Detection of Adverse Event Signals with Severity Grade Classification from Cancer Patient Narrative

Adverse event (AE) management is crucial to improve anti-cancer treatment outcomes, but it is reported that some AE signals can be missed in clinical visits. Thus, monitoring AE signals seamlessly, including events outside hospitals, would be helpful for early intervention. Here we investigated how to detect AE signals from texts written by cancer patients themselves by developing deep-learning (DL) models to classify posts mentioning AEs according to severity grade, in order to focus on those that might need immediate treatment interventions. Using patient blogs written in Japanese by cancer patients as a data source, we built DL models based on three approaches, BERT, ELECTRA, and T5. Among these models, T5 showed the best F1 scores for both Grade ≥ 1 and ≥ 2 article classification tasks (0.85 and 0.53, respectively). This model might benefit patients by enabling earlier AE signal detection, thereby improving quality of life.

Adverse event signal extraction from cancer patients' narratives focusing on impact on their daily-life activities

Adverse event (AE) management is important to improve anti-cancer treatment outcomes, but it is known that some AE signals can be missed during clinical visits. In particular, AEs that affect patients' activities of daily living (ADL) need careful monitoring as they may require immediate medical intervention. This study aimed to build deep-learning (DL) models for extracting signals of AEs limiting ADL from patients' narratives. The data source was blog posts written in Japanese by breast cancer patients. After pre-processing and annotation for AE signals, three DL models (BERT, ELECTRA, and T5) were trained and tested in three different approaches for AE signal identification. The performances of the trained models were evaluated in terms of precision, recall, and F1 scores. From 2,272 blog posts, 191 and 702 articles were identified as describing AEs limiting ADL or not limiting ADL, respectively. Among tested DL modes and approaches, T5 showed the best F1 scores to identify articles with AE limiting ADL or all AE: 0.557 and 0.811, respectively. The most frequent AE signals were "pain or numbness", "fatigue" and "nausea". Our results suggest that this AE monitoring scheme focusing on patients' ADL has potential to reinforce current AE management provided by medical staff.

Preliminary Screening Method for Low Bone Mineral Density Using a Self-Reported Questionnaire among Peri- and Postmenopausal Women

STUDY DESIGN

Retrospective cohort study.

PURPOSE

We propose a method for screening for low bone mineral density (BMD) among perimenopausal and postmenopausal women using a self-reported questionnaire.

OVERVIEW OF LITERATURE

Osteoporosis is a major health problem worldwide. However, it is not cost-effective to evaluate BMD in all patients. Although several tools for predicting osteoporosis have been established, they do not focus much on low BMD prior to the development of osteoporosis.

METHODS

We retrospectively reviewed the medical records of 198 women aged 40-70 years who underwent mass screening for osteoporosis at our hospital between 2016 and 2019. The BMD values and the following data were collected: age, body mass index, fracture history, lower back pain, height loss, kyphosis, history of fragility fracture, family history of vertebral or hip fracture, and menopause. The reliability of each data point for the young adult mean <80% was calculated using discriminant analysis. Variables with large weight coefficients were selected and scored. This scoring tool was examined, and a cutoff score for predicting the young adult mean <80% was determined.

RESULTS

Sixty-four participants (32.3%) had a young adult mean <80%. According to the weight coefficients, the following five variables were scored as follows: age ≥60 years 3 points, body mass index <22 kg/m2 3 points, lower back pain 1 point, height loss (cm) 1 point, and menopause 1 point. The area under the receiver operating characteristic curve was 0.738 (95% confidence interval, 0.669-0.807). At cutoff scores of ≥5 and <5, the sensitivity was 82.8%, with specificity of 52.0%.

CONCLUSIONS

The scoring tool performed well for predicting young adult mean <80% among perimenopausal and postmenopausal women in Japan. This tool may be useful to screen for low BMD.

Identification of hand-foot syndrome from cancer patients' blog posts: BERT-based deep-learning approach to detect potential adverse drug reaction symptoms

Early detection and management of adverse drug reactions (ADRs) is crucial for improving patients' quality of life. Hand-foot syndrome (HFS) is one of the most problematic ADRs for cancer patients. Recently, an increasing number of patients post their daily experiences to internet community, for example in blogs, where potential ADR signals not captured through routine clinic visits can be described. Therefore, this study aimed to identify patients with potential ADRs, focusing on HFS, from internet blogs by using natural language processing (NLP) deep-learning methods. From 10,646 blog posts, written in Japanese by cancer patients, 149 HFS-positive sentences were extracted after pre-processing, annotation and scrutiny by a certified oncology pharmacist. The HFS-positive sentences described not only HFS typical expressions like "pain" or "spoon nail", but also patient-derived unique expressions like onomatopoeic ones. The dataset was divided at a 4 to 1 ratio and used to train and evaluate three NLP deep-learning models: long short-term memory (LSTM), bidirectional LSTM and bidirectional encoder representations from transformers (BERT). The BERT model gave the best performance with precision 0.63, recall 0.82 and f1 score 0.71 in the HFS user identification task. Our results demonstrate that this NLP deep-learning model can successfully identify patients with potential HFS from blog posts, where patients' real wordings on symptoms or impacts on their daily lives are described. Thus, it should be feasible to utilize patient-generated text data to improve ADR management for individual patients.

Extracting Multiple Worries from Breast Cancer Patient Blogs Using Multi-Label Classification with a Natural Language-Processing Model BERT (Bidirectional Encoder Representations from Transformers): Infodemiology Study of Blogs (Preprint)

Background

Patients with breast cancer have a variety of worries and need multifaceted information support. Their accumulated posts on social media contain rich descriptions of their daily worries concerning issues such as treatment, family, and finances. It is important to identify these issues to help patients with breast cancer to resolve their worries and obtain reliable information.

Objective

This study aimed to extract and classify multiple worries from text generated by patients with breast cancer using Bidirectional Encoder Representations From Transformers (BERT), a context-aware natural language processing model.

Methods

A total of 2272 blog posts by patients with breast cancer in Japan were collected. Five worry labels, “treatment,” “physical,” “psychological,” “work/financial,” and “family/friends,” were defined and assigned to each post. Multiple labels were allowed. To assess the label criteria, 50 blog posts were randomly selected and annotated by two researchers with medical knowledge. After the interannotator agreement had been assessed by means of Cohen kappa, one researcher annotated all the blogs. A multilabel classifier that simultaneously predicts five worries in a text was developed using BERT. This classifier was fine-tuned by using the posts as input and adding a classification layer to the pretrained BERT. The performance was evaluated for precision using the average of 5-fold cross-validation results.

Results

Among the blog posts, 477 included “treatment,” 1138 included “physical,” 673 included “psychological,” 312 included “work/financial,” and 283 included “family/friends.” The interannotator agreement values were 0.67 for “treatment,” 0.76 for “physical,” 0.56 for “psychological,” 0.73 for “work/financial,” and 0.73 for “family/friends,” indicating a high degree of agreement. Among all blog posts, 544 contained no label, 892 contained one label, and 836 contained multiple labels. It was found that the worries varied from user to user, and the worries posted by the same user changed over time. The model performed well, though prediction performance differed for each label. The values of precision were 0.59 for “treatment,” 0.82 for “physical,” 0.64 for “psychological,” 0.67 for “work/financial,” and 0.58 for “family/friends.” The higher the interannotator agreement and the greater the number of posts, the higher the precision tended to be.

Conclusions

This study showed that the BERT model can extract multiple worries from text generated from patients with breast cancer. This is the first application of a multilabel classifier using the BERT model to extract multiple worries from patient-generated text. The results will be helpful to identify breast cancer patients’ worries and give them timely social support.

Advances in forecasting harmful algal blooms using machine learning models: A case study with Planktothrix rubescens in Lake Geneva

The development of anthropic activities during the 20th century increased the nutrient fluxes in freshwater ecosystems, leading to the eutrophication phenomenon that most often promotes harmful algal blooms (HABs). Recent years have witnessed the regular and massive development of some filamentous algae or cyanobacteria in Lake Geneva. Consequently, important blooms could result in detrimental impacts on economic issues and human health. In this study, we tried to lay the foundation of an HAB forecast model to help scientists and local stakeholders with the present and future management of this peri-alpine lake. Our forecast strategy was based on pairing two machine learning models with a long-term database built over the past 34 years. We created HAB groups via a K-means model. Then, we introduced different lag times in the input of a random forest (RF) model, using a sliding window. Finally, we used a high-frequency dataset to compare the natural mechanisms with numerical interaction using individual conditional expectation plots. We demonstrate that some HAB events can be forecasted over a year scale. The information contained in the concentration data of the cyanobacteria was synthesized in the form of four intensity groups that directly depend on the P. rubescens concentration. The categorical transformation of these data allowed us to obtain a forecast with correlation coefficients that stayed above a threshold of 0.5 until one year for the counting cells and two years for the biovolume data. Moreover, we found that the RF model predicted the best P. rubescens abundance for water temperatures around 14°C. This result is consistent with the biological processes of the toxic cyanobacterium. In this study, we found that the coupling between K-means and RF models could help in forecasting the development of the bloom-forming P. rubescens in Lake Geneva. This methodology could create a numerical decision support tool, which should be a significant advantage for lake managers.

Free Peroneal Artery Perforator-Based Flap for Soft Tissue Reconstruction of the Finger

Background The peroneal artery perforator-based flap has been widely used as a pedicled propeller flap for soft tissue reconstruction in the lower extremity; however, its application as a free flap has been rarely reported. We report on the utility of the free peroneal artery perforator-based flap for finger soft tissue reconstruction.

Methods Twelve patients underwent reconstructions of soft tissue defects of the finger with free peroneal artery perforator-based flaps. The soft tissue defects were located either dorsally and/or laterally on the fingers. The size of the flaps ranged from 5 × 2 to 8 × 3 cm. The length of the vascular pedicles ranged from 4 to 5 cm. The artery and vein of the perforator vessels were anastomosed in the finger to the digital artery and subcutaneous vein, respectively.

Results All twelve flaps survived completely, and the donor site in the lower leg was closed primarily in all cases. Secondary defatting was performed in six cases, while in the remaining cases, thinning of the flap was performed when the flap was transferred.

Conclusion The advantages of the free peroneal artery perforator-based flap for finger soft tissue reconstruction include the following: the flap is flexible and can be thinned to match the texture of the finger; elevation of the flap is easy; the donor site can be closed primarily; there is no need to sacrifice any main arteries in the lower leg; and the diameter of the perforator vessels is suitable for anastomosis to the digital artery and subcutaneous vein in the finger.

Septic arthritis of the wrist caused by Mycobacterium intracellulare: a case report

Septic arthritis of the wrist is rare entity, especially; atypical mycobacterial infection of the wrist is extremely rare. We report a case of septic arthritis of the wrist caused by Mycobacterium intracellulare, which was successfully treated by radical debridement followed by wrist arthrodesis using vascularised fibular grafting.

Activation of Six1 Expression in Vertebrate Sensory Neurons

SIX1 homeodomain protein is one of the essential key regulators of sensory organ development. Six1-deficient mice lack the olfactory epithelium, vomeronasal organs, cochlea, vestibule and vestibuloacoustic ganglion, and also show poor neural differentiation in the distal part of the cranial ganglia. Simultaneous loss of both Six1 and Six4 leads to additional abnormalities such as small trigeminal ganglion and abnormal dorsal root ganglia (DRG). The aim of this study was to understand the molecular mechanism that controls Six1 expression in sensory organs, particularly in the trigeminal ganglion and DRG. To this end, we focused on the sensory ganglia-specific Six1 enhancer (Six1-8) conserved between chick and mouse. In vivo reporter assays using both animals identified an important core region comprising binding consensus sequences for several transcription factors including nuclear hormone receptors, TCF/LEF, SMAD, POU homeodomain and basic-helix-loop-helix proteins. The results provided information on upstream factors and signals potentially relevant to Six1 regulation in sensory neurons. We also report the establishment of a new transgenic mouse line (mSix1-8-NLSCre) that expresses Cre recombinase under the control of mouse Six1-8. Cre-mediated recombination was detected specifically in ISL1/2-positive sensory neurons of Six1-positive cranial sensory ganglia and DRG. The unique features of the mSix1-8-NLSCre line are the absence of Cre-mediated recombination in SOX10-positive glial cells and central nervous system and ability to induce recombination in a subset of neurons derived from the olfactory placode/epithelium. This mouse model can be potentially used to advance research on sensory development.

Post-traumatic osteonecrosis of the lunate after fracture of the distal radius

We present a case of post-traumatic osteonecrosis of the lunate after fracture of the distal radius. Post-traumatic osteonecrosis of the carpal lunate after a fracture of the distal radius has, to our knowledge, not been reported previously. We treated the patient with vascularised bone graft from the distal radius, with a satisfactory result.

Six1 is a key regulator of the developmental and evolutionary architecture of sensory neurons in craniates

BACKGROUND

Various senses and sensory nerve architectures of animals have evolved during adaptation to exploit diverse environments. In craniates, the trunk sensory system has evolved from simple mechanosensory neurons inside the spinal cord (intramedullary), called Rohon-Beard (RB) cells, to multimodal sensory neurons of dorsal root ganglia (DRG) outside the spinal cord (extramedullary). The fish and amphibian trunk sensory systems switch from RB cells to DRG during development, while amniotes rely exclusively on the DRG system. The mechanisms underlying the ontogenic switching and its link to phylogenetic transition remain unknown.

RESULTS

In Xenopus, Six1 overexpression promoted precocious apoptosis of RB cells and emergence of extramedullary sensory neurons, whereas Six1 knockdown delayed the reduction in RB cell number. Genetic ablation of Six1 and Six4 in mice led to the appearance of intramedullary sensory neuron-like cells as a result of medial migration of neural crest cells into the spinal cord and production of immature DRG neurons and fused DRG. Restoration of SIX1 expression in the neural crest-linage partially rescued the phenotype, indicating the cell autonomous requirements of SIX1 for normal extramedullary sensory neurogenesis. Mouse Six1 enhancer that mediates the expression in DRG neurons activated transcription in Xenopus RB cells earlier than endogenous six1 expression, suggesting earlier onset of mouse SIX1 expression than Xenopus during sensory development.

CONCLUSIONS

The results indicated the critical role of Six1 in transition of RB cells to DRG neurons during Xenopus development and establishment of exclusive DRG system of mice. The study provided evidence that early appearance of SIX1 expression, which correlated with mouse Six1 enhancer, is essential for the formation of DRG-dominant system in mice, suggesting that heterochronic changes in Six1 enhancer sequence play an important role in alteration of trunk sensory architecture and contribute to the evolution of the trunk sensory system.

RISK FACTORS FOR DISLOCATION OF THE ULNAR NERVE AFTER SIMPLE DECOMPRESSION FOR CUBITAL TUNNEL SYNDROME

Anterior dislocation of the ulnar nerve is occasionally encountered after simple decompression of the nerve for treatment of cubital tunnel syndrome. The purpose of this study was to determine whether the incidence of dislocation of the nerve following simple decompression of the nerve is correlated with the patient's preoperative characteristics and/or elbow morphology. We studied 51 patients with cubital tunnel syndrome who underwent surgery at our institution. Intraoperatively, we simulated dislocation of the nerve after simple decompression by flexing the elbow after releasing the nerve in each patient. Univariate and multiple logistic regression analysis showed that young age and a small ulnar nerve groove angle are positively correlated with dislocation of the nerve. Our results suggest that patients who are young and/or have a sharply angled ulnar nerve groove identified radiographically have a high probability of experiencing anterior dislocation of the ulnar nerve after simple decompression.

Clinicopathological features of CA19-9-producing gastric cancer

BACKGROUND/AIMS

The aims of this study were to define CA19-9-producing gastric cancer and investigate its clinicopathological features.

METHODOLOGY

Twenty-three patients showing high preoperative serum CA19-9 levels (> or = 38 U/mL) were enrolled in this retrospective cohort study. The CA19-9 cut-off level was determined on the basis of receiver operating characteristic analysis of CA19-9 levels obtained from patients having survived for 3 years after surgery. Patients in whom the CA19-9 level was the cut-off level or higher were defined as having CA19-9-producing gastric cancer (Group A), and their clinicopathological features were compared with those of patients showing CA19-9 levels less than the cut-off level (Group B).

RESULTS

The preoperative serum CA19-9 cut-off level was set at 77 U/mL. In Group A, lymph node metastasis was seen in all 11 patients, with the incidence being higher than that in Group B (p <0.001). The number of patients with stage III or greater disease was 10 in Group A, compared with only 3 in Group B (p < 0.001). The independent prognostic factors were preoperative serum CA19-9 levels, venous invasion and tumor stage.

CONCLUSIONS

CA19-9-producing gastric cancer is a type of gastric cancer with poor prognosis and characterized by preoperative serum CA19-9 > or = 77 U/mL.

Ewing sarcoma of the proximal phalanx: case report

We report a case of primary Ewing sarcoma of the proximal phalanx of the right middle finger in an 18-year-old boy. He was treated with neoadjuvant chemotherapy, followed by ray amputation. To restore maximum function, the index ray was transferred to the base of the third metacarpal bone and fixed with a plate. The function of his right hand after the operation was excellent and the cosmetic appearance acceptable. There was no evidence of local recurrence or metastasis after 20 months follow up.

Functional reconstruction of bilateral injuries to the dorsum of hand using radial forearm tendocutaneous flaps

We treated a patient with skin and tendon defects of both hands as a result of injury by a heat press. There have been no reports of bilateral hand injuries being treated using simultaneous bilateral tendocutaneous flaps. In this case, we reconstructed the injured tissue using simultaneous bilateral radial forearm tendocutaneous flaps, with satisfactory results.

Reasons and risk factors for intraoperative conversion from laparoscopic to open cholecystectomy

PURPOSE

The aim of this study was to analyze the reasons and risk factors for intraoperative conversion from laparoscopic cholecystectomy to open cholecystectomy.

METHODS

The study involved 407 patients in whom laparoscopic cholecystectomy was planned between January 1998 and July 2006. The patients were divided into two groups (the LC completed group and the conversion group), and the two groups were compared.

RESULTS

Laparoscopic surgery was intraoperatively converted to open surgery in 47 cases (11.6 %). The reasons for the conversion consisted of adhesions (15 cases), inflammation (8 cases), adhesion plus inflammation (9 cases), bleeding (8 cases), common bile duct injury (4 cases), suspected common bile duct injury (1 case), injury of the duodenal bulb (1 case) and respiratory disorder (1 case). The group of patients who required conversion to open surgery had a significantly higher percentage of males (P = 0.042) and prevalence of acute cholecystitis (P < 0.001) than the group of patients for whom laparoscopic surgery could be completed. A multivariate logistic regression analysis of these significant predictors showed that male sex [odds ratio (OR) 1.95] and acute cholecystitis (OR 8.45) were significant.

CONCLUSION

Particular attention is needed when laparoscopic surgery is considered for male patients with acute cholecystitis.

A 7.5-kb 3'-Terminal cDNA Sequence of Chicken Skeletal Muscle Nebulin Reveals Its Actin Binding Regions

Nebulin is an approximately 700 kDa filamentous protein in vertebrate skeletal muscle. It binds to the Z line and also binds side-by-side to the entire thin (actin) filament in a sarcomere. Nebulin is currently thought to be a molecular ruler regulating the length of the thin filament to 1 mum. The complete sequence of human skeletal muscle nebulin was determined by . Because of its large size, only fragmental sequence information has been available for nebulins other than human skeletal muscle. This paper describes for the first time the sequence of about one third (C terminal region) of chicken skeletal muscle nebulin. It was found that the fundamental structure of human nebulin, consisting of 35 amino acid repeats (modules) plus C terminal serine-rich and SH3 domains linked to the Z line are well conserved with chicken nebulin. Sequence identity ranged from 74 to 91%. There were super-repeats (seven modules), a first linker repeat, simple repeat and a second linker repeat in addition to the Z line binding region as in human nebulin. However, there were 2 fewer modules in the first linker repeat and 6 fewer in the simple repeat in chicken nebulin as compared to human nebulin. Two isoforms of chicken nebulin were sequenced indicating insertion of approximately 6 or 11 modules to a structure similar to that of human nebulin. Recombinant first linker repeats M51 approximately 56 were shown to bind to actin using the ELISA technique as well as human nebulin recombinants.

Long-term follow-up of periarterial sympathectomy for chronic digital ischaemia

This study investigates long-term clinical results (> 10 years) of periarterial sympathectomy in chronic ischaemic digits compared with intermediate-term results (3 years). Periarterial sympathectomy via the palm and volar wrist was carried out on 11 hands of seven patients with digital ischaemia but no gangrene or severe ulceration. The aetiology of ischaemia was Buerger's disease in four hands, collagen disease in three hands, and repetitive digital trauma in four hands. Subjective symptoms were evaluated at a mean follow-up period of 12 years. The efficacy of surgery was assessed objectively using thermography and plethysmography. Although five of seven patients continued on oral vasodilators and antiplatelet agents until the final follow-up, improvement of symptoms was maintained in all patients between intermediate- and long-term evaluations. Our results suggest that periarterial sympathectomy via the palm and wrist could prevent long-term aggravation of symptoms of chronic digital ischaemia when combined with adequate postoperative drug therapy.

Regulation of Six1 expression by evolutionarily conserved enhancers in tetrapods

The Six1 homeobox gene plays critical roles in vertebrate organogenesis. Mice deficient for Six1 show severe defects in organs such as skeletal muscle, kidney, thymus, sensory organs and ganglia derived from cranial placodes, and mutations in human SIX1 cause branchio-oto-renal syndrome, an autosomal dominant developmental disorder characterized by hearing loss and branchial defects. The present study was designed to identify enhancers responsible for the dynamic expression pattern of Six1 during mouse embryogenesis. The results showed distinct enhancer activities of seven conserved non-coding sequences (CNSs) retained in tetrapod Six1 loci. The activities were detected in all cranial placodes (excluding the lens placode), dorsal root ganglia, somites, nephrogenic cord, notochord and cranial mesoderm. The major Six1-expression domains during development were covered by the sum of activities of these enhancers, together with the previously identified enhancer for the pre-placodal region and foregut endoderm. Thus, the eight CNSs identified in a series of our study represent major evolutionarily conserved enhancers responsible for the expression of Six1 in tetrapods. The results also confirmed that chick electroporation is a robust means to decipher regulatory information stored in vertebrate genomes. Mutational analysis of the most conserved placode-specific enhancer, Six1-21, indicated that the enhancer integrates a variety of inputs from Sox, Pax, Fox, Six, Wnt/Lef1 and basic helix-loop-helix proteins. Positive autoregulation of Six1 is achieved through the regulation of Six protein-binding sites. The identified Six1 enhancers provide valuable tools to understand the mechanism of Six1 regulation and to manipulate gene expression in the developing embryo, particularly in the sensory organs.

A successful reconstruction using a frozen autograft and a pedicled latissimus dorsi flap after a S12345B shoulder girdle resection in a patient with osteosarcoma

We present a case of high-grade osteosarcoma in the proximal humerus in an 8-year-old boy. Massive tumor expansion required a S12345B shoulder girdle resection according to the system of the Musculoskeletal Tumor Society. After wide resection, only a small portion of the distal humerus and none of the rotator cuff muscles would be spared. Because the humeral portion would be too short to support the stem and the soft tissue would be insufficient to cover prosthetic components, we designed a composite reconstruction using a frozen autograft and a pedicled muscle flap. At 2 years postoperatively, our patient exhibited good adaptation and had acquired fine dexterity of the upper limb. To our knowledge, this is the first report regarding a successful composite reconstruction after a S12345B shoulder girdle resection.

RADIOCARPAL ARTHRODESIS FOR OSTEOARTHRITIS FOLLOWING FRACTURES OF THE DISTAL RADIUS

To compare the radioscapholunate (RSL) arthrodesis and radiolunate (RL) arthrodesis as a treatment for radiocarpal osteoarthritis following fractures of the distal radius, nine patients, 23 to 70 years old (average 41) at the time of surgery, were assessed two to 33 years after surgery. The periods between injury and surgery ranged from four months to 30 years. RSL arthrodesis was performed in three cases and RL arthrodesis in six. Post-operative wrist pain disappeared in six and was decreased in the other three. In the RSL group, the total arc of wrist flexion and extension was reduced from 50° pre-operatively to 35° post-operatively. In the RL group, it was increased from 72° to 76° after surgery. Grip strength improved in most patients, from 7 to 18 kg in the RSL group, and from 16 to 27 kg in the RL group. On roentogenogram, three patients showed arthritic changes in the adjacent joints, but there were no symptoms in two of the three patients. We concluded that partial radiocarpal arthrodesis (preferably RL arthrodesis) is a reliable procedure for radiocarpal osteoarthritis following fractures of the distal radius.

ACUTE CARPAL TUNNEL SYNDROME SECONDARY TO CALCIFIC TENDINITIS: CASE REPORT

Acute carpal tunnel syndrome (CTS) secondary to calcific deposition is rarely reported. In this article we describe a case of acute CTS in the dominant hand of a 94-year-old female patient secondary to calcific tendinitis within the carpal tunnel. Diagnosis was difficult clinically and radiologically. Urgent complete median nerve decompression led to a good clinical recovery.

Changes in blood circulation of the contralateral Achilles tendon during and after acupuncture and heating

The purpose of this study was to investigate the effects of acupuncture and heating (application of hot pack) treatments on blood circulation in the contralateral Achilles tendon. During the treatments (10 min for acupuncture, 20 min for heating) and recovery period (40 min), the blood volume (THb) and oxygen saturation (StO2) of the treated and the non-treated tendons were measured using red laser lights. During both treatments, THb and StO2 of the treated tendon increased significantly from the resting level. The increased THb and StO2 of the treated tendon were maintained until the end of the recovery period after removal of the acupuncture needle, although these values decreased after removal of the hot pack. Although THb of the non-treated sides did not change during both acupuncture and heating treatments, it increased gradually after removal of the acupuncture needle or the hot pack. For both treatments, the amount of increase in THb of the non-treated tendon was significantly correlated to that of the treated tendon during the last phase of recovery period. These results obtained from the healthy subjects imply that blood circulation in the injured tendon in a plaster cast may be improved by applying acupuncture or heating treatments to the contralateral healthy limb.

Conserved expression of mouse Six1 in the pre-placodal region (PPR) and identification of an enhancer for the rostral PPR

All cranial sensory organs and sensory neurons of vertebrates develop from cranial placodes. In chick, amphibians and zebrafish, all placodes originate from a common precursor domain, the pre-placodal region (PPR), marked by the expression of Six1/4 and Eya1/2. However, the PPR has never been described in mammals and the mechanism involved in the formation of PPR is poorly defined. Here, we report the expression of Six1 in the horseshoe-shaped mouse ectoderm surrounding the anterior neural plate in a pattern broadly similar to that of non-mammalian vertebrates. To elucidate the identity of Six1-positive mouse ectoderm, we searched for enhancers responsible for Six1 expression by in vivo enhancer assays. One conserved non-coding sequence, Six1-14, showed specific enhancer activity in the rostral PPR of chick and Xenopus and in the mouse ectoderm. These results strongly suggest the presence of PPR in mouse and that it is conserved in vertebrates. Moreover, we show the importance of the homeodomain protein-binding sites of Six1-14, the Six1 rostral PPR enhancer, for enhancer activity, and that Dlx5, Msx1 and Pax7 are candidate binding factors that regulate the level and area of Six1 expression, and thereby the location of the PPR. Our findings provide critical information and tools to elucidate the molecular mechanism of early sensory development and have implications for the development of sensory precursor/stem cells.

Profile of signs and symptoms in mild and advanced acute appendicitis

The aim of this study was to investigate the relationship between the frequency of common signs and symptoms and the histopathologic findings of resected appendix to identify factors that might be useful for judging the necessity for surgery in patients with acute appendicitis. The association of preoperative clinical characteristics, including age, sex, physical findings, gastrointestinal symptoms, body temperature, and white blood cell count, with histopathologic findings of the appendix was evaluated in 128 patients, who underwent appendectomy for clinical symptoms of acute appendicitis. The frequency of periumbilical pain as the initial symptom was significantly high in patients with catarrhal appendicitis (P < 0.01 versus those with phlegmonous appendicitis, P < 0.01 versus those with gangrenous appendicitis), and vomiting occurred less frequently in these patients (P < 0.05 versus those with phlegmonous appendicitis, P < 0.01 versus those with gangrenous appendicitis). A history of periumbilical pain and vomiting was useful for judging the necessity of appendectomy.

Raloxifene: its ossification-promoting effect on female mesenchymal stem cells

BACKGROUND

Raloxifene acts like estrogen in preventing bone loss in postmenopausal women, but it selectively activates biological responses in bone tissue. It has a direct effect on osteoblasts' differentiation and bone formation in bone marrow culture. However, the point at which raloxifene has an effect on bone marrow-derived mesenchymal stem cells (MSCs), regardless of sex difference, is not known. The purpose of this study was to examine the osteogenic effect of raloxifene on MSCs derived from female and male rats and to assess the sex difference of raloxifene with or without osteogenic supplements (OSs) in the regulation of bone formation.

METHODS

Female and male rat bone marrow cells were cultured with or without OSs. In each experimental group, 10-6 M or 10-8 M raloxifene was added. As a control, cells were cultured without raloxifene. Histologically, mineralization was assessed by alizarin red S staining. Biochemically, alkaline phosphatase (ALP) activity, calcium content, and osteocalcin content were assessed.

RESULTS

On histological analysis, mineralized nodules were seen on alizarin red S staining in the groups treated with OS. On the biochemical analysis, OS increased ALP activity, calcium content, and osteocalcin content. Among female groups with OSs, 10-6 M raloxifene significantly increased ALP activity, calcium content, and osteocalcin content compared with the controls. Among male groups, raloxifene had negligible effects.

CONCLUSIONS

10-6 M Raloxifene had no ossification-inducing effect on female MSCs, but it had an ossification-promoting effect; it had no osteogenic effect on male MSCs. Therefore, raloxifene has a sex difference with regard to its osteogenic effect on MSCs. Moreover, combined treatment with raloxifene plus OS has an effect on female MSCs. These results provide a useful insight into the possible influence of raloxifene after MSC transplantation in clinical practice.

Wrist arthrodesis with vascularized fibular grafting

Six patients underwent wrist arthrodesis using vascularized fibular grafting for treatment of a segmental bone defect across the wrist. Five patients had defects resulting from excision of a giant cell tumor at the distal radius, and one patient had a defect after debridement of a chronic infection. In all cases, bone union was achieved within 3 to 6 months after vascularized fibular grafting without additional procedures. Measurement of postoperative roentgenograms revealed that the average of fixed wrist angle was 13 degrees extension. Postoperatively, average grip strength on the affected side was 59% of that on the unaffected side, and the average range of forearm rotation was 123 degrees. The mean Enneking functional score was 84% at a mean follow-up period of 64 months. There was no recurrence of a tumor or infection. Wrist arthrodesis using vascularized fibular grafting is a useful procedure for the treatment of a segmental bone defect across the wrist.

Treatment of intraosseous ganglia and bone cysts of the carpal bones with injectable calcium phosphate bone cement

This article documents the outcome of treatment of intraosseous ganglia and simple bone cysts of the carpal bones by curettage and injectable calcium phosphate bone cement (CPC) grafting. The patients consisted of five men and three women. One had a cystic lesion in the scaphoid, one in the hamate, and five in the lunate. Curettage of the lesions was performed, and CPC was injected into the cavity. Five patients were diagnosed with a ganglion and three with a simple bone cyst. Among the five patients with wrist pain, the pain disappeared completely in four. Radiographs showed apparent partial absorption of CPC in four patients and no absorption in other four. There were no recurrence of tumours and no other complications were encountered. We conclude that calcium phosphate bone cement is a useful material for repairing bone defect after curettage of an intraosseous ganglion or bone cyst of a carpal bone.

In vivo osteogenic capability of human mesenchymal cells cultured on hydroxyapatite and on beta-tricalcium phosphate

The aim of the current study was to examine in vitro osteogenic capability and in vivo bone formation of mesenchymal stromal cells (MSCs) on two kinds of calcium phosphate ceramics. MSCs derived from human bone marrow were seeded on either hydroxyapatite (HA) ceramic or beta-tricalcium phosphate (beta-TCP) ceramic and then cultured in a medium supplemented with a donor's serum, vitamin C, beta-glycerophosphate, and dexamethasone. The culture revealed the expression of alkaline phosphatase activity, indicating the osteogenic differentiation of the MSCs on the ceramics (fabrication of tissue-engineered construct). The constructs were then implanted subcutaneously into nude rats for 8 weeks. New bone formation was observed in both types of ceramics, and human-specific Alu sequence was detected by in situ hybridization analysis. Quantitative microcomputed tomography showed that the volume of the new bone in the HA ceramic was greater than that in the beta-TCP ceramic in six of seven cases. These results suggest that human MSCs cultured on ceramics could retain their osteogenic capability even after ectopic implantation and provide a rationale for the use of tissue-engineered constructs derived from a patient's MSCs and calcium phosphate ceramics in bone tissue regeneration.

Advanced Kienböck's disease treated with implantation of a tendon roll and temporary partial fixation of the wrist

Twenty-one patients with advanced Kienböck's disease were treated by implantation of a tendon roll and temporary partial fixation of the wrist. There were 13 women and eight men. Their ages at the time of operation ranged from 24 to 72 years. According to Alexander and Lichtman's classification, 12 patients were stage IIIb and nine stage IV. After implantation of the tendon roll, the scaphotrapezio-trapezoidal joint was fixed with Kirschner wires in 19 patients, and the scaphocapitate joint with absorbable pins in two. Postoperative wrist pain disappeared in nine patients and was reduced in 12. The mean postoperative total arc of flexion and extension of the wrist increased from 91 degrees to 103 degrees, and mean grip strength improved from 11.5 to 17.2 kg. Loosening of Kirschner wires during partial fixation of the wrist was seen in six cases, and required early removal of the loose wires.

Plexiform schwannoma of the ulnar nerve

Plexiform schwannoma is a rare benign neurogenic tumour; we report a case that arose in the ulnar nerve of a 59-year-old woman. Exploration showed a continuous multinodular tumour that involved the ulnar nerve from the hand to the upper arm; the length of the tumour was 35 cm.

Radial forearm flaps for reconstruction in hand surgery

Thirty-seven patients were treated using distally-based island radial forearm flaps. There were 31 men and six women. Reconstructed sites involved the dorsum of the hand (n = 17), the thumb (n = 11), the fingers (n = 5), the first web (n = 3), and the palm (n = 1). Sensory flaps were transferred in 15 cases, osteocutaneous flaps in six, and tendocutaneous flaps in eight. All the flaps survived. There were five donor-site complications, but no functional disturbances. Three patients had symptoms of cold intolerance. There were no radial fractures. In the six cases with osteocutaneous flaps, a mean of 2.6 months (range 2-3) was needed to obtain bony union. Among the eight cases with tendocutaneous flaps, postoperative tenolysis was required in two cases, and finally seven achieved a satisfactory outcome. The mean moving 2-point discrimination of the sensory flaps was 13 mm.

Treatment of Kienböck disease in an 11-year-old girl with temporary fixation of the scaphotrapeziotrapezoidal joint

An 11-year-old girl with Kienböck disease (stage IIIA) was treated by temporary scaphotrapeziotrapezoidal fixation. It was fixed in a cast for four weeks and wires removed after eight weeks. Follow up examinations showed that movement of the wrist and grip strength were improved, and she had no pain while revascularisation of the lunate could be seen on magnetic resonance imaging.

Multiple evolutionarily conserved enhancers control expression of Eya1

Eya1 is a homolog of eyes absent in Drosophila, and essential for various organ formations in vertebrates. Mouse and chick Eya1 shows dynamic expression pattern in early development. We identified ten independent Eya1 enhancers by screening evolutionarily conserved sequences. They exhibited enhancer activities in Hensen's node, neural tube, migrating neural crest cells, otic vesicle, olfactory placode, cranial ganglia, and somites at HH6-17 of chick embryo. The sum of the enhancer activities of the enhancers covers the endogenous expression domains of Eya1 common to chick and mouse. Enhancer activities were also observed in species-specific expression domains such as trigeminal ganglia and brain. Mutational study of one of the enhancers revealed that the enhancer is composed of positive and negative cis-regulatory elements. Thus, we successfully identified a comprehensive group of enhancers around Eya1 locus, which are probably involved in the control of the complex expression pattern of Eya1 in vivo.

Computed tomography-based custom-made stem for dysplastic hips in Japanese patients

We investigated 55 hips of 53 patients with dysplastic hips. Individual computed tomography data were used in the manufacturing of cementless custom-made stems made of Ti-6Al-4V. The proximal one third was coated using porous coating covered with hydroxyapatite coating. The average age at surgery was 60 years and the average follow-up was 7 years. Five patients (9%) complained of postoperative thigh pain. According to Engh's radiologic classification system, there was bone-ingrown fixation in all hips. The cortical index and canal flare index were lower, and stem diameter was greater in the 11 hips (20%) with severe stress shielding than in the remaining 44 hips. Although the results obtained with this custom-made stem system for dysplastic hips were excellent, stress shielding is still an issue.