Idiopathic mediastinal fibrosis: report of a case

We report herein the case of a 28-year-old woman who presented with a mediastinal mass, subsequently confirmed to be idiopathic mediastinal fibrosis. Preoperative chest computed tomography (CT) showed a noncalcified mediastinal mass and surgery was performed to exclude malignancy. The mass was hard and dense, involved the left phrenic nerve, vagus nerve, and left upper lobe, and surrounded the subclavian artery, subclavian vein, superior vena cava, and left pulmonary artery. Pathologic examination showed the findings of mediastinal fibrosis and the mass was partially excised. Postoperative medical treatment was performed with prednisolone and tranilast, and a 3-year follow-up has not demonstrated any complications.

Nocistatin, a peptide that blocks nociceptin action in pain transmission

Prolonged tissue damage or injury often leads to chronic pain states such that noxious stimuli evoke hyperalgesia and innocuous tactile stimuli evoke pain (allodynia). The neuropeptide nociceptin, also known as orphanin FQ, is an endogenous ligand for the orphan opioid-like receptor which induces both hyperalgesia and allodynia when administered by injection through the theca of the spinal cord into the subarachnoid space (that is, intrathecally). Here we show that the nociceptin precursor contains another biologically active peptide which we call nocistatin. Nocistatin blocks nociceptin-induced allodynia and hyperalgesia, and attenuates pain evoked by prostaglandin E2. It is the carboxy-terminal hexapeptide of nocistatin (Glu-Gln-Lys-Gln-Leu-Gln), which is conserved in bovine, human and murine species, that possesses allodynia-blocking activity. We have also isolated endogenous nocistatin from bovine brain. Furthermore, intrathecal pretreatment with anti-nocistatin antibody decreases the threshold for nociceptin-induced allodynia. Although nocistatin does not bind to the nociceptin receptor, it binds to the membrane of mouse brain and of spinal cord with high affinity. Our results show that nocistatin is a new biologically active peptide produced from the same precursor as nociceptin and indicate that these two peptides may play opposite roles in pain transmission.

[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.

[A case of aneurysmal bone cyst arising from the left 4th rib]

We reported a case of aneurysmal bone cyst originating in the left 4th rib. This disease originating in a rib was recorded in only 18 cases in Japan in the literature. The patient was a 16-year-old man and he was first found to have an abnormal shadow in the left upper lung field on the chest roentgenogram. In this case, MRI was very useful to show internal septation of the tumor. We performed a thoracotomy through the left 4th intercostal space with an anteroaxillary skin incision and removed the tumor and the 4th rib completely. Pathological findings showed multiple cysts filled with blood and fibrous trabecullae containing osteoid tissue and multinucleated giant cells, confirming the diagnosis of aneurysmal bone cyst. There has been no evidence of recurrence during the 9 months postoperatively.

Intraneural ganglion of the branchial plexus

We report a case of an intraneural ganglion of the brachial plexus. Excision relieved the symptoms.

Ultrasonographically assisted carpal tunnel release

An operative technique of carpal tunnel release using intraoperative ultrasonography is described. In this technique, "safe line" is defined in the transverse carpal ligament and the adjacent deep forearm fascia midway between the ulnar margin of the median nerve and the radial margin of the ulnar artery. After ultrasonographic design of a 1.0 to 1.5-cm skin incision along the safe line at the distal carpal tunnel, the distal ligament is released under direct vision. Proximal release is performed along this line under ultrasonographic monitoring using a device that consists of a basket punch and an outer metal tube. In a prospective randomized study, the outcomes were compared for carpal tunnel release using either this technique in 50 hands of 50 patients or conventional open release in 53 hands of 53 patients. Follow-up assessment at 3, 6, 13, 26, 52, and 104 weeks showed no significant difference with respect to numbness and paresthesias, static two-point discrimination, findings on Semmes-Weinstein monofilament testing, findings on manual muscle testing of the abductor pollicis brevis, and electrophysiologic findings. The ultrasonographic-release group had better outcomes regarding pain, tenderness of the scar, and key-pinch strength at 3, 6, and 13 weeks, and grip strength at 3 and 6 weeks after surgery. The scar was more aesthetic in this group. There were no complications with either technique.

Prototype therapeutic ultrasound emitting catheter for accelerating thrombolysis

The aim of this study was to evaluate the performance of a new therapeutic ultrasound device for accelerating thrombolysis by urokinase. Artificial thrombi were produced in vitro by Chandler's loop method. Urokinase (240 IU) was added to the artificial thrombi (n = 5) before exposure to ultrasound with the new catheter-delivered device. Ultrasound (1.3 MHz) was applied with an intensity of 0.3 W/cm2 for 60 s. The degree of fibrinolysis was obtained by measurement of thrombus weight and calculated as percentages. Fibrinolysis was compared between control thrombus groups (n = 5) treated with urokinase alone or with ultrasound alone (analysis of variance, P < 0.05). Ultrasound plus urokinase (33.1 +/- 6.1% [mean +/- standard deviation]) was significantly different urokinase alone (12.3 +/- 2.4%) after 15 min of incubation. Ultrasound alone resulted in no fibrinolysis (0.9 +/- 2.5%). Ultrasound energy from the catheter-based device was sufficient to induce acceleration of fibrinolysis with urokinase.

[A case of schwannoma arising in the brachial plexus with intrathoracic extension]

A case of benign schwannoma originating from the lowest trunk of the left brachial plexus with intrathoracic extension was reported. Intrathoracic growth of a schwannoma of the brachial plexus has been reported in only 3 cases in the literature. The patient was a 53-year-old man and he was first found to have an abnormal shadow at the left lung apex on the chest roentogenogram. We performed a thoracotomy through the left third intercostal space with an axillary skin incision and removed the tumor completely. There was no neurological problem postoperatively

Frontal midline theta rhythm in young healthy adults

In this study, we examined the relationship between the frontal midline (Fm) theta rhythm that appears when a healthy subject is engaged in mental tasks and the theta rhythm which appears in the frontal region of healthy subjects during light drowsiness. The samples for this study were obtained from 465 EEGs of healthy Japan Air Self Defense Force personnel. The 39 who had frontal theta rhythm during light drowsiness were selected to be included in the theta group. For the control group, 34 subjects were randomly selected from the remaining 426 without frontal theta rhythm. When these subjects were reexamined, the rate of appearance of the frontal midline theta rhythm which appears during light drowsiness was 87.2% in the theta group and 0% in the control group. The rate of appearance of the Fm theta was 94.9% in the theta group and 3.0% in the control group. The two types of frontal theta rhythms closely resembled each other in frequency (94.6%) and distribution (83.8%). Except for the results of the hypomania (Ma) scores, there was no remarkable difference between the two groups when the MMPI was administered. The results of our study suggest that there is a close correlation between the frontal theta rhythm that appears during light drowsiness and the Fm theta.

Identification and characterization of an endogenous ligand for opioid receptor homologue ROR-C: its involvement in allodynic response to innocuous stimulus

We reported here purification and characterization of a novel heptadecapeptide in bovine brain as an endogenous ligand for ROR-C, an opioid receptor homologue cloned from rat cerebrum. The amino acid sequence of the peptide that we purified is identical to those recently identified as nociceptin in rat brain and orphanin FQ in porcine brain. The peptide inhibited the forskolin-induced cyclic AMP accumulation in ROR-C expressing Chinese hamster ovary cells. Studies on inhibitory activity of cyclic AMP accumulation and Northern blot analysis showed that the peptide and its precursor mRNA are present in a number of brain regions, less abundant in the spina cord, and negligible in the cerebellum. In situ hybridization analysis revealed that hybridization-positive neurons were distributed in the superficial layer (lamina I) of the dorsal horn and were also interspersed between the tract of Lissauer in the spinal cord. Intrathecal administration of the peptide into conscious mice induced allodynia, a pain response to innocuous tactile stimuli, in a beli-shaped manner. These results demonstrate that the peptide exists in the brain and spinal cord and plays an important role in pain transmission.

Cryptic origin of SPAI, a plasma protein with a transglutaminase substrate domain and the WAP motif, revealed by in situ hybridization and immunohistochemistry

SPAI, originally isolated as a sodium/potassium-ATPase inhibitor and now considered to be a proteinase inhibitor of unknown specificity based on its similarity to elafin (an elastase inhibitor), is a new type of plasma protein that has a transglutaminase substrate domain, which serves as an anchoring sequence to be covalently cross-linked at target sites. To determine the source of SPAI, we carried out in situ hybridization and immunohistochemistry using an antisense cRNA probe and an antiserum against recombinant SPAI, respectively. Since previous RNase protection analysis had indicated that SPAI mRNA is almost exclusively expressed in the porcine small intestine, we used its frozen sections for the staining. The lower crypt was decorated with both the cRNA probe and antiserum, indicating that SPAI is synthesized and secreted by the enteroendocrine cells located near the crypt base. The native form of SPAI was also characterized by Western blotting. This result together with the previous biochemical and molecular biological characterizations may set the stage for identifying the physiological roles of the conceptually very interesting protein SPAI.

Osteoid osteoma of the radial diaphysis

We report a case of osteoid osteoma of the radial diaphysis. Excision of the nidus relieved pain.

Cubital tunnel syndrome caused by tophaceous gout

We report a case of cubital tunnel syndrome caused by tophaceous gout. The ulnar nerve was compressed by a tophus at the distal cubital tunnel. Surgical decompression relieved the symptoms.

[Needle electromyography in the thoracic paraspinal muscles of motor neuron disease]

Usefulness of needle electromyography (EMG) in the thoracic paraspinal muscles was investigated in 22 patients with amyotrophic lateral sclerosis (ALS). All patients revealed denervation changes in the thoracic paraspinal muscles, though the EMG findings were insufficient to fulfill the WFN criteria of lower motor neuron sign. We could not diagnose three patients as having ALS at their first visits by conventional EMG. One patient had restricted neurogenic change within one limb and two patients had cervical spondylosis causing difficulty to diagnose anterior horn cell involvement at the cervical level. In these patients, however, we believed to having ALS because of the neurogenic findings of EMG in the thoracic paraspinal muscles. Afterwards, they became clinically definite ALS. On relation to respiratory function, patients with acute denervation potentials (fibrillation potentials) in upper thoracic paraspinal muscles innervated by Th1 approximately Th4 had respiratory dysfunction (% VC is less than 80). Two patients had the acute denervation potentials in the upper thoracic paraspinal muscles before the decrease in % VC. We conclude that needle EMG testing in thoracic paraspinal muscle is useful to diagnose ALS in early stage and to predict respiratory failure in ALS patients.

Mechanism-based inactivation of hepatic ethoxyresorufin O-dealkylation activity by naturally occurring coumarins

Several naturally occurring coumarins contained in the human diet have been found to be effective inhibitors and inactivators of murine hepatic ethoxyresorufin O-dealkylase (EROD) and pentoxyresorufin O-dealkylase in vitro [Cai, Y., Bennett, D., Nair, R.V., Ceska, O., Ashwood-Smith, M., and DiGiovanni, J. (1993) Chem. Res. Toxicol. 6, 872-879]. In the present study, these same coumarins decreased the content of cytochrome P450 (P450) in either 3-methylcholanthrene (MC)- or phenobarbital-induced murine hepatic microsomes but did not have a major effect on heme content. Detailed in vitro studies with [14C]coriandrin, which selectively inhibits and inactivates P450 1A1-mediated EROD activity, demonstrated that it covalently bound, in a preferential manner, to hepatic microsomal protein from MC-pretreated mice. A linear relationship was observed between covalent binding and loss of EROD activity. The inclusion of electrophile trapping agents in the incubations significantly inhibited the covalent binding of [14C]coriandrin to microsomal protein. In addition, the covalent binding of [14C]coriandrin was decreased 46% by 7,8-benzoflavone (7,8-BF), 58% by a monoclonal antibody with specificity toward MC-induced form(s) of P450, and 60% by ethoxyresorufin, implicating the bioactivation of coriandrin by P450 1A1. Analysis by sodium dodecyl sulfate-polyacrylamide gel electrophoresis of [14C]coriandrin-bound microsomal protein from MC-pretreated mice showed that [14C]coriandrin bound covalently to a protein with an approximate molecular mass of 49 kDa. Again, addition of 7,8-BF or polyclonal antibody against P450 1A1 reduced the covalent binding of [14C]coriandrin to this specific protein band. Interestingly, coriandrin was also found to be a potent inhibitor and inactivator of purified human P450 1A1. These results demonstrate that certain coumarins to which humans are exposed in the diet are bioactivated by P450 1A1 to reactive intermediates that subsequently form covalent adducts with the apoprotein, effectively destroying enzyme activity. Thus, certain naturally occurring coumarins may have a significant effect on human health.

Increased matrix metalloproteinases as possible cause of osseoarticular tissue destruction in long-term haemodialysis and beta 2-microglobulin amyloidosis

Immunolocalization of matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) in periarticular tissues of beta 2-microglobulin amyloidosis patients was investigated. MMP-1 (interstitial collagenase) the most strongly expressed of the MMPs, was localized in the synovial lining cells, mesenchymal cells in granulation tissue and nodular amyloid deposits, and chondrocytes within areas of cartilage erosion. Expression of MMP-1 was correlated with the degree of macrophage infiltration and synovial cell hyperplasia, but it was not correlated with the degree of amyloid deposition or haemodialysis period. Expression of MMP-1 appeared more intense than that of TIMP-1 and TIMP-2 in highly inflammatory cases. MMP-2 was mildly expressed in the interstitial fibroblasts and MMP-3 was faintly stained in the extracellular matrix of the synovial membrane. MMP-9 (gelatinase B) was found to be strongly positive in the osteoclasts which increased in the progressing osteolytic lesion from the destructive arthropathy. These results suggest involvement of MMPs in inflammation with an imbalance between expression of MMPs and TIMPs being closely related to pathogenesis of the destructive arthropathy.

Accelerated evolution in inhibitor domains of porcine elafin family members

Through the analysis of the porcine gene encoding the elastase inhibitor elafin, we demonstrated that there are at least three closely related members of the elafin family, and their genes have arisen by accelerated evolution. A porcine genomic DNA library was screened with a previously cloned human elafin cDNA probe, and several positive clones were obtained that can be distinguished by a combination of restriction enzymes. Sequence analysis of these clones revealed the presence of three homologous members whose genes, all consisting of three exons and two introns, are almost identical except the exon 2 sequences encoding the inhibitor domain called "WAP motif"; the intron sequences are related to each other with sequence similarities of 93-98%, whereas the exon 2 sequences exhibited only 60-77% similarities among the three members. The extreme divergence in the exon 2 sequences compared to the highly conserved intron sequences may be generated by accelerated mutations confined in a short stretch of the genes following recent duplication events of a single ancestral gene. An RNase protection assay indicated that the messages of the elafin family members are abundantly expressed in the trachea and intestine, suggesting that the most likely selective forces for the accelerated evolution are extrinsic proteinases produced by invasive microorganisms.

[Promotive factors of chronic subdural hematoma in relation to age]

To reveal the pathogenesis of chronic subdural hematoma (CSDH), 256 patients with CSDH over 1 year of age were studied in relation to various traumatic or nontraumatic promotive factors of CSDH including arachnoid cyst, implantation of a cerebrospinal fluid shunt, secondary cerebral atrophy, coagulopathies and past history of acute subdural hematoma or effusion. All patients were grouped according to decade of age. The incidences of associated promotive factors were individually analyzed in each group. The incidences of associated promotive factors in the 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th decades of life were 71%, 89%, 56%, 33%, 9%, 11%, 8%, 8% and 5%, respectively. Thus, they were divided into two groups; youth (1st to 4th decade: n = 34) and elder (5th to 9th decade: n = 222). The incidences of associated promotive factors were 62% and 8%, respectively (P < 0.001). Severity of head injury received was also evaluated in these two groups. In the youth group, 15 out of 34 patients (44.1%) had received severe head injuries with loss of consciousness, while in the elder group, only 22 out of 222 patients (9.9%) had received severe head injuries (P < 0.001). The analysis was repeated after each group was divided into two subgroups regarding the coexistence of promotive factors. Among the youth group, 13 patients had no promotive factors and 21 had one or more promotive factors. In those without any promotive factor, 9 out of 13 had received severe head injuries with loss of consciousness, while in those with promotive factors, 6 out of 21 had received severe head injuries. On the other hand, majority of the elder group had not received severe head injuries irrespective of whether patients had promotive factors or not. The present study revealed that majority of young CSDH patient had some promotive factors or severe head injuries with loss of consciousness, and that majority of patients aged over 40 years had no promotive factors and did not receive severe head injuries.

[Epidemiology of syringomyelia in Japan--the nationwide survey]

The nationwide epidemiological survey of syringomyelia was carried out in Japan by sending inquiries to neurologists, child neurologists, neurosurgeons and orthopedic surgeons for the period of 1991 and 1992. A total of 1,243 cases of syringomyelia were ascertained. Among them, 622 were men and 619 women, and the average age of onset was 28 years old. The classification by Barnett et al was used, presenting syringomyelia with Chiari malformation in 684 cases (51.2%), dysraphism in 47 (3.7%), post traumatic syringomyelia in 139 (11%), post-spinal arachnoiditis in 76 (6%), spinal cord tumor in 132 (10.5%) and others in 204. Its predominant clinical course was slowly progressive, but 202 cases (17.9%) showed rather stable course including spontaneous resolution in 29 cases. The main initial symptoms were numbness in 522 cases (42%), motor disturbance in 504 (40.5%), and pain in 296 (23.8%). Neurologic signs noted in the abnormality of deep tendon reflexes in 836 cases (67.3%), motor disturbance in 763 (60.4%) and positive pathological reflexes in 383 (30.1%). Sensory disturbance was found in 942 cases (75.8%) and the dissociated type were 559 out of them (59.3%). It is noteworthy that 982 out of 1,243 were documented by MRI and surgical operations such as foramen magnum decompression, syringo-subarachnoid shunt and others were performed in 829 cases. Syringobulbia was confirmed on MRI in 101 cases of syringomyelia in which spinal cord tumors were most frequently associated.

Experimental model of chronic tonsillar herniation associated with early stage syringomyelia

This report describes an experimental model of chronic tonsillar herniation and its effects on the spinal cord. In ten rats, a small piece of chemically induced mammary cancer was transplanted to the supraoccipital bone. In all cases, the transplanted cancers grew into the posterior fossa, destroying the supraoccipital bone and compressing the cerebellum extradurally. In six of the ten rats, tonsillar herniation was observed at 8-14 weeks after transplantation. Transdural infiltration of the tumor cells was not apparent in any animal. In those rats with tonsillar herniation (n = 6), the spinal cord from the C5 to the T8 segments showed enlargement of the central canal without exception. Histological examination revealed the following changes: stretching and thinning of the ependymal cells; swelling of the astrocytic processes; and extra-cellular edema, predominantly in the dorsal gray matter, but also in the ventral inner portion of the dorsal column. In the control group (n = 4) and those rats without tonsillar herniation (n = 4), such histological changes of the spinal cord were not observed. Although the lesions can not be regarded as representing mature syringomyelia, they most likely constitute an earlier evolutionary stage.

[Spinal multiple sclerosis mimicking a spinal cord tumor: a case report]

Since the advent of magnetic resonance imaging (MRI), to visualize lesions of multiple sclerosis has become easy to do. However, in some cases with primary spinal cord multiple sclerosis, it is not always easy to obtain a diagnosis in the first instance. We reported a case of primary spinal multiple sclerosis diagnosed through histological examination of a surgical specimen taken by an open biopsy. A 35-year-old woman was admitted with complaints of two-months duration of progressive weakness and sensory disturbance in the legs and buttocks. On radiological examinations including metrizamide CT myelography and MRI, enlargement of the conus medullaris was the only positive finding. Respective to her clinical course, intramedullary spinal cord tumor could not be ruled out, so an open biopsy was performed. Histological examination revealed that the cord lesion was acute demyelination with perivascular inflammation. Her neurological signs were almost completely cured with administration of corticosteroid, though new brainstem signs took place two months later and then a concrete diagnosis of her having multiple sclerosis was finally achieved. Since preoperative examinations can not differentiate spinal cord tumor from any other intramedullary cord lesions such as demyelinating foci of multiple sclerosis, surgical intervention would be approved in such atypical primary spinal cord multiple sclerosis.