Segmental cutaneous leukocytoclastic vasculitis associated with herpes zoster: a case report and literature review.

Varicella zoster virus (VZV) infection may cause large or medium vessel vasculitis, including granulomatous arteritis of the nervous system and central nervous system vasculitis. However, small vessel vasculitis, such as cutaneous leukocytoclastic vasculitis (LCV) associated with localized cutaneous VZV infection, herpes zoster, is uncommon. Herein, we present the case of a 75- year-old man with segmental leukocytoclastic vasculitis associated with herpes zoster on the leg. To the best of our knowledge, there are four cases of segmental leukocytoclastic vasculitis in herpes zoster reported in the English literature; we compared our case with these previous reports. Our review of five patients suggests that most patients were immunosuppressed. We also found that the leg is susceptible to LCV associated with herpes zoster. Anti-viral treatment was effective for LCV as well as herpes zoster. Prior reports have proposed etiologies inducing LCV; for example, immune complexes are mediated by vessel wall damage. In support of this, histopathology in our case showed a C3-positive reaction with the small vessel walls in the dermis in direct immunofluorescence. Although the mechanism of LCV associated with herpes zoster remains unclear, we should consider LCV while diagnosing and treating patients with herpes zoster, especially immunosuppressed patients.

Bilateral ballism as limb-shaking transient ischemic attacks treated with unilateral carotid artery stent placement.

Bilateral limb-shaking transient ischemic attack (LS-TIA) is a rare disease involving carotid artery stenosis, characterized by ballism-like involuntary movements of the arms and legs. We describe the case report of a male patient in his 80s presented with continuous bilateral ballism in the arms and legs and tongue dyskinesia. Magnetic resonance imaging showed no ischemic lesions, while cerebral angiography revealed right internal carotid artery (ICA) occlusion and 80% stenosis of the left ICA. 99mTc-ethyl cysteinate dimer single-photon emission computed tomography demonstrated hypoperfusion in the right cerebral cortex but hyperperfusion in both basal ganglia. Left ICA stenting was performed, and involuntary limb shaking disappeared. This case report highlights the importance of accurate diagnosis and treatment of bilateral ballism as LS-TIA.

Role of VEGF and matrix metalloproteinase-9 in peritumoral brain edema associated with supratentorial benign meningiomas.

Accumulating evidence indicates that VEGF and matrix metalloproteinase-9 (MMP-9) play a central role in the development of peritumoral brain edema (PTBE) associated with human brain tumors. However, the roles of these proteins, particularly of MMP-9, in PTBE associated with benign meningiomas have not been elucidated. We investigated the association between clinical features and biological factors, such as VEGF and MMP-9, and the incidence of PTBE and edema index (EI) in 60 patients with benign meningiomas. In this study, supratentorial lesions were examined for evaluating the extent of PTBE in the surrounding normal brain tissue. VEGF and MMP-9 expression was immunohistochemically examined. Multivariate analysis revealed that the presence of pial blood supply (odds ratio [OR] 12.250; P = 0.0096) and VEGF (OR 7.683; P = 0.0155), but not MMP-9 (OR 1.178; P = 0.8113), expression are significant factors that independently predict the incidence of PTBE and influence EI. VEGF (P = 0.0397) and MMP-9 (P = 0.0057) expression correlates with the presence of pial blood supply. Moreover, tumors with high VEGF and MMP-9 expression had higher EIs than those with high expression of either (P = 0.030). Our findings suggest that MMP-9 expression was positively related to VEGF expression and pial blood supply and promoted the occurrence of PTBE by inducing the disruption of the arachnoid membrane and formation of pial blood supply.

Actual conditions of the mixing of antineoplastic drugs for injection in hospitals in Osaka Prefecture, Japan.

We conducted a questionnaire survey in order to grasp the actual conditions under which antineoplastic drugs are mixed for injection in hospitals. Questionnaires were sent to all 155 hospitals with 100 or more beds for general patients in Osaka Prefecture, Japan. The response rate was 69.0%. Mixing of antineoplastic drugs was done in 81.3% of the hospitals. The questionnaire was answered by doctors in 17.2% of the hospitals with antineoplastic drugs, nurses in 11.5%, and pharmacists in 70.1%. Mixing of antineoplastic drugs was done by doctors in 58.6% of the hospitals, nurses in 44.8%, and pharmacists in 63.2% (multiple answers). Occupational exposure to antineoplastic drugs was recognized in 97.7% of the hospitals. The mean frequency of the mixing operation was 8.8 d per month per worker. The mean number of antineoplastic drugs handled was 7.4 types. Guidelines for the safe handling of antineoplastic drugs were used in 52.8% of the hospitals and a biological safety cabinet was available in 57.4%. Gloves, mask, gown and goggles were used in 82.7, 69.0, 62.1 and 36.8% of the hospitals, respectively, but no personal protective equipment was used in 10.1%. The safety precautions of the hospitals in which the number of beds was small tended to be fewer than those of the hospitals in which the number of beds was large. Used vials and ampoules were disposed of as clinical, infectious or exclusive antineoplastic drug waste by 74.7% of the hospitals. Safety measures for handling the excrement of patients treated with antineoplastic drugs were performed in 8.0% of the hospitals. In 43.7% of the hospitals, the responders had experienced accidents during antineoplastic drug preparation, such as drugs adhering to hands or eyes, drug leakage, accidental injection and cutting by ampoules. Because of the adverse effects of antineoplastic drugs, all hospitals in which the healthcare workers handle them should promote safety precautions.

Skin-derived dendritic cells can mediate deletional tolerance of class I-restricted self-reactive T cells.

Skin-draining lymph nodes contain a number of dendritic cell (DC) subsets of different origins. Some of these are migratory, such as the skin-derived epidermal Langerhans cells and a separate dermal DC subset, whereas others are lymphoid resident in nature, such as the CD8+ DCs found throughout the lymphoid tissues. In this study, we examine the DC subset presentation of skin-derived self-Ag by migratory and lymphoid-resident DCs, both in the steady state and under conditions of local skin infection. We show that presentation of self-Ag is confined to skin-derived migrating DCs in both settings. Steady state presentation resulted in deletional T cell tolerance despite these DCs expressing a relatively mature phenotype as measured by traditional markers such as the level of MHC class II and CD86 expression. Thus, self-Ag can be carried to the draining lymph nodes by skin-derived DCs and there presented by these same cells for tolerization of the circulating T cell pool.

Genotoxic risks to nurses from contamination of the work environment with antineoplastic drugs in Japan.

The aims of the present study were to clarify the work environment contamination by antineoplastic drugs in a hospital ward and to assess the genotoxic risks to nurses who routinely handle antineoplastic drugs in Japan. The exposed group consisted of 19 female nurses who routinely handled antineoplastic drugs. The control group consisted of 18 female nurses who did not handle antineoplastic drugs in the same hospital as the exposed group. The genotoxicity of the 19 antineoplastic drugs used in the hospital ward and 8 wipe samples of the workbench after handling of antineoplastic drugs were measured using the umu assay. Lymphocyte DNA damage (tail length) was measured with alkaline methods of the single cell gel electrophoresis assay (comet assay). Of the 19 antineoplastic drugs, dacarbazine, bleomycin, daunorubicin, doxorubicin, pirarubicin, carboplatin, cisplatin and etoposide induced genotoxicity. Of the 8 sampling d, the umu activity of the wipe sample was positive on 3 d. Contamination of the workbench was found when the nurses handled more drugs than on other days. The medians of the tail length in the comet assay were 8.5 and 5.1 microm, respectively, for the exposed and control groups, with a significant difference (p=0.004 by Mann-Whitney's U-test). In the present study, the nurses of the exposed group were considered to have been exposed to antineoplastic drugs and lymphocyte DNA damage of the exposed group was suggested to be induced by antineoplastic drugs.

[Equipment at the special nursing homes for the elderly: a workplace survey of new nursing homes in Osaka Prefecture].

The number of those who need nursing care and the workers who provide it have been increasing year after year. In April 2000, the public nursing care insurance system was enacted by the Japanese government. After its enaction, care equipment came under scrutiny, but the situation regarding the installation of equipment is not fully understood. In order to understand the present state of care equipment in nursing facilities for the elderly, we conducted a workplace and interview survey. The surveyed facilities were 10 special nursing homes for the elderly in Osaka Prefecture which were established after April 2002. The average number of elderly residents was 79.0, the average value of degree of care was 3.52, and the average number of caregivers was 28.3 per facility. We found all facilities had installed some kinds of bathing equipment: stretcher type, 9 facilities; bath-chair type, 8 facilities. In the facilities with bath-chairs, 6 facilities had special bathtubs, and 6 facilities had general bathtubs. However, all facilities had the working principle that transfer should be done manually, and the equipment for transfer such as a lifts, a transfer and roller board were not be installed. In changing diapers, bed height adjustment was not possible. And the Japanese standard type of wheelchair has a non-detachable armrest, creating a structural barrier when transferring elderly people from a wheelchair to a toilet seat. At all facilities the basis of care was that caregivers should do it manually. In particular, all facilities had only a weak recognition of the risks of transfer. This investigation shows that facilities for the elderly should rethink elderly care based on a reduction of care load and most importantly protection of caregivers' health.

Negative association between serum dioxin level and oxidative DNA damage markers in municipal waste incinerator workers.

OBJECTIVES: To investigate the effect of dioxin on the formation of oxidative DNA damage and urinary mutagenicity, we measured the concentrations of serum dioxins and lymphocytic 8-hydroxydeoxyguanosine (8-OH-dG) in 57 male waste incinerator workers, urinary 8-OH-dG and urinary mutagenicity in 29 male waste incinerator workers. METHODS: Information about the subjects was obtained from a questionnaire. Concentrations of polychlorinated dibenzo-p-dioxin (PCDD), polychlorinated dibenzofuran (PCDF), and coplanar-polychlorinated-biphenyl (Co-PCB) in serum samples from the workers were measured with a high-resolution gas chromatograph /high-resolution mass spectrometer. Lymphocytic and urinary 8-OH-dG levels were measured with a high-performance liquid chromatography-electrochemical detector system. The urinary mutagenicity was measured with umu assay. RESULTS: The lymphocytic 8-OH-dG level showed a negative association with the serum dioxin level (total value of TEQ-PCDD, PCDF, and Co-PCB). Urinary 8-OH-dG did not show correlation with serum dioxin level, but showed positive correlation with the smoking index. CONCLUSIONS: With respect to the subjects' serum dioxin level, dioxin did not increase the urinary 8-OH-dG level by oxidative DNA damage, but upregulation of the primary defenses with oxidative damage and/or DNA repair system activity might have occurred.

Sebaceous carcinoma arising in nevus sebaceus.

A 53-year-old woman had had a pale-brown lesion on her right cheek and neck from birth. Since she was about 40 years old, part of the lesion had gradually elevated and increased in size. At the first examination, there was a huge mass measuring 110 x 70 x 35 mm on the right cheek. A wide local excision of the area including a superficial parotidectomy and submandibular lymph node dissection was performed, followed by full thickness skin grafting. Histological examination of the tumor revealed an invasive dermal neoplasm characterized by lobes that were composed of foamy cells stained with Sudan-IV mixed with many atypical cells showing remarkable variation in the shapes and sizes of their nuclei. The surrounding epithelial changes were consistent with nevus sebaceus. From these findings, the gigantic tumor was diagnosed as a sebaceous carcinoma arising in nevus sebaceus.

[Load on the low back of care workers in nursing homes for the elderly].

In order to evaluate the load on the low back of care workers in nursing homes for the elderly, basic activities and working postures were analyzed for six care workers using the 30-s snap reading method. The trunk inclination angle (TIA) was also measured continuously using an inclination monitor. The analysis of basic activities showed that 22.5% and 21.1% of the workshift were spent on 'bathing and ablution' and 'meal', respectively, and 9.3%, 8.7% and 8.3% were spent on 'assistance with elimination', 'assistance with moving and repositioning' and 'exchange of bed sheet', respectively. Total of the assistance activity was 43.7% of the workshift. The analysis of working posture showed that 'standing' and 'standing bent forward' accounted for 36.1% and 29.5%, respectively, of the workshift. Total of three postures loading the low back ('standing bent forward', 'squatting', 'kneeling') accounted for 39.0%. The time spent in TIA of 20 degrees or more was 45.7%. The postures loading the low back during 'bathing and ablution', 'exchange of bed sheet' and 'assistance with elimination' account for 68.3%, 58.2% and 49.6%, respectively, which suggests that these activities load the low back of the care workers considerably.

Prevention of toxic epidermal necrolysis by regulatory T cells.

To analyze immunoregulation of autoreactive T cells specific for epidermal skin antigens, we crossed transgenic mice expressing ovalbumin selectively in keratinocytes under the keratin 5 promoter (K5-mOVA) with mice expressing a K(b)-restricted OVA-specific T cell receptor transgene (OT-I). In athymic double-transgenic mice, OT-I cells developed extrathymically and, at 8-12 weeks of age, initiated severe epidermal damage mimicking toxic epidermal necrolysis (TEN). In contrast, euthymic double-transgenic mice showed thymic deletion of OT-I cells, had few of these cells in the periphery, and never developed skin changes mimicking TEN. Adoptive transfer of OT-I cells isolated from euthymic double-transgenic mice induced TEN in athymic K5-mOVA single-transgenic mice. This spontaneous disease in athymic double-transgenic mice was prevented by transferring lymph node cells from euthymic mice, but was not prevented when CD4(+) or CD25(+) cells were depleted from this population. Although purified CD4(+)CD25(+) cells scarcely prevented the skin disease induced by adoptive transfer of OT-I cells, they efficiently prevented the disease when co-transferred with CD11c(+) dendritic cells. These results suggested that thymus-derived regulatory T cells cooperate with CD11c(+) dendritic cells to prevent life-threatening skin damage such as TEN.

Rare Helicobacter pylori infection as a factor for the very low stomach cancer incidence in Yogyakarta, Indonesia.

To elucidate factors associated with the very low risk of gastric neoplasia in Yogyakarta, Indonesia, approximately 1/50 of the level in Japan, we recruited 52 male and 39 female participants from the general populace in the city of Yogyakarta in October 2003. Helicobacter pylori IgG antibodies were found in only 5% (0-13) (95% confidence interval) and 4% (0-9) for Javanese males and females, respectively, and were statistically lower than the 62% (58-65) and 57% (53-60), respectively, in Japanese. Furthermore, positive findings of pepsinogen test were only 0 and 2% (0-6) for males and females, in Yogyakarta, and were again significantly lower than the 23% (22-25) and 22% (20-23), in Japan. The very low incidence of stomach cancer in Yogyakarta may be due to a low prevalence of H. pylori infection and chronic atrophic gastritis.

Effects of dioxin on metabolism of estrogens in waste incinerator workers.

The authors measured the concentrations of serum dioxins and urinary estrogen metabolites in 57 male waste incinerator workers to determine whether dioxin influenced the metabolism of estrogens. Concentrations of serum dioxin levels and urinary estrogen metabolites, such as estrone, 17beta-estradiol, 2-hydroxyestrone, 2-methoxyestrone, 2-hydroxyestradiol, 2-methoxyestradiol, 4-hydroxyestrone, 4-hydroxyestradiol, 4-methoxyestradiol, 16-hydroxyestrone, and estriol from the workers were measured. An analysis of covariance showed that mean estriol concentrations, adjusted for confounding factors among 3 serum dioxin levels, indicated a progressive increase with increasing serum dioxin level: 1.30, 1.41, and 2.02 nmol/mol creatinine at < 30.3, 30.3-39.7, and > 39.7 pg toxicity equivalent quantity/g lipid, respectively (F = 3.56, p = .036). This study showed that dioxin acts to metabolize estrogens to 16-hydroxyestrogens rather than to 2- or 4-hydroxyestrogens.

A study on the effect of lead on event-related potentials among lead-exposed workers.

OBJECTIVES: In order to clarify the effect of lead on higher cerebral functions, lead-exposed workers (Pb group) and controls were examined for event-related potentials. SUBJECTS AND METHODS: Fourteen lead-exposed workers with a mean age of 57.1 yr (SD=4.27, range 48-64; lead concentration of whole blood ranged from 33 to 106 microg/dl with a mean of 58.6 and SD 28.6 microg/dl) and 19 age-matched control workers with a mean age of 57.3 yr (SD=4.80, range 48-65) were examined. Visual P300 was recorded by button pushing to the target image (minute checkerboard pattern, 20%), and the NO-GO potential by no button pushing to the target image (same as above, 50%). RESULTS: Latencies of P300 in the Pb group (475+/-46.0 ms) were significantly delayed compared with those in controls (407+/-42.4 ms, p<0.01 by Student's t test). Amplitudes of the NO-GO potential in the Pb group (4.59+/-2.04 microV) significantly increased compared with those in the controls (3.18+/-1.41 microV, p<0.05). CONCLUSION: The finding suggests that lead exposure affects high cerebral functions of cognition and attention, but is unclear in suppression of movement.

[Relationships between dioxin concentrations in deposited dust and those in serum of workers at municipal waste incineration plants].

Relationships between concentrations of polychlorodibenzo-p-dioxins (PCDDs) and polychlorodibenzofurans (PCDFs) in deposited dust and those in the serum of incinerator workers were examined at 13 municipal incineration plants. The following results were found. 1) Dust analysis showed that dominant constituents were octachlorodibenzo-p-dioxin (OCDD) and 1, 2, 3, 4, 6, 7, 8-heptachlorodibenzo-p-dioxin (HpCDD) among PCDDs, and 1, 2, 3, 4, 6, 7, 8-heptachlorodibenzofuran (HpCDF) and octachlorodibenzofuran (OCDF) among PCDFs. The toxicity equivalents (TEQs) of total PCDDs and PCDFs in the deposited dust were 0.54 to 33 ngTEQ/g, which were about 1,000 to 10,000 times as high as those in general soil. 2) The mean of serum TEQ of PCDDs, that of PCDFs and that of total PCDDs and PCDFs in the incinerator workers were 16, 12 and 28 pg TEQ/g lipid, respectively, for all the incinerator workers. Concentrations of hexachlorodibenzofurans (HxCDFs) and HpCDFs in the serum were significantly higher in the incinerator workers than the general population, which suggests that these workers had inhaled these chemicals during their work. 3) The concentration of 1, 2, 3, 4, 6, 7, 8-HpCDF and the TEQ value of PCDFs and in the serum were positively correlated with those in dust except for three plants where large-scale remodeling of the equipment was conducted within the past seven years. Consequently, deposited dust analysis may be useful for judging whether health examination containing blood dioxin measurement is necessary or not.

Vesiculobullous dermatomyositis with panniculitis without muscle disease.

Vesicles and bullae formation is rare in dermatomyositis. We describe a 60-year-old woman who presented with vesiculobullous dermatomyositis with panniculitis and no muscle disease.