Effect of acid suppressant medications on the laxative action of magnesium preparations in patients with opioid-induced constipation: A pharmacovigilance analysis of the FDA Adverse Event Reporting System

Objective: Magnesium oxide is widely used for treating opioid-induced constipation, a serious analgesic-associated problem. Opioid analgesic users are often prescribed non-steroidal anti-inflammatory drugs, which are sometimes combined with acid suppressants to prevent gastrointestinal adverse events. Magnesium preparations combined with acid suppressants may diminish magnesium preparations' laxative effect. This study was aimed at evaluating the effect of magnesium preparations combined with acid suppressants on the incidence of opioid-induced constipation by using the Food and Drug Administration Adverse Event Reporting System. Methods: Adverse events were defined per the Medical Dictionary for Regulatory Activities; the term 'constipation (preferred term code: 10010774)' was used for analysis. After adjusting for patient background factors using propensity score matching, acid suppressants' effect on constipation incidence was evaluated in opioid users prescribed magnesium preparations alone as laxatives by using a test for independence. Key Findings: The Food and Drug Administration Adverse Event Reporting System contains 14,475,614 reports for January 2004 to December 2021. Significantly increased constipation incidence was related to magnesium preparations combined with acid suppressants, especially proton pump inhibitors (P < 0.0001, McNemar's test). Conclusion: Magnesium preparations combined with acid suppressants may diminish magnesium preparations' laxative effect; healthcare professionals should pay attention to this issue.

The First Application of Intraumbilical Longitudinal Incision to Pyloromyotomy for Hypertrophic Pyloric Stenosis

OBJECTIVE

There are several approaches to pyloromyotomy for the treatment of hypertrophic pyloric stenosis including open transumbilical pyloromyotomy and laparoscopic pyloromyotomy. Beginning in 2012, we adopted intraumbilical longitudinal incision as a new transumbilical approach for pyloromyotomy. We describe details of the operative technique and results of this new approach.

METHODS

We reviewed records of patients undergoing transumbilical pyloromyotomy from 2005 to 2018. Perioperative outcomes were compared between intraumbilical longitudinal incision and supraumbilical incision, the latter of which is the conventional incision for transumbilical pyloromyotomy.

RESULTS

Twenty-four patients underwent pyloromyotomy with intraumbilical longitudinal incision (intraumbilical group) and 28 patients with supraumbilical incision (supraumbilical group). The median operative time was longer in the intraumbilical group (58.0 vs. 43.5 min, p = 0.002). However, the time to full feeding did not differ significantly between the two groups, and the median postoperative stay was shorter in the intraumbilical group (3 vs. 5.5 days, p = 0.003). There was no difference in the rate of complications (4.2% vs. 7.1%, p = 1.0). Scars after intraumbilical longitudinal incision were localized inside the umbilicus.

CONCLUSION

Pyloromyotomy can be performed through intraumbilical longitudinal incision as safely as supraumbilical incision and intraumbilical longitudinal incision may improve cosmetic results. This approach can be an alternative technique for pyloromyotomy.

Postoperative anastomotic stricture following excision of choledochal cyst: a systematic review and meta-analysis

PURPOSE

Postoperative anastomotic stricture (PAS) is a well-known complication after correcting choledochal cyst (CC). Although the exact cause of PAS is unknown, various risk factors, such as Todani classification type IV-A, hepaticoduodenostomy, and narrow anastomosis have been reported to be associated with PAS. As far as we know, there is no report with a cumulative analysis of such risk factors of PAS. This systematic review and meta-analysis aimed to investigate the risk factors of PAS following surgical correction of CC in children.

METHODS

A systematic literature search for relevant articles was performed in four databases using the combinations of the following terms "Congenital biliary dilatation", "Congenital choledochal cyst", "Choledochal cyst", "Stenosis", "Stricture", and "Complication" for studies published between 1973 and 2022. The relevant cohorts of PAS were systematically searched for clinical presentation and outcomes.

RESULTS

The search strategy identified 795 reports. Seventy studies met the defined inclusion criteria, reporting a total of 206 patients with PAS. There is no prospective study in this search. The incidence of PAS was 2.1%. The proportion of Todani classification of the patient with PAS was higher in type IV-A with significant difference (2.0% in type I and 10.1% in type IV-A (p = 0.001)). Fourteen studies reported a comparison between hepaticojejunostomy and hepaticoduodenostomy. There was no significant difference between the two groups (p = 0.36). Four studies reported the diameter of the anastomosis at the primary surgery. The mean diameter was 12.5 mm. Nine studies reported a comparison between laparoscopic surgery and open surgery. Pooled odds ratio of PAS did not show a statistical difference (p = 0.29).

CONCLUSIONS

This study suggests that close careful follow-up is important in the patients with type IV-A of CC who underwent excision surgery, considering the possibility of PAS.

The detail profile of cause of recurrences after laparoscopic percutaneous extraperitoneal closure (LPEC) in children: a systematic review

PURPOSE

Laparoscopic repairs for children with inguinal hernia have been established with various technical modifications. Laparoscopic percutaneous extraperitoneal closure (LPEC) is one of the most recognized techniques. Although the rate of complications of LPEC is similar to conventional repairs, the major cause of recurrence is still incompletely understood. The purpose of this study is to evaluate detail profile of the cause of recurrence in children treated with LPEC.

METHODS

A systematic literature search was performed using the combinations of the following terms "pediatric inguinal hernia", "LPEC", "complication", and "recurrence" for studies published between 2002 and 2020. The relevant cohorts of recurrence of LPEC in children were systematically searched for clinical outcomes.

RESULTS

35 studies met defined inclusion criteria, reporting a total of 121 patients who had recurrence after LPEC. The mean age at primary operations was 46.7 ± 52.0 months. The gender proportions were 63.9% (male) and 36.1% (female). The rate of treatment side was 44.5% (right), 37.0% (left) and 18.5% (bilateral). The hernia sac was closed with absorbable suture materials (5.3%) and non-absorbable (94.7%). The recurrence occurred in 6.9 ± 8.5 months postoperatively. Operative findings of reoperation were loosening of the knot of internal rings (61.1%), low ligation of the inguinal canal (16.7%), and skipping (22.2%).

CONCLUSIONS

This study suggests that male infants have a higher risk of recurrence after LPEC, and the majority of recurrences can occur in a year postoperatively. It is important to confirm carefully that the suture is tight and high without skipping.

[A Case of Early Ascending Colon Cancer Complicated the Mesenteric Phlebosclerosis Who Underwent Laparoscopic Subtotal Colectomy]

A 71-year-old woman who have been taking Sanshishi for 50 years until the age of 70 for dermatitis underwent colonoscopy( CS)to reveal the reason of abdominal pain. CS showed ascending colon tumor(AT)with major axis 3 cm and suspicious of the mesenteric phlebosclerosis. Although endoscopic submucosal dissection(ESD)was performed for AT, colon perforation due to colonic wall fibrosis was occurred and ESD was suspended. Therefore, surgical resection was planned. Intraoperative observations by laparoscopy showed that the color of colon serosa from the cecum to the splenic flexure was grayish white and colonic wall thickening with lead tubular change was observed. From the descending colon to the sigmoid colon, wall thickening was mild, and Haustra was confirmed. Although the tumor location was in the ascending colon, laparoscopic subtotal colectomy and functional end-to-end anastomosis of ileum and sigmoid colon was performed for safe intestinal anastomosis. For treat of colon cancer complicated mesenteric phlebosclerosis(MP), endoscopic resection is considered difficult due to fibrosis and extended resection of the colon may be required to reduce the risk of anastomotic leakage. Herein, we report our case and details of past reported literatures.

[A Case of Recurrent Gastric Cancer with Durable Complete Response after Short-Term Nivolumab Therapy]

We report the case of a patient with recurrent gastric cancer that showed a complete response(CR)after short-term nivolumab administration. A 76-year-old woman was diagnosed with unresectable advanced gastric cancer(T4b, N+, M0, cStage ⅣA). The patient was administered 7 courses of SOX. Since the primary lesion was reduced significantly after the chemotherapy, radical gastrectomy was performed. Although postoperative adjuvant chemotherapy with weekly nab-PTX was performed, cancer recurrence occurred in the abdominal cavity, and another surgery was performed. However, complete resection was difficult to achieve. Postoperatively, chemotherapy was continued; however, CEA levels increased, and thus RAM+PTX was administered as second-line treatment. Stable disease was maintained for a while; however, disease progression occurred eventually. Thus, RAM+PTX was discontinued after 8 courses, and nivolumab was administered as the third-line treatment. However, due to the rapid deterioration of renal function, nivolumab could not be continued after 3 courses. After nivolumab discontinuation, CEA levels normalized and the image showed CR. Approximately 1.5 years have passed since then, with no report of recurrence without any treatment. Although nivolumab has been shown to be useful as a third-line treatment for unresectable advanced/recurrent gastric cancer, there are few reports demonstrating CR and none showing maintenance of CR after short-term nivolumab administration. Moreover, the rationale of continuing nivolumab is unclear once clinical CR is achieved. Our experience shows the feasibility of discontinuation of short-term nivolumab if CR is achieved.

[Two Cases of Locally Advanced Lower Rectal Cancer with Pathological Complete Response after Cetuximab plus SOX as Neoadjuvant Chemotherapy]

We have introduced neoadjuvant chemotherapy(NAC)for locally advanced lower rectal cancer(LARC)since 2014. We report 2 LARC cases in which a pathological complete response(pCR)was obtained by using cetuximab(Cmab)plus oxaliplatin plus S-1(SOX)for NAC. Case 1: A 68-year-old woman underwent 4 courses of Cmab plus SOX for Rb rectal cancer (well-differentiated adenocarcinoma, cStage Ⅲc: cT4b[vagina]N3M0). Lap posterior pelvic exenteration was performed. The pathological findings of the resected specimen revealed no carcinoma and we diagnosed it as pCR. As of 31 months after the operation, she is alive without recurrence. Case 2: A 72-year-old man underwent 4 courses of Cmab plus SOX for middle and lower rectal cancer(Rab, moderately differentiated tubular adenocarcinoma, cStage Ⅲc: cT3N3M0). After NAC, with the diagnosis of ycT3N0M0, laparoscopic-assisted(Lap)super-low anterior resection with bilateral lateral pelvic node dissection was performed. The pathological findings of the resected specimen revealed no carcinoma and we diagnosed it as pCR. As of 37 months after the operation, he is alive without recurrence. NAC with Cmab plus SOX may be an effective treatment for LARC.

Fabrication of an anatomy-mimicking BIO-AIR-TUBE with engineered cartilage

Introduction

We devised a strategy for the fabrication of an ‘anatomy-mimicking’ cylinder-type engineered trachea combined with cartilage engineering. The engineered BIOTUBEs are used to support the architecture of the body tissue, for long-segment trachea (>5 cm) with carinal reconstruction. The aim of the present study was to fabricate an anatomy-mimicking cylinder-type regenerative airway, and investigate its applicability in a rabbit model.

Methods

Collagen sponge rings (diameter: 6 mm) were arranged on a silicon tube (diameter: 6 mm) at 2-mm intervals. Chondrocytes from the auricular cartilage were seeded onto collagen sponges immediately prior to implantation in an autologous manner. These constructs were embedded in dorsal subcutaneous pouches of rabbits. One month after implantation, the constructs were retrieved for histological examination. In addition, cervical tracheal sleeve resection was performed, and these engineered constructs were implanted into defective airways through end-to-end anastomosis.

Results

One month after implantation, the engineered constructs exhibited similar rigidity and flexibility to those observed with the native trachea. Through histological examination, the constructs showed an anatomy-mimicking tracheal architecture. In addition, the engineered constructs could be anastomosed to the native trachea without air leakage.

Conclusion

The present study provides the possibility of generating anatomy-mimicking cylinder-type airways, termed BIO-AIR-TUBEs, that engineer cartilage in an in-vivo culture system. This approach involves the use of BIOTUBEs formed via in-body tissue architecture technology. Therefore, the BIO-AIR-TUBE may be useful as the basic architecture of artificial airways.

Tracheoplasty with cartilage-engineered esophagus environments

PURPOSE

Our objective was to investigate the feasibility of engineering cartilage on the esophagus layer and outside the esophagus. Moreover, we investigated the feasibility of tracheoplasty with cartilage engineered on the esophagus in rabbits.

METHODS

Chondrocytes were isolated from auricular cartilages. 1. Engineered cartilage formation by histological findings on/into the esophageal layer was compared with that of injectable scaffold and preformed scaffold with chondrocytes. 2. Chondrocytes adhered to gelatin+vicryl mesh™ and b-FGF, were implanted on the outer esophageal surface. Four weeks after seeding, we found that cartilage was implanted in the midposterior portion of the cervical trachea (n=5), and it was retrieved 8weeks after seeding.

RESULTS

1. A gelatin sponge incorporating β-TCP with vicryl mesh™ showed the best performance for fabricating engineered cartilage on the outer side of the esophagus. 2. Two of 5 rabbits died due to obstructed esophagus. Cartilage engineered outside the esophagus by a composite scaffold as the main material in the gelatin sponge, maintained the airway structure for up to 1month after implantation. Tracheal epithelial regeneration occurred in the internal lumen of this engineered cartilage.

CONCLUSION

Tracheoplasty with cartilage engineered outside the esophagus may be useful for reconstructing airways.

Complications of laparoscopic surgery in neonates and small infants

PURPOSE

The difficulty of performing laparoscopic surgery in small infants remains a common complaint of pediatric surgeons. The aim of this study was to evaluate the complications of laparoscopic surgery in small infants weighing less than 5 kg.

METHODS

Since 1997, 154 infants weighing less than 5 kg underwent laparoscopic surgery (group S). During that same period, 96 infants weighing less than 10 kg (group M) and 335 children weighing more than 10 kg (group L) also underwent laparoscopic surgery. Intra- and postoperative complications were evaluated and compared between the 3 groups, especially in the 60 cases that underwent Nissen fundoplication. P < .05 was considered a significant difference.

RESULTS

Complications such as gastrointestinal perforation and wound infection were observed in 15 (9.7%), 15 (15.6%), and 32 (9.6%) infants of groups S, M, and L, respectively. There were no significant differences in complication rates among the 3 groups. However, in Nissen fundoplication, 5 of 15 patients in group S had complications, thereby significantly increasing the complication rate as compared with group L (1 of 23, P = .04). Major complications in group S were gastrointestinal perforation and vagal nerve injury.

CONCLUSIONS

Laparoscopic surgery is feasible even in small infants. However, in Nissen fundoplication, special attention is necessary to avoid severe intraoperative complications.

Homozygosity and linkage disequilibrium mapping of autosomal recessive distal myopathy (Nonaka distal myopathy)

Autosomal recessive distal myopathy or Nonaka distal myopathy (NM) is characterized by its unique distribution of muscular weakness and wasting. The patients present with spared quadriceps muscles even in a late stage of the disease. The hamstring and tibialis anterior muscles are affected severely in early adulthood. We have localized the NM gene to the region between markers D9S319 and D9S276 on chromosome 9 by linkage analysis. To further refine the localization of the NM gene, we conducted homozygosity and linkage disequilibrium analysis for 14 patients from 11 NM families using 18 polymorphic markers. All of the patients from consanguineous NM families were found to be homozygous for six markers located within the region between markers D9S2178 and D9S1859. We also provided evidence for significant allelic associations between the NM region and five marker loci. Examination of the haplotype analysis identified a predominant ancestral haplotype comprising the associated alleles 199-160-154-109 (marker order: D9S2179-D9S2180-D9S2181-D9S1804), present in 60% of NM chromosomes and in 0% of parent chromosomes. On the basis of the data obtained in this study, the majority of NM chromosomes were derived from a single ancestral founder, and the NM gene is probably located within the 1.5-Mb region between markers D9S2178 and D9S1791.

[Successful direct thrombolysis in a patient with extensive dural sinus thrombosis induced by danazol]

A 43-year-old woman was suffered from an increasing headache with nausea and vomiting for nine days. She had received danazol 400 mg daily for endometriosis last two months. CT scan and neurological examinations revealed no evidence of abnormality. MRI showed isosignal intensity on T1-weighted images and high signal intensity on T2-weighted images in the superior sagittal, right transverse, sigmoid and straight sinuses suggesting thrombosis. With angiography, we confirmed extensive dural sinus thrombosis in the superior sagittal, straight, right transverse and sigmoid sinuses. She, then, developed progressing neurological deterioration with dysarthria and drowsy. Microcatheter was placed directly into the thrombus at dural sinus via transfemoral route. Thrombolytic therapy with urokinase was performed in right transverse, confluens sinuum, superior sagittal and straight sinuses. Successful recanalization with remarkable improvement of symptoms was achieved except right transverse sinus. We believe danazol played a role in the occurrence of dural sinus thrombosis. MRI and MRV were noninvasive and useful for diagnosis and follow-up of dural sinus thrombosis. Direct thrombolysis should be considered for dural sinus thrombosis, especially when clinical symptoms are rapidly deterioration with conventional anticoagulant therapy.

[Brain uptake ratio as an index of cerebral blood flow obtained with 99mTc-ECD]

A new index of cerebral blood flow (brain uptake ratio, BUR) using 99mTc-ECD was developed and evaluated in 66 patients (132 cerebral hemispheres). BUR was calculated from brain count in anterior planar image (60-80 sec after injection of 99mTc-ECD) divided by the summation of the count of aortic arch during first transit of radionuclide. BUR correlated well with brain perfusion index (BPI) obtained with Patlak plot method (r = 0.960, p < 0.001). In conclusion, BUR is useful as a simple and non-invasive index reflecting cerebral blood flow.

[Modifications of fractional uptake method for 123I-IMP]

We intended to improve the fractional uptake (FU) method which was developed to quantify cerebral blood flow using 123I-IMP without blood sampling. The quantification of cardiac output (CO) using first-pass data was adapted to FU method while the original FU method used CO which was estimated from the body surface area of patients. Time-radioactivity curves of the lungs and brain were separately obtained by a small-field-of-view gamma camera. In 24 cases, mean cerebral blood flow (mCBF) obtained by the modified FU method showed the better correlation (r = 0.833, P< 0.001) to mCBF measured by the Patlak plot with 99mTc-HMPAO than the original FU method (r=0.667, p<0.01). With these modifications, the reliability of FU method could be improved and the modified FU method might be performed in the other institutions.

Dissociated motor loss syndrome with cavities in the anterior horns

A 74-year-old man developed proximal muscular weakness and wasting of the left upper extremity without sensory disturbance or myelopathic symptoms. The muscle atrophy had not progressed for a few years. Radiological examination of the spine showed cervical disc herniation. These findings and electrophysiological studies excluded motor neuron diseases, permitting the diagnosis of dissociated motor loss syndrome. Interestingly, delayed computerized tomographic myelography disclosed cavities in the anterior horns of the spinal cord, which coincided with the clinical symptoms. Previous radiological and pathological examinations showed formation of such cavities within the spinal cord resulting from chronic compression, which was followed by ischemic change. In this context, the present case supports ischemia as a cause of dissociated motor loss syndrome.

An autonomously functioning thyroid carcinoma associated with euthyroid Graves' disease

A 39-yr-old man with an autonomously functioning thyroid carcinoma is presented. Only 17 similar cases have been reported in the literature. The patient had unilateral Graves' ophthalmopathy. He was euthyroid as reflected by normal TSH concentration, whereas the results of a T3 suppression test established the presence of autonomous thyroid function. A thyroid scan with (123)I revealed a hot nodule corresponding to the location of a papillary carcinoma and remained substantially unchanged after T3 administration. The hyperfunction of the carcinoma itself was clearly confirmed by the intense concentration of (131)I within the tumor on microautoradiograms. While a hot nodule on radioiodine scan is unlikely to be malignant, the possibility of carcinoma should not be overlooked.

Conformational modification enhances myasthenogenicity in synthetic peptide of acetylcholine receptor alpha-subunit

The induction of myasthenia gravis depends on linked recognition of antigenic sites of acetylcholine receptor (AChR) by B-cells and T-cells. The former is conformationally restrained, and the latter is under the MHC class II restriction. We synthesized an artificially formed peptide (model peptide) by coupling the alpha 190-195 selected as B-cell site and cholinergic binding site and the alpha-107-116 selected as T-cell site and agretope with the intervening chain segment aligned as Asn-Pro-Gly-Gly (NPGG) to adopt beta-turn conformation. This model peptide, alpha 107-116-NPGG-alpha 190-195, was potently immunogenic in Lewis rats to provoke anti-peptide antibody reactive with native AChR and to induce the animal model of immunopharmacologic blockade of acetylcholine (ACh)-binding site. Low immunogenicity compared with this was found when using natural peptides predicted as sequences of B-cell site or T-cell site and the peptide synthesized by linking both without intervention of NPGG. The alpha 190-195 had no function of cholinergic binding either as a single segment or as part of the conformation-modified peptides; results suggest that the conformation modified for high immunogenicity does not assume the bioactive conformation for ACh-binding.

Chemical modification of erythropoietin: an increase in in vitro activity by guanidination

Human recombinant erythropoietin (rHuEPO) was chemically modified with several group-specific reagents in order to study the role of each kind of amino-acid residue in its biological activity. Guanidination of the amino groups of the lysine residues yielded derivatives that showed higher activities in vitro than native rHuEPO, whereas amidination had no effect on the activity. By contrast, modification of the positive charges of the lysine residues to neutral or negative charges, such as in carbamylation, trinitrophenylation, acetylation or succinylation, caused a significant loss of rHuEPO activity. Chemical modification of other amino-acid residues, such as arginine and tyrosine residues or carboxyl groups, also led to loss of activity.

Cholinergic differentiation of clonal rat pheochromocytoma cells (PC12) induced by factors contained in glioma-conditioned medium: enhancement of high-affinity choline uptake system and reduction of norepinephrine uptake system

The effects of glioma-conditioned medium (GCM) and factors contained in GCM on the neurochemical differentiation of the PC12 clone of rat pheochromocytoma cells were investigated. The results obtained are as follows. The accumulation of choline into PC12 cells proceeded through two uptake systems with high (Km = 3.20 microM) and low (Km = 65.2 muM) affinities as revealed by least-squares iterative fitting of a substrate-velocity curve to the data. Culturing of PC12 cells in the presence of GCM led to a 5-fold increase in the Vmax value of the high-affinity uptake system without affecting the Km of the high-affinity uptake system. Both Km and Vmax of the low-affinity uptake system were unaffected by the GCM treatment. The high-affinity choline uptake system in both GCM-treated and untreated PC12 cells was devoid of Na+ dependency and showed low sensitivity to hemicholinium-3. The ratio of [3H]acetylcholine converted from [3H]choline taken up by PC12 cells at 1 muM choline for 1 h was two-fold higher than that by untreated cells. PC12 possess a high-affinity norepinephrine uptake system. Culturing of PC12 cells in the presence of GCM led to a decrease in the rate of uptake of 3 muM norepinephrine to 43% of that in control cells. The 40-K and 10-K fractions isolated by gel filtration of GCM had both abilities to enhance the high-affinity choline uptake system and to suppress the high-affinity norepinephrine uptake system. From these observations it was concluded that GCM contains factors which induce the cholinergic neuronal differentiation of PC12 cells.

Promotion of cell-substratum adhesion of clonal rat pheochromocytoma cells (PC12) by factors contained in glioma-conditioned medium (GCM): separation of two active factors contained in GCM

Culture medium conditioned over C6 glioma cells (GCM) contains factors which induce neurite outgrowth from clonal rat pheochromocytoma (PC12) cells. The effects of GCM on the cell-substratum adhesion of PC12 cells, which is an early event required for the neurite outgrowth, were investigated. The results obtained are as follows. Addition of GCM promoted the adhesion of PC12 cells specifically to collagen-coated tissue culture dish. The GCM-promoted adhesion of PC12 cells was prevented by the treatment of the cells with cytochalasin B, concanavalin A and glycosidase mixture suggesting the contribution of microfilaments and cell surface carbohydrates in the cell adhesion. GCM did not increase significantly the intracellular content of cAMP and the extent of cell adhesion promoted by cAMP or dibutyryl-cAMP was much less than that by GCM. Two active factors contained in GCM were separated by either gel filtration or chromatofocusing using the cell adhesion assay as an index. The first factor with an apparent mol. wt. around 40,000 had the abilities to induce the neurite outgrowth and to enhance the choline acetyltransferase activity in addition to the ability to promote the adhesion of PC12 cells. The second factor with an apparent mol. wt. around 10,000 was devoid of the ability to induce the neurite outgrowth, but had the abilities to enhance the choline acetyltransferase activity and to promote the adhesion of PC12 cells. Both factors were sensitive to trypsin digestion and relatively heat stable. The significance of these factors in the neuronal differentiation was discussed.

Transient infantile hyperthyrotropinaemia. Report of a case

A case of transient hyperthyrotropinaemia was found by mass screening for neonatal hypothyroidism using the paired TSH assay method. The patient was a baby boy born at term after a normal pregnancy who grew without any abnormal signs or symptoms. For the first 7 months after birth, his serum TSH was abnormally high while his total serum T4, T3, and free T4, T3 were within normal limits, exept for slightly low free T4 level at 7 months. The raised serum TSH decreased spontaneously to within normal limits after he was 9 months old.