Relationship between the combination of polyunsaturated fatty acids intake and psychological distress during pregnancy: The Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study

No studies have examined the association of the combination of n-3 polyunsaturated fatty acids (PUFAs) and n-6 PUFAs intake with psychological distress during pregnancy. To examine these associations, we divided Japanese pregnant women into 25 groups based on combining quintiles of n-3 PUFAs intake and quintiles of n-6 PUFAs intake. We conducted multivariable logistic regression analyses to assess the risk of psychological distress during pregnancy (Kessler Psychological Distress Scale ≥ 5 or 13). Compared to the third quintile of both n-3 PUFAs and n-6 PUFAs intake, the groups with unbalanced intake, high intake of both, and low intake of both were associated with a higher risk of both Kessler Psychological Distress Scale ≥ 5 and 13 in early and mid-pregnancy. Further research is needed to identify the precise combination of n-3 PUFAs and n-6 PUFAs intake associated with the lowest psychological distress during pregnancy.

Anti-PD-1 antibody monotherapy versus anti-PD-1 plus anti-CTLA-4 combination therapy as first-line immunotherapy in unresectable or metastatic mucosal melanoma: a retrospective, multicenter study of 329 Japanese cases (JMAC study)

Background

Anti-programmed cell death protein 1 (PD-1) antibody monotherapy (PD1) has led to favorable responses in advanced non-acral cutaneous melanoma among Caucasian populations; however, recent studies suggest that this therapy has limited efficacy in mucosal melanoma (MCM). Thus, advanced MCM patients are candidates for PD1 plus anti-cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) combination therapy (PD1 + CTLA4). Data on the efficacy of immunotherapy in MCM, however, are limited. We aimed to compare the efficacies of PD1 and PD1 + CTLA4 in Japanese advanced MCM patients.

Patients and methods

We retrospectively assessed advanced MCM patients treated with PD1 or PD1 + CTLA4 at 24 Japanese institutions. Patient baseline characteristics, clinical responses (RECIST), progression-free survival (PFS), and overall survival (OS) were estimated using Kaplan–Meier analysis, and toxicity was assessed to estimate the efficacy and safety of PD1 and PD1 + CTLA4.

Results

Altogether, 329 patients with advanced MCM were included in this study. PD1 and PD1 + CTLA4 were used in 263 and 66 patients, respectively. Baseline characteristics were similar between both treatment groups, except for age (median age 71 versus 65 years; P < 0.001). No significant differences were observed between the PD1 and PD1 + CTLA4 groups with respect to objective response rate (26% versus 29%; P = 0.26) or PFS and OS (median PFS 5.9 months versus 6.8 months; P = 0.55, median OS 20.4 months versus 20.1 months; P = 0.55). Cox multivariate survival analysis revealed that PD1 + CTLA4 did not prolong PFS and OS (PFS: hazard ratio 0.83, 95% confidence interval 0.58-1.19, P = 0.30; OS: HR 0.89, 95% confidence interval 0.57-1.38, P = 0.59). The rate of ≥grade 3 immune-related adverse events was higher in the PD1 + CTLA4 group than in the PD1 group (53% versus 17%; P < 0.001).

Conclusions

First-line PD1 + CTLA4 demonstrated comparable clinical efficacy to PD1 in Japanese MCM patients, but with a higher rate of immune-related adverse events.

•

Anti-PD-1 plus anti-CTLA-4 antibody therapy (PD1 + CTLA4) is an option for patients with advanced mucosal melanoma (MCM).

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Data on the efficacy of PD1 + CTLA4 compared with PD-1 monotherapy (PD1) for MCM, however, are limited.

•

We retrospectively analyzed data from 329 Japanese patients with advanced MCM treated with PD1 or PD1 + CTLA4.

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No significant differences in objective response rate, progression-free survival, or overall survival were observed.

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Immune-related adverse events resulting in treatment cessation were higher in the PD1 + CTLA4 group.

Immunoexpression of angiogenesis and proliferation markers in patients treated with cyclosporin A

AIM

In the present immunohistochemical study, the expression of vascular endothelial growth factor, nitric oxide synthase 1 and 3, and Ki-67 in the gingival tissues of renal transplant patients treated with cyclosporin A was assessed. Gingival overgrowth (GO) frequently occurs in transplant patients receiving immunosuppressive drugs such as cyclosporine and this gingival inflammation might play an important role in the pathogenesis of drug-induced GO.

METHODS

Twenty-eight human gingival biopsies were taken from healthy patients with chronic periodontitis (N.=14 control group), and from renal transplant recipients treated with cyclosporin A (N.=14 test group). The retrieved specimens were immunohistochemically processed and stained for vascular endothelial growth factor, nitric oxide synthase 1 and 3, and Ki-67.

RESULTS

The levels of vascular endothelial growth factor, nitric oxide synthase 1 and 3, and Ki-67 were found to be significantly different among groups (P>0.001), with patients treated with cyclosporin A showing higher levels of all the analyzed markers compared to control group.

CONCLUSION

In summary, the data from this pilot study suggests that the investigated factors have a role in the inflammation processes associated to immunosuppressive therapy. However, further studies with a larger sample population need to be conducted for an exhaustive knowledge of the mechanisms leading to GO.

Femtosecond-laser-driven photoelectron-gun for time-resolved cathodoluminescence measurement of GaN

A rear-excitation femtosecond-laser-driven photoelectron gun (PE-gun) is developed for measuring time-resolved cathodoluminescence (TRCL) spectrum of wide bandgap materials and structures such as semiconductors and phosphors. The maximum quantum efficiency of a 20-nm-thick Au photocathode excited using a frequency-tripled Al(2)O(3):Ti laser under a rear-excitation configuration is 3.6×10(-6), which is a reasonable value for a PE-gun. When the distance between the front edge of the PE-gun and the observation point is 10 mm, the narrowest electron-beam (e-beam) diameter is 19 μm, which corresponds to one tenth of the laser-beam diameter and is comparable to the initial e-beam diameter of a typical W hair-pin filament of thermionic electron-gun. From the results of TRCL measurements on the freestanding GaN grown by the ammonothermal method and a GaN homoepitaxial film grown by metalorganic vapor phase epitaxy, overall response time for the present TRCL system is estimated to be 8 ps. The value is the same as that of time-resolved photoluminescence measurement using the same excitation laser pulses, meaning that the time-resolution is simply limited by the streak-camera, not by the PE-gun performance. The result of numerical simulation on the temporal e-beam broadening caused by the space-charge-effect suggests that the present PE-gun can be used as a pulsed e-beam source for spatio-time-resolved cathodoluminescence, when equipped in a scanning electron microscope.

Intracerebral haematomas with agenesis of the internal carotid artery and tetralogy of Fallot

We report a rare case with tetralogy of Fallot (TOF) and agenesis of the internal carotid artery (ICA) who presented serious intracerebral haematomas. In the literature, this is the first documented case having these complications simultaneously. Extreme hypoxic insults followed by recovery were detected by O2 saturation monitor before two bleeds. Chronic brain hypoxia could make the vasculature weak, which was shown in the histological examination. A 2-year-old girl was transferred to us with a general convulsion due to intracerebral haematoma. She had been showing general cyanosis from birth due to TOF. Repeated intracerebral haemorrhages ended her life. Histological study showed dilated vascular channels in the subarachnoid space and necrotizing vasculature obstructed by fibrinous thrombi adjacent to the haematoma. Fibrosis of the vessel wall with infiltration of macrophages suggested subacute or chronic lesions rather than acute necrosis due to the multiple haemorrhages. The intracerebral haematomas and agenesis of the ICA were observed as unilateral hemispheric vascular complications of TOF. Chronic brain hypoxia could play an important role in weakening the vessel wall and erythrocytosis caused obstructing thrombi. We speculate these factors generated the intracerebral haematomas.

Dentatorubral-pallidoluysian atrophy (DRPLA) presenting with psychosis

The authors report on four DRPLA patients who manifested delusions. All patients demonstrated autosomal dominant DRPLA confirmed by standard gene analysis. Patients with DRPLA can exhibit a variety of psychiatric symptoms in addition to extrapyramidal and cerebellar symptoms.

[An epithelial cyst at the frontal convexity]

We report a rare case of an epithelial cyst at the right frontal convexity. A 60-year-old woman came to our hospital suffering from dysarthria and gait disturbance. Computed tomography (CT) of the brain on admission showed a round low-density area, 6 cm in diameter, at the right frontal convexity. Midline shift and displacement of the lateral ventricle are seen. There is no contrast enhancement effect. Excision of the cyst wall and fenestration into the subarachnoid space was carried out and the patient was discharged with no neurological deficits. After 5 years, regrowth of the cyst was seen. Cyst-peritoneal shunt was performed and she was discharged uneventfully. Light microscopy showed the cyst wall consisted of a monolayer of flat epithelium and loose connective tissue. An electronmicrograph of the cyst wall showed a non-ciliated epithelial layer with microvilli and basement membrane. The epithelial cells connecting with each other through desmosome have numerous endoplasmic reticulum and mitochondria. Interdigitation of the cytoplasmic membrane was not seen. The term "epithelial cyst" seems ambiguous. We discuss the pathogenesis and the nomenclature for intracranial benign cystic lesions based on the previous literature.

Acute subdural hematoma in patients who underwent aneurysm clipping--four case reports

Four patients presented with intracranial hemorrhage mainly consisting of acute subdural hematoma (ASDH), who had all undergone aneurysm clipping 2-20 years earlier. Whether the clips had slipped or new trauma had caused the bleeding was difficult to determine, since the initial computed tomography showed that the subarachnoid hemorrhage or the intracerebral hematoma developed near the clips. Angiography in three patients showed that the clips had not slipped off. Three of four ASDHs appeared in the same side as the craniotomy used for the previous aneurysm surgery. Anti-platelet agents and ventriculoperitoneal shunting had been previously used in two patients with no causal signs of trauma. The outcomes were poor in three patients and one patient died. Weakening of the extra- or intracranial structure after aneurysm surgery might have been involved together with the postoperative anti-platelet agent and shunt treatment in the etiology of the present ASDH.

Usefulness of stable HbA(1c) for supportive marker to diagnose diabetes mellitus in Japanese subjects

To evaluate the adequacy and usefulness of the stable glycated hemoglobin (HbA(1c)) value of 6.5% suggested by the Japan Diabetic Society in 1999 for supportive diagnostic marker of diabetes, we assessed the sensitivity and specificity of an HbA(1c) value of 6.5% in patients who were newly diagnosed by the 75 g oral glucose tolerance test (75g-OGTT). A total of 866 Japanese subjects underwent the 75g-OGTT and HbA(1c) measurement (normal range: 4.3-5.8%). They were divided into three groups [normal glucose tolerance (NGT), impaired glucose tolerance (IGT), and diabetes mellitus (DM)], using the WHO criteria, since no subject with impaired fasting glycemia (IFG) was observed. The cut-off value of HbA(1c) separating DM from NGT or DM from IGT on cumulative distribution curve analysis was 5.9% (sensitivity 0.76 and specificity 0.86) and 5.9% (sensitivity 0.76 and specificity 0.77), respectively. The sensitivity of an HbA(1c) of 6.5% for separation of DM from NGT or IGT by the same analysis was 0.49 and 0.49, respectively. Similarly, the specificity for separation of DM from NGT or IGT was 0.98 and 0.98, respectively. These results mean that 49% of diabetic subjects show an HbA(1c)> or =6.5%, and 51% have an HbA(1c) less than 6.5%, while only 2% of NGT and IGT subjects have an HbA(1c)> or =6.5%, and 98% have a value less than 6.5%. Therefore, the sensitivity of an HbA(1c) value of 6.5% in separating DM from NGT or IGT is low, and thus 6.5% is too high value to use when screening for diabetes. However, the specificity is very high, so an HbA(1c) of 6.5% is a useful supportive marker to diagnose diabetes.

Free hand aspiration for large periventricular hemorrhage. Case report

BACKGROUND

At present, there are several therapeutic options, including craniotomy and stereotactic aspiration, for large intracerebral hemorrhage perforating into the lateral ventricle. In the cases with Glasgow Coma Scale (GCS) scores under 6 with anisocoria, external ventricular drainage would be the first choice [2-4]. We have also performed anterior ventricular horn puncture in a standard manner. The target was the foramen of Monro, at a depth of 5.5 cm from the inner table of the skull. The point of insertion was located just anterior to the coronal suture, approximately 10 cm above the nasion, and 3 cm from the midline [1]. However, we noticed that the insertion of a catheter into the periventricular hematoma adjacent to the lateral ventricle was made easier by tilting the catheter 30 degrees laterally as in the first case (Figure 1).

METHODS

In our method, inclining the catheter by 30 degrees laterally, we used a silicone tube 3.5 mm in internal diameter (Silascon ventricle drainage tube, Kaneka Medix Corp., Osaka, Japan) and then replaced it with another Silascon tube with a 2.5 mm-internal diameter. From January 1999 through December 2000, eleven patients who all had GCS scores under 6 and anisocoria preoperatively were treated by this method. The series included two patients who were undergoing hemodialysis because of renal failure, two with bleeding tendency because of liver dysfunction, and one with heart failure.

RESULTS

The insertion itself caused no complications. Cerebrospinal fluid was drained smoothly after removal of hematoma because the hematoma cavity connecting with the lateral ventricle was opened. Two typical cases using this technique are shown (Figures 1 and 2). All patients recovered favorable consciousness postoperatively compared with the preoperative state but hemiparesis remained. Postsurgical follow up at 3 months revealed the outcomes evaluated by Glasgow Outcome Scale (GOS) were moderate disability in 5 patients and severe disability in 6 patients .

CONCLUSION

This direct aspiration and drainage of a large intracerebral hematoma that ruptures into the lateral ventricle is superior to simple ventricular drainage in regard to the removal of the hematoma clot. This technique would be the choice especially in patients with serious complications such as cardiac disease and renal failure.

Classification of psychiatric symptoms in patients with epilepsy

Epilepsy is a neurological disorder, but many patients with epilepsy also have psychiatric symptoms. These symptoms and the underlying psychopathology vary considerably among patients, and the classification of these symptoms is disputed. Some classifications are based on the psychiatric symptomatology, the presence or absence of disturbance of consciousness, the EEG abnormalities, or the temporal relation between the symptoms and the seizures. The International Classification of Mental and Behavioral Disorders: Clinical Description and Diagnostic Guidelines (ICD-10) is accepted worldwide in psychiatry. The feasibility of classifying the psychiatric symptoms associated with the epilepsy according to the ICD-10 classification was studied. It was concluded that only symptoms in cases of epilepsy where there is a clear sensorium might be appropriately classified by the ICD-10. The classification of psychiatric symptoms in epilepsy needs further investigation.

Organized chronic subdural hematoma requiring craniotomy--five case reports

Two child and three elderly patients underwent craniotomy for organized and/or partially calcified chronic subdural hematomas (CSHs). The characteristic feature of magnetic resonance imaging was a heterogeneous web-like structure in the hematoma cavity. Both children had undergone one side subduroperitoneal shunt for bilateral CSHs when infants. As a result, the opposite hematoma cavities persisted and developed into calcified CSHs after a couple of years. All three elderly patients with senile brain atrophy showed various systemic complications such as cerebral infarction, diabetes mellitus, leg ulceration, cirrhosis, and bleeding tendency. Craniotomy for removal of the hematoma and calcification achieved good results in all patients. Subdural space created by shunt, craniotomy, or brain atrophy and persisting for a certain period, and additional various brain damage such as microcirculatory disorder, meningitis, encephalitis, or premature delivery may be important in generating calcified or organized CSH.

Predictive variables of interictal psychosis in epilepsy

OBJECTIVE

To evaluate which variables predict interictal psychosis in epilepsy.

METHODS

The authors reviewed the biological backgrounds, clinical characteristics, and EEG findings in 246 patients with epilepsy and interictal psychosis and in 658 control patients with epilepsy and no psychotic history. With a logistic regression approach, the significance of each variable for the development of interictal psychosis was evaluated.

RESULTS

There are significant differences in family history of psychosis, age at onset of epilepsy, type of epilepsy, lateralization of epileptiform discharges, and level of intelligence between patients with interictal psychosis and those without it. Subsequent logistic regression analysis with all variables demonstrated that family history of psychosis, age at onset of epilepsy, type of seizures, and level of intelligence significantly correlated with psychosis.

CONCLUSIONS

A family history of psychosis, earlier age at onset of epilepsy, complex partial seizures or generalized tonic clonic seizures, and borderline intellectual functioning were the most important predictors for development of interictal psychosis.

Proposal for a new five-axis classification scheme for psychoses of epilepsy

Based on an overview of the literature and a multicenter study in Japan, we propose a new five-axis classification scheme for psychoses of epilepsy: (1) epilepsy variables, (2) psychopathology variables, (3) ictus/EEG variables, (4) precipitating factors of psychoses, (5) organic background. A total of 128 patients, 63 males and 65 females, with epilepsy and psychoses were recruited from five treatment centers. A wide heterogeneity of psychoses of epilepsy was demonstrated and categorization by a single axis was shown to be inadequate. Cluster analysis revealed four subgroups characterized by their psychopathology, temporal relationship to seizure occurrence, and EEG changes during psychoses. By comparing with the control epileptic group without psychoses, higher rates of mild intelligence disturbance and abnormal findings by brain imaging were proven among the psychotic group. The scheme involves a dimensional representation of individual patients to capture the complexity of their clinical background and to relay clinical information accurately and systematically. It is believed to hold direct therapeutic implications and to contribute to promoting research by enabling accumulation of a large number of patients on a multicenter basis.

Inter-ictal and post-ictal psychoses in frontal lobe epilepsy: a retrospective comparison with psychoses in temporal lobe epilepsy

There have been few studies of the psychopathology of patients with frontal lobe epilepsy (FLE). The majority of studies of both inter-ictal and post-ictal psychoses have strongly suggested the influence of temporal lobe disturbance on psychoses. Patients with organic brain damage or schizophrenia, however, sometimes show frontal lobe dysfunction. The purpose of this study was to better understand the effect, if any, of frontal lobe disturbance and seizure on psychopathology. Patients were divided into four groups based on epilepsy type and preceding seizures; 8 with FLE/inter-ictal psychosis, 3 with FLE/post-ictal psychosis, 29 with temporal lobe epilepsy (TLE)/inter-ictal psychosis, and 8 with TLE/post-ictal psychosis. Psychopathologic symptoms were retrospectively reviewed based on case notes, using a modified brief psychiatric rating scale (BPRS). Psychomotor excitement, hostility, suspiciousness, and hallucinatory behaviour were prominent features in all four groups. Six orthogonal factors were derived by factor analysis from the original data based on the 18 BPRS items. FLE patients with inter-ictal psychosis showed marked hebephrenic characteristics (i.e. emotional withdrawal and blunted effect). Our findings suggest that patients with FLE can exhibit various psychiatric symptoms. However, their psychotic symptoms, hebephrenic symptoms in particular, may often be overlooked.

Urokinase cisternal irrigation therapy for prevention of symptomatic vasospasm after aneurysmal subarachnoid hemorrhage: a study of urokinase concentration and the fibrinolytic system

BACKGROUND AND PURPOSE

Cisternal irrigation therapy with urokinase (UK) was performed in multiple institutions to prevent symptomatic vasospasm. The efficacy and safety of this therapy were evaluated, and the optimal concentration of UK was estimated.

METHODS

This therapy was performed in 28 patients who underwent surgery within 72 hours of the onset of severe subarachnoid hemorrhage (Fisher's group 3, CT number [Hounsfield units] >60). After the aneurysm was clipped, irrigation tubes were placed in the Sylvian fissure (inlet) unilaterally and in the prepontine or chiasmatic cistern (outlet). Lactated Ringer's solution with UK (30, 60, or 120 IU/mL) was infused at a rate of 30 mL/h. The presence of symptomatic vasospasm was evaluated by changes in the clinical symptoms and the presence of a new low-density area on CT scan. Drained irrigation fluid and peripheral blood were examined chronologically to evaluate the fibrinolytic system.

RESULTS

Symptomatic vasospasm was observed transiently in 3 cases (10.7%) without any low-density area on CT scan. In the 120-IU/mL group, no symptomatic vasospasm occurred. Analysis of drainage fluid suggested that UK 120 IU/mL is effective. The mean values of total drained blood volume for the respective groups were as follows: 58 mL in 30 IU/mL, 106 mL in 60 IU/mL, and 143 mL in 120 IU/mL. No abnormal changes were observed in the coagulative and fibrinolytic systems after UK irrigation.

CONCLUSIONS

These results suggest that cisternal irrigation therapy with UK is safe and effective for the prevention of symptomatic vasospasm after aneurysmal subarachnoid hemorrhage.

Hyperperfusion in the lateral temporal cortex, the striatum and the thalamus during complex visual hallucinations: single photon emission computed tomography findings in patients with Charles Bonnet syndrome

We report the findings of single photon emission computed tomography using 123I-IMP and magnetic resonance image studies of five patients with Charles Bonnet syndrome (CBS) while they were having visual hallucinations. All patients developed complex visual hallucinations after suffering from eye disease. The mean age at onset of CBS was 71.6 years. Single photon emission computed tomography studies in all patients disclosed hyperperfusion areas with some asymmetrical appearances in the lateral temporal cortex, striatum and thalamus. These results suggest that when elderly people suffer from eye disease, subsequent excessive cortical compensation in the lateral temporal cortex, striatum and thalamus may precipitate the development of visual hallucinations.

Pulsed-Field Ionization Zero-Kinetic-Energy Photoelectron Spectra of Ar(2)

The pulsed-field ionization (PFI) zero-kinetic-energy (ZEKE) photoelectron spectra of Ar(2) were measured between 117 000 cm(-1) (14.5 eV) and 128 300 cm(-1) (15.9 eV) using the penetrating field technique and synchrotron radiation at resolutions of up to 1 meV. The A(2)Sigma(+)(1/2u) ground state and B(2)Pi(1/2g) and C(2)Pi(3/2u) excited states were assigned to those spectra. The first adiabatic ionization potential of Ar(2) was determined to be 14.4572 +/- 0.0007 eV. A Le Roy-Bernstein plot and a Birge-Sponer plot were used to determine the dissociation limit of the A(2)Sigma(+)(1/2u) ground state. The vibrational level of the C(2)Pi(3/2u) excited state was observed for the first time. The effective lifetime for high-n Rydberg states converging on the vibrational levels of the C(2)Pi(1/2u) excited state is estimated to be shorter than those of the A(2)Sigma(+)(1/2u), B(2)Pi(1/2g), and C(2)Pi(3/2u) states, because the spectrum could not be observed on the PFI-ZEKE experiment. The threshold photoelectron-photoion coincidence spectra of Ar(2) were also measured and compared with the spectra obtained from the PFI-ZEKE experiment. Copyright 1999 Academic Press.

Differences in evoked potential characteristics between DRPLA patients and patients with progressive myoclonic epilepsy: preliminary findings indicating usefulness for differential diagnosis

The characteristics of evoked potentials in patients with dentatorubral-pallidoluysian atrophy (DRPLA) were investigated. Twelve patients with DRPLA and three patients with progressive myoclonic epilepsy (PME) attributable to other causes participated in the study. In 11 out of the 12 patients, the diagnosis of DRPLA was genetically confirmed, based on a 56-75 CAG triplet repeat expansion on chromosome 12p; in the remaining patient, the diagnosis was not genetically confirmed but the patient was clinically diagnosed as having DRPLA and was within the same pedigree as one of the 11 genetically confirmed patients. Two out of the three patients with PME, who had been tested for dodecamer repeat expansion in the cystatin B gene, were genetically confirmed as having Unverricht-Lundborg disease (UL); the remaining patient was also clinically diagnosed as having UL, but the patient did not have the aforementioned genetic abnormality. Somatosensory evoked potentials (SEPs) and brainstem auditory evoked responses (BAERs) were recorded. The amplitudes of the SEPs were determined as the peak-to-peak amplitudes between P2 and N2 deflections. The results revealed that high-amplitude SEPs were not evoked in any of the DRPLA patients; on the other hand, high-amplitude SEPs were evoked in all the patients with UL. Moreover, BAERs were absent in seven out of the 12 patients with DRPLA; on the other hand, all UL patients showed BAERs in which all peaks, from I to V, were distinguishable. These results suggest differences in pathophysiology between DRPLA, which predominantly affects the brainstem and subcortical regions, and PME, characterized by cortical hyperexcitability. Thus, evoked potential measurements may be useful to differentiate DRPLA patients from those with progressive myoclonic epilepsy.

Localization of a gene for benign adult familial myoclonic epilepsy to chromosome 8q23.3-q24.1

Benign adult familial myoclonic epilepsy is an autosomal dominant idiopathic epileptic syndrome characterized by adult-onset tremulous finger movement, myoclonus, epileptic seizures, and nonprogressive course. It was recently recognized in Japanese families. In this study, we report that the gene locus is assigned to the distal long arm of chromosome 8, by linkage analysis in a large Japanese kindred with a maximum two-point LOD score of 4.31 for D8S555 at recombination fraction of 0 (maximum multipoint LOD score of 5.42 for the interval between D8S555 and D8S1779). Analyses of recombinations place the locus within an 8-cM interval, between D8S1784 and D8S1694, in which three markers, D8S1830, D8S555, and D8S1779, show no recombination with the phenotypes. Although three other epilepsy-related loci on chromosome 8q have been recognized-one on chromosome 8q13-21 (familial febrile convulsion) and two others on chromosome 8q24 (KCNQ3 and childhood absence epilepsy)-the locus assigned here is distinct from these three epilepsy-related loci. This study establishes the presence of a new epilepsy-related locus on 8q23.3-q24.11.

Effect of metformin on advanced glycation endproduct formation and peripheral nerve function in streptozotocin-induced diabetic rats

The effects of metformin treatment on advanced glycation endproduct formation and peripheral nerve function in streptozotocin-induced diabetic rats were examined. Streptozotocin-induced diabetic rats were treated with low dose metformin (50-65 mg kg(-1) daily) or high dose metformin (500-650 mg kg(-1) daily) for 10 weeks. While the metformin-untreated diabetic group showed a significant increase of advanced glycation endproducts (6.1-fold in the lens, 1.6-fold in the sciatic nerve, 2.3-fold in the renal cortex, and 1.9-fold in plasma; all P < 0.01) compared with the healthy control group, both metformin-treated groups had significantly less advanced glycation endproduct deposition. The % decrease in the diabetes-induced increase in advanced glycation endproduct formation by low and high dose metformin treatment was 25% and 72% in the lens (both P < 0.01), 31% and 42% in the sciatic nerve (both P < 0.05), and 16% and 33% in the renal cortex (P < 0.05 and P < 0.01), respectively. However, the plasma advanced glycation endproduct level showed no significant difference from that in the untreated diabetic group, in spite of slight decrease in plasma glucose and glycated hemoglobin levels in the metformin-treated groups. The diabetes-induced sciatic nerve conduction velocity deficits were improved by 46% and 42% by low and high dose metformin treatment, respectively (both P < 0.01). These data suggest that metformin may have a direct antiglycative action, which in turn contributes to amelioration of peripheral nerve function. Thus, metformin treatment may be effective in the prevention of diabetic complications through not only lowering plasma glucose, but also directly inhibiting advanced glycation endproduct formation.

Usefulness of revised fasting plasma glucose criterion and characteristics of the insulin response to an oral glucose load in newly diagnosed Japanese diabetic subjects

OBJECTIVE

To examine the usefulness of the revised criterion for fasting plasma glucose (FPG) in the diagnosis of diabetes recommended by the American Diabetic Association (ADA) (126 mg/dl, 7 mmol/l), and to characterize insulin response during the 75-g oral glucose tolerance test (OGTT) in newly diagnosed Japanese diabetic subjects.

RESEARCH DESIGN AND METHODS

A series of 2,121 Japanese subjects underwent a 75-g OGTT (0-3 h) and were divided into three groups (normal glucose tolerance [NGT], impaired glucose tolerance [IGT], and diabetes mellitus [DM] according to the current World Health Organization criteria. After the cutoff values of FPG that distinguish NGT and IGT from diabetes were analyzed, the usefulness of the ADA criterion for FPG was examined by comparing diagnostic parameters (sensitivity, specificity, and accuracy) with those for the cutoff value of 140 mg/dl. To assess insulin response, both the insulinogenic index (IsIx), a marker of early secretion, and the area under the insulin response curve (AUCins), a marker of total secretion, were compared between the DM, NGT, and IGT groups.

RESULTS

First, the FPG cutoff value distinguishing NGT from diabetes was 109 mg/dl. An FPG of 126 mg/dl showed a higher sensitivity (0.52 vs. 0.31), the same specificity (1.00), and a higher accuracy (0.82 vs. 0.74) than an FPG of 140 mg/dl, and it had a higher specificity (1.00 vs. 0.86) with a slightly lower accuracy (0.82 vs. 0.85) than an FPG of 109 mg/dl. Second, the FPG cutoff value differentiating IGT from diabetes was 113 mg/dl. An FPG of 126 mg/dl showed a higher sensitivity (0.52 vs. 0.31) and accuracy (0.80 vs. 0.74) and a similar specificity (0.97 vs. 1.00) compared with an FPG of 140 mg/dl, and it had a higher specificity (0.97 vs. 0.82) with the same accuracy (0.80) as an FPG of 113 mg/dl. Third, the DM group showed the lowest IsIx among the three groups at all FPG values. The AUCIns in the DM group increased along with FPG, reached the maximum level at an FPG of 110 mg/dl, and declined thereafter. AUCIns was higher in the DM group than in the NGT group at FPG values > or = 100 mg/dl.

CONCLUSIONS

The revised ADA criterion for FPG of 126 mg/dl may improve diagnostic sensitivity without loss of specificity in Japanese diabetic subjects when compared with an FPG criterion of 140 mg/dl. Although early insulin secretion was impaired, total insulin secretion did not seem to be reduced in newly diagnosed Japanese diabetic subjects.

Gender-specific association of M235T polymorphism in angiotensinogen gene and diabetic nephropathy in NIDDM

This study examined the association between the development of nephropathy in non-insulin-dependent diabetes mellitus (NIDDM) patients and M235T polymorphism in the angiotensinogen gene. White NIDDM patients with diabetic nephropathy (case subjects, n = 117) and patients without any evidence of nephropathy and > or = 10 years of NIDDM (control subjects, n = 125) were selected from among patients of the Joslin Diabetes Center and examined. In addition to a standardized examination, blood was drawn for DNA and determination of M235T genotypes at the angiotensinogen locus. For the angiotensinogen gene, the frequency of the genotype 235T/235T, known to be associated with essential hypertension, was higher among case subjects with nephropathy than in control subjects without this complication. This difference, expressed as the odds ratio for nephropathy among 235T/235T homozygotes in comparison with all other genotypes, was 2.2 (95% confidence interval, 1.1 to 4.4). The difference, however, was confined to men (odds ratio, 4.8; 95% confidence interval, 1.5 to 14.9), with the distribution of genotypes in case and control subjects being equal among women (odds ratio, 1.1). DNA polymorphism M235T in the angiotensinogen gene, which is associated with higher expression of this gene, contributes to the risk of diabetic nephropathy in NIDDM men but not in women.

Identification of homozygous lipoprotein lipase gene mutation in a woman with recurrent aggravation of hypertriglyceridaemia induced by pregnancy

We herein report a case of a 40-year-old Japanese woman (patient IT) with a history of recurrent aggravation of hypertriglyceridaemia, pancreatitis and miscarriages in three previous pregnancies. However, strict dietary intervention was applied during a fourth pregnancy. As a result, acute pancreatitis was avoided, and the patient gave birth to a healthy infant. In patient IT, the underlying etiology of the recurrent aggravation of hypertriglyceridaemia during pregnancy was a lipoprotein lipase (LPL) gene aberration. She was homozygous for LPL deficiency due to a nonsense mutation (TGG1401 --> TGA/Trp382 --> Stop) in exon 8 of the LPL gene, which resulted in the absence of LPL activity and immunoreactive LPL mass. Our findings indicate that, in LPL deficiency, pregnancy seriously exacerbates hypertriglyceridaemia and increases the risk of acute pancreatitis, which endangers both the mother and fetus. Early diagnosis of LPL deficiency and appropriate management thereof are essential for normal childbirth.

[Relationship between imaging and pathological features and clinical factors in surgical cases of temporal lobe epilepsy]

The relationships between imaging, pathology and presumed causes in surgical cases of temporal lobe epilepsy (TLE) was studied. The subject was 62 patients (33 males and 29 females) who had had no attacks for more than one year after surgery. Average age at surgery was 28.2 +/- 9.9 years. Obvious neurological abnormalities were not found in these cases. MRI, PET and SPECT were performed. Hematoxylin and eosin was used for pathological judgement. Their medical charts were used to investigate their clinical factors. Although patients suspected of having encephalitis/meningitis had been hospitalized for 2 days to three months during childhood due to disturbance of consciousness with high fever and convulsion for several days; they were not diagnosed with encephalitis/meningitis at that time, and they suffered almost no handicaps other than epilepsy for several years following their comatose episodes. [Result] (1) On MRI, mesial temporal sclerosis (MTS) was detected in 48 of 52 patients (92%); 32 (62%) had high-signal intensity on T 2-weighted images; 31 (60%) had atrophy ¿23 (44%) had high-signal intensity on T 2 + atrophy¿; 5 (10%) had calcified lesions; and 2 (4%) had cystic lesions. On PET and SPECT, abnormal cerebral blood flow was noted in 33 of 36 (92%). (2) On pathological findings (61 cases), Ammon's horn sclerosis (AHS), tumors, gliosis in lateral temporal and meningeal inflammatory finding were detected in 42 (69%), 10 (23%) and 8 (13%) cases, respectively, whereas 2 showed no abnormalities. The 2 patients with normal pathology showed both high-signal intensity and atrophy on MRI. (3) The presumed causes of TLE were encephalitis/meningitis and/or suspected of these diseases in 15 patients (24%), injuries at birth in 5 (8%), and none in 42 (68%). The presumed causes in the 43 patients with AHS were encephalitis/meningitis in 11, injuries at birth in 3, and none in 29. Of the 15 patients in whom encephalitis/meningitis was estimated as the causes of TLE, only 6 (40%) had pathological evidence of meningeal inflammatory finding. Of the 42 patients in whom cause could not be determined, 2 had pathological evidence of meningeal inflammatory finding.

Sequential assessment of cerebral blood flow in diffuse brain injury by 123I-iodoamphetamine single-photon emission CT

PURPOSE

Our goal was to elucidate the temporal profile of cerebral circulation and its relationship to prognosis in patients with diffuse brain injury by using single-photon emission CT (SPECT) and 123I-iodoamphetamine (IMP).

METHODS

A total of 67 assessments were made in 26 patients with diffuse brain injury (Glasgow Coma Scale score < or = 8). The microsphere method was used for quantifying cerebral blood flow (CBF). The hemispheric CBF was defined as a mean regional CBF (rCBF), and the total cerebral hemispheric CBF (tCBF) as a mean of the bilateral hemispheric CBF. The relationship between patient outcome and tCBF was investigated.

RESULTS

The rCBF in patients with diffuse brain injury showed dynamic and global changes with little regional differences. The tCBF values increased in 1 to 3 days, and they were higher in the poor-outcome group than in the good-outcome group. During the period of 14 to 42 days, the tCBF values stayed within normal range in the good-outcome group, whereas they were below normal range in the poor-outcome group.

CONCLUSION

Our results revealed a good correlation between patient outcome and CBF values. Quantitative and sequential CBF studies with IMP SPECT are promising for helping to determine the prognosis for patients with diffuse brain injury.

Role of glycemic control and blood pressure in the development and progression of nephropathy in elderly Japanese NIDDM patients

OBJECTIVE

To investigate the role of glycemic control and blood pressure in the development and progression of nephropathy and to suggest goals for glycemic control and blood pressure for the prevention of nephropathy in elderly Japanese NIDDM patients.

RESEARCH DESIGN AND METHODS

A total of 123 age- and diabetes duration-matched elderly Japanese NIDDM patients (aged 60-75 years; 74 normoalbuminuric and 49 microalbuminuric) were retrospectively studied for 6 years.

RESULTS

The group that developed microalbuminuria from normoalbuminuria (group NM: n = 24) showed a higher 6-year mean HbA1c than the group that remained normoalbuminuric (group NN: n = 50; 9.0 +/- 0.8 vs. 8.1 +/- 0.8%, P < 0.01) in spite of no significant difference in 6-year mean blood pressure (MBP). On the other hand, the group that progressed from microalbuminuria to overt proteinuria (group MP: n = 26) showed a higher 6-year MBP than the group that remained microalbuminuric (group MM: n = 23; 106 +/- 5 vs. 95 +/- 6 mmHg, P < 0.01) in spite of no significant difference in 6-year mean HbA1c. The cutoff level of HbA1c separating group NN from group NM was 8.5% (normal range < or = 6.5%), and that of MBP separating group MM from group MP was 100 mmHg.

CONCLUSIONS

Glycemic control is a more potent factor than blood pressure level on the development of microalbuminuria. However, as far as the progression of microalbuminuria to overt proteinuria is concerned, hypertension is the most crucial factor in elderly NIDDM patients. Suggested goals for glycemic control and blood pressure level for the prevention of nephropathy in elderly Japanese patients are an HbA1c of < or = 8.5% (equivalent to 7.8% in the current measurement of stable HbA1c; normal range < or = 5.8%) and an MBP of < or = 100 mmHg.

Synergistic effect of angiotensin II type 1 receptor genotype and poor glycaemic control on risk of nephropathy in IDDM

We investigated the contribution of polymorphisms in the angiotensin II type 1 receptor gene (AGTR1) to renal complications in an inception cohort of 152 insulin-dependent diabetic (IDDM) patients examined 15-21 years after diabetes onset. This nested case-control study included 79 normoalbuminuric control subjects and 73 cases with evidence of nephropathy ranging from microalbuminuria to overt proteinuria. Subjects were genotyped for two AGTR1 polymorphisms (T573-->C and A1166-->C), and an adjacent CA repeat microsatellite. Allele C1166 and the 140 bp allele of the microsatellite were more frequent among nephropathy cases than normoalbuminuric control subjects (0.322 vs 0.247, and 0.618 vs 0.521, respectively), but these differences were not statistically significant. Although not significant by themselves, the AGTR1 polymorphisms contributed significantly to the risk of diabetic nephropathy when accompanied by poor glycaemic control. Among patients with frequent severe hyperglycaemia during the first decade of diabetes, the relative risk of nephropathy among allele C1166 carriers was 12.1 (95% CI: 3.7-39.8), whereas it was only 1.4 (95% CI: 0.6-3.5) among allele A1166 homozygotes. The difference between relative risks was highly significant (chi(2) = 8.25, p = 0.004 with 1 df). A similar pattern of higher risk of microalbuminuria, specifically among those carriers of allele C1166 who had poor glycaemic control was also found in an independent study of a cross-sectional sample of 551 IDDM individuals, although the effect was smaller in magnitude. We conclude that DNA sequence differences in the AGTR1 gene may modify the noxious effects of hyperglycaemia on the kidney. Allele C1166 carriers might especially benefit from nephropathy prevention programmes.

Effects of advanced glycation endproducts on the generation of macrophage-mediated oxidized low-density lipoprotein

Macrophages have a receptor that recognizes advanced glycation endproducts (AGE). In this study, we evaluated the effect of AGEs on the generation of macrophage-mediated oxidized low-density lipoprotein (LDL) by measuring the electrophoretic mobilities and lipid hydroperoxide (LHPO) levels of LDL. In the absence of the macrophage monolayer, the differences of the electrophoretic mobilities or LHPO levels of native (n) LDL did not differ significantly between control (c) bovine serum albumin (BSA) and those with AGE-BSA. In the presence of the macrophage monolayer, however, the difference was significant with higher levels after the incubation with AGE-BSA than with c-BSA. In the case of cLDL and glycated (g) LDL, the electrophoretic mobilities and LHPO levels of LDL after 20 h incubation with AGE-BSA in the presence of the macrophage monolayer were significantly higher than those with c-BSA. There were no significant differences, however between the electrophoretic mobilities and LHPO levels of cLDL and of gLDL. These results suggest that AGEs stimulate the generation of macrophage-mediated oxidized LDL, but do not directly stimulate the oxidative modification of gLDL.

[Hyperglycemia and symmetrical proximal neuropathy in diabetes]

A 60-year-old woman, diagnosed as having a diabetic symmetrical proximal motor neuropathy, is presented. In March 1995, she was referred to us because of untreated diabetes mellitus since 1990. Insulin treatment during one month decreased her postprandial plasma glucose level from more than 400mg/dl to about 200mg/dl. Soon after the treatment, she noticed lower proximal limb weakness bilaterally. In several months, her weakness progressed as the fasting plasma glucose level was increased. Her muscle power gradually recovered when the plasma glucose level was normalized. We therefore suggest that metabolic changes related to hyperglycemia, rather than ischemic vascular changes, play an important role in the pathogenesis of a diabetic symmetrical proximal motor neuropathy.

[A case of pineal teratoma arising from hydrocephalus of unknown cause]

We report a case of "functional aqueductal stenosis" which reveals dilatation of the lateral and 3rd ventricles without stenosis at the aqueduct in MRI. This case shows a pineal teratoma which presents one year later with symptoms of hydrocephalus caused by "functional aqueductal stenosis". A seven-year-old boy was admitted to our department owing to headache and vomiting. CT and MRI showed hydrocephalus. The lateral and 3rd ventricles were dilated while the 4th ventricle was normal. Furthermore, tumoral obstruction of the aqueduct was not found. After a ventriculoperitoneal shunt, he recovered well without neurological deficits. One year later, symptoms of precocious puberty, that is the appearance of public hair and deepening of his voice, were found. A follow-up MRI demonstrated a pineal region tumor. Although human chorionic gonadotropin level in the serum and urine was transiently elevated, it normalized before surgery. The operation was performed by the occipital transtentorial approach and the tumor was totally removed. Histological examination proved this tumor to be a mature teratoma, showing three germ cell layers. About two weeks later, he was discharged without any neurological deficit. In this case, although hydrocephalus occurred, MRI didn't demonstrate aqueductal obstruction caused by the tumor. However, one year later, a pineal region tumor was confirmed by MRI. This suggests that hydrocephalus might have some association with the appearance of the pineal region tumor. Therefore, it is necessary to be aware of the possibility of the occurrence of tumors whenever we encounter "functional aqueductal obstruction", when MRI doesn't demonstrate aqueductal obstruction caused by a tumor.

Cerebral perfusion changes in traumatic diffuse brain injury; IMP SPECT studies

Diffuse brain injury (DBI) is characterized by axonal degeneration and neuronal damage which cause diffuse brain atrophy. We have investigated the time course of abnormalities in cerebral perfusion distribution in cases of DBI by using Iodine-123-IMP SPECT, and the relationship to the appearance of diffuse brain atrophy. SPECT scans were performed on eight patients with diffuse brain injury due to closed cranial trauma in acute and chronic stages. All patients showed abnormalities in cerebral perfusion with decreases in perfusion, even in non-depicted regions on MRI, and the affected areas varied throughout the period of observation. Diffuse brain atrophy appeared in all patients. In some patients, diffuse brain atrophy was observed at or just after the time when the maximum number of lesions on SPECT were seen. The abnormalities in cerebral perfusion in cases of DBI might therefore be related to axonal degeneration and neuronal damage which causes diffuse brain atrophy.

[A patient with epilepsy manifesting reversible memory dysfunction--a neuropsychological, electroencephalographical and radiological study]

A 49-year-old man was admitted to our hospital because of epileptic seizures and memory dysfunction. He had been experiencing seizures several times a day since the age of 43 years. Despite antiepileptic drug therapy (sodium valproate [VPA] and clonazepam [CZP], he suffered from frequent complex partial seizures originating in the temporal lobe, and he had a memory disturbance since age 47. When carbamazepine (CBZ) was substituted for VPA and CZP, the epileptic seizures stopped and the memory disturbance improved. Noninvasive regional cerebral blood flow (rCBF) measurements using 99mTc-HMPAO-SPECT imaging were performed twice. The initial measurements on admission showed overall decreased rCBP that was more prominent in the cerebral cortex than in the subcortical nuclei. A follow-up SPECT examination after clinical improvement revealed a marked overall increase in rCBF, especially in the cerebral cortex. The SPECT findings suggest that the memory disturbance in this patient may have been associated with the overall cerebral blood hypoperfusion. This overall hypoperfusion can be attributed to the frequent complex partial seizures and/or the adverse effect of VPA and CZP. SPECT can provide important information suggesting the pathogenesis of memory disturbance associated with epilepsy.

Two forms of hemitonic seizure in patients with infantile hemiplegia and epilepsy

Two forms of unilateral tonic (hemitonic) seizure were observed in two adult epileptic patients with infantile hemiplegia. Their ictal EEGs showed diffuse bilaterally synchronous spike bursts without focal features. In one case, a 31-year-old male, the VTR/EEG recording clearly demonstrated hemitonic seizure which simultaneously involved his paretic limbs and body and were associated with loss of consciousness and autonomic signs. In the other case, a 33-year-old male, partial seizures with secondary unilateral generalization were demonstrated by VTR/EEG recording. The reason why these cases do not exhibit motor seizure activity on the unaffected side despite diffuse bilateral EEG changes, a lower motor threshold in the paretic limbs and inhibitory effect in the brain-stem on undamaged side are postulated. These two cases suggest that hemitonic seizures include heterogeneous characteristics of partial and generalized epilepsy. In patients with diffuse brain damage, such as those with infantile hemiplegia, seizures appear to exhibit complicated patterns, with characteristics of partial and generalized seizures. There is a gradiation of expression of unilateral seizure, range from clearly partial seizures to those with mostly features of generalized seizures, except for an asymmetry of motor expression.

Interictal cerebral and cerebellar blood flow in temporal lobe epilepsy as measured by a noninvasive technique using Tc-99m HMPAO

The usefulness of noninvasive regional cerebral blood flow measurements using Tc-99m hexamethylpropylene amine oxime (HMPAO) was evaluated in 45 patients with interictal temporal lobe epilepsy. Seizure frequency did not show any influence on flow values or side-to-side asymmetry. Patients taking phenytoin had a significantly lower mean cerebral blood flow (mean 9.5%) and lower mean cerebellar blood flow (mean 12.9%) than those not taking it. Moreover, phenytoin reduced regional cerebral blood flow in the temporal regions more prominently on the contralateral side of the epileptic focus than on the ipsilateral side. Positive MRI findings of hippocampal sclerosis along with visually detected temporal hypoperfusion on SPECT showed a lower regional cerebral blood flow and greater flow asymmetry than other imaging findings in the temporal region. Results suggest that noninvasive cerebral blood flow measurements using Tc-99m HMPAO may give useful information about interictal cerebral blood flow around an epileptic focus and about the effects of antiepileptic drugs on brain function in temporal lobe epilepsy.

In situ localization of messenger ribonucleic acid for an oviduct-specific glycoprotein during various hormonal conditions in the golden hamster

The oviductal epithelium secretes specific glycoproteins that associate with the egg after ovulation. Several published reports including our preliminary studies have suggested that ovarian steroids regulate the secretion of oviduct-specific glycoproteins in several mammalian species. The objective of this study, using golden hamsters, was to analyze the hormonal effects on gene expression of these molecules more precisely during various hormonal conditions (estrous cycle, ontogeny, pregnancy, GnRH analogue treatment, and ovariectomy) by in situ hybridization. The message for the hamster oviduct-specific glycoprotein (HOGP) was detected by a digoxigenin-labeled single-strand specific DNA probe in paraffin sections. Data from these studies show the following. 1) In the oviduct, the signal was detected in both the perinuclear region and the basal region in the ampulla but was predominantly detected in the basal region in the isthmus. 2) The signal intensity was high in the ampulla compared with the isthmus. 3) During a normal estrous cycle, the message level was significantly altered between the estrous and diestrous stages in the ampulla but not in the isthmus. In addition, the signal did not disappear at any stage in either the isthmus or ampulla. 4) The HOGP message was first observed from around 14 days of age and then decreased in parallel with serum estradiol levels during aging. 5) The signal was also observed in the oviductal epithelium of pregnant animals at term and of postpartum animals. 6) When we treated the animals with TAP-144-SR (GnRH analogue) or performed an ovariectomy, which caused diminution of serum estradiol and progesterone levels, the message of HOGP was significantly decreased. Moreover, the message expression was greatly induced after estradiol administration to GnRH analogue-treated animals, whereas a high level of serum progesterone slightly inhibited HOGP message expression. These results suggest that elevation of the serum estradiol/ progesterone level affects the HOGP gene expression in the ampulla. However, a high serum estradiol level did not induce the gene expression rapidly, suggesting that an adequate serum hormonal level over a given period of time may be important for the HOGP gene expression.

Adrenal metastasis from hepatocellular carcinoma--report of a case

A 66-year-old man presented with an epigastric tumor demonstrated by both ultrasonography and computed tomography as hepatocellular carcinoma. He referred himself to a specialist at another hospital who performed transarterial embolization (TAE) of the hepatic artery. But the serum alpha fetoprotein (AFP) concentration gradually rose after the procedure. A right adrenal metastasis was discovered by computed tomography 9 months after his presentation, 8 months after first embolization. When TAE was performed for this metastasis, there was transverse palsy of the lower limb secondary to spinal artery embolization. He returned to our hospital where a right adrenectomy was performed 14 months after his first presentation. The operation was successful and he was discharged 6 weeks later. But he was readmitted in 8 months with an elevated serum AFP concentration and died within 2 weeks. The details of this case are presented, and the indications for resection of adrenal metastasis from hepatocellular carcinoma are discussed.