Discrepant histological diagnoses: A cause of early low FJS-12 score and if untreated, unhappy Total Knee Arthroplasty patient.

PURPOSE: Total Knee Arthroplasty (TKA) is one of the most successful operations in orthopedics. Still, a sizable percentage of patients (20%) remain dissatisfied after a well-executed TKA. The study aims to examine the excised synovium from the suprapatellar region in osteoarthritic knees during TKA and evaluate the histopathology (HP) report to know whether discrepant diagnoses affect the Forgotten Joint Score-12 at various time intervals. METHODS: This is a prospective cohort study. Two hundred (160 female; 40 male) end-stage osteoarthritis patients who underwent primary TKA were studied. An inclusion criterion was patient with end-stage osteoarthritis. Clinically and serologically proven rheumatoid arthritis patients were excluded from the study. The synovium excised during the TKA procedure was sent for the HP examination. The statistical significance was measured with the Chi-square test and two-sample t-test. RESULTS: A total of 184 out of the 200 patients (92%) knee synovium showed HP features of osteoarthritis. The discordant diagnoses and discrepant diagnosis rate was 8% and 7%, respectively, which is statistically significant by Chi-square test (p value < 0.0001 and p value = 0.0001). 14 of the patients (12 F:2 M) showed histological features of inflammatory/rheumatoid arthritis who were treated, two patients (all female) showed HP features of villonodular synovitis. The mean (SD) improvement in FJS-12 at six weeks in the concordant group (25.3 [17.6]) is significantly more than the discrepant group (15.3 [12.5]), p-value 0.0385. CONCLUSION: 8% of our patients exhibited unexpected results. The study showed a 7% rate of discrepant diagnosis. This discrepant diagnosis if missed and untreated, would have affected the function and long-term survival of the implanted TKA.

3D micro fractal pipettes for capillary based robotic liquid handling.

Miniaturized and mobile liquid handling devices are essential elements to biological or clinical applications. This will innovate the conventional liquid handling methods such as manual or automated pipetting systems. Here, we propose the micro fractal pipette as the candidate device for this objective. It is made of epoxy polymer and printed by innovative 3D nanoprinting technology based on two-photon absorption polymerization with sub-micrometer resolution. We demonstrated the efficient liquid handling performance by using the micro fractal pipette between the source droplet and the target hydrogel substrate. This is due to the high porosity (78%) and the 8.5 times larger cavity surface area compared to the full pyramid. The biomimetic inner cavity microchannel networks contribute to the low pressure drop. The proposed micro fractal pipette could also innovate the versatile and miniaturized liquid handling system, promising to various biological or clinical applications.

Target region resection in patients undergoing cytoreductive surgery for peritoneal metastases-is it necessary in absence of visible disease?

BACKGROUND: The aim was to study the patterns of target region (greater omentum, lesser omentum, falciform and umbilical round ligament) involvement in patients undergoing cytoreductive surgery (CRS) from various primary tumors, factors affecting involvement and implications on surgical practice. METHODS: All patients undergoing CRS from July 2018 to December 2018 were included in this prospective study. The incidence of target region involvement in presence and absence of visible disease and the impact of primary tumor site, PCI and other variables on target region involvement was evaluated. RESULTS: In 191 patients, greater omentum was involved in over 15% of patients irrespective of the primary tumor type and in 15.7% in absence of visible disease. 75% of these had PCI <20. The involvement of the other three target regions was higher than 20% in ovarian cancer, appendiceal tumors and peritoneal mesothelioma. Involvement of these 3 regions was associated with a higher PCI (p < 0.001 for all) and omental involvement (p < 0.001for all). 2.1% of colorectal cancer patients had umbilical round ligament involvement, 4.2% had falciform ligament involvement and none had lesser omentum involvement. CONCLUSIONS: Target region involvement varies according to primary tumour site and disease extent. Resection of the greater omentum should be performed during CRS for PM arising from all primary sites. Resection of other target organs may be performed for selected patients with ovarian cancer, peritoneal mesothelioma and mucinous appendiceal tumors in absence of visible disease. For other patients, it should be done only in presence of visible disease.

Pathological assessment of cytoreductive surgery specimens and its unexplored prognostic potential-a prospective multi-centric study.

BACKGROUND AND AIM: The grade/histological subtype is one of the most important prognostic markers in patients undergoing cytoreductive surgery (CRS). Our aim was to study other potential prognostic information that can be derived from the pathological evaluation of CRS specimens and provide a broad outline for evaluation of these. METHODS: This prospective study (July to December 2018) included all patients undergoing cytoreductive surgery (CRS). A protocol for pathological evaluation was laid down which was based on existing practices at the participating centers and included evaluation of the pathological PCI, regional node involvement, response to chemotherapy, morphology of peritoneal metastases (PM) and distribution in the peritoneal cavity. RESULTS: In 191 patients undergoing CRS at 4 centers, the pathological and surgical PCI differed in over 75%. Nodes in relation to peritoneal disease were positive in 13.6%. Disease in normal peritoneum adjacent to tumor nodules was seen in >50% patients with ovarian cancer and mucinous apppendiceal tumors. 23.8% of evaluated colorectal PM patients had a complete response and 25.0% ovarian cancer patients had a near complete pathological response to chemotherapy. CONCLUSIONS: Pathological evaluation of extent and distribution of peritoneal disease differs from the surgical evaluation in majority of the patients. Lymph node involvement in relation of peritoneal disease is common. The morphological presentation of PM in ovarian cancer and mucinous appendiceal tumors merits evaluation of more extensive resections in these patients. Standardized methods of synoptic reporting of CRS specimens could help capture vital prognostic information that may in future influence how these patients are treated.

Sublingual immunotherapy for allergic rhinitis: subjective versus objective tools to evaluate its success.

BACKGROUND: Biomarkers that enable objective evaluation of the clinical effects of immunotherapy for allergic rhinitis have yet to be identified. METHODS: This study included 40 patients who were enrolled in a large randomized, double-blind, placebo-controlled, multicenter study examining the efficacy of sublingual immunotherapy (SLIT) using Japanese cedar (JC) pollen extract during two consecutive pollen seasons from 2010 to 2012. Based on changes in total nasal symptom medication score, patients in the SLIT and placebo groups were subdivided into two subgroups: good responders and poor responders. The levels of JC pollen-specific IL-10+Foxp3+ cells and specific Th2 cytokine-producing cells were measured and the association with the efficacy of SLIT was analysed. RESULTS: The total nasal symptom medication score was significantly lower in the SLIT group compared with the placebo group. The number of JC pollen-specific Th2 cytokine-producing cells increased during the pollen season in the placebo group and in poor responders in the SLIT group; however, the increases were inhibited in the good responders in the SLIT group. The number of JC pollen-specific IL-10+Foxp3+ cells increased only in these good responders. CONCLUSIONS: Changes in levels of allergen-specific Th2 cytokine-producing cells and IL-10+Foxp3+ cells could be objective biomarkers for SLIT.

Metastasis from breast cancer presenting as an epulis in the upper gingiva.

Oral metastasis of breast cancer is less common than metastasis to other sites like the lung and liver. Breast cancer can metastasize to the oral cavity, with presentation like a benign oral lesion. We present an interesting case of breast cancer involving the gingiva with sparing of the underlying bone.

Surface expression of toll-like receptor 4 on THP-1 cells is modulated by Bu-Zhong-Yi-Qi-Tang and Shi-Quan-Da-Bu-Tang.

Human Toll-like receptor 4 (TLR4) has recently been identified and has been shown to be the main protein involved in recognizing Gram-negative bacteria. We examined the regulation of TLR4 surface expression in a human monocytic cell line (THP-1 cells) by two traditional Chinese herbal medicines. Bu-Zhong-Yi-Qi-Tang (TJ-41) and Shi-Quan-Da-Bu-Tang (TJ-48). TJ-41 and TJ-48 upregulated TLR4 surface expression in THP-1 cells, as well as enhanced TLR4 surface expression in these cells both dose- and time-dependently. These findings suggest that TJ-41 and TJ-48 increase the receptor involved in the response to Gram-negative bacteria and may enhance defenses against these pathogens.

Toll-like receptor 2 and 4 surface expressions on human monocytes are modulated by interferon-gamma and macrophage colony-stimulating factor.

Human Toll-like receptor 2 (TLR2) and TLR4 are recently identified receptors. TLR4 was shown to be the main protein involved in recognizing Gram-negative bacteria, whereas TLR2 is apparently the key factor in responses to other types of microbial pathogens. We examined regulations of TLR2 and TLR4 surface expressions in human peripheral blood monocytes by interferon-gamma (IFN-gamma) and macrophage colony-stimulating factor (M-CSF). IFN-gamma up-regulated both TLR2 and TLR4, but enhanced the surface expression, on human peripheral blood monocytes of TLR4 more than that of TLR2. On the other hand, M-CSF up-regulated both TLR2 and TLR4 surface expression on human peripheral blood monocytes, with no change in the ratio of TLR2/TLR4 surface expression. These results indicate that IFN-gamma enhances receptors involved in the response to Gram-negative bacteria more than those involved in responses to other types of microbial pathogens, whereas M-CSF enhances the receptor response to Gram-negative bacteria in the same manner as to other types of microbial pathogens.

Mechanical fluid flow and surfactant-TA influence activation of macrophages.

We examined the effect of mechanical fluid flow and surfactant on macrophage aggregation as the indication of macrophage activation. Mechanical fluid flow enhanced aggregation in phorbol myristate acetate (PMA)-treated human myeloid leukemic cell lines (HL-60 cells), but had no effect on differentiation of PMA-treated HL-60 cells. Surfactant-TA (an artificial surfactant) inhibited fluid flow-induced aggregation, but had no effect on differentiation of PMA-treated HL-60 cells. Human alveolar macrophages spontaneously formed small aggregates without stimulation. This aggregation was enhanced by fluid flow and inhibited by surfactant-TA. Taken together, these data suggest that macrophage activation is affected by fluid flow and surfactants.

[A case of nonresectable scirrhous type gastric cancer treated by hypertensive subselective chemotherapy with pharmacokinetic modulating chemotherapy].

There have been few effective chemotherapeutic regimens for scirrhous type gastric cancer. A 62-year-old male patient was admitted to our hospital because of anorexia and abdominal discomfort. Gastroendoscopy showed a type 4 advanced gastric cancer in the upper gastric body. Histologic study of biopsy specimens from the tumor revealed poorly differentiated adenocarcinoma. Examination by computed tomography and ultrasonography revealed swollen paraaortic lymph nodes and peritonitis carcinomatosa. The patient was diagnosed as having a nonresectable scirrhous type gastric cancer with peritonitis carcinomatosa and paraaortic lymph node metastasis. This patient was treated weekly with an intraarterial 5-FU (500 mg) and MTX (100 mg) including AT-II by a subcutaneously implanted port system placed into the thoracic aorta. Furthermore, he was administered tegafur/uracil (400 mg/day) 5 days weekly as a pharmacokinetic modulating chemotherapy (PMC). After eight courses of treatment of PMC, paraaortic lymph node swelling and ascites decreased. This chemotherapy produced a partial response in the peritonitis carcinomatosa and paraaortic lymph nodes. This chemotherapy was repeated preoperatively. We reconsidered this case to show indications for operation. The patient died suddenly of acute heart failure before the operation. This therapy was considered an effective treatment for nonresectable gastric cancer.

A critical role for mouse CXC chemokine(s) in pulmonary neutrophilia during Th type 1-dependent airway inflammation.

Ag-specific Th1 and Th2 cells have been demonstrated to play a critical role in the induction of allergic diseases. Here we have investigated the precise mechanisms of Th1-induced airway inflammation. Airway inflammation was induced in BALB/c mice by transfer of freshly induced OVA-specific Th1 or Th2 cells followed by OVA inhalation. In this model, both Th1 and Th2 cells induced airway inflammation. The former induced neutrophilia in airways, whereas the latter induced eosinophilia. Moreover, we found that Th1 cells induced more severe airway hyperresponsiveness (AHR) than Th2 cells. The eosinophilia induced by Th2 cell infusion was almost completely blocked by administration of anti-IL-5 mAb, but not anti-IL-4 mAb. In contrast, Th1-induced AHR and pulmonary neutrophilia were inhibited by the administration of anti-human IL-8R Ab, which blocks the function of mouse CXC chemokine(s). These findings reveal a critical role of mouse CXC chemokine(s) in Th1-dependent pulmonary neutrophilia and AHR.

Mechanical fluid flow enhances high-affinity-IgE-receptor-mediated secretion by mast cells adherent to fibronectin.

We demonstrated the effect of interaction between mechanical fluid flow and the extracellular matrix on high-affinity-IgE-receptor (FcepsilonRI)-mediated secretion by mast cells (cell line MC/9). Mechanical fluid flow did not affect secretion by the cells in the absence of exogenou agonists. Mechanical fluid flow did not affect secretion by cells adherent tofibronectin in the absence of exogenous agonists, but it did enhance FcepsilonRI-mediated secretion by cells adherent tofibronectin. These finding indicate that fluid-flow-induced enhancement of secretion by mast cells requires both exogenous agonists and interaction between integrins and the extracellular matrix. The present study is thefirst to demonstrate that mechanical fluid flow enhances FcepsilonRI-mediated secretion by a mast cell line adherent tofibronectin.

Diagnosis of pancreatic adenocarcinoma by detection of human telomerase reverse transcriptase messenger RNA in pancreatic juice with sample qualification.

PURPOSE: We evaluated the diagnostic efficacy of detection of human telomerase reverse transcriptase (hTERT) message, a catalytic domain of human telomerase, in endoscopic retrograde pancreatography (ERP)-derived pancreatic juice. EXPERIMENTAL DESIGN: Both hTERT and CD25 expression were detected by reverse transcription-PCR (RT-PCR) in 17 patients with pancreatic adenocarcinoma (PC), 12 patients with chronic pancreatitis (CP), and 7 patients with no ERP abnormality (N). In the same patients, beta-actin message was semiquantified by competitive RT-PCR. K-ras codon 12 mutations were concomitantly analyzed by enriched PCR-SSCP in 11 and 7 PC and CP cases, respectively. RESULTS: Expression of hTERT was detected in 88% of PC cases and 17% of CP cases but not in the normal control (N). Alterations in K-ras were detected in 73% of PC cases and 57% of CP cases, respectively. beta-Actin mRNA was expressed in >3.0 x 10(1) copies/microl in all but two PC cases in which hTERT mRNA was not detected. CD25-positive and -negative peripheral lymphocytes were isolated from a normal volunteer using a fluorescent activating cell sorter. The hTERT message was detected in CD25-positive peripheral lymphocytes and in 18, 25, and 0% of the pancreatic juice samples from PC, CP, and N cases, respectively. All CP cases expressing hTERT message were also CD25 positive. CONCLUSIONS: These results suggest that detection of hTERT mRNA in pancreatic juice is a powerful tool to discriminate PC from CP, particularly when the samples are qualified against beta-actin mRNA levels and contaminating CD25-positive lymphocytes.

[A case of successful management of nonresectable pancreas cancer with liver metastasis by intra-arterial infusion chemotherapy with angiotensin-II and administration of tegafur/uracil].

Nontypical chemotherapy regimens exist for advanced pancreatic cancer. We herein report a 62-year-old man whose nonresectable pancreatic cancer was treated effectively with a new method of intra-arterial regional chemotherapy with angiotensin-II (AT-II). The patient was admitted to our hospital with obstructive jaundice and anorexia. He was diagnosed as having inoperable advanced pancreatic cancer with liver metastasis. Enteric-coated tegafur/uracil (400 mg) was administered for 3 weeks. Simultaneously, intraarterial infusion with 5-fluorouracil (500 mg) and infusion of methotrexate (100 mg) with 50 micrograms of AT-II was given every week. A catheter connected to a subcutaneously implanted port system was placed into the common hepatic artery. As a result of this treatment, the maximum diameter of the pancreatic tumor decreased from 3 cm to 2 cm on the CT-scan. Serum carbohydrate antigen 19-9 (CA19-9) decreased from 24,000 U/ml to 186 U/ml. Moreover, the performance status of patient also improved, and he was discharged from our hospital despite his terminal cancer. This regimen could well be effective in cases of advanced pancreatic cancer.

Induction of Toll-like receptor 4 in granulocytic and monocytic cells differentiated from HL-60 cells.

Toll-like receptor 4 (TLR4) is the main protein expressed on the cell surface and is an essential receptor for lipopolysaccharide (LPS) signalling in human peripheral blood leucocytes. We examined TLR4 expression and the functional response to LPS in retinoic acid-treated HL-60 cells (HL-60-derived granulocytic cells) and interferon-gamma-treated HL-60 cells (HL-60-derived monocytic cells). Slight TLR4 expression was induced in HL-60-derived granulocytic cells, while strong induction was seen in HL-60-derived monocytic cells. LPS induced interleukin 1beta (IL-1beta) production and TLR4 expression in HL-60-derived monocytic cells, but not HL-60-derived granulocytic cells. These data indicate different responses to LPS in the cells. TLR4 surface expression paralleled LPS-induced phagocytosis and TLR4-neutralizing antibody partially inhibited LPS-induced IL-8 production in HL-60-derived monocytic cells, but not in HL-60-derived granulocytic cells. These results suggest that HL-60-derived monocytic cells are partially activated via TLR4, but that HL-60-derived granulocytic cells are not activated via TLR4.

Development of fulminant hepatitis B (precore variant mutant type) after the discontinuation of low-dose methotrexate therapy in a rheumatoid arthritis patient.

A 75-year-old female rheumatoid arthritis patient who was positive for hepatitis B surface antigen and for antibodies to hepatitis Be antigen showed liver dysfunction, and therefore methotrexate (MTX) therapy was discontinued. Her drug lymphocyte stimulation test indicated positivity for MTX. Her liver dysfunction improved briefly, but she developed fulminant hepatitis with elevated levels of hepatitis B virus (HBV)/DNA polymerase and subsequently died. HBV/DNA analysis performed with polymerase chain reaction-mutation site-specific assay revealed that the fulminant hepatitis was caused by a precore mutant virus. Sudden reactivation of the immune system by discontinuation of MTX may have led to the attack on infected cells. Even when hepatitis Be antibodies are present, MTX should not be used in patients who have chronic infection with HBV.

Diabetes mellitus with left transverse sinus thrombosis and right transverse sinus aplasia.

A 67-year-old woman with diabetes mellitus was hospitalized due to a throbbing headache. She appeared neurologically normal, except for meningeal irritation. The cerebrospinal fluid pressure was high. There was increased fluid protein without an increased cell count. Brain CT scan showed no abnormality, however, brain magnetic resonance angiography (MRA) showed complete right transverse sinus stasis and partial left transverse sinus stasis, indicating bilateral transverse sinus thrombosis. At this time thrombin anti-thrombin III complex (TAT) and prothrombin fragment F1+2 (PTF1+2) indicating hypercoagulation had increased. Urokinase, followed by aspirin and ticlopidine hydrochloride were administered. After diet therapy and transient insulin administration, her blood glucose levels improved. By the 22nd day, the headache had disappeared. Subsequently, brain MRA showed left transverse sinus blood flow recovery and complete right transverse sinus stasis, while carotid angiography showed recovered left transverse sinus but right transverse sinus defect. TAT and PTF1+2 levels improved concomitantly with better blood glucose control. We diagnosed this case as left transverse sinus thrombosis because of the hypercoagulable state resulting from diabetes mellitus accompanied by right transverse sinus aplasia.

N-Acetylglucosaminyltransferase V as a possible aid for the evaluation of tumor invasiveness in patients with hepatocellular carcinoma.

BACKGROUND: A close relationship has been shown to exist between the metastatic potential and beta1-6 branched oligosaccharides in human and rodent cells. N-acetylglucosaminyltransferase V (GnT-V) catalyzes this process. Although this phenomenon has been reported, little is known about the clinical usefulness of the determination of GnT-V in the evaluations of tumor invasiveness in hepatocellular carcinoma (HCC). In this study, we measured the GnT-V activity in serum of patients with HCC, together with its activity and gene expression in HCC tissues, and elucidated the clinical usefulness of the GnT-V level in evaluating tumor invasiveness. METHODS: Seventy-three serum samples from 38 patients with HCC, 11 with chronic hepatitis, eight with hepatic cirrhosis and 16 healthy controls were used. Twenty-one liver tissues were obtained by surgical resection from 17 patients with HCC, three with colorectal cancers and one with gallbladder cancer metastatic to the liver. The GnT-V activity was determined by using high performance liquid chromatography. The GnT-V mRNA was quantified by using competitive RT-PCR. RESULTS: There were statistically significant correlations between GnT-V activity in sera of HCC, and GnT-V activity and GnT-V mRNA expression in tumor tissue. The mean GnT-V activity in the sera of patients with HCC increased in accordance with the degree of tumor invasion. The HCC group with intrahepatic and extrahepatic metastases showed the highest serum GnT-V-value. CONCLUSIONS: The present study demonstrated that there was a close association between tumor invasiveness and GnT-V activity in sera, and that the measurement of GnT-V may improve prognostic estimates and therapeutic outcomes for patients with HCC.

Plasma fucosyltransferase activity in patients with hepatocellular carcinoma, with special reference to correlation with fucosylated species of alpha-fetoprotein.

BACKGROUND/AIMS: Our previous results showed that the percentage of fucosylated species of alpha-fetoprotein (AFP) in total AFP, fucosylation index, was a very useful diagnostic tool to distinguish AFP due to hepatocellular carcinoma from AFP due to non-neoplastic liver diseases. On the other hand, alpha1-6 fucosyl-transferase (alphaFT) catalyzes the addition of fucose from GDP-fucose through an alpha1-6 linkage to the reducing end of N-acetylglucosamine residue of N-linked oligosaccharides of glycoproteins. However, the biological and clinical significance of alphaFT in patients with hepatocellular carcinoma is not fully understood. In the present study, we measured alphaFT activity to elucidate the enzymatic background of fucosylated species of AFP in hepatocellular carcinoma. METHODS: Plasma samples from 84 cases of hepatocellular carcinoma, 40 of liver cirrhosis, 40 of chronic hepatitis and 30 of normal controls, and 26 paired samples of hepatocellular carcinoma and surrounding noncancerous tissues were enrolled in the present study. AlphaFT activity was measured by high performance liquid chromatography with a synthesized fluorescence-labeled glycopeptide with an asialoagalactobiantennary sugar chain as a substrate in the presence of GDP-fucose. RESULTS: Plasma alphaFT activities (mean+/-SD, pmol/ml/h) in patients with hepatocellular carcinoma, liver cirrhosis, chronic hepatitis and normal controls were 435+/-271, 490+/-290, 590+/-209 and 380+/-133, respectively. AlphaFT levels in hepatocellular carcinoma and chronic liver diseases were increased compared with that in normal controls. A statistically significant positive correlation was observed between plasma alphaFT activity and fucosylation index of AFP (r=0.34, p= 0.0032) in 60 patients with hepatocellular carcinoma, in which increments of serum AFP were observed. When the tentative cutoff value of fucosylation index was set at 18%, which corresponded to the cutoff value to discriminate between hepatocellular carcinoma and non-neoplastic liver diseases in our previous study, the plasma alphaFT activity in hepatocellular carcinoma patients whose fucosylation index was more than 18% (n=32, 523+/-324 pmol/ml/h) was higher than that in hepatocellular carcinoma patients whose fucosylation index was equal to or less than 18% (n=28, 383+/-229) (p=0.055). An increment of the plasma levels of alphaFT occurred in accordance with an advancement of hepatocellular carcinoma stages. Tissue aFT activity in hepatocellular carcinoma (175+/-178 pmol/mg/h) was higher than those in surrounding noncancerous liver (144+/-134) and in normal liver (79+/-19). The mean alphaFT activities in well-, moderately- and poorly-differentiated hepatocellular carcinoma were 38+/-0.7, 177+/-182 and 219+/-189, respectively, and they tended to increase with dedifferentiation in hepatocellular carcinoma tissues. CONCLUSIONS: The present study indicates that alphaFT is responsible for the formation of the fucosylated species of AFP in hepatocellular carcinoma and suggests that the measurement of alphaFT provides a possible aid in the evaluation of the degree of advancement in patients with hepatocellular carcinoma.