The Impact of Age- and Sex-Specific Reference Ranges for Serum Thyrotropin and Free Thyroxine on the Diagnosis of Subclinical Thyroid Dysfunction: A Multicenter Study from Japan

Background: Reference ranges for serum thyrotropin (TSH), free thyroxine (fT4), and free triiodothyronine (fT3) established without considering age- and sex-based differences are currently used to evaluate thyroid function. Therefore, we investigated age- and sex-based differences in serum TSH and thyroid hormone levels in euthyroid individuals. Methods: We performed cross-sectional analyses of retrospective data collected from two Japanese institutions. We estimated sex-specific 95% reference ranges for TSH and fT4 according to age strata. Results: We included data from 14,860 participants undergoing screening with a Siemens thyroid testing kit and 8,132 participants undergoing screening with an Abbott kit during annual health check-ups at Takasaki Hidaka Hospital. In addition, 515 participants visiting a specialized thyroid-focused hospital were evaluated using Tosoh kits. The median TSH level of women in their 30s was 1.5 mIU/L (2.5th percentile, 0.5; 97.5th percentile, 4.6) using the Siemens kit, while that of women in their 60s was 1.9 (0.7-7.8) mIU/L. The corresponding levels were lower in men; the age-associated increase was small. The median serum fT4 level of men in their 30s was 1.3 (1.0-1.7) ng/dL and that of men in their 60s was 1.2 (1.0-1.6) ng/dL. These levels gradually but significantly decreased with age. fT4 levels in women were lower than those in men and remained consistent with age. Serum fT3 levels were significantly higher in men than in women and gradually but significantly decreased with age. The Abbott and Tosoh kits showed similar results. When using the Siemens kit, ∼60% (216/358) of women diagnosed with subclinical hypothyroidism using manufacturer-recommended reference ranges had normal results when age- and sex-specific reference ranges were applied, demonstrating the high percentage of overdiagnosis, especially in those aged ≥60 years. Conversely, some middle-aged individuals with normal thyroid function were reassessed and classified as having subclinical hyperthyroidism by age- and sex-specific reference ranges. Conclusions: Age- and sex-specific reference ranges should be used to avoid over- and underdiagnosis of subclinical thyroid dysfunction and appropriate therapies.

ODP460 Age- and sex- specific reference ranges for serum thyrotropin (TSH), free T4 and free T3 levels: Significant effects on the definition of subclinical dysfunction

Introduction

Consistent reference ranges of serum TSH, FT4 and FT3 levels without consideration of age and sex have been used to evaluate thyroid function. However, based on the recent development of highly sensitive assays of these hormones, subtle differences significantly affect the diagnosis, especially when diagnosing subclinical dysfunction, which affects more than 5% of the population. In the present study, we investigated the age- and sex- differences in these hormone levels using two different kits.

Methods

A total of 14,860 subjects for the Siemens kit and 6,604 subjects for the Abbot kit who underwent annual health check-ups at Takasaki Hidaka Hospital were included. Exclusion criteria comprised a history of thyroid disease, steroid use, renal failure or liver cirrhosis. All samples were measured at 8–9: 00 AM after overnight fasting.

Results

Regarding serum TSH levels in men, the median of subjects in their 30's was 1.4 mIU/L, the 2.5th percentile was 0.4, and the 97.5th percentile was 3.7 with the Siemens kit. These values in subjects in their 60's were 1.6, 0.5, and 5.7, respectively. They gradually but significantly increased with age based on both kits. Similarly in women, the serum TSH levels gradually increased, particularly with the Siemens kit, and the levels in women were higher than those in men. The median serum FT4 level in men in their 30's was 1.3 ng/dL (1. 0-1.7) and that in those in their 60's was 1.2 (1. 0-1.6) with the Siemens kit. The levels in men gradually but significantly decreased with age, but those in women were lower than those in men and remained consistent with age. Regarding serum FT3 levels in men, they were significantly higher than those in similarly aged women, and also gradually but significantly decreased with age; men in their 30's: 3.37 pg/mL (2.68-3.99), 60's: 3.15 (2.46-3.76) with the Abbot kit.

Discussion

The serum TSH level is highly sensitive to slight changes in the serum level of thyroid hormones even within the normal ranges; therefore, we diagnose subclinical hypothyroidism and hyperthyroidism using serum TSH levels. Many investigators have discussed the effects of subclinical dysfunction on lipid metabolism, osteoporosis, and cognitive mental diseases, and medications to normalize thyroid hormone levels. As there are significant differences in serum TSH, FT4, and FT3 levels according to age and sex, the age- and sex- dependent normal ranges should be used to precisely evaluate thyroid function and decide clinical therapies.

Presentation: No date and time listed

Seasonal variation in thyroid function in over 7,000 healthy subjects in an iodine-sufficient area and literature review

Context

Seasonal variation in thyroid function, especially serum free triiodothyronine (FT3) and free thyroxine (FT4) levels, in healthy subjects remains unclear.

Methods

We examined thyroid function, including serum FT3 and FT4 levels, in healthy Japanese subjects using data of more than 7,000 health check-up participants and applied the analysis of means with transformed ranks (ANOMTR) to compare each month. In addition, we reviewed reports published in the last 2 decades.

Results

The median serum thyrotropin (TSH) level was the highest in January (1.61 mIU/L), and the lowest in May (1.16 mIU/L). ANOMTR revealed that serum TSH levels are high in winter and low in summer. Conversely, the median serum FT3 level was higher in July than in other months, and the ANOMTR plot demonstrated serum FT3 levels to be significantly higher in summer and lower in winter. In contrast, serum FT4 levels were more consistent throughout the year, but statistically, those in February and March, October, and November were higher than those in other months. ANOMTR revealed variations in serum FT4 levels to be small through the year but biphasic.

Conclusions

Taken together with previous reports, our study demonstrated seasonal changes in the serum TSH levels to be high in winter in the northern hemisphere; however, the serum FT3 differed among countries, and those of Japanese, an iodine-sufficient country, were high in summer. In contrast, FT4 levels were more consistent. These changes should be taken into account to precisely evaluate thyroid function.

Influence of Smoking on Thyroid Function in Japanese Subjects: Longitudinal Study for One Year of On-Off Smoking

Context

We previously identified factors affecting thyroid status, including sex, age, and smoking.

Objective

In the current study, we increased the number of subjects examined and investigated the effects of these factors, particularly smoking and the thyroid peroxidase antibody (TPO-Ab), in Japanese patients with euthyroxinemia and serum free T4 levels within the normal range.

Participants

A total of 12,289 subjects who underwent health checkups were analyzed in a cross-sectional and longitudinal study.

Results

The mean age of subjects was 50 ± 10 years (age range: 21 to 88 years). Serum TSH levels and the prevalence of positivity for TPO-Ab increased with age in Japanese subjects with euthyroxinemia. Mean serum TSH levels were significantly lower in the smoking group than in the nonsmoking group except for women older than 50 years. Serum TSH levels were significantly higher in subjects with positivity for TPO-Ab than in those with negativity at all ages and in both sexes; however, smoking did not affect free T4 levels or positivity for TPO-Ab. Among men, the rate of smokers was significantly higher in patients with subclinical hyperthyroidism (25%) than in those with subclinical hypothyroidism (10%; P < 0.05). Furthermore, the results of the longitudinal study revealed a significant decrease in serum TSH levels 1 year after the start of smoking in men (P < 0.05).

Conclusion

Because smoking appeared to lower serum TSH levels in Japanese subjects with euthyroxinemia, their smoking status warrants careful consideration when evaluating subclinical thyroid function.

MON-615 Seasonal Changes in Thyroid Function in Healthy Subjects in Japan: Analysis of 8,489 Health Check Participants

Aim: Thyroid hormone affects the whole-body metabolism, including that of lipids and glucose, and its involvement in NAFLD / NASH has recently been reported. Accurate evaluation of thyroid function is therefore important. In this study, seasonal changes in thyroid function in approximately 10,000 health check participants were investigated, and the effects of age and smoking were also examined.Subjects and methods: The subjects were participants of medical checkups at Hidaka Hospital from 2007 to 2013. Exclusion criteria were a past history of thyroid disease, steroid use, renal failure and liver cirrhosis. To exclude the effects of menstruation, we examined 8,489 men whose blood TSH and FT4 values were within the reference values for monthly changes in thyroid function, and the effects of age and smoking. All blood TSH and FT4 levels were measured at 8 ~ 9:00 AM after over night fasting.Results: The average age was 49 ± 10 years old. The number of participants varied each month, with a minimum of 346 in April and a maximum of 961 in November. The highest median serum TSH level was 1.6 μU/ml in January (winter), and the lowest was 1.3 μU/ml in June, July, August and September (summer). These values were significantly different from the yearly median value of 1.4 μU/ml in April and November. On the other hand, the FT4 level was significantly lower in August than in the other months except for February. The extents of seasonal changes in TSH and FT4 levels were reduced in elderly subjects >60 years old. Furthermore, the median blood TSH level of 2,262 smokers was lower than that of 4,709 non-smokers (median: smoker, 1.2μU/ml vs. non-smoker, 1.5μU/ml). However, seasonal changes were also observed in smokers. Conclusions: This is the first report in a large healthy cohort demonstrating that there are significant seasonal changes in thyroid function including freeT4 levels. Several factors, such as season, age, smoking and gender, need to be taken into account for accurate evaluation of thyroid function.

Age-Dependent Progression of Renal Dysfunction After Adrenalectomy for Aldosterone-Producing Adenomas in Japan

Context

In patients with aldosterone-producing adenomas (APAs), adrenalectomy causes a rapid decrease in blood pressure and increase in blood potassium levels; however, the effects of these intensive metabolic changes on kidney function with age have not yet been examined in Japan.

Objective

To investigate factors related to the progression of kidney dysfunction after adrenalectomy in different age groups.

Participants

Fifty Japanese patients with APAs and 27,572 health checkup patients as controls were examined.

Main Outcome Measures

We investigated changes in estimated glomerular filtration rate (eGFR) after adrenalectomy and characterized patients who progressed to chronic kidney disease (CKD).

Results

The postoperative cutoff age of CKD is 50 years and age is a unique factor for the progression of CKD after adrenalectomy. Among preoperative patients, CKD was 6% for those <50 years old and 40% for those ≥50 years old, indicating a higher prevalence of CKD with APAs than in control subjects. Median eGFR <50 mL/min/1.73 m² did not significantly change after adrenalectomy but decreased from 67 to 42 mL/min/1.73 m² in those with APAs ≥50 years old. Patients with APAs ≥50 years old who progressed to CKD showed higher preoperative aldosterone/renin ratios, lower potassium and chloride levels, lower body mass index, and a higher incidence of a history of cardiovascular events and KCNJ5 mutation rates.

Conclusion

Age is the most important predictor of the progression of kidney dysfunction after adrenalectomy in Japanese patients with APAs, particularly those with a history of cardiovascular events and positivity for KCNJ5 mutations.

Electrospun nanofiber membranes as ultrathin flexible supercapacitors

A highly flexible electrochemical supercapacitor electrode was developed with a novel metal oxide-reinforced nanofiber electrode by utilizing a solution-based electrospinning technique.

Radiofrequency thermal treatment with chemoradiotherapy for advanced rectal cancer

We previously reported that patients with a clinical complete response (CR) following radiofrequency thermal treatment exhibit significantly increased body temperature compared with other groups, whereas patients with a clinical partial response or stable disease depended on the absence or presence of output limiting symptoms. The aim of this study was to evaluate the correlation among treatment response, Hidaka radiofrequency (RF) output classification (HROC: termed by us) and changes in body temperature. From December 2011 to January 2014, 51 consecutive rectal cancer cases were included in this study. All patients underwent 5 RF thermal treatments with concurrent chemoradiation. Patients were classified into three groups based on HROC: with ≤9, 10–16, and ≥17 points, calculated as the sum total points of five treatments. Thirty-three patients received surgery 8 weeks after treatment, and among them, 32 resected specimens were evaluated for histological response. Eighteen patients did not undergo surgery, five because of progressive disease (PD) and 13 refused because of permanent colostomy. We demonstrated that good local control (ypCR + CR + CRPD) was observed in 32.7% of cases in this study. Pathological complete response (ypCR) was observed in 15.7% of the total 51 patients and in 24.2% of the 33 patients who underwent surgery. All ypCR cases had ≥10 points in the HROC, but there were no patients with ypCR among those with ≤9 points in the HROC. Standardization of RF thermal treatment was performed safely, and two types of patients were identified: those without or with increased temperatures, who consequently showed no or some benefit, respectively, for similar RF output thermal treatment. We propose that the HROC is beneficial for evaluating the efficacy of RF thermal treatment with chemoradiation for rectal cancer, and the thermoregulation control mechanism in individual patients may be pivotal in predicting the response to RF thermal treatment.

A novel strategy of radiofrequency hyperthermia (neothermia) in combination with preoperative chemoradiotherapy for the treatment of advanced rectal cancer: a pilot study

The safety of weekly regional hyperthermia performed with 8 MHz radiofrequency (RF) capacitive heating equipment has been established in rectal cancer. We aimed to standardize hyperthermia treatment for scientific evaluation and for assessing local tumor response to RF hyperthermia in rectal cancer. Forty-nine patients diagnosed with rectal adenocarcinoma were included in the study. All patients received chemoradiation with intensity-modulated radiation therapy 5 days/week (dose, 50 Gy/25 times) concomitant with 5 days/week for five times of capecitabine (1700 mg/m(2) per day) and once a week for five times of 50 min irradiations by an 8 MHz RF capacitive heating device. Thirty-three patients underwent surgery 8 weeks after treatment. Three patients did not undergo surgery because of progressive disease (PD) and 13 refused. Eight (16.3%) patients had a pathological complete response (ypCR) after surgery. Among patients without surgery, 3 (6.1%) had clinical complete response (CR) and 3 (6.1%) had local CR but distant PD (CRPD). Ninety percent of ypCR + CR patients were shown in 6.21 W min(-1) m(-2) /treatment or higher group of average total accumulated irradiation output with 429°C min(-1) m(-2) or higher group of total accumulated thermal output. However, a patient with CRPD was in the higher total accumulated thermal output group. We propose a new quantitative parameter for the hyperthermia and demonstrated that patients can benefit from mild irradiation with mild temperature. Using these parameters, the exact output, optimal thermal treatment, and contraindications or indications of this modality could be determined in a multi-institutional, future study.

Subclinical hypothyroidism and indices for metabolic syndrome in Japanese women: one-year follow-up study

CONTEXT

Subclinical hypothyroidism (SCH) and metabolic syndrome (MetS) increase with age; however, their relationship remains unclear.

OBJECTIVE

Our objective was to investigate the relationship between SCH and indices of metabolic syndrome and follow up subjects for 1 year.

DESIGN

Cross-sectional and longitudinal follow-up studies of cases were collected from Takasaki Hidaka Hospital between 2003 and 2007.

PARTICIPANTS

Overall, 11 498 participants of health checkups were analyzed. The mean age was 48 ± 9 years.

MAIN OUTCOME MEASURES

The relationship between SCH and indices of MetS were examined.

RESULTS

Serum free T4 levels were lower in women than men in most of the age groups, and the prevalence of SCH, 6.3% in women vs 3.4% in men, increased with age, reaching 14.6% in 70-year-old women. Multivariate logistic-regression analyses revealed that waist circumference and the serum triglyceride and low-density lipoprotein-cholesterol levels were significantly higher in subjects with SCH than without among women. Reflecting these findings, the adjusted odds ratio of MetS in patients with SCH was higher than in the euthyroid subjects in women with an odds ratio of 2.7 (95% confidence interval 1.1-5.6; P = .017) but not in men. Furthermore, progression from euthyroid into SCH resulted in a significant increase in the serum triglyceride levels but not low-density lipoprotein-cholesterol in women.

CONCLUSION

Japanese women exhibited a high prevalence of SCH associated with low free T4 levels. There was a strong association between SCH and several indices of metabolic syndrome in women. SCH may affect serum triglyceride levels and be a risk factor for metabolic syndrome.

Thalamic lesions produced by gamma thalamotomy for movement disorders

Object. The treatment of Parkinson disease and other kinds of involuntary movement by gamma knife radiosurgery (GKS) is presented. This is an extension of previous work. The clinical course and thalamic lesions were the main factors examined.

Methods. Seventeen new cases were added to the previously reported 36 cases. The course and results for the whole series of 53 patients were examined. Treatment was undertaken using a single 4-mm collimator shot to deliver 130 Gy to the target. The target was determined in the previously treated patients by using classic methods involved in conventional stereotactic thalamotomy with microrecording. More recently, target localization has been performed by relating the target point to the total length of the thalamus. Points may then be defined as percentages of that length measured from the anterior pole. Targets can then be determined in relationship to the appropriate percentage.

Thirty-five patients have been followed for more than 2 years and the longest follow up was 8 years. Two kinds of thalamic lesion were seen after GKS. Volumetric analysis on MR imaging revealed that the larger lesion was 400 to 500 mm3 at the beginning and gradually decreased in size. The smaller lesion occupied approximately 200 mm3 and also shrank over several months. Eighty percent of the treated cases showed good results and no significant complications, with the tremor subsiding at 1 year (Type 1). Several cases deviated from this standard course in four different ways (Types 2–5). If tremor persisted, conventional stereotactic thalamotomy with microrecording was performed. During such operations, normal neuronal activity was recorded from the region adjacent to the GKS thalamotomy target. This was the region showing a high signal on MR imaging. The activity patterns included the rhythmical grouped discharge of tremor rhythm.

Conclusions. Gamma thalamotomy for functional disorders is still under development, but because the results with careful target planning are satisfactory, there are grounds for increasing optimism.

Pituitary adenomas treated by microsurgery with or without Gamma Knife surgery: experience in 122 cases

The clinical outcome of 122 patients with pituitary adenomas treated by microsurgery and/or Gamma Knife radiosurgery (GKRS) was analyzed to evaluate patient selection criteria and the role of GKRS. Sixty-six resections were performed in 59 patients. All tumors were macroadenomas, except for 5 ACTH-producing adenomas. Twenty-four of the 31 hypersecreting adenomas showed normal serum hormone values after treatment. Postoperative complications were rhinorrhea, cranial nerve palsies, and a small thalamic infarct. GKRS was performed on 18 of the operated patients because of residual tumors, mostly in the cavernous sinus. Thirty-five of the 63 patients treated by GKRS were followed for more than 2 years. All adenomas except 2 were stable or had decreased in size. Eleven of 17 functioning adenomas showed normal serum hormone values after treatment. It is concluded that tumors that compress the optic pathway should be removed and that residual tumors in the cavernous sinus are good indications for radiosurgery.

The role of intravascular embolization prior to radiosurgery of cerebral arteriovenous malformations. from the standpoint of hemorrhage and early obliteration after gamma knife radiosurgery

The role of intravascular embolization prior to radiosurgery of cerebral arteriovenous malformations was evaluated based on the basis of the results of gamma knife radiosurgery in relation to hemorrhage and early obliteration after treatment. Nine of 213 patients experienced hemorrhage 4 to 42 months after radiosurgery. All AVMs in these patients had dilated feeding arteries, and the flow of the AVM was rapid and/or high. An intranidal aneurysm was seen in one patient. Drainage of all AVMs consisted of a single and/or deep draining veins, and venous obstruction was found in six. Sixty-three of 87 patients followed for more than four years after radiosurgery were examined angiographically, and total obliteration of AVM was observed in 52 of them (82.5%). Early obliteration was found in 19 of the 34 patients examined within 12 months. The obliteration rate was significantly higher in slow- and low-flow AVMs (73.9%) than in rapid- and/or high-flow AVMs (18.2%). It is concluded that the role of intravascular embolization prior to radiosurgery is not only decreasing the size of the AVM but decreasing the risk of hemorrhage and shortening the latency period by decreasing their flow rate and flow volume.

Gamma thalamotomy for parkinsonian and other kinds of tremor

On the basis of our experiences with selective ventralis intermedius thalamotomy with microrecording, certain cases of tremor with Parkinson's disease (PD, six cases), intentional tremor (one case) and essential tremor (one case) were treated by Gamma Knife. In all cases, 140-150 Gy were irradiated using 4-mm collimators. Three different strategies were used. (1) Gamma thalamotomy as the primary surgical treatment. (2) As a secondary treatment, irradiation of the symmetric point of the contralateral selective thalamotomy. (3) Extension of the previous thalamotomy. For the first three cases (all PD), a special plug pattern (100 plugs) was used, but was not employed for the later cases. No acute untoward effects were noted, and overall there appeared to be a reduction in tremor. The time course of tremor reduction varied from case to case, from about 5-6 months to 1 year.

Pathobiology of cerebral gliomas in children and the role of radiosurgery

Twenty-five gliomas of the cerebral hemisphere in children were examined. Most hemispheric gliomas in children have relatively clear margins and less infiltrative potential. Radiosurgery has a role in the treatment of these tumors in addition to reducing the risk of radiation injuries developing later. Fifteen patients were alive 1-27 years (mean 8.4) following treatment and 10 patients died. Histologic examination demonstrated 10 differentiated gliomas, 10 poorly differentiated gliomas and 5 other gliomas. Most tumors had relatively clear margins on computed tomography and/or magnetic resonance images, and peritumoral edema was slight. In 9 autopsy cases, tumor dissemination and/or metastasis were seen in 7. However, tumor infiltration was not extensive, and clear tumor margins were found in some cases. Thus, cerebral gliomas in children have relatively clear margins and low infiltrative potential. Radiosurgery has a role in the treatment of these tumors.

Gamma Knife radiosurgery for acoustic schwannoma: effects of low radiation dose and functional prognosis

The effects of relatively low dose Gamma Knife irradiation on acoustic schwannoma were evaluated in 29 patients followed over 2 years after treatment. The mean dose delivered to the tumor periphery was 12.1 Gy. Lowering of the magnetic resonance signal intensity in the tumor center appeared in 69% and signs of tumor shrinkage appeared in 59% of cases. The cyst in the tumor enlarged in 3 cases, and 2 cases developed hydrocephalus. The percentage of pure-tone hearing preservation was 82% at 3 months, 73% at 6 months, 68% at 12 months. 64% at 18 months and 59% at 24 months in 22 out of 29 cases. Relatively low dose Gamma Knife radiosurgery was effective in suppressing tumor growth, with preservation of hearing.

Radiobiological effects of gamma knife radiosurgery on brain tumors studied in autopsy and surgical specimens

To elucidate the radiobiological effect of Gamma Knife radiosurgery on brain tumors, we performed a histological study on nine cases. In two, the material was obtained at autopsy and in seven following surgery. In the central region of the radiation field, destructive changes occurred both in tumor cells and in vessels. In the peripheral area, destructive and proliferative vascular changes were intermingled with residual tumor tissue. Immunohistochemical staining of surgical specimens showed that the vascular proliferative changes consisted of pericytic proliferation with or without endothelial proliferation. These characteristic changes might suppress tumor growth, at least in the short-term.

Gamma knife radiosurgery for acoustic schwannoma: early effects and preservation of hearing

The effects of relatively low dose gamma knife irradiation on acoustic schwannoma were evaluated. The signal intensity change and tumor shrinkage on magnetic resonance (MR) images, change in hearing, and complications in 28 patients (mean age 47.0 +/- 13.6 yrs) were studied. Three patients had bilateral tumors. Six were already deaf when treated. The maximum tumor diameter was 35 mm. The mean dose delivered to the tumor was 12.1 +/- 1.6 Gy at the periphery, and 25.2 +/- 4.3 Gy at the center. The mean follow-up time was 16 months and the longest 24 months. Lowering of the MR signal intensity in the tumor center appeared after 3 months at earliest but generally after 6 months. Signs of tumor shrinkage appeared within 12 months on average. Cyst in the tumor enlarged rapidly after treatment in two patients. The percentage of hearing preservation was 85% (17/20) at 3 months, 80% (16/20) at 6 months, 72% (13/18) at 9 months, 75% (12/16) at 12 months, 67% (8/12) at 15 months, 60% (6/10) at 18 months, and 50% (2/4) at 24 months. Subtle changes in hearing were detected by speech tone audiometry. Temporary facial numbness and weakness was seen in one patient each. No patient had lower cranial nerve paresis. Relatively low dose gamma knife radiosurgery is effective in suppressing growth of acoustic schwannoma with preservation of hearing.

[Evaluation of nuclear morphometric risk grade as a prognostic factor of early breast cancer]

The prognostic significance of nuclear areas was studied in 241 patients with primary stage I or II breast cancer. The mean follow-up period was 56.4 months. The nuclear areas of 100 breast cancer cells in HE stained specimen in each patient were measured by means of an image analyzing system, and the mean nuclear area (MNA) and standard deviation of nuclear area (SDNA) were calculated. MNA and SDNA were significantly larger in patients with recurrence than without it. Patients were divided into 2 groups according to the Nuclear Morphometric Risk Grade (NMRG), which was defined as follows: high risk: MNA > or = 80 microns 2 and SDNA > or = 28 microns 2; low risk: MNA < 80 microns 2 or SDNA < 28 microns 2. High risk patients revealed significantly poor disease free and overall survival than low risk patients (p < 0.0001, p < 0.0001). Furthermore, NMRG was a significant prognostic factor in node-negative patients. Cox multivariate analysis showed that nodal status and NMRG were independent predictors of tumor recurrence (n:p = 0.001; NMRG:p = 0.27) and survival (n:p < 0.001; in the NMRG:p = 0.0007). NMRG was a strong prognostic factor in patients in the early stage and it might support the decision for or against adjuvant therapy.

A case of infantile febrile psoriasiform dermatitis

An infant suffered from psoriasiform dermatitis complicated by severe constitutional symptoms. During his 12 months of hospitalization, the symptoms exacerbated periodically despite numerous therapeutic trials. Histologic findings revealed lichenoid psoriasiform dermatitis with striking eosinophilic necrosis of epidermal cells and satellite cell necrosis. Immunohistochemically, CD1+ Langerhans cells had almost disappeared, and CD8+ cytotoxic-suppressor T cells were predominant over CD4+ helper-inducer T cells in the epidermis. These findings in the skin biopsy specimens suggested some similarity to graft-versus-host disease but no known cause of that disorder was proved. Finally, methotrexate was effective. The patient became afebrile, and his skin lesions improved, leaving almost no scarring. This patient seems to have had specific clinical features that do not correspond with any of the known dermatitis. Clinical, histologic, and laboratory findings did not uncover any etiologic factors.

Gamma Knife radiosurgery for the treatment of brainstem tumors

Ten patients with brainstem tumors (BST) underwent Gamma Knife radiosurgery. In 5 cases, there were definitive histological diagnoses; ependymoma (n = 3) and CNS lymphoma (n = 2). The others were diagnosed as ependymoma (n = 1), CNS lymphoma (n = 2) and glioma (n = 2) on clinical grounds. Of 4 cases with ependymoma, the tumor showed a marked response in 3 cases. Of 4 cases with CNS lymphoma, all responded rapidly and the clinical symptoms improved markedly. However, in the 2 cases with glioma, the tumor remained unchanged or continued to grow. Gamma Knife radiosurgery was effective in local growth control of BST without adverse effects. An alternative treatment design will be required in glioma cases.

Gamma Knife thalamotomy for the treatment of functional disorders

Gamma Knife thalamotomy was performed with a 4-mm collimator in 2 cases with thalamic pain following a stroke and in 1 case of Parkinson's disease with tremor. In both cases with pain the maximum dose of 130 Gy was focused at the mediocaudal region of the previous thalamic lesion. In the case with tremor in Parkinson's disease, the maximum dose was 150 Gy. Longer follow-up is now proceeding, but the short-term results are encouraging. Based on data obtained from selective thalamotomy with depth microrecording, Gamma Knife thalamotomy could be a safe and effective technique for the treatment of these functional disorders.

Fractionated Gamma Knife radiosurgery for malignant gliomas: neurobiological effects and FDG-PET studies

Experimental single-dose neural irradiation was performed in rats and monkeys. Acute and 'early' late damage was observed following single high-dose treatments. By contrast, following a single low-dose treatment, neither 'early' nor 'delayed' late damage was noted. Based on these experiments, a clinical trial of fractionated Gamma Knife surgery for malignant gliomas was begun, and patients were followed by FDG-PET studies. An acute response of the tumor was obtained without damage to the surrounding brain. Fractionated Gamma Knife surgery is a potential alternative treatment for malignant gliomas.

Classification of arteriovenous malformations for radiosurgery. Neuroimaging, histopathology and radiobiologic effects

Arteriovenous malformations (AVMs) were classified based on morphologic and hemodynamic factors. They were categorized as Moya type, shunt type or mixed type on the basis of hemodynamic factors, and as homogeneous or heterogeneous types on the basis of morphology. Histopathologic and radiobiologic characteristics were evaluated with respect to these AVM types. Classification depending on the type as well as the size of an AVM is important for modern treatment modalities, especially radiosurgery.

[Blood concentrations of thrombomodulin in patients with various diseases]

Concentrations of thrombomodulin in blood plasma were measured by a one-step sandwich enzyme immunoassay (EIA). The concentrations in normal healthy subjects were 9.9 +/- 2.9 ng/ml. The concentrations were found to be significantly higher in patients with SLE, RA and other collagen diseases in their active stages than at their non-active stages. The concentrations increased in patients with DIC, and significantly higher levels were observed when DIC was complicated by multiple organ failure. These findings indicate that plasma concentrations of thrombomodulin may be a useful parameter for vascular injuries caused by inflammatory processes or coagulation/fibrinolysis reactions.

Origin of ischemia-induced glutamate efflux in the CA1 field of the gerbil hippocampus: an in vivo brain microdialysis study

In vivo brain microdialysis experiments were performed in the gerbil to evaluate the origin of accumulation of extracellular glutamate under transient ischemia. Microdialysis probes were positioned in the CA1 field of the hippocampus in which proliferation of astrocytes, death of CA1 pyramidal neurons, and damage of presynaptic terminals had been induced by 5-min ischemia 10-14 days before the microdialysis experiment; in the white matter of the cerebral cortex, which contained few neurons, few presynaptic terminals, and many astrocytes; or in the histologically normal CA1 field of the hippocampus, and then 5- or 20-min ischemia was induced. When 5-min ischemia was induced, no significant increase in glutamate content was observed in the CA1 field that showed proliferation of astrocytes, death of CA1 pyramidal neurons, and damage of presynaptic terminals and in the white matter of the cerebral cortex, whereas a significant increase in glutamate (15-fold) was observed in the histologically normal CA1 field. When 20-min ischemia was induced, no significant increase in glutamate content was observed in the CA1 field that showed proliferation of astrocytes, death of CA1 pyramidal neurons, and damage of presynaptic terminals and in the white matter during the first 10 min after the onset of 20-min ischemia, but remarkable ischemia-induced increases in glutamate were observed during the last 10 min of 20-min ischemia in both areas. An excessive increase in glutamate (100-fold) was observed during 20-min ischemia in the normal CA1 field of the hippocampus. When a probe was positioned in the CA1 field of the hippocampus in which presynaptic terminals of Schaffer collaterals and commissural fibers had been eliminated by bilateral kainate injections into the lateral ventricles 4-7 days before the microdialysis experiment and then 5-min ischemia was induced, a significant increase in glutamate was observed during the last half of 5-min ischemia. These results suggest that the efflux of glutamate from astrocytes does not contribute to the large ischemia-induced glutamate accumulation in the CA1 field of the hippocampus during 5-min ischemia but contributes to the ischemia-induced increase in glutamate level during ischemia with a longer duration and that ischemia-induced efflux of glutamate in the CA1 field during 5-min ischemia originates mainly from neuronal elements: presynaptic terminals and post-synaptic neurons.

Delayed and severe toxicities of a herbicide containing glufosinate and a surfactant

We report a case of a 59-y-old woman who ingested a herbicide containing glufosinate. Though suffering from severe toxicity of this herbicide, she did not develop convulsions, which experimentally occurs in rats treated with glufosinate. The mechanisms of convulsions are not clear. Several clinical findings in poisoning by this herbicide are suspected to be caused by the surfactant components.

Radiosensitive craniopharyngiomas: the role of radiosurgery

Clinical characteristics of radiosensitive craniopharyngiomas and histologically identical tumours were re-evaluated from among 53 patients. There were 9 squamous cell type and 3 mixed type tumours. Early effects of radiosurgery for two recent cases are reported. Radiosurgery may have an important role to play in the treatment of craniopharyngiomas, especially of the squamous cell type.

Long-term follow-up study of conventional irradiation for brain tumours in children: a role for radiosurgery

21 younger patients (less than 10 years of age) with brain tumours, treated by conventional irradiation, were followed 5 to 20 years (mean 12), using CT scan and/or MR imaging, in order to evaluate adverse effects on the developing brain. Pathological changes such as brain atrophy, lesions in the white matter, calcifications in the brain, and angiopathy were observed in 13 (62%) out of 21 cases. The incidence of abnormalities was related to the age at treatment and the follow-up period. All six cases treated at or under 5 years old and followed more than 10 years showed pathological changes in the brain. In order to minimize the radiation damage, 5 patients with brain tumours less than 5 years old were treated by gamma knife surgery. The early results encourage further trials. Radiosurgery may play a role as an alternative treatment or as a component of future multidisciplinary treatment for brain tumours is children.

Dantrolene protects against ischemic, delayed neuronal death in gerbil brain

The effect was examined of dantrolene, a drug for malignant hyperthermia acting through preventing release of Ca from the ryanodine-type intracellular stores in muscle cells, on ischemic delayed neuronal death in field CA1 of gerbil hippocampus. Dantrolene (1.6 mM in concentration, 3 microliters each in volume), when administered bilaterally in the lateral ventricles 30 min after reperfusion after transient forebrain ischemia for 3 min at 37 degrees C, significantly protected against the neuronal death. It is proposed that the dantrolene-sensitive (most likely, the ryanodine-type) intracellular Ca stores in CA1 pyramidal cells play a pivotal role in the development of ischemic neuronal damage.

Binding of [3H]MK-801, NMDA-displaceable [3H]glutamate, [3H]glycine, [3H]spermidine, [3H]kainate and [3H]AMPA to regionally discrete brain membranes of the gerbil: a biochemical study

Bindings of glutamate receptor agonists and related modulators were investigated in 10 discrete tissues from gerbil brain using a biochemical technique. There appeared considerable discrepancies, in respect of intrahippocampal profiles, from reported data by autoradiography on rat brain. In the gerbil, an almost equivalent level of N-methyl-D-aspartate (NMDA)-displaceable [3H]glutamate binding was found in field CA1 and the dentate gyrus, while approx 30% less in field CA3, a profile which was strikingly similar to that of (+)-5-methyl-10,11-dihydro-5H-dibenzo-[a,d]-cycloheptene-5,10-imin e maleate (MK-801) or of [3H]glycine. [3H]Kainate binding was highest in the dentate gyrus followed by field CA3 and then field CA1, the ratio of the highest to the lowest being 3 to 2. Binding of [3H]DL-alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate (AMPA) differed, to a certain extent, from that of [3H]kainate and showed the dentate gyrus followed by field CA1 and then field CA3 in the rank order of decreasing binding. Taking together, intrahippocampal localization of glutamate receptor subtypes in the gerbil, when analyzed with a biochemical binding assay, looks to be less region selective than the distribution obtained on autoradiography in the rat. Thus, it is likely that these different distribution profiles show different status of receptor function respectively, or are due merely to species difference.

Re-evaluation of ischemia-induced neuronal damage in hippocampal regions in the normothermic gerbil

It has not been discussed whether transient forebrain ischemia of 5-min duration, which is a model frequently used to evaluate pharmacological protection against ischemic injury, is an optimal model in the CA1 field of this animal whose brain temperature is maintained at normothermic levels. The temperature of the brain during an ischemic insult strongly affects the extent of the resulting neuronal injury. If the brain temperature is not regulated, it usually falls in the gerbil by 2 degrees-4 degrees C during 5-min ischemia. However, the brain temperature during ischemic insult was not regulated in many previous studies. In the present study, the effects of transient (1 to 5 min) forebrain ischemia on the development of neuronal degeneration in hippocampal regions of the gerbil whose brain temperature was maintained at 37 degrees C were examined. In the CA1 field of the hippocampus, transient ischemia of 3- and 4-min duration caused almost the same maximal damage (88%-91% neuronal loss) as observed in the gerbils subjected to 5-min ischemia. Transient ischemia of 2- and 2.5-min duration provoked substantial neuronal damage in 25% and 55% of experimental gerbils, respectively. These results indicate that 5-min bilateral forebrain ischemia is more than is necessary to examine ischemia-induced neuronal degeneration in hippocampal CA1 field of the gerbil whose brain temperature is maintained at normothermic levels. In the normothermic gerbil brain, an ischemic period of 3-min already induces extensive neuronal death in the CA1 and, thus, constitutes a sensitive model to evaluate faint protective effects of drugs against ischemic injury in the normothermic gerbil.

Selective vulnerability of hippocampal CA1 neurons cannot be explained in terms of an increase in glutamate concentration during ischemia in the gerbil: Brain microdialysis study

Ischemia-induced selective neuronal injury to field CA1 is not attributable to selective glutamate release in field CA1 during ischemia. Excessive release of glutamate has been proposed to play a major role in ischemia-induced selective neuronal death in field CA1 of the hippocampus. It is well known that, following carotid arterial occlusion of 5 min duration in the gerbil, the pyramidal neurons in field CA1 show delayed neuronal death, whereas the neurons in field CA3 do not show any neuronal degeneration. In the present study, we measured the levels of released glutamate during ischemia in field CA1 and field CA3, separately, and evaluated whether there are subregional differences in the concentration of released glutamate which could be a satisfactory explanation for the selective vulnerability of hippocampal neurons to ischemia. Extracellular glutamate levels were significantly increased during ischemia in both field CA1 and field CA3. No significant differences were detected in the time-course of change in glutamate release and the levels of glutamate between field CA1 and field CA3. This result indicates that the increased glutamate levels do not play a pivotal part in the detrimental effect of glutamate during 5-min ischemia. Some differentiated post-synaptic organization may act as a crucial factor in the development of ischemia-induced selective neuronal death in the gerbil hippocampus.

A multi-arterial clamping method with arterial hypotension does not bring about complete brain ischemia in dogs

The completeness of brain ischemia with a multi-arterial clamping method in dogs was examined using EEG, evoked potentials (EPs) and vessel staining with Evans blue. EEG was monitored by bipolar parietal lead. EPs stimulating electrodes were inserted into the first thoracic (T1) epidural space and recording electrodes into the C2 epidural space, brain stem and cerebral cortex. EPs were measured at 30 s intervals with 50 measurements each time using 3.0 mA current of 100 microseconds duration. In dogs in which brain ischemia was brought about by ventricular fibrillation (VF group, n = 5) EEG disappeared within 40 s in all dogs and the amplitudes of EPs at the C2 spinal cord, brain stem and cerebral cortex after 10 min ischemia were 57%, 0% and 0%, respectively. In the dogs in which a multi-arterial clamping method (clamping internal thoracic arteries, brachiocephalic trunk and left subclavian artery while lowering systolic arterial pressure (AP) below 50 Torr) was used (AC group, n = 5) EEG was still recognizable at 5 min in 2 dogs and the amplitudes of EPs at the C2, brain stem and cerebral cortex at 10 min ischemia were 103%, 53% and 0%, respectively. Stainings with Evans blue were observed in all soft tissue at and below thoracic level, entire intervertebral venous plexus, venous sinuses of cranial dura mater and spinal cord below the lower part of cervical region. Bright red fluorescence by Evans blue was observed microscopically in the vessels of the spinal cord, brain stem and cerebrum (1 dog only). In conclusion a multi-arterial clamping method with arterial hypotension brings about only incomplete brain ischemia.

Transient forebrain ischemia of three-minute duration consistently induces severe neuronal damage in field CA1 of the hippocampus in the normothermic gerbil

We examined the effect of transient forebrain ischemia of 2-, 3-, 4- and 5-min duration on the development of delayed neuronal death in field CA1 of the hippocampus in the gerbil whose brain temperature was maintained at 37 degrees C. Transient ischemia of 3- and 4-min duration caused almost the same maximal damage in field CA1 as observed in the gerbils subjected to 5-min ischemia. A detrimental factor inducing delayed neuronal death in field CA1 may be already set up during the first 3 min after the onset of ischemia in the gerbil whose brain temperature is maintained at normothermic levels.

Delayed neuronal death is induced without postischemic hyperexcitability: continuous multiple-unit recording from ischemic CA1 neurons

It has been proposed that neuronal hyperexcitability during postischemic chronic stage mediates delayed neuronal death in the hippocampal CA1 region. In the present study, multiple-unit spike discharges were continuously recorded from hippocampal CA1 neurons of the awake Mongolian gerbil for 5 days after 5 min of ischemia. Before ischemia, CA1 neurons showed burst-like spike discharges (so-called complex spikes). Spike discharges disappeared 8-40 s after the onset of 5-min ischemia and reappeared 5-30 min after recirculation. The frequency of discharges gradually increased but did not return to the preischemic level. The amplitude of the spike discharges was smaller than that recorded before ischemia and the number of spikes composing the burst-like discharges diminished. CA1 neurons did not show any hyperexcitability for 5 days. However, histological examinations revealed widespread neuronal death in the CA1 region. These results indicate that the delayed neuronal death in the hippocampal CA1 region is induced without postischemic neuronal hyperexcitability.

Sex differences in lactate and glycerol levels during maximal aerobic and anaerobic running

Lactate, glycerol, adrenaline, and noradrenaline in venous blood following 400 m and 3000 m runs were measured in 6 untrained male students, 5 female handball players, 6 female sprinters and 6 female long-distance runners. Physical performance in the two events by the untrained males was the same as for the female handball players, but was less than that by the female sprinters and female long-distance runners. Peak blood lactate levels obtained after 400 m sprinting, and glycerol concentration following the 3000 m run were not significantly different between the untrained males and the female handball players. On the other hand, both peak blood lactate concentrations after 400 m sprinting for female sprinters and peak blood glycerol levels following a 3000 m run for female long-distance runners were significantly higher than those in the untrained male subjects. In both runs there was no significant difference in adrenaline and noradrenaline between the untrained male group and the female handball players. These results suggest that blood lactate in a 400 m run, and glycerol in a 3000 m run might be a reflection of physical performance level but not of sex difference.

[Clinical study on the effect of 24-hour continuous intravenous infusion of CDDP in far-advanced and recurrent carcinoma of the gastrointestinal tract]

This clinical study was undertaken in order to evaluate the effect of CDDP on 43 patients with far-advanced or recurrent carcinoma of the gastrointestinal tract. For all these patients, CDDP at 100 mg/m2 had been administered by continuous intravenous infusion for 24 hours and repeated one to seven times at an interval of 3 to 4 weeks. The effect of this therapy was assessed according to the criteria of clinical evaluation of chemotherapy for solid cancers by Koyama and Saito. The response rate for both complete and partial response was 27.9% among all 43 patients, including 47.1% (8/17) for gastric cancer, 33.3% (1/3) for esophageal cancer, 25.0% (1/4) for hepatocellular carcinoma, 25.0% (1/4) for carcinoma of the gallbladder or bile duct, 20.0% (1/5) for pancreatic cancer and none (0/10) for colorectal cancer. In particular, a good response rate of 37.5% (3/8) was obtained for patients with recurrent tumor and one of 33.3% (6/18) for those with palliative resection of the primary tumor, which was much higher that the rate of 17.6% (3/17) for those without resection. As for the side effects of CDDP therapy, gastrointestinal symptoms were most frequently found in 78.3% of patients followed by bone marrow suppression in 15.2%, and abnormalities of hepatic and renal function in 4.3% and 4.3%, respectively. Consequently, 24-hour continuous intravenous infusion of CDDP was considered to be effective for far-advanced or recurrent carcinoma, especially in cases of gastric cancer.

Normal development of the spinal cord in neonates and infants seen on ultrasonography

The normal development of the spinal cord from the fetal period to infancy was studied by ultrasonography (US) with a 7.5 MHz transducer. Longitudinal and transverse sections of the spinal cord were clearly observed. The sagittal and transverse diameters of the spinal cord increased with age. In order to evaluate disorders of the spinal cord precisely, it is necessary to clarify the normal features as well as the normal development of the spinal canal and cord, and the surrounding structures. US with such a high frequency transducer will be the most suitable for this purpose.