Capillary hemangioma arising from the lesser omentum in an adult: A case report

RATIONALE

Although capillary hemangiomas, common lesions involving the proliferation of small capillary vessels and a single layer of endothelial cells, can arise in any organ, they are rarely reported in the greater or lesser omentum. Here in, we report a case of capillary hemangioma arising from the lesser omentum in an adult with interesting diagnostic imaging findings, including changes in tumor size over time on computed tomography (CT), that was resected using laparoscopic surgery. To our knowledge, this is the first English report to describe a capillary hemangioma arising from the lesser omentum.

PATIENT CONCERNS

A 63-year-old Japanese man received hemodialysis for chronic renal failure due to diabetic nephropathy, and a small, gradually enlarging tissue mass was found near the lesser curvature of the stomach on plain CT performed annually, without any associated complaints. Diagnostic imaging revealed an 18 × 15-mm tumor with a homogenous, highly enhanced effect in the early phase that was attenuated but prolonged in the delayed phase. Magnetic resonance imaging showed a mass with low signal intensity on T1-weighted imaging and relatively high signal intensity on T2-weighted imaging.

DIAGNOSIS

The patient was diagnosed with capillary hemangioma arising from the lesser omentum according to the pathological and immunohistological findings.

INTERVENTIONS

The patient underwent laparoscopy for excision of the tumor from the lesser omentum.

OUTCOMES

At the 1 year follow-up, the patient had no recurrence of the tumor.

LESSONS

We describe the first case worldwide of capillary hemangioma that was a true vascular tumor arising from the lesser omentum. Although capillary hemangioma arising from the lesser omentum is extremely rare, it should be considered in the differential diagnosis of patients presenting with a highly enhanced lesser omental tumor, and laparoscopy can be safely applied for the excision of this tumor.

Diagnosis of incarcerated intramesosigmoid hernia aided by multiplanar reconstruction images of multidetector computed tomography: a case report

Background

Internal hernia is a rare cause of intestinal obstruction, and sigmoid mesocolon hernia is an extremely rare form of this condition.

Among sigmoid mesocolon hernias, intramesosigmoid hernia is the least frequent subtype.

We described a case of intramesosigmoid hernia through the orifice on the right leaf of the mesosigmoid with an incarcerated ileum of 6 cm in length without strangulation. This case was diagnosed by multidetector computed tomography with multiplanar reconstruction images and treated without resection of the small intestine in a 52-year-old man with characteristic diagnostic images.

Case presentation

A 52-year-old man suffering periumbilical cramping pain with sudden onset that had persisted for 1 week without recovery was referred to Fukui Katsuyama General Hospital. Multidetector computed tomography revealed small bowel obstruction, and an incarcerated short intestinal loop was revealed by sagittal slices of the multiplanar reconstruction images of the routine study of the left side of the pelvic space. Sagittal multiplanar reconstruction images also showed narrow belt-shaped fluid retention contacting the tip of the incarcerated short loop toward the cranial direction localized in the mesosigmoid. These findings indicated that the fluid and the herniated small bowel were wrapped together in the mesosigmoid, which was characteristic of intramesosigmoid hernia.

The patient underwent laparotomy operation 2 days after admission. The ileum, which was approximately 75 cm proximal to the ileocecal junction and herniated into the mesosigmoid through the right leaf, was released without resection. The orifice located in the central part of the right leaf was oval shaped and measured less than 2 cm in diameter. The left leaf of the mesosigmoid was intact. The orifice of the right lobe was closed by suture. The patient showed an uneventful recovery.

Conclusion

We report an extremely rare case of incarcerated intramesosigmoid hernia that was diagnosed by multidetector computed tomography with multiplanar reconstruction images. The finding of narrow belt-shaped fluid retention contacting the tip of the incarcerated short intestinal loop is characteristic of intramesosigmoid hernia and will be useful for conclusively differentiating this disease from transmesosigmoid hernia. Although intramesosigmoid hernia is a rare cause of internal hernia, multidetector computed tomography and multiplanar reconstruction images can provide the characteristic findings and proved useful for the precise preoperative diagnosis and treatment of intramesosigmoid hernia.

Accumulation of plasma cells expressing CXCR3 in the synovial sublining regions of early rheumatoid arthritis in association with production of Mig/CXCL9 by synovial fibroblasts

Accumulation of plasma cells in the synovium is one of the diagnostic hallmarks in the histopathological manifestations of rheumatoid arthritis (RA). This seems to be prominent even prior to significant B cell infiltration and/or formation of lymphoid follicles in the synovium. To clarify the mechanism of early plasma cell accumulation, we examined in situ expression of chemokines and their receptors using synovial targeting biopsy specimens, which were obtained under arthroscopy from early RA patients. By immunohistochemical staining, plasma cells were found to express a chemokine receptor CXCR3, while synovial fibroblasts in the synovial sublining regions expressed its ligand, Mig/CXCL9. By reverse transcription-polymerase chain reaction (RT-PCR), using targeted lesions of synovial tissues obtained by laser capture microdissection, expression levels of Mig/CXCL9 in the synovial sublining regions were remarkably high and were likely to be associated with interferon (IFN)-gamma expression. Furthermore, cultured synovial fibroblasts were confirmed to produce Mig/CXCL9 upon stimulation with IFN-gamma. Our results indicate that in the early stage of RA, plasma cells expressing CXCR3 may be recruited directly from the circulation into the synovial sublining regions by its ligand, Mig/CXCL9, produced by synovial fibroblasts.

Immunohistochemical localization of senescence marker protein-30 (SMP30) in the submandibular gland and ultrastructural changes of the granular duct cells in SMP30 knockout mice

Senescence Marker Protein-30 (SMP30) is a calcium-regulating protein that decreases in an androgen-independent manner as aging occurs. An enzyme-labeled antibody technique has demonstrated that SMP30 localized to the ducts (granular, intercalated, and striated ducts) of mouse submandibular glands. Immunoelectronmicroscopy demonstrated that the granular duct cells were strongly positive for SMP30, but that pillar cells in the granular duct were negative for the protein. In SMP30-knockout (KO) mice, the granular ducts were smaller in diameter. Swelling of mitochondria in the granular duct cells was observed; however, this phenomenon was not observed in the pillar cells. After administration of alpha-isoproterenol, a beta-adrenergic stimulant, a large numbers of small secretory granules were present in the granular duct cells and an expansion of the rough endoplasmic reticulum in SMP30-wild type (WT) mice; in contrast, little change was observed in SMP30-KO mice. These results suggest that SMP30 may be closely related to a signal transduction pathway in the granular duct cells of submandibular glands.

Analysis of sputum taken from wheezy and asthmatic infants and children, with special reference to respiratory infections

Children who are destined to develop asthma are considered to be susceptible to a variety of respiratory pathogens. To elucidate respiratory inflammation among these children, we measured the levels of eosinophil cationic protein (ECP) and tryptase in sputum taken from three different groups of wheezy infants and young children: those with a first wheeze (n = 15); those with recurrent wheeze (n = 27); and those with recurrent wheeze with respiratory distress, namely asthma (n = 56). The numbers of eosinophils or metachromatic cells determined by microscopic analysis of sputum samples were also evaluated in combination with the ECP and tryptase levels. Although neither sputum ECP nor tryptase was a clear discriminative marker that differentiated the three different types of wheezy disease, ECP levels in sputum from the asthma group were significantly higher (2,269.2 +/- 6,216.8 ng/g) than those in the recurrent wheezy group (440.3 +/- 1,199.8 ng/g) or in the first-wheeze group (209.0 +/- 172.9 ng/g). A similar trend was observed with tryptase levels in sputum, but there were no significant differences among the three groups. Sputum taken from asthmatic children showed a marked accumulation of eosinophils. However, an accumulation of eosinophils in sputum (even in the presence of an elevated level of sputum ECP) was not identified in the asthmatic infants < 1 year of age. An accumlation of eosinophils in sputum was not evident until children became > 1 year old and thereafter the eosinophils rapidly increased in number until the children reached 5 years of age. It was noteworthy that sputa positive for pathogenic bacteria, taken from the 1- and 2-year-old asthmatic infants, had a tendency to show high levels of ECP but a reduced number of eosinophils. Along with the wheezy episodes induced by viral infection, primarily and occasionally in combination with secondary bacterial infection, eosinophil activation and infiltration may develop. These predestined immune reactions to various pathogens might be associated with triggering the onset of asthma.

[Effects of institutional therapy and factors which influence the prognosis]

We examined the effect of institutional therapy on asthmatic children and evaluating the factors influencing the prognosis. We analyzed the questionnaires and laboratory findings obtained form the 565 children who had been treated with the therapy in National Higashi-Saitama Hospital from April 1978 to March 1997. The institutional therapy seems to be effective in the following 3 aspects. 1) Pulmonary function test such as FEV1.0, and bronchial hypersensitivity test such as acetylcholine inhalation test were improved. 2) Exercise abilities such as free running were improved. 3) More than 40% of the patients had no asthma attack or only a few mild asthma attacks requiring no medication. When compared the group whose symptoms were not improved with the remission group, who had no asthma attack, significant differences were seen in the following points, 1) The dose and the number of the medicines at the end of the hospitalization, 2) the bronchial hypersensitivity test, 3) the age of onset, 4) the age of the symptoms become perennial and 5) the term from the symptoms become perennial to the hospitalization were significantly different. The therapy principles including the recipes for exercise training were not different between the two groups. It is concluded that we should consider institutional therapy or, a combination of physical training and environmental control as one of the most important therepeutic methods when asthmatic symptoms become perennial in spite of the conventional medication.

An improved synthesis of taurine- and glycine-conjugated bile acids

A simple and efficient method for the synthesis of taurine- and glycine-conjugated bile acids is described. The condensation reaction was achieved by the simple mixing of unconjugated bile acid (1.0 eq.), taurine (2.0 eq.) (or glycinate ester), diethyl phosphorocyanidate (1.2 eq.) in the presence of triethylamine at room temperature for 30-60 min. Sample clean-up was effected by the use of a prepacked Sep-Pak C18 cartridge for reversed-phase solid extraction or by direct recrystallization, yielding the desired taurine and glycine conjugates in 89-93 and 92-96% isolated yields, respectively.

[Measurement of portal and splenic venous flow volume (PV and SV), congestion index (CI) and SV/PV% in various liver diseases using by Doppler echo-sonography]

We measured the portal and splenic venous flow volume (PV and SV), congestion index (CI) and SV/PV% in various stages of the liver diseases chronic inactive hepatitis (CIH), chronic active hepatitis (CAH), liver cirrhosis without esophageal varices (LCvarix(-)), and liver cirrhosis with esophageal varices (LCvarix(+))¿, and normal volunteers (NC). The results were as follows: PV was 869.4 +/- 184.0 ml/min in NC, 920.4 +/- 242.5ml/min in CIH, 900.0 +/- 216.9ml/min in CAH, 841.8 +/- 253.0 ml/min in LCvarix(-) and 909.7 +/- 430.7ml/min in LCvarix(+). SV was 241.0 +/- 80.0 ml/min in NC, 289.4 +/- 131.6 ml/min CIH, 286.4 +/- 108.8 ml/min CAH, 272.7 +/- 135.7 ml/min in LCvarix(-), 398.0 +/- 280.5 ml/min in LCvarix(+). SV/PV% was 28.1 +/- 10.1 in NC, 31.4 +/- 14.0 CIH, 32.1 +/- 9.6 in CAH, 32.4 +/- 16.0 in LCvarix(-), 43.1 +/- 23.7 in LCvarix(+). CI was 0.06 +/- 0.019 in NC, 0.07 +/- 0.028 in CIH, 0.09 +/- 0.05 in CAH, 0.11 +/- 0.03 in LCvarix(-), 0.145 +/- 0.047 in LCvarix(+). These results suggested that: (1) From the measurement of CI, portal venous pressure is begun to increase at the stage of chronic active hepatitis. (2) Increasing of splenic venous flow volume is begun at the stage of chronic hepatitis and it effects to the portal hypertension of liver cirrhosis. (3) The change of component of intrahepatic portal venous blood flow and decreasing of liver function tests was affected by increasing of splenic venous flow volume. (4) SV/PV% may be useful parameter to evaluate the decreasing of liver function tests and to estimate the complication of esophageal varices at the liver cirrhosis.

Study of liver function in infants with atopic dermatitis using the 13C-methacetin breath test

Serum glutamic-oxaloacetic transaminase (GOT) levels were determined in 214 infants (133 males and 81 females) with atopic dermatitis during their first visit to the Department of Allergy, National Children's Hospital, Tokyo, Japan. Compared with the normal hospital range, their levels were found to be significantly higher, a tendency which was more conspicuous in lower age groups. We carried out a 13C-methacetin breath test (MBT), administering the stable-isotope-labeled compound to 11 children with higher serum GOT values and 5 within the normal range to investigate hepatic metabolism of methacetin in infants with atopic dermatitis. 13C-methacetin was given orally, and the 13CO2 level in the breath was determined immediately before and after administration, by mass spectrometry. Compared to the normal controls, the atopic infants demonstrated significantly lower 13CO2 peak excretion and delayed peak time. The clearance rate of 13CO2 was also decreased. These results suggest some relationship between atopic dermatitis and liver function in infants.

[Investigation into the therapeutic efficacy of continuous isoproterenol inhalation in relation to respiratory infections in asthmatic children]

In our Department, continuous isoproterenol inhalation therapy has been conducted on status asthmatics over the last 10 years. In the present study, we investigated whether there are any differences in the therapeutic efficacy of continuous inhalation of isoproterenol in the presence or absence of respiratory infections which may induce or aggravate asthma attacks. The treatment period was significantly longer in patients with pneumonia. Further prolongation of the treatment period was noted in patients with atelectasis. However, there were no apparent differences in therapeutic efficacy according to age or the severity of attacks. These findings suggest that continuous inhalation of isoproterenol is very effective for status asthmatics if respiratory infections are thoroughly controlled.

Pharmacokinetics and pharmacodynamics of the tulobuterol patch, HN-078, in childhood asthma

BACKGROUND

Recently, a novel percutaneous adhesive tulobuterol preparation, HN-078, has been developed and tests using healthy adult subjects have indicated it to be effective for controlling exacerbations early in the morning if applied at bedtime. In children, percutaneous application is very important to eliminate side effects, including abdominal pain and appetite loss.

OBJECTIVE

We report the pharmacokinetics and pharmacodynamics of tulobuterol patch, HN-078, in the treatment of childhood asthma.

METHODS

Single applications of HN-078 were applied transdermally in six children with asthma who had been admitted to a hospital. Subjects weighing less than 30 kg received 1 mg of tulobuterol while subjects weighing 30 kg or above received 2 mg on the chest for 24 hours. Serum tulobuterol levels and peak expiratory flow rate were determined before and after each application.

RESULTS

Cmax of tulobuterol was determined to be 1.33 +/- 0.21 ng/mL, Tmax was 14.0 +/- 2.0 hours, and AUCO-t was 27.1 +/- 4.2 ng.hr/mL. These pharmacokinetic parameters per body surface area of children were nearly equivalent to those of adults obtained in other studies. Peak expiratory flow rate values obtained after application of HN-078 significantly increased in comparison to those obtained before application. No significant changes were observed in pulse rate or blood pressure, and no side effects were found with regard to the subjective symptoms and skin conditions.

CONCLUSIONS

These results suggest that the patch formulation of tulobuterol, HN-078, will be very useful for the treatment of pediatric asthma. It is especially significant that no side effects were observed.

[A comparative evaluation of three commercially available peak flowmeters before and after being used 1000 times]

The differences in values, accuracy, reproducibility and interdevice variability of three models of portable peak flowmeters (standard and low range of Assess, mini-Wright, Pulmo-Graph) before use and after they had been used 1000 times. A computerized standard flow generator was used to evaluate. Standard range; The three models showed differences in values before and after 100 uses of less than 3 percent at flow rates below 480 L/min. However, the used flowmeters, especially the Assess, showed higher values compared with the new ones at higher flow ranges. There was no significant difference in accuracy between the new and used mini-Wright and Pulmo-Graph models. The used Assess, howevers, showed higher values at higher ranges, thus demonstrating improved accuracy over the new ones. The reproducibilities of the three models deteriorated at high flow rates. The interdevice variability of the used Pulmo-Graph flowmeter was better than that the new one. No significant changes were observed in the mini-Wright, while the Assess showed deteriorated interdevice variability. Low range; The three models showed no significant differences in values, accuracy, reproducibility or interdevice variability before and after use.

[Adrenocortical function in children with near fatal asthma]

The adrenal function of children with near fatal asthma was evaluated by a modified rapid ACTH test. The rapid ACTH tests, which were performed within six months of each life-threatening asthmatic episode, showed extremely low responsiveness. The response in the subjects was significantly lower than that of patients who had received high dose of corticosteroid therapy. It was suggested that the adrenocortical function of children with near fatal asthma had been already suppressed and that adrenal suppression could easily occur in such patients. We advocate the following measures: (1) environmental control, education of patients and their families, physical training accurate medication should be supplied to reduce the use of corticosteroids, (2) sufficient doses of corticosteroids should, however be given to patients with acute exacerbation, (3) not only lung function tests or allergic examinations, but also adrenocortical function tests should be performed on severe asthmatic patients.

Creatinine-clearance estimates for predicting gentamicin pharmacokinetic values in obese patients

The Cockcroft-Gault and Salazar-Corcoran equations were compared with respect to prediction of gentamicin pharmacokinetic values in obese and nonobese patients, and the results were used to formulate guidelines for calculating initial gentamicin dosages in obese patients. Creatinine clearance (CLcr) was estimated by applying the Cockcroft-Gault equation using total body weight (TBW), ideal body weight (IBW), and dosage weight (DW) and with Salazar-Corcoran equations using fat-free body mass (FBM) in 100 obese and 100 nonobese patients. Gentamicin pharmacokinetic values (k, CL, and t1/2) were estimated by using CLcr estimated by each method and standardized to a body surface area of 1.73 sq m. Actual pharmacokinetic values were determined by using steady-state gentamicin concentrations and a modified Sawchuk-Zaske equation; these values were compared with the predicted values. In the obese patients, pharmacokinetic values predicted from standardized CLcr by the Cockcroft-Gault equation using estimated DW were not significantly biased, compared with actual values; most predictions produced by the other methods were significantly biased. Predictions produced by the DW method were generally more precise than those resulting from the other methods. In nonobese patients, k values estimated by the Cockcroft-Gault equation using IBW were not significantly biased, while values obtained with all other methods were biased. All methods were biased when predicting CL and t1/2 in nonobese patients. Significant correlations existed between standardized estimates of CLcr (by all methods) and pharmacokinetic values in both groups. Predictions of gentamicin k, CL, and t1/2 were best overall when CLcr was estimated by the Cockcroft-Gault equation using DW, rather than by other methods.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluating new and traditional methods for aminoglycoside dosing in patients with various degrees of renal function

Aminoglycosides are widely used, and clinicians continue to seek newer and better methods for initial dosing of these agents. Recently, three new methods were introduced: Thomson, Reesor Nimmo, and dosing in renopathy by easy-to-use multipliers (DREM). In comparing them with older, traditional dosing methods in patients with various degrees of renal function, the pharmacokinetic variables of gentamicin were determined from steady-state peak (Cmax) and trough (Cmin) serum concentrations using individualized regimens in 88 patients. Dosages were determined in each patient using the method of Hull-Sarubbi, rule of eights, and the three new methods, and the resultant Cmax and Cmin values were calculated from dosages generated by each method. The daily doses and Cmax values derived with the Hull-Sarubbi, Thomson, and Reesor Nimmo methods were not significantly different (p > 0.05). The Hull-Sarubbi was the most precise (root mean squared prediction error 1.3) and least biased (mean prediction error -0.05) of the five methods in predicting target gentamicin serum peak concentrations (Cmax 6.5 mg/L). The Hull-Sarubbi (69%), Thomson (86%), and Reesor Nimmo (70%) methods yielded therapeutic Cmax (5-8 mg/L) in a significantly higher percentage of patients than did the rule of eights (32%) and DREM (35%), (p < 0.05). Therefore, if gentamicin serum concentrations are not available, the first three appear to be reasonable methods for initiating gentamicin dosage regimens, but the last two may not be desirable to use in a clinical setting. These conclusions are based on the assumption that patients are adults with stable renal function and relatively stable clinical conditions.

[Changes in histamine levels in skin chambers. Application for clinical evaluation of atopic dermatitis--report 2]

We measured changes in histamine levels in fluids from children with moderate or severe atopic dermatitis by the skin chamber method and evaluated the correlation with clinical symptoms. Skin chambers were applied to the forearm skin which had been scratched with a needle, and extract of Dermatophagoides farinae (mite antigen) at 50 microns filters as a challenge. We measured the concentrations of histamine 2, 6, 12 and 24 hr after challenge. The skin chamber test was performed before and after beach camp therapy or hospitalization therapy. We treated 26 children with beach camp therapy, and compared the effects with hospitalization in Tokyo (20 children). All the children in both groups showed results of mediator releasability in skin chamber was different in the two groups. The histamine levels were dramatically increased 24 hr after challenge with mite antigen. The levels of histamine in the chambers 24 hr after challenge decreased with treatment along with improvements in skin condition. A marked increase in histamine levels in the skin chamber fluids was observed after 24 hours, whereas no increase was observed when they were challenged with vehicle saline. After 7 days of beach camp therapy, challenge with mite antigen produced only a very small increase in histamine levels even after 24 hours, which was significantly lower than the levels before therapy. In the cases involving hospitalization in Tokyo, histamine was observed to be increased at 24 hr (24.9 +/- 8.0 ng/ml SEM), similarly to the beach campgroup (19.0 +/- 7.3 ng/ml).(ABSTRACT TRUNCATED AT 250 WORDS)

[An evaluation of three commercially available peak flowmeters]

The accuracy, reproducibility and interdevice variability of three models of portable peak flowmeters (standard and low range) were evaluated by using a computerized standard flow generator. Standard range; The mini-Wright peak flow meter generally overestimated peak flow from 120 L/min to 540 L/min and the Assess peak flowmeter underestimated peak flow at full range. The Pulmo-Graph peak flowmeter showed a similar pattern to the mini-Wright but with more accuracy. The Assess showed the best linearity. The reproducibilities of the three models deteriorated over 20 L/min at high flow rates. The interdevice variability of the mini-Wright was better than those of the Assess or the Pulmo-Graph. Low range: The accuracy and interdevice variability of the Pulmo-Graph were better than those of the Assess or the mini-Wright. The reproducibility of Assess seemed to be inferior to the other's. The measured flow from the low ranges was not the same as that of the standard ranges. The three peak flowmeter models have different spring mechanisms for their readings, and the measured flows by one model should not be compared with other models.

Growth in methylcellulose of human mast cells in hematopoietic colonies stimulated by steel factor, a c-kit ligand

We examined the effect of Steel factor (SLF) on the development of human mast cells in hematopoietic colonies from cord blood mononuclear cells in methylcellulose culture. When cord blood cells were cultured for 3 weeks, SLF increased the cellular tryptase levels detected in total cultured cells. It also stimulated the formation of small-cell colonies consisting mainly of polymorphonuclear granulocytes and immature blastoid cells in a concentration-dependent manner but not the formation of colonies consisting of large macrophagic cells. A low percentage of tryptase-positive mast-cell-like cells was found in 39 out of 100 granulocyte/blastoid cell colonies. Four of the 100 colonies contained 10-20% tryptase-positive cells, but we failed to observe colonies consisting of > 20% of tryptase-positive cells. These results suggest that the effect of SLF on mast cell growth is brought on by stimulating the growth of primitive hematopoietic progenitors.

[Does clinical stage have any influence on the results of provocation tests in allergic children? I. The best clinical stage for food provocation tests]

To investigate the best clinical stage for food provocation tests, twenty allergic patients who had early allergic reactions induced by any kind of food were tested. The patients were classified into two groups. Group I; open-food challenge tests were performed on eleven patients within 48 hours of admission. Group II; the tests were performed on nine patients seven or more days after admission. In these food provocation tests, there were nine positive results in Group II (p < 0.05). The percentage of eosinophils in the blood was higher in cases of positive provocation than in cases of negative provocation (p < 0.05). Moreover the percentage of eosinophils decreased after admission day by day in the provocation-negative patients of Group II, but there was no change in the provocation-positive patients. These results suggest that individual sensitivity to food decreased after admission. Therefore, in order to assess the actual sensitivity of allergic children it is necessary that food provocation tests be performed within two days of admission or before admission.

[Dermal reactions in children with atopic dermatitis--changes in histamine/tryptase levels in skin chambers. Report 1]

In the present study, we used the skin chamber method to determine histamine and tryptase released by continuous loading of a single antigen on the skin in order to evaluate dermal reactions produced and thereby obtain greater insight into the role of type I allergic reactions in children with atopic dermatitis. The subjects were 46 children, 23 males and 23 females aged 10.6 +/- 4.3 years on the average, who were being treated at the National Children's Hospital for moderate or severer atopic dermatitis. Mite antigen stimulation was carried out by the skin chamber method upon admission and histamine and tryptase levels in collected antigen solution were determined. Histamine levels in the chamber were increased significantly at 6, 12 and 24 hrs after stimulation compared to the control levels (p < 0.01). Tryptase levels were increased 2 hrs after stimulation but decreased with time thereafter. Histamine and tryptase levels were significantly correlated 2 hrs after stimulation, with a correlation coefficient of 0.954 (p < 0.01). No significant correlation was observed 24 hrs after stimulation. These findings indicate that children with severe atopic dermatitis have great skin reactivity and very sensitive to stimulation by antigens. Mast cells and basophils are thought to be involved in immediate and delayed type reactions, respectively.

Incidence of latex allergy in atopic children in Japan

Many cases of latex-induced intraoperatived anaphylaxis have been reported in Europe and the U.S. but not in Japan. We measured latex-specific IgE antibody in sera from the 108 atopic children with high serum IgE levels (over 1,000 U/ml). All of them were diagnosed to have asthma, atopic dermatitis and/or food intolerance. Eleven (10.2%) out of 108 patients were found to have latex-specific IgE by RAST, and 6 of them were positive for latex antigen by skin test. Most of the children did not realize that they were allergic to latex until we discovered it. This data suggest that we should be cautious about latex allergy when atopic children have to be operated upon.

Incidence of latex allergy in atopic children and hospital workers in Japan

The incidence of latex-induced allergy has been reported to be increasing in Europe and the US but not in Japan. We thus measured latex-specific IgE antibodies and latex-specific IgG antibodies in sera from 196 atopic children with low serum IgE levels (under 1,000 U/ml; group 1), 108 atopic children with high serum IgE levels (over 1,000 U/ml; group 2) and 601 hospital employees (group 3). Atopic children were diagnosed as having asthma, atopic dermatitis and/or food intolerance. One out of group 1 (0.5%) and 11 out of group 2 (10.2%) were found to have latex-specific IgE by radioallergosorbent assay (RAST), and 7 were further found to be positive for latex antigen by skin test. Fifty-five percent of group 1, 65% of group 2 and 9.7% of group 3 were found to have latex-specific IgG over 100 units/ml by enzyme linked immunosorbent assay (ELISA). Prior to our diagnosis most of the children and employees did not realize they were allergic to latex. These data suggest that caution should be taken regarding latex allergy when atopic children have to be operated upon as atopic children tend to be sensitized to the latex antigen after even minimal contact with latex products.

Hereditary lipo-muscular atrophy with joint contracture, skin eruptions and hyper-gamma-globulinemia: a new syndrome

We previously reported two siblings with decreased subcutaneous adipose tissue, muscular atrophy, joint contractures, recurrent skin eruptions, hyper-gamma-globulinemia, and reduced natural killer cell activity. Some of their clinical features are similar to those of partial lipodystrophy, but they are distinct in that muscular atrophy, joint contractures and recurrent skin eruptions are not found in patients with partial lipodystrophy. Thirteen other Japanese patients with similar clinical manifestations have been reported. We propose that such cases should be considered a distinct clinical entity.

Blood pressure, heart rate and catecholamine response during riberoptic nasotracheal intubation under general anesthesia

Arterial blood pressure (ABP) and heart rate were recorded at one-minute intervals during several stages of intubation in the fiberscope group and the laryngoscope group, to determine if fiberoptic nasotracheal intubation would result in fewer hemodynamic and catecholamine responses than when intubation was performed with a Macintosh laryngoscope. Blood samples were also taken to measure plasma catecholamine concentration immediately after intubation with the fiberscope. The mean ABP in the laryngoscope group was slightly greater than that of the fiberscope group for 4 min after intubation. Heart rates at 2 min and 4 min after intubation in the laryngoscope group were significantly greater than those for the fiberscope group. Even immediately after intubation, the mean plasma levels of epinephrine and norepinephrine were unchanged in the fiberscope group. Arterial oxygen saturation (Sp(O)(2)) was maintained within normal range during both of intubation procedures, although the time required for intubation was longer than in the laryngoscope group. Other cardiovascular complications were more common in the laryngoscope group than in the fiberscope group. These results suggest that fiberoptic intubation results in less severe stress than does laryngoscopic intubation. Fiberoptic intubation should therefore be used not only in patients with difficult airway, hypertension, ischemic heart disease, or cerebrovascular atherosclerosis, but also it is recommended for all patients for whom nasotracheal intubation is indicated.

[Study of liver function in babies with atopic dermatitis by using 13C-methacetin breath test]

We measured serum GOT levels in babies with atopic dermatitis and food allergy. Two hundred and fourteen babies (133 male, 18 female, under 2 years of age) who first visited the Department of Allergy in the National Children's Hospital were examined. Their serum GOT levels were higher than normal; the younger they were, the higher the serum GOT levels were. We carried out the 13-methacetin breath test (MBT) on 11 babies with atopic dermatitis and high serum GOT levels as well as 5 normal babies to estimate their hepatic microsomal function. 13C-methacetin was administered (0.5 mg/kg) orally, and breath was collected at 30 minutes before and immediately before administration. After administration it was collected at 15 minute intervals for the first hour and 45 minute intervals for 90 consecutive minutes afterwards. The level of 13CO2 in their breath was determined with a mass spectrometer. The peak level of 13CO2 excretion (%dose/hr) in the atopic babies with high serum GOT levels was lower and the time required for 13CO2 excretion to reach its maximum level was longer than in normal babies. Also their 13CO2 clearance rate (%/hr) was lower. These results suggested that there was some relationship between atopic dermatitis and liver dysfunction in babies.

Airway responses to repeated exercises detected by krypton-81m in asthmatic children

A repeated exercise program was used to test 7 asthmatic children for changes in ventilation. These changes were examined by continuously inhaled Krypton-81m and compared in subjects with positive and negative refractoriness, as defined by forced expiratory volume in 1 second (FEV1). Three of the seven patients showed significant refractoriness (% reduction in FEV1 > 50%). After the first exercise, they showed one or two ventilation defects which improved after the second exercise. The patient with incomplete refractoriness showed similar results. On the contrary, subjects without refractoriness showed several ventilation defects which fluctuated after the second or third exercise program. One defected area improved after the second exercise session, but deteriorated after the third; and another area deteriorated after the second exercise and improved after the third. It was concluded that approximately half of the patients were refractory in view of FEV1, but that they were all refractory in view of regional ventilation 81mKr images.

Utilization of a computerized system at the pharmacy department of the University of Tokyo Hospital--impact of prescription order entry and computerized dispensing system

(1) A medication order entry system, (2) a fully automatic tablet counting and packaging machine connected with a medication order entry system, and (3) a check system for one dose package developed and implemented in the University of Tokyo Hospital are described. The principal objectives of these systems are (1) to reduce medication errors and the clerical workload of staff, (2) to make more efficient use of staff, (3) to provide staff with sufficient drug information for patient drug therapy. We compared computerized systems (post-computerization) and traditional multi-dose dispensing systems (pre-computerization) by analyzing inquiry rate and dispensing time in the pharmacy for inpatients. Inquiry rate was 23.0% and 2.6% for pre-computerization and post-computerization, respectively. Total dispensing time per patient was 207 seconds and 147 seconds for pre-computerization and post-computerization, respectively. Implementation of the computerized systems helped significantly in decreasing inquiry rate and time needed to complete the dispensing process when compared with a traditional dispensing system. Implementation of the computerized systems was very useful for physicians, pharmacists, and nurses in conducting drug therapy.

A Creutzfeldt-Jakob disease agent (Echigo-1 strain) recovered from brain tissue showing the 'panencephalopathic type' disease

We used histologic evidence of degenerative changes in both the gray and white matter of the brain to diagnose a patient as having the panencephalopathic type of Creutzfeldt-Jakob disease (CJD). This type of CJD is relatively common in Japan, but not in North America or Europe. We recovered a transmissible pathogen (Echigo-1 strain) from an autopsy specimen of the patient's brain and passed it serially in Hartley guinea pigs. After a long latent period, it caused degenerative changes, mainly in the thalamic area of the guinea pig brain. On the 4th passage, a substrain emerged with a short latent period. When cross-transmitted to Golden Syrian hamsters, this substrain induced severe degeneration in both the thalamus and cerebral cortex. We compare our results with those for other experimental CJDs produced by other types of this disease.

A fulminant case of Guillain-Barré syndrome: topographic and fibre size related analysis of demyelinating changes

In a necropsy case of early fulminant Guillain-Barré syndrome, demyelinating changes were observed throughout the peripheral nervous system, most conspicuous in the spinal nerve roots. The central/peripheral nervous system transition regions and most proximal zones of the roots escaped damage. In some root areas there were widespread early changes in myelin sheaths in the absence of significant infiltrates of inflammatory cells. In the fibre size analytical study, small myelinated fibres were preferentially involved.

[Ocular motor abnormalities in progressive supranuclear palsy]

Eleven patients, 7 males and 4 females, of progressive supranuclear palsy (PSP) were examined neuro-otologically for the purpose of elucidating the characteristics of ocular motor abnormalities. All cases were admitted to our hospital and age at onset was from 52 to 71 years old, duration of illness was 2 to 11 years. Range of voluntary eye movements and abnormal eye movements including nystagmus were examined on naked eyes and with electronystagmography (ENG). Smooth pursuit movements and saccadic eye movements were tested both horizontally and vertically by using visual tracking method with ENG recordings. Optokinetic nystagmus test and caloric test with visual suppression test were also performed. These neurotological examinations were made repetitively in 5 cases and their progressions were observed. Vertical gaze palsy and convergence palsy were observed in all cases as the initial symptom. In this study downward gaze was more severely disturbed than upward gaze. Using ENG, saccadic eye movements (saccades) were disturbed earlier than smooth pursuit movements. Hypometric saccades and decreased saccadic velocity were common abnormalities. In the later stage of the disease, horizontal eye movements were also disturbed. In four cases bilateral adduction palsy was added to vertical gaze paralysis so that the lesion of the MLF to oculomotor nucleus was suggested to exist. These voluntary eye movements were worsened gradually as the disease progressed. By using ENG we could find so called abnormal eye movements more frequently than the previous reports. Eight patients demonstrated horizontal gaze nystagmus, and rebound nystagmus were observed in four cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[A family of spino-cerebellar degeneration with disturbance of ocular movement, choreoathetosis, amyotrophy and dementia--a consideration in clinical features]

Seven cases in a family of hereditary spino-cerebellar degeneration (SCD) similar to dentatorubro-pallido-Luysian atrophy (DRPLA) were reported. The clinical features of these cases were disturbance of ocular movement (limitation of ocular movement and slow eye movement (SEM], remarkable amyotrophy, choreoathetosis, dementia and sleep apnea. The brain CT's revealed marked atrophy in pons and cerebellum. Amyotrophy had been reported in the case of DRPLA, particular ataxo-choreoathetoid form (by Hirayama). Muscle biopsy was performed in these cases, which showed scattered small angulated fiber, severe atrophic fiber with pyknotic nuclear clump, fiber type grouping and small rounded fiber were mixed. These findings indicates neurogenic change of radiculoneuropathy type (by Tanabe). In many reported cases of DRPLA and SCD with amyotrophy, this type of muscle biopsy had not been recognized. In SCD with amyotrophy, a main lesion had existed on peripheral nerve. In this case, there was no definite clinical findings (sensory disturbance, delay of conduction nerve velocity, peripheral neuropathy in nerve biopsy). In recent years, several unclassified cases of SCD with amyotrophy had been reported, which had multi-system degeneration involving peripheral neuropathy. This case is similar to these cases, which is speculates multi-systemic lesions, not only DRPLA but also peripheral nerve involvement. On neuro-otological study, velocity of saccade was slow and persuit was reserved in proband case. In younger onset case, disturbance of saccade and pursuit was mild. In older progressive case, disturbance of saccade and pursuit was progressive and accompanied with severe limitation of ocular movement. Several autopsy cases of SEM had been reported.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of 5-chloro-7-iodo-8-hydroxyquinoline (clioquinol) and nerve growth factor on DNA, RNA and protein syntheses in neonatal rat superior cervical ganglia

To investigate molecular mechanisms involved in the neurotoxicity of clioquinol (5-chloro-7-iodo-8-hydroxyquinoline), the inhibitory effects of this drug on DNA, RNA and protein syntheses were examined, in relation to the action of nerve growth factor (2.5S NGF). We used an organ culture of neonatal rat superior cervical ganglion (SCG). Ten microM clioquinol inhibited completely DNA and protein syntheses and abolished the stimulatory effect of NGF on RNA synthesis. With regard to the chemical structure of clioquinol, hydroxylation at the 8th carbon of quinoline is essential for the inhibition of DNA, RNA and protein syntheses, and the hydrophobicity of the 8-HQ derivatives is a required property for potent inhibition. Compared with effects of EDTA, alizarine, sodium alizarine sulfate, o-phenanthroline and alpha,alpha'-dipyridyl, the loss of the NGF-induced stimulation of RNA synthesis by clioquinol does not seem to be primarily caused by its metal-chelating property. Clioquinol did not significantly alter the uptake rate of thymidine, uridine and leucine, thereby suggesting that the primary action of clioquinol on inhibition of DNA, RNA and protein syntheses does not relate to uptake of the precursor into SCG. Clioquinol did not significantly alter the degradation of 3H-uridine-labeled RNA. NGF suppressed the degradation of RNA and this suppression was overcome by clioquinol. The release of free uridine from SCG into the culture medium was enhanced by clioquinol and was partially suppressed by NGF. The inhibitory effects of clioquinol were completely prevented by bovine serum albumin (BSA), but not by NGF even at a 5-fold concentration of clioquinol.(ABSTRACT TRUNCATED AT 250 WORDS)

5-Chloro-7-iodo-8-hydroxyquinoline (clioquinol) inhibits the nerve growth factor-induced stimulation of RNA synthesis in neonatal rat superior cervical ganglion, in vitro--comparison with effects of methylmercuric chloride and 4-hydroxyaminoquinoline-N-oxide

The inhibitory effects of 5-chloro-7-iodo-8-hydroxy-quinoline (clioquinol), methylmercuric chloride and 4-hydroxyaminoquinoline-N-oxide(4-HAQO) on DNA, RNA and protein syntheses in the neonatal rat superior cervical ganglion (SCG) were studied in relation to the action of mouse 2.5S nerve growth factor (NGF), using organ cultures. RNA and protein syntheses in SCG were stimulated approximately 3- and 2-fold, respectively, by NGF (1 microgram/ml), but the DNA synthesis was only slightly or not at all stimulated. Methylmercuric chloride and 4-HAQO dose-dependently inhibited DNA, RNA and protein syntheses, either in the presence or in the absence of NGF. On the other hand, clioquinol (up to 100 microM) slightly or not at all inhibited RNA synthesis in the absence of NGF; however, it did abolish the NGF-induced stimulation of RNA synthesis in the presence of NGF. The DNA and protein syntheses were dose-dependently inhibited by clioquinol, either in the presence or in the absence of NGF. We conclude from this study that the interaction between clioquinol and the functions of NGF raises the question of a possible toxicity of the drug on specific neurons.

[Usefulness of nerve block therapy in patients with herpetic pain]

A retrospective study was performed on 230 patients with Herpes zoster. Among these patients, 156 patients (67.8%) were over 50 years old. Ninety-four percent of the patients who received the nerve block therapy within a month from the onset became ultimately free from pain while only seventy-nine percent of the patients upon whom this therapy was started after 2 months or more were relieved of pain. It was suggested that the earlier the therapy and the younger the patients, the more easily herpetic pain could be controlled. In conclusion, it became apparent that early treatment of Herpes zoster with nerve block therapy, is extremely important for prevention of post-herpetic neuralgia.

[Endogenous inhibitory system in pain]

Electrical stimulation of several brain sites produces profound analgesia in humans, and inhibits nocifensor reflexes in animal studies. Responses of the dorsal horn nociceptive neurons evoked by stimulation onto the receptive fields are also inhibited by brain stimulation. These brain sites are Periaqueductal Gray Matter (PAG), Nucleus Raphe Magnus (NRM), Nucleus Reticularis magnocellularis (NRmc), Locus Coeruleus (LC), Lateral Hypothalamus, and others. We have explained in a general way the mechanism of these stimulation produced analgesia. The mechanism of PAG stimulation analgesia is partly due to an activation of serotonin containing neurons which descend from NRM to the spinal dorsal horn and activated by PAG stimulation. Activation of NRM neurons may produce inhibition of the nociceptive neurons of the dorsal horn by the mechanism of direct postsynaptic inhibition. Currently there is no evidence to support the theory of presynaptic inhibition. Endogenous opioid peptides do not play an important role in PAG stimulation analgesia. On the other hand, the mechanism of NRmc or LC stimulation analgesia may be due to an activation of noradrenaline containing neurons which similarly inhibit the dorsal horn nociceptive neurons in the spinal cord. At present, it still remains unknown whether endogenous opioid peptides play an important role in this type of analgesia.

Creatine kinase (CK)-linked IgA in Isaacs' syndrome. An immune complex disease?

Electrophoresis of serum from a patient with Isaacs' syndrome revealed an atypical creatine kinase (CK) isoenzyme pattern which contained an extra band migrating between CK2(MB) and CK3(MM). Immunofixation demonstrated that the extra band was a complex of CK3(MM) and IgA. The presence of this complex seemed to correlate with increased serum CK levels which were associated with the aggravation of symptoms. Immunofluorescence studies on muscle biopsy samples revealed the presence of the complex in the muscle fiber membrane and motor endplate. The existence of CK-linked IgA in an Isaacs' syndrome suggests that an immunological abnormality may play a role in the pathological process of this rare syndrome.

Familial Creutzfeldt-Jakob disease in Japan. Three cases in a family with white matter involvement

Three cases of Creutzfeldt-Jakob disease occurring in one family have been clinicopathologically examined. Although the age at onset, duration, and age at death differed for each case, pathological findings, including diffuse neuronal loss, astrocytosis, spongiform changes and patchy and/or diffuse white matter involvement were similar. Life histories and inheritance patterns of the present 3 cases and 2 other families previously reported in Japan are compared with the general findings for familial cases in western countries.

Ultrastructural studies on the neuromuscular junctions of Becker's muscular dystrophy

Ultrastructural studies on muscle biopsies from three patients with Becker's muscular dystrophy showed that the i.m. nerves presented loss or disarrangement of the neurofilaments and an increased number of glycogen granules and/or myelin figures not infrequently in the myelinated and unmyelinated nerve fibers. The neuromuscular junctions showed markedly widened sole-plate areas, and several terminal axons frequently abutted and formed neuromuscular junctions on the same fiber. The secondary synaptic clefts were markedly decreased in number and short in length in type I fibers but not in type II fibers. Most terminal axons showed no degenerative changes. Therefore, the participation of a neural factor might be suggested as the cause of Becker's muscular dystrophy, although it does not mean denervation in the conventional sense of an axonal degeneration.

Mitochondrial encephalomyopathy: fluctuating symptoms and CT

We describe a 29-year-old man with mitochondrial encephalomyopathy. The patient's disorder was characterized by lactic acidosis, hemiparesis, seizures, aphasia, and hemianopia. CT revealed low-density areas that corresponded to the symptoms. His 56-year-old mother is also involved subclinically, demonstrating that muscle biopsy is an important requisite in the final determination of a familial inheritance pattern in mitochondrial myopathy. Neuronal mitochondrial disorders are suggested as the pathogenesis of his neurologic symptoms.