Risk factors for cellulitis in patients with lymphedema: a case-controlled study.

Risk factors for cellulitis in lymphedema (LE) have never been evaluated in controlled studies. The objective of this study was to assess the risk factors for cellulitis in patients with LE using a case-controlled study method. Medical records of patients from November 2009 to September 2011 who met the following criteria were retrieved and analyzed: (a) clinical diagnosis of LE of the limb, (b) aged 18 or above, (c) no food allergy history and (d) no medical diagnosis of cancer metastasis. Overall, there were 179 cases of LE with cellulitis. Each case was matched by age (+/- 5 years) and gender with a patient with LE and without cellulitis for controls. Logistic regression with backward selection procedure was used to identify independent risk factors. The area under the receiver operating characteristics (ROC) curve of the final model was calculated. Independent risk factors for cellulitis in patients with LE were percentage difference in circumference of the limb (adjusted odds ratio (AOR)=1.07, 95% confidence interval (CI)=1.04-1.10), primary LE diagnosis (AOR=3.36, 95% CI=1.37-8.22), food-induced complication experiences (FIE: AOR=6.82, 95% CI=2.82-16.51) and systolic blood pressure (AOR=1.02, 95% CI=1.01-1.04). The area under the curve for the model was 0.80 (95% CI=0.75-0.85, p<0.001). No association was observed with hypertension, diabetes mellitus, body mass index and the duration of LE. This first case-controlled study highlights the important roles of dietary factors, percentage difference in circumference of the limb, and systolic blood pressure for developing cellulitis. The results suggest that controlling the percentage difference in circumference of the limb and systolic blood pressure together with restriction of fatty food and meat consumption may result in a decreased incidence of cellulitis among patients with LE.

The isolated artery: an intrahepatic arterial pathway that can bypass the lobular parenchyma in mammalian livers.

Controversy persists concerning the distribution of intrahepatic arterial termination. Apart from nourishing structures in the portal tract, several authors have suggested arterial supply to some isolated vascular beds that bypass the parenchyma, but this was not verified morphologically. In the present study, the existence of an isolated hepatic artery unaccompanied by a portal vein or a bile duct was shown in livers of pigs and other mammals including the dog, seal, ox, horse, and man. After colored media injection, liver blocks were sampled near the hepatic capsule and hepatic vein and subject to histologic assessment. The hepatic artery dissociated from superficial portal tract, ramified, and anastomosed extensively, forming a capsular plexus that drained at places into peripheral sinusoids in which resistive structural elaborations were observed. The artery also dissociated and fed an intramural plexus (vasa vasorum) of hepatic veins. This was collected into a vessel that penetrated the intima into the vein's lumen. In smaller sublobular veins, the plexus emptied into adjacent sinusoids; in central veins, the plexus was poorly developed. In canine and phocine livers, which have a special throttling musculature in sublobular veins, the isolated arterioles were numerous; in bovine and equine livers, which have a thick fibrous investment, the capsular plexus was well-developed. Occurrence of the isolated artery also was confirmed in the human but not in the rodent liver. In conclusion, the isolated artery is responsible for isolated vascular beds, in which the transintimal pathway can bypass the lobular sinusoids.

In vivo and electron microscopic observations of the responses of the hepatic sinusoid to interleukin-1.

Interleukin-1 (IL-1), which is produced by Kupffer cells and sinusoidal endothelial cells, may play an important role in immunological and microvascular responses to a variety of stimuli in the liver. The responses of the hepatic microvasculature including phagocytic activity of sinusoidal lining cells to IL-1 alpha were examined in C57Bl/6 mice in vivo and using electron microscopy. One hour after recombinant mouse IL-1 alpha was injected at doses of 80 U, the low dose group, and 800 U, the high dose group, the phagocytic activity of sinusoidal lining cells showed significant differences between the two treated groups and between the two groups and the controls. In the low dose group, the numbers of sinusoids containing blood flow and of leukocytes adhering to the sinusoidal lining remained unchanged, but the former decreased and the latter increased significantly in the high dose group. Ultrastructurally, Kupffer cells that phagocytosed latex particles appeared to have decreased in number while the sinusoidal endothelial cells became phagocytic. A considerable number of leukocytes were seen adhering to the sinusoidal endothelium. These findings demonstrate that IL-1 alpha not only elicited sticking and plugging by leukocytes in sinusoids but also activated phagocytic functions in the hepatic sinusoidal endothelial cells. These endothelial responses are similar to those seen following FV3 virus infection, chronic administration of ethanol, or a combination of cocaine and ethanol, or during extracorporal perfusion, suggesting that IL-1 may participate in these responses.

Liver microvascular architecture: an insight into the pathophysiology of portal hypertension.

Structural adaptations in the liver to constantly receive and release a large volume of circulating blood at low pressure are present at many levels; alteration of these structures can modify flow and perturb pressure gradients. Liver growth multiplies the lobule number by a factor of 4-5 after birth. Lobule configuration conforms with observations in space division, each unit being bordered by planes; curvature will impede expansibility and retractability among units. Lobular organization with hepatocytic plates and sinusoids, being radial centrally and reticular peripherally, maximizes its reversible distensibility. Resistance sites in the portal, sinusoidal, and hepatic system are subject to species variations; real portal sphincters are photographed in the frog. Small venules are demonstrably resistive. In endothelin-1-induced rat portal hypertension, the distal segment of preterminal portal venules constricts most intensely, whereas the terminal portal venules and sinusoids are flaccid. Their pericytes and arachnocytes (stellate cells, Ito cells, retinol-storing cells), respectively, possess no effective contractile machinery. In the dog, the initial sublobular veins react with venoconstriction to many stimulations. Well-developed musculature in hepatic veins, as in man and pig, can regulate flow by junctional constriction. These histoarchitectonics provide hepatic hemodynamics with high capacitance and high compliance properties. The hepatic artery supplies oxygenated blood to five stromal compartments: peribiliary vascular plexus, portal tract interstitium, portal vein vasa vasorum, hepatic capsule, and central-sublobular-hepatic vein vasa vasorum. Its role as the nutrient vessel to the veins is established, but what influence it may have in the pathophysiology of portal hypertension awaits clarification.

Zonal and regional differences identified from precision mapping of vitamin A-storing lipid droplets of the hepatic stellate cells in pig liver: a novel concept of addressing the intralobular area of heterogeneity.

Knowledge of hepatic heterogeneity has been strikingly increased, while an accurate means for addressing intralobular positions is still lacking. We examined pig liver preparations of the gold impregnation method for vitamin A-storing lipid droplets in hepatic stellate cells. Droplet morphometry was performed under oil immersion, and the calculated volumes plotted on computerized maps. The heterogeneous results were assessed with five concentric zones and five radial regions; the latter were determined based on midseptum visualized by portal injection. Zonation and regionation thus subdivided lobules into 5-zone/5-region (5Z/5R) compartmentalization. Distribution of values exhibited a distinct zonal gradient, heightened at peripheral zones 1 and 2, decreased over intermediate zone 3 toward centrilobular zones 4 and 5; peak was always found at zone 2. Within a single zone, variations were obvious, forming a regional gradient. Values were significantly higher at periportal than midseptal regions. Digitized mapping showed that low values filled up centrilobular zones, whereas high values concentrated in periportal regions. Along the periphery, inlet venules were quantified, revealing an occurrence rate of 60% at periportal, and 5% at midseptal regions, closely compatible with the regional gradient of vitamin A-storing capacity. The interweaving between zonal and regional gradients results in a vitamin A-low territory, a compound area composed of centrilobular zones plus extensions into midseptal regions. Because the results could account for physiological and pathological events, we regard the 5Z/5R compartmentalization a model worth routine adoption for a precise description of any morphofunctionally demonstrable heterogeneity of the liver lobules.

Endothelin-1-induced vasoconstriction causes a significant increase in portal pressure of rat liver: localized constrictive effect on the distal segment of preterminal portal venules as revealed by light and electron microscopy and serial reconstruction.

Intraportal infusion of endothelin-1 (ET-1), a potent vasoconstrictor, significantly elevates portal venous pressure. To determine the major site of vascular constriction in the intrahepatic porto-sinusoidal system, we performed an in situ perfusion of rat livers with 1 nmol/L ET-1 at a flow rate of 20 mL/min. Portal pressure rose from 22 cm H2O to 54 cm H2O within 25 minutes. Specimens were prepared for light-microscopic serial reconstruction and electron microscopy. The distal segment of preterminal portal venules (DS/PPV) with an inner diameter of 40 to 80 microm showed complete obliteration of the lumen over a 300-microm distance caused by the intense contraction of perivascular smooth muscle cells and protruding of endothelial cells into the lumen. The proximal segment of preterminal portal venules (PS/PPV) with a larger diameter up to 150 microm also underwent strong constriction, but still had luminal space for the flow, while the PS/PPV with a diameter of 150 to 400 microm showed moderate or mild constriction and retained a wide lumen. Neither terminal portal venules, inlet venules, sinusoids, nor central veins, however, exhibited demonstrable constriction. Liver parenchyma fed by the inlet venules that emerged from the PS/PPV exhibited a wide sinusoidal lumen and vacuolated hepatocytes caused by the influx of excess portal perfusate that escaped from the occlusive areas. The present study has revealed that the DS/PPV functions as a presinusoidal quasi-sphincter mechanism and is involved in the redistribution of intrahepatic portal flow under increased portal pressure.

Expression of neuron-specific enolase in the pineal organ of the domestic fowl during post-hatching development.

Immunohistochemistry for neuron-specific enolase (NSE) revealed that NSE is localized in both a limited number of pinealocytes and intrinsic afferent neurons in the pineal organ of the domestic fowl. Furthermore, a computer-assisted three-dimensional imaging technique allowed to clarify the reverse distributional pattern of both elements: NSE-positive pinealocytes displayed a dense distribution especially in the vesicular portion of the gland, whereas NSE-immunoreactive nerve cells were mainly found in the pineal stalk. The number of NSE-positive intrinsic neurons in the pineal organ of chickens decreased rapidly after hatching, with a concentration of these elements in the basal portion (stalk) of the pineal organ. On the other hand, immunoreactive pinealocytes increased remarkably in the end-vesicle of the organ with age, followed by a gradual expansion toward the proximal portion. Thus, the spectacular increase in NSE-positive pinealocytes and the progressive reduction of reactive neurons occurred in parallel during the course of post-hatching development. NSE-immunoreactive pinealocytes displayed morphological characteristics of bipolar elements, endowed with an apical protrusion into the pineal lumen and a short basal process at younger stages, whereas multipolar types of NSE-positive pinealocytes were predominantly found in the adult domestic fowl. These results indicate that in the pineal organ of the domestic fowl (1) the ontogenetic expansion of NSE-immunoreactive pinealocytes is paralleled by a regressive afferent innervation, (2) the NSE-positive pinealocytes transform from a bipolar (columnar) type to a multipolar type during post-hatching development, and (3) these ontogenetic changes in the NSE-immunoreactivity and morphology of pinealocytes may reflect the development of a neurosecretory-like capacity of the organ.

Role of endotoxin in the hepatic microvascular inflammatory response to ethanol.

Kupffer cells (KC) and gut-derived bacterial endotoxin have been implicated in the aetiology of alcoholic liver disease. Using in vivo microscopic methods, we have shown that ethanol ingestion in mice causes a dose dependent increase in leucocyte adhesion and endothelial cell swelling in hepatic sinusoids. Activation of KC is elicited at low doses while depression occurs at high doses and with chronic exposure. The responses are exacerbated in the presence of endotoxaemia or sepsis and are not seen in endotoxin-resistant animals, implicating a role for endotoxin in the ethanol-induced inflammatory response. In addition, the responses are abolished with anti-TNF alpha suggesting that TNF alpha is a primary mediator of these events. Nitric oxide (NO) initially appears to play an important role in these events by stabilizing the TNF alpha-mediated hepatic microvascular inflammatory response to acute ethanol ingestion, thereby helping to protect the liver from ischaemia and leucocyte induced oxidative injury. Finally, an ongoing clinical study has confirmed a mild systemic endotoxaemia in patients hospitalized for alcoholic liver disease. All of these results support important roles for endotoxin, cytokines, nitric oxide and sinusoidal lining cells in the pathophysiology of liver injury resulting from ethanol alone or in combination with infection.

Ethanol exacerbates hepatic microvascular dysfunction, endotoxemia, and lethality in septic mice.

The effect of acute ethanol administration on the hepatic microvascular responses to sepsis was studied. Polymicrobial sepsis was induced 30 min after mice had received ethanol (1 g/kg b.w.) or isocaloric maltose-dextrin by gastric gavage. Lethality within 24 h was 91.7% in the ethanol-treated animals and 40.0% in septic controls. Endotoxin levels in ethanol treated animals were 107 pg/ml at 6 hr and 1205 pg/ml at 12 h, compared with 32 pg/ml and 104 pg/ml, respectively in the controls. In vivo microscopy revealed that at 3 h in the ethanol treated septic animals, Kupffer cell phagocytic activity was increased by 41%, whereas the number of sinusoids containing blood flow were reduced by 34% concomitant with a 144% increase in the adherence of leukocytes to the sinusoidal walls when compared with the septic controls. By 6 h, however, Kupffer cell phagocytic activity was reduced by 48% in the ethanol treated animals; this was accompanied by a further deterioration in sinusoidal blood flow. Thus, a small, acute dose of ethanol causes significant impairment of the hepatic microcirculation followed by suppression of Kupffer cell activity. This results in exacerbation of endotoxemia and lethality during polymicrobial sepsis.

Liver units in three dimensions: I. Organization of argyrophilic connective tissue skeleton in porcine liver with particular reference to the "compound hepatic lobule".

Liver units were investigated in pig livers by means of histologic serial tracing, physical model building, and computer-aided three-dimensional imaging. Observations of the argyrophilic connective tissue skeleton were based mainly on the celloidin-embedded serial sections treated with silver impregnation. The parenchymal mass that clothed the initial segments of hepatic venous radicles was demarcated by fibrous septa which formed isolable units with two basic patterns: the simple hepatic lobule (SHL) and the compound hepatic lobule (CHL). Both lobule types presented regular limiting structures circumscribing each unit. Three-dimensional studies revealed that 25% of the lobules in a section belonged to the SHL type and 75% to the CHL type, the latter being predominant among the surface lobules. When considered in only two dimensions, however, the SHL-like lobules constituted the majority. Polygonal analysis disclosed that the pentagonal lobule was the most typical, instead of the "hexagonal" or "classic" lobule. The CHLs represented a multiaxial unit containing a system of venous tributaries in accordance with intralobular septation, whereas the SHLs were found with one axial vessel having a dendritic tendency at the incipient end; some SHLs were drained eccentrically by separate vessels into a sublobular vein. It was observed that, in dividing CHLs, whereas particular sinosoids were transformed into portal twigs, other sinusoids were changed into central venous tributaries. Fibrous deposition occurred along the septal-line sinusoids, bringing into view the septum-initiating plane. Fibroconnective tissue was supplied from the portal area and central (sublobular) adventitia, where portal triad structures and adventitial arterioles, respectively, were included. The findings of the present study facilitate the understanding of several characters of the lobules that have been reported previously, or occasionally postulated, such as the portal-central bridging tendency, the intralobular arterioles or ductules, the translobular artery or portal vein, the "portal-portal" or "portal-central" anastomoses, and the apposition of pericentral zone close to periportal zone. Based on differences in argyrophilia of sinusoidal reticulum, in proportion of lobule types, and in vasculature, the anatomic heterogeneity of liver unit was demonstrable in zonality, regionality, and locality.

Circadian variations in trichloroethylene toxicity under a 12:12 hr light-dark cycle and their alterations under constant darkness in rats.

In order to investigate the circadian variations in acute toxicity of trichloroethylene (TRI), TRI (1.2 g/kg weight) or saline was injected intraperitoneally in a total of 88 male Wistar rats at four circadian stages (03.00, 09.00, 15.00, and 21.00:hr.min) under two different lighting regimens of a 12:12 hr light-dark cycle (LD; light from 06.00 to 18.00) and of constant darkness (DD). Circadian variations in TRI toxicity were confirmed in both LD and DD. The toxicity of TRI evaluated by the increase in glutamic-pyruvate transaminase activity (GPT) was greatest when injected at 09.00 in LD while at 21.00 in DD. The increases in blood urea nitrogen, serum total cholesterol and triglyceride concentrations reached peaks when injected at 09.00 in LD and 03.00 in DD. The circadian variations in serum trichloroethanol concentration were very similar to those in GPT in both LD and DD, showing a significant correlation (p less than 0.05). The present study revealed that circadian variations in TRI toxicity existed in LD and that these variations persisted in a free-running condition. The peak phase of TRI toxicity was located in a trough phase (09.00) in LD and in a peak phase (21.00 or 03.00) in DD of temperature rhythm. Thus, the phase relationship changed in DD, showing a desynchronization between TRI toxicity rhythm and temperature rhythm, which is an unusual phenomenon. This means that an unexpected potentiation of TRI toxicity during active phase which is not a critical phase in a well-synchronized state could occur in a free-running condition.