Search

Background: Coronavirus disease 2019 (COVID-19) has placed a tremendous strain on healthcare services. This study, prepared by a large international panel of stroke experts, assesses the rapidly growing research and personal experience with COVID-19 stroke and offers recommendations for stroke management in this challenging new setting: modifications needed for prehospital emergency rescue and hyperacute care; inpatient intensive or stroke units; posthospitalization rehabilitation; follow-up including at-risk family and community; and multispecialty departmental developments in the allied professions. Summary: The severe acute respiratory syndrome coronavirus 2 uses spike proteins binding to tissue angiotensin-converting enzyme (ACE)-2 receptors, most often through the respiratory system by virus inhalation and thence to other susceptible organ systems, leading to COVID-19. Clinicians facing the many etiologies for stroke have been sobered by the unusual incidence of combined etiologies and presentations, prominent among them are vasculitis, cardiomyopathy, hypercoagulable state, and endothelial dysfunction. International standards of acute stroke management remain in force, but COVID-19 adds the burdens of personal protections for the patient, rescue, and hospital staff and for some even into the postdischarge phase. For pending COVID-19 determination and also for those shown to be COVID-19 affected, strict infection control is needed at all times to reduce spread of infection and to protect healthcare staff, using the wealth of well-described methods. For COVID-19 patients with stroke, thrombolysis and thrombectomy should be continued, and the usual early management of hypertension applies, save that recent work suggests continuing ACE inhibitors and ARBs. Prothrombotic states, some acute and severe, encourage prophylactic LMWH unless bleeding risk is high. COVID-19-related cardiomyopathy adds risk of cardioembolic stroke, where heparin or warfarin may be preferable, with experience accumulating with DOACs. As ever, arteritis can prove a difficult diagnosis, especially if not obvious on the acute angiogram done for clot extraction. This field is under rapid development and may generate management recommendations which are as yet unsettled, even undiscovered. Beyond the acute management phase, COVID-19-related stroke also forces rehabilitation services to use protective precautions. As with all stroke patients, health workers should be aware of symptoms of depression, anxiety, insomnia, and/or distress developing in their patients and caregivers. Postdischarge outpatient care currently includes continued secondary prevention measures. Although hoping a COVID-19 stroke patient can be considered cured of the virus, those concerned for contact safety can take comfort in the increasing use of telemedicine, which is itself a growing source of patient-physician contacts. Many online resources are available to patients and physicians. Like prior challenges, stroke care teams will also overcome this one. Key Messages: Evidence-based stroke management should continue to be provided throughout the patient care journey, while strict infection control measures are enforced. © 2021 S. Karger AG, Basel. Copyright: All rights reserved.

Funding Acknowledgements Ministry of Health, Labor and Welfare (MHLW) Geriatrics and Gelontorogy sponsored research funds Background & purpose: Recently, many longitudinal studies have shown that heart failure with reduced ejection fraction (HFrEF) is associated with various types of brain abnormalities: cerebral micro-bleeding, atrophy, or pathologic degeneration (white matter hyperintensity; WMH). These brain abnormalities are known to increase with aging and to be closely associated with cognitive impairment. Heart failure with preserved ejection fraction (HFpEF) also increases with aging, but there have been few longitudinal studies to address the relationship between HFpEF and brain abnormalities. Thus, this longitudinal study aimed to clarify this relationship by focusing on WMH volume. METHODS The participants were 111 well-controlled hypertensive patients aged between 65 and 75 years with normal LV contraction and no history of symptomatic heart failure, ischemic heart disease, atrial fibrillation, stroke, or cognitive dysfunction. The participants were classified into 3 groups: Low E/e", E/e" < 8; Middle E/e", 8≤ E/e" ≤ 15; and High E/e", E/e" > 15. WMH volume was quantified on brain magnetic resonance imaging using analytical software. RESULTS During the mean 2.6 ± 1.0-year follow-up period, the rate of increase of WMH volume was significantly higher in the high E/e" group (1.1 ± 1.2 mL/year) than in the low E/e" group (0.30 ± 0.78 mL/year; P = 0.0238). Linear regression analysis including other confounders showed that the only positive association was between the rate of increase of WMH volume and the E/e" ratio (beta- coefficient = 0.225, P = 0.018). CONCLUSION The severity of LV diastolic dysfunction is positively correlated with increasing WMH volume. Abstract P103 Figure. The rates of increase of WMH volumes

Introduction Frailty is a syndrome associated with aging that produces subclinical dysfunction across multiple organ systems and leads to increased risk of mortality. The Kihon Checklist (KCL) was developed by the Japanese Ministry of Health, Labor and Welfare to identify older persons in need of care; it is a reliable tool for predicting general frailty in older adults. There is little information about the relationship between frailty status and exercise capacity. Purpose To investigate whether cardiopulmonary exercise testing (CPX) parameters are associated with frailty in stable elderly patients with heart failure (HF). Methods Ninety-two stable elderly patients with HF were evaluated by using CPX and the total KCL (t-KCL). A t-KCL score of 0–3 was classified as robust, 4–7 as pre-frail, and ≥8 as frail. Diagnostic performance (DP) -plot analysis was used to assess the utility of CPX parameters to distinguish between the presence and absence of frailty. Results Mean age, left ventricular ejection fraction, plasma brain natriuretic peptide, peak work rate (WR), peak VO2, and t-KCL score were 81.7 years, 57.8%, 182 pg/mL, 49.6 W, 13.2 mL/kg/min, and 10.7, respectively. t-KCL score was significantly correlated with peak VO2 (r=−0.53, p Cut-off value for peak WR Conclusions Frailty status was significantly associated with peak WR in stable elderly patients with HF. CPX may be useful for assessing frailty status in stable elderly patients with HF.

Three-dimensional (3D) structures of a rice grain were visualised by means of the new 3D visualisation technique. This technique produced a virtual 3D model of a sample material by stacking a set of captured sequential section images in a personal computer (PC); thus, the internal structure of the sample material was constructed. The 3D structure of an immature rice seed, e.g. the formation of the vascular bundle, was visualised by reconstructing a virtual 3D model from sequential captured images of the cut-off face. The 3D structure of a brown rice grain, e.g. the location of the central line, was also visualised by means of reconstruction from captured images of stained sequential sections.

To enhance the FEL harmonic gain, we have developed a wiggler having a harmonic wiggler field. The modified wiggler consists of a conventional planar wiggler and high-permeability shims. Because of this simpleness, we can develop a wiggler having various types of modified fields, easily and economically. We show the design basis of the modified wiggler and examples of them which contain one harmonic field. Then, we introduce the FEL experiment of the 5th harmonic generation with a modified wiggler.

The therapeutic effects of human IgM and IgG with exogenous complement (fresh guinea pig serum) on experimental infections were compared in mice. Purified IgM and IgG were injected intraperitoneally to mice challenged with Escherichia coli or Pseudomonas aeruginosa , and the protective effects of IgM and IgG were evaluated. However, it was found that the additional administration of fresh guinea pig serum greatly enhanced the protective effect of the immunoglobulins, and that the enhancement was greater with IgM treatment. The results suggested that IgM has a higher protective activity than IgG, and that this activity of IgM is not fully expressed in native mice because of their intrinsically low level of complement activity. In vivo evaluation of immunoglobulins in mice should be carefully examined by co-administering exogenous complement.

The synthesis methodology developed by Kimura(Kimura, 1985) based on the design theory of output regulators essentially due to Wonham(Wonham, 1974) has been applied successfully to the flatness control system for the 6-high cold rolling mill. Our system has the following remarkable features. (1) The structure of the controller is simple. This makes it easy to tune the control system. (2) The controller copes well with the detection time delay, and thus high performance is obtained even at a low rolling speed. (3) The flatness error caused by the rolling force variation in mill acceleration and decceleration time would be kept to a minimum by the function to adjust roll bending force using the signal of rolling force.

A series of 241 consecutive autogenous vein bypasses for chronic lower-limb ischaemia performed by two surgeons since 1980 was reviewed. After 1985, in situ vein bypass was employed preferentially and was compared with reversed vein bypass. The two groups of patients had similar risk factors, indications and outflow. Of the 241 bypasses, 157 were to the below-knee popliteal artery and 84 to infrapopliteal arteries. The utilization rates of a single ipsilateral saphenous vein were 57.5% for reversed and 71.9% for in situ vein bypass. However, in situ vein bypass was impossible in 43 procedures and these were changed to the reversed operation with contralateral vein. The primary 5-year patency rates of reversed and in situ vein bypass grafts to the popliteal artery were 82.5 versus 74.5%, and the primary 4-year patency rates for infrapopliteal bypass 68.5 versus 80.0%. The respective secondary patency rates were 94.2 versus 92.1% and 85.7 versus 91.1%. The main cause of graft failure was vein graft stenosis (reversed vein bypass, 13.0%; in situ, 11.1%), which usually occurred in the first 2 years after surgery. Of 23 grafts revised for stenosis. 21 were salvaged and restenosis rarely occurred. Both reversed and in situ vein bypass grafts were equally effective, but careful surveillance for 2 years and aggressive revision were extremely important after either type of reconstruction.

A 78-year-old man had non-small cell lung cancer (NSCLC) in the left upper lobe (squamous cell carcinoma, cT1N0M0). He preferred less invasive treatment and undertook stereotactic radiotherapy (SRT)[48 Gy/4 Fr] because his forced expiratory volume in 1 second percent (FEV1.0%) was 53.50%. The therapeutic effect was partial response and the adverse reaction was dermatitis (grade 1). Seven months after SRT, local recurrence was detected. The tumor was growing from 3 x 5 mm to 25 x 25 mm in size. Nine months after SRT, left upper lobectomy was performed successfully unaffected by SRT. He is doing well 14 months after the operation without any signs of recurrence. This case might help develop a new strategy for the treatment of stage I NSCLC. It is that patients with stage I NSCLC have SRT as 1st line treatment, and if local recurrence is observed after SRT, lobectomy may be performed.

This study proposes methods for the support of radiotherapy planning for dynamic tumor-tracking irradiation for lung tumors. It aims to simulate the deformation of the lung caused by respiration and to visualize the result as DRRs (Digitally Reconstructed Radiographs) in real time. Our lung- deformation model treats the lung as an elastic object and analyzes the deformation based on linear FEM (the Finite Element Method). The simulation models the lung using CT volume data and generates a model with boundary conditions with freely adjustable regions, displacements, and phases. The doctor planning the radiotherapy can reproduce the movement of the lung tumor by freely adjusting the regions, displacements, and phases of the boundary conditions while comparing the position of the lung tumor in an X-ray photograph. For highspeed display we propose a method for rapid-generation DRRs by slice-based volume rendering. The result of several functional evaluations and trials of simulation established that the proposed method can describe the movement of the lung tumor with adequate precision. The developed system is expected to be useful for radiotherapy planning for real-time tumor-pursuing irradiation.

Insulin-like growth factor I (IGF-I) is a useful therapeutic agent in insulin resistant diabetes mellitus due to insulin receptor disease because of its hypoglycaemic effects through the IGF-I receptor. A girl with typical type A insulin resistant syndrome was treated with IGF-I for two years and the treatment was effective in ameliorating hyperglycaemia. Overproduction of testosterone in polycystic ovaries was aggravated with this treatment, however. Therefore, IGF-I treatment may be used for glycaemic control but with caution because of its possible side effect of aggravating hyperandrogenism in these patients.

Accurate film thickness controls are indispensable for manufacturing defect-free semiconductor devices. Moreover, recent high integration requires simultaneous measurement of each film thickness and optical constants in multi-layers. This paper explains a microspectroscopic film thickness measurement system that measures film thickness at a very small spot (several micrometers in diameter) in several angstrom increments. This system also enables you to measure film thickness on bulk wafers and SOI wafers, and determine optical constants of unknown films. >

Purpose: To verify the geometric accuracy of the X‐ray image‐based dynamic tracking for a four‐dimensional (4D) image‐guidedradiotherapysystem with gimbals mechanism of MHI‐TM2000 (VERO). Methods: This study was performed employing a 3D moving phantom with a steel‐ball target of 9.5‐mm‐diameter; a laser displacement gauge; orthogonal kV x‐ray imaging subsystem, a gimbaled X‐ray head, and a systemcontroller of MHI‐TM2000. The moving phantom was driven based on the programmed motion patterns (seven periodic [Motion range: 20–40 mm, Breathing cycle: 2‐5 s] and 15 of 3D patient's respiratory patterns). Subsequently, the displacements of the target were measured in real time by the laser‐displacement gauge and the orthogonal kV x‐ray imaging subsystem. Meanwhile, the system predicted the future target position, and then the orthogonal gimbals were transferred to the corresponding orientation. The transferred and the current orientation of the gimbals were recorded. Predicted target positional errors (EP), mechanical errors (EM) of the gimbals, and total tracking system errors (ET) derived from EP and EM were computed. Results: Root mean square of ET (RMSET) was up to 0.68 mm for the periodic patterns. As for the entire patient's respiratory patterns, average RMS of EP, EM, and ET were 1.28, 0.12, and 1.24 mm, respectively. The principal component score which was computed from the patient's respiratory motion under the conditions of free breathing decreased with large amplitude, long breathing cycle and high breathing stability. A strong positive correlation was observed between the ratio of the RMSET to the amplitude and the principal component score of the respiratory motion (R2 = 0.76). Conclusions: This study showed that MHI‐TM2000 has the capability for high tracking accuracy. The prediction error mainly caused the total tracking system error while the mechanical error was negligible. In addition, tracking error can be predicted from the principal component analyses. This research was in part sponsored by Mitsubishi Heavy Industries, Ltd., Japan.

Aim To examine whether Cycrobilirubin Formation Capacity (CFC) could be clinically relevant in the treatment of neonatal hyperbilirubinemia. Study design CFC is a sum of irradiances multiplied by the wavelength-specific bilirubin photoisomerization rate, calculated at 40 nm intervals between the ranges 400–520 nm, measured using a novel spectroradiometer. After evaluating CFC and footprints of light emitting diode (LED) device and fluorescent tube (FT) device, we performed a randomised controlled trial (RCT) to test whether phototherapies provided with different light spectra using the same CFC are equally effective. Thirty-two babies were enrolled without any exclusion criteria. Total serum bilirubin (TSB) levels before and after phototherapies were compared. Result Seventeen babies were assigned to FT and fifteen to LED group. Birth characteristics were similar. Changes in TSB levels before and after phototherapy in LED and FT group were not different. Conclusion Under the same CFC evaluated by the spectroradiometer, LED was as effective as FT. This supports the idea that CFC could be relevant in phototherapy for the treatment of hyperbilirubinemia in otherwise healthy newborns.

We report a case of a bright, alert patient with central neurogenic hyperventilation (CNH) associated with cerebral malignant lymphoma. CNH is a syndrome comprising normal or elevated arterial oxygen tension, decreased arterial carbon dioxide tension, and respiratory alkalosis in the absence of cardiac or pulmonary disease that stimulates a compensatory hyperpnea. A-72-year-old man with recurrent central nervous system lymphoma presented with hyperpnea. showing a respiratory rate over 30 per minute. He was fully awake and conscious. Routine laboratory studies and chest X-ray were normal, but arterial blood gas examination on room air showed respiratory alkalosis, regardless of wakefulness or sleep. Pulmonary infarction was denied by pulmonary flow scintigram. Rebreathing from a paper bag, intravenous administration of diazepam, and oxygen inhalation failed to alter the respiratory pattern. Brain MRI demonstrated two mildly enhanced lesions within the left side of the medulla oblongata and right side of the pons. CNH is rare in patients with normal consciousness. It seems to be caused by brainstem injury that includes the respiratory center.

Endotracheal/endobronchial metastases (EEMs) from nonpulmonary neoplasms are rare. However, their definition and developmental modes have not yet been fully elucidated.EEMs were defined as documented nonpulmonary neoplasms metastatic to the subsegmental or more proximal central bronchus, in a bronchoscopically visible range. The clinical and pathologic features of 16 cases were reviewed, with special emphasis on the developmental modes based on five criteria: location in the tracheobronchial tree, number of lesions, laterality of lesions, depth of lesions, and relationship with the associated bronchus.The developmental modes were proposed on the basis of the above five criteria as follows: type I, direct metastasis to the bronchus; type II, bronchial invasion by a parenchymal lesion; type III, bronchial invasion by mediastinal or hilar lymph node metastasis; and type IV, peripheral lesions extended along the proximal bronchus. Primary tumors included colorectal in six patients, breast in three patients, uterus in two patients, osteosarcoma of the bone in two patients, and maxillary, larynx, and parotid carcinoma in one patient each, respectively. The mean recurrence interval was 65.3 months. The developmental modes were as follows: type I, five patients; type II, one patient; type III, four patients; and type IV, nine patients. Three patients underwent surgical resection. One patient has remained well for 5 years after operation. Median and mean survival times were 9 months and 15.5 months, respectively.The mean recurrence interval was long at 65.3 months, but the mean survival time was short at 15.5 months. Type I accounted for only 5 of 16 patients. Type II was found in only one patient. It is thought that this type is a rare form. Type IV affected nine patients. Treatment plans must be individualized, because in some cases, long-term survival can be expected.

The purpose of this study is to determine and recommend the optimal radiation source according to breast size for tangential irradiation in breast conserving therapy.Twenty-eight patients treated at our department from January 1994 to January 1996 were studied. The dose distribution within the irradiated breast was calculated using a (60)Co-gamma ray and 6 MV-X ray. Then we compared 3-D dose distributions of the (60)Co-gamma ray and 6 MV-X ray in different-sized breasts. Three parameters (breast volume, chest wall separation, and breast height) were adopted as representative of breast size. We also examined correlations among the three parameters.When the breast size was large (breast volume400 cm(3), chest wall separation19.5 cm, or breast height6.5 cm), the average volume of normal tissue which received more than 110% of the isocenter dose ("hot spot") was significantly greater with the (60)Co-gamma ray than with the 6 MV-X ray (p0.05). A similar result was obtained with regard to hot spots in the clinical target volume. The cold area that received less than 95% of the isocenter dose was greater using a 6 MV-X ray when the breast size was small (breast volume200 cm(3), chest wall separation17.5 cm, or breast height5.0 cm). However, the difference was not significant. There was a significant correlation between breast volume and chest wall separation (r =0.849, p0.001). Breast volume and breast height were also significantly correlated (r =0.813, p0.001).Since breast volume and shape are different in each patient, the optimal energy should be selected for each case to obtain uniform dose distribution in breast-conserving therapy. Chest wall separation or breast height, which are measurable without a 3-D planning system, can substitute for breast volume as parameters for breast size. We recommend that the (60)Co-gamma ray not be used for treating large breasts, those with chest wall separationor =19.5 cm or breast heightor =6.5 cm.

Results of radiation therapy for 20 patients with recurrent meningioma were analyzed. The patients included 8 men and 12 women, with a median age of 55 years. All of the patients had undergone at least one operation prior to the reoperation preceding radiotherapy. Ten patients had benign meningiomas, while 4 and 6 patients had atypical and malignant meningiomas, respectively, at the time of radiotherapy. The median radiation dose was 59.4 Gy (range: 50-61.2 Gy). The local control rate at 5 years was 36% for all 20 patients (41% for benign meningiomas and 30% for atypical or malignant meningiomas). The 5-year survival rate was 47%. Excluding 2 patients whose follow-up period was shorter than the preradiotherapy interval from the previous operation, the postradiation recurrence-free period was longer than the preradiotherapy interval in 50% (9/18) of the patients. No serious complications of radiotherapy were observed. Radiotherapy seemed to be effective in controlling the tumor or delaying recurrence in at least half of the patients. However, higher doses of radiation, using sophisticated radiation techniques, may be necessary to obtain higher control rates.

Local control for pituitary adenomas treated with external beam radiation therapy was retrospectively analyzed to evaluate the efficacy of radiation.Thirty-eight patients treated with radiation therapy between 1979 and 1994 were analyzed. The median age was 46. Nineteen newly diagnosed tumors were treated with surgery and radiation therapy, while the others were recurrent cases. Twenty-two tumors were non-functioning, while 10 produced growth hormone (GH) and three each were prolactin-, and adrenocorticotropic hormone (ACTH)-producing tumors. The median-radiation dose was 50 Gy in 25 fractions.Non-functioning adenomas and prolactin-producing adenomas were completely controlled, judging from the absence of tumor progression on neuroimaging studies and clinical symptoms, and normalization of the serum prolactin level (25 ng/ml). On the other hand, local control was obtained in only one of the 3 patients with ACTH-producing adenomas, and the control rate at 10 years was only 46% for GH-producing adenomas. Panhypopituitarism developed in 35% of the patients after radiation therapy. No other serious complications were noted.Non-functioning pituitary adenomas and prolactin-producing adenomas were well controlled with external radiation therapy combined with surgery. However, dose escalation might be necessary to control GH-or ACTH-producing tumors. It is important to replace corticosteroid hormone and thyroid hormone in many patients.

Variation in decimal reduction (D) time/value for attaining sterility assurance was reported in terms of difference between lot to lot and/or manufacturer to manufacturer of soybean casein digest (SCD) culture medium. The D value variation phenomenon itself due to SCD culture medium was reported by Graham et al; however, it was not sufficiently clarified what constituent(s) of SCD culture medium would mainly contribute to the variation of D value. If it is not well clarified, the reproducible sterility assurance cannot be successfully attained. The authors studied individually the constituent of SCD broth (SCDB), SCD agar (SCDA) and SCD broth plus 1.5% agar (SCDB/A). As a result, the culture medium constituent causing D value variation among SCD culture medium was determined as the difference of calcium (Ca) amount as well as the presence and the absence of K2HPO4 in SCD culture medium. Additionally, it was clarified D value differed significantly between SCDB and SCDA. D value using the former was around 1 min lower than that using the latter. This phenomenon can be explained from the formation of insoluble CaHPO4 in SCDB culture medium, resulting in insufficiency of usable Ca to B. stearothermophilus in SCDB culture medium.

Systemic chemotherapy has been increasingly used in the primary treatment of intracranial germinoma. However, the recurrence rate seems to be very high after treatment with chemotherapy alone. We used radiation to treat 5 patients harboring intracranial germinoma that recurred following primary chemotherapy. They had received systemic chemotherapy (4 with cisplatin plus etoposide and 1 with adriamycin, vincristine, cyclophosphamide, prednisolone, and cisplatin) 7-24 months before referral. All patients were treated with conventional radiotherapy directed to the primary tumor site or the craniospinal axis with a dose to the primary site ranging from 39.6 to 47.0 Gy (mean, 42.6 Gy). Response to radiation of all the recurrent tumors was good and all tumors disappeared on diagnostic imaging below the dose of 24 Gy. All patients are alive without further recurrence at 61-129 months after salvage radiotherapy. Germinomas recurring after primary chemotherapy do not seem to have acquired cross resistance to radiotherapy. They can usually be cured by standard radiation therapy with 40-47 Gy.

To assess the correlation between angiographic findings, tumor stage, tumor size, histological type, and the effect of transcatheter arterial infusion (TAI) chemotherapy in patients with uterine cervical cancer.Thirty-three patients with untreated cervical cancer underwent two cycles of TAI. Changes in angiographic findings and other clinical and imaging data were assessed using the X2 test, multivariate analysis, and the two-sample t-test.The group with parametric involvement included more patients with hypervascular tumors (21/24) than the group with no parametric involvement (0/5) (p0.001). Multivariate analysis revealed no correlation between initial tumor size, histology, or angiographic pattern and the effect of TAI.The angiographic patterns seen in cervical cancer correlated with tumor stage. However, neither angiographic findings nor other clinical features predicted the effect of TAI.

We present a case of 83-year-old woman with pure red cell aplasia appearing eight months after thymo-thymectomy for an invasive thymoma. She underwent thymo-thymectomy for an invasive thymoma in July 1996. Preoperative examination revealed neither anemia nor hypogammaglobulinemia. About eight months after the operation, she was readmitted because of anemia and hypogammaglobulinemia. Bone marrow aspiration revealed absence of erythroblasts and chest CT revealed norecurrence of thymoma. Her anemia had responded to ciclosporin.

A musical hallucination is defined as a type of auditory hallucination characterised by the perception of music without an external source.1 Reports in the literature state that musical hallucinations are common in women, and are associated with ageing, deafness,2,3 brain diseases (epilepsy, tumour, stroke, meningitis and neurosyphilis),3,4 psychiatric diseases (schizophrenia and manic depression),3,4 toxic states (alcohol)2 and drugs (antidepressants,1 salicylate,5 quinine and aspirin4). Some authors proposed that, when listening to music, the auditory input is processed by three stages, operating in a hierarchical fashion: perception of individual sounds, perception or imagery of pattern in segmented sound, and encoding or recognition of patterned segmented sound.6 It is supposed that musical hallucinations are caused by abnormal autonomous activity in the auditory brain systems responsible for normal musical imagery.7 It seems reasonable to say that, in acquired peripheral deafness, there is impoverished auditory input that allows spontaneous activity between perception or imagery and encoding or recognition of pattern in segmented sound.6 Regarding lesions in the central nervous system, these lesions may alter the threshold of spontaneous activity within the network for the perception and imagery of music.6 We describe a patient with musical hallucination who experienced an increase in the repertoire of musical hallucinations as she sang various songs, and discuss some of the undetermined problems related to cognitive processing of music: melody, accompaniment and timbre. In July 2002, a 75-year-old, right-handed woman was visiting a hospital on a daily …

We report a 69-yr-old female with a liver mass which, when surgically resected, was believed to be the spontaneous complete necrosis of hepatocellular carcinoma. The preoperative level of alpha-fetoprotein was high at 1050 ng/ml, and the mass was grossly an encapsulated nodular lesion with septa. Histologically, no viable tumor cells were demonstrated. The alpha-fetoprotein level decreased to a normal range. The postoperative course was uneventful, and the patient is alive and well 1 yr after surgery.

7-Substituted 5-methyl-2-isopropylamino-4H-3,1-benzoxazin-4-ones (BOZNs) were prepared and tested as inhibitors of human sputum elastase (HSE). The BOZNs with certain amino acid residues at the 7-position proved to be potent inhibitors of HSE. Some of the compounds also showed a high selectivity for HSE versus chymotrypsin. In a hamster model in which acute injury was induced by intratracheal administration of HSE (1.0 mg/kg), these compounds, when administered intratracheally (1.0 mg/kg) either 30 or even 240 min before challenge with HSE, significantly suppressed pulmonary hemorrhage. These findings suggest that 7-substitution of BOZN by amino acid residues can produce strong and HSE-specific inhibitors, with potential use in elastase-mediated disorders.

Purpose: The purpose of this study was to estimate skin dose from real‐time X‐ray fluoroscopyimaging to do clinical trials for real‐time tumor irradiation in MHI‐TM2000 system (Vero). Methods: First, exposure dose with backscatter was measured using a single set of kilovoltage X‐ray tube and a flat panel detector; a cylindrical ionization chamber (DC300, IBA); and a water‐equivalent plate phantom. The chamber was rigidly attached on the plate phantom of 200 mm in thickness. Then, the chamber was positioned to 150 mm upper from the isocenter. Subsequently, exposure dose to an irradiation field of 171 mm × 226 mm was measured at a speed of 5 fps with 200 mA of the X‐ray tube current; and 40∼120 kVp of the X‐ray tube voltage, respectively. The nominal exposure time was set to 5 ms. Next, half‐value layer of aluminum was measured using a spherical ionization chamber (A4, Exradin) to calculate the effective energy and absorbed dose conversion factors of soft tissue. Then, the skin dose was calculated from the exposure dose and absorbed dose conversion factors. Results: There were good liner correlations between the X‐ray tube current and skin doses; and therefore, estimated skin dose from the X‐ray fluoroscopy with 1 mAs and 100 kV was 140 μGy. Furthermore, estimated skin dose for one successive minute exposure at a speed of 5 fps with 0.1 mAs and 100 kV was 4 mGy. The skin doses in the MHI‐TM2000 were greater by a factor of 1.4∼1.6 than those in Elekta Synergy system with the tube voltage of 100 or 120 kV. Conclusions: We have observed that the skin dose is a little larger than in the Synergy system while the filtration to the X‐ray source has not been applied to the MHI‐TM2000. To perform real‐time tumor tracking, further investigation may be required. This research was in part sponsored by Mitsubishi Heavy Industries, Ltd., Japan.

There are few reports on the assessment of left ventricular contraction during cardiopulmonary bypass (CPB) in open heart surgery. LV Emax is thought to be a load-independent index of left ventricular function. We used a left ventricular conductance catheter to measure LV Emax from "non-working beating heart" during CPB in 16 patients who underwent open heart surgery. During CPB, at 45 minutes after aortic declamping, changes of heart rate with atrial pacing (120/min) did not change LV Emax, but after intravenous dobutamine administration (DOB, 10 micrograms/kg/min) LV Emax increased by 26% (p0.01). DOB increased LV Emax in 14 of 16 patients during CPB. These 14 patients were weaned from CPB without difficulty. But in 2 other patients DOB didn't increase LV Emax during CPB. In order to be weaned from CPB, the two patients needed epinephrine and intraaortic balloon pumping. We concluded that change of LV Emax made by intravenous administration of dobutamine is one of useful indexes to assess left ventricular contractility during cardiopulmonary bypass.

Inhibitors of human leukocyte elastase (HLE) may exert potent therapeutic effects on pulmonary emphysema, adult respiratory distress syndrome and other diseases involving tissue degradation. 7-(4-Chlorophenylsulfonyl-L-glutanyl)amino-5-methyl-2-isopro pylamino-4H-3,1- benzoxazin-4-one (TEI-5624) and 7-(4-chlorophenylsulfonyl-L-lysyl)amino-5-methyl-2- isopropylamino-4H-3,1-benzoxazin-4-one (TEI-6344), two derivatives of 5-methyl-4H-3,1-benzoxazin-4-one, showed strong and highly specific inhibition of human sputum elastase (HSE), which is equivalent to HLE, with Ki values of 6.91 and 16.3 nM, respectively. The selectivity of TEI-5624 for HSE vs. several proteinases ranged from 300-fold to 45,000-fold in favor of HSE. TEI-5624 and TEI-6344 also efficiently prevented degradation of insoluble elastin by stimulated polymorphonuclear leukocytes. The elastase inhibitory capacity of these compounds was not affected by treatment with stimulated polymorphonuclear leukocytes or Pseudomonas aeruginosa-origin elastase. When administered intratracheally to hamsters. TEI-5624 and TEI-6344 were eliminated from the lung with half-times of 85 and 240 min, respectively. In acute injury induced by intratracheal administration of HSE in hamsters, these compounds significantly suppressed pulmonary hemorrhage when administered intratracheally (1 mg/kg) either 30 or 240 min before challenge with HSE (1 mg/kg). HSE-induced emphysema in hamsters was also prevented by TEI-5624 (1 mg/kg) administered intratracheally 7 hr after HSE administration (1 mg/kg). These results suggest that TEI-5624 and TEI-6344 may be useful therapeutic agents for the treatment of HLE-mediated diseases.

A successful experience of a case with chronic traumatic thoracic aneurysm is reported. A 51-year-old male patient had a history of a blunt chest trauma in a traffic accident one and a half year ago. He developed gradual hoarseness because of the recurrence nerve paralysis. Computed tomography and angiography revealed a saccular aneurysm at thoracic descending aorta. It was treated with direct closure of the tear under partial clamp of the aorta. His postoperative course was excellent. He is doing well two years after operation.

e12057 Background: Vulvar Paget's disease is difficult to diagnose early because this is a rare disease with an incidence of 10 patients per one million females per year and often ocurrs in elderly women aged 60-70 years old. A randomized controlled trial, meta-analysis and evidence-based medicine are not suitable methods of improving the prognosis of this disease. Vulvar Paget's disease is an adenocarcinoma in situ and a malignant disease. Since early diagnosis and treatment is necessary to improve prognosis, we extracted the causes of late diagnosis and proposals to improve prognosis from the literature. Methods: Literature review was performed through Japana Centra Revuo Medicina and PubMed. Ten articles including our study on 283 Asian women and seven articles on 363 Caucasian women were collected and examined according to patient age, interval between the initial symptom and the start of therapy, reason for delay in treatment and measures to prevent delay. Results: The mean age was 69.2 years (min∼ma...

A 43-year-old man was pointed out an abnormal shadow on chest X-ray film. Chest CT showed a solid mass and a cyst at anterior superior mediastinum. Operation revealed a capsulated thymoma and a multilocular thymic cyst. PTH and CA19-9 level in the cystic fluid was elevated. Histological examination demonstrated the clear separation of the mixed type thymoma and the thymic cyst. There were few reports for cases of thymoma with a thymic cyst.

A 66-year-old male was referred to our department with mediastinal tumor. The chest X-ray and the chest CT showed a large tumor adjacent to pulmonary artery and descending aorta. Cavogram revealed a filling defect of the SVC. He underwent complete resection of the tumor, resection of the SVC and reconstruction of the SVC with ringed PTFE. The main tumor was 12 x 7 cm in size and the tumor in the SVC was 20 x 15 mm in size. Histopathological findings showed a lymphocytic thymoma. Compact invaded nest of tumor cell was found in the innominate vein. The tumor in the SVC was invasive to the intima of the SVC, but its media and adventure were intact. This case is rare among patients with invasive thymoma as far as the growth is concerned.

University of Wisconsin (UW) solution has been reported to extend the safe cold ischemic time in the preservation of the liver, kidney and pancreas. However, there have been few reports of safe cold ischemic time in heart preservation with UW solution. The purpose of this study was to find whether UW solution can extend the safe cold ischemic time in cardiac transplantation in dogs. Heterotopic cardiac transplantation was performed in mongrel dogs after cold ischemic preservation of the hearts with UW solution, ischemic time 8, 16 and 24 hours (Gr.UW8, Gr.UW16 and Gr.UW24, respectively) and with GIK solution, ischemic time 4 hours (Gr.G4) which is considered the safe cold ischemic time in clinical cardiac transplantation. The following was studied: 1) Emax of the LV, myocardial contraction, by pressure-volume curve with the volume measured conductance catheter method, 2) myocardial tissue blood flow of the LV (MTBF), with laser doppler tissue flow meter, 3) serum CPK and electron microscopical evaluation. Emax and MTBF were measured before transplantation and after reperfusion. Their results were expressed as percentage of the values before transplantation. As results, after 120 minutes from reperfusion, Emax was recovered to 94 +/- 13% in Gr.G4, 104 +/- 11% in Gr.UW8, 67 +/- 22% in Gr.UW16 and 66 +/- 16% in Gr.UW24. Emax in Gr.G4 and Gr.UW8 were significantly (p less than 0.01) higher than that in Gr.UW16 and Gr.UW24. After 120 minutes from reperfusion, MTBF was recovered to 90 +/- 19% in Gr.G4, 98 +/- 9% in Gr.UW8, 63 +/- 19% in Gr.UW16 and 61 +/- 6% in Gr.UW24.(ABSTRACT TRUNCATED AT 250 WORDS)

A 38-year-old male was admitted with edema of the neck and face. Chest X-ray revealed a mediastinal tumor. On chest CT and MRI, a tumor infiltrating the superior vena cava and bilateral brachiocephalic veins in the upper mediastinum was observed. Venography revealed obstruction of bilateral brachiocephalic veins. The tumor was diagnosed as thymoma by percutaneous biopsy, but since it was of stage III according to Masaoka's classification, complete extirpation was considered to be impossible. Preoperative chemotherapy with multiple drugs (CDDP, ADM, VCR, CPA) was administered. The superior vena cava syndrome resolved and the tumor diminished in size. Because of leukopenia, rhG-CSF was also used. The tumor infiltrated the left brachiocephalic vein; therefore, total resection and left brachiocephalic vein reconstruction were performed. Histopathological examination showed extensive, necrosis and fibrosis containing residual thymoma. Postoperatively, similar chemotherapy and cobalt irradiation (40 Gy) to the superior mediastinum were performed. We thus present a case of invasive thymoma which responded to preoperative chemotherapy.

A case of invasive thymoma with retroperitoneal recurrence is reported. A 55-year-old man with invasive thymoma (Masaokas classification, Stage IVa) underwent thymo-thymectomy, partial resection of left upper lobe, resection of phrenic nerve and partial resection of parietal pleura on March 14, 1989. Histological findings revealed thymoma with predominantly lymphocytic type. Two years after the operation, the tumor of retroperitoneal recurrence was discovered in abdominal CT. This retroperitoneal tumor was huge in size (16 x 12 cm) and extended into posterior mediastinum via aortic hiatus. The patient underwent resection of tumor through thoracotomy and laparotomy on April 23, 1991, after two cycles of chemotherapy. Histological findings revealed thymoma with predominantly lymphocytic type. This case was rare among patients with recurrence of thymoma as far as the site of recurrence is concerned.

This study examined the incidence of downhill esophageal varices due to SVC syndrome. The presence of downhill esophageal varices was examined by esophagoscopy or autopsy. Downhill esophageal varices were detected in two of nine (22%) patients with SVC syndrome. One case was a 66-year-old male case who and underwent upper lobectomy for lung cancer in September 1985. He developed SVC syndrome due to recurrence in 1986 and died in 1987. Downhill esophageal varices wer in the upper esophagus by esophagoscopy and confirmed by autopsy. The another case was a 61-year-old female who developed carcinoma of the tongue in 1986 and lymph node metastasis to the mediastinum in 1987. Autopsy revealed downhill esophageal varices in the upper and middle esophagus. Eleven cases of downhill esophageal varices due to SVC syndrome reported in Japan were reviewed and discussed.