Prediction of functional outcome in acute cerebral hemorrhage using diffusion tensor imaging at 3T: a prospective study.

BACKGROUND AND PURPOSE: Early evaluation of the pyramidal tract is a prerequisite in patients with intracerebral hemorrhage (ICH) in order to decide the optimal treatment or to assess appropriate rehabilitation. The aim of this study was to evaluate and predict the neuromotor and functional outcome of an ICH by using diffusion tensor imaging (DTI) in the acute phase. MATERIALS AND METHODS: Eighteen patients with a hemiparetic supratentorial ICH were prospectively studied with DTI within 2 days after onset. A region-of-interest-based analysis was performed for the fractional anisotropy (FA) of the pyramidal tract in the cerebral peduncles. The degree of paresis was assessed at day 0 and day 28 by paresis grading (PG). The functional outcome was evaluated by the modified Rankin Scale (mRS). RESULTS: The FA in the affected side was significantly lower compared with that of the unaffected side (P = .001) with the mean diffusivity remaining unchanged (P = .50). The ratio of the FA (rFA) in the affected side to the unaffected side was significantly correlated with the PG at day 0 and 28 and the mRS score at day 28 (P = .002, r = -0.674; P < .001, r = -0.767; and P = .002, r = -0.676). The rFA for the good and poor outcomes based on the PG was significantly different (P < .001). The cutoff point of the rFA for the good and poor outcomes was set at 0.85 (sensitivity, 100%, specificity, 100%). CONCLUSIONS: We conclude that DTI can evaluate the motor deficit quantitatively and may predict the functional outcome in patients with an ICH who were scanned within 2 days after the ICH onset.

Pena-shokeir type I syndrome with thymic and systemic lymphoid hyperplasia: report of an autopsy case.

We report a case of Pena-Shokeir type I syndrome in a female neonate who died of respiratory failure shortly after the birth at 32 weeks of gestation. In general appearance, she had apparent ocural hypertelorism, a depressed tip of the nose, low-set malformed ears, and microglossia in the head. There were severe contractures at the ankle, hand, fingers, and toes, and moderate contractures at the hip, shoulder, knee, and elbow. An autopsy analysis showed severe pulmonary hypoplasia and group atrophy of the skeletal muscle tissues. In addition to these findings which are well known characteristics of the infant with this syndrome, the thymus was markedly hyperplastic and lymph nodes were systemically swollen, especially the mesenteric ones which were visible and measured 2-5 mm in diameter. Histologically, the lymph nodes showed massive paracortical hyperplasia without apparent follicular structures, although no atypical lymphocytes were observed in both the thymus and lymph nodes. Immunohistochemically, proliferating lymphocytes seemed to be immature CD4+/CD8+ T cells, suggesting the insufficiency of T-cell negative selection in the thymus. This report is the first case of Pena-Shokeir type I syndrome with T-lymphocytic disorder.

The results of ingredient patch testing in contact dermatitis elicited by povidone-iodine preparations.

10 cases of contact dermatitis which began during the application of povidone-iodine preparations were examined with patch tests using 2 kinds of povidone-iodine preparations and their ingredients, i.e., povidone-iodine, polyoxyethylene nonylphenyl ether and glycerin, and also the components of povidone-iodine, i.e., iodine and polyvinylpyrrolidone. All 10 cases reacted positively to the povidone-iodine preparations and povidone-iodine, 3 out of the 10 to polyoxyethylene nonylphenyl ether, 1 out of the 9 tested to iodine, while no positive response was found to glycerin or polyvinyl-pyrrolidone. It was difficult to distinguish between allergic responses from irritation, as responses to patches of povidone-iodine and its preparations usually include irritation at high frequencies. Based on comparison of results with a control group, however, those showing + or stronger reactions to 2% povidone-iodine at days 3 to 5 were considered to be allergic. Thus, 4 out of the 10 cases were considered as sensitization to povidone-iodine. Another 3 cases were found to be polyoxyethylene nonylphenyl ether sensitized, and another 1 iodine sensitized, while the patch test reactions of the other 2 were considered to have been elicited by irritation.

[Clinical study of carcinoma in situ of the urinary bladder].

PURPOSE: To evaluate the natural history and the efficacy of treatments for carcinoma in situ (CIS) of the urinary bladder, we reviewed 70 patients with this disease. METHOD: The patients of CIS were divided into 3 groups based on tumor history: primary, secondary and concurrent CIS. We studied 70 patients with primary and secondary CIS treated at our hospital between 1957 and 1995, exclusive of concurrent one. They included 31 patients with primary CIS and 39 with secondary one, ranging in age from 39 to 82, with the average age of 63.1 years. Sixty-one patients were male and 9 were female. RESULTS: In 31 patients with primary CIS, 12 (32.8%) complained of gross hematuria, 10 (32.3%) urinary frequency and 9 (29.0%) pain on urination. The 5-year survival rates for primary and secondary CIS were 89.1% and 91.4%, and the 5-year bladder preservation rates were 54.5% and 57.6%, respectively. Three of 31 patients with primary CIS developed an invasive carcinoma, whereas 4 of 39 patients with secondary CIS did. There was no significant difference between each primary and secondary groups. In both primary and secondary CIS, the group of immediate total cystectomy was not significantly differ from the groups of the following total cystectomy and the bladder preservation in the effect of total cystectomy on the survival rate. A total of 51 cases of CIS was treated with intravesical therapy, 17 intravesical Bacillus Calmette-Guérin (BCG) therapy, 34 intravesical chemotherapy, respectively. Intravesical BCG therapy has shown the complete response rate of 78.6%, intravesical chemotherapy 42.1%. And the bladder preservation rate seemed to be better (but not significantly) in intravesical BCG group than in intravesical chemotherapy group or non-treatment group of intravesical therapy. CONCLUSION: For both primary and secondary CIS, the 5-year survival rate was about 90% and 5-year bladder preservation rate was over 50%. There was no significant difference between the primary and secondary group. The group of immediate total cystectomy was not significantly differ from the groups of the following total cystectomy and the bladder preservation in the effect of total cystectomy on the survival rate. About intravesical therapy, BCG was very effective in CR rate and the bladder preservation rate seemed to be better (but not significantly) in BCG group than in chemotherapy or non-treatment group.

[Primary carcinoma in situ of the ureter: a case report].

A 55-year-old male visited our hospital with a complaint of gross hematuria and right lower abdominal pain. Cytological findings of voided urine suggested the presence of malignant cells. Cystoscopic examination revealed bloody urine discharge from the right ureteral orifice and no abnormality in the bladder wall. The retrograde pyelogram showed no tumor masses. However, malignant cells were detected cytologically in the right ureteral catheteral urine twice. Under the preoperative diagnosis of primary urothelial tumor of the right upper urinary tract, right total nephroureterectomy was performed. A histological study revealed transitional cell carcinoma in situ in the lower portion of the ureter. We reviewed 46 cases of primary carcinoma in situ of the upper urinary tract previously reported in Japan.

[Leydig cell tumor of the testis: a case report].

A 63-year-old male visited our hospital with a complaint of painless swelling of the left scrotum. Left high orchiectomy was performed since ultrasonography suggested a testicular tumor. Histologically, this testicular mass was a Leydig cell tumor. We reviewed 47 cases of this tumor previously reported in Japan.

Decreased level of prosaposin in atopic skin.

In the skin of atopic dermatitis patients, the amount of ceramides in the stratum corneum is decreased. Although the cause of this decrease may be due to the higher activity of acylase, a decrease in the activity of sphingolipid activator proteins may also be the cause. A polyclonal antibody to saposin D, elicited by immunizing rabbits with the synthetic polypeptide from cDNA of saposin D, cross-reacted with a single 65-kDa epidermal protein of pI 5.6 in a 2-dimensional immunoblot study, suggesting that it was prosaposin, the precursor protein of saposin D, from its molecular weight and demonstrating its immunohistochemical localization in the innermost cell layers of the stratum corneum of the skin. The antigenic material was also observed in the epithelium of the esophagus, pneumocytes of the lungs, hepatocytes, and glandular cells of the stomach. Immunoelectron microscopy showed the antigenic material in the cytoplasm of the granular cells and the intercellular spaces, either between the stratum granulosum and the stratum corneum or on the stratum corneum cell envelope. By ELISA, the amount of the 65-kDa protein in the inner surface skin of the upper arm of atopic dermatitis patients (nonlesional skin) [4.1 +/- 2.0 microg per 7 mm2 (mean +/- SD), n = 10] was found to be significantly decreased (p < 0.05) to 66% of that in the normal control (6.2 +/- 1.5 microg per 7 mm2, n = 10). Therefore, the suppression of prosaposin synthesis may be related to the abnormal stratum corneum formation in atopic skin through lower activation of glucosylcerebrosidase or sphingomyelinase.

[Simultaneous bilateral testicular tumors with different cell types: a case report].

A 26-year-old man presented with a painless mass in the right scrotum. Physical examination revealed another smaller mass in the left testis. The patient underwent right radical orchiectomy and enucleation of the tumor in the left testis, followed by radiotherapy for right iliac and para-aortic lymph nodes up to a total dose of 30 Gy. Histology proved typical seminoma of the right testis and mature teratoma in the left testis. Imaging study including abdominal CT and chest X-ray and prompt lowering of beta-HCG level within the normal limit after surgery confirmed the diagnosis of stage I disease. Human leukocyte antigen (HLA)-A24 was identified in this case, suggesting its potential association with bilateral testicular tumor. He is now leading an uneventful life without recurrence of the disease at 30 months after surgery.

Secondary acute monocytic leukemia occurring during the treatment of a testicular germ cell tumor. A case report and review of the literature.

Secondary leukemia following chemotherapy or radiotherapy for mediastinal germ cell tumors is a well-described entity. It also may occur in patients with testicular germ cell tumors. We report a case of acute monocytic leukemia occurring in a 44-year-old man who received etoposide-based chemotherapy and radiotherapy for a recurrent, metastatic testicular germ cell tumor. The patient received 14 cycles of systemic chemotherapy for pulmonary and para-aortic lymph node metastases following his initial orchiectomy. The total amount of etoposide this patient received was 6,400 mg/m2. Leukemia occurred 11 years after orchiectomy. A literature review revealed 25 other reported cases of secondary leukemias after treatment for testicular carcinoma. It is not clear whether chemotherapy, radiotherapy or both are responsible for the secondary leukemias seen in these patients.

Epidural fentanyl improves the onset and spread of epidural mepivacaine analgesia.

PURPOSE: To determine the extent of enhanced blockade by the combined use of epidural fentanyl and mepivacaine. We compared the onset of hypoalgesia, analgesia and the threshold of pressure pain. METHODS: Thirty patients were randomly divided into three groups. The fentanyl group received 10 ml saline containing 0.1 mg fentanyl, mepivacaine group received 10 ml mepivacaine 1% and a mixed group received 10 ml mepivacaine 1% with 0.1 mg fentanyl. All solutions, without epinephrine, were injected through an epidural catheter at T5-6 to T6-7. The change in sensation, loss of pin-prick and pain threshold sensation, measured by pressure algometer, were assessed at 2.5-min intervals for 15 min at the T4 dermatome. Spread of analgesia was determined at 15 min. RESULTS: Loss of pinprick was more rapid in the mixed, 11.0 +/- 2.7 (SD) min, than in the mepivacaine group, 15.0 +/- 2.9 min, (P < 0.05), although there was no difference in change of sensation. Pressure pain threshold increased with time in the mepivacaine (P < 0.05) and mixed (P < 0.05) groups. It was higher in the mixed than in the fentanyl and mepivacaine groups at 5, 7.5 and 10 min (P < 0.05). The lower level of analgesia was lower in the mixed than in the mepivacaine groups (P < 0.05). Blood pressure was unchanged in the three groups, but heart rate decreased at 7.5, 10, 12.5, and 15 min in the mepivacaine and mixed groups (P < 0.05). CONCLUSIONS: The addition of fentanyl to mepivacaine accelerates the onset of analgesia and enhances the analgesic effect of epidural block.

[The level of analgesia with epidural injection of 2% mepivacaine using combined spinal and epidural analgesia].

We studied the level of analgesia obtained with epidural injection of 2% mepivacaine using combined spinal and epidural analgesia (CSE) and compared with the level obtained by epidural analgesia (EA). We inserted a catheter into the epidural space through the L2/3 interspace, and hyperbaric tetracaine was injected through the L3/4 interspace with 26G spinal needle in thirty patients for CSE. We checked the the level of analgesia 90 min after spinal anesthesia. After this, 23 out of 30 patients showed the extension of analgesia 15 min after injection of mepivacaine into the epidural catheter. In these patients, the level of analgesia and the dose of mepivacaine showed the regression line Y = 10.2-0.4X (Y: the level of analgesia, X: the dose of 2% mepivacaine, P < 0.05). We also showed the regression line Y = 16.1-0.7X (P < 0.05) for EA 15 min after epidural injection of mepivacaine in other 23 patients. To achieve the same level of analgesia of Th8 or Th6 with CSE and EA, the doses for epidural injection were calculated as 5.5 ml, 10.5 ml with CSE and 11.5 ml, 14.4 ml with EA, respectively. These results show that the epidural dose of local anesthetic for CSE is 1/2 to 2/3 of that necessary for EA.

Decreased expression of filaggrin in atopic skin.

The amounts of the epidermal proteins filaggrin, involucrin, cystatin A and Ted-H-1 antigen produced during the terminal differentiation of keratinocytes were immunohistochemically measured in lesional and nonlesional skin of atopic dermatitis (AD) patients. In addition, the amount of filaggrin in the skin of the inner surface of the upper arm of AD patients (nonlesional skin) and normal controls, obtained by punch biopsy, was measured by an enzyme-linked immunosorbent assay (ELISA) technique. The immunohistochemical study showed that all four proteins were decreased in lesional skin. By contrast, only filaggrin was decreased in nonlesional skin of AD patients. The ELISA showed that the amount of filaggrin in the skin of the inner surface of the upper arm was 2.48 +/- 0.45 microgram/7 mm2 (n = 8) in AD patients, which was 32% of that in the normal controls (7.7 +/- 0.55 microgram/7 mm2; n = 4). This decrease in filaggrin production in atopic skin may be one of the reasons why atopic skin can easily become dry, because filaggrin is thought to be the precursor protein of the emollient factors in the stratum corneum. The evidence that only the expression of filaggrin was suppressed in AD patients, though the genes of filaggrin and involucrin are localized to a very restricted portion of the same gene 1q21, indicates that the filaggrin gene does not share regulatory elements with the involucrin gene.

[Double cancers of renal cell carcinoma and testicular seminoma: a case report].

A case of metachronous presentation of renal cell carcinoma and testicular seminoma is reported. A 48-year-old man underwent left radical nephrectomy for a renal tumor on September 4, 1991. Pathological examination revealed clear cell carcinoma with no capsular penetration. There was no evidence of distant metastases. During postoperative follow-up, he noticed a painless left testicular induration in July, 1994. Serum human chorionic gonadotropin beta subunit as a tumor marker was elevated. Left radical orchiectomy was performed on October 17, 1994. Pathological examination revealed an anaplastic seminoma localized within the testis. Chest X-ray was normal and CT of the abdomen demonstrated no evidence of retroperitoneal lymphadenopathy. The patient was diagnosed as clinical stage I left testicular seminoma. He was free of disease 8 months postoperatively. Including our case, 15 cases of clinically detected double cancers of renal cell carcinoma and testicular germ cell tumor have been reported worldwide. This is the first case of a metachronous presentation of these two cancer types preceded by renal cell carcinoma.

[Solitary metastasis to residual ureter resulting from renal cell carcinoma after radical nephrectomy: report of a case].

A case of solitary metastasis to residual ureter from renal cell carcinoma is reported. In November, 1987, a 56-year-old male had undergone left radical nephrectomy with renal cell carcinoma (clear cell subtype, G2, Inf alpha). He was doing well until June in 1989 when macroscopic hematuria occurred. A tumor from residual ureter with a large blood clot was detected on cystoscopy. A malignant tumor from the residual ureter was suspected and it was extirpated. Histological diagnosis revealed the same findings as the primary renal tumor. No other metastasis was detected. Only 8 cases of ureteral metastasis from renal cell carcinoma after radical nephrectomy have been previously reported in the Japanese literature.

Correlation of serum basic fetoprotein with acute rejection in kidney transplantation.

We monitored serum BFP, a broad-spectrum tumor marker, in 36 patients with kidney transplantation. Serum BFP was elevated in close association with acute rejection and dropped to a normal level after reversal of rejection. As Western blot analysis has revealed that BFP is present in the normal kidney, it is believed that serum BFP may be useful for the detection of various types of renal damage such as acute rejection.

[MEP (methotrexate, etoposide and cisplatin) and M-VAC (methotrexate, vinblastine, doxorubicin and cisplatin) for advanced uroepithelial cancer--a preliminary report of MEP as second line chemotherapy for recurrence after M-VAC].

Combination chemotherapy with methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC regimen) or with methotrexate, etoposide and cisplatin (MEP regimen) was administered to 32 patients with advanced measurable uroepithelial cancers. Fifteen patients among them were adequately treated with M-VAC regimen, and 11 with MEP regimen. Complete remission was not achieved clinically in any patients. Partial remission occurred in 73.3% (11/15) of M-VAC patients and 72.7% (8/11) of MEP patients. Of eleven MEP patients, six were treated with MEP therapy as second line chemotherapy for the recurrence after other chemotherapy (5 cases after M-VAC, 1 case after intraarterial cisplatin). They showed a considerable response (4 patients, PR; 2 patients, MR) and an appreciable remission period, not inferior to those of first line chemotherapy with M-VAC regimen. The present study shows that MEP may be a promising regimen for advanced uroepithelial cancers, especially as a second line chemotherapy for relapsed cases after M-VAC therapy.

The mechanism for the activation of latent TGF-beta during co-culture of endothelial cells and smooth muscle cells: cell-type specific targeting of latent TGF-beta to smooth muscle cells.

Transforming growth factor-beta (TGF-beta) is secreted in a latent form and activated during co-culture of endothelial cells and smooth muscle cells. Plasmin located on the surface of endothelial cells is required for the activation of latent TGF-beta (LTGF-beta) during co-culture, and the targeting of LTGF-beta to the cellular surface is requisite for its activation. In the present study, the cellular targeting of LTGF-beta was examined. We detected the specific binding of 125I-large LTGF-beta 1 isolated from human platelets to smooth muscle cells but not to endothelial cells. A mAb against the latency-associated peptide (LAP) of large LTGF-beta 1 complex, which blocked the binding of 125I-large LTGF-beta 1 to smooth muscle cells, inhibited the activation of LTGF-beta during co-culture. The binding of 125I-large LTGF-beta 1 could not be competed either by mannose-6-phosphate (300 microM) or by the synthetic peptide Arg-Gly-Asp-Ser (300 micrograms/ml). These results indicate that the targeting of LTGF-beta to smooth muscle cells is required for the activation of LTGF-beta during co-culture of endothelial cells and smooth muscle cells. The targeting of LTGF-beta to smooth muscle cells is mediated by LAP, and the domain of LAP responsible for the targeting to smooth muscle cells may not be related to mannose-6-phosphate or an Arg-Gly-Asp sequence, both of which have been previously proposed as candidates for the cellular binding domains within LAP.