Questionnaire Survey Regarding Troubles and Concerns Related to Clinical Research Based on the Clinical Trial Act for Clinicians and Academics.

The Clinical Trial Act came into force in 2018 in Japan. A questionnaire survey was conducted with personnel at Kumamoto University Hospital engaged in research and development, to explore their perceptions of troubles and concerns about clinical research related to the Clinical Trial Act. We collected 127 comments about troubles and 149 about concerns. Text mining (co-occurrence network and hierarchical cluster analysis) was used to extract the characteristics or tendencies in these comments. The analysis extracted 18 key terms for troubles and 21 for concerns. Most troubles and concerns had to do with concrete examples of clinical research or protocols and biostatistics information. Our results emphasized the importance of clinical research support organizations, and suggested that appropriate workshops and information covering specific situations are necessary to perform clinical research under the new regime.

Route of intrabacterial nanotransportation system for CagA in Helicobacter pylori.

Helicobacter pylori (H. pylori) possesses an intrabacterial nanotransportation system (ibNoTS) for transporting CagA and urease within the bacterial cytoplasm; this system is controlled by the extrabacterial environment. The transportation routes of the system have not yet been studied in detail. In this study, we demonstrated by immunoelectron microscopy that CagA localizes closely with the MreB filament in the bacterium, and MreB polymerization inhibitor A22 obstructs ibNoTS for CagA. These findings indicate that the route of ibNoTS for CagA is closely associated with the MreB filament. Because these phenomena were not observed in ibNoTS for urease, the route of ibNoTS for CagA is different from that of ibNoTS for urease as previously suggested. We propose that the route of ibNoTS for CagA is associated with the MreB filament in H. pylori.

A new type of intrabacterial nanotransportation system for VacA in Helicobacter pylori.

Helicobacter pylori possesses intrabacterial nanotransportation systems (ibNoTSs) for CagA and urease. Both systems are UreI-dependent and urea-independent, and activated by extrabacterial acid. The activation occurs/appears within 15 min after exposure to extrabacterial acid stimulation. Although it has been clarified that VacA is secreted via the type-V secretion machinery, it remains unclear how this toxin is transported toward the machinery. To clarify the intrabacterial nanotransportation system for H. pylori VacA, immunoelectron microscopic analysis was performed in this study. VacA shifted to the periphery of the bacterial cytoplasm at 30 min after the extracellular pH change, whereas CagA and urease did so within 15 min. Studies using an ureI-deletion mutant revealed that unlike CagA and urease transport, VacA transport was not UreI-dependent. VacA secretion was accelerated without an increase in the production of VacA 30 min after the exposure to extrabacterial acid. These findings indicated that H. pylori possesses a novel type of ibNoTS for VacA, which is different from that for CagA or urease, in response time and dependency of UreI.

Interdigitating dendritic cell sarcoma of the ileum recurred in multiple lymph nodes and duodenum three years after operation without chemotherapy.

Neoplasms derived from interdigitating dendritic cell are extremely rare. Here we describe a case of a 47-year-old man with interdigitating dendritic cell sarcoma (IDCS) in the ileum. He was admitted to a hospital due to ileus. The ileal tumor, measuring 2cm, was detected and resected with regional lymphadenectomy. At that time, a pathologic diagnosis of malignant peripheral nerve sheath tumor was made. The patient, who was not treated with chemotherapy, showed no signs of recurrence. After three years, we detected cervical lymphadenopathy and multiple duodenal masses in the patient in our hospital. Oval to spindle-shaped atypical cells, which resembled ileal tumor cells, infiltrated into the lymph node and duodenum. Immunohistochemical staining of these three lesions revealed positivity of S100 protein and several macrophage-related antigens. Based on the histologic and immunohistochemical analysis, the histopathologic diagnosis of IDCS was confirmed. To our knowledge, five cases of IDCS arising in the intestinal tract have been reported to date, and only one case, treated with both surgery and chemotherapy, led to remission. This is the first case that has a comparatively favorable prognosis without chemotherapy after surgery.

Successful treatment of Aspergillus liver abscesses in a patient with acute monoblastic leukemia using combination antifungal therapy including micafungin as a key drug.

While anti-cancer chemotherapy has improved the survival of patients with hematologic malignancies, it has also exposed such patients to the risk of life-threatening infection due to neutropenia. In intensive chemotherapy for leukemia, invasive aspergillosis resulting in death is infrequently observed. In such cases, aggressive diagnostic and therapeutic intervention is required. Herein, we report a case of Aspergillus liver abscesses in a patient with acute monoblastic leukemia. The patient presented with febrile neutropenia and concomitantly with an elevated serum beta-D: -glucan level during chemotherapy. The abscesses were finally diagnosed by liver biopsy. Although antifungal monotherapy of voriconazole or liposomal amphotericin B, both of which are recommended for invasive aspergillosis, showed a poor response, when combined with micafungin, an echinocandin, both had a highly favorable effect against the infection. Therefore, our clinical experience suggests that the serum test is useful for the rapid diagnosis of invasive aspergillosis, especially in deep tissues, and that combination antifungal therapy with micafungin should be considered when initial monotherapy for fungal infection shows an insufficient effect.

Hairy cell leukemia responsive to anti-thymocyte globulin used as immunosuppressive therapy for aplastic anemia.

Hairy cell leukemia (HCL) is occasionally misdiagnosed as aplastic anemia when only a few leukemic cells are present in the circulation. Here, we describe a patient with HCL who initially presented with pancytopenia and received a diagnosis of aplastic anemia. The patient was treated with immunosuppressive therapy including cyclosporine A and anti-thymocyte globulin (ATG). No blood cell transfusion was required for approximately 3 years after ATG therapy. She was referred to our hospital because of an abdominal mass and requiring periodic blood transfusions. A bone marrow biopsy at this time revealed proliferation of lymphocytes with a fried egg appearance and an increase in reticulin fibers that are typical findings of HCL. It is notable that our patient with a presumably long history of HCL and an increase in marrow reticulin fibers showed good recovery of hematopoiesis after cladribine therapy. Some HCL patients may receive an initial diagnosis of aplastic anemia and may show a good response to ATG masking the underlying HCL.

Sialadenoma papilliferum of the bronchus: rare tracheobronchial tumor of salivary gland type.

Presented herein is the second case of sialadenoma papilliferum of the bronchus in a 75-year-old man. The bronchial tumor had an exophytic papillary lesion protruding into the lumen of the ostial region of the right superior lobe bronchus on chest CT and bronchoscopy. Grossly, the resected tumor was pedunculated, 5 x 3 x 3 mm in size and consisted of both an exophytic papillary lesion protruding into the bronchial lumen and a glandular component in the bronchial submucosa. Histologically, the papillary structures were lined by ciliated or non-ciliated columnar epithelium and metaplastic non-keratinizing stratified squamous epithelium. The submucosal glandular components were well circumscribed beneath and in continuity with the papillary lesion. The glandular components of cysts and duct-like structures were lined by a double-layer epithelium composed of luminal cells and basal cells. Sialadenoma papilliferum is a rarely recognized salivary gland tumor, mostly occurring at intraoral mucosal sites including the hard and soft palate and buccal mucosa. There have been sporadic cases of sialadenoma papilliferum of the esophagus, nasopharynx and nasal cavity. To the authors' knowledge only one case of sialadenoma papilliferum of the bronchus has been reported previously.

Aggressive CD5-positive B-cell lymphoma after remission of CD5-negative follicular lymphoma with distinct immunoglobulin heavy chain rearrangement and translocation.

We report a unique, aggressive B-cell lymphoma that developed after the long-term remission of follicular lymphoma (FL). FL cells were negative for CD5, whereas aggressive lymphoma cells were positive for CD5. In FL, one immunoglobulin heavy chain gene (IGH) allele underwent V/D/J recombination and another t(14;18)(q32;q21). In aggressive lymphoma, one IGH allele underwent D/J recombination and another translocation, but not t(14;18)(q32;q21). An aggressive lymphoma-specific D/J sequence was detected in FL tissue. Our results indicated that the two tumors arose from distinct B cells and that they existed concurrently in the same lymph node.

[Aspergillosis of masticator space including mandibular bone responding to itraconazole treatment in a diabetic adult: case report].

Aspergillosis of the bone is rare and resistant to treatment. We report a case of Aspergillus infection of the masticator space including mandibular bone in a diabetic adult. After extraction of a posterior tooth, the patient began to suffer from facial pain. The pain worsened in spite of antibiotic treatment. The results of serum tests and biopsy showed an invasive aspergillosis of the left masticator space including the mandibular bone six months after the onset. Although invasive aspergillosis can be fatal, the infection in our case responded to itraconazole treatment. Even in diabetes mellitus, invasive aspergillosis may occur after surgical interventions such as tooth extraction.

Characteristics of medical school graduates who underwent problem-based learning.

INTRODUCTION: In this study, we compared the choice of medical specialty and subspecialty interest among problem-based-learning (PBL) graduates and non-PBL graduates. MATERIALS AND METHODS: Questionnaires were mailed to a total of 1398 female doctors who graduated from Tokyo Women's Medical University (TWMU) between 1989 and 2003. The response rate was over 30%, giving 248 respondents who had undergone a PBL curriculum (PBL+) and 220 subjects who had not (PBL-). Current specialty of the graduates were compared between the PBL+ and PBL-, and also compared with the general Japanese female doctors (Control 1 and 2) of similar age groups. Respondents were analysed in terms of their interests in subspecialty medical care or general medical practise, which includes comprehensive medical care, primary care and basic medicine. Internal medicine doctors working in the university hospitals were compared with those working outside the university hospitals. Internal medicine doctors were also compared with specialists in ophthalmology, otolaryngology, dermatology and psychiatry. Subjects were compared by odds ratio (OR) to examine group difference in the field of interest. OR >2.0 was considered statistically significant. RESULTS: Most doctors in all groups chose internal medicine. More PBL+ internal medicine doctors showed interests in comprehensive medical care and primary care; more PBL+ internal medicine doctors working outside university hospitals showed interest in comprehensive medical care and primary care when compared with those who were working in the university hospitals. The PBL- graduates did not show such a characteristic. CONCLUSIONS: More PBL+ graduates who chose internal medicine showed interest in holistic medical practices such as primary care and community medicine and more PBL+ specialists showed sustained interest in their respective fields.

PIG-W is critical for inositol acylation but not for flipping of glycosylphosphatidylinositol-anchor.

Many cell surface proteins are anchored to a membrane via a glycosylphosphatidylinositol (GPI), which is attached to the C termini in the endoplasmic reticulum. The inositol ring of phosphatidylinositol is acylated during biosynthesis of GPI. In mammalian cells, the acyl chain is added to glucosaminyl phosphatidylinositol at the third step in the GPI biosynthetic pathway and then is usually removed soon after the attachment of GPIs to proteins. The mechanisms and roles of the inositol acylation and deacylation have not been well clarified. Herein, we report derivation of human and Chinese hamster mutant cells defective in inositol acylation and the gene responsible, PIG-W. The surface expressions of GPI-anchored proteins on these mutant cells were greatly diminished, indicating the critical role of inositol acylation. PIG-W encodes a 504-amino acid protein expressed in the endoplasmic reticulum. PIG-W is most likely inositol acyltransferase itself because the tagged PIG-W affinity purified from transfected human cells had inositol acyltransferase activity and because both mutant cells were complemented with PIG-W homologs of Saccharomyces cerevisiae and Schizosaccharomyces pombe. The inositol acylation is not essential for the subsequent mannosylation, indicating that glucosaminyl phosphatidylinositol can flip from the cytoplasmic side to the luminal side of the endoplasmic reticulum.

Decreased susceptibility of leukemic cells with PIG-A mutation to natural killer cells in vitro.

The cloning of the PIG-A gene has facilitated the unraveling of the complex pathophysiology of paroxysmal nocturnal hemoglobinuria (PNH). Of current major concern is the mechanism by which a PNH clone expands. Many reports have suggested that an immune mechanism operates to cause bone marrow failure in some patients with PNH, aplastic anemia, and myelodysplastic syndromes. Because blood cells of PNH phenotype are often found in patients with these marrow diseases, one hypothesis is that the PNH clone escapes immune attack, producing a survival advantage by immunoselection. To test this hypothesis, we examined the sensitivity of blood cells, with or without PIG-A mutations, to killing by natural killer (NK) cells, using 51Cr-release assay in vitro. To both peripheral blood and cultured NK cells, PIG-A mutant cells prepared from myeloid and lymphoid leukemic cell lines were less susceptible than their control counterparts (reverted from the mutant cells by transfection with a PIG-A cDNA). NK activity was completely abolished with concanamycin A and by calcium chelation, indicating that killing was perforin-dependent. There were no differences in major histocompatibility (MHC) class I expression or sensitivity to either purified perforin or to interleukin-2-activated NK cells between PIG-A mutant and control cells. From these results, we infer that PIG-A mutant cells lack molecules needed for NK activation or to trigger perforin-mediated killing. Our experiments suggest that PIG-A mutations confer a relative survival advantage to a PNH clone, contributing to selective expansion of these cells in the setting of marrow injury by cytotoxic lymphocytes.

Frequent detection of T cells with mutations of the hypoxanthine-guanine phosphoribosyl transferase gene in patients with paroxysmal nocturnal hemoglobinuria.

Acquired mutations of the PIG-A gene result in the hemolysis characteristic of paroxysmal nocturnal hemoglobinuria (PNH). Although the etiology of the mutation(s) is unclear, mutable conditions have been suggested by the coexistence of multiple clones with different mutations of PIG-A and by the appearance of leukemic clones in patients with PNH. This study sought to test this hypothesis by examining the frequency of hypoxanthine-guanine phosphoribosyl transferase (HPRT) gene mutations, identified by both resistance to 6-thioguanine (6-TG) and gene analysis. T-cell colonies resistant to 6-TG formed in methylcellulose culture were found in 8 (67%) of 12 PNH patients and 3 (18%) of 17 age-matched healthy volunteers (P <.02, Fisher exact probability test). The incidence of resistant colonies ranged from 40 to 367 (mean 149, x 10(-7)) in the 8 patients and from 1 to 16 (mean 7, x 10(-7)) in the 3 healthy donors. Thus, the HRPT gene mutated more frequently in patients with PNH than in healthy controls (P <.02, Mann-Whitney test). Analysis of bone marrow cells supported these findings. Like the PIG-A mutations in PNH, the HPRT mutations were widely distributed in the coding regions and consisted primarily of base deletions. Unlike PNH cells, 6-TG-resistant cells expressed CD59, indicating that the HPRT mutations did not occur in PNH clones. No correlation was noted between HPRT mutation frequency and content of therapy received by the patients. It is concluded that in PNH patients, conditions exist that favor the occurrence of diverse somatic mutations in blood cells.