Newly manufactured Marukome MK-34-1 miso with angiotensin-converting enzyme inhibitory activity and its antihypertensive effects in genetic hypertensive rat models

We newly manufactured miso rich in angiotensin-converting enzyme (ACE) inhibitory activity (Marukome MK-34-1, shinki miso) and investigated its antihypertensive properties in rat models of genetic hypertension. ACE inhibitory activity was tenfold higher in shinki miso than in commercially available Marukome Nenrin miso (nenrin miso). The inhibitory activity of shinki miso was confined to <3 kDa fractions and was detected in several fractions with high polarity by C₁₈ high-performance liquid chromatography. Systolic blood pressure (SBP) increased age-dependently in stroke-prone spontaneously hypertensive rats (SHRSP/Izm) given a 0.6% (w/v) NaCl solution (salt solution group) that matched the salt content of the miso solutions. This SBP increase was attenuated in both the 5% nenrin and 5% shinki miso solution groups compared to the salt solution group. The reduction in SBP was greater in rats fed shinki than in rats fed nenrin miso. Similarly, in a salt-induced hypertension model with Dahl rats, the 5% nenrin miso solution attenuated the rising SBP observed in the salt solution group. Moreover, combining 5% nenrin miso with 5% shinki miso (2:1, v/v) (awase miso group) significantly decreased the SBP per gram salt intake by 8% compared with the nenrin miso treatment. However, there were no differences in urinary Na excretion between the nenrin and awase miso groups. In conclusion, we produced a new miso with potent ACE inhibitory activity that reduced spontaneous and salt-induced hypertension. These results suggest that salt sensitivity is decreased by the addition of shinki miso to nenrin miso.

A nationwide survey of pediatric acquired demyelinating syndromes in Japan

OBJECTIVE

To investigate the clinical and epidemiologic features of pediatric acquired demyelinating syndromes (ADS) of the CNS in Japan.

METHODS

We conducted a nationwide survey and collected clinical data on children with ADS aged 15 years or younger, who visited hospitals between 2005 and 2007.

RESULTS

Among 977 hospitals enrolled, 723 (74.0%) responded to our inquiries and reported a total of 439 patients as follows: 244 with acute disseminated encephalomyelitis (ADEM), 117 with multiple sclerosis (MS), 14 with neuromyelitis optica (NMO), and 64 with other ADS. We collected and analyzed detailed data from 204 cases, including those with ADEM (66), MS (58), and NMO (10). We observed the following: (1) the estimated annual incidence rate of pediatric ADEM in Japan was 0.40 per 100,000 children (95% confidence interval [CI], 0.34-0.46), with the lowest prevalence in the north; (2) the estimated prevalence rate of MS was 0.69 per 100,000 children (95% CI, 0.58-0.80), with the lowest prevalence in the south; (3) NMO in Japan was rare, with an estimated prevalence of 0.06 per 100,000 children (95% CI, 0.04-0.08); and (4) the sex ratio and mean age at onset varied by ADS type, and (5) male/female ratios correlated with ages at onset in each ADS group.

CONCLUSIONS

Our results clarify the characteristic clinical features of pediatric ADS in the Japanese population.

Cytokine-related and sodium channel polymorphism as candidate predisposing factors for childhood encephalopathy FIRES/AERRPS

Febrile infection-related epilepsy syndrome (FIRES), or acute encephalitis with refractory, repetitive partial seizures (AERRPS), is an epileptic encephalopathy beginning with fever-mediated seizures. The etiology remains unclear. To elucidate the genetic background of FIRES/AERRPS (hereafter FIRES), we recruited 19 Japanese patients, genotyped polymorphisms of the IL1B, IL6, IL10, TNFA, IL1RN, SCN1A and SCN2A genes, and compared their frequency between the patients and controls. For IL1RN, the frequency of a variable number of tandem repeat (VNTR) allele, RN2, was significantly higher in the patients than in controls (p=0.0067), and A allele at rs4251981 in 5' upstream of IL1RN with borderline significance (p=0.015). Haplotype containing RN2 was associated with an increased risk of FIRES (OR 3.88, 95%CI 1.40-10.8, p=0.0057). For SCN1A, no polymorphisms showed a significant association, whereas a missense mutation, R1575C, was found in two patients. For SCN2A, the minor allele frequency of G allele at rs1864885 was higher in patients with borderline significance (p=0.011). We demonstrated the association of IL1RN haplotype containing RN2 with FIRES, and showed a possible association of IL1RN rs4251981 G>A and SCN2A rs1864885 A>G, in Japanese patients. These preliminary findings suggest the involvement of multiple genetic factors in FIRES, which needs to be confirmed by future studies in a larger number of FIRES cases.

Comparing i-Tree modeled ozone deposition with field measurements in a periurban Mediterranean forest

Ozone flux estimates from the i-Tree model were compared with ozone flux measurements using the Eddy Covariance technique in a periurban Mediterranean forest near Rome (Castelporziano). For the first time i-Tree model outputs were compared with field measurements in relation to dry deposition estimates. Results showed generally a good agreement between predicted and measured ozone fluxes (least sum square=5.6 e(-4)) especially when cumulative values over the whole measurement campaign are considered. However at daily and hourly time-step some overestimations were observed in estimated values especially in hot dry periods. The use of different m values in the Ball-Berry formula in the different periods, produced the best fit between predicted and measured ozone fluxes. This suggests that a variable value for the coefficient m accounting for water availability may be appropriate to improve model estimates for Mediterranean and drought prone regions.

Development and external validation of a nomogram for overall survival after curative resection in serosa-negative, locally advanced gastric cancer

BACKGROUND

Few nomograms can predict overall survival (OS) after curative resection of advanced gastric cancer (AGC), and these nomograms were developed using data from only a few large centers over a long time period. The aim of this study was to develop and externally validate an elaborative nomogram that predicts 5-year OS after curative resection for serosa-negative, locally AGC using a large amount of data from multiple centers in Japan over a short time period (2001-2003).

PATIENTS AND METHODS

Of 39 859 patients who underwent surgery for gastric cancer between 2001 and 2003 at multiple centers in Japan, we retrospectively analyzed 5196 patients with serosa-negative AGC who underwent Resection A according to the 13th Japanese Classification of Gastric Carcinoma. The data of 3085 patients who underwent surgery from 2001 to 2002 were used as a training set for the construction of a nomogram and Web software. The data of 2111 patients who underwent surgery in 2003 were used as an external validation set.

RESULTS

Age at operation, gender, tumor size and location, macroscopic type, histological type, depth of invasion, number of positive and examined lymph nodes, and lymphovascular invasion, but not the extent of lymphadenectomy, were associated with OS. Discrimination of the developed nomogram was superior to that of the TNM classification (concordance indices of 0.68 versus 0.61; P < 0.001). Moreover, calibration was accurate.

CONCLUSIONS

We have developed and externally validated an elaborative nomogram that predicts the 5-year OS of postoperative serosa-negative AGC. This nomogram would be helpful in the assessment of individual risks and in the consideration of additional therapy in clinical practice, and we have created freely available Web software to more easily and quickly predict OS and to draw a survival curve for these purposes.

Clinical and radiological features of rotavirus cerebellitis

BACKGROUND AND PURPOSE

Neurological manifestations, such as benign convulsions and encephalitis/encephalopathy have been reported in patients with rotavirus gastroenteritis. However, cerebellitis has not attracted much attention. The purpose of this study was to identify and report the clinical and radiologic features of rotavirus cerebellitis.

MATERIALS AND METHODS

Records of patients with rotavirus gastroenteritis exhibiting cerebellar lesions on MR imaging were collected from multiple centers in Japan. Their clinical, laboratory, and radiologic data were reviewed retrospectively.

RESULTS

A diagnosis of acute cerebellitis concurrent with encephalitis was made for 11 of 13 patients identified. Two patients who were diagnosed as having injury due to hypovolemic shock were excluded from the study. All 11 patients with acute cerebellitis had disorders of consciousness with onset on days 2 to 4, followed by mutism in 10 patients. Other cerebellar symptoms included dysarthria following the mutism, hypotonia, ataxia, tremor, nystagmus, and dysmetria. MR imaging lesions in the vermis or cerebellar cortex were seen at some point (day 5 to 1 year) in 10 patients. A reversible splenial lesion (3 isolated and 3 with concurrent cerebellar lesions) was found in 6 patients scanned between days 4 and 6. Transient lesions in the cerebellar white matter/nuclei manifesting reduced diffusion were seen in 6 patients during days 5 through 7. The final MR imaging performed after 1 month showed cerebellar atrophy in 10 patients.

CONCLUSIONS

The 11 patients with rotavirus cerebellitis exhibited nearly identical clinical and MR imaging features. Involvement of the cerebellar white matter/nuclei may be associated with the mutism. An isolated splenial lesion with homogeneously reduced diffusion is not always a benign sign indicative of complete clinical and radiologic recovery in patients with rotavirus gastroenteritis.

Medical rehabilitation of the patients with spinal cord injury caused by aortic aneurysm and its operation

OBJECTIVES

To determine the natural course of spinal cord injury (SCI) after aortic aneurysm surgery.

SETTING

Acute care and semi-acute wards in Osaka Rosai Hospital, Japan.

METHODS

From 1998 to 2003, 12 patients with thoracic SCI (eight men and four women; mean age: 69 years) were enrolled and evaluated by the American Spinal Injury Association (ASIA) impairment scale and Functional Independence Measure (FIM), and the results were analyzed.

RESULTS

The level of SCI was distributed from T5 to L1. The ASIA impairment scale was A in four patients, B in four, C in three and D in one. Finally, six patients were discharged to home, and two patients died during hospitalization. Excluding the value of the deceased patients, the mean motor FIM was initially 32+/-15.6 (13-59) points and became 61+/-21.4 (29-88) points at discharge. Referencing the databases of SCI in Japan and USA revealed that the complication rates of pneumonia and aspiration were higher in our cases. The motor FIM before rehabilitation and at discharge were relatively lower than in the databases, but the gain and the rate of gain were similar to the Japanese database.

CONCLUSION

SCI associated with aortic aneurysm surgery was noticed especially in the elderly patients using airways (for example, tracheostomy). The higher age and recurrent nerve palsy were associated with deconditioning state to develop aspiration pneumonia. This state impaired the general condition, and such vicious cycle led to poor prognosis and functional outcome.

Ligand-of-Numb protein X is an endocytic scaffold for junctional adhesion molecule 4

Junctional adhesion molecule 4 (JAM4) is a cell adhesion molecule that interacts with a tight junction protein, membrane-associated guanylate kinase inverted 1 (MAGI-1). Our previous studies suggest that JAM4 is implicated in the regulation of paracellular permeability and the signalings of hepatocyte growth factor. In this study, we performed yeast two-hybrid screening to search for an unidentified JAM4-binding protein and obtained one isoform of Ligand-of-Numb protein X1 (LNX1), LNXp70, that is an interactor of Numb. Ligand-of-Numb protein X1 is expressed in kidney glomeruli and intestinal epithelial cells, where JAM4 is also detected. Immunoprecipitation from kidney lysates supports the in vivo interaction of proteins. Biochemical studies reveal that JAM4 directly binds the second PDZ domain of LNX1 through its carboxyl terminus. Junctional adhesion molecule 4, LNX1 and Numb form a tripartite complex in vitro and are partially colocalized in heterologous cells. Ligand-of-Numb protein X1 facilitates endocytosis of JAM4 and is involved in transforming growth factor beta -induced redistribution of JAM4 in mammary epithelial cells. Experiments using dominant-negative constructs and RNA interference insure that Numb is necessary for the LNX1-mediated endocytosis of JAM4. All these findings indicate that LNX1 provides an endocytic scaffold for JAM4 that is implicated in the reorganization of cell junctions.

[Laparoscopic radical prostatectomy--initial 10 cases]

PURPOSE

We report the clinical results and efficacy of laparoscopic radical prostatectomy for localized prostate cancer.

PATIENTS AND METHODS

Between December, 1999 and June, 2000 we performed transperitoneal laparoscopic radial prostatectomy on 10 patients with T1 or T2 organ confined prostate cancer according to the techniques as described by Guillonneau et al. Different points were as follows: 1) We placed double J catheters during surgery to prevent ureteral injury. 2) We treated dorsal vein complex using an Endo-GIA-stapler. 3) We dissected the bladder neck from the prostate using an ultrasound scalpel in the manner to preserve the bladder neck.

RESULT

We could not completed laparoscopic prostatectomy on two patients because of massive bleeding from dorsal vein and consuming too much time to suture urethra-bladder anastomosis. The average operating time in all cases was 8.1 hours including 1.8 hours in laparoscopic pelvic lymphadenectomy. The average estimated blood loss in all cases was 859 ml. There were 2 surgical complications with bladder injury and port site hernia. The histological examination revealed prostate cancer; pT2pNO in 8, pT3pNO in 2. The surgical margin and lymph nodes were negative in all patients. The duration of an indwelling catheter ranged from 5 to 40 days mean 17 days. The duration to recovery of normal micturition was 6 to 90 days, mean 40 days.

CONCLUSION

Long-term follow-up and extensive studies are necessary to evaluate the efficacy of this procedure. It might provide shorter duration of an indwelling catheter and earlier recovery of normal micturition as compared with the conventional open surgery.

Unusual development of acute compartment syndrome caused by a suction injury: a case report

There have been recent reports of acute compartment syndrome secondary to suction injuries of the hands of children. We report the case of a 68-year-old patient who developed an acute compartment syndrome of the forearm after his arm had been sucked into an exhaust port. He was treated by emergency fasciotomies and the wound was closed five days later with a small skin graft. His recovery was uneventful.

Staged spinal cord decompression through posterior approach for thoracic myelopathy caused by ossification of posterior longitudinal ligament

STUDY DESIGN

Prospective clinical study of the effect of staged elimination of anatomic factors inhibiting posterior shift of the thoracic spinal cord on the degree of posterior shift of the thoracic spinal cord and its significance in augmenting the safety of ossification of posterior longitudinal ligament (OPLL) manipulation in thoracic OPLL myelopathy.

OBJECTIVES

To develop a comprehensive method that enables safe and sufficient decompression of the spinal cord for thoracic OPLL myelopathy.

SUMMARY OF BACKGROUND DATA

Decompression of the spinal cord by direct manipulations of thoracic OPLLs, via either anterior or posterior approach, caused some iatrogenic catastrophic spinal cord injuries, and methods to prevent such injuries during surgery have not yet been developed.

METHODS

Procedures of elimination of anatomic factors inhibiting posterior shift of the thoracic spinal cord were performed in stages at intervals of between 1 month and 11 years depending on patients' neurologic status. The first stage operation consisted of extensive cervicothoracic laminoplastic decompression with or without posterior longitudinal durotomy, and if the decompression were insufficient, measures for OPLL-spinal cord separation with or without OPLL manipulation were added.

RESULTS

All 17 patients with thoracic OPLL myelopathy showed improvements of neurology comparable with those with successful anterior approaches after decompression. The mean follow-up period was 42 months (range 6-101 months). Neurologic improvements persisted for the entire follow-up period in all patients except one patient who developed arachnoid cyst compressing the dorsum of the once-decompressed spinal cord 30 months after surgery.

CONCLUSIONS

Staged posterior decompression to eliminate anatomic factors inhibiting posterior shift of the thoracic spinal cord is the safest and the most reliable method of spinal cord decompression to treat thoracic OPLL myelopathy, so far. However, long-term results are required before the methods can be established.

Skeletal analysis of craniofacial deformities in brachycephaly: comparison with craniofacial deformities in plagiocephaly

The deformities of craniofacial bones in brachycephaly (n = 2) and plagiocephaly (n = 2) were compared using three-dimensional skull replicas. In brachycephaly the bilateral deformities of the cranial base were similar to the unilateral deformities on the affected side in plagiocephaly. Shortening of the anterior-middle cranial fossas and expansion of the middle cranial fossas suggest downward and anterior displacement of both temporomandibular (TM) joints resulting in the underdevelopment of the middle-inferior facial bones, though this is less conspicuous in brachycephaly for three reasons. The most important one is that the patients have an imposing facial morphology characterised by high, protruding facial bones, as found on the affected side in plagiocephaly. Secondly, the frontal bones are flattened and positioned posteriorly in the anteroposterior direction, which also helps to mask the underdevelopment of the middle-inferior facial bones. Finally, as bony deformities are symmetrical in brachycephaly, they are not as obvious as they would be if they were unilateral.

Optimized 3-D CT scan protocol for longitudinal morphological estimation in craniofacial surgery

Frequent three-dimensional computed tomography scanning may cause deterioration of the lenses of the eye, which are susceptible to x-rays. The authors performed an experimental study using a phantom head to establish an optimized three-dimensional computed tomography scan protocol for longitudinal morphological estimation in craniofacial surgery. Volume computed tomography scans were performed using a Hi-Speed Advantage SG CT scanner (GE Medical Systems, Milwaukee, WI) in the axial plane with a combination of scan parameters of varied values. The radiation doses induced by each scanning were measured using thermoluminescent dosimeter chips attached to the position of the lenses in the phantom. Two-dimensional images in the coronal plane and three-dimensional images of the osseous surface were generated from each accumulated data set. For each scan parameter, the images generated from data accumulated using different values were compared. The study showed that lens radiation dose increased with tube potential and was almost directly proportional to tube current and 1/pitch. The slice thickness did not affect lens radiation doses significantly. Images with good contrast resolution and low artifact level sufficient for estimating morphological changes were obtained using a low tube potential of 100 kVp and a tube current of 100 mA. In regard to z-axis spatial resolution, a slice thickness of less than 3 mm was required for precisely pointing out bony edges in the two-dimensional reformation images. These results led us to conclude that volume computed tomography for longitudinal examination in craniofacial surgery should be kept to a minimum frequency and performed using a low-dose technique, small slice thickness, and large pitch.

Localization of BAI-associated protein1/membrane-associated guanylate kinase-1 at adherens junctions in normal rat kidney cells: polarized targeting mediated by the carboxyl-terminal PDZ domains

Brain-specific angiogenesis inhibitor (BAI)-associated protein (BAP)1 (also called membrane-associated guanylate kinase [MAGI]-1) is composed of six PSD-95/Dlg-A/ZO-1 (PDZ) domains, two WW domains, and one guanylate kinase (GK) domain. We previously reported that BAP1 is localized at tight junctions in Madine Darby canine kidney (MDCK) cells and intestinal epithelial cells. Here, we have determined the localization of BAP1 in normal rat kidney (NRK) cells that do not form tight junctions. BAP1 was colocalized with E-cadherin along the lateral membrane, suggesting its localization at adherens junctions. Green fluorescent protein (GFP)-BAP1 was distributed in the cytosol in separate NRK cells, and accumulated to the cell-cell contacts when NRK cells have contact with each other. The GFP-BAP1 mutant containing either the first PDZ and GK domains or the WW and second PDZ domains was localized in the cytosol and the nucleus. The GFP-BAP1 mutant containing the second to fourth PDZ domains was distributed in the cytosol. The construct containing the fifth and sixth PDZ domains was localized at the cell-cell contacts along the lateral membrane and slightly in the nucleus, whereas the construct lacking the fifth and sixth PDZ domains was localized in the cytosol and in the nucleus. BAP1 was tyrosine-phosphorylated in vivo, but the tyrosine phosphorylation of BAP1 was not correlated with its localization. These results suggest that the signal in the carboxyl-terminal PDZ domains functions dominantly in vivo to target BAP1 to the lateral membrane, although potential nuclear localization signals exist in the N-terminal region of BAP1.

The value of a new method for assessing the separate functions of the long tracts and involved segments in patients with cervical myelopathy

In order to assess accurately lesions of the spinal cord in patients with cervical myelopathy we have developed a new method of examination, which is based on the Japanese Orthopaedic Association (JOA) scoring system. The method attempts to assess separately the functions of the long tract and any involved cord segments in respect to the period after treatment. It was used in 117 consecutive patients who were divided into 2 groups based on whether or not there was a T2-high-intensity lesion within the spinal cord, as revealed by a preoperative magnetic resonance imaging scan (MRI). The results of this method correlated well with the MRI findings. It was assumed that the degree of function of the upper limbs in patients with a T2-high-intensity lesion revealed more about a segment than about the long tract.

Application of the distraction technique to scaphocephaly

The case of a 1-year-old boy who underwent correction of a scaphocephalic deformity using distraction devices is described. Double pi-shaped osteotomies were cut. Bilateral temporal bone flaps were gradually expanded, and the frontal bone was pulled back simultaneously. The patient showed a good skull contour 2 years postoperatively. Although previous distractions were aimed only at expansion of the cranium, we used the distraction technique to successfully shorten the cranial vault in the anteroposterior direction. This case demonstrates that the osteotomized bone flaps can be moved in various directions. This feature of the distraction technique may contribute greatly toward meticulous reconstruction of the cranial vault.

A neurodegenerative disorder with early myoclonic encephalopathy, retinal pigmentary degeneration and nephronophthisis

A female case of developmental arrest, early-onset seizures, retinal pigmentary degeneration, progressive central nervous symptoms and peripheral neuropathy, associated with progressive renal dysfunction, anemia and nephrotic syndrome, was presented. Her epileptic syndrome was possibly an early myoclonic encephalopathy, though neonatal seizures were not evident. Serial cranial MRIs showed progressive brain atrophy and a white matter change. Neuropathological examination revealed a neurodegenerative disease mainly involving the white matter with olivopontocerebellar degeneration. She also had the nephronophthisis-medullary cystic disease complex and an early stage of focal segmental glomerulosclerosis. Her grandaunts had renal diseases, one of whom died of renal failure in adolescence, and her father showed cerebellar symptoms since the middle age. All possible metabolic studies were negative. This case is similar to Senior-Loken syndrome, but distinct in terms of the severe and progressive neurological symptoms, suggestive of a new malignant syndrome with some inherent metabolic derangement affecting both the nervous system and the kidneys.

Effects of antigen dose and immunization regimens on antibody responses to a cytomegalovirus glycoprotein B subunit vaccine

The purpose of this phase I study was to evaluate the safety and immunogenicity of 2 doses of cytomegalovirus glycoprotein B (CMV gB)/MF59 vaccine at 3 different immunization schedules. Ninety-five volunteers were randomized to 6 groups. Antibodies to gB represent the majority of the CMV-specific neutralizing response. Three groups received 5 microgram of gB antigen combined with MF59 (a proprietary adjuvant) and 3 groups received a 30-microgram dose at 0, 1, and 2 months; 0, 1, and 4 months; or 0, 1, and 6 months. The vaccine was well tolerated, and there was no significant difference in antibody production between the 2 doses. The vaccine induced highest antibody titers when given at 0, 1, and 6 months. A low dose of CMV gB/MF59 may be the preferred dose for future studies.

Correction of knee deformity in patients with Ellis-van Creveld syndrome

Six knees in three patients with Ellis-van Creveld syndrome were treated with lateral soft tissue release and corrective osteotomy of the tibia at 10 years of age on average. The main feature was valgus deformity with lateral dislocation of the patella. All patellae were reduced. The valgus deformity improved from 35 degrees (range, 48 degrees-20 degrees) to 17 degrees (range, 35 degrees-5 degrees) of the femorotibial angle (FTA) on average, although the FTA in five of six knees was < 5 degrees after surgery. There was one recurrent case and one transient peroneal nerve palsy. The reason for undercorrection was a depression of the lateral tibial plateau. The deformity of the articular surface is the most important problem in correcting the valgus deformity of the knee in this syndrome.

Contact of hydroxyapatite spacers with split spinous processes in double-door laminoplasty for cervical myelopathy

We developed a new type of spacer made of hydroxyapatite (the STSS spacer) for double-door laminoplasty, and evaluated the contact of 93 STSS spacers with the split spinous processes in 20 patients with double-door laminoplasty. Contact was assessed by measuring the extent of touch of the spacer to the spinous processes, classified into four categories based on computed tomography (CT) images: excellent, complete touch on both sides of the spacer to the spinous process; good, complete touch on one side and more than half touch on the other side; fair, more than half touch on both sides; poor, half or less touch on at least one side. Excellent contact was achieved in 65 spacers (69.9%); good, in 13 (14.0%); fair, in 11 (11. 8%); and poor, in 4 (4.3%). The percentages of excellent or good categories were 75.0% at the C3 level, 73.7% at the C4 level, 78.9% at the C5 level, 90.0% at the C6 level, and 100% at the C7 level. The contact rate of the STSS spacer with the spinous process was better than that achieved with other spacers, probably because the characteristic shape of the STSS spacer was compatible with the widened space between the bilateral spinous processes; i.e., it is trapezoidal on both the axial and the frontal sections. However, the appropriate size of the spacer must be selected in accordance with the size of the spinous process to obtain higher percentages of excellent or good contact.

New method of assessing outcome of treatment for cervical myelopathy (M/T method)--preliminary report

In some patients with cervical radiculomyelopathy, neurological examination reveals extreme muscle weakness in an upper extremity with no, or a relatively insignificant, sensory deficit. In assessment of treatment outcome in these patients, the previous method used is thought to be unsuitable. We developed a new method of assessment (the M/T method) in which the recovery of upper extremity muscle weakness is assessed. The purpose of this study was to evaluate this new method. In the M/T method, change in the function of the spinal cord, including the anterior root, is expressed as an index number (recovery rate) in relation to the time-course. The function of the nerve tissue is expressed as the value for the manual muscle testing (MMT) of muscle power, and the muscle tested is represented by one that has the least MMT value before treatment. The unit of measurement of the time-course is 3 months. The index is the difference between the MMT value at the time of follow-up and that before treatment, divided by the number of time units after treatment. The index can be expressed in both fractional and decimal forms. Fractions are useful for examining an individual patient's progress and the decimal form is useful for comparing the data of multiple patients. The M/T method was employed in 16 patients (13 men, 3 women; age, 45-79 years; follow-up, 6 months - 8 years) whose chief complaints were muscle weakness in the upper extremities and who had undergone double-door laminoplasty. Seven patients had an M/T index of 1 or more; the score was 4 in one patient, 2 in four patients, and 1 in two patients. Two patients had an M/T index between 0 and 1; 0.17 and 0.25. Five patients had an index value of 0. The M/T index in two patients was less than 0; -0. 17 and -0.11. Using the M/T method, recovery can be presented as an index number, and as a result, it is easy to compare differences in the recovery rate among patients. The M/T method is useful for evaluation of the viability of the spinal cord, including the anterior root; in particular for those patients in whom neurological examination reveals extreme muscle weakness in an upper extremity with no, or a relatively insignificant, sensory deficit.

New method for measuring area of spinal canal after double-door laminoplasty

In the double-door laminoplasty procedure used for patients with cervical myelopathy, techniques to obtain a wider spinal canal have been tested. We hypothesized that making the lateral gutters as lateral as possible may be effective for obtaining a wider spinal canal. In this study we aimed to test our hypothesis by using a new measurement method to assess the postoperative cross-sectional area of the spinal canal. Fifty-six vertebrae were operated on in 11 patients, using the STSS spacer (Asahi Optical, Tokyo, Japan). On computed tomography (CT) scans, the most posterior edge of a space-occupying lesion was defined as point A and a horizontal line through point A was drawn parallel to the posterior wall of the vertebral body (line X). Two oblique lines were drawn along the medial margin of the bilateral split laminae (lines R and L). The triangular area enclosed by lines X, R, and L was defined as the substantial area of the spinal canal (SASC). A horizontal line through the median points of the bilateral facet joint in the anteroposterior direction was defined as line B. According to the relative position of line X to line B, two types of vertebra were observed: In type 1, line X was located ventral to line B; in type 2, line X was located dorsal to line B. The mean data values for type 1 vertebra were: SASC, 133.1 mm2; ATD, 22.9 mm; angle R, 61.3 degrees; and angle L, 61.8 degrees. The mean data values for type 2 vertebra were: SASC, 99.8 mm2; ATD, 20.1 mm; angle R, 58.6 degrees; and angle L, 57.5 degrees. There were significant differences between types 1 and 2 vertebrae in values both for SASC and ATD (P < 0.01). There were no significant differences between types 1 and 2 vertebrae regarding angles R and L. The difference in SASC in the two types appeared to arise from the difference in ATD. In other words, the degree of enlargement of the spinal canal was determined not by the inclination of the bilateral split laminae, but by the transverse diameter. This result supports the validity of our hypothesis. In a double-door laminoplasty, to obtain a wider spinal canal, the lateral gutters must be made as lateral as possible (i.e., at the medial border of the facet joints, especially in type 2 vertebra). On the preoperative CT scan, the relative positions of the large-volume lesion and the facet joint must be noted.

Craniofacial growth in a whole rat head transplant: how does a non-functional head grow?

To evaluate factors intrinsic to the regulation of craniofacial bone growth, we have developed a new experimental model in which the whole head of an infant rat is transplanted to the body of an isohistogenic rat by means of microvascular anastomosis. In our model, the transplanted head has neither scars nor any moving soft tissue that could modify growth around facial bones. Using this model, we evaluated the growth pattern of the craniofacial complex by means of serial roentgenographic cephalometrics. Ten transplantations were performed using 10-day-old rats as donors and 8-week-old rats as recipients. Cephalograms were taken from the lateral direction at 10, 20, 30, and 40 days after transplantation. Several reference points were selected to analyze the growth pattern. In the present study, we conclude that the size and form of the bony complex are mainly determined genetically. There is craniofacial skeletal growth in the absence of muscle function and brain growth. Further, both the nasal cartilage and the sutures appear to be autonomous growth centers having intrinsic growth potential. Genetic or epigenetic information plays an important role at the skeletal level, but it also affects the muscles through the medium of the muscular tonus responsible for posture and other related phenomena.

Immunohistochemical detection of DNA topoisomerase type II alpha and Ki-67 in adenoid cystic carcinoma and pleomorphic adenoma of the salivary gland

Immunohistochemical detection of cell proliferation-associated antigens was investigated in 28 cases of adenoid cystic carcinoma (ACC) and 20 cases of pleomorphic adenoma (PA), using antibodies against DNA topoisomerase type II alpha (topo-II) (Ki-S1) and Ki-67 (MIB-1). The correlation of staining indices with clinicopathological data, histological features and prognosis was also studied. The topo-II value was significantly higher in ACC than in PA (P<0.0001), and highest in the solid growth pattern of ACC. In addition, significant relationships were found between topo-II values and clinical features such as local recurrence, surgical margins, and distant metastases. By log-rank test, the topo-II index was also correlated significantly with patient survival (P<0.01). The values of topo-II index paralleled those of Ki-67 index in ACC, and a correlation coefficient of 0.97 was obtained. Topo-II may be considered an additional marker for estimating the proliferating fraction of cells and for predicting the short-term prognosis for patients with salivary gland tumors.

Frontoorbital advancement by gradual distraction. Technical note

A substantial number of patients with coronal synostosis who undergo frontoorbital advancement still require additional surgical treatment to correct increased intracranial pressure or unsatisfactory craniofacial structure. However, frontoorbital advancement currently requires elevation of the frontal as well as the orbital bone, which can result in a fragile dura mater and partial resorption of the advanced bone. Thus the dura is easily torn by dissection and the advanced bone is further resorbed and deformed during repeated craniofacial operations. To avoid these drawbacks and to create an easier second surgical treatment via the intracranial approach, a new technique for frontoorbital advancement is presented. In this technique frontoorbital bone is advanced as a single unit, without elevation from the underlying dura, by means of gradual distraction. The details of the technique and an illustrative case are reported.

Chronic meningoencephalitis due to cytomegalovirus infection in a nonimmunocompromised patient: an autopsy case

Congenital cytomegalovirus infection, which is the most common of the intrauterine viral infections, is well known to involve various organs, including the central nervous system. On the other hand, encephalitis due to persistent or acquired infection by cytomegalovirus in the central nervous system is thought to be rare, and to be seen exclusively in immunocompromised patients such as those under immunosuppressant therapy or those with acquired immunodeficiency syndrome (AIDS). We describe chronic meningoencephalitis possibly due to cytomegalovirus seen in an immunocompetent patient with behavior problems.

Secondary lengthening of the reconstructed mandible using a gradual distraction technique--two case reports

We have performed mandibular lengthening to restore oral function in 2 cases after tumour resection. Both cases had already undergone a vascularised fibular graft for mandibular reconstruction and had severe contracture and absence of an alveolar ridge for dentures. Gradual distraction was applied after corticotomy of the fibular bone at 0.9 mm per day. After completion of bone lengthening of 20-30 mm, both patients underwent a split thickness skin graft to obtain a good alveolar ridge for dentures and implants. Osteointegrated implants have since been applied in one of these cases, and the other patient has been able to eat a normal diet using dentures. Gradual distraction is applicable for vascularised bone grafts and useful for restoration of the alveolar ridge to accommodate dentures in cases with severe contracture of the oral space after tumour ablation.

Clinical value of computer-generated acrylic skull replicas produced by laser lithography

To determine for what deformity and utility the computer-generated acrylic (CGA) skull replica has the greatest value, we analyzed retrospectively a consecutive series of patients with craniomaxillofacial deformities (N = 54) whose treatment involved the utilization of CGA skull replicas. Application of the CGA skull replica was divided retrospectively into four groups: (1) use as an aid for preoperative analysis of osseous deformity, (2) use as material for preoperative surgical simulation, (3) use as a navigational aid during an operation, and (4) use as a negative template. Based on the aspects of these utilizations, we evaluated for what deformity the CGA skull replica was useful. Analysis of the data led us to conclude the following. First, the CGA skull replica is a valuable tool in craniomaxillofacial surgery, especially for patients with asymmetrical deformities and delicate convexities and concavities of the skull surface. Second, the largest function that CGA skull replicas can satisfy is standardization of craniomaxillofacial surgery. In carrying out preoperative surgical simulation utilizing a replica, drawing osteotomy lines on it, sterilizing it, and then bringing it to the operating table for consultation whenever required during an operation, we are able to proceed with greater precision and speed than if it was not available.

Gradual cranial vault expansion for the treatment of craniofacial synostosis: a preliminary report

To treat craniosynostosis, skull reshaping (such as fronto-orbital advancement) is widely performed. Surgical techniques have improved, however several problems still remain, such as postoperative relapse, late resorption, and infection. The main reason for this is probably (1) that the "craniotomized" bone for changing skull contour is used as free bone grafts and (2) that dead space between the reshaped bone and dura is created. We have developed a new method in which cranial bone is expanded gradually, together with the dura, using expansion devices. With this approach there is no extradural dead space postoperatively and the cranial bone segment remains vascularized. We have performed this procedure in 2 patients with Crouzon's disease and in 1 patient with sagittal synostosis. In the Crouzon's patients, osteotomies were performed to form a one-piece fronto-orbital bony complex without detaching the bone from the dura, and three expansion devices were applied. In the patient with sagittal synostosis, bilateral temporoparietal osteotomies were done in the same fashion and two expansion devices were applied. Expansion was started on the fourth postoperative day at a rate of about 1 mm per day. After obtaining the proper expansion, the devices were removed and the bone segments were fixed with miniplates and screws. All patients showed good results without any complications.

Mutations in the integrin alpha7 gene cause congenital myopathy

The basal lamina of muscle fibers plays a crucial role in the development and function of skeletal muscle. An important laminin receptor in muscle is integrin alpha7beta1D. Integrin beta1 is expressed throughout the body, while integrin alpha7 is more muscle-specific. To address the role of integrin alpha7 in human muscle disease, we determined alpha7 protein expression in muscle biopsies from 117 patients with unclassified congenital myopathy and congenital muscular dystrophy by immunocytochemistry. We found three unrelated patients with integrin alpha7 deficiency and normal laminin alpha2 chain expression. To determine if any of these three patients had mutations of the integrin alpha7 gene, ITGA7, we cloned and sequenced the full-length human ITGA7 cDNA, and screened the patients for mutations. One patient had splice mutations on both alleles; one causing a 21-bp insertion in the conserved cysteine-rich region, and the other causing a 98-bp deletion. A second patient was a compound heterozygote for the same 98-bp deletion, and had a 1-bp frame-shift deletion on the other allele. A third showed marked deficiency of ITGA7 mRNA. Clinically, these patients showed congenital myopathy with delayed motor milestones. Our results demonstrate that mutations in ITGA7 are involved in a form of congenital myopathy.

Skeletal analysis of craniofacial asymmetries in plagiocephaly (unilateral coronal synostosis)

Why do the craniofacial bones grow asymmetrically in patients with plagiocephaly (unilateral coronal synostosis)? We obtained three-dimensional skeletal replicas of two patients with the condition and analysed the deformities of the facial bones. From this analysis we deduced that the asymmetric deformation of the facial bones in these patients was caused by a combination of three rotations: rotation of the calvaria toward the affected side because of premature synostosis of the coronal and sphenofrontal sutures; rotation of the facial bones on the horizontal plane toward the unaffected side caused by anterior displacement of the TM (temporomandibular)-joint on the affected side; and downward rotation of the facial bones toward the unaffected side caused by inferior displacement of the TM-joint on the affected side.

Reconstruction of skull defects with vascularized omentum transfer and split calvarial bone graft: two case reports

Autogenous calvarial bone grafts have been widely used in craniofacial reconstruction following trauma, congenital anomalies, and head and neck tumors. In cases of late restoration of a collapsed cranial vault, an extradural dead space is occasionally observed which might cause infection and grafted bone absorption. The combined use of a split calvarial bone graft and an omental flap has been an effective technique for treating complicated cranial defects. The omental flap eliminates the extradural dead space between the grafted calvarial bone and the scarred dura, and provides an acceptable vascular bed for grafted bone. The authors report this technique for complex cranioplasties in two cases, with good cosmetic results.

Craniofacial fibrous dysplasia with rapidly increasing proptosis due to a mucocele behind the globe

A 16-year-old male with fibrous dysplasia, in which rapidly increasing proptosis of the left eye was induced by a mucocele behind the globe, is reported. The mucocele was removed and the expanded bone was completely recontoured back to normal dimensions with the aid of an acrylic skull replica fabricated preoperatively by laser lithography on the basis of computed tomographic data. The result was satisfactory and no recurrence of bony swelling or proptosis has been detected for 2 years and 9 months.

Life-size, computer-generated skull replica to assist surgery of craniofacial fibrous dysplasia

Craniofacial fibrous dysplasia is a benign pathological condition but it replaces bone and expands gradually, leading to facial distortion. Surgery is the only effective treatment. The authors describe the usefulness of a life-size, computer-generated skull replica which assists surgeons pre- and intraoperatively. Surgery can be safely performed with less invasion and a shorter operation time by referring to the skull replica. Partial bone resection and bone contouring have been carried out, assisted by skull replicas, in 8 patients with craniofacial fibrous dysplasia, resulting in good cosmesis.

[Study on the most appropriate time for Romurtide administration (Nopia) in radiotherapy patients]

The most appropriate time for administration was studied based on examination of the total number of leukocytes, differential white blood count, and the number of platelets in 30 cases in which 200 micrograms Romurtide (Nopia) was injected subcutaneously on the day of radiotherapy, 5 times a week, for 2 weeks, totally 10 times because leukopenia was caused during treatment with radiotherapy. It was recognized that the number of leukocytes, mainly neutrophils, increased from 1 week after starting administration of Romurtide to after the completion of administration (2 weeks after administration), except 1 week after completion of administration. The increasing effect in the number of platelets was not recognized, and it had decreased from at the completion of administration to 1 week after the completion of administration of Romurtide. The rate of completion of radiotherapy was 100% without any serious adverse events, but there were 4 cases in which fever was observed. Therefore, it is not very favorable to administer Romurtide immediately after radiation, taking account of the treatment period of radiotherapy. It is also considered that it would be necessary to start radiation after sufficient recovery of the number of leukocytes or increase in their number by using G-CSF preparation in cases in which the leukocyte count has fallen since starting radiation due to the influence of the preceding chemotherapy.

Endoscopic lithotomy of common bile duct stones with sublingual nitroglycerin and guidewire

OBJECTIVE

In 21 patients, our objective was the endoscopic removal of common bile duct stones by sphincter dilation with the application of sublingual nitroglycerin.

METHODS

Nitroglycerin 0.3-0.6 mg was needed for proper dilation of the orifice and for successful cannulation of the Dormia basket into the bile duct. Cannulation of the Dormia basket was simplified by placing the guidewire in the common bile duct beforehand. Because of possible stone impaction, a mechanical lithotriptor was applied smoothly in two patients.

RESULTS

Complete stone removal was successful in 18 of the 21 (86%) patients. One patient who developed a mild form of acute pancreatitis recovered in a few days by conservative management with drip infusion of protease inhibitor. Blood pressure dropped transiently in a patient receiving nitroglycerin, but the general condition of the patient was stable.

CONCLUSIONS

This procedure was found to be safe, easy, and effective in extracting common bile duct stones.

Intracaval invasion of left adrenal cortical carcinoma extending into the right atrium

A case of adrenal carcinoma with advanced inferior vena cava (IVC) involvement is reported. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a large mass over the upper pole of the left kidney, with tumor thrombus from the IVC to the right atrium of the heart. Angiography demonstrated that this mass received its blood supply mainly from the left superior adrenal artery, and, parasitically, the left middle adrenal artery, splenic artery, and lumbar arteries. Venacavography revealed obstruction of the IVC and the collateral, dilated azygos vein. Radical surgery was performed, including resection of the tumor and the tumor thrombus in the IVC and right atrium with the aid of cardiopulmonary bypass. Although renal carcinoma with tumor thrombus invasion of the IVC or atrium is common, adrenal tumor thrombus invasive to the atrium is very rare.

Huge pleomorphic adenoma of the upper retromolar area

The case of a 41-year-old female is described wherein a minor salivary gland pleomorphic adenoma originating in the right retromolar area had extended into the infratemporal fossa and enlarged to 5 x 6 x 12 cm. The patient first became conscious of the mass as a slight swelling of the buccal mucosa when she was about 30 years of age, and the swelling since then had gradually gained in prominence. Preoperative computed tomography scan demonstrated a well-circumscribed mass occupying the right infratemporal fossa and medially displacing the pterygoid laminas. The mass was easily removed without much bleeding and no recurrence has been detected for 4 years. The incidence of pleomorphic adenoma originating in the retromolar area, the size of minor salivary gland pleomorphic adenomas at the time of diagnosis, and the treatment of choice are discussed.

Increased expression of cytokines in liver and serum in patients with extrahepatic diseases

To determine whether the liver plays an immunological role in certain extrahepatic disorders, we investigated the expression of interleukin (IL)-1 beta, IL-6, interferon (IFN)-gamma, and tumor necrosis factor (TNF)-alpha in 11 patients who had recovered from cholecystolithiasis, 12 patients with gastric cancer, 20 patients with chronic hepatitis, and 6 healthy controls. Cytokine mRNAs in the liver were detected by semiquantitative reverse transcribed-polymerase chain reaction. Serum cytokines and soluble IL-2 receptor (sIL-2R) were investigated by enzyme-linked immunosorbent assays. Increases in TNF-alpha, IL-6, IL-1 beta, and IFN-gamma mRNAs were found in the livers of patients with extrahepatic diseases. TNF-alpha and IL-6 peptides were increased in the sera of patients with gastric cancer. TNF-alpha in the sera and TNF-alpha mRNA in the liver were correlated in gastric cancer patients. Surprisingly, sIL-2R in the serum of gastric cancer patients was significantly higher than the level in healthy controls. Our findings suggest that the liver produces cytokines in reaction to extrahepatic lesions. Further, the increase in sIL-2R in gastric cancer patients indicates that malignancy may affect the immune network in vivo.

A spheno-orbital encephalocele with unilateral exophthalmos

Encephaloceles are rare congenital defects in the skull, through which the meninges and brain tissue have herilated. We report a case of an 11-year-old boy with a spheno-orbital encephalocele that presented with pulsatile exophthalmos. A two-stage operation resulted in a good outcome.