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Background In the treatment of Rheumatoid arthritis (RA), early diagnosis and early treatment with tight control have become increasingly important with the advent of biological therapy. Ultrasonography (US) of the various joints enables the real-time evaluation of synovial hypertrophy, effusion and bone erosion, Power Doppler (PD) ultrasound is able to identify both subclinical synovitis and early erosive disease. Objectives The objectives of this study were to investigate whether the image of US at the operated joint reflect synovium histological findings or clinical indicators, and to compare the results in the patient treated by non-biological agent (NonBio) and biological agent (Bio) Methods RA related orthopaedic surgery was performed at 1287 joints including 17 shoulders, 160 knees, 96 elbows, 378 wrists, 364 fingers, 38 ankles and 234 toes during the period between January 2011 and December 2018 at our rheumatic center. Preoperatively, ultrasound evaluations were performed and grade of PD signal was determined at the part with the highest signal. PD signal consists 4 grades from grade 0 to 3. The operations were performed within one week after the ultrasound evaluations. Rooney score of the synovium histology, DAS28-ESR(4), MMP-3, CRP were investigated. Rooney score represents the histologic features in the synovium of RA. It includes 6 features i.e. synoviocytes hyperplasia, fibrosis, proliferating blood vessels, perivascular infiltrates of lymphocytes, focal aggregates of lymphocytes, diffuse infiltrates of lymphocytes. They were scored separately on a scale of 1-10.The treatments that the patients received included: biological agents (Bio) (n=389 30%), etanercept (ETN) (n= 102), tocilizumab (TCZ) (n=105), infliximab (IFX) (n=29), adalimumab (ADA) (n=28), certlizumab pegol (CZP) (n=12), golimumab (GLM) (n=56), and abatacept (ABT) (n=55), tofacitinib (TOF) (n=2). Results PD signal (0.97±0.88), DAS28 (3.23±1.13), CRP(0.5±1.25 mg/dL), MMP-3 (119.0±119.0 ng/mL) and Rooney score (23.5±7.7) in the patients treated with Bio were significantly lower than those (1.39±0.95, 3.66±1.07, 0.78±1.37 mg/dL, 146.3±150.0ng/dL, 28.5±9.26) in the patients treated with NonBio. Rooney score fibrosis (9.57±1.44) in patients treated with Bio was significantly higher than those (8.64±2.48) in patients treated by NonBio. Rooney score, synoviocyte hyperplasia (1.16±1.26) and three items of lymphocyte (1.59±2.91, 1.68±2.54, 1.11±2.20) in patients treated with Bio were lower than those (1.72±1.30, 3.79±3.56, 3.73±3.53, 2.40±2.98) in patients treated with NonBio. TCZ, ADA, ABT and IFX had some significant differences for Rooney score and Rooney item score between the patients treated with NonBio. Conclusion The activity of RA synovitis at operated site was suppressed in patients treated with Bio. There were some differences in clinical data, histological score, PD signal and DAS28 among Bio. Disclosure of Interests None declared

症例は83歳，女性．83歳から慢性腎不全のため，血液透析を導入．透析導入時の血液検査で，高ガンマグロブリン血症と抗核抗体320倍を認めたが，その他自己免疫疾患を示唆する所見は認めなかった．また，慢性腎不全の原疾患は不明であった．週3回の外来血液透析を継続中，平成20年6月末から水様性下痢（5～6行/日）が出現．整腸剤，塩酸ロペラミド，バンコマイシンなどの内服を行ったが，下痢は慢性再発性に出現を繰り返していた．下痢に伴う低アルブミン血症，浮腫を認めた．それまで服用していたランソプラゾールを塩酸ラニチジンに変更したが，下痢は出現を繰り返し，大腸内視鏡検査を行った．肉眼では異常所見を認めずほぼ正常の粘膜所見であり，横行結腸からの粘膜生検で粘膜表層部上皮直下にエオシン好性で，マッソントリクローム染色では25～35μm幅の沈着物を帯状に認め，粘膜固有層全層に小型リンパ球，形質細胞といった慢性炎症性細胞浸潤に加え，好酸球浸潤が目立ち，collagenous colitisと診断した．塩酸ラニチジンを中止後，下痢は消失し，低アルブミン血症も徐々に改善した．Collagenous colitisは1976年にLindstromによって報告され，慢性水様性下痢，肉眼的にほぼ正常な大腸所見，特徴的組織所見を有する臨床的症候群である．欧米では数百例の報告があり，慢性水様性下痢の原因として決して稀ではないと報告されている．本邦での報告例はまだ少ないが，年々増加傾向にある．病因は不明だが，自己免疫や薬剤の関与などが考えられている．本例も薬剤中止後に下痢が消失したことから，その関与が考えられた．透析患者での報告はまだないが，慢性下痢の鑑別疾患の一つとして念頭に置くことが必要と考え，報告した．

症例は75歳の男性で, 下血を主訴に入院した. 十二指腸第二部乳頭対側の粘膜下腫瘤からの出血の診断で内視鏡的止血術, 血管造影下塞栓術を試みたが止血困難であり, 緊急手術となった. 十二指腸部分切除にて腫瘤を切除し, 術中迅速病理検査で十二指腸壁内の迷入腺管から発生した高分化型腺癌と診断されたため, 幽門輪温存膵頭十二指腸切除を追加施行した. 術後の免疫組織学的検索にて異所性膵より発生した膵癌と診断した. 異所性膵に発生した悪性腫瘍の報告は非常にまれであり, 術前に正確な診断をつけることは困難である. 異所性膵の手術においては悪性化の可能性を念頭におき, 術中迅速病理検査を行い手術方針を決定することが必要である.

A pCW vector harboring rat liver serine dehydratase cDNA was expressed in Escherichia coli. The expressed level was about 5-fold higher in E. coli BL21 than in JM109 cell extract; the former lacked two kinds of proteases. Immunoblot analysis revealed the occurrence of a derivative other than serine dehydratase in the JM109 cell extract. The recombinant enzyme was purified to homogeneity. Staphylococcus aureus V8 protease and trypsin cleaved the enzyme at Glu-206 and Lys-220, respectively, with a concomitant loss of enzyme activity. Spectrophotometrically, the nicked enzyme showed a ∼50% reduced capacity for binding of the coenzyme pyridoxal phosphate and no spectral change of circular dichroism in the region at 300–480 nm, whereas circular dichroism spectra of both enzymes in the far-UV region were similar, suggesting that proteolysis impairs the coenzyme binding without an accompanying gross change of the secondary structure. Whereas the nicked enzyme behaved like the intact enzyme on Sephadex G-75 column chromatography, it was dissociated into two fragments on the column containing 6 m urea. Upon the removal of urea, both fragments spontaneously refolded. These results suggest that serine dehydratase consists of two folding domains connected by a region that is very susceptible to proteases.

上眼瞼に発生したメルケル細胞癌の1例を経験し, サイトケラチン20の有用性について他の2例のメルケル細胞癌を加えた3例で検討したので報告する. 症例は74歳, 女性, 農業. 上眼瞼腫瘍の捺印細胞診では, 小円形の均一な腫瘍細胞がシート状に多数出現していた. 核は円形～類円形で, N/C比大, クロマチンは細顆粒状で, 小さな核小体が数個認められた. 頸部腫瘤の吸引細胞診では, 小円形の腫瘍細胞はインディアンファイル様配列やモールディングをなし, 核の大小不同や核分裂像が認められた. なおcytoplasmic button-like globulesは明らかでなかったが, CK20による免疫染色では核近傍に滴状ならびに核周囲性の陽性所見を認めた. 免疫染色ではサイトケラチン (CK20, AE1), NSE, Chromogranin A, EMAが強陽性, Neurofilament, Synaptophysinは一部陽性, S-100蛋白, Vimentin, サイトケラチン (AE3), CEA, HMB 45, LCAは陰性だった。電顕像では細胞質内に少量の神経内分泌顆粒と, 核の傍に中間系フィラメントを, 細胞膜の一部にデスモゾーム様構造を認めた. 以上の所見からメルケル細胞癌と診断した. メルケル細胞癌と鑑別を要する他の8組織型の腫瘍における免疫組織学的検討の結果, CK20がび慢性に陽性を示すことがメルケル細胞癌の診断, 鑑別上有用であった.

小児の右副咽頭にまれに発生する胎児型横紋筋肉腫の捺印細胞診を経験したので報告する.患者は1歳1ヵ月の男児で主訴は喘鳴.生検時の捺印細胞診Papanicolaou (Pap.) 染色では, 多数の腫瘍細胞が散在性にみられ, その多くは紡錘形および卵円形で, 一部にラケット状, おたまじゃくし状, 細胞質の不明瞭なものが存在した.クロマチンは増量し, 細胞質は厚みのあるライトグリーン好染色性で, ごく一部の腫瘍細胞に横紋構造が認められた.PAS染色では細胞質内に陽性穎粒を認め, H-E染色ではエオジン好性の細胞質がみられた.組織標本では, 大多数の細胞は紡錘形および卵円形で, それらに混じってラケット状の好酸性細胞質を有する細胞が散在性に出現し, 渦巻き状の流れをもって密に増殖していた.リンタングステン酸ヘマトキシリン (PTAH) 染色では一部の腫瘍細胞に横紋構造を認めた.免疫組織学的に腫瘍細胞は, デスミン, ミオグロビンが強陽性を示し, α-平滑筋アクチン, ビメンチンは一部陽性, ミオシン, アクチン (HHF 35, sarcomeric) は陰性だった.電子顕微鏡的所見では横紋筋芽細胞やZ帯を有するミオフィラメントの所見を認めた.以上の所見より, 比較的低分化の胎児型横紋筋肉腫と診断し, 化学療法および放射線照射後の生検から4ヵ月目に腫瘍摘出術を施行.手術標本では腫瘍細胞は紡錘形, 卵円形のものが消失し, 横紋筋芽細胞からなる分化型のものだけになっていた.

Wistar rats (4-week-old) were administered with streptozotocin (45 mg/kg) through tail veins. After 3 months, diabetic rats were divided into 2 groups. One group (EPA group, n = 16) was fed a lipid-free diet (90%, w/w) plus lard (8%) and 90% pure eicosapentaenoic acid ethyl ester (2%) for 6 months. The other group (control group, n = 16) was fed in the same way except that eicosapentaenoic acid ethyl ester was replaced by safflower oil. Twenty-four-hour urine was collected just before starting the experimental diets and during the 6-month experimental period at monthly intervals. There were no differences in food intake and body weight between the two groups throughout the experiment. The mean microalbuminuria of the EPA group became significantly lower than that of the control group after 4 months on the diets through the end of the study (6 months). The mean microalbuminuria levels at the end of the study were 1.38 mg/day in the EPA group (n = 9) and 5.19 mg/day in the control group (n = 6) (p < 0.01). Eicosapentaenoic acid administration might retard the progression of diabetic nephropathy by reducing microalbuminuria.

It is relatively rare that schwannomas arise in the vagal trunk of the neck or brachial plexus. This paper presents a case of heterochronous schwannomas arising in the left vagal trunk of the neck and brachial plexus. A 52-year-old woman was seen at the hospital because of enlarging left subclavicular tumor with a spontaneous pain, which was noticed 5 years before. There was a history of undergoing enucleation of a schwannoma which occurred in the left left vagus nerve on the neck 17 years earlier. On palpation the tumor was elastic hard and hen's egg-sized. CT, ultrasonography, and needle aspiration biopsy revealed that the tumor was a schwqnnoma of the left brachial plexus. Tumorectomy (intracapsular shelling out) was performed under general anesthesia. Postoperative examination revealed no further neurological deficit of the left upper extremity. Tumorectomy of the schwannoma from the brachial plexus can cause postoperative neurological deficit of the upper extremity. So it seems better to enucleate intracapsularly for thepostoperative quality of life.

This paper describes a 72-year-old male patient with megacolon successfully undergone artificial anus This paper describes a 72-year-old male patient with megacolon successfully undergone artificial anus cerebral infarction and suffered from incontinence of urine and constipation since 4 years ago. In the resected specimen psuedomelanosis coli was found on mucous membrane but no organic stricture was shown. Histologic feature of the dilated sigmoid colon revealed a decrease in mumber and atrophy of nerve plexus, vacuolation of nerve cells, and hypertrophy of muscular tunics. Idiopathic megacolon is a relatively rare disease and 30 cases have been reported in Japan during the past 10 years. In this case his history of cerebral infarction and a decreased number and degeneration of nerve plexus of enteric wall suggested a possible denervation due to cerebral infarction. However, from two, facts, no organic lesion on the colon and a negative result in acetylcholine esterase stain by colon biopsy, a possibility of adult megacolon could mot be denied. Further accumulation of experience for this disease including neurological investigation might be essential.

A 34-year-old woman visited our hospital complaining of a rapid enlargement of masses at the right breast and right axilla, Biopsy of the breast revealed malignant lymphoma, and Br+Ax+Mj+Mn was performed. Histologically the tumor was a diffuse lymphoma in LSG classification, mixed type malignant lymphoma, and Pre-B-originated one. Postoperative VEPA and radiation therapies resulted in a transient remission, however, after 7 months she experienced a recurrence in the peritoneum, resisted various kinds of therapies, and died of general metastasis after 11 months. It might be diagnosed as systemic malignant lymphoma forming a mass in the breast. Malignant lymphoma originating in the mammary duct is relatively rare, and 121 cases have been reported in Japan. The avaraged age (47.7) when the patients first had the disease was slightly younger than that of brast cancer patients. The masses as many as about 1/4 of them were found in the right side C resion, 1/4 of the patients were accompanied by a rapid enlargement, and about a half of them had tumors with the maximum diameter of 5 cm or more. Operation + chemotherapy regimen was the most common. It has poorer prognosis than that of breast cancer. Moreover, a change in LDH appers to reflect the stage of the disease. Eleven cases originated in B cell alone have been reported up to now.

An autopsy case was presented of isolated myocarditis (Fiedler's myocarditis) which was probably affected by fatal generalized infection of 2 rarely encountered infective agents, namely, infectious mononucelosis and cytomegalic inclusion disease.