Incidence and Risk Factors for Adrenal Crisis in Pediatric-onset Adrenal Insufficiency: A Prospective Study

PURPOSE

To determine the incidence and risk factors for adrenal crisis (AC) in patients with pediatric-onset adrenal insufficiency (AI).

MATERIALS AND METHODS

This multicenter, prospective cohort study conducted in Japan enrolled patients diagnosed with AI at ≤ 15 years of age. The incidence of AC was calculated as events per person-year (PY), and risk factors for AC were assessed using Poisson regression multivariable analysis.

RESULTS

The study population comprised 349 patients (164 male, 185 female) with a total follow-up of 961 PY. The median age at enrollment was 14.3 years (interquartile range [IQR] 8.5-21.2 years), and the median follow-up was 2.8 years (IQR 2.2-3.3 years). Of these patients, 213 (61%) had primary AI and 136 (39%) had secondary AI. Forty-one AC events occurred in 31 patients during the study period. The calculated incidence of AC was 4.27 per 100 PY (95% confidence interval [CI] of 3.15-5.75). Poisson regression analysis identified younger age at enrollment (relative risk [RR] 0.93 [95% CI 0.89-0.97]) and increased number of infections (RR 1.17 [95% CI 1.07-1.27]) as significant risk factors. Female sex (RR 0.99 [95% CI 0.53-1.86]), primary AI (RR 0.65 [95 % CI 0.30-1.41]), or equivalent dosage of hydrocortisone per square meter of body area (RR 1.02 [95% CI 0.96-1.08]) was not a significant risk factor.

CONCLUSION

A substantial proportion of patients with pediatric-onset AI experience AC. Younger age and an increased number of infections are independent risk factors for developing AC in these patients.

Classification of pseudohypoaldosteronism type II as type IV renal tubular acidosis: results of a literature review

Pseudohypoaldosteronism (PHA) type II (PHA2) is a genetic disorder that leads to volume overload and hyperkalemic metabolic acidosis. PHA2 and PHA type I (PHA1) have been considered to be genetic and pediatric counterparts to type IV renal tubular acidosis (RTA). Type IV RTA is frequently found in adults with chronic kidney disease and is characterized by hyperchloremic hyperkalemic acidosis with normal anion gap (AG). However, we recently observed that PHA1 was not always identical to type IV RTA. In this study, we focused on the aid-base balance in PHA2. Through a literature search published between 2008-2020, 46 molecularly diagnosed cases with PHA2 were identified (median age of 14 years). They comprised 11 sets of familial and 16 sporadic cases and the pathology was associated with mutations in WNK 4 (n = 1), KLHL3 (n = 17), and CUL3 (n = 9). The mean potassium (K⁺) level was 6.2 ± 0.9 mEq/L (n = 46, range 4.0-8.6 mEq/L), whereas that of chloride (Cl^-) was 110 ± 3.5 mEq/L (n = 41, 100-119 mEq/L), with 28 of 41 cases identified as hyperchloremic. More than half of the cases (18/35) presented with metabolic acidosis. Although AG data was obtained only in 16 cases, all but one cases were within normal AG range. Both Cl^- and HCO3^- levels showed significant correlations with K⁺ levels, which suggested that the degree of hyperchloremia and acidosis reflect the clinical severity, and is closely related to the fundamental pathophysiology of PHA2. In conclusion, our study confirmed that PHA2 is compatible with type IV RTA based on laboratory findings.

Acid-base imbalance in pseudohypoaldosteronism type 1 in comparison with type IV renal tubular acidosis

Context

Pseudohypoaldosteronism type 1 (PHA1) has been treated as a genetic variant of type IV renal tubular acidosis (RTA), leading to the conception that PHA1 develops hyperchloremic acidosis with a normal anion gap (AG).

Objective

To delineate the acid–base imbalance in PHA1A (dominant type) and PHA1B (recessive type).

Methods

We conducted the following: (1) a retrospective chart review of our patient with PHA1B, and (2) a literature search of PHA1 cases focusing on acid–base balance. The main outcome measures were the incidence and nature of acidosis, including chloride levels and AG.

Results

In our patient with PHA1B, 7 salt-wasting episodes were analyzed. Acidosis was ascertained each time, and it was accompanied by hypochloremia except in 1 episode. AG was elevated in 5 episodes, while hyperlacticaemia was present in 3. In the literature, 41 cases of PHA1A and 65 cases of PHA1B have been identified. During salt-wasting crises, acidosis developed in 85% of PHA1A cases and 87% of PHA1B cases. Hypochloremia was present in 69% of PHA1A cases with available data (n = 13) and 54% of eligible PHA1B cases (n = 13), with mean chloride levels of 96 mEq/L and 95 mEq/L, respectively. Increased AG was less frequently reported (14% in PHA1A and 44% in PHA1B).

Conclusions

Patients with PHA1 frequently presented with metabolic acidosis. However, hyperchloremia may not be a universal finding, whereas hypochloremia and increased AG may occur in a substantial proportion of the patients.

Genetic Analysis of Japanese Children Clinically Diagnosed with Familial Hypercholesterolemia

Aim: This study aimed to elucidate the gene and lipid profiles of children clinically diagnosed with familial hypercholesterolemia (FH).

Methods: A total of 21 dyslipidemia-related Mendelian genes, including FH causative genes (LDLR,APOB, andPCSK9) and LDL-altering genes (APOE,LDLRAP1, andABCG5/8), were sequenced in 33 Japanese children (mean age, 9.7±4.2 years) with FH from 29 families.

Results: Fifteen children (45.5%) with pathogenic variants inLDLR (eight different heterozygous variants) and one child (3.0%) with thePCSK9 variant were found. Among 17 patients without FH causative gene variants, 3 children had variants in LDL-altering genes, anAPOE variant and twoABCG8 variants. The mean serum total cholesterol (280 vs 246 mg/dL), LDL-cholesterol (LDL-C, 217 vs 177 mg/dL), and non-HDL cholesterol (228 vs 188 mg/dL) levels were significantly higher in the pathogenic variant-positive group than in the variant-negative group. In the variant-positive group, 81.3% of patients had LDL-C levels ≥ 180 mg/dL but 35.3% in the variant-negative group. The mean LDL-C level was significantly lower in children with missense variants, especially with the p.Leu568Val variant, than in children with other variants inLDLR, whereas the LDL-altering variants had similar effects on the increase in serum LDL-C toLDLR p.Leu568Val.

Conclusion: Approximately half of the children clinically diagnosed with FH had pathogenic variants in FH causative genes. The serum LDL-C levels tend to be high in FH children with pathogenic variations, and the levels are by the types of variants. Genetic analysis is useful; however, further study on FH without any variants is required.

A pediatric patient with hyponatremic hypertensive syndrome without persistent hypertension in acute phase: A case report and review of literature

Hyponatremic hypertensive syndrome is characterized by hypertension, hyponatremia, and hypokalemia due to unilateral renal artery stenosis. We herein report a 1-year-old hyponatremic hypertensive syndrome infant without persistent hypertension in the acute phase. On the ninth hospital day, his systolic and diastolic blood pressure increased up to 154-160 and 70-84 mmHg, respectively. Acute gastroenteritis and dehydration might transiently mask his hypertension. By percutaneous transluminal balloon angioplasty for right renal artery, his blood pressure finally normalized without antihypertensive drugs. We reviewed 23 previously reported pediatric patients with hyponatremic hypertensive syndrome under the age of 15 years. Including our patient, there are only three reports on hyponatremic hypertensive syndrome without persistent hypertension in the acute phase. Hyponatremic hypertensive syndrome is curable with proper diagnosis and timely intervention. Therefore, pediatricians should pay attention to the signs and symptoms associated with hyponatremic hypertensive syndrome, even if persistent hypertension was absent in the acute phase.

Diagnosis of congenital hyperinsulinism: Biochemical profiles during hypoglycemia

OBJECTIVES

To define the ranges of biochemical markers during hypoglycemia for the diagnosis of congenital hyperinsulinism (CHI), using high sensitivity insulin assays.

SUBJECTS

A total of 298 patients with CHI and 58 control patients with non-hyperinsulinemic hypoglycemia, who were diagnosed after 2007.

METHODS

The levels of biochemical markers (glucose, insulin, β-hydroxybutyrate [BHB], free fatty acids [FFA], lactate, ammonia) at the time of hypoglycemia were analyzed along with the maximal glucose infusion rate (GIR) to maintain euglycemia and clinical outcomes.

RESULTS

Median levels of blood glucose in patients with CHI and in controls were 30 and 46 mg/dL, while insulin levels were 9.90 and undetectable (<.5) μU/mL, respectively. Similarly, median levels of BHB were 17.5 and 3745 µmol/L, and those of FFA were 270.5 and 2660 µmol/L, respectively. For patients after 5 months, cutoffs of insulin >1.25 μU/mL, BHB < 2000 µmol/L, and FFA < 1248 µmol/L predicted CHI with sensitivities of 97.5, 96.2, and 95.2% and specificities of 84.2, 89.3, and 92.3%, respectively. Maximal GIR in the CHI groups tended to decrease with age. In addition, decreased gestational age, low birth weight, and elevated lactate at hypoglycemia were significantly more common in patients who were off treatment within 100 days without pancreatectomy.

CONCLUSIONS

After introduction of high-sensitive assays, the diagnostic value of insulin was improved, allowing for more efficient cutoffs to be set for diagnosis of CHI. Premature birth, low birth weight and elevated lactate might be helpful in predicting early remission of hypoglycemia.

A novel de novo germline mutation Glu40Lys in AKT3 causes megalencephaly with growth hormone deficiency

Germline or somatic gain-of-function mutations in the v-akt murine thymoma viral oncogene homolog 3 (AKT3) have been reported to cause syndromic megalencephaly. We describe a novel germline mutation, p.Glu40Lys, in AKT3. Phenotypically, the patient presented with megalencephaly with hypotonia, apparent connective tissue laxity, and growth hormone (GH) deficiency. To our knowledge, this is the first instance of a patient with megalencephaly with GH deficiency, harboring a germline de novo mutation in AKT3. © 2017 Wiley Periodicals, Inc.

Evaluation of Hip/HeightP Ratio as an Index for Adiposity and Metabolic Complications in Obese Children: Comparison with Waist-related Indices

Aim: To investigate whether body adiposity index (BAI; hip/height^1.5–18), pediatric BAI (BAIp; hip/height^0.8–38), and other hip/height^P ratios are useful in obese children.

Method: Ninety obese Japanese children, 55 boys and 35 girls, who visited our University Clinic, were enrolled. The age was 9.92 ± 2.6 (mean ± SD) years, and the percentage overweight (POW) was 51.6 ± 18.8%. We set the power value of the hip/height^P 0, 0.5, 0.8, 1, 1.5, and 2 and studied the association with overweight indices, biochemical data, and fat area measured by computed tomography. Waist, waist/height ratio, and waist/hip ratio were also evaluated.

Results: Hip/height and hip/height^0.8 (BAIp) were more closely correlated with POW, body mass index percentile, and percentage body fat than hip/height^1.5 (BAI). The correlation coefficient of hip/height with POW (r = 0.855) was the highest among the studied hip/height^P indices. The approximate line to predict POW was 411 × hip/height−207. The waist/height was also highly correlated with POW (r = 0.879). Hip and hip/height^0.5 were more closely correlated with visceral fat area than hip/height, BAIp, and hip/height^1.5. Hip and hip/height^0.5 were significantly correlated with insulin. Only hip was also significantly associated with dyslipidemia. All hip/height^P indices were not significantly correlated with alanine aminotransferase (ALT). Waist was significantly correlated with serum lipids, ALT, and insulin.

Conclusion: Hip/height and BAIp are better markers for overweight (adiposity) in obese children than BAI. However, hip/height, BAIp, and BAI are not useful to predict metabolic complications. Waist appears to be the best index for obese children overall at this time.

AICAR Attenuates TNFα-Induced Inappropriate Secretion of Monocyte Chemoattractant Protein-1 and Adiponectin in 3T3-L1 Adipocytes

Aim: The increase in monocyte chemoattractant protein-1 (MCP-1) and the decrease in adiponectin production from hypertrophic adipocytes are associated with adipose tissue inflammation and its metabolic complications. The aim of this study was to determine whether 5-aminoimidazole-4-carboxamide 1-β-D-ribofuranoside (AICAR), an adenosine monophosphate-activated protein kinase (AMPK) activator, modulates these adipocytokine productions in tumor necrosis factor-α (TNFα)-treated adipocytes.

Methods: AICAR and/or other reagents were added to the culture medium, and then, TNFα was added to fully differentiated 3T3-L1 adipocytes. The MCP-1 and adiponectin production in the culture supernatant was measured by ELISA. AMPK, phosphatidylinositol 3-kinase (PI3K), and nuclear factor-κB (NF-κB) activities were also assayed.

Results: Treatment with TNFα increased MCP-1 and decreased adiponectin secretion dose-dependently in the 3T3-L1 adipocytes, and AICAR significantly inhibited these TNFα-mediated changes. Interestingly, metformin, another AMPK activator, did not have such effects on these adipocytokines. Both the AMPK and PI3K systems in the cells were significantly activated by the AICAR treatment, but the effects of AICAR on adipocytokines were not weakened by the addition of dorsomorphin, an AMPK inhibitor, or LY294002, a PI3K inhibitor. Pyrrolidine dithiocarbamate (PDTC), an NF-κB inhibitor, showed protective effects similar to those as AICAR. AICAR, but not metformin, significantly inhibited the TNFα-stimulated activation of NF-κB, and dorsomorphin did not change AICAR's effect.

Conclusion: AICAR attenuates the TNFα-induced secretion of MCP-1 and adiponectin in 3T3-L1 adipocytes. The observed effects of AICAR seem to be mainly due to the inhibition of NF-κB activation rather than the activation of the AMPK pathway, at least in TNFα-treated adipocytes.

Feeding choice has a gender-associated effect on infant growth

BACKGROUND

Appropriate nutrition during childhood is important for preventing future development of lifestyle-related diseases. The effect of feeding choice on infant growth in Japan is not known.

METHODS

Data from 204 healthy schoolchildren (age, 6-9 years) were obtained retrospectively from their parents by questionnaires. Breast-fed (BF) and formula-fed (FF) groups were defined as those fed only breast milk or formula milk at 4 months of age, respectively. There were 71 children (M/F, 31/40) in BF and 30 (M/F, 19/11) in FF. Anthropometric data at birth, and at 1, 4, 7, 10, 18, and 36 months of age in male and female infants were compared between the groups.

RESULTS

In male infants, height was significantly lower at 4 months, bodyweight was lower from 4 to 18 months, and body mass index (BMI) was lower from 10 to 36 months in BF than in FF. The standard deviation scores (SDS) for height, weight and BMI had a similar pattern. No significant differences were observed for these variables for female infants in BF compared with FF. Multiple regression analysis showed that birthweight, mother's pre-pregnancy weight, and infant feeding choice were significant factors associated with weight-SDS at 18 and 36 months. Feeding choice was the only factor associated with BMI-SDS at 18 months.

CONCLUSIONS

Infant feeding choice had a gender-associated effect on growth during infancy. When evaluating infant growth, not only birthweight and mother's pre-pregnancy weight, but also infant feeding choice and gender should be considered.

Cord serum adiponectin is positively related to postnatal body mass index gain

BACKGROUND

The roles of adiponectin and leptin in the early stages of life are poorly understood. We previously studied longitudinal changes in these adipocytokines from birth to 12 months of age. The aim of this investigation was to evaluate the correlation between cord serum adipocytokine levels and postnatal growth by 3 years of age.

METHODS

A questionnaire was sent to obtain the general physical measurements of 3-year-olds from 56 healthy newborn infants born at a gestational age of 35 weeks or more; 45 valid responses were obtained. The correlations between variables, including cord serum adipocytokine levels at birth and general physical measurements at 3 years, were investigated.

RESULTS

Body mass index (BMI) Z-score gain from birth to 3 years was negatively correlated with birthweight SD scores (β=-0.395, P= 0.019) and gestational age (β=-0.557, P= 0.016), and positively correlated with cord serum adiponectin levels (β= 0.253, P= 0.043). BMI Z-score gain from birth to 6 months was negatively correlated with only birthweight SD score (β=-0.442, P= 0.017). Cord serum leptin levels were not a significant predictor of BMI Z-scores gain in our subjects. BMI Z-scores at 6 months, 12 months, and 3 years of age were not related to cord serum adiponectin or leptin levels.

CONCLUSIONS

Birthweight SD score, gestational age, and cord serum adiponectin levels are significant predictors of BMI Z-score gain from birth to 3 years of age in Japanese infants.

Sensitivity of the infectious long form of the macronuclear endosymbiont Holospora obtusa of the ciliate Paramecium caudatum against chemical and physical factors

Effects of various temperatures, pHs and drugs on the morphology, infectivity to the macronucleus of Paramecium caudatum (ability to penetrate macronuclear membrane), and reproductive ability of the infectious long form of Holospora obtusa were examined. The infectivity was not lost between pH 3-12, suggesting that acidosomal fusion with the bacteria-bearing food vacuoles does not inactivate the bacterial infectivity because pH in the food vacuoles at the maximum acidification has been known to be 3. However, bacteria treated with 220 μg/ml α-mannosidase could not infect the macronucleus though they could invade the host cytoplasm, via food vacuoles. This indicates that the bacteria have to escape from the food vacuole and invade the host cytoplasm within 8 min after being engulfed into the food vacuoles for successful infection, because it is known that the lysosomal fusion occurs at 8 min and a-mannosidase activity has been detected in P. caudatum. Other glycoside hydrolases and proteases examined did not affect the bacteria. The bacteria could be kept at -85°C for 6 months without any damage, but they easily lost the infectivity at temperatures higher than 30°C. Treatments with 250 units/ml penicillin and 0.25 % (w/v) kanamycin for 1 week at 25°C did not affect the bacteria, suggesting that the infectious long form is metabolically inactive. The bacteria became cell-wall ghosts in 50 % (w/v) acetic acid and soon lysed in 0.5 N NaOH, but hardly lysed in various detergents used.

Galectin-9 expands immunosuppressive macrophages to ameliorate T-cell-mediated lung inflammation

Galectin-9 (Gal-9) plays pivotal roles in the modulation of innate and adaptive immunity to suppress T-cell-mediated autoimmune models. However, it remains unclear if Gal-9 plays a suppressive role for T-cell function in non-autoimmune disease models. We assessed the effects of Gal-9 on experimental hypersensitivity pneumonitis induced by Trichosporon asahii. When Gal-9 was given subcutaneously to C57BL/6 mice at the time of challenge with T. asahii, it significantly suppressed T. asahii-induced lung inflammation, as the levels of IL-1, IL-6, IFN-gamma, and IL-17 were significantly reduced in the BALF of Gal-9-treated mice. Moreover, co-culture of anti-CD3-stimulated CD4 T cells with BALF cells harvested from Gal-9-treated mice on day 1 resulted in diminished CD4 T-cell proliferation and decreased levels of IFN-gamma and IL-17. CD11b(+)Ly-6C(high)F4/80(+) BALF Mphi expanded by Gal-9 were responsible for the suppression. We further found in vitro that Gal-9, only in the presence of T. asahii, expands CD11b(+)Ly-6C(high)F4/80(+) cells from BM cells, and the cells suppress T-cell proliferation and IFN-gamma and IL-17 production. The present results indicate that Gal-9 expands immunosuppressive CD11b(+)Ly-6C(high) Mphi to ameliorate Th1/Th17 cell-mediated hypersensitivity pneumonitis.

Galectin-9 increases Tim-3+ dendritic cells and CD8+ T cells and enhances antitumor immunity via galectin-9-Tim-3 interactions

A Tim-3 ligand, galectin-9 (Gal-9), modulates various functions of innate and adaptive immune responses. In this study, we demonstrate that Gal-9 prolongs the survival of Meth-A tumor-bearing mice in a dose- and time-dependent manner. Although Gal-9 did not prolong the survival of tumor-bearing nude mice, transfer of naive spleen cells restored a prolonged Gal-9-induced survival in nude mice, indicating possible involvement of T cell-mediated immune responses in Gal-9-mediated antitumor activity. Gal-9 administration increased the number of IFN-gamma-producing Tim-3(+) CD8(+) T cells with enhanced granzyme B and perforin expression, although it induced CD4(+) T cell apoptosis. It simultaneously increased the number of Tim-3(+)CD86(+) mature dendritic cells (DCs) in vivo and in vitro. Coculture of CD8(+) T cells with DCs from Gal-9-treated mice increased the number of IFN-gamma producing cells and IFN-gamma production. Depletion of Tim-3(+) DCs from DCs of Gal-9-treated tumor-bearing mice decreased the number of IFN-gamma-producing CD8(+) T cells. Such DC activity was significantly abrogated by Tim-3-Ig, suggesting that Gal-9 potentiates CD8(+) T cell-mediated antitumor immunity via Gal-9-Tim-3 interactions between DCs and CD8(+) T cells.

Galectin-9 expands unique macrophages exhibiting plasmacytoid dendritic cell-like phenotypes that activate NK cells in tumor-bearing mice

Galectin-9 (Gal-9) inhibits the metastasis of tumor cells by blocking their adhesion to endothelium and the extracellular matrix. In this study, we addressed the involvement of Gal-9 in anti-tumor activity. Gal-9 significantly prolonged the survival of B16F10 melanoma-bearing mice. Gal-9 increased the numbers of NK cells, CD8 T cells and macrophages in tumor-bearing mice. Gal-9-mediated anti-tumor activity was not induced in NK cell-, macrophage- and CD8 T cell-depleted mice. NK cells from Gal-9-treated mice, compared to PBS-treated mice, exhibited significantly higher cytolytic activity. Co-culture of naïve NK cells with macrophages from Gal-9-treated mice resulted in enhanced NK activity, although Gal-9 itself did not enhance the NK activity. We also found that Ly-6C(+)CD11b(+)F4/80(+) macrophages with plasmacytoid cell (pDC)-like phenotypes (PDCA-1 and B220) were responsible for the enhanced NK activity. These results provide evidence that Gal-9 promotes NK cell-mediated anti-tumor activity by expanding unique macrophages with a pDC-like phenotype.

Galectin-9 suppresses tumor metastasis by blocking adhesion to endothelium and extracellular matrices

We previously described an inverse correlation between galectin-9 (Gal-9) expression and metastasis in patients with malignant melanoma and breast cancer. This study verified the ability of Gal-9 to inhibit lung metastasis in experimental mouse models using highly metastatic B16F10 melanoma and Colon26 colon cancer cells. B16F10 cells transfected with a secreted form of Gal-9 lost their metastatic potential. Intravenous Gal-9 administration reduced the number of metastases of both B16F10 and Colon26 cells in the lung, indicating that secreted Gal-9 suppresses metastasis. Analysis of adhesive molecule expression revealed that B16F10 cells highly express CD44, integrin alpha1, alpha 4, alpha V, and beta1, and that Colon26 cells express CD44, integrin alpha2, alpha 5, alpha V, and beta1, suggesting that Gal-9 may inhibit the adhesion of tumor cells to vascular endothelium and the extracellular matrix (ECM) by binding to such adhesive molecules. Indeed, Gal-9 suppressed the binding of hyaluronic acid to CD44 on both B16F10 and Colon26 cells, and also suppressed the binding of vascular cell adhesion molecule-1 to very late antigen-4 on B16F10 cells. Furthermore, Gal-9 inhibited the binding of tumor cells to ECM components, resulting in the suppression of tumor cell migration. The present results suggest that Gal-9 suppresses both attachment and invasion of tumor cells by inhibiting the binding of adhesive molecules on tumor cells to ligands on vascular endothelium and ECM.

Prediction of the permanent dentition in deciduous anterior crossbite

Early prospective evaluation for self-correction of deciduous anterior crossbite can enable identification of patients who require early treatment as well as those who do not. The purpose of the present study was to generate an algorithm that can be used to predict self-correction in the transitional dentition in 3-year-old subjects. The subjects were divided into 2 groups. One group comprised 22 subjects whose anterior crossbite self-corrected during the transitional stage (hereafter referred to as group N). The other group was comprised of 22 subjects whose anterior crossbite persisted during the transitional dentition (hereafter referred to as group R). All subjects were examined using lateral cephalometric radiography in order to evaluate differences in occlusion. Fifteen measurements were used for the evaluation. For each measurement, the variance ratio and the difference in the population mean between groups N and R were tested and t-values were derived. Based on the Student's t-test results, only measurements that had statistically significant differences (P < .05) were extracted. Predictor variables that had a partial F value of 5 or greater were selected for stepwise discriminant analysis, and the following equation was obtained: deciduous indicator (DI) = -0.58(cranial length anterior) + 1.31(posterior facial height) - 0.76(porion location) - 2.02(Wits appraisal) - 70.28. The lower the DI value (negative), the higher the probability that the crossbite will self-correct at the transitional dentition. On the other hand, a high (positive) discriminant score strongly suggests that the subject requires treatment in the primary dentition. The result of this analysis showed that the apparent error rate was 95.46% and the Maharanobis' generalized distance was 8.99.

Displacement and stress distribution in the temporomandibular joint during clenching

The aim of this study was to analyze biomechanical reactions in the mandible and TMJ during clenching under various restraint conditions. A three-dimensional finite element model of the mandible, including the TMJ, was created for test purposes. The results were as follows: (1) Under any restraint conditions, displacement was greatest on the surface of the condyle and less on the articular disc and the surface of the glenoid fossa, in that order. Resultant stresses followed the same trend. (2) Displacement and stress were greatest when the lower central incisor was restrained and attenuated as the posterior teeth were restrained. Because the biomechanical reaction of the TMJ during clenching was greatest when the lower central incisor was restrained, premature contact of these teeth may be one of the factors involved in the initiation of temporomandibular arthrosis.

Cephalometric changes during self-correction of primary anterior crossbite

Longitudinal growth changes were investigated cephalometrically for sixty-one Japanese girls who had anterior crossbite at the initial visit (ages 3 years and 11 months on an average). Cephalograms were taken annually from the initial visit to the end of the observation period (ages 7 years 6 months on an average). Eleven of them (Group N1) showed self-correction of anterior crossbite during the primary dentition; ten (Group N2) showed self-correction when the permanent incisors erupted and forty (Group R) did not show self-correction. There was no statistical skeletal difference between Groups N1 and N2 during the observation period. Groups N1 and N2 were larger, however, than Group R in A'-Ptm'/Pog'-Go (p < 0.05) and Group N1 was smaller than Group R in Pog'-Go/N-S (p < 0.01) at the end of the observation period. In summary, favorable growth of the maxilla relative to the mandible leads to self-correction of primary crossbite and when mandible size relative to the cranial base is large, primary crossbite does not show self-correction.

Three year prospective, randomized evaluation of intraocular lens implantation through 3.2 and 5.5 mm incisions

PURPOSE

To compare the long-term clinical results of two small incision cataract surgery procedures.

SETTING

Seven centers in Japan.

METHODS

Two hundred eyes were randomly assigned to receive a silicone intraocular lens (IOL) through a 3.2 mm incision or a poly(methyl methacrylate) (PMMA) IOL through a 5.5 mm incision. Except for incision size and implantation technique, the surgical methods were identical. Uncorrected and corrected visual acuity, keratometry, flare-cell intensity, specular microscopy, and neodymium:YAG (Nd:YAG) laser posterior capsulotomy rate were analyzed up to 3 years after surgery.

RESULTS

Eyes in the 3.2 mm incision group had significantly better uncorrected and corrected visual acuity in the early postoperative period and lower aqueous flare intensity immediately after surgery, but these differences disappeared after the first postoperative month. However, surgically induced astigmatism was significantly less in the 3.2 mm incision group than in the 5.5 incision group throughout the study. The Nd:YAG laser capsulotomy rate was higher in the silicone IOL group (23.5% at 3 years postoperatively) than in the PMMA IOL group (18.4%) but the difference was not statistically significant.

CONCLUSION

Smaller incision cataract surgery led to early recovery of visual function in the short term and less induced astigmatism in the long term.

Three-dimensional computed tomography evaluation of postsurgical condylar displacement after mandibular osteotomy

OBJECTIVE

The purpose of this study was to examine both condylar displacement of the temporomandibular joint after sagittal split ramus osteotomy with rigid osteosynthesis and intraoral vertical ramus osteotomy without osteosynthesis in patients with mandibular prognathism by means of three-dimensional computed tomography.

STUDY DESIGN

In this pilot study, five patients treated with sagittal split ramus osteotomy and 5 patients treated with intraoral vertical ramus osteotomy were evaluated. A technique to superimpose a postoperative three-dimensional computed tomography image on its corresponding preoperative image was designed. Postoperative condylar displacement, rotation, and tilting were measured in three-dimensional computed tomography images.

RESULTS

Within 3 to 6 months after surgery, changes in the inclination of the condylar axes were distinctly seen, although changes in the position of the condyles within the joints were minimal. In particular, outward rotation of the condylar long axes after intraoral vertical ramus osteotomy was a frequent finding.

CONCLUSIONS

The three-dimensional computed tomography superimposition technique was a practical method of evaluating postsurgical condylar displacement after mandibular osteotomy.

Longitudinal changes in the skeletal pattern of deciduous anterior crossbite

Some patients who have an anterior crossbite in the deciduous dentition lose the crossbite during the transitional stage to permanent anterior teeth without orthodontic and/or orthopedic treatment. We observed 220 anterior crossbite patients at regular intervals and identified three groups of patients: in group N (n = 16) the crossbite corrected when the central incisors erupted; in group R1 (n = 16) the crossbite was within [formula: see text] and remained unchanged following the eruption of the permanent central incisors; in group R2 (n = 12) the crossbite extended over [formula: see text] and remained following the eruption of the permanent central incisors. The purpose of this study was to determine whether any differences existed among the above three groups at the initial examination, or if differences arose during eruption of the teeth. The findings indicate that the mandibular position in group N was more posterior than in groups R1 and R2, and the lengths of Pog'-Go and Gn-Cd in group N were smaller. Tooth axis of the lower incisors in groups R1 and R2 showed lingual tipping, and the maxilla in group R2 was underdeveloped. The findings of the longitudinal changes indicated that the maxillary length in group N increased and mandibular forward growth was suppressed. The initial maxillary position in groups R1 and R2 remained much the same until the permanent central incisors erupted.

Orthodontic treatment of an open bite patient with oral-facial-digital syndrome

A case of oral-facial-digital syndrome was treated orthodontically. Characteristics of this case were mandibular protrusion with open bite. Occlusal stability after correction of this malocclusion was achieved with the uprighting of the posterior teeth, surgical reduction of the enlarged tonsils and highly attached tongue frenum, and oral functional training.

Tenascin: growth and adhesion modulation--extracellular matrix degrading function: an in vitro study

Tenascin (TN), a recently characterised extracellular matrix protein, largely confined to the process with the development of embryo in areas of epithelial-mesenchymal interactions and in areas where there are morphogenetic movements and tissue patterning, has a highly restricted expression in adult tissues. The expression of TN is enhanced in a variety of human neoplastic lesions. However, function(s) and molecular mechanisms of enhanced expression in neoplastic lesions remain unclear. We employed human tongue carcinoma cells (SCCKN), human salivary gland adenocarcinoma cells (SGT-1), normal mouse embryonic fibroblasts (NIH3T3-3) and K-ras-2 transformed fibroblasts (Cle-H3) in an in vitro study to elucidate the biological roles of TN. In in vitro studies, all the cell lines examined had enhanced secretion of TN in the presence of transforming growth factor-beta in a dose-dependent manner and TN itself was found to possess a growth-enhancing activity. Moreover, studies on adhesion of the cell lines on coated substrates of fibronectin (FN), laminin (LN), tenascin (TN), TN/FN and TN/LN showed that all the cells adhere and spread well on FN and LN. However, on TN they attach poorly and remain rounded. The relative concentrations of TN and FN affected the cellular adhesion and morphology. In SCCKN and SGT-1, but not in NIH3T3 and Cle-He3 fibroblasts, a higher concentration of TN inhibited cellular adhesion on fibronectin, suggesting that cells attach poorly on TN, it may interfere with the action of fibronectin, and the relative concentrations of TN, FN or LN may affect cellular adhesion and morphology which may differ in different cell types. When TN was added in the growth medium of exponentially growing cells, the cells lost their cell to cell contact and were seen to be separating. The presence of these extracellular matrix proteins were further tested to determine whether they could modulate the secretion of proteolytic enzymes responsible for extracellular matrix degradation by tumour cells, when the neoplastic cells but not the non-neoplastic cells grown on FN/TN substrate showed positive immunofluorescence for collagenase. FN, LN or TN alone did not induce collagenase in the tumour cells. If the same is true in vivo, although a number of factors and interactions may implicate the ultimate outcome, the enhanced expression of TN in neoplastic lesions may have potential implications for tumour growth, differentiation, cellular adhesion, invasion and metastasis.

Stimulation of in vivo calcification using collagen membranes cultured with osteoblastic cells in vitro: a preliminary report

Guided tissue regeneration (GTR) is a useful modality in the management of periodontal disease and for bone augmentation around osseointegrated implants. This study evaluated the in vivo use of atelocollagen membrane (AC) on which osteoblastic cells (OBCs) were cultured in vitro, for application as a GTR membranous material. Osteoblastic cells isolated in our laboratory from mouse calvaria formed a thin film on the AC in vitro which was easily manipulated after 21 days in culture. The AC and OBCs complex material (ACOB) was subjected to freezing and thawing and implanted in mouse subcutaneous tissue for the study of histologic events surrounding the implanted ACOB. Histologic findings in the subcutaneous tissue showed calcification on the ACOB at 28 days postimplantation, while no such finding was evident at the control site, where only AC without OBCs were grafted. The present study suggests the possibility of membrane calcification for GTR through ACOB produced by OBCs on an AC in vitro.

Posterior bite raising effects on a primary anterior crossbite case

Stainless steel crowns were cemented on the mandibular primary molars to make bite raising for an anterior reversed bite case. Chewing force and MKG were recorded before and after bite raising. Data from MKG revealed that co-ordination pattern of muscle activities after bite raising became higher in masseter muscles than those before anterior reversed bite was corrected easily without any incisal interferences by using this treatment method.

Allotransplantation of cryopreserved menisci in monkey: histological change

The purpose of this study was to carry out a histological evaluation of cryopreserved menisci used as allografts in monkeys. Menisci were evaluated histologically at one, three, six and at twelve months after transplantation. In the deep layer of the allografts, the number of cells and the amount of the extracellular matrix had decreased at three to six months after transplantation. After twelve months, the evaluation revealed that both the cell counts and the extracellular matrix had increased returning to nearly normal levels. However, the colour of the matrix stained with Masson's trichrome had changed to red. This change may correspond with the occurrence that of young newly-formed collagen. Since the articular cartilage showed minimal degenerative change, it is concluded that meniscal transplantation is useful and should be considered for meniscal injuries.

Comparative study of intraocular lens implantation through 3.2- and 5.5-mm incisions

PURPOSE

To prospectively and comprehensively compare the clinical results of two small-incision cataract surgery procedures, silicone intraocular lens (refractive index of 1.46) implantation through a 3.2-mm incision and polymethylmethacrylate intraocular lens implantation through a 5.5-mm incision.

METHODS

Two hundred eyes with cataract randomly were assigned to either procedure. Except for incision size, identical surgical methods were used in every case. Data on uncorrected and corrected visual acuity, keratometry, corneal topography, flare-cell measurement, fluorophotometry, specular microscopy, glare disability measurement, and photographic examination of intraocular lens decentration were analyzed up to 6 months after surgery.

RESULTS

Eyes in the 3.2-mm incision group displayed significantly better uncorrected and corrected visual acuity in the early postoperative period, lower aqueous flare intensity and cell counts immediately after surgery, less operatively induced astigmatism throughout the study period, and less corneal topographic changes taken 3 months after surgery. No significant between-group differences were noted for other parameters. Complications in the two groups were few and comparable.

CONCLUSION

Both procedures of small-incision cataract surgery offered satisfactory clinical results, but 3.2-mm incision cataract surgery allowed significantly earlier recovery of visual function and better preservation of corneal shape.

Multiple symmetrical lipomatosis: no longer just a Mediterranean disease?

Multiple symmetrical lipomatosis is a rare condition, of which the etiology remains unclear. Most reported cases have been from the Mediterranean countries, and it is generally thought of as a disorder characteristic of that region. However, there have been 11 cases reported in Japan since 1978, suggesting that this condition is no longer confined to Mediterranean countries.

An in vivo evaluation of an osteoinductive implantable material produced by osteoblastic cells in vitro

Osteoinductive implantable materials have been a subject of basic science research in clinical implantology. This study examined the osteoinductive effect of an implantable material produced by osteoblastic cells that were isolated in the laboratory from mouse calvaria. After 21 days in culture, osteoblastic cells formed a thin film that could be easily manipulated. This thin film was subjected to freezing and thawing and was implanted in mouse muscle tissue. Osteoblastic cells were strongly positive for alkaline phosphatase reactivity and Von Kossa stain in vitro. Collagen type I, osteocalcin (BGP), and alkaline phosphatase were identified at the immunohistochemical electron microscopic level. Histologic findings showed an osteoinductive effect of the implanted material. The results strongly suggest the possibility of producing an osteoinductive implantable material by culturing osteoblastic cells in vitro.

Effects of OK-432 on in vitro secondary responses of the non-adherent cells to IL-2 and OK-432 in cancer patients without tumor burden

We examined the effect of OK-432 intracutaneous injection on the in vitro responses of non-adherent cells to IL-2 and OK-432, along with changes in lymphocyte subpopulations, in early cancer patients who underwent surgery. We found that 1) repeated injections of OK-432 resulted in an enhancement of LAK activity, the peak of which was seen between 7 and 10 days after the first administration, 2) this augmentation of LAK activity was not associated with changes in lymphocyte subpopulations CD8+ CD11- and CD8+ CD11+ phenotypes, and 3) the cytotoxic activity of lymphocytes stimulated in vitro with OK-432 did not show a definite change in specific pattern after in vitro OK-432 treatment. These findings indicate that repeated injections of OK-432 over a period of a week effectively enhanced LAK activity.

Effect of OK-432 on cytotoxic activity in cancer patients without tumor burden

The present study was designed to determine the optimal therapeutic protocol for OK-432, a streptococcal preparation, and to clarify the kinetics of various immunological parameters following intracutaneous administration of OK-432 in 39 disease-free postoperative patients with early cancer. These patients were randomly divided into 4 groups according to the dose (1KE or 5KE) and the frequency of administration (one or 3 times every other day) of OK-432. NK activity 3-4 days after the first injection increased significantly in patients whose pretreatment baseline activity was below the lower level of normal values (60 LU) in all study groups (P < 0.05). The elevation of post-therapeutic NK activity lasted for 2 weeks in the group of patients given repeated injections. The serum content of cytotoxic activity against L-M cells increased significantly after the injection of OK-432 at doses of more than 5 KE doses (p < 0.05). These findings suggest that repeated injections of OK-432 over a period of a week have important immunotherapeutic results.

[Orthodontic treatment of adults with periodontal disease]

Orthodontic treatment has diversified in recent years along with progress in other dental specialties. Adult orthodontic treatment has become more popular as patients appreciate the need for a higher level of oral health accompanied with progress in orthodontic objectives and treatment methods. At the same time, patients with periodontal disease in number every year. Recently, two adult females with periodontal disease, one with crowding (20 y 1 m at her initial visit) and the other with bimaxillary protrusion (34 y 9 m at her initial visit), obtained good occlusion and periodontal health through orthodontic treatment. As a result of free mandibular movement by applied mild orthodontic forces and balanced occlusion, infrabony defects improved to achieve a higher level of the alveolar crest.

Pathologic and enzyme histochemical studies on bone formation induced by bone morphogenetic protein in mouse muscle tissue

Bone morphogenetic protein (BMP) irreversibly induced the differentiation of mesenchymal-type cells into osteoprogenitor cells for endochondral ossification. During the process of BMP-induced differentiation in mice, 4 cell type (chondroblasts, osteoblasts, chondroclasts, and osteoclasts) were examined for phosphatase and succinate dehydrogenase using a wide range of buffers (4.0 less than or equal to pH less than or equal to 9.2). During the chondroid tissue-forming stage (1 week), chondroblast-like or osteoblast-like cells expressed phosphatase activity at 6.8 less than or equal to pH less than or equal to 9.2; chondroclast-like or osteoclast-like cells expressed phosphatase activity at 4.0 less than or equal to pH less than or equal to 5.8. However, mature chondrocytes found in hyaline cartilage expressed phosphatase activity between 6.6 less than or equal to pH less than or equal to 7.6 (2 weeks). During the process of endochondral ossification, alkaline phosphatase activity decreased in osteoblast-like cells with traces of acid phosphatase activity still detectable. Chondroclastic and osteoclastic giant cells were characterized by intense succinate dehydrogenase activity.

Thiazolo[4,5-d]pyrimidine nucleosides. The synthesis of certain 3-beta-D-ribofuranosylthiazolo[4,5-d]pyrimidines as potential immunotherapeutic agents

Novel analogues of the naturally occurring purine nucleosides were synthesized in the thiazolo[4,5-d]pyrimidine ring system to determine the immunomodulatory effects of insertion of a sulfur atom in place of nitrogen at position 7 of the purine ring. In particular, 5-amino-3-beta-D-ribofuranosylthiazolo[4,5-d]pyrimidine-2,7(3H,6H) -dione (7, guanosine analogue), 3-beta-D-ribofuranosylthiazolo[4,5-d]pyrimidine-2,5,7(3H,4H,6H) trione (8, xanthosine analogue), 3-beta-D-ribofuranosylthiazolo[4,5-d]pyrimidine-2,7(3H,6H)-dione (10, inosine analogue), and 7-amino-3-beta-D-ribofuranosylthiazolo[4,5-d]pyrimidin-2(3H)-one (32, adenosine analogue) were prepared, as well as the 8-mercaptoguanosine (14) and 6-mercaptoguanosine (17) analogues. Single-crystal X-ray studies confirmed the structural assignment of 17 and 32 as having the beta-configuration with the site of glycosylation at N3. The nucleosides were evaluated for their ability to potentiate various murine immune functions in direct comparison to the known active agents 8-bromoguanosine (1), 8-mercaptoguanosine (2), and 7-methyl-8-oxoguanosine (3). Two of the guanosine analogues, 7 and 14, were found to exhibit significant immunoactivity relative to the positive control compounds (1-3), while the adenosine, inosine, xanthosine, and 6-mercaptoguanosine analogues were devoid of activity. Compound 7 exhibited greater immunoactivity than any of the other guanosine analogues and derivatives in all test systems. Specifically, 7 was shown to be about twice as potent as 3 in the murine spleen cell mitogenicity assay. In addition, treatment with 7 produced about a 4-fold increase in natural killer cell cytotoxicity, while treatment with 3 afforded a 3-fold increase over controls. Finally, 7 provided excellent protection (92% survivors compared to 0% for placebo controls) against Semliki Forest virus in mice. Induction of interferon may account for the major mode of action of these guanosine analogues.

[Automatic boundary detection and pathological diagnosis of the maxillary sinus]

A method for automatic boundary detection of the maxillary sinus from a cranial X-ray radiograph has been developed. An algorithm using the local segmental properties of the X-ray image to transform a continuous tone image into a bi-level image is introduced. In addition, the global shape information such as the area, the perimeter, and the complexity, are considered for the boundary detection. The boundary of the maxillary sinus detected by this method coincided precisely with the area plotted-by experienced otolaryngologists. Furthermore, the cumulative distribution function (CDF) calculated from the density histogram of the maxillary sinus has been employed to perform the tonal evaluation of the intra-maxillary pathological changes. The distance between the CDFs successfully demonstrated the difference in pathological stages of the chronic sinusitis.

[A case of carcinoma of the ileum diagnosed as an adenocarcinoma]

A 65-year-old female with a history of cancer of the uterine body and a strong family history of cancer, was admitted with abdominal pain and anemia. During roentgenographic examination of the small intestine, a tumor was recognized about 25 cm from the ileocecal valve, leading us to suspect a carcinoma of the ileum. A colonoscopy demonstrated a constricting, ulcerated lesion, with a round wall: and a subsequent biopsy proved that the patient had a moderately differentiated adenocarcinoma. At surgery, a tumor, measuring 52 x 50 mm, was found to have infiltrated the serosa with a metastasis to the mesenteric lymph node.

A case of the pathogenesis of choledochocele in relation to dysfunction of the sphincter of Oddi

A 47-year-old woman was admitted for evaluation of pain in the right upper quadrant of the abdomen. Seventeen years previously, she had undergone cholecystectomy for cholelithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) showed a cystic dilatation of the terminal portion of the common bile duct (CBD) protruding into the duodenal lumen and delaying the drainage of contrast medium. In this patient the CBD and the pancreatic duct appeared to be unimportant in the formation of the cyst. Repeated changes in the radius of the cyst suggested dysfunction of the ampullary component of the sphincter of Oddi, with maintenance of normal function of the common duct component. The pathogenesis of the choledochocele in this patient is discussed in relation to dysfunction of the sphincter of Oddi. In addition, 2 criteria for the diagnosis of choledochocele by ERCP are proposed: [1] cystic dilatation of the terminal portion of the CBD protruding into the duodenal lumen, and [2] absence of the narrow segment of the CBD.

[Longitudinal changes in the dentition of the deciduous reversed bite using plaster casts]

It is known that some of the deciduous reversed bite cases are corrected spontaneously by themselves. No decisive conclusion, however, has been achieved so far as to what morphological characteristics the self corrected cases have. The purpose of this study, therefore, was to determine whether the difference between the self corrected group (n) and the non-self corrected group (r) exists at their initial examination or if it occurs as a result of changes in occlusion. The materials used in this study were the serial plaster casts of 29 Japanese girls with the deciduous reversed bite at their first visit and these were measured with the three dimensional measurement system. The following results were obtained: 1. Characteristics of the initial examination with the n group: Overjet (-) and overbite in the n group were smaller than in the r group. The arch length and the perimeter of the maxillary dentition in the n group were longer, and the area of the incisive bone (U-C) was wider than in the r group. Moreover, the upper and lower canines in almost all of the n group cases were not touching each other and did not restrict mandibular movement, resulting in easy attrition for the deciduous anterior dentition. 2. Longitudinal changes in the n group: Mean change of this group showed a decrease in overbite caused by the attrition of the deciduous central incisors and the continuous eruption of the maxillary second deciduous molars. Overjet also decreased, because of an increase in the maxillary anterior arch length and of backward movement in the mandibular dental arch. Individual changes were much alike in mean changes in almost all of the measured items. Arch width between canines in the maxilla and arch length in the mandible decreased in some cases, suggesting that a discrepancy would occur when the permanent incisors erupt. 3. Longitudinal changes of the r group: Mean changes showed that overbite decreased in the same pattern as the n group, but overjet did not change and the mandible did not show backward movement. The reason was that overbite in this group was deeper than in the n group at the initial examination. Moreover, deciduous molar to molar width became wider to compensate the decrease in the arch length and the perimeter. Individual changes showed that some of the r group cases had a tendency to improve, but some became worse.

Gas permeability of round window membrane

The perilymphatic oxygen tension in the scala tympani was measured with a polarographic technique after various gases were insufflated into the middle ear cavity of 7 guinea pigs. Pure oxygen, insufflated into the middle ear cavity, easily permeated the round window membrane and elevated the perilymphatic oxygen tension. Oxygen transport to the inner ear, other than by the inner ear vessels, was confirmed. The inner ear function may partially be maintained by oxygenation through this route.