Staged endoscopic mitral valve repair for active infective endocarditis with a mitral annular abscess.

The presence of an annular abscess complicates the operation for infective endocarditis. We report a case of a totally endoscopic repair of a mitral annular abscess using a staged strategy. A 28-year-old woman underwent endoscopic mitral valve repair for active infective endocarditis with Staphylococcus aureus. At the index operation, the mitral annular abscess was completely debrided, yielding an annular defect. The mitral valve was repaired with the autologous pericardial patch and an annuloplasty. Primary repair of the annular defect was not performed because of the fragility of oedematous tissues. Two weeks after index surgery, when the infection was under control, and the scar tissue had formed around the annulus, we performed the second stage operation involving repair of the annular abscess. The scar formation enabled annular reconstruction and additional repair of the mitral valve in a totally endoscopic fashion. The postoperative course was uneventful, and there was no recurrence at 5 months. An annular abscess may be repaired with staged surgery in select situations.

Endoscopic Aortic Valve Replacement: Initial Outcomes of Isolated and Concomitant Surgery.

BACKGROUND: The applicability of totally endoscopic surgical aortic valve replacement (AVR) in multivalve operations is unknown. This study describes an approach and perioperative outcomes of totally endoscopic isolated and concomitant AVR using various valve types. METHODS: A total of 216 patients (114 male; mean age, 71.3 ± 11.3 years) underwent totally endoscopic AVR from May 2017 to October 2022 in a tertiary care center. The 3-port technique was used: a 3- to 4-cm main port without rib spreading, a 10-mm 3-dimensional endoscopic port, and a 5-mm left-hand port with femoral cannulations. Sutures were hand tied with a knot pusher. Descriptive analyses compared perioperative outcomes between patients with or without concomitant procedures. RESULTS: Of 216 patients, concomitant surgery was performed in 33 (15.2%) patients. Of the 33, 21 (63.6%) had a concomitant mitral procedure. A stented bioprosthesis was implanted in 165 (76.3%) patients, a mechanical valve in 22 (10.2%) patients, and a rapid deployment or sutureless valve in 29 (13.4%) patients. Median operation time and aortic cross-clamp time were 175 minutes (interquartile range; 150-194 minutes) and 78 minutes (interquartile range; 67-92 minutes) for isolated AVR, respectively. Thirty-day mortality occurred in 1 patient (0.5%). Two patients (0.9%) had conversion to sternotomy. Major neurologic events occurred in 3 patients (1.4%). The major adverse event rate was similar between patients with or without concomitant procedures. CONCLUSIONS: Endoscopic AVR can safely address concomitant valve diseases.

Glove-shaped Foam with Negative Pressure Wound Therapy for Skin Graft Fixation on the Hand.

Tie-over bolster dressing has been the gold standard for skin graft immobilization. However, skin grafting onto the hand remains challenging. To prevent shearing of the skin, joint fixation with Kirschner wire and casting is often required. However, wire fixation through the joint can disrupt finger growth and cause joint contracture, especially in pediatric patients. So, we performed graft fixation with negative pressure wound therapy (NPWT). The use of NPWT with skin grafting has recently been reported. Previous studies have reported that NPWT can provide even pressure on irregular wounds and in highly mobile areas. However, application of NPWT in the digital region often results in air leaks. This report includes four patients who required skin grafting on the hand. All patients received skin grafts in the affected area. Graft fixation was performed with NPWT. A glove-shaped form was designed. The hand was encased on the ventral and dorsal sides and small pieces of foam were placed between the fingers. The fixation was maintained for 7 days at a pressure of -50 to -80 mmHg. None of the cases had air leak requiring reattachment of the system and graft take was successful in all cases without any complications. The NPWT "glove-shape" technique enabled maintenance of average negative pressure for all skin grafts on the hand. This technique does not require joint fixation and may help to prevent growth disturbance and joint contracture.

Understanding CT imaging findings based on the underlying pathophysiology in patients with small bowel ischemia.

Because acute small bowel ischemia has a high mortality rate, it requires rapid intervention to avoid unfavorable outcomes. Computed tomography (CT) examination is important for the diagnosis of bowel ischemia. Acute small bowel ischemia can be the result of small bowel obstruction or mesenteric ischemia, including mesenteric arterial occlusion, mesenteric venous thrombosis, and non-occlusive mesenteric ischemia. The clinical significance of each CT finding is unique and depends on the underlying pathophysiology. This review describes the definition and mechanism(s) of bowel ischemia, reviews CT findings suggesting bowel ischemia, details factors involved in the development of small bowel ischemia, and presents CT findings with respect to the different factors based on the underlying pathophysiology. Such knowledge is needed for accurate treatment decisions.

Does chemical shift imaging offer a biomarker for the diagnosis and assessment of disease severity in multiple myeloma?: A cross-sectional study.

ABSTRACT: To investigate whether chemical shift imaging (CSI) is useful for differentiating myelomatous infiltration from hematopoietic bone marrow (BM) and for quantitatively assessing disease severity.In this retrospective study, spinal MRI, including a sagittal iterative decomposition of water and fat with echo asymmetry and least-squares estimation T2 fast spin-echo sequence, was performed on 76 myeloma patients (45 men, 67.0 ±â€Š11.4 years; 31 women, 66.5 ±â€Š11.0 years) and 30 control subjects (20 men, 67.0 ±â€Š8.4 years; 10 women, 67.0 ±â€Š9.2 years). The fat-signal fraction (FF) and mean signal dropout ratio (DR) were calculated from lumbar BM that contained no focal lesions. The BM plasma cell percentage (BMPC%) and serological data were obtained. As DR is highest when FF = 50%, the patients were divided into 2 groups: a water-dominant group (FF < 50%) and a fat-dominant group (FF > 50%).Serum monoclonal protein (M protein), ß2-microglobulin, and BMPC% were significantly higher in the water-dominant group than in the fat-dominant group. In the water-dominant group, DR correlated significantly with BMPC% and M protein, whereas in the control group, DR showed a weak correlation with age but no correlation with other clinical factors. No significant differences in any clinical data were seen between high and low DR.CSI proved ineffective for differentiating myelomatous infiltration from hematopoietic BM. For myeloma patients with relatively high BM cellularity, a small signal drop on opposed-phase images indicated a higher tumor burden. For BM with relatively low cellularity, disease severity was not reflected by CSI.

Assessment of early treatment response on MRI in multiple myeloma: Comparative study of whole-body diffusion-weighted and lumbar spinal MRI.

OBJECTIVES: To compare remission status at completion of chemotherapy for multiple myeloma (MM) with changes in total diffusion volume (tDV) calculated from whole-body diffusion-weighted imaging (WB-DWI) and fat fraction (FF) of lumbar bone marrow (BM) by modified Dixon Quant (mDixon Quant) soon after induction of chemotherapy, and to assess the predictive value of MRI. METHODS: Fifty patients (mean age, 66.9 ± 10.5 years) with symptomatic myeloma were examined before and after two cycles of chemotherapy. From WB-DWI data, tDV was obtained with the threshold for positive BM involvement. Mean FF was calculated from lumbar BM using the mDixon Quant sequence. At the completion of chemotherapy, patients were categorized into a CR/very good PR (VGPR) group (n = 15; mean age, 67.6 ± 10.3 years) and a PR, SD or PD group (n = 35; mean age, 69.1 ± 8.6 years). ROC curves were plotted to assess performance in predicting achievement of CR/VGPR. RESULTS: At second examination, serum M protein, ß2-microglobulin, and tDV were significantly decreased and hemoglobin, mean ADC, and FF were significantly increased in the CR/VGPR group and serum M protein was significantly increased in the PR/SD/PD group. The general linear model demonstrated that percentage changes in FF and M protein contributed significantly to achieving CR/VGPR (P = 0.02, P = 0.04, respectively). AUCs of ROC curves were 0.964 for FF and 0.847 for M protein. CONCLUSIONS: Early change in FF of lumbar BM and serum M protein soon after induction of chemotherapy contributed significantly to prediction of CR/VGPR.

IFN-γ Control of an Effector/Target Combination for Skin Allograft Rejection: Macrophage/Skin Components in Normal Mice or T Cell/Endothelial Cells in IFN-γ-Deficient Mice.

Organ, skin, or cell allografts are acutely rejected from normal mice, whereas vascularized organ allografts, but not allografted Meth A cells, are rejected from interferon-γ (IFN-γ)-deficient mice. Here we explored effector/target combinations for i.p. allografted Meth A (cytotoxic T lymphocyte [CTL]-resistant) or RLmale1 (CTL-susceptible) cells into or for BALB/c skin (skin components: CTL resistant) onto normal or IFN-γ-deficient C57BL/6 mice. After allografting, normal mice showed more infiltration but only a little thrombosis/hemorrhage. Monocyte/macrophage MHC receptor (MMR)+ macrophages (on days 5-10) and T cell receptor (TCR)+ CTLs (on days 7-9) were cytotoxic against Meth A cells or skin components and RLmale1 cells, respectively, and the allografts were rejected. After allografting into IFN-γ-deficient mice, MMR- macrophages and highly activated TCR+ CTLs were induced, and the mice died of hemorrhagic ascites with Meth A cells and more acutely rejected RLmale1 cells. The CTLs on days 4-6 were inactive toward skin components at an in vivo effector/target ratio but injured endothelial cells to cause severe thrombosis/hemorrhage and more acute rejection of skin allografts. These results indicate that IFN-γ-dependent MMR expression was essential for macrophage-mediated cytolysis of allogeneic skin components and that IFN-γ-deficient mice more acutely rejected skin allograft by causing CTL-induced injury to endothelial cells.

Extra-axial chordoma of the gingiva.

BACKGROUND: Extra-axial chordomas are exceedingly rare malignant tumours. Herein, we present the first case of an extra-axial chordoma in the gingivae. METHODS AND RESULTS: A 21-year-old man presented with a suspected chordoma in the upper right gingiva. Diagnosis was difficult; however, owing to strong expression of the chordoma marker brachyury, extra-axial chordoma was ultimately diagnosed. The tumour was completely resected without performing a facial incision. To ensure its safety and effectiveness, the surgical procedure was simulated several times before its performance using a three-dimensional (3D) model. Twenty-four months after surgery, the patient remains disease-free. CONCLUSION: A diagnosis of extra-axial chordoma can be confirmed by immunohistochemical staining for brachyury.

Association of COL11A1 4603C/T polymorphism with cervical disc degeneration in collegiate wrestlers.

BACKGROUND: The authors previously identified that COL11A1 gene polymorphism is not a susceptibility factor for lumbar disc degeneration (LDD) in athletes. However, the relationship between COL11A1 gene polymorphism and cervical disc degeneration (CDD) remains unclear. We hypothesized that significant associations between COL11A1 4603C/T gene polymorphism and CDD, but not LDD, in collegiate wrestlers exist. This study aims to examine the relationship between CDD, LDD, and COL11A1 4603C/T gene polymorphism in collegiate wrestlers. METHODS: The subjects enrolled in this study were 92 (Study-1) and 123 (Study-2) Japanese collegiate male wrestlers. Study-1 and Study-2 were conducted in 2010-2012 and 2012-2015, respectively. RESULTS: CDD and LDD prevalence among the wrestlers was 51.1% (47/92) and 43.9% (54/123), respectively. We found that COL11A1 4603C/T was significantly associated with CDD, but not with LDD. Using logistic regression analysis with concomitant confounding factors, we further confirmed that COL11A1 4603C/T was a significant risk factor for CDD (co-dominant genetic model [CC vs. CT+TT]: adjusted odds ratio [OR] 2.28; 95% CI: 1.13-4.59; dominant genetic model [CC+CT vs. TT]: adjusted OR 11.71; 95% CI: 1.36-101.06). CONCLUSIONS: Results suggest that COL11A1 4603C/T gene polymorphism is associated with an increased risk of CDD, but not LDD, in Japanese collegiate wrestlers.

Blood supply--susceptible formation of melanin pigment in hair bulb melanocytes of mice.

BACKGROUND: Allogeneic skin grafts onto C57BL/6 mice are rejected, and the rejected skin is replaced by surrounding skin with black hair. In contrast, syngeneic skin grafts are tolerated, and gray hair grows on the grafts. METHODS: To explore the mechanism of gray hair growing on the tolerated skin grafts, we prepared full-thickness skin (2-cm square) autografts, 2 (2 cm + 2 cm) horizontal or vertical parallel incisions, and U-shaped (2 cm × 2 cm × 2 cm) flaps with or without pedicle vessels. The grafts, incisions, and flaps were fixed by suturing with string and protected by a transparent bandage. On day 14 after the operation, the bandages were removed to observe the color of the hair growing on the skin. RESULTS: Skin autografts from wild-type or hepatocyte growth factor-transgenic (Tg) C57BL/6 mice survived with gray hair, whereas those from steel factor (Kitl)-Tg C57BL/6 mice survived with black hair. In addition, U-shaped flaps lacking both of the 2 main feeding vessels of wild-type mice had gray hair at the tip of the flaps. Light microscopy after staining with hematoxylin and eosin or dihydroxyphenylalanine showed that the formation of melanin pigment in the follicles, but not in the interadnexal skin, was susceptible to the blood supply. CONCLUSIONS: Melanin pigment formation in the hair bulb melanocytes appeared to be susceptible to the blood supply, and melanocytosis was promoted in the follicles and in the epidermis of Kitl-Tg C57BL/6 mice.

Macrophage MHC and T-cell receptors essential for rejection of allografted skin and lymphoma.

BACKGROUND: Skin or organ allograft rejection is dependent on noncytotoxic CD4(+) T cells, but the mechanisms of recognition and rejection remain elusive. Previously, we demonstrated C57BL/6 (H-2D(b)K(b)) macrophage-mediated, cell-to-cell contact-dependent, d haplotype-specific lysis of allografts (e.g., BALB/c skin and Meth A cells; H-2D(d)K(d)) in the rejection site and isolated two cDNA clones encoding receptors on macrophages for H-2D(d) and H-2K(d), macrophage major histocompatibility complex receptor (MMR) 1 and 2, respectively. METHODS: To elucidate the role of MMR2 and T-cell receptors (TCRs) in graft rejection, we generated MMR2 knockout (KO) mice on a C57BL/6 background and transplanted D(d), K(d), or D(d)K(d) transgenic C57BL/6 skin or EL-4 lymphoma cells onto or into these KO mice. RESULTS: MMR2 KO mice lacking MMR2 mRNA or protein expression in their monocytes had no obvious abnormalities in terms of cell number in or composition of their lymphoid tissues or in T lymphocyte responses to alloantigen or nonalloantigen, whereas they failed to reject K(d) transgenic skin grafts. Surprisingly, they also lacked MMR1 mRNA and protein expression in their monocytes and failed to reject D(d) or D(d)K(d) transgenic skin grafts. However, they did reject skin grafts from mice expressing H-2I(d), minor H(d), or third-party major histocompatibility complex. On the contrary, D(d)-, K(d)-, or D(d)K(d)-EL-4 cells injected intradermally or intraperitoneally into MMR2 KO mice were rejected by TCR(αß)(+)/CD8(+) T cells in a transgene number-dependent and MMR-independent manner. CONCLUSIONS: These results demonstrate that MMRs on monocytes/macrophages and TCRs on cytotoxic T lymphocytes in mice were essential for recognition and rejection of allografted skin and lymphoma, respectively.

Effects of positively charged redox molecules on disulfide-coupled protein folding.

In vitro folding of disulfide-containing proteins is generally regulated by redox molecules, such as glutathione. However, the role of the cross-disulfide-linked species formed between the redox molecule and the protein as a folding intermediate in the folding mechanism is poorly understood. In the present study, we investigated the effect of the charge on a redox molecule on disulfide-coupled protein folding. Several types of aliphatic thiol compounds including glutathione were examined for the folding of disulfide-containing-proteins, such as lysozyme and prouroguanylin. The results indicate that the positive charge and its dispersion play a critical role in accelerating disulfide-coupled protein folding.

Anatomical study of medial and lateral sural cutaneous nerve: implications for innervated distally-based superficial sural artery flap.

We report about reconstruction of the foot with an innervated distally-based superficial sural artery flap using the lateral sural cutaneous nerve. The sensation of the lateral part of the leg depends on the sural nerve (SN), and the medial part of the leg on the saphenous nerve. The border of the area between the SN and the saphenous nerve, however, is not clear. To elucidate the distribution of the medial and lateral sural cutaneous nerves, the origin, diameter, course, branches, and distributions were recorded in 40 adult cadaver lower legs. The medial and lateral nerves in all legs (n = 40) were identifiable. In one leg, the SN was a direct continuation of the medial branch, and the lateral branch ended in the middle of the lower leg. Thick (>1 mm) sub-branches from the lateral branch were identified in 26 legs. Most cutaneous branches from it ended in the middle of the sural area. We applied the innervated distally-based sural artery flap using the lateral branch in 2 cases and obtained good recovery of sensation. The lateral branch supplies most of the central sural area and is required for the innervation of the distally-based superficial sural artery flap.

Spontaneous rejection of intradermally transplanted non-engineered tumor cells by neutrophils and macrophages from syngeneic strains of mice.

It is not surprising that tumors arising spontaneously are rarely rejected by T cells, because in general they lack molecules to elicit a primary T-cell response. In fact, cytokine-engineered tumors can induce granulocyte infiltration leading to tumor rejection. In the present study, we i.d. injected seven kinds of non-engineered tumor cells into syngeneic strains of mice. Three of them (i.e. B16, KLN205, and 3LL cells) continued to grow, whereas four of them (i.e. Meth A, I-10, CL-S1, and FM3A cells) were spontaneously rejected after transient growth or without growth. In contrast to the i.d. injection of B16 cells into C57BL/6 mice, which induces infiltration of TAMs into the tumors, the i.d. injection of Meth A cells into BALB/c mice induced the invasion of cytotoxic inflammatory cells, but not of TAMs, into or around the tumors leading to an IFN-γ-dependent rejection. On day 5, the cytotoxic activity against the tumor cells reached a peak; and the effector cells were found to be neutrophils and macrophages. The i.d. Meth A or I-10 cell-immunized, but not non-immunized, mice rejected i.p.- or i.m.-transplanted Meth A or I-10 cells without growth, respectively. The main effector cells were CTLs; and there was no cross-sensitization between these two kinds of tumor cells, suggesting specific rejection of tumor cells by CTLs from i.d. immunized mice. These results indicate that infiltration of cytotoxic myeloid cells (i.e. neutrophils and macrophages, but not TAMs) into or around tumors is essential for their IFN-γ-dependent spontaneous rejection.

Simulation of an absorption-based surface-plasmon resonance sensor by means of ellipsometry.

Through numerical simulations, we point out that introduction of an ellipsometric measurement technique to an absorption-based surface-plasmon resonance (SPR) sensor enhances precision and sensitivity in measuring the imaginary part k of the complex refractive index of the sample. By measuring a pair of ellipsometric Delta-Psi parameters, instead of the conventional energy reflectance R(p) of p-polarized light in the Kretschmann optical arrangement, we can detect a small change of k that is proportional to that of the concentration of the sample, especially when k << 1. While one has difficulty in determining the value of k uniquely by the standard technique, when the thickness of Au under the prism is thin (20-30 nm), the ellipsometric technique (ET) overcomes the problem. Furthermore, the value of k and the thickness d(s) of the absorptive sample that is adsorbed on Au can be determined precisely. The ET based on the common-path polarization interferometer is robust against external disturbance such as mechanical vibration and intensity fluctuation of a light source. Although only the p-polarized light is responsible for the SPR phenomenon, we show that the introduction of the ET is significant for quantitative analysis.