Painless thyroiditis mimicking relapse of hyperthyroidism during or after potassium iodide or thionamide therapy for Graves' disease resulting in remission

The diagnosis of painless thyroiditis (PT) during antithyroid drug (ATD) treatment of Graves' disease (GD) is difficult. We evaluated the thyroidal radioactive iodine uptake (RAIU) in 100 patients with relapsed thyrotoxicosis during or after careful ATD treatment. The RAIU was <5%/5 h in 35 patients (35%) (Group A - PT), 5%-15%/5 h in 6 patients (6%) (Group B - indefinite) and >15%/5 h in 59 patients (59%) (Group C - relapsed GD [rGD]). TSH receptor antibody (TBII) was positive in 4 (11.4%), 3 (50.0%) and 39 (only 66.1%) patients in Groups A, B and C, respectively. In Group A, the serum fT₄ level spontaneously normalized after 35 (26-56) days, sometimes followed by transient hypothyroidism, confirming the diagnosis of PT. Nineteen (54.3%) had been treated with potassium iodide, and PT frequently occurred ironically when the ATD dosage was reduced. PT repeatedly occurred in nine patients. All went into remission smoothly or developed hypothyroidism, except one patient with strongly positive TBII who developed rGD after the resolution of PT (PT on GD). In 10 (50%) of 20 patients with negative TBII despite rGD in Group C, TBII became positive afterwards. In conclusion, it is important to recognize that PT can occur in the clinical course of GD, resulting in frequent remission despite relapse of PT. The thyroid function reflects the balance between the stimulating TBII activity and the responsiveness of the thyroid tissue (sometimes unresponsive and other times autostimulated). The RAIU is still a valuable tool in cases of ambiguous thyrotoxicosis.

Iodide-sensitive Graves' hyperthyroidism and the strategy for resistant or escaped patients during potassium iodide treatment

The effectiveness of potassium iodide (KI) (100 mg/day) was evaluated in 504 untreated patients with Graves' hyperthyroidism (GD). Initial response to KI within 180 days, the effect of additional methylmercaptoimidazole (MMI) or radioactive iodine (RI) in resistant or escaped patients, and long-term prognosis were evaluated. Serum fT₄ levels became low or normal in 422 patients (83.7%, KI-sensitive group) without serious side effects. Among these patients, serum TSH levels became high (n = 92, hypothyroid) or normal (n = 78) in 170 patients (33.7%) (KI-sensitive with a recovered TSH response, Group A), but remained suppressed in 252 patients (50.0%) (KI-sensitive with TSH suppression, Group B). Serum fT₄ levels decreased but remained high in 82 patients (16.3%) (KI-resistant, Group C). Older patients, or those with small goiter and mild GD were more KI-sensitive with a recovered TSH response than others. Escape from KI effect occurred in 0%, 36% and 82% in Group A, B and C, respectively. Patients in Group B and C were successfully treated with additional low-dosage MMI or RI. After 2-23 years' treatment (n = 429), remission (including possible remission) and spontaneous hypothyroidism were significantly more frequent in Group A (74.3% and 11.1%, respectively,) than in Groups B (46.3% and 2.8%, respectively) or C (53.6% and 1.5%, respectively) (p < 0.0001). In conclusion, a high KI sensitivity with a recovered TSH response was observed in about a third of the patients in GD associated with a better prognosis. Additional MMI or RI therapy was effective in escaped or KI-resistant patients with suppressed TSH level.

A case of Graves' disease presenting with internal ophthalmoplegia during methylmercaptoimidazole treatment

A 28-year-old Japanese woman positive for TSH receptor antibody and anti-nuclear antibody complained of difficulty seeing nearby objects, severe throbbing retro-orbital pain, diplopia, blepharoptosis and upward gaze palsy when she became hypothyroid during treatment with 30 mg methylmercaptoimidazole for Graves' hyperthyroidism. Brain magnetic resonance imaging revealed slightly swollen bilateral inferior rectus muscles, suggesting the external ophthalmoplegia due to the muscle pathology commonly encountered in Graves' disease. The retro-orbital pain was associated with marked accommodation failure and the pupillary abnormalities. The left and/or right eye showed intermittent, asymmetric and fluctuating mydriasis, being unresponsive to ordinary light but slowly responsive to strong sunlight and slowly responsive in a dark room. During the 5-year period, mydriasis was observed 9 times on both sides, 11 times only on the right side and 4 times only on the left side. Internal ophthalmoplegia with tonic pupils and accommodation failure affecting both the pupillary sphincter muscle and ciliary muscle due to damage to the parasympathetic outflow to these muscles was suggested. Autoimmune mechanism and/or the mechanism underlying channelopathy affecting the ciliary ganglion or short ciliary nerves might be responsible for this fluctuating complication. This very rare panophthalmopathy affecting both external and internal muscles occurred when the patient was suffering from iatrogenic hypothyroidism during the 30 mg methylmercaptimidazole treatment for Graves' disease.

Clinical experience of treating Graves' hyperthyroidism complicated with malignancy-The possible role of potassium iodide for avoiding the risk of thionamide-associated neutropenia

The treatment of Graves' hyperthyroidism (GD) complicated with malignancy is challenging, as anti-thyroid thionamide drugs (ATDs) and anti-cancer chemotherapy are both associated with a risk of neutropenia. Treatment with conventional ATDs, radioactive iodine (RAI) or potassium iodide (KI) was attempted in 8 patients with malignancy (34-80 years of age; 2 males and 6 females) in whom GD had been fortuitously diagnosed during a detailed systematic examination. Three patients requiring surgery were initially treated conventionally with methylmercaptoimidazole (MMI), MMI and KI or RAI (group A; one patient each). The patients became euthyroid on days 17-31 and underwent surgery on days 25-47. RAI therapy was administered to one patient after surgery. The patients were then treated with KI during chemotherapy. Five other patients who did not require surgery were initially treated with 100 mg KI monotherapy (group B). The serum free T₄ level declined immediately in all of these patients, and they became euthyroid on days 7-18, remaining almost entirely euthyroid for more than 120 days. Anti-cancer chemotherapy was successfully completed for three of the patients while taking KI, despite the patients experiencing repeated episodes of anti-cancer chemotherapy-induced neutropenia. Our present findings suggest that, in patients with GD and malignancy, MMI + KI or RAI may be required if immediate surgery is scheduled, but KI monotherapy may be worth trying, if anti-cancer chemotherapy is scheduled, thus avoiding the possibility of thionamide-induced neutropenia.

PERFORMANCE EVALUATION OF HYPERELASTIC MODELS FOR CARBON-BLACK–FILLED SBR VULCANIZATES

The performance of four recently developed hyperelastic material models (HM models) was evaluated by using stress–stretch relationships of filled styrene butadiene rubber vulcanizates with different contents of carbon black (CB) tested under uniaxial tension (UT), pure shear (PS), and equi-biaxial tensile (BT) conditions. The stress–stretch relationships for the PS and BT tests were obtained with a specially designed specimen having higher accuracy than those obtained with an ordinary specimen. The performances of the HM models were compared via the following three evaluations: (1) ability to reproduce the UT, PS, and BT tests; (2) ability to predict the PS and BT test results with material constants identified from the UT test; and (3) correlation between the identified material constants and CB contents. The evaluations based on a combination of the stress–stretch relationships with high accuracy and four recently developed HM models revealed that the HM model activates only the I1 term, which is the first invariant of the right Cauchy–Green tensor, exhibiting good reproducibility and predictability.

The long-term follow-up of patients with thionamide-treated Graves' hyperthyroidism

Since there have been few reports on the long-term prognosis of Graves' hyperthyroidism, the prognosis of 549 Graves' hyperthyroidism patients initially treated with thionamide and followed for >8 (range: 8.6-36.4) years was studied, evaluating the change in the TSH binding inhibitor immunoglobulin activity (TBII). The distribution of the time required for the first disappearance of TBII was normal after logarithmic conversion, and the mean ± 2 SD was 1.5 (0.3-8.1) years. TBII became negative once within 5 years in 78.9% of patients. However, TBII re-elevation was observed in 47.8% of this group (fluctuating type). Remission was observed in 88.9% of the non-fluctuating type (smooth remission) and 37.2% of the fluctuating type patients. TBII remained positive for >5 years in 21.1% (smoldering type) of patients, with remission observed in only 19.8% of patients. Final remission was observed in 301 (54.8%) patients; the median time to remission was 6.8 (interquartile range: 4.0-10.9) years. A longer time until normalization of TBII and higher final thyroid weight were associated with a poor prognosis. Spontaneous hypothyroidism was observed in 6.0% of patients, independent of the TBII change. Our findings suggest that remission of Graves' hyperthyroidism mostly occurred after 4-11 years treatment. While predicting the prognosis before therapy was difficult, the clinical course may suggest a better prognosis if TBII disappears within five years without TBII fluctuation or enlargement of the goiter. Patients may safely wait more than five years to undergo ablative therapy if they hope to avoid permanent hypothyroidism.

Remission after potassium iodide therapy in patients with Graves' hyperthyroidism exhibiting thionamide-associated side effects

CONTEXT

Thionamides have various side effects.

OBJECTIVE

The effectiveness of potassium iodide (KI) was evaluated in hyperthyroid patients who experienced side effects to thionamides.

DESIGN AND SETTING

An observational study was conducted at an academic medical center.

PATIENTS

Among 1388 patients with Graves' hyperthyroidism treated with thionamides, 204 (14.7%) exhibited side effects, and 44 were treated with KI and followed for 17.6 (median; range, 8.6-28.4) years.

MAIN OUTCOME MEASURES

The primary endpoint was the initial response to KI, and the secondary endpoint was the long-term prognosis.

RESULTS

The conditions of 29 (65.9%) of the 44 patients were well controlled with KI alone (10-400 mg/d) (A group), and 17 (38.6%) patients went into remission after 7.4 (1.9-23.0) years. The conditions of 15 (34.1%) patients were not controlled with KI alone (B group), even at a high dose (100-750 mg/d), but seven patients (15.9%) were controlled with a combination of KI and low-dose thionamides, resulting in remission after 7.2 (2.8-10.8) years. The initial parameters did not predict the response to KI or long-term prognosis. However, remission occurred in 70.8% of the patients treated with less than 200 mg of KI, compared with 35.0% of the patients who required 200 mg or more of KI (P < .05).

CONCLUSIONS

Among hyperthyroid patients with thionamide-associated side effects, KI therapy was effective in two-thirds of cases, and about 40% of the patients experienced remission after KI therapy alone. The chance of remission was small among the patients refractory to KI.

Search for B+-->D*+pi0 decay

We report on a search for the doubly Cabibbo suppressed decay B+-->D*+pi0, based on a data sample of 657x10(6) BB pairs collected at the Upsilon(4S) resonance with the Belle detector at the KEKB asymmetric-energy e+e- collider. We find no significant signal and set an upper limit of B(B+-->D*+pi0)<3.6x10(-6) at the 90% confidence level. This limit can be used to constrain the ratio between suppressed and favored B-->D*pi decay amplitudes, r<0.051, at the 90% confidence level.

Measurement of the tau lepton mass and an upper limit on the mass difference between tau+ and tau-

The mass of the tau lepton has been measured in the decay mode tau-->3pinutau using a pseudomass technique. The result obtained from 414 fb-1 of data collected with the Belle detector is Mtau=[1776.61+/-0.13(stat)+/-0.35(sys)] MeV/c2. The upper limit on the relative mass difference between positive and negative tau leptons is |Mtau+-Mtau-|/Mtau<2.8 x 10-4 at 90% confidence level.

Measurement of CP asymmetry in a time-dependent Dalitz analysis of B0-->(rhopi)0 and a constraint on the quark mixing matrix angle phi2

We present a measurement of CP asymmetry using a time-dependent Dalitz plot analysis of B0-->pi+pi-pi0 decays based on a 414 fb(-1) data sample containing 449 x 10(6) BB pairs. The data was collected on the Upsilon(4S) resonance with the Belle detector at the KEKB asymmetric energy e+ e- collider. Combining our analysis with information on charged B decay modes, we perform a full Dalitz and isospin analysis and obtain a constraint on the CKM angle phi2, 68 degrees < phi2 < 95 degrees as the 68.3% confidence interval for the phi2 solution consistent with the standard model (SM). A large SM-disfavored region also remains.

[Painless thyroiditis]

Painless thyroiditis is characterized by painless low-uptake thyrotoxicosis (thyrotoxicosis without hyperthyroidism). Destructive damage of the thyroid has been thought to be the mechanism for self-limited thyrotoxicosis. However, hydrolysis of thyroglobulin must be responsible for the release of excessive thyroid hormone. Low-uptake of iodine and excessive release of thyroid hormone suggest the uncoupling of hormone synthesis and hormone secretion in the thyroid gland. Suppressed serum TSH level, various cytokines or growth factors including TGFbeta1, and thyroglobulin itself may be responsible for the suppressed hormone synthesis. The mechanism for persistent hormone release despite suppressed hormone synthesis should be clarified. Quantitative TSH binding inhibitor immunoglobulin assay is helpful for the differential diagnosis of painless thyroiditis and Graves' hyperthyroidism.

Elevated bone resorption markers in a patient with hypercalcemia associated with post-partum thyrotoxicosis and hypoadrenocorticism due to pituitary failure

A 36-yr-old woman began to suffer from headache, anorexia and general fatigue at 35 weeks' gestation. About 2 or 3 months after the delivery, fever, tachycardia and generalized musculoskeletal disorder appeared. Thereafter, they worsened rapidly, accompanied by a disturbance of consciousness and hypercalcemia. Thyrotoxicosis, due to a post-partum thyroiditis, and glucocorticoid deficiency, due to a pituitary failure, probably associated with lymphocytic hypophysitis, were also observed. All the symptoms and hypercalcemia disappeared after the glucocorticoid replacement therapy and the normalization of thyroid hormone levels. Serum and urinary bone resorption markers, such as urine pyridinoline (U-Pyr), urine deoxypyridinoline (U-DPD), urine amino-terminal telopeptide of type I collagen (U-NTx) and serum carboxy-terminal telopeptide of type I collagen (ICTP), were extremely high at the hypercalcemic state. In this case, they were 10 to 20 times higher than the normal upper limits, and then markedly decreased in a normocalcemic state, thereby showing an extreme acceleration of bone resorption in a state of both thyrotoxicosis and glucocorticoid deficiency.

Measurements of cosmic-ray low-energy antiproton and proton spectra in a transient period of solar field reversal

The energy spectra of cosmic-ray low-energy antiprotons ( *p's) and protons ( p's) have been measured by BESS in 1999 and 2000, during a period covering reversal at the solar magnetic field. Based on these measurements, a sudden increase of the *p/p flux ratio following the solar magnetic field reversal was observed, and it generally agrees with a drift model of the solar modulation.

Hypercalcemia associated with parathyroid hormone-related protein at the terminal stage of uncomplicated squamous cell carcinoma in the head and neck region

BACKGROUND

Parathyroid hormone-related protein (PTHrP) is mainly responsible for hypercalcemia in squamous cell carcinomas (SCCs).

METHODS

We retrospectively checked the appearance of hypercalcemia among 33 patients who died with head and neck SCC. Serum concentrations of C-terminal region of PTHrP (C-PTHrP) were measured in 15 of them. The intracellular PTHrP expression was immunohistochemically stained in 42 SCC sections obtained from the 33 before the appearance of hypercalcemia.

RESULTS

Hypercalcemia appeared in 24 of the 33, and increased serum C-PTHrP levels were confirmed in 11 of 12 hypercalcemic patients. PTHrP was identified in all SCC sections, and a stronger intensity than in normal squamous epithelia was observed in 50% of those obtained within 1 year before the onset of hypercalcemia.

CONCLUSION

A high incidence of PTHrP-induced hypercalcemia was shown among patients dying with head and neck SCCs. The intracellular increase in PTHrP might be observed preceding hypercalcemia.

Simultaneous optimization based on artificial neural networks in ketoprofen hydrogel formula containing O-ethyl-3-butylcyclohexanol as percutaneous absorption enhancer

The influence of the amounts of additives including 1-O-ethyl-3-n-butylcyclohexanol (OEBC), diisopropyl adipate (DIA), and isopropanol (IPA) on the penetration rate (R(p)) of ketoprofen from hydrogels through rat skin in vivo was investigated. Skin irritation evoked by the application of hydrogels was evaluated based on a microscopic observation of skin cross-sections. Both optimization techniques incorporating an artificial neural network (ANN) and a second-order polynomial regression analysis were applied to the optimization of ketoprofen hydrogel formulations. Findings indicated that the R(p) and total irritation score (TIS) of the skin were predicted quantitatively as a function of quantities of OEBC, DIA, and IPA, employing ANN. In contrast, the prediction ability of the polynomial regression equation was somewhat poorer compared with that of ANN. The observed results of R(p) and TIS in the optimal formulation coincided well with the predictions in the simultaneous optimization technique incorporating ANN.

Interaction of TIP26 from a hyperthermophilic archaeon with TFB/TBP/DNA ternary complex

Interactions of TBP-interacting protein (TIP26), TBP, and TFB from a hyperthermophilic archaeon Thermococcus kodakaraensis KOD1 with TATA-DNA were examined by electrophoretic mobility shift assay. Tk-TFB formed a ternary complex with Tk-TBP and TATA-DNA. Tk-TIP26 did not inhibit the formation of this ternary complex, but interacted with it to form a TIP26/TFB/TBP/DNA quaternary complex. This interaction is rather weak, and a large excess of Tk-TIP26 over Tk-TBP is required to fully convert the TFB/TBP/DNA ternary complex to the quaternary complex. However, determination of the concentration of Tk-TIP26 and Tk-TBP in KOD1 cells by Western blotting analysis indicated that the concentration of Tk-TIP26 is approximately ten times that of Tk-TBP, suggesting that the quaternary complex might also form in vivo.

Multiple intracranial recurrent tumors with hyperprolactinemia combined with a parasellar malignant fibrous histiocytoma long after transfrontal surgery and irradiation to a pituitary adenoma

We herein describe a 40-year-old woman with hyperprolactinemia, an empty sella and two extrasellar intracranial recurrent tumors which were revealed 23 years after the first transfrontal craniotomy and 18 years after the second transfrontal surgery and irradiation to a provable prolactin-producing pituitary macroadenoma. One recurrent tumor was in the right orbital apex causing right oculomotor nerve palsy, and the other tumor was in the right apex partispetrosae and foramen jugulare. Although her serum prolactin level decreased after the administration of bromocriptine mesilate, and the size of the two tumors remained unchanged, a malignant fibrous histiocytoma, which might have been induced by the irradiation 18 years before, grew rapidly in the right suprasellar-prepontine cistern to the right pedunculus cerebralis, leading to a poor prognosis. This case confirmed the importance of the life-lasting follow-up of pituitary adenomas treated with surgery and/or irradiation therapy. Not only ectopic recurrence of the primary tumor but also post-irradiation tumors may become apparent long after the removal of the primary tumor.

Enzyme immunoassay for 6-amino-5-chloro-1-isopropyl-2-(4-methyl-1-piperazinyl)benzimidazole, a novel 5-HT3 receptor antagonist

An enzyme immunoassay (EIA) has been developed for determination of 6-amino-5-chloro-1-isopropyl-2-(4-methyl-1-piperazinyl) benzimidazole (KB-6806), a novel 5-HT3 receptor antagonist. Anti-KB-6806 antiserum was elicited against the KB-6806-bovine serum albumin (BSA) conjugate prepared by a diazo coupling reaction through the inherent 6-amino group. Beta-galactosidase-labeled 6-amino-5-chloro-1-isobutyl-2-(4-methyl-1-piperazinyl)benzimidazole was similarly prepared by diazo coupling reaction as an enzyme-labeled antigen with a hapten heterologous combination of antiserum. The modification at the 4-methyl group of the piperazine moiety of KB-6806 significantly decreased the binding affinity to the antibody. This method could quantitate KB-6806 in dog plasma in the concentration range of 0.078-10 ng/ml with good accuracy and precision. The EIA method has been successfully applied to the determination of KB-6806 in plasma after intravenous administration of KB-6806 to dogs.

Breast reconstruction using a deepithelialized rectus abdominis musculocutaneous flap

There are many methods for breast reconstruction. Using implants can achieve good results without conspicuous scarring, but this method has disadvantages, such as infection, exposure, and capsular contracture. The rectus abdominis musculocutaneous (RAM) flap has become a standard technique because of its safety and abundant volume, but its main problem is the lack of a color and texture match between the skin paddle and the skin around the flap. To overcome such shortcomings, the authors perform breast reconstruction using tissue expansion and a RAM flap. First a tissue expander is inserted superficially to the pectoralis major muscle at the time of or after mastectomy, and is expanded to a size larger than the contralateral breast. The expander is replaced with the deepithelialized RAM flap. Scar revision is performed if the expander is inflated satisfactorily. The authors used this technique in 11 patients and obtained good results without severe complications.

A case of an ameloblastic fibro-odontoma arising from a calcifying odontogenic cyst

This case report describes an ameloblastic fibro-odontoma arising from a calcifying odontogenic cyst (COC) in the mandible of a twenty-three-year old male. The patient was referred to the Department of Oral Surgery, Tokyo Dental College, on March 30th, 2000, complaining of a painful swelling, which had appeared three weeks earlier on his left mandibular molar region. In a pathological view, the lesion was a round cyst the size of a chicken-egg, dark red in color, and surrounded by a thick membrane. The cyst had an epithelium of varying thickness which included many ghost cells and an enamel-like structure on the inside, and a thick wall of connective tissue with an ameloblastic fibro-odontoma on the outside. Enamel organ-like epithelial islands were structured radially in the form of strands with immature dentin. Cytokeratin 19 was strongly immunoreactive in the epithelium of the lesion; osteopontin and osteocalcin reacted in the mesenchymal cells and weakly in the epithelial element of this tumor.

Evaluation and structure-activity relationship of synthesized cyclohexanol derivatives on percutaneous absorption of ketoprofen using artificial neural network

The effect of 35 newly synthesized O-ethylmenthol (MET) derivatives on percutaneous absorption of ketoprofen was investigated in rats. In order to understand the relationship between the structure of compounds and promoting activity (structure-activity relationship), an artificial neural network (ANN) was employed. In the in vivo percutaneous absorption study, male Wistar rats, weighing 160-180 g, were used. The apparent penetration rate (Rp) was estimated based on a pharmacokinetic model with a constant rate of penetration through the skin after a lag time. As an index of the promoting activity of each compound, an enhancement factor (Ef), defined as follows, was used: Ef=Rp(with enhancer)/Rp(without enhancer). An irritation evoked on rat skin was microscopically judged at the end of the in vivo percutaneous absorption experiment and evaluated as a total irritation score (TIS). Ef and TIS were selected as output variables to determine the ANN structure. Calculated logP, molecular weight, steric energy (SE), van der Waals area, van der Waals volume, dipole moment, highest occupied molecular orbital (HOMO) and lowest unoccupied molecular orbital (LUMO) were used as factors to determine the structural nature of cyclohexanol derivatives. Among these parameters, logP, SE and LUMO significantly affected the prediction of Ef and TIS. The predicted values of Ef and TIS coincided well with in vivo percutaneous absorption experimental values. However, results observed with a linear regression method were poor compared with the ANN approach. The contribution index of logP was approximately 50% in the prediction of Ef, suggesting that lipophilicity among physicochemical properties contributes most of the promoting activity of these compounds.

Formula optimization of theophylline controlled-release tablet based on artificial neural networks

Formulation of the controlled-release tablet containing theophylline was optimized based on the simultaneous optimization technique in which an artificial neural network (ANN) was incorporated. As model formulations, 16 kinds of theophylline tablets were prepared. The amounts of Controse, the mixture of hydroxypropylmethyl cellulose with lactose, cornstarch and compression pressure were selected as causal factors. The release profiles of theophylline were characterized as the sum of the fast and slow release fractions. The initial weight, the rate constant in the fast release fraction and the rate constant in the slow release fraction were estimated as release parameters. A set of release parameters and causal factors were used as tutorial data for ANN and analyzed using a computer. Based on the plasma concentration profiles of theophylline predicted by the pharmacokinetic analysis in humans, a desirable set of release parameters was provided. The simultaneous optimization was performed by minimizing the generalized distance between the predicted values of each response and the desirable one that was optimized individually. The optimization technique incorporating ANN showed a fairly good agreement between the observed values of release parameters and the predicted results.

Precision measurement of cosmic-Ray antiproton spectrum

The energy spectrum of cosmic-ray antiprotons ( &pmacr;'s) has been measured in the range 0.18-3.56 GeV, based on 458 &pmacr;'s collected by BESS in a recent solar-minimum period. We have detected for the first time a characteristic peak at 2 GeV of &pmacr;'s originating from cosmic-ray interactions with the interstellar gas. The peak spectrum is reproduced by theoretical calculations, implying that the propagation models are basically correct and that different cosmic-ray species undergo a universal propagation. Future BESS data with still higher statistics will allow us to study the solar modulation and the propagation in detail and to search for primary &pmacr; components.

Formula optimization based on artificial neural networks in transdermal drug delivery

The promoting effect of O-ethylmenthol (MET) on the percutaneous absorption of ketoprofen from alcoholic hydrogels was evaluated in rats in vitro and in vivo. Furthermore, a novel simultaneous optimization technique incorporating an artificial neural network (ANN) was applied to a design of a ketoprofen hydrogel containing MET. When a small quantity of MET (0.25-0.5%) was added to the hydrogels, the permeation of ketoprofen increased remarkably, compared with the control. On the other hand, little change in permeation was observed when small amounts of menthol were used (<1%), and at least 2% menthol was required to obtain a promoting efficiency comparable with 0.25% MET. The partitioning of ketoprofen from the hydrogel to the skin was improved by the addition of a small amount of MET, whereas the diffusivity of the drug was enhanced at higher concentration of MET (0.5-1%). For the optimization study, the amount of ethanol and MET were selected as causal factors. A rate of penetration (R(p)) and lag time (t(L)) and total irritation score (TIS) were selected as response variables. A set of causal factors and response variables was used as tutorial data for ANN and fed into a computer. Nonlinear relationships between the causal factors and the response variables were represented well with the response surface predicted by ANN. The optimization of the ketoprofen hydrogel was performed according to the generalized distance function method. The observed results of R(p) and TIS, which had a lot of influence on the effectiveness and safety, coincided well the predictions.

Application of rapid random stimulation (RRS) to visual evoked potentials in children

The present study was performed to examine the effects of regular (1 Hz) and modified rapid random stimulation (RRS) (6 and 12 Hz) on visual evoked potentials (VEPs), by simultaneously recording negative waves around 100 ms, wave IV-latency, positive waves around 60 ms, wave III-latency, and amplitudes calculated from peak to peak, without causing impairment of visual acuity, in 44 patients aged 5-17 years. The wave IV-latencies of VEPs obtained by 6 and 12 Hz RRS were easily determined, and the latencies were not significantly changed compared to those obtained by previous 1 Hz regular stimulation. On the other hand, the amplitudes decreased in a frequency-dependent manner (1 < 6 < 12 Hz). These results were found to be similar in both preschool and school children. The examination time of VEPs determined by RRS is one-tenth shorter than that of 1 Hz regular stimulation. Thus, this method has the benefit of shortening the examination time, which decreases fatigue and inattention of the subjects, suggesting that modified RRS is a practically useful method for children.

Relapsing polychondritis diagnosed by Tc-99m MDP bone scintigraphy

PURPOSE

Relapsing polychondritis is a generalized recurring disease of cartilage that involves joints, trachea, bronchi, laryngeal cartilages, costal cartilages, and cartilages of the ear and nose. It is associated with autoimmune diseases, including Hashimoto disease in some cases.

METHODS

The authors evaluated a 29-year-old man with relapsing polychondritis who had symptoms and signs of a common cold for 2 months and anterior chest pain near the sternum for 1 month.

RESULTS

After the diagnosis, the authors found that the patient had a history of thyroid therapy for hyperthyroidism 15 years before. Tc-99m MDP bone scintigraphy performed to evaluate anterior chest pain showed diffusely increased accumulation of radioactivity in all costocartilages and sternoclavicular joints. Based on that information, relapsing polychondritis was diagnosed. Ga-67 citrate scintigraphy was preformed to determine the optimum biopsy site of the cartilage. The diagnosis was histologically supported by the results of the open biopsy.

CONCLUSIONS

In this case, Tc-99m MDP bone scintigraphy was useful for diagnosing relapsing polychondritis, and Ga-67 citrate scintigraphy was helpful in determining the biopsy site.

Increased sensitivity to thyroid hormone replacement therapy followed by hyponatremia and eosinophilia in a patient with long-standing young-onset primary hypothyroidism

We describe a 51-year-old woman with long-standing young-onset primary hypothyroidism. Serum cortisol, adrenocorticotropin, and arginine vasopressin levels were normal, but urinary excretion of 17-hydroxycorticosteroid was decreased. Administration of a very small initial dose of thyroid hormone induced severe acute complications including fever, palpitation, and sweating associated with a rapid decrease in serum thyrotropin level, a dramatic increase in serum alkaline-phosphatase level, and a decrease in serum total cholesterol level. A week later, the late complications of nausea, severe hyponatremia, and eosinophilia occurred. Serum cortisol level decreased slightly but remained within normal limits during this hyponatremic period. This rare case suggests that increased sensitivity to thyroid hormone can occur in long-standing primary hypothyroidism with biphasic clinical course of acute thyrotoxic complications followed by severe hyponatremia resembling hypoadrenocorticism.

Hepatitis G virus infection in a high-risk subgroup of hospitalized dental patients

OBJECTIVE

The prevalence of hepatitis G virus infection was evaluated in dental patients whose clinical laboratory test results were positive for hepatitis C virus antibody, hepatitis B virus surface antigen, or elevated serum alanine transaminase concentrations.

STUDY DESIGN

Frozen serum samples from patients with hepatitis C virus antibody (n = 63), hepatitis B virus surface antigen (n = 20), or alanine transaminase concentrations greater than 100 IU (n = 14) were assessed for GB virus C (GBV-C)/hepatitis G virus RNA by a reverse transcriptase-polymerase chain reaction.

RESULTS

Six of 63 patients with hepatitis C virus antibodies had serum hepatitis G virus RNA (9.5%), and 2 of 20 subjects with hepatitis B virus surface antigen had hepatitis G virus RNA (10.0%). None of 14 patients whose alanine transaminase concentration was greater than 100 IU/L had hepatitis G virus RNA. Of 4 subjects with both hepatitis C virus antibody and hepatitis B virus surface antigen, 2 had hepatitis G virus RNA (50%). In the total study population (N = 92), 6 subjects (6.5%) had hepatitis G virus RNA. All hepatitis G virus-infected patients also had hepatitis C virus antibody. Neither serum alanine transaminase nor aspartate transaminase concentrations were different between subjects with and subjects without hepatitis G virus RNA. The lack of a relationship between hepatitis G virus infection and elevation of alanine transaminase and aspartate transaminase might suggest that this virus is not truly a hepatitis virus.

CONCLUSIONS

Hospitalized dental patients are infected with hepatitis G virus at a prevalence similar to or slightly higher than that seen in the general population. Dentists should pay close attention to infection control with respect to the potential new hepatitis virus known as hepatitis G virus.

Repair of the mandibular nerve by autogenous grafting after ablative surgery of the mandible

In this paper, we introduce our original method of autologous nerve grafting for substitution of the mandibular nerve after mandibular resection in three subjects. The lateral cutaneous nerve of the forearm served as a donor nerve, and the graft was imbedded microsurgically at the junctures using an epineurial nerve suture technique. Oversized grafts were chosen in order to insert them without tension in a space between the stumps of the recipient nerve and the regeneration zone of the bone. In all three subjects, sensibility of the lower lip and chin recovered completely after about ten months.

Artificial neural network as a novel method to optimize pharmaceutical formulations

One of the difficulties in the quantitative approach to designing pharmaceutical formulations is the difficulty in understanding the relationship between causal factors and individual pharmaceutical responses. Another difficulty is desirable formulation for one property is not always desirable for the other characteristics. This is called a multi-objective simultaneous optimization problem. A response surface method (RSM) has proven to be a useful approach for selecting pharmaceutical formulations. However, prediction of pharmaceutical responses based on the second-order polynomial equation commonly used in RSM, is often limited to low levels, resulting in poor estimations of optimal formulations. The aim of this review is to describe the basic concept of the multi-objective simultaneous optimization technique in which an artificial neural network (ANN) is incorporated. ANNs are being increasingly used in pharmaceutical research to predict the non-linear relationship between causal factors and response variables. The usefulness and reliability of this ANN approach is demonstrated by the optimization for ketoprofen hydrogel ointment as a typical numerical example, in comparison with the results obtained with a classical RSM approach.

Obui-himo syndrome

Normal variants of the venous system are relatively common and rarely cause severe symptoms. We report the case of a 5-month-old baby who displayed cyanotic color and swelling of arms whenever she was carried on the mother's back with a special band "Obui-himo". It was demonstrated by venography that the symptoms were caused by the absence of a cephalic vein and compression of axillary veins with the Obui-himo. In any country with a custom similar to the Obui-himo, these symptoms, if clinically encountered, are an indication that venography should be performed.

Usefulness of surface phenotype study of intrathyroidal lymphocytes obtained by fine needle aspiration cytology in autoimmune thyroid disease and malignant lymphoma of the thyroid

OBJECTIVES

The surface phenotypes of intrathyroidal lymphocytes have been studied in various thyroid diseases. In most of the previous reports, intrathyroidal lymphocytes were obtained by surgical operation. We evaluated the usefulness of surface phenotype study of intrathyroidal lymphocytes obtained by fine needle aspiration in the diagnosis of Graves' disease, chronic thyroiditis, and malignant lymphoma of the thyroid.

PATIENTS AND DESIGN

Eighty-seven untreated patients including 24 with Graves' disease, 59 with chronic thyroiditis, and 4 with malignant lymphoma of the thyroid, and 2 treated patients with malignant lymphoma of the thyroid were studied. Surface phenotypes of the peripheral lymphocytes and the intrathyroidal lymphocytes obtained by fine needle aspiration were analyzed using a FACScan and the monoclonal antibodies: anti-Leu5b/CD2, Leu4/CD3, Leu3a/CD4, Leu2a/CD8, and Leu12/CD19. Percentages of cells positive for each monoclonal antibody were calculated. In one case with malignant lymphoma, monoclonal antibodies to surface-immunoglobulin markers were also studied.

RESULTS

In peripheral lymphocytes, the percentage of positive cells in each phenotype was almost normal in each disease. In intrathyroidal lymphocytes, the percentage of CD19 positive cells was increased, and the percentage of CD2 and CD3 positive cells was reduced compared to those of peripheral lymphocytes in each disease. The percentage of intrathyroidal CD19 positive cells was remarkably high in malignant lymphoma, constituting more than 70% of cells. In Graves' disease, a relative decrease in the percentage of intrathyroidal CD4 positive cells and an increase in CD8 positive cells compared to peripheral lymphocytes were observed. In 2 treated patients with malignant lymphoma of the thyroid, the intrathyroidal CD19 positive cells almost disappeared in a patient shortly after successful treatment, and reappeared to constitute 76% of cells in a patient in relapse. In one case with malignant lymphoma in which monoclonal antibodies to surface-immunoglobulin markers were studied, the clonality of the affected cells could be demonstrated; more than 70% of the cells were positive for kappa light-chain and mu and delta heavy-chain. This finding was proved by subsequent immunohistochemical study based on open biopsy.

CONCLUSIONS

Surface phenotype study of intrathyroid lymphocytes obtained by fine needle aspiration has limited utility in the evaluation or diagnosis of Graves' disease and chronic thyroiditis. However, this simple rapid method is very helpful in the diagnosis and follow up of malignant lymphoma of the thyroid.

A clinical analysis of the recovery from sensory disturbance after sagittal splitting ramus osteotomy using a Semmes-Weinstein pressure aesthesiometer

A number of studies of evaluation methods for sensory disturbance after sagittal splitting ramus osteotomy (SSRO) are known. To compare postoperative sensory disturbances among patients in different hospitals, a highly reproducible and standardized sensory test is required. In the present study, we measured the tactile threshold in the region innervated by the mental nerves in 45 patients (90 sides) after SSRO using a Semmes-Weinstein pressure aesthesiometer. The percentage of recovery to the normal level defined by Bell was 72.2% at one week, 82.2% at 4 weeks, and 90.0% at 8 weeks after SSRO. The recovery process was evaluated by classifying the postoperative sensory disturbance into 5 grade levels according to Bell's interpretation scale. The results showed that the SW sensory test is useful for evaluation of the recovery process from sensory disturbance after SSRO. Some improvements of this test were also discussed.

Central island tongue flap

Pedicled tongue flaps have proved to be an effective method of repairing defects due to tissue loss in the oral cavity. Their central position, mobility, and excellent blood supply make their use feasible in a variety of sites. This paper describes the use and applications of central island tongue flaps to reconstruct defects of anterior floor of the mouth. This procedure was conducted at the Department of Oral and Maxillofacial Surgery, Medical University Hanover, introducing an improved surgical method and presenting the actual operation performed in our department. This method is considered superior for resurfacing the anterior floor of mouth defects because it is easy to perform and results in recovery of function and cosmetics.

Familial isolated hyperparathyroidism due to multiple adenomas associated with ossifying jaw fibroma and multiple uterine adenomyomatous polyps

We describe three siblings with hyperparathyroidism due to multiple parathyroid adenomas without evidence of other endocrinological abnormalities. A 22-year-old woman had two parathyroid adenomas complicated by multiple ossifying jaw fibromas. Her sister, aged 29, also suffered from primary hyperparathyroidism associated with two parathyroid adenomas one of which was also suspected to be a carcinoma. These two female patients had unusual multiple small uterine polyps, which were diagnosed as adenomyomatous polyps. Their brother, aged 17, had two parathyroid adenomas complicated by urolithiasis. These three patients are characterized by young adult-onset familial isolated hyperparathyroidism due to multiple adenomas with various complications including ossifying jaw fibroma and uterine adenomyomatous polyps. These clinical features are different from those of familial hyperparathyroidism associated with multiple endocrine neoplasia.

Breast reconstruction after mastectomy without additional scarring: application of endoscopic latissimus dorsi muscle harvest

Breast reconstruction with the latissimus dorsi muscle flap combined with a saline-filled implant was performed. Using an endoscope, additional operative scarring due to muscle harvesting was avoided. The operative techniques were easier than usual endoscopic surgery because most of the procedures were performed under direct vision. The procedures are presented in this article.

Anaplastic transformation of a papillary carcinoma of the thyroid in a patient with Graves' disease with varied activity of thyrotropin receptor antibodies

We describe a 75-year-old man who had had a lump in his neck for about 15 years. At his first visit to our hospital, poorly differentiated papillary carcinoma of the thyroid was diagnosed by means of aspiration cytology; x-rays revealed the presence of lung metastases. He was thyrotoxic with positive thyroid stimulating antibody (TSAb). He was reluctant to undergo surgery. In an early stage of the treatment for Graves' disease, he became hypothyroid with decreased TSAb activity and strongly positive thyroid stimulation blocking antibody (TSBAb), and rapid growth of the thyroid carcinoma with anaplastic transformation was observed. The increase in the size of the transformed thyroid carcinoma was shown to be exponential by ultrasonography. This is a rare case in which anaplastic transformation of the thyroid papillary carcinoma became apparent during treatment of Graves' disease with varied activity of thyrotropin receptor antibodies.

Endoscope-assisted transaxillary removal of glandular tissue in gynecomastia

Gynecomastia is a condition commonly associated with puberty. An endoscope-assisted transaxillary procedure was used to treat a patient with this condition. An endoscope system was inserted into a 4-cm skin incision in the axilla, and the glands and adjacent fat were removed en bloc. The resulting scar in the axilla was small and inconspicuous, and the postoperative breast contour satisfied the patient. The endoscopic system provided a useful transaxillary approach. These results show that this method appears to be the most suitable one for surgical management of gynecomastia.

Effect of aging on regulation of brain stem circulation during hypotension

This study was designed to determine age related changes in autoregulatory responses of the brain stem circulation in vivo. In anesthetized adult (4 to 6 months, n = 8) and aged (24 to 26 months, n = 7) Sprague-Dawley rats, local CBF to the brain stem was determined with laser-Doppler flowmetry and diameters of the basilar artery and its branches were measured through an open cranial window during stepwise hemorrhagic hypotension. In aged rats, the lower limit of CBF autoregulation shifted upward to 60 to 75 mm Hg from 30 to 45 mm Hg in adult rats. Dilator responses of the basilar artery (baseline diameter: 254 +/- 15 microns), large branch (109 +/- 23 microns), and small branch (44 +/- 10 microns) to hypotension were much smaller in aged rats than in adult rats. The maximum change in diameter of the basilar artery during profound hypotension was significantly smaller in aged rats (11 +/- 8%) than that in adult ones (23 +/- 12%, P < 0.05); that of the large branch was 12 +/- 8% versus 33 +/- 17% (P < 0.005); and that of the small branch was 17 +/- 7% versus 40 +/- 13% (P < 0.0005), suggesting greater attenuation of the responses in the smaller vessels. Thus, this study provides direct evidence that aging diminishes the compensatory dilatation of brain stem arterioles and arteries during hypotension and modifies the autoregulatory plateau of CBF, which seems to increase the risk of the brain stem ischemia during hypotensive conditions.

Comparison between sporadic cytomegalovirus hepatitis and Epstein-Barr virus hepatitis in previously healthy adults

In order to determine the factors responsible for the differentiation of cytomegalovirus (CMV) hepatitis and Epstein-Barr virus (EBV) hepatitis, the clinical features and laboratory data of both types of hepatitis were retrospectively analyzed in 20 patients with CMV and 11 patients with EBV. While most signs and symptoms of CMV and EBV hepatitis showed no significant differences, we found that cervical lymph- adenopathy was more common in EBV hepatitis than in CMV hepatitis (p < 0.01). Frequency of epigastralgia was more common in CMV hepatitis than EBV hepatitis (p < 0.05). The percentage of peripheral blood monocytes in the white blood cell count in CMV hepatitis was greater than in EBV hepatitis (p < 0.01). Low CD4 levels and high CD8 levels made CD4/CD8 low in peripheral lymphocytes of both groups of hepatitis. Ten EBV hepatitis patients received antibiotics in the early stage of the disease in which two (25%) developed severe erythematous rashes. Four CMV hepatitis patients received antibiotics and did not develop rashes. Identification of early clinical parameters capable of differentiating CMV hepatitis from EBV hepatitis is important.

Age-related changes in response of brain stem vessels to opening of ATP-sensitive potassium channels

BACKGROUND AND PURPOSE

This study was designed to determine regional differences and age-related changes in the contribution of ATP-sensitive potassium (KATP) channels to vasodilator responses in the brain stem circulation in vivo.

METHODS

Changes in diameter of the basilar artery (baseline diameter, 270 +/- 5 microns [mean +/- SEM]), its large branch (112 +/- 5 microns), and its small branch (49 +/- 2 microns) in response to KATP channel openers levcromakalim and Y-26763 were measured through a cranial window in anesthetized adult (4 to 6 months) and aged (24 to 26 months) Sprague-Dawley rats.

RESULTS

Topical application of levcromakalim and Y-26763 produced concentration-dependent vasodilation that was similar among the three vessel groups in adult rats. In aged rats, dilator responses of the branches, but not of the basilar artery, to the KATP channel openers were smaller than those in adult rats (P < .05). Glibenclamide, a selective KATP channel blocker, almost abolished this vasodilation in both groups of rats. Vasodilator responses to sodium nitroprusside were preserved in aged rats.

CONCLUSIONS

In adult rats, there is no regional heterogeneity in vasodilator response to KATP channel openers in the brain stem circulation in vivo. In aged rats, although KATP channels are also functional in the brain stem circulation, dilator response of the microvessels but not of the large arteries to direct activation of KATP channels is impaired.