Risk of perforation during dilation for esophageal strictures after endoscopic resection in patients with early squamous cell carcinoma.

BACKGROUND AND STUDY AIMS: Growing evidence suggests that esophageal stricture frequently develops after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) in early esophageal cancer patients, with an incidence proportional to the greater extent of mucosal defects resulting from improved EMR/ESD techniques. There seems to be a potential risk of perforation during bougienage in such patients. PATIENTS AND METHODS: 648 stricture dilations for 78 lesions in 76 patients were consecutively included. The outcomes after combined use of Maloney and Savary wire-guided bougienage for esophageal strictures after EMR/ESD were analyzed in a single-institute retrospective case series study. The perforation rate was determined and risk factors for perforation were identified. RESULTS: Patients underwent a median of 5.0 dilation procedures performed over a median 3.0 months for post-EMR/ESD strictures. Initial dilation was done a median 14 days following endoscopic resection. Perforations developed in seven patients (7/648 dilation procedures, 1.1%), all in the lower esophagus, and bleeding occurred in one patient (0.1% dilations). Two independent risk factors for development of perforation during dilation therapy for post-EMR/ESD stricture were identified: multiple dilations (odds ratio [OR] 1.2; P=0.012), and lower site of stricture (OR 12.8; P=0.043). Dysphagia was ameliorated by the dilations, and no patient required surgery. CONCLUSIONS: A specific emerging risk of perforation in dilation therapy for post-EMR/ESD strictures was identified. Carefully planned treatment is necessary in patients with severe post-EMR/ESD strictures especially strictures requiring multiple dilations or located in the lower esophagus.

Male death resulting from hybridization between subspecies of the gypsy moth, Lymantria dispar.

We explored the origin of all-female broods resulting from male death in a Hokkaido population of Lymantria dispar through genetic crosses based on the earlier experiments done by Goldschmidt and by testing for the presence of endosymbionts that are known to cause male killing in some insect species. The mitochondrial DNA haplotypes of the all-female broods in Hokkaido were different from those of normal Hokkaido females and were the same as those widely distributed in Asia, including Tokyo (TK). Goldschmidt obtained all-female broods through backcrossing, that is, F1 females obtained by a cross between TK females (L. dispar japonica) and Hokkaido males (L. dispar praeterea) mated with Hokkaido males. He also obtained all-male broods by mating Hokkaido females with TK males. Goldschmidt inferred that female- and male-determining factors were weakest in the Hokkaido subspecies and stronger in the Honshu (TK) subspecies. According to his theory, the females of all-female broods mated with Honshu males should produce normal sex-ratio broods, whereas weaker Hokkaido sexes would be expected to disappear in F1 or F2 generations after crossing with the Honshu subspecies. We confirmed both of Goldschmidt's results: in the case of all-female broods mated with Honshu males, normal sex-ratio broods were produced, but we obtained only all-female broods in the Goldschmidt backcross and obtained an all-male brood in the F1 generation of a Hokkaido female crossed with a TK male. We found no endosymbionts in all-female broods by 4,'6-diamidino-2-phenylindole (DAPI) staining. Therefore, the all-female broods observed in L. dispar are caused by some incompatibilities between Honshu and Hokkaido subspecies.

Effect of triamcinolone administration on content of flavins in rabbit liver.

Triamcinoline acetonide (10 mg per kg of body weight a day) was administered to rabbit fed on a laboratory chow diet. The content of flavins in liver but not in kidney, muscle and brain started to decrease 24 h after a single dose. The activities of enzymes in the liver were determined: the activities of pyruvate dehydrogenase complex, lipoamide dehydrogenase (NADH:lipoamide oxidoreductase EC 1.6.4.3), NADH dehydrogenase (NADH : (acceptor) oxidoreductase EC 1.6.99.3) and D-amino acid oxidase (D-amino acid: oxygen oxidoreductase (deaminating) EC 1.4.3.3) were decreased but those of succinate dehydrogenase (succinate : (acceptor) oxidoreductase EC 1.3.99.1) and xanthine oxidase (xanthine : oxygen oxidoreductase EC 1.2.3.2) remained unchanged. The activities of enzymes in the kidney, however, remained unchanged except the decrease in the activity of pyruvate dehydrogenase complex.

Motor paresis improved by sympathetic block. A motor form of reflex sympathetic dystrophy?

Four patients had a characteristic motor paresis that was dramatically improved by sympathetic block. The cause of this paresis could not be determined by the usual neurological examinations. It was similar to reflex sympathetic dystrophy in that the patients experienced severe pain, swelling, coldness, and muscle atrophy in the affected limbs or other parts of the body in the course of their illness. However, the motor paresis could precede the pain or develop after the pain had disappeared. Even in the absence of pain, the motor paresis was exacerbated by sympathetic stimulation using epinephrine, norepinephrine (nor-adrenalin), or isoproterenol hydrochloride (Proternol) loading and was improved by regional intravenous infusion of reserpine or by sympathetic ganglion block. Loading with pilocarpine, atropine sulfate (Bosmin), and edrophonium chloride (Antirex) did not influence the paresis. This motor paresis is thought to be due to abnormally increased sympathetic tone and may be considered a motor form of reflex sympathetic dystrophy. However, motor paresis closely related to sympathetic dysfunction is quite a new condition that we call "sympathetic motor paresis." This is important clinically because a long-standing effect can be expected from permanent sympathetic ganglion block with dehydrated ethanol.

Gait disturbances in patients with pontine medial tegmental lesions: clinical characteristics and gait analysis.

OBJECTIVE: To determine the clinical characteristics of gait disorders in patients with pontine medial tegmental lesions. DESIGN: We compared features of gait disorders between patients with infarcts in the medial tegmentum and those with stroke in other areas of the pons (pathological control subjects) by measuring electromyographic results of lower limb muscles and several biomechanical parameters. PATIENTS: Two patients with infarcts in the rostral medial tegmentum and 4 control subjects. Two of the control patients had lesions in the pontine base, while the lesions in the other 2 were in the pontine tegmentum and base (combined lesions). RESULTS: Patients with rostral medial tegmental lesions and controls with pontine base lesions showed unstable walking characterized by irregular angular displacements and foot pressures. However, they differed by the following 3 features. (1) Rostral medial tegmental lesions elicited truncal ataxia without limb ataxia. In comparison, pontine base lesions elicited limb ataxia without truncal ataxia and caused hemiparesis. (2) Instability was more severe and persistent in patients with the former lesions than in those with the latter lesions. Slowness of walking speed and prolongation of the double-support period were clearly observed in the former group. (3) Electromyographic changes characteristic of cerebellar ataxia were clearly evident in patients with rostral medial tegmental lesions. The electromyographic amplitudes of the gastrocnemius and tibialis anterior muscles were almost constant throughout the gait cycle, resulting in the disappearance of the inherent periodic pattern of each muscle. CONCLUSION: Medial tegmental lesions in the rostral pons cause prolonged and severe unstable walking that resembles spinocerebellar ataxic pattern, and impairment of the spinocerebellar loop might be the pathomechanism underlying such a gait disturbance.

Sympathetic skin response in patients with cerebellar degeneration.

Sudomotor function was studied based on sympathetic skin responses (SSRs) in 87 patients with various types of cerebellar degeneration. Evaluations of orthostatic hypotension and the R-R interval variation were also performed in these patients. The respective incidences of SSR abnormality and orthostatic hypotension were 44 (50.6%) of 87 and 39 (44.8%) of 87. Fourteen percent of the patients with abnormal SSRs did not have orthostatic hypotension, but 8% of the patients with normal SSRs did have orthostatic hypotension. Sympathetic skin responses were abnormal in most patients with Shy-Drager syndrome, sporadic olivopontocerebellar atrophy (OPCA), and striatonigral degeneration, whereas SSRs were normal in patients with familial OPCA, sporadic cerebellar atrophy, and familial cerebellar atrophy. We demonstrated that SSR can be used to evaluate sudomotor function in degenerative disorders of the central nervous system as well as in peripheral neuropathies. The vasomotor and sudomotor functions usually are both disturbed in patients with cerebellar degeneration, and the SSR can detect autonomic dysfunction as sensitively as does the head-up tilt test. We also concluded that sporadic OPCA differs from familial OPCA in that it has a much higher incidence of autonomic dysfunction and that degeneration of the cerebellar cortex did not affect the autonomic regulation.

Dysautonomia with acute sensory motor neuropathy. A new classification of acute autonomic neuropathy.

OBJECTIVES: To characterize the dysautonomia associated with acute sensory motor neuropathy and to discuss the classification of acute autonomic neuropathy. DESIGN: Case series. METHODS: Sympathetic skin response. Local sweat response to acetylcholine. Norepinephrine infusion test and acetylcholinesterase histochemistry of sural nerve biopsy specimens in addition to making conventional analyses of myelinated and unmyelinated fibers. RESULTS: In 12 patients with chronic neuropathy, acetylcholinesterase-positive fiber density and plantar sympathetic skin response size were well correlated, but in the two patients with acute autonomic sensory and motor neuropathy, there were discrepancies, acetylcholinesterase-positive fiber density being well preserved and sympathetic skin responses being absent. Histologic and electrophysiologic results indicated primary demyelination of the myelinated fibers. In contrast, previous studies of acute autonomic sensory and motor neuropathy reported dysfunction of the sympathetic postganglionic fibers and axonopathic change in myelinated fibers, poor recovery from dysautonomia. CONCLUSIONS: Dysautonomia with acute idiopathic neuropathy can be divided into two categories--postganglionic axonopathic and preganglionic demyelinating types of the sympathetic efferent pathways. The recovery from dysautonomia produced by the former lesion is poor, but recovery is better for that produced by the latter lesion.

Nicotine-sensitive paresis.

Immediately after a patient with myoclonus epilepsy smoked a nicotine-containing cigarette, tetraparesis and hyperreflexia with ankle clonus developed, but disappeared within several minutes. During paresis, the H-reflex size of the soleus muscle increased, EEG showed more slow waves than before smoking, and the cerebral perfusion increased around the motor cortex as shown by single photon emission CT. A similar effect occurred when the patient chewed nicotine gum, and smoking a cigarette with a high nicotine content induced severe positive and negative myoclonus after the development of tetraparesis. Administration of the C6-type nicotinic antagonist mecamylamine not only countered the smoking effect, but ameliorated the spontaneous positive and negative myoclonus. Mecamylamine may prove useful for the treatment of positive and negative myoclonus in myoclonus epilepsy.

Eye-fixation patterns in homonymous hemianopia and unilateral spatial neglect.

Eye-fixation patterns while viewing simple patterns were quantitatively analysed in homonymous hemianopic subjects with or without unilateral spatial neglect (USN), using an eye camera. Hemianopic subjects without USN used the strategy to look at the hemianopic side of the patterns longer in order to compensate for their visual field defect. However, those with USN lacked this compensatory eye-fixation pattern.

A major role for the rho-associated coiled coil forming protein kinase in G-protein-mediated Ca2+ sensitization through inhibition of myosin phosphatase in rabbit trachea.

1 G protein-mediated Ca2+ sensitization of airway smooth muscle contraction was investigated with respect to the relative importance of Rho-associated coiled coil forming protein kinase (ROCK) and protein kinase C (PKC). We examined the effects of Y-27632, a ROCK inhibitor, and GF 109203X, a PKC inhibitor, on guanosine 5'-O-(3-thiotriphosphate) (GTPgammaS)-induced contraction in alpha-toxin- or beta-escin-permeabilized rabbit trachea. 2 Although pre-treatment with Y-27632 dose-dependently inhibited GTPgammaS (10 microM)-induced Ca2+ sensitization of alpha-toxin-permeabilized trachea, a Y-27632-insensitive component (approximately 16% of the maximum contraction) was retained during the early phase of the GTPgammaS response in the presence of Y-27632 (100 microM). 3 GF 109203X (5 microM) abolished 1 microM 4beta-phorbol 12, 13-dibutyrate (PDBu)-induced, but only partially inhibited the GTPgammaS-induced Ca2+ sensitization. A combination of Y-27632 (100 microM) and GF 109203X (5 microM) totally abolished the GTPgammaS response. 4 GTPgammaS caused only a small contraction in the absence of Ca2+. Wortmannin (30 microM), a myosin light chain kinase (MLCK) inhibitor, completely inhibited Ca2+-induced contraction. ATP-triggered contraction of the strip which had been treated with calyculin A (1 microM), a phosphatase inhibitor, in rigor solutions was markedly slowed by worthmannin (30 microM), but not by Y-27632 (100 microM), in the presence of GTPgammaS and Ca2+. 5 GTPgammaS, but not PDBu, contracted the beta-escin-permeabilized trachea in the absence of Ca2+, but the presence of Ca2+-independent MLCK. 6 We conclude that ROCK plays a primary role in G-protein-mediated Ca2+ sensitization, which requires MLCK activity, with minor contribution of PKC to the early phase of contraction, and PDBu utilizes conventional PKC(s) in airway smooth muscle.

Gastrointestinal amyloid deposition in AL (primary or myeloma-associated) and AA (secondary) amyloidosis: diagnostic value of gastric biopsy.

Gastrointestinal amyloid deposition was investigated in 21 autopsy cases of nonhereditary systemic amyloidosis, 18 of the AL (primary or myeloma-associated) type and three of the AA (secondary) type. Vascular deposition of amyloid, most apparent in the submucosa, was found in all cases. Parenchymal deposition was observed mainly in the muscularis mucosae and muscularis externa in the AL type, and in the lamina propria mucosae in the AA type. Comparison of amyloid deposition in the stomach and rectum revealed no differences for the AA type. In the AL type, however, deposition in the lamina propria mucosae and muscularis mucosae was more frequent and marked in the wall of the stomach than in the rectum. Thus, gastric biopsy would be more valuable than rectal biopsy in the diagnosis of AL amyloidosis.

Ozone-induced airway hyperresponsiveness: role of superoxide anions, NEP, and BK receptors.

We investigated the role of reactive oxygen species in ozone-induced airway hyperresponsiveness (AHR) in Brown Norway rats. Airway responsiveness to inhaled acetylcholine (ACh) and bradykinin (BK) and inflammatory cell recruitment in bronchoalveolar lavage fluid (BALF) were measured in vivo. Neutral endopeptidase (NEP) activity assay and measurement of BK-receptor binding sites in Brown Norway rat lungs were carried out in vitro. Apocynin (5 mg/kg), an inhibitor of superoxide anion-generating NADPH oxidase, was administered perorally 30 min before a 3- or 6-h exposure to 3 ppm of ozone, and the animals were studied 18-24 h postexposure. Ozone induced increases in airway responsiveness to ACh and BK and in neutrophil counts in BALF. Apocynin inhibited the increase in airway responsiveness to BK but not to ACh without affecting the neutrophil counts in BALF. The antioxidants allopurinol and deferoxamine prevented ozone-induced AHR to both ACh and BK but did not reduce neutrophil counts. To further examine the mechanisms of ozone-induced AHR to BK, we measured NEP activity and the density of BK receptors in vitro after ozone exposure. Ozone exposure had no significant effect either on NEP activity or on the affinity and the number of BK receptors in lungs from rats treated with or without apocynin. We conclude that superoxide anions released from inflammatory cells in the airway may be involved in ozone-induced AHR. Inactivation of NEP or upregulation of BK receptors do not appear to be involved, but the possibility of localized changes cannot be excluded.

Role of neutral endopeptidase in bronchial hyperresponsiveness to bradykinin induced by IL-1 beta.

Interleukin-1 beta (IL-1 beta) induces bronchial hyperresponsiveness (BHR) to bradykinin but not to acetylcholine. We examined whether this was mediated through the inhibition of neutral endopeptidase (NEP) activity and/or through the enhancement of airway microvascular leakage (AML) by IL-1 beta. We administered human recombinant IL-1 beta (500 U) or saline intratracheally and 24 h later measured the airway responses to bradykinin (1 mM; 45 breaths). IL-1 beta-treated rats showed a decrease of 18.5 and 21.1% of NEP activity in the lungs and tracheobronchial tree, respectively (P < 0.05), associated with an augmented response in total lung resistance to bradykinin but with no increase in Evans blue dye extravasation used as a marker of AML. Phosphoramidon (0.1 and 1 mM; 90 breaths), an NEP inhibitor, induced a dose-dependent increase in lung resistance to bradykinin without further enhancing BHR induced by IL-1 beta. Bradykinin-induced AML was not enhanced by phosphoramidon in either saline- or IL-1 beta-treated rats. Similarly, after captopril (1 mM; 90 breaths), an inhibitor of angiotensin-converting enzyme, there was no further enhancement of BHR to bradykinin induced by IL-1 beta. BHR to bradykinin induced by IL-1 beta may result from an inhibition of peptidase activity, such as NEP and angiotensin-converting enzyme, and is not associated with an enhancement of AML.

Atrial natriuretic peptide inhibits tumor necrosis factor-alpha production by interferon-gamma-activated macrophages via suppression of p38 mitogen-activated protein kinase and nuclear factor-kappa B activation.

We investigated whether the atrial natriuretic peptide (ANP) might have an inhibitory effect on inflammatory cells. Treatment of RAW264.7 macrophages with interferon-gamma (IFN- gamma) caused a significant increase in tumor necrosis factor-alpha (TNF-alpha) and nitric oxide (NO) production. Activation of p38 mitogen-activated protein (MAP) kinase was observed 30 to 120 min after IFN-gamma, and transcription factor nuclear factor-kappa B (NF-kappaB) was activated about 7 to 9 times of the basal activity. Human ANP(99-126) and a specific p38 MAP kinase inhibitor SB203580 inhibited the IFN-gamma-induced TNF-alpha production in a dose-dependent manner without affecting NO production. ANP inhibited the IFN-gamma-induced p38 MAP kinase activation, and ANP and SB203580 inhibited NF-kappaB activation. To study the involvement of oxidative stress in this system, the effects of allopurinol and acetovanillone, inhibitors of xanthine oxidase and NADPH oxidase, respectively, were studied. Allopurinol or acetovanillone did not inhibit the IFN-gamma-induced production of TNF-alpha or NO, suggesting little involvement of oxidative stress in this system. This is the first evidence in vitro that ANP has an anti-inflammatory activity on IFN-gamma-activated macrophages by suppressing signal transduction pathway leading to p38 MAP kinase and NF-kappaB activation.

Early events of chemical transmission of newly formed neuromuscular junctions in monolayers of human muscle cells co-cultured with fetal rat spinal cord explants.

Early events of chemical transmission were examined in our newly established heterotypic co-culture system with human muscle in monolayer and fetal rat spinal cord explants with attached dorsal root ganglia. The mean amplitude, frequency, rise time and half-fall time of miniature end-plate potentials (MEPPs) were 1.04 mV, 3.9/s, 6.1 ms and 54.9 ms, respectively. Time intervals between successive MEPPs were exponentially distributed. Stimulus evoked potentials were successfully obtained. The distribution of stimulus evoked end-plate potential (EPP) amplitudes was approximately equal to a Poisson distribution. This is the first report concerning intracellular recordings of chemical transmission of developing neuromuscular junctions in heterotypic co-culture system using human muscle. In this co-culture system, the heterotypic neuromuscular junctions show significant similarities previously to those observed in nerve-muscle tissues co-cultured from the same species as well as immature nerve-muscle synapses in situ.

Developmental study of the expression of dystrophin in cultured human muscle aneurally and innervated with fetal rat spinal cord.

So far there have been no developmental studies including the influences of innervation and contractile activity on the expression of dystrophin in cultured human muscle. We performed immunocytochemical studies of the localization of dystrophin on aneurally cultured non-contracting (AMs) and innervated continuously contracting cross-striated human muscle fibers (ICMs) with fetal rat spinal cord from normal and Duchenne muscular dystrophy (DMD) biopsied muscles. In normal AMs, myoblasts and some immature AMs showed negative staining of dystrophin, but many AMs had a patchy (discontinuous) distribution of dystrophin in the subplasmalemmal region and with some granularity near the sarcolemma and in the deeper cytoplasm. In normal ICMs, dystrophin was localized continuously at the inner aspect of the sarcolemmal membrane and some periodic dense patterns were detected in some areas. Both AMs and ICMs from DMD had negative staining of dystrophin. To investigate the muscle contractile activity on the distribution of dystrophin, we paralyzed ICMs with tetrodotoxin (TTX) for two weeks from the first appearance of muscle contractions. In paralyzed innervated muscles (PIMs), dystrophin remained in a patchy (discontinuous) pattern at the inner aspect of the plasmalemma similar to that in AMs. It is strongly suggested that muscle contractile activity plays an important role in the continuous and even distribution of dystrophin at the sarcolemma during development.

Cerebral amyloid angiopathy in the aged.

Cerebral amyloid angiopathy (CAA) was found in 57% of 123 autopsy brains removed from patients aged 59-101 years. The incidence of CAA increased with age. CAA was seen most frequently in the occipital cortex. Immunohistochemically, amyloid of CAA was positive for amyloid P component and negative for human AA protein and human prealbumin. The presence and severity of CAA were significantly correlated with the number of senile plaques and neurofibrillary tangles. The incidence of CAA in 17 patients with dementia of Alzheimer type (DAT) was estimated to be 88% and was significantly higher than that in 26 patients with dementia of non-Alzheimer type. CAA had a pathogenetic relationship with both brain ageing and DAT. Lobar cerebral haemorrhage was found in 3 patients with CAA of marked or moderate degree. Lobar cerebral haemorrhage in the aged and in patients with DAT suggest the presence of CAA.

HTLV-I-associated meningitis.

A 69-year-old woman with human T-cell lymphotropic virus type I (HTLV-I) positive chronic myelopathy became comatose with acute meningitis. Most of the cells in the cerebrospinal fluid were similar to those found in adult T-cell leukaemia/lymphoma, which suggests that there is a close relationship between HTLV-I and this form of meningitis.

A case of epidermoid of the fourth ventricle.

The case of woman, aged 52, who had a fourth ventricular epidermoid, which eluded definite diagnosis for six years because of spontaneous remissions, is reported. Computed tomography may be misleading in such cases with spontaneous remission of symptoms because of the low electron density of the tumor which is not enhanced by intravenous contrast medium. Other diagnostic means such as ventriculography should not be neglected.

MRI findings of inferior olives in palatal myoclonus.

Four patients with palatal myoclonus (PM) were studied with magnetic resonance imaging (MRI). Increased signal intensity and bilateral enlargement of the inferior olives were recognized in two patients with bilateral PM, pontine haemorrhage and neuro-Behçet disease, and a similar olivary change on the contralateral side was noted in a case of pontine infarction with unilateral PM. These findings were consistent with the pathology. The changes were more obvious in proton density-weighted images than in T2-weighted images, which thus differ from the changes in common gliosis. The other patient with the syndrome of PM and progressive ataxia did not show any olivary change. These changes on MRI are considered to indicate pseudo-hypertrophy of the inferior olives, although this is not consistently shown by the imaging method.