Different onset pattern of oculocardiac reflex in pediatric medial wall blowout fractures.

PURPOSE: We report the 2 pediatric patients who had radiographic confirmation of a rare case of medial orbital wall "trapdoor" fracture with extraordinary symptoms of oculocardiac reflex (OCR). METHODS: This was a small interventional case series. RESULTS: This is the retrospective report of 2 boys (13 and 10 years old) who developed diplopia, pain, nausea/vomiting, and general malaise following blunt trauma. However, the onset pattern of OCR was absolutely different: delayed onset of OCR just following therapeutic forced duction test to treat the orbital content herniation in the first case and a sudden onset after injury in the second case. In both cases, urgent surgery led to complete normalization of ocular motility. CONCLUSIONS: Prompt diagnosis and proper treatment are critical to maximize clinical outcome for this rare and critical trauma.

Morphologic study of normal, ingrown, and pincer nails.

BACKGROUND: Pincer nail has been confused with ingrown nail for decades. OBJECTIVE: The objectives were to analyze the circumferential length of pincer nail and the relationship between nail deformity and the underlying distal phalangeal shape. METHODS: The circumferential length of 53 pincer nails was determined at successive 5-mm intervals of the nail plate. Sixty great toes, including normal (n=20), ingrown (n=20), and pincer nails (n=20), were assessed with respect to body height, body weight, body mass index, nail height, nail width index, and nail height index. Nail angle and height of osteophyte were measured. RESULTS: Despite the presence or absence of overcurvature, the circumferential length displayed nearly identical values across the proximal to distal range of the nail. In the pincer nail group, only the correlation between the width and height indices was statistically significant; 50%, 80%, and 100% of cases were confirmed based on osteophyte presence in normal, ingrown, and pincer nails. CONCLUSION: The findings suggest that the mechanical cause may be associated with the over curved nail, which is affected by nail bed contraction. Results may support the hypothesis that an osteophyte of the distal phalanx may not be a cause of, but rather a result of, an overcurving deformity.

Pincer nails treated using zigzag nail bed flap method: results of 71 toenails.

BACKGROUND: In instances of pincer nail deformity, patients complain of pain associated with walking, wearing shoes, or light touching. Cosmetic concerns and difficulties in terms of nail clipping also arise. Achievement of a satisfactory nail form remains elusive. OBJECTIVE: To introduce our original surgical procedure and present the satisfactory results. MATERIALS & METHODS: The zigzag nail bed flap method was used on 71 toenails in 49 patients displaying pincer nails (11 male, 38 female; age range 12-88, mean, 48.6). This investigation evaluated 70 nails from the great toe and one nail from a second toe. RESULTS: No postoperative complications, including pain, infection and conspicuous scars, were evident. The degree of improvement was determined objectively with the width and height indices, revealing the accuracy of this therapeutic measure. CONCLUSION: The authors recommend surgical intervention consequent to the vicious cycle corresponding to anatomical abnormalities associated with the nail plate-nail bed-phalanges relationship. Therefore, these architectures should be treated in conjunction rather than singularly.

Nasal bone clip: a novel approach to nasal bone fixation.

BACKGROUND: Nasal bone fracture is a common injury, but its repair can be unexpectedly difficult. To date, intranasal gauze packing has been used to support the nasal bone in position and to maintain contact between the mucosa of the septum and the cartilage. This gauze packing, however, has a tendency to shift, resulting in an inflammatory response characterized by a foul odor until removal, which detracts from the comfort of the patient. We developed a novel device, the nasal bone clip (NBC), which provides a satisfactory nasal airway and improved comfort. METHODS: A 1.2-mm Kirschner wire and a small piece of hydrocolloid wound dressing are used. The single wire is bent into a double-curved shape, after which each of the 2 tips is curled with pliers. The end of the wire in the nasal passage is covered with a piece of wound dressing to protect the mucosa. After reduction, the external portion of the wire is inserted on the surface of the splint. RESULTS: The NBC was applied in 14 cases: 12 instances of fresh fractures and 2 of old fractures; there were 8 men and 6 women; their mean age was 19.9 years. Complications were not observed; moreover, no patients exhibited problems during the treatment. CONCLUSIONS: The advantages of the NBC are that all materials are available in the operating room or outpatient department, it is low cost, it is readily installable and detachable, it affords superior support for gauze packing, it provides effective external splinting with intranasal support, it never disturbs the nasal airway, and it offers comfort.

Interferon-alpha enhances CD317 expression and the antitumor activity of anti-CD317 monoclonal antibody in renal cell carcinoma xenograft models.

A murine (mAHM) and a humanized (AHM) monoclonal antibody against CD317 (also called tetherin, BST2, or HM1.24 antigen), expressed preferentially in neoplastic B cells such as multiple myeloma, exhibited antitumor effects as a result of antibody-dependent cellular cytotoxicity (ADCC). The putative interferon (IFN) response elements IRF-1/2 and ISGF3 are present in the promoter of the CD317 gene, and IFN has been used for the treatment of not only myeloproliferative diseases but also solid tumors such as renal cell carcinoma (RCC) and melanoma. Therefore, we examined the effects of IFN on the expression of CD317 and on the antitumor activity of AHM and mAHM in RCC and melanoma. Flow cytometry and in vitro ADCC assays with human or mouse effector cells demonstrated that IFN-alpha markedly increased the amount of cell surface CD317 and augmented the ADCC activity of mAHM and AHM in RCC cells and to a lesser extent in melanoma cells. Administration of IFN-alpha to mice bearing RCC xenografts also increased the expression of CD317 in tumor cells. When coadministered with IFN-alpha, mAHM exhibited more profound antitumor activity in both IFN-alpha-sensitive and -insensitive RCC xenograft models. Thus, AHM in combination with IFN-alpha may be an effective therapy for the treatment of RCC.

Development of the 3D-cephalogram: a technical note.

INTRODUCTION: The authors developed the 3D-cephalogram via combination of 3D-CT and cephalometric analysis. METHODS: The 3D-cephalogram can directly express cephalometric data on the surface of skeletal structures in a manner similar to a conventional cephalogram. RESULTS: This analysis revealed complex facial asymmetries in particular, on either side of the mandible. Images displayed no geometric error due to magnification nor any overlap effect inherent in the conventional cephalogram. CONCLUSIONS: The 3D-cephalogram is helpful in instructing physicians, and patients themselves regarding pathological anatomy and treatment procedures.

Construction of a conventional non-radioisotope method to quantify HM1.24 antigens: correlation of HM1.24 levels and ADCC activity of the humanized antibody against HM1.24.

A humanized monoclonal antibody (mAb) against HM1.24 (AHM) caused antibody-dependent cellular cytotoxicity (ADCC) against multiple myeloma (MM) cells. Here, we constructed a conventional non-radioisotope method that quantifies the amount of HM1.24 using fluorescein-labeled AHM. More than 10(4) molecules/cell of HM1.24 were detected in 12 out of 14 patients' MM cells, and a linear correlation was found between ADCC by AHM and the amounts of HM1.24. Thus, AHM is likely to be more efficacious against MM cells with high levels of HM1.24. This conventional non-RI method to quantify HM1.24 will be useful to select patients most likely to respond to AHM.

Antitumor activity of humanized monoclonal antibody against HM1.24 antigen in human myeloma xenograft models.

A humanized monoclonal antibody against HM1.24 antigen (AHM), which is highly expressed on multiple myeloma (MM) cells, induced antibody-dependent cellular cytotoxicity (ADCC) in vitro. In this study, we further characterized AHM and evaluated its potency for clinical application. AHM bound to HM1.24 antigen with a dissociation constant of 0.35 nM, and its epitope resided between Leu116 and Leu127 of the HM1.24 antigen. Single intravenous injection of AHM significantly inhibited tumor growth in both orthotopic and ectopic human MM xenograft models. AHM reduced serum M protein levels and prolonged survival of mice intravenously inoculated with KPMM2 and ARH-77 cells. The number of KPMM2 cells in bone marrow or tumor volume of subcutaneously inoculated RPMI 8226 cells was also inhibited by AHM. The antitumor activity of AHM against tumor cells in bone marrow was diminished when the mice were pretreated with anti-Fcgamma receptor III/II antibody, demonstrating that antitumor activity by AHM requires effector cell functions in vivo. Experiments involving in vitro ADCC assays indicated that NK cells and monocytes/macrophages serve as effector cells for AHM-induced ADCC in mouse and human. Thus, AHM will provide an additional treatment option for MM.

Generation of potent antitumor CTL from patients with multiple myeloma directed against HM1.24.

PURPOSE: The purpose of this work was to test the suitability of the HM1.24 antigen as a CTL target for immunotherapy of patients with multiple myeloma. EXPERIMENTAL DESIGN: Antigen-specific T cells were generated from patients with multiple myeloma using stimulation with protein-pulsed dendritic cells and tested in ELISPOT and CTL assays. RESULTS: HM1.24-primed T cells responded selectively to HM1.24-loaded autologous peripheral blood mononuclear cells (PBMC) in an IFN-gamma ELISPOT assay (median, 342; range, 198-495 IFN-gamma-producing cells/10(5) cf. unloaded PBMC median, 98; range, 7-137; P < 0.05, n = 5) and also to autologous malignant plasma cells (MPC; median, 227; range, 153-335; P < 0.05 when compared with the response to allogeneic MPC median, 57; range, 22-158; n = 5). HM1.24-primed T cells lysed autologous MPC (at 20:1 E/T ratio: median, 48% specific killing; range, 23-88%; at 10:1 E/T ratio: median, 43%; range, 15-80%; n = 12) but not allogeneic MPC. Lysis of autologous MPC was inhibited by anti-MHC class I but not anti-MHC class II antibodies and was blocked by Concanamycin A. Lysis of autologous MPC was blocked by competition with autologous HM1.24-transfected dendritic cells (10:1 ratio with autologous MPC). Unmanipulated, or control plasmid-transfected dendritic cells had no effect on lysis of autologous MPC. CONCLUSION: Our results indicate that HM1.24 is a promising target for immunotherapy of multiple myeloma.

A Novel Reconstructive Procedure for the Divided Nevus of the Eyelids Using a Tissue Expander.

Expanded local flaps and skin grafts (expanded/nonexpanded) are a common approach for reconstructing medium (1.5-20 cm) and large (>20 cm) divided nevi of the eyelids. However, this approach does not often provide a satisfactory cosmetic result, particularly in Asian patients, because of different skin types. We recently devised a new surgical procedure using an extended cheek flap and tissue expander for the medium-sized divided nevus of the eyelids. The upper and lower eyelids are concurrently reconstructed by divided flaps. This method is an effective treatment method for the medium-sized divided nevus of the eyelids and can be applied in total reconstruction of the eyelids in the future. This article presents our novel technique and is illustrated using a brief case report.

Stomaplasty with pannicuectomy in an obese patient with stomal retraction: A case report.

INTRODUCTION: Stomal retraction is a common complication following stoma formation. A repeat surgical procedure for stomal revision is an invasive treatment that is often required as a result. CASE PRESENTATION: An 81-year-old woman with obstructive rectal carcinoma and perforative peritonitis underwent an emergent anterior resection and colostomy (Hartmann's operation). After the operation, the patient changed the stoma pouch every day because of stomal retraction and leakage. Thirty-eight days after the operation, we performed a stomaplasty with pannicuectomy. Following this procedure, the patient changed the stoma pouch twice weekly. DISCUSSION: Stomal retraction is caused by the thick subcutaneous fat and abnormal skin folds in obese patients, as well as the excess tension that is the result of inadequate mobilization. Treatment of stomal retraction typically requires an intraperitoneal stoma revision. Our method of panniculectomy with skin excision but without stomal revision does not involve an incision around the stoma and there is no risk of fecal contamination. CONCLUSION: We report a case of an obese patient who underwent stomaplasty with pannicuectomy for stomal retraction. We believe that stomaplasty with pannicuectomy is a feasible option in obese patients with stomal retraction.

Potent induction of activin A secretion from monocytes and bone marrow stromal fibroblasts by cognate interaction with activated T cells.

Activin A is a multifunctional cytokine essential for cell differentiation and apoptosis including erythroid cell differentiation in the bone marrow. In addition, activin A is induced by inflammation and exerts anti-inflammatory effects. However, the mechanism of activin A induction is still unclear, especially by inflammatory processes. Here we show that activin A secretion from monocytes and bone marrow stromal fibroblasts, its major sources in the bone marrow, is markedly enhanced by cognate interaction with activated T cells. This process is mediated by CD40/CD40 ligand interaction as well as concomitantly secreted T cell-derived cytokines, granulocyte macrophage-colony stimulating factor, and interferon-gamma. Furthermore, stromal fibroblasts as well as monocytes provide a costimulatory signal to anti-CD3-treated T cells via CD80 and CD86 to maintain the enhanced activin A production. These findings suggest that activin A is potently induced in the bone marrow and may play a role in the suppression of inflammatory or immune processes.

Primary adult T-cell leukemia/lymphoma of bone.

A 77-year-old man developed primary adult T-cell leukemia/lymphoma (ATL) of the bone with osteolytic lesions. A biopsy of the lesion revealed proliferation of atypical, large lymphoid cells with a local increase of osteoclasts. The clonal integration of human T-lymphotropic virus type I proviral DNA revealed the tumor cells to be ATL. They produced macrophage inflammatory protein 1alpha (MIP-1alpha) but not parathyroid hormone-related protein or other osteoclast-activating factors. Because MIP-1 produced by tumor cells enhances the expression of receptor activator of nuclear factor kappaB ligand (RANKL) of local osteoblasts and stromal cells, even of tumor cells, the increase of osteoclasts in the close vicinity of ATL cells was considered to result in local bone destruction.

Scanning electron microscopic observations of 'fractured' biodegradable plates and screws.

BACKGROUND: We encountered two out of 100 cases in which implanted biodegradable plates and screws had fractured within 1 month postoperatively. MATERIAL: Failure of the material was confirmed through clinical symptoms, radiographs or CT findings. In addition, four specimens obtained from these two cases were examined with regard to their ultrastructure using scanning electron microscopy. RESULTS: Several principal patterns of the fractured surface were found: (1) gradual cracking, i.e. 'circular stair' and, (2) tortuous threads, i.e. a wavy line. It is conceivable that the material may not have been hit by major sudden forces but a disproportion between the thread configuration and the drilled hole may have led to screw loosening and torsion. Subsequently, the threads were deformed in a 'wavy' manner, finally leading to cracking and fracture of plates and screws. Fractures of plates and screws due to these instabilities are thought to be distinguishable from material resorption. CONCLUSION: In the application of biodegradable materials, more than two screws per single bone segment should be used as a principle of plate-fixation technique in order to avoid a stability-compromising situation, particularly in the stress-bearing areas of the maxillofacial region. Moreover, three-dimensional fixation using more than two plates is recommended in the facial skeleton e.g. zygomatic tripod. Intermaxillary fixation should also be considered to reinforce initial stability in stress-bearing areas.

Intracranial migration of fixation wires following correction of craniosynostosis in an infant.

BACKGROUND: In the craniofacial skeleton, osseous fixation techniques for stabilization include stainless steel wire, miniplates or bioresorbable plates; in some cases, stainless steel wires are still indicated. Most recently, several case reports have demonstrated that microplates or stainless steel wires migrate intracranially when used in the craniofacial skeleton in neonates. PATIENT: We present the case of a 7-year-old male who underwent treatment of brachycephaly at the age of 5 months. In this patient, internal migration of wires was observed. CONCLUSION: In our opinion, there is a difference between migration of wires and of plates in the growing cranium. Factors affecting the incidence of material migration in cranioplasty are believed to include (1) age, (2) site and (3) the material itself.

Orbital wall reconstruction with bone grafts from the outer cortex of the mandible.

AIM: The purpose of the study was to assess the efficacy of bone grafting from the mandibular outer cortex for reconstructing the orbital walls. MATERIAL AND METHODS: Bone grafting was performed in 75 patients. The site the transplants were harvested from were: A: mental region, B: area posterior to the mental foramen, C: ramus region. In order to obtain the appropriate curvature for the orbital floor, proper selection of the donor area is required. The bony defect size was confirmed pre-operatively from 3D-CT data. Bone, characteristically 2-3 mm thick, was harvested from each area and grafted into the blow-out fractures. RESULTS: Out of the 75 patients 13 cases underwent reconstruction using mandibular outer cortex bone from area A, 8 from area B, and 54 from area C. The maximum size available for harvest from area C was 7 x 4 cm; material from this area could also be used for the repair of both medial and inferior orbital wall defects if necessary. CONCLUSION: Bone harvest from the mandible affords several advantages including (1) ease of harvest, (2) ease of trimming, (3) appropriate size and curvature, (4) absence of functional disability, (5) no secondary deformity, (6) no visible scars, (7) post-operative immobilization not necessary, (8) absence of post-operative difficulties with respect to breathing and walking and (9) major complications are rare.

Retrograde dacryocystography (RDC) utilizing a round-tipped needle.

Because the application of conventional anterograde dacryocystography has been restricted in cases with an intact lacrimal punctum, the indications are rather limited. The authors developed a new method for retrograde dacryocystography (RDC) using a hand-made round-tipped needle inserted directly into the orifice of the nasolacrimal duct. A 60 mm long aluminum tube (3 mm in diameter) was used to prepare the round-tipped needle. The distal portion of the tube was bent to an angle of about 80 degrees. The tip was then coated with synthetic resin adhesive to make it round. Following the insertion of the round-tipped needle directly into the inferior meatus, the tip was moved back and forth to find the orifice without visual observation. The complete insertion of the tip of the needle into the nasolacrimal duct was recognized by a fixed sensation of the tip. Contrast medium was then injected, and PA radiography was carried out. In the present paper, the authors report the usefulness of RDC, which is applicable even in cases of injury or obstruction in the upper lacrimal system. In 16 of 20 patients, the quality of the RDC images was judged as excellent. RDC can be carried out within a few seconds after acquiring the technical skills, and is thought to be a useful method, especially in cases of upper lacrimal injury.

Bilateral parotid sialoadenitis with gonial hypertrophy.

Sialoadenitis is a non-inflammatory condition that affects mainly the parotid, and is characterised by bilateral, painless swelling, which is an appreciable problem in young women. A 28-year-old woman presented with parotid sialoadenitis with masseteric hypertrophy. She was treated by superficial parotidectomy and ostectomy of the mandibular angle and made an uncomplicated recovery.