Arata Nakajima

Identification of clinical parameters associated with serum oxidative stress in patients with rheumatoid arthritis

Abstract Objectives. Reactive oxygen species (ROS) are considered to be involved in the pathobiology of rheumatoid arthritis (RA); however, their association with disease activity has not been elucidated. In this study, we measured reactive oxygen metabolites (ROM) in patients with RA using a new Free Radical Analytical System and determined clinical parameters associated with ROM. Methods. One hundred and fifty-two patients with RA and 80 patients with diabetes mellitus (DM) were included in this observational study. To measure ROM, the d-ROM test was performed on blood samples drawn from all subjects. The correlation between ROM and biomarkers, disease activity, doses of methotrexate (MTX), and prednisolone (PSL) were investigated. Results. There were significant, positive correlations between ROM and CRP, matrix metalloproteinase 3 (MMP3), Disease Activity Score 28–erythrocyte sedimentation rate (DAS28-ESR), Clinical Disease Activity Index (CDAI), and the Simplified Disease Activity Index (SDAI). Multiple regression analysis revealed that CRP and DAS28-ESR were correlated with ROM. Conclusions. The serum level of ROM was associated with CRP and DAS28-ESR, suggesting that ROM, in conjunction with CRP and MMP3, may be able to be used as a new biological disease marker to evaluate the disease activity of RA.

Evaluation of Nonspecific Low Back Pain Using a New Detailed Visual Analogue Scale for Patients in Motion, Standing, and Sitting: Characterizing Nonspecific Low Back Pain in Elderly Patients

Because we have a clinical impression that elderly patients have low back pain while in motion and standing, but less pain when sitting, we investigate characteristics of nonspecific low back pain (NSLBP), using a new detailed visual analog scale (VAS) scoring system. One hundred eighty-nine patients with NSLBP were divided into an elderly group (≥65 years old, n = 56) and a young group (<65 years old, n = 133). Low back pain was evaluated by a traditional VAS scoring system, the Oswestry Disability Index (ODI), and a new detailed VAS scoring system in which pain is independently evaluated in three different postural situations (in motion, standing, and sitting). No significant differences were observed in traditional VAS and ODI scores between the two groups. The results of the detailed VAS showed no significant differences between the two groups while in motion and standing. However, the elderly group showed significantly lower VAS score while sitting compared to the young group. In this study of the first use of a new detailed VAS scoring system, differences in characteristics of NSLBP between elderly and young patients were successfully detected. This minor modification of the traditional VAS may be useful for characterizing and evaluating low back pain.

Sciatica caused by pyomyositis of the piriformis muscle in a pediatric patient.

Because the sciatic nerve leaves the pelvis through the greater sciatic notch underneath the piriformis muscle, any pathology of the piriformis muscle could result in entrapment of the sciatic nerve; this is widely known as piriformis muscle syndrome. Pyomyositis of the piriformis muscle may be a cause of piriformis muscle syndrome. Piriformis muscle syndrome caused by pyomyositis of the piriformis muscle in pediatric patients is rare. This article describes a case of sciatica caused by pyomyositis of the piriformis muscle in a pediatric patient. A 6-year-old boy presented with right buttock and thigh pain following a mild fever and sore throat. The pain worsened, and he became unable to walk. On admission, his temperature was 38.4°C. He reported severe right-sided buttock and lateral thigh pain. Positive Freiberg sign was observed. Laboratory examination revealed elevated white blood cell count and C-reactive protein level. T2-weighted magnetic resonance images of the pelvis revealed high-intensity changes of the piriformis muscle and iliosacral joint. Thus, piriformis syndrome caused by pyomyositis of the piriformis muscle was diagnosed. Oral antibiotics (10 mg/kg per day of cefdinir) were administered. Pain gradually decreased, and the patient was able to walk. Final follow-up examination at 6 months after symptom onset revealed no sciatic pain. Follow-up magnetic resonance imaging revealed normalized intensities of the piriformis muscle. The endopelvic fascia provides a route for infection from the pelvis to the piriformis. The pyomyositis of the piriformis muscle in the current case may have occurred secondary to the pyoarthritis of the sacroiliac joint. Endopelvic infections involving the piriformis muscle may mimic hip diseases in pediatric patients.

Failure of conservative treatment for thoracic spine fracture in ankylosing spondylitis: delayed neurological deficit due to spinal epidural hematoma

Patients with ankylosing spondylitis (AS) are prone to spinal fracture after even minor trauma. We report a case of thoracic spinal fracture in a patient with AS who developed a secondary neurological deficit due to delayed diagnosis and prolonged conservative treatment. When the neurological deficit occurred, the fractured segment showed no displacement, but a spinal epidural hematoma was present. Surgical treatment produced significant neurological improvement, although incomplete paralysis persisted.

The Elmslie-Trillat Procedure for Recurrent Patellar Subluxation After Total Knee Arthroplasty

Patellofemoral problems are the most common complications after total knee arthroplasty (TKA). We report a patient who had patellar subluxation twice within 7 months after primary TKA. Postoperative radiographs and computed tomography scans revealed a valgus knee with no evidence of malposition of the prostheses. To eliminate the recurrent patellar subluxation, we finally performed an Elmslie-Trillat procedure in combination with extensive lateral release and succeeded in achieving normal patellar tracking. At 1-year postoperative follow-up, the patient was satisfied with the results. The patella tracked well in the femoral trochlear groove during knee flexion after the revision surgery. This procedure, in combination with lateral release, should be considered as a useful surgical treatment that can eliminate patellar subluxation after TKA in cases without component malposition.

Evidence of enhanced expression of osteopontin in spinal hyperostosis of the twy mouse.

Study Design. Gene expression and protein localization of osteopontin (OPN) in spinal hyperostosis of the twy mouse by means of in situ hybridization, immunohistochemistry, and Northern blot analysis. Objective. To verify the involvement of OPN in spinal hyperostosis in the twy mouse and elucidate its ossification pattern at molecular levels. Summary of Background Data. OPN is a molecule that consistently colocalizes with ectopic calcification in human pathologic conditions. The twy mouse, which shows ectopic calcification of the spinal ligament resulting in hind limb paralysis, is considered to be a model for human ossification of the posterior longitudinal ligament of the spine. Methods. Twenty-eight each of age-matched twy, heterozygote, and wild-type mice were killed at 2, 4, 8, 12, and 16 weeks old and subject to histologic and/or molecular analyses. Sections were hybridized with RNA probes for OPN and also stained with anti-OPN antibodies. Total cellular RNA was extracted from the cervicothoracic spine of each genotype at 2- and 16-week-old, and gene expression for OPN and COL10A1 was quantified by Northern blot analysis. Results. Enhanced expression of OPN mRNA was observed in spinal hyperostotic lesions of the twy mouse, specifically in cells of the spinal ligament and chondrogenic cells in the outer layer of the anulus fibrosus. These trends were also confirmed by immunohistochemical analyses. Northern blot analysis showed that a considerable amount of OPN transcripts was detected in all genotypes at 2 weeks old, but the robust expression of OPN mRNA was maintained only in twy mice at 16 weeks old. COL10A1 transcripts were hardly detected regardless of the genotype at 16 weeks old. Conclusion. OPN was overexpressed in the hyperostotic spinal lesions of twy mice, and the hyperostosis was induced mainly by ectopic ossification of the spinal ligament. Because OPN is considered to be an inhibitor of calcification, further studies will be necessary to verify whether OPN overexpressed in the twy mouse is functional.

Radiographic progression of large joint damage in patients with rheumatoid arthritis treated with biological disease-modifying anti-rheumatic drugs

Abstract Objectives: Radiographic progression of damage to the small joints in patients with rheumatoid arthritis (RA) is well known; however, it has not been studied fully in the large joints. In this study, we looked at the prevalence of radiographic progression of large joint damage in patients with RA treated with biological disease-modifying anti-rheumatic drugs (bDMARDs). Methods: A total of 273 large joints in the upper and lower extremities of 67 patients with RA treated with bDMARDs were investigated. Radiographs for tender and/or swollen large joints were taken at least twice during the study period (mean 18.6 months), and the progression of damage was evaluated. Results: Progressive damage was found in 20.9% of patients and 6.2% of joints. A multivariate analysis revealed that the Larsen grade (LG) alone was a risk factor for progressive damage. The LG cutoff value was determined to be 2.5 (sensitivity: 0.529, specificity: 0.805). Conclusions: The only factor to predict progressive damage was the LG of the joints with symptoms, and the damage must be stopped within LG II. Regular radiographic examinations for large joints should be performed in addition to routine examinations for small joints, such as the hand and foot.

Identification of genes required for the spontaneous repair of partial-thickness cartilage defects in immature rats

ABSTRACT Purpose: Our previous study showed that partial-thickness articular cartilage defects (PTCDs) created in immature rats spontaneously healed to resemble normal hyaline cartilage, but that of mature rats did not. To identify molecules involved in the spontaneous cartilage repair observed in this model, gene expression was compared between PTCD and sham-operated cartilage of immature and mature rats. Materials and Methods: Six sets of gene comparisons were made at 12, 24, and 48 hours after the creation of PTCDs in immature and mature rats using microarrays. All the genes upregulated in immature cartilage at 12 hours were selected for further analysis if their expression pattern was not irregular such that diminished at 24 hours and re-upregulated at 48 hours. Relationships among genes selected through the above steps were analyzed using Ingenuity Pathway Analysis (IPA) software. After deriving networks, important molecules were further narrowed down by location within a network. Genes were regarded as central if they had relationships with more than 10 molecules in a network. Protein localization in tissues was confirmed by immunohistochemistry. Results: Five networks were identified. Their functional annotations were gene expression, cell cycle, growth and proliferation, and cell signaling. Transforming growth factor-beta (TGF-β) was centrally located in the network with the highest IPA score and mothers against decapentaplegic homolog-3 (Smad3) were centrally located in the second highest ranking network. Phosphorylated Smad3 was detected in the nuclei of chondrocytes in immature cartilage. Conclusions: Our data suggest the possible importance of Smad3 in the TGF-β signaling in the spontaneous healing of PTCDs in immature rats.

Delayed Neurologic Deficit due to Foraminal Stenosis following Osteoporotic Late Collapse of a Lumbar Spine Vertebral Body

We report an 85-year-old woman with an L3 vertebral body fracture who presented with back pain, bilateral leg pain, and weakness after four months of conservative treatment. Because of unstable pseudoarthrosis, the L3 vertebral body collapsed in the standing position and the L3 nerve root was compressed. The indicated surgery decompressed the L3-L4 foramen and fused the unstable segment. The back pain and neurologic symptoms improved significantly following surgery. We propose that delayed neurologic deficit following an osteoporotic fracture of the lumbar body may be caused not only by retropulsion of vertebral body fragments with significant canal compromise, but also by foraminal stenosis with the late collapse of the vertebral fracture. This new pathomechanism for delayed neurologic deficit has not been previously described. If a collapse takes place in the caudal part of the vertebral body below the base of the pedicle, spine surgeons should be aware of the possibility of foraminal stenosis.

Acupuncture needle-associated prosthetic knee infection after total knee arthroplasty

The case of a patient who previously had permanent acupuncture needles placed in the knee joint and had been doing well, with no evidence of infection, but who eventually underwent a revision total knee arthroplasty due to acupuncture needle-associated prosthetic infection is presented. The microorganism responsible for the infection was Enterococcus faecalis, a bacterium which rarely causes infection following arthroplasty. This case should be highlighted to increase the awareness of healthcare providers to acupuncture-associated subclinical infection that may be exacerbated by surgical manipulation.