Time and cost involved in the care of newly registered patients with diabetes mellitus and other lifestyle diseases at diabetes clinics in Japan (JDDM 4)

AIMS

To study the time and cost involved in the care of newly registered outpatients with Type 2 diabetes mellitus (DM), compared with patients with hypertension and/or hyperlipidaemia (HTL).

METHODS

A total of 313 patients with DM and 58 patients with HTL without diabetes were registered on their first visits to 11 diabetes clinics across Japan. The time and cost involved in their care was recorded over the following 5 months.

RESULTS

In the first 3 months, there was an extensive time commitment to both groups. The time spent by physicians was 1.5 times longer for DM than for HTL. The total care time spent by all the care providers for DM was twice that for HTL. The cost of DM care was twice that for HTL, with the cost of medicines excluded. However, half of the cost for DM was for laboratory tests. When these were excluded, and the remaining cost divided by the time spent, the amount for DM was half of that for HTL. Over the 5 months, mean glycated haemoglobin (HbA(1c)) in DM patients improved from 8.0% to 6.5%, and 72% of DM patients achieved the glycaemic target of HbA(1c) < or = 6.5%.

CONCLUSIONS

DM care in a diabetes clinic requires a great deal more time and resources than HTL to achieve the best outcome. An educational system for self care, presently lacking in the primary care setting in Japan, would improve glycaemic control for DM patients in the community.

u-SHARE: web-based decision support/risk communication tool for healthcare consumers with unruptured intracranial aneurysms

PURPOSE

Clinical management for unruptured intracranial aneurysms (UIA) is controversial and requires professional knowledge which is the main reason that patients have difficulty in making decisions. The purpose of this study is to develop a tool that aids healthcare consumers in making optimal shared decisions with decision analysis.

METHODS

The decision model and relevant data were derived from published literature. A web-based decision analytic tool was designed to provide a systematic guide for patients to understand favorable treatment options, intrinsic uncertainty, and critical factors for decision making. Twenty-nine testers evaluated content appropriateness, usability and clinical usefulness of the tool.

RESULTS

The decision analytic tool has been successfully implemented and evaluated. Testers generally judged the web-based decision analytic tool as functional and useful. Acceptance rate for decision analysis was higher in nonhealthcare professionals than health care professionals.

CONCLUSIONS

Our decision analytic tool was well accepted especially by healthcare consumers. The tool enables UIA patients to enhance their knowledge and understanding toward optimal shared decision making and can be an alternative "structured informed consent tool".

Comparison of the utility of sympathetic skin response and current perception threshold examinations with conventional examinations for the early electrophysiological diagnosis of diabetic polyneuropathy

We compared the utility of sympathetic skin response (SSR) and current perception threshold (CPT) with that of conventional electrophysiological examinations like sural sensory conduction velocity, sensory nerve action potential (SNAP), peroneal motor conduction velocity, compound muscle action potentials, and F-wave latency. Twenty-two type II diabetic patients (mean age, 69.6 years) without sensory symptoms and with a mean glycosylated hemoglobin (HbA1c) level of 7.1%, along with 26 age-matched control patients, were examined. Among the conventional examinations, only the sural SNAP was considerably (although not significantly) depressed in the diabetic group. On the other hand, the mean SSR amplitude in the diabetic group was approximately half of the value in the control group. All the CPT values were also considerably lower in the diabetic group than in the control group, although only the values for hand stimulation at 2000 and 250 Hz were significant. No correlations were observed between the SSR amplitudes and the CPT values at any of the test frequencies. However, a positive correlation between the mean HbA1c level and the CPT value was seen at all frequencies. We concluded that SSR amplitude measurements are superior to conventional examinations and CPT studies with regard to the early electrophysiological diagnosis of diabetic polyneuropathy. Furthermore, CPT values may be useful as an electrophysiological surrogate indicator of recent glycemic control.

Development of a novel systemic gene delivery system for cancer therapy with a tumor-specific cleavable PEG-lipid

For successful cancer gene therapy via intravenous (i.v.) administration, it is essential to optimize the stability of carriers in the systemic circulation and the cellular association after the accumulation of the carrier in tumor tissue. However, a dilemma exists regarding the use of poly(ethylene glycol) (PEG), which is useful for conferring stability in the systemic circulation, but is undesirable for the cellular uptake and the following processes. We report the development of a PEG-peptide-lipid ternary conjugate (PEG-Peptide-DOPE conjugate (PPD)). In this strategy, the PEG is removed from the carriers via cleavage by a matrix metalloproteinase (MMP), which is specifically expressed in tumor tissues. An in vitro study revealed that the PPD-modified gene carrier (Multifunctional Envelope-type Nano Device: MEND) exhibited pDNA expression activity that was dependent on the MMP expression level in the host cells. In vivo studies further revealed that the PPD was potent in stabilizing MEND in the systemic circulation and facilitating tumor accumulation. Moreover, the i.v. administration of PPD or PEG/PPD dually-modified MEND resulted in the stimulation of pDNA expression in tumor tissue, as compared with a conventional PEG-modified MEND. Thus, MEND modified with PPD is a promising device, which has the potential to make in vivo cancer gene therapy achievable.

Prevention of abdominal aortic aneurysms by simultaneous inhibition of NFkappaB and ets using chimeric decoy oligonucleotides in a rabbit model

Abdominal aortic aneurysm (AAA) is one of the major vascular diseases caused by atherosclerosis. Because treatment for AAA mainly consists of surgery to prevent deaths from AAA rupture and there is a conspicuous absence of alternative therapeutic strategies, the development of minimally invasive treatment is needed. To develop a novel therapeutic approach, we examined the simultaneous inhibition of the transcription factors NFkappaB and ets, which regulate inflammation and matrix degradation, in a rabbit AAA model. In this study, we employed chimeric decoy oligodeoxynucleotides (ODN), containing the consensus sequences of both the NFkappaB- and ets-binding sites, to inhibit both the transcription factors simultaneously. Using a delivery sheet, we examined the inhibitory effect of chimeric decoy ODN on aortic dilatation. Ultrasound and angiographic analysis demonstrated that treatment with chimeric decoy ODN significantly prevented the progression of elastase-induced aortic dilatation. The inhibitory effect of chimeric decoy ODN on aortic dilatation was also confirmed by histological studies. Treatment with chimeric decoy ODN reduced the activities of matrix metalloproteinase (MMP)-2 and MMP-9 and markedly inhibited the proteolysis of elastin as compared to scrambled decoy ODN. Interestingly, treatment with chimeric decoy ODN also suppressed VCAM-1 and MCP-1 gene expression, leading to inhibition of macrophage infiltration in the adventitia and media. The present study in a rabbit model provides a novel strategy to treat AAA by the simultaneous inhibition of both NFkappaB and ets using chimeric decoy ODN. Further modification of chimeric decoy ODN would be useful to treat AAA as a decoy-based therapy.

beta-Thromboglobulin and 11-dehydrothromboxane B in tension-type headache

Platelet factor 4, beta-thromboglobulin, thromboxane B2, and 11-dehydrothromboxane B2 were investigated in tension-type headache. Ten cases of episodic tension-type headache (mean age 42.5 years), 10 cases of chronic tension-type headache (mean age 45.3 years), and 10 age-matched healthy controls were studied. The platelet factor 4, beta-thromboglobulin, thromboxane B2 and 11-dehydrothromboxane B2 concentrations in the plasma were significantly higher in the episodic tension-type headache group than in the chronic tension-type headache and healthy control groups. Platelets may be involved in episodic tension-type headache.

Intratumoural expression of thymidylate synthase is an independent predictor of prognosis in patients with squamous cell carcinoma of the tongue: results from a retrospective study

The aim of this study was to assess the importance of immunohistochemical thymidylate synthase (TS) expression level as a prognostic marker in tongue cancer patients. In 140 patients with primary squamous cell carcinoma (SCC) of the tongue, intratumoural TS expression was evaluated by immunohistochemistry. The level of TS expression was determined by a semiquantitative scoring system, ranging from 1+ to 3+ according to the ratio of TS-positive cells. Of 140 patients, 64 (45.7%), 49 (35.0%) and 27 (19.3%) were assessed as 1+, 2+ and 3+, respectively. Univariate analyses demonstrated that both disease-free survival (DFS) and overall survival (OS) were significantly lower in patients with a TS 3+ tumour than in those with a TS 1+/2+ tumour (DFS: P = 0.0082, OS: P = 0.0100). In a multivariate analysis using the Cox regression model, cervical lymph-node status and TS expression level were selected as independent factors for DFS and OS. Maintenance adjuvant chemotherapy by oral 5-fluorouracil (5-FU) significantly improved DFS and OS in patients with a TS 1+/2+ tumour (DFS: P = 0.0027, OS: P = 0.0398). These data suggest that the level of immunohistochemical TS expression is an independent prognosticator in patients with tongue SCC, and may be useful in the selection of patients who would benefit from oral 5-FU adjuvant chemotherapy.

Inhibition of ets, an essential transcription factor for angiogenesis, to prevent the development of abdominal aortic aneurysm in a rat model

The pathophysiology of abdominal aortic aneurysms (AAA) is considered to be complicated. As matrix degradation contributes to the progression of AAA, the destruction and degradation of elastin fibers caused by an increase in matrix metalloproteinases (MMPs) plays a pivotal role in the development of AAA. Although ets, an essential transcription factor for angiogenesis, regulates MMPs, the role of ets in the development of AAA has not yet been clarified. Thus, we evaluated the role of ets in a rat AAA model using a decoy strategy. Transfection of ODN into AAA was performed by transient aortic perfusion of elastase and by wrapping the AAA in a delivery sheet containing decoy ODN. The inhibitory effect of ets decoy ODN on ets binding activity was confirmed by gel mobility shift assay. MMPs expression was decreased in the aorta transfected with ets decoy ODN as compared to scrambled decoy ODN. Also, ultrasound study demonstrated that elastase-induced aneurismal dilation was significantly suppressed by transfection of ets decoy ODN at 4 weeks after treatment as compared to scrambled decoy ODN. Moreover, the destruction of elastin fibers was inhibited in the aorta transfected with ets decoy ODN, accompanied by a reduction of MMPs expression. An inhibitory effect of decoy ODN on MMP expression was confirmed by ex vivo experiments showing that transfection of decoy ODN into an organ culture of human aorta resulted in significant inhibition of the secretion of both MMP-1 and MMP-9. Here, we demonstrated that ets may play a pivotal role in the progression of AAA through the activation of MMPs in a rat model. Ets might be a potential target to develop pharmacotherapy/gene therapy to treat AAA through the inhibition of MMPs.

Generation of a total of 6483 expressed sequence tags from 60 day-old bovine whole fetus and fetal placenta

Expressed sequence tags (ESTs) generated based on characterization of clones isolated randomly from cDNA libraries are used to study gene expression profiles in specific tissues and to provide useful information for characterizing tissue physiology. In this study, two directionally cloned cDNA libraries were constructed from 60 day-old bovine whole fetus and fetal placenta. We have characterized 5357 and 1126 clones, and then identified 3464 and 795 unique sequences for the fetus and placenta cDNA libraries: 1851 and 504 showed homology to already identified genes, and 1613 and 291 showed no significant matches to any of the sequences in DNA databases, respectively. Further, we found 94 unique sequences overlapping in both the fetus and the placenta, leading to a catalog of 4165 genes expressed in 60 day-old fetus and placenta. The catalog is used to examine expression profile of genes in 60 day-old bovine fetus and placenta.

Magnetoencephalographic representation of the sensorimotor hand area in cases of intracerebral tumour

OBJECTIVE

To assess the clinical value of magnetoencephalography (MEG) in localising the primary hand motor area and evaluating cortical distortion of the sensorimotor cortices in patients with intracerebral tumour.

METHODS

10 normal volunteers (controls) and 14 patients with an intracerebral tumour located around the central region were studied. Somatosensory evoked magnetic fields (SEFs) following median nerve stimulation, and movement related cerebral magnetic fields (MRCFs) following index finger extension, were measured in all subjects and analysed by the equivalent current dipole (ECD) method to ascertain the neuronal sources of the primary sensory and motor components (N20m and MF, respectively). These ECD locations were defined as the primary hand sensory and motor areas and the positional relations between these two functional areas in controls and patients were investigated.

RESULTS

The standard range of ECD locations of MF to N20m was determined in controls. In 11 of the 14 patients, MRCFs could identify the primary motor hand area. ECD locations of MF were significantly closer to the N20m in the medial-lateral direction in patients than in controls. In patients with a tumour located below the sensorimotor hand area, relative ECD locations of MF to N20m moved anteriorly over the standard range determined in the control subjects. These MEG findings correlated well with radiological tumour locations. The mean estimated ECD strength of MF was significantly lower in patients than in controls.

CONCLUSIONS

MRCF was useful in localising the primary motor hand area in patients with intracerebral tumour. The relative ECD locations of MF to N20m describe the anatomical distortion of the sensorimotor cortex.

Functional posterior rhizotomy for severely disabled children with mixed type cerebral palsy

The authors evaluated the impact of functional posterior rhizotomy (FPR) for children with severely disabled mixed type cerebral palsy (CP). Three quadriplegic children at the age of 3, 4, and 10 years underwent FPR. They were classified as mixed type CP based on the clinical presentation of marked spasticity with dystonic posture. Preoperative Ashworth score of the lower extremity was 3.5, 4.5, 4.8 respectively. Two children showed prominent opisthotonus and all showed severe subluxation of the hip joint. Advanced scoliosis was associated in two children. FPR was performed from L2 to S1 in one child, L2 to S2 in one and L2 to S1/S2 in one based on the result of pudendal mapping. Rootlet cutting rate ranged from 66 to 75%. Postoperatively, Ashworth score dropped to 1.4, 1.2, 1.3, respectively. Functional improvement of the upper extremity and urination were confirmed in two children. Hip subluxation was reduced in one child and remained stable in two. A one-year follow-up review confirmed no relapse of spasticity among them. FPR achieved highly satisfactory surgical effects in children with severe mixed type CP. Although long-term follow-up is mandatory since there was a report of relapsed spasticity after FPR in this particular population of CP, FPR could be a choice of surgery in severely disabled children with mixed type CP.

Ictal magnetoencephalographic discharges from elementary visual hallucinations of status epilepticus

PURPOSE

To report the rare opportunity to study ictal magnetoencephalography (MEG) in a 26 year old man with simple partial status epilepticus that presented as elementary visual hallucinations (EVHs) in the right upper visual field.

METHODS

The patient described his EVHs as "snowing on TV," "flickering lights," and "rotating coloured balls" that continued for several days. MEG and simultaneous EEG were recorded twice: during an episode of EVHs (ictal recordings) and after EVHs were controlled by medications (interictal recordings).

RESULTS

During EVHs, MEG showed continuous periodic epileptiform discharges over the left posterior superior temporal region, while simultaneous EEG showed rhythmic theta waves and sporadic spikes over the left temporal region. The MEG discharge consisted of a three phase spike complex. Equivalent current dipoles (ECDs), modelled from spike complexes, localised in the left superior temporal area. After drug treatment controlled the EVHs, interictal MEG and EEG showed rare spikes over the same left temporal region. The average ictal ECD moment (mean (SD)) (128.7 (32.8 nAm)) was significantly weaker than the average interictal ECD moment (233.0 (63.9) nAm) (p<0.05).

CONCLUSIONS

The continuous, periodic, and clustered discharges seen on ictal MEG were the sources of EVH. The weaker ictal ECD sources were frequently not detected by scalp EEG, while the stronger interictal sources, presumably originating from an extensive interictal zone, were sufficiently large to be seen as EEG spikes.

Prevention and regression of atopic dermatitis by ointment containing NF-kB decoy oligodeoxynucleotides in NC/Nga atopic mouse model

Atopic dermatitis, a chronic inflammatory skin disease characterized by relapsing eczema and intense prurigo, requires effective and safe pharmacological therapy. In this study, we examined the efficacy of ointment containing NF-kB decoy oligodeoxynucleotides (ODN) on atopic dermatitis lesions in NC/Nga mice, which are characterized by the spontaneous onset of atopic dermatitis in conventional conditions. Topical administration of NF-kB decoy ODN twice a month resulted in a significant reduction in clinical skin condition score and marked improvement of histological findings. Reduction of the atopic skin condition by NF-kB decoy ODN was accompanied by a significant decrease in migration of mast cells into the dermis and an increase in apoptotic cells. Here, we demonstrated the successful treatment of atopic dermatitis with ointment containing NF-kB decoy ODN in a mouse model, promising new therapy for atopic dermatitis.

Surgical strategy and outcomes for epileptic patients with focal cortical dysplasia or dysembryoplastic neuroepithelial tumor

PURPOSE

The purpose of this study was to clarify and compare the influence of surgical strategy on relief from seizures in patients with focal cortical dysplasia (FCD) and those with dysembryoplastic neuroepithelial tumor (DNT).

METHODS

Six patients with FCD and five patients with DNT, all of whom underwent surgical resection for medically intractable epilepsy, were compared in terms of presurgical seizure types and frequency, location of lesions, magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) with 99mTc-ECD, scalp electroencephalogram (EEG), and long-term video-EEG recording. Prolonged subdural recordings and intraoperative electrocorticograms (ECoG) were analyzed. The influences of surgical strategies on seizure outcomes were retrospectively analyzed.

RESULTS

In all the FCD patients, ictal SPECT revealed hyperperfusion in the regions where MRI showed FCD. Interictal epileptiform activity and ictal seizure onset on ECoG performed with subdural electrodes were localized on the FCD itself. In contrast, the tumors of all the DNT patients were depicted as hypoperfuse areas on interictal SPECT scans. Ictal SPECT in one DNT patient showed hyperperfusion in the area enclosing the tumor. Interictal spiking in all DNT patients and ictal seizure onset in two DNT patients were not in the lesions themselves but in an area enclosing the lesion. All but one patient with FCD who underwent total lesionectomy became seizure free. All DNT patients who underwent resection of the epileptogenic cortex associated with lesionectomy became seizure free or achieved a 90% reduction in seizures.

CONCLUSIONS

FCD has intrinsic epileptogenicity, whereas DNT is encompassed by epileptogenic cortical areas. Therefore, total lesionectomy is an essential strategy for FCD, whereas resection of the epileptic focus associated with lesionectomy of a DNT lesion is necessary to control seizures.

Induction of the cytokine signal regulator SOCS3/CIS3 as a therapeutic strategy for treating inflammatory arthritis

Immune and inflammatory systems are controlled by multiple cytokines, including ILs and INFs. These cytokines exert their biological functions through Janus tyrosine kinases and STAT transcription factors. One such cytokine, IL-6, has been proposed to contribute to the development of rheumatoid arthritis (RA). We found that STAT3 was strongly tyrosine phosphorylated in synovial tissue of RA patients, but not those with osteoarthritis. Blockade of the IL-6-gp130-JAK-STAT3-signaling pathway might therefore be beneficial in the treatment of RA. We show here that the mRNA for the endogenous cytokine signaling repressor CIS3/SOCS3 is abundantly expressed in RA patients. To determine whether CIS3 is effective in treating experimental arthritis, a recombinant adenovirus carrying the CIS3 cDNA was injected periarticularly into the ankle joints of mice with antigen-induced arthritis or collagen-induced arthritis (CIA). Periarticular injection of CIS3 adenovirus drastically reduced the severity of arthritis and joint swelling compared with control groups. CIS3 was more effective than a dominant-negative form of STAT3 in the CIA model. Thus, induction of CIS3 could represent a new approach for effective treatment of RA.

Neurohypophyseal germinoma traced from its earliest stage via magnetic resonance imaging: case report

BACKGROUND

We report a case in which magnetic resonance imaging (MRI) documented the formation of a neurohypophyseal germinoma from its earliest stage.

CASE DESCRIPTION

A 9-year-old girl presented with polyuria, polydipsia, and growth retardation. Urinary and endocrinological examination indicated diabetes insipidus (DI) and growth hormone deficiency. No clear evidence of a mass in the hypothalamo-pituitary area was apparent on the first MRI scan. Follow-up MRIs and endocrinological examinations revealed that a tumor, arising from the stalk and posterior lobe of the pituitary gland, formed a mass and caused anterior pituitary function to deteriorate. Histologic diagnosis was germinoma based on open biopsy.

CONCLUSION

Radiologic findings in this case indicated the primary site of this intrasellar germinoma to be the hypothalamo-neurohypophyseal region, designating this a "neurohypophyseal germinoma."

The influence of the laryngeal mask airway on the shape of the submandibular gland

Although transient sialadenopathy of the submandibular gland associated with insertion of the laryngeal mask airway (LMA) has been described, the influence of the LMA on the submandibular gland is unknown. We measured the width and length of the submandibular glands by using ultrasonography in patients in whom the LMA was used. An increased intracuff pressure of the LMA, up to 150 cm H2O, was used in a prospective study of adult patients scheduled for elective surgery. The width of the gland increased with an increasing intracuff pressure from 50 to 100 cm H2O (P < 0.01) and 100 to 150 cm H2O (P < 0.01) but did not change from 0 to 50 cm H2O. There was no change in the length of the gland. We conclude that the submandibular gland was deformed by the insertion of the LMA.

IMPLICATIONS

The findings in our study show that the submandibular triangle can be easily compressed by the insertion of the laryngeal mask airway (LMA). When inserting the LMA, it is important to consider that the LMA cuff may alter these tissues, which are situated between the lingual root and the submandibular triangle.

Correlations between P300 components and regional cerebral blood flows

To evaluate the diagnostic importance of event-related potential P300, the correlation between P300 and regional cerebral blood flow (rCBF) was investigated in various brain regions in patients with multiple cerebral infarction (16 cases), chronic alcoholism (11 cases) and Alzheimer's disease (5 cases) and in seven healthy people. Cognitive function was also evaluated by mini-mental state examination. P300 latency and rCBF was measured by recording of evoked potentials using an oddball paradigm and stable xenon computed tomographic scanning, respectively. A significant (P<0.05) negative correlation between P300 and rCBF was observed in the thalamus in patients with multiple cerebral infarction and chronic alcoholism. In addition, a significant (P<0.01) negative correlation between P300 latency and the mini-mental state examination score and positive correlation between rCBF in the thalamus and the mini-mental state examination score were observed. These findings suggest that P300 latency is associated with rCBF in the thalamus and cognitive function.

Angiotensin-converting enzyme inhibitors and probucol suppress the time-dependent increase in urinary Type IV collagen excretion of Type II diabetes mellitus patients with early diabetic nephropathy

BACKGROUND

A multicenter prospective clinical trial was carried out in 9 National Hospitals in Japan to elucidate the time-dependent change in urinary Type IV collagen excretion rate of Type II diabetes mellitus (DM) patients, and to investigate whether an angiotensin-converting enzyme inhibitor (ACE-I) or probucol is effective in preventing progression of renal involvement of diabetics by evaluating urinary Type IV collagen excretion.

METHODS

Normo- and microalbuminuric patients with Type II DM were recruited. Patients were assigned to either the control (n = 88), ACE-I (n = 43) or probucol (n = 37) group and treated for 24 months. Besides albumin excretion rate (AER), urinary Type IV collagen excretion rate was also measured.

RESULTS

Although, AER, urinary N-acetyl-beta-D-glucosaminidase and beta2-microglobulin excretion rates in the control group did not vary over 24 months, urinary Type IV collagen excretion rate in the control group increased time-dependently (p < 0.01 vs baseline at 18 months and p < 0.005 vs baseline at 24 months). In the ACE-I and probucol groups, time-dependent increases in urinary Type IV collagen excretion rates were not observed. In the ACE-I group, the urinary Type IV collagen excretion rate was significantly lower than that in the control group at 24 months (p < 0.05). In the probucol group, the urinary Type IV collagen excretion rate was significantly lower than that in the control group at 6 months (p < 0.05). In the ACE-I group, AER decreased significantly compared with baseline at 18 months (p < 0.05) and at 24 months (p < 0.005).

CONCLUSIONS

ACE-I has a beneficial effect and probucol may have a beneficial effect in preventing the progression of early diabetic nephropathy. Measurement of the urinary Type IV collagen excretion rate in combination with AER would be useful for the management of early renal involvement in Type II DM.

[A case of Machado-Joseph disease presenting pure cerebellar ataxia]

We report a 61-year-old woman with Machado-Joseph disease (MJD) presenting with pure cerebellar ataxia. The patient exhibited an unsteady gait at the age of 51 years. She was admitted to our hospital at the age of 61 years. Her older brother had been diagnosed as having spinocerebellar degeneration (SCD). Our patient showed gaze-evoked nystagmus, wide-based gait, slight lack of coordination of the four extremities, mildly ataxic speech and slight decrease in the bilateral Achilles tendon reflexes. Babinski's sign was absent. Sensory impairments were not present and muscle tone and muscle strength were normal. There was no autonomic dysfunctions. MRI revealed moderate atrophy of the cerebellum and pons. We performed gene analysis of SCD using white blood cells from the patient, and the analysis showed 70 CAG repeats in the MJD1 gene, which is an abnormally high number of repeats. Compared with three reported cases of MJD presenting pure cerebellar ataxia, only our patient showed a nasal voice. The number of CAG repeats in the MJD1 gene of our patients was the most prolonged of the four cases. MJD should be considered in patients with familial SCD even if their neurological signs and symptoms outside the cerebellum are not obvious.

Clinical factors of recurrent chronic subdural hematoma

The clinical, radiological, and operative factors of recurrent chronic subdural hematoma (CSDH) were retrospectively analyzed in 116 patients with CSDH in 134 hemispheres, treated by one burr hole surgery. The correlation of recurrence was evaluated with personal and clinical factors such as age, sex, history of head injury, and interval from onset of initial symptoms to hospitalization; laboratory findings such as bleeding tendency and liver function; computed tomography (CT) findings such as hematoma density and brain atrophy; and operative findings such as additional procedures and postoperative residual air. The recurrence group (RG) included 10 hemispheres (7.5%) in 10 patients (8.6%). The interval from onset of symptoms to hospitalization was significantly shorter in the RG than in the nonrecurrence group (NRG). Headache was more frequently seen in the RG than in the NRG. Density of hematoma on CT was classified into five types: Low, iso, and high density, niveau, and mixed, and the incidence of recurrence was 0%, 2.3%, 17.2%, 12.5%, and 6.5%, respectively. Larger amounts of residual air in the postoperative hematoma cavity were associated with recurrence of CSDH. CSDH that progresses rapidly in the acute stage and appears as high density on preoperative CT is associated with a high incidence of recurrence. Intraoperative air invasion to the hematoma cavity should be avoided to prevent recurrence.

Large-scale evaluation of imprinting status in the Prader-Willi syndrome region: an imprinted direct repeat cluster resembling small nucleolar RNA genes

Loss of paternal gene expression at the imprinted domain on proximal human chromosome 15 causes Prader-Willi syndrome (PWS), a complex multiple-anomaly disorder involving variable mental retardation, hyperphasia leading to obesity and infantile hypotonia with failure to thrive. Although numerous paternally expressed transcripts have been identified that reside in the candidate region, the individual contributions to the development of PWS have not been firmly established. Recent studies of mouse models carrying a cytogenetic deletion suggest that paternal deficiency of the SNRPN-IPW interval is critical for perinatal lethality of potential relevance to PWS. Here we determined the allelic expression profiles of a total of 118 cDNA clones using monochromosomal hybrids retaining either a paternal or maternal human chromosome 15. Our results demonstrated a preponderance of unusual transcripts lacking protein-coding potential that were expressed exclusively from the paternal copy of the critical interval. This interval was also found to encompass a large direct repeat (DR) cluster displaying a potentially active chromatin conformation of paternal origin, as suggested by enhanced sensitivity to nuclease digestion. Database searches revealed an unexpected organization of tandemly repeated consensus elements, all of which possessed well-defined box C and D sequences characteristic of small nucleolar RNAs (snoRNAs). Southern blot analysis further demonstrated a considerable degree of phylogenetic conservation of the DR locus in the genomes of all mammalian species tested, but not in chicken, Xenopus and Drosophila. These findings imply a potential direct contribution of the DR locus, representing a cluster of multiple snoRNA genes, to certain phenotypic features of PWS.

Electrical bone graft stimulation for spinal fusion: a review

Although electrical stimulation to aid bone fusion is well established in the treatment of long-bone fractures, its use as an aid in spinal fusion is not as well documented. This article presents the history and scientific basis of electrical stimulation to aid bone fusion and extensively reviews the clinical literature. It is intended to provide an objective review of the indications and limitations of electrical stimulation to enhance spinal fusion and to serve as a reference source for further study.

[Acute transient swelling of the submandibular glands after laryngeal mask airway insertion]

A 40-year-old woman was scheduled for abdominal hysterectomy. Moderate difficulty in tracheal intubation was expected on preoperative evaluation. A size 3 laryngeal mask airway (LMA) was inserted after the induction of general anesthesia. The LMA insertion was accomplished smoothly at the first attempt and there was no air leakage during manual ventilation. Soon after the insertion, acute swellings were noted in the bilateral submandibular triangle regions. Enlargement and deformity of the submandibular glands were diagnosed by ultrasonography. The enlargements increased with elevated pressure of the LMA cuff, but disappeared completely in five minutes after removal of the LMA. Such enlargement did not occur with subsequent tracheal intubation. The patient had an uneventful postoperative course without any residual sequelae. We should pay attention to possible submandibular gland swelling by LMA insertion.

Determination of sugar alcohols in confectioneries by high-performance liquid chromatography after nitrobenzoylation

A method was developed for the determination of sugar alcohols, meso-erythritol, xylitol, D-glucitol, D-mannitol, maltitol and parachinit by high-performance liquid chromatography (HPLC). The sugar alcohols were converted into strong ultraviolet (UV)-absorbing derivatives with p-nitrobenzoyl chloride. HPLC was performed on a phenyl column, using acetonitrile-water (67:33) as mobile phase and UV detection (260 nm). The calibration curves for all sugar alcohols tested were linear in the 10-250 microg/ml range. The average recoveries of the sugar alcohols from four sugarless confectioneries spiked at 5 and 10% levels of six sugar alcohol standards ranged from 73.2 to 109.0% with relative standard deviations ranging from 0.7 to 9.0%. The detection limit of the developed method was 0.1% for the above sugar alcohols contained in the samples.

Characterisation of gene expression in bovine adipose tissue before and after fattening

It has been reported that fattening causes bovine adipose tissue development associated with an enlargement in adipocyte cell size. As a first study to elucidate mechanisms of bovine adipose tissue development during fattening, our experiment was designed to characterise gene expression in bovine adipose tissue before and after fattening. We randomly isolated a large number of cDNA clones derived from bovine adipose tissue before and after fattening. Sequence analysis of the isolated clones showed that 3 and 10 clones from before and after fattening, respectively, correspond to genes related to adipocyte development and/or function in the adipose tissue. In addition, we isolated cDNA clones that possess negative signal by hybridising the cDNA population from the adipose tissue after fattening with that before fattening as a probe. As a result, we identified five types of transcripts observed in the adipose tissue after fattening but not before fattening. Two of the five are likely to encode bovine orthologs of phospholipase A2 and RNA helicase p68, while the other three represent unknown genes. Further functional investigation of the identified genes might lead to elucidation of mechanisms of bovine adipose tissue development during fattening.

Detection and mapping of mismatched base pairs in DNA molecules by atomic force microscopy

Attempts were made to apply atomic force microscopy (AFM) imaging to the detection and mapping of the sites of base substitutions in DNA molecules. In essence, DNA fragments to be examined for possible base substitutions were mixed with an equal amount of a corresponding DNA standard and subjected to heat denaturation and subsequent annealing. The reassociated DNA was incubated with MutS protein, a protein that recognizes and binds to mismatched base pairs in duplex DNA. Bound MutS protein molecules were then detected by AFM and their positions along the DNA molecules were determined by calculating the distance from one of the DNA termini, which had been tagged with a biotin-avidin complex. Base substitutions present in DNA molecules >1 kb were effectively detected by this procedure, and the positions determined were in good agreement with the actual mutation sites. This method is quite simple, has virtually no limitations on the size of DNA fragments to be examined and requires only a very small amount of DNA sample.

[A case of multiple cranial neuropathy with positive antinuclear antibody responded to steroid]

A 56-year-old woman was admitted to our hospital because of bilateral ptosis, total ophthalmoplegia, bilateral facial palsy and left hypoglossal nerve palsy. Antinuclear antibody (ANA) showed high titer of 1280 but other data were normal. With oral prednisolone therapy (40 mg/day), the symptoms improved gradually but ANA titer did not show any significant change. We thought multiple cranial neuropathy of the patient was due to autoimmune disease such as collagen disease or cranial nerve type of Guillain-Barré syndrome from her symptoms and positive ANA. In contrast to other reported cases of multiple cranial neuropathy with positive ANA, in our patient ANA titer was high, only motor cranial nerves were impaired, and total ophthalmoplegia was found. Steroid therapy was useful in accordance with other reports. Although our patient has no symptoms related to collagen diseases, a long follow-up of this patient is considered to be necessary.

[A case of sarcoid myopathy presenting muscle pain and muscle weakness and with muscle MRI abnormality]

We experienced a 70-year-old female diagnosed as sarcoidosis. She complained bilateral femoral pain from 70-year-old. 3 months after the onset, she developed muscle weakness extending to her upper extremities with high fever of 38-39 degrees C. The erythema appeared at the right femoral region 4 months after the onset. She admitted to our hospital because of further evaluation. When she was admitted, she had tenderness on grasping the femoral muscles, proximal limb muscle weakness and Gowers' sign. On laboratory examination, CRP, aldorase, myoglobin, lysozyme were increased mildly. The EMG demonstrated a myogenic pattern. Muscle biopsy performed from the left quadriceps femoris muscle revealed non-caseating granuloma and muscle fiber necrosis. A diagnosis of muscle sarcoidosis was made from the biopsy findings and the clinical features. With oral prednisolone administration, muscle weakness and other clinical features improved gradually. On muscle MRI, multiple small high intensity areas were scattered in the femoral muscles. Muscle MRI is considered to be useful for differential diagnosis of muscle sarcoidosis.

Creation and use of a composite polyurethane-expanded polytetrafluoroethylene graft for hemodialysis access

The Thoratec (Vectra) polyurethane vascular access graft (TPVA) is among the most recent additions to the list of materials used to construct prosthetic grafts for vascular access during hemodialysis. We give the TPVA very high marks, and recognize the utility of such a graft for use in hemodialysis. However, the strong elasticity of this graft can lead to unexpected complications after suturing. We devised a new surgical method using a TPVA-ePTFE (expanded polytetrafluoroethylene) composite graft, substituting the anastomosis section of the TPVA with a portion of ePTFE graft material, and have been able to overcome most of the TPVA's potential problems. We herein describe the technique.

Effects of bunazosin hydrochloride sustained-release formulation on cerebral circulation

BACKGROUND

We investigated the cerebral blood flow in mild to moderately hypertensive patients with chronic cerebral infarction before and after the administration of bunazosin hydrochloride sustained-release formulation, a selective sympathetic alpha1 receptor blocker.

METHODS

Eleven mild to moderately hypertensive patients (mean age 65.6 years) with chronic cerebral infarction were studied.

INTERVENTIONS

The patients were on enalapril maleate, an angiotensin converting enzyme inhibitor, for one week and then enalapril maleate was switched to bunazosin hydrochloride sustained-release formulation.

MEASURES

The cerebral blood flow study was performed before and 8 weeks after starting the administration of bunazosin hydrochloride sustained-release formulation. Cerebral blood flow was measured using the stable xenon CT method. The picture analysis was performed using AZ-7000. The regional cerebral blood flow was measured by placing the region of interest on the CT images. The regional cerebral blood flows were measured before and 20 minutes after intravenous injection of 17 mg/kg acetazolamide.

RESULTS

The blood flows in the parietal cortex and caudate nucleus 8 weeks after starting the administration of bunazosin hydrochloride sustained-release formulation were significantly greater than those before. The cerebrovascular acetazolamide reactivity in the occipital cortex and caudate nucleus was significantly lower after switching to bunazosin hydrochloride sustained-release formulation than before.

CONCLUSIONS

Considering the reports that angiotensin converting enzyme inhibitors show little influence on cerebral blood flow, the present study suggests that bunazosin hydrochloride sustained-release formulation may show a good influence on cerebral blood flow in mild to moderately hypertensive patients with chronic cerebral infarction.

Cerebral blood flows in the acute and chronic stages of cerebral infarction

Regional cerebral blood flows (rCBFs) were studied in the acute and the chronic stages of 8 patients with supratentorial cerebral infarction. In 2 patients with cardioembolic infarction, the rCBF increased in one patient and decreased in the other during the chronic stage. This decrease was explained by the risk factors of the latter patient because the patient had more risk factors than the former patient with increased rCBF. In 6 patients with lacunar infarction, the rCBF increased in 2 patients and decreased in 4 during the chronic stage. In all the patients with decreased rCBF, the number of lacunar infarction and/or the degree of leuko-araiosis on MRI increased during the chronic stage. Therefore, the decrease in rCBF during the chronic stage in lacunar infarction is considered to be due to the increase in the number of lacunar infarction, the increased degree of leuko-araiosis or both.

Acetazolamide reactivity in atherothrombotic, cardioembolic and lacunar infarctions

Ten cases of atherothrombotic brain infarction, 10 cases of cardioembolic brain infarction, 10 cases of lacunar brain infarction, 10 cases of transient ischemic attack (TIA) and 10 age-matched controls were studied. The cerebral blood flows in the cerebral cortex and cerebral white matter were significantly lower in the atherothrombotic, cardioembolic and lacunar infarction groups than in the TIA and control groups. The acetazolamide reactivity in the cerebral cortex was significantly lower in the atherothrombotic and lacunar infarction groups than in the cardioembolic, TIA and control groups. The rate of association of hypertension was significantly higher in the atherothrombotic, lacunar and TIA groups than in the cardioembolic and control groups. Plasma fibrinopeptide A, platelet factor 4 and beta-thromboglobulin concentrations were higher in the atherothrombotic, cardioembolic and lacunar groups than in the TIA and control groups. The present study suggests that the degree of thrombolysis and platelet activation is less in TIA than in cerebral infarction and that underlying cerebral arteriosclerosis is more severe in atherothrombotic and lacunar infarction than in cardioembolic infarction.

Diaschisis and acetazolamide reactivity in brainstem infarction

Regional cerebral blood flows (rCBF) were studied in 6 patients with lateral medullary infarction and 4 patients with pontine infarction, using stable xenon computed tomography method. In lateral medullary infarction, the rCBF and acetazolamide reactivity were decreased in the ipsilateral cerebellum and the rCBF was decreased with normal acetazolamide reactivity in the contralateral frontal lobe in one patient accompanying ipsilateral cerebellar infarction. rCBF was decreased with normal acetazolamide reactivity in the cerebellum in 3 patients, and both rCBF and acetazolamide reactivity were decreased in the whole brain in 2 patients. In pontine infarction, rCBF was decreased in ipsilateral frontal lobe and contralateral cerebellum in one patient, rCBF was decreased in the cerebellum with normal acetazolamide reactivity in the other patients. The hypoperfusion with normal acetazolamide reactivity was considered to be due to diaschisis. The rCBF decrease in the remote areas in patients with brainstem infarction was considered to be due to diaschisis or underlying arteriosclerosis.

Effect of cilostazol on cerebral blood flows in chronic stage of cerebral circulation

In order to find out the difference between cilostazol and ticlopidine hydrochloride in the cerebral vasodilating effect in the chronic stage of cerebral infarction, cerebral blood flows were measured while the patients were on ticlopidine hydrochloride and after ticlopidine hydrochloride was switched to cilostazol. Single photon emission computed tomography (SPECT) was performed using Prism 2000XP gamma camera system. Ultrasound examinations of the carotid artery was performed using Ultramark 9. The blood flows in the frontal white matter, temporal cortex and occipital cortex after cilostazol were significantly higher than those before cilostazol. The peak systolic velocity, time-averaged peak velocity and volume flow after cilostazol were significantly higher than those before cilostazol. The total cholesterol, triglyceride and apolipoprotein B concentrations after cilostazol were significantly lower than those before cilostazol. The present study suggests that cilostazol has better influence on cerebral circulation than ticlopidine hydrochloride in the chronic stage of cerebral infarction.

Single lacunar brain infarction with transient signs versus those with long-lasting signs

BACKGROUND

In order to find out the difference between single brain lacunar infarctions with transient signs and those with long-lasting signs, cerebral blood flow studies and blood tests were performed.

METHODS

Ten cases of single lacunar infarction with transient signs and 10 of single lacunar infarction with long-lasting signs were studied. Subcortical cystic infarctions with a diameter of less than 1.5 cm were defined as lacunar infarction. Episodes lasting less than 24 hours were classified as transient signs and those lasting 24 hours or more as long-lasting signs.

MEASUREMENTS

cerebral blood flows were measured using the stable xenon computed tomography method. The regional cerebral blood flows were measured before and 20 minutes after the intravenous injection of 17 mg/kg acetazolamide. Plasma fibrinopeptide A, platelet factor 4 and beta-thromboglobulin concentrations were determined at the Special Reference Laboratories.

RESULTS

Blood flows in the cerebral cortex and cerebral white matter contralateral to the lacunar infarction were lower in the group with long-lasting signs than in that with transient signs. Cerebrovascular acetazolamide reactivity in the cerebral cortex and white matter contralateral to the lacunar infarction were lower in the group with long-lasting signs than in that with transient signs. Plasma fibrinopeptide A, platelet factor 4 and beta-thromboglobulin concentrations were higher in the long-lasting signs group than in that with transient signs.

CONCLUSIONS

There may be some differences in pathogenesis between single lacunar infarction with transient signs and those with long-lasting signs.

Physicochemical characteristics and toxicity of nickel oxide particles calcined at different temperatures

The physicochemical characteristics and cytotoxicity of two types of commercial nickel oxide particles (black and green nickel oxide) and five types of nickel oxide particles prepared by calcination of the black nickel oxide at 600-1000 degrees C were studied. Thermal analysis with mass spectroscopy showed that the black nickel oxide particles contained approximately 1.4% impurity, which seemed to be basic nickel carbonate. The calcination treatment at 600 degrees C increased the nickel content and decreased the oxygen content, but these remained constant in the particles treated at higher temperatures (700-1000 degrees C) and in the green nickel oxide particles. The water solubility of black nickel oxide particles was markedly greater than that of the other particles, especially in the first 24 h after mixing with water. The solubility of the calcined particles decreased with increasing calcination temperature. The cytotoxicity of these particles was evaluated by the viability of rat alveolar macrophages and by the inhibition of cell proliferation in Chinese hamster ovary cells. The black nickel oxide was the most cytotoxic of the particles examined, and this may be attributable, at least in part, to a rapid dissolution of nickel from the contained impurity. The toxicity of the calcined particles decreased with increasing calcination temperature. These results indicate that water solubility, which depends on calcination temperature, modulates the acute cytotoxicity of nickel oxide particles.