Diaphragm pacing with a spinal cord stimulator: current state and future directions

Diaphragm pacing with electrical stimulation of the phrenic nerve is an established treatment for central hypoventilation syndrome. The device, however, is not readily available. We tested the same spinal cord stimulator we use for pain control in phrenic nerve stimulation. We implanted a spinal cord stimulator (Itrel 3 or X-trel, Medtronic, MN) in 6 patients with chronic hypoventilation because of brainstem or high cervical cord dysfunction. The stimulation electrode was placed along the right phrenic nerve in the neck, and the device was implanted in the anterior chest. We used the cyclic mode, and set the parameters at I second ramp up, 2 seconds on, 3 seconds off. The pulse width and the frequency were set at 150 microseconds and 21 Hz, respectively. The amplitude of the output was adjusted to obtain sufficient tidal volume and to maintain PaCO2 at around 40 mm Hg. During a follow-up period up to four years, stable and sufficient ventilation was observed in all patients without any complications. Although further long follow-up is necessary, diaphragm pacing with the spinal cord stimulator is feasible and effective for the treatment of the central hypoventilation syndrome.

The pan-erbB tyrosine kinase inhibitor CI-1033 inhibits human esophageal cancer cells in vitro and in vivo

The epidermal growth factor receptor (EGFR) is a member of the EGFR family of receptors. EGFR and other members of the EGFR family have been shown to play significant roles in human cancer cell proliferation and therefore present important molecular targets for the treatment of cancer. The purpose of this study was to examine the effect of the pan-erbB tyrosine kinase inhibitor CI-1033 against esophageal squamous cell carcinoma in vitro and in vivo. We selected 4 human esophageal squamous cell carcinoma cell lines (TT, TE2, TE6, and TE10), and determined their expression of EGFR and HER2. We examined the ability of CI-1033 to inhibit cell growth in vitro and in vivo. EGFR and HER2 were overexpressed in all 4 esophageal cancer cells. We found that CI-1033 could inhibit the growth of esophageal cancer cell lines in a dose-dependent manner with the inhibition of phosphorylation of both MAPK and AKT. The oral administration of CI-1033 exerted a significant antitumor effect on esophageal cancer tumors in athymic nude mice. Our results suggest that CI-1033 effectively inhibits the growth of esophageal squamous cell carcinoma which co-expresses both EGFR and HER2 with the inhibition of phosphorylation of both MAPK and AKT. Furthermore, in vivo animal studies of CI-1033 suggest that CI-1033 holds significant clinical potential in esophageal cancer.

Acral myxoinflammatory fibroblastic sarcoma of the foot

We report a rare case of acral myxoinflammatory fibroblastic sarcoma (AMFS) in a 68-year-old woman. Tumor excision of a mass between the 1st and 2nd toe of the left foot was performed after a diagnosis of ganglion in February 2003. Examination of the surgical specimen confirmed AMFS. No recurrence or metastasis occurred during the follow-up period of 4 years. Clinical characteristics such as recurrence rate, metastasis rate and period of metastasis are unclear for AMFS. Long-term clinical follow-up is thus required.

Plasma progesterone and prolactin concentrations in overtly pseudopregnant bitches: A clinical study

Plasma concentrations of progesterone (P(4)) and prolactin (PRL) were measured in 35 bitches presented at veterinary clinics for symptoms of overt pseudopregnancy (PSP) between 50 and 95 days after the onset of proestrus. Results were compared to those from samples collected from 35 control bitches at comparable stages of the ovarian cycle (expressed as days after the onset of observed signs of proestrus). In the PSP bitches at 71.4+/-1.6 (mean+/-S.E.M.) days of the cycle, P(4) (1.5+/-0.2ng/mL) was lower (P<0.01) and PRL (16.0+/-1.9ng/mL) was higher (P<0.01), compared to P(4) (2.7+/-0.4ng/mL) and PRL (2.9+/-0.6ng/mL) in control bitches at 70.6+/-1.5 days of the cycle. Low P(4) was not a prerequisite for elevated PRL. Although elevated (> or =10ng/mL) PRL (20.9+/-2.0ng/mL) occurred more often with low (<2ng/mL) P(4) (20 of 24 cases) it also occurred with P(4) above 3ng/mL in two affected bitches and in two control bitches. Whether the occurrence of relatively low PRL concentrations (<4ng/mL) in samples obtained from 4 of the 35 pseudopregnant bitches reflected variable and often elevated PRL secretion or increased sensitivity to PRL in the absence of elevated prolactin in those animals was not determined. We inferred that elevated plasma PRL was often involved in the etiology of overt PSP; furthermore, a premature decline in circulating P(4) concentrations may be a factor in some instances.

Sleep architecture and the apnoea?hypopnoea index in children with obstructive-sleep apnoea syndrome

This study aimed to examine the sleep architecture and craniofacial morphology in a group of children divided by different levels of apnoea-hypopnoea index (AHI), 5, 4.5, 4, 3.5, 3 and 2.5, and to determine an AHI threshold value at which sleep architecture is most affected. 23 children, who were selected from a preliminary questionnaire survey about sleep-related breathing disorders, were evaluated with cephalometric radiographs and overnight polysomnography. The findings indicated that the children with AH1 > or = 2.5 and > or = 3 showed significantly larger numbers of waking (p < 0.005) and desaturation index (p < 0.01) than those with AHI <2.3 and <3, respectively. Significantly (p < 0.05) higher amounts of waking and lower amounts of REM as a percentage of total sleep time (TST) were also found in the children with AH1 > or = 3. In the subgroups with AHI > or = 3.5 and > or = 4, only the percentage of REM was found to be significantly (p < 0.05) lower. No significant differences were found at the AHI threshold of 4.5 and 4. AHI correlated significantly (p < 0.05) with the number of awakenings, amount of waking as a percentage of TST, desaturation index and oxygen saturation nadir. Higher incidence of skeletal Class II pattern was found in children with AHI > or = 2.5 and > or = 3, and Class III in those with AHI <2.3 and <3, respectively. The effects on polysomnographic characteristics demonstrated to be the greatest on children at the AHI threshold of 3. In addition, the evaluation of oxygen saturation can be used to provide some information concerning the severity of sleep-related breathing disorders.

Association study of the tumor necrosis factor-alpha gene and its 1A receptor gene with methamphetamine dependence

Recent preclinical findings that repeated treatment with methamphetamine (METH) induced an increase in tumor necrosis factor-alpha (TNF-alpha) mRNA in some brain regions and that TNF-alpha blocked METH neurotoxicity and rewarding effects suggest TNF-alpha, a multifunctional pro-inflammatory cytokine, may be involved in METH dependence. We hypothesized that genetic polymorphisms of the TNF-alpha gene and its receptor genes may be associated with vulnerability to METH dependence. Genetic association of -308G>A and -857C>T in the promotor region of the TNF-alpha gene, and 36A>G in exon 1 of the TNF receptor 1A gene (TNFR-SF1A), were analyzed in patients with METH dependence (n = 185) and healthy controls (n = 221) in a Japanese population. No significant association of alleles or haplotypes of the TNF-alpha or TNFR-SF1A genes with METH dependence was found. Neither was any significant association of clinical phenotype with METH dependence found. These results suggest that genetic variations in the TNF-alpha gene and its receptor genes may not be involved in individual vulnerability to METH dependence.

Intrathecal baclofen in the treatment of post-stroke central pain, dystonia, and persistent vegetative state

Intrathecal baclofen (ITB) administration is a fully established treatment for severe spasticity. However, it is not widely known that baclofen, an agonist of the GABA-B receptor, has additional beneficial effects in other conditions such as chronic pain, coma, dystonia, tetanus, and hyypothalamic storm. Sporadic cases of dramatic recovery from persistent vegetative state after intrathecal administration of baclofen have been reported. There have been also reports on the use of baclofen for control of dystonia due to cerebral palsy, neuropathic central pain syndrome or reflex sympathetic dystrophy. On the other hand, epidural spinal cord stimulation (SCS) has been used in the management not only of pain but also of spasticity, dystonia, and in order to improve deteriorated consciousness, but the effects so far have been modest and variable. Similarities between ITB and SCS are interesting as both involve the spinal GABAergic system. Based on a 15-year personal experience of intrathecal baclofen, I would stress the importance of this treatment not only for spasticity but also for other difficult neurological disorders.

Association Study of the Dihydropyrimidinase-Related Protein 2 Gene and Methamphetamine Psychosis

Dihydropyrimidinase-related protein 2 (DRP-2 or DPYSL-2)mediates the intracellular response to collapsin, a repulsive extracellular guidance cue or axonal outgrowth. DRP-2 is also referred to as collapsin response mediator protein 2 (CRMP-2). We have previously demonstrated that the DRP-2 gene is associated with susceptibility to schizophrenia, but not to bipolar disorders. In addition, a genetic association was observed with paranoid-type schizophrenia, but not with hebephrenic-type schizophrenia. It has been well documented that repeated abuse of methamphetamine (METH) for a long period frequently produces psychotic symptoms, such as auditory hallucinations and delusions that are hardly distinguishable from those of paranoid-type schizophrenia. Therefore, we hypothesized that a certain genetic variant of the DRP-2 gene may affect individual vulnerability to the development of METH-induced psychosis. We examined the genetic association by a case-control method. The polymorphism *2236T>C in the 3' untranslated region of the DRP-2 gene, which has been shown to be a negative genetic risk factor for paranoid-type schizophrenia, was analyzed in 198 patients with METH psychosis and 221 corresponding healthy controls in a Japanese population. No significant association of the DRP-2 gene with METH psychosis was found. Neither did we find an association with the clinical phenotype of METH psychosis, such as the age of first consumption of METH, latency to development of psychosis after METH abuse, prognosis of psychosis after detoxification from METH use, complication of spontaneous relapse of psychosis without reconsumption of the drug, or multisubstance abuse status. These findings indicate that a genetic variant of the DRP-2 gene may not affect the risk of METH psychosis or any clinical phenotype of the disorder.

Fatal Intratumoral Hemorrhage Immediately after Gamma Knife Radiosurgery for Brain Metastases: Case Report

Radiosurgical treatment of brain tumors is sometimes considered to be free from significant acute complications or adverse effects. A rare case of fatal intratumoral hemorrhage immediately after gamma knife radiosurgery (GKR) for brain metastasis is reported. A 46-year-old woman with lung cancer complicated by systemic dissemination experienced an acute episode of headache, speech disturbances, and right-side hemiparesis. She had no history of arterial hypertension or coagulation disorders. CT and MRI disclosed multiple brain metastases. The largest tumor, which was located in the left frontal lobe and caused a significant mass effect, was removed microsurgically without any complications. GKR for nine residual metastases was done on the fourth postoperative day. The marginal dose, which corresponded to the 50% prescription isodose line, constituted 20 Gy. No complications were noticed during frame fixation, treatment itself, or frame removal. Fifteen minutes after the end of the GKR session the patient acutely fell into a deep coma. Urgent CT disclosed a massive hemorrhage in the left cerebellar hemisphere in the vicinity of the radiosurgically treated lesion. The patient died 4 days later and autopsy confirmed the presence of intratumoral hemorrhage. In conclusion, GKR for metastatic brain tumors should not be considered as a risk-free procedure and, while extremely rare, even fatal complications can occur after treatment.

[Partial anomalous pulmonary venous connection to the high portion of the superior vena cava associated with ventricular septal defect repaired with williams method using right atrial flap: report of a case]

A 3-year-old boy suffered from the poor body weight gain under the diagnosis of partial anomalous pulmonary venous connection (PAPVC) to the high portion of the superior vena cava (SVC) associated with ventricular septal defect (VSD) and intact atrial septum (IAS). Preoperative cardiac catheterization revealed the pulmonary to systemic flow ratio 2.6 and mean pulmonary arterial pressure of 21 mmHg. He successfully underwent surgical repair with Williams method using right atrial (RA) flap out and VSD patch closure. Postoperative course was uneventful and echocardiography demonstrated no obstruction at the both routes of neo-SVC and neo-right upper pulmonary venous return.

A new simple therapeutic method for chronic subdural hematoma without irrigation and drainage

BACKGROUND

We developed a new simple therapeutic method for the treatment of chronic subdural hematoma (CSDH) without irrigation and drainage. This method is characterized by replacement of the hematoma with oxygen.

METHODS

Seventy patients (seventy-eight sides) with CSDH were treated with this method from May 1994 to October 2002. For the complete replacement of the hematoma with oxygen, subdural tapping site was changed from the thickest area of the hematoma to the parietal tuber. Irrigation and drainage were not used in all patients.

RESULTS

Neurological recovery after the treatment was satisfactory in all 70 patients. An average amount of replaced hematoma was 96.1 ml, ranging from 5 to 280 ml. An initial hematoma pressure ranged from 0 to 200 mm H2O (average: 92.1 mm H2O). During the follow up periods, clinical recurrence was noted in 7 patients (10%) and 7 sides (9.0%).

CONCLUSION

The replacement of the hematoma with oxygen via percutaneous subdural tapping without irrigation and drainage is useful and less invasive method for the treatment of CSDH.

Semen quality in a Giant Panda (Ailuropoda melanoleuca) in relation to estrus of a nearby resident female panda

Semen quality was determined in a sexually mature male Giant Panda, electroejaculated 13 times during a 5-year interval, before, during and after estrus of a female Giant Panda housed nearby. Testis volume and plasma testosterone concentrations were also measured. Mean testis volumes were 1223.0 +/- 64.7(S.E.M.)cm3 (before estrus), 1213.2 +/- 218.2 cm3 (during estrus), and 1360.2+/-160.4 cm3 (after estrus). Compared to before and during estrus in the female, testis volume decreased 70 days after estrus and there was no projectile ejaculation. The mean semen volume and sperm count were 2.2+/-0.7 mL and 8.3 +/- 3.1 x 10(8) before estrus, 2.4 +/- 0.9 mL and 5.7 +/- 0.9 x 10(8) during estrus, and 1.3 +/- 0.3 mL and 8.1 +/- 1.7 x 10(8) after estrus, respectively. The semen volume, sperm count, and testis volume markedly differed from 90 days before estrus until 66 days after estrus, whereas no marked differences in sperm motility, sperm viability, and proportion of morphologically abnormal spermatozoa were observed. Plasma testosterone concentrations were elevated both before and during estrus (0.62 +/- 0.23 ng/mL and 0.95 ng/mL), but decreased substantially after estrus (0.20 +/- 0.0 ng/mL). We inferred that spermatogenesis was active in this male panda from approximately 3 months before estrus to 2 months after estrus in the adjacent female.

Endoscope-Controlled Removal of Intrameatal Vestibular Schwannomas

The use of endoscopes for surgery of the cerebellopontine angle tumors is steadily obtaining widespread acceptance. The objective of the present study was a laboratory and clinical evaluation of the safety of the endoscope-controlled microneurosurgical removal of the intrameatal vestibular schwannomas through a retrosigmoid approach. The anatomical investigation was done on formalin-fixed cadaver heads and dry temporal bones. Clinical series included 33 consecutive patients (23 women and 10 men; mean age 50 +/- 15 years). A bayonet-style rigid endoscope with 70 degrees angle of view and 4 mm outer diameter was found to be optimal for observation of the internal auditory canal. Its insertion in the cerebellopontine cistern should be preferably done under control through an operating microscope. Endoscope-controlled manipulations necessitate the use of a special holder system, which provides a stable position of the device and allows bimanual manipulations by the surgeon. A thermographic evaluation did not reveal a significant increase of the local temperature due to use of the endoscope. Use of the endoscope permitted removal of the neoplasm from the most lateral part of the internal auditory canal and identification of the nerve of tumor origin. In total, 28 tumors underwent total removal, and anatomical preservation of the facial nerve was attained in 31 cases. Damage of the facial nerve by the endoscope was met once. In 8 out of 16 patients, who showed serviceable hearing before surgery, this was preserved after tumor removal. In conclusion, endoscope-controlled removal of the intrameatal vestibular schwannomas seems to be a technically feasible, effective and safe procedure. Nevertheless, good equipment and special training are absolutely necessary for attainment of optimal results.

Multimodal neurosurgical strategies for the management of dystonias

Dystonia have many subtypes, and is classified as focal, segmental and generalized. As for focal dystonia, spasmodic torticollis (cervical dystonia) and writer's cramp are most common. Cervical dystonia is mainly treated effectively with selective peripheral denervation, and task specific focal dystonia of the hand (writer's cramp) is effectively alleviated by stereotactic ventro-oral thalamotomy. Generalized dystonia is dramatically improved with deep brain stimulation of the globus pallidus interna. Because the majority of dystonia is medically refractory and surgical treatment results in marked improvement, the authors strongly believe that dystonia should be regarded as a definite neurosurgical indication. Based on personal experience of nearly 200 cases of dystonia surgery, the authors describe a multimodal approach to various types of dystonias. Also we discuss possible relation between dystonias and psychiatric conditions, and future new indication of dystonia surgery.

Fifteen year experience of intrathecal baclofen treatment in Japan

Intrathecal baclofen administration is a fully established treatment for severe spasticity. However, it is scarcely known that Baclofen, an agonist of GABA-B receptor, has other potential effects on pain, restoration coma, dystonia, tetanus, and hypothalamic storm. Sporadic episodes of dramatic recovery from persistent vegetative state are reported after intrathecal administration of baclofen. There are also reports on the use of baclofen for neuropathic pain including poststroke central pain syndrome. Baclofen is also used for control of dystonia due to cerebral palsy or reflex sympathetic dystrophy. On the other hand, epidural spinal cord stimulation has been used for pain, spasticity, dystonia, or attempt to improve deteriorated consciousness, though the effects seem variable and modest. Similarity between baclofen and spinal cord stimulation is interesting in that both involve the spinal GABAergic system. Based on the 15-year personal experience of intrathecal baclofen, I would stress importance of this treatment not only for spasticity but also for other difficult neurological disorders.

Significance of lymph node micrometastasis in pN0 hilar bile duct carcinoma

AIMS

To examine micrometastasis in node-negative hilar bile duct carcinoma (HBDC) using an immunohistochemical method and evaluated the clinical significance.

METHODS

Four hundred and twenty three regional lymph nodes from 28 patients with node-negative HBDC who had undergone a resection were immunostained with an antibody against cytokeratins eight and 18 (CAM 5.2).

RESULTS

Lymph node micrometastasis was detected in 11 of the 28 patients and 14 of the 423 lymph nodes. Lymph node micrometastasis was significantly correlated with the pT classification (p=0.03), the histopathological grading (p=0.01) and venous invasion (p=0.05). The 5-year survival rate of the patients with lymph node micrometastasis was 21.8%, as opposed to 66.5% in the patients without micrometastasis. Patients with micrometastasis showed a significantly poorer survival rate than those without micrometastasis (p=0.02).

CONCLUSION

The results suggest that immunohistochemically detected lymph node micrometastasis has an impact on the outcome in HBDC.