Rabeprazole Coadministration Controls Ulcer Recurrence in Patients on Low-dose Aspirin Therapy: A Multicenter Prospective Study

Objective To evaluate the efficacy and safety of rabeprazole coadministration with low-dose aspirin (LDA). Methods From 2015 to 2018, we conducted a large-scale, multicenter, prospective observational study to assess the safety and efficacy of treatment with rabeprazole (5 or 10 mg/day) in combination with LDA. Results The incidence of adverse reactions was 0.73% (11/1,513 patients), with no serious adverse reactions. We found no trend toward increases in the incidence of adverse reactions with increases in treatment duration. The cumulative recurrence rate of ulcers by Week 52 (Kaplan-Meier estimates) was 3.50% (range, 1.56-7.75%). No gastrointestinal bleeding was reported. Conclusion Rabeprazole in combination with LDA appears as safe and effective in real-world situations as in clinical trials.

Effectiveness of drug safety measures for reducing the incidence of adverse drug reactions: Post-hoc analysis of data from all-case surveillance of iguratimod using generalized estimating equations

A post-marketing study was performed on all patients who had started treatment with iguratimod, a conventional synthetic disease-modifying antirheumatic drug approved in Japan. During the study period, various safety measures were implemented to reduce risks. We investigated the frequency of adverse drug reactions before and after implementation of each safety measure to examine the preventive effect of these measures. Post-hoc analysis was performed using data from all-case surveillance of iguratimod. The subjects were all of the patients receiving iguratimod for whom safety information was obtained. To identify the time after starting administration when adverse drug reactions were most likely to occur, a generalized linear mixed-effect model was applied for the period from initiation of administration until occurrence of reactions in each patient. The mean incidence of adverse drug reactions per patient was compared before and after the implementation of safety measures by using generalized estimating equations based on a two-sided test, 95% confidence interval, and 5% significance level. The number of patients treated with iguratimod was not related to changes in the number of patients with adverse drug reactions. After implementing precautions regarding co-administration with warfarin and liver dysfunction, the estimated mean incidence rate of adverse drug reactions (95% confidence interval) decreased significantly to 0.73 (0.59-0.90) and 0.72 (0.55-0.94), respectively. Accordingly, some of the implementation of safety measures significantly reduced adverse drug reactions. The effectiveness of safety measures implemented during the all-case surveillance of iguratimod was evaluated, revealing that early implementation of safety measures decreased the incidence of adverse drug reactions.

Eriocitrin Contained in Lemon Peel Ameliorates Disuse Muscle Atrophy by Suppressing the Expression of Atrogin-1 and MuRF-1 in Denervated Mice

Unloading stress enhances oxidative stress, which in turn induces disuse muscle atrophy. This study evaluated the suppressive effect of lemon peel extract containing eriocitrin on muscle atrophy. Both lemon peel extract and eriocitrin suppressed weight loss in the gastrocnemius muscle under denervation in C57BL/6 mice. The mRNA level of ubiquitin ligases and their transcription factor were downregulated by eriocitrin. Eriocitrin inhibited the increase in lipid peroxidation and the ratio of glutathione disulfide/glutathione. These data suggest that eriocitrin ameliorated disuse muscle atrophy by suppressing the expression of ubiquitin ligase genes by its antioxidative effect.

Factors influencing physician decisions to discontinue treatment after onset of liver dysfunction: Post-hoc analysis of an all-case post-marketing surveillance study of iguratimod

Objectives: Adverse drug reactions (ADRs) related to liver dysfunction are a common problem in patients with rheumatoid arthritis (RA) receiving iguratimod, but which patient subgroups go on to discontinue iguratimod treatment is unclear. A post-hoc analysis of a post-marketing surveillance study was performed to investigate factors influencing treatment continuation after the onset of liver dysfunction.Methods: Types of ADR were compared between patients in whom iguratimod treatment was discontinued or continued in accordance with the judgment of the patient's physician after the patient developed liver dysfunction as an ADR. Stepwise logistic regression analysis was also conducted to investigate factors associated with treatment discontinuation.Results: The multivariate analysis found that concomitant use of methotrexate (MTX) at >8 mg/week (vs. no use) was associated with a significantly lower risk of discontinuation (OR: 0.136; 95%CI: 0.030-0.620), and previous treatment with MTX (vs. no use) was associated with a significantly higher discontinuation risk (OR: 4.045; 95%CI: 1.098-14.908).Conclusion: Although concomitant use of MTX during iguratimod treatment does not appear to influence treatment discontinuation due to abnormal liver function, liver function tests are of importance to continued treatment in patients receiving iguratimod who have a history of MTX use.

Investigation of the predictors of the response to Iguratimod therapy: A post-hoc analysis of post-marketing surveillance study

Objectives: The treatment response according to patient disease activity during Iguratimod therapy for rheumatoid arthritis has not been sufficiently assessed. A post-hoc analysis of post-marketing surveillance was performed. The treatment effect was evaluated using the European League against Rheumatism (EULAR) response criteria.Methods: Disease Activity Score (DAS) 28 was assessed at various time points. Patients showing a moderate or good response according to the EULAR response criteria at 24 weeks after the start of Iguratimod therapy were considered Responders. Propensity score matching was also performed, after which the factors with the greatest effect on the treatment evaluation were investigated.Results: The mean DAS28 at the start of administration and after 24 weeks was 4.31 and 2.52, respectively, in the Responder and 3.48 and 3.48, respectively, in the Non-responder. After propensity score matching for patient characteristics, the primary factors found to be related to being a Responder were concomitant use of methotrexate (MTX) with Iguratimod, and prior treatment with MTX before the start of Iguratimod.Conclusion: As factors related to the treatment effect, the concomitant use of MTX may contribute to achieving a better effect, and this study has shown that real-world are consistent with the results of clinical trials.

Safety and effectiveness of iguratimod in patients with rheumatoid arthritis: Final report of a 52-week, multicenter postmarketing surveillance study

OBJECTIVES

We evaluated the long-term (52 weeks) safety and effectiveness of iguratimod (IGU) in patients with rheumatoid arthritis (RA).

METHODS

This multicenter, prospective, observational study included all evaluable RA patients who received IGU since its market launch in 2012. We evaluated adverse events (AEs); adverse drug reactions (ADRs); ADRs of special interest, including liver and renal dysfunctions, interstitial lung disease, gastrointestinal and blood disorders, and infection; and change in Disease Activity Score 28-C-reactive protein (DAS28-CRP) at week 52.

RESULTS

Safety and effectiveness were analyzed in 2666 and 1614 patients, respectively. The incidences of AEs, serious AEs, ADRs, and serious ADRs were 46.92, 7.35, 38.26, and 4.58%, respectively. The incidence of ADRs peaked at approximately 4 weeks of treatment. Subsequently, the ADR incidence did not increase over time. Improvement of RA activity was shown up to week 52.

CONCLUSION

Long-term treatment with IGU in patients with RA resulted in a tolerable safety profile and an improvement in RA activity. IGU could be considered a useful treatment option for patients with RA.

Therapeutic Response to Twice-daily Rabeprazole on Health-related Quality of Life and Symptoms in Patients with Refractory Reflux Esophagitis: A Multicenter Observational Study

Objective To investigate the effect of twice-daily rabeprazole doses on health-related quality of life in refractory patients. Methods and Patients Reflux esophagitis patients with an insufficient response to once-daily proton pump inhibitor therapy (Los Angeles Classification grade A-D) received rabeprazole 10 mg or 20 mg twice daily for 8 weeks. The health-related quality of life (SF-8™) and symptoms, using the Frequency Scale for the Symptoms of Gastroesophageal reflux disease, were evaluated before treatment and at weeks 4 and 8. Endoscopy was performed at baseline and at weeks 8 and 32 where possible. The rabeprazole dose was determined by the attending physician. Results There were 1,796 patients analyzed for the efficacy of the twice-daily treatment. Of these cases, 1,462 were treated with rabeprazole 10 mg twice daily, and 334 were treated with rabeprazole 20 mg twice daily. The factors that affected the selection of the twice-daily rabeprazole dose by physicians were evaluated, and as expected, "endoscopic findings when treatment was started" had a strong effect on the selection of the rabeprazole dose. With both regimens, health-related quality of life and subjective symptoms were significantly improved at weeks 4 and 8 compared to baseline (p<0.001). The recurrence rate of erosive esophagitis at week 32 was 9.7% in rabeprazole twice daily-treated patients and 28.4% in proton pump inhibitor (PPI) once daily-treated patients. Both regimens were well tolerated. Conclusion Twice-daily treatment with rabeprazole improved the subjective symptoms and health-related quality of life in patients with refractory reflux esophagitis more effectively than the standard once-daily dose.

Safety and effectiveness of 24-week treatment with iguratimod, a new oral disease-modifying antirheumatic drug, for patients with rheumatoid arthritis: interim analysis of a post-marketing surveillance study of 2679 patients in Japan

OBJECTIVE

To determine the real-world safety and effectiveness of iguratimod (IGU) for rheumatoid arthritis (RA), a 52-week, Japanese, post-marketing surveillance study was conducted. An interim analysis at week 24 was performed.

METHODS

This study included all RA patients who received IGU following its introduction to the market. All adverse events (AEs) and adverse drug reactions (ADRs) were collected. Effectiveness was evaluated by the change in Disease Activity Score 28-C-reactive protein (DAS28-CRP) from baseline to week 24.

RESULTS

Safety was analyzed in 2679 patients. The overall incidences of AEs, ADRs, and serious ADRs were 38.41, 31.65, and 3.21%, respectively; the most commonly reported serious ADRs were pneumonia/bacterial pneumonia, interstitial lung disease, and Pneumocystis jiroveci pneumonia. Concomitant glucocorticoid use and comorbid conditions associated with respiratory disease were identified as risk factors for serious infections. Pulmonary alveolar hemorrhage and increased international normalized ratio of prothrombin time were observed with concomitant use of IGU and warfarin. The DAS28-CRP decreased from baseline to week 24.

CONCLUSION

Although a safety concern was identified with concomitant use of IGU and warfarin, this real-world study showed no other new safety concerns and similar effectiveness to clinical trials. IGU is a new therapeutic option for RA patients.

Determining the Presence of Thin-Walled Regions at High-Pressure Areas in Unruptured Cerebral Aneurysms by Using Computational Fluid Dynamics

BACKGROUND

Thin-walled regions (TWRs) of cerebral aneurysms are at high risk of rupture, and careful attention should be paid during surgical procedures. Despite this, an optimal imaging technique to estimate TWRs has not been established. Previously, pressure elevation at TWRs was reported with computational fluid dynamics (CFD) but not fully evaluated.

OBJECTIVE

To investigate the possibility of predicting aneurysmal TWRs at high-pressure areas with CFD.

METHODS

Fifty unruptured middle cerebral artery aneurysms were analyzed. Spatial and temporal maximum pressure (Pmax) areas were determined with a fluid-flow formula under pulsatile blood flow conditions. Intraoperatively, TWRs of aneurysm domes were identified as reddish areas relative to the healthy normal middle cerebral arteries; 5 neurosurgeons evaluated and divided these regions according to Pmax area and TWR correspondence. Pressure difference (PD) was defined as the degree of pressure elevation on the aneurysmal wall at Pmax and was calculated by subtracting the average pressure from the Pmax and dividing by the dynamic pressure at the aneurysm inlet side for normalization.

RESULTS

In 41 of the 50 cases (82.0%), the Pmax areas and TWRs corresponded. PD values were significantly higher in the correspondence group than in the noncorrespondence group (P = .008). A receiver-operating characteristic curve demonstrated that PD accurately predicted TWRs at Pmax areas (area under the curve, 0.764; 95% confidence interval, 0.574-0.955; cutoff value, 0.607; sensitivity, 66.7%; specificity, 82.9%).

CONCLUSION

A high PD may be a key parameter for predicting TWRs in unruptured cerebral aneurysms.

Imaging alterations due to squamous metaplasia in intracranial neurenteric cysts: A report of two cases

Intracranial neurenteric cysts are rare congenital abnormalities with a broad imaging spectrum, and therefore are occasionally mistaken for other common intracranial cysts such as epidermoid and arachnoid cysts. We report two cases of neurenteric cysts in the posterior cranial fossa that were initially mistaken for other types of cysts. They exhibited signal intensity alterations in magnetic resonance imaging with significant volume expansion during their long-term observation. Both cases received surgical treatment because of clinical deterioration. Histologically, the cysts were lined by flattened or cuboidal epithelium, occasionally showing squamous metaplasia. Xanthogranulomatous inflammation and accumulation of cholesterol clefts, dry keratin and proteinaceous substance were observed in the cysts. These findings may indicate that chronic inflammation in neurenteric cysts induces squamous metaplasia, keratinization and high proteinaceous content, and causes MRI signal intensity alterations and volume expansion. We propose that MRI signal intensity alterations in neurenteric cysts may be a warning sign of their volume expansions, and thus require closer follow-up imaging and eventually surgical treatment.

BRAF V600E-mutated diffuse glioma in an adult patient: a case report and review

Recent advances in genomic technology and genome-wide analysis have identified key molecular alterations that are relevant to the diagnosis and prognosis of brain tumors. Molecular information such as mutations in isocitrate dehydrogenase (IDH) genes or 1p/19q co-deletion status will be more actively incorporated into the histological classification of diffuse gliomas. BRAF V600E mutations are found frequently in circumscribed low-grade gliomas such as pleomorphic xanthoastrocytoma (PXA) and extra-cerebellar pilocytic astrocytoma, or epithelioid glioblastomas (E-GBM), a rare variant of GBM. This mutation is relatively rare in other types of diffuse gliomas, especially in adult onset cases. Here, we present an adult onset case of IDH wild-type/BRAF V600E-mutated diffuse glioma, evolving from grade III to grade IV. The tumor displayed atypical exophytic growth and had unusual histological features not fully compatible with, but indicative of PXA and E-GBM. We discuss differential diagnosis of the tumor, and review previously described diffuse gliomas with the BRAF V600E mutation.

Cleavage of Various Peptides with Pitrilysin fromEscherichia coli: Kinetic Analyses Using β-Endorphin and Its Derivatives

Pitrilysin from Escherichia coli was overproduced, purified, and analyzed for enzymatic activity using 14 peptides as a substrate. Pitrilysin cleaved all the peptides, except for two of the smallest, at a limited number of sites, but showed little amino acid specificity. It cleaved beta-endorphin (beta-EP) most effectively, with a K(m) value of 0.36 microM and a k(cat) value of 750 min(-1). beta-EP consists of 31 residues and was predominantly cleaved by the enzyme at Lys(19)-Asn(20). Kinetic analyses using a series of beta-EP derivatives with N and/or C-terminal truncations and with amino acid substitutions revealed that three hydrophobic residues (Leu(14), Val(15), and Leu(17)) and the region 22-26 in beta-EP are responsible for high-affinity recognition by the enzyme. These two regions are located on the N- and C-terminal sides of the cleavage site in beta-EP, suggesting that the substrate binding pocket of pitrilysin spans its catalytic site.

Parallel insertion endoscopic technique for precise catheter placement in cystic craniopharyngiomas

BACKGROUND

Total removal of craniopharyngioma is the most acceptable therapeutic modality; however, there are cases in which radical excision is not possible. To reduce the cystic component volume, an Ommaya reservoir catheter can be placed endoscopically. However, there are certain complications and risks with this type of maneuver, such as misplacement of the catheter, which may result in leakage of cyst contents or installed fluids such as bleomycin. Thus, accurate placement of intracystic catheter is extremely important.

PATIENTS AND METHODS

The authors placed Ommaya reservoir catheters running over the outer surface of a transparent endoscopic sheath in three cases.

RESULTS

This neuroendoscopic procedure permits easier manipulation of the catheter and precise placement of the catheter tip. This technique was useful for placement of Ommaya reservoir catheters.

CONCLUSIONS

This new technique of catheter placement with neuroendoscopy is more accurate, safer, and less invasive.

Robotic Digital Subtraction Angiography Systems Within the Hybrid Operating Room

BACKGROUND:

Fully equipped high-end digital subtraction angiography (DSA) within the operating room (OR) environment has emerged as a new trend in the fields of neurosurgery and vascular surgery.

OBJECTIVE:

To describe initial clinical experience with a robotic DSA system in the hybrid OR.

METHODS:

A newly designed robotic DSA system (Artis zeego; Siemens AG, Forchheim, Germany) was installed in the hybrid OR. The system consists of a multiaxis robotic C arm and surgical OR table. In addition to conventional neuroendovascular procedures, the system was used as an intraoperative imaging tool for various neurosurgical procedures such as aneurysm clipping and spine instrumentation.

RESULTS:

Five hundred one neurosurgical procedures were successfully conducted in the hybrid OR with the robotic DSA. During surgical procedures such as aneurysm clipping and arteriovenous fistula treatment, intraoperative 2-/3-dimensional angiography and C-arm-based computed tomographic images (DynaCT) were easily performed without moving the OR table. Newly developed virtual navigation software (syngo iGuide; Siemens AG) can be used in frameless navigation and in access to deep-seated intracranial lesions or needle placement.

CONCLUSION:

This newly developed robotic DSA system provides safe and precise treatment in the fields of endovascular treatment and neurosurgery.

Endovascular operating suite: future directions for treating neurovascular disease

Object

The purpose of this study was to evaluate initial experiences in a surgical operating room (OR) with a multi-purpose angiography unit, which offers integrated neurosurgical and radiological capabilities.

Methods

A specially designed biplane digital subtraction (DS) angiography system was installed in the neurosurgery OR. The new suite, which allows three-dimensional DS angiography with C-arm for computerized tomography and microsurgery capabilities, allows the neurosurgeon to perform a wide range of neurosurgical and endovascular procedures. Three hundred thirty-two procedures were performed in the endovascular OR between November 2003 and March 2005. Patients arriving in the emergency department were transferred to the endovascular OR without delay. The neurovascular team performed diagnostic angiography followed by endovascular interventional procedures or surgery.

Conclusions

The newly designed endovascular OR facilitates safe and systemic treatment of neurovascular disease.

Reversible hypocalcemic heart failure with T wave alternans and increased QTc dispersion in a patient with chronic renal failure after parathyroidectomy

Despite the crucial role of calcium in myocardial contractility, hypocalcemia has very rarely been reported as a reversible cause of heart failure. In this article, we describe a case of a 51-year-old woman with advanced stages of chronic renal failure after parathyroidectomy who exhibited congestive heart failure, severe hypocalcemia, hypomagnesemia and hypokalemia. Severe hypocalcemia resulted from discontinuation of taking calcium supplements after parathyroidectomy and from reduced 1.25(OH)2D3 synthesis by damaged kidneys. The patient presented with reduced left ventricular ejection fraction (EF) and ECG abnormalities (T wave alternans and increased QTc dispersion), both of which improved after correction of serum calcium levels. Her serum levels of total calcium corrected for serum albumin, but not serum levels of magnesium or potassium, positively and negatively correlated with EF and QTc dispersion, respectively. In the present case, both heart failure and the ECG abnormalities are directly associated with hypocalcemia.

Molecular Rotor of Cs2([18]crown-6)3in the Solid State Coupled with the Magnetism of [Ni(dmit)2]

Nanoscale molecular rotors that can be driven in the solid state have been realized in Cs2([18]crown-6)3[Ni(dmit)2]2 crystals. To provide interactions between the molecular motion of the rotor and the electronic system, [Ni(dmit)2]- ions, which bear one S=1/2 spin on each molecule, were introduced into the crystal. Rotation of the [18]crown-6 molecules within a Cs2([18]crown-6)3 supramolecule above 220 K was confirmed using X-ray diffraction, NMR, and specific heat measurements. Strong correlations were observed between the magnetic behavior of the [Ni(dmit)2]- ions and molecular rotation. Furthermore, braking of the molecular rotation within the crystal was achieved by the application of hydrostatic pressure.

Phase II evaluation of protracted infusion of cisplatin and 5-fluorouracil in advanced squamous cell carcinoma of the esophagus: a Japan Esophageal Oncology Group (JEOG) Trial (JCOG9407)

BACKGROUND

Surgery for advanced esophageal carcinoma has its limits as regards aggressiveness and therapeutic effect, therefore effective multimodality treatment is required to obtain better survival. The objective of this study was to evaluate whether daily continuous infusion of CDDP could achieve a higher clinical response rate with less toxicity than its drip infusion in the previous phase II study that we had conducted.

METHODS

Patients with primary extensive or relapsed esophageal carcinoma after esophagectomy, which had distant organ metastasis and histologically proven SCC, were eligible for this study. A dose of 20 mg/m(2) of cisplatin and 800 mg/m(2) of 5-fluorouracil was given by continuous infusion for 24 h on days 1-5. This treatment was repeated every 4 weeks for up to four cycles. A total of 36 men and six women with a median age of 64 (range 39-75) years were registered and 36 patients were eligible.

RESULTS

The overall response rate of the registered patients was 33.3% (12/36) and the median response duration was 175 days. Median survival time was 201.5 days and the 1-year survival rate was 27.8%. Change from bolus to continuous infusion of cisplatin affected neither the type nor the degree of toxicity.

CONCLUSION

Daily continuous infusion of cisplatin was not associated with higher response or lower toxicity than those seen with the high-dose bolus or multibolus treatment regimens. We conclude that this regimen in this setting is not worthy of further phase III trials. JEOG is now evaluating other drug combination regimens.

Vascular orientation by intra-arterial dye injection during spinal arteriovenous malformation surgery

OBJECTIVE

Rich and complicated vascular structures on the spinal cord often interfere with obliteration of a spinal arteriovenous malformation (AVM). Vascular orientation during spinal AVM surgery is essential. The authors recently performed six consecutive spinal AVM surgeries in five patients (two with perimedullary AVMs, and three with dural arteriovenous fistulae) with the aid of intra-arterial injection of dye (indigo carmine).

METHODS

Two representative cases are described. A microcatheter was placed preoperatively in the artery of interest. Subsequent to the exposure of the vascular complex, a 1-ml injection of indigo carmine (2 mg/ml) clearly demonstrated the feeding arteries and the draining veins around the AVM or dural arteriovenous fistula.

RESULTS

One patient had repeat surgery because of incomplete obliteration of the AVM owing to migration of the catheter. All patients, except one who had temporary postoperative deterioration and persistent neurological deficits, had good surgical outcomes, however. No apparent side effects caused by the dye were reported.

CONCLUSION

The assistance system for spinal AVM surgery is easy and safe and can be applied in other surgical institutions.

Laparoscopic-assisted hepatectomy (LAH) for the treatment of hepatocellular carcinoma

The treatment of hepatocellular carcinoma associated with liver cirrhosis necessitates local therapy in some patients because of severe hepatic dysfunction. Percutaneous ethanol injection therapy, the local therapy for such cancer of the liver, and percutaneous microwave coagulation therapy are detailed. The significant disadvantages of these procedures is their inability to evaluate precisely whether the tumor will develop complete necrosis after treatment because the cancer tissue cannot be excised with use of these procedures. Conversely, laparoscopic hepatectomy, which is minimally invasive surgery, has a disadvantage, that is, its difficulty in complex maneuvers, including hemostasis, ligation, and suture. The authors developed laparoscopic-assisted hepatectomy, which is hepatectomy by small incision during laparotomy with the use of laparoscopic observation. This report describes laparoscopic-assisted hepatectomy, which may allow the solving of problems with percutaneous ethanol injection therapy, percutaneous microwave coagulation therapy, and laparoscopic hepatectomy.

Globular Cluster Formation Triggered by the Initial Starburst in Galaxy Formation

We propose and investigate a new formation mechanism for globular clusters in which they form within molecular clouds that are formed in the shocked regions created by galactic winds driven by successive supernova explosions shortly after the initial burst of massive star formation in the galactic centers. The globular clusters have a radial distribution that is more extended than that of the stars because the clusters form as pressure-confined condensations in a shell that is moving outward radially at high velocity. In addition, the model is consistent with existing observations of other global properties of globular clusters, as far as comparisons can be made.

[Infratentorial hemorrhage following supratentorial surgery]

Hemorrhage in regions remote from the site of initial intracranial operations is rare, but does occur. We report three cases of cerebellar hemorrhage that developed after supratentorial surgery, all of which had similar clinical findings and CT images. The first case was a 37-year-old man with a craniopharyngioma in the suprasellar lesion. Partial removal of the tumor was performed through frontal craniotomy and the translaminaterminals approach. A large quantity of cerebospinal fluid (CSF) was suctioned from the third ventricle during the operation, resulting in marked brain shrinkage. The second and third cases were 34- and 51-year-old women with unruptured right middle cerebral aneurysms. Clipping of the aneurysms through the pterional approach was performed in both cases. In the second case, CSF was suctioned in large quantity from the carotid and prechiasmal cistern at the operation, resulting in marked brain shrinkage. In the third case, however, only a small volume of CSF was suctioned from the carotid and prechiasmal cistern during the operation, and no marked brain shrinkage was observed. CT scan showed that the hematomas were located mainly in the subdural or the subarachnoid spaces over the cerebellar hemisphere and partially extending into the cerebellar cortex. The mechanism of cerebellar hemorrhage in these series of patients was thought to be multifactorial. The possible etiology for cerebellar hemorrhage in the three cases presented was examined, including the role of CSF suction during surgery and disturbance of venous circulation in the posterior fossa. Suction of the CSF may cause intracranial hypotension. Further reduction of intracranial pressure leads to an increased transluminal venous pressure. There was no episode of hypertension or disturbed blood coagulation during or after the operation. The preoperative angiogram also revealed no abnormality at the region of the posterior fossa. Neuroimaging of infratentorial hemorrhage after supratentorial craniotomy is obviously different from that of hypertensive cerebellar hemorrhage. From the shape or extension of the hemorrhage, the main vessels of hemorrhage are the superior vermian vein and their tributaries damaged by stretching and tearing of these vessels. These vessels are not demonstrable in the angiogram, therefore there is no evidence for this hypothesis and the etiology is still unclear. There is no doubt, however, that there was a disturbance of venous circulation in this complication. We would like to emphasize the possibility of this complication. Patients who show signs of difficulty in awaking from anesthesia or the development of new neurological deficits not attributed to direct operative procedure after supratentorial craniotomy must be evaluated early, with adequate imaging including the posterior fossa.

A case of cerebrospinal fluid eosinophilia associated with shunt malfunction

A 3-month-old female patient presented with a meningomyelocele at the lumber region associated with congenital hydrocephalus. She underwent ventriculoperitoneal (V-P) shunt surgery using the Sophy system. The shunt system was replaced due to a malformation. Following replacement, the patient presented with cerebrospinal fluid (CSF) eosinophilia at the age of 8 months. The eosinophilic granulocytosis of the CSF improved dramatically following systemic prednisolone administration. CSF eosinophilia without accompanying inflammation or pyrexia in the present case may have resulted from an allergic response to a foreign material such as the silicone tube pressure valve of the Sophy system or the sutures rather than bacterial or fungal infection. Based on our results, we believe that some patients may experience CSF eosinophilia following postoperative V-P shunt due to an allergic reaction to the shunt equipment. Prompt steroid treatment can produce spontaneous regression in such cases.

[A case of hearing loss caused by overdrainage of cerebrospinal fluid after ventriculo-peritoneal shunting procedure]

We describe a case of intracranial hypotension syndrome due to overdrainage of cerebrospinal fluid presented with hearing loss after ventriculoperitoneal shunting procedure. A 69-year-old man suffering from subarachnoid hemorrhage presented with an angiogram showing two aneurysms, one of the right internal carotid and one of the middle cerebral artery. Neck clipping was performed. One month later, he developed normal pressure hydrocephalus (NPH), which was treated by ventriculoperitoneal (NPH), which was treated by ventriculoperitoneal shunting procedure using low pressure Pudenz system. Trias of NPH were improved by insertion of shunt system. However, he complained of hearing loss which was worsened by upright position and improved by lying down. Such kinds of phenomenon were demonstrated by audiogram showing that the transitory decrease of hearing and electrocochleography showing the elongation of N1 latency at upright position. These data suggested that his hearing loss was caused by inner ear or auditory nerve lesion. After the shunt system was replaced into the antisiphon device, his hearing disturbance improved. Axial computed tomography of bone window at the level of orbitomeatal line demonstrated widely perilymphatic duct on both sides. This finding suggested that the fluctuation of intracranial pressure was easily transmitted into the cochlear through the widened perilymphatic duct, resulting in hearing disturbance.

Hepatic embolization through extrahepatic collateral pathways after hepatic arterial embolization for the hepatocellular carcinoma

Extrahepatic collateral pathways developing after repeated transcatheter arterial embolization (TAE) for hepatocellular carcinoma (HCC) make therapeutic arterial embolization for recurrent lesions extremely difficult. TAE was performed through the collateral pathways using a sophisticated micro-catheter with good trackability and pushability and a coaxial system. Twenty-three TAEs were undertaken through the collateral pathways in 13 patients with recurrent HCC who had extrahepatic collateral pathways after the previous hepatic arterial TAE. There were 69 extrahepatic collateral pathways, with partially obstructed hepatic arteries. On the average, three feeding arteries were seen in the liver. The main extrahepatic collateral pathways were the inferior phrenic artery and epicholedocal artery, 18 vessels and 29 vessels, respectively, accounting for about 80% of the total collateral pathways. TAEs were successful in all cases and the number of embolized vessels was 2.1 on average. The average time of the first collateral TAE after the initial conventional hepatic arterial TAE was 2.3 years. Excellent prognosis was observed with a one-year survival rate of 77% and 3-year survival rate of 38% after the collateral TAE. We consider that collateral TAE for recurrent HCC with obstruction of the hepatic artery is the procedure of choice, is technically feasible, and provides better prognosis for the patients.

Fragile bone syndrome associated with craniognathic fibro-osseous lesions and abnormal modeling of the tubular bones: report of two cases and review of the literature

OBJECTIVE

To report examples of disorders characterized by bone fragility, calvarial and/or gnathic fibro-osseous lesions, and metadiaphyseal undermodeling of the tubular bones.

DESIGN

The clinical, radiological, and pathological features of two patients are described and the literature reviewed.

PATIENTS

The patients comprised a 10-year-old boy and a 48-year-old woman. The former exhibited multiple fractures starting in early childhood and calvarial masses which developed in late childhood; the latter showed a mandibular mass.

RESULTS

Calvarial doughnut lesions, osteopenia with coarse bony trabeculae, and undermodeling of the lower limbs were radiologically demonstrated in the first patient, while multiple sclerotic foci in the maxilla and mandible, spontaneous bowing of the right femur, and minimal undermodeling of the tibiae were demonstrated in the second. Bone biopsy of the iliac crest in the first patient revealed histologically normal bony trabeculae. Bone histomorphometry suggested an increased osteoid surface. Osteoid volume was also slightly increased. The pathological findings of the mass in the jaw in the latter patient were consistent with it being a fibro-osseous lesion. The literature review revealed several patients whose features overlapped with those of our patients.

CONCLUSION

These patients may represent a group of fragile bone syndromes which differ from osteogenesis imperfecta.

Drug sensitivity testing for clinical samples from oesophageal cancer using adhesive tumour cell culture system

A total of 83 specimens of surgically resected tumours from 78 patients with oesophageal cancer were assayed for drug sensitivity using an adhesive tumour cell culture system (LifeTrac CSA assay). Seventyone of 83 specimens had a sufficient number of cells to permit growth in culture and 57 of 71 (80%) were evaluable for drug response. Cells (3 x 10(3) ml-1 well-1) were cultured for 14 days and exposed to drugs on days 3-8. Growing cells were confirmed as cancer cells by immunohistochemical staining. IC90 values against several anti-cancer drugs were determined and population distributions of IC90 for each drug served as the basis for judging sensitivity. The 10th percentiles of IC90 (microgram ml-1) for CDDP, 5-FU, DOX, CPM, MTX, VP16, IFOS, VDS, BLM and CDDP + 5-FU were 0.3, 0.16, 0.005, 0.9, 0.006, 0.09, 0.8, 0.006, 0.04 and 0.15 + 0.09 respectively. The population distribution of IC90 against each drug showed a specific pattern that was very similar among histopathological gradings and stages of the disease. This system appeared to be a clinically applicable drug sensitivity test for human oesophageal cancer.

Extensive resection of the bile ducts combined with liver resection for cancer of the main hepatic duct junction: a cooperative study of the Keio Bile Duct Cancer Study Group

BACKGROUND

It is necessary to elucidate whether extensive resection of the bile ducts combined with liver resection is a feasible and valid procedure for cancer of the main hepatic duct junction.

METHODS

Based on a multi-institutional study, resectability rate, operative mortality, long-term survival, and factors contributory to long-term survival were investigated.

RESULTS

Between January 1973 and December 1991, a total of 158 patients with this cancer were admitted to Keio University Hospital and six affiliated institutions. Eighty-three (53%) of the 158 patients underwent resection, with seven (8.4%) postoperative deaths. The operations were performed by seven surgeons who were in charge of liver surgery at each respective institution. The 5-year actuarial survival rate of the 83 patients who underwent resection was 20%. Twelve patients survived more than 5 years, and these patients underwent curative resection. Three of the 12 patients were doing well after 10 years. Procedures of liver resection were right trisegmentectomy in two patients and left lobectomy with resection of the right portal vein in one.

CONCLUSIONS

It is clear that cancer of the main hepatic duct junction has become a curable disease. The operation is a valid procedure that can be widely practiced by competent surgeons.

Clinical applications and basic studies of laser in dentistry and oral surgery

In our clinical use of lasers, mainly CO2 laser for oral surgery, we found that the laser had many advantages over an electrome and the laser improved the local control rate for malignant tumors. Low-power laser has been used to treat hypersensitive dentin, to relieve pain caused by neurotic disease around mouth, and to promote the healing of those diseases. The results obtained from the clinical applications showed that irradiation of the hypersensitive dentin with low-power laser was significantly effective in desensitization. An in vitro study showed no effects of diode or He-Ne laser irradiation on the growth of cells, but showed changes in the initial cell adhesion rate. He-Ne laser irradiation to the wound in the skin of hamsters caused to change the activities of the types I and III collagenase. This fact suggest that laser irradiation acted to promote the healing of wound.

[A case of unilateral atypical moyamoya disease of adult onset with stenosis of the basilar artery]

A 29-year-old, 39-week-pregnant female who had headache and nausea was admitted to our hospital. She bore a baby son by natural delivery after several hours. After labor, her headache was continuous. Brain CT scan demonstrated intracerebral and intraventricular hemorrhage. After conservative treatment for two weeks, her only neurological deficiency was visual field defect. Angiography demonstrated that her left internal carotid artery had partial stenosis at the C2 portion. Her right internal carotid artery had stenosis at the C2 portion. Her right middle cerebral artery was occluded at the M1 portion, and abnormal vascular networks had developed in the ganglionic region. Stenosis was also found in the basilar artery. We diagnosed her as being a case of adult-onset, unilateral, atypical Moyamoya disease with basilar artery stenosis. As our case was of adult-onset, and as she showed no ischemic signs, we did not think that reconstructive surgery was indicated. About the posterior circulation of Moyamoya or atypical Moyamoya disease, it was reported that in cases of juvenile onset the vertebral, basilar or posterior cerebral artery was sometimes stenosed or occluded, but, in adult-onset cases, stenosis or occlusion of the posterior cerebral artery would be an abnormality. Our case is a very rare example of unilateral atypical Moyamoya disease of adult onset with basilar artery stenosis.

Adenocarcinoma of the sublingual gland

Primary adenocarcinoma arising in the sublingual gland is very rare. In this report, we have described the details of a case of adenocarcinoma of the sublingual gland. A 27-year-old Japanese male was referred to our department with a swelling of the floor of the mouth on the right side. The patient underwent a wide resection of the lesion and dissection of the right upper neck. Twelve months after his primary surgery, he was readmitted to hospital because of a metastasis in the lower lobe of the right lung and a right lower lobectomy was performed. He has undergone periodical controls for 3 years. No sign of recurrence or metastasis has been observed.

[Intracranial invasion of neuroendocrine carcinoma: a case report]

A rare case of neuroendocrine carcinoma arising from the nasal cavity is reported. A 57-year-old female, who had been complaining of anosmia for 8 years, was admitted to the otolaryngological department because an intranasal tumor was found. Then, removal of the tumor and radiotherapy was carried out. After these procedures, the patient suffered from a high fever and CSF rhinorrhea. At this stage, our neurosurgical department was consulted. CT scan revealed a partially calcified low density mass with a slight enhancement effect at the left frontal base. Under the diagnosis of intracranial invasion by intranasal neuroendocrine carcinoma, the patient was operated on. Through bifrontal craniotomy and a combination of extra- and intradural approach, the tumor was excised. After that, the dura and the skull base were reconstructed. On histological examination, the tumor was found to consist of NSE positive cells forming some glandular structures. Electron microscopic study disclosed neurosecretory granules in the cytoplasmic process. These findings are typical of neuroendocrine carcinoma and compatible to those of the intranasal tumor previously removed. Neuroendocrine carcinoma is rare in itself and there have been reported only two cases of its invasion of the skull base. The clinical features, diagnostic procedures, pathological findings, and treatment of this tumor are discussed in this report.

[Immunohistochemical study on Rosenthal fibers in gliomas using anti-GFAP and anti-ubiquitin antibodies]

Immunohistochemically we investigated Rosenthal fibers (RFs) on specimen surgically removed from patients with glioma (three cerebellar astrocytomas, three optic gliomas, two spinal cord astrocytomas, one spinal ganglioglioma). Pathological diagnoses were pilocytic astrocytoma, fibrillary astrocytoma, and ganglioglioma. We utilized sections from the formalin-fixed paraffin-embedded tissues and stained them with H & E, PTAH, PAS as well as with anti-GFAP (glial fibrillary acidic protein) antibody (Ab) and two anti-ubiquitin Abs...anti-PHF (paired helical filament) monoclonal Ab (DF2) which recognizes ubiquitin (H. Mori in Science) and anti-ubiquitin polyclonal Ab provided by Dr. Haas. The primary antibodies were diluted with Tris-saline as follows: anti-GFAP (1:500), DF2 (culture medium without dilution), anti-ubiquitin (2 micrograms/ml). Sections were deparaffinized and incubated with primary antibodies overnight at room temperature. They were visualized by the avidin-biotin-peroxidase complex (ABC) procedure (Vectastain, Vector, USA) and counterstained with hematoxylin. Negative control sections were treated by omitting the primary antibodies. In the representative specimen we compared H & E, anti-GFAP and anti-ubiquitin staining on 3 microcrons serial sections. RFs were eosinophilic (bright red on H & E), purply-stained with PTAH (metachromasia), black with Heidemhein's iron-hematoxylin, and negative with PAS. Anti-GFAP Ab stained glial filaments diffusely in the cytoplasm and cell process of astrocytomas in every case. The peripheral parts of most RFs were intensely stained with anti-GFAP. The whole part of some RFs showed dark staining, and no part of a few RFs showed positive reactivity.(ABSTRACT TRUNCATED AT 250 WORDS)

[Subclavian artery to external carotid artery bypass with saphenous vein graft in the treatment of common carotid artery stenosis]

A case of TIAs due to proximal common carotid artery stenosis which was successfully treated with autogenous saphenous vein graft between the subclavian artery and the external carotid artery is presented. A 57-year-old, right handed female was admitted to our hospital for the treatment of left common carotid artery stenosis which was pointed out at a local hospital. She had a 7-years' history of repeated transient right hemiparesis and/or left amaurosis fugax. No neurological deficit was revealed on admission. Angiography showed an 80% irregular stenosis of the left common carotid artery at its origin, hypoplastic A1-portion of the left anterior cerebral artery and hypoplasia of the left posterior communicating artery. No other stenotic lesions were disclosed in a four-vessel study. Several kinds of surgical procedures have been reported for the treatment of common carotid stenotic lesion, in accordance with the site and extension of the lesion and hemodynamic factors. To maintain a sufficient blood flow of the left internal carotid artery, we considered four different operative methods such as (1) endarterectomy of the common carotid artery, (2) subclavian to common carotid artery bypass, (3) subclavian to external carotid artery bypass and (4) subclavian to middle cerebral artery bypass. The first two operative procedures force to clamp the common carotid artery which was the only one feeding artery of the left middle cerebral artery because of poor cross flow in this case. These procedures were thought highly possibly to give rise to cerebral infarction on the left side. The fourth method needs a long graft which has higher risk of bypass occlusion.(ABSTRACT TRUNCATED AT 250 WORDS)

[CT findings in acute spinal epidural hematoma caused by a ruptured cavernous angioma]

A case of acute spinal epidural hematoma due to the rupture of cavernous angioma is reported. A 68-year-old man was admitted to our hospital with a complaint of hematoemesis. After the successful treatment of bleeding from a gastric ulcer by using endoscopical method, he noticed severe motor weakness in his lower extremities. Complete paraparesis of his lower limbs, total sensory loss below the level of fifth thoracic vertebrae, and bladder disturbance were revealed on neurological examination. A metrizamide myelogram showed complete block at the level of fourth thoracic vertebrae. A computed tomography (CT) scan disclosed a dorsolateral heterogeneous high density area (92 Hounsfield Unit) on the right with displacement of the spinal cord to the left, extending from the level of second to fifth thoracic vertebrae. He was operated thirty hours after the onset. After the laminectomy, an epidural hematoma covering over the dural sac was recognized. Following the removal of the hematoma, a hemorrhagic mass was disclosed and removed successfully. A pathological examination revealed cavernous angioma. His symptoms improved partially in three months after the operation. There have been thirteen cases of non-traumatic spinal epidural hematoma which had been diagnosed by CT scan, as far as we are aware. Although only four cases out of 13 were diagnosed without using any contrast materials, we stress that the spinal epidural hematoma can be diagnosed only by plain CT scan because of its characteristic clinical feature, attenuation coefficient, and mass effect to the spinal cord.

[Changes in cellular immunity and their effect on pulmonary infections and prognosis after surgery of esophageal cancer patients]

In esophageal cancer patients, pneumonia in an early (20%) and a late (3.5%) period, pythorax except for leakage (8%) and pulmonary tuberculosis (1.4%) were observed characteristically through the post operative course. Changes in cellular immunity through the course were indicated with remarkable depression of PHA stimulation index (s.i.) and T cell number. The lowest values during 5-year survey were observed 2 weeks after surgery. Especially, cases with post operative pulmonary infections had low PHA s.i. and low T cell number for long time, different from cases without them. As regards T cell subsets, both helper T and suppressor T decreased dramatically early after surgery and helper T kept in low value for long time, in contrast to suppressor T returned to normal range gradually, and then H/S ratio also depressively changed. Therefore, suppressive immunity after surgery must result in pulmonary infections and cause critical conditions. Cases with well reacted lymphocytes indicated high 5 year survival rate (40%).

[Radiosensitivity and cell kinetics of the human solid cancer transplanted to nude mouse]

This study was undertaken to analyse the relationship between radiosensitivity and cell kinetics of human solid cancer in experimental nude mouse system. Four strains of tumors used for the experiment were poorly differentiated squamous cell carcinoma of the lung (Lu-9), oat cell carcinoma of the lung (Lu-24), well differentiated squamous cell carcinoma of the tongue (To-1) and moderately differentiated squamous cell carcinoma of the esophagus (Es-4) which were serially transplantable to BALB/c nude mice. Radiosensitivity was evaluated by tumor growth in terms of inhibition rate, histological change and host reaction after irradiation. Cell kinetics were studied by autoradiography with pulse administration of 3H-thymidine to mice. Although Lu-24 was most radiosensitive, followed by To-1, Es-4 and Lu-9 in the order of sensitivity, it was suggested that they might be more radioresistant in nude mice without T-cell function than in human. Regarding squamous cell carcinomas, well differentiated type was more radiosensitive than poorly differentiated one. All of these tumors in nude mouse revealed distinct percent labeled mitosis curves with two clear peaks which were quite different from those in human body. Lu-24 showed a characteristic pattern with a long time lag before visible growth, short G1, and low growth fraction, compared to other three tumors. Three strains of squamous cell carcinoma demonstrated similar cell kinetic factors which were almost the same as those in human body reported previously. The differences in volume doubling time of tumor, growth fraction and cell loss factor were partially related to those of radiosensitivities among tumors except for Lu-24. The theoretical volume doubling time was proved to be most reliable for estimation of effectiveness of irradiation, but the labeling index was not a valuable indicator for it.

The estimation of the ventricular function by means of peak aortic flow velocity-diastolic aortic pressure relationship

Responses of the left ventricle to changes in afterload were tested in 11 open-chest dogs of which left atrial pressure was controlled arbitrarily. Maximal left ventricular dP/dt remained unchanged statistically against changes in afterload when left atrial pressure was kept constant, while it was changed with alteration of preload and by deterioration of left ventricular contractility induced by coronary ligation. Peak aortic flow velocity showed negative linear relationship against diastolic aortic pressure when left atrial pressure and left ventricular contractility were constant. This linear relation shifted downwards not only by reduction of contractility but also by lowering preload. Stroke volume also showed similar relationship, but abrupt decrease in stroke volume in higher range of aortic pressure. Effects of extracardiac factors on stroke volume which was ejected by constant ventricular contractility were considered to be complex. Peak aoratic flow velocity at 50 mmHg of aortic distolic pressure under the constant state of preload could be one of the indexes of ventricular function.

Cell kinetic study of human cancers transplanted to nude mice

Using 3H-TdR pulse labelling, the cell kinetics of four, serially transplantable, human tumors were studied in athymic nude mice. Squamous cell carcinoma of the lung, tongue and esophagus showed relatively similar cell kinetic parameters. The growth of an oat-cell carcinoma was initially very slow in mice and its growth fraction was unexpectedly small with a relatively low labelling index. Its postmitotic phase was very short. It was concluded that the nude mice/human tumor system may be useful for cell kinetic studies of human tumors from the standpoint of tumor biology and therapy.