Enhancing evidence-informed policymaking in medicine and healthcare: stakeholder involvement in the Commons Project for rare diseases in Japan

BACKGROUND

Although stakeholder involvement in policymaking is attracting attention in the fields of medicine and healthcare, a practical methodology has not yet been established. Rare-disease policy, specifically research priority setting for the allocation of limited research resources, is an area where evidence generation through stakeholder involvement is expected to be effective. We generated evidence for rare-disease policymaking through stakeholder involvement and explored effective collaboration among stakeholders.

METHODS

We constructed a space called 'Evidence-generating Commons', where patients, family members, researchers, and former policymakers can share their knowledge and experiences and engage in continual deliberations on evidence generation. Ten rare diseases were consequently represented. In the 'Commons', 25 consecutive workshops were held predominantly online, from 2019 to 2021. These workshops focused on (1) clarification of difficulties faced by rare-disease patients, (2) development and selection of criteria for priority setting, and (3) priority setting through the application of the criteria. For the first step, an on-site workshop using sticky notes was held. The data were analysed based on KJ method. For the second and third steps, workshops on specific themes were held to build consensus. The workshop agendas and methods were modified based on participants' feedback.

RESULTS

The 'Commons' was established with 43 participants, resulting in positive effects such as capacity building, opportunities for interactions, mutual understanding, and empathy among the participants. The difficulties faced by patients with rare diseases were classified into 10 categories. Seven research topics were identified as priority issues to be addressed including 'impediments to daily life', 'financial burden', 'anxiety', and 'burden of hospital visits'. This was performed by synthesising the results of the application of the two criteria that were particularly important to strengthen future research on rare diseases. We also clarified high-priority research topics by using criteria valued more by patients and family members than by researchers and former policymakers, and criteria with specific perspectives.

CONCLUSION

We generated evidence for policymaking in the field of rare diseases. This study's insights into stakeholder involvement can enhance evidence-informed policymaking. We engaged in comprehensive discussions with policymakers regarding policy implementation and planned analysis of the participants' experiences in this project.

Why does it take so long for rare disease patients to get an accurate diagnosis?—A qualitative investigation of patient experiences of hereditary angioedema

Introduction

Many patients with rare diseases experience a diagnostic delay. Although several quantitative studies have been reported, few studies have used a qualitative approach to directly examine how patients with rare disease obtain a diagnosis and why it takes many years. In this study, we focused on hereditary angioedema (HAE), which has been reported to have long diagnostic delays, despite the knowledge that not having an accurate diagnosis can cause life-threatening problems.

Objective

The objective of this study was to analyze patients’ experiences and elucidate why it takes a long time to reach a diagnosis of HAE. We also aimed to propose possible solutions for the problem.

Methods

A qualitative study using semi-structured interviews was conducted. Nine patients who took over 5 years from the presentation of initial symptoms to an HAE diagnosis participated. The contents of the interviews were subjected to an inductive contents analysis.

Results

By analyzing the patients’ struggles that were experienced during the undiagnosed period, three themes were generated: (1) acceptance and resignation towards their conditions, (2) proactive search for a cause, and (3) independent efforts outside of the hospital. While a few patients continued to seek out a diagnosis during the undiagnosed period, many had become accustomed to their health condition without suspecting a rare disease.

Conclusions

We found that one of the most important factors related to the prolonged undiagnosed period is the lack of suspicion of a rare disease by patients and their medical professionals. While current policies tend to focus on the period from suspecting rare diseases to the time of a clear diagnosis, our results strongly suggest that measures are needed to facilitate patients and clinicians to become aware of rare diseases.

Polymorphisms in Vitamin A-Related Genes and Their Functions in Autoimmune Thyroid Disease

Background: Vitamin A is a factor that suppresses immune responses, including T helper (Th)1 and Th17 responses. However, there has been no report showing the association between vitamin A-related genes (CYP26B1, RARB, and RARG) and the prognosis of autoimmune thyroid disease (AITD). The objective of this study was to clarify the association between vitamin A-related genes and the susceptibility and prognosis of AITD. Methods: We genotyped polymorphisms in genes encoding vitamin A-related molecules using the polymerase chain reaction-restriction fragment length polymorphism method. The proportion of T helper cells was analyzed by flow cytometry. Serum interleukin (IL)-17 and interferon (IFN)-γ were examined by enzyme-linked immunosorbent assay. Results:CYP26B1 rs3768641 GG genotype and G allele were significantly more frequent in patients with mild Hashimoto's thyroiditis (HT) than in those with severe HT (p = 0.0013 and 0.0024, respectively). The RARB rs1997352 CC genotype was significantly more frequent in HT patients than in controls (p = 0.0207). The proportion of Th17 cells was significantly higher in CYP26B1 rs2241057 TT genotype than C carrier (CC+CT genotypes) (p = 0.0385), in RARB rs1997352 A carrier (AA+AC genotypes) than those with CC genotype (p = 0.0246), and in RARG rs7398676 G carrier (GG+GT genotypes) than in TT genotype (p = 0.0249). In the RARB rs1997352 polymorphism, HT patients with a high concentration of IFN-γ (≥150 ng/mL) were more frequent in the CC genotype than in A carriers (AA+AC genotypes) (p = 0.0226). Serum levels of IL-17 were significantly elevated in subjects with the TT genotype of the CYP26B1 rs2241057 single nucleotide polymorphism (SNP) (p = 0.0026) and in subjects with the GG genotype of the CYP26B1 rs3798641 SNP (p = 0.030). Subjects with a high concentration of IL-17 (≥0.71 pg/mL) were more frequent in RARG 7398676 G carriers (GG+GT genotypes) than in TT genotype (p = 0.0218). Conclusions: Polymorphisms in the CYP26B1 gene were related to the proportion of Th17 cells, the level of IL-17 and the severity of HT. Polymorphisms in RAR were related to the proportion of Th17 cells, concentrations of IFN-γ and IL-17, and susceptibility to HT.

Inhibition of fibrotic changes in infrapatellar fat pad alleviates persistent pain and articular cartilage degeneration in monoiodoacetic acid-induced rat arthritis model

OBJECTIVE

We have reported that fibrotic changes in infrapatellar fat pad (IFP) after acute joint inflammation are closely associated with persistent pain in rats. In this study, to examine the effects of anti-fibrotic treatment on persistent pain, we used C-type natriuretic peptides (CNP) at the recovery phase after acute joint inflammation.

DESIGN

Thirty-two male Wistar rats were used in this study. Monoiodoacetic acid (MIA) was injected intra-articularly to induce IFP fibrosis and persistent pain. CNP was injected after acute inflammatory phase in the same knee joint. Time-course pain-avoidance behavior tests and histological analyses were performed to examine the effects of CNP.

RESULTS

Histological evaluations indicated that intra-articular injection of CNP inhibited fibrotic changes in IFP after acute inflammation. Incapacitance tests indicated that MIA injection into rat knee joint quickly decreased the percent weight on ipsilateral limb. In the vehicle group, the decrease was maintained up to day 28, suggesting that pain persistence occurred after acute inflammation (Day 0/Day 28, Est Dif -8.15, CI -10.78∼-5.53, Linear mixed-effect model). In contrast, the pain was alleviated in the CNP group after day 14 (Day0/Day 14, -0.51, -2.62-1.59). In addition, we observed significant improvement in the degree of articular cartilage degeneration at day 14 in the CNP group (OARSI score: vehicle 16.14 ± 4.37 vs CNP 6.87 ± 3.44, P < 0.01; Wilcoxon rank sum test).

CONCLUSION

Fibrotic changes in IFP may play important roles in both persistent pain and articular cartilage degeneration.

The practice of active patient involvement in rare disease research using ICT: experiences and lessons from the RUDY JAPAN project

BACKGROUND

The role of patients in medical research is changing, as more emphasis is being placed on patient involvement, and patient reported outcomes are increasingly contributing to clinical decision-making. Information and communication technology provides new opportunities for patients to actively become involved in research. These trends are particularly noticeable in Europe and the US, but less obvious in Japan. The aim of this study was to investigate the practice of active involvement of patients in medical research in Japan by utilizing a digital platform, and to analyze the outcomes to clarify what specific approaches could be put into practice.

METHODS

We developed the RUDY JAPAN system, an ongoing rare disease medical research platform, in collaboration with the Rare and Undiagnosed Diseases Study (RUDY) project in the UK. After 2 years of preparation, RUDY JAPAN was launched in December 2017. Skeletal muscle channelopathies were initially selected as target diseases, and hereditary angioedema was subsequently added. Several approaches for active patient involvement were designed through patient-researcher collaboration, namely the Steering Committee, questionnaire development, dynamic consent, and other communication strategies. We analyzed our practices and experiences focusing on how each approach affected and contributed to the research project.

RESULTS

RUDY JAPAN has successfully involved patients in this research project in various ways. While not a part of the initial decision-making phase to launch the project, patients have increasingly been involved since then. A high level of patient involvement was achieved through the Steering Committee, a governance body that has made a major contribution to RUDY JAPAN, and the process of the questionnaire development. The creation of the Patient Network Forum, website and newsletter cultivated dialogue between patients and researchers. The registry itself allowed patient participation through data input and control of data usage through dynamic consent.

CONCLUSIONS

We believe the initial outcomes demonstrate the feasibility and utility of active patient involvement in Japan. The collaboration realized through RUDY JAPAN was enabled by digital technologies. It allowed busy patients and researchers to find the space to meet and work together for the Steering Committee, questionnaire development and various communication activities. While the practice of active patient involvement in Japan is still in its early stages, this research confirms its viability if the right conditions are in place. (331 words).

High Resolution Computed Tomography of Auditory Ossicles

Auditory ossicular sections were scanned at section thicknesses (mm)/section interspaces (mm) of 1.5/1.5 (61 patients), 1.0/1.0 (13 patients) or 1.5/1.0 (33 patients). At any type of section thickness/interspace, the malleal and incudal structures were observed with almost equal frequency. The region of the incudostapedial joint and each component part of the stapes were shown more frequently at a section interspace of 1.0 mm than at 1.5 mm. The visualization frequency of each auditory ossicular component on two or more serial sections was investigated. At a section thickness/section interspace of 1.5/1.5, the visualization rates were low except for large components such as the head of the malleus and the body of the incus, but at a slice interspace of 1.0 mm, they were high for most components of the auditory ossicles.

Management of paediatric tuberculosis in provincial and district hospitals in Afghanistan

Case detection, diagnosis and treatment of tuberculosis 1 B) in children are challenging issues vorldwide. This study in Afghanistan aimed to evaluate paediatric TB case management, including contact investigation, at health facilities where all diagnostic processes were available. In 7 out of 8 regions of the country 1 province was selected. Documents used for management of paediatric TB cases were reviewed in 15 distinct hospitals and 8 provincial hospitals in the selected provinces. The key issues which emerged were: a low suspect rate among total outpatients (0.4%) and a very low suspect rate among children aged < 5 years; low performance of suspect management (68.5% suspects received further examinations); low utilization of other diagnostic methods; a high early defaulter rate (14.0%); and insufficient coverage of contact management (74.0%). This survey indicated that the Afghanistan national TB programme needs to develop plans to improve the quality of diagnosis, suspect management and contact management in paediatric TB cases.

Intracerebral transplantation of the A7 immortalized astrocytic cell line

The A7 cell line is an astrocyte-like cell immortalized by SV40 large T antigen, using retroviral-mediated gene transfer. These cells were transplanted into rat brains, and the graft-host interaction was investigated immunohistochemically. The A7 cells survived focally 2, 6 and 8 weeks after transplantation and retained the immunocytochemical properties observed in vitro. No immunological response was observed. GAP-43 and N-cadherin immunoreactivities were not expressed by A7 cells, but were seen in the matrix within the area of the graft and in the surrounding brain tissue. This indicates that A7 cells may stimulate expression of GAP-43 and N-cadherin immunoreactivity by host tissue. Expression of Thy 1.1 was not observed within the graft site after 2 weeks of survival, but 6 and 8 weeks after transplantation Thy 1.1 was observed within the graft area, indicating the possible co-existence of grafted cells and host tissue. Although indirect, these observations suggest that the A7 cells induce changes in host brain, including possible growth or regeneration of host tissue into the graft area.

Association of genetic variants for susceptibility to obesity with type 2 diabetes in Japanese individuals

AIMS/HYPOTHESIS

In populations of East Asian descent, we performed a replication study of loci previously identified in populations of European descent as being associated with obesity measures such as BMI and type 2 diabetes.

METHODS

We genotyped 14 single nucleotide polymorphisms (SNPs) from 13 candidate loci that had previously been identified by genome-wide association meta-analyses for obesity measures in Europeans. Genotyping was done in 18,264 participants from two general Japanese populations. For SNPs showing an obesity association in Japanese individuals, we further examined diabetes associations in up to 6,781 cases and 7,307 controls from a subset of the original, as well as from additional populations.

RESULTS

Significant obesity associations (p < 0.1 two-tailed, concordant direction with previous reports) were replicated for 11 SNPs from the following ten loci in Japanese participants: SEC16B, TMEM18, GNPDA2, BDNF, MTCH2, BCDIN3D-FAIM2, SH2B1-ATP2A1, FTO, MC4R and KCTD15. The strongest effect was observed at TMEM18 rs4854344 (p = 7.1 × 10(-7) for BMI). Among the 11 SNPs showing significant obesity association, six were also associated with diabetes (OR 1.05-1.17; p = 0.04-2.4 × 10(-7)) after adjustment for BMI in the Japanese. When meta-analysed with data from the previous reports, the BMI-adjusted diabetes association was found to be highly significant for the FTO locus in East Asians (OR 1.13; 95% CI 1.09-1.18; p = 7.8 × 10(-10)) with substantial inter-ethnic heterogeneity (p = 0.003).

CONCLUSIONS/INTERPRETATION

We confirmed that ten candidate loci are associated with obesity measures in the general Japanese populations. Six (of ten) loci exert diabetogenic effects in the Japanese, although relatively modest in size, and independently of increased adiposity.

High frequency electrical stimulation attenuates progressive necrosis and cavitation following spinal cord injury

This study evaluates the influence of preconditioning by following electrical stimulation on primary and secondary lesion formation following spinal cord injury in rats. The dorsal surface of the spinal cord was stimulated (500 Hz. 10 pulses/train, inter train interval of 10 sec. for 2 hrs) at the T7 level 24 hrs before a right side hemisection, carried out immediately after injury and maintained every 24 hrs for 7 days. Preconditioning by electrical stimulation of the spinal cord activates reactive astrocytes and significantly attenuates edema and progressive necrosis and cavitation, concerning especially the primary (1, 3 weeks post injury) and secondary (24 hrs, 1, 3 weeks post injury) lesion volume. The results suggest that pre-conditioning by electrical stimulation prevents spinal cord secondary lesion formation after injury, and that the beneficial effect is provided by astroglial cells with regard to their ability to attenuate trauma induced cellular cascades.

Motor evoked potentials following transcranial magnetic stimulation after middle cerebral artery and/or basilar artery occlusions in rats

To clarify the significance of motor evoked potentials following transcranial magnetic stimulation (MMEPs) in acute stage of cerebral ischemia, MMEPs were recorded in rats with the right middle cerebral artery (MCA) and/or the basilar (BA) artery occlusions. MMEPs from bilateral forelimb muscle and regional cerebral blood flow (rCBF) of the pons were recorded simultaneously. After MCA occlusion, the amplitudes of MMEPs from left forelimb were increased up to approximately 184-221% of the pre-ischemic value for 60 min, though the latencies were unchanged. On the other hand, in the rats of BA occlusion and both BA and MCA occlusion groups, MMEPs amplitudes were decreased to 8-25% of the pre-ischemic value for 60 min. Pontine rCBF was decreased to 28-44% in both groups. As a mechanism of the facilitation of MMEPs after MCA occlusion, the affection of the inhibitory mechanism between the cerebral cortex and the generator of MMEPs by MCA occlusion is speculated.

Clinical features of symptomatic Rathke's cleft cyst

To investigate the clinical features of Rathke's cleft cysts (RCCs), we retrospectively analyzed 15 cases with histologically confirmed RCCs. All patients underwent formal testing of visual field, endocrinological evaluation and magnetic resonance imagings. As overall presenting symptoms, endocrine disturbance was the most common symptoms, followed by visual disturbance and headache. Among the endocrine disturbances based on adenohypophysial dysfunction, hyperprolactinemia was most common. Considering the size of RCCs, RCCs could induce hyperprolactinemia only when the cysts became large enough to compress the infundibular system. Our series showed relative high incidence of pituitary dwarfism and diabetes insipidus (DI). These facts indicated that RCCs could evoke hyposecretion of growth hormone in young patients and DI in aged patients by direct compression of the pituitary gland in the early stage of progression. All cases who had headache had no other symptoms. We could not prove the evidence that RCCs could induce headaches in these cases. This might be suggested that headache could not be a sole symptom in cases of RCCs.

Midaortic syndrome in childhood associated with a ruptured cerebral aneurysm: a case report

BACKGROUND

We present a patient with a midaortic syndrome who presented with subarachnoid hemorrhage caused by rupture of an anterior communicating artery aneurysm.

CASE DESCRIPTION

A 14-year-old boy with midaortic syndrome was admitted to our hospital because of subarachnoid hemorrhage due to rupture of an anterior communicating artery aneurysm. He also developed acute renal failure due to previously controlled hypotension. After blood dialysis, successful clipping of the aneurysm was performed. The postoperative course was complicated by malignant renovascular hypertension due to midaortic syndrome. Medical treatment failed to control his hypertension; left primary nephrectomy improved his condition.

CONCLUSION

Although midaortic syndrome is rare, it may be significant as a cause of cerebral hemorrhage in childhood.

The key role of the transforming growth factor-beta system in the pathogenesis of diabetic nephropathy

Progressive renal injury in diabetes mellitus leads to major morbidity and mortality. The manifestations of diabetic nephropathy may be a consequence of the actions of certain cytokines and growth factors. Prominent among these is transforming growth factor-beta (TGF-beta) because it promotes renal cell hypertrophy and stimulates extracellular matrix accumulation, the two hallmarks of diabetic renal disease. In cell culture, high ambient glucose increases TGF-beta mRNA and protein in proximal tubular, glomerular epithelial, and mesangial cells. Neutralizing anti-TGF-beta antibodies prevent the hypertrophic and matrix stimulatory effects of high glucose in these cells. In experimental and human diabetes mellitus, several reports describe overexpression of TGF-beta in the glomeruli and tubulointerstitium. We demonstrate that short-term treatment of diabetic mice with neutralizing monoclonal antibodies against TGF-beta significantly reduces kidney weight and glomerular hypertrophy and attenuates the increase in extracellular matrix mRNAs. Long-term treatment of diabetic mice further improves the renal pathology and also ameliorates the functional abnormalities of diabetic nephropathy. Finally, we provide evidence that the renal TGF-beta system is significantly up-regulated in human diabetes. The kidney of a diabetic patient actually elaborates TGF-beta1 protein into the circulation whereas the kidney of a non-diabetic subject extracts TGF-beta1 from the circulation. The data we review here strongly support the hypothesis that elevated production or activity of the TGF-beta system mediates diabetic renal hypertrophy and extracellular matrix expansion.

Increased glomerular and tubular expression of transforming growth factor-beta1, its type II receptor, and activation of the Smad signaling pathway in the db/db mouse

Activation of the renal transforming growth factor-beta (TGF-beta) system likely mediates the excess production of extracellular matrix in the diabetic kidney. To establish the role of the TGF-beta system in type 2 diabetic nephropathy, we examined the intrarenal localization and expression of the TGF-beta1 isoform, the TGF-beta type II receptor, and the Smad signaling pathway in the 16-week-old db/db mouse, a genetic model of type 2 diabetes that exhibits mesangial matrix expansion, glomerular basement membrane thickening, and renal insufficiency that closely resemble the human disease. Compared with its nondiabetic db/m littermate, the db/db mouse showed significantly increased TGF-beta1 mRNA expression by in situ hybridization in both glomerular and tubular compartments. Likewise, TGF-beta1 protein, by immunohistochemical staining, was increased in both renal compartments, but the fractional expression of TGF-beta1 protein was less than that of the mRNA in the glomerulus. In situ hybridization and immunohistochemical staining for the TGF-beta type II receptor revealed concordant and significant increases of both mRNA and protein in the glomerular and tubular compartments of diabetic animals. Finally, immunohistochemistry showed preferential accumulation of Smad3 in the nuclei of glomerular and tubular cells in diabetes. The complementary technique of Southwestern histochemistry using a labeled Smad-binding element demonstrated increased binding of nuclear proteins to Smad-binding element, indicating active signaling downstream of the TGF-beta stimulus. We therefore propose that the TGF-beta system is up-regulated at the ligand, receptor, and signaling levels throughout the renal cortex in this animal model of type 2 diabetes. Our findings suggest that the profibrotic effects of TGF-beta may underlie the progression to glomerulosclerosis and tubulointerstitial fibrosis that characterize diabetic nephropathy.

Leptin stimulates type I collagen production in db/db mesangial cells: glucose uptake and TGF-beta type II receptor expression

BACKGROUND

Serum leptin levels correlate with fat cell mass and are elevated in patients with massive obesity and type 2 diabetes mellitus, which are strong risk factors for the development of glomerulosclerosis. We have previously shown in cultured glomerular endothelial cells that leptin stimulates cellular proliferation and expression of the prosclerotic cytokine transforming growth factor-beta1 (TGF-beta1). Although the effect of leptin on the hypothalamus to regulate energy homeostasis is well known, the effect of leptin on the kidney, and specifically on the glomerular mesangial cell, is unclear.

METHODS

The obese, diabetic db/db mouse, which lacks the functional full-length Ob-Rb leptin receptor, is a suitable model to assess the effects of hyperleptinemia on peripheral tissues that express other receptor isoforms. The effects of leptin on glucose uptake, the TGF-beta system, and type I collagen production were evaluated in db/db mouse mesangial cells in culture. A phosphatidylinositol-3 kinase (PI-3K) inhibitor was used to assess the role of PI-3K in mediating the effects of leptin.

RESULTS

A short form of the leptin receptor (Ob-Ra), but not Ob-Rb, was present by reverse transcription-polymerase chain reaction in the kidney and mesangial cells of both nondiabetic db/m and diabetic db/db mice. In db/db mesangial cells, leptin increased 2-deoxy-D-glucose (2DOG) uptake dose dependently and stimulated gene expression of TGF-beta type II receptor (TbetaRII) and alpha1(I) collagen, but not TGF-beta1. Protein production of type I collagen (enzyme-linked immunosorbent assay) was also increased by leptin. Both leptin-stimulated 2DOG uptake and type I collagen production were suppressed by a PI-3K inhibitor, LY294002. Mesangial cells pretreated with leptin exhibited increased responsiveness to exogenous TGF-beta1, as evidenced by a greater production of type I collagen protein in leptin-pretreated cells exposed to low-dose TGF-beta1 (0.5 ng/mL). The addition of both TGF-beta1 (2 ng/mL) and leptin (100 ng/mL) increased type I collagen production more than addition of either TGF-beta1 or leptin alone.

CONCLUSIONS

Leptin increases glucose uptake and type I collagen in db/db mesangial cells through a PI-3K-dependent pathway. We postulate that increased leptin levels may transmit a signal through the short-form leptin receptor to up-regulate TbetaRII and activate the intraglomerular TGF-beta system, which may contribute to the glomerulosclerosis of obesity or type 2 diabetes.

Retro-odontoid soft tissue mass associated with atlantoaxial subluxation in an elderly patient: a case report

BACKGROUND

We present the case of an elderly patient with a retro-odontoid soft tissue mass associated with atlanto-axial subluxation.

CASE DESCRIPTION

A 74-year-old man was admitted to our hospital with progressive motor weakness in his right arm and neck pain. Radiological examinations revealed atlantoaxial subluxation and diffuse degenerative changes. Cervical MRI revealed a syrinx at the C1 level and a retro-odontoid soft tissue mass that severely compressed the spinal cord. The mass was of low signal intensity on both T1- and T2-weighted images. Conservative therapy could not stop the progression of his symptoms, so posterior decompression via a laminectomy of C1 and occipitocervical fixation was performed. These procedures resulted in an improvement of his neurological condition and in reduction of the mass and the compression of the spinal cord.

CONCLUSION

The patient lacked any specific conditions that might have caused chronic atlantoaxial subluxation. The degenerative changes alone might have provoked chronic atlantoaxial subluxation and a subsequent retro-odontoid soft tissue mass. In patients with this condition, posterior fixation without direct removal of the mass should be the first choice for surgical intervention.

Inner ear anomaly of three-dimensional computed tomography: computed tomographic attenuation and image changes

With regard to image diagnosis of inner ear anomalies, three-dimensional computed tomography (3D-CT) is useful in obtaining very realistic images that are unmatched by 2D-CT. Unlike the step scanning in the existing 2D-CT, in helical 3D-CT, scanning is performed in a spiral motion by continuously rotating the scanner and moving the table along the body axis at a constant speed. As a result, data obtained by this CT are continuous and very smooth curves can be obtained. Among the data, the CT attenuation determines the quality of the final 3D images. In the present paper, the usefulness of 3D-CT was investigated in a case with Mondini-type inner ear malformation.

Three-dimensional magnetic resonance imaging findings of inner ear anomaly

Using three-dimensional magnetic resonance imaging (3D-MRI), the membranous labyrinth was examined in normal cases and in a case with bilateral Mondini-type inner ear malformations. Both ears were also examined by high-resolution computed tomography (CT) of the temporal bone. 3D-MRI provided more detail than findings obtained by conventional high-resolution CT and it enabled 3D observations to be made. Detailed examination of maximum intensity projection images along the cochlea axis revealed the cochlear turns in three dimensions.

Dissecting aneurysm of the anterior cerebral artery requiring surgical treatment--case report

A 45-year-old male presented with spontaneous dissecting aneurysm in the anterior cerebral artery manifesting as headache persisting for several days and speech disturbance. Neurological and laboratory examinations showed no abnormalities. Magnetic resonance imaging revealed infarction in the right cingulate gyrus. Angiography revealed occlusion of the right A2. Repeat angiography 8 months later showed a saccular aneurysm had developed. The interhemispheric approach exposed the aneurysm at the junction between the right frontopolar artery and the pericallosal artery. The aneurysm was fusiform due to the right A2 dissection. The aneurysm was trapped and resected. One month after the operation, the patient was discharged without neurological deficits. Cases of dissecting aneurysms in the anterior cerebral artery with ischemic onset are usually treated conservatively. Cases requiring surgery include those due to trauma, growing aneurysms, giant aneurysms, and uncontrolled hypertension. Some dissecting aneurysms of the distal anterior cerebral artery require only resection without bypass surgery.

Adenovirus-mediated hepatocyte growth factor gene transfer prevents lethal liver failure in rats

Hepatocyte growth factor (HGF) has a potent antiapoptotic effect on hepatocytes in D-galactosamine (D-GalN)/lipopolysaccharide (LPS)-treated rats. Here, we report that adenovirus mediated HGF gene transfer into liver prevents liver failure and reduces mortality of rats treated with d-GalN/LPS. Fisher 344 rats, which were given intraperitoneal injections of pAxCAHGF 48 h before, were treated with D-GalN/LPS. Serum ALT in the HGF group at 6 and 12 h after D-GalN/LPS was decreased to 1/6 and 1/12 of the control group (P < 0.01, each). Concomitant reduction of apoptotic cells were also observed. The Kaplan-Meier analysis showed that a survival rate in the HGF group was improved, compared to that in the control group (P < 0.05). Caspase-3 activity in the HGF group decreased, compared to that in the control group, especially at 12 h (P < 0.05), although it maintained a high level in the control group. Expression of Bcl-xL and cyclooxygenase-2 (Cox-2) was induced in liver by HGF gene transfer. These data suggest that HGF exerts an antiapoptotic effect through dual induction of Bcl-xL and Cox-2, which suppresses caspase-3 activity.

Attempted gene therapy for intractable pain: dexamethasone-mediated exogenous control of beta-endorphin secretion in genetically modified cells and intrathecal transplantation

For optimal neural transplantation using gene engineering, it might be important to control the expression of the transfected gene extrinsically as required. This strategy could be very useful for the treatment of intractable pain that responds to opioids. For this purpose, we established a genetically modified embryonal carcinoma cell line (P19) in which the expression of beta-endorphin (beta-EP) could be controlled by the addition of dexamethasone. To obtain extrinsic control, we transfected the cells with pMAMneo containing mouse MMTV-LTR as a promoter and cDNA of the artificial beta-EP. The upregulation of beta-EP, through the activation of MMTV by the administration of dexamethasone, was confirmed in vitro. Then we transplanted these cells into the subarachonoid space in rats and evaluated the analgesic potential of these cells in vivo by hot plate test and formalin test. In the rats that received beta-EP-producing cells, we observed prominent analgesic effects after the transplantation for a month. The administration of naloxone blocked these effects. Intraperitoneal injection of 100 mg/kg dexamethasone further enhanced these effects by up to two times. These data indicate obvious analgesic effects of the cells after the transplantation and the possible exogenous upregulation of transfected beta-EP gene expression in vivo. The application of this technique might provide a new therapeutic approach to various neurological diseases.