Switching to burosumab from conventional therapy in siblings with relatively well-controlled X-linked hypophosphatemia

Burosumab, a fully human monoclonal antibody against fibroblast growth factor 23, is mainly administered to patients with severe X-linked hypophosphatemia (XLH). However, there have been few reports on its use in relatively mild cases. In this report, we administered burosumab to two siblings with XLH who had been effectively treated with oral phosphate and active vitamin D. Both patients showed further improvement in radiographic and laboratory findings with burosumab compared with conventional treatment. Upon switching treatment, popliteal pain was reported in case 1 until her phosphorus levels normalized. This emphasizes the importance of monitoring not only rickets and calcium/phosphate metabolism but all symptoms of XLH after initiating burosumab. Notably, in cases 1 and 2, burosumab sustained catch-up growth, especially in case 1, who had not yet reached puberty. Further clinical studies are needed to determine whether burosumab improves growth and proportional abnormalities in patients with mild XLH.

Factors Related to Young People's Willingness to Perform Basic Life Support

Background

Survival rates increase when basic life support (BLS) is provided by bystanders to patients with acute diseases, such as out-of-hospital cardiac arrest; however, its implementation rate is not high. In this study, we investigated "interest on BLS," "knowledge on BLS," and "experience on BLS" as factors related to the willingness to implement BLS among junior high school, high school, and college students who have multiple opportunities to learn it.

Methods

This is an observational study using a questionnaire survey. The participants were 112 junior high school students, 114 high school students, and 109 university students (non-medical), totaling 294 (87.8% response rate). The questionnaire listed three items on the strength of willingness to perform BLS, three items on attributes of the participant, four items on the score of interest on BLS, one item on the score of knowledge on BLS, and two items on the score of experience on BLS.

Results

Among junior high school students, the factors that were significantly associated with the willingness to perform BLS were "Presence of someone who died" and "Interest on BLS" score. Among high school and college students, the factors that were significantly associated with the willingness to perform BLS were "Interest on BLS" and "Knowledge on BLS" scores.

Conclusion

For junior high school students, creating an environment in which they can visualize the actual situation may increase their interest, whereas for high school and university students, in addition to such an environment, conducting seminars of short duration may help them to consolidate their knowledge and increase their willingness to implement BLS.

Bystanders' Willingness to Perform Basic Life Support and Its Relationship with Facilitative and Obstructive Factors: A Nationwide Survey in Japan

Background

The administration of basic life support (BLS) by bystanders is essential to improve the survival rates of patients who have experienced out-of-hospital cardiac arrest (OHCA). Although providing BLS to individuals who experience OHCA greatly improves their chances of survival, the actual implementation rate is low. Therefore, we investigated the association between bystanders' willingness to perform BLS and facilitative/obstructive factors with the objective of identifying educational methods that would improve the likelihood of bystanders performing BLS should they encounter a patient with OHCA.

Methods

The study participants included 502 male and 498 female Japanese residents (total, 1000 participants) with no experience in performing BLS and 42 male and 59 female Japanese residents (total 101 participants) with experience in performing BLS. The participants were aged 15-65 years. Both groups graded the strength of their willingness to perform BLS in the future on a 4-point scale, as well as their level of agreement with factors facilitating or obstructing their willingness to perform BLS. These factors were established based on the theory of helping behavior, which defines psychological states when helping others in social psychology.We then analyzed the associations between willingness to perform BLS in the future and their level of agreement with factors facilitating or obstructing their willingness to perform BLS.

Results

The willingness to perform BLS decreased in accordance with the increase in the level of intervention required for patients who experienced OHCA , and was significantly associated with four facilitating factors: sufficient ability and experience to perform BLS, personal advantage, high personal norms, and psychological closeness to the patient.

Conclusion

Our results suggested that workshops and other educational activities focused on these facilitative factors may be helpful in increasing the rate at which bystanders perform BLS.

The process by which mothers of children with special healthcare needs evolve their connections with the community

Mothers of children with special healthcare needs often face many extra difficulties, such as being isolated in the community. This study, conducted in the San'in region of Japan between December 2017 and February 2019, aimed to clarify how the mothers established and adapted their connections within their communities through a qualitative descriptive design study. Participants were 12 mothers caring for children with special healthcare needs. Verbatim data on adapting to life after hospital discharge was collected through interviews and analyzed by the modified grounded theory approach. The data generated 14 concepts, which were grouped into four categories, as follows: Difficulties in life that arise from caring for children in social isolation; gaining an objective view of the current situation and future of caring for children with special healthcare needs; collaboration based on the understanding of relationships with others; and feeling fulfilled in life. These describe four phases that the mothers went through which are similar to each stage of the transition theory. Providing support via a collaborative partnership may be effective for mothers experiencing anxiety during the transition stages.

Genotype-Structure-Phenotype Correlations of Disease-Associated IGF1R Variants and Similarities to Those of INSR Variants

We previously reported genotype-phenotype correlations in 12 missense variants causing severe insulin resistance, located in the second and third fibronectin type III (FnIII) domains of the insulin receptor (INSR), containing the α-β cleavage and part of insulin-binding sites. This study aimed to identify genotype-phenotype correlations in FnIII domain variants of IGF1R, a structurally related homolog of INSR, which may be associated with growth retardation, using the recently reported crystal structures of IGF1R. A structural bioinformatics analysis of five previously reported disease-associated heterozygous missense variants and a likely benign variant in the FnIII domains of IGF1R predicted that the disease-associated variants would severely impair the hydrophobic core formation and stability of the FnIII domains or affect the α-β cleavage site, while the likely benign variant would not affect the folding of the domains. A functional analysis of these variants in CHO cells showed impaired receptor processing and autophosphorylation in cells expressing the disease-associated variants but not in those expressing the wild-type form or the likely benign variant. These results demonstrated genotype-phenotype correlations in the FnIII domain variants of IGF1R, which are presumably consistent with those of INSR and would help in the early diagnosis of patients with disease-associated IGF1R variants.

Effects of a Self-efficacy Theory-Based Training Program for Peers of Patients with Type 2 Diabetes

Background

Training peer leaders to deliver patient education is expected to be a low-cost approach to providing healthcare in urban-poor areas affected by a shortage of healthcare professionals. The purpose of this study was to examine the effects of a training program on the self-efficacy and knowledge of peer leaders with type 2 diabetes.

Methods

A single-group longitudinal survey with baseline, intervention, and follow-up periods was conducted at a diabetes clinic in a small municipality in Metro Manila, Philippines. The intervention, a self-efficacy theory-based training program for peer-leaders of diabetic patients conducted in August 2017, comprised hands-on learning, demonstrations, quizzes, role-playing, group sharing, physical exercise, and a buffet lunch. The primary outcome was participants' self-efficacy for management of their diabetes. Secondary outcomes were participants' knowledge of diabetes and levels of emotional distress, motivation, and confidence for guiding their peers, satisfaction with the training program, hemoglobin A1c, and quality of life.

Results

At 12 and 18 months after the intervention, participants' knowledge of diabetes was significantly increased compared with baseline (both P < 0.05). At earlier time points, an increasing, but not significant, trend was observed. The change in knowledge of diabetes from baseline to 18 months after intervention tended to be positively correlated with the change in self-efficacy (r = 0.594, P = 0.054). No significant differences were observed for any of the other outcomes, although the descriptive statistics showed an increasing trend for all of the outcomes except motivation.

Conclusion

The training program significantly improved participants' knowledge of diabetes at 12 and 18 months after the training programs compared with baseline. A positive correlation between the changes in the levels of knowledge and self-efficacy suggested that the observed improvement of self-efficacy was facilitated by the improvement of knowledge of diabetes.

Impact of Hands-on Experience of a Cadaver Dissection on the Professional Identity Formation of Health Sciences Students

Background

In Japan, some nursing and health science universities that train nurses and/or clinical laboratory technicians have a curriculum in which students observe medical students performing a cadaver dissection. Observing a cadaver dissection is believed to affect the formation of a student's professional identity. This study aimed to investigate the effects of observing a cadaver dissection on the professional identity of nursing and clinical laboratory science students to find an effective educational support system for developing professional identity.

Methods

Sophomores majoring in nursing science or clinical laboratory science were asked to complete a questionnaire with a professional identity scale before and after hands-on experience of a cadaver dissection performed by medical students. After their hands-on session was complete, they responded to a free-answer question about acquiring a professional identity.

Results

The professional identity score of nursing students significantly decreased after the hands-on experience of the cadaver dissection. No significant change in professional identity score was observed in the clinical laboratory science students. However, the effect size (r) was moderate.

Conclusion

Although professional identity formation fluctuates immediately after the experience of the hands-on experience of a cadaver dissection, the findings do suggest that these hands-on sessions will be effective for developing their professional identity if educational support is provided to help them utilize what they learned through reflection.

A Conceptual Model for Quality of Life Among People with Type 2 Diabetes in the Philippines

Background

The increased prevalence of chronic diseases is a social issue in developing countries.

Methods

To create a conceptual model representing the quality of life of low-income people with type 2 diabetes in the Philippines, 117 low-income adult participants in a public support group were studied, and the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores on quality of life (QOL) were analyzed in terms of their relationships with the following factors: basic attributes, physical factors (glycated hemoglobin level, complications, comorbidities, and symptoms), social factors (support, education, and financial status), and cognitive factors (knowledge, attitude, self-efficacy, and self-management behavior).

Results

Based on correlation coefficients among variables and goodness-of-fit test results through a path analysis, 2 models representing causal relationships were created, both of which showed sufficient goodness-of-fit.

Conclusion

Glycated hemoglobin levels, knowledge of blood glucose levels, self-efficacy, and self-management behavior (exercise) influenced PCS scores, while age, glycated hemoglobin levels, neuropathy, knowledge of insulin, self-efficacy, and self-management behavior (exercise) influenced MCS scores. The influence of self-efficacy was prominent in both cases, providing an important insight for healthcare professionals to develop effective support methods.

Childhood dietary intake: Comparison between anorexia nervosa and healthy leanness

BACKGROUND

The number of adolescent patients with anorexia nervosa is increasing. In addition, an increase in pre-adolescent patients with premenarchal onset has also been recognized. Detection of the disease in childhood and adolescence, however, is not always easy because the symptoms are not characteristic during this period. This study was performed to investigate detection of anorexia nervosa in children/adolescents by comparing energy and nutrient intake between patients with anorexia nervosa and healthy thin persons.

METHODS

The subjects consisted of 13 girls aged 14.4 ± 3.5 years with anorexia nervosa and 320 healthy girls aged 12.4 ± 1.3 years. Dietary intake was evaluated using a validated diet history questionnaire designed for children/adolescents. Daily energy and nutrient intake were expressed as a percentage of the age- and sex-matched reference amount.

RESULTS

Healthy lean (body mass index [BMI], <50th percentile) girls with an above-average score for desiring thinness had higher fat and lower cereal intake, and a trend of lower carbohydrate intake. In contrast, patients with anorexia nervosa, compared with thin (BMI <5th percentile) girls, characteristically had significantly lower energy, fat, zinc, vitamin C, and confectionery intake.

CONCLUSIONS

Lean girls with an above-average desire for thinness appear to restrict their energy intake by reducing their intake of carbohydrates such as cereals while maintaining a relatively high fat intake. In contrast, girls with anorexia nervosa avoided fat and had a preference for vegetables. This characteristic eating pattern could be a useful clue for detection of anorexia nervosa in thin children and adolescents.

Qualitative Analysis of the Psychosocial Adaptation Process in Children with Chronic Kidney Disease: Toward Effective Support During Transition from Childhood to Adulthood

Background

Pediatric chronic renal disease only shows abnormal values in a urinalysis in the initial stage, and subjective signs and symptoms are rare. If adolescents with chronic renal disease face a disease crisis combined with the usual developmental crisis, this may cause psychosocial maladaptation. We analyzed psychosocial adaptation in Japanese children with chronic renal disease in order to identify factors influencing healthy adaptation.

Methods

Ten children and adult patients with chronic kidney disease attending Tottori University Hospital, Japan in 2016 participated in a semi-structured interview (a modified version of the grounded theory approach) comprising questions about episodes since disease onset and thoughts/feelings at onset.

Results

Twenty-four concepts extracted from the data were sorted into 5 categories. These concepts and categories were expanded on an orthogonal axis with time and self-esteem in order to establish an adaptation model for children with chronic kidney disease. Category names are as follows. (Cat. 1: Emotional impact on being informed of disease, Cat. 2: Social challenges of treatment and resulting identity diffusion, Cat. 3: Emotional conflict on school return, Cat. 4: Resilience and related factors, Cat. 5: Re-establishment of identity).

Conclusion

Since pediatric chronic renal disease has few manifestations, it is difficult for patients to accept. Children facing a chronic disease crisis plus adolescent developmental crisis may show identity diffusion. In order for children to re-establish their identity and adapt to society, factors supporting resilience are important. Key factors include school life, interactions with friends, counseling by adult mentors and family acceptance. Healthcare professionals need to provide age-appropriate information on renal disease and support patients.

Increased IRS2 mRNA Expression in SGA Neonates: PCR Analysis of Insulin/IGF Signaling in Cord Blood

Context:

Hypoglycemia is the most common metabolic problem among small-for-gestational-age (SGA) neonates. However, the pathological mechanism and insulin/ insulin-like growth factor (IGF) signaling axis in neonates remain unknown.

Objective:

To determine the insulin/IGF axis in neonates, we analyzed the messenger RNA (mRNA) expression of insulin/IGF signaling in fetal umbilical cord blood.

Setting:

The Perinatal Medical Center of Tottori University Hospital.

Participants:

Fifty-two [42 appropriate-for-gestational-age (AGA) and 10 SGA] neonates.

Interventions:

Immediately collected cord blood was placed into a PAXgene Blood RNA Tube. Total RNA from the blood was purified using reagents provided in the PAXgene Blood RNA Kit within 4 days, and reverse transcription polymerase chain reaction (PCR) was performed.

Main Outcome Measure:

Quantitative real-time PCR analysis was applied to evaluate the mRNA expression of insulin receptor (INSR), IGF-I receptor (IGF1R), insulin receptor substrate 1 (IRS1), IRS2, and glucose transporters (SLC2A2 and SLC2A4). β-Actin was used as a control gene.

Results:

Serum glucose and IGF-I levels in SGA neonates were significantly lower. The cord serum insulin levels were similar between AGA and SGA neonates. The IRS2 mRNA expression was significantly higher in SGA than in AGA neonates (P < 0.05). The IRS2 mRNA expression was significantly higher in hypoglycemic SGA neonates than in normoglycemic SGA neonates.

Conclusions:

We determined that intrauterine growth restriction induces increased IRS2 mRNA expression in cord blood, without hyperinsulinemia. The increased expression of IRS2 mRNA might be associated with abnormal glucose metabolism in SGA neonates. Our findings might lead to the elucidation of abnormal glucose metabolism in SGA neonates.

FUT2 non-secretor status is associated with Type 1 diabetes susceptibility in Japanese children

AIM

To examine the contribution of the FUT2 gene and ABO blood type to the development of Type 1 diabetes in Japanese children.

METHODS

We analysed FUT2 variants and ABO genotypes in a total of 531 Japanese children diagnosed with Type 1 diabetes and 448 control subjects. The possible association of FUT2 variants and ABO genotypes with the onset of Type 1 diabetes was statistically examined.

RESULTS

The se2 genotype (c.385A>T) of the FUT2 gene was found to confer susceptibility to Type 1A diabetes in a recessive effects model [odds ratio for se2/se2, 1.68 (95% CI 1.20-2.35); corrected P value = 0.0075].

CONCLUSIONS

The FUT2 gene contributed to the development of Type 1 diabetes in the present cohort of Japanese children.

Current Status of the Utilization of Powered Wheelchair in Preschool Children with Locomotive Disability in Japan

[Purpose] This study aimed to elucidate the actual state of powered wheelchair (PWC) prescription for preschool children with disabilities in Japan, and also to determine the approximate number of preschool children with disabilities who would potentially benefit from PWC use. [Subjects and Methods] A total of 318 facilities providing rehabilitation for disabled children in Japan were enrolled in the study. A questionnaire about PWC use for preschoolers was mailed to the facilities. Each study items were analyzed employing the Fisher's exact test. [Results] Of the 318 facilities, consent to participate in this study was obtained from 108 (return rate: 34.0%). After PWC provision, many facilities reported improvement in quality of life indices for preschool children with disabilities. It was revealed that there were 6 preschool children from 2 to 6 years of age with disabilities who might acquire a means of independent locomotion through PWC provision and thereby experience improved quality of life. [Conclusion] There was no negative comment from the facilities studied about the prescription and provision of PWC for preschool children with disabilities.

A novel frameshift mutation in NR3C2 leads to decreased expression of mineralocorticoid receptor: a family with renal pseudohypoaldosteronism type 1

Pseudohypoaldosteronism type 1 (PHA1) is a rare genetic disease characterized by resistance to aldosterone, and the renal form of PHA1 is associated with heterozygous inactivating mutations in NR3C2, which encodes mineralocorticoid receptor (MR). Here we report a case of renal PHA1 due to a novel frameshift mutation in NR3C2. A 10-day-old Japanese male infant, born at 39 weeks gestation (birth weight, 2,946 g), was admitted to our hospital because of lethargy and vomiting, with a 6.7% weight loss since birth. Laboratory test results were: Na⁺, 132 mEq/L; K⁺, 6.6 mEq/L; Cl⁺, 93 mEq/L. Both plasma aldosterone level and plasma renin activity were markedly elevated at diagnosis, 2,940 ng/dL (normal range: 26.9-75.8 ng/dL) and 560 ng/mL/h (normal range 3.66-12.05 ng/mL/h), respectively. Direct sequence analysis of NR3C2 revealed a novel heterozygous mutation (c.3252delC) in the patient and his father. The mutation causes a frameshift starting at amino acid I 963 within the C terminal ligand-binding domain of MR and results in a putative abnormal stop codon at amino acid 994, with an extension of 10 amino acids compared to normal MR. We performed cell culture experiments to determine the levels of mutant NR3C2 mRNA and MR, and evaluate the effects of the mutation on MR response to aldosterone. The mutation decreased the expression of MR, but not NR3C2 mRNA, and led to decreased MR function, with no dominant negative effect. These results provide important information about MR function and NR3C2 mutation in PHA1.

Variants associated with autoimmune Type 1 diabetes in Japanese children: implications for age-specific effects of cis-regulatory haplotypes at 17q12-q21

AIMS

The aim of this study was to clarify the significance of previously reported susceptibility variants in the development of autoimmune Type 1 diabetes in non-white children. Tested variants included rs2290400, which has been linked to Type 1 diabetes only in one study on white people. Haplotypes at 17q12-q21 encompassing rs2290400 are known to determine the susceptibility of early-onset asthma by affecting the expression of flanking genes.

METHODS

We genotyped 63 variants in 428 Japanese people with childhood-onset autoimmune Type 1 diabetes and 457 individuals without diabetes. Possible association between variants and age at diabetes onset was examined using age-specific quantitative trait locus analysis and ordered-subset regression analysis.

RESULTS

Ten variants, including rs2290400 in GSDMB, were more frequent among the people with Type 1 diabetes than those without diabetes. Of these, rs689 in INS and rs231775 in CTLA4 yielded particularly high odds ratios of 5.58 (corrected P value 0.001; 95% CI 2.15-14.47) and 1.64 (corrected P value 5.3 × 10^-5 ; 95% CI 1.34-2.01), respectively. Age-specific effects on diabetes susceptibility were suggested for rs2290400; heterozygosity of the risk alleles was associated with relatively early onset of diabetes, and the allele was linked to the phenotype exclusively in the subgroup of age at onset ≤ 5.0 years.

CONCLUSIONS

The results indicate that rs2290400 in GSDMB and polymorphisms in INS and CTLA4 are associated with the risk of Type 1 diabetes in Japanese children. Importantly, cis-regulatory haplotypes at 17q12-q21 encompassing rs2290400 probably determine the risk of autoimmune Type 1 diabetes predominantly in early childhood.

Heterozygous nonsense mutations near the C-terminal region of IGF1R in two patients with small-for-gestational-age-related short stature

OBJECTIVE

The type I insulin-like growth factor I receptor (IGF1R) plays an important role in growth. We aimed to evaluate the detailed mechanism underlying the effect of IGF1R on human growth.

PATIENTS AND METHODS

We have performed sequence analysis of IGF1R in 55 patients with SGA short stature in Japan, since 2004, and identified novel heterozygous nonsense mutations in 2 patients: an 8-year-old Japanese boy (case 1), with a birthweight of 2228 g (-3·3 SDS) and height of 46 cm (-2·1 SDS), and a 3-year-old Japanese girl (case 2), with a birthweight of 2110 g (-3·0 SDS) and height of 44·3 cm (-2·8 SDS). Both patients had a short stature (-3·2 SDS, -3·1 SDS). We determined the protein expression of mutated IGF1R, assessed the effect of the endoplasmic reticulum-associated degradation (ERAD) pathway on mutated IGF1R, assessed the dominant-negative effect of IGF1R and performed quantitative RT-PCR analysis of IGF1R mRNA expression in whole blood cells.

RESULTS

Two novel heterozygous nonsense mutations (case 1: p.Q1250X and case 2: p.W1249X) were identified. Although these mutations did not affect blood IGF1R mRNA levels, they significantly decreased the expression of IGF1R protein in transiently transfected cells. Treatment with the proteasome inhibitor MG132 showed significantly increased IGF1R protein.

CONCLUSIONS

Heterozygous nonsense mutations affecting the C-terminal region (p.Q1250X, p.W1249X) of IGF1R decreased the expression of IGF1R through the ERAD pathway. Our study revealed the importance of the C-terminal region and the dosage of this receptor for growth.

Seating arrangements for children with insufficient head control: lessons from trials using the i2i head & neck positioning & support system

[Purpose] An insufficient head control is the most troublesome condition for children with impaired mobility who require optimal seating. [Subjects and Methods] We report on the clinical trial of the newly developed i2i head & neck positioning & support system called i2i for locomotively disabled children with periventricular leukomalacia (PVL). [Results] Two major advantages of the i2i were observed in the trial. The first was its favorable effect on the alignment of the spine to prevent scoliosis and to provide stable breathing and optimal seating, which resulted in improvement of the children’s activities of daily living (ADL). The second was its direct application of force to the head rather than indirectly to the pelvis in a conventional seat arrangement. The conventional way of head support is based on stabilization of the trunk which is based on stabilization of the pelvis by some seating arrangement. [Conclusion] The trial of the i2i device demonstrated its usefulness in helping PVL children with insufficient head control develop their abilities while preventing secondary disability.

A rare CYP 21 mutation (p.E431K) induced deactivation of CYP 21A2 and resulted in congenital adrenal hyperplasia

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is caused by mutations in the CYP21A2 gene. The residual enzyme activity is strongly associated with the phenotype. We describe a rare case of CAH with a rare CYP21A2 mutation. The patient was a one-year-old Japanese boy. At 16 days old, he was referred to our hospital because of elevated serum 17-OH-progesterone (17-OHP) levels in neonatal screening. The compound heterozygous mutations (IVS2-13 A/C>G, and p.E431K) in CYP21A2 were identified at 2 months old, and we diagnosed non-classical CAH, since he did not have significant physical signs (pigmentation and salt-wasting). However, his body weight decreased, and his serum 17-OHP level (99.5 ng/mL) was elevated at 3 months old. Steroid replacement therapy was started at 3 months old. Our patient's clinical course resembled simple virilizing (SV) CAH, but classification was difficult because the patient showed increased renin activity indicating an aldosterone deficiency, and late onset of symptoms. While the IVS 2-13 A/C>G mutation is common in the classical form of CAH, p.E431K is a rare point mutation. Functional analysis revealed that the residual enzyme activity of p.E431L was 5.08±2.55% for 17-OHP and 4.12±2.37% for progesterone, which is consistent with SV CAH. p.E431 is localized in the L-helix near the heme-binding site. The mutation might interfere with heme binding, leading to deactivation of CYP21A2. This report showed that CYP21A2 p.E431 has an important effect on enzyme activity.

Gender differences in childhood food preference: evaluation using a subjective picture choice method

BACKGROUND

A preference for calorie-dense food in men seems to be closely linked with a considerably higher incidence of obesity in adulthood for men than women, but it is not clear in which life stage the gender differences in food preference begin to appear. In order to clarify this, a picture choice method has been developed that is designed to evaluate food preferences or interests in children based on their subjective choices.

METHODS

In total, 486 children aged 6-12 years were enrolled. To evaluate food interest, children were instructed to choose any 10 from 36 pictures in the panel showing 10 different foods and 26 other things. The number of foods chosen was set as the food interest score. For food preference, they were also instructed to choose any 10 from 36 pictures in the other panel depicting 36 different foods. For the 10 foods chosen, Japanese food score, energy density, fat energy content, and saturated fatty acid score were calculated. These indices were compared for sex, age group and body mass index.

RESULTS

Indices reflecting food interest or fat preference were significantly higher in boys than girls both in the 7-9- and 10-12-year-old age groups. Positive correlations were found between food interest score and energy density, fat energy content, and saturated fatty acid score.

CONCLUSIONS

Using the picture choice method, definite gender differences in food preference were identified in early elementary school children. This information could be useful for dietary therapy in childhood obesity.

Clinical overview of nephrogenic diabetes insipidus based on a nationwide survey in Japan

BACKGROUND

Nephrogenic diabetes insipidus (NDI) is a rare disease whose complications include polyuria, renal dysfunction, growth disorder and mental retardation. The details of NDI's clinical course have been unclear. To address this uncertainty, we performed a large investigation of the clinical course of NDI in Japan.

METHODS

Between December 2009 and March 2011, we provided a primary questionnaire to 26,282 members of the Japan Endocrine Society, the Japanese Urological Association, the Japanese Society for Pediatric Endocrinology, the Japanese Society for Pediatric Nephrology, the Japanese Society of Nephrology, the Japanese Society of Neurology and the Japanese Society of Pediatric Urology. In addition, we provided a secondary questionnaire to 121 members who reported experience with cases of NDI. We asked about patient's age at onset, diagnosis, complications, effect of treatment and patient's genotype.

RESULTS

We enrolled 173 patients with NDI in our study. Of these NDI patients, 143 were congenital and 30 were acquired. Of the 173, 73 patients (42%) experienced urologic complications. Among the 143 with congenital NDI, 20 patients (14%) had mental retardation. Patients with NDI mainly received thiazide diuretics, and some patients responded to treatment with desmopressin acetate (DDAVP). Gene analyses were performed in 87 patients (61%) with congenital NDI, revealing that 65 patients had an arginine vasopressin receptor type 2 (AVPR2) gene mutation and that 8 patients (9.2%) had an aquaporin 2 (AQP2) gene mutation. Patients with the AVPR2 mutation (D85N) generally showed a mild phenotype, and we found that DDAVP was generally an effective treatment for NDI among these patients.

CONCLUSION

We suggest that adequate diagnosis and treatment are the most important factors for improving prognoses. We further suggest that gene analysis should be performed for optimal treatment selection and the early detection of NDI among siblings.

Psychosocial profiles of children with achondroplasia in terms of their short stature-related stress: a nationwide survey in Japan

AIMS AND OBJECTIVES

To assess psychosocial profiles of children with achondroplasia using a nationwide survey.

BACKGROUND

Achondroplasia, showing short stature and disproportionately short limbs, causes physical inconvenience such as difficulty in reaching high objects. It is, however, still controversial whether the condition is associated with psychological problems, especially in childhood.

DESIGN

A cross-sectional descriptive design was employed.

METHODS

To evaluate psychosocial profiles and adaptation processes in children with achondroplasia, we developed an inventory of scales based on the psychological stress model of which conceptual framework was comprised of stressor, coping process, coping resource and adaptation outcome domains. Participants were recruited nationwide through the largest advocacy support group for achondroplasia in Japan. Of the 130 group members, 73 X-ray-diagnosed patients, aged 8-18 years, completed the inventory of questionnaires to be analysed.

RESULTS

As for the stressor domain, patients experienced short stature-related unpleasant experiences more frequently (z-score: +1·3 in average, +3·9 in physical inconvenience). Nevertheless, these experiences had little effect on the coping process (threat appraisal: -0·2, control appraisal: +0·1) and the adaptation outcome (stress response: +0·3, self-concept: 0·0). Interestingly, self-efficacy in the coping resource domain was noticeably increased (+3·1) and was strongly correlated with most variables in the coping process and in adaptation outcome domains.

CONCLUSIONS

Although the children with achondroplasia experienced more short stature-related stressors, there was no evidence of any psychosocial maladaptation. This finding suggests that coping process as well as coping resources such as self-efficacy could be important targets for promoting psychological adjustment in children with achondroplasia.

RELEVANCE TO CLINICAL PRACTICE

To help children with achondroplasia adapt socially, nurses and other healthcare providers should routinely assess their psychological adaptation process, especially cognitive appraisal and self-efficacy.

Leprechaunism (Donohue syndrome): a case bearing novel compound heterozygous mutations in the insulin receptor gene

Leprechaunism (Donohue syndrome) is the most severe type of insulin receptor (INSR) gene anomaly with the majority of patients surviving for only 2 years. We report a surviving 2 -year-old male with leprechaunism, bearing novel compound heterozygous mutations in the INSR. The patient is a Japanese boy with acanthosis nigricans, lack of subcutaneous fat, hirsutism, thick lips, gum hypertrophy and extremely high insulin levels (6702 mU/mL). He was as having identified novel compound heterozygous mutations in INSR (p.T910M and p. E1047K). At 24 day-old, recombinant human insulin-like growth factor 1 (rh-IGF1) treatment was started because of poor weight gain. At 2 years old, the patient's serum glucose level and HbA1C value had worsened, and both a bolus of rh-IGF-1 and a subcutaneous injection of a rapid-acting insulin analog after meals, in addition to α-glycosidase inhibitor, were initiated from 2 years onward. Oxygen administration and biphasic positive airway pressure treatment were also initiated from 2 years old due to upper airway obstruction with adenoidal hypertrophy. In the experiments conducted using COS7 cells homozygously transfected with the INSR mutation, T910M INSR failed to process the proreceptor and decreased insulin-stimulated tyrosine phosphorylation. E1047K INSR resulted in a complete absence of insulin-stimulated tyrosine phosphorylation. These findings suggest the near absence of INSR in this patient. We consider that the rhIGF1 treatment contributed to his long survival, but it was not able to prevent his diabetic condition. Our report provides important insights into the function of INSR, and for the treatment of leprechaunism.

Castleman disease in a child with short stature

We report a 14-year-old boy with Castleman disease in this article. He complained of short stature, and his body height was 133.8 cm (<3rd percentile; z score -4.5). There was marked delay in the appearance of secondary sexual characteristics. He was found to have a remittent fever and a lower mid-abdominal tumor. Blood test revealed microcytic hypochromic anemia, thrombocytosis, polyclonal hypergammaglobulinemia, hyperfibrinogenemia, and elevated erythrocyte sedimentation rate. The serum IL-6 and C-reactive protein levels were increased. The mass was found to be mixed hyaline vascular and plasma cell type of Castleman disease through a pathological examination. Lymph nodes affected by Castleman disease cause overproduction of IL-6. It decreases IGF-1, IGFBP-3 and serum testosterone levels. As a result of tumorectomy, his short stature and delay in the development of secondary sexual characteristics were improved.

Novel missense mutation in the IGF-I receptor L2 domain results in intrauterine and postnatal growth retardation

BACKGROUND

IGFs play key roles in intrauterine and postnatal growth through the IGF-I receptor (IGF-IR). We identified a family bearing a new heterozygous missense mutation at the L2 domain of IGF-IR (R431L).

METHOD

We analysed the nucleotide sequences of the IGF1R gene of the family. We prepared R(-) cells (fibroblasts with targeted disruption of the IGF-IR gene) expressing wild-type or R431L IGF-IR and performed functional analyses by evaluating IGF-I binding, IGF-I-stimulated DNA synthesis, tyrosine phosphorylation of IGF-IR and its substrates, and internalization by measuring [(125) I]IGF-I internalization. We also performed confocal microscopy analysis.

RESULTS

We identified a family bearing a new heterozygous missense mutation at the L2 domain of IGF-IR (R431L) through an 8-year-old girl and her mother, both born with intrauterine growth retardation. In experiments conducted using cells homozygously transfected with the IGF-IR R431L mutation; (i) IGF-I binding was not affected; (ii) DNA synthesis induced by IGF-I was decreased; (iii) IGF-IR internalization stimulated by IGF-I was decreased and (iv) IGF-I-stimulated tyrosine phosphorylation was reduced IGF-IR by low concentrations of IGF-I and on insulin receptor substrate (IRS)-1 and IRS-2.

CONCLUSION

A missense mutation (R431L) leads to the inhibition of cell proliferation, attenuation of IGF signalling and decrease in internalization of IGF-IR. The results of this study suggest a novel link between a mutation at the IGF-IR L2 domain and intrauterine and postnatal growth retardation.

HLA-class II and class I genotypes among Japanese children with Type 1A diabetes and their families

OBJECTIVE

To determine the HLA-DRB1, DQB1, DPB1, A, C, and B genotypes among Japanese children with autoimmune type 1 diabetes.

METHODS

Four hundred and thirty patients who were GADAb and/or IA-2Ab-positive (Type 1A) were recruited from 37 medical centers as part of a nationwide multicenter collaborative study. DNA samples from 83 siblings of the children with Type 1A diabetes and 149 parent-child trios were also analyzed. A case-control study and a transmission disequilibrium test (TDT) were then performed.

RESULTS

The susceptible and protective DRB1 and DQB1 alleles and haplotypes were confirmed. DPB1 alleles unique to the Japanese population and those common to multiple ethnic groups were also present. A linkage disequilibrium (LD) analysis showed both susceptible and protective haplotypes. The TDT did not reveal any alleles that were transmitted preferentially from the mother or father to children with Type 1A. Homozygosity for DRB1-09:01-DQB1-03:03 and heterozygosity for DRB1-04:05-DQB1-04:01 and DRB1-08:02-DQB1-03:02 were associated with an extremely high risk of Type 1A. A comparison of children with Type 1A and their parents and siblings suggested a dose effect of susceptible DRB1-DQB1 haplotypes and an effect of protective alleles on immunological pathogenesis. DRB1-09:01 appeared to be strongly associated with an early onset in preschool children with Type 1A diabetes.

CONCLUSIONS

This study demonstrated the characteristic association of HLA-class II and class I genes with Type 1A diabetes among Japanese children. A TDT did not reveal the genomic imprinting of HLA-class II and class I genes in Type 1A diabetes.

Aromatase excess syndrome: identification of cryptic duplications and deletions leading to gain of function of CYP19A1 and assessment of phenotypic determinants

CONTEXT

Aromatase excess syndrome (AEXS) is a rare autosomal dominant disorder characterized by gynecomastia. Although cryptic inversions leading to abnormal fusions between CYP19A1 encoding aromatase and its neighboring genes have been identified in a few patients, the molecular basis remains largely unknown.

OBJECTIVE

The objective of the study was to examine the genetic causes and phenotypic determinants in AEXS.

PATIENTS

Eighteen affected males from six families participated in the study.

RESULTS

We identified three types of heterozygous genomic rearrangements, i.e. a 79,156-bp tandem duplication involving seven of 11 noncoding CYP19A1 exons 1, a 211,631-bp deletion involving exons 2-43 of DMXL2 and exons 5-10 of GLDN, and a 165,901-bp deletion involving exons 2-43 of DMXL2. The duplicated exon 1 functioned as transcription start sites, and the two types of deletions produced the same chimeric mRNA consisting of DMXL2 exon 1 and CYP19A1 coding exons. The DMXL2 exon 1 harbored a translation start codon, and the DMXL2/CYP19A1 chimeric mRNA was identified in only 2-5% of CYP19A1-positive transcripts. This was in contrast to the inversion-mediated chimeric mRNA that had no coding sequence on the fused exon 1 and accounted for greater than 80% of CYP19A1-positive transcripts. CYP19A1 was expressed in a limited number of tissues, whereas its neighboring genes involved in the chimeric mRNA formation were expressed widely.

CONCLUSIONS

This study provides novel mechanisms leading to gain of function of CYP19A1. Furthermore, it appears that clinical severity of AEXS is primarily determined by the tissue expression pattern of relevant genes and by the structural property of promoter-associated exons of chimeric mRNA.

Kinetics of hydrolysis, oxidation, and adsorption during olive oil degradation by activated sludge

Kinetics of the degradation of olive oil by an acclimated activated sludge were studied. Kinetic constants for the lipid removal from the mixed liquor and for that from the supernatant and for the hydrolysis step were evaluated using Michelis-Menten equations. The maximum specific reactions rates (v(max)) and the saturation constants (K(m)) were v(max) = 1.20 mg lipid mg(-1) MLVSS day(-1) and K(m) = 1290 mg/L for lipid removal from the mixed liquor; v(max) = 1.54 mg lipid mg(-1) MLVSS day(-1) and K(m) = 801 mg/L for that from the supernatant; v(max) = 1.57 mg olive oil mg(-1) MLVSS day(-1) and K(m) = 1750 mg/L for the hydrolysis of olive oil (where MLVSS refers to mixed liquor volatile suspended solids). The adsorption of olive oil by the activated sludge contributed to the lipid removal from the supernatant. The specific rate of this adsorption was also estimated. The hydrolysis, rather than the oxidation of free fatty acids, was the rate limiting step in the degradation of olive oil when the concentration of olive oil was lower than about 800 mg/L.

Cytochrome P450 oxidoreductase deficiency: identification and characterization of biallelic mutations and genotype-phenotype correlations in 35 Japanese patients

CONTEXT

Cytochrome P450 oxidoreductase (POR) deficiency is a rare autosomal recessive disorder characterized by skeletal dysplasia, adrenal dysfunction, disorders of sex development (DSD), and maternal virilization during pregnancy. Although multiple studies have been performed for this condition, several matters remain to be clarified, including the presence of manifesting heterozygosity and the underlying factors for clinical variability.

OBJECTIVE

The objective of the study was to examine such unresolved matters by detailed molecular studies and genotype-phenotype correlations.

PATIENTS

Thirty-five Japanese patients with POR deficiency participated in the study.

RESULTS

Mutation analysis revealed homozygosity for R457H in cases 1-14 (group A), compound heterozygosity for R457H and one apparently null mutation in cases 15-28 (group B), and other combinations of mutations in cases 29-35 (group C). In particular, FISH and RT-PCR sequencing analyses revealed an intragenic microdeletion in one apparent R457H homozygote, transcription failure of apparently normal alleles in three R457H heterozygotes, and nonsense mediated mRNA decay in two frameshift mutation-positive cases examined. Genotype-phenotype correlations indicated that skeletal features were definitely more severe, and adrenal dysfunction, 46,XY DSD, and pubertal failure were somewhat more severe in group B than group A, whereas 46,XX DSD and maternal virilization during pregnancy were similar between two groups. Notable findings also included the contrast between infrequent occurrence of 46,XY DSD and invariable occurrence of 46,XX DSD and pubertal growth pattern in group A mimicking that of aromatase deficiency.

CONCLUSIONS

The results argue against the heterozygote manifestation and suggest that the residual POR activity reflected by the R457H dosage constitutes the underlying factor for clinical variability in some features but not other features, probably due to the simplicity and complexity of POR-dependent metabolic pathways relevant to each phenotype.

Late-onset adrenal hypoplasia congenita caused by a novel mutation of the DAX-1 gene

Mutation in the orphan nuclear receptor DAX-1 gene causes X-linked adrenal hypoplasia congenita (AHC). Affected male children classically suffer a salt-losing crisis and adrenal insufficiency in their early infancy or, in some rare exceptions, with late-onset subtype. We report here a patient manifesting late-onset adrenal hypoplasia congenita caused by the premature truncation of the C-terminus of the DAX-1 molecule, which is essential for its function as a transcriptional repressor. A 12-year-old boy was referred to us after being afflicted with generalized skin pigmentation for about 3 years, fatigue and headache. Primary adrenal insufficiency was determined on the basis of a low plasma cortisol level (3.9 microg/dl) despite an extremely high ACTH level (1200 pg/ml). Replacement therapy with hydrocortisone and fludorocortisone acetate was initiated soon thereafter. Hypogonadotropic hypogonadism was confirmed at the age of 18 years, at which time sexual infantilism had become apparent. Direct sequencing of the peripheral lymphocyte-derived DNA revealed a novel 1033del13 mutation on the ligand-binding domain of the NR0B1 (DAX-1) gene, which generated a premature stop codon truncating the C-terminus. This mutation was considered de novo since we could not find it in his mother. This case demonstrates that even a truncated protein lacking the major functional domain of DAX-1 can present late-onset and latent adrenal failure.

Ultrastructure of placental hyperplasia in mice: comparison of placental phenotypes with three different etiologies

Hyperplastic placentas have been reported in several experimental mouse models, including animals produced by somatic cell nuclear transfer, by inter(sub)species hybridization, and by somatic cytoplasm introduction to oocytes followed by intracytoplasmic sperm injection. Of great interest are the gross and histological features common to these placental phenotypes--despite their quite different etiologies--such as the enlargement of the spongiotrophoblast layers. To find morphological clues to the pathways leading to these similar placental phenotypes, we analyzed the ultrastructure of the three different types of hyperplastic placenta. Most cells affected were of trophoblast origin and their subcellular ultrastructural lesions were common to the three groups, e.g., a heavy accumulation of cytoplasmic vacuoles in the trophoblastic cells composing the labyrinthine wall and an increased volume of spongiotrophoblastic cells with extraordinarily dilatated rough endoplasmic reticulum. Although the numbers of trophoblastic glycogen cells were greatly increased, they maintained their normal ultrastructural morphology, including a heavy glycogen deposition throughout the cytoplasm. The fetal endothelium and small vessels were nearly intact. Our ultrastructural study suggests that these three types of placental hyperplasias, with different etiologies, may have common pathological pathways, which probably exclusively affect the development of certain cell types of the trophoblastic lineage during mouse placentation.

Regional rearrangements in chromosome 15q21 cause formation of cryptic promoters for the CYP19 (aromatase) gene

Production of appropriate quantities of estrogen in various tissues is essential for human physiology. A single gene (CYP19), regulated via tissue-specific promoters, encodes the enzyme aromatase, which catalyzes the key step in estrogen biosynthesis. Aromatase excess syndrome is inherited as autosomal dominant and characterized by high systemic estrogen levels, short stature, prepubertal gynecomastia and testicular failure in males, and premature breast development and uterine pathology in females. The underlying genetic mechanism is poorly understood. Here, we characterize five distinct heterozygous rearrangements responsible for aromatase excess syndrome in three unrelated families and two individuals (nine patients). The constitutively active promoter of one of five ubiquitously expressed genes located within the 11.2 Mb region telomeric to the CYP19 gene in chromosome 15q21 cryptically upregulated aromatase expression in several tissues. Four distinct inversions reversed the transcriptional direction of the promoter of a gene (CGNL1, TMOD3, MAPK6 or TLN2), placing it upstream of the CYP19 coding region in the opposite strand, whereas a deletion moved the promoter of a fifth gene (DMXL2), normally transcribed from the same strand, closer to CYP19. The proximal breakpoints of inversions were located 17-185 kb upstream of the CYP19 coding region. Sequences at the breakpoints suggested that the inversions were caused by intrachromosomal nonhomologous recombination. Splicing the untranslated exon downstream of each promoter onto the identical junction upstream of the translation initiation site created CYP19 mRNA encoding functional aromatase protein. Taken together, small rearrangements may create cryptic promoters that direct inappropriate transcription of CYP19 or other critical genes.

Variation analysis of beta3-adrenergic receptor and melanocortin-4 receptor genes in childhood obesity

BACKGROUND

Decreased energy expenditure and increased food intake are principal causes for obesity. In the present study, genotypes of beta(3)-adrenergic receptor (beta(3)AR) and of melanocortin-4 receptor (MC4R), both of which are believed to have a close link to the cause of obesity, were analyzed and compared with phenotypes of childhood obesity.

METHODS

Thirty-five obese children with moderate to severe obesity were enrolled. Direct sequencing of the MC4R coding region and pinpoint-polymerase chain reaction were used to detect genomic variation in the beta(3)AR gene using peripheral blood-derived DNA.

RESULTS

Allele frequency of Trp64Arg variation in the beta(3)AR gene in the obese subjects was 0.16, which is comparable with that in the healthy general population in eastern Asia. Comparison of phenotypical characteristics did not show a significant difference between Trp/Trp and Trp/Arg subjects. It was notable that body height SD was significantly higher in the Trp/Trp than the Trp/Arg subjects (0.93 +/- 1.0 SD vs 0.07 +/- 1.3 SD, P= 0.03). Annual weight gains were far beyond a hypothetical fat gain in an Arg64 heterozygote with decreased energy consumption, suggesting increased food intake in childhood obesity. There was, however, no variation in the MC4R gene despite thorough sequencing of the entire coding region.

CONCLUSIONS

The Trp64Arg variation in the beta(3)AR gene has no relationship to the degree or the incidence of childhood obesity. The majority of childhood obesity can be characterized as tall stature, more rapid weight gain than that expected by decreased energy expenditure. Further investigation is necessary in regard to the increased food intake as a major cause of childhood obesity.

Lower brainstem dysfunction in an infant with persistent primitive trigeminal artery

A 6-month-old boy with persistent primitive trigeminal artery (PPTA) presented with stridor, dysphagia, delayed motor development and postural neck and shoulder dystonia. Magnetic resonance imaging/angiography and ultrasonography revealed PPTA, with flow from the dilated basilar artery to the right internal carotid artery, lower brainstem compression by the dilated basilar artery, and cerebellar vermis hypoplasia. Evoked potentials showed lower pons and medulla oblongata functional disruption. These lesions may be related to vascular etiology in the lower brainstem or to congenital malformation syndrome involving infratentorial structures. The relationship of this condition to Möbius syndrome is discussed.

Estimation of reduced and increasing health risks by installation of urban wastewater systems

This paper aims to propose a methodological framework for quantifying the reduction and increase of health risks associated with urban wastewater systems. A risk assessment model was used to quantify reduction in disease burden while a life cycle assessment approach was used to quantify increasing risks by environmental loading. Disability adjusted life years (DALYs) was used to quantify health risks. This framework was applied to a hypothetical watershed to evaluate health risks by installation of wastewater treatment systems. In this hypothetical case, 55 DALYs per year of health risk would be reduced for 200,000 people in the downstream community by constructing wastewater systems for 200,000 people, while a range from 1.9 to 22 DALYs per year of health risks would be generated by materials and energy consumption for construction and operation of wastewater systems. However, this result would significantly change, depending on the parameters used in this analysis. The proposed methodology should be improved to obtain more precise results, but it will suggest useful information to discuss the overall effects due to the installation of various types of urban wastewater systems.

Evaluation of nitrate removal by continuous culturing of an aerobic denitrifying bacterium, Paracoccus pantotrophus

Nitrate removal under aerobic conditions was investigated using pure cultures of Paracoccus pantotrophus, which is a well-known aerobic-denitrifying (AD) bacterium. When a high concentration of cultures with a high carbon/nitrogen (C/N) ratio was preserved at the beginning of batch experiments, subsequently added nitrate was completely removed. When continuous culturing was perpetuated, a high nitrate removal rate (66.5%) was observed on day 4 post-culture, although gradual decreases in AD ability with time were observed. The attenuation in AD ability was probably caused by carbon limitation, because when carbon concentration of inflow water was doubled, nitrate removal efficiency improved from 18.1% to 59.6%. Bacterial community analysis using the polymerase chain reaction-denaturing gradient gel electrophoresis (PCR-DGGE) method showed that P. pantotrophus disappeared in the suspended medium on day 8 post-culture, whereas other bacterial communities dominated by Acidovorax sp. appeared. Interestingly, this replaced bacterial community also showed AD ability. As P. pantotrophus was detected as attached colonies around the membrane and bottom of the reactor, this bacterium can therefore be introduced in a fixed form for treatment of wastewater containing nitrate with a high C/N ratio.

Underrecognition of the severity of asthma and undertreatment of asthma in a rural area of Japan

BACKGROUND AND AIM

Revised guidelines were released in Japan in 2003 for the assessment, treatment, and management of adult asthmatics, and similar guidelines for child asthmatics were released in 2002. We reassessed the severity and possible undertreatment of asthma according to these guidelines in stable asthmatics.

METHODS

We reviewed medical records of 861 well-controlled asthmatic patients who, in April through June 2004 were cared for by 47 pulmonologists at 29 medical centers and 13 asthma clinics in a rural community in the San-in area of Japan. The physician obtained completed medical records about their symptoms and current treatment of the subjects, 726 adult and 135 children (aged 6 years or older) who were in stable condition and had had no exacerbations in the previous 3 months. The severity of asthma and current treatment for each patient were assessed according to the newly revised Japanese guidelines for the assessment, treatment, and management of adult and child asthmatics.

RESULTS

In adult and child asthmatics, the percentage of predicted forced expiratory volume at 1 second (FEV1.0) was smaller and has a narrower distribution range than the percentage of predicted peak expiratory flow (PEF). When the severity of asthma was classified according to symptoms alone, 50% and 35% of those classified as mildly asthmatics patients with adults and children, respectively, had moderate to severe airflow limitation. Inhaled corticosteroids were prescribed to 90.6% of adult and 14.9% of child patients. When we compared the treatments that patients were actually receiving against the optimal treatments indexed according to a combined symptoms-FEV1.0 classification, we found that 49% of adult asthmatics were overtreated, 21% were properly treated, and 30% were undertreated. Among children, the respective percentages were 35%, 25%, and 40%.

CONCLUSION

In well-controlled adult and child asthmatics, the severity of asthma is poorly judged when symptoms alone are considered. We suggest that the severity of asthma should be assessed through a combination of symptoms and the measurement of FEV1.0 during office visits. We also suggest that the proper dose of inhaled steroid needed to maintain stable conditions should be judged according to this combined symptoms-FEV1.0 classification.

Mutation at cleavage site of insulin-like growth factor receptor in a short-stature child born with intrauterine growth retardation

CONTEXT

Mouse knockout models have clearly demonstrated the critical importance of IGF-I and IGF receptor type 1 (IGF-IR) for embryonic growth as well as postnatal growth.

OBJECTIVE

We hypothesized that mutations of IGF-IR gene might predispose to short stature in children born with intrauterine growth retardation (IUGR).

PATIENTS

Twenty-four children with unexplained IUGR (birth weight < -1.5 SD) and short stature (<-2.0 SD) were screened for abnormalities of the IGF-IR gene.

METHODS

Direct DNA sequencing was used to identify IGF-IR gene mutations. Unprocessed IGF-IR proreceptor in fibroblasts was detected by immunoblot analysis. Functions of mutated IGF-IR in fibroblasts were evaluated by IGF-I binding, and IGF-I-stimulated DNA synthesis and beta-subunit autophosphorylation.

RESULTS

We found the following results: 1) a heterozygous mutation (R709Q) changing the cleavage site from Arg-Lys-Arg-Arg to Arg-Lys-Gln-Arg was identified in a 6-yr-old Japanese girl (case 1) and her mother who also had IUGR with short stature (case 2); 2) fibroblasts from case 2 contained more IGF-IR proreceptor protein (189 +/- 26% of normal) and less mature beta-subunit protein (63 +/- 12%); 3) [125I]IGF-I binding to fibroblasts from case 2 was reduced, compared with normal control (0.61 +/- 0.16 x 10(6) vs. 1.14 +/- 0.12 x 10(6) sites per cell; P < 0.05); and 4) both IGF-I-stimulated [3H]thymidine incorporation and IGF-IR beta-subunit autophosphorylation were low in fibroblasts from case 2, compared with those of control (P < 0.05).

CONCLUSIONS

These findings strongly suggest that this mutation leads to failure of processing of the IGF-IR proreceptor to mature IGF-IR and causes short stature and IUGR.

Risk factors for fatality and neurological sequelae after status epilepticus in children

Using multivariate regression analysis, we examined risk factors for fatality and neurological sequelae after status epilepticus (SE) in children. Possible risk factors included sex, age at onset, the cause of SE, pyrexia, asthmatic attack during SE, past history of seizure, predisposing neurological abnormality, seizure duration, type of seizure, and medication with theophylline. Consecutive patients with SE, aged 1 month to 18 years, who were referred to Tottori University Hospital from 1984 to 2002 were reviewed. Of the 234 patients enrolled, 45 patients (19.2 %) showed poor outcomes, namely early death in 9 and neurological sequela in 36. Acute neurological insult and progressive neurological disease as the cause of SE were very significantly related to poor outcome (OR = 33.68, p = 0.000). We excluded 21 patients with the etiology of acute neurological insult and progressive neurological disease and then reanalyzed risk factors in the remaining 213 patients. Twenty-nine patients (13.6 %) showed poor outcome, namely early death in 6 and neurological sequela in 23. Seizure duration of more than 2 hours (OR = 12.73, p = 0.000) and moderate to severe asthmatic attack (OR = 31.61, p = 0.010) were associated with poor outcome. These results indicate that long-lasting seizure activity and asthmatic attack can exacerbate SE-associated brain injury.

Comparison of aerobic denitrifying activity among three cultural species with various carbon sources

Abilities of three aerobic denitrifiers such as Alcaligenes faecalis, Microvirgula aerodenitrificans and Paracoccus pantotrophus were compared from the viewpoints of nitrate removal efficiency and organic matter utilization. First, the effect of carbon source was investigated. Although nitrate reduction was observed in all strains under aerobic conditions, a change of carbon source considerably affected the denitrification ability. In the case of P. pantotrophus, nitrate and nitrite were completely removed in three days under sodium acetate or leucine as a carbon source. In the case of A. faecalis, sufficient nitrate removal was observed only when sodium acetate or ethanol was added. P. pantotrophus and A. faecalis showed a higher ability of nitrate removal than that of M. aerodenitrificans. Therefore, P. pantotrophus was selected in order to investigate the effects of concentration and repetitive addition of carbon. Sodium acetate was used as a sole carbon source. Nitrate was not reduced when the carbon concentration was below 500 mgC/L. However, when carbon source was added repeatedly, nitrate was reduced under 100 mgC/L after the optical density of the bacterium reached above 1.0. This result indicated that a high enough level of bacterial density was necessary to express aerobic denitrification activity.

Compound heterozygous mutations of cytochrome P450 oxidoreductase gene (POR) in two patients with Antley-Bixler syndrome

Antley-Bixler syndrome (ABS) is characterized by skeletal defects including craniosynostosis and radiohumeral synostosis. Although mutations in the FGFR2 gene have been found in some patients called ABS, genetic heterogeneity of this syndrome has been proposed. We have previously reported three ABS patients with unique abnormalities in steroidogenesis (apparent decreased activity of 17alpha-hydroxylase, 17,20-lyase, and 21-hydroxylase). Decreased activity of lanosterol 14alpha-demethylase has also been described in an ABS patient. Since all these enzymes require cytochrome P450 oxidoreductase (encoded by POR) as an electron donor, we studied POR in two unrelated ABS patients with abnormal steroidogenesis. Direct sequencing of POR revealed that both patients had compound heterozygous mutations (1329insC and R454H in a male patient, 1698insC and R454H in a female patient). The two insertional mutations were assumed to generate truncated and unstable mRNAs. The R454H mutation was assumed to be deleterious because the R454 resides in the FAD-binding domain and is highly conserved among diverse species. Our results demonstrate that mutations in POR cause the ABS phenotype with autosomal recessive inheritance and with characteristic abnormalities in steroidogenesis.

Nitrate removal with low N2O emission by application of sulfur denitrification in actual agricultural field

Sulfur denitrification was applied to the agricultural field and the characteristics of the treatment were evaluated from the viewpoints of nitrate removal efficiency and nitrous oxide (N2O) emission. Two actual sites where sulfur denitrification was performed were surveyed. One is a valley bottom field, where groundwater contaminated with nitrate is coming up as spring water. The nitrate concentration in influent was about 45 mgN/L. The other was wastewater from a plastic greenhouse. The nitrate concentration in inflow water was about 200 mgN/L. Nitrate was almost removed by the containers packed with sulfur (S0)-CaCO3 blocks in both sites. Increase of sulfate indicated that nitrate was removed by sulfur denitrification. This was also estimated stoichiometrically from the relationships between the removed nitrate and produced sulfate. The N2O was supersaturated in water at most sampling points and the highest concentration of dissolved N2O reached 900 microgN/L in Saitama in March. It seemed that insufficient nitrate removal caused accumulation of intermediates during denitrification, such as nitrite and N2O, in this month. However, the emission ratio of N2O to the removed nitrate during these processes was kept low, ranging from 0.01 to 0.19%, at both two sites throughout all surveys.

Criteria for medical intervention in obese children: a new definition of 'obesity disease' in Japanese children

The Committee of the Japan Society for the Study of Obesity reported the new criteria for 'obesity disease' for Japanese adults in 2000. We defined the criteria for the diagnosis of obesity in children with medical problems, corresponding to the 'obesity disease' criteria in adults. Obesity in childhood was defined as follows: percentage of overweight (POW) and body fat exceeded the criteria. 'Obesity disease in childhood' was defined as obesity associated with health or medical problems, and with indications for medical intervention. Medical problems with indications for immediate intervention were grouped as A problems, which consisted of (i). hypertension; (ii). sleep apnea or hypoventilation; (iii). Type 2 diabetes mellitus or impaired glucose tolerance; and (iv). increased waist circumference or accumulation of visceral adipose tissue. Metabolic derangements or equivalent associated with obesity were grouped as B problems: (i). liver dysfunction; (ii). hyperinsulinemia; (iii). hypercholesterolemia; (iv). hypertriglyceridemia; (v). low serum high-density lipoprotein cholesterol; (vi). acanthosis nigricans, and (vii). hyperuricemia. Obese children over 5 years of age with following conditions were diagnosed as 'obesity disease in childhood': (i). any 'A problem', (ii) POW >or= 50% and any 'B problem', or (3) POW < 50% and more than one 'B problem' or equivalent. We decided to take physicosocial problems related to obesity into consideration as the criteria. The resultant criteria are proposed by the Committee for Research of Appropriate Body Build in Children*.