Volume manipulation by phlebotomy for cesarean section in a patient with pulmonary hypertension

Pulmonary hypertension in a parturient is known for its high perioperative mortality. We describe a successful case of cesarean section performed under general anesthesia in a parturient with pulmonary hypertension. A distinctive feature of our management was active blood volume manipulation by phlebotomy and reinfusion of the blood. Just after the baby was delivered, about 250 ml of blood was phlebotomized to counteract autotransfusion by the contracting uterus. We stopped phlebotomy at this volume because moderate systemic hypotension occurred. The blood was slowly infused, with transesophageal echocardiography used to evaluate right ventricle filling. The patient was hemodynamically stable during the operation and had an uneventful postpartum period. Her baby's perioperative course was also uneventful.

Impact of double-balloon endoscopy on the diagnosis of jejunoileal involvement in primary intestinal follicular lymphomas: a case series

In recent years, primary gastrointestinal follicular lymphoma has been increasingly detected in the duodenum on esophagogastroduodenoscopy (EGD). Primary gastrointestinal follicular lymphomas are frequently distributed to multiple sites in the gastrointestinal tract. Therefore, investigation into the spread of follicular lymphomas in the small bowel is important in order to determine the most appropriate treatment strategy. The performance of double-balloon endoscopy (DBE) in the diagnosis of jejunoileal follicular lymphoma lesions has not been fully evaluated. We aimed to investigate the value of DBE in addition to computed tomography (CT) and (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG-PET) in the diagnosis of jejunoileal follicular lymphoma. DBE with biopsy was performed in seven patients with primary duodenal follicular lymphoma diagnosed by EGD, in order to investigate jejunoileal involvement. Jejunoileal follicular lymphoma lesions were detected by DBE in six out of the seven patients (three in the jejunum and three in the jejunum and ileum), whereas CT and (18)F-FDG-PET failed to detect the existence of these lesions. Endoscopic findings of the jejunoileal lesions revealed multiple white nodules and white villi, which were similar to those of duodenal lesions. DBE was more useful for the diagnosis of jejunoileal involvement in primary intestinal follicular lymphoma than CT and (18)F-FDG-PET. The use of DBE will become important for determining the most appropriate treatment for gastrointestinal follicular lymphoma.

Parkinsonism with organophosphate poisoning

Parkinsonism is a primary neurotoxic manifestation of organophosphate pesticide intoxication. We report here the case of a 67-year-old man who developed acute parkinsonism with tremors and rigidity following exposure to fenitrothion, an organophosphate pesticide. His parkinsonism disappeared, and 2 months later he was able to walk alone without antiparkinsonian drug treatment. To identify particular lesions in the brain, Z score images were obtained from SPECT (single photon emission computed tomography) scans of the patient during the acute poisoning and a follow-up scan performed 2 months later. We indicate that reversible parkinsonism correlated with putaminal hyperperfusion as observed in the Z score images obtained during the acute event; this condition resolved later in concert with resolution of the clinical parkinsonism. We believe that the SPECT scan Z score images in this study are an important find in elucidating parkinsonism manifestations due to organophosphate poisoning.

Vascular endothelial growth factor in monochorionic twins with twin-twin transfusion syndrome

OBJECTIVE

The purpose of this study was to determine vascular endothelial growth factor (VEGF) concentrations in the donor and the recipient in monochorionic twin pregnancies with twin-twin transfusion syndrome (TTTS) and single pregnancies in order to investigate the involvement of VEGF in the pathophysiology of TTTS.

METHODS

Six twin pregnancies in 11 monochorionic twin pregnancies complicated with TTTS and 11 single control pregnancies were compared. Gestational age-matched fetal blood and placental samples were obtained at birth. Serum VEGF concentration in the umbilical vein was measured by an enzyme-linked immunoabsorbant assay. Tissue protein expression of VEGF was determined by using immunohistochemistry. Western blot analysis and scanning densitometry were used to quantify and compare the VEGF expression in the terminal villi.

RESULTS

Serum VEGF concentrations in the umbilical vein in both donors and recipients tended to be higher than those in the controls. Immunolocalization of VEGF in terminal villous placenta samples in both donors and recipients was mainly observed in the syncytiotrophoblastic layer and vascular endothelial cells with less intense staining in stromal cells. The expression of VEGF in the donor placenta increased significantly (p=0.006) compared to that in the control placenta, but the expression of VEGF in the recipients tended to be higher than in the controls.

CONCLUSION

Intrauterine circulatory imbalance may induce changes in VEGF expression and these alterations may be involved in both donor and recipient in the pathogenesis of TTTS, due to the maintenance of hemodynamic stability between the circulation of the twins.

Prolonged sevoflurane inhalation therapy for status asthmaticus in an infant

A 3-month-old boy with retractive breathing from his birth was scheduled for a rigid bronchoscopic examination. Anesthesia was induced and maintained with sevoflurane. The examination revealed a slight laryngomalacia which was not compatible with his severe symptom. During the procedure, no respiratory deterioration occurred. He was once extubated in the operating room, however, developed severe desaturation immediately. He was reintubated at the scene and returned to the ward being mechanically ventilated and sedated. The next day, his respiratory condition worsened gradually. Conventional drugs including theophylline, corticosteroid and beta adrenergic agonist did not improve his deleterious condition. He became bradycardic and was on the verge of circulatory collapse as his lungs were unable to ventilate. Then, we commenced inhalation of sevoflurane using a standard anesthesia machine, which relieved him from ventilatory crisis. Although there were some difficulties in using anesthesia machine in the ICU, we could successfully manage mechanical ventilation. After the beginning of sevoflurane inhalation, his condition improved gradually. Discontinuation of sevoflurane was difficult and it took 94 h to wean from sevoflurane inhalation. Despite long duration of inhalation, no adverse effects of sevoflurane were observed except transient mild increase in liver transaminase. There have been very few reports on application of sevoflurane inhalation for such a long period in infants with bronchospasm. Moreover, measured serum fluoride concentration (24.2 micromol x l(-1)) during inhalation was well below harmful level. Sevoflurane inhalation is worth attempting and safe to treat life-threatening bronchospasm even in infants.

Spinal anterior horn cells in sporadic amyotrophic lateral sclerosis show ribosomal detachment from, and cisternal distention of the rough endoplasmic reticulum

AIMS

Sporadic amyotrophic lateral sclerosis (ALS) is a progressive and invariably fatal disease involving the upper and lower motor neurones of adult humans. Among the neuropathological features of the disease, abnormalities in the protein-synthesizing system in motor neurones of the brainstem and spinal cord, such as a decrease of cytoplasmic RNA and rough endoplasmic reticulum (rER) (chromatolysis), defective editing of the Q/R site of the glutamate receptor subunit GluR2 mRNA, fragmentation of the Golgi apparatus and accumulation of ubiquitinated inclusions and abnormal TdP-43 protein have been reported to be essential for the degeneration. In relation to these features, although the possibility of ER stress has been reported in motor neurones of the brainstem and spinal cord of ALS patients, the rER itself has not been a main target of ultrastructural investigation.

METHODS

The present study examined the rER, ultrastructurally and quantitatively in the spinal anterior horn cells (AHCs) of 21 Japanese patients with sporadic ALS and eight Japanese control subjects.

RESULTS AND CONCLUSIONS

It was found that: (i) the rER cisternae in AHCs showing central chromatolysis were fragmented, but retained their width and had normally attached ribosomes, and (ii) the rER cisternae in shrunken AHCs were irregularly distended with detachment of the ribosomes, thus suggesting that (iii) ribosomal detachment was related to rER distention.

Symmetric temporal abnormalities on MR imaging in amyotrophic lateral sclerosis with dementia

BACKGROUND AND PURPOSE

Our aim was to clarify imaging findings of amyotrophic lateral sclerosis with dementia (ALSD).

MATERIALS AND METHODS

T2-weighted MR images (T2WI) of 3 patients with ALSD (2 men, 1 woman; 58-71 years of age) and 21 patients with ALS without dementia (12 men, 9 women; 46-74 years of age) were examined for frontotemporal lobar atrophy and signal-intensity alterations in the white matter of the anterior temporal lobes, corticospinal tracts (CST), and precentral gyri and in precentral cortices. The brain of one of the patients with ALSD was examined at autopsy.

RESULTS

All patients with ALSD showed bilateral frontotemporal atrophy mostly with temporal lobe dominance. In the ALSD group, T2WI demonstrated hyperintensity in the subcortical white matter on the medial side of the anterior temporal lobes, whereas in the group without dementia, none showed this imaging finding. MR images demonstrated no abnormal signal-intensity changes in CST in the internal capsule or the brain stem in the ALSD group. In the group without dementia, 6 patients (28.6%) showed this imaging finding. In neuropathologic examinations of the brain of 1 patient with ALSD, myelin-stained sections of the brain demonstrated loss of myelin in the subcortical white matter on the medial side of the anterior temporal white matter.

CONCLUSIONS

A symmetric pattern of frontotemporal atrophy and anteromedial subcortical hyperintensities in the temporal lobes on T2WI could be characteristic of ALSD.

Effects of cilostazol on cerebral blood flow, P300, and serum lipid levels in the chronic stage of cerebral infarction

The effects of cilostazol (Pletaal, Otsuka Pharmaceutical Co., Tokyo, Japan) on cerebral blood flow, P300 event-related potentials, and serum lipid levels were examined in patients in the chronic stage of cerebral infarction. This study included 20 patients (13 men and 7 women, mean age 67 +/- 11 years) with cerebral infarction who had taken ticlopidine (100 mg orally, twice a day). Quantitative cerebral blood flow measurements by Patlak plot analysis, ultrasound examinations of the common carotid arteries, and measurements of P300 event-related potentials and serum lipid levels were performed. Ticlopidine was then replaced with cilostazol (100 mg orally, twice a day) while other medications remained unchanged. The same examinations were performed again 3 months later. After replacement of ticlopidine with cilostazol, cerebral blood flow significantly increased in the frontal white matter, temporal cortex, and occipital cortex compared with cerebral blood flow before replacement with cilostazol. Ultrasonograms of the common carotid arteries showed no significant differences in intima-media thickness before and after replacement. However, peak systolic velocity, time-averaged peak velocity, and volume flow all significantly increased after replacement. Blood flow in the frontal white matter showed a significant negative correlation with P300 latency before and after replacement of ticlopidine with cilostazol. And P300 latency improved significantly after replacement with cilostazol. Regarding lipid levels, total cholesterol, triglycerides, and remnant-like particles-cholesterol all decreased significantly after replacement with cilostazol. Cilostazol, an inhibitor of platelet aggregation, was thus concluded to be effective in improving cerebral blood flow, cerebral function, and serum lipid levels in patients in the chronic stage of cerebral infarction.

Phase II study of ifosfamide, carboplatin and etoposide (ICE) in recurrent glioblastoma

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Background: To evaluate the efficacy and tolerability of ifosfamide, carboplatin and etoposide ( ICE ) in patients with recurrent glioblastoma. Methods: This was an open-label, single-center phase II trial. Forty-two patients with first recurrent glioblastoma after surgery, standard radiotherapy and a first-line temozolomide-based or ACNU-based chemotherapy, were enrolled.The primary endpoint was progression-free survival at 6 months ( PFS-6 ), and secondary endpoints were response rate, toxicity, and survival. Chemotherapy consisted of Ifosfamide ( 700 mg / m2 on day 1, 2 and 3 ), carbopaltin ( 100 mg / m2 on day 1 ), etoposide ( 70 mg / m2 on day 1, 2, and 3 ), every 6 weeks. Results: PFS-6 was 37 %. The median PFS was 17 weeks. Response rate was 27 %. Adverse events were generally mild ( grade 1 or 2 ) and consisted mainly of alopecia. Conclusions: This regimen is well tolerated and has activity in patients with recurrent glioblastoma.

No significant financial relationships to disclose.

Signal transduction in SARS-CoV-infected cells

abstract: Severe acute respiratory syndrome (SARS) is a newly found infectious disease that is caused by a novel human coronavirus, SARS coronavirus (SARS‐CoV). Because the mortality rate of SARS patients is very high, understanding the pathological mechanisms of SARS not only in vivo but in vitro is important for the prevention of SARS. Activation of signaling pathways caused by SARS‐CoV infection leads to the phosphorylation and activation of downstream molecules. Two conflicting cellular programs, apoptosis to eliminate virus‐infected cells and survival to delay apoptosis by producing antiviral cytokines, occur in SARS patients. Recent studies regarding SARS and SARS‐CoV have clarified that activation of mitogen‐activated protein kinases (MAPKs) plays important roles in upregulation of cytokine expression and apoptosis both in vitro and in vivo. Both Akt and p38 MAPK are keys for determination of cell survival or death in SARS‐CoV‐infected cells in vitro. Agents being developed to target these signaling cascades may be important for the design of anti‐SARS‐CoV drugs. This review highlights recent progress regarding SARS‐CoV biology, especially signal transduction in SARS‐CoV‐infected cells.

An improved procedure for rapid determination of viral RNA sequences of avian RNA viruses

A system for rapid determination of viral RNA sequences, RDV, was improved for detection of avian RNA virus in allantoic fluids. We detected avian paramyxovirus nucleotide sequences using RDV method ver 2.0.

Three-dimensional analysis of pathological characteristics of a microaneurysm

The etiology of Charcot-Bouchard microaneurysms (MAs), especially before rupture, has been unclear.

CASE REPORT

A surgical specimen of an MA was removed from an acute intracerebral hemorrhage in a 69-year-old man. The MA was fixed with formalin and embedded in paraffin, and serial sections were cut and stained by the Azan and Elastica van Gieson methods and immunohistochemically. Three-dimensional reconstructive analysis was performed.

RESULTS AND DISCUSSION

The MA presented as local enlargement of an artery with a maximal diameter of 840 microm, but was not ruptured. The wall of the MA consisted of thickened, fine collagen fibrils, which were found to be similar to adventitia immunohistochemically, but with no internal elastic lamina or medial smooth muscle layer. The lumen was empty, with no mural thrombi, but the inner wall endothelial cells had expanded from the normal and/or residual arterial wall, which suggested that the MA had been present for a long period of time. Because the bare wall of the MA consisted of thickened collagen fibrils, the MA was not ruptured, but the possibility of rupture in the future was deemed high, with the risk of intracerebral hemorrhage.

Enhancement of cytotoxicity against Vero E6 cells persistently infected with SARS-CoV by Mycoplasma fermentans

We previously reported that cells with persistent severe acute respiratory syndrome coronavirus (SARS-CoV) infection were established after apoptotic events. In the present study, we investigated the cytopathic effects of dual infection with SARS-CoV and Mycoplasma fermentans on Vero E6 cells. Dual infection completely killed cells and prevented the establishment of persistent SARS-CoV infection. M. fermentans induced inhibition of cell proliferation, but the cells remained alive. Apoptosis was induced easily in M. fermentans-infected cells, indicating that they were primed for apoptosis. These results indicated that M. fermentans enhances apoptosis in surviving cells that have escaped from SARS-CoV-induced apoptosis.

Prolonged use of dexmedetomidine in an infant with respiratory failure following living donor liver transplantation

We used dexmedetomidine for more than 2 months in a mechanically ventilated infant without serious adverse effects. An infant with liver cirrhosis of unknown cause underwent living donor liver transplantation at the age of 9 months. Long-term mechanical ventilation was required postoperatively, and midazolam with fentanyl had been used to sedate the patient. They required increase to 1.7 mg.kg(-1).h(-1) and 3.5 microg.kg(-1).h(-1), respectively, which were still inadequate. On postoperative day 29, dexmedetomidine was added. The rate of dexmedetomidine infusion was increased gradually to 1.4 microg.kg(-1).h(-1). It was discontinued temporarily to exclude drug-induced liver dysfunction. However, without dexmedetomidine, adequate sedation level was unattainable. Liver dysfunction was likely to be attributed to cytomegalovirus infection and after restarting dexmedetomidine, the respiratory condition improved. He was extubated 10 weeks after the operation. Dexmedetomidine was successfully tapered off over the following 2 weeks with no signs of withdrawal. Dexmedetomidine was a useful sedative for an infant who required mechanical ventilation for a prolonged period of time.

Comparison of the utility of sympathetic skin response and current perception threshold examinations with conventional examinations for the early electrophysiological diagnosis of diabetic polyneuropathy

We compared the utility of sympathetic skin response (SSR) and current perception threshold (CPT) with that of conventional electrophysiological examinations like sural sensory conduction velocity, sensory nerve action potential (SNAP), peroneal motor conduction velocity, compound muscle action potentials, and F-wave latency. Twenty-two type II diabetic patients (mean age, 69.6 years) without sensory symptoms and with a mean glycosylated hemoglobin (HbA1c) level of 7.1%, along with 26 age-matched control patients, were examined. Among the conventional examinations, only the sural SNAP was considerably (although not significantly) depressed in the diabetic group. On the other hand, the mean SSR amplitude in the diabetic group was approximately half of the value in the control group. All the CPT values were also considerably lower in the diabetic group than in the control group, although only the values for hand stimulation at 2000 and 250 Hz were significant. No correlations were observed between the SSR amplitudes and the CPT values at any of the test frequencies. However, a positive correlation between the mean HbA1c level and the CPT value was seen at all frequencies. We concluded that SSR amplitude measurements are superior to conventional examinations and CPT studies with regard to the early electrophysiological diagnosis of diabetic polyneuropathy. Furthermore, CPT values may be useful as an electrophysiological surrogate indicator of recent glycemic control.

Respiratory failure due to morbid obesity in a patient with Prader-Willi syndrome: an experience of long-term mechanical ventilation

Prader-Willi syndrome (PWS) is characterized by obesity, mild mental retardation or learning disability, and behavior problems, especially in association with food and eating. A 19 year-old man, 150 cm, 140 kg (body mass index [BMI], 62.2 kg.m(-2)), whose condition had been diagnosed as PWS, received 41-day mechanical ventilation because of respiratory failure, chiefly due to morbid obesity. Because the patient frequently developed bronchoconstriction, metered-dose inhalers of a corticosteroid (beclomethasone dipropionate) and a beta2 agonist (salbutamol) were needed. To achieve adequate sedation, which was also crucial to control the bronchoconstriction, the concurrent use of midazolam, fentanyl, ketamine, and propofol was required. Pressure-control ventilation was useful to avoid high airway pressure due to low respiratory system compliance associated with the morbid obesity. Because it appeared that the basic problem leading to respiratory failure in this patient was morbid obesity, body weight reduction was considered to be mandatory. Thus, caloric intake was limited to 1000 kcal.day(-1), resulting in body weight reduction by 50 kg during the patient's stay in the intensive care unit (ICU). The patient was successfully extubated on ICU day 35.

An increase in the serum amylase level in patients after peroral double-balloon enteroscopy: an association with the development of pancreatitis

BACKGROUND AND STUDY AIMS

Double-balloon enteroscopy (DBE) is a novel technique that allows the enteroscope to be inserted deep into the small intestine. The procedure has been thought to be safe, but cases of acute pancreatitis after peroral DBE have recently been observed. The aim of this study was to confirm the occurrence of hyperamylasemia after peroral DBE.

PATIENTS AND METHODS

Peroral DBE was carried out in 13 patients from July 2005 to February 2006. Blood samples were taken before and 3 h after the procedure, and serum pancreatic amylase levels were measured. The patients were also evaluated for pancreatic-type abdominal pain after the procedure. Hyperamylasemia after peroral DBE was defined as an elevation of the serum pancreatic amylase level to more than the upper normal limit and twice the level before the procedure. Pancreatitis was diagnosed on the basis of both pancreatic-type abdominal pain and hyperamylasemia.

RESULTS

Hyperamylasemia after peroral DBE occurred in six patients (46.2 %). One of the six patients with hyperamylasemia had pancreatic-type abdominal pain after the procedure and developed acute pancreatitis. The average procedure time was 105 min (range 65 - 155 min) in the patients with hyperamylasemia, and did not significantly differ from that in the group without hyperamylasemia (99 min).

CONCLUSIONS

Hyperamylasemia after peroral DBE occurs frequently and may be associated with development of pancreatitis.

Relation between conduction property and work function of contact metal in carbon nanotube field-effect transistors

We have investigated the relation between the conduction property and the work function of the contact metal in carbon nanotube field-effect transistors (NTFETs). The conduction type and the drain current are dependent on the work function. In contrast to NTFETs with Ti and Pd contact electrodes, which showed p-type conduction behaviour, devices with Mg contact electrodes showed ambipolar characteristics and most of the devices with Ca contact electrodes showed n-type conduction behaviour. This indicates that the barrier height of the metal/nanotube contact is dependent on the work function of the contact metal, which suggests that the Fermi-level pinning is weak at the interface, in contrast to conventional semiconductors such as Si and GaAs. We have also demonstrated nonlinear rectification current-voltage characteristics in a nanotube quasi-pn diode with no impurity doping, in which different contact metals with different work functions are used for the anode and the cathode.

Immunohistochemical detection of ubiquitin-positive intracytoplasmic eosinophilic inclusion bodies in diffuse alveolar damage

AIMS

To clarify the relationship between ubiquitin-positive pneumocytes and intracytoplasmic eosinophilic inclusion bodies (IB) in patients who died of diffuse alveolar damage (DAD).

METHODS AND RESULTS

Eighteen patients with DAD were studied, in whom hyaline membranes were present in one or more out of five sections from each lobe of the lungs and 15 patients with no DAD. Light microscopy revealed hyaline membrane in over 25% of lobes from 18 patients with DAD. The cytoplasm of pneumocytes from six of 18 cases of DAD contained IB. Immunohistochemically, all IBs were characteristically positive for both ubiquitin (Ub) and cytokeratin KL-1. Cytoplasmic granules were also Ub+ in four cases of DAD without IB. IB+ or Ub+ pneumocytes were undetectable in non-DAD patients. We evaluated DAD severity based on hyaline membrane formation; the mean score in DAD with IB (3.60; n = 6) was significantly higher than that in Ub- (2.92; n = 8). Ub+ pneumocytes were found with or without IB among those cases with high DAD scores.

CONCLUSIONS

These findings suggest that disordered proteolysis in the Ub-mediated proteasome system leads to the accumulation of abnormal ubiquitinated protein, which includes cytokeratin, in pneumocytes. This is the first report to suggest that Ub+ pneumocytes are associated with disease severity in patients with DAD.

SWI/SNF complex is essential for NRSF-mediated suppression of neuronal genes in human nonsmall cell lung carcinoma cell lines

Mammalian chromatin remodeling factor, SWI/SNF complex contains a single molecule of either Brm or BRG1 as the ATPase catalytic subunit. Here, we show that the SWI/SNF complex forms a larger complex with neuron-restrictive silencer factor (NRSF) and its corepressors, mSin3A and CoREST, in human nonsmall cell lung carcinoma cell lines. We also demonstrate that the strong transcriptional suppression of such neuron-specific genes as synaptophysin and SCG10 by NRSF in these non-neural cells requires the functional SWI/SNF complex; these neuronal genes were elevated in cell lines deficient in both Brm and BRG1, whereas retrovirus vectors expressing siRNAs targeting integral components of SWI/SNF complex (Brm/BRG1 or Ini1) induced expression of these neuronal genes in SWI/SNF-competent cell lines. In cell lines deficient in both Brm and BRG1, exogenous Brm or BRG1 suppressed expression of these neuronal genes in an ATP-dependent manner and induced efficient and specific deacetylation of histone H4 around the NRSF binding site present in the synaptophysin gene by a large complex containing the recruited functional SWI/SNF complex. Patients with Brm/BRG1-deficient lung carcinoma have been reported to carry poor prognosis; derepression of NRSF-regulated genes including these neuron-specific genes could contribute to enhance tumorigenicity and also would provide selective markers for Brm/BRG1-deficient tumors.

Nested polymerase chain reaction for assessing the clinical course of tuberculous meningitis

The authors examined the usefulness of nested PCR (N-PCR) to detect Mycobacterium tuberculosis (MTB) DNA in CSF for assessing the clinical course of tuberculous meningitis (TBM). N-PCR successfully detected MTB DNA in all nine CSF samples from patients with suspected TBM. During anti-tuberculosis treatments, N-PCR results converted from positive to negative, correlating with the improvement of the patient's clinical condition.

Evaluation of combination therapy using aciclovir and corticosteroid in adult patients with herpes simplex virus encephalitis

OBJECTIVE

Herpes simplex virus encephalitis (HSVE) is associated with significant morbidity and mortality, even with appropriate antiviral therapy. In the present investigation, the first to assess efficacy of corticosteroid treatment with aciclovir therapy in HSVE, multiple logistic regression analysis was performed of predictors of outcome in adult patients with HSVE.

METHODS

A non-randomised retrospective study of 45 patients with HSVE treated with aciclovir was conducted. The patients were divided into poor and good groups based on outcome at three months after completion of aciclovir treatment. The variables evaluated were: clinical variables (sex, age, days after onset at initiation of aciclovir, Glasgow Coma Scale (GCS) at initiation of aciclovir, initial and maximum values for the cell numbers and protein concentration in the cerebrospinal fluid, and corticosteroid administration); neuroradiological variables (detection of lesions by initial cranial computed tomography and by initial magnetic resonance imaging); and one neurophysiological variable (detection of periodic lateralised epileptiform discharges on the initial electroencephalogram). Single variable logistic regression analysis was performed followed by multiple logistic regression analysis. The best set of predictors for the outcome of HSVE was estimated by stepwise logistic regression analysis.

RESULTS

A poor outcome was evident with older age, lower GCS score at initiation of aciclovir, and no administration of corticosteroid. Patient age, GCS at initiation of aciclovir, and corticosteroid administration were found to be significant independent predictors of outcome on multiple logistic regression analysis, and these three variables also formed the best set of predictors (R(2) = 0.594, p<0.0001).

CONCLUSION

Combination therapy using both aciclovir and corticosteroid represents one of the predictors of outcome in HSVE.

Effects of expiratory rib-cage compression on oxygenation, ventilation, and airway-secretion removal in patients receiving mechanical ventilation

BACKGROUND

Expiratory rib-cage compression, a chest physiotherapy technique, is well known as the "squeezing" technique in Japan.

OBJECTIVE

To determine the effects of rib-cage compression on airway-secretion removal, oxygenation, and ventilation in patients receiving mechanical ventilation.

SETTING

An intensive care unit of an emergency and critical care center at a tertiary-care teaching hospital in Tokyo, Japan.

METHODS

Thirty-one intubated, mechanically ventilated patients in an intensive care unit were studied in a randomized, crossover trial. The patients received endotracheal suctioning with or without rib-cage compression, with a minimum 3-hour interval between the 2 interventions. Rib-cage compression was performed for 5 min before endotracheal suctioning. Arterial blood gas and respiratory mechanics were measured 5 min before endotracheal suctioning (baseline) and 25 min after suctioning. The 2 measurement periods were carried out on the same day.

RESULTS

There were no significant differences in the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen, P(aCO2), or dynamic compliance of the respiratory system between the 2 periods (before and after endotracheal suctioning). Moreover, there were no significant differences in airway-secretion removal between the 2 periods.

CONCLUSIONS

This study suggests that rib-cage compression prior to endotracheal suctioning does not improve airway-secretion removal, oxygenation, or ventilation after endotracheal suctioning in this unselected population of mechanically ventilated patients.

Hepatic glycogen breakdown is implicated in the maintenance of plasma mannose concentration

D-mannose is an essential monosaccharide constituent of glycoproteins and glycolipids. However, it is unknown how plasma mannose is supplied. The aim of this study was to explore the source of plasma mannose. Oral administration of glucose resulted in a significant decrease of plasma mannose concentration after 20 min in fasted normal rats. However, in fasted type 2 diabetes model rats, plasma mannose concentrations that were higher compared with normal rats did not change after the administration of glucose. When insulin was administered intravenously to fed rats, it took longer for plasma mannose concentrations to decrease significantly in diabetic rats than in normal rats (20 and 5 min, respectively). Intravenous administration of epinephrine to fed normal rats increased the plasma mannose concentration, but this effect was negated by fasting or by administration of a glycogen phosphorylase inhibitor. Epinephrine increased mannose output from the perfused liver of fed rats, but this effect was negated in the presence of a glucose-6-phosphatase inhibitor. Epinephrine also increased the hepatic levels of hexose 6-phosphates, including mannose 6-phosphate. When either lactate alone or lactate plus alanine were administered as gluconeogenic substrates to fasted rats, the concentration of plasma mannose did not increase. When lactate was used to perfuse the liver of fasted rats, a decrease, rather than an increase, in mannose output was observed. These findings indicate that hepatic glycogen is a source of plasma mannose.

Interferon sensitivity-determining region of nonstructural region 5A of hepatitis C virus genotype 1b correlates with serum alanine aminotransferase levels in chronic infection

The mutations in the interferon (IFN) sensitivity-determining region (ISDR) of nonstructural region 5A (NS5A) of hepatitis C virus (HCV) have been correlated with response to IFN therapy. NS5A appears to disrupt a host antiviral pathway that plays a role in suppressing virus replication and protects hepatocytes from apoptosis. We assessed whether ISDR correlates with viral load and serum alanine aminotransferase (ALT) levels. Serum viral load and ALT levels were prospectively measured bimonthly by HCV core protein assay and monthly, respectively, for 22 months in 87 patients chronically infected with HCV genotype 1b. ISDR of HCV was directly sequenced from the products of reverse transcription and polymerase chain reaction of HCV RNA. Five patients had four or more substitutions (mutant type), 33 had 1-3 (intermediate type), and 49 had no substitutions (wild type) in ISDR. The numbers of substitutions in ISDR were inversely correlated with mean viral load over a 22-month period (r = 0.292, P = 0.0060) and directly with mean serum ALT levels (r = 0.360, P = 0.0006). The numbers of substitutions in ISDR was significantly larger in the patients with changes of viral load more than fivefold during the 22 months (1.4 +/- 2.4) than in those without changes (0.6 +/- 0.8) (P = 0.0188). The present study demonstrates that the patients with more substitutions in ISDR had significantly higher serum ALT levels and smaller viral load. These results suggest that NS5A with more substitutions in ISDR may lose the ability to block host antiviral pathways and to protect hepatocytes from apoptosis.

[Delayed onset malignant hyperthermia after a closure of ventricular septal defect]

An 18 month-old girl was diagnosed as ventricular septal defect (VSD) with mild aortic valve prolapse. She underwent a closure of VSD. Intra-and early postoperative course was uneventful. However, 20 hours after surgery, sudden bradycardia led to cardiac arrest and strong muscle rigidity was seen. Hyperkalemia and metabolic acidosis rapidly progressed and resuscitation was failed. Extracorporeal life support and continuous hemodialysis were initiated, but the patient died with multiple organ failure on 5th postoperative day. Her clinical course supported the diagnosis of delayed onset malignant hyperthermia. Histopathological findings of muscle biopsy were consistent with rhabdomyolysis, and immunopathological stains demonstrated changes as in a Duchenne type muscular dystrophy carrier. Delayed onset malignant hyperthermia is an extremely rare complication of general anesthesia. We should be aware of this lethal condition, which occurs with a certain time lag after surgery, especially when the patient has possible background of myopathy.

Effect of steroid add-back therapy on the proliferative activity of uterine leiomyoma cells under gonadotropin-releasing hormone agonist therapy

Short-term treatment with gonadotropin-releasing hormone agonist (GnRHa) is a useful preoperative medical therapy of uterine leiomyomas. However, adverse effects caused by the hypo-estrogen state sometimes appear, suggesting the necessity of add-back therapy. In this study, we investigated effects of three kinds of add-back therapies on the proliferative activity of uterine leiomyoma cells by examining the expression of Ki-67 in leiomyoma cells by immunostaining. Thirty patients who were to undergo hysterectomy or myomectomy were injected with 3.75 mg depot leuprolide acetate every four weeks until the end of the 12th week. Twenty patients underwent add-back therapy from the 5th week to the end of the 12th week, 8 patients receiving 0.625 mg of conjugated equine estrogen (CEE) /day, 6 patients 5.0 mg of medroxyprogesterone acetate (MPA)/day, 6 patients 0.625 mg CEE plus 2.5 mg of MPA /day. The add-back of CEE or CEE plus MPA suppressed decreases in the proliferative activity of leiomyoma cells caused by GnRHa therapy, but that of MPA did not. These results suggest that the add-back therapy with MPA is of use in preventing the adverse effects caused by hypo-estrogen in the preoperative short-term GnRHa therapy.

Hereditary paroxysmal ataxia with mental retardation: a clinicopathological study in relation to episodic ataxia type 2

A case of hereditary acetazolamide-responsive paroxysmal ataxia with mild mental retardation in an autopsied Japanese man is described. His ataxic attacks had occurred for approximately 65 years since the age of 6. One of his daughters had severe mental retardation and epilepsy, and the other had paroxysmal ataxic attacks and mild mental retardation. Analysis of the subject's CACNA1A gene and that in his daughter revealed neither mutations nor CAG expansion. Neuropathologically, cortical degeneration consisting of the marked loss of Purkinje and granule cells was found exclusively in the cerebellar vermis. This was consistent with findings at autopsy for cases reported as spinocerebellar ataxia 6. In addition, there were minor anomalies, such as hypoplastic cerebellum and brainstem, heterotopic Purkinje cells, and cortical microdysgenesis of the temporal lobe. It is considered that the cerebellar cortical degeneration and the minor malformations found in the brain are closely related to one another, rather than having occurred independently.

Expression of epiregulin and amphiregulin in the rat ovary

We have previously reported that the epidermal growth factor (EGF) family growth factor, epiregulin, is expressed in rat ovarian granulosa cells by induction with pregnant mare serum gonadotropin (PMSG). In this study, we report that amphiregulin, another member of the EGF family, was also induced in the rat ovary by gonadotropin treatment. Northern blot analysis revealed that PMSG treatment induced the expression of both epiregulin and amphiregulin mRNA after 24 h, but the expression then decreased 48 h after treatment. Further treatment with human chorionic gonadotropin (hCG) rapidly induced the expression of both epiregulin and amphiregulin genes and maximal levels were reached 4 h after hCG treatment. A marginal increase in amphiregulin mRNA levels was also observed 6 h after PMSG treatment. In situ hybridization revealed that epiregulin and amphiregulin mRNAs were localized in the granulosa cells of large antral follicles. These spatio-temporal expression patterns were similar to those of cyclo-oxygenase-2 (COX-2) and progesterone receptor (PR). In adult cycling rats, epiregulin and amphiregulin were strongly induced at 1800 and 2000 h on proestrus coinciding with the preovulatory LH surge. An in situ hybridization study also showed that epiregulin and amphiregulin mRNAs were detectable in the granulosa cells of preovulatory ovarian follicles at 2000 h on proestrus, where transcripts of COX-2 and PR were co-localized with those of epiregulin and amphiregulin. These observations suggested that the EGF family members, epiregulin and amphiregulin, may play a role in the ovulatory process of cycling rats as well as in the induction of ovulation in immature rats.

Effects of expiratory rib cage compression combined with endotracheal suctioning on gas exchange in mechanically ventilated rabbits with induced atelectasis

INTRODUCTION

In Japan, expiratory rib cage compression (a chest physiotherapy technique) is frequently used with mechanically ventilated patients. It has not been determined whether rib cage compression combined with endotracheal suctioning improves oxygenation, ventilation, and mucus clearance. We evaluated the effects of rib cage compression with and without endotracheal suctioning on P(aO(2)), P(aCO(2)), dynamic compliance of the respiratory system (C(RS)), and mucus clearance in rabbits with induced atelectasis.

METHODS

Anesthetized adult rabbits had an 18-gauge catheter placed into the airway, together with a tracheal tube via tracheostoma, and were mechanically ventilated. To create atelectasis, artificial mucus was infused into the airway via the catheter. Each rabbit was randomly assigned to one of 4 groups (= 7 in each): (1) control, (2) received endotracheal suctioning alone, (3) received rib cage compression alone, and (4) received both rib cage compression and endotracheal suctioning. After these interventions, for 30 min, each animal was placed supine without intervention for 120 min.

RESULTS

In the groups that received rib cage compression, oxygenation, ventilation, and C.

Changes in respiratory physiological dead space and compliance during non-abdominal, upper abdominal and lower abdominal surgery under general anaesthesia

BACKGROUND AND OBJECTIVE

To evaluate the temporal changes in respiratory physiological dead space and dynamic compliance of the respiratory system during non-abdominal, upper abdominal and lower abdominal surgery under general anaesthesia with intermittent positive pressure ventilation.

METHODS

Thirty-four adult patients were studied (non-abdominal surgery, n = 8; upper abdominal surgery, n = 13 and lower abdominal surgery in lithotomy position, n = 13). Physiological dead space was measured using the single breath carbon dioxide test. The physiological dead space to tidal volume ratio (VD/VT), dynamic compliance of respiratory system, expiratory tidal volume and respiratory rate were measured 10 min after tracheal intubation, and 30, 60 and 120 min later.

RESULTS

In lower abdominal surgery group, VD/VT was significantly increased at 120 min compared with 0 min (P = 0.005) and 30 min (P = 0.009). There were no significant differences in VD/VT between the three groups at any time point. Compliance decreased significantly in patients with upper abdominal (120 min) and lower abdominal surgery (60 and 120 min), but there were no significant changes during non-abdominal surgery.

CONCLUSIONS

We found that the VD/VT increased in patients undergoing lower abdominal surgery in lithotomy and head down tilt, and compliance decreased in those undergoing upper abdominal and lower abdominal surgery over time.

[Complete neurological recovery in a patient with decerebrate rigidity following cardiac arrest from acute airway obstruction by advanced laryngeal cancer]

A 59-year-old man presented with severe dyspnea caused by advanced laryngeal cancer. As he had disregarded the dyspnea for a month, we did not have enough information about the extent of the tumor. The pulse oximeter showed 88% with oxygen inhalation. Because of severe dyspnea, he could not maintain supine position. Fiberoptic laryngoscopy showed tumor bulk obstructing airway directly. In the operating room, at first, a cricothyroid membrane puncture was attempted under local anesthesia but the procedure was abandoned when the patient became hypoxic and unconscious. Immediately tracheostomy and cardiopulmonary resuscitation were performed. Tumor bulk had displaced the trachea and surrounding structures, making a tracheostomy difficult. Nine min after loss of consciousness, a secure airway was obtained. However, he was still unconscious and developed characteristic decerebrate rigidity. Therefore the patient was treated with infusion of thiamylal and free radical scavenger and mild hypothermia therapy (bladder temperature 34 degrees C). On the fifth day of this treatment, after rewarming and discontinuation of thiamylal, the patient responded to command. He recovered with no neurological deficits. This case suggests that combined treatment with barbiturate, free radical scavenger, and mild hypothermia therapy is effective to minimize ischemic brain damage after cardiopulmonary resuscitation.

Modes of hantavirus transmission in a population of Clethrionomys rufocanus bedfordiae inferred from mitochondrial and microsatellite DNA analyses

To elucidate the mode of transmission of Puumala-related hantavirus in a population of gray red-backed voles, Clethrionomys rufocanus bedfordiae, in Hokkaido, Japan, we analyzed the kin structure and dispersal patterns of individual voles using microsatellite and mitochondrial DNA markers. Siblings or dam/offsprings was identified within the population based on the relatedness calculation with the microsatellite data. The pairwise relatedness values obtained could reveal kinship among all vole individuals within the population. Based on the assessment of kinship, we did not find a positive relationship between hantavirus transmission and close kinship. Males infected with the hantavirus carried a relatively uncommon mitochondrial haplotype. However, these infected males shared low relatedness values and were not considered closely related, i.e., they were not siblings or parent/offspring. These observations imply that hantavirus transmission in the vole population may not be related to close kinship but by random horizontal infection.

Synthesis of Seoul virus RNA and structural proteins in cultured cells

Seoul virus is a hantavirus that causes hemorrhagic fever with renal syndrome (HFRS). The virion has a tripartite (S, M, and L) negative-stranded RNA genome, which is characteristic of the family Bunyaviridae. However, the molecular basis of virus replication is not well known. We established a Northern blot hybridization (NB) procedure using digoxygenin-labeled RNA probes, to quantitate the hantaviral plus- and minus-strand RNAs separately. Virus RNA replication was analyzed in infected Vero E6 cells. When the Vero E6 cells were infected with Seoul virus strain KI-83-262 (KI) at m.o.i. = 0.25, the plus-strand RNA was detected within 1 h post-infection (hpi), and the minus-strand RNA was detected subsequently. Using laser confocal microscopy, the nucleocapsid protein (NP) was detected within 2 hpi, and accumulated as scattered granules in the cytoplasm until 24 hpi. In contrast, the G2 protein first appeared at 8 hpi, was immediately transported to the Golgi, and accumulated in the Golgi until 24 hpi. Infectious virus particles were released into the medium at 24 h hpi. These findings indicate that hantavirus RNA replication starts with the appearance of NP at 2 hpi, glycoproteins then accumulate gradually in the Golgi, and virion formation is initiated once the viral RNAs and proteins have accumulated.

A continuing high incidence of subacute sclerosing panencephalitis (SSPE) in the Eastern Highlands of Papua New Guinea

The aims of this descriptive study were to confirm the high incidence of subacute sclerosing panencephalitis (SSPE) previously reported from Papua New Guinea (PNG) and to relate SSPE to previous measles vaccination and measles illness. From February 1997 to April 1999 we diagnosed a total of 55 patients with SSPE at Goroka Base General Hospital in Eastern Highlands Province (EHP) of PNG. The diagnosis was based on high cerebrospinal fluid and serum measles virus antibody titres with progressive neurological disorder and myoclonic jerks. Of these 55 patients 42 were from EHP, including 32 whose onset was in the 2-year period 1997-1998. The annual incidence of SSPE in EHP in these 2 years was 98 per million population under 20 years of age, the highest ever reported. This incidence was more than ten times higher than the highest incidence in the prevaccine era reported from elsewhere. The mean age of onset of SSPE was 7.7 years (range 2.8-14.8 years) and the interval between measles and the onset of SSPE, where known, had a mean of 5.9 years and a range of 2.5-11.1 years. Among the SSPE patients 19 had a documented history of measles vaccination. Eight of these 19 also had documentation of previous measles illness; of these, seven were vaccinated after the development of measles and one was vaccinated 20 days before measles illness. Two non-SSPE children received vaccination twice which was documented and subsequently developed measles which was also substantiated by documentation. Two patients with SSPE yielded amplified nucleotide sequences of measles virus that were different from any of the vaccine strains. We found no evidence to implicate measles vaccination in the development of SSPE.

Neuropathological analysis in spinal muscular atrophy type II

We performed a neuropathological analysis, including in situ nick end labeling (ISEL) and immunohistochemistry, of two cases of clinicogenetically confirmed infantile spinal muscular atrophy (SMA) type II. Both cases showed severe reduction of the motor neurons and gliosis in the spinal cord and brain stem, although the occurrences of central chromatolysis and ballooned neurons were not frequent. Clark's and lateral thalamic nuclei, which are usually altered in SMA type I, were spared, whereas Betz cells in the precentral gyrus and large myelinated fibers in the lateral funiculus were reduced in number. Regarding apoptosis, only the younger case demonstrated a few ISEL-positive nuclei in the dorsal horn, with reduced Bcl-x expression level in the Purkinje cells. Unlike SMA type I, the expression of neurofilaments was not disturbed and the reduction in synaptophysin expression level in the anterior horn was mild. An oxidative stress-related product was deposited in atrophic motor neurons in the spinal cord, and neurons with nuclei immunoreactive for 8-hydroxy-2'-deoxyguanosine were found in the lateral thalamus. In contrast, the expression of glial glutamate transporters was not altered. These data suggest that oxidative stress and, to a lesser extent, apoptotic cell death, but not disturbed neurofilament metabolism or excitotoxicity, may be involved in neurodegeneration in SMA type II.