Petroclival meningiomas: surgical experience in 109 cases

The surgical removal of petroclival meningiomas has historically been associated with a high incidence of morbidity and mortality. The 109 consecutive patients included in the present retrospective study represent a combined series of tumors operated on by the four authors during a period from 1980 to 1992. The series is composed of 40 men and 69 women ranging in age from 25 to 75 years (mean 51 years). Surgical approaches to tumors in this series included simple retromastoid (60 cases), combined supra- and infratentorial petrosal (22), transtemporal (primary transsigmoid retrolabyrinthine, translabyrinthine, or transcochlear (12), subtemporal (11), and frontotemporal transcavernous (eight). Gross-total removal was achieved in 75 patients (69%). Recurrence or progression of disease occurred in 14 patients (13%) over a 6.1-year mean follow-up period, and it was found within the cavernous sinus in 12 of these cases. Four recurrent cases demonstrated histological compatibility with malignant meningioma. Perioperative death occurred in four patients, and there were 56 significant complications in 35 other patients. Review of this series, with the attendant complications, has facilitated the authors' decision-making when considering the risk of gross-total removal in selected patients with asymptomatic cavernous sinus invasion or tumor adherent to the brainstem.

Atrial activation during chronic atrial fibrillation in patients with isolated mitral valve disease

BACKGROUND

A computerized 32-channel mapping system has been developed to investigate the characteristics of the atrial activation sequence. The system is capable of displaying sequential atrial maps and provides a rapid and dynamic means of verifying the activation sequence of atrial fibrillation.

METHODS

Using this system, we performed intraoperative atrial activation mapping in 10 patients with chronic atrial fibrillation who were undergoing isolated mitral valve operations.

RESULTS

Regular and repetitive activation (cycle length ranged from 131 to 228 milliseconds) originated in the left atrium in all 10 patients. Two patterns of repetitive activation in 2 patients and three patterns in 1 patient appeared alternately during the observation period in the left atrium. In contrast to the repetitive activation in the left atrium, the activation sequence of the right atrium was extremely complex and chaotic. In 7 of the 10 patients, the same pattern of right atrial activation was never repeated during the observation period. In 2 patients, revolution of repetitive activation in the right atrium sporadically appeared, but the pattern of activation immediately deteriorated to a complex and chaotic pattern. In 1 patient, repetitive activation emerged from the low lateral portion of the right atrium. Because our mapping technique was limited by the number of available atrial electrodes, discrete reentrant circuits or ectopic foci could not be demonstrated in the present study. However, the activation sequences during chronic atrial fibrillation suggested that (1) the left atrium would act as an electrical driving chamber for atrial fibrillation in the majority of the patients and (2) atrial activation patterns are different in each case.

CONCLUSIONS

Computerized intraoperative mapping should guide surgeons in determining the appropriate surgical procedure and facilitate operation for chronic atrial fibrillation associated with mitral valve disease.

[Problems encountered with a programmable pressure valve (SOPHY) positioned in the chest wall]

Sixty-eight hydrocephalic patients were treated with a shunt system that incorporated a SOPHY programmable valve. This device is very effective for treating disorders of CSF circulation. However, when the valve is placed on the scalp, it produces artifacts on MR imaging due to its small magnetic rotor, and may cause necrosis of the scalp above it. On the other hand, when it is positioned on the chest, MR artifacts decrease and exchanging the valve devices becomes easier. Therefore, we have positioned the device on the chest. However, some complications were encountered, such as the turning over of the valve in the subcutaneous pocket and the twisting of the shunt tube. Moreover, the shunt tube may stretch due to growth of the neck during development in infantile patients or extension of the neck during exercise. These complications are associated only with subcutaneous placement on the chest, so we conclude that such a valve, if placed on the chest, should be placed in a lower position on the chest, and if MR examination will not be performed in the foreseeable future, we recommend that it be placed on the occipital scalp, especially in infantile patients.

Innovations in surgical approach: lateral cranial base approaches

The extradural anterior transpetrosal approach possesses several advantages. First, the majority of the dissection is extradural, providing protection to the overlying neural structures. Second, only limited retraction of the temporal lobe is necessary, protecting venous outflow via the vein of Labbe'. Third, transposition of cranial nerves or vascular structures in unnecessary. Fourth, it enjoys natural compatibility with other surgical approaches to enhance exposure of the posterior cavernous sinus and petroclival region. The disadvantages are mostly related to the unfamiliar anatomy. Most surgeons are not accustomed to visualizing petrous apical anatomy from the middle fossa orientation. Therefore, practice of this technique in the cadaver laboratory is a mandatory prerequisite to its performance in the operating room. The cochlea, carotid artery, labyrinth, and cranial nerves five through eight are all at risk during drilling and dissection. When performed properly, this technique provides a solid adjunct to treating complex lesions of the central cranial base.

A single-base mutation in exon 31 converting glycine 852 to arginine in the collagenous domain in an Alport syndrome patient

In a family with Alport syndrome, molecular analysis of the COL4A5 gene, which encodes the alpha 5(IV) chain of glomerular basement membrane collagen, revealed a GGA-->AGA change in exon 31, resulting in substitution of an arginine for a glycine in position 852 of the polypeptide chain, between interruptions 16 and 17 of the triple-helical collagenous domain. The mutation causes the MaeI restriction sites, and could be easily diagnosed in the family members through restriction analysis. This one point mutation can be expected to interrupt type IV collagen molecules.

Intracellular signaling in neutrophil priming and activation

In order for neutrophils to function effectively in host defense, they have evolved specific attributes including the ability to migrate to the site of inflammation and release an array of toxic products including proteolytic enzymes, reactive oxygen species, and cationic proteins. While these compounds are intended for killing invading pathogens, if released inappropriately, they may also contribute to tissue damage. Such inflammatory tissue injury may be important in the pathogenesis of a variety of clinical disorders including arthritis, ischemia-reperfusion tissue injury, the systemic inflammatory response syndrome (SIRS), and the acute respiratory distress syndrome (ARDS). Despite the importance of neutrophil function in host defense and dysfunction in disease states, much remains unknown about the intracellular signaling pathways regulating neutrophil activity. This review will focus on the signaling molecules regulating leukocyte 'effector' functions including receptors, GTP-binding proteins, phospholipases, polyphosphoinositide metabolism, and protein kinases and phosphatases.

p53 mutations and overexpressions in Japanese breast cancer

Mutations in the p53 gene were analysed in 50 cases with breast cancer by PCR-SSCP and direct DNA sequencing. Mutations were found in 10 of 50 cases (20%) including a case with Tis, and loss of the normal allele was found in five of these cases. Eight of the 10 mutations occurred within highly conserved domains, but no mutational hot spots were found. GC to AT transitions were the most frequent mutations (six of 10 cases), while mutations at CpG dinucleotides were found in three cases (30%). AT to TA transversions were the second most frequent mutation (20%). The level of expression of p53 protein was assessed by Western blot analysis in 62 cases. Overexpression of p53 protein was detected in 21 of 62 cases (34%) including a case with Tis. There was a strong correlation between missense mutations in the p53 gene and overexpression of p53 protein. Overexpression of p53 protein was closely associated with increasing tumour size and ER-negative status among the various factors investigated, suggesting that p53 overexpression may reflect the lack of differentiation in breast cancer.

Surgery for Crohn's anal fistulas

The aim of this study was to analyze the features of Crohn's anal fistulas and to evaluate the efficacy of seton treatment. In 119 patients with Crohn's disease, the incidence of anal fistula was 56% (67/119), with no significant difference in the incidence among patients with ileitis, colitis, and ileocolitis. "Intractable" anal fistulas were found in 17% of patients with ileitis, compared to 64% of those with colitis (P = 0.051) and 68% of those with ileocolitis (P = 0.014). Seton treatment, i.e., non-cutting, long-term seton drainage, was performed for 21 patients (5 with intersphincteric, and 16 with transsphincteric fistulas). In the 16-month follow up, 9 patients required redrainage for recurrent fistulous abscess, mainly because of progressive colorectal disease. Finally, a good result was obtained in 17 of the 21 patients (81%) and no recurrent fistulous abscess developed in the 8 patients in whom all setons were removed. Anal continence was preserved in all the patients. These results indicate that anal fistulas with Crohn's ileitis were cured more easily than those with colitis or ileocolitis, and that seton treatment was effective for intersphincteric fistula with multiple fistula openings and for transphincteric fistulas in patients exhibiting remission of intestinal Crohn's disease.

Double-blind comparative study of sulfasalazine and controlled-release mesalazine tablets in the treatment of active ulcerative colitis

To evaluate the effect of a controlled-release mesalazine tablet, in patients with ulcerative colitis (UC), a multicenter double-blind study was carried out, using sulfasalazine (500 mg tablet) as the control drug. The mesalazine tablet contained 250 mg of ethyl cellulose-coated mesalazine granules. The patients were assigned to two groups, one to receive mesalazine tablets (1500 mg/day) and a sulfasalazine placebo (group M) and the other to receive sulfasalazine tablets (3000 mg/day) and a mesalazine placebo (group S). The test medications were administered orally for 4 consecutive weeks. The study subjects were selected from among patients with mild to moderate active UC, and 118 patients were enrolled. Concomitant use of steroids and immunosuppressors was prohibited during the study period. Of the 118 patients, 9 dropped out. A total of 109 complete records were thus obtained, 52 in group M and 57 in group S. There was no difference in the improvement of clinical symptoms and endoscopic findings between the two groups. The overall safety, based on adverse reactions and laboratory data, was higher, at 86.5%, for group M (n = 52), compared to 66.7% for group S (n = 57). The general usefulness, based on the improvement and safety, was higher, at 65.3%, for group M (n = 49), compared to 45.6% for group S (n = 57). The controlled-release mesalazine tablet thus appears to be useful in the treatment of mild to moderate active UC.

Radical formation site of cerebral complex I and Parkinson's disease

Paraquat was reduced to the paraquat radical via complex I in bovine cerebral mitochondria and accelerated lipid peroxidation. Thirty-kilodalton subunit of complex I was considered to be the radical formation site, because of its marked destruction by the paraquat radical. The lipid peroxidation by the paraquat radical was suppressed not only by superoxide dismutase (SOD) but also by mannitol. The destruction of complex I subunits via lipid peroxidation must have been caused by the hydroxyl radical which was formed from the superoxide radical. The same phenomenon was observed by using 1-methylnicotinamide (MNA), which contains the same partial structure as paraquat in itself and is metabolized from nicotinamide in a living body. We observed NADH oxidation by MNA via cerebral complex I (Km = 26.3 mM), and MNA destroyed some complex I subunits, especially 30-kilodalton protein. Paraquat might be useful for studying the pathogenesis of Parkinson's disease (PD) in vitro, and MNA is expected to be one of the causal substances of PD from the viewpoint of the oxidative stress theory.

[A case of renovascular hypertension with nephrotic syndrome]

A 68-year-old male patient with renovascular hypertension (RVHT) and nephrotic syndrome (NS) is described. He was admitted to our hospital for detailed investigation of severe hypertension and massive proteinuria. After admission, a diagnosis of RVHT with a right non-functional kidney and NS was made. Nephrectomy and contralateral renal biopsy were performed for refractory hypertension and detailed investigation of the NS, respectively. The renal biopsy showed focal segmental glomerulosclerosis (FGS) in the left kidney, whereas the nephrectomised kidney exhibited only ischemic change. After the operation, his blood pressure became stable without anti-hypertensive agents, but proteinuria remained in the nephrotic range. Six months later, proteinuria had disappeared and his renal function was stable. These findings suggest that NS and FGS might have resulted from an activated renin-angiotensin-axis and that the prolonged NS was due to severe glomerular injury. Although there have been many reports describing the relationship between RVHT and FGS in an experimental environment, this relationship is very rare in clinical cases. Therefore we present this case to increase understanding of the cause of FGS.

V-onc mutation associated with host cell growth in retroviral tumors

In sarcomagenesis in rats infected neonatally with feline sarcoma virus (ST-FeSV), v-fes product (P85) was previously shown by us to be a predictive and preventive determinant. In order to explore the part played by P85 in tumor suppression, DNA was extracted from precancerous granulomas and from slow or rapid growing sarcomas induced by neonatal injection of the virus. The v-fes signal from extracted DNA was analyzed by PCR-SSCP. The prototype v-fes gene signal was detected in most lesions and found to be generally amplified in rapid growing sarcomas and in some granulomas. Several v-fes homologs showing varying mobilities in gel were seen in most sarcomas and some granulomas with or without the prototype v-fes signal. In slow growing sarcomas and granulomas induced in hosts that were immunized with ST-FeSV induced syngeneic sarcoma and proved to carry IgG antibody to P85, the prototype v-fes gene was found to be down-regulated and v-fes homologs were found to be reduced in number or eliminated. These results suggest that the development of v-fes mutations is associated with the growth potential of cells carrying the v-fes gene, and that host immunity to v-onc product influences the development of virogene rearrangements and results in slow and suppressed growth of tumors caused by neonatal infection with retrovirus.

[Morphological study of cardiac veins that drain into the coronary sinus, with special reference to the coronary artery dominant pattern]

The morphology of the cardiac veins that drain into the coronary sinus was studied in 31 human hearts, with special reference to the coronary artery dominant pattern (Barnes' classification). The results were as follows: 1. Great cardiac vein (GCV) The average GCV index of Barnes type I (BI) did not differ significantly from that of Barnes type II (BII). 2. Left marginal vein (LMV) (1) The LMVs were divided into two types, according to the angle made by the LMV and the truncal vein: rect (18 cases, 58%) and acute (11 cases, 38%) angular influx type. (2) The average LMV angle of BI (n = 9, mean +/- SD 77.0 +/- 23.2) was greater than that of BII (n = 19, mean +/- SD 48.1 +/- 34.3) and the difference was statistically significant (p < 0.05). (3) The average LMV index of BI did not differ significantly from that of BII. 3. Left posterior ventricular vein (LPVV) (1) The average LPVV influx angle of BI did not differ significantly from that of BII. (2) The average LPVV index of BI did not differ significantly from that of BII. 4. Middle cardiac vein (MCV) The average MCV index of BI did not differ significantly from that of BII. 5. Small cardiac vein (SCV) The average SCV index of BI did not differ significantly from that of BII. 6. Anterior cardiac veins (ACVs) The number of ACVs correlated with the SCV index, and the correlation was statistically significant (n = 31, r = -0.416, p < 0.02). 7. Coronary sinus (CS) The average CS index of BI did not differ significantly from that of BII. The right ventricular wall may not be perfused effectively during open heart surgery when retrograde coronary sinus perfusion (RCSP) is used. The present study demonstrated that this method can produce poor right ventricular perfusion in cases when the ACVs developed well.

Current techniques in cell and molecular biology

Recent advances in the field of molecular biology have revolutionized our understanding of the functioning of living organisms and facilitated the development of robust tools for both diagnosis and treatment of diseases. With particular reference to the field of critical care medicine, development of molecular biology techniques have aided in the following: (1) rapid and highly specific detection of pathogenic infectious agents (eg, Mycobacterium tuberculosis, Pneumocystis carinii, cytomegalovirus, Legionella); (2) development of assays for measurement of circulating cytokines such as tumor necrosis factor (TNF) and interleukin (IL)-1 that has helped our understanding of the pathogenesis of the sepsis syndrome; (3) administration of antibodies or soluble receptors to attempt to prevent untoward effects of cytokines such as TNF or IL-1; and (4) the administration of recombinant deoxyribonucleic acid (DNA) or proteins to patients in an attempt to alter the course of a disease such as antioxidant enzymes (superoxide dismutase). The rapidity of progress in this field has been staggering, which necessitates frequent updating of our knowledge for clinicians to put these molecular tools to their best use. This brief review attempts to explain the basic principles of commonly used techniques in molecular biology including recombinant DNA, polymerase chain reaction, DNA libraries, gene therapy, and protein biochemistry in a manner that is understandable to those without an in-depth knowledge of the field.

Successful treatment of invasive thoracopulmonary mucormycosis in a patient with acute lymphoblastic leukemia

BACKGROUND

Pulmonary mucormycosis associated with hematologic malignancy is an uncommon, but important opportunistic fungal pneumonia that is usually a fatal infection. Only a few survivors of pulmonary mucormycosis have been reported.

METHODS

A case report of invasive thoracopulmonary mucormycosis during remission-induction therapy for acute lymphoblastic leukemia and a review of the literature are presented.

RESULTS

The fungal lesions extended to both lungs, the left ribs, and intercostal muscles. Percutaneous needle biopsy and immunostaining of the fungal hyphae established the diagnosis of thoracopulmonary mucormycosis. The patient was treated with granulocyte-colony stimulating factor (G-CSF) and intravenous amphotericin B for 9 weeks and the lesions in the right lung disappeared. Left pneumonectomy and partial resection of the chest wall were later performed. The left lung was grossly necrotic and contained a large cavity and bronchopulmonary fistula. Thereafter, antileukemic therapy was resumed and completed without recurrence of mucormycosis or leukemia.

CONCLUSIONS

In the management of mucormycosis, the addition of G-CSF to the conventional treatment may substantially improve outcome.

Determination of D-amino acids in serum from patients with renal dysfunction

D-Ala and D-Ser were detected in the sera of both normal subjects and patients with renal dysfunction, and their concentrations were higher in the patients than in the normal subjects. A positive correlation between the concentration of D-Ala or D-Ser and that of creatinine (r = 0.733, p < 0.001 or r = 0.634, p < 0.001) or blood urea nitrogen (BUN) (r = 0.449, p < 0.05 or r = 0.629, p < 0.001) was observed in sera from 20 patients with renal dysfunction. The fraction (%D) of D-Ala in the total Ala in serum ([D/(D+L)] x 100) correlated well with the concentration of creatinine (r = 0.811, p < 0.001), suggesting that it is a candidate as a marker for renal proximal tubular dysfunction. The correlations of %D of Ser with creatinine and BUN levels were 0.796 (p < 0.001) and 0.919 (p < 0.001), respectively, indicating that %D of Ser may reflect protein turnover or catabolism in certain tissues as well as renal proximal tubular dysfunction.

Cytoplasmic motility reflects phagocytic activity in alveolar macrophages from dog lungs

To determine whether cytoplasmic motility relates to phagocytic activity of alveolar macrophages (AM), we measured the remanent field strength (RFS) from the AM containing Fe3O4 particles (5 x 10(6) cells) and the number of phagocytized fluorescent latex spheres in the AM without having Fe3O4 particles (10(6) cells) harvested by broncho-alveolar lavage from dog lungs in vitro. Cytoplasmic motility was estimated from the relaxation rate (lambda o; min-1) calculated from the decay curve of RFS and the number of phagocytized latex spheres was counted using fluorescent microscopy after the addition of latex spheres (5 x 10(7)). The tumor necrosis factor increased both lambda o and the number of phagocytized latex spheres, and cytochalasin D and colchicine decreased them in a concentration-dependent fashion. Increases and decreases in lambda o induced by drugs paralleled the number of phagocytized latex spheres. These results suggest that cytoplasmic motility reflects phagocytic activity of AM and both cytoplasmic movement and phagocytosis may be regulated by a similar mechanism in the cytoskeletal system.

Dermoid cyst of the frontal bone away from the anterior fontanel

A case with a midline dermoid cyst of the frontal bone away from the anterior fontanel is reported. Although a few such cases have been reported, detailed descriptions are not given. Possible intracranial extension of these lesions is discussed with review of the pertinent literature.

Intraductal extension of primary invasive breast carcinoma treated by breast-conservative surgery. Computer graphic three-dimensional reconstruction of the mammary duct-lobular systems

BACKGROUND

Intraductal tumor extension is a characteristic feature of primary breast carcinoma, and is an important consideration in patients undergoing breast conservative surgery. However, there have been no reports of studies of intraductal extension within the mammary ductal tree.

METHODS

Quadrantectomy specimens from 20 patients with primary invasive breast carcinoma were examined by subgross and stereomicroscopic technique to visualize intraductal tumor extension. Serial 2 mm-thick sections were subjected to two-dimensional (2-D) tumor mapping, measuring the distances and angles of extension, and to three-dimensional (3-D) reconstruction of the mammary duct-lobular systems by means of computer graphics.

RESULTS

Intraductal tumor extension was found in 16 of 20 specimens (80.0%), extending continuously from the primary invasive carcinoma through the mammary ductal tree. The distances and angles of extension were larger in tumors with microcalcifications, papillotubular invasive ductal carcinoma, 30% or more of intraductal component, and comedo-type intraductal tumor extension. The 3-D reconstructions demonstrated three types of extension; central (11 cases), peripheral (3 cases), and mixed (2 cases). Further, there were some ductal branches anastomosing with different mammary duct-lobular systems at various sites. In one specimen, intraductal tumor extended widely from the primary invasive carcinoma through a branch connecting adjacent mammary duct-lobular systems.

CONCLUSIONS

Three-dimensional reconstruction images of intraductal extension of invasive breast carcinomas are presented for the first time to the authors' knowledge. Examples of ductal anastomoses were observed, and should be considered as a risk factor for possible widespread intraductal extension through multiple mammary duct-lobular systems.

Determination of D-amino acids, derivatized with 4-fluoro-7-nitro-2,1,3-benzoxadiazole (NBD-F), in wine samples by high-performance liquid chromatography

The concentrations of D-amino acids and their enantiomeric ratios in wind samples were determined by high-performance liquid chromatography with fluorometric detection. We used Pirkle type chiral stationary phases and fluorogenic reagent, 4-fluoro-7-nitro-2,1,3-benzoxadiazole (NBD-F) for simplicity and high sensitivity. The amino acids determined were D-enantiomers of alanine (Ala), aspartic acid, glutamic acid, isoleucine (Ile) and leucine (Leu), D-Asparagine, -glutamine and -lysine were not detected. D-Leu was detected in red and rosé wine samples, and D-Ile was determined only in rosé wine. In contrast, neither D-Leu nor Ile were detected in white wine samples. The concentration of D-Ala was the most prominent among these amino acids with the highest content of approximately 180 microns (D/D + L ratio; 25%) in rosé wine.

Dentatorubral-pallidoluysian atrophy (DRPLA): clinical, genetic, and neuroradiologic studies in a family

The clinical, genetic, and neuroradiologic characteristics of dentatorubral-pallidoluysian atrophy (DRPLA) are delineated in six patients from three generations of a Japanese family. The clinical characteristics of the disease varied, the age at onset depending on patients with juvenile-onset were characterized by myoclonus, epilepsy, and mental retardation whereas cerebellar ataxia, choreoathetosis, and dementia were typical of adult- and senile-onset patients. All affected individuals showed one expanded allele with the repeat number of CAG at the DRPLA locus, ranging from 58 to 82, and a normal allele, ranging from 10 to 21. The most severely affected patient, a case of maternal transmission and with the largest allele, became bedridden in a vegetative state by age 12. On the CT and MRI, varying degrees of brain atrophy were present in all patients. T2-weighted MRI in patients with senile-onset showed symmetric high-signal lesions in the cerebral white matter, globus pallidus, thalamus, midbrain, and pons. However, MRI in younger patients revealed no such lesions and CT failed to demonstrate lesions in the globus pallidus and brain stem. Thus, intrafamilial heterogeneity of DRPLA was also evident on MRI. High-signal lesions involving both, subcortical white matter and thalamus may be characteristics of senile-onset patients and may correlate with their dementia.