Potential Efficacy of Janus Kinase Inhibitors in the Treatment of a Patient With Coexisting Peripheral and Axial Spondyloarthritis and Ulcerative Colitis

Tumor necrosis factor inhibitors are effective and recommended in treating patients with coexisting spondyloarthritis (SpA) and ulcerative colitis (UC); however, the evidence of their superiority over other drugs is insufficient.1 Although Janus kinase inhibitors (JAKi) have shown effectiveness in treating UC and psoriatic arthritis, there are no reports of treating coexisting SpA and UC with JAKi monotherapy.

Th17/IL-17A axis is critical for pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc): SSc patients with high levels of serum IL-17A exhibit reduced lung functions and increased prevalence of PAH

BACKGROUND

It is thought that systemic sclerosis (SSc) might be a T helper 17 (Th17) cell-driven autoimmune disease. Noticeably, pulmonary arterial hypertension (PAH) is a leading cause of death in patients with SSc. Here, we investigated the association between serum Th17-related cytokines and prevalence of PAH in SSc patients.

METHODS

This study included 72 SSc patients and 51 healthy controls (HC). We determined clinical manifestations, immunophenotypes including Th subsets in peripheral blood lymphocytes, and the serum levels of interleukin (IL)-17A, IL-17A/F, IL-17B. IL-17C, IL-17D. IL-1β, IL-6, IL-21, IL-22, and IL-23.

RESULTS

The frequency of Th17 cells was significantly increased in SSc patients compared to HC and was positively correlated with the modified Rodnan skin scores. Furthermore, the serum levels of IL-17A, IL-17D, IL-1β, and IL-6 were significantly increased in SSc patients compared to HC. SSc patients with detected IL-17A showed high levels of IL-17A/F, IL-1β, IL-6, and IL-22, and high frequency of Th17 cells. Interestingly, these patients exhibited the reduced lung functions and increased prevalence of PAH significantly compared to patients with undetected IL-17A. Similarly, SSc patients with detected IL-17A and high IL-6 (≥1.2 pg/mL) exhibited the decreased lung functions and increased prevalence of PAH compared to patients with undetected IL-17A and low IL-6.

CONCLUSION

We found that SSc patients with high levels of serum IL-17A or both IL-17A and IL-6 show reduced lung functions and high prevalence of PAH. Consequently, it is highly probable that Th17/IL-17A axis is critical for the prevalence of PAH in SSc patients.

Successful treatment of refractory enteritis and arthritis with combination of tumour necrosis factor and interleukin-6 inhibition in patients with ulcerative colitis

An 18 year-old man with autoimmune hepatitis-primary sclerosing cholangitis-overlap syndrome and ulcerative colitis was admitted due to relapsed enteritis and polyarthritis after cessation of infliximab. Colonoscopy and articular ultrasonography revealed large ulcers in the colon with crypt abscess in the specimens and active enthesitis and synovitis, respectively. His intestinitis was improved with golimumab but arthritis was persistent. Golimumab was switched to secukinumab, which was effective for arthritis. However, colitis was flared resulting in total colorectal resection. One month after colectomy, polyarthritis was relapsed. Tocilizumab ameliorated arthritis but enteritis emerged again, and switching tocilizumab to adalimumab improved enteritis but arthritis exacerbated. Finally, we restarted tocilizumab for arthritis with continued adalimumab for enteritis. The dual cytokine blocking strategy, tumour necrosis factor-α and interleukin-6 inhibition, subsided both of his refractory enteritis and arthritis and maintained remission for more than 3 years without any serious adverse event. Our case suggests that enteritis and arthritis in inflammatory bowel disease may be different in pathophysiology and raises the possible usefulness of simultaneous inhibition of two inflammatory cytokines in such cases.

Disease-specific expansion of CD29+IL-17RA+ T effector cells possessing multiple signalling pathways in spondyloarthritis

OBJECTIVES

T cells adhere to enthesis fibrocartilage via integrins and intrinsically require IL-17RA-mediated signals to maintain their effector function. We analysed CD29+IL-17RA+ T cells in inflamed lesions and peripheral blood in patients with SpA and investigated their association with disease activity and therapeutic response.

METHODS

Transcriptome analysis of synovial fluid T cells from PsA was performed using publicly available bulk cell RNA sequencing data. Blood samples were obtained from healthy controls (n = 37), RA (n = 12), IgG4-related disease (IgG4-RD; n = 12), large vessel vasculitis (LVV; n = 12) and SpA (n = 28) and were analysed by flow cytometry.

RESULTS

T cells in the inflamed joints of PsA showed CD29 and IL-17RA expression. CD29+IL-17RA+ T cells showed enriched CXCR3+CD45RA+ effector cells and activation of spleen tyrosine kinase (Syk), nuclear factor κB (NF-κB) and Janus kinase-signal transducer and activator of transcription (JAK-STAT) pathways. The proportion of peripheral blood CD29+IL-17RA+ T cells was significantly increased in patients with SpA compared with patients with RA, IgG4-RD or LVV and in healthy controls. Based on the ASDAS-CRP scores, the proportion of CD29+IL-17RA+ T cells was positively correlated with disease activity in treatment-naïve patients with active SpA. Anti-IL-17 but not anti-TNF monoclonal antibodies reduced CD29+IL-17RA+ T cells.

CONCLUSIONS

CD29+IL-17RA+ T effector cells with enhanced Syk, NF-κB and JAK-STAT pathways were specifically increased in SpA and were correlated with disease activity, implicating a role of this newly identified T cell population in the pathogenesis. Anti-IL-17 monoclonal antibodies may be effective for patients by reducing this pathogenic T cell population.

A severe cerebral infarction associated with giant cell arteritis which developed during tocilizumab therapy and was successfully treated with intravenous cyclophosphamide

Giant cell arteritis (GCA) is a large vessel vasculitis that primarily involves aorta and its major branches. Cerebral infarction is a serious complication that can occur secondary to GCA in up to 3% of patients with a mortality rate of over 50%. Due to the rarity of this severe complication, no therapeutic strategies are currently available. Furthermore, despite the recent progress in molecular-targeted therapy for GCA, it remains unknown whether tocilizumab is effective for severe ischemic complications such as cerebral infarction. Accumulation of individual cases in which this fatal complication could be treated is apparently required to build a better management of the disease. We present our case of GCA that developed severe cerebral infarction during high dose glucocorticoid and tocilizumab therapy and its symptoms and image findings were improved by switching to intravenous cyclophosphamide. Our case suggests that an intensive immunosuppressive therapy including cyclophosphamide may be necessary to stabilize this fatal complication of GCA.

AB0621 Characteristics of Anti-Neutrophil Cytoplasmic Antibody Associated Vasculitis With Severe Peripheral Neuropathy

Background

Peripheral neuropathy is one of major manifestations of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and has a significant impingement on patients’ quality of life.1,2

Objectives

The aim of this study was to clarify clinical features of AAV patients with peripheral neuropathy and identify risk factors for severe motor neuropathy.

Methods

All consecutive patients with active, treatment-naïve AAV who were admitted to our hospital between April, 2012 and October, 2021 were reviewed. Patients were divided into two groups according to the presence or absence of peripheral neuropathy, and their baseline clinical characteristics were compared.

Results

A total of 76 patients (microscopic polyangiitis, MPA, n=37, granulomatosis with poly angiitis, GPA, n=24, eosinophilic GPA, EGPA, n=15) were included in the study. Among them, 28 patients (36.8%) had peripheral neuropathy including 12 with MPA, 4 with GPA, and 12 with EGPA. The clinical characteristics of all patients with peripheral neuropathy were younger age (66.0 years versus 74.5 years, p<0.05) and showed higher white blood cell counts (11500/μL versus 8800/μL, p<0.05), higher blood eosinophil counts (788.5/μL versus 139.0/μL, p<0.05), higher creatinine clearance (77.3 mL/min versus 56.3 mL/min, p<0.05), higher levels of serum immunoglobulin (Ig)E (660 IU/mL versus 125 IU/mL, p<0.05), and IgG4 (361.5 mg/dL versus 84.0 mg/dL, p <0.05). In patients with EGPA, the most susceptible type to peripheral neuropathy, 80% of the patients had peripheral neuropathy. Comparison between patients with EGPA with peripheral neuropathy and those without demonstrated significantly younger age (56.0 years versus 80.0 years, p<0.05) and higher blood eosinophil counts (7832/μL versus 2340/μL, p<0.05) were characteristic for the presence of peripheral neuropathy. Patients with EGPA with motor neuropathy (n=8) showed higher white blood cell counts (26850//μL versus 8650//μL, p <0.05) and higher blood eosinophil counts (13134//μL versus 3436//μL, p<0.05) compared with those with only sensory neuropathy (n=4).

Conclusion

Our current study has shown that patients with EGPA are more prone to peripheral neuropathy than patients with MPA or GPA. Severe motor neuropathy was observed only in patients with EGPA and associated with more intense eosinophilic inflammation. Our results suggest that molecular targeted therapy that improves eosinophilic inflammation such as anti-IL-5 therapy is beneficial for peripheral neuropathy.

References

[1]RUTGERS, Abraham; KALLENBERG, Cees GM. Peripheral neuropathy in AAV—when vasculitis hits a nerve. Nature Reviews Rheumatology, 2012, 8.3: 127-128.

[2]NAKAZAWA, Daigo, et al. Pathogenesis and therapeutic interventions for ANCA-associated vasculitis. Nature Reviews Rheumatology, 2019, 15.2: 91-101.

Disclosure of Interests

None declared

Early combination of pulmonary vasodilators prevents chronic kidney disease progression in connective tissue disease-associated pulmonary hypertension

AIM

Pulmonary hypertension (PH) and chronic kidney disease (CKD) are interdependent for their development and exacerbation. We evaluated the effect of PH on CKD progression in patients with connective tissue disease (CTD)-associated PH.

METHODS

We reviewed consecutive patients with CTD who were diagnosed with PH with right heart catheter (RHC) examinations in our hospital. Patients were divided into 2 groups according to the use of vasodilators: monotherapy or combination therapy. We further divided the patients with combination therapy into early and non-early combination groups. Early combination was defined as the addition of the second vasodilator within 1 month after starting the first drug. The clinical course of hemodynamics and CKD progression were compared.

RESULTS

Thirty-eight patients were included in the analysis: 10 were treated with monotherapy and 28 with combination therapy (14 with early and 14 with non-early). At baseline, patients who received combination therapy had a significantly higher mean pulmonary arterial pressure with RHC and a higher right ventricular systolic pressure (RVSP) with echocardiography (P = .04) and showed a greater improvement in RVSP after treatment than those who underwent monotherapy. The incidence of CKD progression was significantly lower in patients who received combination therapy than in those who received monotherapy (P = .05). Among patients who received combination therapy, the early combination group had a lower incidence of CKD progression than the non-early combination group (P = .03).

CONCLUSIONS

Early combination therapy is associated with a lower incidence of CKD progression in patients with CTD-associated PH.

A case of eosinophilic granulomatosis with polyangiitis after prolonged intervals of an anti-interleukin-6 receptor antibody for rheumatoid arthritis

An 83-year-old woman with a history of asthma complained of left abdominal pain and was admitted to our hospital. She was treated with tocilizumab, an anti-interleukin (IL)-6 receptor antibody, with a prolonged interval for rheumatoid arthritis (RA). Laboratory tests revealed a remarkable increase in eosinophil count and inflammatory markers with negative antineutrophil cytoplasmic antibodies. Echocardiography revealed pericardial fluid retention, and contrast-enhanced computed tomography revealed the thickening of the gastric antrum wall. Upper gastrointestinal endoscopy and biopsy revealed eosinophilic infiltration into the gastric mucosal epithelium. She was diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA) with pericarditis and eosinophilic gastroenteritis. High-dose glucocorticoids with intermittent intravenous cyclophosphamide (IVCY) were initiated, resulting in remission. As IL-6 is involved in the pathogenesis of allergic diseases such as asthma, our case can provide insights into the pathogenic role of IL-6 in EGPA as the development of EGPA in our case may have been triggered by IL-6 signals enhanced with tocilizumab interval prolongation.

Successful Treatment of Anti-MDA5 Antibody-Positive Dermatomyositis-Associated Rapidly Progressive-Interstitial Lung Disease by Plasma Exchange: Two Case Reports

Background

Patients with anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive dermatomyositis (DM) are frequently accompanied by rapidly progressive-interstitial lung disease (RP-ILD). They are often refractory to intensive immunosuppressive therapy and have poor prognosis.

Case presentation

A 73-year-old woman presented with fever, cold symptoms, and skin eruption for a month. She also exhibited muscle weakness on upper extremities slightly. The titer of anti-MDA5 antibody was extremely high, and computed tomography showed ground glass opacity and reticular shadows in the lungs. She was diagnosed as anti-MDA5 antibody-positive classical DM-associated RP-ILD and treated with intensive immunosuppressive therapy. However, the titer of anti-MDA5 antibody did not decrease satisfactorily, and plasma exchange was alternatively initiated. The titer decreased remarkably, and she obtained disease remission. Similarly, a 63-year-old woman presented with stiffness of the neck and hands, fever and cough. She was also diagnosed as anti-MDA5 antibody-positive classical DM-associated RP-ILD, because she had skin eruptions, slight muscle weakness, an elevation in anti-MDA5 antibody, and RP-ILD. She was unresponsive to intensive immunosuppressive therapy, but plasma exchange successfully improved the titer of anti-MDA5 antibody, the symptoms, and the findings of computed tomography.

Conclusions

Although anti-MDA5 antibody-positive DM-associated RP-ILD has a high mortality rate, this report suggests the usefulness of plasma exchange to improve the prognosis.

Interleukin-1 pathway in active large vessel vasculitis patients with a poor prognosis: a longitudinal transcriptome analysis

Objectives

Large vessel vasculitis (LVV) is characterised by a high relapse rate. Because accurate assessment of the LVV disease status can be difficult, an accurate prognostic marker for initial risk stratification is required. We conducted a comprehensive longitudinal investigation of next‐generation RNA‐sequencing data for patients with LVV to explore useful biomarkers associated with clinical characteristics.

Methods

Key molecular pathways relevant to LVV pathogenesis were identified by examining the whole blood RNA from patients with LVV and healthy controls (HCs). The data were examined by pathway analysis and weighted gene correlation network analysis (WGCNA) to identify functional gene sets that were differentially expressed between LVV patients and HCs, and associated with clinical features. We then compared the expression of the selected genes during week 0, week 6, remission and relapse.

Results

The whole‐transcriptome gene expression data for 108 samples obtained from LVV patients (n = 27) and HCs (n = 12) were compared. The pathway analysis and WGCNA revealed that molecular pathway related to interleukin (IL)‐1 was significantly upregulated in LVV patients compared with HCs, which correlated with the positron emission tomography vascular activity score, a disease‐extent score based on the distribution of affected arteries. Further analysis revealed that the expression levels of genes in the IL‐1 signalling pathway remained high after conventional treatment and were associated with disease relapse.

Conclusion

Upregulation of the IL‐1 signalling pathway was a characteristic of LVV patients and was associated with the extent of disease and a poor prognosis.

Black pleural effusion caused by pancreatic pseudocyst rupture

The images show the path of pancreatic pleural effusion from the pancreatic pseudocyst in a patient with alcoholic pancreatitis who presented with black pleural effusion, however, without symptoms. Pancreatic pseudocyst rupture rarely causes pleural effusion; however, it should be considered in patients with chronic pancreatitis with black pleural effusion.

Catheter-related bloodstream infection due to Rhodotorula mucilaginosa with normal serum (1→3)-β-D-glucan level

Rhodotorula species are environmental basidiomycete yeasts that have emerged as a cause of fungemia in immunocompromised hosts. The insertion of a central venous catheter was identified as a major risk factor for Rhodotorula fungemia. Few cases reports have reported (1→3)-β-D-glucan testing at the onset of Rhodotorula mucilaginosa fungemia. We report a case of catheter-related bloodstream infection due to R. mucilaginosa. Serum β-D-glucan level was normal at the onset of the bloodstream infection. It took 5 days to culture the isolate. The patient's fever persisted after empiric treatment with micafungin, and a switch to oral voriconazole immediately resolved the fungemia.

Methotrexate-associated Lymphoproliferative Disorder of the Stomach Presumed to Be Mucosa-associated Lymphoid Tissue Lymphoma

The number of patients with methotrexate-associated lymphoproliferative disorder (MTX-LPD) is increasing. We describe a case of MTX-LPD of the stomach. After treatment with methotrexate for rheumatoid arthritis, the patient developed left cervical lymphadenopathy and an ulcerative lesion in the stomach, which was presumed to be a mucosa-associated lymphoid tissue (MALT) lymphoma. However, we suspected MTX-LPD, based on the clinical course and the positivity of in situ hybridization for the detection of the Epstein-Barr encoding region. After the cessation of MTX, the left cervical lymphadenopathy and the gastric lesion disappeared. This is first report of gastric MTX-LPD that was presumed to be MALT lymphoma.

Are common names becoming less common? The rise in uniqueness and individualism in Japan

We examined whether Japanese culture has become more individualistic by investigating how the practice of naming babies has changed over time. Cultural psychology has revealed substantial cultural variation in human psychology and behavior, emphasizing the mutual construction of socio-cultural environment and mind. However, much of the past research did not account for the fact that culture is changing. Indeed, archival data on behavior (e.g., divorce rates) suggest a rise in individualism in the U.S. and Japan. In addition to archival data, cultural products (which express an individual’s psyche and behavior outside the head; e.g., advertising) can also reveal cultural change. However, little research has investigated the changes in individualism in East Asia using cultural products. To reveal the dynamic aspects of culture, it is important to present temporal data across cultures. In this study, we examined baby names as a cultural product. If Japanese culture has become more individualistic, parents would be expected to give their children unique names. Using two databases, we calculated the rate of popular baby names between 2004 and 2013. Both databases released the rankings of popular names and their rates within the sample. As Japanese names are generally comprised of both written Chinese characters and their pronunciations, we analyzed these two separately. We found that the rate of popular Chinese characters increased, whereas the rate of popular pronunciations decreased. However, only the rate of popular pronunciations was associated with a previously validated collectivism index. Moreover, we examined the pronunciation variation of common combinations of Chinese characters and the written form variation of common pronunciations. We found that the variation of written forms decreased, whereas the variation of pronunciations increased over time. Taken together, these results showed that parents are giving their children unique names by pairing common Chinese characters with uncommon pronunciations, which indicates an increase in individualism in Japan.

Clinical significance of dual-energy CT-derived iodine quantification in the diagnosis of metastatic LN in colorectal cancer

BACKGROUND

The purpose of this study was to evaluate the diagnostic value of dual-energy computed tomography (DECT) in detecting lymph node (LN) metastasis in patients with colorectal cancer.

METHODS

Data from 81 LNs from 28 patients with colorectal adenocarcinoma were retrospectively analyzed. All patients received DECT before surgery without any neoadjuvant therapy. The diagnostic value was assessed using the iodine concentration (IC).

RESULTS

In the pathological findings, 35 (43.2%) LNs from 13 patients were metastatic and 46 (56.8%) LNs from 17 patients were non-metastatic. The mean IC of metastatic LNs in the portal venous phase (PP) was 1.60 mg/ml, which was significantly lower compared with non-metastatic LNs (3.25 mg/ml, p < 0.001). Receiver operating characteristic (ROC) analysis revealed that the IC in PP had the highest ability to discriminate LN metastasis (area under the ROC curve [AUC] 0.932). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of IC in PP (cutoff 2.1 mg/ml) were 87.0%, 88.6%, 85.3%, 90.0%, and 87.9%, respectively. When clinically obvious metastatic LNs in conventional CT findings were excluded, 50 LNs remained (5 metastatic and 45 non-metastatic LNs). In this subgroup analysis, the IC in PP remained the most powerful predictor of metastatic LNs (cutoff: 2.1 mg/ml, AUC 0.933).

CONCLUSIONS

The evaluation of IC in DECT may improve the diagnostic capabilities of discriminating metastatic LNs. This method may be particularly useful when conventional CT findings lead to equivocal results.

Risk of perforation during dilation for esophageal strictures after endoscopic resection in patients with early squamous cell carcinoma

BACKGROUND AND STUDY AIMS

Growing evidence suggests that esophageal stricture frequently develops after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) in early esophageal cancer patients, with an incidence proportional to the greater extent of mucosal defects resulting from improved EMR/ESD techniques. There seems to be a potential risk of perforation during bougienage in such patients.

PATIENTS AND METHODS

648 stricture dilations for 78 lesions in 76 patients were consecutively included. The outcomes after combined use of Maloney and Savary wire-guided bougienage for esophageal strictures after EMR/ESD were analyzed in a single-institute retrospective case series study. The perforation rate was determined and risk factors for perforation were identified.

RESULTS

Patients underwent a median of 5.0 dilation procedures performed over a median 3.0 months for post-EMR/ESD strictures. Initial dilation was done a median 14 days following endoscopic resection. Perforations developed in seven patients (7/648 dilation procedures, 1.1%), all in the lower esophagus, and bleeding occurred in one patient (0.1% dilations). Two independent risk factors for development of perforation during dilation therapy for post-EMR/ESD stricture were identified: multiple dilations (odds ratio [OR] 1.2; P=0.012), and lower site of stricture (OR 12.8; P=0.043). Dysphagia was ameliorated by the dilations, and no patient required surgery.

CONCLUSIONS

A specific emerging risk of perforation in dilation therapy for post-EMR/ESD strictures was identified. Carefully planned treatment is necessary in patients with severe post-EMR/ESD strictures especially strictures requiring multiple dilations or located in the lower esophagus.

Mean power frequency during speech in myalgia patients

The purpose of this study was to clarify a difference of mean power frequency (MPF) during speech between control and myalgia patients groups. The control group consisted of 20 asymptomatic volunteers and the myalgia patients group consisted of 19 patients. A bilateral electromyogram (EMG) of masseter muscles during speech movement was recorded using surface electrodes, and the EMG data were stored and analysed with a computer-based EMG analyzer. The MPF during the entire duration of EMG burst during speech was compared between the control and myalgia group. The average (SD) MPFs during speech in the myalgia and control groups were 214.06 (17.23) and 183.39 (22.35) Hz, respectively, significantly higher in the former (P < 0.001). In myalgia patients, firing rates or recruitment of motor units innervated by high threshold motoneurons might decrease and lead to a higher MPF. The result suggests the possibility that muscle pain, that is a subjective experience, could be evaluated by objective data that is calculated from electromyographic activities which is recorded during speech.

AATF mediates an antiapoptotic effect of the unfolded protein response through transcriptional regulation of AKT1

Endoplasmic reticulum (ER) stress-mediated cell death plays an important role in the pathogenesis of chronic diseases including diabetes and neurodegeneration. Although pro-apoptotic programs activated by ER stress have been extensively studied, identification and characterization of anti-apoptotic programs that counteract ER stress is currently incomplete. Through the gene expression profiling of β-cells lacking WFS1, a causative gene for Wolfram syndrome, we have discovered a novel anti-apoptotic gene of the unfolded protein response (UPR), apoptosis antagonizing transcription factor (AATF). Here we study the regulation of AATF, identify its target genes, and determine the basis for its anti-apoptotic activities in response to ER stress. We show that AATF is induced by ER stress through the PERK-eIF2α pathway and transcriptionally activates the Akt1 gene through Stat3, which sustains Akt1 activation and promotes cell survival. Ectopic expression of AATF or a constitutively active form of AKT1 confers on cells resistance to ER stress-mediated cell death, whereas RNAi-mediated knockdown of AATF or AKT1 renders cells sensitive to ER stress. We also discovered positive crosstalk between the AATF and WFS1 signaling pathways. Thus, WFS1-deficiency or AATF-deficiency mediates a self-perpetuating cycle of cell death. Our results reveal a novel anti-apoptotic program relevant to treatment for diseases caused by ER stress-mediated cell death.

Occlusal interference during mastication can cause pathological tooth mobility

BACKGROUND AND OBJECTIVE

Despite little evidence regarding the relationship between tooth mobility and nonworking contact, the evaluation of occlusion is performed mainly by the detection of premature and/or nonworking contacts during tapping movements and lateral excursion. The hypothesis of this study is that occlusal contact during mastication is potentially traumatic to periodontal tissue. It clarifies the relationship between chewing patterns and the status of periodontal tissue.

MATERIAL AND METHODS

Subjects included 73 adults, 20-29 years of age (39 men and 34 women), with complete sets of teeth and no history of orthodontic treatment or periodontal disease. The closing chewing patterns of each subject were classified into three groups by the Masticatory Deviation Index, which depicts the deviation from the normal chewing patterns within 5 mm from the intercuspal position. Periotest was used to diagnose teeth mobility and the values were compared among the three groups.

RESULTS

The present study indicates that the chewing movements which deviated from the normal chewing movements increased the mobility of specific types of teeth.

CONCLUSION

The results of this study imply a relationship between chewing movements and tooth mobility and indicate that functional evaluation of occlusion is necessary for the examination of periodontal tissue. Occlusal evaluation with border and tapping movements might be insufficient, and functional occlusal evaluation during chewing movements can be clinically useful for using to evaluate periodontal tissue.

Influence of abutment substrates on the colour of metal-free polymer crowns

New-generation composite materials have excellent strength and wear resistance, and thus can be used to make metal-free crowns. However, composite materials are translucent, and so when using them to make metal-free crowns, it is necessary to take the effect of the abutments into consideration. In this study, five types of materials including three types of new-generation composite materials, a conventional composite material, and a ceramic material were used to examine the translucency (contrast ratio) of the materials and the effects of the colour of the abutments on the final appearance of metal-free crowns. It was found that the materials varied slightly from one-another in translucency and that it was possible to reproduce the desired colour when gold alloy was used for the background. However, it was difficult to produce an adequate colour match when silver-palladium alloy was used for the background. When a tooth colour material that was darker than the target colour was used for the abutment teeth, some materials could not reproduce the target colour satisfactorily.

Fracture resistance of pressable glass-ceramic fixed partial dentures

The aim of the present study was to evaluate the mechanical strength of the Empress2 system, which is based on the use of a high-strength glass--ceramic core of lithium disilicate, and the fracture resistance of fixed partial dentures fabricated with this material. To evaluate mechanical strength, four types of ceramic materials were tested for four-point flexural strength and diametral tensile strength: Empress2 core material, Empress2 layering porcelain, conventional Empress material and Dicor. Then, using Empress2, conventional Empress and Dicor, actual clinical type anterior fixed partial dentures were fabricated for fracture testing. The results showed that the Empress2 core material, at 329 MPa, has more than twice the flexural strength of conventional materials and at 271 MPa, more than four times the diametral tensile strength of conventional materials. Furthermore, fixed partial dentures fabricated with Empress2 had a fracture resistance of 1424 N. That is, they were more than twice as fracture resistant as fixed partial dentures made with conventional materials.

Influence of abutment substrate and ceramic thickness on the colour of heat-pressed ceramic crowns

All-ceramic crowns made of leucite-based heat-pressed ceramics are widely used to restore non-vital teeth in conjunction with various post and core materials. However, as some light passes through the ceramic, the colour of the abutment substrate can negatively affect the final aesthetic appearance of the all-ceramic crown. In this study, we made background specimens simulating gold-alloy cast posts and other simulating porcelain veneered cast posts, overlaid different thickness of heat-pressed ceramic on these background specimens, and measured the shifts in colour. We found that, when the background specimen was a gold alloy, the background colour had an effect on the apparent colour, unless the ceramic was more than 1.6 mm thick. When the background specimen was porcelain veneered, the background colour had no evident effect, even when the ceramic was not very thick. Therefore, when making a restoration using a leucite-based heat-pressed ceramic crown, it is advisable to use tooth-coloured materials such as a porcelain veneered cast post, if you will not be able to make the ceramic more than 1.6 mm thick.

Stress analysis of metal-free polymer crowns using the three-dimensional finite element method

PURPOSE

The purpose of this study was to evaluate the stress distribution under various loading conditions within posterior metal-free crowns made of new composite materials.

MATERIALS AND METHODS

A three-dimensional finite element model representing a mandibular first molar was constructed. Variations of the model had crowns of two types of composite, a glass ceramic, and porcelain fused to metal. A load of 600 N, simulating the maximum bite force, was applied vertically to the crowns. Loads of 225 N, simulating masticatory force, were applied from three directions (vertically, at a 45-degree angle, and horizontally).

RESULTS

The stress distributions in both types of composite crown were similar to that of the glass-ceramic crown. In the test simulating maximum bite force, the maximum tensile stresses on all crowns (17.9 to 18.3 MPa) concentrated around the loading points. In the masticatory force-stimulation test, the specimens experienced maximum tensile stresses of 20.3 to 26.6 MPa under a horizontal load and 10.9 to 11.0 MPa under a vertical load. When the load was applied horizontally, the maximum tensile stress was observed around the loading points on the surface in the case of composite and glass-ceramic crowns, and in the cervical area of the metal coping in the porcelain-fused-to-metal crowns.

CONCLUSION

It would appear that the strength of occlusal contact points is important to the integrity of posterior metal-free crowns made of new composite materials and that bite forces applied from the horizontal direction are a critical factor determining success and failure.

A novel centrosomal ring-finger protein, dorfin, mediates ubiquitin ligase activity

We cloned a novel gene, Dorfin (double ring-finger protein), from human spinal cord. The Dorfin mRNA transcript was 4.4 kb and expressed ubiquitously in many organs as well as in the central nervous system, including the spinal cord. Dorfin encoded 838 amino acid protein Dorfin, which contains two RING-finger motifs and an IBR (in between RING-fingers) motif at its N-terminus. Dorfin is a short-lived protein. Treatment with MG132, a potent proteasome inhibitor, resulted in the accumulation of ubiquitinated Dorfin and Dorfin-associated cellular proteins in cultured cells. Dorfin bound specifically with human ubiquitin-conjugating enzymes UbcH7 and UbcH8 through the RING-finger/IBR domain. Partial deletion of the RING-finger/IBR domain eliminated these interaction and ubiquitination activities. These results strongly suggest that Dorfin is a new member of RING-finger type ubiquitin ligase. Dorfin is localized in the centrosome and probably functions in the microtubule organizing centers.

Two novel genes, human neugrin and mouse m-neugrin, are upregulated with neuronal differentiation in neuroblastoma cells

We herein report two new genes, human neugrin and mouse homologue m-neugrin, found by screening the cDNA library for the human spinal cord. The neugrin mRNA encodes 219 amino acids and its deduced amino acid sequence contains an NLS-like domain. No previously known motif is found in it. m-neugrin mRNA encodes 233 amino acids. Neugrin and m-Neugrin are 70% homologous in amino acid sequence. Northern analysis revealed that neugrin was strongly expressed in the heart, brain, and skeletal muscle, and m-neugrin in the liver, kidney, and brain. A transfection study indicated that these proteins are localized in the nucleus. Although the expression of neugrin was found to be ubiquitous in the nervous system, in situ hybridization showed that both neugrin and m-neugrin were expressed mainly in the neurons rather than the glial cells. Their expression was highly upregulated with the neurite outgrowth associated with neuronal differentiation in neuroblastoma cell lines. These results indicate that neugrin and m-neugrin are mainly expressed in neurons in the nervous system, and play an important role in the process of neuronal differentiation.

[Pure red cell aplasia induced by clomipramine hydrochloride in a patient with SLE]

A 48-year-old woman, who had been suffering from systemic lupus erythematosus (SLE), developed normochromic normocytic anemia after receiving clomipramine hydrochloride. Her reticulocyte count was low, and a bone marrow aspirate revealed erythroid hypoplasia without involvement of other cell lines. Thus a diagnosis of pure red cell aplasia (PRCA) was made. The anemia gradually resolved following withdrawal of the drug. Although several drugs are known to cause PRCA, this is the first time that clomipramine hydrochloride has been reported to have such an effect. The underlying SLE in this case suggested the possible immunological pathogenesis of drug-induced PRCA.

[Evaluation of a new method for antifungal drugs susceptibility testing to yeasts]

We compared the Etest with a broth microdilution method (FP panel), performed according to the National Committee for modified Clinical Laboratory Standards (NCCLS) document M27-P guidelines, for determining the MICs of 81 clinical isolates of yeasts (7 Candida albicans, 8 Candida glabrata, 10 Candida parapsilosis, 6 Pichia anomala, 10 Candida tropicalis, 4 Candida guilliermondii, 4 Candida krusei, 6 Trichosporon cutaneum, 5 Candida ciferrii, 3 Candida famata, 4 Candida norvegensis, 2 Rhodotorula rubra, 3 Candida lusitaniae, 2 Candida curvata, 1 Candida inconspicua, 1 Candida intermedia, 1 Candida colliculosa, 1 Cryptococcus spp, 1 Tricosporon capitatum, 1 Pichia ohmeri, 1 Saccharomyces cerevisiae). The Etest results for 6 ATCC standard strains correlated well with reference MICs except those of flucytosine (5-FC) for C. krusei, which tended to be 1 to 2 log2 dilution higher than the MIC range determined by NCCLS guidelines. However, the best agreement between the results for clinical isolates was seen with 5-FC (100% agreement [Within +/- 2 log2 dilutions] between the results of the two methods). There was a 91.4% agreement between the results of the two methods with amphotericin B (Etest MICs tended to be 1 to 2 log2 dilution lower than those of the FP panel). The Etest results with litraconazole for clinical isolates except C. tropicalis were similar to MICs of the FP panel (Etest for C. tropicalis showed 1 to 2 log2 dilution lower than FP panel). Also, the Etest results with fluconazole for clinical isolates except C. tropicalis were similar of 1 log2 dilution higher than MICs of the FP panel (Etest for C. tropicalis showed more than 2 log2 dilution lower than FP panel). These results showed a good level of overall agreement between the Etest method and the broth microdilution test (FP panel). Since the Etest is a less laborintensive and much simpler method, it appears to be a useful procedure for testing the susceptibility of yeasts to antifungal agents.

Significance of membrane type 1 matrix metalloproteinase expression in breast cancer

Expression of matrix metalloproteinases (MMPs) plays an essential role in tumor metastasis and invasion through the degradation of extracellular matrix (ECM). MT1-MMP (membrane type 1 matrix metalloproteinase), a membrane-type MMP, is responsible for the activation of MMP2. In this study the significance of MT1-MMP expression in human breast tumors was investigated by immunocytochemical assay, and its correlation with clinicobiological features was analyzed. MT1-MMP expression was detected in tumor cells and/or stromal cells, and there was a strong correlation between the expressions of MT1-MMP in the two cell types. Out of 183 primary tumors, 103 (56.2%) showed positive staining of MT1-MMP in tumor cells. MT1-MMP expression showed no significant correlation with any of the clinicobiological parameters examined, including hormone receptor status and angiogenesis. In postoperative survival analysis, MT1-MMP expression itself was not a significant prognostic factor. However, in the particular subgroup with the accumulation of thymidine phosphorylase (TP)-positive stromal cells, which have been activated by various stimuli, such as cytokines and hypoxia, MT1-MMP expression had a significant prognostic value. These data suggested that MT1-MMP might function cooperatively with tumor-associated stromal cells for the progression of breast cancer.

Metalloproteinases and tissue inhibitors of metalloproteinases

Because the proteolytic degradation of extracellular matrix is required for invasion and metastasis, it would appear that the important family of matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) might be prognostic indicators of the invasive potential of a breast tumor. Nevertheless, there are few data demonstrating an independent prognostic value of any individual MMPs or TIMPs in primary breast cancer patients. It is possible, however, that the balance among levels of certain MMPs and their inhibitors will be more informative, since MMPs are clearly involved in paracrine tumor-stromal interactions and are associated with angiogenesis, which does appear to be prognostic.

Use of PCR serum in diagnosing and monitoring cytomegalovirus reactivation in bone marrow transplant recipients

We previously reported that the use of polymerase chain reaction (PCR) in detecting cytomegalovirus (CMV) DNA in serum (sPCR) enables the detection of CMV viremia, which has not been possible with other methods. In this study, the clinical usefulness of sPCR was investigated by comparison with the results of three other diagnostic methods, i.e., antigenemia assay (AG), shell vial culture test (shell vial), and complement-fixing (CF) antibody titer. The present study included 26 patients with hematological diseases who had undergone allogeneic bone marrow transplantation (BMT). A total of 347 samples were collected, and the results of the sPCR and AG methods were in agreement in 91.1% of the samples. When a subject was positive in both the sPCR and AG tests, and the other two tests (shell vial and CF) were also positive, CMV reactivation was surmised as definite. When only the result of the shell vial test or the CF test was positive, these results were taken as false-positives. The time at which the samples became positive in each of these four tests was 7.5 weeks post-BMT for sPCR, 7.0 weeks post-BMT for the AG test, 7.4 weeks post-BMT for the shell vial test, and 9.7 weeks post-BMT for the CF test. Thus, it was found that samples became positive at almost the same time for the sPCR, AG, and shell vial tests. Interstitial pneumonitis (IP) due to CMV developed in 3 subjects. These cases were positive in the sPCR, AG, and shell vial tests prior to the manifestation of symptoms of IP. The CF test did not become positive until after the onset of the disease. As the IP due to CMV was controlled with treatment, the sPCR and AG tests became negative. With the shell vial and CF tests, on the other hand, the test results continued to be positive even after the IP was cured. These findings demonstrate that the sPCR test method--like the AG test--yields few false-positive results. Therefore, the sPCR method is useful in early diagnosis of reactivation of CMV and for evaluation of the efficacy of therapy administered for IP. In addition, sPCR can be performed simultaneously on a large number of samples, and the evaluation of the test results is simple. We conclude that the sPCR test may be superior to the three other diagnostic methods for evaluation of serum samples from multiple institutions.

[Effect of h-PTH on bone and bone marrow tissue in experimental osteopenia in rat]

We have evaluated changes in bone volume, bone marrow tissue, and the density of osteoclasts caused by intermittent administration of human parathyroid hormone (h-PTH) to experimental osteopenia induced in rat by ovariectomy (OVX) or by diabetes mellitus (use of streptozotocin: STZ). A bone and marrow histomorphometric study was performed on HE-stained and tartrate-resistant acid phosphatase-stained (TRAP-stain) tibial bone sections. Retired Wistar rats, 7-8 months old, were used. They were separated into the following nine groups; sham operated, base line control, vehicle administered, low or high dosage h-PTH administered OVX and STZ groups. 6.0 micrograms/kg/day of h-PTH (1-34) as a low dosage, and 60.0 micrograms/kg/day as a high dosage, was injected subcutaneously six times a week for 4 weeks from 9 weeks after ovariectomy or injection of streptozotocin. The bone volume decreased in both the OVX and STZ groups, while the fat tissue volume increased in the bone marrow in the OVX groups to compensate for this decrease, and the foamy marrow tissue volume increased in the STZ groups. The bone volume and the mean trabecular thickness in both the OVX and STZ groups increased by the intermittent administration of h-PTH, while the TRAP positive trabecular surface and the number of osteoclasts decreased. There was no significantly different bone changes between the low and high dosage groups. It is thought that the TRAP positive trabecular surface represented not only the active bone resorption surface but also the related contiguous uneroded surface.

CMV viraemia demonstrated in the serum of a patient with cytomegalovirus pneumonia

We attempted to demonstrate the expression of cytomegalovirus (CMV) particles in the serum of an acute lymphocytic leukaemia patient with CMV pneumonia. The serum sample was applied to an affinity column coupled with human monoclonal antibody C23 which recognizes the envelope glycoproteins of CMV virus and neutralizes the viral activity. The DNA obtained from each fraction was amplified by double polymerase chain reaction (PCR) and analysed by gel electrophoresis. Bands were clearly observed in the eluted fraction. These results strongly suggest that CMV particles exist in the sera of patients with CMV pneumonia.

Effect of the location of chewing on facial and jaw muscles activity and the mandibular movement

This paper evaluates the influence of the location of chewing on facial and jaw muscles' activity and mandibular movements. Ten subjects with complete dentition performed following chewing sequences; 1) right side chewing (unilateral location-unspecified chewing); 2) chewing on right molars; 3) chewing on right premolars; and 4) chewing on anterior teeth. Bilateral activities of upper lip, cheek, masseter (anterior, middle and posterior parts), and anterior bellies of digastrics were recorded by surface electromyography. Mandibular movements were simultaneously recorded by electrognathography. Chewing on anterior teeth showed smaller masseteric activity in posterior part, smaller envelope of motion, and lower velocity of both opening and closing than unilateral location-unspecified chewing and chewing on right molars. Chewing on premolars showed smaller envelope of motion than chewing on molars. No significant difference was found between unilateral location-unspecified chewing and chewing on premolars or molars.

Diagnostic accuracy of TMJ vibration analysis for internal derangement and/or degenerative joint disease

Lower joint arthrography and videofluoroscopy were used to diagnose 297 joints from temporomandibular disorders (TMD) patients. The surface vibrations of the temporomandibular joints (TMJs) were recorded by electrovibratography and a parameter set was derived through frequency analysis. Total vibration energies were used as the primary separating threshold for abnormal joints. The following conditions were statistically discriminated by multi-variate analyses: I) meniscal displacement with reduction; II) meniscal displacement with a partial disk reduction; III) meniscal displacement without reduction; and IV) degenerative joint disease and/or perforation of the disk. Using the total vibration energy as a threshold, the diagnostic sensitivity for the abnormal joints was 82%, while the diagnostic specificity for the joints with no evidence of internal derangement was 75%. Discriminant analysis for the above-mentioned four conditions revealed a diagnostic sensitivity of 79.0%, 85.7%, 77.1% and 76.3% for conditions I, II, III and IV, respectively. The diagnostic specificity was 76.2%, 79.9%, 59.0% and 77.9% for conditions I, II, III and IV, respectively. It was concluded that vibration analysis of the TMJ could be clinically useful as a screening examination for TMD patients.

Vibration analysis of the temporomandibular joints with degenerative joint disease

The surface vibrations of 42 temporomandibular joints (TMJ) with degenerative joint disease (DJD) and/or perforation of the disk were evaluated using electrovibratography and compared to the surface vibrations of 83 joints with normal TMJ imagings and 61 joints with meniscal displacement without reduction. Through the frequency spectrum analysis, TMJs with DJD showed higher vibration energy above 350-450 Hz and TMJs with perforation showed higher vibration energy between 100-150 and 300-450 Hz. The presence of perforation did not seem to affect the characteristic of vibrations when TMJs were associated with DJD. A threshold was set for the total vibration energy as described in our previous report and used as a parameter in order to separate patients with internal derangement from a pool of TMJ dysfunction patients (diagnostic specificity = 75%, diagnostic sensitivity = 80.2%). Using this criteria, the following were correctly identified as internal derangement and/or DJD: a) 100% of the TMJs with meniscal displacement without reduction associated with DJD; b) 87.0% of the TMJs with meniscal displacement without reduction associated with perforation; c) 88.9% of the TMJs with meniscal displacement without reduction associated with DJD and perforation; and d) 100% of the TMJs with perforation.

Vibration analysis of the temporomandibular joints with meniscal displacement with and without reduction

The vibrations of 102 joints demonstrating meniscal displacement with either early or late reduction (MDR-early/MDR-late) and 70 joints displaying meniscal displacement without reduction either incomplete or complete (MD-incomplete/MD-complete) were analyzed and compared to 83 arthrographically normal but symptomatic joints (NID) using electrovibratography (EVG). The total power density of the vibration [I(T)], peak power density [I(max)] and power density at each 50Hz range between O to 600 Hz [I(f)] showed the highest in the MDR-late group followed by the MDR-early group, suggesting that the level of vibration is related to the degree of disk displacement and reduction. The wave characteristic parameters such as the correlation coefficients between I(T) and each I(f) showed higher correlation at higher frequency ranges as the degree of disk displacement progressed, from MDR-early to MDR-late to MD-incomplete. The diagnostic sensitivity of EVG when using I(T) as a determining parameter was 96.6% for the MDR-early group, 91.8% for the MDR-late group, 77.8% for the MD-incomplete group and 57.4% for the MD-complete group with the specificity for the NID group at 75%.

[A case of advanced mediastinal choriocarcinoma showing complete remission for two years by high-dose chemotherapy with peripheral blood stem cell transplantation]

A twenty-six-year-old male patient with advanced choriocarcinoma originated from mediastinum was treated by high-dose chemotherapy with peripheral blood stem cell (PBSC) transplantation. He had massive tumors in the cervical, mediastinal and bilateral lung fields. After 3 kur of PVeBV therapy (CDDP 60 mg x day 1-3, etoposide 160 mg x day 1-3, BLM 30 mg x day 1, VBL 12 mg x day 1), he obtained complete remission. PBSC was collected at the time of hematopoietic recovery and high-dose chemotherapy with PBSC transplantation was conducted because of the high possibility of recurrence. The hematopoietic recovery was rapid, and the patient remained well with no sign of recurrence for 24 months.