The effects of initial graft tension on femorotibial relationship following anatomical rectangular tunnel anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft

BACKGROUND

The purpose of this study was to elucidate the effects of the difference of initial graft tension on the femorotibial relationship on an axial plane and its chronological change following anatomical anterior cruciate ligament (ACL) reconstruction.

METHODS

A total of 63 patients who underwent anatomical ACL reconstruction were included in this study. The graft was fixed at full knee extension with manual maximum (higher graft tension; group H) and 80 N (lower graft tension; group L) pulls in 31 and 32 patients, respectively. The femorotibial positional relationship in axial computed tomography at 1 week and 1 year postoperatively were retrospectively evaluated. The side-to-side differences (SSDs) and the amount of changes of SSDs over 1 year were compared between groups.

RESULTS

The SSDs of the external rotational angle of the tibia in group H were significantly larger than those in group L at postoperative 1 week (2.7 ± 3.9° vs. 0.3 ± 3.3°; P < 0.01). The amount of internal rotational changes of SSDs of the internal-external rotational angles over 1 year in group H was significantly larger than that in group L (-3.6 ± 3.9° vs. - 0.3 ± 2.7°; P < 0.01). No significant differences were observed on the anterior-posterior translation distance and medial-lateral shift distance.

CONCLUSION

The application of higher initial graft tension resulted in excessive external rotation of the tibia to the femur at 1 week postoperatively in anatomical ACL reconstruction, and the excessive early external tibial rotation had resolved over 1 year.

High initial graft tension increases external tibial rotation on the axial plane after anatomical anterior cruciate ligament reconstruction

PURPOSE

The purpose of this study was to clarify the effects of applying different amounts of initial graft tension on the femorotibial positional relationship on the axial plane after anatomical ACL reconstruction.

METHODS

Eighty patients who underwent isolated ACL reconstructions using bone-patellar tendon-bone grafts were included in this study. In 40 of the 80 patients, the grafts were fixed at full knee extension with maximum manual force (high graft tension; Group H), whereas in the other 40 patients, the grafts were fixed at full knee extension with force of 80 N (low graft tension; Group L). One week postoperatively, all patients underwent computed tomography (CT) on bilateral knee joints with knee extension. The femorotibial positional relationship in axial CT images were retrospectively evaluated. Side-to-side differences (the surgical side minus the unaffected side) were calculated in these variables.

RESULTS

The side-to-side differences in anterior tibial translation distances were - 1.8 ± 2.1 mm in Group H and - 1.9 ± 2.0 mm in Group L, with no significant difference between the two groups. The side-to-side differences in tibial lateral shifts were - 0.2 ± 1.5 mm in Group H and 0.0 ± 1.4 mm in Group L, with no significant difference between the two groups. The side-to-side differences in tibial external rotation angles were 2.7 ± 4.5° in Group H and 0.3 ± 3.3° in Group L, with a significant difference between the two groups (P < 0.01).

CONCLUSION

Applying high initial graft tension (maximum manual force) resulted in the external rotation of the tibia against the femur just after anatomical ACL reconstruction. In contrast, applying low initial graft tension (80 N at full knee extension) did not change the femorotibial rotational relationship.

Use of nutritional supplements by elite Japanese track and field athletes

BACKGROUND

While scientific evidence supports the efficacy of only limited nutritional supplements (NS) on sports performance, the use of NS is widespread in athletes. Given the serious issues of health damage or unintended Anti-Doping Rule Violations due to ingestion of contaminated NS in sports, accurately understanding NS practices by athletes is crucial. This study therefore elucidated the use of NS by elite Japanese track and field (TF) athletes.

METHODS

The subjects were 574 Japanese TF athletes, including 275 junior athletes (under 20 years) and 299 senior athletes, who participated in international competitions from 2013 to 2018. Data on NS use were collected through pre-participation medical forms obtained from all entrants before their participation in competitions. NS users were requested to report the product names and primary components of all NS they were taking.

RESULTS

The overall prevalence of NS use was 63.9%. The mean number of NS products used per athlete was 1.4. The prevalence was significantly higher in women (69.2%) than in men (59.6%) (p = 0.018) and significantly higher in senior athletes (68.9%) than in junior athletes (58.9%) (p = 0.012). The prevalence of NS use was higher in long-distance runners (75.8%) and lower in jumpers (52.3%) and throwers (49.2%) than other disciplines (p < 0.001). The most prevalent components were amino acids (49.3%), followed by vitamins (48.3%), minerals (22.8%), and protein (17.8%).

CONCLUSIONS

Approximately two-thirds of elite Japanese TF athletes reported the use of NS, and NS practices varied by gender, age, and discipline.

Improving the electron spin properties of nitrogen-vacancy centres in nanodiamonds by near-field etching

The nitrogen-vacancy (NV) centre in diamond is a promising candidate for quantum computing applications and magnetic sensing applications, because it is an atomic-scale defect with stable coherence time (T2) and reliable accessibility at room temperature. We demonstrated a method for improving the NV spin properties (the full width half maximum (FWHM) value of the magnetic resonance spectrum and T2) through a near-field (NF) etching method under ambient conditions. The NF etching method, based on a He-Cd ultraviolet laser (325 nm), which is longer than the absorption edge of the oxygen molecule, enabled selective removal of defects on the nanodiamond surface. We observed a decrease in the FWHM value close to 15% and an increase in T2 close to 25%. Since our technique can be easily reproduced, a wide range of NV centre applications could be improved, especially magnetic sensing applications. Our results are especially attractive, because they have been obtained under ambient conditions and only require a light source with wavelength slightly above the O2 absorption edge.

Effects of initial graft tension on femoral tunnel widening after anatomic anterior cruciate ligament reconstruction using a bone-patellar tendon-bone graft

INTRODUCTION

The effects of initial graft tension upon tunnel widening (TW) following anatomic anterior cruciate ligament (ACL) reconstruction have not been elucidated. The purpose of this study was to retrospectively investigate the effect of two different graft-tensioning protocols upon femoral TW following anatomic ACL reconstruction using a bone-patellar tendon-bone (BPTB) graft and a three-dimensional (3D) computed tomography (CT) model.

METHODS

Forty-three patients who underwent isolated ACL reconstruction using BPTB grafts were included in this study. In 18 out of the 43 patients, the graft was fixed at full knee extension with manual maximum pull (Group H). These patients were compared with 25 patients in whom the BPTB graft was fixed at full knee extension with 80-N pull (Group L). Tunnel aperture area was measured using 3D CT 1 week and 1 year postoperatively, thus enabling us to calculate the percentage change in the area of femoral tunnel aperture. Clinical assessment was performed 1 year postoperatively, corresponding to the time period of CT assessment, and involved the evaluation of Lysholm score, anterior knee stability using a KneeLax3 arthrometer, and the pivot-shift test.

RESULTS

When measured at 1 year postoperatively, the mean area of the femoral tunnel aperture had increased by 78.6 ± 36.8% in Group H when compared with at 1 week postoperatively, whereas that of Group L had increased by 27.7 ± 32.3%. Furthermore, TW (%) in Group H was significantly greater than that of Group L (P < 0.001). No significant differences were detected between the two groups with regard to any of the clinical outcomes evaluated.

CONCLUSION

High levels of initial graft tension resulted in greater TW of the femoral tunnel aperture following anatomical ACL reconstruction using BPTB grafts. However, such levels of graft tension did not affect clinical outcome.

Development of the Japanese Version of the Leeds Assessment of the Neuropathic Symptoms and Signs Pain Scale: Diagnostic Utility in a Clinical Setting

OBJECTIVE

We aimed to assess the diagnostic utility of the linguistically validated Japanese version of the Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale (LANSS-J) as a screening tool for neuropathic pain in the clinical setting.

METHODS

Patients with neuropathic pain or nociceptive pain who were 20 to 85 years of age were included. Sensitivity and specificity using the original cutoff value of 12 were assessed to evaluate the diagnostic utility of the LANSS-J. Sensitivity and specificity with possible cutoff values were calculated, along with area under the receiver operating characteristic curve. We then evaluated agreement regarding assessment of the LANSS-J by two investigators. We used the intraclass correlation coefficient (ICC) for the total score and Cohen's kappa coefficient for each item.

RESULTS

Data for patients with neuropathic pain (n = 30) and those with nociceptive pain (n = 29) were analyzed. With a cutoff of 12, the sensitivity was 63.3% (19/30) and the specificity 93.1% (27/29). Sensitivity improved substantially with a cutoff of ≤ 11 (≥ 83.3%, 25/30). High specificity (93.1%, 27/29) was sustained with a cutoff of 9 to 12. The ICC for the total score was 0.85, indicating sufficient agreement. Kappa coefficients ranged from 0.68 to 0.84.

CONCLUSIONS

The LANSS-J is a valid screening tool for detecting neuropathic pain. Our results suggest that employing the original cutoff value provides high specificity, although a lower cutoff value of 10 or 11 (with its high specificity maintained) may be more beneficial when pain attributed to neuropathic mechanisms is suspected in Japanese patients.

Snapping Pes Syndrome after Unicompartmental Knee Arthroplasty

Snapping pes syndrome is defined as a snapping sensation in the medial knee caused by pes anserinus and rarely occurs. Snapping pes syndrome after unicompartmental knee arthroplasty (UKA) has not been reported yet. We experienced two cases with this syndrome after UKA. Conservative treatment was effective in one case, while surgical excision of the gracilis tendon was necessary to relieve painful snapping in the other case. The main cause of the first case might be posteromedial overhang of the tibial tray that reached up to 5 mm. The probable cause of the second case was posteromedial overhang of the mobile bearing.

Secure fixation of femoral bone plug with a suspensory button in anatomical anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft

PURPOSE

the efficacy and safety of using a suspensory button for femoral fixation in anatomical anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BPTB) graft have not been established. The purpose of the current study was to evaluate bone plug integration onto the femoral socket and migration of the bone plug and the EndoButton (EB) (Smith & Nephew, Andover, MA, USA) after rectangular tunnel ACL reconstruction with BPTB autograft.

METHODS

thirty-four patients who underwent anatomical rectangular ACL reconstruction with BPTB graft using EB for femoral fixation and in whom three-dimensional (3D) computed tomography (CT) was performed one week and one year after surgery were included in this study. Bone plug integration onto the femoral socket, bone plug migration, soft tissue interposition, EB migration and EB rotation were evaluated on 3D CT. The clinical outcome was also assessed and correlated with the imaging outcomes.

RESULTS

the bone plug was integrated onto the femoral socket in all cases. The incidence of bone plug migration, soft tissue interposition, EB migration and EB rotation was 15, 15, 9 and 56%, respectively. No significant association was observed between the imaging outcomes. The postoperative mean Lysholm score was 97.1 ± 5.0 points. The postoperative side-to-side difference, evaluated using a KT-2000 arthrometer, averaged 0.5 ± 1.3 mm. There were no complications associated with EB use. Imaging outcomes did not affect the postoperative KT side-to-side difference.

CONCLUSIONS

the EB is considered a reliable device for femoral fixation in anatomical rectangular tunnel ACL reconstruction with BPTB autograft.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Antimicrobial photodynamic therapy using a diode laser with a potential new photosensitizer, indocyanine green-loaded nanospheres, may be effective for the clearance of Porphyromonas gingivalis

BACKGROUND

Antimicrobial photodynamic therapy (aPDT) is a new treatment method for the removal of infectious pathogens using a photosensitizer and light of a specific wavelength, e.g., toluidine blue with a wavelength of about 600 nm. We explored a new photosensitizer and focused on indocyanine green (ICG), which has high absorption at a wavelength of 800-805 nm. We investigated the bactericidal effect of PDT on Porphyromonas gingivalis using a new photosensitizer, ICG-loaded nanospheres with an 805 nm wavelength low-level diode laser irradiation.

METHODS

We designed ICG-loaded nanospheres coated with chitosan (ICG-Nano/c) as a photosensitizer. A solution containing Porphyromonas gingivalis (10(8)  CFU/mL) with or without ICG-Nano/c (or ICG) was prepared and irradiated with a diode laser or without laser irradiation as a negative control. The irradiation settings were 0.5 W with a duty ratio of 10%, for 3-100 ms in repeated pulse (RPT) or continuous wave mode. CFU were counted after 7 d of anaerobic culture.

RESULTS

We observed that ICG-Nano/c could adhere to the surface of P. gingivalis. When ICG-Nano/c was used for aPDT, irradiation with RPT 100 ms mode gave the lowest increase in temperature. Laser irradiation with ICG-Nano/c significantly reduced the number of P. gingivalis (i.e., approximately 2-log10 bacterial killing). The greatest bactericidal effect was found in the RPT 100 ms group. However, laser irradiation (RPT 100 ms) with ICG, as well as without photosensitizer, had no effect on the number of bacteria.

CONCLUSIONS

Within the limits of this study, ICG-Nano/c with low-level diode laser (0.5 W; 805 nm) irradiation showed an aPDT-like effect, which might be useful for a potential photodynamic periodontal therapy.

Resident macrophages are involved in intestinal transplantation-associated inflammation and motoric dysfunction of the graft muscularis

Gut manipulation and ischemia/reperfusion evoke an inflammatory response within the intestinal muscularis that contributes to dysmotility. We hypothesize that resident macrophages play a key role in initiating the inflammatory cascade. Isogenic small bowel transplantation was performed in Lewis rats. The impact of recovery of organs on muscularis inflammation was investigated by comparing cold whole-body perfusion after versus prior to recovery. The role of macrophages was investigated by transplantation of macrophage-depleted gut. Leukocytes were counted using muscularis whole mounts. Mediator expression was determined by real-time RT-PCR. Contractility was assessed in a standard organ bath. Both organ recovery and ischemia/reperfusion induced leukocyte recruitment and a significant upregulation in IL-6, MCP-1, ICAM-1 and iNOS mRNAs. Although organ recovery in cold ischemia prevented early gene expression, peak expression was not changed by modification of the recovery technique. Compared to controls, transplanted animals showed a 65% decrease in smooth muscle contractility. In contrast, transplanted macrophage-depleted isografts exhibited significant less leukocyte infiltration and only a 19% decrease in contractile activity. In summary, intestinal manipulation during recovery of organs initiates a functionally relevant inflammatory response within the intestinal muscularis that is massively intensified by the ischemia reperfusion injury. Resident muscularis macrophages participate in initiating this inflammatory response.

Acute Rejection in Allogeneic Rodent Small Bowel Transplantation Causes Smooth Muscle Dysfunction via an Inflammatory Response Within the Intestinal Muscularis

INTRODUCTION

Isogeneic intestinal transplantation elicits an inflammatory response within the intestinal muscularis that is associated with dysmotility. Usually the inflammation and the postoperative motor dysfunction resolve within a few days after small bowel transplantation (SBTx). However, the onset of acute rejection in allogeneic SBTx is again associated with dysmotility. We hypothesized that dysmotility during acute rejection is based on coexpression of kinetically active mediators by the alloreactive leucocyte infiltrate.

MATERIALS AND METHODS

Rat SBTx (BN to Lew and BN to BN) was performed without immunosuppression. Animals were sacrificed at 1, 4, and 7 days after SBTx. Leukocyte infiltration was investigated in muscularis whole mounts by immunohistochemistry. Mediator mRNA expression was determined by reverse transcriptase polymerase chain reaction. Muscle contractility was assessed in a standard organ bath.

RESULTS

Transplanted animals showed a significant inflammatory response within the muscularis at day 1 after SBTx. However, allogeneic transplanted animals exhibited a significant second inflammatory peak at day 7 (mRNA induction: iNOS 150-fold; tumor necrosis factor-alpha 18-fold; interferon-gamma 397-fold), parallel to the onset of rejection. This change was associated with a significant leukocyte infiltration. Compared to controls, allogeneic transplanted animals showed a 29% decrease in smooth muscle contractility on days 1 and 4 and a 71% decrease of contractility on postoperative day 7.

CONCLUSIONS

The motor dysfunction of transplanted small bowel during acute rejection is associated with an inflammatory reaction in the intestinal muscularis. The initial unspecific inflammation process immediately after transplantation is reactivated and intensified during acute rejection.

Mechanism and Impact of Organ Harvesting and Ischemia-Reperfusion Injury Within the Graft Muscularis in Rat Small Bowel Transplantation

INTRODUCTION

Inflammatory events within the gut muscularis contribute to dysmotility. We hypothesized that manipulation during organ harvesting initiated an inflammatory response via muscularis macrophages and that this cascade was amplified during reperfusion.

METHODS

Small bowel transplantation was performed in Lewis rats. To investigate the impact of organ harvesting on muscularis inflammation, cold whole-body perfusion was performed after versus prior to organ harvesting. The role of macrophages was investigated by transplantation of the macrophage-depleted gut. Leukocyte infiltration was investigated in muscularis whole mounts. Mediator mRNA expression was determined by real-time reverse transcriptase polymerase chain reaction. Contractility was assessed in a standard organ bath.

RESULTS

Organ harvesting and ischemia-reperfusion induced leukocyte recruitment and mRNA upregulation in the muscularis: interleukin-6 12217-fold, monocyte chemoattractant protein-1 62-fold, ICAM-1 12-fold, cyclooxygenase-2: 8-fold, iNOS: 150-fold. Although organ harvesting with cold ischemia prevented early gene expression, peak expression at 3-hour reperfusion was not changed by modification of the harvesting technique. Compared to controls, transplanted animals showed a 63% decrease in smooth muscle contractility. In contrast, transplanted macrophage-depleted gut exhibited significantly fewer leukocytes and only a 16% decrease in contractility.

CONCLUSIONS

Gut manipulation during organ harvesting initiates an inflammatory response within the muscularis that is massively intensified during reperfusion. This change contributes to muscular dysfunction. Furthermore, the results suggested that resident macrophages play a key role in initiating this process.

Indoleamine 2,3-Dioxygenase is Necessary for Cytolytic Activity of Natural Killer Cells

Indoleamine 2,3-dioxygenase (IDO) is a tryptophan catabolic enzyme that is widely distributed in various tissues. In peripheral blood mononuclear cells (PBMCs), production of IDO by macrophages or dendritic cells has been reported to inhibit T-cell activation and proliferation. In the present study, we have determined that other phenotypes of PBMCs also express IDO. In cultures of PBMCs, IDO was found predominantly in monocyte by immunohistochemistry. Reverse transcriptase polymerase chain reaction analysis showed that IDO mRNA was expressed in T lymphocytes, B lymphocytes and natural killer (NK) cells and that expression was increased upon activation with interferon-gamma. The cytotoxicity of NK cells against K562 and HepG2 cells was reduced by IDO inhibitor. These results suggest that IDO in NK cells is essential for NK cells to generate killing activity against cancer cells.

DeltaFosB, but not FosB, induces delayed apoptosis independent of cell proliferation in the Rat1a embryo cell line

The fates of Rat1a cells expressing FosB and DeltaFosB as fusion proteins (ER-FosB, ER-DeltaFosB) with the ligand binding domain of human estrogen receptor were examined. The binding of estrogen to the fusion proteins resulted in their nuclear translocation and triggered cell proliferation, and thereafter delayed cell death was observed only in cells expressing ER-DeltaFosB. The proliferation of Rat1a cells, but not cell death triggered by ER-DeltaFosB, was completely abolished by butyrolactone I, an inhibitor of cycline-dependent kinases, and was partly suppressed by antisense oligonucleotides against galectin-1, whose expression is induced after estrogen administration. The cell death was accompanied by the activation of caspase-3 and -9, the fragmentation of the nuclear genome and cytochrome c release from the mitochondria, and was suppressed by zDEVD-fmk and zLEHD-fmk but not zIETD-fmk. The cell death was not suppressed by exogenous His-PTD-Bcl-x(L) at all, suggesting involvement of a Bcl-x(L)-resistant pathway for cytochrome c release.

[A case of rheumatoid arthritis associated with minimal change nephrotic syndrome]

A 55-year-old Japanese woman has been treated with various kinds of anti-rheumatic drugs under a diagnosis of rheumatoid arthritis(RA) for 18 years of disease duration. She persistently had right elbow joint pain and swelling and X-ray showed bone erosion on humerus. Thus, the synovectomy was performed with typical histopathology of RA on April 1999. On the end of February 2000, she had suddenly fatigue and anasarca with profound proteinuria of nephrotic syndrome. The renal biopsy showed minimal change glomerulopathy and no cellular infiltration in interstitial tissue by light microscopy and partial fusion of foot process by electron microscopy. Renal function was sustained normally. All of anti-rheumatic drugs including D-penicillamine(D-Pc) except NSAID were stopped and she was treated with bed rest, diet therapy, diuretics and albumin infusion without steroid therapy. Edema and proteinuria gradually disappeared. Membranous and amyloid nephropathy in RA patients associated with nephrotic syndrome are found in high incidence in literature. In low incidence, MCNS is associated with NSAID or D-Pc induced nephropathy in RA. In our case, nephrotic syndrome disappeared in 6 weeks without discontinuation of NSAID and application of steroid therapy. Thus, MCNS might be co-incidentally associated with RA.

Pancreatic complications in choledochal cyst and their surgical outcomes

Follow-up results were analyzed to evaluate the surgical managements of pancreatic complications such as pancreatitis and protein plug formation in patients with choledochal cysts. Sixty-two patients with choledochal cysts treated between 1976 and 1999 were reviewed. Twenty-four were children and 38 were adults. Fifty-four patients showed primary cases. Cyst excision and hepaticoenterostomy were finally performed in 56 patients. Surgical sphincteroplasty or endoscopic sphincterotomy was performed to prevent recurrent protein plugs in six patients. The follow-up period was 8.1 +/- 6.1 years. Acute pancreatitis and protein plug formation was observed in 18 (33.3%) and 11 (20.4%) of 54 patients showing primary cases, respectively. Both acute pancreatitis and protein plug formation were observed more frequently in children from 1 to 15 years of age (70.6% and 41.2%, respectively) than in adults (18.6% and 12.5%, respectively). Acute pancreatitis and/or protein plug formation developed in four (57.1%) of seven patients who underwent cystenterostomy. Protein plug formation in the residual cyst after cyst excision was observed in two patients, one of whom had undergone sphincteroplasty. Diabetes mellitus due to chronic pancreatitis developed in one patient who was diagnosed late. No other pancreatitis or protein plug recurred postoperatively in this series. Our results suggested that cystenterostomy did not resolve pancreatic complications of choledochal cysts, and that surgical sphincteroplasty was ineffective in preventing the recurrent protein plug formation in the residual duct. In conclusion, complete cyst excision and an early diagnosis are necessary to prevent the development of chronic or recurrent pancreatitis after surgery.

Experimental small bowel transplantation using a newborn intestine in rats: IV. Effect of cold preservation on graft neovascularization

BACKGROUND/PURPOSE

University of Wisconsin (UW) solution is one of the most superior organ preservation solutions for liver, kidney, and pancreas; however, it still is controversial for intestinal preservation. Here, the authors studied the efficacy of preservation with 2 kinds of solutions, UW and modified TOM (m-TOM) solutions in our experimental newborn intestinal transplantation model. UW solution was used as a standard intracellular and m-TOM solution as an extracellular preservation solution. Lactated ringer (LR) solution was used as a control.

METHODS

Newborn intestine, which were preserved in these solutions for 24 or 48 hours, were transplanted in the subcutaneous spaces of the syngeneic recipients without surgical vascular anastomosis and histologically examined 14 days after grafting. The preserved grafts were evaluated histologically by use of light and electron microscopy just after preservation. The biochemical parameters such as LDH and serotonin also were measured in the supernatants of preservation solutions.

RESULTS

Fresh newborn grafts were revascularized successfully at a rate of 80% (16 of 20). After 24 hours of preservation, 65% (13 of 20), 75% (15 of 20), and 85% (17 of 20) of the grafts were observed to be revascularized in LR, m-TOM, and UW solutions, respectively. After 48 hours of preservation, 60% (12 of 20), 80% (16 of 20), and 80% (16 of 20) of the grafts also were revascularized in the respective solutions (no statistic difference among the groups). The cold-preservation did not affect the neovascularization of newborn intestine until 48 hours. Histologic findings of the preserved intestine and biochemical analyses showed that UW and m-TOM solutions kept villous architectures of the preserved grafts, however, might be harmful to enterochromaffin cells.

CONCLUSION

Long-time preservation of newborn intestine did not interfere with neovascularization and maturation. J Pediatr Surg 36:1805-1810.

Electroretinogram contact lens electrode with tri-color light-emitting diode

PURPOSE

This study was performed to evaluate a new electroretinogram (ERG) contact lens electrode containing four light-emitting diodes (LEDs) that are used for both stimulus and background light.

METHODS

The luminance of each LED could be changed independently and used as stimulus light. Red, blue, bright white, and flickering ERGs were recorded in 12 normal subjects and two patients with progressive cone dystrophy. The long-duration light stimuli separated the on- and off-responses of the ERG. This equipment is not according to the ISCEV standard.

RESULTS

The tri-color LED electrode contact lens can efficiently produce and record ERG responses. Off-responses were recordable separately from on-responses by lengthening the stimulus duration.

CONCLUSION

This combined stimulus-electrode system is compact and portable. Combined with the portable amplifier and the recorder, the ERGs can be recorded easily in an operating room, at patients' bedside, and in remote locations away from clinics and hospitals.

Increased expression of P-cadherin mRNA in the mouse peritoneum after carbon dioxide insufflation

BACKGROUND

Although systemic responses to carbon dioxide (CO(2)) pneumoperitoneum have been studied, there have been few reports of local responses within the peritoneum. We investigated the expression of mRNA for adhesion molecules involved in cell-cell interactions, including ICAM-1, VCAM-1, CD44, E-cadherin, P-cadherin, and N-cadherin, after the induction of a CO(2) pneumoperitoneum in mice.

METHODS

Mice were treated with CO(2) pneumoperitoneum (4-6 mmHg for 30 min) and then killed after 24 h, 48 h, and 72 h. The peritoneum of the abdominal wall was resected, and total RNA was extracted by the acid guanidinium thiocyanate-phenol-chloroform extraction procedure, cDNA were synthesized by reverse transcription. Expression of the mRNA for each gene was normalized to that of b-actin for semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS

The expression of P-cadherin mRNA was significantly increased at 48 h (p = 0.007) and returned to the control level by 72 h after CO(2) pneumoperitoneum. The expression of CD44 increased gradually, reaching a peak at 48 h and returning to the control value by 72 h after CO(2) pneumoperitoneum. Expression of ICAM-1 mRNA was not changed significantly after the application of CO(2).

CONCLUSION

The expression of P-cadherin mRNA in the peritoneum can be induced to repair injuries to mesothelial cells caused by CO(2) pneumoperitoneum.

Green fluorescent protein-transgenic rat: a tool for organ transplantation research

The purpose of this study is to evaluate green fluorescent protein (GFP) transgenic rats for use as a tool for organ transplantation research. The GFP gene construct was designed to express ubiquitously. By flow cytometry, the cells obtained from the bone marrow, spleen, and peripheral blood of the GFP transgenic rats consisted of 77, 91, and 75% GFP-positive cells, respectively. To examine cell migration of GFP-positive cells after organ transplantation, pancreas graft with or without spleen transplantation, heart graft with or without lung transplantation, auxiliary liver and small bowel transplantation were also performed from GFP transgenic rat to LEW (RT1(1)) rats under a 2-week course of 0.64 mg/kg tacrolimus administration. GFP-positive donor cells were detected in the fully allogenic LEW rats after organ transplantation. These results showed that GFP transgenic rat is a useful tool for organ transplantation research such as cell migration study after organ transplantation without donor cell staining.

Dendritic cell vaccination with MAGE peptide is a novel therapeutic approach for gastrointestinal carcinomas

The MAGE gene is selectively expressed in cancer tissues such as melanoma or gastrointestinal carcinomas, whereas no expression is observed in normal tissues except testis. There are several reports of successful induction of HLA class I-restricted antitumor CTLs using MAGE peptides, and some clinical trials with these immunogenic peptides were reported as effective for some patients with malignant melanoma. However, there are no similar studies in gastrointestinal carcinomas, which are important neoplasms. Autologous dendritic cells (DCs) were generated ex vivo and were pulsed with MAGE-3 peptide, depending on the patient's HLA haplotype (HLA-A2 or A24). Patients were immunized with DC pulsed with MAGE-3 peptide every 3 weeks at four times. Twelve patients with advanced gastrointestinal carcinoma (six stomach, three esophagus, and three colon) were treated, and no toxic side effects were observed. Peptide-specific CTL responses after vaccination were observed in four of eight patients. Improvement in performance status was recognized in four patients. Tumor markers decreased in seven patients. In addition, minor tumor regressions evidenced by imaging studies were seen in three patients. These results suggested that DC vaccination with MAGE-3 peptide is a safe and promising approach in the treatment of gastrointestinal carcinomas.

Orthotopic intestinal transplantation using the cuff method in rats: a histopathological evaluation of the anastomosis

Segmental small intestine transplantation (SIT) in rats, using a cuff technique, has achieved a high success rate. However, there have been few reports on the influence of the foreign body reaction to polyethylene cuff on vessel anastomoses and graft after SIT. This study involves the histopathological examination of the site of cuff anastomosis and grafts in the short- and long-term survival of segmental SIT. The data obtained from the suture anastomosis model also served as a control. One week after heterotopic segmental SIT using the cuff technique, orthotopic continuations were carried out in syngeneic combination. Twenty-five of 30 rats surviving >200 days (83.3%) were examined for vessel anastomosis. All arterial anastomoses were patent, but the portovenous anastomoses in 10 grafts (33%) were totally occluded and were associated with the formation of collateral vessels. Histopathological examination demonstrated good patency of the artery and vein anastomotic site in the short term, but granulation, fibrosis, and neovascularization at the anastomosis site surrounding the cuffs in the long-surviving group. However, the grafts appeared to be intact, with normal features of the villi. On the contrary, the site of the sutured anastomosis in the long-survival rats showed no inflammatory reaction. Although a polyethylene cuff caused foreign body reaction, the graft blood supplies were maintained by collateral vessels. Considering the low mortality and high success rate, polyethylene cuff is good for short-term study and an alternative method for long-term SIT experiments.

Anti-apolipoprotein A-I autoantibody: characterization of monoclonal autoantibodies from patients with systemic lupus erythematosus

OBJECTIVE

The autoantibody to apolipoprotein A-I (apoA-I), a major constituent of high density lipoproteins (HDL), has been detected in sera of patients with systemic lupus erythematosus (SLE). We established a series of monoclonal anti-apoA-I antibodies (MAAI) from 2 patients with SLE and report the reactivities of MAAI with oxidized HDL, anionic substances, and blood coagulation factors.

METHODS

Peripheral blood B cells from patients with SLE were immortalized by Epstein-Barr virus, and B cells secreting anti-apoA-I antibodies (AAI) were fused with mouse myeloma cells. Six MAAI reactive with human apoA-I in both ELISA and immunoblotting analysis were established. The reactivities of MAAI with HDL, ssDNA and dsDNA, phospholipids such as cardiolipin (CL), and coagulation factors were examined by ELISA.

RESULTS

Although all MAAI bound effectively to apoA-I after the protein had been denatured and transferred to the filter membrane (in immunoblotting analyses), they bound less effectively to apoA-I present in HDL. Both oxidation of HDL in the presence of Mn2+ and an association of apoA-I with autoxidized trilinolein strongly enhanced the binding of MAAI to apoA-I, suggesting that MAAI recognize a defined region of apoA-I, which is exposed upon interacting with oxidatively modified lipids. MAAI showed a functional heterogeneity in their cross-reactivity with self-components: some MAAI were shown to cross-react with anionic substances such as CL and ssDNA, and one MAAI was shown to bind effectively to thrombin.

CONCLUSION

We identified a novel family of AAI that shows preferential binding to apoA-I in oxidatively modified HDL. These AAI are composed of antibodies with heterogeneous cross-reactivities to various self-components such as anionic phospholipids, ssDNA, and thrombin.

Experimental small bowel transplantation using newborn intestine in rats: III. Long-term cryopreservation of rat newborn intestine

BACKGROUND

If long-term organ cryopreservation can be attained, a significant achievement will have been made to address the problem for donor shortage. Fetal intestine has been known to revascularize naturally without vascular anastmosis. The authors have confirmed previously that the newborn intestine also could develop to maturity in the host omentum. Here, the authors examined whether the cryopreserved newborn intestine could revascularize in the syngeneic combination using the 2 different solutions and whether cryopreservation affect their antigenicity in the allogeneic combination.

METHODS

Inbred rat strains of LEW (MHC haplotype; RT1(l)) and BN (RT1(n)) were used. LEW newborn intestinal grafts were stored in RPMI-1640 or University of Wisconsin solution with 10% DEMSO (n = 10 in each group). The grafts were placed into a cold (4 degrees C) preservation solution for 30 minutes and then placed into a freezing chamber and cooled to -80 degrees C at -1 degrees C/min after 12 hours quenched to -180 degrees C in liquid nitrogen for longer than 30 days. Then, the cryopreserved grafts under the 2 different solutions were transplanted syngenicaly (LEW to LEW). The cryopreserved BN grafts also were implanted into the LEW omentum pouch. The allotransplantation was received with a 14-day high-dose course of tacrolimus (0.64 mg/kg, intramuscularly). The grafts were evaluated histologically at 4 weeks after transplantation. Fresh newborn intestines implanted in this syngeneic and allogeneic combination were evaluated as each control group.

RESULT

In the syngeneic combination, more than 90% of the mature intestine were obtained. There was no significant difference among the different solution and the fresh group. However, in the allogeneic combination, both fresh and cryopreserved grafts were histologically poor.

CONCLUSIONS

This is the first report showing that long-term cryopreservation was not harmful for neovascularization of newborn intestine. Long-term cryopreservation did not reduce the antigenicity of the newborn intestine. J Pediatr Surg 36:602-604.

Cholangitis associated with cystic dilatation of the intrahepatic bile ducts after antireflux valve construction in biliary atresia

An intussusception-type antireflux valve (ARV) has been introduced to prevent postoperative ascending cholangitis in the management of biliary atresia (BA). We investigated the characteristics of cholangitis in the management of BA using the ARV in 38 patients who had undergone an operation at our institution; 29 underwent ARV construction at the same time as portenterostomy (PEO) or hepaticojejunostomy. One patient underwent ARV construction for refractory cholangitis with cystic dilatation of the intrahepatic bile ducts (CDIB) long after the PEO. Five of 29 patients who had ARV construction developed CDIB complicated by severe, refractory cholangitis. One or two episodes of mild cholangitis were observed in 5 (20.8%) of 24 patients who did not show CDIB. An ARV created for postoperative recurrent cholangitis associated with CDIB was ineffective. Preoperative cholangitis associated with a type I choledochal cyst and CDIB was observed in 1 patient. In conclusion, the ARV was effective in preventing refractory cholangitis without CDIB, but ineffective in preventing cholangitis with CDIB. Our findings suggest that CDIB resulting from the ongoing process of BA could be a potential target of bacterial infection through other routes than bilioenteric reflux.

Clinicopathologic study of mixed hepatocellular and cholangiocellular carcinoma: modes of spreading and choice of surgical treatment by reference to macroscopic type

BACKGROUND AND OBJECTIVES

Clinicopathologic features and the choice of surgical treatment for mixed hepatocellular and cholangiocellular carcinoma (MHC) remain controversial.

METHODS

We evaluated the clinicopathological features of seven cases of MHC (one autopsied and six surgically resected cases). MHCs were divided into two classes by reference to macroscopic appearance: four were of the single nodular (SN) type and three were of the multinodular (MN) type.

RESULTS

The mean age of patients and mean preoperative level of serum alpha-fetoprotein were 44.5 years and 56,457 ng/ml for the SN type and 63.7 years and 1,227 ng/ml for the MN type, respectively. Histologically, invasion of the portal vein, the hepatic vein, and the perineural space was found in three, two, and zero cases of SN type tumors and in three, three, and one cases of MN type tumors, respectively. Lymph node metastases were found only in two patients with MN type MHC.

CONCLUSIONS

MHC of the SN type had a pattern of infiltration similar to hepatocellular carcinoma. By contrast, MHC of the MN type resembled intrahepatic cholangiocellular carcinoma. It is suggested that lymphadenectomy might be necessary for treatment of selected MHC, in particular MHC with a multinodular appearance.

MAGE-specific cytotoxic T lymphocytes require non-specific CD54 adherence receptors on carcinoma cells

We investigated several factors that could regulate the susceptibility of carcinoma cells to MAGE-2-specific CTL mediated lysis. Cytofluorometric analysis showed that the cytolysis correlated with the expression of CD54. IFN-gamma treatment induced the TAP-1 and LMP-2 genes, continuously up-regulated the HLA class I expression and increased cytolysis. Although HLA class I were highly induced in MRKnu1 cells, CD54 was not induced and the cytolysis was minimal. Cytotolysis of IFN-gamma-treated MKN-1 cells was completely inhibited by a monoclonal anti-CD54 antibody. These results suggest that HLA-restricted CTL lysis requires non-specific CD54 adherence receptors in addition to specific TCR signals.

A case of seborrhoeic blepharitis

A fifty five-year old woman suffered from itching and scaling of the edge of her eyelid. She had long used topical corticosteroid for this condition. Direct examination of the scale by Parker KOH showed numerous fungal elements of spores and hyphae of Malassezia furfur. She was treated with oral itraconazole (100 mg daily or twice a week) for 8 weeks and was cured clinically and mycologically. The result suggests the possibility of treatment with an anti-fungal drug for seborrhoeic blepharitis or seborrhoeic dermatitis.

Intrafractional tumor position stability during computed tomography (CT)-guided frameless stereotactic radiation therapy for lung or liver cancers with a fusion of CT and linear accelerator (FOCAL) unit

PURPOSE

To evaluate intrafractional tumor position stability during computed tomography (CT)-guided frameless stereotactic radiation therapy (SRT) for lung or liver cancers, we checked repeated CT scanning, with a fusion of CT and linear accelerator (FOCAL) unit.

METHODS AND MATERIALS

The FOCAL unit is a combination of a linear accelerator (Linac), CT scanner, X-ray simulator (X-S), and carbon table, and is designed to achieve CT-guided SRT with daily CT positioning followed by immediate irradiation while patients keep reduced shallow respirations. To evaluate intrafractional tumor position stability, 50 lung or liver lesions in 20 patients were checked by repeated CT scanning just before and after irradiation, and the obtained images were compared.

RESULTS

There was no case with the intrafractional error judged to be greater than 10 mm. In 68% of cases, the intrafractional positioning errors were negligible (0-5 mm).

CONCLUSIONS

Using the FOCAL unit, SRT for lung or liver cancers could be performed with intrafractional positioning errors not greater than 10 mm.

Comparative study of lymphocyte-suppressive potency between prednisolone and methylprednisolone in rheumatoid arthritis

We compared lymphocyte-suppressive potencies of prednisolone and methylprednisolone in rheumatoid arthritis (RA). IC(50)s of the glucocorticoids (GCs) on concanavalin A-induced blastogenesis of peripheral-blood mononuclear cells (PBMCs) from 44 RA patients and 30 healthy subjects were estimated in vitro, and differences in the IC(50)s of the two GCs were evaluated. The mean (+/-SD) IC(50)s for prednisolone and methylprednisolone on PBMC-blastogenesis of RA were 17.2+/-17.1 and 12.6+/-18.4 ng/ml, respectively, and no significant differences were observed between prednisolone-IC(50) and methylprednisolone-IC(50). In contrast, the mean IC(50)s of prednisolone and methylprednisolone on healthy PBMCs were 19.4+/-22. 4 and 3.7+/-3.9 ng/ml, respectively, and thus methylprednisolone potency was significantly higher than prednisolone potency (p<0.01). Methylprednisolone potency against PBMCs in RA patients exhibiting a high level of rheumatoid factor (RF) (>20 IU/ml) and the rheumatoid arthritis particle-agglutination value (RAPA) (>80) was significantly higher than that of patients exhibiting a lower level of RF or RAPA (p<0.05). In prednisolone-IC(50), however, such differences between the two patient-subgroups were not observed. Unlike reported cases of renal transplantation and healthy subjects, there was no difference in the lymphocyte-suppressive potencies for both prednisolone and methylprednisolone on RA-PBMCs. However, PBMCs from RA patients exhibiting high levels of RF or RAPA are more sensitive to methylprednisolone rather than prednisolone.

Choledochal cyst associated with duodenal obstruction

The association between congenital duodenal obstruction and concomitant choledochal cyst has not been reported, although duodenal obstruction is known to be associated with many other anomalies. The authors describe 2 patients with choledochal cyst with duodenal obstruction. In 1 patient, a diverticulum type of choledochal cyst was found within an annular pancreas. Cyst excision, choledochojejunostomy, and side-to-side duodeno-duodenostomy were performed. The other patient showed separated duodenal atresia and other multiple anomalies including imperforate anus. A choledochal cyst was noted at the time of duodeno-duodenostomy and sigmoid colostomy. Cyst-enterostomy was performed at the age of 8 months, but the patient died of multiple anomalies. Intraoperative cholangiography indicated an anomalous pancreatobiliary ductal junction (APBDJ). In both patients the bile in the cyst contained high levels of amylase, suggesting the presence of an APBDJ. An APBDJ is considered to play an etiologic role in the development of the choledochal cysts associated with duodenal obstruction.

Cetraxate, a mucosal protective agent, combined with omeprazole, amoxycillin, and clarithromycin increases the eradication rate of helicobacter pylori in smokers

BACKGROUND

Our previous study demonstrated that Helicobacter pylori eradication was less effective in smokers than in non-smokers. Cetraxate is an anti-ulcer drug that increases gastric mucosal blood flow.

AIM

To evaluate the effect of cetraxate combined with new triple therapy for the eradication of H. pylori in smokers.

METHODS

This study had a single-centre, double-blind, randomized non-placebo design. A total of 106 consecutive H. pylori-positive smoking patients were randomly allocated to one of two regimens: one group received omeprazole (20 mg), amoxycillin (1500 mg), and clarithromycin (600 mg) for 7 days (OAC, n=55). The other group recieved OAC plus cetraxate (600 mg) for 7 days (OAC + CET, n=51). The success of H. pylori eradication was evaluated by histology and the 13C-urea breath test at 4 weeks after completion of treatment.

RESULTS

By intention-to-treat analysis, the H. pylori eradication rate was 55% in the OAC group and 92% in the OAC + CET group (P<0.01). By per protocol analysis, the H. pylori eradication rate was 58% in the OAC group and 94% in the OAC + CET group (P<0.01).

CONCLUSION

Cetraxate combined with new triple therapy increases the eradication of H. pylori in smokers.

The prevalence and clinical significance of blocking thyrotropin receptor antibodies in untreated hyperthyroid Graves' disease

The goal of this study was to evaluate the clinical significance of the blocking thyrotropin receptor antibodies (TSHRAb) in Graves' disease. The amount of blocking and stimulating TSHRAb were measured in 200 patients with untreated hyperthyroid Graves' disease using several cell lines carrying different TSHR chimera. Stimulating TSHRAb were measured in Chinese hamster ovary (CHO) cells with wild-type human TSHR (CHO-hTSHR) or a TSHR chimera with residues 90-165 (Mc2) or 8-165 (Mc1+2) substituted by equivalent residues of rat luteinizing hormone/chorionic gonadotrophin (LH/CG) receptor or in FRTL-5 cells. Blocking TSHRAb were measured in Mc2 cells. The activities of different TSHRAb were assessed and clinical features were compared to patients who were positive or negative for blocking TSHRAb antibodies. Blocking TSHRAbs were detected in 18.5% of patients (37/200) with hyperthyroid Graves' disease. Patients with blocking antibodies had significantly lower mean stimulating TSHRAb activities than those without blocking antibodies in wild-type CHO-hTSHR cells (301 +/- 179 vs. 446% +/- 537%, p = 0.005). Mean stimulating TSHRAb activities measured by FRTL-5, Mc1+2, or Mc2 cells and mean thyrotropin receptor inhibitor immunoglobulin (TBII) activities were not different between the two groups. The patients with blocking antibodies were not different from those without blocking antibodies in age, gender ratio, initial serum free thyroxine (T4) levels, or goiter size. However, the prevalence of exophthalmos was higher (35.1% vs. 17.5%, p = 0.024) in the patients with blocking antibodies than those without. In summary, the presence of blocking TSHRAb is not rare in patients with hyperthyroid Graves' disease when measured with chimeric receptor expressing cells. Blocking TSHRAb in Graves' sera do not strongly antagonize the action of stimulating TSHRAb in vivo, but could be a major factor responsible for underestimation of stimulating TSHRAb activities measured by CHO-hTSHR. The association of blocking TSHRAb with ophthalmopathy suggests that the TSHRAb repertoire of Graves' patients is different in those who do and who do not have ophthalmopathy.

Hashimoto's thyroiditis with heterogeneous antithyrotropin receptor antibodies: unique epitopes may contribute to the regulation of thyroid function by the antibodies

Blocking-type TSH-binding inhibitor Igs (TBIIs) are known to cause hypothyroidism and an atrophic thyroid gland in patients with primary myxedema. They can block the activity of thyroid-stimulating antibodies (TSAbs) in Graves' patients as well as the activity of TSH. The majority of the epitopes for these blocking-type TBIIs have been, and are shown herein, to be present on the C-terminal region of the extracellular domain of the human TSH receptor (TSHR), whereas those for Graves' TSAbs are on the N-terminus. We report on a patient with Hashimoto's thyroiditis who suffered from mild hypothyroidism and a moderately sized goiter. Her serum had a potent blocking-type TBII and a weak TSAb in human and porcine TSHR systems. Using human TSHR/lutropin-CG receptor chimeras, we determined that the functional epitope of her blocking-type TBII was uniquely present on the N-terminal, rather than the C-terminal, region of the extracellular domain of the TSHR, unlike the case for blocking-type TBIIs in primary myxedema patients. The epitope of her TSAb was also unusual. Although the functional epitopes of most TSAbs are known to involve the N-terminal region of the receptor, her TSAb epitope did not seem to be present solely on the N- or C-terminus of the extracellular domain of the receptor. Blocking-type TBIIs from patients with primary myxedema blocked her TSAb activity as well as stimulation by TSH; her blocking-type TBII was able to only partially block her TSAb. In contrast, her blocking-type TBII almost completely blocked TSAbs from Graves' patients. Thus, we suggest that the unique epitopes of this patient's heterogeneous population of TSH receptor antibodies, at least in part, contribute to regulation of her thyroid function.

Laparoscopic resection of an adrenal neuroblastoma detected by mass screening that grew in size during the observation period

Neuroblastomas (NB) identified by mass screening tests are characterized by benign features. Recently, laparoscopic resection has been applied to the treatment of patients with small adrenal NB (<2-3 cm). However, an increasing number of cases of small NB are followed without any treatment in Japan because many cases regress spontaneously. We describe a case of right adrenal NB detected by mass screening that increased in size during an observation period of 8 months. In this case, laparoscopic resection was performed successfully. The size of the tumor was 27 x 20 x 18 mm at diagnosis and 51 x 42 x 35 mm when it was excised. Small adrenal NB that do not regress during the observation period may require laparoscopic resection before they reach 5 cm in maximum diameter.

Postoperative complications of repeat hepatectomy for liver metastasis from colorectal carcinoma

BACKGROUND/AIMS

When a repeat hepatectomy is possible, it is the most effective treatment modality for recurrent colorectal liver metastasis. The aim of this study was to evaluate the surgical risks of repeat hepatectomy for liver metastasis from colorectal carcinoma.

METHODOLOGY

Between 1986 and 1996, 60 patients with hepatic metastasis from colorectal carcinoma underwent surgery in the Department of Surgery I, Oita Medical University. Ten of them underwent a repeat hepatectomy. The cases of these 10 patients were studied retrospectively; in particular, postoperative complications and intraoperative blood loss were compared between the initial and second operation.

RESULTS

During the second surgery, recurrence was detected adjacent to the hepatic stump in 9 of the 10 patients. During the initial surgery, 6 underwent non-anatomic resections, and 4 had anatomic resection, including 1 extended lobectomy, 1 lobectomy, and 2 segmentectomies. For the second surgery, 3 had anatomic resections, including 2 lobectomies, and 1 segmentectomy, and 7 underwent non-anatomic resections. There were no mortalities during the initial or second operation. There was no morbidity following the initial surgeries and 7 postoperative complications (intraabdominal abscess, 4 cases; biloma, 3 cases) following the second surgeries. Mean blood loss during the second operation (1044 mL) was significantly greater than during the initial operation (561 mL).

CONCLUSIONS

The present results show that repeat hepatectomy for recurrent liver metastasis from colorectal carcinoma resulted in significantly greater intraoperative blood loss and postoperative complications than those of the initial surgeries. The blood loss and complications in the second operation, the one for the recurrence, were directly associated with the fact that the recurrence was so close to the hepatic stump. Since the resection line in the second surgery was adjacent to the hepatic hilus, resection of the lesion caused much more injury to the main bile duct and main portal vein than that caused by the.

[Two cases of rheumatoid arthritis associated with IgA -type multiple myeloma]

We report here two Japanese cases of rheumatoid arthritis (RA) associated with IgA [symbol: see text]-type multiple myeloma (MM). Case 1. The patient was a 68-year-old man with eight-years history of RA. The M-proteinemia (IgA 2838 mg/dl) in laboratory findings suggested a complication of MM which had been noticed since four years ago. On May 1997, he was referred and admitted to our hospital because of cough, right chest pain and dyspnea. Serum immunoelectrophoresis showed monoclonal IgA[symbol: see text]-type light chain. Bone marrow aspirate contained 6.5% atypical plasma cells. The X-ray findings revealed radiolucent myelomatous foci in the skull. From these findings, IgA[symbol: see text]-type MM was diagnosed. His condition was recovered by administration of antibiotics for bacterial pleuritis. Case 2. The patient was a 75-year-old woman with twelve-years history of RA. The laboratory findings of M-proteinemia (IgA 1215 mg/dl) with the decrease of other serum immunoglobulin level (IgG 611 mg/dl, IgM 60 mg/dl) and monoclonal IgA[symbol: see text]-type light chain in serum immunoelectrophoresis suggested MM four years ago. Bone marrow aspirate contained 5% plasma cells. From these findings, IgA[symbol: see text]-type MM was diagnosed. In the review of reported Japanese cases of RA associated with MM, it might be characteristic that IgA type MM was found more frequently in RA patients than other immunoglobulin types.