Video-assisted blebectomy using a flexible scope and a bleb implement

We describe herein our new technique of performing video-assisted thoracic surgery (VATS) using a flexible scope and a bleb implement which allows for a reduction in the risk of overlooking small and flat blebs in patients with a spontaneous pneumothorax (SP). This technique was performed in 26 consecutive patients with a SP. A skin incision about 18 mm long was made in the area over which the patients had specified preoperatively, and meticulous observation of the apex and superior segment was performed using a bleb implement. Partial pneumonectomy with endoscopic staplers and laser ablation were carried out for pleural lesions. We found that VATS combined with a flexible scope and a bleb implement resulted in better visibility for detection and removal of any small and flat blebs.

Spinal tanycytic ependymomas

Three cases of spinal tanycytic ependymoma are reported, a man aged 45 years and two women aged 36 and 55 years. Each patient developed gradual paraparesis over a few months prior to admission. Magnetic resonance imaging showed an enhancing, well-circumscribed tumor in the spinal cord in each case. Histologically, the tumors consisted of monotonous proliferation of long spindle cells with markedly eosinophilic cell processes; focally forming perivascular pseudorosettes. The tumor cells were strongly immunopositive for glial fibrillary acidic protein, S-100 protein and vimentin. Ultrastructurally, in addition to massive intermediate filaments, many tumor cells showed abundant microtubules. Well-developed desmosomes and microvilli/cilia-lined microlumina were occasionally observed. The tumors were grossly totally removed and the patients remain recurrence free at 9, 9, and 2 years postoperatively. Reviewing reported cases including our three cases, tanycytic ependymoma may occur frequently in spinal cord, especially in the cervical region of the spinal cord. Since histologically it resembles pilocytic astrocytoma and schwannoma, tanycytic ependymoma should be included in the differential diagnosis of benign spindle cell tumors of the central nervous system.

Enlarged median nerve in idiopathic carpal tunnel syndrome

To delineate change in median nerve size in carpal tunnel syndrome (CTS), we compared ultrasonograms of nerve cross-sections from patients (201 wrists of 125 women with idiopathic CTS) and controls (200 dominant wrists of 200 women). Major and minor axes, cross-sectional area, and the flattening ratio (major axis/minor axis) were measured at four levels: 1, distal edge of the flexor retinaculum; 2, center of the hook of the hamate; 3, wrist crease; and 4, distal one-third level of the forearm. Axes and areas were greater in the patients at levels 1, 2, and 3. The flattening ratio was greater in the controls at levels 1 and 2, and in the patients at level 3. When the groups were combined, there were linear correlations between the cross-sectional nerve area and electrophysiologic severity at levels 1, 2, and 3. These findings indicate that idiopathic CTS is characterized by severity-correlated intracarpal enlargement of the median nerve and not by compressive deformation, such as a reduction in the caliber of the nerve.

Ultrasonography in the diagnosis of ulnar tunnel syndrome caused by an occult ganglion

We report a case of ulnar tunnel syndrome caused by an occult ganglion which was diagnosed preoperatively by ultrasonography.

Median nerve compression by a radially inserted palmaris longus tendon after release of the antebrachial fascia: A complication of carpal tunnel release

We describe a case that had recurrent median nerve compression after release of the antebrachial fascia in carpal tunnel release. The nerve was compressed by a palmaris longus tendon that was inserted radially into the thenar fascia. After decompression (detachment of the tendon) the patient had symptom relief. Release of the antebrachial fascia in the presence of this tendon variant carries a risk of median nerve compression by the tendon.

Involvement of polyamines in the chilling tolerance of cucumber cultivars

The possible involvement of polyamines (PAs) in the chilling tolerance of cucumber (Cucumis sativus L. cv Jinchun No. 3 and cv Suyo) was investigated. Plants with the first expanded leaves were exposed to 3 degrees C or 15 degrees C in the dark for 24 h (chilling), and then transferred to 28 degrees C/22 degrees C under a 12-h photoperiod for another 24 h (rewarming). Chilling-tolerant cv Jinchun No. 3 showed a marked increase of free spermidine (Spd) in leaves, once during chilling and again during rewarming. Putrescine increased significantly during rewarming, but the increase of spermine was slight. Any of these PAs did not increase in chilling-sensitive cv Suyo during either period. PA-biosynthetic enzyme activities appear to mediate these differences between cultivars. Pretreatment of Spd to cv Suyo prevented chill-induced increases in the contents of hydrogen peroxide in leaves and activities of NADPH oxidases and NADPH-dependent superoxide generation in microsomes and alleviated chilling injury. Pretreatment of methylglyoxal-bis-(guanylhydrazone), a PA biosynthesis inhibitor, to chilled cv Jinchun No. 3 prevented Spd increase and enhanced microsomal NADPH oxidase activity and chilling injury. The results suggest that Spd plays important roles in chilling tolerance of cucumber, probably through prevention of chill-induced activation of NADPH oxidases in microsomes.

[Preoperative bronchial arterial infusion of docetaxel for squamous cell carcinoma of the lung--clinical evaluation and correlation between anti-tumor effect and apoptosis]

As an induction therapy for advanced lung cancer, a patient received bronchial arterial infusion of 30 mg/m2 of docetaxel (TXT). Two weeks after infusion, although the tumor size was not reduced, the central necrotic area was significantly increased. There were no adverse effects. Nineteen days after infusion, we performed a right lower lobectomy and lymph nodal dissection. The resected specimen was examined by immunohistochemistry and biochemistry. The anti-tumor effects were evaluated clinically and the correlation between arterial TXT infusion therapy and apoptosis was studied. Hematoxylin and eosin staining demonstrated moderately differentiated squamous cell carcinoma associated with central necrosis, and cells with chromatin condensation scattered in both the necrotic areas and the margin of this area. It is thought that these findings were the result of this therapy, rather than just the self-necrosis seen in an untreated group.

Characterization of a bioflocculant produced by Citrobacter sp. TKF04 from acetic and propionic acids

A bacterial strain, TKF04, capable of producing a bioflocculant from acetic and/or propionic acids was isolated from a biofilm formed in inside a kitchen drain. It was identified as a Citrobacter based on its morphological and physiological characteristics and the partial sequences of its 16S rRNA. TKF04 produced the bioflocculant during the logarithmic phase of growth, and the optimum temperature and pH for the bioflocculant production were 30 degrees C and 7.2-10.0, respectively. It could utilize some organic acids and sugars for its growth as the sole carbon sources when yeast extract was supplemented; however, only acetate and propionate were found to be good substrates for the bioflocculant production. The crude bioflocculant could be recovered from the supernatant of the culture broth by ethanol precipitation and dialysis against deionized water. It was found to be effective for flocculation of a kaolin suspension, when added at a final concentration of 1-10 mg/l, over a wide range of pHs (2-8) and temperatures (approximately 3-95 degrees C), while the co-presence of cations (Na+, K+, Ca2+, Mg2+, Fe2+, Al3+ or Fe3+) did not enhance the flocculating activity. It could efficiently flocculate a variety of inorganic and organic suspended particles, including kaolin, diatomite, bentonite, activated carbon, soil and activated sludge. It contained glucosamine as the major component, and the molecular weight was estimated to be between 232 and 440 kDa by gel filtration. The observation that the flocculating activity was completely lost following chitinase treatment and its analysis with a Fourier transform infrared spectrometer suggested that the bioflocculant is a biopolymer structurally-similar to chitin or chitosan.

Expression of endothelin-1 in rats developing hypobaric hypoxia-induced pulmonary hypertension

Experimental pulmonary hypertension induced in a hypobaric hypoxic environment (HHE) is characterized by structural remodeling of the heart and pulmonary arteries. Endothelin-1 (ET-1), a 21-amino acid peptide, is a novel and long-lasting vasoconstrictor that increases pulmonary arterial pressure in both in vivo and in vitro experiments. To study the effects of HHE on ET-1 activity in the lungs, 59 male rats were subjected to the equivalent of an altitude of 5500 m for 1 to 4 weeks. In rats exposed to HHE, the mean pulmonary arterial pressure increased significantly from 15.2+/-0.3 (ground level) to 30.6+/-1.5 mm Hg (5500-m level) at 4 weeks, whereas their mean systemic arterial pressure remained normal. The levels of ET-1 mRNA and protein, measured respectively by Northern blot analysis and enzyme immunoassay, increased rapidly in the lungs on exposure to HHE. By in situ hybridization and immunohistochemistry, respectively, ET-1 mRNA and protein were detected in control rats in nonciliated bronchiolar epithelial cells and alveolar epithelial cells, as well as in the endothelial cells of pulmonary arteries, but minimally in the smooth muscle cells of pulmonary arteries. ET-1 mRNA- and protein-reactive smooth muscle cells in pulmonary arteries and ET-1 mRNA-reactive airway epithelial cells were significantly more abundant in rats exposed to HHE than in ground level controls. These results suggest the possibility that in smooth muscle cells in pulmonary arteries and airway epithelial cells, ET-1 may play an autocrine or paracrine role in the remodeling of blood vessels during the development of the pulmonary hypertension that is induced by HHE.

Determination of a novel calmodulin antagonist, 3-[2-[4-(3-chloro-2-methylphenyl)-1-piperazinyl]ethyl]-5,6-dimethoxy-1- (4-imidazolylmethyl)-1H-indazole dihydrochloride 3.5 hydrate, DY-9760e, in human plasma using solid-phase extraction and high-performance liquid chromatography with fluorescence detection

A high-performance liquid chromatographic method for the determination of a novel calmodulin antagonist, 3-[2-[4-(3-chloro-2-methylphenyl)-1-piperazinyl]ethyl]-5,6-dimethoxy-1-( 4-imidazolylmethyl)-1H-indazole dihydrochloride 3.5 hydrate, DY-9760e and its major metabolite, 3-[2-[4-(3-chloro-2-methylphenyl)-1-piperazinyl]ethyl]-5,6-dimethoxyi ndazole, DY-9836 in human plasma has been developed. DY-9760e, DY-9836 and the internal standard (I.S.) were extracted from plasma by means of an Isolute C18 (EC) column. The extracts were chromatographed on a reversed-phase TSK-gel ODS-80Ts column using 0.1 M acetate buffer (pH 5)-CH3CN (65:35, v/v) as the mobile phase at a flow-rate of 1.0 ml/min. Fluorescence detection at an excitation wavelength of 303 nm and an emission wavelength of 347 nm resulted in a limit of quantitation of 1.000 ng/ml for plasma. The method showed satisfactory sensitivity, precision, accuracy, recovery and selectivity. Stability studies showed that DY-9760 and DY-9836 were stable in plasma up to at least eight weeks at -80 degrees C.

[Application of ultrasound energy as a new drug delivery system]

Ultrasound is frequently used in medicine for diagnostic purposes. Recently, there have been numerous reports on application of ultrasound energy for controlling drug release or targeting. This new concept of therapeutic ultrasound combined with drugs has induced excitement in various areas. Ultrasound energy can enhance effects of thrombolytic agents as urokinase. Ultrasound emitting catheters are currently being developed for cardiovascular diseases. Device with ultrasound transducers implanted in transdermal drug patches are also being evaluated for possible delivery of insulin through the skin. Chemical activation of drugs by ultrasound energy for treatment of cancers is another new field recently termed as "Sonodynamic Therapy". Various examples of application of ultrasound for drug delivery systems are discussed.

The outer membrane protein I of Pseudomonas aeruginosa PAO1, a possible pollutant of dialysate in hemodialysis, induces cytokines in mouse bone marrow cells

The finding of outer membrane protein I (OprI) of Pseudomonas aeruginosa in hemodialyzers used by patients with end-stage renal failure led us to study the possible role of OprI as cytokine inducer. However, there are few reports on the biological activity of OprI, because it is difficult to obtain highly purified OprI. In this study, we attempt to establish a procedure for the efficient purification of OprI, which does not include lipopolysaccharide, from the bacterial culture broth, not hemodialyzers, to demonstrate that OprI is a potent cytokine inducer. From bacterial culture broth (1 liter), P. aeruginosa PAO1, which was confirmed previously by the sequence coding, was separated by centrifugation, high-performance liquid chromatography, and disk electrophoresis. Mouse bone marrow cells were stimulated by purified OprI, and the supernatants of the culture were analyzed by several enzyme-linked immunosorbent assay kits. The tumor necrosis factor alpha production stimulated by purified OprI was confirmed and degraded within 24 h. Furthermore, interleukin (IL) 1alpha, IL-1beta, IL-6, and granulocyte-macrophage colony-stimulating factor were also induced by OprI despite the absence of lipopolysaccharide. We conclude that OprI has the potential to induce tumor necrosis factor alpha production in mouse bone marrow cells and that tumor necrosis factor alpha contributes to the induction of inflammatory cytokines, namely IL-1alpha, IL-1beta, IL-6, and granulocyte/macrophage colony-stimulating factor, while lipopolysaccharide has little effect on these cells. These results suggest the presence of a pathway of inflammatory signal transduction triggered by OprI. In addition, OprI is possibly one of the harmful dialysate pollutants in hemodialysis patients besides the well-known lipopolysaccharide.

Insufficiency fracture of the femoral neck after intramedullary nailing

We report a patient with insufficiency fracture that occurred after intramedullary nailing for a subtrochanteric fracture. Intramedullary nailing is speculated to have increased the stress in the already osteoporotic subcapital region. It therefore should be recognized as a causative factor in insufficiency fracture of the femoral neck. Careful follow-up is needed for patients with this condition.

Identification of human, rat and mouse nocistatin in brain and human nocistatin in brain and human cerebrospinal fluid

Nocistatin was recently isolated from bovine brain and shown to block hyperalgesia and allodynia induced by nociceptin and prostaglandin (PG) E2. The counterparts of human, rat and mouse are deduced from their precursor prepronociceptin to be 30, 35, and 41 residue peptide respectively. To identify these mature forms of nocistatin, three peptides were synthesized and a detection program for nocistatin was developed, using high pressure liquid chromatography (HPLC) along with specific radioimmunoassay (RIA). Nocistatin extracted from human, rat and mouse brain were subjected to HPLC and nocistatin-like immunoreactivity (NST-IR) was determined. All three species showed two NST-IR peaks, one of which coincided with that of the corresponding putative nocistatin. The same NST-IR was also detected in human cerebrospinal fluid (CSF).

[Examination of the stability of chloral hydrate and its preparation by capillary electrophoresis]

Stabilities of chloral hydrate in an aqueous solution and its medicated syrup were examined by high performance capillary electrophoresis. Analysis of the concentration of chloral hydrate indicated that there was no obvious change in the concentration of chloral hydrate both in the aqueous solution and in the syrup preparation after keeping them for 3 months at room temperature or at 60 degrees C. The lowering of pH was more obvious in the syrup solution than in the aqueous solution, and this tendency was estimated to be due to the formation of hydrochloric acid. We propose that the stabilities of the preparation of chloral hydrate should be monitored by observing pH changes.

Lumbar spinal subdural hematoma following craniotomy--case report

A 52-year-old female complained of lumbago and weakness in the lower extremities 6 days after craniotomy for clipping an aneurysm. Neurological examination revealed symptoms consistent with lumbosacral cauda equina compression. The symptoms affecting the lower extremities spontaneously disappeared within 3 days. Magnetic resonance (MR) imaging 10 days after the operation demonstrated a lumbar spinal subdural hematoma (SSH). She had no risk factor for bleeding at this site, the symptoms appeared after she began to walk, and MR imaging suggested the SSH was subacute. Therefore, the SSH was probably due to downward movement of blood from the cranial subdural space under the influence of gravity. SSH as a complication of cranial surgery is rare, but should be considered if a patient develops symptoms consistent with a lumbar SSH after craniotomy.

[Two surgical cases of intrathoracic lipoma]

We experienced two cases of intrathoracic lipoma arising from the chest wall. The first case was a 55-year-old male, and another case was a 70-year-old female. In the second case, the computed tomography was highly suggestive of a pleural tumor with almost same density as the subcutaneous adipose tissue. This findings may be diagnostic in assessing intrathoracic chest wall type lipoma. Both cases had thoracotomy to remove the tumors. The tumors were easily resectable, though their capsules were partially unclear. We resected the tumors completely together with pleura, periosteum and intercostal muscle. The diagnosis of intramuscular lipoma was confirmed postoperatively by histopathologic examination in each case. When the capsule of lipoma is not clear, combined resection of the tumor and chest wall should be considered. There have been no recurrence of the tumors in our cases.

Association of head trauma with cervical spine injury, spinal cord injury, or both

BACKGROUND

Links between cervical spine and/or spinal cord injuries and head trauma have not been reported in detail.

METHODS

188 patients with cervical spine and/or spinal cord injury were divided into two groups, i.e., with upper cervical and mid-lower cervical injury, and compared for head injury.

RESULTS

Associated head trauma was investigated in 188 patients with cervical spine and/or spinal cord injuries; 35% had moderate or severe injuries. Brain damage was more frequently observed in patients with upper cervical injury than in those with mid to lower cervical injury. Those patients with upper cervical injury appeared to have an elevated risk of suffering skull base fractures, traumatic subarachnoid hemorrhage, and contusional hemotoma.

CONCLUSIONS

Approximately one third of patients with cervical spine and/or spinal cord injuries had moderate or severe head injuries. Brain damage was more frequently associated with upper cervical injury. Those patients with upper cervical injury are at greater risk of suffering from skull base fractures and severe intracranial hematomas than those with mid to lower cervical injury.

[A case of rheumatoid arthritis with bucillamine-induced myasthenia gravis treated by immunoadsorption therapy]

We report a case of 48-year old female with rheumatoid arthritis (RA) complicated with myasthenia gravis. In 1988, she was diagnosed of having RA, and several therapeutic drugs were administered, but her disease activity was in poor control. In July 1993, bucillamine (BU) was started at a dose of 100 mg/day, and her arthritis subsided. However, in October 1996, she was admitted with a rapidly progressive ptosis and double vision in the left eye, which became prominent in the evening. Because serum concentration of the antibody to acetylcholine receptors (AchR Ab) was elevated at 12.6 nmol/l, and the ptosis was reversed immediately after a tensilon test, ocular type myasthenia gravis (MG) was diagnosed and it was thought to have been induced by BU. Immunoadsorption therapy was started after discontinuation of this drug, and was continued for 6 months, resulting in improvement of neurological symptoms and decrease in AchR Ab level. MG has not recurred since. Although several cases of D-penicillamine (DP) induced MG are reported, only two cases are reported which were induced by BU, sulfhydryl compound which has a structure similar to DP. Since BU has been widely used as one of the disease modifying anti-rheumatic drugs in Japan, MG induced by this drug should be paid attention as one of the adverse effects.

Innervation and reinnervation of cricothyroid muscle in the rabbit

The m. cricothyroideus of the rabbit is innervated by two motor nerves (n. laryngeus superior and n. laryngeus medius). No indication of extensive polyneuronal innervation was found in gold stained isolated muscle fibers and groups of fibers. Double end plates were found on about 2.5% of the fibers. It could not be ascertained whether they were supplied by different motor fibers or by branches of the same fiber. Intracellularly recorded spike potentials were observed in the same muscle fiber by stimulation of the two motor nerves in 6% of the fibers examined. The use of intracellular recording as a criterion for polyneuronal innervation was discussed. After resection of the n. laryngeus medius a fargoing reinnervation of the muscle by the n. laryngeus superior takes place.

Histology of the transverse carpal ligament and flexor tenosynovium in idiopathic carpal tunnel syndrome

Histology of the transverse carpal ligament and flexor tenosynovium was investigated in 166 wrists from 130 patients with idiopathic carpal tunnel syndrome. Nine wrists from 9 controls were used for comparison. In the patients, 73.5% of the ligament and 56.0% of the tenosynovium showed normal histology. In the remaining specimens, the ligament showed mucoid change (17.5%), amyloid deposits (7.8%), inflammation (3.0%), and chondrometaplasia (2.4%), and the tenosynovium showed fibrosis (25.3%), edema (7.2%), inflammation (10.2%), amyloid deposits (8.4%), and vascular hypertrophy (4.8%). The majority of these changes were mild in degree and the pathophysiology did not appear to be meaningful. We conclude that in idiopathic carpal tunnel syndrome, the ligament and tenosynovium often show normal histology and there are no typical or consistent changes with which idiopathic carpal tunnel syndrome can be associated.

Iatrogenic injury of the spinal accessory nerve. Results of repair

We reviewed the results of repair of the spinal accessory nerve in seven patients seen between September 1994 and January 1996. The nerve had been injured during biopsy of a cervical lymph node in six patients and during removal of a bullet in one. The average interval between the time of the injury and the repair of the nerve was eight months (range, three to fourteen months). An end-to-end repair of the nerve was performed in six patients, and a neurolysis was done in one. The average duration of follow-up was thirty-two months (range, twenty-four to thirty-nine months). Postoperatively, all seven patients had relief of pain and stiffness in the shoulder girdle. Manual muscle-testing revealed normal strength of the trapezius, which was comparable with that on the unaffected side. Four patients regained normal function of the shoulder. Three patients reported a stretching sensation or discomfort in the neck, periscapular discomfort, and fatigue of the extremity when lifting heavy objects or performing overhead activities. However, these residual symptoms were mild and tolerable and thus were different in nature from the preoperative pain and stiffness. Iatrogenic injury of the spinal accessory nerve should be suspected if a patient has pain or stiffness in the shoulder girdle and a history of a recent operation on the neck. The nerve should be explored if spontaneous recovery does not occur.

Distance between the median nerve and ulnar neurovascular bundle: clinical significance with ultrasonographically assisted carpal tunnel release

In ultrasonographically assisted carpal tunnel release, the zone of the transverse carpal ligament between the median nerve and ulnar neurovascular bundle is of significance because proximity of the cutting device to these structures depends on its width. In this study, we measured the width of the zone at 5 levels in 60 wrists from 54 patients with surgery-indicated idiopathic carpal tunnel syndrome. The width of the 5 levels ranged from 2.8 to 11.2 mm (mean, 7.1 mm) at the hook of the hamate, 3.0 to 12.5 mm (mean, 7.9 mm) at the distal one fourth of the carpal tunnel, 2.8 to 12.4 mm (mean, 8.0 mm) at the midsection of the tunnel, 1.5 to 13.0 mm (mean, 7.4 mm) at the proximal one fourth of the tunnel, and 5.3 to 17.2 mm (mean, 10.2 mm) at the wrist crease. These widths were not significantly correlated with radiographic measurements of the hand (cord of the radiocarpal joint arc, carpal height, third metacarpal, and hand length). We conclude that there is considerable variation of the width among individuals. Based on our clinical experience (3 wrists of 3 patients in this study), patients with a width of < or =3 mm at any level should be screened out preoperatively by wrist imaging. Our findings also may be of use to surgeons performing endoscopic carpal tunnel release.

Clinical and neuroimaging features of Chiari type I malformations with and without associated syringomyelia

The clinical and neuroimaging characteristics of 22 consecutive patients with Chiari type I malformations were evaluated to investigate the pathogenesis of syrinx formation. All patients underwent magnetic resonance imaging and x-ray tomography before surgery. The electric manometric Queckenstedt test was performed on 16 patients pre- and postoperatively. Syringomyelia was present in 17 patients and absent in five patients. All patients without syringomyelia suffered from foramen magnum compression syndrome, with a wider basal angle, more acute clivo-axial angle, shorter clivus, and more prominent tonsillar ectopia than patients with syringomyelia. Low brain stem position, basilar impression, and beaking of the cervicomedullary junction were also more prominent in patients without syringomyelia. Marked to complete block with the neck in flexed position by Queckenstedt test was present in all patients except one. Patients with Chiari malformation not associated with syringomyelia have more pronounced compression of the brain stem at the foramen magnum. Therefore, despite a block of the cerebrospinal fluid pathway at the foramen magnum, syrinx formation may be prevented by severe compression.