Can brexpiprazole be switched safely in patients with schizophrenia and dopamine supersensitivity psychosis? A retrospective analysis in a real-world clinical practice

BACKGROUND

Several studies have reported that a switch to the dopamine partial agonist (DPA) aripiprazole (ARP), especially when the switch is abrupt, is likely to fail and sometimes worsen psychosis in schizophrenia patients already under high-dose antipsychotic treatment. Such a switching failure is speculated to be related to be the dopamine supersensitivity state. The risks of switching to the DPA brexpiprazole (BREX) have not been reported.

AIMS AND METHODS

We retrospectively analyzed the cases of 106 patients with schizophrenia to identify any factors related to the success or failure of switching to BREX.

RESULTS

The comparison between the patients with dopamine supersensitivity psychosis (n = 44) and those without (n = 62) revealed no significant difference in the switching failure judged at the sixth week. A comparison of the patients with successful switching (n = 80) and those who failed (n = 26) revealed that patients with treatment-resistant schizophrenia (TRS) were significantly more likely to fail. A logistic regression analysis also revealed that patients with past failure of switching to ARP are likely to succeed in switching to BREX. The 2-year follow-up of the patients with successful switching to BREX suggested that the patients who were treated with BREX, even temporarily, experienced some improvement in their Global Assessment of Functioning and Clinical Global Impression-Severity scores.

CONCLUSIONS

Overall, the results indicate that patients with schizophrenia can be switched more safely to BREX compared to ARP. However, the failure of switching to BREX could be higher in patients with TRS, and thus, starting BREX treatment in refractory patients warrants careful monitoring.

Successful rechallenge with paliperidone after clozapine treatment for a patient with dopamine supersensitivity psychosis

We describe the case of a 49-year-old Japanese male patient successfully treated with a paliperidone rechallenge following 2-year treatment with clozapine for treatment-resistant schizophrenia. He had responded well to conventional antipsychotic treatment for the initial psychotic episode but gradually developed dopamine supersensitivity; even treatment with paliperidone and another antipsychotic medication (a total up to 1700 mg in chlorpromazine-equivalent dose) had not improved his psychotic symptoms. Clozapine treatment produced temporary symptomatic relief, but the clozapine dose could not be increased to > 150 mg due to the patient’s intolerance. Following low-dose clozapine treatment for 2 years, a rechallenge with paliperidone monotherapy ameliorated his psychotic symptoms. This suggests that clozapine may have the potential to release the dopamine supersensitivity state. Our patient’s case indicates that for patients with dopamine supersensitivity psychosis, a rechallenge with a previously ineffective antipsychotic after clozapine treatment may be successful.

The TriAGe+ Score for Vertigo or Dizziness: A Diagnostic Model for Stroke in the Emergency Department

BACKGROUND

Vertigo or dizziness is a common occurrence, but it remains a challenging symptom when encountered in the emergency department (ED). A diagnostic score for stroke with high accuracy is therefore required.

METHODS

A single-center observational study (498 patients) was conducted. The predictor variables were derived from a multivariate logistic regression analysis with Akaike information criterion. The outcome was the occurrence of stroke. We evaluated the utility of a new diagnostic score (TriAGe+) and compared it with the ABCD2 score.

RESULTS

The cohorts included 498 patients (147 with stroke [29.4%]). Eight variables were included: triggers, atrial fibrillation, male gender, blood pressure ≥140/90 mm Hg, brainstem or cerebellar dysfunction, focal weakness or speech impairment, dizziness, and no history of vertigo or dizziness or labyrinth or vestibular disease. We derived the TriAGe+ score from these variables. In the cohort, the prevalence of stroke increased significantly using the diagnostic score: 5.9% for a score of 0-4; 9.1% for 5-7; 24.7% for 8-9; and 57.3% for 10-17. At a cutoff value of 10 points, the sensitivity of the score was 77.5%, the specificity was 72.1%, and the positive likelihood ratio was 3.2. When the cutoff was defined as 5 points, the score obtained a high sensitivity (96.6%) with a good negative likelihood ratio (.15). The new score outperformed the ABCD2 score for the occurrence of stroke (C statistic, .818 versus .726; P < .001).

CONCLUSIONS

The TriAGe+ score can identify the occurrence of stroke in patients with vertigo or dizziness presenting to the ED.

Milnacipran treatment and potential biomarkers in depressed patients following an initial SSRI treatment failure: a prospective, open-label, 24-week study

BACKGROUND

We assessed the effect of switching patients with major depressive disorder to milnacipran following an initial selective serotonin reuptake inhibitor treatment failure, and explored potential biomarkers in their blood.

METHODS

We conducted a prospective, open-label, 24-week trial. Depression was assessed with the 17-item Hamilton Depression Rating Scale. Patients showing a ≥50% reduction in Hamilton Depression Rating Scale scores from baseline to final visit were considered responders. Regarding adverse effects (AEs), moderate-to-severe AEs were specifically identified as effects that required any medical treatment or that induced treatment withdrawals. We also measured blood levels of various molecules including inflammatory cytokines.

RESULTS

Of the 30 participants who enrolled, 17 completed this study. The responder rate was 30% (n=10). Baseline serum levels of interleukin-6 (Z=-2.155; P=0.031) and interleukin-8 (Z=-2.616; P=0.009) were significantly higher when moderate-to-severe AEs were present (n=13 patients with moderate-to-severe AEs). Serum levels of macrophage inflammatory protein-1β showed a significant continuous decrease from the baseline level (Friedman's test: χ (2)=23.9, df=4, P<0.001) only in non-responders.

CONCLUSION

These results demonstrate that serum levels of interleukin-6, interleukin-8, and macrophage inflammatory protein-1β as potential blood biomarkers could be utilized to identify the responsiveness of patients to serotonin and norepinephrine reuptake inhibitor like milnacipran, or to identify those patients who may experience AEs strong enough to warrant discontinuation of treatment.

Clinical benefits and tolerability of increased fill volumes in Japanese peritoneal dialysis patients

BACKGROUND

Increasing fill volume is an effective means of improving clearances in patients on peritoneal dialysis (PD). Since Japanese PD patients are physically smaller than their Western counterparts, there is some concern that PD patients in Japan may be unable to tolerate larger fill volumes.

OBJECTIVE

To determine patient tolerance and changes in solute clearance and net ultrafiltration resulting from increased fill volumes in Japanese patients on PD.

DESIGN

Prospective double-blind study, randomizing patients to three different fill volumes (2.5% dextrose solution: 1.5 L, 2.0 L, or 2.5 L) administered in random order on three different occasions separated by 1 week.

RESULTS

Twenty-one patients with a mean age of 55.4 +/- 2.1 years and a mean body surface area of 1.66 +/- 0.03 m2 were studied. On a scale of 0 to 10, patients' mean discomfort scores were 2.14 +/- 0.59, 3.48 +/- 0.54, and 3.81 +/- 0.63 (p = 0.047) at the end of the 1.5-L, 2.0-L, and 2.5-L dwells, respectively. There were no reports of cramps or shortness of breath with any fill volume. Patients were able to correctly guess the actual fill volume for only 34 of the 63 total exchanges (54.0%). Increasing fill volume resulted in an incremental improvement in peritoneal creatinine clearance, from 3.74 +/- 0.16 to 4.49 +/- 0.21 (p < 0.001, 2.0 L vs 1.5 L) to 5.12 +/- 0.20 mL/minute (p< 0.001, 2.5 L vs 2.0 L) for 1.5-L, 2.0-L, and 2.5-L dwells, respectively. Peritoneal urea clearance also increased significantly, from 5.65 +/- 0.13 to 7.04 +/- 0.17 (p < 0.001, 2.0 L vs 1.5 L) and 8.16 +/- 0.29 mL/minute (p < 0.001, 2.5 L vs 2.0 L), with incremental increases in fill volume. Similarly, net ultrafiltration in a 4-hour dwell increased significantly with fill volume, from 255.24 +/- 24 mL with 1.5 L, to 356 +/- 24 (p < 0.004, 2.0 L vs 1.5 L) and 392 +/- 29 mL (p < 0.086, 2.5 L vs 2.0 L) in patients receiving 2.0 L and 2.5 L, respectively.

CONCLUSION

Increasing the fill volume results in improvement in solute clearance and net ultrafiltration in Japanese PD patients, with minimal increase in patient discomfort. A large percentage of patients were unable to identify the actual fill volume.

[The effectiveness of thin-section computed tomography in diagnosing bullous lesions in patients with spontaneous pneumothorax]

We investigated the effectiveness of thin-section computed tomography (CT) for the diagnosis of bullous lesions in patients with spontaneous pneumothorax. The study group consisted of 74 patients. Apical regions of the lung were scanned for lesions by thin-section CT prior to operation. The presence, number, and locations of bullous lesions were assessed. Bullous lesions were also classified into 2 groups according to their shape as demonstrated by CT findings. Operative findings confirmed that 73 of the 74 patients had bullous lesions. Of these, 33 had a single bulla and 40 had multiple bulla. Thin-section CT accurately detected the presence and location of the bullous lesions, accurately identified the number in all but 6 patients with multiple bulla (accuracy: 91.8%), and also classified them accurately by type. Precise evaluations of bullous lesions are crucial to the treatment of patients with spontaneous pneumothorax. The presence of bullous lesions, as well as their location and shape, are important factors in determining whether to operate or not. Such information also allows for a better understanding of the surgical options available. Our study demonstrated that thin-section CT of apical regions of the lung is an effective diagnostic procedure for patients with spontaneous pneumothorax.

Abdominal incisional hernia occurring after an esophagectomy reconstructed with a gastric tube through an antesternal route: report of a case

A Japanese man, who had undergone a subtotal esophagectomy reconstructed with a gastric tube through an antesternal route for esophageal carcinoma 16 years previously, was admitted to our hospital because of an abdominal incisional hernia. The abdominal incisional hernia was in his upper abdomen and was difficult to push back into the intraabdominal cavity by hand. The hernia was successfully repaired by operation. We thus conclude that an abdominal incisional hernia is a rare but important late-phase complication occurring after an esophagectomy reconstructed with either an antesternal or retrosternal route, and an operation should be the treatment of choice.

[A case of marginal zone B-cell lymphoma]

A 60-year-old woman had an abnormal shadow in the right lower lung field on chest roentgenogram. Transbronchial lung biopsy revealed findings consistent with malignant lymphoma, and a right middle lobectomy was performed. Pathological findings showed that tumor cells had infiltrated the epithelium, forming so-called lymphoepithelial lesions. Flow cytometric analysis of the resected specimen revealed that B-cell associated antigens (CD 19, 20) were expressed, and that the tumor cells were CD 5-, CD 10-. A marked increase in the number of lymphocytes with an IgM kappa component suggested monoclonal origin for the tumor cells in the resected specimen. Southern blot analysis showed clonal rearrangement of the heavy chain of the immunoglobulin gene. A diagnosis of malignant lymphoma of bronchus-associated lymphoid tissue was made. This tumor was defined according to the revised European. American classification of lymphoid neoplasms as a marginal zone B-cell lymphoma.

Differences in thermal salivation between the FOK rat (a model of genotypic heat adaptation) and three other rat strains

Rats secrete saliva in response to heat. In the present study, details of thermal salivation were investigated using the FOK rat in comparison with Sprague-Dawley (SD), Donryu, and ACI rats. The FOK rat is a strain inbred for genotypic heat adaptation and endures heat for long periods. Conscious rats of all four strains were exposed to 42.5 degrees C. The order of heat endurance times at this temperature was FOK >> SD > Donryu = ACI. FOK rats spread their saliva over their entire ventral surface, their faces, and their outside legs. This saliva area was wider than those made by the other three strains. SD rats spread in an area wider than those of the Donryu and ACI rats. Saliva spreading in the FOK rats continued for 4.0-4.5 h, far longer than in the other strains. Under ketamine anesthesia and exposure to 40 degrees C, the FOK rats secreted saliva at 1390+/-235 microL/100 g of body weight during a 60-min observation period. This was the highest rate among the four rat strains (p < 0.0001). The body temperature increase rate in anesthetized FOK and SD rats was lower than in the other two strains, suggesting a minor contribution of unknown factors. Ligation of the submandibular gland ducts abolished the thermal salivation of the FOK rats, whereas ligation of the parotid duct had no effect. The submandibular, sublingual, and lachrymal glands in the FOK rats were 1.3-1.5, 1.25-1.4, and 1.3-1.5 times heavier, respectively, than those in the other three strains, whereas the parotid gland of the FOK rats was not enlarged. These findings indicate that the rats' saliva spreading and ET values are significantly correlated. A potentiated and long-lasting salivation from the submandibular gland was acquired during development of genotypic heat adaptation. This salivation is actuated in response to heat. The pronounced thermal salivation is probably attributable to adaptive changes in the superior salivatory nucleus-chorda tympani-submandibular gland pathway.

Endoscopic submucosal tumorectomy for gastrointestinal submucosal tumors restricted to the submucosa: a new form of endoscopic minimal surgery

BACKGROUND

Endoscopic minimally invasive therapy for submucosal tumors of the gastrointestinal tract by use of endoscopic ultrasound has not yet come into widespread use, and this technique has not been fully evaluated. We therefore investigated this method of treatment in patients with gastrointestinal submucosal tumors.

METHODS

Forty-five patients with suspected gastrointestinal submucosal tumors (esophagus [5], stomach [1], duodenum [16], colon [23]) based on barium enema studies and endoscopy underwent endoscopic ultrasound by the water-filled or balloon method. The layer of origin and the internal echogenicity of the lesions were evaluated. After confirming that the tumors were submucosal, the lesions were resected using injection of physiological saline solution and electrocautery.

RESULTS

Using a one-channel or two channel method, all tumors were completely resected without serious complications and the diagnosis was histologically confirmed. Ulceration at the site of resection healed within 2 to 4 weeks (mean 23 days) and there has been no local recurrence.

CONCLUSIONS

Our technique of endoscopic submucosal tumorectomy appears to be a safe and useful diagnostic-cum-therapeutic procedure for gastrointestinal submucosal tumors.

Multicenter evaluation of a colorimetric microplate antimycobacterial susceptibility test: comparative study with the NCCLS M24-P

A colorimetric test method using the microplate culture technique for the determination of susceptibility of Mycobacterium tuberculosis against antimycobacterial agents was developed and evaluated by the multicenter study. The test method utilizes an oxidation-reduction dye, 2,3-diphenyl-5-thienyl-(2)-tetrazolium chloride (STC), as an indicator of mycobacterial growth. When compared to the presently available test method, some modifications were also included; lower inoculum density (10-fold dilution), inclusion of an inoculum diluted 1:100 as a growth control, and the preparation of inoculum preincubated in Middlebrook 7H9 broth and spectrophotometrically adjusted to McFarland #1 turbidity. The test method evaluated was highly precise and reliable to detect antimycobacterial resistances when the ATCC reference strains were tested. Also, the interpretations of the test result were highly comparable to those determined by the method of NCCLS M24-P, the % agreements ranging from 76.1% (ethambutol) to 91.3% (streptomycin). The test results were also comparable to those determined by Ogawa media; > 90% agreed with susceptible, intermediate, or resistant. The appearance of mycobacterial colonies on the test media was easily read, and the test results were more comparable to those of NCCLS M24-P. With these results, it can be concluded that the colorimetric microplate susceptibility test method described will be more suitable for clinical mycobacteriology laboratories.

Correlation between tumor volume doubling time and histologic findings in gastric smooth muscle tumors: clinical implications of tumor volume doubling time

To assess the clinical implications of the tumor volume doubling time of gastric smooth muscle tumors based on a comparison with the histologic findings, seven tumors (four leiomyomas and three leiomyosarcomas) were followed up by consecutive upper gastrointestinal studies between March 1985 and December 1993. The patients were four men and three women with an average age of 58 years (range: 50-71 years). The observation period ranged from 6 to 51 months, with an average of 35 months. All tumors were surgically resected and the histologic diagnosis was confirmed. The following microscopic features were evaluated: 1) mitotic rate, 2) nuclear atypia, and 3) cellularity. Each tumor was also evaluated for the presence or absence of necrosis, hemorrhage, and degeneration. The doubling time ranged from 5 to 27 months with a mean of 16 months. There was a strong negative correlation between the mitotic rate and the doubling time (r = -0.935, P = 0.0019). The doubling time was also significantly related to nuclear atypia, but the number of tumors studied was so small that its reliability was questionable. The doubling time was not related to any other histologic findings. This study shows that the doubling time is useful for estimating the malignant potential of gastric smooth muscle tumors, and that tumors with a doubling time of 16 months or less should be considered as malignant.

Gastric syphilis: case report and review of the literature

A 35-year-old Japanese woman consulted our clinic with a one-month history of epigastric pain. Although a superficial depressed type of early gastric carcinoma was highly suspected from the results of upper gastrointestinal barium studies and gastroscopy, there was no evidence of malignancy in the biopsy specimen. Gastric syphilis was then considered based on skin lesions and serological studies. Diagnostic antisyphilitic therapy improved the symptoms and gastric lesion promptly. A review of the recent reports indicated that most cases of early phase gastric syphilis seem to present morphologically either as a narrowing lesion or shallow ulcero-nodular lesion at the pyloric antrum. Therefore, whenever such findings are recognized either radiologically or gastroscopically and no malignant cells are found in biopsy specimens, gastric syphilis and diagnostic antisyphilitic therapy should be considered.

Blind loop syndrome: multiple ileal ulcers following side-to-side anastomosis

A 59 yr old woman who had multiple ileal ulcers following side-to-side anastomosis without bowel resection is reported. She had a surgical history of adhesive ileus 15 yrs earlier, and was admitted with a complaint of lower abdominal pain. A barium meal study showed a stagnant and dilated distal ileum. At laparotomy, a previously performed side-to-side ileal anastomosis was encountered, and a markedly dilated bypassed loop was recognized. The affected intestine was resected revealing multiple longitudinal ulcers and small shallow ulcers mostly located on the mesenteric side. This feature is similar to that of ischemic enteritis. This case further supports the fact that when side-to-side anastomosis is performed as a bypass operation, multiple ulcers may develop in a bypassed loop after a long period of time.

Immunosuppressive mechanism of 15-deoxyspergualin on sinusoidal lining cells in swine liver transplantation: suppression of MHC class II antigens and interleukin-1 production

To elucidate the precise mechanism of action of 15-deoxyspergualin (DSG) in swine liver transplantation, the expression of MHC class II antigens (Ia) on hepatic sinusoidal lining cells (SLC) and their production of interleukin-1 (IL-1) were examined. In our previous study, we isolated sinusoidal endothelial cells (SEC) and Kupffer cells (KC) by enzymatic digestion and centrifugal elutriation, and demonstrated that both SEC and KC present alloantigens effectively and generated IL-1 in response to allogenic or lipopolysaccharide stimulation. Animals were divided into three groups: group 1, nontransplanted normal controls (n = 3); group 2, no immunosuppressive treatment following liver transplantation (n = 5); group 3, DSG (0.8 mg/kg/day) intravenously for 7 days following liver transplantation (n = 5). At 1 week after transplantation, the three liver grafts in groups 2 and 3 were processed for the study of Ia expression and IL-1 production on SEC and KC. The expression of Ia was detected in 21.5 +/- 4.7% of SEC and 24.3 +/- 11.1% of KC in group 1. In group 3, Ia expression was suppressed compared with group 2, being 3.6 +/- 2.8% versus 22.0 +/- 2.8% for SEC (P less than 0.02) and 15.5 +/- 11.3% versus 24.3 +/- 7.1% for KC. IL-1 production by SEC and KC was respectively 11,483 +/- 3311 cpm and 9077 +/- 2161 cpm in group 1. In group 3, IL-1 production was inhibited compared with that in group 2, being 7190 +/- 883 cpm versus 19,297 +/- 5182 cpm for SEC (P less than 0.05) and 16,130 +/- 3769 cpm versus 25,857 +/- 3963 cpm for KC.(ABSTRACT TRUNCATED AT 250 WORDS)

Induction of antiidiotypic antibodies by donor-specific blood transfusions. Establishment of a human-mouse hybridoma secreting the MLR-inhibiting factor

We describe a patient transfused with 200 ml of donor fresh whole blood three times at 2-week intervals. Three weeks after the last transfusion, transplantation and splenectomy were done at the same time. Splenic cells from this DST pretreated patient were fused with murine myeloma cells (X63-Ag8, 653). With DST pretreatment, various clones were developed in vivo, and finally 69 human immunoglobulin-secreting clones were obtained. Modulation of the alloantigen-specific MLR by supernatants from 69 clones showed various degrees of suppression or augmentation. The hybridoma clone 7 and clone 2, which had been secreting IgG antibody for more than 6 months, showed some degree of suppression in the alloantigen-specific MLR (mean suppression = 63%, 46% respectively). According to the result of MLR, clone 7 antibody was directed against recipient lymphocytes and clone 2 antibody was against donor lymphocytes. Immunoprecipitation was carried out by clone 7-IgG and clone 2-IgG. Clone 7-IgG specifically precipitated 1 molecule from the recipient lymphocyte with a molecular weight of 120 KD, similar to the molecular weight range reported for T cell receptors. Clone 2-IgG precipitated a 20 KD molecule from the donor lymphocyte. The data suggest that DST induces antibodies directed against the blood donor alloantigen-specific receptors on the recipient's T lymphocytes--and, at the same time, induces antibodies against donor lymphocyte antigens. These antibodies may be essential to prolongation of kidney allograft survival following DST.

[In vivo antitumor effect of LAK cells induced from various lymphocytes--experimental study in rats]

A MRMT-1 was inoculated in the thigh of SD rats. On day 7, regional lymph node lymphocytes (TB-LN), thymus cells (TB-TC) and spleen cells (TB-SC) or non-tumor bearing spleen cells (NB-SC), were obtained. LAK were induced with lug/ml of R-IL2 (TGP-3) using above lymphocytes, and were examined as for their in vivo and in vitro cytotoxic activities. In vitro: Against MRMT-1, cytotoxic activity of LAK increased with lapse of culturing time. Thus on day 4 of culture, it was the highest (46.5%) in TB-SC-LAK, while that of TB-LN-LAK was the lowest (5.8%). Against YAC-1, they also increased except TB-LN-LAK. In vivo: When the mixture of MRMT-1 and LAK was sc inoculation, diameter of the tumor were the smallest in TB-LN-LAK and the largest in TB-SC-LAK. When it was injected intraperitoneally, in non-irradiated rats, the survival prolongation was the best in TB-LN-LAK and the worst in TB-SC-LAK. In pre-irradiated rats; the cytotoxicity was almost the same as the results of in vitro. When it was injected intravenously, number of lung metastatic nodes were the smallest in TB-LN-LAK and the largest in TB-SC-LAK. R-IL2 substitution therapy was also effective. In conclusion, the effectiveness of LAK-AIT was estimated more accurately by in vivo cytotoxic assay. TB-LN was most useful as a source of LAK cells.

[Application of transbronchial brushing for histological diagnosis of lung cancer]

In order to improve the preoperative diagnostic rate of lung cancer, histological examination was performed by transbronchial brushing in 35 cases, and diagnostic contribution of brushing specimen was compared with that of transbronchial forceps biopsy (TBFB). Histological structures were well preserved in the histology section of brushing specimens, especially in cases of small cell lung cancer. The positive rate of brushing histology was 46%, which was the same as that of TBFB. The total histological diagnostic rate was 66% with simultaneous examination of bronchial brushing and TBFB specimens. Consequently, the use of brushing specimens for histologic evaluation made an additional contribution to the correct positive histology diagnostic rate. Brushing histology is indicated for all types of lung cancer, because in most TBFB-negative cases, biopsies were performed from inappropriate sites of tumors or their materials wer crushed by forceps. It was suggested that concomitant application of brushing specimen for histology examination, contributed to more accurate preoperative histology diagnosis for lung cancer.

[Clinical evaluation of tumor markers in breast cancer patients]

During the past 4 years, the performances of various tumor markers such as CA15-3, CEA, ferritin, beta 2-microglobulin and TPA have been evaluated in 78 cases of mammary cancer. The results were categorised according to differences in stages, difference in values from patients with recurrent tumors, the incidence of abnormal values and differences in values before and after surgery. When the incidence of values higher than the cutoff value was determined for each of stage I, II and III + IV, the rates for CEA were 14.3%, 4.9% and 27.8%, respectively, whereas those for TPA were 25.0%, 22.2% and 26.7%, respectively. In addition, for CA15-3, the incidences were 0% in stage I, 5.0% in stage II and 57.1% for combined stages III + IV. The average values for patients with recurrent tumors were 3.2 ng/ml CEA, 194.5 ng/ml ferritin, 316.2 U/l TPA and 81.3 U/ml CA15-3. The rates of abnormal values were 40.0% for CEA, 40.0% for ferritin, 85.7% for TPA and 63.6% for CA15-3. Differences in the values after surgical removal of the tumor were observed with these tumor markers: the CEA value was reduced from 1.6 +/- 1.4 to 1.1 +/- 0.5 (p less than 0.01) and the CA15-3 value from 12.2 +/- 8.4 to 9.3 +/- 4.1 (p less than 0.05), respectively, whereas that for ferritin was conversely increased from 48.9 +/- 48.0 to 74.0 +/- 70.0 (p less than 0.01). However, the values for TPA, despite showing a tendency to decrease, did not show any statistically significant alteration. The fluctuations of these marker levels in patients with recurrent tumors reflects the progress of the disease, with a sudden elevation in values indicating imminent death. The diagnostic significance of these markers is not high, but they are considered to be useful in detecting the progress or condition of a recurrent tumor.

Diagnostics of small gastric carcinoma

We studied the diagnostic features of 32 early gastric carcinomas less than or equal to 1 cm in maximum diameter, which were detected in 28 patients. A correct preoperative qualitative diagnosis was made in 19% of the lesions by means of barium studies, in 72% by endoscopy, and in 90% by endoscopic biopsy. Endoscopy and endoscopic biopsies are the most useful diagnostics for detection of these small cancers. Since most carcinomas with a diameter between 6 and 10 mm have a mucosal unevenness such as a shallow depression with an irregular perimeter and are associated with or without elevated marginal mucosa on gross inspection, it was not very difficult to detect these carcinomas with careful endoscopic observations. When endoscopists procure such evidence, biopsies should be done for confirmation. Even in ulcers that appear benign, biopsies are recommended. With regard to carcinomas of less than or equal to 5 mm in diameter, it is difficult to detect the lesions, particularly the flat-type, which make up a relatively large percentage of those minute carcinomas.

[5-FU concentration in blood and tissue of patients with primary lung cancer after oral administration of UFT]

Concentration of FT-207, 5-FU and Uracil in blood and normal lung tissue were estimated for lung cancer patients to whom UFT was orally administered. The histological types of these cases were as follows: 10 squamous cell carcinomas, 10 adenocarcinomas, 2 large cell carcinomas and 1 small cell carcinoma. Average concentration of 5-FU in these tumor tissues was 0.101 +/- 0.107 microgram/g. This was a significantly higher 5-FU concentration in comparison to those in serum and normal lung tissue. Comparison of 5-FU concentration between squamous cell carcinomas and adenocarcinomas showed no significant difference. Between metastasis-positive lymph nodes and metastasis-negative lymph nodes, there was also no significant difference in 5-FU concentration, but there was a significant difference in Uracil concentration. This result showed an effective transition of 5-FU from serum to tumor tissues with oral administration of UFT. It was therefore concluded that UFT would be expected to have an antitumor effect in primary lung cancer patients.

[Primary carcinoma of the vermiform appendix]

A 54-year-old Japanese woman with primary adenocarcinoma of the appendix was treated. The diagnosis was established before surgery by means of barium studies and ultrasound examination. Histologically, the tumor was a mucinous cystadenocarcinoma. The patient was treated by ileocecal resection, and a 10-month follow-up has revealed neither evidence of recurrence nor of metastases. The preoperative investigations, pathologic features and surgical management in this case are briefly discussed.

Experimental study on postlaminectomy deterioration of cervical spondylotic myelopathy. Influences of intradural surgery and persistent spinal block

This experiment studied the postoperative changes around the dural tube at the site of cervical laminectomy, which are influenced by intradural operative procedures and the flow of cerebrospinal fluid. Forty dogs were divided into four groups in accordance with the type of decompressive procedure done, and three types of dural surgery were added: none (laminectomy alone), dura resection, or arachnoid resection. While the scar tissue did not adhere to the spinal cord after arachnoid resection in normal dogs, adhesion of scar to spinal cord was seen to a small extent after arachnoid resection with sufficient posterior decompression in dogs whose spinal cord was compressed anteriorly by a screw through the vertebral body. In the cases with insufficient posterior decompression adherence was observed much more extensively.

[Percutaneous fine needle biopsy for malignant mediastinal tumors]

Seventeen patients with mediastinal malignant tumors (four neurogenic tumors, four thymomas, three germ cell tumors, two malignant lymphomas and one each of carcinoid, malignant melanoma, multiple myeloma and carcinoma simplex) were examined for the evaluation of percutaneous fine needle biopsy. In 16 cases of them, adequate materials for cytodiagnosis were obtained. Fifteen of the 17 cases (88%) were positive for malignant cells, and 1 case was negative. As for the histological types, 9 cytological diagnoses (60%) were compatible and 4 diagnoses (27%) were not. Regarding complications of percutaneous fine needle biopsy, 1 case of subcutaneous needle tract implantation was noted. Percutaneous fine needle biopsy is strongly recommended for diagnosis of mediastinal tumors.

Simultaneous early carcinomas of the ampulla of Vater and the stomach. Report of a case involving chronic inactive hepatitis

Early carcinoma occurred simultaneously in both the stomach and the ampulla of Vater of a 69-year-old Japanese woman. A tentative diagnosis of early carcinoma of the stomach and acute hepatitis was made and needle biopsy of the liver revealed chronic inactive hepatitis. A carcinoma in the ampulla of Vater was detected by duodenoscopy. Cholangiography did not reveal the biliary tract. Pancreatoduodenectomy was performed and histological study of the resected specimen showed an early carcinoma restricted to the mucosa and an early carcinoma of the ampulla of Vater invading the sphincter of Oddi. There was no apparent metastasis or invasion of surrounding tissues.

[Experimental study on the post-laminectomy deterioration in cervical spondylotic myelopathy--influences of the meningeal treatment and persistent spinal cord block]

Free, rhythmical movement of cerebrospinal fluid (CSF) is regarded as the inhibitory factor of subarachnoidal adhesion. When the block of CSF flow remains after the laminectomy for cervical spondylotic myelopathy, danger of postoperative subarachnoidal adhesion and ensuing deterioration of operative results is present. Such risk may increase when the meningeal treatment is combined with the laminectomy. The experimental study was practiced on dogs to confirm the surmise mentioned above. First, the gradual anterior cord compression was made at the C4 and C6 levels to produce multiple block of CSF flow. Then, 3 types of posterior surgical decompression, i.e. simple laminectomy, dura mater resection, and arachnoid resection were performed at the C6 level. The fourth type of posterior decompression was also performed, that is, the arachnoid resection at the C6 level accompanied with simple laminectomy up to the level of C4 in order to know the influence of the improvement of CSF passage. Dogs were classified into 4 groups according to the type of the posterior surgery and sacrificed after a certain period to examine the changes around the spinal cord mainly at the C6 level. The results and conclusions are as follows. In the presence of anterior spinal cord compression and CSF flow disturbance, the cord was compressed again by the laminectomy membrane when the dura mater was resected and not compressed when it was preserved. And when the arachnoid was also resected, the scar tissue adhered to the dorsal aspect of the cord and tightly compressed it. The improved CSF passage diminished the extent of subarachnoidal adhesion and the degree of cord compression. From these results, it may be concluded that the laminectomy for the cervical myelopathy should be done sufficiently so as to improve the CSF passage, and at the same time, the meningeal treatment should be avoided as long as possible.

Epilepsy in the adolescence

The impact of recurrent seizures during childhood has a different influence upon the brain condition and mental activity of young epileptics at certain ages. Epilepsy has specific clinical features and characteristic EEG abnormalities, which occur at the developmental stage. Adolescence causes more extra burden to epileptic patients, particularly in the development of mental and/or emotional levels. In this paper, the authors report on two types of age-related phenomena--one benign in nature, and the other malignant. That is, RD (= rolandic discharge) is shown as a benign EEG feature with which sylvian seizure of Lombroso is associated. As a malignant example, psychopathic personality which appeared after the disappearance of epileptic fits, around puberty, was described. We epileptologists are convinced that children with epilepsy, particularly in puberty, have a considerable psychiatric or psychological problem, and must be treated with effective medicines, including medical service and social care.

Epilepsy above 70 years of age--four cases with spike and wave complex

The authors have reported clinical features, EEG and CT findings of four cases with senile genuine epilepsy, with late onset after 50 years of age. One of these was similar to the case of petit mal status episodes with myoclonous in a woman of 77 years, which Terzano et al. reported in 1978. Three of our cases were non-focal major epilepsy. We confirmed the existence of primarily generalized epilepsy, occurring late in life. At present, with only a few reports of senile epilepsy with spike and wave complex being available, we should make further efforts to obtain well-defined features of senile genuine epilepsy.

Surgical treatment of fungating lesion of foot due to Moraxella phenylpyruvica. Case report

We present a case report of a man who had an abscess-like lesion on his left foot. The lesion discharged pus, enlarged, and became thicker, so that we could not differentiate the real toes from the out-growths. Moraxella phenylpyruvica and Pseudomonas putrefaciens were identified; direct agglutination tests were postive M. phyenylpyruvica. He was given antibiotics and antituberculosis therapy and had topical treatments. The foul odor disappeared with treatment, and the lesions were removed surgically 3 months later. The M. phenylpyruvica finally disappeared after the surgery. The final condition of this patient was markedly improved, although he had some residual scar contracture.