Immunosuppressive therapy with tacrolimus is a potential drug candidate for the prevention of unexplained or preeclamptic stillbirths with Th1-dominant immune states: a case series of five patients

Some of obstetrical complications such as unexplained pregnancy loss and preeclampsia (PE) are associated with maternal-fetal immune abnormalities, leading to uteroplacental dysfunction, insufficient fetal immune tolerance, or fetal rejection. Immunosuppressants with calcineurin inhibitors could be useful for the prevention of these complications by modulating the cellular immune balance by directly inhibiting activated T-helper (Th) 1 and natural killer (NK)/NKT cells. We present our experience with the immunosuppressant tacrolimus in five pregnant women who had a previous pregnancy history of unexplained or preeclamptic stillbirth. Th1 and Th2 cell populations and NK cell activities in peripheral blood were measured as clinical parameters during pregnancy. Case 1-3 achieved suppressions of predominant Th1 immunity and live births without pregnancy-related complications. In case 4, increased tacrolimus dose after a miscarriage resulted in her first live birth; however, she developed PE and severe fetal growth restriction with elevated Th1/Th2 cell ratios at 26 weeks of gestation. Case 5 had a previous history of early onset PE and the hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, and an emergency cesarean section was needed for maternal safety at 20 weeks of gestation. The course of the next pregnancy was stable under tacrolimus treatment; however, the HELLP syndrome recurred after PE at 33 weeks of gestation. Although an imbalance in the Th1/Th2 cell ratio was not observed during pregnancy, NK cell activity was markedly elevated before delivery. In conclusion, tacrolimus is a potential drug candidate for the prevention of unexplained or preeclamptic stillbirth with Th1-dominant immune states.

Multicenter, 2-dose single-group controlled trial of tacrolimus for the severe infertility patients

INTRODUCTION

Infertility is estimated to affect 8% to 12% of reproductive-aged couples worldwide. While approximately 85% of infertile couples have an identified cause, the remaining 15% suffer physically and emotionally from unexplained intractable infertility. In recent years, maternal-to-fetal immunological abnormalities have attracted attention as mechanisms that differ from the conventional factors contributing to infertility and pregnancy loss. A T-helper 2 (Th2)-dominant immune state has been proposed as a maternal immune alteration to eliminate rejection and induce tolerance to a semi-allogeneic fetus. An imbalance in Th1 responses would not induce adequate maternal immune tolerance to the fetus or early embryos. Tacrolimus, widely used as an immunosuppressant agent in solid organ transplant recipients, is expected to suppress maternal rejection and promote tolerance to early embryos after assisted reproductive technology by modulating the immunological environment of the preimplantation endometrium. We planned an exploratory clinical trial to determine the efficacy, safety, and dosage of tacrolimus in women with intractable infertility.

METHODS AND ANALYSIS

This is a multicenter, 2-dose, single-group controlled trial in infertile women who failed to achieve a chemical pregnancy despite multiple in vitro fertilization (IVF) and embryo transfer (ET) treatment cycles. The following 2 key selection criteria were set: no underlying factors of infertility despite appropriate evaluation and presence of Th1-dominant immune state, defined as a Th1/Th2 cell ratio ≥ 10.3 in the peripheral blood. A total of 26 eligible participants are randomly assigned (in a 2:1 ratio) to receive immunosuppressive therapy with oral tacrolimus at a daily dose of 2 mg or 4 mg. Tacrolimus is administered for 16 days starting from 2 days before ET. The primary endpoint is the presence of clinical pregnancy 3 weeks after IVF/ET treatment, and the secondary endpoint is the presence of biochemical pregnancy 2 weeks after IVF/ET treatment. Safety evaluation and biomarker discovery for tacrolimus treatment in infertile women will be conducted simultaneously.

TRIAL REGISTRATION NUMBER

Japan Registry of Clinical Trials (jRCT; jRCTs031220235).

Changes in the T-helper 1 and 2 cell populations during pregnancy in tacrolimus-treated women with repeated implantation failure and recurrent pregnancy loss

Tacrolimus has received considerable attention as a treatment approach for infertility associated with maternal-foetal immune abnormalities, such as repeated implantation failure (RIF) and recurrent pregnancy loss (RPL). This study examined the changes in T-helper (Th) 1 and 2 cell populations during pregnancy in peripheral blood of tacrolimus-treated RIF patients who delivered a liveborn infant from August 2012 to February 2020 at the National Centre for Child Health and Development. A total of 58 eligible study subjects were divided into two groups according to the presence of a history of RPL: (i) RIF-alone group (n = 31); and (ii) RIF-plus-RPL group (n = 27). In a flow cytometric analysis, the Th1/Th2 cell ratios were significantly higher before pregnancy than after pregnancy, and during the first trimester than the second trimester in the RIF-alone group (p = 0.0071 and p = 0.0087, respectively). However, no significant differences were present in the RIF-plus-RPL group. Although the Th1 immunity was suppressed under tacrolimus treatment in both groups, a delayed reduction in the Th1 cell percentage after initiation of treatment was observed in the RIF-plus-RPL group. In conclusion, the cellular immune alterations in tacrolimus-treated patients with RIF were different depending on the presence or absence of a history of RPL.

Obstetric and perinatal outcome of the women with repeated implantation failures or recurrent pregnancy losses who received pre- and post-conception tacrolimus treatment

PROBLEM

Previously, we reported the clinical efficacy of tacrolimus in women with repeated implantation failures (RIF) of immune etiologies. Safety of tacrolimus in pregnant women has been reported in women with organ transplantations. However, the safety of tacrolimus for women with RIF undergoing assisted reproductive technology cycles and their babies has not been reported prior.

METHOD OF STUDY

This study is a prospective observational study of 109 women with RIF or recurrent pregnancy losses (RPL) who showed elevated peripheral blood Th1/Th2 (CD4⁺ IFN-γ⁺ /CD4⁺ IL-4⁺ ) cell ratios (≥10.3). All received tacrolimus before and during pregnancy (1-4 mg/d) and delivered a live-born infant(s). Blood concentrations of tacrolimus were measured. Neuromotor development of the babies was also evaluated.

RESULTS

Total 113 babies were born from 109 women, including four twin pregnancies. Nine pregnancies including four twins were delivered prematurely (8.3%). Two of 109 women showed obstetric complications, such as hypertensive disorder of pregnancy, and only one baby (0.9%) had a congenital abnormality. There were no differences in babies' birthweight, placental weight, and lymphocyte proportion (%) of the umbilical cord among the women with different tacrolimus dosing. Tacrolimus was detected in the maternal plasma, and its concentration did not significantly fluctuate during pregnancy while on daily administration regimen. Neuromotor development of the babies exposed to tacrolimus in utero was comparable with that of babies from the general population.

CONCLUSION

According to our data, tacrolimus treatment for women with RIF and RPL was not associated with obstetrical and perinatal complications. A large size study is needed to confirm this finding.

Tacrolimus treatment saved a rho-incompatible pregnancy

A Rho-incompatible pregnancy induces anemia in the fetus and can ultimately lead to fetal hydrops and intrauterine fetal death. A patient who had experienced recurrent implantation failures following a first successful delivery finally succeeded in achieving a second pregnancy via the use of tacrolimus. The second pregnancy was Rho-incompatible. During the course of the pregnancy, the treatment with tacrolimus was continued because the patient's T helper type 1 (Th1) cell population remained at a high level following the achievement of pregnancy. The dose was increased during pregnancy because of the elevated Th1 cell count at 28-week gestation. Tacrolimus maintains a stable state of pregnancy while simultaneously suppressing the production of anti-D antibodies. Using tacrolimus, we succeeded in resolving the infertility and inhibition of antibody production in this case of an alloimmunized pregnancy.

Persistent Primary Cytomegalovirus Infection After Deceased Donor Kidney Transplant: Ganciclovir Susceptibility of Human Cytomegalovirus With UL97 D605E Mutation: A Case Report

BACKGROUND

Cytomegalovirus (CMV) could cause rejection in immunocompromised patients during early post-renal transplant stage. The American Transplant Society guidelines recommend prophylactic therapy with ganciclovir (GCV) for 3 to 6 months to prevent CMV infections in adult renal transplant patients. However, there is no recommended CMV treatment regimen for pediatric patients.

MAIN FINDINGS

We performed deceased donor kidney transplant from an anti-CMV antibody-positive donor to an anti-CMV antibody-negative 15-year-old female recipient with end-stage renal disease caused by bilateral renal hypoplasia. One month after transplant, increase in positive cells in the CMV antigenemia assay indicated a primary CMV infection in the patient, who immediately received GCV. She was switched to foscarnet after 4 months of anti-CMV therapy because of clinical GCV resistance. CMV was isolated from the peripheral blood mononuclear cells but neutralizing antibody was not detected. Isolated CMV was susceptible to GCV and foscarnet, although it carried the UL97 D605E mutation, assumed to be associated with GCV resistance.

CONCLUSIONS

The primary CMV infection presented a phenotypic clinical drug resistance, but all recovered CMV isolates were drug-susceptible even if isolated after prolonged anti-CMV therapy, indicating that immune status was more important for recovery from primary CMV infection than anti-CMV therapy.

Lower urinary tract symptoms in children and adolescents with Williams-Beuren syndrome

INTRODUCTION

Williams-Beuren syndrome (WBS) is a genetic condition caused by a microscopic deletion in the chromosome band 7q11.23. Individuals with WBS may present with congenital cardiovascular defects, neurodevelopmental disturbances and structural abnormalities of the urinary tract. Lower urinary tract symptoms (LUTS) seem to be frequent in this population, but studies on this topic are scarce and based on small case series.

OBJECTIVE

To systematically evaluate the prevalence of lower urinary tract symptoms (LUTS) and the acquisition of bladder control in a large population with WBS.

STUDY DESIGN

A cross-sectional study evaluating 87 consecutive patients with WBS; there were 41 girls and 46 boys. Genetic studies confirmed WBS in all patients. Subjects were clinically evaluated with: a history of LUTS obtained from the parents and child, a structured questionnaire of LUTS, a 3-day urinary frequency-volume chart, a quality of life question regarding LUTS, and physical examination. A history regarding the acquisition of bladder control was directly evaluated from the parents.

RESULTS

Mean age of patients was 9.0 ± 4.2 years, ranging from 3 to 19 years. Based on the symptoms questionnaire and the frequency-volume chart, 70 patients (80.5%) were symptomatic. The most common symptom was urgency, affecting 61 (70.1%) patients, followed by increased urinary frequency in 60 (68.9%) patients, and urge-incontinence in 53 (60.9%), as shown in Summary Fig. More than half of the children reported nocturnal enuresis, including 61% of the girls and 52% of the boys. Twenty-three patients (25.6%) had a history of urinary tract infections. The mean age for acquisition of dryness during the day was 4.4 ± 1.9 years. Parents of 61 patients (70.1%) acknowledged that LUTS had a significant impact on the quality of life of their children.

DISCUSSION

A high prevalence of LUTS was confirmed with a significant negative impact on quality of life in a large population of children and adolescents with WBS. It was shown for the first time that the achievement of daytime bladder control is delayed in children with WBS. Although LUTS are not recognized as one of the leading features of the syndrome, it is believed that it should be considered as a significant characteristic of the clinical diagnosis of WBS.

CONCLUSIONS

LUTS are highly prevalent in children and adolescents with WBS and have a significant negative impact on patient's quality of life.

Molecular genetic analysis of 30 families with Joubert syndrome

Joubert syndrome (JS) is rare recessive disorders characterized by the combination of hypoplasia/aplasia of the cerebellar vermis, thickened and elongated superior cerebellar peduncles, and a deep interpeduncular fossa which is defined by neuroimaging and is termed the 'molar tooth sign'. JS is genetically highly heterogeneous, with at least 29 disease genes being involved. To further understand the genetic causes of JS, we performed whole-exome sequencing in 24 newly recruited JS families. Together with six previously reported families, we identified causative mutations in 25 out of 30 (24 + 6) families (83.3%). We identified eight mutated genes in 27 (21 + 6) Japanese families, TMEM67 (7/27, 25.9%) and CEP290 (6/27, 22.2%) were the most commonly mutated. Interestingly, 9 of 12 CEP290 disease alleles were c.6012-12T>A (75.0%), an allele that has not been reported in non-Japanese populations. Therefore c.6012-12T>A is a common allele in the Japanese population. Importantly, one Japanese and one Omani families carried compound biallelic mutations in two distinct genes (TMEM67/RPGRIP1L and TMEM138/BBS1, respectively). BBS1 is the causative gene in Bardet-Biedl syndrome. These concomitant mutations led to severe and/or complex clinical features in the patients, suggesting combined effects of different mutant genes.

Evaluation of measles-rubella vaccination for mothers in early puerperal phase

BACKGROUND

The postpartum period is an ideal opportunity to vaccinate mothers with inadequate immunity to vaccine-preventable diseases including measles and rubella.

METHODS

A prospective study of measles-rubella (MR) vaccination in the early puerperal phase was conducted in 171 mothers, who had insufficient antibody titers when screened for immunity to measles (≤ 1:4 on the neutralization test [NT]) or rubella (≤ 1:16 on the hemagglutination inhibition [HI] test) during pregnancy. To evaluate the efficacy of MR vaccination in the postpartum period, we determined their post-vaccination antibody titers and immune responses to vaccination, and investigated the association between these and their prolactin (PRL) levels and Th1/Th2 ratios at the time of vaccination. We also examined the passage of viral RNA and antigen into breast milk.

RESULTS

Of the 169 participants who completed the study schedule, 117 and 101 had low antibody titers against measles and rubella, respectively. In the measles-seronegative group, the antibody-positive rate was 87% on the NT assay, and the NT geometric mean antibody titer was 11.4 (95% confidence interval [CI], 10.0-13.0). In the rubella-seronegative group, the antibody-positive rate was 88% on the HI test assay, and the HI geometric mean antibody titer was 64.0 (95% CI, 53.9-76.0). There was no association between the post-vaccination antibody titers and the PRL levels or Th1/Th2 ratios at the time of vaccination. In the rubella-seronegative group, subjects with higher Th1/Th2 ratios showed higher rates of responsiveness than those with lower ratios (P=0.045). Although measles virus RNA was isolated from the breast milk of two vaccinated mothers, breastfeeding was not associated with clinical disease in any infants.

CONCLUSION

MR vaccination in the early puerperal phase is considered an effective way to prevent the diseases, regardless of the mother's immunological status and hormonal milieu.

Hepatitis B virus surface antibody titers in babies administered hepatitis B immune globulin both intravenously and intramuscularly after birth

OBJECTIVE

High rates of vertical transmission of hepatitis B virus (HBV) infection from carrier mothers to their babies are observed in hepatitis B e antigen (HBeAg)-positive mothers under the existing protocol. The current status suggests that the existing protocol may be insufficient for the prevention of mother-to-child transmission (MTCT) in HBeAg-positive mothers. To achieve complete prevention of HBV vertical transmission, we designed a protocol implementing intravenous administration along with ordinary intramuscular administration of HBV immune globulin (HBIG) to the baby after birth.

METHODS

We compared the HBV surface antibody (HBsAb) titer in babies who were simultaneously administered HBIG both intravenously and intramuscularly after birth with that in babies who received HBIG only intramuscularly.

RESULTS

The HBsAb titer rose rapidly after administration in the combined administration group, and the elevated titer was maintained for approximately 2 months. Although the antibody titer at the peak was nearly 6 times greater in the combined administration group than in the intramuscular administration group, the combined administration of HBIG did not have any effect on total IgG antibody levels in the bloodstream.

CONCLUSION

The combined protocol was demonstrated to be safe and superior to the protocol of only intramuscular HBIG administration with respect to rapid elevation of HBsAb in the bloodstream. It could be an effective method for the prevention of MTCT in HBeAg-positive mothers.

Measurement of oxidative stress in the follicular fluid of infertility patients with an endometrioma

PURPOSE

Follicular fluid (FF) might reflect the environment during follicle and oocyte growth, and an evaluation of oxidative stress in the FF might be useful in predicting oocyte quality. In order to measure the oxidative stress (OS) in the FF from a single follicle of patients with endometrioma (EM), we evaluated whether an EM might affect the environment of follicular growth.

METHODS

Between December 2011 and July 2013, 26 patients with a unilateral EM (EM group) and 29 without EM (control group) were enrolled in this study. The FF was obtained during the first puncture of follicular aspiration, and was stored at -30 °C until it was assayed. A Free Radical Elective Evaluator (WISMERLL, USA) was used to perform d-ROM and BAP tests to measure oxidative stress (U.CARR) and antioxidant power (μmol/L).

RESULTS

The d-ROM values in the EMC and control groups were 328.7 ± 97.8 and 414.9 ± 84.2, respectively, and the BAP values for the two groups were 2474.3 ± 432.0 and 2552.8 ± 435.58, respectively. These values were similar between the two groups (mean ± SD). The number of patients with a modified BAP/d-ROM ratio of <1.0 in the EM group was similar to that for the control group at 16 and 15, respectively (61.5 and 51.7 %).

CONCLUSIONS

The oxidative stress and antioxidant potential in the FF of the patients with unilateral EM showed values similar to those without an EM. Therefore, we concluded that EMs do not affect the environment for follicle growth during ART treatment.

Successful prevention of exacerbation of thrombocytopenia in a pregnant patient with idiopathic thrombocytopenic purpura by anticoagulation treatment

BACKGROUND

Corticosteroid or intravenous immunoglobulin is used in the management of idiopathic thrombocytopenic purpura during pregnancy.

CASE PRESENTATION

A patient with idiopathic thrombocytopenic purpura had a previous history of interrupted pregnancy due to severe thrombocytopenia, and was unresponsive to high doses of corticosteroids and intravenous immunoglobulin. Immediately following pregnancy, our patient had a marked elevation in plasma levels of fibrinogen degradation products, D-dimer, and platelet factor 4, with a decrease in platelets, suggesting platelet activation and thrombogenesis. Combined treatment with an anticoagulant agent could prevent exacerbation of thrombocytopenia throughout pregnancy. Although the underlying causes leading to the series in her pregnancy course were uncertain, there were notable serological abnormalities, such as weakly positive antinuclear antibody and anti-U1-RNP antibody.

CONCLUSION

When thrombocytopenia rapidly develops in patients with idiopathic thrombocytopenic purpura immediately following pregnancy, the possibility of a thrombogenic state and differential diagnosis, including antiphospholipid syndrome and collagen vascular disease, should be considered. Treatment with an anticoagulant agent might then be appropriate.

Influenza vaccination during pregnancy and its usefulness to mothers and their young infants

The current approach to protecting pregnant women from influenza infection and serious influenza-related complications is vaccination. It is, therefore, critical to evaluate the vaccine's safety, immunogenicity, and protection efficacy during pregnancy. However, because it is affected by previous influenza vaccination or infection, the efficacy of the seasonal trivalent inactivated influenza vaccine is difficult to evaluate in pregnant women. The A/H1N1pdm pandemic in 2009 provided us with the opportunity to evaluate the immunogenicity of the influenza vaccine unaffected by previous vaccinations or infections. Vaccination with inactivated influenza virus during pregnancy elicited neutralizing antibody titers that were sufficient and comparable to those of naturally infected individuals. Furthermore, post-pandemic surveys provided a wealth of definitive information on vaccine efficacy and safety. In addition, transplacental transfer of antibodies following vaccination protected newborn infants against influenza infection. With reports showing the effectiveness of influenza vaccine during pregnancy, it is suggested that influenza vaccination benefits both mothers and their young infants.

Changes in the prevalence of the measles, rubella, varicella-zoster, and mumps virus antibody titers in Japanese pregnant women

In the present study, immunity against infectious diseases, which are capable of influencing both the mother and fetus during pregnancy and the infant in the postnatal period, were assessed in pregnant women to elucidate the necessity of vaccination during the childbearing age. It was determined that there was a trend of increases in the proportion of patients that had low antibody titers observed at a young age. Overall, after adjusting for age, low antibody titers of measles (≤ 4 via the neutralization test [NT]), rubella (≤ 16 via the hemagglutination inhibition [HI]), and varicella and mumps (plus minus or negative on the enzyme-linked immunosorbent assay [EIA]) indicated that the rates of necessity for vaccination against measles, rubella, varicella, and mumps were 27.6%, 16.1%, 3.9%, and 23.8%, respectively. In Japan, acquired immunity for measles, rubella, and mumps was dependent on vaccination, whereas acquired immunity for varicella was dependent on natural infection. We recommend that women be vaccinated after delivery, as these vaccines are live, and thereby, are contraindicated during pregnancy.

Successful completion of pregnancy in a woman with chronic granulomatous disease

Chronic granulomatous disease (CGD) used to be a fatal illness of childhood and patients rarely survived past the first decade. Although antimicrobial prophylaxis has dramatically reduced mortality and morbidity in recent years, CGD remains a life-threatening condition. We present the successful obstetric course of a patient with CGD.

[Influenza vaccination safety during pregnancy]

Increased morbidity and mortality in pregnant women were reported following three major historical influenza pandemics. To prevent influenza infection during pregnancy, the Centers for Disease Control (CDC) and the American College of Obstetricians and Gynecologists (ACOG) recommend that all pregnant women and those intending to get pregnant during the influenza season be vaccinated. In 2004, they advised expanding vaccination guidelines from the second and third trimester to all three trimesters. We evaluated the safety of influenza vaccination during pregnancy in 182 subjects from 2007-2009. No adverse events were seen in pregnancy or fetal medical condition regardless of the pregnancy stage at which vaccine was administered.

Vitamin B6 deficiency and anemia in pregnancy

Iron deficiency is the most common cause of anemia in pregnancy. Pregnant women with anemia are, in general, exclusively treated with iron supplementation. We observed that several pregnant women with anemia who were nonresponsive to iron supplementation also had vitamin B6 deficiency, and that anemia in these cases improved with the administration of vitamin B6. Our prospective study in healthy pregnant women showed that blood levels of iron, ferritin and vitamin B6, in particular, fell to the lower limit of the nonpregnant reference range by the third trimester. We conclude that it is important to take into account the deficiency of vitamin B6 besides iron in the evaluation of anemia during pregnancy.

Bacteria-associated haemophagocytic syndrome and septic pulmonary embolism caused by Burkholderia cepacia complex in a woman with chronic granulomatous disease

Chronic granulomatous disease (CGD) is a primary immunodeficiency characterized by recurrent infections with certain types of bacteria and fungi. Presented herein is the case of a 29 year old woman with CGD who suffered from bacteria-associated haemophagocytic syndrome and a septic pulmonary embolism following a uterine infection and sepsis, caused by Burkholderia cepacia complex.

An acromegalic woman first diagnosed in pregnancy

BACKGROUND

Reports of pregnancy in acromegalic women are uncommon, numbering less than 100, in which a case of acromegaly first diagnosed in pregnancy is rare.

CASE

A 40-year-old woman in 19-week gestation was presented with a 10-week history of photophobia and visual disturbance. Elevated growth hormone (GH) levels in the serum, an inadequate suppression of GH secretion with glucose administration and a mass image in the pituitary fossa confirmed the diagnosis of acromegaly. We initiated dopamine agonist treatment, bromocriptine at a weekly dose of 1 mg at 27-week gestation. Ten weeks after the start of the bromocriptine treatment, the GH levels gradually decreased to a normal range, and visual symptoms were improved. Enlargement of the tumor was not observed throughout the pregnancy and the patient delivered a healthy infant following an eventful pregnancy. At 3 weeks after delivery, she underwent a transsphenoidal resection of a pituitary adenoma.

CONCLUSION

Pregnancy may lead to pituitary tumor growth and increase the risk of developing loss of vision. It is important to take pituitary tumors into consideration when encountering gravida with visual disturbance.

Temporomandibular joint internal derangement in mandibular asymmetry. What is the relationship?

The purpose of this study was to clarify the contributing factors and their influences on temporomandibular joint internal derangement (TMJ ID) symptoms in subjects with mandibular asymmetry. Postero-anterior (PA) cephalograms of 187 pre-orthodontic treatment subjects (aged 18-45 years, mean 23.9 years) were used to investigate the inclination of the frontal occlusal (FOP) and frontal mandibular (FMP) planes to determine vertical asymmetry. Mandibular dental midline shift (DMS) and mandibular midline shift (MMS) were studied to determine transverse asymmetry. The degree of asymmetry was analysed in conjunction with the results from self-administered TMJ ID history forms. A prevalence of TMJ ID was most related to the inclination of the FMP (P < 0.01), with the symptoms being notably higher when the cant was greater than 3 degrees. The symptomatic side was related only to the inclination of the FOP and FMP. Symptoms confined to the ipsilateral side were primarily found in subjects with mild asymmetry, whereas symptoms on both sides and those on the contralateral side were greater in those with moderate and severe asymmetry, respectively. No significant correlation was found for DMS and MMS. The results suggest that the degree of asymmetry in the vertical dimension is significantly correlated with TMJ ID symptoms.

Effect of biomechanical disturbance of the temporomandibular joint on the prevalence of internal derangement in mandibular asymmetry

The aim of the present study was to elucidate the relationship between biomechanical changes of the temporomandibular joint (TMJ) and internal derangement (ID) symptoms in mandibular asymmetry. Posteroanterior cephalograms (PA) of 140 patients with TMJ ID associated with mandibular asymmetry were used to investigate the inclination of the frontal occlusal plane (FOP), and were analysed in conjunction with the results of a report providing information on ID symptoms. A three-dimensional (3D) finite element model (FEM) of the entire mandible was created to investigate the distribution of TMJ forces during clenching. The inclination of the FOP was modified to simulate various degrees of vertical asymmetry. The stresses on the TMJ on the ipsilateral and contralateral sides were analysed and their values were compared with those of the standard model. The results showed that the symptomatic sides were significantly related to the degree of inclination of the FOP. Increasing its angulation resulted in a decrease of the symptoms on the ipsilateral side and an increase of those on the contralateral side. The analysis showed that stress-distribution patterns and overall stresses of the articular disc were influenced by the angulation of inclination of the FOP. These mechanical changes exhibited a distinct relationship with the prevalence of ID in the patients. These results suggest that disturbances in the stresses either in amount or direction due to occlusal inclination can be responsible for ID. Therefore, an attempt to establish a flat occlusal plane is an important orthodontic treatment objective in maintaining the normal health and structure of the TMJ.

Herpes simplex virus 2-associated hemophagocytic lymphohistiocytosis in a pregnant patient

BACKGROUND

Uncontrolled phagocytosis of normal hemopoietic cells by activated histiocytes in bone marrow is collectively referred to as hemophagocytic lymphohistiocytosis.

CASE

We present a case of hemophagocytic lymphohistiocytosis associated with herpes simplex virus-2 infection in the second trimester. Cytopenia, elevated C-reactive protein, ferritin, soluble interleukin-2 receptor, and interleukin-6 with high-grade fever were observed following genital herpes infection, and the existence of hemophagocytes in bone marrow confirmed the diagnosis of hemophagocytic lymphohistiocytosis. Corticosteroid therapy failed to arrest the hemophagocytic process, whereas cyclosporin A was effective. The patient delivered a healthy infant after remission and has not experienced exacerbation.

CONCLUSION

It is often important to take into consideration hemophagocytic lymphohistiocytosis when encountering cytopenia with high-grade fever. Cyclosporin A was a safe and available strategy for this corticosteroid-resistant case.

Urinary leukotriene E4 in Henoch-Schonlein purpura

BACKGROUND

Children with Henoch-Schonlein purpura (HSP) occasionally have allergic disease. We have previously shown that pranlukast hydrate was effective for purpura in HSP. Pranlukast hydrate is a leukotriene (LT) receptor antagonist; therefore, it is likely that LTs take part in the cause of HSP. Urinary leukotriene E4 (LTE4u) levels are a useful index of whole-body cysteinyl LT production in vivo. In this study, LTE4u was examined in children with HSP.

OBJECTIVE

The purpose of this study was to examine the relation between the level of LTE4u and the cause of HSP.

METHODS

Eighteen HSP children (six boys and 12 girls) and six healthy children were enrolled.

RESULTS

LTE4u levels in patients with HSP were significantly higher (P< 0.05) at the onset than those in healthy children. Four weeks therapy with pranlukast hydrate lowers LTE4u levels in patients with HSP (P< 0.05). There were no differences in LTE4u between the group of HSP patients with purpura nephritis and the group of HSP patients without purpura nephritis.

CONCLUSION

These results indicate that csyteinyl LTs may play a role in the pathophysiology of purpura in HSP.

Dynamic analysis for clarifying occlusal force transmission during orthodontic archwire application: difference between ISW and stainless steel wire

The purpose of our study was to utilize the dynamic finite element analysis to clarify the difference between Improved Super-elastic Ti-Ni alloy Wire (ISW) and Stainless Steel Wire (SSW) on occlusal force transmission during orthodontic treatment. ABAQUS/Standard was used to analyze three finite models over a 30-ms period: ISW, SSW, and wireless models; which consisting of premolar, molar, periodontal ligament (PDL), and alveolar bone. Wire model was established by beam element. A Joint C, which exhibits viscoelasticity to buffer occlusal force, was applied between the wire and bracket. The load was applied on the occlusal surface. At load withdrawal point, the average amounts of von Mises stress on PDL in three models were of the same value. However as time progressed, the stress in wireless model became higher than ISW and SSW models. In contrast, as time progressed further, the stress in SSW model became higher than the other two models and maintained its higher level until the end of analysis. Results showed that high damping capacity of ISW had an ability to buffer the transmission of occlusal force to the PDL. Besides, the dynamic analysis demonstrated an advantage to investigate the stress alterative response between models versus time period.

The interrelationship between bolus breakdown, mandibular first molar displacement and jaw movement during mastication

The purpose of this study was to clarify the interrelationship between food bolus breakdown, mandibular first molar displacement and jaw movement during mastication. Finite element models were constructed of the maxillary first molar crown, the mandibular first molar consisting of crown, root, periodontal ligament and alveolar bone, as well as the food bolus were constructed. Based on the actual measurement of the jaw movement pattern and the characteristics of food bolus, the patterns of mandibular first molar displacement and bolus breakdown on time course in the progress of mastication were simulated, to investigate the biomechanical significance of tooth displacement and jaw movement during mastication, using finite element non-linear dynamic analysis. The results showed that the patterns of tooth displacement and jaw movement and characteristics of food bolus changed with an interrelationship to each other as mastication progressed. Particularly at the initial phase, it was suggested that the patterns of mandibular first molar displacement and jaw movement worked inter-dependently to accomplish an efficient hard-bolus breakdown.

Inhibitory effect of catechin against the superantigen staphylococcal enterotoxin B (SEB)

Staphylococcal superantigens (SsAgs) have gained attention as one of the factors aggravating atopic dermatitis (AD) and several potential mechanisms of AD aggravation by SsAgs have been reported. Tea catechin has been found to have many unique antimicrobiological activities such as antibacterial, antiviral, antifungal and antitoxic effects. In the present study, we investigated the inhibitory effect of the green tea catechin extract, Polyphenon, and (-)-epigallocatechin gallate (EGCg) on staphylococcal enterotoxin B (SEB) and its mechanisms of action, and we also discuss the possibility of therapeutic benefits for AD patients of tea catechin. Polyphenon inhibited the lethal toxicity of SEB and the SEB-induced production of TNF-alpha, IFN-gamma and IL-4 following its intraperitoneal administration to BALB/c mice. Although Polyphenon is composed of several isomers among which EGCg is approximately 50% of the total, we considered that most of the inhibitory effect of Polyphenon in mice could be attributed to EGCg. EGCg was immediately bound to SEB molecules and neutralized SEB in a dose- and incubation time-dependent manner without molecular weight alteration of the SEB molecule. Furthermore, EGCg inhibited SEB-induced TNF-alpha and IFN- gamma production and IL-2, IFN-gamma, IL-10 and IL-12 p40 mRNA expression in human PBMCs from normal donors in a dose-dependent manner. Inhibition of SsAg-induced T-cell activation by catechin was observed in both in vivo and in vitro studies, suggesting that catechin may be useful in the treatment of AD.

Relationship between the flow of bolus and occlusal condition during mastication--computer simulation based on the measurement of characteristics of the bolus

The purpose of the present study was to clarify the relationship between the flow of a bolus and occlusal condition during mastication. First, the characteristics of a bolus under mastication was measured in subjects having different occlusal conditions. Secondly, the flow of a bolus between the upper and lower first molars under mastication was simulated using finite element non-linear dynamic analysis. Measurement of the elasticity of the bolus clarified the phenomenon of its communition. The measurement of the viscosity of the bolus clarified the phenomenon of its mixing with saliva. In addition, a relationship between the elasticity and the viscosity of the bolus at the point of just before swallowing was investigated. The flow of the bolus under mastication was revealed to vary according to the occlusal condition. These results suggest a close relationship between the occlusal condition, the flow of the bolus and its characteristics.

Immunomodulatory effect of gold sodium thiomalate on murine acquired immunodeficiency syndrome

Induction of IL-2 production and increased expression of CD25 were observed in C57BL/10 mice after weekly treatment with gold sodium thiomalate (GST). LP-BM5 murine leukemia virus (MuLV) infected mice treated with GST survived longer, had less cervical lymph node swelling, lower spleen weight, and fewer abnormalities in the expression of the cell surface markers, CD4, CD8a and CD45R/B220 on spleen cells than those that were not treated with GST. Thus, GST treatment may be beneficial through a decrease in disease progression via IL-2 induction in MuLV infected mice. This may have application in human immunodeficiency virus-infected individuals.

Tyrosine phosphorylation of the linker for activator of T cells in mast cells by stimulation with the high affinity IgE receptor

Aggregation of the high affinity IgE receptors (FcepsilonRI) on basophils and mast cells, members of the immune receptor family, initiates a cascade of events that results in the release of inflammatory mediators. This pathway involves the activation of several protein-tyrosine kinases, including Lyn, Syk, Btk, and Fak that induce the tyrosine phosphorylation of various proteins. The linker for activation of T cells (LAT), was originally found as a ZAP-70 tyrosine kinase substrate that linked T cell receptors to cellular activation, and was expressed in T cells, NK cells and mast cells. Here we show that LAT expressed in the RBL-2H3 rat mast cell line is tyrosine-phosphorylated after aggregation of FcepsilonRI. The tyrosine phosphorylation of the LAT was dramatically enhanced after receptor aggregation. Furthermore, a tyrosine-phosphorylated 80-kDa protein associated with LAT transiently after receptor aggregation. GST fusion proteins containing parts of PLCgamma or PI3 kinase can bind LAT. These results suggest that LAT plays an important role not only in T cell, but also in mast cell activation, and that the association among these signaling molecules is critical for FcepsilonRI-mediated intracellular signal transduction in mast cells.

The inhibitory effect of anti-allergic agent suplatast tosilate (IPD-1151T) on methacholine- and allergen-induced bronchoconstriction in sensitized mice. asakazu@med.showa-u.dc.jp

The influence of an anti-allergic agent, suplatast tosilate (IPD-1151T; (+/-)-[2-[4-(3-ethoxy-2-hydroxypropoxy)phenyl-carbamoyl]-ethyl] dimethylsulfonium p-toluenesulfonate) on allergic bronchoconstriction induced by allergen and methacholine (MCh) were examined in mice. BALB/c mice were sensitized by intraperitoneal injection of dinitrophenylated-keyhole limpet hemocyanin (DNP-KLH) mixed with A1(OH)3 (DNP-KLH). IPD-1151T was administered orally once a day for either 5 or 14 days in doses of 10, 30 or 100 mg/kg. Bronchoconstriction was measured 24h after the final drug administration. IPD-1151T inhibited both antigen- and MCh-mediated bronchoconstriction in actively sensitized mice. The inhibition induced was closely related to the dose and frequency of oral administration of the agent. We also examined the effect of IPD-1151T on IgE production in response to DNP-KLH immunization. IPD-1151T inhibited dose-dependently both total and specific IgE concentrations in serum prepared from mice 15 days after immunization. These results strongly indicate that IPD-1151T inhibits IgE production in vivo and results in attenuating effect on bronchoconstriction.

Energy-based re-evaluation of Angle's class I molar relationship

The energy used to break down food was calculated in Angle Class I and rigid interdigitation, as well as in various malocclusions using a computer simulation. As a result, the energy applied to the food was the highest in Angle's Class I molar relationship and rigid interdigitation, with a simple pattern of masticatory movement. This relationship also tended to produce maximum efficiency in the posterior teeth, including the premolars. Furthermore, energy decreased with the degree of malocclusion. Thus, we were able to provide an alternative definition of Angle's Class I molar relationship and rigid interdigitation. In addition, the extent of malocclusion could be evaluated quantitatively.

Energy-based evaluation of occlusion

The purpose of this study was to establish an index for evaluating occlusal conditions using energy levels. For this purpose, first, the movement of mastication under five occlusal conditions in which the positional relationship varied mesiodistally was simulated and the energy applied to the food being masticated was calculated, based on theoretical values of computing mechanics using finite element static analysis. As a model experiment, the energy generated under each occlusal condition was then measured using the electrical output from an occlusion pressure sensor composed of pressure-sensitive rubber. By comparing the theoretical values of computing mechanics and the measured values, the changes in the energy level under occlusal conditions were consistent with the trends, and the maximum value of the energy was obtained under the occlusal condition of Angle Class I and consisting of rigid interdigitation. In conclusion, our results demonstrated that occlusal conditions can be evaluated using the energy level as an index.

[The availability of personality traits in the hierarchical structure: an exploration of the "basic level"]

Personality traits have a structure that is hierarchically organized in terms of trait abstractness. Which level of the hierarchy is most available to the person perceiver? We started out with four levels, and tried to determine which was most available and therefore became the "basic level", as in the Rosch, Mervis, Gray, Johnson, and Boyes-Braem's natural categories (1976). Two methods were employed. First, rating of trait descriptiveness showed that information effectiveness was relatively high at the second level from the top. Second, subjects preferred the same level when they described target persons. These results suggested that a "basic level" indeed existed in the hierarchy of personality traits. However, social desirability of traits and who the target person was also affected the results. Implications are discussed about theories of cognitive style, especially cognitive complexity, which assume the generality of our cognitive system and have been in confusion with contradictory findings.

[A study of hierarchical structure in personality traits: asymmetry judgments in category breadth and class inclusion]

Many personality theorists postulate a hierarchical structure in trait words. However, most evidences are indirect, mainly because the theorists rely on factor-analytic methods. Assuming a global structure, the factor approach is not necessarily adequate to investigate concrete relationship among trait words. In this study, we used two direct measures to study the hierarchical structure: direct comparison of breadth and asymmetry class-inclusion judgment on trait concepts. Results of three experiments in general confirmed robustness of the hierarchical structure in the domain of personality traits. Traits were organized in the structure at several different levels of abstractness. But the structure was fuzzy in nature, unlike the taxonomy in biology. It was also found that inter-relations among traits could vary considerably from individual to individual. Cognitive complexity may be one of the variables that explain such an individual difference.

[High accuracy measuring device for dental cast--using device with flat laser beam]

A new system has been developed for measuring the surface morphology of the occlusal material. The main characteristic of the system is utilizing a flat laser beam to produce high accuracy measuring and to enable measuring 200 points at the same time on a line of 30 mm in length. It takes 8 to 10 minutes to digitize the whole morphology of a dental cast. The system has a central processing unit that assembles a series of digitized points into a data file of the dental morphology. It is also able to recognize the graphical image of the numerically reconstructed morphology on the CRT. Application of this measuring system enables the approach to the qualitative and quantitative evaluation of the spatial relationship between the opposing teeth at near the occlusal contact.