Hung Wing Yin Vivian. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2004. / Includes bibliographical references (leaves 128-142). / Abstracts in English and Chinese ; appendix in Chinese. / ABSTRACT --- p.i / ABSTRACT (in Chinese) --- p.iv / ACKNOWLEDGMENT --- p.vii / TABLE OF CONTENTS --- p.viii / LIST OF TABLES --- p.xiv / LIST OF FIGURES --- p.xvi / LIST OF ABBREVIATIONS --- p.xix / Chapter I. --- INTRODUCTION --- p.1 / Chapter 1.1. --- Scoliosis --- p.1 / Chapter 1.1.1. --- Classification of scoliosis --- p.1 / Chapter 1.1.2. --- Idiopathic scoliosis --- p.1 / Chapter 1.1.3. --- Clinical examination --- p.2 / Chapter 1.1.4. --- Curve pattern --- p.2 / Chapter 1.2. --- Etiology of AIS --- p.3 / Chapter 1.2.1. --- Prevalence of AIS --- p.5 / Chapter 1.2.2. --- Anthropometric Measurement in AIS --- p.5 / Chapter 1.2.3. --- Bone mass --- p.6 / Chapter 1.2.4. --- Bone mineral density measurements --- p.6 / Chapter 1.2.5. --- Osteopenia in AIS --- p.7 / Chapter 1.3. --- Natural history ofAIS --- p.8 / Chapter 1.3.1. --- Curve progression --- p.9 / Chapter 1.3.2. --- Treatment of scoliosis --- p.11 / Chapter 1.4. --- Research questions --- p.12 / Chapter 1.5. --- Objectives --- p.13 / Chapter II. --- METHODOLOGY --- p.20 / Chapter 2.1 --- Study Design --- p.20 / Chapter 2.2 --- Subject recruitment --- p.20 / Chapter 2.2.1 --- AIS patients --- p.20 / Chapter 2.2.2 --- Inclusion criteria --- p.20 / Chapter 2.2.3 --- Exclusion criteria --- p.20 / Chapter 2.2.4 --- Informed consent --- p.21 / Chapter 2.3 --- Grouping for chronological age --- p.21 / Chapter 2.4 --- Radiography assessments --- p.21 / Chapter 2.4.1 --- Cobb angle measurement --- p.21 / Chapter 2.4.2 --- Curve pattern --- p.22 / Chapter 2.4.3 --- Risser grade --- p.22 / Chapter 2.5 --- Definition of curve progression --- p.22 / Chapter 2.6 --- Bone mineral density (BMD) measurements --- p.23 / Chapter 2.6.1 --- Dual energy X-ray Absorptiometry (DXA) --- p.23 / Chapter 2.6.2 --- Peripheral quantitative computed tomography (pQCT) --- p.24 / Chapter 2.6.3 --- Definition of osteopenia or low bone mass --- p.24 / Chapter 2.7 --- Anthropometric measurements --- p.25 / Chapter 2.7.1 --- Body height --- p.25 / Chapter 2.7.2 --- Body weight --- p.26 / Chapter 2.7.3 --- Arm span --- p.26 / Chapter 2.7.4 --- Sitting height --- p.27 / Chapter 2.8 --- Family history --- p.27 / Chapter 2.9 --- Menstrual status --- p.27 / Chapter 2.10 --- Medication and fracture history --- p.27 / Chapter 2.11 --- Statistical analysis --- p.27 / Chapter 2.11.1 --- Sample size power calculation --- p.28 / Chapter 2.11.2 --- Student t test --- p.28 / Chapter 2.11.3 --- Paired t-test --- p.28 / Chapter 2.11.4 --- Predicting the incidence of curve progression --- p.28 / Chapter 2.11.4.1 --- Predictive outcome --- p.28 / Chapter 2.11.4.2 --- Potential risk factors --- p.28 / Chapter 2.11.4.3 --- Coding system for categorical variables --- p.29 / Chapter 2.11.4.4 --- Univariate analysis --- p.30 / Chapter 2.11.4.5 --- Logistic regression --- p.30 / Chapter 2.11.4.6 --- Receiver operating characteristics (ROC) curves --- p.32 / Chapter III. --- RESULTS --- p.54 / Chapter 3.1 --- Patients Characteristics --- p.54 / Chapter 3.1.1 --- Sample size --- p.54 / Chapter 3.1.2 --- Distribution of patient characteristics --- p.54 / Chapter 3.1.3 --- Drop out --- p.54 / Chapter 3.1.4 --- Prevalence of osteopenia (BMDage-adjusted ≤ -1) and low bone mass (BMCage-adjusted ≤ -1) --- p.55 / Chapter 3.1.5 --- Comparison between the BMD of the bilateral hip and tibia --- p.55 / Chapter 3.2 --- Comparison of AIS patients with osteopenia and with normal bone status --- p.55 / Chapter 3.3 --- Univariate analysis --- p.56 / Chapter 3.3.1 --- Growth related factors --- p.56 / Chapter 3.3.2 --- "Skeletal related parameters (areal BMD, volumetric BMD and BMC)" --- p.56 / Chapter 3.3.2.1 --- DXA lumbar spine --- p.56 / Chapter 3.3.2.2 --- DXA proximal femur at the convex-side hip --- p.56 / Chapter 3.3.2.3 --- DXA proximal femur at the concave-side hip --- p.57 / Chapter 3.3.2.4 --- pQCT at non-dominant distal radius --- p.57 / Chapter 3.3.2.5 --- pQCT - vBMD at convex-side distal tibia --- p.57 / Chapter 3.3.2.6 --- pQCT - vBMD at concave-side distal tibia --- p.58 / Chapter 3.3.3 --- Curve related factors --- p.58 / Chapter 3.3.4 --- Anthropometrics parameters --- p.58 / Chapter 3.3.5 --- Family history --- p.58 / Chapter 3.3.6 --- Summary of univariate analysis --- p.59 / Chapter 3.4 --- Logistic regression model (single factor) --- p.59 / Chapter 3.5 --- Logistic regression model (multiple factors) --- p.60 / Chapter 3.5.1 --- BMD inclusive model --- p.60 / Chapter 3.5.2 --- BMC inclusive model --- p.61 / Chapter 3.5.3 --- Conventional model --- p.63 / Chapter 3.6 --- ROC curve --- p.63 / Chapter 3.6.1 --- BMD inclusive model --- p.64 / Chapter 3.6.2 --- Conventional model --- p.64 / Chapter 3.7 --- Predictive equation obtained from different logistic regression models --- p.64 / Chapter 3.7.1 --- BMD inclusive model --- p.65 / Chapter 3.7.2 --- Conventional model --- p.65 / Chapter IV. --- DISCUSSION --- p.105 / Chapter 4.1 --- Prognostic factors for curve progression --- p.105 / Chapter 4.1.1 --- Well-known prognostic factors --- p.105 / Chapter 4.1.1.1 --- Growth-related factors --- p.106 / Chapter 4.1.1.2 --- Initial curve magnitude --- p.107 / Chapter 4.1.2 --- A new predictor 一 Osteopenia --- p.107 / Chapter 4.2 --- Non-significant prognostic factors for curve progression --- p.109 / Chapter 4.2.1 --- Anthropometric parameters --- p.109 / Chapter 4.2.2 --- Family History --- p.110 / Chapter 4.2.3 --- Curve pattern --- p.110 / Chapter 4.3 --- Predictive model --- p.111 / Chapter 4.4 --- Comparison of predictive models between BMD inclusive model and conventional model derived from our population --- p.115 / Chapter 4.5 --- Possible relationship between osteopenia and etiopathogensis of AIS --- p.116 / Chapter 4.6 --- Axial measurement has a better predictive power in curve progression than peripheral measurement --- p.117 / Chapter 4.7 --- Discordance of BMD in bilateral hips --- p.118 / Chapter 4.8 --- Method justifications --- p.119 / Chapter 4.8.1 --- Definition of curve progression --- p.119 / Chapter 4.8.2 --- Incidence of progression as the outcome of prediction --- p.119 / Chapter 4.8.3 --- Selection on bone densitometers --- p.119 / Chapter 4.9 --- Clinical significance --- p.121 / Chapter 4.10 --- Limitations and Future Studies --- p.122 / Chapter 4.10.1 --- Limited follow-up time --- p.122 / Chapter 4.10.2 --- No defined cutoff value for 226}0´ببosteopenia 226}0ح or low BMC in paediatric area --- p.122 / Chapter 4.10.3 --- Predictive model could only applied in local population --- p.122 / Chapter 4.10.4 --- Intrinsic error in Risser grade measurement --- p.123 / Chapter 4.10.5 --- Further studies --- p.123 / Chapter 4.10.5.1 --- Validation of the newly developed predictive model --- p.123 / Chapter 4.10.5.2 --- Possible intervention of osteopenia --- p.124 / Chapter 4.10.5.3 --- Long term follow-up BMD measurements and fracture risk in AIS patients --- p.124 / Chapter 4.10.5.4 --- Discordance of bilateral hips BMD contributed by the shift of center of gravity --- p.125 / Chapter 4.10.5.5 --- Axial QCT can be an alternative method in assessing BMDin scoliotic patients --- p.125 / Chapter V. --- CONCLUSION --- p.126 / Chapter VI. --- APPENDIX --- p.127 / Chapter VII. --- BIBLIOGRAPHY --- p.128 / Chapter VIII. --- CONFERENCE PUBLICATIONS --- p.142

by Tang Shengping. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2002. / Includes bibliographical references (p. 217-244). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Mode of access: World Wide Web. / Abstracts in English and Chinese.

Yim, Po Yee Annie. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2011. / Includes bibliographical references (leaves 166-219). / Abstracts in English and Chinese. / Acknowledgements --- p.ii / Abstract --- p.iv / Abbreviations --- p.xi / Table of Content --- p.xiii / List of Figures --- p.xviii / List of Tables --- p.xxi / Major Conference Presentations --- p.xxiii / Publication in Preparation --- p.xxvi / Chapter Chapter 1 --- Introduction --- p.1 / Chapter 1.1 --- General Overview of Adolescent Idiopathic Scoliosis (AIS) --- p.2 / Chapter 1.2 --- Natural History --- p.3 / Chapter 1.3 --- Current Treatments --- p.5 / Chapter 1.3.1 --- Non-operative Treatments --- p.5 / Chapter 1.3.2 --- Surgical Treatments --- p.6 / Chapter 1.4 --- Current Hypothesis on the Etiology of AIS --- p.8 / Chapter 1.4.1 --- Genetic Factors --- p.8 / Chapter 1.4.2 --- Neuromuscular Impairment --- p.10 / Chapter 1.4.3 --- Abnormalities in Skeletal Development --- p.11 / Chapter 1.4.4 --- Metabolic Dysfunction --- p.12 / Chapter 1.4.4.1 --- Lower Bone Mineral Density --- p.12 / Chapter 1.4.4.2 --- Delayed Sexual Maturity --- p.14 / Chapter 1.4.4.3 --- Hormonal Dysfunction --- p.14 / Chapter 1.5 --- Skeletal arid Spinal Growth in AIS --- p.16 / Chapter 1.5.1 --- Abnormal Growth during Puberty --- p.16 / Chapter 1.5.2 --- Growth Pattern --- p.17 / Chapter 1.5.3 --- Disproportional Growth in AIS --- p.18 / Chapter 1.5.4 --- Asymmetric Growth --- p.20 / Chapter 1.6 --- Melatonin and its Receptor --- p.22 / Chapter 1.6.1 --- Introduction --- p.22 / Chapter 1.6.2 --- Melatonin Receptor --- p.24 / Chapter 1.6.3 --- Melatonin's Role in t h e Skeletal System --- p.25 / Chapter 1.6.4 --- Melatonin-Deficient Scoliotic Animal Model --- p.27 / Chapter 1.6.5 --- Melatonin and AIS --- p.29 / Chapter 1.6.5.1 --- Melatonin Level in AIS --- p.30 / Chapter 1.6.5.2 --- Melatonin Receptor in AIS --- p.30 / Chapter Chapter 2 --- Hypothesis and Objectives --- p.39 / Chapter 2.1 --- Study Hypothesis --- p.40 / Chapter 2.2 --- Objectives --- p.41 / Chapter Chapter 3 --- Abnormal skeletal growth patterns in adolescent idiopathic scoliosis - A longitudinal study till skeletal maturity --- p.42 / Chapter 3.1 --- Introduction --- p.43 / Chapter 3.2 --- Methodology --- p.44 / Chapter 3.2.1 --- Recruitments of Subjects --- p.44 / Chapter 3.2.1.1 --- Patients with AIS --- p.44 / Chapter 3.2.1.2 --- Normal Controls --- p.44 / Chapter 3.2.1.3 --- Patients Consents --- p.45 / Chapter 3.2.2 --- Anthropometric Measurements --- p.45 / Chapter 3.2.3 --- Data Analysis --- p.46 / Chapter 3.2.3.1 --- Cross-sectional Study --- p.46 / Chapter 3.2.3.2 --- Longitudinal Study --- p.46 / Chapter 3.3 --- Results --- p.47 / Chapter 3.3.1 --- Cross-sectional Study of Anthropometric Measurements --- p.47 / Chapter 3.3.2 --- Longitudinal Study of Anthropometric Measurements --- p.48 / Chapter 3.3.2.1 --- Comparison Adjusted for Chronological Age --- p.49 / Chapter 3.3.2.2 --- Comparison Along Year Since Menarche (YSM) --- p.49 / Chapter 3.4 --- Discussion --- p.51 / Chapter Chapter 4 --- Establishment of a Melatonin-Deficierit Induced Scoliotic Model with Locally Bred Chicken --- p.63 / Chapter 4.1 --- Introduction --- p.64 / Chapter 4.2 --- Methodology --- p.67 / Chapter 4.2.1 --- Animals --- p.67 / Chapter 4.2.2 --- Materials and Reagents --- p.67 / Chapter 4.2.3 --- Pinealectomy --- p.68 / Chapter 4.2.4 --- Confirmation of Pineal Gland Removal --- p.69 / Chapter 4.2.5 --- Development of Scoliosis --- p.69 / Chapter 4.2.6 --- Measurement of Long Bone Growth --- p.70 / Chapter 4.2.7 --- Measurement of Weight --- p.71 / Chapter 4.2.8 --- Measurement of Bone Mineral Density (BMD) --- p.71 / Chapter 4.2.8.1 --- Micro Computed Tomography (MicroCT) --- p.71 / Chapter 4.2.8.2 --- Image Processing and Evaluation of BMD --- p.71 / Chapter 4.2.9 --- Data Analysis --- p.72 / Chapter 4.2.9.1 --- Measurements of Long Bone Growth and Weight --- p.72 / Chapter 4.2.9.2 --- Bone Mineral Density --- p.72 / Chapter 4.3 --- Results --- p.73 / Chapter 4.3.1 --- Confirmation of Pineal Gland Removal --- p.73 / Chapter 4.3.2 --- Occurrence of Scoliosis --- p.73 / Chapter 4.3.3 --- Measurements of Long Bone and Weight --- p.74 / Chapter 4.3.4 --- Measurement of Bone Mineral Density --- p.75 / Chapter 4.4 --- Discussion --- p.76 / Chapter Chapter 5 --- Expression of Melatonin Receptor in AIS and Control --- p.102 / Chapter 5.1 --- Introduction --- p.103 / Chapter 5.2 --- Methodology --- p.105 / Chapter 5.2.1 --- Subjects Recruitments --- p.105 / Chapter 5.2.2 --- Cell Isolation --- p.106 / Chapter 5.2.2.1 --- Bone Biopsies for Osteoblasts Isolation --- p.106 / Chapter 5.2.2.2 --- Materials and Reagents --- p.106 / Chapter 5.2.2.3 --- Isolation of Osteoblasts from Bone Biopsies --- p.107 / Chapter 5.2.3 --- Expression Level and Pattern of Melatonin Receptors 1A and IB --- p.108 / Chapter 5.2.3.1 --- Materials and Reagents --- p.108 / Chapter 5.2.3.2 --- Validation of Specificities of Antibodies by Co-immunoprecipitation --- p.113 / Chapter 5.2.3.3 --- Quantification of Protein Expression of Melatonin Receptors in Osteoblasts --- p.115 / Chapter 5.2.3.4 --- Quantification of mRNA Expression of Melatonin Receptor in Osteoblast --- p.117 / Chapter 5.2.3.5 --- Localization of Melatonin Receptor 1A and IB by Immunofluorescence Staining --- p.119 / Chapter 5.2.4 --- Evaluation and Correlation of Clinical Phenotypes with Melatonin Receptor Expression --- p.120 / Chapter 5.2.5 --- Data Analysis --- p.120 / Chapter 5.3 --- Results --- p.121 / Chapter 5.3.1 --- Protein Expression of Melatonin Receptor 1A and IB --- p.121 / Chapter 5.3.2 --- mRNA Expression of Melatonin Receptor 1A and IB --- p.121 / Chapter 5.3.3 --- Localization of Melatonin Receptors 1A and IB --- p.122 / Chapter 5.3.4 --- Evaluation and Correlation of Clinical Phenotypes with Melatonin Receptor Expression --- p.123 / Chapter 5.4 --- Discussion --- p.124 / Chapter Chapter 6 --- Summary and Overall Discussion --- p.152 / Chapter 6.1 --- Study Flowchart --- p.153 / Chapter 6.2 --- Summary and Discussion --- p.159 / Chapter 6.3 --- Limitations and Further Studies --- p.163 / Bibliography --- p.166

青少年特發性脊柱側凸(Adolescent idiopathic scoliosis , AIS)是一種複雜的脊柱三維畸形，常見於10-16 歲處於生長發育高峰期的青少年女性。儘管AIS 發生率較高並且臨床影響較大，但是到目前為止其病因未明。在眾多關於AIS 病因學的假設和理論研究中，普遍認為低骨密度是AIS 的一個重要影響因素。然而近年來對於AIS 患者低骨密度研究不足，其潛在的機制尚不明確。我們之前初步的組織學研究發現，AIS 患者的松質骨中成骨細胞功能下降，此研究為AIS中存在骨礦化異常提供了初步依據。 / 骨橋蛋白是骨組織中一種重要的非膠原細胞外基質蛋白，其在骨礦化過程中起著重要作用。近期的研究報導AIS 患者血漿中骨橋蛋白水準高於年齡匹配的正常對照。因此本研究假設AIS 患者血漿及骨組織中骨橋蛋白高於正常對照，并可能影響了骨基質的礦化，從而導致低骨密度。 / 本系列研究的第一部分旨在通過外周定量電腦斷層掃描（pQCT）明確AIS患者中皮質骨密度及松質骨密度是否均低於正常對照。pQCT 可以準確地三維評估皮質骨密度，松質骨密度及其他骨品質的相關參數。採用雙能X 線骨密度儀（DXA）測量受試者的非優勢側近端股骨面積骨密度（包括股骨頸，Ward’s 三角及大轉子）。而採用pQCT 測量受試者非優勢側橈骨遠端容積骨密度，包括皮質骨密度及松質骨密度。結果顯示AIS 患者面積骨密度，皮質骨密度及松質骨密度在不同年齡段和月經時間分組中均低於正常對照。並且AIS 與正常對照皮質骨密度的差異隨著年齡增長越來越大，而松質骨密度差異則隨著年齡增長越來越小。 / 第二部分通過顯微CT 及組織形態測定研究AIS 及正常骨組織的骨礦化及骨微結構。採用顯微CT 檢測骨組織的三維結構參數，包括材料骨密度及骨微結構。未脫鈣骨組織的切片通過Goldner’s 染色進行組織形態學測量。結果顯示AIS患者的骨體積分數，骨小梁數目，骨小梁厚度及結構模型指數與正常對照之間均無顯著差異，而材料骨密度顯著低於正常對照。組織形態學分析結果顯示AIS中低礦化骨顯著多於正常對照。 / 第三部分旨在研究AIS 及正常對照血漿中骨橋蛋白水準及其與骨密度的關係。採用酶聯吸附免疫法測量AIS 患者及年齡匹配的正常對照血漿中的骨橋蛋白水準。血漿骨橋蛋白水準與骨密度的關係採用多元回歸分析。研究結果顯示AIS 患者及正常對照血漿骨橋蛋白水平均與年齡及月經時間呈負相關。AIS 患者的血漿骨橋蛋白水準顯著高於正常對照，並且與松質骨密度呈顯著負相關。 / 本研究第四部分旨在探討骨組織中的骨橋蛋白表達與骨形態學及骨礦化指標在AIS 及正常對照中的關係。骨組織中骨橋蛋白的表達採用半定量免疫組織化學法評估。研究結果顯示在AIS 中血漿骨橋蛋白水準與骨組織中骨橋蛋白的表達呈正相關。且AIS 骨組織中骨橋蛋白的表達也顯著高於正常對照。進一步的研究發現骨組織中骨橋蛋白的表達與材料骨密度呈負相關，而與低礦化骨量呈正相關。 / 本研究明確了AIS 中骨礦化水準低於正常對照，進一步證明AIS 患者中的皮質骨及松質骨密度下降可能與骨礦化的調控異常有關。本研究發現的骨橋蛋白與低骨密度及低骨礦化水準的關係，可以推測AIS 患者中異常升高的骨橋蛋白水準可能在骨礦獲取的調解中起重要作用。本系列研究提供證據支援AIS 患者中骨橋蛋白的異常表達可能影響了骨基質的礦化，從而導致低骨密度。本研究為AIS 中低骨密度可能的機制提供了全新的見解，並可能進一步解釋AIS 的發病機理及其發生，發展。 / Adolescent idiopathic scoliosis (AIS) is a complex three-dimensional deformity of the spine occurring most commonly in girls between ages 10-16 during the pubertal growth spurt. Despite its high prevalence and clinical impact, etiology of AIS remains largely unknown. Among the number of proposed hypothesis and observations on the etiopathogenesis of AIS, low bone mineral density (BMD) is one of the most reported factor (Cheng et al. 1999; Hung et al. 2005; Cheung et al. 2006; Hui et al. 2011). However, the underlying mechanism of low BMD in AIS has not been sufficiently studied scientifically and its link to the etiopathogenesis is still not clear. From a previous pilot study, our group has reported the histological features of reduced osteoblastic activity in bone biopsy specimens obtained from AIS subjects intraoperatively, thus providing the early evidence of abnormal bone mineral acquisition and mineralization (Cheng et al. 2001). / Osteopontin (OPN) has been recognized as one the major non-collagen extracellular matrix proteins in bone and plays an important role in bone mineralization. Recent report suggested that AIS patients have higher OPN level than normal controls (Moreau et al. 2009). It was hypothesized that the low BMD in AIS is associated with abnormal bone matrix mineralization which may be related to abnormal expression of OPN in the plasma and at tissue level. / In this series of studies, the first part aimed to investigate the differential cortical and trabecular bone mineral density of AIS Vs normal controls. The non-dominant proximal femur areal BMD (aBMD) (femoral neck, Ward’s triangle and greater trochanter) of the subjects were measured with dual-energy x-ray absorptiometry (DXA). The volumetric bone mineral density (vBMD) in non-dominant distal radius was measured with peripheral quantitative computed tomography (pQCT) that allows accurate three dimensional assessment of the cortical and trabecular bone mineral density and other parameters of bone quality. AIS was found to have lower aBMDs, trabecular BMD (TBMD) and cortical BMD (CBMD) in different age groups and year since menarche (YSM) groups. Furthermore, the percentage difference of CBMD between AIS and controls was increased with age while a decreasing trend was observed in the TBMD. / The second part of the study investigated the bone mineralization and bone micro-architecture with micro-computed tomography (micro-CT) and histomorphometry study of bone biopsies obtained from AIS and normal controls. Three-dimensional structural parameters including material bone mineral density (mBMD) and bone architecture were evaluated by micro-CT. Bone histomorphometry was assessed by undecalcified sectioning with Goldner’s trichrome staining. mBMD of trabecular bone in AIS was found to be significantly lower than the normal control while no difference could be demonstrated in BV/TV, Tb.N, Tb.Th and SMI measurement between the two groups. It was also shown that the percentage of low-mineralized bone in AIS was significantly higher than that in normal controls. / The third part aimed to study the plasma OPN level and its association with the BMD in AIS Vs normal controls. Plasma OPN level in AIS and age-matched controls was measured by ELISA. With multivariate regression analysis, the plasma OPN level was found to be negatively correlated with Age and YSM in both AIS and normal controls. In addition, the plasma OPN level in AIS was significantly higher and correlated with the low trabecular BMD. / The fourth part of the study investigated the OPN expression in bone tissues level and its association with histomorphometric bone mineralization and bone micro-architectural parameters in AIS Vs normal controls. OPN expression in bone biopsy was semi-quantified by immunohistochemistry. It was found that the bone tissue OPN level was significantly higher in AIS and also positively correlated with plasma OPN level. In addition, in this pilot study, we found the trend that OPN expression in trabecular bone was negatively associated with mBMD, and positively with the percentage of low-mineralized bone. / The present study showed that AIS had lower bone mineralization than normal controls. The low cortical and trabecular BMD found in AIS is likely to be resulting from abnormal regulation of bone mineralization. The association of OPN with abnormal BMD and bone mineralization further suggested that abnormal OPN level might play an important role in affecting the bone mineral acquisition in AIS. All of these findings strongly supported the hypothesis that the low BMD in AIS is associated with abnormal bone matrix mineralization which could be related to abnormal expression of OPN. This study provided important additional insight into the possible mechanism of lower bone mineral density that might be linked to theetiopathogenesis, development and progression of the spinal deformity in AIS. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Sun, Guangquan. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2012. / Includes bibliographical references (leaves 143-160). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract and appendix A also in Chinese. / THE CHINESE UNIVERSITY OF HONG KONG --- p.I / ACKNOWLEDGEMENTS --- p.II / ABSTRACT --- p.IV / ABBREVIATION --- p.XI / TABLE OF CONTENTS --- p.XIII / LIST OF TABLES --- p.XVII / LIST OF FIGURES --- p.XIX / LIST OF PUBLICATIONS --- p.XXI / Chapter CHAPTER 1 --- STUDY BACKGROUND --- p.1 / Chapter 1.1 --- GENERAL OVERVIEW OF ADOLESCENT IDIOPATHIC SCOLIOSIS (AIS) --- p.2 / Chapter 1.1.1 --- NATURAL HISTORY --- p.4 / Chapter 1.1.2 --- CURRENT TREATMENTS --- p.6 / Chapter 1.1.2.1 --- Observation --- p.7 / Chapter 1.1.2.2 --- Bracing --- p.7 / Chapter 1.1.2.3 --- Surgical treatments --- p.9 / Chapter 1.1.3 --- CURRENT HYPOTHESIS ON THE ETIOLOGY OF AIS --- p.11 / Chapter 1.1.3.1 --- Genetic factors --- p.12 / Chapter 1.1.3.2 --- Neuromuscular impairment --- p.14 / Chapter 1.1.3.3 --- Abnormalities in skeletal development --- p.16 / Chapter 1.1.3.4 --- Low bone mineral density in AIS --- p.16 / Chapter 1.2 --- BONE MINERALIZATION --- p.18 / Chapter 1.2.1 --- Overview of bone mineralization --- p.18 / Chapter 1.2.2 --- Bone modeling --- p.18 / Chapter 1.2.3 --- Bone remodeling --- p.19 / Chapter 1.2.4 --- Factors affecting bone mineralization --- p.21 / Chapter 1.3 --- OSTEOPONTIN --- p.23 / Chapter 1.3.1 --- Structure of osteopontin --- p.23 / Chapter 1.3.2 --- Osteopontin - cellular and tissue distribution --- p.24 / Chapter 1.3.3 --- Osteopontin functions --- p.25 / Chapter 1.3.4 --- Osteopontin functions in bone --- p.25 / Chapter 1.3.5 --- Osteopontin and bone mineral density in human --- p.29 / Chapter CHAPTER 2 --- STUDY HYPOTHESIS AND PLAN --- p.31 / Chapter 2.1 --- INTRODUCTION --- p.32 / Chapter 2.2 --- HYPOTHESIS --- p.33 / Chapter 2.3 --- OBJECTIVES --- p.34 / Chapter 2.4 --- STUDY PLAN --- p.34 / Chapter CHAPTER 3 --- LOW BONE MINERAL DENSITY IN ADOLESCENT IDIOPATHIC SCOLIOSIS - AREAL VS VOLUMETRIC, CORTICAL VS TRABECULAR BONE MINERAL DENSITY --- p.36 / Chapter 3.1 --- INTRODUCTION --- p.37 / Chapter 3.2 --- SUBJECTS AND METHODS --- p.39 / Chapter 3.2.1 --- Subjects --- p.39 / Chapter 3.2.2 --- BMD Measurement --- p.40 / Chapter 3.2.3 --- Statistical Analysis --- p.41 / Chapter 3.3 --- RESULTS --- p.42 / Chapter 3.3.1 --- aBMD of AIS and normal controls by age groups --- p.42 / Chapter 3.3.2 --- TBMD and CBMD in AIS and normal controls by age groups --- p.42 / Chapter 3.3.3 --- aBMD in AIS and normal controls by year since menarche --- p.43 / Chapter 3.3.4 --- TBMD and CBMD in AIS and normal controls by year since menarche --- p.43 / Chapter 3.3.5 --- Correlation between CBMD & TBMD and chronological age or year since menarche --- p.44 / Chapter 3.3.6 --- Comparisons adjusted for chronological age or year since menarche --- p.44 / Chapter 3.4 --- DISCUSSION --- p.45 / Chapter 3.5 --- TABLES AND FIGURES --- p.50 / Chapter CHAPTER 4 --- ABNORMAL BONE MATRIX MINERALIZATION AND BONE MICROARCHITECTURE IN ADOLESCENT IDIOPATHIC SCOLIOSIS - A HISTOMORPHOMETRIC AND MICRO-CT STUDY --- p.60 / Chapter 4.1 --- INTRODUCTION --- p.61 / Chapter 4.2 --- SUBJECTS AND METHODS --- p.62 / Chapter 4.2.1 --- Subjects --- p.62 / Chapter 4.2.2 --- Micro-computed tomography --- p.63 / Chapter 4.2.3 --- Bone histomorphometry --- p.64 / Chapter 4.2.4 --- Statistical analysis --- p.68 / Chapter 4.3 --- RESULTS --- p.68 / Chapter 4.3.1 --- Results of micro-CT analysis --- p.68 / Chapter 4.3.2 --- Results of histomorphometric analysis --- p.69 / Chapter 4.3.3 --- Relationship of mBMD and percentage of low-mineralized bone --- p.69 / Chapter 4.4 --- DISCUSSION --- p.70 / Chapter 4.5 --- TABLES AND FIGURES --- p.74 / Chapter CHAPTER 5 --- PLASMA OSTEOPONTIN LEVEL AND ITS ASSOCIATION WITH BONE MINERAL DENSITY IN ADOLESCENT IDIOPATHIC SCOLIOSIS --- p.82 / Chapter 5.1 --- INTRODUCTION --- p.83 / Chapter 5.2 --- SUBJECTS AND METHODS --- p.84 / Chapter 5.2.1 --- Subjects --- p.84 / Chapter 5.2.2 --- Anthropometric assessment --- p.84 / Chapter 5.2.3 --- Plasma osteopontin measurement --- p.85 / Chapter 5.2.4 --- BMD Measurement --- p.86 / Chapter 5.2.5 --- Statistical Analysis --- p.86 / Chapter 5.3 --- RESULTS --- p.86 / Chapter 5.3.1 --- Comparison of anthropometric parameters between AIS and controls --- p.86 / Chapter 5.3.2 --- Correlation between OPN plasma level with age or YSM in AIS and controls --- p.87 / Chapter 5.3.3 --- Comparison of OPN plasma level between AIS and controls --- p.87 / Chapter 5.3.4 --- Correlation between OPN plasma level and curve severity in AIS --- p.87 / Chapter 5.3.5 --- Relationship between OPN plasma level and vBMD --- p.88 / Chapter 5.4 --- DISCUSSION --- p.88 / Chapter 5.5 --- TABLES AND FIGURES --- p.94 / Chapter CHAPTER 6 --- OSTEOPONTIN EXPRESSION IN BONE TISSUE AND ITS ASSOCIATION WITH BONE MATRIX MINERALIZATION IN ADOLESCENT IDIOPATHIC SCOLIOSIS - A PILOT STUDY --- p.102 / Chapter 6.1 --- INTRODUCTION --- p.103 / Chapter 6.2 --- SUBJECTS AND METHODS --- p.104 / Chapter 6.2.1 --- Subjects --- p.104 / Chapter 6.2.2 --- Micro-computed tomography --- p.104 / Chapter 6.2.3 --- Bone histomorphometry --- p.104 / Chapter 6.2.4 --- Semi-quantification of OPN expression in bone biopsy by immunohistochemistry --- p.105 / Chapter 6.2.5 --- Plasma osteopontin measurement --- p.107 / Chapter 6.2.6 --- Statistical Analysis --- p.108 / Chapter 6.3 --- RESULTS --- p.108 / Chapter 6.3.1 --- Comparison of anthropometric parameters between AIS and control subjects --- p.108 / Chapter 6.3.2 --- Comparison of OPN expression detected by immunohistochemistry in bone biopsy between AIS and control groups --- p.108 / Chapter 6.3.3 --- Comparison of histomorphometric and micro-CT results between AIS and control groups --- p.109 / Chapter 6.3.4 --- Relationship between plasma OPN level and OPN expression in bone biopsy --- p.109 / Chapter 6.3.5 --- Relationship between percentage of low-mineralized bone and OPN expression in bone biopsy --- p.109 / Chapter 6.3.6 --- Relationship between material bone mineral density and OPN expression in bone biopsy --- p.110 / Chapter 6.4 --- DISCUSSION --- p.110 / Chapter 6.5 --- TABLES AND FIGURES --- p.114 / Chapter CHAPTER 7 --- SUMMARY STUDY FLOWCHART, OVERALL DISCUSSION, CONCLUSIONS, LIMITATIONS AND FURTHER STUDIES --- p.119 / Chapter 7.1 --- SUMMARY OF THE STUDY FLOW CHART WITH KEY FINDINGS --- p.120 / Chapter 7.2 --- OVERALL DISCUSSION --- p.125 / Chapter 7.2.1 --- The novel findings on bone mineralization abnormality in AIS in this study --- p.125 / Chapter 7.2.2 --- OPN is a key modulator in AIS --- p.128 / Chapter 7.3 --- OVERALL CONCLUSIONS --- p.130 / Chapter 7.4 --- LIMITATION OF THIS STUDY AND FUTURE RESEARCH --- p.131 / Chapter APPENDIX A. --- CONSENT FORM OF AIS RESEARCH --- p.135 / Chapter APPENDIX B. --- CONSENT FORM OF BONE BIOPSY COLLECTION --- p.137 / Chapter APPENDIX C. --- MATERIALS AND REAGENTS INFORMATION AND PROTOCOL FOR SOLUTIONS PREPARATION --- p.138 / BIBLIOGRAPHY --- p.143

INTRODUÇÃO: A síndrome de Kabuki (SK) é uma doença genética de etiologia desconhecida, cujas características cardinais são: dismorfismos faciais, baixa estatura de inicio pós-natal, anomalias esqueléticas, déficit cognitivo e alteração de dermatóglifos. Já foram descritas alterações em outros órgãos e sistemas. O diagnóstico é clínico. OBJETIVOS: Descrever os achados clínicos, e a evolução clínica de pacientes com SK. CASUÍSTICA E METODOLOGIA: Foram estudados 12 pacientes, oito do sexo feminino e quatro do sexo masculino, onde foram realizados: anamnese, exame físico, revisão de prontuário, avaliação cardiológica e odontológica, exames de imagem e laboratoriais. RESULTADOS: Todos pacientes tinham: face típica, déficit cognitivo, alterações esqueléticas e persistência de padrão fetal em coxins digitais. As alterações esqueléticas mais freqüentes foram: braquidactilia do quinto dedo, frouxidão ligamentar e luxação de quadril. A baixa estatura foi encontrada em 8/12 pacientes. Oito apresentavam ausência de dentes. Alterações oftalmológicas foram identificadas em sete. Na avaliação da audição, três tinham otites e dois, perda auditiva. Cinco pacientes apresentaram doenças respiratórias. Três pacientes apresentavam cardiopatias, e uma tinha somente alteração eletrocardiográfica. Seis pacientes tiveram dificuldades alimentares nos primeiros anos de vida e cinco, refluxo gastroesofágico. Três pacientes tinham anomalias renais, dois apresentaram enurese noturna e dois criptorquidia. Hipotonia estava presente em cinco pacientes e convulsões em quatro. Hipotireoidismo estava presente em duas pacientes e uma paciente tinha deficiência de hormônio de crescimento. Dois pacientes relataram um episódio de púrpura trombocitopênica. Alterações imunológicas foram identificadas em três pacientes. Anomalias do cromossomo X foram identificadas em duas pacientes. Nenhum paciente faleceu durante o estudo. Dos pacientes com mais de 18 anos, 3/4 tinham baixa estatura e nos pacientes com mais de 10 anos 4/7 tornaram-se obesos. DISCUSSÃO: A maioria de nossos achados foi compatível com a encontrada na literatura. As pacientes com alterações no cromossomo X, apresentavam características de SK e síndrome de Turner, não podendo descartar ou confirmar a coexistência destas duas doenças. CONCLUSÕES: a SK apresenta uma grande variabilidade clínica, devendo seus portadores, ter suporte multidisciplinar. As anomalias renais, cardíacas, imunológicas e esqueléticas, foram responsáveis pelas principais complicações clínicas relatadas / INTRODUCTION: Kabuki syndrome (KS) is a genetic disease which cardinal manifestations are: facial dysmorfism, short stature of postnatal onset, skeletal abnormalities, mental retardation and abnormal dermatolyphics. Beside these manifestations, abnormalities of every organ system, has been described. The diagnosis is clinical. OBJECTIVES: The objective is to describe the clinical manifestations and the follow-up of patients with Kabuki syndrome. PATIENTS AND METHODS: Twelve patients were studied, eight female and four male, not related, in which anamnesis, physical examination, review of their clinical records, odontological and ophthalmological evaluation, radiological and laboratorial tests, were performed. RESULTS: All patients have: typical face, mental retardation, skeletal abnormalities and presence of fingertip pads. Short stature was present in 8/12 patients. The most frequent skeletal abnormalities were: short fingers, hypotony and hip dislocation. Eight patients have absence of teeth. Ophthalmologic abnormalities were found in seven patients. On hearing evaluation, three patients have recurrent otitis and hearing lost was identified in two patients. Apnea and laryngo malacia was present in one patient. Three patients presented congenital cardiopathy and one patient without cardiopathy had an anomaly at electrocardiography. At the first years of life, six patients had feeding difficulties, with one whom needed a gastrostomy tube and five had gastroesofageal reflux. A kidney and urinary tract malformation was found in three patients, two had nocturnal enuresis, and two had undescended testis. Hypotonia was present in five patients and four reported seizures. Hypothyroidism was present in two patients and one had growth hormone deficiency. Two patients had an episode of thrombocytopenic purpura. Immunologic abnormalities were identified in three patients. Cytogenetic abnormalities of X chromosome were identified in two female patients. During the study, no one patient died. In adult patients, 3/4 had short stature, and, in patients with 10 years or more, 4/7 were obese. DISCUSSION: Most of our findings were compatible with the literature. The patients with X chromosome abnormalities presented characteristics of KS and Turners syndrome and we are not able to make an exact distinction if they have or not both diseases. CONCLUSION: KS has a wide clinical variability and the affected ones should be followed by a multidisciplinary clinic. Renal, cardiac, skeletal and immunological abnormalities are those with most morbidity related by the patients

INTRODUÇÃO: A síndrome de Kabuki (SK) é uma doença genética de etiologia desconhecida, cujas características cardinais são: dismorfismos faciais, baixa estatura de inicio pós-natal, anomalias esqueléticas, déficit cognitivo e alteração de dermatóglifos. Já foram descritas alterações em outros órgãos e sistemas. O diagnóstico é clínico. OBJETIVOS: Descrever os achados clínicos, e a evolução clínica de pacientes com SK. CASUÍSTICA E METODOLOGIA: Foram estudados 12 pacientes, oito do sexo feminino e quatro do sexo masculino, onde foram realizados: anamnese, exame físico, revisão de prontuário, avaliação cardiológica e odontológica, exames de imagem e laboratoriais. RESULTADOS: Todos pacientes tinham: face típica, déficit cognitivo, alterações esqueléticas e persistência de padrão fetal em coxins digitais. As alterações esqueléticas mais freqüentes foram: braquidactilia do quinto dedo, frouxidão ligamentar e luxação de quadril. A baixa estatura foi encontrada em 8/12 pacientes. Oito apresentavam ausência de dentes. Alterações oftalmológicas foram identificadas em sete. Na avaliação da audição, três tinham otites e dois, perda auditiva. Cinco pacientes apresentaram doenças respiratórias. Três pacientes apresentavam cardiopatias, e uma tinha somente alteração eletrocardiográfica. Seis pacientes tiveram dificuldades alimentares nos primeiros anos de vida e cinco, refluxo gastroesofágico. Três pacientes tinham anomalias renais, dois apresentaram enurese noturna e dois criptorquidia. Hipotonia estava presente em cinco pacientes e convulsões em quatro. Hipotireoidismo estava presente em duas pacientes e uma paciente tinha deficiência de hormônio de crescimento. Dois pacientes relataram um episódio de púrpura trombocitopênica. Alterações imunológicas foram identificadas em três pacientes. Anomalias do cromossomo X foram identificadas em duas pacientes. Nenhum paciente faleceu durante o estudo. Dos pacientes com mais de 18 anos, 3/4 tinham baixa estatura e nos pacientes com mais de 10 anos 4/7 tornaram-se obesos. DISCUSSÃO: A maioria de nossos achados foi compatível com a encontrada na literatura. As pacientes com alterações no cromossomo X, apresentavam características de SK e síndrome de Turner, não podendo descartar ou confirmar a coexistência destas duas doenças. CONCLUSÕES: a SK apresenta uma grande variabilidade clínica, devendo seus portadores, ter suporte multidisciplinar. As anomalias renais, cardíacas, imunológicas e esqueléticas, foram responsáveis pelas principais complicações clínicas relatadas / INTRODUCTION: Kabuki syndrome (KS) is a genetic disease which cardinal manifestations are: facial dysmorfism, short stature of postnatal onset, skeletal abnormalities, mental retardation and abnormal dermatolyphics. Beside these manifestations, abnormalities of every organ system, has been described. The diagnosis is clinical. OBJECTIVES: The objective is to describe the clinical manifestations and the follow-up of patients with Kabuki syndrome. PATIENTS AND METHODS: Twelve patients were studied, eight female and four male, not related, in which anamnesis, physical examination, review of their clinical records, odontological and ophthalmological evaluation, radiological and laboratorial tests, were performed. RESULTS: All patients have: typical face, mental retardation, skeletal abnormalities and presence of fingertip pads. Short stature was present in 8/12 patients. The most frequent skeletal abnormalities were: short fingers, hypotony and hip dislocation. Eight patients have absence of teeth. Ophthalmologic abnormalities were found in seven patients. On hearing evaluation, three patients have recurrent otitis and hearing lost was identified in two patients. Apnea and laryngo malacia was present in one patient. Three patients presented congenital cardiopathy and one patient without cardiopathy had an anomaly at electrocardiography. At the first years of life, six patients had feeding difficulties, with one whom needed a gastrostomy tube and five had gastroesofageal reflux. A kidney and urinary tract malformation was found in three patients, two had nocturnal enuresis, and two had undescended testis. Hypotonia was present in five patients and four reported seizures. Hypothyroidism was present in two patients and one had growth hormone deficiency. Two patients had an episode of thrombocytopenic purpura. Immunologic abnormalities were identified in three patients. Cytogenetic abnormalities of X chromosome were identified in two female patients. During the study, no one patient died. In adult patients, 3/4 had short stature, and, in patients with 10 years or more, 4/7 were obese. DISCUSSION: Most of our findings were compatible with the literature. The patients with X chromosome abnormalities presented characteristics of KS and Turners syndrome and we are not able to make an exact distinction if they have or not both diseases. CONCLUSION: KS has a wide clinical variability and the affected ones should be followed by a multidisciplinary clinic. Renal, cardiac, skeletal and immunological abnormalities are those with most morbidity related by the patients