The pathophysiology of the Rett syndrome from the standpoint of polysomnography

Twelve polysomnographies were performed on eight cases of the Rett syndrome and the results were compared between cases under and over 5 years of age. There observed an increase in the ratio of stage REM (sREM) against slow wave sleep (SWS) with age. The ratio of the number of mentalis twitch movement (ment TM) during sREM against the number of rapid eye movements (REMs) (reflecting dopaminergic activities) was below normal in the younger cases but increased markedly. The ratio of ment TM in the period of REMs burst against the total ment TM during sREM (reflecting the noradrenergic hypofunction) was high in the younger group, while it decreased later. The nocturnal variation became inapparent with age in % SWS and the phasic components of sREM, while that of % sREM exaggerated at later ages. The early hypofunctions of the noradrenergic and dopaminergic neurons later modified by the serotonergic dysfunction and dopaminergic postsynaptic supersensitivity are suggested.

Clinical features of the early stage of the Rett syndrome

Our previous reports have pointed out that the Rett syndrome (RS) starts from early infancy with autistic behavior and muscle hypotonia, and we have raised the hypothesis in regard to the pathophysiology that RS can be an early developmental disorder of the monoaminergic and indolamine systems. This paper presents the reanalysis of early motor and behavioral features performed on 16 patients. The most frequent complaint was developmental delay, but 2 cases were presented with autistic behaviors. Development showed delay even from head control. Crawling was particularly difficult. Muscle hypotonia was present in all cases. Early autistic behaviors were seen in high degree and the most frequent was the pervasive lack of social association. Autistic behaviors characterizing older autism were seen in various degrees. These findings reconfirm our previous reports and hypothesis. Furthermore, it can be suggested that the onset may even be in the fetal stage and that lesions of specific neuronal systems occurring in early ontogeny could result in specific abnormality in the higher system which manifest later in development, after these structures reach certain levels of maturation.

[Analysis of prognostic factors in patients with hepatocellular cancer treated by hepatic arterial infusion chemotherapy]

Analyses of the prognoses of thirty-four patients with hepatocellular cancer, who were treated by hepatic arterial infusion chemotherapy and/or transcatheter arterial embolization (TAE) and/or hyperthermotherapy, were performed by multivariate analysis using Cox's proportional hazard model and generalized Wilcoxon test. In the multivariate analysis on the conditions of patients, nine of fifteen variables were associated with the prognosis of patients who received regional cancer chemotherapy. The variables are: sex, liver cirrhosis, esophageal varices, GOT, GPT, albumin and gamma-globulin. One of three variables was associated with the prognosis in the therapy analysis, and the variable is TAE. Significant differences in survival curves which were estimated by generalized Wilcoxon test were noted in age, portal vein invasion, ascites, GOT and TAE. From these results it is suggested that the conditions of patients with unresectable hepatocellular cancer must be carefully investigated before regional cancer chemotherapy and the good therapy effects is obtained by hepatic arterial infusion chemotherapy combined with transcatheter arterial embolization therapy.

[Experimental study on changes of temperature at palatal mucosa after denture wearing]

The purpose of this study is to estimate objectively temperature changes of palatal mucosa after denture wearing. Temperature at 7 measurement points of palatal mucosa in 10 normal dentate subjects were measured to determine the time constant by carrying out a least square approximation of the relation between temperature and time from the time of commencement of temperature measurement until the time of temperature elevation to a steady state. Changes in the time constant by thermal stimulation with cold and warm water and by wearing of an experimental palatal plate were studied. It was found that if the time constant is obtained from values measured at 60-second intervals, the predicted and measured values of steady-state temperature are well approximated and that the time constant is significantly reduced from 3 days after wearing of an experimental palatal plate and is significantly increased (prolonged) from 3 days after thermal stimulation. These results demonstrated that temperature changes of the palatal mucosa during the use of a removable denture can be subjectively and quantitatively estimated with accuracy on the basis of the time constant obtained by least square.

[A neurologic model of early infantile autism]

Based on the abnormalities in sleep-wakefulness cycle of early infantile autism, the author discussed its pathophysiology focusing on its main lesion in the raphe nuclei. These neurons, located in the midline portion of the brainstem send their axons to various neurons of the upper and lower nervous systems, including the locus coeruleus and the dopamine neurons of the tegmentum, the former having a broad innervation and the latter a restricted area in the central nervous system. These monoaminergic neurons modulate the functions of the involved neurons and regulate their functional and structural maturation in the early developmental course. The early lesion of the raphe nuclei causes poor adaptation to environment which develops as abnormal circadian oscillation and pervasive lack of responsiveness. Combined hypofunction of the locus ceruleus, particularly of its dorsal bundle, results in the failure of extinction of acquired memory in mice which relates clinically to the excellent memory and resistance to change peculiar interests and attachments in humans. From early childhood, the disturbance of dopaminergic neurons becomes apparent clinically, and causes hyperkinesia and stereotyped activities. With the other two monoaminergic neurons, dopaminergic neurons cause occasional aggressiveness or self-mutilation. The latter behaviors are like those of pampered children and are simulated to "muricide" and "friendliness" observed in rats with these monoaminergic lesions. The particular language disturbance with echolalia is due to the right hemispheric dominance, which might have been caused by a delayed functional lateralization of the hemisphere resulting also from the delayed development of the circadian oscillation in infancy. The motor disturbances consisting of hypotonia and impaired locomotion might be due to decreased tonic innervations of the locus ceruleus and the raphe nuclei to the spinal locomotion center. CT examination of symptomatic autism showed the amygdala as one of the causative nuclei for the autistic behavior.

[An intensification therapy of adults acute leukemia]

Between January 1980 and March 1983, a study was conducted on the effects of intensification therapy in 20 adult acute leukemia patients who had achieved complete remission with induction therapy. Intensification therapy consisted of cyclic administration of six combination therapies given at gradually longer intervals, using daunorubicin, cytosine arabinoside, 6-mercaptopurine and prednisolone (DCMP), cyclocytidine (DCyMP), vincristine (DCVP), behenoyl-ara-c (BHAC-DMP), aclacinomycin (BHAC-AMP) and (ACM-MP). Six combinations were given sequentially at one-month intervals, at 2-, 3-, 4-, 5- and eventually 6-month intervals, until 5-year survival. The median remission duration was 38 months for AML, and 17 months for ALL. The median survival was 66 months for AML, and 37 months for ALL. The five year survival rate was 50%. Nine of the 20 patients are still alive. Methotrexate and prednisolone were administered intrathecally for prophylaxis of CNS leukemia on Day 4 for each intensification therapy. There was no CNS leukemia. This intensification protocol was shown to be effective in improving the prognosis of adults acute leukemia.

The development of electroretinogram abnormalities and the possible role of polyol pathway activity in diabetic hyperglycemia and galactosemia

This study examined the induction of electroretinogram abnormalities in hyperglycemia and the possible role of increased polyol pathway activity in the development of these changes. Both diabetic hyperglycemia and galactosemia caused the prolongation of peak latencies and in some cases a reduction in the amplitudes of oscillatory potentials on the b-wave. Diabetic hyperglycemia-associated abnormalities were prevented and normalized by insulin or ADN-138, an aldose reductase inhibitor. Galactosemia-induced abnormalities were inhibited by ADN-138, and were reversed either by ADN-138 treatment or by withdrawal of galactose from the diet. Polyol accumulation was prevented by insulin or ADN-138, and the elevated polyol level was reversed by insulin, ADN-138, or withdrawal of galactose in diabetic hyperglycemia and/or galactosemia. These results suggest that the increased polyol pathway activity in the hyperglycemia may be involved in the development of electroretinogram abnormalities similar to those in human diabetes; therefore, ADN-138 could be a useful drug for therapy of retinopathy in the early diabetic stage.

[Effect of a hybrid artificial pancreas in totally pancreatectomized dogs]

This study was undertaken to estimate the effect of hybrid artificial pancreas (HAP) containing xenogeneic hamster islets in totally pancreatectomized dogs. HAP were attached either to the systemic circulation or to the portal circulation for 12 to 24 hours in totally pancreatectomized dogs. Following the systemic attachment of HAP containing 10,000 islets, in four out of 6 dogs the plasma glucose levels decreased to normoglycemic levels within 5.8 +/- 1.3 hours and thereafter maintained within normal range at least 12 hours until the removal of HAP. When HAP containing 10,000 islets were attached to the portal circulation, no decrease in the plasma glucose levels was observed in all four dogs. However, HAP containing 14,000 islets were able to restore normoglycemia in four out of 5 dogs within 7.0 +/- 1.6 hours after the portal attachment. No significant difference in the plasma glucose level was observed between the dogs with HAP containing 10,000 islets attached to the systemic circulation and those with HAP containing 14,000 islets attached to the portal circulation. Those results suggested that the systemic circulation, concerning with the quantity of the islets, was the superior site of the attachment of HAP to the portal circulation for controlling hyperglycemia in apancreatic dogs.

[An electron microscopic study of malignant giant cell tumor of bone]

Three cases of malignant giant cell tumors were studied by light microscope and electron microscope. Light microscopic observation revealed three different types of tumor cells, namely, malignant stromal cells, fibrosarcomatous cell and osteosarcomatous cells. Electron microscopic observation revealed that fibrosarcomatous cells had ultrastructure similar to that of malignant stromal cells. Both types of cells showed nuclear pseudo-inclusions (NPI), and well developed organellae related to matrix synthesis in the cytoplasm. Polysaccharide staining of the same cells revealed positive products in the cytoplasm. Osteosarcomatous cells showed irregular nuclei which contained NPI and well developed r-ER. The cells were located in the non-calcified matrix which consisted of collagen fibers. No alkaline phosphatase activity was observed in this area. These facts suggest that: (1) malignant stromal cells and fibrosarcomatous cells synthesize collagenous stroma as normal fibroblasts do, and (2) osteosarcomatous cells are devoid of the ability to promote matrix calcification.

Determination of ABO blood groups by radioimmunoassay using 125I-protein A

Since the crystallizable fragment (Fc) portion of the immunoglobulin G (IgG) molecule is the binding site of Protein A, a radioimmunoassay procedure using 125I-Protein A was developed for identification of the ABO blood groups. The isotope level bound to Group A, B, or AB red cells decreased with the dilution of anti-A or -B, respectively. After sensitization by anti-A plus B in Group O serum, the isotope bindings were observed in Groups A, B, and AB cells, while no significant radioactive count appeared in Group O cells. Furthermore, there was little significant isotope binding in both Group A and B red cells sensitized by the serum from Group A or B blood containing mainly IgM anti-A or -B. A radioimmunoassay using 125I-Protein A is an excellent method for identifying ABO blood groups.

Localization of Rh1(D), 2(C), 3(E), 4(c), 5(e) and 25(LW) antigens of human Rh blood groups in fetal erythrocyte membranes

The fetal erythrocyte membranes were partially solubilized with Triton X-100 at the low concentration (0.5%). The localizations of Rh1(D), 2(C), 3(E), 4(c), 5(e) and 25(LW) were investigated. Using hemagglutination inhibition assay, Rh1(D) antigen activity was observed in the Triton-treated membrane (Triton shell) containing mainly band 1, 2 (spectrin), band 5 (actin), band 4.1 and a part of band 3, while Rh2(C), 3(E), 4(c), 5(e) and 25(LW) antigens were detected in the supernatant containing band 3, 6, 2.2, 2.3 and 4.2. It is suggested that: Rh1(D) antigen would associate with cytoskeleton matrix of fetal erythrocyte membranes; Rh1(D) and Rh25(LW) antigens might be integral membrane proteins, while Rh2(C), 3(E), 4(c) and 5(e) antigens would be surface membrane proteins which are easily released from membranes by EDTA, mercaptoethanol and alkaline treatments.

Pathophysiology of Rett syndrome

Rett syndrome is a distinct clinical entity with an unknown cause. In previous publications we stressed the age related sequential appearance of pathognomonic symptoms of Rett syndrome and suggested the early central monoaminergic deficiency disorder as the pathophysiology. In this report we present a series of cinefilms made of one patient at different ages which clearly show the age dependent changes of motor disturbances. Furthermore, the record of sleep-wakefulness rhythm and the series of polysomnography of another patient who was on L-DOPS are presented. The results of sleep studies again confirm the early involvement of the noradrenergic and serotonergic systems and relatively early development of postsynaptic supersensitivity of the dopaminergic system. The possibility of the involvement of the cholinergic system is also suggested. The summary of the sensory evoked potentials (SEP) performed on six patients is also presented and the pathomechanism of cortical involvement is discussed. Based on these new and past findings, we confirm our speculation on the pathophysiology. The basic mechanism is probably the deficient states of the monoaminergic systems occurring at a very early developmental stage. These derangements occurring at an early stage cause serious abnormality in the higher centers during development. The striking age dependent clinical manifestations and measurable physiological parameters are the reflexion of the underlying patho-physiology of Rett syndrome.