The outcome and a new ISN/RPS 2003 classification of lupus nephritis in Japanese

BACKGROUND: A considerable diversity in prognosis is seen with lupus glomerulonephritis (LGN). Hence, the clinical usefulness of a recent International Society of Nephrology/Renal Pathology Society (ISN/RPS) 2003 classification to judge the long-term outcome of human LGN has been investigated. METHODS: We studied retrospectively 60 subjects with LGN (7 males, 53 females, mean age of 33 years old) who underwent renal biopsies and were followed from 1 to 366 months, with a mean of 187 months. We diagnosed renal pathology as classes, active and sclerosing lesions, according to the new and WHO1995 classification of LGN, and analyzed the clinicopathologic factors affecting to the prognosis of LGN. RESULTS: New classification got much higher consensus in the judgment of classes (98% vs. 83%, P = 0.0084). The group of Class IV-S (N = 6) or IV-G (N = 17) at initial biopsies showed higher rate of end-stage renal failure (ESRF) compared with that of Class I, II, III or V (40.9% vs. 2.6%, P < 0.001). The mean 50% renal survival time of Class IV was 189 +/- 29 months, and patients with Class IV-S tended to have a poorer prognosis (95 +/- 22 months for IV-S vs. 214 +/- 35 months for IV-G, P = 0.1495). Class IV was also selected as the most significant risk factor for ESRF by stepwise model (P = 0.002). In subanalysis for ESRF in Class IV (-S or -G), treatment including methylprednisolone pulse therapy was only selected as a significant improving factor for primary outcome (P = 0.034). In addition, activity index was the significant risk factor of death and/or ESRF after initial renal biopsies (P = 0.043). As for actuarial patient death during all follow-up periods, complications with anti-phospholipid syndrome or nephrotic syndrome were significant risk factors (P = 0.013, P = 0.041, respectively). CONCLUSION: New ISN/RPS 2003 classification provided beneficial pathologic information relevant to the long-term renal outcome and the optimal therapy preventing ESRF and/or death in patients with LGN.     

Histopathologic aspects of photodynamic therapy for dysplasia and early adenocarcinoma arising in Barrett's esophagus

The efficacy of photodynamic therapy (PDT) is currently evaluated for the treatment of superficial neoplasms arising in Barrett's esophagus (BE). An accurate assessment of this technique requires the evaluation of biopsies before and after treatment. However, despite the importance of pathology, only a limited number of studies have systematically assessed the mucosal changes after PDT. To evaluate mucosal changes after PDT, and pathologic variables that may impact on the success of this therapy, we analyzed the pre- and post-PDT biopsies of a cohort of patients treated by this modality. Thirty-three patients (mean age, 71 years) with high-grade dysplasia (HGD) and/or intramucosal carcinoma (IMC) arising in BE and followed up after PDT using Porfimer sodium form the basis of this study. In all patients, a review of all pre- and post-PDT biopsies was performed. The variables recorded included the histologic grade and architecture of neoplasms, the distribution of neoplasms, and squamous re-epithelialization. IMC and HGD coexisted in the pre-PDT biopsies of 18 patients (54.5%). IMC and HGD showed a prominent tubular proliferation in 14 patients and displayed a papillary pattern (at least partially) in 19 patients. In post-PDT, patches of specialized columnar epithelium were buried under squamous epithelium in 17 patients (51.5%), and foci of dysplasia/carcinoma covered by squamous epithelium were found in 9 patients (27.3%). HGD and/or IMC were eradicated in 17 patients (eradicated group) and persisted in 16 patients (persistent group). In the persistent group, grade and architecture were unchanged after PDT in 62.5% and 87.5% of patients, respectively. The persistent group was characterized by: 1) a more frequent papillary architecture (P < 0.05), and 2) a diffuse distribution of the neoplasms on pre-PDT biopsies (P = 0.05). Singularly, the persistent neoplastic lesions were observed in the distal esophagus (P < 0.05). A systematic histopathologic evaluation allowed us to draw attention to the fact that distally located and papillary-type neoplasia seem resistant to PDT. The higher than expected incidence of buried residual neoplastic epithelium should also be emphasized since it represents a risk for undetected growth of malignancy.     

Surgical treatment for cervical myelopathy in patients aged > 80 years

The surgical outcomes of 13 patients who were diagnosed with cervical spondylotic myelopathy were reviewed retrospectively. Mean patient age at surgery was 83 years. The severity of cervical spondylotic myelopathy was evaluated using the Japanese Orthopaedic Association score. Daily activities were evaluated using the Barthel index. The preoperative JOA score and Barthel index were 7.8 and 63.5, respectively. The mean JOA score and Barthel index maximum recovery rate were 35% and 24%, respectively. The results of this study imply that surgery for patients with cervical spondylotic myelopathy aged > 80 years is warranted.     

Comparison of the psychophysical properties of various intraoral film and digital systems by means of the perceptibility curve test

OBJECTIVES: To compare psychophysical properties of two intraoral films and three digital systems using the perceptibility curve (PC) test. MATERIALS AND METHODS: A test object was used to determine the exposures and exposure differences between the total thickness of the test object and details consisting of holes of increasing depth. The PCs for the two intraoral films, UltraSpeed and EktaSpeed Plus, were constructed employing exposure and exposure differences from dose response functions. Integrals of the PCs were calculated to obtain the psychophysical properties of the two films. Psychophysical properties of the two films were compared with those of the three digital systems published previously (CDR, Dixel and Digora). RESULTS: The PC for the EktaSpeed Plus showed a slightly higher peak than that for the UltraSpeed. Available exposure ranges were comparable. The PC for the EktaSpeed Plus was shifted to the left of the exposure axis indicating its higher sensitivity as compared with UltraSpeed. All three digital systems had narrower but higher peaks compared with the films. The integrals for the digital systems were considerably larger than those for the two film types. CONCLUSIONS: All the three digital systems have superior psychophysical properties compared with the two tested films.     

Postural reaction during maximum grasping maneuvers using a hand dynamometer in healthy subjects

The purpose of this study was to quantitatively evaluate spontaneous body sway during maximum grasping maneuver with a hand dynamometer, which we sometimes encounter in clinical practice. The postural reaction of the whole body during maximum grasping maneuver was analyzed in 26 right-handed healthy male volunteers using a three-dimensional motion analysis system (VICON system, Oxford Metrics, UK) and force plates. We found that the gravity center of the body moved toward the grasping side. Also, voluntary rotation of the trunk and flexion of the neck was observed during grasping on each side.     

Differences in the contribution of HLA-DR and -DQ haplotypes to susceptibility to adult- and childhood-onset type 1 diabetes in Japanese patients

To clarify heterogeneity in Japanese adult-onset type 1 diabetes, we analyzed the HLA-DR and -DQ haplotypes, depending on the clinical phenotype, and compared them with those in childhood-onset type 1 diabetes (CO). The patients in a previously reported Ehime Study were divided into subgroups by the mode of onset of diabetes: 68 acute-onset type 1 diabetic patients (AO) and 28 slowly progressive type 1 diabetic patients (SO). HLA haplotypes were compared with those of 80 CO patients and 190 control subjects. Two major susceptible HLA haplotypes in the Japanese, DRB1*0405-DQB1*0401 (DR4) and DRB1*0901-DQB1*0303 (DR9), were significantly increased in the AO and CO groups, but only DR9 was increased in the SO group. AO subjects had a higher frequency of DR9 than CO subjects. Accordingly, the DR9:DR4 frequency increased with increasing age of onset. Another susceptible haplotype, DRB1*0802-DQB1*0302 (DR8), was involved only in the CO group. Analysis of haplotype combinations revealed that DR4 and DR9 had significant dosage effects on the AO and CO groups (P < 0.0001), but only DR9 had such an effect in the SO group (P < 0.03). These results suggest differences in the contribution of HLA class II haplotypes to susceptibility of type 1 diabetes depending on the clinical phenotype and also indicate that HLA class II haplotypes may be associated with the onset age of type 1 diabetes.     

Anesthetic management of a patient with severe hyponatremia

A 62-year-old woman was scheduled for an operation for ileus. Before the operation, we noticed severe hyponatremia (Na 117 mEq x l(-1)) probably due to dehydration. We corrected her hyponatremia slowly to avoid central pontine myelinolysis. Serum Na level increased to 131 mEq x l(-1) after surgery. She recovered from anesthesia without any neurologic problems.     

Intra-aortic balloon pumping is effective for hemodynamic management of catecholamine resistant ampulla (Takotsubo) cardiomyopathy

Ampulla (Takotsubo) cardiomyopathy resembles acute myocardial infarction, with absent coronary stenosis. We report a case of catecholamine resistant ampulla cardiomyopathy, successfully managed using intra-aortic balloon pumping (IABP). After laparotomy, the patient developed circulatory collapse. T wave inversion was observed on electrocardiogram. In spite of circulatory support using high dose cathecholamines, the hemodynamics of the patient showed no improvement. Upon starting IABP, the patient's hemodynamics were improved and the dose of catecholamines could be reduced. Because the ampulla cardiomyopathy is considered a subtype of 'stunned myocardium' and the hemodynamic disorder is temporary and reversible, IABP appears effective for hemodynamic management.