Clinical features and surgical outcome in patients with asymptomatic meningiomas

The clinical features and surgical outcomes of 108 patients with an asymptomatic meningioma were studied in patients who were admitted to any neurosurgical institute in the Yamaguchi prefecture in the southern part of Japan between 1986 and 1995. Their clinical characteristics were compared with 414 patients with symptomatic meningiomas over the same period. Asymptomatic patients were older than symptomatic patients, although not significantly so. Tumours were located in the right cerebral hemisphere (46 versus 31%, p = 0.003) more frequently in asymptomatic than in symptomatic patients. Four of 75 surgically-treated asymptomatic patients had a poor outcome, including two with severe disability and two deaths. Such outcomes did not differ significantly in frequency compared with those of 356 surgically-treated symptomatic patients which included 11 with severe disability and 11 deaths. Postoperative morbidity and mortality in asymptomatic patients are not negligible. Poor outcome was associated with more advanced age and with midline tumours.

Calcification characteristics of porcine stentless valves in juvenile sheep

OBJECTIVE

To compare calcification characteristics of two porcine stentless valves (Toronto SPV and Freestyle) with different designs, fixation and antimineralization techniques using a juvenile sheep model of valve implantation inside the circulation.

METHODS

The stentless valves (n = 2 x 6) were implanted in juvenile sheep in the pulmonary artery as an interposition, while the circulation was maintained with a right ventricular assist device. The model was validated by the implantation of, clinically well-known, porcine (Hancock II) and pericardial (Pericarbon) valves. Half of the valves were explanted after 3 months, the rest after 6 months. Valves were examined macroscopically, by X-ray, light microscopy (HE, Masson, Von Giesson, Von Kossa, PTAH stains), and transmission electron microscopy. Quantitative determination of the calcium content of the cusps was performed with atomic absorption spectrometry.

RESULTS

After 3 months, the Freestyle had an extensively calcified aortic wall, most prominent at the outflow side of the porcine valve. After 6 months, calcification increased transmurally, but the valve cusps were free of calcification, and the inflow side was only slightly calcified. The Toronto SPV valve also started to calcify at the inflow side of the valve after 3 months with increased calcification after 6 months. The base of the Toronto SPV valve cusps showed slight calcification after 6 months of implantation.

CONCLUSIONS

The pattern of calcification of the porcine aortic wall differs between the two studied stentless valves, with calcification located predominantly at the outflow side in the Freestyle valve, but also at the inflow side in the Toronto SPV valve. The cusps of the Freestyle valve were less prone to calcification than those from the Toronto SPV valve.

[Polyarteritis nodosa]

Polyarteritis nodosa (PAN) is the systemic necrotizing vasculitis on small and median muscular vessels. Recent studies reveal that PAN consists of classical PAN and microscopic polyangitis (MPA). MPO-ANCA, which is one of anti-neutrophil cytoplasmic antibody (ANCA), is involved in the pathogenesis of MPA. In future, by the progress of research of ANCA, the definition or criteria of systemic vasculitis including PAN or MPA will be changed.

Distortion of the stentless porcine valve induces accelerated leaflet fibrosis and calcification in juvenile sheep

BACKGROUND AND AIM OF THE STUDY

Stent mounting of a porcine aortic valve induces loss of mobility and reduces the effective orifice area. Any stentless design conserves the flexibility of the valvular apparatus, but unfortunately, these valves require a more elaborate implantation technique which is considered a major drawback by many surgeons. In an attempt to see if the insertion of the Toronto SPV stentless valve could be made easier, we altered the configuration by lowering the profile at the depth of both coronary sinuses. Theoretically, this could enable insertion of the valve by a single suture layer under the two coronary ostia, in addition to some fixation points at the commissures.

METHODS

Two modified 20 mm Toronto SPV valves were tested in vitro for hydrodynamics in a computer-controlled pulse duplicator system and compared with two standard 20 mm valves. Animal implant studies using three standard versus three modified valves (21, 23 and 25 mm) were conducted in juvenile sheep for durability and biocompatibility over a period of three months.

RESULTS

The standard Toronto SPV valve provided excellent hemodynamics. The altered configuration performed less optimally during hydrodynamic testing with increased transvalvular gradients. In animal implant studies, cusps adjacent to all reduced-height sinuses showed markedly accelerated fibrosis and substantial calcification, in contrast to only mild fibrosis on the inflow aspects of the standard leaflets.

CONCLUSIONS

The more pronounced the deformation of the stentless valve, the faster the calcification of the leaflets adjacent to the distorted sinuses. As both valves types were prepared using an identical preservation technique, the role of loss of mobility in leading to early failure is clearly demonstrated. These findings also underline the extreme importance of correct implantation technique for all stentless valves in order to prevent degeneration.

Comparative genomic hybridization analysis of genetic alterations associated with malignant progression of meningioma

Little is known about genetic alterations during malignant progression of meningioma. We used comparative genomic hybridization (CGH) in 20 patients (13 with typical, 4 with atypical and 3 with anaplastic meningiomas) to investigate the genetic pathway underlying the development of meningioma. Typical meningiomas displayed only a few genetic changes such as monosomy 22. Anaplastic meningiomas manifested more aberrations than typical meningiomas, frequently exhibiting losses of 1p, 2p, 6q, chromosome 10 and 14q, and gain of 20q, in addition to monosomy 22. The average number of alteration sites in each patient with typical meningioma was significantly less than those in each patient with atypical (p < 0.01) and with anaplastic meningioma (p < 0.05). Anaplastic meningiomas showed the chromosomal changes seen in atypical meningiomas together with other aberrations. These CGH findings suggest that losses of 1p, 2p, 6q, chromosome 10 and 14q, and gain of 20q are genetic changes implicated in the malignant progression of meningioma.

Intratumoral cytogenetic heterogeneity detected by comparative genomic hybridization and laser scanning cytometry in human gliomas

Although it is well-known that cancers show intratumoral phenotypic heterogeneity, genotypic studies have been scarce. Using comparative genomic hybridization and laser scanning cytometric analyses, we investigated intratumoral cytogenetic heterogeneity in 21 surgically removed gliomas including 11 glioblastomas (GBMs), 8 anaplastic astrocytomas (AAs) and 2 low-grade astrocytomas. Comparative genomic hybridization analysis revealed gain or amplification of 7p in 63%, gain of 7q in 73%, loss of 9p in 53%, loss of 10p in 47%, loss of 10q in 47%, loss of 13q in 53%, and loss of 22q in 37% of high-grade astrocytomas. Because these aberrations were region-independent within the same tumor, they did not contribute to intratumoral cytogenetic heterogeneity. Such heterogeneity was due to cytogenetic changes other than the above region-independent aberrations. Intratumoral cytogenetic heterogeneity was detected in 8 of 11 GBMs, 4 of 8 AAs, and none of the 2 low-grade astrocytomas. These observations suggest that cytogenetic changes at chromosomes 7, 9p, 10, 13, and 22 are primary events in high-grade astrocytomas and that subsequent cytogenetic changes involving increases in copy number provide intratumoral heterogeneity. DNA aneuploidy was detected by laser scanning cytometry in 5 of 11 GBMs and 1 of 8 AAs. All tumors with DNA aneuploidy exhibited intratumoral cytogenetic heterogeneity, and there was a significant correlation between DNA aneuploidy and intratumoral cytogenetic heterogeneity. These results support the notion that cytogenetic heterogeneity results from genetic instability within a tumor.

Periodic fatigue symptoms due to desynchronization in a patient with non-24-h sleep-wake syndrome

A 43-year-old man complaining of recurrent fatigue symptoms and sleep disorders occurring periodically every 4 weeks was studied. Using a wrist worn actigraphy and an ambulatory rectal temperature monitoring apparatus, his sleep-wake cycle and rectal temperature were measured continuously for 4 months, while diagnostic evaluation and therapeutic interventions were conducted. It was found that after he gave up an attempt to keep to a 24-h-day, a free-running sleep wake pattern appeared but his fatigue symptoms disappeared. An analysis of the relationship between his sleep-wake cycle and the rectal temperature rhythm found that his fatigue symptoms did not appear when both rhythms were synchronized with each other. Artificial bright light therapy entrained him to a 24-h day without relapsing of fatigue symptoms. Desynchronization between a 24-h sleep-wake schedule and his circadian pacemaker may have caused his periodically appearing fatigue symptoms.

Circadian rhythm sleep disorders in adolescents: clinical trials of combined treatments based on chronobiology

Delayed sleep phase syndrome (DSPS) and non-24-h sleep-wake rhythm are circadian rhythm sleep disorders that are common in adolescents. Most patients have difficulty adjusting to school life, poor class attendance or refuse to go to school. Since a treatment has not been established, the present paper is presented to propose a strategy for treating circadian rhythm sleep disorders in adolescents, based on our clinical studies. Twenty subjects (12 males and eight females, mean age 16.2+/-1.7 years) participated in the study. The onset of sleep disorder occurred between the ages of 11 and 17. The most common factors affecting the onset of disorders were changes in social environment. The subjects kept a sleep-log for the periods before and during treatments. The treatments were based on chronobiology: resetting the daily life schedule, chronotherapy, regulation of the lighting environment, methylcobalamin, and/or melatonin. Bright light exposure was successful in 10 patients, of whom four were treated with methylcobalamin. Melatonin treatment was successful in two patients (one with and one without chronotherapy). Thirteen of the 20 patients were successfully, treated with therapies based on chronobiology. After consideration of these results, a step-by-step procedure of combined treatments for the circadian rhythm sleep disorders is proposed.

Consistency of lumbar discograms of the same disc obtained twice at a 2-week interval: influence of needle tip position

: Although numerous papers have emphasized the importance of accurate needle positioning in lumbar discography, no concrete evidence is available to support this contention, and no study has evaluated the image consistency of discography as influenced by this factor. By observing the consistency of two images in relation to needle tip position we aimed to clarify the importance of needle positioning in discography. One hundred and ninety-two patients (324 discs) receiving steroid intradiscal therapy in whom discography of the same disc was performed twice at a 2-week interval and in whom the needle tip position was within the acceptable range (as defined by us) were studied. The patients were divided into two groups: in group G, in whom the needle tip was within a limited range on both discograms, and group P, in whom the needle tip was in this range on only one discogram. Image consistency was compared roentgenographically in the two groups. The consistent image rate for the total number of discs was 48.5%, being significantly higher in group G (53.2%) than in group P (39.0%). The rates were lower in the nucleus pulposus and the posterior portion of the disc than in the other disc areas, but were significantly higher in group G (85. 4% and 75.0%, respectively, for these two areas). The necessity for accurate needle tip positioning was proved roentgenographically.

Cloning of follistatin-related protein as a novel autoantigen in systemic rheumatic diseases

In an attempt to identify autoantigens of synovium in rheumatoid arthritis (RA), we constructed lambda phage expression cDNA libraries from synovium and screened them by IgG purified from synovial fluids, both of which were derived from RA patients. As a result of this unique combination of the libraries and probes, we cloned follistatin-related protein (FRP) as a novel autoantigen in systemic rheumatic diseases. FRP is a secreted protein containing a similar amino acid sequence to follistatin, an inhibitor of activin. FRP was first cloned as a transforming growth factor-beta1-inducible protein (called TSC-36) from a mouse osteoblastic cell line and was suggested to have some roles in the negative regulation of cellular growth. Immunoblotting analyses detected synovial fluid and serum anti-FRP antibodies of IgG class more frequently in RA than any other systemic rheumatic diseases and controls. Synovial fluid anti-FRP antibodies appeared in 44% of RA (n = 18) and none of osteoarthritis (OA) (n = 15) patients. Serum antibodies were detected in 30% of RA (n = 67), 17% of systemic sclerosis (n = 18), 10% of systemic lupus erythematosus (n = 51) and Sjögren's syndrome (n = 10), and none of polymyositis/dermatomyositis (n = 13) patients and healthy subjects (n = 30). These antibodies recognized an EC domain, an extracellular Ca2+ binding module. In anti-FRP antibody-positive RA patients, serum C-reactive protein level and erythrocyte sedimentation rate were more elevated than negative patients (P < 0.05 and P < 0.01, respectively). FRP gene expression was higher in RA than OA synovium (P < 0.05). However, there was no difference between these groups in the amount of synovial FRP, suggesting its elevated turnover in RA. As follistatin inhibits activin, FRP might inhibit some growth factor-like molecule. Detection of anti-FRP antibodies, possibly having disease-promoting effects as the blocking antibodies, could be one of the markers for clinical evaluation of systemic rheumatic diseases.

Quantitative assessment of macular edema with retinal vein occlusion

PURPOSE

To evaluate the retinal thickness analyzer, a new image analyzer involving laser-slit biomicroscopy, for quantitative assessment of retinal thickness in patients with macular edema secondary to retinal vein occlusion.

METHODS

Fifty-eight patients (central retinal vein occlusion, 22 eyes; branch retinal vein occlusion, 36 eyes) with a clinical diagnosis of macular edema associated with retinal vein occlusion were evaluated. Retinal thickness analysis was performed with the retinal thickness analyzer. A green helium-neon laser slit directed into the eye was scanned to generate optical cross-sections of the retina. Images were analyzed by an automated software algorithm, and a detailed map of the retinal thickness was obtained.

RESULTS

Laser-slit images obtained with the retinal thickness analyzer in patients with macular edema associated with retinal vein occlusion disclosed intraretinal changes such as retinal edema, cystoid spaces, and hemorrhages. Linear regression analysis showed a significant relationship between the macular thickness in the central fovea and corrected visual acuity reported on a logMAR scale (P = .002, adjusted R2 = 0.40 in central retinal vein occlusion; P = .002, adjusted R2 = 0.34 in branch retinal vein occlusion).

CONCLUSION

We confirmed the capability of the retinal thickness analyzer to provide rapid and precise evaluation of macular thickening in patients with retinal vein occlusion.

[Sarpogrelate hydrochloride for Raynaud's phenomenon of patients with collagen diseases]

OBJECTIVE

To evaluate clinical efficacy of sarpogrelate hydrochloride (SPG), a novel 5HT2- serotonergic receptor antagonist, for Raynaud's phenomenon associated with collagen diseases.

PATIENTS AND METHODS

Thirty two patients with collagen diseases such as scleroderma, mixed connective tissue disease, systemic lupus erythematosus, Sjögren's syndrome, and rheumatoid arthritis were enrolled. SPG (300mg/day) was administered for 8 weeks. Patients were asked to record the frequency of Raynaud's phenomenon and subjective symptoms in a diary, and evaluations were made in weeks 4 and 8 of treatment. Thermography and determination of whole blood serotonin levels were also conducted in some patients.

RESULTS

The frequency and duration of Raynaud's phenomenon and subjective symptoms such as coldness and pain significantly improved in weeks 4 and 8 compared to the pre-treatment baseline. Thermography showed significantly improvements of skin temperature recovery rate following cold water loading after treatment with SPG. Epigastric distress was reported by 3 patients, but no other adverse reaction or abnormal changes in laboratory tests were observed. Whole blood serotonin levels per platelet increased significantly after treatment with SPG, suggesting that administration of SPG might inhibit activation of the platelets.

CONCLUSION

A global improvement rate ("markedly improved" + " moderately improved") of 66% was obtained and SPG was regarded as safe in 85% of patients and useful or very useful in 82%. SPG is expected to be a useful new therapy for Raynaud's phenomenon in patients with collagen disease.

Radioimmunodetection of human myeloma xenografts with a monoclonal antibody directed against a plasma cell specific antigen, HM1.24

BACKGROUND

To develop a new immunologic approach to multiple myeloma, the authors generated a monoclonal antibody against a human plasma cell specific antigen, HM1.24. Their previous study showed the antitumor effect of this antibody in severe combined immunodeficiency (SCID) mice bearing human myeloma xenografts. In the current study, the efficacy of anti-HM1.24 immunoglobulin (Ig) G and its F(ab')2 fragment were evaluated for radioimmunologic detection of the myeloma xenografts.

METHODS

SCID mice bearing subcutaneous RPMI 8226 tumors were injected with 125I-labeled antibodies, and radioactivity in the tumor and normal tissues was measured. Radioimmunoscintigraphy and autoradiography were performed to investigate the distribution of the antibodies.

RESULTS

In comparative biodistribution studies, the maximum tumor localization index of anti-HMl.24 F(ab')2 fragment was significantly higher than that of anti-HM1.24 IgG. Anti-HM1.24 F(ab')2 consistently had higher tumor-to-tissue ratio than anti-HM1.24 IgG and gave distinct tumor images by radioimmunoscintigraphy. Autoradiographic study showed that anti-HM1.24 F(ab')2 penetrated the tumor mass more uniformly than whole IgG antibody.

CONCLUSIONS

These results indicate that anti-HM1.24 antibody has the potential to provide a new approach to the immunodetection and immunotherapy of multiple myeloma and related plasma cell dyscrasias.

[Lethal paraquat poisoning caused by spraying in a vinyl greenhouse of causing pulmonary fibrosis with a hepatorenal dysfunction]

A 46-year-old man was hospitalized because of general fatigue. He died of respiratory failure caused by hepatorenal dysfunction. Histologic findings in the lungs were consistent with paraquat poisoning. However, he did not have a history of drinking paraquat, but did have an occupational history of spraying paraquat in a vinyl greenhouse. Retrospectively, chest X-ray films and CT scans showed findings typical of paraquat poisoning. We should inform farmers that paraquat can be toxic when used in vinyl greenhouses.

Clinical characteristics of circadian rhythm sleep disorders

From our practice at the sleep disorders clinic in Kohnodai Hospital, National Center of Neurology and Psychiatry (NCNP), we report the clinical characteristics of circadian sleep-wake rhythm disorders. Nearly 90% of circadian rhythm sleep disorders were diagnosed as delayed sleep phase syndrome (DSPS) or as non-24 sleep-wake syndrome (non-24). While DSPS was equally common in males and females, non-24 was more frequently seen in men. It was of psychiatric interest that a considerable number of patients had depressive states in the course of their circadian rhythm sleep disorders. Difficulty in adapting to social life was more severe in patients with non-24 than in those with DSPS.

Prevalence and characterization of novel pANCA, antibodies to the high mobility group non-histone chromosomal proteins HMG1 and HMG2, in systemic rheumatic diseases

OBJECTIVE

To determine the immunodiagnostic value of antibodies to the high mobility group non-histone chromosomal proteins HMG1 and HMG2, which have been identified as novel target antigens of perinuclear antineutrophil cytoplasmic antibodies (pANCA), in sera from patients with systemic rheumatic diseases.

METHODS

Anti-HMG1 or HMG2 antibody was assayed by ELISA and Western blotting in sera from patients with systemic rheumatic diseases. These antibodies were analyzed for the relationship with pANCA detected by indirect immunofluorescence in these diseases, and with clinical features in rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE).

RESULTS

Anti-HMG1 or HMG2 antibody was frequently detected in sera from patients with RA (48%), SLE (45%), Sjögren's syndrome (SS) (44%), and systemic sclerosis (SSc) (41%). In these diseases, anti-HMG1 antibody was detected more frequently than anti-HMG2 antibody. In sera from patients with RA, the positivity for anti-HMG1 and HMG2 antibodies was significantly correlated with the positivity for pANCA (p < 0.0001). Anti-HMG1/HMG2 antibodies were associated with some disease activity variables, e.g., erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, joint score and hand grip strength in RA, and CH50, C3, C4, and IgG in SLE.

CONCLUSION

Anti-HMG1/HMG2 antibodies are detected commonly in systemic rheumatic diseases, particularly in RA, SLE, SS, and SSc. HMGI and HMG2 seem to be the significant target antigens of pANCA in RA. These antibodies are significantly associated with disease activity indices in RA and SLE.

Continuous measurement of temperature in non-24 hour sleep-wake syndrome

The onset of the low temperature (LT) zone which was defined as a period when the rectal temperature was below its daily mean is a convenient circadian phase marker. In this study, we document three cases of non-24 h sleep-wake syndrome in which identification of the LT zone as an evening circadian phase marker contributed to clinical judgments. We found that the LT zone was correlated well with dim light melatonin onset. Moreover, calculating the LT zone was useful in determining phase position in irregular sleep pattern and in determining the timing of bright light therapy.

Melatonin treatment for circadian rhythm sleep disorders

We administered 1-3 mg melatonin to 11 patients (eight men, three women, aged 16-46 years) with circadian rhythm sleep disorders; nine with delayed sleep phase syndrome and two with non-24-hour sleep-wake syndrome. Sleep logs were recorded throughout the study periods and actigraph and rectal temperature were monitored during treatment periods. Melatonin was administered 1-2 h before the desirable bedtime for expected phase-shifting, or 0.5-1 h before habitual bedtime for gradual advance expecting an hypnotic effect of the melatonin. Melatonin treatments were successful in 6/11 patients. Timing and dose of melatonin administration, together with its pharmacological properties for circadian rhythm sleep disorders, should be further studied.

Effects of evening light on body temperature

Six healthy male subjects aged 21-35 years participated in the present study. The subjects were exposed to dim light (150 lux) or bright light (3000 lux) at eye level, from 19.00 to 21.30 h for 5 days. Rectal temperature and wrist activity were monitored throughout the study period. Rectal temperature nadir was delayed significantly after the bright light exposure. Ease in sleep initiation and overall sleep quality, measured by questionnaire, were aggravated significantly by the evening bright light exposure. These results suggest that strong illumination at night may disturb nocturnal sleep.

[Spinal cord stimulation therapy at an early stage for unresponsive patients with hypoxic encephalopathy]

Recently, spinal cord stimulation (SCS) has been used for the treatment of patients in prolonged coma. However, the results of SCS in unresponsive patients with hypoxic encephalopathy at the chronic stage have not been satisfactory. Considering these circumstances, we began SCS from one month after the onset of hypoxic encephalopathy and evaluated its effect. Twelve patients (5 males and 7 females) with hypoxic encephalopathy, ranging in age from 7 to 72 years, were treated with SCS. The causes of hypoxia were acute cardiac failure in 4, automobile exhaust gas poisoning in 2, and asthma, pneumothorax, anaphylaxis, asphyxia, drowning and hypotension during aortic surgery in one patient each. One month after the onset, an electrode for electrical stimulation was implanted in the epidural space at the C2-C4 level under general anesthesia. The spinal cord was stimulated for 8 hours each day, starting on the day after implantation, and was continued for 3 months. Magnetic resonance imaging (MRI), cerebral blood flow (CBF) measurement using xenon-computed tomography (Xe-CT), and measurement of auditory evoked potential (AEP) and somatosensory evoked potential (SEP) were carried out 3 weeks after the onset for presurgical evaluation. Among the 12 patients, 7 (58%) showed clinical improvement, beginning within two weeks after starting stimulation. They were able to communicate with others and to express their emotion. However, disturbance of writing, picture drawing and calculation were not improved by stimulation. From presurgical evaluation, cases in which SCS therapy was effective had the following features: 1) No hemorrhagic infarction in the basal ganglia was demonstrable by MRI. 2) Mean hemispheric CBF measured by the Xe-CT method exceeded 25 ml/100 g per min. 3) The mean increase in hemispheric CBF 20 min after acetazolamide administration exceeded 5 ml/100 g per min. 4) An N20 peak was evident on the median nerve SEP, SCS appears to be an effective supplementary for unresponsive patients with hypoxic encephalopathy at the subacute stage, in addition to rehabilitation and drug therapy.