Establishment and application of a new 4/6 infarct nephrectomy rat model for moderate chronic kidney disease

PURPOSE

To develop a new 4/6 infarct nephrectomy (INx) model rat mimicking moderate chronic kidney disease (CKD) and to evaluate its application.

METHODS

We modified the conventional 5/6 INx rat model to create the 4/6 INx model by ligating the renal artery branch to induce infarction of one-third of the left kidney after right kidney removal and compared biochemically and histologically both models. To demonstrate the application of the 4/6 INx model, the effects of a supplementary compound containing calcium carbonate, chitosan, palm shell activated charcoal etc., that is effective for both CKD and its complications, were compared between both models.

RESULTS

Impairment of renal function in the 4/6 INx group was significantly more moderate than in the 5/6 INx group (P < 0.05). The 4/6 INx group showed less histological damage in kidney than in the 5/6 INx group. The supplementary compound did not improve CKD in the 5/6 INx group, but ameliorated elevation of blood urea nitrogen in the 4/6 INx group.

CONCLUSIONS

We developed the 4/6 INx model, which is more moderate than the conventional 5/6 INx model. This model could potentially demonstrate the effectiveness of drugs and supplements intended to prevent CKD and its progression.

Anaerobic threshold using sweat lactate sensor under hypoxia

We aimed to investigate the reliability and validity of sweat lactate threshold (sLT) measurement based on the real-time monitoring of the transition in sweat lactate levels (sLA) under hypoxic exercise. In this cross-sectional study, 20 healthy participants who underwent exercise tests using respiratory gas analysis under hypoxia (fraction of inspired oxygen [FiO2], 15.4 ± 0.8%) in addition to normoxia (FiO2, 20.9%) were included; we simultaneously monitored sLA transition using a wearable lactate sensor. The initial significant elevation in sLA over the baseline was defined as sLT. Under hypoxia, real-time dynamic changes in sLA were successfully visualized, including a rapid, continual rise until volitionary exhaustion and a progressive reduction in the recovery phase. High intra- and inter-evaluator reliability was demonstrated for sLT's repeat determinations (0.782 [0.607-0.898] and 0.933 [0.841-0.973]) as intraclass correlation coefficients [95% confidence interval]. sLT correlated with ventilatory threshold (VT) (r = 0.70, p < 0.01). A strong agreement was found in the Bland-Altman plot (mean difference/mean average time: - 15.5/550.8 s) under hypoxia. Our wearable device enabled continuous and real-time lactate assessment in sweat under hypoxic conditions in healthy participants with high reliability and validity, providing additional information to detect anaerobic thresholds in hypoxic conditions.

MRP1-Dependent Extracellular Release of Glutathione Induces Cardiomyocyte Ferroptosis After Ischemia-Reperfusion

BACKGROUND

The membrane components of cardiomyocytes are rich in polyunsaturated fatty acids, which are easily oxidized. Thus, an efficient glutathione-based lipid redox system is essential for maintaining cellular functions. However, the relationship between disruption of the redox system during ischemia-reperfusion (IR), oxidized lipid production, and consequent cell death (ferroptosis) remains unclear. We investigated the mechanisms underlying the disruption of the glutathione-mediated reduction system related to ferroptosis during IR and developed intervention strategies to suppress ferroptosis.

METHODS

In vivo fluctuations of both intra- and extracellular metabolite levels during IR were explored via microdialysis and tissue metabolome analysis. Oxidized phosphatidylcholines were assessed using liquid chromatography high-resolution mass spectrometry. The areas at risk following IR were assessed using triphenyl-tetrazolium chloride/Evans blue stain.

RESULTS

Metabolomic analysis combined with microdialysis revealed a significant release of glutathione from the ischemic region into extracellular spaces during ischemia and after reperfusion. The release of glutathione into extracellular spaces and a concomitant decrease in intracellular glutathione concentrations were also observed during anoxia-reperfusion in an in vitro cardiomyocyte model. This extracellular glutathione release was prevented by chemical inhibition or genetic suppression of glutathione transporters, mainly MRP1 (multidrug resistance protein 1). Treatment with MRP1 inhibitor reduced the intracellular reactive oxygen species levels and lipid peroxidation, thereby inhibiting cell death. Subsequent in vivo evaluation of endogenously oxidized phospholipids following IR demonstrated the involvement of ferroptosis, as levels of multiple oxidized phosphatidylcholines were significantly elevated in the ischemic region 12 hours after reperfusion. Inhibition of the MRP1 transporter also alleviated intracellular glutathione depletion in vivo and significantly reduced the generation of oxidized phosphatidylcholines. Administration of MRP1 inhibitors significantly attenuated infarct size after IR injury.

CONCLUSIONS

Glutathione was released continuously during IR, primarily in an MRP1-dependent manner, and induced ferroptosis. Suppression of glutathione release attenuated ferroptosis and reduced myocardial infarct size following IR.

Estimation of maximal lactate steady state using the sweat lactate sensor

A simple, non-invasive algorithm for maximal lactate steady state (MLSS) assessment has not been developed. We examined whether MLSS can be estimated from the sweat lactate threshold (sLT) using a novel sweat lactate sensor for healthy adults, with consideration of their exercise habits. Fifteen adults representing diverse fitness levels were recruited. Participants with/without exercise habits were defined as trained/untrained, respectively. Constant-load testing for 30 min at 110%, 115%, 120%, and 125% of sLT intensity was performed to determine MLSS. The tissue oxygenation index (TOI) of the thigh was also monitored. MLSS was not fully estimated from sLT, with 110%, 115%, 120%, and 125% of sLT in one, four, three, and seven participants, respectively. The MLSS based on sLT was higher in the trained group as compared to the untrained group. A total of 80% of trained participants had an MLSS of 120% or higher, while 75% of untrained participants had an MLSS of 115% or lower based on sLT. Furthermore, compared to untrained participants, trained participants continued constant-load exercise even if their TOI decreased below the resting baseline (P < 0.01). MLSS was successfully estimated using sLT, with 120% or more in trained participants and 115% or less in untrained participants. This suggests that trained individuals can continue exercising despite decreases in oxygen saturation in lower extremity skeletal muscles.

Non-Modified CpG Oligodeoxynucleotide Forming Guanine-Quadruplex Structure Complexes with ε-Poly-L-Lysine Induce Antibody Production as Vaccine Adjuvants

Unmethylated cytosine-phosphate-guanosine oligodeoxynucleotides (CpG ODNs) induce inflammatory cytokines and type I interferons (IFNs) to activate the immune system. To apply CpG ODNs as vaccine adjuvants, the cellular uptake and stability of phosphodiester-based, non-modified ODNs require further improvement. Previously developed new CpG ODNs forming guanine-quadruplex (G4) structures showed higher nuclease resistance and cellular uptake than linear CpG ODNs; however, the complex formation of G4-CpG ODNs with antigen proteins is necessary for their application as vaccine adjuvants. In this study, we utilized a cationic polymer, ε-poly-_L-lysine (ε-PLL), as a carrier for G4-CpG ODNs and antigen. The ε-PLL/G4-CpG ODN complex exhibited enhanced stability against nucleases. Cellular uptake of the ε-PLL/G4-CpG ODN complex positively correlated with the N/P ratio. In comparison to naked G4-CpG ODNs, the ε-PLL/G4-CpG ODN complex induced extremely high levels of interleukin (IL)-6, IL-12, and IFN-β. Relative immune cytokine production was successfully tuned by N/P ratio modification. Mice with the ε-PLL/G4-CpG ODN/ovalbumin (OVA) complex showed increased OVA-specific immunoglobulin (Ig)G, IgG1, and IgG2c levels, whereas total IgE levels did not increase and weight gain rates were not affected. Therefore, ε-PLL can serve as a safe and effective phosphodiester-based, non-modified CpG ODN delivery system, and the ε-PLL/G4-CpG ODN/antigen complex is a highly promising candidate for vaccine adjuvants and can be further used in clinical research.

H2 Inhibits the Formation of Neutrophil Extracellular Traps

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NETs have been implicated as therapeutic targets to address inflammation and thrombotic tissue damage in conditions such as sepsis, acute respiratory disease syndrome, COVID-19, and CVDs.

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H₂ has been clinically and experimentally proven to ameliorate inflammation; however, the underlying molecular mechanisms remain elusive.

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Compared with control neutrophils, PMA-stimulated human neutrophils exposed to H₂ exhibited reduced citrullination of histones and release of NET components; mechanistically, H₂-mediated neutralization of HOCl produced during oxidative bursts suppresses DNA damage.

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Inhalation of H₂ inhibited the formation and release of NET components in the blood and BAL of the LPS-induced sepsis in mice and aged mini pigs.

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H₂ therapy is potentially a new therapeutic strategy for inflammatory diseases involving NETs associated with excessive neutrophil activation.

Neutrophil extracellular traps (NETs) contribute to inflammatory pathogenesis in numerous conditions, including infectious and cardiovascular diseases, and have attracted attention as potential therapeutic targets. H₂ acts as an antioxidant and has been clinically and experimentally proven to ameliorate inflammation. This study was performed to investigate whether H₂ could inhibit NET formation and excessive neutrophil activation. Neutrophils isolated from the blood of healthy volunteers were stimulated with phorbol-12-myristate-13-acetate (PMA) or the calcium ionophore A23187 in H₂-exposed or control media. Compared with control neutrophils, PMA- or A23187-stimulated human neutrophils exposed to H₂ exhibited reduced neutrophil aggregation, citrullination of histones, membrane disruption by chromatin complexes, and release of NET components. CXCR4^high neutrophils are highly prone to NETs, and H₂ suppressed Ser-139 phosphorylation in H2AX, a marker of DNA damage, thereby suppressing the induction of CXCR4 expression. H₂ suppressed both myeloperoxidase chlorination activity and production of reactive oxygen species to the same degree as N-acetylcysteine and ascorbic acid, while showing a more potent ability to inhibit NET formation than these antioxidants do in PMA-stimulated neutrophils. Although A23187 formed NETs in a reactive oxygen species–independent manner, H₂ inhibited A23187-induced NET formation, probably via direct inhibition of peptidyl arginine deiminase 4-mediated histone citrullination. Inhalation of H₂ inhibited the formation and release of NET components in the blood and bronchoalveolar lavage fluid in animal models of lipopolysaccharide-induced sepsis (mice and aged mini pigs). Thus, H₂ therapy can be a novel therapeutic strategy for NETs associated with excessive neutrophil activation.

A microsurgical technique for catheter insertion in the rat femoral artery

Purpose:

To modify a surgical catheterization method using the bent needle introducer in small animals.

Methods:

Eight-week-old male Lewis rats were used in the study. A needle introducer was created by bending a 21G injection needle at 45°. The bent needle introducer was used for catheter insertion into the left femoral artery of the rats under anesthesia. As a control, a catheter was directly inserted into the blood vessel without the introducer. The insertion time of each method was measured. Blood pressure and heart rate were measured 24 h after catheter insertion using the telemetry system.

Results:

Using the introducer, the catheter was successfully inserted within a short time in all rats. Without the introducer, a longer duration was required for catheter insertion. The frequency of the insertion with no catheter-based errors with the introducer tended to be higher than that without the introducer. The mean arterial pressure and heart rate 24 h after catheter insertion in each group were almost the same.

Conclusions:

We developed a surgical catheterization method using the introducer in small animals. This could potentially reduce the frequency of the insertion with catheter-based errors and insertion time.

Acute encephalitis with refractory, repetitive partial seizures (AERRPS): a peculiar form of childhood encephalitis

OBJECTIVE

We conducted a nationwide multicenter study in Japan to elucidate the clinical and laboratory characteristics of acute encephalitis with refractory, repetitive partial seizures (AERRPS).

MATERIALS AND METHODS

Clinical and laboratory features, treatment, and outcome were assessed using a structured questionnaire.

RESULTS

Twenty-nine children were enrolled in the study. Refractory and repetitive partial seizures accompanied by fever were the cardinal clinical features. Partial seizures consisted principally of eye deviation or facial twitching, being periodically repeated during the acute phase. These seizures were refractory to conventional anticonvulsants and were only suppressed by high-dose intravenous barbiturate administration. Rhythmic activities on electroencephalography and non-specific cerebral atrophy on neuroimaging were common. Serum or cerebrospinal antibodies against GluRepsilon2 were positive in six patients. General prognosis was unfavorable due to intractable epilepsy and cognitive deficits.

CONCLUSION

Based on the peculiar and homogenous features, AERRPS can be regarded as a distinct clinical entity.

Aberrant midsagittal fiber tracts in patients with hemimegalencephaly

BACKGROUND AND PURPOSE

In hemimegalencephaly, MR imaging often reveals midsagittal bandlike structures between the 2 lateral ventricles. To determine whether these structures are aberrant midsagittal fibers, we retrospectively reviewed them on conventional MR imaging and prospectively examined them by diffusion tensor MR and fiber tract (FT) reconstruction imaging.

MATERIALS AND METHODS

We retrospectively reviewed conventional MR images of 26 consecutive patients with hemimegalencephaly by 2 neuroradiologists, focusing on abnormal midsagittal structures. The distance between the 2 anterior horns and widths of midsagittal bandlike structures were measured. Prospective analysis was performed in 7 consecutive patients with hemimegalencephaly examined for midsagittal aberrant fibers by diffusion tensor imaging, and cortical distribution areas of the fibers were observed.

RESULTS

The distance between the 2 anterior horns was wide (>4 mm) due to white matter-intensity structures in 20 of 26 patients (76.9%). Mid-sagittal bandlike structures were observed in 15 patients (57.7%). Asymmetry of the fornices was detected in 7 patients (26.9%), and both fornices were thickened in 7 (26.9%) patients. On FT reconstruction, images showed that 4 of 7 patients with hemimegalencephaly had aberrant midsagittal fibers connecting frontal, occipital, or parietal lobes, bilaterally (n = 3) or ipsilaterally (n = 1). All 4 patients had increased width between the 2 anterior horns, and 3 of them exhibited midsagittal bandlike structures on conventional MR imaging. On the other hand, these MR imaging findings were not noted in 3 patients who did not have aberrant midsagittal fibers on diffusion tensor imaging.

CONCLUSIONS

Aberrant midsagittal FTs running intra- or interhemispherically do not infrequently exist in patients with hemimegalencephaly.

Treatment of convulsive status epilepticus in infants and young children in Japan

We review the types and causes of convulsive status epilepticus (CSE) in infants and young children in Japan, and discuss the current recommendations for the use of intravenous (IV) drugs in managing this condition, and report on our clinical experiences. There are prolonged or continuous CSE and clustered or intermittent CSE, and treatments are different between them. In Japan, fosphenytoin and IV preparation of lorazepam and phenobarbital are not available. Recently, midazolam and lidocaine (LDC) have been widely used, although neither of these drugs have official approval for the management of CSE. Febrile seizures and epilepsies are common causes of CSE in infants and young children in Japan, followed by benign infantile convulsions (BIC), convulsions with gastroenteritis (CwG), and acute encephalitis with refractory CSE and intractable epilepsy (AECSEE), which are familiar disorders in Japan. BIC and CwG frequently present with clustered CSE and do not respond to IV diazepam, but have an excellent response with oral carbamazepine or IV LDC. CSE in AECSEE requires control with barbiturate coma. The Research Committee on Clinical Evidence of Medical Treatment for Status Epilepticus in Childhood has developed a proposed guideline for the treatment of CSE in childhood in Japan by an evidence-based approach and consensus conference. Initial management of seizures should be attempted mainly with IV diazepam, the second-line treatment involves IV midazolam followed by IV phenytoin if seizures persist, and the third-line treatment requires barbiturate coma. However, our experience of 247 episodes of CSE in 77 patients, predominantly with chronic epilepsy, required different second-line treatments for prolonged CSE compared with clustered CSE: the former were treated with IV midazolam or pentobarbital, and the latter were given IV phenytoin or LDC. We propose modifications to the guideline for CSE that the second-line treatment is divided by prolonged CSE and clustered CSE, and that the procedures for brain protection and systemic management are added.

Hemimegalencephaly: a study of abnormalities occurring outside the involved hemisphere

BACKGROUND AND PURPOSE

Hemimegalencephaly is a rare but well-known congenital malformation with ipsilateral enlargement of the hemicerebrum. However, very little is known about changes in structures outside the involved hemisphere in patients with this condition. We investigated morphologic abnormalities occurring outside the affected hemisphere by MR imaging in a large series of patients with hemimegalencephaly.

MATERIALS AND METHODS

MR imaging findings for 30 patients with hemimegalencephaly were retrospectively reviewed and evaluated for structures outside the involved hemisphere on routine MR images, such as cranial nerves (I, II, V), brain vessels, subdural and subarachnoid spaces, brain stem, and cerebellum, on both the ipsilateral and contralateral sides.

RESULTS

The ipsilateral olfactory and optic nerves were enlarged in 8 (26.7%) and 1 (3.3%) of the 30 patients, respectively, without enlargement on the contralateral side. No asymmetry was noted in the trigeminal nerves. Asymmetric vascular dilations in the ipsilateral cerebral hemisphere were observed in 12 of the 30 patients (40%), in deep cerebral vessels in 11 patients (36.7%), and in superficial cerebral vessels in 8 patients (26.7%). Ipsilateral brain stem and hemicerebellar asymmetric enlargement was detected in 2 patients (6.7%) and 14 patients (46.7%), respectively. Abnormal cerebellar folia were observed on the ipsilateral side in 6 patients (20%) and on the contralateral side in 3 patients (10%).

CONCLUSION

Ipsilateral olfactory nerve enlargement, cerebral vascular dilations, cerebellar enlargement, and bilateral or ipsilateral abnormal architecture of the cerebellar folia are often associated with hemimegalencephaly.

Treatment of convulsive status epilepticus in infants and young children in Japan

We review the types and causes of convulsive status epilepticus (CSE) in infants and young children in Japan, and discuss the current recommendations for the use of intravenous (IV) drugs in managing this condition, and report on our clinical experiences. There are prolonged or continuous CSE and clustered or intermittent CSE, and treatments are different between them. In Japan, fosphenytoin and IV preparation of lorazepam and phenobarbital are not available. Recently, midazolam and lidocaine (LDC) have been widely used, although neither of these drugs have official approval for the management of CSE. Febrile seizures and epilepsies are common causes of CSE in infants and young children in Japan, followed by benign infantile convulsions (BIC), convulsions with gastroenteritis (CwG), and acute encephalitis with refractory CSE and intractable epilepsy (AECSEE), which are familiar disorders in Japan. BIC and CwG frequently present with clustered CSE and do not respond to IV diazepam, but have an excellent response with oral carbamazepine or IV LDC. CSE in AECSEE requires control with barbiturate coma. The Research Committee on Clinical Evidence of Medical Treatment for Status Epilepticus in Childhood has developed a proposed guideline for the treatment of CSE in childhood in Japan by an evidence-based approach and consensus conference. Initial management of seizures should be attempted mainly with IV diazepam, the second-line treatment involves IV midazolam followed by IV phenytoin if seizures persist, and the third-line treatment requires barbiturate coma. However, our experience of 247 episodes of CSE in 77 patients, predominantly with chronic epilepsy, required different second-line treatments for prolonged CSE compared with clustered CSE: the former were treated with IV midazolam or pentobarbital, and the latter were given IV phenytoin or LDC. We propose modifications to the guideline for CSE that the second-line treatment is divided by prolonged CSE and clustered CSE, and that the procedures for brain protection and systemic management are added.

Low-dose prednisolone ameliorates acute renal failure caused by cholesterol crystal embolism

AIMS

The prognosis of renal cholesterol crystal embolism (CCE) is poor. Although various treatments for CCE have been attempted, there is no optimal therapy. We tested the effect of low-dose prednisolone (PS) on CCE-related acute renal failure (ARF).

PATIENTS AND METHODS

7 patients (mean age 69 years) diagnosed with CCE-related ARF were treated with oral PS at 15-20 mg/day for 2-4 weeks, which was then tapered at 5 mg/day over 2-4 weeks, followed by 5 mg/day maintenance dose. Recurrent ARF during PS tapering was treated with a larger dose of PS.

RESULTS

Inciting factors were identified in four patients: coronary angiography (n=3) and cerebral angiography (n=1). On admission, serum creatinine (SCr) was 2.1 +/- 0.3 mg/dl (mean +/- SEM). SCr and eosinophil count before treatment were 4.2 +/- 0.4 mg/dl and 682 +/- 73/microl, respectively. PS therapy improved ARF in all cases at week 2 (SCr 3.8 +/- 0.5 mg/dl) parallel to a decrease in eosinophilia (116 +/- 30/microl), and at week 4 (3.1 +/- 0.4 mg/dl and 134 +/- 20/microl, respectively). At last follow-up, renal function was improved or maintained in 5 patients compared with that at week 4 post-treatment. One patient died of lung cancer. Another required LDL apheresis and hemodialysis but died due to CCE-related multi-organ failure. A third patient had recurrent ARF and was re-treated with a larger dose of PS, which resulted in an immediate decrease in SCr. However, the patient developed acute renal dysfunction due to congestive heart failure, and required hemodialysis.

CONCLUSIONS

Low-dose PS improved CCE-related ARF, probably through amelioration of inflammatory reaction surrounding affected renal vessels.

Undetectable levels of CSF hypocretin-1 (orexin-A) in two prepubertal boys with narcolepsy

We report on two prepubertal narcoleptic boys with undetectable levels of hypocretin-1 (orexin-A) in their cerebrospinal fluid (CSF). The disease onset times were 6 and 8 years, and CSF was collected 8 and 20 months after the onset, respectively. The initial symptoms were excessive daytime sleepiness, cataplexy and disrupted nocturnal sleep. Both subjects are DRB1*1501 and DQB1*0602 positive. The measurement of CSF hypocretin-1 is valuable for the decisive diagnosis of narcolepsy and for selecting the type of treatment in prepubertal children. Our results suggest that a significant degree of hypocretin deficiency is already present at the disease onset.

Diagnosis of Alexander disease in a Japanese patient by molecular genetic analysis

Alexander disease is a leukodystrophy that is neuropathologically characterized by the presence of numerous Rosenthal fibers in astrocytes. Recently, mutations in the gene encoding glial fibrillary acidic protein (GFAP) were identified in patients with Alexander disease. We sequenced the GFAP gene of a Japanese girl who presented with typical symptoms of Alexander disease but in whom the diagnosis was not proven by histopathology. We identified a missense mutation, R239C, which is identical to the mutation previously reported to be most frequent. As was the case in previously described patients, our patient was also heterozygous for the de novo mutation. Interestingly, despite the fact that this is a de novo mutation, R239C was found to be common in different ethnic groups, implying that the site is a "hot spot" for mutagenesis. Molecular genetic analysis now makes the antemortem diagnosis of Alexander disease possible.

Mechanical ventilation care in severe childhood neurological disorders

Forty-five patients underwent long-term life-sustaining mechanical ventilation care in the Child Neurology Ward, National Center Hospital for Mental, Nervous and Muscular Disorders from 1990 to 2000. Twenty patients had chronic respiratory insufficiency due to neuromuscular disorders, nine of whom underwent home mechanical ventilation care. Nineteen of the 45 patients had chronic respiratory insufficiency due to progressive central nervous system disorders, three of whom underwent home mechanical ventilation care. Six patients with chronic respiratory insufficiency due to the sequelae of transient events were on ventilation, two of whom underwent home mechanical ventilation care. In some patients, especially ones with neuromuscular disorders, mechanical ventilation care is very useful for improving their daily activity and quality of life. In other patients, however, mechanical ventilation care is merely a means of prolonging life without visible improvement of their quality of life. As medical resources are limited, home mechanical ventilation care is a recommended method for patients who need life-sustaining mechanical ventilation care. Considering an individual or social consensus, the indication of long-term life-sustaining mechanical ventilation care for chronic respiratory insufficiency due to severe childhood neurological disorders should be further discussed.

Surgical treatment of early-infantile epileptic encephalopathy with suppression-bursts associated with focal cortical dysplasia

A surgically treated case of early-infantile epileptic encephalopathy (EIEE) with suppression-bursts associated with focal cortical dysplasia is reported. Tonic-clonic seizures followed by a series of spasms occurred at age of a few days. Interictal electroencephalogram (EEG) revealed a suppression-burst pattern and magnetic resonance imaging suggested focal cortical dysplasia in the left prefrontal area. Combination therapies of antiepileptic treatments showed only partial efficacy. The patient underwent lesionectomy at 4 months of age and the spasms decreased to zero to two series daily. At age 2 years, his seizures increased in number and EEG showed that residual left hemisphere was the main epileptogenic focus. Modified functional hemispherectomy of the left hemisphere was applied at age 3 years. The patient, now 5 years old, is free from seizure and gaining psychomotor development gradually. In cases of EIEE with focal cortical dysplasia, surgical treatment may have beneficial effects on both psychomotor development and seizure control.

Clinical and pedigree study on familial cases of West syndrome in Japan

Nationwide survey on familial cases of West syndrome (WS) in first- and second-degree relatives was conducted by mailing a questionnaire to 64 major university hospitals, children's hospitals, and epilepsy centers in Japan, and by review of the Japanese cases in the literatures. Thirty-four familial cases, 20 males and 14 females, were obtained in 15 families including one with five affected members in two generations and another with three affected male siblings including a half brother by a different father (X-linked WS). A mother and the child or children were involved in three families. Nine families had 21 cryptogenic cases and six families had 13 symptomatic cases, and the etiologies were same among the affected members in each family. Familial cases of WS have characteristic clinical features and genetic mechanisms. Age of onset, seizure types, electroencephalographic abnormalities, early seizure outcome, effective treatment, long-term seizure prognosis, and long-term developmental prognosis were concordant among the affected members in each family. Long-term seizure and developmental prognoses were far better than those in WS in general, with seizure-free rate of 82% and normal mental development rate of 44%. Poor prognosis was limited to specific symptomatic cases. Adrenocorticotropic hormone (ACTH) was a treatment of choice, and even in relapse of WS after ACTH therapy, the patients well responded to antiepileptic drugs. Specific inheritance pattern was difficult to imagine in the majority of the present cases, except for one family with X-linked WS and another family with five patients of maternal inheritance. These results are helpful for the treatment choice and prognostication of clinical course for familial cases of WS.

[Three cases of Costello syndrome presenting with intractable epilepsy and profound psychomotor retardation/regression]

We report three cases of Costello syndrome (CS) presenting with intractable epilepsy and profound psychomotor retardation/regression. Previous reports on CS described mild to moderate psychomotor retardation, and epilepsy in only 8% of the cases. The details of these neurological complications have not been reported so far. All the present cases had intractable epilepsies and profound psychomotor retardation/regression. Two of them had symptomatic localization-related epilepsies and the other had Lennox-Gastaut syndrome following West syndrome. Unusual complication of profound psychomotor retardation/regression in our cases seems to be caused by intractable epilepsy. It should be noted that CS patients with epilepsy may have more severe central nervous symptoms than those previously reported.

Paroxysmal discharges on EEG in young autistic patients are frequent in frontal regions

EEGs were recorded in 86 autistic patients during sleep. Epileptic discharges were observed in 37 cases (43%). Twenty-seven (73%) of these 37 cases had localized spikes, 8 had multiple spike foci, one had generalized spikes, and one had both multiple spike foci and generalized spikes. Forty-seven epileptic discharge foci were registered in 36 cases, the exception being one with generalized spikes. Thirty-six (76.6%) of the registered 47 epileptic discharge foci were in the frontal region, one (2.1%) in the temporal region, 7 (14.1%) in the centro-parietal region, and 3 (6.4%) in the occipital region. Twenty (55.6%) of the 36 frontal spikes were at midline (11 at Fz and 9 at Cz), 8 on the left side, and 8 on the right side. The dipole of midline spikes was in the deep midline frontal region. These results suggest that frontal dysfunctions are important in the mechanism of symptoms in autism.

A severely brain-damaged case of 3-hydroxyisobutyric aciduria

We report a male case of 3-hydroxyisobutyric aciduria (3HiB-uria) with severe brain damage. He had mild asphyxia at birth. He needed tube feeding for a month. He showed mild dysmorphic features, including low set ears, a long philtrum and micrognathia. At 4 months of age he had acute encephalopathy. Thereafter, severe brain damage remained and mechanical ventilation care was needed all day. After he had been admitted to our hospital at 3 years of age, repeated organic acid analysis of urine confirmed the diagnosis of 3HiB-uria. This patient had been previously diagnosed as having cerebral palsy and sequelae of acute encephalopathy.

Current status of bacterial contamination of autologous blood for transfusion

Autologous transfusion, although not without risk, does decrease the risk of transmitted diseases via homologous transfusion. However, strict quality control is required for autologous transfusion. In Japan, a recent enactment requires that written informed consent be obtained prior to blood transfusion, which therefore requires that clinicians provide sufficient explanation of the risks involved with this procedure. To the best of our knowledge, this is the first study to comprehensively evaluate the manner in which the safety of autologous blood transfusion can be compromised by bacterial contamination. For a 24-month period, between April 1996 and March 1998, bacterial contamination of all kinds of autologous blood samples was tested by sampling the culture immediately prior to transfusion. Subculturing, identification and susceptibility testing of the isolates were performed. From the 287 units of all kinds of autologous blood transfused, 18 were culture positive (6.3%). Positive blood cultures were obtained in two of the 59 units (3.4%) of autologous transfusion donated preoperatively (ATDP) that was infused intraoperatively, in three of the 117 units (2.6%) of hemodilution/autologous transfusion (HAT) and in three of the 81 (3.7%) of ATDP infused postoperatively. There was a high percentage (33.3%) of positive blood cultures in the cases of intraoperative blood salvage (IOBS). The total rate of positive blood cultures was 6.3% including IOBS and 3.1% excluding IOBS. The most common microorganism isolated from autologous blood was coagulase-negative Staphylococci in 12 of 18 culture-positive units (66.7%). Alpha Streptococcus uiridans was isolated in 2 units (11%) and Staphylococcus aureus was isolated in 1 unit (5.5%). However, none of the patients who received the culture-positive autotransfusion blood showed clinical signs or laboratory findings of bacteremia. Safe ATDP is threatened by bacterial contamination that can be introduced by numerous sources, such as the donors' blood, the skin at the site of venipuncture, the environment and the phlebotomist's finger. In the cases of IOBS, protection against bacterial contamination at the surgical site is crucial. Here we discuss the relevance of our findings to the efforts to minimize the risks of contamination associated with autologous blood transfusion; risks that must be communicated to the patient in the process of informed consent. Continued research is required to identify the safest method of autologous blood transfusion.

[Life-sustaining mechanical ventilation care for children with progressive or degenerative brain disorders]

In the past 10 years, we have treated 25 patients with chronic respiratory insufficiency due to a progressive or degenerative brain disorder. Ten patients died and the other 15 survived. Five of the former and 12 of the latter received life-sustaining mechanical ventilation care. Even in the terminal stage of progressive or degenerative brain disorders, patients can survive for a longer period than previously, if life-sustaining mechanical ventilation care is given. In Japan we do not have a guideline for medical indication or decision-making for children with progressive or degenerative brain disorders. Whenever we see such patients, we have great difficulty in making a decision. It may therefore be necessary to discuss whether we should have such a guideline.