[Usefulness of urethral descent for evaluating the type of female stress urinary incontinence]

BACKGROUND

To select suitable treatment for stress urinary incontinence (SUI), both urethral function and urethral mobility must be assessed. Abdominal leak point pressure (ALPP) is considered to be useful to evaluate urethral function, and radiographic findings are effective to evaluate urethral mobility. However no adequate methods to measure urethral mobility with videourodynamics study (VUDS) exist. We measured the downward movement of the membranous urethra at the same time as ALPP was measured on VUDS, and examined whether or not the urethral descent on VUDS is useful to evaluate urethral mobility.

METHODS

The subjects were 28 women with over grade II SUI (according to McGuire's grading) who underwent bead chain cystography and VUDS. As a classical index of urethral mobility, we measured the change of posterior urethrovesical angle (PUVA) and vesical neck descent during Valsalva maneuver on bead chain cystography. The videourodynamic urethral catheter had a radiographic marker that permitted the identification of the location of the urethral pressure sensing aperture. The catheter was fixed at the position where the urethral pressure aperture reached the point of highest pressure. The urethral descent was defined as the downward movement of the urethral marker during Valsalva maneuver while measuring ALPP. According to the urethral descent the patients were classified as follows: 1) hyper-mobile group; urethral descent was over 5 mm. 2) non-mobile group: urethral descent was under 5 mm. The severity of SUI was evaluated with 1 hr. pad weighting test, ALPP and maximum urethral pressure.

RESULTS

The urethral descent was significantly related to vesical neck descent and PUVA change. In the non-mobile group (11 cases), ALPP was significantly lower, and urine loss on the pad weighting test was significantly greater than that in the hyper-mobile group (17 cases). The non-mobile group exhibited more severe incontinence than the hyper-mobile group. When the patients were classified according to Blaivas's classification, all patients in type III and 2 in type I were in the non-mobile group. These 2 type I patients had low ALPP (40 cm. water and 70 cm. water) and a history of radical hysterectomy. Therefore these patients were diagnosed with ISD due to the fixed urethra.

CONCLUSIONS

Urethral descent is an useful index of urethral mobility. In the non-mobile group, the pathophysiological cause of SUI was not urethral hypermobility but ISD, and it was diagnosed as type III SUI without urethral mobility. We consider that urethral descent assesses urethral mobility more accurately than vesical neck descent, and that urethral descent is a valuable parameter on VUDS.

Evidence for attenuation of gonadotropin pulse frequency in hypergonadotropic women with estradiol secretion in the menopausal transition

To investigate neuroendocrine interventions for climacteric symptoms in peri- and post-menopausal periods, the association between endocrine status and symptoms was examined in 519 peri- and post-menopausal women with climacteric symptoms. Furthermore, we evaluated the nature of putative disturbances in pulsatile gonadotropin (FSH and LH) secretion in 14 hypergonadotropic women with estradiol secretion and 16 hypergonadotropic women with hypoestrinism. We observed that 68.6% (356/519) of women with climacteric symptoms and 49.2% (121/246) of women in good health showed hypergonadotropinemia, and that 39.3% (140/356) of hypergonadotropic women with climacteric symptoms and 23.1% (28/121) of healthy women (controls) showed estradiol secretion (p < .002). In particular, the endocrinological profile of hypergonadotropinemia with estradiol secretion was observed in 67.1% (60/92) of pre-menopausal women with climacteric symptoms, approximately 2 x higher than that in healthy women (p < .005). Mental symptoms were observed at a significantly higher incidence in women with the endocrinological profile of hypergonadotropinemia with estradiol secretion compared with that in women with hypergonadotropic hypoestrinism showing a symptomatic profile, namely 25.0 versus 6.9% for mood lability (p < .001), and 21.4 versus 9.3% for anxiety symptoms (p < .001). Moreover, in vivo FSH and LH pulse frequencies were observed in only 14.3 and 18.6% of women with hypergonadotropinemia with estradiol secretion whereas such pulses were observed in all women with hypergonadotropic hypoestrinism. We also observed FSH and LH pulse frequencies in hypergonadotropinemia with estradiol secretion 0.14 +/- 0.35 and 0.29 +/- 0.45/3 h, respectively compared with those in hypergonadotropinemia without estradiol secretion 2.25 +/- 0.91 and 2.81 +/- 0.73/3 h, respectively (p < .001). Such findings are considered to be consistent with diminished hypothalamic GnRH impulse strength. In summary, we infer that decreased pulse frequencies in FSH and LH secretion are due to decreased hypothalamic GnRH impulse strength in women with the endocrinological profile of hypergonadotropinemia with estradiol secretion. As the potential mechanisms of this finding, it should be considered that specific endocrine environments damage the pulse generator mechanism in the diencephalon, and that changes occur in the pituitary responsiveness to GnRH (changes in receptor function).

The effect of high-dose inhaled beclomethasone dipropionate in patients with stable COPD

BACKGROUND

The benefits of inhaled corticosteroids in the management of COPD are less apparent than they are in asthma therapy, and the potential for adverse systemic effects of high-dose inhaled corticosteroids has been recognized recently. It is therefore essential to know the maximal obtainable benefits in order to assess the risk/benefit ratio of this treatment.

PURPOSE

The aim of this study was to investigate the maximal obtainable benefits of high-dose inhaled corticosteroids, 3 mg/d of beclomethasone dipropionate (BDP), when used in combination with adequate doses of regular bronchodilators in patients with stable COPD.

STUDY DESIGN

Thirty patients with stable COPD completed a randomized, double-blind, placebo-controlled cross-over trial with either 3 mg/d of BDP or with a matching placebo using a metered-dose inhaler with a spacer device for 4 weeks during each treatment period. All of the patients continued to inhale both 400 microg of salbutamol qid and 80 microg of ipratropium bromide qid.

RESULTS

The mean prebronchodilator FEV1 was 0.97+/-0.35 L during the placebo period and 1.08+/-0.38 L during the BDP period (p < 0.001). While on BDP, five patients demonstrated a response in their FEV1 of more than 8.5% of the predicted value, which was above the range that covered 95% of the distribution of the placebo response. The mean absolute improvement in the FEV1 in these 5 objective responders was 0.34+/-0.10 L, compared to 0.06+/-0.09 L in the 25 objective nonresponders. Symptom scores for wheezing and dyspnea were significantly better with BDP than with placebo. Hoarseness and sore throat were associated more with BDP treatment.

CONCLUSION

Although a considerable minority of patients benefited substantially from this treatment, the overall outcome does not seem to justify the widespread use of this treatment in the light of increasing recognition of the potential adverse systemic effects of high-dose inhaled corticosteroids.

[Imipenem/cilastatin sodium and other beta-lactams for respiratory tract infections: clinical benefit and treatment days for cure]

Therapeutic efficacy and the treatment days for cure of imipenem/cilastatin sodium (IPM/CS) in treatment of pulmonary infections were prospectively determined in comparison with those of beta-lactams other than carbapenems mainly ceftazidime (CAZ) or sulbactam/cefoperazone (SBT/CPZ). The overall response rate was 84.9% (62/73) in the IPM/CS group and 74.7% (56/75) in the beta-lactam group, the difference not being significant. In the subjects having underlying respiratory diseases, the response rate was 91.1% (41/45) and 73.9% (34/46) in the IPM/CS and beta-lactam groups, respectively. In patients with infections secondary to chronic respiratory disease, the rate was 91.2% (31/34) in the former group and 66.7% (24/36) in the latter group, respectively. The differences were significant for both stratified analyses. The treatment days for cure judged by the attending physician were 12.9 +/- 0.6 days in the IPM/CS group, and 14.5 +/- 0.7 days in the beta-lactam group. The difference was not, however, significant. In patients with mild to moderate infections, the treatment days for cure was 12.0 +/- 0.6 days (n = 64) in the IPM/CS group and 14.3 +/- 0.7 days (n = 70) in the beta-lactam group. In patients with underlying respiratory disease, the treatment days for cure were 11.8 +/- 0.7 days (n = 45) and 14.7 +/- 0.9 days (n = 46) in the IPM/CS and beta-lactam groups, respectively. In patients with infections secondary to chronic respiratory disease, the days were 11.1 +/- 0.7 days (n = 34) and 14.7 +/- 1.1 days (n = 36), respectively. Thus, IPM/CS therapy significantly reduced the number of treatment days until cure. There was, however, no significant difference between the two therapy groups in treatment of the patients with severe infections, those without underlying respiratory disease, or those with pneumonia and/or lung abscess. The treatment days for cure were also assessed by the members of review committee taking into consideration of body temperature, leukocyte count, and C-reactive protein. As the result, it was 6.9 +/- 0.5 days in the IPM/ CS and 10.3 +/- 0.7 days in the beta-lactam groups; respectively, and the difference was significant. Time (days) until cure was also compared between the two groups using survival time analysis, confirming a more rapid response in the IPM/CS group. Although IPM/CS therapy was associated with a shorter response time as assessed by both the attending physicians and the review committee, there were considerable differences between the results of these judgements. Thus, the duration of treatment with injectable antibiotics requires reevaluation in the future. No significant differences were observed between the groups with respect to parameters indicating side effects and laboratory abnormalities. There were no severe symptoms or laboratory findings, and symptoms and changes in laboratory values, if any resolved during the course of therapy or after the withdrawal of treatment. In conclusion, IPM/CS seems to be very useful as first-line therapy for respiratory tract infections and for shortening the duration of treatment.

[Electrophysiological study of intractable epileptogenicity in human epilepsy: clinical usefulness of ictal DC shifts and cavernous sinus EEG]

In order to clarify the clinical and electrophysiological features in intractable epileptogenicity in human epilepsy, we applied the new techniques, ictal DC shifts and cavernous sinus EEG recording, for presurgical evaluation of patients with intractable partial epilepsy. (1) Ictal DC shifts were successfully recorded with subdural electrodes in 8 patients with intractable neocortical epilepsy, and an analysis of ictal DC shifts would add useful information to delineate an epileptogenic area. Scalp-recorded ictal DC shifts were also investigated in 3 patients with intractable neocortical epilepsy. It also delineated the epileptogenic area, but it was vulnerable for artifacts. (2) By using the techniques of intravascular EEG recording, we recorded EEG from the bilateral cavernous sinus (cavernous sinus EEG) in patients with intractable temporal lobe epilepsy. Cavernous sinus EEG well sensitively recorded interictal, also ictal in selected patients, epileptiform discharges which arose from the mesial temporal structure even though they were not recorded by scalp electrodes. It is concluded that the above two techniques are clinically useful for delineating an epileptogenic area in patients with neocortical epilepsy and temporal lobe epilepsy.

Molecular characterization of a novel tubby gene family member, TULP3, in mouse and humans

Tubby and related proteins are derived from a small family of novel genes. The carboxytermini of this family are highly conserved across a number of species including humans, mice, Caenorhabditis elegans, Arabidopsis, rice, and maize. Splicing defects in both tub and another member of the gene family, TULP1 (tubby-like protein 1), lead to phenotypes of retinal degeneration in mice and humans, respectively. We describe here the isolation of the human and mouse homologs of a new family member, TULP3. The cDNAs code for proteins of 442 and 460 amino acids, respectively. The level of identity between the human TULP3 and the mouse homolog is 69%, lower than that observed for the homologs of the other family members (96% for human and mouse TUB), and is higher at the amino- and carboxytermini than in the central region of the protein. Phylogenetically, TULP3 is the family member most closely related to TUB. Also, like TUB, it has a wider pattern of tissue expression than either TULP1 or TULP2. TULP3 is detected at high levels in human RNA from testis, ovaries, thyroid, and spinal chord. Tulp3 is also highly expressed in mouse RNA from eyes and adipose depots, tissues not tested in the human Northern analysis. We also report that TULP3 maps to human chromosome 12p13. The murine homolog, Tulp3, maps to the telomere of mouse chromosome 6.

Analysis of clinical methods used to evaluate dyspnea in patients with chronic obstructive pulmonary disease

When dyspnea must be assessed clinically, there are three methods of assessment: the measurement of dyspnea with activities of daily living using clinical dyspnea ratings such as the modified Medical Research Council (MRC), the Baseline Dyspnea Index (BDI), and the Oxygen Cost Diagram (OCD); the measurement of dyspnea during exercise using the Borg scale; to assess the influence of dyspnea on health-related quality of life (HRQoL) using disease-specific questionnaires such as the St. George's Respiratory Questionnaire (SGRQ) and the Chronic Respiratory Disease Questionnaire (CRQ). The purpose of the present cross-sectional study was to clarify relationships between dyspnea ratings and HRQoL questionnaires by applying factor analysis. One hundred sixty-one patients with mild to severe COPD completed pulmonary function tests, progressive cycle ergometer testing for exercise capacity, assessment of dyspnea, HRQoL, anxiety, and depression. Factor analysis demonstrated that the MRC, BDI, OCD, and Activity of the SGRQ, and Dyspnea of the CRQ, were grouped into the same factor, and the frequency distribution histograms of these five measures showed virtually the same distribution. The Borg scale at the end of maximum exercise was found to be a different factor. The MRC, BDI, OCD, and Activity in the SGRQ, and Dyspnea in the CRQ demonstrated the same pattern of correlation with physiologic data, and they had significant relationships with FEV1 (correlation coefficients [Rs] = 0.31 to 0. 48) and maximal oxygen uptake (Rs = 0.46 to 0.60). Disease-specific HRQoL questionnaires, the SGRQ and the CRQ, which contain a specific dimension for evaluating dyspnea, may be substituted for clinical dyspnea ratings in a cross-sectional assessment. Dyspnea rating at the end of exercise may provide further information regarding dyspnea.

Four-week exposure to diesel exhaust induces nasal mucosal hyperresponsiveness to histamine in guinea pigs

It has been reported that diesel exhaust (DE) particulates augment increases in nasal congestion and nasal secretion induced by histamine (His). We also showed that short-term (3-h) exposure to DE induces nasal mucosal hyperresponsiveness to His. Therefore, in the present study we investigated that whether 4-week exposure of guinea pigs to diesel exhaust would likewise induce nasal mucosal hyperresponsiveness to His. Sneezing number, nasal secretion from the nostril, and intranasal airway resistance induced by His were measured as indices of sneezing response, rhinorrhea, and nasal congestion, respectively. Guinea pigs of each group were exposed to filtered air, with or without a low or high concentration of DE for 3, 7, or 28 days. Exposure to a low or high concentration of DE itself did not induce sneezing, nasal secretion, or nasal congestion. However, exposure to a high concentration of DE augmented that the number of sneezes induced by His, whereas exposure to a low concentration of DE had no significant effect. Exposure to DE for 7 and days tended to augment an increase in nasal secretion induced by exposure to His aerosol in a DE concentration-dependent fashion. The augmentation, however, was not statistically significant. Exposure to high or low DE for 3 or 7 days had no significant effect on the increase in intranasal pressure (INP) induced by a 10-min exposure to His aerosol, but exposure to high DE for 28 days augmented the increase in INP induced by His, significantly. Exposure to low DE for 28 days did not augment the increase in INP immediately after inhalation of His aerosol. These results reveal that 4-week exposure to high DE induces nasal mucosal hyperresponsiveness in guinea pigs.

[Evaluation of antibacterial activities of various antibiotics against glucose non-fermentative gram-negative rods other than Pseudomonas aeruginosa]

MICs of piperacillin, sulbactam/cefoperazone, minocycline (MINO), gentamicin, amikacin, flomoxef, ceftazidime, cefozopran, cefsulodin and imipenem were determined, against 189 clinical isolated strains of glucose non-fermentative Gram-negative Rods (NFGNR; Acinetobacter baumannii (44), Alcaligenes faecalis (5), Alcaligenes xylosoxidans (25), Burkholderia cepacia (12), Chryseobacterium indologenes (23), Chryseobacterium meningosepticum (9), Pseudomonas fluorescens (8), Pseudomonas putida (12), Stenotrophomonas maltophilia (51). Most species of these NFGNR show resistance to many antibiotics tested. Among the antibiotics used in this study, the only antibiotic effective against all species of NFGNR tested is MINO. The spectrums of antibacterial activities of various antibiotics determined by MICs may be useful in preliminary test for identification of these NFGNR.

Obesity and insulin resistance in human growth hormone transgenic rats

A line of transgenic rats (heterozygotes) carrying a chimeric gene comprising a regulatory portion of murine whey acidic protein and a structural portion of human GH (hGH) genes developed severe obesity with age. To characterize physiological mechanisms that lead to fat accumulation, an array of parameters related to obesity were studied. Blood hGH levels were continuously low, endogenous rat GH secretion was suppressed, and the pulsatility in peripheral GH levels was absent. Plasma glucose, insulin, triglyceride, and FFA levels in the male transgenic rats significantly exceeded those in nontransgenic littermates at 12 and 17 weeks, but not at 7 weeks, of age. All symptoms except hyperlipidemia were restored to normal by treatment with an antidiabetic agent, thiazolidinedione (troglitazone), for 1 week from 17 weeks of age. As phenotypic expression of obesity was already evident before aberration of physiological parameters, it was assumed that animals had a condition in which obesity or hyperlipidemia caused hyperinsulinemia. Gene expression and enzymatic activity of lipoprotein lipase in the adipose tissue in the transgenic rats were not different from those in normal rats. In contrast, the gene expression level of glycerol-3-phosphodehydrogenase was markedly elevated, suggesting that glycerol synthesis was much enhanced in the adipocytes of the transgenic rats. In an i.p. glucose tolerance test, the transgenic rats were not hyperglycemic at 7 weeks of age; however, the animal became hyperglycemic at 15-17 weeks of age. Finally, treatment with recombinant hGH for 1 week to produce pulsatile secretion reduced the size of epididymal and kidney fat pads and restored normal weight gain. These observations suggest that continuously low peripheral GH levels with the lack of pulsatile secretion resulted in obesity and noninsulin-dependent diabetes mellitus.

Reappraisal of the effect of electrode property on recording slow potentials

Subdural electrodes made of stainless steel, which were believed to be unsuitable for recording slow potentials, can still record Bereitschaftspotential (BP) (Neshige, R., Lüders, H. and Shibasaki, H. Recording of movement-related potentials from scalp and cortex in man. Brain, 1988, 11: 719-736) and ictal DC shifts (Ikeda, A., Terada, K., Mikuni, N., Burgess, R.C., Comair, Y., Taki, W., Hamano, T., Kimura, J., Lüders, H.O. and Shibasaki, H. Subdural recording of ictal DC shifts in neocortical seizures in humans. Epilepsia, 1996b, 37: 662-674) sufficiently. In this study, therefore, the effects of different kinds of metals on slow potential recordings were reevaluated. First, slow electro-oculograms (EOGs) were recorded with 3 different levels of input impedance (200 M omega, 470 k omega and 10 k omega) of a DC amplifier by using surface electrodes made of silver (Ag), silver/silver chloride (Ag/AgCl) and stainless steel. Secondly, BP was recorded by using the above electrodes with a long time constant of 3 s and with a fixed input impedance of 100 M omega. As a result: (1) slow EOGs were equally recorded with the input impedance of 200 M omega and 470 k omega regardless of the kind of metals used, although stainless steel electrodes caused baseline fluctuation, (2) low input impedance of 10 k omega allowed only the Ag/AgCl electrode to record slow EOGs without any decay, and (3) electrodes made of stainless steel could record BP as efficiently as the other two types of electrode with high input impedance. In conclusion, electrodes with a large surface area contact such as cup electrodes and an amplifier with a large input impedance, electrodes made of Ag, and even of stainless steel, can record slow potentials reasonably well.

Comparison of different computed tomography scanning methods for quantifying emphysema

Computed tomography (CT) is used to detect emphysematous changes in the lungs of living patients. It is therefore important to develop a standard method for the radiographic quantification of emphysematous lesions using CT. The authors determine the best CT scanning methods for assessing the degree of pulmonary emphysema. Computed tomography scanning was performed in 85 consecutive patients with stable chronic obstructive pulmonary disease. Scans were obtained using 2-mm or 5-mm collimation, at full inspiration or full expiration, and with standard or high spatial-resolution reconstruction images (eight images each). Emphysema was then assessed by visual scoring using a five-point scale for each lung. Emphysema was scored as significantly less severe using standard reconstruction images. There were no significant differences in CT-scored emphysema on scans obtained with 2-mm and 5-mm collimation. Emphysema was scored as significantly less severe on expiratory scans. The postbronchodilator forced expiratory volume in one second value correlated better with emphysema scored on expiratory scans. Computed tomography-scored emphysema obtained by all methods correlated well with the diffusion capacity and total lung capacity, regardless of the method used. Using a visual scoring system with a five-point scale, narrow collimation is probably not necessary for the quantification of emphysema, although a high spatial-resolution reconstruction appears to be of value. Scans obtained in exhalation appear to underemphasize the severity of emphysema.

Molecular cloning of the gene encoding a 2Fe-2S ferredoxin from extremely halophilic archaeon Haloarcula japonica strain TR-1

A ferredoxin was purified from extremely halophilic archaeon Haloarcula japonica strain TR-1, and then characterized. The Ha. japonica ferredoxin proved to contain a 2Fe-2S cluster. A part of the gene encoding the ferredoxin was amplified by PCR. Subsequently, the entire ferredoxin gene was cloned from chromosomal DNA of Ha. japonica using the PCR product as a probe. The structural gene consisted of an open reading frame of 387 nucleotides. The deduced amino acid sequence showed 89-98% identities with those of the ferredoxins from other extremely halophilic archaea.

Pathogenesis of cortical myoclonus studied by magnetoencephalography

Myoclonus-associated cortical activities were studied by simultaneous recording of a magnetoencephalogram and an electroencephalogram in 6 patients with cortical myoclonus due to various causes. Cortical activities were averaged, with respect to the precise onset of the myoclonic jerk, to evaluate the myoclonus-associated cortical magnetic fields. The estimated generator of their earliest peak was localized at the contralateral precentral gyrus in all patients. As judged from the direction of the electrical current, surface positive activity preceding the electromyographic discharge was detected in 3 patients with cortical reflex myoclonus and in 1 patient with possible corticobasal degeneration. In contrast, in the remaining 2 patients (Lennox-Gastaut syndrome and Alzheimer's disease), magnetic fields time-locked to the myoclonic jerk were associated with surface negative activity at the precentral cortex. The present study, applying for the first time an off-line jerk-locked back-averaging analysis to magnetoencephalography, demonstrated the important role of the precentral cortex in generating spontaneous myoclonus. It is most likely that the differing polarity of the electromagnetic activity reflects the differing activation patterns within the cortical laminar structure in the precentral area, underlying the generation of various types of myoclonus.

A CT study of the course of growth of the maxillary sinus: normal subjects and subjects with chronic sinusitis

We measured the maxillary sinus volume of normal children and those with bilateral chronic sinusitis by coronal CT scan of the paranasal sinus, and compared the results with findings previously obtained from adult patients. The distribution of mean maxillary sinus volume by age group from 4-9 to 70-79 years exhibited a monomodal pattern with a peak in the 20s in both the normal group and the surgical therapy group. The maxillary sinus volumes of children aged 10-15 years and adults tended to be smaller in the surgical therapy group than in the normal group; this tendency was more prominent in the adult group. These findings appear to support the hypothesis that the ethmoid infundibulum and middle meatus are narrowed by inflammation of the ostiomeatal complex and by various bony anatomic variations in the nasal cavity, leading to impaired pneumatization of the maxillary sinus.

Serial processing of the somesthetic information revealed by different effects of stimulus rate on the somatosensory-evoked potentials and magnetic fields

In order to evaluate information processing in the somatosensory cortex, the effect of two different stimulus rates was investigated by simultaneously recording somatosensory-evoked potentials (SEPs) and magnetic fields (SEFs) in nine healthy adults. During electric stimulation of the median nerve at the wrist, SEFs were recorded with the helmet-shaped whole-head coverage magnetometer array with 122 first-order planar gradiometers while SEPs were simultaneously recorded from seven scalp positions. Interstimulus intervals (ISIs) of 0.9 s and 4 s were compared. In all subjects, N20 as well as its magnetic counterpart, N20m, was clearly demonstrated over the contralateral somatosensory area. Subsequent deflections around 80-200 ms did not make any clear peak and were smaller than those at 20-60 ms (P30m, P40m, N50m and P60m). After 200 ms, SEFs were negligible, whereas SEPs had larger amplitude than those of shorter latencies, constituting a peak around 250 ms (P250). Both SEF and SEP deflections later than 40 ms were decreased in responses at the shorter ISI; this diminution was most prominent for P250. Therefore, it is concluded that the tangential currents in the somatosensory cortex (area 3b) mainly contribute to responses during the first 200 ms after the stimulus, whereas the radially oriented currents (most likely in the crown of the postcentral gyrus) take over for subsequent information processing.

Effects of theophylline and ipratropium bromide on exercise performance in patients with stable chronic obstructive pulmonary disease

BACKGROUND

The effects of theophylline or anticholinergic agents on exercise capacity in patients with chronic obstructive pulmonary disease (COPD) remain controversial. The aim of the present study was to compare the effect of an oral theophylline with an inhaled anticholinergic agent and to examine the effects of combined therapy on exercise performance using progressive cycle ergometry.

METHODS

Twenty one men with stable COPD and a mean (SD) forced expiratory volume in one second (FEV1) of 1.00 (0.40) 1 were studied. Theophylline (600 or 800 mg daily), ipratropium bromide (160 micrograms), a combination of both drugs, and placebo were given in a randomised, double blind, four period crossover design study. Spirometric data, pulse rate, and blood pressure were assessed before and at 90 and 120 minutes after inhalation. Symptom limited progressive cycle ergometer exercise tests (20 watts/min) were performed 90 minutes after each inhalation, and dyspnoea was measured during exercise using the Borg scale.

RESULTS

The mean (SD) serum theophylline concentration was 18.3 (6.3) micrograms/ml, and seven patients had side effects during treatment with theophylline. Theophylline and ipratropium bromide produced greater increases in FEV1, maximal oxygen consumption, maximal minute ventilation, and several dyspnoea ratios than placebo. There were no differences between theophylline and ipratropium bromide except in maximal heart rate. A combination of both drugs produced greater improvements in pulmonary function and exercise capacity than either drug alone.

CONCLUSIONS

Both high dose theophylline and high dose ipratropium bromide improved exercise capacity in patients with stable COPD. Although data based on short term effects cannot be directly applied to long term therapy, theophylline added to an inhaled anticholinergic agent may have beneficial effects on exercise capacity in patients with COPD.

Cortical myoclonus: sensorimotor hyperexcitability

Cortical or cortical reflex myoclonus is characterized by abnormally enlarged cortical somatosensory evoked potentials (giant SEPs), which most likely reflect pathologically hyperexcitable sensorimotor cortex. To clarify the pathogenesis of myoclonus of cortical origin, we simultaneously recorded SEPs and whole head somatosensory evoked magnetic fields (SEFs) following electric stimulation of the median nerve at the wrist in six patients with cortical myoclonus. N20m and enlarged P30m were observed in all patients and were localized at the posterior bank of the central sulcus (Brodmann area 3b of the primary somatosensory cortex). In addition, P25m and N35m components of SEFs were recognized in five and four patients, respectively. P25m component, that is, the magnetic counterpart of P25 in EEG, was the earliest cortical component showing enhancement in patients. Multidipole analysis combined with magnetic resonance imaging (MRI) coregistration revealed that the generators of P25m were in the precentral gyrus in four patients and in the postcentral gyrus in one patient. The second SEFs around 200 msec after the single stimulus were recorded in three patients at area 3b (repetitive SEFs); two of whom showed negative as well as positive myoclonus. The importance of motor cortex for the generation of cortical reflex myoclonus was thus demonstrated. The pathologic features of SEFs suggest abnormal excitability of primary sensorimotor cortex.

[A case of hypothalamic hamartoma manifesting gelastic seizure and multifocal independent seizure foci]

A 25-year-old man manifesting gelastic seizure in association with hypothalamic hamartoma was reported. The epileptogenic focus was evaluated by long-term video EEG monitoring, single photon emission computed tomography (SPECT) and positron emission tomography (PET). Multiple independent ictal foci were found in the ictal EEG recording, and glucose metabolism and cerebral blood flow were decreased in scattered cortical areas. Facial asymmetry seen during gelastic seizure in this case may be caused by contraction of mimetic contralateral to the ictal focus in the temporal lobe.

Clinical usefulness of the dipole tracing method for localizing interictal spikes in partial epilepsy

PURPOSE

To clarify the clinical usefulness of the dipole tracing method in evaluation of interictal EEG spikes in patients with partial epilepsy.

METHODS

Eight patients with partial epilepsy were studied. We compared the generator source of interictal spikes detected by the dipole tracing method with the results of magnetic resonance imaging (MRI), interictal/ictal measurement of cerebral blood flow (CBF) by single photon emission computed tomography (SPECT), interictal measurement of glucose metabolism by positron emission tomography (PET) and invasive electrocorticogram (ECoG).

RESULTS

In 5 patients with mesial temporal lobe epilepsy (TLE), including 3 patients who underwent standard temporal lobectomy, the dipole tracing method showed results consistent with those of other examinations and better correlation with ECoG than with other noninvasive examinations. In a patient with mesial TLE who had defects in the skull due to previous surgery, the dipoles were located more laterally than expected. In a patient with frontal lobe epilepsy (FLE) who was finally proved to have an epileptogenic area in the lateral frontal area, the spike dipoles were identified in the medial side of the frontal lobe.

CONCLUSIONS

The dipole tracing method used in the present study is useful for localizing epileptogenic areas in patients with mesial TLE. However, in patients with partial skull defects and in those with FLE, the reliability of this method is still in accuracy of the lobe level.

Human supplementary motor area is active in preparation for both voluntary muscle relaxation and contraction: subdural recording of Bereitschaftspotential

Bereitschaftspotentials (BPs) preceding muscle relaxation and contraction were compared by using subdural electrodes which were implanted onto the right medial frontal surface in two patients with supplementary motor area (SMA) seizure. The applied movement paradigm (muscle relaxation and contraction tasks) was completely the same as employed in our previous study [Terada, K., Ikeda, A., Nagamine, T. and Shibasaki, H., Electroenceph. clin. Neurophysiol., 95 (1995) 335-345]. In both patients, either negative or positive BPs were observed in the SMA-proper and supplementary negative motor area (SNMA) starting at 1.2-1.8 prior to both movements. In one patient, BP was more widespread in the relaxation task whereas more restricted to the hand area in the contraction task. In the other patient, the BPs were observed in the cortical area rostral to SNMA (pre-SMA), in addition to the SMA-proper, in both tasks. It is concluded that SMA-proper and SNMA, and probably pre-SMA as well, in humans are similarly active in preparation for both voluntary muscle contraction and relaxation.