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We report the case a 54-year-old male patient who was admitted to our hospital with a sore throat and evidence of a high inflammatory reaction. Computed tomography revealed a peritonsillar abscess extending from the inferior right tonsil to the cervical esophagus, and thickening of the esophageal wall. The pharyngeal abscess was drained through an intraluminal incision in the mesopharynx. Culture of the abscess fluid showed growth of Streptococcus constellatus, one of the organisms of the Streptococcus milleri group. We diagnosed the patient as having phlegmonous esophagitis secondary to peritonsillar abscess. The inflammation was judged to have extended to the submucosal space of the esophagus from the pharyngeal mucosal space. Since the inflammation was contained within the esophageal wall and did not progress to mediastinitis, critical symptoms did not appear and the patient improved through conservative management with antibiotics

Objective: The academic achievement in Japanese and arithmetic of children born with very low birth weights (VLBW) was examined by means of academic skill tests at the age of 10 years., Methods: The participants were 14 VLBW children who could be followed up in our hospital at the age of 10 years, and 6 men and 8 women. They had a mean gestational age of 27 weeks and 6 days and a mean birth weight of 988 g. The tests of the fourth grade of Japanese and arithmetic were performed during the waiting time of outpatient. The results were compared with those in typical development (TD) children., Results: Concerning the comprehension of Japanese, the correct answer rate as to the problems answered in their own word was 42.9 ± 51.4% in the VLBW children and 69.7 ± 46.3% in the TD children, respectively. The correct answer rate as to composition was 28.6 ± 46.9% in the VLBW children and 72.7 ± 44.9% in the TD children, respectively, that in the VLBW children being obviously low. The correct answer rate as to calculation laws of arithmetic was 55.4 ± 14.7% in the VLBW children and 66.3 ± 15.5% in the TD children, respectively. The sentence resolving as to arithmetic was 42.9 ± 50.4% in the VLBW children and 52.9 ± 50.1% in the TD children, respectively., Conclusions: The VLBW children had difficulty in Japanese and arithmetic which required the sentence understanding, compared with the TD children.

We have made new instructions with onomatopoeic sounds and their own signs in order to improve the accuracy of the upper gastrointestinal study, and compared these new instructions with the conventional ones. After the examinations, we asked the patients to fill out a questionnaire regarding how they felt about the new instructions. In the esophagus X-ray fluoroscopy, the number of patients who took the proper amount of Barium meal showed a rate of increase of 31.6 percent compared to the conventional method. For the patients' movements in the right rotation direction, the number of the patients showed a rate of increase of 18.2 percent using the oral instructions with onomatopoeic sounds, and 25.0 percent using the oral instruction with onomatopoeic sounds and signs. From the results of the questionnaire, 87.6 percent of the patients answered that the signs were "Effective" or "Very Effective." Including the answer "Doesn't Matter," the sign instructions being useful increased to 94.8 percent of the patients. Ninety-four point eight percent of the patients answered that the oral instructions during this X-ray examination were "Easy To Understand" or "Very Easy To Understand." With these results, I believe we should give the oral instructions using onomatopoeic sounds and signs.

A 63-year-old woman complained of continuous dry cough and high fever for two months. Chest radiography showed no abnormality, but inspiratory fine crackles were audible. Interstitial lung disease was suspected and bronchoalveolar lavage was performed via a bronchoscope. Disseminated minute granular lesions with redness and hypervascularity from the upper trachea to bilateral lober bronchi were detected. Lesions were also present in the membranous portion of the left main bronchus. Histological results for bronchial biopsy and transbronchial lung biopsy showed non-caseous epithelioid cell granuloma. This, together with a high CD4/8 lymphocyte ratio (4.11) in bronchoalveolar lavage fluid and the gallium scintigraphic findings, confirmed the diagnosis of sarcoidosis. To the best of our knowledge there are no other reports of cases with a similar bronchoscopic appearance in which the chest roentgenologic classification was stage 0, despite severe respiratory symptoms. Nodular lesions are seen in some cases of endobronchial sarcoidosis, but in this case, these widespread granular lesions were a unique feature that prompted us to make this report.

A 64-year-old woman was admitted with a chest radiograph abnormality. She had no compliant and the results of her physical examination were normal. A chest radiograph showed a 25-mm area of patchy opacity in the left upper lung field. Chest CT demonstrated a finger-like opacity along the left B3a and c that was highly suggestive of mucoid impaction of the bronchi. Bronchofiberscopy revealed mucous plugs in left B3, in which the filariform fungul hyphae were detected by Grocott stain. Rosenberg's clinical criteria have been cited frequently for the diagnosis of allergic bronchopulmonary aspergillosis (ABPA). On the one hand his criteria have historical significance, but at the same time various problems have been pointed out. Although the patient was not given a diagnosis of ABPA based on Rosenberg's criteria, she was given it based on the presence of type I immunologic response, mucoid plugs, hyphae of Aspergillus, central bronchiectasis. She had localized opacity only along a segmental bronchus. Our report may provide valuable information on the course of ABPA.

A dysphagia rehabilitation team at National Ehime Hospital treated fifty-seven patients with severe motor and intellectual disabilities suspected of having dysphagia. The rehabilitation team graded the degree of dysphagia by observing the patients at mealtimes. The grades were compared with the videofluoroscopic examination of swallowing results. There was some correlation with the dysphagia grades and videofluoroscopic examination of swallowing results (solid food:p = - 0.434, n =54, p < 0.0001, liquid:p = - 0.482, n = 54, p = 0.005). There were cases in which manifestations of severe dysphagia such as retention of solid food in the pharynx could only be detected on videofluoroscopic examination of swallowing. Dietary manipulation allowed shortening of the time taken at mealtimes for some patients. The dysphagia rehabilitation was useful in many cases in decreasing the number of days with fever, and improving the eating functional level, but the results as a whole were not statistically significant.

We report a case of follicular lymphoma with chylothorax. A 45-year-old man visited our hospital complaining of shortness of breath and abdominal distension. Chest X-rays showed bilateral pleural effusion, and an abdominal CT scan revealed a large intraperitoneal tumor around the abdominal aorta and pancreas. Bilateral cervical and inguinal lymph nodes were swollen. Biochemical study of the pleural fluid revealed the presence of chylomicrons, and an inguinal lymph node biopsy led to a follicular lymphoma diagnosis. The patient achieved complete remission, with disappearance of pleural effusion, following 8 cycles of chemothreapy (R-CHOP). Cases of malignant lymphoma with chylothorax are rarely reported in Japan, but should be taken into account when examining cases of non-traumatic chylothorax.

Background: There are some reports on the incidence of awareness during general anesthesia that is usually stable at the maintenance period. The aim of this study is to evaluate the incidence of awareness during the induction period of general anesthesia in which the effects of anesthetics are unstable., Methods: The research-nurses interviewed the patients, who had undergone general anesthesia, on the awareness during anesthesia within a week after operation. The patients were excluded from the study if they were in deep sedation or unconscious because of the medical reasons. We defined the induction period from the administration of hypnotic drugs to the tracheal intubation., Results: Seven cases with ages from 20 s to 70 s out of 1922 cases were identified as the residual awareness cases during the induction period. Six cases were managed with low concentrations of inhalation anesthetics after injection of intravenous hypnotics. The incidence was lower, but not significant, if they were managed with total intravenous technique. The BIS values were above 60 in all these cases if the monitor was attached., Conclusions: The incidence of awareness during the induction was 0.36%. We have to pay more attention to the disappearance of the hypnotic effect at the induction period.

We reported a case of eyelid myoclonia with absences treated for 10 years. Seizures of eyelid myoclonia accompanied by absence, precipitated by sunlight, began at the age of 4 years and disappeared at the age of 11 years. Non-convulsive status epilepticus, occurring shortly after awakening, began at the age of 10 years and have occurred intermittently until the age of 18 years. While generalized EEG abnormalities disappeared after initiation of treatment, the patient still had occipital spikes on interictal EEG at the age of 18 years, suggesting occipital hyperexcitability as the basis of photosensitivity. Along with poor drug compliance due to her living apart from her parents, it was difficult to completely suppress non-convulsive status epilepticus, posing serious concern in her adult life.

During a period of five years from January 1996 through December 2000 total intravenous anesthesia with mainly propofol, fentanyl and ketamine was administered to 26,079 patients including cardiac and neurosurgical patients at the University of Hirosaki Hospital and five other affiliated hospitals. The patients studied ranged from 1 year 8 months to 93 years in age, 9.2 kg to 135.0 kg in body weight and from 18 min to 22 hours 50 min in anesthetic time. With adequate monitoring, fentanyl 1-2 micrograms.kg-1 was given at first, then total-dose of ketamine 1 mg.kg-1 and propofol 1-2 mg.kg-1 were administered for the induction of anesthesia in adult patients. A total dose of fentanyl 3-15 micrograms.kg-1 was given combined with propofol 5-10 mg.kg-1 and ketamine 0.3-1.0 mg.kg.h-1. In craniotomy patients, ketamine was excluded. For pediatric patients, sevoflurane anesthesia was employed to establish i.v. route, and intravenous agents were given almost same as in the same manner as in adult patients. None of them developed either cardiac arrest or severe cardiovascular insufficiencies due to anesthesia alone. Their postoperative hepatic and renal functions evaluated by various biochemical indices and urine output were adequately maintained during anesthesia and for a week postoperatively. They were followed up to 3 months postoperatively only to fail to detect any adverse events related directly to this method of anesthesia. These data suggest that total intravenous anesthesia with propofol, fentanyl and ketamine has a very wide margin of safety.

The changes of systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse rate (PR) during implant surgery under local anesthesia were analyzed in 38 normal healthy patients. The results were as follows: 1. SBP significantly increased compared with the preoperative control throughout surgery. 2. DBP did not change significantly compared with the preoperative control throughout surgery. 3. PR increased just after the local anesthesia, and lowered afterward. 4. Both SBP and DBP increased in correlation with age. 5. SBP, DBP, and PR increased in correlation with surgical procedure time. 6. SBP, DBP, and PR increased in correlation with number of implantation. From these results, it was indicated that implant surgery might be accompanied by a risk, even in healthy patients.

To clarify the medical and educational support necessary for ordinary school life of children with neuromuscular disorders, a questionnaire was sent to their homeroom teachers. The 13 outpatients consisted of 7 with Duchenne muscular dystrophy, 5 other muscular dystrophies, and 1 with another myopathy. Their teachers desired the environment and system, such as elevators and personnel to support their movements, should be improved. Regarding the school curriculum, special advice of medical staff was considered to be necessary to provide physical education and to promote their well-retained activities. The teachers regarded it valuable to teach them together with healthy children, for the children with or without neuromuscular disorders, teachers, and people in the community. In the future, it is expected that national sanatariums and schools for the handicapped will function as special facilities that are open to the community for general counselling and provide various informations. Pediatric neurologists should play a role as managers caring for the patients, their families, teachers, schools, and communities.

A retrospective study on medically compromised patients was made using 1,000 outpatients who visited the Clinic for Oral Implant, University Hospital, Faculty of Dentistry, Tokyo Medical and Dental University between April 1995 and June 1998. The results were as follows: 1. 35.3% (353 patients: 140 males and 213 females) of the outpatients were medically compromised. 2. The greatest number of medically compromised patients was in the 50-59 age group (118 cases), followed by those in the 40-49 and 60-69 age groups. 3. The highest ratio of medically compromised patients was in the 60-69 age group (48.2%), followed by those in the 70-79 and 50-59 age groups. 4. Among the 353 patients, 96 (27.2%) underwent surgical treatment such as insertion of implant (68 cases), removal of implant, extraction of tooth, and free gingival graft. 5. Among the 68 patients who underwent insertion of implant, in a classification by type of disease, the patients with cardiovascular diseases were the most numerous (33.9%), followed by metabolic and digestive tract diseases. 6. All surgical treatments of implant insertion were performed under local anesthesia, while monitoring cardiac and respiratory function, and SpO2. Among the 68 patients, 9 underwent operation under intravenous sedation and 2 under nitrous oxide inhalation sedation. All 11 patients had hypertension. The results suggested that identification of preoperative risk factors, precise recognition of general condition, and establishment of control system are important to manage medically compromised patients for dental implant treatment.

Host-derived blood protein adsorption is much more rapid than the migration of cells to foreign surfaces, so the effect of host proteins in blood on blood cells and bone marrow cells was investigated by means of in vitro culturing of blood and bone marrow cells on titanium. A material preincubated with plasma induced high nonspecific esterase (NSE) activity and polymorphonuclear neutrophil (PMN) elastase activity, but neither a serum- nor albumin-coated material had the same effect as the plasma-coated material. Therefore, attention was paid to fibrinogen. On titanium coated with fibrinogen increases in not only NSE activity and PMN elastase activity in blood and bone marrow, but also tartrate-resistant acid phosphatase (TRACP) activity were observed in bone marrow cultures. A decrease in alkaline phosphatase (ALP) activity was also observed in the cultures. These changes of bone marrow cultures were reversed by the addition of recombinant human bone morphogenetic protein-2 to the cultures. These results suggested that bleeding around titanium affects the function of macrophages or neutrophils due to the effect of fibrinogen. Furthermore, it was suggested that this factor may affect the functions of osteoblasts anti osteoclasts around a titanium implant with the inevitable side effects of implantation in bone tissue: bleeding and clotting.

We reported a 6-year-old girl with acute idiopathic pandysautonomia (AIPD) associated with syndrome of inappropriate secretion of anti-diuretic hormone (SIADH). She showed various symptoms indicating the impairment of widespread sympathetic and parasympathetic nervous functions and SIADH, which followed common cold. Sural nerve biopsy showed severe reduction of both myelinated and unmyelinated fibers. The main site of the lesion of AIPD has been assumed to be the peripheral autonomic nervous system. However, there are a few reports indicating the involvement of the central nervous system in AIPD. The present case also indicates the involvement of hypothalamus in addition to the peripheral autonomic nervous system.

Ninety nine patients with ischemic changes of the heart on preoperative and intraoperative ECG tracings were studied to evaluate effects of intravenous infusion of isosorbide dinitrate on hemodynamics during anesthesia and surgery. These patients ranging in ages from 24 to 80 years were administered intravenous isosorbide dinitrate at a rate of either 0.5 or 1 microgram.kg-1 x min-1 during anesthesia and surgery. Arterial blood pressure was not influenced with intravenous isosorbide dinitrate at the speed of 0.5 microgram.kg-1 x min-1 during anesthesia and surgery. The arterial pressure of the patients decreased slightly but significantly 30 min after the start of 1 microgram.kg-1 x min-1 of isosorbide dinitrate infusion, but it recovered to the control level at the end of administration of isosorbide dinitrate. Heart rate was unchanged with intravenous isosorbide dinitrate during anesthesia and surgery in both groups, except a mild increase at the end of isosorbide dinitrate infusion of 1 microgram.kg-1 x min-1. Arterial blood oxygen tension showed no decrease during the administration of isosorbide dinitrate and no adverse reactions associated with administration of the drug was detected in this study. Significant improvement of ischemic changes on ECG tracings were observed in about 25% of the patients who received 1 micrograms.kg-1 x min-1 of intravenous isosorbide dinitrate.

We reported the first case of typical infantile-type neuronal ceroid-lipofuscinosis (INCL) in Japan. The patient was a 1-year-old girl presenting with rapidly progressive psychomotor deterioration and blindness. Muscular hypotonia, microcephaly and myoclonic jerks became marked with the progression of her disease. Diminution in amplitude of EEG, VEP and ERG was prominent in the initial stage, but ABR was normal. MRI showed progressive brain atrophy. Electron microscopic examination of the biopsied skin revealed granular matrix, the specific inclusion bodies, in the epithelial cell of sweet glands. Many sea-blue histiocytes were demonstrated in her bone marrow samples. INCL is a common progressive encephalopathy in the Scandinavian countries, but a typical case had not yet been fully reported in Japan. This prompted us to report our case. Future reports are need for the study of INCL in Japan.

A three year-old boy with congenital sensory neuropathy with anhidrosis (CSNA) was described. Sural nerve biopsy specimens revealed an almost complete absence of unmyelinated fibers and a marked decrease of the density of small myelinated fibers with preservation of the density of large myelinated fibers. No evidence of active degeneration of unmyelinated or myelinated fibers was found. Skin biopsy specimens revealed the absence of nerve terminals and fibers innervating sweat glands, although sweat glands seemed to be apparently normal in their morphological findings. Therefore, it was concluded that the absence of pain and temperature sensations with preservation of touch sensation in our patient was compatible with the morphometric findings of nerve fibers of the sural nerve described. Similarly anhidrosis was concluded to be well explained by the absence of the innervation of sweat glands and the vessels around them. On the other hand, electrophysiologic studies, such as motor and sensory nerve conduction, short latency somatosensory evoked potential and auditory brainstem response, in which the function of the large myelinated fibers is presumably tested, were all normal. Therefore, the structure and function of such large myelinated fibers were spared in this case. From clinical viewpoints, electrophysiologic studies described above are useful to differentiate CSNA from other types of congenital sensory neuropathies, in which large myelinated fibers are affected.

The effects of prostaglandin E1 (PGE1) on blood pressure during anesthesia and the postoperative changes in organ functions were examined and compared in 358 cases. Two hundred and eighty patients were under 64 years of age and 128 patients were over 65 years. It was possible to control blood pressure satisfactorily with PGE1 in both non-elderly and elderly groups. However in the elderly group, it was more difficult to control blood pressure with PGE1 under NLA as compared with enflurane anesthesia. In both groups, urinary flow increased during and after the administration of PGE1, and the livers and kidneys showed neither dysfunction nor deterioration after operation. We had very few incidences of side effects with this drug. PGE1 is also considered safe and useful for elderly people during and after surgery.

A 23-year-old-man was admitted to our department complaining of chest oppression. He had had a diagnosis of intestinal-Behçet because of a 7-year history of recurrent oral and genital ulcers, arthritis, cutaneous folliculitis and ulcer in the ileocecal region. Cardiac catheterization revealed total occlusion at the proximal portion of the left anterior descending artery (LAD) without aneurysm formation at other coronary trees. During medical follow-up, this case showed vasospastic angina probably associated with active coronary vasculitis. The incidence of vascular involvement in the total number of cases of Behçet's disease reported in the literature is 3.6-7.7%. Overall, thrombophlebitis and arterial aneurysm formation is relatively common and frequently reported in cases of vasculo-Behçet. Our case demonstrated the following uncommon pattern as vasculo-Behçet; 1) initial clinicopathologic manifestation at the coronary artery without any other vascular lesion, 2) abrupt total occlusion (clear cut lesion) at LAD, 3) complication of vasospastic angina, which has not yet been reported in medical literature.

Magnetic resonance imaging of skeletal muscles in thirteen patients with Duchenne muscular dystrophy was performed to estimate pathological changes. Serial axial and sagittal sections of the right lower extremity were recorded. In the early stage, the T1 values of gastrocnemius and soleus muscles were slightly lower than the control values, and in the late stage, the values were much lower in all muscles examined. In sagittal sections, the gastrocnemius muscles in the early stage showed a high density area at the distal region adjacent to soleus muscle, and the soleus muscle showed a high density area adjacent to the gestrocnemius muscle. In serial axial sections, high density areas of the anterior and posterior tibialis muscles appeared first at their proximal and peripheral regions. It was concluded that the sequence of appearance of pathological changes was different not only among individual muscles but also among various regions of each muscle; the high density changes appeared first at myotendon junctions.

The effect of early myocardial reperfusion (within six hours after the onset of symptoms) on left ventricular (LV) function in 106 patients with acute myocardial infarction was studied. The subjects consisting of 26 with conventional therapy, 19 with percutaneous transluminal coronary recanalization (PTCR), 16 with percutaneous transluminal coronary angioplasty (PTCA) after PTCR, 32 with direct-PTCA and 13 with coronary artery bypass graft (CABG) were randomly observed after 1981. In these patients, left ventricular ejection fraction (LVEF), regional wall motion, end-diastolic pressure and the contractility index were measured as the indices of LV function. 1. Compared to the conventional therapy group, LVEF and regional wall motion improved significantly in all groups with reperfusion therapy except in the PTCR group. This LV function in patients with subtotal obstruction or good initial collaterals significantly improved compared to patients with total obstruction and no collateral circulation. Patients with a 75 percent or more residual stenosis after reperfusion therapy had significantly decreased LV function compared to those with residual stenosis of less than 75 percent. These findings support the potential role for reperfusion therapy in patients with acute myocardial infarction.

Plasma levels of cortisol, ACTH and beta-endorphin like immunoreactivity (beta-ELI) were measured to evaluate postoperative pain relief with epidural morphine and systemic analgesics in conjunction with endocrine functions in 16 patients who underwent gastrectomy. Eight of these patients (epidural morphine group) obtained postoperative analgesia with continuous epidural infusion of morphine with a pump as in our previous report. A bolus of epidural morphine was administered through an indwelling thoracic (Th8,9) catheter at 3 hrs prior to the proposed end of the surgery, which was followed with continuous epidural infusion of morphine at a rate of 0.167-0.042 mg.hr-1 with a pump (CADD-PCA, Model 5200P, Pharmacia) during and after anesthesia and surgery with gradual decrease in dose until the third postoperative day. The remaining eight patients (systemic analgesics group) repeatedly received systemic pentazocine and buprenorphine when needed. Plasma cortisol levels increased significantly at the end of surgery and after in both groups. However plasma concentrations of cortisol in the epidural morphine group were significantly lower than those in the systemic analgesics group on the first and second postoperative days. Plasma levels of ACTH and beta-ELI increased significantly at the end of surgery but returned to levels of the previous day in both groups postoperatively. Our study suggests that continuous epidural infusion of morphine is adequate for postoperative pain relief and has suppressing effect on plasma cortisol levels as compared with systemic analgesics regimen.

We studied 73 patients with acute myocardial infarction (AMI) treated by percutaneous transluminal coronary angioplasty (PTCA) without thrombolysis (direct PTCA) and 52 patients with AMI treated by PTCA immediately after thrombolysis (PTCR + PTCA). The initial results, angiographic findings and preservation of ventricular functions of the direct PTCA group were compared with those of the PTCR + PTCA group. 1. The success rate of coronary recanalization was higher in the direct PTCA group than in the PTCR + PTCA group, but there was no statistical significance (89% vs 77%; p = NS). 2. Major complications occurred in 4.1% of the direct PTCA group and in 5.8% of the PTCR + PTCA group (p = NS). 3. The incidence of acute coronary reocclusion was higher in the PTCR + PTCA group than in the direct PTCA group (7.4% vs 22%; p less than 0.05). 4. Angiographic haziness at the dilated site following PTCA was seen more frequently in patients in the PTCR + PTCA group than in those of the direct PTCA group (43% vs 23%; p less than 0.05). 5. Patients with haziness at the dilated site had a significantly higher incidence of acute coronary reocclusion than did the patients without such haziness (28% vs 6.3%; p less than 0.05). 6. Left ventricular ejection fraction and regional wall motion were better preserved in the direct PTCA group than in the PTCR + PTCA group, but there was not statistical significance. It was suggested that direct PTCA is safe and can be performed with good success rates. It is superior to PTCR + PTCA in avoiding acute coronary reocclusion, and thus we supposed that the response of lesions to angioplasty may be altered by the administration of thrombolytic agents.

Studies on efficacy and safety of aspoxicillin (ASPC) were carried out to 14 cases of pediatric infections, and the following results were obtained. Clinical efficacy of ASPC to 10 respiratory infections, 1 urinary tract infection and 1 otitis media was excellent in 6 cases (50%) and good in 6 cases (50%). The efficacy rate was 100%. Bacteriological effect of ASPC to 6 cases which detected the causative organisms (S. aureus, E. faecalis, H. influenzae and P. mirabilis) was eliminate in 3 cases (50%) and replace in 3 cases (50%). The bacterial eliminated rate was 100%. Side effects of ASPC to 14 administered cases were observed in 2 cases, that were urticaria in 1 case and elevation of GOT in 1 case. From the above results, it was concluded that ASPC was the useful and secure antibiotic drug for treatment of infections in pediatric field.