Oral Health Interventions in Natural Disasters: A Scoping Review

OBJECTIVES

This work aimed to identify, appraise, and summarize existing knowledge about oral health interventions in the context of natural disasters and verify the main research gaps.

METHODS

We searched in PubMed (National Library of Medicine, Maryland, USA), EMBASE (Elsevier, Amsterdam, Netherlands) and Epistemonikos (Epistemonikos Foundation, Santiago, Chile) until 2021 for primary studies and systematic reviews, assessing any oral health intervention in the context of natural disasters. The interventions were classified according to Cochrane Effective Practice and Organization of Care (EPOC) categories, and the type of natural disaster was defined according to the classification by the Centre for Research on the Epidemiology of Disasters (CRED).

RESULTS

We assessed a total of 19 studies (majorly in Japan, n = 8), all performed in the context of an earthquake or mixed natural disasters (earthquake and tsunami). Regarding interventions, 12 studies reported a promotional/ preventive intervention, with oral examination being the most frequent. 7 studies reported therapeutic interventions, mainly related to emergency management of fractures and injuries.

CONCLUSIONS

The evidence accessed in our study was limited, highlighting the need for further research to focus on different oral health care interventions and outcomes in the context of different natural disasters, thus enhancing the formulation and implementation of recommendations and protocols worldwide.

Abstract OT2-01-02: Thoracic interfascial nerve blocks versus paravertebral block for improving quality of recovery after breast cancer surgery: A randomized, double-blind, non-inferiority trial

Background: Chronic pain after breast cancer surgeryhas harmful effects on patients' daily life. Paravertebral block (PVB) can prevent not only acute but chronic pain after breast cancer surgery, although the block is not easily put into practice because of technical difficulty or necessity to change patients' position. Thoracic interfascial nerve blocks (TINB) have been reported that it gives similar analgesic efficacy as PVB as with fewer risks, however there are no reports comparing analgesic efficacy of PVB with TINB. Although there are several scales evaluating postoperative pain including visual analog scale (VAS) or numerical rating scale, Quality of Recovery (QoR) have been set up to assess the impact of postoperative morbidity on patients' ability to return to normal function and quality of life. Among those assessment scales, QoR-40 has been mainly applied. It consists of 40 questions including five dimensions: psychologic support, physical comfort, emotional state, physical independence, and pain. There is a report suggesting that PVB improve QoR-40 after ambulatory breast tumor resection.

Methods: This is a single center single arm phase 2 study for early breast cancer patients. Exclusion criteria are pregnant and parturient women, allergy to local anesthetics, significant psychiatric or mental disorders, and patients with chronic pain. All blocks are subjected to ultrasound guidance. Patients were randomized to receive PVB with 40 ml ropivacaine or TINB with 60 ml ropivacaine. TINB consisted of modified PECS II block and transversus thoracic muscle plane block. For assessment of QoR, QoR-40 score which was consisted of 5 elements including postoperative pain was used. The trial was activated in July 2016.

Statistical Method: We conducted a pilot study on 16 patients who received a PVB during breast cancer surgery. Based on the standard deviation (SD) of QoR-40 on postoperative day (POD) 1, the SD was set to 7.2. Since the non-inferiority limit needs to be reduced to about half as much as the effect quantity used in the average value superiority test, it is set to 8, which is half of the effect quantity 16 in the pilot study. When one-sided test with α error = 0.025 and β error = 0.2, about 13 cases in each group are required. Given that dropout rate is about 30-40%, 18 cases in each group were taken as the number of subject cases.

Results: Thirty-six patients were accrual, 18 of PVB group and 18 of TINB group. Two patients declined the trial, 36/38 (95%) acceptors completed the trial. Total of QoR-40 scores on POD 1 was designated as the primary outcome. For secondary outcomes, both QoR-40 score and pain score were assessed on POD 3 and in postoperative month(s) 1, 3, 6, 12. Other secondary outcomes included pain score by POD 1, incidence of rescue analgesia, time to rescue analgesia, incidence of nausea and vomiting. All patients provided written informed consent before undergoing any study-related procedures.

Conclusions: This trial will provide non-inferiority that TINB preserve the effect of QoR as good as PVB after breast cancer surgery.

If interested, please contact T Horiuchi at t_horiuchi@seichokai.or.jp.

Clinical trial information: UMIN000023340

Citation Format: Abe H, Horiuchi T, Teramoto A, Tanaka Y, Takei Y, Nagahata T. Thoracic interfascial nerve blocks versus paravertebral block for improving quality of recovery after breast cancer surgery: A randomized, double-blind, non-inferiority trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-01-02.

Investigation of factors related to the occurrence of osteochondral lesions of the talus by 3D bone morphology of the ankle

Aims

The aims of this study were to evaluate the morphology of the ankle in patients with an osteochondral lesion of the talus using 3D CT, and to investigate factors that predispose to this condition.

Patients and Methods

The study involved 19 patients (19 ankles) who underwent surgery for a medial osteochondral lesion (OLT group) and a control group of 19 healthy patients (19 ankles) without ankle pathology. The mean age was significantly lower in the OLT group than in the control group (27.0 vs 38.9 years; p = 0.02). There were 13 men and six women in each group. 3D CT models of the ankle were made based on Digital Imaging and Communications in Medicine (DICOM) data. The medial malleolar articular and tibial plafond surface, and the medial and lateral surface area of the trochlea of the talus were defined. The tibial axis-medial malleolus (TMM) angle, the medial malleolar surface area and volume (MMA and MMV) and the anterior opening angle of the talus were measured.

Results

The mean TMM angle was significantly larger in the OLT group (34.2°, sd 4.4°) than in the control group (29.2°, sd 4.8°; p = 0.002). The mean MMA and MMV were significantly smaller in the OLT group than in the control group (219.8 mm2, sd 42.4) vs (280.5 mm2, sd 38.2), and (2119.9 mm3, sd 562.5) vs (2646.4 mm3, sd 631.4; p < 0.01 and p = 0.01, respectively). The mean anterior opening angle of the talus was significantly larger in the OLT group than in the control group (15.4°, sd 3.9°) vs (10.2°, sd 3.6°; p < 0.001).

Conclusion

3D CT measurements showed that, in patients with a medial osteochondral lesion of the talus, the medial malleolus opens distally, the MMA and MMV are small, and the anterior opening angle of the talus is large. This suggests that abnormal morphology of the ankle predisposes to the development of osteochondral lesions of the talus. Cite this article: Bone Joint J 2018;100-B:1487–90.

Abstract PD2-06: Preoperative diagnosis of sentinel lymph node metastasis using computed tomography lymphography for early breast cancer patients

Background: Sentinel lymph nodes (SLN) biopsy has been established as a standard of care in the treatment of early breast cancer. This technique represents a minimally invasive, highly accurate method of axillary staging and is an alternative to conventional axillary lymph node dissection. However, an indication of SLN navigation to metastatic disease may lead to misdiagnosis for staging. Recently, SLN identification using computed tomography lymphography (CTLG) has been reported in Japan. This study investigated the value of CTLG for preoperative prediction of SLN status in early breast cancer patients.

Patients and method: Between January 2013 and August 2016, 350 breast cancer patients without clinical evidence of lymph node metastasis were treated. On the day before the operation, CTLG was performed using 64-row multidetector helical CT scanner. Patients were placed in a supine position with their arms positioned in a cranial direction with CT guidelineattached to the skin at the axilla. We performed an intradermal injection in the periareolar area, using 4 ml of iopamidolwith 1 ml of local anesthetic. The contrasted lymph route and SLN were identified in reconstructed three-dimensional imaging. The SLN spot was indicated by CT laser light navigator system. We established typical pattern of the lymphography: stain defect of SLN, stagnation of lymphatic route for preoperative diagnosis of metastatic SLN. SLN biopsy was performed using the fluorescence imaging system, Photpdynamic Eye (pde-neo, Hamamatsu Photonics Co., Japan) referring to the point by axillary compression technique by plastic device. Intraoperative pathological analysis of SLN was examined, and an axillary lymph node dissection was performed in patients with SLN metastasis pathologically.

Results: The median age of the 350 patients was 59 (range 28 – 90) years old. One patient was male and others were female. CTLG were safely performed in all patients. CTLG could visualize lymphatic route and accurately identify SLN in 336 (96.0 %) and 343 (98.0 %) cases, respectively. Lymphatic routes of CTLG were completely consistent with those of fluorescence imaging. The mean number of SLN identified by CTLG was 1.1. Fifty of 350 patients had metastatic SLN pathologically, and 11 of them had micrometastases of SLNs. The accuracy for metastatic diagnosis of SLN using CTLG without micrometastasis was 84.1 %, sensitivity was 82.1 % and specificity was 84.3 %. The positive predictive value was 40.5 % and negative predictive value was 97.3 %. There were no complications associated with SLN identification.

Conclusion: CTLG in SLN biopsy has some advantages in that this method is simple and quite useful for obtaining accurate anatomic images of the SLN, lymph vessels, and tumor. CTLG could select the candidate with truly node negative cases in early breast cancer patients, because it predicts lymph node metastasis preoperatively from natural status of the lymphographic image.

Citation Format: Abe H, Teramoto A, Tanaka M, Yamasaki K, Yoneda K. Preoperative diagnosis of sentinel lymph node metastasis using computed tomography lymphography for early breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-06.

Abstract P2-01-17: The combination of preoperative computed tomography lymphography and intraoperative fluorescence imaging navigation for sentinel lymph node biopsy of early breast cancer patients

Background: Sentinel lymph nodes (SLN) biopsy has been established as a standard of care in the treatment of early breast cancer. This technique represents a minimally invasive, highly accurate method of axillary staging and is an alternative to conventional axillary lymph node dissection. The combination of the radioisotope and dye-staining methods is the most accurate way to identify SLN. We had reported feasibility and safety of a new technique of SLN identification using fluorescence imaging of indocyanine green (ICG) injection without any need for training. Recently, SLN identification using computed tomography lymphography (CTLG) has been reported in Japan. This study investigated a usefulness of the combination of CTLG and fluorescence imaging for SLN biopsy of early breast cancer patients.

Patients and method: Between January 2013 and March 2016, 296 breast cancer patients without clinical evidence of lymph node metastasis were treated. On the day before the operation, CTLG was performed using 64-row multidetector CT. We performed an intradermal injection in the periareolar area, using 4 ml of contrast agent with 1 ml of local anesthetic. The contrasted lymph route and SLN were identified in reconstructed three-dimensional imaging. The SLN spot was indicated by CT laser light navigator system. We established typical pattern of the lymphography: stain defect of SLN, stagnation of lymphatic route for preoperative diagnosis of metastatic SLN. During the operation, fluorescence images were obtained using the fluorescence imaging system, Photpdynamic Eye (pde-neo, Hamamatsu Photonics Co., Japan). After 0.5 ml dye mixed indigocarmin and ICG was injected intradermally into the periareolar skin, lymphatic route was observed with fluorescence images. SLN biopsy was performed referring to the point by axillary compression technique by plastic device. Intraoperative pathological analysis of SLN was examined.

Results: The median age of the 296 patients was 59 (range 28 – 90) years old. One patient was male and others were female. CTLG and fluorescence imaging were safely performed in all patients. CTLG could visualize lymphatic route and accurately identify SLN in 284 (95.9 %) and 290 (98.0 %) cases, respectively, whereas fluorescence imaging identified successfully lymphatic route and SLN in all patients. Lymphatic routes of CTLG were completely consistent with those of fluorescence imaging. The number of SLN identified by CTLG was significantly lower than that by fluorescence imaging (1.1 vs. 1.6, p&lt;0.01). Thirty-nine of 296 patients had metastatic SLN pathologically, and 10 of them had micrometastases of SLNs. The accuracy for metastatic diagnosis of SLN using CTLG without micrometastasis was 83.9 %, sensitivity was 82.1 % and specificity was 84.1 %. The positive predictive value was 35.9 % and negative predictive value was 97.7 %.

Conclusion: The combination of CTLG and fluorescence imaging revealed easy and effective to detect SLN. The fluorescence imaging was more high detection rate and number of SLN than CTLG. Otherwise, preoperative diagnosis of SLN metastasis using CTLG would be useful to detect negative SLNs.

Citation Format: Abe H, Teramoto A, Yamasaki K, Yoneda K, Ogawa M, Kawasaki M, Kameyama M. The combination of preoperative computed tomography lymphography and intraoperative fluorescence imaging navigation for sentinel lymph node biopsy of early breast cancer patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-17.

Abstract P3-01-02: A comparison of significance with indocyanine green fluorescence imaging method and computed tomography-lymphography in sentinel lymph node identification for early breast cancer patients

Background: Sentinel lymph nodes (SLN) biopsy has been established as a standard of care in the treatment of early breast cancer. This technique represents a minimally invasive, highly accurate method of axillary staging and is an alternative to conventional axillary lymph node dissection. The combination of the radioisotope and dye-staining methods is the most accurate way to identify sentinel lymph nodes. We had reported feasibility and safety of a new technique of SLN identification using fluorescence imaging of indocyanine green (ICG) injection without any need for training. Recently, SLN identification using computed tomography-lymphography (CTLG) has been reported in Japan. This study investigated the comparison of significance with fluorescence imaging method and CTLG.

Patients and method: Between January 2013 and May 2015, 213 breast cancer patients without clinical evidence of lymph node metastasis were treated. On the day before the operation, CTLG was performed using 64-row multidetector CT. We performed an intradermal injection in the periareolar area, using 4 ml of contrast agent with 1 ml of local anesthetic. The contrasted lymph flow and SLN were identified in reconstructed three-dimensional imaging. The SLN spot was indicated by CT laser light navigator system. During the operation, fluorescence images were obtained using the fluorescence imaging system, Photpdynamic Eye (pde-neo, Hamamatsu Photonics Co., Japan). After 5 mg / 0.3ml ICG was injected intradermally in to the periareolar skin, lymphatic drainage was observed with fluorescence images. SLN biopsy was performed referring to the point by axillary compression technique by plastic device.

Results: The median age of the 213 patients was 59 (range 28 – 87) years old. CTLG and fluorescence imaging was safely performed in all patients. CTLG could visualize lymphatic flow and accurately identify SLN in 189 (89 %) and 196 (92 %) cases, respectively, whereas fluorescence imaging identified successfully lymphatic flow and SLN in all patients. Fluorescence imaging with axillary compression technique was visually easy to identify the location of SLN on the axillary skin even in obese patients. Lymphatic flows of CTLG were completely consistent with those of fluorescence imaging. The number of SLN identified by CTLG was significantly lower than that by fluorescence imaging (1.1 vs. 1.6, p&lt;0.01). Twenty seven patients (13%) were found to have lymph node metastases pathologically, and 7 of them had micrometastases of lymph node. In case of partial enhancement of SLN with CTLG, the rate of positive metastasis was significant higher compared to the cases of whole enhancement (p&lt;0.01), however, even if enhancement is poor, about 70 % cases without metastasis are present.

Conclusion: Both of fluorescence imaging and CTLG revealed easy and effective to detect SLN. The fluorescence imaging with fluorescence mapping showed strong fluorescence from all parts of the surgical field, which hindered identification of SLNs, and fluorescence imaging was more high detection rate of SLN.

Citation Format: Abe H, Yamasaki K, Teramoto A, Yoneda K, Ogawa M, Kawasaki M, Kameyama M. A comparison of significance with indocyanine green fluorescence imaging method and computed tomography-lymphography in sentinel lymph node identification for early breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-01-02.

Bilateralstruktur der Wolle

Die von der Bilateralstruktur herrührende teilweise Färbung der Wollhaare ist nicht nur auf die speziellen Farbstoffe beschränkt, sondern läßt sich auf alle wichtigen Farbstoffklassen erweitern, wenn der pH-Wert des Bades nicht stark von 7 abweicht und die Farbstoffkonzentration nicht zu groß ist.

Die scheinbaren isoelektrischen Punkte der beiden Teile des Cortex, die in den färberischen Eigenschaften voneinander verschieden sind, wurden histochemisch bestimmt. Es wurde vorgeschlagen, den auf der Innenseite der Krümmung liegenden acidophilen Teil (sog. Para-Cortex) „A-Cortex" und den auf der Außenseite liegenden basophilen Teil (sog. Ortho-Cortex) „B-Cortex" zu nennen.

A- und B-Cortex zeigen die voneinander unterschiedenen UV- Absorptionen: bei 3130 A weist der A-Cortex größere Absorption als der B-Cortex auf, während das Verhältnis bei 2800 und 2650 A gerade umgekehrt ist.

Von etwa einem Drittel der unter der Haut befindlichen Länge ab nach der Spitze hin besitzt das Haar eine Bilateralstruktur wie die des Haarteils außerhalb der Haut, während der unmittelbar über der Tiefe der Wurzel stehende Teil gleichmäßig die färberische Eigenschaft wie der B-Cortex aufweist.

A transfection method for short interfering RNA with the lipid-like self-assembling nanotube, A6K

The aim of the present study was to develop a novel transfection method for short interfering RNA (siRNA). A nanotube with surfactant activity, A6K, consisting of six alanine residues and a hydrophilic head, lysine, was compared to the conventional cationic transfectant reagents siFECTOR and Lipofectamine 2000. Cytotoxicity for the human glioblastoma cell lines U87MG, A172, and T98G was examined with the MTS assay. Transfection efficiency was analyzed with FITC-labeled siRNA targeting matrix metalloproteinase (MMP)-2 mRNA by fluorescent activity on microscopy. The ultrastructure of A6K was evaluated by electron microscopy. The level of cytotoxicity associated with A6K in the U87MG cells was significantly lower than with siFECTOR and Lipofectamine 2000. Transfection efficiency for siRNA was increased in a dose- and time-dependent fashion. The relative expression of MMP-2 mRNA to β-actin was reduced in a dose-dependent manner by real-time RT-PCR analysis. The ultrastructure of the A6K was transformed to micelle formation when mixed with the siRNA. The lipid-like self-assembling peptide, A6K, has genes in the micelle associated with the hydrophilic tail. This transfection method is a novel and stable technique with lower cytotoxicity than the current standard methods.

Preoperative embolization of meningiomas with N-butyl cyanoacrylate

Meningiomas are often embolized before their surgical resection to reduce blood loss during surgery. Polyvinyl alcohol (PVA) particles have been the most frequently used material for embolization of meningiomas. We have used n-butyl cyanoacrylate (NBCA) as the first-choice material since 2001. Thirty-one meningiomas were embolized with NBCA. We report the result of embolization of meningiomas with NBCA in comparison with PVA particles.

Detection of Epstein-Barr virus DNA and expression of CD30 antigen in primary anaplastic diffuse large B-cell lymphoma of the brain

We describe a case of primary anaplastic diffuse large-cell lymphoma arising in the central nervous system (CNS). Primary CD30-positive anaplastic diffuse large B-cell lymphoma of the brain is very rarely reported. Given that this tumor is immunohistochemically heterogeneous, polymerase chain reaction (PCR) and Epstein-Barr virus (EBV) analysis of tumor DNA are essential techniques for early and accurate histological diagnosis in these CD30-positive cerebral lymphoma cases. We report an early CD30- and EBV-positive anaplastic diffuse large B-cell lymphoma in the CNS that was diagnosed not only from the immunohistochemical study and MRI findings, but also from the genotype confirmations. This tumor was documented to have EBV episomes of monoclonal origin by PCR analysis of immunoglobulin gene rearrangement.

Novel approach to analysis of in vitro tumor angiogenesis with a variable-pressure scanning electron microscope: suppression by matrix metalloproteinase inhibitor SI-27

Degradation of basement membrane by metalloproteinases (MMP) is a critical step in tumor angiogenesis. To evaluate in vitro angiogenesis, several models have been employed, including bovine cornea, fenestrated rat brain, Matrigel, and others. These models did not provide quantitative analysis of capillary formation. The current study aimed for a novel approach to in vitro assay of angiogenesis with a "wet scanning electron microscope (SEM)" to investigate suppression of tumor angiogenesis by the MMP inhibitor, SI-27. The effects of noncytotoxic concentrations of SI-27 (1-100 microM) were determined on nonmitogenic vascular endothelial growth factor (VEGF) (10 ng/ml)-mediated cell motility and in vitro angiogenesis of human umbilical vein endothelial cells (HUVECs). Activities of MMP and tissue inhibitor of metalloproteinase (TIMP) were determined by enzyme-linked immunosorbent assay (ELISA). Subsequently, the inhibitory effect of SI-27 was examined on in vitro angiogenesis stimulated by supernatants of human glioma cell lines (U87MG, U251MG, or U373MG). In vitro angiogenesis was quantitatively analyzed with a variable-pressure SEM. Cell motility and in vitro angiogenesis by HUVECs were significantly increased by VEGF along with elevated MMP-1 and -2 activity, whereas SI-27 significantly suppressed VEGF-mediated in vitro angiogenesis and inactivated both MMP-1 and MMP-2, but not inhibited cell motility. The angiogenesis promoted by glioma supernatants showed a significant reduction in the presence of SI-27. SI-27, a novel MMP inhibitor, inhibited tumor angiogenesis in vitro. It can be anticipated to prevent tumor growth through its angiosuppressive effect. Quantitative analysis with a variable-pressure SEM is a novel approach to in vitro angiogenesis assay.

Ki-67 and minichromosome maintenance-7 (MCM7) expression in canine pituitary corticotroph adenomas

Pituitary-dependent hyperadrenocorticism (PDH) caused by pituitary corticotroph adenoma is a common endocrine disorder in dogs. The ratio between pituitary height and the area of the brain (P/B) has been used to evaluate the pituitary size. A P/B ratio > 0.31 indicates an enlarged pituitary, whereas a P/B ratio ≤ 0.31 indicates a nonenlarged pituitary. The aim of this study was to investigate the expression of proliferation markers Ki-67 and minichromosome maintenance-7 (MCM7) in canine corticotroph adenomas in enlarged and in nonenlarged pituitaries and to evaluate their relation with the size of canine pituitary corticotroph adenomas. Ki-67 and MCM7 expression in ACTH-positive tumor cells was determined by dual-labeling immunohistochemistry in resected corticotroph adenomas from 15 dogs with PDH. The mean ± SD Ki-67 labeling index (LI) was 0.55% ± 0.59% in corticotroph adenomas with nonenlarged pituitaries and 1.6% ± 0.6% in adenomas with enlarged pituitaries. The MCM7 LI in corticotroph adenomas with nonenlarged pituitaries and in adenomas with enlarged pituitaries was 2.9% ± 2.2% and 10.9% ± 3.7%, respectively. The Ki-67 LI and MCM7 LI were significantly greater in the adenomas with enlarged pituitaries than in the adenomas with nonenlarged pituitaries (P < 0.01 and P < 0.01, respectively). The MCM7 LI was significantly greater than the Ki-67 LI in adenomas (P < 0.01). The Ki-67 LI was positively correlated with the MCM7 LI (r = 0.820, P < 0.01), and the P/B ratio was positively correlated with the Ki-67 LI (r = 0.560, P = 0.03) and the MCM7 LI (r = 0.854, P < 0.01). In conclusion, canine corticotroph adenomas in enlarged pituitaries show greater proliferation potential than do adenomas in nonenlarged pituitaries. MCM7 expression was significantly greater than Ki-67 expression in canine pituitary corticotroph adenomas. Thus, MCM7 may be superior to Ki-67 as a proliferation marker in pituitary tumors.

A helical polymer with a cooperative response to chiral information

Polyisocyanates, long studied as theoretical models for wormlike chains in dilute solution and liquid crystals, differ from their biological helical analogs in the absence of a pre-determined helical sense. These polymers have an unusual sensitivity to chiral effects that arises from a structure in which alternating right- and left-handed long helical blocks are separated by infrequent and mobile helical reversals. Statistical thermodynamic methods yield an exact description of the polymer and the cooperative nature of its chiral properties. Minute energies that favor one of the helical senses drive easily measurable conformational changes, even though such energies may be extremely difficult to calculate from structural theory. In addition, the chiral nature of the polymer can be used to test theoretical ideas concerned with cholesteric liquid crystals, one of which solves the problem of assigning the helical sense.

Combined non-isotopic in situ hybridisation and indirect immunohistochemical analysis of hormone production in the rat pituitary gland

An understanding of the intracellular relation between hormonal expression (storage) and gene expression (production) is essential for elucidating the functional status of the individual cells in endocrine tissue such as the pituitary gland. To this end, mRNA expression was visualised by using a combined in situ hybridisation and immunohistochemistry method in routinely processed, formalin fixed, paraffin wax embedded rat pituitaries. mRNA was detected by non-isotopic in situ hybridisation (alkaline phosphatase antialkaline phosphatase method, with nitroblue tetrazolium and 5-bromo-4-chloro-3-indolylphosphate as substrates). Sections were then stained by using the immunoperoxidase method to demonstrate pituitary hormone expression. The specificity of the combined staining method was confirmed by staining adjacent sections separately. The antigenicity of rat growth hormone and prolactin was adequately preserved following hybridisation. In conclusion, this method is specific, easy to use and permits the determination of the functional status of individual cells.

Cardiopulmonary haemodynamic changes after severe head injury

Haemodynamic studies were performed by pulmonary artery catheter in 15 patients with severe head injury. To our knowledge, few data are available about the detailed haemodynamic changes after head injury using pulmonary artery catheter. All patients were assessed by the Glasgow Coma Scale, computed tomography and intracranial pressure monitoring. We divided the patients into hypotensive and normotensive groups. All patients showed a high pulmonary vascular resistance and a high pulmonary capillary wedge pressure, probably due to pulmonary vasoconstriction. In the hypotensive group, the two major changes were a marked decrease of the cardiac index and a slight increase of systemic vascular resistance. The low cardiac index was the result of heart failure secondary to myocardial dysfunction. In contrast, the normotensive group was characterized by a high systemic vascular resistance that was induced by generalized vasoconstriction. Increased intracranial pressure is initially associated with an increase of the cardiac index and systemic vascular resistance, so patients with severe head injury also suffer from profound circulatory disturbance.

Use of diffusion-weighted magnetic resonance imaging in empyema after cranioplasty

External decompression can be an effective treatment for acute intracranial hypertension, but the cranial defect must be repaired. The most serious complication of cranioplasty is late infection. Confusing an empyema that occurs after cranioplasty with a fluid collection (haematoma or liquor) can have catastrophic consequences, such as the development of cerebritis. The goal of this study was to assess the ability of diffusion-weighted (DW) magnetic resonance imaging (MRI) to diagnose empyema after cranioplasty. DW MRI and apparent diffusion coefficient (ADC) maps were studied in six patients with surgically verified empyema after cranioplasty. The findings were compared with those in five patients who had surgically verified haematoma or liquorrhoea. In the patients with empyema, the lesion was hyperintense, whereas the fluid collections (haematoma and liquorrhoea) were visualized as hypointense lesions. The ADC maps showed that empyema had a significantly lower intensity than the fluid collections (haematoma or liquorrhoea). DW MRI can be used to identify empyema after cranioplasty and can help to differentiate it from other fluid collections. Hence, this is a useful additional imaging modality for the diagnosis of empyema after cranioplasty.

Signalling pathway mediated by CXCR7, an alternative chemokine receptor for stromal-cell derived factor-1α, in AtT20 mouse adrenocorticotrophic hormone-secreting pituitary adenoma cells

Stromal cell-derived factor (SDF)-1 and its receptor, CXCR4, have been identified in both neurones and glia of many brain areas. Previous studies have mainly focused on the role of SDF-1 and CXCR4 in modulating the hypothalamic-pituitary axis and their possible involvement in the development of pituitary adenomas. An alternative SDF-1 receptor, CXCR7, has recently been identified, but it has not been studied in the context of pituitary adenomas. The present study aimed to investigate the distribution and function of CXCR7 in pituitary adenomas. The expression of CXCR7, normalised to β-actin, was assessed by tissue microarray analysis of 62 adenomas, including 23 growth hormone (GH)-producing adenomas, 22 nonfunctioning adenomas, seven prolactin (PRL)-producing adenomas, six adrenocorticotrophic hormone-producing adenomas and four thyroid-stimulating hormone-producing adenomas. In vitro functional studies used RNA interference (RNAi) and cDNA microarray analysis to evaluate the CXCR7 signalling pathway in AtT-20 mouse pituitary adenoma cells treated with recombinant mouse SDF-1α and transfected with RNAi against Cxcr7 or control RNAi. In tissue microarray analysis, prominent expression of CXCR7 was observed in GH-producing adenomas and PRL-producing adenomas, and in macroadenomas (P < 0.05). Intracellular signalling via CXCR7 up-regulated Bub1, Cdc29 and Ccnb1, and down-regulated Asns, Gpt, Pycr1, Cars and Dars. The present study demonstrates that the SDF-1α ⁄ CXCR7 signalling pathway regulates genes involved in cell cycle control, amino acid metabolism and ligase activity, which comprise targets that are distinct from those of CXCR4.

Safety and efficacy of growth hormone (GH) during extended treatment of adult Japanese patients with GH deficiency (GHD)

OBJECTIVES

To assess the effects of a growth hormone (GH) replacement therapy using a GH dose regimen based on serum insulin-like growth factor (IGF-I) concentrations in Japanese adults with GH deficiency (GHD).

DESIGN

In this multicentre, uncontrolled, open-label study, Japanese adults with GHD who had received either GH replacement therapy (GH-GH group, n=35) or placebo (Placebo-GH group, n=36) in a previous randomised, double-blind, placebo-controlled trial were treated with GH replacement therapy for 48 weeks. GH treatment was started at a dose of 0.003 mg/kg/day administered by subcutaneous injection for the first 8 weeks, after which the dose was adjusted to maintain patients' serum IGF-I levels within the reference range adjusted for age and gender. Body composition, serum lipids, serum IGF-I and IGF binding protein-3 (IGFBP-3) levels were measured throughout study. Symptom and quality of life scores were also determined.

RESULTS

Lean body mass (LBM) was increased compared with baseline (the end of the preceding double-blind trial) at 24 and 48 weeks, with a mean (+/-SD) increase of 1.3% (+/-4.2%) at week 48 in the GH-GH group (an increase of 6.6% [+/-6.0%] from the start of the preceding double-blind trial) and a larger increase of 4.7% (+/-5.9%) in the Placebo-GH group. Body fat mass (BFM) increased slightly from baseline in the GH-GH group with a mean increase of 2.9+/-10.6% at week 48 (a decrease from the start of the preceding double-blind trial at 48 weeks of 7.8% [+/-15.0%]) but decreased by 6.5% (+/-11.7%) at week 48 in the Placebo-GH group. Serum lipids were unchanged or slightly increased from baseline in the GH-GH group but patients' lipid profiles improved in the Placebo-GH group. In patients who received placebo during the double-blind study, individualised GH therapy in this open-label study increased mean LBM at 48 weeks by 6.2+/-6.8% in patients with CO GHD and by 3.0+/-4.4% in patients with AO GHD. Changes in mean LBM and mean BFM at week 48 were +4.1+/-4.5% and -2.4+/-10.5%, respectively, in females and +5.0+/-6.7% and -8.9+/-11.8%, respectively, in males. In patients who received GH treatment during the double-blind study, overall changes in LBM, BFM and IGF-I SD score after 24 weeks and 48 weeks were small, with no significant differences between subgroups. While the overall incidence of adverse events was broadly similar in the GH-GH and Placebo-GH groups (97% and 89%, respectively), the incidence of treatment-related events was higher in the GH-GH group (83% vs 42% in the Placebo-GH group). Most adverse events in both treatment groups were of mild or moderate severity and not clinically significant. The incidences of oedema and cases of high IGF-I during the IGF-I level-adjusted treatment regimen were lower than those during the preceding fixed dose titration.

CONCLUSION

Long-term GH replacement therapy was well tolerated in Japanese adults with GHD. GH treatment maintained the improvements in body composition and lipid profiles in the patients previously treated in the double-blind study (GH-GH group) and improved these parameters in previously untreated patients (Placebo-GH group). Individualised GH administration based on IGF-I levels was well-tolerated and effective.

Anterior vertebral artery decompression with an ultrasonic bone curette to treat bow hunter's syndrome

We report a patient with bow hunter's syndrome who was treated by anterior decompression of the vertebral artery (VA) using an ultrasonic bone curette (SONOPET). This 60-year-old man reported almost losing consciousness upon head rotation. Although the right VA appeared normal at the natural head position, upon left head rotation it became completely occluded at the transverse foramen of C2. We performed anterior decompression of the right VA at the axis using a high-speed drill and SONOPET. For anterior decompression of the VA in a deep and narrow operative field, we recommend use of SONOPET, which permits safe, easy bone dissection.

Petrous apex cholesterol granuloma treated via the endoscopic transsphenoidal approach

Numerous surgical approaches have been used to treat petrous apex cholesterol granulomas. They are usually treated via the transtemporal- or middle fossa approach; some are managed endoscopically. We present a patient treated by the endoscopic transsphenoidal approach and review the literature.

Efficacy and safety of growth hormone (GH) in the treatment of adult Japanese patients with GH deficiency: a randomised, placebo-controlled study

OBJECTIVE

The aim of this study was to assess the effect of growth hormone (GH) replacement therapy on lean body mass (LBM) and other variables including body fat mass, serum lipids and quality of life measures in GH-deficient Japanese adults.

DESIGN

This was a multicentre, double-blind, placebo-controlled, parallel group study. Following initial screening, patients were randomly assigned to GH treatment (n=37) or placebo (n=36). GH treatment was started at an initial dose 0.003 mg/kg/day s.c. each day for the first 4 weeks after which the dose was increased to 0.006 mg/kg/day for 4 weeks and then to 0.012 mg/kg/day for the last 16 weeks (n=37). Body composition, serum lipids, serum IGF-I and IGFBP-3 levels were measured during the 24-week study. Short Form-36 and Quality of Life Assessment of GH Deficiency in Adults scores were also determined.

RESULTS

LBM was significantly increased from baseline at 24 weeks in GH-treated patients, with a mean (+/-SD) increase of 4.7% (+/-5.3%) compared with an increase of 1.0% (+/-4.4%) in the placebo group (p<0.0001 versus baseline, p=0.0003 versus placebo). Percentage body fat decreased significantly from baseline in GH-treated patients (9.3%, p<0.0001), compared with a non-significant 0.2% increase in the placebo group (p<0.0004 for difference between treatment groups). In addition, significantly increased serum IGF-I and IGFBP-3 levels and improvements in the patients' serum lipid profiles were observed in patients who received GH therapy. Changes in quality of life measures did not differ between treatments, probably because of the small number of patients studied. GH therapy was well tolerated, with adverse events of any cause reported in 86.5% of the GH treatment group and 83.3% of the placebo group.

CONCLUSION

GH treatment significantly improved body composition and serum lipid profiles in adult Japanese patients with GH deficiency compared with placebo and had no clinically relevant adverse effects.

Giant intracranial aneurysm of the anterior communicating artery treated by direct surgery using A3-A3 side-to-side anastomosis and A3-RA graft-STA anastomosis

We describe a giant aneurysm of the anterior communicating artery (ACoA) which was treated with a STA-RA graft-A3 bonnet bypass and A3-A3 side-to-side anastomosis. A giant and partially thrombosed ACoA aneurysm was partially coated 3 years before his current presentation, its gradual increase producing visual field disturbances. An A3-A3 side-to-side anastomosis and STA-RA graft-A3 bonnet bypass were performed. The aneurysm was dissected, and the thrombus removed under transient parent-artery occlusion. The aneurysmal neck was successfully clipped without encountering ischemic changes. This strategy may be useful for treating giant or thrombosed aneurysms in the region of the ACoA.

Interleukin-18 mRNA expression in the rat pituitary gland

The present study investigated the expression of IL-18 mRNA under several stimuli, and molecular structures of IL-18 mRNA of the rat pituitary. Real-time PCR demonstrated that IL-18 mRNA, highly expressed in anterior pituitary, significantly increased following stress and adrenalectomy. In situ hybridization combined with immunohistochemistry demonstrated that corticotrope cells expressed IL-18 mRNA. RACE and sequence analysis demonstrated that pituitary IL-18 mRNA possesses five new exons at the upstream of exon 1 and between exon 1 and exon 2, indicating the preferential usage of promoter 1. The present study suggests that IL-18 in the corticotrope cells may play some roles in stress responses.

Intracisternal neurinoma of the C1 posterior root

We report a rare intracisternal C1 posterior root neurinoma in a 35-year-old man without neurofibromatosis who presented with headache, nuchal pain, bilateral motor weakness of the upper extremities, and numbness in the right distal upper extremity. CT and MRI study showed a 20-mm intracisternal lesion at the foramen magnum. At surgery, there was an anastomosis between the C1 posterior root and a spinal accessory nerve at the site of the tumor; the root from the collateral sulcus of this C1 root was absent. Postoperatively, the patient remains free of symptoms. Foramen magnum neurinomas have been described as accessory nerve tumors. We present new anatomical consideration regarding this lesion.

A case of pleomorphic xanthoastrocytoma presenting with massive tumoral hemorrhage

Pleomorphic xanthoastrocytoma has been generally conceived to be in a benign nature, showing a relatively favorable prognosis. Apoplectic attack attributable by massive hemorrhage in this distinct form of the supratentorial glioma is an exceedingly rare event. A 61-year-old female presented with a sudden onset of generalized tonic--clonic convulsion. CT and MRI disclosed the presence of a tumor composing of massive intra-tumoral hemorrhage filling the cyst associated with mural nodule in the left frontotemporal lobe. At surgery, the subpial mass involving hematoma was well marginated and slightly adherent to the dura mater. It could be removed totally and proved to be a pleomorphic xanthoastrocytoma. The unusual hemorrhagic presentation of this typically benign entity is extremely rare and is thought to be intra-tumoral bleeding in this case, since subarachnoid hemorrhage was absent.

The glutamate AMPA receptor antagonist, YM872, attenuates regional cerebral edema and IgG immunoreactivity following experimental brain injury in rats

We previously reported the neuroprotective effects of the glutamate AMPA receptor antagonist YM872 on neurobehavioral motor function and cortical tissue loss (lesion volume) in a brain-injured rat model. Here we examined its effect on brain edema and the breakdown of the blood-brain barrier (BBB). Rats subjected to severe right lateral (parasagittal) fluid-percussion brain injury or sham injury received a 4-hr intravenous infusion of YM872 (20 mg/kg/ hr, 20 mg/3 ml) or normal saline starting at 15 min post-injury. At 48 hr we removed their brains and evaluated the cerebral regional edema by the wet weight/dry weight method. Another group of rats was transcardially fixed with 10% formalin at 2 weeks after injury. Serial brain sections were immunostained for endogenous IgG and the extent and intensity of staining were evaluated. The administration of YM872 resulted in a significant reduction in regional cerebral edema in the injured parietal cortex and a markedly reduced area of IgG immunoreactivy in the injured cortex. Our results indicate that the post-traumatic administration of YM872 may be neuroprotective by reducing BBB breakdown and regional cerebral edema.

A new tumour forceps for use during removal of pineal region tumours

A new forceps for grasping and cutting tumour in a narrow surgical field is described. The working length is 12 cm and the grasping element at the tip is 1 mm in diameter. To avoid damage to surrounding structures caused by pulling out the tumour, the grasping portion consists of two hollow cylinders with sharp edges that divides, rather than tears tissue.

Prions prevent brain damage after experimental brain injury: a preliminary report

The physiological function of the normal cellular form of prion protein (PrPC) is not yet fully understood. In the current study we used prion protein gene knock-out mice (Prnp-/-) to assess the role of PrPC in traumatic brain injury. Prnp+/- and Prnp-/- mice were subjected to weight-drop contusional brain injury over the left parietal cortex. Prnp-/- mice manifested a significantly larger lesion volume and worse neuromotor scores than did their Prnp+/- littermates. IgG immunostaining revealed that in Prnp-/- mice the breakdown in the blood-brain barrier (BBB) was more extensive at 1 month after brain injury. Our results are in agreement with previous in vitro findings of the neuroprotective role of PrPC and further support the hypothesis that functional loss of PrPC plays a pathogenic role in prion diseases. We also suggest that PrPC modulates BBB function.

Highly reproducible rat model of reversible forebrain ischemia--modified four-vessel occlusion model and its metabolic feature

BACKGROUND

The four-vessel occlusion method introduced by Pulsinelli et al. is widely used as an experimental model for reversible forebrain ischemia in rats.

METHOD

In this study, we further developed highly reproducible model of reversible forebrain ischemia. Under the microscope the visible vertebral arteries at the second vertebra could be easily electrocauterized and completely cut to yield complete cessation of circulation of both vertebral arteries. After 24 hours, male Wistar rats were subjected to 15, 30 and 45 minutes of forebrain ischemia by occluding both common carotid arteries with Sugita's temporary clips. (31)P-magnetic resonance spectra ((31)P-MRS) and (1)H-magnetic resonance images ((1)H-MRI) were obtained with a 6.3-T spectrometer to investigate sequential change of the in vivo brain metabolism. Electroencephalogram and the cortical blood flow by laser Doppler flowmetry were measured during ischemia and recirculation. Determination of endogenous superoxide scavenging activity in the brain cortex was performed by electron spin resonance spectrometry.

FINDINGS

Brain water contents evaluated by the dry-wet weight method were increased at 1 hour and 48 hours after recirculation, which were demonstrated by (1)H-MRI. The superoxide scavenging activity showed a significant decrease at 45 minutes of recirculation and a significant increase at 12 hours of recirculation. The present modified model demonstrated that the mortality rates by 72 hours were 8.3% (15 minutes ischemia), 15.0% (30 minutes ischemia), and 42.9% (45 minutes ischemia), all of which were higher than that of the original method described by Pulsinelli et al.

INTERPRETATION

In conclusion, this modified four-vessel occlusion method gives a high level of success in producing reversible forebrain ischemia.

Cytochemical and molecular biological aspects of the pituitary and pituitary adenomas--cell differentiation and transcription factors

The anterior pituitary is composed of several cell types, each responsible for the production of specific hormones. Each hormone secreting cells is defined by the activation of its respective hormone genes in a temporally and spatially regulated manner. Recent development in cytochemistry and molecular biology have provided various aspects of human pituitary adenomas, i.e., functional differentiation and classification. The molecular factors that determine hormone production have now been identified as transcription factors. Many novel transcription factors that play a role in anterior pituitary development are implicated. In this review, we focus on the transcriptional factors roles on functional differentiation of the pituitary cells and adenomas and the contribution of cytochemistry and recent development in molecular biological techniques.

Exogenous expression of Pit-1 in AtT-20 corticotropic cells induces endogenous growth hormone gene transcription

The pituitary-specific POU-homeodomain transcription factor, Pit-1, is known to regulate the expression of the GH gene in somatotropes, prolactin (PRL) in lactotropes, and TSH in thyrotropes. It is not normally expressed in corticotropes or gonadotropes. We addressed the question of whether exogenous Pit-1 was sufficient to induce ectopic transcription of the GH gene in the corticotropic cell line, AtT-20, or the gonadotropic cell line, alpha T3-1. A fusion gene composed of enhanced green fluorescent protein gene and human Pit-1 cDNA was transfected into AtT-20 and alpha T3-1 cells. The endogenous mouse GH mRNA was induced in three of nine AtT-20 cell lines and one of three alpha T3-1 cell lines containing the fusion gene. A small amount of GH protein was also detected in these cell lines. These data indicate that transfected Pit-1 is capable of inducing transcription of the GH gene in AtT-20 cells and alpha T3-1 cells. These data also suggest that synergistic co-factors might be required to transcribe the GH gene effectively for translation into GH protein. Furthermore, our findings support the hypothesis that the function of anterior pituitary cells is determined by the combinatorial action of specific transcription factors.

A case of solitary fibrous tumor of the meninges

We report a rare case of solitary fibrous tumor (SFT) of the meninges of the posterior fossa presenting as an intracerebellar hemorrhage. A 29-year-old woman was admitted with sudden-onset severe headache, nausea, and vomiting. A computed tomographic (CT) scan of the brain revealed an intracerebellar hemorrhage 3.5cm in diameter. Gadolinium-enhanced magnetic resonance imaging (MRI) showed a heterogeneous enhancement mass. A posterior craniotomy found a firm, highly vascular tumor attached to the meninges. Histologically, the tumor showed mostly sclerotic tissues with spindle cells. In few areas, the tumor had a more compact arrangement of spindle-shaped cells with vascular spaces and highly cellular components. Immunohistochemical study revealed strong CD-34 immunopositivity in many tumor cells. The tumor was diagnosed as SFT of the meninges. We report the clinical and histological features of this newly described tumor with a heterogeneous component.

Interplay of the main chain, chiral side chains, and solvent in conformational transitions: poly([(R)-3,7-dimethyloctyl]-[(S)-3-methylpentyl]silylene)

Light scattering, sedimentation equilibrium, viscosity, circular dichroism (CD), and UV absorption (UV) measurements were made on dilute solutions of poly([(R)-3,7-dimethyloctyl]-[(S)-3-methylpentyl]silylene)(PRS) as functions of molecular weight. From light scattering and viscosity data, PRS is found to be a very stiff polymer of persistence length q as large as 103 nm at 25 degrees C, essentially a 7(3) helix found in the solid state; q increases only gradually with lowering temperature between -15 and 25 degrees C. The CD data show that PRS undergoes a conformational transition around 3 degrees C in isooctane (transition temperature T(c)). The CD signal is largely positive at low temperatures, passes through zero at T(c), and becomes largely negative at higher temperatures; T(c) is independent of sample's chain length N. This is a highly cooperative helix (M)-to-helix (P) transition depending remarkably on N, as PRS is substantially rodlike. The CD data are converted to the fraction f(P) of P helix as a function of N and analyzed successfully by a statistical mechanical theory based on a helix reversal model, where a polymer chain consists of M and P helices intervened by helix reversals, with the result that the free energy difference DeltaG(h) between P and M shows a temperature dependence similar to that of 2f(P) - 1, whereas the helix reversal energy is substantially constant at 1.2 x 10(4) J mol(-1); the latter value means that the helix reversal occurs only once in 100 Si units or less. This DeltaG(h) change and solvent dependence of T(c) are explained by a double-well potential for the rotation about Si-Si bonds, which incorporates into DeltaG(h) the solvent interactions with the helical grooves of side chains surrounding the main chain. Detailed features of UV absorption spectra at different temperature and molecular weights are also presented.

Immunohistochemical analysis of RCAS1 in human pituitary adenomas

It has been reported that RCAS1 (receptor-binding cancer antigen expressed on SiSO cells) acts as a ligand for a receptor present on normal peripheral lymphocytes and induces apoptotic cell death. It is expressed in uterine and ovarian carcinomas, especially in invasive cancers. This immunohistochemical study is aimed to elucidate the expression of RCAS1 in human pituitary adenomas in order to clarify its role in their proliferative regulation and invasiveness. Five normal pituitary glands, 50 human pituitary adenomas, and one malignant glioma were subjected to immunohistochemical studies. In normal pituitary glands, immunostaining of RCAS1 and MIB-1 was not found. In malignant glioma, large numbers of cell nuclei were positive for MIB-1 (MIB-1 index: 28%), and RCAS1 was detected both in the cytoplasm and on the membrane of the tumor cells. Expression of RCAS1 was noted in 48% of pituitary adenomas immunohistochemically (60.0% of growth hormone-secreting adenomas, 60.0% of prolactin-secreting adenomas, 42.9% of adrenocorticotrophin-secreting adenomas, 40.0% of thyroid-stimulating hormone-secreting adenomas, 33.3% of nonfunctioning adenomas, and 44.4% of gonadotropin-subunit-positive adenomas). It showed no correlation with tumor type, size, and invasiveness. The statistically significant relationship between RCAS1 and MIB-1 positivity was identified in our study. These results suggest that expression of RCAS1 as well as MIB-1 positivity predict the growth potential of individual pituitary adenomas.

[Dissecting aneurysm of the posterior inferior cerebellar artery--studied by serial angiography]

We report the case of a 34-year-old male with cerebellar hemorrhagic infarction caused by a dissecting aneurysm of the left posterior inferior cerebellar artery (PICA). The patient suffered from a headache and vomiting for two days and was transferred to our hospital with sudden deterioration of consciousness. On admission, he was semicomatose. A CT scan revealed hemorrhagic infarction in the left cerebellum and upward herniation. The emergency operation for posterior fossa decompression was performed. Postoperatively, his consciousness level improved promptly and he had no neurological deficits except for slight gait disturbance. The first vertebral angiography was performed on Day 27. It showed a sausage-like dissecting aneurysm of the left distal PICA. We planned conservative therapy with careful observation because of there being no indication for an operation. Serial angiography was performed and demonstrated the regression of the dissecting aneurysm on Day 258. Dissecting aneurysms of the distal PICA are rare and their natural history is not well understood. Conservative therapy for vertebrobasilar dissecting aneurysms has often been reported. We suggest that conservative therapy with serial angiography is the treatment of choice especially for ischemic-type dissecting aneurysms. We review 17 cases of dissecting aneurysm of the distal PICA in this study.

Aneurysm of the distal posteroinferior cerebellar artery of extracranial origin: case report

OBJECTIVE AND IMPORTANCE

We describe a very rare case involving a ruptured intracranial aneurysm at the distal posteroinferior cerebellar artery (PICA) branching from the extracranial vertebral artery.

CLINICAL PRESENTATION

A 53-year-old woman experienced the sudden onset of a severe occipital headache and vomiting. Computed tomographic scanning revealed subarachnoid and intraventricular hemorrhage. Cerebral angiography of the left vertebral artery demonstrated the left PICA branching from the extracranial segment of the extracranial vertebral artery at the level of C2; a saccular aneurysm arose from the intracranial portion of the distal PICA.

INTERVENTION

Via the transcondylar approach, we were able to obtain adequate visualization without retracting important structures. To avoid injury to the anomalous PICA, the aneurysm was clipped.

CONCLUSION

Only four other cases of a distal aneurysm of the PICA branching from the extracranial vertebral artery have been reported in the literature. In all cases, the aneurysm originated at the intradural extracranial portion of the PICA. To our knowledge, the case presented here is the first report of a ruptured aneurysm at the level of the intracranial portion of the PICA branching from the extracranial segment of the vertebral artery.

The c-Jun NH2-terminal kinase3 (JNK3) gene: genomic structure, chromosomal assignment, and loss of expression in brain tumors

By examining 19 human cell lines derived from brain tumors for altered expression of expressed sequence tags (ESTs) in chromosomal band 4q21-22, we detected loss of expression, in 10 cell lines, of two sequences, WI6336 and WI7913. Both corresponded to the c-Jun NH2-terminal kinase (JNK) 3. In the present study, genomic cloning revealed that the JNK3 gene consists of 14 exons interrupted by 13 introns; its transcription-initiation site is within exon 3 and the termination codon lies in exon 14. Fluorescence in situ hybridization (FISH) and radiation-hybrid mapping confirmed the gene to 4q21-22. Together with prior evidence that, in JNK3-deficient mice, the JNK3 signaling pathway mediates apoptosis in central nervous tissue, our results suggest that loss of expression of the JNK3 gene may play an important role in the development of brain tumors in humans.

Thyrotropin-secreting pituitary adenomas. Clinical and biological heterogeneity and current treatment

Thyrotropin (TSH)-secreting pituitary adenomas represent about 1-2% of all pituitary adenomas and cause secondary or central hyperthyroidism. TSH-secreting adenomas are part of the syndrome of 'inappropriate secretion of TSH' (SITSH). The hormonal profile is characterized by nonsuppressed TSH in the presence of high levels of free thyroid hormones (FT3 and FT4). Previous reports have described the surgical cure of TSH adenoma to be more difficult than other functional adenomas because of large and invasive features. However, with the current introduction of ultrasensitive immunometric assays, TSH-secreting adenomas are more often recognized. Early diagnosis of TSH-secreting adenomas leads to a high rate of remission of hyperthyroidism after surgery. However, some of those type of adenomas have clinical heterogeneity, and subsequently cannot be cured by surgery alone. We present our experiences and review reported cases of TSH-secreting adenomas to direct current management.

[A case of iatrogenic carotid artery dissection treated with radial artery graft]

A case of iatrogenic intracranial artery dissection is reported. A 52-year-old female developed severe headache and nausea. Brain CT showed diffuse subarachnoid hemorrhage. On admission, carotid angiography revealed an aneurysm in the right middle cerebral artery and the intact right internal carotid artery. The aneurysm was clipped successfully. Carotid angiography on day 7 revealed dissection in the right internal carotid artery. Repeated angiograms at 10 and 31 days showed progression of the carotid artery dissection. Findings of ECD-SPECT on day 31 (Balloon occlusion test) suggested low perfusion of the right internal carotid artery territory. The patient underwent surgical reconstruction of the right internal carotid artery using a radial artery. She presented with right abducens nerve palsy three days after the radial artery graft. The patency of the radial artery graft was proved by the post-operative angiography. Internal carotid artery dissection may occur spontaneously or as a result of trauma. An iatrogenic dissection is an uncommon complication of cerebral angiography. There are no evidence-based guidelines for the treatment although anticoagulation therapy is most commonly used. The present case emphasizes the usefulness of radial artery graft for traumatic carotid artery dissection.