Neuropathological analysis in spinal muscular atrophy type II

We performed a neuropathological analysis, including in situ nick end labeling (ISEL) and immunohistochemistry, of two cases of clinicogenetically confirmed infantile spinal muscular atrophy (SMA) type II. Both cases showed severe reduction of the motor neurons and gliosis in the spinal cord and brain stem, although the occurrences of central chromatolysis and ballooned neurons were not frequent. Clark's and lateral thalamic nuclei, which are usually altered in SMA type I, were spared, whereas Betz cells in the precentral gyrus and large myelinated fibers in the lateral funiculus were reduced in number. Regarding apoptosis, only the younger case demonstrated a few ISEL-positive nuclei in the dorsal horn, with reduced Bcl-x expression level in the Purkinje cells. Unlike SMA type I, the expression of neurofilaments was not disturbed and the reduction in synaptophysin expression level in the anterior horn was mild. An oxidative stress-related product was deposited in atrophic motor neurons in the spinal cord, and neurons with nuclei immunoreactive for 8-hydroxy-2'-deoxyguanosine were found in the lateral thalamus. In contrast, the expression of glial glutamate transporters was not altered. These data suggest that oxidative stress and, to a lesser extent, apoptotic cell death, but not disturbed neurofilament metabolism or excitotoxicity, may be involved in neurodegeneration in SMA type II.

The gene copy ratios of SMN1/SMN2 in Japanese carriers with type I spinal muscular atrophy

Spinal muscular atrophy is an autosomal recessive neurodegenerative disorder with progressive weakness and atrophy of voluntary muscles. The survival motor neuron gene (SMN) is present in two highly homologous copies (SMN1 and SMN2) on chromosome 5q13. Homozygous deletion of exons 7 and 8 of SMN1 is responsible for spinal muscular atrophy. In spinal muscular atrophy patients, SMN2 partially compensates for the lack of SMN1. Previously, we reported the relatively high incidence of a large deletion including the SMN1 region in Japanese spinal muscular atrophy type I patients. In order to further establish the genetic background of Japanese spinal muscular atrophy type I patients, we investigated the SMN1/SMN2 ratio in the carriers. In normal individuals, there is one copy of each gene on the chromosome (the SMN1/SMN2 ratio was 1). Among 15 carriers (14 parents and one carrier sibling of Japanese type I spinal muscular atrophy patients with homozygous deletion of exons 7 and 8 of SMN1), we found that the SMN1/SMN2 ratio was 0.5 or 1 in 11 (73.3%) carriers. The remaining four carriers had an SMN1/SMN2 ratio of 1/3. This finding supports the idea that deletion rather than conversion is the main genetic event in type I spinal muscular atrophy. In addition, the ratio of SMN1/SMN2 among Japanese carriers, which was thought to be higher than that of the Western population, was compatible with the results obtained in Western populations. For further insight into the characteristic genetic background of spinal muscular atrophy in Japanese, determination of the gene copy number is essential.

Enhanced expression of a-series gangliosides in fibroblasts of patients with peroxisome biogenesis disorders

Peroxisome biogenesis disorders (PBD) are classified into Zellweger syndrome (ZS), infantile Refsum disease (IRD) and neonatal adrenoleukodystrophy. Disturbances in the differentiation of neural cells such as migration arrest are characteristic of PBD. So far the pathogenesis of these disturbances is not clearly understood. We describe an altered metabolism of glycosphingolipids in PBD which has not yet been investigated. We observed an increased amount of a-series gangliosides, GM2, GM1 and GD1a, in the fibroblasts of patients with ZS and IRD. Gangliosides GM1 and GD1a were not present in detectable amounts in normal subjects. A key step in the synthesis of a-series gangliosides is a transfer of GalNAc to ganglioside GM3, so we determined the level of ganglioside GM3 by immunohistochemical methods. We found a granular structure, which was positive toward anti-ganglioside GM3 antibody in the cytoplasm of the patients' fibroblasts. In control cells, the cell membrane was slightly positive toward anti-GM3 antibody. These results may help to clarify the pathogenesis of PBD with respect to the functional roles of glycosphingolipids in cell differentiation, proliferation and apoptosis.

Varicella-associated acute necrotizing encephalopathy with a good prognosis

A patient with acute necrotizing encephalophathy (ANE) following varicella infection with a good prognosis is reported. A somatosensory evoked magnetic field (SEF) study using a 37-channel-magnetoencephalography system demonstrated normal latency and strength of the first component (N20m) elicited by median nerve stimulation, despite bilateral symmetrical thalamic lesions on MRI. The normal SEF findings and the good prognosis suggested a reversible breakdown of the blood-brain barrier, and an edematous process as the brain pathology. Furthermore, our results support the idea of distinct generators for the three earliest cortical SEF components (N20m, P30m, N45m).

Neuronal expression of the fukutin gene

Fukuyama-type congenital muscular dystrophy (FCMD), a relatively common autosomal recessive disorder in Japan, is characterized by severe congenital muscular dystrophy in combination with cortical dysgenesis (polymicrogyria). The gene responsible for FCMD encodes a novel protein, fukutin, which is likely to be an extracellular protein. Pathological study of brain tissue from FCMD fetuses revealed frequent breaks in the glia limitans and basement membrane complex. Disruption of the basal lamina in FCMD muscle was also seen. Thus, structural alteration of the basal lamina appears to play a key role in the pathophysiology of FCMD. To investigate the role of fukutin in brain anomalies, we examined fukutin mRNA expression in the human brain. Northern blot and RT-PCR analysis revealed that the fukutin gene is expressed at similar levels in fetal and adult brain, whereas its expression is much reduced in FCMD brains. Tissue in situ hybridization analysis revealed fukutin mRNA expression in the migrating neurons, including Cajar-Retzius cells and adult cortical neurons, as well as in hippocampal pyramidal cells and cerebellar Purkinje cells. However, we observed no expression in the glia limitans, the subpial astrocytes (which contribute to basement membrane formation) or other glial cells. In the FCMD brain, neurons in regions with no dysplasia showed fair expression, whereas transcripts were nearly undetectable in the overmigrated dysplastic region. These observations suggest that fukutin function may influence neuronal migration itself rather than formation of the basement membrane. Furthermore, differences in mRNA levels among neurons in early developmental stages may partially differentiate normal and abnormal regions.

Long-term ventilator support in patients with Werdnig-Hoffmann disease

BACKGROUND

Withholding and withdrawing life-sustaining treatment for patients with Werdnig-Hoffmann disease (WHD) have been accepted as standard medical practice in most Western countries. However, a number of Japanese pediatricians are providing ventilator care for patients with this otherwise fatal disorder. We investigated the attitude of physicians in Japan who are providing ventilator care for patients with WHD.

METHODS

A postal questionnaire was sent to 40 hospitals where pediatricians were taking care of 55 ventilator-assisted patients with WHD. Their views were sought on aspects of the care of these patients.

RESULTS

Thirty-three pediatricians from 31 hospitals responded to the questionnaire. Mechanical ventilation was initiated as an emergency measure in one-third (12/32) of the patients before obtaining full informed consent from the parents. Two-thirds (19/32) of parents asked the physicians to start ventilator care for the patients, while only three parents asked for the life-sustaining treatment to be withheld. Although 80% (24/30) of the physicians thought that the quality of life of the ventilator-dependent patients with WHD was inadequate, about half (17/30) answered that they would start ventilator assistance if they had a new patient with WHD.

DISCUSSION

Strong familial endorsement for the prolongation of a patient's life, the secure national insurance and general pro-life beliefs could have affected physicians' decisions in favor of providing life-sustaining treatments for patients with WHD.

Magnetoencephalographic study of giant somatosensory evoked responses in patients with rolandic epilepsy

We report five patients with rolandic epilepsy associated with giant somatosensory responses to median nerve stimulation, in whom we analyzed the pathophysiologic relationship between rolandic discharges and the somatosensory responses using magnetoencephalography. Four of the five patients showed giant P30m, the current source of which was localized in the primary somatosensory cortex, while the first cortical response, N20m, was not enhanced, except in one patient. The current source of the giant middle-latency component, N70m, was localized posterior to that of N20m, possibly in the posterior parietal cortex, in all patients. The initial positive peak and large negative peak of rolandic discharges were identical to P30m and N70m with respect to the current source localization, wave form, topographic pattern, and time relationship in the electroencephalogram and magnetoencephalogram, and somatosensory evoked magnetic field and somatosensory evoked potential records, respectively. In addition, the secondary sensory cortex was considered to be the generator of the middle-latency component in one patient. In one patient, the current intensity of the N70m was normalized along with clinical improvement and the disappearance of rolandic discharges, whereas those of other somatosensory evoked magnetic field components remained unchanged. Our data suggest that the rolandic discharge generator mechanism in these patients could be closely related to the developmental alteration of excitability in the primary somatosensory cortex, posterior parietal cortex, and secondary somatosensory cortex, which decreased with age, and it could share a common neuronal pathway, at least in part, with the giant P30m-N70m (N90m) in the somatosensory evoked magnetic field through the sequential and parallel processing of somatosensory information.

Zonisamide - induced urinary lithiasis in patients with intractable epilepsy

We report here three patients with intractable epilepsy who developed urinary lithiasis during zonisamide (ZNS) treatment. Abdominal pain due to left-sided hydronephrosis was the initial symptom in the first patient, and it was resolved after the excretion of a stone. The second patient, who had no specific symptoms, was found to have a thick sludge of calcium phosphate in the bladder when he suffered from aspiration pneumonia and dehydration. The third patient, who had a history of recurrent urinary obstruction, was also found to have a thick sludge of calcium oxalate in the bladder. The urinalysis of the three patients revealed alkaline urine and hypercalciuria. Although their urinary lithiasis was resolved by discontinuation of ZNS and supportive therapy, routine examination of urine parameters such as pH and sediments, and daily urine-output checks are thought to be necessary during treatment with ZNS, especially for patients who are bedridden for a long time and receive multiple antiepileptic drugs.

[Medical care and support for children with mental retardation in school]

Development of medical knowledge and technology has greatly improved our understanding of mental retardation. However, clinically applicable treatment of mental retardation is still limited. As described in the definition of mental retardation by the American Association of Mental Retardation, functional maladaptations in various aspects of everyday life are the most integral part of disabilities in mental retardation. The role of pediatric neurologist in the medical care for children with mental retardation is not limited in medical treatment. Pediatric neurologists should play an important role as a coordinators in integrated care. Providing of medical care in special schools for children with mental retardation is among the most important issues, since children spend most of their time either at home or in school. The current situation of "medical care" in school, and its problems are discussed.

Ethical attitudes of Japanese physicians regarding life-sustaining treatment for children with severe neurological disabilities

Ethical attitudes of Japanese physicians regarding life-sustaining treatment for children with severe neurological disabilities (SND) were investigated by mailing a translated questionnaire which the Child Neurology Society (CNS) of the United States used for their survey. The questionnaire was sent to 202 council members of the Japanese Society of Child Neurology (JSCN), and the answers of 147 respondents (72.8%) were analyzed. It was found that the majority (85. 0%) of respondents believed that the same level of care should be provided to children with SND as those without it. However, fewer respondents (15.6%) believed that cardiopulmonary resuscitation was indicated for children with progressive or degenerative brain disorders. With respect to the authoritative role of medical indications and family/guardian's wishes in clinical decision-making for children with SND, about 30% of respondents believed that medical indications should override family/guardian's wishes. However, almost as many respondents (29.9%) chose an ambivalent answer. If compared with the results of the preceding CNS survey, considerably more respondents gave ambivalent answers (average 26. 6%) than in the CNS survey (5.8%). About half of the respondents (49. 0%) acknowledged the need for ethical guidelines to help physicians make ethically difficult decisions. Although statistical comparison was not possible, there were considerable differences between the results of the current study and those of the CNS survey.

New ocular movement detector system as a communication tool in ventilator-assisted Werdnig-Hoffmann disease

A non-contact communication system was developed for a ventilator-assisted patient with Werdnig-Hoffmann disease who had lost all voluntary movements except for those of the eye. The system detects the extraocular movements and converts them to either a 'yes' signal (produced by one lateral eyeball movement) or a 'no' signal (produced by two successive lateral eyeball movements) using a video camera placed outside the patient's visual field. The patient is thus able to concentrate on performing a task without any intrusion from the detection system. Once the setting conditions of the device have been selected, there is no need for any resetting, as the patient is unable to move his body. In addition to playing television games, the child can use the device to select television channels, compose music, and learn written Japanese and Chinese characters. This seems to broaden the patient's daily world and promote mental development.

Control of dengue fever with active surveillance and the use of insecticidal aerosol cans

An interventional study was conducted in southern Vietnam to evaluate the feasibility and effectiveness of a new approach to control dengue fever. The approach consisted of active surveillance of dengue patients and the use of insecticidal aerosol cans. Febrile patients were tested serologically at local health centers and insecticidal aerosol cans were given to the family and employed in the neighborhood of dengue patients instead of ultra low volume (ULV) fogging with insecticide. The number of dengue IgM antibody positive cases among febrile patients, the number of reported dengue hemorrhagic fever patients and the total cost were compared in the 2 approaches (prompt focal ULV fogging and the use of insecticidal aerosol cans) in 1997. The aerosol cans were employed 5 times (in June, July, August, September and October) in the study area. ULV fogging in the control area was performed 5 times (in March, May, July, August and September). Twenty-two serologically positive cases were found in the study area which was about half that found in the control area (43 cases). A total of 16 dengue hemorrhagic fever patients was reported in the study area and 43 in the control area. Compared with the reported numbers of the previous year, the reduction rate in the number of dengue hemorrhagic fever cases was 71.4% in the study area and 51.7% in the control area. There were statistically significant differences in the morbidity of dengue fever and the reduction rate of dengue hemorrhagic fever. The cost of the insecticidal aerosol cans was US$393 which was lower than the cost of US$553 for ULV fogging. The findings suggest that insecticidal aerosol cans were effective and feasible for dengue fever control.

Hyperinsulinaemic hypoglycaemia associated with persistent hyperammonaemia

Two cases of hyperinsulinaemic hypoglycaemia associated with persistent hyperammonaemia in unrelated infants of 7 days and 4 months of age are reported. Blood ammonia levels were 100-300 micromol/l (normal values <40 micromol/l). The hyperammonaemia was asymptomatic and not associated with any of the abnormalities of amino acids or organic acids observed in urea cycle enzyme defects. Orotic aciduria was normal. The hyperammonaemia was not influenced by the levels of blood glucose nor by subtotal pancreatectomy. On admission blood glucose was ca. 1.2 mmol/l (21.6 mg/dl) corresponding to blood insulin levels of 35 and 22 mU/l respectively in both infants. Continuous intravenous glucose perfusion was necessary to prevent hypoglycaemia. Furthermore 2-oxoglutaric acid in urine was increased in the second infant to 3.15 mg/mg creatinine (normal 0.41+/-0.12). This may point to mutations in the glutamate dehydrogenase gene.

CONCLUSION

2-Oxoglutaric aciduria may be an important clue to the diagnose in this syndrome.

Accumulation of glycolipids in mutant Chinese hamster ovary cells (Z65) with defective peroxisomal assembly and comparison of the metabolic rate of glycosphingolipids between Z65 cells and wild-type CHO-K1 cells

The influence of peroxisomal dysfunction on glycosphingolipid metabolism was investigated using mutant Chinese hamster ovary (CHO) cells (Z65) with defective assembly of the peroxisomal membranes. In accordance with previous observations, the concentration of very long chain fatty acid (C24:0) was shown to be higher in Z65 cells than in control cells. We then compared the composition of glycolipids in Z65 cells with that in CHO-K1 cells, which are wild-type Chinese hamster ovary cells with intact peroxisomes, and found significantly increased concentrations of ceramide monohexoside (CMH) and ganglioside GM3 in Z65 cells. However, there were no differences in the concentrations of glycerophospholipids, triglycerides, free fatty acids and cholesterol between Z65 and CHO-K1 cells. Further, to investigate the metabolic rate of the major lipids, Z65 and CHO-K1 cells were pulse-labeled with [3-14C]serine. [3-14C]Serine was incorporated into phosphatidylserine, phosphatidylethanolamine and sphingomyelin more quickly in CHO-K1 than in Z65 cells. However, after 48 h, the radioactivity incorporated into those lipids, including CMH, was greater in Z65 cells than in CHO-K1 cells. Thus, the altered metabolism of glycosphingolipids, probably due to peroxisomal dysfunction, was thought to be responsible for the change in glycosphingolipid composition in Z65 cells.

An ancient retrotransposal insertion causes Fukuyama-type congenital muscular dystrophy

Fukuyama-type congenital muscular dystrophy (FCMD), one of the most common autosomal recessive disorders in Japan (incidence is 0.7-1.2 per 10,000 births), is characterized by congenital muscular dystrophy associated with brain malformation (micropolygria) due to a defect in the migration of neurons. We previously mapped the FCMD gene to a region of less than 100 kilobases which included the marker locus D9S2107 on chromosome 9q31. We have also described a haplotype that is shared by more than 80% of FCMD chromosomes, indicating that most chromosomes bearing the FCMD mutation could be derived from a single ancestor. Here we report that there is a retrotransposal insertion of tandemly repeated sequences within this candidate-gene interval in all FCMD chromosomes carrying the founder haplotype (87%). The inserted sequence is about 3 kilobases long and is located in the 3' untranslated region of a gene encoding a new 461-amino-acid protein. This gene is expressed in various tissues in normal individuals, but not in FCMD patients who carry the insertion. Two independent point mutations confirm that mutation of this gene is responsible for FCMD. The predicted protein, which we term fukutin, contains an amino-terminal signal sequence, which together with results from transfection experiments suggests that fukutin is a secreted protein. To our knowledge, FCMD is the first human disease to be caused by an ancient retrotransposal integration.

Decreased membrane fluidity and unsaturated fatty acids in Niemann-Pick disease type C fibroblasts

Niemann-Pick disease type C (NP-C) is an autosomal recessive disorder characterized by the sequestration and trapping of endocytosed cholesterol in lysosomes. The NPC1 gene on chromosome 18 was recently identified but its physiological function remains unknown. We have studied the lipid compositions of cultured human NP-C fibroblasts and mouse SPM-3T3 cell line derived from the C57BL/KsJ NP-C model mouse, which belongs to the same complementation group. Fibroblasts derived from apparently normal age-matched individuals and a subline of SPM-3T3 cells which restores cholesterol metabolism by transfer of human chromosome 18 were used as controls. Levels of free cholesterol in whole cell homogenates increased about 1.5-fold in human NP-C fibroblasts and mouse SPM-3T3 cells, while in the plasma membrane, cholesterol content did not significantly change in NP-C fibroblasts but rather decreased in SPM-3T3 cells. The total phospholipid content did not significantly change; however, among phospholipid head groups, increases in sphingomyelin and decreases in other classes were observed in human NP-C fibroblasts and mouse SPM-3T3 cells. The ratios of saturated fatty acids to unsaturated fatty acids increased in both human and mouse cells. The increase was also confirmed in the plasma membrane fraction of SPM-3T3 cells. Membrane fluidity was examined using a 1,6-diphenyl-1,3,5-hexatriene (DPH) fluorescent probe. The DPH anisotropy values were markedly increased in NP-C fibroblasts and in SPM-3T3 cells. The results suggest that a NP-C mutation causes complex alterations in cellular lipid contents and biophysical properties of the membrane.

A case of parietal lobe epilepsy with distinctive clinical and neuroradiological features

We present a case of parietal lobe epilepsy, the epileptogenic focus of which was conspicuously demonstrated on magnetoencephalography (MEG). The remarkable fluctuation in the seizure frequency and the presence of atonic seizures were suggestive of atypical partial benign epilepsy of childhood (APBEC). An interictal positron emission tomography (PET) scan performed during the cluster of fits revealed hypermetabolism around the epileptogenic focus, which might be related to the marked tendency of clustering of seizures in this patient.

A novel mutation found in an adrenoleukodystrophy patient who underwent bone marrow transplantation

We identified a novel mutation, L322P, in a patient with X-linked adrenoleukodystrophy (ALD) who underwent bone marrow transplantation (BMT). An identification of the ALD gene mutation enabled us to employ an approach not dependent on the use of radioisotopes for detecting mixed chimerism. This assay could show more than 99.0% of the patient's peripheral white blood cells were replaced by the donor's cells.

Correlation between deletion patterns of SMN and NAIP genes and the clinical features of spinal muscular atrophy in Japanese patients

We conducted molecular analysis of two candidate genes for spinal muscular atrophy (SMA), the survival motor neuron gene (SMN) and the neuronal apoptosis inhibitory protein gene (NAIP), in 16 Japanese patients with SMA and compared the phenotypic features of SMA in these patients with the corresponding genotypes. Exons 7 and/or 8 of SMN were homozygously deleted in 11 SMA type I (Werdnig-Hoffmann disease) patients, two SMA type II patients and one SMA type III patient. Exons 5 and 6 of NAIP were homozygously deleted in six SMA type I patients. No patient had a deletion in NAIP without a deletion in SMN. Mechanical ventilation was required during the first 7 months of life in the SMA type I patients who had a deletion in both SMN and NAIP. Ventilatory support was initiated within 2 years after birth in patients who had a deletion in SMN but not in NAIP. We detected homozygous deletion of exon 5 of NAIP in the unaffected mothers of two SMA type I patients. In these families, the patients exhibited a deletion in both SMN and NAIP. The parents and unaffected siblings of these patients did not have a deletion in SMN. The present findings support the hypothesis that SMN deletion plays an important role in the development of SMA and suggest that combined deletion of both SMN and NAIP may be relevant for determining the disease severity.

[Acute necrotizing encephalopathy with horizontal gaze palsy]

Acute necrotizing encephalopathy (ANE) of childhood is a newly proposed disease entity characterized by symmetrically distributed necrotic brain lesions in the thalamus, cerebral white matter, brainstem, and cerebellum. We report a 4-year-old girl with severe psychomotor delay and horizontal gaze palsy as sequelae of ANE at 17 months of age. The computed tomography showed bilaterally symmetrical low density areas in the thalamus and low density areas in the left middle cerebral artery (MCA) region and the posterior cerebral artery (PCA) region. MRI (T 1-weighted) revealed unevenly distributed small low signal intensity areas with scattered high intensity regions in the thalamus bilaterally. The T2-weighted images showed multiple small low intensity areas around high intensity areas, and low signal intensity areas in the left middle cerebral artery (MCA) region and the posterior cerebral artery (PCA) region. In addition to severe psychomotor delay, the patient exhibited a peculiar eye movements. Horizontal ocular movement was impaired, but vertical ocular movement was almost completely normal. As clearly shown by MRI of the brain, the pontine tegmentum, including bilateral abducens nucleus, paramedian pontine reticular formation (PPRF), medial longitudinal fasciculus (MLF), and the facial nerve were affected, but the thalamo-mesencephalic junction, including the rostral interstitial medial longitudinal fasciculus (riMLF) and the nucleus of Cajal, was spared. To our knowledge, this is the first case of ANE associated with this selective ocular movement disorder ever reported. Because of the multiple symmetrical lesions and pons and the asymmetrical lesions of the MCA and PCA regions in the present case, occlusion of a single vessel could not account for the pathology. The pathophysiological mechanism of ANE is unknown. We postulate that some toxic or vasoactive agent caused vasospasm and subsequent breakdown of the blood-brain barrier, especially in the thalamus and pons, resulting in the unique distribution of the lesions and the rare eye movement disorder observed in the present case.

Transcranial magnetic stimulation in an adrenoleukodystrophy patient

We experienced an 11-year-old boy diagnosed as having adrenoleukodystrophy (ALD), and studied his motor evoked potentials (MEPs) elicited by transcranial magnetic stimulation (TMS). He had intellectual and visual impairment, and MRI revealed high intensity of the parieto-occipital white matter. On evaluation of the long tracts, slight spasticity with equivocal Babinski signs was noted: however, the long tracts appeared intact on MRI, and short latency somatosensory evoked potentials (SSEPs) were completely normal. On TMS delivered through a circular coil, MEPs recorded from the relaxed first dorsal interosseous muscle showed that only the duration was significantly prolonged, which may be due to temporal dispersion of descending volleys in the pyramidal tracts, while the latency was not prolonged. TMS in ALD was considered sensitive and useful for detecting subtle involvement of the long tracts.

Long-term ventilator-assisted children in Japan: a national survey

Owing to improved technology and care for patients who need mechanical ventilation, the quality of life as well as the prognosis for long-term ventilator-assisted patients has improved significantly in recent years. However, the increased number of these patients has raised economic, ethical and medical problems. In order to assess the magnitude of these problems, we conducted the first nationwide survey on the status of long-term ventilator-assisted children in Japan. Questionnaires were mailed to 2524 pediatric departments at hospitals in Japan with more than 100 beds. At the time of the survey, 282 hospitals had 567 patients who had been ventilated for more than a month. Among these patients, 434 were younger than 20 years and had been ventilated for more than 3 months. The most common basic disorders were: various myopathies (n = 65), hypoxic-ischemic encephalopathy (n = 60), spinal muscular atrophy type 1 (Werdnig-Hoffmann disease, n = 55), chronic lung disorders of prematurity (n = 21), Ondine's curse (n = 22), drowning (n = 17) and congenital heart diseases (n = 16). Of these 434 patients, only 61 were ventilated at home. Although home care was considered suitable for chronic ventilator patients by many pediatricians who responded to the survey, its realization has been hampered by the lack of a system and regulations to support it. The fact that many pediatricians in Japan have actively prolonged the life of Werdnig-Hoffmann patients, from whom aggressive life saving measures have been withheld in most Western countries, has raised ethical as well as medical issues.

Temporary improvement of neurological symptoms with gammaglobulin therapy in a boy with adrenoleukodystrophy

A 10-year-old boy with adrenoleukodystrophy was treated with gammaglobulin in conjunction with a mixture of glyceryl trioleate and glyceryl trierucate. With a high dose of gammaglobulin, clinical improvement, including the reduction of visual field defects, was noted. On magnetic resonance imaging, attenuation of the enhancement of the rim with gadolinium was observed, suggesting repair of the blood-brain barrier. When auditory agnosia developed later, a temporary improvement was again obtained with gammaglobulin. Although the progress of the disease could not be arrested permanently, gammaglobulin therapy seemed to have been associated with temporary improvement of the clinical symptoms in this patient with adrenoleukodystrophy.

Reduction of seizure frequency with clomipramine in patients with complex partial seizures

Two patients with complex partial seizures who had been refractory to various antiepileptics were treated with clomipramine. The frequency of the seizures was reduced to 0-30% of the original levels. It has been reported that imipramine is effective in absence and minor motor seizures, and its antiepileptic effect is thought to be related to the inhibition of the presynaptic re-uptake of serotonin and norepinephrine. The basic effect of clomipramine is the same as that of imipramine except that the inhibitory action of clomipramine on serotonin re-uptake is 5- to 10-times more potent than that of imipramine. It is implied that clomipramine may be of use in the treatment of partial epilepsies.

Effects of peroxisomal beta-oxidation antagonist on 2',3'-cyclic-nucleotide 3'-phosphohydrolase, membrane lipid compositions, and membrane fluidity in C-6 glial cells

In order to understand the relationship between peroxisomal dysfunction and clinical manifestations of peroxisomal disorders, the effect of thioridazine, a peroxisomal beta-oxidation antagonist, on the differentiation, membrane lipid composition and membrane fluidity of C-6 glial cells was examined. In our study, induction of 2',3'-cyclic-nucleotide 3'-phosphohydrolase (CNP), which was considered to be a membrane-associated enzyme closely associated with myelination, was inhibited with supplementation of thioridazine, followed by an increase in the relative concentration of longer chain fatty acids in cell membrane lipids, indicating that thioridazine causes impaired differentiation in the glial stem cell system. Membrane fluidity of C-6 glial cells was examined using a fluorescent probe 1,6-diphenyl-1,3,5-hexatriene (DPH). The DPH anisotropy value was decreased in the glial cells treated with thioridazine. These results indicate that the alteration of the membrane lipid composition caused by thioridazine affects the differentiation of glial cells via the changes in membrane properties.

Spinal muscular atrophy with oculomotor palsy, epilepsy, and cerebellar hypoperfusion

We report a boy with spinal muscular atrophy (SMA) type 1, who developed novel clinical and neuroradiologic features, indicating the broad spectrum of this degenerative disease. Widespread lesions in the central nervous system were disclosed by magnetic resonance imaging and single photon emission computed tomography (SPECT) studies. In particular, scattered regions of hypoperfusion demonstrated by SPECT suggested multisystem involvement including the cerebellum. The novel features of this patient were complex partial seizures and oculomotor palsy.

Changes in surgical strategies for peptic ulcers before and after the introduction of H2-receptor antagonists and endoscopic hemostasis

A total of 902 surgical patients with peptic ulcer disease were evaluated to clarify the effects of H2-receptor antagonists and endoscopic hemostasis on surgical treatment. Following the introduction of these treatments to our institute in 1982, the number of operations performed annually decreased by 40%, or 36 cases per year. However, a remarkable increase in the frequency of surgical emergency intervention since 1982 was concurrently observed, with the ratio of emergency procedures to the total number of operated cases increasing to 72.5% in the last 5 years of the study. Moreover, intractability as an indication for surgery decreased to 34.1%, compared with an increase in the number of patients with bleeding and perforated ulcers requiring operation. There were 13 postoperative deaths recorded (1.4%). All of the deaths were in patients who had undergone emergency surgery in poor health. Of these 13 patients, 10 had bleeding ulcers. A study of bleeding ulcers for which endoscopic hemostasis had been unsuccessful revealed that shock on admission and a concomitant medical condition had been evident in all the patients who died, and in 52.2% and 30.4% of the survivors, respectively. The current study suggests that the frequency of high-risk patients requiring surgery is increasing since the introduction of H2-receptor antagonists and endoscopic hemostasis, and thus, prompt surgical treatment and intensive management for such patients is essential.

A new protocol for the perinatal management of patients with congenital diaphragmatic hernia with severe hypoplastic lungs and its clinical application

It is prerequisite for the pre-operative management of patients with congenital diaphragmatic hernia (CDH) to avoid the factors that increase pulmonary vascular resistance, because such patients easily fall into the state of persistent fetal circulation (PFC). In this paper, a new protocol is proposed for the perinatal management of CDH patients to prevent the PFC which is facilitated by the enlargement of hernia and the deviation of mediastinum caused by spontaneous breathing just after birth. We also describe the usefulness of this protocol based on our experience in which we successfully treated a patient with CDH with severe hypoplastic lungs that were diagnosed antenatally by ultrasonographic examination. In treating the CDH patient with severe hypoplastic lungs, it is effective for the respiratory control and the prevention of PFC to administer morphine and pancuronium to the neonate through the umbilical vein before the resection of the umbilical cord. In the case of Cesarean section, in addition to the direct administration of morphine to the patient, administration of morphine to the patient's mother just before the delivery is more effective to prevent PFC, which can be easily induced by the initial resuscitation at birth.

Acute heart failure and acute renal failure in Kawasaki disease

Acute renal failure and acute heart failure are rare in Kawasaki disease. We experienced two patients with Kawasaki disease who presented acute renal failure and acute heart failure. These two patients gave us an important insight into the understanding of water balance and fluid therapy in Kawasaki disease. One patients showed acute prerenal failure due to fluid exudation from the intravascular to the extravascular space, and subsequent acute heart failure. The other patient showed acute heart failure caused by fluid infusion for the treatment of dehydration. It is suggested that acute renal failure could be caused by a fluid shift from the intravascular to the extravascular space in Kawasaki disease. It is also demonstrated that the reserve of cardiac function could be decreased in patients with Kawasaki disease due to myocarditis even with normal echocardiography and chest X-rays.

Ventricle works as a converting organ of atrial blood flow: physiological significance of mean ventricular pressure

The roles and characteristics of the ventricle were examined using mean ventricular pressure (MVP) in ventricular-vascular association. One hundred and two patients with congenital heart diseases who had undergone cardiac catheterization were studied. They were divided into five groups: Group 1, atrial septal defect without pulmonary hypertension (PH); Group 2, ventricular septal defect (VSD) without PH; Group 3, VSD with PH; Group 4, pulmonary valvular stenosis; and Group 5 as a control group. Then, we examined the relationships between mean pulmonary artery pressure (MPAP) and mean right ventricular pressure (MRVP), and also between mean systemic arterial pressure (MSAP) and mean left ventricular pressure (MLVP) among the five groups. Furthermore, we defined new indicators to express the ease of blood flow through each ventricle. They were referred to as a conductance of the right ventricle (CDR) and a conductance of the left ventricle (CDL), respectively. Then they were compared among the five groups. The values of MPAP/MRVP and MSAP/MLVP were kept constant to be about 1.3 and 1.7, respectively. Furthermore, CDR was different between each group according to the property of the pulmonary vascular bed, whereas CDL took almost the same value among the five groups. The ventricle works as a converter of atrial blood flow so that it can achieve efficient blood transport.

Elevated levels of dolichol in the brains of mucopolysaccharidosis and related disorders

The contents of total dolichol were measured in the cerebral cortex of various patients with lysosomal storage disorders, including mucopolysaccharidosis. Strikingly high levels of dolichol were demonstrated in GM1-gangliosides, Sanfilippo B syndrome, and a severe type of Hunter syndrome as well as neuronal ceroid-lipofuscinosis. An increased level of dolichol in cerebral cortex in neuronal ceroid-lipofuscinosis (NCL) was once regarded as pathognomonic for NCL. Our data, however, suggest that an increased level of dolichol in cerebral cortex is a nonspecific phenomenon related to some lysosomal dysfunction secondary to various neurodegenerative disorders.

A rapid microassay for dichloroacetate in serum by gel-permeation chromatography

We have developed a novel, rapid microassay for dichloroacetate in the serum. The serum sample is directly injected into a gel-permeation high-performance liquid chromatography apparatus. The peak of dichloroacetate appears after a giant protein peak. The method requires a very small amount of serum (10 microliters), and the analysis time is short (20 min). Using this micro method, we measured the serum concentrations of dichloroacetate in healthy adult volunteers and paediatric patients with congenital lactic acidosis. Although the effect of dichloroacetate on the neurological manifestations of congenital lactic acidosis has not been proved to be beneficial, the potential usefulness of dichloroacetate in refractory lactic acidosis in cardiac and respiratory failure has been recognized, and human as well as animal studies have been undertaken in many laboratories. To prevent possible side effects of dichloroacetate, it has been recommended that the minimal effective dose be used. Our microassay method is useful for both human and animal experiments, even after administration of minimal doses.

Limitations of endoscopic haemostasis by ethanol injection and surgical management for bleeding peptic ulcer

Two hundred and fifty-three patients with bleeding peptic ulcer underwent therapeutic endoscopy using local ethanol injection and were evaluated to determine the need for surgery and outcome. Permanent endoscopic haemostasis was achieved in 178 (70.4%) cases. Pulsatile arterial bleeding in ulcers and shock on admission (respectively, P < 0.01, P < 0.05) were significantly more frequent in patients with unsuccessful endoscopic treatment. Postoperative stay was significantly longer (P < 0.05) for patients with bleeding peptic ulcer than for patients requiring surgery for intractable ulcer without bleeding. Surgery was recommended if three attempts at endoscopic treatment did not achieve permanent haemostasis. The need for more than three such treatment sessions and the presence of a large excavated ulcer with an exposed vessel in an elderly patient were considered to indicate the necessity for surgery. Surgical procedures to which the operator is accustomed and intensive management were recommended for emergency cases to optimize the likelihood of survival.

[Efficacy of FEM (5-fluorouracil, epirubicin, mitomycin C) therapy for resected advanced gastric cancer. Ehime Gastric Cancer Study Meeting]

Between April 1990 and March 1991, postoperative adjuvant chemotherapy for resected gastric cancer employing 5-fluorouracil, epirubicin and mitomycin C (FEM) was performed. Forty-two patients subjected to the therapy were considered to have positive serosal invasion and underwent curative operation. FEM therapy consisted of intraoperative intraperitoneal administration of mitomycin C (0.3-0.4 mg/kg) combined with 8 cycles of intravenous bolus injection of epirubicin (20 mg/body) every 2-3 weeks which was started 2 weeks after the operation. Daily oral administration of 5-fluorouracil (150-200 mg/body) was started 2 weeks after the operation and continued for more than 6 months. Thirty-four of the 42 cases were assessable. Major adverse effects were nausea, vomiting, and general fatigue. There were no cardiovascular symptoms. The cumulative two-year survival rate was 74.2%, and follow-up was still under way at this writing.

Cooperative program for Asian pediatricians

The Cooperative Program for Asian Pediatricians (CPAP) is a non-government organization established in 1989 to promote mutual understanding and friendship among young pediatricians in Asian countries. Unlike other government programs and non-government organizations, CPAP is solely facilitating mutual relationships among young inexperienced pediatricians who would otherwise have no chance to travel overseas. It has been funded by donations from members of the alumni association of the Department of Pediatrics at the University of Tokyo and many private companies and individuals. The Cooperative Program for Asian Pediatricians has so far invited 36 Asian pediatricians from 11 countries. By constructing a human network among Asian pediatricians, it is hoped that CPAP will contribute to making international cooperation in the Asian region easier and smoother.

Calcification of basal ganglia in a patient with partial trisomy 5q and partial monosomy 18q

A patient with partial trisomy for the distal segment of the long arm of chromosome 5 (q35.1-->qter) with partial 18q monosomy is presented. The mother of the patient was phenotypically normal and was proved to be a carrier of a reciprocal translocation of the long arm of chromosomes 5 and 18 46,XX,t(5;18)(q35.1;q23). The patient shows mild mental retardation, short stature, mild obesity, dysmorphic face, eczema, minor malformations of the extremities, and bilateral intracranial calcification in the basal ganglia. Most of the clinical manifestations of the patient are compatible with the previously reported clinical features of partial trisomy of the distal segment of 5q. However, the calcification of bilateral basal ganglia has not been reported for this chromosomal anomaly.

Chronic ventilator-assisted children in university hospitals in Japan

The status of chronic ventilator-assisted children admitted to university hospitals in Japan was investigated. Of 81 university hospitals which responded to the survey, 52 hospitals had admitted 102 patients requiring chronic ventilatory support. More than 60% of the patients were suffering from neurologic disorders. Werdnig-Hoffmann disease was the most common disease, followed by hypoxic-ischemic encephalopathy, congenital heart disorders and various myopathies. The average duration of ventilator care was 823 days. Only nine patients were weanable from the mechanical ventilation. Although the population of chronic ventilator-dependent patients was not large, the chronic nature of the basic disorders and the need for intensive care of the patients have raised serious social and medical issues.

Moebius syndrome associated with pituitary dwarfism and hypoplastic optic disc

A 17 year old male patient with Moebius syndrome with pituitary dwarfism and unilateral hypoplastic optic disc is presented. Although there have been several reports of an association of Moebius syndrome and pituitary dysfunction, growth hormone deficiency has not been reported previously. These associations may give some insight into the pathogenesis of Moebius syndrome.

Partition of free dolichol in human urine

We have demonstrated that dolichol is present in the urinary supernatant. Most of the dolichol present in the supernatant seems to be associated with cellular debris or membrane fragments. The amount of sediment in healthy subjects correlate well with the volume of urine. Although it is illogical to express urinary dolichol relative to urine volume, a good correlation between the amount of sediment and urine volume has made its use justifiable. Because of the presence of a substantial amount of dolichol in the supernatant, it seems better to use uncentrifuged whole urine as the sample for measurement of dolichol.

[Autonomic dysfunction in metabolic diseases]

Among many metabolic disorders, porphyrias and Fabry disease are known to affect autonomic nervous system. In patients with acute intermittent porphyria, hereditary coproporphyria, and variegate porphyria, autonomic symptoms such as abdominal pain, vomiting, hypertension and tachycardia are among the most prominent clinical manifestations. Fabry disease is clinically characterized by severe limb pain, hypohidrosis, angiokeratomas and various autonomic symptoms. In both porphyrias and Fabry disease, pathological changes in the central and peripheral autonomic nervous system have been documented. In porphyrias, a loss of myelinated fibers, axonal degeneration, and segmental demyelination in peripheral autonomic nerves as well as chromatolysis of several brain stem nuclei have been found. In Fabry disease, abnormal amount of the substrates of alpha-galactosidase, i.e. ceramide di- and trihexoside, are found to be accumulated in the central and peripheral autonomic nerves.