Progressive myoclonic epilepsy as an expanding phenotype of NGLY1-associated congenital deglycosylation disorder: A case report and review of the literature

INTRODUCTION

NGLY1-associated congenital disorder of deglycosylation (CDDG1: OMIM #615273) is a rare autosomal recessive disorder caused by a functional impairment of endoplasmic reticulum in degradation of glycoproteins. Neurocognitive dysfunctions have been documented in patients with CDDG1; however, deteriorating phenotypes of affected individuals remain elusive.

CASE PRESENTATION

A Japanese boy with delayed psychomotor development showed ataxic movements from age 5 years and myoclonic seizures from age 12 years. Appetite loss, motor and cognitive decline became evident at age 12 years. Electrophysiological studies identified paroxysmal discharges on myoclonic seizure and a giant somatosensory evoked potential. Perampanel was effective for controlling myoclonic seizures. Exome sequencing revealed that the patient carried compound heterozygous variants in NGLY1, NM_018297.4: c.857G > A and c.-17_12del, which were inherited from mother and father, respectively. A literature review confirmed that myoclonic seizures were observed in 28.5% of patients with epilepsy. No other patients had progressive myoclonic epilepsy or cognitive decline in association with loss-of-function variations in NGLY1.

CONCLUSION

Our data provides evidence that a group of patients with CDDG1 manifest slowly progressive myoclonic epilepsy and cognitive decline during the long-term clinical course.

Heterogeneity and mitochondrial vulnerability configurate the divergent immunoreactivity of human induced microglia-like cells

Microglia play versatile roles in progression of and protection against neuroinflammatory diseases. Little is known, however, about the mechanisms underlying the diverse reactivity of microglia to inflammatory conditions. We investigated how human induced microglia-like (iMG) cells respond to innate immune ligands. Quantitative PCR showed that poly-I:C and lipopolysaccharide (LPS) activated the expression of IL1B and TNF. Immunoreactivity of iMG did not differ between controls (n = 11) and patients with neuroinflammatory diseases (n = 24). Flow cytometry revealed that CD14high cells expressed interleukin (IL) -1β after LPS treatment. Immunoblotting showed that poly-I:C and LPS differentially activated inflammatory pathways but commonly induced mitochondrial instability and the expression of pyruvate kinase isoform M2 (PKM2). Furthermore, a potent stimulator of PKM2 (DASA-58) alleviated IL-1β production after LPS treatment. These data indicate that heterogeneous cell populations and mitochondrial stability underlie the divergent immunoreactivity of human iMG in environments.

Shank3a/b isoforms regulate the susceptibility to seizures and thalamocortical development in the early postnatal period of mice

Epileptic seizures are distinct but frequent comorbidities in children with autism spectrum disorder (ASD). The hyperexcitability of cortical and subcortical neurons appears to be involved in both phenotypes. However, little information is available concerning which genes are involved and how they regulate the excitability of the thalamocortical network. In this study, we investigate whether an ASD-associated gene, SH3 and multiple ankyrin repeat domains 3 (Shank3), plays a unique role in the postnatal development of thalamocortical neurons. We herein report that Shank3a/b, the splicing isoforms of mouse Shank3, were uniquely expressed in the thalamic nuclei, peaking from two to four weeks after birth. Shank3a/b-knockout mice showed lower parvalbumin signals in the thalamic nuclei. Consistently, Shank3a/b-knockout mice were more susceptible to generalized seizures than wild-type mice after kainic acid treatments. Together, these data indicate that NT-Ank domain of Shank3a/b regulates molecular pathways that protect thalamocortical neurons from hyperexcitability during the early postnatal period of mice.

Neurodevelopmental Outcomes of High-Risk Preterm Infants: A Prospective Study in Japan

Objectives

To determine the neurodevelopmental outcomes of very-low-birth-weight infants (VLBWIs, birth weight <1,500 g) after 9 years of follow-up.

Methods

This study prospectively recruited 224 VLBWIs born from 2003 to 2009 in Kyushu University Hospital, Japan. Comorbidities of neurocognitive impairment, epilepsy, and autism spectrum disorder or attention-deficit hyperactivity disorder (ASD/ADHD) were assessed at age 3, 6, and 9 years.

Results

Neurodevelopmental profiles were obtained from 185 (83%), 150 (67%), and 119 (53%) participants at age 3, 6, and 9 years, respectively. At age 9 years, 25 (21%) VLBWIs showed intelligence quotient (IQ) <70, 11 (9%) developed epilepsy, and 14 (12%) had a diagnosis of ASD/ADHD. The prevalence of epilepsy was higher in children with an IQ <70 at age 9 years than in those with an IQ ≥70 (44% vs 0%). In contrast, ASD/ADHD appeared at similar frequencies in children with an IQ <70 (16%) and ≥70 (11%). Perinatal complications and severe brain lesions on MRI were considered common perinatal risks for developmental delay and epilepsy but not for ASD/ADHD. Male sex was identified as a unique risk factor for ASD/ADHD.

Conclusion

These data suggest that VLBWIs showed a higher prevalence of developmental delay, epilepsy, and ASD/ADHD at age 9 years than the general population. Distinct mechanisms might be involved in the pathogenic process of ASD/ADHD from those of developmental delay and epilepsy.

Favorable outcomes of interferon-α and ribavirin treatment for a male with subacute sclerosing panencephalitis

Subacute sclerosing panencephalitis (SSPE) is a slow virus infection associated with mutant measles virus (MeV). The long-term outcome of antiviral treatments remains to be determined. We herein present a Japanese boy who was diagnosed with SSPE at 10 years of age. Intraventricular infusions of interferon-α effectively prevented the progress of symptoms during 14 years of follow-up period. Flow-cytometric analysis demonstrated higher proportion of T helper 17 cells (Th17, 18.2%) than healthy controls (4.8-14.5%) despite the normal subpopulation of peripheral lymphocytes. These data suggest that a group of patients with SSPE may show favorable responses to intraventricular infusions of interferon-α.

De novo p.G696S mutation in COL4A1 causes intracranial calcification and late-onset cerebral hemorrhage: A case report and review of the literature

BACKGROUND

The collagen type IV alpha 1 chain (COL4A1) is an essential component of the basement membrane in small vessels. Pathogenic variants in COL4A1 cause perinatal cerebral hemorrhages in an autosomal-dominant fashion. However, little is known about the long-term outcomes of patients with mildly affecting COL4A1 mutations.

CASE REPORT

We report a 17-year-old boy, who presented with recurrent intracranial hemorrhages in the periventricular white matter. He had been followed-up as a child with cerebral palsy bearing intracranial calcifications, developmental delay and epilepsy. Screening tests in infancy provided negative results for intrauterine infections. Severe motor and cognitive deficits persisted after admission. Carbazochrome was introduced on day 19 of admission, which appeared to prevent extension and reactivation of cerebral hemorrhages for over 6 months after discharge.

RESULTS

Targeted sequencing of NOTCH3 and TREX1 excluded causal mutations in these genes. The whole-exome sequencing revealed that he carried a de novo mutation in COL4A1 (p.Gly696Ser). An overview of the literature for 345 cases with COL4A1 mutations supported evidence that p.Gly696Ser is associated with the unique phenotype of late-onset hemorrhage among patients with COL4A1-associated cerebral angiopathy.

CONCLUSIONS

This case first demonstrates that infants with COL4A1-associated leukoencephalopathy and calcifications have a risk for developing the rupture of small vessels in the cerebral white matter after 10 years of age.

Early Intervention With Adrenocorticotropin for Acute Encephalopathy-Associated Epileptic Spasms: Report of Two Cases

PURPOSE

Acute encephalopathy with biphasic seizures and reduced diffusion (AESD) is a leading cause of childhood-onset encephalopathy in Japan. Children with AESD frequently develop intractable epilepsy, whereas their treatment options remain to be determined.

METHOD

We present 2 unrelated girls, who developed AESD at 25 months (case 1) and 12 months of age (case 2). Both cases underwent intensive cares from the first day of illness, whereas severe neurological impairments were left on discharge. They showed repeated signs of epileptic spasms at 2 months (case 1) and 8 months (case 2) after the onset of AESD. Video-monitoring electroencephalograms (EEG) detected the recurrent attacks accompanying slow-wave bursts and transient suppressions of the precedent epileptiform discharges, as typically observed in epileptic spasms.

RESULTS

Intramuscular injection of adrenocorticotropic hormone (ACTH, 0.0125 mg/kg/d) was introduced within 1 month from the onset of epileptic spasms and continued for 2 weeks. The ACTH treatment disrupted the paroxysmal activity in EEG, and it has relieved these patients from epileptic seizures for more than 1 year.

CONCLUSION

This report illustrates the potential efficacy of ACTH for a group of children with epileptic spasms after AESD.

Surface electromyographic evaluation of the neuromuscular activation of the inspiratory muscles during progressively increased inspiratory flow under inspiratory-resistive loading

This study aimed to evaluate neuromuscular activation in the scalene and sternocleidomastoid muscles using surface electromyography (EMG) during progressively increased inspiratory flow, produced by increasing the respiratory rate under inspiratory-resistive loading using a mask ventilator. Moreover, we attempted to identify the EMG inflection point (EMG^IP) on the graph, at which the root mean square (RMS) of the EMG signal values of the inspiratory muscles against the inspiratory flow velocity acceleration abruptly increases, similarly to the EMG anaerobic threshold (EMG^AT) reported during incremental-resistive loading in other skeletal muscles. We measured neuromuscular activation of healthy male subjects and found that the inspiratory flow velocity increased by approximately 1.6-fold. We successfully observed an increase in RMS that corresponded to inspiratory flow acceleration with ρ ≥ 0.7 (Spearman's rank correlation) in 17 of 27 subjects who completed the experimental protocol. To identify EMG^IP, we analyzed the fitting to either a straight or non-straight line related to the increasing inspiratory flow and RMS using piecewise linear spline functions. As a result, EMG^IP was identified in the scalene and sternocleidomastoid muscles of 17 subjects. We believe that the identification of EMG^IP in this study infers the existence of EMG^AT in inspiratory muscles. Application of surface EMG, followed by identification of EMG^IP, for evaluating the neuromuscular activation of respiratory muscles may be allowed to estimate the signs of the respiratory failure, including labored respiration, objectively and non-invasively accompanied using accessory muscles in clinical respiratory care.

Relationship of Metabolic Syndrome to Periodontal Disease in Japanese Women: The Hisayama Study

Recent studies have suggested that several systemic conditions—such as obesity, hypertension, hyperlipidemia, and diabetes—are related to periodontitis. The objective of this study was to examine the relationship between periodontitis and 5 components of metabolic syndrome—abdominal obesity, triglyceride level, high-density lipoprotein cholesterol level, blood pressure, and fasting blood sugar level—in 584 Japanese women. In multivariate analyses, persons exhibiting more components of metabolic syndrome had significantly higher odds ratios for a greater pocket depth and clinical attachment loss than did those with no components; the odds ratios for a greater pocket depth and clinical attachment loss of the persons exhibiting 4 or 5 components were 6.6 (95% confidence interval = 2.6–16.4) and 4.2 (95% confidence interval = 1.2–14.8), respectively. These results indicate that metabolic syndrome increases risk of periodontitis, and suggest that people exhibiting several components of metabolic syndrome should be encouraged to undergo a periodontal examination.

Lichen Planus Annularis: An Immunohistochemical Study

Lichen planus annularis is a relatively rare skin manifestation of lichen planus. The mechanisms in the formation of annular lesions are not fully understood. We reported here a 57-year-old female with this disease. The eruption initially occurred as lichen-papules, then enlarged (bean-sized, umbilicated small plaques), and finally developed annular manifestations. We performed immunohistochemical examinations of specimens taken from different types of eruptions. In all specimens, HLA-DR was expressed in the focal keratinocytes adjacent to the dermal HLA-DR positive cell infiltration. Both in the initial papule and in the final annular lesion, expression of ICAM-1 was present only in the keratinocytes above the dermal cell infiltration, similar to HLA-DR. It is of interest that, in the umbilicated small plaques, the peripheral epidermis other than the central site extensively reacted to ICAM-1. LFA-1 expression was most prominent in the mononuclear cells impinging on the dermo-epidermal junction in all specimens. In addition, in the periphery of the umbilicated small plaques, which showed no bandlike dense cell infiltration nor degeneration of basement membrane, TNF-alpha, but not LFA-1, was positive in the infiltrated cells of the upper dermis. These results suggest that expressions of ICAM-1 and TNF-alpha in the peripheral keratinocytes and dermal infiltrated cells are important molecular events in the mechanisms of formation of the annular lesions.

Trends in prevalence of Alzheimer's disease and vascular dementia in a Japanese community: the Hisayama Study

OBJECTIVE

To examine secular trends in the prevalence of Alzheimer's disease (AD) and vascular dementia (VD) in a general Japanese population.

METHOD

Four cross-sectional examinations were conducted among residents of a Japanese community aged >or=65 in 1985, 1992, 1998 and 2005.

RESULTS

The age- and sex-adjusted prevalence of all-cause dementia significantly increased with time (6.0% in 1985, 4.4% in 1992, 5.3% in 1998 and 8.3% in 2005; P for trend = 0.002). A similar trend was observed for AD (1.1%, 1.3%, 2.3% and 3.8% respectively; P for trend < 0.001), while the age- and sex-adjusted prevalence of VD and other/unclassified dementia showed J-shaped patterns (for VD: 2.3%, 1.5%, 1.5% and 2.5%, respectively, P for trend = 0.82; for other/unclassified dementia: 2.6%, 1.7%, 1.5% and 2.0%, P for trend = 0.26). The prevalence of AD was likely to increase with time from 1985 to 2005 among subjects aged 75 or older. The ratio of the prevalence of VD to that of AD decreased with time (2.1 in 1985, 1.2 in 1992, 0.7 in 1998 and 0.7 in 2005).

CONCLUSION

Our findings suggest that the prevalence of all-cause dementia and AD significantly increased over the past two decades in the general Japanese population.

Incidence and survival of dementia in a general population of Japanese elderly: the Hisayama study

OBJECTIVE

To estimate the incidence and survival rates of total and cause specific dementia in a general Japanese population.

METHODS

A total of 828 subjects without dementia, aged 65 years or over, were followed-up prospectively for 17 years. Dementia was subdivided into cause specific subtypes: namely, Alzheimer's disease (AD), vascular dementia (VD), dementia with Lewy bodies (DLB), combined dementia and other types of dementia. During the follow-up, 275 subjects developed dementia; of these, 251 (91.2%) were evaluated morphologically, with 164 subjected to brain autopsy examination and the remaining 87 to neuroimaging.

RESULTS

The incidences of total dementia, AD, VD, DLB, combined dementia and other types of dementia were 32.3 (n = 275), 14.6 (124), 9.5 (81), 1.4 (12), 3.8 (33), and 3.1 (16) per 1000 person years, respectively. The incidences of AD, combined dementia and other types of dementia rose with increasing age, particularly after the age of 85 years, but this tendency was not observed for VD or DLB. The survival curve of dementia cases aged 65-89 years was significantly lower than that of age and sex matched controls (10 year survival rate, 13.6% vs 29.3%; hazard ratio 1.67; 95% confidence interval 1.31 to 2.13). The 10 year survival rates were not significantly different among dementia subtypes.

CONCLUSIONS

Our findings suggest that the Japanese elderly population has a high risk for the development of dementia, specifically AD and VD, and once dementia is established, the risk of death is considerable.

Serum levels of resistin and adiponectin in women with periodontitis: the Hisayama study

Resistin and adiponectin, recently discovered adipokines, are secreted from adipose tissue, with postulated opposing functions in insulin resistance and inflammation. More recently, an abundance of resistin was detected in macrophages, which suggests its important role in inflammation. The aim of this study was to clarify circulating serum adipokine levels in women with periodontitis. Thirty-four women with moderate to severe periodontitis and 42 control individuals with healthy gingiva (50- to 59-year-old women) were selected. The serum level of adipokines was analyzed between groups, along with the obesity index, smoking status, and age. Having periodontitis was significantly associated with an increased level of resistin, both in bivariate (OR, 3.0; 95% CI, 1.2-7.6) and multivariate (adjusted OR, 3.1; 95% CI, 1.1-8.6) analyses. The association of periodontitis with a decreased level of adiponectin did not reach statistical significance. It was concluded that an increased serum resistin level in middle-aged Japanese women with periodontitis may affect systemic health.

Decreasing incidence of lacunar vs other types of cerebral infarction in a Japanese population

BACKGROUND

There is scant information on secular trends in the incidence and survival of ischemic stroke subtypes.

METHODS

The authors established three cohorts of Hisayama residents age > or =40 years in 1961 (1,618 subjects), 1974 (2,038 subjects), and 1988 (2,637 subjects). They followed up with each cohort for 12 years, comparing the incidence and survival rate of ischemic stroke subtypes. Morphologic examinations by autopsy or brain imaging was performed on most of the ischemic stroke cases in all cohorts.

RESULTS

The age-standardized incidence of lacunar infarction significantly declined by 59% for men and by 28% for women from the first to the second cohort. It continued to decline by 41% for men, but the decline decelerated for women between the second and third cohort. The age-standardized incidence of atherothrombotic infarction tended to decline from the first to the second cohort, whereas it was sustained between the second and third cohort for both sexes. The age-standardized incidence of cardioembolic infarction was unchanged throughout the cohorts. In these cohorts, mean blood pressure levels among hypertensive subjects and the prevalence of current smoker decreased with time, though the prevalence of hypertension remained stable. The 5-year survival rate after lacunar infarction significantly improved among the cohorts, but those of atherothrombotic and cardioembolic infarction did not.

CONCLUSIONS

These data suggest that, in the Japanese population, the incidence of lacunar infarction steadily declined for the last 40 years. The improvement of hypertension control and decreasing prevalence of smoking might be responsible for this trend.

First Report of Pythium aphanidermatum on Basella rubra in Japan

Basella rubra L. (Indian spinach, Japanese name Tsurumurasaki) is cultivated worldwide as an ornamental and its aerial parts are consumed as a vegetable and health food. A severe rot of leaves, stems, and roots was found on B. rubra cv. Midori grown in a commercial field at Naruto-City (34°11'N, 134°36(E) in Tokushima Prefecture, Japan from May to September 2004. More than 50% of approximately 2,100 plants in the field were destroyed by the disease. Soft, black lesions appeared initially at the base of the stems in 2- to 5-month-old plants and enlarged gradually upward and downward within 2 days after plant injury caused by heavy rainfall. A fluffy, white mass of mycelium appeared on the surface of lesions under moist conditions. A Pythium species was routinely isolated from rotted stems and roots and identified as Pythium aphanidermatum (Edson) Fitzpatrick on the basis of its morphology on a grass leaf water culture (2). Characteristics of isolate OPU743 (NBRC No. 101556, MAFF No. 239847) included hyphae as much as 10 μm wide, terminal oogonia 17.8 to 28.8 μm in diameter, and monoclinous or diclinous antheridia 8.8 to 10.9 μm wide, either terminal or intercalary, with one or rarely two per oogonium. Oospores were aplerotic, 13.5 to 22.6 μm in diameter. Sporangia were terminal or occasionally intercalary, and either inflated filamentous hyphae or complexes of swollen hyphal branches were present in cultures. Cardinal temperatures for growth on potato carrot agar were 10°C minimum, 37°C optimum, and 40°C maximum with a daily radial growth rate of 32.9 mm at 25°C. Pathogenicity tests were conducted on potted 3-month-old B. rubra (cv. Midori). A wound (1 mm deep and 5 mm long made by a razor) on the surface of the stem of the plant was inoculated with an 8-mm-diameter agar disk of isolate OPU743 (grown at 25°C for 48 h on potato dextrose agar) attached to a stem of the plant using a paraffin film. The inoculated plants were placed in transparent plastic bags and kept in a growth chamber at 24 to 26°C with continuous light (82 to 126 μmol·m^-2·s^-1). The experiment was done four times with three plants in each experiment. The same number of plants was used for the noninoculated control. Dark brown rot of stems and leaves developed on 66.7% of inoculated plants within 2 days after inoculation. P. aphanidermatum reisolated from diseased tissues was morphologically identical to the original isolate OPU743. Noninoculated control plants showed no symptoms. P. aphanidermatum has been described on B. rubra in Brazil (1), but has not been reported from other regions of the world. To our knowledge, this is the first report of P. aphanidermatum on B. rubra in Japan. References: (1) C. F. Robbs. A Lavoura 74:43, 1972. (2) A. J. Van Der Plaats-Niterink. Stud. Mycol. 21:1, 1981.

CD56-Positive cutaneous lymphoma with multicentric Castleman's disease-like systemic manifestations

We report a 55-year-old Japanese male with CD56+ cutaneous lymphoma. The patient had multiple cervical lymphadenopathy, a red nodule on his neck, and parotid gland nodularity. Histologic features of the biopsied cervical lymph node showed follicular hyperplasia with numerous plasma cells. A biopsied skin specimen of the nodule on his neck demonstrated dense infiltration of atypical large lymphocytes into the dermis. Immunohistochemical study of this specimen revealed CD3+, CD4+, and CD56+ expression in the majority of neoplastic cells. Polymerase chain reaction assays for the detection of Epstein-Barr virus sequences were positive for lymph node and skin DNA. Laboratory examinations showed polyclonal gammopathy, pancytopenia, and high serum interleukin-6 levels. These clinical and histological findings resembled those of multicentric Castleman's disease.

Cricoarytenoid arthritis with rheumatoid arthritis and systemic lupus erythematosus

A 56-year-old woman with rheumatoid arthritis (RA) suddenly developed severe respiratory distress and laryngeal stridor, which required endotracheal intubation. She had had RA for 12 years, which had been controlled well with prednisolone (3 mg/day) at the orthopedic clinic. Laryngoscopy revealed cricoarytenoid arthritis. She was finally diagnosed as having overlap syndrome with RA and systemic lupus erythematosus. She was given high dose corticosteroids that improved her clinical symptoms and laryngoscopic findings. She represents the first patient with overlap syndrome who developed an acute airway obstruction due to cricoarytenoid arthritis.

Diffuse large B-cell lymphoma associated with skin, muscle and cranial nerve involvement

The present case, a 75-year-old man with extranodal B-cell lymphoma showed facial hemiplegia, paresthesia and cutaneous manifestations. He was initially diagnosed as having a facial paralysis of unknown etiology. One month after the original diagnosis, erythematous indurated plaques developed on his left cheek and nose. A skin biopsy from the plaque on his cheek showed dense infiltrates of large lymphocytes with irregularly shaped nuclei and prominent nucleoli in the dermis and subcutaneous tissue. The lymphocytes were positive for L26 and CD79a. A diagnosis of diffuse large B-cell lymphoma was made. A muscle biopsy from facial muscle in the area of the erythematous plaque showed massive destruction of the muscle tissues by the lymphomatous infiltrates. Furthermore, electrodiagnostic study showed peripheral cranial nerve palsies, involving the left facial and trigeminal nerves. We conclude that diffuse large B-cell lymphoma may develop symptoms such as facial hemiplegia and paresthesia prior to cutaneous manifestations. Diffuse large B-cell lymphoma must be considered as one of the important causes of palsies of cranial nerves at the peripheral level.

Evaluation and treatment of shoulder subluxation in hemiplegia: relationship between subluxation and pain

Shoulder subluxation in hemiplegic patients has been recognized as a difficult problem to manage. In the study contained herein, our aims are to evaluate shoulder subluxation, to clarify if shoulder subluxation causes pain, and to discuss the treatment of shoulder subluxation. The study included 75 hemiplegic patients with shoulder subluxation. Each patient was evaluated for the degree of shoulder pain, motor recovery of the upper limb, and shoulder range of motion. Some indexes for evaluating subluxation were measured with radiographs of the shoulders. Arthrograms of the affected shoulder joint were taken in 23 patients. The following results were found: (1) shoulder pain was significant more frequently in left hemiplegia; (2) vertical disparity was strongly correlated with discrepancy of the descendant ratio; (3) severe inferior subluxation had a tendency to show medial displacement of the humeral head; (4) there were correlations between shoulder pain and shoulder range of motion, especially external rotation; (5) adhesive changes in the arthrograms were seen in most subjects. These results indicate that there is no relation between shoulder subluxation and pain, and adhesive capsulitis is a main cause of shoulder pain. We conclude that correct positioning and shoulder range of motion exercises are advisable in hemiplegic patients with shoulder subluxation.

Silent nucleotide substitution in the sterol 27-hydroxylase gene (CYP 27) leads to alternative pre-mRNA splicing by activating a cryptic 5' splice site at the mutant codon in cerebrotendinous xanthomatosis patients

A functionally silent nucleotide substitution of the sterol 27-hydroxylase gene (CYP 27), identified in two families with cerebrotendinous xanthomatosis (CTX), was confirmed to cause alternative pre-mRNA splicing of the gene. Full-length RT-PCR analysis of the CYP 27 gene in a patient from one of the CTX families revealed one major and an additional faint band. Sequence analysis of the cloned RT-PCR product showed three species of cDNA: 3' terminal 13 bp of exon 2 deleted cDNA, exon 2 skipped cDNA, and full-length cDNA with a functionally silent G to T mutation at codon 112 (GGG 112Gly to GGT 112Gly). Only a single base change was identified by genomic DNA sequence analysis of the CYP 27 gene in the patient: T replaced G at the third position of codon 112, 13 bp upstream from the 3' terminus of exon 2. Transfection of constructed minigenes, with or without the mutation, confirmed that this silent mutation resulted in alternative pre-mRNA splicing by activating a cryptic 5' splice site around the mutant codon. The mutation was also identified in two patients from another CTX family, with a compound heterozygous pattern of A for G substitution at codon 372, a mutation reported previously by our group. The results elucidate a novel molecular basis for the CTX and suggest the significance of a silent nucleotide substitution with regard to pre-RNA splicing.

Genomic organization and alternative splicing of human PACE4 (SPC4), kexin-like processing endoprotease

PACE4 (paired basic amino acid cleaving enzyme) is a member of a family of the mammalian kexin-like proprotein convertases containing a subtilisin-like catalytic domain. Previously we reported seven isoform mRNAs of PACE4 that vary in size and 3'-coding sequence [A. Tsuji et al. (1994) Biochem. Biophys. Res. Commun. 200, 943-950; K. Mori et al. (1997) J. Biochem. 121, 941-948]. To determine the origin of these isoforms, the entire human PACE4 gene has been isolated as a set of overlapping genomic DNA fragments, and analyzed by restriction enzyme digestion and nucleotide sequence determination. The human PACE4 gene spans at least 250 kb and is distributed over 25 exons that range in size from 39 to 1,422 base pairs. Human PACE4 gene is the largest kexin-like proprotein convertase gene reported to date. The most striking feature of its genomic structure is the size of the introns and the number of exons, although the general organization of signal peptide, propeptide, and catalytic domains, which are conserved in this family, is very similar to that reported for other kexin-like protease genes. The structural analysis of PACE4 genomic DNA indicates that multiple PACE4 transcripts are produced as a consequence of alternative RNA splicing events, including exon skipping, and differences in the usage of the inner 5'-splicing donor and polyadenylation sites. A major transcriptional start site was detected 314 bp upstream from the ATG translational start site by primer extension analysis. Sequence analysis of the 5'-flanking region revealed that PACE4 gene lacks TATA and CCAAT boxes in the proximal upstream region of the start site, although potential binding sites for several transcription factors including SP1, AP1, AP2, PEA3, Ets-1, GHF (growth hormone factor)-1, CREB (cyclic AMP response element binding protein), and basic helix-loop-helix proteins, were present. An unusual sequence of six tandem repeats of a nonadecamer (GGCCTGGGGGTTCACCTGC) containing an E box is found in the 5'-flanking region. These results suggest that PACE4 is not a constitutive gene product and its expression is regulated by various transcription factors.

Bowen's disease: statistical study of a 10 year period

According to histological records, a total of 74 patients were diagnosed with Bowen's disease (B.d.) between 1 January 1984 and 31 December 1993 at the Department of Dermatology of Kitasato University. There was slight female predominance (36 male, 38 female), and 73% of the patients were older than 60 years; the mean age was 66.8 years. Fifteen patients had multiple (two-five) lesions. In 13 patients, other benign skin lesions were also found. Arsenic exposure as etiologic factor could have been present in 2 cases. Only 3 patients had other associated malignant tumors, which does not confirm the paraneoplastic nature of B.d. One-fifth of the lesions were on sun-exposed areas (head, neck and hands). Although we excluded invasive carcinomas from our statistical study, we mention the 8 invasive carcinomas developing from B.d. in that period. Histopathological classification of B.d. is uncommon. Classifying our cases by Darier's histopathological classification, 63.3% of them belonged to the lenticular type. The malignant potential of different histopathological types of B.d. needs further investigation.

Inhibitory effect of magnesium L-ascorbyl-2-phosphate (VC-PMG) on melanogenesis in vitro and in vivo

BACKGROUND

An inhibitory effect of ascorbic acid (AsA) on melanogenesis has been described. However, AsA is quickly oxidized and decomposed in aqueous solution and thus is not generally useful as a depigmenting agent.

OBJECTIVE

Our purpose was to examine the effect on pigmentation of magnesium-L-ascorbyl-2-phosphate (VC-PMG), a stable derivative of AsA.

METHODS

Percutaneous absorption of VC-PMG was examined in dermatomed human skin, and its effect on melanin production by mammalian tyrosinase and human melanoma cells in culture was also measured. A 10% VC-PMG cream was applied to the patients.

RESULTS

VC-PMG suppressed melanin formation by tyrosinase and melanoma cells. In situ experiments demonstrated that VC-PMG cream was absorbed into the epidermis and that 1.6% remained 48 hours after application. The lightening effect was significant in 19 of 34 patients with chloasma or senile freckles and in 3 of 25 patients with normal skin.

CONCLUSION

VC-PMG is effective in reducing skin hyperpigmentation in some patients.

Histological examination of surface repair tissue after successful osteotomy for osteoarthritis of the hip joint

In this study biopsy specimens of the surface repair tissue from the weightbearing area of the hip joint were collected from 15 patients who had undergone successful valgus osteotomy, and these were examined histologically. In 6 of the 15 patients the specimens stained strongly with safranin-O in all three layers of the matrix. However, the repair tissue from another 6 patients showed strong staining only in the intermediate and deep layers, while that from 2 patients stained only in the deep layer. Specimens from 5 patients were stained for S-100 protein and positive cells were detected in all cases, demonstrating that the cells in the repair tissue were chondrocytes. However, there was no tide mark in the repair tissue and the arrangement of the cells differed from that in normal cartilage. Discontinuity of the subchondral bone was also noted. These findings make it likely that the repair tissue was of bone marrow origin.

Valgus-flexion osteotomy for middle-aged patients with advanced osteoarthritis of the hip: a clinical and radiological evaluation

We followed up 34 secondary osteoarthritis patients with 38 hips treated by valgus-flexion osteotomy between 1979 and 1985. The average age of the patients at surgery was 45 years and the follow-up period ranged from 5 to 11 years. After surgery, the clinical evaluations were made according to the JOA Hip Score which remained unchanged in all 38 hips for 5 years. After 6 years there were some hips whose score declined with time. It was found that the preoperative extension-flexion range was the factor that was most closely associated with the result of the surgery (p less than 0.01). Radiological examination at 5 years revealed that the joint space had been widely broadened and the trabecular structure nearly normalized in 23 hips (60.5%), while 15 hips (39.5%) showed a slight degree of joint space broadening and were left with sclerosis and pseudocysts. After a lapse of 10 years or more, in 13 hips out of 10 patients, seven were found to have osteoarthritic changes and revision had to be done by THR in 2 patients. Valgus-flexion osteotomy can therefore be said to provide one of the useful means to preserve joints when employed in middle-aged patients with secondary OA.

Radiological evaluation on allograft reconstruction of the acetabulum combined with supporting device in revision total hip replacement

We reviewed the radiographs of 25 hips of 20 patients who had received revisions of the acetabular components of total hip replacement supplemented by allograft for bone defects. Bone defects in 20 hips (80%) were classified into type D (cranio-central defect) according to Itoman's classification. In eight, sockets were installed directly on the allografts (group A). A metallic supporting device was used for reinforcing the grafts in 17 hips (group B). The position of the acetabular socket was measured on a radiograph, taken immediately after revision surgery and again at the latest follow-up. Using a MEM template, cranial and central migrations were determined. Mean cranial migration in hips of group A was 3.6 mm. Group B was 0.2 mm. Maintenance of thickness of the allografts was 60.6% in the cranial region and 75% in the central in group A. In the hips of group B, however, almost 100% of the initial thickness was maintained cranially and centrally. Allograft reconstruction of acetabular bone defect in revision total hip replacement is a beneficial procedure. The remaining pelvic bone is usually in poor condition, therefore, it is necessary to ensure primary fixation by the metallic supporting device.

Pathological and laboratory findings in LEC/Otk rats that spontaneously develop hepatic injury

The LEC strain of rats that spontaneously develops hepatic injury has been introduced into specific pathogen-free (SPF) conditions (SPF-LEC/Otk). The present communication describes the clinical and pathological features of the SPF-LEC/Otk rats. The characteristic features of these animals are as follows: (i) Jaundice develops in almost all rats with increase in the P-GPT level; (ii) The animals show episodes of jaundice, a high P-GPT level and liver cell necrosis, but only slight inflammatory cell infiltration; (iii) The liver cells show characteristic microvesicular fatty changes; (iv) The P-GPT level shows increases, first at 18 weeks and then at 25 weeks of age; (v) The rats show immunological disorders, such as deficiency of immunoglobulins, especially IgG1, and of helper T cells; (vi) Infectious agents such as viruses do not seem to be involved, although this possibility cannot be absolutely excluded; (vii) The immunological disorders are not directly associated with the occurrence of liver cell necrosis; and (viii) The pattern of inheritance (autosomal single-recessive trait) of the disease strongly suggests that it is due to a genetic metabolic disorder.

Effects of deoxyspergualin on collagen arthritis in mice

We have studied the effect of the immunosuppressive agent deoxyspergualin (DSG) on collagen arthritis in mice. DSG, when given prophylactically, was capable of suppressing the development of collagen arthritis in mice as well as the immunological response to native type II collagen in a dose-dependent manner. Further, treatment of DSG, started 7 days after the primary immunization, also resulted in the inhibition of development of arthritis and immunity to collagen. The treatment of DSG, started after a booster injection, did not suppress the development of arthritis, despite suppression of antibody production in collagen. These findings suggest the possibility that a threshold level of anti-type II collagen antibodies may exist which must be exceeded before arthritis develops. Its therapeutic use in mice did not affect the clinical course of arthritis or the immune response to collagen, which is similar to the results obtained with cyclosporin.

[Characteristics of gamma glutamyl transferase in melanoma]

Gamma glutamyl transferase (GGT) is widely distributed in mammalian tissues, and its biological heterogeneity has been demonstrated among various tissues. In order to investigate the biological characteristics of GGT in melanomas, enzyme-histochemical and biochemical studies were performed using amelanotic/melanotic and murine/human melanomas as materials. Enzyme-histochemically, GGT activity appeared to be present only in melanogenic cells in vitro. Biochemical assays of tissue extracts revealed that the specific activity was much higher in melanotic melanomas than in amelanotic. In addition, analysis of GGT-isoenzymes demonstrated that an isoenzyme band at approximately 110KD was expressed in tumorigenic or highly-metastatic tissues. These findings suggest that GGT in melanoma is closely related to the ability of melanin production and that the possible existence of a unique isoenzyme may reflect the intensity of tumorigenic and/or metastasis.

Autosomal recessive distal muscular dystrophy: a comparative study with distal myopathy with rimmed vacuole formation

To clarify the clinical and morphological characteristics of distal muscular dystrophy, clinical and pathological material from 4 affected persons was compared with similar studies in 4 patients with distal myopathy with rimmed vacuole formation. Although these two forms of autosomal recessive distal myopathy with onset in young adulthood were highly similar in their clinical symptoms, histochemical and electron microscopic findings of muscles subjected to biopsy were quite different. The muscle abnormalities in distal muscular dystrophy were almost the same as those in Duchenne muscular dystrophy, showing massive fiber necrosis followed by active fiber regeneration. In contrast, distal myopathy with rimmed vacuole formation showed a progressive muscle fiber atrophy and loss, rimmed vacuoles in the sarcoplasm, and no apparent fiber necrosis or regeneration.

Effects of 4-tertiary butyl catechol on glutathione-metabolizing enzymes in vivo and in vitro

4-Tertiary butyl catechol (TBC) causes depigmentation in humans and animals and stimulates formation of pheomelanosomes. In this study, we investigated the effects of noncytotoxic doses of TBC on glutathione S-transferase (GST) activity in the skin of Uscd strain mice and B16 murine melanoma cells in culture, in relation to changes in activities of glutathione reductase (GR) and gamma-glutamyl transpeptidase (GGT) reported to be involved in pheomelanogenesis. Occurrence of pheomelanosomes in skin melanocytes was demonstrated by electron microscopy and reduction (25%) of eumelanin content in melanoma cells was shown by spectrophotometry. Topical application of 1 M TBC-DMSO-acetone solution on the ear skin elevated GST activity about 27%, and activities of GGT and GR to 35% and 19%, respectively, within 1 week. Melanoma cells cultured in 10(-4) M TBC-containing medium for 2 h showed no changes in GST and GGT activities, but 12% increase of GR activity during the first 12 h. Activities of all 3 enzymes was elevated (11-17%) 24 h later. The elevation detected by 48 h was 25% for GST, 26% for GGT, and 14% for GR. The findings were interpreted to show that depigmentation produced by the antioxidant results from stimulated pheomelanogenesis through activation of glutathione-metabolizing enzymes and suppressed oxidation of eumelanin intermediates.

Glutathione reductase activity in skin exposed to 4-tertiary butyl catechol

The effect of 4-tertiary butyl catechol (TBC), a potent depigmenting chemical, on glutathione reductase (GR) in pigmented ear skin of hairless mice was investigated. Three topical applications of TBC, which cause neither skin color changes nor melanocyte degeneration, induced an increase in enzyme activity. Since the same treatment resulted in pheomelanin formation as evidenced by electron microscopy, it is suggested that the GR increase correlates at least in part with changes in melanocyte metabolism. This enzyme generates a reduced form of glutathione which may be involved in the formation of glutathionedopas, substrates for hydrolytic enzymes to produce cysteinyldopas, and pheomelanin. Elevation of GR may be an indication of melanogenesis before clinical skin color changes due to TBC appear. It may be used for the early detection of occupational leukoderma.

Reduction in eumelanin by the activation of glutathione reductase and gamma-glutamyl transpeptidase after exposure to a depigmenting chemical

Topical application of 4-tertiary butyl catechol (TBC) causes vitiligo in the skin of man and animals, and previous electron microscopic studies showed pheomelanin formation in the affected areas. In the present study, we investigated changes of enzyme activities, eumelanin content and amount of sulfur in tissue cultured human melanoma cells exposed to the depigmenting chemical. TBC enhanced glutathione reductase activity without changing the eumelanin content by 24 hr after exposure and subsequently (by 42 hr) increased gamma-glutamyl transpeptidase activity and sulfur content in the cells with a decrease in eumelanin content. It is suggested that this chemical alters the types of melanin formed by modulation of these enzyme activities.

Measurement of the footsole pressure distribution of normal subjects by pressure sensitive films

A simple method measuring the pressure on the footsole was described using "Prescale", pressure sensitive films. Prescale consists of two films, one coated with microcapsules which contain a color-producing agent and rupture when a pressure is applied, and the other coated with a color-developing agent. Then, when a pressure is applied on the former film, the latter one display a color of various density corresponding to the pressure applied. Distribution of the pressure on the footsole was studied in normal subjects by this method. Pressure distribution in each subject was compared with his foot structure examined radiologically. And the clinical implications and indication of this method were discussed.

A simple method of measuring the footsole pressure of normal subjects using prescale pressure-detecting sheets

A simple method of measuring the pressure beneath the footsole was described using 'Prescale', pressure detecting sheets. These are two sheets, one coated with microcapsules which contain a color-producing agent, and the other coated with a color-developing agent. As the applied pressure determines the amount of microcapsules that rupture, the coloring sheet reveals its density corresponding to the pressure applied. At the application of this method, normal subjects were studied quantitatively on distribution of the pressure beneath the footsole. The results were compared with the structure of the foot as revealed by X-ray examination in order to study the correlation between the two. The clinical benefits and indication of this method were discussed.

Effect of chest wall vibration on ventilation in patients with spinal cord lesion

Changes of respiration caused by chest wall vibration were studied in 13 patients with cervical cord lesions. Vibrators applied on the chest wall were intermittently triggered by the patient's respiratory movements. The vibrators were triggered to be applied in three ways. 1) Upper vibrations were bilaterally applied during inspiration on the 2nd or 3rd parasternal intercostal spaces (insp "in-phase" vibration). 2) Lower vibrations were bilaterally applied during expiration on the 7th-to 10th intercostal spaces anterior to midaxillary lines (exp "in-phase" vibration). 3) Inspiratory and expiratory vibrations were combined to produce alternating in phase vibration. Both inspiratory and expiratory vibrations increased tidal volume (VT), but the alternating in-phase vibration increased it to significantly higher values (P less than 0.05). Minute volume of ventilation (VE l/min) also increased with insp or exp in-phase vibration. The alternating in-phase vibration increased VE l/min to even higher values (P less than 0.05). The responses described probably depend on segmental vibration reflexes arising in the inspiratory and expiratory intercostal muscles underlying the vibrators. The alternating in-phase vibration may well be useful to improve the breathing in patients with respiratory insufficiency.