Eosinophilic granuloma of the spine: early spontaneous disappearance of tumor detected on magnetic resonance imaging. Case report

Two cases of eosinophilic granuloma (EG) of the spine associated with neurological deficits are presented. The patients were treated conservatively by using external fixation with a brace as well as bed rest. Neurological deficits and pain diminished and finally disappeared as the tumor mass decreased in size, as seen on magnetic resonance (MR) imaging. During the 5-year follow-up period no recurrence of the tumors was detected on MR images. Surgical treatment for spinal EG in children presenting with typical vertebra plana is not recommended except for those with severe or progressive palsy and for those in whom the disease requires differential diagnosis.

Bioactive bone cement: effect of surface curing properties on bone-bonding strength

The fact that bisphenol-a-glycidyl methacrylate (bis-GMA)-based cements contain an uncured surface is believed to play an important role when determining the surface curing properties of the cements. Therefore, in the present study, the bone-bonding strength of cement plates having an uncured surface on one side and a cured surface on the other side has been evaluated. These cement plates were composites of a bis-GMA-based resin with either an apatite- and wollastonite-containing glass-ceramic (AW-GC) powder or a hydroxyapatite (HA) powder, respectively designated AWC and HAC. The amount of each of these powders in a composite cement was 70 wt %. We formulate the hypothesis that the uncured surface of a cement plate is bioactive having bone-bonding properties. The goal of the present study was to indicate the bone-bonding strength of the uncured surfaces of AWC and HAC and compare the strength with the respective cured surfaces by a detaching in vivo test, as well as to histologically examine the bone-cement interface. Each plate has been implanted into the tibiae of male Japanese white rabbits, taking care to retain the surface properties, and the so-called "failure load has been measured using a detaching test followed 8 weeks after implantation. The failure load for AWC-plates at the uncured surface (2.05 +/- 1.11 kgf, n = 8) was significantly higher than AWC at its cured surface side (0.28 +/- 0.64 kgf, n = 8). The failure load for HAC-plates at the uncured surfaces (1.40 +/- 0.68 kgf, n = 8) was significantly higher than HAC at its cured surface (0.00 +/- 0.00 kgf, n = 8). Failure loads for AWC at its uncured and cured surfaces were both higher than for HAC, although not significantly. Direct bone formation has been observed histologically for both AWC and HAC on the uncured surfaces, and a Ca-P-rich layer was observed only at the uncured surface of AWC. These findings strongly suggest that uncured surfaces are useful for exposing a bioactive filler on a surface of composites, being very effective in inducing bone bonding.

Bioactive polymethyl methacrylate-based bone cement: comparison of glass beads, apatite- and wollastonite-containing glass-ceramic, and hydroxyapatite fillers on mechanical and biological properties

A new bioactive bone cement (designated GBC) consisting of polymethyl methacrylate (PMMA) as an organic matrix and bioactive glass beads as an inorganic filler has been developed. The bioactive beads, consisting of MgO-CaO-SiO(2)-P(2)O(5)-CaF(2) glass, have been newly designed, and a novel PMMA powder was selected. The purpose of the present study was to compare this new bone cement GBC's mechanical properties in vitro and its osteoconductivity in vivo with cements consisting of the same matrix as GBC and either apatite- and wollastonite-containing glass-ceramic (AW-GC) powder (designated AWC) or sintered hydroxyapatite (HA) powder (HAC). Each filler added to the cements amounted to 70 wt %. The bending strength of GBC was significantly higher than that of AWC and HAC (p < 0.0001). Cements were packed into intramedullar canals of rat tibiae in order to evaluate osteoconductivity as determined by an affinity index. Rats were sacrificed at 2, 4, and 8 weeks after operation. An affinity index, which equaled the length of bone in direct contact with the cement expressed as a percentage of the total length of the cement surface, was calculated for each cement. At each time interval studied, GBC showed a significantly higher affinity index than AWC or HAC up to 8 weeks after implantation (p < 0.03). The value for GBC increased significantly with time up to 8 weeks (p < 0.006). The handling property of GBC was comparable with that of PMMA bone cement. Our study revealed that the higher osteoconductivity of GBC was due to the higher bioactivity of the bioactive glass beads at the cement surface and the lower solubility of the new PMMA powder to MMA monomer. In addition, it was found that the smaller spherical shape and glassy phase of the glass beads gave GBC strong enough mechanical properties to be useful under weight-bearing conditions. GBC shows promise as an alternative with improved properties to the conventionally used PMMA bone cement.

Peroral infection of nuclear polyhedrosis virus budded particles in the host, Bombyx mori l., enabled by an optical brightener, Tinopal UNPA-GX

Perorally inoculated budded particles of a nuclear polyhedrosis virus was used to infect Bombyx mori (BmNPV) (Lepidoptera; Bombycidae), aided by an optical brightener, Tinopal UNPA-GX (Tinopal). BmNPV budded particles not occluded in the occlusion body do not infect successfully the host, B. mori, when administered perorally. It was found that feeding the host Tinopal enabled perorally delivered BmNPV budded particles to infect the host. B. mori larvae ingesting BmNPV budded particles (1.3 x 10(6) TCID(50) units per larva) after they consumed an artificial diet containing 0. 3% Tinopal died of the viral infection. Peroral administration of these particles to host larvae with 1% Tinopal also resulted in virus infection. Tinopal is a candidate for viral activity enhancing agent promoting viral insecticide infection in hosts. The results suggest that B. mori-BmNPV budded particles are convenient for detecting viral infection enhancement activity of a chemical of interest. Since recombinant baculovirus vectors are constructed by replacing the polyhedrin gene with the foreign gene of interest, they do not produce occlusion bodies, i.e. polyhedra. Budded particles of a baculovirus vector not occluded in polyhedra cannot infect their hosts when administered perorally. The peroral inoculation of BmNPV budded particles by Tinopal leads to industrial pharmaceutics production using a baculovirus vector for a huge number of insect hosts, i.e. an 'insect factory'.

Bioactive polymethyl methacrylate-based bone cement: comparison of glass beads, apatite- and wollastonite-containing glass-ceramic, and hydroxyapatite fillers on mechanical and biological properties

A new bioactive bone cement (designated GBC) consisting of polymethyl methacrylate (PMMA) as an organic matrix and bioactive glass beads as an inorganic filler has been developed. The bioactive beads, consisting of MgO-CaO-SiO(2)-P(2)O(5)-CaF(2) glass, have been newly designed, and a novel PMMA powder was selected. The purpose of the present study was to compare this new bone cement GBC's mechanical properties in vitro and its osteoconductivity in vivo with cements consisting of the same matrix as GBC and either apatite- and wollastonite-containing glass-ceramic (AW-GC) powder (designated AWC) or sintered hydroxyapatite (HA) powder (HAC). Each filler added to the cements amounted to 70 wt %. The bending strength of GBC was significantly higher than that of AWC and HAC (p < 0.0001). Cements were packed into intramedullar canals of rat tibiae in order to evaluate osteoconductivity as determined by an affinity index. Rats were sacrificed at 2, 4, and 8 weeks after operation. An affinity index, which equaled the length of bone in direct contact with the cement expressed as a percentage of the total length of the cement surface, was calculated for each cement. At each time interval studied, GBC showed a significantly higher affinity index than AWC or HAC up to 8 weeks after implantation (p < 0.03). The value for GBC increased significantly with time up to 8 weeks (p < 0.006). The handling property of GBC was comparable with that of PMMA bone cement. Our study revealed that the higher osteoconductivity of GBC was due to the higher bioactivity of the bioactive glass beads at the cement surface and the lower solubility of the new PMMA powder to MMA monomer. In addition, it was found that the smaller spherical shape and glassy phase of the glass beads gave GBC strong enough mechanical properties to be useful under weight-bearing conditions. GBC shows promise as an alternative with improved properties to the conventionally used PMMA bone cement.

LambdaN spin-orbit splittings in (9)(Lambda)Be and (13)(Lambda)C studied with one-boson-exchange LambdaN interactions

Movitated by the on-going gamma-ray experiments at the Alternating Gradient Synchrotron at Brookhaven National Laboratory, we discuss the energy splittings of the 5/2(+)(1)-3/2(+)(1) doublet in (9)(Lambda)Be and the 3/2(-)(1)-1/2(-)(1) doublet in (13)(Lambda)C for which the LambdaN spin-orbit ( LS) and antisymmetric spin-orbit ( ALS) forces are relevant. In the microscopic 2alpha+Lambda ( 3alpha+Lambda) model for (9)(Lambda)Be ( (13)(Lambda)C), all the available Nijmegen one-boson-exchange (OBE) model LambdaN interactions lead to a wide range of splittings of 0.08-0.20 MeV in (9)(Lambda)Be and 0.39-0.96 MeV in (13)(Lambda)C. On the other hand, if we use information from quark-model LambdaN interactions which have generally large ALS force, the splittings become about half of the smallest OBE model prediction.

Thoracic epidural desmoplastic fibroma

Desmoplastic fibroma is a relatively uncommon tumor and rarely involves the spine. The authors describe a 20-year-old woman with a thoracic epidural desmoplastic fibroma treated by complete resection and posterior spinal fusion. Four years after surgery, neither the tumor nor clinical symptoms have recurred. Thus, complete resection is considered necessary to treat this tumor.

Cervical pedicle screw insertion: assessment of safety and accuracy with computer-assisted image guidance

We used a commercially available computer-assisted image-guidance system for cervical pedicle screw insertion in both the laboratory and in a preliminary clinical setting. Nine plastic cervical spine models (C2-C7) were used in the laboratory test. The StealthStation was used to create the preoperative plan for each screw such that it would be inserted down the center of the pedicle, parallel to the long axis. Using a light-emitting diode-equipped drill guide, 2-mm holes were drilled in 108 pedicles. A total of 108 pedicle holes were drilled. The mean trajectory deviation from the surgical plan in the axial plane was 1.7+/-1.7 degrees (range, 0 to 8 degrees), and the mean deviation of the position of the hole was 1.7+/-0.6 mm (range, 0.1 to 2.9 mm). Eighty-three drill holes (76.9%) were contained within the pedicles, whereas partial cortical perforation was noted in 25 pedicles (23.1%). In the clinical setting, 36 cervical pedicle screws were inserted in nine patients using the image-guided system. Within the limits of imaging artifact, all 36 pedicle screws appear to have been inserted accurately by postoperative computed tomographic examination. No neurologic or vascular complications were encountered.

Cellular distribution of mucosa-associated lymphoid tissue with otitis media in children

This study examined mucosa-associated lymphoid tissue (MALT) in the eustachian tube (ET), middle ear (ME), and mastoid antrum (MA) in 163 celloidin-embedded temporal bones from children with or without otitis media. Otitis media was defined by the presence of histopathologically identified inflammatory cell infiltration in the mucosa or cavity of the ME. We found MALT in the ET in 30 cases (46.2%), in the ME in 19 cases (29.2%), and in the MA in 4 cases (6.2%) out of 65 cases of otitis media, and in the ET in 7 (7.1%), in the ME in 0, and in the MA in 0 out of 98 specimens without otitis media. No MALT appeared in any children under the age of 1 month. Immunohistochemical methods were used to investigate MALT in 12 horizontally cut temporal bones with OM. The follicular area contained OPD4-positive (helper-inducer T) cells and a few CD8-positive (cytotoxic and suppressor T) cells, whereas the parafollicular area contained OPD4-positive and CD8-positive T cells. CD57-positive (natural killer) cells were confined to the germinal center. CD30-positive (activated T and B) cells were observed throughout the follicles. A few CD15-positive (granulocyte, monocyte) cells were found in the follicles. Histopathologic and immunohistochemical findings were indistinguishable for MALT in the ET, ME, and MA. Our results suggest that MALT may be a mechanism for producing a rapid and massive local immune reaction to repeated bacterial infections via the ET.

A new system for the anterior restoration and fixation of thoracic spinal deformities using an endoscopic approach

STUDY DESIGN

A report on the results of animal experiments in which the authors' new system that enables the anterior correction and fixation of thoracic spinal deformity by use of a thoracic endoscope and small incisions was used. The results suggest that the new approach involving thoracoscopic anterior correction and fusion for thoracic spinal deformity could be adapted successfully for the clinic.

OBJECTIVE

To develop a new system that enables the anterior correction and fixation of thoracic spinal deformity by use of a thoracic endoscope and small incisions.

SUMMARY OF BACKGROUND DATA

Anterior correction and fusion through open thoracotomy have been applied mainly for thoracic scoliosis because this approach provides effective correction with short fusion. However, excellent visualization of the spine during thoracic surgical procedures led to the development of thoracoscopic spine surgery. Therefore, the authors postulated that a thoracoscopic approach could allow not only discectomy but also correction and fusion of the deformed thoracic spine in a single surgical event.

METHODS

The vertebral columns and attached thoracic walls were dissected from fresh porcine cadavers and used in the experimental surgery to evaluate the new system. As a next step, thoracoscopic surgery using this new system was performed on four or five vertebrae of five live pigs with an average weight of 50 kg. Initially, the discs and rib heads were removed through the thoracic wall. For each vertebra, a screw connected to a shaft used as a screw holder was inserted through the thoracic wall in a posterior to anterior direction. Each shaft then was linked outside the body to an outrigger. This outrigger was used to both create and restore scoliosis. A rod then was introduced through the thoracic wall and fixed to the screw heads.

RESULTS

The animal experiments clearly showed that it was possible to change the Cobb angles of the spine through the use of the outrigger apparatus. In cadaver experiments, it was possible to create scoliosis and re-store it by 25 degrees to 35 degrees. Also, surgery on live pigs resulted in scoliosis of approximately 30 degrees, which means approximately 5 degrees to 10 degrees for each disc space. The procedures used also demonstrated that it was possible to fix a rod, introduced into the pleural cavity through a port, with screw heads.

CONCLUSIONS

The use of this system successfully changed the Cobb angle of the spine, which suggests that its use should make it possible to correct spinal deformities. This apparatus also succeeded in fixing the rods in the screw heads, which raises the possibility of its use in spinal fixation. The authors believe that this apparatus could be adapted successfully for clinical use. Studies currently are under way in clinics using the new system.

Functional retinoid receptors in budding ascidians

A homolog of retinoid X receptors (RXR), named PmRXR, was cloned from the budding ascidian, Polyandrocarpa misakiensis. Gel-shift assays revealed that PmRXR and a previously identified P. misakiensis retinoic acid receptor (PmRAR) formed a complex to bind vertebrate-type retinoic acid response element (RARE). Transfection assays were carried out using a reporter gene containing a RARE upstream of lacZ. Two chimeric effector genes were constructed by placing PmRXR and PmRAR cDNA fragments (containing the DNA-binding, ligand-binding and ligand-dependent transactivation domains) downstream of the human RXR alpha and RAR alpha cDNA (covering the N-terminal coding region), respectively. Each chimeric cDNA was ligated to a notochord-specific enhancer. In case the embryos were transfected with all three transgenes and treated with retinoic acid (RA), the reporter gene was activated in the notochord cells. The result suggests that the PmRXR/PmRAR complex functions as an RA-dependent transcriptional activator. The PmRXR mRNA was detected in a mesenchymal cell type, called glomerulocyte, in the developing Polyandrocarpa bud. As this cell type has been shown to express PmRAR mRNA, it seems possible that the PmRXR/PmRAR complex mediates RA signaling in this cell type to induce the expression of genes involved in the morphogenesis of the developing bud.

Anterior surgery with short fusion using the Zielke procedure for thoracic scoliosis: focus on the correction of compensatory curves

Anterior instrumentation is recommended to correct idiopathic thoracolumbar or lumbar scoliosis through short fusion within the major curve. Only a few reports exist of anterior surgical correction for thoracic scoliosis. This study assessed the results of Zielke instrumentation for thoracic curve and analyzed the three-dimensional correction of deformity, especially correction of the uninstrumented compensatory curve. Seventeen patients, who had undergone selective thoracic correction and fusion using the Zielke procedure to treat thoracic scoliosis, had been followed for at least 3 years. Three-dimensional correction was evaluated radiographically. Furthermore, three-dimensional back deformities were evaluated using a topographic body scanner. Twelve patients with a single thoracic curve and five with a double curve were all female, with a mean age of 14.6 years. The preoperative main thoracic curve was 54.8 degrees +/- 10.5 degrees (range, 40-78 degrees), and it was 23.8 degrees +/- 10.5 degrees (range, 7-40 degrees) at the final follow-up examination (p < 0.0001). The average correction rate of the main curves was 56.6%. By correcting the thoracic curve, the upper and lower compensatory curves were corrected spontaneously without surgical instrumentation, with average correction rates of 45.1% and 50.2%, respectively. The average correction loss of the main curve was 2.3 degrees. The hump angle measured using a topographic body scanner decreased from 12.8 degrees +/- 4.5 degrees to 8.4 degrees +/- 4.3 degrees after surgery (p = 0.0001). Of the three patients in whom the rod broke up, only one showed a correction loss of 10 degrees; however, bony fusion was obtained. Anterior short fusion for thoracic scoliosis appears to offer significant correction, stabilization, and spontaneous correction of the compensatory lumbar curve without limiting lumbar motion.

Percutaneous transpedicular biopsy of thoracic and lumbar vertebrae--method and diagnostic validity

BACKGROUND

Percutaneous transpedicular needle biopsy was performed on thoracic and lumbar vertebral bodies with a thin trocar (2.0 mm outer diameter) under observation with a conventional X-ray image intensifier in order to establish a correct histopathological diagnosis. We also evaluated the clinical validity of this less invasive diagnostic method in terms of the accuracy of the pathological diagnosis.

METHODS

Twenty-eight thoracic or lumbar vertebrae of 26 patients with abnormalities observed on routine X-ray, CT, or MRI images underwent percutaneous transpedicular needle biopsy under local anesthesia. A threaded trocar with an outer diameter of 2.0 mm was screwed into the intra-vertebral lesion through the pedicle from the posterior side under control of X-P imaging, and a small amount of tissue or fluid was collected.

RESULTS

For all patients but two, where inadequate specimens were obtained, correct diagnoses were made, which were confirmed by pathological diagnoses of massive tissue obtained during subsequent reconstructive surgery.

CONCLUSIONS

The accuracy rate of diagnosis with this biopsy method was 92% without significant intra- or postoperative complications. Therefore, it can be concluded that this less invasive biopsy method used in conjunction with conventional X-ray apparatus has good potential to result in correct preoperative diagnosis of thoracic and lumbar lesions so that more effective treatment can be determined.

[Body surface ultrasonography-guided bronchofiberscopy]

Transbronchial lung biopsies and cytologic studies under ultrasonographic guidance from the body surface were conducted in 39 patients whose lesions were adjacent to the thoracic wall. In 26 patients, biopsy, curettage, or brushing forceps were visualized in the mass or infiltrative lesion by thoracic echogram. Positive findings were obtained in 23 patients, for a conclusive diagnostic rate of 88.5%. Of the 13 patients in whom forceps could not be visualized by echogram, 10 had positive findings, for a diagnostic rate of 76.9%. For visualization by thoracic echogram, abnormal lung lesions must be in direct contact with the thoracic wall. Occasionally, diagnostic procedures may be impeded by anatomical structures such as shoulder joints or scapula. Despite these disadvantages, the ultrasonography-guided bronchofiberscope is quite useful because it facilitates real-time confirmation of the positioning of the forceps relative to the lesions. It is also useful in cases when the peripheral lesions are too small or vague to be demonstrated by fluoroscopy alone, because the echo probe can be the target of the forceps instead of the missing shadows. The diagnostic rate should be higher when the forceps are visualized in the lesions ultrasonographically.

Experimental spinal fusion with use of recombinant human bone morphogenetic protein 2

STUDY DESIGN

Posterolateral lumbar spinal fusion with use of recombinant human bone morphogenetic protein 2 (rhBMP-2) was tested in rabbits by implanting composites of rhBMP-2 and collagen carrier.

OBJECTIVES

To examine the bone-formation-inducing activity of rhBMP-2 and find the optimal amount of rhBMP to add to a collagen carrier to constitute bone-formation-inducing implants to be substituted for bone graft in posterolateral spinal fusion in rabbits.

SUMMARY OF BACKGROUND DATA

In animal models, rhBMP-2--impregnated collagen has been successfully used for posterolateral spinal fusion, indicating that it is a potential substitute for the autogenous corticocancellous bone graft currently used most routinely in posterolateral lumbar spinal fusion.

METHODS

Nine rabbits were divided into three equal groups. The bilateral L4-L5 transverse processes were exposed, and collagen strips impregnated with rhBMP-2 (10, 50, or 200 micrograms) were placed on the left transverse processes, and collagen strips alone were inserted on the right. All rabbits were killed 24 weeks after surgery. The implanted sites were assessed for new bone formation and bony fusion by radiography and histologic examination.

RESULTS

New bone formation was noted in intertransverse spaces on the left side of all rabbits except one (10 micrograms rhBMP-2). Twelve weeks after implantation, no new bone formation was seen on the right side of all animals. The newly formed bone masses were significantly larger in the 50-microgram and 200-microgram rhBMP-2 groups than in the 10-microgram rhBMP-2 group (P < 0.01), but there was no significant difference between bone formation in the 50-microgram and 200-microgram groups (P = 0.647).

CONCLUSIONS

The rhBMP-2/collagen composite implant was an effective bone graft substitute for achieving posterolateral spinal fusion. When combined with a collagen carrier, the optimal rhBMP-2 dose for achieving posterolateral spinal fusion seemed to be approximately 50 micrograms per segment in rabbits.

Accurate pedicle screw insertion under the control of a computer-assisted image guiding system: laboratory test and clinical study

We used a commercially available computer-assisted navigation system (StealthStation; Sofamor Danek, Memphis, TN, USA) in both an in-vitro and a clinical study performed in 1996-1998. The basic data used for navigation were preoperative computed tomography (CT) scan imaging data. The position of the probe or drill guide was superimposed in real-time on a monitor. For the in-vitro study, ten plastic lumbar spine models (50 vertebrae) were used. The entrance hole for the screw was made by drilling, following navigation. Using the navigation system, we drilled 88 holes through the pedicles into the vertebral bodies of 44 vertebral models. All 88 pedicle holes were contained within the pedicle without perforation. The mean deviation of the hole positions from the surgical plan was 1.78 +/- 0.81 mm, and the mean angular deviation was 2.28 degrees +/- 1.92 degrees. In 29 patients, using the navigation system, we introduced 169 pedicle screws at the planned position. Fifty-one screws were used for thoracic and 118 screws for lumbar spinal fixation. All screws correctly passed through the pedicles. There were no neurological complications after surgery. Using this guided surgery system, we achieved satisfactory results both in the laboratory and in a clinical setting.

Individual differences in physiological responses and type A behavior pattern

The relationships between individual differences in psychophysiological responses and tendency of Type A behavior pattern (TABP) were investigated during mental arithmetic (MA) at a steady rhythm, challenging calculation (Uchida-Kraepelin serial addition test: UK test), music listening, and exposure to an 80 dB SPL of white noise. Each mental task was sustained for 5 minutes. Sixteen healthy Japanese adults, (10 males and 6 females) with an age from 18 to 36 years old volunteered for this study. The KG's Daily Life Questionnaire (KG Questionnaire) was used to investigate the tendency toward TABP, which included three sub-factors: aggression-hostility, hard-driving and time urgency, and speed-power items. Recorded physiological variables were respiratory rate (RR), skin resistance response (SRR), eyeblinks, and heart rate (HR) calculated using frequency analysis to render high frequency power (HF) and the ratio of low/high frequencies (L/H ratio). During the MA and UK tests, significant increases in HR, L/H ratio, RR occurred, while significant decreases in HF were observed. Eyeblinks significantly increased during the MA test and significantly decreased during the UK test. During music and white noise, no significant changes occurred except for SRR, which decreased significantly. The coefficient of variances in each response was over 20% for almost all variables, indicating that individual differences in the magnitude of each response were large, even if the direction (increase or decrease) of the change was the same in almost all subjects. The highest correlation coefficients (r) between the mean values of relative magnitude for each variable and TABP scores during the MA and UK tests were obtained for the L/H ratio (MA: r = 0.591, UK test: r = 0.577) and the RR (MA: r = -0.576, UK test: r = -0.511). These values were statistically significant (p < 0.05). Similar results were obtained for TABP sub-factors. Though other investigations have reported relationships between HF and TABP, we found no significant relationship. It was suggested that sympathetic nerve activity became greater for TABP individuals than for Type B individuals under stress conditions.

Treatment of cervical compressive myelopathy with a new dorsolateral decompressive procedure

OBJECT

A new dorsolateral decompressive procedure involving a unilateral approach has been devised for the treatment of cervical compressive myelopathy. In this operation, the posterior spinal elements of the contralateral side are not disturbed, and thus, postoperative deformity of the cervical spine can be avoided. Following decompressive surgery via the unilateral approach, the cervical spine was kept more stable compared with the results obtained after wide laminectomy or other expansive laminoplasty procedures.

METHODS

Twenty-six patients underwent dorsolateral decompressive surgery, and the patients' clinical and radiological results were examined during the follow-up period to evaluate neurological function and postoperative deformities of the cervical spine. The underlying conditions for myelopathy were cervical spondylosis (19 patients), ossification of posterior longitudinal ligament (three patients), and ossification of yellow ligament (four patients). The follow-up period ranged from 6 to 110 months (average 35.5 months). Functional recovery, which was rated by using the Japanese Orthopaedic Association scoring system, was an average of 56% in all patients (100% being equal to full recovery). The recovery rate was compatible with those attained after other expansive laminoplasty procedures. Radiographically, progression to swan-neck or kyphotic deformity was not observed in any patient. No postoperative spinal instability was noted. Based on computerized tomography myelograph evaluation, the average transectional area of the dural tube at the C4-5 level was expanded from 122 mm2 to 169 mm2, and the transectional area of the spinal cord at the C4-5 level was expanded from 39.6 mm2 to 52.9 mm2 after surgery.

CONCLUSIONS

The authors conclude that this operative procedure could be used as a new option for the treatment of cervical compressive myelopathy.

Nontraumatic lumbar vertebral compression fracture as a risk factor for femoral neck fractures in involutional osteoporotic patients

To screen a potential risk factor for femoral neck fracture, we characterized lumbar vertebral fractures in 120 patients with femoral neck fractures (19 men, 101 women; mean age, 78.7 years) by investigating the frequency of patients with lumbar vertebral fracture, the number of vertebral fractures per patient, and the severity of deformity of the fractured vertebral bodies. These findings were compared with data gathered from a population of age- and sex-matched control patients (20 men, 89 women; mean age, 77.6 years) who had no evidence of femoral neck fracture. The heights of the anterior and posterior walls together with the midpart of the lumbar vertebrae were measured on lateral radiographs to identify fractures. The extent of height loss in the fractured vertebrae was calculated for each group. The incidence of patients with vertebral compression fractures was significantly higher in the femoral neck fracture group than in the control group (65.0% vs 41.1%). In terms of age, the difference in the incidence of vertebral fractures in the two groups was greater in the less aged (60-79 years old) than in the more aged (>80 years old) population. The mean number of lumbar vertebral fractures was also significantly greater in the femoral neck fracture group than in the control group (1.59 +/- 1.39 vs 0.75 +/- 1.19; P < 0.001). The incidence of more deformed vertebral fractures, which were defined as a vertebral height loss of more than 50%, was also significantly higher in the group with femoral neck fracture than in the control group (23.0% vs 7.3%). Based on these results, we concluded that multiple and more severely deformed vertebral fractures might represent a high risk for femoral neck fracture, particularly in patients less than 79 years of age. Care measures that encompass fall prevention and protection of proximal femurs in addition to drug therapy for osteoporosis should be recommended to individuals in this category.

Irinotecan (CPT-11) in combination with weekly administration of cisplatin (CDDP) for non-small-cell lung cancer

PURPOSE

CPT-11 (60 mg/m2 on days 1, 8 and 15) in combination with CDDP (80 mg/m2 on day 1) has shown promising antitumor activity for non-small-cell lung cancer (NSCLC), but dose-limiting toxicities (DLT) are leukopenia and diarrhea, with a wide variation among patients. To estimate weekly CDDP administration in combination with CPT-11, a phase I study for patients with advanced NSCLC was conducted.

METHODS

Patients were treated with CPT-11 at a fixed dose of 60 mg/m2 together with CDDP at 27 mg/m2 (level 1, 6 patients), 33 mg/m2 (level 2, 12 patients), and 40 mg/m2 (level 3, 6 patients) with 1600 ml hydration on days 1, 8 and 15 over 4 weeks. During the treatment course, drug was not administered on the day it was due in the presence of leukopenia (< 3000/ml) and/or diarrhea.

RESULTS

The planned administration was completed in 5 of 6 patients at level 1, 6 of 12 patients at level 2, and 2 of 6 patients at level 3. The most common toxicity observed was leukopenia (five patients with grade 3 and one patient with grade 4). Leukopenia was considered to be a DLT, and the maximum tolerated dose (MTD) was level 2. Although there were patients who suffered from diarrhea (four patients with higher than grade 2), diarrhea was judged not to be a DLT with this weekly regimen. Nausea and vomiting were mild. Pharmacokinetic analysis of free platinum from CDDP demonstrated that the area under the curve (AUC) from 33 mg/m2 CDDP was 0.92 +/- 0.29 microg/ml h. In 13 patients evaluated for response, the response rate was 54%.

CONCLUSION

The value of weekly administration of CDDP in combination with CPT-11 was shown by (1) diarrhea not being dose-limiting, (2) mild nausea, (3) well-maintained AUC of free platinum, and (4) promising activity.

[Familial pulmonary arteriovenous malformation diagnostic of the Osler-Weber-Rendu disease]

A 53-year-old woman was admitted to the hospital for investigation of an abnormal shadow in the middle lobe of the right lung on a chest X-ray film. The filling of most of the shadowed area with contrast media on a chest CT scan suggested a vascular lesion. Further investigation by intravenous digital subtraction angiography and color doppler sonography led to the diagnosis of pulmonary arteriovenous malformation. An abdominal CT scan suggested the presence of an arteriovenous malformation in the liver, and a bronchoscopic study revealed telangiectatic lesions on the laryngeal mucosa. The patient's father had died at the age of 61, due to intracranial bleeding, which suggested he might have had an arteriovenous malformation in the brain. The patient's daughter has a pulmonary arteriovenous malformation. This family of vascular malformation indicates that the patient had Osler-Weber-Rendu disease. Osler-Weber-Rendu disease is an autosomal-dominant inherited disorder that may give rise to arteriovenous malformations, mainly in the lungs and the brain. We found that color doppler sonography can be useful for the diagnosis of pleural-based pulmonary arteriovenous malformation.

Malignant lymphoma demonstrating sick sinus syndrome

We report a case of T-cell-rich large B-cell lymphoma demonstrating sick sinus syndrome as a single initial symptom, followed by the retention of pericardial and pleural effusions. Intrapleural administration of interferon-alpha prevented reaccumulation of the pleural effusion for one and a half months, whereas systemic chemotherapy failed to control tumor growth in the skin and lymph nodes. The autopsy revealed involvement of the sinoatrial node of the heart by lymphoma cells.

[Legionella pneumonia caused by aspiration of hot spring water after sarin exposure]

A 72-year-old man was exposed to the sarin gas attack in a Tokyo subway on March 20 th, 1995. After exposure, he noticed eye discomfort, chest tightness, headache and weakness of the lower limbs and oropharyngeal muscles. Despite these symptoms, he visited a hot spring on the same day with his family. On March 25 th, his muscle weakness progressed, and a low grade fever appeared. His muscle weakness disappeared 8 days after exposure to sarin, but respiratory failure rapidly developed, necessitating artificial ventilation within four day after hospitalization on March 28th. Chemotherapy with erythromycin, imipenem/cilastatin, and steroid pulse therapy was begu. PCR and culture of sputum collected by bronchofiberscopy were positive for Legionella pneumophila, serogroup I. His respiratory state improved, but subsequent infection with Pseudomonous aeruginosa. Enterobacter cloacae, and Candida tropicalis/glabrata caused his death 71 days after admission. Oropharyngeal muscle weakness caused by sarin-mediated cholinesterase inhibition was strongly suspected as the cause of hot spring water aspiration. Transbronchial lung biopsy revealed organizing pneumonia with fibrosis. Bronchoscopic findings included redness, edema and fragility of all visible areas of the airway, which was thought to be due to bronchitis caused by Legionellosis.

Tissue-specific and stage-specific expression of two silkworm ecdysone receptor isoforms -- ecdysteroid-dependent transcription in cultured anterior silk glands

Previously, we isolated a cDNA clone for the ecdysone receptor B1 isoform of the silkworm, Bombyx mori (BmEcR-B1). Here we report the cloning of a cDNA that encodes the Bombyx ecdysone receptor A isoform (BmEcR-A) and mRNA expression of the two BmEcR isoforms during molting and metamorphosis. At larval-pupal transformation, mRNA expression of BmEcR-B1 was predominant in most tissues examined, including three larval tissues (midgut, epidermis, and fat body) and the wing imaginal disc. The anterior silk gland was the only tissue where BmEcR-A was predominant. These expression patterns were different from observations demonstrated in Drosophila. In the anterior silk gland, both EcR isoforms were expressed synchronously during the fifth larval instar, while expression of the A isoform preceded that of the B1 isoform by two days in the fourth instar. Precedence of BmEcR-A during the fourth instar and synchronization of both isoforms during the fifth instar were also observed in the middle and posterior silk glands, suggesting that transcription of BmEcR in the silk gland is regulated differently in these two instars. In the cultured anterior silk glands of day 0 of the fifth instar, transcription of BmEcR-A and BmEcR-B1 was induced dose dependently by more than 5 ng/ml 20-hydroxyecdysone. BmEcR-A and BmEcR-B1 mRNAs were induced within 2 h and 1 h, respectively, of the addition of 20-hydroxyecdysone. These results suggest that the increase of BmEcR mRNAs during the fifth instar is induced in vivo by a small increase in ecdysteroids.