[Retroperitoneal xanthogranuloma: a case report]

A 48-year-old man was admitted to our hospital for lumbago. Computerized tomographic (CT) scan, aortography and venacavography indicated a solid retroperitoneal tumor at the right renal hilus. The tumor was removed and right nephrectomy was conducted. Some of the tumor remained owing to strong adhesion to the inferior vena cava and lumbar spine. Histological diagnosis of the resected tumor was retroperitoneal xanthogranuloma. One year after surgery, the CT scan revealed a gradual decrease in size of the remaining retroperitoneal mass.

Multicentricity in resected occult bronchogenic squamous cell carcinoma

The frequency and the treatment of multicentricity in 127 patients with resected roentgenographically occult bronchogenic squamous cell carcinoma were studied. The cumulative rate and the incidence of postoperative metachronous multiple primary lung cancer were 0.11 at 5 years after initial operation and 0.022 per patient-year, respectively. The cumulative rate and the incidence of second primary lung cancer, which includes synchronous and subsequent metachronous cancer in patients with initial lung cancer, were 0.17 at 5 years after the initial operation and 0.041 per patient-year, respectively. The cumulative rate and the incidence of third primary lung cancer in patients with second primary lung cancer were 0.47 at 5 years, which was significantly higher (p = 0.05) than that of second primary lung cancer, and 0.11 per patient-year, respectively. In all 12 patients with synchronous multiple primary lung cancer, no recurrence was observed after treatment, but 3 had subsequent multiple primary lung cancer. Among the 13 patients with postoperative metachronous multiple primary lung cancer, recurrence was observed in 1 of the 6 patients who underwent resection and in 2 of the 4 patients treated with laser or radiation therapy or both. The overall survival rate at 5 years after initial operation in patients with solitary and those with multicentric occult bronchogenic squamous cell carcinomas was 0.90 and 0.59, respectively.

A double-blind controlled study of granulocyte colony-stimulating factor started two days before induction chemotherapy in refractory acute myeloid leukemia. Kohseisho Leukemia Study Group

We conducted a prospective, double-blind controlled study to determine the efficacy of a recombinant granulocyte colony-stimulating factor (G-CSF, 200 microgram/m2) starting daily from 2 days before an induction therapy until neutrophils recovered to above 1,500/microL or until 35 days after the therapy in 58 patients with relapsed or refractory acute myeloid leukemia (AML). Twenty-eight patients in the G-CSF group showed significantly faster recovery of neutrophils (P < .001) than 30 patients in the placebo group. The incidence of febrile episodes and of documented infections was almost the same in both groups. However, among 39 patients who did not show any infectious episodes during the 2-week period after the start of chemotherapy, the incidence of documented infections after the third week tended to be lower in the G-CSF group, but not statistically significantly. There was no evidence that G-CSF stimulated the growth of AML cells in the bone marrow during the 2-day period before the chemotherapy, nor that G-CSF accelerated the regrowth of AML cells during the 5-week period after the therapy. Fifty percent of patients in the G-CSF group and 37% in the placebo group had complete remission (CR). Although the rate was higher in the G-CSF group, the difference was not statistically significant (P = .306). There was no difference between the two groups in event-free survival of all patients and in disease-free survival of patients who had achieved CR.

Platelet-derived growth factor is a potent stimulator of expression of intercellular adhesion molecule-1 in human arterial smooth muscle cells

The effects of platelet-derived growth factor (PDGF) on the expression of intercellular adhesion molecule-1 (ICAM-1) as an indicator of cell activation were investigated in cultured human arterial smooth muscle cells (SMC). PDGF-BB and -AB but not -AA at 2-10 ng/ml stimulated ICAM-1 expression at a subconfluent but not a confluent state in a dose-dependent manner. ICAM-1 expression was induced at 2h, reached a plateau at 4h, and continued for at least 24h after stimulation with PDGF. The maximal stimulatory effect of PDGF-BB at 10 ng/ml was comparable to that by optimal concentrations of other cytokines and inflammatory agents. These data suggested that PDGF was a potent stimulator of ICAM-1.

[Flow cytometric analysis of nuclear DNA content of lung cancer--correlation between nuclear DNA content and tumor doubling time]

A total of 65 resected cases with primary lung cancer were examined on correlation between nuclear DNA content by flow cytometry and other prognostic factors, including tumor doubling time (DT). 1) DNA diploidy was found in 18 cases (28%) and DNA aneuploidy in 47 cases (72%). Percent aneuploidy was 79.5% in cases with adenocarcinoma, which tended to be higher than that in cases with squamous cell carcinoma (57.1%). 2) Percent aneuploidy in cases with advanced carcinomas tended to be higher than that in cases with earlier carcinomas, and percent aneuploidy in cases with rapid growing carcinomas tended to be higher than that in cases with slow growing carcinomas. 3) The geometric mean of DT of DNA aneuploid tumor was 130.0 day, which tended to be shorter than that of DNA diploid tumor (171.9 days), but the difference was not significant. There was not a significant correlation between DT and DNA Index. 4) The five-year survival rate of 47 patients with DNA aneuploid tumor was 45%, which was significantly lower than that of 18 patients with DNA diploid tumor (78%).

Identification of the sites in MAP kinase kinase-1 phosphorylated by p74raf-1

Many growth factors whose receptors are protein tyrosine kinases stimulate the MAP kinase pathway by activating first the GTP-binding protein Ras and then the protein kinase p74raf-1. p74raf-1 phosphorylates and activates MAP kinase kinase (MAPKK). To understand the mechanism of activation of MAPKK, we have identified Ser217 and Ser221 of MAPKK1 as the sites phosphorylated by p74raf-1. This represents the first characterization of sites phosphorylated by this proto-oncogene product. Ser217 and Ser221 lie in a region of the catalytic domain where the activating phosphorylation sites of several other protein kinases are located. Among MAPKK family members, this region is the most conserved, suggesting that all members of the family are activated by the phosphorylation of these sites. A 'kinase-dead' MAPKK1 mutant was phosphorylated at the same residues as the wild-type enzyme, establishing that both sites are phosphorylated directly by p74raf-1, and not by autophosphorylation. Only the diphosphorylated form of MAPKK1 (phosphorylated at both Ser217 and Ser221) was detected, even when the stoichiometry of phosphorylation by p74raf-1 was low, indicating that phosphorylation of one of these sites is rate limiting, phosphorylation of the second then occurring extremely rapidly. Ser217 and Ser221 were both phosphorylated in vivo within minutes when PC12 cells were stimulated with nerve growth factor. Analysis of MAPKK1 mutants in which either Ser217 or Ser221 were changed to glutamic acid, and the finding that inactivation of maximally activated MAPKK1 required the dephosphorylation of both serines, shows that phosphorylation of either residue is sufficient for maximal activation.

A new, effective, and safe therapeutic option using proton irradiation for hepatocellular carcinoma

BACKGROUND/AIMS

Conventional radiation is almost useless for hepatocellular carcinoma (HCC) because of the severe adverse effects of the irradiation to the accompanying liver cirrhosis. In contrast, the proton beam has Bragg peak, which limits distribution of the beam. The aim of this study was to prove the usefulness of proton irradiation for HCC.

METHODS

The proton irradiation was performed in 32 nodular lesions in 24 patients with HCC who had unresectable tumors or serious complications; the proton irradiation was performed either as monotherapy (15 lesions) or as combination therapy to insufficient Lipiodol-targeted chemotherapy (Kodama Co. Ltd., Tokyo, Japan) (17 lesions). The energy was 250 MeV, and 50-87 Gy (76.5 +/- 9.5, mean +/- SD) in total was irradiated for a time period of 17-69 days.

RESULTS

After 1 year, size reduction was seen in 12 out of 13 lesions (92%) in the monotherapy group and 9 out of 9 lesions (100%) in the combination therapy group; after 2 years, size reduction was seen 4 out of 5 lesions (80%) in the monotherapy group and 5 out of 5 lesions (100%) in the combination therapy group. Local tumor control has being assured for 2 years of the observation, which is continuing for another 2 years. None of the patients have experienced any serious adverse effects.

CONCLUSIONS

These results show that proton irradiation is a new, safe, and effective therapeutic option in cases of HCC, even in patients with unresectable tumors or those with serious complications.

[Experience with surgery for metachronous double cancer originated from thymus and lung]

A case with thymic cancer who developed pulmonary cancer ten years after the initial surgery was reported. A 50-year-old man was admitted to our hospital due to SVC syndrome. Chest X-ray examinations including venogram showed a mass lesion at the superior mediastinum. The patient underwent surgical removal and reconstruction of SVC, followed by radio-chemotherapy. The histologic diagnosis was thymic squamous cell carcinoma. He was admitted to our hospital again ten years after the initial surgery under the diagnosis of pneumonia. Bronchoscopic examination revealed nodular lesions at the right upper lobe bronchus and lower lobe bronchus, those lesions were diagnosed with squamous cell carcinomas cytologically. Right pneumonectomy was performed and the diagnosis was confirmed pathologically. Postoperative course was uneventful as of 10 months after the operation. It was concluded that this case showed metachronous double cancer of the thymus and the lung, as well as synchronous multiple bronchogenic carcinomas, which, to our knowledge, has never been reported yet.

Microbial synthesis and properties of poly(3-hydroxybutyrate-co-4-hydroxybutyrate) in Comamonas acidovorans

Comamonas acidovorans DS-17 was isolated from activated sludge and found to produce copolymers of 3-hydroxybutyrate (3HB) and 4-hydroxybutyrate (4HB) at 30 degrees C under growth-limited conditions. When 1,4-butanediol or 4-hydroxybutyric acid was used as the sole carbon source, a P(4HB) homopolymer was produced. Random copolymers of 3HB and 4HB units were produced on the addition of glucose or 3-hydroxybutyric acid to the culture solution of 4-hydroxybutyric acid. The physical properties of P(3HB-co-4HB) copolyesters with high 4HB fractions (64-100 mol%) were investigated. The copolyester films with high 4HB fractions exhibited the characteristics of a thermoplastic elastomer, and the tensile strength increased from 17 to 104 MPa as the 4HB fraction was increased from 64 to 100 mol%. The biodegradabilities of P(3HB-co-4HB) films were studied in aqueous solutions of extracellular polyhydroxybutyrate (PHB) depolymerase from Alcaligenes faecalis or of lipase from Rhizopus delemer. The erosion rate of P(3HB-co-4HB) films by PHB depolymerase decreased as the 4HB fraction in copolyester was increased from 64 to 100 mol%. In contrast, the erosion rate of films by lipase increased with the 4HB fraction.

[Assessment of nucleolar organizer regions (Ag-NORs) in primary lung cancer--correlation between Ag-NORs and tumor doubling time]

A total of 86 resected cases with primary lung cancer were examined on relationships between argyrophil nucleolar organizer regions (Ag-NORs) and other prognostic factors and correlation between Ag-NORs and tumor doubling time (DT). Survival rates were compared between patients with low Ag-NOR counts and patients with high Ag-NOR counts. 1) After logarithmic conversion of mean Ag-NOR counts in lung cancer, a small skewness (0.00486) and a small kurtosis (-0.7859) showed a normal distribution. Mean Ag-NOR counts was found to have a log-normal distribution. 2) There was a significantly inverse correlation between mean Ag-NOR counts and DT (correlation coefficient -0.705, p < 0.001). By plotting log (DT) on X axis and log (Ag-NORs) on Y axis, a formula representing a linear correlation was obtained: Y = 1.17-0.312 X, correlation coefficient -0.886. 3) The five-year survival rate (35%) of 46 patients with mean Ag-NOR counts which were more than or equal to 3.0 significantly lower than that (74%) of 40 patients with mean Ag-NOR counts of less than 3.0.

The influences of casein phosphopeptides on metabolism of ectopic bone induced by decalcified bone matrix implantation in rats

The effect of casein phosphopeptides (CPP) on bone metabolism was studied in the ectopic bone induced by the implantation of decalcified bone matrix in rats. Forty-two Wistar male rats of 7 weeks old were fed low calcium diets (0.39% of calcium) with or without supplying 0.50% of CPP, or a control diet (0.91% of calcium) without CPP supplementation. After a 1-week preliminary period, each rat was subcutaneously implanted with 30 mg of demineralized bone matrix powder. Fourteen and 21 days after the implantation, the implants were harvested from 7 rats of each group. Calcium content in the graft was not significantly different among all groups on day 14. Subsequently, the content of calcium rapidly increased in the grafts irrespective of diets given. However, the graft of the CPP- group contained less calcium than the other groups and the calcium content was more in the control rats compared to the CPP+ animals on day 21. Alkaline phosphatase activity (an index of bone and cartilage calcification) was lower in the control group than in the CPP+ group on day 14. The enzyme activity subsequently decreased in the control group but the activity was not changed in the other groups. As a result, the activity of alkaline phosphatase was lower in the control animals than in the other rats on day 21. Tartrate-resistant cap phosphatase activity (an index of bone resorption) was higher in the CPP--group compared to the control on day 14. On day 21, the activity was higher in the CPP--group compared to the others.(ABSTRACT TRUNCATED AT 250 WORDS)

The threonine residues in MAP kinase kinase 1 phosphorylated by MAP kinase in vitro are also phosphorylated in nerve growth factor-stimulated rat phaeochromocytoma (PC12) cells

The residues on MAP kinase kinase-1 (MAPKK1) phosphorylated by MAP kinase in vitro have been identified as Thr-291 and Thr-385. Both threonines are phosphorylated in PC12 cells and the 32P-labelling of each residue increases after stimulation with nerve growth factor (NGF). The results establish that MAPKK1 is a physiological substrate for MAP kinase. The two active forms of MAPKK that are resolved by Mono Q chromatography of PC12 cell extracts are both phosphorylated at Thr-291 and Thr-385, demonstrating that neither species is the MAPKK2 isoform which lacks Thr-291.

Overexpression of nef as a marker for restricted HIV-1 infection of astrocytes in postmortem pediatric central nervous tissues

In previous studies, using polymerase chain reaction amplification of HIV-1 genes directly from pathologic tissues of children who died with AIDS encephalopathy, we showed that the reading frame of the HIV-1 regulatory nef gene is open, suggesting that the nef protein was expressed. We now show, using immunocytochemistry and in situ hybridization with nef-specific probes in postmortem pediatric CNS tissues, that nef mRNA and protein are present in up to 20% of astrocytes in tissue sections selected for extensive histopathology. By contrast, HIV-1 structural proteins such as gag and their coding mRNAs are present in multinucleated giant cells that harbor productive infection and are the hallmark of HIV-1 infection in the CNS. These findings are consistent with the nonproductive infection of glial cells observed in vitro, and imply that HIV-1 infection of astrocytes is restricted to early regulatory gene products, of which nef is the best target as it is expressed at high levels and is membrane-anchored. In developing central nervous tissues of children, restricted and latent HIV-1 infection of astrocytes may be extensive and contribute significantly to HIV-1 neuropathogenesis.

[An infradian rhythm of weight increment velocity in patients with Crohn's disease during nutritional therapy]

We examined the rhythm of weight velocity in eight patients with Crohn's disease. In this paper we used the spline smoothing technique to study the cycle in the weight increment velocity curves derived from individual data during nutritional therapy. As a result of the weight measurement at four-day intervals, an infradian rhythm with the average cycle of 9.6 +/- 0.7 was recognized in all of the subjects in terms of the weight increment velocity. This rhythm was especially conspicuous in three adolescent patients with serious nutritional lesion. The cycle of the rhythm was unaffected by any of the following factors: energy intake, contents of nutritional therapy, medical examination during the period. Our findings of a common cycle in the process of convalescence from a low nutritious stage in patients with Crohn's disease suggest that, in others as well, the weight increment velocity might have an infradian rhythm with a kind of inherent periodicity.

[A case of bronchial neurinoma treated with bronchofiberscopic electrosurgery and right S6 sleeve segmentectomy]

A 30-year-old woman was admitted for cough and fever over a period of two months. Her chest X-ray film showed atelectasis of the right middle and lower lobes. Bronchofiberscopic examination revealed complete obstruction of the truncus intermedius by polypoid tumor. Its punched biopsy specimen was diagnosed as the benign tumor. Bronchofiberscopic resection was performed by high frequency snare, however the tumor remained at the membranous portion of the truncus intermedius and the right B6 orifice. Therefore, right S6 sleeve segmentectomy was carried out after two weeks. The pathological diagnosis of the exturpated tumor was neurinoma. There were no complications and she is well without any evidence of recurrence after surgery. Neurinoma of the tracheobronchial tree is extremely rare and only 84 cases have been reported.

Protective effects of kamikihi-to, a traditional Chinese medicine, against cerebral ischemia, hypoxia and anoxia in mice and gerbils

The protective effects of Kamikihi-To (KMK), a traditional Chinese medicine, against cerebral ischemia, hypoxia and anoxia were investigated with various experimental models in mice and gerbils. KMK (2.0 g/kg/day, p.o. for 5 days) significantly prolonged the survival time of mice subjected to bilateral common carotid artery occlusion. KMK (0.5 and 2.0 g/kg/day, p.o. for 5 days) also prolonged the survival time of mice injected with N-methyl-D-aspartic acid (NMDA: 80 mg/kg, i.v.). Furthermore, KMK (in a diet containing 8% KMK given orally for 34 days) showed protective effects against delayed neuronal death in CA1 pyramidal cells in the gerbil hippocampus after transient forebrain ischemia. On the other hand, we failed to show any protective effects of KMK (0.5-2.0 g/kg/day, p.o. for 5 days) against normobaric hypoxia and KCN-induced cytotoxic anoxia in mice. These results suggest that KMK may have protective effects against cerebral ischemic disorders, but not against severe hypoxic and anoxic disorders.

Late relapse of small cell lung cancer treated with radiation therapy alone--case report

This report describes an unusual case of a long-term survivor with small cell lung cancer (SCLC), treated with radiation therapy alone having a late relapse with solitary brain metastasis 6.5 years after the initial treatment. He received radiation therapy and died of the brain metastasis 8.5 years after the initial treatment. Autopsy revealed no tumor recurrence at the primary site and no distant metastases except for the brain. The histology of the brain tumor was small cell carcinoma.

Characterization of microsomal long-chain acyl-CoA hydrolase activity in the rat submandibular gland

1. Long-chain fatty acyl-CoA hydrolase in submandibular gland microsomes was characterized and compared to that in liver ones. 2. In rat submandibular gland, the microsomal long-chain acyl-CoA hydrolase showed a higher relative activity for polyunsaturated fatty acyl-CoAs than that of liver microsomes. 3. It was suggested that the hydrolase in rat submandibular gland microsomes may play a role in modulation in the acyl-CoA pool size.

Changing mortality and morbidity rates and the health status and life expectancy of the older population

This paper demonstrates the consequences of changes in mortality and health transition rates for changes in both health status life expectancy and the prevalence of health problems in the older population. A five-state multistate life table for the mid-1980s provides the baseline for estimating the effect of differing mortality and morbidity schedules. Results show that improving mortality alone implies increases in both the years and the proportion of dependent life; improving morbidity alone reduces both the years and the proportion of dependent life. Improving mortality alone leads to a higher prevalence of dependent individuals in the life table population; improving morbidity alone leads to a lower percentage of individuals with problems in functioning.

Augmentation of NK activity after oral administration of a traditional Chinese medicine, xiao-chai-hu-tang (shosaiko-to)

We have shown that a traditional Chinese medicine, Xiao-chai-hu-tang (Japanese name: Shosaiko-to) augments natural killer (NK)1 activity in mice. The maximum augmentation of NK activity in the peripheral blood and liver was observed at 12 hr after administration of Shosaiko-to. NK activity was augmented by Shosaiko-to dose-dependently. The augmentation became significantly positive at a dose of 500 mg/kg, and the maximum effect was observed at a dose of 1000 mg/kg. The augmentation of NK activity appeared at first in the liver from 6 hr after administration of Shosaiko-to and became detectable later in the peripheral blood from 12 hr after the administration. Activation of NK cells by Shosaiko-to may occur in the liver and subsequently the activated NK cells may be supplied to the peripheral blood. Changes in percentages of cell surface markers (asialo GM1, CD3, CD4, CD8) after Shosaiko-to treatment were hardly detected, but augmentation of NK activity induced by Shosaiko-to was abrogated by anti-asialo GM1 antibody treatment before the cytotoxicity assay. In addition, cytotoxic activity to P-815 target cells was not detected in Shosaiko-to treated mice. Augmentation of NK activity by Shosaiko-to is probably mediated by functional activation of classical NK cells of asialo GM1+ phenotype. These results suggest that augmentation of NK activity in the liver is one of mechanisms involved in clinical efficacy of Shosaiko-to in patients with virus chronic hepatitis.

Diabetic control and progression of retinopathy in elderly patients: five-year follow-up study

OBJECTIVE

To assess whether control of diabetes mellitus is as important in the elderly as in young and middle-aged diabetic patients in terms of progression of retinopathy.

DESIGN

A 5-year longitudinal cohort study.

SETTING

Outpatient diabetic clinic.

PATIENTS

One hundred fourteen non-insulin-dependent diabetic patients (30 males, 84 females) > or = 60 years of age.

MEASUREMENTS

Retinopathy was checked at the beginning and end of the follow-up period. During the 5-year follow-up period, demographic variables, body mass index, HbA1c, blood pressure, and plasma lipids were monitored. Retinopathy was classified as follows: grade 0, no lesion; grade 1, non-proliferative retinopathy; grade 2, pre-proliferative retinopathy; grade 3, proliferative retinopathy. Progression of retinopathy during the 5-year follow-up was defined as an increase in its grade.

RESULTS

At the start of the study, 13% of the patients already had retinopathy, all of grade 1. The 5-year follow-up study showed that progression of retinopathy was 23.6% in all cases, 22.2% in those with grade 0 initially, and 33.3% in those with grade 1 initially. The progression rates of retinopathy as a function of the mean HbA1c during the follow-up were as follows: lower than 7%, 2%; 7-8%, 20%; 8-9%, 40%; more than 9%, 61%. Multiple logistic regression analysis showed that, of the parameters examined, only HbA1c was a significant risk factor for progression of retinopathy.

CONCLUSIONS

Control of diabetes mellitus is the most important factor associated with prevention of progression of retinopathy in elderly patients.

[Clinical examination and therapies of hydronephrosis after radical hysterectomy]

We investigated postoperative hydronephrosis in 50 patients (100 ureter) undergoing radical hysterectomy for uterine cervical cancer from Jan. 1989 to Dec. 1991 at Department of Obstetrics and Gynecology in Nagasaki University Hospital. The incidence of hydronephrosis was 68.1% of patients, and hydronephrosis was seen significantly more frequently and was of a higher grade on the right kidney than the left. After one year, hydronephrosis disappeared in 59.1% of patients (65.1% of right kidney, 88.2% of left kidney), and only 2 of 93 kidney have worsened. In cases without hydronephrosis, hydronephrosis developed in only 3 of 31 kidney after one year due to local recurrence or nodule metastasis of the original disease. We compared therapeutic effects of 3 methods (ureteral stent, PNS, no treatment). But there was no significant difference between these methods, we could not determine which was the best treatment. And we observed that indwelling ureteral stent might interrupt spontaneous healing of ureter. Radiotherapy didn't significant influence hydronephrosis after radical hysterectomy; Therefore, we suggest that, in patients with hydronephrosis without other severe urological complications after radical hysterectomy, clinical course should be observed for at least one year, first and them some treatments should be applied if cases worsen gradually than before.

Effects of treatment with bezafibrate on lipoprotein lipase activity and mass in patients with hypertriglyceridemia

The activity and mass of lipoprotein lipase (LPL) in postheparin plasma (PHP) from patients with hypertriglyceridemia coupled with hypertension, impaired glucose tolerance, hyperinsulinemia were investigated in order to clarify the cause of hypertriglyceridemia and the effects of bezafibrate (CAS 41859-67-0), a novel lipid lowering agent. Eight weeks of treatment with bezafibrate (200 mg/d) lowered plasma total cholesterol and triglyceride by 7 and 39%, respectively, and increased plasma high density lipoprotein (HDL) cholesterol by 23% in the patients (n = 15). The LPL activity and mass of PHP in the patients were found to be lower than in the normal controls. The LPL activity and mass of PHP in the patients before treatment with bezafibrate (n = 15) were 2.05 +/- 1.06 mumol/ml/h and 147 +/- 45 ng/ml, respectively, whereas after treatment with 200 mg/d of bezafibrate for 8 weeks, these values were 3.62 +/- 1.30 mumol/ml/h (p < 0.01) and 226 +/- 57 ng/ml (p < 0.05), respectively. The increases of LPL mass were positively correlated with the decrease of triglyceride levels during the same period. These results suggest that the expression of LPL enzyme protein is impaired in patients with hypertriglyceridemia coupled with hypertension, impaired glucose tolerance and hyperinsulinemia, and the impaired expression of LPL recovers during treatment with bezafibrate, resulting in improvement of hypertriglyceridemia.