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OBJECTIVE: In this study, we evaluated the effect of hip-joint rotation on the interface pressure over the sacrum and greater trochanter with a new protocol for positioning of bedridden elderly patients. METHOD: The interface pressure values over the sacrum and greater trochanter in bedridden patients were evaluated. These were collected in the supine position, 90° lateral position, and 30° and 40° laterally inclined positions with external rotation or neutral positioning of the hip joint. Each interface pressure was assessed with a device measuring pressure distribution, after which, the peak pressure index (PPI) was calculated. RESULTS: In the 17 patients examined, the PPI over the sacrum in the supine position was significantly greater than that in other positions. In the 30° and 40° laterally inclined positions, the PPIs over the greater trochanter were significantly lower in the neutral position of the hip joint compared with those in the external rotation position. CONCLUSION: Our findings revealed the effects of hip-joint rotation on the interface pressure for the greater trochanter, possibly due to the increased distance between the greater trochanter and the sacrum caused by neutral position of the hip joint. The results demonstrate that it is to best place the hip joint in a neutral position when the legs are in contact with the bed in order to distribute the pressure over the greater trochanter in the 30° and 40° laterally inclined positions. These results can be applied to the clinical setting to improve patient positioning and decrease pressure ulcers. DECLARATION OF INTEREST: The authors declare that they have no competing financial interests.

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AIM: We reviewed the importance of six angiosomes concept in the foot area through arterial-arterial connections. METHODS: We retrospectively analyzed 145 limbs from 111 critical limb ischemia (CLI) patients to investigate whether the wound location corresponded with the occlusion of the feeding artery. We also analyzed 57 limbs that underwent endovascular therapy (EVT). Regardless of which target vessel underwent EVT in the calf area, it was considered "direct" if the feeding artery flow in the foot area was achieved and "indirect" if not achieved. The wound healing rate was compared between the direct group and the indirect group relative to the six angiosomes of the foot. Further, we analyzed the absolute difference of the skin perfusion pressure (SPP) values measured before and after EVT. RESULTS: A concordance rate of 82.1% (119/145 limbs) was observed between the wound location and the site of vessel occlusion. The wound healing rate of the six angiosomes-direct group was significantly higher than that of the six angiosomes-indirect group (96.6% vs. 72.7%; P=0.03). The SPP values were significantly higher in the six angiosomes-direct group than those in the six angiosomes-indirect group (20.3±18.1 mmHg vs. 5±14.5 mmHg; P=0.039). CONCLUSION: In the case of the patency of the arterial-arterial connections, even if one undergoes EVT for any of the three vessels in the lower leg, wound healing is likely to be achieved, if we can achieve six angiosome-direct flow.

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OBJECTIVE: In this study, we develop methods to measure galvanotaxis of fibroblasts and determined the optimum conditions of electrical stimulation. METHOD: An inverted 35mm dish containing cell suspensions (3×105 primary human skin fibroblasts, DMEM, and 10% FBS) was placed on the centre of a 100mm dish. The 35mm dish was removed 24 hours later, and culture medium was added to the 100mm dish. Fibroblasts were randomised (double-blind) into three groups, where electrical stimulation was given at varying intensities: 0UA (control), 50UA, and 100UA. Electrical stimulation (frequency=0.3Hz) was conducted, for a duration of 4 hours, with platinum electrodes in a CO2 incubator. We took pictures immediately before and 20 hours after stimulation. We calculated the migration ratio to the negative pole by dividing the area of attached fibroblasts after stimulation with that before stimulation. RESULTS: The migration ratio to the negative pole was significantly higher in the 100UA group than in the control group (p<0.05). The ratios were 0.902±0.292 in the control group, 1.128±0.253 in the 50UA group, and 1.24±0.300 in the 100UA group. CONCLUSION: This study observed the change in cell proliferation during the initial 24-hour period after plating and was thus able to quantitatively evaluate the migration. The results suggest that a low-intensity direct current promotes migration to the negative pole of human dermal fibroblasts, which is charged with positive electricity. Several clinical reports using the methods in this study showed the microcurrent efficacy for pressure ulcer healing. Electrical stimulation based on our in vitro experiment might be important for the development of physical therapy for pressure ulcers.

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OBJECTIVE: To evaluate the effect of ultrasound irradiation when used alongside standard care in the treatment of pressure ulcers; outcome measures were reduction in wound size and exudate weight. METHOD: Five patients (two male and three female, age range: 76-92 years) with seven ulcers participated in this study. They had National Pressure Ulcer Advisory Panel (NPUAP) stage III or IV pressure ulcers. We conducted an ABABA study (A: standard treatment with dressings that promote a moist wound healing environment; B: ultrasound irradiation administered to the pressure ulcer through the same dressing used in period A; each period lasted 2-4 weeks). Six ulcers each were randomised to either the treatment group or control group. One ulcer was not randomised, but was the first to receive ultrasound in the BABA sequence, with a view to determining if the pilot was feasible. The control group received sham ultrasound in period B. Pulsed ultrasound (20% duty cycle, 0.5W/cm2 on the wound surface, 1MHz or 3MHz, for 10 minutes) was applied five times weekly. RESULTS: In the treatment group, two ulcers markedly decreased in size after 3-4 weeks of US treatment, one ulcer decreased in size soon after initiation of treatment and one ulcer showed no clear reduction in size. The volume of exudate was greater in period B than A in two ulcers that reduced markedly in size after 3-4 weeks of US treatment. None of the ulcers in the control group decreased markedly in size. CONCLUSION: This pilot study suggests that US used alongside standard treatment might promote the healing of pressure ulcers. However, larger studies are required to determine the efficacy and mechanism of US treatment for PUs. DECLARATION OF INTEREST: None.

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BACKGROUND: Mondor's disease (MD) is considered an inflammatory condition of superficial vasculitis that develops mainly in the anterolateral thoracoabdominal wall. The pathogenesis of the disease has been controversial, however, because of the lack of histopathologic methods for differentiating between the small vein and the lymphatic vessel. AIM: To objectively examine the origin of vascular lesions in MD, we investigated the endothelial cells of their blood and lymphatic vessels. METHODS: Immunohistochemical examinations were carried out on specimens involving vascular lesions from 16 patients with MD, using antibodies against von Willebrand factor and human lymphatic vessel endothelial hyaluronan receptor-1, which specifically discriminate between lymphatic and blood vessels. RESULTS: The histopathologic findings clearly showed thrombophlebitis in 14 patients, a lesion originating in the lymphatic vessel in one patient, and sclerosis that consisted of the artery together with veins in another. CONCLUSION: This study suggests that almost all cases of MD are due to thrombophlebitis, with a small minority due to lymphangitis or other conditions. We believe this study will contribute to the better recognition of the factual changes in the condition designated MD.

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We reported a 74-year-old male case of progressive supranuclear palsy (PSP) who responded to tandospirone citrate, a serotonin receptor (5-HT1A) agonist. The patient manifested postural instability and gait disturbance at 71 years. Additionally, he showed vertical gaze paresis, regidity of the neck, extremities and trunk, bradykinesia and mild cognitive impairment. A brain MRI revealed moderate atrophy of bilateral frontal/temporal lobes and of midbrain tegmentum one year after the onset. The patient had been diagnosed as PSP and treated with L-DOPA. However, L-DOPA therapy showed only transient response for a few months. His symptoms deteriorated gradually, and he became unable to sit, stand up or walk by himself. Tandospirone citrate was additionally administered at 30 mg/day. Rigidity and bradykinesia were remarkably improved in two weeks after the start of tandospirone treatment. He became able to stand up and walk a short distance with supports in four weeks. Cognitive disturbance was also slightly improved. Tandospirone citrate was effective on our case of PSP, especially on rigidity. Our findings suggest that combination of levodopa and tandospirone citrate is a useful therapy for PSP.

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The interaction between melanocytes and keratinocytes in epidermal tissue suggest a bidirectional interchange between these two cell types. Although keratinocytes appear to affect melanocyte function, there are no reported effects of melanocytes on keratinocytes. Using cell strains, we examined the effect of melanocytes on keratinocyte proliferation. Two conditioned medium techniques were used: one was a co-culture system, where both cell types, grown on separate surfaces shared a common volume of medium. The second was simply feeding keratinocytes melanocyte-conditioned medium. Mixed cultures (both cell types together in a monolayer) where also studied. Our results showed that melanocyte-conditioned medium and melanocytes in co-culture significantly stimulated keratinocyte proliferation as measured by bromodeoxyuridine incorporation assay. However, growth of both cell types together in culture did not affect the growth rate of either cell type. Our results showed that cultured human melanocytes produce one or more soluble factors that stimulate the growth of cultured keratinocytes.

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BACKGROUND: Cerebral vasospasm is a poor resulting outcome of a ruptured cerebral aneurysm; to clarify the mechanism of vasospasm it is important to improve this outcome. C-type natriuretic peptide (CNP) is present in the brain as a cerebral vasodilator; it is also an endothelium-derived relaxing factor produced via cGMP. We speculated that CNP might be an inhibitor of cerebral vasospasm after subarachnoid hemorrhage (SAH). METHODS: To clarify the role of CNP in cerebral vasospasm after SAH, we conducted 1 week monitoring of CNP concentrations in the plasma and cerebrospinal fluid (CSF) of 26 patients who had undergone clipping within 24 hours of the occurrence of SAH, and divided them into group A (positive for angiographic spasm) and group B (negative for angiographic spasm). We also examined CNP concentrations in the CSF of patients who were receiving spinal anesthesia for small orthopedic operations, as reference patients. RESULTS: The CNP concentration in the CSF on day 1 was higher than in the reference patients and decreased in both test groups, but we did not observe any significant difference between the groups. CNP concentrations in the plasma did not change in either group. CONCLUSIONS: CNP concentrations in the CSF were high in the acute phase after SAH, whereas plasma CNP concentrations remained constant. However, our findings did not support our hypothesis because we did not find any relationship between vasospasm and changes in CNP concentrations in the CSF.

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The effect of three different Korean Traditional Medicines (KTM) was studied on several functional parameters of adult human cells in culture. The cells were non-transformed strains of normal, skin epidermal cells (keratinocytes) from adult humans. Aqueous extracts of the herbal medicines were tested using two types of cell strains: one type was essential fatty acid deficient (EFAD) cells which grow rapidly in medium that was low in calcium and had no essential fatty acids; the second type was a cell strain grown in medium supplemented with essential fatty acid (EFA-supplemented). These cells had much slower, in vivo skin growth rates, and the fatty acid composition resembled that measured in epidermal biopsy tissue. The KTMs chosen for this study were tae-gang-hual-tang (for treating osteoarthritis), hual-ak-tang (for pain relief) and sip-zeon-tae-bo-tang (for fortifying immune systems). Because high proliferation rates usually correlate with skin inflammation and because many of the chemotactic agents mediating inflammatory response are modified fatty acids, this study focused on cell growth rate and membrane fatty acid composition as signals for the effects of the herbal medicines. By monitoring growth rate, these experiments measured both a stimulatory and a regulatory effect on the growth of keratinocytes. Some toxicity was seen at the highest doses of the KTMs. These effects were modeled mathematically, and the results showed varying effects on growth rate depending on dose and herbal recipe. The fitting parameters were discussed as they relate to biological function. The experimental design was also discussed and alternatives were suggested.

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To investigate whether the striatal dopamine receptor function is involved in the development of vascular parkinsonism (VP), a positron emission tomography (PET) study was conducted on 9 patients with VP by using [11C] N-methylspiperone as the tracer. The rate of binding availability in the striatal dopamine D2 receptor (k3) was determined semiquantitatively, and the values were compared to the predicted normal values based on the results from 7 normal volunteers. Of 9 patients with VP, the normalized D2 receptor binding [%k3] was more than 90% in 5 patients, 89 to 87% in 3, and 75% in one. These values showed no evident correlation with the Hoehn and Yahr stage. The laterality of the striatal %k3 did not correspond to that of the parkinsonism. Thus, the striatal dopamine D2 receptor binding was not severely impaired and did not correlate with the neurological status in patients with VP. This may indicate that striatal dopamine D2 receptor function is not primarily associated with the development of the parkinsonism in VP.

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Merkel cell carcinoma is characterized by specific neuroendocrine features and the expression of several neuropeptides. We report a case of Merkel cell carcinoma with post-surgical hyponatremia in an 85-year-old Japanese woman. A tumor on the left cheek histopathologically showed the characteristics of Merkel cell carcinoma together with Bowen's disease. Although an increased level of ACTH was found both in the tumor and in the peripheral blood, the postoperative hyponatremia in our patient seems more likely to have been caused by the stress of the operation and indapamide, considering that the ACTH level in the tumor was much lower than those in other ectopic ACTH-producing tumors in previous reports.

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The phospholipid component of the cellular membrane is crucial to the structure and function of cells. Basal cells from three epithelial tissues, adult human skin epidermis, oral mucosa, and hair follicles, grow rapidly in serum- and lipid-free medium. Analysis of phospholipid extracts from the above three types of stratified squamous epithelium in both in vivo and in vitro was done to relate fatty acid cell composition to cell function. The fatty acid composition of hair follicles in vivo was analyzed in plucked scalp hairs, and those of skin epidermis and oral mucosa in vivo were analyzed after separating the tissue into suprabasal and basal layers. The fatty acid composition of the in vivo cells from hair follicles shows a partial essential fatty acid (EFA)-deficient state. There was no significant difference between the skin epidermis and the oral mucosa in the fatty acid composition of the in vivo cells from each basal layer. However, in the suprabasal layers, the percent of linoleic acid (18:2) from the skin epidermis was higher than that from the oral mucosa. This study shows that total fatty acid composition in cell membranes of stratified squamous epithelium varies with their keratinization pattern. When cultured, the three types of rapidly growing keratinocytes showed the same essential fatty acid deficient pattern in the membrane phospholipids.

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The authors report the rare case of a patient with neurocutaneous vascular hamartomas mimicking Cobb syndrome. An 8-year-old boy was admitted to the authors' hospital with progressive urinary disturbance and upper back pain. Multiple skin nevi had been noted at the child's birth. Radiological examination revealed multiple cavernous angiomas in the spinal cord in the same metamere in which the skin nevi had been observed and also in the left cerebral hemisphere. His symptoms gradually improved without surgical intervention. Four years later he was readmitted because of a cerebral hemorrhage involving the left cerebral peduncle. Nonsurgical treatment was chosen because his symptoms promptly improved. To the best of the authors' knowledge, this is the first case of multiple cavernous angiomas in the brain and spinal cord associated with skin nevi. The authors discuss this clinical entity and the significance of the disease.

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The present study endeavored to differentiate Alzheimer's disease (AD) from vascular dementia (VaD) by comparing the metabolic and hemodynamic parameters. Positron emission tomographic (PET) studies were carried out in 13 patients with probable AD and 20 patients with VaD. PET findings were not included in the diagnostic criteria of AD or VaD. Using oxygen-15 labeled compounds, cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO2), oxygen extraction fraction (OEF), cerebral blood volume, and vascular transit time (VTT) were measured quantitatively during the resting state. To evaluate vascular reactivity (VR), CBF was also measured during 7% CO2 inhalation. Regional CBF from the parietal cortex positively correlated with the neuropsychological scores in both AD and VaD groups. The typical parietotemporal pattern of hypoperfusion and hypometabolism was observed in the AD group, whereas the frontal lobe including the cingulate and superior frontal gyri were predominantly affected in the VaD group. The occipital cortex was preserved in both groups. A significant increase of the OEF was found in the parietotemporal areas in the AD group. No significant prolongation was seen with VTT. There was a marked difference in VR between the two groups: VR was depleted in the VaD group, whereas VR was normal in the AD group. The increased OEF with preserved vascular reserve seen in AD may implicate participation of a vascular factor in the pathogenesis of AD, possibly at the capillary level. Thus, PET provides important functional information in discriminating AD from VaD by comparing the patterns of hypoperfusion and/or hypometabolism, and in the understanding of the underlying hemodynamic pathophysiology.

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A problem maxillofacial surgeons face is a lack of sufficient autogenous oral mucosa for reconstruction of the oral cavity. Split-thickness or oral mucosa grafts require more than one surgical procedure and can result in donor site morbidity. Skin has disadvantages of adnexal structures and a different keratinization pattern than oral mucosa. In this study, we successfully assembled, ex vivo, a human oral mucosa equivalent, consisting of epidermal and dermal components, in a defined, essential-fatty-acid-deficient, serum-free culture medium without a feeder layer, that could be used for intra-oral grafting in humans. Autogenous oral keratinocytes were seeded onto a cadaveric dermis, AlloDerm. The oral mucosa equivalent was cultured at an air-liquid interface for 2 wks. The resulting equivalent had a well-stratified parakeratinized epithelial layer similar to native oral keratinized mucosa. Expression of differentiation markers, filaggrin and cytokeratin 10/13, suggested a premature keratinized state. The presence of proliferation markers, proliferating cell nuclear antigen (PCNA) and Ki-67, suggested a state of hyperproliferation. Fatty acid composition of the equivalent was similar to that of in vitro cultured oral keratinocytes but differed from the that of in vivo native tissue, showing a lower content of 18:2 and 20:4, and a higher content of 16:1 and 18:1 fatty acids, respectively. The keratinocytes of the equivalent appeared to be in a more active and proliferative state than native keratinized mucosa. The dynamic nature of the cell population on the oral mucosa equivalent may be beneficial for intra-oral grafting procedures and for transfection of the keratinocytes.

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BACKGROUND: The rate of recurrence of basal cell carcinoma (BCC) in the periorbital region is higher than that in other areas because of the spread of the tumor along barrier structures. OBJECTIVE: A better understanding of the biological behavior of BCC in this area, in particular as it relates to the lacrimal system, should improve the outcome of surgery. METHODS: A study was made of two cases of BCC that developed in the periorbital region and invaded the lacrimal system. RESULTS: The tumors were found to have invaded the lacrimal system along the mucosal epithelium. Magnetic resonance imaging (MRI) did not suggest any abnormalities in this area. In one patient, the tumor had infiltrated the nasal cavity without destruction of the periorbital bone and nasal cartilage. A preoperative fiberscopic examination clearly demonstrated the involvement of the nasal cavity in this case. CONCLUSION: The lacrimal system is often invaded by BCC that originates from the periorbital region. Physicians and surgeons need to be well aware of the possibility of such aggressive infiltration by BCC.

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A 40-year-old man developed squamous cell carcinoma on a perianal lesion of linear porokeratosis after renal transplantation. The tumor metastasized to the left inguinal lymph node 25 months after the primary tumor was excised. p53 overexpression was observed in the tumor cells, but not in the porokeratotic lesion. Interestingly, continuous subcutaneous infusion of peplomycin for the lymph node metastasis significantly improved the warty lesions of porokeratosis. In this patient, immunosuppressive agents might have accelerated the development of carcinoma on a skin area with malignant potential.

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PURPOSE: The aim of this study was the ex vivo development of a composite oral mucosal equivalent composed of a continuous stratified layer of human oral keratinocytes grown on a cadaveric human dermal matrix in a defined medium without a feeder layer. MATERIALS AND METHODS: Enzymatically dissociated human oral keratinocytes from keratinized oral mucosa were cultured, submerged in a serum-free, low-calcium (0.15 mmol/L) supplemented medium, and expanded through several passages. Once a sufficient population of keratinocytes was reached, they were seeded on 1-cm2 pieces of AlloDerm (LifeCell Co, Woodlands, TX), an acellular nonimmunogenic cadaveric human dermis, at cell densities of 2.5 X 10(4), 5.0 X 10(4), 1.25 X 10(5), or 2.5 X 10(5). The oral keratinocyte-AlloDerm composites were cultured while submerged in a high-calcium (1.8 mmol/L) medium for 4 days. After 4 days, the composites were raised to an air-liquid interface. Samples of the composites were taken for histologic examination at 4, 11, and 18 days postseeding of the keratinocytes on the AlloDerm. RESULTS: At day 4, only the seeded cell density of 2.5 X 10(5) cells/cm2 formed a continuous monolayer on the AlloDerm. At day 11, a continuous stratified epithelium was seen, and at day 18 a well-differentiated, confluent parakeratotic epithelial layer was developed at cell densities of 5.0 X 10(4), 1.25 X 10(5), and 2.5 X 10(5)cells/cm2. CONCLUSION: With the method used, it was possible to successfully develop an ex vivo composite oral mucosal equivalent that consisted of a stratified epidermis on a dermal matrix.

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BACKGROUND: Hair follicle preservation for the purpose of delayed application would help us to transplant hair follicles more efficiently. METHODS: Isolated single hair follicles were preserved at 4 degrees C in four different solutions. Viability of preserved follicles was judged by organ culture and cell culture. In addition, a small number of hair follicles were transplanted into athymic mice. RESULTS. By cell culture, both dermal papilla and outer root sheath cells could be cultivated after 7 days of preservation. Hair follicles preserved for 48 hours showed a significant increase of hair shafts in organ culture. Those preserved for 7 days regrew well when transplanted into athymic mice. CONCLUSION: Preservation of hair follicles at 4 degrees C could be one option to prepare many follicular units at one time for transplantation.

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