Radiation exposure in pediatric patients with early onset scoliosis: A longitudinal single-center study

BACKGROUND

There is no consensus regarding the acceptable level of medical radiation exposure in patients with early-onset scoliosis. This study aimed to quantify radiation exposure in these patients and investigate factors associated with high exposure.

METHODS

Patients with early-onset scoliosis who received care for their spine deformity and other comorbidities in our institution were retrospectively reviewed. Cumulative radiation exposure and total number of imaging studies were recorded. Patients with ≥30 mSv exposure were classified as high exposure and analyzed to clarify factors associated with high exposure.

RESULTS

Thirty-five patients were included for analysis. The etiology of scoliosis was idiopathic in 8 patients, congenital in 7, syndromic in 8, and neuromuscular in 12. Fifteen patients underwent 19 spinal surgeries. The types of operation performed were definitive fusion (n = 12), vertebrectomy for hemivertebra (n = 2), growing rod (n = 1), lengthening (n = 3), and revision/partial implant removal (n = 1). The mean cumulative radiation dose was 22.3 mSv (range, 2.5-94.5 mSv). Spine radiography and computed tomography combined accounted for 15.0 mSv (range, 2.4-52.5 mSv, 67.3% of the mean cumulative dose). The mean radiation dose was significantly higher in patients who underwent spinal surgery than in those who did not (31.2 mSv vs. 15.6 mSv). The high-exposure group comprised 10 patients (1 idiopathic, 1 congenital, 5 syndromic, and 3 neuromuscular scoliosis) and 8 underwent 11 spinal operations. Among 8 patients who underwent spinal surgery, the cumulative radiation dose for spine was ≥30 mSv and spine computed tomography was performed an average of 4.0 times.

CONCLUSIONS

Nearly one-third of patients with early-onset scoliosis and half of patients who underwent spinal surgery had >30 mSv radiation exposure due to multiple computed tomography. Medical radiation exposure and associated cancer risk should be considered when treating these patients.

Elevation of Anticancer Drug Toxicity by Caffeine in Spheroid Model of Human Lung Adenocarcinoma A549 Cells Mediated by Reduction in Claudin-2 and Nrf2 Expression

Claudin-2 (CLDN2), a component of tight junctions, is abnormally expressed in human lung adenocarcinoma tissue. CLDN2 contributes to chemoresistance in human lung adenocarcinoma-derived A549 cells, and it may be a target for cancer therapy. Here, we found that coffee ingredients, namely caffeine and theobromine, decreased the protein level of CLDN2 in human lung adenocarcinoma-derived A549 cells. In contrast, other components, such as theophylline and chlorogenic acid, had no effect. These results indicate that the 7-methyl group in methylxanthines may play a key role in the reduction in CLDN2 expression. The caffeine-induced reduction in the CLDN2 protein was inhibited by chloroquine, a lysosome inhibitor. In a protein-stability assay using cycloheximide, CLDN2 protein levels decreased faster in caffeine-treated cells than in vehicle-treated cells. These results suggest that caffeine accelerates the lysosomal degradation of CLDN2. The accumulation and cytotoxicity of doxorubicin were dose-dependently increased, which was exaggerated by caffeine but not by theophylline in spheroids. Caffeine decreased nuclear factor-erythroid 2-related factor 2 (Nrf2) levels without affecting hypoxia-inducible factor-1α levels. Furthermore, caffeine decreased the expression of Nrf2-targeted genes. The effects of caffeine on CLDN2 expression and anticancer-drug-induced toxicity were also observed in lung adenocarcinoma RERF-LC-MS cells. We suggest that caffeine enhances doxorubicin-induced toxicity in A549 spheroids mediated by the reduction in CLDN2 and Nrf2 expression.

Unilateral premature osteoarthritis of the hip with excessive anteversion of the femoral neck developing in the early second decade: two surgical cases

Background

Osteoarthritis (OA) of the hip rarely develops in the early second decade. As the incidence of this disease is low, no treatment method has been established. We report two patients with unilateral OA in their early teens in whom the anteversion angle of the femoral neck on the affected side was greater than that on the unaffected side.

Case presentation

Case 1 was an 11-year-old girl with left coxalgia and limited range of motion. There was no history of femoroacetabular impingement (FAI) or developmental dysplasia of the hip (DDH). Plain X-rays revealed the disappearance of the Y cartilage, joint space narrowing of the left hip, and acetabular/femoral head osteosclerosis. In CT images, the anteversion angle of the femoral neck (lt/rt) was 45/35 degrees. As osteoarthritis was severe, proximal femoral flexional derotational varus osteotomy (PFFDVO) and triple pelvic osteotomy (TPO) were performed.

Case 2 was a 13-year-old girl with left coxalgia and limited range of motion. There was no history of FAI or DDH. Plain X-ray revealed irregularity of the left anterolateral femoral head, and a subcartilaginous cyst. In CT images, the anteversion angle of the femoral neck (lt/rt) was 30/20 degrees. As osteoarthritis was severe, PFFDVO was performed. In addition, we resected bone spurs on the femoral head because flexion was limited owing to the presence of osteophytes. In both patients, coxalgia and claudication/gait disorder resolved postoperatively, and joint space narrowing and osteosclerosis improved. However, in Case 1, there was a 3-cm difference in the leg length, and in Case 2, range-of-motion limits remained.

Conclusions

We present the findings in two patients with unilateral OA in their early second decade in whom the femoral anteversion angle on the affected side was greater than that on the unaffected side. PFFDVO + TPO was performed in Case 1, and PFFDVO + bone spur resection on the femoral head was performed in Case 2. Coxalgia resolved, and plain X-ray demonstrated improvements in OA; however, a difference in the leg length and range-of-motion limits remained.

Upregulation of Chemoresistance by Mg2+ Deficiency through Elevation of ATP Binding Cassette Subfamily B Member 1 Expression in Human Lung Adenocarcinoma A549 Cells

Several anticancer drugs including cisplatin (CDDP) induce hypomagnesemia. However, it remains fully uncertain whether Mg²⁺ deficiency affects chemosensitivity of cancer cells. Here, we investigated the effect of low Mg²⁺ concentration (LM) on proliferation and chemosensitivity using human lung adenocarcinoma A549 cells. Cell proliferation was reduced by continuous culture with LM accompanied with the elevation of G1 phase proportion. The amounts of reactive oxygen species (ROS) and stress makers such as phosphorylated-ataxia telangiectasia mutated and phosphorylated-p53 were increased by LM. Cell injury was dose-dependently increased by anticancer drugs such as CDDP and doxorubicin (DXR), which were suppressed by LM. Similar results were obtained by roscovitine, a cell cycle inhibitor. These results suggest that LM induces chemoresistance mediated by ROS production and G1 arrest. The mRNA and protein levels of ATP binding cassette subfamily B member 1 (ABCB1) were increased by LM and roscovitine. The LM-induced elevation of ABCB1 and nuclear p38 expression was suppressed by SB203580, a p38 MAPK inhibitor. PSC833, an ABCB1 inhibitor, and SB203580 rescued the sensitivity to anticancer drugs. In addition, cancer stemness properties were suppressed by SB203580. We suggest that Mg²⁺ deficiency reduces the chemotherapy sensitivity of A549 cells, although it suppresses cell proliferation.

Down-Regulation of Claudin-2 Expression by Cyanidin-3-Glucoside Enhances Sensitivity to Anticancer Drugs in the Spheroid of Human Lung Adenocarcinoma A549 Cells

Claudin-2 (CLDN2), an integral membrane protein located at tight junctions, is abnormally expressed in human lung adenocarcinoma tissues, and is linked to drug resistance in human lung adenocarcinoma A549 cells. CLDN2 may be a target for the prevention of lung adenocarcinoma, but there are few compounds which can reduce CLDN2 expression. We found that cyanidin-3-glucoside (C3G), the anthocyanin with two hydroxyl groups on the B-ring, and cyanidin significantly reduce the protein level of CLDN2 in A549 cells. In contrast, pelargonidin-3-glucoside (P3G), the anthocyanin with one hydroxyl group on the B-ring, had no effect. These results suggest that cyanidin and the hydroxyl group at the 3-position on the B-ring play an important role in the reduction of CLDN2 expression. The phosphorylation of Akt, an activator of CLDN2 expression at the transcriptional level, was inhibited by C3G, but not by P3G. The endocytosis and lysosomal degradation are suggested to be involved in the C3G-induced decrease in CLDN2 protein expression. C3G increased the phosphorylation of p38 and the p38 inhibitor SB203580 rescued the C3G-induced decrease in CLDN2 expression. In addition, SB203580 rescued the protein stability of CLDN2. C3G may reduce CLDN2 expression at the transcriptional and post-translational steps mediated by inhibiting Akt and activating p38, respectively. C3G enhanced the accumulation and cytotoxicity of doxorubicin (DXR) in the spheroid models. The percentages of apoptotic and necrotic cells induced by DXR were increased by C3G. Our data suggest that C3G-rich foods can prevent the chemoresistance of lung adenocarcinoma A549 cells through the reduction of CLDN2 expression.

METHIMAZOLE-INDUCED AGRANULOCYTOSIS AND SEPSIS: WAS THYROID STORM PRESENT OR JUST BEING MIMICKED?

Introduction

Agranulocytosis induced by thioamides is rare, occurring only in 0.2-0.5% of cases.

Case presentation

We present the case of a 45-year-old woman previously diagnosed with Graves' disease that discontinued the use of methimazole on her own. She attended the Emergency Department presenting fever (40.5¯C), agitation and diaphoresis. A thyroid storm diagnosis was initially thought, but after laboratory results showing neutrophil count near 0.06x109/L, sepsis due to neutropenia seemed the most logical hypothesis. Cephepime was promptly initiated. For thyrotoxicosis management, cholestyramine and atenolol were prescribed. In her second day of hospitalization, subcutaneous granulocyte colony-stimulating factor was started for an earlier medullar response. The patient was discharged after 7 days with atenolol 50mg/day and instructed to have a definite treatment for Graves disease as soon as possible.

Conclusion

Such case purpose is to remember clinicians that sepsis diagnosis can be challenged, especially when a thyroid storm is a possible diagnosis as well. In this particular case, both conditions should be treated, but life-threatening sepsis should have the focus for a quick therapeutic approach.

Inhibitory effect of low density lipoprotein on the inflammation-inducing activity of calcium pyrophosphate dihydrate crystals

OBJECTIVE

It has been proposed that low density lipoprotein (LDL) plays a role in the self-limiting nature of pseudogout inflammation. We investigated changes of LDL concentration in rat air pouch fluid during periods of acute and subsiding inflammation to evaluate whether LDL contributes to inhibiting inflammation of pseudogout. We examined whether LDL binds to calcium pyrophosphate dihydrate (CPPD) crystals as a possible mechanism for reduction of inflammation.

METHODS

In this in vivo study, 5 mg suspensions of CPPD crystals and saline were injected into the rat air pouch. Fluid samples were taken from rat air pouch at 0, 3, 6, 12, 24, and 48 h after injection. White blood cells in the samples were counted; the remaining fluid was centrifuged and concentrations of beta-glucuronidase and PGE2 in the supernatant were measured as inflammatory markers. LDL in the supernatant was immunochemically identified by Western blotting, then pellets containing crystals were examined by the same technique.

RESULTS

LDL was identified in the air pouch 3 h after CPPD crystal injection, and its concentration increased and reached a peak level after 24 h. Inflammatory markers reached maximal level from 6 to 12 h, then decreased after 24 h. In the pellets containing crystals, LDL could not be identified in every specimen.

CONCLUSION

LDL in the rat air pouch increased during the inflammatory course induced by CPPD crystal and the inflammation subsided as the LDL increased. Since some reports indicate LDL was related to reduction of crystal induced inflammation such as gout or pseudogout, we concluded that LDL could contribute to the resolution of acute pseudogout arthritis in vivo with or without binding to CPPD crystals.

[A case of non-small-cell lung cancer successfully treated using combination chemotherapy with CDDP and vinorelbine]

A 67-year-old woman presented to our hospital with a chief complaint of bloody sputum. A plain chest X-ray a CT scan revealed a tumor shadow 3 cm in size in the middle lobe of the right lung, multiple nodular shadows in the bilateral lung fields and enlarged hilar and mediastinal lymph nodes. A tumor biopsy done under bronchoscopy revealed poorly differentiated adenocarcinoma of the lungs (cT2N3M1). She was given two courses of combination therapy consisting of cisplatin (80 mg/m2) and vinorelbine (20 mg/m2). The primary tumor in the middle lobe of the right lung and the lung metastases were markedly reduced in size, and a complete response was obtained. The only adverse events were grade 4 neutropenia and grade 2 nausea and vomiting.

The vasocontractive action of norepinephrine and serotonin in deep arterioles of rat cerebral gray matter

To examine the direct effects of norepinephrine (NE) and serotonin (5-HT) on the contractility of arterioles in the gray matter of the rat cerebrum, we micro-perfused arterioles in vitro and observed the changes in luminal diameter under the stop-flow condition with constant intraluminal pressure. While the average diameter of the lumen of arterioles was 39.9 +/- 9.7 microm (n=7) in Hepes-buffered saline, the average in 10(-7) M NE in the extraluminal solution changed into smaller in saline by 21.1 +/- 5.4% (n=7). The contractile effect of NE shows a dose-dependent curve between the 10(-7) and 10(-5) M. The contractile response to 10(-6) M NE was significantly reduced by yohinbin, an alpha2 blocker. 10(-6) M NE applied to the lumen also caused contraction of arterioles by 12.4 +/- 5.3% in diameter (n=5). 5-HT at 10(-7) M in the extraluminal solution caused contraction of arterioles by 10.9 +/- 4.4% in diameter (n=7). 5-HT in the extraluminal solution caused contraction of arterioles in a dose dependent manner between 10(-10) and 10(-6) M. The contractile effect of 5-HT at 10(-6) M was strongly reduced by 10(-6) M ketanserin, a 5-HT2 receptor antagonist. 5-HT applied to the lumen had no effect at all (n=6), however NE applied to the lumen caused contraction. These results strongly suggest that 5-HT plays a significant role in arteriolar contractility only from the cerebrospinal fluid (CSF) side, while NE is an important regulator of arteriolar contractility from both the CSF and blood circulation sides.

Detection and differentiation of Aino and Akabane Simbu serogroup bunyaviruses by nested polymerase chain reaction

Reverse transcription-polymerase chain reaction (RT-PCR) and nested PCR were developed to detect and differentiate Aino (AINO) and Akabane (AKA) virus S RNA. Two pairs of AINO- and AKA-specific primers for nested PCR were synthesized and examined for their capacity to amplify PCR products using 7 Simbu serogroup viruses isolated in Japan and Australia. RT- and nested PCR using AKA-specific primers amplified cDNA from Tinaroo virus RNA as well as homologous RNA. Nested PCR products were differentiated by Hph I and Bst EII digestion. Peaton (PEA) virus S cDNA was also amplified using AINO- specific primers. The nested PCR products of PEA virus were not digested by 3 restriction enzymes (Ava II, Eco RI and Hae II), whereras those of AINO virus were digested as expected. Using this technique, AINO and AKA viruses were detected at concentrations as low as 10(-3) plaque-forming units (PFU) and 10(-5) PFU, respectively, in a supernatant of virus-infected cells. It was possible to detect AINO and AKA genome from various tissues of experimentally infected mice, and also the AKA nested PCR products from serum samples from sentinel cattle naturally infected with AKA virus. The present nested PCR appears a simple, rapid and valuable method for diagnosing AINO and AKA infection.

A possible role of immunoglobulin E in patients with hyperthyroid Graves' disease

To investigate the possible participation of immunoglobulin E (IgE) in the autoimmune process of Graves' disease, incidence of elevation of serum IgE level, TSH receptor antibody (TRAb), and thyroid status were studied in 66 patients with hyperthyroid Graves' disease, 54 patients with Hashimoto's thyroiditis, 19 patients with bronchial asthma, and 15 patients with pollen allergy. In hyperthyroid Graves' patients, elevation of serum IgE levels (> or = 170 U/mL) was found in 19 of 66 patients (29%), 11 of whom had hereditary and/or allergic conditions. Elevations of serum IgE levels were found in 63% of patients with bronchial asthma and in 40% of patients with pollen allergy. Mean values of serum IgE were the same in patients with hyperthyroid Graves' disease and with bronchial asthma. During methimazole treatment TRAb decreased without fluctuation of IgE levels in both groups. The decrease in TRAb was significantly greater in patients with normal IgE than in patients with IgE elevation. After prednisone administration, reduction in TRAb was greater in patients with normal IgE than that in patients with IgE elevation. High incidence of IgE elevation in hyperthyroid Graves' disease and slower reduction in TRAb in association with IgE elevation suggest a difference in the autoimmune processes in Graves' disease with and without elevation of IgE.

An elevation of stem cell factor in patients with hyperthyroid Graves' disease

Graves' disease is an autoimmune disorder characterized by the presence of antibodies against thyrotropin receptor (TRAb). Stem cell factor (SCF), derived from bone marrow, is known to promote lymphohematopoiesis. To investigate the relation between the alteration in plasma levels of SCF, thyroid hormone status, and TRAb measured by thyrotropin binding inhibition (TBI), 13 untreated, 21 treated, and 4 relapsed hyperthyroid Graves' disease patients, 21 patients with Hashimoto's thyroiditis, 6 patients with subacute thyroiditis, and 11 control subjects were examined. In untreated hyperthyroid Graves' disease patients, serum levels of thyroxine (T4) and triiodothyronine decreased rapidly by methimazole treatment, and TBI decreased progressively, but variably. Simultaneously, the elevated plasma levels of SCF decreased gradually and progressively. The plasma levels of SCF correlated curvilinearly with the serum levels of T4. In 4 patients with relapsed hyperthyroid Graves' disease, TBI was marginally positive in 3 patients and negative in 1, but plasma levels of SCF were elevated significantly in all 4 patients. In patients with subacute thyroiditis and Hashimoto's thyroiditis with or without T4 replacement, plasma levels of SCF did not differ from that of controls. These findings indicate that the elevation of plasma levels of SCF relates to the longstanding thyrotoxic state and that short-term thyrotoxicosis does not significantly affect plasma levels of SCF. It remains to be determined whether the elevation in plasma levels of SCF is induced by excess thyroid hormone, reflecting the hypermetabolic state, or whether the elevation of plasma levels of SCF contributes to stimulation of lymphocytes producing TRAb.

Vertebral pedicle diameter as determined by computed tomography: inaccuracies observed by direct measurement of cadaveric lumbar spine

The isthmic diameter of the vertebral pedicle is an important dimension affecting the stability of transpedicular screwing. The isthmic diameter of the pedicle was measured in the lumbar spines of 18 Japanese cadavers (10 male, 8 female) by axial computed tomographic (CT) scan and directly with calipers. In L1 and L2, there was no significant difference between the average value of the isthmic diameter as determined by the two methods (Student's t-test). However, in L3-5, the average value of the isthmic diameter as determined by axial CT scan was significantly greater than that given by caliper measurement. In view of the fact that caudally the longitudinal axis of the pedicle diverges towards the mid-line of the vertebral body in the coronal plane, the plane of the CT scan cannot be parallel to the real isthmic diameter of the pedicle. Therefore, it is suggested that below L2 the diameter as determined by axial CT scanning is greater than the real isthmic diameter.

Immunohistochemical studies of infiltrating cells in early and chronic lesions of psoriasis

The expression of surface antigens on infiltrating cells, epidermal keratinocytes, and dendritic cells in biopsy specimens from 31 patients with psoriasis was examined immunohistochemically. The specimens were divided into early-phase and chronic-phase groups and then examined in a double blind manner. Among the infiltrating cells in the epidermis, CD4-positive cells were dominant in the early phase; CD8-positive cells were dominant in the chronic phase, resulting in a markedly decreased CD4/CD8 ratio in the latter. On the other hand, among the infiltrating cells in the dermal papillae, CD4-positive cells were dominant in both the early and chronic phases; both CD4-positive and CD8-positive cells were more dominant in the chronic phase than in the early one. However, the CD4/CD8 ratios were decreased in both the dermal papillae and the epidermis in the chronic phase. CD1-positive dendritic cells (probably Langerhans cells) were more numerous in the chronic phase than in the early phase. There were no significant differences between the early and chronic phases with regard to the expression of HLA-DR and HLA-DQ antigens on the infiltrating cells. However, the HLA-DR antigens and ICAM-1 (intracellular adhesion molecule-1) were more strongly expressed on epidermal keratinocytes in the chronic phase than in the early phase. LFA-1 alpha (lymphocyte function-associated antigen-1 alpha)-positive cells were also significantly more numerous in the chronic phase than in the early one, consistent with the expression of HLA-DR antigens and ICAM-1 on keratinocytes mentioned above. On the other hand, VLA-4 (integrin alpha 4 beta 1) positive cells were expressed more abundantly in the epidermis in the early phase than in the chronic phase. These results suggest, first, that the chronic phase of psoriasis is as immunologically active as or more active than the early phase. Second, CD4-positive T cells are more important than CD8-positive T cells in the early phase of psoriasis; CD8-positive rather than CD4-positive T cells are more important in the chronic phase. Third, the LFA-1/ICAM-1 pathway may play an important role with regard to cell adhesion of the infiltrating cells in the psoriatic lesions in disease exacerbation or prolongation, whereas the VLA-4/VCAM-1 (vascular cell adhesion molecule-1) pathway may be more important in disease onset.

Steroid injection therapy for pseudocyst of the auricle

In our clinic, we encountered 8 patients with pseudocyst of the auricle during a 6-year period from 1987 to 1992 and injected steroid solution locally into the pseudocysts. Three of these patients had no recurrences and 4 were treated successfully after 1-3 recurrences. In only one case was this therapy ineffective. After 11 injections, which resulted in permanent deformity of the auricle, the patient underwent surgery. We believe that local steroid injection therapy should be the first choice method for treating auricular pseudocysts. However, frequent injections can cause auricular deformity and if there are more than 3 recurrences, the pseudocyst should be managed surgically. The lactate dehydrogenase levels of the cystic fluid were determined in 3 of the 8 patients and proved high; in only one patient was the etiology of the pseudocyst thought to be associated with minor trauma.