Hiroki Irie

Wild-type transthyretin-derived amyloidosis in various ligaments and tendons ☆

Transthyretin-derived amyloid deposition is commonly found in intercarpal ligaments of patients with senile systemic amyloidosis. However, the frequency of transthyretin-derived amyloid deposits in ligaments of other tissues remains to be elucidated. This study aimed to determine the frequency of amyloid deposition and the precursor proteins of amyloid found in orthopedic disorders. We studied 111 specimens from patients with carpal tunnel syndrome (flexor tenosynovium specimens), rotator cuff tears (rotator cuff tendon specimens), and lumbar canal stenosis (yellow ligament specimens). To identify amyloid precursor proteins, we used immunohistochemical staining with antibodies that react with transthyretin, immunoglobulin light chain, amyloid A protein, and β(2)-microglobulin. By means of Congo red staining, we identified 47 (42.3%) amyloid-positive samples, 39 of which contained transthyretin-derived amyloid (18 flexor tenosynovium specimens, 5 rotator cuff tendon specimens, and 16 yellow ligament specimens). Genetic testing and/or clinical findings suggested that all patients with transthyretin amyloid deposits did not have familial amyloidotic polyneuropathy. The occurrence of amyloid deposition in those tissues depended on age. These results suggest that transthyretin-derived amyloid deposits may occur more frequently in various ligaments and tendons than originally expected. In the future, such amyloid deposits may aid determination of the pathogenesis of ligament and tendon disorders in older patients.

New Equations for Predicting Postoperative Risk in Patients with Hip Fracture

AbstractPredicting the postoperative course of patients with hip fractures would be helpful for surgical planning and risk management. We therefore established equations to predict the morbidity and mortality rates in candidates for hip fracture surgery using the Estimation of Physiologic Ability and Surgical Stress (E-PASS) risk-scoring system. First we evaluated the correlation between the E-PASS scores and postoperative morbidity and mortality rates in all 722 patients surgically treated for hip fractures during the study period (Group A). Next we established equations to predict morbidity and mortality rates. We then applied these equations to all 633 patients with hip fractures treated at seven other hospitals (Group B) and compared the predicted and actual morbidity and mortality rates to assess the predictive ability of the E-PASS and Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) systems. The ratio of actual to predicted morbidity and mortality rates was closer to 1.0 with the E-PASS than the POSSUM system. Our data suggest the E-PASS scoring system is useful for defining postoperative risk and its underlying algorithm accurately predicts morbidity and mortality rates in patients with hip fractures before surgery. This information then can be used to manage their condition and potentially improve treatment outcomes. Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

The Effect of Perfusion with UW Solution on the Skeletal Muscle and Vascular Endothelial Exocrine Function in Rat Hindlimbs

BACKGROUND The effect of University of Wisconsin (UW) solution perfusion for extremity preservation is still unknown although it is widely used. The purpose of this study is to examine the effect of UW solution perfusion on skeletal muscle preservation in a rat model. MATERIALS AND METHODS Rat hindlimbs were amputated and either preserved with UW solution perfusion (UW perfusion group) or given no perfusion (no-perfusion group) for 5 h at 25 degrees C. They were then transplanted to other isogeneic rats. ATP in the muscle and serum creatine phosphokinase were measured after 24 h of reperfusion. The vascular endothelial function of the femoral artery rings was measured before and after 24 h of reperfusion in the presence or absence of indomethacin (cyclooxygenase inhibitor) and L-NMMA (nitric oxide synthase inhibitor). TEA (calcium-activated potassium channel inhibitor) was also used to verify the vasodilator function. Reperfusion blood flow was monitored during the first 2 h of reperfusion. RESULTS ATP in the UW perfusion group was significantly decreased after 24 h of reperfusion, while that in the no-perfusion group recovered. Reperfusion blood flow in the UW solution perfusion group was significantly lower than that in the no-perfusion group. Acetylcholine-induced relaxation in the UW perfusion group was significantly reduced before and after 24 h of reperfusion compared to that in the no-perfusion group and was mostly diminished by indomethacin and L-NMMA administration. CONCLUSIONS Skeletal muscle injury is augmented by UW solution perfusion, probably due to deterioration of the vascular endothelial function resulting in blood supply diminution.

Comparison of the McGrath MAC video laryngoscope and the Pentax Airwayscope during chest compression: a manikin study

We tested the utility of the McGrath MAC® (McG) video laryngoscope during chest compression compared with the Pentax Airwayscope® (AWS). We recruited 59 participants into the simulation study. The difference in the time to intubation (TTI [sec]) between without and with chest compression was significant for the AWS attempts (median 13, range 6–28 vs. median 15, range 6–72, p = 0.0247) but not significant for the McG attempts (median 16, range 6–75 vs. median 16, range 6–71); however, the difference of the TTIs is not serious clinically. The utility of the two devices during chest compressions is almost similar although their characteristics are different.

PAINFUL HETEROTOPIC PACINIAN CORPUSCLE IN THE HAND: A REPORT OF THREE CASES

Severe pain in the finger caused by an abnormal Pacinian corpuscle is a rare condition. We have recently encountered three patients diagnosed with a heterotopic Pacinian corpuscle, based on histopathological findings. When making a differential diagnosis of unexplained severe pain in the finger, abnormal Pacinian corpuscles must be taken into account in addition to glomus tumour and other types of painful soft-tissue tumour.

Development and validation of formulae to predict leg length following medial opening-wedge osteotomy of the proximal tibia with hemicallotasis

BACKGROUND A medial open-wedge osteotomy of the proximal tibia with hemicallotasis (HCO) affects the relative coronal alignment of the femur and tibia with respect to the floor; this also potentially reflects a change in leg length. PURPOSE The aims of this study are to develop and verify formulae for predicting the postoperative whole leg length (WLL) in HCO. METHODS We analyzed a training set of 25 HCOs in 25 patients. Formulae for predicting the postoperative leg length were developed using various factors including the length and coronal alignment of the femur and tibia, the length of the proximal or distal fragment from the tibial osteotomy site, the femoro-tibial angle, and the correction angle. The formulae were then verified using the interclass correlation coefficient in an independent consecutive set of 25 HCOs. RESULTS Significant postoperative increases in tibial bone length and WLL were noted with no postoperative change in femoral bone length. Furthermore, the coronal alignments of femoral and tibial bone axes were significantly abducted. For the formulae for predicting postoperative WLL developed in the training set, the interclass correlation coefficients between the predicted values and the real radiographic measurements in the validation set were more than 0.90, showing great consistency. CONCLUSION The mathematical models established in this study seemed to predict almost completely the change in leg length after HCO. Our results suggest that these formulae may offer accurate, extremely useful information about the postoperative possibility of leg lengthening for patients planning an HCO. LEVEL OF EVIDENCE Therapeutic case series; level 4.

Transthyretin-derived amyloidosis in musculoskeletal systems.

Transthyretin-derived amyloid deposition is commonly found in tenosynovium of senile systemic amyloidosis patients. However, that in ligaments of other organ sites remains to be elucidated. The purpose of this study was to determine the frequency and types of amyloid deposits found in musculoskeletal systems. We investigated patients with carpal tunnel syndrome, rotator cuff tears, and lumbar canal stenosis. We identified 39 cases with TTR amyloid deposits. The mean age in TTR positive cases was higher than non-TTR cases in tenosynovium and yellow ligaments, but not significantly in rotator cuff samples. In the elderly, TTR-derived amyloid deposits were frequently found in ligaments and tendons of various organ sites. Those amyloid deposits may be involved in the pathogenesis of the orthopedic disorders. Abbreviations: FAP1⁄4 familial amyloidotic polyneuropathy; SSA1⁄4 senile systemic amyloidosis; TTR1⁄4 transthyretin Introduction: Amyloidosis is a clinical disorder caused by extracellular deposition of insoluble abnormal fibrils, derived from aggregation of misfolded normally soluble protein [1]. So far, 27 different precursor proteins have been identified in different kinds of amyloidosis [1,2]. It has been well documented that mutated forms of amyloidogenic proteins are more prone to form amyloid fibrils [3]. Transthyretin (TTR) is one of amyloidogenic proteins causing two types of amyloid diseases because TTR itself has b-sheet rich structure and is highly amyloidogenic [1,4]. One is familial amyloid polyneuropathy (FAP), which is hereditary amyloidosis mainly derived from mutated-TTR [5] and the other is senile systemic amyloidosis (SSA). Recently, SSA has been focused in the recent attention [6]. SSA, non-hereditary form of amyloidosis in which wild-type (WT) TTR generates amyloid deposits especially in cardiac and plumonary tissues and occasionally in other systemic organs in the elderly [7]. It has been well documented that most of patients with SSA show a slowly progressive, infiltrative amyloid cardiomyopathy [7]. This disease is believed to be associated with the aging process. In addition, localized type of TTR amyloid has been sometimes reported [8]. However, it was not well known whether it became the pathogenesis of the disease. Accompanied with orthopedic disorders, amyloid deposition in the ligament and tendon has been reported [9], the relationship with disease and the pathogenesis remains to be elucidated. In this report, we examined the frequency of amyloid deposition in tissues resected by operations because of orthopedic disorders. In addition, relationship between amyloid deposition and clinical manifestations were also discussed. Patients and methods: Patients: We investigated 111 specimens of patients with carpal tunnel syndrome (54 specimens), rotator cuff tears (21 specimens), and lumbar canal stenosis (36 specimens). Those patients were diagnosed at the Department of Orthopaedic Surgery in Kumamoto University Hospital and its associated faculties based on clinical finding and radiological examinations from 2008 to 2009. Congo red staining and immunohistochemistry: Formalin-fixed, paraffin-embedded specimens were stained with hematoxylin–eosin and Congo red, as described previously [3]. Elucidation of FAP: To exclude TTR-related FAP, we performed genetic testing, such as a real time PCR or sequencing. Mass spectrometry using surface-enhanced laser desorption/ionization time-offlight mass spectrometry (SELDI/TOF MS) [10] was performed to confirm the patients who did not posses variant TTR in serum. Ethics: The study protocol was approved by Human Ethics Review Committee of Kumamoto University and a signed consent form was obtained from the family of subjects. All patients’ family members gave their informed consent for performing an autopsy. Results: The presence of amyloid deposits was determined by a positive reaction in paraffin sections with Congo red staining, and by an apple green birefringence in the same sections in polarized light. Histochemical analysis with Congo red staining revealed 47 (39%) amyloid positive samples (Figure 1A). Immunohistochemical examination was performed using anti-amyloid precursor proteins as mentioned in section ‘Materials and method’. AntiTTR antibody reacted with the lesions where amyloid deposition was positive in 39 cases (Figure 1B): 18 cases in flexor tenosynovium, 5 cases in rotator cuff tendons, and 16 cases in the yellow ligaments. In eight samples, any antibodies 163

Comparison of the conventional Macintosh laryngoscope, the Pentax Airwayscope, and the McGrath MAC video laryngoscope under restricted cervical motion: a manikin study

We compared the utility of the conventional Macintosh laryngoscope, the Pentax Airway Scope, and the McGrath MAC video laryngoscope under restricted cervical motion using a manikin.

Comparison of the utility of the Pentax Airway Scope (AWS) with that of the conventional Macintosh laryngoscope during chest compression: is the AWS an easy‐to‐use device for a novice?

The Pentax Airway Scope occasionally contacts the arm of the chest compressor at insertion because of its large body. Here, we test the Airway Scopes ease of use compared to that of the conventional Macintosh laryngoscope during chest compression, when operated by a novice.

Electrocardiogram findings of patients with serum potassium levels of nearly 10.0 mmol/L: a report of two cases

In Case 1, a 63‐year‐old woman was admitted with muscular weakness. She had hypertension, diabetes mellitus, and chronic renal failure on hemodialysis. She was taking a beta‐blocker. Her pulse rate was 42 b.p.m. (irregular rhythm); serum potassium level was 9.8 mmol/L; electrocardiogram revealed widening of the QRS complex (0.256 s). In Case 2, a 59‐year‐old man was admitted with muscular weakness. He had hypertension and chronic renal failure, and was taking a renin–angiotensin–aldosterone system inhibitor. His pulse rate was 42 b.p.m. (irregular rhythm); serum potassium level was 10.1 mmol/L; electrocardiogram revealed widening of the QRS complex (0.180 s).