Paroxysmal Nocturnal Hemoglobinuria: The Role of Antibodies in the Diagnostic Thrombin Test

1. The thrombin test for paroxysmal nocturnal hemoglobinuria (PNH) consists in the demonstration that PNH hemolysis in vitro is increased by theaddition of a small amount of thrombin. This ability of thrombin is not substantially changed by preliminary removal of the heterophil antibodies whichare present in commercial preparations of bovine thrombin, provided the testis performed in the way it was originally described.

2. Dilution of the serum with saline and the addition of imidazole bufferabolish the phenomenon of thrombin enhancement of PNH hemolysis.

3. Certain commercial thrombin preparations contain additives which inactivate the PNH hemolytic system. These materials are unsuitable for usein the thrombin test.

Submitted on July 13, 1959 Accepted on August 10, 1959     

Natural polyreactive immunoglobulin A antibodies produced in mouse Peyer’s patches

To understand the biological function of natural immunoglobulin A (IgA) antibodies in Peyer’s patches (PP), we generated IgA monoclonal antibody (mAb) clones from the PP of normal, unimmunized, specific pathogen-free BALB/c mice and examined their reactivities by enzyme-linked immunosorbent assay (ELISA). Many of these antibodies reacted with more than one antigen examined, suggesting that they were polyreactive Abs. Two mAbs agglutinated several different strains of commensal bacteria isolated from mice. To examine the genetic features of these polyreactive mAbs, the V_H genes of seven different IgA mAbs were sequenced. The V_H genes from the VGAM, J558 and 7183 families were compared with sequence from the mAbs with distinct VDJ rearrangements. One of the mAbs that agglutinated bacteria was encoded by a germline V_H gene, but the V_H region of the other polyreactive mAbs contained between seven and 11 mutated sites. No indication of antigenic selection was observed in the pattern of these mutated sites. Our results show that polyreactive IgA Abs are present in PP as a part of the normal B-cell repertoire. These polyreactive Abs may establish a natural immune homeostasis, and function as a polyreactive sensor to detect pathogenic invasion and to control immune response in the gut.     

FACTORS RELATED TO LATERAL MARGIN POSITIVITY FOR CANCER IN GASTRIC SPECIMENS OF ENDOSCOPIC SUBMUCOSAL DISSECTION

Background: With the widespread use of endoscopic submucosal dissection (ESD), more large early gastric cancers (EGC) have become candidates for endoscopic resection. A precise diagnosis of the extent of cancer is indispensable to obtain R0 resection. The aim of the present study was to clarify the factors related to lateral margin positivity for cancer in specimens resected by ESD for EGC. Methods: Among 1549 EGC treated by ESD during September 2002 to December 2008, lesions that were resected in an en‐bloc fashion and resulted in a pathological diagnosis of lateral margin positive (LM+) for cancer, were extracted. The reason for LM+ and pathological characteristics of the lesions were studied and compared to lesions successfully resected with margins negative for cancer. Results: There were three types of lesion that resulted in LM+ resection: lesions with a flat spreading area, lesions with an unexpected nearby lesion, and lesions with lateral extension beneath a non‐cancerous mucosa. Compared to lesions resected with margins negative for cancer, diameter of the tumor, recurrent‐type cancer, submucosal cancer, and undifferentiated‐type cancer were factors significantly related to LM+ resection. Conclusion: Other than misdiagnosing a small portion of cancer extension, lateral margin positivity for cancer by ESD could result from a neighboring lesion and an unexpected lateral submucosal cancer extension. To avoid LM+ resection of EGC by ESD, one should be careful of unexpected lateral extension and simultaneous multi‐lesions.     

A Trial of 13C-urea Breath Test Combined with Endoscopic Phenol Red Test for Detection of Helicobacter pylori Infection

Abstract: Several tests for the diagnosis of Helicobacter pylori [H. pylori) infection have been employed in clinical studies. To minimize inaccuracies of these tests, we developed a new method which combines the ¹³C-urea breath test (UBT) with phenol red dye spraying endoscopy. We have designated this innovation the endoscopic ¹³C-urea breath test (EUBT). EUBT was conducted on 103 patients with gastroduodenal diseases. After the collection of a baseline breath sample, gastroduodenal endoscopy was performed. Twenty milliliters of 0.05% phenol red solution containing 100 milligrams of ¹³C-urea was sprayed onto the entire gastric mucosa. A breath sample was collected 15 minutes after spraying. We measured ¹³CO₂ in the breath samples by ratio mass spectrometry. Two biopsy specimens each from the antrum and the middle corpus were obtained for culture and histological examination. The mean EUBT values (±standard deviation) in H. pylori -positive and negative patients were 38.56±30.34%< and 0.19± 0.18%), respectively. The cut-off value for EUBT was 0.73%. The sensitivity and specificity of EUBT were 100% and 95.5%, as compared with culture, and 100% and 95.5%, as compared with histological evaluation. The EUBT value of the patients with the diffuse staining type (50.28±31.26%) was significantly higher than that of patients with the regional staining type (26.76±23.17%). EUBT is an accurate method of detecting H. pylori infection and a good indicator of the distribution of the infection within the stomach.     

Review: Diagnosis of Helicobacter pylori infection

A number of diagnostic tests have been developed for the detection of H. pylori. Diagnostic techniques can be divided into invasive and noninvasive methods. The invasive methods require upper gastrointestinal endoscopy and involve culture of gastric biopsy specimens, examination of stained biopsies and detection of urease activity in the biopsies themselves. In addition, we have developed endoscopic diagnosis of H. pylori infection in gastric mucosa using phenol red dye-spraying. The noninvasive methods include urea breath test and serological techniques. Although there has been considerable improvement in the techniques, a combination of at least two different techniques should be used in order to optimize the diagnostic yield. We recommend the use of one rapid test in the combination. The rapid urease test, cytology and the phenol red dye-spraying endoscopy give results available before the patient leaves the endoscopy suite.     

A Case of Early Gastric Carcinoma with Lymphoid Stroma: Diagnostic Usefulness of Endosonography

Abstract: A case of early gastric carcinoma with lymphoid stroma (GCLS) showing features of submucosal tumor is reported here. A characteristic endoscopic ultrasonographic (EUS) finding was helpful for preoperative diagnosis. The patient, a 75-year-old woman without any previous complaints, visited our hospital for detailed examination of a small gastric lesion. Upper Gl studies revealed a submucosal tumor-like lesion measuring about 1.8 cm with a central slight depression on the greater curvature of the middle gastric body. Histologic findings of the specimens obtained by conventional biopsy indicated a poorly differentiated adenocarcinoma, although the possibility of malignant lymphoma was not completely ruled out. EUS examination was, therefore, performed in order to obtain further detailed information about the tumor. EUS disclosed that the tumor, which existed in the third layer, was composed of many small round clustered lesions, the echogenicity of which was lower than that of the muscle layer, and was almost covered with a normal mucosal layer. Taking these findings into consideration, a gastric cancer with lymphoid stroma whose invasion would be limited within the submucosa was highly suspected. It was proven by histological analysis of a surgically resected specimen that this peculiar multiple small round hypoechoic lesion was equivalent to the lymphoid aggregates infiltrating the GCLS. Since it has been reported that the prognosis of GCLS is better than that of common gastric cancers, accurate diagnosis is important for the selection of optimal treatment. While it is still not definitively proven that EUS is useful for diagnosis of GCLS, this procedure may potentially provide an excellent image of this special tumor and be of use for preoperative diagnosis.     

Psychological trauma and longitudinal course of psychiatric problems among evacuees of a volcanic eruption

The percentage of evacuees showing a high score (≥8), the mean General Health Questionnaire (GHQ) scores and the scores of the five subscales derived from the GHQ-30 in evacuees of the Mt Unzen volcanic eruptions were obtained at three intervals, 6 months, 12 months and 24 months after evacuation. The percentage of evacuees showing a high score as well as mean GHQ scores had significantly improved by the second investigation, and this trend was continued at the third investigation. However, at the third investigation the percentage of evacuees with a high score was 57.3%, and the mean GHQ score was still 11.21, representing extremely high values. Factor 1 (Anxiety, Tension, Insomnia) was significantly improved in both males and females at the second investigation. A difference by sex was seen in Factor 2 (Anergia, Social Dysfunction), which had improved significantly in females, whereas no improvement was seen in males. There were no remarkable changes in Factor 3 (Depression) or Factor 4 (Anhedonia), but Factor 5 (Interpersonal Dysfunction) had significantly worsened in both males and females over the course of time. It is suggested that these results are due to the disruption of community functions and weakened community consciousness induced by prolonged evacuation to a temporary dwelling despite escaping from a potentially fatal situation.     

6-Sulfatoxymelatonin excretion and self-reported sleep in good sleeping controls and 55–80-year-old insomniacs

The pineal hormone melatonin is thought to play a role in sleep initiation and maintenance. This was examined in a large sample of good sleeping controls ( n =52) and sleep maintenance insomniacs ( n =56), aged 55–80 y. Subjects collected 5 d of self-reported sleep diary measures, and 12-h urine samples (08.00–20.00 and 20.00–08.00 h) for analysis of the urinary melatonin metabolite, 6-sulphatoxymelatonin (aMT.6S). Insomniacs reported a significantly greater amount of wake after sleep onset, less sleep in total, less efficient sleep and poorer quality sleep compared to controls. However, no significant differences in melatonin excretion were observed between controls and insomniacs, with both groups showing similar mean (SEM) 12-h night-time [30.9 (2.9) vs. 30.6 (3.3) nmoles, respectively] as well as 24-h total [38.7 (3.4) vs. 36.7 (3.8)] aMT.6S excretion levels. No significant correlations were observed with any sleep parameters nor any effects of medication (anti-inflammatory agents, hormone replacement therapy, and an undifferentiated group of medications). The present results do not support a simple relationship between total melatonin production and self-reported sleep quality and duration in the aged.