Association between oral health and nutritional status among older patients requiring long-term care who received home-visit dental care

PURPOSE

This study examined the association between oral health and nutritional status among older patients receiving home-visit dental care.

METHODS

This study enrolled 110 older patients (age ≥65 years) requiring long-term care who received home-visit dental care. The oral health indicators evaluated included number of teeth, occlusal support, number of functional teeth, tongue pressure, tongue coating index (TCI), and rinsing ability. Nutritional indicators included skeletal muscle mass index (SMI) and the mini-nutritional assessment short-form (MNA-SF). A multivariate modified Poisson regression analysis (adjusted for age, sex, medical history, care level, and housing type) was used to calculate prevalence ratios and 95% confidence intervals (CIs).

RESULTS

The prevalence ratio for low SMI was not significantly higher for patients with ≥20 teeth than for those with 1-19 or no teeth. Number of teeth was not significantly associated with MNA-SF score. A high TCI score (2.15, 95% CI: 1.07-4.32) and poor rinsing ability (2.32, 95% CI: 1.25-4.30) were significantly associated with low SMI. High TCI scores were associated with low scores in MNA-SF categories (1.25, 95% CI: 1.01-1.55).

CONCLUSION

TCI and rinsing ability, rather than number of teeth, were associated with nutritional status in older patients requiring long-term care.

Associations of Dental Health With the Progression of Hippocampal Atrophy in Community-Dwelling Individuals: The Ohasama Study

BACKGROUND AND OBJECTIVES

Although tooth loss and periodontitis have been considered risk factors of Alzheimer disease, recent longitudinal researches have not found a significant association with hippocampal atrophy. Therefore, this study aimed to clarify a longitudinal association between the number of teeth present (NTP) and hippocampal atrophy dependent on the severity of periodontitis in a late middle-aged and older adult population.

METHODS

This study included community-dwelling individuals aged 55 years or older who had no cognitive decline and had undergone brain MRI and oral and systemic data collection twice at 4-year intervals. Hippocampal volumes were obtained from MRIs by automated region-of-interest analysis. The mean periodontal probing depth (PD) was used as a measure of periodontitis. Multiple regression analysis was performed with the annual symmetric percentage change (SPC) of the hippocampal volume as the dependent variable and including an interaction term between NTP and mean PD as the independent variable. The interaction details were examined using the Johnson-Neyman technique and simple slope analysis. The 3-way interaction of NTP, mean PD, and time on hippocampal volume was analyzed using a linear mixed-effects model, and the interaction of NTP and time was examined in subgroups divided by the median mean PD. In all models, dropout bias was adjusted by inverse probability weighting.

RESULTS

Data of 172 participants were analyzed. The qualitative interaction between NTP and the mean PD was significant for the annual SPC in the left hippocampus. The regression coefficient of the NTP on the annual SPC in the left hippocampus was positive (B = 0.038, p = 0.026) at the low-level mean PD (mean -1 SD) and negative (B = -0.054, p = 0.001) at the high-level mean PD (mean +1 SD). Similar results were obtained in the linear mixed-effects model; the interaction of NTP and time was significant in the higher mean PD group.

DISCUSSION

In a late middle-aged and older cohort, fewer teeth were associated with a faster rate of left hippocampal atrophy in patients with mild periodontitis, whereas having more teeth was associated with a faster rate of atrophy in those with severe periodontitis. The importance of keeping teeth healthy is suggested.

Regular dental visits, periodontitis, tooth loss, and atherosclerosis: The Ohasama study

Objective

We aimed to explore the association between regular dental visits and atherosclerosis and between periodontitis, number of remaining teeth, and atherosclerosis among community dwellers in Japan.

Background

Few studies have examined the association between regular dental visits, periodontitis, tooth loss, and atherosclerosis in community dwellers in Japan.

Methods

The participants of this cross‐sectional study included community dwellers aged ≥55 years and residing in Ohasama. Exposure variables were regular dental visits; periodontitis, defined as radiographic alveolar bone loss (BL); the Centers for Disease Control/American Academy of Periodontology (CDC/AAP) classification; and number of remaining teeth. The primary outcome was atherosclerosis, defined as maximum carotid intima‐media thickness ≥1.1 mm or confirmation of atheromatous plaque.

Results

Of 602 participants, 117 had atherosclerosis. In the multivariate model, compared to those with regular dental visits, the odds ratio (OR) (95% confidence intervals [CIs]) of atherosclerosis among those with the absence of regular dental visits was 2.16 (1.03–4.49). Regarding BL‐max, compared with those in the first quartile, ORs (95% CIs) of those in the second, third, and fourth quartiles were 1.15 (0.65–2.30), 0.65 (0.32–1.35), and 1.57 (0.81–3.01), respectively. Regarding CDC/AAP classification, compared to those with no or mild periodontitis, ORs (95% CIs) for those with moderate and severe periodontitis were 2.48 (0.61–10.1) and 4.26 (1.01–17.5), respectively. Regarding the number of remaining teeth, compared to those with ≥20 teeth, ORs (95%CIs) for those with 10–19 and 1–9 teeth were 1.77 (1.004–3.12) and 0.96 (0.52–1.80), respectively.

Conclusion

The absence of regular dental visits and presence of periodontitis are associated with atherosclerosis among community dwellers in Japan.

Oral health-related quality of life is associated with the prevalence and development of depressive symptoms in older Japanese individuals: The Ohasama Study

OBJECTIVE

This prospective study investigated the cross-sectional association between impaired oral health-related quality of life (OHRQoL) and the prevalence of depressive symptoms, and the longitudinal association between impaired OHRQoL and development of depressive symptoms among older adults.

BACKGROUND

Previous studies have shown a relationship between poor oral health and depression among older adults; however, findings are inconsistent.

MATERIALS AND METHODS

Participants were 669 community-dwelling older Japanese individuals aged≥55 years (mean: 67.8 ± 7.2 years). Data of 296 participants were used for longitudinal analyses. OHRQoL was evaluated using the Oral Impacts on Daily Performances scale. Impaired OHRQoL was defined as the presence of at least one impact on the scale. Depressive symptoms were assessed using the Japanese version of the Zung self-rating depression scale with a cut-off score of 40.

RESULTS

The cross-sectional logistic regression model demonstrated that impaired OHRQoL was significantly associated with depressive symptoms (odds ratio [OR], 5.17; 95% confidence interval [CI], 2.99-8.95) independent of age, sex, body mass index, hypertension, cerebrovascular/cardiovascular disease, smoking, drinking alcohol, education, cognitive function, objective oral health (dentition status) and oral health behaviour (dental visit within 1 year). Similarly, impaired OHRQoL predicted the development of depressive symptoms within 4 years in a fully adjusted longitudinal model (OR, 6.00; 95% CI, 1.38-26.09).

CONCLUSION

Impaired OHRQoL was identified as a potential comorbidity of depressive symptoms and a predictor for depressive disorder later in life. OHRQoL may be a useful clinical outcome for elder patients with regard to their mental and oral health.

Relationship Between Oral Health and Fractures in Community-Dwelling Older Japanese Adults

OBJECTIVE

To investigate the relationship between poor oral health and the incidence of fall-related fractures in older Japanese individuals.

DESIGN

A 9-year prospective cohort study.

SETTING AND PARTICIPANTS

Participants comprised 937 community-dwelling older Japanese adults aged 70 years or older. They all lived in the Tsurugaya district, a suburban area of Sendai city, and underwent comprehensive geriatric assessment, including an oral examination, in a public facility.

MEASUREMENTS

The exposure variables were related to oral health status (posterior occlusal support, number of remaining teeth, and occlusal force). The outcome measure was the incidence of fall-related fractures, which was determined by National Health Insurance data. Analyzed covariates included age, sex, medical history, smoking, alcohol drinking, educational level, depressive symptoms, cognitive impairment, physical function, body mass index, and history of falls. Statistical relationships were examined by calculating hazard ratios (HRs) at 95% confidence intervals (CIs) using the Cox proportional hazard model.

RESULTS

In the multivariate analysis, the HRs of fall-related fractures were significantly higher in those with unilateral posterior occlusal support (HR, 2.72; 95% CI, 1.13-6.55) and no posterior occlusal support (HR, 2.58; 95% CI, 1.29-5.15) than in those with bilateral posterior occlusal support. The HRs (95% CIs) of fall-related fractures in individuals with 10-19 and 1-9 teeth and edentulous individuals were 1.77 (0.81-3.89), 2.67 (1.24-5.75), and 2.31 (1.01-5.28), respectively, compared to those with ≥20 teeth.

CONCLUSIONS AND IMPLICATIONS

Poor oral health status is a risk factor for the incidence of fall-related fractures in community-dwelling older Japanese individuals. The findings suggest that attention should be focused on oral health status to further understand the risk of fall-related fractures among community-dwelling older adults.

The Association between Number of Remaining Teeth and Maintenance of Successful Aging in Japanese Older People: A 9-Year Longitudinal Study

With population aging, an increasing attention has been paid to quality of life rather than mere longevity. Now, it is urgently needed to clarify predictors of well-being in later life, i.e., "successful aging (SA)." The aim of this study is to investigate whether the number of remaining teeth impacts on maintenance of SA among Japanese older people. The present study was conducted in Tsurugaya district, a suburban area of Sendai, in northern Japan, and included older people aged ≥ 70 years who had met the criteria for SA at a 2003 baseline survey. At the baseline survey, dentists obtained data for the number of remaining teeth. We obtained information about Long-term Care Insurance certification, including the dates of incident functional disability and death between 2003 and 2012. Data pertaining to health-related quality of life (HRQOL) were collected at the 2003 baseline survey and the 2012 follow-up survey. Maintenance of SA was defined in terms of survival, disability-free status and high HRQOL in both 2003 and 2012. Among 450 participants, 108 (24.0%) were considered to have maintained a state of SA. When participants were classified into three groups according to previous studies, in comparison with participants who retained 0-9 teeth, the multivariate prevalence ratios (95% confidence intervals) were 1.39 (0.81-2.36) for those who retained 10-19 teeth and 1.58 (1.002-2.50) for those who retained ≥ 20 teeth (p trend = 0.046). The present results suggest that retaining ≥ 20 teeth is associated with maintenance of SA among Japanese older people.

The association between bilateral maximum occlusal force and all-cause mortality among community-dwelling older adults: The Tsurugaya project

PURPOSE

This study aimed to investigate the relationship between the bilateral maximum occlusal force (MOF) of full dental arches and all-cause mortality in a group of community-dwelling older males and females in Japan.

METHODS

This 13-year prospective cohort study was conducted among 815 older adults (395 male and 420 female) aged 70 years or over (mean age ± standard deviation: 75.1 ± 4.5 years). Bilateral MOF in the intercuspal position was recorded with horseshoe-shaped pressure-sensitive film. Participants were grouped by gender into tertiles according to MOF. Demographic variables, chronicity, comorbidity, physical status, cognitive and psychological status, social functioning, and blood chemistry data were also assessed. Information regarding all-cause mortality and migration was obtained from the Sendai Municipal Authority. Cox proportional hazard modeling was performed to assess all-cause mortality during the follow-up period.

RESULTS

In total, 159 male and 109 female participants died over a median 12.9-year follow-up period, and the cumulative mortality significantly increased with lower MOF in both males and females. The multivariate Cox proportional hazard model demonstrated a significant increase in the risk of all-cause mortality associated with lower tertiles of MOF, relative to the upper tertile in males (hazard ratio: 1.62; 95% confidence interval: 1.05-2.51) and females (hazard ratio: 1.94; 95% confidence interval: 1.10-3.56).

CONCLUSIONS

There was a significant and independent association of bilateral MOF with all-cause mortality in community-dwelling elderly males and females in Japan. These findings suggested that maintenance of oral functioning contributes to general health.

Dental Status is Associated With Incident Functional Disability in Community-Dwelling Older Japanese: A Prospective Cohort Study Using Propensity Score Matching

Background

A growing number of epidemiology studies have shown that poor oral health is associated with an increased incidence of functional disability. However, there are few studies in which the confounding bias is adjusted appropriately. In this study, we examined whether dental status is associated with functional disability in elderly Japanese using a 13-year prospective cohort study after elimination of confounding factors with propensity score matching.

Methods

Participants were community-dwelling Japanese aged 70 years or older who lived in the Tsurugaya district of Sendai (n = 838). The number of remaining teeth (over 20 teeth vs 0–19 teeth) was defined as the exposure variable. The outcome was the incidence of functional disability, defined as the first certification of long-term care insurance (LTCI) in Japan. The variables that were used to determine propensity score matching were age, sex, body mass index (BMI), medical history (stroke, hypertension, myocardial infarction, cancer, and diabetes), smoking, alcohol consumption, educational attainment, depression symptoms, cognitive impairment, physical function, social support, and marital status.

Results

As a result of the propensity score matching, 574 participants were selected. Participants with 0–19 teeth were more likely to develop functional disability than those with 20 or more teeth (hazard ratio 1.33; 95% confidence interval, 1.01–1.75).

Conclusions

In this prospective cohort study targeting community-dwelling older adults in Japan, having less than 20 teeth was confirmed to be an independent risk factor for functional disability even after conducting propensity score matching. This study supports previous publications showing that oral health is associated with functional disability.

Association between tooth loss and cognitive impairment in community-dwelling older Japanese adults: a 4-year prospective cohort study from the Ohasama study

BACKGROUND

Numerous prospective studies have investigated the association between the number of remaining teeth and dementia or cognitive decline. However, no agreement has emerged on the association between tooth loss and cognitive impairment, possibly due to past studies differing in target groups and methodologies. We aimed to investigate the association between tooth loss, as evaluated through clinical oral examinations, and the development of cognitive impairment in community-dwelling older adults while considering baseline cognitive function.

METHODS

This 4-year prospective cohort study followed 140 older adults (69.3% female) without cognitive impairment aged ≥65 years (mean age: 70.9 ± 4.3 years) living in the town of Ohasama, Iwate Prefecture, Japan. Cognitive function was evaluated with the Mini-Mental State Examination (MMSE) in baseline and follow-up surveys. Based on a baseline oral examination, the participants were divided into those with 0-9 teeth and those with ≥10 teeth. To investigate the association between tooth loss and cognitive impairment, we applied a multiple logistic regression analysis adjusted for age, sex, hypertension, diabetes, cerebrovascular/cardiovascular disease, hypercholesterolemia, depressive symptoms, body mass index, smoking status, drinking status, duration of education, and baseline MMSE score.

RESULTS

In the 4 years after the baseline survey, 27 participants (19.3%) developed cognitive impairment (i.e., MMSE scores of ≤24). Multiple logistic regression analysis indicated that participants with 0-9 teeth were more likely to develop cognitive impairment than those with ≥10 teeth were (odds ratio: 3.31; 95% confidence interval: 1.07-10.2). Age, male gender, and baseline MMSE scores were also significantly associated with cognitive impairment.

CONCLUSIONS

Tooth loss was independently associated with the development of cognitive impairment within 4 years among community-dwelling older adults. This finding corroborates the hypothesis that tooth loss may be a predictor or risk factor for cognitive decline.

Practice-Based Longitudinal Study of Multifactorial Risk Assessment for Periodontal Condition and Survival of Remaining Teeth in Patients with Removable Partial Dentures

PURPOSE

This retrospective cohort study examined factors affecting the periodontal condition and survival of remaining teeth 5 years after removable partial denture (RPD) placement using multivariate analyses.

MATERIALS AND METHODS

Of 231 patients who received RPDs at Tohoku University Hospital, 108 patients who had agreed to undergo a 5-year follow-up were examined. The outcomes of RPD treatment were assigned to one of three categories: successful (n = 58), remake (n = 36), and failure (n = 14). A total of 80 patients in the successful and remake groups were included in this study. The parameters analyzed to evaluate the periodontal condition were probing depth, Miller index of tooth mobility, and bone resorption level. Criterion variables were the outcome of each periodontal condition, deterioration, and tooth loss. Independent variables were sex, age, smoking habit, number of periodic maintenance appointments, location of RPD, number of abutment teeth, denture base material, design, and existence of a denture in the opposite jaw. Bivariate analyses were performed using chi-square test, and multivariate regression analysis was used to assess significance.

RESULTS

Sex and frequency of maintenance care were independently associated with deterioration of the periodontal condition. Sex and existence of a denture in the opposite jaw were independently associated with tooth loss.

CONCLUSION

The findings suggest that periodic maintenance care and condition of the opposite jaw are essential for maintaining the condition of the remaining teeth.

Association Between Tooth Loss, Receipt of Dental Care, and Functional Disability in an Elderly Japanese Population: The Tsurugaya Project

OBJECTIVES

To examine whether number of remaining teeth and regular dental care affect incident functional disability in elderly Japanese adults.

DESIGN

Prospective cohort study.

SETTING

Tsurugaya district, Sendai, Japan.

PARTICIPANTS

Community-dwelling individuals aged 70 and older (N = 834).

MEASUREMENTS

The outcome measurement was incident functional disability, defined as first certification of long-term care insurance in Japan, which is determined on the basis of a strictly established uniform nationwide standard. During a median follow-up of 7.9 years (interquartile range 4.8-7.9 years), information on long-term care insurance was obtained from the Sendai Municipal Authority. Oral health was assessed according to number of remaining teeth and presence or absence of regular dental care. Data were also collected on age, sex, body mass index, medical history, smoking, alcohol consumption, duration of education, depressive symptoms, cognitive impairment, physical functioning, and social support.

RESULTS

Participants with 10 to 19 teeth (adjusted hazard ratio (aHR) = 1.42, 95% confidence interval (CI) = 1.03-1.94), one to nine teeth (aHR = 1.46, 95% CI = 1.04-2.03), and no teeth (aHR = 1.49, 95% CI = 1.03-2.14) were more likely to develop functional disability than those with 20 or more teeth. There was no significant difference in risk of functional disability between participants with 20 or more teeth and those with zero to 19 teeth who were receiving regular dental care, whereas those with zero to 19 teeth without regular dental care had a significantly greater risk of functional disability than those with 20 or more teeth (HR = 1.46, 95% CI = 1.11-1.92).

CONCLUSION

Tooth loss was associated with greater risk of functional disability in community-dwelling elderly Japanese. Regular dental care might moderate the risk of functional disability in elderly individuals with missing teeth.

Periodontitis-associated septic pulmonary embolism caused by Actinomyces species identified by anaerobic culture of bronchoalveolar lavage fluid: a case report

Background

Periodontal disease is a less common but important cause of septic pulmonary embolism (SPE). However, the pathogens causing periodontal disease-associated SPE (PD-SPE) have been poorly understood. Actinomyces species are resident microbiota in the oral cavity. Here we report a case of PD-SPE caused by Actinomyces species, which was identified by anaerobic culture of bronchoalveolar lavage fluid (BAL).

Case presentation

A 64-year-old Asian man, complicated with severe chronic periodontitis, was admitted with chest pain and fever. Chest CT revealed multiple bilateral pulmonary nodules located subpleurally. We diagnosed the case as SPE associated with periodontitis. Although blood cultures were negative for the usual 5-day incubation, anaerobic culture of the BAL fluid sample yielded Actinomyces species. Antibacterial therapy alone did not ameliorate the symptoms; however, additional dental treatment, including tooth extraction, promptly did. The patient was discharged 23 days after admission. The 3-month follow-up revealed no recurrence of the symptoms and complete resolution of the lung lesions.

Conclusion

This case demonstrated that Actinomyces species can cause PD-SPE. Additionally, clinicians should consider performing appropriate anaerobic culture of BAL fluid to identify the pathogen of SPE, and to ordering dental treatment, if necessary, in addition to antibiotics for the initial management of PD-SPE.

Hypermethylation of CpGs in the promoter of the COL1A1 gene in the aged periodontal ligament

Although the human periodontal ligament shows age-associated histological alterations, the molecular mechanisms are not yet understood. We previously found that COL1A1 gene expression declines with age. In this study, we asked whether DNA methylation in the regulatory region of the gene alters in the aging process, as a possible cause of the decline. The method used was a bisulfite modification of cytosine and nucleotide sequencing of DNA. While the 1st intron region was kept demethylated at young and old ages, the levels of methylation at most CpG sites in the proximal and distal regions of the promoter showed elevation at older ages. Analysis of the data indicates the possible importance of DNA hypermethylation in the promoter region for the age-associated decrease of COL1A1 gene expression.

Rapid disease progression correlates with instability of mutant SOD1 in familial ALS

Studies on the clinical course of familial ALS suggest that the duration of illness is relatively consistent for each mutation but variable among the different mutations. The authors analyzed the relative amount of mutant compared with normal SOD1 protein in the erythrocytes from 29 patients with ALS with 22 different mutations. Turnover of mutant SOD1 correlated with a shorter disease survival time.

Distal myopathy with rimmed vacuoles is allelic to hereditary inclusion body myopathy

BACKGROUND

Distal myopathy with rimmed vacuoles (DMRV) is an autosomal-recessive disorder with preferential involvement of the tibialis anterior muscle that starts in young adulthood and spares quadriceps muscles. The disease locus has been mapped to chromosome 9p1-q1, the same region as the hereditary inclusion body myopathy (HIBM) locus. HIBM was originally described as rimmed vacuole myopathy sparing the quadriceps; therefore, the two diseases have been suspected to be allelic. Recently, HIBM was shown to be associated with the mutations in the gene encoding the bifunctional enzyme, UDP-N-acetylglucosamine 2-epimerase/N-acetylmannosamine kinase (GNE).

OBJECTIVE

To determine whether DMRV and HIBM are allelic.

METHODS

The GNE gene was sequenced in 34 patients with DMRV. The epimerase activity in lymphocytes from eight DMRV patients was also measured.

RESULTS

The authors identified 27 unrelated DMRV patients with homozygous or compound-heterozygous mutations in the GNE gene. DMRV patients had markedly decreased epimerase activity.

CONCLUSIONS

DMRV is allelic to HIBM. Various mutations are associated with DMRV in Japan. The loss-of-function mutations in the GNE gene appear to cause DMRV/HIBM.

Bilateral paramedian thalamo-midbrain infarction showing electroencephalographic alpha activity

A 57-year-old man became unresponsive and mute with bilateral ophthalmoplegia and quadriplegia. Magnetic resonance imaging (MRI) showed bilateral infarctions at the ventral midbrain and the dorsomedial nucleus of the thalamus. Serial studies with MR and vertebral angiography disclosed hypoperfusion and spontaneous reperfusion of the bilateral posterior cerebral arteries at their origin from the basilar artery. Electroencephalographically, a posteriorly distributed alpha rhythm was clearly recorded and it was reactive in response to external stimuli. The findings seen in the present patient suggest that the ventral midbrain and medial dorsal thalamus are not necessary to produce posterior electroencephalographic alpha activity.

Development of severe longitudinal atrophy of thoracic spinal cord following lupus-related myelitis

A 26-year-old woman suffered from acute myelitis at Th 6 level associated with systemic lupus erythematosus. Methyl-prednisolone pulse therapy, intravenous high-dose immunoglobulin administration and plasmapheresis were not effective. Her neurological signs had persisted in spite of subsequent administration of oral prednisolone and azathiopurine. Magnetic resonance imaging (MRI) of spinal cord at the onset showed a marked swelling with intramedullary high intensity signals on T2WI along the whole thoracic cord. Three years later, MRI demonstrated a severe longitudinal and segmental atrophy of the mid to low thoracic cord which resulted in transverse spinal signs.

A case of varicella complicated by cellulitis and scarlet fever due to Streptococcus pyogenes

We report a 4-year-old boy with cellulitis and scarlet fever due to streptococcal infection following the onset of varicella. He developed a painful ulcer and subcutaneous induration on the left shoulder and a small, light-red-colored rash on the trunk at approximately the same time as the development of vesicles over the entire body. Streptococcus pyrogenes was isolated from samples from the posterior intranasal space and the ulcer on the shoulder. The clinical symptoms improved with the administration of antibiotics and intravenous drip infusion, but it took approximately one month from the first visit for the subcutaneous induration to disappear and the ulcer to heal with epithelialization. The complication of secondary streptococcal infection in varicella is relatively rare in Japan, but in Western countries there have been many reported cases of life-threatening necrotizing fasciitis and necrotizing pyomyositis due to secondary streptococcal infection following varicella. Close attention should be paid to streptococcal infection as a complication of varicella.

A case of dermatomyositis associated with mechanic's hand

A 67-year-old man was referred to the Department of Internal Medicine at Tokyo Medical University with interstitial pneumonia in July 1999. He presented with keratotic plaques on both palsm and on the ventral and lateral sides of his fingers. Erythematous keratosis was observed on the dosal aspect of his fingers and metatarsophalangeal (MP) joints. Edematous erythema was seen on the patient's chest, back, and the extensor surfaces of his arms. Electromyography revealed a myogenic pattern and an increased level of myogenic enzymes was found in the blood. Histological findings of the ventral sides of his fingers showed hyperkeratosis and parakeratosis of the dermal tissue and liquefaction degeneration of the basal layer at the papilla. Based on these findings, the patient was given a diagnosis of dermatomyositis associated with mechanic's hand. A systemic examination confirmed interstitial pneumonia and carcinoma of the duodenal papilla. Mechanic's hand is a type of dermatitis associated with myopathy first reported by Stahl et al. in patients with collagen disease. We report herein the first documented case of mechanic's hand in Asians.

Two novel mutations in the adrenoleukodystrophy gene in two unrelated Japanese families and the long-term effect of bone marrow transplantation

We identified two novel missense mutations in exon 1 of adrenoleukodystrophy (ALD) gene in two unrelated Japanese families. The first, G(874)C transition results in Arg(163)Pro substitution in the cytoplasmic domain of the ALD protein in adrenomyeloneuropathy family. The second, C(679)G results in Ser(98)Trp substitution in the first transmembrane loop in childhood onset cerebral ALD family. Both mutations cause the substitution of polar amino acid (arginine and serine) with non-polar amino acid (proline and tryptophan). Bone marrow transplantation (BMT) from his non-affected his younger sister was performed on a boy with childhood onset cerebral ALD who showed neurological deficit and brain MRI abnormalities. We evaluated the effect of BMT over a 6-year period in terms of neurological deficit, the level of very-long-chain fatty acids (VLCFA) in plasma and fibroblasts, and brain MRI. After BMT, patient's peripheral white blood cells were replaced by donor's XX ones carrying a normal ALD gene confirmed by in situ hybridization using satellite DNA of the centromere of X and Y chromosomes as probes and the level of VLCFA in lymphocytes was within normal limit. However, his neurological state progressively deteriorated. BMT was not beneficial to him.

[A case with symptomatic epilepsy and mirror movement due to unilateral schizencephaly]

Schizencephaly is an extremely rare congenital disease caused by abnormal neuronal migration. The etiology of schizencephaly is not established but vascular disturbance in early childhood could cause this condition. We have cared of a patient with schizencephaly. The patient was 47 year old male. He had focal motor seizure with secondary generalization. Neurological examination revealed, mild left hemiparesis, left pyramidal signs with no sensory impairment, left hemiatrophy, and mirror movement. MRI findings showed schizencephaly, open lip type(type II) in right cerebral hemisphere. His epileptic seizure was controlled by administration of sodium valproate. The possible mechanism of this mirror movement in his left hand and leg could be reorganization of non-affected brain and disinhibition on homolateral pyramidal tract in non-affected left cerebral hemisphere by the transcallosal inhibitory pathyway from affected right cerebral hemisphere. Sodium valpronate can not suppress this mirror movement.

Acute myocardial infarction in a patient with anomalous left coronary artery origin and primary antiphospholipid syndrome

Anomalous left main coronary artery (LMCA) originating from the right coronary sinus and running between the aorta and pulmonary trunk is a rare congenital condition. Although this disease is known to be associated with myocardial infarction and sudden death, the precise mechanism is uncertain. A 14-year-old male with this anomaly developed myocardial infarction during exercise complicated by primary antiphospholipid syndrome. He was admitted to hospital with persistent chest pain and sudden cardiac collapse that occurred while he was running. Cardiac catheterization demonstrated a narrowed segment in the LMCA and impaired blood flow, prompting a diagnosis of extensive anterior myocardial infarction. Emergency bypass surgery was performed using a single saphenous vein graft to the left anterior descending artery. Postoperative angiography showed the presence of an anomalous LMCA arising from the right sinus of Valsalva and running between the great vessels. The aortic samples were pathologically normal. He was discovered to also have primary antiphospholipid syndrome and was discharged without symptoms after warfarin therapy. Complicated primary antiphospholipid syndrome may trigger myocardial infarction in asymptomatic patients with this type of coronary anomaly.

Genotype-phenotype correlation of patients with multiple endocrine neoplasia type 2 in Japan

BACKGROUND

Multiple endocrine neoplasia type 2 (MEN 2) is a hereditary syndrome characterized by medullary thyroid carcinoma (MTC), pheochromocytoma and hyperparathyroidism. MEN 2 is caused predominantly by germ-line mutations of the RET proto-oncogene. This study aimed to clarify the genotype-phenotype correlation in MEN 2 patients in Japan in order to modify the clinical management according to the genotype.

METHODS

Constitutive DNA of 64 MEN 2 patients (48 kindreds) were searched for mutations at exons 10, 11, 13, 14 and 16 of the RET proto-oncogene using polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP), direct sequencing and restriction enzyme digestion. The clinical characteristics of the patients were obtained from a previous nationwide questionnaire survey.

RESULTS

Overall, 62 (96.9%) out of 64 patients had a germ-line point mutation at the hot spots. MTC and pheochromocytoma occurred equally in every genotype except C630S. Specific genotype had a correlation between tumor size and age at the operation for MTC or extent of MTC, i.e. C618S developed late onset type of MTC as compared with that of C634R, C634Y and M918T. Small MTC in C634R may be less aggressive than those in C634Y and M918T.

CONCLUSIONS

DNA testing has good clinical implications for the management of patients with MEN 2 and the timing and operative procedures of thyroidectomy can be modified according to the genotype.

[A case of acute polyradiculoneuritis with multiple cranial nerve palsy and cerebral lesion--possible evidence of encephalo-myelo-radiculo-neuropathy]

We report a case of acute polyradiculoneuritis with multiple cranial nerve palsy and cerebral lesions. A boy, born on July 26, 1987, developed unusual sensation on the extremities, backache and sleep disturbance on June 23, 1996. On July 2, following a complaint of blindness he developed a convulsion and was admitted to our hospital. Neurological examination revealed intact consciousness, severe external ophthalmoplegia, bifacial palsy and generalized areflexia. On the next day, flaccid tetraplegia and respiratory dysfunction developed and progressed without disturbance of consciousness. After tracheal intubation he was under mechanical ventilation. A lumbar puncture examination showed clear CSF with increased protein 166 mg/dl. no cells and normal myelin basic protein. Serum antibodies against gangliosides (GM1, asialo-GM1, GD1b and GQ1b) were not detected. A posterior tibial nerve conduction velocity was mildly delayed with disappearance of F- wave. On the other hand, very slow background activity was shown by EEG, extensive focal hypoperfusion of cerebral blood flow by SPECT and supratentorial multiple high intensity lesions by T2 weighted MRI of the brain. There were no abnormal signals in the brainstem and cerebellum on MRI. His condition dramatically improved after plasmapheresis. The abnormal findings of SPECT and MRI promptly disappeared within 3 weeks, although abnormal signs on EEG persisted. He was successfully weaned off the respirator and recovered strength of the limbs. He was discharged on August 28, 1996, with supported walk and bifacial palsy, then he completely recovered by 7 months. The condition of case was compatible with 'encephalo-myelo-radiculo-neuropathy', a disease entity that had previously been reported in a few patients in whom with Guillain-Barré or Fisher syndrome and cerebral symptoms co-existed.

Therapeutic effects of aldose reductase inhibitor on experimental diabetic neuropathy through synthesis/secretion of nerve growth factor

We investigated alterations in nerve growth factor (NGF) and ciliary neurotrophic factor (CNTF) contents during treatment with epalrestat, an aldose reductase inhibitor (ARI), on streptozotocin (STZ)-induced diabetic neuropathy in rats. Diabetic rats showed a statistically significant reduction in H-wave-related sensory nerve conduction velocity (HSNCV) and in NGF content in sciatic nerves during the experiment of 8 weeks. No reduction in the CNTF content in sciatic nerves was seen in the diabetic rats. The epalrestat treatment, which started 4 weeks after STZ injection, resulted in a significantly greater NGF content and faster HSNCV than those in untreated diabetic rats. But no statistically significant alterations of motor nerve conduction velocity (MNCV) or CNTF content were seen during the treatment. ARI showed the stimulating effect for NGF synthesis/secretion in rat Schwann cell culture in vitro. These findings suggest that decreased levels of NGF in diabetic sciatic nerves may be involved in the pathogenesis of diabetic neuropathy in these rats and further show that epalrestat treatment can be useful for the treatment of diabetic neuropathy through NGF-induction in Schwann cells and/or inhibition of the polyol pathway.

Simple and defined method to detect the SOD-1 mutants from patients with familial amyotrophic lateral sclerosis by mass spectrometry

Mutations in Cu/Zn superoxide dismutase (SOD1) cause a subset of cases of familial amyotrophic lateral sclerosis (FALS). We established a simple and defined method to detect the mutant SODI in erythrocytes by electrospray ionization mass spectrometry (ESIMS) using materials precipitated with specific antiserum. Hemolysate was mixed with anti-SOD1 antiserum and the generated precipitate, which was soluble in the solvent for MS analysis, was injected on to an LC column connected to an ESI-mass spectrometer. MS spectra of the reduced SOD1 prepared from normal individuals showed ion peaks corresponding to free monomer SOD1. The spectra from FALS patients revealed doublet ion peaks corresponding to normal and mutant components. The ratios of mutant to normal SOD1 were about 1/2 in cases of (G37R) and (A4S), and about 0.15 in a case of (H46R). This method provides for the rapid diagnosis using small amount of specimens, and will contribute to elucidate the pathomechanism of FALS through the quantification of SOD1 mutants in erythrocytes and in tissues of nervous systems.

[An abnormality of facial nerve conduction velocity distribution (FNCVD) in Bell's palsy patients]

We studied bilateral facial nerve conduction velocity distribution (FNCVD) of 8 Bell's palsy patients in their paretic and recovered state and unilateral FNCVD of 13 normal control using collision method. Dual supramaximal stimuli were adapted to marginalis mandibulae branch of facial nerve and compound muscle action potential (CMAP) was recorded from the surface of mentalis muscles. Peak of FNCVD in normal control was present at 22-23 m/sec. In Bell's palsy patients, there was no significant change in FNCVD either at paretic or recovery state. Peak of involved side FNCVD of Bell's palsy patient was almost normal but its amplitude was low. However, in healthy side of Bell's palsy patient, peak of FNCVD was present at 18-19 m/sec. This finding shows that facial nerve diameter distribution in the healthy side of Bell's palsy patient has smaller peak than that of normal control.

Cervical spinal epidural abscess following acupuncture: successful treatment with antibiotics

A 67-year-old man with poorly controlled diabetes mellitus (DM) had acupuncture several times a month for chronic shoulder muscle stiffness. A few days after acupuncture in the posterior nuchal region, a low-grade fever and backache developed, and subacutely progressed. Finally he complained of gait disturbance, and then respiratory distress appeared. Magnetic resonance imaging (MRI) demonstrated high cervical epidural abscess with massive soft tissue inflammation and vertebral osteomyelitis. Conservative treatment with antibiotics was effective and it was well documented by following serial MRIs. This case suggested that needle acupuncture should be avoided for immunocompromised subjects such as patients with poorly controlled DM.

[Clinical and neuroradiological evaluation of the long-term surviving siblings of Sanfilippo syndrome A type]

The siblings of Sanfilippo syndrome type A (MPS III A) have been reported. The relationship of their parents was the first cousins. Case 1: A 30-year-old Japanese man was hospitalized because of gait disturbance and mental impairment. His early somatic and mental development was normal until 9 years of age when mental deterioration had developed. Speech and gait disturbances and double incontinence occurred at 18 years of age. He could not walk at 21 years of age. Those symptoms were slowly progressive. Case 2: A 32-year-old Japanese man, the elder brother of case 1, had a similar clinical history to that of case 1. Their neurological findings revealed mental impairment, coarse face, positive forced grasp and sucking reflexes, and pyramidal signs. Lumbar X-ray showed platyspondylitis, compression fracture of L 1 and osteoporotic changes. Brain MRI of both cases showed brain atrophy, ventricular dilatation and abnormal high intensity signals near the posterior horn of the lateral ventricles on T2 weighted image. Low perfusion images of fronto-parietal regions were seen in the early phase of SPECT using 123I-IMP. This siblings were diagnosed as Sanfilippo syndrome type A because of heparan sulfaturia and deficiency of heparan sulfate sulfamidase of the lymphocytes. Average life span of Sanfilippo syndrome type A is not so long but the age of our cases is over 30 years of age.

Correlation of middle latency auditory evoked potentials and cerebral blood flow changes

The purpose of this study is to find the correlation between middle latency auditory evoked potentials (MLAEP) and sound activated single photon emission computed tomography (SPECT) studies. This study was performed on six normal right-handed volunteers with a mean age of 35.2 +/- 7.6 years, using the split-dose technique. First, a SPECT study was performed on subjects in blinded, awake and silent states. After bilateral ears were stimulated with a click sound, MLAEP and a second SPECT study were performed. Subtraction of the first SPECT from the second SPECT revealed a statistically significant increase of cerebral blood flow (CBF) in the bilateral superior temporal region. Bilateral Na amplitudes of MLAEP had a statistically significant and good correlation with the percentages of CBF changes in the bilateral superior temporal region. The superior temporal cerebral blood flow activation can be expressed by electrophysiological activation. Moreover, correlation during the left Na components and left frontal and occipital lobe are discussed.

[A Japanese family with Lesch-Nyhan syndrome resulting from a new point mutation in hypoxanthine-guanine phosphoribosyltransferase gene]

Lesch-Nyhan syndrome is associated with complete deficiency of hypoxanthine-guanine phosphoribosyltransferase (HPRT), characterized by hyperuricemia and severe neurological signs. The HPRT gene has been mapped to the q26 region on the long arm of the X-chromosome. We are taking care of a family of Lesch-Nyhan syndrome. A 14-year-old male was noted the growth disturbance at the age of 7 months and self-mutilation behavior characterized by compulsive biting of his lip and fingers at the age of 18 months. In 1987, at the age of 4, he was diagnosed as Lesch-Nyhan syndrome from neurologic signs and hyperuricemia (9.8 mg/dl). Neurological examination revealed mild mental and growth retardation, spasticity and hyperreflexia of lower extremities, choreoathetoid movements of extremities, and compulsive self-mutilation. The HPRT activity in erythrocytes of this patient was 0.02 nmol/min/mg hemoglobin (control value 1.76 +/- 0.06), and adenine phosphoribosyltransferase (APRT) activity was 1.08 nmol/min/mg hemoglobin (control value 0.43 +/- 0.06). Using polymerase chain reaction (PCR) method coupled with direct sequencing, we analyzed the nucleotide sequences of each exon from the genomic DNA as well as the entire HPRT coding region of the cDNA by RT-PCR method. In the HPRT gene from the patient, a guanine to adenine substitution at base position 209 in exon 3 was identified, which resulted in a single amino acid substitution of glycine with glutamic acid at codon 70. The family studies indicated that his mother, sister and grandmother were heterozygotes. PCR-restriction fragment length polymorphism (RFLP) utilizing Mnl I site which created by the mutation, was useful for detection of the mutant gene. We have identified a new missense mutation of the HPRT gene in a Japanese patient. This mutation was reported at the same codon as foreign mutants and mighty be indicative of a location of mutation activity in the HPRT gene.

Keratoacanthoma developing in prurigo nodularis treated with cryotherapy

We describe an elderly woman in whom keratoacanthoma developed from one nodule of prurigo nodularis that had been treated with cryotherapy for 3 months. Since in our case keratoacanthoma developed after treatment with liquid nitrogen for prurigo nodularis which had been constantly scratched in the past, we hypothesize that irritations of cryotherapy in addition to repeated mechanical traumas of scratching might have played a role in the formation of this tumor.

Functional analyses of the stratum corneum in scars. Sequential studies after injury and comparison among keloids, hypertrophic scars, and atrophic scars

OBJECTIVE

To characterize the functional properties of the stratum corneum (SC) of various scars.

DESIGN

A prospective cohort study.

SETTING

University hospital medical center.

PATIENTS

Thirty-two consecutive patients surgically treated for various skin diseases and 26 consecutive patients with hypertrophic scars or keloids.

MAIN OUTCOME MEASURES

Noninvasive bioengineering measurements of functional properties of the SC, such as transepidermal water loss (TEWL), high-frequency conductance, and SC turnover time.

RESULTS

The SC barrier function assessed by TEWL was found to be a better parameter for the functional evaluation of scars than the hydration state of the skin surface measured by high-frequency conductometry. In general, the SC on the scars of deeper wounds in the dermis took longer to normalize functionally than the SC on the scars of superficial wounds, especially on the high compared with the abdomen. Thus, elevated levels of TEWL observed on scars at the donor sites of split-thickness grafts normalized between 200 and 400 days in contrast to fewer than 50 days for those of subepidermal erosions. Both TEWL and high-frequency conductance remained high in hypertrophic scars and keloids, and the SC involved showed a faster turnover time than that of adjacent normal skin.

CONCLUSIONS

Scars, a proliferative change of the dermis, can be objectively evaluated according to functional abnormalities of the SC, because the dermis has a close relationship with the epidermis and with the SC. The functional characteristics of the SC of fresh scars and those of hypertrophic scars and keloids resemble those of retinoid-treated skin, rather than those found in epidermal hyperproliferative conditions such as psoriasis and dermatitis.

Distribution of and age-related changes in ciliary neurotrophic factor protein in rat tissues

We developed a sensitive enzyme-linked immunosolvent assay for measuring ciliary neurotrophic factor (CNTF) and examined age-related changes in the CNTF contents of a variety of rat tissues during postnatal development. CNTF contents were substantially higher in the sciatic nerve and spinal cord than in the other tissues tested, the kidney coming third. In all the tissues except the sciatic nerve (90 ng/g), the CNTF content was less than 1 ng/g at 1 week of age, then gradually increased. It was highest at 5 weeks of age in the sciatic nerve (3171 ng/g), spinal cord (118 ng/g), and kidney (36.8 ng/g), after which it slowly decreased. In contrast, the maximum in the brain stem (9 ng/g) and cerebellum (3.6 ng/g) was at 8 weeks of age, whereas in skeletal muscle it was at 2 weeks of age (14.6 ng/g). These findings indicate that CNTF functions in the postnatal development of the rat.