Therapeutic strategy for atypical ulnar fracture in long use of bisphosphonate: A systematic review

BACKGROUND

Atypical fractures are caused by the combined effects of severe suppression of bone metabolism (SSBT) due to long-term bisphosphonate therapy and chronic repetitive bone microdamage. Atypical ulnar fractures (AUFs) due to SSBT are rare, and there is no standard treatment strategy for such fractures. The relevant literature was reviewed, and the treatment strategy for AUF is discussed.

METHODS

A systematic review was conducted. All studies on ulnar fractures in individuals with a history of bisphosphonate use were included, and the data were extracted and analyzed from the perspective of the therapeutic strategy.

RESULTS

Forty limbs of 35 patients were included. As for the treatment of AUF, 31 limbs were treated surgically, and conservative treatment with casting was performed for 9 limbs. The bone fusion rate was 22/40 (55.0%), and non-union was seen in all patients treated conservatively. There was a significant difference in the bone fusion rate between patients with surgical treatment and those with conservative treatment. The bone fusion rate of patients with parathyroid hormone (PTH) and surgery was 82.3% (14/17 limbs); the bone fusion rate with PTH and bone graft was 69.2% (9/13 limbs). However, there were no significant differences in the fusion rate in the groups with or without PTH, with or without bone grafting, or the combination of the two treatments. There was also no significant difference in the bone fusion rate in the groups with or without low-intensity pulsed ultrasound (LIPUS) treatment.

CONCLUSIONS

Based on the literature review, surgery is necessary to achieve bone union, but surgery alone is not adequate to achieve bony union. Bone grafting and the administration of PTH and LIPUS may promote early bone fusion, but the present study did not show significant advantages of these additional treatments for bone union.

Presurgical imaging of the subscapular artery with three-dimensional-computed tomography angiography: Application to harvesting subscapular system free-flaps

A subscapular system free-flap is extremely useful for maxillofacial reconstruction since it facilitates the simultaneous harvesting of multiple flaps using one subscapular artery (SSA) alone. However, cases of aberrations in the SSAs have been reported. Therefore, the morphology of SSA needs to be confirmed preoperatively before harvesting the flaps. Recent developments in imaging, such as three-dimensional (3D) computed tomography angiography (3D CTA), facilitate obtain high-quality images of blood vessel images. Therefore, we examined the utility of 3D CTA in navigating the course of the SSA before harvesting subscapular system free-flaps. We examined the morphology and aberrations of the SSA using 39 sides of the 3D CTA data and 22 sides of Japanese cadavers. SSAs can be classified into types S, I, P, and A. Type S SSAs are significantly long (mean length = 44.8 mm). Types I and P SSAs have short mean lengths, measuring ≤2 cm in approximately 50% of cases. In type A, the SSA is absent. The frequency of types S, I, P, and A SSAs were 28.2%, 7.7%, 51.3%, and 12.8%, respectively. Type S can be advantageous for harvesting the SSA in subscapular system free-flaps, because it is significantly longer. In contrast, types I and P might be dangerous because their mean lengths are shorter. In type A, caution is needed not to injure the axillary artery because the SSA is absent. When surgeons need to harvest the SSA, presurgical 3D CTA is recommended.

Wide-Awake Local Anesthesia No Tourniquet Surgery for Zone VII Extensor Tendon Reconstruction: Stages in Active Range of Motion From Intraoperative to Final Recovery

PURPOSE

We investigated chronological changes in active range of motion (ROM) of the metacarpophalangeal (MCP) joint after zone VII extensor tendon reconstruction with wide-awake local anesthesia no tourniquet (WALANT) surgery.

METHODS

Reconstruction of the extensor tendons ruptured in zone VII of 82 fingers in 40 patients was performed using WALANT techniques. The mean patient age was 71.3 years. During surgery, we evaluated passive stretch distance and active contraction distance of the ruptured musculocutaneous unit. The sum of passive stretch distance and active contraction distance was defined as total excursion. In cases with total excursion ≥30 mm, we selected bridge tendon grafting for tendon reconstruction. In cases with total excursion <30 mm, end-to-side tendon transfer was performed. Active ROM of the MCP joint was measured before surgery; during surgery; 1, 3, and 5 months after surgery, and at the final follow-up.

RESULTS

Extension lag of the MCP joint was 49.2° before surgery, improving to 2.9° during surgery, deteriorating to 18.7° at 1-month, and improving again to 15.6° at 3-months, 13.6° at 5-months, and 10.5° at the final follow-up. Meanwhile, the active flexion angle of the MCP was 87.9° before surgery, 87.3° during surgery, 67.6° at 1-month, 76.0° at 3-months, 79.7° at 5-months, and 81.0° at the final follow-up. Extension and flexion angles at each time point remained nearly constant regardless of whether tendon grafting or tendon transfer was used.

CONCLUSIONS

Extensor tendon reconstruction using WALANT surgery allowed intraoperative measurement of active ROM, confirming near-complete extension and flexion after reconstruction. The changes in ROM of the MCP joint during follow-up are an approximate indication of the progression of postoperative recovery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic Ⅳ.

Effect of hyperdry amniotic membrane in preventing tendon adhesion in a rabbit model

BACKGROUND

No anti-adhesive materials are currently in clinical use for orthopaedic surgery. We developed a hyperdry amniotic membrane (HD-AM) for easy storage and transplantation as amniotic membrane. The purpose of this study was to examine the application of HD-AM to reduce peritendinous adhesions without impairing tendon healing.

METHODS

We randomly divided 3 digits (2nd, 3rd, and 4th digits) from each rabbit into three groups: a tendon repair group; a tendon repair with HD-AM group (HD-AM group); and a control group (cast only). The effects of HD-AM on peritendinous adhesions and tendon healing were examined using microscopic, histological, and mechanical analyses in a rabbit flexor digitorum profundus tendon model.

RESULTS

Adhesions on macroscopic evaluation of the tendon repair site were significantly smaller in the HD-AM group than in the tendon repair group. Little adhesion formation or foreign body reactions were seen by on histologic evaluation in the HD-AM group. Range of motion following tendon repair was significantly better in the HD-AM group than in the tendon repair group. Maximal tensile strength required to pull the tendon from the site of adhesion was significantly smaller in the HD-AM group than in the tendon repair group. As for tendon repair site, no significant difference was seen between the tendon repair and HD-AM groups.

CONCLUSIONS

HD-AM prevented peritendinous adhesion macroscopically, pathologically, and mechanically without impairing the sutured tendon. HD-AM has already been clinically applied in neurosurgery, ophthalmology, and otolaryngology, and clinical application as an anti-adhesive materials may be achieved in the future.

Clinical outcome and ultrasonographic evaluation of treatment using polyglycolic acid-collagen tube for chronic neuropathic pain after peripheral nerve injury

BACKGROUND

A novel polyglycolic acid (PGA)-collagen tube has been available in Japan since March 2013, and the development of high-resolution ultrasonography has recently allowed detailed evaluation of nerves. The purpose of this study was to report the clinical outcomes and evaluations of in-vivo changes under high-resolution ultrasonography for treatment using PGA-collagen tube for painful chronic nerve injury.

METHODS

Four patients underwent surgical management of peripheral nerve neuroma, with nerve defects after neuroma resection reconstructed using PGA-collagen tube. Mean duration of follow-up was 30 months. Patients were surveyed to determine visual analog scale scores for pain before surgery and at final follow-up. At final follow-up, sensory function was evaluated using the Semmes-Weinstein test, static 2-point discrimination (2PD), and moving 2PD. Furthermore, we performed ultrasonography for all patients every 1 month after surgery.

RESULTS

In all cases, resting pain, radicular pain, and dysesthesia were improved immediately after the operation and remained improved until the last follow-up. At the time of final follow-up, the Semmes-Weinstein test was red in 2 cases and blue in 2 cases. Mean static 2PD was 15.5 ± 5.3 mm and mean moving 2PD was 11.5 ± 5.3 mm. Ultrasonography revealed that the PGA outer wall had disappeared by 3 months postoperatively, and a hypoechoic linear shadow bridged the proximal and distal stumps. Swelling of the junction between nerve and nerve conduits was revealed at 4 months after surgery and remained until last follow-up.

CONCLUSIONS

All patients were very satisfied with pain relief, but recovery of sensory function was insufficient. Ultrasonographic evaluation after using PGA-collagen tube for painful chronic peripheral nerve injury was useful for observing in-vivo changes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Radial Dislocation of Extensor Tendon Over the Metacarpophalangeal Joint of the Thumb due to Cerebral Hemorrhage: A Case Report

We report a rare case of radial dislocation of the extensor tendon over the metacarpophalangeal (MCP) joint of the thumb. Ulnar dislocation has been reported, but previous reports have not mentioned radial dislocation of the extensor tendon in the thumb. Radial dislocation of the extensor tendon of the thumb gradually progressed after cerebral hemorrhage and the patient could not extend MCP joint of the thumb. To resolve difficulty in extending the MCP joint, surgical centralization of the extensor tendon and partial resection of the flexor pollicis brevis (FPB) and abductor pollicis brevis (APB) insertions was performed. The patient recovered function of thumb extensors.

CONTINUOUS PERIPHERAL NERVE BLOCK IN FOREARM FOR SEVERE HAND TRAUMA

We studied the use of a continuous peripheral nerve block (CPNB) in the distal forearm and wrist immediately after emergent surgery for severe hand trauma in 22 hands. After emergent surgery, a 2–3 cm longitudinal incision was made at the distal forearm and an 18-gauge catheter was inserted along the peripheral nerves. All patients received postoperative analgesia by continuous infusion of 0.2% ropivacaine at 2 ml/h for seven to 21 days. Pain score remained low during postoperative period and only a small number of analgesic rescues were needed. There were no major complications related to the CPNB and one patient showed mild superficial infection at the insertion site that immediately recovered after catheter removal. This method provides good postoperative analgesia without loss of motor function in extrinsic hand muscles and should be considered as a postoperative pain management for severe hand trauma.

Bulk shear-mode contribution to thermally generated capillary waves on a room-temperature ionic-liquid surface

In the present work, we show that the autocorrelation function of the capillary-wave displacement is expressed by the sum of the ordinary oscillator and the bulk shear-mode terms. The former is expressed by a simple damped oscillator form or a sum of exponentially damping functions depending on the extent of damping. The latter is also written by superposition of exponentially damping modes, and an analytically exact formulation is obtained. We performed surface dynamic light-scattering experiment for the surface of an ionic liquid, 1-butyl- 3-methylimidazolium bis[(trifluoromethyl)sulfonyl]imide, and compared the experimental autocorrelation function with the theoretical one. We observed for the first time the bulk shear-mode contribution, and confirmed that the experimental data is well explained by the theoretical autocorrelation function.

Dispersion relation of capillary waves on ionic liquids: observation of the fast overdamped mode

We measured the capillary wave spectra on the surface of ionic liquids using dynamic light scattering techniques. Empirical dispersion relations deduced from the time domain analysis clearly reveal the transition from oscillating to overdamped behavior with changing temperature and the wave vector. In particular, not only slow but also fast modes were observed in the overdamped regime. The empirical dispersion relations coincide with the theoretical dispersion relations deduced from the linearized Navier-Stokes equation when experimentally determined density, viscosity, and surface tension are assigned to the latter.

Multicentric diffuse-type giant cell tumor of the hand

Diffuse-type giant cell tumor (D-TGCT) is relatively rare. We report a case of multicentric D-TGCT located in the finger and wrist. A 79-year-old man presented with a more than two-year history of tumors. Marginal resection was performed. Histological study of the specimens disclosed D-TGCT. Recurrence occurred two years and five months postoperatively and was again excised. Clinical presentation, radiological features and histopathological findings are discussed with reference to the literature.

Vulvar Paget's disease with underlying adenocarcinoma simulating breast carcinoma: case report and review of the literature

We report a case of extramammary Paget's disease with underlying adenocarcinoma simulating breast carcinoma of the vulva. An 82-year-old woman was found to have a 5 x 3-cm bulky tumor located in the left labium major, infiltrating to the clitoris, left labium minor, and left lateral tissue of the vulva. Small biopsy of the vulva showed intraepidermal proliferation of Paget cells. The patient underwent wide local excision of the vulvar tumor and dissection of left inguinal lymph nodes. Histopathological examination of the resected specimens revealed that Paget cells were distributed singly or tended to form small nests in the epidermis, and that association of these cells with the underlying carcinoma invading to the subcutis could be seen. The underlying carcinoma was composed of squamoid solid nests with central necrotic debris, mimicking 'comedocarcinoma' of the breast. In other areas, the tumor cells were present in tubular formations and solid cords reminiscent of invasive ductal carcinoma of the breast. Immunohistochemically, the Paget cells and the underlying carcinoma cells were positive for carcinoembryonic antigen, epithelial membrane antigen, estrogen receptors, and glandular keratins except for CK 20. We speculate that our case is vulvar Paget's disease presenting as a manifestation of underlying breast carcinoma of the vulva, which might have arisen from either the ectopic breast tissue or anogenital mammary-like glands.

Vulvar Paget's disease with underlying adenocarcinoma simulating breast carcinoma: case report and review of the literature

We report a case of extramammary Paget's disease with underlying adenocarcinoma simulating breast carcinoma of the vulva. An 82-year-old woman was found to have a 5 × 3-cm bulky tumor located in the left labium major, infiltrating to the clitoris, left labium minor, and left lateral tissue of the vulva. Small biopsy of the vulva showed intraepidermal proliferation of Paget cells. The patient underwent wide local excision of the vulvar tumor and dissection of left inguinal lymph nodes. Histopathological examination of the resected specimens revealed that Paget cells were distributed singly or tended to form small nests in the epidermis, and that association of these cells with the underlying carcinoma invading to the subcutis could be seen. The underlying carcinoma was composed of squamoid solid nests with central necrotic debris, mimicking ‘comedocarcinoma’ of the breast. In other areas, the tumor cells were present in tubular formations and solid cords reminiscent of invasive ductal carcinoma of the breast. Immunohistochemically, the Paget cells and the underlying carcinoma cells were positive for carcinoembryonic antigen, epithelial membrane antigen, estrogen receptors, and glandular keratins except for CK 20. We speculate that our case is vulvar Paget's disease presenting as a manifestation of underlying breast carcinoma of the vulva, which might have arisen from either the ectopic breast tissue or anogenital mammary-like glands.

Periodontoid pannus migration into the spinal canal with reduction of rheumatoid atlantoaxial subluxation: a case report

We report a patient with rheumatoid arthritis in whom periodontoid pannus migrated into the spinal canal with reduction of atlantoaxial subluxation. In this case, magnetic resonance imaging in the extension position was valuable for determining the therapeutic strategy.

Prediction of neurologic outcome in patients with spinal cord injury by using hyperbaric oxygen therapy

The effectiveness of hyperbaric oxygen therapy (HBO) in predicting neurological recovery in patients with spinal cord injury was evaluated. HBO has been used to treat spinal cord injury, but HBO does not appear to greatly alter the neurological outcome. This is the first report of the use of HBO as a diagnostic tool to evaluate neurological recovery after spinal cord injury. The study group consisted of 22 patients, aged 21-73 years, with spinal cord injuries. The effect of HBO was evaluated on admission and categorized as one of four grades (excellent, good, fair, or poor). The neurological status was evaluated on admission and at the time of follow-up, according to Frankel grade and the American Spinal Injury Association (ASIA) motor score. Correlations between the HBO effect and Frankel grade recovery and correlations between the HBO effect and recovery rate of the ASIA motor score were evaluated. The recovery in Frankel grade from admission to the final follow-up became better as the effectiveness of HBO increased (r = 0.445; P = 0.0414). The Frankel grade (r = 0.036; P = 0.871) and ASIA motor score (r = 0.029; P = 0.893) on admission did not correlate with the recovery in Frankel grade. There was a significant correlation between the HBO effect and the recovery rate of the ASIA motor score (r = 0.586; P = 0.0072), but this correlation was weaker than that for the ASIA motor score on admission (r = 0.752; P = 0.0006). We conclude that HBO can be employed to assess the status of spinal cord function recovery after spinal cord injury.

Increased nitric oxide production in nasal epithelial cells from allergic patients--RT-PCR analysis and direct imaging by a fluorescence indicator: DAF-2 DA

BACKGROUND

Nitric oxide (NO) is believed to participate in the regulation of airway clearance and non-specific cellular immunity. Recent studies have suggested that airway epithelial cells of allergic and non-allergic individuals may differ in their ability to produce this molecule.

OBJECTIVE

The aim of this study was to detect the difference in NO production in human nasal epithelial cells between normal subjects and patients with perennial allergic rhinitis (AR), and to assess the relationship between the expression of nitric oxide synthase (NOS) isoforms and the severity of the disease.

METHODS

Nasal epithelial cells were obtained from the inferior turbinate. The expression of mRNAs encoding constitutive endothelial NOS (eNOS) and inducible NOS (iNOS) was studied by reverse transcription-polymerase chain reaction (RT-PCR). Direct NO production in living cells was visualized and quantified by a fluorescent indicator, DAF-2 DA.

RESULTS

RT-PCR analysis demonstrated that AR patients with a RAST score of 5 or 6 showed significant increases in the levels of iNOS mRNA and slight reductions in those of eNOS mRNA. Patients with a RAST score of 2-4 also revealed the same tendency however, the difference was not significant. DAF-2 DA imaging demonstrated that epithelial cells, especially the ciliated cells, produced a larger amount of NO than non-epithelial inflammatory cells. Preincubation with L-NAME resulted in an approximate 40% decrease in both groups.

CONCLUSION

These results directly indicate that nasal epithelial cells of AR patients overall produce higher levels of NO through the concomitant expression of different NOS isoforms. Continuous NO production by the epithelial cells in normal subjects further support the hypothesis that NO derived from epithelium may play dual roles in the regulation of nasal airway clearance and in the host defense. In addition, the use of DAF-2 DA provides a reliable method to visualize and quantify the direct NO production of living cells.

Minimum 10-year follow-up study of anterior lumbar interbody fusion for isthmic spondylolisthesis

The aims of the current study were to evaluate the long-term clinical and radiologic results of anterior lumbar interbody fusion (ALIF) for isthmic spondylolisthesis. Between 1981 and 1988, a total of 35 patients underwent ALIF for isthmic spondylolisthesis. Of these, 23 patients were followed clinically and radiographically for more than 10 years (average, 13.3 years). The Japanese Orthopaedic Association low-back pain score was used to evaluate the outcome of subjective symptoms and clinical signs. The preoperative and postoperative percentage of slip, preoperative and postoperative intervertebral disk height, interbody graft union, and pars defect union were evaluated by serial radiographs. The adjacent disk degeneration was also evaluated by radiographs and magnetic resonance imaging. Although the low-back pain score worsened after 5 years, ALIF provides satisfactory overall long-term clinical results. The preoperative percentage of slip and the disk height were corrected after surgery, but at the time of interbody graft union, slip and disk height recurred as a result of grafted bone collapse. The rate of union in the grafted area was 83%. In the nonunion cases, the scores gradually deteriorated with time, but the overall results were not different from those of union cases. Radiographs showed adjacent disk degeneration in 52% of cases in the upper adjacent level and in 70% of cases in the lower adjacent level, but these changes were not correlated with clinical outcomes.

Warning from Nagano: increase of vulvar hematoma and/or lacerated injury caused by snowboarding

BACKGROUND

On the basis of the number of women snowboarders whose vulvar injuries we have recently treated, we believe that the cases of vulvar hematoma and lacerated injuries caused by snowboarding have been increasing. To analyze the causal relation between snowboarding and vulvar injuries, we investigated how women were injured during snowboarding.

METHODS

During the last three ski-ing seasons at the five hospitals near the ski resorts in Nagano Prefecture, Japan, the clinical charts of all patients with vulvar injuries during snowboarding were reviewed for the number of patients treated, the condition of the patients at diagnosis, and the characteristics of vulvar injuries. All patients were also asked by phone about how their vulvar injury was caused during snowboarding.

RESULTS

The number of patients with vulvar injuries during the last three seasons was 16, 14, and 35, respectively. The types of vulvar injuries included hematoma in 33 (51%) patients, hematoma with lacerated injury in 17 (26%), and lacerated injury in the remaining 15 (23%). Of the 65 patients, 45 (69%) needed surgical treatment. Characteristically, 54 (88%) patients were injured when they tumbled onto the binding of the snowboard at the same time that one foot was left off the board and the binding was not turned down but left erect.

CONCLUSION

It is important for women snowboarders to realize that in snowboarding there are dangers that may cause vulvar injuries. The prevention of such injuries requires that the binding should be turned down when the foot is left off the board and that snowboarders should try not to tumble onto the board.

Nitric oxide mediates the change of proteoglycan synthesis in the human lumbar intervertebral disc in response to hydrostatic pressure

STUDY DESIGN

This in vitro study clarifies the role of nitric oxide (NO) in human lumbar intervertebral disc metabolism.

OBJECTIVE

To investigate the effects of NO on proteoglycan synthesis in human lumbar discs and to test the hypothesis that NO is a mediator of the changes in proteoglycan synthesis in response to hydrostatic pressure.

SUMMARY OF BACKGROUND DATA

The authors have clarified that hydrostatic pressure has an apparent effect on proteoglycan synthesis as well as matrix metalloproteinase production in the intervertebral disc. The cellular mechanisms underlying the response of disc cells to hydrostatic pressure remain to be clarified. Herniated lumbar discs produce NO in response to interleukin (IL)-1 beta. In articular cartilage, NO mediates the change of proteoglycan synthesis by IL-1 or shear stress.

METHODS

Fifty-eight lumbar intervertebral disc specimens were obtained from patients who had undergone posterior discectomy. The specimens were chopped into 1-2-mm cubes and were incubated in a plastic syringe with 1 mL Dulbecco's modified Eagle's medium (DMEM). The syringes were placed in a water-filled pressure vessel kept at 37 C. Hydrostatic pressures of 1 (control), 3, and 30 atmospheres (atm) were applied. Proteoglycan synthesis was determined from (35)S-sulfate incorporation rates. Nitrite (the stable oxidation product of NO) concentration in DMEM was determined by a spectrophotometric method based on the Griess reaction. As a competitive inhibitor of NO synthases, N(G)-methyl-l-arginine (l-NMA, 10-1000 micromol) and as an organic donor of NO, S-nitroso-N-acetylpenicillamine (SNAP, 1-200 micromol) were used.

RESULTS

Addition of l-NMA suppressed NO production and increased proteoglycan synthesis rates in the intervertebral disc specimens in a dose-dependent fashion. Addition of SNAP increased exogenous NO content in the medium significantly and suppressed proteoglycan synthesis rates in a dose-dependent fashion. Three-atmosphere hydrostatic pressure stimulated the proteoglycan synthesis rates. Rates were approximately 1.3-fold greater than at 1 atm, whereas 30-atm pressure inhibited proteoglycan synthesis rates. However, the hydrostaticpressure had inverse effect on NO production. At 3 atm, NO production decreased slightly relative to 1 atm, whereas at a pressure of 30 atm, NO production was increased and was approximately 1.32-fold greater than at 1 atm. L-NMA enhanced the 3-atm pressure-induced increase in proteoglycan synthesis and also relieved the suppression of proteoglycan synthesis at a pressure of 30 atm.

CONCLUSION

The current study confirmed the previous finding that human herniated lumbar disc cultures spontaneously produce NO. Endogenously generated and exogenously supplied NO inhibited proteoglycan synthesis in the intervertebral disc. Hydrostatic pressure influenced NO production by disc cells, and NO is one of the mediators that changes proteoglycan synthesis in response to hydrostatic pressure. These results may show that autocrine and paracrine mechanisms of NO play an important role in the regulation of disc cell metabolism under mechanical stress and in the pathophysiology of intervertebral disc degeneration.

Analysis of local cytokine gene expression in patients with allergic rhinitis treated with CO2 laser surgery

OBJECTIVES/HYPOTHESIS

Laser surgery of the inferior turbinates has become a popular surgical treatment for patients with allergic rhinitis, particularly for those who have persistent nasal obstruction and do not respond well to pharmacological therapy. The aim of this study was to investigate the effects of the laser surgery on local cytokine gene expression at the mucosal surface in relation to the improvement of nasal symptoms.

STUDY DESIGN

A prospective analysis of 25 patients with allergic rhinitis caused by the house dust mite who underwent laser surgery twice with a 1-month interval on an outpatient basis. Fifteen healthy volunteers served as normal control subjects.

METHODS

Improvement of the nasal symptoms was evaluated on a graded scale. Nasal mucosal cells were obtained by brushing from the inferior turbinate at each visit. The expression of messenger RNA (mRNA) encoding granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin (IL)-6, IL-8, RANTES (regulated on activation, normal T-cell expressed and secreted), and eotaxin was semiquantitatively analyzed by reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS

Two months after treatment, the nasal symptom scores significantly decreased from baseline. The decrease was most apparent in nasal obstruction. RT-PCR analysis revealed that a significant decrease in IL-8 and RANTES expression (P < .001 and P = .012, respectively) was observed after successive laser treatment, and the reduction in these cytokines was significantly correlated. On the other hand, mRNA expression of GM-CSF, IL-6, and eotaxin remained unchanged.

CONCLUSIONS

This study provided evidence that the expression of local inflammatory cytokines can be attenuated in part by CO2 laser treatment, which may be closely related to the clinical effectiveness of this procedure.

Decreased cellular activity and replicative capacity of osteoblastic cells isolated from the periarticular bone of rheumatoid arthritis patients compared with osteoarthritis patients

OBJECTIVE

Periarticular osteopenia is frequently observed in rheumatoid arthritis (RA). Bone loss has been considered to be at least partly due to inadequate bone formation, which in turn, is largely dependent on the number of osteoblasts and the osteoblastic activity. Normal human somatic cells undergo a finite number of cell divisions and ultimately enter a nondividing state called replicative senescence. It has been proposed that the telomere, the terminal sequence of chromosomes, is the mitotic clock that triggers senescence. In the present study, we sought to clarify the relationship between periarticular osteopenia and osteoblast replicative senescence in RA.

METHODS

We examined age-related changes in cellular activity (alkaline phosphatase activity, osteocalcin and C-terminal type I procollagen secretion, and cAMP response to parathyroid hormone), replicative capacity, and senescent cell expression in osteoblasts from periarticular bone samples obtained from 15 patients with RA and 15 age-matched patients with osteoarthritis (OA). Cellular replicative capacity was analyzed by the mean telomere length and in vitro remaining replicative lifespan of the cells.

RESULTS

In both OA and RA groups, the cell proliferation rate, the levels of osteoblastic markers, mean telomere length, and replicative lifespan in osteoblastic cells gradually decreased with the increasing age of the donor. The percentage of senescent osteoblastic cells in the periarticular bone increased with age in both groups, and the rate of expression of senescent cells was higher in RA patients than in age-matched OA patients. The osteoblastic activities and replicative capacity of osteoblastic cells from RA patients were lower than those from OA patients at any donor age. The age-related decreases in the osteoblastic activity and replicative capacity of osteoblastic cells from periarticular bone were greater in RA patients than in OA patients.

CONCLUSION

Our results suggest that osteoblast replicative senescence in periarticular bones occurs more rapidly with aging in RA than in OA patients and contributes to periarticular osteopenia in RA.

Nd:YAG laser irradiation of the human dental pulp: implications as a predictor of pulp hemodynamics

BACKGROUND AND OBJECTIVE

The aim of study this was to evaluate in vivo the pulpal blood flow rate, pulpal responsiveness, systemic blood pressure, and pulse rate during Nd:YAG laser irradiation of an isolated tooth.

STUDY DESIGN/MATERIALS AND METHODS

Thirteen volunteers from the Tsurumi Dental University faculty participated in this study after giving their consent to the Nd:YAG laser irradiation test protocol. Gingivobuccal areas adjacent to mandibular canines were used for clinical evaluation. Each area was coated with India ink and treated with a Nd:YAG laser for 30 sec at 120-mJ pulses at 10 pulses/sec. Pulpal blood flow was measured by a laser Doppler flowmeter during Nd:YAG laser irradiation of the tooth. All pulp responses were measured by an electric pulp tester before and after Nd:YAG laser irradiation. In addition, the systemic blood pressure and pulse rate were monitored throughout the laser irradiation procedure.

RESULTS

For all subjects involved in this study, the pulpal blood flow rate increased during laser irradiation. Threshold values of the electric pulp tests increased in six cases and decreased in six cases. One case showed no change. After 1 month, the threshold values for each subject had returned to previously recorded values. Neither systemic blood pressure nor pulse rate was affected during Nd:YAG laser irradiation. Pulpal blood flow was strongly influenced immediately after Nd:YAG laser irradiation, seen as an increase in the flow rate.

CONCLUSION

The results of this study suggest that effects of the Nd:YAG laser irradiation are similar to those of low power laser for the improvement of local blood flow.

Modulation of ciliary activity by tumor necrosis factor-alpha in cultured sinus epithelial cells. Possible roles of nitric oxide

The primary function of well-differentiated ciliated epithelium in the paranasal sinus is to eliminate harmful agents through the beating action of cilia. Respiratory epithelium also contributes to local inflammatory processes through the release of various proinflammatory cytokines. Recently, considerable attention has been focused on the intimate relationship between the cytokine-dependent regulation of the ciliary beat frequency (CBF) and intra-cellular production of nitric oxide (NO) in ciliated epithelial cells. The aims of this study are to examine the effect of tumor necrosis factor-alpha (TNF-alpha), one of the major proinflammatory cytokines, on the ciliary activity of human sinus epithelial cells and to assess the hypothesis that NO is involved in this regulatory mechanism. Human maxillary or ethmoidal sinus mucosa (n = 23) were cultured by the explant-outgrowth method. CBF of the outgrowth ciliated cells was measured by the photoelectrical method before and after being treated with TNF-alpha (0.1, 1 and 10 ng/ml) or dexamethasone (10(-6) M and 10(-7) M). We also investigated the expression of nitric oxide synthase (NOS) isoforms, enzymes responsible for NO synthesis, by fluorescent immunohistochemistry. TNF-alpha increased CBF at relatively low concentrations (0.1 and 1 ng/ml) and decreased CBF at a high concentration (10 ng/ml). Dexamethasone decreased CBF at a concentration of 10(-6) M. Fluorescent immunohistochemistry demonstrated that the expression of inducible NOS was augmented by TNF-alpha and attenuated by dexamethasone, whereas that of endothelial NOS remained unchanged. We conclude that human sinus epithelial cells potentially contribute to the inflammatory process by regulating their ciliary motility through an NO-dependent pathway. Proinflammatory cytokines and steroids are able to modulate this mechanism by the induction or inhibition of expression of different NOS isoforms.

Association between an aggrecan gene polymorphism and lumbar disc degeneration

STUDY DESIGN

A case-control study using magnetic resonance imaging findings and a polymerase chain reaction assay to investigate the association between aggrecan gene polymorphism and lumbar disc degeneration.

OBJECTIVE

To analyze whether the aggrecan gene polymorphism is related to lumbar disc disease in young women.

SUMMARY OF BACKGROUND DATA

It has been suggested that a genetic factor or familial predisposition contributes to the development of lumbar disc herniation. However, the precise genetic component related to disc disease remains unclear. Recently, a polymorphism has been identified in the region of the human aggrecan gene. The expressed variable numbers of tandem repeat polymorphism occur in the highly conserved repeat region.

METHODS

The participants were 64 young women with or without low back problems. Magnetic resonance imaging was used to evaluate the degeneration and herniation of the intervertebral disc. Genomic deoxyribonucleic acid was extracted from all participants. A polymerase chain reaction assay was carried out to detect the alleles of the aggrecan gene. The association of intervertebral disc degeneration and herniation with the distribution of the aggrecan gene alleles was analyzed.

RESULTS

Findings showed an overrepresentation of alleles with small numbers of repeats in subjects with multilevel disc degeneration, thus indicating a significant distribution difference. There also was a significant difference between the distribution of alleles and the severity of disc degeneration. No significant association was found between any of the alleles either in number or type of disc herniation.

CONCLUSIONS

The current study showed that multilevel and severe disc degeneration was present in the participants with shorter variable numbers of tandem repeat length of the aggrecan gene. This suggests that subjects with shorter variable numbers of tandem repeat length of the aggrecan gene have a risk of having multilevel disc degeneration develop at an early age.

Incidence of Prevotella intermedia and Prevotella nigrescens in periodontal health and disease

The incidence of black-pigmented rods (BPRs), especially Prevotella intermedia and Prevotella nigrescens, in periodontal health and disease were examined. Furthermore, the degradative enzyme activities of P. intermedia were compared among the strains from periodontal health and disease. Microbiological specimens were collected from subgingival crevice or periodontal pocket by paper point. The BPRs were found in 71.1% of periodontally healthy subjects (n=45), and in 47.1% of healthy sites (n=34) and 87.8% of active sites (n=41) among periodontally diseased patients. Porphyromonas gingivalis was detected only in active sites of periodontally diseased patients (17.8% of 180 strains). P. intermedia was the predominant BPR in both healthy and active sites (37.3 and 41.7%, respectively) of the patients. However, P. nigrescens was the predominant BPR (70.5% of 173 strains) in periodontally healthy subjects. The enzyme activities of esterase, esterase-lipase, acid-phosphatase and alpha-fucosidase of P. intermedia strains isolated from active sites in patients were significantly higher (P<0.05) than those of healthy subjects. The results suggest that P. intermedia might increase the activity of degradative enzymes under a certain condition and support the progression of periodontitis.

Ovarian yolk sac tumor with endometrioid carcinoma arising from endometriosis in a postmenopausal woman, with special reference to expression of alpha-fetoprotein, sex steroid receptors, and p53

A case of a yolk sac tumor (YST) with an ovarian endometrioid adenocarcinoma arising from endometriosis in a postmenopausal woman is described. Clinically, the case showed an aggressive course and did not respond to chemotherapy; the patient died of her disease 6 months after the operation. Histologically, the tumor consisted predominantly of an endometrioid adenocarcinoma, but it also showed microscopic features characteristic of YST. The tumor also contained benign endometriotic lesions with direct transition to the endometrioid adenocarcinoma. Immunohistochemical study revealed that not only the YST, but also the endometrioid adenocarcinoma was partly positive for alpha-fetoprotein. There was an inverse relationship between the endometriosis and the endometrioid adenocarcinoma in terms of the expression of sex steroid receptors and p53: adenocarcinoma cells were positive for p53 but negative for sex steroid receptors, whereas endometriotic epithelial cells were positive for sex steroid receptors but negative for p53.

Effects of irradiation of an erbium:YAG laser on root surfaces

The application of erbium:YAG laser (Er:YAG) irradiation has been investigated for periodontal therapy. The purpose of this study was to evaluate the effects of Er:YAG laser irradiation on root surfaces using a scanning electron microscope (SEM) and to determine the laser's ability to remove lipopolysaccharides (LPS). Infrared spectrophotometry was used to investigate the effects of the laser on LPS applied to root dentin pellets. Premolars extracted for orthodontic reasons were prepared for this study. The crowns were resected below the cemento-enamel junction, longitudinally sectioned, and the contents of the pulp chamber were removed. Then 15 root tips (5 x 5 x 1 mm) were classified into 3 groups of 5 each as follows: group 1, tips without any treatment; group 2, planed tips with the cement layers left untouched; and group 3, planed until the dentin surface was disclosed. The center of each specimen was used as the experimental irradiated area and the peripheral area served as a control. The quantity of vapor delivered by Er:YAG laser was highly increased, and the irradiated areas displayed little morphogenetic changes. The lyophilized sample LPS 0111 B4 from E. coli was then mixed with potassium bromide and pressed into a tablet, which was examined at 4,000-650 Kayser. The lyophilized LPS had a peak at 2.94 microns. LPS on the root dentin pellets was cleared away as much as possible by 150 washings in pyrogen-free water using an ultrasonic cleaner. Five microliters of 24 EU LPS solution was dropped on the root dentin pellets, which were then irradiated by the Er:YAG laser, and washed using the ultrasonic cleaner in pyrogen-free water. The amount of the extracted LPS solution was determined by spectrophotometer at 405 nm. The Er:YAG laser could remove 83.1% of the LPS. This study suggests that Er:YAG laser irradiation might be useful for root conditioning in periodontal therapy. However, clinical testing is necessary to establish what, if any, utility the Er:YAG laser has as a part of periodontal therapy.

Facet joint asymmetry as a radiologic feature of lumbar intervertebral disc herniation in children and adolescents

STUDY DESIGN

This study compared the incidence of facet joint asymmetry between adult and juvenile patients with lumbar intervertebral disc herniation.

OBJECTIVES

To determine the different distribution of the facet joint asymmetry between the adult and juvenile patients.

SUMMARY OF BACKGROUND DATA

As early as 1967, it was suggested that asymmetry of the facet joints is correlated with the development of disc herniation. There have been numerous arguments for and against Farfan's hypothesis, however, most studies were carried out on adult patients, and this hypothesis has not been verified in juvenile patients.

METHODS

The study group consisted of 29 levels of 25 patients aged 12-20 years (juvenile group) and 50 levels of 33 patients aged 30-49 years (adult group) who underwent posterior discectomy. The shape of facet joints, the facet joint angle, and the moment arm angle and length were measured for each facet joint using computed tomography. Facet joint asymmetry was defined as the difference in facet joint shape or a difference of more than 10 degrees in facet joint angles between the right and left sides. The incidence of facet joint asymmetry and the relationships among the facet joint asymmetry and the location, type of disc herniation, and disc degeneration were examined in juvenile and adult groups.

RESULTS

The overall incidence of facet joint asymmetry was significantly higher in the juvenile group (12 levels, 41%) than in the adult group (four levels, 8%; P < 0.01). There were no significant relationships among the facet joint asymmetry, the location, type of disc herniation, and disc degeneration.

CONCLUSIONS

This study revealed that the frequency of facet joint asymmetry in the juvenile group was five times higher than that in the adult group. This result indicates that facet joint asymmetry is a radiologic feature of lumbar intervertebral disc herniation in children and adolescents.

Effects of hydrostatic pressure on matrix synthesis and matrix metalloproteinase production in the human lumbar intervertebral disc

STUDY DESIGN

This study is a unique in vitro study on the effects of hydrostatic pressure on human intervertebral disc metabolism.

OBJECTIVE

To investigate the effects of hydrostatic pressure on matrix synthesis and matrix metalloproteinase production in the human lumbar intervertebral disc.

SUMMARY OF BACKGROUND DATA

Mechanical stress and hydrostatic pressures influence proteoglycan and protein synthesis rates in bovine articular cartilage and coccygeal discs. However, the mechanism of matrix synthesis regulation of the intervertebral disc under mechanical stress has not been elucidated.

METHODS

Twenty-eight human lumbar intervertebral discs obtained from surgery and from cadavers at autopsy were used. Each tissue fraction was charged with medium in a plastic syringe and placed in a water-filled hydrostatic pressure-control vessel. The hydrostatic pressures applied were 1 (control), 3, and 30 atm (atm = atmospheres) for 2 hours. The proteoglycan and protein synthesis rates were determined by radioisotope incorporation. The production of matrix metalloproteinase-3 and tissue inhibitor of metalloproteinases-1 were measured by a one-step enzyme immunoassay method using monoclonal antibodies.

RESULTS

Three atm pressure stimulated proteoglycan synthesis rates in the nucleus pulposus and inner anulus (n = 14 in each tissue). Compared with the control group, 30 atm pressure significantly inhibited proteoglycan synthesis in the inner anulus (P = 0.011). In the nucleus pulposus, matrix metalloproteinase-3 production was stimulated at a pressure of 30 atm relative to 3 atm (P = 0.014, n = 16 in each tissue). The highest tissue inhibitor of metalloproteinases-1 production showed highest values at 3 atm pressure in the inner anulus (n = 16 in each tissue).

CONCLUSION

The results suggest that hydrostatic pressure influences intervertebral disc cell metabolism. A physiologic level of hydrostatic pressure (3 atm) may act as an anabolic factor for stimulation of proteoglycan synthesis and tissue inhibitor of metalloproteinases-1 production. This may be essential for maintaining the matrix of the disc. If the pressure was 30 atm or more or 1 atm or less, a catabolic effect will be predominant, with reduction of proteoglycan synthesis rate and increase of matrix metalloproteinase-3 production. Abnormal hydrostatic pressure, therefore, may accelerate disc degeneration.

Autocrine/paracrine mechanism of insulin-like growth factor-1 secretion, and the effect of insulin-like growth factor-1 on proteoglycan synthesis in bovine intervertebral discs

The present study was undertaken to investigate the effect of insulin-like growth factor-1 on proteoglycan synthesis and the autocrine/paracrine mechanism involving insulin-like growth factor-1 in the bovine coccygeal intervertebral disc. Insulin-like growth factor-1 stimulated proteoglycan synthesis in cultured cells of the nucleus pulposus of bovine intervertebral discs in a dose-dependent manner, and the effect was inhibited by an anti-insulin-like growth factor-1 monoclonal antibody. In situ hybridization histochemistry revealed the expression of insulin-like growth factor-1 mRNA in the cultured cells, and its production in these cells was demonstrated by radioimmunoassay. Insulin-like growth factor-1 receptor in the cultured cells was also demonstrated immunohistochemically. Scatchard analysis using an [125I]insulin-like growth factor-1 binding assay showed that the cells cultured in monolayer had a single type of insulin-like growth factor-1 receptor, whose affinity and number were estimated to be 7.38 x 10(8)/M and 9.27 x 10(4)/cell, respectively. These results suggest that insulin-like growth factor-1 stimulates proteoglycan synthesis in cells of the nucleus pulposus and that these cells in culture have an insulin-like growth factor-1 autocrine/paracrine mechanism. The expressions of insulin-like growth factor-1 mRNA and insulin-like growth factor-1 receptor in disc tissue were greater in cells of the nucleus pulposus of fetal bovine intervertebral discs than in those of the adult discs. These findings suggest that the action of autocrine/paracrine insulin-like growth factor-1 is more active in cells of the young nucleus pulposus than in cells of mature subjects.

Morphologic variation of lumbar posterior longitudinal ligament and the modality of disc herniation

The authors investigated the relationship between the type of lumbar disc herniation (471 discs) and the gross anatomy of the posterior longitudinal ligament (PLL) in the lumbar region of 10 cadavers. The size of PLL diminished significantly as the disc level became lower (P < 0.00001), and there are loose attachment of the central area of rhomboidal expansion of PLL. In the upper lumbar region, central or central-lateral herniation with an intact PLL was predominant. The type of disc herniation appeared to be influenced by the width and development of the PLL with a loosely connected central area. In the lower lumbar region, posterior-lateral extrusion with a ruptured PLL was predominant. This may be related to the small or poorly developed PLL in lower lumbar/lumbosacral region. It is suggested that the type of disc herniation (PLL intact or ruptured) is related to the morphologic variation of PLL.

High-performance liquid chromatographic determination of aromatization of 16 alpha-hydroxylated androgens with human placental microsomes

A sensitive nonradiometric assay of aromatization of 16 alpha-hydroxylated androgens, 16 alpha-hydroxy-4-androstene-3,17-dione (16 alpha-OHA), and 16 alpha-hydroxytestosterone (16 alpha-OHT), has been developed using reverse-phase high-performance liquid chromatography with voltametric detector. The estrogens produced by human placental microsomes, estriol (E3) and 16 alpha-hydroxyestrone (16 alpha-OHE1), were simultaneously detected in quantities as low as 1-2 ng using 3-methoxy-1,3,5(10)-estratriene-2, 16 alpha,17 beta-triol as an internal standard. E3 was the only estrogen detected from the incubate of 16 alpha-OHT with the microsomes and NADPH, while 16 alpha-OHA gave 16 alpha-OHE1 and E3 under the same conditions. Apparent Km and Vmax of the microsomal aromatase for 16 alpha-OHA and 16 alpha-OHT were 2.56 microM and 71.4 pmol/min/mg and 13.33 microM and 15.4 pmol/min/mg, respectively.