[Case of frontal lobe epilepsy with gelastic seizures induced by emotion]

Gelastic seizures without hypothalamic hamartoma is a rare forms of epilepsy. Here, we report the case of 4-year-old girl with gelastic seizures. There was no delay in mental or motor development of the patient. The patient exhibited a peculiar seizure pattern that suddenly clung to her mother stiffening her body and an outburst of laughter with no apparent cause. The frequency of the seizures increased over a period of 1 month. Although the brain MRI and interictal EEG showed no abnormality, ictal EEG showed a 14 Hz wave discharge and subsequent slow-wave activity and suppression in bilateral frontal areas. The seizures responded favorably to oral administration of carbamazepine. The induction of the seizures could be related to theophylline administration and emotional excitation.

Tenascin‐C levels in pseudosynovial fluid of loose hip prostheses

OBJECTIVE

Aseptic loosening is one of the most important problems that can occur after total hip arthroplasty (THA). In this study, we analysed levels of large tenascin-C (TN-C) variants and compared them in pseudosynovial fluid from patients with aseptic loosening after THA with those in synovial fluid from patients undergoing primary THA (control).

METHODS

Pseudosynovial fluid samples (n = 24) were obtained by aspiration at the time of revision THA performed due to aseptic loosening. Synovial fluid samples (n = 12) were obtained by aspiration at the time of primary THA. Expression of TN-C splice variants was examined using immunoblotting. TN-C levels were measured using an enzyme-linked immunosorbent assay (ELISA) system that we developed previously.

RESULTS

Western blotting showed the presence of large TN-C variants in pseudosynovial fluid of artificial joints with loosening. TN-C levels were approximately three times higher in pseudosynovial fluid of loose artificial joints (median 151.9 ng/mL) than in synovial fluid controls (median 50.1 ng/mL) (p = 0.035).

CONCLUSION

Levels of TN-C including large variant subunits are elevated in pseudosynovial fluid of loose artificial joints, indicating that TN-C is a useful novel biochemical marker of loose hip prostheses.

Cabergoline Effectively Induced Remission of Prolactinoma in a 9-year-old Japanese Boy

Prolactinomas are rarely diagnosed in children under the age of 10. A 9-yr-old Japanese boy complained of severe headache and progressive visual disturbance. His growth had been retarded for approximately 3 yr, and his serum PRL level was 811.6 ng/ml. Brain magnetic resonance imaging (MRI) revealed an enlarged pituitary (2.8 × 2.6 × 2.1 cm) with heterogeneous enhancement. He was diagnosed as having a macroprolactinoma accompanied by pituitary apoplexy and growth hormone deficiency. A surgical approach was initially undertaken due to the progressive visual deficits, but a residual tumor was observed, and the level of serum PRL was still high after the surgery. Cabergoline was then started, and the dose was gradually increased to 1.5 mg/wk. The serum PRL level decreased from 138.8 ng/ml to 32.5 ng/ml and 17.7 ng/ml after 5 wk and 19 wk, respectively. At 33 wk of cabergoline treatment, brain MRI demonstrated no evidence of the residual tumor. Thereafter, the serum level of PRL decreased to less than 10 ng/ml, and remission was consistently confirmed on repeated MRI. No adverse events have been observed. The present case suggests that cabergoline can be an effective treatment for prolactinomas in prepubertal children as well as in adults.

Asymptomatic disseminated carcinomatosis of bone marrow presenting as hyperphosphatasia: report of a case

Metastatic involvement of the musculoskeletal system is one of the most significant clinical issues facing orthopaedic oncologists. The number of patients with metastasis to the skeletal system from a carcinoma is 15 times greater than the number of patients with primary bone tumours of all types. However, progression patterns like disseminated carcinomatosis of bone marrow are comparatively rare. The pathophysiology for disseminated carcinomatosis of bone marrow, with a prognosis reported to be very poor, is still unknown. We describe a patient who had no symptoms with hyperphosphatasia. Bone scintigraphy showed a so-called super bone scan and a needle biopsy from the ileum showed adenocarcinoma cells. Additional endoscopic investigation was performed and signet cell gastric cancer was found. From the bone scan and biopsy, we established the diagnosis of disseminated carcinomatosis of the bone marrow. From the experience of this case, we believe that intensive stomach investigation should be considered in cases with hyperphosphatasia, even when the patient has no symptoms.

Changes in biochemical markers and prediction of effectiveness of intra-articular hyaluronan in patients with knee osteoarthritis

OBJECTIVE

Intra-articular injection of hyaluronan (HA) is frequently used to treat knee osteoarthritis (OA). We studied whether HA injections induced significant changes in levels of biochemical markers in synovial fluid (SF). In addition, we investigated the possibility of predicting the effectiveness of HA based on these biochemical markers.

METHODS

Twenty-eight patients with knee OA underwent five weekly intra-articular injections of HA. Knee pain was measured on visual analog scale (VAS) before and after the five injections. Levels of biochemical markers, including chondroitin 6-sulfate (C6S), chondroitin 4-sulfate (C4S), keratan sulfate (KS), and tenascin-C (TN-C), were determined before and after the five injections. Correlations between the biochemical markers before HA injection and the improvement of VAS after the five injections were evaluated.

RESULTS

After HA injections, levels of C6S, C4S, and KS decreased significantly. Inverse correlations were observed between the levels of TN-C and C4S before HA injection and improvement of VAS after the five injections. In contrast, no significant correlation was seen between levels of C6S and KS before injections and improvement of VAS after the five injections.

CONCLUSION

The reduction in C6S, C4S, and KS levels after HA injections reflects that HA could help maintain normal cartilage metabolism. Our findings suggest that HA injections are effective in patients whose knees contain low levels of TN-C and C4S, reflecting an early stage of OA and limited synovitis.

A Japanese patient of congenital hypothyroidism with cerebellar atrophy

We encountered a Japanese patient of congenital hypothyroidism with severe cerebellum atrophy. The boy was born after 40 weeks of gestation by normal vaginal delivery from nonconsanguineous parents. There were no abnormal physical findings; however neonatal mass screening for congenital hypothyroidism at 5 days of age demonstrated elevated thyrotropin (TSH) level (15.5 microU/ml, normal range 0.54-10.0 microU/ml). He was suspected to have subclinical or mild congenital hypothyroidism (CH). Thus he was treated with L-thyroxine using a regimen that rendered his serum TSH concentration within normal range from 27 days of age. Despite early and adequate treatment, he showed signs of global developmental delay and became gradually hypotonic and exhibited a staggering gait at 3 years of age. Brain magnetic resonance imaging (MRI) demonstrated marked cerebellar atrophy with an intact brainstem. Thyroidal uptake of radioiodide and thyroid gland size were normal, indicating a functional defect only. The relation between congenital hypothyroidism and severe cerebellar atrophy in our patient is not clear. As only a few cases of the combination of CH and cerebellar anomalies have been described previously, cerebellar symptoms in CH should be examined carefully.

Aberrant somatosensory-evoked responses imply GABAergic dysfunction in Angelman syndrome

A role for gamma-aminobutyric acid (GABA)ergic inhibition in cortical sensory processing is one of the principle concerns of brain research. Angelman syndrome (AS) is thought to be one of the few neurodevelopmental disorders with GABAergic-related genetic involvement. AS results from a functional deficit of the imprinted UBE3A gene, located at 15q11-q13, resulting mainly from a 4-Mb deletion that includes GABA(A) receptor subunit genes. These genes are believed to affect the GABAergic system and modulate the clinical severity of AS. To understand the underlying cortical dysfunction, we have investigated the primary somatosensory-evoked responses in AS patients. Subjects included eleven AS patients with a 15q11-q13 deletion (AS Del), two AS patients without a 15q11-q13 deletion, but with a UBE3A mutation (AS non-Del), six epilepsy patients (non-AS) and eleven normal control subjects. Somatosensory-evoked fields (SEFs) in response to median nerve stimulation were measured by magnetoencephalography. The N1m peak latency in AS Del patients was significantly longer (34.6+/-4.8 ms) than in non-AS patients (19.5+/-1.2 ms, P<0.001) or normal control subjects (18.4+/-1.8 ms, P<0.001). The next component, P1m, was prolonged and ambiguous and was only detected in patients taking clonazepam. In contrast, SEF waveforms of AS non-Del patients were similar to those of control individuals, rather than to AS Del patients. Thus, GABAergic dysfunction in AS Del patients is likely due to hemizygosity of GABA(A) receptor subunit genes, suggesting that GABAergic inhibition plays an important role in synchronous activity of human sensory systems.

Possible involvement of the tip of temporal lobe in Landau-Kleffner syndrome

Landau-Kleffner syndrome (LKS) is a childhood disorder of unknown etiology characterized by an acquired aphasia and epilepsy. We have performed comprehensive neurofunctional studies on an 8-year-old girl with typical LKS, with the aim of identifying lesions that may be responsible for her condition. 18F-fluoro-D-glucose (FDG) positron emission computed tomography (PET), 11C-Flumazenil (FMZ) PET, 99mTc-hexamethylpropyleneamine oxime single photon emission computed tomography (SPECT) and magnetoencephalography were performed before and after changes to the patient's medication led to a clinical improvement. Interictal SPECT showed hypoperfusion in the left frontal, left temporal, and left occipital lobes. 18F-FDG PET demonstrated a decrease in glucose metabolism medially in both temporal lobes and superiorly in the left temporal lobe. 11C-FMZ PET revealed a deficit in benzodiazepine receptor binding at the tip of the left temporal lobe. Magnetoencephalography demonstrated equivalent current dipoles located superiorly in the left temporal lobe. Our results suggest that the tip of the left temporal lobe plays an important role in the pathogenesis of LKS in our patient.

Large-scale gene expression profiles, differentially represented in osteoarthritic synovium of the knee joint using cDNA microarray technology

Osteoarthritis (OA) is one of the most common age-related chronic disorders of articular cartilage, joints and bone tissue. Diagnosis of OA commonly depends on clinical and radiographic findings. However, changes in cartilage associated with the early stage of OA cannot be detected using radiographs, because significant cartilage degeneration must occur before radiographic findings show alterations of the appearance of cartilage. To identify new biomarkers of OA, we analysed gene expression profiles of synovium from 43 patients with OA, ten patients with rheumatoid arthritis (RA), and eight non-OA/non-RA patients using a novel cDNA microarray chip. We identified 21 genes with simultaneous significant differences in expression between OA and non-OA/non-RA groups and between OA and RA groups. Linear discriminant analysis showed that the three groups could be well separated using those 21 genes. Statistical analysis also revealed that several of the 21 genes were associated with disease progression and clinical presentation. The graphical modelling method indicated that some of the 21 genes are significantly associated with a particular clinical presentation, suggesting biological relationships among those genes. This is the first report of the use of cDNA microarray technology to create large-scale gene expression profiles differentially expressed in situ in OA synovium of the knee joint.

Osteonecrosis of the femoral head caused by bone marrow blockage: a case report

Interruption of the blood flow may occur in intra-osseous arteries within the femoral head. We report a 72-year-old woman who developed osteonecrosis of the femoral head 11 months after surgery involving massive cementing of a segmental distal femoral rotating hinge prosthesis to treat nonunion of the distal femur. The bone cement filled the cavity up to the femoral neck and the superolateral portion of the femoral head, blocking the bone marrow.

Changes in bone mineral density in transient osteoporosis of the hip

Transient osteoporosis of the hip is a disorder characterised by pain, and associated with temporary osteopaenia. Although osteopaenia is the essence of the condition, data do not exist about the local bone density of the femoral neck if no medication is administered. We describe three patients who were treated with limitation of weight-bearing only. Repeated bone mineral density measurements were obtained, and that at the femoral neck was lowest two months after the onset of the condition. The mean reduction in bone mineral density when compared with an age-matched control group was 13% (3% to 24%). Spontaneous recovery was observed in all patients.

Alumina ceramic-on-ceramic total hip replacement with a layered acetabular component

A modular layered acetabular component (metal-polyethylene-ceramic) was developed in Japan for use in alumina ceramic-on-ceramic total hip replacement. Between May 1999 and July 2000, we performed 35 alumina ceramic-on-ceramic total hip replacements in 30 consecutive patients, using this layered component and evaluated the clinical and radiological results over a mean follow-up of 5.8 years (5 to 6.5). A total of six hips underwent revision, one for infection, two for dislocation with loosening of the acetabular component, two for alumina liner fractures and one for component dissociation with pelvic osteolysis. There were no fractures of the ceramic heads, and no loosening of the femoral or acetabular component in the unrevised hips was seen at final follow-up. Osteolysis was not observed in any of the unrevised hips. The survivorship analysis at six years after surgery was 83%. The layered acetabular component in our experience, has poor durability because of unexpected mechanical failures including alumina liner fracture and component dissociation.

Diffusion MRI abnormalities after prolonged febrile seizures with encephalopathy

BACKGROUND

Patients with encephalopathy heralded by a prolonged seizure as the initial symptom often have abnormal subcortical white matter on diffusion-weighted MRI (DWI).

OBJECTIVE

To determine if these patients share other common features.

METHODS

Patients with encephalopathy heralded by a prolonged seizure and followed by the identification of abnormal subcortical white matter on MRI were collected retrospectively. Their clinical, laboratory, and radiologic data were reviewed.

RESULTS

Seventeen patients were identified, ages 10 months to 4 years. All had a prolonged febrile seizure (longer than 1 hour in 12 patients) as their initial symptom. Subsequent seizures, most often in clusters of complex partial seizures, were seen 4 to 6 days after the initial seizure in 16 patients. Outcome ranged from almost normal to severe mental retardation. MRI performed within 2 days of presentation showed no abnormality. Subcortical white matter lesions were observed on DWI between 3 and 9 days in all 17 patients. T2-weighted images showed linear high intensity of subcortical U fibers in 13 patients. The lesions were predominantly frontal or frontoparietal in location with sparing of the perirolandic region. The diffusion abnormality disappeared between days 9 and 25, and cerebral atrophy was detected later than 2 weeks. Three patients having only frontal lesions had relatively good clinical outcome.

CONCLUSIONS

Although the pathophysiologic mechanism remains unknown, these patients seem to have a distinctive encephalopathy syndrome. MRI is helpful in establishing the diagnosis of this encephalopathy.

Elevated levels of soluble fibrin or D-dimer indicate high risk of thrombosis

BACKGROUND

Fibrin-related markers such as soluble fibrin (SF) and D-dimer are considered useful for the diagnosis of thrombosis. However, the evidence for diagnosis of thrombosis by fibrin-related markers is not well-established.

OBJECTIVE

To evaluate the cutoff values of D-dimer and SF in the diagnosis of thrombosis.

PATIENTS AND METHODS

Plasma concentrations of SF and D-dimer were measured in 784 inpatients suspected of having thrombosis between 1 August 2003 and 31 December 2004, and then correlated with thrombosis.

RESULTS AND CONCLUSIONS

Plasma concentrations of D-dimer and SF were significantly higher in patients with disseminated intravascular coagulation (DIC), deep vein thrombosis (DVT) and cerebral thrombosis, compared with those in patients without thrombosis. When cutoff values of > 3.0 microg mL(-1) for D-dimer and > 6.0 microg mL(-1) for SF were used for the diagnosis, more than 50% of patients (with the exception of liver transplant patients and postoperative patients) had thrombosis. Receiver operating characteristic analysis showed that SF was more useful than D-dimer for the diagnosis of thrombosis (i.e. DVT and DIC). The cutoff value of D-dimer (7.87 microg mL(-1)) was the same for DVT and DIC, while that of SF was slightly lower for DVT (7.05 microg mL(-1)) than for DIC (8.60 microg mL(-1)). Our findings suggest that high levels of plasma fibrin-related markers reflect high risk for thrombosis.

Prevalence of osteoarthritis, osteoporotic vertebral fractures, and spondylolisthesis among the elderly in a Japanese village

PURPOSE

To study the prevalence of osteoarthritis, osteoporotic vertebral fractures, and spondylolisthesis among elderly residents of a Japanese village and to examine the correlation between radiographic evidence of abnormality and lower back pain.

METHODS

205 men (mean age, 70.7 years) and 323 women (mean age, 70.5 years) in a Japanese village participated in this cross-sectional study. Plain lateral radiographs were taken from the lower thoracic spine to the sacral spine. They were evaluated by 3 independent orthopaedic surgeons for degree of osteoarthritis (using Weiner grading system) and the presence of osteoporotic vertebral fractures and spondylolisthesis.

RESULTS

The prevalence of osteoarthritis in elderly Japanese villagers was 38.3%, whereas that of osteoporotic vertebral fractures and spondylolisthesis was 17.8% and 8.9%, respectively. There was no significant difference in osteoarthritis between men and women, but osteoporotic vertebral fractures and spondylolisthesis were significantly more common in females (p<0.01). No significant correlation was observed between lower back pain and radiographic evidence of degenerative spinal disease.

CONCLUSION

The prevalence of spondylolisthesis in elderly Japanese was much lower than that in whites or African Americans. The prevalence of osteoarthritis or osteoporotic vertebral fractures was comparable with other English or US studies. Radiographic evidence of osteoarthritis, osteoporotic vertebral fractures, and spondylolisthesis is not necessarily associated with lower back pain.

An infantile-juvenile form of Alexander disease caused by a R79H mutation in GFAP

Alexander disease is a degenerative white matter disorder due to mutations in the glial fibrillary acidic protein (GFAP) gene. It has been classified into three forms based on the age of onset and severity: an infantile, a juvenile, and an adult form. In a 6-year-old patient with a relatively mild form of Alexander disease, we detected a common R79H mutation in GFAP, previously only described in the infantile form. These results suggest the need for further studies of the genotype-phenotype correlation.

Cochlear damage due to germanium-induced mitochondrial dysfunction in guinea pigs

This investigation addressed the effect of germanium dioxide (GeO(2))-induced mitochondrial dysfunction on hearing acuity. Guinea pigs were fed chow that contained 0%, 0.15%, or 0.5% GeO(2). The animals that were fed 0.5% GeO(2) for 2 months developed hearing impairment chiefly due to degeneration of stria vascularis and cochlear supporting cells, which exhibited electron-dense mitochondrial inclusions. Cytochrome c oxidase activity was decreased in the skeletal muscles and kidney, which also exhibited electron-dense mitochondrial inclusions. No apparent pathological changes were observed in the utricle, semicircular canal, or among the vestibular nerve fibers, or in the liver or heart. The untreated animals and those treated with 0.15% GeO(2) did not exhibit hearing impairment or pathological changes in any organs. These findings suggest that administration of 0.5% GeO(2) induces mitochondrial dysfunction in the stria vascularis and supporting cells in the cochlea, as in the skeletal muscles and kidney, thereby causing hearing impairment in the guinea pigs.

Uniparental disomy and imprinting defects in Japanese patients with Angelman syndrome

We examined 54 patients with deletion-negative Angelman syndrome (AS) using DNA methylation testing and microsatellite polymorphism analysis, and identified three patients with paternal uniparental disomy (UPD) and seven patients with imprinting defects (ID). The three patients with UPD were shown to have paternal isodisomy 15, which we hypothesized to have arisen from duplication of chromosome 15. Two of the patients with ID were siblings and carried microdeletions of the imprinting center (IC), while the remaining five patients had no evidence of deletions and represented sporadic cases. Two of the three patients with UPD and two of the seven patients with ID had not developed seizures. The only patients displaying microcephaly were those with ID who had microdeletions at the IC. These data support the previous findings that indicate that patients with UPD and ID may have a milder phenotype of AS.

Microvascular density of rapidly destructive arthropathy of the hip joint

PURPOSE

To assess the vascularity of the femoral head and determine how it is related to the destruction of the arthritic hip joint. The process of destructive arthropathy in arthritic hip joints is variable. Some patients with osteoarthritis of the hip have rapidly progressive destructive changes resulting in the disappearance of the femoral head.

METHOD

Six femoral heads from patients diagnosed with rapidly destructive arthropathy and 6 femoral heads from patients with secondary osteoarthritis caused by acetabular dysplasia were analysed to reveal the association between blood capillaries and osteoclasts. The von Willebrand Factor immunostaining and counterstaining with Mayer's haematoxylin were used to label the microvessels and osteoclasts in formalin-fixed, paraffin-embedded specimens of femoral heads. The numbers of immunostained microvessels and osteoclasts in selected regions were counted.

RESULT

The microvascular density of the bone surfaces of rapidly progressive arthritic hips was hypervascular. Osteoclasts were also found in increased numbers on the bone surfaces of rapidly progressive arthritic hips. The higher microvascular density coincided with extensive bone destruction and with the increased osteoclast count.

CONCLUSION

These findings suggested that hypervascularity of the granulation in the femoral head may be associated with bone and joint destruction.

Dynamic statistical parametric mapping for analyzing the magnetoencephalographic epileptiform activity in patients with epilepsy

Our current purpose is to evaluate the applicability of dynamic statistical parametric mapping, a novel method for localizing epileptiform activity recorded with magnetoencephalography in patients with epilepsy. We report four pediatric patients with focal epilepsies. Magnetoencephalographic data were collected with a 306-channel whole-head helmet-shaped sensor array. We calculated equivalent current dipoles and dynamic statistical parametric mapping movies of the interictal epileptiform discharges that were based in the minimum-L2 norm estimate, minimizing the square sum of the dipole element amplitudes. The dynamic statistical parametric mapping analysis of interictal epileptiform discharges can demonstrate the rapid change and propagation of interical epileptiform discharges. According to these findings, specific epileptogenic lesion-focal cortical dysplasia could be found and patients could be operated on successfully. The presurgical analysis of interictal epileptiform discharges using dynamic statistical parametric mapping seems to be promising in patients with a possible underlying focal cortical dysplasia and might help to guide the placement of invasive electrodes.

Leigh syndrome caused by mitochondrial DNA G13513A mutation: frequency and clinical features in Japan

The mitochondrial DNA (mtDNA) G13513A mutation in the ND5 subunit gene has been recently reported as a common cause of some phenotypes of mitochondrial myopathy. Until now, the prevalence and characteristics of this mutation in Leigh syndrome (LS) has not been determined. We screened 84 patients with Leigh syndrome (LS) and found the mutation in six (7%) of them. The proportions of mutant mtDNA in muscles were relatively low (42-70%). The onset of symptoms for patients with this mutation was from 9 months to 5 years. It should be noted that five patients had cardiac conduction abnormalities, particularly Wolff-Parkinson-White (WPW) syndrome (three patients). This study suggests that G13513A mutation is a frequent cause of LS and that patients with this mutation may have a characteristic clinical course.

The incidence of deep vein thrombosis after hip and knee arthroplasties in Japanese patients: a prospective study

PURPOSE

To document the incidence of proximal deep vein thrombosis and pulmonary embolism in 58 consecutive Japanese patients undergoing total hip arthroplasty or total knee arthroplasty.

METHODS

Patients were routinely examined for proximal deep vein thrombosis by B-mode ultrasonography before and after surgery. Those patients who had ultrasonographic findings of deep vein thrombosis were also investigated for pulmonary embolism by ventilation-perfusion lung scan.

RESULTS

The incidence of deep vein thrombosis after total hip arthroplasty and total knee arthroplasty were 9.1% and 4.0% respectively, and the incidence of pulmonary embolism were 3.0% and 0%, respectively. There were no cases of fatal pulmonary embolism.

CONCLUSION

The incidence of deep vein thrombosis and pulmonary embolism in Japanese patients may have increased over the last few decades.

Congenital monomelic neurogenic disorder with calf muscle hypertrophy

An 8-year-old girl had hypertrophy of the right calf muscle since birth, with progressive ankle contracture and mild muscle weakness. Her right leg was 3 cm shorter than her left. Electromyography and biopsy of the affected muscle showed neurogenic changes. She also had neurogenic bladder and spina bifida occulta at the S1 level. We believe that the spina bifida was responsible for the neurogenic changes in her right calf, but could not find definite evidence for this association. Although cases with neurogenic muscle hypertrophy, especially calf muscle hypertrophy, have been reported, none of them was congenital or associated with spina bifida occulta.

High uptake on 11C-methionine positron emission tomographic scan of basal ganglia germinoma with cerebral hemiatrophy

We herein describe a 12-year-old male patient with a germinoma of the basal ganglia who presented with progressive hemiparesis. MR imaging showed ipsilateral cerebral hemiatrophy predominantly in the left basal ganglia, whereas no mass or enhancement was depicted. Single photon emission CT revealed no significant uptake of thallium, whereas (11)C-methionine positron emission tomography showed clearly discernible uptake in the left putamen. Stereotactic biopsy, referencing the results of (11)C-methionine positron emission tomography, was performed, allowing histologic verification of germinoma to be established. (11)C-methionine positron emission tomography was the only technique that indicated the precise localization of the tumor in our patient and enabled biopsy-based final diagnosis of the basal ganglia germinoma without any overt mass formation.

Comparison of bone mineral density among residents of a mountain village and a fishing village in Japan

OBJECTIVE

To compare the bone mineral density of residents of a mountain village with that of residents of a fishing village in Mie Prefecture, Japan.

METHODS

Microdensitometry was used to measure bone mineral density of the second metacarpal bone of 202 participants living in a mountain village and of 852 participants living in a fishing village to identify contributory factors for osteoporosis. The participants were interviewed using a questionnaire on alcohol consumption, fish intake, milk intake, and daily activity.

RESULTS

Analysis of covariance revealed that bone mineral density was significantly higher among the participants living in a fishing village than among those living in a mountain village (2.5-2.9 versus 2.1-2.7 mmAl; p<0.001). A higher proportion of women in the fishing village than of those in the mountain village consumed alcohol (17% versus 10%; p<0.05).

CONCLUSION

Nutrition may be a contributory factor to the lower incidence of osteoporosis among residents of the fishing village compared with those of the mountain village.

Cerebellar and brainstem involvement in familial juvenile nephronophthisis type I

We report on an 11-year-old boy with familial juvenile nephronophthisis type I associated with cerebellar ataxia and nystagmus, but not with ocular motor apraxia. An MRI revealed hypoplasia of the brainstem and vermis, and an enlargement of the fourth ventricle. A molecular genetic analysis demonstrated a homozygous deletion including the NPHP1 gene. These findings suggest that NPHP1 may play an important role in the normal development of the brainstem and the cerebellum as well as renal tissue.

Germline mosaicism of a novel mutation in lysosome-associated membrane protein-2 deficiency (Danon disease)

We identified a family with lysosome-associated membrane protein-2 deficiency (Danon disease) associated with a novel 883 ins-T mutation in the lysosome-associated membrane protein-2 gene located at Xq24. Although the affected son and daughter carried the same mutation, it was not detected in their mother's peripheral blood or buccal cells; this indicated germline mosaicism. This is the first molecular evidence for germline mosaicism in Danon disease and has important implications for genetic counseling.

[Overlap syndrome of systemic lupus erythematosus and dermatomyositis presented a large demyelinating subcortical lesion mimicking brain tumor and high level of CSF antineuronal and serum anti-ribosomal P antibodies]

We reported a 50-year-old man with an overlap syndrome of dermatomyositis and SLE, whose magnetic resonance image of the brain showed a rapidly increasing large tumor-like focal lesion unequally enhanced by Gd-DTPA in the left frontal lobe. Its pathological finding by the brain biopsy was fibrinoid necrosis, inflammatory cell aggregation around blood vessels and many myelin-laden macrophages with central necrosis. Although many cases of blood vessel injury are reported in CNS lupus, in this case the brain lesion partly took reversible course and neural symptoms such as paresis were slight and the lesion well responded to steroid. Moreover we considered that the measurement of serum anti-ribosomal P and CSF antineuronal antibodies are useful to diagnose cases as CNS lupus.

Autoantibodies to osteopontin in patients with osteoarthritis and rheumatoid arthritis

OBJECTIVE

Osteopontin (OPN), secreted mainly from chondrocytes, is suggested to be involved in the ossification and remodeling of bone and also in regulation of cytokine profiles. We investigated whether patients with osteoarthritis (OA) and rheumatoid arthritis (RA) display autoimmunity against OPN.

METHODS

Recombinant human OPN (rhOPN) was prepared as a fusion protein with beta-galactosidase using E. coli. Serum samples from patients with OA or RA and from age matched healthy donors were tested for autoantibodies to rhOPN using ELISA and Western blotting. Reactivity of the same samples to purified native human OPN (nhOPN) was investigated by ELISA separately, to evaluate conformational epitopes.

RESULTS

By ELISA, autoantibodies to rhOPN were found in one (0.95%) of 105 patients with OA and 2 (2.3%) of 88 patients with RA. These autoantibodies to rhOPN were confirmed by Western blotting. In contrast, 11 (9.5%) of 105 OA serum and 13 (15%) of 88 RA serum samples reacted to nhOPN. The anti-OPN positive RA patients showed high serum levels of rheumatoid factor and C-reactive protein and accelerated erythrocyte sedimentation rate compared to the anti-OPN negative group, although the differences did not achieve statistical significance.

CONCLUSION

Our data showed that OPN is one of the autoantigens in OA and RA. Preferential recognition of nhOPN to rhOPN indicates that major epitope(s) of OPN would be conformational. Clinically, existence of the anti-OPN antibodies may be linked to disease severity in RA.

Induction of c-Src in human blood monocytes by anti-CD98/FRP-1 mAb in an Sp1-dependent fashion

Freshly isolated human blood monocytes expressed neither c-src mRNA nor c-Src. However, when monocytes were incubated with anti-CD98 heavy chain (HC) mAb, expression of c-src mRNA, c-Src, and activated c-Src was induced. Many binding sites for the ubiquitous transcription factor Sp1 were identified in the promoter region of the c-src gene. Surprisingly, Sp1 and Sp1 mRNA were not found in monocytes that were freshly isolated or incubated with control antibody. Stimulation with anti-CD98HC mAb also resulted in the expression of Sp1 and its translocation to the nucleus. Herbimycin A, genistein, manumycin A, PD-98059, SB203580, and HBJ127 suppressed CD98HC-mediated c-src and Sp1 mRNA induction. On the contrary, H-7, Wortmannin, HA1077, and Y-27632 showed no effect on c-Src and Sp1 induction. Furthermore, anti-CD98HC mAb induced activation of tyrosine kinases and ERK kinases. These findings suggest that the tyrosine kinase(s)-Ras-MAPK-Sp1 pathway(s) is involved in CD98HC-mediated induction of c-Src in human blood monocytes.

[Serum anti-arrestin antibody and disease activity of multiple sclerosis--a case report of 4-year-old child]

We report a 4-year-old girl with multiple sclerosis (MS) and increased serum anti-arrestin antibody. She was admitted to our hospital because of sustained fever, headache and anorexia. Serial magnetic resonance imaging (MRI) revealed diffuse high intensity of cerebral white matter and basal ganglia on T2-weighted imaging. We treated her with high-dose intravenous methylprednisolone under a diagnosis of ADEM. She recovered without any neurological sequelae in three months and the MRI lesion almost disappeared. However, she developed optic neuritis and two episodes of neurologic involvement associated with multiple white matter lesions in the next two years. She was then diagnosed as having clinically definite MS. Anti-arrestin antibody is reportedly present specifically in adult patients with MS and uveitis. We performed an immunoblot assay using bovine retina, and our case revealed the presence of anti-arrestin antibody. Serial examinations showed that the serum anti-arrestin antibody titer correlated well with the disease activity. These results indicate that anti-arrestin antibody may be a good parameter of the disease activity of MS even in childhood.

Spindle-shaped cells derived from giant-cell tumor of bone support differentiation of blood monocytes to osteoclast-like cells

Spindle-shaped cells were established from four giant-cell tumors of bone. When human blood monocytes were co-cultured with these cells, multinucleated giant-cell formation of monocytes was induced. Intriguingly, even when a filter (pore size: 0.45 microm) was interposed between monocytes and the spindle-shaped cells, polykaryocytes also appeared. These multinucleated giant cells were positive for tartrate-resistant acid phosphatase, expressed calcitonin receptor, and showed bone-resorption activity, characteristics of osteoclast-like cells. These findings indicate that soluble factors secreted from these cells play an important role in osteoclast-like cell formation from blood monocytes. These data additionally suggest that these cells support osteoclast-like cell formation in giant-cell tumors of bone. The cells also expressed mannose receptor, fibronectin, receptor activator of nuclear factorkappaB, and several cytokine mRNAs, including interleukin-6, receptor activator of nuclear factorkappaB ligand/osteoclast differentiation factor/osteoprotegerin ligand, and macrophage colony-stimulating factor. However, all of these molecules except receptor activator of nuclear factorkappaB ligand mRNA could also be detected in control HeLa and CV-1 cells. Although the soluble receptor activator of nuclear factorkappaB ligand has not been found under physiological conditions, it is possible that it is cleaved by cellular proteases and the truncated receptor activator of nuclear factorkappaB is released from cells. Identification of the soluble factors capable of inducing osteoclast formation from blood monocytes is a pressing problem to be solved.

[Improvement of obstructive sleep apnea by uvulopalatopharyngoplasty and tonsillectomy in a case of Duchenne muscular dystrophy]

A 10-year-old boy with Duchenne muscular dystrophy (DMD) underwent uvulopalatopharyngoplasty and tonsillectomy for obstructive sleep apnea (OSA). He has snored loudly during nocturnal sleep since infancy, and OSA developed one and a half years after he was wheel chair-bound at 8 years. Magnetic resonance imaging (MRI), conventional spirometry and overnight polysomnography were performed before and after the surgery. MRI before surgery revealed moderate tonsillar hypertrophy and a long uvula which narrowed the upper airway. After the surgery, his vital capacity (VC) was not changed (% VC; from 77 to 78%), but forced expiratory volume (FEV) was improved (FEV 1.0%; from 75 to 86%). A preoperative apnea index of 32.8/hour decreased to 0.8/hour postoperatively. REM-related falls in HbSaO2 improved remarkably. The present case suggests that subjects with DMD with tonsillar hypertrophy and a redundant uvula tend to develop noctrurnal OSA earlier than DMD cases with a normal tonsil and uvula. Assessment of respiratory function, particularly FEV 1.0%, is important for determining surgical indication of OSA in patients with DMD.

Ability of osteoclast formation from peripheral monocytes using anti-fusion regulatory protein-1/CD98/4F2 monoclonal antibodies in patients with osteoporosis

We investigated the difference in osteoclast formation between patients with osteoporosis and two healthy control groups by inducing it from peripheral blood monocytes with use of anti-fusion regulatory protein- monoclonal antibody. The group of patients with osteoporosis consisted of 35 women and excluded secondary osteoporosis, and the control groups consisted of 12 young healthy volunteers (control I) or 10 individuals age-matched to the patients with osteoporosis (control II). Osteoclast formation declined with age between the two control groups, but this decline was not significant. Fusion rate and the mean number of nuclei in osteoclasts were significantly less in the patients with osteoporosis than in the young or age-matched controls. It was clearly demonstrated that the ability of monocytes to fuse declines significantly in patients with osteoporosis.

Biological performance of a three-dimensional fabric as artificial cartilage in the repair of large osteochondral defects in rabbit

A new artificial cartilage [A three-dimensional fabric (3-DF) comprising ultra-high molecular weight polyethylene fiber with a triaxial three-dimensional structure and coated with hydroxyapatite] was used to repair large osteochondral defects in rabbit knees. The knees with the 3-DF implanted in the osteochondral defects were evaluated 2-24 weeks after the operation macroscopically and microscopically. The 3-DF coated with hydroxyapatite was fixed firmly to the subchondral bone with the newly formed bone into and around the 3-DF. Hyaline-like cartilage was formed to a certain extent on the surface of the 3-DF, and the surface damage of the patella opposed to the 3-DF was minimal. In addition, the 3-DF caused no adverse effects such as particle disease, infection or severe synovitis during the experimental period. Consequently, the 3-DF seems to have successful biocompatibility in this rabbit experiment.

Gene expression during osteoclast-like cell formation induced by antifusion regulatory protein-1/CD98/4F2 monoclonal antibodies (MAbs): c-src is selectively induced by anti-FRP-1 MAb

Human blood monocytes can differentiate into osteoclast-like cells when they are cultured in the presence of anti-FRP-1. Messenger (mRNA) expression of markers related to osteoclasts was analyzed during differentiation of osteoclasts from monocytes. As markers related to osteoclasts, we selected cathepsin-K, carbonic anhydrase (CA) II, vacuolar H(+)-ATPase (v-ATPase), vitronectin receptor (VNR), tartrate-resistant acid phosphatase (TRAP), osteopontin (OPN), galectin-3, c-src, c-fos, and c-fms. The mRNAs other than c-src mRNA were expressed in freshly isolated monocytes or monocytes incubated with control antibody or anti-FRP-1 monoclonal antibody (MAb) for 14 days. Of these mRNAs, cathepsin-K, CA II, v-ATPase, VNR, TRAP, OPN, and c-fms mRNAs were expressed at higher levels in the osteoclast-like cells than those in monocytes cultured with control antibody. On the other hand, galectin-3 mRNA was expressed at lower levels in the osteoclast-like cells, and there was no significant difference in c-fos mRNA expression between the monocytes cultured with control antibody and anti-FRP-1 MAb. c-src mRNA could not be detected in monocytes freshly isolated or incubated with control antibody. Surprisingly, expression of c-src mRNA was induced in monocytes by anti-FRP-1 MAb and was detectable as early as 3 h after anti-FRP-1 MAb treatment, indicating that c-src is selectively induced by anti-FRP-1 MAb treatment. Furthermore, the osteoclast-like cells expressed calcitonin receptor. Receptor activator of NF-kappaB (RANK) mRNA was detectable in freshly isolated monocytes or monocytes cultured with control antibody or anti-FRP-1 MAbs. Maximal expression of RANK was observed in osteoclast-like cells. On the other hand, no receptor activator of NF-KB ligand (RANKL) mRNA was detectable in any of the samples, suggesting that anti-FRP-1 mAb can induce osteoclast-like cells from blood monocytes without RANKL.

[Intramedullary metastasis of small cell lung cancer]

A 64-year-old man complaining of hoarseness received a diagnosis of small cell lung cancer (T4 N3 M1, Stage IV) in May 1997. He responded well to chemotherapy and radiotherapy, and afterward underwent brain irradiation for prophylactic purposes. However, on Nov. 27 the patient experienced lumbar pain and numbness in his left leg. and was admitted to our hospital on Dec. 2 because his symptoms deteriorated to palsy of the left leg. Brain computed tomographic scans and lumbar magnetic resonance imaging (MRI) were normal, as was serum pro-GRP. Palsy developed in both legs 3 days later. T2 weighted MRI revealed high intensity within the spinal cord at the level between Th 9 and Th 11, and T1 weighted MRI showed heterogeneous low intensity at the same levels. In addition, Gd-DTPA enhanced T1 weighted images disclosed high intensity in the spinal cord at the Th 10 level. Although 3 spinal taps were all cytologically negative for malignancy, the high pro-GRP titer (1,400 pg/ml) suggested the presence of a carcinomatous lesion. At autopsy, cross sections of the spinal cord revealed the longitudinal extension of a tumor 11 cm in length. Microscopic findings indicated that the tumor was a metastasis of the patient's small cell carcinoma. To our knowledge, this report was the first to histologically examine a case of intramedullary metastasis of small cell lung cancer.

Urinary and salivary stress hormone levels while performing arithmetic calculation in a noisy environment

The effects of environmental conditions on stress responses to mental work, were examined by measuring urinary catecholamine and cortisol excretion and salivary cortisol concentrations before, during and after an arithmetic calculation task under 90 dB(A) white noise and quiet conditions. Adrenaline excretion increased similarly during the task under both environmental conditions. The salivary cortisol level was significantly higher than the pre-task level during the task with noise, but not under quiet, conditions. The subjects reported that they felt more irritable when performing the task with noise, than under quiet conditions. The results suggest that environmental conditions may affect on the pattern of hormonal response to mental work, which may be related to psychological states of the subjects.

Induction of human osteoclast-like cells by treatment of blood monocytes with anti-fusion regulatory protein-1/CD98 monoclonal antibodies

We have developed a new and simple system of human osteoclast formation by fusing peripheral blood monocytes with anti-Fusion Regulatory Protein-1 (anti-FRP-1) monoclonal antibody (mAb). When human blood monocytes were cultured in the presence of anti-FRP-1/CD98 mAbs, polykaryocytes began to appear at approximately 15 h and increased in size with time until 3-4 days of incubation with anti-FRP-1 mAb. These fused cells showed positive staining in tartrate-resistant acid phosphatase, possessed numerous calcitonin receptors, and were capable of bone resorption. These results strongly suggest that anti-FRP-1 antibody-induced multinucleated cells are osteoclasts. Furthermore, FRP-1 antigens were detected in osteoclasts isolated from human bone and in the osteoclast-like cells obtained from human giant cell tumors of bone.

Noise levels and hearing ability of female workers in a textile factory in Vietnam

Noise and hearing ability profiles were determined in a textile factory in Vietnam. Noise mapping done in the weaving section showed that the noise levels exceeded the Vietnamese standard of 90 dBA by as much as 9 dBA in some areas. Audiometric tests performed on 69 female workers from the weaving section revealed that workers with more than 10 years of noise exposure had the worst hearing threshold levels at 1,000 and 4,000 Hz. Similar findings were observed for workers greater than 35 years old. The 4,000 Hz notch, suggestive of exposure to intense noise, was noted in the audiograms of 26 subjects.

Commitment of motoneuron progenitors of chick embryo along the anterior-posterior axis

To identify molecules that might be involved in the early development of motoneurons, we performed RT-PCR for receptor tyrosine kinases (RTKs) and mRNA differential display with embryonic day 5 (E5) chick motoneurons enriched by panning. In situ hybridization revealed that Cek88 RTK among the cloned molecules was specifically expressed on motoneurons at the brachial and lumbar segments of the spinal cord which innervate limb muscles. We found that the expression of Cek8 in limb motoneurons was already intrinsically determined at E2. To analyze how motoneurons acquire regional specification along the anterior-posterior (A-P) axis and in the transverse plane, we observed the expression of Cek8, Islet-1, SC1 and low-affinity NGF receptor on ectopic motoneurons induced by implanting a supernumerary notochord or floor plate. The ectopic motoneurons induced by the graft obtained from either the thoracic or lumbar segments had the same expression profile as the in situ motoneurons at each A-P level. These findings suggest that regional specification of motoneurons is independent of the notochord and the floor plate and that the whole neural tube is committed to differentiate into the motoneuron subtypes along the A-P axis at the operative stages.

An increase in noradrenaline excretion during prolonged mental task load

To investigate the effects of prolonged mental work, urinary excretion of catecholamines and cortisol was measured in 18 human subjects from 9:30 to 17:00. On the "task day,' the subjects performed mental tasks during the morning (10:20-11:45) and afternoon sessions (13:00-17:00), otherwise taking chair rest. On the "control day,' the subjects took chair rest in the afternoon after performing mental tasks in the morning. In the morning session, urinary excretion of adrenaline during mental work increased greatly compared to that before the mental work. Mental work in the afternoon session also caused a marked increase in adrenaline excretion compared to the rest level in the afternoon on the control day. Cortisol levels in the first hour of the afternoon mental work were significantly higher than those during the corresponding time on the control day. Urinary excretion of noradrenaline during mental work in the morning session only increased slightly compared to that before the mental work. In the afternoon session, however, noradrenaline excretion during mental work on the task day was markedly elevated compared to that during the rest condition at the corresponding time on the control day. These findings suggest that prolonged exposure to mental work, but not short-term mental work, produces a marked increase in noradrenaline excretion in human subjects.

Adaptation of circadian corticosterone and catecholamine rhythms to light-dark cycle reversal in the rat

Circadian rhythms of urinary excretion of corticosterone and catecholamines were examined in the rat before and after phase reversal of a 12-hour light and 12-hour dark cycle. After the reversal, the acrophase of rhythm was delayed and became constant again on the 6th day for corticosterone and on the 7th or 8th day for adrenaline. The ratios of light-period output to 24-hour output of adrenaline and noradrenaline, however, adjusted to the new light-dark cycle on 10th day, whereas this ratio became constant on 6th day for corticosterone. Thus, circadian corticosterone rhythm seems to adapt to light-dark reversal more quickly than catecholamine rhythm.

Effects of earplugs on catecholamine and cortisol excretion in noise-exposed textile workers

To investigate physiological and psychological effects of industrial noise, a survey was performed on 50 female workers exposed to machinery noise [93-100 dB(A)] (noise group) and 25 female workers in less-noisy environments [71-75 dB(A)] (control group) in a textile factory in Vietnam. Urine was collected for analysis of catecholamines and cortisol. The subjects were also asked to fill out a questionnaire. Each subject was examined over 2 working days. The workers in the noise group were asked to put earplugs in their ears during the working hours of the 2nd day. On the 1st day without earplugs, urinary excretion of catecholamines in the noise group were greater than those in the control group. Cortisol in urine showed a similar tendency. Differences in catecholamine excretion between the noise group and the control group decreased on the 2nd day when the earplugs were used for attenuation of noise level in the noise group. Frequency of subjective fatigue symptoms was lower on the 2nd day than that on the 1st day in noise group, while the control group showed almost no day-difference. The results indicate that the catecholamine response to noise in workers was reduced through the use of earplugs.

[Epidemiological study of osteoporosis]

An epidemiological investigation of osteoporosis was carried out in a community in which fishing is the primary industry, and correlations were investigated between the bone mass and various risk factors for osteoporosis and biochemical findings. In 852, who could be examined directly, of the 3541 males and females aged 40 years or above living in Nansei Town, Watarai District, Mie Prefecture, the age, sex, height, body weight, years after menopause, married or unmarried, area of residence, daily activity, and intakes of milk, fish, and alcohol were studied by direct oral inquiry, and the serum calcium, inorganic phosphorus, alkaline phosphatase, and total protein were measured. The subjects were divided into a decreased bone mass group who showed grade I or more advanced loss in bone mass and a normal bone mass group who showed no or only slight loss in bone mass on the basis of microdensitometry (MD). Eighty-two subjects (9.6%) were classified as the decreased bone mass group. Items that showed a close correlation with sigma GS/D, which is an index of bone density, were age, years after menopause, serum alkaline phosphatase level, height, and body weight in females, age and serum alkaline phosphatase level in males. In the decreased bone mass group, 79 of the 82 subjects were females. Significant differences were observed between the decreased bone mass group and the normal bone mass group in age, years after menopause, serum alkaline phosphatase level, height, and body weight. From these results, a high age, being a female, low height, and a low body weight were found to be factors correlated with osteoporosis. Also, the bone mass was correlated with the serum alkaline phosphatase level and years after menopause.

[Workload of women workers rearing their children, evaluated by catecholamine excretion, salivary cortisol and self-rated scores of fatigue]

The study was designed to examine the extent of the workload in female workers with children, in the office and at home, as compared with that of male workers with children and single women workers. Urine and saliva were collected during the daytime and evening on workdays and days off, and catecholamines in urine and cortisol in saliva were analyzed. Heart rate, blood pressure and frequencies of subjective fatigue symptoms were also measured. In the three groups, urinary excretion of adrenaline during daytime work was found to be significantly higher than on days off. The difference between workdays and days off in evening adrenaline excretion tended to be greater in the 'women with children' group than in their male counterparts. Urinary noradrenaline and salivary cortisol in women with children showed a tendency to be higher in the afternoon and evening on workdays than that on days off, while no difference between workdays and days off was observed in the other two groups. The heart rate in women with children was greater during the evening on workdays than that on days off. The frequency of subjective fatigue symptoms in women with children increased with the time of day on workdays, but remained unchanged on days off. The findings suggest that the workload of female workers rearing their children is greater than that of male counterparts, both in the office and at home, on workdays.