Diffusion Mediates Molecular Transport through the Perivascular Space in the Brain

The perivascular space has been proposed as a clearance pathway for degradation products in the brain, including amyloid β, the accumulation of which may induce Alzheimer's disease. Live images were acquired using a two-photon microscope through a closed cranial window in mice. In topical application experiments, the dynamics of FITC-dextran were evaluated from 30 to 150 min after the application and closure of the window. In continuous injection experiments, image acquisition began before the continuous injection of FITC-dextran. The transport of dextran molecules of different sizes was evaluated. In topical application experiments, circumferential accumulation around the penetrating arteries, veins, and capillaries was observed, even at the beginning of the observation period. No further increases were detected. In continuous injection experiments, a time-dependent increase in the fluorescence intensity was observed around the penetrating arteries and veins. Lower-molecular-weight dextran was transported more rapidly than higher-molecular-weight dextran, especially around the arteries. The largest dextran molecules were not transported significantly during the observation period. The size-dependent transport of dextran observed in the present study strongly suggests that diffusion is the main mechanism mediating substance transport in the perivascular space.

Multiple Cerebral Infarctions Accompanied by Subcortical and Subarachnoid Hemorrhaging in Bilateral Border Zone Areas in a Patient with Eosinophilic Granulomatosis with Polyangiitis

Eosinophilic granulomatosis with polyangiitis (EGPA) is often associated with peripheral neuropathy, but reports of central nervous system involvement are quite rare. We herein report a patient with EGPA first identified as having hypereosinophilia who later developed asthma, eosinophilic otitis media, sinusitis, and hemorrhagic colitis. She subsequently developed hemiparesis. Head magnetic resonance imaging revealed multiple cerebral infarctions with subcortical and subarachnoid hemorrhaging colocalized at the bilateral border zone areas. She was diagnosed with EGPA-induced stroke and successfully treated with oral prednisolone. Inflammation in the small cerebral arteries in EGPA may induce bilateral border zone infarction with colocalizing subcortical and subarachnoid hemorrhaging.

Liver injury after methylprednisolone pulse therapy in multiple sclerosis is usually due to idiosyncratic drug-induced toxicity rather than autoimmune hepatitis

BACKGROUND

In patients with multiple sclerosis (MS), development of hepatic injury has been sporadically reported after methylprednisolone (MP) pulse therapy. Some studies suggest autoimmune hepatitis, while other studies reported direct hepatotoxicity as a cause for hepatic injury. Here, we studied the pathological mechanism of such liver injury in patients with MS.

METHODS

From 2005 to 2016, eight patients with MS developed liver injury after MP pulse therapy. Their average age was 38 years (range: 28-49 years, all female). Autoimmune antibodies were measured and a liver biopsy was performed in seven patients.

RESULTS

Liver injury developed within two weeks in two patients and later (30-90 days after MP) in six patients. No hepatitis-related autoantibody or hepatitis virus were found. All cases were classified as hepatocellular injury and none as cholestatic or mixed. A liver biopsy in five cases revealed centrilobular necrosis with lobular infiltrates of inflammatory cells, suggesting drug-induced acute hepatitis. The biopsy findings in another case suggested a residual stage of acute hepatitis. Only one patient showed portal expansion with periportal fibrosis, suggesting autoimmune hepatitis. All patients recovered spontaneously or with only hepatoprotective drugs, although one patient with possible autoimmune hepatitis recovered slowly.

CONCLUSION

Liver injury develops usually later than two weeks after MP treatment. The prognosis is good in most cases and rarely autoimmune hepatitis may be involved.

Amyloid-Negative Dementia in the Elderly is Associated with High Accumulation of Tau in the Temporal Lobes

Background:

We previously reported that among cases clinically diagnosed with Alzheimer’s disease, the proportion of amyloid beta (Aβ) -negative case increases in the elderly population. Tauopathy including Argyrophilic Grain Disease (AGD) and Neurofibrillary Tangle-Predominant Dementia (NFTPD), may be the leading causes of such dementia.

Objective:

To evaluate the involvement of tau, we studied tau accumulation in Amyloid-Negative Dementia Cases in the Elderly (ANDE) with Positron Emission Tomography (PET).

Methods:

Seven cases with slowly progressive dementia who were older than 80 years and were negative for Aβ were studied. In one case, autopsy obtained 2 years after the PET examination revealed neurofibrillary tangles limited around the parahippocampal gyrus. Four cases showed strong laterality in magnetic resonance imaging atrophy (clinical AGD), while the other three cases had no significant laterality in atrophy (clinical NFTPD). Age-corrected PET data of healthy controls (HC; n = 12) were used as control. Tau accumulation was evaluated with [11C]PBB3-PET.

Results:

High accumulation was found in the lateral temporal cortex in ANDE. In autopsy case, scattered neurofibrillary tangles were found in the parahippocampal gyrus. In addition, there was a very high accumulation of PBB3 in the large area of bilateral parietal lobes, although no corresponding tau component was found in the autopsied case.

Conclusion:

Relatively high burden of tau deposition was commonly observed in the lateral temporal cortex and parietal cortex of ANDE, part of which may explain dementia in these subjects. [11C]PBB3 may be useful in detecting tauopathy in ANDE.

Abstract TP575: Amyloid Accumulation Evaluated With Pib Pet in Patients With Cerebral Amyloid Angiopathy

Purpose: Cerebral amyloid angiopathy (CAA) is a disease with deposition of amyloid beta protein to meninges or intracerebral vessel walls. CAA is known as a cause of cerebral hemorrhage or subarachnoid hemorrhage occurring most frequently in the occipital lobe. CAA is usually accompanied with Alzheimer's disease, which shows specific pattern of amyloid accumulation. In this study we evaluated the distribution of the amyloid deposition in CAA patients using PIB-PET.

Methods: Five patients, 3 males and 2 females, who developed cerebral hemorrhage or subarachnoid hemorrhage and clinically diagnosed as CAA were evaluated. Age of the patients was 28 - 74 years old. To detect amyloid accumulation, we injected 250-350mBq or 400-500mBq of [11C]PiB, followed by 60 minutes or 70 minutes dynamic scan using Eminence B PET camera (Shimadzu Corporation).

Results: PIB accumulation was detected predominantly in the frontal lobe, parietal lobe, and lateral temporal lobe, but much less in the occipital lobe. The distribution of PIB accumulation was mostly similar to that in patients with Alzheimer disease. Little accumulation in the occipital lobe may reflect apparent effects of intracerebral hemorrhage.

Conclusion: In most CAA patients, the examination by PIB-PET fails to detect amyloid deposition in the vessel walls of the occipital lobes. Instead, it more frequently reflect intracerebral amyloid deposition of accompanying Alzheimer's disease.

Amyloid deposition and CBF patterns predict conversion of mild cognitive impairment to dementia

Mild cognitive impairment (MCI) can include the transition from a normal state to dementia. To explore biomarkers for the development of dementia, we performed an 18-month follow-up study in 28 patients with amnestic MCI. Amyloid deposition was examined using PiB PET, and cerebral blood flow (CBF) was examined using SPECT. Cognitive function was periodically assessed. The rate of conversion to dementia was higher in the PiB-positive/equivocal group (74%) than in the PiB-negative group (33%) (p = 0.041). Perfusion SPECT was performed in 16 patients. MCI patients with an AD-characteristic pattern of reduced CBF had a higher PiB-positive/equivocal rate (82%) than those with a non-AD pattern (20%) (p = 0.018), and patients with an AD pattern had a higher conversion rate (82%) than those with a non-AD pattern (40%) (p = 0.094). Clinically, all PiB-positive converters were diagnosed as having Alzheimer's disease (AD), whereas PiB-negative converters were thought to have some form of dementia other than AD. Amyloid PET is useful for predicting conversion to AD in MCI patients. A pattern analysis of perfusion SPECT findings might also be helpful for predicting conversion to AD, but with a lower specificity.

An autopsy case of globular glial tauopathy presenting with clinical features of motor neuron disease with dementia and iron deposition in the motor cortex

Globular glial tauopathy (GGT) is a 4-repeat (4R) tauopathy in which 4R tau accumulates to form globular glial inclusions (GGIs), predominantly in oligodendroglia. To date, little has been reported on iron deposits in patients with GGT. We report a case of GGT with iron deposits in a 78-year-old woman presenting with an 8-year history of slowly progressing limb weakness and cognitive decline. Susceptibility-weighted imaging revealed a low signal intensity in the right precentral gyrus, suggesting iron deposition. A clinical diagnosis of motor neuron disease with dementia was made 4 years after onset. At autopsy, gross pathological findings showed atrophy of the frontal and temporal lobes. A localized area of the precentral gyrus corresponding to the most severely affected limb showed the strongest atrophy, macroscopically, and displayed 4R tau-immunoreactive GGIs and microscopically many ferritin-immunoreactive neurons. We diagnosed this patient as having GGT. This is the first GGT case with iron deposition confirmed both radiologically and pathologically.

Successful treatment of hepatocellular carcinoma with lung metastasis using hepatic and bronchial artery infusion chemotherapy

We herein report a case of hepatocellular carcinoma (HCC) with lung metastasis that was successfully treated with transcatheter arterial infusion chemotherapy via the hepatic and bronchial arteries. A 64-year-old man diagnosed with HCC in 2003 was treated with locoregional therapy followed by sorafenib for recurrent HCC. Tumor thrombosis and lung metastasis were noted in April 2012. We administered IA-call(®), a fine-powder formulation of cisplatin, via the hepatic and bronchial arteries. This therapy resulted in the disappearance of the lung metastases and a partial response to tumor thrombosis. The patient remained alive for 23 months after developing lung metastasis.

Local and retrograde gene transfer into primate neuronal pathways via adeno-associated virus serotype 8 and 9

Viral vector-mediated gene transfer has become increasingly valuable for primate brain research, in particular for application of genetic methods (e.g. optogenetics) to study neuronal circuit functions. Neuronal cell tropisms and infection patterns are viable options for obtaining viral vector-mediated transgene delivery that is selective for particular neuronal pathways. For example, several types of viral vectors can infect axon terminals (retrograde infections), which enables targeted transgene delivery to neurons that directly project to a particular viral injection region. Although recent studies in rodents have demonstrated that adeno-associated virus serotype 8 (AAV8) and 9 (AAV9) efficiently transduce neurons, the tropisms and infection patterns remain poorly understood in primate brains. Here, we constructed recombinant AAV8 or AAV9, which expressed an enhanced green fluorescent protein (EGFP) gene driven by a ubiquitous promoter (AAV8-EGFP and AAV9-EGFP, respectively), and stereotaxically injected it into several brain regions in marmosets and macaque monkeys. Immunohistochemical analyses revealed almost exclusive colocalization of EGFP fluorescence via AAV9-mediated gene transfer with a neuron-specific marker, indicating endogenous neuronal tropism of AAV9, which was consistent with our previous results utilizing AAV8. Injections of either AAV8-EGFP or AAV9-EGFP into the marmoset striatum resulted in EGFP expression in local striatal neurons as a result of local infection, as well as expression in dopaminergic neurons of the substantia nigra via retrograde transport along nigrostriatal axonal projections. Retrograde infections were also observed in the frontal cortex and thalamus, which are known to have direct projections to the striatum. These local and retrograde gene transfers were further demonstrated in the geniculocortical pathway of the marmoset visual system. These findings indicate promising capabilities of AAV8 and AAV9 to deliver molecular tools into a range of primate neural systems in pathway-specific manners through their neuronal tropisms and infection patterns.

Comparison of artifacts on coronal reformation and axial CT pulmonary angiography images using single-detector and 4- and 8-detector multidetector-row helical CT scanners

RATIONALE AND OBJECTIVES

The aim of this study is to compare the degree of stair-step artifact on coronal reformation computed tomographic (CT) pulmonary angiography images obtained using single-detector helical CT (SDCT), four-detector (4-MDCT), and eight-detector multidetector-row CT (8-MDCT) and compare the degree of motion artifact on the corresponding axial CT images.

MATERIALS AND METHODS

Three groups of consecutive patients imaged by means of CT angiography for suspected pulmonary embolus were retrospectively identified by using CT records at our institution: (1) group A (n = 38), SDCT; (2) group B (n = 36), 4-MDCT; and (3) group C (n = 74), 8-MDCT. For each case, coronal multiplanar volume reformation maximal intensity projection images were created by using a standard technique. All images were reviewed in a randomized fashion by two thoracic radiologists who were blinded to the type of CT scanner. Stair-step artifact of pulmonary arteries on coronal reformation images was graded by consensus agreement using a four-point scale (0 = no artifact to 3 = severe artifact). Axial images were assessed for six parameters of motion artifact. The sum of these grades resulted in a total motion score, with a potential range of 0 (no motion) to 12 (severe motion). Statistical analysis was performed using the Mann-Whitney test.

RESULTS

Stair-step artifacts were significantly higher for SDCT (mean, 2.9; median, 3) compared with 4-MDCT (mean, 2.2; median, 2; P < .0001) and 8-MDCT (mean, 1.5; median, 1; P < .0001). Total motion scores were significantly higher for SDCT (mean, 9.3) compared with 4-MDCT (mean, 8.4; P = .03) and 8-MDCT (mean, 6.8; P < .0001).

CONCLUSION

Stair-step artifacts are significantly higher with SDCT compared with MDCT. For MDCT, eight-detector scanners produce images with significantly less artifact than four-detector scanners.

Interactions between clarithromycin and digoxin in patients with end-stage renal disease

OBJECTIVE

To report a significant increase in the serum levels of digoxin associated with the use of clarithromycin in six patients undergoing renal replacement therapy.

CASE SUMMARY

All six patients were males with end-stage renal disease and in need of renal replacement therapy. Four patients were anuric. The mean age was 78.8 +/- 5.8 (66-83) years. All patients except one, who was treated by hemofiltration, were treated by hemodialysis. All patients except one, who had been treated with metildigoxin (0.35 mg/week), were also taking digoxin (0.375 mg/week). Clarithromycin was administered at a dose of 200-400 mg/day for the treatment of bronchitis in all patients. The concomitant administration of clarithromycin increased serum digoxin levels from 1.8-4.0-fold in all cases. In two of six cases, a high probability of digoxin intoxication and suspicion of digoxin intoxication was evident. In three of six cases, serum digoxin levels increased within 12 days after the co-administration of clarithromycin, while in the other three cases, serum digoxin levels were increased 53-190 days after the administration of clarithromycin.

CONCLUSION

The simultaneous administration of clarithromycin caused an increase in digoxin levels in six patients undergoing renal replacement therapy. The increase in the serum digoxin can be attributed to the inhibition of P-glycoprotein in the intestine and/or bile capillary rather than the kidney by clarithromycin since renal function was dramatically impaired, and four of the patients were anuric. The issue of why serum digoxin levels were increased so late in three patients undergoing renal replacement is unclear. However, this interaction seemed to be clinically significant even in ESRD patients, whose renal function was highly impaired. The simultaneous use of digoxin and clarithromycin should be avoided even in patients undergoing renal replacement therapy whose renal function is impaired, since digoxin levels may increase unexpectedly.

High-Resolution CT Using MDCT: Comparison of Degree of Motion Artifact Between Volumetric and Axial Methods

OBJECTIVE

The purpose of this study was to compare the degree of motion artifact on high-resolution CT images obtained using volumetric and axial (nonvolumetric) CT methods.

CONCLUSION

Volumetric high-resolution CT is associated with significantly greater motion artifact compared with axial noncontiguous high-resolution imaging.

Frequency and Severity of Air Trapping at Dynamic Expiratory CT in Patients with Tracheobronchomalacia

OBJECTIVE

The purpose of this study was to compare the frequency and severity of air trapping in patients with and without tracheobronchomalacia using dynamic expiratory volumetric CT.

MATERIALS AND METHODS

The study group consisted of 20 subjects, including 10 patients with bronchoscopically proven tracheobronchomalacia and 10 control subjects of similar ages without tracheobronchomalacia. All 20 subjects underwent MDCT performed at the end of deep inspiration and during dynamic expiration. The images were analyzed at three lung levels, and the extent of air trapping was assessed visually using a 5-point scale. For each subject, a total air-trapping score was derived by summing the values for the three lung levels (possible range, 0-12). Statistical analysis was performed using the Mann-Whitney U test.

RESULTS

In the tracheobronchomalacia group, 10 (100%) of 10 patients showed air trapping, with a median score of 5 (range, 2-12). In the control group, six (60%) of 10 subjects showed air trapping, with a median score of 2 (range, 0-3). The median total air-trapping score was significantly higher (p < 0.001) for the tracheobronchomalacia group compared with the control group. Excessive central airway collapse (expiratory reduction in cross-sectional area of > 50%) was seen on CT scans in all tracheobronchomalacia patients but in none of the control subjects.

CONCLUSION

Air trapping was observed with a higher frequency and greater severity in patients with tracheobronchomalacia than in a control group of patients of similar ages without tracheobronchomalacia.

Plasma triglyceride-rich lipoprotein remnants as a risk factor of 'Pokkuri disease'

In our recent report, it remained unclear whether or not triglyceride-rich lipoprotein remnants (RLP) were associated with the risk of sudden coronary death in younger cases without coronary atherosclerosis that were detected in about 10% of all sudden coronary death cases in Japan. These cases were categorized as 'origin unknown, but suspected to be due to coronary spasm', the so called 'pokkuri disease' in Japan. The present study population consisted of 108 sudden death cases without coronary atherosclerosis [(pokkuri disease n=57) and non-cardiac sudden death (control n=51)] aged 20-69 years from Kanagawa prefecture in Japan. All individuals had died suddenly and unexpectedly, most had no significant history of medical conditions including cardiac symptoms and had not taken medications prior to death according to their medical records. All the autopsies were performed within 12 h after death. Plasma total cholesterol (TC), triglycerides (TG), phospholipids, RLP-C and RLP-TG, VLDL-C, LDL-C, HDL-C, apolipoproteins A-I, A-II, B, C-II, C-III, E, Lp (a) and homocysteine were measured in postmortem plasma samples. The TG-rich lipoprotein remnants measured as RLP-C and RLP-TG were significantly higher in pokkuri disease compared with controls both in fasting and postprandial states (P<0.05 and P<0.001), indicating that RLP-C and RLP-TG were the most significant risk factor in pokkuri disease among the parameters tested in this study. In conclusion the TG level in RLP (RLP-TG) appeared to be strongly associated with the risk of sudden death in the absence of coronary atherosclerosis (pokkuri disease).

A case of adenocarcinoma with mixed subtypes displaying ground-glass opacity on high-resolution CT

We report a case of adenocarcinoma with mixed subtypes with pleural dissemination and lymphatic permeation, although the CT results showed ground-glass opacity that led to the diagnosis of bronchioloalveolar carcinoma without foci of active fibroblastic proliferation.

Neural mechanisms of memory retrieval: role of the prefrontal cortex

In the primate brain, long-term memory is stored in the neocortical association area which is also engaged in sensory perception. The coded representation of memory is retrieved via interactions of hierarchically different cortical areas along bottom-up and top-down anatomical connections. The functional significance of the fronto-cortical top-down neuronal projections has been relevantly assessed in a new experimental paradigm using posterior-split-brain monkeys. When the splenium of the corpus callosum and the anterior commissure were selectively split, the bottom-up visual signal originating from the unilateral striate cortex could not reach the contralateral visual cortical areas. In this preparation, long-term memory acquired through visual stimulus-stimulus association learning was prevented from transferring across hemispheres. Nonetheless, following the presentation of a visual cue to one hemisphere, the prefrontal cortex could instruct the contralateral hemisphere to retrieve the correct stimulus specified by the cue. These results support the hypothesis that the prefrontal cortex can regulate memory recall in the absence of bottom-up sensory input. In humans, functional neuroimaging studies have revealed activation of a distributed neural network, including the prefrontal cortex, during memory retrieval tasks. Thus, the prefrontal cortex is consistently involved in retrieval of long-term memory in primates.

Short communication: mapping of somatosensory cortices with functional magnetic resonance imaging in anaesthetized macaque monkeys

Functional magnetic resonance imaging (fMRI) in macaque monkeys is emerging as a potent candidate to bridge the gap between data from human fMRI studies and data from anatomy, electrophysiology and lesion studies in monkeys. The primary (SI) and secondary (SII) somatosensory cortices are the principal regions for somatosensory information processing and contain systematic representations of the body surface map (somatotopy). To examine the functional organization of the somatosensory cortices in anaesthetized macaque monkeys with fMRI, we asked whether focal and differential activation could be observed in SI and SII in response to tactile stimulation with two parameters: body sides (right and left) and body regions (hand and face). We found that changes in stimulus parameters elicited differential focal activation in both SI and SII in two ways. First, the hand and face stimulation activated SI and SII in the contralateral, but not in the ipsilateral, hemisphere. Second, the hand and face stimulation differentially activated two adjacent regions in both SI and SII. These fMRI results appear to correlate with previous mapping studies by other methods in the macaque somatosensory cortices. This study shows the feasibility of fMRI studies in mapping multiple sensory areas in monkeys by which we can distinguish between adjacent functionally distinct regions.

Memory retrieval under the control of the prefrontal cortex

Memory retrieval is a process wherein a distributed neural network reactivates the brain's representation of past experiences. Sensory long-term memory is represented among a population of neurones in the modality-specific posterior association cortex. The coded representation of memory can be retrieved by interactions of hierarchically different cortical areas along bottom-up and top-down anatomical connections. We examined the function of the prefrontal cortex in memory retrieval by two different approaches. Firstly, a meta-analysis of brain imaging studies revealed that the prefrontal cortex is reliably activated by memory retrieval in humans. Secondly, in order to determine the causal relationship between the prefrontal activations and memory retrieval, we designed a new experimental paradigm using posterior-split-brain monkeys. Following section of the splenium of the corpus callosum and the anterior commissure, visual stimulus-stimulus association learning within one hemisphere did not transfer to the other. Nevertheless, when a visual cue was presented to one hemisphere, the prefrontal cortex could instruct the contralateral hemisphere to retrieve the correct stimulus specified by the cue. These findings suggest that the prefrontal cortex can regulate the recall of long-term memory in the absence of bottom-up sensory inputs.

Bronchopulmonary arterial anastomosis at the precapillary level in human lung. Visualization using CT angiography compared with microangiography of autopsied lung

PURPOSE

To investigate the interrelationships between the bronchial and pulmonary circulations including the existence of precapillary bronchopulmonary arterial anastomoses.

MATERIAL AND METHODS

CT of bronchial arteriography (BAG-CT) was performed in 10 patients and BAG-CT during a pulmonary artery block test (PA-block) in 5 patients with lung cancer. Bronchial and pulmonary circulations were evaluated in 5 autopsied normal lungs by injecting silicone rubber with different colors into the bronchial and pulmonary arteries.

RESULTS

BAG-CT correlated well with the findings at silicone rubber injection into lung autopsy samples. BAG-CT demonstrated inflow of contrast medium into the pulmonary artery during PA-block in all cases, while no inflow was observed before and following reversal of PA-block. Mixed silicone rubber was observed in the lobar to subsubsegmental bronchial arteries in all cases and in the subsubsegmental pulmonary artery in one case.

CONCLUSION

Precapillary bronchopulmonary arterial anastomoses may exist at the level of the lobar bronchi to the periphery. If either the pulmonary or bronchial circulation is disturbed, flow occurs inside the anastomoses to supplement the other flow, especially flow from the bronchial to the pulmonary arteries via the anastomoses, which occurs within 30 min.

Top-down signal from prefrontal cortex in executive control of memory retrieval

Knowledge or experience is voluntarily recalled from memory by reactivation of the neural representations in the cerebral association cortex. In inferior temporal cortex, which serves as the storehouse of visual long-term memory, activation of mnemonic engrams through electric stimulation results in imagery recall in humans, and neurons can be dynamically activated by the necessity for memory recall in monkeys. Neuropsychological studies and previous split-brain experiments predicted that prefrontal cortex exerts executive control upon inferior temporal cortex in memory retrieval; however, no neuronal correlate of this process has ever been detected. Here we show evidence of the top-down signal from prefrontal cortex. In the absence of bottom-up visual inputs, single inferior temporal neurons were activated by the top-down signal, which conveyed information on semantic categorization imposed by visual stimulus-stimulus association. Behavioural performance was severely impaired with loss of the top-down signal. Control experiments confirmed that the signal was transmitted not through a subcortical but through a fronto-temporal cortical pathway. Thus, feedback projections from prefrontal cortex to the posterior association cortex appear to serve the executive control of voluntary recall.

Prediction of preterm delivery by combined use of simple clinical tests

OBJECTIVE

To investigate the usefulness of 4 clinical tests in detecting both the major symptoms (premature uterine contractility and cervical change) and causes (intrauterine infection) of preterm delivery (PTD). These were performed simultaneously on 683 pregnant women at 26 to 28 weeks of gestation.

METHODS

The following four tests were performed at study entry: 1) uterine contractility by the nipple stimulation test (NST); 2) cervical length (CL) measured by transvaginal ultrasonography; 3) measurement of granulocyte elastase in cervical secretion; and 4) measurement of oncofetal fibronectin in vaginal secretion. Pregnancy outcomes were followed up and recorded for the 683 women.

RESULTS

Those women with a CL <25 mm showed a significantly higher PTD rate than those with a CL > or =30 mm (13.3 vs. 2.3%). This difference was dominant in primiparous women. Those women with a CL of 25 to 29 mm formed a potentially high-risk group in which a positive NST was associated with a high incidence of PTD. In contrast, granulocyte elastase in cervical secretion had no predictive efficacy for PTD during these weeks of gestation. The oncofetal fibronectin test had a very low (0.5%) positivity rate and proved to be unsuitable for routine clinical use.

CONCLUSION

The data demonstrated the usefulness of the uterine contraction induction test by nipple stimulation (NST) and cervical length (CL) measurement by transvaginal ultrasonography. The combined evaluation of the NST, CL measurement, and fibronectin assay, when necessary, was useful for the prediction of PTD.

Effect of troglitazone on endocrine and ovulatory performance in women with insulin resistance-related polycystic ovary syndrome

OBJECTIVE

To investigate the effect of troglitazone, a new antidiabetic agent that improves insulin resistance, on endocrine, metabolic, and ovulatory performance in women with insulin resistance-related polycystic ovary syndrome (PCOS).

DESIGN

Prospective clinical study.

SETTING

Infertility outpatient clinic, Niigata University Hospital, Niigata, Japan.

PATIENT(S)

Thirteen women with PCOS and insulin resistance.

INTERVENTION(S)

Troglitazone (400 mg/d) was administered for 12 weeks.

MAIN OUTCOME MEASURE(S)

Insulin and other hormone (gonadotropins, androgens) levels; various parameters relating to glucose and lipid metabolism before, during, and after troglitazone administration; and ovulation rate.

RESULT(S)

The mean (+/-SD) fasting insulin concentration was significantly reduced, from 18.3+/-8.9 to 10.5+/-7.1 microU/mL. The LH level was reduced from 9.7+/-3.4 to 4.8+/-3.9 mIU/mL and the testosterone level was reduced from 0.9+/-0.5 to 0.5+/-0.3 ng/mL in accordance. Atherosclerotic lipid levels also were normalized. Before troglitazone administration, the ovulation rate during clomiphene citrate therapy was 34.9% per cycle (15/43). This increased significantly to 72.7% (8/11) during troglitazone coadministration. Further, an ovulation rate of 42.3% (11/26) was achieved with troglitazone alone.

CONCLUSION(S)

In women with PCOS and insulin resistance, the reduction of hyperinsulinemia that is produced by troglitazone improves the hyperandrogenism that characterizes PCOS, restoring ovulation.

Polycystic ovary syndrome. Insulin resistance and ovulatory responses to clomiphene citrate

OBJECTIVE

To evaluate insulin secretion detected on oral glucose tolerance testing in relation to clomiphene citrate (CC) responses in women with polycystic ovary syndrome (PCOS).

STUDY DESIGN

A total of 37 PCOS women were enrolled. Plasma baseline levels of gonadotropins, sex hormone binding globulin, androstenedione, dehydroepiandrosterone sulfate and testosterone (T) were determined. Insulin and glucose serum concentrations were analyzed in all samples after a 75-g oral glucose tolerance test. A dose of 100 mg/d of CC was given for ovulation induction. Ovulation was detected by ultrasonographic observation in conjunction with a serum progesterone level.

RESULTS

During three consecutive cycles of CC administration, two or more anovulatory cycles were observed in 12 of 37 PCOS women (defined as CC nonresponders). The serum T level and the area under the curve (AUC) of insulin were significantly higher in CC nonresponders. The receiver operating characteristic curve of the AUC of insulin provided the most appropriate cutoff point for the prediction of CC resistance.

CONCLUSION

We found higher androgen secretion and insulin resistance in CC nonresponders. The AUC of insulin was the most reliable method for the prediction of CC resistance associated with insulin resistance.

Prednisolone plus low-dose aspirin improves the implantation rate in women with autoimmune conditions who are undergoing in vitro fertilization

OBJECTIVE

To evaluate the effect of prednisolone plus low-dose aspirin (PSL/LDA) in women with autoimmune conditions who were enrolled in an IVF-ET program.

DESIGN

A retrospective clinical study.

SETTING

In vitro fertilization unit, Niigata University Hospital, Niigata, Japan.

PATIENT(S)

Three hundred seven women who underwent IVF-ET between January 1996 and December 1997.

INTERVENTION(S)

Prednisolone (10 mg/d) and aspirin (81 mg/d) were administered to the women with autoantibodies who chose to participate.

MAIN OUTCOME MEASURE(S)

Pregnancy and implantation rates with IVF-ET.

RESULT(S)

Women undergoing IVF who had positive antinuclear antibodies, with or without antiphospholipid antibodies, had significantly lower pregnancy and implantation rates than did women without autoantibodies (14.8% versus 21.7% and 6.8% versus 10.4%, respectively). The administration of PSL/LDA to women with antinuclear antibodies significantly improved the outcome of IVF-ET (40.6% pregnancy rate and 20.3% implantation rate).

CONCLUSION(S)

A high proportion of women who are undergoing IVF-ET have autoantibodies, which are associated with poor IVF outcomes. The administration of PSL/LDA to these women may improve their implantation rate.

Fatal bilateral adrenal hemorrhage following acute toluene poisoning: a case report

CASE REPORT

A 19-year-old woman was admitted to the emergency center with the development of quadriparesis after prolonged inhalation of lacquer thinner (67% toluene). Laboratory findings were compatible with a distal renal tubular acidosis manifest as metabolic acidosis, hypokalemia, and hyperchloremia. Despite potassium replacement, her condition deteriorated drastically 30 hours later. Blood pressure became refractory to vasopressors, temperature was persistently above 40 degrees C, and death occurred 56 hours later. At autopsy, adrenal insufficiency secondary to bilateral adrenal hemorrhage was diagnosed. Bilateral adrenal hemorrhage should be considered as a potential cause of sudden clinical deterioration during treatment of serious toluene intoxication.

Callosal window between prefrontal cortices: cognitive interaction to retrieve long-term memory

A perceptual image can be recalled from memory without sensory stimulation. However, the neural origin of memory retrieval remains unsettled. To examine whether memory retrieval can be regulated by top-down processes originating from the prefrontal cortex, a visual associative memory task was introduced into the partial split-brain paradigm in monkeys. Long-term memory acquired through stimulus-stimulus association did not transfer via the anterior corpus callosum, a key part interconnecting prefrontal cortices. Nonetheless, when a visual cue was presented to one hemisphere, the anterior callosum could instruct the other hemisphere to retrieve the correct stimulus specified by the cue. Thus, although visual long-term memory is stored in the temporal cortex, memory retrieval is under the executive control of the prefrontal cortex.

Consolidation of visual associative long-term memory in the temporal cortex of primates

Neuropsychological theories have proposed a critical role for the interaction between the medial temporal lobe and the neocortex in the formation of long-term memory for facts and events, which has often been tested by learning of a series of paired words or figures in humans. We have examined neural mechanisms underlying the memory "consolidation" process by single-unit recording and molecular biological methods in an animal model of a visual pair-association task in monkeys. In our previous studies, we found that long-term associative representations of visual objects are acquired through learning in the neural network of the anterior inferior temporal (IT) cortex. In this article, we propose the hypothesis that limbic neurons undergo rapid modification of synaptic connectivity and provide backward signals that guide the reorganization of neocortical neural circuits. Two experiments tested this hypothesis: (1) we examined the role of the backward connections from the medial temporal lobe to the IT cortex by injecting ibotenic acid into the entorhinal and perirhinal cortices, which provided massive backward projections ipsilaterally to the IT cortex. We found that the limbic lesion disrupted the associative code of the IT neurons between the paired associates, without impairing the visual response to each stimulus. (2) We then tested the first half of this hypothesis by detecting the expression of immediate-early genes in the monkey temporal cortex. We found specific expression of zif268 during the learning of a new set of paired associates in the pair-association task, most intensively in area 36 of the perirhinal cortex. All these results with the visual pair-association task support our hypothesis and demonstrate that the consolidation process, which was first proposed on the basis of clinico-psychological evidence, can now be examined in primates using neurophysiolocical and molecular biological approaches.

[Combination of transcatheter arterial infusion of SMANCS and embolization (SMANCS-TAE) for hepatocellular carcinoma--second report]

Patients with unresectable hepatocellular carcinoma (hepatoma) with hypervascularity were treated by SMANCS-TAE. A superselective catheterization technique was used to inject gelatin sponge particles after administration of SMANCS. In 30 patients of first hepatoma treated by SMANCS-TAE. Grade 4 was obtained after 1.7(1-3) courses. The 2-year survival rate was 22%. Some of the 24 patients of second hepatoma treated by SMANCS-TAE have survived over 2 years. Sixteen patients with advanced hepatoma (Vp2-3 or T4) were treated only by SMANCS injection, but none survived over 1 year. SMANCS-TAE appears to have the same potential and safety as L-TAE, when used selectively. Moreover, we can reduce the course of treatment and obtain good QOL for hepatoma patients except in advanced cases.

Uterine blood flow. Assessment in an intrauterine insemination program for unexplained infertility

OBJECTIVE

To evaluate the diagnostic usefulness of color Doppler velocimetry for infertility treatment.

STUDY DESIGN

Sixty-one women undergoing controlled ovarian hyperstimulation and intrauterine insemination with their husbands' semen due to unexplained infertility were enrolled in the study. The Doppler waveforms of the uterine artery, subendome-trial radial artery and intraovarian artery were analyzed around ovulation, and the calculated pulsatility indices (PIs) were correlated with subsequent pregnancy results.

RESULTS

Those women who conceived exhibited a significantly lower uterine artery PI and higher frequency of positive diastolic blood flow in the subendometrial arteries shortly after ovulation. The PI of the intraovarian arteries prior to ovulation was also significantly lower in conception cycles than in nonconception cycles. Uterine artery PIs between different cycles correlated well in the same individual. Lower uterine artery impedance was noted in women receiving supplementation with human menopausal gonadotropins as compared to clomiphene citrate alone.

CONCLUSION

Doppler velocimetry is a useful tool for evaluating uterine receptiveness in infertility treatment. Intrinsically poor uterine perfusion should be investigated in cases of unexplained infertility.

Chromosome analysis of aborted conceptuses of recurrent aborters positive for anticardiolipin antibody

OBJECTIVE

To elucidate the relationship between anticardiolipin antibody and recurrent abortion.

DESIGN

Prospective clinical study.

SETTING

Institutional practice in which patients with recurrent abortion were registered at the outpatient clinic for infertility of Niigata University Hospital.

PATIENT(S)

Five hundred sixty-one patients with recurrent abortions and 148 patients who were not recurrent aborters and who had experienced sporadic abortion.

INTERVENTION(S)

Aborted conceptuses for chromosome analyses were collected from the patients.

MAIN OUTCOME MEASURE(S)

The positive rate of anticardiolipin antibody was assessed in patients with recurrent abortion. Chromosome analyses of aborted conceptuses were performed in 10 patients with positive anticardiolipin antibody who had experienced another pregnancy that resulted in repeated abortion. Similar analyses of aborted conceptuses from 148 sporadic early abortions (controls) were performed.

RESULT(S)

The incidence of chromosome abnormalities in anticardiolipin antibody-positive recurrent aborters was 20.0% (2 of 10 cases), which was significantly lower than that of patients with sporadic abortion (60.1%, 89 of 148 cases).

CONCLUSION(S)

The low incidence of chromosome abnormalities in aborted conceptuses of patients with positive anticardiolipin antibody suggests that this antibody is strongly implicated in the genesis of recurrent abortions.

Mutational analysis of BRCA1 gene in ovarian and breast-ovarian cancer families in Japan

We analyzed the alteration of BRCA1 in DNA obtained from 83 individuals of 13 Japanese site-specific ovarian cancer families and 6 breast-ovarian cancer families. Six germline mutations were detected in 7 families, which consisted of 4 breast-ovarian cancer and 3 site-specific ovarian cancer families, by single-strand conformation polymorphism analysis, followed by direct sequence determination. The mutations included three frameshifts, two nonsense mutations, and one missense mutation causing loss of a zinc-binding motif. The frequency of loss of heterozygosity at the microsatellite markers on the BRCA1 gene was 57% (8 of 14 cases) in site-specific ovarian cancer families, and 100% (6 of 6 cases) in breast-ovarian cancer families. All tumors of the patients carrying a mutation of BRCA1 showed deletion of wild-type alleles, implicating BRCA1 as a tumor suppressor gene. These results suggest that germline mutations of the BRCA1 gene play an important role in the carcinogenesis of breast and/or ovarian cancer in a majority of breast-ovarian cancer families and in some site-specific ovarian cancer families.

Direct intratumoral gene transfer of the herpes simplex virus thymidine kinase gene with DNA-liposome complexes: growth inhibition of tumors and lack of localization in normal tissues

To constitute the site-specific expression of the herpes simplex virus thymidine-kinase (HSV-TK) gene in tumor cells, we have assessed the promoter function of the simian virus 40 (SV40) promoter and the 5'flanking region of c-erbB-2 gene using a luciferase-expressing reporter plasmid. After the transfection of the luciferase plasmid directed by the promoter region of c-erbB-2 gene, a large amount of luciferase activity was observed in c-erbB-2-expressing cells (Colo201, MCF-7, and HEC1-A), while none was detected in cells with no expression of c-erbB-2 protein (HRA and KF cells). On the other hand, a high level of luciferase activity was detected in all tumor cell lines tested, when the transfection was performed with SV40 promoter. The repeated transfection of the liposome-conjugated HSV-TK gene regulated by the SV40 promoter or by the promoter region of c-erbB-2 gene with cultivation in 100 micrograms/ml of aciclovir for 5 days in vitro resulted in growth inhibition for all four cell lines examined or for only c-erbB-2-expressing cells in the presence of SV40 promoter or c-erbB-2 promoter, respectively. Finally, direct injection of the DNA-liposome complex into established tumors in the presence of 50 mg/kg of aciclovir led to significant tumor volume reduction in all three tumors tested when SV40 promoter was employed. However, this anti-tumor effect was noted only in c-erbB-2-positive cells (Colo201 cells) upon intratumoral injection of HSV-TK gene regulated by c-erbB-2 promoter. In the case of intratumoral gene transfer, foreign DNA was detected in only one of seven mice by polymerase chain reaction (PCR) analysis performed 7 days following injection. When PCR analysis was carried out at 14 or 21 days following injection, no DNA signal was found at all. However, DNA was detected in several normal tissues at all three times tested in the case of intravenous injection. No abnormalities were seen in histologic examinations of normal tissues or in serum biochemical parameters following DNA liposome delivery. These results suggest that the direct gene transfer of HSV-TK gene regulated by tumor-specific transcriptional units may be one of the most clinically promising of the selective genetic strategies against cancer.

[Genetic testing of BRCA1 for familial ovarian cancers]

Ovarian cancer is the most lethal kind of gynecological malignancy. Though combination therapy has improved, the prognosis is still poor. It is a risk factor to have a member affected with breast or ovarian cancer in one's family or to have been affected with these diseases. Genetic testing will more effectively enable earlier diagnosis and cure of such diseases. Including the selected results of familial ovarian cancers, we discuss the effectiveness and difficulty of genetic testing of BRCA1 in Japan.

Transvaginal ultrasonographic cervical assessment for the prediction of preterm delivery

To determine the usefulness of transvaginal ultrasonographic cervical assessment for the prediction of preterm delivery in an apparently normal population, 729 pregnant women (between 15 and 34 weeks' gestation) were randomly enrolled in the study in ten tertiary perinatal centers in Japan. Cervical parameters, including cervical length, internal os dilatation, and funneling depth, were measured by transvaginal ultrasound. The predictive values of these measurements for preterm delivery were investigated in a prospective fashion. Among various cervical parameters, cervical length showed the best correlation with pregnancy outcome. Cervical length (mm) was gradually decreased as the gestational age progressed, the regression line being y = 41.21-0.22x. When the mean cervical length minus 1 standard deviation at each gestational age was chosen as a cut-off value, the group with a shortened cervix showed a significantly high preterm delivery rate exclusively in the primigravidae (odds ratio: 4.86, 95% CI: 1.85-12.72). Internal os dilatation, in contrast, was a useful predictor in multiparous women (odds ratio: 6.00, 95% CI: 1.65-21.71). It was concluded that tranvaginal ultrasonographic cervical assessment, especially the measurement of cervical length, was effective for the prediction of preterm delivery in the primigravidae.

The roles of oligomenorrhoea and fetal chromosomal abnormalities in spontaneous abortions

The pathogenesis of spontaneous abortions, other than fetal chromosomal abnormalities, is not fully understood. We examined the incidence of oligomenorrhoea in relation to fetal chromosomal analyses and ultrasonographic examination in women who aborted spontaneously. The data demonstrated that the incidence of oligomenorrhoea was higher in women with normal fetal karyotyped abortions, especially normal karyotyped anembryonic pregnancies, than in those with abnormal karyotyped abortions (34.0 versus 12.5%, P < 0.01). Furthermore, the incidence of oligomenorrhoea was inversely correlated with fetal size exclusively in abortions with normal fetal karyotypes. It is suggested that oligomenorrhoea, i.e. delayed ovulation, itself may be closely associated with sporadic spontaneous abortion.

Accumulation of Tc-99m HMDP in hepatic metastasis from colon carcinoma without detectable calcification

A 51-year-old man was found to have hepatic metastasis from colon carcinoma. Bone scintigraphy with 99mTc-hydroxymethylene diphosphonate showed a ringlike accumulation corresponding to the hepatic mass, which was without calcification on computed tomography. Treatment with chemotherapeutic agents was started. After 4 months, computed tomography showed that the mass was smaller than before and that the margin was calcified. The extraosseous accumulation of the radionuclide may be evidence supporting earlier speculation on calcification that could not yet be detected by computed tomography.

Studies on the cytogenetic and endocrinologic background of spontaneous abortion

OBJECTIVE

To determine whether chronic menstrual irregularity with elevated LH levels has a role in spontaneous abortion.

DESIGN

In 41 consecutively examined women with spontaneous abortions occurring within 11 complete gestational weeks, fetal chromosomal analyses were performed. The differences of endocrinologic background in relation to the result of fetal chromosomal analyses were investigated.

MAIN OUTCOME MEASURES

Endocrinologic profiles, including menstrual history, basal hormone levels (LH, FSH, and PRL), ovarian morphology on ultrasound, and fetal chromosomal karyotypes.

RESULTS

The women with normal fetal karyotypes compared with those with abnormal fetal karyotypes showed higher frequency of menstrual irregularity (47.1% versus 8.3%), elevated basal LH levels (7.42 +/- 5.12 versus 4.41 +/- 1.39 mIU/mL; conversion factor to SI unit, 1.00), and higher frequency of polycystic ovary (41.2% versus 8.3%).

CONCLUSION

Elevated LH-polycystic ovary may be involved in the genesis of spontaneous abortions that are not explainable by fetal chromosomal abnormality.

Treatment for patients with recurrent abortion with positive antiphospholipid antibodies using a traditional Chinese herbal medicine

Twelve patients with recurrent abortion who had shown positive antiphospholipid antibodies were treated through the administration of a Japanese modified traditional Chinese herbal medicine Sairei-To (Chan ling-Tang) The patients had experienced a total of 27 spontaneous abortions in their previous pregnancies and had no other pregnancy history except for one patient. The patients were treated with 9.0 g of Sairei-To per day before their next pregnancy. The positive value of antiphospholipid antibodies returned to negative in 9 patients out of 12 patients through the treatment. Out of 12 patients, in 10 patients, their new pregnancy continued uneventfully and delivered an offspring (Success rate: 83.3%). Thus, the current treatment was considered to be an effective therapy for patients with recurrent abortion who were found to be positive for antiphospholipid antibodies.

Establishment of two distinct anti-cardiolipin antibody-producing cell lines from the same individual by Epstein-Barr virus transformation

Two anti-cardiolipin antibody (ACA)-producing cell lines were established, using Epstein-Barr virus transformation followed by a repeated cluster-picking from the same individual with antiphospholipid syndrome who had a history of 8 consecutive fetal losses and deep venous thrombosis. Characterization of the two ACAs derived from these cell lines revealed that one (Ab-019, subclass IgM, kappa) reacted exclusively with cardiolipin and showed strong lupus anticoagulant activity, while the other (Ab-226, subclass IgM, lambda) reacted with negatively charged phospholipids such as phosphatidylserine and phosphatidylglycerol, as well as cardiolipin. Furthermore, Ab-226 showed reactivity with human umbilical vein endothelial cells whereas Ab-019 did not. It is suggested that ACA is heterogeneous even in the same individual, and that reactivity against negatively charged phospholipids corresponds to reactivity against endothelial cell.

[Significance of the glucose concentration in amniotic fluid for the prediction of chorioamnionitis in preterm labor]

For the rapid and accurate prediction of the presence of chorioamnionitis (CAM) in preterm labor, amniotic fluid analyses were performed in 46 women with preterm labor between 24 to 34 weeks' pregnancy. Ultrasound-guided transabdominal amniocentesis was performed on admission and the amniotic fluid was subjected to the measurement of cell count, glucose, protein and chlorine concentration according to cerebrospinal fluid and neutrophil esterase analysis. The data demonstrated that the amniotic fluid glucose concentration was significantly lower in women with preterm birth/CAM(+) than that with preterm birth/CAM(-) and term birth (19.0 +/- 9.1, 28.0 +/- 7.6, 51.6 +/- 14.5 mg/dl, respectively). All of the women with a glucose concentration of 20mg/dl or less showed signs of CAM. By setting up a cut off value of 25mg/dl, both high sensitivity (81.8%) and specificity (91.4%) for the prediction of CAM were obtained. Positive predictive values for CAM of a glucose concentration of 20mg/dl or less and 25mg/dl or less were 100% and 75% respectively. It was concluded that amniotic fluid glucose concentration measurement is useful for the prediction of CAM. The presence of CAM should be considered when the amniotic fluid glucose concentration is 25mg/dl or less.