[Survey of Fukuyama type congenital muscular dystrophy in Tokyo]

On the 1st of April in 1988, we identified 26 children with Fukuyama type congenital muscular dystrophy (FCMD) among 1,227,000 children in Tokyo whose ages ranged from 6 to 14 years. The prevalence rate of FCMD was 2.1 per 100,000. All affected children attended special school for crippled children. Mean absence from school on account of illness was 33.9 days in a year. Fifteen among 26 affected children had ability of verbal communication. The loss of gross motor function started at ages 6-7 years but muscle weakness might have occurred earlier. Ten affected children were treated with antiepileptic drugs. Six affected children needed to be hospitalized for the treatment of vomiting with dehydration, acute bronchitis, or pertussis infection during one year until the 1st of April in 1989. Two cases among 26 with FCMD died of respiratory complications shortly after admission.

[Treatment of 300 patients with bladder cancer]

From September 1973 to September 1989, 300 patients with bladder cancer were treated at the Department of Urology, Hyogo College of Medicine. They were 231 males and 69 females with an average age of 65.3 years old. The overall 5-year survival rate (Kaplan-Meier's method) was 64.7%. The 5-year survival rates were not different between male patients and female patients, or between patients with single tumor and patients with multiple tumors. Patients with vesical irritation symptoms had more unfavorable prognosis than patients with painless hematuria. Size and configuration of the tumors also affected the prognosis. Histological diagnosis was transitional cell carcinoma in 291 patients, squamous cell carcinoma in 7 patients, adenocarcinoma in one patient and undifferentiated carcinoma in one patient. In patients with transitional cell carcinoma, the 5-year survival rates according to histological grades were 93.5% for G1, 77.8% for G2 and 31.6% for G3. The 5-year survival rate according to clinical stage was 94.4% for Ta, 79.7% for T1, 66.7% for Tis, 46.1% for T2, 38.5% for T3 and 26.6% for T4. Transurethral resection of bladder tumor (TUR-b.t.) was performed in 208 patients as an initial operation and the 5-year survival rate in these patients was 78.6%. The 5-year survival rates for total cystectomy (52 patients), partial cystectomy (6 patients) and simple tumor resection (4 patients) were 51.9%, 25.0% and 37.5%, respectively. These findings suggest that superficial tumors (Ta, T1) can be controlled with TUR-b.t. but infiltrating tumors (T2, T3, T4) should be treated more vigorously with multidisciplinary approaches.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cyclosporine A inhibits allergen-induced late asthmatic response and increase of airway hyperresponsiveness in guinea pigs]

Considerable interest has recently focused on the role of T-cell function in the pathogenesis of asthma. We have previously demonstrated that repeated inhaled antigen (ovalbumin; OA) exposure resulted in an appearance of late phase airway obstruction (LAR) in more than 50% and significant increase of airway hyperresponsiveness (AH) in guinea pig experimental models. We have studied the effect of cyclosporine A (CsA), a potent helper T-cell suppressant, on these models in vivo. Respiratory resistance (Rrs) of sensitized guinea pigs by repeated OA inhalation was measured by the oscillation method and AH estimated as an inhaled concentration of histamine, causing a 200% increase in the baseline Rrs (PC200 Hist). The magnitude of immediate OA (10 mg/ml/min) inhalation-induced bronchoconstriction was not significantly different in CsA-treated (25 mg/kg/day, 7-day oral administration) and non-treated groups. However, the development of LAR was markedly inhibited in CsA treatment groups (n = 5). Antigen-induced increase of AH at 24 hr and 5 days was also significantly inhibited by CsA pretreatment. We conclude that CsA is capable of inhibiting the development of LAR and increase of AH, and thus the regulation of T-cell function may contribute to the treatment of asthma.

MRI and CT findings in Krabbe disease

The progression and characteristics of magnetic resonance imaging (MRI) and computed tomographic (CT) findings in 3 patients with infantile Krabbe disease (i.e., globoid cell leukodystrophy or galactocerebroside beta-galactosidase deficiency) are reported. We obtained initial CT and MRI studies when patients demonstrated hyperirritability and hypertonicity. The following results facilitated early diagnoses: increased density in the thalami, corona radiata, and cerebellar cortex on CT and plaque-like, high signal intensity in the periventricular region and cerebellar white matter on MRI T2-weighted images. After severe motor and mental deterioration and spasticity had developed, progressive brain atrophy, low density in the white matter, and calcification-like, symmetric, punctate high-density areas in the corona radiata were evident on CT and high signal intensity in T2-weighted images and low signal intensity in T1-weighted images in the white matter were present on MRI. In particular, linear patterns were observed in the centrum semiovale on MRI.

[Cerebral white matter lesions in a case of incontinentia pigmenti with infantile spasms, mental retardation and left hemiparesis]

A Japanese girl with incontinentia pigmenti had characteristic skin lesions at birth. The diagnosis was confirmed by skin biopsy and positive family history. Her mother and sisters also suffered from IP. She had generalized tonic seizures at 1 month of age, and infantile spasms at 7 months. ACTH therapy was very effective to infantile spasms. At 9 years now, she is suffering from atypical absence, mild mental retardation and mild left hemiparesis. MRI revealed marked atrophy of the cerebral white matter predominantly around the posterior horn of right lateral ventricle, cystic lesions in the white matter around the anterior horns of both lateral ventricles, which were not clear by CT scan, and atrophy of the right cerebral peduncle and pontine basis. Although these findings are non-specific, they may be clues which explicate the mechanism of central nervous system involvement in incontinentia pigmenti.

[Negative myoclonus; a simple partial seizure]

Negative myoclonus in a 4-year-old boy was analyzed by polygraphic study, which lead to the diagnosis of simple partial seizure. He had irregularly trembling movements of right upper limb when he held some objects with his right hand. There were also coarse trembling movements in his body and lower limbs while sitting or standing. Polygraphic recording showed that the involuntary movements were caused by intermittent inhibition of muscle contraction associated with electrical silence on EMG and spikes in the left central area on EEG.

[Congenital lower urinary tract obstruction and enuresis in children]

We reviewed enuretic children among patients with congenital lower urinary tract obstructions experienced in the Department of Urology, Hyogo College of Medicine during 16 years from 1974 to 1989. Among 612 patients with congenital lower urinary tract obstructions, 139 (22.7%) had enuresis nocturna and/or diurna. The incidence of enuresis was 24.7% with posterior urethral valve (77 cases), 50.0% with anterior urethral valve (6 cases), 23.8% with congenital bulbar urethral stenosis in boys (303 cases) and 19.9% with congenital distal urethral stenosis in girls (226 cases). Diurnal enuresis was more common in enuresis associated with congenital lower urinary tract obstructions than in usual enuresis. In urodynamic examinations, more than half of enuretic children with congenital lower urinary obstructions showed hyperactive detrusor activity. Treatment of congenital lower urinary tract obstructions through operation resulted in cure or amelioration of enuresis in about 80% of the patients. Enuresis associated with lower urinary tract obstruction or neurogenic bladder is sometimes called complicated enuresis and it is an important role of a urologist to differentiate complicated enuresis from simple enuresis.

[Involvement of platelet activating factor (PAF) in ovalbumin antigen-induced late asthmatic response and increase of airway hyperresponsiveness in a guinea pig experimental model of asthma]

Platelet activating factor, a potent chemical mediator, has been implicated in the pathogenesis of asthma in terms of inflammatory cell recruitment and activation. We have recently demonstrated that repeated antigen (ovalbumin; OA) exposure by inhalation to guinea pigs results in a development of late asthmatic response (LAR) in more than 50% of the animals and significant increase in airway hyperresponsiveness (AH). We have studied the effect of WEB 2086, a specific PAF receptor-antagonist, on this model. Respiratoly resistance (Res) of guinea pigs was measured by a oscillation technique and AH was evaluated by the provocative concentration of aerosols of histamine causing 200% increase of Rrs over the baseline Rrs (PC200 Hist). Four out of 5 actively sensitized and diphenhydramine-pretreated animals developed LAR 3 to 9 hr after allergen (20 mg/ml OA, 10 min inhalation)-induced immediate bronchoconstriction (LAR). Treatment with WEB 2086 (3 mg/kg intravenously) 30 min before and 3 hr after the exposure suppressed LAR clearly without affecting the IAR. Significant increase in AH from 2.80 +/- 0.03 to 2.51 +/- 0.01 and 2.60 +/- 0.08 (p less than 0.05, n = 8) of PC200 Hist (mg/ml, log) was observed 24 hr and 5 day after the OA exposure, respectively. The WEB 2086 treatment also prevented the increase of AH after the OA exposure (PC200 Hist; 2.82 +/- 0.09 before the challenge 2.80 +/- 0.07 and 2.75 +/- 0.09 24 hr and 5 days after, respectively. n = 8). Administration of WEB 2086 did not affect baseline Rrs and PC200 Hist in normal guinea pigs without any antigen challenge. We conclude that WEB 2086 is capable of preventing the development of LAR and increase in AH, and thus PAF may play an important causal role in LAR and increased AH observed in asthma.

[A case of malakoplakia of the kidney and urinary bladder]

A case of malakoplakia which co-existed in the kidney and the urinary bladder is reported. The patient was a 51-year-old female who had been suffering from asymptomatic macroscopic hematuria. Cystoscopic examination revealed multiple yellow-red nodules in the posterior and lateral wall of the bladder. Transurethral punch biopsy of the mucosa was performed and histopathological examination of the specimens revealed the diagnosis of malakoplakia. The laboratory data at admission were within normal limits except for slightly accelerated erythrocyte sedimentation rate. The culture of urine was negative. The cytology of urine was interpreted as Papanicolaou class I. Intravenous pyelography demonstrated filling defect of the left upper renal calyx, which was confirmed by retrograde pyelography. Computerized tomography showed dilatation of the left upper calyx. An exploratory operation disclosed that the upper calyceal neck was obstructed by several small nodular lesion, which were very similar to the lesions in the bladder. Because intraoperative pathological diagnosis of the frozen section was malakoplakia, partial nephrectomy was performed. Histopathological examination of the kidney and the bladder showed typical Michaelis-Gutmann bodies in the granulomatous lesions. Follow-up examinations 4 months after operation revealed some residual lesions in the bladder which were treated with bethanechol, but no recurrence in the kidney.

A rare case with diurnal fluctuation of head instability, hypotonia and choreoathetotic movements improved by L-dopa treatment

This report concerns a 6-year-old girl who showed peculiar symptoms but responded favourably to L-dopa. She developed normally until around 1 year of age, at which time head instability, hypotonia, increased deep tendon reflexes and choreoathetotic movements developed. These symptoms appeared to worsen in the afternoon and were alleviated after sleep. An extremely small dose of L-dopa (2 mg/kg) showed dramatic effects and her symptoms disappeared. This condition may be associated with the supersensitivity of the dopamine receptors, caused by hypofunction of the dopamine neurones.

Giant somatosensory evoked potentials in the Rett syndrome

Somatosensory evoked potentials (SEP) were recorded in ten patients with the Rett syndrome. Seven cases showed abnormal SEP, and five of these cases showed giant SEP. The five cases with giant SEP were relatively young girls with epilepsy and parieto-central spikes on the electro-encephalogram (EEG). Older patients did not show giant SEP. These giant SEP may be the reflection of cortical hyperexcitability and they may subside as the disease progresses.

[A case of spontaneous disappearance of pulmonary metastasis of renal cell carcinoma following nephrectomy]

A 76-year-old man was admitted to our hospital on October 3, 1988 complaining of general fatigue and left flank pain. A large movable mass was palpable in his left flank. Intravenous pyelography and computerized tomography confirmed left renal tumor. Chest X-ray showed a coin lesion in the left lung. Left nephrectomy was performed on October 14, 1988. Histopathological diagnosis was adenocarcinoma of clear cell type. Chest X-rays, on the postoperative eleventh day, showed disappearance of the pulmonary coin lesion which was seen preoperatively. Recurrence of pulmonary metastasis has not been seen for 14 months after operation.

[Paradoxical alpha waves seen in the course of subacute sclerosing panencephalitis]

Serial EEG findings of two cases with subacute sclerosing panencephalitis were compared with concurrent clinical status and CT findings. Case 1, a 16-year-old boy, showed transient abnormal diffuse alpha waves during sleep record. That had been seen for six months after the disappearance of periodic synchronous discharges. Clinically this abnormal EEG finding was observed at the transitional phase from stage II to III, when CT showed severe brain atrophy. Case 2, an 11-year-old boy, showed similar abnormal alpha waves for three months in the same phase as case 1. There have been many reports regarding the EEG findings of SSPE. However, these abnormal EEG findings were not reported. These abnormal alpha waves during sleep are considered to develop at the transitional phase from stage II to III, when pathologically SSPE goes from inflammation to destruction.

Combined cisplatin and radiation therapy in patients with invasive bladder cancer

Thirty-five patients with T2-T4 invasive bladder cancer were treated with combined cisplatin and radiation therapy. In 18 patients radical cystectomy was performed after the combined therapy. In the other 17 patients radical cystectomy could not be performed for various reasons. Pathological examination of the cystectomy specimens showed down-staging in 66.7% and no residual tumour in 33.3%. These results suggest a synergistic action of cisplatin and radiation. Side effects were not severe and were well tolerated. This combined therapy of cisplatin and radiation is very effective for invasive bladder cancer.

[Clinical statistics on outpatients, inpatients and operations in 1988]

Statistical studies were made on 1,766 outpatients, 657 inpatients and 687 operative procedures at our department in 1988. The most frequent diseases among the outpatients were urogenital infections followed by anomalies, tumors and stones. The major diseases among the inpatients were congenital urethral stenosis, hypospadias, vesicoureteral reflux, benign prostatic hypertrophy and bladder tumor. A total of 687 operations were performed. The five major operations were optic internal urethrotomy, hypospadias repair, transurethral resection of prostate, ureterocystoneostomy and transurethral resection of bladder tumor.

Ultrasonographically demonstrated nutcracker phenomenon: alternative to angiography

We report on a child with nutcracker phenomenon, which is a possible cause of intermittent gross haematuria of unknown origin. Early serial ultrasound examinations can demonstrate the lesions. The merits and demerits of conventional angiographic imaging are also discussed.

[Nemaline myopathy of severe infantile type: a case report of a 9-year-old girl]

A girl with severe infantile type of nemaline myopathy was reported, who is still alive at the age of 9 years and 3 months. Myopathy was so severe that antigravity movement has been seen only at fingers and toes since early infancy. Skeletal muscles of extremities and lumbogluteal regions were found to be replaced by fat on CT examination. Her daily activity has been improved by speech therapy and introduction of an electric wheel chair controlled with her chin. Cor pulmonale has gradually progressed by 8 years of age, although myopathic symptoms were apparently nonprogressive. Most patients of nemaline myopathy of this type were reported to have died of respiratory insufficiency by two years of age. Our present case was probably the oldest recorded in the literature, surviving up to the age of 9 years.

[Autotransfusion in urological surgery--experience with transurethral resection]

With the purpose to avoid the risk of homologous transfusion, autologous blood transfusion was performed in 26 patients who underwent transurethral resection of the prostate (TUR-P). Autologous blood (200-400 ml/time, 1-3 times, total 200-800 ml, mean 381 ml) was predeposited 4 days to 3 weeks prior to elected TUR-P and was transfused during or just after the operation. Since the start of this program in February 1988, homologous transfusion rate was decreased to 13.1%, whereas it has been 22.3% in 203 cases between January 1984 and January 1988. The mean hemoglobin level fell to 81.6% of the predeposition level. However, the hemoglobin level recovered to 90.1% one month after operation. The circulatory condition of the patients with autologous transfusions was stabler than that of the patients with homologous transfusion or no transfusion. No clinical hemostatic problems occurred. In cases with mild to moderate volume resection of the prostate, this autologous blood transfusion is recommended.