Prevalence and predisposing factors of neuropathic pain in patients with rotator cuff tears

BACKGROUND

The management of pain in patients with rotator cuff tears can be challenging. Neuropathic pain is reportedly associated with pain occurrence in musculoskeletal diseases. However, to date, few studies have reported on the prevalence of neuropathic pain in patients with rotator cuff tears or identified the factors associated with neuropathic pain in a multicenter study.

METHODS

A total of 391 patients (205 males and 186 females; median age, 67.7 years; range, 27-92 years) with rotator cuff tears were included in this study. The prevalence of neuropathic pain in rotator cuff tears was investigated using the Japanese version of the painDETECT questionnaire for all patients. In addition, factors significantly associated with the occurrence of neuropathic pain were examined using multivariate logistic regression analysis.

RESULTS

Twenty-eight patients (7.2%) were classified into the neuropathic pain group (score ≥19), 97 (24.8%) into the uncertainty regarding neuropathy group (score 13-18), and 266 (68.0%) into the nociceptive pain group (score ≤12). According to the multivariate logistic regression analysis, the independent predictors of neuropathic pain were the VAS score (most severe pain during the past 4 weeks; odds ratio, 1.55; 95% confidence interval [CI], 1.23-2.09) and UCLA shoulder score (odds ratio, 0.81; 95% CI, 0.65-0.97).

CONCLUSIONS

Based on the study findings, the prevalence of neuropathic pain in patients with rotator cuff tear was 7.2%. It is important to investigate the presence or absence of neuropathic pain when treating patients with painful rotator cuff tears, because neuropathy associated with rotator cuff tears may adversely affect patient outcomes.

Risk factors for excessive postoperative sliding of femoral trochanteric fracture in elderly patients: A retrospective multicenter study

INTRODUCTION

The application of a load on the internal fixation of a trochanteric fracture exerts a moment along the lag screw, causing the proximal bone fragment to slide along the lag screw, allowing contact between the proximal and distal bone fragments, which promotes healing. However, excessive sliding is related to poor postoperative outcomes. We aimed to identify the risk factors for excessive sliding.

MATERIALS AND METHODS

We conducted a multicenter retrospective study including 115 trochanteric fractures sustained through low-energy trauma in 19 male and 96 female patients aged 60 years or older (mean age: 82.9 years) between September 2013 and December 2014. We measured the postoperative sliding distance after osteosynthesis using a sliding hip screw or intramedullary nailing, and classified participants with ≥8 mm of sliding into the excessive sliding group (ESG) and with <8 mm into non-ESG. Finally, we investigated the risk factors of excessive postoperative sliding.

RESULTS

Fifty participants were classified into the ESG and 65 participants into the non-ESG. Female sex (p = 0.0264), an A3 fracture type (p = 0.0003), greater tip-apex distance (p = 0.0250), and poor reduction in either the anteroposterior or lateral radiographic views (p = 0.0156) were identified as risk factors for excessive sliding by multivariate regression analysis.

CONCLUSIONS

Female sex, an unstable fracture type, a greater tip-apex distance, and a poor reduction, in either the anteroposterior or lateral views, are associated with excessive postoperative sliding. Therefore, surgery should aim to achieve good reduction and stabilization from both radiographic views.

Stump classification was correlated with retear in the suture-bridge and double-row repair techniques for arthroscopic rotator cuff repair

PURPOSE

The Stump classification is significantly correlated with a retear after arthroscopic rotator cuff repair. However, no study has evaluated whether or not the stump classification is correlated with retear in the suture-bridge or double-row repair techniques. The aim of this study was to evaluate the relationship between a retear and the stump classification in the suture-bridge and double-row repair techniques.

METHODS

Among 389 patients who underwent arthroscopic repairs of full-thickness rotator cuff tears using suture-bridge or double-row repair techniques, 326 patients (median age 67.0 years; range 25-85) were included. There were 51 small, 172 medium, 83 large, and 20 massive tears. Two hundred forty patients were treated with the suture-bridge technique, and 86 patients were treated with the double-row technique. The following variables were analyzed: age, sex, the Cofield classification, anteroposterior and mediolateral tear size on preoperative MRI, global fatty degeneration index, and the stump classification. Cuff integrity was evaluated on magnetic resonance imaging at 6 months after surgery. The patients were divided into the intact and retear groups and the relationship between the variables and retear was evaluated by multivariate logistic regression analysis.

RESULTS

The overall retear rate was 10.1%. In the multivariate logistic regression analysis, the independent predictors of a retear were the stump classification type 3 (Odds ratio: 4.71, p = 0.0246), global fatty degeneration index (Odds ratio: 3.87, p = 0.0030), and anteroposterior tear size (Odds ratio: 1.07, p = 0.0077) in the suture bridge technique. In the double-row technique, the independent predictors of retear were stump classification type 3 (Odds ratio: 7.82, p = 0.0348), and age (Odds ratio: 1.22, p = 0.0163).

CONCLUSION

The stump classification was significantly correlated with retear in the suture-bridge and double-row repair technique. Stump classification type 3 was indicated to be an important risk factor for predicting retear.

LEVEL OF EVIDENCE

III.

Refracture of pediatric both-bone diaphyseal forearm fracture following intramedullary fixation with Kirschner wires is likely to occur in the presence of immature radiographic healing

PURPOSE

Refracture of pediatric both-bone diaphyseal forearm fractures (PBDFFs) may occur, even if the fractures are treated with intramedullary nailing. The purpose of this study was to investigate the risk of refracture of PBDFFs treated with intramedullary Kirschner wires (K-wires), which are commonly used in our clinic.

METHODS

The present multicenter retrospective study included 60 consecutive patients with 60 PBDFFs who were treated with intramedullary K-wires at 5 hospitals between 2007 and 2016. The age of the patients at the time of the primary fracture ranged from 2 to 15 years. The characteristics of the primary fractures and treatment course were evaluated.

RESULTS

Refracture occurred in 6 patients (10.0%). Three of the patients were young girls; the other 3 were adolescent boys. Refractures were caused by falling or during sports activity. The duration from primary fracture to refracture ranged from 46 to 277 days, and in 5 of the 6 patients refractures occurred within 6 months. Although we were unable to identify factors significantly contributing to refracture (e.g. fracture type or treatment procedures), radiographs at the latest visit before refracture demonstrated findings of immature healing in five of six patients. Both K-wires and external immobilization had been removed before complete fracture healing in a large proportion of patients with refracture (80.0%).

CONCLUSIONS

Refracture of PBDFF may occur several months after treatment with intramedullary K-wires if the primary fracture shows immature healing. Physicians should pay special attention when judging radiographic fracture healing, even when the fracture is deemed to have clinically healed.

Secondary T790M mutation and novel G796A mutation in exon20 of EGFR gene in patients with non-small cell lung cancer who show resistance to gefitinib

7703

Background: Somatically acquired mutations in the EGFR gene in non-small cell lung cancer are associated with a significant clinical response to a tyrosine kinase inhibitor (TKI). EGFR mutations occur predominantly in exon19 and/or exon21, namely, an in-frame deletion in exon19 or a missense mutation in exon21 (L858R), which have been found to be related to the sensitivity to TKI. However, most patients with such sensitive mutations in their tumor show progression during the TKI treatment. In such resistant tumors, a secondary threonine- to-methionine mutation at codon 790 (T790M) in exon20 has been reported to be related the resistance to either gefitinib or erlotinib. Methods: EGFR mutations in exons19–21 were examined by sequencing in 37 pretreatment tumors obtained from patients with NSCLC, who were treated by gefitinib. Of the 22 cases having sensitive EGFR mutations (19del or L858R), 15 showed CR/PR and 7 showed SD/PD. Of the 15 patients with CR/PR, 4 tumor samples (2 lung, 1 liver, and 1 pleural effusion) that became refractory to gefitinib, were obtained. In pretreatment tumor samples from 4 patients, an in-frame deletion of exon19 was observed in 3 tumors and a L858R mutation of exon21 was in 1 tumor. We next examined whether a secondary mutation occurred in a tumor with acquired resistance to gefitinib in 4 patients by the sequencing of exons 19–21, with informed consent. Results: Three of 4 tumor samples had a secondary T790M mutation, which was not detected in the pretreatment tumor samples. These 3 samples also had an in-frame deletion in exon19. There were no other novel secondary mutations in exons 19,20,21. In 7 cases showing resistance to gefitinib (SD/PD) in spite of the existence of sensitive mutations, 1 tumor demonstrated the co-existence of a missense mutation (G796A) in exon20. In vitro, a stable clone of cells bearing the G796A mutation was approximately 50,000-fold less sensitive to gefitinib in comparison to the cells carrying exon19 deletion. Conclusions: The T790M mutation is common in patients with acquired resistance to gefitinb. Our results suggest that screening tumor samples for a range of EGFR mutations may therefore improve our ability to identify the patients most likely to benefit from treatment with TKI.

No significant financial relationships to disclose.

A prospective phase II study of gefitinib in non-small cell cancer patients with epidermal growth factor receptor gene (EGFR) mutations

18081

Background: Somatically acquired mutations in the EGFR gene in non-small cell lung cancer are associated with a significant clinical response to gefitinib, a tyrosine kinase inhibitor that targets EGFR, especially in patients with adenocarcinoma, females, and/or never/light smokers. In our retrospective study, cases with EGFR mutations (exon19del or L858R) showed a high sensitivity to gefitinib, and the patients with sensitive EGFR mutations also tended to have a more favorable prognosis than those with wild-type after gefitinib treatment (Uramoto, et al. Lung Cancer 2006;51:71). In the present study, we prospectively assessed the efficacy of gefitinib and the survival benefit for patients with EGFR mutations. Methods: Patients with either recurrent disease after undergoing surgery or advanced disease (IIIB or IV) of NSCLC which demonstrated EGFR mutations were eligible for this study. EGFR mutations in exons 19–21 were examined by our previously described screening method (Sugio, et al. Br J Cancer 2006;94:896) and confirmed by direct sequencing after informed consent was obtained from all patients. The patients with EGFR mutations were enrolled in this study after obtaining informed consent a second time, and they were thereafter treated with gefitinib. Results: Between 2005 and 2006, 16 patients (10 males/6 females, all adenocarcinoma) who had EGFR mutations were enrolled onto this study. Six pts had a deletion in exon 19, 8 pts had a missense mutation in exon 21 (L858R), 1 pt had both an exon 19 del and L858R, and 1 pts had an exon19 del and missense mutation in exon 20 (G796A). The overall response rate was 50%, and the disease control rate was 88%. In patients with exon19 del and L858R, the response rates were 83% and 25%, respectively. A case with a deletion in exon19 and a missense mutation in exon20 (G796A) showed resistance to gefitinib. The median progression-free survival time was 8.8 months, and the median survival time was 15.4 months. No life-threatening toxicity was observed. Conclusions: EGFR mutations in exons 19 or 21 are therefore considered to a good predictor of the efficacy of gefitinib, and the treatment with gefitinib was also found to achieve a prolonged survival.

No significant financial relationships to disclose.

The influence of GoldbonderTM and pre-heat treatment on the adhesion of titanium alloy and porcelain

The present study examines the influence of a goldbonder and pre-heat treatment of the titanium on the adhesion of porcelain. Three groups of titanium substrates were given various heat treatments, namely; none, 200 degrees and 600 degrees C, respectively before applying goldbonder. The surfaces of the titanium specimens following heat treatment were examined with an electron spectroscopy for chemical analysis (ESCA). The adhesion strength was measured by the strain energy release rate (G), which was proposed by Suansuwan N and Swain MV (Int J Prosthodont. 1999;12:547). After bonding porcelain onto titanium substrates with the aid of the goldbonder, the porcelain side of specimens was notched to the interface with a thin diamond saw. Then the samples were subject to a four-point bending test. Following fracture testing, specimens were examined with a scanning electron microscope (SEM) and SEM with energy-dispersive spectroscopic analysis (EDS). The mean G-values were 38.87, 28.64 and 16.33 J m(-2), respectively. ESCA analysis showed the composition of aluminium of the surface of 600 degrees C pre-heat treatment became richer than that of the others. SEM images of the fracture surfaces showed that for the 600 degrees C pre-heat treatment fracture occurred within the oxidation layer on the titanium. High temperature pre-heat treatment prior to bonding significantly reduces porcelain bonded to titanium with the goldbonder. The Influence of Goldbonder and Pre-heat Treatment on the Adhesion of Titanium Alloy and Porcelain.

The effect of GoldbonderTM on the adhesion between porcelain and pure titanium

The present study examines the effect of a Goldbonder on the adhesion between titanium and porcelain as measured by the strain energy release rate (G) associated with the interfacial fracture of porcelain and titanium. The influence of surface treatment of titanium prior to Goldbonder application was also examined. The porcelain side of the specimens was notched to the interface with a thin diamond saw, and then a pre-crack was made at the metal-porcelain interface by a special jig. The samples were subjected to a four-point bending test resulting in stable crack extension from which G was calculated. Both the cracked cross-section of interface and peeled fracture surface were examined with scanning electron microscope (SEM). The mean G values were 81.57 +/- 10.34, 46.01 +/- 14.83, and 15.98 +/- 1.76 J m(-2) for the sandblasted surface with the Goldbonder, polished surface with the Goldbonder, and sandblasted surface with the Pastebonder, respectively. The G values revealed significant differences (P < 0.01) between Goldbonder and Pastebonder, and between the sandblasted and polished surfaces with Goldbonder. The SEM photographs and elemental analysis showed that Goldbonder developed both chemical and mechanical bonding to titanium and porcelain.

[Clinical outcome of the coronary arterial bypass graft with inferior epigastric artery as a composite graft]

Based on a good long-patency of the internal thoracic arteries (ITA) in coronary arterial bypass graft (CABG), the postoperative early patency of the inferior epigastric artery (IEA) was evaluated by means of the proximal anastomosed types as a composite graft. Among patients performed with CABG during October in 1998 to June, 2000, 39 cases with the IEA composite graft were studied for this clinical outcome (31 males and 8 females, the averaged age was 66.4 +/- 8.0 year old). The preoperative diagnosis were done as acute myocardial infarction (4), old myocardial infarction with angina pectoris (8), effort angina (12), and unstable angina (15). The coronary disease was left main trunk disease (8), 3 vessels (22), and 2 vessels (9). The operation was performed with cold blood-cardioplegia (20 degrees C, blood-GIK liquor used) on cardiopulmonary bypass with a single atrial and aortic cannulation. The averaged extracorporeal circulation time and the aortic clamping one were done for 169 and 131 min, respectively. The bypass number was double (n = 5), triple (n = 10), quadruple (n = 16), and quintuple (n = 8). Total bypass number was 150 (the averaged bypass number was 3.7 +/- 0.9), and total anastomosal number was 145. The postoperative early-patency of IEA was 94.9% (37/39). The proximal sites of IEA were anastomozed to ITA with I-shaped end-to-end (n = 15), to ITA with Y-shaped end-to-side (n = 5), and to SVG with Y-shaped end-to-side (n = 19). Compared with the postoperative early-patency of I-shaped anastomosis to ITA and that of Y-shaped one to ITA or SVG, there was no significance among these cases (100%, 15/15 versus 91.7%, 22/24, p = 0.6738), however, that of Y-shaped one to ITA was significantly better than that of Y-shaped one to SVG (60%, 3/5 versus 100%, 19/19, p = 0.0488). It should be available for spreading of the anastomotic objective vessels that the IEA as a composite graft was used with the proximal site anastomozed to ITA by I-shaped end-to-end and with to SVG by Y-shaped end-to-side, which clinical outcome would sufficiently benefit to the patients.

[Reevaluation of 201Tl-SPECT for patients with solitary pulmonary nodule--comparison study with biopsy method and tumor marker measurement]

We compared the differential diagnostic capabilities of 201Tl-SPECT and biopsy methods and serum tumor marker in 125 patients with solitary pulmonary lesions composed of 87 lung cancer and 38 benign lesions. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of 201Tl-SPECT were 76%, 95%, 97%, 63%, and 82%, respectively. These parameters are similar in biopsy methods. Although sensitivity improved to be 85% by the combination with tumor marker methods, both specificity and accuracy deteriorated to be 55% and 76%. Using combination method with 201Tl-SPECT and biopsy, sensitivity, NPV and accuracy improved to be 84%, 70% and 85%. Based on its high PPV value, 201Tl-SPECT could be useful when biopsy method could not prove lung cancer or in case whose biopsy is considered to be invasive. Because of the lower NPV value owing to false negative cases in some adenocarcinoma, negative 201Tl-SPECT case should be followed up carefully.

[A case of lupoid hepatitis satisfying criteria for systemic lupus erythematosus associated with psychosis]

A 26-year-old female was admitted to our hospital because of arthralgia and general fatigue. On examination, she had malar rash and arthritis. Laboratory data revealed AST, ALT and gamma-globulin elevation, antinuclear antibody and double-stranded DNA antibody positivity, and LE cell phenomenon. Liver biopsy showed marked lymphocytic infiltration and slight fibrosis in the portal areas. She was diagnosed with lupoid hepatitis, and also satisfied the criteria for SLE including malar rash, arthritis, immunologic disorder and antinuclear antibody. She was administered prednisolone, after which AST and ALT decreased. She developed psychosis and her electroencephalogram showed diffuse slow waves corresponding to psychosis by SLE. Lupoid hepatitis is frequently associated with various systemic manifestations. However, only a few cases of lupoid hepatitis satisfying the criteria for SLE associated with psychosis have been reported.

C-type natriuretic peptide concentrations in the plasma and cerebrospinal fluid of patients with subarachnoid hemorrhage

BACKGROUND

Cerebral vasospasm is a poor resulting outcome of a ruptured cerebral aneurysm; to clarify the mechanism of vasospasm it is important to improve this outcome. C-type natriuretic peptide (CNP) is present in the brain as a cerebral vasodilator; it is also an endothelium-derived relaxing factor produced via cGMP. We speculated that CNP might be an inhibitor of cerebral vasospasm after subarachnoid hemorrhage (SAH).

METHODS

To clarify the role of CNP in cerebral vasospasm after SAH, we conducted 1 week monitoring of CNP concentrations in the plasma and cerebrospinal fluid (CSF) of 26 patients who had undergone clipping within 24 hours of the occurrence of SAH, and divided them into group A (positive for angiographic spasm) and group B (negative for angiographic spasm). We also examined CNP concentrations in the CSF of patients who were receiving spinal anesthesia for small orthopedic operations, as reference patients.

RESULTS

The CNP concentration in the CSF on day 1 was higher than in the reference patients and decreased in both test groups, but we did not observe any significant difference between the groups. CNP concentrations in the plasma did not change in either group.

CONCLUSIONS

CNP concentrations in the CSF were high in the acute phase after SAH, whereas plasma CNP concentrations remained constant. However, our findings did not support our hypothesis because we did not find any relationship between vasospasm and changes in CNP concentrations in the CSF.

Comparison of bacterial community structures in the rhizoplane of tomato plants grown in soils suppressive and conducive towards bacterial wilt

It has been reported that the growth of Ralstonia solanacearum is suppressed at the rhizoplane of tomato plants and that tomato bacterial wilt is suppressed in plants grown in a soil (Mutsumi) in Japan. To evaluate the biological factors contributing to the suppressiveness of the soil in three treated Mutsumi soils (chloroform fumigated soil; autoclaved soil mixed with intact Mutsumi soil; and autoclaved soil mixed with intact, wilt-conducive Yamadai soil) infested with R. solanacearum, we bioassayed soil samples for tomato bacterial wilt. Chloroform fumigation increased the extent of wilt disease. More of the tomato plant samples wilted when mixed with Yamadai soil than when mixed with Mutsumi soil. Consequently, the results indicate that the naturally existing population of microorganisms in Mutsumi soil was significantly able to reduce the severity of bacterial wilt of tomato plants. To characterize the types of bacteria present at the rhizoplane, we isolated rhizoplane bacteria and classified them into 22 groups by comparing their 16S restriction fragment length polymorphism patterns. In Yamadai soil a single group of bacteria was extremely predominant (73.1%), whereas in Mutsumi soil the distribution of the bacterial groups was much more even. The 16S rDNA sequence analysis of strains of dominant groups suggested that gram-negative bacteria close to the beta-proteobacteria were most common at the rhizoplane of the tomato plants. During in vitro assays, rhizoplane bacteria in Mutsumi soil grew more vigorously on pectin, one of the main root exudates of tomato, compared with those in Yamadai soil. Our results imply that it is difficult for the pathogen to dominate in a diversified rhizobacterial community that thrives on pectin.

Heterotopic nasopharyngeal brain tissue associated with cleft palate

OBJECTIVE

The occurrence of extracranial brain tissue is rare. Most of the literature describes cases in which it is located around the nose and throat and has been classified as nasal glioma. Even more unusual is heterotopic brain tissue in the nasopharynx. We were able to find only 17 previously reported cases. Of these 17 cases, 6 had heterotopic brain tissue located in a cleft palate. This report comments on the identification and treatment of heterotopic brain tissue associated with cleft palate without connection to the central nervous system. Our case subject is a 10-month-old girl diagnosed with heterotopic nasophranygeal brain tissue associated with cleft palate.

RESULTS

Excision and palatoplasty were performed conjunctively with excellent results.

CONCLUSIONS

Simultaneous excision of heterotopic nasopharyngeal brain tissue and palatoplasty of the cleft palate is an excellent option for treatment of these cases.

Cloning of cellulose synthase genes from Acetobacter xylinum JCM 7664: implication of a novel set of cellulose synthase genes

Three sets of cellulose synthase genes were cloned from a cellulose-producing bacterium Acetobacter xylinum JCM 7664. One set of genes (bcsAI/bcsBI/bcsCI/bcsDI) were highly conserved with the well-established type I genes in other strains of A. xylinum, while the other two (bcsABII-A, bcsABII-B) were homologous to the known type II (acsAII). Unexpectedly, they were immediately followed by a gene cluster of bcsX/bcsY/bcsCII/ORF569, likely forming an operon. Western blotting demonstrated that the BcsY protein accumulated in cells. Since BcsY showed striking similarities to a number of membrane-bound transacylases, it was hypothesized that the type II cellulose synthase produces acylated cellulose, which might be anchored on the cytoplasmic membrane. An insertion sequence of IS1380-type was found just upstream of the one type II gene (bcsABII-B), suggestive of nonfunctioning.

Detection of DNA damages and repair in human culture cells with simulated space radiation

DNA damages and its repair of cultured WI38 human fibroblast cells and T98G human glioblastoma cells were studied by exposing to carbon ion beams of HIMAC accelerator. The exposed cells were incubated at 37 degrees C for appropriate intervals and the damages were analyzed by alkaline comet assay and quantitative RT-PCR with p53 mRNA. Highly inhomogeneous DNA damages were observed among the electrophoretic cell images of the comet assay. The degree of the damages was analyzed semi-quantitatively by using the Comet Index. The damaged fraction of WI38 cells was 85% immediately after 4 Gy (100keV/micrometer) irradiation and decreased to 50% after 120 min. incubation indicating a repair of cell DNA. Time dependent p53 gene expression as also analyzed by the quantitative RT-PCR method.

[A fatal case of streptococcal toxic shock-like syndrome probably caused by acupuncture]

A 41-year-old male received acupuncture in the right shoulder for the sake of arthralgia. Three days after acupuncture he was admitted due to severe epigastralgia. Erythematous change and swelling were observed around the right shoulder. A study by magnetic resonance showed an increased signal intensity in a portion of the right subscapular muscle. Four hours after admission he became hypotensive. The erythematous and necrotic change in the right shoulder skin rapidly spread. Excisional debridement in the right lateral chest wall was immediately done. However, the patient died one day after admission despite administration of a high-dose ampicillin and other supportive therapies. Bacteriological and histological examinations confirmed severe streptococcal myositis. This is a case report of toxic shock-like syndrome probably caused by acupuncture.

Expression of bcl-6 protein in normal skin and epidermal neoplasms

Bcl-6 protein is a recently identified novel transcription factor whose deregulated expression is associated with diffuse large B cell lymphomas. It was recently shown by us that the protein is located in germinal center B cells and their neoplastic counterparts. In the present study, the expression of bcl-6 protein on normal epidermis, benign, and malignant tumors originating from epidermal cells, and squamous cell carcinoma (SCC) cell lines are investigated. With the use of immunohistochemistry, bcl-6 protein was shown to stain intensely on normal prickle cells, but none to only slightly on epidermal basal cells. Papillomas and keratoacanthomas copied their normal counterparts in the mode of expression. Various levels of expression were found on seborrheic keratoses, while the expression level on basal cell epitheliomas was low. Peculiarly, eccrine poromas and undifferentiated spindle-shaped basal cell epitheliomas were totally unstained. Squamous cell carcinomas showed a variety of expression levels, while two undifferentiated spindle-shaped carcinomas and one undifferentiated SCC cell line remained unstained. These results suggest that the expression of bcl-6 protein may be associated with morphological differentiation in normal and neoplastic epidermal cells.

Regulation of BCL-6 gene expression in human myeloid/monocytoid leukemic cells

We demonstrated in the present study that the BCL-6 transcripts were detectable not only in B cells, but also in circulating granulocytes and monocytes from normal individuals, and in human acute nonlymphocytic leukemia cells of certain subtypes (M3, M4, M5). Then, with an assumption that the BCL-6 gene expression may be related to the differentiation of myeloid cells, we analyzed the inducibility of BCL-6 gene expression along monocytic lineage differentiation in HL-60 and U-937 cells by treating them with 12-O-tetradecanoylphorbol-13-acetate (TPA). Although the expression of BCL-6 transcripts was very low or undetectable in untreated HL-60 or U-937 cells, treatment of these cells with TPA to induce monocytic differentiation resulted in an apparent increase of BCL-6 mRNA, suggesting that BCL-6 gene expression is not limited to B cells and it is closely associated with monocytic lineage differentiation. The BCL-6 transcripts in TPA-treated U-937 cells were superinduced by the treatment with cycloheximide (CHX) and the half-life of the BCL-6 mRNA was apparently prolonged when TPA-treated U-937 cells were exposed to CHX in the presence of actinomycin D (ACD). Furthermore, the nuclear run-on assay revealed that the BCL-6 transcription signals were enhanced by TPA treatment. These results suggest that the increase of BCL-6 mRNA in U-937 cells stimulated with TPA to induce monocytic lineage differentiation is mediated by both transcriptional and post-transcriptional regulation.

A new cleft palate repair

Cleft palate can be repaired by a palatal mucoperiosteal flap, but we have devised a new technique for cleft palate repair using a wide mucoperiosteal flap with an alveolar ridge mucosa and a cleft margin flap. This technique leaves the mucosa of the nasal cavity and vomer intact. The results include (1) good velopharyngeal competence and normal articulation, (2) few cases of fistula formation, and (3) minimal maxillary retardation.

Congenital bilateral zygomatico-mandibular fusion with mandibular hypoplasia

We report a very rare case of congenital bilateral zygomatico-mandibular fusion with mandibular hypoplasia. Soon after birth, the patient underwent tracheotomy because of upper airway obstruction. At the age of one and a half years, reconstruction of the temporomandibular joint and lengthening of the ramus with a costochondral graft were performed. Only a few cases of congenital bony syngnathia revealed in this case have been described in the literature.

Influence of boiling water treatment on surface roughness and surface microstructure of set gypsum (dental stone)

The influence of boiling water treatment on the surface roughness and surface microstructure of set gypsums was investigated. Typical surfaces before and after immersion in boiling water were compared by means of SEM observation, the Knoop hardness test, and a surface roughness test. The surfaces of set gypsums were rougher than that of an acrylic resin plate, and after immersion in boiling water, highly roughened surfaces and thinner crystal bodies were observed on each specimen under SEM. The knoop hardness of set gypsums was considerably lowered after boiling water immersion. That of die stones was the same or lower than set dental stones. The results showed that even brief immersion in boiling water had profound effects on the dental stone cast, resulting in rougher surfaces and lower hardness of set gypsums.

A mirror image of the first and second branchial arch syndrome associated with cleft lip and palate in monozygotic twins

A rare case of monozygotic twins revealing a mirror image of the first and second branchial arch syndrome with accessory ear and hemifacial microsomia, associated with unilateral cleft lip and palate, is presented. Although the concordance and/or discordance rate of monozygotic or dizygotic twins with cleft lip and palate is well reported, that of twinning of the first and second branchial arch syndrome has been very rarely described. First and second branchial arch syndrome occurs sporadically but cleft lip and palate are strongly related to the influence of environmental factors with a considerable hereditary tendency. The study of twinning of congenital anomalies is important in the investigation of the pathogenesis of genetic and environmental effects. The twins were diagnosed as monozygotic with almost complete certainty by ABO blood typing, HLA typing, finger prints, and DNA typing. Concordance was noticed, which suggests a hereditary tendency. Since concordance in these monozygotic twins was exhibited by a precise mirror image of first and second branchial arch syndrome, spinal scoliosis and cleft lip and palate, it is possible that an environmental factor induced these complex anomalies.

BCL-6 gene product, a 92- to 98-kD nuclear phosphoprotein, is highly expressed in germinal center B cells and their neoplastic counterparts

The BCL-6 gene is known to be located on chromosome 3q27, at the breakpoint of the 3q27-associated translocations that occur frequently in human non-Hodgkin's lymphomas (NHLs). To identify the BCL-6 protein, two antibodies that recognized distinct domains of this protein were raised in rabbits. Immunoprecipitation and immunoblotting of lysates of BCL-6-expressing cells using both antibodies showed a broad 92- to 98-kD band. Dephosphorylation of BCL-6 protein reduced the size of this band to 87 kD, suggesting that BCL-6 may be expressed in a phosphorylated form. Immunostaining with both antibodies showed that BCL-6 protein was localized in the nuclei of most of the germinal center B cells and a small number of marginal zone B cells. Furthermore, BCL-6 protein was expressed in follicular, Burkitt's, and diffuse large B-cell lymphomas. These results suggest that the BCL-6 protein, expressed in B cells of the germinal centers which are important in the maturation of immune responses, may play some physiological role(s) in the germinal center B cells.

Treatment of nevus Ota by liquid nitrogen cryotherapy

Nevus Ota is a disfiguring facial dermal melanosis that is observed rarely in Caucasians but is common in Asians. Until recently, carbon dioxide snow cryotherapy had been used most frequently to treat this disorder, but the results were not always satisfactory and often left scarring after treatment. During the past 15 years, we have treated a total of 600 cases of dermal pigmentary facial disfiguration using CRYO-MINI, a liquid nitrogen cryogenic instrument with a removable disk-shaped copper tip. We have found this method to be simple and extremely effective in the treatment of nevus Ota and senile lentigines, and it is also useful for treatment of delayed nevus spilus and blue nevus. This report presents our techniques and experiences as well as the results achieved with four patients who have a deeply situated type of nevus Ota. Associated problems to be considered in future treatment are discussed also.

Our mini-facelift for Orientals

Facelifts are classified into (1) the extra skin facelift in which redundant skin around the ear is excised without skin undermining, (2) the mini-facelift in which cheek skin is undermined up to the lateral side of the canthus, (3) the radical facelift in which subcutaneous undermining is done up to the nasolabial groove, and (4) the total facelift that includes forehead, eyelids, lips, chin, and so on. The authors checked the results of each facelift by measuring width of the preauricular that was excised. They report that the mini-facelift for Orientals yields the same results but less complications when compared with other facelift procedures except for the total facelift. The authors explain their mini-facelift technique and also the differences in the skin thickness, skeleton, and so on, between Caucasians and Orientals which influence the results of the facelift.

[IgD myeloma with skin tumor]

A 66-year-old man was treated for IgD (lambda) multiple myeloma with 2mg/day melphalan and 20mg/day prednisolone. Subsequently, he developed pneumonia for which he received antibiotics, an antifungal agent and granulocyte colony-stimulating factor (G-CSF) twice. Myeloma cells appeared in the peripheral blood 10 days after the second G-CSF course. In addition, skin tumors developed on his extremities and chest 14 days after the second use of G-CSF. The skin tumors consisted of immunohistochemically IgD (lambda)-positive myeloma cells. The skin tumors may have been formed from the bone marrow by metastasis, a very rare occurrence in multiple myeloma. Before the development of the tumors we administered G-CSF, which may also have been related to the formation of the skin tumors.

Ankyloblepharon, ectodermal dysplasia, cleft lip and palate (AEC) syndrome: surgical corrections with an 18-year follow-up including maxillary osteotomy

A rare case of AEC syndrome is presented. Surgical corrections and an 18-year follow-up, including maxillary advancement osteotomy, are described.

[Experience with atrioventricular valve replacement in infants and children]

From 1980 to 1989, nine infants and children underwent valve replacement. These replacements consisted of seven mitral valve replacement (MVR), one left atrioventricular valve replacement, and one aortic valve (AVR) replacement. We excluded AVR from this report. Follow-up period of 8 cases were 68 months in an average. During this period, 2 cases were not thought to be satisfactory as antithrombotic therapy, in which one revealed malfunctioning prosthesis, and secondary MVR implantation was performed. Another one is free from any complications. We experienced the difficulty of antithrombotic therapy following valve replacement in infants and children. It is supposed that combined use of anticoagulant therapy agent and antiplatelet agent may be necessary as antithrombotic therapy, especially in childhood.

A new osteotomy for genioplasty--stepped osteotomy: preliminary report

A new osteotomy for genioplasty, stepped osteotomy, is described. This osteotomy is a combination of horizontal and sagittal osteotomy of the mandibular symphysis. It consists of horizontal osteotomy at a distance of 3 to 4 mm below the apexes of the anterior teeth, connecting at right angles with the conventional horizontal osteotomy below the mental foramen, making a step-fashioned osteotomy of the chin. This procedure is particularly advantageous in simultaneous elongation and advancement genioplasty because the central portion between the apexes of the anterior teeth and the conventional horizontal osteotomy line is available as augmentation and the bony contact of the osteotomized mandible can be retained in elongating the chin. The characteristics of this procedure are described and typical patients are shown.

[Successful treatment with deferoxamine in a case of refractory anemia]

A 60-year-old female was admitted to our hospital because of macrocytic anemia with anisopoikilocytosis and thrombocytopenia. A bone marrow aspiration revealed hypolasia with nuclear deformity of neutrophils and decrease of megakaryocytic numbers. Karyotype analysis showed 47, XX, +8. A diagnosis of refractory anemia was made. The patient was treated with metenolone acetate without clinical response. Deferoxamine (2g/day) was given intravenously by continuous infusion. Ten days after deferoxamine treatment, the levels of RBC and platelet increased and the effect lasted 100 days after discontinuance of deferoxamine. Bone marrow aspiration showed normoplasia with normal megakaryocytes numbers. However, anisopoikilocytosis, abnormality of MCH and MCHC, and karyotype abnormality similar to the first medical examination remained. These data might suggest that deferoxamine induced differentiation of abnormal hemopoietic cells in refractory anemia. Retrobulbar neuritis which developed 30 days after initiation of treatment disappeared after halting deferoxamine treatment.

[Parapsoriasis en plaque suspected of progression to mycosis fungoides associated with extranodal malignant B cell lymphoma of the cheek]

A 59-year-old female, clinically diagnosed as having parapsoriasis en plaque for ten years, was referred on June 1991 to the Department of Oral Surgery in the Dental School of showa University with a complaint of painless swelling of the left malar area. The swelling was found to have been caused by a tumor. Since the excised tumor was suspected to be a malignant lymphoma, she was admitted to our hospital. The specimen was subsequently confirmed to be a malignant lymphoma of the diffuse large cell type according to the LSG classification, and was immunologically confirmed to be a B cell lymphoma. In addition, the excised skin was suspected of incipient mycosis fungoides. She was classified as having stage IE disease according to her bone marrow biopsy and other examinations. she was treated with combination of chemotherapy (CHOP) and radiation therapy. This subject was interesting because her tumor probably resulted from a parapsoriasis en plaque skin lesion.

Use of a free conchal cartilage graft for closure of a palatal fistula: an experimental study and clinical application

In order to establish an operative procedure for the closure of palatal fistulas, the usefulness of free conchal cartilage grafts was confirmed through animal experiments, and a clinical application of this procedure was attempted. In the animal experiment, an oronasal penetrating fistula 10 mm in diameter was formed in the hard palate of 33 rabbits. One month later, the size of the palatal fistula decreased to 2 to 3 mm in diameter in all the rabbits. These rabbits were divided into two groups. Group 1 (n = 8) was used as a control group. In group 2 (n = 25), the palatal fistula was closed by an autograft of conchal cartilage, and the conchal cartilage graft site was observed for a period of 16 weeks. In 75 percent (6 of 8) of group 1, the palatal fistula persisted even after 1 year, but in 96 percent (24 of 25) of group 2, the palatal fistula was closed. The palatal fistula closure procedure using a conchal cartilage graft was found to be remarkably effective (chi 2c = 10.9, p < 0.001). In the clinical application, a fistula closure procedure with the use of conchal cartilage grafts was attempted in 24 patients with palatal fistulas. The procedure was modified into three types according to the size of the palatal fistula. For type I (diameter less than 2 mm) a conchal cartilage graft was created as in the animal experiment. For type II (2 to 5 mm in diameter), a palatal fistula closure procedure was used employing both a small hinge flap and a conchal cartilage graft.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative study of reverse flow island flaps in the lower extremities--peroneal, anterior tibial, and posterior tibial island flaps in 25 patients

The reverse flow island flap is one of the most versatile reconstructive procedures in the lower extremity. There are three major arteries, the peroneal, the anterior tibial, and the posterior tibial artery, and a reverse flow island flap pedicled by each vessel and its intermuscular cutaneous perforators is available. Twenty-five reverse flow island flaps were clinically applied for soft tissue defects in the lower leg (10 peroneal, 8 anterior tibial, and 7 posterior tibial flaps). We report a comparative study of the characteristics and indications of the peroneal, anterior tibial, and posterior tibial reverse flow flaps. We conclude that the anterior tibial reverse flow flaps are more likely, without venous anastomosis, to become congested and necrose than the peroneal and posterior tibial flaps.

[Testicular relapse, with Ph-positive chromosome after bone marrow transplantation for acute lymphocytic leukemia]

A 25-year-old man with acute lymphocytic leukemia (ALL) had received bone marrow transplantation (BMT). Testicular relapse occurred 6 months after BMT as the first relapse, and couple of weeks later, bone marrow relapse developed. At that time, karyotypic analysis showed Ph-chromosome which was not observed before the first remission and DNA analysis revealed rearrangements of minor BCR, IgL, IgH, TCR and TCR genes. Testicular relapse often develops in ALL of children after BMT. However, some reports, including this report, indicate that testicular relapse following BMT can also occur in adults, so that the incidence of testicular relapse could be reduced either by total body irradiation (TBI) or testicular irradiation before transplantation. Incidence of Ph-positive chromosome following BMT is a key to illuminate the mechanism of the Philadelphia chromosome. Rearrangements of Ig and TCR gene can be considered as an abnormal gene rearrangement occurring at an early stage of B cell proliferation.

Aesthetic camouflage of bilateral cleft lip scars: technical revisions

We have attempted to change the two scar lines of bilateral cleft lip repair into one zigzag scar line. The prolabium is used to push up the columella and the nasal tip. The donor site of the prolabium is closed by transposition of the nasolabial flap. The postoperative scar shows one zigzag line at the center of the lip. This method has many advantages including an inconspicuous scar, repair of the short columella and flat nasal tip, repair of a wide nose, and repair of the whistling deformity. Complications of this method are maxillary retardation, long lip deformity, and keloid formation. However, these can be avoided by modifying the method.

[Treatment of hemobilia after percutaneous transhepatic cholangiography and drainage (PTCD)]

PTCD was performed in 206 of our patients during the past 6 years and 7 months. Of the 206, hemobilia occurred in 14 patients (6.8%). The hemorrhage was completely stopped by irrigation of the bile duct in 3 patients, compression with a larger catheter in 7 patients, and transcatheter anterior embolization (TAE) in 4 patients. TAE was performed on the patients whose hemobilia could not controlled by the compression with a larger catheter. In TAE, either a steel coil or a sponge was used as an embolus. Rebleeding occurred in one patients for whom the right hepatic artery was chosen as a embolization site. Therefore, it was decided that the embolization was going to be done in all the hepatic arteries when the blood stream in the portal vein and preserved functions of the liver of the subjected patients including the one with rebleeding were fully normal. A complete control of the hemorrhage was obtained in all patients. The PTCD root caused hemobilia was removed after TAE in considering the possibility of rebleeding from the root, and a new PTCD root was made.

Thyroid papillary adenocarcinoma in a woman with Peutz-Jeghers syndrome

We present a rare case of Peutz-Jeghers(P-J) syndrome in a 29-year-old woman who developed adenocarcinoma of the thyroid and polyps in the gastrointestinal tract. Polyps removed from the stomach, colon and ileum showed features typical of hamartomas. Histological examination indicated that the tumor resected from the right lobe of the thyroid was a papillary adenocarcinoma. This appears to be the first precise report of a P-J syndrome associated with thyroid carcinoma. This case adds an example of predisposition of P-J syndrome to extra-intestinal malignancy and indicates the importance of long-term observation of malignancy.

A modified Le Fort I osteotomy for maxillofacial deformity: a preliminary report

A new technique of Le Fort I osteotomy using a wedge-shaped bony incision is described. After forward mobilisation of the osteotomised maxilla, the bone graft is held firmly in contact under some compression between the maxilla and the mobilised wedged portion to achieve greater stability. This is a very effective technique for those maxillary osteotomies which need bone graft stabilisation, such as in cleft lip and palate patients.