Antibody-mediated insulin resistance treated by cessation of insulin administration

A 45-year-old Japanese man was referred to our hospital because of hyperglycemia despite the administration of as much as 120 U/day of human insulin. He had no history of injecting animal insulin. Free insulin was below 5 microU/ml, but a high titer of total insulin (about 3,000 microU/ml) was observed, suggesting the presence of antibodies against human insulin. Scatchard analysis showed an increased insulin binding capacity in the plasma characterized by a higher affinity for insulin. He was successfully treated by cessation of insulin administration. A Scatchard analysis series showed that a reduction in the insulin binding capacity of antibodies paralleled the improvement in glycemic control.

Delapril versus manidipine in hypertensive therapy to halt the type-2-diabetes-mellitus-associated nephropathy

Thirty-nine hypertensive patients with type 2 diabetes mellitus were followed under long-term treatment (mean, 20.7 months) with manidipine hydrochloride, a Ca antagonist, or delapril hydrochloride, an ACE inhibitor, at nine institutions. Both the treatments showed similar antihypertensive effects, although slight but significantly larger decreases were observed in systolic and mean blood pressures at months 12 and 24 in the patients treated with manidipine (P < 0.02). The urinary albumin excretion index (AEI) tended to increase throughout the study in both treatment groups, but no significant difference in AEI was observed between the two treatment groups at any time point. Overt albuminuria developed in four patients on manidipine but did not appear in any of the patients on delapril. The risk of progression to overt albuminuria was significantly different between manidipine and delapril groups (P = 0.011). No increase in serum creatinine (Cr) was observed with delapril. The average excretion indexes of tubular markers such as beta2-microglobulin, alpha1-microglobulin, and NAG tended to be higher in the patients on manidipine than in those on delapril. Taken in sum, these findings suggest that the ACE inhibitor delapril is more beneficial than the Ca antagonist manidipine in the treatment of diabetic renal diseases via mechanisms other than the blood pressure regulation, partly through their different effects on tubular function. In conclusion, delapril was significantly more effective than manidipine in inhibiting progression to overt albuminuria in hypertensive type 2 diabetes mellitus patients.

A device for removal of femoral distal cement plug during hip revision arthroplasty: a high-powered drill equipped with a centralizer

A removal procedure of a femoral cement mantle in hip revision arthroplasty has a risk of causing perforation or fracture, especially when removing a well-fixed distal cement plug. A high-powered drill equipped with a centralizer was developed to remove the distal cement plug safely. Using the drill equipped with a centralizer, the cement plug was removed well enough to insert a new component without causing perforation during the operation.

Worldwide differences in the incidence of insulin autoimmune syndrome (Hirata disease) with respect to the evolution of HLA-DR4 alleles

The relationship between the geographic distribution of susceptibility genes to insulin autoimmune syndrome (IAS) and the incidence of insulin autoimmune syndrome was investigated in order to examine the distribution of the genetic background to susceptibility to certain diseases. The HLA-DR4 allele, DRB1*0406, is associated with increased susceptibility to IAS among Japanese, while the DRB1*0403 and DRB1*0407 alleles are not (the odds ratio of which are 1.6 and 1.1, respectively). The worldwide geographic distribution of the three DR*04 alleles showed that the distribution of DRB1*0403 encompassed that of DRB1*0406 and DRB1*0407. Taken together with the findings that Glu at position 74 in the DRB1 molecule is shared by the three DRB1*04 alleles, there are only a few differences between the DRB1 molecule-nucleotide sequences of DRB1*0403, DRB1*0406 and DRB1*0407, and that all the three DRB1*04 alleles are carried by the same class II haplotype, DQA1*0301/DQB1*0302, it may be considered that DRB1*0403 is the ancestral allele of DRB1*0406 and DRB1*0407. Therefore, populations with a higher prevalence of DRB1*0406 have a higher risk of developing IAS. The extremely low prevalence of IAS among Caucasians can be explained by the low prevalence of DRB1*0406 in this population. This is a good example of the association between the predisposition to risk of development of certain diseases and the evolution of susceptibility genes.

[Insulin sensitizer and urate metabolism]

Gout patients often have various characteristics of insulin resistance (IR) syndrome such as glucose intolerance, hyperlipidemia, hypertension and obesity. In addition, epidemiological data suggest that hyperuricemia is associated with higher rates of death due to cardiovascular and cerebrovascular disorders. However, it has not conclusively been shown whether the association between hyperuricemia and increased death rate is secondary to the association between IR and death or hyperuricemia itself is an independent risk of death. It is of interest to examine the effects of insulin sensitizer which was developed recently on serum urate concentration because it may provide a new idea as to the mechanism of the association between IR, hyperuricemia and vascular disorders. In the present paper, we discuss the relevance of IR to hyperuricemia and gout, and show the data of urate and glucose metabolism obtained from control subjects or the patients with hyperuricemia, gout or type 2 diabetes.

[Troglitazone for treatment of polycystic ovary syndrome]

Polycystic ovary syndrome(PCOS) is characterized by clinical symptoms such as menstrual dysfunction, unovulatory infertility, masculinization, obesity, polycystic ovary by ultrasound, and endocrine abnormalities such as hyperandrogenism, and elevated LH to FSH ratio. Recent reports suggest that insulin resistance plays an important role in the pathogenesis of PCOS, and several insulin sensitizing agents have been used for the treatment of PCOS. Troglitazone, one of the thiazolidinediones, improves not only insulin sensitivity but also hyperandrogenism and ovulatory function. Troglitazone appears to be useful in treating women with PCOS. Further investigations are needed to assess the effectiveness and safety.

Beta-cell transcription factors and diabetes: no evidence for diabetes-associated mutations in the hepatocyte nuclear factor-3beta gene (HNF3B) in Japanese patients with maturity-onset diabetes of the young

Mutations in the transcription factors hepatocyte nuclear factor (HNF)-4alpha and -1alpha, insulin promoter factor-1, and HNF-1beta are the causes of four forms of maturity-onset diabetes of the young (MODY1 and 3-5, respectively). The winged-helix transcription factor HNF-3beta has been implicated in the regulation of expression of each of these MODY genes, suggesting that mutations in the HNF-3beta gene (HNF3B) may also cause MODY. We have tested this hypothesis by screening a panel of 57 unrelated Japanese subjects with a clinical diagnosis of MODY for mutations in HNF3B. This analysis revealed four frequent polymorphisms that were not associated with MODY, including one in the promoter region (-213A/G), two silent mutations in the codons for Ala 97 (291C/T) and Gly 279 (837A/G), and one in the 3'-untranslated region (1424C/T). Two rare substitutions in the 5'-untranslated region, -156C/T and -67A/C, were found in a heterozygous state in two subjects, and two subjects were heterozygous for putative missense mutations, S109N (326G > A) and A328V (983C>T). The two missense mutations were not found in 106 normal chromosomes from nondiabetic subjects. It was not possible to test for co-segregation of these mutations with diabetes and thus, it is unclear whether or not these mutations can cause MODY. The results of our study suggest that mutations in HNF3B are not a common cause of MODY in Japanese subjects.

Nerve sheath ganglion of the ulnar nerve

We report a case of a nerve sheath ganglion of the ulnar nerve at the canal of Guyon. This case involved a ganglion which was confined to the epineurium of the ulnar nerve. and it was completely excised without any damage to the nerve fiber. A nerve-sheath ganglion is rare, but it should be considered in the differential diagnosis of any tumor which is causing neural disturbance.

Expression of hepatocyte growth factor (HGF)/scatter factor and its receptor c-MET correlates with poor prognosis in synovial sarcoma

The hepatocyte growth factor (HGF)/c-MET signaling system plays an important role in the carcinogenesis of various organs. We investigated the expression of HGF and its receptor c-MET by immunohistochemistry (IHC) in 69 cases of synovial sarcoma and compared the findings with clinicopathologic parameters, proliferating activities evaluated by MIB-1 labeling index (MIB-1 LI), and patients' prognosis. Furthermore, mRNA analysis of HGF, c-MET, and SYT-SSX fusion gene was performed by reverse transcriptase-polymerase chain reaction (RT-PCR) in 22 concordant frozen materials. Twenty-one of 69 (30.4%) tumors showed positive reaction for c-MET, whereas 22 tumors (31.9%) were positive for HGF. In 10 cases, co-expression of HGF and c-MET was observed; however, there was no significant correlation between HGF and c-MET expression. HGF expression was correlated with female patients, large tumors (more than 5 cm), the presence of rhabdoid cells, low frequency of mast cells (<20/10 HPF), high nuclear grade (grade III), and high American Joint Committee (AJC) stage (III and IV). Conversely, c-MET expression was only correlated with large tumors. However, the coexpression of HGF and c-MET was significantly correlated with large tumor size, the existence of rhabdoid cells, and high AJC stage. Both the expression of HGF and the co-expression of HGF and c-MET showed a significantly high MIB-1 LI and were correlated with poor prognosis according to univariate analysis. Multivariate Cox analysis showed that high AJC stage, the expression of HGF, and a high MIB-1 LI (12.0>) independently had a negative impact on overall survival. In 22 frozen material cases evaluated by both IHC and RT-PCR, a statistically significant correlation was found between the 2 techniques. SYT-SSX fusion transcripts were detected in all 22 cases. Three tumors had SYT-SSX2 fusion transcripts, whereas 19 had SYT-SSX1 phenotype. Our results suggest that HGF/c-MET paracrine signaling may contribute to tumorigenesis and progression in synovial sarcoma.

A comparative study of fibrous dysplasia and osteofibrous dysplasia with regard to expressions of c-fos and c-jun products and bone matrix proteins: a clinicopathologic review and immunohistochemical study of c-fos, c-jun, type I collagen, osteonectin, osteopontin, and osteocalcin

Fibrous dysplasia and osteofibrous dysplasia are both benign fibro-osseous lesions of the bone and are generally seen during childhood or adolescence. Histologically, the features of these bone lesions sometimes look quite similar, but their precise nature remains controversial. We retrospectively studied clinicopathologic findings in 62 cases of fibrous dysplasia and 20 cases of osteofibrous dysplasia with regard to their anatomic location and histological appearance. From among these cases, the immunohistochemical expressions of c-fos and c-jun proto-oncogene products and bone matrix proteins of type I collagen, osteonectin, osteopontin, and osteocalcin were evaluated in 20 typical fibrous dysplasias and 17 osteofibrous dysplasias using paraffin sections, and these expressions were then assessed semiquantitatively. Microscopically, fibrous dysplasia showed various secondary changes, such as hyalinization, hemorrhage, xanthomatous reaction, and cystic change in 22 of the 62 cases (35%). This was a higher incidence than in osteofibrous dysplasia, in which only 2 of the 20 cases (10%) showed such changes. In the elderly fibrous dysplasia cases, the cellularity of fibroblast-like cells was rather low, and those cases were hyalinized. Almost all of the cases of fibrous dysplasia and osteofibrous dysplasia showed positive expressions of c-fos and c-jun products. The expressions of type I collagen and osteopontin showed no difference between fibrous dysplasia and osteofibrous dysplasia. Immunoreactivity for osteonectin in bone matrix was detected in only 1 case of fibrous dysplasia (1 of 20), whereas it was recognized in 14 of the 17 cases of osteofibrous dysplasia. Furthermore, the immunoreactivity for osteocalcin in bone matrix and fibroblast-like cells was higher in fibrous dysplasia than it was in osteofibrous dysplasia, semiquantitatively. Our immunohistochemical results regarding osteonectin and osteocalcin suggest that the bone matrix of fibrous dysplasia is somewhat more mature than that of osteofibrous dysplasia, and that the fibroblast-like cells in fibrous dysplasia share some phenotypic features with osteoprogenitor cells of normal osteogenic tissues. Fibrous dysplasia and osteofibrous dysplasia share some similar histological features, including c-fos and c-jun expressions, although different clinicohistologic features and immunohistochemical expressions of osteonectin and osteocalcin were observed. These features suggest that the mechanisms behind the development of fibrous dysplasia and osteofibrous dysplasia are similar, but this is not necessarily indicative of a closer relationship between the 2 diseases.

Fluid shear stress increases interleukin-11 expression in human osteoblast-like cells: its role in osteoclast induction

It is unclear how mechanical stress influences bone cells. Mechanical stress causes fluid shear stress (FSS) in the bone. Osteoblast lineage cells are thought to sense FSS and regulate bone remodeling. We therefore investigated the effects of FSS on human osteoblast-like osteosarcoma cells: SaOS-2 cells in vitro. The conditioned medium of the SaOS-2 cells after 24 h of FSS (24 h-FSS CM) showed such osteoclastic phenotype inductions as significantly increasing the number of tartrate-resistant acid phosphatase (TRAP) positive multinuclear cells in rat bone marrow cells and TRAP-positive cells in human preosteoclastic cells: FLG 29.1 cells. An enzyme-linked immunosorbent assay showed interleukin-11 (IL-11) protein to increase 7-fold in the 24 h-FSS CM. A Northern analysis showed that IL-11 mRNA increased 4-fold in the SaOS-2 cells after 6 h-FSS; however, no IL-6 mRNA expression was detected. Furthermore, the anti-human IL-11 antibody significantly neutralized the osteoclastic phenotype induction of the 24 h-FSS CM. The IL-11 mRNA up-regulation in SaOS-2 cells by the 6 h-FSS was not inhibited by the anti-human transforming growth factor-beta1 antibody, but it was significantly inhibited by indomethacin. An enzymeimmunoassay showed prostaglandin E2 to increase 7-fold in the 1 h-FSS CM. These findings thus suggest that FSS induces osteoblasts to produce IL-11 (mediated by prostaglandins) and thus stimulates bone remodeling.

Expression of syndecan-2, -4, and fibroblast growth factor receptor type 1 in human periodontal ligament fibroblasts and down-regulation of these membrane proteins during maturation in culture

Syndecans are transmembrane heparan sulfate proteoglycans. They are known to interact with basic fibroblast growth factor (bFGF), and it has been suggested that they play important roles in the growth, morphology, and migration of a variety of cell types. We examined the expression of syndecans and fibroblast growth factor receptor type 1 (FGFR1) in periodontal ligament (PDL) cells, because these membrane proteins may play roles in the control of growth and differentiation during regeneration of PDL. Reverse-transcription/polymerase chain-reaction (RT-PCR) showed that PDL cells expressed syndecan-2 and -4 mRNAs. This was confirmed by sequence analysis of the PCR products. When PDL cells were maintained for 25 days, alkaline phosphatase (ALPase) activity gradually increased and reached a maximal level on day 20. Northern blotting analysis showed that PDL cells expressed 2.3-kb syndecan-2, 2.6-kb syndecan-4, and 2.8-kb FGFR1 mRNAs throughout the entire culture period, whereas no syndecan-1 mRNA was detectable by this method. Maximal levels of syndecan-2, -4, and FGFR1 mRNAs were observed on day 5. However, their levels were markedly decreased on days 20 and 25. Accordingly, the inhibitory effect of bFGF on ALPase activity was less on day 20 than on day 5. When PDL cells were pre-treated with heparitinase, a mitogenic response of PDL cells to bFGF was decreased. These observations indicate that PDL cells express syndecan-2, -4, and FGFR1 mRNAs, and that those levels are changed with the increase in ALPase activity in culture. The reductions in syndecan-2, -4, and FGFR1 levels may be involved in the control of growth and differentiation of PDL cells during development and regeneration.

Börjeson-Forssman-Lehmann syndrome in a woman with skewed X-chromosome inactivation

Börjeson-Forssman-Lehmann (BFL) syndrome is an X-linked recessive disorder characterized by minor facial anomalies, obesity, epilepsy, and severe mental retardation. The phenotype of male patients is usually severe, whereas that of carriers is less severe, suggesting X-linked incompletely recessive inheritance. A recent linkage study mapped the BFL syndrome gene to Xq26-q27. The etiology of the condition in female patients with full manifestations is not known, although nonrandom X-chromosome inactivation has been considered. We recently developed an assay for X-inactivation studies based on the methylation-specific polymerase chain reaction (PCR) technique. Using the methylation-specific PCR assay, a woman with typical findings of this syndrome was shown to have an extremely skewed X-inactivation pattern. This finding suggests that the full manifestations of the BFL syndrome in carriers may be caused by skewed X inactivation with a high proportion of cells in which the X chromosome with a normal gene be inactivated, leaving the X chromosome with a mutant gene active.

Inhibitory effects of activin-A on osteoblast differentiation during cultures of fetal rat calvarial cells

Activin-A is a member of the transforming growth factor-beta (TGF-beta) superfamily and is expressed by osteoblasts. However, the role of activin-A on osteoblasts is not clearly understood. We examined the effects of activin-A on osteoblast proliferation or differentiation, and mineralization by the osteoblasts in the first subcultures of fetal rat osteoblasts obtained from calvarial bones. Exogenous activin-A led to impaired formation of bone nodules in a dose-dependent manner, although it did not influence cell proliferation using an MTT assay. This inhibitory effect depended upon the time at which activin-A was added to the culture media, and the effect was most significant when addition took place at the early phase of the culture. In addition, exogenous activin-A inhibited gene expression of type I procollagen, alkaline phosphatase, osteonectin, and osteopontin in the cultured cells using Northern blot analysis. The peak of osteocalcin mRNA was delayed. Gene expression for TGF-beta was not influenced by exogenous activin-A. The betaA subunit (activin-A) mRNA was detected during the early phase of this culture. These results indicate that activin-A inhibited early differentiation of the fetal rat calvarial cells, or osteoblasts.

Inhibition of endochondral ossification during fracture repair in experimental hypothyroid rats

Using a rat fracture model, we investigated the effects of a decrease in serum levels of thyroid hormone on the fracture-repair process. Rats were divided into the following groups: (a) controls, (b) those treated with methimazole for the duration of the experiment, and (c) those treated with methimazole and L-thyroxine, receiving both for the same duration. Three weeks after the initiation of pharmacologic treatment, closed femoral fractures were produced. The formation of cartilage tissue in the fracture callus in all rats was not obviously different on day 7 after fracture. In the rats treated with methimazole, differentiation from proliferating to hypertrophic chondrocytes in the fracture callus was less advanced and vascular invasion was clearly inhibited on day 12. Gene expression of alkaline phosphatase and osteocalcin in the callus was significantly lower in these rats than in the controls on days 10, 12, and 14. The mechanical properties of the fracture callus were also significantly weaker in these animals than in the controls on day 21, resulting in impaired fracture repair. These results demonstrate that hypothyroidism inhibits endochondral ossification, resulting in an impaired fracture-repair process. L-thyroxine replacement in the rats treated with methimazole caused the impaired repair process to revert to normal. These results indicate that thyroid hormone is one of the critical systemic factors for fracture repair.

Estradiol enhances the production of mineralized nodules by human periodontal ligament cells

A primary objective in the treatment of periodontal disease is the regeneration of the mineralized and soft connective tissue. PDL cells produce mineralized nodules in vitro which is one of the important functions of PDL cells for regenerative therapy. The purpose of this study was to investigate the effects of estradiol on mineralized nodule formation by human PDL cells. PDL cells were obtained from healthy donors and maintained in DMEM with 10% fetal bovine serum. Serum-free medium was used when the effects of estradiol were tested. ALP activity in the supernatant of cells disrupted by sonication was analyzed spectrophotometrically. The formation of mineralized nodules was assessed by staining the PDL cells with alizarine red and counting the number of nodules. at Estradiol 20 ng/ml significantly enhanced the ALP activity and mineralized nodule formation compared to the control. These results suggested that estrogen status may modify the regenerative activity of periodontal tissue.

A clinicopathologic study of transient osteoporosis of the hip

OBJECTIVE

It has been proposed that transient osteoporosis of the hip (TOH) may represent the early reversible phase of osteonecrosis of the femoral head (ON). The purpose of this study was to investigate the clinicopathologic characteristics of three cases of TOH.

DESIGN AND PATIENTS

A bone biopsy was performed on three patients who had been diagnosed as having TOH based on the clinical course, radiograph, bone scintigram, and MR images. The biopsy specimens were studied histopathologically by light and electron microscopy.

RESULTS

The most characteristic feature of TOH was focal areas of thin and disconnected bone trabeculae covered by osteoid seams and active osteoblasts. The surrounding bone marrow tissue showed edematous changes and mild fibrosis, frequently associated with vascular congestion and/or interstitial hemorrhage. No osteonecrotic region was observed in either the bone trabeculae or the bone marrow tissue. All patients have improved clinically and in the 3.5-9 years of follow-up have shown no evidence of ON.

CONCLUSIONS

This study supports the concept that transient osteoporosis of the hip is a distinct entity.

Pilot study on the effect of a mouthrinse containing silver zeolite on plaque formation

A double-blind cross-over study was performed to evaluate the inhibitory activity of silver zeolite (SZ) mouthrinse on plaque formation. Eleven dental students participated in this study. SZ mouthrinse was prepared by suspending SZ powder into phosphate-buffered saline (PBS) at a concentration of 3% (w/w). Type-A zeolite was used as a placebo. Before the experiment, the subjects were rendered plaque-free by professional prophylaxis. They then suspended any oral hygiene for five days, during which time they rinsed with either SZ or type-A zeolite mouthrinse twice a day. SZ significantly reduced plaque formation compared to the placebo (p < 0.05), suggesting that silver ions released from the SZ inhibited plaque formation.

A new friction tester of the flexor tendon

We have developed a new device to measure the friction force and calculate the friction coefficient between a rabbit flexor tendon, a pulley and a proximal phalanx. The flexor digitorum fibularis tendon of a rabbit was taken intact with the proximal phalanx, and tendon pulleys were attached to both ends of the bone. Both ends of the tendon were clamped to acrylic plates and connected to stainless-steel plates equipped with strain gauges. A pretension of 1.96 N was applied so as not to loosen the tendon. The proximal phalanx was fixed to an acrylic plate on the actuator, which gave 8 mm of transfer to the acrylic plate at a speed of 2 mm/s. The interface between the tendon and the surrounded tissue created the friction force, when the load was applied on the distal pulley. The friction force could be obtained from the difference between the tension of both ends of the tendon, which was measured with strain gauges and sampled with a personal computer. The friction force and the friction coefficient were calculated from the measured force and the applied load. The load and the pre-loading time, which was defined as loading duration before gliding, were varied in order to observe the change of the friction coefficient. The friction coefficient was not affected by the load and increased with the pre-loading time. The value of mu(s) ranged from 0.027 to 0.111 (0.072 +/- 0.023), and that of (mu)d ranged from 0.010 to 0.069 (0.039 +/- 0.014) (pre-loading time was 5 s). Our method will allow for the examination of various surgical treatments and lubricants. Moreover, it can be applied to other tissues of any animals with similar structures to the rabbit's digitorum.

Expression of insulin-like growth factor I messenger ribonucleic acid in developing osteophytes in murine experimental osteoarthritis and in rats inoculated with growth hormone-secreting tumor

Osteophytes are one of the characteristic features of osteoarthritis and are often found in acromegalic arthropathy. The aim of this study was to investigate insulin-like growth factor I (IGF-I) involvement in osteophyte formation. One percent collagenase solution was injected into murine knee joints as an osteoarthritis model. In a different animal group, GH-secreting tumor cells were inoculated s.c. to the rat thigh as an acromegaly model. A series of osteophyte formation was examined histologically. IGF-I messenger RNA was detected using the in situ hybridization method. Type I IGF receptors were detected immunohistochemically. In the osteoarthritis model, osteophyte formation appeared as synovial or perichondral cell proliferation adjacent to the articular cartilage on day 5, followed by cartilage formation on day 7 and endochondral ossification on day 14. In the acromegaly model, synovial or perichondral cell proliferation was observed 4 weeks after inoculation, followed by osteophyte formation at 8 weeks. In both models, IGF-I messenger RNA and type I IGF receptor were coexpressed by proliferating synovial or perichondral cells, proliferating chondrocytes, and osteoblasts within the developing osteophytes. These results suggest that IGF-I regulated the initiation and development of osteophyte formation in both models in an autocrine and/or paracrine fashion.