Parental report of dental pain and discomfort in preschool children is associated with sleep disorders: a cross-sectional study in Brazilian families.

PURPOSE: To evaluate the prevalence of sleep disorders in Brazilian preschool children and its associations with parental report of dental pain and discomfort. METHODS: This cross-sectional study involved 604 Brazilian preschoolers (4-5 years old). Sleep disorders (SD) and the parental report of dental pain and discomfort (DPD) were evaluated using the Brazilian versions of the Sleep Disturbance Scale for Children (SDSC) and the Dental Discomfort Questionnaire (DDQ-B), respectively. Bivariate and multivariate Poisson regression analyses with robust variance were performed to analyze the association between SDSC and DP. RESULTS: Prevalence of SD ranged from 7 to 21%. 7.9% of the children had DPD indicating the need for more invasive dental procedures (DDQ-B ≥ 5). Significant associations were found between DPD and the following SDSC domains: sleep hyperhidrosis (p = 0.024; PRa = 1.38; 95% CI: 1.04-1.83), disorders of initiating and maintaining sleep (p < 0.001; PRa = 1.41; 95% CI: 1.15-1.73), parasomnias (p < 0.001; PRa = 1.82; 95% CI: 1.39-2.37), and sleep-wake transition disorders (p = 0.018; PRa = 1.28; 95% CI: 1.04-1.58). Children with higher prevalence of DPD presented 20% higher prevalence of SD than children lower prevalence of DPD (p = 0.039; PRa = 1.20; 95% CI: 1.01-1.44). CONCLUSION: Preschool children with higher prevalence of DPD are more likely to have SD, such as hyperhidrosis, disorders of initiating and maintaining sleep, parasomnias, and sleep-wake transition.

Perioperative evaluation of carotid endarterectomy by 3D-CT angiography with refined reconstruction: preliminary experience of CEA without conventional angiography.

Three-dimensional CT angiography (3D-CTA) was employed for perioperative evaluation of carotid endarterectomy (CEA) as an alternative to conventional angiography. A total of 62 carotid arteries were examined before and after CEA, 26 with an early 3D-CT system and 36 with multidetector helical CT allowing sophisticated reconstruction by a personal workstation. In addition to patients who had undergone conventional angiography at other institutes, 10 subjects underwent CEA on the basis of 3D-CTA findings alone. The findings provided detailed information with an excellent view of carotid stenoses. Volume rendering images comprehensively visualized lesions and surrounding structures as well as calcifications, which were also well depicted by maximum intensity projection images. Evaluation of the cerebral circulation is one problem that still requires solution, although cerebral vessels were delineated by 3D-CTA. One patient experienced transient hemiparesis, but no significant permanent deficit. We conclude that 3D-CTA is a safe and accurate modality that is a practical alternative to conventional perioperative angiography.

B-mode flow imaging of the carotid artery.

BACKGROUND AND PURPOSE: B-mode ultrasonography has been used to evaluate cervical carotid artery lesions. Recently, the technology for direct visualization of blood reflectors has made B-mode flow imaging (B-flow) possible without the limitations of Doppler technology. We evaluated the efficacy of B-flow in examining the cervical carotid artery. METHODS: Sixty patients with ischemic cerebrovascular disease were examined. Conventional B-mode imaging and blood flow images by power Doppler imaging (PDI) and B-flow were obtained. RESULTS: B-flow enabled simultaneous imaging of tissue and blood flow. Compared with PDI, B-flow provided higher spatial resolution and higher frame rate hemodynamic imaging. Consequently, a clear definition of the vessel lumen was obtained even in the stenotic portion of the carotid artery. In evaluating the degree of carotid stenosis, B-flow measurement agreed with digital subtraction angiography as well as PDI measurement. In addition, bloodstream swirl at the site of wall ulceration or vascular elongation was observed. CONCLUSIONS: B-flow was prominent in visualizing hemodynamic flow and detection of stenotic lesion in the cervical carotid artery. Combined with conventional B-mode technique, B-flow seems to be useful in evaluating carotid stenosis.

Dissociation of hemopoietic chimerism and allograft tolerance after allogeneic bone marrow transplantation.

Creation of stable hemopoietic chimerism has been considered to be a prerequisite for allograft tolerance after bone marrow transplantation (BMT). In this study, we demonstrated that allogeneic BMT with bone marrow cells (BMC) prepared from either knockout mice deficient in both CD4 and CD8 T cells or CD3E-transgenic mice lacking both T cells and NK cells maintained a high degree of chimerism, but failed to induce tolerance to donor-specific wild-type skin grafts. Lymphocytes from mice reconstituted with T cell-deficient BMC proliferated when they were injected into irradiated donor strain mice, whereas lymphocytes from mice reconstituted with wild-type BMC were unresponsive to donor alloantigens. Donor-specific allograft tolerance was restored when donor-type T cells were adoptively transferred to recipient mice given T cell-deficient BMC. These results show that donor T cell engraftment is required for induction of allograft tolerance, but not for creation of continuous hemopoietic chimerism after allogeneic BMT, and that a high degree of chimerism is not necessarily associated with specific allograft tolerance.

Optimization of atrioventricular delay and follow-up in a patient with congestive heart failure and with bi-ventricular pacing.

Cardiac function is improved by bi-ventricular pacing in patients with severe reduced cardiac function. Atrioventricular (AV) delay optimization is also important in this therapy. However, the AV delay required to achieve the optimal AV synchrony varied from time to time. We have reported that the critical AV delay that induces diastolic mitral regurgitation (MR) may represent the upper limit of the optimal AV delay. The optimal AV delay can be predicted by a simple method; slightly prolonged AV delay-interval between the end of atrial kick and complete closure of the mitral valve (duration of diastolic MR) at the AV delay setting. [Case] 60 year old Japanese male with dilated cardiomyopathy. He was repeatedly admitted to our hospital due to congestive heart failure. Ejection fraction was 14%. ECG showed complete left bundle branch block and his PQ interval was 0.22 sec. He was dependent on intravenous injections of catecolamine and could not be discharged from the hospital for over one year. Optimal AV delay was predicted as 80 msec during bi-ventricular pacing by our formula. Cardiac output was 4.9, 6.0, 5.1 l/min when the AV delay was set at 50, 80, 110 msec. Cardiac function was improved from NYHA class III to II and he has been relieved from the dependency on intravenous catecholamine injections. AV delay was optimized (70-100 msec) by our method during follow-up for one year. This case indicates that AV delay optimization is important in bi-ventricular pacing.

Donor T cells are not required for induction of allograft tolerance in mice treated with antilymphocyte serum, rapamycin, and donor bone marrow cells.

BACKGROUND: Postgraft infusion of donor bone marrow cells (BMC) effectively induces tolerance to skin allografts in antilymphocyte serum- and rapamycin-treated recipients in fully major histocompatibility complex-mismatched mouse strain combinations. We used various gene knockout mice to examine the role of donor T cells and B cells in BMC-induced allograft tolerance. METHODS: All recipient mice received ALS on days -1 and 2 and rapamycin (6 mg/kg) on day 7 relative to fully major histocompatibility complex-mismatched skin grafting on day 0. Donor BMC prepared either from mice lacking CD4- and/or CD8a-, or CD3epsilon-expressing cells or B cells, or from corresponding wildtype mice, were given on day 7. The level and phenotypes of chimerism was determined by flow cytometry. RESULTS: All T cell- and B cell-deficient BMC were as effective as wild-type BMC in inducing prolongation of skin graft survival. A low degree of chimerism without donor type T cells was detected in tolerant mice given T cell-deficient BMC or wild-type BMC 60 days after transplantation. Chimeric cells were composed of B cells and macrophages/monocytes. Low level chimerism without donor T or B cells was also present in tolerant mice given B cell-deficient BMC. CONCLUSION: Donor type T cells and T cell chimerism are not required for induction of allograft tolerance by the antilymphocyte serum/rapamycin/donor BMC-infusion protocol. Donor B cells also do not participate in tolerance induction. Thus, infusion of T cell-depleted BMC in conjunction with conventional immunosuppressive regimens will be a simple, safe, and effective way to induce allograft tolerance in clinical organ transplantation.

Quantitative measurement of cerebral blood flow by (99m)Tc-HMPAO SPECT in acute ischaemic stroke: usefulness in determining therapeutic options.

OBJECTIVE: Early recanalisation by thrombolysis is a conclusive therapy for acute ischaemic stroke. But this therapy may increase the risk of intracerebral haemorrhage or severe brain oedema. The purpose was to evaluate usefulness of quantitative measurement of cerebral blood flow by single photon emission computed tomography (SPECT) in predicting the risk of haemorrhage or oedema, and determining the therapeutic options in acute hemispheric ischaemic stroke. METHODS: The relation was studied retrospectively between initial regional cerebral blood flow (rCBF) quantitatively measured by technetium-99m-labelled hexamethylpropyleneamine oxime ((99m)Tc-HMPAO) SPECT and final clinical and radiological outcome in 20 patients who presented hemispheric ischaemic stroke and were treated conservatively or received early recanalisation by local intra-arterial thrombolysis. The non-invasive Patlak plot method was used for quantitative measurement of rCBF by SPECT. RESULTS: Regions where residual rCBF was preserved over 35 ml/100 g/min had a low possibility of infarction without recanalisation and regions where residual rCBF was preserved over 25 ml/100 g/min could be recovered by early recanalisation. However, regions where residual rCBF was severely decreased (< 20 ml/100 g/min) had a risk of intracerebral haemorrhage and severe oedema. CONCLUSIONS: A quantitative assessment of residual rCBF by (99m)Tc-HMPAO SPECT is useful in predicting the risk of haemorrhage or severe oedema in acute ischaemic stroke. Therapeutic options should be determined based on the results of rCBF measurement.

Establishment of stable multilineage hematopoietic chimerism and donor-specific tolerance without irradiation.

BACKGROUND: Induction of tolerance to organ transplants will increase graft survival and decrease patient mortality and morbidity. Radiation-induced cytoreduction/ablation followed by donor hematopoietic cell reconstitution has been the most consistently successful approach to experimental tolerance induction. However, reluctance of clinicians to expose recipients to radiation has hampered its clinical application. METHODS: In the studies described, administration of polyclonal antilymphocyte serum (ALS), donor-specific bone marrow (DSBM) (150x10(6) cells), and sirolimus (24 mg/kg) in a completely mismatched murine model (B10.A donor, C57B/10 recipient) produced 100% indefinite (>250 days) skin graft survival. The level and character of donor-specific chimerism was evaluated with flow cytometry. RESULTS: Specific tolerance was confirmed by continued acceptance of primary and secondary donor-specific skin allografts and rejection of third-party grafts. The level and duration of chimerism induced was directly related to the dose of DSBM administered. Mice given 150x10(6) DSBM cells showed levels of 8-10% donor peripheral blood mononuclear cell chimerism by 30 days, and these levels persisted indefinitely (>250 days) in association with permanent tolerance of donor grafts. Eighty percent of donor chimeric cells were B lymphocytes (MHC class I and II positive, Fc receptor positive, CD45/B220 positive but negative for CD4, CD8 and Thy 1.2) and 20% were sorted in the macrophage monocyte population. CONCLUSIONS: These studies demonstrate for the first time that cytoreduction/ablation with ALS combined with sirolimus and reconstitution with donor bone marrow induces tolerance and chimerism in a completely mismatched murine combination. The use of ALS and sirolimus, currently employed therapies in clinical transplantation, and the lack of requirement for radiation make this tolerance protocol attractive for clinical application.

Donor MHC class II antigen is essential for induction of transplantation tolerance by bone marrow cells.

Posttransplant infusion of donor bone marrow cells (BMC) induces tolerance to allografts in adult mice, dogs, nonhuman primates, and probably humans. Here we used a mouse skin allograft model and an allogeneic radiation chimera model to examine the role of MHC Ags in tolerance induction. Infusion of MHC class II Ag-deficient (CIID) BMC failed to prolong C57BL/6 (B6) skin grafts in ALS- and rapamycin-treated B10.A mice, whereas wild-type B6 or MHC class I Ag-deficient BMC induced prolongation. Removal of class II Ag-bearing cells from donor BMC markedly reduced the tolerogenic effect compared with untreated BMC, although graft survival was significantly longer in mice given depleted BMC than that in control mice given no BMC. Infusion of CIID BMC into irradiated syngeneic B6 or allogeneic B10.A mice produced normal lymphoid cell reconstitution including CD4+ T cells except for the absence of class II Ag-positive cells. However, irradiated B10.A mice reconstituted with CIID BMC rejected all B6 and a majority of CIID skin grafts despite continued maintenance of high degree chimerism. B10.A mice reconstituted with B6 BMC maintained chimerism and accepted both B6 and CIID skin grafts. Thus, expression of MHC class II Ag on BMC is essential for allograft tolerance induction and peripheral chimerism with cells deficient in class II Ag does not guarantee allograft acceptance.

Crossed cerebellar hyperperfusion in symptomatic epilepsy--two case reports.

A 74-year-old female with cerebral infarction and a 78-year-old female with cerebral glioblastoma suffered complex partial seizure. Ictal perfusion single photon emission computed tomography in these patients showed the interesting phenomenon of 'crossed cerebellar hyperperfusion,' a reversed crossed cerebellar diaschisis. The mechanism is probably spread of electrical seizure through efferent projections, and may be related to the cerebellar atrophy seen in patients with long-standing partial epilepsy.

Visual disturbance by lymphocytic hypophysitis in a non-pregnant woman with systemic lupus erythematosus.

The authors present the case of a patient with systemic lupus erythematosus who developed visual disturbance and amenorrhea. Though the clinical and radiological findings resembled those of pituitary adenoma, the patient was finally diagnosed as having lymphocytic hypophysitis after the operation. We briefly describe this relatively rare entity in relation to its autoimmune pathogenesis.

[A case of rhinocerebral mucormycosis presenting orbital apex syndrome].

A 62-year-old man with untreated diabetes complained of diplopia and headache. Neurological examination demonstrated left abducens nerve palsy. MRI showed a mass lesion in the left orbital apex. Total left ophthalmoplegia and visual loss rapidly developed in the next two weeks. A craniotomy was performed to decompress the orbital apex and remove the mass. The optic nerve was tightly encased by fibrous tissue. The pathological diagnosis was mucormycosis. Systemic administration of amphotericin B and fluconazole was started immediately. But the lesion rapidly invaded the cavernous sinus and occluded the left internal carotid artery. Finally, the patient died with intracranial extension of mucormycosis four months after the operation. Rhinocerebral mucormycosis is a rapidly progressive fatal disease. Successful treatment seems to be based on early diagnosis, control of the underlying disease, radical surgical resection, and systemic administration of amphotericin B. Mucormycosis should be considered as a differential diagnosis of orbital apex syndrome.

Intravenously administered macrophage colony-stimulating factor (M-CSF) specifically acts on the spleen, resulting in the increasing and activating spleen macrophages for cytokine production in mice.

IL-6 was transiently expressed in sera of mice after a bolus intravenous injection with LPS and it peaked 2 h later. Intravenous administration of M-CSF at 250 micrograms/kg/day for 5 days prior to an injection of 25 micrograms/kg of LPS elevated the serum IL-6 level 10-fold higher than that of mice which were not given M-CSF. Although M-CSF had no effect on the number of macrophages in alveoli and peritoneal cavity, it tripled the number of spleen macrophages and increased macrophage-progenitor cells 7-fold when injected intravenously. Spleen macrophages from M-CSF-injected mice produced 5-fold more IL-6 in response to LPS-stimulation in-vitro. However, M-CSF-injection had lesser effects on LPS-induced IL-6 production from liver, alveolar and peritoneal macrophages. Exogenously administered M-CSF was detected at higher concentration and for longer duration in the spleen than in any other organs examined. Spleen macrophages incubated in-vitro with more than 1000 U/ml of M-CSF for 3 days also produced more LPS-induced IL-6 than untreated cells. These results indicate that intravenously administered M-CSF not only enhances macrophage development in the spleen, but also primes mature macrophages for cytokine production.

Pure amnesia caused by bilateral temporal lobe astrocytoma--case report.

A 32-year-old male presented with progressive pure amnesia caused by astrocytoma invading the bilateral medial temporal lobes. Methionine positron emission tomography demonstrated the extent of tumor invasion well. His memory impairment was partially improved by treatment for the astrocytoma. Lesion of the bilateral hippocampus causes memory impairment, but pure memory loss without other associated neurological sign or deterioration of consciousness is rare in a case of cerebral neoplasm.