Recombinant human soluble thrombomodulin and mortality in severe pneumonia patients with sepsis-associated disseminated intravascular coagulation: an observational nationwide study.

BACKGROUND: The association between recombinant human soluble thrombomodulin (rhTM) use and mortality in patients with sepsis-associated disseminated intravascular coagulation (DIC) remains controversial. OBJECTIVES: To examine the hypothesis that rhTM could be effective in the treatment of patients with sepsis-associated DIC following severe pneumonia. METHODS: Propensity score and instrumental variable analyses using a nationwide administrative database, the Japanese Diagnosis Procedure Combination inpatient database, were used. The main outcome was 28-day in-hospital all-cause mortality. RESULTS: Eligible patients (n = 6342) from 936 hospitals were categorized into the rhTM group (n = 1280) or control group (n = 5062). Propensity score matching created a matched cohort of 1140 pairs with and without rhTM. No significant difference in 28-day mortality was documented between the two groups in the unmatched analysis (rhTM vs. control, 37.0%, 474/1280 vs. 36.9%, 1866/5062; odds ratio [OR], 1.00; 95%CI, 0.98-1.03), nor in the propensity-matched analysis (37.6%, 429/1140 vs. 37.0%, 886/1140; OR, 1.01; 95%CI, 0.93-1.10). The logistic regression analysis did not show a significant association between the use of rhTM and 28-day mortality in propensity-matched patients (OR, 1.00; 95%CI, 0.87-1.22). An analysis using the hospital rhTM-prescribing rate as an instrumental variable found that receipt of rhTM was not associated with reduction in mortality at 28 days (risk difference, 0.008; 95% CI, -0.08-0.98). CONCLUSIONS: This large retrospective nationwide study demonstrated that there might be little association between the use of rhTM and mortality in severe pneumonia patients with sepsis-associated DIC. A multinational randomized trial is required to confirm this.

Necrotising soft-tissue infections of the upper limb: risk factors for amputation and death.

Necrotising soft-tissue infections (NSTIs) of the upper limb are uncommon, but potentially life-threatening. We used a national database to investigate the risk factors for amputation of the limb and death. We extracted data from the Japanese Diagnosis Procedure Combination database on 116 patients (79 men and 37 women) who had a NSTI of the upper extremity between 2007 and 2010. The overall in-hospital mortality was 15.5%. Univariate analysis of in-hospital mortality showed that the significant variables were age (p = 0.015), liver dysfunction (p = 0.005), renal dysfunction (P < 0.001), altered consciousness (p = 0.049), and sepsis (p = 0.021). Logistic regression analysis showed that the factors associated with death in hospital were age over 70 years (Odds Ratio (OR) 6.6; 95% confidence interval (CI) 1.5 to 28.2; p = 0.011) and renal dysfunction (OR 15.4; 95% CI 3.8 to 62.8; p < 0.001). Univariate analysis of limb amputation showed that the significant variables were diabetes (p = 0.017) mellitus and sepsis (p = 0.001). Multivariable logistic regression analysis showed that the factors related to limb amputation were sepsis (OR 1.8; 95% CI 1.5 to 24.0; p = 0.013) and diabetes mellitus (OR 1.6; 95% CI 1.1 to 21.1; p = 0.038). For NSTIs of the upper extremity, advanced age and renal dysfunction are both associated with a higher rate of in-hospital mortality. Sepsis and diabetes mellitus are both associated with a higher rate of amputation.

Antithrombin and mortality in severe pneumonia patients with sepsis-associated disseminated intravascular coagulation: an observational nationwide study.

BACKGROUND: The association between antithrombin use and mortality in patients with sepsis-associated disseminated intravascular coagulation (DIC) remains controversial. OBJECTIVES: To examine the hypothesis that antithrombin could be effective in the treatment of patients with sepsis-associated DIC following severe pneumonia. METHODS: Propensity score and instrumental variable analyses were performed by use of a nationwide administrative database, the Japanese Diagnosis Procedure Combination inpatient database. The main outcome was 28-day mortality. RESULTS: Severe pneumonia patients diagnosed with sepsis-associated DIC (n = 9075) were categorized into antithrombin (n = 2663) and control (n = 6412) groups. Propensity score matching created a matched cohort of 2194 pairs of patients with and without antithrombin use. Mortality differences were found between the two groups (antithrombin vs. control: unmatched, 40.8% vs. 45.7%; propensity-matched, 40.6% vs. 44.2%; inverse probability-weighted, 41.1% vs. 45.1%). Multiple logistic regression analyses showed an association between antithrombin use and 28-day mortality (unmatched with propensity score adjusted, adjusted odds ratio [OR] 0.87, 95% confidence interval [CI] 0.78-0.97; propensity-matched, adjusted OR 0.85, 95% CI 0.75-0.97; inverse probability-weighted, adjusted OR 0.85, 95% CI 0.79-0.90). An analysis with the hospital antithrombin-prescribing rate as an instrumental variable showed that receipt of antithrombin was associated with a 9.9% (95% CI 3.5-16.3) reduction in 28-day mortality. CONCLUSIONS: This retrospective, large, nationwide database study demonstrates that antithrombin administration may be associated with reduced 28-day mortality in patients with severe pneumonia and sepsis-associated DIC. A large, multinational randomized trial is required.

Impact of hospital volume on hospital mortality, length of stay and total costs after pancreaticoduodenectomy.

BACKGROUND: High morbidity and mortality rates after pancreaticoduodenectomy (PD) have led to concentration of this surgery in high-volume centres, with improved outcomes. The extent to which better outcomes might be apparent in a healthcare system where the mortality rate is already low is unclear. METHODS: The Japanese Diagnosis Procedure Combination database was used to identify patients undergoing PD between 2007 and 2010. Patient data included age, sex, co-morbidities at admission, type of hospital, type of PD, and the year in which the patient was treated. Hospital volume was defined as the number of PDs performed annually at each hospital, and categorized into quintiles: very low-, low-, medium-, high- and very high-volume groups. The Charlson co-morbidity index was calculated using the International Classification of Diseases, tenth revision, codes of co-morbidities. RESULTS: A total of 10 652 patients who underwent PD in 848 hospitals were identified. The overall in-hospital mortality rate after PD was 3·3 per cent (350 of 10 652), and for the groups ranged from 5·0 per cent for the very low-volume group to 1·4 per cent for the very high-volume group (P < 0·001). Multivariable analysis revealed a significant linear relationship between higher hospital volume and shorter postoperative length of stay compared with the very low-volume group, and between increasing hospital volume and lower total costs. CONCLUSION: A significant relationship exists between increasing hospital volume, lower in-hospital mortality, shorter length of stay and lower costs for patients undergoing PD in Japan. Centralization of PD in this healthcare system is therefore justified.

Effect of rehabilitation on mortality of patients with Guillain-Barre Syndrome: a propensity-matched analysis using nationwide database.

BACKGROUND: Rehabilitation for patients with Guillain-Barre Syndrome (GBS) is recommended as it improves the outcome of neurological deficits. Few studies focused on the effect of rehabilitation on mortality of the patients. AIM: To investigate the effect of rehabilitation on hospital mortality of patients with GBS using the Japanese Diagnosis Procedure Combination (DPC) nationwide administrative claims database. DESIGN: A retrospective observational cohort study. SETTING: Hospitals adopting the Japanese DPC system. POPULATION: Patients hospitalized with a diagnosis of GBS between July 2007 and October 2011. METHODS: Data analyzed included sex, age, Barthel index at admission, use of ventilation, immune therapy, and rehabilitation during hospitalization, comorbidity, hospital volume, type of hospital, and in-hospital death. One-to-one propensity score-matching was used to compare hospital mortality rates within 30- and 90-days after admission in rehabilitation and non-rehabilitation groups. The adjusted odds ratios of rehabilitation to hospital mortality were also estimated. RESULTS: A total of 3835 patients were identified and analyzed. Patients with advancing age, lower Barthel index at admission, comorbidities, ventilation, or immune therapy were more likely to receive rehabilitation during hospitalization. Propensity-matched analysis of 926 pairs showed that the rehabilitation group had lower hospital mortality rates within both 30- and 90-days than the non-rehabilitation group. The adjusted odds ratios of rehabilitation to hospital mortality within 30- and 90-days were 0.14 and 0.23, respectively. CONCLUSION: After matching patients' background, rehabilitation was associated with lower hospital mortality of patients with GBS. CLINICAL REHABILITATION IMPACT: Rehabilitation treatment is essential for patients with GBS to improve their survival.

A novel strategy inducing autophagic cell death in Burkitt's lymphoma cells with anti-CD19-targeted liposomal rapamycin.

Relapsed or refractory Burkitt's lymphoma often has a poor prognosis in spite of intensive chemotherapy that induces apoptotic and/or necrotic death of lymphoma cells. Rapamycin (Rap) brings about autophagy, and could be another treatment. Further, anti-CD19-targeted liposomal delivery may enable Rap to kill lymphoma cells specifically. Rap was encapsulated by anionic liposome and conjugated with anti-CD19 antibody (CD19-GL-Rap) or anti-CD2 antibody (CD2-GL-Rap) as a control. A fluorescent probe Cy5.5 was also liposomized in the same way (CD19 or CD2-GL-Cy5.5) to examine the efficacy of anti-CD19-targeted liposomal delivery into CD19-positive Burkitt's lymphoma cell line, SKW6.4. CD19-GL-Cy5.5 was more effectively uptaken into SKW6.4 cells than CD2-GL-Cy5.5 in vitro. When the cells were inoculated subcutaneously into nonobese diabetic/severe combined immunodeficiency mice, intravenously administered CD19-GL-Cy5.5 made the subcutaneous tumor fluorescent, while CD2-GL-Cy5.5 did not. Further, CD19-GL-Rap had a greater cytocidal effect on not only SKW6.4 cells but also Burkitt's lymphoma cells derived from patients than CD2-GL-Rap in vitro. The specific toxicity of CD19-GL-Rap was cancelled by neutralizing anti-CD19 antibody. The survival period of mice treated with intravenous CD19-GL-Rap was significantly longer than that of mice treated with CD2-GL-Rap after intraperitoneal inoculation of SKW6.4 cells. Anti-CD19-targeted liposomal Rap could be a promising lymphoma cell-specific treatment inducing autophagic cell death.

Body mass index and outcomes following gastrointestinal cancer surgery in Japan.

BACKGROUND: Recent studies in the USA have shown a lower postoperative mortality rate in mildly obese patients, described as the 'obesity paradox'. The results from the relatively obese population in Western countries may not be generalizable to Asian countries, prompting the present study to investigate the relationship between body mass index (BMI) and outcomes after gastrointestinal surgery. METHODS: Patients who underwent gastrectomy or colorectal resection for stage I-III cancer between July and December 2010 were identified from a nationwide inpatient database in Japan. Multivariable logistic regression models for in-hospital mortality and postoperative complications, and a linear regression model for total costs were established, with adjustment for age, sex, co-morbidities, cancer stage and BMI. Restricted cubic spline functions were used to consider potential non-linear associations between BMI and the outcomes. RESULTS: Among 30 765 eligible patients, associations between BMI and the outcomes were U-shaped, with the lowest mortality, morbidity and total costs in patients with a BMI of around 23·0 kg/m(2) . A BMI of 18·5 kg/m(2) was associated with significantly greater mortality (odds ratio (OR) 2·04, 95 per cent confidence interval 1·64 to 2·55), postoperative complications (OR 1·10, 1·03 to 1·18) and total costs (difference €1389, 1139 to 1640) compared with a BMI of 23·0 kg/m(2) . Patients with a BMI exceeding 30·0 kg/m(2) had significantly higher rates of postoperative complications and total costs than those with a BMI of 23·0 kg/m(2) , but no significant association was evident between a BMI of more than 23·0 kg/m(2) and in-hospital death. CONCLUSION: Unlike previous studies in the USA, in the present national Japanese cohort of patients undergoing surgery for gastrointestinal cancer, those who were either underweight or overweight had more postoperative complications and greater perioperative costs than those of normal weight.

The burden of Clostridium difficile-associated disease following digestive tract surgery in Japan.

BACKGROUND: Although surgery is considered a risk for Clostridium difficile-associated disease (CDAD), large-scale data on outcomes of postsurgical CDAD are rare. AIM: Using the Japanese Diagnosis Procedure Combination inpatient database, we analysed factors affecting the occurrence of CDAD and the outcomes of CDAD following digestive tract surgery. METHODS: We identified patients postoperatively diagnosed with CDAD among patients undergoing oesophagectomy, gastrectomy, and colorectal resection for cancer from 2007 to 2010. We performed logistic regression analyses for the occurrence of CDAD and in-hospital mortality, and multiple linear regressions and one-to-one propensity-matched analyses for postoperative length of stay and total costs, with adjustment for patient backgrounds and hospital factors. FINDINGS: Of 143,652 patients undergoing digestive tract surgery, 409 (0.28%) CDAD patients were identified. Higher Charlson comorbidity index, longer preoperative length of stay and non-academic hospitals were significantly associated with higher occurrence of CDAD. In-hospital mortality was higher in the CDAD patients compared with non-CDAD patients [3.4% vs 1.6%; odds ratio: 1.83; 95% confidence interval (CI): 1.07-3.13; P = 0.027]. Attributable postoperative length of stay and total costs related to CDAD were 12.4 days (95% CI: 9.7-15.0; P < 0.001) and US$6,576 (3,753-9,398; P < 0.001) in the linear regressions and 9 days (P < 0.001) and US$6,724 (P < 0.001) in the propensity-matched paired analyses. CONCLUSIONS: High mortality, long hospital stay and high costs were associated with postsurgical CDAD. The results indicate the necessity of further CDAD control measures for patients undergoing digestive tract surgery.

Stromal cells expressing hedgehog-interacting protein regulate the proliferation of myeloid neoplasms.

Aberrant reactivation of hedgehog (Hh) signaling has been described in a wide variety of human cancers including cancer stem cells. However, involvement of the Hh-signaling system in the bone marrow (BM) microenvironment during the development of myeloid neoplasms is unknown. In this study, we assessed the expression of Hh-related genes in primary human CD34(+) cells, CD34(+) blastic cells and BM stromal cells. Both Indian Hh (Ihh) and its signal transducer, smoothened (SMO), were expressed in CD34(+) acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS)-derived cells. However, Ihh expression was relatively low in BM stromal cells. Remarkably, expression of the intrinsic Hh-signaling inhibitor, human Hh-interacting protein (HHIP) in AML/MDS-derived stromal cells was markedly lower than in healthy donor-derived stromal cells. Moreover, HHIP expression levels in BM stromal cells highly correlated with their supporting activity for SMO(+) leukemic cells. Knockdown of HHIP gene in stromal cells increased their supporting activity although control cells marginally supported SMO(+) leukemic cell proliferation. The demethylating agent, 5-aza-2'-deoxycytidine rescued HHIP expression via demethylation of HHIP gene and reduced the leukemic cell-supporting activity of AML/MDS-derived stromal cells. This indicates that suppression of stromal HHIP could be associated with the proliferation of AML/MDS cells.

The incidence of pertussis hospitalizations among Japanese infants: excess hospitalizations and complications?

We examined pertussis hospitalizations among infants aged <1 year between 2006 and 2008 using the nationwide inpatient database in Japan. A total of 660 infants hospitalized for pertussis were identified. Peak incidence occurred at age 1 month and infants aged 0-2 months (too young for pertussis vaccination) and ≥3 months (eligible for at least one dose of vaccination) accounted for 44·5% and 55·5% of hospitalizations, respectively. Complications related to pertussis were found in 165 (25·0%) cases, including one death; the age at admission did not differ significantly between patients with and those without complications (mean age 4·1 vs. 4·5 months, P=0·12). Seventeen patients required mechanical ventilation. Of the 17 cases, 14 infants were aged <3 months and three infants were aged ≥3 months. Our findings highlight that the vaccination schedule against pertussis may often be delayed in Japan.

Resumption of JRR-4 and characteristics of neutron beam for BNCT.

The clinical trials of Boron Neutron Capture Therapy (BNCT) have been conducted using Japan Research Reactor No. 4 (JRR-4) at Japan Atomic Energy Agency (JAEA). On December 28th, 2007, a crack of a graphite reflector in the reactor core was found on the weld of the aluminum cladding. For this reason, specifications of graphite reflectors were renewed; dimensions of the graphite were reduced and gaps of water were increased. All existing graphite reflectors of JRR-4 were replaced by new graphite reflectors. In February 2010 the resumption of JRR-4 was carried out with new graphite reflectors. We measured the characteristics of neutron beam at the JRR-4 Neutron Beam Facility. A cylindrical water phantom of 18.6 cm diameter and 24 cm depth was set in front of the beam port with 1cm gap. TLDs and gold wires were inserted within the phantom when the phantom was irradiated. The results of the measured thermal neutron flux and the gamma dose in water were compared with that of MCNP calculation. The neutron energy spectrum of the calculation model with new reflector had little variation compared to that with old reflector, but intensities of the neutron flux and gamma dose with new reflector were rather smaller than those with old reflector. The calculated results showed the same tendency as that of the experimental results. Therefore, the clinical trials of BNCT in JRR-4 could be restarted.

Incidence and clinical features of priapism in Japan: 46 cases from the Japanese diagnosis procedure combination database 2006-2008.

We investigated the incidence and clinical features of priapism in Japan, using a national administrative claims database, the Diagnosis Procedure Combination database. Priapism patients were identified using the International Classification of Diseases and Related Health Problems, 10th Revision code, N483 (priapism). Verified patient characteristics included age, comorbidities and management of priapism. Among 6.93 million inpatients, 46 patients with priapism were identified. Four had two admissions each for repeated events. The median age was 41.5 years (range, 11-89 years). A total of 21 patients had comorbidities; 3 had haematological malignancies, 4 had haemodialysis, 1 had a renal transplant, 2 had neurological problems, 4 had non-haematological malignancies, 3 had trauma and 6 had psychoses (2 cases had two comorbidities). All patients with non-haematological malignancies were over the age of 70 years, indicating that close attention is required to search for associated malignancies in elderly patients. The medical treatments included 6 vascular embolizations, 11 Winter method surgeries and 18 other operations. The incidence was estimated to be 0.13 (95% confidence interval, 0.097-0.17) per 100,000 person-years. This incidence was lower than that reported in other parts of the world.

Investigation of irradiation conditions for recurrent breast cancer in JRR-4.

Clinical trials of boron neutron capture therapy (BNCT) for recurrent breast cancers are considered at Japan Research Reactor No. 4 (JRR-4). In this study, the irradiation technique for a total mastectomy patient with recurrent cancer was optimized by dosimetric calculations using JAEA computational dosimetry system (JCDS). The evaluation was performed using an en face technique and a tangents technique with thermal neutron beam mode at JRR-4. The results revealed that equivalent doses of lung, heart, liver and skin were similar in each irradiation technique due to the isotropic scattering of thermal neutrons in the body. On the other hand, the irradiation time with the tangents technique was a few times longer than with the en face technique. We concluded that the en face technique was an optimal irradiation technique for recurrent breast cancers using thermal neutron beam mode in terms of shorter irradiation time and easier patient positioning.

Cost of open versus laparoscopic appendectomy.

AIMS: There are several literatures on outcome variations between patients treated with an open appendectomy (OA) and a laparoscopic appendectomy (LA). However, there are no studies assessing differences in cost and outcome that adjust for age and hospital function or region. This study examines the differences in cost and procedure-related complications of OA and LA procedures. MATERIALS AND METHODS: This study contains 1703 appendectomy patients treated for appendicitis in 76 academic hospitals and 80 community hospitals. Demographic variables, clinical variables, length of stay (LOS), total charges (TC; US$) and complication rates were analyzed for both OA and LA procedures. The specific contributions of LA to LOS, TC, and complication rate were identified using multivariate analysis. RESULTS: 1469 (86.3%) patients underwent OA and 234 (13.7%) underwent LA. Complicated appendicitis was diagnosed in 13.1% of OA cases and 15.4% of LA cases. The complication rates were 3.4% in OA and 2.6% in LA (p=0.504). There were significant differences in LOS and TC by severity of appendicitis and by procedure type. After risk adjustment for the other study variables, LA was associated with a higher TC than OA ($1458, p0.001). However there were no significant differences in LOS or complication rates between the two treatment groups. CONCLUSIONS: This study suggests that LA increases cost, but has no significant impact on LOS or complication rates. However, other outcomes such as quality of life or subgroup analysis for obese patients are needed for a more complete economic analysis of OA and LA.

Identification of equol producers in a Japanese population by high-performance liquid chromatography with coulometric array for determining serum isoflavones.

Using a method of high-performance liquid chromatography (HPLC) with coulometric array, we measured isoflavone levels in sera from seven volunteers before and after three days of ingesting Soyaflavone E (an isoflavones powder) and from 129 female farmers (Japanese Multiple Environmental Toxicants Study; JMETS). Results showed that the serum isoflavone concentrations rose dramatically after three days of ingesting Soyaflavone E in all subjects except for the serum equol concentrations in two subjects. The geometric mean concentrations of daidzein, genistein, and equol in the serum of 129 Japanese women were 25.0 ng/ml of daidzein, 94.1 ng/ml of genistein, and 9.6 ng/ml of equol. Interestingly, there existed two dominant groups in terms of serum equol concentrations in an independent manner of soy-derived product intake among the study participants.

Isolation and characterization of resident macrophages from the smooth muscle layers of murine small intestine.

Macrophages within the murine tunica muscularis were isolated and cultured for physiological studies. Following dispersion, macrophages were identified by phagocytotic activity of fluorescein isothiocyanate (FITC)-dextran. Immediately following isolation, macrophages were rounded and possessed fluorescent granula but developed a ramified shape after 3-4 days in culture. Resident and cultured macrophages were immunopositive for F4/80 and I-Ad/I-Ed. Greater than 90% of F4/80 positive cultured cells were FITC-dextran positive. Macrophages had resting membrane potentials (RMP) of -33.3 +/- 1.5 mV after 1 day in culture, which increased to -53.9 +/- 4.4 mV after 3-4 days. The change in RMP was associated with the development of an inward rectifying K+ current, and a decrease in a voltage-dependent, inactivating outward current. After 3-4 days in culture the inflammatory mediated substances adenosine triphosphate (ATP), platelet-activating factor and bacterial lipopolysaccharide induced increases in cytoplasmic Ca2+ ([Ca2+]i). Forskolin suppressed the ATP-induced increase in [Ca2+]i. Macrophages exhibited oxidative bursts, measured by oxidation of dihydrorhodamine-123 to rhodamine-123. Oxidative bursts coincided with a reduction in intracellular pH. Macrophages expressed a proton conductance that may participate in pH maintenance during reactive oxygen production. These results suggest that resident macrophages in the intestine may play a role in the immunological protection of the gut.

[Clinical analysis of surgically resected multiple primary lung cancer].

Synchronous and metachronous lung cancer is occasionally encountered. Frequency of the occurrence is increasing because of recent progress of imaging technique such as high resolution CT and CT based annual lung survey. We analyzed clinical characteristics of both synchronous and metachronous lung cancer treated surgically in our facility. There were 20 cases of multiple lung cancer cases, which is consisted of 12 synchronous multiple lung cancer cases and 8 metachronous lung cancer cases. Mean age was 62 years old and there were 14 male and 6 female cases. Among synchronous group, 8 cases have multiple shadow in ipsilateral hemithorax and 4 cases in both side. Surgery was carried out according to the extent of the disease and lung reserve. Associated cancer was diagnosed stage IA or IB in all cases. Five-year survival was 58.9%. Meanwhile, as regards to metachronous group, mean interval between first cancer and second cancer was 73 months. Seven cases have contralateral second primary lung cancer and one case has ipsilateral second primary lung cancer. In 3 cases, histology of the first and the second disease were different and in 5 cases that were the same. The first procedures were complete resection with systemic mediastinal LN dissection. The second procedures were determined based on the lung reserve. Pathological stage of the second disease were either stage IA or IB. There were no operative mortality and 5 years survival was 75%. Since there is no operative mortality and the outcome seems satisfactory when the patient has enough lung reserve, aggressive surgical resection should be considered in the case of multiple primary lung cancer. There is an increasing chance of synchronous multiple primary lung cancer because of improvement of imaging system. We have to prepare new therapeutic strategy for those patients.

Topographical analysis of p53 expression and DNA ploidy in early bronchial squamous cell carcinoma and preneoplastic lesions.

The significance of p53 mutations and DNA aneuploidy in carcinoma cells has been investigated on the basis of a multi-step development theory of carcinogenesis. It has, however, not been determined whether these alterations can be used as diagnostic markers for the early detection of bronchial squamous cell carcinoma (BSqCC). To address this problem, we topographically investigated p53 alterations and DNA aneuploidy in 24 X-ray-negative, early BSqCC patients with various preneoplastic lesions and in 25 non-carcinoma patients with preneoplastic lesions. Bronchial lesions (n=88) were morphologically classified as hyperplasia (HP, n=5), squamous metaplasia (SM, n=23), low-grade dysplasia (LGD, n=14), high-grade dysplasia (HGD, n=11), intraepithelial carcinoma including 'carcinoma in situ' (CIS) (IEC, n=15), and microinvasive carcinoma (MIC, n=20). Immunohistochemistry for the p53 protein and image cytometry for DNA ploidy detection were performed in serial sections of each lesion. Overexpression of p53 protein was detected in 36, 73, and 65% of the HGD, IEC, and MIC lesions, respectively. Aneuploid DNA profiles were found only in carcinoma lesions, 33% in IEC and 85% in MIC. The topographical analysis revealed two types of early BSqCCs, one with adjacent preneoplastic lesions (sequential type, n=8) and another without such lesions (de novo type, n=16). The p53 protein was frequently overexpressed in both types (sequential type, 79%; de novo type, 62%). In the sequential type, however, the p53 protein was overexpressed in HGD lesions that were directly adjacent to p53-overexpressing carcinoma lesions without exception. The present topographical study suggests that p53 mutations play an important role in the carcinogenesis of BSqCC and that p53-overexpressing HGD lesions in sequential types should be regarded as 'truly' preneoplastic lesions that actually develop into carcinomas. In addition, our study demonstrated that DNA aneuploidy might occur at times after p53 alteration with increasing frequency, as invasive growth begins. Such combination analysis of p53 immunohistochemistry and nuclear DNA ploidy in routine histology may contribute to estimates of malignant potential in preneoplastic and intraepithelial squamous lesions and provide additional information for early detection of BSqCC.

Peroxisomal catalase in the methylotrophic yeast Candida boidinii: transport efficiency and metabolic significance.

In this study we cloned CTA1, the gene encoding peroxisomal catalase, from the methylotrophic yeast Candida boidinii and studied targeting of the gene product, Cta1p, into peroxisomes by using green fluorescent protein (GFP) fusion proteins. A strain from which CTA1 was deleted (cta1Delta strain) showed marked growth inhibition when it was grown on the peroxisome-inducing carbon sources methanol, oleate, and D-alanine, indicating that peroxisomal catalase plays an important nonspecific role in peroxisomal metabolism. Cta1p carries a peroxisomal targeting signal type 1 (PTS1) motif, -NKF, in its carboxyl terminus. Using GFP fusion proteins, we found that (i) Cta1p is transported to peroxisomes via its PTS1 motif, -NKF; (ii) peroxisomal localization is necessary for Cta1p to function physiologically; and (iii) Cta1p is bimodally distributed between the cytosol and peroxisomes in methanol-grown cells but is localized exclusively in peroxisomes in oleate- and D-alanine-grown cells. In contrast, the fusion protein GFP-AKL (GFP fused to another typical PTS1 sequence, -AKL), in the context of CbPmp20 and D-amino acid oxidase, was found to localize exclusively in peroxisomes. A yeast two-hybrid system analysis suggested that the low transport efficiency of the -NKF sequence is due to a level of interaction between the -NKF sequence and the PTS1 receptor that is lower than the level of interaction with the AKL sequence. Furthermore, GFP-Cta1pDeltankf coexpressed with Cta1p was successfully localized in peroxisomes, suggesting that the oligomer was formed prior to peroxisome import and that it is not necessary for all four subunits to possess a PTS motif. Since the main physiological function of catalase is degradation of H2O2, suboptimal efficiency of catalase import may confer an evolutionary advantage. We suggest that the PTS1 sequence, which is found in peroxisomal catalases, has evolved in such a way as to give a higher priority for peroxisomal transport to peroxisomal enzymes other than to catalases (e.g., oxidases), which require a higher level of peroxisomal transport efficiency.

Combined therapeutic approach of intra-arterial thrombolysis and carotid endarterectomy in selected patients with acute thrombotic carotid occlusion.

PURPOSE: The feasibility and clinical outcome of intra-arterial thrombolysis followed by carotid endarterectomy (CEA) for acute thrombotic occlusion of the internal carotid artery (ICA) were evaluated. METHODS: Intra-arterial thrombolysis and CEA were performed in four patients with acute thrombotic ICA occlusion. Computed tomography scans, cerebral angiograms, and the severity of carotid plaques were examined, and the patients' clinical outcome was evaluated. RESULTS: All 4 patients had severe hemiparesis; 3 patients were alert, and 1 patient was lethargic at the time of hospital admission. New lesions were not shown by means of the initial computed tomography scan. ICA occlusion was indicated in all four patients by means of cerebral angiograms; in three patients, middle cerebral artery occlusion was noted. Collateral circulation was manifested in all patients. Partial recanalization of the occluded ICA was obtained in all patients. Two patients with severe residual ICA stenosis underwent an emergency CEA soon after thrombolysis; the other two patients were treated by means of CEA in the subacute or chromic stage. Plaque rupture and intraplaque hemorrhage were seen in all four patients. All four patients recovered completely, and restenosis of the ICA was not shown by means of follow-up angiograms. CONCLUSION: Intra-arterial thrombolysis followed by CEA may be an effective therapeutic approach for treating acute thrombotic ICA occlusion. The optimal timing of CEA remains controversial.