Laryngeal preservation surgery using a free flap patch following resection of a carcinoma of the posterior wall of the oropharynx

A carcinoma originating from the posterior wall of the oropharynx is not common, and radiotherapy has been used for years in this event without acceptable success. A free flap patch was used in 4 patients to reconstruct the defect after resection of a T2 or T3 carcinoma on the posterior wall of the oropharynx without laryngectomy. The free flaps used were the radial forearm and the free jejunal patch in 2 patients each. There was no flap loss, and successful laryngeal preservation was obtained in 3 of 4 patients. Laryngeal preservation surgery using a free flap patch proved very useful in selected patients with carcinoma of the posterior wall of the oropharynx. Based on our clinical experience, the free jejunal patch seems superior to the free forearm flap with regard to postoperative functional results.

Utility of measuring serum parathyroid hormone-related protein concentration in leukemic patients with hypercalcemia for assessing disease status

OBJECTIVE

To evaluate serum parathyroid hormone-related protein (PTHrP) as a marker of hypercalcemia in leukemic patients.

DESIGN AND METHODS

We measured the serum levels of PTHrP, lactate dehydrogenase (LDH) and calcium in three patients with hypercalcemia due to leukemia.

RESULTS

Serum levels of PTHrP, LDH and calcium were elevated at admission in all patients, and these levels were reduced to within the normal range after chemotherapy. However, normalization of serum PTHrP concentration occurred more rapidly than normalization of serum LDH levels after chemotherapy. The increase in serum PTHrP concentration accompanied leukemic cell proliferation and preceded the increases in serum LDH and calcium. Serum LDH concentration increased, but serum PTHrP concentration did not after administration of granulocyte colony-stimulating factor.

CONCLUSION

These findings suggest that serum PTHrP may be a more useful marker than serum LDH or calcium in assessing the status of leukemic patients with hypercalcemia.

Successful treatment of anomalous origin of the left coronary artery from the pulmonary artery in a 5-week-old male infant

A 5-week-old male infant who was referred to our hospital because of tachypnea and poor feeding. An electrocardiogram showed a deep Q wave in lead aVL, negative T waves in leads I, II, III, aVF and V6 and a positive T wave in VL. Echocardiography revealed severely impaired left ventricular function. Aortography confirmed with a diagnosis of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). Takeuchi's procedure was performed and the patient maintained postoperatively on assisted circulation for 7 hours even though sternal closure delayed until 7 days post operatively. His left ventricular function showed and marked improvement gradually.

Proton-relay system of carboxypeptidase Y as a sole catalytic site: studies on mutagenic replacement of his 397

His397 was replaced with alanine by site-directed mutagenesis of the cloned PRC1 gene in order to confirm the role of this residue in the proton-relay system of carboxypeptidase Y (CPY). The expressed and purified H397A showed a CD spectrum almost identical to that of the wild type enzyme, but its heat stability and conformation on heating differed somewhat. Kinetic analysis showed that the kcat values of the purified H397A toward the peptide substrates, Z-Phe-Leu and Z-Gly-Phe, were reduced to approximately 4 x 10(-5)-fold, whereas the Km values remained almost unchanged. The activity of the H397A preparation with the ester substrate, Ac-Phe-OEt, was negligible. The low activity of our H397A was lost on treatment with DFP and Z-Phe-CH2Cl, site-specific inhibitors, respectively, for Ser146 and His397, and with the HgCl2 and PCMB, SH-reagents for Cys341. After treatment with these inhibitors, the kcat value for the H397A preparation toward Z-Phe-Leu decreased 1 x 10(3)-fold or more. The value was approximately 10(-8) for the wild type enzyme. This level of activity is 10(3)-fold lower than the reported value for the same mutant of CPY [Carlsberg Res. Commun. 54, 165-171 (1989)], and more than 10-fold lower than the values for the corresponding His-to-Ala mutants of trypsin [J. Am. Chem. Soc. 114, 1784-1790 (1992)] and subtilisin [Nature 332, 564-568 (1988)]. These findings, together with the pH profiles and chromatographic behavior, are evidence that the low activity of the H397A preparation is due to contamination by wild type CPY. The decreased kcat value of our H397A mutant is the lowest reported among the corresponding histidine mutants of serine proteases. We conclude that the proton-relay system composed of Ser146 and His397 is the sole catalytic center of CPY, and that its destruction leads to complete inactivation.

Reduction of activity, but no decrease in concentration, of erythrocyte Cu,Zn-superoxide dismutase by hyperglycaemia in diabetic patients

Cu,Zn-superoxide dismutase(SOD) activity in erythrocytes is affected by various diseases, including diabetes mellitus (DM). We investigated changes in the Cu,Zn-SOD activity compared to changes in the Cu,Zn-SOD concentration in erythrocytes obtained from patients with Type 2 (non-insulin-dependent) diabetes mellitus. Cu,Zn-SOD activity in erythrocytes was significantly lower in Type 2 DM patients than in healthy non-diabetic subjects. The activity correlated negatively with HbA1c, but not with other indicators of metabolic control, such as fasting blood glucose or plasma cholesterol or triglyceride. However, there was no statistically significant difference in erythrocyte concentration of Cu,Zn-SOD between diabetic and control samples. Concentration did not correlate with enzymatic activity or HbA1c. These findings indicate that the inactivation of Cu,Zn-SOD activity in erythrocytes of Type 2 DM patients by hyperglycaemia may be slow, because there is a negative correlation between the enzyme activities and HbA1c levels, but not fasting blood glucose levels. This is consistent with glycosylation of the active site of Cu,Zn-SOD, without any effect of hyperglycaemia on the concentration of Cu,Zn-SOD.

Surface expression and release of soluble forms of CD8 and CD23 in CD40- and IL-4-activated mononuclear cells from patients with Graves' disease (GD)

We investigated the effect of T cell-dependent B cell activation on the surface expression and release of the soluble forms of CD8 and CD23 by peripheral blood mononuclear cells (PBMC) obtained from patients with GD, versus patients with Hashimoto's thyroiditis, and normal controls. Incubating the PBMC with anti-CD40 MoAbs and IL-4 increased the soluble CD23 levels in cells from all three groups. An increase in the number of CD23+ cells was observed in the PBMC from the patients with GD, but not in PBMC from Hashimoto's thyroiditis or controls. Less soluble CD8 was released from anti-CD40 antibody and IL-4-stimulated PBMC obtained from patients with GD relative to those from the controls. In addition, the number of CD8+ cells was significantly reduced in stimulated PBMC from the GD patients relative to those from controls. Incubation of PBMC with anti-CD40 antibody plus IL-4 did not affect the proportions of CD4+, CD20+, Fas+ CD4+, and Fas+ CD8+ cells. The addition of T3 to cultured PBMC from controls did not reproduce the changes in CD23+ and CD8+ cells noted in the samples froin GD patients. Thus, T cell-dependent B cell activation, mediated by a CD40 pathway, may reduce the number of CD8+ cells, causing exacerbation of GD.

Chest radiography as a predictor of outcome in posttransplantation lymphoproliferative disorder in lung allograft recipients

OBJECTIVE

The radiologic findings of posttransplantation lymphoproliferative disorder in lung transplant recipients have received little attention compared with the findings for recipients of other solid organ transplants. We describe the intrathoracic findings and explore whether the radiographic presentation can predict outcome.

MATERIALS AND METHODS

Twenty-six patients (mean age, 32 years; range, 2-63 years; 18 female, eight male) with histologically proven lymphoproliferative disorder were identified from 518 lung transplantation patients, a 5.0% frequency. Chest radiographs, obtained within 1 week of diagnosis, were compared with baseline posttransplantation radiographs for all 26 patients and with chest CT scans for 20 patients.

RESULTS

The interval between transplantation and diagnosis ranged from 6 weeks to 7 years (mean, 16 months; median, 6 months). The thorax was involved in 18 (69%) of 26 patients. A new chest radiographic abnormality was present in all 18 patients and provided the first indication of disease in 14 (78%) of 18 patients. The most common finding was a solitary pulmonary nodule, seen in nine (50%) of 18 patients. Other findings included multiple nodules, multifocal alveolar infiltrates, and hilar and mediastinal adenopathy. CT scans detected additional nodules and lymph nodes but did not show occult disease in any case that appeared normal on radiography. Eight (89%) of nine patients with solitary pulmonary nodules at presentation were alive 1 year after diagnosis, compared with six (35%) of 17 patients with other presentations (p < .01).

CONCLUSION

Thoracic manifestations are present in most lung transplant recipients with lymphoproliferative disorder. Patients with solitary nodules have a better outcome in the first year after diagnosis than do patients with other presentations.

Role of Phe120 in the activity and structure of bovine pancreatic ribonuclease A

Phenylalanine120 is a candidate residue juxtaposing catalytic His12 and His119 in ribonuclease A (RNase A). To clarify its role in construction of the catalytic center, Phe120 was replaced by alanine, tryptophan, leucine, or glutamic acid by site-directed mutagenesis. The transphosphorylation and hydrolysis activities of the mutant RNase As, respectively, toward cytidinyl 3',5' adenosine (CpA) and cytidine 2',3' cyclic monophosphate (C>p) were compared with those of the wild type enzyme. The Km values of the two reactions increased markedly with slight changes in the Kcat values. The pKe values of His12 and His119 in the wild type and mutant enzymes, estimated from the pH dependence of the kcat/Km values, showed little change. The rate of carboxymethylation was reduced markedly by the mutations. The Ki values of the phosphate anion as to hydrolysis activity increased only slightly when Phe120 was replaced by leucine, tryptophan, or alanine. These findings suggest that Phe120 participates in the binding of the substrate, juxtaposing His12 and His119, and in stabilizing the transition state intermediate in the hydrolysis reaction. Furthermore, the decreases in the thermal denaturation temperatures of all the mutants, particularly F120E, indicate that Phe120 also helps maintain the conformational stability of RNase A.

A new concept and technique for reconstruction of the lower pharyngeal space using the free jejunal graft

OBJECTIVE

To report on a new concept and simple operative procedure to conform the diameter of the oral end of free jejunal grafts to that of pharyngeal defects for reconstruction of the lower pharyngeal space.

DESIGN AND METHODS

A preliminary study showed that the jejunum is supplied by a highly vascular network and that longitudinal paramesenteric incisions can be made without disturbing the blood supply of the jejunum. We then developed the following operative procedure. The position of the highest point of the pharyngeal defect and the site of the recipient vessels are determined. The free jejunal graft is positioned with its mesentery in correspondence with the location of the recipient vessels. The position of a longitudinal incision 180 degrees to the highest point of the defect is then determined. After the oral border of the jejunum is opened with scissors, a pharyngojejunal end-to-end anastomosis is performed.

PATIENTS

Eighteen patients with defects of the lower pharyngeal space after cancer treatment.

RESULTS

We transferred jejunal grafts in 18 patients using this operative procedure. In 7 of these patients, paramesenteric incisions were made. The lengths of the incisions ranged from 2 to 8 cm. Transfer was successful in all 18 patients. Postoperative leakage occurred in 1 patient in whom an antimesenteric incision had been made; however, a fistula did not develop.

CONCLUSIONS

Our method allows defects of the lower pharyngeal space to be reconstructed with end-to-end anastomosis of free jejunal grafts regardless of the location of the defect or of recipient vessels. This method is simple and appropriate for correcting large pharyngeal defects.

A physical map of Arabidopsis thaliana chromosome 3 represented by two contigs of CIC YAC, P1, TAC and BAC clones

We have constructed a physical map of Arabidopsis thaliana chromosome 3 by ordering the clones from CIC YAC, P1, TAC and BAC libraries using the sequences of a variety of genetic and EST markers and terminal sequences of clones. The markers used were 112 DNA markers, 145 YAC end sequences, and 156 end sequences of P1, TAC and BAC clones. The entire genome of chromosome 3, except for the centromeric and telomeric regions, was covered by two large contigs, 13.6 Mb and 9.2 Mb long. This physical map will facilitate map-based cloning experiments as well as genome sequencing of chromosome 3. The map and end sequence information are available on the KAOS (Kazusa Arabidopsis data Opening Site) web site at http://www.kazusa.or.jp/arabi/.

Transglutaminase activity in serum and cerebrospinal fluid in sporadic amyotrophic lateral sclerosis: a possible use as an indicator of extent of the motor neuron loss

The activity of transglutaminase (TGase), a marker enzyme for tissue degeneration, was examined in serum and cerebrospinal fluid (CSF) obtained from patients with sporadic amyotrophic lateral sclerosis (SALS), and compared to those from patients without SALS. When the serum TGase activity values from SALS patients were compared against the 'ALS-scale', which is used for clinical evaluation of the progression of ALS, the TGase activity values were higher at the initial stage of the disease than in non-ALS subjects, whereas they became extremely low at the late stage of ALS. The TGase activity in the CSF taken at later than middle stage from ALS patients with definite clinical motor dysfunctions was significantly lower than in that from non-ALS subjects. We have previously demonstrated marked reduction of tissue TGase activity in all regions of spinal cord tissue transections from ALS patients, not only in ventral but also lateral and dorsal regions, relative to that in non-ALS patients. These results suggest that some TGase may be leaked out of the spinal cord tissue into the CSF and then into the blood-stream during the progression of ALS, and the enzymic activity finally becomes depleted at the terminal stages of the disease when most of the spinal motor neuronal perikarya have been destroyed.

Influence of diabetes during pregnancy on gestational age-specific newborn weight among US black and US white infants

This study examined the impact of maternal diabetes on birth weight for gestational age patterns of all term black infants and white infants in the United States using data derived from the 1990-1991 US Live Birth File of the National Center for Health Statistics. Infants of both black mothers and white mothers exhibited the expected fetal overgrowth associated with maternal diabetes. However, the increase in birth weight was much greater in infants of black than white diabetic mothers in comparison with their nondiabetic counterparts, as measured by the discrepancy in birth weight between infants of diabetic and nondiabetic mothers at each gestational week, the incidence of large for gestational age, high birth weight, small for gestational age, and low birth weight. After adjustment for maternal hypertension, prenatal care use, and sociodemographic factors, the disparity in mean birth weight associated with diabetes was 211.67 g in black infants and 115.74 g in white infants. The adjusted odds ratios of birth weight > or = 4,000 g were 2.98 (95% confidence interval 2.89-3.12) for black infants and 1.83 (95% confidence interval 1.78-1.89) for white infants. Given the potential risks for mothers and infants consequent to maternal diabetes and fetal hyperinsulinemia, further investigation of the prevalence, characteristics, and outcomes of diabetes during pregnancy among black mothers and infants is warranted.

[A case of autosomal dominant, pure form spastic paraplegia with thinning of the corpus callosum]

Autosomal dominant hereditary spastic paraplegia (HSP) is genetically classified into three types, all of which are characterized by insidiously progressive spasticity of the lower extremities. Patients with a complicated form of autosomal recessive HSP associated with hypoplasia of the corpus callosum have been reported by Iwabuchi et al. Here we report a 64-year-old patient with a pure form of autosomal dominant HSP with thinning of the corpus callosum. He had been well until 12 years of age, when spasticity and weakness of the lower extremities began to develop. His symptoms gradually worsened and he had difficulty in walking at the age of 44. When he was 56 years old, he visited our hospital. Eleven family members over five generations have been affected, and anticipation, i.e., an apparent decrease in age of onset, has been observed. On admission, he had mild cataracts, equinovarus and pes cavus, and neurological examination revealed spastic paraplegia. However, the intelligence test was normal, and nystagmus, ataxia of the extremities, involuntary movement, orthostatic hypotension or urinary disturbance was not observed. Trinucleotide repeat diseases, such as Huntington's disease, spinocerebellar ataxia type 1, spinocerebellar ataxia type 2, Machado-Joseph disease and dentatorubral-pallidoluysian atrophy, were excluded by DNA analysis. Brain MRI at the age of 64 revealed marked thinning of the corpus callosum. We considered this patient had a pure form of HSP. However, thinning of the corpus callosum has never been reported in autosomal dominant HSP.

Efficacy of a low-dose subcutaneous lisuride infusion in Parkinson's disease

Five parkinsonian patients with motor fluctuations and dyskinesia after long-term treatment with levodopa were treated with subcutaneous lisuride infusion (0.24-0.42 mg/day) together with oral levodopa for a mean period of 27 (range 13-36) months. All 5 patients showed marked initial improvement in mobility. Mild psychiatric side effects were observed in three patients; however, these side effects disappeared with reduction in the dosage of lisuride to 0.06 mg per day without a significant increase in motor fluctuations. A low dose of subcutaneous lisuride infusion with oral levodopa is an effective treatment for fluctuations of motor performance in parkinsonian patients without adverse psychiatric effects.

Vitamin E and coenzyme Q concentrations in the thyroid tissues of patients with various thyroid disorders

To clarify the different roles of free radical scavenging systems in various thyroid disorders, we measured the levels of alpha-, beta-, and gamma-tocopherols and coenzyme Q in the thyroid tissues of patients with thyroid tumors and Graves' disease using high-performance liquid chromatography. The levels of alpha-tocopherols and gamma-tocopherols in the thyroid tissue of patients with papillary carcinoma and the level of gamma-tocopherol in the thyroid tissue of patients with malignant lymphoma were elevated compared with those in normal thyroid tissues. The level of coenzyme Q was reduced in the thyroid tissue of patients with Graves' disease and follicular and papillary thyroid carcinomas. These findings imply that vitamin E and coenzyme Q as scavengers play some role in thyroid follicular cell hyperfunction or dysfunction.

Bovine spleen cathepsin A: characterization and comparison with the protective protein

Cathepsin A was purified approximately 550-fold with an overall yield of 4% from bovine spleen crude extracts by successive chromatographies on DEAE-Sephadex A-50, phenyl-Toyopearl 650C, and Con A-agarose. PAGE of the purified enzyme without 2-mercaptoethanol revealed an apparent molecular size of 110 kDa, and SDS-PAGE with 2-mercaptoethanol gave two polypeptide bands corresponding to 32 and 25 kDa and without 2-mercaptoethanol a single polypeptide 52 kDa band. These results indicate that the enzyme has an (alpha beta)2 tetrameric structure in which the alpha (32 kDa) and beta (25 kDa) subunits are linked by disulfide bond(s). The enzyme exhibited peptidase activities, hydrolyzing various Z-dipeptides with optimum pHs between 5.0 and 5.8. The hydrolytic rate for Z-Phe-Ala was 15 times higher than that for Z-Glu-Tyr, the traditional cathepsin A substrate. The enzyme also catalyzed the hydrolysis of the C-terminal amino acids of RCM-RNase A and showed esterase activity toward BTEE at pH around 7.5. DFP and TPCK completely inhibited both peptidase and esterase activities, and [1,3-3H]DFP was bound to the alpha subunit. All these results support the fact that the enzyme is a serine carboxypeptidase. The N-terminal amino acid sequences of the alpha and beta subunits are highly homologous to those of the human protective protein in galactosialidosis, strongly supporting the identity between cathepsin A and the protective protein.

Effects of thyroid hormone on catecholamine and its metabolite concentrations in rat cardiac muscle and cerebral cortex

Clinical and experimental data suggest that thyroid hormone affects the actions of catecholamine (CA). However, the serum or tissue levels of CA during thyroid disorders have not been well defined. Accordingly, we investigated the levels of CA and their metabolites in the cardiac muscle, the cerebral cortex, and the plasma of rats with hyperthyroidism and hypothyroidism versus euthyroid animals. The Neurochem analyzer system (ESA, Inc., Bedford, MA) was used in such determinations. The cardiac muscles of hyperthyroid rats exhibited a 16% decrease in the levels of 1-dopa, 3-methoxytyramine (3-MT) and homovanillic acid (HVA) as compared with those in euthyroid rats. The levels of norepinephrine (NE) in cardiac muscle of these rats increased significantly (5.2-fold) relative to the levels in euthyroid rats. NE was undetectable in the cardiac muscles of the hypothyroid rats. Epinephrine (E) and dopamine (DA) were not detected in the cardiac muscles of the rats with either thyroid disorder. Levels of E and 3,4-dihydroxymandelic acid (DOPEG) were detected only in the cerebral cortex of hyperthyroid rats. The cerebral cortex levels of 3-methyoxytyramine (3-MT), 3,4-dihydroxyphenylacetic acid (DOPAC), metanephrine (MN), and homovanillic acid (HVA) were all significantly increased in the hyperthyroid versus the euthyroid rats. The cerebral cortex levels of DA, NE, normetanephrine (NMN), and VMA in the hyperthyroid rats all showed a significant decrease. Levels of NE, NMN, and DOPAC in the cerebral cortex increased significantly in the hypothyroid rats. The level of VMA was undetectable in cerebral cortex of such animals. Data from studies on cardiac muscle and cerebral cortex indicate that the changes in CA and CA metabolites are responsible in part for the cardiovascular and the central nervous system symptoms observed in hyperthyroidism and hypothyroidism.

Afferent feedback in the triphasic EMG pattern of leg muscles associated with rapid body sway

Electromyographic (EMG) patterns of leg muscles associated with rapid body sway were studied in relation to displacement of the center of foot pressure (CFP). Standing subjects were instructed to shift the CFP by swaying their bodies, pivoting at the ankle as rapidly and accurately as possible after an auditory signal. CFP position was designated as N when the subject maintained a relaxed bending posture and as F when a maximally forward-leaning posture was maintained. A serial, stereotyped triphasic EMG pattern was observed in the rapid shift of CFP from N to F: cessation of EMG activity in the gastrocnemius (GC) muscle was followed by a burst in the tibialis anterior (TA) muscle (acceleration phase), and then resumed discharge occurred in the GC muscle with cessation of activity in the TA muscle (deceleration and stop). When the subject shifted the CFP from N to F to different degrees, the duration and amount of EMG activity in the TA muscle during acceleration and the GC muscle in deceleration were proportionate to the amount of CFP displacement associated with forward body sway. To determine the functional roles of sensory inputs from the foot on the triphasic EMG pattern, body sway was studied under the condition of sensory block in the feet induced by ischemia from tourniquets placed bilaterally just above the ankle joints. The triphasic EMG pattern persisted during ischemia. The time of GC cessation and the onset of TA burst at acceleration remained unchanged, but the times of TA cessation and resumption of GC discharge at deceleration were altered during ischemia. Moreover, subjects were unable to stop at F and eventually fell. These results indicate that both amount and duration of EMG activity associated with rapid body sway are functions of the amount of CFP displacement. Somatic sensation from the feet is important for control of burst and cessation timing and duration in leg muscle activity.

Familial hemiplegic migraine with irreversible brain damage

Familial hemiplegic migraine (FHM) is an autosomal dominant syndrome characterized by recurrent episodes of varying degrees of hemiparesis associated with migraine. The aura including hemiparesis may be prolonged and in severe attacks may often be associated with confusion or coma. We describe a case of FHM whose aura was atypically prolonged and resulted in irreversible brain deficit which on magnetic resonance imaging (MRI) was suggestive of cortical hyperperfusion. A subsequent MRI showed left brain atrophy.

[Auditory evoked magnetic fields in patients of pure word deafness]

Auditory evoked magnetic fields (AEF) were recorded in 2 cases with pure word deafness. AEF examination were performed with a novel 129-channel vector neuromagnetic imaging system (SBI 100). The latency and the location of equivalent current dipole (ECD) of N100 m after 1,000 Hz tone burst stimulation, one of the most prominent peak of AEF, were evaluated. One patient, 59-year-old man, suffered from left putaminal hemorrhage and the other, 59-year-old man, had a history of bilateral putaminal hemorrhage. There was no N100 m detected in the left temporal lobe with the right ear stimulation in both patients. However normal N100 m was obtained in the right hemisphere with the left ear stimulation in both cases. And the position of ECD of N100 m in the right hemisphere were correctly superimposed on the Heschl gyrus in brain MRI. The pathophysiology of pure word deafness has been postulated that a disconnection between Wernicke area and bilateral auditory inputs played one of important roles in progression of pure word deafness. Because there was no pathological lesion in temporal lobe verified by MRI study in both patients, N100 m in the left could not be evoked due to interception of the auditory pathway to the Heschl gyrus, but not due to destruction of Heschl gyrus. AEF test is one of the most useful tools in order to estimate central auditory function in patients with pure word deafness.

Impaired modulation of tonic muscle activities and H-reflexes in the soleus muscle during standing in patients with Parkinson's disease

The presence of postural disturbance in patients with Parkinson's disease (PD) was assessed by the displacement of the centre of foot pressure (CFP) and by changes in the amplitude of the soleus H-reflex when patients maintained an upright standing posture, followed by a forward-leaning posture. Thirteen patients and 13 age-matched normal controls (N) were studied. PD patients showed the following differences when compared to normal subjects: (1) the range of displacement of the CFP associated with forward leaning was significantly smaller (P<0.01); (2) the ratio of the increase in the soleus EMG activity to the CFP displacement (deltaEMG/deltaCFP) was larger (P<0.01), and the value of the deltaEMG/deltaCFP increased significantly in relation to the scale of clinical severity (P<0.01); and (3) the ratio of the increase in the amplitude of the soleus H-reflex to the soleus muscle EMG activity (deltaH-reflex/deltaEMG) was significantly lower in PD patients (P<0.05). The value of the deltaH-reflex/deltaEMG decreased significantly with the scale of clinical severity among the patients (P<0.05). These results suggest that the modulation of both the tonic stretch reflex and the phasic stretch reflex in the soleus muscle during standing are impaired in PD patients, and these impairments may partly cause their disability in the maintenance of a standing posture. Abnormalities in Ib inhibition and presynaptic inhibition are considered to be possible mechanisms in the disturbed modulation of the tonic stretch reflex and the phasic stretch reflex in PD patients during standing.

Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects

OBJECTIVE

The anterolateral thigh flap has many advantages in head and neck reconstruction. However, it has not yet come into widespread use because of the anatomic variations of its perforators. Herein, we describe a safe operative technique related to the patterns of the perforators and discuss its wide versatility.

SETTING

A national cancer center hospital.

PATIENTS

Thirty-eight anterolateral thigh flaps were transferred. Confirmation and dissection of the flap pedicle were simultaneously performed with tumor resection. The design and elevation of the flap were carried out immediately after the tumor resection was completed.

RESULTS

From the study of the anatomic variations of the perforators, septocutaneous patterns were recognized in 10 cases (26.3%) and musculocutaneous patterns in 28 cases (73.7%). All flaps were easily and safely elevated with our techniques. Thirty-six flaps survived. Partial necrosis was noted owing to excessive thinning procedure in one patient and total necrosis was noted owing to venous thrombosis at the anastomosis part in another patient.

CONCLUSIONS

We found that the anterolateral thigh flap has numerous advantages. It is possible to perform the flap elevation and the tumor resection simultaneously. The flap is generally thin and is suitable for reconstruction of intraoral defects. Combined flaps with neighboring tissues and other, distant flaps can be used. Furthermore, since our technique minimizes the problems of confirmation and dissection of the perforators, we conclude that this flap can be successfully used to repair a variety of large defects of the head and neck.