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The purpose of this study was to verify the dose absorbed by an implantable cardioverter defibrillator (ICD) from an (192)Ir sealed source during uterine intracavitary brachytherapy, and to confirm its immunity to radiation effects. First, prior to treatment, the doses around the ICD position of an anthromorphic phantom were evaluated. Next, we also measured the dose at the ICD position using a fluorescent glass dosimeter and silicon diode dosimeter during the treatment of intracavitary brachytherapy of a patient implanted with an ICD. The results of the phantom study showed the dose percentage at the ICD location, 2 cm deep, to be 0.074% of the prescribed dose. The results of a treatment study similarly showed the dose, measured using a fluorescent glass dosimeter in the ICD position, to be 0.071% of the prescribed dose. During the application of the total prescribed dose, 30 Gy/5 fraction, the dose at the surface of the ICD position was estimated to be 21.2 mGy, well below the 1 Gy maximum recommended in the JASTRO guidelines. We regard dose verification and monitoring during treatment to be both necessary and useful in the treatment of individual cases.

Object: Superior cluneal nerve (SCN) entrapment neuropathy is a poorly understood clinical entity that can produce low-back pain. The authors report a less-invasive surgical treatment for SCN entrapment neuropathy that can be performed with local anesthesia., Methods: From November 2010 through November 2011, the authors performed surgery in 34 patients (age range 18-83 years; mean 64 years) with SCN entrapment neuropathy. The entrapment was unilateral in 13 patients and bilateral in 21. The mean postoperative follow-up period was 10 months (range 6-18 months). After the site was blocked with local anesthesia, the thoracolumbar fascia of the orifice was dissected with microscissors in a distal-to-rostral direction along the SCN to release the entrapped nerve., Results: were evaluated according to Japanese Orthopaedic Association (JOA) and Roland-Morris Disability Questionnaire (RMDQ) scores. Results In all 34 patients, the SCN penetrated the orifice of the thoracolumbar fascia and could be released by dissection of the fascia. There were no intraoperative surgery-related complications. For all patients, surgery was effective; JOA and RMDQ scores indicated significant improvement (p < 0.05)., Conclusions: For patients with low-back pain, SCN entrapment neuropathy must be considered as a causative factor. Treatment by less-invasive surgery, with local anesthesia, yielded excellent clinical outcomes.

The genus Citrus includes mandarin, orange, lemon, grapefruit and lime, which have high economic and nutritional value. The family Rutaceae can be divided into 7 subfamilies, including Aurantioideae. The genus Citrus belongs to the subfamily Aurantioideae. In this study, we sequenced the chloroplast matK genes of 135 accessions from 22 genera of Aurantioideae and analyzed them phylogenetically. Our study includes many accessions that have not been examined in other studies. The subfamily Aurantioideae has been classified into 2 tribes, Clauseneae and Citreae, and our current molecular analysis clearly discriminate Citreae from Clauseneae by using only 1 chloroplast DNA sequence. Our study confirms previous observations on the molecular phylogeny of Aurantioideae in many aspects. However, we have provided novel information on these genetic relationships. For example, inconsistent with the previous observation, and consistent with our preliminary study using the chloroplast rbcL genes, our analysis showed that Feroniella oblata is not nested in Citrus species and is closely related with Feronia limonia. Furthermore, we have shown that Murraya paniculata is similar to Merrillia caloxylon and is dissimilar to Murraya koenigii. We found that "true citrus fruit trees" could be divided into 2 subclusters. One subcluster included Citrus, Fortunella, and Poncirus, while the other cluster included Microcitrus and Eremocitrus. Compared to previous studies, our current study is the most extensive phylogenetic study of Citrus species since it includes 93 accessions. The results indicate that Citrus species can be classified into 3 clusters: a citron cluster, a pummelo cluster, and a mandarin cluster. Although most mandarin accessions belonged to the mandarin cluster, we found some exceptions. We also obtained the information on the genetic background of various species of acid citrus grown in Japan. Because the genus Citrus contains many important accessions, we have comprehensively discussed the classification of this genus.

Background: Misdiagnosis and inadequate treatment of lumbar foraminal stenosis (LFS) are the most common causes of failed back surgery. Although several surgical procedures have been reported, the optimal surgical treatment remains controversial., Aim: We describe our method of microsurgical medial fenestration using an ultrasonic bone curette (Sonopet, Stryker Corp., Kalamazoo, MI, USA) to treat patients with LFS and report our early results., Patients and Methods: We followed up 26 patients who had undergone microsurgical medial fenestration at least 1 year earlier. The patients were 15 men and 11 women with a mean age at surgery of 59.5 years; the mean follow-up period was 30.6 months. The affected nerve root was at L4 in 1 patient and at L5 in 25. Evaluation of our clinical results was based on the Japanese Orthopedic Association score., Results: There were no intraoperative surgery-related complications. After surgery, 1 patient had recurrence of L5 radiculopathy associated with iatrogenic spondylolysis. He was successfully treated with resection of the inferior articular process without fusion surgery; there was loss of disc height without obvious instability at the corresponding level. The Japanese Orthopedic Association scores showed significant improvement at 1 month after surgery and at final follow-up (p<0.001). No patient had spinal instability or malalignment postoperatively., Conclusions: Microsurgical medial fenestration using Sonopet, a less-invasive surgical technique that does not result in spinal instability or malalignment, yielded excellent clinical outcomes.

To identify an orally available drug candidate, a series of 3-benzoylaminophenylacetic acids were synthesized and evaluated as prostaglandin D(2) (PGD(2)) receptor antagonists. Some of the compounds tested were found to exhibit excellent inhibitory activity against cAMP accumulation in human platelet rich plasma (hPRP), which is one of the indexes of DP antagonism. The optimization process including improvement of the physicochemical properties such as solubility, which may result in an improved pharmacokinetic (PK) profile, is presented. Optimized compounds were studied for their pharmacokinetics and in vivo potential. A structure-activity relationship study is also presented. Some of the test compounds were found to have in vivo efficacy towards the inhibition of PGD(2)-induced and OVA-induced vascular permeability in guinea pig conjunctiva., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

To identify new cost-effective prostaglandin D₂ (DP) receptor antagonists, a series of novel 3-benzoylaminophenylacetic acids were synthesized and biologically evaluated. Among those tested, some representative compounds were found to be orally available. Receptor selectivity and rat PK profiles were also evaluated. The structure-activity relationship (SAR) study is presented., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

A series of N-benzoyl-2-methylindole-3-acetic acids were synthesized and biologically evaluated as prostaglandin (PG) D₂ receptor antagonists. Some of the selected compounds significantly inhibited OVA-induced vascular permeability in guinea pig conjunctiva after oral dosing. Structure-activity relationship study is presented., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

In anterior fusion, we use autologous bone grafts from cervical vertebral bodies (Williams-Isu method; WI-method). To reduce the fusion level, we combine the WI-method and the transvertebral approach (TVA). The wide window yielded by the removal of the bone graft from vertebral bodies at the fusion level provides for the safe decompression of neural structures. Further decompression with TVA is performed from the wide window to the adjacent level. After a two-level decompression, anterior fusion at one level is performed by autologous bone grafting. We subjected 20 patients with cervical disease to this approach. All recovered from their symptoms without surgical complications and in all patients we confirmed fusion and the retention of mobility at the TVA level. The wide operative field yielded by the WI-method is an advantage when the procedure is combined with TVA, and this technique is less invasive in patients with multilevel cervical disease., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Posterior decompression of the cervical spine is an accepted treatment for patients with cervical canal disease, but some patients experience postoperative axial pain and C5 or C6 palsy that affect their quality of life. Here we describe selective posterior decompression using a spinous process-splitting approach to prevent these complications performed in 17 patients with myelopathy treated at median 2.4 levels by selective posterior decompression via the transspinous approach. Clinical symptoms, axial pain, and C5 or C6 palsy were compared before and after treatment. The range of motion of the cervical spine and shift of the cervical cord were studied at the C5 level. All patients experienced symptom improvement and none suffered deterioration or required reoperation. The Japanese Orthopaedic Association score improved from 10.9 to 14.4 points and none of the patients reported C5 or C6 palsy or axial pain at the last follow-up visit. There was no statistically significant change in pre- and postoperative cervical alignment and range of motion. The posterior shift of the spinal cord at the C5 level was 1.7 mm. None of our 17 patients experienced significant postoperative axial pain after selective posterior decompression via the transspinous approach. Minimal spinal cord shift at the C5 level may have contributed to the reduced incidence of postoperative C5 or C6 palsy in our series. Selective posterior decompression is less invasive and effective in some patients with cervical canal disease.

A 25-year-old woman and a 31-year-old man presented with chronic lower back pain and unexplained lower abdominal pain. Both patients had groin tenderness at the medial border of the anterior superior iliac spine. The results of radiographical and physical examinations suggested sacroiliac joint dysfunction. Sacroiliac joint injection relieved their symptoms, including groin tenderness. In our experience, groin tenderness is highly specific for sacroiliac joint dysfunction. We speculate that spasm of the iliac muscle can cause groin pain and tenderness. Groin pain and a history of unexplained abdominal pain, with lower back pain, are symptoms that suggest sacroiliac joint dysfunction. Additionally, compression of the iliac muscle is a simple and useful maneuver; therefore, it can be used as a screening test for sacroiliac joint dysfunction, alongside other provocation tests.

Detailed changes involved in the worsening of the fused segment angle were assessed after application of the Williams-Isu method using autologous bone grafts from cervical vertebral bodies in 30 patients with cervical disease treated by single-level anterior fusion. The mean follow-up duration was 25.4 months. The fused segment angle was measured on serial radiographs. Whole cervical spine alignment changed from 12.8° to 9.9°. The alignment of the fused segment worsened by mean 3.3°. To elucidate the characteristics of worsening of the fused segment, the 30 patients were divided into 2 groups: Group I (n = 20) without and Group II (n = 10) with postoperative worsening of the fused segment. The loss in the fused segment angle was significantly greater in Group II (8.0°) than Group I (0.9°). Preoperative range of motion and disc height were significantly greater in Group II than Group I. Worsening of the fused segment angle occurred within 1 month in Group I, whereas stabilization was observed after 3 months in Group II. Graft subsidence was primarily posterior and inferior. Our results indicate that the preoperative range of motion and disc height of the fused segment must be considered to prevent worsening in that segment after anterior fusion. Such detailed information is useful for the selection and postoperative monitoring of patients eligible for treatment by the Williams-Isu method.

This 60-year-old man with cervical spondylosis experienced bilateral arm pain and weakness. After anterior cervical fusion and posterior decompression at a local hospital his symptoms worsened and he was admitted to our hospital. On admission he manifested bilateral motor weakness, neuropathic pain, and numbness below the C5 level. Radiological findings showed spinal cord compression at the C4 to C7 level. He again underwent posterior decompression and anterior fusion. Although his paresis was improved, his severe neuropathic pain and numbness persisted. Because treatment with NSAIDs, clonazepam, and gabapentin failed to control his symptoms we administered ketamine (NMDA receptor antagonist) because his symptoms were alleviated upon ketamine test challenge. His severe symptoms improved and there were no complications. However, upon cessation of ketamine treatment they reappeared. Therefore, we continued daily ketamine treatment for 6 months, after which we changed to codeine phosphate. His symptoms were controlled without any complications. Ketamine is useful for the control of severe neuropathic pain, however, as long-term ketamine administration is inadvisable, we suggest that treatment be tailored to each patient's particular clinical status.

Sacroiliac joint (SIJ) can cause low back pain when its joint capsule and ligamentous tissue are damaged. We report our experience in treating three SIJ dysfunction patients presenting with acute low back pain (a 38 year-old male, a 24 year-old male, and a 32 year-old female). SIJ dysfunction was diagnosed using the one-finger test, the modified Newton test, and SIJ injection. In all three patients, lumbar MRI demonstrated slightly degenerated lumbar lesions (lumbar canal stenosis, lumbar disc hernia). Two patients had paresthesia or pain in the leg and all three patients showed iliac muscle tenderness in the groin, which was thought to be a referred symptom because of improvement after SIJ injection. The two male patients returned to work and the problems have not recurred. Although our female patient resumed daily life as a housewife, her condition recurred at intervals of 2-3 months and she required regular SIJ injections. The prevalence of SIJ dysfunction of low back pain is about 10%, so it should be considered as a differential diagnosis when treating low back pain and designing treatment for lumbar spinal disorders.

Autologous bone grafts from cervical vertebral bodies (Williams-Isu method) are used for anterior fusion of the cervical spine. When adequate amounts of bone cannot be harvested from the vertebral body, hydroxyapatite (a ceramic) is placed between the bone grafts (the sandwich method). We conducted a radiological study to examine the efficacy of the sandwich method by comparing the alignment of the whole spine and the fused segment between patients who had received a sandwich graft (n=20) and a control group (n=20). Although there was no difference between the two groups with respect to the alignment of the whole spine, the alignment and height of the fused segment was significantly better in the patients in the sandwich graft group. In both groups the position of the anterior edge of the graft and the loss in the angle of the fused segment were significantly correlated (p<0.05). We found that the sandwich method not only reinforced the graft, but also yielded better results with respect to the angle and height of the fused segment., ((c) 2009 Elsevier Ltd. All rights reserved.)

A 58-year-old man presented with a hypertrophic synovial mass manifesting as left C8 radiculopathy. Computed tomography revealed hypertrophic changes in the left C7-T1 facet joint and widening of the interarticular space. Magnetic resonance imaging showed left C7-T1 foraminal stenosis attributable to a periarticular mass enhanced with gadolinium. Decompression surgery of the left C8 nerve root was performed. During left C7-T1 facetectomy we detected inflamed soft tissue occupying the interarticular space with extension toward the intervertebral foramen. The mass markedly compressed the left C8 nerve root and was gross totally removed. The histological diagnosis was proliferated fibrous connective tissue compatible with hypertrophic synovial tissue. Postoperatively, his neurological condition improved remarkably. The surgical and pathological findings in our patient indicate that this clinical condition is important in the differential diagnosis in adult patients presenting with cervical radiculopathy.

Three men aged 40 to 60 years presented with rare lumbar spinal intradural lipomas without spina bifida manifesting as worsening numbness, pain of the lower extremities, and bladder dysfunction. All 3 patients underwent decompressive laminectomy. The lipoma and cauda equina nerves were dissected from the dura mater under the operating microscope, untethering the spinal cord and returning the cauda equina nerves to the original position. Duralplasty was performed using an expanded polytetrafluoroethylene sheet. Postoperatively, all patients experienced improvement of their neurological deficits. In the surgical treatment of spinal lipomas, the primary purpose is untethering and decompression, which can be achieved by untethering the spinal cord, returning the cauda equina nerves to the normal position, laminectomy, and duralplasty, without removal of the lipoma.

Background: In anterior fusion, we use autologous bone grafts from cervical vertebral bodies and bioabsorptive screws to prevent graft extrusion (Williams-Isu method). We report the application of and indication for the Williams-Isu method for OPLL and present our clinical and radiological results., Methods: Using the Williams-Isu method, we treated 17 patients with cervical OPLL; 15 had segmental- and 2 had continuous-type OPLL. The median follow-up term was 24 months. The patients underwent anterior decompression and fusion at a single level (n = 8) or at two levels (n = 9). As a control, 17 patients with cervical spondylosis underwent anterior single-level decompression and fusion using the Williams-Isu method. Pre- and postoperative radiographs of the cervical spine were obtained in all patients, and the alignment of the whole cervical and fused segment and the height of the fused segment were compared., Results: All but one patient experienced alleviation of clinical symptoms without deterioration during the follow-up period. The recovery rate on the JOA score was 71.7%. The patient with continuous-type OPLL suffered postoperative neurological deterioration because of a remnant of the upper-level OPLL. Radiological studies confirmed the absence of bone graft dislocation and fracture, and of satisfactory bone fusion in all patients. There was no significant difference between the two patient groups with respect to whole spine alignment and the alignment and height of the fused segment., Conclusions: The Williams-Isu method is useful for treating not only cervical spondylosis but also cervical segmental OPLL at one or two levels.

Cervical anterior fusion is useful for the treatment of patients with cervical disease, but carries the risk of postoperative worsening of the cervical spine alignment and kyphosis. Preoperative prediction of the risk for kyphosis could help to avoid such postoperative complications. We attempted to predict the postoperative development of kyphosis in 59 patients scheduled for cervical anterior fusion using autologous vertebral bone grafting. Of these, 36 underwent single and 23 two level fusion with median follow up of 58.2 months. Whole spine alignment, fused segment alignment, and mobility of the intervertebral disc were compared using pre- and postoperative radiographs. Alignment of the whole spine changed from 13.7 degrees to 11.1 degrees , and the angle of the fused segment changed from 3.6 degrees to -3.2 degrees . Postoperative alignment was not worse than the preoperative flexion posture in any of the 59 patients. Forty-nine patients with preoperative lordotic alignment did not develop postoperative kyphosis. Nine patients with preoperative straight alignment had several types of postoperative alignment, including kyphosis. Two patients with postoperative kyphosis showed marked loss in the angle of the fused segment, which affected mobility to flexion of the fused segment. One patient with preoperative kyphotic alignment manifested postoperative kyphosis. The postoperative alignment was influenced by the preoperative alignment. Kyphosis may develop in patients with preoperative straight alignment and large mobility to flexion of the fused segment. This information is useful for surgical planning of anterior cervical fusion using autologous vertebral bone grafting.

Lumbar foramimal stenosis is one of the important disorders underlying radicular symptoms and unrecognized or recurrent foraminal stenosis may result in failed back surgery. We report a 47-year old man with foraminal stenosis of the lumbar spine associated with a bone spur at the pars interarticularis. He suddenly experienced severe right leg pain, lumbago and gait disturbance. Radiographic studies revealed foraminal stenosis on the right L5/S1associated with a bone spur at the pars interarticularis. There was no dural sac compression by spondylolysis. As his symptoms failed to respond to conservative treatment, he underwent decompression without fusion with an ultrasonic bone curette. We performed lateral fenestration and foraminotomy at the right L5/S1 using the extraforaminal approach. After partial foraminotomy, the right L5 nerve root was compressed by the bone spur at the pars interarticularis. For satisfactory decompression we removed the bone spur using an ultrasonic bone curette. His symptoms disappeared immediately after surgery. Although long-term follow-up is necessary, we suggest that microdecompression with an ultrasonic bone curette is a useful method to treat patients with foraminal stenosis of the pars interarticularis.

Objective: Preoperative magnetic resonance imaging (MRI) myelography scans demonstrated a dural defect in a 50-year-old man with an epidural arachnoid cyst who had a 29-year history of untreated weakness and numbness both lower limbs., Methods: MRI scans showed a dorsal intraspinal extradural cystic lesion at the level from Th11 to L1. Although preoperative cine-MRI scans failed to display the dural defect, an MRI myelography scan showed cerebrospinal fluid in the subarachnoid space containing a cyst., Results: The site of shunting between the subarachnoid space and the cyst was visualized as a pulsating flow void to the right of Th12. We removed the cyst wall and closed the dural defect via laminectomy., Conclusion: Because the preoperative MRI myelography scan correctly identified the existence and location of the dural defect, we conclude that MRI myelography is helpful for detecting dural defects in patients with epidural arachnoid cysts.

Objective: We report our experience with the SONOPET ultrasonic bone curette., Methods: Between September 2001 and July 2005, 546 patients underwent microscopic spinal surgeries using a high-speed drill and the SONOPET instrument., Results: We encountered operative complications thought to be attributable to the use of the SONOPET in six patients (1.1%). There were five instances of dural puncture and one spinal cord injury. All dural tears occurred when the dura mater was aspirated into the tip of the SONOPET. None of the affected patients developed postoperative clinical complications because cerebrospinal fluid leakage was avoided by appropriate closure. We think that the transient spinal cord injury occurred because the vibration emanating from the SONOPET was transmitted directly to the spinal cord. Some patients experienced damage to the epidural venous plexus for reasons similar to those described above., Conclusion: SONOPET facilitates the removal of bone in a narrow field, such as that encountered during keyhole surgery. It aids in the removal of the lateral edge of bone and is especially useful for expanding the foramen intervertebrale or opening the lateral recess. However, its use is not without risk. To prevent dural tears and venous plexus injury, we recommend that cotton be placed between the SONOPET and important structures. To avoid spinal cord injury, we suggest that the SONOPET be inserted horizontal with the dura mater to avoid the direct transmission of vibrations emanating from the instrument to the spinal cord. SONOPET is suitable for decompression on the lateral side, but not for decompression above the spinal cord.

Background: Basophils possess characteristics of both mast cells and eosinophils, and all 3 cell types often are found together, particularly during allergic reactions. A mAb (J175-7D4) generated against the recombinant pro-form of human eosinophil granule major basic protein 1 (rproMBP1) appeared to stain only basophils in tissue specimens., Objective: We investigated J175-7D4 to characterize its specificity for basophils., Methods: Fluid-phase immunoprecipitation, Western blotting, and immunocytochemistry and immunohistochemistry were used to establish the specificity of J175-7D4., Results: First, J175-7D4 binds to various glycosylated and proteolytically processed forms of rproMBP1, but not to major basic protein. Second, cells transfected with the rproMBP1 gene and human placental tissue (known to express the pro-form of major basic protein 1 [proMBP1]) stain specifically with J175-7D4. In contrast, although mature eosinophils contain substantial major basic protein, they lack proMBP1 and do not stain. Neutrophils, lymphocytes, monocytes, and skin mast cells also are not stained. However, blood basophils are stained by J175-7D4, anti-IgE, Wright-Giemsa (metachromatically), and a previously characterized basophil-specific mAb, 2D7. Finally, formaldehyde-fixed, paraffin-embedded basophils are identically detected by J175-7D4 and 2D7, and J175-7D4 also recognizes putative basophils in formaldehyde-fixed, paraffin-embedded tissue specimens from inflammatory dermatoses, such as atopic dermatitis and delayed pressure urticaria., Conclusion: The J175-7D4 mAb recognizes proMBP1 as a novel marker for human basophils. J175-7D4 should prove useful for characterizing basophil involvement in human health and disease.

The process of discovering a series of N-(p-alkoxy)benzoyl-2-methylindole-4-acetic acid analogs is presented since these compounds represent a new class of potent, selective, and orally active prostaglandin D2 (PGD2) receptor antagonists. Most of these compounds exhibit strong PGD2 receptor binding and PGD2 receptor antagonism in cAMP formation assays. When given orally, these new antagonists dramatically suppress allergic inflammatory responses, such as the PGD2-induced or OVA-induced increase of vascular permeability. Structure-activity relationship (SAR) data are also discussed.

The process of discovery for highly potent prostaglandin D(2) (PGD(2)) receptor antagonists is reported. A series of N-(p-alkoxy)benzoyl-2-methylindole-4-acetic acids were synthesized and identified as a new class of selective PGD(2) receptor antagonists. Most of them exhibited strong PGD(2) receptor antagonism in binding studies and the cAMP formation assay. The structure-activity relationships (SAR), including subtype selectivity of the synthesized compounds, are also discussed.

Ecalectin, produced by Ag-stimulated T lymphocytes, is a potent eosinophil-specific chemoattractant in vitro as well as in vivo and thus is implicated in allergic responses. Ecalectin differs structurally from other known eosinophil chemoattractants (ECAs); ecalectin belongs to the galectin family defined by their affinity for beta-galactosides and by their conserved carbohydrate recognition domains. These characteristic features suggest that ecalectin has unique activities associated with allergic inflammation besides ECA activity. Conversely, ecalectin may mediate ECA activity by binding to a receptor of a known ECA via affinity for the beta-galactosides present on this receptor. In this study, we have tested whether ecalectin mediates ECA activity by binding to a receptor of a known ECA, and we have assessed its effects on eosinophils. Ecalectin did not mediate ECA activity by binding to the IL-5R or to CCR3. Also, the ECA activity of ecalectin was mainly chemokinetic. In addition, ecalectin induced concentration-dependent eosinophil aggregation, a marker for eosinophil activation. Ecalectin induced concentration-dependent superoxide production from eosinophils but did not induce degranulation; usually these two events are coupled in eosinophil activation. Moreover, ecalectin directly prolonged eosinophil survival in vitro and did not trigger eosinophils to secrete cytokines that prolong eosinophil survival. These results demonstrate that ecalectin has several unique effects on eosinophils. Therefore, we conclude that ecalectin is a novel eosinophil-activating factor. Presumably, these effects allow ecalectin to play a distinctive role in allergic inflammation.