[Congenital chylothorax treated with video-assisted thoracic surgery]

A 35-day-old female was referred to our department because of congenital chylothorax. Medical treatment with dietary restriction was undertaken for 5 weeks without resolution of the effusion. A video-assisted thoracic surgery was performed. The mediastinal pleura was covered with fibrin glue. The postoperative course was satisfactory. She was discharged with resolution of the effusion. Video-assisted thoracic surgery offers an effective means of treating chylothorax.

In vivo kinematic analysis of a high-flexion posterior stabilized fixed-bearing knee prosthesis in deep knee-bending motion

The objective of this study was to evaluate in vivo kinematics of a high-flexion, posterior-stabilized fixed-bearing, total knee arthroplasty in weight-bearing deep knee-bending motion. A total of 20 knees implanted with the Scorpio Non-Restrictive Geometry knee system in 17 patients were assessed in this study. The Scorpio Non-Restrictive Geometry is a recent implant design with modifications made to accommodate a higher flexion range of motion and greater axial rotation, particularly during more functionally demanding activities. Patients were examined during a deep knee-bending motion using fluoroscopy, and femorotibial motion was determined using a 2-dimensional to 3-dimensional registration technique. The average flexion angle was 126.5 degrees (110 degrees -149 degrees ). The femoral component demonstrated a mean of 13.5 degrees (5.2 degrees -21 degrees ) external rotation. The external rotation increased up to maximum flexion. The pivot pattern was a medial pivot pattern similar to that reported in normal knee kinematics.

[Endosaccular embolization of an intrasellar aneurysm with hypopituitarism: case report]

An 81-year-old male presented with weight loss and hyponatremia. A baseline endocrinological examination revealed anterior pituitary dysfunction. A computed tomography and MRI revealed a large, unruptured intrasellar aneurysm protruding from the right internal carotid artery and pushing the pituitary stalk leftward. The patient developed polyuria and polydipsia from 10 days after commencing corticosteroid supplementation and was diagnosed with partial central diabetes insipidus (DI). Balloon assisted endosaccular embolization was performed about one month after the posterior pituitary dysfunction was identified. The unruptured aneurysm was successfully embolized with Guglielmi detachable coils (GDCs) without narrowing of the parent vessel. DI resolved completely and the posterior pituitary dysfunction improved soon after endosaccular embolization. The remission of DI after coil embolization suggested that the DI might have been induced by the progressive mass effect of the aneurysm rather than by the steroid. An endocrinological evaluation and cerebral angiography confirmed partial recovery of anterior pituitary dysfunction and almost complete obliteration of the aneurysm, respectively at 1 year after the operation. We report a case of hypopituitarism secondary to the large intrasellar aneurysm. This aneurysm was embolized with GDCs, resulting in partial recovery of anterior pituitary dysfunction and complete recovery of posterior pituitary dysfunction.

A new control scheme of multilevel quantum system based on effective decomposition by intense CW lasers

We propose a new scheme for quantum dynamics control of multilevel system using intense lasers. To do so, we apply intense CW lasers to create a strongly coupled subsystem with which one can make the complementary space effectively isolated, and we apply the established control schemes to the isolated subsystem. We have also obtained an effective Hamiltonian for the target subsystem with the help of the second-order perturbation theory. Numerical demonstrations on model systems show that the present decomposition scheme effectively works for population dynamics control. It is also found that relaxation processes can be suppressed under the proposed scheme.

Medical rehabilitation of the patients with spinal cord injury caused by aortic aneurysm and its operation

OBJECTIVES

To determine the natural course of spinal cord injury (SCI) after aortic aneurysm surgery.

SETTING

Acute care and semi-acute wards in Osaka Rosai Hospital, Japan.

METHODS

From 1998 to 2003, 12 patients with thoracic SCI (eight men and four women; mean age: 69 years) were enrolled and evaluated by the American Spinal Injury Association (ASIA) impairment scale and Functional Independence Measure (FIM), and the results were analyzed.

RESULTS

The level of SCI was distributed from T5 to L1. The ASIA impairment scale was A in four patients, B in four, C in three and D in one. Finally, six patients were discharged to home, and two patients died during hospitalization. Excluding the value of the deceased patients, the mean motor FIM was initially 32+/-15.6 (13-59) points and became 61+/-21.4 (29-88) points at discharge. Referencing the databases of SCI in Japan and USA revealed that the complication rates of pneumonia and aspiration were higher in our cases. The motor FIM before rehabilitation and at discharge were relatively lower than in the databases, but the gain and the rate of gain were similar to the Japanese database.

CONCLUSION

SCI associated with aortic aneurysm surgery was noticed especially in the elderly patients using airways (for example, tracheostomy). The higher age and recurrent nerve palsy were associated with deconditioning state to develop aspiration pneumonia. This state impaired the general condition, and such vicious cycle led to poor prognosis and functional outcome.

Activation of p38 MAPK and/or JNK contributes to increased levels of VEGF secretion in human malignant glioma cells

Malignant gliomas are typically angiogenic and secrete high levels of VEGF. Hypoxia has been identified as an important regulator of VEGF. However, malignant gliomas express high levels of VEGF in both hypoxic perinecrotic and vital tumor areas. In this study, we examined intracellular signaling pathways involved in the secretion of VEGF in glioma cells under normoxic conditions. Human malignant glioma cell lines, T98G, U373MG, U87MG, and A172, and human fetal lung fibroblasts (HFL) were cultured both with and without IL-1beta under normoxic conditions. VEGF, IL-1, IL-6, and TNF-alpha were measured with ELISA. VEGF mRNA levels were estimated by RT-PCR. Inhibitors of COX-2, MAPK, and phosphatidyl inositol 3-kinase (PI3-K), and blocking antibodies to TGF-beta II and TNF-alpha, or IL-1 receptor antagonist, were used to examine their effects on VEGF secretion. Phosphorylation of MAPK was examined by immunoblotting. The basal levels of VEGF secretion were significantly higher in U87MG, U373MG, and T98G, than HFL. IL-1beta significantly stimulated VEGF secretion in these glioma cells. Inhibitors of p38 MAPK and/or JNK significantly suppressed VEGF secretion both in the presence and absence of IL-1beta, while inhibitors of COX-2, ERK1/2, and PI3-K did not. Constitutive phosphorylation of p38 MAPK and JNK was observed in these glioma cells. The levels of IL-1beta in U87MG were significantly higher than in other glioma cell lines, and IL-1 receptor antagonist suppressed basal secretion of VEGF from U87MG. In conclusion, p38 MAPK and JNK pathways play an important role in VEGF secretion from malignant glioma cells under normoxic conditions, possibly contributing to VEGF-induced angiogenesis in malignant gliomas at vital tumor areas where there is no hypoxia.

Activation of p38 MAPK and/or JNK contributes to increased levels of VEGF secretion in human malignant glioma cells

Malignant gliomas are typically angiogenic and secrete high levels of VEGF. Hypoxia has been identified as an important regulator of VEGF. However, malignant gliomas express high levels of VEGF in both hypoxic perinecrotic and vital tumor areas. In this study, we examined intracellular signaling pathways involved in the secretion of VEGF in glioma cells under normoxic conditions. Human malignant glioma cell lines, T98G, U373MG, U87MG, and A172, and human fetal lung fibroblasts (HFL) were cultured both with and without IL-1beta under normoxic conditions. VEGF, IL-1, IL-6, and TNF-alpha were measured with ELISA. VEGF mRNA levels were estimated by RT-PCR. Inhibitors of COX-2, MAPK, and phosphatidyl inositol 3-kinase (PI3-K), and blocking antibodies to TGF-beta II and TNF-alpha, or IL-1 receptor antagonist, were used to examine their effects on VEGF secretion. Phosphorylation of MAPK was examined by immunoblotting. The basal levels of VEGF secretion were significantly higher in U87MG, U373MG, and T98G, than HFL. IL-1beta significantly stimulated VEGF secretion in these glioma cells. Inhibitors of p38 MAPK and/or JNK significantly suppressed VEGF secretion both in the presence and absence of IL-1beta, while inhibitors of COX-2, ERK1/2, and PI3-K did not. Constitutive phosphorylation of p38 MAPK and JNK was observed in these glioma cells. The levels of IL-1beta in U87MG were significantly higher than in other glioma cell lines, and IL-1 receptor antagonist suppressed basal secretion of VEGF from U87MG. In conclusion, p38 MAPK and JNK pathways play an important role in VEGF secretion from malignant glioma cells under normoxic conditions, possibly contributing to VEGF-induced angiogenesis in malignant gliomas at vital tumor areas where there is no hypoxia.

Vanishing N = 20 shell gap: study of excited states in (27,28)Ne

This Letter reports on the (1)H((28)Ne, (28)Ne) and (1)H((28)Ne, (27)Ne) reactions studied at intermediate energy using a liquid hydrogen target. From the cross section populating the first 2(+) excited state of (28)Ne, and using the previously determined BE(2) value, the neutron quadrupole transition matrix element has been calculated to be M(n)=13.8 +/- 3.7 fm(2). In the neutron knockout reaction, two low-lying excited states were populated in (27)Ne. Only one of them can be interpreted by the sd shell model while the additional state may intrude from the fp shell. These experimental observations are consistent with the presence of fp shell configurations at low excitation energy in (27,28)Ne nuclei caused by a vanishing N=20 shell gap at Z=10.

[Stent-assisted coiling of an acutely ruptured large aneurysm of the internal carotid artery: case report]

A 48-year-old female was referred to our hospital for the management of a ruptured 22-mm-diameter internal carotid aneurysm, located immediately distal to the ophthalmic artery. The right internal carotid artery was completely involved in the aneurysm. Because the right carotid siphon was relatively nontortuous stent-assisted coiling of the aneurysm was attempted 4 days after subarachnoid hemorrhage. A new coil-type coronary stent, a DRIVER stent, was deployed after microcatheter insertion into the aneurysm dome under systemic heparinization, followed by dome packing using Guglielmi detachable coils. Systemic heparinization was continued for 18 hours postoperatively, and aspirin (100 mg/day) was administered orally immediately after the embolization. However, 4 hours after heparin administration cessation, left hemiparesis became apparent. Immediate magnetic resonance angiography revealed a right internal carotid artery occlusion. Diffusion-weighted images demonstrated ischemic spots in the watershed zones of the right cerebral hemisphere. Following an immediate thrombolysis of the right internal carotid artery, systemic heparinization was continued for 5 days, and aspirin and ticlopidine were administrated orally. The patient was discharged on day 37, following the recovery from left hemiparesis within ten days. A DRIVER stent is a low profile coil-type coronary stent, which can be used for the stent-assisted coiling of large internal carotid aneurysms, located distal to the carotid siphon. It seems necessary to continue systemic heparinization for more than 2 days and to administer increased dose or two types of antiplatelet after the stent-assisted coiling of large cerebral aneurysms.

Malignant transformation eight years after removal of a benign epidermoid cyst: a case report

Malignant transformation of benign epidermoid cysts is rare and their prognosis remains poor. A 56-year-old woman presented with left facial hypoesthesia and photophobia in the left eye. She had undergone removal of a benign epidermoid cyst in the cerebellopontine angle 8 years previously. Magnetic resonance imaging of the brain revealed a cystic lesion in the left cerebellopontine angle. The cyst wall was enhanced by gadolinium-DTPA. She underwent removal again and the histopathologic diagnosis was squamous cell carcinoma. Gamma knife radiosurgery was performed on the remnant lesion with a marginal dose of 15 Gy. The tumor shrank rapidly for 2 months after radiosurgery, but recurred 9 months later. She underwent radiosurgery again with a marginal dose of 12 Gy. A gradual increase in the size of the enhanced lesion was seen during the 4-month follow-up period subsequent to the second radiosurgery. Careful observation, employing serial magnetic resonance images, is necessary for incompletely resected epidermoid cysts because intervals before malignant transformation reportedly range from 3 months to 33 years. Newly identified contrast enhancement strongly indicates malignant change in epidermoid cysts. Gamma knife radiosurgery may be useful for short-term control of intracranial squamous cell carcinomas, but long-term effects are presently unknown.

Coil Embolization for Ruptured Cerebral Aneurysms of 2x3 mm Diameter

SUMMARY

Small ruptured cerebral aneurysms, such as those of 2x3 mm diameter, are considered to be difficult to embolize by detachable coils because of the risk of procedural perforation of the aneurysms. We have treated these small aneurysms and report the techniques and pitfalls of these embolizations. Twenty-four patients with ruptured cerebral aneurysms of 2x3 mm diameter were intended for treatment by coil embolization. Before coil embolization, three-dimensional digital subtraction angiography was performed, and the simulation of the volume embolization ratio (VER) was performed in all patients, except for the first basilar artery aneurysm patient. The tip of the microcatheter was steam-shaped several times and was placed on the neck of the aneurysm. A balloon neck remodeling technique was used for two aneurysms. GDC 10 softs and soft SRs were used for the first ten aneurysms, and Ultrasofts were used for the last eleven aneurysms. Out of twentyfour aneurysm embolizations, we aborted the procedure in three cases, because of a failure in catheterization; we performed clipping surgery for these cases. For the first case of a basilar tip aneurysm, the aneurysm was perforated, due to the use of too long a coil and the insertion of the tip of the microcatheter into the aneurysmal dome. Minor infarction occurred in one patient. The mean VER was 33.9%, and two aneurysms recanalized, and out of these one needed a second embolization. Six months postoperatively, 81% of patients had made in a good recovery or had a moderate disability.We recommend the following techniques to embolize aneurysms of 2x3 mm diameter: the tip of the microcatheter should be stabilized on the aneurysmal neck by steam shaping of the microcatheter, GDC 10 soft and Ultrasoft should be selected for use, and the simulation of the VER should be performed before embolization to select coils of a suitable length.

Usefulness of L-[methyl-11C] methionine-positron emission tomography as a biological monitoring tool in the treatment of glioma

OBJECT

The authors retrospectively analyzed the data obtained in patients who had undergone L-[methyl-11C] methionine (MET)-positron emission tomography (PET) studies to clarify the relationship between MET uptake and tumor biological features and to discuss the clinical usefulness of MET-PET studies.

METHODS

One hundred ninety-four patients with cerebral glioma or suspected glioma underwent PET scanning 20 minutes after injection of MET, whose uptake into the tumor was expressed as a ratio to contralateral healthy brain tissue (T/N ratio). Analyses were performed to determine how MET uptake correlated with tumor pathological features and prognosis. The T/N ratios before and after various treatments were also examined. There were significant differences in the T/N ratio among the nonneoplastic lesions, low-grade gliomas, and malignant gliomas. Furthermore, there were significant correlations between patient survival and pretreatment T/N ratios. Among patients with malignant gliomas, a significant difference in survival was observed between cases with and without postoperative tumor remnant based on elevated MET uptake. The MET uptake was heterogeneous even among the homogeneous tumor areas demonstrated on MR imaging. Malignant pathological features were detected in the areas with the highest MET uptake. The effectiveness of radiotherapy or chemotherapy was expressed as a significantly decreased T/N ratio in some of the tumor types.

CONCLUSIONS

The ability of MET-PET to reflect the biological nature of gliomas makes it an excellent method for monitoring active tumor tissue, and treatments based on its findings should provide a powerful clinical protocol in the course of glioma therapy.

Endovascular surgery as the first-choice treatment for ruptured cerebral aneurysms: how far has it come?

SUMMARY

One hundred and seventy patients with ruptured cerebral aneurysms were treated by coil embolization from September 1997 to December 2002. After January 2000, coil embolization was selected as the first-choice treatment for ruptured aneurysms. During this period, the authors investigated the number of aborted cases, the number of complications, and how many patients could be treated by coil embolization according to the locations of ruptured cerebral aneurysms. One hundred and ninety-five sessions were performed on 170 patients, and 13 sessions (6.7%) were aborted mainly because of the difficulty of the approach and the wide necks of the aneurysms. In four patients, although procedural perforation and haemorrhage occurred, the outcome was good or excellent. Eight poorgrade patients experienced haemorrhage after coil embolization and seven patients died. The volume embolization ratios of small and large aneurysms were 27% and 21%, and the recanalization of small and large aneurysms occurred in 9% and 38% of patients, respectively. From January 2000 to December 2002, 119 (66%) of 180 ruptured cerebral aneurysms were treated by coil embolization. According to the location of aneurysms, 89% vertebrobasilar, 87% anterior cerebral, 65% internal carotid and 24% middle cerebral artery aneurysms could be treated by coil embolization. Because the tight packing of large aneurysms was difficult, the recanalization rate of large aneurysms was high. However, the results of small aneurysms were satisfactory. Almost 90% of vertebrobasilar and anterior cerebral artery aneurysms could be treated by coil embolization.

Anomalously hindered E2 strength B(E2;2+(1)-->0+) in 16C

The electric quadrupole transition from the first 2(+) state to the ground 0(+) state in 16C is studied through measurement of the lifetime by a recoil shadow method applied to inelastically scattered radioactive 16C nuclei. The measured mean lifetime is 77+/-14(stat)+/-19(syst) ps. The central value of mean lifetime corresponds to a B(E2;2+(1)-->0(+)) value of 0.63e(2) fm(4), or 0.26 Weisskopf units. The transition strength is found to be anomalously small compared to the empirically predicted value.

Impairment of Both Apoptotic and Cytoprotective Signalings in Glioma Cells Resistant to the Combined Use of Cisplatin and Tumor Necrosis Factor α

PURPOSE

Tumor necrosis factor (TNF)-alpha elicits two opposing effects, the induction of apoptosis and the transcription of antiapoptotic genes. We have recently shown that cisplatin sensitizes glioma cells to TNF-induced apoptosis, but only in some cell lines. To understand the mechanism involved in the different susceptibilities, we examined both the activation of caspases and cytoprotective signaling by TNF-alpha.

EXPERIMENTAL DESIGN

Caspase activation was examined by estimating the cleavage of substrate peptides and by immunoblot to identify the cleavage of procaspases. Peptide inhibitors of caspases were used to reverse the cytotoxicity. The binding of TNF-alpha to the receptor was analyzed by flow cytometry. Nuclear factor (NF)-kappaB activation was assayed by the binding of NF-kappaB to oligonucleotides containing the consensus binding site. Interleukin (IL)-1beta, IL-6, IL-8, and manganous superoxide dismutase (MnSOD) were measured by enzyme-linked immunoassays.

RESULTS

T98G and U87MG underwent apoptosis on treatment with cisplatin and TNF-alpha, but U373MG and A172 were resistant. Caspases 2, 3, and 6-10, but not caspases 1, 4, and 5, were activated in sensitive cells, and none were activated in resistant cells. The binding of TNF-alpha to the receptor was the same in all four of the cell lines. In the sensitive cells, NF-kappaB activation and the production of IL-1beta, IL-6, IL-8, and MnSOD were significantly elevated by TNF-alpha. However, in the resistant cells, the production of IL-1beta and IL-6 were specifically impaired in response to TNF-alpha.

CONCLUSIONS

Our results indicate that both apoptotic and cytoprotective pathways are impaired in glioma cells that are resistant to treatment with cisplatin and TNF-alpha.

Chronological changes of perihematomal edema of human intracerebral hematoma

Recent investigations have indicated the importance of secondary brain damage in the pathophysiology of intracerebral hemorrhage (ICH), which includes ischemic brain damage and edema formation around a hematoma. The purpose of the current study is to investigate chronological changes of perihematomal edema in patients with human ICH and also the correlation between volume of perihematomal edema and neurological status. Fourteen patients with medium-sized putaminal hemorrhage (29.4 +/- 13.2 ml) without hematoma enlargement were included in this study. To investigate chronological changes of perihematomal edema, we performed CT scans prospectively on the day of hemorrhage and repeated them on days 1, 3, 7, 14, and 28. We evaluated the patients neurologically using the NIH stroke scale on the day a CT scan was performed. The volume of perihematomal edema in human ICH increased rapidly three days after hemorrhage and the score on the NIH stroke scale showed a deterioration. The volume of perihematomal edema then increased slowly until day 14 after hemorrhage, and decreased thereafter. Despite progression of perihematomal edema, the score on the NIH stroke scale improved gradually after day 3.

Increased levels of tissue endostatin in human malignant gliomas

PURPOSE

Malignant gliomas are typically angiogenic and express greater amounts of angiogenic factors. We examined glioma tissues for their expression of an endogenous inhibitor of angiogenesis, endostatin, a COOH-terminal fragment of collagen XVIII.

EXPERIMENTAL DESIGN

We examined frozen tissues from 51 patients with astrocytic tumors (grade 2, 13; grade 3, 9; and grade 4, 29). Frozen tissues were subjected to immunoblot analysis and immunohistochemistry for endostatin. Tumor vascular density was determined by calculating the percentage of tumor capillary vessel areas/tissue section area. Tissue concentrations of vascular endothelial growth factor and basic fibroblast growth factor were examined by enzyme immunoassay.

RESULTS

The levels of endostatin protein estimated by immunoblotting were significantly higher in grade 4 than lower-grade glioma tissues. The immunoreactive bands for endostatin were identified as the fragment derived from noncollagenous domain 1 of collagen XVIII, a peptide 15 residues longer than endostatin toward the NH(2)-terminal end, by NH(2)-terminal amino acid sequencing. In addition to an intense immunoreactivity for endostatin in tumor blood vessels, sections from malignant gliomas showed widely distributed immunoreactivity around tumor cells near the hyperplastic microvessels. The tumor vascular density and the levels of vascular endothelial growth factor in grade 4 glioma tissues were significantly higher than grade 2 and grade 3 gliomas, whereas the levels of basic fibroblast growth factor were the same.

CONCLUSIONS

The results indicate a positive correlation between the levels of tissue endostatin and malignancy grades in gliomas. The endostatin may be released near the tumor blood vessels with hyperplasia to counteract angiogenic stimuli in malignant gliomas.

[Subdiaphragmatic bronchogenic cyst in the left crus of diaphragm: report of a case]

A 39-year-old man who had a subdiaphragmatic bronchogenic cyst in the left crus of diaphragm received surgical treatment. The cyst was located in the retroperitoneum just below the diaphragm and was adhered to the left crus of diaphragm and unconnected with any other structures. The surgically resected cyst was 50 x 25 x 22 mm diameter and the wall was thin and contained white turbid mucus. Histologically, the cyst consisted of ciliated epithelium, mucus glands, smooth muscle, cartilage and this evidence established the final diagnosis of bronchogenic cyst. The post operative course was uneventful and the patient was discharged 10 days after operation. This is the 4th reported case of a subdiaphragmatic bronchogenic cyst in the Japanese literature.

Longitudinal study of functional spinal alpha motor neuron loss in amyotrophic lateral sclerosis

Using a microstimulation technique for obtaining motor unit number estimates (MUNEs) of the hypothenar and extensor digitorum brevis (EDB) muscles, we performed a longitudinal study on the natural course of change in the clinical rating scale (Appel score) and of loss of functional spinal alpha motor neurons in amyotrophic lateral sclerosis. The Appel score increased to about 150% of normal at 12 months after onset, about 225% at 18 months after onset, and about 370% at 24 months after onset. By contrast, MUNEs decreased to about 27% of normal at 12 months after onset, about 12% at 18 months after onset, and about 5% at 24 months after onset. The relative merits of these different approaches in detecting changes in the disease process in its early phase are discussed.