Recombinant monoclonal thyrotropin-stimulation blocking antibody (TSBAb) established from peripheral lymphocytes of a hypothyroid patient with primary myxedema.

Anti-TSH receptor antibodies (TRAbs) have been known to be involved in Graves' disease and primary hypothyroidism. We previously isolated and reconstituted immunoglobulin (Ig) genes of Epstein-Barr virus-transformed B cell clones producing monoclonal TRAbs obtained from Graves' patients. In the present study, we performed a similar experiment using a B cell clone, 32A-5, derived from a patient with primary hypothyroidism. The variable region genes of Ig heavy (H) and light (L) chains were isolated and sequenced from the 32A-5 clone. A significant number of somatic mutations were found in variable regions of H and L chain gene segments. Each pair of H and L chain cDNAs was ligated into an expression vector for IgG1 production and stably introduced into myeloma cells. The transfectants were injected ip into BALB/c mice to yield ample volume of the antibody for following applications. Interactions of recombinant 32A-5 with Graves' sera with varying thyroid-stimulating antibody (TSAb) activities were studied. The recombinant antibody tended to suppress TSAb activities in 10 of 15 Graves' sera, in which four were significantly inhibited. In summary, this is the first study to analyze human monoclonal TSH-stimulation blocking antibodies (TSBAb) at the molecular level. Use of human recombinant monoclonal TSBAb may be an analytical tool for molecular-basis etiology and an alternative therapeutic path for Graves' disease.

Drug-induced neutropenia associated with anti-neutrophil cytoplasmic antibodies (ANCA): possible involvement of complement in granulocyte cytotoxicity.

Although antineutrophil antibodies are thought to be involved in drug-induced neutropenia, neither the precise mechanisms nor the particular antigens on the neutrophil surface have yet been clarified. Recently, we examined a patient with Graves' disease who developed antineutrophil cytoplasmic antibodies (ANCA) after propylthiouracil treatment and exhibited neutropenia. Because several target antigens of ANCA are expressed on the surface of neutrophils, it was suggested that ANCA might contribute to neutropenia. The patient's serum bound specifically to neutrophils and HL-60 cells differentiated into granulocytes, and lysed the HL-60 cells via a complement-mediated mechanism. Furthermore, two representative ANCA antigens, proteinase 3 and myeloperoxidase, significantly inhibited both the binding and cytotoxicity of the serum. Finally, tumour necrosis factor-alpha, which is known to up-regulate cell surface expression of several ANCA antigens, enhanced both the binding and cytotoxicity of the serum. These findings suggest that ANCA induced by propylthiouracil contributed to leucopenia through a complement-mediated mechanism.

Substantial production of ghrelin by a human medullary thyroid carcinoma cell line.

Ghrelin, an endogenous ligand for the GH secretagogue receptor, is a novel acylated peptide produced in the gastrointestinal endocrine cells as well as neuroendocrine cells in the hypothalamus. The Ser(3) residue of ghrelin is modified by n-octanoic acid, a modification necessary for hormonal activity. Human medullary thyroid carcinoma is known to produce a variety of gastrointestinal and neuroendocrine peptides. In the present study we investigated ghrelin production in the thyroid gland, especially in human medullary thyroid carcinoma. PCR amplification demonstrated prepro-ghrelin gene transcripts in normal human thyroid tissue and two medullary thyroid carcinoma cell lines (human TT cells and rat 6-23 cells), but not in a rat thyroid follicular cell line. TT cells showed the expression of prepro-ghrelin mRNA of about 0.6 kb by Northern blot analysis. Furthermore, production of ghrelin in TT cells was demonstrated by RIA and immunocytochemistry. Accumulation of des-n-octanoyl ghrelin in the cultured medium of the cells was confirmed. Finally, human medullary thyroid carcinoma surgical specimens showed significantly higher des-n-octanoyl ghrelin contents than normal thyroid tissues. In conclusion, we revealed that ghrelin was produced by the human thyroid parafollicular carcinoma cell line, TT cells. These findings suggest that ghrelin is produced in the thyroid C cells as well as in medullary thyroid carcinoma and may provide opportunities to investigate its physiological role in the thyroid gland.

A low dose of ghrelin stimulates growth hormone (GH) release synergistically with GH-releasing hormone in humans.

The synergistic relationship between GH-releasing secretagogue (GHS) and GH-releasing hormone (GHRH) with respect to GH secretion is well known. In the present study, we report a similar relationship between GHRH and ghrelin, a recently identified endogenous ligand for the GHS receptor. In normal male adults, various doses of ghrelin were intravenously administered alone or together with 1.0 microg/kg GHRH. At small doses of 0.08 and 0.2 microg/kg ghrelin, combined administration of the two peptides significantly stimulated GH release in a synergistic manner; the mean GH response values of the two peptide combinations were more than the summed mean GH response values of each peptide alone (P < 0.05). In addition, at 1.0 microg/kg ghrelin, the tendency of the synergistic effect was observed, although the comparison was not statistically significant probably due to a submaximal dose ceiling effect. No synergistic effects with respect to ACTH or prolactin secretion were observed. In conclusion, the synergistic interaction between ghrelin and GHRH was clearly shown and might be useful for a provocation test to diagnose GH deficiency.

An anatomic examination of the suprascapular flap.

To investigate the potential utility of a suprascapular flap, the authors examined dissected cadavers to identify the ramification of the suprascapular artery, and directly injected 2.5% patent blue dye to observe the distribution of its cutaneous perforators. Results indicate that a suprascapular flap is not practicable. The branching pattern of the suprascapular artery from the subclavian artery varies widely, making dissection of the vessels highly problematic. Moreover, no constant presence of cutaneous perforators from the artery could be identified in either the suprascapular fossa or the shoulder.

Retrograde intra-arterial infusion of prostaglandin E1 and heparin for the no-reflow phenomenon after oromandibular reconstruction with a free fibular flap.

The authors encountered a patient with a tumor of the floor of the mouth in whom the no-reflow phenomenon occurred after excision of the lesion and the mandible, followed by reconstruction using a free fibular flap. A catheter was inserted retrogradely from the point where the peroneal artery had been ligated at the time of flap preparation. Continuous intra-arterial infusion of prostaglandin E1 and heparin was performed, and the flap survived. This method salvaged free flaps subject to the no-reflow phenomenon.

Chondroid syringoma of the orbit.

Chondroid syringoma is a rare subcutaneous tumor that mainly affects the face and the neck. The authors present an occurrence in the orbit, which they believe to be the first reported at that site. Computed tomography and magnetic resonance imaging suggested that the tumor had invaded the globe, but at surgery the mass was well circumscribed and did not invade or adhere to other structures. The tumor was resected easily under general anesthesia. Epithelial cells of characteristic appearance within a chondroid matrix were demonstrated histologically. No recurrence has been evident in more than 1 year of follow-up. Most chondroid syringomas are benign, but because several cases have exhibited malignant behavior, periodic observation following complete resection is required.

Functional reconstruction of total lower lip defects with a radial forearm free flap combined with a depressor anguli oris muscle transfer.

Two total lower lip reconstructions were accomplished by combining a radial forearm free flap and a depressor anguli oris muscle transfer. The radial forearm flap was used to reconstruct the inner surface of the lower lip. The bipedicled musculofascial flap, which includes both depressor anguli oris muscles, the depressor labii inferioris muscles, and the mentalis muscles, was elevated onto the chin and sutured superiorly to the modioli to obtain innervated sphincter function. Good results were obtained both aesthetically and functionally. Electromyography revealed almost normal mobility of the depressor anguli oris muscles 6 months after the operation. No drooling was seen during mastication, and no air leakage was observed during puffing of the cheeks. This is an effective procedure for the reconstruction of the sphincter function of the lower lip.

Bead and wire intermaxillary fixation.

We have developed a method of intermaxillary fixation using beads and wires. This method was effective in mandibular fractures that underwent both open and closed reduction. Our procedure is simple, requires little time, and is inexpensive. We also found several advantages of our technique when compared with the classic arch bar, wire, and eyelet method of intermaxillary fixation.

Monitoring the free radial forearm flap in pharyngo-oesophageal reconstruction.

Monitoring the viability of the free radial forearm flap after pharyngo-oesophageal reconstruction poses technical problems. A method of monitoring using a small island flap elevated distal to the main forearm flap is presented. This monitor flap is easy to elevate. It is placed externally and provides information about the perfusion of the buried reconstruction flap. Postoperative management requires only assessment of tissue colour, turgor, capillary refill and bleeding, as for standard skin flap monitoring.

Reconstruction of burned nasal alae with vascular island skin flaps pedicled on the infraorbital vessels.

A 31-year-old man suffered burns to the forehead, alar grooves and forearms. Vascular island skin flaps, with the infraorbital vessels as the pedicle, were used to reconstruct the burned nasal alae. The case is reported here and the relevant literature is reviewed.

Vermilionplasty using medical tattooing after radial forearm flap reconstruction of the lower lip.

Vermilionplasty using medical tattooing was performed after radial forearm flap reconstruction of the lower lip in 2 patients. This technique is easy to perform in the outpatient setting, does not involve sacrifice of tissue, and results in an acceptable aesthetic outcome. We recommend vermilionplasty with medical tattooing as the procedure of choice after lip reconstruction with a distant flap.

Diffuse and broad podocytic detachment in a case of nephrotic syndrome associated with Kimura's disease.

We report a 49-year-old Japanese male with nephrotic syndrome associated with Kimura's disease. Renal biopsy revealed diffuse podocytic detachment from the glomerular basement membrane (GBM). He had an episode of nephrotic syndrome when complete remission was induced with steroid therapy six years prior to the present admission. However, complete remission of the nephrotic syndrome was not achieved by the steroid on this admission and massive proteinuria (5 g/day) persisted. We suggest that steroid-resistant proteinuria is closely related to podocytic detachment from the GBM and that the production of extracellular matrix by epithelial cells may participate in segmental sclerotic lesions in the patient.

Lid margin reconstruction with an orbicularis oculi musculocutaneous advancement flap and a conchal cartilage graft.

A simple method to reconstruct the midlateral lid margin defect is described using an orbicularis oculi musculocutaneous advancement flap and a free conchal cartilage graft. This method is easy to perform not only in the lower eyelid, but also in the upper one, provides a natural gray line and a stable lid margin without postoperative eversion, and substitutes for the Leone and van Gemert procedure.