Three Cases of Ampullary Neuroendocrine Tumor Treated by Endoscopic Papillectomy: A Case Report and Literature Review

We herein report three cases of patients with an ampullary neuroendocrine tumor (NET), who underwent endoscopic papillectomy (EP). No tumor recurrence or metastasis was detected in the patients for more than two years after EP. Generally, surgical resection is recommended for ampullary NETs by the European Neuroendocrine Tumor Society. However, as EP is less invasive than surgical resection, there are some reports of low-grade small ampullary NETs curatively treated by EP with long-term follow-up. We consider that EP may be a curative treatment for small and low-grade ampullary NETs without regional or distant metastasis.

Complete nucleotide sequence of a new potexvirus, 'Cnidium virus X', isolated from Cnidium officinale in Japan

A flexuous virus was detected in a Cnidium officinale plant in Japan showing mosaic symptoms. The virus was assigned to the genus Potexvirus based on analysis of its complete nucleotide sequence. The genomic RNA of the virus was 5,964 nucleotides in length, excluding the 3'-terminal poly(A) tail. It contained five open reading frames (ORFs), consistent with other members of Potexvirus. The ORF sequences differ from those of previously reported potexviruses. Phylogenetic analysis indicated that the polymerase of the virus is closely related to that of strawberry mild yellow edge virus; and the CP, to those of both yam virus X and vanilla virus X. We propose that this virus be designated as "cnidium virus X" (CnVX).

Positive association of free triiodothyronine with pancreatic β-cell function in people with prediabetes

AIM

To analyse the effects of thyroid hormones on β-cell function and glucose metabolism in people with prediabetes who are euthyroid.

METHODS

A total of 111 people who were euthyroid underwent 75-g oral glucose tolerance tests, of whom 52 were assigned to the normal glucose tolerance and 59 to the prediabetes groups. Homeostatic model assessment of β-cell function, insulinogenic index and areas under the curve for insulin and glucose were evaluated as indices of pancreatic β-cell function.

RESULTS

In both groups, BMI, fasting insulin, homeostasis model assessment ratio and HDL cholesterol correlated significantly with all indices of pancreatic β-cell function. Free triiodothyronine correlated positively with all insulin secretion indices in the prediabetes group. Multiple linear regression analysis showed that free triiodothyronine was an independent variable that had a positive correlation with all indices of β-cell function in the prediabetes group. By contrast, no such correlation was found in the normal glucose tolerance group.

CONCLUSIONS

Free triiodothyronine is associated with both basal and glucose-stimulated insulin secretion in people with prediabetes who are euthyroid; therefore, the regulation of insulin secretion by thyroid hormones is a potentially novel therapeutic target for the treatment of diabetes.

Detection of parasitizing coccidia and determination of host crane species, sex and genotype by faecal DNA analysis

In Japan, the three main crane species are the endangered red-crowned crane (Grus japonensis) inhabiting Hokkaido, the northernmost island of Japan; the vulnerable hooded crane (Grus monacha); and the vulnerable white-naped crane (Grus vipio). Both the hooded and white-naped cranes migrate in winter to Izumi in Kyushu, the southern island of Japan. In this study, we investigated the cranes and their coccidian parasites, through a targeted molecular approach using faecal DNA to develop a noninvasive method for infectious disease research. To determine the origin of noninvasively collected faecal samples, host species were identified by sequencing a region of approximately 470 bp of the mitochondrial 16S ribosomal RNA gene in the faecal DNA. Furthermore, to avoid sample redundancy, individual determination was performed by fragment analysis using microsatellite and sex-linked markers. For microsatellite genotyping, previously reported markers and markers isolated in this study were examined, and seven loci for red-crowned cranes, eight for hooded cranes and six for white-naped cranes displayed polymorphisms. A low error rate was demonstrated by comparing microsatellite data generated from faecal DNA samples with that generated from feather DNA samples, indicating a high reliability. Polymerase chain reaction-based capillary electrophoresis (PCR-CE), employing genetic markers in the second internal transcribed spacer (ITS2) of nuclear ribosomal DNA, was employed to detect crane coccidia. The sensitivity of detection of PCR-CE using faecal DNA was inferior to that with traditional microscopy; however, our results suggest that PCR-CE can depict crane coccidia diversity with higher resolution and it is a useful tool to characterize community composition of coccidia in detail.

Disseminated visceral coccidiosis in Eurasian cranes (Grus grus) in the UK

Clinical disease and mortalities due to disseminated visceral coccidiosis were identified for the first time in a group of captive juvenile Eurasian cranes (Grus grus) in the UK during 2008. Presumptive diagnosis was made from the finding of granulomatous nodules in the liver, spleen and other organs at gross postmortem examination, and confirmed histologically by the presence of intracellular coccidial stages within lesions. The species of coccidian was determined to be Eimeria reichenowi on the basis of faecal oocyst morphology and sequencing of 18S rDNA by PCR. A further outbreak of clinical disease occurred in the same enclosure in 2009, affecting a new group of juvenile Eurasian cranes and demoiselle cranes (Anthropoides virgo) and indicating the persistence of infective oocysts in the environment. Clinical sampling of birds during both years demonstrated positive results from examination of both faecal samples and peripheral blood smears.

Feasibility of sequential fixed S-1 followed by paclitaxel for the treatment of advanced or recurrent gastric cancer

15113

Background: First-line chemotherapy for advanced/recurrent gastric cancer has limited efficacy, achieving a median survival time (MST) of about 7 months, while addition of second-line and subsequent chemotherapy may prolong MST to about 11.5 months. In practice, however, about half of patients failing with first-line chemotherapy are unable to receive second-line chemotherapy because of worsening of their performance status (PS), disease progression, or toxicities during protracted first-line chemotherapy. We studied the feasibility of a sequential fixed regimen devised to ensure prompt initiation of second-line chemotherapy after first-line failure. Methods: Between December 2002 and December 2006, patients with advanced or recurrent gastric cancer were enrolled who met the following requirements: 1) major organ function preserved; 2) PS 0–2; 3) presence of at least one evaluable lesion; and 4) written informed consent. The treatment regimen consisted of 3 courses of single-agent S-1 or S-1/cisplatin combination followed by weekly paclitaxel (wPTX). The endpoints of the study were entry to the second-line treatment, time to failure (TTF), and MST. Results: Of 39 patients enrolled, 37 completed first- line S-1. Twenty-eight patients (76%) then received wPTX, 2 non-wPTX chemotherapy, and 6 surgery; only 1 received no additional treatments. Second-line wPTX was followed by a third-line treatment in 23/28 patients (82%). The TTF with the sequential fixed regimen was 7 months. The MST and the 1- and 2-year survival rates in the 37 completing first-line treatment were 14.6 months, 61% and 25%, while those in the 28 switched over to wPTX were 12.5 months, 51% and 17%. Conclusions: Patients with advanced/recurrent gastric cancer treated sequentially with a fixed number of courses of S-1 followed by wPTX may have a good chance of treatment continuation. A sequential fixed regimen may further improve survival of patients with advanced/recurrent gastric cancer only with combinations of currently available drugs.

No significant financial relationships to disclose.

Serodiagnostic potential of chemically synthesized glycosphingolipid antigens in an enzyme-linked immunosorbent assay for alveolar echinococcosis

In the serodiagnosis of alveolar echinococcosis, the detection of specific reactions against not only protein but also carbohydrate antigen is useful and both antigens supplement each other. Though recombinant protein antigens have recently advanced, the preparation of carbohydrate antigen still depends on extraction from crude antigens. In the latter case, it is not conventional to obtain carbohydrate antigen as a single component for examination and research. Therefore, chemically synthesized carbohydrate antigens were prepared for serodiagnosis by the enzyme-linked immunosorbent assay (ELISA). Four antigens with the structure of glycosphingolipids fromEchinococcus multiloculariswere examined and one antigen, Galβ1-6(Fucα1-3)Galβ1-6Galβ1-ceramide, was found to show significant serodiagnostic potential in differentiating alveolar from cystic echinococcosis.

Effect of steroid add-back therapy on the proliferative activity of uterine leiomyoma cells under gonadotropin-releasing hormone agonist therapy

Short-term treatment with gonadotropin-releasing hormone agonist (GnRHa) is a useful preoperative medical therapy of uterine leiomyomas. However, adverse effects caused by the hypo-estrogen state sometimes appear, suggesting the necessity of add-back therapy. In this study, we investigated effects of three kinds of add-back therapies on the proliferative activity of uterine leiomyoma cells by examining the expression of Ki-67 in leiomyoma cells by immunostaining. Thirty patients who were to undergo hysterectomy or myomectomy were injected with 3.75 mg depot leuprolide acetate every four weeks until the end of the 12th week. Twenty patients underwent add-back therapy from the 5th week to the end of the 12th week, 8 patients receiving 0.625 mg of conjugated equine estrogen (CEE) /day, 6 patients 5.0 mg of medroxyprogesterone acetate (MPA)/day, 6 patients 0.625 mg CEE plus 2.5 mg of MPA /day. The add-back of CEE or CEE plus MPA suppressed decreases in the proliferative activity of leiomyoma cells caused by GnRHa therapy, but that of MPA did not. These results suggest that the add-back therapy with MPA is of use in preventing the adverse effects caused by hypo-estrogen in the preoperative short-term GnRHa therapy.

Adequacy of flow capacity of bilateral internal thoracic artery T graft

BACKGROUND

With the T graft configuration, multiple arterial revascularization can be accomplished using bilateral internal thoracic arteries. However, concern remains about the flow capacity of the main stem of the left internal thoracic artery (LITA).

METHODS

Forty patients who underwent multiple revascularization of the entire territory of the left coronary system with a T graft were investigated. Six months after the operation, they were examined angiographically. During the same period, dobutamine stress echocardiography was performed to evaluate the adequacy of the myocardial blood supply from the T graft. The T graft revascularized two branches in 5 patients, three branches in 23, four branches in 11, and five branches in 1 of the left coronary system. Other conduits were used if revascularization was required for the right coronary system.

RESULTS

Complete revascularization was achieved in the left coronary territory in all patients. The LITA main stem showed a wide lumen in all patients. Luminal narrowing was present in the distal segment of the LITA in 3 patients. The right internal thoracic artery (RITA) was patent in all patients, whereas luminal narrowing was observed in the distal segment of the RITA in 5 patients. No patient exhibited ischemic wall motion abnormality in the anteroseptal, lateral, or posterolateral region of the left ventricle where the T graft revascularized. Eight patients showed ischemic response in the inferoposterior region, that is, the territory of the right coronary artery.

CONCLUSIONS

The LITA main stem, forming a T-graft configuration with the free RITA, has an adequate flow reserve to supply at least the entire left coronary arterial system with sufficient blood. Therefore, multiple coronary revascularization using the T-graft technique is feasible.

[A case of mandibular gingival cancer T4N0M0 which markedly responded to a combined therapy of nedaplatin with 5-fluorouracil]

We recently experienced a case of mandibular gingival cancer T4N0M0 which markedly responded to a combination therapy of nedaplatin (254-S) with 5-fluorouracil (5-FU). The patient was a 68-year-old male who visited our department with the main complaint of ulceration in the left mandibular gingiva. Biopsy revealed a moderately differentiated squamous cell carcinoma which extended to the mandible, mandibular gingiva, buccal mucosa, half tongue and oral floor on the left side of the face. As a neoadjuvant chemotherapy (NAC), 254-S at a dose of 100 mg/m2 was intravenously administered on day 1, while 5-FU at a dose of 700 mg/m2/day was intravenously administered from day 1 to 5 in succession. Hydration (2,000 ml/day) was performed from day 1 to 3. Adverse reactions observed included thrombocytopenia, anorexia, nausea, vomiting, stomatitis and SIADH, but no sign of renal dysfunction was observed. The clinical outcome was evaluated as CR. Surgery was performed later. Pathological examination of the extracted tissues showed tumor cells in the tongue only, indicating an excellent effect of this combination therapy of 254-S and 5-FU.

[A case of endobronchial tuberculosis associated with bronchial asthma treated with high doses of inhaled corticosteroid]

A 46-year-old woman had been treated with 1,600-2,000 micrograms/day of beclomethasone dipropionate (BDP) and oral theophylline on the basis of a diagnosis of bronchial asthma in 1993. Eosinophilic pneumonia was diagnosed in June 1999, and she was then treated with 40 mg/day of oral prednisolone (PSL), which was gradually tapered off, and then stopped in October 1999. She was referred to our hospital because acid-fast bacilli were found in the sputum on January 18, 2000. Her chest radiographs and CT scans showed partial atelectasis of the right upper lobe, and fiberoptic bronchoscopy revealed bronchial inflammatory changes and whitish mucosal nodular lesions in the walls of the lower trachea, the right main bronchus and the orifice of the right upper lobe bronchus. She was found to have endobronchial tuberculosis. Anti-tuberculosis treatment with isoniazid, rifampicin, streptomycin and pyrazinamide was started. Serum levels of interferon-gamma were markedly elevated on admission. Asthma symptoms improved for a period of one month after the beginning of anti-tuberculosis treatment, despite the termination of inhaled corticosteroid. However, as the tuberculosis improved, the frequency and severity of the asthma increased and so corticosteroid inhalation was started again. Four months after administration of the anti-tuberculosis drug, fiberoptic bronchoscopy revealed that the endobronchial lesions had improved without any stenosis or constrictive changes. It was speculated that high doses of inhaled corticosteroid may have the potential to cause endobronchial tuberculosis whilst, ironically, at the same time preventing bronchial stenosis by endobronchial tuberculosis. This is an interesting case in which the asthma symptoms first decreased during the acute phase of endobronchial tuberculosis and then increased again after the tuberculosis improved.

Effects of bright light at lunchtime on sleep in patients in a geriatric hospital II

Inpatients with sleep disturbances in a geriatric hospital received 1 h of exposure to approximately 8000 lx bright light per day for 3 weeks. Polysomnogram was recorded for four female patients. Two (aged 68 and 87 years) were non-demented patients with weak cataracts and the other two (aged 92 and 93 years) were demented patients with severe cataracts. Electroencephalogram results showed that light exposure decreased the proportion of Stage W, while increased the proportion of Stage 2, and these effects continued for at least 3 weeks after the cessation of light exposure. These results suggest that exposure to bright light is effective in improving the disturbed sleep of patients.

Effects of bright light exposure on heart rate variability during sleep in young women

To investigate the effects of evening bright light on the autonomic nervous system, heart rate variability (HRV) during sleep was analyzed in dim light (DL) and bright light (BL) conditions. We recorded polysomnography in nine healthy young women aged 20-21 years. Time series of % delta power was calculated in the 0.49-2.20 Hz band. Heart rate variability was analyzed from a 10-min segment of slow wave sleep. The low- to high-frequency ratio and the low-frequency component decreased significantly in the BL conditions compared with the DL conditions. However, the power of the high-frequency component did not change in the two conditions. These results indicate that evening BL affects the autonomic nervous system during slow wave sleep.

Occlusive arterial diseases of the upper and lower extremities found in workers occupationally exposed to vibrating tools

Hand-arm vibration syndrome (HAVS) is primarily a disorder of the fingers and hands. However, in some cases, vibration-exposed workers are observed to have also episodic blanching of the hands and feet. In latter cases, arteriographies of both the upper and lower extremities are necessary to diagnose the background arterial disorders. In this study, eight HAVS subjects with such disorders were examined by arteriography for differential diagnosis in cases of workers' accident compensation. In three HAVS cases with thromboangiitis obliterans, the arteriographic examination revealed obstructive changes in the palm and forearm as well as three below-knee lesions in the lower extremities. In five HAVS cases with arteriosclerosis obliterans, obstruction kinking or coiling, stenosis and/or tapering-off of the proper digital arteries were observed together with two below-knee lesions and three high lesions in the lower extremities. From the viewpoint of occupational health, palpation of superficial arteries of both the upper and lower extremities should be routinely performed during both pre-placement and periodic medical examinations for workers exposed to vibrating tools for early detection and/or prevention of any worsening of the background disorders.

Limited flow capacity of the right gastroepiploic artery graft: postoperative echocardiographic and angiographic evaluation

BACKGROUND

The flow capacity of the right gastroepiploic artery graft has not been clarified.

METHODS

Angiographic and echocardiographic studies were conducted in 30 patients who had undergone coronary artery bypass grafting using both the internal thoracic and right gastroepiploic arteries. The luminal diameter of the arterial grafts was measured from the postoperative angiograms. The adequacy of the myocardial blood supply from the arterial grafts was evaluated by dobutamine stress echocardiography.

RESULTS

With echocardiography, 14 patients exhibited an ischemic response in the gastroepiploic artery grafted region, whereas no patients exhibited an ischemic response in the internal thoracic artery grafted area. The luminal diameter of the gastroepiploic artery and a younger age were correlated with the ischemic response observed in the dobutamine stress echocardiography. A luminal diameter of the gastroepiploic artery of greater than 2.6 mm had the highest sensitivity and specificity for a nonischemic change.

CONCLUSIONS

To generate the maximal flow reserve, the luminal diameter of the gastroepiploic artery when used as a graft should be sufficiently large enough, nearly 3 mm at the anastomosis.

Endovascular stent grafting for the treatment of blunt thoracic aortic injury

OBJECTIVE

Recent advances of endovascular stent-grafting (ESG) provide a new therapeutic option with minimum surgical damage for blunt aortic injury (BAI) during its acute phase. To clarify the effectiveness of ESG for BAI, a prospective clinical study at a university hospital was conducted.

METHODS

All patients with blunt thoracic injury underwent thoracic contrast-enhanced computed tomographic (CT) scan. Six patients age 48.8 +/- 19.8 years, with Injury Severity Scores of 35.8 +/- 8.1, and with BAI were treated according to our protocol. The stent-graft covered by woven Dacron was placed at the injury site. Endoleakage was then checked by aortography and CT scan was again performed once a day on days 7 through 14.

RESULTS

All patients had injury of the aortic isthmus. ESG placement was performed within 8 hours after injury except in one (48 hours). The operating time was 159.5 +/- 21.1 minutes and bleeding volume was 105 +/- 26.6 mL. No endoleakage was found. Repeat CT scan revealed disappearance of hematoma. All patients except one had an event-free clinical course. One patient died because of rupture of the ascending aorta on day 6; however, autopsy revealed evidence of the healing process at the injury site sealed by ESG.

CONCLUSION

An ESG is a valid therapeutic option with minimal surgical invasion for patients with acute-phase aortic injury.

Resting Ultrasonic Tissue Characterization and Dobutamine Stress Echocardiography for Prediction of Functional Recovery in Chronic Left Ventricular Ischemic Dysfunction

This study was designed to assess the diagnostic accuracy of the percentage of resting systolic wall thickening (WT), dobutamine stress echocardiography (DSE), resting cyclic variation of integrated backscatter (IBS-CV), and low-dose dobutamine stress IBS-CV (DSE-IB) for the prediction of regional function recovery (RFR) in patients with chronic left ventricular (LV) ischemic dysfunction. The study also evaluated whether or not global LV function affected the diagnostic accuracy. All studies were conducted before percutaneous transluminal coronary angioplasty (PTCA) and RFR was assessed after PTCA (mean interval, 10 months) in 30 patients with chronic LV ischemic dysfunction. Patients were divided into 2 groups according to the LV ejection fraction (LVEF): group A, LVEF<40%, n=14; group B, LVEF> or =40%, n=16. Of a total of 480 segments, 37 initially demonstrating akinetic wall motion before PTCA were analyzed. The wall motion of 24 of the 37 segments improved on visual analysis after PTCA. In the prediction of RFR, resting WT, DSE, resting IBS-CV and DSE-IB had sensitivities of 79%, 79%, 92% and 62%, and specificities of 54%, 84%, 83% and 69%, respectively. In particular, the resting IBS-CV in group A, as well as DSE, was an excellent predictor of RFR (sensitivity, 100%; specificity, 86%; vs sensitivity, 82%; specificity, 78%; respectively). Therefore, both resting IBS-CV and DSE are useful predictors for RFR in patients with chronic LV ischemic dysfunction.

Malignant histiocytosis in cattle

Malignant histiocytosis was diagnosed in 4 cows. In all cases the tumor tissues were composed of cytologically atypical histiocytes with evidence of erythrophagocytosis. The tumor in case 1 appeared highly anaplastic with marked nuclear pleomorphism, and had areas of spindle cell differentiation, but had no relation to malignant fibrous histiocytoma. The neoplastic tissue in case 2, characterized by cohesive growth of tumor cells, was distinguishable from anaplastic carcinoma cells by cytokeratin immunostaining. There were many hemosiderin-laden neoplastic cells suggestive of high phagocytic activity in a lymph node of case 3. The neoplastic cells in case 4, frequently multinucleated, were less atypical than in the other cases. All cases expressed histiocyte-associated markers (lysozyme and HAM56), and were negative for cytokeratin, S100, and T- and B-cell lineage-specific markers (CD3 and CD79a). The most frequent HAM56 immunoreactivity was detected in case 4, and the giant, multinucleated forms, reminiscent of epithelioid cell differentiation. seemed not to indicate cytological pleomorphism as a result of neoplastic transformation.

[Severe hemolysis and SIADH-like symptoms induced by vincristine in an ALL patient with liver cirrhosis]

An 11-year-old boy was diagnosed as having acute lymphoblastic leukemia (ALL, L1) in 1987 and underwent treatment with an ALL high-risk protocol (prednisolone, vincristine (VCR), daunorubicin, 1-asparaginase), which resulted in complete remission. In 1990 he developed chronic hepatitis C and received interferon therapy. In December 1994, ALL recurred, and the patient was treated with VCR. He subsequently developed severe hemolysis (Hb 12.5 g/dl-->6.8 g/dl) with increases of indirect bilirubin, AST, and LDH. Furthermore, symptoms resembling a syndrome of inappropriate secretion of ADH (SIADH) and DIC developed. Upon incubation of the patient's red blood cells with VCR in vitro, extreme deformity of the cells was observed. These findings suggested that splenomegaly, due to liver cirrhosis which had developed rapidly from chronic hepatitis C while the patient was in an immunosuppressed state induced by anticancer drugs, had trapped the deformed red blood cells and resulted in severe hemolysis. The patient died on the 165th day after admission due to liver failure.

Molecular design, synthesis, and hypoglycemic activity of a series of thiazolidine-2,4-diones

A series of imidazopyridine thiazolidine-2,4-diones were designed and synthesized from their corresponding pyridines. These compounds represent conformationally restricted analogues of the novel hypoglycemic compound rosiglitazone (5). The series was evaluated for its effect on insulin-induced 3T3-L1 adipocyte differentiation in vitro and its hypoglycemic activity in the genetically diabetic KK mouse in vivo. The structure-activity relationships are discussed. On the basis of the in vivo potency, 5-[4-(5-methoxy-3-methyl-3H-imidazo[4, 5-b]pyridin-2-ylmethoxy)benzyl]thiazolidine-2,4-dione (19a) was selected as the candidate for further studies in a clinical setting.

Clinical factors associated with post-ictal headache in patients with epilepsy

OBJECTIVES

To determine the incidence of post-ictal headaches (PIH) and clinical risk factors associated with the occurrence of PIH in patients with localization-related epilepsy.

MATERIALS AND METHODS

The subjects were 77 patients with temporal lobe epilepsy (TLE), 34 patients with occipital lobe epilepsy (OLE), and 50 patients with frontal lobe epilepsy (FLE). The subjects were directly asked whether headaches occurred just after seizures. Medical charts were reviewed to ascertain the clinical characteristics of epilepsy in these patients.

RESULTS

The incidence of PIH was 23% for TLE, 62% for OLE, and 42%, for FLE. The risk of PIH was significantly higher for OLE than for TLE or FLE, and for patients with generalized tonic-clonic seizures. Younger age at onset of epilepsy was also a risk factor for PIH.

CONCLUSION

The occurrence of PIH may be related to the region of epileptic focus and the region of spread of epileptic discharges.

Autonomic nervous function after evening bright light therapy: spectral analysis of heart rate variability

In order to investigate the effects of 5000 lx evening bright light on autonomic nervous function, a spectral analysis was used to assess heart rate variability in consecutive 5-min epochs just after 60 min of bright light therapy was given to 12 young women (range: 20-21 years of age). The study revealed that a low frequency band (LF) increased in bright light conditions (BL) in comparison with controlled conditions (CL). High frequency band (HF), LF:HF ratio and the coefficient of variance (CV R-R) were not significantly different between the two conditions. These results indicate that 5000 lx evening bright light may affect sympathetic nervous system activity in healthy women.

Differences in electroencephalogram power densities between genuine narcolepsy and secondary narcolepsy

Diagnosing narcolepsy is not always simple. Some patients secondarily show narcoleptic tetrad through irregular sleep patterns or psychotic diseases. The power densities of daytime electroencephalograms in genuine narcolepsy and secondary narcolepsy were analysed and compared. Electroencephalogram power densities for a 6.5-h period after waking in genuine narcoleptic patients were lower than those of secondary narcoleptic patients in the 11.0-12.5 Hz bands. Arousal levels may be lower in genuine narcoleptic patients than in secondary narcoleptic patients. Spectral analysis may be useful in clarifying differences between the two groups.

Effect of short duration morning bright light in elderly men: sleep structure

Sleep structure was measured in five healthy elderly men in their homes. The subjects were exposed to bright light (6000 lx) for 30 min in the morning or instructed to sit in front of a desktop lighting device without light. Relative to the control conditions, bright light exposure significantly decreased time in bed and the number of awakenings. Rapid eye movement sleep was significantly fragmented by stage 1 sleep in the control condition compared with the bright light condition. These findings indicate that a short duration of morning bright light changes sleep structure and is effective in maintaining sleep.

Symptomatic generalized epilepsy associated with an inverted duplication of chromosome 15

An inverted duplication of chromosome 15 (inv dup[15] chromosome) is the most common supernumerary marker chromosome in humans. Inv dup(15) chromosomes are commonly associated with mental retardation, epilepsy, behavioral problems and structural malformations. Though epilepsies associated with inv dup(15) chromosomes are often intractable, there have been very few reports regarding the seizure manifestations or types. We report a patient with severe mental retardation and intractable epilepsy, associated with an inv dup(15) chromosome. The seizures recorded with EEG-VTR monitoring were axial and generalized tonic seizures, and our case was diagnosed as symptomatic generalized epilepsy. Molecular and cytogenetic analysis showed an inv dup(15) chromosome containing the Prader-Willi syndrome/Angelman syndrome region mapped within bands 15q 11-q13.

N-Glycan structures of an osteopontin from human bone

N-Glycan structures of osteopontin (a bone matrix protein) from human bone (lumbar vertabrate) are reported in detail. Asn-linked glycan portion was released from 100 microg of osteopontin by digestion with glycoamidase A (from sweet almond), and the reducing ends of the N-glycans were reductively aminated with 2-aminopyridine. The derivatized N-glycans were separated and structurally identified by a multidimensional mapping technique on HPLC columns. Two major N-glycan structures were also confirmed by mass spectrometry. The proposed structures are shown below. The result should permit future comparison with the N-glycan structures of osteopontins obtained from other sources (kidney tissues, macrophages, urinary stones, human milk, etc.).

A comparison of post-ictal headache between patients with occipital lobe epilepsy and temporal lobe epilepsy

We investigated post-ictal headaches (PIH) using a questionnaire to ascertain their characteristics and compare them among different types of epilepsy. The subjects consisted of 34 patients with occipital lobe epilepsy (OLE) and 75 patients with temporal lobe epilepsy (TLE). PIH occurred in 62% of OLE and 23% of TLE (P < 0.05). The quality of pain in PIH was 'steady' in 71% of OLE and 29% of TLE (P < 0.05) as opposed to 'pounding'. Other factors, such as frequency, severity, duration, and accompanying symptoms showed no significant differences. We found very few patients with migraine-like headaches. Analyses of clinical factors, such as age at onset, duration of epilepsy, seizure frequency, family history of headache, and interictal headache did not reveal any relationship to PIH, although generalized tonic-clonic seizures are associated with PIH in TLE (P < 0.05). These results suggest that the nature of PIH may be different between OLE and TLE, and that the region of epileptic focus or spreading area of epileptic discharge may have a close relation to the induction of PIH. An association with migraine, which has been reported previously, was unclear in our study.

Effects of morning bright light on sleep in healthy elderly women

Subjective sleep feeling and polysomnography were measured in 10 elderly women to investigate the effects of 8000 lux morning bright light (BL) exposure. The profile of sleep feeling in the BL condition was better than in the control condition. The proportion of awakening time in the first one-third of night sleep decreased, and the amount of awakening time in the last one-third increased in BL condition. Daytime napping reduced in BL condition. These findings suggested the effectiveness of exposure to bright light on the improvement of sleep quality and daytime vigilance of healthy elderly women.

Gender difference of slow wave sleep in middle aged and elderly subjects

Sleep EEG of eight healthy males and eight females aged 54-72 years were recorded at their homes. The electroencephalograms were visually scored and analyzed by spectral analysis using the FFT method. There were no significant differences in sleep parameters except for a higher percentage of stage 3+4 in females. The spectral power of the delta band EEG was classified into two frequencies: 0.5-2 Hz and 2-4 Hz. The total amount of the delta band spectral power through the night was significantly larger in females. Periodic fluctuation of delta band power was observed in females along with non-rapid eye movement-rapid eye movement cycles.

Effects of morning bright light in healthy elderly women: effects on wrist activity

To investigate the effects of 8000 lux morning bright light in the elderly, home-based motor activity on sleep was monitored for 5 days in 10 healthy women (mean age: 59.7 years old, range: 50-69 years old). The activity level and movement index on night 4 were significantly lower in bright light conditions, compared with the controlled condition. The activity level during the day was not significantly different between the two conditions. These results indicate that 8000 lux morning bright light improves sleep quality in healthy elderly women.

Analysis of rapid eye movement periodicity in narcoleptics based on maximum entropy method

We examined REM sleep periodicity in typical narcoleptics and patients who had shown signs of a narcoleptic tetrad without HLA-DRB1*1501/DQB1*0602 or DR2 antigens, using spectral analysis based on the maximum entropy method. The REM sleep period of typical narcoleptics showed two peaks, one at 70-90 min and one at 110-130 min at night, and a single peak at around 70-90 min during the daytime. The nocturnal REM sleep period of typical narcoleptics may be composed of several different periods, one of which corresponds to that of their daytime REM sleep.

Effects of moderately bright light on subjective evaluations in healthy elderly women

Eight healthy elderly women aged 56-72 years (mean age: 67.4 years) participated in this study. They were exposed to moderately bright light (1000 lux) for 1h in the morning every 6 days in their homes. Moderately bright light improved self evaluations for alertness, mood, motivation, happiness, refreshment, concentration and appetite after the second exposure to the light. Sleep maintenance, anxiety and integrated sleep feeling also improved after the fourth exposure to the light. The phase of rectal temperature rhythm did not change in a moderately bright light condition. These results suggest that bright light influences sleep quality and self evaluations without changing the biological rhythm phase.

Negative U-wave as a predictor of antihypertensive treatment effect on regression of echocardiographic hypertrophy in hypertensive patients

To clarify the mechanism and the predictors of the reduction in left ventricular mass (LVM) induced by antihypertensive drugs, forty hypertensive patients were classified according to the presence of left ventricular hypertrophy (LVH) as a defined by echocardiographic LVM findings (LVH group: 27 patients, non-LVH group: 13 patients) and according to the presence of negative U-waves (NU) (NU group: 10 patients, non-NU group: 30 patients). Negative U-waves appeared in the LVH group only (10 of 27 patients). The hemodynamic determinants were investigated as a mechanism of LVM reduction in 38 of these patients who were treated for 2 years with antihypertensive drugs. In the LVH group, thickness of interventricular septum (IVST), posterior wall thickness (PWT) and LVM increased significantly compared to the non-LVH group. In the NU group, the left ventricular end-diastolic dimension (LVDD) was significantly larger and the relative wall thickness was significantly smaller compared to the non-NU group in the LVH group, with no difference in LVM between the two groups. Negative U-waves disappeared in all cases after treatment. Significant decreases in LVDD and LV wall thickness were observed in the NU group and significant decrease in LV wall thickness in the non-NU group. LVM index was reduced by 24.0% in the NU group and 9.5% in the non-NU group. The disappearance of negative U-waves was an independent predictor of the reduction of LVH.

[A study of neuroleptic malignant syndrome in the presenium and senium]

Recently, with the increase in elderly population, we have had more opportunities to administer neuroleptics to elderly patients for hallucinatory delusional state, delirium, psychomotor excitement, wandering etc. However, little is known about the characteristics of the neuroleptic malignant syndrome (NMS) in elderly patients, which is the most serious side effect of neuroleptics. In this paper, we present the clinical course of five NMS patients in the presenium and senium. Case 1 was 72-year-old male who was diagnosed as having dementia of Alzheimer's type (with late onset). He showed nocturnal wandering, insomnia, and irritability. Tiapride 60 mg per day had been administered previously. Just after the addition of oxypertine 10 mg per day, NMS occurred, and he died of pneumonia a week later. Case 2 was 75-year-old male who was diagnosed as having vascular dementia. He showed insomnia, hyperactivity and wandering. He had been given levomepromazine (LPZ) 10 mg per day over a long period of time. At first, he had daily episodic fever, however, serum CPK levels did not increase at that time. A month later, all the symptoms of NMS appeared and then the patient's condition suddenly deteriorated and he died three days later. Case 3 was a 64-year-old male who was diagnosed as having dementia of Alzheimer's type (with early onset). He showed insomnia, irritability and violence. Tiapride 50-125 mg per day was administered along with oxypertine 50-115 mg per day. Almost two months later, NMS occurred. He had daily episodic fever at first, extrapyramidal symptoms and autonomic instabilities gradually increased. Soon after symptoms of NMS were completed. In this case, NMS seemed to be induced by bacterial pneumonia after long term administration of LPZ 5 mg per day. Case 4 was a 75-year-old female who was diagnosed as having dementia of Alzheimer's type (with late onset). She showed hallucinatory delusional state. Although she had autonomic instabilities just after adminstration of haloperidol 1-2 mg per day, NMS itself occurred after discontinuing the neuroleptic. Case 5 was a 61-year-old female who was diagnosed as having schizophrenia at the age of forty. She was given various neuroleptics over a period of time. The neuroimaging in SPECT showed her cerebral cortex was generally hypoactive. She had a tendency to have autonomic instabilities after the administration of relatively high potential neuroleptics. Risperidone 3-6 mg per day was administered, and almost a month later, autonomic instabilities increased and she was diagnosed as having NMS. All the patients would be able to have brain dysfunction, which suggested that such patients may be liable to NMS. In our patients, NMS occurred after the additional administration of oxypertine 10 mg per day or after long time administration of LPZ 5 mg per day. It was suggested that NMS could occur after the administration of low dose and relatively low potential neuroleptics in elderly patients. Our 3 of 5 patients showed the delayed type of NMS, which might be relatively more frequent in senior and presenior patients than in younger patients. In case 3, NMS was induced by the somatic disease (bacterial pneumonia), however in other cases, NMS was not always induced by somatic disease. Our 4 of 5 patients experienced some of the symptoms of NMS--episodic fever, extrapyramidal symptoms and autonomic instabilities--before the onset of NMS. Such symptoms may be "pre-steps" to NMS. Once NMS occurred, the patient's systemic condition tended to deteriorate acutely. Due to the fact that our 2 of 5 patients died, it was suggested that the prognosis of the NMS patients in presenium and senium tends to be much worse. It is important to find the "pre-steps" to NMS and treat them as soon as possible for better prognosis.

Effects of short duration morning bright light in healthy elderly subjects. I: subjective feeling and ophthalmological examinations

Seven aged subjects aged 61-78 years were exposed to 6000 lx bright light for 30 min during morning hours at their homes for 1 week. Visual analog scale was recorded before bedtime and after rising to assess subjective feelings. Ophthalmological examinations were made before and after light exposure, to exclude pre-existing ocular disorders and to detect ocular damage. Furthermore, ocular fatigue was self-evaluated immediately before and after exposure. Visual analog scale results indicated that alertness reduced significantly before bedtime. Ophthalmological abnormalities were not found after exposure. These findings suggest that short duration morning bright light exposure reduces night-time vigilance.

Gender differences in the sleep of middle-aged individuals

The study was designed to investigate gender differences in the sleep-wake patterns of healthy middle-aged individuals in their home environment. Polysomnography showed that daytime napping was more common in men than in women. Men had lower sleep efficiency index and experienced more stage 1 sleep. Males had significantly less stages 3 + 4 sleep, less stage REM sleep, and more transitions to wake from REM sleep. Men could not maintain stage REM as well as women. This study indicates that the gender differences in the sleep-wake patterns have appeared in a group of middle-aged individuals.

Gender differences in self-evaluated sleep quality and activity of middle-aged and aged subjects

In order to investigate the gender difference of sleep and activity in middle-aged and aged individuals, home-based sleep was self-evaluated for sleep quality and activity for 5 nights in 20 healthy adults (50-76 years old; 11 women, nine men). There was no significant gender difference for subjective sleep quality. However, the activity level and movement index at night were significantly higher in men than in women, and the activity level during the day was significantly lower in men than in women. The objective sleep quality of men was significantly worse than that of women, however, subjective sleep quality does not differ.

Motor activity rhythm in dementia with delirium

Using an actigraph, the activity patterns in 13 demented patients with delirium were examined. We analyzed the data of the eight patients, wearing the actigraphs for more than 10 days. They were classified into four types: type A, nocturnal delirium type; type B, wandering type; type C, hypobulia type; and type D, lying down type. The day to day activity variation was most prominent in type A and seemingly the least in type B. The dominant period of activity rhythm was nearly 24 h in all cases. Additional 12-h period was observed in type C. Actigraphs might become useful in making therapeutic decisions regarding demented patients with delirium.