Diagnostic Accuracy of Point-of-Care Gram Stains in Obstructive Pyelonephritis due to Ureteral Stones

Background

The diagnostic utility of point-of-care (POC) Gram stains for obstructive pyelonephritis with hydronephrosis is not well established. The current study aimed to assess the diagnostic accuracy of urine Gram stains in patients with obstructive pyelonephritis due to ureteral stones.

Methods

A retrospective observational study was conducted on patients with obstructive pyelonephritis admitted to our hospital between January 2011 and December 2021. The diagnostic accuracy of Gram stains was evaluated based on the severity of hydronephrosis, including Gram stains performed by both trained physicians and microbiological technicians.

Results

After analyzing 210 patients, POC Gram stains of bladder urine presented a sensitivity, specificity, positive predictive value, and negative predictive value of 86.8%, 81.8%, 93.7%, and 66.7%, respectively, for gram-negative rods and 65.7%, 83.4%, 48.9%, and 91.0%, respectively, for gram-positive cocci. The agreement between POC Gram stains and urine culture was good for gram-negative rods, with a kappa (κ) coefficient of 0.637 and agreement rate of 85.6%, and moderate for gram-positive cocci, with a κ coefficient of 0.435 and agreement rate of 80%. The agreement between POC Gram stains and bladder urine culture results for gram-negative rods was higher in the mild hydronephrosis group (κ coefficient = 0.677) than in the severe hydronephrosis group (κ coefficient = 0.466). Discrepancies in Gram stain results between physicians and technicians were observed in 21 of 180 cases (11.7%).

Conclusions

POC Gram stains for gram-negative rods may be a useful diagnostic tool for obstructive pyelonephritis, particularly in cases of mild hydronephrosis.

Wernicke encephalopathy: limitations in a laboratory and radiological diagnosis

Wernicke encephalopathy is an emergent neurological disorder caused by vitamin B1 (thiamine) deficiency. Here, we present a case of Wernicke encephalopathy in a male patient in his 70s with normal serum thiamine levels and MRI findings on admission. He had a history of heavy alcohol consumption and a gradual decrease in food intake. On arrival at the hospital, his consciousness was impaired which persisted even after glucose replacement. Moreover, horizontal nystagmus and cerebellar ataxia were observed. Head CT scan and MRI revealed no abnormal findings. Further, his serum thiamine level was within the normal range. The patient was clinically diagnosed with Wernicke encephalopathy, and high-dose thiamine therapy was started. Then, his symptoms improved immediately. Thus, in case of clinical suspicion, treatment for Wernicke encephalopathy must be initiated promptly even in patients with normal serum thiamine levels.

Acute dacryoadenitis due to primary Epstein-Barr virus infection

We herein present the case of a 28-year-old male patient who presented with fever and bilateral upper eyelid edema without other upper airway symptoms and was diagnosed with acute dacryoadenitis due to Epstein-Barr virus (EBV) infection. The patient’s medical history was unremarkable. Laboratory tests revealed lymphocytosis with atypical lymphocytes and abnormal liver function tests. Physical examination and computed tomography revealed swelling in the lacrimal glands, and serological tests confirmed EBV infection. Although rare, ocular symptoms of primary EBV infection are important for diagnosis. Acute dacryoadenitis should be considered as a rare manifestation and an underdiagnosed complication of primary EBV infection.

Glecaprevir/Pibrentasvir and Renal Dysfunction in Deceased Donor Renal Transplantation: A Case Report

BACKGROUND

Glecaprevir/pibrentasvir is a novel anti-hepatitis C virus (HCV) drug, and it is currently the only drug available for patients with severe renal impairment. Here we report a case with renal dysfunction after an administration of glecaprevir/pibrentasvir.

CASE REPORT

The case was 66-year-old Japanese man who turned out to be HCV-positive 14 years ago at the time of his second deceased renal transplantation. He had no prior history of HCV treatment. HCV genotype was serogroup 1, and baseline HCV-RNA was 5.3 LOG IU/mL. Since glecaprevir/pibrentasvir became available, he started to take it for treatment of HCV. His immunosuppressants were tacrolimus (trough levels 4.3∼6.5 ng/mL) and 5 mg of prednisolone. His baseline renal function was serum creatinine (Cr) 2.1 mg/dL and urine protein (-). Shortly after starting glecaprevir/pibrentasvir, the serum Cr started to increase. Serum Cr reached up to 2.92 mg/dL and urine protein was (+) at day 36. Right pleural effusion was observed while cardiac function was normal. His liver function had been consistently normal. We concluded glecaprevir/pibrentasvir was the cause of renal dysfunction as no other drugs were added. Immediately after discontinuation of glecaprevir/pibrentasvir at day 36, serum Cr decreased to 1.9 mg/dL and urine protein turned negative at day 64. Although the patient completed a half course of glecaprevir/pibrentasvir, HCV-RNA turned to be negative at day 36.

CONCLUSIONS

We experienced a case with renal dysfunction after the initiation of glecaprevir/pibrentasvir in deceased donor renal transplant recipient. Renal dysfunction caused by glecaprevir/pibrentasvir has not been reported so far.

Photobacterium damselae subsp. damselae bacteraemia in a patient with liver cirrhosis

Photobacterium damselae subsp. damselae is a family of Vibrionaceae and exists in the marine environment. The organism rarely causes soft-tissue infection in humans; moreover, most of the infected individuals have a history of fishing or exposure to brackish water. We experienced the case of a 63-year-old patient with a history of liver cirrhosis (Child-Pugh class B) who presented with a fever and swelling of the left leg with pain. His symptoms developed after fishing and eating raw fish with exposure of brackish water. He was diagnosed with cellulitis, and Photobacterium damselae spp. damselae was detected in blood culture. The patient was treated with ceftazidime and minocycline and he was discharged after recovery. We need to be aware that in immunocompromised patients with cellulitis exposed to brackish water, organisms other than Staphylococci and Streptococci may be the causative organisms.

Empyema associated with a cough-induced rib fracture

A 44-year-old man presented to the emergency department with fever and right anterior chest pain. He reported a persistent cough and the development of sudden-onset right anterior chest pain after coughing. The inspiratory pain in the right lung was severe, and therefore deep breathing was impossible. Chest CT revealed a fracture in the right seventh rib with consolidation and pleural effusion. A pleural fluid culture test result was positive for methicillin-susceptible Staphylococcus aureus. He was diagnosed with empyema associated with a cough-induced rib fracture. Thoracic drainage tube placement and intravenous antibiotic therapy successfully ameliorated his condition. He was discharged on day 13 and switched to an 8-week course of oral antibiotic therapy. There was no clinical relapse at the 6-month follow-up.

Case Report: Ninjin'yoeito May Improve Quality of Life After Hospitalization for Acute Illness in Patients With Frailty

Introduction: Frail patients are susceptible to a large number of diseases, and frailty particularly is known to develop after acute illness. No conventional drugs are known to prevent such exacerbation after acute illness. However, traditional Japanese medicine, Kampo, is thought to confer efficacious energy and nutritional supplements and serve to improve malaise after acute illness. Ninjin'yoeito is a representative Kampo medicine for such situation.

Cases: We describe three frail patients hospitalized for acute illness who started taking ninjin'yoeito at the time of discharge.

Case 1: An 87-year-old man admitted with acute prostatitis complicated by hypertension and chronic obstructive pulmonary disease (COPD). His 36-Item Short Form Health Survey (SF-36) score, which is representative of total quality of life and comprises eight components, showed consistent improvements after 4 and 12 weeks of ninjin'yoeito administration, especially for body pain (BP; scores from 41 to 51 and 100, respectively), social function (SF; 50, 100, 100), and mental health (MH; 75, 75, 90).

Case 2: A 65-year-old man admitted with urinary tract infection complicated by primary sclerosing cholangitis and COPD. All SF-36 component scores showed improvement 12 weeks later: physical function (PF; 70–95), role physical (RP; 75–100), BP (72–84), general health (GH; 45–52), vitality (VT; 37.5–75), SF 75–100, role emotional (RE; 75–100), and MH (70–90).

Case 3: An 80-year-old man admitted for pneumonia complicated with hypertension. SF-36 score was improved 4 weeks later for RP (68.8–100), BP (52–61), GH (52–72), VT (43.8–62.5), SF (37.5–100), and RE (58.3–91.7).

Conclusion: Patients with frailty often have a worsened SF-36 score after discharge following acute illness, but the score may be improved by taking ninjin'yoeito.

Long-term impact of baseline serum uric acid levels on living kidney donors: a retrospective study

BACKGROUND

Preoperative characteristics of living kidney donors are commonly considered during donor selection and postoperative follow-up. However, the impact of preoperative uric acid (UA) levels is poorly documented. The aim of this study was to evaluate the association between preoperative serum UA levels and post-donation long-term events and renal function.

METHODS

This was a single-center retrospective analysis of 183 living kidney donors. The donors were divided into high (≥5.5 mg/dl) and low (< 5.5 mg/dl) UA groups. We analyzed the relationship between preoperative UA levels and postoperative estimated glomerular filtration rate (eGFR), as well as adverse events (cardiovascular events and additional prescriptions for hypertension, gout, dyslipidemia, and diabetes mellitus), over 5 years after donation.

RESULTS

In total, 44 donors experienced 52 adverse events over 5 years. The incidence of adverse events within 5 years was significantly higher in the high UA group than in the low UA group (50% vs. 24%, p = 0.003); this was true even after the exclusion of hyperuricemia-related events (p = 0.047). UA emerged as an independent risk factor for adverse events (p = 0.012). Donors with higher UA levels had lower eGFRs after donation, whereas body mass index, hemoglobin A1c, blood pressure, and low-density lipoprotein cholesterol did not have any impact on the eGFR.

CONCLUSIONS

The findings suggest that preoperative UA levels should be considered during donor selection and postoperative follow-up.

Multimode-based polarization independent WDM devices using different order modes for TE and TM polarizations

Multimode based polarization independent (PI) wavelength division multiplexing (WDM) devices are proposed and experimentally demonstrated. The key concept is to utilize two different order modes for the orthogonal polarizations, ith-order mode for TE and jth-order mode for TM (i ≠ j) polarization respectively to extend the flexibility for designing devices. PI coupler composed of a multimode directional coupler and mode converters is introduced as a basic device. Then, we apply PI coupler to Mach Zehnder interferometer (MZI) and Bragg grating bandpass filters. PI MZI is achieved by optimizing the combination of two phase shifters in the interferometer arms. PI bandpass uses 3dB-PI coupler and polarization rotate Bragg gratings that induce mode coupling between the polarizations. Each device showed good matching in the spectrum between TE and TM polarizations in term of operation wavelength. The proposed concept can be a promising approach to realize PI WDM functions without introducing polarization diversity scheme in which a polarization beam splitter, two devices designed for each polarization and a polarization beam combiner are required.

HbA1c and Aortic Calcification Index as Noninvasive Predictors of Pre-Existing Histopathological Damages in Living Donor Kidney Transplantation

We previously reported that allografts from living donors may have pre-existing histopathological damages, defined as the combination of interstitial fibrosis (ci), tubular atrophy (ct), and arteriolar hyalinosis (ah) scores of ≧1, according to the Banff classification. We examined preoperative characteristics to identify whether the degree of these damages was related to metabolic syndrome-related factors of donors. We conducted a single-center cross-sectional analysis including 183 living kidney donors. Donors were divided into two groups: chronic change (ci + ct ≧ 1 &cap; ah ≧ 1, n = 27) and control (n = 156). Preoperative characteristics, including age, sex, blood pressure, hemoglobin A1c (HbA1c), aortic calcification index (ACI), and psoas muscle index (PMI), were analyzed. Comparing the groups, the baseline estimated glomerular filtration rate was not significantly different; however, we observed a significant difference for ACI (p = 0.009). HbA1c (p = 0.016) and ACI (p = 0.006) were independent risk factors to predict pre-existing histopathological damages, whereas PMI was not. HbA1c correlated with ct scores (p = 0.035), and ACI correlated with ci (p = 0.005), ct (p = 0.021), and ah (p = 0.017). HbA1c and ACI may serve as preoperative markers for identifying pre-existing damages on the kidneys of living donors.

Optimizing Intraoperative Blood Pressure to Improve Outcomes in Living Donor Renal Transplantation

BACKGROUND

Adequate renal perfusion at the time of unclamping is important because it has been known to affect outcomes in renal transplantation. Nevertheless, the ideal intraoperative systolic arterial pressure (SAP) has not been well defined.

METHODS

We performed a retrospective analysis of 106 living donor renal transplants performed at our center from June 2010 to May 2019. We divided the cohort into 2 groups according to our center's goal SAP of ≥150 mm Hg: 57 patients had SAP ≥150 mm Hg and 49 patients had SAP <150 mm Hg. We analyzed pretransplant characteristics, intraoperative measurements, and postoperative laboratory values to validate our center's target SAP at the time of reperfusion. This study strictly complied with the Helsinki Congress and the Istanbul Declaration regarding donor sources.

RESULTS

Patients with SAP ≥150 mm Hg had been on dialysis for a significantly shorter duration before transplant compared with those who had SAP <150 mm Hg. In the SAP ≥150 mm Hg group, urinary sodium excretion normalized earlier, and they had a significantly smaller stroke volume variation, higher cardiac output and cardiac index, earlier initial urination, and higher intraoperative urine output. There were no differences in intraoperative volume repletion, central venous pressure, or postoperative estimated glomerular filtration rate.

CONCLUSION

Achieving SAP ≥150 mm Hg at the time of reperfusion may be associated with early stabilization of graft function. Nevertheless, our data suggested that recipients with a prolonged dialysis history are less likely to achieve SAP ≥150 mm Hg at the time of unclamping in living donor renal transplantation.

Impact of Very Low-Dose Trimethoprim-Sulfamethoxazole on Serum Creatinine after Renal Transplantation: A Retrospective Study

BACKGROUND

It is well known that high-dose trimethoprim, through its effect of inhibiting creatinine secretion, increases serum creatinine levels without changes in real glomerular filtration rate. However, there has been no report regarding the effect of very low-dose trimethoprim on serum creatinine levels after renal transplantation.

METHODS

We retrospectively investigated 76 renal transplantation recipient outpatients who completed their course of initial prophylaxis at our institution. Twelve patients who experienced events that might affect their serum creatinine levels were excluded. Fifty-one patients who required readministration of trimethoprim-sulfamethoxazole to prevent a possible outbreak of pneumocystis jirovecii pneumonia and 13 patients who did not receive readministration (control) were analyzed. Dosage was 80 mg/400 mg (per tablet), administered as 3 tablets per week for 30.6 ± 13.5 days. This study strictly complied with the Helsinki Congress and the Istanbul. Declaration regarding donor source.

RESULTS

All patients completed readministration without adverse events. Serum creatinine increased significantly in the readministration group (1.40 ± 0.64 mg/dL to 1.48 ± 0.70 mg/dL, P < .01) while not in the control group. The higher the initial serum creatinine level, the greater the increase of Δ serum creatinine (R = 0.59, P < .001). Sex, baseline urine protein level, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use, donor type, and time after renal transplantation did not affect Δ serum creatinine. Serum creatinine returned to baseline levels after cessation.

CONCLUSIONS

Very low-dose trimethoprim-sulfamethoxazole prophylaxis significantly raised serum creatinine reversibly by 6% after renal transplantation.

Is the Living Donor Kidney Profile Index Valuable in Japanese Patients?

INTRODUCTION

The Living Kidney Donor Profile Index (LKDPI) was recently proposed in the United States to evaluate living donor quality. Japan has a largely different renal transplant circumstance, such as a high ABO incompatibility rate. The aim of this study was to validate the LKDPI among the Japanese population and adjust the score.

METHODS

We performed a retrospective analysis of 133 living donors in renal transplant in our institution. We analyzed the clinical characteristics and outcomes, and created a modified LKDPI score considering the favorable ABO incompatible kidney transplant outcomes in Japan.

RESULTS

Median (interquartile range [IQR]) donor age was 59 (51 to 65) and median (IQR) body mass index was 22.9 kg/m² (20.9 to 25.2). ABO incompatibility rate was 28.5%. Median (IQR) donor estimated glomerular filtration rate (eGFR) (Chronic Kidney Disease Epidemiology Collaboration equation) was 108.7 mL/min/1.73 m² (99.9 to 115.5). The 1-year graft survival rate was 98.5%, and the 3-year graft survival rate was 97%. The incidence of antibody mediated rejection was 5.2%. The median (IQR) LKDPI score was 30.2 (11.8 to 46.8). This was significantly higher than the previously reported score in the United States, which was 12.8 (-0.8 to 27.2). The modified LKDPI (mLKDPI) score was 23.2 (4.1 to 35.1). LKDPI and mLKDPI did not show a diagnostic value in graft survival; however, LKDPI and mLKDPI showed significant diagnostic value in eGFR at 1 year (area under the curve [AUC]=0.627, P = .017; and AUC=0.673, P = .01).

CONCLUSION

Our outcomes had better survival even though with higher ABO incompatibility rate. According to original LKDPI, our donor pool is higher than the general US population. In this study, lower LKDPI tended to be associated with good allograft function, and mLKDPI has better diagnostic value than LKDPI. To compare internationally, an adjusted model for Japan might be necessary based on the outcomes of a large population.

78 Evaluation of the genomic estimated breeding value of carcass traits in blastocyst-stage embryos derived from Japanese Black cattle

Genomic selection based on a high-throughput microarray for genotyping single nucleotide polymorphism (SNP) is expected to accelerate genetic improvement in cattle. Recently, a genomic evaluation system for carcass traits, such as carcass weight and marbling score, is being established in Japanese Black cattle. To further increase genetic improvement efficiency in this breed, establishing a genomic evaluation system for pre-implantation embryos before embryo transfer (ET) is required. Here, we examined the correlation between genomic estimated breeding value (GEBV) of carcass traits calculated from embryonic (blastocyst) biopsy cells and from a corresponding calf produced by ET (Experiment 1); we also evaluated the pregnancy rate following ET of GEBV-evaluated blastocysts (GEBV blastocysts) preserved by vitrification (Experiment 2). In total, 16 Japanese Black dams and cryopreserved semen from 6 Japanese Black sires were used for producing in vivo blastocysts (Day 7-8). In Experiment 1, four blastocysts (IETS code 1) were divided into biopsy cells (15-20 cells) and biopsied embryos using a micromanipulator equipped with a micro blade. Biopsy cells were processed for DNA extraction and whole-genome amplification. Freshly biopsied embryos were transferred to recipient cows, and DNA was extracted from the blood or ear cells of the resulting 4 calves. Then SNP genotyping was performed using Illumina bovine LD BeadChip (Illumina, San Diego, CA, USA). The GEBV of 6 carcass traits (carcass weight, ribeye area, rib thickness, subcutaneous fat thickness, estimated yield percent, and marbling score) were calculated using phenotypic and genotypic data from 4,311 Japanese Black steers, and these were compared between biopsy cells and the corresponding calf. In Experiment 2, 134 blastocysts (IETS code 1 and 2) in total were biopsied (10-20 cells), and the biopsied embryos were vitrified by the cryotop method. Biopsy cells were processed for SNP genotyping as in Experiment 1, and the samples in which the call rate was more than 85% were used for GEBV calculation. Based on GEBV records, 24 vitrified GEBV blastocysts were warmed, cultured for 3 to 5h, and 22 GEBV blastocysts that survived (re-expanded) post-culture were transferred to recipient cows. Pregnancy in these cows was diagnosed using ultrasonography during Day 55 to 60 of gestation. In Experiment 1, the SNP call rates of the biopsy cells and corresponding calf were 98.5 to 99.3% and 99.7 to 99.8%, respectively. The GEBV of 6 carcass traits from biopsy cells and from the corresponding calf had almost the same values. In Experiment 2, the SNP call rates of the biopsy cells were ranged from 26.1 to 99.3%. The GEBV of 6 carcass traits varied among full-sib embryos. The pregnancy rate following ET of vitrified GEBV blastocysts was 40.9% (9/22). These results suggest the possible application of a genomic evaluation system for carcass traits at the blastocyst stage in Japanese Black cattle. Further large-scale assessment of pregnancy rates following ET of cryopreserved GEBV blastocysts is required for practical application of the evaluation system.

Development of cerebral sulci and gyri in fetuses of cynomolgus monkeys (Macaca fascicularis)

This study aimed to clarify the development of sulci and gyri on the external surface of the cerebrum of cynomolgus monkeys. Sulcus formation began with the appearance of the lateral fissure on embryonic day (ED) 70, followed by delineations of four cerebral lobes by the emergence of the parietooccipital sulcus, central sulcus, and preoccipital notch on EDs 80-90. The following primary sulci were then visible until ED 120: the superior temporal sulcus on ED 90; the intraparietal sulcus, lunate sulcus, inferior occipital sulcus, and arcuate sulcus on ED 100; and the principle sulcus on ED 110; the occipitotemporal sulcus, anterior middle temporal sulcus, and superior postcentral dimple on ED 120. These sulci demarcated the superior temporal gyrus on ED 90, the precentral gyrus, supramarginal gyrus, and angular gyrus on ED 100, and the inferior and middle temporal gyri, postocentral gyrus, superior parietal lobule, superior, middle and inferior frontal gyri, and inferior occipital gyrus on ED 120. Except for the intermediate and lateral orbitofrontal sulci, the sulci that appeared on ED 130 and thereafter were not related to the gyrus demarcations. Intriguingly, the brain markedly gained weight on EDs 100 and 120, corresponding to the embryonic ages when almost all gyri were visible. The results suggest that a rapid growth of the cerebrum involves convolutions of the gyri by a regular sequence of the sulcus formation in cynomolgus monkeys. This study further provides a standard of reference for normal development in the cerebral cortical morphology of cynomolgus monkeys.

Cocoa supplementation for copper deficiency associated with tube feeding nutrition

OBJECTIVE

Because of an increasing number of case reports of copper deficiency associated with long-term tube feeding nutrition in Japan, we identified patients with copper deficiency associated with long-term tube feeding and described the prevalence, clinical data and cocoa treatment for these patients.

MATERIALS AND METHODS

We conducted a retrospective study to identify patients who were referred from long-term care institutions and had copper deficiency associated with tube feeding. We reviewed all serum copper concentration data during a 6-year period. We also compared admission and post-treatment peripheral blood counts.

RESULTS

Among 210 consecutive admissions with nutritional tube feeding from long-term care institutions (N=210), we identified 13 (6.2%) patients with copper deficiency (aged 46-91; 12 women). All patients had anemia, while most had neutropenia. The range of serum copper concentrations of these patients was 0.1-2.4 microg/L (normal; 6.8-12.8 microg/L). Their feeding formulas revealed a low copper content (5 to 12 microg per 100 kcal of each formula). Cocoa powder was used as the treatment. With cocoa supplements, the blood leukocyte count and hemoglobin significantly improved in all patients. Median leukocyte counts were 1,800 /mm(3)at admission and 6,300/mm(3) at follow-up (p=0.001). Median hemoglobin were 7.0 g/dl at admission and 10.3 g/dl at follow-up (p=0.001). Two patients developed transient tachycardia as a possible adverse effect of cocoa.

CONCLUSION

We identified many cases with copper deficiency associated with tube feeding in Okinawa, Japan. Cocoa supplement appeared to be a safe and effective treatment. Increasing the copper content of Japanese tube feeding formulas should be considered for its prevention.

A successfully treated case of mycetoma due to Nocardia veterana

We report a successfully treated case of mycetoma from which an unusual Nocardia species was isolated. The isolate was identified as N. veterana by biochemical characterization and 16S ribosomal RNA gene sequencing, and it has not been previously reported as a causative agent of human mycetomas. Treatment with various antibiotics over 6 years and surgical resection failed to cure the disease. However, the combination of intravenous imipenem/cilastatin and amikacin along with oral clarithromycin and minocycline proved very effective in this case. This is the first case report of mycetoma due to N. veterana in a clinical setting.

Evaluation of the usefulness of the limited cone-beam CT (3DX) in the assessment of the thickness of the roof of the glenoid fossa of the temporomandibular joint

OBJECTIVES

The purpose of this study was to evaluate the usefulness of the limited cone-beam X-ray CT (3DX) (Morita Co., Japan) in measuring the thickness of the roof of the glenoid fossa (RGF) of the temporomandibular joint (TMJ).

MATERIALS AND METHODS

Twenty-one TMJs removed at autopsy from 21 cadavers were investigated macroscopically using dissection and 3DX imaging. A Digimatic Outside Micrometer and a 3DX-image tool were used to measure the minimum thickness of the RGF. Multiple measurements were made to identify the thinnest area. Once the thinnest areas had been identified, three linear measurements were made and the average value was used for statistical analysis.

RESULTS

The average macroscopic examination measurement was 1.37 mm (range 0.55-3.6 mm) and the average 3DX image measurement was 1.22 mm (range: 0.51-3.0 mm). There was no significant difference between these two groups using the Mann-Whitney U-test (P < 0.05). The Spearman's correlation coefficient by rank between these two groups was r = 0.93(P < 0.001).

CONCLUSION

These results suggest that bone thickness measurements of the RGF by 3DX imaging was effective.

Single air contrast arthrography for temporomandibular joint disorder using limited cone beam computed tomography for dental use

MRI has the problem of artefacts caused by metal or body motion and is also incompatible for patients with claustrophobia. Arthrography is invasive and involves the risk of perforation or allergy to a contrast medium. This report discusses a patient with temporomandibular joint (TMJ) disorder who required soft tissue imaging of the TMJ. As she had claustrophobia and a reaction to iodine, air contrast arthrography and pumping manipulation therapy using limited cone beam computed tomography for dental use (3DX) was performed. We conclude that the 3DX examination method used in the study is practical as a diagnostic procedure and thus recommend this method to be used for patients with TMJ disorder in the presence of iodine contraindication.

[A case of pneumonia due to coinfection by Mycoplasma pneumoniae and Chlamydia pneumoniae]

Few cases of Mycoplasma pneumoniae and Chlamydia pneumoniae coinfection in pneumonia have been reported in adults. We report a case of such a double infection in a young adult. A 16-year-old boy was admitted to our hospital with dry cough and fever. Laboratory findings revealed elevated serum GOT and GPT levels. The patient had been administered a beta-lactam antibiotic before admission to our hospital. Antibodies to M. pneumoniae were significantly elevated. Titers of IgM and IgG specific for C. pneumoniae titer were high, as measured by the enzyme-linked immunosorbent assay method. The patient was treated with clarithromycin and discharged after a satisfactory recovery. M. pneumoniae and C. pneumoniae may act as cofactors in community-acquired pneumonia. Further studies are needed to clarify the relationships of these pathogens to community-acquired pneumonia.

Role of ICAM-1 in the aggregation and adhesion of human alveolar macrophages in response to TNF-alpha and INF-gamma

Intracellular adhesion molecule-1 (ICAM-1)-mediated cell-cell adhesion is thought to play an important role at sites of inflammation. Recent evidence suggests that ICAM-1 surface expression on alveolar macrophages is increased in pulmonary sarcoidosis and that inflammatory granuloma formation is characterized by the aggregation of macrophages. The present study shows that ICAM-1 expression is significantly elevated on alveolar macrophages from patients with sarcoidosis in response to tumor necrosis factor-alpha (TNF-alpha) and interferon-gamma (INF-gamma) compared with healthy controls. Aggregation and adhesion were significantly increased in alveolar macrophages treated with TNF-alpha and INF-gamma, and significantly inhibited in those pretreated with a monoclonal antibody to ICAM-1. Similarly, aggregation and adhesion were inhibited in macrophages treated with heparin, which then exhibited a wide range of biological activities relevant to inflammation. These results suggested that the surface expression of ICAM-1 on alveolar macrophages in response to TNF-alpha and INF-gamma is important in mediating aggregation and adhesion. Additionally, heparin may be useful for developing novel therapeutic agents for fibrotic lung disease.

Safe and effective treatment of refractory facial lesions in atopic dermatitis using topical tacrolimus following corticosteroid discontinuation

BACKGROUND

Topical corticosteroids are commonly applied in atopic dermatitis (AD) treatment. However, their chronic use may be associated with significant side effects at the application site. Skin atrophy and other undesirable effects are frequently seen after long-term corticosteroid treatment. In addition, when application of corticosteroids is discontinued, a rebound phenomenon in the facial lesions can occur within several days. Topical tacrolimus, an immunosuppressant currently used to prevent rejection after solid-organ transplantation, presents a potential alternative therapeutic agent for AD.

OBJECTIVE

The present study is the first trial designed to evaluate the efficacy and safety of topically applied tacrolimus ointment after corticosteroid discontinuation without a washout phase in severe, long-term facial AD.

PATIENTS/METHODS

Forty-seven patients with facial refractory AD were recruited, of whom 38 had undergone topical corticosteroid treatment for at least 4 weeks before enrollment (group 1) and the other 9 had not received steroid treatment (group 2). All 47 patients received 0.1% tacrolimus ointment, and the severity index and pruritus score were assessed as an AD clinical activity index every week and compared with baseline data.

RESULTS

Both the severity index and pruritus score improved significantly in group 1 after 1 and 2 weeks of application (p < 0.01, respectively). Group 2 showed the greatest improvement at 4 weeks (p < 0.05). In this trial, none of the patients experienced a rebound phenomenon associated with tacrolimus treatment. A transient sensation of burning at the application site was the only adverse event in 31 of the 47 (66%) enrolled patients, but this condition improved after several days. Spectrophotometric assessment of the facial lesion following treatment revealed significant improvement in group 1 (p < 0.05).

CONCLUSION

The present results indicate that topical tacrolimus treatment following corticosteroid discontinuation is safe and effective in refractory facial AD.

Erythromycin and clarithromycin modulation of growth factor-induced expression of heparanase mRNA on human lung cancer cells in vitro

Heparanase activity is correlated with the metastatic potential of several cancer cells and is a key enzyme in the breakdown of tissue barriers. It is also involved in the regulation of growth factor and cytokine activity. However, little is known about the factors that induce heparanase in cancer cells. We investigated the effect of three growth factors, platelet-derived growth factor (PDGF), hepatocyte growth factor (HGF) and basic fibroblast growth factor (bFGF), on heparanase mRNA induction in lung cancer cells in vitro. In addition, we examined the effect of erythromycin (EM) and clarithromycin (CAM), which are 14-membered ring macrolide antibiotics that act as biological response modifiers, on the expression of heparanase mRNA induced by growth factors. PDGF, HGF and bFGF stimulated cell migration activity and enhanced the expression of heparanase mRNA in the human lung adenocarcinoma cell line A549. Via different mechanisms, EM and CAM modulate the induction by these factors of heparanase mRNA expression on A549 cells. EM also significantly suppressed A549 cell migration induced by PDGF and HGF, and CAM significantly suppressed A549cell migration induced by bFGF. The results suggest that the growth factors PDGF, HGF and bFGF are important inducers of heparanase in potentially invasive and metastatic cancer cells. The suppressive effect of heparanase mRNA expression by EM and CAM may have interestingtherapeutic applications in the prevention of metastasis.

[A case of bronchioloalveolar cell carcinoma with bilateral diffuse interstitial infiltrative shadow during the treatment of Takatsuki's disease]

A 54-year old man treated with Takatsuki's disease was referred to us complaining of cough and excessive sputum. A chest roentgenogram showed bilateral diffuse interstitial infiltrative shadow. Chest CT showed banding shadows around the bronchioles and lobule-septum thickening in the right middle and both lower lung fields, and many small nodules in both lower lung fields. The histological diagnosis was adenocarcinoma replaced with one layer of bronchiolar epithelium, and partly bronchiolo-alveolar carcinoma. The patient received 3 courses of combination chemotherapy with docetaxel and cisplatin. After chemotherapy, the chest CT showed no change. The clinicopathological characteristics of this rare case included adenocarcinoma mixed with bronchioloalveolar carcinoma, in which radiography showed bilateral diffuse interstitial infiltrative shadow.

Serum levels of soluble stem cell factor and soluble KIT are elevated in patients with atopic dermatitis and correlate with the disease severity

BACKGROUND

Mast cell infiltration in skin lesions of atopic dermatitis (AD) is considered to play an important role in the pathogenesis of the disease. The most common factor that stimulates mast cell growth, migration and differentiation is stem cell factor (SCF), and the interaction of SCF and its receptor, KIT (tyrosine kinase transmembrane receptor), appears to be the key event in the recruitment and proliferation of mast cells.

OBJECTIVES

To determine whether any altered metabolism of SCF and/or KIT is present in patients with AD.

METHODS

We measured serum levels of soluble SCF (sSCF) and soluble KIT (sKIT) using enzyme-linked immunosorbent assay in 54 patients with AD, five patients with erythrodermic psoriasis vulgaris and 64 healthy individuals.

RESULTS

Serum levels of both peptides in AD patients were significantly higher than those in healthy individuals, whereas patients with psoriasis vulgaris did not show any difference from healthy controls. Both sSCF and sKIT levels were positively correlated with the disease severity in AD patients, and decreased after effective treatment with topical corticosteroids. Conclusion Serum levels of sSCF and sKIT may be useful indicators for evaluation of the activity and severity of AD.

A case of unilateral dermatomal cavernous haemangiomatosis

We report a 39-year-old man with unilateral dermatomal cavernous haemangiomatosis (UDCH). Clinically, three haemangiomas were unilaterally distributed in the C6 dermatome. Histologically, these haemangiomas were distinct from routine cavernous haemangioma in that hyperplasia of smooth muscle cells on the vascular wall was observed, and electron microscopy showed that smooth muscle cells contained myofilaments and a crystal-like structure in the endothelial cells. This is distinct from Weibel-Palade bodies, which are rod-shaped cytoplasmic organelles measuring approximately 0.1 microm in diameter with a parallel linear structure. In UDCH, the haemangiomas occur only in the skin. They are clinically and histologically similar to those of blue rubber bleb naevus syndrome (BRBNS), but in BRBNS there are multiple haemangiomas in the digestive tract and other organs. UDCH is distinct from Maffucci syndrome in that enchondromata and malignant tumours are absent. To our knowledge, this is the second case of UDCH reported in the literature.

A case of black dot ringworm with a review of Japanese cases

Black dot ringworm (BDR), caused by Trichophyton violaceum var. glabrum (T. glabrum), was observed in a 28-year-old Japanese female who had been treated with prednisolone (22.5 mg/day) for systemic lupus erythematosus. It was successfully treated with oral terbinafine (125 mg/day) for 12 weeks. The causative fungus was identified by molecular analysis as well as morphological and biochemical examination. The chitin synthase 1 (CHS1) gene cleavage pattern of the clinical isolate with restricted enzyme HinfI was identical to that of T. violaceum. We reviewed previous reports of BDR to determine the historical trend of this infection in Japan. Since 1974, 93 Japanese cases have been reported. The age distribution was bi-modal: the higher peak consisted of children (aged 0-15 years), and the lower peak was composed of the elderly (aged 60-75 years). In the elderly group, females were predominant (M:F=1:22, p<0.001). T. violaceum, including T. glabrum, was identified as the most common causative fungus of BDR (75.3%). Sixty percent of cases showed slight erythema. In 8 families, 16 cases were found to be intrafamilial infections. A history of previous steroid treatment was described in about 40%.

Molecular confirmation of a Trichophyton violaceum isolate from human black-dot ringworm

A clinical isolate from a black-dot ringworm lesion of a 28-year-old female Japanese was investigated by morphological and biochemical analyses as well as molecular analyses. The isolate grew well on thiamine enriched agar and did not produce violet pigment, macro-conidia or micro-conidia on Sabouraud's dextrose agar. Approximately 620-bp genomic DNA fragments of the CHS1 gene were amplified from Trichophyton mentagrophytes, T. rubrum, T. tonsurans and T. violaceum by polymerase chain reaction (PCR) and sequenced. The chitin synthase 1 (CHS1) nucleotide sequences of the clinical isolate showed more than 97% similarity to that of T. violaceum and less than 96% similarity to that of T. mentagrophytes, T. rubrum and T. tonsurans. The phylogenetic analysis of their sequences revealed that the clinical isolate was genetically close to T. violaceum and distinct from T. mentagrophytes, T. rubrum and T. tonsurans. Therefore, the isolate was confirmed as T. violaceum by mycological examination and molecular analyses.

Characterization of the activity of L-ascorbic acid 2-[3,4-dihydro-2,5,7,8-tetramethyl-2-(4,8,12-trimethyltridecyl)-2H-1-be nzopyran-6-yl-hydrogen phosphate] potassium salt in hydroxyl radical elimination

The effect of L-ascorbic acid 2-[3,4-dihydro-2,5,7,8-tetramethyl-2-(4,8,12-trimethyltridecyl)-2H -1-benzopyran-6-yl-hydrogen phosphate] potassium salt (EPC-K1) on hydroxyl radical (*OH) elimination was studied using electron spin resonance (ESR) and spectrophotometric experiments. The addition of EPC-K, and *OH scavengers eliminated the *OH generated from Cu2+/H2O2, Fe2+/H2O2 and H2O2/UV-irradiation reaction systems. However, in competitive reactions using different concentrations of a spin-trap agent, the addition of the *OH scavenger altered the IC50 values, whereas the addition of EPC-K1 and a metal chelater did not change the value in the Cu2+/H2O2 and Fe2+/H2O2 reaction systems. The addition of EPC-K1 and metal chelater changed the ESR signal for free Cu2+. The spectrophotometric experiments confirmed that the addition of EPC-K1 and metal chelater altered the absorption spectra due to CuCl2 and FeSO4, whereas the *OH scavenger did not alter the spectra. Therefore, it was demonstrated that EPC-K, has the ability both to scavenge *OH directly and to inhibit the generation of *OH by the chelation of Cu2+ and Fe2+.

Differences among chitin synthase I gene sequences in Trichophyton rubrum and T. violaceum

Nucleotide sequences of chitin synthase 1 (CHS1) gene were analysed for the phylogenetic relation between Trichophyton violaceum and T. rubrum, including two isolates of T. raubitschekii and one isolate of T. rubrum var. nigricans. About 620-bp genomic DNA fragments of the CHS1 gene were amplified from these dermatophytes by polymerase chain reaction (PCR) and sequenced. The CHS1 nucleotide sequences of these dermatophytes showed more than 95% similarity between the species. The phylogenetic analysis of their sequences revealed that T. rubrum was genetically distinct from T. violaceum. The specific restriction endonuclease site for HinfI was present in the CHS1 gene sequence of T. rubrum but not in that of T. violaceum. A molecular analysis of CHS1 genes will provide useful information for the identification of these Trichophyton species and the understanding of their evolution.