Theoretical framework of population genetics with somatic mutations taken into account: application to copy number variations in humans.

Traditionally, population genetics focuses on the dynamics of frequencies of alleles acquired by mutations on germ-lines, because only such mutations are heritable. Typical genotyping experiments, however, use DNA from some somatic tissues such as blood, which harbors somatic mutations at the current generation in addition to germ-line mutations accumulated since the most recent common ancestor of the sample. This common practice may sometimes cause erroneous interpretations of polymorphism data, unless we properly understand the role of somatic mutations in population genetics. We here introduce a very basic theoretical framework of population genetics with somatic mutations taken into account. It is easy to imagine that somatic mutations at the current generation simply add individual-specific variations, as errors in mutation detection do. Our theory quantifies this increment under various conditions. We find that the major contribution of somatic mutations plus errors is to very rare variants, particularly to singletons. The relative contribution is markedly large when mutations are deleterious. Because negative selection also increases rare variants, it is important to distinguish the roles of these mutually confounding factors when we interpret the data, even after correcting for demography. We apply this theory to human copy number variations (CNVs), for which the composite effect of somatic mutations and errors may not be negligible. Using genome-wide CNV data, we demonstrate how the joint action of the two factors, selection and somatic mutations plus errors, shapes the observed pattern of polymorphism.

Generalized peritonitis due to spontaneously perforated pyometra presenting as pneumoperitoneum: report of a case.

We report a rare case of generalized peritonitis due to a ruptured pyometra in an 86-year-old woman, and also conduct a review of the previous Japanese literature. The patient presented with muscle guarding and rebound tenderness. Computed tomography (CT) disclosed a cystic mass in the peritoneal cavity, in which an air-fluid level was noted. Pneumoperitoneum around the uterus due to gas production of anaerobic bacteria was noted on a CT. At laparotomy, the uterus was markedly enlarged with a necrotic area on the uterine fundus, which was found to be perforated. A supravaginal hysterectomy and drainage were performed. We found only eight cases of a ruptured pyometra presenting as pneumoperitoneum in the Japanese literature between 1977 and 1999. The most common cause of pneumoperitoneum is a perforation of the gastrointestinal tract. However, other possible causes, as seen in our patient, should also be taken into consideration. Although it is rare, a perforated pyometra should therefore also be considered when elderly women present with acute abdominal pain.

[Factors in continuation of home health care for patients with intractable neurological diseases].

OBJECTIVE: This study was carried out to elucidate factors related to difficulty in continuing home health care and to investigate problems of the corresponding support system for patients with intractable neurological diseases. SUBJECTS AND METHODS: Subjects were 139 cases of amyotrophic lateral sclerosis (ALS), 376 cases of spino-cerebellar degeneration (SCD) and 1,048 cases of Parkinson's disease (PD) who were collected from the nationwide survey of health and social service needs of the patients with intractable diseases in 1995. Factors and problems related to limited activity due to diseases and necessity for medical care were analysed. The need for facilities of long-term care was also studied. RESULTS: The characteristic conditions of patients with ALS were shorter duration of the illness, higher percentage of conditions requiring medical care and disorders of swallowing or respiration and full nursing care in daily life compared with the other two diseases. The characteristics of PD were higher percentage of female and older age in both patients and their family caregivers. The proportion of cases for whom health care was judged to be prone to difficulty was 23.0% in ALS, 10.9% in PD and 7.2% in SCD, respectively. Regarding the factors related to difficulty in continuing home health care, conditions requiring medical care, the need for full nursing care in daily life, and the duration of the illness were recognized in ALS. In SCD, 5 factors, including conditions requiring medical care, the need for full nursing care in daily life, patients age greater than 65 years, the duration of the illness, and patients being nursed by their sons or daughters were detected. In PD, 4 factors, such as conditions requiring medical care, the need for full nursing care in daily life, the patients being nursed by persons other than the spouse, and the need of nursing care were found. CONCLUSION: These results suggest the necessity of social functions of medical care, nursing and family support that can be supplied at home effectively according to symptoms in progress, and the need for facilities of long-term care of patients for whom continuation of home health care may become difficult, which will work as a support system for long-term care of patients with intractable neurological diseases.

[Public health nurses' disaster responses for intractable neurological patients at home].

OBJECTIVE: This paper describes the 1995 Hanshin-Awaji Earthquake experience of the local public health nurses. The purpose of the study was to identify problems regarding assistance of intractable neurological patients at home during and after the earthquake and to discuss ways to improve future local disaster responses by public health nurses for those patients. METHODS: Approximately 2 hours of a group interview of public health nurses from 2 public health centers in Kobe City was conducted in August, 1996. Interview data was collected via audio-tape and transcribed. The data was organized according to phases of the earthquake. The acute phase of the earthquake disaster ended within 72 hours. The data was then analyzed to identify problems in assisting intractable neurological home patients in order to discuss disaster responses by public health nurses. RESULTS: There was a delay in confirming the safety of and providing needed assistance for intractable neurological patients at home by public health nurses. During the first 3 days after the earthquake, the majority of public health nurses were unable to commute to work due to the shutdown of transportation systems. In addition, nurses, who were able to come to work, were preoccupied with treating earthquake casualties and distributing medical supplies. Other factors associated with the delay included the following: lack of a registration list for intractable neurological patients at home; lack of close contacts between public health nurses and patients, and between public health nurses and patient support groups; and sparing nurses for guiding volunteers and for coordinating between shelters and hospitals. CONCLUSION: Measures to improve future disaster responses are as follows: a) teaching patients and their families how to safeguard against disaster; b) preparing registration lists; c) establishing support networks and cooperating with network members; and d) upon disaster, assigning some nurses to assess the needs of patients.

Mucosa-associated lymphoid tissue (MALT) lymphoma of the thyroid: report of a case.

The patient was 59-year-old Japanese woman who presented with a neck swelling. Ultrasonography and computed tomography demonstrated a round tumor in the thyroid right lobe measuring 2.5 x 1.5 cm in size. A right hemithyroidectomy with lymph node dissection was performed. Histopathological findings demonstrated low-grade B cell lymphoma of the mucosa-associated lymphoid tissue (MALT) associated papillary microcarcinoma. A previous report showed an excellent prognosis of MALT lymphoma of the thyroid without capsular invasion or lymph node involvement. We also describe the concept of MALT lymphoma as a primary lesion in which lymphoid tissue is not present in the normal state.

A phase II study of carboplatin-cisplatin-etoposide combination chemotherapy in advanced non-small-cell lung cancer.

It is reported that the combination of cisplatin (CDDP) and carboplatin (CBDCA) is synergistic in vitro. The objective of this study was to evaluate the therapeutic effect and safety of the two platinum compounds in combination with etoposide in the treatment of non-small-cell lung cancer (NSLC). Forty patients were registered. Based on the results of a phase I study, patients were treated with CDDP (80 mg/m2 i.v. on day 1), CBDCA (280 mg/m2 i.v. on day 1), and etoposide (80 mg/m2 i.v. on days 1-3). Of the 40 patients, 30 were men and 10 women. Histology revealed adenocarcinoma(AC) (n = 20), squamous cell carcinoma(SCC) (n = 18), and large cell carcinoma(LCC) (n = 2). Staging: IIIA (n = 3); IIIB (n = 17); and IV (n = 20). A 32.5% overall response rate [13 of 40; 95% confidence interval (CI) 18-47%] was achieved. The response rates in patients with SCC and AC were 55.6 and 10.0% (p < 0.005), respectively. The median duration of response was 47.1 weeks and the overall median survival time was 57.1 weeks. Leukopenia and thrombocytopenia--World Health Organization (WHO) grade IV--occurred in nine and 11 patients, respectively. Nonhematological toxicities were mainly nausea, vomiting, and alopecia. In conclusion, further investigations of this regimen are warranted in the treatment of NSLC.

Comparative analysis of CD45RA- and CD45RO-positive CD4+T cells in peripheral blood, synovial fluid, and synovial tissue in patients with rheumatoid arthritis and osteoarthritis.

To determine whether the predominant infiltration with memory CD4+T cells in joints is specific to the local immune and inflammatory response in rheumatoid arthritis (RA), the proportions of CD45RA+ or CD45RO+ cells in the CD4+T cell populations in three different compartments (i.e., peripheral blood, synovial fluid, and synovial tissue) from patients with RA and osteoarthritis (OA) were compared by two-color flow-cytometric analysis. In the CD4+T cell population of peripheral blood, the number of CD45RO+ cells was relatively higher than CD45RA+ cells in both RA and OA patients, but their percentages did not differ from those found in healthy individuals. However, the great majority of CD4+T cells present in synovial fluid and synovial tissue were CD45RO-positive and CD45RA-negative in both patient groups; although CD4+T cells infiltrating both the disease compartments were markedly greater in RA joints, their mean percentages of CD45RO+ cells were not significantly different from those in OA joints. These data indicate that an accumulation of CD45RO+ memory CD4+T cells is a generalized phenomenon during local inflammatory responses in both RA and OA joints, and may be due mainly to the propensity of these cells to preferentially transmigrate into the inflamed joint via adhesion molecules as compared with CD45RA+ naive CD4+T cells.

CYFRA 21-1: an indicator of survival and therapeutic effect in lung cancer.

CYFRA 21-1 is a new tumor marker using two different monoclonal antibodies which recognize the divergent epitope on the N- or C-terminal region of domain 2 of cytokeratin 19 fragment, respectively. In this study, we investigated the relationship between levels of CYFRA 21-1 and survival duration, as well as the efficacy of chemotherapy associated with changes in CYFRA 21-1. Serum samples were obtained from 87 patients with nonoperable lung cancer (35 cases with squamous-cell carcinoma, 33 with adenocarcinoma, 3 with large-cell carcinoma, and 16 with small-cell carcinoma). The cutoff point was set at 3.5 ng/ml. In a CYFRA 21-1 assay, significantly more patients with squamous-cell carcinoma and adenocarcinoma were positive compared to patients with small-cell and large-cell carcinomas (p = 0.0017). Following chemotherapy, blood levels of CYFRA 21-1 decreased significantly in responders versus nonresponders (p = 0.0246). A significant correlation was noted between survival periods and pretreatment levels of CYFRA 21-1 (p = 0.0036). The present study suggests that CYFRA 21-1 might be useful as a possible indicator of survival and therapeutic effect for lung cancer.

Incidence of ocular complications in rheumatoid arthritis and the relation of keratoconjunctivitis sicca with its systemic activity.

To investigate the incidence of ocular complications in patients with rheumatoid arthritis under modern modalities of treatment and find the relationship between its systemic activity and ocular complications, routine ophthalmological examinations were done as a prospective study in 111 consecutive patients including 89 inpatients and 22 outpatients with rheumatoid arthritis seen from April to May 1995, in a hospital with a special clinic for rheumatology. Keratoconjunctivitis sicca (secondary Sjögren's syndrome) was found in 19 patients (17.1%), scleritis in one patient (0.9%), central retinal vein occlusion in 2 patients (1.8%), and idiopathic retinal hemorrhage in 3 patients (2.7%). Patients with keratoconjunctivitis sicca had significantly higher titers of rheumatoid factor (Mann-Whitney's U-test, p = 0.0048), higher levels of IgM (p = 0.0484), and lower levels of HDL-cholesterol (p = 0.0191), compared to patients without it. The incidence of ocular complications was comparable to the previous studies and keratoconjunctivitis sicca should be considered in patients with high titers of rheumatoid factor.

[Rapid progression of adenocarcinoma of the lung in a patient with high levels of granulocyte colony-stimulating factor].

A 51-year-old man was referred and admitted to our hospital for further examination of an abnormal shadow on a chest X-ray film. One month before admission, a chest X-ray film had shown no abnormality. On admission, chest X-ray films and computed tomograms showed a tumor shadow in the right hilum, obstructive pneumonia in the right upper lobe, and a right-sided pleural effusion. Cytological examination of the pleural offusion revealed adenocarcinoma. The patients was given supportive care. The tumor grew rapidly and by the 13th hospital day it occupied whole right upper lobe. The patient died on the 21st day after admission. The white blood cell count had increased to 26540/mm3 as the adenocarcinoma grew. Serum granulocyte colony-stimulating factor (G-CSF), which increases the number of neutrophils in blood in vivo was examined. The serum G-CSF level reached 112 pg/ml. On immunohistochemical examination, the tumor cells stained positively with anti-G-CSF monoclonal antibody. The growth of this tumor was more rapid than expected for adenocarcinoma of the lung. These findings suggest that G-CSF induced growth of the tumor.

Phase I study of a carboplatin-cisplatin-etoposide combination chemotherapy in advanced non-small-cell lung cancer.

Cisplatin (CDDP)-containing chemotherapy has become the mainstay of clinical trials in unresectable non-small-cell lung cancer (NSCLC), but the role of chemotherapy in the routine management of NSCLC remains controversial. We conducted a phase I study with the combination carboplatin (CBDCA), CDDP, and etoposide (Etop) in unresectable NSCLC. CBDCA, at a starting dose of 80 mg/m2, on day 1, was combined with a fixed dose of CDDP (80 mg/m2, day 1) and Etop (80 mg/m2, days 1-3). Escalation was performed after four patients entered at each dose level. If no World Health Organization (WHO) grade 4 toxicity developed after the first cycle in more than half of the patients or WHO grade 3/4 toxicity in more than two thirds, the dose was escalated. The maximum tolerated dose was established at 300 mg/m2 for CBDCA. Thrombocytopenia and leukopenia were the dose-limiting toxicities. No grade 3/4 nonhematologic toxicities were seen. The recommended dose of CBDCA to be combined with CDDP (80 mg/m2, day 1) and Etop (80 mg/m2, days 1-3) is 280 mg/m2. This trial suggests that our combination chemotherapy may be effective in patients with advanced NSCLC. A multicenter phase II study based on these findings is now under way.

[QOL and nursing care of a ventilator-assisted child at home].

QOL is the important issue for chronically ill children. We visited a girl, 8 years old and 24 hours dependent on a ventilator. We talked to her, and observed her daily life, mainly on the following points: (1) what she is doing; and (2) how often, and what kind of care she needs at school and at home. Then we discussed the problems, QOL and nursing care. She enjoyed her school life with her many friends, and received respiratory care, sanitary care, and other care for 11 hours and 19 minutes in average per day. 93.1% of the care was taken by her parents and volunteer care givers, so that they wanted to have nurses care for her. Many kinds of nursing care service were necessary as soon as possible.

Induction of apoptosis by ubenimex (Bestatin) in human non-small-cell lung cancer cell lines.

We studied the direct anti-tumor effects of ubenimex on five human lung cancer cell lines; ABC-1, RERF-LC-OK, RERF-LC-MS (adenocarcinoma) and SQ-5, EBC-1 (squamous cell carcinoma). Ubenimex dose-dependently inhibited the growth of these cancer cell lines except RERF-LC-MS. The results indicated that lung squamous cell carcinoma cell lines were more sensitive to ubenimex than lung adenocarcinoma cell lines. Coincidentally, histological observation by Hematoxylin eosine (HE) staining revealed that ubenimex induced nuclear condensation and apoptic body in the cancer cell lines. Immunohistochemical study showed ubenimex-treated cells expressed LeY antigen which is a useful phenotypic marker predictive of apoptosis. The induction of DNA fragmentation was also observed in the ubenimex treated cancer cell lines by ELISA. We conclude that ubenimex exhibits its direct anti-tumor effect against non-small-cell lung cancer cell lines, more effectively against squamous carcinoma cell lines, through the induction of apoptosis.

A phase II study of 72-hour continuous infusion consisting of cisplatin and 5-fluorouracil for treatment of non-small cell lung cancer.

A combination chemotherapy consisting of a 72-hour continuous infusion of cisplatin (CDDP; 100 mg/m2/72 h) and 5-fluorouracil (5-FU; 3 g/m2/72 h) was conducted for inoperable non-small cell lung cancer (NSCLC). Sixty patients were accepted for this study between June 1988 and December 1990. Forty-seven patients were male (median age 68). Thirty-four patients had stage III and 26 had stage IV disease. The response rate was 25.0% (95% confidence interval, CI, 14.0-36.0%), median survival was 15.7 months. In squamous cell carcinoma, the response rate was 35.5% (95% CI, 18.7-52.3%) and median survival was 15.1 months. In non-squamous cell carcinoma, the response rate was 13.8% (95% CI, 1.2-26.4%) and median survival was 17.7 months. There was a significant difference in response rate (p < 0.01), but no significant difference in survival (p = 0.36). Grade 3 leukopenia was 11.7%, grade 3 and 4 thrombocytopenia was 13.3%. Grade 3 nausea and vomiting were 8.3%. One patient had grade 4 renal toxicity. However, there was no treatment-related death. This regimen was well tolerated. In multivariate analysis, the significant parameters were CEA, performance status and response. In conclusion, 72-hour continuous infusion of CDDP and 5-FU for treatment of NSCLC provides similar response and toxicity as previously reported regimens using CDDP.

[Clinical study of intrapleural administration of pirarubicin (THP-ADM) in the treatment of malignant pleural effusion secondary to lung cancer].

The efficacy of intrathoracic administration of pirarubicin (THP-ADM), a derivative of adriamycin, was evaluated in 20 patients with malignant effusion due to lung cancer. All 20 patients had no previous intrapleural therapy. According to the criteria of ECOG, eight patients were at performance status 1 (P.S.1), nine were P.S.2, and three were P.S.3. Fourteen patients were clinical stage IIIB, and six stage IV. The effusions were first completely drained by thoracocentesis or tube thoracostomy drainage, and 30 mg/m2 THP-ADM was instilled. Overall response rate was 50.0%. The response rate for treatment with tube thoracostomy drainage was 69.2%, which was significantly higher than that for treatment with thoracocentesis (14.3%). Significant difference in survival was not seen between the tube thoracostomy drainage group and the thoracocentesis group. There were no severe side effects. In conclusion, intrapleural administration of THP-ADM with tube thoracostomy drainage was considered to be useful for the control of malignant pleural effusion due to lung cancer.

[A case of long-term survival in a patient with small cell lung carcinoma with syndrome of inappropriate secretion of anti-diuretic hormone].

A 73-year-old man was admitted on April 1984 because of an abnormal shadow on chest X-ray. He was diagnosed as having small cell lung carcinoma (oat cell type) with inappropriate secretion of antidiuretic hormone (SIADH). Initial chemotherapy with cyclophosphamide, ACNU, vincristine, adriamycin, cis-platinum and etoposide was administered. The mass subsequently disappeared, and the serum sodium level normalized. About 2 years later, the patient developed a relapse of the primary lesion with hyponatremia. The same regimen as the initial chemotherapy was initiated and a complete response was again obtained. Similar episodes were repeated four times, and he died in April 1991. This patient survived for about seven years after the initial treatment without maintenance chemotherapy.