficiency mice by transferring patient's peripheral blood cells containing CD34+ cells. These animals were inoculated subcutaneously with human gastric cancer lines transduced with cytokine genes. Tumorigenicity of interleukin-2-producing cells was significantly reduced in reconstituted but not in non-reconstituted mice, whereas that of wild-type and interleukin-6 producer cells was not affected irrespective of the reconstitution status. An inability to induce protective immunity in the reconstituted mice, which had rejected interleukin-2-producers, suggested that the effector cells mediating the antitumor response were non-T cells of donor origin. The experimental system presented in this study seems to be a feasible model to investigate applicable cytokines for patients.

Morphological and immunocytochemical identification of periacinar fibroblast-like cells derived from human pancreatic acini

Fibroblast-like cells in the periacinar region may play an important role in periacinar fibrosis. In the present study, we isolated and cultured periacinar fibroblast-like cells (PFCs) derived from human pancreatic acini and examined the characteristics of human PFCs morphologically and immunocytochemically. Immunocytochemical study of human PFCs showed that they were positively stained with antibodies against type I collagen/procollagen, type III collagen/procollagen, fibronectin, prolyl hydroxylase beta sub-unit, type IV collagen, laminin, alpha-smooth muscle actin, vimentin, and nonmuscle myosin. Electron microscopic study showed that human PFCs contained a number of microfilaments, forming dense bodies in the cytoplasm. These results indicated that human PFCs possess characteristics of myofibroblasts. Expression of alpha-smooth muscle actin, a marker of the myofibroblast-like phenotype, was increased with time in culture and was enhanced by treatment with transforming growth factor (TGF)-beta 1. Collagen synthesis in human PFCs was stimulated by TGF-beta 1 and the proliferation of human PFCs was stimulated by platelet-derived growth factor. These findings suggest that PFCs from human pancreas seem to be involved in periacinar fibrosis.

[Two patients with acute promyelocytic leukemia whose relapse was noted by cytodiagnosis of middle ear discharge]

Patient 1 was a 36-year-old male and diagnosed as APL in April 1989, and treated with BHAC-DMP and BHAC-AMP. In January 1990, a diagnosis of exudative otitis media was made, but intractable. In June, left facial paralysis appeared and cytodiagnosis of the discharge from the middle ear confirmed leukemic cells. Otitis media and facial paralysis improved after high dose Ara-C, but developed again 5 months later. The condition improved after high dose Ara-C and irradiation of the temporal bones. In September 1992, he died of recurrence but no aggravation in facial paralysis or otitis media. Patient 2 was a 24-year-old female and diagnosed as APL in July 1989, and treated with BHAC-DMP. In May 1990, exudative otitis media was appeared. In July, recurrence was observed but improved by high dose Ara-C. In October, otitis media was aggravated again, and cytodiagnosis confirmed leukemic cell infiltration. She was treated with high dose Ara-C and irradiation of the temporal bones, then achieved complete remission. Maintenance therapy was continued until August 1992, she has been alive. When exudative otitis media developed during the course of leukemia, cytodiagnosis of the discharge from the middle ear should be performed. High dose Ara-C and irradiation of the temporal bone were effective.

Survey of risk factors for expulsive choroidal hemorrhage: case reports. Substantiation of the risk factors and their incidence

To evaluate the interaction of risk factors for expulsive hemorrhage, we evaluated 3 cases of expulsive hemorrhage and 2 of acute intraoperative choroidal effusion that occurred at the University of Tsukuba Hospital over a 16-year-period and investigated the common findings in these 5 cases. We also selected randomly 500 cataractous cases operated at the University of Tsukuba Hospital and investigated the probabilities of risk factors for expulsive hemorrhage in these control cases. The 5 affected patients exhibited more than four risk factors of expulsive hemorrhage. The probability of more than four risk factors being involved in any cataract operation was approximately 0.33% (0.17 approximately 0.67%; 95% confidence interval). The incidence of expulsive hemorrhage at our hospital was approximately 0.2%, which is similar to the probability rate. Thus, we concluded that the development of expulsive hemorrhage was proved to be related to an accumulation of the risk factors for expulsive hemorrhage.

[Molecular evidence for a single clonal origin in a patient with multiple myeloma and non-Hodgkin's lymphoma]

A 49-year old man was admitted in November 1989, because of anemia, abnormal shadowing on chest X ray and hyperproteinemia. Biclonal gammopathy (IgG kappa + IgA kappa) was shown in serum, and Bence Jones protein in urine. The bone marrow examination showed an increased number of abnormal plasma cells (15.7%) and no evidence of lymphoma, A diagnosis of multiple myeloma (MM) was made. In April 1990, while the patient was treated with the modified M2 regiman, swelling of the right cervical lymph node was observed. Lymph node biopsy revealed that he had non-Hodgkin's Lymphoma (:NHL, diffuse, mixed, B cell type). He was retreated with the CHOP regimen for both disease, but died of respiratory failure in October. 1991. To establish the clonal origin of this case of concominant MM and B-cell NHL, the immunoglobulin gene rearrangements in his lymph node and bone marrow were analyzed. Southern blot analysis with the JH probe and Ck probe showed one common band and one different band in the two samples. Our data suggest that two B-cell malignancies may have arisen from a single B-cell progenitor.

[Change in cross-bridge activation rate constant (Kac) after six-minute walk in patients with heart failure]

Cardiac adrenergic activity is increased in patients with congestive heart failure (CHF) and is excessively increased during mild exercise. Changes in cardiac adrenergic activity were examined in normal individuals and patients with CHF before and after mild exercise using the cross-bridge activation rate constant (Ka), which may represent the adrenergic activity related to the working left ventricular myocardium. Ten normal volunteers and 31 patients with stable CHF underwent echocardiography. The left ventricular ejection fraction (LVEF) was measured in all the CHF patients using left ventriculography or radionuclide cineangiography. The patients were classified into two groups: group 1 with an LVEF > or = 50% (n = 16) and group 2 with an LVEF < 50% (n = 15). The cause of CHF was old myocardial infarction in 25 patients and dilated cardiomyopathy in 6. All subjects exercised by walking for 6 min after resting in the supine position for 30 min. The blood pressure, electrocardiogram, phonocardiogram, and M-mode echocardiogram were recorded simultaneously before and after exercise. The values of Ka and Kac (Ka corrected for the individual heart rate) were calculated from the QS2 interval and the heart rate (HR) as follows: Ka = 3/QS2 interval, and Kac = Ka +0.0249 (66-HR). Before exercise, the HR was significantly higher in group 2, but the Kac value showed no significant difference between all three groups. The increase of HR with exercise (delta HR) and the Kac value after exercise were not significantly different between all three groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Labetalol in hypertension during the third trimester of pregnancy: its antihypertensive effect and pharmacokinetic-dynamic analysis

The hypotensive effect, kinetics, and concentration-response relationship of labetalol, alpha beta- and alpha 1-adrenoceptor blocking drug, were studied in seven women with a moderate-to-severe hypertension (averaged diastolic blood pressure [DBP] of 100 to 120 mm Hg measured during a 1- to 2-day hospitalization period) during the third trimester of pregnancy who received the oral twice-daily doses of 150 to 450 mg. These dosages were individually selected by attaining a therapeutic goal of DBP < or = 100 mm Hg or systolic blood pressure (SBP)/DBP reduction of > 30/15 mm Hg, as compared with the pretreatment value, at any time during the 12-hour dosing interval for a 3- to 5-day dosage escalation period. Labetalol concentrations in plasma were measured by a high-performance liquid chromatography with fluorescence detection, and the plasma drug concentration-response relationship was analyzed by a sigmoidal Emax model. Labetalol decreased significantly (P < 0.05 to 0.01) the pretreatment SBP/DBP (166.3 +/- 5.2/110.3 +/- 3.0 mm Hg, mean +/- SEM) without any recognizable side-effects during the twice-daily dosing period in the mothers. Peaked concentrations occurred at 1 hour postdose in all patients. The elimination half-lives ranged from 4.3 to 6.9 hours, and the apparent oral clearance from 31.9 to 73.3 mL/min/kg. The pharmacodynamic parameters (Emax and EC50) analyzed by the Emax model revealed a 3- to 5-fold interindividual variability. The gestational ages at delivery ranged from 34 to 37 weeks, and the birth weights were < 2000 g in 6 of the 7 neonates. Four neonates developed respiratory distress syndrome after delivery, and one infant died of pulmonary hypoplasia 3 months later. The results indicate that 1) labetalol orally administered in a twice-daily regimen as done in this study is an effective antihypertensive drug in women with hypertension during late pregnancy, and 2) interindividual variability in the kinetic factor (e.g., oral clearance) as well as that in the pharmacodynamic factor (e.g., EC50) appear to be related to the overall variability in the hypotensive responsiveness to the drug. However, whether labetalol and/or hypertension per se would have been related to the fetal outcome remains unanswered from the present study.

Plasma protein binding of disopyramide in pregnant and postpartum women, and in neonates and their mothers

1. The protein binding of disopyramide was measured in plasma obtained from nonpregnant women, pregnant women in the first, second, and third trimesters, matched pairs of mothers and neonates (cord plasma), and 1 month postpartum women (n = 6 or 8 of each). 2. Plasma samples spiked with 0.2-12.0 micrograms ml-1 of the drug were ultrafiltered and the free fractions were measured with a fluorescent polarization immunoassay. 3. The mean (+/- s.d.) percentages of free drug at a total concentration of 3.0 micrograms ml-1 observed in the third trimester (46 +/- 9%) and neonate (79 +/- 5%) groups were greater (P less than 0.05 or 0.01) than that in the non-pregnant group (34 +/- 7%). In contrast, the corresponding value observed in the postpartum group (23 +/- 8%) was less (P less than 0.05) than that in the non-pregnant group. In addition, there was a significant (P less than 0.01) difference in the mean percentage of free drug at 3.0 micrograms ml-1 in plasma from mothers (43 +/- 9%) and neonates (79 +/- 5%). 4. A multiple regression analysis indicated that alpha 1-acid glycoprotein (r = -0.88, P less than 0.01), rather than albumin (r = -0.008), dominated the binding of disopyramide within the therapeutic range of drug concentration. An analysis of the binding parameters of disopyramide suggested that alterations in binding were attributable to changes in the capacity rather than the affinity of binding.(ABSTRACT TRUNCATED AT 250 WORDS)