Robotic-assisted latissimus dorsi muscle flap for autologous chest reconstruction in poland syndrome

BACKGROUND

As chest reconstructions in Poland syndrome are performed for patients at young ages, patients are generally concerned about conspicuous scars. Meanwhile, a robotic-assisted latissimus dorsi (LD) muscle harvest with inconspicuous scars has been performed for autologous breast reconstruction. As our experience with robotic-assisted LD flap harvest has increased over the years, we have made improvements in surgical techniques to optimize results. The purpose of this study was to introduce and identify the role of the refined robotic-assisted LD muscle flap harvest technique in autologous chest reconstruction in patients with Poland syndrome.

METHODS

Autologous chest reconstruction using a robotic-assisted LD muscle flap harvest was performed for 21 patients with Poland syndrome. Subjective assessments were performed to evaluate improvement in chest deformity, patient satisfaction with overall outcomes, chest symmetry, and scars. Assessments by the operator and two independent evaluating investigators were carried out with patients' photographs. The complication rates and the time for robotic surgery were also evaluated.

RESULTS

At the last visit, the average patient grades for improvement in chest deformity, satisfaction with overall outcomes, chest symmetry, and scars were 4.80, 4.72, 4.18, and 4.87, respectively. Assessments by the operator and two independent evaluating investigators demonstrated that improvement in chest deformity was achieved in all patients. No serious complications such as flap loss were recorded for any patient. The time for robotic surgery markedly decreased as experience accumulated.

CONCLUSIONS

Surgical refinements for robotic-assisted LD flap harvest might be effective and reduce operative times for patients with Poland syndrome.

Autonomic function test in progressive lacunar infarction

OBJECTIVE

Neurological progression is a major problem in managing the patients with acute lacunar infarction. The purpose of this was to investigate whether autonomic dysfunction is associated with neurological progression in patients with acute lacunar infarction.

MATERIALS AND METHODS

The study comprised 60 patients with acute lacunar infarction. All enrolled subjects underwent autonomic function tests including the 30° head-up tilt test, Valsalva test, heart rate response to deep breathing, and sympathetic skin response. The primary endpoint is the neurological progression, and the secondary endpoint is the 3-month outcome.

RESULTS

Increased initial National Institute of Health stroke scale (NIHSS), decreased time to admission from onset, decreased rise of heart rate in the 30° head-up tilt test, abnormal blood pressure response in the Valsalva test, and decreased rise of systolic blood pressure in stage IV of the Valsalva test are associated with neurological progression of acute lacunar infarction; an abnormal blood pressure response in the Valsalva test is significant in logistic regression analysis of neurological progression. Advanced age, increased initial NIHSS and modified Rankin scale, decreased expiration/inspiration ratio of heart rate to deep breathing, decreased rise of systolic blood pressure in stage IV of the Valsalva test, and neurological progression were associated with an unfavorable 3-month outcome; neurological progression was significant in logistic regression analysis of 3-month outcome.

CONCLUSIONS

An abnormal blood pressure change in the Valsalva test is associated with neurological progression in patients with acute lacunar infarction, and neurological progression can induce an unfavorable 3-month outcome.

Progressive topological disorganization of brain network in focal epilepsy

OBJECTIVE

Increasing evidence has suggested that epilepsy is a network disease. Graph theory is a mathematical tool that allows for the analysis and quantification of the brain network. We aimed to evaluate the influences of duration of epilepsy on the topological organization of brain network in focal epilepsy patients with normal MRI using the graph theoretical analysis based on diffusion tenor imaging.

METHODS

We prospectively enrolled 66 patients with focal epilepsy (18/66 patients were newly diagnosed) and 84 healthy subjects. All of the patients with epilepsy had normal MRI on visual inspection. All of the subjects underwent diffusion tensor imaging that was analyzed using graph theory to obtain network measures.

RESULTS

The measures of characteristic path length and small-worldness in the patients with focal epilepsy were significantly decreased, even after multiple corrections (P < .01). Moreover, the measures including mean clustering coefficient and global efficiency in the patients with epilepsy had strong tendency to decrease compared to those in healthy subjects (P = .0153 and P = .0138, respectively). When comparing the measures among the patients with newly diagnosed/chronic epilepsy and healthy subjects using ANOVA, the characteristic path length (P = .006), small-worldness (P = .032), and global efficiency (P = .004) were significantly different. In addition, the duration of epilepsy was negatively correlated with global efficiency (r = -.249, P = .0454).

CONCLUSIONS

We newly found a progressive topological disorganization of the brain network in focal epilepsy. In addition, we demonstrated disrupted topological organization in focal epilepsy, shifting toward a more random state.

Effective connectivity in temporal lobe epilepsy with hippocampal sclerosis

OBJECTIVE

We hypothesized that temporal lobe epilepsy (TLE) patients with and without hippocampal sclerosis (HS) showed differences in their limbic networks. This study aimed to evaluate the role of the thalamus in TLE patients with HS.

MATERIALS AND METHODS

Twenty-nine TLE patients with HS and 30 controls were enrolled in this study. In addition, we included eight TLE patients without HS as a disease control group. Using whole-brain T1-weighted MRIs, we analyzed the volumes of the limbic structures, including the hippocampus, thalamus, and total cortex, with FreeSurfer 5.1. We also investigated the effective connectivity among these structures using SPSS Amos 21 based on these volumetric measures. Moreover, we quantified correlations between epilepsy duration and the volumes of these structures.

RESULTS

There was a statistically significant effective connectivity from the hippocampus to the thalamus in TLE patients with HS. Moreover, the volumes of the left and right thalamus were negatively correlated with epilepsy duration (r=-.42, P=.0315 and r=-.52, P=.0062, respectively). However, neither TLE patients without HS nor normal controls had a significant effective connectivity from the hippocampus to the thalamus.

CONCLUSIONS

The limbic networks of TLE patients with and without HS could be different, and the thalamus might play a critical role in TLE patients with HS.

ILAE official report: a practical clinical definition of epilepsy

Epilepsy was defined conceptually in 2005 as a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures. This definition is usually practically applied as having two unprovoked seizures >24 h apart. The International League Against Epilepsy (ILAE) accepted recommendations of a task force altering the practical definition for special circumstances that do not meet the two unprovoked seizures criteria. The task force proposed that epilepsy be considered to be a disease of the brain defined by any of the following conditions: (1) At least two unprovoked (or reflex) seizures occurring >24 h apart; (2) one unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years; (3) diagnosis of an epilepsy syndrome. Epilepsy is considered to be resolved for individuals who either had an age-dependent epilepsy syndrome but are now past the applicable age or who have remained seizure-free for the last 10 years and off antiseizure medicines for at least the last 5 years. "Resolved" is not necessarily identical to the conventional view of "remission or "cure." Different practical definitions may be formed and used for various specific purposes. This revised definition of epilepsy brings the term in concordance with common use. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here.

Microsatellite analysis as a tool for discriminating an interfamily hybrid between olive flounder and starry flounder

An interspecific artificial hybrid was produced between two economically important aquaculture flatfish: olive flounder (Paralichthys olivaceus) and starry flounder (P. stellatus). This hybrid displays the rapid growth characteristic of the former and tolerance to low temperatures and low salinity of the latter, but the genetics of inheritance in this hybrid have not been elucidated. Polymorphic microsatellite markers developed for P. olivaceus and P. stellatus were tested to determine if these markers can be used for analysis of parentage and genetic inheritance. Multiplex PCR using two primer sets that were specific to each species produced PCR products of different sizes; these could be used for the identification of interspecific hybrids. Among the 192 primers derived from olive flounder, 25.5% of the primer sets successfully amplified genomic DNA from starry flounder, and 23% of the 56 primer sets originating from starry flounder amplified DNA from olive flounder. Analysis of genetic inheritance in the hybrid using seven of the 62 microsatellite markers common to both species demonstrated classic Mendelian inheritance of these markers in the hybrid progeny, with the exception of one locus identified as a null allele in the hybrid. These results demonstrate that cross-specific microsatellite markers can be used tools for parentage analysis of hybrid flatfish, for mapping quantitative trait loci, for marker-assisted selective breeding, and for studies of the evolution of fish.

Inhibition of apoptosis signal-regulating kinase 1 reduces endoplasmic reticulum stress and nuclear huntingtin fragments in a mouse model of Huntington disease

Huntington's disease (HD) is characterized clinically by chorea, psychiatric disturbances, and dementia, while it is characterized pathologically by neuronal inclusions as well as striatal and cortical neurodegeneration. The neurodegeneration arises from the loss of long projection neurons in the cortex and striatum. In this study, we investigated the role of apoptosis signal-regulating kinase 1 (Ask1) in the pathogenesis of HD. We analyzed the expression of Ask1 and huntingtin (htt) within the striatum and cortex and also examined the interaction of Ask1 with htt fragments in HD (R6/2) mice. Additionally, we inhibited Ask1 and analyzed the resulting changes in brain-derived neurotrophic factor (BDNF) expression, motor function, and striatal atrophy. Ask1 activity was blocked using an Ask1 antibody raised against the C-terminus of the Ask1 protein. The anti-Ask1 antibody was infused into the striatum of the HD mice for four weeks using a micro-osmotic pump. The levels of Ask1 protein and endoplasmic reticulum (ER) stress were increased in HD mice. Binding of inactivated Ask1 to htt fragments was more prevalent in the cytosol than the nucleus of cortical neurons. Binding of inactivated Ask1 to htt fragments prevented translocation of the htt fragments into the nucleus, resulting in an improvement in motor dysfunction and atrophy. In the normal state, active Ask1 may help htt fragments enter the nucleus, while inactivated Ask1 hinders this translocation by binding to but not releasing fragmented htt into the nucleus. We propose that Ask1 may interact with htt fragments and subsequently induce ER stress. BDNF depletion may be prevented by targeting Ask1; this would decrease ER stress and possibly ameliorate behavioral or anatomical abnormalities that accompany HD. Therefore, regulating the amounts and activity of the Ask1 protein is a novel strategy for treatment of HD.

Lamotrigine extended-release as adjunctive therapy for partial seizures

OBJECTIVE

To evaluate the efficacy and tolerability of once-daily adjunctive lamotrigine extended-release (XR) for partial seizures in epilepsy.

METHODS

Patients more than 12 years old diagnosed with epilepsy with partial seizures and taking one to two baseline antiepileptic drugs were randomized to adjunctive once-daily lamotrigine XR or placebo in a double-blind, parallel-group trial. The study comprised a baseline phase, a 7-week double-blind escalation phase, and a 12-week double-blind maintenance phase during which doses of study medication and concomitant antiepileptic drugs were maintained.

RESULTS

Of the 243 randomized patients, 239 (118 lamotrigine XR, 121 placebo) entered the escalation phase and received study medication. Lamotrigine XR was more effective than placebo with respect to median percent reduction from baseline in weekly partial seizure frequency (primary endpoint-entire 19-week treatment phase: 46.6% vs 24.5%, p = 0.0001 [corrected] via Wilcoxon test; escalation phase: 29.8% vs 15.6%, p = 0.027; maintenance phase: 58.4% vs 26.8%, p [corrected] < 0.0001). The percentage of patients with >or=50% reduction in partial seizure frequency (44.0% vs 20.8%, p = 0.0002) [corrected] and time to >or=50% reduction in partial seizure frequency (p = 0.0001) [corrected] also favored lamotrigine XR over placebo. A similar pattern of results was observed for secondarily generalized seizures. The most common adverse events were headache (lamotrigine XR 16%, placebo 18%) [corrected] and dizziness (lamotrigine XR 19%, [corrected] placebo 5%). Differences between lamotrigine XR and placebo on health outcomes measures were not significant.

CONCLUSIONS

Once-daily adjunctive lamotrigine extended-release compared with placebo effectively reduced partial seizure frequency and was well tolerated in this double-blind study. Results support the clinical utility of this new once-daily formulation.

Diffusion PDE-based denoising technique for magnetic resonance electrical impedance tomography

Recent progress in magnetic resonance electrical impedance tomography (MREIT) research has shown that conductivity images with higher spatial resolution and accuracy are achievable. One of the most important remaining problems to be solved in MREIT before we can apply the technique to human subjects is how to reduce the amount of injection current. Since we use an MRI scanner to measure the induced magnetic flux density data subject to an injection current, the data is contaminated with random noise. In order to obtain enough signal-to-noise ratio (SNR), we need to inject a large amount of current into the subject. However, it is obvious that we must comply with the electrical safety regulations and this means that we should deal with noisy data having a low SNR due to the limited amount of injection current. Furthermore, in the developed reconstruction algorithms, the required numerical differentiations of the noisy data may result in deterioration of the reconstructed conductivity image leading to a loss of important information. We propose a PDE-based denoising technique that diminishes the degradation of reconstructed conductivity images due to the noise in measured data. The proposed PDE-based technique is advantageous in reducing the random noise while preserving useful features in MREIT.

Conductivity images of biological tissue phantoms using a 3.0 tesla MREIT system

We present cross-sectional conductivity images of a biological tissue phantom obtained by using a 3.0 Tesla magnetic resonance electrical impedance tomography (MREIT) system. Inside the cylindrical phantom with 140 mm diameter and 140 mm height, biological tissues such as bovine tongue and liver, porcine muscle, and chicken breast were placed within an agar gelatin. Injecting current of 480 mA.ms into the tissue phantom, we measured the z-component B/sub z/ of the induced magnetic flux density B=(B/sub x/, B/sub y/, B/sub z/). Using the harmonic B/sub z/ algorithm, we reconstructed cross-sectional conductivity images from the measured B/sub z/ data. Reconstructed images clearly distinguish different tissues in terms of both their shapes and conductivity values.

Association of aortic plaque with intracranial atherosclerosis in patients with stroke

OBJECTIVE

To determine whether there is a relationship between aortic plaques and intracranial (IC) atherosclerosis.

METHODS

We reviewed 922 patients with stroke who had both transesophageal echocardiography and cerebral angiography. The plaques of these patients were classified as either complex aortic plaques (CAP), which protruded > or =4 mm or were present as mobile lesions in the proximal aorta, or simple aortic plaques (SAP), which were <4 mm or present in the descending aorta. Cerebral artery atherosclerosis was classified as either an IC or extracranial (EC) atherosclerosis.

RESULTS

Among the 922 patients, we found aortic plaques in 237 patients (26%). There were 111 (47%) patients of SAP, 74 (31%) patients with CAP, and 52 (22%) patients that had both SAP and CAP. Angiography showed IC or EC atherosclerosis in 511 patients (55%). The presence of aortic plaques was significantly associated with IC or EC atherosclerosis. The significance appeared to be due to the strong association between the presence of SAP and IC atherosclerosis (51% SAP vs 35% no plaques; odds ratio = 1.94, 95% CI: 1.17 to 3.21). In the multiple logistic regression analysis, SAP were independent predictors of IC atherosclerosis

CONCLUSIONS

The presence of simple aortic plaques may be a marker of advanced vascular disease. Detection of simple aortic plaques during transesophageal echocardiography may have clinical implications because patients with these plaques frequently had concomitant intracranial atherosclerosis, a risk factor for stroke.

Physical phantom of typical Korean male for radiation protection purpose

Dose distribution within a human body can be measured using physical anthropomorphic phantoms. In an effort to establish reference Korean physical model, the first Korean physical phantom of average Korean adult male was constructed using computed tomography (CT) images of a healthy volunteer. The body dimension of the subject was close to that of average Korean male. The source images were obtained using fusion positron emission tomography machine at Radiation Health Research Institute in Korea, and ported into rapid prototyping process. The physical phantom was composed of three tissue-equivalent materials: epoxy resin, urethane foam and polyurethane representing bone, lungs and soft tissues, respectively. The densities of the tissue-equivalent materials were close to those recommended by the International Commission on Radiation Units and measurements. To facilitate dose mapping, the phantom was sliced into 2 cm sections. Hole grids for thermoluminescence (TL) dosemeter chips were drilled. To verify the appropriateness of the physical phantom, organ doses of selected organs were measured for reference photon beam, and compared with those computed by tomographic model constructed from the same CT images. Absorbed doses converted from TL relative response showed good agreement within 7% with those calculated.

The TB structural genomics consortium: a resource for Mycobacterium tuberculosis biology

The TB Structural Genomics Consortium is an organization devoted to encouraging, coordinating, and facilitating the determination and analysis of structures of proteins from Mycobacterium tuberculosis. The Consortium members hope to work together with other M. tuberculosis researchers to identify M. tuberculosis proteins for which structural information could provide important biological information, to analyze and interpret structures of M. tuberculosis proteins, and to work collaboratively to test ideas about M. tuberculosis protein function that are suggested by structure or related to structural information. This review describes the TB Structural Genomics Consortium and some of the proteins for which the Consortium is in the progress of determining three-dimensional structures.

Thyrotoxic autoimmune encephalopathy: a repeat positron emission tomography study

Thyroid related autoantibodies have been related to the development of encephalopathy, known as Hashimoto's encephalopathy. However, their relation with the encephalopathy occurring in patients with Graves' disease has not been well established. The case is reported of a 51 year old woman presenting with subacute progressive dementia with evidence of hyperthyroidism. She had Graves' disease associated with high titres of thyroid related autoantibodies. Her encephalopathy was not improved by antithyroid drugs, but promptly responded to corticosteroid treatment, and stabilised with a gradual reduction of thyroid related autoantibody titres. Brain positron emission tomography initially showed a diffuse and multifocal cerebral hypometabolism with subsequent normalisation on her clinical recovery, which was consistent with the acute and reversible cerebral inflammation probably mediated by autoimmune mechanisms.

Yonsei Stroke Registry. Analysis of 1,000 patients with acute cerebral infarctions

BACKGROUND AND PURPOSE

The hospital-based stroke registry is a well-established method useful for understanding diverse clinical characteristics of stroke related to geographical, racial or environmental differences. We analyzed the data from 1,000 patients with acute cerebral infarctions registered with the Yonsei Stroke Registry (YSR) which is the first prospective hospital-based observational study in Korea.

METHODS

All patients had cerebral infarctions and presented within 7 days of onset. CT or MRI was performed in all patients and a vascular imaging study (digital subtraction or magnetic resonance angiography) was conducted in 53.9% of the patients. Subtype classification was made through a consensus approach based on the strict application of TOAST criteria.

RESULTS

The mean age of patients was 62 +/- 12 years, and 60.8% were males. Undetermined cause (UD) was the most frequent subtype (40.6%), which was followed by lacunar stroke (LS 21.5%), cardiac embolism (CE 18.3%), large-artery atherosclerosis (LAA 16.5%) and other determined causes (3.1%). Hypertension was found in 64.3%, smoking in 35.2%, diabetes mellitus in 26.9%, hypercholesterolemia in 24.1%, high hematocrit (> or = 50%) in 21.8%, clinically identified potential cardiac sources of embolism in 18.3%, a history of previous stroke in 22.0% and a history of previous transient ischemic attack in 4.7%. Recurrent stroke was associated with a higher number of risk factors (p < 0.001) and a higher incidence of LAA (p = 0.003) than the first stroke. Vertebrobasilar artery territorial infarction was found in 39.8%, which was associated with higher incidences of LAA and LS and a lower incidence of CE than carotid artery territorial lesions (p = 0.001). The 30-day mortality rate was 5.3% and cerebral herniation caused early death in 52%.

CONCLUSION

The distribution of stroke subtypes in the YSR was largely comparable with that of western registries. The highest incidence of UD might be related to the strict application of TOAST criteria.

Bcl-2 blocks cisplatin-induced apoptosis by suppression of ERK-mediated p53 accumulation in B104 cells

Bcl-2 has been reported to inhibit neurotoxicity induced by cisplatin. However, neither the mechanism of cisplatin-induced neurotoxicity nor the mechanism by which Bcl-2 confers neuroprotection is clear. In this study, the signaling pathways involved in cisplatin-induced neurotoxicity were examined using a rat neuroblastoma cell line, B104. Treatment of B104 cells with cisplatin induced apoptosis, accompanying the accumulation of p53 and Bax protein. Interestingly, extracellular signal-regulated kinase 1/2 (ERK1/2) activities of MAP kinases were markedly enhanced prior to cisplatin-induced accumulation of p53 and Bax. Inhibition of ERK1/2 activities using PD98059, a selective MEK inhibitor, blocked the apoptotic cell death preventing cisplatin-induced accumulation of p53 and Bax. These results suggest that ERK mediates cisplatin-induced p53 activation to trigger apoptosis in B104 cells. Overexpression of Bcl-2 in B104 cells resulted in the complete resistance to cisplatin-induced apoptosis blocking ERK activation and the subsequent signaling pathway of p53. Our study clearly demonstrates that the action site of Bcl-2 localizes upstream of ERK in cisplatin-induced apoptotic signaling pathway.

Crystallization and preliminary X-ray crystallographic analysis of deoxyuridine triphosphate nucleotidohydrolase from Saccharomyces cerevisiae

Deoxyuridine triphosphate nucleotidohydrolase (dUTPase) from Saccharomyces cerevisiae is essential for cell viability. It has been overexpressed in Escherichia coli and has been crystallized at 296 K using polyethylene glycol (PEG) 1500 as a precipitant. The crystals belong to the orthorhombic space group P2(1)2(1)2(1), with unit-cell parameters a = 59.48, b = 138.54, c = 157.91 A, alpha = beta = gamma = 90 degrees. Two molecules of trimeric dUTPase from S. cerevisiae are present in the asymmetric unit, giving a crystal volume per protein mass (V(M)) of 3.36 A(3) Da(-1) and a solvent content of 63%. The diffraction limit of the crystals could be significantly extended by the crystal-annealing procedure. A set of native data extending to 2.7 A resolution has been collected at 100 K using synchrotron X-rays.

Ictal automatisms with preserved responsiveness in a patient with left mesial temporal lobe epilepsy

PURPOSE

To describe the possible mechanism of ictal automatisms with preserved responsiveness (APRs) in a patient with left mesial temporal lobe epilepsy, which had not been reported previously.

METHODS

Ictal EEGs recorded from bilateral foramen ovale electrodes with scalp-sphenoidal electrodes were analyzed in respect to the ictal semiology.

RESULTS

The patient had a right hemispheric language dominance in the dextral. Electroclinical analysis revealed that the onset of oroalimentary automatisms coincided with the involvement of the left mesial and lateral temporal structures by spreading ictal discharges. The ictal discharge spreading was limited to the ipsilateral hemisphere throughout the seizure, which explained the intact consciousness and preserved responsiveness of the patient.

CONCLUSIONS

This case suggests that APRs take place in seizures originating from the nondominant temporal lobe, during which ipsilateral mesial and lateral temporal structures are diffusely involved without spreading to the contralateral side.

Crystal structure of the MJ0490 gene product of the hyperthermophilic archaebacterium Methanococcus jannaschii, a novel member of the lactate/malate family of dehydrogenases

The MJ0490 gene, one of the only two genes of Methanococcus jannaschii showing sequence similarity to the lactate/malate family of dehydrogenases, was classified initially as coding for a putative l-lactate dehydrogenase (LDH). It has been re-classified as a malate dehydrogenase (MDH) gene, because it shows significant sequence similarity to MT0188, MDH II from Methanobacterium thermoautotrophicum strain DeltaH. The three-dimensional structure of its gene product has been determined in two crystal forms: a "dimeric" structure in the orthorhombic crystal at 1.9 A resolution and a "tetrameric" structure in the tetragonal crystal at 2.8 A. These structures share a similar subunit fold with other LDHs and MDHs. The tetrameric structure resembles typical tetrameric LDHs. The dimeric structure is equivalent to the P-dimer of tetrameric LDHs, unlike dimeric MDHs, which correspond to the Q-dimer. The structure reveals that the cofactor NADP(H) is bound at the active site, despite the fact that it was not intentionally added during protein purification and crystallization. The preference of NADP(H) over NAD(H) has been supported by activity assays. The cofactor preference is explained by the presence of a glycine residue in the cofactor binding pocket (Gly33), which replaces a conserved aspartate (or glutamate) residue in other NAD-dependent LDHs or MDHs. Preference for NADP(H) is contributed by hydrogen bonds between the oxygen atoms of the monophosphate group and the ribose sugar of adenosine in NADP(H) and the side-chains of Ser9, Arg34, His36, and Ser37. The MDH activity of MJ0490 is made possible by Arg86, which is conserved in MDHs but not in LDHs. The enzymatic assay showed that the MJ0490 protein possesses the fructose-1,6-bisphosphate-activated LDH activity (reduction). Thus the MJ0490 gene product appears to be a novel member of the lactate/malate dehydrogenase family, displaying an LDH scaffold and exhibiting a relaxed substrate and cofactor specificities in NADP(H) and NAD(H)-dependent malate and lactate dehydrogenase reactions.

Enhanced detection of right-to-left shunt through patent foramen ovale by transthoracic contrast echocardiography using harmonic imaging

When the results of transesophageal echocardiography was regarded as the gold standard for detecting a patent foramen ovale (PFO) in 136 consecutive patients referred for evaluation of cardiac source of embolism, transthoracic harmonic imaging using saline contrast was superior to fundamental imaging in accuracy for detecting a PFO (sensitivity, 22.5%; specificity [p < 0.05] and sensitivity, 100%; specificity 100%, respectively.)

Diffusion-weighted image and MR spectroscopic analysis of a case of MELAS with repeated attacks

We report the clinical and MR manifestations of an 18 year-old girl with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome. Recurrent status epilepticus caused reversible cytotoxic edema on diffusion-weighted images (DWI). Initial and one month follow-up MR spectroscopy, after seizure control, showed some discrepancies in the ratio of metabolites. N-acetylaspartate (NAA) partially recovered (NAA/creatine (Cr) ratio: 1.27-->1.84). This was because of a normalization of decreased NAA due to cellular dysfunction as a result of status epilepticus. A low ratio of NAA/Cr due to abnormal mitochondria remained in the decreased state. Reversible NAA/Cr ratios in the acute lesion suggested that NAA reflects the neuronal function as well as the level of neuronal structural damage. The altered NAA/Cr ratio better correlated with the abnormal signal intensity area of T2-weighted images (T2WI) and DWI than the lactate (Lac)/Cr ratio. With conservative treatment with anti-epileptics not accompanied by coenzyme Q or sodium dichloroacetate, lactate persistently increased (Lac/Cr ratio: 1.01-->1.21) because of the continued production of lactate in cells with respiratory deficiency, which is the main pathology of MELAS.

Radionuclide cisternography in spontaneous intracranial hypotension with simultaneous leaks at the cervicothoracic and lumbar levels

This case report clearly illustrates defined simultaneous cerebrospinal fluid leaks at the cervicothoracic and upper lumbar areas. A 53-year-old woman without a remarkable medical history was hospitalized for sudden onset of severe headache. The headache lasted more than 1 week and standing or sitting positions exaggerated the symptoms, although it was relieved when the patient was recumbent. Radionuclide cisternography was performed using 150 MBq (4 mCi) Tc-99m DTPA. It revealed two cerebrospinal fluid leaks from the cervicothoracic junction bilaterally and the left side of the upper lumbar area. Epidural blood patching was tried at the lumbar level (L1-L2) and showed only a transient effect. A second trial of this method at the level of C7-T1 performed 2 days later resulted in immediate improvement of the symptoms without recurrence. The simultaneous cerebrospinal fluid leaks were detected successfully with radionuclide cisternography using Tc-99m DTPA, which provided a useful guideline for treatment despite the limitations of delayed scanning.

MS-275, a histone deacetylase inhibitor, selectively induces transforming growth factor beta type II receptor expression in human breast cancer cells

Transcriptional repression of the transforming growth factor (TGF)-1P type II receptor (TPRII) gene appears to be a major mechanism to inactivate TGF-beta responsiveness in many human cancers. Because histone acetylation/deacetylation plays a role in transcriptional regulation, we have examined the effect of MS-275, a synthetic inhibitor of histone deacetylase, in human breast cancer cell lines. MS-275 showed antiproliferative activity against all human breast cancer cell lines examined and induced TbetaRII mRNA, but not TGF-beta type I receptor mRNA. MS-275 caused an accumulation of acetylated histones H3 and H4 in total cellular chromatin. An increase in the accumulation of acetylated histones H3 and H4 was detected in the TbetaRII promoter after treatment with MS-275. However, the level of histone acetylation did not change in chromatin associated with the TGF-beta type I receptor gene. MS-275 treatment enhanced TGF-beta1-induced plasminogen activator inhibitor 1 expression. Thus, antitumor activity of MS-275 may be mediated in part through the induction of TbetaRII expression and consequent potentiation of TGF-beta signaling.

Mechanism of induction of transforming growth factor-beta type II receptor gene expression by v-Src in murine myeloid cells

Transforming growth factor (TGF)-beta1 plays an important role during hematopoiesis. Previously, we had shown that the growth of a v-Src-transformed myeloid cell line was markedly more inhibited by TGF-beta treatment when compared with the wild-type myeloid cell line. To investigate the increased growth sensitivity of the v-Src-transformed myeloid cell line, 32D-src, to TGF-beta, we examined expression of the TGF-beta type II receptor (TGF-beta RII) gene in myeloid cell lines. Northem blot analysis showed that expression of approximately 8- and 6-kb species of TGF-beta RII transcripts was markedly increased in the 32D-src cell line. The expression of the TGF-beta RII promoter linked to a reporter gene was increased 23-fold by v-Src. DNA transfection and electrophoretic mobility shift assay revealed that v-Src induces TGF-beta RII promoter activity through an AP1/ATF2-like sequence (-219 to -172), ETS binding sites (+1 to +36), and the inverted CCAAT box (-81 to -77). Novel DNA-protein complexes with ETS binding sites are significantly increased in v-src-transformed cell lines compared with the control cell line. These results suggest that v-Src induces activity of the TGF-beta RII promoter through multiple elements by inducing expression of nuclear proteins interacting with these elements.

Evaluation of ictal brain SPET using statistical parametric mapping in temporal lobe epilepsy

An automated voxel-based analysis of brain images using statistical parametric mapping (SPM) is accepted as a standard approach in the analysis of activation studies in positron emission tomography and functional magnetic resonance imaging. This study aimed to investigate whether or not SPM would increase the diagnostic yield of ictal brain single-photon emission tomography (SPET) in temporal lobe epilepsy (TLE). Twenty-one patients (age 27.14 +/- 5.79 years) with temporal lobe epilepsy (right in 8, left in 13) who had a successful seizure outcome after surgery and nine normal subjects were included in the study. The data of ictal and interictal brain SPET of the patients and baseline SPET of the normal control group were analysed using SPM96 software. The t statistic SPM¿t¿ was transformed to SPM¿Z¿ with various thresholds of P<0.05, 0.005 and 0.001, and corrected extent threshold P value of 0.05. The SPM data were compared with the conventional ictal and interictal subtraction method. On group comparison, ictal SPET showed increased uptake within the epileptogenic mesial temporal lobe. On single case analysis, ictal SPET images correctly lateralized the epileptogenic temporal lobe in 18 cases, falsely lateralized it in one and failed to lateralize it in two as compared with the mean image of the normal group at a significance level of P<0.05. Comparing the individual ictal images with the corresponding interictal group, 15 patients were correctly lateralized, one was falsely lateralized and four were not lateralized. At significance levels of P<0.005 and P<0.001, correct lateralization of the epileptogenic temporal lobe was achieved in 15 and 13 patients, respectively, as compared with the normal group. On the other hand, when comparison was made with the corresponding interictal group, only 7 out of 21 patients were correctly lateralized at the threshold of P<0.005 and five at P<0.001. The result of the subtraction method was close to the single case analysis on SPM at P<0.05. However, at higher thresholds (P<0.005 and 0.001) the subtraction method was comparable to the SPM results only when individual ictal images were compared with the normal control group, and not when comparison was with the interictal group. It is concluded that SPM is an alternative diagnostic method for the localization or lateralization of the seizure focus in temporal lobe epilepsy and that interictal SPET could be omitted if a normal brain SPET database were to be established. The medical cost of seizure localization would thereby be reduced.

Abnormal band of the lateral meniscus of the knee

We report 2 cases of an abnormal band of the lateral meniscus of the knee joint. A 23-year-old man complained of mechanical symptoms in both knees and an arthroscopic procedure was performed. We found meniscal abnormalities in the both knees. A 20-year-old man sustained a posterior cruciate ligament injury. In the course of an arthroscopy for his torn posterior cruciate ligament, an abnormal band of the lateral meniscus was seen. It was characteristic that the upper abnormal band was loose and serpentine and connected at the posterior horn and the middle segment of the lower normal lateral meniscus. Arthroscopic resection of abnormal bands successfully eliminated the symptoms. Because of its characteristic appearance and bilaterality, it was evident that this abnormal band was a congenital anomaly.

Correlation of electrodiagnostic findings with subjective symptoms in carpal tunnel syndrome

The records of 138 patients (222 hands) who had been evaluated by preoperative nerve conduction study (NCS) and consecutive self-administered questionnaires were analyzed to determine diagnostic relations in carpal tunnel syndrome. Hands were categorized into six grades (extreme, severe, moderate, mild, minimal, and negative) according to the three modalities: the NCS data of the median sensory nerve, Symptom Severity Scale score, and Functional Status Scale score. The authors evaluated the correlation, independence, homogeneity, and association among parameters, and found the following: (1) the NCS data correlated more significantly (p < 0.05) and was associated more linearly with Symptom Severity Scale score than the Functional Status Scale score; (2) the choice of modality exerted an influence on grading severities, thus grades varied according to the modalities; and (3) the distribution of patients was not homogenous; there were more extremes in NCS, and more severe scores on the Symptom Severity Scale. Patients rated as one homogeneous severity by NCS data may be interpreted into different severities (from negative to extreme) by self-administered questionnaires and vice versa.

MRI features of infarcts with potential cardiac source of embolism in the Yonsei Stroke Registry (YSR), Korea

The determination of the embolic source is crucial to understanding the pathogenesis of ischemic stroke, the initiation of appropriate therapy, and the prevention of recurrent infarctions. In this study we undertook to identify the characteristic features on magnetic resonance images of patients who had suffered from stroke due to cardiac embolism (CE), as classified by TOAST (possible and probable). We retrospectively studied magnetic resonance imaging (MRI) findings of patients with ischemic stroke from the Yonsei Stroke Registry (YSR). On the basis of the TOAST classification, 92 patients were identified to have a potential cardiac source of embolism (PCSE), in which 69 patients were found to have high-risk PCSE and 23 patients medium-risk PCSE. To compare their imaging characteristics, another group of 49 patients who were found to have had a stroke due to large artery-to-artery (ATA) embolism-common or internal carotid artery (CCA, ICA)-were identified. Involvement of the simultaneous superficial and deep territories (58.7%; 6.1%, p < 0.001), and combined new anterior and old posterior circulation (15.2%; 2.0%, p = 0.016) were more frequent in PCSE than ATA embolism. Bilateral anterior hemispheric involvement was also more frequent in the PCSE group, but it did not reach statistical significance (13.0%; 4.1%, p = 0.090). ATA embolism tended to involve only superficial territories compared to PCSE (71.4%; 28.3%, p < 0.001). There were no topographic differences between the high-risk and medium-risk groups. With respect to the etiology of PCSE in our population, atrial fibrillation was the most common. Characteristic MRI features of patients with PCSE, which were not documented previously by computed tomography (CT) included: old and new, involvement of multiple different vascular territories, bilateral anterior hemisphere, as well as anterior and posterior circulation. These MRI features, together with simultaneous superficial and deep territorial involvement, help to differentiate the underlying embolic sources, whether they are cardiac or ATA in origin.

Topical and systemic anticoagulation in the treatment of absent or compromised venous outflow in replanted fingertips

Adequate venous repair is not always possible in fingertip replantation. We have used topical and systemic anticoagulation for fingertip replantation to overcome venous congestion in cases without venous repair or in cases in which there is obstruction of a repaired vein. Our technique consists of continuous external bleeding via a stab incision on the paraungal area and dripping heparinized saline solution at the incision site to maintain external bleeding. From July 1985 to December 1993, 157 fingers in 140 patients with complete amputation of the fingertip were replanted at Korea University Guro Hospital. Of these, 74 fingers in 68 patients were managed by topical and systemic anticoagulation due to the impossibility of repair or obstruction of a repaired vein. The overall survival rate of the fingertip replantations was 76%; that of the topical and systemic anticoagulation group was 64%.

The effects of the number and ratio of repaired arteries and veins on the survival rate in digital replantation

From January 1990 to December 1998, 631 consecutive single-digit replantations were reviewed retrospectively to determine the essential number of vascular anastomoses and the artery-to-vein ratio for successful finger replantation. The correlations between the number and the ratio of anastomosed vessels and the survival rate were examined according to the amputated digital levels, and all of the correlated results were compared with each other statistically. In zone I, the survival rate of the digits with a vein repaired was higher than that of digits treated with the external bleeding method. In zone II, repairing more arteries than veins led to venous congestion and resulted in a failure of replantation. Thus, the ratio of an equal or greater number of veins repaired to the arteries repaired was an important factor in successful replantation in zone II, which may be due to the large amount of arterial input relative to the small volume of venous drainage via small veins in the replanted digit. In zone III, the equal number of arteries and veins repaired was also an important factor in successful replantation. However, unlike zone II, even when more arteries were repaired than veins, venous congestion occurred rarely because the vein in this area was larger, providing sufficient venous drainage. In zone IV, repair of two veins was needed to yield good results. Because the volume of the amputated part in zone IV was larger than in other zones, it was desirable to repair both arteries, even though repairing one artery yielded good results. In conclusion, it is desirable to repair as many vessels as possible to increase the possibility of a good result. However, digital amputations and their conditions for replantation differ. Therefore, the number and ratio of vessels that need to be repaired should be modified and adjusted in each case.

Lactate dehydrogenase from the hyperthermophilic archaeon Methanococcus jannaschii: overexpression, crystallization and preliminary X-ray analysis

L(+)-Lactate dehydrogenase (LDH) is a key enzyme in anaerobic metabolism which converts pyruvate to lactate. LDH from the hyperthermophilic archaebacterium Methanococcus jannaschii has been overexpressed in Escherichia coli and crystallized in two crystal forms at 297 K using 2-methyl-2,4-pentanediol as precipitant. Type I crystals grew rapidly and diffracted to at least 2.8 A Bragg spacing upon exposure to Cu Kalpha X-rays. X-ray diffraction data to 2.9 A have been collected from a native crystal. The type I crystal is tetragonal, belonging to the space group P4(2)2(1)2, with unit-cell parameters a = b = 99.74, c = 170.00 A. The asymmetric unit contains two LDH subunits, with a corresponding crystal volume per protein mass (V(m)) of 3.05 A(3) Da(-1) and a solvent content of 59.7%. Type II crystals, which grew more slowly, diffracted to at least 1.8 A Bragg spacing upon exposure to Cu Kalpha X-rays. X-ray diffraction data to 1.9 A have been collected from a native crystal. The type II crystal is orthorhombic, belonging to the space group P2(1)2(1)2, with unit-cell parameters a = 47.65, b = 125.10, c = 58.08 A. The asymmetric unit contains a single LDH subunit, with a corresponding crystal volume per protein mass (V(m)) of 2.50 A(3) Da(-1) and a solvent content of 50.8%. Therefore, the type II crystal is more suitable for high-resolution structure determination than the type I crystal.

The RAD2 domain of human exonuclease 1 exhibits 5' to 3' exonuclease and flap structure-specific endonuclease activities

The RAD2 family of nucleases includes human XPG (Class I), FEN1 (Class II), and HEX1/hEXO1 (Class III) products gene. These proteins exhibit a blend of substrate specific exo- and endonuclease activities and contribute to repair, recombination, and/or replication. To date, the substrate preferences of the EXO1-like Class III proteins have not been thoroughly defined. We report here that the RAD2 domain of human exonuclease 1 (HEX1-N2) exhibits both a robust 5' to 3' exonuclease activity on single- and double-stranded DNA substrates as well as a flap structure-specific endonuclease activity but does not show specific endonuclease activity at 10-base pair bubble-like structures, G:T mismatches, or uracil residues. Both the 5' to 3' exonuclease and flap endonuclease activities require a divalent metal cofactor, with Mg(2+) being the preferred metal ion. HEX1-N2 is approximately 3-fold less active in Mn(2+)-containing buffers and exhibits <5% activity in the presence of Co(2+), Zn(2+), or Ca(2+). The optimal pH range for the nuclease activities of HEX1-N2 is 7.2-8.2. The specific activity of its 5' to 3' exonuclease function is 2.5-7-fold higher on blunt end and 5'-recessed double-stranded DNA substrates compared with duplex 5'-overhang or single-stranded DNAs. The flap endonuclease activity of HEX1-N2 is similar to that of human flap endonuclease-1, both in terms of turnover efficiency (k(cat)) and site of incision, and is as efficient (k(cat)/K(m)) as its exonuclease function. The nuclease activities of HEX1-N2 described here indicate functions for the EXO1-like proteins in replication, repair, and/or recombination that may overlap with human flap endonuclease-1.

Expression specificity of the mouse exonuclease 1 (mExo1) gene

Genetic recombination involves either the homo-logous exchange of nearly identical chromosome regions or the direct alignment, annealing and ligation of processed DNA ends. These mechanisms are involved in repairing potentially lethal or mutagenic DNA damage and generating genetic diversity within the meiotic cell population and antibody repertoire. We report here the identification of a mouse gene, termed mExo1 for mouse exonuclease 1, which encodes a approximately 92 kDa protein that shares homology to proteins of the RAD2 nuclease family, most notably human 5' to 3' exonuclease Hex1/hExo1, yeast exonuclease 1 (Exo1) proteins and Drosophila melanogaster Tosca. The mExo1 gene maps to distal chromosome 1, consistent with the recent mapping of the orthologous HEX1 / hEXO1 gene to chromosome 1q42-q43. mExo1 is expressed prominently in testis, an area of active homologous recombination, and spleen, a prominent lymphoid tissue. An increased level of mExo1 mRNA was observed during a stage of testis development where cells that are actively involved in meiotic recombination arise first and represent a significant proportion of the germ cell population. Comparative evaluation of the expression patterns of the human and mouse genes, combined with previous biochemical and yeast genetic studies, indicate that the Exo1-like proteins are important contributors to chromosome processing during mammalian DNA repair and recombination.

Evaluation of reperfusion and recovery of brain function before and after intracarotid arterial urokinase therapy in acute cerebral infarction with brain SPECT

PURPOSE

Perfusion defects can be demonstrated reliably at an early stage with regional cerebral blood flow studies using SPECT. The administration of thrombolytic therapy in ischemic stroke is targeted at restoring cerebral perfusion immediately, leading to salvage of ischemic penumbra, smaller infarct size, and improved clinical outcome. This study considered the role of brain perfusion SPECT in the evaluation of reperfusion and brain function recovery of the infarcted area after early recanalization (less than 6 hours) of the occluded artery using intracarotid arterial urokinase therapy (ICAU).

METHODS

Intracranial artery occlusion was confirmed in seven patients using emergency carotid angiography performed within the initial 6-hour period. Intracarotid arterial urokinase (500,000 to 800,000 units) was administered into the occluded arterial system (the left middle cerebral artery in four and the right middle cerebral artery in three patients). CT scanning was performed when the patients arrived in the emergency department and was repeated 24 to 48 hours after ICAU and at 7 days or earlier if clinically indicated. All patients had two SPECT studies, the first before urokinase administration and the second 24 or 48 hours later.

RESULTS

Complete recanalization of the occluded vessels was seen in one patient after ICAU, effective partial recanalization was achieved in four patients, and minimal recanalization occurred in the other two. Before ICAU, Tc-99m HMPAO brain SPECT showed decreased uptake of the infarcted area in all patients, whereas the follow-up brain SPECT performed 24 or 48 hours after ICAU revealed improvement in the uptake of the recanalized area on qualitative and semiquantitative assessments using an asymmetry index, suggestive of brain function recovery and clinical improvement. Hemorrhagic transformation adjacent to the reperfused regions occurred in two patients with partial recanalization of the left middle cerebral artery.

CONCLUSIONS

Reperfusion of the recanalized area and brain function recovery could be achieved if the occluded artery is recanalized within the initial 6-hour period using ICAU, and this was documented using brain perfusion SPECT without a delay in the therapeutic time window. Because the number of patients we studied was limited, further study is necessary to evaluate the effect of ICAU and to determine its prognostic significance.

A structural determinant of the unique interfacial binding mode of bovine pancreatic phospholipase A2

The catalytic steps of the phospholipase A2 (PLA2)-catalyzed hydrolysis of phospholipids are preceded by interfacial binding. Among various pancreatic PLA2s, bovine pancreatic PLA2 (bpPLA2) has a unique interfacial binding mode in which Lys-56 plays an important role in its binding to anionic lipid surfaces. To identify the structural determinant of this unique interfacial binding mode of bpPLA2, we systematically mutated bpPLA2 and measured the effects of mutations on its interfacial binding and activity. First, different cationic clusters were generated in the amino-terminal alpha-helix by the N6R, G7K, and N6R/G7K mutations. These mutations enhanced the binding of bpPLA2 to anionic liposomes up to 15-fold. For these mutants, however, the K56E mutation still caused a large drop in interfacial affinity for and activity toward anionic liposomes, indicating that the generation of a cationic patch in the amino-terminal alpha-helix of bpPLA2 did not change its interfacial binding mode. Second, residues 62-66 that form a part of the pancreatic loop were deleted. For this deletion mutant (Delta62-66), which was as active as wild-type toward anionic liposomes, the K56E and K116E mutations (Delta62-66/K56E and Delta62-66/K116E) did not have significant effects on interfacial affinity. In contrast, the K10E mutation showed a much larger decrease in interfacial affinity (10-fold), indicating the deletion of residues 62-66 caused a major change in the interfacial binding mode. Finally, hydrophobic residues in positions 63 and 65 were replaced by bulkier ones (V63F and V63F/V65L) to pinpoint the structural determinant of the interfacial binding mode of bpPLA2. The effects of K10E and K56E mutations on the interfacial affinity and activity of these mutants showed that Val-63 and Val-65 of bpPLA2 are the structural determinant of its unique interfacial binding mode and that relatively conservative substitutions at these positions result in large changes in the interfacial binding mode among mammalian pancreatic PLA2s. Taken together, this study reveals how minor structural differences among homologous PLA2s can lead to distinct interfacial binding behaviors.

Differential interfacial and substrate binding modes of mammalian pancreatic phospholipases A2: a comparison among human, bovine, and porcine enzymes

To identify the residues essential for interfacial binding and substrate binding of human pancreatic phospholipase A2 (hpPLA2), several ionic residues in the putative interfacial binding surface (R6E, K7E, K10E, and K116E) and substrate binding site (D53K and K56E) were mutated. Interfacial affinity of these mutants was measured using anionic polymerized liposomes, and their enzymatic activity was measured using various substrates including phospholipid monomers, zwitterionic and anionic micelles, and anionic polymerized mixed liposomes. Similar mutations (R6E, K10E, K56E, and K116E) were made to porcine pancreatic phospholipase A2 (ppPLA2), and the properties of mutants were measured by the same methods. Results indicate that hpPLA2 and ppPLA2 have similar interfacial binding mechanisms in which cationic residues in the amino terminus and Lys-116 in the carboxy terminus are involved in binding to anionic lipid surfaces. Small but definite differences between the two enzymes were observed in overall interfacial affinity and activity and the effects of the mutations on interfacial enzyme activity. The interfacial binding of hpPLA2 and ppPLA2 is distinct from that of bovine pancreatic phospholipase A2 in that Lys-56 is involved in the interfacial binding of the latter enzyme. The unique phospholipid headgroup specificity of hpPLA2 derives from the presence of Asp-53 in the substrate binding site. This residue appears to participate in stabilizing electrostatic interactions with the cationic ethanolamine headgroup, hence the phosphatidylethanolamine preference of hpPLA2. Taken together, these studies reveal the similarities and the differences in the mechanisms by which mammalian pancreatic phospholipases A2 interact with lipid aggregates and perform interfacial catalysis.

The prognosis for control of seizures with medications in patients with MRI evidence for mesial temporal sclerosis

PURPOSE

Mesial temporal sclerosis (MTS) is the most common and important pathology in temporal lobe epilepsy (TLE), and its presence in magnetic resonance imaging (MRI) scans is strongly correlated with a successful surgical outcome. Despite the general assumption that patients with MTS respond poorly to medication, the long-term prognosis for such patients has not yet been investigated. We studied the overall clinical prognosis of patients with MTS and analyzed the factors related to the degree of medical responsiveness.

METHODS

Case patients were actively followed up at the Yonsei Epilepsy Clinic in Seoul, Korea, for >2 years. A structured interview and a thorough clinical evaluation were conducted. MRI scans, at the field strength of 1.0 or 1.5 Tesla, were performed with T1- and T2-weighted coronal and axial spin-echo images. All coronal slices were < or = 5-mm thick with no gap. Two neurologists and one radiologist determined the presence of MTS in MRIs by visual analysis.

RESULTS

The MTS group consisted of 104 patients. Of these, 26 (25%) were completely controlled with adequate therapy, and 40 (38%) were intractable, despite aggressive anticonvulsant polytherapy. The remaining 37% had their seizure frequencies reduced by > or = 50%, but were not seizure free. The age of seizure onset was significantly younger in the intractable group than in the well-controlled group. Patients with a history of febrile convulsions or with epileptiform discharges in their electroencephalogram (EEG) had poorer seizure control (p < 0.05) than those who did not. Among the 16 patients who had no previous treatment, five (31%) became seizure free, and two were intractable.

CONCLUSIONS

Not all patients with MTS are medically intractable; 25% of the patients in our study achieved complete control while receiving medication. Poor seizure control was related to an early age of seizure onset, a history of febrile convulsions, and epileptiform discharges on the EEG.

Serial brain SPECT images in a case of Sydenham chorea

BACKGROUND

The pathophysiological nature of Sydenham chorea (SC) has been presumed to be an autoimmune-mediated inflammatory process. Positron emission tomography in SC has revealed a striatal hypermetabolism that might explain the transient neuronal dysfunction. However, any focal hyperperfusion in the striatum or its related structures has not been demonstrated in previous single photon emission computed tomographic (SPECT) imaging studies, which raised a concern about the pathogenesis of the striatal hypermetabolism.

OBJECTIVE

To investigate the cerebral perfusion patterns of the subcortical structures by using serial technetium Tc 99m-ethyl cysteinate dimer SPECT in a case of SC, which may provide a clue for the pathophysiological mechanisms.

DESIGN

A case report and serial SPECT studies.

CASE PRESENTATION

A girl aged 4 years 3 months showed severe generalized choreic movements with concomitant signs of acute pharyngitis. Results of a laboratory study taken 7 days after the onset of chorea showed elevated antistreptolysin O titer, C-reactive protein levels, and erythrocyte sedimentation rate. Other laboratory data, throat culture, echocardiography, brain magnetic resonance imaging, and electroencephalography did not reveal any abnormalities. Five days after treatment with haloperidol and penicillin, the chorea began to improve slowly, and completely resolved in 2 months.

RESULTS

Three serial SPECT images and semiquantitative analysis of cerebral perfusion were obtained. Cerebral perfusion in the striatum and thalamus was markedly increased bilaterally during the stage of active chorea and then returned nearly to its baseline level during the convalescent phase. These cerebral perfusion patterns were concordant with semiquantitative analysis.

CONCLUSIONS

Hyperperfusion in both the striatum and thalamus in our patient may reflect the subcortical inflammatory processes in SC. The unequivocal SPECT findings in our patient are difficult to reconcile with the negative findings of previous SPECT studies but may suggest the heterogeneity of the perfusion patterns in SC.

Localized pigmented villonodular synovitis of the knee: arthroscopic treatment

Pigmented villonodular synovitis (PVNS) is a relatively rare condition. It occurs in two forms: a diffuse form involves the entire synovium and occurs in the majority of cases, and a localized form involves a discrete section of the synovium. The disorder almost always involves a single joint and the knee is most commonly affected. We report on three cases of localized PVNS that involved the patellar fat pad and synovium. Diagnostic and therapeutic arthroscopies were performed, and typical localized PVNS was found. Complete resection of the lesions was performed arthroscopically. Arthroscopy can be used as an effective diagnostic and therapeutic tool for identification and treatment of intra-articular localized PVNS of the knee.

Clinical courses of pure sleep epilepsies

This study aims to understand seizure control outcomes and the risk of developing new wake seizures (WS) related to the different types of pure sleep epilepsies (SE), which is important in making rational management plans. A retrospective review of the Yonsei Epilepsy Clinic Registry identified 63 patients with pure SE not belonging to any specific epileptic syndromes. They were divided into the group of generalized tonic-clonic seizures during sleep (S-GTCS : n = 21) and the group of partial epilepsies during sleep (S-PE: n = 42) on the basis of seizure phenomenology, EEG, and neuroimaging data. These patients were followed for 2 years and their clinical variables were analysed for seizure control outcomes and development of new WS. Of 21 patients with S-GTCS, 17 achieved a seizure-free outcome and only one patient developed a new WS, which was consistent with a partial-onset secondary GTCS in phenomenology. Of 42 patients with S-PE only 15 patients achieved a seizure-free outcome and 11 patients developed WS during the 2-year follow-up period. Higher baseline seizure frequency and longer duration of epilepsy were associated with a higher incidence of new WS. The results suggest that the patients with S-GTCS carry a favorable clinical course, thus driving privileges or freedom of daily activities can be conferred without delay once their seizures are well controlled. However, the seizure control outcome was poor and the development of WS was frequent in patients with recurrent S-PE.

Bent stents: a method to facilitate delivery of the Palmaz-Schatz stent in tortuous and rigid coronary arteries

The Palmaz-Schatz stent delivery system (PS 153) and "bare" PS 204 stents are relatively high-profile, rigid devices that can be difficult to deliver to lesions beyond tortuous, irregular, or rigid proximal segments. Described herein is a method of mounting and shaping a Palmaz-Schatz stent on a low-profile balloon that provides a steerable, low-profile, and secure stent delivery system. Also described is the successful use of this method in four consecutive cases where Palmaz-Schatz stents could not be delivered to the lesion site due to severely angulated, irregular, or rigid proximal vessel segments.

The reverse digital artery island flap: clinical experience in 120 fingers

Fingertip injuries represent the most common type of injuries seen in the upper extremity. Their management is functionally and aesthetically important but at the same time very controversial. The aim of this study is to report usefulness and postoperative results of reverse digital artery island flaps for fingertip reconstruction. From July of 1984 to December of 1995, 120 fingers in 110 patients with defects of the distal phalanx were reconstructed by reverse digital artery island flaps at Korea University Guro Hospital. We reviewed the medical records of our cases and analyzed them in several aspects. In 21 cases, neurorrhaphy was performed to improve sensibility. In the majority of the cases, the defect was covered primarily, whereas in 27 cases it was covered secondarily after composite graft, replantation, and so on. All the flaps survived except for one. Long-term follow-up for more than 6 months was possible in 44 fingers in 41 patients. Light touch and temperature sensation could be detected in all the evaluated flaps. The mean values of the static two-point discrimination test in sensate and insensate flaps were 6.2 and 10.2 mm, respectively. The reverse digital artery island flap is a safe and reliable procedure with a high survival rate and therefore is an excellent choice for coverage of fingertip defects.

Ipsilateral thalamic hypoperfusion on interictal SPECT in temporal lobe epilepsy

Interictal brain SPECT is useful for the localization of a seizure focus. Concomitant hypoperfusion of the ipsilateral thalamus on interictal SPECT has been noted for temporal lobe epilepsy. In this study, we aimed to evaluate the prevalence of thalamic hypoperfusion ipsilateral to temporal hypoperfusion (ipsilateral thalamic hypoperfusion) and to assess the usefulness of this finding for the lateralization of epileptic foci on interictal SPECT for temporal lobe epilepsy patients.

METHODS

Forty-six patients with refractory temporal lobe epilepsy underwent interictal brain SPECT after intravenous injection of 555-740 MBq of 99mTc-ECD. Perfusion impairments in the brain, especially the temporal lobe and thalamus, were evaluated. The localization of seizure foci was determined in conjunction with scalp, ictal and cortical electroencephalography, MRI and clinical outcomes. Ictal SPECT was performed for 5 of the 12 patients.

RESULTS

Concomitant decreased perfusion in both the temporal lobe and the ipsilateral thalamus was observed for 12 (26%) of 46 temporal lobe epilepsy patients on interictal brain SPECT. Seven patients showed hypoperfusion in the left temporal lobe and ipsilateral thalamus. Five patients showed hypoperfusion in the right temporal lobe and ipsilateral thalamus. In addition, hypoperfusion in the ipsilateral basal ganglia (ten patients) or contralateral cerebellum (four patients) was observed.

CONCLUSION

Ipsilateral thalamic hypoperfusion is not uncommon in temporal lobe epilepsy. The exact mechanism causing ipsilateral thalamic hypoperfusion is uncertain; however, corticothalamic diaschisis may be an important factor. This finding may aid in the lateralization of seizure foci on interictal brain SPECT.

Single photon emission computed tomography-EEG relations in temporal lobe epilepsy

The role of single photon emission computed tomography (SPECT) as an independent confirmation test in presurgical evaluation of medically intractable temporal lobe epilepsy has not been critically investigated. Because spreading ictal discharges may cause a concomitant increase of cerebral blood flow in remote cerebral regions, a careful analysis of peri-injection EEG patterns and their relation to ictal SPECT may be important in evaluating the reliability of ictal SPECT. Both interictal and ictal EEG and SPECT were reviewed in 19 patients with temporal lobe epilepsy who achieved a successful seizure outcome after surgery. Patients were divided into unitemporal and bitemporal groups according to the lateralization of interictal epileptiform discharges (IED). Ictal EEG features were classified into lateralized and nonlateralized groups. The concordance between SPECT and EEG lateralizations was examined in each patient and correlated to the documented epileptogenic temporal lobe. Interictal SPECT correctly lateralized in eight of nine patients with unitemporal IED and in five of 10 patients with bitemporal IED. Ictal SPECT was highly concordant with the peri-injection ictal EEG but correctly lateralized the epileptogenic region in only 11 of 19 patients. When both pre- and postinjection EEG epochs lateralized ipsilaterally, all ictal SPECT images showed concordant lateralization. If pre- and postinjection EEG epochs were either different in lateralization or nonlateralization, ictal SPECT images often showed complex patterns of cerebral perfusion with a high incidence of false lateralization. Interictal SPECT was more sensitive and reliable in patients with unitemporal IED than in patients with bitemporal IEDs. Ictal SPECT was closely related with peri-injection EEG epochs but with frequent false lateralization. The role of ictal SPECT as an independent confirmation test in presurgical evaluation should be reappraised.