Enhancement of apoptosis in developing chick neural retina cells by basic fibroblast growth factor

To evaluate the role of various growth factors in naturally occurring cell death during development of the neural retina, we examined the effects of such factors on the nuclear morphology and the size of DNA in cultured chick embryonic neural retina cells. Basic fibroblast growth factor (bFGF) increased internucleosomal cleavage of DNA and nuclear fragmentation in a time- and dose-dependent manner. The effect was inhibited by anti-bFGF antibody, suramin, and cycloheximide. Epidermal growth factor, platelet-derived growth factor, nerve growth factor, tumor necrosis factor-alpha, and dexamethasone had no effect. These results provide evidence that bFGF may eventually act as a lethal factor inducing apoptotic cell death during the development of the neural retina in chick embryo.

Molecular cloning and growth hormone-regulated gene expression of carp insulin-like growth factor-I

Two distinct insulin-like growth factor-I (IGF-I) cDNAs were isolated from a juvenile carp liver cDNA library. Both of the cDNAs encoded a full length prepro IGF-I with 161 amino acids: a mature peptide (70 residues), its signal peptide (44 residues), and a carboxy-terminal E domain (47 residues). The similarity of the two cDNA in the open reading frame was 95.1%. The amino acid sequences of E domain predicted by the two cDNAs were different while those of the signal peptide and the mature peptide were the same. By Northern blot analysis, four different sizes (1, 1.5, 2, and 4.5 kb) of IGF-I mRNA were recognized in the liver of juvenile carp. The two smaller species (1 kb and 1.5 kb) were not detected in adult carp. The expression of these two species was preferably induced by exogenous growth hormone administration in the liver of juvenile carp.

Risk factors predictive of para-aortic lymph node metastasis in endometrial carcinomas

OBJECTIVE

To identify risk factors predictive of para-aortic lymph node (PAN) metastasis in endometrial carcinomas.

METHODS

Sixty patients with endometrial carcinomas Stage I to III (FIGO, 1988) who each underwent a complete pelvic and para-aortic lymphadenectomy with a semiradical or radical hysterectomy, bilateral salpingo-oophorectomy, between April 1988 and March 1996, were included in this study. The relationship between PAN metastasis and clinico-pathological factors such as histological type, grade, depth of myometrial invasion (MI), vascular space involvement (VSI), cervical invasion (CI), peritoneal cytology, tumor size, pelvic lymph node (PLN) metastasis, and glutathione S-transferase pi (GST-pi) expression was examined using univariate and multivariate analysis.

RESULTS

Seven variables--G3 grade, more than one-half MI, positive VSI, positive CI, tumor size of more than 2 cm in diameter, positive PLN metastasis, and positive GST-pi--were significantly correlated with PAN metastasis using univariate analysis. Multivariate analysis revealed that of the above 7 variables, 3 were significantly and independently correlated with PAN metastasis: more than one-half MI, positive PLN, and positive GST-pi. The relative risk of a patient with these 3 factors having PAN metastasis was 18.0 times greater than the risk for a patient without them.

CONCLUSION

These variables--More than one-half MI, positive PLN, and positive GST-pi--were significantly related to PAN metastasis.

Proliferative responses of lymphocytes to food antigens are useful for detection of allergens in nonimmediate types of food allergy

Food allergy is clinically classified into two types, immediate and nonimmediate. Radioallergosorbent test (RAST) is a sensitive procedure for the diagnosis of IgE-mediated hypersensitivity but not for other types of hypersensitivity. There is not yet a sensitive blood examination for detection of allergens in nonimmediate types of food allergy. Of the total number of subjects in our study, twenty-two children had nonimmediate types of food allergy (hen's egg, cow's milk, soybean, or buckwheat flour), atopic dermatitis, allergic tension fatigue syndrome or pulmonary hemosiderosis. For these children, manifestations of the allergy did not appear earlier than 2 hours after ingestion of the offending food. Eighteen children in the study developed acute urticaria, angioedema, or bronchial asthma appearing within 2 hours of the challenge. Fifteen nonatopic healthy children were selected as controls. Proliferative responses of peripheral blood mononuclear cells (PBMCs) to food antigens were measured in nonimmediate types of food allergy. The proliferative responses of PBMCs to each offending food antigen in patients with nonimmediate types of food allergy were significantly higher than those of healthy controls and patients with immediate types of food allergy, respectively. Moreover, in each case with nonimmediate type, the proliferative responses to food antigens other than the offending food were not detected. When PBMCs were twice stimulated with the offending food antigen, the same results were obtained. These results indicate that the proliferative response of PBMCs to food antigens is specific to each offending food antigen in nonimmediate types of food allergy. Taken together, proliferative responses of PBMCs to each food antigen are useful for detection of allergens in nonimmediate types of food allergy.

Indispensability of pelvic and paraaortic lymphadenectomy in endometrial cancers

The purposes of this study were to analyze the relationship between retroperitoneal lymph node (RLN) metastasis and clinical and pathologic risk factors in endometrial cancers, and to clarify the correlation between RLN metastasis and survival of patients with the disease. This analysis included 63 patients with endometrial cancer who underwent simultaneous pelvic lymph node (PLN) and paraaortic lymph node (PAN) dissection between April 1988 and December 1995. Patients with stage Ia grade 1 and stage IV disease were excluded from this analysis. Both PLN and PAN metastases were found in 10.0% (4/40) of patients with stage I (FIGO, 1988) disease. Of 14 cases with PLN metastases, 8 (57.1%) had PAN metastases simultaneously, whereas 4 (8.2%) of 49 cases without PLN metastases had PAN metastases. There was no significant relationship between the sites or numbers of positive PLN and PAN metastases. Multivariate analysis revealed that poor grade and deep myometrial invasion had an independent relationship with PAN metastases, whereas vascular space invasion and cervical invasion were independently associated with PLN metastases. When divided into the groups of stage I-II and stage III, the prognosis of patients with RLN metastases was significantly poorer than that of patients without RLN metastases in each stage. Furthermore, survival of patients with PAN metastases was significantly worse compared with that of patients with only PLN metastases (44.4 and 80.0%, respectively, P < 0.05). These results reveal that PLN and PAN metastases occur frequently even in early-stage endometrial cancer, and that RLN metastases, especially PAN metastases, have a serious impact on patient survival. In conclusion, systemically simultaneous pelvic and paraaortic lymphadenectomy is essential for all the patients with endometrial cancer except those with stage Ia grade 1 and stage IV to provide prognostic information and select suitable postoperative treatment as well as to perform accurate FIGO staging, provided the condition of the patient permits.

Endosonography-guided endoscopic resection of duodenal carcinoid tumor

Endoscopic resection techniques using snare polypectomy with or without submucosal saline injection have also been applied to resect smaller duodenal carcinoid tumors. We report on two patients where endoluminal ultrasound using a small diameter probe was used to visualize the adherence of the carcinoids to the underlying wall layers and the separating effect of subtumoril saline injection. One patient, in whom a clear separation between the tumor and the underlying tissue after saline injection was visualized, underwent successful endoscopic resection. In the other patient no clear separation could be achieved after saline injection and the patient underwent surgical removal of his tumor; both tumors were 1 cm or less in their maximal diameter.

Growth inhibition of cultured human leukemia cells by 3-aminothymidine and its analogue

In a previous report, we demonstrated that 3-aminothymidine (1) strongly inhibits the growth of the human T-cell acute lymphoblastoid leukemia cell line CCRF-HSB-2. In order to further study cell growth inhibition by this compound, several of its derivatives and analogues were synthesized and their growth inhibition activities examined using various cultured cell lines. Compound 1 was the most active among the compounds tested and the most effective against cells of the human T-cell acute lymphoblastoid leukemia cell line CCRF-CEM. 3-Methylthymidine (2) also inhibited the growth of CCRF-CEM cells but at a level about one thirtieth that of 1. Introduction of a methyl or acetyl group at the 3-amino group of 1 resulted in the loss of growth inhibition activity. 3-Amino- and 3-methyl-5-bromo-2'-deoxyuridines (6 and 7), the analogues of 1 and 2 both exhibited an ability to inhibit cell growth and their levels of activity were similar in extent, in spite of the difference in their 3-amino and 3-methyl groups, however, these levels were less than that of 1. Compounds 1, 2, 6 and 7 all showed evidence of growth inhibition in every human leukemia cell line examined.

[Efficacy of increase of cardiac index during exercise in the chronic phase of various cardiovascular diseases: evaluation by exercise tolerance and brain natriuretic peptide]

Cardiac index is widely used as a parameter of cardiac function for cardiovascular patients, but its value is limited when measured in the resting supine position, because it never demonstrates the maximal cardiac index performance. The incremental increase in cardiac index (delta CI) was evaluated during incremental exercise (delta work rate: delta WR), delta CI/delta WR, in patients with chronic congestive heart failure, and compared to brain natriuretic peptide (BNP), which is known to be increased in patients with chronic left ventricular dysfunction. The subjects were 18 heart failure patients (16 males and 2 females, mean age [+/-SD] 63.8 +/- 8.9 years). Symptom-limited cardiopulmonary exercise test using cycle ergometer was performed. Cardiac index was calculated with the Benchmark Exercise Test device using oxygen uptake, carbon dioxide output and respired flow. Blood samples were taken in the resting state before the exercise test. A positive correlation was obtained between delta CI/delta WR and peak oxygen uptake (peak VO2) (r = 0.71, p < 0.01), and delta CI/delta WR and peak oxygen pulse (r = 0.66, p < 0.01). A negative correlation was obtained between delta CI/delta WR and BNP (r = 0.45) in the resting state. Peak VO2 (20.9 +/- 7.5 vs 13.9 +/- 2.7 ml/min/kg, p < 0.05), peak cardiac index (7.2 +/- 1.7 vs 5.5 +/- 0.9 l/min/m2, p < 0.05), and delta CI/delta WR (20.1 +/- 8.1 vs 12.4 +/- 2.5 ml/m2/W, p < 0.05) were significantly higher in the group with normal BNP (mean [+/-SD] 11.0 +/- 3.2 pg/ml) than in the group with high BNP (40.7 +/- 22.7 pg/ml). Delta CI/delta WR reflects the grade of exercise tolerance and may be useful for evaluating exercise capacity in patients with congestive heart failure.

Localisation of a 10q breakpoint within the PAX2 gene in a patient with a de novo t(10;13) translocation and optic nerve coloboma-renal disease

We describe a 5 year old boy with a de novo t(10;13) translocation and optic nerve coloboma-renal disease (ONCR). On the basis of GTG banding analysis of prometaphase chromosomes, the patient's karyotype was interpreted as either 46,XY,t(10;13)(q24.3;q12.3) or t(10;13) (q25.2;q14.1). Fluorescence in situ hybridisation (FISH) studies using a YAC clone containing the PAX2 gene and YAC clones adjoining FRA10B at 10q25.2 showed that the 10q breakpoint had occurred just within the PAX2 gene and was proximal to FRA10B. These FISH results suggest that the translocation causes a disruption of the PAX2 gene and leads to ONCR, in agreement with the recent reports of PAX2 mutations in two unrelated families with ONCR. Furthermore, we refined the regional mapping of the human PAX2 gene to the junction of bands 10q24.3 and 10q25.1.

Quantitative evaluation of brain distribution and blood-brain barrier efflux transport of probenecid in rats by microdialysis: possible involvement of the monocarboxylic acid transport system

This study was performed to evaluate quantitatively the brain distribution and the efflux transport across the blood-brain barrier of probenecid, using in vivo microdialysis and in situ brain perfusion techniques. The brain interstitial fluid (ISF)-to-plasma cerebrospinal fluid (CSF)-to-plasma and brain tissue-to-plasma unbound concentration ratios of probenecid at steady state were less than unity, which suggests restricted distribution in the brain. An uphill concentration gradient from ISF to plasma and a downhill concentration gradient from CSF to ISF were observed. Kinetic analysis revealed that the efflux clearance from brain ISF to plasma (0.0373 ml/min/g brain) was significantly greater than the influx clearance from plasma to brain (0.00733 ml/min/g brain). The ratio of the ISF concentration (Cisf) to the plasma unbound concentration (Cp,f) of probenecid was increased 2- to 3-fold by salicylate (3.7 mM) and benzoate (3.6 mM), which are accepted as substrates of the monocarboxylic acid transport system, compared with the same ratio for the control. In addition, the ratio Cisf/Cp,f was increased by treatment with N-ethylmaleimide, a sulfhydryl-modifying agent, whereas p-aminohippuric acid and choline did not produce increasing effects on Cisf/Cp,f. These data suggest that the restricted distribution of probenecid in the brain may be ascribed to efficient efflux from the brain ISF, which may be regulated by the monocarboxylic acid transport system at a relatively high ISF concentration.

[Actual conditions of help and support of childcare in families with multiple birth children]

A mailed questionnaire survey was conducted on a population of 705 mothers of twins, 96 mothers of triplets, 7 mothers of quadruplets and 2 mothers of quintuplets to study the actual conditions of help and support of childcare in the families with multiple birth children. The following results were obtained. 1) In this study, 90.6% of the mothers of twins, 89.6% of the mothers of triplets, 100.0% of the mothers of quadruplets and 100.0% of the mothers of quintuplets had at least one relative and friend from whom they received practical help and regular support. However, 5.8% of the mothers of twins and 8.3% of the mothers of triplets did not have others from whom they received help and support. 2) Lack of time to take care of the other children was reported by approximately 90% of mothers with twins who did not have others from whom they received help and support for childcare. 3) Mothers who did not receive help and support from others for childcare reported severe fatigue, compared to mothers who received help and support from others: mothers of twins, especially reported severe mental fatigue and mothers of triplets or more, severe physical fatigue. 4) Mothers of twins who had no way to alleviate stress reported severe physical and mental fatigue, compared to mothers who had ways to alleviate stress. Mothers of triplets or more showed a similar tendency as mothers of twins. These mothers alleviated stress by talking with other mothers of multiple birth children, friends, their maternal mother or their husband.

Silver-stained nucleolar organizer regions in adenocarcinoma of the cervix--a light and electron microscopic study

An increase in the number of Ag-NORs has been described as a possible marker for histopathological cancer diagnosis. The ultrastructural correlation of the reaction, however, has never been elucidated. In tissue samples of the endocervix of the uterus, we compared the ultrastructural configuration of Ag-NORs with the number of Ag-NORs dots. Light microscopic studies showed that the number of Ag-NORs in adenocarcinoma cells significantly increased, but the relation to the bromodeoxyuridine labeling index was not determined. By electron microscopy, Ag-NORs were only observed in the nucleoli and the nuclear bodies of nuclei. Ag-NORs were localized on all components of the nucleolar structure, but the dense fibrillar component was the predominant site in several cases. The nuclear bodies were exclusively found in adenocarcinoma cells and were argyrophilic. A spotted distribution of Ag-NORs was often found in the nucleoli of adenocarcinoma cells that showed an increased Ag-NOR count. The number of Ag-NORs was attributed not only to the number of nucleoli and nuclear bodies in a nucleus but also to the speckled distribution of silver deposits in a nucleolus. These results imply that the Ag-NOR count is a more definitive indicator of a hyperactive state of the cells than the combined number of nucleoli and nuclear bodies in adenocarcinoma of the uterine cervix.

Depressive states and health problems in caregivers of the disabled elderly at home

This study investigated the prevalence of depression and health problems in caregivers for the disabled elderly at home, and identified factors associated with the risk of depression. Four hundred thirty-four caregivers for disabled elderly persons in a suburban city were surveyed by in-home interviews. Two hundred ten non-caregivers were also interviewed as an age and gender-matched control group. Overall, 16.8% of caregivers met the DSM-III-R criteria for major depression and 10.6% met the criteria for depressive disorders not otherwise specified, for a total of 27.4% meeting the criteria for affective disorders, while 8.6% of controls met the criteria for depressive disorders not otherwise specified. The prevalence of major depression in caregivers was associated with mental problems and ADL limitations of the elderly. Moreover, non-cooperation by other family members or relatives contributed to an increase in the prevalence of depression. Caregivers who met the criteria for major depression had a higher frequency and longer duration of upper respiratory infections than other caregivers or controls, and showed greater fatigue than the other caregivers or controls. Approximately 90% of caregivers who met the criteria for major depression had also insomnia. Overall, it was shown that caregivers who met the criteria for major depressin had not only emotional distress but also higher morbidity.

Microdissection-mediated selection of chromosome region-specific cDNAs

K562 is a cell line with two acrocentric marker chromosomes containing abnormally banded regions (ABRs), derived from a Ph-positive chronic myelogenous leukemia (CML) patient. Using reverse and forward chromosome painting FISH analysis, we found that 9q34, 13q31, and 22q11 regions co-amplified in the ABRs-bearing acrocentric marker chromosomes of K562. Utilizing the ABRs of the cell line as target DNA for cDNA selection, we established a simple procedure for chromosome region-specific cDNA isolation. After first strand cDNA synthesis from fetal brain mRNAs, short fragment cDNAs (sf-cDNAs) were synthesized with a two-step amplification system by use of our modified Degenerate Oligonucleotide Primed Shuttle Polymerase Chain Reaction (DOP-Shuttle-PCR) method. The sf-cDNAs were hybridized onto RNase A treated metaphases from K562, and the ABRs were microdissected and reamplified with DOP-Shuttle-PCR primer-II. The reamplified sf-cDNAs were cloned into a pBluescript vector. Twenty randomly chosen clones were sequenced and classified into 8 groups. Three out of the 8 grouped clones had been mapped to the long arm of chromosome 22 (22q11), whereas the other 5 were novel cDNAs. Quantitative Southern blot analysis indicated that 7 out of the 8 grouped clones (87.5%) were derived from the co-amplified regions.

Disaccharide analysis of skin glycosaminoglycan in localized scleroderma

BACKGROUND

Altered metabolism of skin glycosaminoglycan has rarely been investigated in localized scleroderma in contrast to systemic sclerosis.

OBJECTIVE

The aim of this investigation is to elucidate the change in skin glycosaminoglycan of localized scleroderma.

METHODS

We analyzed 5 skin samples of localized scleroderma and 10 site-matched control skin samples using high performance liquid chromatography after 1-phenyl-3-methyl-5-pyrasolone labeling.

RESULTS

The involved skin constantly showed an increased amount of delta Di-4S(DS), the main disaccharide unit of dermatan sulfate, a decreased amount of delta Di-HA, the main disaccharide unit of hyaluronic acid, and an elevated ratio of delta Di-4S(DS)/delta Di-HA as compared with the uninvolved skin or the site matched control skin.

CONCLUSION

These results correlate well with those findings in systemic sclerosis, indicating that the alteration in skin GAG may be closely related to the fibrotic process.

Modulation of c-fms proto-oncogene in an ovarian carcinoma cell line by a hammerhead ribozyme

Co-expression of macrophage colony-stimulating factor (M-CSF) and its receptor (c-fms) is often found in ovarian epithelial carcinoma, suggesting the existence of autocrine regulation of cell growth by M-CSF. To block this autocrine loop, we have developed hammerhead ribozymes against c-fms mRNA. As target sites of the ribozyme, we chose the GUC sequence in codon 18 and codon 27 of c-fms mRNA. Two kinds of ribozymes were able to cleave an artificial c-fms RNA substrate in a cell-free system, although the ribozyme against codon 18 was much more efficient than that against codon 27. We next constructed an expression vector carrying a ribozyme sequence that targeted the GUC sequence in codon 18 of c-fms mRNA. It was introduced into TYK-nu cells that expressed M-CSF and its receptor. Its transfectant showed a reduced growth potential. The expression levels of c-fms protein and mRNA in the transfectant were clearly decreased with the expression of ribozyme RNA compared with that of an untransfected control or a transfectant with the vector without the ribozyme sequence. These results suggest that the ribozyme against GUC in codon 18 of c-fms mRNA is a promising tool for blocking the autocrine loop of M-CSF in ovarian epithelial carcinoma.

Immunohistochemical study of estradiol, epidermal growth factor, transforming growth factor alpha and epidermal growth factor receptor in endometrial neoplasia

In a total of 113 cases of endometrial neoplasm, we studied the immunohistochemical expression of estradiol (E2), epidermal growth factor (EGF), transforming growth factor alpha (TGFalpha), and epidermal growth factor receptor (EGFR). Positive immunoreactivity of E2 was found in 61% of the neoplasms. E2 immunoreactivity correlated well with high histologic grade and early clinical stage. Positive immunoreactivity for EGF or EGFR was found in 25.6% or 53.1% of the neoplasms, respectively. However, this was unrelated to histologic grade or clinical stage. On the other hand, TGFalpha immunoreactivity was found in 67% of endometrial neoplasias and was correlated with poor histologic grade and advanced stage. Contingency tables indicated a significant negative association between the status of E2 and that of TGFalpha. Simultaneous expression of E2, EGF and EGFR, or E2, TGFalpha and EGFR was found in 6.8% and 15.9% of endometrial carcinomas, respectively. These results suggest that a predominant number of endometrial carcinomas escape autocrine/paracrine growth regulation by EGF and E2 or TGFalpha and E2, and that TGFalpha may be involved in the progression of endometrial carcinoma.

Establishment of gastric Helicobacter pylori infection in Mongolian gerbils

An animal model of Helicobacter pylori infection was obtained with Mongolian gerbils. Culture broth of H. pylori ATCC 43504 was orally administered to the gerbils. Animals were killed 1, 7, 14, 21, and 42 days after the oral inoculation and the stomachs were excised. Colonization of H. pylori was maintained in the stomachs of all animals throughout the study period of up to 42 days. On microscopic examination after immunological and hematoxylin and eosin staining, the organisms were detected in the mucus layer of the gastric epithelium. All gerbils exhibited a slowly progressive but typical gastritis, showing superficial erosion with increasing numbers of infiltrating neutrophils and mononuclear cells. Forty-two days after the inoculation, lymph follicles were detected in the gastric submucosa. These features are similar to the manifestations of H. pylori infection in humans and, accordingly, this model could be of value for studying H. pylori pathogenicity and for research into agents for the treatment of H. pylori infection in humans.

Effects of cilazapril on exercise tolerance in the chronic phase of acute myocardial infarction

The present study was conducted to investigate the effects of cilazapril on exercise tolerance and the hormone kinetics of catecholamines, the reninangiotensin-aldosterone system and alpha-atrial natriuretic peptide (ANP) in patients in the chronic phase of acute myocardial infarction (AMI). The subjects consisted of 19 cases of AMI. Cardiopulmonary exercise testing was performed 1 month after the onset of AMI, and patients were randomly assigned to either a group treated with 1 mg/day of cilazapril (9 cases) and or an untreated group (10 cases). After the completion of 2 months of exercise training at the anaerobic threshold (AT), blood samples were taken during a cardiopulmonary exercise test and various hormones were measured. In comparing the parameters of exercise tolerance before and after the completion of exercise training there were no significant differences between the 2 groups with respect to oxygen uptake, oxygen pulse, or exercise time at AT or at peak exercise. With regard to temporal changes in exercise tolerance, oxygen uptake, oxygen pulse and exercise time all tended to increase in both groups. With regard to hormone kinetics, the alpha-ANP concentration at peak exercise was significantly lower, and the noradrenaline secretions also tended to be lower, in the cilazapril-treated group, even though the peak exercise time was similar in both groups. These results may be support the hypothesis that cilazapril mitigates the left ventricular load during exercise therapy in patients in the chronic phase of AMI.

[A case of internal supravesical hernia]

We report a case of internal supravesical hernia. A 74-year-old male with complaint of abdominal pain underwent an operation for small intestinal obstruction due to its incarceration into the internal supravesical hernia. Retrospectively, the preoperative abdominal CT film showed the relation of the incarcerated intestine, the urinary bladder, and the middle umbilical ligament. This is the first case of the internal supravesical hernia in which the preoperative CT had taken and it will contribute to the preoperative correct diagnosis in the future.

[A case of cerebral aspergillosis associated with induction chemotherapy for acute lymphoblastic leukemia]

A case of cerebral aspergillosis during induction chemotherapy for acute lymphoblastic leukemia was described. A 5-year-old boy complained of headache and left homonymous hemianopsia during induction chemotherapy for acute lymphoblastic leukemia. CT scan and MR imaging survey demonstrated cerebral fungal lesion as well as multifocal lung lesions. A cerebral lesion appeared as a low density mass in right occipital lobe with marginal enhancement on CT scan, and iso- and high-signal intensity appeared with marginal gadolinium enhancement on T1- and T2-weighted MR imaging. Although fungus balls in the lung responded well to daily intravenous administration of amphotericin-B for 2 months, the cerebral lesion showed a rather expansive character as invading into neighbouring falx, opposite occipital lobe, meninges, and occipital bone. Extensive removal of the brain lesion from the parenchyma, falx, invaded dura, and skull was surgically performed. The lesion was confirmed as aspergillosis by Grocott's methenamine histological stain. Surgical intervention and concomitant use of amphotericin-B for a month resulted in complete remission of the aspergillosis. After 6 years, a cranioplasty was successfully completed for the occipital bone defect.