[Cervical pyogenic spondylodiscitis: 4 cases report and a review of the literature]

We report 4 cases of cervical spondylodiscitis presenting neurological and/or neuroradiological abnormalities. Such a lesion is rare in the cervical spine of adults, but should be suspected when the patient has radiculopathy and/or myelopathy associated with inflammatory signs. We discussed the clinical characteristics and the procedures of the diagnosis and treatment of cervical spondylodiscitis. Early and definitive diagnosis can be achieved by cervical X-ray, MR imaging and biopsy. It is very important to evaluate the pyogen for the lesion by needle biopsy. When the patient has the compression of the spinal cord and/or nerve roots and the neurological findings of radiculopathy and/or myelopathy, surgical exploration and decompression of the spinal cord and/or nerve roots should be carried out as soon as possible. Anterior debridement and fusion should be performed using the effective antibiotics. We were able to achieve good prognosis by treatment following this procedure of diagnosis in the four cases of cervical spondylodiscitis mentioned.

Balloon-occluded arterial infusion chemotherapy, simple total hysterectomy, and radiotherapy as a useful combination-therapy for advanced cancer of the uterine cervix

We first performed 3 or 4 courses of balloon-occluded arterial infusion (BOAI) chemotherapy in 19 patients with advanced cancer of uterine cervix classified as stage III-IV according to the International Federation of Gynecology and Obstetrics. In the patients in whom the first BOAI resulted in insufficient drug accumulation in tumor tissue, the ovarian arteries and veins were ligated to improve the therapeutic effect. Ultimately simple total hysterectomy and radiotherapy were performed in 9 patients in whom the uterus was resectable (the combination group), and radiotherapy alone was conducted in the other 10 patients in whom hysterectomy was not practicable (the incomplete group). The survival rates were significantly higher in the combination group (2-year survival 88. 9%; 5-year survival 66.7%) than in the incomplete group (p=0.0013).

Three-dimensional shape measurement of a diffusing surface by use of a femtosecond amplifying optical Kerr gate

We propose a system for three-dimensional (3D) shape measurement of a diffusing surface by use of a previously developed femtosecond amplifying optical Kerr gate (fs-amp OKG). The system has an opening time of 459 fs and a maximum transmittance of 185%. It also provides good 3D imaging performance: a transverse imaging resolution of 70 microm, a depth resolution of 100 microm, and a positioning accuracy of 5.9 microm in depth. It is found that the optical Kerr effect and the amplification process in the fs-amp OKG do not cause the quality of a time-resolved image to deteriorate. We prove the effectiveness of the proposed system by measuring the shapes of completely diffusing objects with stepped and spherical surfaces.

Combination of automatic HPLC-RIA method for determination of estrone and estradiol in serum

We developed a highly sensitive assay for estrone and 17 beta-estradiol in serum. Estrone and 17 beta-estradiol, obtained by solid-phase extraction using a Sep pak tC18 cartridge, were purified by high-performance liquid chromatography (HPLC). Quantitation of estrone and 17 beta-estradiol were carried out by radioimmunoassay. Not insignificantly, this automatic system of extraction and HPLC succeeded in analyzing 80 samples a week. Intra-assay coefficients of variation (CV) for estrone and 17 beta-estradiol ranged from 19.5 to 28.7%, and from 8.5 to 13.7%, respectively. The minimum detectable dose for estrone and 17 beta-estradiol were 1.04 pg/ml and 0.64 pg/ml, respectively. The serum levels of 17 beta-estradiol using our method strongly correlated with those by Gas chromatography mass spectrometry (GC-MS). The serum levels of estrone and 17 beta-estradiol in 154 peri- and postmenopausal women were estimated to be between 15 and 27 pg/ml and between 3.5 and 24.0 pg/ml, respectively, while the serum level of 17 beta-estradiol in postmenopausal women, in particular, was estimated to be from 3.5 to 6.3 pg/ml. For postmenopausal women who suffered from vasomotor symptoms, the mean levels of estrone and 17 beta-estradiol at 12 to 18 hours after treatment with daily 0.625 mg conjugated equine estrogen (CEE) and 2.5 mg medroxyprogesterone acetate (MPA) were 135.0 and 21.3 pg/ml at 12 months, respectively. On the other hand, levels of estrone and 17 beta-estradiol at 12 to 18 hours after treatment with CEE and MPA every other day, were 73.4 and 15.3 pg/ml, respectively. These highly sensitive assays for estrone and 17 beta-estradiol are useful in measuring low levels of estrogen in postmenopausal women, and monitoring estrogen levels in women receiving CEE as hormone replacement therapy.

Rhabdomyosarcoma of the bladder in an adult

We report a case of rhabdomyosarcoma of the bladder in an adult. A 73-year-old male was referred to our hospital due to macrohematuria. Ultrasonography, CT and MRI revealed a bladder tumor, and cystoscopic biopsy of the tumor pathologically revealed rhabdomyosarcoma. Total cystectomy with ileal conduit urinary diversion was performed.

Expression of nerve growth factor in hepatolithiasis

AIMS/BACKGROUND

Nerve growth factor (NGF) has recently been shown to influence the survival and function of non-neuronal inflammatory cells, possibly through its activity as a colony-stimulating factor. It may also play an important role in acute inflammation and tissue repair. However, no prior report has focused on NGF in chronic inflammatory diseases of the gastrointestinal and biliary tracts. The aim of this study was to examine the expression of NGF in hepatolithiasis.

METHODS

Twenty-six liver specimens resected from 22 patients with intrahepatic calcium bilirubinate stones and from 4 patients with intrahepatic cholesterol stones were examined immunohistochemically.

RESULTS

The 22 patients with calcium bilirubinate stones demonstrated NGF immunoreactivity associated with surrounding inflammatory cells that was localized to the epithelia of proliferative peribiliary glands in the ductal wall. However, neither the surface lining of the bile duct nor hepatocytes expressed detectable NGF immunoreactivity. In the cholesterol stones cases in contrast, peribiliary glandular elements and inflammatory cell infiltration were less extensive than those observed in cases of calcium bilirubinate stones, and NGF immunoreactivity was not noted.

CONCLUSIONS

These observations suggest that proliferative peribiliary glands express NGF protein in chronic proliferative cholangitis. This is characteristic of intrahepatic calcium bilirubinate stones.

Expansive suboccipital cranioplasty for the treatment of syringomyelia associated with Chiari malformation

In order to treat syringomyelia associated with adult type Chiari malformation, the authors developed a method of expansive suboccipital cranioplasty (ESC) that involves enlarging the small posterior fossa to obtain a sufficient flow of cerebrospinal fluid (CSF). The relative effectiveness of ESC with the obex plugged and not plugged was also examined, as well as other factors influencing the operative results. Twenty patients without arachnoid adhesion at the major cistern underwent ESC without opening the arachnoid membrane at the major cistern. After surgery, all improved with no recurrence and CSF flow study using magnetic resonance (MR) imaging showed significant improvement of the flow at the major cistern. Another 20 patients without arachnoid adhesion also underwent ESC but with obex plugging. Sixteen improved and one displayed only temporary improvement with recurrent syringomyelia due to postoperative arachnoid adhesions. The remaining three showed no change in spite of shrinkage of the syrinx on postoperative MR imaging. These three patients had displayed pre-operative symptoms over an approximately 10-year period involving almost the entire axial plain of the spinal cord, and presented a large syrinx before surgery. In 4 patients with arachnoid adhesions, all required intra-arachnoid procedures in addition to ESC. Intra-arachnoid procedures are not necessary to facilitate restoration of CSF flow in patients without arachnoid adhesions, because ESC can release the CSF flow blockage in the major cistern even without plugging of the obex. An associated arachnoid adhesion at the major cistern or a long-standing syringomyelia with irreversible damage of the spinal cord results in a poor operative prognosis. When posterior fossa surgery fails, insufficient decompression or postoperative arachnoid adhesions at the major cistern as the cause of treatment's failure should be evaluated by CSF flow studies using phase contrast MR imaging.

Mimicry of CD40 signals by Epstein-Barr virus LMP1 in B lymphocyte responses

The effect of the Epstein-Barr virus (EBV) latent membrane protein 1 (LMP1) on the activation and differentiation of normal B cells was investigated. B cells of transgenic mice expressing LMP1 under the control of immunoglobulin promoter/enhancer displayed enhanced expression of activation antigens and spontaneously proliferated and produced antibody. Humoral immune responses of LMP1 transgenic mice in CD40-deficient or normal backgrounds revealed that LMP1 mimics CD40 signals to induce extrafollicular B cell differentiation but, unlike CD40, blocks germinal center formation. Thus, these specific properties of LMP1 may determine the site of primary B cell infection and the state of infection in the natural course of EBV infection, whereas subsequent loss of LMP1 expression may affect the site of persistent latent infection.

Adult leigh syndrome: treatment with intravenous soybean oil for acute central respiratory failure

This study reports a 38-year-old woman with adult Leigh syndrome associated with partial deficiency of the pyruvate dehydrogenase complex. The patient had intermittent diplopia, loss of vision, dystonia, central respiratory failure and unconsciousness with lactic acidosis. Treatment with an intravenous ketogenic emulsion resulted in rapid clinical and biochemical improvement. In patients with acute respiratory failure under these circumstances, intravenous ketogenic emulsion therapy is worth consideration.

Vectorcardiographic evaluation of myocardial infarct size: comparisons with thallium myocardial scintigraphy

OBJECTIVE

To determine the usefulness of vectorcardiography (VCG) in assessing myocardial infarct size.

METHODS

The correlation of spatial and scalar parameters of VCG with the percent defect volume (%DV) of thallium myocardial single photon emission computed tomography (SPECT) was investigated in 63 patients with first-onset myocardial infarction (MI). VCG parameters included: (1) spatial parameters: magnitude, azimuth and elevation of the maximal vector, vectors at 20 ms and 30 ms, and (2) scalar parameters: amplitudes of 20 ms and 30 ms vectors at X, Y, and Z scalar leads abbreviated as X20, Y20, Z20, X30, Y30 and Z30, respectively.

RESULTS

For anteroseptal MI, the azimuth of 30 ms vector and Z20 showed a significant correlation with %DV (r = 0.572, P < 0.05 and r = 0.832, P < 0.001) while in anteroseptal MI with involvement of lateral wall, the azimuth of 30 ms vector and X30 were correlated with %DV significantly (r = 0.775, and r = 0.780, P < 0.01). For inferior and inferoposterior MI, the elevation of 30 ms vector and Y30 were correlated well with %DV (r = 0.871, P < 0.01, r = 0.928, P < 0.001 for inferior MI and r = 0.678, P < 0.01, r = 0.760, P < 0.001 for inferoposterior MI).

CONCLUSION

VCG parameters, especially scalar parameters, can be used to evaluate myocardial infarct size easily and non-invasively with remarkable accuracy.

Intraoperative lavage for cytological examination in 1,297 patients with gastric carcinoma

BACKGROUND

This study examined the clinical value of intraoperative peritoneal lavage for cytological examination in patients with gastric cancer. Peritoneal dissemination is the most frequent mode of recurrence for this tumor.

METHODS

A retrospective of lavage findings, other factors, and outcome was performed in 1,297 patients with gastric cancer who underwent intraoperative peritoneal lavage.

RESULTS

The 5-year survival rate of patients with positive lavage cytology was only 2%. Patients who underwent curative resection and had negative cytology had a significantly better 5-year survival rate (P < 0.001). Even among patients with macroscopic peritoneal dissemination, the survival rate was significantly better with negative cytology, which reflected fewer free cancer cells in the peritoneal cavity. Serum concentrations of carcinoembryonic antigen and carbohydrate antigen 19-9 were significantly higher in patients with positive cytology. Multivariate analyses indicated that intraoperative cytological findings was an independent prognostic factor for survival, and was the most important factor for predicting peritoneal recurrence.

CONCLUSIONS

Intraoperative peritoneal lavage cytology is important in predicting survival and peritoneal recurrence in gastric cancer.

Brachial plexus and supraclavicular nerve injury caused by manual carotid compression for spontaneous carotid-cavernous sinus fistula

BACKGROUND

Manual carotid compression is an established treatment for a spontaneous carotid-cavernous sinus fistula unless emergency treatment is required for it.

CASE REPORT

A 63-year-old woman presented with a spontaneous carotid-cavernous sinus fistula. Manual carotid compression of 5 minutes duration, twice a day, for 10 days resulted in injury to the upper trunk (C 5-6) of the brachial plexus and the supraclavicular nerve (C 3-4), which subsequently resolved within a month after cessation of the procedure.

CONCLUSION

It is important to know the possible neurological complications of manual carotid compression.

[Metastatic tumor of the epididymis from pancreatic carcinoma: a case report]

A 58-year-old male who complained of painful left scrotal swelling consulted a local clinic in August 1998. Because his symptoms did not improve after antibiotic therapy, he was transferred and admitted to Jyouhoku City Hospital on September 14, 1998. Pelvic computed tomography (CT) was performed, and revealed left epididymitis. However, antibiotic treatment did not improve the condition. Then, because carcinoma of the epididymis was suspected, left inguinal orchiectomy was performed. We found a tumor in the spermatic cord and another tumor in the epididymis. The pathological diagnosis was adenocarcinoma, and metastatic carcinoma from the digestive tract was suspected. Therefore, examinations were performed to detect the primary cancer. CT and magnetic resonance imaging (MRI) demonstrated an invasive irregular tumor from the pancreas to the left kidney. Irregular mucosa was observed by gastrointestinal fiberscopy. A biopsy was performed and the pathological diagnosis was adenocarcinoma. Based on these findings, the patient was diagnosed as having a metastatic tumor of the epididymis and spermatic cord caused by pancreatic carcinoma. This is the 3rd case of adenocarcinoma of the pancreas that presented as an epididymal nodule, and this is the 12th case of adenocarcinoma of the pancreas that presented as a spermatic cord nodule.

Quantification of osteopontin in the urine of healthy and stone-forming men

Osteopontin (OPN) is one of the most important components in calcium stone matrix, but its role in stone formation is not clear. Since quantitative data regarding the excretion of OPN are necessary to assess its role, we have developed a quantitative enzyme-linked immunosorbent assay (ELISA) for OPN, and measured the urinary OPN concentrations in urolithiasis patients. Forty-seven men with urinary stones composed chiefly of calcium oxalate participated in the study. The controls were 13 normal healthy male volunteers. Urine samples were collected early in the morning and analyzed by a quantitative ELISA employing purified polyclonal antibodies to synthesized OPN aminopolypeptides. The urinary ratio of the concentrations of OPN and creatinine (OPN/Cre) in the urolithiasis patients (0.039 +/- 0.029) was significantly lower than that in the control subjects (0.062 +/- 0.030) (P<0.05). Single stone formers (n = 26; 0.050 +/- 0.020) had significantly higher OPN/Cre ratios compared with recurrent stone formers (n = 21; 0.031 +/- 0.021) (P<0. 05). The results show that OPN excretion in urolithiasis patients was lowered, presumably because of the incorporation of OPN by kidney stones.

Expression of bone matrix proteins in urolithiasis model rats

Urinary calcium stones are a pathological substance, and they show similarities to physiological mineralization and other pathological mineralizations. The expression of messenger (m) RNAs of osteopontin (OPN), matrix Gla protein (MGP), osteonectin (ON) and osteocalcin (OC) in bones and teeth has been described. We previously identified OPN as an important stone matrix protein. In addition, the spontaneous calcification of arteries and cartilage in mice lacking MGP was recently reported, a finding which indicates that MGP has a function as an inhibitor of mineralization. Here, we examined the mRNA expressions of OPN, MGP, ON, and OC in the kidneys of stone-forming model rats administered an oxalate precursor, ethylene glycol (EG) for up to 28 days. The Northern blotting showed that the mRNA expressions of OPN and MGP were markedly increased with the administration of EG, but their expression patterns differed. The OPN mRNA expression reached the maximal level at day 7 after the initiation of the EG treatment and showed no significant difference after 14 and 28 days, whereas the MGP mRNA expression rose gradually to day 28. The in situ hybridization demonstrated that the cell type expressing OPN mRNA was different from that expressing MGP. We suggest that OPN acts on calcification and MGP acts on suppression.

An adult-onset case of argininosuccinate synthetase deficiency presenting with atypical citrullinemia

A 52-year-old heavy drinker presented with repeated episodes of disturbance of consciousness and an increase in serum ammonia level, triggered by excessive alcohol intake. He was diagnosed as having adult-onset citrullinemia with deficiency of hepatic argininosuccinate synthetase (ASS) activity. Cranial magnetic resonance imaging (MRI) showed high-intensity lesions in the central pons and the bilateral middle cerebellar peduncles on T2-weighted images. Although almost all cases of adult-onset citrullinemia have been reported to be enzymologically classified as type II, the serum amino acid pattern and serum level of human pancreatic secretory trypsin inhibitor (hPSTI) were atypical for type II in the present case.

Fusiform vertebral artery aneurysms as a cause of dissecting aneurysms. Report of two autopsy cases and a review of the literature

Two autopsy cases of angiographically determined fusiform aneurysms of the vertebral arteries (VAs) are reported and the appropriate literature is reviewed to investigate the pathological characteristics of both fusiform and dissecting VA aneurysms and the pathogenesis of dissecting aneurysms. One patient had suffered a subarachnoid hemorrhage (SAH) due to dissection of a previously documented incidental fusiform aneurysm. The other patient had harbored incidental fusiform aneurysms coexistent with a ruptured aneurysm of the posterior inferior cerebellar artery. The location and pathological features of the aneurysms were similar in the two cases. The aneurysms in both cases displayed intimal thickening, disruption of the internal elastic lamina, and degeneration of the media. A mural hemorrhage and patchy calcification were also found in the case that included SAH. Based on their pathological investigation of these two cases and a review of reported cases, the authors propose that incidental fusiform aneurysms in the VAs are characterized by weakness in the internal elastic lamina and, therefore, have the potential to become dissecting aneurysms, resulting in a fatal prognosis. This suggests that long-term control of blood pressure is mandatory in patients with incidental fusiform aneurysms in the VAs.

Gamma knife surgery for skull base meningiomas. The effectiveness of low-dose treatment

BACKGROUND

The surgical removal of skull base meningiomas has a high morbidity rate, even by modern microsurgical standards. We evaluated the results of gamma knife surgery for skull base meningiomas using a relatively low radiation dose for the tumor margins.

METHODS

We reviewed 24 cases of skull base meningiomas during a 30-month period. The locations of the tumors were the petroclival region in 11 cases, the cavernous sinus region in 9 cases, and the cerebellopontine angle region in 4 cases. Eight patients (33%) had been operated on previously and fourteen patients (67%) had been treated by neuroimaging. The marginal doses for the tumors were 8 Gy to 15 Gy (median, 10.6 Gy). A large petroclival tumor 58 mm in diameter was treated with a staged treatment protocol with a 6-month interval between treatments.

RESULTS

Tumor regression was observed in 46% of the patients imaged during the follow-up period (median, 17.1 months). No patients revealed tumor growth in the follow-up period (100% tumor control rate). Eleven patients (46%) had improved clinically by the time of the follow-up examinations. Preexisting cranial nerve deficit in one patient worsened because of radiation injury.

CONCLUSION

Although a longer follow-up period is required, the relatively low minimum tumor radiation dose treatment for skull base meningiomas using a gamma knife seems to be an effective treatment with low morbidity.

Lipolytic activity of anemia-inducing substance from tumor-bearing rabbits

Anemia-inducing substance (AIS) is a protein of approximately 50,000 molecular weight secreted by malignant tumor tissue that depresses erythrocyte and immuno-competent cell functions; in this study, its biological effects on adipocytes were examined. Changes in body weight, total body fat, and food intake were investigated in rabbits after VX2 carcinoma transplantation, and the results showed reductions of 11%, 24%, and 30%, respectively, at 40 days after transplantation compared with baseline values (before transplantation). The values were even more markedly reduced 70 days after transplantation. When cyclic plasma perfusion (2 times/wk) was started at 40 days after transplantation, the values at 70 days after transplantation (30 days after beginning plasma perfusion) recovered to 91%, 84%, and 87%, respectively, of the baseline values. AIS fractions were isolated from rabbit plasma by using a phenyl-Sepharose column before transplantation, 40 and 70 days after transplantation, and 30 days after start of plasma perfusion, and AIS activity and lipolytic activity were measured. The results showed enhancement of AIS activity and lipolytic activity as the tumors grew. Lipolytic activity also returned to baseline value as AIS was removed by adsorption by plasma perfusion, and there was a high correlation between lipolytic activity and AIS kinetics. These results strongly suggest that AIS might be one of the substances involved in the enhanced lipolytic activity in advanced tumor-bearing subjects.

Metabolic and morphologic characteristics of adipose tissue associated with the growth of malignant tumors

Changes in total body fat and the metabolic and morphologic characteristics of adipose tissue were sequentially investigated in individual rabbits implanted with VX2 tumors to elucidate the pathology of the fat reduction in animals with malignant tumors as compared with that of diet-restricted rabbits. Lipogenesis in normal, VX2-implanted, and diet-restricted rabbit groups on day 40 after the start of the experiments was 19.1 +/- 2.9, 13.3 +/- 3.5, and 41.7 +/- 6.0 x 10(5) cpm/g/h, respectively, and glycerol liberation by their adipose tissue was 199 +/- 21, 528 +/- 94, and 301 +/- 45 nmol/g/h, respectively. In addition, apoptotic cells were noted in the adipose tissue of VX2-implanted rabbits on days 20-30 after implantation, but not in diet-restricted rabbits. The results showed clear differences between the total body fat reduction profiles of VX2-implanted rabbits and diet-restricted rabbits, suggesting a characteristic lipid metabolism with enhanced lipolysis and diminished lipogenesis in VX2-implanted rabbits. The results strongly suggest that adipocyte apoptosis might be involved in these phenomena.

Muscle cell apoptosis is responsible for the body weight loss in tumor-bearing rabbits

In order to elucidate the cause of body weight loss in the early stage of tumor progression, morphological changes of striated muscle were investigated in rabbits every 10 days after VX2 carcinoma implantation. The lean body mass started to decrease in the tumor-bearing rabbits 10 days after implantation, and body fat ratio showed a significant decrease from 30 days, different from the starved rabbits, whose lean body mass and body fat ratio started to decrease from 10 days. Morphological hallmarks of apoptosis in muscle cells were detected in tumor-bearing animals prior to the tumor growth but not in starved animals. These findings suggest that muscle cell apoptosis may be responsible for the body weight loss in the early tumor-bearing.

High incidence of persistent primitive arteries in moyamoya and quasi-moyamoya diseases

This study investigated the incidences of persistent primitive arteries in patients with moyamoya disease, unilateral moyamoya disease, and quasi-moyamoya disease. Cerebral angiograms of 50 patients (39 moyamoya disease patients, 6 unilateral moyamoya disease patients, and 5 quasi-moyamoya disease patients) were retrospectively reviewed. There were 35 females and 15 males, aged from 3 to 63 years (mean 27.4 years). Persistent primitive carotid-basilar artery anastomoses were observed in three patients: primitive hypoglossal artery in one moyamoya disease patient, primitive trigeminal artery variant in one unilateral moyamoya disease patient, and an anastomosis between the accessory meningeal artery and the anterosuperior cerebellar artery in one quasi-moyamoya disease patient. The ophthalmic artery originated from the middle meningeal artery in three moyamoya and two quasi-moyamoya disease patients. The incidence of the persistent primitive arteries is significantly higher in patients with moyamoya disease (10.7%) and quasi-moyamoya disease (60%) than in patients with other disease (0.67%) (p < 0.001), so congenital factors may be important in the pathogenesis of moyamoya disease.