Human mesenchymal stem cells in synovial fluid increase in the knee with degenerated cartilage and osteoarthritis

We investigated whether mesenchymal stem cells (MSCs) in synovial fluid (SF) increased in the knee with degenerated cartilage and osteoarthritis. SF was obtained from the knee joints of 22 patients with anterior cruciate ligament (ACL) injury during ACL reconstruction, and cartilage degeneration was evaluated arthroscopically. SF was also obtained from the knee joints of 6 healthy volunteers, 20 patients with mild osteoarthritis, and 26 patients with severe osteoarthritis, in which the grading was evaluated radiographically. The cell component in the SF was cultured for analyses. Synovium (SYN) and bone marrow (BM) were also harvested during total knee arthroplasties. The MSC number in SF was correlated with the cartilage degeneration score evaluated by arthroscopy. The MSC number in the SF was hardly noticed in normal volunteers, but it increased in accordance with the grading of osteoarthritis. Though no significant differences were observed regarding surface epitopes, or differentiation potentials, the morphology and gene profiles in SF MSCs were more similar to those in SYN MSCs than in BM MSCs. We listed 20 genes which were expressed higher in both SYN MSCs and SF MSCs than in BM MSCs, and 3 genes were confirmed by quantitative RT-PCR. MSCs in SF increased along with degenerated cartilage and osteoarthritis.     

How transplant surgeons can overcome the inevitable insufficiency of allograft size during adult living-donor liver transplantation: strategy for donor safety with a smaller-size graft and excellent recipient results

Small-for-size grafts are an issue in liver transplantation. Portal venous pressure (PVP) was monitored and intentionally controlled during living-donor liver transplantation (LDLT) in 155 adult recipients. The indocyanine green elimination rate (kICG) was simultaneously measured in 16 recipients and divided by the graft weight (g) to reflect portal venous flow (PVF). The target PVP was <20 mmHg. Patients were divided by the final PVP (mmHg): Group A, PVP < 12; Group B, 12 ≤ PVP < 15; Group C, 15 ≤ PVP < 20; and Group D, PVP ≥ 20. With intentional PVP control, we performed splenectomy and collateral ligation in 80 cases, splenectomy in 39 cases, and splenectomy, collateral ligation, and additional creation in five cases. Thirty-one cases received no modulation. Groups A and B showed good LDLT results, while Groups C and D did not. Final PVP was the most important factor for the LDLT results, and the PVP cutoffs for good outcomes and clinical courses were both 15.5 mmHg. The respective kICG/graft weight cutoffs were 3.5580 × 10(-4) /g and 4.0015 × 10(-4) /g. Intentional PVP modulation at <15 mmHg is a sure surgical strategy for small-for-size grafts, to establish greater donor safety with good LDLT results. The kICG/graft weight value may have potential as a parameter for optimal PVF and a predictor for LDLT results.     

History of the development of surgical treatments for moyamoya disease

Many surgical treatments for moyamoya disease have been developed over the past 40 years. The optimum treatment for ischemic-type moyamoya disease is almost established. The first surgical treatment for the disease was the superficial temporal artery to middle carotid artery (STA-MCA) anastomosis. The discovery of spontaneous collateral formation following the STA-MCA anastomosis surgery led to the development of various indirect bypass procedures. Collateral formation and clinical outcomes from direct and indirect procedures have been compared to assess the merits and limitations of each technique. Experience and a greater understanding of the surgical effects of moyamoya disease have led to the development of surgical procedures combining various direct and indirect bypass techniques for optimal restoration of perfusion. This review of the historical development and efficacy of each procedure will aid surgeons in selecting the most appropriate surgical procedure for patients of different ages with different symptoms and disease severities.     

Significance of low-level DSA detected by solid-phase assay in association with acute and chronic antibody-mediated rejection

We sought to clarify the controversial issue of whether detecting low‐level anti‐donor‐specific HLA antibody (HLA‐DSA) by single‐antigen flow‐bead assay (SAFB) may have a potential role in reducing acute and chronic antibody‐mediated rejection (AMR). We retrospectively studied the preoperative serum of ABO‐compatible living kidney transplantation recipients transplanted between 2001 and 2004 by SAFB using a Luminex platform. HLA‐DSA was detected only by SAFB in 24 patients, although all of them showed negative T‐cell and B‐cell complement‐dependent cytotoxicity (CDC) crossmatches. The HLA‐DSA patients went on to have surprisingly high levels of acute and chronic AMR despite being only weakly sensitized (acute AMR, 33.3%; chronic AMR, 41.7%). After 2005, we implemented SAFB routinely and any patient having a positive HLA‐DSA was considered to be a desensitization candidate. The 52 patients found to have HLA‐DSA underwent kidney transplantation after prior treatment with a single dose of rituximab (RIT) and three or four sessions of double‐filtration plasmapheresis (DFPP) in addition to regimens commonly used between 2001 and 2004. After 2005, there was a significant reduction in the occurrence of acute and chronic AMR (acute AMR, 4.7%, P < 0.001; chronic AMR, 4.7%, P < 0.001). The 5‐year graft survival rate also improved after implementing SAFB (83.3–98.1%, P = 0.032). The RIT/DFPP‐induction protocol may improve graft survival even in patients with low‐level DSA.     

12-hydroxyheptadecatrienoic acid promotes epidermal wound healing by accelerating keratinocyte migration via the BLT2 receptor

Leukotriene B₄ (LTB₄) receptor type 2 (BLT2) is a G protein–coupled receptor (GPCR) for 12(S)-hydroxyheptadeca-5Z,8E,10E-trienoic acid (12-HHT) and LTB₄. Despite the well-defined proinflammatory roles of BLT1, the in vivo functions of BLT2 remain elusive. As mouse BLT2 is highly expressed in epidermal keratinocytes, we investigated the role of the 12-HHT/BLT2 axis in skin wound healing processes. 12-HHT accumulated in the wound fluid in mice, and BLT2-deficient mice exhibited impaired re-epithelialization and delayed wound closure after skin punching. Aspirin administration reduced 12-HHT production and resulted in delayed wound closure in wild-type mice, which was abrogated in BLT2-deficient mice. In vitro scratch assay using primary keratinocytes and a keratinocyte cell line also showed that the 12-HHT/BLT2 axis accelerated wound closure through the production of tumor necrosis factor α (TNF) and matrix metalloproteinases (MMPs). A synthetic BLT2 agonist accelerated wound closure in cultured cells as well as in C57BL/6J and diabetic mice. These results identify a novel mechanism underlying the action of the 12-HHT/BLT2 axis in epidermal keratinocytes and accordingly suggest the use of BLT2 agonists as therapeutic agents to accelerate wound healing, particularly for intractable wounds, such as diabetic ulcers.Skin wound healing is a complex, multi-step process that encompasses various cells, growth factors, cytokines, and components of the extracellular matrix (Baum and Arpey, 2005). An essential feature of a healed wound is the restoration of an intact epidermal barrier. Re-epithelialization is a key event in wound healing and is mainly achieved by keratinocyte migration, proliferation, and differentiation (Coulombe, 2003). The absence of keratinocyte migration at the wound edge is a critical defect related to the clinical phenotype of chronic nonhealing wounds, such as diabetic ulcers (Brem and Tomic-Canic, 2007). However, the exact manner in which keratinocyte migration is regulated during wound healing also remains largely unknown.The skin is an organ that displays a highly active metabolism of fatty acids, such as prostaglandins (PGs), HETEs (hydroxyeicosatetraenoic acids), and leukotrienes, etc. (Ziboh et al., 2000). Numerous studies showed that lipid mediators are involved in regulating skin inflammation (Serhan et al., 2008; Kendall and Nicolaou, 2013) related to psoriasis (Mayser et al., 2002), ichthyosis (Yu et al., 2005), and contact dermatitis (Miki et al., 2013). Recently, ATL (aspirin-triggered 15-epi-lipoxin A₄), and resolvin D1 and E1 have been reported to enhance wound healing and epithelial cell regeneration via limiting PMN (polymorphonuclear leukocyte) infiltration and directly stimulating epithelial cells (Norling et al., 2011) in many inflammation-driven diseases, such as cantharidin-induced skin blisters in human (Morris et al., 2009) and TNBS (2,4,6-trinitrobenzene sulfonic acid)-induced colitis in mouse (Arita et al., 2005). More investigations are still required to further clarify the roles of lipid mediators in wound healing, especially in regulating keratinocyte migration.Leukotriene B₄ (LTB₄) is a potent attractant and activator of phagocytic cells, differentiated T cells, and dendritic cells. As such, LTB₄ plays crucial roles in inflammation and immune responses (Luster and Tager, 2004; Mathis et al., 2007). Two G protein–coupled receptors (GPCRs) for LTB₄ were originally cloned in our laboratory. These receptors were designated as the high-affinity LTB₄ receptor BLT1 (Yokomizo et al., 1997) and the low-affinity LTB₄ receptor BLT2 (Kamohara et al., 2000; Yokomizo et al., 2000a). More recently, we identified 12(S)-hydroxyheptadeca-5Z,8E,10E-trienoic acid (12-HHT), a downstream metabolite of COX (cyclooxygenase) enzymes, as the endogenous ligand for BLT2 (Okuno et al., 2008). Mouse BLT2 is primarily expressed in epidermal keratinocytes and intestinal tissues (Iizuka et al., 2005), whereas human BLT2 is ubiquitously expressed throughout the body (Kamohara et al., 2000; Yokomizo et al., 2000b). Several lines of evidence suggest that BLT2 participates in DSS (dextran sulfate sodium)–induced colitis (Iizuka et al., 2010), carcinogenesis (Yoo et al., 2004; Hennig et al., 2008), arthritis (Shao et al., 2006), and bronchial asthma (Cho et al., 2010), but the detailed mechanisms of BLT2 action in vivo are yet to be determined.Today, aspirin is the best-known of the nonsteroidal anti-inflammatory drugs (NSAIDs). The generally accepted mechanism of high-dose aspirin action is its ability to decrease PG and thromboxane (Tx) production by blocking the activity of COX, which occurs through covalent acetylation of the serine residue in the catalytic pocket of the enzyme. Therefore, aspirin may also inhibit the COX-dependent production of 12-HHT. Aspirin is associated with several recognized clinical benefits, ranging from a reduced risk of heart attack (Group, 1989) and colon polyposis (Chan et al., 2007) to its frequently exploited capacity to alleviate inflammation and pain. However, in addition to its beneficial actions, aspirin (mostly at high doses) triggers serious adverse events (Woodward et al., 2011), the most problematic of which is mucosal injury to the gastrointestinal tract (Awtry and Loscalzo, 2000). Aspirin also delays the onset of labor (Sugimoto et al., 1997) and skin wound healing (Pollack, 1984; McGrath and Breathnach, 2004; Kaushal et al., 2007). However, the precise mechanisms responsible for the aspirin-related delay in wound healing are as yet wholly unknown.The current study therefore investigated the role of the 12-HHT/BLT2 axis in regulating keratinocyte migration both in vivo and in vitro, and consequently revealed a novel mechanism underlying the aspirin-dependent delay in wound healing. Most importantly, the results presented herein provide a promising new therapeutic approach for the treatment of intractable ulcers.     

Diagnostic ability of 99mTc-HSA-DTPA scintigraphy in combination with SPECT/CT for gastrointestinal bleeding

Purpose

Gastrointestinal (GI) bleeding scintigraphy in combination with single-photon emission computed tomography/computed tomography (SPECT/CT) remains to be studied in detail. This study aimed to examine the diagnostic ability of this tool.

Methods

GI bleeding scintigraphy using ^99mTc-human serum albumin-diethylenetriaminepentaacetic acid was performed for 38 patients with suspected GI bleeding. Twenty-four patients were diagnosed using planar images alone (planar group) and 14 patients were diagnosed using planar images and additional SPECT/CT images (planar + SPECT/CT group). The diagnostic ability of each method was analyzed.

Results

GI bleeding was observed in 20 of the 38 patients. For the existence of GI bleeding, planar images alone showed a sensitivity of 70%, specificity of 93%, positive predictive value (PPV) of 88%, negative predictive value (NPV) of 81%, and an overall accuracy of 83%, whereas planar images + SPECT/CT showed a sensitivity of 100%, specificity of 75%, PPV of 91%, NPV of 100%, and an overall accuracy of 93%. The source of bleeding was accurately diagnosed in 50% in the planar group and 78% in the planar + SPECT/CT group. In the planar + SPECT/CT group, 44% of the evaluable patients showed correct localization of the source of GI bleeding by additional SPECT/CT images, although planar images only showed incorrect localization.

Conclusion

GI bleeding scintigraphy in combination with SPECT/CT is a noninvasive and useful tool for the examination of GI bleeding.     

Surgical treatment for portosystemic encephalopathy in patients with liver cirrhosis: Occlusion of portosystemic shunt in combination with splenectomy

Aim: Operative ligation of the portosystemic shunt may control hepatic encephalopathy effectively, but the subsequent increase in portal vein pressure (PVP) leads to high mortality. Splenectomy can decrease inflow into the portal system, resulting in decreased portal pressure. Methods: We retrospectively examined the effect of splenectomy in combination with shunt closure on portosystemic encephalopathy. Results: Clinical symptoms of encephalopathy disappeared in all six patients who underwent splenectomy in combination with portosystemic shunt ligation, with the exception of one patient who had relapsing encephalopathy after 6 months. Follow‐up computed tomography showed complete obliteration of the portosystemic shunts, except in the one patient with relapsing encephalopathy who underwent balloon‐occluded retrograde transvenous obliteration for the remaining splenorenal shunt 8 months after surgery. PVP significantly decreased after splenectomy. PVP did not increase to the baseline PVP value after ligation of the shunts, except in two patients who had elevated PVP after surgery: PVP increased from 18 to 19 mmHg after ligation in one patient and from 18 to 23 mmHg in one patient. Conclusion: Splenectomy followed by surgical ligation of the portosystemic shunt may be feasible and safe for cirrhotic patients with portosystemic shunts.     

Drug-induced liver injury associated with Agaricus blazei Murill which is very similar to autoimmune hepatitis

Agaricus blazei Murill (ABM) is one of the most popular complementary alternative medicines (CAM). We experienced a case of a 60-year-old woman with severe hepatitis associated with extract of ABM and extract of Ganoderma lucidum, and a case of a 75-year-old man with drug-induced liver injury (DILI) associated with extract of ABM and fucoidan. Their clinical courses from the start of CAM until the onset of DILI were observed unexpectedly, because they were under observation for stable malignant neoplasms: stage III malignant thymoma and stage IV lung cancer, respectively. However, they did not talk about taking CAM with their physicians. There were two common points between these two cases. First, they were diagnosed as compatible with DILI by using an international diagnostic scale, the Roussel Uclaf Causality Assessment Method. The second point was that histological findings of the liver were very similar to autoimmune hepatitis (AIH). In addition, serum immunoglobulin G and zinc sulfate turbidity tests gradually increased from the start of CAM to the onset of DILI. Their clinical course and liver histology suggested that the immunostimulating action of ABM caused liver injury which was very similar to that seen in AIH.     

Probiotics promote rapid-turnover protein production by restoring gut flora in patients with alcoholic liver cirrhosis

Background and aims

Accumulating evidence suggests that deterioration of the gut flora contributes to the pathogenesis of alcoholic liver cirrhosis (ALC). However, the ALC flora profile and its response to probiotic treatment have not been fully examined. This double-blind placebo-controlled study aimed to evaluate whether the probiotic beverage Yakult 400 (Y400), which contains Lactobacillus casei strain Shirota, improves liver function in ALC patients, and to analyze the precise gut flora profile by real-time quantitative PCR (qPCR).

Methods

A total of 37 hospitalized ALC patients were randomly allocated to Y400 (n = 18) and placebo (n = 19) groups. Y400 or placebo was served twice a day during the first half of the four-week study. Serum concentrations of rapid-turnover proteins (i.e., transthyretin and transferrin), hypersensitive C-reactive protein, and interleukin-6 were measured weekly. qPCR analysis of fecal bacteria was performed biweekly; stocked fecal samples from 46 healthy subjects were used as references.

Results

Serum transthyretin levels significantly increased in the Y400 group in week 3; similar—although statistically insignificant—increases were seen for transferrin and albumin. Levels of hypersensitive C-reactive protein, but not interleukin-6, significantly decreased in week 4. Before treatment, populations of obligate anerobic bacteria were significantly smaller and those of Enterobacteriaceae were larger in patients than in healthy subjects examined in a previous study. Y400 corrected this imbalance.

Conclusions

This is the first report describing the unique gut flora of ALC patients. Y400 treatment normalized the gut flora and improved liver function. These promising findings warrant further investigation in larger, multicenter studies.