Background: High Mobility Group Box 1 (HMGB-1) is a 30 kDa protein that is a lethal mediator in sepsis and is a recognized therapeutic target. However, no consensus has been reached for acute blood purification therapy as a treatment for sepsis targeting HMGB-1. Previous studies demonstrated that a high anti-HMGB-1 antibody titer and the suppression of HMGB-1 activity improved survival rate in animal sepsis models. The aim of this study was to evaluate whether plasma adsorption therapy is able to decrease the level of HMGB-1, representing a new potential treatment strategy against sepsis. Methods: Plasma adsorption therapy has been known as a treatment for various autoimmune diseases. Three different adsorbent columns, including TR-350 (IM-TR), PH-350 (IM-PH), and BRS-350 (BRS), were used in this study for comparison. We made a 1/350 scale of these three columns. Fetal bovine serum (FBS) contains a significant amount of HMGB-1. After priming with saline, FBS was passed through the columns and the adsorption rates of HMGB-1 at 25 minutes, 50 minutes, and 75 minutes were evaluated. The total adsorbed HMGB-1 level at 75 minutes was also calculated. Results: The highest adsorption rate and total adsorbed amount of HMGB-1 were observed in IM-TR, followed by BRS and IM-PH. IM-TR showed a decline in adsorption rate over time. BRS showed a steady adsorption rate at all time points. IM-TR removed HMGB-1 significantly more than IM-PH and BRS. Conclusions: Our findings showed that plasma adsorption therapy efficiently adsorbed HMGB-1 and could be safely applied for the treatment of sepsis.

Background: Aging is a primary risk factor for the development of osteoarthritis (OA). Recently, advanced glycation end products (AGEs) have received much attention in relation to aging and OA. Some AGEs are reported to be brownish, but the association between AGE levels and browning in articular cartilage is unknown. The purposes of this study were first, to develop a colorimetric device to evaluate the quality and aging of the articular cartilage, and second, to investigate the relationship between AGE levels and color of articular cartilage by using this device without enzymatic digestion of the articular surface. Design: Open-label, single-center, prospective study Methods: Seven patients with OA (1 man, 6 women; mean age, 74.4 years; age range 58-81 years) who underwent primary total knee arthroplasty at our university hospital between July and December 2014 were enrolled in the study. Articular cartilage was harvested from the femur and tibia during surgery. The color and chromaticity of the articular cartilage was assayed by using a newly developed device with high validity. The characteristics of the articular cartilage were examined using the CIE XYZ Color Coordinate System (International Commission on Illumination, Vienna, Austria), and the color indicative of browning of the cartilage was defined on the X- and Y-axes. The brightness was adjusted and the specimen was photographed submerged in distilled water and the color was measured using a commercial luminance and color analyzer. Measurement of X and Y was repeated 3 times per site at 9 different points on the articular cartilage surface, and the mean value per specimen was calculated. Pentosidine (a well characterized biomarker of AGEs) levels and hydroxyproline content in articular cartilage were determined by high-performance liquid chromatography (HPLC). The correlation between age, articular cartilage AGE levels, and browning was analyzed using Spearman's rank correlation coefficient. The association between the degree of macroscopic degeneration and AGE levels was analyzed using one-way analysis of variance. Results: Age was positively correlated with pentosidine levels in articular cartilage (r_s=0.322) and browning of articular cartilage (r_s=0.261). However, a weak negative correlation was observed between pentosidine levels and browning of articular cartilage (r_s=-0.564, p=0.004). No positive relationship was observed between pentosidine levels and browning of articular cartilage in the visible spectrum. Conclusions: This study developed an original colorimetric device with high validity. Browning of articular cartilage increased with age, but this study did not detect pentosidine-caused browning. Further study is needed to clarify the factors associated with browning of cartilage.

Background: The purpose of this study was to evaluate mid- and long-term clinical and radiologic outcomes of arthroscopic coracoclavicular ligament reconstruction (ACCLR) with an artificial ligament for acute dislocation of the acromioclavicular joint (ACJ). Methods: Twelve male patients (average age at the time of surgery: 40.8 years, range: 21-64 years) underwent ACCLR with an artificial ligament for acute dislocation of the ACJ type III or type V according to the Rockwood classification. Arthroscopic surgery was performed with the patient under general anesthesia and interscalene brachial plexus block in the beach-chair position. Reduction of the ACJ was performed manually or using an elevator under control of an imaging intensifier. The ACJ was fixed temporarily with a Kirschner wire. Bone tunnels of the coracoid process and clavicle were made with a cannulated drill. An artificial ligament was pulled out through the bone tunnels and fixed on the upper surface of the clavicle with a staple and interference screw, and on the undersurface of the coracoid process with an Endobutton. The shoulder was immobilized with a shoulder brace for 4 weeks postoperatively, and rehabilitation was started in the first postoperative week. The Japan Shoulder Society Acromioclavicular Joint Function Assessment (JSS-ACJ) score was used for evaluation of clinical outcomes, and plain radiographs were performed after a minimum follow-up period of 5 years postoperatively. Results: The average follow-up period after surgery was 106.3 months (range: 62-128 months). The average postoperative JSS-ACJ score was 97.2 points (range: 92-100). The seven patients who had been playing sports before injury all returned to their pre-injury level. No patients complained of pain or shoulder dysfunction in daily activities, work, or sports. There were no complications such as neurovascular injuries during surgery, infection, or foreign body reaction from the artificial ligament. Radiographs at the final follow-up showed subluxation of the ACJ and non-symptomatic osteoarthritic changes of the ACJ in two patients, respectively. Conclusion: ACCLR for acute dislocation of the ACJ is a useful surgical procedure that gives satisfactory clinical and radiologic outcomes on mid- and long-term follow-up. ACCLR can stabilize vertical instability of the ACJ. If instability in the horizontal direction remains, repair or reconstruction of the acromioclavicular ligament should be added to prevent osteoarthritic changes of the ACJ.

Cogan's syndrome (CS) is defined by the combination of hearing loss, vertigo, and ocular inflammation of uncertain cause, and can be associated with variable vessel vasculitis. Vasculitic manifestations may include arteritis (affecting large, medium or small arteries), aortitis, and aortic and mitral valvulitis. Cutaneous manifestations including erythema, papules, subcutaneous nodules, and purpura sometimes occur; however, to date, only six cases have been histologically confirmed to have genuine vasculitis. Here, we report two cases of CS, one of which involved a patient who developed the typical symptoms of Takayasu arteritis and purpuric lesions in the legs, with histologic findings consistent with small vessel vaculitis in the dermis. The second case involved a patient who developed subcutaneous nodules in the legs and the axilla, and histologic findings revealed a necrotizing vasculitis of the small arteries in the interlobular area. Both cases were successfully treated with systemic steroid therapy. Based on the clinical features and the examination data, there is a possibility that a Chlamydia trachomatis infection played a pivotal role in the pathogenesis of those vasculitides.

Background: Multiple endocrine neoplasia type 2B (MEN2B) is an extremely rare syndrome mainly caused by RET918 germline mutations. MEN2B typically causes medullary thyroid carcinoma (MTC), pheochromocytoma, and unique physical characteristics including mucosal neuroma, distinctive facial appearance, and Marfanoid habitus. Most patients have abdominal symptoms such as bloating, intermittent constipation, and diarrhea. MTC is the most important determinant of mortality in patients with MEN2B. Establishing the diagnosis of MEN2B at a curative stage of MTC is crucial. Case Presentation: We have encountered four patients with MEN2B. Two were hereditary cases from the same family, and two were considered de novo cases with phenotypically normal parents. Mean age at diagnosis was 25.5 years (range, 13-39 years). Although all patients had shown mucosal neuroma on the lips and tongue, in addition to gastrointestinal symptoms from infancy, diagnoses were made from symptomatic MTC even for the hereditary patients (our index case was a 14-year-old girl, whose mother was subsequently diagnosed with advanced MTC). Genetic tests for RET mutations revealed the M918T mutation in all patients. Two patients developed pheochromocytoma, two died from distant metastases of MTC, and two received treatment for multiple metastases of MTC (one with vandetanib). Conclusions: In our patients with MEN2B, prophylactic or early thyroidectomy could not be performed. The characteristic phenotype associated with MEN2B is almost always seen prior to detection of MTC or pheochromocytoma. Knowledge about the non-endocrine manifestations of MEN2B needs to be shared among pediatricians and gastroenterologists.

Incisional surgical site infection (SSI) is a leading complication of stoma reversal procedures. This retrospective study was conducted to assess the incidence of incisional SSI and other wound complications when wound closure was achieved by subcuticular suturing and closed suction drainage following stoma reversal. We analyzed data from a total of 49 patients, all of whom had undergone insertion of a 10 Fr closed suction drainage tube in the fascia, following irrigation with approximately 300 mL of physiological saline. We then performed subcuticular suturing with 4-0 monofilament absorbable sutures. The median age of our patient population (34 men and 15 women) was 68 (range, 35-84) years. Six patients had an end stoma and 43 had a loop stoma. The wound category was 'contaminated' in 18 patients, while an incisional SSI was observed in one patient (2.0%). No wound disruptions, seromas, or drain infections were evident. Our data are reliable, but our study is limited in terms of general applicability; however, the low SSI rate indicates that the procedure is acceptable. Further research into this procedure will require a randomized trial design.

Background: Infantile aseptic meningitis is a rare infection of the central nervous system. Coxsackievirus B5 (CVB5) is an enterovirus that is sometimes associated with aseptic meningitis and encephalitis. Case presentation: We report on three isolated infants with aseptic meningitis caused by CVB5 in the spring and summer of 2016 with nearly identical 404-bp CVB5 Viral Capsid Protein 1 (VP1) sequences. In addition, viral analysis of sewage samples from Chiba Prefecture in 2016 showed similar 404-bp CVB5 VP1 sequences from May to September 2016. Conclusion: These results indicate that viral screening of sewage water may help detect occult outbreaks of viral infection, particularly for enterovirus strains.

We report a case of subclinical central diabetes insipidus (DI), due to Rathke's cleft cysts, that was initially misdiagnosed as transient DI of pregnancy because it presented in the third trimester of pregnancy. A 37-year-old primigravida visited the Department of Obstetrics in the 30th week of gestation due to polyuria. She was admitted due to oligohydramnios; the amniotic fluid index was 3.24. A vasopressin challenge test was performed and her urine osmolality increased by >100% from baseline after the administration of desmopressin. Because central DI or transient DI of pregnancy was suspected, we prescribed her a desmopressin nasal spray. She gave birth to a relatively healthy baby at 37 weeks and 4 days of gestation. Several months after delivery, discontinuation of desmopressin resulted in recurrence of her polyuria. Magnetic resonance imaging of her brain revealed Rathke's cleft cysts, and finally central DI was diagnosed.