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Background Non-surgical treatment has generally been recommended for stage II medication-related osteonecrosis of the jaw (MRONJ) in preference to surgery. However, non-surgical treatment is not empirically effective. The aim of this study was to evaluate whether surgical or non-surgical treatment leads to better outcomes for stage II MRONJ. Material and Methods In this retrospective study, surgery was performed in a total of 28 patients while 24 patients underwent non-surgical treatment. The outcomes of both treatment approaches after 6 months were evaluated and statistically compared. In addition, risk factors for surgical and non-surgical treatments were assessed for each. Results Surgical treatment in 25 patients (89.3%) resulted in success, with failure in 3 patients (10.7%). Non-surgical treatment was successful for 8 patients (33.3%) and failed in 16 patients (66.7%). There was therefore a significant difference between surgical and non-surgical treatment outcomes (P

Rationale: Oral adenosquamous carcinoma (ASC) is rare and its origins are controversial. We here present a patient with oral ASC that developed after surgery for oral squamous cell carcinoma (SCC). Patient concerns: A 70-year-old man with SCC on the oral floor underwent surgical resection. However, the enlarged ulcer presented on the oral floor 9 month after surgery. Diagnoses: The biopsy of the ulcer revealed a SCC. Imaging examinations detected enhancement of a large lesion expanded to the tongue, but no evidence of regional lymph node or distant metastasis was shown. Based on these results, local recurrence of the cancer was diagnosed (cT4aN0M0). Interventions: The surgery for the recurrent tumor was performed. Outcomes: The pathological examination of the surgical specimen indicated recurrent tumor was ASC. Thus, histopathological and immunohistochemical analyses of both the initial SCC and the subsequent ASC were performed in an attempt to explore the origin of the ASC. As the results, pathological review of both tumors suggested the subsequent ASC was developed from the tumor cells with adenoid phenotype in the initial SCC. Lessons: This report suggests that the oral ASC was origin from the oral SCC, which can contribute to new knowledge for pathogenesis of oral cancer.

Rationale: Although an ototoxicity is well-known as adverse event of the radiotherapy, it is not widely known that immunosuppressed patients who underwent radiotherapy in head and neck region have risk of malignant external otitis. Patient concerns: A 68-year-old man with diabetes, who had been diagnosed as intraosseous squamous cell carcinoma of the right mandible, underwent surgical resection. He received a total of 60 Gy/30Fr postoperative radiation. Four months after the course of radiation, he suffered from right aural fullness, otalgia and otorrhea. Diagnoses: Clinical examination revealed granulation and existence of Pseudomonas aeruginosa in the external auditory canal. Computed tomography showed expansive inflammation and erosion in the temporal bone. The patient is elderly and diabetes. These findings led to the diagnosis of malignant external otitis. Interventions: The ear irrigation and administration of quinolones were started. Afterwards, fistula was formed in the oral cavity, and connected to the right external auditory canal. Therefore, irrigations were performed not only from ear but also from the oral fistula. Outcomes: Eight weeks after starting treatment, the malignant external otitis was completely healed. Lessons: Physicians should raise awareness of malignant external otitis in immunosuppressed patients with oral cancer after radiotherapy.

In order to study the prevalence of intestinal parasites among Japanese expatriates of developing countries, we conducted fecal specimen examinations annually from 1995 to 2000. Fecal specimens were collected from Japanese expatriates of each area: Asia, the Middle East, East Europe, Africa and Latin America. The specimens were fixed with 10% formalin in the local area, and then examined in Japan. We used the formalin-ether sedimentation method to find protozoan cysts or helminth eggs. In 1995, the infection ratio was 3.0% (N = 981), decreasing to 2.4% (N = 1,275) in 1996, 2.3% (N = 1,620) in 1997 and 1.6% (N = 1,574) in 1998. However, the ratio began to increase in 1999 (2.0%, N = 1,713) and 2000 (2.5%, N = 1,806). The ratio in Africa was the highest in each year, followed by Asia and Latin America. Heterophyidae (51 cases), Giardia lamblia (42) and Trichuris trichiura (30) were detected most frequently. In Egypt, the ratio of Heterophyidae rose by 28.8% in 2000. This was the prime reason for the increase in the overall ratio of infections worldwide. Most of the Japanese infected with Heterophyidae in Egypt had ingested dried mullet roe. This may explain the reason for the increase in the infection ratio there. Although the prevalence of intestinal parasites among Japanese expatriates in developing countries is decreasing, those who eat fish in these areas are still at risk. In order to eradicate intestinal parasitosis from this group, we must continue preventive measures such as health education.

To investigate the subsequent behaviour of doctor-shopping patients (defined as those attending multiple hospitals for the same complaint) who consulted our department and factors related to cessation of doctor shopping.Patients who presented without referral to the Department of General Medicine at Chiba University Hospital in Japan (our department) completed a questionnaire at their first visit. A follow-up questionnaire was also sent to them in order to assess doctor shopping after 3 months. Then items in the questionnaires were investigated for significant differences between patients who continued or stopped doctor shopping. Logistic regression analysis was performed with items showing a significant difference between patients who stopped doctor shopping and those who continued it, in order to identify independent determinants of the cessation of shopping.A total of 978 patients who presented spontaneously to our department consented to this study, and 929 patients (95.0%) completed questionnaires correctly. Among them, 203 patients (21.9%) were identified as doctor shoppers. The follow-up survey was completed correctly by 138 patients (68.0%). Among them, 25 patients (18.1%) were found to have continued doctor shopping, which was a significantly lower rate than before (P0.001). Logistic regression analysis selected the following factors as independent determinants of the cessation of doctor shopping: 'confirmation of the diagnosis' (odds ratio: 8.12, 95% confidence interval: 1.46-45.26), and 'satisfaction with consultation' (odds ratio: 2.07, 95% confidence interval: 1.42-3.01).Doctor shopping decreased significantly after patients consulted our department, with 'confirmation of the diagnosis' and 'satisfaction with consultation' being identified as contributing factors.

It has been proposed that lithium ion desensitizes neuronal receptors that function via the inositol phospholipid signaling mechanism. We examined the effects of lithium chloride on the morphologic outcome after 5 minutes of cerebral ischemia induced in gerbils by occluding both common carotid arteries under brief halothane anesthesia. In three treated groups of 10 gerbils each, 5 meq/kg i.p. lithium chloride was given 2 days, 1 day, and 2 hours before ischemia; 2 hours before ischemia; or immediately after the end of ischemia. Corresponding control groups of nine or 10 gerbils each received equivalent volumes of saline injected at comparable times. All gerbils were perfusion-fixed 1 week later, and neuronal density of the hippocampal CA1 pyramidal cells was determined. Lithium induced very mild intraischemic systemic hypothermia, but postischemic hyperthermia developed in both treated and control groups. Neuronal densities were equal in corresponding groups. The results indicate that our regimen of lithium administration provides no benefit in survival of hippocampal neurons, and intraischemic hypothermia of less than 0.8 degrees C is not protective. Other strategies to inactivate the signal transduction system that is specific for excitatory neurotransmission should be evaluated.

OBJECTIVE Familial Mediterranean fever (FMF) had been considered a rare disease in Japan, but since the identification of the causative gene (MEFV) for pyrin/marenostrin in 1997, the occurrence of FMF has been successively reported. We reviewed the clinical features of 7 patients diagnosed with FMF by gene analysis. METHODS During April 2003 and March 2005, we investigated the clinical symptoms, treatment and MEFV types of 7 FMF patients who consulted the General Outpatient Clinic of Chiba University Hospital. RESULTS Six patients were in their 20-30s, and one was 54 years of age. There were 4 males and 3 females including a mother and child, and an adult male and his female cousin. Three were solitary incidences. In addition to intermittent fever, 4 patients had chest pain, 1 had abdominal pain, and 1 had chest or abdominal pain. The frequency of attacks was once per 3 months to 1 year in the early stage of the disease, but it slowly increased with disease progression. Leukocytosis and C-reactive protein (CRP) elevation were noted during attacks in all patients. On investigation of MEFV, heterozygosity for the compound pyrin L110P-E148Q/M694I, E148Q/M694I, L110P/E148Q and heterozygosity for pyrin variant M694I alone were detected. Daily administration of colchicine at 0.5 mg prevented attacks in 6 patients, however 1 patient required 1.0 mg for adequate prevention. CONCLUSIONS Although the incidence is rare, internists should be aware of the characteristic symptoms of FMF: periodic fever and serositis symptoms, and its presence in Japan despite the disease name.

There are many reports about complications of transphenoidal surgery for pituitary adenomas. We report a patient who suffered severe subarachnoid hemorrhage due to an indirect injury of the intradural internal carotid artery during or immediately after transsphenoidal surgery for pituitary adenoma. An autopsy suggested that a small branch of the intradural internal carotid artery was strongly adherent to the suprasellar portion of the tumor capsule and its avulsion from the internal carotid artery might have been caused as the capsule fell down during the intracapsular removal of the tumor. In a case of pituitary adenoma operated by the transsphenoidal approach the possibility of subarachnoid hemorrhage due to this type of arterial injury, though rare, should be kept in mind.

Most spinal dural arteriovenous malformations are located in the thoracic and lumbar regions. The symptoms include pain, weakness, sensory disturbances, and sphincter dysfunction, which are usually gradual in onset. They are attributed to venous hypertension with a resultant ischemia of the cord, and hemorrhage from them is rare. The authors report an unusual case of a patient with a dural arteriovenous malformation in the cervical spine who was admitted with a sudden onset of severe headache and dysesthesia due to subarachnoid hemorrhage.

We report a case of lumbar spinal synovial cyst located on the midline. A 72-year-old man was admitted to our hospital with the chief complaint of low back pain radiating to the left buttock and posterior thigh. An MR image revealed an extradural cystic lesion adjacent to the dorsal side of the dural sac at the L4-5 level. The cyst was remote from the facet joints and existed on the midline just in front of the L4 lamina. A CT scan showed a concave deformity of the ventral aspect of the L4 lamina because of compression by the cyst. The patient underwent L4 laminectomy and total removal of the cyst. The cyst was in contact with the anterior surface of the ligamentum flavum and it had no connection with the facet joint. In the histological examination, the cyst was multilobular and lined with synovial epithelium. Therefore the cyst was diagnosed as a synovial cyst. After the operation, the pain radiating to the buttock and thigh completely disappeared. Intraspinal synovial cysts are usually located in the lower lumbar spine and most of them are adjacent to the facet joint. The cysts that are located on the midline are very rare. We review previous reports and discuss clinical and pathological features of spinal synovial cysts.

A case of acute subdural hematoma immediately after surgical intervention for the contralateral chronic subdural hematoma in a regularly hemodialyzed patient is reported. A 59-year-old male was admitted because of progressive right hemiparesis after six years of regular hemodialysis. A computed tomography (CT) scan revealed typical left chronic subdural hematoma. Irrigation and drainage of the hematoma through a single burr hole was performed. The right hemiparesis was improved after surgery and a CT scan two hours after surgery revealed a marked reduction of the hematoma cavity. However, the patient suddenly became comatose eight hours after surgery, and another CT scan showed a contralateral acute subdural hematoma. The patient expired the following morning. Postmortem pathologic examination showed an old left subdural hematoma membrane and a massive subdural hematoma without any membrane in the right fronto-temporal area. Subdural hematoma has a higher mortality rate among hemodialysis patients than in the normal population, and many authors have reported disappointing results of surgical intervention in such cases. This case suggests that the high frequency of subdural hematoma can be attributed to the accompanying coagulopathy and the acute decrease of intracranial pressure. The authors emphasize careful management including peritoneal dialysis before and after the surgical intervention.

A new method of discriminating pathological cerebral atrophy from physiological atrophy during aging is reported. The authors advocate a pixel counting method using a minicomputer for the quantitative measurement of cerebral atrophy. Five hundred cases were studied with this quantitative method and the normal range of the physiological atrophy was determined statistically. In order to estimate the degree of cerebral atrophy easily, the conventional linear measurement methods were compared with the pixel counting method using multivariant analysis, and a simple formula for the calculation of the degree of cerebral atrophy is proposed. Using this formula and the normal range, pathological cerebral atrophy is easily detectable.

✓ A radiopaque synthetic sponge is proposed as a prosthesis for microvascular decompression. Displacement of the prosthesis can be easily detected on a plain x-ray skull film.

The authors previously reported the effect of preoperative factors affecting the reduction of chronic subdural hematoma. In this report, we evaluated some operative factors, including operative methods, duration of drainage, and residual air volume, with newly developed CT volumetry technique. As described before, the hematoma volume reduces exponentially. An exponential curve was fitted to the reduction curve using the least square method, and its half reduction days (HRD) was calculated. This HRD represents a mathematical indicator of the reduction rate of CSDH. Using this technique, the relationship between this HRD and operative method, the duration of drainage and the volume of the postoperative residual air were examined in 61 patients. Operative method (burr hole or small craniotomy) has no correlation with HRD. The duration of drainage also has no correlation. However, the volume of the residual air was highly correlated with the reduction rate of hematoma (r = 0.430; p less than 0.01). These results suggest that the residual air in the hematoma cavity may delay the reduction rate of the hematoma. Based on these results, the authors pay attention to the following points; 1) Less invasive burr hole method should be selected. 2) Patient's head position should be controlled to make the burr hole at the highest level in the operative field. 3) Hematoma cavity should be filled with saline as much as possible. 4) The inner membrane should never be injured, as it may cause tension pneumocephalus. Moreover, the drainage of cerebrospinal fluid may reduce the counter pressure and it leads to the delay of the hematoma reduction.

A case of a cerebellopontine angle arachnoid cyst spontaneously disappeared is reported. A 1-year-and-11-month old boy was suffered from sudden onset of left facial palsy. CT scan demonstrated dilatation of left internal auditory canal and a cystic lesion in the left cerebellopontine angle. Neurological examination disclosed only left facial palsy and left hearing loss. There was no signs and symptoms of increased intracranial pressure. He was followed up by CT scan. Repeated CT scan showed non-enhanced cystic lesion, the attenuation value of which was similar to that of cerebrospinal fluid. The cyst expanded gradually, and the brain stem was severely compressed. Then operation was planned under the diagnosis of left cerebellopontine angle arachnoid cyst about 2 years after the onset. But CT scan performed before operation showed disappearance of the cyst. Without operation the patient was followed by CT scan. There is no recurrence of the cyst. Natural history of arachnoid cyst will be well understood with repeated CT scan.

A 45-year-old man was well until February 1986, when he experienced gait disturbance and psychiatric symptoms. On February 11 he fell down several times and developed generalized convulsion on the following day. He was admitted to a hospital in a delirious condition. The chest X-ray film showed infiltration in the left upper lobe, but computed tomographic (CT) scan of the head revealed no abnormality. Cerebrospinal fluid obtained by lumbar puncture contained 155 cells/mm3, all of which were lymphocytes, and protein and glucose concentrations were 372 mg/dl and 68 mg/dl respectively. In spite of negative smear tests of sputum and cerebrospinal fluid for tubercle bacilli he was administered antituberculosis drugs on the suspicion of pulmonary tuberculosis and tuberculous meningitis. His level of consciousness gradually returned to normal but the follow-up CT scans showed a low density area with contrast enhancement in the right thalamus and obliteration of the right quadrigeminal cistern which was also enhanced with contrast medium. He was transferred to our hospital on March 28 for further evaluation. On admission to our hospital he was alert and oriented, his pupils were equal and reactive to light and he had mild left hemiparesis, left hyperreflexia and left hemihypesthesia. Cell count of the cerebrospinal fluid was 243/mm3, 90% of which were lymphocytes and protein and glucose contents were 340 mg/dl and 42 mg/dl respectively. Both smear and culture of the cerebrospinal fluid were negative for tubercle bacilli and other organisms. Cytological examination of the cerebrospinal fluid demonstrated clusters of cells of various sizes with high N/C ratio which suggested these cells were malignant.(ABSTRACT TRUNCATED AT 250 WORDS)

In 22 subjects, selective venous sampling from the inferior petrosal sinus was performed under provocative tests along with simultaneous sampling of pituitary blood from the antecubital vein, after retrograde cavernous sinography. The difference of hormonal levels between sinus blood (Bs) and peripheral blood (Bv) was measured by two antibody radioimmunoassay. Most extreme difference of hormonal levels was observed in acromegalic subjects, where Bs/Bv ratio of GH was 6.0 in the basal value and 4.9 in the peak value, and that of PRL 3.5 and 4.6, respectively. In subjects who reacted to provocative tests, the average ratio of Bs/Bv ranged from 6.9 to 1.1 in the order of GH, PRL, LH, TSH and FSH. Non-reactive subjects showed no significant difference in the hormonal levels between Bs and Bv. From the results obtained above, we assume a possible relationship between Bs/Bv ratio and metabolic clearance rate and between difference of Bs-Bv and basal production. The integral of Bs-Bv difference measured from time zero to the time returned to the basal value under provocative tests represents the sum of basal production and pituitary reserve according to compartment analysis.

An eleven-month-old male infant with an ependymal cyst is reported. He was born after full-term pregnancy and vacuum extraction. His growth and development was somewhat retarded and he could control his head at the age of five months. He was admitted to our hospital because of the enlargement of his head and the paretic right upper limb. On admission he was found to be a well-nourished infant with the head circumference of 54.5 cm and the height of 75.5 cm. Physical examination disclosed slight weakness in the right upper extremity but no signs of increased intracranial pressure. Computed tomography (CT) revealed a huge low density area in the left frontoparietooccipital region which extended to the right across the midline. Another low density area was seen in the quadrigeminal cistern. CT findings also suggested an association with agenesis of the corpus callosum. The huge supratentorial cyst was isolated from the ventricles and subarachnoid space, which was shown by administration of metrizamide into the cyst. Carotid angiograms showed displacement of both anterior cerebral arteries to the right, which were dissociated from each other. This fact and an association with agenesis of the corpus callosum supported the idea that the cyst originiated in the interhemispheric fissure and expanded into both hemispheres. Cyst fluid was watery clear and protein and sugar contents were 13 mg/dl and 56 mg/dl respectively. The patient underwent a left frontal craniotomy and partial removal of the cyst wall was performed to make a communication with the ventricle. His postoperative course was uneventful and the weakness of the right upper extremity gradually improved.(ABSTRACT TRUNCATED AT 250 WORDS)

Microfibrillar collagen hemostat (Avitene) is a new absorbable hemostatic agent, of which mechanisms are adhesion to the bleeding site and platelet aggregation. Histopathological examinations revealed that Avitene was biocompatible with cerebral cortex in an animal experiments. Our previous studies indicated that Avitene is very effective and safe to use as a topical hemostatic agent during craniotomy in an experimental animal. Avitene was used as a topical hemostatic agent during craniotomy in 36 patients with intracranial organic lesions. Its effectiveness of hemostasis was revealed in 95%. This agent was especially useful to prevent oozing during craniotomy. Side effect of this agent was not reported in this study. Therefore, Avitene is very effective and safe to use as a topical hemostatic agent in the neurosurgical field.

The authors examined the preoperative factors affecting the reduction of chronic subdural hematoma (CSDH). A new method was developed to calculate the reduction rate of CSDH using CT volumetry technique. Postoperative serial CT films were examined and each hematoma volume was calculated by microcomputer. A postoperative exponential decrease of hematoma volume was observed, and the log-transformation of the hematoma volume turned the curve to a linear decrease. The least square method was used to fit an exponential curve, and the half reduction date (HRD) was calculated from the fitting curve. This HRD represents a mathematical indicator of the reduction rate of CSDH. Using this technique, the relationships between this HRD and the following parameters were examined in 61 patients. The preoperative factors examined are as follows; 1) patient's age, 2) preoperative hematoma volume, 3) CT number of the hematoma, 4) time interval between the head injury and the onset of symptom, and 5) the degree of cerebral atrophy. The degree of cerebral atrophy was calculated by means of a simple approximate formula as described by one of the authors (K.N.). Patient's age and the hematoma volume were correlated with HRD, and the correlation coefficients were 0.346 (p less than 0.01) and 0.298 (p less than 0.05) respectively. On the other hand, preoperative CT findings and the duration from the trauma had no correlation with HRD. Cerebral atrophy has hitherto been thought to affect the reduction of hematoma. However, our quantitative study revealed no correlation between cerebral atrophy and the reduction of hematoma rate. This unexpected result may be attributed to the difference between cerebral atrophy and cerebral elasticity.(ABSTRACT TRUNCATED AT 250 WORDS)

The preliminary results from the clinical use a prototype whole body nuclear magnetic resonance (NMR) machine constructed by Toshiba Inc. are presented. Cranial NMR scans were performed on more than 30 cases with broad spectrum of neurologic diseases using saturation-recovery and inversion-recovery sequences with a field strength of 1500 Gauss. Selective excitation sequence was used for the slice selection and filtered backprojection was used to reconstruct the images. They were displayed on a 256 X 256 matrix as 12 mm thick sections. Data acquisition time varied between 3 and 12 minutes. Our initial experiences with six cases harboring cerebellopontine angle lesions disclosed advantages and disadvantages of NMR imaging in comparison with X-ray CT. The advantages were the absence of linear artifacts from the surrounding bone, the marked gray-white matter differentiation, and the variety of tomographic planes available. The disadvantages included the lack of bone detail, the lack of visualization of the major intracranial vessels, and the long time required for scanning (several minutes per slice). Although much continued evaluation is necessary, NMR seems to have vast potential as a diagnostic tool.

Magnetic resonance images of a case of superior sagittal sinus thrombosis before and after complete recanalization are presented. The patient was a 61-year-old man with two days history of intermittent right hemiconvulsion followed by post-ictal hemiplegia. Mild erythrocytosis was noted on admission. CT scans revealed left frontal hemorrhagic infarction with empty delta sign in the middle portion of the superior sagittal sinus. Left carotid angiogram showed occlusion of two frontal cortical veins and retrograde filling of these veins into the cavernous sinus. Lack of filling of the middle and anterior part of the superior sagittal sinus was noted. These studies led to the diagnosis of superior sagittal sinus thrombosis associated with hemorrhagic infarction. He was treated with intravenous infusion of low molecular dextran and venesection. Neither heparin, urokinase, hyperosmolar solutions nor steroids were used because of the presence of hemorrhagic infarction and of the lack of signs of increased intracranial pressure. He completely recovered neurologically and recanalization of the superior sagittal sinus was confirmed angiographically eight weeks after the onset. Magnetic resonance images were taken with a Siemens 1.5 T Magnetom scanner using spin-echo pulse sequences. A T 1-weighted mid-sagittal magnetic resonance image ten days after the onset showed hyperintensity in the middle part of the superior sagittal sinus which corresponded to the thrombus. Both T 1 and T 2 weighted coronal images revealed a small area of hypointensity indicating the existence of residual blood flow in the superior sagittal sinus in addition to the thrombus both in the sinus and in the cortical vein.(ABSTRACT TRUNCATED AT 250 WORDS)

Calcified chronic subdural hematoma is a well-known disease to many neurosurgeons as it is diagnosed with only a plain skull X-ray film. Although several reports on this condition are seen, many of them are dealing with those in children or young people, and those in the aged are only few. One case of calcified chronic subdural hematoma in an old man is described. An 86-year-old man with a sudden attack of left hemiparesis was admitted to the Kanto Rosai Hospital. Two years before, he had had a history of head injury on his right temporal area, which caused no neurological deficit before this attack. Neurological examination on admission revealed mild confusional state and severe left hemiparesis. A plain skull film of A-P projection showed a linear calcification in the right temporal area. CT scan revealed a right temporal chronic subdural hematoma with some calcification in the internal membrane, which caused moderate midline shift. Right temporal small craniotomy was performed. The hematoma contained no fluid as usual but paste-like substance, and was partially removed. Postoperatively, he showed an improvement in unstability, but the left hemiparesis remained. On the 23rd postoperative day, he expired of severe pneumonia. Autopsy showed 14.0 X 8.0 X 1.2cm sized subdural hematoma in the right temporal area. Microscopically, the internal layer of the dura markedly thickened, and the appearance of "pachymeningitis hemorrhagica interna" was clearly seen. The thicked internal layer was devided into two layers, and the hematoma was existed just between the two layers.(ABSTRACT TRUNCATED AT 250 WORDS)