CT-guided lumbar facet cyst rupture and corticosteroid injection: technique, approach, and procedural and clinical success rates

PURPOSE

To evaluate success rates of computed tomography (CT)-guided lumbar facet synovial cyst (LFC) rupture.

MATERIALS AND METHODS

We retrospectively reviewed all LFC ruptures performed by a single musculoskeletal radiologist with > 10 years of experience, using posterior facet approach and/or direct puncture by ipsilateral/contralateral interlaminar, or transforaminal approach. All patients also received a corticosteroid injection. Rupture rates were calculated, and clinical success rate was determined through medical record review. Pre-procedure magnetic resonance imaging (MRI) images and CT procedure images were also reviewed for LFC and facet joint imaging features that may predict rupture.

RESULTS

There were 37 patients, 17 (46%) female and 20 (54%) male, ages 62 ± 12 (range 39-87) years. Thirty-four (92%) of LFC were successfully ruptured, 17 (50%) by facet approach and 17 (50%) by direct cyst puncture. At least one direct puncture approach was possible in 35 (95%) patients. No MRI or CT LFC or facet joint features predicted cyst rupture. Thirty-one (91%) of patients reported immediate pain relief, and 19 (53%) did not have further intervention for LFC-related pain. Sixteen (84%) of these patients remained pain-free for an average follow-up time period of 28 months. Fourteen (39%) of patients required surgical intervention. There were no complications.

CONCLUSION

Our systematic approach to CT-guided LFC rupture is safe and has high technical and clinical success rates similar to prior studies. Since there are no definitive imaging features that determine rupture success, this procedure can almost always be attempted as a first-line treatment for LFC.

CERKL is upregulated in cutaneous squamous cell carcinoma and maintains cellular sphingolipids and resistance to oxidative stress

BACKGROUND

Ceramide kinase-like protein (CERKL) was originally described in retinal tissue. CERKL has been shown to protect cells from oxidative stress, and mutations in CERKL underlie the inherited disease retinitis pigmentosa. CERKL expression maintains cellular sphingolipids via an unknown mechanism.

OBJECTIVES

To determine whether CERKL is expressed in epidermis and cutaneous squamous cell carcinoma (cSCC) and whether CERKL expression affects cSCC sphingolipid metabolism and susceptibility to oxidative stress.

METHODS

CERKL expression was determined by RNA-Seq, quantitative polymerase chain reaction and immunohistochemistry. CERKL was knocked down in cSCC cells using small interfering RNA. Sphingolipid content was analysed by liquid chromatography-mass spectrometry. Oxidative stress was induced by treatment with H₂ O₂ , and apoptosis was measured using flow cytometry to determine annexin V binding.

RESULTS

CERKL mRNA and protein are highly expressed in actinic keratosis and cSCC in comparison with normal epidermis. CERKL is also expressed in metabolically active epithelial cells in normal hair bulbs and sebaceous glands. CERKL knockdown in cultured cSCC cells reduces cellular sphingolipid content and enhances susceptibility to oxidative stress.

CONCLUSIONS

These findings suggest that CERKL may be important in cSCC progression and could lead to novel strategies for prevention and treatment of cSCC.

CERKL is Upregulated in Cutaneous Squamous Cell Carcinoma and Maintains Cellular Sphingolipids and Resistance to Oxidative Stress

BACKGROUND

Ceramide Kinase-Like Protein (CERKL) was originally described in retinal tissue. CERKL has been shown to protect cells from oxidative stress, and mutations in CERKL underlie the inherited disease, retinitis pigmentosa. CERKL expression maintains cellular sphingolipids via an unknown mechanism.

OBJECTIVES

To determine whether CERKL is expressed in epidermis and cutaneous squamous cell carcinoma (cSCC) and whether CERKL expression affects cSCC sphingolipid metabolism and susceptibility to oxidative stress.

METHODS

CERKL expression was determined by RNA-Seq, qPCR and immunohistochemistry. CERKL was knocked down in cSCC cells using siRNA. Sphingolipid content was analyzed by liquid chromatography-mass spectrometry (LC-MS). Oxidative stress was induced by treatment with H2 O2 , and apoptosis was measured using flow cytometry to determine annexin v binding.

RESULTS

CERKL mRNA and protein are highly expressed in actinic keratosis and cSCC in comparison with normal epidermis. CERKL also is expressed in metabolically active epithelial cells in normal hair bulbs and sebaceous glands. CERKL knockdown in cultured cSCC cells reduces cellular sphingolipid content and enhances susceptibility to oxidative stress.

CONCLUSIONS

These findings suggest that CERKL may be important in cSCC progression and could lead to novel strategies for prevention and treatment of cSCC.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Dose escalation of low molecular weight heparin to manage recurrent venous thromboemblic events despite systemic anticoagulation in cancer patients

e20580

Background: Cancer patients with venous thromboembolism (VTE) are at high risk of recurrent VTE. The rate of recurrent VTE ranges from 9 to 17% despite therapy with low molecular weight heparins (LMWH) or vitamin K antagonists (VKA) respectively. To date, no published evidence is available to guide treatment of cancer patients with recurrent VTE. We sought to evaluate the benefit and risk of LMWH dose escalation in cancer patients with recurrent VTE. Methods: Retrospective cohort study was conducted in consecutive cancer outpatients referred for management of an objectively confirmed, symptomatic, recurrent VTE while receiving an anticoagulant. Patients were treated with either dose escalation of weight-adjusted LMWH in patients already anticoagulated with LMWH or initiation of a therapeutic dose LMWH in patients who were taking a VKA. All patients were followed for a minimum of 3 months after the index recurrent VTE. Results: Seventy cancer patients with a recurrent VTE despite ongoing anticoagulation were included. The median time between the initial VTE to the index recurrence was 3.5 months (range 0.3 to 193 months). At the time of the recurrence, 67% of patients were on LMWH, while 33% were on VKA. Following the treatment with either dose escalation or initiation of LMWH, a total of 6 patients (8.6%; 95% confidence interval (CI): 4.0% to 17.5%) had a second recurrent VTE during the three-month follow-up period, at an event rate of 9.9 per 100 patient-years (95% CI: 2.0 to 17.8). The median time between the index and second recurrent VTE was 1.9 months (range 0.6 to 3.0 months). One patient (1.4%; 95% CI: 0.3% to 7.7%), or 1.6 per 100 patient-years (95% CI: 0.0% to 4.8%) of follow-up, had a major bleeding event. The median time between the index recurrent VTE to death was 11.4 months (range 0 to 83.9 months). Conclusions: Patients with recurrent VTE have a poor prognosis. Escalating the dose of LMWH can be effective for treating cases that are resistant to standard, weight-adjusted doses of LMWH or a VKA.

[Table: see text]

Dose escalation of low molecular weight heparin to manage recurrent venous thromboembolic events despite systemic anticoagulation in cancer patients

SUMMARY BACKGROUND

Cancer patients with venous thromboembolism (VTE) are at high risk of recurrent VTE despite standard anticoagulation. To date, very little published literature is available to guide the treatment of cancer patients with recurrent VTE.

OBJECTIVES

To evaluate the benefit and risk of low molecular weight heparin (LMWH) dose escalation in cancer patients with recurrent VTE.

PATIENTS AND METHODS

This was a retrospective cohort study of consecutive cancer outpatients referred for management of a symptomatic, recurrent VTE while receiving an anticoagulant. Confirmed episodes of recurrent VTE were treated with either dose escalation of LMWH in patients already anticoagulated with LMWH, or initiation of therapeutic dose LMWH in patients who were taking a vitamin K antagonist (VKA). All patients were followed for a minimum of 3 months after the index recurrent VTE unless they died during this period.

RESULTS

Seventy cancer patients with a recurrent VTE despite ongoing anticoagulation were included. At the time of the recurrence, 67% of patients were receiving LMWH, and 33% were receiving a VKA. A total of six patients [8.6%; 95% confidence interval (CI) 4.0-17.5%] had a second recurrent VTE during the 3-month follow-up period, at an event rate of 9.9 per 100 patient-years (95% CI 2.0-17.8%). Three patients (4.3%; 95% CI 1.5-11.9%), or 4.8 per 100 patient-years (95% CI 0.0-10.3%) of follow-up, had bleeding complications. The median time between the index recurrent VTE to death was 11.4 months (range, 0-83.9 months).

CONCLUSIONS

Cancer patients with recurrent VTE have a short median survival. Escalating the dose of LMWH can be effective for treating cases that are resistant to standard, weight-adjusted doses of LMWH or a VKA.

The association of mood with quality of life ratings in epilepsy

OBJECTIVE

To determine the relative contributions of psychological (mood and anxiety), social, and seizure-related variables to quality of life (QOL) scores in epilepsy.

METHODS

Outpatients (n = 435) with epilepsy completed the Quality of Life in Epilepsy 31 Inventory (QOLIE-31), Beck Depression Inventory II (BDI-II), Beck Anxiety Inventory, and a social survey. Stepwise linear regression and general linear model analyses determined the set of best predictors and the most unique predictors of composite QOLIE-31 score and subscale scores.

RESULTS

A three-variable model accounted for 56% of the variance for the composite QOLIE-31 score. The BDI-II was the strongest (often by several multiples in terms of variance explained) and most consistent predictor of the composite and QOLIE subscales in both types of analytic approaches. In no case did BDI-II significantly interact with the other variables, suggesting that its effect on QOL was direct and not mediated by other factors. Throughout the results, depression had an inverse relation to scores, i.e., lower levels of depression correlated with high QOL scores. Separate correlational analyses showed that poor seizure control was associated with increased numbers of depressive symptoms.

DISCUSSION

Quality of Life in Epilepsy (QOLIE) scores, reflecting both general and specific aspects of quality of life, are strongly influenced by mood state, such as depression. Factors such as seizure control exert a more limited effect on the QOLIE. Health-related quality of life measures are needed in which mood does not play such a dominant role.

Mobilization factors of peripheral blood stem cells in healthy donors

As a source of hematopoietic stem cells for transplantation, the use of peripheral blood stem cells (PBSCs) has become routine and comparable to that of the use of bone marrow. Recently, elderly patients with hematological malignancies also have been allowed to receive minitransplantations with nonmyeloablative conditioning regimens under sufficient PBSC infusion. As a result of these minitransplantations, elderly donors have been chosen increasingly from the siblings of elderly patients. We analyzed factors influencing the condition of CD34+ cells in the first days of collection in 49 healthy donors from July 1995 to January 2001. The median dose of recombinant human granulocyte colony-stimulating factor was 8 microg/kg/day (range 8 - 10) over 3 days. The target number of CD34+ cells used in this study was > or = 3 x 10(6) cells/kg of recipient body weight. The median apheresis volume was 12 L. Except for one 60 year old man, we obtained an adequate number of stem cells. In the regression analysis, a negative correlation was seen between donor age and the number of CD34+ cells/kg of recipient body weight per 12 L volume (Y = aX + b; a = -0.07507; b = 6.629996; r = -0.50985; p = 0.000252). Significantly higher apheresis results were obtained in donors younger than 45 years compared with donors 45 years old and older (p < 0.0227). There were no correlations among the number of CD34+ cells, donor body weight, and the number of leukocytes in peripheral blood on the first day of apheresis.

Morphological and biochemical changes of isolated chicken egg-envelope during sperm penetration: degradation of the 97-kilodalton glycoprotein is involved in sperm-driven hole formation on the egg-envelope

The chicken egg-envelope is made of two major glycoprotein components, which are designated as gp97 and gp42 (after their molecular masses). To elucidate how these two components are involved in macromolecular organization of the chicken egg-envelope, the isolated egg-envelope was characterized by immunochemical and biochemical methods. The gp97 was suggested to be a homologue of mouse ZPB based on the similarities of N-terminal and internal sequences. Immunoblotting using anti-gp97 monoclonal antibodies and two-dimensional gel electrophoresis with or without mercaptoethanol treatment revealed that gp97 formed a homodimer through disulfide bonds, whereas gp42 did not. Under indirect immunofluorescence microscopy, the anti-gp97 antibody visualized indistinct, small spots on the egg-envelope, whereas the anti-gp42 antibody showed a meshwork of blurry, fibrous structures. The hole formation on the egg-envelope by in vitro sperm penetration was completely inhibited by two anti-gp97 monoclonal antibodies. Interestingly, the anti-gp97 monoclonal antibodies blocked the proteolysis not only of gp97 but also of gp42 during incubation of the egg-envelope with either sperm or the crude chicken acrosin. Taken together, these results indicate that gp97 may play pivotal roles not only in constitution of the macromolecular organization of the egg-envelope but also in triggering hydrolysis of the egg-envelope during sperm penetration.

Ectopic adrenocorticotropin syndrome exhibiting paradoxical adrenocorticotropin responsiveness to gonadotropin-releasing hormone

In a 37-year-old man who had Cushing's syndrome, investigations, including overnight dexamethasone suppression test, corticotropin-releasing hormone (CRH) test, pituitary MRI and inferior petrosal sinus sampling suggested the presence of ectopic adrenocorticotropin (ACTH) production. Interestingly, gonadotropin-releasing hormone (GnRH) increased plasma ACTH from 73 pg/ml to 708 pg/ml at 15 min. Furthermore, desmopressin also increased plasma ACTH whereas CRH and thyrotropin-releasing hormone (TRH) had no effect. Such paradoxical responses of plasma ACTH were observed repeatedly. A thoracic CT scan revealed a right anterior mediastinal mass, which was surgically resected. Histological and immunohistochemical examination confirmed that the tumor was an ACTH-producing carcinoid. ACTH and cortisol decreased immediately following surgery. Neither desmopressin nor GnRH administration resulted in elevation of plasma ACTH while ACTH-responsiveness to dexamethasone and CRH was restored. To our knowledge, this is the first report documenting GnRH responsiveness in ectopic ACTH syndrome.

Enhancement of rat hypoglossal nerve regeneration by chitin sheet plus gangliosides

The effects of chitin sheet interposition with and without brain gangliosides on the regeneration of hypoglossal nerve fibres was studied in the rat following resection of a 5mm length of the nerve. At 10 weeks after operation, the number of horseradish peroxidase (HRP)-labelled motor neurones, indicative of the axonal repair process, on the side treated with chitin and gangliosides was higher than on the control side (where 5mm of the nerve was simply resected). The ratios of HRP-positive neurones in the right hypoglossal nucleus (treated side)/left hypoglossal nucleus (intact side) was 0 in the 5mm-resected group, 53% in the chitin-grafted group, 88% in the ganglioside (0.2 microg)-injected group, 90% in the ganglioside (2 microg)-injected group, 91% in the chitin with ganglioside (0.2mg)-injected group, 91% in the chitin with ganglioside (2 microg)-injected group and 85% in the autograft group, respectively. There were significant differences between the 5 mm-resected group and chitin-grafted group, ganglioside-injected group, chitin with ganglioside group and autograft group, and between the chitin-grafted group and ganglioside-injected, chitin with ganglioside and autograft groups (P< 0.005, respectively). Our results indicated that the use of chitin and gangliosides stimulated the regeneration of severed motor nerve fibres. These findings suggest that chitin and gangliosides might be therapeutically useful for treatment of neuronal degeneration.

Predominant information transfer from layer III pyramidal neurons to corticospinal neurons

Connections of layer III pyramidal neurons to corticospinal neurons of layer V and corticothalamic neurons of layer VI in the rat primary motor cortex were examined in brain slices by combining intracellular staining with Golgi-like retrograde labeling of corticofugal neurons. Forty layer III pyramidal neurons stained intracellularly were of the regular-spiking type, showed immunoreactivity for glutaminase, and emitted axon collaterals arborizing locally in layers II/III and/or V. Nine of them were reconstructed for morphologic analysis; 15.2% or 3.8% of varicosities of axon collaterals of the reconstructed neurons were apposed to dendrites of corticospinal or corticothalamic neurons, respectively. By confocal laser scanning and electron microscopy, some of these appositions were revealed to make synapses. These findings suggest that corticospinal neurons receive information from the superficial cortical layers four times more frequently than corticothalamic neurons. The connections were further examined by intracellular recording of excitatory postsynaptic potential (EPSP) that were evoked in layer V and layer VI pyramidal neurons by stimulation of layer II/III. EPSPs evoked in layer V pyramidal neurons showed short and constant onset latencies, suggesting their monosynaptic nature. In contrast, most EPSPs evoked in layer VI pyramidal neurons had long onset latencies, showed double-shock facilitation of onset latency, and were largely suppressed by an N-methyl-D-aspartic acid receptor blocker, suggesting that they were polysynaptic. The results suggest that information from the superficial cortical layers is transferred directly and efficiently to corticospinal neurons in layer V and thereby exerts an important influence on cortical motor output. Corticothalamic neurons are, in contrast, considered relatively independent of, or indirectly related to, information processing of the superficial cortical layers.

The effects of single dose nefazodone and paroxetine upon 5-HT2A binding potential in humans using [18F]-setoperone PET

RATIONALE

Alterations in 5-HT2A receptor binding are implicated in suicidality and depression. 5-HT2A receptors may also be involved in the therapeutic effects of antidepressants.

OBJECTIVES

The purpose of this study was to assess the effect of paroxetine and nefazodone on 5-HT2A receptors after a single dose.

METHODS

Seven subjects received a single dose of nefazodone 200 mg and five subjects received a single dose of paroxetine 20 mg. Before and after the dose, 5-HT2A binding potentials (Bmax/Kd) were determined in each subject using [18F]-setoperone PET.

RESULTS

Nefazodone induced a significant change in 5-HT2A binding potential (-39+/-17%,, P = 0.003) while paroxetine showed no significant alteration of 5-HT2A binding potential (+3+/-13%, P = 0.73).

CONCLUSIONS

The change in 5-HT2A binding potential seen with nefazodone represents blockade of 5-HT2A receptors by the drug. We do not find evidence for acute downregulation of 5-HT2A receptors with paroxetine within 9 h.

Is amoxapine an atypical antipsychotic? Positron-emission tomography investigation of its dopamine2 and serotonin2 occupancy

BACKGROUND

All currently available atypical antipsychotics have, at clinically relevant doses: i) high serotonin (5-HT)2 occupancy; ii) greater 5-HT2 than dopamine (D)2 occupancy; and iii) a higher incidence of extrapyramidal side effects when their D2 occupancy exceeds 80%. A review of pharmacologic and behavioral data suggested that amoxapine should also conform to this profile; therefore, we undertook a positron-emission tomography (PET) study of its 5-HT2 and D2 occupancy.

METHODS

Seven healthy volunteers received 50-250 mg/day of amoxapine for 5 days and then had [11C]-raclopride and [18F]-setoperone PET scans.

RESULTS

5-HT2 receptors showed near saturation at doses of 100 mg/day and above. The D2 receptor occupancies showed a dose-dependent increase, never exceeding 80%; at all doses 5-HT2 occupancy exceeded D2 occupancy.

CONCLUSIONS

PET data show that amoxapine's profile is very similar to that of the established atypical antipsychotics. These data, together with amoxapine's in vitro pharmacologic profile, effectiveness in animal models, and efficacy in psychotic depression raise the possibility of amoxapine as an "atypical" antipsychotic agent in the treatment of schizophrenia.

Relationship between central and peripheral serotonin 5-HT2A receptors: a positron emission tomography study in healthy individuals

5-HT2A receptors on platelet membranes are often measured as indirect markers of the central 5-HT2A receptors. However, the 5-HT2A receptors on the platelets and those in the brain have never been assessed simultaneously in humans. The purpose of this study was to evaluate the relationship between platelet membrane and neocortical 5-HT2A receptors measured simultaneously in normal healthy volunteers. Twelve healthy volunteers had the 5-HT2A receptors on their platelet membranes assessed in vitro using [3H]lysergic acid diethylamide ([3H]LSD) and their central 5-HT2A receptors measured in vivo using [18F]setoperone and positron emission tomography (PET) imaging. We find no significant correlation between the binding potential (Bmax/Kd) of 5-HT2A receptors on platelets and in brain in the same individual (F1,10 = 0.7, P = 0.42). The study was limited by a small sample and the fact the two different ligands were used (i.e. LSD for platelets and setoperone for brain); nonetheless, the findings suggest that changes in platelet 5-HT2A receptors may not indicate similar changes in central 5-HT2A receptors.

A 2-Mb YAC contig and physical map of the natural killer gene complex on mouse chromosome 6

We have constructed a physical map of a > 2-Mb region on mouse chromosome 6 that contains the natural killer gene complex (NKC). The map comprises a contig of 14 overlapping yeast artificial chromosomes onto which we positioned 25 NKC markers. NKC genetically linked genes encode > 17 proteins that directly control innate NK cell-mediated tumor lysis and disease resistance. Herein we show that Nkrp1 genes are clustered in a region flanked by A2m and Cd69 genes and that most Ly49 genes are clustered in a distal region -1 Mb distant. Importantly, syntenic intervals of mouse chromosome 6 and human chromosome 12p that include the NKC are conserved. NKC species conservation suggests that the human NKC may contain orthologues for the mouse viral disease resistance genes, Cmv1 and Rmp1. The high-resolution NKC map will facilitate investigation of NKC gene regulation and identification of phenotypically defined gene products that confer NK cell defense against viral pathogens.

The Cmv1 host resistance locus is closely linked to the Ly49 multigene family within the natural killer cell gene complex on mouse chromosome 6

Natural killer (NK) cells play important roles in controlling tumor cells and against a range of infectious organisms. Recent studies of mouse NK cell surface receptors, which may be involved in the specificity of NK cells, have shown that many of these molecules are encoded by the Ly49 and Ly55 (Nkrp1) multigene families that map to distal mouse chromosome 6. Also mapping to this NK cell gene complex (NKC) is the resistance locus, Cmv1, which is involved in genetically determined resistance to murine cytomegalovirus (MCMV). The aim of this study was to localize Cmv1 more precisely in relation to other NKC loci by generating a high-resolution genetic map of the region. We have analyzed 1250 backcross mice comprising panels of 700 (BALB/c x C57BL/6J)F1 x BALB/c and 550 (A/J x C57BL/6J)F1 x A/J progeny. A total of 25 polymorphic genes or microsatellite markers were analyzed over a region of 10 map units from D6Mit134 to D6Mit59. The Cmv1 phenotypes of mice recombinant in this interval were tested by infection with MCMV. The results obtained indicate that the functionally important NKC region is a tightly linked cluster of loci spanning at least 0.4 map units. Furthermore, Cmv1 maps distal to, but very closely linked to, the Ly49 multigene family (< 0.2 map units), suggesting that MCMV resistance may be conferred by MHC class I-specific NK cell receptors.

[The combination therapy with vinca-alkaloid slow infusion and cholchicine was effective to refractory idiopathic thrombocytopenic purpura. The patient could receive femoral head replacement in safety]

A 46-year-old man with idiopathic thrombocytopenic purpura (ITP) refractory to corticosteroid, splenectomy and other drugs was admitted to our hospital in August, 1994, because of aseptic necrosis of the right femoral head. Although high-dose intravenous gamma-globulin was ineffective, the platelet count was increased within two weeks by the combination therapy that consisted of 0.02 mg/kg vincristine alternating with 0.1 mg/kg vinblastine by slow infusion at a 1-week interval, and oral 1.5 mg/day colchicine. He subsequently underwent the femoral head replacement. This combination therapy seems to be useful for refractory ITP in preparation for surgery.

[Prostaglandin E1 bladder instillations for late-onset hemorrhagic cystitis following allogeneic bone marrow transplantation]

Between July, 1990 and March, 1994, 31 patients with hematological malignancies or severe aplastic anemia underwent allogeneic bone marrow transplantation (BMT) at the Second Department of Internal medicine, Chiba University Hospital. Among the 29 evaluable patients who survived over 100 days after transplant, 11 patients (37.9%) developed late-onset hemorrhagic cystitis with a median time of onset of 57 days (range 11-205) from BMT. Adenovirus type 11 was isolated from the urine of 4 patients. Five patients recovered with fluid hydration and forced diuresis, while 6 patients had persistent gross hematuria with clot formation, 5 of whom also developed hydronephrosis. Seven-day courses of 500 micrograms prostaglandin E1 (PGE1) bladder instillations was initiated to control hematuria in these 6 patients. Complete resolution of gross hematuria was achieved in 4, and partial response with decreased clot formation and partial clearing of the urine was observed after 4 of 9 courses of the treatment. Although all patients experienced bladder spasm or lower abdominal pain during the PGE1 instillations, these symptoms were manageable with sedative drugs and morphine. No systemic side effect was apparent. PGE1 bladder instillations is a safe and useful treatment for severe, life-threatening late-onset hemorrhagic cystitis after allogeneic BMT.

A patient with malignant paraganglioma that simultaneously produces adrenocorticotropic hormone and interleukin-6

BACKGROUND

To the authors' knowledge, there have been no reports describing a case of malignant paraganglioma that produces both adrenocorticotropic hormone (ACTH) and interleukin-6 (IL-6).

METHODS

The clinical course and pathophysiology of a patient with Cushing's syndrome induced by ectopic ACTH syndrome caused by a cervical malignant paraganglioma with elevated plasma levels of IL-6 was investigated.

RESULTS

Ultrasonography, computed tomography, and magnetic resonance imaging of the neck revealed the presence of a tumor around the area from which the blood sample that showed the highest levels of ACTH and IL-6 was obtained by selective catheterization. Immunohistochemical staining of the removed tissue demonstrated the presence of ACTH and IL-6 proteins in the tumor cells. Reverse transcriptase-polymerase chain reaction also revealed the existence of IL-6 mRNA in those cells.

CONCLUSION

The malignant paraganglioma of ectopic ACTH syndrome may produce IL-6. The present investigation provides new observations concerning ectopic ACTH syndrome.

[A study of attitudes toward illness and its effect on mortality in patients with Parkinson's disease]

The standardized mortality ratio (SMR), i.e. the ratio of observed to expected deaths, was investigated among 433 patients with Parkinson's disease (172 males and 261 females), who had been visited by public health nurses for a period of more than one year between 1978 and 1987 in Osaka Prefecture. The mean age of the patients was 58.7, and the average duration of the disease was 6.1 years at study entry. The follow-up period averaged 4.1 years during which sixty eight deaths were observed. The SMR of the patients was 2.54 relative to the general population of Osaka Prefecture. The SMR of those who were able to walk without assistance at study entry was 1.73, while that of patients with severe gait disturbance was 3.81. Patients were divided into three groups according to the extent of daily physical exercise performed to maintain their remaining function. Among patients who had been able to walk, those doing daily physical exercise showed the lowest SMR of 1.46. Among those with severe gait disturbance, the SMR of the exercising group was also the lowest at 1.72. These results indicate that daily physical exercise affects the mortality of Parkinsonian patients independently of the grade of disability. Participation in daily exercise was strongly influenced by the patient's will to battle his illness, and was significantly related to the presence of a spouse, economic situation of household, and the number of rooms in their dwelling.