Distinct X chromosomal rearrangements in four haemophilia B patients with entire F9 deletion.

INTRODUCTION: Haemophilia B is an X-linked bleeding disorder caused by a coagulation factor IX gene (F9) abnormality. Numerous F9 defects have been identified to date; however, only a few with an entire F9 deletion have been reported in detail. AIM: To elucidate the cause of severe haemophilia B, we investigated the precise X chromosome abnormalities in four Japanese patients who did not show all amplifications in F9-specific PCR. METHODS: We analysed the patient's genomic DNA using Multiplex ligation-dependent probe amplification (MLPA). To assess the extent of any deletions, we further performed mapping PCRs, inverse PCRs or long-range PCRs and direct sequencing analyses of the X chromosome. RESULTS: We detected entire F9 deletions in four haemophilia B patients and identified the precise deleted regions of the X chromosome including F9. Patient 1 had a 149-kb deletion with breakpoints 90-kb upstream and 30-kb downstream from F9. Patients 2 and 3 showed 273-kb and 1.19-Mb deletions respectively. Patient 4 had two deleted regions: a 1663-bp deletion 1.34-Mb upstream from F9 and a 7.2-Mb deletion including F9. These distinct breakpoints found in four different patients suggest that the mechanism of X chromosome deletion may be different between individuals. Non-allelic homologous recombination (NAHR), microhomology-mediated break-induced replication (MMBIR) or fork stalling and template switching (FoSTeS) may occur in respective X chromosomes of the four haemophilia B patients analysed. CONCLUSIONS: We identified diverse X chromosomal rearrangements in four haemophilia B patients, which might be caused by distinct mechanisms of genomic rearrangement.

Phase II trial of S-1 and cisplatin with concurrent radiotherapy for locally advanced non-small-cell lung cancer.

BACKGROUND: To assess the efficacy and safety of S-1 and cisplatin with concurrent thoracic radiation for unresectable stage III non-small-cell lung cancer (NSCLC). METHODS: Eligible patients were 20-74 years old and had histologically or cytologically confirmed NSCLC, a performance status of 0-1, and no prior chemotherapy. Patients were treated with cisplatin (60 mg m(-2) on day 1) and S-1 (orally at 40 mg m(-2) per dose, b.i.d., on days 1-14), with the treatment repeated every 4 weeks for four cycles. Beginning on day 2, a 60-Gy thoracic radiation dose was delivered in 30 fractions. RESULTS: Of 50 patients, 48 were eligible. Partial response was observed in 42 patients (87.5%; 95% CI: 79.1-96.9%). This regimen was well tolerated. Common toxicities included grade 3/4 neutropenia (32%), grade 3/4 leukopenia (32%), grade 3/4 thrombocytopenia (4%), grade 3 febrile neutropenia (6%), grade 3 oesophagitis (10%), and grade 3 pneumonitis (5%). Median progression-free survival was 12.0 months and median overall survival was 33.1 months. The 1- and 2-year survival rates were 89.5 and 56%, respectively. CONCLUSION: This chemotherapy regimen with concomitant radiotherapy is a promising treatment for locally advanced NSCLC because of its high response rates, good survival rates, and mild toxicities.

Bone marrow transplantation from unrelated donors for patients with adult T-cell leukaemia/lymphoma.

Adult T-cell leukaemia/lymphoma (ATLL) is a highly aggressive haematological malignancy. More than 40 cases of ATLL treated by allogeneic bone marrow transplantation (BMT) from sibling donors have been reported, while there have been only a few cases of unrelated BMT for treatment of this disease. We began performing allogeneic BMT from unrelated donors in 1999 to improve the outcome of ATLL patients with no suitable sibling donors. Eight ATLL patients underwent unrelated BMT; five received the conventional conditioning regimen consisting of cyclophosphamide and total body irradiation, while three received a reduced-intensity preparative regimen. Two patients died due to encephalopathy of unknown aetiology on days 10 and 35, and one patient died due to progression of ATLL 25 months after BMT. Five patients are currently alive and disease-free at a median of 20 months after BMT. Proviral human T-lymphotropic virus type-I (HTLV-I) DNA load in peripheral blood mononuclear cells (PBMCs) was assessed in four cases before and after BMT. HTLV-I proviral DNA load was reduced significantly after transplantation. Unrelated BMT is feasible for treatment of ATLL. Further studies in a larger number of cases are required to determine the optimal conditioning regimen and stem cell source.

DNA repair characteristics and skin cancers of xeroderma pigmentosum patients in Japan.

Fifty xeroderma pigmentosum patients in Japan were examined for clinical characteristics and DNA repair of their cells, Skin cancers developed in 22 patients. Most of the patients without skin cancers were children, except for 5 older patients who had intermediate or nearly normal levels of DNA repair in their cells. All patients younger than 10 years old had no or very low activity of unscheduled DNA synthesis after ultraviolet light irradiation. Three genetic complementation groups, A, D, and E, and variants were found. Many Group A patients and no Group C patients characterized Japanese patients, compared with those in Europe and the United States, where Group C patients were most frequent. The high frequency of patients with low DNA repair capacities in their cells may account for the apparent high frequency of xeroderma pigmentosum patients in Japan. Age distribution of the cancer-bearing patients and their DNA repair characteristics suggest that almost all xeroderma pigmentosum patients will develop skin cancers unless their cells have nearly normal levels of DNA repair.

Assessment of the intrapulmonary ventilation-perfusion distribution after the Fontan procedure for complex cardiac anomalies: relation to pulmonary hemodynamics.

In 12 patients who underwent the Fontan procedure for complex cardiac anomalies, lung scanning with xenon-133 was performed to assess the intrapulmonary ventilation-perfusion distribution, and comparison was made with a control group. All data were then analyzed in relation to either pre- or postoperative pulmonary hemodynamic data. In ventilation scans, the intrapulmonary distribution in the right lung was almost normal. In perfusion scans, an abnormal increased upper to lower lobe perfusion ratio greater than the normal value found in the control group was noted in seven patients (58.3%). There was a significant correlation (p less than 0.02) between the upper to lower lobe perfusion ratio and postoperative pulmonary vascular resistance. Furthermore, this perfusion ratio correlated inversely with the preoperative (p less than 0.005) and postoperative (p less than 0.02) right pulmonary artery area index, defined as the ratio of cross-sectional area to the normal value. Of five patients with less than 90% arterial oxygen saturation, four showed an abnormal distribution of pulmonary blood flow greater than the normal perfusion ratio. No patient had evidence of a pulmonary arteriovenous fistula by the echocardiographic contrast study. These results suggest that abnormal distribution of pulmonary blood flow to the upper lung segment may develop in patients after the Fontan procedure, and that insufficient size of the pulmonary artery before operation and the consequent postoperative elevation of pulmonary vascular resistance may be responsible for this perfusion abnormality.

Assessment of severity of cardiac rejection in heterotopic heart transplantation using indium-111 antimyosin and magnetic resonance imaging.

Seven canine donor hearts in which atrial septal defect and tricuspid regurgitation had previously been produced were heterotopically transplanted into the recipients' chest cavities. Indium-111 antimyosin myocardial imaging of the excised heart was performed using a scinticamera. Magnetic resonance imaging was also performed and the T2 relaxation time calculated. Subsequently, these data were correlated with pathological findings, which indicated the degree of rejection. Indium-111 antimyosin uptake was high in moderate and severe rejection, but the T2 relaxation time was prolonged even in mild rejection. Thus indium-111 antimyosin uptake was specific, and the T2 relaxation time was sensitive, for detecting the severity and extent of cardiac rejection. Although ex vivo experimental results have been reported, these new methods allow characterisation and accurate evaluation of myocardial tissue undergoing cardiac rejection.

Prostaglandin D2 release by guinea pig skin during in vitro anaphylaxis induced by antigen and compound 48/80.

The release of prostaglandin D2 (PGD2), prostaglandin E2 (PGE2), and histamine induced by antigen and compound 48/80 was studied using an in vitro model of anaphylaxis in guinea pig skin. Abdominal skin from ovalbumin-sensitized guinea pigs was cut into 0.5-1.0 mm-thick slices which were incubated in Tyrode solution at 37 degrees C with or without either ovalbumin or 48/80. Released PGD2 and PGE2 were measured by radioimmunoassay and gas chromatography-mass spectrometry, respectively. Release of PGD2 was detectable at 2 min after challenge (50 micrograms/ml ovalbumin), reaching a maximum at about 15 min. Histamine release was more rapid, achieving 50% of maximum at about 4 min compared to about 7 min for PGD2. In 11 experiments incubation with ovalbumin (50 micrograms/ml for 10 min) induced a significant 6-fold increase in PGD2 compared to unchallenged controls (399 +/- 53 and 67 +/- 19 ng/g dry weight skin, respectively; mean +/- SEM) and a net 47.2% histamine release. In contrast, a smaller (27%) rise in PGE2 was found. Indomethacin (14 microns) completely suppressed evoked PGD2 and PGE2 synthesis without evident effect on histamine release, suggesting that the release of histamine in this model is not dependent on prostaglandin production. The mast cell degranulating agent compound 48/80 (50 micrograms/ml) released significant amounts of PGD2 (340 +/- 86 ng/g skin compared to 89 +/- 30 ng/g for control skin, n = 5) but had no appreciable effect on PGE2. These results show that guinea pig skin can synthesize significant quantities of PGD2 in anaphylactic reactions. Prostaglandin D2 produced in acute allergic reactions in skin in vivo may contribute to the inflammatory reaction, either directly or in synergism with other mediators.

Long-term coenzyme Q10 therapy for a mitochondrial encephalomyopathy with cytochrome c oxidase deficiency: a 31P NMR study.

For 2 years we administered high doses of coenzyme Q10 (CoQ) to a patient having mitochondrial encephalomyopathy with cytochrome c oxidase deficiency. Abnormal elevation of the serum lactate per pyruvate ratio and the increased concentration of serum lactate plus pyruvate induced by exercise decreased with CoQ treatment. This therapeutic effect continued for 2 years. 31P nuclear magnetic resonance spectroscopy showed acceleration of the postexercise recovery of the ratio of phosphocreatine to inorganic phosphate in muscle during CoQ treatment. These observations support the beneficial effect of CoQ on the impaired mitochondrial oxidative metabolism in muscle. Also, impaired central and peripheral nerve conductivities consistently improved during CoQ treatment. These results indicate that CoQ has clinical value in the long-term management of patients with mitochondrial encephalomyopathies, even though there are clinical limitations to the effects of this therapy.

Acute radiation thyroiditis.

PURPOSE: Radiation-induced thyroid dysfunction is considered a late effect. We prospectively assessed acute reactions of the thyroid to external neck irradiation. METHODS AND MATERIALS: This study included 22 patients in whom the thyroid was incidentally exposed to therapeutic doses of radiation. Thyroid function tests included measurements of serum thyroid stimulating hormone (TSH), free and total triiodothyronine (T3) and thyroxine (T4), thyroglobulin, and antithyroid antibodies. These tests were performed before radiotherapy (baseline values), after approximately 40 Gy had been administrated, 2 weeks after the end of radiotherapy, and 3 and 6 months after the beginning of radiotherapy. RESULTS: Mean serum levels of TSH were 1.53, 0.55, 0.78, 2.14, and 7.57 microU/ml before radiotherapy, after 40 Gy irradiation, 2 weeks after the end of radiotherapy, and 3 and 6 months after radiotherapy, respectively. Thus, levels of TSH exhibited two phases: a significant decrease during radiotherapy (thyrotoxic phase) and an increase after radiotherapy (hypothyroid phase) (baseline vs. 40 Gy: p < 0.0001, baseline vs. 6 months: p = 0.003). Increases of thyroid hormones were subtle during radiotherapy. CONCLUSIONS: We believe that radiation promotes release of excessive amounts of thyroid hormones during radiotherapy owing to suppression of TSH secretion. In addition to the late damage (hypothyroidism), thyrotoxicosis occurs when the thyroid gland receives a therapeutic doses of external radiation.

Diagnostic value of technetium-99m radionuclide angiography for detecting thrombosis in left atrial appendage.

In mitral valve disease, it is important to know whether thrombi are present in the left atrium when deciding upon a course of treatment. The left atrial thrombus usually locates in the left atrial appendage. In most cases of mitral valve disease, the left atrial appendage is clearly demonstrated by radionuclide angiography using 99mTc-labeled red blood cells and it can be speculated that the cases in which left atrial appendage are not demonstrated by RNA have left atrial thrombi. On the basis of this hypothesis, the diagnostic accuracy of radionuclide angiography to detect left atrial thrombi was evaluated retrospectively in 60 patients with mitral valve disease who had undergone surgery. The sensitivity of first-pass and equilibrium radionuclide angiography to detect left atrial thrombi was 83% and 67%, the specificity 79% and 54%, and the accuracy 80% and 57%, respectively. Although there were two false-negative cases in which the left atrial thrombi did not locate in the appendage and 10 false-positive cases in which left atrial appendages were not dilated, the negative predictive value was so high that a clearly demonstrated left atrial appendage can be translated into the absence of left atrial thrombi.

Effects of spontaneous respiration on right and left ventricular function: evaluation by respiratory and ECG gated radionuclide ventriculography.

To clarify the mechanism of inspiratory reduction of left ventricular (LV) stroke volume (SV) during spontaneous respiration, we measured right and left ventricular volume changes from expiration to inspiration using radionuclide ventriculography with respiratory gating technique. In this method, scintigraphic data were acquired in a list mode with ECG R wave triggers and respiratory volume curve derived from respiratory flowmeter. Cardiac cycles occurring during the second halves of inspiratory and expiratory phases were separately selected and used to produce multigated images for the respective phases. Twelve patients with normal LV ejection fraction (EF) (greater than 50%) and right ventricular (RV) EF (greater than 40%) and without pulmonary diseases were studied. LV end-diastolic volume (EDV) decreased during inspiration in all subjects (by 11 +/- 5%), whereas LV end-systolic volume (ESV) was insignificantly changed. Accordingly, LVSV decreased during inspiration in all subjects (by 17 +/- 7%). LVEF decreased from 64 +/- 6% during expiration to 60 +/- 6% during inspiration (p less than 0.001). In contrast to the left ventricle, RVEDV and RVSV increased during inspiration by 13 +/- 11% and 22 +/- 18%, respectively. RVESV did not change significantly. RVEF increased from 48 +/- 6% during expiration to 52 +/- 5% during inspiration (p less than 0.05). These results indicate that inspiratory reduction of LVSV during spontaneous respiration is due to a decrease in LVEDV which may be derived from an increase in RVEDV during inspiration through the mechanism of ventricular interdependence.

Evaluation of effective portal venous flow in chronic liver diseases using echo-Doppler flowmetry combined with per jejunal portal scintigraphy.

Portal circulation changes due to the progression of chronic liver disease and portal venous flow are also affected by pharmacotherapy. Thus, noninvasive measurement of effective portal venous flow (EPVF) is highly desirable. We evaluated EPVF under steady-state conditions using echo-Doppler flowmetry combined with per jejunal portal scintigraphy in 32 patients with chronic liver disease. After introduodenal administration of 37 MBq (1 mCi) of 123I-iodoamphetamine, scintigraphy of the pulmonary and hepatic regions was performed and a portosystemic shunt index (SI) calculated. EPVF was calculated as follows: EPVF = PVFx (1-SI/100). EPVF in chronic hepatitis, compensated cirrhosis and decompensated cirrhosis was 12.0 +/- 1.8 ml/min/kg, 10.3 +/- 1.6 ml/min/kg and 8.0 +/- 2.5 ml/min/kg, respectively. There were significant differences in EPVF between all groups, although PVF was similar in each group. EPVF correlated with liver function tests and was a better indicator of liver function than PVF. Measurement of EPVF may provide useful information in the management of patients with chronic liver disease.

A new apparatus for brain imaging: four-head rotating gamma camera single-photon emission computed tomograph.

The development of a new rotating gamma camera SPECT device for imaging the brain was undertaken with the objective of achieving the highest full volume imaging spatial and temporal resolution performance. For this purpose, four rectangular gamma camera detectors were arranged as close to the head as possible, and united in a block to insure detector head registration and alignment as well as to enable rotation stability at high speeds. Phantom and clinical studies performed demonstrated 42 sequential, 4-mm thick transaxial images acquired in one scan and with sufficient volume to permit the entire cerebrum and cerebellum to be imaged with high sensitivity. The central field of view reconstructed spatial resolution measured 7.0 mm full width of half maximum utilizing the high-resolution collimator, and tomographic images of arbitrary planes including sagittal and coronal demonstrated equally high resolution. The high sensitivity and high speed rotational acquisition capability of the device permits dynamic SPECT studies to be carried out in the analysis of rapidly varying radiotracer concentrations.

Iodine-131-labeled fibronectin: potential agent for imaging atherosclerotic lesion and thrombus.

Fibronectin is known to interact with fibrin, collagen, etc. We have labeled fibronectin with 131I, and measured its accumulation in the deendothelialized lesion in the rabbit aorta to evaluate it as a candidate for imaging atherosclerotic lesions and thrombi. Accumulation of [131I] fibronectin in the deendothelialized lesion was apparent at 48 hr, and increased at 72 hr after injection of the agent. Our results indicate that radiolabeled fibronectin may be a useful tracer for imaging early atherosclerotic lesion and thrombus.

Intraventricular repair of single ventricle associated with transposition of the great arteries.

Intraventricular repair was performed successfully in a 6-year-old body having a ventricle associated with d-loop and d-transposition in situs solitus of the atria and viscera. A spiral Teflon patch was utilized to partition the ventricle. Complete heart block did not result, and the patient is doing well 8 months after the operation. Details of the pre- and postoperative studies, as well as details of the surgical technique, are presented. A review is presented of the operative procedures that have been designed for the correction of a single ventricle associated with transposition of the great arteries and have been reported previously in the literature. The advantages for use of the techniaue employed in the present case are discussed.

Single-exposure dual-energy chest images with computed radiography. Evaluation with simulated pulmonary nodules.

RATIONALE AND OBJECTIVES: Dual-energy subtraction radiography using computed radiography (CR) can aid in the detection of pulmonary abnormalities such as nodules, but the subtracted image requires higher x-ray exposure than usual to reduce quantum mottle. To reduce quantum mottle without increasing x-ray exposure, a new dual-energy subtraction algorithm was investigated that included an edge-adaptive smoothing process and a subtraction process. The signal-to-noise ratio and the image quality of this new subtracted image was significantly superior to that of conventional subtracted images. METHODS: Observer performance of the subtracted digital radiography in detecting simulated pulmonary nodules was compared with original CR images and conventional subtracted digital radiography of 50 patients. RESULTS: A combination of an original CR image and a new subtracted CR image was significantly superior to a single original CR image or a combination of an original CR image and a conventional subtracted CR image (P < .01). DISCUSSION: The single-exposure dual-energy subtraction method is superior to the conventional subtraction method in the detection of pulmonary nodules.

Transthoracic percutaneous ethanol injection into the liver.

RATIONALE AND OBJECTIVES: The feasibility of the new transthoracic approach of percutaneous ethanol injection through the lower lung to the subphrenic region of the liver was evaluated in normal rats. METHODS: Fourteen normal rats received percutaneous ethanol injection. A 22-gauge fine needle was inserted into the liver via the thoracic cage and through the lower lung parenchyma under computed tomographic (CT) guidance. After ethanol (0.1-0.2 mL) was injected, three follow-up CT scans were performed: immediately after, 1 day after, and 1 week after the initial injection. All animals were killed 1 week after injection to evaluate macroscopic changes of the diaphragm and pleura. RESULTS: No major complications were observed. Minor complications were observed in six rats; these included one pneumothorax (7%) and five band-like and streaky shadows (presumably pulmonary hemorrhages) (35%) on the CT scan obtained immediately after the procedure. However, all complications had disappeared spontaneously in the follow-up CT scan obtained 1 day after the procedure. At autopsy, no pleural changes were seen. CONCLUSIONS: This study demonstrates that percutaneous ethanol injection through the lower lung parenchyma is achievable. Although this study was performed only in normal rats, the transthoracic approach can be a complementary method of ultrasound-guided percutaneous ethanol injection for tumors in the subphrenic region of the liver. Further study will be needed in abnormal livers and then in human subjects to verify the safety and efficacy of this procedure.

An image analyzing system for interstitial lung abnormalities in chest radiography. Detection and classification by Laplacian-Gaussian filtering and linear opacity judgment.

RATIONALE AND OBJECTIVES: The effectiveness of a computerized analysis system to detect and characterize interstitial lung abnormalities seen on chest radiographs was evaluated. This method included a process of four-directional Laplacian-Gaussian filtering and a process of linear opacity judgement. For quantitative analysis of interstitial opacities, the radiographic index, which is the percentage of opacity areas in a region of interest, was obtained and evaluated in the images. These opacities represented interstitial lung abnormalities. METHODS: Two regions of interest were selected in each right lung of 50 patients with normal lung parenchyma and 50 patients with diffuse interstitial lung abnormalities, confirmed with high-resolution computed tomography. These regions of interest were processed by our computerized analysis system. RESULTS: Abnormal lungs were well differentiated from normal lungs by the radiographic indices obtained from the images filtered by four-directional Laplacian-Gaussian filters and from those processed by linear opacity judgement. However, honeycomb lesions and other interstitial abnormalities (interstitial changes other than honeycombing) were differentiated from each other only by the radiographic indices obtained from the image processed by linear opacity judgment (P < .05). DISCUSSION: These results indicate that this system is useful for the detection and characterization of interstitial lung abnormalities.

Mechanism of gravity-dependent atelectasis. Analysis by nonradioactive xenon-enhanced dynamic computed tomography.

RATIONALE AND OBJECTIVES: The physiologic mechanism of gravity-dependent atelectasis (GDA), a common finding identified during anesthesia, is not well understood. The purpose of this study was to determine whether an inherent reduction in alveolar volume or a reduction in alveolar ventilation is the more important causative factor for the development of GDA in an experimental animal model. METHODS: After uniform reduction of lung volume in ten rabbits by artificially induced pneumoperitoneum, dynamic inhalation computed tomography (CT) was performed using 50% nonradioactive xenon in oxygen. Time-CT attenuation value curves were fitted to an exponential function, CT value = a - b x e(-kt), and K value, which is proportional to the alveolar ventilation/alveolar volume ratio, was calculated by regression analysis. RESULTS: Gravity-dependent atelectasis occurred only in 5 of 10 rabbits. In this group, K values in the dorsal regions increased before the appearance of GDA. No significant change in K values in the ventral regions was observed. CONCLUSION: One mechanism of GDA may be a preferential reduction in alveolar volume without small airway collapse rather than alveolar volume loss secondary to decreased ventilation.

Artificial ventilation-induced diffuse alveolar damage in rabbits: preliminary study of early detection on expiratory high-resolution computed tomography.

RATIONALE AND OBJECTIVES: To investigate whether expiratory high-resolution computed tomography (HRCT) is more useful than inspiratory HRCT for the detection of early-phase diffuse alveolar damage. METHODS: Eleven anesthetized rabbits were scanned with both inspiratory and expiratory HRCT every 30 minutes during mechanical ventilation. Ten rabbits were killed after the detection of pulmonary abnormalities on both inspiratory and expiratory HRCT. The remaining rabbit was killed when the pulmonary abnormalities appeared only on expiratory HRCT. RESULTS: In four cases (36%), the abnormal findings were detected earlier on expiratory HRCT than on inspiratory HRCT. In seven cases (64%), the abnormalities appeared simultaneously on inspiratory and expiratory HRCT. In all 11 cases, the histopathological changes of areas with abnormal CT findings corresponded to the exudative or proliferative phase of diffuse alveolar damage. CONCLUSIONS: Expiratory HRCT has the potential to detect the abnormalities of diffuse alveolar damage earlier than inspiratory HRCT.