Are T1-Weighted Three-Dimensional Magnetic Resonance Images Inferior to T2-Weighted Images for Diagnosing Lumbar Foraminal Stenosis in the Fifth Lumbar Nerve Root? A Prospective, Comparative Study in Identical Patients

Introduction

Imaging analysis of foraminal stenosis in the fifth lumbar (L5) nerve root remains to be a challenge because of the anatomical complexity of the lumbosacral transition. T2-weighted three-dimensional (3D) magnetic resonance images (MRI) have been dominantly used for diagnosis of lumbar foraminal stenosis, while the reliability of T1-weighted images (WI) has also been proven. In this study, we aim to compare the reliability and reproducibility of T1- and T2-weighted 3D MRI in diagnosing lumbar foraminal stenosis (LFS) of the L5 nerve root.

Methods

In this study, 39 patients with unilateral L5 radiculopathy (20 had L4-L5 intracanal stenosis; 19 had L5-S foraminal stenosis) were enrolled, prospectively. T1- and T2-weighted 3D lumbar MRI were obtained from each patient. T1WI and T2WI were blinded and then separately reviewed twice by four examiners randomly. The examiners were instructed to answer the side of LFS or absence of LFS. The correct answer rate, sensitivity, specificity, and area under the curve were analyzed and compared between T1WI and T2WI. Also, intra- and interobserver agreements were calculated using kappa (κ)-statistics and compared in the same manner.

Results

The average correct answer rate, sensitivity, specificity, and area under the curve of the T1WI/T2WI were 84.6%/80.1%, 82.9%/80.3%, 86.3%/81.3%, and 0.846/0.801, respectively. The intraobserver κ-values of the four examiners ranged from 0.692 to 0.916 (average: 0.762) and from 0.669 to 0.801 (average: 0.720) for T1WI and T2WI, respectively. The interobserver κ-values calculated in a round-robin manner (24 combinations in total) ranged from 0.544 to 0.790 (average: 0.657) and from 0.524 to 0.828 (average: 0.652), respectively.

Conclusions

As per our findings, T1- and T2-weighted 3D MRI were determined to have nearly equivalent reliability and reproducibility in terms of diagnosing LFS of the L5 nerve root.

Radical decompression without fusion for L5 radiculopathy due to foraminal stenosis

Background

The highest incidence of lumbar foraminal stenosis (LFS) occurs in the L5-S1 segment and its anatomical features differ from those of other segments. Few previous reports have exhaustively assessed surgical outcomes after decompression surgery, limiting the materials to patients with LFS at the L5-S1 segment. We aimed to prospectively investigate instability and neurological improvement following our novel surgical technique for LFS at L5-S1, named "radical decompression" of the nerve root.

Methods

Patients with foraminal stenosis at L5-S1 who underwent surgery using our technique were prospectively evaluated two years postoperatively. The Japanese Orthopaedic Association (JOA) score and the JOA Back Pain Evaluation Questionnaire (JOABPEQ) were evaluated preoperatively and two years postoperatively. The following radiological parameters at L5-S1 were measured: lateral translation, sagittal translation, the difference in sagittal translation (DST) between flexion and extension, disc wedging angle, lordotic angle, the difference in lordotic angle (DLA) between flexion and extension, and disc height. Pre- and postoperative data were compared using paired t-tests. In addition, the patients were classified into a disc group (Group D) and a non-disc group (Group ND) according to whether a discectomy was performed intraoperatively. Changes in each parameter before and after surgery were compared between the groups.

Results

Twenty-eight patients were included in this analysis. The JOA scores improved in all patients. The mean preoperative and two-year postoperative JOA scores were 14.5±3.2 (range, 8-21) and 24.3±3.3 (range, 18-29), respectively (P<0.01). All JOABPEQ categories improved two years postoperatively (P<0.05). None of the patients underwent revision surgery. No significant changes were observed in any of the radiological parameters. No significant differences in the changes in each parameter before and after surgery were found between groups D and ND.

Conclusions

Our surgical technique resulted in good neurological recovery and was associated with a low risk of postoperative segmental instability, regardless of additional discectomy.

Surgical management of facet cysts in the thoracic spine: Radiological manifestations and results of fenestration

BACKGROUND

Facet cysts in the thoracic spine are a rare cause of thoracic myelopathy. We aimed to investigate the clinical/radiological features and surgical results of these lesions.

METHODS

Nine thoracic facet cysts in eight patients (seven men, one woman) were diagnosed based on magnetic resonance imaging (MRI) and computed tomography (CT) with facet arthrography findings and surgically treated. The mean patient age was 71 (59-83) years. The cysts were distributed as follows: one each at T8-9 and T9-10, two each at T1-2 and T11-12, and three at T10-11. The mean follow-up period was 1.8 (1-5) years. Clinical and radiological features were retrospectively investigated, and surgical outcomes were evaluated according to modified Japanese Orthopaedic Association (JOA) scores for thoracic myelopathy (full score: 11).

RESULTS

Neurological examination revealed progressive thoracic transverse myelopathy in all patients with a mean disease duration of 1.2 months (2 weeks-2 months). MRI revealed a total of nine cysts across the eight patients: four in the median region and five in the paramedian portion of the spinal canal. CT revealed degeneration in all involved facet joints. All the cysts were in communication with the neighboring facet joint confirmed by CT facet arthrography. All patients underwent bilateral fenestration, and the cysts were resected with the ligamentum flavum. The mean preoperative and postoperative modified JOA scores were 4.5 and 8.8, respectively. The mean recovery rate was 67.5%. Differences in the degree of local kyphosis were 2° or less between before and after surgery. On histopathology, synovial lining cells were not noted in any case.

CONCLUSIONS

Decompression surgery is recommended for treating progressive myelopathy in patients with cystic lesions. Our study suggests that thoracic facet cyst resection with satisfactory surgical outcomes would be possible through fenestration.

Imaging diagnosis of lumbar foraminal stenosis in the fifth lumbar nerve root: reliability and reproducibility of T1-weighted three-dimensional lumbar MRI

BACKGROUND

Various magnetic resonance imaging (MRI) techniques have been reported in detection of lumbar foraminal stenosis (LFS), especially for T2-weighted three-dimensional MRI (3D-MRI) describing the shape of nerve roots. The detection of LFS in the fifth lumbar nerve root (L5 root), however, is still less reliable compared to other lumbar nerve roots. Then we have been using T1-weighted 3D-MRI aiming to depict the shape of, and also pathology affecting the L5 root. The aim of this study is to evaluate our T1-weighted 3D-MRI in diagnosing LFS of the L5 root.

METHODS

This retrospective study included 24 patients with intracanal stenosis (ICS) at L4-5, and 30 patients with LFS at L5-S causing unilateral L5 root lesion. The pre-operative T1-weighted 3D-MRI aiming bilateral L5 nerve roots of each patient were blinded and reviewed twice by five spine surgeons, independently. The image evaluation was performed in two conditions: (I) the symptomatic side was judged in 30 patients of LFS patients, and (II) the symptomatic side or the absence of LFS was judged in images of all the 54 patients including LFS and ICS patients. The correct-answer-rate, sensitivity and specificity of the imaging study were calculated. Also, the intra- and interobserver agreement of the imaging study by five spine surgeons were evaluated by the kappa (κ) statistics.

RESULTS

For conditions (I) and (II) above, the mean correct-answer-rate was 92.3% and 69.8%, respectively. The sensitivity and specificity of the imaging study was 72.6% and 66.3%, respectively. The average of intraobserver κ-value of five examiners was 0.874 and 0.708, and the average of interobserver κ-value was 0.837 and 0.578, respectively.

CONCLUSIONS

As well as previously reported T2-weighted 3D-MRI, our T1-weighted 3D-MRI was found to be reliable in diagnosing LFS of the L5 root.

The Effect of the COVID-19 Pandemic on South Korea's Stock Market and Exchange Rate

This study examines COVID-19 pandemic effects on the stock market and exchange rate of South Korea. With daily data from January 2, 2019 to August 31, 2020, we show that a new infection spike increases stock price index volatility and decreases foreign investors' holdings of domestic stocks, and indirectly leads to the depreciation of the South Korean won. We indicate that investors may have repurchased the South Korean won seven days after an infection spike, thereby slightly increasing its value. We also find that the Bank of Korea's foreign exchange intervention had a short-run effect with a limited impact. The intervention did not have a significant effect on exchange rate volatility.

Reoperation Rates after Laminoplasty for Cervical Disorders: A 26-Year Period Survival Function Method Analysis

Introduction

Laminoplasty is a common surgery for cervical myelopathy. Previous studies have analyzed the reoperation rates in posterior decompression surgeries of the cervical spine. However, few studies have solely focused on midline-splitting laminoplasty (MSL) using a large number of patients. This aims to analyze the reoperation rates after MSL using the survival function method.

Methods

Between 1988 and 2013, 4,208 MSLs were performed as a primary operation for cervical myelopathy and enrolled in our spinal surgery registration system. The Kaplan-Meier survival function method was used to analyze the rates of reoperation.

Results

Of 4,208 patients with primary MSL, 40 underwent reoperation for neurological complications. The overall reoperation rate was 0.26%, 0.64%, 0.83%, 0.93%, and 0.95% at 1, 5, 10, 20, and >20 years, respectively. The causes of reoperation were postoperative cervical radiculopathy in 10 patients, stenosis at an adjacent level in 8, stenosis due to failed “open-door” lamina in 6, instability of the cervical spine in 4, cervical disc herniation in 3, elongation of ossification of the posterior longitudinal ligament in 3, spinal cord injury in 1, fracture of the cervical spine in 1, postoperative scar formation in 1, ossification of anterior longitudinal ligament in 1, and unknown in 2. The number of patients with surgical site infection (SSI) who needed surgical debridement was 34 (0.81%).

Conclusions

Excluding reoperations for SSI, the reoperation rate of MSL was approximately 1.0% at the maximum of 26 years after surgery. MSL was determined to be a reliable surgical procedure regarding postoperative complications requiring additional surgeries.

Lumbosacral Transitional Vertebrae Cause Spinal Level Misconception in Surgeries for Degenerative Lumbar Spine Disorders

Human lumbar spine usually consists of five vertebrae; however, some individuals have vertebral anomalies with four or six lumbar vertebrae because of sacralized fifth lumbar vertebra (L5 sacralization) or lumbarized first sacral vertebra (S1 lumbarization), respectively. These vertebral anomalies are called lumbosacral transitional vertebra (LSTV). Although LSTV is an asymptomatic anomaly, it is known to cause misconception in spinal counts and in spinal level at lumbar spinal surgery. The purpose of this study is to evaluate how LSTV affects the diagnosis and surgeries in lumbar spine disorders. In 550 consecutive patients who underwent lumbar spinal surgeries, a whole-spine X-ray was taken on admission to assess the true number of lumbar vertebrae. We assessed the coherence between the neurological level diagnosis and the level of spinal canal stenosis on imaging studies before and after the recognition of LSTV to clarify how recognition of LSTV affected pre-operative surgical planning. Out of 550 patients, LSTV was found in 71 (12.9%) patients: 37 cases with L5 sacralization and 34 cases with S1 lumbarization. The number of vertebrae was miscounted at the outpatient department (OPD) in 38 cases (54%): 10 L5-sacralization cases and 28 S1-lumbarization cases. Moreover, surgical spinal levels were altered from the original surgical plans at OPD in 11 cases (15%; 3 L5-sacralization and 8 S1-lumbarization cases), after recognizing the true spinal counts by the whole spine X-ray. To avoid errors in spinal level diagnosis, we should recognize the possibility of LSTV that could be assessed by a whole spine X-ray.

Rate of spinal surgery in a rapidly aging society: the 27-year changes in Miyagi prefecture, Japan

BACKGROUND

Japan has had a rapidly aging population during the past 30 years. This study aimed to investigate longitudinal changes in the surgical rate for spinal disorders in Miyagi Prefecture (2.35 million inhabitants) with a similar population composition to Japan.

METHODS

Data of spinal surgeries were collected using the spine registry by Tohoku University Spine Society. Data on the annual number of spinal surgeries between 1988 and 2014 of all populations, in those aged ≥65 years old, in those aged ≥75 years old, and for each pathology were collected. The annual surgical rate per 100,000 inhabitants was calculated.

RESULTS

The surgical rate in 2010-2014 in total, at ≥65 years old, and at ≥75 years old showed 3.2-, 3.8- and 7.1-fold increases, respectively, compared with that in 1988-1989. Degenerative spinal disorders, spinal trauma and pyogenic spondylitis markedly increased, while metastatic spinal tumor and tuberculous spondylitis decreased over time. The surgical rate at ≥75 years with lumbar spinal stenosis showed a 12.6-time increase.

CONCLUSIONS

During a rapid period of aging, the rate of spinal surgeries has markedly increased, particularly, that for degenerative disorders. This is the first report on the long-term longitudinal changes in the rate of spinal surgery.

Elderly-onset degenerative "lumbar spondylotic myelopathy" in a patient with a low-placed spinal cord successfully treated by laminotomy: a case report

The authors report a rare case of elderly-onset "lumbar spondylotic myelopathy" occurred on a low-placed spinal cord compressed at multiple levels with thickened ligamenta flava. A posterior decompression surgery could alleviate neurological symptoms successfully instead of untethering of the spinal cord, a widely accepted surgery for tethered cord.

Bilateral spondylolysis of inferior articular processes of the fourth lumbar vertebra: a case report

Lumbar spondylolysis, a well known cause of low back pain, usually affects the pars interarticularis of a lower lumbar vertebra and rarely involves the articular processes. We report a rare case of bilateral spondylolysis of inferior articular processes of L4 vertebra that caused spinal canal stenosis with a significant segmental instability at L4/5 and scoliosis. A 31-year-old male who had suffered from low back pain since he was a teenager presented with numbness of the right lower leg and scoliosis. Plain X-rays revealed bilateral spondylolysis of inferior articular processes of L4, anterolisthesis of the L4 vertebral body, and right lateral wedging of the L4/5 disc with compensatory scoliosis in the cephalad portion of the spine. MR images revealed spinal canal stenosis at the L4/5 disc level. Posterior lumbar interbody fusion of the L4/5 was performed, and his symptoms were relieved.

Cervical myelopathy due to degenerative spondylolisthesis

OBJECTIVE

To investigate clinical-radiological features of cervical myelopathy due to degenerative spondylolisthesis (DSL).

METHODS

A total of 448 patients were operated for cervical myelopathy at Nishitaga National Hospital between 2000 and 2003. Of these patients, DSL at the symptomatic disc level was observed in 22 (4.9%) patients. Clinical features were investigated by medical records, and radiological features were investigated by radiographs.

RESULTS

Disc levels of DSL were C3/4 in 6 cases and C4/5 in 16 cases. Distance of anterior slippage was 2 to 5 mm (average 2.9 mm) in flexion position. Space available for the spinal cord (SAC) was 11 to 15 mm (average 12.8 mm) in flexion position and 11 to 18 mm (average 14.6 mm) in extension position; 11 cases were reducible and 11 cases were irreducible in extension position. Myelograms demonstrated compression of spinal cord by the ligamentum flavum in extension position. Compression of spinal cord was not demonstrated in flexion position. C5-7 lordosis angle was lower than control. C5-7 range of motion (ROM) was reduced compared to controls. These alterations were statistically significant.

CONCLUSIONS

DSL occurs in the mid-cervical spine. Lower cervical spine demonstrated restricted ROM and lower lordosis angle. Pathogenesis of cervical myelopathy due to DSL is compression of spinal cord by the ligamentum flavum in extension position and not by reduced SAC in flexion position.

Eighteen microsatellite loci in Salix arbutifolia (Salicaceae) and cross-species amplification in Salix and Populus species

Salix arbutifolia is a riparian dioecious tree species that is of conservation concern in Japan because of its highly restricted distribution. Eighteen polymorphic loci of dinucleotide microsatellites were isolated and characterized. Among these, estimates of the expected heterozygosity ranged from 0.350 to 0.879. Cross-species amplification was successful at 9-13 loci among six Salix species and at three loci in one Populus species.

Spine-shortening vertebral osteotomy in a patient with tethered cord syndrome and a vertebral fracture

The authors report a rare case of tethered cord syndrome with low-placed conus medullaris complicated by a vertebral fracture that was successfully treated by a spine-shortening vertebral osteotomy. The patient was a 57-year-old woman whose neurological condition worsened after a T-12 vertebral fracture because a fracture fragment and the associated local kyphotic deformity directly compressed the tethered spinal cord. An osteotomy of the T-12 vertebra was performed in order to correct the kyphosis, remove the fracture fragment, and reduce the tension on the spinal cord. Postoperative radiographs showed the spine to be shortened by 22 mm, and the kyphosis between T-11 and L-1 improved from 23° to 0°. Two years after the surgery, the patient's neurological symptoms were resolved. The bone union was complete with no loss of correction.

Sagittal alignment changes after thoracic laminectomy in adults

Object

The increased kyphosis after thoracic laminectomy in adult patients was retrospectively evaluated and various factors affecting this spinal deformity were analyzed.

Methods

The authors conducted a retrospective study of 58 cases in which laminectomy was performed and more than half of the facet joints were left intact. The study group included 44 men (mean age 59 years) and 14 women (mean age 61 years) with thoracic myelopathy due to ossifications of the ligamentum flavum and/or the posterior longitudinal ligament or due to posterior bone spurs. Patients were followed up for a minimum of 2 years. Their neurological condition was evaluated using the Japanese Orthopaedic Association (JOA) scale (a full score is 11), and the magnitude of local kyphosis in the laminectomized area was determined using the Cobb angle method.

Results

The mean preoperative JOA score was 5.4; the mean postoperative score was 8.3. No relationship was found between postoperative JOA score and increased kyphotic angle. The mean preoperative kyphotic angle was 7.0°. The mean postoperative kyphotic angle was 10.8°. Thus local kyphosis in the treated area increased by only 3.8°. The mean increase in kyphosis per spinal segment, calculated by dividing the kyphotic angle of the surgically decompressed area by the number of resected laminae, was 1.9°. Female patients with ≥ 3-level laminectomies showed a significant increase of kyphosis in both the laminectomized area and each spinal segment.

Conclusions

The increase in kyphosis after thoracic laminectomy is not large and thus spinal fusion is usually not necessary. In cases involving female patients who undergo long-segment laminectomies, however, careful radiographic follow-up is recommended.

Spinal dumbbell tumors: an analysis of a series of 118 cases

Object

The authors analyzed a series of 118 cases of spinal dumbbell tumors to elucidate the feature of the tumors.

Methods

Of 674 cases of spinal cord tumors, the incidence of dumbbell tumors was studied. The tumors were analyzed, and the authors focus on the distribution of age and sex, the pathological diagnoses, their locations, Eden classification, and the surgical methods used.

Results

The incidence of dumbbell tumors was 18%. The mean patient age was 43 years, which was younger than that for all spinal cord tumors (mean 50 years). There were 11 patients younger than 10 years of age. The rate of dumbbell tumors in the cervical spine was significantly higher than that of all spinal cord tumors. Fifteen (18%) of the 81 schwannomas were observed in the C-2 nerve root, thus having a higher incidence than those in the other nerve roots. In 99 cases (84%), the tumors were removed through a hemilaminectomy with or without a facetectomy and posterior fusion. Of 118 cases, 69% of the tumors were schwannomas, and malignant tumors were found in 10 cases (8.5%). Seven (64%) of 11 patients younger than 10 years of age had malignant tumors. Three patients older than 10 years of age had malignant tumors, thus accounting for 2.8% of the 107 older patients.

Conclusions

The incidence of dumbbell tumors was 18%, and they are not uncommon. Malignant dumbbell tumors were more common in children younger than 10 years of age than in older patients.

Thoracic myelopathy in Japan: epidemiological retrospective study in Miyagi Prefecture during 15 years

Thoracic myelopathy is defined as spinal cord compression in the thoracic region, leading to sensory and motor dysfunctions in the trunk and lower extremities, and can be caused by various degenerative processes of the spine. Thoracic myelopathy is rare, and there are many unsolved problems including its epidemiological and clinical features. We have established a registration system of spinal surgeries, which covered almost all surgeries in Miyagi Prefecture, and enrolled the data of 265 patients with thoracic myelopathy from 1988 to 2002. The annual rate of surgery gradually increased and averaged 0.9 per 100,000 inhabitants, which was less than 1/10 of that for cervical myelopathy. About 20 patients with thoracic myelopathy are operated on in Miyagi Prefecture each year. It frequently develops in middle-aged males. About half of the cases were caused by ossification of the ligamentum flavum, followed by ossification of the posterior longitudinal ligament, intervertebral disc herniation and posterior spur. Patients usually noticed numbness or pain in the legs and the preoperative duration was long, averaging 2 years. Its symptomatic similarities to lumbar disorders might cause difficulty in making a correct diagnosis. Since thoracic myelopathy can markedly restrict the activities of daily life, even general physicians should recognize this entity.

Flexion-distraction injuries in the thoracolumbar spine: an in vitro study of the relation between flexion angle and the motion axis of fracture

A new concept, the motion axis of fracture (MAF), which is defined as the transitional point from anterior compressive to posterior splitting failure on a lateral radiograph, has provided a true understanding of the mechanisms of flexion-distraction injuries in clinical cases. This study was designed to produce in vitro injuries that have MAFs and to clarify the relation between the flexion angle and the MAF location. Adolescent porcine thoracolumbar spines were exposed to a vertical compressive load to failure at three different flexion angles and then examined radiographically. The MAF location was recorded as the distance from the anterior border to the MAF expressed as a percentage of the anteroposterior diameter of the vertebral body. All specimens showed similar injuries, with MAFs consisting of anterior compression fractures in the vertebral bodies and posterior disruptions. A significant negative correlation emerged between the flexion angle and the MAF location (r = -0.890; p < 0.0001). These results suggest that even a vertical compressive load contributes to the production of a flexion-distraction injury with an MAF in the thoracolumbar spine. They also indicate that the flexion angle of the spine at which the vertical compressive load is applied is an important factor in determining the MAF location; that is, the larger the flexion angle, the more anterior the MAF.

A case of duodenal involvement of multiple myeloma imaged by positron emission tomography with 18F-fluorodeoxyglucose

A 61-year-old woman had been treated for multiple myeloma for 4 years when she developed abdominal pain. Ultrasonography and computed tomography revealed a tumor in the abdomen. Positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) showed increased FDG uptake in the tumor. In previous bone marrow lesions, which were in clinical remission after chemotherapy and radiotherapy, abnormal FDG uptake was not recognized. Pathological examination after surgery revealed the tumor to be a plasmacytoma of the duodenum. Plasmacytoma of the duodenum is rare but can be seen during the clinical course of multiple myeloma. A few reports have described FDG PET findings of plasmacytoma. Those previous reports and our present case suggest a potential value of FDG PET in the evaluation of multiple myeloma.

Proximal gastrectomy and jejunal pouch interposition: evaluation of postoperative symptoms and gastrointestinal hormone secretion

Reflux esophagitis, dumping syndrome and malnutrition are included in the postgastrectomy complications. To prevent or minimize such sequelae, proximal gastrectomy with an interposed jejunal pouch has been advocated as an organ-preserving surgical strategy to improve quality of life for the patients. Proximal gastrectomy was performed in 44 patients with tumors in the upper third of the stomach; 21 had reconstruction using jejunal pouch interposition between the esophagus and the remnant stomach (JP group), while 23 had reconstruction by esophagogastrostomy (EG group). Re-construction method was selected by each patient on the basis of the informed consent. Thirty-five patients had early gastric cancer. Postoperative courses of patients were reviewed in terms of symptoms, weight maintenance, nutritional status, blood chemistry values, endoscopic findings, and radiographic appearances after a barium meal. Concentrations of gastrointestinal hormones were measured in response to a test meal. The JP procedure permitted increased dietary volume. The JP group showed fewer severe postoperative symptoms than the EG group. After operation, all patients examined in both groups showed hypergastrinemia and all patients examined in the JP group showed hypersecretinemia. In proximal gastrectomy, the JP procedure improved patient's post-operative quality of life.

[Effects of body control and attention on body sway induced by a tilting room]

The purpose of this study was to examine the effects of body control and attention on body sway that was induced by a "tilting room". With an initial instruction, 18 subjects were divided into two groups: target and body attention groups, and then stood on a stabilometer in a room that tilted forwardly. Body sway that was induced by the tilting room was measured with the stabilometer. During the training session, subjects received Dohsa training (Naruse, 1973) in order to control their body movement. Analyses indicated the following: (1) Subjects swayed in the same direction as tilting of the room; (2) No difference in the body sway was found for the two groups before training; and (3) After training, subjects increased the controllable area on the stabilometer and learned to use their bodily sensation better. Subjects in the target attention group had a greater increase in body sway than the other group. These results suggest that adult flexibility appeared in an ecological situation where conflicting information was received through visual and bodily sensation.

[The effect of alpha-glucosidase inhibitor on burning epigastralgia in dumping syndrome: a case report]

Dumping syndrome results from a rapid passage of carbohydrate in the small intestine after gastric surgery. A 50-year-old man developed the syndrome after surgery for peptic ulcer. He often complained of burning epigastralgia after meals. Various methods of treatment had only a limited effect. Acarbose, alpha-glucosidase inhibitor, suppresses the breakdown of carbohydrates in the small intestine and consequently reduced osmolarity. The patient had a dramatic improvement in the dumping syndrome including epigastralgia, diarrhea and perspiration with an administration of acarbose 50 mg. There was no intractable side effect. Preprandial administration of acarbose is a reasonable treatment in the case of dumping syndrome.

[Expression of human papillomavirus (HPV) gene in HPV-positive laryngeal tumors and activity of the HPV long control region in cultured normal laryngeal epithelial cells]

Expression of the human papillomavirus (HPV) gene was examined in HPV-positive laryngeal tumors. Moreover, the activity of the HPV long control region (LCR) was tested in cultured laryngeal epithelial cells. HPV-11 early genes were heterogeneously expressed in adult laryngeal papillomas. We found one laryngeal carcinoma case in whom the HPV-16 transforming genes, E6 and E7, were expressed. Both HPV-11 and -16 LCRs were active in cultured laryngeal epithelial cells from vocal cords. These results suggest that laryngeal epithelial and tumor cells are target cells for HPV gene expression.

Quantitative analysis of platelet-activating factor in rat brain

Age-related decrease of the platelet-activating factor (PAF) content in rat brain was shown by a convenient method consisting of solid extraction of lipids with a Sep-Pak C-18 cartridge, lipid separation by HPLC and bioassay on rabbit platelets. This method was sufficiently sensitive to allow measurement of PAF in a single brain, and the recovery of PAF was quite high throughout the procedure.

[Detection of human papillomavirus DNA in hypopharyngeal carcinoma]

The detection of human papillomavirus type-16 and -6b was performed in 28 cases of hypopharyngeal squamous cell carcinomas by polymerase chain reaction. Human papillomavirus (HPV) DNAs extracted from paraffin-embedded metastatic lymph node tissue were used for polymerase chain reaction with amplification of the E1 region of HPV genotype 6b and the E6 region of HPV genotype 16. HPV type 6b sequences were detected in three cases; positive amplification of type 16 sequences was also seen in three cases. These findings suggest that HPV infection might be closely associated with the development of some hypopharyngeal carcinomas as it is with laryngeal and uterine cervical carcinogenesis.

Detection of Epstein-Barr virus DNA in formalin-fixed paraffin-embedded tissue of nasopharyngeal carcinoma using polymerase chain reaction and in situ hybridization

The polymerase chain reaction method for amplification of DNA in formalin-fixed, paraffin-embedded tissue sections was used to detect Epstein-Barr virus DNA in nasopharyngeal carcinomas from Japanese patients. Thirty-one cases of nasopharyngeal carcinoma and 8 cases of lymph node metastasis of nasopharyngeal carcinoma were studied. Detection rates of Epstein-Barr virus in various types of nasopharyngeal carcinoma according to the World Health Organization classification were as follows: 10 of 10 undifferentiated carcinomas, 8 of 13 nonkeratinizing carcinomas, and 5 of 7 keratinizing carcinomas. Eight lymph node metastases, for which the primary was positive for Epstein-Barr virus, also contained Epstein-Barr virus DNA. By in situ hybridization using a biotinylated Epstein-Barr virus probe, it was clearly demonstrated that Epstein-Barr virus DNA was localized in the nuclei of the neoplastic cells. The clinical features of nasopharyngeal carcinoma with or without Epstein-Barr virus were not different. These results demonstrate that nasopharyngeal carcinoma in Japanese patients is closely associated with Epstein-Barr virus infection, similar to nasopharyngeal carcinoma of other endemic and nonendemic areas.

Effects of attention and expectation on tickle sensation

The purpose of the present study was to examine the changes of the tickle sensation reflected in effects of the direction of attention to one's own body (Exp. 1) and the expectation of the experimenter's gestures (Exp. 2). In Exp. 1, for 15 subjects, when tickled on their own foot soles, the tickle sensation was not significantly changed by attending to the stimulus and to one's own sole. These results suggested the importance of instructions. In Exp. 2, 6 subjects were tickled and were required to report their experience while they looked at the experimenter's gestures and were tickled. Although the subjects' stimulations were unaffected by looking at the gestures, the tactual stimulus elicited a tickle sensation. From these results, quantitative and qualitative differences in subjects' tickle sensation may be identified.

Detection of human papillomavirus DNA in laryngeal squamous cell carcinomas by polymerase chain reaction

The presence of human papillomavirus genomes-16 and -6b in metastatic cervical lymph nodes was examined in 34 cases of laryngeal carcinomas by means of polymerase chain reaction, which had been fixed in formalin and embedded in paraffin. Human papillomavirus DNAs extracted from paraffin-embedded tumor tissues were used for polymerase chain reaction with amplification of the E6 region of human papillomavirus genome-16 and the E1 region of human papillomavirus genome-6b. Human papillomavirus genome-16 sequences were positively amplified in six (17.6%) metastatic tumors; -6b sequence was positively amplified in one (2.9%) metastatic tumor. Laryngeal carcinomas of glottic origin showed high human papillomavirus genome-16 DNA-positive rates (4 of 9 cases, 44.4%) compared to those of other sites. These results suggest that human papillomavirus genome-16 infection might be closely associated with the development of some laryngeal squamous cell carcinomas of glottic origin similar to uterine cervical carcino-genesis.

Detection of Epstein-Barr virus DNA in Reed-Sternberg cells of Hodgkin's disease using the polymerase chain reaction and in situ hybridization

Thirty-one cases of Hodgkin's disease were examined for the occurrence of Epstein-Barr virus (EBV) genome by using the polymerase chain reaction (PCR) of DNA in formalin-fixed paraffin-embedded tissues and in situ hybridization technique. The cases were subdivided into 17 cases of nodular sclerosis (NS), nine cases of mixed cellularity (MC), four cases of lymphocyte predominance (LP), and one case of lymphocyte depletion (LD). EBV DNA was detected in eight cases including four cases of NS, three cases of MC and one case of LP. The sensitivity of PCR was higher than that of Southern blot hybridization of DNA from fresh frozen tissue, because Southern blot hybridization using the BamHI-W fragment of EBV detected virus DNA only in two of three cases which were positive by PCR. The results of in situ hybridization studies confirmed that EBV genome was localized within the nuclei of Reed-Sternberg (RS) cells and their mononuclear variants. Furthermore, double-labeling studies combining in situ hybridization and immunocytochemistry using CD30 (BerH2) and CD15 (LeuM1) as markers of RS cells, as well as pan B-marker (L26) and pan T-marker, CD45RO (UCHL1), were performed to demonstrate the phenotype of EBV DNA-positive cells, confirming that EBV DNA was present in RS cells but not in lymphocytes. The results of this study indicate a significant association between EBV and some cases of Hodgkin's disease.

[Plasma and tumor gastrin in patients with primary hyperparathyroidism]

It is well known that primary hyperparathyroidism is often associated with peptic ulcer. The purpose of this study is to confirm the relationship between the gastrin-levels before and after parathyroidectomy in fourteen patients with primary hyperparathyroidism, and to determine the localization of gastrin in the surgically resected parathyroid tumor. The results obtained were as follows: 1) Three patients had peptic ulcer (gastric ulcer and duodenal ulcer), the incidence being 21%. 2) The basal serum gastrin levels were 123.0% +/- 68.1 pg/ml before operation and decreased to 90.2 +/- 44.5 pg/ml after operation. In the 3 patients with slightly elevated gastrin levels, the mean level before operation was 209.1 +/- 61.2 pg/ml. The gastrin level decreased to 116.4 +/- 62.0 pg/ml after operation. 3) Gastrin immunoreactivity was detected in 10 out of 14 tumors and its localization was at the periphery of tumor cells. From these results, we conclude that extragastric gastrin secretion from parathyroid tumors may be one of the cause of peptic ulcer in patients with primary hyperparathyroidism.

Heart rate and metabolic responses to participation in golf

Five healthy middle-aged men were asked to perform 18 holes of golf. Heart rate was measured throughout the play, and blood samples were compared before and after play. Oxygen uptake during play was estimated from their heart rate response during a treadmill-walking test. Mean heart rate was 108 (range 92-121) beats/min, which corresponded to 38 (range 35-41) %VO2max. Caloric cost of golf is 4-6 kcal/min and total energy expenditure was estimated more than 960 kcal during 18 holes. Blood glucose decreased and FFA increased following 18 holes of play. Golfing seems to be a suitable sport for middle-aged and elderly persons to enhance energy expenditure.

[A case of small cell carcinoma of the esophagus]

The case of a 51-year-old man, complaining of a sense of pressure on his chest, is reported. Tests led to a diagnosis of a cancer in the midesophagus and a subtotal esophagectomy was performed. The tumor was found to be a protruded type, 8.5 X 7.0 cm in size. A histologic diagnosis revealed it to be a small cell anaplastic carcinoma. The tumor cells were found negative in a Grimelius staining and did not contain hormones such as ACTH. Some cytokeratins, however, were detected by an immunohistochemical examination, Cancer invasion into the adventitia was seen, though no lymph node metastasis or a distant metastasis was shown. Six months after operation, a recurrence in the mediastinum and in the distant lymph nodes was found. Chemotherapy and irradiation were found to be useful, and the postoperative survival period was 25 months.

[Surgical problems of Kock's continent ileostomy in patients with ulcerative colitis]

Postoperative problems including pathophysiology at follow up were investigated in Kock's continent ileostomy in patients with ulcerative colitis. The results obtained were as follows: Though postoperative complication was found in all 4 cases, it was improved in 3 of them by conservative or surgical treatment. Troublesome skin irritation, such as erosion or ulcer, was not found in any case. The patients empty the reservoir when it is convenient and intestinal discharge was 1 to 4 times per day and these results were proved from the studies of the pressure and capacity in the Kock's ileostomy. Various plasma amino acids in patients with Kock's ileostomy showed almost similar levels to those of the normal subjects. Bacteriological examination in the stool in Kock's ileostomy also revealed almost similar results to those of the normal subjects. From these results, we conclude that Kock's continent ileostomy should be more widely performed for the patients with ulcerative colitis when ileostomy is required.

[The concentration of cefmenoxime after intravenous drip infusion in digestive organs and exudates from abdominal and thoracic cavities in human]

We investigated the concentrations of cefmenoxime (CMX) after administration of 2 g of CMX, in the tissues resected during operation 2 hours after the beginning of intravenous drip infusion, and in the exudates from abdominal or thoracic cavities in the postoperative period. The results were as follows: The highest tissue concentration of CMX was found in the liver (59.0 +/- 20.3 micrograms/g), and the lowest was in the pancreas (13.9 +/- 8.1 micrograms/g). The concentrations of CMX in the tissues were in order of liver much greater than colon = esophagus = stomach greater than pancreas. The peak concentration of CMX in exudate from thoracic cavity was 15.6 +/- 10.1 micrograms/ml, and was observed 2 hours after the beginning of intravenous drip infusion, later than that in serum. Furthermore, the concentration of the exudate was maintained to a reasonable extent for 5 hours. The concentrations of CMX in both tissues and exudates were enough to inhibit the growth of many kinds of bacteria isolated from abdominal infections.