Interobserver agreement in endoscopic evaluation of reflux esophagitis using a modified Los Angeles classification incorporating grades N and M: a validation study in a cohort of Japanese endoscopists

The Los Angeles classification system is the most widely employed criteria associated with the greatest interobserver agreement among endoscopists. In Japan, the Los Angeles classification system has been modified (modified LA system) to include minimal changes as a distinct grade of reflux esophagitis, rather than as auxiliary findings. This adds a further grading M defined as minimal changes to the mucosa, such as erythema and/or whitish turbidity. The modified LA system has come to be used widely in Japan. However, there have been few reports to date that have evaluated the interobserver agreement in diagnosis when using the modified LA classification system incorporating these minimal changes as an additional grade. A total of 100 endoscopists from university hospitals and community hospitals, as well as private practices in the Osaka-Kobe area participated in the study. A total of 30 video clips of 30-40 seconds duration, mostly showing the esophagocardiac junction, were created and shown to 100 endoscopists using a video projector. The participating endoscopists completed a questionnaire regarding their clinical experience and rated the reflux esophagitis as shown in the video clips using the modified LA classification system. Agreement was assessed employing kappa (kappa) statistics for multiple raters. The kappa-value for all 91 endoscopists was 0.094, with a standard error of 0.002, indicating poor interobserver agreement. The endoscopists showed the best agreement on diagnosing grade A esophagitis (0.167), and the poorest agreement when diagnosing grade M esophagitis (0.033). The kappa-values for the diagnoses of grades N, M, and A esophagitis on identical video pairs were 0.275-0.315, with a standard error of 0.083-0.091, indicating fair intraobserver reproducibility among the endoscopists. The study results consistently indicate poor agreement regarding diagnoses as well as fair reproducibility of these diagnoses by endoscopists using the modified LA classification system, regardless of age, type of practice, past endoscopic experience, or current workload. However, grade M reflux esophagitis may not necessarily be irrelevant, as it may suggest an early form of reflux disease or an entirely new form of reflux esophagitis. Further research is required to elucidate the pathophysiological basis of minimal change esophagitis.

Pseudolymphomatous folliculitis: a clinicopathologic study of 15 cases of cutaneous pseudolymphoma with follicular invasion

We report the clinical, histopathologic, and immunohistologic features of 15 cases of pseudolymphomatous folliculitis (PLF). The patients comprised seven males and eight females (mean age, 38.6 years; age range, 2-67 years). All patients had dome-shaped or flat-elevated nodules suggestive of cutaneous lymphoid hyperplasias (CLHs). The lesions were solitary in all 15 cases, except in one case with duplex lesions. All lesions were located on the face and measured less than 1.5 cm. In 14 cases with one lesion each, five lesions showed rapid regression after incisional biopsy, whereas the remaining nine underwent excisional biopsy. In the case with duplex lesions, one regressed spontaneously after excisional biopsy of the other. Histopathologically, all PLFs showed dense lymphocytic infiltrates from the dermis to the subcutis simulating cutaneous lymphomas. The walls of hair follicles in all cases were enlarged and irregularly deformed with their epithelium blurred by lymphocytic infiltrates; we called this change "activation" of hair follicles. In nine cases, many atypical lymphocytes were intermingled; three of these cases had been misdiagnosed as cutaneous T-cell lymphoma at other institutions. Immunohistologically, 10 and 5 cases showed predominantly B cells and predominantly T cells, respectively. Remarkably, all lesions showed increased numbers of perifollicular histiocytes expressing anti-S-100 protein and CD1a, and seven lesions showed histiocytes in aggregates. We conclude that PLF is a subset of CLH with characteristic clinical and pathologic features showing perifollicular clustering of T-cell-associated dendritic cells with activation of pilosebaceous units. PLF is an entity to be differentiated from malignant lymphomas and other cutaneous pseudolymphomas.

Baculovirus virions displaying Plasmodium berghei circumsporozoite protein protect mice against malaria sporozoite infection

The display of foreign proteins on the surface of baculovirus virions has provided a tool for the analysis of protein-protein interactions and for cell-specific targeting in gene transfer applications. To evaluate the baculovirus display system as a vaccine vehicle, we have generated a recombinant baculovirus (AcNPV-CSPsurf) that displays rodent malaria Plasmodium berghei circumsporozoite protein (PbCSP) on the virion surface as a fusion protein with the major baculovirus envelope glycoprotein gp64. The PbCSP-gp64 fusion protein was incorporated and oligomerized on the virion surface and led to a 12-fold increase in the binding activity of AcNPV-CSPsurf virions to HepG2 cells. Immunization with adjuvant-free AcNPV-CSPsurf virions induced high levels of antibodies and gamma interferon-secreting cells against PbCSP and protected 60% of mice against sporozoite challenge. These data demonstrate that AcNPV-CSPsurf displays sporozoite-like PbCSP on the virion surface and possesses dual potentials as a malaria vaccine candidate and a liver-directed gene delivery vehicle.

Intramolecular 1,3-dipolar cycloaddition strategy for enantioselective synthesis of FR-900482 analogues

[reaction: see text] Enantioselective synthesis of FR-900482 analogues is described. The key reaction of the synthesis is intramolecular 1,3-dipolar cycloaddition of a highly functionalized nitrile oxide with complete stereo- and regioselectivities to construct the eight-membered benzazocine ring.

Abundance and genetic damage of barn swallows from Fukushima

A number of studies have assessed or modeled the distribution of the radionuclides released by the accident at the Fukushima-Daiichi Nuclear Power Plant (FDNPP). Few studies however have investigated its consequences for the local biota. We tested whether exposure of barn swallow (Hirundo rustica) nestlings to low dose ionizing radiation increased genetic damage to their peripheral erythrocytes. We estimated external radiation exposure by using thermoluminescent dosimeters, and by measuring radioactivity of the nest material. We then assessed DNA damage by means of the neutral comet assay. In addition, we conducted standard point-count censuses of barn swallows across environmental radiation levels, and estimated their abundance and local age ratio. Radioactivity of nest samples was in the range 479-143,349 Bq kg(-1), while external exposure varied between 0.15 and 4.9 mGy. Exposure to radioactive contamination did not correlate with higher genetic damage in nestlings. However, at higher levels of radioactive contamination the number of barn swallows declined and the fraction of juveniles decreased, indicating lower survival and lower reproduction and/or fledging rate. Thus, genetic damage to nestlings does not explain the decline of barn swallows in contaminated areas, and a proximate mechanism for the demographic effects documented here remains to be clarified.

Neurofibromatosis 2 and neurilemmomatosis gene are identical

Neurofibromatosis 2 (NF2) is an autosomal dominant disorder characterized by the occurrence of bilateral acoustic neuromas, as well as meningiomas and schwannomas. The gene locus for NF2 resides on chromosome 22q12 and has been cloned recently. Neurilemmomatosis is characterized by multiple cutaneous and spinal neurilemmomas without other signs of NF1 or NF2. Many cases with this disorder include the diagnosis of neurofibromatosis or other rare diseases unexplained by current nosology. In this study, we analyzed the peripheral leukocytes and tissue from cutaneous neurilemmomas of seven patients with neurilemmomatosis using DNA markers for different regions of chromosome 22. We detected allelic losses in three of seven tumors from seven patients with a probe for the NF2 region of the long arm of chromosome 22 and the germ-line mutations in two of three tumors from the same three patients. Mutations in the NF2 gene were a deletion from at least codon 334 to 579 and G insertion at codon 42. We conclude that the neurilemmomatosis locus lies within the NF2 region and that these diseases might be identical.

The abnormal occurrence and the differentiation-dependent distribution of N-acetyl and N-glycolyl species of the ganglioside GM2 in human germ cell tumors. A study with specific monoclonal antibodies

Human primary germ cell tumors were analyzed for the presence of the ganglioside GM2 using three specific monoclonal antibodies which can distinguish the molecular species of the sialic acid moiety: the antibody MK1-16 is specific for N-acetyl GM2, MK2-34 is specific for N-glycolyl GM2, and MK1-17 detects both N-acetyl and N-glycolyl GM2. When the occurrence of the GM2 antigen was tested in 107 cases of human germ cell tumors by the immunohistochemical technique using these antibodies, seminoma was characterized as having the highest frequency of N-acetyl GM2 (89.4%, 42 of 47 cases) among germ cell tumors, followed by embryonal carcinoma (40.0%), and teratocarcinoma (26.6%). Compared with this, yolk sac tumors and choriocarcinoma had a much lower positive incidence of the N-acetyl GM2 antigen. On the other hand, the N-glycolyl GM2 antigen was not found at all in 47 cases of seminoma (0%), and the positive incidence was very low in embryonal carcinoma (6.6%), although considerably higher incidences were obtained with choriocarcinoma (25.0%), yolk sac tumor (22.2%), and teratocarcinoma (13.3%). The presence and molecular species of the GM2 antigens in these human germ cell tumors were also ascertained chemically by the thin-layer chromatography (TLC) immunostaining of the ganglioside fractions prepared from primary germ cell tumors. These results indicate that seminoma specifically contains N-acetyl GM2 and no N-glycolyl GM2, suggesting that N-acetyl GM2 could be a good marker for seminoma. On the other hand, non-seminomatous germ cell tumors were characterized by the presence of N-glycolyl GM2, one of the Hanganutziu-Deicher antigens (H-D antigens). Moreover, the positive occurrence of N-glycolyl GM2 correlated very well with the degree of differentiation of non-seminomatous germ cell tumors, i.e., the differentiated tumors such as yolk sac tumors, choriocarcinoma, and teratocarcinoma had a higher positive incidence of N-glycolyl GM2 type H-D antigen but a lower positive incidence of N-acetyl GM2 when compared with embryonal carcinoma, the most undifferentiated tumors among non-seminomatous germ cell tumors.

Cutaneous histiocytic malignancy. Immunohistochemical re-examination of cases previously diagnosed as cutaneous "histiocytic lymphoma" and "malignant histiocytosis"

True histiocytic lymphoma (THL) and malignant histiocytosis (MH) have been defined by clinical and histologic findings and enzyme histochemistry. We reviewed cases previously diagnosed as cutaneous histiocytic lymphoma (HL) and MH with cutaneous lesions. These cases had been classified as "histiocytic" on the basis of previous enzyme histochemistry profiles of frozen tissue. Cutaneous tumor cells were reevaluated using a panel of immunohistochemical stains in formalin-fixed, paraffin-embedded tissue in correlation with histopathologic examination. The antibodies used in this study were directed against CD45 (leukocyte common antigen [LCA]), CD20 (L26) for B cells, CD3 and CD45RO (UCHL-1) for T cells, CD68 (KP-1) and lysozyme for histiocytes, as well as CD30 (BerH2) for Ki-1 positive cells. On re-evaluation, the seven cases originally classified as HL were reclassified as one case of THL with neoplastic cells positive for CD68 (KP-1) and lysozyme, two cases with immunohistochemical features of Ki-l lymphoma (including one of T-cell lineage), three cases of T-cell lymphoma, and one case of B-cell lymphoma, all associated with variable degrees of reactive histiocytosis. The four cases originally classified as MH were reclassified as two cases of MH and two cases of uncertain lineage. Although rare, histiocytic malignancies do exist. However, the diagnosis of histiocytic malignancy should be made only after careful correlation of atypical tumor cells in histopathologic sections and sections stained immunohistochemically. Erroneous classification of reactive histiocytes as neoplastic histiocytes using only enzyme histochemistry in frozen sections is a pitfall to be avoided.

Hemodynamic infarction of the spinal cord: involvement of the gray matter plus the border-zone between the central and peripheral arteries

OBJECTIVE

Hemodynamic infarction of the spinal cord that affected an 81-year-old female having a dissecting aortic aneurysm is presented. During the graft replacement operation, systemic hypotension occurred and the patient was subsequently complicated with paraplegia of the lower limbs. The patient died 2 weeks after the surgery due to gastrointestinal bleeding. An autopsy, which did not include the brain, was performed and the spinal cord was sampled. The aim of this report is to describe the pathologic profile of the spinal cord of the patient, and to gain insight into the pathogenesis of the lesion.

METHODS

Histochemical and immunohistochemical methods were employed to study the spinal cord ranging from the lower thoracic to sacral segments.

RESULTS

The whole central areas of the spinal cord showed coagulation and/or liquefaction necroses, while the white matter on the circumference of the cord remained unaffected, thus exhibiting a 'ring-like' appearance.

CONCLUSION

This case is an example of hemodynamic infarction of the spinal cord involving the gray matter that is supplied by the central artery, plus the border-zone that is supplied by both the central and peripheral arteries. The former is probably associated with selective vulnerability of the gray matter to ischemia, while the latter is probably associated with intrinsic vulnerability of the border-zone to systemic hypotension or low blood-flow states.

Primary cutaneous T-cell-rich B-cell lymphoma

A 61-year-old man presented with a skin tumour in the right axilla of 2 months' duration. An excision biopsy revealed a malignant lymphoma, of diffuse mixed small and large cell type, morphologically suggestive of T-cell lymphoma, but shown to be a T-cell-rich B-cell lymphoma by subsequent immunohistochemical staining. A review of the literature revealed 47 cases of T-cell-rich B-cell lymphoma with descriptions of primary sites, 35 nodal and 12 extranodal, of which only one was a cutaneous primary.

Septum formation of the common hepatic duct associated with an anomalous junction of the pancreaticobiliary ductal system and gallbladder cancer: report of a case

We herein describe a 48-year-old woman who developed a septum formation of the bile duct combined with an anomalous arrangement of the pancreaticobiliary ductal system in conjunction with gallbladder cancer. A preoperative endoscopic retrograde cholangiogram demonstrated a filling defect in the common hepatic duct which was misdiagnosed to be an elevated lesion. Further exploration revealed a septum formation of the bile duct along with gallbladder cancer. A resection of the dilated bile duct and gallbladder along with a dissection of the regional lymph nodes was performed. A histological evaluation showed the septum to consist of a normal bile duct wall while the tumor in the gallbladder was poorly differentiated adenocarcinoma. The patient made an uneventful recovery. The septum formation was presumed to be congenital in origin.

Specific skin lesions as the presenting symptom of hairy cell leukemia

A 68-year-old Japanese man with a chief complaint of eczema-like dermatosis was diagnosed as having B-cell hairy cell leukemia (HCL) by demonstration of hairy cells in the skin lesions as well as in blood and bone marrow. He was treated with alpha-interferon, resulting in disappearance of skin lesions and reduction of his massive splenomegaly from 18 to 5 cm in about 14 months. Although specific skin lesions in HCL, shown by a review of the literature to occur in about 8% of cases, are not as uncommon as generally assumed, it is rare for HCL to present with specific skin lesions, the present case being only the second of its type mentioned in the literature.

Superior mesenteric arteriovenous fistula: report of a case and review of the literature

Iatrogenic arteriovenous fistula of the superior mesenteric vessels is rare, with only 22 cases being documented. We report herein a case of a 63-year-old man with an iatrogenic arteriovenous fistula which developed after a small bowel resection for intestinal tuberculosis. The patient was admitted to our hospital for a gastric ulcer, at which time an ultrasonogram demonstrated cystic dilatation of the superior mesenteric vein, proving to be an arteriovenous fistula of the mesenteric vessels. An angiogram of the superior mesenteric vessels subsequently confirmed this diagnosis and resection of the fistula was performed, followed by an uneventful recovery. Iatrogenic mesenteric arteriovenous fistula with no presenting symptoms, as in our case, is uncommon and surgery performed before the development of associated portal hypertension should achieve good results. A review of the literature follows the report of this case.

Constitutional translocation t(4;22) (q12;q12.2) associated with neurofibromatosis type 2

We report on a female patient with bilateral acoustic neurinomas and other tumors in the central nervous system (neurofibromatosis type 2: NF2) and the constitutional translocation, t(4;22) (q12;q12.2). The precise identification of the translocation breakpoint (q12.2) on chromosome 22 implies the refined localization of a gene responsible for NF2, and would provide a clue to its molecular characterization and to the isolation of the gene. Chromosomes of a paraspinal neurinoma from the patient were also analyzed, and the same karyotype as seen in cultured peripheral lymphocytes was found. The patient's father was also a carrier of the translocation, but he had no clinical symptoms of NF2, nor did other relatives. Several explanations are offered for the different expression of the translocation between the patient and her father.

Mycosis fungoides and Sézary syndrome in Japan. Clinicopathologic study of 107 autopsy cases

We reviewed 111 clinical and pathological materials of patients who had been entered as mycosis fungoides (MF) or Sézary syndrome (SS) in the Annuals of the Pathological Autopsy Cases in Japan during the 29-year-period since the Annuals' inception in 1958. One hundred and seven patients were classified. Of these, 64 were in Group 1 (mycosis fungoides, MF), 23 in Group II (Sézary syndrome, SS), and 20 in Group III (non-Hodgkin's lymphoma, NHL). The clinicopathologic features of Groups I and II (MF, SS) were similar to those of cutaneous T cell lymphoma (CTCL) in Europe and the United States. Those of Group III (NHL) were indistinguishable from primary cutaneous non-Hodgkin's lymphoma. It was suggested that some patients with adult T cell leukemia/lymphoma (ATLL) with skin lesions used to be misdiagnosed as MF or SS in earlier years when ATLL was still unknown. It was concluded that CTCL in Japan has clinicopathologic features quite like those of CTCL in Europe and the United States and that they are probably the same disease.

Detection of Acinetobacter pittii ST220 co-producing NDM-1 and OXA-820 carbapenemases from a hospital sink in a non-endemic country of NDM

OBJECTIVES

NDM-1 is by far one of the most commonly prevalent carbapenemases in Enterobacteriaceae and Acinetobacter baumannii. This study presented an Acinetobacter pittii (A. pittii) isolate co-harboring bla_NDM-1 and bla_OXA-820 from a university hospital sink, where New Delhi metallo-β-lactamase (NDM) producers have not been found in either patients or their environments.

METHODS

Whole-genome sequencing was performed on the HiSeq 4000 platform, and the reads were de novo assembled using the A5-miSeq Assembly pipeline. Annotation of the resulting scaffolds were performed by using the DDBJ Fast Annotation and Submission Tool (DFAST). The bla_NDM-1-carrying plasmid was determined.

RESULTS

The A. pittii ST220 strain SU1805 detected from a sink strainer in the treatment room was resistant to imipenem and meropenem. Antimicrobial resistance genes bla_NDM-1, bla_OXA-820, bla_ADC-43, and aphA6 were found in this strain. The bla_NDM-1 was found to be located downstream of an ISAba125 element on a plasmid pSU1805NDM with a size of 41,022 bp, and GC content of 38.3% harbouring 48 protein-coding genes. The aphA6 gene was also located upstream of the ISAba125 on the same plasmid. The A. pittii intrinsic bla_OXA-213-like gene bla_OXA-820 was located between fxsA and yncA genes in the chromosome. The strain also harboured biofilm-associated genes such as ompA, the csu operon and their regulating genes bfmRS.

CONCLUSION

This study described the first isolation of NDM-1-producing A. pittii in Japan, and highlighted the importance of proper implementation of measures against AMR for sink drainage systems, since NDM producers may have already been hidden in such environments in a non-endemic country of NDM.

Characterization of the translocation breakpoint on chromosome 22q12.2 in a patient with neurofibromatosis type 2 (NF2)

We previously described a patient with neurofibromatosis type 2 (NF2) who showed a constitutional balanced translocation, t(4;22). To characterize the breakpoint on chromosome 22 in this patient in relation to a candidate gene (NF2) responsible for NF2, we analyzed DNAs from this patient and her parents using parts of NF2 cDNA as probes. Southern analyses and DNA sequencing revealed that the chromosome 22 breakpoint in this patient lies within the intron between exons 14 and 15 of NF2. The results lend support to the conclusion that NF2 is the gene responsible for the CNS form of neurofibromatosis.

Generalized eruptive histiocytoma: report of a pediatric case

A one-year-old boy was seen with brownish, flat papules on his face, neck and upper arms. The lesions were symmetric, discrete, slightly raised, firm to the touch, and asymptomatic papular eruptions. Histological and immunohistochemical investigation revealed monomorphous infiltration of S-100 negative, lysozyme negative, and alpha 1-antitrypsin negative, but alpha 1-antichymotrypsin positive and vimentin positive histiocytic cells with small numbers of lymphocytic cells. The histiocytic cells did not show any foamy changes in the cytoplasm. No giant cells were found. The lesions increased in number during the first few years and then spontaneously regressed by the sixth year of age, leaving partial brownish pigmentation.

Role of apoptosis in spontaneous regression of peripheral T-cell lymphoma arising in the skin or subcutis

Apoptosis was suspected to play a significant role in spontaneous regression of skin lesions in four cases of peripheral T-cell lymphoma arising in the skin or subcutis. All of the patients had skin tumors with ulcer formation, but no metastasis to the lymph nodes or viscera. Biopsy showed a sea of CD3-positive lymphoma cells involving the dermis to the subcutis with scattered foci of coagulative necrosis. In the zone of incipient necrosis surrounding the core of coagulative necrosis, frequent apoptotic bodies were identified by electron microscopy (EM), and DNA strand breaks were detected in 34% to 51% (mean, 42%) of lymphoma cells by the TdT-mediated deoxyuridine triphosphate (dUTP)-biotin nick end-labeling (TUNEL). As for the pathogenesis of coagulative necrosis, ischemic necrosis attributable to lymphocytic vasculitis appeared unlikely, because necrotic foci were devoid of neutrophils and had no relation to vascular distribution. Primary cataclysmic apoptosis appeared more likely, but its pathogenetic role could not be established, because EM and TUNEL could not be applied to the core of the debris-ridden coagulative necrosis. Although these cases had been classified as pseudolymphomas because they were histologically malignant but clinically benign, they were in fact true lymphomas characterized by extensive coagulative necrosis with a high rate of apoptosis demonstrable in the zone of incipient necrosis.

Chromosome 1q terminal deletion resulting from de novo translocation with an acrocentric chromosome

Distal deletion of chromosome 1q has been reported in nearly 30 patients, all being associated with a deletion ranging from the 1q42 or q43 band to 1qter region. Here, we describe a girl with 1q terminal deletion resulting from an unbalanced de novo translocation t(1;D or G)(q44;p11), as revealed by the presence of a satellited feature and an NOR-stained region at the tip of 1q. We suggest that most of the phenotypic abnormalities seen in patients with 1q distal deletion are attributable to the monosomy for band 1q44.

[Case of fulminant mixed cryoglobulinemia developing after atrial myxoma resection]

A 63-year-old man, with a 13-year history of asymptomatic proteinuria, was diagnosed with left atrial myxoma at the onset of heart failure. After resection of the tumor by hypothermal surgery, the patient developed fever, renal failure and skin rash. The diagnosis was type II mixed cryoglobulinemia accompanied by an IgMlambda clone with high titers of rheumatoid factor activity and polyclonal IgG. Treatment with high doses of steroids and plasmapheresis was ineffective, and the patient died of colon necrosis due to thrombotic occlusion in the supra-mesenteric arteries. Although the patient had suffered from sporadic Raynaud's phenomenon and purpura of the lower extremities from the age of 60 years, cryoglobulinemia was not suspected before surgery because of the atrial myxoma. Thus, we suggest that it is important to perform laboratory tests for cryoproteins before hypothermal surgery.