Familial Paget's disease of bone with ocular manifestations and a novel TNFRSF11A duplication variant (72dup27).

INTRODUCTION: Paget's disease of bone (PDB) is a skeletal disorder characterized by disorganized bone remodeling due to abnormal osteoclasts. Tumor necrosis factor receptor superfamily member 11A (TNFRSF11A) gene encodes the receptor activator of nuclear factor kappa B (RANK), which has a critical role in osteoclast function. There are five types of rare PDB and related osteolytic disorders due to TNFRSF11A tandem duplication variants so far, including familial expansile osteolysis (84dup18), expansile skeletal hyperphosphatasia (84dup15), early-onset familial PDB (77dup27), juvenile PDB (87dup15), and panostotic expansile bone disease (90dup12). MATERIALS AND METHODS: We reviewed a Japanese family with PDB, and performed whole-genome sequencing to identify a causative variant. RESULTS: This family had bone symptoms, hyperphosphatasia, hearing loss, tooth loss, and ocular manifestations such as angioid streaks or early-onset glaucoma. We identified a novel duplication variant of TNFRSF11A (72dup27). Angioid streaks were recognized in Juvenile Paget's disease due to loss-of-function variants in the gene TNFRSF11B, and thought to be specific for this disease. However, the novel recognition of angioid streaks in our family raised the possibility of occurrence even in bone disorders due to TNFRSF11A duplication variants and the association of RANKL-RANK signal pathway as the pathogenesis. Glaucoma has conversely not been reported in any case of Paget's disease. It is not certain whether glaucoma is coincidental or specific for PDB with 72dup27. CONCLUSION: Our new findings might suggest a broad spectrum of phenotypes in bone disorders with TNFRSF11A duplication variants.

[External auditory canal cholesteatoma with chronic renal failure or hemodialysis].

BACKGROUND: External auditory canal cholesteatoma (EACC) is a rare otologic disease, characterized by focal osteonecrosis, sequestration and overlying epithelial loss of the bony external auditory canal (EAC). The etiology and pathogenesis of EACC remain controversial. There are only 2 reports on the association between EACC and chronic renal failure (CRF)/hemodialysis (HD). METHOD & RESULT: (1) This study reviewed seven EACC cases with CRF. The mean age was 68.4 years (range: 56 -81 years), and the male-female ratio was 5:2. There were 12 ears with EACC (5 cases were bilateral and 2 cases were unilateral). The EACCs were found in the inferior or posterior inferior part of the EAC in 11 ears. The number of the ears in stage III or IV was 6. Five cases were on HD. (2) Seventy-six cases with CRF on HD were examined for EACC, and 2 out of those 70 cases were diagnosed as having EACC. (3) A comparative study of the 7 EACC cases on HD and 68 non-EACC cases on HD revealed no significant differences in the sex, age, period on CRF/HD, complications (diabetes mellitus or skin disease), smoking, ear cleaning and the use of an earphone or a hearing aid. CONCLUSION & DISCUSSION: Six out of all 9 EACC cases with CRF developed bilaterally, and in the inferior or posterior inferior part of the EAC, which implies a common pathological condition that contributes to the development of EACC. The mean age of 9 patients with EACC was relatively older (66.7 years), therefore age-related changes in the EAC are suspected in the cases with CRF on HD. The patients with CRF on HD have a high incidence of EACC. This strongly suggests the association between EACC and CRF/HD, but the mechanism of this pathogenesis has not been revealed.

HDR syndrome, detected in the neonatal period by newborn hearing screening.

Hypoparathyroidism, deafness, and renal dysplasia (HDR) syndrome is an autosomal dominant disorder. Because HDR syndrome is caused by haploinsufficiency in GATA3, it exhibits variation in the onset and progression of hearing loss. In previous reports, the automated auditory brainstem response (AABR) was considered insufficient to detect sensorineural hearing loss caused by HDR syndrome. We report a case of HDR syndrome whose congenital hearing loss was detected by newborn hearing screening (NHS) using AABR. In this case, HDR syndrome was suspected due to hearing loss, hypocalcemia, and her family history. Genetic testing confirmed the diagnosis of HDR syndrome at 5 months of age. Because the phenotype of hearing loss due to HDR syndrome is variable and includes progressive hearing loss, these cases may not be detected by the HNS. However, most of the previous reports were published before the NHS became common and given the frequency of hearing loss complications in HDR syndrome. We consider that there is a reasonable number of HDR syndrome cases with abnormalities on the NHS. We believe that the NHS may also be useful for early detection of hearing loss due to HDR syndrome.

Examination of Factors Affecting the Likelihood of Whether Individuals Would Purchase Cartilage Conduction Hearing Aids.

Cartilage conduction hearing aids (CC-HAs) are a novel type of hearing aid relying on cartilage conduction, the so-called third auditory conduction pathway. However, CC-HAs have only recently entered routine clinical use, and therefore data on their usefulness are lacking. The purpose of this study was to examine the possibility of assessing whether individual patients would show good adaptation to CC-HAs. Thirty-three subjects (41 ears in total) underwent a free trial of CC-HAs. Age, disease category, and the pure-tone threshold of air and bone conduction, unaided field sound threshold, aided field sound threshold, and functional gain (FG) at 0.25, 0.5, 1, 2, and 4 kHz were compared between patients who subsequently purchased and did not purchase the CC-HAs. Overall, 65.9% of the subjects purchased CC-HAs after the trial. In comparison to non-purchasers, those who decided to purchase CC-HAs showed better pure tone hearing thresholds at high frequencies for both air conduction (2 and 4 kHz) and bone conduction (1, 2, and 4 kHz), as well as for aided thresholds in the sound field (1, 2, and 4 kHz) when using CC-HAs. Therefore, the high-frequency hearing thresholds of subjects trialing CC-HAs might be helpful for identifying those who are likely to benefit from them.

Impact of palatoplasty techniques on tympanic membrane findings and hearing prognosis in children with cleft palate.

OBJECTIVE: Children with cleft palate (CP) are at high risk of developing otitis media with effusion (OME) due to Eustachian tube (ET) dysfunction. Palatoplasty has been reported to decrease the frequency of middle ear disease and improve ET function, and although various techniques have been developed, there is no consensus on the differences in the impact of different techniques on the middle ear. The purpose of this study was to determine the differential effects of palatoplasty on middle ear function and hearing. METHODS: We performed a retrospective observational survey of pediatric patients who underwent palatoplasty for CP between June 2010 and October 2018 at Tohoku University Hospital. Cases were divided into three groups depending on the palatoplasty procedures performed: the push-back palatoplasty group, the two-flap palatoplasty group, and the Furlow double-opposing Z-plasty group. We examined the differences in clinical characteristics between patients who underwent each procedure. The primary outcome variable was tympanic membrane (TM) findings, and the secondary outcome was hearing test results. RESULTS: Children who underwent the two-flap palatoplasty had a higher tympanostomy tube (TT) insertion rate and a higher total number of TT insertions than those who underwent the Furlow double-opposing Z-plasty or the push-back palatoplasty. The TM retraction rate tended to be lower in the Furlow double-opposing Z-plasty group than in the push-back palatoplasty group or the two-flap palatoplasty group. The hearing test results at the last visit were not significantly different among the three groups. CONCLUSIONS: Children who underwent the two-flap palatoplasty had a higher rate of TT insertions, potentially increasing the risk of TM perforation. In contrast, the Furlow double-opposing Z-plasty group had a lower tendency for TM regression, possibly due to improved ET function and reduced incidence of OME. It is important to understand the advantages and disadvantages of each technique before selecting one suitable for the child's cleft and arch width. Additionally, it is important to conduct regular follow-up of TM findings and hearing test results even after palatoplasty.

Intragastrically administered lysophosphatidic acids protect against gastric ulcer in rats under water-immersion restraint stress.

BACKGROUND AND AIM: Lysophosphatidic acid exerts important physiological effects on many types of animal cells through its specific binding to several G protein-coupled receptors. In particular, its potent wound-healing effect has attracted much attention. To determine whether lysophosphatidic acids in a foodstuff and Chinese medicine are effective in protecting against gastric ulcer, we subjected rats to water-immersion restraint stress. METHODS AND RESULTS: Three direct administrations of a solution of lysophosphatidic acid with a C18 fatty acyl group to the rat stomach in a concentration range of 0.001-0.1 mM resulted in a significant reduction in the number of gastric ulcers induced during water-immersion restraint stress, and the potencies were as follows: linoleoyl species=α-linolenoyl species>oleoyl species. Intragastric administrations of a solution of highly purified lysophosphatidic acid from soybean lecithin significantly protected against the stress-induced gastric ulcers at lower concentrations than partially purified lysophosphatidic acid from soybean lecithin did. In addition, administration of a decocted solution of antyu-san, and lysophosphatidic acid-rich Chinese medicine, to the stomach was more effective in protecting against stress-induced ulcer than decoctations of antyu-san lacking the corydalis tuber component that is rich in lysophosphatidic acid. CONCLUSIONS: These results clearly show that lysophosphatidic acid is the effective component of soybean lecithin and antyu-san in protection against stress-induced gastric ulcer in the rat model, and suggest that daily intake of lysophosphatidic acid-rich foods or Chinese medicines may be beneficial for prevention of stress-induced gastric ulcer in human subjects.

Ecto-lysophospholipase C controls lysophospholipid uptake and metabolism in porcine kidney epithelial cell line LLC-PK1.

Lysophosphatidylcholine (LPC) has diverse biological activities through different mechanisms including its conversion into other types of lipid mediators such as lysophosphatidic acid and 2-arachidonoylglycerol. Previously, we found that a large portion of the fluorescent analog of alkyl type LPC (Bodipy-lysoPAF) on porcine kidney epithelial cells (LLC-PK1) was degraded to monoalkylglycerol by lysophospholipase C-like activity and then quickly internalized into the cells. In this study, we investigated whether exogenous fluorescently labeled LPC (NBD-LPC) itself was also metabolized and internalized by a similar mechanism. LLC-PK1 cells converted NBD-LPC to either NBD-MG, possibly due to lysophospholipase C-like activity of ecto-nucleotide pyrophosphatase/phosphodiesterase-6, or to free fatty acid (FA), due to lysophospholipase activity in the culture medium at both sites. The resultant NBD-MG was further degraded to NBD-FA by lipase activity before or after its uptake into the cells, and a portion of NBD-FA was finally released into the culture medium on the opposite side.

Steroid pulse therapy transiently destroys the discriminative histological structure of tonsils in IgA nephropathy: Tonsillectomy should be performed before or just after steroid pulse therapy.

OBJECTIVE: Tonsillectomy combined with steroid-pulse therapy is a widely accepted method for the treatment of IgA nephropathy (IgAN) in Japan. However, the indication of tonsillectomy for IgAN is still controversial, and the timing of tonsillectomy is not clearly defined for the protocol of this therapy. Based on the results of a randomized control trial in Japan, the Evidence-Based Clinical Practice Guidelines for IgA nephropathy 2014 (edited in Japan) recommended tonsillectomy combined with steroid-pulse therapy for Grade C1. However, this is not widely accepted worldwide. To clarify the validity and timing of tonsillectomy, we evaluated how the three-consecutive steroid-pulse therapy method affects the tonsil tissues of IgAN patients. METHODS: We examined tonsil specimens from 35 IgAN patients and 8 chronic tonsillitis patients. We compared the proportion of follicular area to total tonsillar area and the number of germinal centers between each group on hematoxylin and eosin stained pathological specimens to clarify the histopathological characteristics of tonsils from IgAN patients. Based on these findings, we examined the tonsils of patients after three-consecutive steroid-pulse therapy treatments (n=34) to determine the influence of this therapy on the tonsil tissues of IgAN patients. Moreover, we observed chronological changes in tonsil tissues after steroid-pulse therapy. RESULTS: The extrafollicular area was enlarged in IgAN patients before steroid-pulse therapy compared with chronic tonsillitis patients. Just after steroid-pulse therapy, the follicles became very small with blurry outlines, and the number of germinal centers was remarkably decreased. With a gradual decrease in oral prednisolone, the tonsil tissue structure was gradually restored. CONCLUSION: Tonsillectomy combined with steroid-pulse therapy is considered a reasonable treatment for IgAN. Steroid-pulse therapy-induced histological changes in tonsils were transient, indicating tonsillectomy should be performed before or just after steroid-pulse therapy.

The size of palatine tonsils cannot be used to decide the indication of tonsillectomy for IgA nephropathy.

Background. Tonsillectomy is one of the treatment strategies for immunoglobulin A nephropathy (IgAN). The relationship between the indication of tonsillectomy and the size of palatine tonsils (PTs) in patients with IgAN remains controversial. Methods. This retrospective cohort study investigated 57 patients with IgAN who underwent tonsillectomy combined with steroid pulse therapy (SPT). They were classified into two groups, the hypertrophy group and the nonhypertrophy group, according to the weight of their excised PTs. The effects of tonsillectomy combined with SPT on clinical remission (CR) and the histopathological findings of PTs were compared between the two groups. Results. During the mean follow-up period of 45.5 (range 6-133) months, 78.9% of the patients achieved CR (79.3 versus 78.6%, P = 0.945) and the baseline serum creatinine doubled only in one patient in the nonhypertrophy group (0 versus 3.6%, P = 0.491). No significant difference was observed in the incidence of CR between the two groups by the Kaplan-Meier method (P = 0.839). The predictor for CR, identified in Cox proportional hazards models, was baseline proteinuria [hazard ratio 0.14 (95% CI 0.032-0.621) P = 0.010]. Although macroscopic pus plugs were observed on the surface of PTs in almost 60% of patients in each group, microscopic pus plugs in the crypt and the enlarged interfollicular area were observed in all patients. Conclusions. The treatment effect of tonsillectomy combined with SPT and the pathological features of PTs in IgAN were equal, regardless of the size of the PTs. Therefore, the size of PTs should not be included as a factor when deciding the indication of tonsillectomy for IgAN.

[Treatment of Henoch-Schönlein purpura nephritis in children with tonsillectomy].

Henoch-Schönlein purpura nephritis (HSPN) is an important complication of Henoch-Sch6nlein purpura (HSP). Pathological findings in the kidney are similar to those for IgA nephritis, which is characterized by the deposition of IgA immune complex in the glomerular mesangium. Since a tonsillectomy is useful for IgA nephritis, this procedure holds great promise for the treatment HSPN. In the present study, we assessed the effectiveness of a tonsillectomy in children with HSPN whose conditions could not be controlled by medication, including predonisone and cyclophosphamide. Seven patients (four boys and three girls) with histologically well-defined HSPN who had undergone a tonsillectomy between 1998 and 2000 and who had been followed for more than 6 postoperative months were retrospectively examined. The age of the patients ranged between 3 and 13 years (average, 7.6 +/- 3.2 years) at the time of operation. Postoperative changes in urinary data were assessed according in the severity of the pathological findings in the kidney and the patient's clinical condition. The severity of the pathological findings in the kidney was determined based on the classification of the International Study of Kidney Disease (ISKDC) and the Index of Glomeruler Lesion (IGL). All patients examined in the present study had an ISKDC classification of over grade II. One patient had a grade IV classification, 3 had a grade III classification, and 3 had a grade II classification. The patients were placed in one of five clinical groups: (1) nephritic-nephrotic syndrome, (2) acute nephritic syndrome, (3) nephritic syndrome, (4) over 1 g/day of proteinuria without hypoalbuminemia or oedema, or 5) below 1 g/day of proteinuria with or without hematuria. One patient was classified in group 1, 1 was group classified in 2, 2 were classified in group 3, 2 were classified in group 4 and 1 was classified in group 5. The mean observation period was 74 +/- 6.4 months. The hematuria and proteinuria resolved in all patients, regardless of their preoperative pathological or clinical severity, within 12 postoperative months. During the observation period, no relapse was observed. Moreover, all medication, including steroid use, was stopped within the observation period. Therefore, a tonsillectomy was considered to be effective for the treatment of children with HSPN whose conditions cannot be controlled using medication.

Comparison of lysophospholipid levels in rat feces with those in a standard chow.

Although lysophospholipids have attracted much attention due to their diverse physiological activities through their specific receptors, little is known about their metabolic fates in mammalian digestive systems after their ingestion as a minor food component. In this study, we analyzed five lysophospholipids in lipid extracts of a standard rat chow and feces of rats fed the chow by two-dimensional thin layer chromatography and liquid chromatography-tandem mass spectrometry. The most abundant lysophospholipid in the rat chow was lysophosphatidylcholine followed by lysophosphatidylethanolamine, lysophosphatidic acid (LPA), lysophosphatidylinositol and lysophosphatidylserine (LPS) in an increasing order, but their concentrations were very low in rat feces. Among the molecular species of LPS in the chow, only saturated species were detected in the feces in significant amounts. In addition, several molecular species of LPA remained in the feces in variable portions (saturated > monounsaturated > polyunsaturated). These results suggest that a portion of ingested LPA and LPS reach the rat large intestine, affecting physiological colon functions.

Presence of bioactive lysophosphatidic acid in renal effluent of rats with unilateral ureteral obstruction.

AIMS: Abnormal production of lysophosphatidic acid (LPA), an important lysophospholipid mediator, in the kidney was examined to participate in the pathogenesis of renal fibrosis in rats. The secretory lysophospholipase D activity of autotoxin was considered as a possible pathway for extracellular production of LPA in the pathological renal fluids. MAIN METHODS: In this study of rats with unilateral ureteral obstruction for two weeks, we measured concentrations of LPA and its precursor, lysophosphatidylcholine stored in the urinary bladder and present in the swollen pelvis of the ligated kidney as well as the corresponding blood plasma by liquid chromatography-tandem mass spectrometry. KEY FINDINGS: We found that concentrations of LPA and lysophosphatidylcholine accumulated in the effluent in the swollen pelvis of the ligated kidney of unilateral ureteral obstruction rats were much higher than those in the urinary bladder. The molecular species composition of LPA in the former was considerably different from that in the blood plasma, indicating the involvement of an additional source other than the blood circulation supplying LPA to the effluent in the swollen kidney. A potential mechanism is increased release of LPA from activated renal cells in the ureter-ligated kidney. SIGNIFICANCE: Both pathways for supply of extracellular LPA may participate in the induction and progression of renal tubulofibrosis.

Clinical observation of palatine tonsils with IgA nephropathy.

We have previously reported that clinical remission could be achieved by combination therapy consisting of steroid pulse therapy and tonsillectomy in patients with IgA nephropathy. However, there is no consensus as to the indications for tonsillectomy in IgA nephropathy (IgAN) patients. To clarify whether there is any correlation between characteristics of removed palatine tonsils and clinical remission rate, we evaluated the relationships between the remission rate of urinary abnormalities and characteristics of 186 IgAN patients (aged 11-65 years) with mild or moderate renal pathology and their tonsils. Remission of proteinuria was observed in 134 patients (72%) and remission of hematuria was observed in 111 patients (60%). There was no significant difference in remission rate of either proteinuria or hematuria in terms of the past history of recurrent tonsillitis, episodes of synpharyngitic gross hematuria, pus plugs in the tonsillar lacunae, size of tonsils, age and the results of tonsillar provocation tests. Our findings suggest that it is very difficult to predict the efficacy of tonsillectomy and steroid pulse therapy based on the gross appearance of tonsils, the tonsillar provocation test or clinical episodes of tonsillitis. Moreover, contraindication of tonsillectomy for aged IgAN patients is not always justified.