Radiological image features of the atypical teratoid/rhabdoid tumor in adults: a systematic review

PURPOSE

Atypical teratoid/rhabdoid tumor (AT/RT) occurs in children less than 3 years old, and has a very poor prognosis. AT/RT seldom occurs in adult. We have experienced four cases of AT/RT at our institute. The purpose of this study is to evaluate the radiological image findings of adult-onset AT/RT and to conduct a systematic review.

METHODS

Image findings of four AT/RTs in our institute were retrospectively evaluated by an experienced neuroradiologist. If the images were unavailable, image findings were evaluated from the former image interpretation report. We assembled papers of adult-onset AT/RT (n = 38) and evaluated the image findings.

RESULTS

AT/RT occurs in a variety of sites (spinal region, pineal region, suprasellar region, jugular foramen, and so on). High density on computed tomography (CT) was seen in 10 of 11 cases; mixed intensity in T2-weighted image was seen in 13 of 18 cases; and high intensity on diffusion-weighted image (DWI) was seen in 3 of 3 cases. Contrast enhancement was observed in all cases in which images were available.

CONCLUSIONS

We have experienced four adult-onset AT/RT cases at our institute and have evaluated image findings through systematic review. The image findings of high density on CT, high intensity on DWI, with low apparent diffusion coefficient, and a heterogenous component should lead to an inclusion of AT/RT in the differential diagnosis of a tumor; these findings may be able to suggest AT/RT; however, they cannot make the diagnosis.

Visualization of the trochlear nerve in the cistern with use of high-resolution turbo spin-echo multisection motion-sensitized driven equilibrium

BACKGROUND AND PURPOSE

The trochlear nerve is so thin that it is rarely observed with MR imaging. Therefore, we used high-resolution MSDE to reliably visualize the cisternal segments of the trochlear nerve.

MATERIALS AND METHODS

Participants were 10 healthy young adults (mean age, 24 years), and 20 trochlear nerves were examined. HR-MRC, BS-MRC, and HR-MSDE were performed. A neuroradiologist judged the visibility of the trochlear nerves as 1 of 4 grades ("Excellent," "Good," "Fair," and "Not") in each MR imaging sequence. The findings were then statistically analyzed with the χ(2) test.

RESULTS

Of all 20 trochlear nerves, 6 with HR-MRC, 13 with BS-MRC, and 18 with HR-MSDE were judged as "Excellent." CSF flow-related artifacts and vessels in the cistern and cerebellar tentorium in HR-MRC tended to prevent the neuroradiologists from identifying the trochlear nerve. Vessels in the cistern and cerebellar tentorium in BS-MRC also tended to prevent the neuroradiologists from identifying the trochlear nerve. Compared with other sequences, HR-MSDE visualized the trochlear nerve more often. The χ(2) test revealed statistically significant differences among the 3 MR imaging sequences (P < .01). The scan time of HR-MSDE was approximately 1.5-2.2 times longer than that of the other sequences.

CONCLUSIONS

HR-MSDE is able to clearly visualize the trochlear nerve and has the same or better ability to delineate the trochlear nerve compared with other MR imaging sequences, though its long scan time does not yet yield practical use.

Influence of deteriorating ability of emotional comprehension on interpersonal behavior in Alzheimer-type dementia

This study investigated the relationship between the ability to recognize emotion and interpersonal behavior in dementia of the Alzheimer type (DAT). After examining the validity and reliability of the Emotion Recognition Test (ERT), an improved version of the tasks used by Shimokawa et al. (2000), 100 patients with DAT underwent evaluation for general cognition using the Mini-Mental State Examination (MMSE) and emotion recognition using the ERT. Within a week of these tests being administered, ward staff rated the patients using the Interpersonal Behavior Checklist (IBC), composed of two behavior scales: indifference to interpersonal relationships and difficulties with patient treatment/management. After investigating the validity and reliability of the scales, the correlations between the MMSE, the ERT, and the two scales of the IBC were calculated. The results suggested that the MMSE did not correlate with either of the two behavior scales, while the ERT correlated significantly with both of the scales. The study results lead to the conclusion that deteriorating emotion recognition ability, rather than deterioration of general cognition, influences the indifferent and awkward interpersonal behaviors of DAT patients.

Stretch and quick release of rat cardiac trabeculae accelerates Ca2+ waves and triggered propagated contractions

Rapid shortening of active cardiac muscle [quick release (QR)] dissociates Ca2+ from myofilaments. We studied, using muscle stretches and QR, whether Ca2+ dissociation affects triggered propagated contractions (TPCs) and Ca2+ waves. The intracellular Ca2+ concentration was measured by a SIT camera in right ventricular trabeculae dissected from rat hearts loaded with fura 2 salt, force was measured by a silicon strain gauge, and sarcomere length was measured by laser diffraction while a servomotor controlled muscle length. TPCs (n = 27) were induced at 28 degrees C by stimulus trains (7.5 s at 2.65 +/- 0.13 Hz) at an extracellular Ca2+ concentration ([Ca2+]o) = 2.0 mM or with 10 microM Gd3+ at [Ca2+]o = 5.2 +/- 0.73 mM. QR during twitch relaxation after a 10% stretch for 100-200 ms reduced both the time between the last stimulus and the peak TPC (PeakTPC) and the time between the last stimulus and peak Ca2+ wave (PeakCW) and increased PeakTPC and PeakCW (n = 13) as well as the propagation velocity (Vprop; n = 8). Active force during stretch also increased Vprop (r = 0.84, n = 12, P < 0.01), but Gd3+ had no effect (n = 5). These results suggest that Ca2+ dissociation by QR during relaxation accelerates the initiation and propagation of Ca2+ waves.

Analysis of the early blood kinetics of 99mTc-GSA and its verification: new one-compartment model and regression equation

Technetium-99m-galactosyl human serum albumin (99mTc-GSA) is a radiopharmaceutical that binds to asialoglycoprotein receptors in the hepatocyte membrane; the level of 99mTc-GSA accumulation in the liver correlates well with the parameters of hepatic function tests. We hypothesized that the early blood kinetics of 99mTc-GSA could be described by a simple one-compartment model expressed as an offset + a monoexponential function (y=y0 +Ae(-alpha)t). The aims of this study were to assess the validity of this hypothesis using sequentially measured blood levels of 99mTc-GSA, which were approximated by a regression expression, and to analyse the regression equation. 99mTc-GSA levels were measured in blood samples collected from 30 patients with liver disease. From sequential changes in radioactivity up to 30 min after injection, a regression equation expressed as an offset+ a monoexponential function was calculated and evaluated by multiple correlation coefficients and absolute deviations (% error). The liver uptake rate 15 min after injection of 99mTc-GSA (liver uptake rate 15, UTR 15) was calculated from the regression equation in each case. The respective relationships of this parameter to the coefficient [A] and gradient [alpha] were evaluated. In all cases, the measured values of radioactivity in blood samples could be fitted to an offset + a monoexponential function. The validity of our hypothesis was supported by examining regression equations calculated from blood 99mTc-GSA levels. Analysis of the regression equations suggested a potential for a new index of hepatic functional reserve.

Current status of bacterial contamination of autologous blood for transfusion

Autologous transfusion, although not without risk, does decrease the risk of transmitted diseases via homologous transfusion. However, strict quality control is required for autologous transfusion. In Japan, a recent enactment requires that written informed consent be obtained prior to blood transfusion, which therefore requires that clinicians provide sufficient explanation of the risks involved with this procedure. To the best of our knowledge, this is the first study to comprehensively evaluate the manner in which the safety of autologous blood transfusion can be compromised by bacterial contamination. For a 24-month period, between April 1996 and March 1998, bacterial contamination of all kinds of autologous blood samples was tested by sampling the culture immediately prior to transfusion. Subculturing, identification and susceptibility testing of the isolates were performed. From the 287 units of all kinds of autologous blood transfused, 18 were culture positive (6.3%). Positive blood cultures were obtained in two of the 59 units (3.4%) of autologous transfusion donated preoperatively (ATDP) that was infused intraoperatively, in three of the 117 units (2.6%) of hemodilution/autologous transfusion (HAT) and in three of the 81 (3.7%) of ATDP infused postoperatively. There was a high percentage (33.3%) of positive blood cultures in the cases of intraoperative blood salvage (IOBS). The total rate of positive blood cultures was 6.3% including IOBS and 3.1% excluding IOBS. The most common microorganism isolated from autologous blood was coagulase-negative Staphylococci in 12 of 18 culture-positive units (66.7%). Alpha Streptococcus uiridans was isolated in 2 units (11%) and Staphylococcus aureus was isolated in 1 unit (5.5%). However, none of the patients who received the culture-positive autotransfusion blood showed clinical signs or laboratory findings of bacteremia. Safe ATDP is threatened by bacterial contamination that can be introduced by numerous sources, such as the donors' blood, the skin at the site of venipuncture, the environment and the phlebotomist's finger. In the cases of IOBS, protection against bacterial contamination at the surgical site is crucial. Here we discuss the relevance of our findings to the efforts to minimize the risks of contamination associated with autologous blood transfusion; risks that must be communicated to the patient in the process of informed consent. Continued research is required to identify the safest method of autologous blood transfusion.

Abducens nerve enhancement demonstrated by multiplanar reconstruction of contrast-enhanced three-dimensional MRI

We describe contrast enhancement of the cisternal portion of the abducens nerve and discuss its clinical significance. We examined 67 patients with ophthalmoplegia using contrast-enhanced 3-dimensional (3D) MRI with multiplanar reconstruction along the nerves and found 16 patients (ten men, six women), aged 10-73 years (mean 34.4 years), with contrast enhancement of the abducens nerve. Of the 36 patients who had an abducens palsy, 14 (39%) showed contrast enhancement. In the 16 patients, 23 abducens nerves enhanced; 13 were symptomatic and 10 asymptomatic at the time. The causes were disseminated tumour (1), an inflammatory process (3), trauma (2), ischaemia (2) and autoimmune diseases (8), such as the Miller Fisher syndrome, acute ophthalmoparesis, polyneuropathy and multiple sclerosis. Abducens and/or oculomotor nerve enhancement was the only abnormality on MRI in the patients with traumatic or ischaemic neuropathy or autoimmune diseases. There were 14 patients who recovered fully within 1-6 months after treatment, and resolution of the enhancement correlated well with recovery.

Identification of the intraparotid facial nerve on magnetic resonance imaging

As a result of recent advances in magnetic resonance imaging (MRI) technology, direct imaging of the intraparotid facial nerve has become possible. The usefulness of MRI is well known in the diagnosis of parotid tumors. Using a 0.5 T midfield MR unit, this study aimed to visualize the intraparotid facial nerve in 5 normal volunteers and 14 patients with parotid tumors (on 24 normal sides and 14 affected sides). Under appropriate conditions for MRI, the facial nerve was detectable on 9 out of 10 affected sides and 17 out of 20 normal sides. The running course of the facial nerve was consistent with MRI findings in five patients who underwent surgery. The imaging conditions suitable for visualizing the intraparotid facial nerve are reported and the usefulness of MRI in the diagnosis of parotid tumors is discussed.

High-resolution computed tomography using multiplanar reconstruction for the facial nerve canal

Multiplanar reconstruction (MPR) images along the facial nerve canal were prepared with high-resolution computed tomography (HRCT) and their clinical usefulness was evaluated. Over a period of 6 years, temporal bone HRCT was performed on 628 cases. Of these cases, 6 patients exhibited facial nerve lesions, including facial nerve schwannoma (n = 3), traumatic facial nerve palsy (n = 2) and congenital facial nerve palsy (n = 1). Thirty patients without facial nerve lesions, such as chronic otitis media, were randomly selected as controls. Two types of MPR image were composed. One was along the labyrinthine and tympanic segment, and the other was along the tympanic and mastoid segment. Other MPR images, such as those along the facial nerve canal and bone fracture line, were composed as needed. All MPR images were prepared with real-time observation of delicate angles. In all cases, MPR images delineated the labyrinthine and tympanic segment in one image, and the tympanic and mastoid segment in another image. In two patients with traumatic facial nerve palsy, the MPR images revealed a relationship between the facial nerve canal and the bone fracture. In conclusion, MPR images of the facial nerve canal are easy to obtain and are useful in detecting facial nerve schwannoma, traumatic facial nerve palsy and congenital facial nerve palsy.

Relationship between clear cell/compact cell ratio and computed tomographic attenuation number in adrenocortical adenoma

Clear cell/compact cell ratio in histologic sections from 21 resected adrenocortical adenomas was assessed. Seven patients had Cushing's syndrome another 7 had primary aldosteronism caused by adrenal adenomas and 7 had non-hyperfunctioning adenomas. The results were correlated with the corresponding unenhanced CT attenuation numbers. There was a negative correlation between clear cell/compact cell ratios and unenhanced CT attenuation numbers. However, CT attenuation numbers did not show significant differences between cortisol-producing, aldosterone-producing and nonfunctioning adenomas. These facts suggest that clear cell/compact cell ratio in adrenocortical adenomas accounts for their attenuation number on unenhanced CT scans. However, it is difficult with the use of unenhanced CT attenuation numbers to differentiate cortisol-producing adenomas from aldosterone-producing and nonhyperfunctioning adenomas.

Effect of transient stretch on intracellular Ca2+ during triggered propagated contractions in intact trabeculae

Transient stretch of cardiac muscle during a twitch contraction may dissociate Ca2+ from myofilaments into the cytosol at the moment of quick release of the muscle. We studied the effect of stretch and quick release of trabeculae on changes in intracellular Ca2+ ([Ca2+]i) during triggered propagated contractions (TPCs). Trabeculae were dissected from the right ventricle of 9 rat hearts. [Ca2+]i was measured using electrophoretically injected fura-2. Force was measured using a silicon strain gauge and sarcomere length was measured using laser diffraction techniques. Reproducible TPCs (n = 13) were induced by trains of electrical stimuli (378 +/- 19 ms interval) for 7.5 s at [Ca2+]o of 2.0 mM (27.9 +/- 0.2 degrees C). The latency of the TPC force and the underlying increase in [Ca2+]i was calculated from the time (TimeF) between the last stimulus and the peak of TPC force (PeakF), or the time (TimeCa) between the last stimulus and the peak of the increase in [Ca2+]i during the TPCs (PeakCa). As a result of a 10% increase in muscle length for 150-200 ms during the last stimulated twitches, TimeF and TimeCa decreased and PeakF and PeakCa increased significantly (n = 13). In addition, transient stretch sometimes induced a twitch contraction subsequent to the accelerated TPC and its underlying increase in [Ca2+]i. These results suggest that Ca2+ binding and dissociation from the myofilaments by the stretch and quick release of muscle may modulate the TPC force and the underlying increases in [Ca2+]i and play an important role in the induction of arrhythmias.

TT virus mRNAs detected in the bone marrow cells from an infected individual

Although replicative forms of TT virus (TTV) DNA have been found in the liver and bone marrow cells, mRNAs of TTV have not yet been detected in these tissues. The entire nucleotide sequence of a TTV clone [TYM9 (3759 bases)] isolated from a patient with high TTV viremia (10(6) copies/ml) was determined, and the poly(A)(+) RNAs from bone marrow cells were subjected to reverse transcription-polymerase chain reaction with primers specific for the TYM9 sequence. Sequence analysis of the amplified products revealed the presence of three distinct species of spliced TTV mRNAs [2.9, 1.2, and 1.0 kilobases (kb)] with common 5' and 3' termini as well as splicing to bind nucleotide (nt) 181 to nt 283. The shorter mRNAs of 1.2 kb and 1.0 kb possessed another splicing to join nt 681 with nt 2341 or nt 2579. The transcription profile of TTV found in an infected human corroborates that observed in vitro.

[Clinical features of late onset dementia with Lewy bodies]

We conducted a retrospective study to elucidate clinical features of late onset dementia with Lewy bodies (DLB). Nineteen patients with DLB of neocortical category were neuropathologically diagnosed out of 500 consecutive autopsies at Yokufukai Hospital by using the pathological criteria of the consortium on DLB International Workshop. Medical history and clinical signs and symptoms were reviewed from the medical records. The age at onset was 55-88 years (mean 75.9 years), the age at death was 62-91 years, and duration of illness was 1-14 years. The initial symptoms were memory disturbance (10 cases), delirium (6 cases), gait disturbance (3 cases), visual hallucination (3 cases). We divided nineteen cases of DLB into two group: the age of onset was under 75 years (9 cases) and over 76 years (10 cases). The early onset group showed parkinsonism (67%), and visual hallucination (55%). The sensitivity of the clinical diagnosis of probable DLB based on DLB international workshop consensus criteria was 67%. On the other hand, the late onset group (10cases) presented with delirium (70%), parkinsonism (20%), and visual hallucination (30%). The sensitivity of a clinical diagnosis of probable DLB was 30%. Our results indicated considerable difficulty of the diagnosis of late onset DLB cases by the consensus criteria, requiring more sensitive criteria and diagnostic tests for DLB.

Comprehension of emotions: comparison between Alzheimer type and vascular type dementias

This study investigated the ability of recognizing emotion in dementia. Twenty-five patients with dementia of the Alzheimer type (DAT), 25 patients with vascular dementia (VD), and 12 normal control subjects were evaluated as to general cognition, visuoperception and emotion recognition. The score on the emotion recognition task significantly correlated with that of the Mini-Mental State Examination for VD patients while this was not the case for DAT patients. Moreover, VD patients performed significantly worse than DAT patients on the emotion recognition task in spite of the fact that there was no difference in the general cognitive and visuoperceptual abilities between them. The result of this study coupled with the past studies led to the hypothesis that the relationship between intellectual deficits and the deterioration in recognizing emotions differs according to type of dementia. Caregivers in nursing homes and hospitals need to take into account their patients' intellectual deficits but also their deteriorating ability of identifying emotions.

Replicative forms of TT virus DNA in bone marrow cells

TT virus (TTV) is a human virus consisting of a single-stranded, circular DNA genome of 3.8 kilobases (kb). To examine whether TTV replicates in peripheral blood mononuclear cells (PBMCs) and bone marrow cells (BMCs), DNA was extracted from the PBMCs and/or BMCs of six TTV-infected individuals and separated by agarose gel electrophoresis. The TTV DNAs from the PBMCs migrated to the 2.0- to 2.5-kb region. The TTV DNAs from the BMCs migrated to the 2.0- to 2. 5-kb and 3.3- to 6.1-kb regions. The faster-migrating TTV DNAs were sensitive to S1 nuclease, while the slower-migrating TTV DNAs were resistant and their position on the agarose gel shifted to the position of the full genomic size upon digestion with restriction enzyme PstI. Full-length inverted polymerase chain reaction on the slower-migrating, double-stranded TTV DNAs from the BMCs amplified a 3.8-kb product. Replicative intermediate forms of TTV DNA are present in BMCs but not in PBMCs.

[Regional cerebral blood flow of the basal ganglia and thalamus measured using Xe-CT]

Cerebral blood flow (CBF) images obtained using Xe-CT have a much higher spatial resolution than SPECT or PET images. The regional CBF (rCBF) of deep brain regions, the basal ganglia and thalamus, was able to be measured using Xe-CT in 6 subjects. Average rCBF was 87.1 +/- 20.7 ml/100 g/min in the caudate nucleus, 83.5 +/- 15.8 ml/100 g/min in the putamen, 50.0 +/- 8.7 ml/100 g/min in the globus pallidus and 88.9 +/- 12.4 ml/100 g/min in the thalamus. The average rCBF value of the globus pallidus was lower than the values of the caudate nucleus, putamen and thalamus. These observations may be explained by reduced cellularity of the globus pallidus in comparison to the other regions. SPECT and PET are not able to clearly demonstrate the globus pallidus on CBF images. However, precise rCBF values can be measured in the globus pallidus using Xe-CT.

Response to percutaneous transhepatic portal embolization: new proposed parameters by 99mTc-GSA SPECT and their usefulness in prognostic estimation after hepatectomy

Accumulation of 99mTc-galactosyl human serum albumin (GSA) in the liver correlates well with the parameters of hepatic function tests. We performed 99mTC-GSA SPECT before and after percutaneous transhepatic portal embolization (PTPE) to induce compensatory hypertrophy of the remnant lobe before extensive hepatic resection and analyzed the responses of new proposed parameters in the future remnant lobe that showed hypertrophy. The aim of this study was to evaluate the usefulness of these parameters in prognostic estimation after hepatectomy.

METHODS

We studied 10 patients with cholangiocarcinoma and 1 patient with metastatic liver tumor from sigmoid colon cancer. 99mTc-GSA SPECT was performed immediately before and 2 wk after PTPE. We analyzed the responses of the liver uptake ratio (LUR), functional volume (FV), and liver uptake density (LUD) in the future remnant lobe and evaluated their relationship with the prognosis after subsequent hepatic resection.

RESULTS

LUR and FV increased slightly but were not associated with the prognosis after hepatic resection. LUD increased significantly after PTPE in the group showing a good outcome after hepatic resection but decreased after PTPE in the group showing a poor outcome (post-PTPE LUD, 0.064+/-0.017%/cm3 versus 0.035+/-0.006%/ cm3, P<0.05; response rate, 22.2%+/-11.9% versus -8.9%+/-17.6%, P<0.01).

CONCLUSION

Responses of LUD to PTPE before hepatic resection in the future remnant lobe represent changes in asialoglycoprotein receptor activity per hepatocyte and predict responses to subsequent hepatic resection. LUD may be an important parameter for determining the outcome after hepatic resection.

Delayed adverse reactions to iodinated contrast media and their risk factors

PURPOSE

The present prospective survey was performed to obtain information on delayed adverse reactions (DARs) to five types of low-osmolar iodinated contrast media, including their frequency, common manifestations, and the patient's history of allergy.

METHODS

We investigated data from 15,890 consecutive patients who underwent contrast-enhanced computed tomography (CT) during a 15-month period. All patients were given a questionnaire asking about the occurrence of DARs, their symptoms and duration, and asked to consult a dermatologist if they had a skin reaction.

RESULTS

Of 11,121 patients who returned the questionnaire (response rate, 70.0%), DARs were observed in 1,058 patients (9.5%). DARs tended to occur with higher incidence in patients with no previous history of examinations using contrast media, with past adverse reactions caused by contrast media, with a history of allergy, or with a serum creatinine level greater than 2.0 mg/dl. Among the 331 patients who reported skin reactions, 41 patients consulted a dermatologist. Skin reactions were observed significantly more frequently in patients for whom iotrolan was used, and 60% of these reactions were severe or moderate.

CONCLUSIONS

Four risk factors for DARs were identified in the present investigation.

[The efficacy of SEMS for malignant upper gastrointestinal stenosis, evaluated by a "home index"]

We used a self expandable metalic stent (SEMS) on 24 patients (average age 68.6 years, 20 males, 4 females) with malignant upper gastrointestinal stenosis from August, 1997 to March, 1999. The primary diseases of the 24 patients were gastric cancer (13 cases: 54%), esophageal cancer (10 cases: 42%) and paraesophageal lymph node metastasis of breast cancer (one case: 4%). In this study, we present a "Home Index" as an indicator to evaluate a patient's quality of life, and investigated the efficacy and problem of SEMS.

Quasispecies of TT virus (TTV) with sequence divergence in hypervariable regions of the capsid protein in chronic TTV infection

Three hypervariable regions were identified in a central portion of open reading frame 1 of TT virus DNA, which codes for a putative capsid protein of 770 amino acids. TT virus circulates as quasispecies, with many amino acid substitutions in hypervariable regions, to evade immune surveillance of the hosts and to establish a persistent infection.

Analysis of liver single photon emission computed tomography in a case of fulminant hepatic failure

Fulminant hepatic failure is associated with a high mortality rate. Thus, accurate assessment of hepatic functional reserve and hepatic regeneration is important. We describe a 67-year-old woman who survived subacute hepatic failure. We had an opportunity to monitor the clinical course of the patient using single photon emission computed tomography (SPECT) with 99mTc-galactosyl-human serum albumin (99mTc-GSA) and frequent hematological examinations. On admission, prothrombin time was remarkably prolonged (23.1% of control). The liver uptake of 99mTc-GSA was also considerably low. She responded well to treatment. Four weeks after admission, SPECT analysis showed a dramatic increase in liver uptake of 99mTc-GSA, suggesting promotion of hepatic regeneration. Moreover, functional liver volume calculated from the SPECT data showed a marked increase at 4 weeks after admission, whereas CT scan showed no change at that point. This indicated that SPECT with 99mTc-GSA reflected functional hepatocytes more accurately than liver volume determined by CT scan, which cannot exclude nonfunctional hepatocytes. The patient's condition improved in parallel with the improvements in the indices measured by SPECT and hematological examinations. SPECT analysis is practically useful for the prompt assessment of improvement in patients with fulminant hepatic failure.

[The calculated reference value of the tubular extraction rate in infants and children: an attempt to use a new regression equation]

This study was designed to investigate the empirical tubular extraction rate (TER) of the normal renal function in childhood and then propose a new equation to obtain TER theoretically. The empirical TER was calculated using Russell's method for determination of single-sample plasma clearance and 99mTc-MAG3 in 40 patients with renal disease younger than 10 years of age who were classified as having normal renal function using diagnostic criteria defined by the Paediatric Task Group of EANM. First, we investigated the relationships of the empirical value of absolute TER to age, body weight, body surface area (BSA) and distribution volume. Next we investigated the relationships of the empirical value of BSA corrected TER to age, body weight, BSA and distribution volume. Linear relationship was indicated between the absolute TER and each body dimensional factors, especially regarding to BSA, its correlation coefficient was 0.90 (p value). The BSA-corrected TER showed a logarithmic relationship with BSA, but linear regression did not show any significant correlation. Therefore, it was thought that the normal value of TER could be calculated theoretically using the body surface area, and here we proposed the following linear regression equation: Theoretical TER (ml/min/1.73 m2) = (-39.8 + 257.2 x BSA)/BSA/1.73 The theoretical TER could be one of the reference values of the renal function in the period of the renal maturation.

"White coat effect" induced by therapist's presence during speech therapy for stroke rehabilitation: a single case study

The excessive pressor response triggered in patients by an alerting reaction to a doctor's presence has been termed the "white coat effect." A 68-year-old man with verbal apraxia after multiple lacunar infarctions was referred to the hospital for speech rehabilitation. He experienced difficulty in talking with the speech therapist during therapy sessions but not when talking with his friends or family. Because the therapist's presence was stressful to the patient, it was considered that his anxiety might produce an excessive increase in blood pressure. Blood pressure monitoring was performed during 2 separate days of speech therapies consisting of two sessions each. In one session, therapy was directed by the therapist; in the other, therapy was self-directed. The therapist-directed approach substantially increased both systolic and diastolic blood pressures, whereas the self-directed therapy slightly increased only systolic pressure. It was concluded that the excessive pressor response seen in this patient during therapist-directed speech therapy resulted from the white coat effect induced by the therapist's presence.

[Evaluation of the liver uptake rate measured by 99mTc-GSA SPECT to assess liver function]

Whether the global liver uptake rate of 99mTc-GSA directly measured by SPECT is useful as a new index of liver function was evaluated in comparison with biochemical test results (PT%, ChE, Alb, ICG R15, KICG) and Child classification. 99mTc-GSA SPECT was performed in 157 patients with diffuse hepatic disease or hepatobiliary tumor, and two indices, namely the global liver uptake rate measured by SPECT 15 minutes after intravenous injection of 99mTc-GSA (LUS 15) and liver uptake per volume (liver uptake density) were examined. Both LUS 15 and liver uptake density were significantly correlated with biochemical test results and Child classification. In particular, close relationships between LUS 15 and ICGR15 (r = -0.720, p < 0.0001), LUS 15 and KICG (r = -0.750, p < 0.0001), and between LUS 15 and ChE (r = 0.720, p < 0.0001), indicate that LUS 15 is a useful index to evaluate liver function. Moreover, the local liver uptake rate measured by SPECT represented regional liver function and was considered a useful index to predict the function of the remnant liver after invasive treatment such as surgery.

[Discrepancy between 99mTc-HMPAO and 99mTc-ECD in Alzheimer's disease: does the retention mechanism depend on the disease?]

The discrepancy between 99mTc-hexamethyl-propyleneamine oxime (HMPAO) and 99mTc-ethyl cysteinate dimer (ECD) in Alzheimer's disease (AD) was investigated and compared with in cerebral ischemic disease (CID). The subjects were fourteen AD and thirty-one CID patients with clinically reasonable rCBF reduced lesion on 133Xe SPECT. The subjects did not include the cases of acute and subacute CID. These SPECT were performed within two weeks by ring-type dynamic SPECT (HEADTOME, Shimadzu, Japan). In the CID group, both of HMPAO and ECD SPECT could hardly detect the mildly reduced rCBF lesion on 133Xe SPECT but normal on X-CT. In the case of AD group, the rCBF-reduced lesion on 133Xe SPECT could be detected well by ECD SPECT, but the HMPAO hardly detected the reduced lesion. This discrepancy between HMPAO and ECD may be due to the difference of the retention mechanism. In the case of AD, the injury of esterase activity that participates with the ECD retention may be more notable than that of glutathione activity for the HMPAO retention. These results suggest suggest that the reduction of ECD or HMPAO density depends directly on the insufficiency of retention mechanism rather the than rCBF reduction. And the insufficiency of this retention mechanism depends on also type of the disease i.e. AD or CID.

Familial spinocerebellar ataxia with cerebellar atrophy, peripheral neuropathy, and elevated level of serum creatine kinase, gamma-globulin, and alpha-fetoprotein

Here, we report a familial spinocerebellar ataxia (FSCA), which has clinical features similar to Friedreich's ataxia, an ataxia with isolated vitamin E deficiency, and ataxia telangiectasia. However, the serum levels of creatine kinase, gamma-globulin, and alpha-fetoprotein were elevated, and biochemical and genetic analyses ruled out diagnosis of these three ataxias as well as other FSCAs. Thus, this family is thought to have a new type of FSCA.

[Study of the validity of ADL assessment by Minsei-iin of bed ridden elderly cared for at home]

We studied the validity of assessment of activities of daily living (ADL) by minsei-iins of the bed ridden elderly cared for at home. The cases, 66 male and 128 female elderly in a county of Gunma Prefecture, had been registered by minsei-iins (non-professional district welfare commissioners) as bed ridden cared for at home. Minsei-iins interviewed the case and the caregiver at home, asking them about the term of care, the levels of independence in their daily living, and seven items of ADL. Out of the 194 cases registered, PTs or OTs interviewed 136 cases, 42 male and 94 female, and calculated the Barthel index score. The Quantification method of the first type was applied to the data to predict the Barthel index score. The independent variables were five items of ADL assessed by the minsei-iins. The relation was close between the assessment of all items of ADL by the minsei-iins and the Barthel index calculated by the PTs or OTs. The Quantification method of the first type revealed that bathing, excreting and walking contributed most to the measured Barthel index. The multiple correlation coefficient was 0.687. There were three cases who scored 100 in the Barthel index.

Infection with GB virus C in patients with chronic liver disease

Infection with putative non-A to E hepatitis virus, designated GB virus C (GBV-C), was surveyed in 286 patients with chronic liver disease in Japan. RNA of GBV-C was detected, by reverse-transcription polymerase chain reaction with nested primers from the 5'-noncoding region, in 19 patients (6.6%) at a frequency higher (P < 0.001) than in three of 275 (1.1%) normal controls. It was detected in three of 83 (4%) patients with hepatitis B virus infection, 15 of 188 (8%) patients with hepatitis C virus infection, and one of 12 (8%) patients without evidence of ongoing infection with hepatitis B or C virus. GBV-C RNA was detected in nine of 186 (5%) patients with chronic hepatitis aged 51.2 +/- 13.3 years, six of 64 (9%) with liver cirrhosis aged 62.9 +/- 11.4 years, and four of 36 (11%) with hepatocellular carcinoma aged 62.0 +/- 11.1 years. Nucleotide sequences of 100 base pairs in the helicase region of GBV-C isolates from the 19 patients varied up to 21%, while sequences of 33 deduced amino acids were conserved and differed only by up to 6%. These results indicate that infection with GBV-C in patients with non-B, non-C chronic liver disease would not be frequent, although the sensitivity of the detection method could be improved. Coinfection of GBV-C with hepatitis B or C virus, as well as the duration of infection, might accelerate the progression of chronic liver disease.

[HGBV-C infection in patients with chronic liver disease]

Infection with HGBV-C was surveyed in 286 patients with chronic liver disease. HGBV-C RNA was detected in 19 patients (6.6%), by nested RT-PCR with 5'UTR-derived primers. There were no appreciable differences in clinical and virological features between patients with and without HGBV-C RNA in serum. HGBV-C RNA was detected in three of 83(4%) patients with HBV infection, 15(8%) of 188 patients with HCV infection, and one of 12(8%) patients without evidence of ongoing infection with HBV or HCV, suggesting that the contribution of HGBV-C to non-B non-C hepatitis would not be high. HGBV-C RNA was detected more frequently in the patients with liver cirrhosis or hepatocellular carcinoma than in those with chronic hepatitis. This could reflect a possible role of HGBV-C in aggravating liver disease in co-operation with the other hepatitis viruses.

GB virus C and hepatitis C virus infections in hemodialysis patients in eight Japanese centers

RNA of a putative non-A to E hepatitis virus, designated GB virus C (GBV-C), was detected in 40 (6.2%) of 645 hemodialysis patients, at a frequency significantly higher than in 3 (0.9%) of 336 blood donors in Japan (p < 0.001). A history of transfusion was more frequent (88 vs. 58%, p < 0.001), the duration of dialysis was longer (13.2 +/- 7.9 vs. 7.9 +/- 6.5 years, p < 0.001), and the detection of hepatitis C virus RNA was more often (38 vs. 18%, p < 0.01) in the 40 patients with GBV-C RNA than in the 605 patients without it. The prevalence of GBV-C RNA varied widely from 0 to 10% among the 8 dialysis centers. These results indicate that hemodialysis patients would be at increased risk of GBV-C transmitted by transfusions. The detection of GBV-C RNA in the 5 patients without a history of transfusion and a high prevalence restricted to certain dialysis centers would reflect nosocomial infection.

[Glucose metabolism and Alzheimer's dementia]

Blood glucose levels are abnormally low in Alzheimer's dementia. We therefore examined glucose metabolism before death in relation to Alzheimer's dementia as determined at autopsy in 106 men and 161 women. The mean age was 81.8 +/- 8.6 years for men and 85.8 +/- 7.9 years for women (p < 0.001). The fasting plasma glucose level and hemoglobin Alc levels did not differ by sex. Alzheimer's dementia was detected in 88 patients (25.5%). More women than men had the disease, but the difference was not significant. Only 8.8% (3/34) of patients with diabetes mellitus had Alzheimer's dementia, as compared with 27.9% of patients without diabetes mellitus (65/233, p < 0.03). The fasting plasma glucose level was 89.9 +/- 13.4 mg/dl in patients with Alzheimer's dementia and 102.9 +/- 34.5 mg/dl in those without the disease. The hemoglobin Alc level was 5.7 +/- 0.8% in patients with Alzheimer's dementia and 6.4 +/- 1.5% in those without the disease. Both the fasting glucose level and hemoglobin Alc level were significantly lower in patients with Alzheimer's dementia than in those without the disease, p < 0.01. These data suggest that the development of Alzheimer's dementia is suppressed by the high plasma glucose levels in patients with diabetes mellitus.

CT detection of facial canal dehiscence and semicircular canal fistula: comparison with surgical findings

OBJECTIVE

The purpose of this study was to determine the accuracy of high resolution CT (HRCT) in the detection of facial canal dehiscence and semicircular canal fistula, the preoperative evaluation of both of which is clinically very important for ear surgery.

MATERIALS AND METHODS

We retrospectively reviewed the HRCT findings in 61 patients who underwent mastoidectomy at Yamagata University between 1989 and 1993. The HRCT images were obtained in the axial and semicoronal planes using 1 mm slice thickness and 1 mm intersection gap.

RESULTS

In 46 (75%) of the 61 patients, the HRCT image-based assessment of the facial canal dehiscence coincided with the surgical findings. The data for the facial canal revealed sensitivity of 66% and specificity of 84%. For semicircular canal fistula, in 59 (97%) of the 61 patients, the HRCT image-based assessment and the surgical findings coincided. The image-based assessment in the remaining two patients, who both had massive cholesteatoma, was false-positive.

CONCLUSION

HRCT is useful in the diagnosis of facial canal dehiscence and labyrinthine fistula, but its limitations should also be recognized.

Hepatitis B virus with mutations in the core promoter for an e antigen-negative phenotype in carriers with antibody to e antigen

Hepatitis B virus (HBV) DNA clones were propagated from 57 carriers with antibody to hepatitis B e antigen (HBeAg) and sequenced within nucleotides (nt) 1685 to 1926 including the core promoter (nt 1742 to 1849) and the pre-C region (nt 1814 to 1900). Mutations in the core promoter or those in the pre-C region, or both, were detected in 328 (97.9%) of 335 clones from them. Five carriers were infected with HBV mutants with mutations in the core promoter alone, while 20 carriers were infected only with those in the pre-C region to abort the translation of HBeAg precursor; the remaining 32 carriers were infected with HBV mutants with mutations in both the core promoter and pre-C region. Some carriers infected with HBV with mutations in the core promoter exclusively had high HBV DNA titers, comparable with those in carriers infected with wild-type HBV, thereby indicating that such mutations would not affect the transcription of the HBV pregenome extensively. Two point mutations in the core promoter, from A to T at nt 1762 and from G to A at nt 1764, were most prevalent. The other mutations included a point mutation at either of the two nucleotides and their deletion. All of these mutations involved the TTAAA sequence (nt 1758 to 1762) at 28 bp upstream of the initiation site for shorter pre-C mRNAs (nt 1790 +/- 1). The ATAAATT sequence (nt 1789 to 1795) at 23 bp upstream of the initiation site for the pregenome RNA (nt 1818), however, remained intact in all 335 HBV DNA clones. HBV mutants with mutations in the core promoter, unaccompanied by pre-C mutations, prevailed and replaced wild-type HBV in two carriers as they seroconverted from HBeAg to the corresponding antibody. These results indicate that HBV mutants with an HBeAg- phenotype would be generated by mutations in the core promoter which might abort the transcription of pre-C mRNA but do not seriously affect that of pregenome RNA.

[Angiographical frequency of unruptured incidental intracranial aneurysms]

We reviewed cerebral angiograms studied between May 1985 and December 1992 focusing on unruptured incidental intracranial aneurysms. In a total of 605 cases of cerebral angiograms except for patients with SAH, 43 patients (7.1%) were found to have unruptured aneurysms. In the 72 patients with headache, 11 patients (15.3%) were found to have unruptured aneurysms. This high frequency of unruptured aneurysms in headache patients is significant as a factor showing that headache may be due to unruptured aneurysms. The result of this observation is that as a screening study for headache patients, cerebral angiography may be required in spite of the invasive and high-risk method. But we think that MR angiography is, at present, a useful screening study only for detecting cerebral aneurysms with a diameter of over 5mm, and which are considered to need an operation.

Hepatitis C virus infection in spouses of patients with type C chronic liver disease

OBJECTIVE

Survey for markers of hepatitis C virus (HCV) infection in spouses of patients with HCV-related chronic liver disease.

DESIGN

Cross-sectional clinical, serologic, and molecular biological study of spouses of patients with HCV viremia and chronic liver disease.

SETTING

University and city hospitals.

PARTICIPANTS

Spouses (52 men and 102 women; mean age, 56 +/- 11 years) of 154 patients with HCV viremia (102 men and 52 women; mean age, 58 +/- 10 years), of whom 66 had chronic hepatitis, 49 had liver cirrhosis, and 39 had primary hepatocellular carcinoma.

METHODS

Tests for HCV-associated antibodies were done using a second-generation enzyme immunoassay and immunoassays with synthetic oligopeptides deduced from the HCV core gene. Hepatitis C virus RNA was detected by polymerase chain reaction with primers deduced from the 5'-noncoding region and HCV genotypes by reaction with type-specific primers deduced from the HCV core gene.

RESULTS

Hepatitis C virus-associated antibodies were detected in 42 (27%) spouses, of whom 25 were also positive for HCV RNA. Of 112 (73%) spouses without detectable antibodies, 2 had chronic liver disease. The development of markers of HCV infection in spouses increased with the duration of marriage, ranging from 1 to 60 years (30 +/- 11 years).

CONCLUSIONS

Spouses of patients with HCV viremia and chronic liver disease have an increased risk for acquiring HCV, which is proportional to the duration of marriage. They should be followed routinely for markers of HCV infection and liver disease.

[Hemodynamics in the territory of balloon occluded internal iliac artery--problems of balloon occluded arterial infusion therapy for urinary bladder cancer]

Balloon occluded arterial infusion therapy (BOAI) with anticancer drugs has been performed widely for urinary bladder cancer. It is expected that a dense anticancer drug would perfuse the territory of the vesical arteries under occlusion of the bilateral internal iliac arteries. In balloon occluded internal iliac arteriography, however, contrast media are gradually washed out in spite of complete occlusion of the bilateral internal iliac arteries. This washout process takes place via collateral flow to the acute occlusion and varies according to the position of occlusion and arterial variations in branching. We wondered whether anticancer drug administered by BOAI would perfuse the territory of the vesical arteries as expected. We analyzed the washout process of balloon occluded internal iliac arteriography in 41 patients with urinary bladder cancer in whom preoperative BOAI had been performed. We estimated the hemodynamics and perfusion of the anticancer drug to the urinary bladder on the basis of analysis of balloon occluded internal iliac arteriography in each case. Perfusion scintigraphy and histological examination of surgical specimens of urinary bladder cancer (21 cases) confirmed the validity of our estimates. In some cases it was presumed that the anticancer drug did not reach the territory of the vesical arteries.

[Perioperative renal functions in patients with chronic renal disease]

Renal function was studied in patients with compensated renal failure and in those with slight renal disorder during and after operations focusing on several aggravating factors. After perioperative episodes of hypovolemia, bleeding and shock, the levels of urine beta 2 microglobulin and FENa were elevated, showing the abnormal renal tubule functions. Elevation of NAG and the decrease of Ccr were observed, showing the organic damage on the renal tubular cell and the influence on GFR. These aggravating factors should be eliminated to prevent the irreversible renal changes.

Digital angiography using hand-operated table movement for vascular disease of the pelvis and lower extremities

We developed a new technique using hand-operated table movement during digital angiography (DA) for the study of vascular disease of the pelvis and lower extremities. Digital video memory (DVM) is used in this technique to digitize, record, and display fluorographic images without subtraction in real time. This allows free table movement and the imaging of a large area with a single injection of contrast medium. Forty-five examinations for vascular disease of the pelvis and lower extremities were performed by this DA technique. Good images of an extensive area from the lower abdomen to the lower leg were obtained in a single study.