A refined method of en bloc open-door laminoplasty for resection of intradural spinal tumors in the thoracic and lumbar spine

BACKGROUND

The open-door laminoplasty has been used to treat cervical spondylotic myelopathy. This technique has been applied to the surgical treatment of thoracic and lumbar spinal canal tumors instead of simple laminectomy or hemilaminectomy. However, previously reported laminoplasty methods did not keep posterior supporting elements intact such as the laminae and the spinous processes with supraspinous and interspinous ligaments, and almost all of them needed instruments for the fixation of reconstructed laminae. The purpose of this paper is to introduce our open-door laminoplasty method, which keep all posterior supporting elements intact and reconstruct the laminae without instrument.

METHODS

Eight patients (mean age 61 years) underwent en bloc open-door laminoplasty in the thoracic and lumbar spine for resection of intradural spinal tumors. Two grooves are made bilaterally on the laminae just medial side of the facet joints. One-half of each spinous process of the adjacent vertebrae above and below the laminoplasty is cracked diagonally to create a green stick fracture and bent to the hinged side for sufficient elevation of the laminar flap. After tumor resection, the laminar flap is restored to its original site, resulting in the complete preservation of the posterior supporting elements.

RESULTS

Operative exposure was good and permitted complete resection. No complications such as postoperative spinal canal stenosis or kyphosis were observed. Computed tomography(CT) indicated that bony fusion occurred in all cases.

CONCLUSION

The supraspinous and interspinous ligaments above and below laminoplasty were kept intact during surgery in our method. Therefore, the continuity of posterior supporting elements (laminae and spinous processes connected by supraspinous and interspinous ligaments) were completely preserved.

Randomized trial of granulocyte colony-stimulating factor for spinal cord injury

Attenuation of the secondary injury of spinal cord injury (SCI) can suppress the spread of spinal cord tissue damage, possibly resulting in spinal cord sparing that can improve functional prognoses. Granulocyte colony-stimulating factor (G-CSF) is a haematological cytokine commonly used to treat neutropenia. Previous reports have shown that G-CSF promotes functional recovery in rodent models of SCI. Based on preclinical results, we conducted early phase clinical trials, showing safety/feasibility and suggestive efficacy. These lines of evidence demonstrate that G-CSF might have therapeutic benefits for acute SCI in humans. To confirm this efficacy and to obtain strong evidence for pharmaceutical approval of G-CSF therapy for SCI, we conducted a phase 3 clinical trial designed as a prospective, randomized, double-blinded and placebo-controlled comparative trial. The current trial included cervical SCI [severity of American Spinal Injury Association (ASIA) Impairment Scale (AIS) B or C] within 48 h after injury. Patients are randomly assigned to G-CSF and placebo groups. The G-CSF group was administered 400 μg/m²/day × 5 days of G-CSF in normal saline via intravenous infusion for five consecutive days. The placebo group was similarly administered a placebo. Allocation was concealed between blinded evaluators of efficacy/safety and those for laboratory data, as G-CSF markedly increases white blood cell counts that can reveal patient treatment. Efficacy and safety were evaluated by blinded observer. Our primary end point was changes in ASIA motor scores from baseline to 3 months after drug administration. Each group includes 44 patients (88 total patients). Our protocol was approved by the Pharmaceuticals and Medical Device Agency in Japan and this trial is funded by the Center for Clinical Trials, Japan Medical Association. There was no significant difference in the primary end point between the G-CSF and the placebo control groups. In contrast, one of the secondary end points showed that the ASIA motor score 6 months (P = 0.062) and 1 year (P = 0.073) after drug administration tend to be higher in the G-CSF group compared with the placebo control group. The present trial failed to show a significant effect of G-CSF in primary end point.

Prescription patterns of psychotropics in patients receiving synthetic glucocorticoids

OBJECTIVE

Synthetic glucocorticoids cause various psychiatric symptoms. Prescription of psychotropic drugs could be considered to be a proxy for manifestation of psychiatric symptoms. The aim of this study was to investigate the prescriptions of psychotropics in outpatients receiving synthetic glucocorticoids.

METHODS

We used the claims sampling data during January 2015 from the National Database of Health Insurance Claims and Specific Health Checkups of Japan made by the Ministry of Health, Labor, and Welfare in Japan. We compared the prescription rates of psychotropics between outpatients receiving oral synthetic glucocorticoids and age- and sex-matched controls and the prescription rates of psychotropics among the eight dosage groups of synthetic glucocorticoids by chi-squared test, and chlorpromazine/imipramine/diazepam equivalent doses (or daily defined doses) of respective psychotropics among these groups using Welch's t-test.

RESULTS

Synthetic glucocorticoids were prescribed to 3.1% (n = 18 122) of 581 990 patients. The prescription rates of psychotropics were significantly higher among the synthetic glucocorticoid recipients than among the non-recipients: antipsychotics, 1.8% (n = 321) vs. 1.1% (n = 201) (P = 1.4 × 10^-7 ); antidepressants, 4.0% (n = 724) vs. 2.0% (n = 359) (P = 8.7 × 10^-30 ); anxiolytics/hypnotics, 16.7% (n = 3029) vs. 10.2% (n = 1841) (P = 2.7 × 10^-75 ); and mood stabilizers, 1.3% (n = 238) vs. 0.7% (n = 120) (P = 3.6 × 10^-10 ) respectively. There was no significant difference in the prescription rates of any psychotropic drugs, other than anxiolytics/hypnotics, among the eight synthetic glucocorticoid dosage groups.

CONCLUSION

Prescriptions of oral synthetic glucocorticoids were found to be associated with the use of any of the types of psychotropic drugs, other than anxiolytics/hypnotics, although a causal relationship could not be confirmed due to the retrospective and cross-sectional nature of this study.

Placebo effects in adult and adolescent patients with schizophrenia: combined analysis of nine RCTs

OBJECTIVE

To examine characteristics of placebo responders and seek optimal criteria of early improvement with placebo for predicting subsequent placebo response in patients with schizophrenia.

METHOD

Data of 672 patients with schizophrenia randomized to placebo in nine double-blind antipsychotic trials were analyzed. Multiple logistic regression analyses were conducted to examine associations between placebo response at week 6 (i.e., a ≥ 25% reduction in the Positive and Negative Syndrome Scale [PANSS] score) and gender, age, study locations, baseline PANSS total or Marder 5-Factor scores, and per cent PANSS score reduction at week 1. Predictive power of improvement at week 1 for subsequent response was investigated; sensitivity and specificity of incremental 5% cutoff points between 5% and 25% reduction in the PANSS total score at week 1 were calculated.

RESULTS

Per cent PANSS total score reduction at week 1 and lower PANSS Marder disorganized thought scores at baseline were significantly associated with subsequent placebo response. A 10% reduction in a per-protocol analysis or a 15% reduction in last-observation-carried-forward analysis in the PANSS total score at week 1 showed the highest predictive power.

CONCLUSION

These findings are informative to identify potential placebo responders at the earliest opportunity for optimal trial design for schizophrenia.

Study protocol for the G-SPIRIT trial: a randomised, placebo-controlled, double-blinded phase III trial of granulocyte colony-stimulating factor-mediated neuroprotection for acute spinal cord injury

INTRODUCTION

Granulocyte colony-stimulating factor (G-CSF) is generally used for neutropaenia. Previous experimental studies revealed that G-CSF promoted neurological recovery after spinal cord injury (SCI). Next, we moved to early phase of clinical trials. In a phase I/IIa trial, no adverse events were observed. Next, we conducted a non-randomised, non-blinded, comparative trial, which suggested the efficacy of G-CSF for promoting neurological recovery. Based on those results, we are now performing a phase III trial.

METHODS AND ANALYSIS

The objective of this study is to evaluate the efficacy of G-CSF for acute SCI. The study design is a prospective, multicentre, randomised, double-blinded, placebo-controlled comparative study. The current trial includes cervical SCI (severity of American Spinal Injury Association (ASIA) Impairment Scale B/C) within 48 hours after injury. Patients are randomly assigned to G-CSF and placebo groups. The G-CSF group is administered 400 µg/m²/day×5 days of G-CSF in normal saline via intravenous infusion for 5 consecutive days. The placebo group is similarly administered a placebo. Our primary endpoint is changes in ASIA motor scores from baseline to 3 months. Each group includes 44 patients (88 total patients).

ETHICS AND DISSEMINATION

The study will be conducted according to the principles of the World Medical Association Declaration of Helsinki and in accordance with the Japanese Medical Research Involving Human Subjects Act and other guidelines, regulations and Acts. Results of the clinical study will be submitted to the head of the respective clinical study site as a report after conclusion of the clinical study by the sponsor-investigator. Even if the results are not favourable despite conducting the clinical study properly, the data will be published as a paper.

TRIAL REGISTRATION NUMBER

UMIN000018752.

Religiosity and psychological resilience in patients with schizophrenia and bipolar disorder: an international cross-sectional study

OBJECTIVE

The impact of religious/spiritual activities on clinical outcomes in patients with serious mental illnesses remains controversial, which was addressed in this international cross-sectional study.

METHOD

Three-hundred sixty-nine subjects were recruited from Austria (n = 189) and Japan (n = 180), consisting of 112 outpatients with paranoid schizophrenia, 120 with bipolar I disorder (DSM-IV), and 137 healthy controls. Religiosity was assessed in terms of attendance and importance of religious/spiritual activities, while resilience was assessed using the 25-item Resilience Scale. General linear models were used to test whether higher religiosity will be associated with higher resilience, higher social functioning, and lower psychopathology. The association between levels of spiritual well-being and resilience was also examined.

RESULTS

Attendance of religious services (F_[4,365] = 0.827, P = 0.509) and importance of religion/spirituality (F_[3,365] = 1.513, P = 0.211) did not show significant associations with resilience. Regarding clinical measures, a modest association between higher importance of religion/spirituality and residual manic symptoms was observed in bipolar patients (F_[3,118] = 3.120, P = 0.029). In contrast to the findings regarding religiosity, spiritual well-being showed a strong positive correlation with resilience (r = 0.584, P < 0.001).

CONCLUSION

The protective effect of religiosity in terms of resilience, social functioning, and psychopathology was not evident in our sample. Spiritual well-being appears more relevant to resilience than religiosity.

High serum total cholesterol is associated with suicide mortality in Japanese women

OBJECTIVE

To investigate the association between serum total cholesterol (TC) and suicide using a large general population cohort with long follow-up times.

METHOD

Analyses included 16 341 men and 28 905 women aged 40-69 from the Japan Public Health Center-based Prospective Study followed from 1990 to 2012. TC levels were defined per clinical guidelines: low (<4.66 mmol/l [180 mg/dl]), normal (4.66-5.70 mmol/l [180-220 mg/dl]), and high (≥5.70 mmol/l [220 mg/dl]). Cox proportional hazards regression models were used to determine hazard ratios (HR) and confidence intervals (CI) for suicide according to TC level. Mean follow-up time was 19 years for men and 20 years for women.

RESULTS

There were 185 suicides (men: 107; women: 78) during follow-up. Compared to women with normal TC, women with high TC had a significantly increased risk of suicide (HR = 1.90, 95% CI, 1.13-3.19). Incremental increases (0.26 mmol/l [10 mg/dl]) of low-density lipoprotein (HR = 1.11, 95% CI, 1.02-1.21) and non-high-density lipoprotein cholesterol (HR = 1.09, 95% CI, 1.01-1.18) were also associated with increased risk of suicide in women. There was no association between TC levels, or lipid fractions, and suicide in men.

CONCLUSION

High TC levels may be associated with an increased risk of suicide in women.

Quality of life in schizophrenia and bipolar disorder: The impact of symptomatic remission and resilience

BACKGROUND

Health-related quality of life (HRQOL) is significantly affected in individuals with schizophrenia or bipolar I disorder (BD-I). The current study investigated whether symptomatic remission and resilience might differently impact HRQOL in these patients.

METHODS

Fifty-two patients with schizophrenia and 60 patients suffering from BD-I from outpatient mental health services as well as 77 healthy control subjects from the general community were included into a cross-sectional study. HRQOL and resilience were assessed using the WHOQOL-BREF and the Resilience Scale. In patients, psychopathology was quantified by the Positive and Negative Syndrome Scale or the Montgomery Asberg Depression Rating Scale and the Young Mania Rating Scale, respectively.

RESULTS

Notably, both patient groups showed lower HRQOL and resilience compared to control subjects, non-remitted patients indicated lower HRQOL than remitted ones. The effect of remission on HRQOL was significantly larger in patients with BD-I than in those with schizophrenia but did not explain the difference in HRQOL between groups. Resilience predicted HRQOL in all three groups. When accounting for the effect of resilience among remitted patients, only the difference in HRQOL between schizophrenia patients and control subjects was significant.

CONCLUSION

These findings demonstrate the impact of symptomatic remission and resilience on HRQOL of both patients suffering from schizophrenia and BD-I and indicate that these factors are especially relevant for HRQOL of patients with BD-I.

Retrospective analysis of the survival benefit of chemotherapy for recurrent or advanced epithelial ovarian carcinoma in patients previously treated with paclitaxel plus platinum-based chemotherapy

AIM

The outcomes of treatment for women with recurrent or advanced epithelial ovarian carcinoma previously treated with pacli- taxel plus platinum-based chemotherapy were analyzed.

MATERIALS AND METHODS

Retrospective analysis was performed in a total of 65 series of treatments provided for 35 patients with a history of paclitaxel plus platinum-based chemotherapy. The chemotherapy regimens used were classified into the following four types for analysis: conventional paclitaxel plus carboplatin therapy (TC arm), pegylated liposomal doxorubicin-containing regimens (PLD arm), CPT-11-containing regimens (CPT-11 arm), and others. Disease-control rates (DCRs) were compared and subjected to univariate analysis. Progression-free survival (PFS) was determined from the date of the first cycle of each chemotherapy with the Kaplan-Meier method, and comparisons were performed using the log-rank test.

RESULTS

DCR was 80%, 71%, and 26% for the TC, PLD, and CPT-l arms, respectively. The median PFS was 286, 372, and 76 days for the TC, PLD, and CPT-11 arms, respectively. There was no discernible difference in PFS between the TC and the PLD arm. In contrast, PFS of the CPT- 11 arm was significantly shorter than that of the TC and PLD arms. In addition, three of seven (42.9%) treatments in the PLD arm maintained a progression-free period for longer than one year, while only one of 25 (4%) treatments in the TC arm maintained a progression-free period for more than one year.

CONCLUSIONS

The PFS of PLD is similar to that of TC. PLD-containing regimens might have a potential benefit with a higher PFS over one year than the TC regimen.

Predicting Plasma Olanzapine Concentration Following a Change in Dosage: A Population Pharmacokinetic Study

INTRODUCTION

Due to high inter-individual variability in peripheral pharmacokinetic parameters, dosing of antipsychotics currently relies on clinical trial-and-error, and predicting antipsychotic plasma concentrations before changing a dose has been a challenge.

METHODS

Patients with schizophrenia receiving a stable dose of olanzapine were included. 2 plasma samples were collected at 2 given time points for the measurement of plasma olanzapine concentrations. At least 7 days after a dosage change of olanzapine, a third sample was collected. The plasma concentration of the third sample was predicted in a blinded fashion using a mixed-effects model with NONMEM(®), using the following information: the 2 baseline plasma concentrations, the interval between the last dose and blood draw, and clinical and demographic information.

RESULTS

31 subjects (mean±SD age=56.0±11.6; 19 men) were enrolled. The mean prediction (95% confidence interval) errors were 1.6 (-2.8 to 6.0) ng/mL. A highly significant correlation was observed between the observed and predicted concentrations of the third sample (r=0.91, p<0.001).

DISCUSSION

Plasma olanzapine concentrations following an actual dosage change can be predicted in advance with a high degree of certainty.

Timing of adjunctive therapy in the treatment of depression: a chart review

INTRODUCTION

The objective of this study was to examine the evolution of antidepressant switch and adjunctive therapy.

METHODS

This chart review was conducted at 6 primary psychiatric clinics or hospitals, in Tokyo, Japan. A chart review of longitudinal prescriptions was conducted regarding 633 outpatients with major depressive disorder for up to 2 years after their first visit. Patients who had already received antidepressants prior to the visit were excluded.

RESULTS

22.6% (N=143) of the patients completed or continued the outpatient treatment over the 2 years while 27 (4.3%), 23 (3.6%), and 439 (69.4%) patients discontinued it due to hospitalization, referral to another clinic, and loss to follow-up, respectively. A total of 597 episodes of antidepressant treatment were identified. Among them, 482 episodes (80.7%) were associated with the suggested dose ranges while antidepressant drugs were under-dosed in 19.3% (N=115) of the episodes. 50 patients (7.9%) received adjunctive therapy; it was employed after a median of only one antidepressant had been tried.

CONCLUSION

Psychiatrists may be hasty in prescribing an adjunctive therapy in the treatment of depression.

Improved non-invasive total haemoglobin measurements after in-vivo adjustment

We hypothesised that an in-vivo adjustment method and/or a newer sensor would increase the accuracy of non-invasive and continuous haemoglobin monitoring (SpHb) measurements. Two sensors, the R1-25 and R2-25a (the newer version), were used with laboratory total haemoglobin concentration (tHb) values simultaneously recorded. In-vivo adjusted SpHb (AdHb) was calculated by a simple formula: AdHb = SpHb - (1(st) SpHb - 1(st) tHb). The correlation coefficients between SpHb (or AdHb) and tHb were compared: SpHb in both sensors correlated strongly with tHb (p < 0.0001). In-vivo adjustment improved the correlation coefficient between SpHb and tHb from 0.86 to 0.95 for the R1-25 and from 0.83 to 0.93 for the R2-25a. There was no difference between the R1-25 and R2-25a sensors. The in vivo adjustment method improved the accuracy of SpHb measurements in both sensors.

Incidence of nocturnal leg cramps in patients with lumbar spinal stenosis before and after conservative and surgical treatment

PURPOSE

To examine the effects of conservative and surgical treatments for nocturnal leg cramps in patients with lumbar spinal stenosis (LSS). Nocturnal leg cramps is frequently observed in patients with peripheral neuropathy. However, there have been few reports on the relationship between nocturnal leg cramps and LSS, and it remains unknown whether conservative or surgical intervention has an impact on leg cramps in patients with LSS.

MATERIALS AND METHODS

The subjects were 130 LSS patients with low back and leg pain. Conservative treatment such as exercise, medication, and epidural block was used in 66 patients and surgical treatment such as decompression or decompression and fusion was performed in 64 patients. Pain scores and frequency of nocturnal leg cramps were evaluated based on self-reported questionnaires completed before and 3 months after treatment.

RESULTS

The severity of low back and leg pain was higher and the incidence of nocturnal leg cramps was significantly higher before treatment in the surgically treated group compared with the conservatively treated group. Pain scores improved in both groups after the intervention. The incidence of nocturnal leg cramps was significantly improved by surgical treatment (p=0.027), but not by conservative treatment (p=0.122).

CONCLUSION

The findings of this prospective study indicate that the prevalence of nocturnal leg cramps is associated with LSS and severity of symptoms. Pain symptoms were improved by conservative or surgical treatment, but only surgery improved nocturnal leg cramps in patients with LSS. Thus, these results indicate that the prevalence of nocturnal leg cramps is associated with spinal nerve compression by LSS.

Simultaneous anterior and posterior screw fixations confined to the axis for stabilization of a 3-part fracture of the axis (odontoid, dens, and hangman fractures): report of 2 cases

Fractures of the axis are considered to be one of the most common injuries to the cervical spine, accounting for more than 20% of all cervical spine fractures. Multiple fractures of the axis are much rarer, accounting for 1% of all cervical fractures. Management of such complex fractures is still challenging, and there is no strong consensus for the treatment. The authors describe the cases of 2 patients who presented with 3-part fractures of the axis consisting of an odontoid Type II fracture and a Levine-Edwards Type IA fracture, which were treated with concurrent insertion of an anterior odontoid screw and bilateral posterior pedicle screws. The cases presented were characterized by 1) a Type II odontoid fracture; 2) a Type IA traumatic spondylolisthesis with no or a little translation and angulation of C-2 on C-3 in a ring fracture of the axis; and 3) no disorders at the C2-3 disc on MR images. Therefore, the authors performed surgery confined to the axis by concurrently inserting an anterior odontoid screw and posterior bilateral pedicle screws without arthrodesis of C2-3. This was followed with cervical soft collar fixation for only 1-2 weeks. The outcomes were favorable, including good osteosynthesis, high primary stability, early patient mobilization, and preserved range of motion of the cervical spine at C2-3 as well as at C1-2.

Conservative and surgical treatment improves pain and ankle-brachial index in patients with lumbar spinal stenosis

PURPOSE

The pathological mechanism of lumbar spinal stenosis is reduced blood flow in nerve roots and degeneration of nerve roots. Exercise and prostaglandin E1 is used for patients with peripheral arterial disease to increase capillary flow around the main artery and improve symptoms; however, the ankle-brachial index (ABI), an estimation of blood flow in the main artery in the leg, does not change after treatment. Lumbar spinal nerve roots contain somatosensory, somatomotor, and unmyelinated autonomic nerves. Improved blood flow by medication with prostaglandin E1 and decompression surgery in these spinal nerve roots may improve the function of nerve fibers innervating muscle, capillary, and main vessels in the lower leg, resulting in an increased ABI. The purpose of the study was to examine whether these treatments can improve ABI.

MATERIALS AND METHODS

One hundred and seven patients who received conservative treatment such as exercise and medication (n=56) or surgical treatment (n=51) were included. Low back pain and leg pain scores, walking distance, and ABI were measured before treatment and after 3 months of conservative treatment alone or surgical treatment followed by conservative treatment.

RESULTS

Low back pain, leg pain, and walking distance significantly improved after both treatments (p<0.05). ABI significantly increased in each group (p<0.05).

CONCLUSION

This is the first investigation of changes in ABI after treatment in patients with lumbar spinal stenosis. Improvement of the spinal nerve roots by medication and decompression surgery may improve the supply of blood flow to the lower leg in patients with lumbar spinal stenosis.

Craniospinal irradiation using helical tomotherapy: evaluation of acute toxicity and dose distribution

The purpose of this study was to evaluate acute toxicity of craniospinal irradiation (CSI) using helical tomotherapy (HT) and compare its dose distribution with that of conventional linac-based plans. Twelve patients with various brain tumors were treated with HT-CSI. Median patient age was 14 years (range: 4-37 years). Median CSI dose was 30.6 Gy in 18 fractions (range: 23.4-40 Gy in 13-25 fractions). Toxicities were assessed according to the Common Terminology Criteria for Adverse Events version 4.0. Before CSI, 11 patients (92%) received neoadjuvant chemotherapy, so acute toxicity was evaluated by comparing patient status before and after CSI. HT-CSI plans were compared with linac-based CSI plans made using Pinnacle(3) planning system in 9 patients. All patients completed planned CSI without interruption. Grade 3 or higher toxicities were leukopenia seen in 11 patients (92%), anorexia in 6 (50%), anemia in 5 (42%), and thrombopenia in 5 (42%). Administration of granulocyte colony-stimulating factor, platelet transfusion and total parenteral nutrition were required in 8 (67%), 5 (42%) and 5 (42%) patients, respectively. HT plans were superior to linac-based plans in terms of homogeneity and conformality in planning target volume (PTV). For most organs at risk (OARs), volumes receiving more than 10 Gy (V10 Gy) or 20 Gy (V20 Gy) were lower in HT plans. However, HT plans significantly increased mean doses to the lung, kidneys and liver, and V5 Gy of 6 OARs including the lung. Despite intensive neoadjuvant chemotherapy, acute toxicity of HT-CSI was acceptable. HT provided better dose distribution in PTV than conventional linac. In most OARs, smaller volumes received >10-20 Gy in HT plans, although larger volumes received 5-10 Gy.

Rotational hypermobility of disc wedging using kinematic CT: preliminary study to investigate the instability of discs in degenerated scoliosis in the lumbar spine

The number of patients showing lumbar degenerative scoliosis, including disc wedging, has increased, and examination of the mechanism of spinal nerve compression due to lateral and rotational mobility of the lumbar spine is necessary. Thirty-two patients with L4-L5 disc wedging but without antero- or retrospondylolisthesis and ten age-matched controls were examined. The angle of disc wedging and change in the angle between left and right bending were evaluated by anterior-posterior X-ray images of patients while they were in a standing position. The degree of disc degeneration and existence of vacuum phenomena were evaluated at the L4-L5 discs. Rotational mobility between maximal right and left rotation was examined by computed tomography (CT). Rotational mobility was measured using the spinal transverse processes of L4 and L5. The relationship between these factors was statistically evaluated using multivariate analysis and Spearman's correlation test. There was a significant increase in the average rotational mobility of the L4-L5 disc-wedging group. In the L4-L5 disc-wedging group, the increased angle of disc wedging and change in the angle between left and right bending correlated with increased rotational mobility. The degree of disc degeneration did not affect rotational mobility. However, existence of vacuum phenomena increased the rotational mobility of the L4-L5 disc-wedging group. This is the first study to evaluate the rotational hypermobility of L4-L5 disc wedging in patients without antero- or retrospondylolisthesis using kinematic CT. Increases in the wedging angle and abnormal instability of lateral bending correlated with increased rotational mobility. For surgical planning of degenerative L4-L5 disc wedging, it is important to consider rotational hypermobility using kinematic CT or X-ray imaging findings of lateral bending.

Local adaptation at the range peripheries of Sitka spruce

High-dispersal rates in heterogeneous environments and historical rapid range expansion can hamper local adaptation; however, we often see clinal variation in high-dispersal tree species. To understand the mechanisms of the species' distribution, we investigated local adaptation and adaptive plasticity in a range-wide context in Sitka spruce, a wind-pollinated tree species that has recently expanded its range after glaciations. Phenotypic traits were observed using growth chamber experiments that mimicked temperature and photoperiodic regimes from the limits of the species realized niche. Bud phenology exhibited parallel reaction norms among populations; however, putatively adaptive plasticity and strong divergent selection were seen in bud burst and bud set timing respectively. Natural selection appears to have favoured genotypes that maximize growth rate during available frost-free periods in each environment. We conclude that Sitka spruce has developed local adaptation and adaptive plasticity throughout its range in response to current climatic conditions despite generally high pollen flow and recent range expansion.

Adaptive gradients and isolation-by-distance with postglacial migration in Picea sitchensis

Fossil pollen records suggest rapid migration of tree species in response to Quaternary climate warming. Long-distance dispersal and high gene flow would facilitate rapid migration, but would initially homogenize variation among populations. However, contemporary clinal variation in adaptive traits along environmental gradients shown in many tree species suggests that local adaptation can occur during rapid migration over just a few generations in interglacial periods. In this study, we compared growth performance and pollen genetic structure among populations to investigate how populations of Sitka spruce (Picea sitchensis) have responded to local selection along the historical migration route. The results suggest strong adaptive divergence among populations (average Q(ST)=0.61), corresponding to climatic gradients. The population genetic structure, determined by microsatellite markers (R(ST)=0.09; F(ST)=0.11), was higher than previous estimates from less polymorphic genetic markers. The significant correlation between geographic and pollen haplotype genetic (R(ST)) distances (r=0.73, P<0.01) indicates that the current genetic structure has been shaped by isolation-by-distance, and has developed in relatively few generations. This suggests relatively limited gene flow among populations on a recent timescale. Gene flow from neighboring populations may have provided genetic diversity to founder populations during rapid migration in the early stages of range expansion. Increased genetic diversity subsequently enhanced the efficiency of local selection, limiting gene flow primarily to among similar environments and facilitating the evolution of adaptive clinal variation along environmental gradients.

A comparative study of the efficacy and safety profiles between fluvoxamine and nortriptyline in Japanese patients with major depression

OBJECTIVE

The aim of this study was to compare the efficacy and safety profiles between fluvoxamine and nortriptyline in Japanese patients with major depression.

METHODS

The efficacy and safety profiles of fluvoxamine, a selective serotonin-reuptake inhibitor, and nortriptyline were compared under a single-blind fashion in 74 Japanese patients with major depression. The efficacy was assessed using the 17-item Hamilton Rating Scale for Depression (HAM-D), Clinical Global Impression Scale (CGI) severity and improvement scores, while the safety profiles were assessed using the UKU Side Effect Rating Scale at baseline, and on days 7, 14, 28 and 56. Moreover, with the aim of determining the distinct efficacy profiles of each drug, the effects on each of the factor scores extracted by the principal component analysis performed for HAM-D scores were compared between drugs.

RESULTS

Both drug groups showed significant amelioration of depressive symptomatology over the trial period lasting for 8 weeks. Statistical analyses revealed no significant between-group differences regarding the efficacy assessed by either HAM-D or CGI scores; however, the efficacy of nortriptyline tended to appear earlier than that of fluvoxamine. Moreover, no significant differences were obtained for the factor scores, representing 'depressed mood', 'physical symptoms' or 'sleep disturbances', although 'sleep disturbances' appeared to improve earlier in the nortriptyline group than in the fluvoxamine group. As for the safety profiles, the nortriptyline group scored a significantly higher incidence of adverse events such as dysarthria or orthostatic dizziness, as well as increased heart rate.

CONCLUSIONS

These findings suggest that fluvoxamine is generally comparable to nortriptyline in its efficacy and superior in its safety profile, in accordance with findings obtained in previous comparative clinical trials conducted in Caucasian populations.

Recognition of emotion from moving facial and prosodic stimuli in depressed patients

BACKGROUND

It has been suggested that depressed patients have a "negative bias" in recognising other people's emotions; however, the detailed structure of this negative bias is not fully understood.

OBJECTIVES

To examine the ability of depressed patients to recognise emotion, using moving facial and prosodic expressions of emotion.

METHODS

16 depressed patients and 20 matched (non-depressed) controls selected one basic emotion (happiness, sadness, anger, fear, surprise, or disgust) that best described the emotional state represented by moving face and prosody.

RESULTS

There was no significant difference between depressed patients and controls in their recognition of facial expressions of emotion. However, the depressed patients were impaired relative to controls in their recognition of surprise from prosodic emotions, judging it to be more negative.

CONCLUSIONS

We suggest that depressed patients tend to interpret neutral emotions, such as surprise, as negative. Considering that the deficit was seen only for prosodic emotive stimuli, it would appear that stimulus clarity influences the recognition of emotion. These findings provide valuable information on how depressed patients behave in complicated emotional and social situations.

Primary malignant melanoma of the oral cavity: assessment of outcome from the clinical records of 35 patients

Oral malignant melanoma is extremely rare and carries a poor prognosis. The treatment of choice remains controversial. We retrospectively studied 35 patients with primary malignant melanoma of the oral cavity between 1970 and 2001 to define the clinical features of this disease and evaluate treatment methods. The main variables studied were clinical findings, response to therapy, and outcome. Surgery with complete macroscopic resection was performed at the primary site in 13 patients (surgery group) and radiotherapy was done without surgery in 17 (non-surgery group). The 5-year cumulative survival rate was 15.4% in the surgery group, 35.3% in the non-surgery group, and 21.8% overall. Distant metastasis was present in 64.7% (11/17) of the non-surgery group and 76.9% (10/13) of the surgery group. Improved outcome in oral malignant melanoma requires the development of new therapies and the prevention of distant metastasis.

Constant involvement of the Betz cells and pyramidal tract in amyotrophic lateral sclerosis with dementia: a clinicopathological study of eight autopsy cases

We investigated clinicopathologically pyramidal signs, including hyperreflexia, Babinski sign, and spasticity, and the involvement of the primary motor cortex and pyramidal tract, in eight Japanese autopsy cases of amyotrophic lateral sclerosis (ALS) with dementia. Pyramidal signs were observed in seven (88%) of the eight autopsy cases. Hyperreflexia and Babinski sign were evident in seven (88%) and three (38%) patients, respectively, but spasticity was not observed in any of the eight patients. Loss of Betz cells in the primary motor cortex was evident in the seven cases in which this structure was examined. Astrocytosis in the fifth layer of the primary motor cortex was noticed in three cases. In all eight cases, involvement of the pyramidal tract was obvious in the medulla oblongata, but no involvement of the pyramidal tract was found in the midbrain. Involvement of the pyramidal tract in the spinal cord, particularly of large myelinated fibers, was observed in all six cases in which the spinal cord was examined. In ALS with dementia, pyramidal signs were shown to be present more frequently than previously believed, and the clinicopathological correlation between pyramidal signs and involvement of the pyramidal tract was obvious. Constant involvement of Betz cells and the pyramidal tract in ALS with dementia has not been reported. Our clinicopathological findings may make a contribution to the understanding of the clinicopathological hallmarks of this disorder. Furthermore, we believe that this study will also contribute to the elucidation of the nosological status of ALS with dementia.

Microvilli and desmosomes of squamous cell carcinoma cells in tongue carcinoma related to regional lymph node metastasis: ultrastructural and immunohistochemical studies with transferrin receptor

Squamous cell carcinomas of the tongue (n = 49), consisting of 21 cases with cervical lymph node metastasis and 28 nonmetastatic cases, were examined by electron microscopy with special emphasis on tumor cell attachment. No difference of tumor size (T classification) or pathological findings between the metastatic group and the nonmetastatic group was found. The metastatic cases had numerous microvilli and a small number of desmosomes regardless of the width of the intercellular spaces. The nonmetastatic cases had few microvilli in relatively wide intercellular spaces, or, in the cases in which numerous microvilli were present in the narrow intercellular spaces, the tumor cells were connected by a large number of desmosomes. Transferrin receptor, which is a marker of cell proliferation, was localized in the cell membrane by immunohistochemistry and especially in microvilli by immunoelectron microscopy. It is suggested that microvilli might be related to the proliferation and the metastasis of squamous cell carcinoma cells.

Investigation of titanium leak to bone tissue surrounding dental titanium implant: electron microscopic findings and analysis by electron diffraction

This study investigated the tissue response associated with dental titanium implants. The mandibular third and fourth premolars and first molar of three adult beagle dogs were extracted bilaterally. Healing was then allowed for 3 months. Six titanium implants were placed in the mandibles of a dog. Three weeks after the implantation, mandibular sections containing the implants were retrieved with the use of a bone saw and investigated by light and electron microscopy, X-ray microanalyzer, and electron diffraction. Scanning electron microscopic observation showed titanium particles on the implant-bone interface, and investigation by microanalyzer revealed titanium not only on the implant-bone interface but also in the bone tissue. Transmission electron microscopic observation and investigation by electron diffraction showed titanium in the bone matrix and cells other than macrophages. In this study, titanium particles from the dental implant were recognized morphologically in the surrounding bone tissue. Thus, study of the influence of titanium particles on the human body is needed.

Palinopsia and perilesional hyperperfusion following subcortical hemorrhage

We report a patient who exhibited transient palinopsia and visual hallucinations. Disturbances initially included an auditory component and increasingly were localized to the left visual field. These events occurred during recovery from a right subcortical hematoma with left homonymous hemianopia. Single-photon emission computed tomography (SPECT) demonstrated extensive perilesional hyperperfusion involving parts of the right parietal, temporal, and occipital cortex. Perilesional hyperperfusion disappeared as the visual abnormalities diminished. We believe that excitatory neuronal activation in perilesional cortex during recovery contributed importantly to the transient abnormal perceptions.

Rational design, discovery, and synthesis of a novel series of potent growth hormone secretagogues

In the joint experimental and computational efforts reported here to obtain novel chemical entities as growth hormone secretagogues (GHSs), a small database of peptides and non-peptides known to have GHS activity was used to generate and assess a 3D pharmacophore for this activity. This pharmacophore was obtained using a systematic and efficient procedure, "DistComp", developed in our laboratory. The 3D pharmacophore identified was then used to search 3D databases to explore chemical structures that could be novel GHSs. A number of these were chosen for synthesis and assessment of their ability to release growth hormone (GH) from rat pituitary cells. Among the compounds tested, those with a benzothiazepin scaffold were discovered with micromolar activity. To facilitate lead optimization, a second program, a site-dependent fragment QSAR procedure was developed. This program calculates a library of chemical and physical properties of "fragments" or chemical components in a known pharmacophore and determines which, if any, of these properties are important for the observed activity. The combined use of the 3D pharmacophore and the results of the site-dependent fragment QSAR analysis led to the discovery and synthesis of a novel series of potent GHSs, a number of which had nanomolar in vitro activity.

Malignant melanoma in the oral region: ultrastructural and immunohistochemical studies

Malignant melanoma in the oral region is reviewed in its clinicopathological aspects. Clinically the melanomas were classified into five types; however, there were no histopathological differences according to these clinical types. Electron microscopic observation of the melanomas and primary culture cells derived from oral malignant melanoma revealed that, in patients whose prognoses were relatively good, many mature-stage melanosomes were found. Immunohistologically, there was a positive reaction for transferrin receptor and the expression of pRb2/p130 was found in only 2 of 13 patients, who are still alive after periods of over 14 years. The radiosensitivity of a cell line derived from human oral malignant melanoma was greater than that in cell lines derived from human cutaneous melanoma and with radiation, the number of melanosomes increased. There are very few clinical cases of oral malignant melanoma and very few cell lines derived from oral malignant melanoma, and so findings in these patients and these cell lines should be accumulated in order to clarify the biological behavior of oral malignant melanoma.

Expression of Rb, pRb2/p130, p53, and p16 proteins in malignant melanoma of oral mucosa

We previously reported that pRb2/p130 gene, one of the Rb family members, was immunohistochemically abundantly expressed in well-differentiated oral squamous cell carcinomas, whereas in undifferentiated ones the expression was low. Oral malignant melanoma is extremely rare, however the prognosis is poor because it tends to locally invade tissue or metastasize and its biological behavior appears to be different from cutaneous malignant melanoma. The present study dealt with the expression of pRb2/p130, Rb, p53, and p16 in 13 cases of malignant melanoma of oral mucosa as revealed by immunohistochemical staining. The stage classification of the 13 patients was as follows; stage II: eight patients, stage III: three patients, and stage IV: two patients. pRb2/p130 was expressed in only two stage II-cases, neither of which have shown any evidence of recurrence or metastasis for over 14 years. Positive staining for Rb was found in three cases consisting of one stage II-case, one stage III-case, and one stage IV-case. p53 was expressed in two cases, one a stage II and the other a stage IV. Positive staining for p16 was found in seven cases consisting of four stage II-cases, two stage III-cases, and one stage IV-case. pRb2/p130 may be inversely correlated with the malignancy of oral malignant melanoma, but further study is needed.

[Generalized tonic-clonic seizure induced by propofol in a patient with epilepsy]

A 47-year-old female was scheduled for ulnar osteotomy under general anesthesia combined with brachial plexus block. She had a history of symptomatic epilepsy due to subarachnoid hemorrhage. Immediately after giving 100 mg bolus of propofol to the patient, she developed generalized convulsion similar to a grand mal. The seizure was suppressed by the administration of thiamylal. After that no further convulsive attack occurred. Although it has been known that propofol has anticonvulsive properties, there have been several reported cases of seizure following the administration of propofol. Further studies are needed to clarify the mechanism of seizure induced by propofol in the patients with epilepsy.

Corticobasal degeneration presenting with nonfluent primary progressive aphasia: a clinicopathological study

A 62-year-old woman initially presented with slowly progressive nonfluent aphasia with minimal intellectual involvement. Echolalia and personality change were prominent whereas parkinsonian features and signs suggesting parietal lobe dysfunctions were not present. The patient's language deficit was consistent with transcortical motor aphasia. She did not manifest extrapyramidal signs. The patient was diagnosed as having Pick's disease or frontal lobe dementia. She died at age 65, 2 years and 9 months following disease onset. Neuropathological findings including cytoskeletal abnormalities, however, were clearly distinct from those of classical Pick's disease and were consistent with those reported in corticobasal degeneration (CBD). The distribution of her cortical lesions was accentuated in the frontal language-related area. The clinical manifestations in CBD are diverse, and primary progressive nonfluent aphasia should be considered as an initial symptom of CBD. Neuropathological examination of such patients should include cytoskeletal abnormality studies.

[A case of moyamoya disease presenting with geographic mislocation, person misidentification and fantastic confabulation]

A 52-year-old woman presented with geographical mislocation (misidentification for place), person misidentification and fantastic confabulation as a result of cerebral infarction. Head MRI demonstrated a focal lesion in the right frontal lobe. Cerebral angiogram demonstrated occlusion in the circle of Willis with moyamoya vessels. The neuropsychological examination revealed memory impairment and frontal lobe dysfunction. The patient's misidentification for place and person as well as confabulation lasted for 1.5 months since admission, then gradually disappeared. We speculate that there existed a common mechanism for these three symptoms; i.e., misidentification and confabulation were based upon the impaired interpretation of the small events and partial objects in the surrounding circumstances, which might interfere with the appropriate integration and judgments of the outside information in general. The impaired monitoring and frontal dysfunction caused by the right frontal lesion appeared to be responsible for causing her deficits.

[Support for patients with a respirator at home]

Five patients with a respirator were managed at home by staff from our visiting nurse station. One patient has been at home for 4 years after discharge. She is 60 years old. Her disease was striatonigral degeneration. Five years ago she could not breathe because of her disease and breathing with a respirator was started. However, she and her family wanted her to be at home. We respected their wish, and helped her stay at home. She has maintained a good condition with nursing at home, and her QOL is high.