Search for η^{'} Bound Nuclei in the ^{12}C(γ,p) Reaction with Simultaneous Detection of Decay Products

We measured missing mass spectrum of the ^{12}C(γ,p) reaction for the first time in coincidence with potential decay products from η^{'} bound nuclei. We tagged an (η+p) pair associated with the η^{'}N→ηN process in a nucleus. After applying kinematical selections to reduce backgrounds, no signal events were observed in the bound-state region. An upper limit of the signal cross section in the opening angle cosθ_{lab}^{ηp}<-0.9 was obtained to be 2.2  nb/sr at the 90% confidence level. It is compared with theoretical cross sections, whose normalization ambiguity is suppressed by measuring a quasifree η^{'} production rate. Our results indicate a small branching fraction of the η^{'}N→ηN process and/or a shallow η^{'}-nucleus potential.

Adjunctive levetiracetam in the treatment of Chinese and Japanese adults with generalized tonic-clonic seizures: A double-blind, randomized, placebo-controlled trial

Objective

To assess the efficacy, safety, and tolerability of adjunctive levetiracetam (LEV) in Chinese and Japanese adults with generalized tonic-clonic (GTC) seizures (N01159; NCT01228747).

Methods

This double-blind, randomized, placebo-controlled, multicenter phase III trial comprised: 4-week retrospective and 4-week prospective baseline, 12-week dose-adjustment, and 16-week evaluation periods. Chinese and Japanese patients ≥16 years old with idiopathic generalized, symptomatic generalized, or undetermined epilepsy with GTC seizures received a single-blind placebo during the prospective baseline, and then were randomized 1:1 to placebo or LEV 1,000 mg/day administered twice daily. Patients reporting GTC seizures up to week 8 had the LEV dosage increased to 3,000 mg/day. The primary efficacy variable was percent reduction from combined baseline in GTC seizures/week during the 28-week treatment period.

Results

Overall, 251 patients were randomized (208 from China; 43 from Japan); 141 (56.2%) completed the 28-week treatment period. Least-squares mean percent reduction from combined baseline in GTC seizures/week (treatment period) was placebo 12.6% versus LEV 68.8% (95% confidence interval, 44.0-68.2; p < 0.0001). GTC seizure frequency reduction occurred in both patients with idiopathic and symptomatic generalized epilepsy. The 50% responder rate (treatment period) was placebo 28.4% versus LEV 77.8%. Freedom from GTC seizures (evaluation period) was placebo 3.1% versus LEV 29.6%. Incidence of treatment-emergent adverse events (TEAEs; treatment period) was placebo 52.0% versus LEV 57.1%; most frequently nasopharyngitis, protein in urine, decreased platelet count, and pyrexia. Incidence of TEAEs leading to discontinuation was 4.8% versus 3.2%; incidence of serious TEAEs was 3.2% versus 0.8% for placebo and LEV, respectively; 3 patients taking placebo died versus none taking LEV.

Significance

In this trial, adjunctive LEV 1,000-3,000 mg/day was effective in reducing GTC seizure frequency in Chinese and Japanese patients ≥16 years old with GTC seizures. Seizure reduction occurred in both patients with idiopathic and symptomatic generalized epilepsy. LEV was well tolerated in this population.

Abstract P2-11-03: Phase I/II randomized study of combination immunotherapy with or without polysaccharide krestin (PSK) concurrently with a HER2 ICD peptide-based vaccine in patients with stage IV breast cancer receiving HER2-targeted monoclonal antibody therapy

Natural killer (NK) cell defects, commonly seen in metastatic breast cancer (MBC) lead to decrease in dendritic cell (DC) maturation, proinflammatory cytokine production, and tumor infiltrating T-cells (TILs). This results in a protumorigenic Th2 immune microenvironment with low response rates to immunotherapy (i.e., immune checkpoint blockade) and standard chemotherapy. PSK, a potent TLR-2 agonist, activates NK cells to produce IFN-γ and IL-12 and promote DC maturation/differentiation toward a Th1 profile in the tumor microenvironment which results in antigen specific TIL that can eradicate tumor. The combination immunotherapy of PSK and HER2 directed therapy described here, aims at inducing Th1 immunity and tumor specific T-cells. This proposed regimen could eradicate microscopic residual disease and prevent recurrence in optimally treated HER2+ MBC patients. Moreover, the regimen could result in enhanced trafficking of TILs to the site of tumor and improve the efficacy of checkpoint inhibitors and other therapies. A phase I/II randomized 2 arm study of combination immunotherapy with oral PSK (or placebo) given with a HER2 peptide vaccine and HER2 mAb therapy (trastuzumab (TZ) +/- pertuzumab (PZ)) was initiated to assess the safety of the approach and evaluate the effect of PSK on NK cell activity, pro-inflammatory cytokine/chemokine profile; and HER2 vaccine-induced T cell immunity.

Methods: Up to 30 patients with HER2+ MBC who are without evidence of disease after definitive therapy and currently on maintenance TZ +/- PZ are enrolled and randomly assigned in equal numbers to 1 of 2 arms (15 patients/arm): Arm 1: HER2 ICD vaccine + placebo or Arm 2: HER2 ICD vaccine + PSK. All patients receive concomitant treatment with 4 months of daily oral PSK or placebo, 3 monthly intradermal HER2 ICD vaccinations and continued TZ +/- PZ. Toxicity is evaluated per CTEP CTCAE 4.0, during and post vaccination. Serial blood draws for immunologic evaluation of NK cell activity and antigen-specific T cell immunity via flow cytometry and IFN-γ ELISPOT, respectively; and pro-inflammatory cytokines/chemokines.

Results: 24 subjects have been enrolled and 60 vaccines have been given. 16 subjects have completed all 3 vaccines and PSK/placebo; and 6 subjects are currently in progress. 2 subjects received &lt; 3 vaccines and were taken off study. Of 144 reported adverse events (AEs), 97% were Grade 1-2; 66 (46%) were possibly, probably, or definitely related to study treatment. Most common AEs are injection site reaction and flu-like symptoms. There have been a total of four Grade 3 AEs, 1 episode of self-limited nausea/vomiting attributed to study treatment; and cognitive disturbance, fatigue, and lymphopenia all in 1 subject and attributed to disease progression. There have been no Grade 4 AEs. Immunologic analyses are ongoing and will be presented along with completed clinical data on all patients.

Conclusion: Combination immunotherapy with PSK/placebo and concurrent HER2 directed therapy is safe and well-tolerated. Further ongoing immunologic studies will help define the immunogenicity of the approach.

Citation Format: Salazar LG, Higgins D, Childs J, Coveler AL, Liao J, Stanton S, Gooley T, Standish LJ, Sasagawa M, DISIS ML. Phase I/II randomized study of combination immunotherapy with or without polysaccharide krestin (PSK) concurrently with a HER2 ICD peptide-based vaccine in patients with stage IV breast cancer receiving HER2-targeted monoclonal antibody therapy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-11-03.

Efficacy and tolerability of levetiracetam as adjunctive therapy in Japanese patients with uncontrolled partial-onset seizures

AIMS

The aim of this study was to confirm the efficacy and safety of adjunctive levetiracetam in adult Japanese patients with uncontrolled partial-onset seizures.

METHODS

In a double-blind, placebo-controlled, confirmatory trial, eligible patients were randomized to receive levetiracetam 500, 1000, 2000, or 3000 mg/day or placebo for 16 weeks. The primary end-point was percentage reduction from baseline in seizure frequency/week over a 12-week evaluation period. Tolerability assessments were also conducted. Findings of this and a previous randomized, double-blind trial were compared.

RESULTS

Of 401 patients screened, 352 were randomized and 316 completed the study. Median percentage reduction in seizure frequency/week from baseline was 12.92%, 18.00%, 11.11% and 31.67% in the levetiracetam 500, 1000, 2000 and 3000-mg groups, respectively, compared with 12.50% in the placebo group. Unlike the previous trial, the primary efficacy analysis between the levetiracetam 1000 and 3000-mg and placebo groups did not reach statistical significance (P = 0.067). Exploratory analyses demonstrated that the difference in seizure reduction versus placebo was 14.93% (95% confidence interval, 1.98-27.64; P = 0.025) for the levetiracetam 3000-mg group. All levetiracetam doses were well tolerated. The main difference between the two trials was a high placebo response in the present trial.

CONCLUSIONS

The primary efficacy analysis did not reach statistical significance, a finding that could be attributed to an unexpectedly high placebo response. Nonetheless, exploratory analysis suggests that levetiracetam at 3000 mg/day may, at least marginally, be beneficial for patients with uncontrolled partial-onset seizures.

Altered activity of the primary visual area during gaze processing in individuals with high-functioning autistic spectrum disorder: a magnetoencephalography study

BACKGROUND

Individuals with autistic spectrum disorder (ASD) demonstrate an impaired ability to infer the mental states of others from their gaze. Thus, investigating the relationship between ASD and eye gaze processing is crucial for understanding the neural basis of social impairments seen in individuals with ASD. In addition, characteristics of ASD are observed in more comprehensive visual perception tasks. These visual characteristics of ASD have been well-explained in terms of the atypical relationship between high- and low-level gaze processing in ASD.

METHOD

We studied neural activity during gaze processing in individuals with ASD using magnetoencephalography, with a focus on the relationship between high- and low-level gaze processing both temporally and spatially. Minimum Current Estimate analysis was applied to perform source analysis of magnetic responses to gaze stimuli.

RESULTS

The source analysis showed that later activity in the primary visual area (V1) was affected by gaze direction only in the ASD group. Conversely, the right posterior superior temporal sulcus, which is a brain region that processes gaze as a social signal, in the typically developed group showed a tendency toward greater activation during direct compared with averted gaze processing.

CONCLUSION

These results suggest that later activity in V1 relating to gaze processing is altered or possibly enhanced in high-functioning individuals with ASD, which may underpin the social cognitive impairments in these individuals.

Neural activity in the posterior superior temporal region during eye contact perception correlates with autistic traits

The present study investigated the relationship between neural activity associated with gaze processing and autistic traits in typically developed subjects using magnetoencephalography. Autistic traits in 24 typically developed college students with normal intelligence were assessed using the Autism Spectrum Quotient (AQ). The Minimum Current Estimates method was applied to estimate the cortical sources of magnetic responses to gaze stimuli. These stimuli consisted of apparent motion of the eyes, displaying direct or averted gaze motion. Results revealed gaze-related brain activations in the 150-250 ms time window in the right posterior superior temporal sulcus (pSTS), and in the 150-450 ms time window in medial prefrontal regions. In addition, the mean amplitude in the 150-250 ms time window in the right pSTS region was modulated by gaze direction, and its activity in response to direct gaze stimuli correlated with AQ score. pSTS activation in response to direct gaze is thought to be related to higher-order social processes. Thus, these results suggest that brain activity linking eye contact and social signals is associated with autistic traits in a typical population.

[Titration comparative study of TOPINA Tablets in patients with localization related epilepsy: double-blind comparative study by rapid and slow titration methods]

To compare the tolerability and efficacy of two titration methods (rapid and slow titration) for TOPINA Tablets with different dosages and periods of escalation, a double-blind comparative study was conducted in patients with localization-related epilepsy. A total of 183 patients were randomized to either rapid titration (initial dosage 100 mg/day increased by 100-200 mg at weekly intervals) or to slow titration (initial dosage 50 mg/day increased in 50 mg/day increments at weekly intervals). TOPINA Tablets were administered for 12 weeks to the maximum dosage of 400 mg/day. The incident of adverse events leading to treatment interruptions or withdrawals was 18.9% in rapid titration and 14.8% in slow titration, with no statistical significance (p = 0.554). The incident of adverse events and adverse reactions of slow titration was slightly lower than that of rapid titration. The common adverse events and adverse reactions reported in the two titration methods were comparable and were well tolerated. On the other hand, the efficacy of slow titration, percent reduction in seizure rate and responder rate, was comparable with that of rapid titration. In conclusion, there were no significant differences of therapeutic response to TOPINA Tablets between the two titration methods.

[Social resources for a patient with epilepsy]

Epilepsy is a common episodic neurological disorder and is often accompanied by mental, psychiatric, and physical disorders; therefore, a comprehensive treatment, including seizure control, is needed to treat it. Epilepsy patients need frequent seizure preventive treatment, which is likely to induce medication dependence. This paper presents a report on the social resources involved in epilepsy treatment. "Services and Support for Persons with Disabilities Acts" is applicable to epilepsy patients and provides public compensation for psychiatric outpatient treatment, enabling disabled persons to apply for disability pension to support their living and medical expenditures. The Mental Health Welfare Notebook is issued to provide welfare services for the disabled, and it plays an important role in promoting employment of disabled persons. The welfare services for the disabled are diverse, ranging from home-based services to services aiding the disabled to step out of their homes, go to day care centers, or pay for house rent. The details of the welfare services for the disabled are available on the homepage of the website for the Ministry of Health, Labour and Welfare. The roles of physicians involve maximizing social resources in coordination with psychiatric social workers, aiming for normalization of disabled persons so that they are able to live comfortably in the community.

False lateralization of mesial temporal lobe epilepsy by noninvasive neurophysiological examinations

Mesial temporal lobe epilepsy (mTLE) is the most common form of symptomatic localization-related epilepsy and is surgically remediable. Lateralization of the seizure onset is particularly important to determine from a surgical perspective. A 39-year-old woman with intractable mTLE first exhibited seizure at the age of 3 years. She experienced epigastric sensation and placed her right hand on her abdomen before falling backward. Although interictal scalp electroencephalography (EEG), sphenoidal scalp ictal EEG, and magnetoencephalography showed right temporal side focus, computed tomography and magnetic resonance imaging showed atrophy of the left cerebral hemisphere. Single photon emission computed tomography with technetium-99m ethyl cysteinate dimmer and I-123 iomazenil showed obscure focus on the left side. As a discrepancy existed between the results of neurophysiological examinations and imaging, we performed subdural electrode implantation on the bilateral temporal lobe. Although a bemegride-induced seizure arose from the right side during the subdural recording, the onset of 5 habitual seizures was observed in the left hippocampus. On the basis of these results, the seizure was diagnosed as left mTLE, and left anterior temporal lobectomy and amygdalohippocampectomy were performed. The patient has been free from the seizures for more than 1.5 years of follow up. Bilateral subdural electrode measurement of habitual seizures is indispensable for clarifying the actual focus when a discrepancy exists between neuroimaging and noninvasive neurophysiological examinations.

Magnetoencephalography in Patients with Tuberous Sclerosis and Localization-related Epilepsy

PURPOSE

To clarify the usefulness of magnetoencephalography (MEG) for diagnosis of the spatial relations between spike foci and suspicious epileptogenic tubers on MRI in patients with tuberous sclerosis (TS) and to compare MEG spike foci with single-photon emission computed tomography (SPECT) findings.

METHODS

We analyzed magnetic fields of epileptic spike discharges in 15 patients with TS and localization-related epilepsy (LRE) by using MEG (a whole-head 204-channel magnetometer system). We investigated the spatial relation between the equivalent current dipoles (ECDs) of interictal spike discharges and visible cortical tubers on MRI. We also compared results of MEG and MRI with SPECT findings.

RESULTS

MEG detected a cluster of ECDs around one cortical tuber in six of 15 patients and clusters of ECDs around two cortical tubers in five patients. Interictal SPECT was disappointing in detection of epileptic foci in TS. However, MEG spike foci showed spatial consistency with ictal hyperperfusion areas in two patients. Three patients with single ECD clusters underwent surgical treatment: two have been seizure free, and one has obtained seizure reduction of >90%.

CONCLUSIONS

ECDs were located around visible tuber nodules. MEG enabled precise localization of the epileptic foci and provided crucial information for surgical treatment in patients with TS and partial epilepsy. TS patients showing a single ECD cluster on MEG may be appropriate candidates for surgical treatment.

Single and Multiple Clusters of Magnetoencephalographic Dipoles in Neocortical Epilepsy: Significance in Characterizing the Epileptogenic Zone

PURPOSE

To characterize the epileptogenic zone in neocortical epilepsy (NE) by using magnetoencephalography (MEG).

METHODS

We defined and compared locations of single and multiple clusters of equivalent current dipoles (ECDs) for interictal spikes with MRI findings, ictal-onset zones (IOZs) from subdural electroencephalography (SDEEG), resected areas, and postsurgical outcomes of 20 patients who underwent cortical resection for medically intractable NE.

RESULTS

Fourteen patients had single clusters; six had multiple clusters. Overlap of clusters and IOZs defined group A (nine patients), in which a single cluster coincided with the IOZ; group B1 (four patients), in which a single cluster was within or partially overlapped the IOZ; group B2 (five patients), in which multiple-cluster sections overlapped IOZs; group C (two patients; one single; one multiple), in which no overlap was seen. More single clusters (nine of 14) than multiple clusters (none of six) coincided with the IOZ (p = 0.014). More patients with single clusters (10 of 14) than patients with multiple clusters (one of six) had seizure-free outcomes (p = 0.049). Eight of nine patients in group A, versus three of 11 in groups B1, B2, and C, achieved seizure-free outcomes (p = 0.0098). Correlations between MRI findings and postsurgical outcomes were not statistically significant; eight of 13 patients with single lesions, one of four with no lesions, and two of three with multifocal lesions had seizure-free outcomes.

CONCLUSIONS

In neocortical epilepsy, MEG ECD clusters correlated with SDEEG IOZs. Single clusters indicated discrete epileptogenic zones that required complete resection for seizure-free outcome. Multiple clusters necessitated that the multiple or extensive epileptogenic zones be completely identified and delineated by SDEEG.

Multi-institutional study on the correlation between chromosomal abnormalities and epilepsy

While there is an abundance of literature describing the association of chromosome aberrations with epilepsy, only a few refer to the detailed features of epilepsy. It is important to investigate the associations between specific chromosome abnormalities and features of epilepsy to identify genes involved in epilepsy and treat them more effectively. We investigated the correlation between specific chromosome aberrations and epilepsy by sending questionnaires to the members of Kyoto Multi-institutional Study Group of Pediatric Neurology. Seventy-six patients were collected from 10 institutions. Chromosome abnormalities included: Down syndrome (n = 19); Angelman syndrome (n = 8); Prader-Willi syndrome (n = 4); 4p- syndrome (n = 3); 1q- syndrome (n = 2); 5p- syndrome (n = 2); Miller-Dieker syndrome (n = 2); 18q- syndrome; (n = 2); Klinefelter syndrome; (n = 2); and 32 other individual chromosomal aberrations. Overall, the severity of mental retardation correlated with the severity of epilepsy. We could abstract characteristic features of epilepsy in some syndromes. In Angelman and Prader-Willi syndromes, febrile seizures occurred frequently, the onset of epilepsy was in early childhood and seizure phenotype was multiple. Paroxysmal discharge of the occipital region and diffuse high voltage slow wave on electroencephalography were characteristic in Angelman syndrome. In Down syndrome, West syndrome and focal epilepsy were common and the prognosis of epilepsy in West syndrome with Down syndrome was good. In 4p- syndrome, febrile seizures were often seen, and unilateral or generalized clonic or tonic-clonic status epilepticus were characteristic. For the other chromosomal aberrations investigated here, the patient numbers were too small to abstract common features of epilepsy.

Neuropsychological changes after surgical treatment for temporal lobe epilepsy

PURPOSE

The effect of unilateral temporal lobectomy on seizure frequency is well recognized, but little is known about the neuropsychological changes that occur after surgical treatment. We assessed neuropsychological status in 26 patients with an average age of 35 years before and after unilateral temporal lobectomy for medically intractable TLE.

METHODS

Neuropsychological examination to assess cognitive function, memory, attention, visuospatial analysis, language, and emotional functions was performed preoperatively and at 1 month and 1 year after the surgery.

RESULTS

At both 1 month and 1 year after the surgery, the patients had improved scores, compared with the preoperative scores, on the Wechsler Adult Intelligence Scale-Revised (WAIS-R: verbal IQ, performance IQ, and full-scale IQ), Wechsler Memory Scale-Revised (WMS-R: verbal, general, and delayed paired associates memory), and Raven Colored Progressive Matrices. In the Minnesota Multiphasic Personality Inventory (MMPI), significant decreases were observed at 1 year after the surgery in the scores for infrequency, hypochondriasis, psychasthenia, and schizophrenia. Patients in whom the seizures had been relieved postoperatively also had improved scores on the WAIS-R, WMS-R, and Raven Colored Progressive Matrices.

CONCLUSIONS

These data suggest that neuropsychological improvement postoperatively is influenced by the reduction in the frequency of seizures after surgery.

Surgical strategy and outcomes for epileptic patients with focal cortical dysplasia or dysembryoplastic neuroepithelial tumor

PURPOSE

The purpose of this study was to clarify and compare the influence of surgical strategy on relief from seizures in patients with focal cortical dysplasia (FCD) and those with dysembryoplastic neuroepithelial tumor (DNT).

METHODS

Six patients with FCD and five patients with DNT, all of whom underwent surgical resection for medically intractable epilepsy, were compared in terms of presurgical seizure types and frequency, location of lesions, magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) with 99mTc-ECD, scalp electroencephalogram (EEG), and long-term video-EEG recording. Prolonged subdural recordings and intraoperative electrocorticograms (ECoG) were analyzed. The influences of surgical strategies on seizure outcomes were retrospectively analyzed.

RESULTS

In all the FCD patients, ictal SPECT revealed hyperperfusion in the regions where MRI showed FCD. Interictal epileptiform activity and ictal seizure onset on ECoG performed with subdural electrodes were localized on the FCD itself. In contrast, the tumors of all the DNT patients were depicted as hypoperfuse areas on interictal SPECT scans. Ictal SPECT in one DNT patient showed hyperperfusion in the area enclosing the tumor. Interictal spiking in all DNT patients and ictal seizure onset in two DNT patients were not in the lesions themselves but in an area enclosing the lesion. All but one patient with FCD who underwent total lesionectomy became seizure free. All DNT patients who underwent resection of the epileptogenic cortex associated with lesionectomy became seizure free or achieved a 90% reduction in seizures.

CONCLUSIONS

FCD has intrinsic epileptogenicity, whereas DNT is encompassed by epileptogenic cortical areas. Therefore, total lesionectomy is an essential strategy for FCD, whereas resection of the epileptic focus associated with lesionectomy of a DNT lesion is necessary to control seizures.

[Juvenile ischemic type of moyamoya disease: a case report]

Moyamoya disease is a rare, chronic cerebrovascular disorder characterized by progressive stenosis of the arteries composing the circle of Willis. The ischemic type of Moyamoya disease progresses insidiously. To prevent irreversible cerebral damage and psychomotor deterioration, early surgical treatment is considered indispensable. The patient may present with nonspecific symptoms and no specific abnormalities on brain MRI, and might be erroneously suspected as having psychosomatic disorder. The disease must be diagnosed as early as possible. Electroencephalography (EEG) is of little value in the diagnosis of the juvenile type of Moyamoya disease, except for the demonstration of "re-build up" after hyperventilation. Half of the children with Moyamoya disease have been demonstrated to exhibit "re-build up" after hyperventilation. Our patient showed normal background activities, no spike discharges and no slowing during hyperventilation. Nonetheless, we emphasize the appearance of irregular high voltage slow waves de novo after hyperventilation. The findings may be potentially useful for the screening of patients with the juvenile type of Moyamoya disease.

[Efficacy of sustained-released theophylline on peak expiratory flow rate in asthmatic patients]

Nocturnal worsening is an important problem in asthma management. We evaluated the efficacy of two sustained-released theophylline formulations, administered twice-a-day (TD) and once-a-day (UP). In 20 asthmatic patients with low peak expiratory flow rate (PEF) in the morning (< 80% of predicted) administered TD (mean dose 475 mg/day) for 2 weeks, we evaluated PEF, diurnal variability of PEF, symptom score, results of spirometry and serum theophylline concentration (STC) and then changed theophylline, from TD to UP (mean dose 470 mg/day) for 2-4 weeks. PEF in the morning was higher during the UP period (mean +/- SD: 335 +/- 110 L/min) than during the TD period (mean +/- SD: 308 +/- 95 L/min) (p < 0.05), and diurnal variabirity of PEF was lower during the UP period (17.1 +/- 8.0%) than TD period (22.9 +/- 13.4%) (p < 0.05). However, there were no changes in PEF at night or daytime, symptom score, spirometry parameters or STC during the study period. The improvement in morning PEF observed in this study was consistent with the differences in pharmacokinetics between the two theophylline formulations. Morning PEF was increased during the UP period, probably because STC in the early morning during the UP period was higher than STC during the TD period.

[Epilepsy surgery for focal cortical dysplasia and dysembryoplastic neuroepithelial tumor]

We studied six patients with focal cortical dysplasia (CD) and four patients with dysembryoplastic neuroepithelial tumor (DNT) who had surgical resection for medically intractable epilepsy. In all CD patients, ictal single photon emission computed tomography (SPECT) using 99mTc-ECD revealed hyperperfusion in the regions where magnetic resonance (MR) imaging showed CD abnormalities. Interictal epileptiform activity and ictal seizure onset on electrocorticography using subdural strip or grid electrodes were demonstrated in the CD itself. In contrast, in all DNT patients, interictal SPECT disclosed hypoperfusion in the area of the lesions. Ictal SPECT in one DNT patient disclosed hyperperfusion in the superior area of the region where MR imaging showed cystic abnormalities. Interictal spiking in all DNT patients and ictal seizure onset in two DNT patients were demonstrated not in the lesions themselves but in the distinct zone from the region of the tumor-involved brain. All CD patients who underwent lesionectomy became seizure-free with a mean follow-up period of 33.5 months. All DNT patients who underwent lesionectomy and resection of the epileptogenic cortex became seizure-free or had their seizure significantly reduced a mean follow-up period of 41.5 months. We conclude that CDs have intrinsic epileptogenicity, while DNTs have epileptogenicity not intrinsically but in encompassed cortical surface areas.

Anomalous insertion of the right hepatic duct into the cystic duct: report of a case diagnosed before laparoscopic cholecystectomy

Although an aberrant hepatic duct entering the cystic duct is not especially rare, the main right hepatic duct entering the cystic duct is extremely rare, with only six cases reported thus far. All of the reported patients underwent open cholecystectomy, during which one patient received a bile duct injury. The anomaly was unsuspected preoperatively in all of these cases. We report an additional patient with this anomaly, the first such case diagnosed before laparoscopic cholecystectomy using direct cholangiography. Cholangiography may be mandatory whenever biliary anomalies are suspected during laparoscopic cholecystectomy. As the right hepatic duct entering the cystic duct can lead to ductal injury, this anomaly should be kept in mind when performing laparoscopic cholecystectomy.

Helical computed tomography diagnosis of pleural dissemination in lung cancer: comparison of thick-section and thin-section helical computed tomography

Pleural dissemination in lung cancer was prospectively evaluated by helical computed tomography (CT), and the usefulness of thick-section CT (10-mm collimation; pitch 1) and thin-section CT (2-mm collimation; pitch 1) were compared. The study included 54 patients with pulmonary adenocarcinoma in whom plain chest radiographs showed no evidence of pleural effusion and in whom the primary lesion was seen to be contiguous with the pleural surface on thick-section CT. Thin-section CT was performed for evaluation of the costal, mediastinal, interlobar, and diaphragmatic pleural surfaces. Pathologic examination revealed pleural dissemination in 20 patients (8 resected, 12 nonresected). Pleural dissemination was diagnosed in 12 patients on thick-section CT, and in 20 patients on thin-section CT. False negatives occurred in ten and two patients, respectively. The same two patients were false positives by both methods. Accuracy was 78% for thick-section CT and 93% for thin-section CT, and sensitivity was 50% and 90%, respectively. Thin-section CT provided more useful information than thick-section CT for the evaluation of pleural dissemination in lung cancer.

Utility of low-dose helical CT as a second step after plain chest radiography for mass screening for lung cancer

We evaluated the usefulness of low-dose helical computed tomography (CT) as a routine second step in patients screened for lung cancer with plain chest radiography (PCR). Of 5,437 people who underwent mass screening for lung cancer by PCR, further work-up was required for 230 because of abnormal findings. Of 221 subjects who had CT as a second step, abnormal shadows were detected in 110 and no abnormal shadows were seen in 111. Screening CT (helical scan; beam collination, 10 mm; pitch of 2:20 mm/s; and tube current, 50 mA) detected 17 lung cancers, 87 benign lesions, and 6 extrapulmonary lesions, with an average diameter of 10 mm (range, 2-35 mm). All lung cancers were peripheral (12 stage I, 4 stage IIIA, and 1 stage IV). In 40% of screened subjects, 37 with benign lesions and 7 with lung cancer (6 stage I), lesions were delineated only by screening CT. In conclusion, low-dose helical CT was found to be useful as a second step in patients who have been screened for lung cancer by PCR and can delineate the early stage of lung cancer.

[Differentiation of extravillous trophoblast during normal pregnancy]

The implantation site in 25 pregnant uteri was studied morphologically and immunohistochemically to clarify the developmental process of extravillous trophoblasts (EVTs). 1. Dense trophoblastic invasion of the decidua was observed. Multinuclear trophoblasts appeared in the deciduo-muscular junction from the 10th week. Trophoblasts infiltrated decidual vessel walls, where extensive perivascular degeneration existed. EVTs may be indispensable for construction of the placenta. 2. In villous trophoblasts (VTs) the location of hCG and hPL was limited to multinuclear cells, whereas in EVTs hCG was present in a few mononuclear cells and hPL was observed in most mononuclear and multinuclear cells. The immunoreactivity of trophoblast-related monoclonal antibodies also differed: neither anti-Tropl (reactive with cytotrophoblasts (CTs)) nor NDOG1 (reactive with syncytiotrophoblasts (STs)) was reactive with EVTs. 3. The absence of hCG and hPL in mononuclear trophoblasts of the cell column indicates that EVTs differentiate after invading the decidua. Kurman et al. proposed the term intermediate trophoblast, indicating cells in transition from CTs to STs and EVTs, and this is based on the concept that the developmental processes of EVTs and VTs are identical. But the results of this study suggested an independent developmental process for EVTs and therefore it seemed that the term intermediate trophoblast should not be employed for EVTs.

[A study on the association between glandular dysplasia and cervical squamous neoplasia in surgical specimens]

To clarify the pathogenesis of cervical adenocarcinoma, we studied the biological properties of glandular dysplasia (GD). The coexistence of squamous neoplasia with cervical adenocarcinoma has been demonstrated. We analyzed the incidence of the coexistence of GD with squamous neoplasia in this study. Materials were surgically removed uterine cervix specimens (n = 142), 52 benign disease cases, 19 squamous dysplasias of the uterine cervix, 66 squamous cell carcinomas of the uterine cervix and 5 cervical adenocarcinomas. Diagnosis of GD was based on the general rules for clinical and pathological management of uterine cervical cancer and Ng's criteria (1983). We divided GD into two types: I: endocervical type, and II: endometrioid type. These fell into subtypes, a (mild) and b (severe) based on the observed degrees of cell atypia. 1. GD coexisted in 17.3% of benign disease cases, 15.8% of squamous dysplasias, 24.2% of squamous cell carcinomas and 100% of cervical adenocarcinomas. 2. GD Ib and IIb were not found in any of the benign disease cases, but were present in 15.8% of squamous dysplasias, 13.6% of squamous cell carcinomas and 100% of cervical adenocarcinomas. If GD was defined as only Ib and IIb, GD coexisted with squamous neoplasia in this study. Our results support the theory that both cervical squamous atypia and cervical glandular atypia are derived from reserve cells.

Conservative management of idiopathic pneumoperitoneum masquerading as peritonitis: report of a case

Pneumoperitoneum is most commonly caused by the perforation of a hollow viscus, in which case an emergency laparotomy is indicated. We report herein the case of a patient who presented with the signs and symptoms of peritonitis, but who was found to have idiopathic pneumoperitoneum which was successfully managed by conservative treatment. A 70-year-old man presented with epigastric pain, nausea, and a severely distended and tympanitic abdomen. Abdominal examination revealed diffuse tenderness with guarding, but no rebound tenderness. He was febrile with leukocytosis and high C-reactive protein. Chest X-ray and abdominal computed tomography demonstrated a massive pneumoperitoneum without pneumothorax, pneumomediastinum, pneumoretroperitoneum, or subcutaneous emphysema, and subsequent examinations failed to demonstrate perforation of a hollow viscus. Thus, a diagnosis of idiopathic pneumoperitoneum was made, and the patient was managed conservatively, which resulted in a successful outcome. This experience and a review of the literature suggest that idiopathic pneumoperitoneum is amenable to conservative management, even when the signs and symptoms of peritonitis are present.

A follow-up study of patients with cervical cancer after resection, with special emphasis on the incidence of second primary cancers

The causes of death in long-term survivors after resection of cervical cancer were investigated in a follow-up study of 375 women, focusing especially on the postoperative development of second primary cancers. The 5- and 10-year overall survival rates were 75.0 and 66.0%, respectively, in cases that showed frank invasion, 94.7 and 92.8%, respectively, in those showing microinvasion, and 96.2 and 96.2% respectively, in those showing carcinoma in situ. Multivariate analysis identified patient age and cancer stage at the time of diagnosis as separate factors prognostic for overall survival. During the observation period, 10 patients developed a second primary cancer, but no significantly elevated risk of developing a second primary cancer was demonstrated. However, during the same period, 20 patients also died of noncancerous disease, 9 of this number succumbing to acute myocardial infarction and/or heart failure. These results suggest that patients with cervical cancer may not have an increased risk of developing second primary cancer. It is felt that continued follow-up of long-term cervical cancer survivors should be pursued in order to prevent or arrest the development of noncancerous disease and/or second primary cancer, so that increased prolongation of survival can be achieved.

Detection of nodular lesions in the lung helical computed tomography: comparison between 360 degrees and 180 degrees reconstruction algorithms

The present study has evaluated helical computed tomography (HS-CT) performed at a fast couch-top sliding speed (20 mm/sec, sufficient to cover the entire lung field during the holding of a single breath) with regard to its ability to detect pulmonary nodules in patients with metastatic lung disease. The detectability of lesions by HS-CT was compared between 360 degrees and 180 degrees reconstruction algorithms. The subjects were eight consecutive patients with metastatic lung tumors, in whom 214 lesions had been detected by conventional CT. The average diameter of the nodules detected was 7.7 mm (2-22 mm). To scan the entire lung, we first used conventional CT (10-mm slice thickness, 10-mm stepping) and then HS-CT with a couch-top speed of 20 mm/sec and a tube current of 50 mA. Both 360 degrees and 180 degrees algorithms were used to reconstruct images at intervals of 20 and 10 mm from HS-CT data. Detection rates of 79% for 20-mm images and 94% for 10-mm images were achieved with the 360 degrees algorithm. Detection rates of 81% for 20-mm images and 99% for 10-mm images were achieved with the 180 degrees algorithm. The detection of nodules was greater for 10-mm images than 20-mm images (P < 0.01). There was no significant difference between the 360 degrees and 180 degrees algorithms. Images acquired using the 180 degrees algorithm, however, depicted lesions with greater sharpness than those acquired using the 360 degrees algorithm. It is presumed that they indirectly show the superiority of the 180 degrees algorithm over the 360 degrees algorithm. HS-CT should prove a useful screening technique for lesions in the lung field.

[Identification of Mycobacterium avium and Mycobacterium intracellulare using DNA probe test, and their ratio in Niigata area]

Using Gen-Probe test, both the Mycobacterium avium and Mycobacterium intracellulare strains were identified in the 76 disease-associated Mycobacterium-avium complex (MAC) strains isolated in the NIIGATA area. The following results were obtained: 1) Fifty-four MAC strains (71.1%) reacted with M. avium-probe and 22 strains (28.9%) reacted with M. intracellulare-probe. 2) There were no significant differences between the ratio of two strains before and after 1991. 3) The ratio of female cases with M. avium was significantly higher (22/32) in the later period (after 1991) than in the former period (9/22).

Detection of nodular lesions in the lung using helical computed tomography: comparison of fast couch speed technique with conventional computed tomography

The present study assessed the ability of helical CT performed at fast couch speeds (20 mm or 25 mm/sec), sufficient to cover the entire lung field during a single breath hold, compared with conventional CT for detecting pulmonary nodules in patients with metastatic lung disease. The subjects were seven consecutive patients with metastatic lung tumors in whom 152 lesions were detected by conventional CT. The average diameter of the nodules was 8.3 (range 2-23 mm). To scan the entire lung, we first employed conventional CT (10-mm slice thickness, 10 mm couchtop slide). We then used helical CT with couchtop speeds of 20 and 25 mm/sec, permitting easy scanning of the entire lung field during a single breath hold (images of reconstruction intervals; 25, 20, 12.5 and 10 mm). We assessed each image to compare detection capabilities in the lung. The detection capabilities for each reconstruction interval were 78, 83, 91 and 97%, respectively. The detection of nodules was superior for 12.5 and 10 mm images than for 25 and 20 mm images (P < 0.01). In 25 and 20 mm images, the detection capability was significantly lower in the apical area than in the middle area (P < 0.01). For nodules 5 mm in diameter, 10 mm images permitted complete detection. Helical CT fast couch speeds (20 or 25 mm/sec), which allow imaging of the entire lung during a single breath hold, may be useful in detecting metastatic pulmonary nodules, and helical CT is expected to be a useful method for lung screening.

Mediastinal lymph node metastasis from lung cancer: evaluation with Tl-201 SPECT--comparison with CT

PURPOSE

To assess the usefulness of thallium-201 single photon emission computed tomography (SPECT) in detection of mediastinal lymph node metastasis from lung cancer.

MATERIALS AND METHODS

Computed tomography (CT) and Tl-201 SPECT were performed in 113 patients with lung cancer. Surgical staging was performed in all patients, and the results of the two modalities were compared with the pathologic findings in 364 node stations.

RESULTS

Cancerous nodes were found in 32.7% of the patients. The sensitivity of CT in detecting mediastinal node metastasis was 62%; specificity was 80%. These rates were higher for Tl-201 SPECT (76% and 92%, respectively). Furthermore, these rates were excellent in patients with enlarged mediastinal nodes at CT (87% and 93%, respectively). However, Tl-201 SPECT had more limited spatial resolution than did CT.

CONCLUSION

Tl-201 SPECT is useful in evaluation of mediastinal node metastasis in lung cancer, especially for patients with enlarged nodes at CT.

Blood levels of leukotrienes (LTC4, D4, E4, B4) in asthmatic patients during attack and remission

To assess the contribution of the leukotrienes, LTC4, D4, E4 and B4 during bronchial asthma attacks, simultaneous determination was made of their levels in venous blood. 25 patients with bronchial asthma (15 atopic types, 10 non-atopic types) participated in this study and 4 normal controls were used. Samples were obtained using heparinized syringe from the patients before treatment. A radioimmunoassay was conducted to measure LTs after purification with a Sep-pak column and separation by HPLC. In normal subjects, the levels were less than the minimal detectable amounts. LTC4, D4, E4 and B4 during asthmatic attacks were 100 +/- 179, 88 +/- 116, 479 +/- 291, and 55 +/- 73 (Mean +/- SD) pg/ml respectively (n = 27). Peptide LTs in remission were below minimal detectable levels. LTD4 in patients with moderate attacks was significantly (p < 0.05) higher than in those with mild attacks. Peptide LTs in moderate attack exceeded those in mild attacks, although not to a statistically significant degree. No significant differences in LT during attacks could be detected in atopic or non-atopic type patients. LTs would thus appear importantly involved in asthmatic attacks in atopic and non-atopic type patients, although other chemical mediators may give rise to airway inflammation.

A follow-up study of resected stomach cancer patients with special emphasis on the incidence of second primary cancers

The causes of death in long-term survivors of stomach cancer after a gastrectomy have been investigated in a follow-up study of 320 such patients, with special focus on the postoperative development of a second primary cancer. The five- and 10-year overall survival rates of early stomach cancer patients were 87.5 and 75.8%, respectively, and of advanced stomach cancer patients, 44.2 and 37.5%, respectively. A multivariate analysis identified the patient's age and stage of cancer at the time of diagnosis as separate prognostic factors for overall survival. During the observation period, 15 (4.7%) patients developed a second primary cancer, so that no significantly elevated risk of developing a second primary cancer was demonstrated. During the same observation period, however, 48 (15%) of the patients died of a non-cancerous disease, 12 succumbing to an acute myocardial infarction and/or heart failure. Given these results, it is felt that continued follow-up of long-term stomach cancer survivors should be pursued to prevent or impede the development of a non-cancerous disease and/or a second primary cancer, so that the life of such former patients can be prolonged.

Continuous 5-fluorouracil infusion causing acute gastric mucosal lesions

A 59-year-old woman with advanced gastric cancer was treated with continuous 5-fluorouracil infusion for thirty-five days. Endoscopy of the upper gastrointestinal tract was performed due to continuing nausea seven days after the cessation of 5-fluorouracil infusion and revealed multiple erosions in the antrum which were absent before chemotherapy. Continuous 5-fluorouracil infusion was probably the cause of acute gastric mucosal lesions and should be included in the differential diagnosis of dyspepsia in 5-FU-treated patients.

[Evaluation of helical scan CT in the detection of lung nodules of pulmonary metastasis]

The purpose of this study was to evaluate the diagnostic capability of helical scan CT (HS-CT). We investigated the ability of HS-CT to detect lesions by scanning 129 small nodular lesions in the lung field in six cases of pulmonary metastasis. HS-CT was then employed to scan the same regions at table slide speeds of 20 mm/sec and 25 mm/sec. The acquired images were recorded on film and a video tape recorder (VTR), using axial multiplanar reconstruction. We then compared the various images to evaluate the effectiveness of conventional CT (slice thickness: 10 mm, table slide pitch: 10 mm) and HS-CT in visualizing the lesions. HS-CT images acquired at 20 mm/sec and at 25 mm/sec were equally effective in visualizing the lesions. Diagnostic capability was significantly lower in the apical area than in the middle and subdiaphragmatic areas. VTR images were better than film images in terms of diagnostic capability. The disadvantage of VTR images was that VTR processing required much time and labor, and thus is not practical at present. In conclusion, HS-CT is useful in detecting small nodular lesions in the lung field. However, the scanning conditions of HS-CT and interpretation of images, especially in the apical area, require further improvement.

[A study of the clinical factors which have the greatest effect on bronchial hyperresponsiveness in atopic asthma by multiple regression analysis]

We studied the clinical factors which have the greatest effect on bronchial hyperresponsiveness, with 37 atopic asthma patients (23 males and 14 females). They were from 13 to 59 years old. We measured the control value of the respiratory conductance (Grs.cont), the minimum dose of methacholine (bronchial sensitivity, Dmin), the linear slope of the Grs (= 1/Rrs) decreased (bronchial reactivity, SGrs) and SGrs/Grs.cont by the "Astograph" method (Chest 80, 600, 1981). Statistical analysis was performed by multiple regression analysis. Grs.cont, log Dmin, SGrs and SGrs/Grs.cont were regarded as objective variables. Age, onset age of asthma, period of disease, smoking history, family history of atopy, serum IgE, blood eosinophil counts, positive skin test counts, FEV1.0% and type of asthma attack (perennial or seasonal) were regarded as explanatory variables. The results were as follows: 1) The explanatory variable which showed the highest partial correlation coefficients, was the type of asthma attack in multiple regression analysis of Grs.cont and log Dmin (p < 0.05, p < 0.05). 2) Grs.cont of perennial asthma attack (0.247 +/- 0.064) was significantly lower than that of seasonal attack (0.318 +/- 0.097) (p < 0.02). Log Dmin of perennial asthma attack (-0.837 +/- 0.457) was significantly lower than that of seasonal attack (-0.254 +/- 0.429) (p < 0.005). Therefore in mild atopic asthma, the clinical factor which has the greatest effect on bronchial hyperresponsiveness is the type of asthma attack. We conclude that the existence of perennial asthma attacks is mostly related to increased bronchial hypersensitivity.

[Respiratory control in diffuse interstitial lung disease]

Whether the change of lung volume affect ventilatory responsiveness to chemical stimuli has not been studied in patients with interstitial lung disease (ILD). We measured the responses of minute ventilation (VE), tidal volume (VT), and occlusion pressure (P0.1) to hypercapnia (HCVR) and hypoxia (HVR) in these patients. Breathing efficiency (delta VE/delta P0.1) and effective compliance (delta VT/delta P0.1) were also measured under the same stimuli. 1) HCVR and HVR were measured in one female patient with hypersensitivity pneumonitis. VE responses during low VC phase (VC; 71% of predicted value) were similar to that during increased VC phase (VC; normal level) in both HCVR and HVR. However, VT responses of low VC phase were lower than those of increased phase, and P0.1 responses of low VC phase were higher than those of increased VC phase. Both breathing efficiency and effective compliance of low VC phase were lower than those of increased VC phase. 2) Thirty one patients with ILD were divided into two groups: low VC group; VC < 80% of predicted value, and normal VC group; VC > 80% of predicted value. HCVR and HVR were compared between two groups. Mean values of VE response to hypercapnia and hypoxia in low VC group were lower than those of in normal group, although they were not significantly different. VT response to hypercapnia and hypoxia were significantly lower of low VC group than those of normal VC group. Mean values of P0.1 responses to hypercapnia and hypoxia of low VC group were higher than those of normal VC group, although they were not significantly different.(ABSTRACT TRUNCATED AT 250 WORDS)

[Sputum leukotrienes in chronic airway diseases and bronchial asthma attacks]

To determine the pathogenetic role of leukotrienes in chronic airway diseases, sputum samples from patients with bronchial asthma (BA), diffuse panbronchiolitis (DPB), sinobronchial syndrome (SBS), and bronchiectasis (BE) were examined for the presence of leukotrienes (LT) C4, D4, E4, B4, all apparently derived from airway inflammatory cells. Sputum samples from 21 patients, including 10 with BA attack (5 atopic type, 5 non-atopic type) and 11 with chronic obstructive airway diseases (3 DPB, 6 SBS, and BE), were studied. Patients expectorated sputum directly into test-tubes containing 80% ethanol. Following ethanol extraction and partial purification by a C18 SEP-PAK column, LTs were further purified by high performance liquid chromatography (HPLC). Fractions from HPLC with elution times corresponding to synthetic LTC4, D4, E4, and B4 were used to quantify LTs by radioimmunoassay. Eosinophils and neutrophils in the sputum (0.5 ml) were counted following Papanicolaou staining. Percentages of eosinophils in sputum were higher in BA, while those of neutrophils were higher in DPB. Sputum levels of LTC4 were 1.2 +/- 1.6 in BA, 0.12 +/- 0.11 in SBS, and 0.42 +/- 0.14 ng/ml in DPB. Those of LTD4 were 0.21 +/- 0.27 in BA, 0.9 +/- 0.13 in DPB, and 0.10 +/- 0.07 in SBS. LTE4 levels were 5.06 +/- 3.83 in DPB and 2.66 +/- 4.32 in BA. Levels of LTB4 were 1.36 +/- 1.19 in DPB, 0.28 +/- 0.27 in BA, 0.12 +/- 0.07 in SBS, and 0.04 +/- 0.04 in BE. In asthmatics, peptide leukotriene content in sputum was higher than that in chronic airway disease patients.(ABSTRACT TRUNCATED AT 250 WORDS)