A clinical, genetic, neuropathological study in a Japanese family with SCA 6 and a review of Japanese autopsy cases of autosomal dominant cortical cerebellar atrophy

This report concerns a Japanese family with genetically confirmed SCA 6, including an autopsy case, and a review of Japanese autopsy cases of autosomal dominant cortical cerebellar atrophy (ADCCA). The proband (Case 1) was a Japanese woman. She developed gait disturbance at age 62. The father and younger sister (Case 2) had the same disorder. She died at age 67 due to subarachnoid hemorrhage. Neuropathological examination revealed severe loss of Purkinje cells in the cerebellum, prominently in the dorsal vermis, and absence of neuronal loss in the inferior olives. Molecular genetic study showed the CAG-repeat expansion of SCA 6 gene. The younger sister (Case 2) developed gait disturbance at age 62. Neurological examination at age 66 revealed cerebellar signs without sensory disturbance. Neuroimaging at this time showed cerebellar atrophy, prominently in the vermis. She died of multiple myeloma at age 66. A neuropathological review of Japanese autopsy cases of ADCCA showed that there are two patterns in the distribution of cerebellar cortical lesions of Japanese patients with ADCCA. The distribution of cerebellar cortical lesions in genetically confirmed Japanese patients with SCA 6 is more prominent in the vermis than in the hemisphere.

[Difficulty to diagnose the cause of death in emergency room]

We evaluated the diagnoses noted on the medical records of 275 patients admitted to Saga Medical College Hospital during the six-year period 1990-1995: 245 patients with cardiopulmonary arrest on arrival (CPAOA) and 30 patients with cardiopulmonary arrest occurring in the emergency room (CPAER). The most frequent cause of CPAOA was heart disease, and the next frequent cause was respiratory disease. In the CPAER patients, the most frequent cause was heart disease, while the next frequent was acute aortic dissection. There were discrepancies in the respective causes of cardiac arrest between the CPAOA and CPAER patients, which was probably due to difficulty in diagnosis in the emergency room. In the emergency room, the cardiopulmonary resuscitation is the first treatment to be performed for CPAOA, the examination for the cause of cardiac arrest is the next followed after the heart beating. However, the cause of cardiac arrest can not be diagnosed in the emergency room for the CPAOA patients without the successful resuscitation, because the examinations for the cause of cardiac arrest can not be performed for the patients without beating heart in the emergency room. Therefore, it is concluded that there exists a need to improve the training for finding out the abnormal death with the inspection and the medico-legal autopsy. It may be suggested that the training system of forensic medicine is ideal for clinical physician who can study the decision of the diseases ranging from toxicosis to acute cardiopulmonary arrest in both the emergency and the forensic medicine.

Regulatory mechanisms in expression of the traY-I operon of sex factor plasmid R100: involvement of traJ and traY gene products

BACKGROUND

The plasmid R100 encodes tra genes essential for conjugal DNA transfer in Escherichia coli. Genetic evidence suggests that the traJ gene encodes a positive regulator for the traY-I operon, which includes almost all the tra genes located downstream of traJ. The molecular mechanism of regulation by TraJ, however, is not yet understood. traY is the most proximal gene in the traY-I operon. TraY promotes DNA transfer by binding to a site, sbyA, near the origin of transfer. TraY is suggested to have another role in regulation of the traY-I operon, since it binds to two other sites, named sbyB and sbyC, located in the region preceding traY-I.

RESULTS

Using a traY-lacZ fusion gene, we showed that the traY-I operon was expressed only in the presence of traJ. The TraJ-dependent expression of traY-I required the E. coli arcA gene, which encodes a host factor required for conjugation. TraJ-dependent transcription occurred from a promoter (named pY) located upstream of traY-I. The isolated TraJ protein was found to bind to a dyad symmetry sequence, named sbj (specific binding site of TraJ), which existed in the intergenic region between traJ and traY-I. We also demonstrated that TraY repressed the TraJ-dependent expression of traY-I at the TraY binding sites, sbyB and sbyC, which overlapped with pY.

CONCLUSIONS

TraJ is a protein which binds to the sbj site in the region upstream of the promoter pY and positively regulates expression of the traY-I operon in the presence of the E. coli arcA gene. Since sbj is located 93bp upstream of pY in the intergenic region between traJ and traY-I, TraJ presumably contacts with a transcription apparatus to promote transcription from pY. TraY, which is known to activate the initiation of conjugal DNA transfer, has a new role in the transcriptional autoregulation of traY-I expression. At levels which are sufficient to initiate conjugal DNA transfer, TraY represses traY-I transcription in the presence of TraJ.

Effect of oral clonidine premedication on hemodynamic response during sedated nasal fiberoptic intubation

Although oral clonidine premedication is known to reduce the hemodynamic response under general anesthesia, effects of the hemodynamic response during sedated fiberoptic nasal intubation have not yet been examined. Our aim was to compare the effects of clonidine premedication on hemodynamic responses with those of atropine and hydroxyzine premedication during sedated fiberoptic nasal intubation. Thirty adult patients were randomly assigned to one of two groups: Group 1 patients (n = 15) were premedicated with atropine sulfate (0.01 mg/kg) and hydroxyzine hydrochloride (1mg/kg) intramuscularly, and group 2 patients (n = 15) were premedicated with clonidine (5 micrograms/kg) orally. We compared the hemodynamic response and sedation level in fiberoptic nasal intubation between the two groups. there were no significant differences in sedation levels and postoperative complaints between the two groups. But the oral clonidine premedication (Group 2) blunted hemodynamic changes during the fiberoptic intubation. No profound hypotension or marked bradycardia was noted in group 2. We concluded that the oral clonidine premedication might contribute to hemodynamic stability during sedated fiberoptic nasal intubation.

Distribution of cerebellar cortical lesions in multiple system atrophy: a topographic neuropathological study of three autopsy cases in Japan

We investigated neuropathologically the distribution of the cerebellar cortical lesions in three Japanese autopsy cases of multiple system atrophy (MSA) using hemisphere specimens. The lesions were classified as mild, moderate or severe. The distribution of cerebellar cortical lesions in all three cases were uniform: the cerebellar cortical lesions were more conspicuous in the vermis than in the hemisphere. These neuropathological findings differ from the established theory that cerebellar lesions of MSA are more pronounced in the hemisphere than in the vermis. The degree of cerebellar cortical lesions in our cases increased in relation to the duration of the disease. Our pathological data may contribute to the morphological differential diagnosis in various neurodegenerative disorders including late cortical cerebellar atrophy. Our neuropathological findings may also make a contribution to the neuroradiological progress in the differential diagnosis of spinocerebellar disease.

Emergency extracorporeal life support for patients with near-fatal status asthmaticus

Extracorporeal life support (ECLS) was used to treat three patients with near-fatal status asthmaticus who did not respond to aggressive medical therapies and mechanical ventilation under controlled permissive hypercapnia. ECLS was instituted in patient 1 because PaCO2 was excessively high and pH was excessively low, in patient 2 because hypoxemia and shock were not responsive to treatment, and in patient 3 because of sustained severe hypotension. ECLS supported adequate gas exchange until pulmonary function improved, diminishing the need for mechanical ventilation and preventing pulmonary complications. Pulmonary dysfunction improved markedly after only 21 to 86 hours of ECLS. Aggressive medical treatments were continued during ECLS. Our findings indicate that ECLS is a useful method for preventing death in patients with near-fatal status asthmaticus.

Preprodynorphin-, preproenkephalin-, and preprotachykinin-expressing neurons in the rat neostriatum: an analysis by immunocytochemistry and retrograde tracing

Specific antibodies were produced against C-terminal portions of rat preprodynorphin (PPD), preproenkephalin (PPE), and preprotachykinin A (PPT). PPD, PPE, and PPT C-terminal immunoreactivity was observed in many cell bodies of medium-sized neurons in the rat neostriatum (caudate-putamen). Intense PPE immunoreactivity was found in neuropil of the globus pallidus, whereas intense to moderate PPD and PPT immunoreactivity was distributed in neuropil of the substantia nigra and the entopeduncular nucleus. A double-immunofluorescence analysis revealed that PPE-immunoreactive neostriatal neurons rarely showed immunoreactivity for PPD (<1%) or PPT (<2%). In contrast, more than 95% of PPD-immunoreactive neostriatal neurons showed PPT immunoreactivity, and vice versa. No PPD-, PPE-, or PPT-immunoreactive neostriatal neurons showed immunoreactivity for the markers of neostriatal intrinsic neurons, such as calretinin, choline acetyltransferase, parvalbumin, or somatostatin. When tetramethylrhodamine-dextran amine (TMR-DA) was injected into the substantia nigra, almost all neurons that were labeled retrogradely with TMR-DA showed immunoreactivity for PPD (98%) or PPT (99%), but very few of them exhibited PPE immunoreactivity (1%). After injection of TMR-DA into the globus pallidus, 86%, 17%, and 10% of the retrogradely labeled neurons showed immunoreactivity for PPE, PPD, and PPT, respectively. These results support the notion that the neostriatal projection neurons are divided into at least two groups: The projection neurons of one group contain enkephalins and send projection fibers almost exclusively to the globus pallidus, and the others contain tachykinins and dynorphins/Leu-enkephalin and send projection fibers mainly to the substantia nigra.

General anaesthesia for cleft lip and palate surgery team activities in Cambodia

Cleft lip and palate surgery team activities in Cambodia were launched in 1989 by a Japanese non-governmental organization. The objectives of the project were to provide appropriate surgical treatment and safe general anaesthesia for local patients, and also to teach general anaesthesia and surgery to local medical staff. A surgery team was sent on four occasions between 1991 and 1993 and a total of 130 patients received surgical treatment and general anaesthesia. Anaesthesia techniques employed included total intravenous anaesthesia in 70 patients and intravenous anaesthesia and low dose halothane in 60 patients. There were no major complications, such as airway obstruction or apnoea in the postoperative period. Total intravenous anaesthesia is an appropriate technique for patients in developing countries. The teaching of anaesthesia should be emphasized during the surgery team activities.

Immunohistochemical and ultrastructural examination of smooth muscle cells in aortocoronary saphenous vein grafts

In this study, phenotypic modulation and remodulation of smooth muscle cells and associated intermediate filament expression were demonstrated by means of immunohistochemistry and ultrastructure to understand the development of intimal hyperplasia in aortocoronary saphenous vein grafts. In nongrafted saphenous veins, all smooth muscle cells expressed vimentin and desmin and were of a contractile form. In saphenous vein grafts showing stenotic intimal hyperplasia (luminal stenosis < 75%), expression of desmin was notably lower, whereas that of vimentin was higher. The cells were shown to be of a synthetic phenotype, suggesting modulation from the original contractile form. In saphenous vein grafts showing occlusive intimal hyperplasia (luminal stenosis > 76%), desmin expression in smooth muscle cells was increased again, and such cells were of a contractile form, suggesting remodulation from the synthetic phenotype. Some of the smooth muscle cells of the synthetic phenotype were positive for an antibody against proliferation cell nuclear antigen. Smooth muscle cells of the contractile form were negative for this antibody. The study suggests that smooth muscle cells of synthetic phenotype are highly responsible for "growing" intimal hyperplasia of aortocoronary saphenous vein grafts.

[Epidural buprenorphine does not improve diaphragmatic function after upper abdominal surgery]

We investigated the effect of epidural buprenorphine on diaphragmatic function using respiratory inductive plethysmography (RIP) in seven healthy patients after upper abdominal surgery. After surgery, changes of rib cage contribution to tidal volume (%RC) increased significantly from 25.3 +/- 7.3 (mean +/- SD) to 50.7 +/- 14.8% (P < 0.05). After the injection of epidural buprenorphine, visual analogue scale (VAS) score decreased significantly from 8.3 to 3.3 (P < 0.05). But, %RC was unchanged compared to the value before the injection. These results indicate that pain relief by epidural buprenorphine does not improve diaphragmatic function after upper abdominal surgery.

Effect of hemidiaphragmatic paresis caused by interscalene brachial plexus block on breathing pattern, chest wall mechanics, and arterial blood gases

We investigated the effects of hemidiaphragmatic paresis caused by interscalene brachial plexus block on breathing patterns, chest wall mechanics, and arterial blood gas tensions using respiratory inductive plethysmography. Ten healthy patients received interscalene block with 20-40 mL 1.5% lidocaine with epinephrine. Rib cage contribution to tidal volume (%RC) increased from 28.9% +/- 9.7% to 50.0% +/- 8.3% (P < 0.01), respiratory frequency (f) increased from 14.6 +/- 3.2/min to 16.3 +/- 2.4/min (P < 0.05), and PaO2 decreased from 84.7 +/- 7.3 mm Hg to 78.0 +/- 9.5 mm Hg (P < 0.05). No significant changes were observed in tidal volume (VT), minute volume (VE), or PaCO2. These results indicated that VT, VE, and PaCO2 were maintained after interscalene block, apparently by increases in f and %RC to compensate for hemidiaphragmatic paresis caused by interscalene block. Nevertheless, PaO2 was reduced, presumably due to increased ventilation-perfusion mismatching. Recognizing that we studied healthy patients, the decrease in PaO2 may be more in patients with cardiopulmonary disease.

Acetazolamide-induced inhibition of carbonic anhydrase influences energy metabolism and respiratory work in healthy subjects

To assess the usefulness of acetazolamide in weaning a patient from a respirator, we monitored the changes in the respiratory quotient ratio (RQ ratio), the ventilation volume (VE; l/min.), carbon dioxide elimination (VCO2; ml/min.), the oxygen consumption (VO2; ml/min.) and the metabolic energy expenditure (EE; Cal/day) for 6 hours before (baseline) and after the intravenous administration of acetazolamide, 6 mg/kg, in 12 healthy adult volunteers. The RQ ratio decreased significantly from 0.88 to 0.82 after the injection of acetazolamide, 6 mg/kg, and remained below baseline throughout the 6 hours of observation. VCO2 decreased significantly and VE increased significantly after acetazolamide administration. There were no significant changes in VO2 or EE. The RQ ratio increased only slightly, from 0.85 to 0.87, in the control group (no acetazolamide). No significant changes in VCO2 or VE were observed in the control group. Findings suggest that acetazolamide may alter the main pathway of energy metabolism from being carbohydrate-dominant to being fat-dominant, with a resulting fall in CO2 production to maintain the adequate work of ventilation. The inhibition of carbonic anhydrase by acetazolamide may be useful in reducing respiratory work in a patient who is weaned from a respirator.

Vascular changes in acute Wernicke's encephalopathy

The nature and distribution of vascular changes in acute Wernicke's encephalopathy (WE) were analyzed in three autopsy cases. Lesions of the lateral vestibular nucleus of the medulla oblongata (three cases) and lateral ventricular wall (one case) were examined by reconstruction of 200 serial sections, and the capillary diameter in the tegmentum of the medulla oblongata was measured morphometrically in all cases. The vascular changes commonly found in and around the parenchymal lesions in all cases were: (1) dilatation and endothelial swelling of almost all vessels ranging from small arteries to veins, being especially severe with undulation in small arteries and arterioles, and (2) fibrinoid degeneration and hemorrhage involving selectively the arterioles and capillaries on the arterial side. These vascular changes in the medulla oblongata were essentially the same as those in the third ventricular wall, but differed in their severity. Capillary diameter in these cases was significantly larger than that in seven control cases. Such vascular changes, especially a dysoric change on the arterial side, could not be ascribed to secondary change following changes in the parenchyma, and were, therefore, considered to be a lesion essential to WE, as in the case of the parenchymal lesion.

Triangular flap repair of the congenital earlobe cleft

Repair of a congenital earlobe cleft was performed on 16 patients using a new surgical technique derived from the Tennison-Randall triangular flap operation for cheiloplasty. There were no complications. This method was applied because the deformities and desired outcomes in the congenital earlobe cleft are similar to those of the cleft lip. Many papers have described surgery for congenital and acquired clefts; the former differs from the latter in some respects. The techniques described for the repair of acquired clefts are not always appropriate for congenital clefts. In addition, some operations specifically designed for congenital clefts require more complicated techniques. Using our technique to correct lobule deformities with a triangular flap in proportion to the angle and extent of the cleft, a superior cosmetic result was obtained in the repair of longitudinal earlobe clefts.

[Distribution of glutathione peroxidase in the glomeruli of IgA nephropathy]

To study the role of reactive oxygen species in chronic renal disease, we studied the location of Glutathione peroxidase (GSH-Px) in glomeruli of patients with IgA nephropathy. In normal kidney, GSH-Px was localized in tubular cells, and not in glomeruli. In the kidney with IgA nephropathy, GSH-Px was detected in glomerular cells in addition to the tubular cells. As for the relation between the extent of GSH-Px and clinical findings, the following results were obtained. When GSH-Px are strongly stained in glomeruli, histological change of glomeruli was milder. Concerning the renal function, when GSH-Px was stained weakly, Ccr reduced significantly one year after the renal biopsy. Thus, when this enzyme are present in glomeruli, renal function appeared to be more preserved. These results suggest that this enzyme have the beneficial action for renal function as antioxidative factors in IgA nephropathy.

[Autosomal dominant spinocerebellar degeneration with pigmentary retinopathy in a Japanese family]

We report a pedigree of autosomal dominant spinocerebellar degeneration associated with pigmental retinopathy. The proband is a 75-year-old man. He noticed night blindness at the age of 10 years and a diagnosis of bilateral pigmentary retinopathy was made at age 63. At the age of 65 years, he developed dysarthria and difficulty in walking. At age 69, neurological examination revealed cerebellar signs, and brain CT scans showed mild atrophy of the brain stem and cerebellum. Repeated brain CT scans revealed slight progression of the brain stem and cerebellar atrophy. Molecular genetic studies showed the absence of any mitochondrial DNA mutation at 8993. The father of the proband exhibited cerebellar signs and pigmentary retinopathy. One older brother had cerebellar signs and another had pigmentary retinopathy. To our knowledge, hereditary spinocerebellar degeneration with retinal degeneration is rare in Japan. This study is the first full report on hereditary spinocerebellar degeneration with pigmentary retinopathy in Japan, although an abstract was published by Konishi et al. We also discuss the neuropathological discordance on hereditary olivoponto-cerebellar atrophy with retinal degeneration.

[Strategies of general anesthesia for cleft palate surgery in Cambodia]

Hare lip and cleft palate surgery team activities in Cambodia were launched in 1989 by a non-governmental Japanese organization, Operations Unies. The objectives of the project are to provide appropriate surgical treatment and safe general anesthesia for local patients and also to conduct technology transfer of general anesthesia and surgery to the local medical staffs. From June 1991 to January 1993, a surgery/anesthesia team was dispatched 4 times and a total of 130 patients received surgical treatments under general anesthesia. Anesthesia techniques employed included total intravenous anesthesia in 70 patients (54%) and intravenous anesthesia with 0.3-0.7% of halothane in 60 patients (46%). There were no major complications, such as airway obstruction and apnea, in the recovery room and in the ward. The reasons why we chose intravenous agents are difficulty in obtaining inhaled agents in Cambodia and lack of scavenging system in a operating room. Although halothane anesthesia with spontaneous breathing has been recommended in developing countries, total intravenous anesthesia could be one of the applicable techniques in these countries. In Cambodia, shortage of medical doctors and the absence of anesthesiologist constitute a major barrier to technology transfer in clinical anesthesia.

Emergency and long-term extracorporeal life support following acute myocardial infarction: rescue from severe cardiogenic shock related to stunned myocardium

There has been no report regarding therapy of extracorporeal life support (ECLS) that showed stunned myocardium echocardiographically and electrocardiographically in patients with acute myocardial infarction. ECLS was performed in eight patients with cardiogenic shock or arrest unresponsive to catecholamines and intra-aortic balloon pumping following myocardial infarction; these patients required prolonged external cardiac massage. After the initiation of ECLS, both blood pressure and metabolic acidosis improved in all patients. Four of eight patients were weaned from ECLS after a mean of 69.3 h, which was far longer than previously reported in patients with ischemic heart disease. Three of these patients survived, and cardiac function recovered to NYHA class II in two of the survivors and class III in the other. The other five patients did not recover from coma during ECLS and died. A marked improvement of ventricular wall motion was seen in two survivors with the disappearance of pathologic Q waves after the initiation of ECLS. No occlusion of the coronary arteries or bypass grafts was observed in any of the survivors. These findings suggested the existence of stunned myocardium with myocardial reperfusion. The recovery of stunned myocardium may be delayed for days or even weeks, hence the extended period of ECLS therapy was theoretically justifiable. We conclude that long-term ECLS is a useful therapeutic method for patients with severe cardiogenic shock that is related to stunned myocardium.

Focal hepatocellular necrosis and portal lymphocytic infiltration of the liver in chronic alcoholics: histopathological study of 40 liver biopsies

Forty liver biopsies of hepatitis B surface antigen negative chronic alcoholics were histologically studied to assess the influence of hepatitis C virus (HCV)-infection. A moderate degree of focal hepatocellular necrosis and/or portal lymphocytic infiltration (FHN-PLI) was observed in 28% of the specimens, being especially prevalent in advanced cases of fibrosis and cirrhosis, and significantly correlated with HCV-infection. Eleven of these cases were examined in detail: HCV-infection was detected in eight and lymphocytic infiltration was apparent in the portal area, accompanied by formation of lymph follicles. The FHN-PLI was ascribed to alcoholic hepatitis in two HCV-negative cases and was concluded to be of unknown etiology in the remaining one HCV-negative case. This study thus indicated that over two-thirds of cases of chronic hepatitis in alcoholics can be attributed to HCV-infection, with the remainder being at least partly related to alcoholic hepatitis. The prevalence of alcohol-induced chronic hepatitis based on immunopathological findings was unclear, but was probably less frequent than previously reported.