Basement membrane zone IgE deposition is associated with bullous pemphigoid disease severity and treatment results.

BACKGROUND: A subset of patients with bullous pemphigoid (BP) show deposition of IgE in the basement membrane zone (BMZ), yet the relationship between BMZ IgE and the clinical presentation of BP remains unclear. OBJECTIVES: To investigate the relationship between IgE deposition, IgE levels in serum, and disease severity in patients with BP. METHODS: We investigated IgE autoantibodies in 53 patients with BP by direct immunofluorescence (DIF), indirect immunofluorescence and enzyme-linked immunosorbent assay. RESULTS: Of 53 patients with BP, 23 (43%) had IgE deposition, 10 (19%) of whom were IgE+ and 13 (25%) IgE± according to DIF analyses. Erosion/blister (E/B) Bullous Pemphigoid Disease Area Index (BPDAI) scores were significantly higher in IgE+ patients than in IgE- patients (n = 15), while no significant differences were found for urticaria/erythema BPDAI scores. IgE+ and IgE± patients took longer to reduce their E/B BPDAI score by 75% after systemic corticosteroid treatment. BP180-IgE levels were significantly higher among IgE+ patients than IgE± or IgE- patients (n = 10). Total IgE levels in the serum and blood eosinophil counts did not differ between IgE+, IgE± and IgE- patients. A significant correlation was detected between BP180-IgG and BP180-IgE, but not between BPDAI scores and any of BP180-IgG, BP180-IgE or blood eosinophil count. CONCLUSIONS: IgE deposition in the BMZ is associated with higher E/B BPDAI scores and longer treatment periods. We conclude that IgE binding in the BMZ may contribute to BP pathogenesis by promoting blister formation. What's already known about this topic? BP180-IgE autoantibodies have an important role in the pathogenesis of bullous pemphigoid (BP). A subset of patients with BP display deposition of IgE within the basement membrane zone (BMZ) of skin tissue. What does this study add? Patients with in vivo IgE deposition in the BMZ displayed higher erosion/blister Bullous Pemphigoid Disease Area Index (BPDAI) scores, while urticaria/erythema BPDAI scores were not significantly different. Patients with in vivo IgE deposition in the BMZ took longer to reduce their erosion/blister BPDAI score by 75% after systemic corticosteroid treatment. BP180-specific IgE levels in serum were higher among patients with linear IgE deposition in the BMZ than in those with granular or no IgE deposition.

Results of the guideline-based treatment for pemphigus: a single-centre experience with 84 cases.

BACKGROUND: The Japanese guidelines for the management of pemphigus (JG) were published in 2010. However, further progress in the treatment of pemphigus requires their validation. OBJECTIVES: To examine the efficacy and safety of treatments based on the JG. METHODS: A retrospective study of 84 Japanese patients with moderate to severe pemphigus, who were initially treated in accordance with the JG and then followed up for >2 years, was performed in a single centre. Treatment typically consisted of 0.5-1 mg prednisone (PSL)/kg/day accompanied by 100 mg azathioprine/day as a steroid-sparing agent. RESULTS: In 83 of the 84 patients (98.8%), complete remission on minimal therapy (≤10 mg PSL/day and concomitant immunosuppressive agent) was achieved. The time between initiation of therapy and remission was 13.9 ± 9.4 months. In 78 patients (92.9%), remission was accomplished within the 2-year follow-up. The 32 patients with recalcitrant disease (38.1%) received additional treatment. Relapse occurred in 12 patients (14.3%) either during tapering of the PSL dose (six patients) or after achieving remission (six patients). Adverse events, mostly liver enzyme elevation, infections and diabetes, occurred in 67 patients (79.8%). One patient (1.2%) died during the observation period after gastrointestinal haemorrhage. CONCLUSIONS: Our results suggested that the elderly and patients requiring additional therapies were at higher risk of adverse events, including severe infections, and should thus be monitored carefully. This study provided clinical data that could inform revised guidelines and contribute to the evaluation of future novel therapies.

Combined reconstructive surgery involving uterosacral colpopexy and anterior vaginal mesh implantation for pelvic organ prolapse.

AIM: The optimal treatment for pelvic organ prolapse has been the subject of much discussion. The aim of this study was to assess the utility of a combination of uterosacral colpopexy and anterior vaginal mesh implantation. METHODS: A single-center prospective cohort study was conducted. Twenty-eight patients with stage III-IV cystocele and uterine prolapse underwent reconstructive surgery. A combination of vaginal hysterectomy, McCall culdeplasty, and trocar-guided anterior vaginal mesh implantation was performed, and the patients' postoperative outcomes were analyzed. Patient satisfaction was investigated using the modified Short Form 12 version 2 (SF-12v2) questionnaire, and interviews regarding sexual behavior were conducted at 1 postoperative year. RESULTS: A bladder injury occurred during the dissection in one case (3.6%). Recurrent vaginal vault prolapse beyond the hymen was observed in one patient (cure rate: 96.4%), and further mesh augmentation was required in this case. Another patient developed mild cystocele (Ba = 0), but was simply observed because she did not complain of any symptoms caused by vaginal descent. We did not experience any other mesh-related complications, such as protrusion, chronic pain, or chronic inflammation, during the follow-up period. The patients' modified SF-12 scores at 12 months were significantly better than their preoperative scores in all eight domains. CONCLUSION: The satisfactory correction of pelvic organ prolapse was achieved using a combination of vaginal hysterectomy and uterosacral ligament colpopexy augmented by anterior vaginal mesh implantation. © 2016 Japan Society of Obstetrics and Gynecology.

Time-interval analysis of ductus venosus flow velocity waveforms in twin-to-twin transfusion syndrome treated with laser surgery.

OBJECTIVES: To investigate time-interval variables of ductus venosus (DV) flow velocity waveforms (FVWs) in twin-to-twin transfusion syndrome (TTTS), comparing the results with reference ranges from normal singleton fetuses. The impact of laser surgery and the effect of prognostic factors were also evaluated. METHODS: In 107 TTTS cases, DV-FVWs of both recipients and donors were recorded 1 day before and 2 days after laser therapy. Time intervals for systolic (S) and early diastolic (D) peaks were analyzed retrospectively with regard to acceleration time (acc-S and acc-D for S and D, respectively) and deceleration time (dec-S and dec-D for S and D, respectively). For each variable, Z-scores were calculated with respect to previously reported normal reference ranges. RESULTS: Z-scores for all variables showed statistically significant differences from those observed previously in normal fetuses, with the exception of dec-S of donors. The most striking differences were observed in longer dec-S of recipients (P < 0.001) and longer dec-D of donors (P < 0.001). Laser therapy showed significant impact on dec-S and acc-D in recipients and on all variables in donors. Regarding the short-term prognosis, acc-S and dec-S showed significant differences for the prediction of intrauterine fetal demise in donors (P = 0.009 and P = 0.011, respectively). CONCLUSION: This study demonstrates that time-interval variables of DV-FVWs may differentiate the characteristic hemodynamic changes caused by unbalanced blood volume between recipients and donors.

Alterations in time intervals of ductus venosus and atrioventricular flow velocity waveforms in growth-restricted fetuses.

OBJECTIVE: To investigate time intervals of the ductus venosus (DV) flow velocity waveform (FVW) and those of the cardiac cycle that correspond with each DV-FVW component in fetuses with intrauterine growth restriction (IUGR) due to placental insufficiency. METHODS: Women with a pregnancy complicated by IUGR were recruited into the study, as was a normal control group. Time intervals for systolic (S) and diastolic (D) components were measured in DV-FVW as follows: S(DV), from the nadir of the a-wave during atrial contraction to the nadir between the S-wave and D-wave; D(DV), from the nadir between S-wave and D-wave to the nadir of the a-wave. Regarding cardiac cycles, the following variables were measured from ventricular inflow through the tricuspid valve (TV) and mitral valve (MV): S(TV) and S(MV), from the second peak of ventricular inflow caused by atrial contraction (A-wave) to the opening of the atrioventricular valve; D(TV) and D(MV), from the opening of the atrioventricular valve to the peak of the A-wave. In the IUGR group, only the last examination performed within 1 week of delivery was used for analysis. All variables were analyzed statistically using Z-scores. RESULTS: Data were obtained from 249 normal fetuses and 26 fetuses with IUGR. Compared to normal fetuses, S(DV) showed a significant decrease (P < 0.001), while D(DV) showed a significant increase (P < 0.001) in the IUGR group. Regarding cardiac cycles, S(TV) and S(MV) showed significant decreases (P = 0.014 and P < 0.001, respectively) and D(TV) and D(MV) showed significant increases (P = 0.008 and P = 0.002, respectively) in fetuses with IUGR. CONCLUSION: Time-interval alterations of DV-FVW in growth-restricted fetuses reflect the hemodynamic events caused by placental insufficiency.

Revision of the Massarineae (Pleosporales, Dothideomycetes).

We here taxonomically revise the suborder Massarineae (Pleosporales, Dothideomycetes, Ascomycota). Sequences of SSU and LSU nrDNA and the translation elongation factor 1-alpha gene (tef1) are newly obtained from 106 Massarineae taxa that are phylogenetically analysed along with published sequences of 131 taxa in this suborder retrieved from GenBank. We recognise 12 families and five unknown lineages in the Massarineae. Among the nine families previously known, the monophyletic status of the Dictyosporiaceae, Didymosphaeriaceae, Latoruaceae, Macrodiplodiopsidaceae, Massarinaceae, Morosphaeriaceae, and Trematosphaeriaceae was strongly supported with bootstrap support values above 96 %, while the clades of the Bambusicolaceae and the Lentitheciaceae are moderately supported. Two new families, Parabambusicolaceae and Sulcatisporaceae, are proposed. The Parabambusicolaceae is erected to accommodate Aquastroma and Parabambusicola genera nova, as well as two unnamed Monodictys species. The Parabambusicolaceae is characterised by depressed globose to hemispherical ascomata with or without surrounding stromatic tissue, and multi-septate, clavate to fusiform, hyaline ascospores. The Sulcatisporaceae is established for Magnicamarosporium and Sulcatispora genera nova and Neobambusicola. The Sulcatisporaceae is characterised by subglobose ascomata with a short ostiolar neck, trabeculate pseudoparaphyses, clavate asci, broadly fusiform ascospores, and ellipsoid to subglobose conidia with or without striate ornamentation. The genus Periconia and its relatives are segregated from the Massarinaceae and placed in a resurrected family, the Periconiaceae. We have summarised the morphological and ecological features, and clarified the accepted members of each family. Ten new genera, 22 new species, and seven new combinations are described and illustrated. The complete ITS sequences of nrDNA are also provided for all new taxa for use as barcode markers.

Topical application of PPARα (but not ß/δ or γ) suppresses atopic dermatitis in NC/Nga mice.

BACKGROUND: Peroxisome proliferator-activated receptors (PPARs) are nuclear receptors, which regulate not only adipogenesis and proliferation/differentiation but also the immune response of cells. Because topical application of the activators of some PPAR isoforms improved clinical symptoms in patients with atopic dermatitis (AD), we investigated the role of PPAR activators using a murine AD model in NC/Nga mice; to the best of our knowledge, this has not been previously reported. METHODS: Activators of three PPAR isoforms (α, ß/δ, γ) were topically applied on inflamed skin in a murine AD model that was developed by repeated topical application of mite antigen in NC/Nga mice. The efficacy of each topical PPAR activator was evaluated immunologically and serologically. RESULTS: Topical application of the PPARα activator, but not of the activators of PPARß/δ or PPARγ, improved clinical dermatitis, reduced inflammatory cell infiltration in the dermis, and alleviated the elevation of serum IgE levels. In addition, PPARα expression was downregulated in the epidermis in our murine AD model, as is seen in patients with AD. CONCLUSIONS: Topical application of PPARα activator could be a potent therapeutic agent for patients with AD and could take the place of topical steroid treatments.

The macrophage scavenger receptor type A is expressed by activated macrophages and protects the host against lethal endotoxic shock.

During gram-negative bacterial infections, lipopolysaccharide (LPS) stimulates primed macrophages (Mphi) to release inflammatory mediators such as tumor necrosis factor (TNF)-alpha, which can cause hypotension, organ failure, and often death. Several different receptors on Mphi have been shown to bind LPS, including the type A scavenger receptor (SR-A). This receptor is able to bind a broad range of polyanionic ligands such as modified lipoproteins and lipoteichoic acid of gram-positive bacteria, which suggests that SR-A plays a role in host defense. In this study, we used mice lacking the SR-A (SRKO) to investigate the role of SR-A in acquired immunity using a viable bacillus Calmette Guérin (BCG) infection model. We show that activated Mphi express SR-A and that this molecule is functional in assays of adhesion and endocytic uptake. After BCG infection, SRKO mice are able to recruit Mphi to sites of granuloma formation where they become activated and restrict BCG replication. However, infected mice lacking the SR-A are more susceptible to endotoxic shock and produce more TNF-alpha and interleukin-6 in response to LPS. In addition, we show that an antibody which blocks TNF-alpha activity reduces LPS-induced mortality in these mice. Thus SR-A, expressed by activated Mphi, plays a protective role in host defense by scavenging LPS as well as by reducing the release by activated Mphi of proinflammatory cytokines. Modulation of SR-A may provide a novel therapeutic approach to control endotoxic shock.

Aortic arch malformations and ventricular septal defect in mice deficient in endothelin-1.

Endothelin-1 (ET-1) is a 21-amino acid peptide with various biological activities including vasoconstriction and cell proliferation. To clarify the physiological and pathophysiological role of ET-1, we disrupted the mouse Edn1 locus encoding ET-1 by gene targeting and demonstrated that ET-1 is essential to the normal development of pharyngeal arch-derived tissues and organs. In this study, we focused on the phenotypic manifestations of Edn1-/- homozygous mice in the cardiovascular system. Edn1-/- homozygotes display cardiovascular malformations including interrupted aortic arch (2.3%), tubular hypoplasia of the aortic arch (4.6%), aberrant right subclavian artery (12.9%), and ventricular septal defect with abnormalities of the outflow tract (48.4%). The frequency and extent of these abnormalities are increased by treatment with neutralizing monoclonal antibodies or a selective ETA receptor antagonist BQ123. At an earlier embryonic stage, formation of pharyngeal arch arteries and endocardial cushion is disturbed in Edn1-/- homozygotes. In situ hybridization confirmed ET-1 expression in the endothelium of the arch arteries and cardiac outflow tract and the endocardial cushion as well as in the epithelium of the pharyngeal arches. Thus, ET-1 is involved in the normal development of the heart and great vessels, and circulating ET-1 and/or other ET isoforms may cause a functional redundancy, at least partly, through the ETA receptor.

Targeting gene expression to the vascular wall in transgenic mice using the murine preproendothelin-1 promoter.

To develop a system for overexpressing genes in the vascular wall, we created transgenic mice using the reporter gene luciferase and the murine preproendothelin-1 promoter. In vitro analysis suggested that the murine 5'-flanking region contained endothelial-specific elements in a 5.9-kb fragment. Five transgenic mice colonies established from independent founders all exhibited the highest level of luciferase activity in the aorta with up to 8,540 light units per microgram of protein. Immunohistochemistry with anti-luciferase antisera revealed high levels of expression in the endothelial cells of both large and small arteries and lower levels of expression in veins and capillaries. Significant expression was also seen in arterial smooth muscle cells and in select epithelial surfaces which is consistent with the known distribution of endothelin-1 in mammals. The further demonstrate the targeting capability of this system, we overexpressed the lipid-peroxidating enzyme, human 15-lipoxygenase, in the vessel wall of transgenic mice. As with luciferase, expression of active enzyme and immunohistochemical localization in vascular cells were documented in transgenic animals. Hence, this new system can be used to direct expression of molecules to the vascular wall for the purpose of examining the biological significance of either overexpression or inhibition of select proteins.

ADAMTS-1: a metalloproteinase-disintegrin essential for normal growth, fertility, and organ morphology and function.

A disintegrin and metalloproteinase (ADAM) represents a protein family possessing both metalloproteinase and disintegrin domains. ADAMTS-1, an ADAM family member cloned from cachexigenic colon adenocarcinoma, is unusual in that it contains thrombospondin type I motifs and anchors to the extracellular matrix. To elucidate the biological role of ADAMTS-1, we developed ADAMTS-1-null mice by gene targeting. Targeted disruption of the mouse ADAMTS-1 gene resulted in growth retardation with adipose tissue malformation. Impaired female fertilization accompanied by histological changes in the uterus and ovaries also resulted. Furthermore, ADAMTS-1(-/-) mice demonstrated enlarged renal calices with fibrotic changes from the ureteropelvic junction through the ureter, and abnormal adrenal medullary architecture without capillary formation. ADAMTS-1 thus appears necessary for normal growth, fertility, and organ morphology and function. Moreover, the resemblance of the renal phenotype to human ureteropelvic junction obstruction may provide a clue to the pathogenesis of this common congenital disease.

Elevated sympathetic nervous activity in mice deficient in alphaCGRP.

alpha-Calcitonin gene-related peptide (alphaCGRP) is a pleiotropic neuropeptide implicated in a variety of physiological processes. To better understand the biological functions of alphaCGRP, we developed an alphaCGRP-null mouse model using a gene targeting approach. Recordings of mean arterial pressure (MAP) and heart rate (HR) showed that basal MAP and HR were significantly higher in both anesthetized and conscious, unrestrained alphaCGRP-null mice than in corresponding wild-type mice. The elevated MAP in alphaCGRP-null mice was shown to be the result of elevated peripheral vascular resistance by alpha-adrenergic blockade with prazosin and by transthoracic echocardiogram, which revealed no significant differences between alphaCGRP-null and wild-type mice in the stroke volume, fractional shortening, and ejection fraction. Moreover, evaluation of autonomic nervous activity by measuring HR after pretreatment of atropine and/or atenolol and by analyzing arterial baroreceptor reflexes showed sympathetic nervous activity to be significantly elevated in alphaCGRP-null mice; elevated levels of urinary catecholamine metabolites and decreased HR variability in mutant mice were also consistent with that finding. These findings suggest that alphaCGRP contributes to the regulation of cardiovascular function through inhibitory modulation of sympathetic nervous activity.