A case of Arnold-Chiari Type I malformation presenting with dysrhythmic breathing during sleep

A 43-year-old woman presented with dull headache, left tinnitus and dizziness. Neurological examination revealed down-beat gaze nystagmus, left tinnitus, positive Romberg sign, poor standing on the left foot, poor tandem gait, left spastic gait and positive pathological reflexes in the bilateral upper and lower extremities. Plain X-ray of the skull and cervical vertebrae demonstrated basilar impression and atlantoaxial fusion. Magnetic resonance imaging of the brain and cervical spine showed cerebellar tonsil descent and syringomyelia located in the left side of the spine at the II-III vertebral level which communicated with the fourth ventricle. The patient was diagnosed as having cervical syringomyelia. Arnold-Chiari type I malformation and basilar impression. Preoperative polysomnography showed dysrhythmic breathing and bradypnea during sleep. Abnormal breathing improved after suboccipital decompression craniotomy and upper cervical laminectomy. It was suggested that dysrhythmic breathing was caused by a disorder of the medullary respiratory center. Herniation of the cerebellar tonsil and syringomyelia might have compressed the medulla.

The value of endoscopic ultrasonography in preoperative evaluation of rectal cancer

BACKGROUND

In rectal cancer, preoperative evaluation of the depth of cancer invasion and the presence of pararectal lymph node metastasis is essential to determine appropriate operative procedures, especially in autonomic nerve preserving operations. For this evaluation, endoscopic ultrasonography (EUS) was performed prospectively in the following cases.

METHODS

During the past 5 years, 70 patients with rectal cancer underwent EUS examination by using 7.5MHz and 12MHz-EUS sonoprobe systems.

RESULTS

The depth of cancer invasion was accurately predicted by EUS in 76% of cases (53/70). Seventeen cases were incorrectly estimated, 12 of those underestimated, and 5 overestimated. The evaluation of pararectal lymph node metastasis was accurate in 44 patients (69%). The sensitivity rate was 36% and specificity was 90%.

CONCLUSIONS

EUS is a very useful technique for determining therapeutic procedures for rectal cancer, especially in deciding whether or not sphincter preserving and/or autonomic nerve preserving operations should be undertaken.

Interleukin-10 reduces natural killer sensitivity and downregulates MHC class I expression on H-ras-transformed cells

We examined the effect of IL-10 on sensitivity to NK-cell-mediated cytotoxicity of the H-ras-induced transformants, W14 and W31. Incubation of cells with recombinant human (rh) IL-10 resulted in a dose-dependent decrease in the expression of MHC class I antigens, but not in the ICAM-1 expression. However, prior incubation of W31 cells with rhIL-10 markedly decreased their susceptibility to cytolysis by rat splenic NK cells. This fact suggested that the IL-10-mediated decrease in MHC class I expression might not dominate the regulation of the NK sensitivity. This was true when rat IL-10 cDNA-introduced W31 cells were used as an endogenous IL-10 producer. The NK sensitivity in vitro of W31T-H, a high IL-10-producer clone, was suppressed downward to the equivalent level of W31 cells pretreated with exogenous rhIL-10. The decreased NK-sensitivity of W31T-H cells was further confirmed by in vivo Winn assay, in which nude mice challenged with W31T-H cells and rat NK cells together developed tumors, whereas nude mice challenged with W31T-L, a minimal-IL-10 producer clone, and NK cells did not. Since neither exogenous nor endogenous IL-10 affected the proliferation of W31 cells, the data indicated that W31T-H cells could evade the NK-cell-mediated immune response in vivo. Taken together, our data reveal a novel mechanism for an IL-10-mediated escape of tumor cells from host immune system by NK cells.

Alteration of expression of liver-enriched transcription factors in the transition between growth and differentiation of primary cultured rat hepatocytes

In the present study, we showed the role of the liver-enriched transcription factors in the transition during which proliferating hepatocytes become quiescent. We used primary rat hepatocytes cultured in modified L-15 medium. The cells proliferated and, after the addition of 2% dimethyl sulfoxide (DMSO) from day 4, they stopped growing and gradually differentiated. During hepatic proliferation, expression of hepatocyte nuclear factors (HNF)1alpha, HNF4, C/EBP alpha, and C/EBP beta mRNAs was depressed, whereas that of HNF3alpha and HNF3beta transcripts was enhanced. After the addition of DMSO, the expression of HNF1alpha, HNF3gamma, and HNF4 returned to the level in isolated cells and HNF1beta mRNA expression gradually increased. However, expression of C/EBP alpha and C/EBP beta mRNAs was partially recovered. The mitoinhibitory agents, IL-1beta, IL-6, TGF-beta, and activin A, were examined to determine whether they could induce differentiation of proliferating hepatocytes as shown in cells treated with DMSO. Although these factors inhibited cell growth, the cells did not differentiate. The expression pattern of HNF3gamma mRNA was quite different in the cells cultured with DMSO and those cultured with cytokines. Therefore, hepatic differentiation requires not only inhibition of DNA synthesis but also induction of appropriate transcription factors. Thus, expression of HNF3gamma, C/EBP alpha, and C/EBP beta may be necessary for hepatocytes to acquire highly differentiated functions in addition to coexpression of certain amounts of transcripts of HNF1alpha, HNF1beta, HNF3alpha, HNF3beta, and HNF4 as well as suppression of C/EBP delta.

[Nutrition and cancer patients]

Nutritional therapy for cancer patients includes various objectives such as improvement of cachexia, elucidation of the mechanism of malnutrition, development of therapy for anorexia, nutrition support during chemotherapy or radiotherapy, and inhibition of tumor growth under controlled caloric intake. This review describes recent remarkable developments in nutritional therapy for cancer patients. Cytokines such as interleukin (IL)-1, IL-6, and tumor necrosis factor which induce proteolysis and lipolysis are involved in the cause of malnutrition and cachexia in cancer patients. IL-1 also plays a significant role in the development of cancer anorexia via direct action in the brain. For anorexia therapy, progestogens have been shown to improve appetite and food intake in cancer patients. Moreover, glutamine supplementation improves the host protein metabolism without enhancement of tumor growth during chemotherapy. Among the effects of caloric intake on anticancer therapy, AO-90, a methionine-free intravenous amino acid solution, has been shown to increase the antitumor effect of 5-fluorouracil in clinical studies. From these observations, recent progress in nutritional therapy for cancer patients has been remarkable. Further study of nutritional therapy is required in order to maintain or improve the quality of life of cancer patients in the future.

Lack of survival benefit of extended lymph node dissection for ductal adenocarcinoma of the head of the pancreas: retrospective multi-institutional analysis in Japan

It has not been established that extended lymph node resection is necessary for ductal adenocarcinoma of the head of the pancreas. According to the general rules for the study of pancreatic cancer, a multiinstitutional, retrospective clinical study was undertaken to investigate the efficiency of extended lymph node dissection for this malignancy. Altogether 501 patients underwent resection of the pancreas between 1991 and 1994 at 77 medical facilities; the surgical procedures, staging, lymph node dissection, curability, and survival rate were analyzed retrospectively. Eighteen of the patients died within 30 postoperative days, leaving 483 patients to be studied. The resection was curative microscopically in 94 patients, resulting in a 3-year survival of 29%. Macroscopically curative resection resulted in a 3-year survival of 14%; noncurative resection produced a 3-year survival of 6%. Although extended lymph node dissection was performed on 38 patients in stage I, 42 patients in stage II, 206 patients in stage III, and 1 patient in stage IV, there was no improvement in survival when the results were compared to those seen after standard or palliative lymph node dissection. The extent of lymph node dissection has not affected the prognosis for ductal adenocarcinoma of the head of the pancreas at any stage of the course of the disease. Excessive lymph node dissection in advanced cases does not necessarily lead to a favorable prognosis. The patients who undergo a radical operation with an adequate lymph node dissection have longer survivals.

[Usefulness of rapid examination method by test tape for cerebrospinal fluid]

We evaluated the usefulness of the test tape for cerebrospinal fluid (CSF), with which glucose and protein were examined, in aid of rapid diagnosis of various neurological diseases. Twenty-eight patients were examined to estimate the level of CSF glucose and protein using test tape. The data accuracy was confirmed with the data from standard measurements because the data from test tape correlated significantly with the data measured by standard method (glucose, p < 0.05; protein, p < 0.01). The test tape is useful for the rapid examination of CSF. We hope that more accurate test tape method will be developed for CSF glucose and protein determination.

Desmoplastic variant of ameloblastoma in an 83-year-ald Asian female: report of a case with literature review

The desmoplastic ameloblastoma is a rare histologic variant of ameloblastoma. This presentation outlines the successful treatment of an 83-year-old Asian female with this type of tumour by surgical resection and peripheral ostectomy with preservation of the interior border of the mandible. Clinical, radiographic, histopathologic and surgical aspects of this tumour were reviewed.

[Cardiac surgery in Jehovah's Witness]

Clinical experiences of 35 cardiothoracic operations in Jehovah's Witness patients were presented with special reference to a method of taking informed consent for surgery. At first the surgeon explained the details of the proposed surgery including its risks and benefits. He should also express his confidence in accomplishing the operation without blood transfusion. Otherwise he should not dare to perform the operation. The surgeon asked the patient to talk about his or her religious belief in transfusion denial. Then the surgeon was allowed to talk about his professional duty and ethical belief in saving the patient at all costs. Finally, both the patient and the surgeon would sign the document of informed consent without fully determining whether or not the patient would undergo transfusion at an unexpected situation since the possibility of such unexpected necessity of blood transfusion was believed extremely low by both the surgeon and the patient. The trust of the patient in the technique of the surgeon was the key to this agreement.

[Partial splenic embolization for idiopathic thrombocytopenic purpura]

Twelve patients with idiopathic thrombocytopenic purpura (ITP) who were resistant to conventional steroid therapy under went partial splenic embolization (PSE). PSE was effective for 7 out of 10 eligible cases. The reduction ratio of PAIgG was significantly higher in effective cases. The PAIgG level before treatment and platelet counts one week after PSE were higher in effective cases than those of non-effective cases. The effects of PSE did not depent on age, sex, the duration of disease, platelet count, embolization rate or the effect of intravenous immunoglobulin therapy. No serious side effects were observed. PSE can be an alternative therapy to splenectomy for ITP.

Control of circadian variation in skin blood flow response to heat stress

Six male subjects had their lower legs immersed in water at 42 degrees C for 60 min at 4 different times of the day to study whether the skin blood flow response to passive heat stress shows circadian variation in the relationship between skin blood flow and local sweating rate. When skin blood flow was plotted against local sweating rate, three distinct phases were observed. Phase A, an increase in skin blood flow without sweating was maximal at night. But the slope of the regression line did not change over the day in Phase C. These findings suggest that there is circadian variation in the skin blood flow response before onset of sweating during passive heat stress. This variation might be related, in part, to the circadian rhythm in vasoconstrictor activity.

Frequency of chromosome 7 gain in human breast cancer cells: correlation with the number of metastatic lymph nodes and prognosis

Trisomy 7 has been reported in various malignant neoplasms, but there are no reports in breast cancer. In order to evaluate the contribution of chromosome 7 gain to breast cancer, we investigated the relationship of numerical abberation of chromosome 7 with clinicopathological variables and prognosis in seventy-nine breast cancer cases (invasive carcinomas) using the technique of fluorescence in situ hybridization (FISH) on paraffin-embedded sections. A significant correlation of the frequency of cells with extra copies of chromosome 7 (percent polysomy 7 cell score) was found with tumor size, regional lymph node status, tnm stage, histological extension, estrogen receptor (ER), and DNA ploidy. The number of metastatic lymph nodes was positively correlated with percent polysomy 7 cell score (correlation coefficient=0.623, p < 0.01). Furthermore, cases with a high percent polysomy 7 cell score had a shorter disease-free survival and overall survival times, especially in the lymph node-positive group. It was demonstrated that percent polysomy 7 cell value was closely associated with lymph node metastasis and prognosis and might be a useful prognostic predictor of breast cancer patients.

Enhancement of albumin production by hepatocyte growth factor in rat hepatocytes: distinction in mode of action from stimulation of DNA synthesis

Hepatocyte growth factor (HGF) has been shown to enhance albumin production as well as stimulate DNA synthesis in hepatocytes. The mode of action of HGF in exerting both effects is to be elucidated. We previously observed that hepatocyte proliferation occurred in normal rats given recombinant human HGF (rhHGF) intravenously. When rats received rhHGF similarly, serum albumin levels were significantly increased compared to controls. In primary culture of rat hepatocytes, albumin concentration in culture medium was significantly increased by rhHGF added at 24 h of culture compared to controls, increasing with time of culture. This effect of rhHGF was dose-related. When actinomycin D was added to the medium, the albumin concentration was reduced in a dose-related manner, but its enhancement by rhHGF was maintained. Albumin mRNA levels were not increased by rhHGF. When rhHGF was added similarly to the medium, immunocytochemically positive hepatocytes for 5-bromo-2'-deoxyuridine (BrdU) incorporation appeared 30 h later. Of these labeled hepatocytes, 12.5% were concomitantly stained for albumin. In contrast, albumin-positive hepatocytes were seen in 77% of BrdU-non-labeled hepatocytes (p<0.01). We conclude that HGF may enhance albumin production through post-transcriptional regulation in non-proliferating hepatocytes, but not in proliferating hepatocytes.

Increased expression of selectins in kidneys of patients with diabetic nephropathy

In diabetic nephropathy leukocytes, mainly composed of monocytes/macrophages, which accumulate in the glomeruli and the interstitium, play an important part in the progression of glomerulosclerosis. The infiltration of leukocytes into inflammatory tissues or atherosclerotic lesions is mediated by adhesion molecules, which are expressed on the vascular endothelial cells, although little is known about the mechanism of leukocyte infiltration into diabetic renal tissues. P- and E-selectin are leukocyte adhesion molecules, which are expressed on the vascular endothelial cells and promote the adhesion of leukocytes to the endothelium. We investigated the expression of P- and E-selectin in the kidney tissue of patients with diabetic nephropathy and compared it with that of patients with other glomerular diseases (minimal change nephrotic syndrome, membranous nephropathy, IgA nephropathy, mesangioproliferative glomerulonephritis, and lupus nephritis). Expression of P- and E-selectin were both significantly increased in the glomeruli and the interstitium of patients with diabetic nephropathy as compared with those with other glomerular diseases. P- and E-selectin were both expressed along the glomerular capillaries and the peritubular capillaries in the interstitium. Neither P- nor E-selectin were correlated with the number of infiltrated leukocytes in the glomeruli, however, interestingly the E-selectin expression on peritubular capillaries was correlated with the number of infiltrated CD14 positive cells in the interstitium. These results suggest that E-selectin may play a key role in leukocyte infiltration into the renal interstitium in patients with diabetic nephropathy.

[The significance of telomerase activity in patients with gastric cancer]

The activation of telomerase is one of step in carcinogenesis. Therefore, it indicates that the detection of telomerase activity in tissues is useful for cancer diagnosis. TRAP assay developed by Kim et al. is sensitive enough to detect telomerase activity from a telomerase expressing cell. Using TRAP assay kit provided by Oncor Inc., we estimated quantitatively the telomerase activity from benign (atrophic gastritis), premalignant (intestinal metaplasia), and malignant tissues in the stomach. Telomerase activity in gastric cancer tissues was significantly higher than that in tissues which are characterized histologically as intestinal metaplasia or atrophic gastritis. In addition, to exclude interference with TRAP assay by telomerase or PCR inhibitor when telomerase activity was not observed in cancer tissues, the use of internal control (ITAS or TSNT) and dilution of samples should be performed.

5-HT1Dbeta receptor mediates the supersensitivity of isolated coronary artery to serotonin in variant angina

Although serotonin (5-hydroxytryptamine; 5-HT) is used for provocation of coronary spasm, 5-HT receptor subtypes in spastic coronary arteries remain undetermined. We demonstrated the supersensitivity of isolated coronary artery to ergonovine, 5-HT, and sumatriptan, a 5-HT1D receptor agonist, in a patient with variant angina. Furthermore, we detected gene expression of 5-HT1Dbeta and 5-HT2A receptors in spastic coronary artery using RNase protection assay. These findings suggest that the leftward shift of the dose-response curve for 5-HT, which plays an important role in the pathogenesis of coronary spasm, is mediated by activation of 5-HT1Dbeta receptor.

High thoracic epidural block relieves acute herpetic pain involving the trigeminal and cervical regions: comparison with effects of stellate ganglion block

BACKGROUND AND OBJECTIVES

Stellate ganglion block can promptly relieve acute herpetic pain (AHP) involving the trigeminal and cervical regions. However, repeated blocks are needed to maintain pain relief in most patients with severe AHP. Because continuous epidural block is easily performed using an indwelling catheter, we compared the effect of high thoracic epidural block with that of stellate ganglion block to relieve moderate-to-severe AHP involving these regions.

METHODS

Six patients received stellate ganglion blocks and seven patients received high thoracic epidural blocks. Six milliliters 1% of mepivacaine was given to each patient. Acute herpetic pain was evaluated before and up to 60 minutes after the blocks, using a visual analog scale (VAS) of pain.

RESULTS

There was no significant difference in VAS pain scores before the blocks between the groups, but there were significant (P < .05) decreases in VAS pain scores for both groups between 10 and 60 minutes after the blocks. There were no significant differences in VAS pain scores between the groups after the blocks.

CONCLUSIONS

High thoracic epidural block was as effective as stellate ganglion block in relieving moderate-to-severe AHP involving the trigeminal and cervical regions.

Beat-to-beat variation of the ST segment in a patient with right bundle branch block, persistent ST segment elevation, and ventricular fibrillation: a case report

The authors describe a patient with ventricular fibrillation associated with right bundle branch block-like QRS morphology and persisting ST segment elevation in the precordial leads, in whom the morphology of the ST segment changed from the coved type to the saddle-back type or vice versa on a beat-to-beat basis. Such an observation has never been reported in the previous literature.

Risk factors of pneumonitis following chemoradiotherapy for lung cancer

The purpose of this retrospective study was to identify risk factors associated with development of pneumonitis following chemoradiotherapy (CRT). We examined 60 patients (pts) who received CRT from May 1993 to August 1995. Factors evaluated included total radiation dose, field-size, irradiated site, type of chemotherapy, pulmonary fibrosis and treatment schedule (concurrent versus sequential). There were 17 pts (28.3%) who had > or = Grade 2 pulmonary toxicity. There was no significant relationship between total radiation dose, field-size > or = 200 cm2, pulmonary fibrosis or treatment schedule and risk of pneumonitis. In the sequential treatment group (22 pts), no relationship was noted between any factor and the risk of pneumonitis, while in the concurrent treatment group (38 pts), the incidence of pneumonitis was more frequent (53.8%) in patients with field-size > or = 200 cm2 than in patients with field-size < 200 cm2 (P < 0.05). In those who received concurrent treatment, including weekly CPT-11, pneumonitis was more frequent (56.3%) than in those without CPT-11 (13.6%, P < 0.01). When the lower lung field was included in the radiation site, the incidence of pneumonitis was 70% compared with 20% for other sites (P < 0.01). Multivariate analysis revealed a significant relationship between radiation site and the risk of pneumonitis (P = 0.0096). CPT-11 was significant (P = 0.038) only in the concurrent group. Pneumonitis was reversible in all but one pt by steroid therapy. Thus, irradiated site (included lower lung field) and concurrent CRT used with weekly CPT-11 were treatment factors significantly associated with a higher risk of pneumonitis following CRT.

Close association of IgA anti-ganglioside antibodies with antecedent Campylobacter jejuni infection in Guillain-Barré and Fisher's syndromes

IgA has an important function in the gastrointestinal immune system. We investigated IgA anti-ganglioside antibodies in Guillain-Barré syndrome (GBS) and Fisher's syndrome (FS) subsequent to Campylobacter jejuni enteritis. In previous studies, serological diagnosis of C. jejuni infection was based on the detection of IgG, IgA, and IgM anti-C. jejuni antibodies. Our study, however, showed that the detection of IgG anti-C. jejuni antibody alone was sufficient for the serological diagnosis of antecedent C. jejuni enteritis in GBS and FS, when the cut-off level was defined for results of sera from C. jejuni-isolated patients. Serological evidence of C. jejuni infection was found in 62 (31%) of 201 GBS patients and 12 (18%) of 65 FS patients. IgA anti-GMI antibody was detected in sera from 33 (16%) of the GBS patients, 1 (2%) of the FS patients, and none of the 46 normal control subjects. IgA anti-GM1 antibody titers were significantly higher in the GBS patients with positive C. jejuni serology than in those with negative serology (P < 0.0001) or the FS patients with positive C. jejuni serology (P = 0.007). IgA anti-GQ1b antibody was detected in sera from 18 (28%) of the FS patients, 9 (4%) of the GBS patients, and none of the normal control subjects. FS patients with positive C. jejuni serology had significantly higher titers of IgA anti-GQ1b antibody than those with negative serology (P = 0.01) or the GBS patients with positive C. jejuni serology (P < 0.0001). We conclude that anti-GM1 and anti-GQ1b IgA antibodies are closely associated with antecedent C. jejuni enteritis in GBS and FS, respectively.

Inhibitory effect of inducible type nitric oxide synthase on oxidative modification of low density lipoprotein by vascular smooth muscle cells

Oxidative modification of low density lipoprotein (LDL) plays an important role in atherogenesis. Inducible type nitric oxide synthase (iNOS) has been shown to be expressed in vascular smooth muscle cells (VSMC) of atherosclerotic arteries. Nitric oxide (NO) donors have been shown to inhibit metal ion- or cell-mediated oxidation of LDL. To elucidate whether NO produced by iNOS in VSMC inhibit oxidation of LDL, we investigated the effect of NO donors and iNOS-induction in VSMC on oxidation of LDL. NO donor, S-Nitroso-n-acetylpenicillamine (SNAP) or 3-morpholinosydnonimine (SIN-1) (0.1-1.0 mmol/l) dose-dependently reduced copper-induced oxidation of LDL as demonstrated by the inhibition of electrophoretic mobilities on agarose gels and the formation of thiobarbituric acid-reactive substances (TBARS) and conjugated dienes. Moreover, treatment with IL-1beta (5-50 ng/ml) reduced the increases in electrophoretic mobilities on agarose gels and TBARS formation in association with increases in NO production. In addition, inhibition of NO production by NG-monomethyl-L-arginine monoacetate reduced the inhibitory effect of IL-1beta on LDL oxidation. These results indicate that NO release via iNOS action induced by cytokines in VSMC may play protective roles in oxidative modification of LDL during the atherosclerosis process.

Syntheses and antifungal activity of dl-griseofulvin and its congeners. III

Several congeners (1b-g), with novel substituents on the benzene ring of griseofulvin, were prepared by the application of a synthetic method developed by us. Antifungal activity of these congeners decreased in order of dl-griseofulvin (1a) = 1d > 1b, c >> 1e-f (inactive). The relationship between the antifungal activity and the position or kind of substituents on the benzene ring of griseofulvin is discussed.

Increased expression of intercellular adhesion molecule-1 (ICAM-1) in diabetic rat glomeruli: glomerular hyperfiltration is a potential mechanism of ICAM-1 upregulation

Mononuclear cells, including monocytes/macrophages and T-cells, are considered to be involved in the progression of diabetic nephropathy, although the mechanism of their recruitment into diabetic glomeruli is unclear. The intercellular adhesion molecule-1 (ICAM-1) promotes the infiltration of leukocytes into atherosclerotic lesions as well as inflammatory tissues. In the present study, we investigated the expression of ICAM-1 in the glomeruli of streptozotocin-induced diabetic rats. The expression of ICAM-1 was increased significantly during the early stage of diabetes. The number of mononuclear cells, primarily monocytes/macrophages and lymphocytes, was significantly increased in diabetic glomeruli. Mononuclear cell infiltration into diabetic glomeruli was prevented by anti-ICAM-1 monoclonal antibody. Insulin treatment decreased ICAM-1 expression and mononuclear cell infiltration. The ICAM-1 expression on cultured human umbilical vein endothelial cells was not induced under high glucose culture conditions. Glomerular hyperfiltration is a characteristic change in the early stage of diabetic nephropathy. Treatment with aldose reductase inhibitor, which prevented glomerular hyperfiltration without changes in blood glucose levels, decreased ICAM-1 expression and mononuclear cell infiltration. Moreover, we examined the ICAM-1 expression in the glomeruli of the 5/6 nephrectomized rat, which is a model for glomerular hyperfiltration without hyperglycemia. The ICAM-1 expression and infiltration of mononuclear cells was significantly increased in the glomeruli of 5/6 nephrectomized rats. We conclude that ICAM-1 is upregulated and promotes the recruitment of mononuclear cells in diabetic glomeruli. Moreover, glomerular hyperfiltration that occurs in the early stage of diabetic glomeruli may be one of the potential mechanisms of ICAM-1 upregulation in diabetic nephropathy.