Hepatitis C virus infection increases autophagosome stability by suppressing lysosomal fusion through an Arl8b-dependent mechanism

Autophagy is a conserved cellular process involving intracellular membrane trafficking and degradation. Pathogens, including hepatitis C virus (HCV), often exploit this process to promote their own survival. The aim of this study was to determine the mechanism by which HCV increases steady-state autophagosome numbers while simultaneously inhibiting flux through the autophagic pathway. Using the lysosomal inhibitor bafilomycin A1, we showed that HCV-induced alterations in autophagy result from a blockage of autophagosome degradation rather than an increase in autophagosome generation. In HCV-infected cells, lysosome function was normal, but a tandem RFP-GFP-LC3 failed to reach the lysosome even under conditions that activate autophagy. Autophagosomes and lysosomes isolated from HCV-infected cells were able to fuse with each other normally in vitro, suggesting that the cellular fusion defect resulted from trafficking rather than an inability of vesicles to fuse. Arl8b is an Arf-like GTPase that specifically localizes to lysosomes and plays a role in autophagic flux through its effect on lysosomal positioning. At basal levels, Arl8b was primarily found in a perinuclear localization and co-localized with LC3-positive autophagosomes. HCV infection increased the level of Arl8b 3-fold and redistributed Arl8b to a more diffuse, peripheral pattern that failed to co-localize with LC3. Knockdown of Arl8b in HCV-infected cells restored autophagosome-lysosome fusion and autophagic flux to levels seen in control cells. Thus, HCV suppresses autophagic flux and increases the steady-state levels of autophagosomes by increasing the expression of Arl8b, which repositions lysosomes and prevents their fusion with autophagosomes.

In prenatally diagnosed CPAM, does the affected lobe influence the timing of symptom onset?

PURPOSE

We investigated the relationship between the affected lobe and symptom onset in prenatally diagnosed congenital pulmonary airway malformation (CPAM).

METHODS

53 CPAM patients diagnosed prenatally were reviewed retrospectively by creating 2 groups according to symptom onset. Group Sneo: (symptomatic during the neonatal period; n = 13) and group S > neo: (symptomatic after the neonatal period; n = 40) were compared for type of CPAM, affected lobes, types of symptoms/infections, treatment, duration of follow-up, and histopathology. Requirement for surgery (Sx) was then used to create three subgroups: Sneo + Sx, S > neo + Sx, and Sx-.

RESULTS

Some cases had multiple affected lobes. In Sneo, symptoms developed in 55.6%, 50.0%, 0%, 0%, and 36.8% of right upper lobes (RUL), right middle lobes (RML), right lower lobes (RLL), left upper lobes (LUL), and left lower lobes (LLL) diagnosed with CPAM, prenatally. In S > neo, symptoms developed in 0%, 0%, 6.3%, 55.6%, and 33.3% of RUL, RML, RLL, LUL, and LLL diagnosed with CPAM, prenatally.

CONCLUSION

In prenatally diagnosed CPAM, RUL and RML lesions are more likely to become symptomatic in neonates, and LUL lesions in infants. Surgery is recommended before the onset of respiratory infections after 1 year of age.

Effect on inclined medial proximal tibial articulation for varus alignment in advanced knee osteoarthritis

BACKGROUND

The inclination of the medial compartment of the proximal tibia (MCT) is assumed to be a critical factor for varus alignment in advanced knee osteoarthritis (OA). This study was aimed at investigating; (1) whether the inclination of MCT is aligned parallel to the ground under weight-bearing (WB) conditions; (2) whether this is associated with the change in alignment and the relative position between the bones; and (3) whether the tibia or femur mainly contributes to the changes.

METHODS

We examined 102 knees (84 women, 18 men; mean 75 years). A three-dimensional (3D) assessment system was applied on biplanar whole lower extremity radiographies using 3D-to-2D image registration technique. The evaluation parameters were 1) MCT angle, 2) femorotibial angle (FTA), 3) medial-lateral femoral location to the tibia (M-L femoral location), 4) WB line passing point, and 5) tibial position to WB line (tibial position) and 6) femoral postion to WB line (femoral position). Each parameter was evaluated in non-WB and WB conditions, and the differences (Δ-parameters).

RESULTS

MCT angle in the world coordinate system was larger than that in the tibial coordinate system (p <  0.0001). ΔMCT angle was correlated with ΔFTA (p = 0.002) and ΔM-L femoral location (p = 0.004). The tibial position was the more dominant factor for ΔMCT angle (p = 0.001), ΔFTA (p <  0.0001), and ΔWB line passing point (p <  0.0001) .

CONCLUSIONS

The inclination in MCT was aligned parallel to the ground under WB conditions (tibial parallel phenomenon). The parallel phenomenon was associated with the change of alignment and the relative position between the bones in the coronal plane. These phenomena were produced mainly by the tibia, not the femur.

LEVEL OF EVIDENCE

Level IV.

Refractory Hypotension during Combined General and Epidural Anaesthesia in a Patient on Tricyclic Antidepressants

We report a case of refractory hypotension that occurred after epidural injection of local anaesthetic, in a patient who was receiving tricyclic antidepressant therapy and was under general anaesthesia. The patient failed to respond to repeated injections of appropriate doses of sympathomimetics, but did respond to high-dose catecholamine infusions. We suggest that epidural anaesthesia should be used with care when combined with general anaesthesia for patients on long-standing tricyclic antidepressant therapy. If refractory hypotension should occur in such patients, the use of direct-acting vasoconstrictors such as noradrenaline should be considered.

Epidermolysis Bullosa Acquisita: The 2019 Update

Epidermolysis bullosa acquisita (EBA) is an orphan autoimmune disease. Patients with EBA suffer from chronic inflammation as well as blistering and scarring of the skin and mucous membranes. Current treatment options rely on non-specific immunosuppression, which in many cases, does not lead to a remission of treatment. Hence, novel treatment options are urgently needed for the care of EBA patients. During the past decade, decisive clinical observations, and frequent use of pre-clinical model systems have tremendously increased our understanding of EBA pathogenesis. Herein, we review all of the aspects of EBA, starting with a detailed description of epidemiology, clinical presentation, diagnosis, and current treatment options. Of note, pattern analysis via direct immunofluorescence microscopy of a perilesional skin lesion and novel serological test systems have significantly facilitated diagnosis of the disease. Next, a state-of the art review of the current understanding of EBA pathogenesis, emerging treatments and future perspectives is provided. Based on pre-clinical model systems, cytokines and kinases are among the most promising therapeutic targets, whereas high doses of IgG (IVIG) and the anti-CD20 antibody rituximab are among the most promising "established" EBA therapeutics. We also aim to raise awareness of EBA, as well as initiate basic and clinical research in this field, to further improve the already improved but still unsatisfactory conditions for those diagnosed with this condition.

Pediatric plexiform fibromyxoma: A PRISMA-compliant systematic literature review

BACKGROUND

Plexiform fibromyxoma (PF) is a rare gastric mesenchymal tumor, with approximately 80 cases reported to date. Gastrointestinal stromal tumor, the most common primary mesenchymal tumor of the stomach, shows different biological and clinical characteristics between adult and pediatric patients.

OBJECTIVES

This systematic literature review was conducted to elucidate the pathological and clinical features of pediatric PF compared to adult PF.

METHODS

MEDLINE (1948 to March 2018) and EMBASE (1947 to March 2018) were searched, and all English articles that reported clinical data on PF patients were identified. Two authors independently reviewed the articles and extracted data to assess immunohistochemistry, sex, chief complaint, tumor size, tumor-related mortality, and tumor recurrence and metastasis.

RESULTS

A total of 41 reports with 80 PF patients (of whom 70 were adult PF and 10 were pediatric PF patients) confirmed by histological and immunohistochemical findings were included. Of a total of 80 tumors, 62 (78%) were located in the gastric antrum, 42 (65%) presented with ulceration, and 48 (74%) were resected by partial gastrectomy. Median tumor size of the resected specimen was larger in pediatric PF than in adult PF cases (5.3 cm vs 4.0 cm, P = .036). However, there was no difference between pediatric and adult PFs in immunohistochemical expression, sex predominance, chief complaint, tumor-related mortality, and tumor recurrence and metastasis during the follow-up periods.

CONCLUSION

Other than increased tumor growth in pediatric PFs, PF is a single disease entity with similar pathological features and benign clinical behavior regardless of onset age.

Detection of anti-type VII collagen IgE antibodies in epidermolysis bullosa acquisita

BACKGROUND

Epidermolysis bullosa acquisita (EBA) is a rare pemphigoid disease involving autoantibodies to type VII collagen (COL7), a major structural component of anchoring fibrils. IgE autoantibodies to type XVII collagen (BP180) have been identified in bullous pemphigoid (BP), the prototype of pemphigoid diseases. Although the pathogenic relevance of IgG anti-COL7 has been investigated, that of IgE in EBA remains unclear.

OBJECTIVES

To reveal the presence and pathogenic relevance of IgE anti-COL7 in EBA.

METHODS

We examined IgE antibodies in 109 patients with EBA by indirect immunofluorescence (IIF) and enzyme-linked immunosorbent assay (ELISA).

RESULTS

IIF with normal human skin revealed IgE reactivity in the basement membrane zone in 29 (26·6%) cases. To verify whether the IgE antibodies were specific to COL7, we performed IIF with 21 clearly positive cases and the skin of a patient with dystrophic EBA, which does not involve COL7. All cases showed negative results, indicating that IgE antibodies were specific to COL7. In a modified IgG COL7 ELISA for IgE, 16 (14·7%) cases were positive (three and 13 cases were negative and positive on IIF, respectively). We compared anti-COL7 IgG and IgE, and found a weak but significant correlation (r = 0·459, P < 0·001). EBA is clinically divided into a mechanobullous (MB; noninflammatory) type and an inflammatory (INF) type resembling BP. Of the IIF-positive cases, 11 of 30 (37%) had INF and nine of 48 (19%) had MB.

CONCLUSIONS

This study is the first to demonstrate the presence of circulating anti-COL7 IgE in patients with EBA, which may correlate with the clinical phenotype.

Efficacy and safety of nivolumab in combination with ipilimumab in Japanese patients with advanced melanoma: An open-label, single-arm, multicentre phase II study

AIM

The aim of the study was to evaluate the efficacy and safety of nivolumab combined with ipilimumab in treatment-naïve Japanese patients with advanced melanoma.

METHODS

In this multicentre, single-arm study, treatment-naïve Japanese patients with unresectable stage III/IV or recurrent melanoma received nivolumab (1 mg/kg) plus ipilimumab (3 mg/kg) every 3 weeks for four doses, followed by biweekly doses of nivolumab (3 mg/kg). The primary end-point was centrally assessed objective response rate (ORR). Secondary end-points included overall survival (OS), progression-free survival (PFS), disease control rate and safety.

RESULTS

The subtypes of the thirty patients enrolled were: 12, mucosal; eight, non-acral cutaneous; seven, acral; two, uveal and one, unknown primary melanoma. The ORR was 43.3% (95% confidence interval [CI]: 25.5, 62.6) with central and local assessment. The centrally and locally assessed disease control rate (95% CI) were 73.3% (54.1, 87.7) and 86.7% (69.3, 96.2), respectively. At the median follow-up period of 14.1 months (range 5.2-27.7), median OS and centrally assessed PFS were not reached. OS (95% CI) at 6, 12, 18 and 24 months was 93.3% (75.9, 98.3), 83.3% (64.5, 92.7), 72.9% (50.0, 86.5) and 65.6% (40.4, 82.2), respectively. Treatment-related adverse events (AEs) occurred in all patients. Grade III-IV and serious AEs occurred, mostly during the combination phase, in 23 (76.7%) and 20 (66.7%) patients, respectively. No treatment-related deaths occurred.

CONCLUSIONS

This study confirmed the efficacy and safety of nivolumab plus ipilimumab in treatment-naïve Japanese patients with advanced melanoma including rare subtypes. Incidence rates for grade III-IV AEs were high but manageable with appropriate medical attention and treatment.

TRIAL REGISTRATION

JapicCTI-152869.

Relationship between birth weight to placental weight ratio and major congenital anomalies in Japan

Recent studies have indicated that birth weight to placental weight (BW/PW) ratio is related to perinatal outcomes, but the effect of congenital abnormalities on BW/PW ratio remains unclear. We performed this study to elucidate correlations between BW/PW ratio and congenital abnormalities. Subjects were 735 singleton infants born at 34–41 weeks of gestation admitted to our center between 2010 and 2016. Of these, 109 infants (15%) showed major congenital anomalies. Major congenital anomalies and subgroups were diagnosed according to European Surveillance of Congenital Anomalies criteria. The primary outcome was the association between BW/PW ratio and major congenital anomaly, and secondary outcomes were the distribution pattern of BW/PW ratio with major anomalies and by major anomaly subgroups in each categorization (<10th percentile, 10–90th percentile, or >90th percentile) of BW/PW ratio. BW/PW ratio was not associated (P = 0.20) with presence (adjusted mean BWPW ratio = 5.02, 95% confidence interval [CI] 4.87–5.18) or absence (adjusted mean BW/PW ratio = 4.91, 95%CI 4.85–4.97) of major anomalies, after adjusting for gestational age and sex. Proportions of infants with major anomalies according to BW/PW ratio categories were as follows: 12% in <10th percentile, 15% in 10–90th percentile, and 25% in >90th percentile of BW/PW ratio. Among major anomalies of the nervous system, congenital heart defects, and orofacial clefts, BW/PW ratio showed equally distributed trend across the three BW/PW ratio categories, but showed unequally distributed trend for anomalies of the digestive system, other anomalies/syndromes, or chromosomal abnormalities. BW/PW ratio was not associated with major congenital anomaly, and was distributed diffusely according to major anomaly subgroups. Major anomalies may tend to aggregate in the 90th percentile of the BW/PW ratio.

Optimal Doses of H1 Antihistamines Do Not Increase Susceptibility to Febrile Convulsions in Children

BACKGROUND

The purpose of this study was to elucidate whether H1 antihistamine administration increases susceptibility to febrile convulsions in children.

METHODS

A single-center, retrospective observational study was conducted in Japan. The study included 380 children with febrile convulsions between the ages of six months and five years transported via ambulance from 2011 through 2016. They were divided into the preseizure H1 antagonist "use group" and the "nonuse group." The former consisted of children who took H1 antagonists within 24 hours before the seizure onset. The primary outcome (seizure duration) and the secondary outcome (interval from fever to seizure onset) were compared between the two groups.

RESULTS

Of the 380 study patients, 70 (18%) were identified as the use group. None of the patients was taking excessive doses of H1 antagonists. The prevalence of seizures lasting 15 minutes or longer was not different between the use group and the nonuse group (11% versus 8%, prevalence ratio 1.47 [95% confidence interval, 0.63 to 3.42], P = 0.37). The prevalence of fever to seizure onset less than six hours was significantly lower in the use group (26% versus 52%, prevalence ratio 0.33 [95% confidence interval 0.19 to 0.60], P < 0.001). Similar results were obtained when analyses were conducted separately by different generations (first and second) of H1 antagonists.

CONCLUSIONS

Prolonged seizure duration and shortened interval from fever to seizure were not observed in children who received H1 antagonists. This study provides evidence that H1 antagonists at optimal doses could be safely used in febrile children with allergic symptoms.

Bacteremia in autoimmune bullous disease patients undergoing double-filtration plasmapheresis

Background: Plasmapheresis is one of the treatment options for autoimmune bullous disease (AIBD). Objective: To evaluate the incidence of adverse events occurring during a course of plasmapheresis. Methods: This study enrolled 42 courses of double-filtration plasmapheresis (DFPP) from 28 patients with AIBD treated in Kurume University Hospital between 2007 and 2016. We examined the frequency of adverse events during the course of DFPP and associated features. Results: The most frequent adverse event was bacteremia (13 of 42 courses, 31.0%), followed by subcutaneous hemorrhage (1 course, 2.4%), and an abscess at the catheterization sites (1 course, 2.4%). No adverse event-related death was recorded. In the analysis of bacteremia occurrence, the erosion at the catheterization sites, the use of central venous catheter (CVC), and the number of DFPP cycles per course were significantly more or greater in the bacteremia group than in the non-bacteremia group (p = .0474, .0005, and .0035, respectively). Conclusions: Although DFPP is a good treatment option for AIBD, attention needs to be paid for the development of possible risks during a DFPP course. We believe that our results can be applied to other plasmaphereses in AIBD management.

Correlation between posterior tibial slope and sagittal alignment under weight-bearing conditions in osteoarthritic knees

INTRODUCTION

Posterior tibial slope (PTS) and sagittal alignment are important factors in the etiology of knee osteoarthritis and knee surgery. Clinically, sagittal alignment, which indicates flexion contracture of the knee, contributes to knee function in weight-bearing (WB) conditions. PTS and sagittal alignment under WB conditions in varus osteoarthritic knees are presumed to affect each other, but their association remains unclear. In this study, we aimed to clarify the association.

MATERIAL AND METHODS

In total, 140 osteoarthritic varus knees were investigated. Under WB conditions, a three-dimensional (3D) alignment assessment system was applied via biplanar long-leg X-rays, using 3D-to-2D image registration technique. The evaluation parameters were as follows: 1) 3D mechanical flexion angle (3DMFA) in regards to sagittal alignment, 2) passing point in the WB line (PP), and 3) medial and lateral PTS.

RESULTS

The medial and lateral PTS showed a positive correlation with 3DMFA and PP, respectively (medial PTS-3DMFA, p = 0.001; medial PTS-PP, p < 0.0001; lateral PTS-3DMFA, p < 0.0001; lateral PTS-PP, p = 0.002). The flexion contracture group with 3DMFA >5° demonstrated greater PTS than non-flexion contracture group (medial PTS, p = 0.006; lateral PTS, p = 0.006).

CONCLUSIONS

Both medial and lateral PTS were correlated with sagittal alignment under WB conditions and were larger in the flexion contracture group. This finding can explain the function to take the load articular surface parallel to the ground for holding the balance in WB conditions in the sagittal plane for osteoarthritic knees. Moreover, surgeons may be required to decrease the PTS during knee arthroplasty to restore full extension in knees of patients with fixed flexion contracture.

Meta-analysis of the clinical and immunopathological characteristics and treatment outcomes in epidermolysis bullosa acquisita patients

Background

Epidermolysis bullosa acquisita (EBA) is an orphan autoimmune disease. Several clinical phenotypes have been described, but subepidermal blistering is characteristic of all variants. Limited data on clinical and immunopathological characteristics and treatment outcomes in EBA are available. To fill this gap, we collected this information from EBA cases, meeting current diagnostic criteria, published between 1971 and 2016.

Results

We identified 1159 EBA cases. This number must be, however, interpreted with caution, as it is not possible to check for multiple reporting. The analysis of all cases indicated that EBA affects all age groups (median: 50 years, range: 1 to 94 years) at an equal gender distribution. Non-mechanobullous (non-MB) forms of EBA were observed in 55% of patients, whereas the mechanobullous variant (MB-EBA) or a combination of both variants was described in 38 or 7% of patients, respectively. Type VII collagen (COL7)-specific autoantibodies were primarily of the IgG isotype, but anti-COL7 IgA, IgM and IgE were also documented. Comparison of the 2 clinical EBA types showed a higher frequency of IgA deposits in non-MB EBA as opposed to MB EBA. Mucous membrane involvement was observed in 23% of patients, and 4.4% of cases were associated with other chronic inflammatory diseases. Of note, IgA deposits were more frequently observed in cases with mucous membrane involvement. Our analysis indicated that EBA is difficult to treat and that the choice of treatment varies widely. Chi square was applied to identify medications associated with complete remission (CR). Considering all EBA cases, intravenous immunoglobulin (IVIG, p = 0.0047) and rituximab (p = 0.0114) were associated with CR. Subgroup analysis demonstrated that no treatment was associated with CR for non-MB EBA, while IVIG (p = 0.003) was associated with CR in MB EBA.

Conclusions

Within the limitations of the study, we here document the clinical and immunopathological characteristics and treatment outcomes in a large cohort of EBA patients. The observed associations of single drugs with treatment outcome may serve as a guide to develop clinical trials.

Electronic supplementary material

The online version of this article (10.1186/s13023-018-0896-1) contains supplementary material, which is available to authorized users.

Quadriceps muscle weakness is related to increased risk of radiographic knee OA but not its progression in both women and men: the Matsudai Knee Osteoarthritis Survey

PURPOSE

The purpose of this study was to investigate the causal relationship between quadriceps muscle strength and radiographic knee osteoarthritis (OA) in a longitudinal study.

METHODS

The present study included 976 knees from 488 subjects who participated in both the 5th (2007) and 7th (2013) surveys of the Matsudai Knee Osteoarthritis Survey. Bilateral quadriceps strengths of each subject were measured using the quadriceps training machine (QTM-05F, Alcare Co., Ltd., Tokyo, Japan). Additionally, weight-bearing standing knee radiographs were obtained, and knee OA was graded according to the Kellgren-Lawrence classification system. The relationships between quadriceps strength and the incidence and progression of radiographic knee OA were assessed using multiple logistic regression analysis.

RESULTS

After adjusting for age and body mass index (BMI), both female and male knees in the lowest quantile of quadriceps strength had higher risk of the incidence of radiographic knee OA compared with the highest quantile of quadriceps strength (women: OR 2.414, 95% CI 1.098-5.311; men: OR 2.774, 95% CI 1.053-7.309). In contrast, after adjusting for age, BMI and femorotibial angle, both female and male knees in the lowest quantile compared with the highest quantile of quadriceps strength did not differ in risk of the progression of radiographic knee OA (women: OR 1.040, 95% CI 0.386-2.802; men: OR 2.814, 95% CI 0.532-14.898).

CONCLUSION

Quadriceps muscle weakness was related to increased risk of the incidence of radiographic knee OA, but not its progression, in both women and men. Therefore, the clinically important finding of this study is that, in both women and men, maintaining higher quadriceps muscle strength may be one of the most effective prevention methods for incident radiographic knee OA.

LEVEL OF EVIDENCE

II.

Serum 5-S-cysteinyldopa behavior in the early phase of nivolumab treatment of 12 melanoma patients

Along with the expansion of therapeutic options for metastatic melanoma, the development of useful biomarkers is urgently required to predict and monitor treatment response. Serum 5-S-cysteinyldopa (5-S-CD) has been identified as a diagnostic marker of malignant melanoma, but its utility as a biomarker for emerging therapeutic agents remains unknown. We assessed serum 5-S-CD in 12 metastatic melanoma patients (median age, 76 years; six men and six women) who had been treated with nivolumab (Nivo) at Shinshu University Hospital between 2014 and 2016. Serum 5-S-CD and lactate dehydrogenase levels before and at 3-6 weeks of Nivo treatment were obtained and their changes were compared with clinical responses as defined by the Response Evaluation Criteria in Solid Tumors criteria (version 1.1). A decrease of 10 nmol/L or more of serum 5-S-CD was observed only in partial response patients (2/3 cases, 67%), while an increase of 10 nmol/L or more of serum 5-S-CD was witnessed only in progressive disease patients (4/8 cases, 50%). Serum 5-S-CD changes were within ±10 nmol/L in the remaining six patients (partial response, one; stable disease, one; progressive disease, four). The results of the four moderately affected progressive disease patients were suspected to have been influenced by small-sized metastatic lesions, a mixed response that included diminished and enlarged metastatic lesions, prior therapy to Nivo with BRAF inhibitors or radiation, or the development of brain metastasis. Serum 5-S-CD in the early phase of Nivo treatment may be helpful to predict therapeutic response in metastatic melanoma.

Therapeutic Effect of a Novel Phosphatidylinositol-3-Kinase δ Inhibitor in Experimental Epidermolysis Bullosa Acquisita

Epidermolysis bullosa acquisita (EBA) is a rare, but prototypical, organ-specific autoimmune disease, characterized and caused by autoantibodies against type VII collagen (COL7). Mucocutaneous inflammation, blistering, and scarring are the clinical hallmarks of the disease. Treatment of EBA is difficult and mainly relies on general immunosuppression. Hence, novel treatment options are urgently needed. The phosphatidylinositol-3-kinase (PI3K) pathway is a putative target for the treatment of inflammatory diseases, including EBA. We recently discovered LAS191954, an orally available, selective PI3Kδ inhibitor. PI3Kδ has been shown to be involved in B cell and neutrophil cellular functions. Both cell types critically contribute to EBA pathogenesis, rendering LAS191954 a potential drug candidate for EBA treatment. We, here, demonstrate that LAS191954, when administered chronically, dose-dependently improved the clinical phenotype of mice harboring widespread skin lesions secondary to immunization-induced EBA. Direct comparison with high-dose corticosteroid treatment indicated superiority of LAS191954. Interestingly, levels of circulating autoantibodies were unaltered in all groups, indicating a mode of action independent of the inhibition of B cell function. In line with this, LAS191954 also hindered disease progression in antibody transfer-induced EBA, where disease develops dependent on myeloid, but independent of B cells. We further show that, in vitro, LAS191954 dose-dependently impaired activation of human myeloid cells by relevant disease stimuli. Specifically, immune complex-mediated and C5a-mediated ROS release were inhibited in a PI3Kδ-dependent manner. Accordingly, LAS191954 also modulated the dermal–epidermal separation induced in vitro by co-incubation of immune complexes with polymorph nuclear cells, thus pointing to an important role of PI3Kδ in EBA effector functions. Altogether, these results suggest a new potential mechanism for the treatment of EBA and potentially also other autoimmune bullous diseases.

High Index Values of Enzyme-Linked Immunosorbent Assay for BP180 at Baseline Predict Relapse in Patients With Bullous Pemphigoid

Bullous pemphigoid (BP) presenting with erythema plaques and tense blisters is the most frequent autoimmune bullous disease. Immunologically, BP is characterized by the presence of circulating anti-epidermal basement membrane zone (BMZ) antibodies. The autoantigens in BMZs targeted by patient's antibodies are mainly BP180 (type XVII collagen) and BP230. Previous reports have indicated that IgG to the immunodominant region of BP180 in BP, 16th non-collagenous domain (NC16A), and anti-BP180NC16A IgE are related to disease activity. In the cytokine profile, serum levels of IL-6, TNF-α, IL-15, and CCL18 were associated with the severity or activity of the disease. Blood eosinophilia is seen frequently, especially in severe cases. These biomarkers are helpful to evaluate efficacy of treatment and disease severity. Due to the high frequency of disease relapse, prediction of relapse at initiation of treatment (baseline) must be beneficial for clinicians. Therefore, we evaluated biomarkers anti-BP180 IgG (BP180 ELISA), anti-BP230 IgG (BP230 ELISA), peripheral eosinophils, and serum IgE at baseline between BP patients with (n = 16) and without (n = 31) relapse. We found significantly higher index values of BP180 ELISA in the relapse group, whereas no significant difference was found in BP230 ELISA, peripheral eosinophils, and serum IgE. This study indicated that a high index value of BP180 ELISA (cutoff value, 53.09 U/mL; sensitivity, 81.3%; specificity, 48.4%) at baseline may predict relapse in patients with BP. This may help clinicians treating BP patients in decision-making regarding duration and intensity of treatment.

No differences in objective dynamic instability during acceleration of the knee with or without subjective instability post-total knee arthroplasty

INTRODUCTION

Instability after total knee arthroplasty is a critical problem. The purpose of this study was to clarify the stability of implanted knees during walking by comparing differences in dynamic instability during knee acceleration between individuals with or without previously experienced subjective instability, as measured by self-reported questionnaire.

MATERIALS AND METHODS

We examined 92 knees with medial pivot implants. Mean patient age and follow-up duration were 78.4 years and 32.8 months, respectively. An accelerometer was used to investigate the accelerations along three axes; that is, vertical (VT), mediolateral (ML), and anteroposterior (AP) directions in 3-dimensional (3D) space. The analysis in the stance phase and gait cycle was performed by: (1) root mean square (RMS) values of acceleration and (2) frequency domain analysis using fast Fourier transformation (FFT). A self-reported knee instability score was used for the subjective feeling of instability.

RESULTS

A total of 76 knees did not feel unstable (group 0), but 16 knees felt unstable (group 1) in patients during activities of daily living. Regarding the RMS, there were no differences in each direction between the groups. For FFT, the cumulative amplitude in the frequency < 30 Hz also showed no significant differences in all directions between the groups during the stance phase (VT, p = 0.335; ML, p = 0.219; AP, p = 0.523) or gait cycle (VT, p = 0.077; ML, p = 0.082; AP, p = 0.499).

DISCUSSION

Gait analysis based on the acceleration data showed that there were no between-group differences in objective dynamic instability during acceleration of the knee, with or without reports of previously experienced subjective instability, as assessed by the self-reported questionnaire.

Clinical and Immunological Profiles of 14 Patients With Bullous Pemphigoid Without IgG Autoantibodies to the BP180 NC16A Domain

Importance

Enzyme-linked immunosorbent assay (ELISA) and/or chemiluminescent enzyme immunoassay (CLEIA) for BP180 noncollagenous 16A (NC16A) extracellular domain is a sensitive diagnostic tool for bullous pemphigoid (BP). However, some patients with BP have negative results for these assays.

Objective

To elucidate the clinical and immunological features of patients with BP without antibodies that react to BP180 NC16A.

Design, Setting, and Participants

This retrospective case series study included 152 patients who were diagnosed with BP and followed up at the Kurume University Hospital in Japan from 2007 to 2016. The diagnosis was made using clinical, histological, and immunological findings.

Main Outcomes and Measures

Clinical and immunological features of patients with BP who had negative results for BP180 NC16A using ELISA and/or CLEIA.

Results

Of the 152 patients, 69 (45.4%) were men and 83 (54.6%) were women. The mean (SD) age of participants was 75.2 (14.4) years. Of the 152 patients with BP, 14 (9.2%) had negative results for BP180 NC16A on ELISA and/or CLEIA; most of these patients exhibited no erythema and had relatively mild phenotypes. Two (14%) of the 14 patients had positive results for intact BP180 in epidermal extracts, 10 (71%) had positive results for a 120-kD fragment of BP180 (LAD-1) and 3 (21%) had positive results for BP180 C-terminal domain. Seven (50%) patients tested positive in BP230 ELISA. Five (36%) patients did not require oral prednisolone treatment, whereas the others required a dose of prednisolone at less than 30 mg per day. Three (21%) patients were administered a dipeptidyl peptidase-4 inhibitor (DPP4i) before disease onset. This ratio was not significantly higher than that in patients with BP who tested positive for BP180 NC16A ELISA and/or CLEIA (19 [14%] of 138 patients). Our follow-up study (mean [SD], 31.9 [33.2] weeks; range, 0-108 weeks) revealed that patients with BP tested negative for BP180 NC16A ELISA and/or CLEIA during the later stages of the disease.

Conclusions and Relevance

This study indicates that patients with BP negative for BP180 NC16A ELISA and/or CLEIA had milder phenotypes, fewer erythemas, and required less extensive treatments.

Increasing incidence of fracture and its sex difference in school children: 20 year longitudinal study based on school health statistic in Japan

BACKGROUND

Studies on the epidemiology of pediatric fractures have been scarce in recent years although fractures are very common in childhood. Boys have a higher incidence of fractures than girls. Currently, societal trends have seemed to influence the difference in activity patterns between boys and girls, but the sex difference regarding longitudinal changes in fracture incidence is not well known.

METHODS

We analyzed the school accident report in Niigata city, Japan and compared the incidence of fractures in elementary and junior high school students and the sex-related risk ratio between two 9-year periods separated by 20 years from their start and end points (1999-2007 and 1979-1987).

RESULTS

The study included 383,273 students from 1999 to 2007 and 561,109 students from 1979 to 1987. Comparing these periods, the fracture incidence increased significantly by 2.4 times in boys vs 2.1 times in girls from elementary school and by 2.2 times in boys vs 2.9 times in girls from junior high school (all p ＜ 0.001). The sex-related risk ratio of boys to girls increased significantly from 1.47 to 1.64 in elementary school students. In contrast, it decreased significantly from 3.29 to 2.52 in junior high school students and the change was markedly significant because of the drastic increase in fracture incidence in junior high school girls.

CONCLUSIONS

The reasons proposed for the increase in schoolchildren's fractures were an improvement in diagnosis owing to social background and increased participation in sports activities despite the general decline in children's physical fitness and exercise ability. In junior high school girls, in particular, there was an increase in fracture risk due to increased participation in sports activities.