IgG4-related disease–like fibrosis as an indicator of IgG4-related lymphadenopathy

The significance of IgG4-related diseases including IgG4-related lymphadenopathy has recently been recognized worldwide. Inflammatory pseudotumors in lymph nodes, as well as in other organs, are also recognized as IgG4-related diseases. Only a few case reports have described IgG4-related lymphadenopathy with fibrosis (IgG4-fibrosing lymphadenopathy), and IgG4-fibrosing lymphadenopathy has not been compared clinicopathologically with non–IgG4-related lymphadenopathy with fibrosis. We have evaluated the pathologic features in 13 patients with IgG4-fibrosing lymphadenopathy, including IgG4 and IgG expression in lymph nodes, and compared these features with those of patients with non–IgG4-related lymphadenopathy with fibrosis with reactive inguinal lymphadenopathy and focal fibrosis and lymph nodes at least 10 mm in diameter. IgG4-fibrosing lymphadenopathy was characterized by lymphoplasmacytic and eosinophilic infiltration, many IgG4-positive plasma cells in fibrotic areas, and high serum IgG4 concentrations. The IgG4-positive/IgG-positive plasma cell ratio was significantly higher in the IgG4-fibrosing lymphadenopathy than in the non–IgG4-fibrosing lymphadenopathy group. The presence of even minor fibrosis with characteristics of IgG4-related disease such as IgG4-fibrosing lymphadenopathy may facilitate the diagnosis of IgG4-related lymphadenopathy.     

The effects of electromyography-controlled functional electrical stimulation on upper extremity function and cortical perfusion in stroke patients

Objective

The relation was investigated between hemiparetic arm function improvement and brain cortical perfusion (BCP) change during voluntary muscle contraction (VOL), EMG-controlled FES (EMG-FES) and simple electrical muscle stimulation (ES) before and after EMG-FES therapy in chronic stroke patients.

Methods

Sixteen chronic stroke patients with moderate residual hemiparesis underwent 5 months of task-orientated EMG-FES therapy of the paretic arm once or twice a week. Before and after treatment, arm function was clinically evaluated and BCP during VOL, ES and EMG-FES were assessed using multi-channel near-infrared spectroscopy.

Results

BCP in the ipsilesional sensory-motor cortex (SMC) was greater during EMG-FES than during VOL or ES; therefore, EMG-FES caused a shift in the dominant BCP from the contralesional to ipsilesional SMC. After EMG-FES therapy, arm function improved in most patients, with some individual variability, and there was significant improvement in Fugl–Meyer (FM) score and maximal grip strength (GS). Clinical improvement was accompanied by an increase in ipsilesional SMC activation during VOL and EMG-FES condition.

Conclusion

The EMG-FES may have more influence on ipsilesional BCP than VOL or ES alone.

Significance

The sensory motor integration during EMG-FES therapy might facilitate BCP of the ipsilesional SMC and result in functional improvement of hemiparetic upper extremity.     

Therapeutic Use of Oral Sodium Phosphate (Phosribbon? Combination Granules) in Hereditary Hypophosphatemic Rickets

Oral sodium phosphate formulations indicated for hypophosphatemia are commercially available worldwide. In Japan, however, many medical institutes have used hospital dispensary or foreign over-the-counter formulations because no such medication with an indication covered by the health insurance system is domestically available. To address this problem, we initiated the development of Phosribbon^®. The present study evaluated the efficacy and safety of Phosribbon^® in 16 patients with hereditary hypophosphatemic rickets. The optimal dosage and an administration pattern were also investigated. Administration of the agent resulted in an increase in the level of serum phosphorus in all patients, which implied that the employed dosage was appropriate. The dosage and administration pattern were adjusted based on comprehensive considerations, including changes in clinical laboratory values such as serum phosphorus, alkaline phosphatase and intact PTH, the dosage of a concomitantly administered activated vitamin D formulation and characteristics of individual patients. Adverse drug reactions were observed in 2 patients, neither of which were serious or necessitated therapy dose reduction or discontinuation. We conclude that Phosribbon^® is a safe and effective treatment for patients with hypophosphatemic rickets and that dose adjustment in this therapy can be guided by the results of regular clinical examination and renal ultrasonography. (ClinicalTrials.gov Identifier: {"type":"clinical-trial","attrs":{"text":"NCT01237288","term_id":"NCT01237288"}}NCT01237288)     

Living donor liver transplantation for pediatric patients with metabolic disorders: The Japanese multicenter registry

LDLT is indicated for a variety of metabolic disorders, primarily in Asian countries due to the absolute scarcity of deceased donor LT. We analyzed data for all pediatric LDLTs performed between November 1989 and December 2010, during which 2224 pediatric patients underwent LDLT in Japan. Of these patients, 194 (8.7%) underwent LDLT for metabolic disorders. Wilson's disease (n = 59; 30.4%) was the most common indication in the patients with metabolic disorders, followed by OTCD (n = 40; 20.6%), MMA (n = 20; 10.3%), and GSD (n = 15; 7.7%). The one‐, five‐, 10‐, and 15‐yr patient and graft survival rates were 91.2%, 87.9%, 87.0%, and 79.3%, and 91.2%, 87.9%, 86.1%, and 74.4%, respectively. Wilson's disease and urea cycle deficiency were associated with better patient survival. The use of heterozygous donors demonstrated no negative impact on either the donors or recipients. With regard to X‐linked OTCD, symptomatic heterozygote maternal donors should not be considered potential donor candidates. Improving the understanding of the long‐term suitability of this treatment modality will require the registration and ongoing evaluation of all patients with inherited metabolic disease considered for LT.     

Incidence of death from congenital toxoplasmosis in 0–4‐year‐old children in Japan

Congenital toxoplasmosis is caused by Toxoplasma gondii. The incidence of death due to congenital toxoplasmosis in Japan from 1974 to 2007 was calculated using the autopsy database of the Japanese Society of Pathology and vital statistics from the Ministry of Health, Labour and Welfare. Two neonatal deaths due to congenital toxoplasmosis were reported during that time. As there were 161 195 neonatal deaths during this period and 32 465 autopsies were performed, the yearly neonatal death from congenital toxoplasmosis was calculated as 2 × 161 195/32 465/34 = 0.29 and the autopsy rate as 32 465/161 195 = 0.2014 (20.14%). The calculated number of annual deaths in infants was 0.82 and in children aged 1–4 years it was 2.09; thus, although few, deaths from congenital toxoplasmosis do still occur in neonates, infants, and young children. Therefore, obstetricians and pediatricians should be aware of the potential for congenital toxoplasmosis, and pregnant women should make every effort to avoid T. gondii infection.     

Inflammation of colon adenoma in the setting of type 1 autoimmune pancreatitis

Although immunoglobulin G4‐related diseases (IgG4‐RD) have been found to affect many organs, little is known about their effects on the colonic mucosae. Pathological examination of colon adenomas has shown inflammatory cell infiltration into the stroma. We therefore assessed the clinicopathological characteristics of colon adenomas in patients with type 1 autoimmune pancreatitis (AIP‐1), a representative IgG4‐RD. Both colon adenomas from patients with (IgG4 adenomas) and without (Non‐IgG4 adenomas) IgG4‐RD were characterized by moderate to severe lymphoplasmacytic and eosinophilic inflammation without fibrosis or phlebitis. The ratio of IgG4‐positive to IgG‐positive plasma cells (IgG4/IgG ratio) and the numbers of IgG4‐positive plasma cells were significantly higher in IgG4 adenomas than in Non‐IgG4 adenomas. IgG4‐positive plasma cells tended to be distributed diffusely in lower areas of the mucosae in IgG4 adenomas. We were unable to confirm whether IgG4 adenomas constituted an IgG4‐RD. However, IgG4 adenomas in the setting of IgG4‐RD may provide useful pathological information, supplementing a diagnosis of IgG4‐RD outside the colon, or may facilitate examination for IgG4‐RD, especially AIP‐1. IgG4 adenomas warrant further investigation.     

Elucidating the molecular mechanism for the intracellular trafficking and fate of block copolymer micelles and their components

Block copolymer micelles have shown promise for the intracellular delivery of chemotherapeutic agents, proteins, and nucleic acids. Understanding the mechanism of their intracellular trafficking and fate, including the extracellular efflux of the polymers, will help improve their efficacy and minimize their safety risks. In this Leading Opinion paper, we discuss the molecular mechanism of block copolymer micelle trafficking, from intracellular uptake to extracellular efflux, on the basis of studies with HeLa cells. By using FRET (fluorescence resonance energy transfer) with confocal microscopy, we found that, following their intracellular transport via endocytosis, the micelles dissociated into their polymeric components in late endosomes and/or lysosomes. Furthermore, we confirmed that the intrinsic proteins NPC1 and ORP2 are involved in the intermembrane transfer of polymers from the endosome to the plasma membrane via the ER (endoplasmic reticulum) by using knockdown experiments with siRNAs. After the polymers were transported to the plasma membrane with the aid of ORP2, they were extruded into the cell medium via ABC transporter, ABCB1. Experiments with ABCB1-expressing vesicles indicated that the polymer itself, and not the fluorescent compounds, was recognized by the transporter. These findings, and the analysis of related mechanisms, provide valuable information that should help minimize the potential risks associated with the intracellular accumulation of block copolymer micelles and to improve their therapeutic efficacy.     

Salivary biomarkers for predicting the progression of chronic periodontitis

ObjectivePredicting the progression of periodontitis would allow for targeted supportive periodontal therapy. The purpose of this study was to determine the usefulness of salivary biomarkers for predicting the progression of periodontitis.DesignEighty-five chronic periodontitis patients were enrolled in an 18-month longitudinal study. Amongst them, 57 experienced progression of periodontitis, indicated at the end of the 18 months by at least one site with >3 mm loss of attachment compared with baseline. We determined the levels of aspartate aminotransferase, alanine aminotransferase (ALT), lactate dehydrogenase, alkaline phosphatase and free haemoglobin as biomarkers, as well as the counts of Porphyromonas gingivalis, Prevotella intermedia and Tannerella forsythia, which represented the periodontal bacteria, in the stimulated saliva. The Mann–Whitney U test was used to compare patients with and without progression. After categorising the diagnostic values, the chi-square test was applied.ResultsCounts and ratios (ratio to total bacteria) of P. gingivalis and P. intermedia were found to be significant predictors of the progression of periodontitis. To increase prediction accuracy, combination analyses were performed. The combination of ALT level and the P. gingivalis ratio showed the highest likelihood (p < 0.001, sensitivity 0.40, specificity 0.96, likelihood 11.30).ConclusionOur findings suggest that salivary ALT level and the P. gingivalis ratio may be potential indicators for the progression of periodontitis. Such a salivary test could be a useful diagnostic tool for predicting periodontal disease progression.     

Single-stage intraoperative transhepatic biliary stenting in patients with unresectable hepatobiliary pancreatic tumors

Background

The current study was conducted to evaluate the safety and utility of intraoperative transhepatic biliary stenting (ITBS) in patients with unresectable malignant biliary obstruction (UMBO) diagnosed intraoperatively.

Methods

In this study, 50 patients who underwent ITBS for UMBO between April 2001 and May 2009 were retrospectively reviewed. For 26 patients who underwent preoperative percutaneous transhepatic biliary drainage (PTBD), the expandable metallic stent (EMS) was inserted intraoperatively by the PTBD route in a single stage. For 24 patients, the intrahepatic bile ducts were intentionally dilated by injection of saline via the endoscopic nasobiliary drainage or the percutaneous transhepatic gallbladder drainage route, and the puncture was performed under intraoperative ultrasound guidance followed by guidewire and catheter insertion. Thereafter, the EMS was placed in the same manner. The initial postoperative complications and long-term results of ITBS were evaluated.

Results

In all cases, ITBS was technically successful. Stenting alone was performed in 22 patients and stenting combined with other procedures in 28 patients. Hospital mortality occurred for three patients (6 %), and complication-related mortality occurred in two cases (4 %). There were nine cases (18 %) of postoperative complications. The median survival time was 179 days, and the EMS patency time was 137 days. During the follow-up period, EMS occlusion occurred in 23 cases (46 %). Best supportive care was a significant independent risk factor for early mortality within 100 days after ITBS (p = 0.020, odds ratio, 9.398).

Conclusions

Single-stage ITBS is feasible for palliation of UMBO and seems to have a low complication rate.     

The feasibility and potential benefit of preoperative chemotherapy for colorectal liver metastasis (CLM): a single-centered retrospective study

Purposes

The benefit of neo-adjuvant chemotherapy for liver-limited metastatic colorectal cancer is still controversial. This study defined the resectability regardless of the size and number of liver metastases, and attempted curative hepatic resection in all cases.

Methods

Sixty-four patients that tolerated chemotherapy were diagnosed with CLM (colorectal liver metastases) without extrahepatic metastase from January 2007 to November 2010, and received an oxaliplatin-based regimen. This study assessed the resectability after chemotherapy, and the patients were divided in two groups; the resected and unresected group. Sixteen patients underwent hepatic resection without chemotherapy.

Results

Thirty-five patients underwent surgical resection (resected group) and twenty-nine patients were considered unresectable (unresected group). All 35 patients in the resected group safely received oxaliplatin-based chemotherapy safely without serious adverse effects. No serious postoperative complications were observed. The median overall survival (MST) was significantly higher in the resected than in the unresected group (56.93 [95 % CI 38.13–75.73] and 25.07 months [95 % CI 17.87–32.26], respectively; P < 0.001). The median disease-free survival was 20.2 [95 % CI 8.82–31.65] months in the resected group.

Conclusion

Preoperative chemotherapy for CLM is well tolerated and does not increase postoperative complications. Curative surgery with preoperative chemotherapy has the potential to improve the overall survival in patients with CLM.