Urinary excretion of thyroid hormone in CKD patients: a proof-of-concept of nephrogenic hypothyroidism

PURPOSE

Patients with chronic kidney disease (CKD) complicated by hypothyroidism exhibit a higher prevalence of urine protein than that in the general population. This study was aimed at investigating thyroid hormones and thyroid hormone-binding proteins excreted in urine to elucidate the urine protein-associated underlying mechanisms of hypothyroidism.

METHODS

Between November 2016 and August 2018, thyroid function (serum free T3 [sFT3], free T4 [sFT4], and thyroid-stimulating hormone [sTSH]), kidney function (estimated glomerular filtration rate [eGFR]), thyroid antibodies and albumin (Alb) were evaluated in 99 Japanese CKD patients with proteinuria at our outpatient clinic. A urine examination was also performed to assess the following parameters: total T3, total T4, TSH, Alb, preAlb, thyroid-binding globulin, and protein.

RESULTS

The median patient age at study recruitment was 60 years; 50 patients (50.5%) were male. The median eGFR and Alb level were 20.3 ml/min/1.73 m2 and 3.8 g/dL, respectively. 21 patients (21.2%) were diagnosed with nephrotic syndrome (NS). The median sFT3, sFT4, and sTSH levels were within normal limits. Approximately 70% of the patients had thyroid dysfunction and 51.5% had overt or subclinical hypothyroidism without predominantly antibody positive. Regarding NS and non-NS patients, age and Alb were significantly different between these groups, while sex and eGFR were not significant, but the urinary T4 and TSH levels were higher in the NS group; thus, more severe hypothyroid.

CONCLUSION

We found a significant association between hypothyroidism and NS regardless of sex and antibodies. Urinary loss of thyroid hormones must be a factor influencing hypothyroidism independent of autoimmunity.

Fibroblast growth factor 23-Klotho and mineral metabolism in the first year after pediatric kidney transplantation: A single-center prospective study

BACKGROUND

The role of fibroblast growth factor 23 (FGF23) levels in mineral metabolism before and after kidney transplantation in pediatric patients is poorly understood.

METHODS

We prospectively evaluated 24 patients under 18 years of age (4.5 [3.3-9.8] years) who underwent living kidney transplantation between July 2016 and March 2018, and measured intact FGF23 and serum αKlotho levels, and other parameters of mineral metabolism before and after transplantation (Day 7, 1 and 4 months, and 1 year). Relationships between parameters were examined by linear analysis.

RESULTS

FGF23 level was 440.8 [63.4-5916.3] pg/ml pre-transplant and decreased significantly to 37.1 [16.0-71.5] pg/ml at Day 7 post-transplant (-91.6%, p < .001). Thereafter, it remained at normal levels until 1 year. αKlotho level was 785 [568-1292] pg/ml pre-transplant and remained low at Day 7 and 1 month post-transplant, with an increasing trend at 4 months. Post-transplant phosphorus levels were significantly decreased compared with pre-transplant, with a lowest level of 1.7 [1.3-2.9] mg/dl, -5.7 [-6.8, -3.8] SD at Day 4, followed by gradual recovery. Phosphorus levels and the ratio of tubular maximum phosphate reabsorption were significantly and negatively associated with pre-transplant FGF23 until 4 months of post-transplant. Pre-transplant αKlotho was negatively associated with pre-transplant FGF23 but not FGF23 or other parameters after transplantation.

CONCLUSION

FGF23 in pediatric kidney transplant patients decreased rapidly after transplantation and associated with post-transplant hypophosphatemia and increased phosphorus excretion. Post-transplant αKlotho was low early post-transplant but tended to increase subsequently. Post-transplant αKlotho was unaffected by pre-transplant FGF23 or other factors, suggesting pre-transplant chronic kidney disease status has no effect.

Prevalence of hypothyroidism in Japanese chronic kidney disease patients

Background

Major symptoms of progressive chronic kidney disease (CKD) are similar to those of hypothyroidism. Hidden symptoms of hypothyroidism underlying CKD are often observed in clinical practice. This study aimed to ascertain the frequency of hypothyroidism complicated by CKD, and to analyze factors impacting thyroid function.

Methods

During the period from April 2012 through October 2016, 510 CKD patients at our outpatient clinic were measured thyroid and kidney function for diagnosing hypothyroidism (overt hypothyroidism, OH; subclinical hypothyroidism, SH; non-thyroidal illness, NTI) and evaluating the stage of CKD. All patients were over 15 years of age.

Results

There were significant differences in age, estimated glomerular filtration rate (eGFR), urinary protein (UP), and serum albumin (Alb) among patients with OH, SH, and NTI compared to the normal group in univariate and multivariate analyses. UP showed the highest odds ratio of OH, SH, and NTI but no differences were recognized in gender in each group. Frequency distribution showed that the prevalence of thyroid dysfunction was greater among more severe stage of CKD with higher amount of UP. OH and SH did not show high positive ratio of anti-thyroglobulin antibody (TgAb) and anti-thyroid peroxidase antibody (TPOAb). NTI and normal subjects showed higher positive ratio as 50.0% and 42.9% of TgAb and TPOAb than OH and SH.

Conclusions

Hypothyroidism complicated by CKD exhibited a high prevalence. Age, eGFR, UP, and serum Alb were related to the prevalence of hypothyroidism, whereas gender was not and this was contradicted to the prevalence of hypothyroidism in general population. The prevalence of OH and SH was higher among patients with higher stage of CKD with increased UP. Hypothyroidism complicated by CKD may involve different onset mechanisms unrelated to antithyroid antibodies (ATAb). In CKD patients, assessments of OH and SH, as well as NTI, are needed for proper diagnosis.

Changes in the fluid volume balance between intra- and extracellular water in a sample of Japanese adults aged 15–88 yr old: a cross-sectional study

The fluid volume balance between intracellular water (ICW) and extracellular water (ECW) gradually changes with age and various medical conditions. Comprehension of these physiological changes would aid in clinical decision-making related to body fluid assessments. A total of 1,992 individuals (753 men and 1,239 women) aged ≥15 yr included in this study had their body composition measurements performed at training gyms in 2014. We developed a regression formula to assess the association of age with the ratio of ECW to ICW in these subjects. The mean ages of male and female subjects were 51.2 ± 15.2 and 57.4 ± 15.2 yr, and their mean body mass indexes were 23.4 ± 3.3 and 21.1 ± 2.8 kg/m2, respectively. The total fluid volumes of male and female subjects were 39.6 ± 4.9 and 27.7 ± 3.0 liters, whereas the percent body fat mass per kilogram of body weight were 19 and 26%, respectively. The ECW-to-ICW ratio increased with age because of the steeper decrease in the ICW content than in the ECW content, especially after the age of 70 yr. The regression formulas used for calculating the age-adjusted ECW/ICW ratio were as follows: 0.5857 + 7.4334 × 10−6 × (age)2 in men and 0.6062 + 5.5775 × 10−6 × (age)2 in women. In conclusion, the fluid imbalance between ICW and ECW contents is driven by decreased cell volume associated with aging and muscle attenuation. Therefore, our proposed formula may serve as a useful assessment tool for the calculation of body fluid composition.

Placement of self-expandable metallic stents for tracheal stenosis secondary to thyroid cancer

The indications and suitable approaches for treating upper airway obstruction secondary to thyroid cancer are controversial. Patients with thyroid cancer generally have a good prognosis, but airway stenosis and vocal cord paralysis are not uncommon. Subglottic airway stenting may be challenging, due to stent migration, granulation tissue formation and supraglottic stenosis. In this study, we evaluated the application of covered self-expandable metallic stents to relieve upper airway obstruction. This was a retrospective study of 5 patients with airway stenosis due to thyroid cancer treated in 2009 and 2010. Immediate airway enlargement was achieved in 3 patients with stenosis at the middle mediastinum. Gradual enlargement over 2 months was observed in the remaining 2 patients with stenosis at the cervical level. The performance status was improved in all 5 patients, including a case with anaplastic carcinoma. The follow-up averaged 13 months (range, 8-27 months). Granulation tissue developed at both ends of the stent in 3 patients, sputum was retained in 2 cases and bacterial colonization was detected in all 5 cases. No stent migration was reported. Additional tracheostomy was required in 2 patients, due to proximal tumor growth or progressive bilateral vocal cord paralysis after 10 and 6 months, respectively. In conclusion, stenting for central airway stenosis secondary to thyroid cancer may be beneficial, even in patients with anaplastic carcinoma. Long-term regular bronchoscopic follow-up is required to monitor complications, as patients with thyroid cancer are at high risk of granulation tissue formation, sputum retention and bacterial colonization.

Ciliated muconodular papillary tumor of the lung: a newly defined low-grade malignant tumor with CT findings reminiscent of adenocarcinoma

A ciliated muconodular papillary tumor has been reported to be a peripheral low-grade malignant tumor, consisting of ciliated columnar cells and goblet cells with basaloid cell proliferation. Although ciliated muconodular papillary tumors have not yet been classified according to the World Health Organization classification, they can pose diagnostic and therapeutic problems. Here we report a resected case of ciliated muconodular papillary tumor with computed tomography findings reminiscent of adenocarcinoma, showing a small irregular nodule adjacent to the intersegment pulmonary vein. There was no uptake of F-18 fluorodeoxyglucose positron emission tomography. The patient underwent surgical resection, and a lobectomy was performed because intraoperative needle biopsy suggested neoplastic proliferation. No EGFR mutations were detected. No recurrence was noted during 24-month follow-up after lobectomy.

The relation of initial methimazole dose to the incidence of methimazole-induced agranulocytosis in patients with Graves' disease

The relation between the incidence of methimazole (methylmercaptoimidazole; MMI)-induced agranulocytosis and initial MMI dose was evaluated in a group of 514 patients with Graves' disease who were treated between 1995 and 2005. One hundred and forty-six (28.40%) patients had received an initial dose of 30 mg MMI and 277 (53.89%) patients had been treated with 15 mg MMI. Nine patients (1.75%) developed agranulocytosis due to MMI treatment. Six (4.11%) of 146 patients who received an initial dose of 30 mg MMI, two (4.54%) of 44 patients given an initial dose of 20 mg MMI, and one (0.36%) of 277 patients given an initial dose of 15 mg MMI developed agranulocytosis. There was a statistically significant difference in agranulocytosis incidence between patients receiving an initial dose of 30 mg MMI and those who received an initial dose of 15 mg. Although 8 (4.10%) of 195 patients in the high-dose group (20 mg or higher) developed agranulocytosis, only 1 (0.31%) of 319 patients in the low-dose group (15 mg or lower) did. In conclusion, the incidence of agranulocytosis with low-dose MMI therapy was ten times lower than that of the high-dose regimen.

Simple underlay myringoplasty

OBJECTIVE

To introduce simple underlay myringoplasty which is widely performed in Japan.

PATIENTS

391 ears with perforated eardrum underwent simple underlay myringoplasty from 2000 to 2004, and which were followed up for more than six months after surgery.

METHODS

After removing the margin of the perforation by a transcanal approach under local anaesthesia, a connective tissue graft was inserted through the perforation and lifted to contact the edge. Fibrin glue was dropped on the contact area. There was no packing in the canal or in the middle-ear cavity. If the perforation remained, re-closure was attempted using the patient's frozen tissue.

RESULTS

The rate of closure after the initial attempt was 304/391 (77.7 per cent), and that after re-closure for unsuccessful cases was 70/87 (80.5 per cent). The overall rate was 374/391 (95.7 per cent). There were no serious complications such as sensorineural hearing loss.

CONCLUSIONS

Simple underlay myringoplasty is a simple and minimally invasive procedure employing fibrin glue and has led to a high closure rate of the eardrum.

Mutation at codon 130 in hepatitis B virus (HBV) core region increases markedly during acute exacerbation of hepatitis in chronic HBV carriers

Mutations within T-cell or B-cell epitopes are suggested to have some influence on the clinical course of chronic hepatitis B virus (HBV) infection. To investigate the relationship between liver cell injury and heterogeneity of the HBV core gene, we focused on the sequence of codon 130, which is located on both T- and B-cell epitopes, and serially analyzed the proportion of mutant virus (core130Thr) to wild-type virus (core130Pro) during the exacerbation of chronic hepatitis B. Sera obtained serially from five HBV carriers who had exacerbation of hepatitis, and three asymptomatic HBV carriers (ASCs) with persistently normal serum aminotransferase (ALT) values were studied, using the restriction fragment length polymorphism (RFLP) method. Core130Pro predominated in the sera in the remission state, but core130Thr increased markedly in parallel with ALT elevation and decreased again after the ALT peak, followed by the predominance of core130Pro, in all the five patients. In one patient, the ratio of core130Thr/core130Pro (Thr/Pro) was more than 70% at the ALT peak. On the other hand, in sera from the three ASCs core130Pro always predominated, and no divergence was identified in the ratio of Thr/Pro. Our data suggest that codon 130 is one of the most important immunogenic regions in the HBV core gene and that elevation of Thr/Pro could be the result of immune selection.

[Neuroimaging findings of hemiconvulsions, hemiplegia, epilepsy (HHE) syndrome]

A 32-year-old man with hemiconvulsions, hemiplegia, epilepsy (HHE) syndrome is described. He was well developed with a normal pregnancy and delivery, but at age 10 months, he had status epilepticus during a febrile illness. Thereafter, he was noted to have left hemiparesis and mental retardation with recurrent hemiconvulsions. Magnetic resonance (MR) images showed atrophy and degeneration of the right cerebral cortex and white matter, homolateral thalamus, caudate nucleus, and hippocampus, with hyperintensities in both T2-weighted (TR/2200, TE/90) and proton (TR/2200, TE/30) images. There were also slight bilateral cerebellar atrophies. Quantitative single photon emission computed tomographic (SPECT) images using technetium-99m-ethyl cysteinate dimer (99mTc-ECD) revealed markedly reduced cerebral blood flow (CBF) in the right cerebral hemisphere, homolateral thalamus, caudate nucleus and bilateral cerebellum. Bilateral putamen and the medial occipital lobe showed normal findings on MR images and normal regional CBF in SPECT images. We suppose these selective neuronal injures in this case of HHE syndrome will be mainly due to histotoxic factors in epileptic brain damage.

Sound localization for a virtual sound source in cases of chronic otitis media

Sound localization in subjects with chronic otitis media (COM) was examined before and soon after ear surgery by means of virtual sound presented by headphones, sound being synthesized based on the head-related transfer functions (HRTFs) in a normal subject. The localization ability in COM patients was usually worse than that in normal subjects, but was better than expected when compared with cases of acute loss. On the other hand, the effects of hearing improvement on localization ability observed in COM patients were smaller than those of simulated acute hearing loss achieved by earplugs in normal subjects. This seems to suggest that the localization cues in patients with chronic hearing loss are different from those under normal conditions.

Serum androgen levels in hyperthyroid women

Thyroid hormone is known to affect androgen metabolism, however, there are few studies in which alterations of androgen metabolism are simultaneously examined in patients with clinical thyroid disorders. In this study, we investigated the alterations of thyroid hormone and androgens before and during treatment in patients with hyperthyroidism. Fifteen female patients with hyperthyroidism due to Graves' disease were studied. From these patients, blood samples were obtained before treatment and at 1 month (M), 2M, 3M, 4M and 6M after beginning of treatment. Concentrations of free T4(FT4), free T3(FT3), testosterone (T), androstenedione (delta 4A), dihydrotestosterone (DHT), 5 alpha-androstane-3 alpha, 17 beta-diol(3 alpha-diol) and androsterone (AD) and sex hormone binding globulin (SHBG) were measured by radioimmunoassays (RIAs) or immunoradiometric assay (IRMA). As normal controls, ten healthy women were also studied. Before treatment concentrations of DHT (mean +/- SD: 3.35 +/- 0.78 nmol/L), 3 alpha-diol (0.78 +/- 0.11 nmol/L), AD (6.73 +/- 0.64 nmol/L) and SHBG (184.9 +/- 68.1 nmol/L) were significantly elevated compared with those of normal controls. T and delta 4A levels were not significantly different from normal values. DHT/T ratio indicating 5 alpha-reductase activity was 4.62 +/- 2.55 and significantly higher than that in normal controls. At 2 months after beginning of treatment with anti-thyroid drugs, thyroid function (FT4 and FT3) became normal and at 3 months after beginning of treatment, DHT, 3 alpha-diol, AD and DHT/T ratio decreased to normal range. SHBG level was gradually decreased, however still higher than that of the normal control group at 6 months after beginning of treatment. There was a time lag in recovery between serum androgen levels and SHBG level.

Interferon-alpha-induced thyroid dysfunction in patients with chronic active hepatitis C: a transient, reversible and self-limited dysfunction

To survey the prognoses of interferon-alpha (IFNalpha)-induced thyroid dysfunction, a total of 100 patients (49 males and 51 females) with biopsy-proven chronic active hepatitis C were studied. Either during or after IFNalpha therapy, 29 patients (33.7%) revealed suppression/elevation of thyroid stimulating hormone (TSH) or both, transient thyrotoxicosis (TSH less than 0.1 microU/ml) or transient hypothyroidism (TSH 5.0-190.95 microU/ml). However, the thyroid function normalized without supplementation of the thyroid hormone in the follow-up period. In the same period, one of the 14 control patients (7.1%) developed thyroid dysfunction. Thyroid abnormalities developed significantly more in patients with IFNalpha therapy than in those without IFNalpha therapy. The findings suggest that the occult autoimmune disorder becomes overt with IFNalpha treatment in patients with pre-existent autoimmune thyroid disease. IFNalpha-induced thyroid dysfunction is transient, reversible and self-limited. It is not necessary to discontinue IFNalpha therapy when thyroid dysfunction develops.

[Congenital cholesteatomas in Japanese--forty from our experience and fifty-five from a survey of the Japanese literature]

To determine the locations of congenital cholesteatomas and to elucidate the relationship between ossicular anomalies and congenital cholesteatomas, cholesteatomas from our patients and those reported in the Japanese literature were investigated. We analyzed 40 ears with congenital cholesteatomas (38 patients) experienced by us during the past 9 years. Our criteria of congenital cholesteatoma were as follows: 1. The tympanic membrane manifests neither retraction, perforation, nor granulation, 2. There is no continuity between the tympanic membrane and the matrix of a cholesteatoma. Twenty patients with past histories of otitis media were included. Thirty-three patients (87%) were males and 2 had bilateral congenital cholesteatomas. The ages of the patients ranged from 2 to 46 years (mean: 10.7). A survey of the Japanese literature revealed 55 additional cases of congenital cholesteatoma reported by others.

Hemorrhage and abnormal veins in acoustic neurinoma: MR findings

We reviewed the MR imaging findings of 57 acoustic neurinomas which were verified at surgery or diagnosed on the basis of neuroradiological and neurootological data. Two uncommon MR findings of acoustic neurinoma were found. First, hypointense areas were observed on T2-weighted images in five of the 12 tumors larger than 25 mm in diameter. These hypointense areas represented hemosiderin deposition secondary to occult intratumoral hemorrhage. Second, curvilinear or round signal voids were noted at the periphery of 11 large or medium-sized tumors, and these corresponded to "abnormal veins" seen on angiographic studies.

Selegiline (L-deprenyl) and L-dopa treatment of Parkinson's disease: a double-blind trial

To confirm the clinical utility of selegiline (L-deprenyl), a selective inhibitor of monoamine oxidase B, as an anti-Parkinson's disease (PD) agent, the first Japanese multi-center, double-blind comparative study of this drug was conducted. The subjects were patients who had responded poorly or suffered with other problems related to L-dopa treatment. A total of 112 patients in two groups, one given selegiline at a dose of 7.5 mg/day (Group D, n = 60) and another given a placebo (Group P, n = 52), were compared over an 8-week treatment period. The percentage patients showing "moderate improvement" or better was 34.5% in Group D, while that in Group P was 11.5% (P < 0.01). In the assessment of overall safety, 66.7% in Group D showed no adverse reactions, which was not significantly different from the result of 78.9% for Group P.

Immunopathological features of palatine tonsil characteristic of IgA nephropathy: IgA1 localization in follicular dendritic cells

IgA nephropathy (IgAN) is generally thought to be mediated by the glomerular deposition of circulating immune complexes containing IgA as the major antibody component. Upper respiratory infections and tonsillitis often precede IgAN, and in some cases tonsillectomy is effective for the treatment of IgAN. Thus, the tonsil seems to be a unique organ causing initial and/or progressive events to generate nephritogenic immune complexes in IgAN. In this study we focused on the analysis of immunopathological features of the palatine tonsil characteristic of IgAN patients by using an immunohistochemical technique. The IgA1 subclass was demonstrated in follicular dendritic cells (FDC) of the tonsil of IgAN patients, but not in FDC of non-IgAN controls. On the other hand, IgA2, IgG, IgM and C3 did not show any differences in distribution between the two groups. Moreover, the expression of decay-accelerating factor (DAF), an inhibitor of homologous complement activation, and transforming growth factor-beta 1 (TGF-beta 1), an inducer of antibody-producing cells to IgA class switching, in FDC and interdigitating dendritic cells of the tonsil, respectively, which was also clarified in this study for the first time, was found to be identically distributed in the two groups. These findings may support the idea that IgA1, possibly in an immune complex form, is trapped by FDC and plays an important role in the persistent activation of particular B cell repertoires responsible for the onset and/or progression of IgAN.

[A case of a right bronchial foreign body (rice cake)]

We had a case of a bronchial foreign body (rice cake). A 73-year-old male with severe dyspnea was taken by emergency car. His right breathing sound was very weak, but chest X-ray showed no changes. We diagnosed it as right bronchial foreign body and we could endoscopically remove the foreign body with basket-forcep successfully. We could save his life.

Reinforcing aerosol cisplatin for radiotherapy of laryngeal cancer

To attain its increased tumor concentration and to avert its systemic adverse effects, aerosol cisplatin (CDDP) was incorporated into radiotherapy (RT) of laryngeal cancer. Nine patients were asked to inhale the aerosol following each RT session. Their clinical tumor response was favorable, and histopathologic survey in selected cases revealed elimination of viable cancer cells. However limited, there have been no reports of cancer recurrence yet. This reinforcing plan of aerosol CDDP for RT bleomycin would certainly offer a better way of treating laryngeal cancer, and probably those malignancies facing the nasopharyngobronchial airway as well.

[Upper and lower airway diseases in children with persistent cough]

Persistent cough is a frequent and frustrating problem in the pediatric field. One hundred and seventy two children presenting with persistent cough for longer than 2 weeks were evaluated by both otolaryngologists and pediatricians. One hundred and twenty nine cases (75%) were found to have lower airway diseases, of which bronchial asthma, bronchitis and pneumonia, in that order, were the most common. One hundred and forty two cases (82%) had sinusitis, in 34 cases of which no causative diseases except sinusitis were found to be responsible for the persistent cough. Sinusitis was found in 90% of patients with pneumonia, 81% of those with bronchitis and 65% of those with poorly controlled asthma cases. These results revealed that sinusitis is an important causative factor for persistent cough in children. All the patients with pneumonia and bronchitis were cured by antibiotic administration for 2 weeks, whereas conservative treatment of sinusitis for as long as 6 months was less satisfactory resulting in only 60% cure, 18% improvement and 22% without improvement. In cases with sinusitis and lower airway diseases, continuous treatment for sinusitis is necessary even after treatment of the lower airway diseases has been completed.

Iodide induces transforming growth factor beta 1 (TGF-beta 1) mRNA in sheep thyroid cells

We examined TGF-beta mRNA levels in primary sheep thyroid cell cultures to determine whether the inhibitory effects of iodide on thyroid cells could be explained by an induction of TGF-beta mRNA and if this induction was mediated by iodine organification. Thyroid cells were incubated with TSH and five additives (insulin, somatostatin, growth hormone, transferrin, and glycyl-L-histidyl-L-lysin) for 2-3 weeks and then were exposed to sodium iodide (NaI) or 1-methylimidazole-2-thiol (methimazole, MMI), or both for 72 h. Iodide at 10(-6) M and 10(-4) M significantly increased the amount of TGF-beta mRNA as determined by Northern blot analysis with a rat TGF-beta 1 cDNA probe. This increase in TGF-beta 1 mRNA was abolished by the addition of methimazole, an inhibitor of organification. These data indicate that the effects of iodide on thyroid growth and function may be mediated by a process that involves organification of iodide and increases in TGF-beta 1 mRNA levels.

Bone destruction mechanisms in chronic otitis media with cholesteatoma: specific production by cholesteatoma tissue in culture of bone-resorbing activity attributable to interleukin-1 alpha

To clarify specific mechanisms underlying cholesteatoma-induced bone destruction, surgical specimens of middle ear inflammatory granulation tissue with or without cholesteatoma were maintained in vitro and the bone-resorbing activity in their culture supernatants was analyzed by means of calcium release from mouse calvaria. Almost the same levels of bone-resorbing activity and prostaglandin (PG) E2 were found in the supernatants of both types of tissue. By contrast, aural polyp tissue yielded hardly any such activity or PGE2. Under the influence of indomethacin, however, only tissue with cholesteatoma produced considerable bone resorption activity, whereas PGE2 production was suppressed completely. Such activity in the cholesteatoma culture supernatant was not due to contamination of endotoxin and proved to be blocked by the introduction of anti-interleukin (IL)-1 alpha antibody into the calvarial assay system. Anti-IL-1 beta antibody had no effect on such activity. Interleukin-1 alpha was detected only in cholesteatoma tissue culture supernatants by means of enzyme-linked immunosorbent assay and by bioassay. These data suggest that the bone destruction in otitis media with cholesteatoma may be attributed to IL-1 alpha in addition to PGE2.

[Gellé test in patients of Menière's disease and fluctuating low tone hearing loss]

The threshold shift at 500 Hz bone conduction under positive and negative static pressure of 400 mmH2O applied to the external auditory canal was examined in 20 patients of Meniere's disease with fluctuating low tone hearing loss, 21 patients of sensorineural hearing loss without fluctuating and 24 normal controls. In contrast to the 10 to 15 dB threshold shift in the latter two groups (non-fluctuating group, 14.8 +/- 5.1 dB at positive and 11.1 +/- 5.7 dB at negative; normal controls, 13.6 +/- 5.4 dB at positive and 9.3 +/- 5.3 dB at negative), the former showed a significantly smaller shift (3.2 +/- 6.1 dB at positive and 2.3 +/- 4.5 dB at negative) while hearing was depressed. However, when the hearing was improved, the pressure effect became greater even in the former group (11.3 +/- 5.3 dB at positive and 9.1 +/- 4.8 dB at negative). To understand further details of these phenomena, we performed electrophysiological animal experiments. Through a small hole made on the guinea pig's cochlear bony wall, 300 mmH2O pressure was applied to the scala tympani and the threshold of 500 Hz CM was examined in both endolymphatic sac obliterated ears and non-obliterated ears. In 14 non-obliterated ears 21.1 +/- 5.1 dB threshold shift was recorded, whereas it was only 1.6 +/- 2.6 dB in 9 obliterated ears at 4-6th postoperative days. These results seem to reflect that the endolymphatic pressure is great during the early stage of hydrops.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of external auditory canal pressure upon the hearing threshold in patients with Menière's disease

Fluctuation of hearing at low frequencies is one of the most characteristic findings in Meniere's disease and seems to be a phenomenon closely related to changes of endolymphatic pressure and volume. In the present study, pressure was applied to the external auditory canal of patients with Meniere's disease, and the effect on the bone conduction threshold was examined at times of depressed and improved hearing. In more than half of these cases, it was found that the pressure effect was marked at the time of improved hearing acuity, but not at the time of depressed hearing. This effect was also confirmed in more objective experiments with guinea pigs. It is concluded that the fluctuation of hearing in Meniere's disease seems to be a phenomenon accompanying the endolymphatic pressure change in the scala media.

A case of carcinoid tumor of the middle ear producing peptide hormones

We report 6th case of carcinoid tumor of the middle ear in a 16-year-old man. The clinical, histologic, immunohistochemical and ultrastructural features are discussed. The tumor in the attic and the tympanic cavity was successfully excised by radical mastoidectomy. Microscopically, the argyrophilic property and neurosecretory granules which are characteristic of carcinoid tumor were found in the cytoplasm of tumor cells. Furthermore, peptide hormones were confirmed immunohistochemically in this case. This tumor should be considered in the differential diagnosis when biologically lowgrade tumor with glandular and trabecular architectures are encountered in the middle ear.

Sensation of aural fullness and its treatment with an autonomic nerve blocking agent

One hundred and eighteen patients (143 ears) complaining of a full sensation in the ear without any evidence of other ear diseases were selected for treatment with an autonomic nerve blocking agent and were analysed clinically. Females were extremely predominant in number, 79% of the cases. Sixty-five of 143 ears (45.4%) showed normal hearing and 54 ears (37.8%) had sensorineural hearing loss in low tone. Four mg of butropium bromide, Coliopan, an anti-cholinergic routinely used as an antispastic agent, was injected intravenously. Subsequently, the aural fullness diminished or disappeared in 72.7% (104/143) and 33.5% (48/143) was dramatically relieved within 30 min after the injection. Sensorineural hearing loss in low tone which was recognized in 57 ears in this series also improved remarkably in 57.9% (33/57). These results suggest a close relationship between the autonomic nervous system, aural fullness and sensorineural hearing loss in low tone. According to this study, we recommend anti-cholinergics as the treatment for patients, especially for women, complaining chiefly of aural fullness but with normal otoscopic findings and normal tympanogram, and with or without sensorineural hearing loss in low tone.

Ultrastructural pathology of the middle ear mucosa in otitis media with effusion

To elucidate the histopathological features of the middle ear mucosa in otitis media with effusion (OME), 33 specimens were obtained from OME patients (28 from children and 5 from adults) at the time of the ventilation tube insertion, and examined by light- and electron-microscopy. The mucosa from both pediatric and adult OME patients with glue effusion consisted mostly of non-ciliated cells containing numerous low electron-dense granules with or without a core, and many macroapocrine sections were observed on the apical surface of the cells. The mucosa with mucoid effusion showed various secretory activity, but macroapocrine secretions were rarely found. The intercellular space was intact and the junctional complex was well preserved. In serous otitis cases, the epithelia consisted mostly of cuboid ciliated cells and non-ciliated cells without definite secretory activity. But the intercellular space became widened and the junctional complex was occasionally damaged, indicating that the epithelium was quite permeable. We concluded that there was no significant histopathological difference between the OME mucosa of children and that of adults, although the nature of the effusion was closely correlated with the morphological features of the epithelial linings.

Prognosis and endotoxin contents in middle ear effusions in cases after acute otitis media

We analysed the endotoxin content of middle ear effusion (MEE) from patients after acute otitis media, by a Limulus assay. Endotoxin was positive in 70% of the cases treated with antibiotics at an acute event for more than 5 days, while the incidence of bacteria was only 22%. One month after the sample collection, cases with a high concentration of endotoxin in MEE still tended to have effusion. These results suggest that endotoxin in MEE cannot be easily inactivated and may be involved in the development of acute otitis media into chronic otitis media with effusions.

[Radiochemotherapy of head and neck cancers: dose reduction through the combination of cisplatin, bleomycin and tegafur]

Twenty-four cases of squamous cell carcinomas of the larynx and maxillary sinus were irradiated with or without cisplatin during a period from April 1973 through March 1984. Both bleomycin in oil and tegafur were administered irrespective of cisplatin. Therapeutic effectiveness was critically evaluated by means of serial biopsy and/or surgery. Radiotherapy alone could not bring about negative conversion of the biopsies, but ultimate negative conversion was observed in 18 out of the 24 cases when chemotherapeutics were appropriately combined. The five positives underwent surgery. In the cases of maxillary cancer, mixed infections appeared to interfere with the curative effectiveness of the radiochemotherapy. A resulting dosage reduction of 15Gy was observed in radiotherapy for negative conversion and one of 10mg for bleomycin as a result of incorporation of cisplatin.

Endotoxin in middle ear effusions: in cases with persistent effusion after acute otitis media

Endotoxin in persistent middle ear effusions (MEEs) from children with acute otitis media (AOM) whose acute inflammation had cleared was assayed by Limulus test, parallel with the detection of bacteria. Seventy-five percents of MEEs were endotoxin positive, and the concentration of endotoxin in MEE was not related to the interval between the onset of AOM and the date of sample collection. However, the cases with MEE that had high concentration of endotoxin tended to have persistent MEE for more than one month after sample collection. Therefore, the presence of endotoxin may be one of the causal factors of a delayed recovery of AOM and of the development of otitis media with effusion.

[Ototoxicity of micronomicin sulfate--audiometric assessment]

Micronomicin sulfate (MCR) is a new aminoglycoside antibiotic, and its antibacterial spectrum is similar to that of gentamicin (GM). According to the animal test, MCR has less ototoxicity than other aminoglycoside antibiotics such as GM. To check its clinical ototoxicity, MCR was given intramuscularly to 20 patients at dose of 120--240 mg/day, respectively for 2--8 days, and audiometry was carried out before and after administration of MCR. No evident change was detected between the preadministration hearing levels and the postadministration hearing levels. These data suggest that MCR is sufficiently safe in ototoxicity within dose of 120 mg/day for 4 days.

Organic acids and anaerobic microorganisms in the contents of the cholesteatoma sac

Organic acids in the contents of the cholesteatoma sac from 28 cases were studied by gas chromatographic technique. Five volatile fatty acids (acetate, propionate, isobutyrate, butyrate and isovalerate) and lactate were detected in large amounts, which may lower the pH of the cholesteatoma content. These acids were considered to be derived from products of anaerobic microorganisms. Therefore, the contents from 12 cases were cultured anaerobically in a glove box. Obligate microorganisms were identified in 92% of the cases and Peptococcus, Bacteroides, and Clostridium species were frequently isolated. In vitro, such obligate anaerobes produced various organic acids from the cholesteatoma content. Facultatives such as Staphylococcus aureus and Proteus mirabilis produced acetate in the content under aerobic and anaerobic conditions, whereas no organic acid was produced by Pseudomonas aeruginosa. Organic acids in the cholesteatoma content could be fermentative products made by the microorganisms, anaerobes and facultatives, which use the content as a substrate for acid production.

Bone destruction due to the rupture of a cholesteatoma sac: a pathogenesis of bone destruction in aural-cholesteatoma

Severe bone destruction in a cholesteatoma is one of the characteristic clinical features. To clarify the mechanism of bone destruction in cholesteatoma, the matrix of cholesteatoma and the attached bone, obtained during middle ear surgery, was observed by light microscope. Rupture of the epithelial lining in a cholesteatoma and the escaping contents (keratin), which gave rise to intense characteristic granulations in subepithelial tissue, were found. Furthermore bone destruction was always found at the site of subepithelial tissue of cholesteatoma. From these facts, the escape of contents from the sac of cholesteatoma into the subepithelial layer is considered to be an important factor in the mechanism of bone destruction.