Search

Chronic periodontitis is a silent infectious disease prevalent worldwide and affects lifestyle-related diseases. Therefore, efficient screening of patients is essential for general health. This study was performed to evaluate prospectively the diagnostic utility of a blood IgG antibody titer test against periodontal pathogens. Oral examination was performed, and IgG titers against periodontal pathogens were measured by ELISA in 1,387 individuals. The cut-off value of the IgG titer was determined in receiver operating characteristic curve analysis, and changes in periodontal clinical parameters and IgG titers by periodontal treatment were evaluated. The relationships between IgG titers and severity of periodontitis were analyzed. The best cut-off value of IgG titer against Porphyromonas gingivalis for screening periodontitis was 1.682. Both clinical parameters and IgG titers decreased significantly under periodontal treatment. IgG titers of periodontitis patients were significantly higher than those of healthy controls, especially in those with sites of probing pocket depth over 4 mm. Multiplied cut-off values were useful to select patients with severe periodontitis. A blood IgG antibody titer test for Porphyromonas gingivalis is useful to screen hitherto chronic periodontitis patients (ClinicalTrials.gov number NCT01658475).

Background Colonoscopic and clinical differences between primary ileocolonic mucosa-associated lymphoid tissue (MALT) lymphoma and mantle cell lymphoma (MCL) have not been defined. Methods We reviewed colonoscopic and clinical features in eight patients with primary MALT lymphoma and eight patients with MCL in the terminal ileum and/or colorectum. All cases were examined for CD5 and/or cyclin D1 expression. Results Endoscopic features of MALT lymphoma were characterized as protrusions that were covered with normal-appearing mucosa with or without ulceration. The gross appearances of MALT lymphomas were categorized as solitary (4 patients), multiple (3 patients), and multiple lymphomatous polyposis (MLP) (1 patient). The gross features of MCL at endoscopy were categorized as multiple protrusions (2 patients), and MLP (6 patients). The clinical stages of patients with MCL were more advanced than in patients with MALT lymphoma. Conclusions Solitary or multiple protrusions at an early clinical stage is the most common presentation pattern of patients with MALT lymphoma, but an MLP appearance at an early stage is also possible. On the other hand, MLP appearance with an advanced clinical stage is the main presentation pattern in patients with MCL, although multiple protrusions with an early clinical stage is also possible. Histological and immunohistochemical investigation including that of cyclin D1 and CD5 expression is essential to make the final diagnosis.

Nicotine is responsible for smoking dependence and is mainly metabolised by CYP2A6. Several types of genetic polymorphism of CYP2A6 have been reported, but their relation to smoking habit and chronic obstructive pulmonary disease (COPD) phenotypes has not been fully clarified.203 current or ex-smokers (lifelong cigarette consumption (CC)/=10 pack years) with subclinical and established COPD phenotypes were clinically evaluated and pulmonary function tests and a chest CT scan were performed (smoker group). The non-smoker group consisted of 123 healthy volunteers. CYP2A6 genotypes were determined in both groups.The percentage of subjects with a CYP2A6del allele (genotype D) was lower in heavy smokers (20.5%, n=88, CC/=60 pack years) than in light smokers (37.4%, n=115, CC 10-59 pack years, chi(2)=6.8, p=0.01) or non-smokers (36.1%, n=122, chi(2)=6.0, p=0.01); lower in ex-smokers (20.7%, n=111) than in current smokers (41.3%, n=92, chi(2)=10.1, p0.01); and lower in smokers with a high LAA (low attenuation area) score on the chest CT scan (18.4%, n=76, LAA/=8.0) than in those with a low LAA score (37.0%, n=127, LAA8.0, chi(2)=7.8, p0.01).Subjects with the CYP2A6del allele tend not to be heavy habitual smokers but can be light habitual smokers. The CYP2A6del polymorphism may inhibit smokers from giving up smoking, but appears to function as a protective factor against the development of pulmonary emphysema independent of smoking habit.

We recorded full-field pattern seversal electroretinograms (PERGs) and visual evoked potentials (PVEPs) simultaneously in 15 migraine with aura, 14 migraine without aura patients during the interictal period, and in 23 sex- and age-matched normal subjects. All subjects had normal visual fields. The visual aura in all patients was hemianopsia or fortification spectra. Neither migraine group showed significant differences from normal in latency and amplitude of PERGs. In migraine with aura, the amplitudes of PVEPs in classic migraine at the mid-occipital electrode were significantly ( p

Objective: Vitamin K is known to influence bone metabolism by facilitating the synthesis of osteocalcin (BGP). The bone mineral density decreases drastically after menopause. We investigated the relationship of bone mineral density, vitamin K levels and other biological parameters of bone metabolism in post-menopausal women. Methods: Serum levels of vitamin K, BGP and other markers of bone metabolism were measured in 71 post-menopausal women (19 with reduced bone mineral density and 52 with normal bone density), and 24 women with climacteric symptoms receiving hormone replacement therapy (HRT), (6 with reduced bone mineral density and 18 with normal density). Results: In the first group, women with reduced bone mineral density showed lower levels of vitamin K1 and K2 than those with normal bone mineral density. In the other group, the level of BGP decreased but levels of vitamin K showed no increase during HRT. Conclusion: The present findings suggested that vitamin K was related to post-menopausal bone mineral loss.

The ligand for CD40 (CD40L) is a membrane protein on activated T cells that induces B cell proliferation and differentiation. Several mutations of the CD40L gene were reported responsible for defective class switching of B cells in an X-linked immunodeficiency with hyper IgM (X-HIM). We studied four affected males from three families and found three independent mutations including new mutations of CD40L gene. In every X-HIM patient tested, however, anti-CD40 plus IL-10 did not induce class switching from IgM to IgG or IgA, even in the presence of Staphylococcus aureus Cowan I strain (SAC). CD4+ T cell clones, expressing CD40L on their surface, also did not rescue IgG or IgA induction by X-HIM peripheral blood B cells in vitro. But signaling through CD40 induced both B cell proliferation and IgE secretion when IL-4 was added to the culture. Taken together, these results show that in vitro signaling through CD40 rescues IgE but not IgG or IgA secretion by peripheral blood X-HIM B cells and suggest that in vivo CD40 and CD40L interaction might be necessary for IgG and IgA differentiation in X-HIM.

Montelukast, a cysteinyl leukotriene receptor 1 antagonist, is safe and efficacious in patients with asthma. The mechanisms underlying the significant interpatient variability in response to montelukast are not clear but are believed to be, in part, because of genetic variability.To examine the associations between polymorphisms in candidate genes in the leukotriene pathway and outcomes in patients with asthma on montelukast for 4-8 weeks, we evaluated the changes in peak expiratory flow (PEF), forced expiratory volume in 1 s (FEV(1·0) ) and patients' subjective symptom before and after montelukast treatment. DNA was collected from 252 Japanese participants.Two single-nucleotide polymorphisms (SNPs) in the ALOX5 (rs2115819) and LTA4H (rs2660845) genes were successfully typed. There was no difference between members of the general population (n = 200) and patients (n = 52) in each genotype frequency. Significant associations were found between SNP genotypes in the LTA4H gene and changes in PEF and FEV(1·0) . The PEF and FEV(1·0) responses to montelukast in the A/A genotypes (n = 4) for the LTA4H SNP were significantly higher than those in the G allele carriers (A/G+G/G) (n = 17).Despite the small sample size, our results suggest that genetic variation in leukotriene pathway candidate genes contributes to variability in clinical responses to montelukast in Japanese patients with asthma.

The concentrations of tissue plasminogen activator (t-PA) and urokinase (UK) were measured in the plasma of patients with benign or malignant ovarian and uterine tumors. Plasma levels of t-PA were higher in patients with malignant ovarian and uterine tumors than in patients with benign tumors. Plasma UK levels were, however, not different between patients with ovarian and uterine tumors (benign or malignant) and normal persons. The concentrations of t-PA and UK of tissues of uterine myoma were lower than those in normal uterine muscular layer. UK levels of tissues of endometrial and cervical cancers were significantly higher than those in normal endometrium and uterine cervix, whereas t-PA levels were not different between these tumors compared with those in normal uterine tissues.

A 24-year-old woman with Graves' disease treated with methimazole for 4 years, developed recalcitrant ulcers on the lower legs. Histological studies demonstrated vasculitis in deep dermal vessels accompanied by C3 deposition. Laboratory investigation revealed lupus-like abnormalities (leucocytopenia, positive antinuclear and antidouble strand (ds) DNA antibodies, and positive ANCA). The leg ulcers dramatically improved after methimazole was withdrawn. In addition, leucocytopenia and the immunological abnormalities soon faded. Although lupus-like syndrome is well known to be induced by antithyroid drugs, vasculitis is a rare complication. To the best of our knowledge, this is the first report describing ANCA-associated vasculitis caused by methimazole.

This phase II study investigated the efficacy, tolerability and dose-response relationship of oral zolmitriptan in the treatment of a single migraine attack in Japanese patients. A bridging analysis then assessed the validity of extrapolating western clinical data to these Japanese patients. In this multicentre, randomized, double-blind, placebo-controlled study, patients received a single dose of placebo or zolmitriptan 1, 2.5 or 5 mg. The primary endpoints were 2-h headache response and the tolerability of zolmitriptan. A statistically significant dose-response relationship was observed for the 2-h headache response ( P = 0.003). The 2.5 mg group had significantly greater 2-h headache response than the placebo group ( P = 0.032). The adverse event profile was similar to that reported in western patients, and no adverse events unique to the Japanese population were observed. The bridging analysis report confirmed similar efficacy and tolerability of zolmitriptan in Japanese and western populations. In the Japanese patients, the estimated response rates were 34.3%, 45.2%, 57.7% and 66.2% for placebo, and zolmitriptan 1, 2.5 and 5 mg, respectively, while in the western population the corresponding rates were 39.9%, 49.6%, 61.2% and 71.7%. Zolmitriptan is effective and well tolerated in the acute treatment of migraine in Japanese patients. The optimal dose was 2.5 mg, although the 5 mg dose may provide further benefit for some patients. The bridging analysis supports extrapolation of data from western to Japanese patients.

We experienced a case of 62-year-old woman who was admitted for the evaluation of her trembling hands. She was diagnosed as Williams syndrome (WS) by fluorescent in situ hybridization (FISH) analysis. She was short in stature, had a characteristic face and moderate mental retardation, whereas she was talkative and gregarious. She also presented impaired visuospatial cognition, cerebellar ataxia and tremor like involuntary movement of the hands. No remarkable abnormality is noted in MRI of the brain. MRA study of the brain revealed the arteriosclerotic vascular change, such as elongation of basilar artery and dilatation of bilateral carotid arteries. Heterozygous microdeletion of chromosome 7q11.23 of this patient is typical for WS, the delction including elastin (ELN) and LIMK 1 gene. Although she was complicated by diabetes mellitus and hyperlipidemia, she had no cardiovascular abnormalities like supravalvular aortic stenosis (SVAS), and survived to her age in good condition. The tremor-like involuntary movement disappeared after her discharge and its mechanism remains to be elucidated.

A 39-year old woman was admitted to our hospital because of cough and abnormal shadows on chest radiographs. She had been treated for 5 months for acne vulgaris with minocycline hydrochloride (MINO). Chest computed tomographic (CT) scans showed multiple ring-shaped opacities in both lungs. Bronchoalveolar lavage disclosed an increase in the total number of cells and a marked increase of lymphocytes. A lung specimen obtained by transbronchial lung biopsy (TBLB) was pathologically diagnosed as bronchiolitis obliterans organizing pneumonia (BOOP). Withdrawal of minocycline led to rapid remission without treatment. The clinical course and histological findings for TBLB suggested that this case was minocycline-induced BOOP. Several cases with minocycline-induced pneumonitis have been reported. However, there are few reported cases of minocycline-induced BOOP, the present case being only the second found in the literature.

We have been investigating the mechanism of remnant liver dysfunction after extensive hepatectomy in a canine model since 1990. This study focused on the role of heat shock protein and hepatocyte apoptosis.Adult mongrel dogs were randomly divided into 3 groups: Group 1, sham operation; Group 2, 70% hepatectomy; and Group 3, 84% hepatectomy. Heat shock protein and hepatocyte apoptosis after hepatectomy were examined by using isolated hepatocytes and Kupffer cells.Heat shock protein significantly increased in Groups 2 and 3, but rose much higher in Group 3. Examination of pure hepatocyte culture showed no apoptosis in Group 2, but significant apoptosis occurred in Group 3. In co-cultures of hepatocytes and Kupffer cells, induction of apoptosis in Group 2 was mild, but it increased earlier and reached very high levels in Group 3. The TNF-alpha level in co-culture supernatant was significantly higher in Group 3 than Group 2.After extensive (84%) hepatectomy, apoptosis signal transduction predominates over anti-apoptosis signal transduction, despite high expression of heat shock protein in the remnant liver. Accordingly, the cytotoxic mechanism overcomes the cytoprotective mechanism, leading to significant induction of hepatocyte apoptosis and severe liver damage.

To investigate the correlation of the cerebral white matter hyperintensities (WMH) on MRI, and latency and amplitude of visual evoked potentials (VEPs) in elderly subjects.Pattern VEP (PVEP) and flash VEP (FVEP) were recorded in 25 patients with WMH consisting of 12 patients with frontal dominant WMH (FMH) and 13 patients with occipital dominant WMH (OMH) and 25 patients with basal ganglionic hyperintensities (BGH).In WMHs, there were significantly larger P100 and P2 amplitudes than in BGHs and controls. Regarding the distribution of WMH, OMH showed significantly larger P100 amplitudes than FMH. In OMH in males, there was significantly prolonged P100 latency compared with females, and in females, there were significantly larger P100 and P2 amplitudes compared with males.Appropriate clinical values in VEP should take into consideration WMH in addition to gender and age-related changes.

The cell kinetics and homeostasis of biliary epithelial cells may be maintained differently along the biliary tree. In this study, the role of apoptosis in the maintenance and homeostasis of the intrahepatic biliary tree was evaluated.By counting apoptotic biliary cells and by immunostaining apoptosis-related proteins in normal liver, fatty liver, and those with acute viral hepatitis, chronic viral hepatitis, and hepatitis virus-related cirrhosis, it was found that the larger the intrahepatic bile ducts became, the more biliary epithelial cells underwent apoptosis. bcl-2, an inhibitor of apoptosis, was diffusely expressed in the interlobular bile ducts, but rarely detectable in the large and septal bile ducts. bcl-XL and mcl-1, inhibitors of apoptosis, and bax, a promoter of apoptosis, were diffusely expressed along the intrahepatic biliary tree. CD95, a direct inducer of apoptosis, was present in the large and septal bile ducts, but rarely in the interlobular bile ducts.The ratio of bax to bcl-2, as well as the expression of CD95 which differed at the interlobular versus large and septal bile ducts, may be responsible for the unique distribution of apoptotic biliary cells and involved in the homeostasis of the intrahepatic biliary tree.

We explored the prognosis for 123 patients with either idiopathic interstitial pneumonia (IIP) or bronchiolitis obliterans organizing pneumonia (BOOP). All patients underwent either open lung biopsy or thoracoscopic lung biopsy procedures. The histopathologic diagnosis of IIP included patients with usual interstitial pneumonia (UIP), nonspecific interstitial pneumonia (NSIP), and desquamative interstitial pneumonia with respiratory bronchiolitis-associated interstitial lung disease. The prognosis was poorest for patients with a histologic diagnosis of UIP, and excellent for those who received a diagnosis of BOOP. Although the prognosis is generally considered to be good for patients with NSIP, some NSIP patients in our study died. Histopathologic diagnosis based on surgical lung biopsy is useful in evaluating the prognosis for patients with IIP.

A 16-year-old girl developed acute left choreic movements during her fourth week of pregnancy. She had sometimes had transient ischemic attacks since she was 10 years old. During the eighth week of pregnancy, a brain MRI showed old ischemic lesions deep in the right frontal white matter. Her angiograph revealed a complete obstruction of the terminal portion of the right internal carotid artery with a developed moyamoya net work. After her abortion, all involuntary movements completely subsided. The choreic movements might have been caused not only by ischemia, but also by enhanced dopaminergic sensitivity mediated by elevations in female sex hormones due to pregnancy.

Apoptosis, including the Fas system, has been implicated in progressive bile duct loss in primary biliary cirrhosis (PBC). In this study, we attempted to analyze Fas ligand (FasL) expressing mononuclear cells infiltrating in the portal tracts of PBC.We immunohistochemically assessed co-expression of leukocyte markers and FasL on infiltrating mononuclear cells in 18 patients with PBC. Twenty-five patients with chronic hepatitis C (CH-C) were used as controls.In PBC, FasL expressing cells were scattered in the portal tracts, and some were accentuated around the damaged bile ducts. In addition, these cells co-expressed CD68 (71%), a marker of monocytes, but not UCHL-1, CD3 and CD57, markers of activated T cells and natural killer cells. By contrast, in CH-C, the biliocentric pattern of FasL expression was not evident, and about half of FasL expressing cells (42-56%) co-expressed UCHL-1, CD3 or CD57. CD14, a receptor for bacterial products such as lipopolysaccharides, was also detected on a proportion of FasL expressing mononuclear cells around the damaged bile ducts in PBC.The results suggest that in PBC, FasL expressing CD68+ monocytes are at least partly involved in apoptotic bile duct loss mediated by the Fas system, and a surface molecule, CD14, participates in this process.

To investigate the role of sinusoidal endothelial cells in the mechanism of the remnant liver dysfunction after extensive hepatectomy, morphological alteration of sinusoidal endothelial cells and cytoprotective effects of prostaglandin I2 analog were studied by ultrastructural analysis.Mongrel dogs (n = 24) were divided into 3 groups according to the extent of hepatectomy and the use of prostaglandin I2 analog preoperatively. Group 1: 70% hepatectomy (n = 8), Group 2: 84% hepatectomy (n = 8), and Group 3: 84% hepatectomy with administration of prostaglandin I2 analog, preoperatively (n = 8). Morphology of hepatic sinusoidal endothelial cells was examined after hepatectomy in all cases.Group 2: Enlargement of the sinusoidal endothelial fenestrations was transitorily occurred immediately after hepatectomy, but were dramatically decreased in size 24 h after the operation. Most sinusoidal endothelial cells were destroyed and separated from the sinusoidal wall. Fibrin deposits and sludge were found in the Disse's space and sinusoidal lumens, resembling liver failure at 24 h after the operation. Group 1 and 3: sinusoidal endothelial fenestrations remained slightly enlarged at 24 h after the operation, but fibrin deposits or sludge were not observed in sinusoidal lumens.Our data suggest that extensive hepatectomy changed the morphology of sinusoidal endothelial cells. Administration of prostaglandin I2 analog helped maintain structural integrity of sinusoidal endothelial cells, improved hepatic microcirculation and thus served to reduce remnant liver dysfunction.

Pioglitazone is the second thiazolidinedione derivative to be clinically used for type 2 diabetes in Japan. It is ten times more potent than troglitazone in glucose-lowering effect. Favourable effects against abnormal lipid levels including decreasing blood triglyceride levels, free fatty acid levels and increasing HDL-cholesterol is advantage to treat obese diabetic patient who may develop atherosclerosis. Up to now, there has been no report of severe hepatic dysfunction due to pioglitazone treatment. Pioglitazone should be carefully monitored in its clinical treatment regarding possible its side effect of hepatic dysfunction.

A 67-year-old woman developed severe sicca manifestations after initial treatment of Parkinson's disease with an anti-cholinergic drug, which prompted us to look for the presence of Sjögren's syndrome. The results of sialography, labial salivary gland biopsy, Rose-Bengal test as well as the presence of antinuclear antibody were consistent with the diagnosis of Sjögren's syndrome. The sicca symptoms diminished by cessation of the anti-cholinergic drug, and the parkinsonian features were controlled by levodopa. We suggest that Sjögren's syndrome should be considered, if patients with Parkinson's disease complain severe xerostomia.

A 62-year-old woman was admitted because of a tumor on her right thigh, fever, generalized lymphadenopathy, and diffuse nodular shadows on chest X-ray films. She was given a diagnosis of miliary tuberculosis based on the findings of a cervical lymph-node biopsy and a broncho-alveolar lavage. Acute respiratory failure and disseminated intravascular coagulation developed, but resolved after the start of anti-tuberculous therapy. The tumor on the right thigh was diagnosed as a subcutaneous tuberculous abscess because tuberculous bacilli were detected in tumor tissue samples obtained by aspiration. The patient's fever disappeared and the abnormal shadows on her chest X-ray films receded significantly after drainage of the subcutaneous abscess. These findings suggested that miliary tuberculosis was associated with the subcutaneous tuberculous abscess in this case.

Pattern reversal visual evoked potentials (PVEPs) were recorded in 20 patients with migraine with aura (MA), 19 patients with migraine without headache (migraine equivalent; ME) during interictal periods, and 34 normal subjects. All migraine patients had hemianopsia or fortification spectra during attacks. In both MA and ME patients of less than 49 years of age, there were significant ( p

We report a 62-year-old woman who was admitted to our hospital because of abrupt onset of ptosis, and alternating and recurrent bilateral external ophthalmoplegia in a short period without pupillary sphincter muscle abnormality. She had been suffering from uveitis of unknown origin for four years before admission, which was improved with the local administration of steroid. Her brain CT and MRI showed a parasellar mass lesion, and cerebral angiography revealed total occlusion of the right internal carotid artery with little arteriosclerotic change in other blood vessels. She was diagnosed as having sarcoidosis because of elevated serum creatinine kinase and lysozyme levels, and the pathological finding of granuloma in muscle biopsy. The oral administration of prednisolone resulted in disappearance of her external ophthalmoplegia completely in ten months. We postulate that in this patient, the alternating and recurrent external ophthalmoplegia in a short period was related to ischemic neuropathy caused by vascular lesion of neurosarcoidosis.

We report a patient who underwent a resection of the right lateral frontal lobe after a venous thrombosis of the superior sagittal sinus. The patient showed inertia, obsessive-compulsive behavior and disinhibition two weeks after the operation and hyperlogia and hypergraphia four weeks later, all of which disappeared within six weeks. General intelligence, language and memory were consistently preserved, though the scores of the performance IQ and the visual memory were relatively decreased. A few months after the operation emotional and personality change such as impatience and apathy became evident. We suggest that the right lateral prefrontal area is concerned with personality and behavior and that the widespread resection holds general intelligence, language and memory within normal range but relatively decreases non-verbal cognitive function that requires manual responses.

Regarding the changing trends in the concept, definition, etiological classification, and criteria for diagnosis of amblyopia, we reviewed a total of 4,693 cases of amblyopia seen during the past 37 years. The amblyopia was divided into four types: strabismic, anisometropic, ametropic, and form vision deprivative. There was a definite trend for the incidence to decrease and for the diagnosis to be made during earlier age in recent years. Although favorable recovery of visual acuity is obtained after treatment of amblyopia and strabismus, there are difficulties in obtaining good binocular functions in early-onset amblyopia and strabismus. This feature was evaluated in regard to motion perception asymmetry (MPA) and binocular depth from motion (DFM). Many cases of early-onset amblyopia and strabismus showed no disparity stereopsis, or position stereopsis, in spite of the presence of DFM. The MPA appeared to be closely related to early-onset esotropia regardless of age, while it disappeared and motion perception became symmetric 4 to 5 months after birth in normal infants. The DFM seemed to play an important role in maintaining good motor alignment for several years after surgery. I developed a checkerboard pattern stimulator in 1978. This method proved to be useful in developing binocular functions and motor alignment by applying simultaneous bifoveolar stimulation and anti-suppression. Extensive exposure to the stimulation was essential for therapeutic success.

We encountered three cases of thymic hyperplasia associated with hyperthyroidism. Case 1 was in a 35-year-old woman; a chest CT scan showed an anterior mediastinal mass and right-sided pleural effusion, which suggested the presence of a thymoma Case 2 was in a 21-year-old man who complained of palpebral ptosis and also had myasthenia gravis (Osserman type I). Case 3 was in a 47-year-old woman; a chest CT scan showed thymic hyperplasia and mediastinal lymphadenopathy. In all cases, anti-thyroid medication was given first, because of the associations with hyperthyroidism. Moreover, in cases 1 and 2 no tumor was found, and only hyperplasia was detected in the thymus, although both patients underwent extended thymectomy. Furthermore, surgery was not effective against the hyperthyroidism (anti-thyroid medication could not be withdrawn or reduced). In cases 2 and 3, thymic hyperplasia, as seen on chest CT scans, resolved as thyroid function was normalized by anti-thyroid medication. The pretracheal lymphadenopathy seen in case 3 also resolved. Thymic hyperplasia may have been a result, not a cause, of hyperthyroidism. When we encounter patients with thymic masses and hyperthyroidism, we should give anti-thyroid medication and observe the thymus for some time before resorting to surgery.

A 66-year-old woman was admitted to our hospital because of abrupt onset of left hemiparesis and confusional state. Ten hours prior to admission, she developed difficulty in left hand movement, and her family noticed cloudiness of consciousness and gait disturbance. Neurological examination revealed only a hollow hand sign of the left hand without other neurological deficits. Cranial CT showed a low density area in the right superior parietal region, and the follow up CT on 6th hospital day exhibited contrast enhancement and hemorrhagic transformation in this area. Cerebral angiography demonstrated capillary blush and early venous filling in the right posterior parietal region. Transesophageal color-coded Doppler echocardiography (TEE-CD) showed a shunt flow via patent foramen ovale (PFO). Thus, we diagnosed this case as paradoxical cerebral embolism through PFO, which is characterized by rapid recovery of clinical manifestation, so-called spectacular shrinking deficit. Even in elderly patients with embolic stroke of unknown origin, TEE-CD should be performed to investigate PFO.

Sleep apnea with neuromuscular disorders has been successfully treated with bi-level positive airway pressure ventilation (BiPAP), which, unlike continuous positive airway pressure ventilation (CPAP), creates pressure difference between expiratory and inspiratory phases. Hence if the respiration of patients stops longer than a pre-set duration, BiPAP can automatically force them to breath through a nasal mask. We report a 60-year-old woman with olivo-ponto-cerebellar atrophy (OPCA), whose mixed-type sleep apnea was difficult to treat with conventional CPAP. We therefore tried BiPAP on this patient at night. Nocturnal CO2 retention was nearly resolved, and unexpectedly daytime PaCO2 was also corrected with marked improvement of daytime somnolence. BiPAP is totally non-invasive, and may be one of the most effective treatments in patients with OPCA suffering from sleep apnea.

We report a 79-year-old woman with basilar artery occlusion. She had a sudden onset of tetraplegia and disturbed consciousness, and within four days from the onset she showed a varied, fluctuating eye symptoms. On admission, she showed ocular bobbing, skew deviation with the right eye lower-positioned, upward gaze palsy, one-and-a-half syndrome, and paralytic pontine exotropia (PPE). On the third day after the onset, she showed wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) syndrome, and on the fourth day, she showed one-and-a-half syndrome again. Her right-gaze palsy improved repeatedly, and on the 19th day from the onset, only right MLF syndrome remained. Her eye symptoms fluctuated probably according to the distal migration of emboli, there by the responsible lesion and the mechanism of these eye symptoms are considered to be closely inter-correlated. On the fourth day after onset, the magnetic resonance imaging revealed cerebral infarctions in bilateral middle pons, the left paramedian lower pons, and the right paramedian midbrain, and a hemorrhagic infarction in the right inferior cerebellar hemisphere. We believe that that the eye symptoms of this patient were caused by lesions in the paramedian midbrain or pons.

We studied clinicopathological characteristics of interstitial pneumonia associated with amyopathic dermatomyositis. The subjects comprised two men and three women, and their mean age was 58.2 years. All subjects had cruptions specific for dermatomyositis, but had no signs of myositis. They all presented with acutely or subacutely developed coughing and dyspnea. Results of tests for anti-Jo-1 antibody were negative in all cases. Chest X-ray films showed infiltrations or streaky shadows, or both in the middle and lower lung fields. Analysis of bronchoalveolar lavage fluid revealed abnormally high percentages of lymphocytes and neutrophils. In one patients a specimen obtained by open lung biopsy showed homogeneous cell infiltrations in alveolar septa and regional alveolar damage. That patient was successfully treated with cyclosporin and corticosteroids in early phase of the disease. The other four patients received immunosuppressive agents after respiratory failure developed. All four died despite having received high-dose corticosteroid and immunosuppressive therapy. Examination of autopsy specimens showed diffuse alveolar damage.

Pattern reversal visual evoked potentials (PVEPs) to transient checkerboard were recorded in 19 patients with migraine with visual aura (i.e., classic migraine), 14 patients with migraine without aura (i.e., common migraine) in the interictal period and 43 normal subjects. Latencies and amplitudes of PVEPs in each group were analyzed. In classic migraine patients, P100 amplitude was significantly higher than in normal subjects (p < 0.01), whereas latencies of PVEPs did not significantly differ. There were no significant differences between the common migraine and normal subjects, nor within the classic and common migraine groups in latencies and amplitudes of PVEP. Four patients with classic migraine underwent PVEPs during or 1–2 h immediately after their migraine attacks. Two of these patients who underwent PVEPs 1.5–2 h after their attacks showed abnormally increased PVEP amplitudes. These results suggest that there are different pathophysiologies in the visual pathway between classic and common migraine and furthermore, classic migraine patients in interictal periods may have hyperexcitability in the visual pathway and that the increased amplitude of PVEPs after attacks may be due to cortical spreading depression. © 1997 Elsevier Science B.V. All rights reserved.

The aim of this study is to evaluate the accuracy of three-step diagnosis in discriminating subtypes of acute ischemic stroke. A total of 120 consecutive patients with first-ever ischemic stroke, admitted to one general hospital, were prospectively studied. In the first step (within 24 hours of clinical onset), the first diagnosis was made according to clinical symptoms and signs, and patients were subdivided into four groups according to the classification of Oxfordshire Community Stroke Project: lacunar infarcts (LACI), total anterior circulation infarcts (TACI), partial anterior circulation infarcts (PACI), and posterior circulation infarcts (POCI). In the second step (24 hours to 72 hours from the onset), neuroimaging diagnosis was performed by CT and/or MRI. Four lesion sites were classified: 1) small subcortical infarctionor = 1.5 cm in diameter in the perforating artery territory (SSI), 2) supratentorial cortical or striatocapsular infarction (CI), 3) low-flow infarction (LFI) which includes centrum semiovale infarct and internal junctional infarct, and 4) posterior circulation infarction other than SSI (PI). In the third step, etiological diagnosis was made by examination including trans-thoracic echocardiography and MRA (3-D, PC). In accordance with the TOAST Study, the presumed stroke mechanism was categorized as either small-vessel occlusion (lacune), cardioembolism (CE), large-artery atherosclerosis (LAA), or others. The majority of patients with TACI, PACI or POCI showed the corresponding lesions on CT or MRI, while only 69% of LACI patients demonstrated SSI. Seventy-five percent of patients with TACI were categorized as CE in the third diagnosis, while the etiology of the patients with PACI was either CE or LAA in equal numbers. Only 60% of LACI patients were classified as lacune and 21% of them as LAA. Patients with LACI but classified as LAA usually had atypical clinical symptoms (e.g. monoparesis) and lesions other than SSI. The positive predictive value (PPV) of lacune in the combination of LACI and SSI was 0.75. Eighty-two percent of patients with CE had atrial fibrillation (af), which was the most frequent cardioembolic source. When patients with TACI or PACI had af, the PPV of CE was 0.93, but when they did not, the PPV of LAA was only 0.68. The etiology of POCI was variable. In conclusion, the agreement of the three-step diagnosis is considerable, but more rigorous clinical examination is needed for some clinical groups (POCI and LACI) and the etiological diagnosis of LAA.

Miller Fisher syndrome (FS) is thought to be a variant of Gullain-Barré syndrome (GBS), both of which rarely relapse. We report a rare case of GBS that followed FS. A 38-year-old woman had ophthalmoplegia, ataxia and areflexia following an upper respiratory tract infection with a diagnosis of FS. Serum anti-GQ1b IgG antibody was found to be increased, but decreased through immunoadsorption as the neurological symptoms of the patient improved. She became completely asymptomatic three months after the onset of FS. Following a common cold two months later, however, she developed weakness of all four limbs and dysesthesia of hands and feet with albuminocytologic dissociation of cerebrospinal fluid, which was consistent with the diagnosis of GBS. Moreover, serum anti-GQ1b IgG antibody had increased again. Anti-GQ1b IgG antibody frequently becomes positive not only in FS but also GBS with ophthalmoplegia. However, the antibody was positive in this particular patient with GBS, even in the absence of ophthalmoplegia. This case suggests that anti-GQ1b IgG antibody might be a common pathogenesis of both FS and GBS.

A 66-year-old woman was admitted to the hospital because of general malaise and loss of appetite. Laboratory examination revealed an abnormally high level of CA19-9 in serum and a chest roentgenogram revealed soft reticular shadows in the right mid-lung field. An extensive examination revealed no malignant disease. Bronchoalveolar lavage fluid obtained from the right B5 contained an abnormally high level of CA19-9. Immunochemical staining for CA19-9 was positive in the epithelial cells of respiratory bronchioles. The level of CA19-9 decreased during anti-tuberculosis therapy. This case suggests that the CA19-9 level can reflect the activity of pulmonary tuberculosis.

Recent epidemiological studies have suggested that 15 to 30% of all ischemic stroke is comprised of cardioembolic stroke. The presence of intracardiac thrombi might prove to be the most reliable tool when making a diagnosis of cardioembolic stroke, although not always easy to determine even with recent advanced technique. In this study, sensitivities to detect intracardiac thrombi of transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), cardiac-enhanced CT (CCT) and scintigraphy with indium-111-tropolone-labelled platelets (PSG) were compared, in order to provide a relevant guideline for the diagnosis of intracardiac thrombi in 83 patients suspected of cardioembolic stroke. Also studied was the correlation of intracardiac thrombi with activation of platelets and coagulation-fibrinolysis through performing various hemostatic tests in order to investigate their utility for the evaluation of in situ thrombosis or prothrombotic state in the heart chamber. Detection rates of intracardiac thrombi were 35% in TEE, 26% in CCT, 19% in PSG, and 11% in TTE. There was a significant difference in the sensitivity between TEE and TTE (p0.05). Left atrial thrombi were frequently detected in TEE (4 out of 5 patients) and CCT (7 out of 10), while they were found less in PSG (2 out of 4) an TTE (4 out of 10). Thrombi in the left appendage were visualized in 3 out of 3 by TEE, while only in 1 out of 3 by PSG, 1 out of 4 by TTE and 1 out of 4 by CCT. Left ventricular thrombi; CCT (3 out of 3), TTE (2 out of 3), PSG (1 out of 1); TEE was not performed since this technique could not be expected to provide high-quality images of left ventricular thrombi. Thus, left atrial thrombi were considered to be more sensitively detected by TEE and CCT, left appendage thrombi by TEE, and left ventricular thrombi by TTE and CCT. There was no patient in whom an intracardiac thrombus was visualized by PSG alone. On the basis of the results above, we propose the following guideline for the detection of intracardiac thrombi in patients presented with cardioembolic stroke. First, TTE and CCT appear to be relevant for screening tests because of simple and non-invasive techniques. These two tools might be sensitive enough to find left ventricular thrombi. Second, TEE should be recommended when a thrombus is suspected in the left atrium or appendage. Finally, PSG may be used to determine the activity of the thrombus, according to its necessity. Among the patients having intracardiac thrombi, frequently observed was the increase of beta-thromboglobulin, platelet factor 4, platelet lysis, thrombin-antithrombin III complex, D-dimer in 67%, 75%, 71%, 80% and 80%, respectively, as well as the shortening of platelet survival in 100%, while anrithrombin III was reduced in only 38%. In addition, when hemostatic abnormalities were compared between positive and negative groups of intracardiac thrombi, the shortening of platelet survival (p0.0001), the increase of platelet lysis, and the increase of D-dimer (p0.04) were more frequent in the positive group than in the negative group. These results indicate that the findings of activation of platelets and coagulation-fibrinolysis, except for the reduction of antithrombin III, especially the findings of platelet consumption and lysis as well as fibrinolysis activation are useful as sensitive parameters of in situ thrombosis or prothrombotic state, which may lead to the formation of intracardiac thrombi.

We evaluated the incidence of middle lobe syndrome in the Haibara area, and its relationship to atypical mycobacterial infection. Of the 30,588 persons who underwent annual mini-chest roentgenography in 1992 or 1993 or both, 51 (0.17%) had middle lobe syndrome, diagnosed from posteroanterior and lateral chest X-ray films. The incidence was significantly higher in persons over 50 years old than in persons under 50 years old (0.26% vs 0.02%: p0.001), and was higher in femals than in males (0.20% vs 0.11%: p = 0.527). Of 16 patients examined by bronchoscopy and computed tomography, 7 showed evidence of cylindrical bronchiectasis, and four had mycobacterium avium complex pulmonary disease presenting as middle lobe syndrome. All four were women who were 51 years of age or older and none had predisposing pulmonary disorders. Computed tomography showed multiple nodular shadows with or without bronchiectasis located in the middle lobe or the lingula. Cavitary lesions were not seen. These results indicate that middle lobe syndrome is not rare, and that infection with mycobacterium avium complex should be considered when multiple nodular shadows are seen in the middle lobe or the lingula.

We present a 32-year-old Japanese man with psoriatic arthritis who developed recurrent episodes of hypopyon-iridocyclitis associated with exacerbations of the arthropathy.To evaluate the mechanism of the association between psoriasis and uveitis, we analyzed the rheological characteristics of the patient's peripheral blood neutrophils during attacks and during remissions.The rheological activity of neutrophils was determined by the micropore filtration method. It was expressed as micropore filtration time when a neutrophil-erythrocyte suspension passes through a micropore filter (pore size 5 microns).The micropore filtration time in this patient was longer than that of healthy control subjects (p0.01) and of psoriatic patients without uveitis (p0.05); it was also longer during the appearance of the eye disorder with the exacerbation of psoriatic arthritis than during remissions.Activated neutrophils in the peripheral blood of our patient were probably responsible for the attacks of hypopyon-iridocyclitis as well as the exacerbation of psoriatic skin lesions and/or arthritis.

We studied the clinical and immunological characteristics of patients with bronchiolar diseases associated with collagen vascular disease (15 patients with rheumatoid arthritis and 1 primary Sjögren's syndrome). Histological examinations showed that 9 patients had follicular bronchiolitis and 7 had bronchiolitis obliterans. Follicular bronchiolitis was characterized by hyperplasia of bronchus-associated lymphoid tissue, and immunohistochemical studies revealed that the pattern of distribution of T cells and B cells in bronchus-associated lymphoid tissue from patients with follicular bronchiolitis was similar to that in diffuse panbronchiolitis, which may be used as a representative model of chronic respiratory infection. In addition, bacterial cultures of sputum samples were positive in 44% of patients with follicular bronchiolitis and in 71% of patients with bronchiolitis obliterans. These results suggest that antigen stimulation is involved in the development of bronchiolar diseases associated with collagen vascular disease.

Our objective was to evaluate the predictive value of uterine artery Doppler flow velocimetry with regard to a serious risk of adverse perinatal outcome in growth-retarded fetuses. A prospective comparative study of pregnancies complicated with growth-retarded fetus with normal and abnormal uterine artery blood flow was performed. Ninety-three pregnancies were assessed by Doppler flow velocimetry in terms of the resistance index at 27-36 weeks. The relative risks (95% Confidence Interval) in 52 pregnancies with abnormal uterine artery blood flow compared with 41 pregnancies with normal uterine artery blood flow were as follows: Premature delivery: 2.29 (1.32-3.97), birth weight2,000g: 2.94 (1.74-4.97), cesarean section for fetal distress: 2.57 (1.30-5.05), admission to NICU: 3.27 (1.60-6.69). The findings in this study suggest that abnormal uterine artery blood flow is associated with a serious risk of adverse perinatal outcome in a pregnancy complicated with a growth-retarded fetus. Doppler flow velocimetry of the maternal uterine artery is useful for determining the clinical management of a pregnancy complicated with a growth-retarded fetus.

Creutzfeldt-Jakob disease (CJD) is one of the "prion" diseases. MRI has been reported to detect some findings in this disease, particularly high intensity in the basal ganglia on T2WI. We reviewed six cases of CJD, and found additional characteristic findings. Cerebral atrophy was detected in two of six cases, and in one of these two, it progressed markedly during 8 months. No abnormal density or abnormal signal intensity was detected on CT or T1WI of MRI. Cerebral angiography was done in one patient, and no abnormality was detected. High signal intensity on T2WI in the basal ganglia was detected in five of six cases (83%). T2WI showed high signal intensity in the cerebral cortex in four of six cases (67%), and in three cases the temporal cortex was involved. The high signal intensity in the temporal cortex appeared prior to the appearance of abnormal intensity in the basal ganglia in two cases. We conclude that the high signal intensity in the temporal cortex on T2WI is an important sign and can lead to early diagnosis of CJD. We consider that these MR findings may represent a "prion" disease, not only CJD.

To further clarify the significance of renal kininases in patients with Cushing's syndrome, daily urinary excretions of total kininase, kininase I, Ii and neutral endopeptidase 24.11 (NEP) were examined and evaluated for the relations between plasma cortisol level and these kininases. Urinary total kininase kininase I, II and NEP were significantly higher in patients with Cushing's syndrome than in normotensives. There was a significant positive correlation between plasma cortisol level and total kininase or NEP, and the same tendency was observed between plasma cortisol level and kininase I. After adrenalectomy, urinary kininases decreased to normal levels. These findings suggested that: 1) kininase I, II and NEP are accelerated in Cushing's syndrome; 2) glucocorticoids may regulate renal kininases; and 3) accelerated renal kininases may play some role in disorders of the renal water-sodium metabolism and in high blood pressure in Cushing's syndrome.

To elucidate the significance of renal kininases in primary aldosteronism (PA), urinary total kininase, kininase I, II and neutral endopeptidase 24.11 (NEP) were examined and evaluated for the regulation mechanisms of these kininases. Total kininase, kininase I and NEP were significantly higher in PA than in normotensives (NT), whereas no difference was found for kininase II. Moreover, 42% of total kininase consisted of unknown kininase(s), different from kininase I, II or NEP. There were significantly positive correlations between plasma aldosterone concentration and total kininase, kininase I and unknown kininase(s) in PA. After the adrenalectomy, urinary kininases decreased into normal ranges, and unknown kininase(s) were negligible. These findings suggested that: 1) kininase I and NEP are accelerated in PA; 2) unknown kininase(s) differing from kininase I, II or NEP may exist in PA; 3) mineralocorticoids may regulate renal kininases; and 4) accelerated renal kininases may play some role in disorders of the renal water-sodium metabolism and in high blood pressure in PA.

We studied the clinical effectiveness of botulinum toxin type A for spasmodic torticollis and that for facial spasm by multicenter, non-blinded study. The freeze-dried crystalline botulinum toxin type A (AGN 191622; Allergan Inc., Irvine, CA) was injected into the hyperactive muscles and the clinical course was followed for 22 weeks. Repeated injections were done, if necessary, with an interval of 4 weeks. The toxin was highly effective in both disorders. In spasmodic torticollis, clinical severity improved in 38 (63.3%) and the global improvement was seen in 39 (65.0%) out of 60 patients. Subjective improvement was seen in 56 (93.3%). In facial spasm, 52 (92.9%) out of 56 patients improved after the treatment. Unfavorable reactions, mainly consisting of neck muscle weakness and dysphagia in torticollis and facial weakness in facial spasm, were mostly due to the excessive action of the toxin. They were usually mild and transient. No patients discontinued the trial because of side effects. Botulinum toxin injection is a very useful and safe method for the symptomatic treatment of spasmodic torticollis and facial spasm.

The efficacy and safety of video thoracoscopic lung biopsy (VTLB) and of open lung biopsy (OLB) were compared in patients with diffuse lung diseases. Thirty-three patients who had undergone VTLB were retrospectively studied and compared with 67 patients who had undergone OLB. There were no significant differences in age (52.8 +/- 10.9 vs 53.4 +/- 10.3), in the number of biopsies per patient (2.6 +/- 0.6 vs 2.7 +/- 0.6), or in the rate of diagnosis (94% vs 93%) between the two groups. However, the rate of diagnosis was low when the number of VTLB or OLB performed per patient was low. The patients undergoing VTLB had significantly shorter operative times (VTLB, 100.2 +/- 27.2 min. vs OLB, 119.8 +/- 42.6 min; p0.01) and less blood loss (VTLB, 4.7 +/- 14.6 ml vs OLB, 65.7 +/- 77.0 ml; p0.001). Complications occurred in 3 of the 33 who underwent VTLB, and in 18 of the 67 who underwent OLB. These results indicate that VTLB is an effective and safe alternative in the diagnosis of diffuse lung diseases.