Focal coagulative necrosis of the liver in a patient with sustained virologic response to anti-hepatitis C virus therapy

A 69-year-old woman with chronic hepatitis C virus (HCV) infection was referred to our hospital due to liver enzyme abnormalities. Four years after anti-HCV therapy, the patient with sustained virologic response and no clinical symptoms developed an oval hepatic mass with mixed high and low internal echoes near the portal vein on ultrasound. Magnetic resonance imaging (MRI) of the liver lesion showed a slightly hypo intense pattern on T1-weighted images, a hyper intense pattern both on T2- and diffusion-weighted images, a slight rim enhancement pattern with no intra-lesional enhancement up to the late phase, and a very low intense pattern on hepatobiliary phase images. Positron emission tomography/computed tomography (PET / CT) showed no areas of avid radiotracer uptake in the liver. No tumor markers showed abnormally high values. All these images and laboratory findings led us to the assessment of the liver lesion as a non-neoplastic disorder. However, due to the patient's strong preference to get both definitive diagnosis and cure of the lesion, the patient underwent laparoscopic partial hepatectomy. Pathological study showed 2 necrotic areas surrounded by multiple lymph follicles, epithelioid cells, lymphocytes, collagen fibers, and plasma cells, leading to the diagnosis of focal coagulative necrosis of the liver (FCNL). Physicians should note that FCNL can occur without any symptoms and can be diagnosed at least as a non-neoplastic disorder with combined MRI and PET/CT analysis.

Successful endoscopic treatment of a huge trichobezoar in a 10-year-old girl

A 10-year-old girl was admitted to our hospital due to acute pancreatitis. Computed tomography showed an intra-gastric mass containing multiple small air bubbles. Ultrasound showed a well-circumscribed large oval mass with a broad acoustic shadow. Endoscopy revealed a huge trichobezoar with many movable hairs, being judged by the cause of acute pancreatitis. Due to the parents' strong preference not to leave any surgical scars on their daughter, the patient underwent endoscopic treatment. The trichobezoar grasped with a snare was too large to pass through the esophageal-gastric junction. In addition, the outer layer of the trichobezoar was too hard to be cut with conventional endoscopic devices but was successfully cut with a FlushKnife. The content of the trichobezoar was much softer than its hard surface but needed appropriate counter-traction to be torn off the tissue. Two alligator forceps via a dual-channel multi-bending scope were able to give sufficient counter-traction to the inner tissue of the trichobezoar, successfully removing the trichobezoar through piece-by-piece tearing off. All the endoscopic procedures took seven hours for the complete trichobezoar removal. The total weight of the dissected mass was 180 g. The girl resumed eating on the next day and was discharged on the third day. Physicians should note that a medical team with full endoscopic expertise can remove huge trichobezoars using a FlushKnife, a dual-channel multi-bending scope, and two alligator forcepses.

A PTHrP Gradient Drives Mandibular Condylar Chondrogenesis via Runx2

The mandibular condylar cartilage (MCC) is an essential component of the temporomandibular joint, which orchestrates the vertical growth of the mandibular ramus through endochondral ossification with distinctive modes of cell differentiation. Parathyroid hormone-related protein (PTHrP) is a master regulator of chondrogenesis; in the long bone epiphyseal growth plate, PTHrP expressed by resting zone chondrocytes promotes chondrocyte proliferation in the adjacent layer. However, how PTHrP regulates chondrogenesis in the MCC remains largely unclear. In this study, we used a Pthrp-mCherry knock-in reporter strain to map the localization of PTHrP+ cells in the MCC and define the function of PTHrP in the growing mandibular condyle. In the postnatal MCC of PthrpmCherry/+ mice, PTHrP-mCherry was specifically expressed by cells in the superficial layer immediately adjacent to RUNX2-expressing cells in the polymorphic layer. PTHrP ligands diffused across the polymorphic and chondrocyte layers where its cognate receptor PTH1R was abundantly expressed. We further analyzed the mandibular condyle of PthrpmCherry/mCherry mice lacking functional PTHrP protein (PTHrP-KO). At embryonic day (E) 18.5, the condylar process and MCC were significantly truncated in the PTHrP-KO mandible, which was associated with a significant reduction in cell proliferation across the polymorphic layer and a loss of SOX9+ cells in the chondrocyte layers. The PTHrP-KO MCC showed a transient increase in the number of Col10a1+ hypertrophic chondrocytes at E15.5, followed by a significant loss of these cells at E18.5, indicating that superficial layer-derived PTHrP prevents premature chondrocyte exhaustion in the MCC. The expression of Runx2, but not Sp7, was significantly reduced in the polymorphic layer of the PTHrP-KO MCC. Therefore, PTHrP released from cells in the superficial layer directly acts on cells in the polymorphic layer to promote proliferation of chondrocyte precursor cells and prevent their premature differentiation by maintaining Runx2 expression, revealing a unique PTHrP gradient-directed mechanism that regulates MCC chondrogenesis.

Discontinuing Hemodialysis through Corticosteroid Treatment in a Patient with Cryofibrinogen-associated Glomerulonephritis

Cryofibrinogen-associated glomerulonephritis (CryoFiGN) is rare, and its diagnosis is difficult while treatment is not established. We herein report an elderly woman with CryoFiGN who experienced recurrent purpura and nephritic features that subsequently progressed to nephrotic syndrome and required hemodialysis during the 18-month clinical course. The patient was treated with corticosteroids, which led to the discontinuation of hemodialysis. The diagnosis of CryoFiGN was based on the clinical presentation, characteristic glomerular deposits, and results of laser microdissection and liquid chromatography-tandem mass spectrometry of the glomeruli. This case highlights the potential utility of corticosteroids as a treatment option for patients with CryoFiGN, even after hemodialysis.

Element-ratio dependence of the 5d-states of Au and Pt in solid-solution-type Au-Pt alloy nanoparticles studied by X-ray absorption spectroscopy and density functional theory

Solid-solution-type Au-Pt alloy nanoparticles (NPs) were prepared from the nanoclusters of each metal using the polymer-conjugated fusion growth method. The elemental mapping analysis showed that the mixing state of the elements in the NPs drastically changed in the narrow reaction-temperature range from 100 °C to 180 °C. For their various mixing states, the 5d-states of Au and Pt atoms in the alloy NPs were investigated on the basis of the white line intensities of X-ray absorption near edge structure (XANES). Then, the 5d-states of Au and Pt atoms in a model crystalline ordered alloy structures were investigated on the basis of the theoretically calculated XANES spectra using density functional theory (DFT) in the whole composition range. The DFT calculation showed that the changes in the absorption spectra near the Pt and Au edges are caused by the change in the occupation of the Pt 5d-states and the orbital hybridisation of the Au 5d-states with the 5d-states of neighbouring Pt atoms around an Au atom, respectively.

Renin inhibition and the long-term renal function in patients with hypertensive emergency: a retrospective cohort study

BACKGROUND

The rehospitalization rate in hypertensive emergency is high, indicating the necessity for optimizing its long-term management. The role of the renin-angiotensin system (RAS) blockade in this disorder remains uncertain.

METHODS

We conducted a retrospective analysis involving 20 admitted patients who received aliskiren, a direct renin inhibitor (DRI), for the management of hypertensive emergency associated with elevated plasma renin activity (PRA). We analyzed the changes in blood pressure (BP), kidney function, and RAS activity in the subacute and chronic phases.

RESULTS

The use of DRI was associated with a marked reduction in PRA (median, from 25.0 to 1.2 ng/mL/hr) and serum aldosterone levels (from 404 to 130 pg/mL) during the index admission. BP also decreased from 226/143 to 142/80 mmHg. A comparison of clinical characteristics according to the renal function indicated that dialysis-dependent patients had higher aldosterone levels than non-dialysis-dependent patients at admission, despite comparable BP levels. After a median follow-up of 567 days in non-dialysis-dependent patients with DRI, median eGFR levels were significantly increased from 14.3 to 23.1 mL/min/1.73 m2. PRA levels were consistently suppressed at 0.8 ng/mL/hr. We found a significant correlation between the degree of PRA suppression and changes in eGFR (r = -0.58), indicating that the effective blockade of RAS is associated with the preservation of eGFR in the study subjects.

CONCLUSIONS

DRI can successfully suppress PRA in patients with high-renin hypertensive emergency in both subacute and chronic phases. An efficient RAS blockade is associated with preserved renal function in these patients.

Successful endoscopic submucosal dissection of colorectal lipoma with an overlying adenoma

We report the case of a 65-year-old woman whose colonoscopy revealed a soft submucosal tumor approximately 7 cm in diameter in the ascending colon with an overlying flat lesion. The tumor was diagnosed as a lipoma with an overlying adenoma. Endoscopic submucosal dissection (ESD) was performed. Pathological examination revealed that the epithelium was a low-grade tubulovillous adenoma, while the submucosal yellow tumor was a lipoma. ESD appears to be a safe and effective treatment for colorectal lipomas overlying lipomas with colorectal adenomas.

Epithelioid Hemangioendothelioma of the Liver Showing Spontaneous Complete Regression after the Cessation of Methotrexate Intake

A 71-year-old man with slight fever and dull abdominal pain was referred to our hospital. He had been receiving methotrexate (MTX) to treat his rheumatoid arthritis for more than 6 years but stopped taking MTX after admission due to the rapid aggravation of his liver function. Computed tomography (CT) showed multiple liver lesions with late enhancement, highly suggesting them to be cholangiocarcinomas. Tumor marker levels were normal except for a slightly elevated PIVKA-II level, i.e., 45 mAU/mL (range 0-40 mAU/mL). We did a biopsy to the largest lesion and endoscopic biliary drainage to make a definitive diagnosis of the hepatic lesions and treat jaundice, respectively. Pathological study showed round, polygonal, and spindle-shaped epithelial atypical cells growing in a sarcomatoid fashion. Atypical cells were positive for CD31, CD34, vimentin, and TFE3, and some of them had intracellular vacuoles, leading to the diagnosis of epithelioid hemangioendothelioma (EHE) of the liver. The patient got well 4 weeks after the endoscopic biliary drainage. CTs showed marked regression of the EHE lesions 3 months after biliary drainage and complete regression in 12 months. The patient further developed Hodgkin lymphoma in the para-aortic lymph nodes 23 months after the biliary drainage and is now under chemotherapy for the malignant lymphoma. We, however, have not detected any EHE lesions in the liver or distant organs for at least 16 months after the confirmation of complete regression of the EHE lesions. Oncologists should note the spontaneous regression of the EHE and investigate the correlation between MTX cessation and EHE regression.

A Young Patient with Microscopic Polyangiitis Requiring Hemodialysis with Complications of Repeated Episodes of Posterior Reversible Encephalopathy Syndrome Probably Due to Different Etiologies

A young woman with microscopic polyangiitis (MPA) requiring hemodialysis showed repeated posterior reversible encephalopathy syndrome (PRES) with spatiotemporal multiple lesions over a period of two months. The first PRES episode with confusion and the second PRES episode with vertigo and nausea were caused by MPA, hypertension and renal failure. These symptoms were improved by the reinforcement of MPA treatment and blood pressure management. The third PRES episode with nausea, headache, seizure and visual changes was induced by rituximab infusion and hypertension. The PRES was improved with blood pressure and convulsant management. These conditions are challenging to diagnose and treat.

Effects of the thermal denaturation degree of a whey protein isolate on the strength of acid milk gels and the dissociation of κ-casein

In this study, the effects of the degree of thermal denaturation of whey protein (WP) added to milk on the dissociation of κ-casein from casein micelles were investigated, since they are related to the strength of acid milk gel and its factors. Acid milk gels were prepared by heating thermally denatured WP isolate (WPI) and undenatured milk mixtures and treating them with glucono-δ-lactone as a coagulant. The strength of these gels was negatively correlated with the WPI denaturation degree and strongly positively correlated with the extent of κ-casein dissociation from casein micelles. This behavior was ascribed to the fact that α-lactalbumin (α-La) and β-lactoglobulin (β-Lg) contained in WPI denatured after heating and engaged in disulfide bond formation with each other. With an increase in the degree of denaturation and disulfide bond formation, the bonding between β-lactoglobulin and κ-casein was suppressed to decrease the amount of κ-casein-WPI complexes. When β-Lg forms SS bonds with α-La, the number of highly reactive, free SH groups decreases, which complicates the formation of SS bridges between β-Lg and κ-casein. Thus, the denaturation degree of WPI largely determined the degree of κ-casein dissociation from casein micelles and, consequently, the strength of acid milk gels. Adding WP to milk increases the strength of acid milk gel, and it can be controlled by changing the degree of thermal denaturation of the WP. Furthermore, it was clarified for the first time that the dissociation of κ-casein from casein micelles influences this effect. Further studies are needed to elucidate the structural features of κ-casein-dissociated micelles.

Influence of the bone graft materials used for guided bone regeneration on subsequent peri-implant inflammation: an experimental ligature-induced peri-implantitis model in Beagle dogs

Purpose

We aimed to histologically evaluate the influence of bone materials used during guided bone regeneration (GBR) on subsequent peri-implantitis in an experimental ligature-induced peri-implantitis model in beagle dogs.

Methods

Bilateral mandibular premolars (PM2-4) were extracted from six beagle dogs. After 3 months, standardized bone defects (3 mm [mesio-distal width] × 2 mm [bucco-lingual width] × 3 mm [depth]) were created in the experimental group, with simultaneous dental implant placement at the center of the defects. The defects were randomly filled with either autograft (AG) or deproteinized bovine bone mineral (DBBM) and covered with a collagen membrane. In the control group, implant fixtures were placed without creating an intrabony defect. After 3 months, a healing abutment was placed. Four weeks later, a 3–0 silk thread was ligated around the implants to induce peri-implantitis. After 4 weeks, the specimens were dissected and histologically examined.

Results

There were no clinical findings of inflammation until silk thread ligation. Four weeks after the onset of peri-implantitis, gingival redness and swelling were seen with mild resorption of the peri-implant bone on dental radiographs. There were no significant differences between the AG, DBBM, and control groups for the following parameters: bone-to-implant contact, distance from the implant shoulder to the base of the bone defect, area of bone defect, and area of new bone.

Conclusions

Within the limitations of this study, it can be concluded that peri-implant tissues after GBR using AG and DBBM underwent the same degree of bone resorption by peri-implantitis as the no defect group.

SAT-271 Block and Replace Therapy Successfully Improved Symptoms in Recurrent Cyclic Cushing’s Disease

BACKGROUND: Cyclic Cushing’s disease is rare and treatments have not been established for post-surgical recurrent cases. Here, we report a patient with recurrent cyclic Cushing’s disease, whose subjective symptoms improved by administration of metyrapone and hydrocortisone. Clinical Case: A 45‐year-old woman had exhibited face and peripheral edema, hyperphagia, weight gain, hair loss and limb numbness since September X-10. In May X-9, her ACTH and cortisol levels were high (87.8 pg/mL and 28.8 µg/dL, respectively), and she was referred to our department. A brain MRI revealed a pituitary adenoma of 7mm in diameter. Because blood ACTH and cortisol levels turned normal and typical Cushingoid features were absent at the admission to our department, cyclic Cushing’s disease was suspected. Later in September, because subjective symptoms recurred accompanied with blood cortisol level elevation, she was diagnosed as cyclic Cushing’s disease with the examinations including inferior petrosal sinus sampling. Transsphenoidal surgery was performed in November, and immunohistology confirmed ACTH-producing pituitary adenoma based on ACTH positivity. After the surgery, endocrine test results were normalized and subjective symptoms were ameliorated. In March X-3, the blood ACTH level increased again; however, no subjective symptoms were observed. From May X, she had experienced limb numbness, hyperphagia and weight gain again. MRI showed no apparent recurrence, but endocrine tests showed the activity of Cushing’s disease. Urinary free cortisol (UFC) increased to 300–400 µg/day in a 1-week cycle, indicating the recurrence of cyclic Cushing’s disease. Metyrapone treatment was initiated, and the patient was finally discharged after block and replace therapy with metyrapone 2,000 mg/day and hydrocortisone 15 mg/day. After metyrapone treatment, subjective symptoms improved and UFC was normalized. Conclusion: Block and replace therapy with metyrapone and hydrocortisone may be effective for recurrent cyclic Cushing’s disease, especially in cases with a very short cycle.

MON-465 Novel Thyroid Hormone β Mutation L266s Causes Atrial Fibrillation & Cerebral Infarction

Background: Resistance against thyroid hormone β (RTHβ) is characterized by reduced tissue sensitivity to thyroid hormone. Patients with RTHβ resistance typically demonstrate increases in FT3 and FT4 accompanied by inappropriately elevated TSH. Mutations in the TRβ gene are the most common genetic disorder in thyroid hormone resistance and result in impaired thyroid receptor functions due to a dominant negative effect. Here, we describe a case with a novel TRβ mutation, presenting atrial fibrillation and cerebral infarction.

Clinical case: A 55-year-old man presented chronic atrial fibrillation and tachycardia as the onset of cerebral infarction. Because blood tests revealed 5.6 pg/ml FT3 (reference range: 2.36–4.06), 3.39 ng/ml FT4 (0.71–1.5), 0.98 TSH μIU/ml (0.541–4.261), and negative TRAb, suggesting inappropriate secretion of TSH (SITSH). He was referred to our department for further investigation. All three test kits, including LUMIPULSE, ECLusys, and TOSOH, showed an unsuppressed TSH value despite hyperthyroxinemia, demonstrating genuine SITSH. His family history was unclear, but his father had died of heart disease. A pituitary MRI suggested microadenoma, but TSH-secreting pituitary adenoma was excluded because of a negative α subunit and responsiveness to a TRH stimulation test. The TRβ gene was analyzed with informed consent from the patient, and a novel mutation replacing the 266^th amino acid serine (TCG) with leucine (TTG) in the 8^th exon was found, confirming the diagnosis of RTHβ. Tachycardia and atrial fibrillation were considered to be caused by thyrotoxicosis in heart, which dominantly expresses TRα rather than TRβ. Therefore, β-blockers and anticoagulants, were continued.

Conclusion: This is the first report of a case of RTHβ with the TRβ L266S mutation. This novel mutation is located in the thyroid hormone-binding area of the TRβ gene, suggesting that reduced hormone binding may cause thyroid hormone resistance.

Ridge reconstruction in damaged extraction sockets using tunnel β-tricalcium phosphate blocks: A 6-month histological study in beagle dogs

OBJECTIVE

The present study aimed to evaluate the histological outcome of tunnel β-TCP blocks grafting in extraction sockets missing the buccal bone wall, after 6 months of healing.

BACKGROUND

Tunnel β-tricalcium phosphate (β-TCP) blocks made of randomly organized tunnel-shaped β-TCP ceramics appeared promising for alveolar ridge preservation in tooth extraction sockets missing the buccal bone, in a previous study in dogs, with a 2-month healing time.

METHODS

In six beagle dogs, the maxillary first premolars were extracted and the buccal bone was surgically removed to create bone defects of 4 mm (mesio-distal) × 5 mm (apico-coronal) × 4 mm (bucco-palatal). Thus, extraction sockets missing the buccal bone plate were grated with tunnel β-TCP blocks (test) or left empty for spontaneous healing (control). Histology/histomorphometry was performed after 6 months of healing.

RESULTS

The horizontal bucco-palatal width of the alveolar ridge was significantly greater at test sites than at control sites. The amount of mineralized tissue was greater at test sites (57.8% ± 11.1%) than at control sites (28.9% ± 8.5%), while the amount of connective tissue was significantly greater at control sites (41.7% ± 6.4%) than at test sites (19.6% ± 9.2%). No significant difference was found between sites in terms of basic multicellular units and bone marrow. Residual β-TCP at test sites was 5.8% ± 3.2%.

CONCLUSION

Grafting with tunnel β-TCP block significantly limited the resorption of the alveolar ridge at extraction sockets missing the buccal bone compared with sites left to heal spontaneously, even after 6-month follow-up.

Long-term follow-up characteristics of patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) receiving chronic hemodialysis at a single center

BACKGROUND

The clinical characteristics and treatment of patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) after initiating chronic hemodialysis remain unknown.

METHODS

We retrospectively enrolled 11 adult patients with AAV receiving chronic hemodialysis in our hospital from 2000-2016. We collected data describing each patient's clinical findings and treatment before and after initiating hemodialysis. Patients with AAV with and without post-hemodialysis AAV relapse were compared statistically.

RESULTS

The average observation period was 6.8 ± 4.1 years, and the interval between diagnosis and initiating chronic hemodialysis was 1.9 ± 2.6 years. Before initiating chronic hemodialysis, five patients (45%) experienced 12 AAV relapses, with diagnoses made serologically or symptomatically. After initiating chronic hemodialysis, four patients experienced nine relapses, with no significant difference between the number of relapses and the number of patients experiencing relapse (p = 0.067 and 0.083, respectively). For patients' entire clinical courses before initiating chronic hemodialysis, the average steroid dose was 11.6 ± 6.9 g/y. Comparing before and after initiating chronic hemodialysis, the steroid dose decreased significantly to 3.3 ± 1.4 g/y after initiating chronic hemodialysis (p = 0.0012). Two of 11 patients died of serious infections after initiating chronic hemodialysis.

CONCLUSIONS

Our results showed that the number of relapses tended to be lower despite a significantly different lower amount of steroid after initiating hemodialysis compared with before initiating hemodialysis, and the burn-out phenomenon specific to uremic patients was inferred. We believe that early tapering of steroids should be considered to avoid death rather than focusing only on relapse.

Mesenchymal Progenitor Regulation of Tooth Eruption: A View from PTHrP

Tooth eruption is a unique biological process by which highly mineralized tissues emerge into the outer world, and it occurs concomitantly with tooth root formation. These 2 processes have been considered independent phenomena; however, recent studies support the theory that they are indeed intertwined. Dental mesenchymal progenitor cells in the dental follicle lie at the heart of the coupling of these 2 processes, providing a source for diverse mesenchymal cells that support formation of the highly functional tooth root and the periodontal attachment apparatus, while facilitating formation of osteoclasts. These cells are regulated by autocrine signaling by parathyroid hormone-related protein (PTHrP) and its parathyroid hormone/PTHrP receptor PPR. This PTHrP-PPR signaling appears to crosstalk with other signaling pathways and regulates proper cell fates of mesenchymal progenitor cell populations. Disruption of this autocrine PTHrP-PPR signaling in these cells leads to defective formation of the periodontal attachment apparatus, tooth root malformation, and failure of tooth eruption in molars, which essentially recapitulate primary failure of eruption in humans, a rare genetic disorder exclusively affecting tooth eruption. Diversity and distinct functionality of these mesenchymal progenitor cell populations that regulate tooth eruption and tooth root formation are beginning to be unraveled.

Diverse contribution of Col2a1-expressing cells to the craniofacial skeletal cell lineages

OBJECTIVES

Craniofacial skeletal development requires deliberate coordination of two distinct mechanisms of endochondral and intramembranous ossification. Col2a1-expressing cells encompass growth-associated skeletal progenitors in endochondral bones of the limb. The objective of this study was to determine the contribution of Col2a1-expressing cells to the craniofacial skeletal cell lineages. We hypothesize that Col2a1-expressing progenitors significantly contribute to various modes of ossification associated with the craniofacial development.

METHODS

Cellular fates of Col2a1-expressing cells were studied based on a cre-loxP system using a Col2a1-cre transgene and an R26R-tdTomato reporter allele. We analysed three distinct locations of the craniofacial skeletal complex representing unique ossification mechanisms: the cranial base, the calvaria and the mandibular condyle.

RESULTS

Col2a1-cre consistently marked a majority of skeletal cells in the cranial base. Interestingly, Col2a1-cre also marked a large number of osteoblasts and suture mesenchymal cells in the calvaria, in addition to chondrocytes in the underlying transient cartilage. In the mandibular condyle, Col2a1-cre marked chondrocytes and osteoblasts only during the growth phase.

CONCLUSIONS

Col2a1 is expressed by progenitors of the skeletal lineage in canonical endochondral bone formation occurring in the cranial base. In contrast, other ossification mechanisms of the craniofacial complex utilize Col2a1-expressing cells in a different manner, whereby Col2a1 may be expressed in more differentiated or transient cell types of the skeletal lineage.

The fate of Osterix-expressing mesenchymal cells in dental root formation and maintenance

OBJECTIVES

Osterix (Osx)-expressing mesenchymal cells are progenitors for tooth root forming cells. The aim of this study was to reveal the fates of Osx-expressing cells during and after root formation using a lineage tracing experiment.

MATERIAL AND METHODS

To reveal the fates of Osx-expressing dental mesenchymal progenitors, we took advantage of tamoxifen-inducible Cre reporter system. Osx-creER; R26R-tdTomato mice received tamoxifen (0.1 mg/body) at postnatal day 3 (P3). In this system, Osx-expressing at P3 (Osx-P3) cells undergo recombination, and they and their descendants continue to express Tomato red fluorescence protein permanently. Mandibles were dissected at serial time points ranging from P4 to P116 to investigate how Osx-P3 cells participated in root formation. Tomato⁺ cells on frozen sections were imaged under fluorescence microscopy.

RESULTS

Osx-P3 cells and their descendants differentiated into all kinds of cells that contributed to the root and periodontal tissues, such as odontoblasts, cementoblasts, alveolar bone osteoblasts and periodontal ligament (PDL) cells during root formation. Even after root formation was completed, they persisted in dental pulp and PDL to provide progenitor cells for odontoblasts and cementoblasts.

CONCLUSION

Osx-expressing cells play important roles in the entire processes of tooth root formation; their progeny continue to contribute to maintenance of tooth root even after root formation is complete.

Msx2 Marks Spatially Restricted Populations of Mesenchymal Precursors

Craniofacial development requires a set of patterning codes that define the identities of postmigratory mesenchymal cells in a region-specific manner, in which locally expressed morphogens, including fibroblast growth factors (FGFs) and bone morphogenetic proteins (BMPs), provide instructive cues. Msx2, a bona fide target of BMP signaling, is a transcription factor regulating Runx2 and osterix (Osx), whose mutations are associated with cranial deformities in humans. Here we show that Msx2 defines osteo-chondro precursor cells in specific regions of the craniofacial mesenchyme at the postmigratory stage, particularly in the mandibular process and the posterior cranial vault. Analysis of Msx2-creER mice revealed that early mesenchymal cells in proximity to the BMP4-expressing mesenchyme were marked upon tamoxifen injection, and their descendants contributed to diverse types of mesenchymal cells in the later stage, such as chondrocytes and perichondrial cells of the transient cartilage, as well as osteoblasts and suture mesenchymal cells. By contrast, Osx-creER marked osteoblast precursors at the later stage, and their descendants continued to become osteoblasts well into the postnatal stage. Therefore, Msx2 marks spatially restricted populations of mesenchymal precursor cells with diverse differentiation potential, suggesting that extrinsic molecular cues can dictate the nature of postmigratory mesenchymal cells in craniofacial development.

Implant Insertion into an Augmented Bone Region Using the Canine Mandible Augmented by the "Casing Method"

The purpose of this study was to examine the efficacy of bone augmentation using the "Casing Method," which enables large-scale osteogenesis, and the feasibility of using the augmented bone in dental implants. Three Beagle dogs were used. After tooth extraction, a polyethylene terephthalate case (20 mm × 5 mm × 10 mm) was placed on the buccal surface of the mandible. A mixture of hydroxyapatite and beta-tricalcium phosphate (volume ratio = 1:1) was infiltrated into a suspension of autologous superfine bone powder and plasma, and the resulting mixture was packed into the case. After 16 weeks, the implant was inserted into the augmented bone and the original bone. Specimens of the mandible were collected at 2, 4, 8, and 16 weeks after implant insertion, and undecalcified sections were prepared. The integration of the implant into the surrounding bone tissue was observed histologically. Favorable bone formation was observed in the regions where bone augmentation was performed. The space between the cut bone surface and the implant was filled with newly formed bone in both the augmented and original bone regions. In addition, there was higher bone density in the augmented bone than that in the original bone at the coronal half of the implant at 16 weeks. As a result, bone-to-implant contact was significantly higher in the augmented bone region than in the original bone region. These results suggest that bone augmentation surgery using the "Casing Method" is an effective technique for expanding the application of dental implants. Anat Rec, 301:892-901, 2018. © 2018 Wiley Periodicals, Inc.

Endoscopic antralplasty for severe gastric stasis after wide endoscopic submucosal dissection in the antrum

A 75-year-old female underwent esophagogastroduodenoscopy, revealing a widely spreading tumor occupying the anterior wall, lesser curvature, and posterior wall of the antrum and lower body. Endoscopic submucosal dissection was performed and resulted in more than five-sixths circumferential antral mucosal resection. One month later, she complained of nausea, vomiting, and abdominal distention. Endoscopy showed residual food in the stomach and deformation of the antrum with traction toward the contracted scar in the lesser curvature. The pyloric ring could not be seen from the antrum although the endoscope was able to pass easily beyond the area of deformation and the pyloric ring was intact. Despite repeated endoscopic balloon dilations, the patient’s symptoms remained refractory. The problem was speculated to be not due to any potential stricture but to antrum deformation resulting from the traction force toward the healing ulcer. We hypothesized that an additional countertraction force opposite the previous ESD site might resolve the problem, and ESD of approximately 2.5 cm size was performed in the greater curvature of the antrum. Along with development of a scar, traction toward the greater curvature was added, and the pyloric ring could be observed on repeat esophagogastroduodenoscopy. The symptoms were also gradually ameliorated. Afterwards, the endoscopic findings have now been unchanged during 7 years of follow-up.

Clinical significance of the muscle-retracting sign during colorectal endoscopic submucosal dissection

BACKGROUND AND STUDY AIMS

During colorectal endoscopic submucosal dissection (ESD), the feature of a muscle layer being pulled toward a neoplastic tumor is sometimes detected. We call this feature the muscle-retracting sign (MR sign). The aim of this study was to evaluate whether the MR sign is associated with particular types of neoplastic lesions and whether it has any clinical significance for ESD sessions.

PATIENTS AND METHODS

A total of 329 patients underwent ESD for 357 colorectal neoplasms. The frequency of positivity for the MR sign was evaluated in different morphologic and histopathologic types of neoplasm. The success rate of complete resection and the incidence of complications were also evaluated according to whether lesions were positive or negative for the MR sign.

RESULTS

The rates of positivity for the MR sign in the various lesion types were as follows: laterally spreading tumor - granular nodular mixed type (LST-G-M), 9.6 %; laterally spreading tumor - granular homogeneous type (LST-G-H) and laterally spreading tumor - nongranular type (LST-NG), 0 %; sessile type, 41.2 %. The resection rate was 100 % (329 /329) in lesions negative for the MR sign; however, it was 64.3 % (18 /28) in lesions positive for the MR sign, which was significantly lower (P < 0.001).

CONCLUSIONS

The MR sign was present only in some protruding lesions, and more importantly, it was associated with a high risk of incomplete tumor removal by ESD. Our data indicate that lesions positive for the MR sign lesions should be dissected with great caution; alternatively, based on the features of the individual case, a switch to surgery should be considered for the benefit of the patient.

Emergency balloon-occluded retrograde transvenous obliteration of ruptured gastric varices

AIM: To evaluate the effectiveness and safety of emergency balloon-occluded retrograde transvenous obliteration (BRTO) for ruptured gastric varices.

METHODS: Emergency BRTO was performed in 17 patients with gastric varices and gastrorenal or gastrocaval shunts within 24 h of hematemesis and/or tarry stool. The gastric varices were confirmed by endoscopy, and the gastrorenal or gastrocaval shunts were identified by contrast-enhanced computed tomography (CE-CT). A 6-Fr balloon catheter (Cobra type) was inserted into the gastrorenal shunt via the right internal jugular vein, or into the gastrocaval shunt via the right femoral vein, depending on the varices drainage route. The sclerosant, 5% ethanolamine oleate iopamidol, was injected into the gastric varices through the catheter during balloon occlusion. In patients with incomplete thrombosis of the varices after the first BRTO, a second BRTO was performed the following day. Patients were followed up by endoscopy and CE-CT at 1 d, 1 wk, and 1, 3 and 6 mo after the procedure, and every 6 mo thereafter.

RESULTS: Complete thrombosis of the gastric varices was not achieved with the first BRTO in 7/17 patients because of large gastric varices. These patients underwent a second BRTO on the next day, and additional sclerosant was injected through the catheter. Complete thrombosis which led to disappearance of the varices was achieved in 16/17 patients, while the remaining patient had incomplete thrombosis of the varices. None of the patients experienced rebleeding or recurrence of the gastric varices after a median follow-up of 1130 d (range 8-2739 d). No major complications occurred after the procedure. However, esophageal varices worsened in 5/17 patients after a mean follow-up of 8.6 mo.

CONCLUSION: Emergency BRTO is an effective and safe treatment for ruptured gastric varices.

1,635 Endoscopic submucosal dissection cases in the esophagus, stomach, and colorectum: complication rates and long-term outcomes

Background

Endoscopic submucosal dissection (ESD) enables en bloc resection of early gastrointestinal neoplasms; however, most ESD articles report small series, with short-term outcomes performed by multiple operators on single organ. We assessed short- and long-term treatment outcomes following ESD for early neoplasms throughout the gastrointestinal tract.

Methods

We performed a longitudinal cohort study in single tertiary care referral center. A total of 1,635 early gastrointestinal neoplasms (stomach 1,136; esophagus 138; colorectum 361) were treated by ESD by single operator. Outcomes were complication rates, en bloc R0 resection rates, and long-term overall and disease-specific survival rates at 3 and 5 years for both guideline and expanded criteria for ESD.

Results

En bloc R0 resection rates were: stomach: 97.1 %; esophagus: 95.7 %; colorectum: 98.3 %. Postoperative bleeding and perforation rates respectively were: stomach: 3.6 and 1.8 %; esophagus: 0 and 0 %; colorectum: 1.7 and 1.9 %. Intra criteria resection rates were: stomach: 84.9 %; esophagus: 81.2 %; colorectum: 88.6 %. Three-year survival rates for lesions meeting Japanese ESD guideline/expanded criteria were for all organ-combined: 93.4/92.7 %. Five-year rates were: stomach: 88.1/84.6 %; esophagus: 81.6/57.3 %; colorectum: 94.3/100 %. Median follow-up period was 53.4 (range, 0.07–98.6) months. Follow-up rate was 94 % (1,020/1,085). There was no recurrence or disease-related death.

Conclusions

In this large series by single operator, ESD was associated with high curative resection rates and low complication rates across the gastrointestinal tract. Disease-specific and overall long-term prognosis for patients with lesions within intra criteria after curative resection appeared to be excellent.

A case of very large intrahepatic bile duct adenoma followed for 7 years

A 70-year-old man was referred to our hospital due to abnormal liver function. A tumor of 92 mm × 61 mm was detected on ultrasound screening of the left liver lobe. Although the tumor was suspected to be intrahepatic bile duct carcinoma, he had chronic heart disease and was unable to undergo surgery. Therefore, he was followed without further testing. No increase in tumor serum markers or tumor size was observed for the subsequent 7 years. We continued to suspect intrahepatic bile duct carcinoma, and we decided to perform a tumor biopsy. Tumor biopsy findings indicated intrahepatic bile duct adenoma (BDA), which is a rare benign epithelial liver tumor typically ranging from 1 mm to 20 mm. We herein report a case of very large BDA followed for 7 years.

Three benefits of microcatheters for retrograde transvenous obliteration of gastric varices

AIM: To evaluate the usefulness of the microcatheter techniques in balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices.

METHODS: Fifty-six patients with gastric varices underwent BRTOs using microcatheters. A balloon catheter was inserted into gastrorenal or gastrocaval shunts. A microcatheter was navigated close to the varices, and sclerosant was injected into the varices through the microcatheter during balloon occlusion. The next morning, thrombosis of the varices was evaluated by contrast enhanced computed tomography (CE-CT). In patients with incomplete thrombosis of the varices, a second BRTO was performed the following day. Patients were followed up with CE-CT and endoscopy.

RESULTS: In all 56 patients, sclerosant was selectively injected through the microcatheter close to the varices. In 9 patients, microcoil embolization of collateral veins was performed using a microcatheter. In 12 patients with incomplete thrombosis of the varices, additional injection of sclerosant was performed through the microcatheter that remained inserted overnight. Complete thrombosis of the varices was achieved in 51 of 56 patients, and the remaining 5 patients showed incomplete thrombosis of the varices. No recurrence of the varices was found in the successful 51 patients after a median follow up time of 10.5 mo. We experienced one case of liver necrosis, and the other complications were transient.

CONCLUSION: The microcatheter techniques are very effective methods for achieving a higher success rate of BRTO procedures.

Usefulness of microcatheters inserted overnight for additional injection of sclerosant after initial balloon-occluded retrograde transvenous obliteration of gastric varices

In patients with large gastric varices, dose limitation of the sclerosant can cause difficulties in achieving complete thrombosis of varices during a single balloon-occluded retrograde transvenous obliteration (BRTO) procedure. For patients with incomplete variceal thrombosis after the first BRTO, additional sclerosant must be injected in a second BRTO. We report a successful case of BRTO for large gastric varices in whom additional sclerosant was injected through a microcatheter that remained inserted overnight. To achieve complete variceal thrombosis in a patient with incomplete thrombosis of large gastric varices after a first BRTO, a retained microcatheter can be used to inject additional sclerosant in a second BRTO the next day.

The performance of a novel ball-tipped Flush knife for endoscopic submucosal dissection: a case-control study

BACKGROUND

Endoscopic submucosal dissection (ESD) using short needle knives is safe and effective, but bleeding is a problem due to low haemostatic capability.

AIM

To assess the performance of a novel ball-tipped needle knife (Flush knife-BT) for ESD with particular emphasis on haemostasis.

METHODS

A case-control study to compare the performance for ESD of 30 pairs of consecutive early gastrointestinal lesions (oesophagus: 12, stomach: 32, colorectum: 16) with standard Flush knife (F) vs. Flush knife-BT (BT). Primary outcome was efficacy of intraprocedure haemostasis. Secondary outcomes included procedure time, procedure speed (dividing procedure time into the area of resected specimen), en bloc resection rate and recurrence rate.

RESULTS

Median intraoperative bleeding points and bleeding points requiring haemostatic forceps were smaller in the BT group than in the F group (4 vs. 8, P < 0.0001, 0 vs. 3, P < 0.0001). There was no difference between groups for procedure time; however, procedure speed was shorter in the BT group (P = 0.0078). En bloc and en bloc R0 resection rates were 100%, with no perforation or post-operative bleeding. No recurrence was observed in either group at follow-up 1 year postprocedure.

CONCLUSIONS

Ball-tipped Flush knife (Flush knife-BT) appears to improve haemostatic efficacy and dissection speed compared with standard Flush knife.

The performance of a novel ball-tipped Flush knife for endoscopic submucosal dissection: a case-control study

BACKGROUND

Endoscopic submucosal dissection (ESD) using short needle knives is safe and effective, but bleeding is a problem due to low haemostatic capability.

AIM

To assess the performance of a novel ball-tipped needle knife (Flush knife-BT) for ESD with particular emphasis on haemostasis.

METHODS

A case-control study to compare the performance for ESD of 30 pairs of consecutive early gastrointestinal lesions (oesophagus: 12, stomach: 32, colorectum: 16) with standard Flush knife (F) vs. Flush knife-BT (BT). Primary outcome was efficacy of intraprocedure haemostasis. Secondary outcomes included procedure time, procedure speed (dividing procedure time into the area of resected specimen), en bloc resection rate and recurrence rate.

RESULTS

Median intraoperative bleeding points and bleeding points requiring haemostatic forceps were smaller in the BT group than in the F group (4 vs. 8, P < 0.0001, 0 vs. 3, P < 0.0001). There was no difference between groups for procedure time; however, procedure speed was shorter in the BT group (P = 0.0078). En bloc and en bloc R0 resection rates were 100%, with no perforation or post-operative bleeding. No recurrence was observed in either group at follow-up 1 year postprocedure.

CONCLUSIONS

Ball-tipped Flush knife (Flush knife-BT) appears to improve haemostatic efficacy and dissection speed compared with standard Flush knife.

Does the nature of deposited basic calcium phosphate crystals determine clinical course in calcific periarthritis of the shoulder?

OBJECTIVE

Two typical clinical courses of calcific periarthritis in the shoulder are known: acute, with severe inflammation, and chronic, in the form of impingement syndrome with secondary subacromial bursitis. It remains unclear what factors determine these clinical courses. Our objectives were to clarify whether the calcified deposits that occur in both acute and chronic cases are composed of carbonate apatite; and to compare the Ca:P molar ratio in the 2 forms and to determine if there was any correlation in this respect with the intensity of inflammation induced by basic calcium phosphate crystals.

METHODS

Ten samples were aspirated from 10 women (ages 42-65 yrs) with acute inflammation. The average time from first attack to aspiration was 2.3 days. A further 10 samples were operatively removed from 10 women (ages 35-58 yrs) with refractory chronic subacromial bursitis, among whom an average of 7.8 months had passed since the onset of symptoms. All samples were analyzed by x-ray diffraction, Fourier transform infrared spectroscopy, and Raman spectroscopy, and Ca:P molar ratios were measured by x-ray fluorescence spectrometry.

RESULTS

Calcified deposits from both acute and chronic cases were identified as carbonate apatite, and not hydroxyapatite, octacalcium phosphate, tricalcium phosphate, or dicalcium phosphate dihydrate. The average Ca:P molar ratio of calcified deposits was calculated as 1.71 +/- 0.16 in acute cases and 1.71 +/- 0.16 in chronic cases (statistically nonsignificant).

CONCLUSION

Deposits around the shoulder in both acute and chronic calcific periarthritis are composed of carbonate apatite, Ca:P molar ratios being almost identical in the 2 forms. The results suggest that some factor other than the composition of the crystalline deposits may determine clinical course in calcific periarthritis of the shoulder.

Uremic tumoral calcinosis in hemodialysis patients: clinicopathological findings and identification of calcific deposits

OBJECTIVE

Extraskeletal calcifications generally develop in uremic patients. Periarticular massive calcifications, referred to as uremic tumoral calcinosis (UTC), represent solitary or multifocal calcium phosphate deposits. Our objectives were to clinically analyze a series of 8 patients with UTC undergoing hemodialysis, and to characterize calcium deposits in UTC.

METHODS

The clinical, radiological, and pathological features of 8 consecutive patients (4 men and 4 women, mean age 49 yrs) with UTC were analyzed, and treatment and outcome were evaluated. Calcific specimens from the 8 patients were analyzed by x-ray diffraction, Raman spectroscopy, and infrared spectroscopy.

RESULTS

Unifocal UTC was observed in 5 patients, whereas multifocal lesions occurred in 3 patients. The most common sites of UTC were the shoulders, elbows, and hands. Elevated serum calcium and phosphorus and intact parathyroid hormone were detected in 63% (n = 5), 100% (n = 8), and 63% (n = 5) of the patients, respectively. An increased calcium-phosphorus (Ca P) product was observed in 6 patients. Medical intervention to decrease the Ca P product achieved complete remission in 3 of 5 patients with solitary UTC, whereas this treatment was ineffective for multiple UTC. The 8 calcium deposits were identified as carbonate apatite.

CONCLUSION

The most important pathogenic factors in UTC are an increased Ca P product and hyperphosphoremia, which is not necessarily related to hyperparathyroidism. Medical intervention is effective for solitary UTC, but combined treatment (surgery and medical therapy) is required for multiple UTC. Calcium deposits in UTC are composed of carbonate apatite.

Analysis of calcium deposits in calcific periarthritis

OBJECTIVE

To determine if hydroxyapatite (HAP), octacalcuim phosphate (OCP), or tricalcium phosphate (TCP) can be found in the calcium deposits in calcific periarthritis.

METHODS

Thirty-six specimens from 34 patients who had acute inflammation and roentgenographically recognized calcification in soft tissue were analyzed. Twenty-three patients with calcific tendinitis in the shoulder and 11 with calcific periarthritis at other sites were included. We prepared 2 kinds of samples from each specimen; a dried sample (washed and dried calcific deposit), and a sample heated to 1,000 degrees C. All were analyzed by X-ray diffraction, Raman spectroscopy, infrared absorption spectroscopy, and X-ray fluorescence spectrometry for calcium and phosphorus molar ratio. Synthetic HAP was used as the control in each analysis.

RESULTS

The X-ray diffraction patterns of all dried samples were similar to those of HAP and carbonate apatite. We found no diffraction patterns of OCP or TCP. However, an OH- group at 3570cm(-1) was observed with Raman spectroscopy for samples heated to 1,000 degrees C and synthetic HAP, but not for the dried samples. Infrared absorption spectroscopy also confirmed an OH- group for samples heated to 1,000 degrees C and synthetic HAP, and confirmed that dried samples contained carbonate.

CONCLUSION

Calcium deposits are composed of carbonate apatite. HAP, OCP, and TCP were not identified in any deposits.

Nondiffuse fatty change of the liver: discerning pseudotumor on MR images enhanced with ferumoxides-initial observations

PURPOSE

To clarify the findings of nondiffuse fatty change of the liver on ferumoxides-enhanced magnetic resonance (MR) images.

MATERIALS AND METHODS

Of 202 patients who underwent ferumoxides-enhanced MR imaging, eight who had nondiffuse fatty change of the liver at computed tomography (CT) were examined as study subjects. MR imaging findings before and 1 hour after ferumoxides administration were compared with CT findings.

RESULTS

Focal fatty areas of the liver showing low attenuation on CT images were depicted as areas of relatively high intensity on the ferumoxides-enhanced T1-weighted images in all patients. On enhanced T2-weighted images, focal fatty change showed relatively high intensity in three and isointensity in one of the four patients. Focal spared areas appearing as areas of relatively high attenuation on CT images were depicted as areas of relatively low intensity on the ferumoxides-enhanced T1- and T2-weighted images in all patients.

CONCLUSION

Although prior reports of hepatic MR imaging with ferumoxides indicated that there is accumulation of ferumoxides within focal fatty areas that are no longer seen after the administration of contrast medium, this study revealed that focal fatty change and focal spared areas of fatty liver may be pseudotumors because of the relatively high intensity of fatty areas of the liver. Radiologists can distinguish these conditions from hepatic tumors by using the opposed-phase gradient-echo sequence or the fat-saturation technique.

Serum nucleotide pyrophosphohydrolase activity; elevated levels in osteoarthritis, calcium pyrophosphate crystal deposition disease, scleroderma, and fibromyalgia

OBJECTIVE

Quantification of serum nucleotide pyrophosphohydrolase (NTPPHase) activity in healthy subjects and in patients with various rheumatic diseases or with quad/hemiplegia, hemodialysis, or renal transplant.

METHODS

Colorimetric assay of enzyme activity in serum.

RESULTS

Serum NTPPHase activity in 85 healthy subjects was independent of age or sex and was highly reproducible in each individual. The biologic and methodologic coefficients of variation were nearly identical. Elevated enzyme levels were found in sera from patients with osteoarthritis/spondylosis, calcium pyrophosphate dihydrate (CPPD) crystal deposition, scleroderma, fibromyalgia, or hemodialysis. Renal transplant patients receiving cyclosporine had the highest enzyme activity of any group, whereas transplant patients not taking this drug had normal levels. Histograms of values in all groups showed a normal distribution.

CONCLUSION

Serum NTPPHase activity levels were significantly elevated in patients with degenerative arthritis whether or not CPPD crystals were present, in patients with either scleroderma or fibromyalgia, and in patients receiving hemodialysis therapy or taking cyclosporine.

Optimal dose of hepatobiliary contrast agent for MR cholangiography: experimental study in rats

The purpose of this study is to clarify the optimal dose of gadolinium-ethoxybenzyl-diethylenetriaminepentaacetic acid (Gd-EOB-DTPA) for cholangiography in conventional T1-weighted imaging. We divided 30 rats into three dose groups (3, 10, and 30 micromol/kg). For the in vitro study, we collected bile and measured the concentration of gadolinium in bile after Gd-EOB-DTPA injection. T1-weighted images of the collected bile were obtained for measurement of signal intensity. For the in vivo study, we obtained T1-weighted images before and after injection and evaluated bile duct/liver contrast by the signal intensity ratio and visual assessment of the images. The gadolinium concentration had an early peak; however, the signal intensity of the bile had a later peak because of the high gadolinium concentration during the early phase, which induced a T2-shortening effect. Optimal bile duct/liver contrast was obtained in the 10-micromol/kg groups at all time points. We conclude that the optimal dose of Gd-EOB-DTPA for MR cholangiography in rats is 10 micromol/kg, one-third of the dose used in liver imaging.

[Calcification of cervical ligamentum flavum--analysis of calcium compounds and histopathological findings]

We operated 3 patients with cervical myelopathy due to calcification of ligamentum flavum (CLF). Specimens collected surgically were subjected to X-ray diffraction (XRD), Fourier transform infrared spectroscopy (FTIR) and Raman spectroscopy (Raman) analysis and also histopathological examination. The calcium compounds deposited were calcium pyrophosphate dihydrate (CPPD) in Case 1, apatite in Case 2, and a double-layer structure with an outer CPPD layer and an inner carbonate apatite layer in Case 3. Histopathologically, CPPD deposition in Case 1 could be distinguished from apatite deposition in Case 2 and 3 by hematoxylin-eosin stain. Chondrocytes were observed in all 3 cases, suggesting the chondrocytes may have played a role in calcification in these three cases. To date, 62 cases of CLF (including the present cases) have been reported, and analysis of calcium compound has been performed for 29 of them. Of these 29, 15 were analyzed as calcium phosphate compounds, 9 as CPPD and 4 cases as mixed crystals like Case 3. However the analysis method and result about CPPD are no problem, the analysis result of calcium phosphate compounds depends on the using methods. Calcium phosphate or undetectable compounds was identified by XRD as hydroxyapatite (HAp), and by FTIR as calcium phosphate or undetectable compound. Analysis of calcium phosphate compounds should be condacted and identified by XRD, FTIR, and Raman. We propose two possible mechanisms for the formation of the double-layer structure in Case 3: one is formation of apatite first followed by deposition of CPPD outside, and the other is formation of CPPD first followed by conversion of CPPD in the central region to apatite. What the process of formation of the double-layer was in this cases remains unclear.

Nucleotide pyrophosphohydrolase in human synovial fluid

OBJECTIVE

To identify the molecular forms of ectonucleotide pyrophosphohydrolase (NTPPHase) in human synovial fluid (SF).

METHODS

We examined synovial fluids from 32 patients with various joint diseases [10 calcium pyrophosphate dihydrate (CPPD) deposition disease; 7 osteoarthritis (OA); 6 rheumatoid arthritis (RA); 3 after total knee arthroplasty (TKA); 6 olecranon bursa] and 3 normal joint fluids. Joint fluids were analyzed after sequential centrifugation for NTPPHase activity and by Western blot using polyclonal antibodies against 127 kDa porcine articular cartilage vesicle-associated NTPPHase and against PC-1 and 58 kDa, 2 other ecto-NTPPHases. Lysate from human synoviocytes, porcine chondrocytes, and their conditioned media were examined using antibodies to these ecto-NTPPHases. Radiographs of joints from which fluid was obtained were graded for degenerative changes 0-4 using a standard method.

RESULTS

NTPPHase activity was found in all pathological and normal SF tested and correlated with the degree of radiographic degeneration (r = 0.55, p < 0.05). NTPPHase specific activity in ultracentrifugation pellets was highest in CPPD deposition disease fluids (p < 0.05). 127 kDa enzyme was found in both sedimentable and soluble fractions from CPPD, OA, TKA, and normal fluids, and was extensively degraded in all inflammatory fluids. Intact 115 kDa PC-1 was found only in the 2 CPPD fluids with the highest NTPPHase activity. 58 kDa enzyme was found in most fluids, predominantly in the soluble fraction. 127 kDa protein was identified in human synoviocyte conditioned media but not in cell lysate, while PC-1 and 58 kDa proteins were found in the cell lysate but not in the conditioned media.

CONCLUSION

There was no disease specific association with any one ecto-NTPPHase. Total enzyme activity correlated with the degree of degenerative change. The specific activity of pelletable 127 kDa enzyme was higher in fluids containing CPPD crystals. All 3 ecto-NTPPHases or their presumed degradation products were detectable in some pathologic and normal fluids. A 200 kDa reactive band often accompanied reactivity to the 127 kDa enzyme. PC-1 and 127 kDa proteins were extensively degraded in inflammatory SF, while 58 kDa protein was not. The relative contribution of each of these enzymes to inorganic pyrophosphate production by human joint tissues remains unclear.

MR cholangiopancreatography and MR urography: improved enhancement with a negative oral contrast agent

At magnetic resonance (MR) cholangiopancreatography and MR urography with an oral negative contrast agent, low signal intensity was produced in phantoms. In 20 patients suspected of having biliary tract and pancreatic diseases and in 20 healthy volunteers, the signal intensity in the gastrointestinal tract was almost completely eliminated with the negative contrast agent. Differences in image quality between pre- and postcontrast images were statistically significant.

Identification of a nucleotide pyrophosphohydrolase from articular tissues in human serum

OBJECTIVE

To characterize the nucleotide pyrophosphohydrolase (NTPPHase) in human serum.

METHODS

NTPPHase activity and kinetic analysis were performed using thymidine monophosphate paranitrophenyl ester (TMPNP) or 32Pgamma-labeled ATP as substrate. Sera were chromatographed (dye column), and peak fractions were analyzed kinetically and by immunoblot using antibodies to 127-kd articular cartilage vesicle (ACV) NTPPHase as well as to PC-1 and to 58 kd, two plasma membrane ecto-NTPPHases. Enzyme activity was measured before and after sample ultracentrifugation.

RESULTS

NTPPHase activity was found in all sera tested (2 normal subjects, 9 arthritis patients). Specific activity was increased 9-32-fold after chromatography; 60-80% of total activity was recovered in a single peak containing an approximately 100-kd soluble peptide related to the 127-kd ACV enzyme. The apparent Km of this peptide (TMPNP) was virtually identical to that of the porcine ACV 127-kd enzyme. No immunoreactivity against PC-1 or 58-kd NTPPHase was found.

CONCLUSION

Human serum NTPPHase is derived from 127-kd ACV-related enzyme.