A family with type A insulin resistance syndrome caused by a novel insulin receptor mutation.

Summary: A 17-year-old boy was referred to our endocrinology clinic for a clinical investigation of hyperinsulinemia. An oral glucose tolerance test showed plasma glucose concentrations in the normal range. However, insulin concentrations were considerably elevated (0 min: 71 µU/mL; 60 min: 953 µU/mL), suggesting severe insulin resistance. An insulin tolerance test confirmed that he had insulin resistance. There was no apparent hormonal or metabolic cause, including obesity. The patient had no outward features of hyperinsulinemia, including acanthosis nigricans or hirsutism. However, his mother and grandfather also had hyperinsulinemia. Genetic testing showed that the patient (proband), his mother, and his grandfather had a novel p.Val1086del heterozygous mutation in exon 17 of the insulin receptor gene (INSR). Although all three family members have the same mutation, their clinical courses have been different. The onset of the mother's diabetes was estimated at 50 years, whereas the grandfather developed diabetes at 77 years. Learning points: Type A insulin resistance syndrome is caused by mutations in the insulin receptor (INSR) gene and results in severe insulin resistance. Genetic evaluation should be considered in adolescents or young adults with dysglycemia when an atypical phenotype, such as severe insulin resistance, or a relevant family history is observed. Clinical courses may differ even if the same genetic mutation is found in a family.

[Laparoscopic Partial Adrenalectomy for Primary Aldosteronism Combined with Cushing's Syndrome : Report of a Case].

A 65-year-old man was referred to our hospital with a chief complaint of hyperglycemia. Computed tomography showed left clear-bordered adrenal mass. The serum aldosterone/renin ratio was elevated, and the low-dose dexamethasone suppression test revealed no suppression of serum cortisol. Adrenal venous samplingdemonstrated excess secretion of cortisol from the left adrenal gland, and excess secretion of aldosterone from bilateral adrenal glands. Laparoscopic left partial adrenalectomy for primary aldosteronism combined with Cushing's syndrome was performed. The result was insulin withdrawal and the reduction of antihypertensive drugs.

[Early relapse after autologous peripheral blood stem cell transplantation in an elderly patient with enteropathy-associated T-cell lymphoma].

A 73-year-old male with melena was admitted to our hospital. Computed tomography (CT) scan revealed the thickening of the jejunal and ileal walls and swelling of the mesenteric lymph nodes. Type II enteropathy-associated T-cell lymphoma (EATL) was diagnosed based on the pathological analysis of the resected specimen. Positron emission tomography and CT scan showed complete remission (CR) after surgery, and he further received CHOP therapy. However, 2 months after the completion of the therapy, the patient's disease relapsed, and he presented with abdominal pain. Ifosfamide, dexamethasone, etoposide, and cytarabine therapy was administered, and the second CR was observed in the patient. Subsequently, the patient was administered high-dose chemotherapy (MCEC) with autologous peripheral blood stem cell transplantation (auto-PBSCT). The treatment was well tolerated. Engraftment was performed on day9, and he was discharged on day17 after auto-PBSCT. However, at 6 months after auto-PBSCT, the second relapse of the disease was observed in the patient. He received salvage therapy; however, the patient died because of disease progression. Because of the dismal prognosis of EATL treated with conventional chemotherapy, the feasibility and efficacy of auto-PBSCT have been investigated. To the best of our knowledge, there is no report on an elderly patient (age >70 years) with EATL who underwent auto-PBSCT. Thus, more data should be collected and analyzed to confirm that this therapy could be a promising treatment option for elderly patients with EATL.

Acute Appendicitis Caused by Previous Endoscopic Submucosal Dissection for an Adenoma Adjacent to the Appendiceal Orifice.

Endoscopic submucosal dissection (ESD) is a groundbreaking treatment for tumors adjacent to the appendiceal orifice that are difficult to remove by conventional endoscopic mucosal resection, and successful cases are increasingly reported. However, little is known about the subsequent complications, especially long-term complications. A female in her early 70s with a 15-mm cecal tumor adjacent to the appendiceal orifice - discovered incidentally during a screening colonoscopy - underwent hybrid ESD of the lesion. We completely resected the tumor, and she was discharged 5 days later with a pathological diagnosis of high-grade tubular adenoma. Ten months postoperatively, she experienced sudden-onset right lower quadrant pain and was diagnosed with acute appendicitis at another hospital. Due to suspicion that her condition was the result of residual tumor, her surgeon performed an emergency laparoscopic cecectomy. The pathological examination of the resected specimen showed thick scarring adjacent to the appendiceal orifice and no residual tumor. The previous ESD was identified as the cause of the scar, and the scar was the only finding to account for the patient's appendicitis. This case is significant because the patient required additional surgery due to a complication of ESD. Further, it indicates that acute appendicitis may be a late complication of submucosal dissection near the appendiceal orifice. As ESD becomes more widely used, it is likely that more cecal tumors will be treated endoscopically. It is important to be aware of the late complications of ESD for these tumors.

SAFB1, an RBMX-binding protein, is a newly identified regulator of hepatic SREBP-1c gene.

Sterol regulatory element-binding protein (SREBP)-1c plays a crucial role in the regulation of lipogenic enzymes in the liver. We previously reported that an X-chromosome-linked RNA binding motif (RBMX) regulates the promoter activity of Srebp-1c. However, still unknown was how it regulates the gene expression. To elucidate this mechanism, we screened the cDNA library from mouse liver by yeast two-hybrid assay using RBMX as bait and identified scaffold attachment factor B1 (SAFB1). Immunoprecipitation assay demonstrated binding of SAFB1 to RBMX. Chromatin immunoprecipitation assay showed binding of both SAFB1 and RBMX to the upstream region of Srebp-1c gene. RNA interference of Safb1 reduced the basal and RBMX-induced Srebp-1c promoter activities, resulting in reduced Srebp-1c gene expression. The effect of SAFB1 overexpression on Srebp-1c promoter was found only in the presence of RBMX. These results indicate a major role for SAFB1 in the activation of Srebp-1c through its interaction with RBMX.

Higher arterial stiffness, greater peripheral vascular resistance and lower blood flow in lower-leg arteries are associated with long-term hyperglycaemia in type 2 diabetic patients with normal ankle-brachial index.

BACKGROUND: Higher arterial stiffness and greater peripheral vascular resistance reduce blood flow in lower-leg arteries and contribute to the development of ischaemic limb in diabetic patients even without peripheral artery occlusive disease. The aim of this study was to clarify whether these vascular parameters are associated with long-term hyperglycaemia in diabetic patients. METHODS: We examined 45 type 2 diabetic patients and 38 age-matched nondiabetic subjects without peripheral artery occlusive disease assessed by ankle-brachial index consecutively admitted to our hospital, and followed them over a 3-year period (3.7 +/- 0.7 years) with no vasodilative medication. Blood flow and resistive index, a measure of peripheral vascular resistance, at the popliteal artery were evaluated using gated two-dimensional cine-mode phase-contrast magnetic resonance imaging. Brachial-ankle pulse wave velocity was measured to assess arterial stiffness. RESULTS: At baseline, consistent with our previous report, diabetic patients showed higher brachial-ankle pulse wave velocity (p < 0.0001) and resistive index (p < 0.0001) and lower flow volume (p = 0.0044) than those of nondiabetic subjects. Stepwise multiple regression analysis revealed that duration of diabetes, mean HbA(1c) during the study, use of renin-angiotensin system inhibitors and change per year in resistive index were identified as significant independent variables predicting change per year in blood flow (r(2) = 0.733, p < 0.0001) in diabetic patients. Mean HbA(1c) during the study was positively correlated with changes per year in brachial-ankle pulse wave velocity (p = 0.00007) and resistive index (p = 0.0014) and was negatively correlated with that in blood flow (p < 0.0001) in diabetic patients. CONCLUSIONS: Long-term hyperglycaemia is a major cause of impaired peripheral circulation in lower-leg arteries in diabetic patients without peripheral artery occlusive disease.

Massive pericardial effusion secondary to Hashimoto's disease.

Although relatively rare, hypothyroidism remains a significant cause of moderate to severe pericardial effusion. Pericardial effusion secondary to hypothyroidism does not usually cause symptoms since it tends to regress slowly and ultimately disappear several months after the patient has reverted to the euthyroid state. Thus, hypothyroidism must be ruled out in patients with an unexplained pericardial effusion, both to improve prognosis and to avoid unnecessary pericardiocentesis. Even when they have a massive pericardial effusion, patients should receive the standard treatment for hypothyroidism. We herein describe a 79-year-old woman with a massive pericardial effusion associated with hypothyroidism who showed a good response to standard levothyroxine replacement therapy after 5months.

[Osteoporosis and atherosclerosis].

Many epidemiological studies have shown an association between osteoporosis and vascular calcification or atherosclerotic diseases (coronary heart disease, stroke, peripheral vascular disease) in the elderly or postmenopausal women. These results indicate that osteoporosis and atherosclerosis might be linked by common risk factors or pathological mechanisms. Dyslipidemia has the correlation to both osteoporosis and atherosclerosis. Statins, nitorogen-containing bisphosphonates, and estrogens have the favorable effects on lipid profiles as well as vasculature, or bone mineral density. Thus, these therapeutic approaches might have dual effects on bone and vasculature.

The relationship between NY-ESO-1 mRNA expression and clinicopathological features in non-small cell lung cancer.

Tumor-associated antigens recognized by cellular or humoral effectors of the immune system are potential targets for antigen-specific cancer immunotherapy. NY-ESO-1 is one of the most immunogenic cancer/testis (CT) antigens and emerges as the potential candidate for specific immunotherapy. We studied mRNA expression status of NY-ESO-1 in 63 cases of NSCLCs using the real-time reverse transcription PCR to examine the relationship between its expression and clinicopathological features. NY-ESO-1 expression was present in 20 (32%) of 63 NSCLC cases and significantly increased with the advancement of disease stage in TNM classification (P=0.013), especially related to lymph node metastasis (P=0.020). Moreover, frequency of NY-ESO-1 expression was related to the degree of pathological differentiation (P=0.035). The quantity of NY-ESO-1 expression by real-time RT-PCR was not correlated with any clinicopathological factor. Our results demonstrate that the NY-ESO-1 expression was frequently present in primary NSCLC, especially advanced cases with lymph node metastasis. In addition, the high incidence of NY-ESO-1 expression in NSCLC suggests the possibility of a specific immunotherapy for NSCLC.