Prospective study on planned biliary stent placement to treat small common bile duct stones

Aims

Small common bile duct stones are known to occasionally clear spontaneously. This study aimed to prospectively assess the role of biliary stent placement in promoting the spontaneous clearance of small common bile duct stones.

Methods and Results

We analyzed patients presenting with common bile duct stones of ≤5 mm diameter between June 2020 and May 2022. The exclusion criteria included asymptomatic patients, biliary pancreatitis, altered gastrointestinal anatomy, bile duct strictures (malignant or benign), and a history of EST. The biliary stents were inserted without stone removal. Stone clearance was assessed using endoscopic ultrasonography or endoscopic retrograde cholangiopancreatography after 3 months. Our primary endpoint was the clearance rate of common bile duct stones over 6 months, targeting a lower limit for the 95% confidence interval (CI) exceeding 25%. Of the 32 enrolled patients, 18 (56.3%; 95% CI: 37.7-73.6%) exhibited stone clearance. Early complications occurred in 11 patients (34.4%), totaling 12 incidents: acute cholecystitis in four, acute pancreatitis in three, biliary pain in three, and cholangitis in two patients. No severe complications occurred. Six (18.8%) patients experienced asymptomatic stent migration. Following stone clearance, four (12.5%) patients experienced stone recurrence, with an average duration of 256 ± 164 days.

Conclusion

Biliary stenting appeared to effectively promote the clearance of small common bile duct stones in approximately half of the patients. However, the potential complications and risks of stone recurrence warrant close monitoring.This trial was registered in the Japan Registry of Clinical Trials (jRCT1042200020).

[A case of thrombotic microangiopathy during chemotherapy with gemcitabine in a patient with pancreatic cancer]

A 57-year-old male patient with unresectable pancreatic head cancer was treated with chemotherapy, 5 courses of gemcitabine plus nab paclitaxel therapy, and 9 courses of gemcitabine monotherapy. After 12 months of treatment, he was admitted to our hospital with headache and dyspnea. He was diagnosed with gemcitabine-induced thrombotic microangiopathy (TMA) due to acute kidney dysfunction, hemolytic anemia, and thrombocytopenia. Gemcitabine was discontinued, and symptoms were improved without using hemodialysis and plasma exchange. After his renal function recovered, we started S-1 chemotherapy. Eighteen months later, the patient was alive. Looking back, we realized that fragment red blood cells appeared in complete blood count and serum LDH elevated at 5 months prior to admission, serum creatinine level increased slowly at 4 months prior to admission, and blood pressure elevated significantly at 2 months prior to admission. Therefore, physicians must be aware of TMA as a possible adverse event to gemcitabine. As in this case, hemolytic findings and hypertension in patients treated with gemcitabine may help early detection of TMA.

A rare case of Epstein-Barr virus-positive early gastric carcinoma with lymphoid stroma successfully treated by endoscopic submucosal dissection alone

Gastric carcinoma with lymphoid stroma (GCLS), a rare subset of gastric cancer, has a low frequency of lymphovascular invasion and a relatively better prognosis compared with conventional gastric cancer. We herein report a rare case of early GCLS successfully treated by endoscopic submucosal dissection alone. The lesion was located in the upper gastric body and approximately 9 mm in size. We assessed that the lesion was within an absolute indication for endoscopic resection. We performed endoscopic submucosal dissection and succeeded in en bloc resection. A histopathological assessment disclosed that the carcinoma was poorly differentiated with massive infiltration of lymphocyte and invaded the submucosal layer massively at 1000 μm in depth. There were no visible lymphovascular invasions in the specimen. Since the Epstein-Barr virus (EBV)-encoded small RNA in situ hybridization revealed that cancer cells were positive for EBV, the patient was finally diagnosed with EBV-positive GCLS. We persuaded the patient to receive an additional surgery; however, the patient refused to undergo it. The patient has been followed for more than 5 years without recurrence.

Minimizing antipsychotic medication obviated the need for enema against severe constipation leading to paralytic ileus: a case report

OBJECTIVE

To report the usefulness of antipsychotic dose-reduction for avoiding paralytic ileus in a patient with chronic schizophrenia and comorbid dementia.

CASE SUMMARY

A 65-year-old in-patient developed severe paralytic ileus warranting a transfer to the general hospital. Constipation was very troublesome and he often needed enema to prevent intestinal obstruction. He had originally been treated with 24 mg of bromperidol, which was reduced to 4 mg, and other psychotropic treatments were simultaneously simplified. As a result, bowel habits improved and enema is now only rarely necessary. Constipation is a frequent adverse effect of antipsychotics and adjunctive psychotropics, which can be severe and may lead to life-threatening paralytic ileus. Dose-reduction obviated a necessity of enema against persistent constipation, while the patient's mental status remained under control. Assessment using the Naranjo probability scale revealed a definite causal relationship.

DISCUSSION

With an increasing number of elderly patients with schizophrenia, more cases of severe gastrointestinal motility problems from antipsychotic medication are to be expected. In this patient population dose-reduction of antipsychotics and simplification of concomitant psychotropics should be seriously considered.

Changes in regional cerebral blood flow during acute electroconvulsive therapy in patients with depression: positron emission tomographic study

BACKGROUND

Although electroconvulsive therapy (ECT) is widely used to treat psychiatric disorders such as depression, its precise neural mechanisms remain unknown.

AIMS

To investigate the time course of changes in cerebral blood flow during acute ECT.

METHOD

Cerebral blood flow was quantified serially prior to, during and after acute ECT in six patients with depression under anaesthesia using [(15)O]H(2)O positron emission tomography (PET).

RESULTS

Cerebral blood flow during ECT increased particularly in the basal ganglia, brain-stem, diencephalon, amygdala, vermis and the frontal, temporal and parietal cortices compared with that before ECT. The flow increased in the thalamus and decreased in the anterior cingulate and medial frontal cortex soon after ECT compared with that before ECT.

CONCLUSIONS

These results suggest a relationship between the centrencephalic system and seizure generalisation. Further, they suggest that some neural mechanisms of action of ECT are mediated via brain regions including the anterior cingulate and medial frontal cortex and thalamus.

Mediastinal cavernous hemangioma in a child: report of a case

We present herein a rare case of mediastinal cavernous hemangioma in a 5-year-old boy. The patient was referred to our hospital for an evaluation of cough and high fever. On admission, a chest computed tomogram and magnetic resonance imaging revealed a large tumor arising from the left-sided mediastinum which compressed the left main pulmonary artery and left lung. The tumor, measuring 105 x 60 x 60 mm in size and weighing 170 g, was completely resected without any major bleeding, and a pathological examination confirmed the diagnosis of cavernous hemangioma.

Stress analysis of metal-free polymer crowns using the three-dimensional finite element method

PURPOSE

The purpose of this study was to evaluate the stress distribution under various loading conditions within posterior metal-free crowns made of new composite materials.

MATERIALS AND METHODS

A three-dimensional finite element model representing a mandibular first molar was constructed. Variations of the model had crowns of two types of composite, a glass ceramic, and porcelain fused to metal. A load of 600 N, simulating the maximum bite force, was applied vertically to the crowns. Loads of 225 N, simulating masticatory force, were applied from three directions (vertically, at a 45-degree angle, and horizontally).

RESULTS

The stress distributions in both types of composite crown were similar to that of the glass-ceramic crown. In the test simulating maximum bite force, the maximum tensile stresses on all crowns (17.9 to 18.3 MPa) concentrated around the loading points. In the masticatory force-stimulation test, the specimens experienced maximum tensile stresses of 20.3 to 26.6 MPa under a horizontal load and 10.9 to 11.0 MPa under a vertical load. When the load was applied horizontally, the maximum tensile stress was observed around the loading points on the surface in the case of composite and glass-ceramic crowns, and in the cervical area of the metal coping in the porcelain-fused-to-metal crowns.

CONCLUSION

It would appear that the strength of occlusal contact points is important to the integrity of posterior metal-free crowns made of new composite materials and that bite forces applied from the horizontal direction are a critical factor determining success and failure.

Unidimensional scale for dementia

A cognitive test comprising 27 subscales was administered to 262 demented patients and 92 normal subjects. Principal factor analysis followed by varimax and Harris-Kaiser rotation and Guttman's scalogram analysis was performed. The analysis yielded three factors, i.e. "recent memory", "immediate memory or attention" and "remote memory". The relationships between the three-dimensional distribution of the scores and the DSM-IIIR grade of dementia indicated the existence of a continuum of dementia severity. Scalogram analysis showed unidimensionality in the difficulty level of the subscales as well as in the severity of the cases. Thus, the simple summary score can be used as a good measure of the severity of dementia.

Functional relevance of human adh polymorphism

This article represents the proceedings of a symposium at the 2000 ISBRA Meeting in Yokohama, Japan. The chairs were C. J. Peter Eriksson and Tatsushige Fukunaga. The presentations were (1) 4-Methylpyrazole as a tool in the investigation of the role of ADH in the actions of alcohol in humans, by Taisto Sarkola and C. J. Peter Eriksson; (2) ADH2 polymorphism and flushing in Asian populations, by Wei J. Chen, C. C. Chen, J. M. Ju, and Andrew T. A. Cheng; (3) Role of ADH3 genotypes in the acute effects of alcohol in a Finnish population, by Hidetaka Yamamoto, Kathrin Kohlenberg-Müller, and C. J. Peter Eriksson; (4) Clinical characteristics and disease course of alcoholics with different ADH2 genotypes, by Mitsuru Kimura, Masanobu Murayama, Sachio Matsushita, Haruo Kashima, and Susumu Higuchi; (5) ADH2 polymorphism, alcohol drinking, and birth defects, by Lucinda Carr, D. Viljoen, L. Brooke, T. Stewart, T. Foroud, J. Su, and Ting-Kai Li; and (6) ADH genotypes and alcohol use in Europeans, by John B. Whitfield.

Corticobasal degeneration presenting with nonfluent primary progressive aphasia: a clinicopathological study

A 62-year-old woman initially presented with slowly progressive nonfluent aphasia with minimal intellectual involvement. Echolalia and personality change were prominent whereas parkinsonian features and signs suggesting parietal lobe dysfunctions were not present. The patient's language deficit was consistent with transcortical motor aphasia. She did not manifest extrapyramidal signs. The patient was diagnosed as having Pick's disease or frontal lobe dementia. She died at age 65, 2 years and 9 months following disease onset. Neuropathological findings including cytoskeletal abnormalities, however, were clearly distinct from those of classical Pick's disease and were consistent with those reported in corticobasal degeneration (CBD). The distribution of her cortical lesions was accentuated in the frontal language-related area. The clinical manifestations in CBD are diverse, and primary progressive nonfluent aphasia should be considered as an initial symptom of CBD. Neuropathological examination of such patients should include cytoskeletal abnormality studies.

The cost of juvenile-onset recurrent respiratory papillomatosis

OBJECTIVE

To assess the medical costs and the number of quality-adjusted life years lost owing to juvenile-onset recurrent respiratory papillomatosis (JORRP).

DESIGN

We examined hospital and physician charges for JORRP surgical procedures in Maryland in 1994 adjusting for inflation and the cost-charge ratio. Centers for Disease Control and Prevention data on treatment intensity for JORRP were augmented with a review of treatment records for 18 patients with JORRP. Sensitivity analyses were performed. To illustrate the application of our cost estimates, we compare the costs of JORRP to the costs of the surgical procedures that would be necessary to prevent it.

RESULTS

We find that the present value at birth of the cost of a single case of JORRP is $201,724 (range, $61,822-$474,334). The annual cost for a single case of JORRP is $57,996 (range, $32,407-$94,114). The annual cost of JORRP in the United States is between $40 million and $123 million depending on the prevalence. Cesarean section (CS) for women with condyloma has been suggested as a potential strategy to prevent JORRP, but its efficacy remains to be determined. Our results suggest that if only 1% of the CSs actually prevented JORRP, this strategy would be a cost-effective means to prevent JORRP.

CONCLUSIONS

Studies to reduce the uncertainty surrounding the efficacy of CS and the effect of both CS and JORRP on families need to precede consideration of a policy of CS for women with clinically evident genital condyloma. Patients should be kept thoroughly informed about the role of CS for the prevention of JORRP and the nature of the remaining uncertainties.

Current trends in cognitive rehabilitation for memory disorders

Progress in the neuropsychology of memory disorders has provided a foundation for development of cognitive rehabilitation for amnesic patients. Accumulating evidence in the past two decades suggested that certain training techniques could be beneficial to many amnesic patients, such as teaching and acquisition of domain-specific knowledge, motor coding, reality orientation, and meta-cognition improvement. In this article we review and discuss the current trends in cognitive rehabilitation of memory disorders and provide a future direction in this emerging field. In addition, our experience in the successful rehabilitation of Korsakoff syndrome patients is also introduced.

Prospective and retrospective studies of recovery in aphasia. Changes in cerebral blood flow and language functions

Prospective and retrospective language evaluations and single photon emission computed tomography (SPECT) scans were performed in order to study the relationship between post-stroke recovery from aphasia and changes in cerebral blood flow (CBF) in groups of patients who had made a good recovery and those who had not. For the prospective study, 20 right-handed patients with aphasia secondary to an acute cerebrovascular accident (CVA) in the left middle cerebral artery territory received language evaluations with a Japanese Standard Language Test of Aphasia (SLTA), and SPECT scans performed twice, at a mean of 3.2 and a mean of 9.2 months post-onset. Only one slice of SPECT data was analysed. A significant correlation was observed between the severity of the initial language deficit and initial CBF on the left side, but not the right. Initial CBF was not a predictor for future language recovery in either hemisphere. There was a correlation between the change in the left mean hemispheric CBF (but not the right) and the change in the overall SLTA severity rating from 3 to 9 months post-stroke. In the retrospective study, 16 right-handed patients with residual aphasia secondary to CVA in the left middle cerebral artery territory received SLTA and SPECT at a mean of 82.8 months post-onset. The patients had also received initial language evaluation with SLTA at a mean of 6.5 months post-onset. In contrast to the prospective study, the results demonstrated that the mean left hemispheric CBF at approximately 7 years post-onset did not differ between good and poor recovery groups. However, the mean right hemispheric CBF of the good recovery group was higher than that of the poor recovery group in the frontal and the thalamic regions, and also in the left frontal region. The results of these complementary studies suggest that the initial language recovery within the first year post-onset may be linked primarily to functional recovery in the dominant hemisphere, where an increase in CBF was observed at 9 months post-onset. The increased perfusion adjacent to the lesion may be crucial for early recovery in aphasia. Subsequent language recovery and the long-term recovery in aphasia may be related to slow and gradual compensatory functions in the contralateral hemisphere, specifically in the homotopic frontal and thalamic areas.

[Analysis of air pollution and prevalence rate of allergic diseases among elementary school children in Kawaguchi and Hatogaya city]

Kawaguchi and Hatogaya City are located on the northern edge of Tokyo. We analysed between air pollution and prevalence rate of allergic diseases among elementary school children in this area. A prevalence rate of allergic diseases in 1996 May and June was as follows; bronchial asthma 13.5%, atopic dermatitis 24.5%, allergic rhinitis and/or conjunctivitis 22.8%, urticaria 12.4%, food allergy 7.8% and drug allergy 2.2%, respectively. Air pollution of this area was analysed to check the levels of nitrogen dioxide (NO2), sulfur dioxide (SO2) and suspended particulate matters (SPM). NO2 pollution was relatively high in urban area, and SPM pollution was especially high around the highways. SO2 pollution was lower than the environmental standard. No relationship was found between the prevalence rate of bronchial asthma, atopic dermatitis, allergic rhinitis and/or conjunctivitis and air pollution, but it was found that these diseases are slightly related to population density (p < 0.1, p < 0.01, p < 0.1, respectively).

Memory for subject performed tasks in patients with Korsakoff syndrome

We examined the ability of alcoholic Korsakoff patients to remember verbal and action-related information. Eight Korsakoff patients and eight alcoholic control subjects learned action phrases in either subject-performed tasks (SPTs) or verbal tasks (VTs). Free recall and recognition tests were then administered. Despite the severe anterograde amnesia observed in Korsakoff patients for VTs, their memory performance for SPTs was similarly facilitated over VTs as was the case with alcoholic controls. Domains preserved in this amnesic syndrome may account for the benefit seen when using SPTs in Korsakoff patients. The therapeutic utilization of action events for memory rehabilitation is discussed.

Apolipoprotein E epsilon 4 allele distribution in Wernicke-Korsakoff syndrome with or without global intellectual deficits

Recent genetic studies show that the apolipoprotein E (ApoE) epsilon 4 allele is a risk factor for Alzheimer's disease (AD). Whether this allele is associated with other dementing diseases is the next important question. The information could provide a clue to the pathogenetic role of ApoE. In the present study, patients with Wernicke-Korsakoff syndrome (WKS) of alcoholic etiology were divided into two groups according to the severity of intellectual deficits, i.e., those of "classical" Korsakoff patients with preserved intellectual function other than amnesia and those with global intellectual deficits. Genotyping showed that the frequency of ApoE epsilon 4 allele was significantly higher in the patients with global deficits, suggesting the involvement of this allele in the intellectual decline of WKS. In contrast, distributions of other two markers, alpha 1-antichymotrypsin and presenilin-1, did not differ between the two groups. These results added further support to the notion that the consequence of acute insult to the brain is influenced by the ApoE genotype, and suggested ApoE's role in the development of a certain group of "alcoholic dementia."

'Alice in Wonderland' syndrome as a precursor of depressive disorder

A 54-year-old Japanese businessman who was found to exhibit the 'Alice in Wonderland' syndrome and went on to develop a depressive disorder is described. Lengthening and shortening of time experience continued intermittently for about 3 months, and metamorphopsia, distortion of body image, and the quick-motion phenomenon (alteration in time sense) persisted for almost 2 days without interruption. There were no abnormal physical findings. The authors review studies on 'Alice in Wonderland' syndrome and suggest that depressive illness may be a causal factor.

[Autobiographical memory loss following herpes encephalitis]

We report a patient with prominent autobiographical memory (ABM) impairment, and discussed possible mechanisms of her deficits. The patient was a 36-year-old woman who suffered from herpes simplex encephalitis in November 1994. Four months after the onset, the neuropsychological examination disclosed that her intelligence, attention, language and frontal lobe functions were normal. Moderate anterograde amnesia was evident for visual materials, and she showed difficulties in retrieving visual images. Deficits in verbal learning were minimal. In contrast, her retrograde amnesia (RA) was severe. Further analyses clarified that memory for public events and personal semantic memory were relatively well preserved whereas ABM was severely impaired with no evidence of temporal gradient. Her performance on the ABM questionnaire was even worse than that of alcoholic Korsakoff patients. Interestingly, however, deficits in memory for public events also emerged when questions were presented with pictures instead of ordinary verbal questionnaires. The results suggest that her principle deficits consisted in utilizing visual information of the past events. Her access to and manipulation of the past visual representation/images were impaired. Consequently, her deficits were almost exclusive to ABM because visual information is most crucial for ABM. This material specific ABM impairment demonstrated in the present patient could be differentiated from nonspecific retrograde amnesia observed in typical focal RA patients. MRI, SPECT and PET demonstrated that the present patient had lesions basically in the right hemisphere, specifically in the medical temporal area including the hippocampus.

Performance characteristics of chronic schizophrenia on attention tests sensitive to unilateral brain damage

The aims of this study were to investigate the lateralization hypothesis of schizophrenia, comparing chronic schizophrenics with unilateral brain-damaged subjects and normal controls, using attentional tests sensitive to the unilateral brain damage. Three attentional tests with different modes of stimuli, two vigilance tasks that require the self-paced or nonself-paced responses of subjects and one divided attention task, were administered to 28 chronic schizophrenics, 26 right and 24 left unilateral brain-damaged subjects, and 20 normal controls. The results indicated that schizophrenics performed a possible right-hemisphere damages pattern and also a left pattern in part, with failure of all tasks to show either pattern related to a number of differences between the three tasks. Furthermore, the attention deficits of schizophrenics are less than those of brain-damaged subjects but are clearly abnormal compared with the normal controls.

[Cytomegalovirus fetal infection. Porencephaly with polymicrogyria in a 15-year-old boy]

A boy, born after 41 weeks of gestation, presented with splenomegaly, microcephaly and chorioretinitis accompanied by immaturity signs. His mother was in good health but her previous pregnancy had been aborted owing to rubella. Laboratory data, including serological and virological evidence, confirmed the diagnosis of fetal cytomegalovirus infection. CT scan indicated a large cyst in the left temporal lobe and periventricular calcifications. At about 8 months of age, convulsions were noticed which were not controlled effectively by medication. There was spastic rigidity without significant psychomotor development. He died at the age of 15. Postmortem neuropathological examination revealed polymicrogyria predominant in the right cerebral hemisphere as well as a large cavity in the left temporal lobe communicating with the lateral ventricle. Widespread heterotopias and calcifications were observed notably in the periventricular white matter. No typical inclusion was found. By the method of Holzer and GFAP immunocytochemistry, no gliosis was noted in the cerebral cortex having the feature of polymicrogyria. This might support the theory that polymicrogyria is caused by neuronal migration failure.

[Cognitive dysfunction following anterior communicating artery aneurysm rupture. Comparison with alcoholic Korsakoff syndrome on neuropsychological performance]

The present study aims to compare neuropsychological performance of patients following anterior communicating artery aneurysm rupture (ACoA) with that of patients with alcoholic Korsakoff syndrome (AKS). Fifteen ACoA patients and ten age-and education-matched AKS patients were included in the study. All the patients were tested at least one year post onset of their illness at a stable condition. The WAIS and forward digit span scores of AKS were also matched to ACoA, and simple attention and general intelligence were well preserved both in ACoA and AKS. Frontal function as measured by the Wisconsin card sorting test (Keio version) (KWCST) was equivalently impaired in the two groups. Anterograde memory as measured by Wechsler memory scale subtests, serial seven word learning test, Rey auditory verbal learning test, and logical memorizing test (Luria's paired word-picture association), was more severely impaired in AKS than ACoA in contrast to the comparable attention, intelligence, and frontal function: (1) memory tasks with low correlations to KWCST (serial word learning tasks and paired verbal associates), reflecting primary simple serial memorizing, and (2) memory tasks with high correlations to KWCST (logical memory and logical memorizing), reflecting higher and complicated strategic mnemonic activities. However, the correlations between these anterograde memory subtests and KWCST were substantially equivalent in ACoA and AKS. This suggests that the differences in anterograde amnesia demonstrated in ACoA and AKS may be of quantitative, not of qualitative property. The extent of deficits in semantic encoding as measured by Wickens' release from proactive interference paradigm (PI release) was also milder in ACoA than AKS. Both AKS and ACoA failed to show PI release in contrast to normal PI release demonstrated in age-matched ten healthy subjects. PI release in ACoA, however, was in between AKS and healthy subjects. The results were interpreted in the light of a recently postulated hypothesis that a combination of frontal lobe damage and memory impairment is crucial for causing a deficit in semantic encoding. The extent of damage in the memory circuit in ACoA may be variable, which may result in milder degree of anterograde amnesia and semantic encoding than AKS in the present study.

[A case of diffuse brain injury involving the medial part of the brain--its difference from diffuse axonal injury]

A 30-year-old male clinico-pathological case survived for 1 year and 9 months after being hit by a truck while riding on his motorbike on Aug. 21, 1988. On admission, his consciousness level was 5 according to the Glasgow Coma Scale, and a traumatic intraventricular hemorrhage and cerebral contusion were revealed by CT scanning. He underwent immediately an operation in order to drain blood from the ventricles at which time a right side dominant quadriplegia was noted. He made a gradual improvement and by January 1989 was able to tell us his name and address correctly. However, he remained incontinent and bedridden owing to the contracture of joints. He was put on rehabilitation exercises in March 1989 which trained him to operate a wheelchair. In April 1990 he regained urinary control, but was remarkably devoid of will power, perseverance and memory. He expired of pneumonia on May 11, 1990. At autopsy, his brain weighed 1180g. The cerebral convexity was discolored, especially the rectal gyri and bilateral olfactory bulbs were brownish-yellow. Old gross contusional scars were observed on the left rectal and orbital gyri, and the 3rd ventricle and inferior horns of the lateral ventricles were enlarged. Holzer's method revealed fibrillary gliosis in the corpus callosum, fornix, cingulate gyrus and a part of the caudate nucleus adjacent to the thalamus. Microscopically, axons were seen to be disrupted in the corpus callosum as well as in the anterior commissure, having the appearance of macrophages. (ABSTRACT TRUNCATED AT 250 WORDS)

[Dementia and amyotrophy in Kufs disease. The adult type of neuronal ceroid lipofuscinosis]

A 26-year-old housewife, born of consanguineous parentage, began to have gait and speech disturbance. Her brother had died from suffocation because of dysphagia. At thirty-two, she developed difficulty in swallowing, clumsiness and incontinence. When she was thirty-six she had pseudobulbar palsy, vertical gaze paresis, hyperreflexia and muscular atrophy of the upper half of the body. CT scan showed cerebral atrophy. Her mental function progressively deteriorated and amyotrophic lateral sclerosis associated with dementia was suspected. She died at the age of thirty-seven. Diagnosis was made only by autopsy. There was no particular general pathologic finding excepting aspiration pneumonia. Microscopical examination revealed numerous distended neurons with accumulation of light brown pigments by Luxol fast blue/H & E stains, especially in hypothalamus, substantia nigra and nuclei of oculomotor nerves. To a lesser extent such neurons were noted ubiquitously. The stored material was mainly composed of lipofuscin and ceroid. Ultrastructurally they presented the various structures which have previously been reported, except for finger print profiles. The pigmentary deposits were shown to be immunoreactive with polyclonal antibody directed against amyloid beta-protein.

Sites of predilection in recurrent respiratory papillomatosis

Florid and widespread respiratory papillomatosis is a devastating disorder in a subset of patients with recurrent respiratory papillomatosis, and it poses a major dilemma for the patient and the surgeon. Contrary to common belief, the distribution of papilloma lesions is not random, but follows a predictable pattern, with lesions occurring at anatomic sites in which ciliated and squamous epithelia are juxtaposed. The predominant sites of disease in recurrent respiratory papillomatosis are the limen vestibuli, the nasopharyngeal surface of the soft palate, the midzone of the laryngeal surface of the epiglottis, the upper and lower margins of the ventricle, the undersurface of the vocal folds, the carina, and bronchial spurs. These sites have the common histologic feature of a squamociliary junction. Papillomata also occur at the tracheostomy tract and at the midthoracic trachea in patients with tracheostomies. At the latter sites, abrasion injury to ciliated epithelium heals with metaplastic squamous epithelium and creates an iatrogenic squamociliary junction. The apparent preferential localization of papilloma at squamociliary junctions has at least 2 implications: first, that detection of occult asymptomatic papillomata is enhanced by careful examination of squamociliary junctions, and, second, that iatrogenic papilloma "implantation" is preventable by avoiding injury to nondiseased squamous and ciliated epithelia.

[Common acute lymphoblastic leukemia showing hypo-gamma-globulinemia and cerebral infarction due to cerebral artery obstruction]

A patient who developed hypo-gamma-globulinemia and cerebral infarction during the treatment for acute lymphoblastic leukemia (ALL) is reported. In this patient fever and rash during radio-therapy for central nervous system (CNS) prophylaxis and nausea and vomiting were observed during maintenance therapy. On the laboratory findings high level of the protein level in the cerebrospinal fluid and the eosinophil count of the peripheral blood were found in every examination. We attempted to isolate various viruses in consideration of the possibility of infection, but no virus could be detected. The effects of methotrexate (MTX) and l-asparaginase were also suspected. Since nausea and vomiting disappeared after discontinuation of MTX administration, the drug may had some effect, and the possibility of cerebral damage by MTX can not be excluded. Complication of irradiation are reported to occur often more than 10 years after the treatment, but this patient had the onset only 2 years after the treatment. Therefore, irradiation was unlikely to be responsible for the symptoms. The relation between the hypo-gamma-globulinemia and cerebral infarction was also unknown.

Inverted papilloma: evaluation with MR imaging

The authors examined the magnetic resonance (MR) appearance of inverted papillomas to determine if this histologically benign lesion could be distinguished from malignancies of the sinonasal cavity. MR images in 10 patients with histologically proved inverted papilloma were retrospectively reviewed. The signal intensity of inverted papillomas on short repetition time (TR) images was iso- to slightly hypertintense to muscle in all 10 patients. Inverted papillomas had intermediate signal intensity on the long TR/echo time (TE) images. The tumors were iso- or slightly hypointense to fat on long TR/short TE images. In the seven patients who received gadopentetate dimeglumine, all inverted papillomas showed solid inhomogeneous enhancement. A review of eight sinonasal malignancies showed no distinctive signal intensity or enhancement characteristics to help differentiate inverted papillomas from various malignant tumors. The authors conclude that there is no signature MR appearance for the benign inverted papilloma. The main utility of MR imaging is in defining the extent of the lesion.

Systemic lupus erythematosus in a child receiving long-term interferon therapy

Systemic lupus erythematosus (SLE) developed in a 10 1/2-year-old white boy with juvenile laryngeal papillomatosis who had been treated with interferon alfa-n1 for 7 years. His age, gender, and fast recovery after discontinuation of interferon therapy and institution of appropriate treatment for SLE are compatible with a diagnosis of drug-induced SLE. Autoimmune disorders may occur as a complication of interferon therapy.

[Diffuse axonal injury (DAI) in an autopsy case of head trauma with long survival]

The authors reported a clinico-pathological case survived 11 months after a traffic accident. A 41-year-old man had been hit by a motor car and was found in a state of semicoma. On admission, his consciousness level was III-100 to 200 (Japan Coma Scale). Pupils were isocoric; light reflex was present. Linear fracture of occipital bone was disclosed by Skull X-ray and subarachnoid hemorrhage was revealed on CT scan. This comatose state, lasting 24 hours, slowly improved and eventually he presented the so-called Korsakoff's syndrome until his death. He could not recognized his relatives, only uttered some meaningless words. He was unable to obey simple verbal orders. The patient was incontinent and right pyramidal sign was positive. On repeated CT scans, cerebral ventricles gradually increased in size; especially the enlargement of the fourth ventricle was remarkable. He expired of septic shock caused by bed sores. At autopsy brain weighed 1190 g. Old gloss contusional scars were observed on the bilateral frontal lobes including the orbital area and on the left temporal pole. Gliding contusions were revealed in the subcortical white matter beneath the left superior frontal convolution. Fibrillary gliosis was noted in this region, the deep white matter underlying the left temporal pole and the tissue surrounding the anterior horn of the left lateral ventricle. Nerve fibers were fragmented and lacerated at corpus callosum, anterior commissure and posterior limb of the left internal capsule. Bilateral pyramidal tracts showed mild myelin pallor at the brainstem. Loss of Purkinje cells were observed. This case would correspond to mile type of diffuse axonal injury proposed by Adams and Gennarelli. (ABSTRACT TRUNCATED AT 250 WORDS)

Mixed blasts crisis following extramedullary involvement with the cytogenetic evidence of clonal evolutions in Philadelphia chromosome-positive chronic myelocytic leukemia

We describe a unique case of a young girl with adult type chronic myelocytic leukemia (CML). Clinically she had an extramedullary blastic crisis (BC) prior to that in peripheral blood and in bone marrow. The blasts were primitive cells and always CD7, CD33, CD34 and HLA DR-positive. During the course of illness the blasts became negative for CD5 and positive for CD41a and for platelet-peroxidase. Additional chromosomal appearances and subsequently clonal evolution were seen during the clinical course. Surface antigen modulation and morphological changes, which were observed by microscopic examination and flow cytometry, were induced by in vitro incubation. Surface antigen modulation was more induced in the presence of phytohemagglutinine-conditioned media (PHA-CM) but the effects of PHA-CM on morphological changes were not clear.

Stage T1 glottic carcinoma: results of radiation therapy or laser excision

A retrospective analysis was made of the data on 60 patients with stage T1 glottic carcinoma (43 T1a, 17 T1b) who received radiation therapy and 17 patients with T1a disease who underwent laser excision as the primary treatment modality. Patients who received radiation therapy achieved 3- and 5-year actuarial local control rates of 92% and 89% for T1a and 77% and 77% for T1b disease, respectively. In patients who underwent laser excision (all with T1a disease), the 3-year local control rate was 77%. Of the 42 evaluable irradiated T1a patients, 31 (74%) had a normal to near-normal voice, eight (19%) had mild or intermittent hoarseness, and three (7%) had persistent hoarseness. Of the 13 evaluable patients in the laser-excision group, four (31%) had a normal to near-normal voice, five (38%) had mild or intermittent hoarseness, and four (31%) had persistent hoarseness. The difference in the quality of voice between these two groups is statistically significant (P = .012), although the ultimate local control rate after salvage therapy for irradiated patients (97%) was similar to that for laser-excision patients (94%).

Carbon dioxide laser posterior cordectomy for treatment of bilateral vocal cord paralysis

Upper airway obstruction due to bilateral vocal cord paralysis was successfully relieved by carbon dioxide laser posterior cordectomy. All patients achieved satisfactory airway and decannulation. Flow-volume loop spirograms obtained preoperatively and postoperatively documented improved flow rates on inspiration and expiration. Final voice quality was subjectively good in all patients. Follow-up has ranged from 1 year 10 months to 5 years 8 months, and initial improvement has been sustained in all cases. Carbon dioxide laser posterior partial cordectomy is an alternative management option for relief of upper airway obstruction due to bilateral vocal cord paralysis. The procedure can be performed without prophylactic tracheotomy. Subjectively good voice quality is preserved.

Carcinoma ex-papilloma: histologic and virologic studies in whole-organ sections of the larynx

A patient with adult-onset recurrent respiratory papillomatosis (RRP), initially diagnosed at age 28 years, was treated with radiation therapy due to the rapid regrowth of lesions. Following 6 years of apparently inhibited growth, papilloma recurred, and squamous carcinoma was diagnosed from a laryngeal biopsy. A spontaneous laryngocutaneous fistula developed, and laryngectomy was performed 14 years after irradiation. The laryngectomy specimen was snap frozen and representative tissues were stored frozen for viral studies. The larynx was whole-organ sectioned for histologic examinations; residual papilloma, as well as carcinoma, was observed. Koilocytosis and other virus-associated histologic changes were also found. HPV capsid antigen was present in papilloma, carcinoma, and clinically normal epithelium. HPV nucleic acids, conforming to HPV type 6, were present in keratin pearls and dysplastic cells. According to prior reports, carcinoma developing in preexisting papilloma arises from juvenile-onset RRP. Irradiated papilloma develop cancer at about 10 years, and the patients rarely survive. Nonirradiated cases develop cancer after 30 years, and some develop papilloma in the hypopharynx and trachea, but most patients survive. Irradiation is not an obligatory precursor for malignant transformation of cancer; however, until now there have been no case reports of favorable outcome after irradiation of papilloma.

Interferon alfa-n1 (Wellferon) in juvenile onset recurrent respiratory papillomatosis: results of a randomized study in twelve collaborative institutions

Sixty-six patients with clinically severe juvenile-onset recurrent respiratory papillomatosis (RRP) were entered into a 12-month randomized crossover study to evaluate interferon alpha-n1 Wellferon (WFN) as an adjuvant to CO2 laser surgical excision. Eligibility required disease onset to be before age 16, and an endoscopic excision requirement of at least three operations in the 6 months immediately prior to entry. Patients were randomized to Observation versus WFN at a dose of 5 MU/m2 daily for 28 days and three times weekly for 5 months. The patient groups were comparable in extent of disease at entry. Total extent of disease was determined by a composite score derived from the number of diseased anatomic sites and extent of surface area and lumen encroachment present at each site. Standard endoscopic excisions were performed every 2 months and clinical courses compared on a basis of composite scores determined at each endoscopy. Statistically significant improvement occurred in the patient group which received WFN. We conclude that interferon alpha n-1 is an effective adjuvant to surgery in RRP management.

Rarity of cesarean delivery in cases of juvenile-onset respiratory papillomatosis

Papillomas of the respiratory and genital tracts are caused by the same papillomavirus genotypes, and mothers of children with respiratory papillomatosis often have a history of genital warts. Only one of 109 cases reviewed gave a history of birth by cesarean section, whereas ten cesarean deliveries would have been the expected number for this group on the basis of national rates. The single case was delivered by elective cesarean section before the rupture of the membranes, and the child developed respiratory papillomatosis in the first year of life. These findings suggest that in juvenile-onset disease, the transmission of infection from mother to child occurs most often during passage through an infected birth canal, but that intrauterine infection of the fetus is also possible. Papillomavirus infection of the female genital tract is common, but respiratory papillomatosis is rare. On the basis of crude estimates of annual number of children born to infected mothers and of new cases of juvenile-onset disease, the risk of developing disease for a child born to an infected mother was calculated to be one in several hundred exposures.

Demonstration of human papillomavirus capsid antigen in carcinoma in situ of the larynx

We have undertaken a retrospective study to investigate the role of human papillomavirus (HPV) in the development of laryngeal carcinoma in situ (CIS). Sixty paraffin-embedded tissue specimens, collected from 20 patients with a history of laryngeal CIS, were examined for the presence of HPV capsid antigen. All but four individuals were men, with an average age at diagnosis of 64 years. An immunoperoxidase technique showed that 20 specimens from 14 patients contained detectable HPV capsid antigen. An independent evaluation for histopathologic features characteristic of HPV infection identified viral changes in the 14 patients as well as an additional two. No correlation was found between clinical course, as determined by histologic severity of vocal cord lesions, and presence of HPV. These results suggest that HPV should be considered an etiologic agent in the development of laryngeal CIS.

Clinical evaluation of patients with metastatic squamous carcinoma of the neck with occult primary tumor

Between 1976 and 1982, we systematically evaluated 33 patients with a diagnosis of metastatic squamous carcinoma of the neck (excluding the supraclavicular fossa) from an occult primary tumor. In 11 patients the primary lesion was identified by physical and indirect mirror examinations, in four by examinations done under anesthesia and panendoscopies, and in an additional three by random biopsies. Primary lesions were in the nasopharynx (five patients), hypopharynx (five), tonsillar fossa (three), epiglottis (two), lateral oropharyngeal wall (one), the base of the tongue (one), and the anterior tonsillar pillar (one). In 15 patients (45%), the primary lesion was not identified after complete evaluation; these patients remained free of primary lesions in the head and neck area during a follow-up of two to six years. Our results indicate that patients with metastatic carcinoma of the neck should have a complete evaluation before treatment is started; in the majority of these patients, the primary site can be identified, with a resultant change in the treatment plan. A review of the literature shows that metastatic squamous carcinoma of the neck with an unknown primary tumor is a treatable disease with a cure rate as high as 50%.

Response of cranial nerve abnormalities in nasopharyngeal carcinoma to radiation therapy

Eighteen of 36 patients (50%) with the diagnosis of nasopharyngeal carcinoma had cranial nerve deficits before definitive radiotherapy. Within this group of 18 patients, there were 34 cranial nerve abnormalities and four Horner's syndromes. Overall, 62% of cranial nerve deficits recovered completely (CR) and 32% recovered partially (PR), for a total response rate of 94% to definitive radiotherapy. The magnitude of response (complete versus partial) depended upon the individual cranial nerve and the pretreatment duration of the abnormality. All of the responses except one occurred within 1 month after the completion of therapy. Complete responses were not obtained when deficits had existed longer than 2 months. However, PRs were obtainable. Seven of seven cases of posttreatment new or recurrent cranial nerve deficits were caused by recurrent tumor. The actuarial 5-year disease-free survival for this group of 18 patients was 31%. The results indicate that patients with cranial nerve deficits will respond to definitive radiotherapy and long-term disease-free survival can be achieved in some patients.

The Swallowing Center: concepts and procedures

This paper describes the purpose and organization of a dedicated center at The Johns Hopkins Medical Institutions for the evaluation of swallowing problems. The multidisciplinary approach outlined will permit a better understanding and more accurate diagnosis of the functional or organic lesions affecting the swallowing mechanisms. Illustrative cases are presented.

Identification of genital tract papillomaviruses HPV-6 and HPV-16 in warts of the oral cavity

Warty lesions of the oral cavity were examined for etiologic association with genital tract papillomaviruses HPV-6, HPV-11, and HPV-16. DNAs extracted from ten oral biopsies were screened for HPV genomic sequences by Southern transfer hybridization with 32P-labeled viral DNA probes. Nonstringent hybridization with an HPV-6 probe revealed papillomavirus DNA sequences in four of seven tissues with histologic evidence of papillomatosis, in none of two tissues without histologic evidence of papillomatosis, and in one tissue that was not examined by histology. Stringent hybridization tests with HPV-6 and HPV-16 probes identified the genome in one tissue as being HPV-16, in a second tissue as being HPV-6 subtype a, and in a third tissue as HPV-6 (subtype unidentified); papillomavirus DNA sequences in two tissues are as yet not identified. An additional case of HPV-6 or HPV-11 related oral cavity lesion was diagnosed by in situ hybridization of paraffin sections with a 35S-labeled, mixed HPV-6 + HPV-11 probe. The hybridization in the positive section was extensive and confined to epithelial nuclei. The oral lesions associated with genital tract papillomaviruses were asymptomatic, multiple or single, and were located in different parts of the oral cavity, for example, on the gingivae, on the tongue, on the lip, on the tonsillar pillar, and on the floor of the mouth.

[An autopsy case with peculiar acidophilic bodies in the dentate nucleus and brain stem, associated with degeneration of the pyramidal-extrapyramidal systems]

Case S.S. 59 years of age, male. At the age of 25, he had admitted to sanatorium for 7 years because of pulmonary tuberculosis. After his discharge, at the age of 45, he had started complaining of depressive mood or the idea of suicide and admitted to a mental hospital. Psychiatric diagnosis was depression and slight mental retardation. Shortly after, his depressive mood was improved, but his hypochondriac attitude was unchanged. No tendency toward dementia was proven. At the age of 54, he became enable to walk. Neurologically, pyramidal and some sort of extrapyramidal signs, dysarthria, disturbance of swallowing, fecal and urinary incontinence became apparent. Laboratory data showed scarcely any abnormality. At the age of 59, he died of bronchopneumonia. Neuropathologically, moderate degeneration of dentate nucleus, slight degeneration of pyramidal tract from medulla oblongata to spinal cord, striatum, substantia nigra were found. Neither senile plaques nor neurofibrillary changes could be seen throughout central nervous system. The most important finding is the presence of peculiar acidophilic bodies. They are round or oval, 10 approximately 20 mu in diameter and distributed in dentate nucleus, oculomotor nucleus, central grey of midbrain, superior colliculus, putamen, pallidum, subthalamic nucleus, Zona incerta, hypothalamus, Locus coeruleus, reticular formation of midbrain and pons, pontine nucleus, raphe nucleus, vestibular nucleus, inferior olive in order of number of the bodies. These bodies are scattered in so-called ground substance, and have no relations to any cell bodies or cell processes.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary manifestations of juvenile laryngotracheal papillomatosis

Juvenile laryngotracheal papillomatosis spreads to involve the lungs in less than 1% of cases, and when this occurs, the prognosis is poor. In seven such cases, the lung lesions, which appeared either solid or cystic on radiographs, proved to be benign squamous cell proliferations or papillomas, with central cavities containing debris or air. They seemed to grow centrifugally, using the alveolar walls as scaffolding with central coalescence and lung destruction. Papillomas spread inferiorly from the larynx by direct extension as far as the major bronchi, but rarely beyond. However, the parenchymal lesions were widely scattered, and some were subpleural. This discrepancy suggests that fragments become detached, particularly during endoscopic resection, and are carried down the airways by airflow. Those that lodge proximal to the respiratory bronchioles may be removed by mucociliary action and cough. Those that travel more distally are poorly cleared and may grow. If enough lung parenchyma is destroyed, the patient can develop symptoms of restrictive lung disease in addition to signs of upper airway obstruction.

Carcinoma of the cervical esophagus: diagnosis, management, and results

Nine of 168 patients (5.3%) with carcinoma of the esophagus had primary tumors in the cervical esophagus. The principal symptoms and signs of carcinoma of the cervical esophagus were dysphagia, hoarseness, neck mass, and weight loss. The esophagogram was a very reliable study, revealing the abnormality in all nine patients. The true extent of the disease was better delineated by computerized tomography which demonstrated not only the intraluminal mass but also the extraesophageal spread. Endoscopic examination of the cervical esophagus was the definitive procedure to establish the diagnosis. All nine patients were treated with definitive radiotherapy, three surviving two to five years. The major cause of death was the failure to control local disease.

Association of human papillomavirus subtype and clinical course in respiratory papillomatosis

The relationship of human papillomavirus type 6 (HPV-6) subtypes to the clinical manifestations of respiratory papillomatosis was investigated. DNA was isolated from biopsy specimens of 21 patients and the viral genome analyzed by molecular hybridization. Four subtypes, designated HPV-6c through HPV-6f, were distinguishable by restriction endonuclease cleavage patterns of the viral genome. Patient records were reviewed to identify associations between viral subtype and sex, race, age at onset of papilloma, duration of disease, frequency of operations, history of tracheotomy and anatomical extension of papilloma. HPV-6c was present in 13 cases which were characterized by extensive anatomical spread of disease, higher frequency of operations, and a need for tracheotomy. HPV-6d occurred in 4 black patients with juvenile onset papilloma. HPV-6c was found in 2 white patients--1 with juvenile onset and 1 with adult onset papilloma. HPV-6f was identified in 2 white patients with adult onset disease.

Computed tomography of the neck

Thorough familiarity with the anatomy of the neck depicted in axial sections is fundamental to the interpretation of computed tomography (CT) scans. Fifteen consecutive sections are selected at 1 cm-intervals beginning at the level of the nasopharynx and extending down to the level of the thoracic inlet. Each scan is referenced to a profile drawing of the neck. Each CT scan is reproduced in the line drawing, which is labeled for major organs and discrete structures appearing in that section. Twelve representative cases illustrate the usefulness of CT in the evaluation of neck masses by documenting tumor size, location and relationship to adjacent structures. Intravenous contrast improves recognition of vascular structures and distinguishes lymph nodes from blood vessels. The location and relative density of lesions facilitate their specific identification. Demineralization of bone and cartilage is accurately documented in the illustrative cases. Symmetry is the key to the interpretation of subtle pathologies.