Effects of exogenous GIP and GLP-2 on bone turnover in individuals with type 2 diabetes

CONTEXT

Individuals with type 2 diabetes (T2D) have an increased risk of bone fractures despite normal or increased bone mineral density (BMD). The underlying causes are not well understood but may include disturbances in the gut-bone axis, in which both glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-2 (GLP-2) are regulators of bone turnover. Thus, in healthy fasting participants, both exogenous GIP and GLP-2 acutely reduce bone resorption.

OBJECTIVE

The objective of this study was to investigate the acute effects of subcutaneously administered GIP and GLP-2 on bone turnover in individuals with T2D.

METHODS

We included 10 men with T2D. Participants met fasting in the morning on three separate test days and were injected subcutaneously with GIP, GLP-2, or placebo in a randomized crossover design. Blood samples were drawn at baseline and regularly after injections. Bone turnover was estimated by circulating levels of collagen type 1 C-terminal telopeptide (CTX), procollagen type 1 N-terminal propeptide (P1NP), sclerostin, and PTH.

RESULTS

GIP and GLP-2 significantly reduced CTX to (mean ± SEM) 66 ± 7.8% and 74 ± 5.9% of baseline, respectively, compared with after placebo (p = 0.001). In addition, P1NP and sclerostin increased acutely after GIP whereas a decrease in P1NP was seen after GLP-2. PTH levels decreased to 67 ± 2.5% of baseline after GLP-2 and to only 86 ± 3.4% after GIP.

CONCLUSION

Subcutaneous GIP and GLP-2 affect CTX and P1NP in individuals with T2D to the same extent as previously demonstrated in healthy individuals.

Acarbose diminishes postprandial suppression of bone resorption in patients with type 2 diabetes

AIMS

The alpha-glucosidase inhibitor acarbose is an antidiabetic drug delaying assimilation of carbohydrates and, thus, increasing the amount of carbohydrates in the distal parts of the intestines, which in turn increases circulating levels of the gut-derived incretin hormone glucagon-like peptide 1 (GLP-1). As GLP-1 may suppress bone resorption, acarbose has been proposed to potentiate meal-induced suppression of bone resorption. We investigated the effect of acarbose treatment on postprandial bone resorption in patients with type 2 diabetes and used the GLP-1 receptor antagonist exendin(9-39)NH₂ to disclose contributory effect of acarbose-induced GLP-1 secretion.

METHODS

In a randomised, placebo-controlled, double-blind, crossover study, 15 participants with metformin-treated type 2 diabetes (2 women/13 men, age 71 (57-85 years), BMI 29.7 (23.6-34.6 kg/m²), HbA1c 48 (40-74 mmol/mol)/6.5 (5.8-11.6 %) (median and range)) were subjected to two 14-day treatment periods with acarbose and placebo, respectively, separated by a six-week wash-out period. At the end of each period, circulating bone formation and resorption markers were assessed during two randomised 4-h liquid mixed meal tests (MMT) with infusions of exendin(9-39)NH₂ and saline, respectively. Glucagon-like peptide 2 (GLP-2) was also assessed.

RESULTS

Compared to placebo, acarbose impaired the MMT-induced suppression of CTX as assessed by baseline-subtracted area under curve (P = 0.0037) and nadir of CTX (P = 0.0128). During acarbose treatment, exendin(9-39)NH₂ infusion lowered nadir of CTX compared to saline (P = 0.0344). Neither parathyroid hormone or the bone formation marker procollagen 1 intact N-terminal propeptide were affected by acarbose or GLP-1 receptor antagonism. Acarbose treatment induced a greater postprandial GLP-2 response than placebo treatment (P = 0.0479) and exendin(9-39)NH₂ infusion exacerbated this (P = 0.0002).

CONCLUSIONS

In patients with type 2 diabetes, treatment with acarbose reduced postprandial suppression of bone resorption. Acarbose-induced GLP-1 secretion may contribute to this phenomenon as the impairment was partially reversed by GLP-1 receptor antagonism. Also, acarbose-induced reductions in other factors reducing bone resorption, e.g. glucose-dependent insulinotropic polypeptide, may contribute.

Testicular torsion and subsequent testicular function in young men from the general population

STUDY QUESTION

Is prior testicular torsion associated with testicular function (semen quality and reproductive hormones) in young men from the general population?

SUMMARY ANSWER

In young men from the general population, no differences in semen parameters were observed in those who had experienced testicular torsion compared to controls and observations of higher FSH and lower inhibin B were subtle.

WHAT IS KNOWN ALREADY

Testicular function may be impaired after testicular torsion, but knowledge is sparse and based on studies with small sample sizes and no control group or a less than ideal control group.

STUDY DESIGN, SIZE, DURATION

A cross-sectional population-based study was carried out including 7876 young Danish men with unknown fertility potential, examined from 1996 to 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All men (median age 19.0 years) had a physical examination, provided a blood and semen sample, and filled in a questionnaire including information about prior testicular torsion, birth, lifestyle and current and previous diseases. Markers of testicular function, including testis volume, semen parameters and reproductive hormones, were compared between men operated for testicular torsion and controls, using multiple linear regression analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

The average participation rate was 24% for the entire study period. In total, 57 men (0.72%) were previously operated for testicular torsion (median age at surgery 13.4 years) of which five had only one remaining testicle. Men with prior testicular torsion were more often born preterm (25% versus 9.5% among controls), and they had significantly higher FSH and lower inhibin B levels, and a lower inhibin B/FSH ratio than controls in crude and adjusted models. The association was mainly driven by the subgroup of men who had undergone unilateral orchiectomy. No differences in semen parameters were observed.

LIMITATIONS, REASONS FOR CAUTION

A limitation is the retrospective self-reported information on testicular torsion. Also, results should be interpreted with caution owing to the high uncertainty of the observed differences.

WIDER IMPLICATIONS OF THE FINDINGS

Overall, the results of our study are reassuring for men who have experienced testicular torsion, especially when treated with orchiopexy, for whom reproductive hormone alterations were subtle and without obvious clinical relevance. Our study found no differences in semen parameters, but follow-up studies are needed to assess any long-term consequences for fertility.

STUDY FUNDING/COMPETING INTEREST(S)

Financial support was received from the Danish Ministry of Health; the Danish Environmental Protection Agency; the Research fund of Rigshospitalet, Copenhagen University Hospital; the European Union (Contract numbers BMH4-CT96-0314, QLK4-CT-1999-01422, QLK4-CT-2002-00603, FP7/2007-2013, DEER Grant agreement no. 212844); A.P. Møller and wife Chastine Mckinney Møllers Foundation; Svend Andersens Foundation; the Research Fund of the Capital Region of Denmark; and ReproUnion (EU/Interreg). The authors have nothing to declare.

TRIAL REGISTRATION NUMBER

N/A.

Self-Reported Asthma Is Associated with Reduced Sperm Count-A Cross-Sectional Study of More than 6000 Young Men from the General Population

Asthma is driven by an inflammatory response that may impact testicular function. In this cross-sectional study, we investigated the association between self-reported asthma and testicular function (semen parameters, reproductive hormone levels), and determined whether potential further inflammation due to self-reported allergy modified this association. A total of 6177 men from the general population completed a questionnaire including information on doctor-diagnosed asthma or allergy, had a physical examination, delivered a semen sample, and had a blood sample drawn. Multiple linear regression analyses were performed. A total of 656 (10.6%) men reported having ever been diagnosed with asthma. Generally, self-reported asthma was consistently associated with a poorer testicular function; however, few estimates were statistically significant. Specifically, self-reported asthma was associated with statistically significant lower total sperm count [median: 133 vs. 145 million; adjusted β (95% CI): -0.18 (-0.33 to -0.04) million on cubic-root-transformed scale] and borderline statistically significant lower sperm concentration compared with no self-reported asthma. The association between asthma and total sperm count was of similar magnitude among men with and without allergy. In conclusion, men with self-reported asthma had poorer testicular function than men without asthma. However, the cross-sectional design of the study limits ascertainment of causality.

The role of GLP-1 in the postprandial effects of acarbose in type 2 diabetes

AIMS

The alpha-glucosidase inhibitor acarbose is believed to reduce plasma glucose by delaying hydrolysis of carbohydrates. Acarbose-induced transfer of carbohydrates to the distal parts of the intestine increases circulating glucagon-like peptide 1 (GLP-1). Using the GLP-1 receptor antagonist exendin(9-39)NH2, we investigated the effect of acarbose-induced GLP-1 secretion on postprandial glucose metabolism in patients with type 2 diabetes.

METHODS

In a double-blinded, placebo-controlled, randomized, crossover study, 15 participants with metformin-treated type 2 diabetes (age: 57-85 years, HbA1c: 40-74 mmol/mol) were subjected to two 14-day treatment periods with acarbose or placebo, respectively, separated by a 6-week wash-out period. At the end of each period, two randomized 4-h liquid mixed meal tests with concomitant infusion of exendin(9-39)NH2 and saline, respectively, were performed.

RESULTS

Compared to placebo, acarbose increased postprandial GLP-1 concentrations and decreased postprandial glucose. We observed no absolute difference in the exendin(9-39)NH2-induced increase in postprandial glucose excursions between placebo and acarbose periods, but relatively, postprandial glucose was increased by 119 ± 116% (mean ± s.d.) during exendin(9-39)NH2 infusion in the acarbose period vs a 39 ± 27% increase during the placebo period (P = 0.0163).

CONCLUSIONS

We confirm that acarbose treatment stimulates postprandial GLP-1 secretion in patients with type 2 diabetes. Using exendin(9-39)NH2, we did not see an impact of acarbose-induced GLP-1 secretion on absolute measures of postprandial glucose tolerance, but relatively, the effect of exendin(9-39)NH2 was most pronounced during acarbose treatment.

N-terminally and C-terminally truncated forms of glucose-dependent insulinotropic polypeptide are high-affinity competitive antagonists of the human GIP receptor

Background and Purpose

Glucose‐dependent insulinotropic polypeptide (GIP) affects lipid, bone and glucose homeostasis. High‐affinity ligands for the GIP receptor are needed to elucidate the physiological functions and pharmacological potential of GIP in vivo. GIP(1–30)NH₂ is a naturally occurring truncation of GIP(1–42). Here, we have characterized eight N‐terminal truncations of human GIP(1–30)NH₂.

Experimental Approach

COS‐7 cells were transiently transfected with human GIP receptors and assessed for cAMP accumulation upon ligand stimulation or competition binding with ¹²⁵I‐labelled GIP(1–42), GIP(1–30)NH₂, GIP(2–30)NH₂ or GIP(3–30)NH₂.

Key Results

GIP(1–30)NH₂ displaced ¹²⁵I‐GIP(1–42) as effectively as GIP(1–42) (K_i 0.75 nM), whereas the eight truncations displayed lower affinities (K_i 2.3–347 nM) with highest affinities for GIP(3–30)NH₂ and GIP(5–30)NH₂ (5–30)NH₂. Only GIP(1–30)NH₂ (E_max 100% of GIP(1–42)) and GIP(2–30)NH₂ (E_max 20%) were agonists. GIP(2‐ to 9–30)NH₂ displayed antagonism (IC₅₀ 12–450 nM) and Schild plot analyses identified GIP(3–30)NH₂ and GIP(5–30)NH₂ as competitive antagonists (K_i 15 nM). GIP(3–30) NH₂ was a 26‐fold more potent antagonist than GIP(3–42). Binding studies with agonist (¹²⁵I‐GIP(1–30)NH₂), partial agonist (¹²⁵I‐GIP(2–30)NH₂) and competitive antagonist (¹²⁵I‐GIP(3–30)NH₂) revealed distinct receptor conformations for these three ligand classes.

Conclusions and Implications

The N‐terminus is crucial for GIP agonist activity. Removal of the C‐terminus of the endogenous GIP(3–42) creates another naturally occurring, more potent, antagonist GIP(3–30)NH₂, which like GIP(5–30)NH₂, was a high‐affinity competitive antagonist. These peptides may be suitable tools for basic GIP research and future pharmacological interventions.

Species-specific action of (Pro3)GIP - a full agonist at human GIP receptors, but a partial agonist and competitive antagonist at rat and mouse GIP receptors

Background and Purpose

Specific, high potency receptor antagonists are valuable tools when evaluating animal and human physiology. Within the glucose‐dependent, insulinotropic polypeptide (GIP) system, considerable attention has been given to the presumed GIP receptor antagonist, (Pro3)GIP, and its effect in murine studies. We conducted a pharmacological analysis of this ligand including interspecies differences between the rodent and human GIP system.

Experimental Approach

Transiently transfected COS‐7 cells were assessed for cAMP accumulation upon ligand stimulation and assayed in competition binding using ¹²⁵I‐human GIP. Using isolated perfused pancreata both from wild type and GIP receptor‐deficient rodents, insulin‐releasing, glucagon‐releasing and somatostatin‐releasing properties in response to species‐specific GIP and (Pro3)GIP analogues were evaluated.

Key Results

Human (Pro3)GIP is a full agonist at human GIP receptors with similar efficacy (E_max) for cAMP production as human GIP, while both rat and mouse(Pro3)GIP were partial agonists on their corresponding receptors. Rodent GIPs are more potent and efficacious at their receptors than human GIP. In perfused pancreata in the presence of 7 mM glucose, both rodent (Pro3)GIP analogues induced modest insulin, glucagon and somatostatin secretion, corresponding to the partial agonist activities observed in cAMP production.

Conclusions and Implications

When evaluating new compounds, it is important to consider interspecies differences both at the receptor and ligand level. Thus, in rodent models, human GIP is a comparatively weak partial agonist. Human (Pro3)GIP was not an antagonist at human GIP receptors, so there is still a need for a potent antagonist in order to elucidate the physiology of human GIP.

Insulin analogues and severe hypoglycaemia in type 1 diabetes

INTRODUCTION

The effect of insulin analogues on glycaemic control is well-documented, whereas the effect on avoidance of severe hypoglycaemia remains tentative. We studied the frequency of severe hypoglycaemia in unselected patients with type 1 diabetes treated with insulin analogues, human insulin, or mixed regimens.

METHODS

A questionnaire was posted from six Danish diabetes clinics to 6112 unselected patients with type 1 diabetes and filled in by 3861 patients (63.2%). Primary endpoint was number of episodes of severe hypoglycaemia in the preceding year. Mild hypoglycaemia was also reported.

RESULTS

The frequency of severe hypoglycaemic episodes per patient-year in patients receiving long-acting insulin analogues was 1.47±0.18 versus 1.09±0.10 in patients on long-acting human insulin (p=0.01). The frequency of severe hypoglycaemic episodes per patient-year was 1.09±0.11 in patients on short-acting insulin analogues versus 1.26±0.13 in patients on short-acting human insulin (p=0.15), which was statistically significant in an adjusted analysis.

CONCLUSIONS

Severe hypoglycaemia is more frequent in patients with type 1 diabetes treated with long-acting insulin analogues. Confounding by indication may be involved. Clinical intervention trials using insulin analogues in patients prone to severe hypoglycaemia are highly needed.

Gender differences in diabetes mellitus and effects on self-care activity

BACKGROUND

Effective self-care, including adherence to diet, exercise, and medication regimens, is an essential component of health care for individuals with diabetes mellitus (DM).

OBJECTIVE

The goals of this study were to examine sex-based differences in DM and to explore the effects of gender on self-care.

METHODS

This study was conducted retrospectively using data from the 2001 Medical Expenditure Panel Survey (MEPS). People with DM were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code; analyses were stratified by sex. Variables included age, race/ethnicity, education, income, body mass index (BMI), number of comorbidities, physical and cognitive limitations, smoking status, and depression. Outcome measures were assessed by Short Form-12 (SF-12) Mental Component Summary (MCS) and Physical Component Summary (PCS) scores. Univariate analyses were determined using t, chi(2), or Fisher exact tests, as appropriate. Multivariate analyses examined associations between sex and SF-12 MCS/PCS scores adjusted for other variables.

RESULTS

A total of 1653 MEPS respondents (883 women, 770 men) with DM were identified for the current study. The women were significantly older than the men (61.2 vs 59.1 years), had less education (11.1 vs 12.0 years), and had lower incomes. Women had higher calculated BMI (31.4 vs 30.3), more comorbidities (7.8 vs 6.4), more depression, and more physical and cognitive limitations than did men. Women also scored lower than men on the SF-12 MCS and PCS (47.8 vs 49.9 and 38.2 vs 41.4, respectively). All these measures were statistically significant (P < 0.01). In multivariate analyses, physical limitations, BMI, and number of comorbidities were negatively correlated, and income and education were positively correlated, with MCS and PCS scores.

CONCLUSIONS

Compared with their male counterparts, diabetic women scored lower on measures of health status and functioning-factors that are likely to affect self-care activities. Sex-based differences should be considered when developing screening and treatment programs for people with DM.

Treatment of acute severe asthma and chronic obstructive pulmonary disease in Danish hospitals. Do national recommendations improve on the quality of the treatment?

Studies have demonstrated suboptimal treatment of acute severe asthma and chronic obstructive pulmonary disease (COPD). We examined the quality of treatment in Denmark and the effect of intervention, by publication of recommendations for standardised treatment. All 70 hospitals in Denmark with emergency facilities participated in a telephone questionnaire, examining treatment behaviours among house officers. The survey was repeated 3 years later, after publication of national recommendations for treatment of acute exacerbations of asthma and COPD. The response rate in both surveys was 100%. An insufficient handling of nebulisers, a huge variation in the delivered dose of bronchodilators and a suboptimal use of corticosteroids was found. A significant trend towards more liberate use of oxygen was seen in both asthma (3.2 l min(-1) versus 4.8 l min(-1), P<0.001) and COPD (1.5 l min(-1) versus 1.9 l min(-1), P = 0.047). Further, a huge difference in treatment behaviours was revealed from this survey The knowledge among house officers of basic principles of treatment was insufficient. Treatment behaviour was only moderately affected by national publication of detailed recommendations for treatment. This study indicates a need for implementing tools for quality control.

A proposal for a practical treatment guideline designed for the initial two-hours of the management of patients with acute severe asthma and COPD using the principles of evidence-based medicine

We have proposed a clinical treatment guideline for the management of acute, severe asthma and chronic obstructive pulmonarydisease (COPD) using the principles of evidence-based medicine. The content is based upon practical clinical issues in need of consensus. A previous study has shown that this particular area is in serious need of quality control. Based on a strict 2 h time schedule with a unified treatment plan for both asthma and COPD, it is possible to secure for the patients a well-documented medical therapy promoting decision-making and clarification of the patient within this time limit. A summary of the statements is presented in a one-page, user-friendly format in order to cope with the clinician's need of having access to published evidence quickly and easily. A website (www.phanareth.dk or a website provided by Respiratory Medicine) has been established providing regular updates. A strategy for the implementation and the evaluation process has been planned after the publication of this paper. We believe this approach to be an important step towards an increase in the quality of guidelines and also a tool to make "guideline writers" aware of the responsibility of making their recommendations work.

Effect of temperature on parasitism and host-feeding of Trichogramma turkestanica (Hymenoptera: Trichogrammatidae) on Ephestia kuehniella (Lepidoptera: Pyralidae)

The egg parasitoid Trichogramma turkestanica Meyer is being evaluated as a biological control agent against the Mediterranean flour moth, Ephestia kuehniella Zeller, in flour mills. The longevity, parasitism and host-feeding of the parasitoid at four constant temperatures (15-30 degrees C) has been determined in the laboratory. The highest fecundity occurred at intermediate temperatures. The number of host eggs killed by host-feeding per female was highest at the two lower temperatures. A very conservative estimate of host-feeding showed that it accounts for approximately half of the mortality of host eggs at 20 and 25 degrees C and thus could constitute a major mortality factor for the flour moth population.

Neonatal cocaine exposure, activity, and responsivity to cocaine in a rodent model

This study examined the effects of neonatal cocaine exposure on running wheel activity and subsequent responsivity to cocaine using a rodent model. Subjects were artificially reared from postnatal (PND) days 4-10 via an intragastric cannula. The four treatment groups included two cocaine doses (20 mg/kg/day and 40 mg/kg/day), an artificially reared control and a normally reared suckled control. Subjects were tested at either PND 21 through PND 24 (Experiment 1) or PND 60 through PND 70 (Experiment 2) for 2 consecutive days. Testing consisted of a 30-min habituation period followed by injection of either saline (Day 1) or cocaine (Day 2) and an additional 60-min test session. Neonatal treatment had little effect on baseline activity or activity following saline injection at either age. All subjects showed an activation with cocaine injections, however, the activation was more pronounced in juveniles. Again, neonatal treatment did not interact with response to cocaine. These findings suggest that neonatal cocaine exposure does not alter activity or long-term responsivity to 20 mg/kg cocaine as measured in the running wheel apparatus.

Histopathology of smokeless tobacco lesions in professional baseball players. Associations with different types of tobacco

We examined 142 biopsy specimens of smokeless tobacco-associated oral mucosal lesions from 133 professional baseball players. Four types of epithelial change were observed in the specimens: hyperparakeratosis, hyperorthokeratosis, pale surface staining, and basal cell hyperplasia. These types of epithelial change were associated with the type of smokeless tobacco used (snuff or chewing tobacco) but not with the duration (years) or amount (hours per day) of use. The thickness of hyperkeratosis in a specimen correlated directly with the amount of smokeless tobacco use. The use of snuff was more frequently associated with development of oral mucosal lesions than was the use of chewing tobacco, and snuff appeared to cause a greater variety and severity of epithelial change than did chewing tobacco.

Choristomas of the oral cavity: a review

The choristoma is a tumorlike mass of normal cells in an abnormal location. Intraoral choristomas have been reported under a wide variety of names. This comprehensive review of the English-language literature on oral choristomas offers a classification of these lesions, analyzes their clinical and histologic features, and discusses possible pathogeneses and treatment.

Peripheral (extraosseous) calcifying odontogenic cyst. A review of forty-five cases

The peripheral calcifying odontogenic cyst (PCOC) is a rare lesion. The number of well-documented cases reported in the English-language literature until now is 38. The purpose of the present study is twofold: (1) to report seven new cases of PCOC and (2) to review and analyze the clinical and histomorphologic features of the previously reported cases of PCOC together with those of the present study. Most of the lesions were located in the maxillary and mandibular gingiva or alveolar mucosa anterior to the region of the first molar. Histologically, 66% of the lesions were of the cystic variant and 34% of the solid (neoplastic) variant. The terminology of the lesion and its histogenesis are discussed.

Assessing the influence of reversible disease indicators on survival

In a randomized clinical trial of the effect of prednisone versus placebo on survival in patients with liver cirrhosis, follow-up visits were scheduled after 3, 6 and 12 months of treatment and thereafter once a year. At each follow-up the prothrombin index, a measure of liver function, was recorded and scored as either low or normal. The interaction between treatment and prothrombin index was analysed using a three-state illness-death model with recovery. The continuous-time Markov process model with constant or piecewise constant intensities suggested by Kay allows inference to proceed even though the status of the disease indicator, here the prothrombin index, is only known at the time of each visit and not between visits. We compare the analysis with the theoretically incorrect, but practically rather common approximation, where the status of the disease indicator is assumed to remain constant from one visit until just before the next. Under this approximation both standard parametric methods and non-parametric approaches developed by Aalen and Johansen are available.

Melanocytic hyperplasia of the oral mucosa

Lesions that exhibit melanocytic hyperplasia are uncommon in the oral mucosa. They are even more rare than the various morphologic types of nevomelanocytic lesions. This article reports the clinicopathologic features of oral lesions diagnosed as lentigo simplex, junctional lentigo ("jentigo"), atypical melanocytic hyperplasia (melanoma in situ), and melanocanthoma. The proper terminology for these lesions is also discussed.

Oral focal mucinosis

Oral focal mucinosis (OFM) is an uncommon clinicopathological entity which is considered to be the oral counterpart of cutaneous focal mucinosis and/or cutaneous myxoid cyst. It is comprised of a clinically elevated mass with a histological picture of localized areas of myxomatous connective tissue. The present study adds 15 new cases of OFM to the literature and analyzes their clinical, histological and histochemical features. Most of the lesions were located in the gingiva and alveolar mucosa. The nature of the lesion is unclear and it is suggested that the mucinous accumulation is the result of fibroblastic overproduction of hyaluronic acid.

Hyaline ring granuloma: a distinct oral entity

Hyaline ring granuloma (HRG) is a distinct oral entity. In this study, 64 cases from the literature are analyzed and two new cases are reported. The lesions could be classified by location as central hyaline ring granuloma (42%) and peripheral hyaline ring granuloma (53%). Radiographically, a radiolucent area irregularly outlined by well-formed trabeculae of bone was found in central HRG, and a poorly defined erosion at the crest of the alveolar ridge was often found in peripheral HRG. Occasionally, the lesion occurred in the connective tissue wall of cysts (5%). The etiology of this condition is controversial, but most lesions were in edentulous areas and most patients had a history of tooth extraction or other trauma. The majority of cases (83%) occurred in the mandible, usually posterior to the premolar. The mean age of patients at diagnosis was 43 years, and the male/female ratio was 1.9:1. Pain was not a symptom, although local discomfort, such as recurrent swelling and tenderness, was noted in many cases. Hyaline rings with giant cell inclusions are the significant features for histopathologic diagnosis. HRG is treated by curettage or surgical excision, care being taken to remove the entire lesion. The removal of a peripheral HRG in an edentulous jaw should be followed by careful smoothing of the bone surface, since the lesion tends to infiltrate and is not well demarcated. Recurrence, probably due to incomplete excision, is uncommon.

The retrocuspid papilla of the mandibular lingual gingiva

The retrocuspid papilla (RCP) is a circumscribed nodule that lies lingual to the mandibular cuspid on the gingival tissue. RCP is observed more frequently in young children and seems to regress or disappear with age. Little information is available in the literature on this entity and there are contradictory reports regarding its histologic features. Histomorphologic analysis of 30 specimens diagnosed as RCP revealed that in most cases (80%) it is composed of loosely-arranged delicate fibrous connective tissue with stellate and multinucleated fibroblasts. Elongation of the rete ridges and/or increased vascularity are also present in a significant number of cases. Stellate and multinucleated fibroblasts are not unique to RCP and they have been described as prominent histologic features in other lesions of skin and mucous membrane. RCP is considered to be a "normal anatomical structure" or an "anatomic variation" of the gingiva. The clinical significance of RCP is that it may simulate pathological gingival conditions from which it must be differentiated.

A comparison of carbon dioxide laser, liquid nitrogen cryosurgery, and scalpel wounds in healing

With the carbon dioxide surgical laser, the liquid nitrogen cryoprobe, and the scalpel, wounds were created on the shaved abdomen of 24 rats, and the patterns of healing were studied. The laser wounds were the first to epithelialize, followed by the scalpel wounds, with the cryosurgery wounds the slowest to epithelialize. The results were confirmed histologically.

[Utilization of medical services for children in an area of Copenhagen]

As part of the development of models for community services for children, the utilization of the medical services for children in a local area in Copenhagen viz the catchment region of the Osterbro Social Centre was reviewed. By means of contact investigations in the above mentioned region with the general practitioners and duty roster doctors in two selected weeks and by information from the Casualty Department Register in the University Hospital and from the National Danish Patient Register, the pattern of illness for children aged 0-14 years and utilization of medical services in the year 1986 was described. Utilization of casualty departments was uniform throughout childhood. In the course of one year, every third child, on an average, had had contact with a casualty department. This is in contrast with other sections of medical services where utilization decreases with increasing age of the child. The frequency of admission to hospital was high, particularly for the youngest children. The majority of all contacts were on account of infectious diseases. A community, multidisciplinary effort to reduce ill health is suggested to combat the many illnesses due to infection, the numerous contacts with doctors and hospital admission. Choice of doctor in cases of acute illness in children is discussed.

Ganglioneuroma of the mandible

This article reports a very rare case of ganglioneuroma within the mandible. The patient, 15 years of age at first diagnosis, has now had 17 years of followup and remains generally healthy, despite the continued presence of the tumor. Possible origin of the lesion, histologic differentiation of this tumor from normal ganglia, and recommendations for management are discussed. Two reported cases of ganglioneuroma that occurred centrally in the mandible are also reviewed.

Clear cell odontogenic carcinoma: report of three cases with pulmonary and lymph node metastases

Three cases of a newly described rare odontogenic tumor are reported. One patient died with pulmonary metastases, one had an associated odontogenic cyst and one exhibited regional lymph node metastasis. The cases lend support to the odontogenic origin and metastatic capability of the clear cell odontogenic tumor. The authors recommend aggressive therapy and believe that the tumor should be considered a clear cell odontogenic carcinoma.

Mixed odontogenic tumors: an analysis of 23 new cases

The ameloblastic fibroma, ameloblastic fibrodentinoma, and ameloblastic fibro-odontoma are mixed odontogenic tumors that are considered to arise from both epithelial and mesenchymal elements of the tooth germ. This article presents the clinical and histopathologic characteristics of 23 new cases. The patients' ages ranged from 3 to 19 years (median 9). Most tumors were asymptomatic and were associated with an unerupted tooth or teeth. All patients were treated with simple enucleation of the tumor. We found that histologically these lesions comprise a spectrum. Some were probably benign odontogenic tumors (neoplasms) and others were odontomas undergoing maturation (hamartomas); however, in any given case we were, on histologic grounds, unable to differentiate the two. The majority, if not all, of our cases were nonaggressive with little or no tendency to recur, whereas some reported cases have exhibited local aggressiveness and recurrence, suggestive of neoplasia. In our opinion, it is clinically important to distinguish the mixed odontogenic tumors from ameloblastoma since the mixed tumors, found mostly in children, are relatively benign when compared to ameloblastoma, which is found in all age groups (usually adults). The usually innocuous behavior of these lesions does not justify aggressive treatment initially, and simple enucleation should be appropriate in most cases.

Nuclear DNA analysis of oral hyperplasia and dysplasia using image cytometry

We investigated the value of image analysis in discriminating among oral white lesions with hyperplasia without dysplasia and oral white or white-and-red lesions with moderate or severe dysplasia. Normal oral epithelial tissue was used as a control. Image analysis was applied to 5-micron formalin-fixed sections stained with the azure A-Feulgen reaction for nuclear DNA. For 150-200 cells from each section, 5 nuclear variables were assessed: area, form factor, total stain, average stain and ellipticity. For each variable, 2 measurements were obtained, the mean and the interquartile range, and were used for stepwise discriminant analysis. Using this test, a model of 3 measurements with the most discriminating power was developed. When the jackknife classification test was applied to this model, we could discriminate with 81% accuracy between the 4 groups of tissue studied.

Peripheral odontogenic fibroma

Peripheral odontogenic fibroma (WHO type) is an uncommon lesion of the gingiva; 18 well-documented cases have been published. It is considered to be the extraosseous counterpart of the central odontogenic fibroma. Because of the paucity of reported cases, the full histomorphologic spectrum of this lesion has not yet been established. This article presents nine cases of peripheral odontogenic fibroma that illustrate the variety of its histopathologic findings. The connective tissue ranged from loose (almost myxomatous) to markedly cellular to relatively acellular and well-collagenized. Islands and/or strands of odontogenic epithelium were present in all lesions. Matrix of mineralized material was present in three cases, and juxtaepithelial hyalinization was seen in one case. To avoid the introduction of additional diagnostic terms, we suggest that all these lesions be considered a spectrum of the peripheral odontogenic fibroma (WHO type). We also suggest that the term WHO type be used to distinguish peripheral odontogenic fibromas from the peripheral ossifying fibroma with which they have often been confused.

Central giant cell lesions of the mandible and maxilla: a clinicopathologic and cytometric study

Computer-assisted image analysis was used to measure four histopathologic parameters (number of giant cells, mean number of nuclei per giant cell, fractional surface area, and relative size index) in two groups of patients with central giant cell lesions in a search for possible histologic predictors of clinical behavior. The lesions of 22 patients were classified clinically into nonaggressive and the lesions of 10 patients were classified into aggressive categories in accordance with the method of Chuong and Kaban. The majority of patients with aggressive lesions had recurrent tumors within 2 years and/or experienced pain, root resorption, and cortical perforation. Giant cells were selected in 25 random high-power magnification (X400) fields and measured by means of the Leitz Texture Analysis System-Plus. Linear stepwise discriminant analysis was applied to each parameter studied. Clinically aggressive giant cell lesions were characterized by a higher number of giant cells and greater fractional surface area when compared with the nonaggressive tumors. With the use of the "jackknife" classification procedure, the accuracy of the two statistically significant parameters (number of giant cells and fractional surface area) in predicting the aggressiveness or the nonaggressiveness of our group of central giant cell granulomas was, respectively, 70% and 82%. This study provides further evidence that the use of cytometric analysis of giant cells may be helpful in predicting prognosis and in planning treatment for these often difficult-to-manage lesions.

Pigmented nevi of the oral mucosa: a clinicopathologic study of 36 new cases and review of 155 cases from the literature. Part II: Analysis of 191 cases

Review and analysis of data on 191 cases of oral pigmented nevi from the literature and from two studies at the University of California, San Francisco, revealed that nevi of the intramucosal type are the most common, followed by the common blue nevus. Compound and junctional nevi are rare, and combined nevi are the rarest. The data on location, presence of clinical pigmentation, configuration, size, and duration of the nevi, as well as on the patient's age, sex, and race, are analyzed. Blue nevi were found mostly on the hard palate, whereas intramucosal nevi occurred on the buccal mucosa, on the gingiva, and on the lips as well as on the palate. Nonpigmented nevi were especially common (22%) in the intramucosal group. Most oral nevi are raised, which can be of help in the differential diagnosis. Oral nevi are small, most being between 0.1 and 0.6 cm at the largest dimension. Because the malignant potential of oral nevi is still uncertain and because preexisting macular pigmentation is present in about one third of all patients with oral melanoma, it is advisable to accurately diagnose all oral pigmented lesions, many of which will require microscopic examination.

Granulocytic sarcoma (chloroma) of the oral cavity: a case with aleukemic presentation

A case of granulocytic sarcoma, or chloroma, of the palatal mucosa, which developed 15 months before the onset of acute myelogenous leukemia (AML), is reported. The diagnosis was suspected on the basis of the light microscopic findings and confirmed by histochemical studies. Granulocytic sarcomas are rare, may be observed in a variety of body locations, and are considered specific lesions of AML or of the onset of blast crisis in chronic myelogenous leukemia. Primary granulocytic sarcomas of the oral cavity without systemic manifestations of AML are extremely rare. Clinical diagnosis of these lesions in patients with normal peripheral blood and bone marrow may be very difficult.

Pigmented nevi of the oral mucosa: a clinicopathologic study of 36 new cases and review of 155 cases from the literature. Part I: A clinicopathologic study of 36 new cases

Pigmented nevi are uncommon oral lesions. This study adds data on 36 new cases. The most common type of nevus was the intramucosal type (20 cases), followed by the common blue nevus (11 cases). Only three cases were of the compound type and only two were of the junctional type. The hard palate was the most frequent location for the blue nevus, whereas the buccal mucosa was the most frequent site for the intramucosal nevus. One nevus (intramucosal type) was located on the tongue, and to our knowledge, this is the first reported example of pigmented nevus at this site. The individual data on the 36 cases are presented and compared with a previous study on oral nevi from the University of California at San Francisco. The previously unpublished clinical details on the 32 nevi from the previous study are also presented.

Peripheral ameloblastoma. A case report

The peripheral or extraosseous ameloblastoma is a rare tumour of the oral cavity. Only a few well-documented cases have been reported. One additional case of this infrequent tumour in a 70-year-old edentulous man is described. The tumour arose on the mucosa of the lower alveolar crest. It was asymptomatic tender, with a raised and red appearance. The tumour was excised and no evidence of recurrence was seen five years later. Peripheral ameloblastoma probably arises from oral mucosa or from cell rests. It is less invasive than its intraosseous counterpart, and surgical excision with adequate margins is the treatment of choice.

Intramural calcifying epithelial odontogenic tumor

The calcifying epithelial odontogenic tumor (CEOT) is a rare lesion of the jaws. It accounts for about 1% of all odontogenic tumors. The CEOT occurs primarily in the molar-premolar region of the mandible, and 52% of cases are associated with an unerupted tooth. This report describes an unusual case in a 37-year-old woman. The tumor arose in the molar area of the right mandible, appeared radiographically as a radiolucent lesion, and was thought to be a dentigerous cyst in association with an impacted first molar. The lesion was enucleated. Microscopic examination showed it to be a dental sac, within which were the 3 elements of a typical CEOT: squamoid cells with eosinophilic cytoplasm, the homogeneous eosinophilic substance, and calcium salt deposits in the form of Liesegang rings.

The histomorphologic spectrum of peripheral ossifying fibroma

A series of 207 cases of peripheral ossifying fibroma was analyzed both clinically and histologically. Almost 60% of the lesions occurred in the maxilla, and in both jaws more than 50% occurred in the incisor-cuspid region. The lesion was most common in the second decade. Females were affected more frequently than males; the ratio was 1.7:1. The recurrence rate--16%--was relatively high. Histologically, in 66% of the cases the surface epithelium was ulcerated and in the remainder it was intact. The ulcerated lesions were composed of highly cellular fibroblastic connective tissue, whereas in the nonulcerated lesions part of the tissue was more collagenized. Both types contained mineralized products in the form of bone, cementum-like material, and/or a dystrophic type of calcification. The dystrophic calcification was most prevalent in the ulcerated lesions. The mean duration at time of excision for the ulcerated lesions was 5.6 months and for the nonulcerated lesions was 24 months. It is proposed that the ulcerated and nonulcerated lesions represent a spectrum of one lesion with different stages of maturation.

Thalassemia diagnosed through facial distortion

Thalassemia is an inherited genetic disorder of hemoglobin synthesis characterized by a reduction of either alpha or beta chains of globin. Typical features of patients with thalassemia are skeletal modifications, particularly in the skull and in the malar bone. This report describes a patient who was originally found to have an oro-facial deformity and subsequently demonstrated clinical and laboratory findings consistent with those recorded for thalassemia intermedia.

Combined nevi of the oral mucosa

Pigmented nevi are uncommon oral lesions. We report the clinical and microscopic features of three cases of combined nevus, characterized by the association of an intramucosal nevus and a common blue nevus. Two cases were clinically suspected to be melanoma. The lesions were located on the maxillary gingiva, the mandibular gingiva, and the mucosa of the left posterior portion of the hard palate. Combined nevi of the skin vary considerably in histologic appearance. The microscopic findings demonstrated by oral combined nevi also appear to exhibit substantial histologic variation. The oral combined nevus should be differentiated from malignant melanoma by histopathologic means for, as in the skin, it appears to be clinically benign.

Artefacts created during oral biopsy procedures

Biopsy specimens removed from the oral cavity are often small, and there is high potential for causing artefacts at several stages: during removal, fixation, embedding, or staining. This report describes several of the most common artefacts created by erroneous handling of oral tissue and lists recommendations for preventing them.

The intraoral keratoacanthoma: a diagnostic problem

A case of keratoacanthoma occurring on the palatal gingivae of a 23 year-old male is reported. The differential diagnosis between this lesion and well-differentiated squamous cell carcinoma is discussed.

Oral melanoma: report of case

A case is presented of a patient whose death might have been prevented if the dentist had been aware of the malignant potential of a benign-appearing oral mucosa pigmentation. Early recognition, diagnosis, and treatment of pigmented oral lesions are emphasized.

Intraoral solitary glomus tumor (glomangioma): case report and literature review

The glomus tumor, or glomangioma, is a benign neoplasm arising from the normal glomus. Glomus tumors of the oral cavity are rare, with only ten cases reported in the literature. We report the light and electron microscopic features of an additional case of glomus tumor of the lip which occurred as a solitary, painless, submucosal mass in a 51-year-old woman. Clinical, diagnostic, and histogenetic aspects are discussed.

Malignancy grading in oral squamous cell carcinoma. I. Squamous cell carcinoma of the tongue and floor of mouth: histologic grading in the clinical evaluation

In a retrospective histological and clinical study, a multifactorial grading system was used for histological classification and grading of malignancy in 51 cases of squamous cell carcinoma of the tongue and floor of mouth. The results indicated that the use of such a multifactorial grading system, consisting of 7 morphological parameters, including an evaluation of both the tumor cell population itself and the tumor-host relationship, can serve as an important supplement to clinical judgement in determining the outcome of the oral tumor.

Idiopathic lingual mandibular bone "depression"

A case of Stafne's idiopathic lingual bone depression is described. This occurred in the classical position below the mandibular molars. On surgical exploration, the defect was found to contain a lymph node rather than the more usual salivary tissue. This may throw some light on the possible etiology of this condition.

Clear cell odontogenic tumor--a new histologic variant with aggressive potential

This report delineates the clinical and laboratory findings for a previously unreported neoplasm of putative odontogenic origin. We describe the clinical, radiographic, operative, histologic, histochemical, and ultrastructural findings of the tumor in three women. All lesions were centrally located in the jaw bones, were expansile, and, except for mobile teeth and/or jaw enlargement, exhibited few symptoms. Radiographically, there was bone and tooth destruction resulting in poorly delineated margins. Microscopically, the tumors were nearly identical in that they consisted primarily of large sheets and islands of uniform vacuolated and clear cells without evidence of amyloid deposition, calcification, or glandular differentiation. One of the lesions recurred 1 1/2 years after removal without evidence of metastasis. The results, based only on these cases, suggest that this is a locally aggressive neoplasm of odontogenic origin. Casual microscopic examination of this rare neoplasm could result in misdiagnosis as a metastatic clear cell neoplasm, especially renal cell carcinoma.

Limited Wegener's granulomatosis. Report of a case with oral, renal, and skin involvement

Limited Wegener's granulomatosis is a form of the disease in which only one or two organ systems are involved. A rare case is reported in which the initial symptoms were in the skin and the lip, complicated by skin lesions exhibiting features of a clinical variant of lupus erythematosus.

Proliferative verrucous leukoplakia. A long-term study of thirty patients

Up to 6% of oral leukoplakia, a relatively common mucosal disease, can be expected to become malignant. This report describes a long-term study of 30 patients in whom a particular form of leukoplakia was identified and labeled proliferative verrucous leukoplakia (PVL), a disease of unknown origin, which exhibits a strong tendency to develop areas of carcinoma. PVL begins as a simple hyperkeratosis but tends to spread and become multifocal. PVL is slow-growing, persistent, and irreversible, and in time areas become exophytic, wartlike, and apparently resistant to all forms of therapy as recurrence is the rule. The disease was most commonly seen in elderly women and had been present for many years. Patients were followed for 1 to 20 years. Thirteen died of or with their disease, 14 were alive with PVL, and 3 were alive without PVL at last contact. PVL rarely regressed despite therapy. All patients who died had persistent or recurrent disease. PVL appears to constitute a continuum of hyperkeratotic disease, ranging from a simple hyperkeratosis at one end to invasive squamous cell carcinoma at the other. Microscopic findings are dependent upon the stage of the disease's development and the location and adequacy of the biopsy.