Complete endoscopic carpal tunnel release in long-term haemodialysis patients

The roof of the carpal tunnel (or canal) consists of the distal portion of the flexor retinaculum, the flexor retinaculum (or the transverse carpal ligament) and the proximal portion of the flexor retinaculum. We tried to determine which anatomical structures were relevant to complete endoscopic carpal tunnel decompression in long-term haemodialysis patients with carpal tunnel syndrome. Carpal tunnel pressure was measured using the continuous infusion technique before and after endoscopic release of the flexor retinaculum, distal portion of the flexor retinaculum and the proximal portion of the flexor retinaculum respectively in 257 hands. We concluded that release of the distal portion of the flexor retinaculum, in addition to the flexor retinaculum, is essential for complete carpal tunnel decompression in long-term haemodialysis patients.

Cytochrome P450 species involved in the metabolism of quinoline

Quinoline is a hepatocarcinogen in rats and mice and a well-known mutagen in bacteria after incubation with rat liver microsomes. The specific cytochrome P450 enzymes involved in quinoline metabolism in human and rat liver microsomes were determined using cDNA-expressed cytochrome P450s, correlations with specific cytochrome P450-linked monooxygenase activities in human liver microsomes and inhibition by specific inhibitors and antibodies. CYP2A6 is the principal cytochrome P450 involved in the formation of quinoline-1-oxide in human liver microsomes (correlation coefficient r = 0.95), but is formed in only minute quantities in rat liver microsomes. CYP2E1 is the principal cytochrome P450 involved in the formation of 3-hydroxyquinoline (r = 0.93) in human liver microsomes and is involved in the formation in rat liver microsomes. A high correlation coefficient (r = 0.91) between CYP2A6 activity and quinoline-5,6-diol formation in human liver microsomes was observed, but this most likely reflects the involvement of CYP2A6 in the formation of quinoline-5,6-epoxide, from which the quinoline-5,6-diol is formed, as conversion of quinoline-5,6-epoxide to quinoline-5,6-diol on incubation of the epoxide with CYP2A6 could not be demonstrated. A cDNA-expressed human microsomal epoxide hydrolase, however, efficiently converted the epoxide to the diol and the microsomal epoxide inhibitor cyclohexene oxide inhibited quinoline-5,6-diol formation in rat liver microsomes. A preliminary kinetic analysis of quinoline metabolism in human liver microsomes was carried out and Eadie-Hofstee plots indicate that the formation of quinoline-5,6-diol is monophasic, while that of quinoline-1-oxide and 3-hydroxyquinoline is biphasic.

Use of metronidazole gel to control malodor in advanced and recurrent breast cancer

Intolerable malodor emanating from ulcerated tumors as a result of anaerobic infection is a serious problem in the management of advanced and recurrent breast cancer. Metronidazole can control this malodor, but its oral use may cause adverse reactions. We therefore formulated a metronidazole gel, since no equivalent preparation is commercially available in Japan, and used it in five female patients (four with advanced cancer and one with recurrent cancer) admitted to our hospital between March 1994 and July 1995. The patients were aged between 47 and 71 (median: 59) years, and the duration of morbidity in the four patients with advanced cancer ranged from 10 months to four years. In three patients, the tumors were larger than 10 cm x 10 cm. Metronidazole gel was applied to the surface of ulcerated tumors once or twice daily. Independent assessments by the patient, doctor and nurse were unanimous, and revealed that the malodor was alleviated in one patient after three days, and removed in four patients after two to five (median: four) days of metronidazole gel treatment. Culture of swabs showed a decrease or disappearance of anaerobic colonies. Adverse reactions characteristic of metronidazole did not occur. The topical use of metronidazole in a gel form will improve the quality of life for patients with malodorous ulcerated tumors and facilitate intensive treatment of the underlying disease.

Nickellike soft-x-ray lasing at the wavelengths between 14 and 7.9 nm

We report what we believe is the first observation of clear soft-x-ray lasing in Ni-like Ag, Te, La, Ce, and Pr and also in Nd covering the spectral range 14.3-7.9 nm. A curved slab target was irradiated with quadruple 1.053-microm laser pulses. The pulse-to-pulse separation for the first three pulses was 400 ps, and that between the third and the fourth pulses was 1.6 ns. The pulse duration and irradiance on the target were 100 ps and ~7 x 10(13) W/cm(2), respectively. For all the targets the most intense lasing was observed at the fourth pump pulse.

Complete endoscopic carpal canal decompression

We made a model of the endoscopic decompression of the carpal canal in clinical cases. The model entailed the release of the transverse carpal ligament, ie, the flexor retinaculum, first; then the transverse fibers: deep layer of the midpalmar fascia or distal portion of the flexor retinaculum; and, finally, release of the forearm fascia. Carpal canal pressure was measured using the continuous infusion technique, and the carpal canal was observed endoscopically at each step. Carpal canal pressure data were analyzed by using the Wilcoxon matched pairs signed-rank test. When the transverse carpal ligament and the transverse fibers were divided, carpal canal pressure was significantly statistically lower than that with release of the transverse carpal ligament alone. We conclude that release of both the transverse carpal ligament and the transverse fibers are essential for complete decompression of the carpal canal in endoscopic surgery.

Long-term follow-up results of rotational acetabular osteotomy in painful dysplastic hips: efficacy in delaying the onset of osteoarthritis

We evaluated the results of rotational acetabular osteotomies in 13 severely dysplastic hips (11 patients) with subluxation. All of the patients were women, aged 20 to 35 years at the time of surgery, and 40 years or more at the time of follow-up. At a minimum follow-up period of 10 years, the patients had minimal or no pain. Of the 13 hips, 12 showed no significant findings of osteoarthritis. Comparing the outcome of these patients with the natural evolution of severely dysplastic hips, we concluded that rotational acetabular osteotomy may prevent the onset of osteoarthritis.

Isolation of a testis-specific cDNA on chromosome 17q from a region adjacent to the breakpoint of t(12;17) observed in a patient with acampomelic campomelic dysplasia and sex reversal

Campomelic dysplasia (CMPD), a rare congenital disorder, is characterized by a variety of skeletal anomalies, low-set ears and, in nearly half of genotypical-male patients, sex reversal. Observations of chromosomal translocations involving chromosome 17q24-q25 in several CMPD patients have implied that disruption of one or more genes in the breakpoint region is responsible for this disease. Using fluorescence in situ hybridization, we mapped the chromosome-17 breakpoint in a patient with acampomelic CMPD and sex reversal, who carries a de novo constitutional t(12;17) translocation, between two known cosmid markers in the 17q24-q25 region. Through positional cloning, we isolated a 3.5 kb cDNA that is located at a close but distinct position from the SOX9 gene, from the region surrounding this breakpoint. Its mRNA, approximately 3.7 kb long, was expressed specifically in testis among 16 adult tissues examined by Northern blot analysis. As we were unable to find any long open reading frame in the 3.5 kb cDNA sequence or to detect any peptide following an in vitro translation experiment using RNA transcribed from this cDNA, we speculate that this gene may play a critical role in differentiation or sex determination as a functional RNA.

Evaluation of carpal canal pressure in carpal tunnel syndrome

Preoperative electrophysiologic testing and intraoperative carpal canal pressure measurements were performed on 957 hands in 647 patients with clinical signs of carpal tunnel syndrome. Fifty-five symptomatic hands in 48 patients were normal in both distal sensory latency and distal motor latency preoperatively. Carpal canal pressure was, however, significantly elevated compared to control data in all 55 hands. After complete subcutaneous release of the carpal canal using the Universal Subcutaneous Endoscope system, carpal canal pressure was reduced to within the normal control range. Clinical symptoms of carpal tunnel syndrome improved in all 55 hands. Postoperative electrophysiologic data remained within normal range in patients who agreed to receive electrophysiologic examinations.

Acampomelic campomelic syndrome and sex reversal associated with de novo t(12;17) translocation

The association of rare chromosomal rearrangements involving a specific 17q breakpoint with campomelic syndrome (CMPS) and/or sex reversal (SR) has led to an assignment of the CMPS1/SRA1 locus to 17q24.3-->q25.1. We describe a patient with multiple anomalies and SR, who had a de novo t(12;17) translocation. The phenotype was consistent with that of CMPS except for the lack of lower limb bowing and talipes equinovarus. Chromosome painting indicated that the breakpoints appeared to have occurred at 12q21.32 and 17q24.3 or q25.1. This study suggests that acampomelic CMPD with SR represents a variant of the CMPS1/SRA1 locus disorder. We emphasize the likelihood that CMPS may be a contiguous gene syndrome.

Interchange trisomy 9 due to maternal t(6;9) translocation

The occurrence of interchange trisomy due to a 3:1 malsegregation has been documented in only a few cases with trisomy 21. We describe the first case of interchange trisomy 9 due to a maternal t(6:9) translocation. The patient, a boy neonate who died immediately after birth, had intra-uterine growth retardation, specific craniofacial features including microcephaly with a high forehead, low-set ears, upslanting short palpebral fissures, microphthalmia, bulbous nose and micrognathia, cryptorchidism, cystic kidney and various skeletal anomalies. His phenotype was consistent with that of the trisomy 9 syndrome. Cytogenetic analysis showed his karyotype of 47,XY,-6, + der(6), + der(9)t(6;9)(q27;q21.1)mat. The present report indicates that a very rare interchange mode of a 3:1 segregation can give rise to a live birth with full trisomy 9 in female carriers with reciprocal translocations involving the proximal long arm of chromosome 9.

Effects of endoscopic release of the transverse carpal ligament on carpal canal volume

Ten hands in 10 patients with carpal tunnel syndrome were treated by subcutaneous transverse carpal ligament release using the Universal Subcutaneous Endoscope system. We analyzed the morphologic changes of the carpal canal with magnetic resonance imaging (0.064 T) before and after the operation. The axial plane, which includes the beak of the trapezium and the hook of the hamate, was selected for analysis. The soft tissue boundaries of the carpal canal were outlined at the plane. The cross-sectional area of the carpal canal was 232 +/- 49 mm2 before surgery and 320 +/- 108 mm2 after surgery. There was a 33% +/- 15% increase of the carpal canal cross-section after transverse carpal ligament release. The transverse carpal ligament became more outwardly convex after the operation. The endoscopic procedure is effective for increasing the cross-sectional area and volume of the carpal canal.

Pharmacokinetics of droloxifene in mice, rats, monkeys, premenopausal and postmenopausal patients

The pharmacokinetics of droloxifene have been studied in female mice, rats, monkeys, and premenopausal and postmenopausal patients. Droloxifene was rapidly and almost completely absorbed after oral dosing. The bioavailability was 8% in mice, 18% in rats and 11% in monkeys due to extensive first-pass metabolism. Droloxifene is widely distributed as demonstrated by its large volume of distribution and the fact that radioactivity in most tissues and organs was higher than in the blood. After oral dosing, the serum and plasma concentrations of unchanged drug declined with terminal half-lives of 1.6 h in mice, 4.3 h in rats, 10.6 h in monkeys and 25 h in patients. The systemic clearance was in the order of mice > rats > monkeys, and nearly equalled the hepatic blood flow in each species. Most of the 14C from [14C]-droloxifene administered orally and i.v. to rats and monkeys was excreted in the faeces. Droloxifene was metabolized extensively by phase I and phase II metabolism. 3-methoxy-4-hydroxy droloxifene was the major metabolite in rat faeces. The metabolites in rat and monkey faeces were not so different qualitatively. Pharmacokinetic parameters were not significantly different between premenopausal and postmenopausal patients.

Craniosynostosis and hemizygosity for D7S135 caused by a de novo and apparently balanced t(6;7) translocation

Craniosynostosis (CRS) is frequently seen in the del(7p) syndrome, and the gene for this cranial anomaly (CRS1) has been assigned to 7p21. We present a 3-year-old boy with CRS involving the sagittal and coronal sutures, who had a de novo and apparently balanced translocation, t(6;7)(q16.2;p15.3). Southern blot analysis of several loci on 7p14-->pter showed that the patient was heterozygous for HOX1I and IL6, possibly homozygous for D7S149, but hemizygous for D7S135 with a loss of the paternal allele. These findings suggest the localization of a candidate gene for CRS1 to be on 7p15.3 in the close proximity to the D7S135 locus.

Reproductive risk in mating between two translocation carriers: case report and review of the literature

We conducted a study to determine the reproductive risk in a couple who were translocation carriers. This couple, who carried balanced reciprocal translocations, experienced habitual abortions. The wife had a karyotype of 46,XX,t(7;13)(p15.3;q12.3) and the husband of 46,XY,t(1;7)(p11.1;p11.1). Chromosome study of their fourth abortus demonstrated a chimera consisting of two cell lines with a 46,XY and a 46,XX,t(1;7)(p11.1;p11.1)pat, -13, + der(7)t(7;13)(p15.3;q12.3)mat, karyotype. A review of the literature indicates that the risk of having unbalanced live offspring or of spontaneous abortion/stillborns is similar in couples in whom both were translocation carriers and in couples in whom one individual was a translocation carrier. The apparent lack of increased reproductive failure may result from the selective disadvantage of aneusomic gametes at fertilization or very early spontaneous abortions of unbalanced conceptuses.

Polylactide screws in acetabular osteotomy. 28 dysplastic hips followed for 1 year

Absorbable polylactide screws were used for internal fixation of rotational acetabular osteotomy (RAO) in 28 dysplastic hips. No cast was used and the patients were allowed to walk with partial weight bearing 1 month after surgery. Clinical and radiographic results were evaluated after 14 (6-24) months. Union occurred in all cases within 4 months without displacement of the osteotomy. No foreign-body inflammatory reaction on radiographs was observed, nor were there any local reactions, such as redness or swelling. Polylactide screws seem to provide sufficient strength for the internal fixation of RAO. Further observation is necessary to identify any late foreign body reaction.

[Avascular necrosis of the femoral head: staging by MR imaging]

Magnetic resonance (MR) images and conventional radiographs were compared in 142 hips with avascular necrosis, and a staging system for the disease based on MR imaging was developed. MR images were classified into three patterns: class I: a band of low signal intensity, class II: an area of low signal intensity with internal spot (s) of high signal, and class III: an area of low signal intensity without internal spots of high signal. Most MR class I lesions were in radiographic stage I (normal) or II (sclerotic or cystic changes without collapse). Most MR class II lesions were in radiographic stage III (segmental collapse), and most MR class III lesions were in stage III or IV (secondary degenerative changes). The MR image classification was closely correlated with radiographic staging (p < 0.01, using chi square test). We considered that this classification closely reflected the different stages of the disease according to the histopathology of the bone marrow.

Avascular necrosis of the femoral head. Natural history and magnetic resonance imaging

We studied the prognostic value of MRI in 32 radiographically normal, asymptomatic hips in 25 patients at risk of osteonecrosis from glucocorticoids or alcoholism. The early findings were band-like hypointense zones on spin-echo images. No operations were performed. Life-table survival curves showed that femoral heads in which the hypointense zone traversed the middle portion of the head were most at risk of subsequent segmental collapse.

Characterization of specific cytochrome P450 enzymes responsible for the metabolism of diazepam in hepatic microsomes of adult male rats

The role of several P450 enzymes in the metabolism of diazepam (DZ) has been investigated. Hepatic microsomes of adult male rats were pretreated with antisera raised against the P450s CYP3A2, 2B1, 2C6, 2C11, 2D1 and 2E1, and their influence on the subsequent metabolism of DZ was determined by simultaneously measuring the changes in the relative rates of formation of its metabolites. Several forms of P450 were found to be positively involved in DZ metabolism. Antisera of the "male-specific" P450 enzyme CYP2C11 partially inhibited both DZ N-demethylase and C3 hydroxylase activities (60%) which resulted in decreased formations of N-desmethyl-DZ (NDZ) and 3-hydroxy-DZ (3HDZ), respectively. In a reconstitution experiment with the purified enzyme, CYP2C11 predominantly catalysed the formation of NDZ from DZ. Antisera of a further male-specific P450 CYP3A2 strongly inhibited (95%) the C3 hydroxylase of DZ and thus 3HDZ formation. A corresponding reconstitution experiment with this same P450 enzyme gave 3HDZ as principal product. CYP2D1 antisera inhibited the aromatic hydroxylation of DZ (98%) and subsequent formation of 4'-hydroxy-DZ (4'HDZ). This enzyme was also observed to inhibit DZ N-demethylase activity (60%). A reconstitution experiment with pure CYP2D1 catalysed the formation of both 4'HDZ and NDZ.

Dynamic external finger fixator for fracture dislocation of the proximal interphalangeal joint

The treatment of fracture dislocations of the proximal interphalangeal joint often results in pain and stiffness. A small dynamic external finger fixator was designed to maintain the reduced position of the dislocated middle phalanx and allow early active range-of-motion exercise. Four patients with acute unstable fracture dislocations and three with old malunited fracture dislocations of the proximal interphalangeal joint were treated with this apparatus. The average range of the proximal interphalangeal joint motion with this device was 88 degrees. The average follow-up period was 21 months.

Results of endoscopic management of carpal tunnel syndrome

This paper is a retrospective study of 27 women with carpal tunnel syndrome (39 hands) who underwent a new endoscopic operative procedure utilizing the Universal Subcutaneous Endoscope system developed by the lead author. Operations on 199 hands were performed under local anesthesia on an outpatient basis. The etiology was considered idiopathic in all cases. Complete preoperative and postoperative clinical and electrophysiologic data were analyzed in 39 hands. The follow-up period ranged from 12 to 45.8 months (mean, 18.3 months). Symptoms of sensory disturbances disappeared in an average of 20 weeks in all patients. Electrophysiologic studies showed definite improvement when compared with preoperative studies. No complications were recorded. Clinical and electrophysiologic results showed that the less-invasive management of carpal tunnel syndrome by endoscopy is safe and effective.

High ulnar nerve palsy caused by the arcade of Struthers

A case of ulnar nerve entrapment neuropathy caused by the arcade of Struthers is reported. Nerve conduction studies showed a complete block and surgical decompression was successful.

[Allergy among Japanese patients with chronic fatigue syndrome]

Allergy is a common feature of patients with chronic fatigue syndrome (CFS). Because of this strong association, we attempted to explore the prevalence of allergies among Japanese patients with CFS. Of the present 18 patients, 78% had allergies during their premorbid and/or postmorbid conditions. Their allergies were mainly cutaneous reactions including drug allergies and 43% of the patients had 2 or more allergic reactions. In the case of a premorbid condition, allergies improved spontaneously after onset of CFS. Clinical manifestations of CFS, however, became worse during the period of an association with allergies. Immunologic tests, including peripheral blood lymphocyte-subsets, blastogenesis, natural killer-cell functions and cytokine-assays, were not any correlation between both patients with and without allergies.

Case of ovarian dysgenesis and dilated cardiomyopathy supports existence of Malouf syndrome

We describe an 18-year-old girl with ovarian dysgenesis, dilated cardiomyopathy, mild mental retardation, broad nasal base, blepharoptosis, and minor skeletal abnormalities. This unusual association of manifestations was first reported by Malouf et al. [1985]. Our patient, although a sporadic case, supports the existence of Malouf syndrome.

Autosomal dominant congenital cataract and microphthalmia associated with a familial t(2;16) translocation

We describe a family in which autosomal dominant congenital cataract and microphthalmia were segregating together with a reciprocal translocation t(2;16) (p22.3;p13.3) through three generations. This family included four individuals with balanced translocations, three with partial trisomy 2p derived from this translocation, and two with a normal karyotype. All of the subjects with balanced and unbalanced translocations had congenital cataract and microphthalmia, whereas the two individuals with normal karyotypes did not show any ocular anomalies. These observations suggest that the altered function of a gene that lies on the 16p13.3 band and that has an important role in the development of the eye is responsible for this disorder.

[Study on the pharmacokinetics of cefepime (I)]

The pharmacokinetics of 14C-cefepime dihydrochloride (14C-CFPM), were studied in rats upon both single and repeated intravenous administration. 1. Blood level of radioactivity was 59.27 micrograms eq./ml at 5 minutes after single intravenous administration at a dose of 20 mg/kg, and declined biexponentially thereafter. The values of AUC and T 1/2 were 70.1 micrograms eq..hr/ml and 38.0 hours, respectively. 2. Blood level of radioactivity was 59.41 micrograms eq./ml at 5 minutes after administration on the 7th day of repeated intravenous administration at a daily dose of 20 mg/kg, and declined more slowly as compared to the case of single administration. The values of AUC and T 1/2 after repeated administration were 159.7 micrograms eq..hr/ml and 44.5 hours, respectively. 3. Urinary and fecal excretion rates after single administration were 93.3% and 3.3%, respectively. 4. Urinary and fecal excretion rates were almost constant throughout the repeated administration; 88.4-90.7% and 2.3-3.7%, respectively. 5. 14C-CFPM distributed rapidly to the whole body except to the central nervous system. Although the radioactivity was removed rapidly from tissues, high levels of radioactivity remained in the kidney and the spleen as compared to other tissues. 6. Tissue concentrations of radioactivity at 5 minutes after the final dose of repeated administration were about the same as those after single administration but they declined more slowly than those after single administration. High levels of radioactivity were found in the kidney and the spleen as were found upon single administration. The ratios of these levels between repeated and single dosing were 4.3 and 2.6 for kidney and spleen, respectively. 7. Data obtained with autoradiograms of the whole body were consistent with measured tissue distribution obtained in both cases of single and repeated administration.

[Study on the pharmacokinetics of cefepime (II)]

The pharmacokinetics of 14C-cefepime dihydrochloride (14C-CFPM), was studied in dogs after single intravenous administration at a dose of 20 mg/kg. Protein binding was also investigated both in vitro and in vivo. 1. Blood level of radioactivity was 83.53 microns eq./ml at 5 minutes after single intravenous administration and declined biexponentially thereafter. The values of AUC and T1/2 were 229 microns eq.(.)hr/ml and 90 hours, respectively. 2. Urinary and fecal excretion rates were 95.1% and 2.7%, respectively. 3. The in vitro protein binding at 1 to 100 microns/ml of drug concentration was 7.9 to 12.7% in rat, 12.4 to 18.6% in human, and 12.5 to 14.5% in dog. In vivo protein binding, which increased with time after administration, was 10.8 to 92.9% in rat and 17.5 to 64.9% in dog at 5 minutes to 6 hours.

Terminal 22q deletion associated with a partial deficiency of arylsulphatase A

A 7 month old girl with psychomotor retardation, hypotonia, and minor malformations was found to have a terminal deletion of the long arm of chromosome 22, del(22)(q13.31). The partial deficiency of arylsulphatase A (ARSA) and the normal level of NADH diaphorase 1 (DIA1) suggests that the ARSA locus can be regionally assigned to 22q13.31----qter and the DIA1 locus can be excluded from the same segment. This report is the third published case with a terminal 22q deletion.

Magnetic resonance imaging and scintigraphy of avascular necrosis of the femoral head. Prediction of subsequent segmental collapse

For the purpose of an effective management of patients at high risk for nontraumatic avascular necrosis of the femoral head (ANFH), it is expedient to examine the femoral heads of patients most likely to undergo subsequent segmental collapse. The purpose of this study was to evaluate the ability of magnetic resonance imaging (MRI) and radionuclide bone scanning (RS) to predict segmental collapse of the femoral head at the roentgenographically normal stage. Fifty-five hips in 37 patients at risk for ANFH and having normal roentgenograms were included in this study. Magnetic resonance imaging was performed in all hips and RS in 29 hips. The patients were observed during a period of more than two years without any invasive intervention, and nine femoral heads manifested collapse during this period. Predictive values for subsequent segmental collapse of a positive test of MRI and RS were 31% and 13%, respectively, whereas those indicative of a negative test were 100% and 76%, respectively. Magnetic resonance imaging was more useful than RS in detecting patients in need of intensive follow-up examination. In particular, a bandlike area of low intensity that traversed the femoral head in midcoronal slices on MR images seemed to be a significant indicator of subsequent collapse.

Growth hormone deficiency and empty sella syndrome in a boy with dup(X) (q13.3----q21.2)

A 2 8/12-year-old boy with severe growth failure and mental retardation was found to have a maternally derived tandem duplication of the long arm of X chromosome, dup(X) (q13.3----q21.2). Karyotypic interpretation was further confirmed in this patient by a double gene dose for red blood cell phosphoglycerate kinase. DNA replication study showed that the duplicated X chromosome was always late replicating in peripheral blood lymphocytes as well as in skin fibroblasts from the mother. Endocrine studies in the patient demonstrated growth hormone deficiency. Magnetic resonance imaging of the head then disclosed the empty sella syndrome. This appears to be the first report of a dup(Xq) patient associated with a growth hormone deficiency and the empty sella syndrome. We emphasize that duplication of the proximal Xq in males represents another microduplication syndrome (Thode-Leonard syndrome).

Coracoacromial ligament release for shoulder impingement syndrome using the Universal Subcutaneous Endoscope system

We developed a new operative procedure of coracoacromial ligament release for shoulder impingement syndrome. The operative procedure was confirmed by cadaveric studies and applied to clinical cases in 40 shoulders of 37 patients who suffered from shoulder impingement without bony abnormalities. The subacromial space was observed under local anesthesia using the Universal Subcutaneous Endoscope (USE) system on an outpatient basis. A popping phenomenon was observed between the coracoacromial ligament and the greater tuberosity of the humerus, which was covered by the rotator cuff, and the coracoacromial ligament was resected with a rongeur under endoscopic visualization in all shoulders. Resection of the coracoacromial ligament relieved the impingement and clinical signs, as in open or arthroscopic resection of the coracoacromial ligament. Resection of the coracoacromial ligament using the USE system is a safe and less-stressful surgical invasion than open or standard arthroscopic resection of the coracoacromial ligament.

De novo complex chromosome rearrangement in identical twins with multiple congenital anomalies

A de novo and apparently balanced complex chromosome rearrangement (CCR) was found in monozygotic (MZ) twin infants with multiple congenital anomalies. The rearrangement involved 4 chromosomes with 6 breakpoints including 2p23, 2q13, 2q21.1, 3p23, 11q13.1, and 12q24.1. This seems to be the first report of a CCR in MZ twins. The relationship between this chromosome abnormality and MZ twinning is discussed.

Unique karyotypes in two patients with Prader-Willi syndrome

A physical disruption of the Prader-Willi syndrome (PWS) chromosome region is thought to cause PWS. We describe 2 girls with PWS phenotype, who had unique chromosome 15 abnormalities. The first patient showed mosaicism: 45,XX,t(15;15)(qter----p11.1::q11.200----qter)/46,XX,t(15;15)(qter----p1 1.1::q 11.200----qter), +mar. The band 15q11.2 apparently remained intact in the t(15;15) chromosome, and the mar chromosome was considered as r(15) (p11.1q11.1). The second patient had a karyotype of 47,XX,del(15)(q11.200----q11.207), +idic (15)(pter----q11.1::q11.1----pter). The complex breakage and reunion involving the 15q11.2 regions of the father's homologous chromosomes 15 at meiosis appeared to have resulted in the idic(15) and the del(15) chromosomes. These cytogenetic findings suggest that the PWS chromosome region may be localized on the very proximal portion of band 15q11.2.

Transient osteoporosis of the hip. Magnetic resonance imaging

Magnetic resonance (MR) images of seven hips were reviewed in six patients with transient osteoporosis of the hip. The MR images of the affected joint showed increased joint fluid and diffuse signal abnormalities in the marrow of the femoral head, corresponding to a decreased signal intensity on T1-weighted images and an increased signal intensity on T2-weighted images. The MR images at the time of clinical improvement showed regression of the abnormalities. These MR abnormalities reflect the pathophysiology of this condition.

[Correlation between the findings of magnetic resonance imaging and prognosis of patients with predisposing factors of aseptic necrosis of the femoral head]

Eighteen patients with the predisposing factors for aseptic necrosis of the femoral head were followed up for more than two years after the initial magnetic resonance (MR) imaging. At the time of the initial examination, 24 femoral heads showed abnormal low-intensity areas on MR images without abnormal findings on plain radiographs. Among them, six femoral heads collapsed in the follow-up period. The initial mid-coronal T1-weighted MR images of these femoral heads had shown characteristic findings, that is, band-shaped low-intensity areas with the lateral end not covered by the acetabulum. Subchondral fracture of the femoral head occurred in the vicinity of the lateral end of the band. The findings of initial MR imaging seem to predict subsequent collapse of the femoral head.

Fat intensity within the hypointense zone on MR imaging of avascular necrosis of the femoral head

In some patients with avascular necrosis of the femoral head (ANFH), an area of signal intensity similar to that of subcutaneous fat tissue is found within or proximal to the hypointense zone of spin echo MR images. We refer to these MR findings as the "fat intensity" sign. This fat intensity sign was positive in 62 (47%) of 133 MR examinations of femoral heads with radiographically proven ANFH; this sign was negative in all hips with other diseases including degenerative joint disease, transient osteoporosis, rapidly destructive coxoarthrosis, and rheumatoid arthritis.

Renal and skin involvement in a patient with complete Kearns-Sayre syndrome

We report on a 13-year-old girl with complete Kearns-Sayre syndrome (KSS) and unusual manifestations of anhidrosis and de Toni-Fanconi-Debré syndrome which preceded by several years the onset of KSS triad. Histochemical examination of skeletal muscle showed focal deficiency of cytochrome c oxidase (CCO). Southern blot analysis of mitochondrial DNA (mtDNA) demonstrated a deletion of 5.4 kb in 60% of the total mtDNAs isolated from the muscle and kidney. On electron microscopy, epithelial cells of the proximal and distal renal tubules and the sweat glands showed an increased number of giant mitochondria with complicated and concentric cristae. This appears to be the first report of complete KSS associated with renal and skin involvement. Data obtained in this patient provide important information on the clinical heterogeneity and tissue specificity of CCO deficiency.

Endoscopic management of shoulder pain in long-term haemodialysis patients

In 48 shoulders of 29 patients receiving long-term haemodialysis and complaining of intolerable shoulder pain, endoscopic resection of the coracoacromial ligament was performed under local anaesthesia on an outpatient basis, using the Universal Subcutaneous Endoscope system. Predominant endoscopic findings were proliferation of the subacromial bursae and popping between the coracoacromial ligament and the rotator cuff. Amyloid originating from beta 2 microglobulin (beta 2-M) was demonstrated in 87% of the resected coracoacromial ligaments and 86% of the subacromial bursae. Resection of the coracoacromial ligament relieved the shoulder pain in all patients.

[Avascular necrosis of the femoral head: chronological change of MR images]

Tl-weighted MR images of thirty-six hips in 25 patients with avascular necrosis of the femoral head were obtained two to five times during the course of 2 to 26 months. We investigated these MR images in the light of the chronological change and compared them with plain radiographs. MR images change in 16 femoral heads; in general, the abnormal low intensity area in the femoral head reduced in extent and the internal high intensity area became smaller of disappeared. Thirteen femoral heads among them became more flattened on plain radiographs in the same period. It is noted that four different zones are defined in the femoral head after bone necrosis takes place: the dead bone marrow, the dead marrow which still contains fat, the reactive interface and the hyperemic bone marrow. In Tl-weighted MR images, the dead bone marrow, the reactive interface and the hyperemic bone marrow are demonstrated as low intensity area, while the dead marrow containing fat may remain high in intensity. On the basis of this knowledge of histopathology and MR images of this disease, we suggest that reduction of the abnormal low intensity area and disappearance of the internal high intensity area on MR images can be regarded as diminution of hyperemia in the living bone marrow and loss of fat in the dead bone marrow, respectively.

[MR imaging of idiopathic transient osteoporosis of the hip]

Four patients with idiopathic transient osteoporosis of the hip were examined by magnetic resonance imaging (MRI). MRI clearly showed low signal intensity in the affected femoral head on T1-weighted images and high signal intensity on T2-weighted images. After regression of hip pain, MR images became normal. MRI was a useful method for diagnosis and follow-up study of idiopathic transient osteoporosis of the hip.

Rotational acetabular osteotomy for the severely dysplastic hip in the adolescent and adult

Rotational acetabular osteotomy performed since 1968 is a circumacetabular osteotomy of the acetabulum for the dysplastic hip. The preoperative center-edge angle of Wiberg of 95 hips (89 patients) was -15 degrees or less. Forty-one hips (39 patients) form the basis of this report. They were followed from four years to 16 years and seven months (average, seven years and nine months). Twenty-one hips were classified as the Severin Group IV (subluxation) and 20 hips as the Severin Group V (a secondary acetabulum). A detailed assessment using a number of roentgenographic indices confirmed that the majority of the severely dysplastic hips could be corrected to nearly normal anatomy. The postoperative clinical results were assessed by the modified clinical classification of Severin proposed by Gibson and Benson. This procedure may be indicated for the severely dysplastic hip with subluxation or a secondary acetabulum in the adolescent and adult.

Measurement of pressure in the carpal canal before and after endoscopic management of carpal tunnel syndrome

In forty-six patients who had carpal tunnel syndrome, a technique of continuous infusion, given under local anesthesia and without a pneumatic tourniquet, was used to measure pressures in the carpal canal before and after endoscopic release of the transverse carpal ligament (retinaculum flexorum manus). Pressures were similarly measured in sixteen subjects in a control group. The mean preoperative pressures were significantly higher in the patients who had carpal tunnel syndrome than in the patients in the control group when the pressures were measured under four conditions: with the wrist in the resting position, with active grip, and with maximum passive extension and flexion of the wrist. The mean pressures improved significantly postoperatively and were in the range of values that were found under each condition for the control group. Measurement of pressure in the carpal canal before and after operation may be useful in diagnosing carpal tunnel syndrome and in determining the effectiveness of endoscopic management.

[Magnetic resonance imaging and histopathology in the femoral head]

To correlate the magnetic resonance (MR) images with the histopathological findings in the femoral head, the histopathology of 24 femoral heads, 15 with osteonecrosis, five with osteoarthritis and four with other hip disorders were subjected to preoperative MR imaging which demonstrated low intensity areas due to long T1 relaxation time in the femoral head. The MR signal was low where fibrovascular tissue, disintegrated fibrovascular tissue, amorphous necrotic material, bone, or cartilagenous tissue occupied the medullary space. From this study, it seems possible to predict the histopathologic changes in the femoral head using MR images.