Partial-thickness tears of the rotator cuff. A clinicopathological review based on 66 surgically verified cases

This review is based on 66 patients with partial-thickness tears of the rotator cuff, verified at operation. Their average age was 54 years, and all had symptoms of subacromial impingement. The duration of shoulder pain was for between 2 and 108 months (mean 11.4 months). Ultrasonography, arthrography and bursography were helpful in establishing the diagnosis. On exploration, tears were found in the supraspinatus tendon, with 9 extending into the infraspinatus. After anterior acromioplasty, excision of the diseased portion and tenorrhaphy were undertaken. Satisfactory results were obtained in 62 patients (94%) with an average follow-up of 32 months. Spontaneous repair at the torn site was never seen. In addition to Neer's staging of impingement, we propose a new classification based on the integrity of the cuff tendon. We conclude that a partial-thickness cuff tear is an important cause of shoulder disability, which deserves much more clinical attention; misdiagnosis is common and leads to mismanagement. When conservative treatment fails, accurate diagnosis and proper surgical repair are essential.

Suppression of diet-induced atherosclerosis in low density lipoprotein receptor knockout mice overexpressing lipoprotein lipase

Lipoprotein lipase (LPL) is a key enzyme in the hydrolysis of triglyceride-rich lipoproteins. Conflicting results have been reported concerning its role in atherogenesis. To determine the effects of the overexpressed LPL on diet-induced atherosclerosis, we have generated low density lipoprotein receptor (LDLR) knockout mice that overexpressed human LPL transgene (LPL/LDLRKO) and compared their plasma lipoproteins and atherosclerosis with those in nonexpressing LDLR-knockout mice (LDLRKO). On a normal chow diet, LPL/LDLRKO mice showed marked suppression of mean plasma triglyceride levels (32 versus 236 mg/dl) and modest decrease in mean cholesterol levels (300 versus 386 mg/dl) as compared with LDLRKO mice. Larger lipoprotein particles of intermediate density lipoprotein (IDL)/LDL were selectively reduced in LPL/LDLRKO mice. On an atherogenic diet, both mice exhibited severe hypercholesterolemia. But, mean plasma cholesterol levels in LPL/ LDLRKO mice were still suppressed as compared with that in LDLRKO mice (1357 versus 2187 mg/dl). Marked reduction in a larger subfraction of IDL/LDL, which conceivably corresponds to remnant lipoproteins, was observed in the LPL/LDLRKO mice. LDLRKO mice developed severe fatty streak lesions in the aortic sinus after feeding with the atherogenic diet for 8 weeks. In contrast, mean lesion area in the LPL/LDLRKO mice was 18-fold smaller than that in LDLRKO mice. We suggest that the altered lipoprotein profile, in particular the reduced level of remnant lipoproteins, is mainly responsible for the protection by LPL against atherosclerosis.

Dose-dependent effect of niceritrol on plasma lipoprotein-a

Lipoprotein-a, Lp(a), is a variant form of low density lipoprotein (LDL) that contains apolipoprotein-a, whose structure has 75-85% homology with plasminogen. Elevated plasma levels of Lp(a) are considered to be one of the independent risk factors for cardiovascular disease. We studied the effects of niceritrol, a nicotinic acid derivative, on plasma Lp(a) levels in 72 patients with hypercholesterolaemia. The dose of niceritrol was increased every 4 weeks, from 750 to 1500 and then to 2250 mg day-1. The final dose was adjusted to obtain a plasma cholesterol level less than 5.69 mmol l-1. Niceritrol led to significant decreases in plasma levels of median Lp(a), from 16.1 mg dl-1 (interquartile intervals, 8.7 to 32.8) to 11.1 mg dl-1 (interquartile intervals, 6.6 to 21), the mean reduction rate being 17.6%. In the group with pretreatment Lp(a) levels of over 20 mg dl-1, Lp(a) decreased by 10.0, 22.0 and 31.8% at the doses of 750, 1500, and 2250 mg day-1, respectively. In the group with levels less than 20 mg dl-1, only the dose of 2250 mg day-1 was effective in the reduction of Lp(a). The results suggest that the reduction of Lp(a) was dependent on the dose of niceritrol and on the pretreatment level of Lp(a). In conclusion, niceritrol is effective, in a dose-dependent manner, for reducing Lp(a) levels.

Combined treatment of a dural arteriovenous malformation of the lateral sinus using transarterial and direct lateral sinus embolisation

An 80-year-old man presented with a dural arteriovenous malformation (DAVM) involving the left lateral sinus. A carotid angiogram showed the lateral sinus to be occluded proximally and distally, with unusual retrograde venous outflow from the residual sinus to the cortical veins, including a dilated vein of Labbé. Single photon emission computed tomography showed reduced left frontal and temporal cerebral blood flow. We concluded that the risk of bleeding from the DAVM was high and that the patient needed to be treated immediately. However, his age made surgical removal of the DAVM hazardous and we therefore chose to treat him by transarterial and direct lateral sinus embolisation via a burr hole.

[Diagnosis of superficial-type early carcinoma of the gallbladder by endoscopic ultrasonography--comparison with ultrasonography]

The detectability of superficial-type carcinoma of the gallbladder by ultrasonography (US) and endoscopic ultrasonography (EUS) were investigated. Eight patients with such carcinoma of the gallbladder were reviewed. They had undergone both US and EUS previous to surgery. The tumor was detected in 3 patients by US, 2 patients with IIa + IIb-type carcinoma and 1 patient with IIa-type carcinoma. Those lesions were visualized as localized thickening of the gallbladder wall or as broad-based tumor. In 2 patients, lesions were not initially detected by US, but were shown by US after the examination by EUS. The tumor was detected by EUS also in 1 case of IIb + IIa-type carcinoma besides those 3 patients mentioned above. All four of these lesions were visualized as broad-based tumor by EUS. It was difficult to detect pure IIb-type or small IIa-type carcinoma even by EUS. In patients with concomitant acute cholecystitis or gallbladder stone, it was difficult to evaluate the abnormal findings of the gallbladder wall.

Transgenic mouse and gene therapy

In the transgenic mouse, a specific gene can be transduced or deleted to study its function and relation to human diseases. Recently, various lines of transgenic mice that overexpress or lack a specific gene have been established and are available to study the pathophysiology of human diseases, including atherosclerosis, diabetes, and hyperlipidemia. We have established transgenic mouse lines with an integrated rat apolipoprotein (apo) E gene under control of the metallothionein promoter. Overexpression of apoE in the liver reduced plasma cholesterol and triglyceride levels and prevented diet-induced hypercholesterolemia. Another transgenic model with overexpression of apoE under control of the H2 Ld promoter in the arterial wall was established. In this model, the formation of fatty streak lesions was markedly inhibited, suggesting that apoE has antiatherogenic actions. Finally, we discuss gene therapy, which will be an important therapeutic approach to correct genetic abnormalities found in metabolic diseases.

Study of gastric emptying in patients with pancreatic diabetes (chronic pancreatitis) using acetaminophen and isotope

The gastric emptying function tests were carried out in eight patients with pancreatic diabetes, who were classified into two groups according to the coefficient of variation in the R-R interval in ECG (C.V. R-R) on the normal subjects: < or = the mean - 2SD (the autonomic nerve dysfunction group: AND+ group) and > the mean - 2SD (the autonomic nerve normal group: AND- group). Both the gastric emptying of liquid food by the acetaminophen method and that of solid food by the isotope method were significantly reduced in the AND+ group than in the AND- and normal groups. In addition, a significant correlation was found between the C.V. R-R and the serum acetaminophen concentration (a 45 min value) and the % gastric retention of isotope (a 120 min value). The above results demonstrated that even pancreatic diabetes might be complicated by gastroparesis diabeticorum among autonomic nerve dysfunction. There was a close relation of delayed gastric emptying to the C.V. R-R in ECG or an index of the vagus nerve function.

Echogenic fetal bowel in the third trimester associated with trisomy 18

We present the first case of trisomy 18 in which echogenic fetal bowel was detected in the third trimester after normal echogenicity was documented during the second trimester. Fetal karyotyping should be considered in cases of increased echogenicity of the fetal lower abdomen in the second as well as the third trimester.

Effect of alcohol on tumor growth of hepatocellular carcinoma with type C cirrhosis

To investigate the influence of alcohol intake on tumor growth of hepatocellular carcinoma (HCC) in patients with type C cirrhosis, we examined the tumor volume doubling time (TVDT) of 35 nodules from 35 cases of HCC, calculated through ultrasonographic imaging. The patients were divided into two groups according to their drinking habit; 21 habitual drinkers (alcohol group; 80g ethanol/day for 5 years), and 14 patients without alcohol abuse (non alcoholic group). The average value of TVDT in the alcoholic group was 78 +/- 47 days, although that of the non alcoholic group was 142 +/- 60 days. A statistically significant difference (p < 0.01) was found between the two groups. Of the 21 habitual alcohol drinkers, 8 refrained from drinking after detection of HCC; their TVDT was about 30 days shorter than those who continued alcohol intake. In conclusion we found that alcohol intake was closely related to the tumor growth of HCC in patients with type C cirrhosis.

[A case of predominant right thalamic infarction with severe verbal memory disturbance]

We encountered a 45-year-old right-handed man who had suffered a predominant right thalamic infarction and complained of memory loss. Performance on the Miyake Test (recall of ten pairs of related and unrelated words), the Rey Osterrieth Complex Figures, the Benton Test of Visual Retention and the Wechsler Memory Scale-R disclosed a severe verbal memory disturbance associated with a little, if any, visual memory disturbance. An MRI study revealed bilateral lesions limited to the thalamus involving most of the right anterior nucleus (AN), mediodorsal nucleus (MD), ventrolateral nucleus (VL), and centromedial nucleus (CM), as well as a small part of the left MD, and CM. HM-PAO-SPECT scans showed areas of decreased cerebral blood flow not only in the right thalamus but in the medial and basilar region of the right temporal lobe. It is noteworthy that our patient had a predominant right thalamic lesion and exhibited a severe verbal memory disturbance rather than visual memory disturbance. This suggests that the right hemisphere is dominant for verbal memory function in this patient.

Mucopolysaccharidosis IVA: four new exonic mutations in patients with N-acetylgalactosamine-6-sulfate sulfatase deficiency

We report four new mutations in Japanese patients with mucopolysaccharidosis IVA (MPSIVA) who were heterozygous for a common double gene deletion. A nonsense mutation of CAG to TAG at codon 148 in exon 4 was identified, resulting in a change of Q to a stop codon and three missense mutations. V (GTC) to A (GCC) at codon 138 in exon 4, P (CCC) to S (TCC) at codon 151 in exon 5, and P (CCC) to L (CTC) at codon 151 in exon 5. Introduction of these mutations into the normal GALNS cDNA and transient expression in cultured fibroblasts resulted in a significant decrease in the enzyme activity. V138A and Q148X mutations result in changes of restriction site, which were analyzed by restriction-enzyme assay. P151S and P151L mutations that did not alter the restriction site were detected by direct sequencing or allele specific oligohybridization. Detection of the double gene deletion was initially done using Southern blots and was confirmed by PCR. Haplotypes were determined using seven polymorphisms to the GALNS locus in families with the double gene deletion. Haplotype analysis showed that the common double gene deletion occurred on a single haplotype, except for some variation in a VNTR-like polymorphism. This finding is consistent with a common founder for all individuals with this mutation.

Transcription factor PU.1 mediates induction of c-fms in vascular smooth muscle cells: a mechanism for phenotypic change to phagocytic cells

The macrophage colony-stimulating factor receptor encoded by the c-fms gene is expressed in vascular intimal smooth muscle cells isolated from atherosclerotic lesions. A combination of platelet-derived growth factor-BB and epidermal growth factor induces stable expression of c-fms in normal vascular medial smooth muscle cells. The mechanism by which these growth factors induce c-fms expression has now been investigated in an attempt to gain insight into the events that underlie the phenotypic conversion of vascular smooth muscle cells in atherosclerosis. Deletion analysis of the c-fms promoter revealed that the region including a binding site for transcription factor PU.1 was required for transcriptional activity in human aortic medial smooth muscle cells. Mutation in the PU.1 binding site markedly reduced promoter activity. Northern (RNA) blot analysis demonstrated that growth factors induced the expression of PU.1 mRNA in vascular medial smooth muscle cells and that PU.1 mRNA was expressed in vascular intimal smooth muscle cells. PU.1 antisense oligonucleotides inhibited growth factor-induced c-fms expression and foam cell formation. These results suggest that transcription factor PU.1 plays an essential role in the phenotypic conversion of vascular smooth muscle cells to macrophagelike cells by mediating the induction of c-fms.

Enhanced expression of platelet-derived growth factor-beta receptor by high glucose. Involvement of platelet-derived growth factor in diabetic angiopathy

Coronary heart disease is a major complication of diabetic subjects, and platelet-derived growth factor (PDGF) has been implicated in the development of atherosclerosis. We investigated the effects of high glucose on expression of PDGF-beta receptor. In a binding assay with 125I-labeled PDGF-BB homodimer, high concentrations of glucose increased high-affinity binding of PDGF-BB on human monocyte-derived macrophages and rabbit aortic medial smooth muscle cells. Northern blot analysis confirmed the enhanced effect of glucose on expression of PDGF-beta receptor mRNA in human monocyte-derived macrophages. The protein kinase C inhibitor, staurosporin, completely suppressed an increase in PDGF-BB binding by high glucose, and high glucose significantly activated protein kinase C. These results indicated that PDGF-beta receptor expression was enhanced by high glucose through the activation of protein kinase C. Furthermore, we observed similar effects of high glucose on both PDGF-beta receptor expression and protein kinase C activation in rat mesangial cells and human capillary endothelial cells. Our results suggest that stimulation of the PDGF system is significantly involved in the development not only of diabetic atherosclerosis but also of microangiopathy.

Bone morphogenetic protein type IB receptor is progressively expressed in malignant glioma tumours

The distribution of bone morphogenetic protein (BMP) type I receptors and the activin type I receptor (ActR-I) was investigated in 16 cases of human glioma and five cases of non-tumourous gliosis tissue by immunohistochemical technique. Both BMP type IA (BMPR-IA) and the type IB (BMPR-IB) receptors were detected in human glioma cells. A significant increase in BMPR-IB in tumour cells was observed in malignant glioma compared with both low-grade astrocytomas (n=16, P<0.005) and gliosis (n=13, P<0.001). However, enhancement of BMPR-IA staining was moderate and ActR-I staining was only weakly expressed in the malignant glioma tumours. Osteogenic protein (OP)-1/BMP-7, which is known to bind BMPR-IA, BMPR-IB and ActR-I, was expressed in nervous tissue and was also detected in anaplastic areas of malignant glioma. In contrast to the tissue materials, BMPR-IA was expressed to a stronger degree than BMPR-IB in human glioma cell lines; the growth of these cells was suppressed by OP-1. These results suggest the presence of BMP receptors and a functional role for BMPs in malignant glioma.

Effects of beraprost sodium and prostaglandin E1 on skin blood flow in diabetic rats and normal dogs

1. The present study was undertaken to compare the effects of beraprost sodium (BPS), a stable prostaglandin I2 analog, with prostaglandin E1 (PGE1) on the skin blood flow in anesthesized diabetic rats and anesthetized dogs. 2. In anesthetized diabetic rats, BPS, but not PGE1, caused a dose-dependent and significant increase in femoral skin blood flow. 3. In anesthetized dogs, PGE1 significantly increased femoral arterial blood flow than BPS. However, BPS significantly increased in-step skin blood flow than PGE1. 4. The above data suggest that BPS may be clinically useful for the treatment of circulatory insufficiency of lower extremities in diabetic patients.

Mucopolysaccharidosis IVA: a comparative study of polymorphic DNA haplotypes in the Caucasian and Japanese populations

Mucopolysaccharidosis IVA (MPS IVA) is an autosomal recessive disorder caused by deficiency of the lysosomal enzyme N-acetylgalactosamine-6-sulphate sulphatase (GALNS). The genetic heterogeneity at the GALNS locus was studied in 62 mutant alleles and 376 normal alleles in the Caucasian population and also in 40 mutant and 100 normal alleles in the Japanese population. For this study, six different restriction fragment length polymorphisms (RFLPs) at the GALNS locus were analysed to search for the frequency of each RFLP produced by StyI, SphI, RsaI, HaeIII, StuI and HapII restriction endonucleases. We detected a total of 27 haplotypes in the Caucasian and Japanese population. Of these 27 haplotypes, 18 haplotypes were present in the Caucasian population and the most common of these was haplotype 1 (ABHcde) in both mutant and normal alleles. In contrast, in the Japanese population we found 20 of the 27 haplotypes and the most common in mutant and normal alleles was haplotype 2 (abhcDE). Within these two populations a parent in the MPS IVA family has an average probability of greater than 77% (in the Caucasian population 77.27% and in the Japanese population 78.26%) of being heterozygous, and hence informative for linkage, at one or more GALNS RFLP sites. Our results delineate the molecular heterogeneity of MPS IVA haplotypes, as well as their significant interpopulation variation, and make prenatal diagnosis and carrier detection possible in the majority of families with one affected child.

Scanning electron microscopy of the basal surface of the epidermis of human digits

The epidermal-dermal junction of the volar skin of human digits was examined by scanning electron microscopy (SEM). Fixed specimens obtained from cadavers were treated with 6 N NaOH to exfoliate the epithelium. The three-dimensional features of the basal surfaces were clearly visualized by SEM. Epithelial prolongations (intermediate and limiting ridges) protruded towards the dermis, and transverse ridges were visible between them. Nerve fibers and Schwann cells were aggregated around the sweat ducts on the intermediate ridges. Discoid structures were visible among the nerve fibers and Schwann cells. Examination by transmission electron microscopy of ultrathin sections of re-embedded specimens confirmed that the discoid structures were nerve endings that covered the Merkel cells. Minute projections were studded on the basal surfaces of basal keratinocytes. The projections in the intermediate ridges appeared to be villous, whereas the profiles of those in the limiting ridges resembled cobblestones. This morphological difference might be a reflection of function.

Role of macrophages in pulmonary late-phase reaction in guinea pigs

To examine the role of macrophages in pulmonary late-phase reaction (LPR), macrophages were reduced in sensitized guinea pigs by an intravenous injection of liposome-encapsulated dichloromethylene diphosphonate (Cl2MDP). Macrophage reduction was evaluated by bronchoalveolar lavage (BAL) fluid analysis. In Cl2MDP liposome-treated animals, the number of macrophages in BAL fluid significantly decreased by 56% compared with PBS liposome-treated animals (1.6 +/- 0.1 vs. 3.6 +/- 0.4 x 10(6) cells, p < 0.01). The number of neutrophils, eosinophils, or lymphocytes in BAL fluid showed no significant changes in these two groups. Both PBS and Cl2MDP liposome-treated sensitized guinea pigs were challenged with an inhalation of antigen, and respiratory resistance (Rrs) was measured. PBS liposome-treated animals (control) exhibited both immediate (IPR) and late (LPR) increases in Rrs. The maximal increases in Rrs at IPR and LPR were 217 +/- 19 and 187 +/- 20% of baseline values, respectively (n = 9). On the other hand, Cl2MDP liposome-treated animals showed an immediate increase in Rrs (IPR); however, the late increase in Rrs (LPR) was significantly suppressed (p < 0.05). The maximal increases in Rrs at IPR and LPR were 200 +/- 13 and 134 +/- 11% of baseline values, respectively (n = 8). In Cl2MDP liposome-treated animals, the numbers of macrophages and neutrophils in BAL fluid 4 hr after antigen challenge decreased by 45% and 54%, respectively, compared with PBS liposome-treated animals (p < 0.05). In Cl2MDP liposome-treated animals, neutrophil chemotactic activity in BAL fluid 4 hr after antigen challenge decreased by 59% compared with PBS liposome-treated animals (p < 0.05). These results suggest that macrophages play an important role in the development of pulmonary LPR through the induction of neutrophil accumulation in the airways.

[Significance of 123I-metaiodobenzylguanidine SPECT for detecting left ventricular involvement in patients with arrhythmogenic right ventricular dysplasia]

The right ventricle being primarily involved in ARVD, recent reports indicate the presence of histological and functional abnormalities in the left ventricle for some patients with ARVD. The aim of this study was to evaluate the significance of myocardial sympathetic dysfunction as an early sign of left ventricular (LV) involvement by 123I-MIBG (MIBG) SPECT and to compare the findings with those of 201TlCl (Tl) SPECT, radionuclide left ventriculography, ultrafast computed tomography (UFCT), magnetic resonance imaging (MRI) and echo-cardiography in 10 patients (pts) with ARVD. MIBG defects in LV regions were detected in 9 pts. Seven of the 9 pts showed MIBG defects in LV regions adjacent to RV. The subjects were divided into 2 groups based on left ventriculography, 5 with normal LVEF (> 55%) and 5 with reduced LVEF. In the normal LVEF group, 4 pts showed MIBG defects and 2 pts showed TI defects, and MIBG defects were larger than TI defects (ES: 14 +/- 6 vs. 5 +/- 7, p <0.05). In reduced LVEF group, all of 5 pts showed MIBG and TI defects, and MIBG defects were larger than TI defects (ES: 42 +/- 12 vs. 25 +/- 3, p <0.05). In comparison with normal LVEF group, reduced LVEF group showed larger and more severe MIBG defects (ES: 42 +/- 12 vs. 14 +/- 6, p <0.01, SS: 44 +/- 31 vs. 8 +/- 7, p <0.05). UFCT and MRI showed abnormal findings indicating LV fatty infiltration in only 3 of reduced LVEF group. Thus, MIBG showed abnormal distributions in the left ventricle with the highest frequency in all these modalities. These results suggest that MIBG SPECT provides a sensitive marker for detecting LV involvement in ARVD. Also, the extent of MIBG distribution abnormalities is helpful in assessing the severity of left ventricular involvement in patients with ARVD.