Differences between primary care physicians and specialised neurotologists in the diagnosis of dizziness and vertigo in Japan

OBJECTIVE

Vertigo and dizziness are frequent symptoms in patients at out-patient services. An accurate diagnosis for vertigo or dizziness is essential for symptom relief; however, it is often challenging. This study aimed to identify differences in diagnoses between primary-care physicians and specialised neurotologists.

METHOD

In total, 217 patients were enrolled. To compare diagnoses, data was collected from the reference letters of primary-care physicians, medical questionnaires completed by patients and medical records.

RESULTS

In total, 62.2 per cent and 29.5 per cent of the patients were referred by otorhinolaryngologists and internists, respectively. The cause of vertigo or dizziness and diagnosis was missing in 47.0 per cent of the reference letters. In addition, 67.3 per cent of the diagnoses by previous physicians differed from those reported by specialised neurotologists.

CONCLUSION

To ensure patient satisfaction and high quality of life, an accurate diagnosis for vertigo or dizziness is required; therefore, methods or materials to improve the diagnostic accuracy are needed.

Reduced induction of human β-defensins is involved in the pathological mechanism of cutaneous adverse effects caused by epidermal growth factor receptor monoclonal antibodies

Epidermal growth factor receptor inhibitors (EGFRIs) frequently cause cutaneous adverse effects such as papulopustular eruptions. However, the mechanism of the reactions remains unclear. To assess the pathological mechanism of cutaneous adverse reactions caused by EGFRIs, we investigated whether EGFRIs have an influence on the innate immune response of the skin. Levels of human β-defensins (hBDs), which serve as the first line of defence against infection by pathogenic microorganisms, in the stratum corneum samples of patients treated with EGFR. monoclonal antibodies were measured before and after starting therapy. There were no obvious trends in hBD production in patients without eruptions, whereas a significant decrease in hBD1 and hBD3 production and a nonsignficant decrease in hBD2 production were observed in patients who developed papulopustular eruptions. Our results suggest that a reduction in hBD contributes to the increased incidence of papulopustular eruptions.

Basic evaluation of a novel 4D target and human body phantom

Stereotactic body radiation therapy (SBRT) is usually verified with a dynamic phantom or solid phantom, but there is a demand for phantoms that can accurately simulate tumor dynamics within an individual that would allow customized validation in every patient. We developed a new 4D dynamic target phantom (multi-cell 4D phantom) that allows simulation of tumor movement in patients. The basic quality and dynamic reproducibility of this new phantom was verified in this investigation. The newly developed multi-cell 4D phantom comprises four main components: soft tissue, bones, lungs, and tumor (target). The phantom structure was based on computed tomography (CT) data of a male. In this study, we investigated the basic performance of a multi-cell 4D phantom. All the CT numbers of the phantom were very close to those of human data. The geometric maximum amplitudes were 4.57 mm in the lateral direction, 4.59 mm in the ventrodorsal direction, and 3.68 mm in the cranio-caudal direction. Geometric errors were 0.84, 0.58, and 0.40 mm, respectively. Movements of the abdominal surface were stable for 60 s. Repeated measurements show no actual differences in target movements between multiple measurements and indicated high reproducibility (r  >  0.97). End-to-end tests using Gafchromic film revealed a gamma pass rate of 98% or above (2 mm/3%). Although our phantom performed limited reproducibility in the movement of the patient tumor at present, a satisfactory level of precision was confirmed in general. This is a very promising device for use in the verification of radiation therapy for moving targets.

International consensus (ICON) on treatment of Ménière's disease

OBJECTIVE

To present the international consensus for recommendations for Ménière's disease (MD) treatment.

METHODS

Based on a literature review and report of 4 experts from 4 continents, the recommendations have been presented during the 21st IFOS congress in Paris, in June 2017 and are presented in this work.

RESULTS

The recommendation is to change the lifestyle, to use the vestibular rehabilitation in the intercritic period and to propose psychotherapy. As a conservative medical treatment of first line, the authors recommend to use diuretics and Betahistine or local pressure therapy. When medical treatment fails, the recommendation is to use a second line treatment, which consists in the intratympanic injection of steroids. Then as a third line treatment, depending on the hearing function, could be either the endolymphatic sac surgery (when hearing is worth being preserved) or the intratympanic injection of gentamicin (with higher risks of hearing loss). The very last option is the destructive surgical treatment labyrinthectomy, associated or not to cochlear implantation or vestibular nerve section (when hearing is worth being preserved), which is the most frequent option.

Autoimmune pancreatitis as the initial presentation of systemic lupus erythematosus

Pancreatitis is a relatively rare complication in systemic lupus erythematosus (SLE). Here we present a case of SLE associated with autoimmune pancreatitis. A 37-year old woman was admitted to our hospital because of fever, skin rash, proteinuria and abdominal pain. A diagnosis of SLE was made based on her clinical, laboratory and renal histological findings showing diffuse proliferative lupus nephritis. Elevated serum amylase, typical radiographic findings and selective increase in serum IgG4 all suggested that the patient also had autoimmune pancreatitis. Systemic administration of glucocorticoid successfully induced remission of pancreatitis and nephritis along with the reduction of IgG4. Autoimmune pancreatitis is a newly recognized type of pancreatitis, in which IgG4 immune response is thought to participate pathophysiologically. Although the disease has been observed to develop in patients having various connective tissue diseases, our report is the first to describe IgG4 related autoimmune pancreatitis in a patient with SLE.

Ceramide synthase 4 is highly expressed in involved skin of patients with atopic dermatitis

BACKGROUND

Ceramide is a crucial lipid in the stratum corneum (SC) which maintains the barrier function and hydration of the skin. In atopic dermatitis (AD) patients who have defective skin barrier function, ceramide levels are altered. We previously reported that although the amount of total ceramide was lower in involved skin compared with uninvolved skin of AD patients and with healthy control skin, the amounts of smaller ceramide species of Cer[NS] (<40 total carbons, which are total carbons of both sphingoid base and amide-linked fatty acid), especially Cer[NS] with 34 total carbons (C34-Cer[NS]), were higher. However, the enzyme(s) that produces the higher levels of smaller ceramide species in involved skin of AD patients was unclear.

OBJECTIVE

To identify the enzyme(s) that produces higher levels of smaller ceramide species of Cer[NS] in the involved skin of AD patients.

METHODS

Eight female Caucasian subjects who were diagnosed with AD on their arms (age range: 21-45 years) were enroled in this study. We compared ceramide levels in the SC and the expression levels of enzymes involved in ceramide metabolism using real-time PCR and immunohistochemistry between involved and uninvolved skin of AD patients.

RESULTS

Level of mRNA encoding ceramide synthase 4 (CERS4), which is one of the enzymes that synthesize ceramide from a sphingoid base and an amide-linked fatty acid, was significantly higher in involved skin than in uninvolved skin (P < 0.01). Additionally, the protein expression level of CERS4 in the epidermis was also higher in involved skin compared with uninvolved skin. The expression level of CERS4 correlated with the amount of C34-Cer[NS] (P < 0.01) and the skin hydration value (P < 0.05).

CONCLUSIONS

The elevated expression level of CERS4 contributes to the increase of C34-Cer[NS] and the impaired SC barrier function in involved skin of AD patients.

Post-operative infection of endoscopic submucosal dissection of early colorectal neoplasms: a case-controlled study using a Japanese database

WHAT IS KNOWN AND OBJECTIVE

Endoscopic submucosal dissection of early colorectal neoplasms (ESD-ECN) is known to be an operation with risk of contamination, possibly requiring pre-operative antimicrobial prophylaxis for the prevention of post-operative infection. However, an evaluation of the need for pre-operative antimicrobial prophylaxis for ESD-ECN has yet to be reported. The objective of this study was to determine whether pre-operative antimicrobial prophylaxis is associated with a reduced incidence of post-operative infection following ESD-ECN.

METHODS

The present retrospective case-controlled study utilized a database built from the medical records of 14 university hospitals throughout Japan. Patients who were admitted and discharged from the hospital from April 2012 to October 2013 and who had undergone ESD-ECN were included in the study. Patients who had been undergone any other operation during their course of hospitalization, and patients who were prescribed antimicrobial agents for reasons other than post-operative infection or for prophylaxis were excluded. Characteristics of the study population, pre-operative antimicrobial prophylaxis and antimicrobial therapy for post-operative infection were investigated. In addition, we compared the characteristics of patients with post-operative infection (PI) and those with no post-operative infection (NPI). Univariate analyses were used to estimate the odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS AND DISCUSSION

We obtained the records of 522 patients who had undergone ESD-ECN from the database. After application of exclusion criteria, 421 patients were enrolled. The post-operative infection rate was 1·2%. Peritonitis was found most to be the most common post-operative infection (44%). Pre-operative antimicrobial prophylaxis was used for 314 patients (75%), with a median duration of 3·0 (range 1-11) days. Cefotiam was most frequently prescribed for pre-operative antimicrobial prophylaxis (56%). Antimicrobial therapies were started 1-10 days after ESD-ECN for a duration of 1-14 days. Pre-operative antimicrobial prophylaxis was not associated with post-operative infection rate, with an OR (95% CI) of 0·73 (0·08-6·61). However, digestive tract perforation was shown to be associated with post-operative infection and had an OR (95% CI) of 17·1 (1·66-176·45).

WHAT IS NEW AND CONCLUSION

Post-operative infection is an exceedingly rare event following ESD-ECN. Pre-operative antimicrobial prophylaxis had no significant effect on post-operative infection following ESD-ECN and thus may be unnecessary. Instead, prevention of digestive tract perforation may be more critical for the decrease in post-operative infections.

Impact of platelet transfusion on survival of patients with intracerebral hemorrhage after administration of anti-platelet agents at a tertiary emergency center

This study examined the impact of platelet transfusion (PLT) on the survival of intracerebral hemorrhage (ICH) patients who had been administered anti-platelet agents (APA). This retrospective cohort analysis investigated 432 patients (259 men, 60%) who were newly diagnosed with ICH between January 2006 and June 2011 at the tertiary emergency center of Kitasato University Hospital. Median age on arrival was 67.0 years (range, 40-95 years). ICH was subcortical in 72 patients (16.7%), supratentorial in 233 (53.9%), and infratentorial in 133 (30.8%). PLT was performed in 16 patients (3.7%). Within 90 days after admission to the center, 178 patients (41.2%) had died due to ICH. Before the onset of ICH, 66 patients had been prescribed APA because of atherosclerotic diseases. Multivariate regression analysis indicated APA administration was an independent risk factor for death within 7 days (odds ratio, 5.12; P = 0.006) and within 90 days (hazard ratio, 1.87; P = 0.006) after arrival. Regarding the effect of a PLT in ICH patients with APA, no patient with PLT died. PLT had a survival benefit on patients with ICH, according to our analysis. Further prospective analysis is necessary to confirm the effects of PLT on survival in ICH with APA.

Yokukansan improves distress of medical staff, and cognitive function and motivation in patients with destructive and aggressive behaviors after traumatic brain injury

Aim

Yokukansan (a Japanese Kampo medicine) has been reported to be safe and useful in treating behavioral and psychological symptoms in dementia patients. This study aimed to investigate the effects of yokukansan on destructive and aggressive behaviors in patients after traumatic brain injury.

Methods

From April 2008 to July 2010, 189 patients who suffered traumatic brain injury were admitted to our tertiary emergency center. Of these, patients with destructive and aggressive behaviors were treated with neuroleptics. Seven patients (five men and two women) who could not be controlled by neuroleptics were given yokukansan (2.5 g powder) three times a day before meals. Main underlying conditions included brain contusion in three patients, acute subdural hematoma in two, and acute epidural hematoma in two. The following assessments were carried out at baseline and 1 and 2 weeks after initiation of treatment: the Glasgow Coma Scale for the assessment of disturbed consciousness after traumatic brain injury; Neuropsychiatric Inventory for the distress of medical staff; Mini-Mental State Examination for cognitive function; Barthel Index for activities of daily living; Vitality Index for motivation; presence of adverse effects and drug interactions.

Results

After treatment with yokukansan, patients showed significant improvements in Glasgow Coma Scale (P = 0.001), Neuropsychiatric Inventory (P = 0.016), Mini-Mental State Examination (P = 0.029), Barthel Index (P = 0.043), and Vitality Index (P = 0.013). No adverse effects or drug interactions between yokukansan and Western medicines were observed.

Conclusion

Yokukansan improved the Glasgow Coma Scale, Neuropsychiatric Inventory, Mini-Mental State Examination, Barthel Index, and Vitality Index without any adverse effects or drug interactions with Western medicines in patients with destructive and aggressive behaviors after traumatic brain injury.

[Classification of heat illness]

In the type of heat illness, several medical terms such as heat syncope, heat cramp, heat exhaustion, heat stroke are included. But their Japanese medical terms are neither unified nor clearly defined. To eliminate this problem, the new classification for heat illness is proposed. By the severity of heat illness, they are divided into three grades. Grade I is corresponded to heat cramp and heat syncope. Grade III is corresponded to heat stroke, and used for any one of the three following clinical findings, (1) Central nervous system dysfunction, i.e., consciousness disturbance, seizure, ataxia. (2) Liver and kidney dysfunction. (3) Clotting disorder, i.e., DIC. This classification can be beneficial not only to the diagnosis in the hospital, but also to the early detection and management of heat illness in the field.

A case of HELLP syndrome with multiple complications

Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome is a rare complication of pregnancy. The mortality rate associated with HELLP syndrome increases when life-threatening complications occur. A 37-year-old woman at 37 weeks of gestation developed severe cerebral hemorrhage at the beginning of labor induction and was transferred to our hospital, where HELLP syndrome was diagnosed. She developed disseminated intravascular coagulation (DIC), hepatic hematoma, and cerebral infarction after surgery. On day 68, she was transferred to her local hospital. Careful observation and rapid management can save patients with severe complications of HELLP syndrome.

Efficacy of endovascular surgery for ruptured aneurysms with vasospasm of the parent artery

INTRODUCTION

In the presence of vasospasm it is recommended that surgical clipping for a ruptured aneurysm should be delayed until it disappears, but this may be associated with re-rupture of the aneurysm resulting in a poor outcome. The indications for endovascular coil embolization in such cases are discussed.

METHODS

Since November 2002, endovascular coil embolization has been used in 18 consecutive patients with ruptured aneurysm with vasospasm of the parent artery ranging from 2 to 28 days (mean 9 days) after the initial subarachnoid hemorrhage. After successful obliteration of the aneurysm, a microcatheter preceded by a guidewire was introduced into the peripheral vessels with vasospasm of the A2 or M2 portions in order to release the vasospasm mechanically.

RESULTS

Endovascular procedures were performed successfully in all but one of the cases (94%), resulting in complete occlusion in 14 of 17 patients and mild dilation of the vasospasm in all 17 patients without technical complications or re-rupture of the aneurysm. In the one case of failure because of a tortuous artery, surgical clipping was performed after disappearance of the vasospasm. Cerebral infarction occurred in four patients, but only one correlated with the distribution of catheterization and the neurological deficits had completely disappeared 3 months after the onset.

CONCLUSION

Catheterization of parent vessels in cases of vasospasm is safe for coiling and also mechanically releases vasospasm. Vasospasm of M2 and A2 segments can be treated with microcatheterization only.

Linear fractures invisible on routine axial computed tomography: a pitfall at radiological screening for minor head injury

Computed tomography (CT) is now widely used as the only screening method for fractures in patients with head injury. However, clear depiction of a fracture requires a discontinuity in the skull, so linear fractures parallel to the CT slice may not be visualized. We retrospectively evaluated 302 patients with minor head injuries aged from 0 to 91 years, who had undergone routine skull radiography (anteroposterior and lateral views) and head CT to study these types of fracture and discuss the risk of nondetection. Three patients had linear fractures (0.99%) that were invisible on bone window axial CT but detected on skull radiography, which all ran parallel to the scan slice. Two patients developed acute epidural hematoma or traumatic subarachnoid hemorrhage. Evaluation of head injury by only axial CT may miss such fractures and result in sequelae, so diagnosticians should be alert to the possible presence of this type of fracture.

Outcomes analysis of ruptured distal anterior cerebral artery aneurysms treated by endosaccular embolization and surgical clipping

Although endovascular surgery is now widely used to treat intracranial aneurysms, no comparative studies of clipping versus endovascular surgery to address distal ACA aneurysms at the same institution are available. We compared the results of these treatment modalities to address distal ACA aneurysms at our institution. We treated 68 patients with ruptured distal ACA aneurysms (endovascular surgery, n=13; clipping surgery, n=55). We performed a retrospective comparison of the treatment outcomes. To study the efficacy of endovascular surgery we classified all our cases into three types: type A were small-necked aneurysms, type B were wide-necked aneurysms on the parent artery, and type C were aneurysms in which the A3 portion of the ACA arose from the aneurysmal dome near the neck. Intraoperative hemorrhage occurred in 7.7% of aneurysms treated by endovascular surgery and in 34.5% treated by clipping surgery. In 7.7% of the endovascularly-treated aneurysms we noted coil migration during embolization surgery; venous infarction due to cortical vein injury occurred in 7.3% of clipped aneurysms. Of the endovascularly-treated aneurysms, 7.7% manifested post-embolization hemorrhage; 23.1% manifested coil compaction. In clipping surgery, postoperative rerupture occurred in 1.8% of the aneurysms; one patient presented with postoperative acute epidural hematoma. Clip dislocation was noted in 1.8% of aneurysms. Angiography was indicative of post-treatment vasospasm in 7.7% of aneurysms treated endovascularly and in 50.9% of the clipped aneurysms. The clinical outcome showed no significant difference between endovascular surgery and clipping surgery.

Expression and translocation of aquaporin-2 in the endolymphatic sac in patients with Meniere's disease

Meniere's disease, characterised by episodic vertigo, fluctuating hearing loss and tinnitus, can occur under conditions of stress. Its pathology was first revealed to be inner ear hydrops through temporal bone studies in 1938. Although its pathogenesis has been proposed to be a disorder of water transport in the inner ear, subsequently, it remains unsolved, until now. A recent study revealed that both plasma stress hormone, vasopressin (pAVP) and its receptor, V2 (V2R) expression in the inner ear endolymphatic sac were significantly higher in Meniere's patients. In the present study, to link V2R-related molecules and inner ear hydrops, we examined V2R-linked water channel molecule, aquaporin-2 (AQP2) expression and translocation in human endolymphatic sac. AQP2 mRNA expression in the endolymphatic sac was significantly higher in Meniere's patients by using real-time polymerase chain reaction, as further confirmed by western blotting. AQP2-like immunoreactivity (-LIR) was translocated from luminal to basolateral side with endosomal trapping in the endolymphatic sac at the time of AVP exposure in human endolymphatic sac tissue culture. The similar AQP2-LIR translocation was also demonstrated by forskolin and blocked by vasopressin/V2R specific antagonist, OPC31260 and protein kinase A (PKA) specific antagonists, H-89 and KT-5720. We concluded that in the pathogenesis of inner ear hydrops resulting in Meniere's attacks, pAVP elevation as a result of stress and subsequent V2R-cAMP-PKA-AQP2 activation and endosomal trapping of AQP2 in the endolymphatic sac, might be important as a basis of this disease. Further experimental and clinical studies are needed to better clarify the neuroscientific relationship between stress and Meniere's disease.

Subarachnoid haemorrhage due to a lateral spinal artery aneurysm misdiagnosed as a posterior inferior cerebellar artery aneurysm: case report and literature review

CLINICAL DESCRIPTION

A 61 year old man presenting with subarachnoid haemorrhage had a distal posterior inferior cerebellar artery (PICA) aneurysm diagnosed on the initial cerebral angiogram. However, a PICA aneurysm was not found during surgery. A follow-up, super-selective vertebral artery (VA) performed demonstrated a saccular aneurysm located on the lateral spinal artery (LSA). A right sub-occipital craniotomy was performed and the aneurysm arising was identified and obliterated with a small titanium clip.

CONCLUSION

We describe the first example of an LSA aneurysm without occlusion or severe stenosis of the VA and PICA. This extremely rare lesion illustrates how knowledge of the angiographic features and super-selective cerebral angiography aids the precise diagnosis and the prevention of surgical complications.

Effect of eutrophication on the distribution of arsenic species in eutrophic and mesotrophic lakes

Effects of eutrophication on arsenic speciation were studied in eutrophic Lake Kiba and mesotrophic Lake Biwa, Japan. By combining hydride generation atomic absorption spectrometry with ultraviolet irradiation, inorganic, methyl and ultraviolet-labile fractions of arsenic were determined. In both Lakes, inorganic species (As(V+III)) dominated over other forms of arsenic all the year round. Most of methylarsenic fraction was dimethylarsinic acid (DMAA), and the concentration of monomethylarsonic acid (MMAA) was below the detection limit. Measurements of size-fractioned arsenic concentrations in water column indicate that most of the DMAA was distributed in truly dissolved fraction (<10 kDa), while ultraviolet-labile fractions were distributed in particulate (>0.45 microm) and colloidal (10 kDa-0.45 microm) fractions. Arsenic speciation in eutrophic Lake Kiba fluctuated greatly with season. The ultraviolet-labile fractions were observed with the increase of DMAA from May to October, and they disappeared with the decrease of DMAA in January. In mesotrophic Lake Biwa, the ultraviolet-labile fractions of arsenic were not influenced as much as those in eutrophic Lake Kiba. On the other hand DMAA concentration was higher in Lake Biwa compared to that in Lake Kiba. The results suggest that the biosynthesis of complex organoarsenicals was enhanced by eutrophication, and the arsenic speciation would be influenced by the balance of biological processes in natural waters.

Meniere's attacks occur in the inner ear with excessive vasopressin type-2 receptors

Meniere's disease is peculiar to humans and is characterised by episodic vertigo, fluctuating hearing loss and tinnitus, and attacks of the affliction occurring under conditions of stress. Its pathology was first revealed to be inner ear hydrops through temporal bone studies in 1938. Although subsequently proposed as a disorder of water metabolism in the inner ear, its pathogenesis remains unsolved. The present study aimed to assess the link between the inner ear pathology in Meniere's disease and vasopressin, an anti-diuretic stress hormone with a potential role in inner ear fluid homeostasis. Blood samples were obtained from Meniere's disease patients in the morning, before any surgical treatment, to examine plasma vasopressin (pAVP) levels, and then from inner ear tissue during surgical treatment, to examine vasopressin type-2 receptor (V2R) in the endolymphatic sac. pAVP and the relative V2R mRNA expression in the endolymphatic sac were examined using a real-time polymerase chain reaction. Relative cAMP activity in the endolymphatic sac was also examined using tissue culture and cAMP assay. Both pAVP (1.6-fold versus controls; P = 0.048) and inner ear V2R mRNA expression (41.5-fold versus controls; P = 0.022) were significantly higher in Meniere's patients. cAMP activity was basally up-regulated (2.1-fold versus controls) and cAMP sensitivity to vasopressin application was largely elevated (4.9-fold versus controls) in Meniere's patients. We conclude that, in the pathogenesis of inner ear hydrops, resulting in Meniere's attacks, elevation of pAVP levels (probably as a result of stress) may present as a matter of consequence, but susceptibility of the V2R-overexpressed and cAMP-hypersensitized inner ear to pAVP elevation might be essential as the basis of this disease. Further experimental and clinical studies are needed to better clarify the relationship between Meniere's disease and stress.

Comparison of 40 and 60 milliliters of contrast in assessment of the carotid artery by computed tomography angiography

BACKGROUND

Although fast acquisition of multidetector-row computed tomography (MDCT) can make it possible to acquire sufficient early vascular enhancement using small volumes and high concentrations of contrast material (CM), there are still some problems with nephrotoxicity and costs related to CM.

PURPOSE

To compare the qualitative and quantitative performance in cervicocranial CT angiography (CTA) using two different iodine volumes and concentrations of CM.

MATERIAL AND METHODS

CTA ranging from the aortic arch (AA) to distal to the circle of Willis (cW) was performed on a 32-MDCT system. Fifty-eight patients were randomly divided into two groups: group A (29 patients) received 60 ml of 300 mg I/ml CM, and group B (the other 29 patients) received 40 ml of 370 mg I/ml CM. Time to peak arterial enhancement at cW (T(c)) was calculated. As scan speed was 96.9 mm/s and injection rate was 4.0 ml/s, scanning delay was individually decided according to T(c) and scan duration between AA and cW. Arterial attenuation along the z-axis at eight points in the carotid-cerebral artery and venous attenuation of the internal jugular vein (IJV) at carotid bifurcation were measured. Mean attenuation values were then quantitatively analyzed. Postprocessing images were qualitatively assessed.

RESULTS

Arterial attenuation profiles revealed maximum attenuation at the distal common carotid artery in both groups. Although there were no significant differences in mean arterial attenuation in group A versus group B (402+/-70 HU vs. 407+/-67 HU; P=0.78), venous attenuation of the IJV was lower in group B than in group A (114+/-57 HU vs. 224+/-81 HU; P<0.001). Although arterial images demonstrated no difference qualitatively between the two groups, the venous contamination of IVC was less prominent in group B.

CONCLUSION

Although a different amount of CM was administered in both groups, quantitative and qualitative arterial images did not show significant differences between the two groups.

[Infectious aneurysm rerupture caused by delayed diagnosis: an operative case report]

A 21-year-old febrile woman with sudden onset of headache and semicoma was transferred to our institute. CT and 3D-CT angiography showed subaracnoid hemorrhage and intracranial hemorrhage in the left hemisphere due to a saccular aneurysm at the occluded M2 portion of the middle cerebral artery (MCA). Her present illness started with a toothache and lumber pain 3 weeks earlier. Echocardiography revealed active infective endocarditis. We could have treated her by administering antibiotics, but during a cerebral angiography, she became comatose due to an aneurismal rerupture. Immediately, an emergency operation for aneurismal trapping was performed, but she died 19 days later because of left hemispheric swelling. We report a relatively rare case of infectious aneurysm at the proximal artery and discuss the pitfalls of its diagnosis and treatment. We should educate general physicians about infectious endocarditis because misdiagnosis or delayed diagnosis of infectious aneurysm due to endocarditis results in unpleasant outcomes. We should treat infectious aneurysm at the proximal side artery by first administering antibiotics, and if necessary, subsequent direct surgery of the aneurismal trapping should be performed with a bypass. Unnecessary invasive treatment must be avoided while the disease is in the active infectious stage.

A Randomized Controlled Trial of Hydrocortisone Against Hyponatremia in Patients With Aneurysmal Subarachnoid Hemorrhage

BACKGROUND AND PURPOSE

Hyponatremia is common after aneurysmal subarachnoid hemorrhage (SAH). It is caused by natriuresis, which induces osmotic diuresis and decreases blood volume, contributing to symptomatic cerebral vasospasm (SCV). Hypervolemic therapy to prevent SCV will not be efficient under this condition. We conducted a randomized controlled trial to assess the efficacy of hydrocortisone, which promotes sodium retention in the kidneys.

METHODS

Seventy-one SAH patients were randomly assigned after surgery to treatment with either a placebo (n=36) or 1200 mg/d of hydrocortisone (n=35) for 10 days and tapered thereafter. Both groups underwent hypervolemic therapy. The primary end point was the prevention of hyponatremia.

RESULTS

Hydrocortisone prevented excess sodium excretion (P=0.04) and urine volume (P=0.04). Hydrocortisone maintained the targeted serum sodium level throughout the 14 days (P<0.001), and achieved the management protocol with lower sodium and fluid (P=0.007) supplementation. Hydrocortisone kept the normal plasma osmolarity (P<0.001). SCV occurred in 9 patients (25%) in the placebo group and in 5 (14%) in the hydrocortisone group. No significant difference in the overall outcome was observed between the 2 groups.

CONCLUSIONS

Hydrocortisone overcame excess natriuresis and prevented hyponatremia. Although there was no difference in outcome, hydrocortisone supported efficient hypervolemic therapy.

Endovascular surgery for ruptured aneurysms with vasospasm

SUMMARY

With the existence of vasospasm, it is recommended that direct clipping surgery for a ruptured aneurysm be delayed until its disappearance, but this may be associated with aneurysmal re-rupture resulting in a poor outcome for the patients. Indications for endovascular coil embolization in such cases are discussed. Since November in 2003, we have applied endovascular coil embolization in 11 consecutive patients with ruptured aneurysms and apparent vasospasm of the parent artery from two to 17 days (average: eight days) after initial subarachnoid hemorrhage. Three patients had aneurysmal re-rupture before treatment, but the other eight had only experienced the one episode of subarachnoid hemorrhage. With one exception, all endovascular procedures could be successfully performed, resulting in complete occlusion of aneurysms and remarkable dilatation of inserted spastic vessels without technical complications or aneurysmal re-rupture. For the one case of failure because of a tortuous artery, direct clipping surgery was performed after disappearance of vasospasm. Cerebral infarction occurred in four, but only one correlated with the distribution of catheterization, and neurological deficits had completely disappeared three months after the onset. This preliminary report concerning a small number of patients suggests that endovascular coil embolization is not contra-indicated for aneurysms with vasospasm requiring catheterization. A large study for confirmation is now warranted.

Gene transfer in human skin with different pseudotyped HIV-based vectors

Pseudotyping lentiviral vector with other viral surface proteins could be applied for treating genetic anomalies in human skin. In this study, the modification of HIV vector tropism by pseudotyping with the envelope glycoprotein from vesicular stomatitis virus (VSV), the Zaire Ebola (EboZ) virus, murine leukemia virus (MuLV), lymphocytic choriomeningitis virus (LCMV), Rabies or the rabies-related Mokola virus encoding LacZ as a reporter gene was evaluated qualitatively and quantitatively in human skin xenografts. High transgene expression was detected in dermal fibroblasts transduced with VSV-G-, EboZ- or MuLV-pseudotyped HIV vector with tissue irregularities in the dermal compartments following repeated injections of EboZ- or LCMV-pseudotyped vectors. Four weeks after transduction, double-labeling immunofluorescence of beta-galactosidase and involucrin or integrin beta1 demonstrated that VSV-G-, EboZ- or MuLV-pseudotyped HIV vector effectively targeted quiescent epidermal stem cells which underwent terminal differentiation resulting in transgene expression in their progenies. Among the six different pseudotyped HIV-based vectors evaluated, VSV-G-pseudotyped vector was found to be the most efficient viral glycoprotein for cutaneous transduction as demonstrated by the highest level of beta-galactosidase expression and genome copy number evaluated by TaqMan PCR.

Efficacy of a direct puncture approach for anterior circulation aneurysms using a newly developed guiding catheter—especially for geriatric patients

BACKGROUND

Endovascular surgery is being increasingly used as an alternative to craniotomy clipping surgery, especially for aged patients and complicated cases. However, tortuous atherosclerotic arteries sometimes interfere with advancement of catheters so that direct puncture may be necessary. Short guiding catheters for use with this approach have been newly developed, as discussed in this article.

METHODS

One hundred twenty three anterior circulation aneurysms in 121 patients were consecutively treated by endovascular coil embolization, of which 42 (34%) were older than 70 years.

RESULTS

With 21 aneurysms, coil embolization via the transfemoral approach failed, but all could be successfully treated with the direct puncture approach with minor complications such as 1 transient ischemic attack and 1 nonsymptomatic minor leakage. In the aged patients, the direct puncture approach with short guiding catheter resulted in complete obliteration of aneurysms in 20 (71%) of 28 with follow-up angiography.

CONCLUSION

Direct puncture using newly developed short guiding catheters is an alternative to femoral approaches for patients with anterior circulation aneurysm with tortuous arteries and obvious atherosclerotic change at bifurcations of the common carotid artery.

Data Processing for Radioimmunoassay Standard Curve Using Microcomputer: A New Basic Program for Weighted Logit-Log Transformation

A new BASIC program of the weighted linear, quadratic and cubic logit-log regression methods for data processing of radioimmunoassay standard curve was developed using a microcomputer. Using this program, three regression analyses are calculated and the table for root mean square of residuals in each regression are shown for the selection of the regression method. The data of three radioimmunoassays of human pancreatic enzymes and pancreatic secretory trypsin inhibitor were examined by this program and compared with those processed by the four parameter logistic method. The weighted cubic logit-log regression showed better fit in radioimmunoassays of human pancreatic enzymes with larger molecular weights. The present program is useful and practicable for its simplicity and accuracy.

Late-onset neuropsychological symptoms in a Japanese patient with megalencephalic leukoencephalopathy with subcortical cysts

We herein report a Japanese patient with megalencephalic leukoencephalopathy with subcortical cysts (MLC) who developed late-onset neuropsychological symptoms. He demonstrated characteristic clinical features of MLC during childhood, such as slowly progressive megalencepaly, motor impairment with ataxia and spasticity, mild mental retardation, and well-controlled epilepsy. Thereafter, he showed specific neuropsychological symptoms, such as motor and vocal tics, compulsive behavior, perseveration, acquired stuttering, and dystonia since the age of 12. His performance abilities had been unchanged but his verbal abilities had degraded during the past 14 years. Higher cortical dysfunction tests revealed a frontal lobe dysfunction. On repeated brain MRI, a leukoencephalopathy with subcortical cysts remained stationary from infancy. On single photon emission computed tomography (SPECT), a hypoperfusion in the frontal lobe was detected at the age of 3.5 and 17, but the severity of hypoperfusion was also unchanged, respectively. Our results indicate that the frontal lobe dysfunction may be relevant to the late-onset neuropsychological symptoms with MLC.

Developmental changes in craniofacial morphology in subjects with Duchenne muscular dystrophy

Lateral cephalometric radiographs of 35 Japanese male patients suffering from Duchenne muscular dystrophy (DMD) were taken longitudinally from 10 to 20 years of age. Eighteen landmarks were placed and 15 angles and four linear distances calculated. Profile diagrams (profilograms) were produced to analyse changes in craniofacial morphological growth in the DMD subjects. The measurements were then compared with Japanese standards. In young patients with DMD, compared with the controls, the following were observed: a large gonial angle; clockwise rotation of the mandible; short sagittal length of the cranial base and protrusion of the upper incisors. In adult patients, the maxillary alveolus and the upper incisors were protruded, compared with the controls. Overbite in DMD subjects also showed a tendency to decrease. In the controls, mandibular growth direction tended to be straight down and forward, while in patients with DMD, the growth direction was down until approximately 16 years of age and, after that, a forward vector of growth was apparent. As a result, the tendency towards a clockwise rotation of the mandible in the adults was less than in the young patients. These findings showed that DMD significantly affects craniofacial morphology.