Coil Embolization for Intracranial Aneurysm by Direct Puncture of the Carotid Artery in Elderly Patients

Seven aneurysms in elderly patients (average 78 year-old) were treated by intra-aneurysmal coil embolization. The 19 gage elastic needle or 4.0Fr. sheath introducer was placed into the carotid artery, and 3.0Fr. microcatheter was advanced into the aneurysm.

An operative difficulty to approach to the aneurysm due to arteriosclerosis was ameliorated by this method. Mobility related to this procedure was a local hematoma at the puncture site in one case.

A clinical and ultrasonographic study of risk factors for elbow injury in young baseball players

PURPOSE

To determine the risk factors for elbow injury and its association with glenohumeral internal rotation deficit among young baseball players.

METHODS

229 baseball players aged 9 to 14 (mean, 11) years completed a self-administered questionnaire with items related to years of playing baseball, hours of training per weekday, days of training per week, and past and present experience of elbow pain. Two orthopaedic surgeons measured the range of motion of both shoulders and elbows. Another 2 orthopaedic surgeons performed ultrasonography to detect any elbow abnormality such as fragmentation of the medial epicondylar apophysis and osteochondritis dissecans of the capitellum. Using univariate and multivariable analyses, participants with or without elbow abnormality were compared to determine the risk factors for elbow abnormality.

RESULTS

Elbow abnormality was detected in 100 of the participants and comprised osteochondritis dissecans of the capitellum (n=18) and fragmentation of the medial epicondylar apophysis (n=82). Elbow abnormality was associated with being a pitcher, past and present experience of elbow pain, loss of elbow extension, and the side-to-side internal rotation difference. The 100 participants with elbow abnormality were stratified into symptomatic (n=57) or asymptomatic (n=43) of elbow pain. Those with elbow abnormality and elbow pain was associated with being a pitcher.

CONCLUSION

Being a pitcher was a risk factor for both elbow abnormality and elbow pain. Nonetheless, 43% of baseball players with elbow abnormality were asymptomatic. The use of ultrasonography was effective in detecting elbow abnormality and enabling early treatment.

Human skin epidermal adenylate cyclase systems: defective beta-adrenergic responsiveness in the involved epidermis of Darier's disease

It has been reported that pig skin epidermis contains at least four independent adenylate cyclase systems, i.e. 1) beta-adrenergic-, 2) histamine H2-, 3) adenosine and, 4) prostaglandin E-adenylate cyclase systems, resulting in the accumulation of cyclic AMP. Using human skin epidermis, we investigated the responses of adenylate cyclase to epinephrine, histamine, and adenosine. In normal human skin, all three agents increased cyclic AMP levels of the skin. The epinephrine effect was inhibited by a beta-adrenergic blocking agent, propranolol. The histamine effect was inhibited by a histamine H2 inhibitor, cimetidine. The adenosine effect was inhibited by theophylline. The effects of epinephrine and histamine were augmented by the addition of the cyclic AMP phosphodiesterase inhibitor, theophylline. Another phosphodiesterase inhibitor, papaverine, augmented the effects of all three agents. In contrast to pig skin epidermis, where histamine and adenosine-induced cyclic AMP accumulations were marked, in human skin, epinephrine-induced cyclic AMP accumulation was more marked than those induced by histamine and adenosine. Using the epidermis of Darier's disease, we also investigated the effects of epinephrine, histamine and adenosine on the cyclic AMP levels of the skin. The involved skin of Darier's disease was shown to be characterized by a defective beta-adrenergic responsiveness. These findings show that normal human skin possesses at least three independent adenylate cyclase systems (beta-adrenergic, histamine H2-, and adenosine-adenylate cyclase), as in pig skin epidermis, with a different responsiveness pattern to these stimulators. Our data also show that the responsiveness to each receptor-adenylate cyclase system may be modified in a pathological condition of epidermis such as in Darier's disease. The significance of decreased beta-adrenergic responsiveness in the involved skin in Darier's disease was discussed in relation to our previous finding of the same type of defect in the psoriatic-involved epidermis.

Cyclic GMP system in the epidermis

A great deal of knowledge has been gained concerning the activation of adenylate and guanylate cyclase in epidermal cells. Adenylate cyclase is activated by 4 different independent receptors-responding respectively to catecholamine (beta), to prostaglandins (E), to histamine (H2), and to adenosine and it phosphorylated derivatives. Upon activation, each of these receptors becomes unresponsive to further stimulation by its specific stimulator. Guanylate cyclase, on the other hand, is activated by histamine (H1) and epidermal growth factor (EGF). Unlike EGF, the histamine activation is extremely rapid (less than 5 minutes). Epidermal cells are permeable (leak) to cyclic GMP but not cyclic AMP. When the skin is traumatized or injured in any way (even by intradermal injection) there is a sudden catastrophic change in the intracellular levels of the cyclic nucleotides (and of ATP). Cyclic AMP rapidly rises to perhaps 5-10 times its normal resting level while cyclic GMP falls to 10-20% of its level in vivo. The rise in cyclic AMP is due to activation of adenylate cyclase while the fall in cyclic GMP is due in major part to activation of cyclic GMP phosphodiesterase (and perhaps the fall in ATP is due to activation of ATPase). The changes in ATP and cyclic AMP can be reversed by incubating the tissue in a buffered salt solution containing glucose, but this does not normalize the cyclic GMP content. The fall in cyclic GMP can be prevented by a phosphodiesterase inhibitor (IBMX ). This series of events has been called the "ischemia effect." However, it implies that a lack of oxygen is at fault, and that has not been shown to be the case. Its underlying cause and possible physiologic significance are not known. Do these changes in cyclic nucleotides have effects on epidermal proliferation? And does EGF? Agents which increase cyclic AMP do inhibit the epidermal outgrowth and mitotic activity of explant cultures of pig skin. Cyclic GMP does increase outgrowth at a particular concentration. Histamine, which elevates both cyclic nucleotides, has a biphasic action depending on its concentration. These findings imply that these nucleotides do act as one of the controls of epidermal proliferation. The action of cyclic GMP is not accompanied by detectably increased phosphorylation of epidermal proteins. On the other hand, EGF action which also enhances epidermal outgrowth is characterized by an increased protein phosphorylation that precedes any increase in cellular cyclic GMP. We conclude that the action of EGF is independent of the cyclic nucleotide system.

Adult orbital xanthogranulomatous disease: adult-onset xanthogranuloma of periorbital location

Adult orbital xanthogranulomatous disease (AOXGD) is a rare granulomatous disorder, which has four subtypes: adult-onset xanthogranuloma (AOX), adult-onset asthma with periocular xanthogranuloma, necrobiotic xanthogranuloma and Erdheim-Chester disease. We report a 42-year-old woman who presented with yellowish nonulcerative nodules on her eyelids. On histopathological examination of a nodule, mild degeneration of collagen fibres was seen, with surrounding infiltration of numerous foam cells and Touton giant cells in the deep dermis. Lymphoid follicles were seen in the reticular dermis. There was no apparent necrobiosis of collagen fibres. There were no clinical symptoms of asthma and no laboratory signs of paraproteinaemia during a follow-up of more than 5 years. We diagnosed this case as AOX, but further long-term follow-up would be required for the differentiation from the other AOXGDs. Dermatologists should be aware of these rare granulomatous disease conditions with ocular/orbital location, because they may cause ophthalmological complications.

The nuclear factor kappa B p50 subunit and cortactin as markers to distinguish between keratoacanthoma and well-differentiated squamous cell carcinoma

BACKGROUND

Distinguishing keratoacanthoma (KA) from well-differentiated squamous cell carcinoma (SCC) is sometimes difficult. Recent evidence indicates that the nuclear factor kappa B p50 subunit (p50) and cortactin might be useful to distinguish between these two conditions.

AIM

To verify whether p50 and cortactin are useful differentiation markers to distinguish between subungual KA and well-differentiated SCC.

METHODS

Immunohistochemistry using p50, cortactin and Ki-67 was performed on 20 patients with KA and 20 patients with facial well-differentiated SC. Ki-67 staining was also evaluated and scored.

RESULTS

Both p50 and cortactin had higher levels of expression in KA than in SCC. Both were localized to the basal-cell layer of KA, whereas they were scattered without polarity throughout the SCC lesions. Although the Ki-67 index was not significantly different between KA and SCC, the staining pattern also showed loss of polarity in SCC.

CONCLUSION

p50 and cortactin might be useful makers to distinguish between KA and well-differentiated SCC.

Recalcitrant facial pemphigus vulgaris: correlation of skin lesions with the ratio of antidesmoglein antibodies 1 and 3

Pemphigus vulgaris (PV) is an autoimmune bullous disease characterized by autoantibodies against desmogleins. We report a case of recalcitrant PV, which progressed from the mucosal to the mucocutaneous type, with a corresponding increase in anti-desmoglein (Dsg)1 and decrease in anti-Dsg3 antibody titres. Thus, the clinical features seemed to correlate with the ratio of anti-Dsg1 and 3. The patient also had anti-Dsg4 antibodies, which might be related to the nonscarring diffuse hair loss and marked facial involvement she also had. The patient did not respond to treatment with systemic steroid, ciclosporin, azathioprine, cyclophosphamide or double filtration plasmapheresis, and eventually died from fulminant thrombotic thrombocytopenic purpura of unknown cause.

Serum cytokines and growth factor levels in Japanese patients with psoriasis

BACKGROUND

Although the precise pathomechanism of psoriasis is still unknown, various cytokines and growth factors derived from T cells, dendritic cells or keratinocytes, are critically involved in this disease. There have been several studies determining the serum levels of cytokines in patients with psoriasis, but with conflicting results. The levels of various cytokines and growth factors were measured in the sera of patients with psoriasis and compared with those of healthy controls. The correlation with disease severity was also determined.

METHODS

Sera were collected from 122 patients with psoriasis and 78 healthy controls for ELISA analysis to evaluate the levels of cytokines and growth factors. The severity of psoriasis was determined by the Psoriasis Area and Severity Index (PASI).

RESULTS

Serum levels of tumour necrosis factor (TNF)-alpha, interferon (IFN)-gamma, interleukin (IL)-2, IL-6, IL-7, IL-8, IL-12, IL-17, IL-18 and vascular endothelial growth factor (VEGF) were significantly increased in patients with psoriasis compared with those of healthy controls. The serum levels of IL-2, soluble intercellular adhesion molecule-1, epidermal growth factor, hepatocyte growth factor and amphiregulin were not significantly different from those of healthy controls. Increased serum levels of TNF-alpha, IFN-gamma, IL-12, IL-17, IL-18 and VEGF correlated with PASI. Furthermore, these cytokine levels were decreased after psoriasis treatment. In contrast, serum levels of IL-10 were decreased in psoriasis and negatively correlated with PASI.

DISCUSSION

Serum levels of TNF-alpha, IFN-gamma, IL2, IL-6, IL-7, IL-8, IL-12, IL-17, IL-18 and VEGF were positively correlated and that of IL-10 was negatively correlated with PASI in Japanese patients with psoriasis. These parameters might be useful for determining the disease activity of psoriasis.

Endoscopic submucosal dissection for colorectal tumors

BACKGROUND

Endoscopic submucosal dissection (ESD) is a state-of-the-art method that enables resection of larger tumors than those resectable by conventional endoscopic mucosal resection (EMR). However, the individual role of each method in the treatment of colorectal tumors remains undetermined.

OBJECTIVE AND METHODS

To consider the respective indications of ESD and EMR for colorectal tumors, we analyzed the results of the two treatments retrospectively.

RESULTS

Tumors treated by ESD (44 tumors) were significantly larger, more often located in the rectum and more often coexistent with cancer than those treated by EMR (512 tumors). EMR was used in the majority of adenomas, and showed high rates of both one-piece resection (OPR) and complete resection (CR) for adenomas less than 20 mm. However, for adenomas and cancers greater or equal to 20 mm, the CR rate for EMR was significantly lower than that for ESD because of the incidence of OPR with a positive lateral margin (16% vs 0% with ESD vs EMR). Histopathology (cancer), size (> or =20 mm) and macroscopic type (laterally spreading tumors) were shown to be significant risk factors for that incidence. For tumors with these factors, ESD showed a higher CR rate than did EMR. However, ESD required longer operating times and tended to have a higher rate of perforation compared with EMR. ESD was aborted halfway in seven cases due to technical difficulties and perforation.

CONCLUSION

ESD and EMR have different characteristics as treatment for colorectal tumors. Careful evaluation of the lesion and of the balance between benefits and risks are mandatory before selecting either of these treatments for colorectal tumors.

Morphological study of aneurysms at the junction of the superior cerebellar artery

SUMMARY

Superior cerebellar artery (SCA) aneurysms sometimes involve the origin of the SCA making treatment difficult. We focused on the morphological characteristics of SCA aneurysms and adjacent vascular structures to apply clinical decision-making for the treatment strategy. Sixty-nine SCA aneurysms, including 34 ruptured and 35 unruptured ones, had been treated for over 12 years. Multiple aneurysms were associated in 30 patients. The pattern of the neck position of aneurysms was classified into three types: Type A: no SCA-involved type; Type B: half involved type with SCA originating from the aneurysmal neck; Type C: pure SCA aneurysm with all the neck mounting on SCA. Morphological and clinical analysis was done between ruptured and unruptured aneurysms and among the three types. There was no difference in patient profile between ruptured and unruptured aneurysms. The angle formed by the posterior cerebral artery and SCA on the aneurysm side was obtuse in 62 (90%) patients. From the morphological point of view the SCA-involved type (types B + C) was significantly more prevalent in ruptured aneurysms (77%). Bleb formation was particular in ruptured aneurysms. As for the treatment, the risk of SCA occlusion and incomplete and attempted operation was particularly high in cases with SCA-involved type. Although SCA aneurysms may grow due to the hemodynamic stress at the opened bifurcation between the PCA and SCA, the neck shifting to the origin of SCA, particularly in ruptured lesions,may suggest some other etiological mechanism. SCA-involved type aneurysms had a high treatment risk of SCA occlusion and tended to incomplete treatment to avoid such ischemic complications.

Hutchinson?Gilford progeria syndrome with severe skin calcinosis

We describe a case of Hutchinson-Gilford progeria syndrome (HGPS) with long-term follow-up. A 1-month-old girl with marked sclerodermatous skin changes developed various symptoms of HGPS during follow-up. These included sclerotic skin, pigmentation, skin atrophy with translucent veins, wispy hair and alopecia, nail dystrophy and decreased sweating. Marked skin calcinosis was observed over almost the entire body, a symptom that has apparently been ignored in the literature. At 16 years old, the girl underwent surgery for a skull fracture and subdural haematoma, which was followed by chronic ulceration. Wet dressing with insulin-like growth factor was used with considerable effect. Mutation of the lamin A/C (LMNA) gene mutation, which encodes nuclear lamin A and C, has been reported to be the cause of HGPS. Our case showed the mutation G608G (GGC-->GGT), which resulted in a cryptic splice site and consequently in a truncated lamin A/C protein.

Effects of phthalate esters on the sensitization phase of contact hypersensitivity induced by fluorescein isothiocyanate

BACKGROUND

Many different types of phthalate ester are used as plasticizers and are thus found in the air. There have been several studies that suggest an association between allergies and phthalate esters. We previously found that di-butyl phthalate (DBP) has an adjuvant effect in a mouse contact hypersensitivity model, in which fluorescein isothiocyanate (FITC) is involved as an immunogenic hapten.

OBJECTIVE

We examined whether other phthalate esters enhance the process of sensitization to FITC by facilitating the trafficking of FITC-presenting dendritic cells or macrophages from skin sites to draining lymph nodes.

METHODS

Mice were epicutaneously sensitized with FITC dissolved in acetone containing a phthalate ester. Sensitization was evaluated as ear swelling after a challenge with FITC. Draining lymph node cells obtained 24 h after skin sensitization were examined for FITC fluorescence by means of flow cytometry. FITC-positive cells were characterized with anti-CD11c and anti-CD11b by three-colour flow cytometry.

RESULTS

When mice were sensitized with FITC in acetone containing DBP or di-n-propyl phthalate (DPP), strong enhancement of the ear-swelling response was observed. Di-methyl phthalate (DMP) and di-ethyl phthalate (DEP) were less effective but produced some enhancement. Consistent enhancement was not observed with di-(2-ethylhexyl) phthalate or di-isononyl phthalate. Upon sensitization in the presence of DBP or DPP, the number of FITC-positive dendritic cells (total CD11c+ as well as CD11c+/CD11b+) was increased in draining lymph nodes. As to the other four phthalate esters, there was no significant increase in the FITC-positive cell number in the draining lymph nodes.

CONCLUSION

During the process of sensitization to FITC, DBP, and DPP exert strong adjuvant effects that are associated with enhancement of trafficking of antigen-presenting dendritic cells from the skin to draining lymph nodes.

Endoscopic submucosal dissection for rectal tumors

BACKGROUND AND STUDY AIM

Endoscopic submucosal dissection (ESD) has recently been developed for one-piece resection of gastric tumors. In order to improve patients' quality of life, it may be desirable to use the same technique for rectal tumors.

METHODS

35 consecutive patients with rectal tumors were enrolled. ESD was carried out using the same technique as for the stomach. The efficacy, technical feasibility, operation time, complications, and follow-up results were assessed.

RESULTS

The mean size of the epithelial tumors was 26.2 +/- 14.0 mm, and the rates of one-piece resection and one-piece resection with tumor-free margins were 73.3% (22 of 30) and 70.0% (21 of 30), respectively. The median operation time was 70 min (range 8-360 min). All five carcinoid tumors were completely resected. No patient needed blood transfusion or had the complication of problematic bleeding. Perforation during ESD occurred in one patient (2.9%), who was managed with conservative medical treatment after endoscopic closure of the perforation. Excluding seven patients, who either underwent additional surgery or whose follow-up period was less than 1 year, all 23 patients with epithelial tumors were free of recurrence during a mean follow-up period of 25.7 months (range 12-53 months).

CONCLUSIONS

ESD was thus found to be feasible for the treatment of rectal tumors, with promising results although the follow-up periods were short. ESD may therefore be indicated for rectal tumors which are not resectable en bloc by conventional procedures, in order to improve the patients' quality of life.

The Current Status of Treatment Strategies for Cerebral Aneurysms in Nagoya University and Affiliated Hospitals Based on a Questionnaire Survey

We investigated differences in the treatment strategies for ruptured aneurysms among 26 hospitals affiliated with Nagoya University and any changes in those strategies based on responses to a questionnaire. We also surveyed the data concerning patients with a ruptured aneurysm collected from our affiliated hospitals between 2001 and 2002. In half of the institutes, angiography is performed immediately after an urgent medical examination, there are only five hospitals (20%) which have a basic policy of terminating the angiography within three to six hours after onset. In half of the institutes, the timing of the treatment also depends on the location of the aneurysm. In particular, the treatment for vertebro-basilar aneurysms tends to be done the next day or later. Low-grade subarachnoid hemorrhage (SAH) patients with mild symptoms tended not to be given any sedative drugs (46%), while patients with SAH in some institutes were sedated without informed consent regardless of the severity. The main treatment method for most anterior circulation aneurysms was clipping. Concerning aneurysms located in the posterior circulation and the origin of the ophthalmic artery, clipping and coiling were equally selected. Almost all the hospitals (92%) responded that their treatment strategy had not changed even after the report of the International Subarachnoid Aneurysm Trial (ISAT). There is a great deal of difference in treatment strategies and indications among institutions. In particular, institutions without neuroendovascular interventionists (NETists) frequently persist in the conventional policy, making it urgently necessary to bring NETists up-to-date on the latest advance in endovascular treatment.

Endoscopic submucosal dissection for early gastric cancers and large flat adenomas

BACKGROUND AND STUDY AIM

Endoscopic submucosal dissection (ESD) is a new diagnostic and treatment technique for early gastric cancer (EGC). The present study aims to identify the technical feasibility, operation time, and complications associated with ESD.

METHODS

We reviewed the patients who underwent ESD for EGCs at Maebashi Red Cross Hospital.

RESULTS

There were 160 patients with 171 EGCs treated by ESD. The mean age was 71.4 +/- 8.9 years (median 72). The rate for one-piece resection with tumor-free margins was 94.2 % (161/171), and was 93.2 % (82/88) for large lesions (> 20 mm) and 92.1 % (35/38) for ulcerative lesions. The median operation time was 80 min (range 10-600 min). Evidence of immediate bleeding was found in 2.9 % (5/171), delayed bleeding was seen in 7.6 % (13/171), and perforation was observed in 3.5 % (6/171) of the lesions. All patients with complications, including perforation, were successfully treated endoscopically. There were no local or distant metastases in the lesions which met our indication criteria for ESD.

CONCLUSION

The present study shows the technical feasibility of ESD, which provides the capability of one-piece resection even in large and ulcerative lesions.

Endoscopic submucosal dissection for early gastric cancers and large flat adenomas

BACKGROUND AND STUDY AIM

Endoscopic submucosal dissection (ESD) is a new diagnostic and treatment technique for early gastric cancer (EGC). The present study aims to identify the technical feasibility, operation time, and complications associated with ESD.

METHODS

We reviewed the patients who underwent ESD for EGCs at Maebashi Red Cross Hospital.

RESULTS

There were 160 patients with 171 EGCs treated by ESD. The mean age was 71.4 +/- 8.9 years (median 72). The rate for one-piece resection with tumor-free margins was 94.2 % (161/171), and was 93.2 % (82/88) for large lesions (> 20 mm) and 92.1 % (35/38) for ulcerative lesions. The median operation time was 80 min (range 10-600 min). Evidence of immediate bleeding was found in 2.9 % (5/171), delayed bleeding was seen in 7.6 % (13/171), and perforation was observed in 3.5 % (6/171) of the lesions. All patients with complications, including perforation, were successfully treated endoscopically. There were no local or distant metastases in the lesions which met our indication criteria for ESD.

CONCLUSION

The present study shows the technical feasibility of ESD, which provides the capability of one-piece resection even in large and ulcerative lesions.

ATX-S10(Na)-photodynamic therapy is less carcinogenic for mouse skin compared with ultraviolet B irradiation

BACKGROUND

Photodynamic therapy (PDT) is available for the treatment of various skin tumours and other skin diseases. Ultraviolet (UV) irradiation induces DNA damage, cyclobutane pyrimidine dimers (CPD) (6-4) photoproducts (6-4PP) and 8-hydroxy-2'-deoxyguanosine (8-OHdG), all of which are carcinogenic for the skin. However, effects of PDT on DNA damage and carcinogenesis are unclear.

OBJECTIVES

To compare the production of photoproducts and the induction of skin tumours in mouse epidermis treated with UVB or PDT.

METHODS

We performed UVB irradiation or ATX-S10(Na)-PDT on the skin of 20 hairless mice, in each case, and analysed DNA damage and tumour induction.

RESULTS

After a single irradiation of UVB on mouse skin, CPD, 6-4PP and 8-OHdG were detected in the nuclei of keratinocytes. In contrast, PDT-treated mouse keratinocytes showed induction of 8-OHdG, but not of CPD or 6-4PP. Skin tumours induced by UVB irradiation (3 kJ m(-2) three times weekly) were observed following 15 weeks of irradiation (mean +/- SEM tumour incidence 3.2 +/- 1.8%; tumour number 3.2 +/- 1.6 per mouse) and increased depending on irradiation times and doses. Following 30 weeks of UVB irradiation (3 kJ m(-2) three times weekly), mean +/- SEM tumour incidence and tumour number were 28.7 +/- 4.8% and 14.2 +/- 2.8% per mouse, respectively. Although skin tumours were also detected in PDT-treated mouse skin following 80 weeks of treatment (mean +/- SEM tumour incidence 9.1 +/- 1.8%; tumour number 12.2 +/- 2.3 per mouse), the number of tumours was not statistically different from untreated mouse skin (mean +/- SEM tumour incidence 4.1 +/- 3.8%; tumour number 5.2 +/- 3.3 per mouse).

CONCLUSIONS

PDT induced 8-OHDG but not CPD or 6-4PP, and was shown to be a relatively safe modality following multiple applications to mouse skin.

Prevalence of atopic dermatitis in Japanese elementary schoolchildren

BACKGROUND

Although there have been several reports on the prevalence of atopic dermatitis (AD) in Japanese schoolchildren based on questionnaires, there has been no nation-wide study of the frequency of this condition diagnosed by dermatologists in regular health check-ups of schoolchildren.

OBJECTIVES

The objective of this work was to evaluate precisely the prevalence of AD in elementary schoolchildren in Japan based on regular health check-ups by dermatologists.

METHODS

In 2001/2, elementary schoolchildren: first graders (age 6-7 years) and sixth graders (age 11-12 years) were examined by dermatologists in eight prefectures of Japan (Hokkaido, Iwate, Tokyo, Gifu, Osaka, Hiroshima, Kochi and Fukuoka). In each prefecture, public elementary schools were randomly selected from urban and rural districts. We planned to examine about 700 schoolchildren in each of urban first, urban sixth, rural first and rural sixth grades from the eight areas, a total of 22 400 children (700 x 4 x 8). AD was diagnosed by the dermatologists based on the Japanese Dermatological Association criteria for the disease.

RESULTS

The point prevalence of AD was 11.2% overall (2664 of 23 719) ranging from 7.4% (Iwate) to 15.0% (Fukuoka) in the eight areas. Seventy-four per cent, 24%, 1.6% and 0.3% of those afflicted were in the mild, moderate, severe and very severe groups, respectively. Overall, the prevalence of first graders was slightly higher than that of sixth graders (11.8% vs. 10.5%, P < 0.01). There was no apparent difference in prevalence between urban and rural districts, or between boys and girls.

CONCLUSIONS

The prevalence of AD in Japanese elementary schoolchildren was about 10%, three-quarters of those being mildly affected. This is the first nation-wide study made of Japanese elementary schoolchildren examined by dermatologists to evaluate the frequency of AD.

Effects of bepotastine, cetirizine, fexofenadine, and olopatadine on histamine-induced wheal-and flare-response, sedation, and psychomotor performance

Although many antihistamines are now in clinical use, few studies directly compare their pharmacodynamic and sedative activities in humans in vivo. We designed a double-blind, placebo-controlled, crossover study to compare the inhibitory effects of bepotastine, cetirizine, fexofenadine, and olopatadine on histamine-induced flare-and-wheal response. Systemic sedative effects and impaired psychomotor activities by these drugs were also evaluated. Bepotastine (10 mg twice a day), cetirizine (10 mg once a day), fexofenadine (60 mg twice a day), and olopatadine (5 mg twice a day) or placebo was given in a double-blind manner to seven healthy volunteers before histamine challenge by iontophoresis. At 0, 1, 2, 4, 8, 12, and 24 h following the oral administration of these drugs, histamine iontophoresis-induced wheal-and-flare response was measured. Sedative effects by the drugs were also evaluated by a visual analogue scale for subjective sedation, and by word processor test for psychomotor activity. Each volunteer was tested with all of the drugs (including placebo), administered in a random order with a washout period of at least 1 week. Histamine iontophoresis induced marked wheal-and-flare response in all participants. Bepotastine, cetirizine, fexofenadine, and olopatadine yielded significant reduction of histamine-induced wheal-and-flare response compared to placebo (P < 0.01). Among the drugs, olopatadine and cetirizine suppressed most markedly and persistently histamine-induced wheal-and-flare response, while bepotastine and fexofenadine produced a significant, but less persistent suppression. Olopatadine, fexofenadine, and cetirizine showed a significant systemic sedative effect in this order with bepotastine showing the least sedative effect. Moreover, olopatadine affected psychomotor performance most markedly, which was followed by fexofenadine and cetirizine. These results indicate that bepotastine, cetirizine, fexofenadine, and olopatadine inhibit histamine-induced wheal-and-flare response of humans in vivo and induce a variable systemic sedative effect and impaired psychomotor activity. Although olopatadine and cetirizine showed the strongest and most persistent suppression of histamine-induced wheal-and-flare response, olopatadine showed a considerable sedative effect with impaired psychomotor performance.

Epidermolysis bullosa acquisita sera react with distinct epitopes on the NC1 and NC2 domains of type VII collagen: study using immunoblotting of domain-specific recombinant proteins and postembedding immunoelectron microscopy

BACKGROUND

The sera of epidermolysis bullosa acquisita (EBA) react with type VII collagen, a major component of anchoring fibrils, in which the major epitopes have been considered to be present in the N-terminal noncollagenous (NC) 1 domain.

OBJECTIVES

To determine whether there are also epitopes in the C-terminal NC2 domain, and to determine their ultrastructural localization.

METHODS

Immunoblotting using recombinant proteins of the NC1 and NC2 domains of type VII collagen, and postembedding immunoelectron microscopy.

RESULTS

Twenty of 28 EBA sera tested reacted with the NC1 domain and eight sera reacted with the NC2 domain. The sera that reacted with the NC1 domain showed immunoreactivity within the lamina densa and the sera that reacted with the NC2 domain showed immunoreactivity in the dermis 300-360 nm below the lamina densa.

CONCLUSIONS

This study clearly identified the presence of epitopes in the NC2 domain, and showed that the epitope in the NC1 domain is present in the lamina densa and that the epitope in the NC2 domain is in the dermis below the lamina densa.

A Japanese case of segmental Darier's disease caused by mosaicism for the ATP2A2 mutation

Darier's disease is an autosomal dominant skin disorder that is characterized by multiple keratotic papules, focal loss of adhesion and abnormal keratinization. Mutations in the ATP2A2 gene encoding sarco/endoplasmic reticulum calcium pumping ATPase type 2 have been identified as the molecular basis of Darier's disease. Segmental Darier's disease is a rare type of Darier's disease in which there is characteristic localization of the keratotic papules in a linear pattern following Blaschko's lines. In this study we examined ATP2A2 mutations in a Japanese patient with segmental Darier's disease. The samples from affected skin, unaffected skin and peripheral leucocytes were subjected to polymerase chain reaction (PCR). Direct sequencing of the PCR products was performed. Sequence analysis revealed that the patient had 160A-->G substitution mutation which predicts I54V. This novel mutation was present in the affected skin, but not in the unaffected skin or peripheral leucocytes. This is the first report of segmental Darier's disease caused by mosaicism for an ATP2A2 mutation in Japan.

Treatments of hamartoma with neuroendoscopic surgery and stereotactic radiosurgery: a case report

Hypothalamic hamartoma is a non-neoplastic tumor manifesting as gelastic seizure, precocious puberty, and abnormal behavior. Treatment of it is very complicated due to its location. We report a case of hypothalamic hamartoma treated by neuroendoscopic surgery and stereotactic radiosurgery. A 5-year-old girl presented with violent behavior, precocious puberty, gelastic seizure and atonic seizure. She was diagnosed with hypothalamic hamartoma by CT and magnetic resonance imaging at 11 months of age. Tumor size did not change, but tumor intensity had changed on the MR image at 5 years of age. Magnetic resonance spectroscopy revealed decreased N-acetylaspartate and increased choline and creatine in the tumor. After neuroendoscopic biopsy, she underwent linear accelerator stereotactic radiosurgery. But her symptoms remained unchanged for 6 months. She then underwent partial resection and laser coagulation of the tumor by a neuroendoscopic approach. After the procedure, the frequency of her seizures was remarkably decreased, and her violent behavior improved. The transventricular neuroendoscopic approach to the hypothalamus is less invasive than the radical surgery. Neuroendoscopic surgery can be one of the treatments of choice for hypothalamic hamartoma.

Lessons from disorders of epidermal differentiation-associated keratins

A number of diseases have been associated with mutations in genes encoding keratin intermediate filaments. Several of these disorders have skin manifestations, in which histological changes highlight the role of various different keratins in epidermal differentiation. For example, mutations in either K1 or K10 (the major keratin pair expressed in differentiated keratinocytes) usually lead to clumped keratin filaments and cytolysis. Furthermore, the precise nature of the mutation has direct implications for disease phenotype. Specifically, mutations in the H1 and alpha-helical rod domains of K1/K10 result in bullous congenital ichthyosiform erythroderma, underscoring the critical role for this keratin filament domain in maintaining cellular integrity. However, a lysine to isoleucine substitution in the V1 domain of K1 underlies a form of palmoplantar keratoderma, which has different cell biological implications. Keratins are cross-linked into the cornified cell envelopes through this particular lysine residue and the consequences of the mutation lead to changes in keratin-desmosome association and cornified cell morphology, suggesting a role for this keratin subdomain in cornified cell envelope formation. Recently, to extend genotype-phenotype correlation, a frameshift mutation in the V2 region of the K1 tail domain was identified in ichthyosis hystrix (Curth-Macklin type), in which keratin filaments show a characteristic shell-like structure and fail to form proper bundles. In this case, the association of desmosomes with loricrin was also altered, implicating this keratin domain in organizing the intracellular distribution of loricrin during cornification. Collectively, these mutations in K1/K10 provide a fascinating insight into both normal and abnormal processes of epidermal differentiation.

Fractures of the posterior part of the body and unilateral spinous process of the axis: a case report

STUDY DESIGN

A case report and review of the literature.

OBJECTIVES

To present a case of the fractures of the posterior part of the body and unilateral spinous process of the axis.

SUMMARY OF BACKGROUND DATA

A few authors have described fractures involving the body of the axis. Fractures of the posterior part of the body and unilateral spinous process of the axis are extremely rare.

METHODS

A fracture of the posterior part of the body and unilateral spinous process was treated nonsurgically by a halo and a Philadelphia brace. The relevant literature was reviewed.

RESULTS

Solid bony union was shown by plain radiographs and computed tomography. The patient was free of pain and obtained a full range of motion.

CONCLUSION

The presumed mechanism of injury in the fracture described here was flexion and axial rotation.

Syringocystadenocarcinoma papilliferum: case report and immunohistochemical comparison with its benign counterpart

Syringocystadenocarcinoma papilliferum (SCACP) is the malignant counterpart of syringocystadenoma papilliferum (SCAP), although only a few cases have been reported in the literature and its clinical and histologic characteristics are not well known. We report a case of SCACP that started as an enlarging nodule over 10 years in the perianal area of a 61-year-old man. Macroscopically, the lesion was a black exophytic tumor, 6 cm in diameter, with a granular surface. Histologically, it was an in situ adenocarcinoma, showing cytologic atypia and pagetoid spread in the surrounding epithelia, although the clinicopathologic features were distinct from extramammary Paget's disease. The tumor lacked the typical double-layered pattern of SCAP but had some similar histopathologic features to SCAP. Decapitation secretion was apparent and there was positive immunoreactivity to epithelial membrane antigen and human milk fat globules subclass 2. SCACP is a rare cutaneous tumor but nevertheless represents a specific dermatopathologic entity.

Nuclear localization of beta-catenin in the hair matrix cells and differentiated keratinocytes

Beta-catenin is a structural component of adherens junctions and also a downstream effector of Wnt signaling pathway. Beta-catenin has been detected in the adherens junctions in almost all normal tissues including the epidermis. Only in some malignant tumor cells was it found in the cytoplasm and nuclei. Recently pilomatricoma was found to be caused by mutations of amino-terminal segment of beta-catenin, normally involved in phosphorylation-dependent ubiquitin-mediated degradation of the protein. Since nuclear beta-catenin has not been detected in pilomatricoma or any other benign follicular tumors, we investigated localization of beta-catenin in the normal hair follicle, follicular tumor cells, normal and psoriatic epidermis by using immunohistochemical method with a high temperature antigen unmasking technique. The nuclear localization of beta-catenin was detected not only in the matrix cells of follicular tumors including pilomatricoma but also in the normal hair matrix cells and the differentiated keratinocytes of the upper layers of the epidermis. Cell membrane staining of beta-catenin and E-cadherin was decreased in these differentiated keratinocytes. This coincided with the emergence of nuclear beta-catenin. The present immunohistochemical method has revealed hitherto unproven nuclear localization of beta-catenin in hair matrix cells. Our results also provided evidence suggesting that beta-catenin plays an important role in keratinocyte differentiation.

Ultraviolet B irradiation induces apoptosis of keratinocytes by direct activation of Fas antigen

Ultraviolet B (UVB) irradiation induces apoptosis of keratinocytes, where p53 has been suggested to play an important role. Recently we have shown that UVB irradiation induces apoptosis of SV40-transformed human keratinocytes (SVHK cells). Because p53 function is impaired in SVHK cells by large T antigen, a UVB-induced p53-independent apoptotic pathway was suggested. We investigated the UVB-induced apoptotic pathway using various keratinocytes. Cultured mouse keratinocytes of homozygous p53 deficient mice (p53(-/-)) were markedly resistant to UVB-induced apoptosis compared with keratinocytes from wild or heterozygous p53 deficient mice (p53(-/+)). Twenty per cent of keratinocytes derived from p53 (-/-) mice, however, induced apoptosis following UVB irradiation. Analysis using caspase inhibitors disclosed activation of caspase 8 and 3 in UVB-irradiated SVHK cells. Keratinocytes derived from MRL/lpr mice, which have mutated Fas antigen, showed diminished UVB-induced apoptosis suggesting that Fas antigen is significantly involved in UVB-induced apoptosis. Immunohistochemical analysis revealed that UVB irradiation induces aggregation of Fas antigen showing a dense dot-like staining, which was also observed in SVHK cells treated with agonistic anti-Fas antibody, CH11. Pretreatment of antagonistic anti-Fas antibody, ZB4, inhibited CH11-induced but not UVB-induced multimerization of Fas antigen. Furthemore, UVB irradiation did not affect the basal expression of Fas ligand mRNA, protein and soluble Fas ligand. These results indicate that UVB irradiation induces multimerization of Fas antigen that results in apoptosis without the Fas ligand.

Extensor musculature of the cervical spine after laminoplasty: morphologic evaluation by coronal view of the magnetic resonance image

STUDY DESIGN

A radiographic study in 22 patients using magnetic resonance imaging was conducted.

OBJECTIVE

To describe the relation between postoperative cervical alignment and morphologic evaluation of the cervical extensor musculature, especially semispinalis cervics in laminoplasty.

SUMMARY OF BACKGROUND DATA

Cervical laminoplasty has been widely accepted as a treatment for cervical myelopathy. Posterior procedures, however, involve the extensor musculature of the cervical spine.

METHODS

In this study, 22 patients who underwent laminoplasty for repair of the extensor musculature were reviewed prospectively. The semispinalis cervics was evaluated by coronal view of the magnetic resonance image 1 month, 12 months, and 24 months after surgery. Cervical alignment at last follow-up assessment was compared with preoperative alignment using the lateral view of cervical radiographs.

RESULTS

In 18 patients (82%), morphologic repair of semispinalis cervics had been maintained (Group A), but in 4 patients (18%), but it had not been maintained at the last follow-up assessment (Group B). Cervical alignment in Group A had been maintained, but maximum loss of cervical lordosis occurred in Group B. Moreover, Group B consisted of elderly women.

CONCLUSIONS

The findings from this magnetic resonance imaging study suggest that the degree of semispinalis cervics repair affects postoperative cervical alignment, and significant loss of cervical lordosis tends to occur in elderly women who undergo laminoplasty.

Loricrin keratoderma: a cause of congenital ichthyosiform erythroderma and collodion baby

A group of hereditary palmoplantar keratodermas due to heterozygous mutation in the loricrin gene has recently been identified. Of five reported pedigrees, four presented as mutilating keratoderma with ichthyosis (variant Vohwinkel syndrome), and one as progressive symmetric erythrokeratoderma. We report a new Japanese pedigree of loricrin keratoderma. A 14-year-old male and his 11-year-old female sibling had both been born as collodion babies and were initially diagnosed as having non-bullous congenital ichthyosiform erythroderma, but later developed palmoplantar keratoderma with pseudoainhum. Their father was similarly affected. Direct sequencing of genomic DNA revealed a G residue insertion at codon 230-231 of the loricrin gene. Antibody studies confirmed the presence of mutant loricrin in the retained nuclei. We conclude that loricrin gene mutation may present as congenital ichthyosiform erythroderma, and should be included in the differential diagnosis of collodion baby.

In vitro and in vivo transfer of bcl-2 gene into keratinocytes suppresses UVB-induced apoptosis

Bcl-2 is a member of the large Bcl-2 family and protects cells from apoptosis. Ultraviolet B (UVB) irradiation induces apoptosis of keratinocytes that is known as "sunburn cells." Previously we reported that UVB irradiation induces apoptosis accompanied by sequential activation of caspase 8, 3 and 1 in keratinocytes, and that the process is inhibited by various caspase inhibitors. Using bcl-2-expressing adenovirus vector we investigated the effect of Bcl-2 on UVB-induced apoptosis. Adenovirus vector efficiently introduced bcl-2 gene in cultured normal mouse keratinocytes (NMK cells); almost all NMK cells (1 x 10(6)) were transfected at 1 x 10(8) plaque-forming unit (PFU)/mL. Bcl-2-transfected NMK cells were significantly resistant to UVB-induced apoptosis with the suppressive effect dependent on the Bcl-2 expression level. Following UVB irradiation caspase 8, 3 and 9 activities were stimulated in NMK cells, whereas in bcl-2-transfected cells only caspase 8, but not caspase 3 or 9, activity was stimulated. In order to investigate the effect of Bcl-2 in vivo topical application of Ad-bcl-2 on tape-stripped mouse skin was performed. Following the application Bcl-2 was efficiently overexpressed in almost all viable keratinocytes. The expression was transient with the maximal expression of Bcl-2 on the first day following the application of 1 x 10(9) PFU in 200 microL. The introduced Bcl-2 remained at least for 6 days. UVB irradiation (1250 J/m2) induced apoptosis within 12 h and the maximal effect was observed at 24 h in control mouse skin. Both bcl-2-transfected and topical caspase 3 inhibitor-treated mice skin were resistant to UVB-induced apoptosis. The suppressive effect of Bcl-2 was more potent than that of caspase 3 inhibitor application. Topical application of empty adenovirus vector alone had no effect on Bcl-2 expression or UVB-induced apoptosis. These results indicate that adenovirus vector is an efficient gene delivery system into keratinocytes and that Bcl-2 is a potent inhibitor of UVB-induced apoptosis both in vitro and in vivo.

Expression of human cystatin A by keratinocytes is positively regulated via the Ras/MEKK1/MKK7/JNK signal transduction pathway but negatively regulated via the Ras/Raf-1/MEK1/ERK pathway

Cystatin A, a cysteine proteinase inhibitor, is a cornified cell envelope constituent expressed in the upper epidermis. We previously reported that a potent protein kinase C activator, 12-O-tetradecanoylphorbol-13-acetate, increases human cystatin A expression by the activation of AP-1 proteins. Here, we delineate the signaling cascade responsible for this regulation. Co-transfection of the cystatin A promoter into normal human keratinocytes together with a dominant active form of ras increased the promoter activity by 3-fold. In contrast, a dominant negative form of ras suppressed basal cystatin A promoter activity. Further analyses disclosed that transfection of dominant negative forms of raf-1, MEK1, ERK1, ERK2, or wild-type MEKK1 all increased cystatin A promoter activity in normal human keratinocytes, whereas wild-type raf-1, ERK1, ERK2, or dominant negative forms of MEKK1, MKK7, or JNK1 suppressed the promoter activity. The increased or decreased promoter activity reflected the expression of cystatin A on mRNA and protein levels. These effects were not observed when a cystatin A promoter with a T2 (-272 to -278) deletion was used. In contrast, transfection of dominant negative forms of MKK3, MKK4, or p38 did not affect cystatin A promoter activity. Immunohistochemical analyses revealed that phosphorylated active extracellular signal-regulated kinases and c-Jun N-terminal kinase were expressed in the nuclei of basal cells and cells in the suprabasal-granular cell layer, respectively. These results indicate that the expression of cystatin A is regulated via mitogen-activated protein kinase pathways positively by Ras/MEKK1/MKK7/JNK and negatively by Ras/Raf/MEK1/ERK.

Interposed colon between remnants of the small intestine exhibits small bowel features in a patient with short bowel syndrome

We describe herein the case of a 48-year-old man who underwent emergency massive resection of the small intestine due to a strangulated ileus, which led to short bowel syndrome (SBS), as he was left with only 7 cm of jejunum and 8 cm of ileum with ileocecal valve. He then received interposition of a colon segment between the jejunum and ileum remnants isoperistaltically. For 24 months after the operation, he has been able to tolerate oral intake, but still requires partial home parenteral nutritional support during the night on a bimonthly basis. Biochemical and nutritional parameters, including the analysis of minerals and trace elements, indicated that the patient was in relatively good health. Histological examination revealed that the mucosa of the interposed colon showed hypertrophy and hyperplasia of the crypt glands, and cells resembling Paneth cells which are usually seen in the small intestine, suggesting that the colon segment exhibits adaptive changes to the small intestine. Colon interposition may be a useful technique in patients with SBS when the small bowel is too short for the other surgical considerations.