Directional characteristics of incipient temporomandibular joint disc displacements: A magnetic resonance imaging study.

INTRODUCTION: Disc displacement (DD) is common in adolescents, but not much is understood about its cause. Assessment of the directionality of incipient DDs may provide clues about the etiology. METHODS: The sample consisted of magnetic resonance images of 143 temporomandibular joints with incipient DD from 89 preorthodontic patients (mean age, 10.8 years). The severity of DD was evaluated by grading the degree of displacement depicted in the images in the sagittal and coronal planes, and each incipient DD was categorized based on the directionality. RESULTS: Of the 143 incipient DDs, rotational anterolateral DD (43.36%) and partial anterior DD in the lateral portion (27.27%) were the most common; rotational anteromedial DD (9.09%) and partial anterior DD in the medial portion (1.40%) accounted for only 10.49%. Anterior DD was seen in 12.59%. Pure sideways shift was rare; lateral DD was seen in 2.80%, and medial DD in 3.50%. Thus, the lateral part of the joint was involved in a majority of the incipient DDs and the medial part far less. No sex difference was noted in this trend, but the difference between the right and left sides was statistically significant. CONCLUSIONS: These results indicate a predilection for the lateral part of the joint in incipient DDs and may have etiologic implications.

Prevalence of disc displacement of various severities among young preorthodontic population: a magnetic resonance imaging study.

PURPOSE: There has been no study on the prevalence of disc displacement (DD) of different levels in children and adolescents with adequate sample size using magnetic resonance images (MRIs). This retrospective cross-sectional study was designed to investigate the relationship between increasing age and the prevalence of DD of various severities in a young preorthodontic population. MATERIALS AND METHODS: Of 199 preorthodontic patients aged 6 to 15 years visiting a private orthodontic office for initial examination, 153 patients with signs and symptoms of temporomandibular joint (TMJ) disorders had MRIs of their TMJs taken for further evaluation. Of those, 302 TMJs from 151 patients' MRIs of diagnostic quality were divided into three age groups (I: 6 to 9, II: 10 to 12, and III: 13 to 15 years). DD of each patient was categorized based on its severity from stage 0 (normal) to stage 4 (total DD without reduction). The distribution of DD stages in each age group was plotted on a line graph and statistically analyzed for intergroup comparison. RESULTS: A graphical representation of the results clearly demonstrated a trend for higher occurrence of more advanced DD with an increase in age. No gender difference was observed. Statistical analysis showed that DD was significantly more advanced in group II than group I (p < 0.01) and group III than group I (p < 0.01). CONCLUSIONS: The study revealed a high prevalence of DD in the young preorthodontic population and significant increase in the proportion of patients with more advanced stages of DD in older patients.

A reference line on temporomandibular joint MRI.

PURPOSE: The aim of this study was to establish a reference line and the 12 o'clock position on sagittal MRI images of the temporomandibular joint (TMJ) for close observation of early changes in disk position. MATERIALS AND METHODS: The study included 106 joints of 53 consecutive male and female patients (mean age 13.3 years) with available MRI and limited cone-beam computed tomography (LCBCT) images, from a pool of postorthodontic patients who had finished phase I or phase II orthodontic treatment between March 2006 and March 2008 in a private orthodontic office. High-resolution (0.1 pixel) LCBCT images taken in natural head position in the same time period and adjusted to the same magnification were superimposed on corresponding MRI images. The true horizontal line (THL) determined by natural head position on the LCBCT image was transferred to the MRI image. A clinically easy-to-use reference line (RL) approximating THL was drawn by connecting two readily locatable anatomical landmarks, the most inferior point of the articular eminence and the center of the auditory canal, and correspondence between THL and RL was assessed. RESULTS: The mean angle formed by THL and RL on the MRI images of the TMJs studied was 2.2° (SD 2.8°) clockwise around the center of the auditory canal, and the angulations of THL and RL on MRI images of the TMJs studied demonstrated a high positive correlation (r = 0.84). CONCLUSIONS: THL can be established directly on MRI images using the THL-RL angle obtained by this study in patients without advanced disk displacement resulting in bony changes of the joint. The deepest point on the glenoid fossa that meets the THL can be used as the 12 o'clock position for evaluation of incipient disk position change.

Comparison of whole-body cooling and selective head cooling on changes in urinary 8-hydroxy-2-deoxyguanosine levels in patients with global brain ischemia undergoing mild hypothermia therapy.

BACKGROUND: We evaluated changes in the levels of urinary 8-hydroxy-2-deoxyguanosine (8-OHdG) in patients undergoing mild hypothermia therapy and compared 8-OHdG expressions in those receiving whole-body cooling or selective head cooling. MATERIAL/METHODS: The subjects were 15 patients undergoing mild hypothermia therapy following resuscitation after cardiac arrest in our intensive care unit. We divided the patients into 2 groups receiving either whole-body cooling or selective head cooling, according to their circulatory stability. We examined urinary 8-OHdG level for 1 week and neurological outcomes 28 days after admission. RESULTS: We observed significant decreases in urinary 8-OHdG levels on days 6 and 7 compared with that on day 1 in the whole-body cooling group. Furthermore, we noted significantly lower urinary 8-OHdG levels after days 5, 6 and 7 in the whole-body cooling group than in the selective head-cooling group. Neurological outcomes were similar in both groups. CONCLUSIONS: Mild hypothermia therapy with whole-body cooling had a greater effect on the suppression of free radical production than selective head cooling. However, selective head cooling might be an appropriate indication for patients with circulatory instability after resuscitation, because it provides neuroprotection similar to that of whole-body cooling.

HMGB-1 as a useful prognostic biomarker in sepsis-induced organ failure in patients undergoing PMX-DHP.

BACKGROUND: High mobility group box 1 (HMGB-1) has recently received attention as a late mediator of lipopolysaccharide-induced shock, and is thought to function as a mediator in such a disorder as multi-organ failure (MOF). In Japan, we have access to an immobilized polymyxin B fiber column using a direct hemoperfusion (PMX-DHP) for patients with septic shock to improve hemodynamics and organ dysfunction. In this study, we looked at HMGB-1 levels in each category based on the sequential organ failure assessment (SOFA) scores to further dissect its importance in specific aspects of organ failure in patients undergoing PMX-DHP. PATIENTS AND METHODS: Sixty patients with septic shock (40 survivors and 20 non-survivors). We analyzed HMGB-1 and IL-6 levels before and after PMX-DHP and defined organ failure as two or more SOFA points. RESULTS: There was a significant positive correlation between SOFA score and HMGB-1 level (P<0.05). The HMGB-1 level before PMX-DHP significantly increased as the number of organ failures increased (P<0.01: comparing 2 versus 5 organ failures). IL-6 levels decreased after PMX-DHP (P<0.05 compared with before PMX-DHP), but HMGB-1 levels remained unchanged. HMGB-1 levels of survivors with organ failure in liver decreased after PMX-DHP, but those of non-survivors significantly increased 24h after PMX-DHP compared with before PMX-DHP (P<0.01). In non-survivors with organ failure in liver, HMGB-1 levels were significantly higher than among survivors 24h after PMX-DHP (P<0.01). CONCLUSIONS: Our results indicate that HMGB-1 is a useful prognostic biomarker in sepsis-induced organ failure in patients undergoing PMX-DHP.

Assessment of optimal condylar position in the coronal and axial planes with limited cone-beam computed tomography.

PURPOSE: No quantitative standards for the optimal position of the mandibular condyle in the glenoid fossa are yet available in the coronal and axial planes. We previously reported measurements of this position in the sagittal plane, using recently developed limited cone-beam computed tomography (LCBCT) capable of imaging the craniofacial structures with high accuracy. In this study, we assessed the optimal condylar position in the coronal and axial planes. MATERIALS AND METHODS: The study included 24 joints in 22 asymptomatic patients (10 male, 12 female; age range 12-25 years, mean age 18 years) who had no disc displacement as confirmed by magnetic resonance imaging. Their joints had optimum function with the starting and end points of all functional jaw movements coincident with maximum intercuspation. Joint-space distances between the condyle and glenoid fossa were measured at the medial, central, and lateral positions in the coronal plane, and medial and lateral positions in the axial plane. RESULTS: The mean coronal lateral space (CLS), coronal central space (CCS), and coronal medial space (CMS) were 1.8 ± 0.4 mm, 2.7 ± 0.5 mm, and 2.4 ± 0.5 mm, respectively. The ratio of CLS to CCS to CMS was 1.0 to 1.5 to 1.3. The mean axial medial space (AMS) and axial lateral space (ALS) were 2.1 ± 0.6 mm and 2.3 ± 0.6 mm, respectively. There were no significant sex differences in these measurements. CONCLUSIONS: These coronal and axial data, along with previously reported sagittal data, might provide norms for 3D assessment of optimal condylar position with LCBCT.

Assessment of optimal condylar position with limited cone-beam computed tomography.

INTRODUCTION: There are no quantitative standards for the optimal position of the mandibular condyle in the glenoid fossa. Recently developed limited cone-beam computed tomography (LCBCT) allows measurement of this position with high accuracy. METHODS: LCBCT was used to assess 24 joints in 22 symptom-free subjects (10 male, 12 female; mean age, 18 years) who had no disc displacement as verified by magnetic resonance imaging. Their joints had optimum function with the starting and end points of all functional jaw movements coincident with maximum intercuspation. Linear measurements of anterior space (AS), superior space (SS), and posterior space (PS) were made to determine the position of the condyle for each joint. RESULTS: The mean AS, SS, and PS values were 1.3 mm (SD +/- 0.2 mm), 2.5 mm (SD +/- 0.5 mm), and 2.1 mm (SD +/- 0.3 mm), respectively. The ratio of AS to SS to PS was 1.0 to 1.9 to 1.6. No significant sex difference was noted in joint space distances. The results showed less variability of condylar position in the fossa than previously reported in normal subjects. CONCLUSIONS: These data from optimal joints might serve as norms for the clinical assessment of condylar position obtained by LCBCT.

High-Risk Neuroblastoma with Metastases to Bilateral Kidneys at Diagnosis.

Renal metastasis at diagnosis with neuroblastoma is rare. We present a 14-month-old boy who was diagnosed with high-risk neuroblastoma with multiple metastases, including bilateral kidneys. He received five cycles of induction chemotherapy and high-dose chemotherapy with autologous peripheral blood stem cell transplantation. All of the lesions shrank, and magnetic resonance imaging indicated that some of the metastases had disappeared. However, there were residual masses in the bilateral kidneys, and histological examination revealed the presence of tumor cells. Therefore, the patient underwent unrelated cord blood stem cell transplantation, which involved killer-ligand incompatibility in the graft-versus-host direction, in addition to human leukocyte antigen C and DRB1 mismatches. Three months later, tumor progression occurred from the residual mass in the sacral canal and a new lesion in the pancreas. Although tumor progression could not be controlled by additional chemotherapy and local radiotherapy, the metastatic nodules in bilateral kidneys did not increase in size before his death. To the best of our knowledge, this is the first report of neuroblastoma with bilateral renal metastases in the English medical literature. In addition, this case suggests that the combination of chemotherapy and immunotherapy may inhibit the progression of the renal lesions under certain conditions.

Superantigen-induced multiple organ dysfunction in a toxin-concentration-controlled and sequential parameter-monitored swine sepsis model.

OBJECTIVE: In order to examine the biological activity of low-dose and continuously infused superantigen, and to establish a superantigen-induced multiple organ dysfunction animal model, several pathophysiological parameters were sequentially monitored in a toxin-concentration-controlled pig model. METHODS: Anesthetized, mechanically ventilated and Swan-Ganz thermodilution catheter-inserted pigs were treated with toxic shock syndrome toxin-1 (TSST-1) by infusion at 2 microg/kg/h for 5 h. Monitoring was performed for both the infusion period and a subsequent 1-h post-infusion period. RESULTS: The serum concentration of TSST-1 was controlled so as to elevate it to a level over 1000 pg/mL within 1 h of initiation of infusion, and then gradually increased further and reached a plateau of about 2500 pg/mL at 4h after initiation. The animals showed a significant increase in cardiac output, the intrapulmonary arteriovenous shunt ratio, and infiltration of white blood cells into the lung. Although the observed increase in pulmonary vascular resistance was not statistically significant, it did correlate with the reduction in white blood cell counts. CONCLUSION: The superantigen TSST-1 plays an important role in the pathogenesis of Gram-positive bacterial sepsis by inducing multiple organ dysfunction. Thus, this model provides the first tool to allow the simultaneous examination of the serum toxin levels and other organ parameters in a time-course manner.

Clinical evaluation of PMX-DHP for hypercytokinemia caused by septic multiple organ failure.

Endotoxin-adsorbing fibers have been applied to treat septic shock patients. The limitations of endotoxin hemoadsorption therapy (PMX-DHP) and the optimal time to start PMX-DHP were examined in patients with septic multiple organ failure with hypercytokinemia (interleukin-6 = 1000 pg/mL). Subjects were separated into those who survived more than 28 days after the start of PMX-DHP therapy (S group) and those who did not (N-S group). Severity of symptoms and background factors, blood biochemical parameters, hemodynamic parameters, PaO(2)/FiO(2), pathogens, endotoxin, cytokines, and vascular endothelial cell function-related markers were examined before and after PMX-DHP. Number of days from onset of shock (or symptom development) to PMX-DHP initiation was longer in the N-S group than in the S group. These results suggest that PMX-DHP could save more lives in patients with septic multiple organ failure with IL-6 = 1000 pg/mL when applied early after the onset of shock.

Usefulness of the endotoxin activity assay as a biomarker to assess the severity of endotoxemia in critically ill patients.

The aim of this study was to investigate the prevalence of endotoxemia in critically ill Japanese patients using the endotoxin activity assay, a newly developed rapid assay of endotoxin. The endotoxin levels (EA levels) in the blood of 314 patients admitted to our university hospital's intensive care unit (ICU) were measured within 24 h of admission, and its correlation with disease severity and outcome examined. In addition, the EA levels in 61 samples from healthy volunteers were measured. EA level was 0.39 ± 0.25 (mean ± SD) in patients admitted to the ICU and 0.10 ± 0.09 in healthy controls. There was less overlap of EA level distribution between patients and controls compared with previous reports measuring EA level in mainly Caucasian populations. Our patients' EA levels were significantly correlated with disease severity criteria and 28-d mortality. When EA and procalcitonin levels were used concomitantly, disease severity could be assessed more precisely than when either marker was used alone. These results suggest that EA level is a useful marker for disease severity assessment and outcome prediction in critically ill patients.

Autophagy-related IRGM polymorphism is associated with mortality of patients with severe sepsis.

OBJECTIVE: Autophagy is the regulated catabolic process for recycling damaged or unnecessary organelles, which plays crucial roles in cell survival during nutrient deficiency, and innate immune defense against pathogenic microorganisms. Autophagy has been also reported to be involved in various conditions including inflammatory diseases. IRGM (human immunity-related GTPase) has an important function in eliminating Mycobacterium tuberculosis from host cells via autophagy. We examined the association between genetic polymorphism and clinical course/outcome in severely septic patients. METHODS: The study included 125 patients with severe sepsis/septic shock (SS) and 104 non-sepsis patients who were admitted to the intensive care unit (ICU) of Chiba University Hospital between October 2001 and September 2008 (discovery cohort) and 268 SS patients and 454 non-sepsis patients who were admitted to ICUs of five Japanese institutions including Chiba University Hospital between October 2008 and September 2012 (multi-center validation cohort). Three hundred forty seven healthy volunteers who consented to this study were also included. Genotyping was performed for a single-nucleotide polymorphism (SNP) within the coding region of IRGM, IRGM(+313) (rs10065172). Lipopolysaccharide challenge of whole blood from randomly selected healthy volunteers (n = 70) was performed for comparison of IRGM mRNA expression among different genotypes. RESULTS: No significant difference in genotypic distributions (CC/CT/TT) at the IRGM(+313) locus was observed among the three subject groups (SS, non-sepsis, and healthy volunteers) in either cohort. When mortality were compared, no significant difference was observed in the non-sepsis group, while TT homozygotes exhibited a significantly higher mortality than the CC+CT genotype category in the SS group for both cohorts (P = 0.043, 0.037). Lipopolysaccharide challenge to whole blood showed a significant suppression of IRGM mRNA expression in TT compared with the CC+CT genotype category (P = 0.019). CONCLUSIONS: The data suggest that the IRGM(+313), an autophagy-related polymorphic locus, influences outcome in severely septic patients, with the possible involvement of autophagy in sepsis exacerbation.

Successful management by recombinant activated factor VII in a case of disseminated intravascular coagulopathy caused by obstetric hemorrhage.

Postpartum hemorrhage (PPH) is a life-threatening emergency in obstetrics. Although recombinant activated factor VII (rFVIIa) has become used for the treatment of some cases of massive hemorrhage, its applications in the field of obstetrics are still limited. We describe a case of successful treatment with rFVIIa for PPH due to placenta accreta. The patient was a 33-year-old woman with placental previa. Cesarean section (CS) was performed at gestational week 35. During CS, there was massive hemorrhage due to placenta accreta. After CS, disseminated intravascular coagulopathy and hypovolemic shock were diagnosed. The PPH was not controlled by transfusion therapy. On the fourth day after CS, rFVIIa (90 microg/kg x 2) was given because of the persistent PPH. Bleeding decreased and no further transfusion was required from 2 days after administration. rFVIIa was useful in the treatment of this case of obstetric hemorrhage.

Usefulness of procalcitonin serum level for the discrimination of severe sepsis from sepsis: a multicenter prospective study.

Procalcitonin serum level has been recommended as a new marker of bacterial infectious diseases. The aim of this prospective, multicenter study was to determine the clinical usefulness of procalcitonin in differentiating patients with sepsis from those with severe sepsis. Eighty-two patients were enrolled: 20 without systemic inflammatory response syndrome (SIRS), 9 with SIRS, 34 with sepsis, and 19 with severe sepsis. The patients with severe sepsis had significantly higher procalcitonin levels (median, 36.1 ng/ml) than those with sepsis (median, 0.6 ng/ml). With a procalcitonin cutoff value of 2.0 ng/ml, sensitivity for the detection of severe sepsis and specificity for the detection of sepsis were 94.7% and 78.1%, respectively. A good correlation was found between the serum procalcitonin level and the Sepsis-Related Organ Failure Assessment (SOFA) score (r = 0.680), although no correlation was found between the C-reactive protein (CRP) level and the SOFA score. In conclusion, the procalcitonin serum level may be useful not only for aiding the diagnosis of sepsis but also for discriminating between sepsis and severe sepsis.

Physiological response to superantigen-adsorbing hemoperfusion in toxin-concentration-controlled septic swine.

BACKGROUND/AIMS: Superantigens are suspected of being potent initiators of gram-positive sepsis, and new therapies for superantigen elimination are required. The effects of hemoadsorption with a superantigen-adsorbing device (SAAD) were evaluated in septic swine. METHODS: Toxic shock syndrome toxin-1 (TSST-1) was infused, and blood concentration was maintained at the clinical level for 6 h. Endotoxin was then infused to induce lethal shock. All animals were hemoperfused with SAAD or a control column for 8 h and changes in pathological parameters and mortality were examined. RESULTS: Animals perfused with SAAD had a highly significant (p < 0.01) survival advantage compared with control groups at 24 h after initiation of the TSST-1 infusion. SAAD also suppressed the increase in the arteriovenous shunt ratio and decrease of partial arterial oxygen pressure at 6 h after TSST-1 infusion initiation. CONCLUSION: We suggest that there is a potential application of SAAD in treating superantigen-induced respiratory dysfunction and sepsis.

Multicenter prospective study of procalcitonin as an indicator of sepsis.

The clinical significance of serum procalcitonin (PCT) for discriminating between bacterial infectious disease and nonbacterial infectious disease (such as systemic inflammatory response syndrome (SIRS)), was compared with the significance of endotoxin, beta-D: -glucan, interleukin (IL)-6, and C-reactive protein (CRP) in a multicenter prospective study. The concentrations of PCT in patients with systemic bacterial infection and those with localized bacterial infection were significantly higher than the concentrations in patients with nonbacterial infection or noninfectious diseases. In addition, PCT, endotoxin, IL-6, and CRP concentrations were significantly higher in patients with bacterial infectious disease than in those with nonbacterial infectious disease (P<0.001, P<0.005, P<0.001, and P<0.001, respectively). The cutoff value of PCT for the discrimination of bacterial and nonbacterial infectious diseases was determined to be 0.5 ng/ml, which was associated with a sensitivity of 64.4% and specificity of 86.0%. Areas under the receiver operating characteristic curves (POCs) were 0.84 for PCT, 0.60 for endotoxin, 0.77 for IL-6, and 0.78 for CRP in the combined group of patients with bacterial infectious disease and those with nonbacterial infectious disease, and the area under the ROC for PCT was significantly higher than that for endotoxin (P<0.001). In patients diagnosed with bacteremia based on clinical findings, the positive rate of diagnosis with PCT was 70.2%, while that of blood culture was 42.6%. PCT is thus essential for discriminating bacterial infection from SIRS, and is superior in this respect to conventional serum markers and blood culture.

Change in the concentration of vitamins C and E in rat tissues by paraquat administration.

Paraquat causes lung injury by oxidative stress. After 48 h of intraperitoneal administration of paraquat (50 mg/kg of body weight) to rats, the vitamin C concentration in the lungs was significantly decreased, while lung vitamin E content was increased after 12 h. These results indicate that vitamin C directly reflected the oxidative stress in the lungs.

Colloid osmotic pressure (COP) can be a good indicator of occurrence of vasospasm following subarachnoid hemorrhage (SAH).

BACKGROUND: The aim of this study was to evaluate the value of measurement of colloid osmotic pressure (COP) directly concerned with cerebral vasospasm following subarachnoid hemorrhage (SAH). MATERIAL/METHODS: The subjects were 20 patients who received clipping operation within 48 hours after onset. We conducted a two weeks monitoring of COP measured directly by osmometer and evaluated serum concentrations of albumin at the same time. We divided the patients into Group A (angiographical vasospasm +) and Group B (spasm -) according to the angiographical findings. The differences of the data between the groups were analyzed by ANOVA test (p<0.05). Furthermore, the correlations between the serum concentrations of albumin and COP levels were estimated. RESULTS: Vasospasm was angiographically confirmed in 10 of the 20 patients. Significant decrease of COP levels was observed from day 7 until day 11 and significant decrease of albumin was observed on day 6 and from day 8 until day 11 in the Group A. We did not observe any significant change of COP and albumin levels in the Group B. A liner analysis was performed and a significant correlation was determined between the COP levels and albumin in the Group A, but we did not observe significant correlation between them in the Group B. CONCLUSIONS: These results showed that a significant decrease of COP levels indicate the occurrence of cerebral vasospasm. We concluded that COP measurement could be a useful monitor of the occurrence of vasospasm following SAH.