International promotion of Japanese aging-related health services and products: Perspective of an international agency

Asia is at a critical juncture of health development. The population is aging and shrinking. At the same time, the economy is developing rapidly. These two factors, which necessitate a new paradigm of health development: departing from dependence on Official Development Assistance (ODA) and transitioning towards a model with more involvement of industries (private sector), academia, and health care providers, the so-called public-private partnership (PPP) model. The Economic Research Institute for ASEAN and East Asia (ERIA) is studying the potential for broader application of the new concept for collaboration between Asian countries and Japan. In this article, the authors attempt to introduce the complete picture of a new health ecosystem advocated by Japan. We first look at the impacts of population aging and shrinking, followed by introducing two new approaches; regional and country-specific, with the involvement of ERIA. Then, the outcomes of the projects and Japanese technology, services and products relevant to the older population are introduced. Finally, based on the various projects and products, we focus more closely on the new health development model, the PPP model. We start from the theory and move to examine a tool for implementation, which is the formulation of a dialogue forum named the MEX (Medical Excellence X, where X can be substituted by the acronym of any participating country) project. The experience of these projects and case studies will benefit all ASEAN member countries and beyond. ERIA finds that the facilitation works of the Institute catalyze the progress. ERIA will remain committed to helping the endeavors initiated by Japan for the benefit of all.

Unusually strong electronic correlation and field-induced ordered phase in YbCo2

We report the first study of electrical resistivity, magnetization, and specific heat on YbCo₂. The measurements on a single-phased sample of YbCo₂bring no evidence of magnetic ordering down to 0.3 K in a zero magnetic field. The manifestations of low Kondo temperature are observed. The specific heat value divided by temperature,C/T, keeps increasing logarithmically beyond 7 J/mol K²with decreasing temperature down to 0.3 K without no sign of magnetic ordering, suggesting a very large electronic specific heat. Analysis of the magnetic specific heat indicates that the large portion of the low-temperature specific heat is not explained simply by the low Kondo temperature but is due to the strong intersite magnetic correlation in both the 3dand 4felectrons. Temperature-dependent measurements under static magnetic fields up to 7 T are carried out, which show the evolution of field-induced transition above 2 T. The transition temperature increases with increasing field, pointing to a ferromagnetic character. The extrapolation of the transition temperature to zero field suggests that YbCo₂is in the very proximity of the quantum critical point. These results indicate that in the unique case of YbCo₂, the itinerant electron magnetism of Co 3d-electrons and the Kondo effect within the vicinity of quantum criticality of Yb 4f-local moments can both play a role.

Melanoma antigens recognized by T cells and their use for immunotherapy

Melanoma has been a prototype for cancer immunology research, and the mechanisms of anti-tumor T-cell responses have been extensively investigated in patients treated with various immunotherapies. Individual differences in cancer-immune status are defined mainly by cancer cell characteristics such as DNA mutations generating immunogenic neo-antigens, and oncogene activation causing immunosuppression, but also by patients' genetic backgrounds such as HLA types and genetic polymorphisms of immune related molecules, and environmental and lifestyle factors such as UV rays, smoking, gut microbiota and concomitant medications; these factors have an influence on the efficacy of immunotherapy. Recent comparative studies on responders and non-responders in immune-checkpoint inhibitor therapy using various new technologies including multi-omics analyses on genomic DNA, mRNA, metabolites and microbiota and single cell analyses of various immune cells have led to the advance of human tumor immunology and the development of new immunotherapy. Based on the new findings from these investigations, personalized cancer immunotherapies along with appropriate biomarkers and therapeutic targets are being developed for patients with melanoma. Here, we will discuss one of the essential subjects in tumor immunology: identification of immunogenic tumor antigens and their effective use in various immunotherapies including cancer vaccines and adoptive T-cell therapy.

Interlaboratory Evaluation of Two Enzyme-Linked Immunosorbent Assay Kits for the Determination of Crustacean Protein in Processed Foods

The labeling of foods containing material derived from crustaceans such as shrimp and crab is to become mandatory in Japan because of increases in the number of allergy patients. To ensure proper labeling, 2 novel sandwich enzyme-linked immunosorbent assay (ELISA) kits for the determination of crustacean protein in processed foods, the N kit (Nissui Pharmaceutical Co., Ltd, Ibaraki, Japan) and the M kit (Maruha Nichiro Holdings, Inc., Ibaraki, Japan), have been developed. Five types of model processed foods containing 10 and/or 11.9 g/g crustacean soluble protein were prepared for interlaboratory evaluation of the performance of these kits. The N kit displayed a relatively high level of reproducibility relative standard deviation (interlaboratory precision; 4.08.4 RSDR) and sufficient recovery (6586) for all the model processed foods. The M kit displayed sufficient reproducibility (17.620.5 RSDR) and a reasonably high level of recovery (82103). The repeatability relative standard deviation (RSDr) values regarding the detection of crustacean proteins in the 5 model foods were mostly <5.1 RSDr for the N kit and 9.9 RSDr for the M kit. In conclusion, the results of this interlaboratory evaluation suggest that both these ELISA kits would be very useful for detecting crustacean protein in processed foods.

Determination of Walnut Protein in Processed Foods by Enzyme-Linked Immunosorbent Assay: Interlaboratory Study

Because food allergens from tree nuts, including walnuts, are a frequent cause of adverse food reactions for allergic patients, the labeling of foods containing ingredients derived from tree nuts is required in numerous countries. According to Japanese regulations, the labeling of food products containing walnuts is recommended. To ensure proper labeling, a novel sandwich ELISA kit for the determination of walnut protein in processed foods (Walnut Protein [2S-Albumin] Kit; Morinaga Institute of Biological Science, Inc.; walnut kit) has been developed. We prepared seven types of incurred samples (model processed foods: biscuits, bread, sponge cake, orange juice, jelly, chicken meatballs, and rice gruel) containing 10 g walnut soluble protein/g of food for use in interlaboratory evaluations of the walnut kit. The walnut kit displayed sufficient reproducibility relative standard deviations (interlaboratory precision: 5.89.9 RSDR) and a high level of recovery (81119) for all the incurred samples. All the repeatability relative standard deviation (RSDr) values for the incurred samples that were examined were less than 6.0. The results of this interlaboratory evaluation suggested that the walnut kit could be used as a precise and reliable tool for determination of walnut protein in processed foods.

Enzyme-Linked Immunosorbent Assay Kit for the Determination of Soybean Protein in Processed Foods: Interlaboratory Evaluation

The labeling of foods containing ingredients derived from soybean is recommended in Japan because of an increasing number of patients who are allergic to soybeans. To ensure proper labeling, a novel sandwich ELISA kit for the determination of soybean protein in processed foods (FASTKIT Ver. II, Soybean, Nippon Meat Packers, Inc.; soy kit) has been developed. Five types of incurred samples (model processed foods: rice gruel, sausage, sweet adzuki bean soup, sweet potato cake, and tomato sauce) containing 10 g soybean soluble protein/g food were prepared for use in interlaboratory evaluations of the soy kit. The soy kit displayed a sufficient RSDR value (interlaboratory precision: 9.313.4 RSDR) and a high level of recovery (97114) for all the incurred samples. The RSDr value for the incurred samples was mostly <4.8. The results of this interlaboratory evaluation suggest that the soy kit can be used as a precise and reliable tool for the determination of soybean proteins in processed foods.

Intratumoural immune cell landscape in germinoma reveals multipotent lineages and exhibits prognostic significance

AIMS

Alterations in microenvironments are a hallmark of cancer, and these alterations in germinomas are of particular significance. Germinoma, the most common subtype of central nervous system germ cell tumours, often exhibits massive immune cell infiltration intermingled with tumour cells. The role of these immune cells in germinoma, however, remains unknown.

METHODS

We investigated the cellular constituents of immune microenvironments and their clinical impacts on prognosis in 100 germinoma cases.

RESULTS

Patients with germinomas lower in tumour cell content (i.e. higher immune cell infiltration) had a significantly longer progression-free survival time than those with higher tumour cell contents (P = 0.03). Transcriptome analyses and RNA in-situ hybridization indicated that infiltrating immune cells comprised a wide variety of cell types, including lymphocytes and myelocyte-lineage cells. High expression of CD4 was significantly associated with good prognosis, whereas elevated nitric oxide synthase 2 was associated with poor prognosis. PD1 (PDCD1) was expressed by immune cells present in most germinomas (93.8%), and PD-L1 (CD274) expression was found in tumour cells in the majority of germinomas examined (73.5%).

CONCLUSIONS

The collective data strongly suggest that infiltrating immune cells play an important role in predicting treatment response. Further investigation should lead to additional categorization of germinoma to safely reduce treatment intensity depending on tumour/immune cell balance and to develop possible future immunotherapies.

Upper gastrointestinal pathophysiology due to mouse malaria Plasmodium berghei ANKA infection

Background

Epigastric pain, vomiting, and other gastrointestinal problems are among the most important symptoms of malaria infection as they suggest the possibility that the condition is serious. Pathophysiologies such as gastric mucosal changes and delayed gastric emptying have been reported in serious cases of malaria infection. However, it is unclear whether or not pathophysiological involvement of the upper gastrointestinal tract occurs in Plasmodium berghei ANKA (PbA)-infected mice.

Methods

PbA-infective Anopheles mosquitoes were used to infect mice via the natural route of infection. Fifteen PbA-C57BL/6 mice were used as a cerebral malaria model and the same numbers of PbA-BALB/c mice were used as a cerebral malaria-resistant model, and then we investigated the pathophysiological involvement of the stomach and small intestine.

Results

On day 8 post infection, six PbA-C57BL/6 mice showed cerebral malaria and nine others had uncomplicated infection. All the PbA-C57BL/6 mice on that same day showed severe weight loss with multiple, red gastric patches and changes to the course of the small intestine with villus goblet cell enlargement. In addition, cerebral malaria cases showed gastric gas retention with submucosal edema and small intestinal shortening. In PbA-BALB/c mice, overextension of the stomach and gas retention were evident from week 2 after PbA infection, as well as changes to the course of the small intestine and mesenteric thinning with fragility.

Conclusions

We described the upper gastrointestinal pathophysiology representing new findings directly linked to malarial severity and subsequent death in PbA-infected mice as a mouse model of malaria infection.

Study of Immune Tolerance Cases in Adult Living Donor Liver Transplantation

BACKGROUND

Complete immune tolerance is the chief goal in organ transplantation. This study aimed to evaluate patients who successfully withdrew from immunosuppressive (IS) agents after living donor liver transplantation (LDLT).

MATERIALS AND METHODS

A retrospective review of all adult LDLT from July 1999 to March 2012 was conducted. In patients who acquired immune tolerance after LDLT, their background and the course of surgical procedures were evaluated.

RESULTS

Of a total of 101 adult LDLT patients, 8 patients were completely free of IS agents. Six of these patients (75%) were female, and the median age at the time of transplantation was 56 years (range, 31-66 years). The primary disease causing liver failure was type C liver cirrhosis (50%), fulminant hepatitis (25%), type B liver cirrhosis (12%), and alcoholic liver cirrhosis (12%). The median Child-Pugh score and MELD score were 13 points (range, 8-15 points) and 19 points (range, 10-18 points), respectively. The living related donor was the recipient's child (75%), sibling (12%), or parent (12%). ABO compatibility was identical in 62%, compatible in 25%, and incompatible in 12%.

CONCLUSIONS

In this study, we evaluated the adult patients who successfully withdrew from IS agents after LDLT. In most cases, it took more than 5 years to reduce IS agents. Because monitoring of the serum transaminase level is not adequate to detect chronic liver fibrosis in immune tolerance cases, further study is required to find appropriate protocols for reducing IS agent use after LDLT.

Successful Endoscopic Management of Acute Necrotic Pancreatitis and Walled Off Necrosis After Auxiliary Partial Orthotopic Living-Donor Liver Transplantation: A Case Report

Endoscopic management of acute necrotic pancreatitis and walled off necrosis is less invasive than surgical treatment and has become the 1st choice for treating pancreatic necrosis and abscess. We treated a case of acute necrotic pancreatitis and walled off necrosis after auxiliary partial orthotopic living-donor liver transplantation (APOLT). A 24-year-old woman was admitted to our university hospital for removal of the internal biliary stent, which had already been placed endoscopically for the treatment of biliary stricture after APOLT. She had been treated for acute liver failure by APOLT 10 years before. After we removed the internal stent with the use of an endoscopic retrograde approach, she presented with severe abdominal pain and a high fever. Her diagnosis was severe acute pancreatitis after endoscopic retrograde cholangiography (ERC). Her symptoms worsened, and she had multiple organ failure. She was transferred to the intensive care unit (ICU). Immunosuppression was discontinued because infection treatment was necessary and the native liver had already recovered sufficiently. After she had been treated for 19 days in the ICU, she recovered from her multiple organ failure. However, abdominal computerized tomography demonstrated the formation of pancreatic walled off necrosis and an abscess on the 20th day after ERC. We performed endoscopic ultrasonography-guided abscess drainage and repeated endoscopic necrosectomy. The walled off necrosis diminished gradually in size, and the symptoms disappeared. The patient was discharged on the 87th day after ERC. This is the 1st report of a case of acute necrotic pancreatitis and walled off necrosis that was successfully treated by endoscopic management after APOLT.

Six-Year Graft Survival After Partial Pancreas Heterotopic Auto-Transplantation: A Case Report

BACKGROUND

Long-term graft survival of partial pancreas auto-transplantation after total pancreatectomy has not been clarified. The clinical implications of repeat completion pancreatectomy for locally recurrent pancreatic carcinoma in the remnant pancreas after initial pancreatectomy also have not been clarified.

METHODS

We have previously reported a 61-year-old woman presenting with re-sectable carcinoma of the remnant pancreas at 3 years after undergoing a pylorus-preserving pancreaticoduodenectomy for invasive ductal carcinoma of the pancreas head. We also performed distal pancreas auto-transplantation with the use of a part of the resected pancreas to preserve endocrine function.

RESULTS

The patient was discharged at 20 days after surgery without any complications. She had been followed regularly in our outpatient clinic. She had been treated with S-1 as adjuvant chemotherapy; 72 months after the completion total pancreatectomy with distal partial pancreas auto-transplantation, the patient was alive without any evidence of the pancreatic carcinoma recurrence. The pancreas graft was still functioning with a blood glucose level of 112 mg/dL, HbA1C of 6.7%, and serum C-peptide of 1.2 ng/mL; and urinary C-peptide was 11.6 μg/d.

CONCLUSIONS

Our patient demonstrated that repeated pancreatectomies can provide a chance for survival after a locally recurrent pancreatic carcinoma if the disease is limited to the remnant pancreas. An additional partial pancreas auto-transplantation was successfully performed to preserve endocrine function. However, the indications for pancreas auto-transplantation should be decided carefully in the context of pancreatic carcinoma recurrence.

Surgical treatment of patients with unruptured intracranial aneurysms

We present our experience with elective microsurgical clipping of unruptured intracranial aneurysms (UIA) and analyze this management. A total of 150 patients with UIA were reviewed and data were collected with regard to age, sex, presence of symptoms, location and size of the aneurysms, surgical complications and postoperative 1 year outcomes. Aneurysm size was assessed either by three-dimensional CT angiography or digital subtraction angiogram. Glasgow Outcome Scale was used to assess clinical outcomes. One hundred and fifty patients with 165 aneurysms were treated in this series. The mean size of the UIA was 5.6mm. Eighty aneurysms (48.5%) were less than 5mm in size, and 73 (44.2%) were from 5 to 10mm. Ten (6.1%) of the aneurysms were large and two (1.2%) were giant. One hundred and forty-three were asymptomatic and seven were symptomatic before surgery. The outcome was good in 147 patients (98%), and only three patients (2%) had a treatment-related unfavorable outcome. Five patients experienced transient neurological deficits and one patient experienced permanent neurological deficits. Overall 98.7% of the treated aneurysms were satisfactorily obliterated. Wound complications were seen only in three patients. In conclusion, UIA pose a significant challenge for neurosurgeons, where a delicate balance between benefits and possible risks must be weighed. If the requisite expertise is available, they can be treated surgically with low morbidity and a good outcome at specialized neurovascular centers.

Quick-scanning x-ray absorption spectroscopy system with a servo-motor-driven channel-cut monochromator with a temporal resolution of 10 ms

We have developed a quick-scanning x-ray absorption fine structure (QXAFS) system and installed it at the recently constructed synchrotron radiation beamline BL33XU at the SPring-8. Rapid acquisition of high-quality QXAFS data was realized by combining a servo-motor-driven Si channel-cut monochromator with a tapered undulator. Two tandemly aligned monochromators with channel-cut Si(111) and Si(220) crystals covered energy ranges of 4.0-28.2 keV and 6.6-46.0 keV, respectively. The system allows the users to adjust instantly the energy ranges of scans, the starting angles of oscillations, and the frequencies. The channel-cut crystals are cooled with liquid nitrogen to enable them to withstand the high heat load from the undulator radiation. Deformation of the reflecting planes is reduced by clamping each crystal with two cooling blocks. Performance tests at the Cu K-edge demonstrated sufficiently high data quality for x-ray absorption near-edge structure and extended x-ray absorption fine-structure analyses with temporal resolutions of up to 10 and 25 ms, respectively.

Intraoperative near-infrared indocyanine green-videoangiography (ICG-VA) and graphic analysis of fluorescence intensity in cerebral aneurysm surgery

We present our preliminary experience with intraoperative near-infrared indocyanine green-videoangiography (ICG-VA) and analysis of blood flow dynamics using fluorescence intensity assessment in cerebral aneurysm clipping surgery. Thirty-nine patients with 43 intracranial aneurysms underwent microsurgical clipping. Intraoperative ICG-VA was performed before and after clip application. An infrared fluorescence module integrated into a surgical microscope was used to visualize fluorescence in the surgical field and we recorded the emitted fluorescent light. An integrated analytical visualization tool simultaneously analyzed the video sequence and converted it into an intensity diagram, which allowed an objective evaluation of the results rather than the subjective assessment of fluorescence using ICG-VA. Overall, ICG-VA was performed 137 times. Incomplete clipping was detected in four patients, which allowed suitable adjustment to completely obliterate the aneurysm. In 12 patients, perforators arising close to, or from, the aneurysmal neck were identified in the surgical field. In three patients, the ICG-VA intensity diagram provided valuable information leading to modification of the primary surgical maneuver. ICG-VA provides high resolution images allowing real-time assessment of the blood flow in the parent artery and arterial branches, including the perforators. The intensity diagram is useful for providing a more objective record of the hemodynamics than the traditional ICG-VA, which relies more on subjective assessment and may allow interobserver variability. We conclude that ICG-VA, combined with the intensity diagram, can reduce the morbidity and complications associated with aneurysm clipping and improve patient outcomes.

Comparison of cerebral aneurysm volumes as determined by digitally measured 3D rotational angiography and approximation from three diameters

This study compared digital measurement of aneurysm volume by 3D rotational angiography (3D-RA) with an approximation technique using three diameters of an aneurysm to re-interpret previously reported optimal packing densities (volume embolization ratio, VER) in coil embolization of intracranial aneurysms. Estimation of the volume of saccular aneurysms is important for calculation of the VER, which is in turn reported to be useful for prediction of coil compaction. The conventional formula for the volume estimation is V=4/3 π(A/2) (B/2) (C/2), where A, B, and C are the aneurysmal height, length, and width measured on 3D-RA image respectively. Using 3D rotational angiography data from 74 aneurysms, the approximated volume generated using the conventional formula was directly compared with the digitally measured volume. The digitally measured volume varied from 0.003 ml to 7.935 ml, and the dome-to-neck ratio (D/N) from 0.79 up to 4.62. We found that the conventional formula almost systematically underestimated the volume by up to 50 %, particularly when the neck was large relative to the dome (D/N<2). On average, digitally measured volume was 1.26~1.29 times larger than the approximated volume obtained using the conventional formula.Conventional 2D angiography based aneurysm volume calculation tends to underestimate an aneurysm volume, so the so-called VER (volume embolization ratio) could be overestimated.

The application of intraoperative near-infrared indocyanine green videoangiography and analysis of fluorescence intensity in cerebrovascular surgery

OBJECTIVE

To evaluate the usefulness and limitations of the intraoperative near-infrared (NIR) indocyanine green videoangiography (ICG-VA) and analysis of fluorescence intensity in cerebrovascular surgery.

METHODS

Forty-eight patients received ICG-VA during various surgical procedures from May 2010 to August 2010. Included among them were 45 cases of cerebral aneurysms and 3 cases of cerebral arteriovenous malformations (AVMs). The infrared fluorescence module integrated into the surgical microscope was used to visualize fluorescent areas in the surgical field. An integrated analytical visualization tool constantly analyzed the fluorescence video sequence and generated it in the form of an intensity diagram for objective interpretation.

RESULTS

Overall, the procedure of ICG VA was done 158 times in 48 patients. There was no adverse effect of ICG dye. In cerebral aneurysm cases, the images obtained were of high resolution. In 4 cases, incomplete clipping was detected by ICG-VA and allowed suitable adjustment to completely obliterate the aneurysm. In 3 aneurysm cases, the intensity diagram of ICG VA provided valuable information. ICG-VA identified the feeding arteries, the draining veins, and nidus in all 3 AVM cases, which was confirmed by an immediate analysis of fluorescence intensity.

CONCLUSIONS

ICG-VA provides high resolution images allowing real-time assessment of the blood flow in surgical field. The intensity analysis function, in addition, is a useful adjunct to improve the accuracy of the clipping and decrease the complication rates in cerebral aneurysm cases. In cerebral AVM cases, with the help of color map and intensity diagram function, the superficial feeders, drainers, and nidus can be identified easily.

Safety studies of LP20 powder produced from heat-killed Lactobacillus plantarum L-137

The safety of LP20 and its prototype, a powder, with potential use in food, produced from a mixture of dextrin and heat-killed Lactobacillus plantarum L-137, was assessed in an acute study in mice, and in an in vitro bacterial reverse mutation assay, an in vitro chromosome aberration assay, and an in vivo mouse micronucleus assay. LP20 prototype was not acutely toxic when administered to male and female Slc:ICR mice by single gavage at 2000mg/kg bw. Dosing was not associated with mortality, clinical signs, changes in bodyweight, or macroscopic abnormalities. The LD(50) in mice was greater than 2000mg/kg bw. There was no evidence of genotoxicity of LP20 in the Ames assay (0-5000microg/plate) or in the in vitro chromosome aberration assay with Chinese hamster lung fibroblasts (0-5000microg/mL). Administration of two consecutive daily doses of 500, 1000, or 2000mg/kg bw by gavage to male Crlj:CD-1 mice was not associated with an increased incidence of micronuclei and did not alter the ratio of polychromatic to normochromatic erythrocytes. These studies show that LP20 powder is not acutely toxic and is without genotoxic activity both in vitro and in vivo.

Fluid-fluid level formation: a rare finding of extracranial head and neck schwannomas

SUMMARY

We present 3 cases of extracranial head and neck schwannomas exhibiting fluid-fluid levels. In the described cases, CT and MR imaging showed predominantly cystic components, intermixed with cellular components. Histopathologic examinations of excised specimens revealed hemosiderin deposition, reflecting intratumoral hemorrhages, which was presumably a cause of fluid-fluid levels. Although fluid-fluid levels are nonspecific findings, schwannoma should be considered when radiologic images demonstrate marked cystic formation with fluid-fluid levels in extracranial head and neck tumors.

Endoscopic ultrasound-guided fine needle aspiration biopsy for splenic tumor: a case series

Splenic tumors are occasionally found in clinical practice but the diagnosis is often difficult if only serologic and imaging tests are used. Therefore, pathologic sampling is required in such cases. Endoscopic ultrasonography (EUS) provides a good image of the spleen through the gastric wall, and a transgastric EUS-guided fine needle aspiration (EUS-FNA) biopsy may be easier than the percutaneous approach. Furthermore, a large-gauge needle may raise the capability of EUS-FNA for the histopathologic diagnosis. The aim of this study was to evaluate the yield of EUS-FNA using a large-gauge needle for a splenic tumor. Five patients with splenic tumor were subjected to EUS-FNA with a 19-gauge needle to obtain histopathologic materials. A pathologic sample was obtained in all cases, and the diagnoses were lymphoma (n = 2), sarcoidosis (n = 2), and inflammatory pseudotumor (n = 1). EUS-FNA using a 19-gauge needle is safe and useful for the diagnosis of splenic tumors.

Successful treatment of amegakaryocytic thrombocytopenia with anti-CD20 antibody (rituximab) in a patient with systemic lupus erythematosus

Amegakaryocytic thrombocytopenia is an extremely rare disorder in systemic lupus erythematosus, and its mechanism and treatment are still largely unknown. We describe a 42-year-old woman with systemic lupus erythematosus who presented various clinical manifestations of life-threatening amegakaryocytic thrombocytopenia (10,000 platelets/mm3 with a marked decrease of megakaryocytes in the bone marrow), proteinuria, psychosis, refractory chylothorax, ascites, and type II diabetes caused by the anti-insulin receptor autoantibody. She was initially treated with prednisolone (25-50 mg/day) and cyclosporine A (200 mg/day) without any improvement in severe thrombocytopenia. However, her clinical symptoms, including platelet counts, dramatically improved, with a concurrent decrease in the anti-c-Mpl antibody, an autoantibody against the thrombopoietin receptor, after a subsequent treatment with rituximab (375 mg/m2 intravenously, weekly, for two consecutive weeks). Our case suggested that amegakaryocytic thrombocytopenia in patients with systemic lupus erythematosus might be mediated by the anti-c-Mpl antibody and could be treated with rituximab through elimination of pathogenic B cells producing autoimmune antibodies.

Carcinoma ex pleomorphic adenoma of the parotid gland: radiologic-pathologic correlation with MR imaging including diffusion-weighted imaging

We present 4 cases of carcinoma ex pleomorphic adenoma of the parotid gland. In 3 of the 4 cases, diffusion-weighted and apparent diffusion coefficient (ADC) mapping images clearly revealed carcinoma as a hypercellular area with low ADC values and pleomorphic adenoma as a hypocellular area with high ADC values. Diffusion-weighted images demonstrated well complex tissue components in carcinoma ex pleomorphic adenoma, which may be useful for the diagnosis of this disease.

The yield of endoscopic ultrasound-guided fine needle aspiration for histological diagnosis in patients suspected of stage I sarcoidosis

BACKGROUND AND STUDY AIM

Sarcoidosis is a systemic disorder of unknown cause that is characterized by a pathological hallmark, noncaseating granuloma. Bilateral hilar lymphadenopathy (BHL) is a major clinical feature, but it is sometimes difficult to exclude other diseases, especially in cases where there are no pulmonary abnormalities (stage I). Bronchoscopic transbronchial biopsy is currently a popular method by which to obtain pathological material, but its diagnostic power is insignificant. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), also attempted recently, makes the sampling of pathological material easier and better, but the diagnoses are still based on cytological findings. Our study aimed to evaluate the yield of transesophageal EUS-FNA for histological confirmation of stage I sarcoidosis.

METHODS

The study was a prospective comparative study to investigate the diagnostic sensitivities of FNA cytology and FNA histology. Subjects were consecutive patients with BHL without lung lesions on chest radiographs or chest CT who were referred to our hospitals between December 2003 and April 2006. Transesophageal EUS-FNA was performed with 19-gauge needles instead of the conventional 22-gauge needles.

RESULTS

Forty-one patients were included in this study, and both histological and cytological materials were obtained successfully by EUS-FNA in all patients. Histopathological examination of the FNA sample showed noncaseating granuloma in 34 (94.4%) of the 36 patients with a final diagnosis of sarcoidosis. In contrast, only 28 of the 36 (77.8%) were diagnosed as having sarcoidosis on the basis of cytological findings. The difference was statistically significant (P = 0.0444).

CONCLUSION

FNA histology is better suited than FNA cytology to establishing the diagnosis of stage I sarcoidosis, and EUS-FNA with a 19-gauge needle plays a important role in this process.

A preliminary study on driver's stress index using a new method based on differential skin temperature measurement

Prolonged periods of driving in monotonous situations may lower a driver's activation state as well as increasing their stress level due to the compulsion to maintain safe driving, which may result in an increased risk of a traffic accident. There is therefore an opportunity for technological assessment of driver physiological status to be applied in-car, hopefully reducing the incidence of potentially dangerous situations. As part of our long-term aim to develop such a system, we describe here the investigation of differential skin temperature measurement as a possible marker of a driver's stress level. 10 healthy male subjects were studied, under environment-controlled conditions, whilst being subjected to simulated monotonous travel at constant speed on a test-course. We acquired measurements of relevant physiological variables, including truncal and peripheral skin temperatures (T(s)), beat-by-beat blood pressure (BP), cardiac output (CO), total peripheral resistance (TPR), and normalized pulse volume (NPV) used as an indicator of local peripheral vascular tone. We then investigated the driver's reactivity in terms of cardiovascular haemodynamics and skin temperatures. We found that the simulated monotonous driving produced a gradual drop in peripheral T(s) following the driving stress, which, through interpretation of the TPR and NPV recordings, could be explained by peripheral sympathetic activation. On the other hand, the truncal T(s) was not influenced by the stress. These findings lead us to suggest that truncal-peripheral differential T(s) might be used as a possible index indicative of the driver's stress.

Ossifying pleomorphic adenoma of the parotid gland: a case report and review

Pleomorphic adenoma is the most common parotid gland neoplasm and occasionally arises from the deep lobe of the parotid gland with extension into the parapharyngeal space. However, ossification of pleomorphic adenoma is rare, although chondroid and myxochondroid tissue formation is frequently seen histologically. We report an unusual case of ossifying pleomorphic adenoma arising from the deep lobe of the parotid gland in the parapharyngeal space.

Feasibility study on driver's stress detection from differential skin temperature measurement

Prolonged monotonous driving may lower a driver's awareness level as well as increasing their stress level due to the compulsion to maintain safe driving, which may result in an increased risk of a traffic accident. There is therefore an opportunity for technological assessment of driver physiological status to be applied in-car, hopefully reducing the incidence of potentially dangerous situations. As part of our long-term aim to develop such a system, we describe here the investigation of differential skin temperature measurement as a possible marker of a driver's stress level. In this study, healthy male (n=18) & female (n=7) subjects were investigated under environment-controlled conditions, whilst being subjected to simulated monotonous travel at constant speed on a test-course. We acquired physiological variables, including facial skin temperature which consists of truncal and peripheral skin temperatures (Ts) using thermography, beat-by-beat blood pressure (BP), cardiac output (CO), total peripheral resistance (TPR), and normalized pulse volume (NPV) used as an indicator of local peripheral vascular tone. We then investigated the driver's reactivity in terms of skin temperatures with this background of cardiovascular haemodynamics. We found that the simulated monotonous driving produced a gradual drop in peripheral Ts following the driving stress, which, through interpretation of the TPR and NPV recordings, could be explained by peripheral sympathetic activation. On the other hand, the truncal Ts was not influenced by the stress. These findings lead us to suggest that truncal-peripheral differential Ts could be used as a possible index indicative of the driver's stress.

Clonality analysis of lymphoproliferative disorders in patients with Sjögren's syndrome

The aim of this study was to clarify the nature of the clonal lymphocyte infiltration in Sjögren's syndrome (SS) patients associated with lymphoproliferative disorders. We examined B cell clonality in lymphoproliferative tissues from six primary SS patients associated with lymphoproliferative disorders or lymphoma by cloning and sequencing of the gene rearrangement of the immunoglobulin heavy chain complementarity determining region 3 (IgVH-CDR3). Three patients with sequential observation showed progressional clonal expansion with the presence of the same subclone in different tissues during the course of disease. Among them, one patient developed mucosa-associated lymphoid tissue (MALT) lymphoma in glandular parotid. The other three SS patients concomitant with malignant B cells lymphomas showed different clonal expansion of B cells between nodal sites and salivary glands. The cloanality analysis indicated that monoclonal B cell population could spread from one glandular site to another site during the course of SS, suggesting that the malignant clone may arise from the general abnormal microenvironment, not restricted to the glandular tissue, in some SS patients.