Distinct decrease in peripheral lymphocytes in EBER-positive cases of MTX-LPD.

OBJECTIVES: To determine the clinical characteristics of methotrexate-associated lymphoproliferative disorder (MTX-LPD). METHODS: In this study, 12 RA patients who developed MTX-LPD were assessed. The peripheral blood lymphocyte (PBL) count at the onset of MTX-LPD was compared to that 6 months before the onset, in Epstein-Barr virus-encoded RNA (EBER)-positive and -negative subgroups. We examined the change in the PBL count after MTX withdrawal. In patients with relapsed LPD, changes in the PBL count before relapse were also examined. RESULTS: Regression of LPD after MTX withdrawal was noted in eight patients. In these patients, the PBL count was decreased at the onset of MTX-LPD compared to 6 months before the onset; the decrease was significantly more prominent in EBER-positive patients. In cases of spontaneous regression of LPD, the PBL count recovered quickly after MTX withdrawal. Four of eight patients showed a recurrence of LPD after they improved following MTX withdrawal. These patients also exhibited a decreased PBL count at recurrence compared to 6 months before recurrence. CONCLUSION: A decrease in the PBL count might be involved in the pathogenesis of MTX-LPD, especially in EBER-positive cases and in patients with LPD relapse after MTX withdrawal following initial improvement.

A case of rheumatoid arthritis with multiple lung rheumatoid nodules successfully treated with tofacitinib.

Sporadic cases of rheumatoid nodules (RNs) in the lung during treatment with tumour necrosis factor (TNF) inhibitors have been reported, but no treatment has been established. Here, we report a case of symptomatic lung RNs refractory to abatacept (ABT) and intravenous cyclophosphamide (IVCY) that improved with tofacitinib (TOF) treatment. A 75-year-old Japanese woman with a 10-year history of rheumatoid arthritis (RA) presented with a cough and haemoptysis during treatment with etanercept (ETN). Radiographic examinations revealed multiple nodules that were diagnosed as lung RNs via biopsy. The ETN was discontinued and ABT followed by IVCY was introduced; however, neither was sufficiently effective against the lung RNs. Thereafter, TOF was started and the lung RNs improved rapidly. The precise mechanisms that induce RNs during treatment with TNF inhibitors are unknown. Cytokines (IL-23 and IL-6) are suspected to be involved. TOF may be a reasonable strategy for treating symptomatic lung RNs.

Mortality in patients with hip fracture aged over 90 years: a report from a progressively aging island.

INTRODUCTION: In our aging society, hip fractures are common in elderly patients, especially those aged above 90 years. Improving mortality rates after this injury is an important part of medical management for the elderly. This study assessed mortality rates after hip fracture in patients aged ≥90 years and examined factors that contribute to mortality. METHOD: Between April 2003 and March 2009, 186 patients aged ≥65 years were studied. Of these, 50 patients were aged ≥90 years. Walking ability before injury and at discharge, preoperative physical status, number of comorbidities, postoperative survival, sex, fracture type, and patients' residential status were investigated. RESULTS: One-year mortality was higher in patients aged ≥90 years (24%) than in younger patients (10%) (p=0.01). Moreover, older patients were less likely to retain walking ability at discharge, and poor postoperative ambulatory levels were associated with increased mortality. Preoperative physical status according to the grading system of the American Society of Anesthesiologists (ASA) did not differ between the two age groups. Poor ASA grade was associated with mortality in the entire population, but this association was not significant in the older group. Although older patients had a higher number of trochanteric fractures, fracture type and mortality did not significantly correlate with age. CONCLUSION: Acceptable outcomes of hip fracture surgery can be achieved in very old patients. In addition, postoperative ambulatory level may be a predictor of mortality.

Postoperative antimicrobial prophylaxis following spinal decompression surgery: is it necessary?

BACKGROUND: Antimicrobial prophylaxis (AMP) can reduce the risk of surgical-site infection (SSI) following many types of surgery, particularly spinal surgery. After publication of the Guideline for Prevention of Surgical Site Infection by the Centers for Disease Control and Prevention in 1999, a large number of studies confirmed the effectiveness of AMP. However, because the concept of AMP is not clear in Japan, the duration of postoperative AMP tends to be long. The purpose of this study was to compare the infection rates following spinal surgery for postoperative AMP versus no postoperative AMP. METHODS: The study comprised 284 patients who underwent spinal surgery without instrumentation at our hospital from October 2003 to August 2009. The patients were divided into two groups based on the method of AMP administration: a postoperative dose group and a no postoperative dose group. SSI incidences were calculated for the two groups. RESULTS: The incidence of SSI was 2.1% (6/284) overall and 2. 8% (4/141) vs. 1.4% (2/143) for the postoperative dose and no postoperative dose groups, respectively. The infection rate difference between the two groups was not significant. The incidence of SSI showed a downward trend as the frequency of antibiotics decreased. Two cases of pseudomembranous colitis, both in the postoperative dose group, were the only complications of the antibiotics. CONCLUSIONS: AMP duration was not related to the SSI rate. SSIs trended lower in the no postoperative dose group compared with the postoperative dose group. Postoperative administration of AMP appears to be unnecessary for spinal decompression surgery without instrumentation.

Dumbbell-type spinal solitary fibrous tumor with paraplegia.

Solitary fibrous tumors are rare tumors that most commonly arise in the pleura. This article describes a case of a large dumbbell-shaped solitary fibrous tumor of the thoracic spine that was causing partial paraplegia. The patient was a 75-year-old woman who presented with swelling of the upper back and weakness of the lower extremities. Magnetic resonance imaging revealed a dumbbell-shaped tumor mass compressing the spinal cord, predominantly at the level of T8. The tumor extended transversely from the bilateral foramen of T8-T10 to the back muscles. The patient experienced increasing weakness of the lower extremities, so a T7-T11 laminectomy was performed and the tumor was excised piecemeal. Microscopically, the tumor was found to be composed of a proliferation of fibroblastic spindle cells. Immunohistochemically, it was strongly positive for CD34 but negative for S100. These findings were consistent with a solitary fibrous tumor. Three months postoperatively, thoracic radiographs showed progression of spinal kyphosis. Posterior fusion with instrumentation was performed. Three years postoperatively, there was no clinical evidence of tumor recurrence. Spinal solitary fibrous tumors are rare, particularly dumbbell-shaped tumors; to our knowledge, only 2 have been reported in the literature. The correct diagnosis is aided by noting the bland fibrous histology, strong CD34 immunostaining, and absence of S100 and cytokeratin positivity. Although solitary fibrous tumors of the spine are rare, they should be considered in the differential diagnosis of intraspinal lesions, particularly those occurring near pleura.

[The effect of non-steroidal anti-inflammatory drugs on upper gastrointestinal disorders in orthopaedic patients].

We investigated the effect of non-steroidal anti-inflammatory drugs (NSAIDs) on upper gastrointestinal(GI) disorders in orthopaedic patients. Among a total of 1,923 patients (946 men and 977 women, mean age: 53 years) who received NSAIDs, 486 patients (25%) experienced some adverse reactions including mild GI symptoms, 364 patients (19%) had gastric mucosal lesion, and 37 patients (2%) had gastric ulcer. The number of patients with upper GI disorders was significantly higher in patients aged 50 years or older, than those under 50 years. Irrespective of the kinds of NSAIDs applied, our results suggest an increased risk of adverse effect causing upper GI disorders in orthopaedic patients who are administered NSAIDs for a long-term.

Thioredoxin gene expression in rat knee articular cartilage after full-thickness injury.

To study the expression of the antioxidative protein thioredoxin (TRX) in intact and injured articular cartilage, we examined the presence of trx mRNA in rat knee joints by in situ hybridization. Our results showed that in the intact knee, most cells, including articular cartilage chondrocytes, expressed trx mRNA. We examined joints at 1, 7, 14, and 28 days after the infliction of full-thickness cartilage injuries on distal femoral condyles. At 1 day after injury, no significant changes were observed in the wound or in trx expression pattern. However, at 7 to 28 days after injury, the wound became filled with repair tissue. Also, trx expression was detected in differentiating mesenchymal cells in the deeper zones of the wound but not in fibroblast-like cells in the upper part of the repair tissue, toward the joint cavity. This lack of TRX expression in the fibroblast-like cells may underlie the susceptibility of the repair tissue fibrocartilage to oxidative stress.

Involvement of ATP, increase of intracellular calcium and the early expression of c-fos in the repair of rat fetal articular cartilage.

To compare the potential of adult and fetal animals to repair articular cartilage, we investigated the early process after creating superficial defects in the femoral knee cartilage in rat models. In fetuses at 19 days of gestation, both chondrocytes and the extracellular matrix responded notably by 48 h after artificial injury. Staining patterns with safranin O revealed that, by 1 h after injury, some components of the extracellular matrix around the wound were modified, and the change spread from the limited region to the entire knee cartilage within 24 h. The chondrocytes in the area surrounding the wound transiently expressed increased level of c-fos from 1 h to 6 h. The wound remained 1 day after birth, i.e., 72 h after injury, but was completely repaired 10 days after birth. In contrast, neither visible responses nor transient c-fos expression was observed in 12-week-old adult articular cartilage 48 h after injury. We also examined the relationships between the intracellular Ca2+ concentration ([Ca2+]i) and the induction of c-fos expression in the cartilage. Applications of ATP or Ca2+ ionophore A23187, both of which increase [Ca2+]i, induced immediate expression of c-fos in primary cultured chondrocytes: 1 microM ATP elicited an increase of [Ca2+]i in chondrocytes in fetal cartilage slices, but 1 mM was required in adult cartilage slices. Our findings show the presence of a signaling pathway that is apparently active in the repair of fetal but not adult articular cartilage and that involves the intercellular transfer of ATP, increase of [Ca2+]i, and expression of c-fos in cartilage.

Arthroscopic drilling with debridement of remaining cartilage for osteochondral lesions of the talar dome in unstable ankles.

BACKGROUND: Arthroscopic examination has shown that the regenerative cartilage that appears after arthroscopic drilling for the treatment of osteochondral lesions of the talar dome does not always cover the cartilage defect sufficiently. HYPOTHESIS: The remaining degenerative cartilage at the lesions may obstruct the healing of the articular cartilage. STUDY DESIGN: Prospective cohort study. METHODS: Thirty-nine patients underwent arthroscopic drilling that kept the remaining cartilage at the lesion (group A), and 30 patients underwent arthroscopic drilling that removed the remaining cartilage at the lesion (group B). At 1 year after the operation, we performed ankle arthroscopy to evaluate the cartilage condition. RESULTS: The arthroscopic findings revealed that in group A, 11 cases (28.2%) were improved, 12 cases (30.8%) were unchanged, and 16 cases (41.0%) had deteriorated; in group B, 27 cases (93.1%) were improved and 2 cases were unchanged. There were significant differences between group A and group B in the rate of cases whose cartilage condition was seen to improve under arthroscopic examination (P < 0.0001). CONCLUSIONS: The study shows that in the treatment of osteochondral lesions of the talar dome, the removing of the remaining degenerative cartilage may be of some benefit in the treatment of these lesions.