Herpetiform pemphigus with characteristic transmission electron microscopic findings of various-sized ballooning vacuoles in keratinocytes without acantholysis.

We report a unique case of a Japanese woman with herpetiform pemphigus (HP) who had IgG autoantibodies reactive with nondesmosomal sites of keratinocytes and presented characteristic transmission electron microscopic (TEM) findings of various-sized vacuoles in keratinocytes without acantholysis. The patient presented with pruritic annular oedematous erythemas with small blisters lining the margins on the trunk and extremities. Histopathological examinations showed intraepidermal blisters with prominent infiltrations of eosinophils. Direct and indirect immunofluorescence tests revealed the presence of in vivo bound and circulating IgG autoantibodies to the keratinocyte cell surfaces. However, enzyme-linked immunosorbent assays for desmoglein (Dsg) 1, Dsg3 and desmocollins 1-3 showed negative results. Immunoblotting using the full-length human Dsg1 recombinant protein showed a positive band. TEM examination showed various-sized vacuoles squashing the nuclei in many keratinocytes, resulting in rupture of the cells. Immunoelectron microscopic examination revealed IgG deposition over the entire keratinocyte cell surfaces, which spared the desmosomes. IgG antibodies were also present on the inside walls of the vacuoles around the nuclei of keratinocytes and on the cell surfaces of infiltrating eosinophils. This patient also had marked eosinophilia and high levels of thymus and activation-regulated chemokine and interleukin-5 in the serum. These results indicated a novel autoantigen on the nondesmosomal keratinocyte cell surfaces and the pathogenesis of bullous spongiotic change with inflammation in HP.

An in situ hybridization study of perlecan, DMP1, and MEPE in developing condylar cartilage of the fetal mouse mandible and limb bud cartilage.

The main purpose of this in situ hybridization study was to investigate mRNA expression of three bone/cartilage matrix components (perlecan, DMP1, and MEPE) in developing primary (tibial) and secondary (condylar) cartilage. Perlecan mRNA expression was first detected in newly formed chondrocytes in tibial cartilage at E13.0, but this expression decreased in hypertrophic chondrocytes at E14.0. In contrast, at E15.0, perlecan mRNA was first detected in the newly formed chondrocytes of condylar cartilage; these chondrocytes had characteristics of hypertrophic chondrocytes, which confirmed the previous observation that progenitor cells of developing secondary cartilage rapidly differentiate into hypertrophic chondrocytes. DMP1 mRNA was detected in many chondrocytes within the lower hypertrophic cell zone in tibial cartilage at E14.0. In contrast, DMP1 mRNA expression was only transiently detected in a few chondrocytes of condylar cartilage at E15.0. Thus, DMP1 may be less important in the developing condylar cartilage than in the tibial cartilage. Another purpose of this study was to test the hypothesis that MEPE may be a useful marker molecule for cartilage. MEPE mRNA was not detected in any chondrocytes in either tibial or condylar cartilage; however, MEPE immunoreactivity was detected throughout the cartilage matrix. Western immunoblot analysis demonstrated that MEPE antibody recognized two bands, one of 67 kDa and another of 59 kDa, in cartilage-derived samples. Thus MEPE protein may gradually accumulate in the cartilage, even though mRNA expression levels were below the limits of detection of in situ hybridization. Ultimately, we could not designate MEPE as a marker molecule for cartilage, and would modify our original hypothesis.

Criteria for preserving posterior cruciate ligament depending on intra-operative gap measurement in total knee replacement.

OBJECTIVES: Because posterior cruciate ligament (PCL) resection makes flexion gaps wider in total knee replacement (TKR), preserving or sacrificing a PCL affects the gap equivalence; however, there are no criteria for the PCL resection that consider gap situations of each knee. This study aims to investigate gap characteristics of knees and to consider the criteria for PCL resection. METHODS: The extension and flexion gaps were measured, first with the PCL preserved and subsequently with the PCL removed (in cases in which posterior substitute components were selected). The PCL preservation or sacrifice was solely determined by the gap measurement results, without considering other functions of the PCL such as 'roll back.' RESULTS: Wide variations were observed in the extension and flexion gaps. The flexion gaps were significantly larger than the extension gaps. Cases with 18 mm or more flexion gap and with larger flexion than extension gap were implanted with cruciate retaining component. A posterior substitute component was implanted with the other cases. CONCLUSIONS: In order to make adequate gaps, it is important to decide whether to preserve the PCL based on the intra-operative gap measurements made with the PCL intact. Cite this article: Bone Joint Res 2014;3:95-100.

Perioperative management of severe anorexia nervosa.

As the prevalence of anorexia nervosa (AN) increased, surgery in severe AN patients also increased in the 2000s. We experienced a surgical case of a patient with severe AN, showing an extremely low BMI of 8.6 kg m(-2). We investigated the problems associated with this case and propose criteria to manage severe AN. We endeavour to report on the perioperative management of rare and severe symptoms and surgical indications of severely malnourished patients. All published reports were identified through comprehensive searches using PubMed, BioMedLib, and the Japan Medical Abstracts Society with the following terms and keywords: 'anorexia nervosa', 'eating disorder', 'hypoglycaemia', 'leucocytopaenia', 'gelatinous bone marrow', 'surgery', and 'operation'. In cases of AN with a BMI under 13 kg m(-2), marked hypoglycaemia, leucocytopaenia <3.0×10(9) litre(-1), or both, potentially fatal complications frequently occur. Accordingly, patients need strict nutritional support to avoid re-feeding syndrome until surgery. During the course of anaesthesia, careless loading of glucose or catecholamine may lead to disturbance of electrolytes or fatal arrhythmia. Intensive care and early feeding as soon as possible after surgery are important to prevent surgical site infection. Although not many perioperative cases of AN have been reported, clinicians must be aware of the danger and the causes of mortality in critical cases. Thus, the decision to undertake surgery must be taken carefully and close perioperative coordination among physicians, surgeons, psychiatrists, anaesthesiologists, and intensivists is essential.

Analysis of serum chemokine levels in patients with HIV-associated eosinophilic folliculitis.

BACKGROUND: Patients with human immunodeficiency virus (HIV) infection exhibit various skin diseases. HIV-associated eosinophilic folliculitis (EF) and pruritic papular eruption (PPE) are frequently seen. OBJECTIVE: To understand the mechanisms underlying HIV-associated EF and PPE. METHODS: In order to know frequencies of EF and PPE among patients with HIV infection, we first collected HIV(+) patients who visited dermatology clinic in National Center for Global Health and Medicine during February 2007. We next collected 25 serum samples from HIV(+) patients with skin diseases from May 2008 to May 2010. Eight of 25 patients had EF (EF group), four had PPE (PPE group) and others had non-itchy skin problems such as condyloma acuminatum (no itch group). RESULTS: We first confirmed high frequencies of EF (10.7%) and PPE (5.3%) among 75 HIV(+) patients who visited our clinic during one month. We then measured serum levels of CCL11, CCL17, CCL26 and CCL27. Serum CCL17 levels in EF were significantly higher than those of PPE and no itch group. Serum CCL26 and CCL27 levels in EF were higher than those of no itch group. The number of CD4(+) cells in EF was significantly lower than that in no itch group. CONCLUSION: High serum levels of CCL17, CCL26 and CCL27, and low CD4(+) cell counts may account for the development of HIV-associated EF.

Thermographic findings in a case of type 2 diabetes with foot ulcer and osteomyelitis.

Using thermography, skin temperature was evaluated in a 76-year-old patient with type II diabetes mellitus, presenting with diabetic foot ulceration on the right hallux and a corn on the left fourth toe. Increased skin temperature was observed in both the right hallux and the left fourth toe, though there were no visible clinical signs of infection. Unexpectedly, the high temperature area was seen to extend from the left fourth toe to the ankle. The patient was later diagnosed with osteomyelitis, due to the presence of a high-intensity area on T2-weighted magnetic resonance imaging, suggesting the elevated skin temperature was due to osteomyelitis. Based on these observations, thermography could prove useful for screening for foot ulcers with osteomyelitis.

Diagnostic accuracy of 18F-2-deoxy-fluoro-D-glucose positron emission tomography for pN1 lymph nodes in patients with lung cancer.

BACKGROUND: Nodal status has been reported to be one of the most important factors affecting survival in patients with lung cancer. For determining treatment strategy, accurate evaluation of nodal status is expected. PURPOSE: To evaluate the accuracy of (18)F-2-deoxy-fluoro-D-glucose (FDG) positron emission tomography (PET) for diagnosing nodal status in lung cancer patients with pathologically proven N1 (pN1) lymph node metastases, in comparison with that of computed tomography (CT). MATERIAL AND METHODS: Nineteen pN1 patients with primary lung cancer undergoing preoperative CT and FDG-PET were investigated. The diagnosis was confirmed by surgery in all patients. Lymph nodes were considered to be positive when uptake higher than the surrounding mediastinum level was visually observed. Radiological and pathological correlation was investigated, and the association between FDG uptake and the size of metastatic nodes was evaluated. RESULTS: Of the 19 pN1 patients, nodal stage determined by FDG-PET was cN0 in eight, cN1 in four, cN2 in six, and cN3 in one. Thus, FDG-PET provided correct N-staging in 21%, under-staging in 42%, and over-staging in 37%. FDG-PET could not depict pN1 lymph node in six (32%) of 19 patients. In two patients (11%), mild symmetrical hilar and mediastinal accumulation was found and considered as benign physiological uptake. In six patients (32%), the ipsilateral mediastinal uptake was depicted and diagnosed as cN2. One patient was diagnosed as cN3 because of FDG accumulation at the supraclavicular fossa. On CT, nodal staging was cN0 in nine, cN1 in six, and cN2 in four. CT staging was therefore correct in 32%, underestimated in 47%, and overestimated in 21%. CONCLUSION: The diagnostic accuracy of FDG-PET (21%) was low and similar to that of CT (32%); under- and over-diagnosis were found in similar proportions. The limitation of FDG-PET should be recognized when nodal staging might alter the therapeutic strategy in patients with primary lung cancer.

Reduced-intensity hematopoietic stem-cell transplantation for malignant lymphoma: a retrospective survey of 112 adult patients in Japan.

We conducted a nation-wide survey of 112 adult Japanese patients who underwent reduced-intensity stem cell transplantation (RIST) from 1999 to 2002. Underlying diseases included indolent (n=45), aggressive (n=58) and highly aggressive lymphomas (n=9). Median age of the patients was 49 years. A total of 40 patients (36%) had relapsed diseases after autologous stem cell transplantation and 36 patients (32%) had received radiotherapy. RIST regimens were fludarabine-based (n=95), low-dose total body irradiation-based (n=6) and others (n=11). Cumulative incidences of grade II-IV acute graft-versus-host disease (GVHD) and chronic GVHD were, respectively, 49 and 59%. Cumulative incidences of progression and progression-free mortality were 18 and 25%, respectively. With a median follow-up of 23.9 months, 3-year overall survival rates were 59%. A multivariate analysis identified three significant factors for progression, which are history of radiation (relative risk (RR) 3.45, confidential interval (CI) 1.12-10.0, P=0.03), central nervous system involvement (RR 6.25, CI 2.08-20.0, P=0.001) and development of GVHD (RR 0.28, CI 0.090-0.86, P=0.026). RIST may have decreased the rate of transplant-related mortality, and GVHD may have induced a graft-versus-lymphoma effect. However, whether or not these potential benefits can be directly translated into improved patient survival should be evaluated in further studies.

Effect of pitavastatin on apolipoprotein A-I production in HepG2 cell.

There are few reports describing the mechanism of HDL-elevating action of HMG-CoA reductase inhibitors (statins). As it is considered that the key step of HDL production is the secretion of apolipoprotein A-I (apoA-I), we investigated the effect of statins on apoA-I synthesis and secretion by HepG2 cell to elucidate the mechanism of the action. Each statin induced apoA-I expression (mRNA and protein) dose-dependently: the rank order of the apoA-I induction pitavastatin (3 microM)>simvastatin (10 microM)>atorvastatin (30 microM). The induction of apoA-I by statins disappeared with addition of mevalonate, which indicates that the effect is HMG-CoA reductase inhibition-dependent. Based on HMG-CoA reductase inhibition, pitavastatin-induced apoA-I more efficiently than simvastatin and atorvastatin. Further study revealed that pitavastatin increased ABCA1 mRNA in HMG-CoA reductase-dependent manner and that Rho and Rho kinase inhibitor (C3T and Y27632) increased apoA-I production in the HepG2 cells. These results suggest that pitavastatin efficiently increases apoA-I in the culture medium of HepG2 cells by promoting apoA-I production through inhibition of HMG-CoA reductase and suppression of Rho activity and by protecting apoA-I from catabolism through ABCA1 induction and lipidation of apoA-I.

Cardiopulmonary haemodynamic changes after severe head injury.

Haemodynamic studies were performed by pulmonary artery catheter in 15 patients with severe head injury. To our knowledge, few data are available about the detailed haemodynamic changes after head injury using pulmonary artery catheter. All patients were assessed by the Glasgow Coma Scale, computed tomography and intracranial pressure monitoring. We divided the patients into hypotensive and normotensive groups. All patients showed a high pulmonary vascular resistance and a high pulmonary capillary wedge pressure, probably due to pulmonary vasoconstriction. In the hypotensive group, the two major changes were a marked decrease of the cardiac index and a slight increase of systemic vascular resistance. The low cardiac index was the result of heart failure secondary to myocardial dysfunction. In contrast, the normotensive group was characterized by a high systemic vascular resistance that was induced by generalized vasoconstriction. Increased intracranial pressure is initially associated with an increase of the cardiac index and systemic vascular resistance, so patients with severe head injury also suffer from profound circulatory disturbance.

Treatment of supracondylar fracture of the humerus in children by skeletal traction in a brace.

In 1980, we developed a specially designed brace for treating supracondylar fractures of the humerus in children, along with an easy and safe technique of reduction by skeletal traction. This method, which takes into consideration only the medial tilting and anterior angulation of the distal fragment, achieves complete reduction, ignoring any lateral, posterior and minor rotational displacements of the fragment. Skeletal traction is applied through a screw inserted into the olecranon and the angulation at the fracture site is reduced regardless of the anatomical position without manipulation. We treated 193 children with displaced supracondylar fractures of the humerus using this method between 1980 and 2001. Only four children (2%) developed cubitus varus. The majority obtained an excellent range of movement at the elbow; one had a 25 degree limitation of flexion. This technique is an effective and easy method of treating supracondylar fractures of the humerus in children.

Use of diffusion-weighted magnetic resonance imaging in empyema after cranioplasty.

External decompression can be an effective treatment for acute intracranial hypertension, but the cranial defect must be repaired. The most serious complication of cranioplasty is late infection. Confusing an empyema that occurs after cranioplasty with a fluid collection (haematoma or liquor) can have catastrophic consequences, such as the development of cerebritis. The goal of this study was to assess the ability of diffusion-weighted (DW) magnetic resonance imaging (MRI) to diagnose empyema after cranioplasty. DW MRI and apparent diffusion coefficient (ADC) maps were studied in six patients with surgically verified empyema after cranioplasty. The findings were compared with those in five patients who had surgically verified haematoma or liquorrhoea. In the patients with empyema, the lesion was hyperintense, whereas the fluid collections (haematoma and liquorrhoea) were visualized as hypointense lesions. The ADC maps showed that empyema had a significantly lower intensity than the fluid collections (haematoma or liquorrhoea). DW MRI can be used to identify empyema after cranioplasty and can help to differentiate it from other fluid collections. Hence, this is a useful additional imaging modality for the diagnosis of empyema after cranioplasty.

Development of cone and plate-type rheometer for quantitative analysis of endothelial cell detachment by shear stress.

We developed an apparatus, which has a structure based on a cone and plate-type rheometer, to facilitate quantitative analysis of the detachment process of endothelial cells (EC) from diverse materials including 3-dimensional scaffolds such as plate, membrane and porous-shaped materials. As an artificial vascular model, a material inoculated with EC to a polycarbonate membrane coated with laminin was prepared. In consequence, reduced cell number, medium volume, and material size was enough to evaluate cell detachment from various materials by shear stress in our system. When shear stress was loaded to a material with EC, the ratio retained of initially inoculated cells decreased with time. Increase of magnitude of shear stress also decreased the ratio. We conclude that our apparatus could analyze quantitatively detachment of EC with ease for screenings to find materials that enhance adhesive force of EC. To produce artificial blood vessels with small diameter, our apparatus could become a useful instrument.

Apoptosis in normal tissues induced by anti-cancer drugs.

To investigate the damage mediated by anti-cancer drugs in normal cells, we examined the effect of such drugs on apoptosis of normal cells of the small intestinal epithelium and the bone marrow by in situ DNA end-labelling and transmission electron microscopy. Mice received a single dose of 5-fluorouracil (5-FU) or cisplatin, or repeated daily doses of 5-FU for 7 days. In mice treated with a single dose of 5-FU 50 mg/kg or cisplatin 5 mg/kg, the number of apoptotic cells appearing in the small intestine 12 h after injection was relatively small, but increased steadily reaching a peak after 36 h and then decreasing to close to that in the control group by 48 h. In bone marrow cells, results were similar in mice treated with single doses of 5-FU 50 mg/kg but apoptosis increased much less in those treated with cisplatin 5 mg/kg. The proportion of apoptotic cells reached peak values earlier at higher concentrations of 5-FU or cisplatin both in small intestine and in bone marrow. In the mice treated repeatedly with 5-FU 50 mg/kg, the proportion of apoptotic small intestinal epithelial cells reached a succession of peaks at 48-h intervals. Mice treated repeatedly with 5-FU 50 mg/kg also showed a rapid increase in diarrhoea symptoms and a steady decrease in the height of villi. Our results suggest it may be possible to prevent the side-effects of anti-cancer drugs by inhibiting apoptosis in the gastrointestinal tract.

Endothelin-1 is a potent stimulator of alpha1beta1 integrin-mediated collagen matrix remodeling by rat mesangial cells.

Endothelin-1 (ET) is known to stimulate mesangial cell (MC) proliferation, extracellular matrix (ECM) synthesis, and thereby contribute to the progression of glomerulonephritis (GN). To clarify the molecular and cellular mechanisms of how ET is involved in the development of glomerular sclerosis, we investigated the influence of ET on the MC-alpha1beta1 integrin-mediated collagen matrix reorganization using a collagen gel contraction assay. ET enhanced MC-alpha1beta1 integrin-mediated gel contraction in a dose-dependent manner. Addition of the endothelin A (ETA) receptor antagonist, BQ123, into collagen gels abolished ET-induced gel contraction by MC. Cell behavior involved in ET-induced gel contraction was investigated in combination with function-blocking anti-alpha1-integrin antibody. Migration and adhesion assays revealed that ET stimulated alpha1beta1 integrin-mediated MC migration but did not influence cell adhesion to type I collagen (collagen I). Integrin-function blocking studies using anti-alpha1 integrin antibody indicated that MC-alpha1beta1 integrin is required not only for collagen-dependent migration, but also for gel contraction. Zymography showed that ET increased MC matrix metalloproteinase-2 (MMP-2) activity in a dose-dependent manner during MC-induced gel contraction process. Finally, flow cytometry analysis indicated that ET did not affect the cell surface expression of the MC-alpha1beta1 integrin within the collagen gel. These data suggested that ET promotes collagen matrix reorganization through the enhancement of MC-alpha1beta1 integrin-dependent migration and MMP-2 activity. We therefore conclude that ET is a potential molecule inducing pathological collagen matrix remodeling observed in progressive GN.

Reconstruction of a scalp and skull defect with free latissimus dorsi myocutaneous flap following dermatofibrosarcoma protuberans.

A 53-year-old male underwent more than 10 surgical treatments over 14 years, including a simple excision and local flap transfer, after recurrences of dermatofibrosarcoma protuberans of the head. Clinical results indicated that simple excision of dermatofibrosarcoma protuberans should not be performed as initial treatment. Instead, free flap transplantation, which permits a wide excision and complete reconstruction, should be the first treatment option.

Rotatory subluxation of the scaphoid in Kienböck's disease is not a cause of scapholunate advanced collapse (SLAC) in the wrist.

We have examined whether the rotatory subluxation of the scaphoid which is seen in patients with advanced Kienböck's disease is associated with scapholunate advanced collapse (SLAC) wrist. We studied 16 patients (11 men, 5 women) who had stage-IV Kienböck's disease with chronic subluxation of the scaphoid. All had received conservative treatment. The mean period of affection with Kienböck's disease was 30 years (14 to 49). No wrist had SLAC. In eight patients, 24 years or more after the onset of the disease, the articular surface of the radius had been remodelled by the subluxed scaphoid with maintenance of the joint space. The wrists of six patients were considered to be excellent, nine good, and one fair according to the clinical criteria of Dornan. Our findings have shown that rotatory subluxation of the scaphoid in Kienböck's disease is not a cause of SLAC wrist and therefore that scaphotrapeziotrapezoid arthrodesis is not required for the management of these patients.

Anti-U5 snRNP antibody as a possible serological marker for scleroderma-polymyositis overlap.

OBJECTIVE: To determine the prevalence of the anti-U5 small nuclear ribonucleoprotein (snRNP) antibody in patients with systemic sclerosis. METHODS: Sera from 281 patients with systemic sclerosis, including 10 patients with overlapping polymyositis, were assayed using RNA immunoprecipitation and protein immunoprecipitation. RESULTS: Only one serum sample showed precipitation of U5 snRNA with scarce precipitation of U2, U1, U4 and U6 snRNAs. In addition, the serum precipitated a 200 kDa protein. The serum was from a 35-yr-old Japanese male patient with overlapping systemic sclerosis and polymyositis accompanied by large-cell lung carcinoma. The clinical appearance was similar to that of a case reported previously. CONCLUSION: The presence of the anti-U5 snRNP antibody in serum may be specific for scleroderma-polymyositis overlap syndrome.