Longer withdrawal time is not associated with increased patient discomfort in colonoscopy: a retrospective observational study

PURPOSE

Withdrawal time of sufficient length is a quality indicator for colonoscopies. Nonetheless, whether extending the withdrawal time contributes to patient discomfort remains unknown. This study aimed to clarify the relationship between colonoscopy withdrawal time and patient discomfort.

METHODS

A cohort of consecutive patients who underwent colonoscopy at a single institution from October 2018 to January 2020 was retrospectively analyzed. Initially, the relationship between the mean withdrawal time for each colonoscopist in no-finding examinations and polyp detection rate was investigated in 2,043 patients. Subsequently, the primary outcome of association between withdrawal time and patient discomfort, as determined by patient questionnaire, was assessed for each examination in 481 patients from the initial cohort.

RESULTS

The mean withdrawal time was strongly correlated with polyp detection rate (correlation coefficient, 0.72; P<0.001). In contrast, longer withdrawal time was not associated with increased discomfort; however, there was a weak inverse correlation between patient discomfort and longer withdrawal time (correlation coefficient, -0.25; P<0.001). Similarly, multiple regression analysis adjusted for confounding variables revealed that longer withdrawal time was not associated with increased patient discomfort (regression coefficient, -0.04 for each 1-minute increase in the length of withdrawal time; P=0.45).

CONCLUSION

This study showed for the first time that longer withdrawal times did not result in increased discomfort, indicating that withdrawal time can be extended to sufficient length for optimal patient examination and polyp detection.

Recent trends in the prevalence and distribution of colonic diverticula in Japan evaluated using computed tomography colonography

BACKGROUND

Computed tomography colonography (CTC) may be superior to colonoscopy and barium enema for detecting diverticula. However, few studies have used CTC to diagnose diverticula.

AIM

To evaluate the current prevalence and distribution of colonic diverticula in Japan using CTC.

METHODS

This study was conducted as part of the Japanese National Computed Tomographic Colonography Trial, which included 1181 participants from 14 hospitals in Japan. We analyzed the prevalence and distribution of colonic diverticula and their relationships with age and sex. The relationship between the diverticula and the length of the large intestine was also analyzed.

RESULTS

Diverticulosis was present in 48.1% of the participants. The prevalence of diverticulosis was higher in the older participants (P < 0.001 for trend). The diverticula seen in younger participants were predominantly located in the right-sided colon. Older participants had a higher frequency of bilateral type (located in the right- and left-sided colon) diverticulosis (P < 0.001 for trend). The length of the large intestine with multiple diverticula in the sigmoid colon was significantly shorter in those without diverticula (P < 0.001).

CONCLUSION

The prevalence of colonic diverticulosis in Japan is higher than that previously reported. The prevalence was higher, and the distribution tended to be bilateral in older participants.

Inverse time trends of peptic ulcer and reflux esophagitis show significant association with reduced prevalence of Helicobacter pylori infection

INTRODUCTION

Recent prevalence and trends of gastric/duodenal ulcer (GU/DU) and reflux esophagitis (RE) are inadequate.

METHODS

We reviewed the records of consecutive 211,347 general population subjects from 1991 to 2015.

RESULTS

During the 25 years, the prevalence of GU and DU has gradually decreased (from 3.0% to 0.3% and from 2.0% to 0.3%) whereas that of RE has markedly increased (from 2.0% to 22%). The prevalence of Helicobacter pylori (HP) infection has decreased from 49.8% (in 1996) to 31.2% (in 2010). Multivariable logistic regression analyses demonstrated that HP infection was positively associated with GU/DU and negatively associated with RE with statistical significance. The panel data analyses showed that reduced rate of HP infection is proportionally correlated with decrease of GU/DU and inversely correlated with increase of RE. It is further suggested other latent factors should be important for changed prevalence of these three acid-related diseases. Age-period-cohort analysis indicated the significant association of older age, male gender, and absence of HP infection with RE.

CONCLUSIONS

The prevalence of GU and DU has gradually decreased whereas that of RE has markedly increased in Japan. Inverse time trends of peptic ulcer and reflux esophagitis are significantly associated with reduced prevalence of HP infection. KEY MESSAGES The prevalence of gastric and duodenal ulcer has gradually decreased whereas that of reflux esophagitis has markedly increased in Japan. The prevalence of Helicobacter pylori infection in Japan has greatly decreased from 49.8% to 31.2% during the 14 years (from 1996 to 2010). Inverse time trends of peptic ulcer and reflux esophagitis are associated with reduced prevalence of Helicobacter pylori infection with statistical significance.

Causative factors of discomfort in esophagogastroduodenoscopy: A large-scale cross-sectional study

BACKGROUND

It is important to reduce patient discomfort in esophagogastroduodenoscopy. Remedial measures can be taken to alleviate discomfort if the causative factors are determined; however, all the factors have not been elucidated yet.

AIM

To clearly determine the factors influencing discomfort in transoral esophagogastroduodenoscopy using a large-size cross-sectional study with readily available data.

METHODS

Consecutive patients who underwent screening transoral esophagogastroduodenoscopy consecutively between August 2017 and October 2017 at a health check-up center were included. Discomfort was evaluated using a face scale between 0 and 10 with a 6-level questionnaire. Univariate and multiple regression analyses were performed to investigate the factors related to the discomfort in esophagogastroduodenoscopy. Univariate analysis was performed in both the unsedated and sedated study groups. Age, sex, height, body mass index, smoking status, alcohol intake, hiatal hernia, history of gastrectomy, biopsy during examination, Lugol’s solution usage, administration of butylscopolamine with/without a sedative (pethidine, midazolam, or both), endoscope model, history of endoscopy, and endoscopists were considered as possible factors of discomfort.

RESULTS

Finally, 1715 patients were enrolled in this study. Overall, the median discomfort score was 2 and the interquartile range was 2-4. High discomfort (score ≥ 6) was recorded in 18% of the participants. According to univariate analysis, in the unsedated group, young age (P < 0.001), female sex (P < 0.001), and no history of endoscopy (P < 0.001) were factors associated with increased discomfort. Significant differences were also noted for height (P = 0.007), smoking status (P = 0.003), and endoscopists (P < 0.001). In the sedation group, young age (P < 0.001), female sex (P < 0.001), and no history of endoscopy (P = 0.004) were associated with increased discomfort; additionally, significant differences were found in smoking status (P < 0.001), type of sedation (P < 0.001), and endoscopists (P = 0.027). There was also a marginal difference due to alcohol intake (P = 0.055). Based on multiple regression analysis, young age, female sex, less height, current smoking status, and presence of hiatal hernia [regression coefficients of 0.08, P < 0.001 (for -1 years); 0.45, P = 0.013; 0.02, P = 0.024 (for -1 cm); 0.35, P = 0.036; and 0.34, P = 0.003, respectively] were factors that significantly increased discomfort in esophagogastroduodenoscopy. Alternatively, sedation significantly reduced discomfort and pethidine (regression coefficient: -1.47, P < 0.001) and midazolam (regression coefficient: -1.63, P = 0.001) significantly reduced the discomfort both individually and in combination (regression coefficient: -2.92, P < 0.001). A difference in the endoscopist performing the procedure was also associated with discomfort.

CONCLUSION

Young age, female sex, and smoking are associated with esophagogastroduodenoscopy discomfort. Additionally, heavy alcohol consumption diminished the effects of sedation. These factors are easily obtained and are thus useful.

Multiple White and Flat Elevated Lesions Observed in the Stomach: A Prospective Study of Clinical Characteristics and Risk Factors

Objective Multiple white and flat elevated lesions (MWFLs) observed in the stomach have only been presented in abstracts at academic conferences over the last decade; therefore, relatively little is known about these lesions. Our aim was to prospectively clarify the clinical characteristics of MWFLs, to identify their risk factors and to retrospectively evaluate the clinical progression of these lesions. Methods A prospective analysis of clinical characteristics and risk factors was conducted in participants who underwent esophagogastroduodenoscopic screening at our hospital. A retrospective analysis of the medical chart of patients identified as having MWFLs was conducted to describe the clinical progression of these lesions. Results The prevalence rate of MWFLs was 10.4% (80/767), with the following risk factors identified on a logistic regression analysis: use of proton pump inhibitors [odds ratio (OR), 3.51; 95% confidence interval (CI), 1.92-6.43], female sex (OR, 1.92; 95% CI, 1.19-3.12) and a 1-year increase in age (OR, 1.05; 95% CI, 1.02-1.08). Among the 70 cases with MWFLs observed over a mean duration of 2.3 years, no progression of MWFLs was detected in 67 cases (96%). Among the 3 remaining cases, progression was mild, with none of the lesions progressing to malignancy. Conclusion The use of proton pump inhibitors (PPIs), female sex, and age are risk factors for MWFLs. We believe that endoscopists should recognize these lesions.

Diagnostic Performance and Patient Acceptance of Reduced-Laxative CT Colonography for the Detection of Polypoid and Non-Polypoid Neoplasms: A Multicenter Prospective Trial

Purpose To evaluate the diagnostic accuracy and patient acceptance of reduced-laxative computed tomographic (CT) colonography without computer-aided detection (CAD) for the detection of colorectal polypoid and non-polypoid neoplasms in a population with a positive recent fecal immunochemical test (FIT). Materials and Methods Institutional review board approval and written informed consent were obtained. This multicenter prospective trial enrolled patients who had positive FIT results. Reduced-laxative CT colonography and colonoscopy were performed on the same day. Patients received 380 mL polyethylene glycol solution, 20 mL iodinated oral contrast agent, and two doses of 20 mg mosapride the day before CT colonography. The main outcome measures were the accuracy of CT colonography for the detection of neoplasms 6 mm or larger in per-patient and per-lesion analyses and a survey of patient perceptions regarding the preparation and examination. The Clopper-Pearson method was used for assessing the 95% confidence intervals of per-patient and per-lesion accuracy. Survey scores were analyzed by using the Wilcoxon and χ² tests. Results Three hundred four patients underwent both CT colonography and colonoscopy. Per-patient sensitivity, specificity, positive predictive value, and negative predictive value of CT colonography for detecting neoplasms 10 mm or larger were 0.91 (40 of 44), 0.99 (255 of 258), 0.93 (40 of 43), and 0.98 (255 of 259), respectively; these values for neoplasms 6 mm or larger were 0.90 (71 of 79), 0.93 (207 of 223), 0.82 (71 of 87), and 0.96 (207 of 215), respectively. Per-lesion sensitivities for detection of polypoid and non-polypoid neoplasms 10 mm or larger were 0.95 (40 of 42) and 0.67 (six of nine), respectively; those for neoplasms 6 mm or larger were 0.90 (104 of 115) and 0.38 (eight of 21), respectively (P < .05 for both). Patient acceptance of preparation and examination with CT colonography was significantly higher than that with colonoscopy, and 62% (176 of 282) of patients would choose CT colonography as the first examination if they have a positive FIT result in the future. Conclusion Reduced-laxative CT colonography without CAD is accurate in the detection of polypoid neoplasms 6 mm or larger but is less accurate in the detection of non-polypoid neoplasms. Reduced-laxative CT colonography has high patient acceptance and is an efficient triage examination for patients with a positive FIT. ^© RSNA, 2016 Online supplemental material is available for this article.

Emergency carotid artery stent placement in patients with acute ischemic stroke

BACKGROUND AND PURPOSE

An effective intervention has not yet been established for patients with acute ischemic stroke who present with serious neurologic symptoms due to occlusion or a high-grade stenosis of the internal carotid artery (ICA). The aim of our retrospective study was to investigate the feasibility, safety, and efficacy of emergency carotid artery stent placement to improve neurologic symptoms and clinical outcome.

METHODS

Of 896 consecutive patients with acute ischemic stroke who were admitted to our institution within 7 days of onset from July 2000 to June 2003, 17 patients (1.9%) with occlusion or a high-grade stenosis of the ICA underwent emergency carotid artery stent placement. We reviewed their records for neurologic outcome, per the National Institutes of Health Stroke Scale (NIHSS) score, before and at 7 days after stent placement; clinical outcome, per the modified Rankin Scale score (mRS), at 90 days; frequency of procedure-related complications within 30 days; and recurrence rate of ipsilateral ischemic stroke within 90 days.

RESULTS

Carotid lesions were dilated completely in all patients. Median NIHSS scores before emergency stent placement and at 7 days were 12 and 5, respectively, showing significant improvement (P < .01, Wilcoxon rank sum test). Ten patients (59%) had favorable outcomes (mRS score 0-1) at 90 days. Irreversible complications occurred in two patients (12%): distal embolism in one and intracerebral hemorrhage in the other. No ipsilateral ischemic stroke recurred.

CONCLUSION

Emergency carotid artery stent placement can improve the 7-day neurologic outcome and may improve the 90-day clinical outcome in selected patients with ischemic stroke.

Hepatocellular carcinoma after radiofrequency ablation therapy: dynamic CT evaluation of treatment

The aim of this study is to analyze the dynamic CT findings after radiofrequency (RF) ablation for hypervascular hepatocellular carcinoma (HCC). RF ablation was used for 22 tumors in 20 patients. Peripheral enhancement was noted in 89% of regions within 1 month in the arterial phase. In 1-3 months, peripheral enhancement remained at 56% and was reduced to 22% by 3-6 months. It is difficult to determine the therapeutic result within 3 months due to continued peripheral enhancement in the arterial phase.

Shape of lens epithelial cells after intraocular lens implantation

PURPOSE

To evaluate the morphological behavior of lens epithelial cells (LECs) after human cataract surgery with implantation of a poly(methyl methacrylate) (PMMA) or silicone intraocular lens (IOL).

SETTING

Department of Ophthalmology, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Aichi, Japan.

METHODS

Morphological observations of LECs in the patients with IOLs were made by light and transmission electron microscopy. The LECs were from 4 areas: (1) the region below the anterior capsule, touching the IOL; (2) the area between region 1 and the equatorial region; (3) the equatorial region; and (4) the central equatorial region and of the posterior capsule not touching the IOL. Case 1 had implantation of a single-piece IOL with a PMMA optic and haptics. Case 2 had a 3-piece IOL with a PMMA optic and polypropylene haptics. Case 3 had a 3-piece IOL with a silicone optic and polypropylene haptics. Areas 1 and 4 could not be observed in Case 2.

RESULTS

The major difference between the patient with a PMMA IOL (Case 1) and the patient with a silicone IOL (Case 3) was that among the 4 areas observed, collagen fibers were present only in area 1 in Case 1 but in areas 2 or 3 as well in Case 3.

CONCLUSIONS

Fibrous collagen fibers appeared in regions in which LECs adhered and there was capsule contact with the IOL optic. In addition fibrous collagen fibers appeared in more areas in the eye with the silicone IOL than in that with the PMMA IOL, perhaps because IOLs with silicone optics move slightly while in the capsular bag.

Synthesis of a terbium fluorescent chelate and its application to time-resolved fluoroimmunoassay

A new nonadentate ligand, N, N, N1, N1-[2,6-bis(3'-aminomethyl-1'-pyrazolyl)-4-phenylpyridine]tetrakis(acetic acid) (BPTA) for a Tb3+ fluorescent complex was synthesized. The Tb3+ complex is strongly fluorescent, having a large fluorescence quantum yield of 1.00 and very long fluorescence lifetime of 2.681 ms in 0.05 M borate buffer of pH 9.1. Streptavidin (SA) was labeled with BPTA by using its succinimidyl monoester, and the BPTA-Tb(3+)-labeled SA was used in sandwich-type time-resolved fluoroimmunoassay (TR-FIA) of alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA) in human sera. The Tb(3+)-labeled SA was also used in competitive-type TR-FIA of bensulfuron-methyl (BSM) in water. The detection limits of these assays are 42 pg/mL for AFP, 70 pg/mL for CEA, and 0.4 ng/mL for BSM. In addition, a new simultaneous measurement method for AFP and CEA in a human serum sample was developed by using 4,4'-bis(1",1",2",2",3",3" -heptafluoro-4",6"-hexanedion-6"-ly)chlorosulfo- o-terphenyl (BHHCT)-Eu(3+)-labeled anti-AFP antibody, biotinylated anti-CEA antibody, and BPTA-Tb(3+)-labeled SA. The concentrations of AFP and CEA in 39 human serum samples were determined, and the results were compared with those of the independently determined AFP and CEA by TR-FIA with a single-label method. A good correlation was obtained with the correlation coefficients of 0.991 for AFP and 0.994 for CEA.

[New duct caliber measurement methods on magnetic resonance cholangiopancreatography]

PURPOSE

To report the feasibility of new duct caliber measurement methods using signal intensity on MR cholangiopancreatography (MRCP).

MATERIALS AND METHODS

A phantom with 0.25-8 mm caliber ducts was imaged with a 1.5-Tesla MR system using the usual MRCP sequence. Each caliber was measured by conventional method (full width at half maximum, FWHM) and two new methods: the maximum intensity measurement method (MIM), in which caliber was calculated from maximum signal intensity, and the area intensity measurement method (AIM), in which caliber was calculated from the area under the signal intensity curve. Errors in calculated caliber were compared among the three methods of measurement.

RESULTS

Mean measurement errors of each caliber for 1-8 mm ducts by MIM [14% (2.1-25%)] and by AIM [6.8% (0.4-16%)] were significantly lower than those by FWHM [30% (17-64%)]. AIM was significantly more accurate than MIM for caliber measurement of ducts over 1 mm.

CONCLUSION

Two new caliber measurement methods for pancreatobiliary ducts in MRCP, MIM and AIM are accurate and should play an important role in clinical MRCP.

Effect of epidermal growth factor upon morphological changes of human lens epithelial cells

Phase-contrast and transmission electron microscopic studies were performed to evaluate the effect of epidermal growth factor (EGF) upon the morphology of lens epithelial cells (LECs) obtained from human cataractous lenses, cultured on human anterior lens capsules, and divided into the following three groups: group 1 receiving no EGF supplement, group 2 supplemented with 1 ng/ml EGF, and group 3 supplemented with 10 ng/ml EGE Phase-contrast microscopy revealed that the cells in the group supplemented with 1 ng/ml EGF concentration had elongated, and those supplemented with 10 ng/ml EGF disclosed changes indicating fibroblast-like cells. Under transmission electron microscopy, the cells in the group supplemented with 1 ng/ml EGF concentration had become multilayered and a few cells had a ball-and-socket junction structure and nucleolar chromatin condensation, while those supplemented with 10 ng/ml EGF showed changes not only in the cells but also in the anterior lens capsules to present numerous microfibers. This is the first study to confirm the effect of EGF upon LECs cultured on anterior lens capsules, a condition closely resembling the intraocular environment, and these findings are significant.

Histopathological and cell biological analyses of the formation mechanism of anterior polar cataract

Anterior polar cataract, defined as an opacification limited to the anterior polar region of the crystalline lens, results in a significant decline of vision even though the area of opacification is generally small. Having performed histopathological and cell biological studies in an attempt to identify the formation mechanism of anterior polar cataract, we found that lens epithelial cells (LECs) in contact with the opacified region were arranged in a monolayer and contained vacuoles. Furthermore, compared to LECs obtained from cortical and nuclear cataractous lenses and cultured for the study, these LECs revealed a significantly diminished proliferation, suggesting that their physiological activity had been reduced. On the other hand, LECs existing within the opacified region were multi-layered, and there were structureless deposits including remnants of organelles among the cells. Based on these findings, we have concluded that the formation mechanism of anterior polar cataract is as follows: LECs contacting the opacified region initially undergo significant mitosis; rather than migrating towards the equator, these proliferating cells accumulate and form a multilayer in the anterior polar region. Since multi-layered cells are surrounded by the anterior lens capsule and the lens cortex, there is a limit as to how many layers the cells can continue to form; when this limit is reached, these cells next undergo endocytosis and exocytosis. Because the physiological activity has been reduced as a result of having undergone significant proliferation, the cells contacting the opacified area are no longer able to force the proliferating cells towards the anterior polar region; hence multi-layering of the cells and the entire cellular movement are terminated at this point and result in cells with vacuoles and diminished physiological activity. While further studies are required to confirm our hypothesis, we believe this is the first study to suggest a possible mechanism of formation of anterior polar cataract.

Cell biological analysis with respect to cause of fibrous opacification of the anterior capsule after cataract extraction

It has been assumed that lens epithelial cells (LECs) existing at the capsulotomy edge have been traumatized through anterior capsulotomy in cataract extraction. In this study, the correlation between traumatized LECs remaining at the anterior capsulotomy edge and epidermal growth factor (EGF) found in the aqueous humor, a cell growth factor though to affect cell morphology, was determined. Anterior lens capsules with adhering LECs were obtained following anterior capsulotomy performed during cataract surgery to first confirm the presence of EGF receptors on LECs, which are needed for EGF to be biologically active. Besides, to identify any EGF receptors on traumatized LECs, I next intentionally traumatized the cells by pressing them with a forceps from the anterior capsular side. It has been found that the LECs containing EGF receptors were always those existing at the edge of the anterior capsular opening and LECs containing EGF receptors existed along the pressed region too. The present results indicate that traumatized LECs along the capsulotomy edge have undergone changes to manifest EGF receptors, thus allowing EGF from the aqueous humor to become more active. The physiological effect of EGF upon these LECs may therefore be one of the causative factors of fibrous opacification of the anterior capsulotomy edge after cataract extraction.

Cell-biological analysis of atopic cataractous lenses

The number of people suffering from atopic dermatitis, a recent social problem believed to have arisen from environmental pollution and changes, continues to increase today, and these patients often encounter complications such as cataract and retinal detachment. In this study, I have conducted (1) a comparative study on the rate of cell proliferation between lens epithelial cells (LECs) obtained from 7 atopic cataractous lenses and from 1 normal lens, (2) a comparative study on cell density and alignment between LECs obtained from 5 nonatopic cataractous lenses and from 5 atopic cataractous lenses and (3) transmission electron microscopy of LECs obtained from 3 atopic cataractous lenses. My findings were as follows: (1) except for 1 case disclosing increased proliferative activity of the cells to become multilayered, LECs of atopic cataractous lenses showed diminished proliferative activity; (2) LECs of atopic cataractous lenses had decreased in cell density and revealed irregular cell alignment; (3) transmission electron microscopy of LECs of atopic cataractous lenses demonstrated multilayered cells, increased intercellular spaces, and degeneration and disappearance of some cells. A longer follow-up period and further studies using cells from additional atopic cataractous lenses are necessary before any conclusions can be drawn. However, obtaining human LECs especially of atopic cataract patients is not easy, and I do feel that my present study, although its number of patients may not be large enough, provides significant findings for further studies on the mechanism of atopic cataract formation.

Total and pancreatic amylase measured with 2-chloro-4-nitrophenyl-4-O-beta-D-galactopyranosylmaltoside

BACKGROUND

: Many different methods have been used to assay amylase activity, using nitrophenylated oligosaccharides as substrate; however, the hydrolysis steps in these methods are complex.

METHODS

: We developed a new continuously monitoring assay for amylase activity in biological fluids, using 2-chloro-4-nitrophenyl-4-O-beta-D-galactopyranosylmaltoside (GalG2CNP) as the substrate; this assay was used with anti-human salivary amylase monoclonal antibodies for specific determination of the pancreatic isoenzyme. Amylase converted GalG2CNP into beta-D-galactopyranosylmaltose and 2-chloro-4-nitrophenol, which was measured at 405 nm.

RESULTS

: GalG2CNP was cleaved between 2-chloro-4-nitrophenol and beta-D-galactopyranosylmaltose and did not undergo transfer reactions. The within-assay CVs (n = 20) for total amylase (T-AMY) and pancreatic amylase (P-AMY) were 0.6-1.6% and 0.5-2.5%, respectively; and day-to-day CVs (n = 10) for T-AMY and P-AMY were 0.8-3.7% and 0.6-4.1%, respectively. T-AMY and P-AMY activities in serum or urine obtained by the proposed method correlated well with those determined by the 2-chloro-4-nitrophenyl 4-O-beta-D-galactopyranosyl-beta-maltotetraoside method or the modified IFCC method.

CONCLUSIONS

: This novel assay for T-AMY and P-AMY measures both activities stoichiometrically, directly, and easily, and may be suitable for routine procedures.

A case of normotensive scleroderma renal crisis after high-dose methylprednisolone treatment

A 68-year-old male was admitted for interstitial pneumonia associated with scleroderma. High-dose methylprednisolone was administered for treatment of the pneumonitis. Two weeks later, anemia, thrombocytopenia and progressive increase in BUN, creatinine and LDH were observed. Although the blood pressure remained normotensive, renal biopsy showed thrombosis of the polar arterioles and glomerular capillaries. The affected interlobular artery included concentric intimal thickening and thrombosis in the lumen. Our findings suggested that the antecedent use of high-dose corticosteroids is involved in precipitating normotensive renal crisis. Corticosteroids should be used in low doses and with great caution in scleroderma patients.

The Drosophila Bruton's tyrosine kinase (Btk) homolog is required for adult survival and male genital formation

We isolated a Drosophila fickleP (ficP) mutant with a shortened copulatory duration and reduced adult-stage life span. The reduced copulatory duration is ascribable to incomplete fusion of the left and right halves of the apodeme that holds the penis during copulation. ficP is an intronic mutation occurring in the Btk gene, a gene which encodes two forms (type 1 and type 2) of a Bruton's tyrosine kinase (Btk) family cytoplasmic tyrosine kinase as a result of alternative exon usage. The ficP mutation prevents the formation of the type 2 isoform but leaves expression of the type 1 transcript intact. Ubiquitous overexpression of the wild-type cDNA by using a heat shock 70 promoter during the late larval or pupal stages rescued the life span and genital defects in the mutant, respectively, establishing the causal relationship between the ficP phenotypes and the Btk gene mutation. The stage specificity of the rescuing ability suggests that the Btk gene is required for the development of male genitalia and substrates required for adult survival.

Sequence analysis of the genome of Bombyx mori nucleopolyhedrovirus

The genome of the nucleopolyhedrovirus (NPV) (T3 strain) pathogenic for Bombyx mori (Bm) was sequenced and analysed. The BmNPV genome was 128,413 nucleotides long with a G+C content of 40% and contained 136 open reading frames (ORFs) encoding predicted proteins of over 60 amino acids. Although phenotypically different, the genome organizations of BmNPV and Autographa californica multinucleocapsid NPV (AcMNPV) were closely related. The BmNPV genome was over 90% identical to about three-quarters of the genome of AcMNPV. The relatedness of predicted amino acid sequences of corresponding ORFs between BmNPV and AcMNPV was about 90%. However, the BmNPV genome lacked homologues of the following AcMNPV ORFs: Ac3 (conotoxin), Ac7 (orf603), Ac48 (etm), Ac49 (pcna), Ac70 (hcf-1), Ac86 (pnk/pnl) and Ac134 (p94). In addition, BmNPV contained five ORFs related to Ac2. A high frequency of multiple 3 bp insertions was also found within BmNPV and AcMNPV coding sequences.

Determination of alpha-amylase using 4-O-beta-D-galactopyranosylmaltotetraose (Gal-G4) as a substrate

A new substrate, 4-O-beta-D-galactopyranosylmaltotetraose (Gal-G4) is applied for the determination of alpha-amylase in serum and urine in a coupled assay with alpha-glucosidase (EC 3.2.1.20), glucokinase (EC 2.7.1.2) and glucose-6-phosphate dehydrogenase (EC 1.1.1.49) as auxiliary enzymes. Gal-G4 having a 4-position of the non-reducing-end glucose residue modified by a beta-galactopyranose group is resistant for degradation by alpha-glucosidase as auxiliary enzyme. Moreover, this substrate is hydrolyzed at just one position by alpha-amylase in serum and urine. More than 99% of the products generated from Gal-G4 by alpha-amylase are identified 4-O-beta-D-galactopyranosylmaltose (Gal-G2), maltose, respectively. Glucose and maltose do not interfere the value of alpha-amylase activity at least up to 0.056 mmol/l (1 g/dl) glucose and 0.027 mmol/l (1 g/dl) maltose, respectively. We are now carrying out this work under the authority of The Enzyme committee of Japanese Society of Clinical Chemistry (JSCC) as a standard method for determination of alpha-amylase in clinical chemistry.

The relationship between morphological changes of lens epithelial cells and intraocular lens optic material

To examine the morphological changes of lens epithelial cells (LECs) occurring directly beneath and at regions contacting various intraocular lens (IOL) optic materials, human LECs were cultured on human anterior lens capsules and were further incubated upon placing above the cells lens optics made of polymethylmethacrylate, silicone, and soft acrylic material. Observations as to the morphological changes of LECs under phase-contrast microscope and scanning electron microscope were performed on the 14th day of incubation. Gatherings of LECs were observed at regions contacting the soft acrylic material under phase-contrast microscope, and gatherings of LECs were observed accurately at the same regions mentioned above under scanning electron microscope. On the other hand, LECs in contact with two other optic materials did not show morphological changes. The results suggest that LECs attached to and proliferated on not only the anterior lens capsules but also the soft acrylic IOL optics. The model used in this study may be useful in studying the relationship between cellular movement of LECs and IOL optic material.

Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects

OBJECTIVE

The anterolateral thigh flap has many advantages in head and neck reconstruction. However, it has not yet come into widespread use because of the anatomic variations of its perforators. Herein, we describe a safe operative technique related to the patterns of the perforators and discuss its wide versatility.

SETTING

A national cancer center hospital.

PATIENTS

Thirty-eight anterolateral thigh flaps were transferred. Confirmation and dissection of the flap pedicle were simultaneously performed with tumor resection. The design and elevation of the flap were carried out immediately after the tumor resection was completed.

RESULTS

From the study of the anatomic variations of the perforators, septocutaneous patterns were recognized in 10 cases (26.3%) and musculocutaneous patterns in 28 cases (73.7%). All flaps were easily and safely elevated with our techniques. Thirty-six flaps survived. Partial necrosis was noted owing to excessive thinning procedure in one patient and total necrosis was noted owing to venous thrombosis at the anastomosis part in another patient.

CONCLUSIONS

We found that the anterolateral thigh flap has numerous advantages. It is possible to perform the flap elevation and the tumor resection simultaneously. The flap is generally thin and is suitable for reconstruction of intraoral defects. Combined flaps with neighboring tissues and other, distant flaps can be used. Furthermore, since our technique minimizes the problems of confirmation and dissection of the perforators, we conclude that this flap can be successfully used to repair a variety of large defects of the head and neck.

Deletion analysis of four of eighteen late gene expression factor gene homologues of the baculovirus, BmNPV

Nucleotide sequence analysis of the genome of the baculovirus Bombyx mori nuclear polyhedrosis virus (BmNPV) identified 18 homologues of the Autographa californica NPV (AcNPV) lefs (late expression factor genes). These BmNPV lefs showed high (73-98%) amino acid sequence identities to AcNPV lefs and were localized to similar positions in the genome. One lef, p35, was previously characterized in AcNPV and BmNPV deletion experiments. Functional deletion of each of the BmNPV lef homologues was attempted here by insertion of a beta-galactosidase gene cassette into the coding region of each lef. Four of 18 BmNPV lef (39K, ie-2, lef-7, and p35) deletion mutants were successfully isolated, indicating that the other 14 BmNPV lefs were likely essential for viral replication in cell culture. Further analysis showed that deletion of lef-7, p35, and ie-2 resulted in lower levels of viral DNA replication, indicating that the BmNPV lef-7, p35, and ie-2 products have stimulating effects on DNA replication. Deletion of 39K resulted in a significantly lower level of late gene transcription and extremely low (over 10(2)-fold less at 48-80 hr p.i.) production of progeny budded virus in BmN cells. In contrast, the deletion did not affect viral DNA replication, indicating that BmNPV 39K is involved in late gene transcription. Reduced late gene expression presumably affected production and/or release of progeny budded virus particles. This was corroborated by transmission electron microscopy, which showed that virus replication was abnormal in BmN cells infected with a BmNPV mutant lacking 39K and virion production was low. Even though 39K deletion resulted in a loss of oral infectivity, the 39K deletion mutant replicated in silkworm larvae when injected into the body cavity, as did the ie-2, lef7, and p35 deletion mutants. In addition, a BmNPV homologue of the baculovirus very late expression factor gene (vif-1) found in AcNPV was essential, implying an essential function of the BmNPV vif-1 homologue at a step before the onset of very late gene expression.

Presence of growth factor in human vitreous

The aqueous humor and the vitreous not only maintain integrity of the eye but also play a vital role in providing nutrients to ocular tissues. While the presence of epidermal growth factor, basic fibroblast growth factor, and transforming growth factor-beta (TGF-beta) have been confirmed in human aqueous humor, only TGF-beta has been found to exist in human vitreous. In this study I obtained eyes for keratoplasty from 20 male and 20 female donors, or a total of 40 subjects; upon removing the corneal button. I extracted 500 microliters of the vitreous humor in order to confirm, using the ELISA method, the presence of transforming growth factor-alpha (TGF-alpha) and epidermal growth factor (EGF) in the vitreous. TGF-alpha ranging from 78 to 250 pg/ml, or an average of 130.65 +/- 40.89 pg/ml, was found in all eyes. On the other hand, EGF was not confirmed in all eyes. This is the first study to confirm the presence of TGF-alpha in the human vitreous.

Lens epithelial cells in postoperative aqueous humor

The aqueous humor during or after cataract surgery often contains red blood cells (RBCs) from blood; inflammatory cells from white blood cells (WBCs); fibrin, pigment cells, and fibroblasts from either the iris or the ciliary body; lens epithelial cells (LECs); and corneal endothelial cells. Since LECs may be related to postoperative complications, including a fibrin reaction and a secondary cataract, confirmation of their presence postoperatively not only in the capsular bag, but also in the aqueous humor, is necessary for identifying these complications. Using aqueous humor obtained from pig eyes, I attempted to identify LECs immunohistochemically in the aqueous humor, following phacoemulsification (PEA) and aspiration of the cortex, and found the presence of cells that react to keratin antibody, the marker for epithelial cells. Although these cells could be lens, conjunctival, or corneal epithelial cells, they were found following PEA and aspiration of the cortex, and therefore are believed to be LECs.

An evaluation of the biocompatibility of intraocular lenses

BACKGROUND AND OBJECTIVE

The degree of cell adhesion to intraocular lenses (IOLs) was studied through the cell culture system and the morphology of adhering cells was studied using a light electron microscope and a scanning electron microscope.

MATERIALS AND METHODS

Human lens epithelial cells were used as materials. The IOL materials were classified into four groups: polymethylmethacrylate (PMMA), heparin surface modified PMMA, surface passivated PMMA, and silicone.

RESULTS

PMMA showed greater adhesion than did the other materials. Cells hardly adhered to silicone. Use of a light electron microscope and a scanning electron microscope revealed that cells adhered uniformly to the surface of PMMA and were elongated, but did not adhere uniformly to IOLs of other materials. Only a few cells without the tendency of elongation were noted on the silicone the second day after culture. The 14th day after culture, the surfaces of IOLs, except those of silicone, were covered with cells.

CONCLUSION

Such differences in the surface adhesion and morphology of cells adhering to the IOL surface are important in evaluating IOL biocompatibility.

A case of true exfoliation

Using light and transmission electron microscopy, we have performed a histopathological evaluation of the anterior lens capsule, isolated during cataract extraction from an eye revealing a cellophane-like membrane on the lens surface of the pupil area. In addition to light microscopy showing one third of the anterior capsule had partially detached, transmission electron microscopy demonstrated irregular alignment of capsular structure near the detached regions. These microscopic features, together with clinical findings, led us to believe that this is a case of true exfoliation.

[Severe cases of pulmonary tuberculosis required mechanical ventilation]

We report severe cases of pulmonary tuberculosis with respiratory failure who required mechanical ventilation. Of 99 patients with pulmonary tuberculosis admitted to Daido Hospital from November 1991 to November 1993, 6 patients had been mechanically ventilated. Four of these 6 patients were vagrants and had long delay from onset of the symptom to the admission. Chest X-rays of ventilated patients showed bilateral, extensive shadows consistent with those of typical pulmonary tuberculosis, and a large number of acid-fast bacilli were detected in their sputa. Though all ventilated patients except one HCV carrier had no underlying disease, they showed remarkable emaciation and malnutrition. They also showed weak PPD-skin reactions and reduced number of lymphocytes that suggested immunological disorders. Four cases have recovered, so we conclude that mechanical ventilation is necessary and useful for the treatment of severe cases of pulmonary tuberculosis.

Cell biological analysis of the human cataractous lens: implication of lens epithelial cells in the development of aftercataract

Lens epithelial cells (LECs) from 3 patients with congenital cataract aged 2, 4 and 12 months, respectively, were cultured. The findings were compared with those from 26 eyes of 26 patients with senile cataract, with ages ranging from 60 to 89 years. The significantly higher growth potential of LECs in patients with congenital cataract compared to those with senile cataract, seems to be the cause of the higher frequency of aftercataract following cataract surgery in infants.

Human lens epithelial cells proliferate in response to exogenous EGF and have EGF and EGF receptor

While epidermal growth factor (EGF) has been found to exist in the human aqueous humor, which is necessary for maintaining the physiological condition of the lens, our immunohistochemical study confirmed the presence of EGF receptors and EGF in human lens epithelial cells (LECs), with EGF promoting growth potential and morphological change of the cells. Based on these findings, we feel that the effect of EGF upon human LECs is related to the movement of the cells in vivo.

[The existence of epidermal growth factor and basic fibroblast growth factor in human lens epithelial cells]

The aqueous humor supplies the lens with nutrition. Recently, the existence of epidermal growth factor (EGF) and basic fibroblast growth factor (b-FGF) has been confirmed in the human aqueous humor. For this reason, it was thought that the function of these growth factors was related to the physiological condition of the lens epithelial cells (LEC). Therefore, we looked for the existence of receptors for EGF, FGF, and the internalization of EGF and b-FGF using LEC from human cataractous lenses in immunohistochemistry. We confirmed the existence of receptors for EGF and FGF as well as the internalization of EGF and b-FGF. From these results. We inferred that the function of EGF and b-FGF was strongly related to the physiological condition of LEC.

[A case of acute eosinophilic pneumonia with acute onset of dyspnea]

A 16-year-Old boy was admitted with acute onset of fever, cough, and dyspnea. Chest radiography showed diffuse infiltrated shadow and right pleural effusion. BALF revealed a high level of eosinophils (56.8%), and TBLB specimen showed infiltration of inflammatory cells, chiefly eosinophils. Symptoms and radiographic findings resolved spontaneously within a few days after admission. Acute eosinophilic pneumonia was diagnosed as in the case reported by Allen et al. However, the present patient had a high IgE level and history of atopic allergic rhinitis. In more than one third of previously reported cases in Japan, there was a history of atopy, unlike in Allen's report.

A cysteine protease encoded by the baculovirus Bombyx mori nuclear polyhedrosis virus

Sequence analysis of the BamHI F fragment of the genome of Bombyx mori nuclear polyhedrosis virus (BmNPV) revealed an open reading frame whose deduced amino acid sequence had homology to those of cysteine proteases of the papain superfamily. The putative cysteine protease sequence (BmNPV-CP) was 323 amino acids long and showed 35% identity to a cysteine proteinase precursor from Trypanosoma brucei. Of 36 residues conserved among cathepsins B, H, L, and S and papain, 31 were identical in BmNPV-CP. In order to determine the activity and function of the putative cysteine protease, a BmNPV mutant (BmCysPD) was constructed by homologous recombination of the protease gene with a beta-galactosidase gene cassette. BmCysPD-infected BmN cell extracts were significantly reduced in acid protease activity compared with wild-type virus-infected cell extracts. The cysteine protease inhibitor E-64 [trans-epoxysuccinylleucylamido-(4-guanidino)butane] inhibited wild-type virus-expressed protease activity. Deletion of the cysteine protease gene had no significant effect on viral growth or polyhedron production in BmN cells, indicating that the cysteine protease was not essential for viral replication in vitro. However, B. mori larvae infected with BmCysPD showed symptoms different from those of wild-type BmNPV-infected larvae, e.g., less degradation of the body, including fat body cells, white body surface color due presumably to undegraded epidermal cells, and an increase in the number of polyhedra released into the hemolymph. This is the first report of (i) a virus-encoded protease with activity on general substrates and (ii) evidence that a virus-encoded protease may play a role in degradation of infected larvae to facilitate horizontal transmission of the virus.

Detection of interleukin-5 messenger RNA and interleukin-5 protein in bronchial biopsies from asthma by nonradioactive in situ hybridization and immunohistochemistry

Recently direct evidence for the role of interleukin-5 (IL-5) in eosinophilic inflammation in the airways of persons with asthma has been provided by an in situ hybridization study that used radioisotope-labeled IL-5 complementary RNA probes. Radioisotope-labeled probes, although sensitive, require autoradiographic detection, which is time-consuming. In the most recent study we attempted to detect IL-5 messenger RNA in the bronchial biopsy specimens from patients with asthma using nonradioactive in situ hybridization, which gives rapid results. Bronchial biopsy specimens were obtained from eight patients with asthma and seven diseased control subjects. IL-5 complementary DNA probes were labeled with digoxigenin-deoxyuridine triphosphate and hybridized to permeabilized sections. Hybridization signals were visualized by an immunohistochemistry technique. Positive hybridization signals were observed in six of the eight biopsy specimens from patients with asthma. Pretreatment with ribonuclease or hybridization with an unrelated probe produced negative results. Immunohistochemical staining of serial sections with a monoclonal antibody to IL-5 revealed that a few cells within the mucosa positively stained, suggesting active synthesis of IL-5. Biopsy results from the seven diseased control subjects did not show any hybridization signal. These results confirm and extend previous observations of IL-5 messenger RNA expression in the airways of patients with asthma, and suggest that digoxigenin-labeled IL-5 complementary DNA probes would be a powerful research tool.

[A case of anti-glomerular basement membrane antibody (AGBMA) nephritis associated with myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA)]

A 68-year-old patient visited our hospital, because of progressive renal failure. Laboratory data were serum creatinine 13.3 mg/dl, BUN 74.3 mg/dl, AGBMA 134U, MPO-ANCA 37% and CIC 1.6 g/dl. Hemodialysis was performed on admission and renal biopsy was conducted. Though the histological findings showed fibrocellular crescents and global sclerosis in many glomeruli, renal function was gradually ameliorated by administration of prednisolone (40 mg/day) and cyclophosphamide (50 mg/day). After 3 weeks of therapy, hemodialysis was withdrawn temporarily. Because of the complication of pneumocystis carini, prednisolone and cyclophosphamide were discontinued, and maintenance hemodialysis was resumed. In spite of progressed histological findings, hemodialysis was withdrawn at least temporarily through the use of pharmacological therapy. Thus, the presence of ANCA may indicate a relatively good prognosis of AGBMA nephritis.

Divergence and evolution of homologous regions of Bombyx mori nuclear polyhedrosis virus

Homologous regions (hrs) (hr1,hr2-left,hr2-right,hr3,hr4-left,hr 4-right, and hr5) similar to those found in the Autographa californica nuclear polyhedrosis virus (AcNPV) genome were found in the Bombyx mori NPV (BmNPV) genome. The BmNPV hrs contained two to eight repeats of a homologous nucleotide sequence which were on average about 75 bp long. All of these homologous sequence repeats contained a 26-bp-long palindrome motif with an EcoRI or EcoRI-like site at its core. The consensus sequence of the BmNPV hrs showed 95% conservation with respect to those found in AcNPV. Nucleotide sequence analysis indicated that hr2-left and hr2-right of BmNPV evolved from an ancestor similar to hr2 of AcNPV by inversion, cleavage, and ligation. The polarities of the BmNPV and AcNPV hrs were conserved except for that of hr4-left. Within hr4-right of BmNPV, four repeats of a previously underscribed palindrome motif were found. Bmhr5D, a BmNPV mutant which lacked hr5, replicated at a rate similar to that of wild-type BmNPV in BmN cells and silkworm larvae, indicating that hr5 was not essential for viral replication. After ten passages of Bmhr5D in BmN cells, no detectable changes in its genome were observed by restriction endonuclease analysis. The evolution and divergence of the BmNPV genome are also discussed.

[The effect of epidermal growth factor on the growth potential of epithelial cells from human lens]

The growth promoting effect of epidermal growth factor (EGF) was studied in cultures of epithelial cells from human normal and cataractous lenses. The growth potential of lens epithelial cells was measured by MTT assay. The concentration of EGF in culture medium were classified into 7 groups (0 ng/ml-10(3) ng/ml). When the concentration of EGF was 1 ng/ml, EGF induced the highest increase of growth potential epithelial cells compared with an EGF-free group.

[Hormone therapy of tamoxifen in resected carcinoma of the pancreas]

Greenway et al reported estrogen receptor existed in the carcinoma of the exocrine pancreas in 1981. We followed the study by using immunohistochemical method with monoclonal antibody ER-D5 (Amersham) and found high levels of estrogen receptor in 21 cases out of 27 carcinomas of the pancreas (77.8%). Furthermore, we gave randomly the hormone therapy by Tamoxifen 20 mg per day adding to immuno-chemotherapy (Tegaful, Mitomycin, Krestin, OK-432) to the patients with resected carcinoma of the pancreas. There was no significant difference of the survival rate of pancreatic carcinoma without hormone therapy between 10 cases with estrogen receptor and 4 cases without estrogen receptor at the 6th month and 12th month. However, in cases treated by Tamoxifen, remarkable high survival rate at 12 months of 11 cases with estrogen receptor was obtained to be 85.7% according to Kaplan-Meier method. Two cases without estrogen receptor died within 5 months. One year survival rate of Tamoxifen group (13 cases) was 78.6% and that of non Tamoxifen group (14 cases) was 21.4%. These findings indicated that estrogen receptor existed at the high level in the carcinoma tissues of the pancreas and anti-estrogen treatment might offer a new approach to the treatment of pancreatic carcinomas.

Identification and characterization of the p35 gene of Bombyx mori nuclear polyhedrosis virus that prevents virus-induced apoptosis

Nucleotide sequence analysis of the Bombyx mori nuclear polyhedrosis virus (BmNPV) genome revealed the existence of a gene homologous to the p35 gene of Autographa californica NPV (AcNPV), which has been shown to prevent virus-induced apoptosis. The BmNPV p35 gene showed 96.1% nucleotide and 89.6% predicted amino acid sequence identity to the AcNPV p35 gene. A mutant BmNPV (BmP35Z) lacking a functional p35 gene induced apoptosis-like cell degradation in infected BmN cells. However, unlike the p35-deleted AcNPV mutant (vAcAnh), BmP35Z replicated normally and produced polyhedral inclusion bodies. The patterns of protein synthesis and the percentages of viable BmN cells remaining following infection with either wild-type BmNPV or BmP35Z were nearly identical. BmP35Z also replicated in silkworm larvae without showing any apparent apoptotic response in infected hemocytes, fat body, or other tissues. Time to death of larvae infected with BmP35Z was similar to that for wild-type-infected larvae, and significant numbers of polyhedral inclusion bodies were produced. These results indicate that viral factors (or genes) other than p35 or host cell factors play a role in inducing, accelerating, or interfering with apoptotic processes. The evolution of baculovirus genomes is also discussed with reference to comparative analysis of the p35 and p94 gene sequences. The p94 gene is found immediately upstream of p35 in AcNPV; in BmNPV, however, the p94 gene was nearly completely missing, presumably because of large deletions in a BmNPV ancestor virus having a gene similar to the AcNPV p94 gene.

[A case of Fabry's disease associated with lupus nephritis]

A 36-year-old woman was hospitalized because of nephrotic syndrome. On admission, laboratory studies revealed total protein 5.9g/dl, total cholesterol 381mg/dl, urine protein 2-4g/day, C3 68mg/dl(90-185mg/dl) and the immunological tests showed that antinuclear factor, anti-DNA antibodies and the LE cell phenomenon were positive. Renal function was within normal range. After admission, renal biopsy was done. Light microscopic finding showed diffuse membranous glomerulonephritis, and vacuolization of epithelial cells. Immunofluorescent microscopic finding showed a granular specific staining for IgG, IgM, C3 and C1q along the capillary loops. Electron microscopic finding showed subepithelial and subendothelial dense deposits, and visceral epithelial cell cytoplasm containing osmiophilic multilamellar lipoid bodies. In the studies of the enzyme activities, the patient's fibroblast extract demonstrated a partial deficiency of alpha-galactosidase, and urine ceramide trihexoside was positive. But the patient's leukocyte extract did not demonstrate a deficiency of alpha-galactosidase. So Fabry's disease associated with lupus nephritis was diagnosed. It seems that the case of Fabry's disease which is an X-linked disorder caused by deficiency of the lysosomal enzyme alpha-galactosidase, associated with lupus nephritis, is extremely rare.

Intracranial mycotic aneurysm caused by Aspergillus--case report

A 75-year-old female with chronic renal failure diagnosed as Wegener's granulomatosis was receiving steroids and immunosuppressive agents when subarachnoid hemorrhage developed. Cerebral angiography showed a fusiform aneurysm arising from an angular branch of the left middle cerebral artery. Hemorrhage occurred and the aneurysm was excised by emergency surgery. Microscopic examination of the aneurysm revealed dense infiltration of hyphae identified as Aspergillus. She died of subsequent hemorrhage. Autopsy showed numerous Aspergillus hyphae in the lung. Fungal mycotic aneurysm should be considered in the differential diagnosis of an immunocompromised patient with subarachnoid hemorrhage.