Novel scoring system and algorithm for classifying chronic rhinosinusitis: the JESREC Study.

BACKGROUND: Chronic rhinosinusitis (CRS) can be classified into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). CRSwNP displays more intense eosinophilic infiltration and the presence of Th2 cytokines. Mucosal eosinophilia is associated with more severe symptoms and often requires multiple surgeries because of recurrence; however, even in eosinophilic CRS (ECRS), clinical course is variable. In this study, we wanted to set objective clinical criteria for the diagnosis of refractory CRS. METHODS: This was a retrospective study conducted by 15 institutions participating in the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis (JESREC). We evaluated patients with CRS treated with endoscopic sinus surgery (ESS), and risk of recurrence was estimated using Cox proportional hazard models. Multiple logistic regression models and receiver operating characteristics curves were constructed to create the diagnostic criterion for ECRS. RESULTS: We analyzed 1716 patients treated with ESS. To diagnose ECRS, the JESREC scoring system assessed unilateral or bilateral disease, the presence of nasal polyps, blood eosinophilia, and dominant shadow of ethmoid sinuses in computed tomography (CT) scans. The cutoff value of the score was 11 points (sensitivity: 83%, specificity: 66%). Blood eosinophilia (>5%), ethmoid sinus disease detected by CT scan, bronchial asthma, aspirin, and nonsteroidal anti-inflammatory drugs intolerance were associated significantly with recurrence. CONCLUSION: We subdivided CRSwNP in non-ECRS, mild, moderate, and severe ECRS according to our algorithm. This classification was significantly correlated with prognosis. It is notable that this algorithm may give useful information to clinicians in the refractoriness of CRS before ESS or biopsy.

Targeted disruption of the plasmodium berghei CTRP gene reveals its essential role in malaria infection of the vector mosquito.

CTRP (circumsporozoite protein and thrombospondin-related adhesive protein [TRAP]-related protein) of the rodent malaria parasite Plasmodium berghei (PbCTRP) makes up a protein family together with other apicomplexan proteins that are specifically expressed in the host-invasive stage 1. PbCTRP is produced in the mosquito-invasive, or ookinete, stage and is a protein candidate for a role in ookinete adhesion and invasion of the mosquito midgut epithelium. To demonstrate involvement of PbCTRP in the infection of the vector, we performed targeting disruption experiments with this gene. PbCTRP disruptants showed normal exflagellation rates and development into ookinetes. However, no oocyst formation was observed in the midgut after ingestion of these parasites, suggesting complete loss of their invasion ability. On the other hand, when ingested together with wild-type parasites, disruptants were able to infect mosquitoes, indicating that the PbCTRP gene of the wild-type parasite rescued infectivity of disruptants when they heterologously mated in the mosquito midgut lumen. Our results show that PbCTRP plays a crucial role in malaria infection of the mosquito midgut and suggest that similar molecular mechanisms are used by malaria parasites to invade cells in the insect vector and the mammalian host.

Diffusion-weighted MR imaging in carotid angioplasty and stenting with protection by the reversed carotid arterial flow.

BACKGROUND AND PURPOSE: Distal embolism during carotid angioplasty with stent (CAS) can be protected by a flow-reversal device. Diffusion-weighted MR imaging was used to evaluate this protective procedure and perform a comparison with the control. METHODS: Cases of CAS with protection procedures were included in this study. Sixty-five men (68 procedures) and 5 women (5 procedures), with an average age of 68.8 years, having severe carotid stenosis were treated in our department between 2002 and 2004. Eleven cases were treated with the Parodi Anti-Emboli System, with which the internal carotid blood flow is reversed by simultaneous occlusion of the proximal common carotid artery and external carotid artery. Diffusion-weighted MR imaging was performed within 1-3 days after CAS. As controls, data from diffusion-weighted MR imaging in 26 patients who had diagnostic angiography were included. RESULTS: Diffusion-weighted MR imaging in diagnostic angiography showed 11.5% appearance of ischemic spots after procedures. In the Parodi Anti-Emboli System, this value was 18.2%. In the CAS group, ischemic lesions appeared only in the hemisphere ipsilateral to carotid stenosis. There were no ischemic lesions in the opposite carotid or vertebrobasilar territory. The appearance rate of new ischemic spots was not significantly different between the control group and the group of CAS with Parodi Anti-Emboli System (chi2 test, P = .6227, Fisher exact method). CONCLUSIONS: Protection results obtained with the Parodi system were excellent and comparable with conventional angiography.

Suspected Metallic Embolism following Endovascular Treatment of Intracranial Aneurysms.

We describe a case series of suspected metallic embolism after coil embolization for intracranial aneurysms. Between January 2012 and December 2014, 110 intracranial aneurysms had been treated by coil embolization in our institution. In 6 cases, the postprocedural MR imaging revealed abnormal spotty lesions not detected on the preprocedural MR imaging. The lesions were also undetectable on the postprocedural CT scan. They were demonstrated as low-intensity spots on T1WI, T2WI, DWI, and T2*-weighted imaging. On DWI, they were accompanied by bright "halo," and on T2*-weighted imaging, they showed a "blooming" effect. In 3 of the 6 cases, follow-up MR imaging was available and all the lesions remained and demonstrated no signal changes. Although histologic examination had not been performed, these neuroradiologic findings strongly supported the lesions being from metallic fragments. No specific responsible device was detected after reviewing all the devices used for the neuroendovascular treatment in the 6 cases.

V3 loop of human immunodeficiency virus type 1 reduces cyclin E expression and induces G1 arrest in interleukin 2-dependent T cells.

We previously described that V3 loop derived from the HTLV-III BH10 clone V3-BH10 markedly suppressed IL-2-driven T cell proliferation and produced G1 arrest of the cells. Here, we tested the effect of V3-BH10 on the molecules that are involved in transition from the G1 to S phase of the cell cycle. The effect of V3-BH10 on the IL-2-induced expression of G1 cyclins, Cdk inhibitors, and phosphorylation of retinoblastoma protein (pRb) was tested by immunoblotting, using the IL-2-dependent CD4-positive cell line Kit 225. Furthermore, IL-2-dependent kinase activity of the cyclin E-Cdk2 complex was investigated with histone H1 as a substrate. V3-BH10 reduced the IL-2-dependent expression of cyclin E, but not that of cyclin D and Cdk inhibitors such as p21 and p27. As the result of reduction of cyclin E, histone H1 kinase activity of the cyclin E-Cdk2 complex was markedly reduced even in the presence of rIL-2, followed by incomplete phosphorylation of pRb. The reduction in hyperphosphorylation of pRb by V3-BH10 led to G1 arrest of the cell cycle. Thus, V3-BH10 induced G1 arrest in IL-2-dependent cell cycle progression by reducing cyclin E expression, which may be one of the mechanisms underlying the dysfunction of T cells in HIV-1-infected people.

V3 loop of human immunodeficiency virus type 1 suppresses interleukin 2-induced T cell growth.

We tested the effect of three linear or two loop peptides derived from the V3 region of the HTLV-III BH10 clone or the SF2 strain of human immunodeficiency virus type 1 on IL-2-driven T cell proliferation. V3-BH10, which consists of 42 amino acids and has a loop structure, suppressed IL-2-driven proliferation of all IL-2-dependent cells [Kit225, ED-40515(+), KT-3, 7-day PHA-blasts, and fresh peripheral blood mononuclear cells] tested, whereas it did not suppress the cell growth of IL-2-independent cell lines (Hut102, Molt-4, and Jurkat). This suppressive effect was also seen in IL-2-driven cell growth of CD8-positive lymphocytes purified from 7-day PHA-blasts, indicating that CD4 molecules were not required for the suppression. The treatment with anti-V3 loop monoclonal antibody (902 antibody) completely abolished the suppressive effect of V3-BH10. In addition, V3-BH10 generated the arrest of Kit225 cells and also purified CD8-positive lymphocytes in G1 phase in the presence of IL-2. Neither chromatin condensation nor DNA fragmentation was detected in Kit225 cells cultured with V3-BH10 and IL-2. V3-BH10 neither blocked radiolabeled IL-2 binding to IL-2 receptors nor affected tyrosyl phosphorylation of several cellular proteins (p120, p98, p96, p54, and p38), which is immediately induced by IL-2 stimulation. However, V3-BH10 enhanced IL-2-induced mRNA expression of c-fos but not c-myc or junB. Thus, the binding of V3 loop of gp120 to the cell surface molecule(s) appears to affect intracellular IL-2 signaling, which leads to the suppression of IL-2-induced T cell growth.

Substrate specificity of human monoamine (M)-form phenol sulfotransferase: preparation and analysis of Dopa 3-O-sulfate and Dopa 4-O-sulfate.

Upon two-dimensional thin-layer separation, the sulfated L-3, 4-dihydroxyphenylalanine (L-DopaS) generated enzymatically was found to co-migrate with only one of the two ninhydrin-stained spots corresponding to the two sulfated forms (3-O-sulfate and 4-O-sulfate) of synthetic L-DopaS. To clarify precisely the identity of the enzymatically generated L-DopaS, the two sulfated forms of synthetic L-DopaS were separated and purified using high performance liquid chromatography. Purified L-Dopa 3-O-sulfate and L-Dopa 4-O-sulfate were identified by 1H-nuclear magnetic resonance (NMR) spectrometry and used as standards in the analysis of the L-DopaS generated during metabolic labeling of HepG2 human hepatoma cells or enzymatic assay using recombinant human monoamine (M)-form phenol sulfotransferase. The results obtained demonstrated unequivocally the generation of L-Dopa 3-O-sulfate, indicating the specificity of the M-form phenol sulfotransferase being for the meta-hydroxyl group of L-Dopa.

Giant pseudoaneurysm of the extracranial vertebral artery successfully treated using intraoperative balloon catheters.

Traumatic pseudoaneurysms of the extracranial vertebral artery rarely occur, because of its deeply protected anatomical location. Because the direct surgical approach has resulted in high morbidity and mortality rates, ligation of the vertebral artery has been adopted, but this can cause an ischemia in the vertebrobasilar system. We report the case of a 73-year-old woman with a huge pseudoaneurysm of the right vertebral artery that occurred after attempted placement of a cardiac pacemaker. The aneurysm was 7 x 7 x 5 cm in size and its neck was situated just distal to the right subclavian artery. Direct surgical repair of the injured vessel and removal of the aneurysm were successfully performed using balloon catheters placed intraoperatively in both the innominate artery and the right vertebral artery.

Vascular reconstruction of a vertebral artery loop causing cervical radiculopathy and vertebrobasilar insufficiency. Case report.

The authors present the case of a 62-year-old man with a 4-month history of progressive left-sided C-5 radiculopathy and dizziness. Neuroimaging studies revealed a looped vertebral artery (VA) that had migrated into the widened left C4-5 intervertebral foramen. The patient underwent vascular reconstruction of the VA loop, in which there was minimal manipulation of the C-5 nerve root, via a left-sided anterolateral approach after a balloon occlusion test. Postoperatively the patient's symptoms improved immediately, and there were no signs of recurrence within the 2-year follow-up period. This excellent outcome supports the belief that a proper surgical reconstruction of the compressive, tortuous VA should be the therapeutic option of choice, which carries a lower risk of the nerve root injury and improves the hemodynamics in the posterior circulation.

Os odontoideum associated with hypertrophic ossiculum terminale. Case report.

The authors report on the case of a 20-year-old man who presented with a transient tetraparesis. Neuroimaging studies demonstrated atlantoaxial dislocation and ventral compression of the rostral spinal cord caused by a quite rare association of os odontoideum and hypertrophic ossiculum terminale. The patient underwent removal of two free ossicula via a transoral approach and posterior fusion in which an autogenous bone graft was placed. The majority of cases of os odontoideum are believed to be an acquired form; however, controversy with regard to the congenital causes of os odontoideum remains. One hypothesis is that os odontoideum results from the failure of fusion and the hypertrophy of the proatlas, although considerable confusion surrounds this hypothesis because definitive classification of os odontoideum-to differentiate between similar anomalies-has not been established. This rare coincidence in the current case supports the belief that os odontoideum has a different embryological origin from ossiculum terminale, which is thought to be a proatlantal remnant.

Thoracic spinal angiomyolipoma with extracanal extension to the thoracic cavity. A case report.

STUDY DESIGN: Case report and review of the literature. OBJECTIVE: To describe a 72-year-old man with thoracic spinal angiomyolipoma in the ventral aspect of the epidural space and extracanal extension to the posterior mediastinum, to discuss the clinical and radiologic features and unique biologic behavior of this entity, and to review of the literature on angiolipoma and angiomyolipoma. SUMMARY OF BACKGROUND DATA: Spinal angiolipoma and angiomyolipoma are rare tumors, which are localized almost exclusively in the dorsal epidural space of the thoracic spine. Most reported cases have no tendency to involve the surrounding tissue. METHODS: The authors describe the radiologic, surgical, and pathologic findings of this patient and review the findings from other reported cases. RESULTS: Anterior decompression was performed using a right transthoracic incision, and the neurologic symptoms improved immediately. There were no signs of recurrence of the tumor or neurologic deficit within a 2-year follow-up period. CONCLUSION: Results of a literature survey of these tumors support management by prompt and radical surgical intervention for long-term cure, even in cases in which the infiltrating nature is recognized.

An unusual clinical course after mole evacuation: a case report.

A 27-year-old woman evacuated a hydatidiform mole at 11 weeks of gestation. Her serum human chorionic gonadotropin (hCG) levels declined progressively but reached a plateau of 2-3 mIU/ml thereafter. The patient was treated with two courses of methotrexate, which did not affect her hCG levels. She refused further chemotherapy and, for more than one year, she was managed expectantly until a significant rise in her hCG titer. Fortunately, an unexpected pregnancy and subsequent missed abortion led to a spontaneous regression of her hCG levels.

Relapsing polychondritis diagnosed by Tc-99m MDP bone scintigraphy.

PURPOSE: Relapsing polychondritis is a generalized recurring disease of cartilage that involves joints, trachea, bronchi, laryngeal cartilages, costal cartilages, and cartilages of the ear and nose. It is associated with autoimmune diseases, including Hashimoto disease in some cases. METHODS: The authors evaluated a 29-year-old man with relapsing polychondritis who had symptoms and signs of a common cold for 2 months and anterior chest pain near the sternum for 1 month. RESULTS: After the diagnosis, the authors found that the patient had a history of thyroid therapy for hyperthyroidism 15 years before. Tc-99m MDP bone scintigraphy performed to evaluate anterior chest pain showed diffusely increased accumulation of radioactivity in all costocartilages and sternoclavicular joints. Based on that information, relapsing polychondritis was diagnosed. Ga-67 citrate scintigraphy was preformed to determine the optimum biopsy site of the cartilage. The diagnosis was histologically supported by the results of the open biopsy. CONCLUSIONS: In this case, Tc-99m MDP bone scintigraphy was useful for diagnosing relapsing polychondritis, and Ga-67 citrate scintigraphy was helpful in determining the biopsy site.

Cerebrospinal fluid rhinorrhea secondary to small tumor invasion into the superior sagittal sinus--case report.

A 53-year-old male presented with non-traumatic cerebrospinal fluid rhinorrhea due to obstructive extension of a small parasagittal meningioma. Radical excision of the tumor was curative. The rhinorrhea apparently developed due to increased intracranial pressure associated with primary empty sella.

[Bilateral aneurysms of extracranial internal carotid arteries. Case report].

A 52-year-old male was admitted because of right hemiparesis. Computed tomography scan showed a low-density area in the basal ganglia on the left side. Left carotid angiography showed an aneurysm of the extracranial internal carotid artery at the level of the C1-C2 vertebral body. Right carotid angiography also showed an aneurysm of the extracranial internal carotid artery. Because there were neither steno-occlusive changes in the intracranial vessels nor abnormality in the heart, the right hemiparesis seemed to be due to embolism from the extracranial aneurysm. Aneurysmectomy and end-to-end anastomosis of the left internal carotid artery were performed. Extracranial carotid aneurysms are rare conditions. In surgery on these aneurysms, ischemic changes of the brain during arterial clump must be detected and treated. Hypothermia, induced hypertension, and/or internal shunting have been used during arterial clump. The pathogenesis, symptoms, prognosis, and surgical treatments of these aneurysms are discussed.

[Ossification of the thoracic ligamentum flavum presenting with intercostal neuralgia. Case report].

A 46-year-old female was admitted complaining of progressive, severe girdle pain consistent with the left Th3 dermatome. Neurological examination on admission revealed dysesthesia and radiating pain in the left Th3 territory. Plain X-rays and tomograms of the thoracic spine revealed a beak-like bony excrescence arising from the lamina and projecting moderately to the Th3/4 intervertebral foramen, suggesting ossification of the thoracic ligamentum flavum (OYL). Myelography showed the dural sac compressed from laterally just below the left Th3 pedicle, which suggested that the Th3 nerve root was compressed by the OYL. After Th3 nerve root decompression through hemilaminectomy and foraminotomy, the girdle pain disappeared. OYL is known to cause thoracic radiculomyelopathy, but presentation with intercostal neuralgia only is very rare. The authors review the literature and stress the importance of myelography for diagnosis.

[Clinical analysis of ossified thoracic ligaments and thoracic disc hernia].

Thoracic lesions present several clinical problems, particularly in their diagnosis and treatment, compared with cervical or lumbar lesions. Since 1983, 18 cases of thoracic space lesions, excluding spinal tumors or trauma have been experienced: nine cases of ossification of yellow ligament (OYL), five of ossification of posterior longitudinal ligament (OPLL), and four of disc hernia (DH). In these 18 patients, problems of clinical manifestations, neuroradiological examination, and surgical approaches are analyzed and discussed. As clinical manifestations, there was a preponderant occurrence in males in the OYL group, while in the OPLL group all the patients were females. OYL and DH occurred at lower thoracic levels. Thirteen of the 18 patients showed combined lesions either in the cervical or in the lumbar regions, such as cervical OPLL, cervical spondylosis, lumbar DH, and lumbar canal stenosis. In the neuroradiological examinations diagnosis of the upper thoracic lesions was difficult. Computed tomography (CT) scan with intrathecal metrizamide injection seemed essential for examination of ossified thoracic lesions. However, because CT imaging of the entire spine is impractical, efficient use of this examination requires previous localization of the offending vertebral level from either the neurological findings or other neuroradiological examinations such as myelography. Magnetic resonance imaging seemed most useful for ruling out the thoracic compressing lesions. As for surgical approaches, posterior decompression was effective for OYL and the anterior approach was useful for OPLL and DH. In patients with "tandem lesions," neurological and neuroradiological findings played an important role in deciding the responsible site.

Complete remission of metastatic teratoma from malignant testicular tumor using salvage chemotherapy with VP-16 (etoposide), CDDP, and ACNU--case report.

A 26-year-old male with an intracranial teratoma, metastasizing from a testicular yolk sac tumor refractory to cis-diamminedichloroplatinum (CDDP), vinblastin, and bleomycin (PVB) therapy, was successfully treated with a combination of etoposide (VP-16), CDDP, and ACNU (salvage chemotherapy). Emergency surgery for subcortical hemorrhage discovered the metastasis, diagnosed as a yolk sac tumor. CDDP chemotherapy failed to prevent recurrence, and total removal was impossible due to subdural invasion. He underwent radiation therapy and salvage chemotherapy. A third operation found only scar tissue. Maintenance salvage chemotherapy was continued. He was doing well 30 months after the first operation.

[Surgical treatment of cervical spondylotic radiculomyelopathy with abnormal involuntary neck movements. Report of three cases].

Cervical spondylotic myelopathy usually arises in patients in their late 40s or early 50s, most frequently at the C5/6 and C6/7 levels. Recently, excellent results have been attained with microsurgery in cases of cervical spondylosis. On the other hand, treatment of cervical spondylotic myelopathy in patients with athetoid dystonic cerebral palsy entails several problems. The authors report three cases of such troublesome myelopathy. A 34-year-old male with severe athetoid movement showed cervical spondylotic myelopathy. Myelography and magnetic resonance (MR) imaging demonstrated compression of the spinal cord through the C3-C5 levels. A 47-year-old female with athetoid dystonic cerebral palsy presented myelopathy. Myelography and MR imaging showed instability and spinal cord compression at the C5/6 level. A 34-year-old male with spasmodic torticollis showed C6 radiculopathy due to cervical disc hernia at the C5/6 level. Cervical anterior decompression with interbody fusion brought temporary improvement in all the three patients. However, such problems as slippage of Halo-vest, difficulty in eating during Halo-vest fixation, relapse of neurological deficit, were experienced. Due to postoperative cervical instability, cervical laminectomy is considered to be contraindicated in such patients. Anterior decompression with bone fusion has been reported effective, but, if athetoid dystonia continues, there is a potential for myelopathic deterioration due to spondylotic changes adjacent to the fused vertebrae.

Chronic encapsulated intracerebral hematoma associated with angiographically occult arteriovenous malformation--case report.

A 34-year-old female presented with a rare chronic encapsulated intracerebral hematoma associated with an angiographically occult arteriovenous malformation. A neovascularized fibrous capsule containing various stages of intracerebral hematoma formation was removed. These unusual entities mimic brain tumors or abscesses because of gradual growth and slowly progressive neurological deficits. Repeated bleeding or exudation from the capillaries of the capsule may allow expansion of the chronic encapsulated intracerebral hematoma.