Urinary myo-inositol levels in Japanese schoolchildren with normal glucose tolerance

BACKGROUND

Urinary myo-inositol (UMI) level is elevated in adult diabetic patients, and also increases after glucose loading. However, the relationship between UMI and plasma glucose levels in children is unknown. We aimed to assess whether UMI is a practical marker for glucose intolerance in children or not.

METHODS

In Study 1 (328 schoolchildren), fasting and postprandial UMI were measured, with ΔUMI defined as the difference between fasting and postprandial UMI levels. In Study 2, oral glucose tolerance tests and UMI measurements were conducted in 18 children with suspected having diabetes.

RESULTS

For Study 1, ΔUMI was observed [-0.65 (-3.9, 1.35) mg/g creatinine]. For Study 2, children with diabetes or impaired glucose tolerance had a significantly higher ΔUMI than children with normal glucose tolerance.

CONCLUSIONS

These studies demonstrated the normal range of UMI in children and possibility of a novel biomarker for early detection of glucose intolerance in children.

Development of waist circumference percentiles for Japanese children and an examination of their screening utility for childhood metabolic syndrome: a population-based cross-sectional study

BACKGROUND

In Japan, waist circumference (WC) percentiles to screen for childhood metabolic syndrome (MetS) are unavailable. The objectives of this study were to develop WC and WC-to-height ratio (WC/Ht) percentile curves by age and sex for Japanese children, and to test their utility in screening for MetS in children with obesity who are otherwise healthy.

METHODS

The WC and WC/Ht percentiles were developed using the LMS method of summarizing growth standards, which monitors changing skewness (L), medians (M), and coefficients of variation (S) in childhood distributions. A representative dataset was used, which consisted of 3,634 boys and 3,536 girls aged 4.5-12.75 years in Shizuoka prefecture, Japan, between 2010 and 2012. Children who were obese (355 boys and 230 girls) aged 6-12 years from Osaka prefecture, Japan, were screened for childhood MetS using the new percentiles and the International Diabetes Federation's (IDF's) definition of MetS.

RESULTS

The number of participants with certain metabolic abnormalities (high systolic and diastolic blood pressure, and a high level of triglycerides) was significantly higher in boys aged 10-12 years, with a WC ≥ 90th percentile, than among those with a WC < 90th percentile. None of the participants with a WC < 90th percentile exhibited two or more metabolic abnormalities, regardless of their age or sex. Among the participants aged 10-12 years, 11.4 % of boys and 4.4 % of girls with a WC ≥ 90th percentile were diagnosed with MetS.

CONCLUSIONS

The new percentiles may have a certain level of potential to screen Japanese children for childhood MetS in accordance with the IDF definition.

[Causes and pathophysiology of pediatric obesity and its diagnostic criteria]

Recently, obesity has been listed as important health problems not only in adults but also in children. Prevalence of pediatric obesity has been rising in the last half century in most of the developed countries including Japan. In addition to changes in lifestyle, which are shown to have contributed greatly to promote weight gain in recent years, patients with some syndromes or diseases may have obesity as one of the manifestations of the disorders especially in childhood. Obese individuals are commonly accompanied by derangement in various organs, such as metabolic and cardiovascular systems, in children as well as adults. Diagnostic criteria for obesity-disease and metabolic syndrome were proposed on the basis of data obtained from Japanese children.

Rate of trabecular bone area in 3-6-year-old children and relation to intrauterine growth

BACKGROUND

The aim of the present study was to investigate bone mass using rate of trabecular bone area (RTBA) in Japanese children to determine its relationship with indices of growth such as height and weight from before birth through childhood.

METHODS

  A cross-sectional study was conducted. The sample consisted of Japanese boys (n= 716) and girls (n= 586) aged 3-6 years. RTBA was measured using quantitative ultrasound (ultrasonic bone densitometer, Benus III; Ishikawa Seisakusho, Kanazawa, Japan). The relation between RTBA and height and weight during childhood and also at birth was assessed.

RESULTS

The average RTBA in boys was 27.7 ± 1.59% (mean ± SD) and that in girls was 27.9 ± 1.59%. RTBA significantly correlated with weight both in boys (P= 0.013) and girls (P= 0.016). Significant correlation was demonstrated between RTBA and height, especially in girls (P= 0.045). Statistical significance was shown between RTBA and birth length in boys (P= 0.015) and girls (P= 0.007), and weight at birth in boys (P= 0.014). On multiple regression analysis RTBA correlated significantly with birthweight for boys (standardized coefficient β= 0.093, P= 0.028) and birth length for girls (β= 0.122, P= 0.007).

CONCLUSION

Augmentation of bone mass is related not only to weight and height during childhood but also to prenatal factors such as growth, and possibly with nutrition in utero.

Carbenoxolone alters the morphology of adipose tissues and downregulates genes involved in adipogenesis, glucose transport and lipid metabolism in high-fat diet-fed mice

Glucocorticoid (GC) excess promotes adipose tissue accumulation, and 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) plays an important role in the local amplification of GC. Therefore, in this study, we investigated the effects of carbenoxolone (CBX), an 11β-HSD1 inhibitor, on morphological changes in visceral fat, and the expression of genes involved in adipogenesis and lipid metabolism in high-fat (HF) diet-fed mice. Mice were fed a HF diet from 5 weeks of age. At 10 weeks of age, the mice received an intraperitoneal injection of CBX or vehicle every day for 2 weeks. CBX decreased body weight and visceral fat mass, and improved insulin sensitivity in HF-fed mice. This was accompanied by reduced adipocyte size and a decrease in large-sized adipocytes in visceral fat. The expression of adipogenesis (PPARγ and C/EBPα), glucose transport (GLUT4) and lipid metabolism (LPL, ATGL, and HSL)-related genes were suppressed in CBX mice. CBX treatment induced beneficial morphological changes in visceral fat and decreased the expression of adipogenesis, glucose transport and lipid metabolism-related genes. These findings reveal a potential mechanism underling the effects of CBX on reduced fat accumulation and improved insulin sensitivity.

Prevalence of congenital heart disease assessed by echocardiography in 2067 consecutive newborns

AIM

There are discrepancies in the reported prevalence of congenital heart disease (CHD). This study prospectively evaluated the prevalence of CHD in consecutive newborns using echocardiographic screening.

METHODS

A cohort screening study was conducted in an unselected series of all live-birth newborns. Two-dimensional and colour Doppler echocardiography was performed at 0-4 days of life in 2067 consecutive neonates who were born at the Hamamatsu University Hospital, Japan, between May 2005 and April 2010.

RESULTS

There were 104 cases of CHD in the 2067 live births. Ventricular septal defect and patent ductus arteriosus were the most frequent cardiac abnormalities. The prevalence of newborns with CHD who had signs or symptoms of CHD and/or required invasive intervention was 21.3 per 1000 live births. However, 60 patients (29.0 per 1000 live births) with CHD were asymptomatic and did not need invasive intervention. The overall prevalence of CHD in this series was 50.3 per 1000 live births.

CONCLUSION

This prospective study using echocardiography for all newborns shows a higher prevalence of CHD than almost all of the previous studies.

Expression of 11beta-hydroxysteroid dehydrogenase 2 contributes to glucocorticoid resistance in lymphoblastic leukemia cells

Synthetic glucocorticoids (GCs) form a crucial first-line treatment for childhood acute lymphoblastic leukemia (ALL). However prolonged GC therapy frequently leads to GC-resistance with an unclear molecular mechanism. 11β-hydroxysteroid dehydrogenase (11β-HSD) 2 inactivates GCs within cells. Here, we show the association between GC sensitivity and 11β-HSD2 expression in human T-cell leukemic cell lines. 11β-HSD2 mRNA and protein levels were considerably higher in GC-resistant MOLT4F cells than in GC-sensitive CCRF-CEM cells. The 11β-HSD inhibitor, carbenoxolone pre-treatment resulted in greater cell death with prednisolone assessed by methyl-thiazol-tetrazolium assay and caspase-3/7 assay, suggesting that 11β-HSD2 is a cause of GC-resistance in ALL.

Altered gene expressions of ghrelin, PYY, and CCK in the gastrointestinal tract of the hyperphagic intrauterine growth restriction rat offspring

Intrauterine growth restriction (IUGR) is associated with a substantially greater incidence of metabolic syndrome in adulthood. Animal studies have shown that IUGR offspring are hyperphagic during the early postnatal period and therefore exhibit obesity. The molecular mechanisms underlying food intake regulation in the gastrointestinal tract have not been clarified in IUGR. In the present study, we utilized a rat model of IUGR by restricting the food intake of the mother (50% of the normal intake, ad libitum; FR group) from day 7 of gestation until delivery. Pups from undernourished mothers were fostered by control mothers. We examined the food intake and assessed the gene expressions of ghrelin, peptide YY (PYY), and cholecystokinin (CCK) in the alimentary tract of male newborns (postnatal day1) and adult offspring (age, 7 months). Compared to the offspring whose mothers received the standard diet ad libitum (CON offspring), FR offspring were hyperphagic from the weaning time until the end of the experiment, and resulted in a heavier final weight. Both newborn and adult FR offspring had higher ghrelin gene expression in the stomach and higher ghrelin plasma levels than did the controls. Although the gastrointestinal gene expressions and plasma levels of the anorexic peptides, PYY and CCK, were elevated in the FR newborns, they decreased in the FR adults. Our findings suggest that the altered gene expressions of orexigenic and anorexigenic gut peptides in the gastrointestinal tract in the maternal undernutrition-induced IUGR offspring provide a potential mechanism to explain hyperphagia and obesity seen in these offspring.

Hereditary spherocytosis coexisting with UDP-glucuronosyltransferase deficiency highly suggestive of Crigler-Najjar syndrome type II

Patients with co-existing hereditary spherocytosis (HS) and UDP-glucuronosyltransferase 1A1 (UGT1A1) deficiency as Gilbert's syndrome (GS) have been reported, and previous studies have demonstrated an increased risk for developing gallstones in patients with co-inheritance of GS and HS. We experienced an interesting case of HS showing persistent jaundice after splenectomy, and upon further evaluation, the 25-year-old female patient was found to have HS combined with UGT1A1 deficiency. Sequence analysis of the UGT1A1 gene revealed that she was a compound heterozygote with p.[G71R; Y486D] + [Y486D] mutations, which suggests Crigler-Najjar syndrome type II rather than GS. Careful evaluation of inappropriately elevated bilirubin level compared with the degree of hemolysis is important, reflecting the therapeutic implication of splenectomy and cholecystectomy.

Abdominal obesity is associated with cardiovascular risk in Japanese children and adolescents

BACKGROUND

Metabolic syndrome is listed as a risk for atherosclerosis. However, changes in that risk during childhood and adolescence have not been well-documented. It is also unclear whether individuals with abdominal obesity, but with as yet undiagnosed metabolic syndrome, have cardiovascular risks.

METHODS AND RESULTS

Ninety-two patients were studied at the Hamamatsu University School of Medicine Department of Pediatrics. Physical measurements including abdominal circumference (AC), body mass index (BMI), body fat (BF), intima media thickness (IMT), arterial elasticity: beta index (Beta), carotid artery compliance (CAC), and Young's elastic modulus (YEM) using ultrasonography were taken. A positive correlation between systolic blood pressure, AC, BMI, and BF was observed (AC, r = 0.717, p < 0.001; BMI, r = 0.672, p < 0.001; BF, r = 0.518, p < 0.001). IMT showed a weak positive correlation with AC, BMI and BF (AC, r = 0.211, p = 0.044; BMI, r = 0.233, p = 0.025; BF, r = 0.232, p = 0.026). The relationship between AC, BMI, BF and arterial elasticity, especially in AC, positively correlated with beta index and YEM but negatively correlated with CAC.

CONCLUSION

We suggest that AC is the most sensitive marker in the detection of arterial elasticity, even in school age children. Earlier pre-diagnostic intervention, especially in the prevention of abdominal obesity, may reduce the incidence of metabolic syndrome in children and adolescents.

Dynamics of endogenous glucocorticoid secretion and its metabolism in Kawasaki disease

OBJECTIVE

Kawasaki disease (KD) is a severe inflammatory disease that occurs in childhood. Recently, the initial corticosteroid therapy for KD has been reconsidered because its efficacy is controversial. The aim of this study was to evaluate the dynamic change in endogenous glucocorticoid levels and their relation with 11beta-hydroxysteroid dehydrogenase (11beta-HSD) activity in the acute phase of KD.

STUDY DESIGN

Sixteen KD patients were investigated. Cortisol and cortisone levels, the cortisol/cortisone ratio and C-reactive protein (CRP) levels were measured on admission, before the first intravenous immunoglobulin (IVIG) therapy and convalescence.

RESULTS

The 16 patients were divided into two groups. Group A included patients who received the first IVIG on admission and blood samples were collected before the first IVIG and convalescence. Group B included patients whose blood samples were collected at three different time points (on admission, before the first IVIG, and convalescence). CRP and cortisol levels and the cortisol/cortisol ratio were markedly higher before the first IVIG than those of convalescence in all patients except in one patient. In Group B patients, both serum cortisol levels and the cortisol/cortisone ratio on admission were significantly increased compared with those before the first IVIG (cortisol: p<0.005, cortisol/cortisone: p<0.001).

CONCLUSIONS

Decreases in cortisol levels and the cortisol/cortisone ratio before the first IVIG may be explained by a reduction in adrenal secretion and/or local glucocorticoid action through 11beta-HSD activity. These findings suggest that exogenous glucocorticoid treatment in combination with the first IVIG at the acute stage may play a synergetic role in KD.

Effects of maternal high-fat diet on serum lipid concentration and expression of peroxisomal proliferator-activated receptors in the early life of rat offspring

Peroxisomal proliferator-activated receptors (PPARs) play an important role in the regulation of lipid metabolism. The aim of this study was to investigate the effects of a maternal high-fat (HF) diet on serum lipid concentration and PPAR gene expression in liver and adipose tissue in the early life of the rat offspring. Female Sprague-Dawley rats were fed either an HF or control (CON) diet 6 weeks before mating and throughout gestation and lactation. Blood and tissue samplings of male offspring were carried out at birth or weaning. Birth weights were similar and serum triglyceride (TG) and nonesterified fatty acid (NEFA) levels showed no significant difference between HF and CON newborns, despite greatly increased hepatic PPARα mRNA expression in the HF newborns (p<0.05). Both HF newborns and weanlings revealed significantly decreased hepatic PPARγ expression compared with controls (p<0.0001). Hepatic PPARα expression in the HF weanlings was reduced markedly compared with CON weanlings (p<0.0001) and showed a negative correlation with serum TG levels (r=-0.743, p<0.05). However, epididymal expression of PPARγ in the HF weanlings was upregulated significantly compared with controls (p<0.05) and demonstrated a positive correlation with epididymal fat mass (r=0.733, p<0.05). These were accompanied by obesity as well as a rise in serum TG by 79% (p<0.05) and NEFA concentration by 36% (p<0.05) in these HF weanlings. Our findings suggest that maternal HF diet leads to alterations in PPAR gene expression in the weanling offspring, which is associated with the disturbed lipid homeostasis.

Age and sex differences in fat distribution in non-obese Japanese children

OBJECTIVE

To assess fat distribution in non-obese Japanese children and adolescents.

DESIGN

130 non-obese Japanese children (73 boys and 57 girls) from Kikugawa, Hamamatsu were included. The visceral fat area (VFA) and subcutaneous fat area (SFA) were measured by computed tomography (CT) and calculated (in cm(2)). Subjects were divided into three groups based on age: group A (6-10 years), group B (11-15 years), and group C (16-20 years).

RESULTS

Girls had more subcutaneous fat than boys in groups B and C (P<0.01). Boys had an age-dependent increase in visceral fat, but girls did not. In group C (16-20 years), boys had more visceral fat than girls (P<0.01).

CONCLUSIONS

In non-obese Japanese children, there are significant differences in visceral and subcutaneous fat amounts by age and sex. VFA seems to accumulate more in boys than in girls, and SFA is more prevalent in girls than boys.

Impact of leptin and leptin-receptor gene polymorphisms on serum lipids in Japanese obese children

AIM

Leptin is one of the factors affecting serum lipid profile. We investigated the association between serum lipids and leptin/leptin receptor (LEPR) gene polymorphisms in obese Japanese children.

METHODS

One hundred and thirty-six obese children (99 males and 37 females, relative weight over than 20%) from 5 to 17 years of age were recruited from 10 institutes. Four known polymorphisms in leptin gene [(+19)A G, (-2548)G A, (-188)C A, (-633)C T] and four known polymorphisms in LEPR gene [Lys109Arg, Gln223Arg, Pro(G)1019Pro(A), Ser(T)343Ser(C)] were determined using polymerase chain reaction-restriction fragment length polymorphism-based analyses.

RESULTS

No associations were found between leptin gene polymorphisms and serum lipid profile. On the other hand, Lys109Arg and Ser343Ser polymorphism in LEPR gene, but not Gln223Arg or Pro1019Pro, had significant relationships with serum lipid profile; lower total and low-density lipoprotein cholesterol levels in Arg109Arg homozygotes, and lower TG levels in Ser343Ser(C/C) homozygotes. In addition, LEPR gene also associated with relative weight; Arg109Arg homozygotes had higher relative weight and Ser343Ser(C/C) homozygotes had lower one.

CONCLUSION

These results suggest that LEPR gene polymorphisms may partly contribute to serum lipid profile in obese children.

Delayed enhancement cardiac magnetic resonance imaging in propionic acidemia

We report on cardiomyopathy in propionic acidemia (PA) diagnosed using delayed-enhancement cardiac magnetic imaging (DECM) in a 27-year-old woman. DECM demonstrated hyperenhancement at the lateral wall of the left ventricle, suggesting myocardial changes occurring after a metabolic crisis, which improved during the convalescent period. DECM was useful for the diagnosis of cardiomyopathy in PA.

Effect of cibenzoline on biventricular pressure gradients in a pediatric patient with hypertrophic obstructive cardiomyopathy

This report presents the case of an 8-year-old male with biventricular hypertrophic obstructive cardiomyopathy who achieved a successful reduction of the pressure gradients by treatment with cibenzoline. Ultrasound echocardiography showed marked intraventricular septal hypertrophy and left midventricular and right ventricular outflow obstructions. A cardiac catheterization revealed left midventricular and right outflow obstructions associated with pressure gradients of 100 and 35 mmHg, respectively. An intravenous injection of 28 mg (1.4 mg/kg) cibenzoline immediately improved the biventricular pressure gradients. Therefore, oral cibenzoline treatment was initiated, the dose was increased to 150 mg/day, and both pressure gradients remained low, without any complications at the time of discharge, 4 months later.

Postnatal changes in adrenal size in very low-birth-weight infants: sonographic evaluation for the prediction of late-onset glucocorticoid-responsive circulatory collapse

We investigated the postnatal pattern of changes in adrenal size in very low-birth-weight (VLBW) infants and its relation to late-onset glucocorticoid-responsive circulatory collapse (LGCC) that may be associated with adrenal insufficiency. In 36 VLBW infants born at <33 weeks' gestation, ultrasound examinations of postnatal changes in adrenal size during the first 3 weeks of life were performed. VLBW infants were classified into three groups: group A (N = 6), the actual adrenal area was greater than or equal to the predicted value at birth and unchanged at 3 weeks; group B (N = 24), the actual adrenal area was greater than or equal to the predicted value and decreased at 3 weeks; and group C (N = 6), the actual adrenal area was less than the predicted value and unchanged at 3 weeks. Five infants developed LGCC, and all five were in group A. These observations suggest that the life of the adrenal fetal zone might be extended beyond 3 weeks after birth in some VLBW infants and that prolonged fetal zone activity might correlate with LGCC. On the other hand, adrenal maturation might have already occurred at birth in some VLBW infants. Sonographic evaluation of adrenal size may enable prediction of subsequent LGCC in VLBW infants.

Differential regulation of 11beta-hydroxysteroid dehydrogenase-1 by dexamethasone in glucocorticoid-sensitive and -resistant childhood lymphoblastic leukemia

Glucocorticoid therapy forms a crucial first-line treatment for childhood acute lymphoblastic leukemia (ALL). However, glucocorticoid resistance is a therapeutic problem with an unclear molecular mechanism. 11beta-Hydroxysteroid dehydrogenase-1 (11beta-HSD1) is expressed in glucocorticoid target tissue, where it regenerates active glucocorticoids from inert 11keto-glucocorticoids, amplifying intracellular glucocorticoid levels. Here, we show 11beta-HSD1 expression in leukemic cells from ALL patients (n=14). 11beta-HSD1 was differentially regulated by glucocorticoids between glucocorticoid-sensitive and -resistant ALL cells. Dexamethasone increased 11beta-HSD1 mRNA levels in glucocorticoid-sensitive ALL cells, but decreased levels in the resistant group. Our data suggest that differential induction of 11beta-HSD1 contributes to the glucocorticoid sensitivity in leukemia.

Cytochrome P450 oxidoreductase deficiency with Antley-Bixler syndrome: steroidogenic capacities

For patients with cytochrome P450 oxidoreductase deficiency (PORD), steroid replacement is recommended at times of stress. However, it is unknown how hormones respond to actual physical stress in these patients. We report a female infant with PORD accompanied by the Antley-Bixler syndrome phenotype. Her urinary steroid profile revealed defective CYP17A1 and CYP21A2 activities, and an adrenocorticotropin (ACTH) stimulation test showed potential adrenal insufficiency. Hormonal responses to actual physical stress were as follows: Vigorous crying during blood sampling rarely affected the serum cortisol level. Acute viral gastroenteritis led to marked increases in blood ACTH and 17alpha-hydroxyprogesterone levels in proportion to the severity of the illness. The serum cortisol level also responded to this stress, but the response might have been blunted. Regarding peri-operative steroid replacement, intravenous hydrocortisone administration even at a dose of 6 mg/kg, which is lower than that recommended for congenital adrenal hyperplasia in Japan, proved to be excessive.

Glucocorticoid regulation of the promoter of 11beta-hydroxysteroid dehydrogenase type 1 is indirect and requires CCAAT/enhancer-binding protein-beta

11beta-Hydroxysteroid dehydrogenase type 1 (11beta-HSD1) converts inert 11keto-glucocorticoids to active 11beta-hydroxy forms, thereby amplifying intracellular glucocorticoid action. Up-regulation of 11beta-HSD1 in adipose tissue and liver is of pathogenic importance in metabolic syndrome. However, the mechanisms controlling 11beta-HSD1 transcription are poorly understood. Glucocorticoids themselves potently increase 11beta-HSD1 expression in many cells, providing a potential feed-forward system to pathology. We have investigated the molecular mechanisms by which glucocorticoids regulate transcription of 11beta-HSD1, exploiting an A549 cell model system in which endogenous 11beta-HSD1 is expressed and is induced by dexamethasone. We show that glucocorticoid induction of 11beta-HSD1 is indirect and requires new protein synthesis. A glucocorticoid-responsive region maps to between -196 and -88 with respect to the transcription start site. This region contains two binding sites for CCAAT/enhancer-binding protein (C/EBP) that together are essential for the glucocorticoid response and that bind predominantly C/EBPbeta, with C/EBPdelta present in a minority of the complexes. Both C/EBPbeta and C/EBPdelta are rapidly induced by glucocorticoids in A549 cells, but small interfering RNA-mediated knockdown shows that only C/EBPbeta reduction attenuates the glucocorticoid induction of 11beta-HSD1. Chromatin immunoprecipitation studies demonstrated increased binding of C/EBPbeta to the 11beta-HSD1 promoter in A549 cells after glucocorticoid treatment. A similar mechanism may apply in adipose tissue in vivo where increased C/EBPbeta mRNA levels after glucocorticoid treatment were associated with increased 11beta-HSD1 expression. C/EBPbeta is a key mediator of metabolic and inflammatory signaling. Positive regulation of 11beta-HSD1 by C/EBPbeta may link amplification of glucocorticoid action with metabolic and inflammatory pathways and may represent an endogenous innate host-defense mechanism.

A case of congenital chloride diarrhea: information obtained through long-term follow-up with reduced electrolyte substitution

Congenital chloride diarrhea (CCD) is an inherited disorder of intestinal electrolyte transport that results in a large wastage of electrolytes and water. The patient, who is now 24 years old, was diagnosed at the age of 16 months with CCD based on hypochloremic alkalosis, hyponatremia, and hypokalemia with increased plasma renin and aldosterone levels, and high fecal Cl(-). Serum Na(+) and plasma aldosterone levels were normalized by replacement therapy with NaCl [8 mmol/(kg day)] and KCl [3 mmol/(kg day)]. On follow-up, watery diarrhea persisted, and she was frequently noted to have hypokalemia despite normal serum Na(+) and Cl(-) and plasma aldosterone levels with only reduced dosages of KCl [1-1.5 mmol/(kg day)] substitution due to only sporadic ambulatory care and unsatisfactory compliance with medication, and a normal diet. However, she had acceptable growth, normal renal function, and had an uneventful pregnancy and delivery of a healthy child. In adolescence and adulthood, hypokalemia may be the main problem requiring treatment, and substitution therapy with adequate doses of KCl alone may be sufficient, although a combination of NaCl and KCl is generally recommended even after childhood.

Ultrasound-guided versus landmark-guided femoral vein access in pediatric cardiac catheterization

BACKGROUND

This study aimed to evaluate whether an ultrasound-guided technique can improve upon a landmark-guided technique in achieving femoral vein access in pediatric cardiac catheterization.

METHODS

This study examined 87 consecutive subjects with a median age of 2 years (range, 1 month to 19 years) who had congenital or other heart disease. Femoral vein puncture was attempted using either an ultrasound-guided technique (US group, n = 43) or a landmark-guided technique (LM group, n = 44). The patients were assigned alternately to either an ultrasound- or landmark-guided group. Overall success and traumatic complication rates were compared between the two groups, as well as the influence of patient size and age.

RESULTS

The overall rate of success in achieving femoral vein access did not differ between the two groups. Among the successful cases in the two groups, there were no significant differences in patient size or age. Inadvertent femoral artery puncture occurred with 3 (7%) of 43 patients in the US group and with 14 (31.8%) of 44 patients in the LM group, for a significantly higher complication rate in the LM group (p < 0.01).

CONCLUSIONS

Ultrasound-guided access to the femoral vein minimizes the complication of inadvertent arterial puncture as compared with the landmark-guided approach.

[Genetic regulation of the biosynthesis of steroid hormones]

Steroid hormones play the critical roles in human. Glucocorticoid is indispensable for the life. Mineralocorticoid regulates the balance of electrolytes. Androgen and estrogen are necessary for sexual development. In the biosynthesis of steroid hormone, many cytochrome P450 enzymes and hydroxysteroid dehydrogenases work. P450 enzymes catalyze the hydroxylation and cleavage of the steroid substrate. They function as monooxygenases utilizing NADPH as the electron donor for the reduction of molecular oxygen. The hydroxysteroid dehydrogenases belong to the short-chain alcoholdehydrogenase reductase superfamily. They are involved in the reduction and oxidation of steroid hormones requiring NAD+/NADP+ as acceptors. Most genes and genetic regulation of these enzymes have been clarified. This review presents a description of the enzymes and the genes involved in the biosynthesis of active steroid hormones.

Extremely low birthweight infant with wolf-hirschhorn syndrome: a dilemma in determination of the optimal timing of delivery

Wolf-Hirschhorn syndrome (WHS) is characterized by multiple malformations as well as mental and developmental defects resulting from the absence of a distal segment of the short arm of chromosome 4. We experienced an extremely low birthweight infant with WHS. The male infant (birthweight 934 g) was born at 31 weeks’ gestation by cesarean section due to intrauterine growth restriction and presented with the typical WHS phenotype. Chromosomal analysis showed a deletion: 46,XY,del(4)(p15.3 p16). Although the patient’s respiratory distress syndrome resolved favourably and his subsequent condition was also stable, he had unusually severe retinopathy of prematurity and periventricular leukomalacia. We suppose that these severe complications were associated with not only prematurity but also with latent structural fragility due to WHS. Herein, we discuss the prenatal detection of WHS and the optimal timing of delivery.

Metabolic syndrome in youths

The metabolic syndrome (MetS), characterized by a clustering of cardiovascular disease and type 2 diabetes (T2DM) risk factors, has become prevalent in children and adolescents in recent years. However, the reported prevalence data on the MetS in youths has varied markedly, in large part, because of the disagreement among the variously proposed definitions of the MetS. Obesity is defined by using body mass index, waist circumference, or percent overweight, pointing to the need for standardized use of anthropometric variables to define obesity with a well-defined reference year for each ethnic population. In addition, slightly different cutoff values are used for triglycerides, high-density lipoprotein cholesterol, blood pressure, and fasting plasma glucose. Therefore, International Diabetes Federation recently proposed unified, easy-to-use criteria for diagnosing the MetS in youths. To provide insight into the mechanisms underlying the MetS in youths, the degree of insulin sensitivity/resistance and its correlation with the serum lipid and blood pressure levels have been evaluated. In addition, the serum levels of adipocytokines, such as adiponectin, leptin, tumor necrosis factor-alpha, resistin, interleukin-6, plasminogen activator inhibitor-1, and their correlation with childhood obesity have been extensively investigated. Recommendations for future research include exploring ways to assess visceral adiposity, to identify better biochemical markers for prediction of T2DM and disease progression, and to effectively intervene to prevent the MetS in youths.

Severe, widespread vasculopathy in late-onset group B streptococcal meningitis

Although improvements in antimicrobial therapy during the last few decades have decreased mortality in childhood bacterial meningitis, some patients are left with neurologic sequelae. Cerebrovascular complications are often associated with unfavorable clinical outcome of the disease. We report a 36-day-old infant with severe, widespread cerebrovascular complications due to group B streptococcal meningitis. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) contributed to a non-invasive demonstration of meningeal inflammatory changes and vascular lesions with the meningitis in this patient.

Diabetic pregnancy in rats leads to impaired glucose metabolism in offspring involving tissue-specific dysregulation of 11beta-hydroxysteroid dehydrogenase type 1 expression

Population-based studies have shown that the offspring of diabetic mothers have an increased risk of developing obesity, insulin resistance, type 2 diabetes and hypertension in later life. To investigate mechanism for the high incidence of metabolic diseases in the offspring of diabetic mothers, we focused on the tissue-specific glucocorticoid regulation by 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1) and studied offspring born to streptozotocin-induced diabetic rats. The body weights of newborn rats from diabetic mothers were heavier than those from control mothers. Offspring born to diabetic mothers demonstrated insulin resistance and mild glucose intolerance after glucose loading at 10 weeks and showed significantly increased 11beta-HSD1 mRNA and enzyme activity in adipose tissue at 12 weeks of age without obvious obesity. Hepatic 11beta-HSD1 mRNA was also elevated. We propose that the 11beta-HSD1 in adipose tissue and liver may play a key role in the development of metabolic syndrome in the offspring of diabetic mothers. Tissue-specific glucocorticoid dysregulation provides a candidate mechanism for the high incidence of metabolic diseases in the offspring of diabetic mothers. Therefore early analyses before apparent obesity are needed to elucidate the molecular mechanisms that may be programmed during the fetal period.

Pilot study of ifosfamide/carboplatin/etoposide (ICE) for peripheral blood stem cell mobilization in patients with high-risk or relapsed medulloblastoma

OBJECTIVES

The purpose of this study is to evaluate the stem cell mobilization capacity, anti-tumor effect, and feasibility of ifosfamide/carboplatin/etoposide (ICE) for transplant-eligible patients with medulloblastoma.

MATERIALS AND METHODS

Six patients (23 months to 18 years old) with high-risk or relapsed medulloblastoma received one cycle of ICE, which consisted of ifosfamide at 1.8 g/m(2) for 5 days, carboplatin 400 mg/m(2) for 2 days, and etoposide 100 mg/m(2) for 5 days. Stem cells were mobilized with ICE followed by granulocyte colony-stimulating factor at 10 microg kg(-1) day(-1).

RESULTS

After one cycle of ICE, the median number of harvested CD34+ cells per apheresis session was 11.85 x 10(6) cells/kg (range, 0.2 to 71.2 x 10(6) cells/kg). Two patients obtained a complete response and three patients a partial response. All patients experienced severe myelosuppression, and three infectious toxicities were observed.

CONCLUSIONS

These results suggest that ICE is optimal for mobilizing stem cells, effective for high-risk or relapsed medulloblastoma, and tolerable with limited non-hematological toxicity.

Ulinastatin Therapy in Kawasaki Disease

BACKGROUND AND OBJECTIVE

Ulinastatin therapy may be an additional therapeutic approach to Kawasaki disease (KD). This study set out to determine whether primary intravenous ulinastatin therapy has more beneficial effects than intravenous immunoglobulin (IVIG) therapy in the acute phase of KD, and whether addition of ulinastatin to IVIG might improve outcomes in KD.

METHODS

Patients were included in the study if they had a diagnosis of KD with a Harada's score that predicted coronary artery lesions. Subjects were selected to receive either primary ulinastatin therapy (30 000 U/kg/day for 3 days) or IVIG therapy (1 g/kg/dose) using sealed envelopes. Of the 27 study subjects, 18 were assigned to the ulinastatin group, and nine to the IVIG group. IVIG therapy could be added to ulinastatin therapy if patients experienced adverse effects of ulinastatin, were found to have complicated coronary artery lesions, or developed prolonged fever or elevated white blood cell counts or C-reactive protein levels.

RESULTS

More patients receiving IVIG as primary therapy had reduced fever and C-reactive protein levels than patients receiving ulinastatin as primary therapy. Five patients in the ulinastatin group (28%) improved without additional IVIG therapy. These patients had lower white blood cell counts and C-reactive protein levels on admission.

CONCLUSION

Primary ulinastatin therapy prevented coronary artery lesions in only 28% of cases of KD with a Harada's score predictive of such lesions. Primary ulinastatin therapy may not be the treatment of first choice for preventing coronary artery lesions in patients with KD.

Differential effect of DHEA on mitogen-induced proliferation of T and B lymphocytes

Dehydroepiandrosterone (DHEA) is the predominant steroid hormone secreted by adrenal gland, and it has been proposed in recent years that DHEA has significant effects on immune function. We investigated the effect of DHEA (1 x 10(-5) - 1 x 10(-8)M) on proliferation of human T cells and B cells and on immunoglobulin production, a representative function of B cells. High doses of DHEA (1 x 10(-5)) significantly inhibited proliferation of peripheral blood mononuclear cells (PBMCs) and T cells induced by T cell mitogens hemagglutinin (PHA) and concanavalin A (Con A). Proliferation of PBMCs induced by B cell mitogens pokeweed mitogen (PWM) was increased by 1 x 10(-7) - 1 x 10(-6)M DHEA. Proliferation of PBMCs and B cells induced by Staphylococcus aureus Cowan strain I (SAC) was not significantly changed at any concentrations of DHEA. However, a concentration of 1 x 10(-7)M DHEA tended to potentiate their proliferation. This study suggested that DHEA acted on T and B lymphocytes differentially in immune system.