Morphometric inflammatory cell analysis of human liver allograft biopsies

To quantitate the inflammatory cell response within the portal tracts of liver allografts during acute rejection, we retrospectively and in a blinded fashion reviewed 431 biweekly, protocol, core allograft biopsies in 58 consecutive adult recipients. Following the determination of the cross-sectional area of each portal tract, the number of eosinophils, neutrophils, and lymphocytes therein was tabulated. The average number, percentage, and density of each type of portal inflammatory cell were calculated for each biopsy. Each biopsy was prospectively and independently classified as either associated (REJ+) or not associated (REJ-) with acute rejection. Acute rejection consisted of simultaneous allograft dysfunction and qualitative pathologic findings of acute rejection. Biopsies obtained during periods of normal allograft function or during episodes of dysfunction due to other causes were classified as not associated with rejection (REJ-). Ninety biopsies were classified as associated with acute rejection (REJ+) while 241 biopsies were classified as not associated with acute rejection (REJ-). In general, the average portal-tract number, percentage, and density of all inflammatory cells were significantly increased in biopsies associated with acute rejection. In contrast, only the portal-tract eosinophil values were consistently predictive of acute rejection following receiver-operating characteristic curve analysis (sensitivity = 82-86%, specificity = 91-92%). This quantitative method of allograft assessment appears to improve the objectivity of the serial biopsy protocol. By using this method, we found the eosinophil's appearance within the portal tracts to be a dependable indicator of acute rejection.     

Pathological evaluation of intervertebral disc tissue specimens after routine cervical and lumbar decompression. A cost-benefit analysis retrospective study.

BACKGROUND: After decompression of cervical and lumbar nerve roots for radicular pain, pathological evaluation of the extracted disc material is commonly performed. Although histological examination rarely detects clinically significant unsuspected disease, it remains a common practice in most hospitals in the United States. To determine the cost-effectiveness of this routine practice, we conducted a retrospective study. The results are contained within this report. METHODS: Using the University Neurosurgery database, we retrospectively identified 1,387 patients who had spinal decompression surgery (laminectomy and/or discectomy). These cases were broadly classified into routine and non-routine cases depending on the preoperative diagnosis. Benign and noninfectious cases were classified as routine; malignant and all other cases were classified as nonroutine. We reviewed the medical records and pathology reports of these routine and nonroutine cases in an attempt to study the efficacy of the pathological evaluation of the disc material. The cost-benefit value of histopathology in these cases was analyzed, retrospectively. RESULTS: In all routine cases, the histopathology was consistent with benign disc disease and yielded no additional information that could have altered the treatment plan. In the nonroutine cases, however, histopathology was significant in the management of the patient. The cost factor for pathological study was the same for both case groups. CONCLUSIONS: Pathological study of intervertebral disc specimens is cost beneficial only in cases with significant preoperative clinical diagnoses. Pathological evaluation of routine herniated nucleus pulposus extracted during decompressive surgeries is not warranted.     

Intraoperative evaluation of the depth of invasion of gallbladder cancer

BACKGROUND: It is sometimes very difficult to diagnose the depth of invasion of gallbladder cancer preoperatively. Therefore, we investigated intraoperative examinations to diagnose the depth of invasion. METHODS: A total of 104 patients were included in this study. The relation between macroscopic morphology and the depth of invasion and evaluation of the depth of invasion by intraoperative ultrasonography and frozen section examination were investigated. RESULTS: In all cases of a pedunculated type and a subpedunculated type with thin base, invasion remained within the mucosa. In other types, the depth of invasion was various. The accuracy of diagnosing the depth of invasion by intraoperative ultrasonography and frozen section examination was 73.9% and 85.7%, respectively. CONCLUSIONS: The cancer classified as a pedunculated type or a subpedunculated type with thin base can be diagnosed to remain within the mucosa. In other types, intraoperative ultrasonography and frozen section examination are useful in the diagnosis of the depth of invasion.     

Evaluation of St. Jude Medical valve's long-term function by Doppler echocardiography.

In this study, the long-term function of St. Jude Medical valve (SJM valve) is evaluated by Doppler echocardiography. The subjects were 191 patients who underwent mitral or aortic valve replacement using SJM valve in our institute since July 1978 and had no clinical problem showing more than 50% of left ventricular ejection fraction. The patients were classified into 3 groups according to measurement period (within 5 years, 10 years and 15 years and more), and further classified by size and their results were compared. In every group by size, there was no significant difference among groups by measurement period. In the mitral valve position, peak pressure gradient and pressure half-time were not significantly different among groups by size. On the other hand, in the aortic valve position, pressure gradient in 21-mm group was significantly high among 21-mm, 25-mm, and 27-mm groups, showing a negative correlation with size. As the result, it was suggested that SJM valve kept a good function more than 15 years after operation. From these results, it was considered that the patients with small annlus of the aortic valve needed annulus-enlarging procedure or use of Hemodynamic Plus series valves to keep the size of more than 23 mm.     

Multidimensional ultrasound imaging of the wrist: Changes of shape and displacement of the median nerve and tendons in carpal tunnel syndrome

Dynamics of structures within the carpal tunnel may alter in carpal tunnel syndrome (CTS) due to fibrotic changes and increased carpal tunnel pressure. Ultrasound can visualize these potential changes, making ultrasound potentially an accurate diagnostic tool. To study this, we imaged the carpal tunnel of 113 patients and 42 controls. CTS severity was classified according to validated clinical and nerve conduction study (NCS) classifications. Transversal and longitudinal displacement and shape (changes) were calculated for the median nerve, tendons and surrounding tissue. To predict diagnostic value binary logistic regression modeling was applied. Reduced longitudinal nerve displacement (p≤ 0.019), increased nerve cross‐sectional area (p≤ 0.006) and perimeter (p≤ 0.007), and a trend of relatively changed tendon displacements were seen in patients. Changes were more convincing when CTS was classified as more severe. Binary logistic modeling to diagnose CTS using ultrasound showed a sensitivity of 70–71% and specificity of 80–84%. In conclusion, CTS patients have altered dynamics of structures within the carpal tunnel. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:1332–1340, 2015.     

The graft-versus-host reactivity in AG-B/MLR disparate strains of rats.

Inbred strains of rats can currently be classified into eight Ag-B groups. Within an Ag-B group, individual strains generally share identity both the Ag-B histocompatibility antigens and mixed lymphocyte responses. In this report we present data from three strains which are Ag-B and mixed lymphocyte reaction (MLR) disparate: KGH (Ag-B7, MLR-1), MNR (Ag-B4, MLR-5), and B3 (Ag-B3, MLR-4). Popliteal lymph node assays involving these three strains and standard inbred strains demonstrate that the graft-versus-host reaction and MLR reactions in the rat are closely related. Positive graft-versus-host reactions were observed only in strain combinations incompatible for the MLR and were unaffected by differences in their Ag-B histocompatibility antigens. The close association of the MLR and graft-versus-host reaction provides additional evidence that the Ag-B/MLR disparity in these strains is the result of natural genetic recombinations within the major histocompatibility complex.     

前臂间隔区综合征与缺血性肌孪缩的手术治疗

总结１９８９年至１９９４年间收治的３８例前臂间隔区综合征及缺血性肌孪缩的治疗体会。从治疗观点将其分成３期：（１）减压期，即间隔区综合征期（４８小时内）；（２）缺血性肌挛缩期（４８小时至１年以内）；（３）功能重建期（１年以上）。本组１３例间隔区综合征，及时行切开减压后，无１例发生缺血性肌孪缩。而２５例在４８小时内末及时有效治疗者，均出现不同程度的缺血性肌孪缩，经神经肌肉松解后，功能部分或完全恢复。故松解术越早越好。前臂缺血性肌挛缩治疗效果不佳者，主要是合并神经裂伤。     

Tibial shaft fractures treated by rigid internal fixation: the early results in a 4-year series.

Ninety-nine fractures of the shaft of the tibia in 98 patients were treated by rigid internal fixation over 4 years. One patient died after operation from myocardial infarction; and one patient went abroad. The healing course of the remaining 97 fractures is described, classified according to the type of fracture and the accuracy of operative reduction. Seventy-five fractures had a normal time to union, defined as the lasting achievement of full weight-bearing within 4 months. In 7 fractures the healing period was moderately delayed (full weight-bearing being achieved in 4-6 months) and in 5 it was seriously delayed, requiring 6-11 months after injury. Nonunion occurred in 4 cases and refracture in 6 cases. Osteitis developed in 2 cases and was successfully treated with antibiotics within 6 weeks. A second internal fixation was necessary in 12 patients. In 5 patients a plaster cast was applied to treat delayed union. Amputation was necessary in a 75-year-old man with senile dementia who developed infection after a second operation for refracture. One patient still has a pseudarthrosis after 2 years and 2 further operations. In the other 95 fractures union was the end-result. Of the 21 comminuted and open fractures only 13 healed within 4 months. We recommend a different approach in the treatment of badly comminuted and open 'high-energy' fractures. With this reservation, we find that the method of rigid internal fixation which we employ has given satisfactory early results. The frequency of both delayed healing and infection is reasonably low compared to the results in similar series.     

Impact of proliferation index on outcome in childhood malignant gliomas: results in a multi-institutional cohort

OBJECTIVE: Prognoses of pediatric high-grade gliomas are unpredictable, even when clinical and histological factors are taken into account. In preliminary studies with an institutional cohort of pediatric high-grade gliomas, we observed a strong association between outcome and proliferation index, as assessed by immunolabeling with the MIB-1 antibody. To determine whether this marker could provide prognostically useful information independent of tumor histology, we examined the prognostic usefulness of this marker in the multi-institutional cohort of Children's Cancer Group Study 945, the largest group of childhood high-grade gliomas analyzed to date. METHODS: The study group consisted of tumors within this cohort that were classified as high-grade gliomas on central review according to contemporary World Health Organization guidelines and that had sufficient histopathological material to permit proliferation index assessment. Paraffin-embedded sections were cut and processed, microwave antigen enhancement was used, and MIB-1 indices were calculated by percent labeling in approximately 2000 cells (5-10 high-power fields) in the areas with greatest labeling. To ensure that the review diagnostic classification and proliferation labeling index were assigned independently for each tumor, these analyses were performed by two different neuropathologists at separate institutions, and each was blinded to the results of the other. RESULTS: Ninety-eight tumors met eligibility criteria for this study. Among these high-grade gliomas, there was a strong association between MIB-1 labeling and patient outcome: 5-year progression-free survival was 33 +/- 7% in 43 patients whose tumors had MIB-1 indices of less than 18%, 22 +/- 8% in the 27 patients whose tumors had indices between 18 and 36%, and 11 +/- 6% in the 28 patients whose tumors had indices greater than 36% (P = 0.003). As anticipated, a strong association was also observed between histology and MIB-1 labeling index in these cases. Mean labeling indices were 19.4 +/- 2.66 for tumors classified as anaplastic astrocytoma versus 32.1 +/- 3.08 for those classified as glioblastoma multiforme (P = 0.0024). Notwithstanding this correlation, a significant association was noted between labeling index and progression-free survival, even after the analysis had been stratified by histology (P = 0.001). Although histology had an independent association with outcome, the prognostic value of MIB-1 labeling transcended histological subgrouping and was apparent both in tumors classified as anaplastic astrocytoma (P = 0.02) and in those classified as glioblastoma multiforme (P = 0.046). Multivariate regression modeling confirmed the strong independent association between MIB-1 labeling index and outcome. As a group, tumors with labeling indices higher than 36% had an almost uniformly poor outcome, regardless of histology. CONCLUSION: MIB-1 labeling index and histological categorization are each prognostically relevant in childhood high-grade gliomas. MIB-1 labeling index can help to refine the accuracy of histologically based prognostic assessments.     

Variable expressivity familial cherubism: woman transmitting cherubism without suffering the disease

Cherubism is classified within the group of benign osteo-fibrous lesions. Aside from facial deformities, it may account for major complications. It has been observed that the disease is caused by a mutation in the gene SH3BP2 (SH3-domain binding protein 2), which is located at chromosome 4pl6.3. Here we present two cases of familial cherubism, uncle and nephew, with variable clinical involvement (“Expressivity”), and one case of a woman (sister and mother, respectively), who transmitted cherubism without suffering the disease. In this article we have shown that, in familial cherubism cases, the mutation is inherited through an autosomal dominant transmission. Mutations affecting gene SH3BP2 cause variable clinical involvement (variable expressivity), involvement can be moderate, severe or may result merely in asymptomatic carriers. Since the possibility of transmission reaches 50% of chances, we believe that it is important to develop genetic counseling for both patients and carriers, in order to prevent or minimize new affected offspring.     

Surgical treatment of hypertensive cerebellar hemorrhage; stereotactic aspiration surgery vs suboccipital craniectomy]

Patients with severe types of hypertensive cerebellar hemorrhage have been treated usually by suboccipital craniectomy and hematoma evacuation. However, since 1981, we have treated such patients with stereotactic aspiration surgery. The purpose of this study was to evaluate the prognosis of patients treated by stereotactic aspiration surgery for cerebellar hemorrhage in comparison with those who underwent suboccipital craniectomy. Between May 1976 and December 1989, 246 patients with hypertensive cerebellar hemorrhage were admitted to our university hospital and affiliated hospitals. The patients were classified into four categories according to the grading of hypertensive cerebellar hemorrhage proposed by Matsumoto in 1982; benign, moderate, severe, and fulminant. Then we decided the most appropriate therapy according to this grading. Fifty-nine patients (24.0%) underwent suboccipital craniectomy and 38 (15.4%) underwent stereotactic aspiration surgery. There was no significant difference in the postoperative outcome between suboccipital craniectomy and stereotactic aspiration surgery in the overall study. However prognosis of the fulminant type was significantly better with stereotactic aspiration surgery than with suboccipital craniectomy. Possible reasons for this include: 1) All patients of this type who underwent aspiration surgery had this procedure within 12 hours after the onset of cerebellar hemorrhage. 2) The hematoma volume of most patients of this type who had aspiration surgery was under 30ml. 3) The age of all patients of this type with aspiration surgery was under 70 years old. In conclusion, we suggest that aspiration surgery for hypertensive cerebellar hemorrhage is indicated for all patients with moderate, severe and fulminant types of hemorrhage.     

New classification of ocular foreign bodies

Foreign bodies (FBs) in the eye are usually classified as intraocular (IOFB) or extraocular (EOFB). In IOFB the FB is within the eye ball and in EOFB it is outside. This classification seems oversimplified. Hence a new classification is proposed on the basis of FB locations, in which adnexal FBs (in orbit, lids, conjunctiva and lacrimal apparatus) are also included. These are further classified according to their exact location. FBs can also be classified in many other ways. Besides IOFB and EOFB, another condition IMFB (intramural foreign body) is also described. The FBs are situated within cornea or sclera and are neither IOFB nor EOFB. Ocular trauma also includes trauma to ocular adnexa and hence the terms IOFB and EOFB have been replaced by IGFB (intraglobal foreign body) and EGFB (extraglobal foreign body).     

Ultrasonographical approach for the diagnosis on the depth of invasion in early bronchogenic squamous cell carcinoma

It is important to evaluate the depth of invasion to determine the appropriate treatment for roentgenographically occult bronchogenic squamous cell carcinoma (ROSCC). In order to evaluate the actual significance of TUS as a diagnostic tool of intraluminal carcinoma invasion, we have conducted a prospective trial. TUS was performed on 29 lesions of ROSCCs. We ultrasonographically classified the degree of the depth of intraluminal invasion into 2 groups; A: "inside of cartilaginous layer" and B: "cartilaginous layer or over". The patients were treated by irradiation, photodynamic therapy (PDT) or surgical resection. Clinicopathological findings and response to the treatment were compared with this ultrasonographical classification. In the evaluation of invasion within cartilage, the sensitivity was 88.2%, the specificity was 77.8%, the accuracy was 84.6%, and the positive predictive value was 88.2%. With TUS, the decision of treatment modality would be more appropriate.     

Factors Associated with Prolonged Impairment of Consciousness in Adult Patients Admitted for Seizures: A Comprehensive Single-center Study

Seizures are common neurological emergencies that occasionally cause prolonged impairment of consciousness. The aim of this retrospective single-center study is to clarify factors associated with prolonged impairment of consciousness for admitted adult patients investigating patient backgrounds, blood tests, electroencephalographic patterns, and MRI findings. The patients who were admitted to the hospital due to epileptic seizures were classified into two groups: (1) early recovery group, in which patients recovered their consciousness within 6 hr, and (2) delayed recovery group, in which patients showed impairment of consciousness more than 6 hr. Factors associated with prolonged impairment of consciousness were compared between these groups. In this study, 42 cases (33 patients), with a mean age of 67.8 years, were included. Fifteen cases (13 patients) and 27 cases (20 patients) were classified into the early and delayed recovery groups, respectively. The populations of older patients and patients from a nursing home were significantly higher in the delayed recovery group. With regard to radiological analyses, a high grade of periventricular hyperintensity (PVH), high Evans index score, and enlarged bilateral atrial widths were significantly associated with prolonged impairment of consciousness. Multivariable analyses showed that a high grade of PVH was significantly associated with delayed recovery of consciousness independent of age and status epilepticus. In conclusion, we proposed that diffuse white matter degeneration around the lateral ventricles contributes to prolonged impairment of consciousness.     

The controversy on the treatment of aortic dissection]

It is obvious that there are many controversies regarding to the treatment of aortic dissection. In this report, we discuss following points such as 1) classification, 2) thrombosed type dissection, and 3) simultaneous graft replacement of ascending and aortic arch with the reconstruction of cervical branches. From the patho-morphological status, dissection will be classified into two types, localized and extended types. From the anatomical and surgical points of view, it will be also classified as 1) ascending-arch, 2) descending-thoracoabdominal, and 3) abdominal. With the combination of these two, dissection will be classified more clearly. The thrombosed type will be incorporated into localized type. We have experienced 76 cases of this dissection, and clinical features and outcome by medical treatment only are presented. The simultaneous reconstruction of ascending aorta and aortic arch for the dissection at ascending-arch type was undertaken in total of 35 patients. The surgical results as well as follow up data are presented and the benefit of this extended procedure is presented as well.     

Dupuytren's contracture; increased cellularity--proliferation, is there equality?

BACKGROUND: Dupuytren's disease is a chronic inflammatory process which causes contractures of the fingers by shortening and thickening the palmar fascia. During the proliferative phase, fibroblasts transform into myofibroblasts apparently under the influence of several different factors. The disease usually develops slowly, but in some patients it tends to develop aggressively. The pathogenesis of Dupuytren's disease remains unsolved. In this study, we analyzed some histological characteristics that seem to predict rapid recurrence. MATERIAL AND METHODS: 21 patients were divided into two groups. In 11 patients the disease was classified as aggressive because it had recurred within two years after an operation. In 10 cases it was non-aggressive, as no recurrence had been seen. Five control samples were taken from healthy palmar aponeurosis. The differences in cellularity, collagen, Ki-67, MSA, alpha-SMA and tenascin between the specimens were analyzed using immunohistochemistry. RESULTS: Alpha-SMA and Ki-67 were present more often in the aggressive specimens. Immunohistochemical stainings for macrophages and lymphocytes were negative. CONCLUSION: There may be differences in the histology and/or immunohistochemical appearance of pathological palmar connective tissue cords in aggressive and normal Dupuytren's disease. Further studies are needed to elucidate the pathogenesis of this disease.     

Lipid volume fraction in atherosclerotic plaque phantoms classified under saline conditions by multispectral angioscopy at near-infrared wavelengths around 1200 nm

To identify high-risk atherosclerotic lesions, we require detailed information on the stability of atherosclerotic plaques. In this study, we quantitatively classified the lipid volume fractions in atherosclerotic plaque phantoms by a novel angioscope combined with near-infrared multispectral imaging. The multispectral angioscope was operated at peak absorption wavelengths of lipid in vulnerable plaques (1150, 1200, and 1300 nm) and at lower absorption wavelengths of water. The potential of the multispectral angioscope was demonstrated in atherosclerotic plaque phantoms containing 10–60 vol.% lipid and immersed in saline solution. The acquired multispectral data were processed by a spectral angle mapper algorithm, which enhanced the simulated plaque areas. Consequently, we classified the lipid volume fractions into five categories (0–5, 5–15, 15–30, 30–50, and 50–60 vol.%). Multispectral angioscopy at wavelengths around 1200 nm is a powerful tool for quantitatively evaluating the stability of atherosclerotic plaques based on the lipid volume fractions.     

Non-Hodgkin's lymphomas of the stomach. Therapy from the surgical viewpoint]

About 2-5% of all gastric tumours are Non-Hodgkin Lymphomas (NHL). In the last years we treated 15 patients with NHL of the stomach. Six of these patients were classified to group IE according to Ann Arbor classification, four to group II (three II 1 E and one II 2 E). In group III E were two patients (one III S and one III E) and one patient was classified to group IV. Ten patients displayed low grade and five high grade malignancies with respect to the Kiel classification. We performed in group I three gastrectomies and three BI resections. In four patients of group II two gastrectomies and two BI resections were carried out and in group III two BI resection. Our treatment policy consisted of operation and radiation in IE, to operation and chemotherapy in high grade lymphomas of group II, and operation plus radiation in low grade malignancies of group II. In group III we treated radiation, chemotherapy and operation and in group IV radiation and chemotherapy. In group I five patients survived, in group II two out of four and in group III one of two. The patient of group IV died within two years after diagnosis.     

Effect of mismatching serologically defined residues on kidney transplant survival.

Amino acids within the HLA class I and II molecules were first examined individually for correlation with antibody reactions of over 50,000 antisera. The amino acids that correlated with the serologic reactions were classified as serologically defined: approximately half of the amino acids fell within that category, and the other half were employed as controls. The cadaver donor kidney transplant survival for patients who were mismatched for each of the sera-defined amino acids were compared to mismatches of the nonserologically defined amino acids. No differences were noted in the graft survivals of patients with mismatches for the serologically defined amino acids of HLA-A, -B, and -DR loci and for the nonserologically defined amino acids. Since many of the patients also had additional amino acids of mismatch, we cannot yet conclude that the serologically defined amino acids do not significantly influence graft outcome. In other words, the test may not have been sensitive enough to detect the degree of immunogenicity that may exist. However, we can conclude that mismatches for no single amino acid are strongly immunogenic.     

Medical devices: US medical device regulation

Medical devices are regulated by the US Food and Drug Administration (FDA) within the Center for Devices and Radiological Health. Center for Devices and Radiological Health is responsible for protecting and promoting the public health by ensuring the safety, effectiveness, and quality of medical devices, ensuring the safety of radiation-emitting products, fostering innovation, and providing the public with accurate, science-based information about the products we oversee, throughout the total product life cycle. The FDA was granted the authority to regulate the manufacturing and marketing of medical devices in 1976. It does not regulate the practice of medicine. Devices are classified based on complexity and level of risk, and “pre-1976” devices were allowed to remain on the market after being classified without FDA review. Post-1976 devices of lower complexity and risk that are substantially equivalent to a marketed “predicate” device may be cleared through the 510(k) premarket notification process. Clinical data are typically not needed for 510(k) clearance. In contrast, higher-risk devices typically require premarket approval. Premarket approval applications must contain data demonstrating reasonable assurance of safety and efficacy, and this information typically includes clinical data. For novel devices that are not high risk, the de novo process allows FDA to simultaneously review and classify new devices. Devices that are not legally marketed are permitted to be used for clinical investigation purposes in the United States under the Investigational Device Exemptions regulation.