[A case of early-onset and slowly progressive chronic inflammatory demyelinating polyneuropathy--electrophysiological findings with clinical course]

A case of early-onset and slowly progressive chronic inflammatory demyelinating polyneuropathy (CIDP) was reported. Her progressive gait disturbance began at six years of age and she developed pes cavus. At the age of 13 years, a diagnosis of CIDP was made, and oral corticosteroid therapy was started. This therapy was effective, but the disease relapsed soon. Muscular strength improved after supplementation of an immunosuppressant with oral corticosteroid, following steroid pulse therapy. On peripheral motor conduction study, M waves showed very low amplitudes and remarkably delayed onset-latencies. New units of M wave appeared and amplitudes increased soon after initiation of the corticosteroid therapy because of an improvement of conduction block, and durations of M wave were prolonged. Then, in accordance with shortening of M wave latencies, some dispersed units were synchronized and durations reduced. At relapse, changes of M wave showed an inverse relationship to the changes of M wave with clinical improvement. The electrophysiological findings started improving 1 week after the therapy, while clinical improvement was detected several weeks later. We conclude that the change of M wave was a sensitive marker to evaluate the effect of the therapy in our CIDP case.

Hemostatic studies in patients with carbohydrate-deficient glycoprotein syndrome

The carbohydrate deficient glycoprotein (CDG) syndrome is a newly described disorder characterized by impaired glycosylated molecules. It has been reported that transient stroke-like episodes appear in half of the patients. We performed hemostatic studies on three CDG syndrome patients belonging to two unrelated families. The most characteristic findings were decreases in antithrombin III (AT III), protein C and alpha 2 plasmin inhibitor to nearly half normal levels. Protein S was reduced in two (siblings) patients. Isoelectric focusing of AT III in native plasma revealed decreased intensity of the major band and increased intensity of a minor cathodal band. These minor AT III molecules were considered to lack an oligosaccharide sidechain. A 12-year-old girl defective not only for AT III but also protein C and protein S developed disseminated intravascular coagulation accompanied by arterial thrombosis in her left hand following dyspnea associated with bronchial asthma. These findings suggest that thrombotic predisposition in patients with CDG syndrome is due to decreased levels of major coagulation inhibitors, particularly as a result of impaired glycosylation of AT III.

[A case of adenine phosphoribosyltransferase (APRT) deficiency discovered by urine examination]

APRT deficiency is an enzyme disorder which is inherited as an autosomal recessive trait. The use of adenine in purine metabolism is disturbed and it accumulates in the body, where it is oxidised by xanthine oxidase to poorly insoluble 2, 8-dihydroxyadenine (DHA). The dihydroxyadenine forms stones which cause recurrent urolithiasis, frequent episodes of urinary tract infection or interstitial nephritis, and finally renal insufficiency in some cases. We report a case of APRT deficiency discovered by urine examination. The patient was a 33-year-old man who had never had any episodes of urolithiasis. He was admitted to our hospital because of pseudoarthrosis of his left arm caused by a traffic accident. His urinalysis revealed no proteinuria nor hematuria, but disclosed numerous round brown crystals in the sediment. These crystals had the characteristics of 2, 8-DHA. The enzyme activity of APRT in his blood was completely deficient. He was diagnosed as an APRT* QO homozygote. In addition, diagnostic imaging revealed that his right kidney was poorly hypoplastic and the pelvis of his left kidney was extra-renal. The renal function was slightly disturbed. In Japan 6 cases of 2, 8-DHA urolithiasis associated with hypoplastic kidney had been reported by 1989. Theoretically, the incidence of hypoplastic kidney is around 20% of all 2, 8-DHA urolithiasis cases. We suspect a genetic correlation between hypoplastic kidney and APRT deficiency. This patient was treated with Allopurinol, which inhibits the process of xanthine oxidation, after which crystals were no longer detected in his urine.

Cervical magnetic stimulation in children and adolescents: normal values and evaluation of the proximal lesion of the peripheral motor nerve in cases with polyradiculoneuropathy

Cervical magnetic stimulation was used to establish the normal values of the peripheral motor nerve conduction of the upper extremity muscle in normal children and adolescents. Seven patients with peripheral neuropathy were also examined to evaluate a lesion in the proximal site of the peripheral motor nerve. In normal subjects, onset latencies and negative wave durations tended to increase with age. The developmental profile of the latency, corrected for arm length, revealed a significant decline until the age of about 5 years. In 4 cases with polyradiculoneuropathy, motor evoked potentials following cervical magnetic stimulation showed increased latencies, prolonged durations and polyphasic shapes. The time differences between latencies by magnetic stimulation and peripheral motor conduction times by F technique were significantly prolonged. Motor evoked potentials obtained in 3 cases of axonal degeneration, on the other hand, showed slightly increased latencies and normal durations. The time differences between latencies and peripheral motor conduction times were within the normal range. Thus, we consider that cervical magnetic stimulation is a useful method for study of peripheral motor conduction in children and adolescents, and in particular to evaluate the proximal lesion of the nerve in patients with polyradiculoneuropathy.

[Hodgkin's disease with a giant thymic cyst]

An asymptomatic 26-year-old male was admitted to our hospital for examination of an abnormal mediastinal shadow on chest X-ray. Chest CT showed a large mass in the anterior mediastinum with marked para-aortic lymph node enlargement. The mass consisted mostly of multiloculated low-density areas surrounded by a rim of enhancing parenchymal tissue. Both the cystic tumor and surrounding lymph nodes were resected. The tumor measured 18 x 10 x 2 cm and contained about 450 ml of straw colored fluid. Pathological examination revealed a thymic cyst, the wall of which was composed of Hodgkin's lymphoma cells and nodular sclerotic lesions containing many lacunar cells and Reed-Sternberg cells.

Single-port laparoscopy assisted appendectomy under local pneumoperitoneum condition

We describe herein a novel, simplified technique of laparoscope-assisted appendectomy under local pneumoperitoneum condition. A 12-mm-outer-diameter laparoscope fitted with a transparent plastic cap is inserted through a single, small, open laparotomy incision. This scope has a 5-mm working channel for insertion of the multifunctional metallic catheter which maintains the local pneumoperitoneum condition. When we have located the inflamed appendix by tracing the tenia of cecum, we use the grasping forceps protruding from the working channel of this laparoscope to grasp its tip or root on the cecum. This allows us to pull the appendix up and out through the small incision and to resect it in the conventional surgical way. This procedure permits the surgeon to perform appendectomy by making only one small incision under spinal anesthesia, and also eliminates development of the intracavitary concomitant diseases.

Morphometric evaluation of neonatal brainstem development by means of the ultrasonographic method

Development of the midbrain in 260 newborn infants was studied by means of the ultrasonographic method. The 260 infants were divided into four groups; 211 appropriate-for-date (AFD) infants without intracranial abnormalities or chromosomal disorders, 41 light-for-date (LFD) infants without intracranial abnormalities or chromosomal disorders, 5 cases of Down syndrome and 3 cases of trisomy 18. The midbrain area (MBA) was measured in transverse sections using a Sonos 1000 (YHP) within 24 h of birth. MBA of the 211 AFD infants was correlated with gestational age (GA), the standard curve being -0.0029(GA)2 + 0.2611(GA) -3.335 (r = 0.87, P < 0.0001). MBA of the other three groups were compared with this standard curve. Thirty-seven of the 41 LFD cases and all the Down syndrome infants showed MBA within 1.5 S.D. of the standard curve. However, all the infants with trisomy 18 had smaller MBA than -1.5 S.D. of the standard curve. The standard curve should be useful for assessing the gestational age of newborn infants and for detecting abnormal development of the brainstem in developmental disorders.

Clinicopathologic features of gastric cancer infiltrating the lower esophagus

A total of 211 patients with gastric cancer in the upper third of the stomach were clinicopathologically evaluated. Of the 211 patients, 82 had esophageal infiltration and 129 did not. These two groups were compared. The study on patients who had undergone resection and radioisotope (99mTc-phytate) uptake testing revealed that it was important to dissect the lymph nodes (predominantly nodes 7, 9, 11, and 16) during surgery in the patients with gastric cancer plus esophageal infiltration. When cancer infiltration of the esophagus exceeds 1 cm, the preferred surgical procedure is lower esophagectomy and total gastrectomy with abdominal and intrathoracic lymphadenectomy via the left thoracoabdominal approach. When residual cancer is suggested in the more proximal esophageal stump due to intramural metastasis from vascular invasion, rapid pathologic diagnosis should be made by frozen sections during surgery and then subtotal esophagectomy by blunt removal of the esophagus proximally from the aortic arch using a left thoracotomy considered.

Cystic islet cell tumors: radiologic findings in three cases

We report three cases of cystic islet cell tumors, two caused by gastrinomas and the other by an islet cell carcinoma. All three patients underwent computed tomography (CT) and angiography and two also had magnetic resonance (MR) imaging. Several common radiographic findings were present as follows: thickening of the cyst wall and irregularity of the inner surface on postcontrast CT and MR images, neovascularity and a densely staining hypervascular rim on angiography, and moderately increased signal intensity of the cyst content on T1-weighted MR images, which indicated fluid containing blood and/or necrotic tissue. These findings are helpful in defining the nature of these lesions and strongly suggest that cystic islet cell tumor should be included in the differential diagnosis.

A one-stage method for obtaining CT during arterial portography and hepatic arteriography

We describe a new technique for performing CT during arterial portography (CTAP) and during hepatic arteriography (CTHA) in a one-stage procedure, using a coaxial balloon catheter system and slip-ring CT equipment. This technique was employed in 10 patients with liver neoplasms. Both CTAP and CTHA images were obtained in all patients.

Effect of repeated injection of somatomedin C on drug metabolizing enzyme activities in rats

The effect of somatomedin C on the hepatic drug-metabolizing enzyme system in rat liver after sc injection, a clinically applicable dosing route, was studied. Although liver weight was slightly increased after somatomedin C (1 mg/kg) was injected for 7 days, no significant changes were observed in other dosing group (0.1 and 10 mg/kg). There were no significant effects of somatomedin C on cytochrome P-450 and b5 contents, and NADPH-cytochrome c reductase, aminopyrine demethylase, aniline hydroxylase, and ethoxyresorufin deethylase. Additionally, somatomedin C treatment did not affect the activities of 2 alpha-, 2 beta-, 6 beta- and 16 alpha-hydroxytestosterone and androstenedione formation from testosterone. Changes relation to dosing period were also examined with 1 mg/kg of somatomedin C. In this case, hepatic levels of cytochrome P-450 and b5, NADPH-cytochrome c reductase and drug oxidations did not differ significantly among groups treated for 3, 7, or 14 days. These results suggest that somatomedin C has no effect on the hepatic mixed-function oxidase system.

[Pathogenesis of hypoxic encephalopathy during pre- and peri-natal periods: conclusion]

Perinatal asphyxia is a well recognized cause of cerebral palsy and related disabilities. However, uncertainties exist regarding the degree of asphyxia required to cause brain injury. Determination of degree of asphyxia is a simple matter of measuring blood gases and pH. However, the mechanism of asphyxia required to produce cellular damage in a particular individual varies widely, depending not only on depth and duration of the asphyxia but even more on other biochemical changes, especially glucose, excitatory amino acids, calcium activated protein, or the receptor side of ionic channels. The mechanism of delayed neuronal cell death or cell-to-cell connection is also mysterious. The immature brain is not a reduced version of the adult brain. Studies should develop to a wide variety of approaches to clear the complex interactions between birth asphyxia and anoxic brain damage.

Cerebral oxygenation in childhood moyamoya disease investigated with near-infrared spectrophotometry

In children with moyamoya disease, the time courses of hemoglobin concentrations before and after hyperventilation were examined using near-infrared spectrophotometry (NIRS) to determine brain tissue oxygenation. Five patients were studied: 1 was studied both before and after surgery and 4 were studied only after surgery. Nine hemispheres of these 5 patients were examined. The oxygenated hemoglobin concentration increased immediately after beginning hyperventilation. This parameter later decreased sharply to below the prehyperventilation level and remained at the reduced level for a prolonged period. These changes in oxygenated hemoglobin concentration were similar to those previously reported in arterial blood oxygen and CO2 tension. The magnitude of variance in oxygenated hemoglobin concentration (C-HV) was significantly greater in moyamoya disease patients than in healthy controls (P < .003, Wilcoxon test). The changes of NIRS after operation were markedly more sensitive than those of electroencephalography or single-photon emission computed tomography. NIRS could be applied to cerebral oxygenation as well as cerebral hemodynamics, which may be used to better define the time sequence and pathologic processes of various childhood encephalopathies.

[Hepatocellular transplantation for metabolic support in experimental acute liver failure in rats]

The function of intrasplenic transplanted hepatocytes in acute liver failure was studied in an experimental model using rat (Lewis syngeneic rat). Acute ischemic liver failure was induced by occlusion of the proximal portal vein and hepatic artery immediately following extracorporeal porto-femoral venous bypass. Rats in group I were untreated and served as control (n = 6). Rats in group II received an intrasplenic transplant of hepatocytes (4 x 10(7) cells) 2 days before liver ischemia (n = 6). Rats in group III received an intrasplenic injection of the equal quantitative liver homogenate instead of hepatocytes 2 days before liver ischemia (n = 6). Serum ammonia and blood glucose were measured before, 1 hour and 2 hour after ischemia. The survival times of animals were evaluated. Serum ammonia was remarkably increased after ischemia in group I (1 hr = 937, 2 hr = 1220 micrograms/dl). On the other hand, in group II, the elevation of serum ammonia was significantly suppressed, less than half of that in group I (1 hr = 425, 2 hr = 463 micrograms/dl). That in group III was similar to group I. Blood glucose was remarkably decreased in all groups, but it was statistically higher in group II (1 hr = 48, 2 hr = 28 mg/dl) than in others (group I 1 hr = 23, 2 hr = 2, group III 1 hr = 29, 2 hr = 10 mg/dl). The mean survival time in group II (191 minutes) was two times longer than those in another two groups.

Identification of homeobox genes expressed in human T-lymphocytes

Homeobox genes encode transcription factors involved in the process of normal development and differentiation of cells and organs. Recently, some homeobox genes are found implicated in hemato-lymphoid neoplasms. To assess the role of homeobox genes in normal development and neoplastic transformation of T-cells, we have surveyed for homeobox-containing gene expression in a human T-cell leukemia line with a polymerase chain reaction. Ten members of homeobox genes were isolated, including one novel sequence. The novel sequence was most related to mouse Cdx. One of the others, HOXB7, is expressed in most malignant T-cell lines and CD4-positive peripheral blood T-cells. Together with the recent observations, these results suggest that the protein products of these genes may participate in normal functions and/or transformation of T-cells.

Growth and developmental patterns in Prader-Willi syndrome

Eleven Japanese patients with Prader-Willi syndrome were studied from infancy, and examined with respect to their growth and development. The chromosomal aberration was observed in 40% of the patients using a high-resolution chromosome banding technique. The birth weight in 10 out of the 11 patients was below the mean and the rate of body weight gain was severely retarded by 6 months in all cases, which suggested an insufficient utilization of nutrients in uterine life and in early infancy. The rate of height increase as well as that of body weight increase were also transiently retarded from 10 to 18 months of age in eight cases, and the body weight gain increased dramatically after 10-18 months due to hyperphagia. The patients' mean milestones of development were delayed (the mean developmental quotient was 50) in comparison with those of control patients; there was no difference between the developmental milestones of the two groups with and without the chromosomal aberration.

Endoscopic and clinicopathological features of primary gastric lymphoma

Thirty-three patients with primary gastric lymphoma over a period of 32 years were studied. Endoscopic findings indicated that there were many cases of multiple lymphoma in the stomach, or with extensive tumor-infiltration, and that it was necessary to carefully inspect the entire stomach to determine the scope of resection and improve diagnostic accuracy. It is also particularly important not to damage the tissue during biopsy and to take deep large specimens from the ulcer margin, surrounding wall, and area of erosion. As compared clinicopathologically with gastric carcinoma, primary gastric lymphoma is found more frequently in younger females, with invasion of the entire stomach and extensive lymph node infiltration. By performing adequate resection of lymph nodes, as is done for gastric carcinoma, and administering appropriate combination chemotherapy, postoperative longterm results were similar to, or better than, those obtained with gastric carcinoma.

Expression of the leukemia-associated gene, p18, in normal and malignant tissues; inactivation of expression in a patient with cleaved B cell lymphoma/leukemia

p18 is a well conserved gene coding for an 18 kDa cytosolic phosphoprotein. Although the function of p18 is unknown, it is suspected of playing a role in regulation of cell proliferation or the proliferation-differentiation switch. Here we have found p18 mRNA expression highest in testis, brain, thymus and a multipotent hematopoietic stem cell line and lowest in liver. p18 was also expressed vigorously in all but one of 85 diverse tumor cell lines and primary human malignant specimens examined. In five primary tumors, expression was substantially elevated with respect to expression in contiguous normal tissue. Expression in chronic phase chronic myelogenous leukemia cells was far greater than in normal blood cells and increased with progression of disease. In liver material, the highest level of p18 was found in a primary hepatoblastoma, a stem cell tumor, whereas a benign adenoma demonstrated very low level expression. Cells from a cleaved B cell lymphoma/leukemia failed to express p18 whereas 18 specimens from other B lymphoid malignancies, including a second cleaved cell malignancy, expressed p18 at substantial levels. These data are consistent with p18 playing a role in control of cell proliferation in at least certain tissues. The questions arise if high level p18 expression in certain malignancies may play a primary role in driving cell proliferation or, based on chromosomal localization and inactivation of p18 expression in one lymphoma, if p18 may act as a tumor suppressor.

[A case of acute hepatitis A associated with acute renal failure from the onset]

A 42-year-old female was admitted to a hospital, because of acute hepatitis A. Laboratory data were GOT 8210mU/ml. GPT 4650mU/ml, LDH 11860mU/ml, total bilirubin 4.7mg/dl, BUN 19.5mg/dl and creatinine 1.9mg/dl. Urinalysis showed proteinuria 3+ and occult blood 1+. Soon after admission, she suffered from anuric acute renal failure and was transferred to our hospital for hemodialysis. Her urine-volume was under 20 ml per day. Urinalysis showed proteinuria 4+, occult blood 1+ and casts. Laboratory data showed BUN 58.2mg/dl and creatinine 8.5mg/dl. She was treated by hemodialysis for 35 days, before recovering from renal failure. However, her renal function did not recover perfectly and her 24-hour creatinine clearance remained at 50ml/min after 6 months. Renal biopsy was performed on the 17th day after admission. Examination by light microscopy revealed the findings of acute tubular necrosis and examination by immunofluorescence antibody method was negative. Urinalysis of 8 patients with acute hepatitis A showed that all patients had proteinuria at the onset. Patients with acute hepatitis A have symptoms of appetite-loss, nausea, vomiting and/or diarrhea. These symptoms cause hypovolemia, and hepatic dysfunction causes discontrol of vasoactive hormones, which gives rise to disturbance of renal circulation. Subsequently, acute tubular necrosis and acute renal failure occur.