Large capillary fluid permeability in skeletal muscle and skin of man as a basis for rapid beneficial fluid transfer between tissue and blood. Our previous studies strongly indicate that the capillary filtration coefficient (CFC) in skeletal muscle and skin of man is much larger than previously believed, or about 0.050 ml min-1 100 ml-1 mmHg-1. The hypothesis that this large capillary fluid permeability is a factor of primary importance for plasma volume control was approached. Experimental hypovolaemia induced by lower body negative pressure (LBNP of 70-95 cmH2O) was associated with a rapid net fluid gain from the studied upper arm into the circulation of 0.17 ml min-1 100 ml-1 tissue. The transcapillary driving force for this fluid transfer, probably caused by adrenergic adjustment of vascular resistance, with a decline of capillary pressure, was relatively small, or 1.7 mmHg on average. CFC was instead very high during LBNP, increasing from a control value of 0.054 +/- 0.004 (SE) to no less than 0.097 +/- 0.007 ml min-1 100 ml-1 mmHg-1, probably reflecting an increased number of effectively perfused capillaries. It is suggested that the large capillary fluid permeability in skeletal muscle and skin of man, with large tissue mass and fluid reservoir, may be of great functional importance for plasma volume control after blood loss and also in other (patho)physiological situations. As demonstrated, it can thus permit rapid transfer of large fluid volumes into the circulation and, perhaps of special importance, with only small transcapillary driving force (capillary pressure decline).(ABSTRACT TRUNCATED AT 250 WORDS)


Post-prandial cardiovascular responses in man after ingestion of carbohydrate, protein or fat. Changes in cardiac output and in superior mesenteric arterial flow were followed with Doppler ultrasound techniques in five young, healthy persons for 2 h after ingestion of medium-sized (4 MJ), fluid meals containing either carbohydrate, protein, fat or water only. Measurements were carried out before meals and at regular post-meal intervals, during which mean arterial blood pressure was also followed. All energy-containing meals caused marked and gradually developing post-prandial increases in cardiac output as well as in superior mesenteric arterial flow. The maximum flow levels were reached in the course of 30-60 min and maintained until the observations ended after 2 h. The intake of water caused no such flow increases. There were considerable interpersonal variations in the size and in the speed of development of the flow increases after the three types of energy-containing meals. The flow-increasing effects of the three meal types were not significantly different, even if the most marked increases (median values about 11 min-1 for both cardiac output and superior mesenteric arterial flow) occurred after carbohydrate meals. The marked effects on circulation of the three food components were also revealed in the calculated, integrated amounts of 'extra' cardiac output and superior mesenteric arterial flow observed in the course of the 2 h following the meal. Values of more than 100 1 for such 'extra' flows were seen after carbohydrate meals. The marked ingestion-released increase in blood flow to the splanchnic organs is apparently partly met by an increase in cardiac output, and partly by some redistribution of flow, which benefits the digestive system.


Evidence for long-term fluctuations in regional blood flow within the rabbit left ventricle. The regional distribution of coronary perfusion within the left ventricle is markedly heterogenous. The perfusion pattern is composed of both spatial and temporal variations in perfusion among single myocardial samples. Previous investigators have mostly studied short-term (< 1 min) temporal variability. The aim of this study was to quantify long-term fluctuations in perfusion to single samples within the rabbit left ventricle. Coronary perfusion was estimated from the deposition of microspheres in myocardial samples (range 32-96 mg). Two batches of microspheres were infused either simultaneously or sequentially over specified periods of time. The paired values for regional perfusion were compared and Kendalls correlation coefficient (tau) calculated. The assumption being that the lower tau, the higher degree of temporal perfusion variability was present. The tau for paired values of regional myocardial perfusion based on two sequential infusions lasting either 10 s, 5, 10 or 30 min, averaged 0.40, 0.55, 0.80 and 0.80, respectively. No difference was detected between awake and anaesthetized animals. The tau for two simultaneous infusions averaged 0.95 irrespective of the duration of the infusion, indicating negligible methodological error. The coefficient of variation for spatial perfusion heterogeneity ranged from 0.3 to 0.4 irrespective of the infusion duration. The findings suggest that regional coronary vasomotion is characterized by a wide range of cycle times, some of which have cycle times of more than 30-min duration. Although part of the regional perfusion heterogeneity was due to long-term fluctuations in perfusion, temporal variations with cycle times less than 5 and 10 min, respectively, were more prominent.


Secretin stimulates bile ductules to secrete both H+ and HCO3(-)-ions. Secretin-dependent ductular HCO3- secretion into bile may involve secretion of H+ to interstitial fluid and HCO3- to bile by the ductular epithelium. To determine whether secretin causes bile ductules to secrete H+, we have examined the effect of secretin on the elimination of an intracellular acid load from bile ductular epithelium during pharmacological blockade of Na(+)-H+ exchange and in the absence of HCO3-. Microdissected bile ductules from pigs were suspended in HCO3- free HEPES buffer and loaded with acid using an NH4Cl prepulse technique. Intracellular pH was measured using dual-wavelength excitation of BCECF fluorescence. Na(+)-H+ exchange was defined as a Na(+)-dependent and amiloride- and 5-(N,N-hexamethylene)-amiloride-sensitive efflux of H(+)-ions following acid loading. We found that secretin stimulated ductular H+ secretion independent of Na(+)-H+ exchange. Blockade of Na(+)-H+ exchange by hexamethylene-amiloride did not affect secretin-dependent ductular HCO3- choleresis in vivo. We conclude that secretin stimulates bile ductules to secrete H(+)-ions to interstitial fluid as well as HCO3- ions to bile by a mechanism independent of Na(+)-H+ exchange.


Pain-induced inhibition of gastric motility is mediated by adrenergic and vagal non-adrenergic reflexes in the rat. Painful stimuli have been shown to inhibit gastric motility in animal experiments and delay gastric emptying in humans. The aim of the present study was to investigate in detail mechanisms involved in pain-induced gastric inhibition. Pain stimulation by exerting pressure on a testicle induced a prompt gastric relaxation which lasted throughout the period of stimulation. Pain-induced gastric relaxation was significantly reduced by the selective alpha-1 blocker, prazosin, and by the non-selective beta-blocker, propranolol. Similarly pain-induced inhibition of gastric tone was significantly reduced by bilateral cervical vagotomy. In contrast, gastric relaxation following pain stimulation was significantly potentiated by the selective adrenergic alpha-2 blocker, yohimbine. Combined administration of prazosin and propranolol followed by bilateral cervical vagotomy abolished gastric relaxation in response to pain stimulation. In conclusion, gastric relaxation in response to painful stimulation was found to be reflex-mediated via sympathetic neurons acting on alpha-1 and beta receptors and possibly also via vagal non-adrenergic fibres. Pain-induced inhibition of gastric tone was significantly increased by yohimbine. It is suggested that yohimbine by blocking presynaptic inhibitory receptors on adrenergic neurons facilitates the release of noradrenaline in response to pain stimulation.


Non-linearity of skin resistance response to intraneural electrical stimulation of sudomotor nerves. Intraneural electrical stimuli (0.3 mA, 0.2 ms) were delivered via a tungsten microelectrode inserted into a cutaneous fascicle in the median nerve at the wrist in 16 normal subjects, and the effects on the sweat glands within the innervation zone were recorded as changes of skin resistance. In order to examine the relationship between the skin resistance level and the amplitude of transient resistance responses, trains of high frequency stimulation were used to reduce the skin resistance level and then transient resistance responses were evoked by single stimuli at 0.1 Hz. Regional anaesthesia of the brachial plexus in the axilla eliminated spontaneous sympathetic activity and reflex effects. At high skin resistance levels response amplitudes to single stimuli were low but they increased successively to a maximum at intermediate levels and then decreased again at low resistance levels. Repeated stimulation sequences evoked qualitatively similar response curves but quantitatively both response amplitudes and skin resistance levels were slightly reduced upon repetition. We suggest that the changes of response amplitudes are due to variable resistivity of the corneal layer. The shifts of the response curves with repetition of stimulation may result from increased hydration of the corneum. It is concluded that the variability of response amplitudes to constant stimuli makes the amplitude of a skin resistance response unsuitable as an indicator of the strength of sympathetic sudomotor nerve traffic.


Renal interstitial pressure and tubuloglomerular feedback control in rats during infusion of atrial natriuretic peptide (ANP). Atrial natriuretic peptide (ANP), injected at physiological concentrations, is known to induce both natriuresis and diuresis. It has been suggested by some investigators that these changes result from an increasing glomerular filtration rate (GFR), but others have been unable to demonstrate an increased GFR. The tubuloglomerular feedback (TGF) mechanism is an important regulator of GFR, and the sensitivity of TGF is decreased during ANP administration. Furthermore, resetting of TGF is, in most instances, related to changes in renal interstitial hydrostatic and oncotic pressures. It is also known that ANP may increase capillary permeability which may change renal interstitial pressure. The present study was performed to examine renal interstitial pressures and the TGF mechanism during ANP infusion. In accordance with previous studies, TGF sensitivity was found to be decreased. The tubular flow rate which elicited half the maximal drop in stop-flow pressure (Psf) was increased from 18.5 to 25.7 nl min-1. In contrast, ANP infusion resulted in a decreased interstitial hydrostatic pressure and an increased interstitial oncotic pressure. From previous experiments, such changes in interstitial pressures would be expected to increase TGF sensitivity. The changes in interstitial pressure cannot, therefore, directly explain the resetting of the feedback mechanism. In conclusion, the present paper shows a decreased renal net interstitial pressure after intravenous administration of ANP.


Projective invariance and the kinetic depth effect. Seven experiments test the assumption that, in the kinetic depth effect, observers have reliable and direct access to the equivalence of shapes in projective geometry. The assumption is implicit in 'inverse optics' approaches to visual form perception. Observers adjusted a comparison shape to match a standard shape; both standard and comparison were portrayed as in continuous rotation in space, using a graphics computer. The shapes were either plane quadrilaterals or solid prisms. The angular difference of the planes of the shapes was varied, as was the dot density of a texture in those planes. Departure from projective equivalence was measured in six studies by measuring the planar analogue of cross ratio, and in a seventh by measuring the cross ratio for points in space. Projective equivalence was not found to be perceived uniformly, except in one experiment that did not involve rotation in depth. Otherwise changes in orientation of up to 180 degrees about a single coordinate axis had no significant effect on matches in shape, while changes in orientation about more than one coordinate axis produced significant effects. The addition of texture and a change in rotation speed did not correct departures from projective equivalence.


Manipulating procedural variables in a spatial precuing task. Spatial precuing tasks have yielded a consistent pattern of differential reaction time benefits. Specifically, precuing of two fingers on the same hand has been shown to result in faster discrete finger responses than precuing of two fingers on different hands. This phenomenon is called the hand advantage. Within the context of the spatial precuing task originally developed by Miller (1982), a series of four experiments investigated the influences of two procedural variables on the hand advantage: preparation instruction and presentation mode of preparation intervals. Two preparation instruction conditions were compared: implicit versus explicit instructions regarding preparation possibilities. Also, two presentation modes of preparation intervals were studied: a random condition, in which the preparation intervals varied randomly, and a blocked condition, in which the preparation intervals were grouped together in blocks of trials. Results showed that these two procedural variables, when manipulated independently, did not affect the hand advantage. However, when combined, they significantly reduced the hand advantage by half. Moreover, both procedural variables were shown to produce a precuing benefit for two homologous fingers on different hands. We concluded that, in spatial precuing tasks, procedural variables play an important role by inducing preparation strategies, which affect the pattern of reaction time benefits.


The family profile: a new self-report instrument for family assessment. The Family Profile is a new self-report family assessment instrument that is grounded in family theory and designed following a construct validation approach to instrument design that integrated theoretical concepts with test construction and empirical analysis. Development consisted of three component phases: rational theoretical design, empirical structural analysis, and psychometric validation. The first theoretical design phase resulted in a 231-item instrument with 13 construct scales. Structural analysis data were collected from a pilot sample of 160 patients selected from 6 family practice clinics in urban, suburban, and rural locations. After revision based on item and scale analysis, a 129-item instrument was administered to a random sample of 876 patients from family practices throughout Minnesota. Responses were analyzed for item- and scale-distribution characteristics, item-scale and scale-scale correlations, correlation with social desirability, factor analysis to confirm or disconfirm the existence of the theoretical dimensions, internal consistency reliability, and test-retest reliability. This analysis reduced the instrument to 90 items from all 13 postulated constructs that cluster into 6 main factors--Family Concordance, Family Discordance, Marital Strength, Active Involvement, Religiosity, and Parental Leadership. The Family Profile is also temporally stable and free from social desirability bias. Validation (construct and criterion) and normative data studies of various populations are in progress.


Ethnography and family medicine: issues and overview. Ethnography is a qualitative research model generally associated with anthropology. Ethnographic methods include inductively oriented strategies such as participant observation, structured interviews, and open-ended interviews. Issues in family medicine such as patient compliance, doctor-patient relationships, and patients' subjective experience of illness may be optimally studied with ethnography. Because it is inductive, ethnography is cognitively similar to clinical reasoning. Making use of ethnography provides family physicians with a greater array of research methods compatible with clinical practice.


Gender bias in the evaluation and management of acute nontraumatic chest pain. The St. Louis Emergency Physicians' Association Research Group. Prior studies suggest a gender-based difference in the management of myocardial ischemia in nonacute settings. We examined whether there was a gender difference in the emergency department evaluation and management of patients with acute chest pain. A record review from 10 St. Louis metropolitan emergency departments was done on all patients over 35 years old who presented with acute nonpleuritic, nontraumatic chest pain. We reviewed for the presence of cardiac risk factors, prior cardiac disease, time to physician evaluation, and time to initial electrocardiogram. In the patient subgroup admitted from the emergency department with a diagnosis of myocardial infarction or unstable angina, disposition was noted. Women waited longer than men for an initial physician evaluation and an initial electrocardiogram. In the patient subgroup with acute myocardial ischemia, a smaller percentage of women than men (56.0% vs 82.8%) were admitted to an intensive care unit. In patients with acute nonpleuritic, nontraumatic chest pain, women were evaluated and managed less aggressively than men.


Antepartum biopsychosocial risk and perinatal outcome. This paper describes a study of biomedical and psychosocial risks and the perinatal outcome. Two hundred nineteen pregnant women completed three instruments to identify their biomedical and psychosocial risk: anxiety, family function, life events. Biomedical risk was assessed through analyses of self-reported health histories. Information on complications of pregnancy, labor, and delivery was obtained from the hospital delivery records. In the sample studied, biomedical risk alone was not substantially related to perinatal complications. Four psychosocial items were the best psychosocial predictors of perinatal complications: emotional tension; depressive humor; neurovegetative symptoms of anxiety; and dissatisfaction with the time, space, and money shared with the family (p < 0.05). The interaction between these critical psychosocial items and biomedical risk also reliably predicted complications (p < 0.00001). The results of this study suggest that psychosocial risk assessment alone and in interaction with biomedical risk assessment may significantly improve the ability to identify women who may experience perinatal complications.


Natural history of phobic anxiety.

Natural history of phobic anxiety. The characteristics of those with phobic anxiety--anxiety with or without avoidance of specific fear-provoking situations--seen in family practice have not been previously described. However, patients with agoraphobia--extreme avoidance of fear-provoking situations--are frequently seen in the general health sector. In addition, panic attacks, which are spontaneous episodes of intense anxiety associated with at least four autonomic symptoms that build rapidly in intensity, are believed to be antecedent to phobic anxiety. This secondary analysis used 29 patients with panic attacks. During a structured interview, these patients completed a phobic anxiety questionnaire and the Health Locus of Control questionnaire. Of the 21 patients with phobic anxiety, 16 (76%) reported that they avoided at least one situation. Although patients frequently left home during the week (mean = 10.8 times), 11 (58%) felt that their fears controlled their lives. Patients' responses generally supported the model of fear causing anticipatory anxiety that in turn causes avoidance; however, panic attacks frequently began after phobic anxiety but before the fear was reported by patients to control their lives. Recognition and early intervention with those with phobic anxiety may minimize its severity and pervasiveness.


Improving prescription documentation in the ambulatory setting. Use of a standard prescription pad, although it adequately meets the needs of drug delivery, requires the physician to document prescribed medications separately in the medical record. Failure to do so may lead to under-recognition of problems of potential drug interactions and adverse drug reactions, delays in prescription refills, and other areas of quality of care, especially in a setting where multiple physicians may be involved in the care of a patient. Of 83 prescriptions written in a primary care clinic, only 11 (13%) were noted on the chart medication form when physicians used prescription pads. Implementation of a "one-write" noncarbon prescription form that generated an instant copy increased prescription documentation to 83% (49 of 59 prescriptions) (x2 = 68.86; p < 0.005) over a one-week period. In a follow-up study conducted approximately 3.5 years after the initial intervention, use of the "one-write" form had maintained at 82% prescription documentation (32 of 39) prescriptions) (x2 = 52.05; p < 0.005). A "one-write" copy system could improve clinical care by improving medication documentation in the medical record.


Physicians' recognition of depression.

Physicians' recognition of depression. Depression is a common but underrecognized disorder in family practice. The purpose of this study was to determine the relationship between physician attitudes toward psychosocial aspects of care and psychiatric knowledge and recognition of depression in a family practice residency clinic. Adult patients (n = 582) presenting to 16 family practice residents were screened for depression using the short form of the Beck Depression Inventory. A regression model was created with the rate of recognition of depression for each physician as the dependent variable. Independent variables included in the model were resident scores on the Physician Belief Scale and the psychiatric subsection of the in-training exam scores, patient familiarity, and whether the attending physician was consulted. Orientation toward psychosocial aspects of medical care was found to be significantly related to recognition of patients at risk for depression. In-training examination psychiatric subsection scores were unrelated to a resident's clinical recognition of depression risk. This study suggests that physician attitude is a significant factor in successful recognition of depression by family practice residents.


[Dupuytren's disease. Analysis of a 10 year caseload]. The authors present an analysis concerning patients operated on for Dupuytren contracture over the past ten years. One hundred and ten patients (94 males and 16 females) were reviewed. At the time of surgery the average was 52 years old. The 125 hands (292 fingers) were rated 3,136, according to the simplified Tubiana's score. In 82.7% of the patients, selective regional fasciectomy was applied. In the long term, recurrence appeared in 58 hands (96 fingers); 74.1% being in the first five years. 48 of them were graded Stage Nodular, 28 Stage 1, 16 Stage 2, 4 Stage 3. Some factors seem to be of a bad prognosis regarding recurrence: ectopic localisations, age (under 55 years old), alcoholism, diabetes mellitus, epilepsy, and family history. Results after operative procedure were satisfactory. The hands were rated 1,316 and the Coefficient of Amelioration was above 0.75 in more than 50%.


[Abdominal versus thoracic approach for myotomy in esophageal achalasia]. Miotomy is the most common operation for the treatment of achalasia of the esophagus. The most important complication of this operation is gastro-esophageal reflux, and controversy exists in the choice of a thoracic or abdominal approach to this operation. From 1974 until 1988, our group performed 45 miotomies for achalasia of the esophagus. Follow-up was obtained in 82% of the patients. The thoracic approach was used in 21 cases (tor), and 24 patients were operated through an abdominal approach (abd). All the miotomies had an anti-reflux procedure associated. Post-operative evaluation consisted of: clinical score determination; endoscopy with biopsy; manometry; 24 Phmetry. The clinical score revealed that 47% of the patients in the group tor were asymptomatic, and in the group abd this rate was 53%. Absence of macroscopic esophagitis was registered in 75% of the patients in the group tor, and in 91% in the group abd. Microscopic esophagitis was observed in 42% of the cases in the group tor, and in 45% of the group abd. Manometry revealed a low pressure in the inferior esophageal sphincter in 90% of the cases of the group tor, and in 80% of the group abd. Pathological gastro-esophageal reflux, detected by 24 h Phmetry, was present in 29% of the group tor, and in 36% of the group abd. The results in these two groups were very similar, uniformly favourable, and without evidence of superiority of either operation. The choice of a thoracic, or abdominal approach should depend on associated factors such as patient age, respiratory disease, etc.


[Perimesencephalic hemorrhage].

[Perimesencephalic hemorrhage]. Among 293 subarachnoid hemorrhages admitted to the Neurology and Neurosurgery departments of Sta Maria Hospital, 108 patients had a normal cerebral angiography. Twenty-three meet the radiological criteria for perimesencephalic hemorrhage (center of the hemorrhage located in front of the mesencephalon, without blood in the interhemispheric and lateral sylvian fissures, nor significant intraventricular hemorrhage). The clinical picture was one of sudden, severe headache with meningeal signs, without focal signs or decreased alertness. Evolution was benign: there was no intrahospital mortality, morbidity or rebleeds on follow-up (3.5 years). In this subgroup of subarachnoid hemorrhage there is no need for a repeated angiogram if the first angiography is considered normal.


Percutaneous sclerotherapy of varicocele. Percutaneous sclerotherapy of varicocele was considered in 21 patients with left sided varicocele, 16 of whom had recurrences after left spermatic vein ligation in the past. Percutaneous sclerotherapy was possible in 17 patients (80.9%). There were no serious complications with venography or sclerotherapy, and the recurrence rate was 17.6%. Percutaneous sclerotherapy is therefore a simple, safe and effective treatment of testicular vein insufficiency.


[Umbilical flowmetry in twin pregnancy. A method for identifying discordant fetal growth?]. Umbilical artery velocimetry was performed in 33 twin gestations to evaluate the predictivity of the test (umbilical artery S/D difference between the pair > 0.4) in the screening of discordant fetal growth. Four out of 10 cases of discordant fetal growth were identified by the test and it was abnormal in 1 out of 23 concordant twins. The sensitivity was 40%, specificity 95%, positive predictive value 80% and negative predictive value of 79%. In spite of its low sensitivity the test can be useful in detecting discordant fetal growth in twin pregnancies.


[Malignant melanoma. A current problem]. Malignant Melanoma is a tumor of high malignancy which incidence has been shown to increase dramatically during last decades. The genesis of the tumor is uncertain, however the cutaneous fair complexion, the number and type of pigmented nevei and acute intermittent sun exposure with sunburn may play a significant role in its development. Histopathology of suspicious lesions is obligatory as diagnostic proof and to measure the tumor thickness and the skin invasion level. Distinct therapeutic attitudes are reviewed. Correct surgical excision is essential in localized primary lesions. The two main factors regarding surveillance and survival of patients afflicted with Malignant Melanoma are precocious diagnosis of early lesions and quick surgical intervention. On a prophylactic ground, for the early detection of Malignant Melanoma, one should point out the need for a complete and careful skin observation of every individual in current medical examinations.


[Research in child psychiatry].

[Research in child psychiatry]. The research in child psychiatry faces general restrictions related to the observation and interpretation of child psychopathological phenomena. These restrictions are increased by the limits of the methodological credibility of the psychopathological and psychiatric research with adults. The specific form of the emergence of child psychological suffering lies in a great number of factors. These can be derived from the child itself, the interaction that the child has with adults or be related with the mental health of the adults themselves. The research in this field favours the detection of risk situations either individual or social. Assuming the preventive perspective, the early identification of these situations will allow an improvement in medical care. The authors intend to raise pertinent and suggestive questions on child psychiatry research by means of the introduction of update situations. Several areas, which are still being studied, are approached, namely the parental mental pathology and its association with pregnancy and post-delivery, parental drug and alcohol addiction and its relation to the child's development, recent fields of research such as fertilization in vitro and the acquired immunodeficiency syndrome and, lastly, family separation and human communication.


[Prefrontal syndrome as a manifestation of intracranial dural arterio-venous malformation]. The authors present a clinical case of an intracranial dural arteriovenous malformation with clinical manifestations of a prefrontal syndrome, documented with its respective diagnostic tests, including imaging studies. A number of considerations are being enlarged upon, concerning possible pathophysiological mechanisms.


[William Harvey: his life and his works (Part I)]. William Harvey's biography is briefly summarized in this essay. The author shows a bird's-eye view of the 16th and the 17th centuries, with regard to the transformations which occurred in science, and narrates Harvey's life. A short description is given of his precursors and their ideas. His most important works are analysed, as well as contemporary scientists' reactions to them. Special emphasis was laid on the discovery of the blood circulation.


The effect of transforming growth factor beta on the plasminogen activator activity of normal human osteoblast-like cells and a human osteosarcoma cell line MG-63. Transforming growth beta (TGF-beta) has been proposed to have a role in bone remodeling by affecting the differentiation and activity of osteoblasts and osteoclasts and by inhibiting the production of proteinases, such as plasminogen activators (PAs). Studies on PAs have largely been based on data from nonhuman and fetal cell lines, however. The purpose of this study was to investigate the effect of TGF-beta on the PA activity of normal human osteoblast-like cells and to compare this with its action on the human osteosarcoma cell line MG-63. The action of interleukin-1 beta (IL-1 beta) was also assessed because it has been shown to increase PA activity in other connective tissue cell types. Normal osteoblast-like cells had low to undetectable basal urokinase (uPA) and tissue plasminogen activator (tPA) activity, which was significantly stimulated by TGF-beta 1. This action was shown to be dependent on transcription and new protein synthesis. TGF-beta 2 had a similar action. IL-1 beta did not stimulate PA activity. In contrast, the MG-63 cell line had high basal tPA and uPA activities. TGF-beta 1 decreased basal PA activity, the effect being most marked for uPA activity. IL-1 beta stimulated uPA and tPA activity. TGF-beta 1 inhibited IL-1 beta-stimulated uPA activity, but the effect on tPA was more variable. This study has shown that TGF-beta has opposite effects on the PA activity of the two osteoblast-like cell types studied. Care must therefore be used before extrapolating data from one cell type to another.(ABSTRACT TRUNCATED AT 250 WORDS)


Bone mass measurement by DXA: influence of analysis procedures and interunit variation. Interunit variability among bone densitometers is due to different factors, including different calibration procedures and algorithms and variability in photon source energies and/or intensities. Other factors, such as the choice of scan parameters or the analysis procedures, can also introduce variability. The new generation of dual-energy x-ray absorptiometry (DXA) has partially improved this situation. The aim of this study was to investigate the operator-dependent analysis procedures that can affect scan results and to evaluate the phantom and in vivo interunit variation of some DXA instruments. Four DXA instruments (QDR 1000 and 1000/W, Hologic, Inc.) were used. Potential sources of variability in the analysis procedures of anteroposterior lumbar spine and hip scans were considered: in most cases these procedures significantly influenced scan results. On lumbar spine, an enlargement of the scan window of less than 3 cm was responsible for an average increase in bone mineral density (BMD) of about 3%. On the hip, lowering the scan window by about 1 cm accounted for an increase in the whole-segment BMD of about 4%. After standardization of analysis procedures, interunit and intraunit coefficients of variation and percentage differences among instruments were less than 1% for all the parameters considered (area and bone mineral content and density) with both an anatomic and a geometric phantom, and in nine subjects scanned by two different devices the percentage difference in BMD was greater than 2%. This study shows that present interunit variability allows comparisons among laboratories, but only if highly standardized analysis procedures are used.


Reduced vertebral bone density in hypercalciuric nephrolithiasis. Dual-energy x-ray absorptiometry and single-photon absorptiometry were used to determine bone density at the lumbar spine and radial shaft in 62 patients with absorptive hypercalciuria, 27 patients with fasting hypercalciuria, and 31 nonhypercalciuric stone formers. Lumbar bone density was significantly lower in patients with absorptive (-10%) as well as in those with fasting hypercalciuria (-12%), with 74 and 92% of patients displaying values below the normal mean, whereas only 48% of the nonhypercalciuric stone formers had bone density values below the normal mean. In contrast, radial bone density was similar in all three groups of renal stone formers investigated. The comparison of urinary chemistry in patients with absorptive hypercalciuria and low normal bone density compared to those with high normal bone density showed a significantly increased 24 h urinary calcium excretion on random diet and a trend toward a higher 24 h urinary uric acid excretion and a higher body mass index in patients with low normal bone density. Moreover, among the patients with absorptive hypercalciuria we found a statistically significant correlation between the spinal bone density and the 24 h sodium and sulfate excretion and the urinary pH. These results gave evidence for an additional role of environmental factors (sodium and animal proteins) in the pathogenesis of bone loss in absorptive hypercalciuria. In conclusion, our data suggest an osteopenia of trabecular-rich bone tissues in patients with fasting and absorptive hypercalciurias.


Measurement of serum osteocalcin with a human-specific two-site immunoradiometric assay. We developed a sensitive and specific two-site radioimmunoassay (IRMA) for human osteocalcin using human osteocalcin as a standard and two monoclonal antibodies raised against human osteocalcin purified from human cortical bone, a solid-phase anti-25-37 region and a tracer anti-5-13 sequence of the molecule. A wide range of osteocalcin levels (up to 300 ng/ml) can be measured with a sensitivity of 0.4 ng/ml. The intra- and interassay coefficients of variation are less than 4 and 6%, respectively. The recovery of human osteocalcin from serum samples ranges from 96 to 103%. IRMA was linear for serial sample dilutions in a wide range of serum osteocalcin levels, even in patients with chronic renal failure on hemodialysis. Depletion of serum in intact osteocalcin demonstrated that IRMA detects, in addition to the intact peptide, a large N-terminal midregion fragment that represents about 50% of total osteocalcin levels in normals and patients with Paget's disease and up to 75% in patients with chronic renal failure. This large fragment, previously unrecognized because it cannot be distinguished from intact osteocalcin with gel filtration chromatography, is not generated in vitro by incubation of the serum up to 26 h. We measured osteocalcin in the serum of 309 healthy adults (180 men and 129 women, age range 20-95 years), 36 patients with Paget's disease, 12 patients with primary hyperparathyroidism, 70 patients with chronic renal failure on hemodialysis, and 10 patients on corticosteroid therapy, simultaneously with human IRMA and with a conventional radioimmunoassay (RIA) based on bovine reagents. A tight correlation (r = 0.889) was observed between the two assays in the normal population, but the values obtained with IRMA were about threefold higher (mean 23.3 +/- 10.5 versus 7.5 +/- 3.4 ng/ml) than those obtained with RIA. Reported as Z scores, that is, number of standard deviations from the predicted normal mean adjusted for sex and age, these two assays (IRMA and RIA) gave concordant results in patients with Paget's disease (4.05 +/- 6.21 versus 2.41 +/- 2.53), primary hyperparathyroidism (4.14 +/- 7.17 versus 2.13 +/- 2.28), chronic renal failure (25.32 +/- 24.49 versus 6.93 +/- 5.48), and glucocorticoid treatment (-1.48 +/- 0.78 versus -1.11 +/- 0.57). However, IRMA was more discriminant from controls for all these metabolic bone diseases because the absolute values of mean Z scores with IRMA were significantly higher than those obtained with the RIA (p < 0.05-0.0001).(ABSTRACT TRUNCATED AT 400 WORDS)


Effects of 4-amino-1-hydroxybutylidene bisphosphonate on bone biomechanics in rats. Bisphosphonates inhibit osteoclast-mediated bone resorption, but their effects on the mechanical behavior of bone remain uncertain. This study investigated the effects of 4-amino-1-hydroxybutylidene bisphosphonate (AHBuBP) on the biomechanical and morphologic properties of bone in ovariectomized rats. Sprague-Dawley rats (four groups, n = 6) were ovariectomized at 3 months of age. From 7 to 13 months, the groups received vehicle or 0.28, 2.8, or 28 micrograms/kg of AHBuBP twice weekly through subcutaneous injection. An additional group of control animals (n = 6) received neither surgery nor drug. We determined the stiffness, yield, and ultimate loads of the femoral midshaft, the sixth lumbar (L6) vertebra, and the femoral neck. Geometric properties of the cortical bone were measured from digitized images of the tibial diaphysis at the level of the synostosis. The area fraction of trabecular bone was determined through the midsagittal plane of the fifth lumbar (L5) vertebra. There were no significant differences in the structural properties of the femoral neck and midshaft, with the exception that the medium-dose group had a greater ultimate load than the vehicle group for the femoral midshaft in bending. Cross-sectional analysis of the tibia did not show significant differences in the inertial properties or area. Ovariectomy caused a significant reduction in the stiffness and ultimate load of L6 and in the area fraction of trabecular bone of L5.(ABSTRACT TRUNCATED AT 250 WORDS)


Bone and mineral metabolism in the adult guinea pig: long-term effects of estrogen and androgen deficiency. The effects of androgen and estrogen deficiency on skeletal homeostasis were studied in the guinea pig. Male and female adult (7 months old) guinea pigs were either sham operated (9 females and 7 males) or gonadectomized [9 ovariectomized (OVX) females and 6 orchidectomized (ORX) males] and sacrificed 4 months later for evaluation of bone mass, bone turnover, and serum calcium homeostasis. Parameters of bone turnover, calcium homeostasis, and vitamin D metabolites were similar in all groups except for increased serum IGF-I concentrations (+30%) in males compared to females. Gonadectomy resulted in a 50% decrease in serum IGF-I concentrations in males only (p < 0.001). Volume, total calcium content, and cortical density of the tibia were significant higher in males than in females. Estrogen deficiency had no effect on bone volume or calcium content. Androgen deficiency resulted in a significant lower volume and calcium content of the tibia and in a lower calcium content of the distal lumbar vertebrae. Single-photon absorptiometry of the tibia showed that only cortical, not trabecular bone density of the tibia was decreased after ORX. Histomorphometric studies of the tibial metaphysis also did not show significant differences in trabecular bone volume between sham-operated and ORX males. We conclude that in adult male guinea pigs androgen deficiency results in a decrease in (cortical) bone volume and content concomitant with decreased IGF-I levels. In female guinea pigs of the same age, estrogen deficiency did not affect total or regional bone mass.


A cruciate ligament injury produces considerable, permanent osteoporosis in the affected knee. Bone mineral density (BMD) and clinical status of 42 patients treated surgically 10-11 years earlier for an acute knee ligament injury were determined. The BMD was measured at the spine (L2-4) and the femoral neck, distal femur, patella, proximal tibia, and calcaneus of both lower extremities using dual-energy x-ray absorptiometric (DXA) scanner. The relative BMD results of the injured knee were correlated with sex, age, activity level, knee stability, and functional scores of the patient. In the 11 patients with moderate injury (isolated rupture of the medial collateral ligament), the BMDs of the injured and uninjured extremities were equal. In the 31 patients with severe injury (cruciate ligament rupture), the BMDs were significantly lower in the injured knee: distal femur, -6.0% (p = 0.0000); patella, -9.0% (p = 0.0000); and proximal tibia, -3.3% (p = 0.0012). Neither the femoral neck nor the calcaneus showed any differences. There were no significant differences either between men and women or between patients with different activity levels. The relative BMDs of the injured knee did not correlate with age or static knee stability but correlated significantly (r = 0.42-0.78, p < 0.01-0.001) with the functional scores of the same knee: the better the knee function in comparison with the healthy knee, the higher the relative BMD. The spinal BMDs corresponded with the age-adjusted reference values of the used densitometry. In conclusion, a severe knee ligament injury results in permanently decreased BMD in the injured knee. Other parts of the same extremity and lumbar spine are not affected.(ABSTRACT TRUNCATED AT 250 WORDS)


Adhesion molecules in skeletogenesis: I. Transient expression of neural cell adhesion molecules (NCAM) in osteoblasts during endochondral and intramembranous ossification. We report that neural cell adhesion molecules (NCAM) are expressed transiently in developing chicken osteoblasts during osteogenesis using immunostaining on cryostat sections. NCAM is strongly expressed in most osteoblasts along bone trabeculae that coincide with the presence of collagen I and alkaline phosphatase activity. In endochondral ossification, NCAM is highly expressed in osteogenic buds as seen in the epiphysis and diaphysis of tibia and vertebrae. In intramembranous ossification, NCAM is seen in osteogenic condensation of calvaria and in the periosteum of tibial diaphysis. The expression is transient because NCAM is not expressed in mesenchymal cells before osteogenic condensation and NCAM expression is lost in osteocytes in later stages. The staining pattern suggests that NCAM is present on the cell membrane of osteoblasts. Using a specific monoclonal antibody, the osteoblast NCAM is shown to contain polysialic acid, which is enriched in embryonic brain. Northern blot analysis using chicken brain NCAM cDNA as probes showed two major sizes of mRNA at 6.4 and 4.2 kb in calvarial mRNA as opposed to bands at 7.2, 6.4, and 4.2 kb in the brain. An immunoblot showed major proteins at Mr 165 and 110 kd, unlike brain NCAM, which are 180, 140, and 120 kD. That NCAM is involved in bone morphogenesis is consistent with the general hypothesis that NCAM plays pivotal roles in mesenchymal condensation, as shown in the formation of muscle, kidney, skin, and cartilage. The results establish NCAM as a cell surface molecule expressed transiently during osteoblast lineage. The implication that NCAM may mediate osteoblast interaction and regulate skeletal morphogenesis is discussed.


Osteoporosis and chronic back pain: a study with single-photon emission computed tomography bone scintigraphy. A group of 26 patients aged 47-81 years (average 67) with spinal osteoporosis and back pain for more than 6 months were investigated with planar and SPECT bone scintigraphy and anterior and lateral x-rays of the thoracolumbar spine. Abnormal activity on bone scintigraphy was found in all patients, of whom 22 had multiple lesions. A total of 17 (65%) patients had abnormal activity associated with collapsed vertebral bodies, 5 (19%) had degenerative disk disease, and 21 (81%) had facetal joint disease. Of 112 lesions identified by SPECT, 60 (54%) were localized to the apophyseal joints. Facetal lesions were commoner in those patients with more collapsed vertebrae, and 32 facetal lesions (54%) were associated with collapse of the vertebra immediately above or below. Bone scintigraphy findings suggest that in some individuals with osteoporosis and chronic back pain, collapse of the vertebral body or degenerative disk disease are causes of pain. However, the high frequency of increased apophyseal joint activity suggests that the facet joint may also be an important site of origin of pain in these individuals. Bone scintigraphy may identify a subgroup of osteoporotic patients with chronic back pain who would benefit from treatment to the facet joints.


Absence of calbindin-D28 expression in nonclassical 1,25-dihydroxyvitamin D targets: analysis by polymerase chain reaction. CaBP-D28 mRNA expression in rat heart, testis, and lung was assessed by polymerase chain reaction (PCR). The animal model used was the hyperinduced vitamin D-treated rat (100 ng 1,25-dihydroxyvitamin D subcutaneously, daily for 7 days). For the PCR studies, two pairs of 20 mer oligonucleotide primers (designated 1-4 according to their position on the coding strand, but with primers 3 and 4 in reverse orientation) derived from the rat CaBP-D28 cDNA sequence were tested in various combinations. Optimal conditions were established using a 1:100 dilution of cDNA from normal rat kidney. Bands of the predicted sizes of 869 (1, 3), 994 (1, 4), 725 (2, 3), and 850 (2, 4) nucleotide base pairs resulted, but with varying intensities: 2,4 approximately 1,3 > 1,4 > 2,3. Repeat PCR (recycling after 1:100 dilution and readdition of reagents and primers with at least one different primer) provided strong additional amplification, particularly with the 1,4/2,4 combination. Under these conditions, mixing experiments showed that CaBP-D28 transcripts were detectable at 10(-7)- to 10(-9)-fold lower levels of expression than in D+ kidney. When RNA was isolated and cDNA generated from test tissues from 4 individual vitamin D-stimulated (D+) and vitamin D-deficient (D-) rats, repeat PCR (1,4/2,4 primer combination) provided no evidence of significant CaBP-D28 mRNA expression in the nonclassic target tissues, in contrast to strong bands in both the D- kidney (undiluted) and D+ kidney (1:100 dilution) preparations.(ABSTRACT TRUNCATED AT 250 WORDS)


Osteoporosis in anorexia nervosa: the influence of peak bone density, bone loss, oral contraceptive use, and exercise. Anorexia nervosa occurs early in life and predisposes to osteoporosis. Exercise may be protective. We asked: (1) Does failure to attain peak bone density contribute to the deficit in bone density? (2) Does oral contraceptive use protect against osteoporosis? (3) Is any protective effect of exercise confined to weight-bearing sites? Areal bone density (g/cm2) and body composition were measured by dual x-ray absorptiometry in 65 patients with anorexia nervosa and 52 controls. Comparing the 12 patients with primary amenorrhea and the 37 patients with secondary amenorrhea, bone density (mean +/- SEM) at the lumbar spine was 0.88 +/- 0.04 versus 1.06 +/- 0.03 (P = 0.001), respectively. Bone density at the femoral neck was 0.80 +/- 0.04 versus 0.92 +/- 0.03 (P < 0.05), respectively. These values differed before, but not after, adjusting for the respective duration of illness (73.0 +/- 10.3 versus 34.1 +/- 4.8 months, P < 0.001) and fat-free mass (31.6 +/- 1.3 versus 35.4 +/- 0.5 kg, P < 0.01). Bone density at the lumbar spine in the 16 patients with 31.8 +/- 8.3 months of contraceptive exposure was higher than in the 49 patients with no contraceptive exposure (1.14 +/- 0.05 versus 1.02 +/- 0.02 P < 0.02) but was lower than in controls (1.14 +/- 0.05 versus 1.27 +/- 1.02, P < 0.01). No protective effect of contraceptive exposure was detectable at the femoral neck.(ABSTRACT TRUNCATED AT 250 WORDS)


Bone resorption and formation on the periosteal envelope of the ilium: a histomorphometric study in healthy women. Continuation of net periosteal bone gain after cessation of longitudinal growth has been inferred from sequential radiographic morphometry. Accordingly, we performed histomorphometry of the periosteal surfaces of transilial bone biopsies from 57 healthy women aged 24-74 years, 29 premenopausal and 28 postmenopausal. Compared to the endocortical surface, the extents of eroded and osteoid surfaces were very similar, but the extents of osteoclast- and osteoblast-covered surfaces were 80-90% smaller, and both wall thickness and osteoid thickness were about 30% lower. Double tetracycline labels were present in only 11 cases. The second (demethylchlortetracycline) label was almost four times as long as the first (oxytetracycline) label, a much greater difference than on the endocortical surface, so that the extent of mineralizing surface was based only on the second label. Even so, adjusted apposition rates and bone formation rates were only about 20% of the endocortical values, and unlike the endocortical surface, formation rates were not higher in the postmenopausal than in the premenopausal women. Resorption, reversal, and formation periods were each much longer than on the endocortical surface. There was no correlation between periosteal and endocortical values for any variable. At least 54% of total cement line length was scalloped, implying reversal of remodeling direction from resorption to formation, and at least 18% of total cement line length was smooth, implying temporary arrest of bone formation. Convincing evidence of modeling, related to growth or mechanical stimulation, was not observed.(ABSTRACT TRUNCATED AT 250 WORDS)


Postoperative anosmia after removal of pituitary gland adenomas using the pterional approach. There have been several studies on anosmia following operations on anterior circulation aneurysms, but no similar study has yet been reported on pituitary gland adenomas which required the transcranial approach. In this study, 38 cases with pituitary gland adenomas, for whom the pterional approach was employed, were observed retrospectively from the point of view of postoperative olfactory nerve function. In the postoperative period only one case complained of impaired sense of smell on the operated side. Eight cases objectively showed olfactory nerve dysfunctions. The olfactory nerve function could be preserved at a relatively high rate of 79 per cent. This high rate, we think, resulted from the microtechnique employed as well as the relatively cautious frontal retraction which was less than 1.5 cm.


Central projections of the sensory innervation to the middle cerebral artery in the squirrel monkey. To analyze the brainstem projections of the innervation to the middle cerebral artery (MCA) in the squirrel monkey, transganglionic tracing of wheat germ agglutinin conjugated with horseradish peroxidase (WGA-HRP) was used. After application of WGA-HRP to the middle cerebral artery (MCA), labelled cell bodies were identified in the ipsilateral trigeminal and superior cervical ganglia. In the brainstem, positive labelling indicative of preterminals and terminals occurred in a discontinuous pattern throughout the trigeminal brainstem nuclear complex. At the level of the obex, nerve terminations were identified in the nucleus tractus solitarius, nucleus motorius dorsalis nervi vagi and the nucleus nervi hypoglossi. Positive WGA-HRP profiles were also observed in the periaqueductal gray matter.


Cerebral blood flow changes induced by electrical stimulation of the Gasserian ganglion after experimentally induced subarachnoid haemorrhage in pigs. The effect of trigeminal electrical stimulation on cerebral blood flow has been studied in conditions of normal or reduced cerebral blood flow (CBF). Autologous blood was injected into the subarachnoid space of ten Pittmann-Moore pigs to induce subarachnoid haemorrhage (SAH) accompanied by cerebral blood flow (CBF) reduction. One week later, in six of ten animals, a considerable decrease of CBF was noted as evaluated by means of a recording-system monitoring over the right parieto-temporal calvarium the washout of 133Xenon injected into the internal carotid artery after the external carotid had been clamped. Continuous electrical stimulation of the Gasserian ganglion performed in the six animals with severely induced CBF reduction produced a remarkable cerebrovascular dilation and increase of CBF lasting over 3 h. Electrical stimulation of the Gasserian ganglion produced a similar pattern of vasodilation in six pigs in which no blood was injected and no reduction of CBF was evident. The mechanisms and the anatomical pathways which underlie these results are discussed.


Computerized infusion test compared to steady pressure constant infusion test in measurement of resistance to CSF outflow. Resistance to cerebro-spinal fluid outflow is together with intracranial pressure the most important parameter in the investigation of patients with disturbances of CSF dynamics. The methods for determination of resistance are either unreliable or too time-consuming for routine clinical use, which has limited the popularity of this kind of measurement. In this paper a method for computerized acquisition and processing of an infusion test is described. A good correlation to a standard technique is documented.


Cerebral blood flow autoregulation in experimental subarachnoid haemorrhage in rat. Haemodynamic instability is of great importance in clinical management of patients with subarachnoid haemorrhage (SAH). The significance of angiographically demonstrable vasospasm for disturbances of cerebral blood flow (CBF) and cerebral autoregulation has not yet been clarified. The present study was designed to describe disturbances of cerebral autoregulation during the timecourse of experimental SAH (eSAH) in rats. A second aim of the study was to relate the results to a reported timecourse of angiographic vasospasm in the same animal model. Previous studies have shown that the timecourse of angiographically visible vasospasm in eSAH is biphasic with maximal spasm at 10 min and 2 days after induction of eSAH. At 5 days, the vasospasms have resolved. CBF was measured using a 133-Xenon intracarotid injection method which allowed serial measurements of mean hemispheric CBF during controlled manipulations of arterial blood pressure. In this way, an autoregulation curve could be constructed. The present study shows that autoregulation is severely disturbed or even totally absent at 2 and 5 days after eSAH. Thus there seems to be no direct correlation between presence of angiographic vasospasm and impairment of autoregulation, or that the impairment of autoregulation is more protracted than the presence of cerebral vasospasm, presuming a correlation exist.


Effect of intracisternal and intravenous calcitonin gene-related peptide on experimental cerebral vasospasm in rabbits. We investigated the vasodilatory effect of intracisternal (i.c.) and intravenous (i.v.) administration of calcitonin gene-related peptide (CGRP) on arterial narrowing after experimental subarachnoid hemorrhage (SAH). Forty-one rabbits were divided into five groups: control (normal animals); SAH plus i.c. infusion of vehicle; SAH plus i.c. infusion of CGRP; SAH plus i.v. infusion of vehicle; SAH plus i.v. infusion of CGRP. In all but the control group, either CGRP (100 ng/kg/min) or vehicle solution was infused for two hours immediately prior to sacrifice by perfusion-fixation. A morphometric technique was employed to measure the luminal diameter of rabbit basilar arteries two days after SAH. The diameter of the basilar arteries in either the i.c. or i.v. CGRP groups was significantly greater than that of the respective vehicle group (i.c., p < 0.001; i.v., p < 0.01). Although there was no significant difference in systemic arterial blood pressure after infusion between the i.c. vehicle and i.c. CGRP groups, i.v. CGRP caused significant hypotension. Our results suggest that exogenous CGRP has some therapeutic potential for arterial narrowing after SAH not only by intrathecal application, but also by systemic use.


Pathological study of diffuse axonal injury patients who died shortly after impact. It is generally considered that axonal injury is apparent only on electron microscopy in the very early stage after a closed head injury. To clarify the pathological findings in head injury patients dying very shortly after the impact, we analyzed 8 fatal cases of diffuse axonal injury (DAI) who underwent medicolegal autopsy at the Department of Forensic Medicine of Kyoto Prefectural University of Medicine. Seven cases died within one hour after injury and another one case died 3 days after injury. We studied these cases macroscopically, microscopically, and electron microscopically. Macroscopically all cases showed the typical findings of diffuse axonal injury. Microscopical study of the cases who died within one hour revealed no characteristic findings of DAI such as appearance of retraction balls or microglia. On the other hand, in the case who died only 3 days after injury it showed the typical retraction balls. Electron microscopic study showed the remarkable destruction of cytoskeletal structure of axons in all cases. From our results, it is reasonable to speculate that DAI may be common among head injury patients who die very soon after the impact.


Stereotactic radiotherapy instead of conventional epilepsy surgery. A case report. A case report is made on a 29 year old male suffering from drug resistant epilepsy with a left temporal focus and normal neuroradiological findings. Instead of the conventional partial temporal resection, the focus was stereotactically irradiated in five fractions using a standard linear accelerator (6 MeV), to a total dose equivalent of 10 Gy in a single shot. Two months after the treatment the frequency of seizures decreased and the patient has been free of attacks since the seventh postirradiation month, up to 27 months by now, and in excellent condition. Noninvasive stereotactic radiotherapy may turn out to be a rational way to eliminate an epileptic focus.


Computer assisted localizer for planning of surgery and intra-operative orientation. There is discrepancy between the exact representation of anatomical structures and tumours in the CT or MRI scan and the more or less accurate intra-operative localisation methods based mostly upon landmarks of the skull and extracerebral space and visible abnormalities of the cerebral surface. To overcome these problems of exact intra-operative localisation a Computer Assisted Localizer (CAL) is presented which allows precise intra-operative orientation without these aids. It consists of a mechanically articulated arm with six degrees of freedom with a high precision digital incremental and an image processor for 3 D data of the head. MRI and/or CT investigation is done pre-operatively with four reference markers fixed on the patient's head. They are visible on the CT or MRI slices and are used as reference points during surgery for adjustment of the device. The co-ordinates of the digitalizer arm tip are projected into the corresponding axial, sagittal and coronal CT slices so that the system simultaneously presents three orthogonal multiplanar CT reconstructions with a reticule indicating the position of the tip of the arm. As the surgeon directs the arm to the region of interest the corresponding CT slices are displayed on the monitor at a rate of 20 slices/sec determined by the motion of the arm. The accuracy of measurement of the device itself lies within 1 mm. The accuracy is somewhat reduced however by the thickness of CT or MRI slices (routinely 2 mm slices were taken) and by deviations of the reference markers on the skin surface which amount up to 3 mm.(ABSTRACT TRUNCATED AT 250 WORDS)


Direct skull marking for a pre-operative localization in regional cerebral surgery. Technical note. A method is described in which an open neurosurgical target is pre-operatively marked on the skull of a patient. A target point of the scalp surface localized from neuroimaging studies is transferred onto the skull by an injection of pyoktanin blue. Its accuracy and reliability is far superior than that of the usual scalp marking. The method is simple, practical, and allows a smaller, regional craniotomy with the advantage of minimum operative invasiveness.


Localization of central lesions by correlation of CT findings and neurological deficits. In a prospective study involving 100 patients with lesions in the precentral gyrus or pyramidal tract we sought to correlate clinical findings and the results of an axial computed tomography (CT) to localize the lesion. In 85% of patients the size and location of the lesion visible on CT correlated well with the type and severity of the neurological symptoms and signs. However, in the remaining 15% of patients the CT findings did not correlate well with the patient's neurological deficit, showing that in these patients the anatomy of the central area was variable or distorted by the space-occupying lesion. We suggest that in such patients neurophysiological techniques be used intra-operatively for reliable localization of the motor strip.


Repair of skull base dural defects: the dura sandwich. Technical note. A technique for skull base dural defect repair is presented, using two layers of periosteum and biological (Tisseel glue), one on either side of the defect. The method is reliable and relatively simple, and was used to repair a recurrent skull base encephalocoele with great success. The method has application in the reconstruction of any dural defect, whether congenital, traumatic or surgical.


Safe surgery of lesions near the motor cortex using intra-operative mapping techniques: a report on 50 patients. In 50 patients lesions located in or adjacent to the motor strip were microsurgically removed with the help of intra-operative electrophysiological mapping of the sensorimotor cortex. Mapping consisted of cortical stimulation and/or recording of somatosensory evoked potentials. Depending on the patient's pre-operative neurological status, surprisingly good results could be achieved: The surgery resulted in increased permanent sensorimotor deficit in only 4% of cases and in improved neurological status in 30% of cases. It is concluded that surgical removal of centrally located lesions using a microsurgical technique and intra-operative mapping of the motor cortex is safe and permits extensive or radical resection of lesions, even those in the motor cortex itself.


Subarachnoid haemorrhage of unknown aetiology. Eighty-six of 996 patients with primary subarachnoid haemorrhage (SAH) had negative pan-angiography studies. These 86 patients with subarachnoid haemorrhage of unknown origin (SAH-NUD) were compared with 853 patients sustaining an aneurysmal bleed (SAH-A) admitted during the same period 1980-1989. The age and sex distribution of both groups were similar. The SAH-NUD group was in better condition on admission, with less blood evident on CT scan. All 16 (repeat control) angiography studies in the SAH-NUD group were negative. During a follow-up period ranging from 1 to 10 years (mean 5.4 years), two patients experienced rebleeding with negative repeat angiographies and subsequent total recovery. Using the Glasgow Outcome Scale (GOS) the final outcome was good in 86% of the study group and 54% of the aneurysm group. However, half of the SAH-NUD patients complained of persistent symptoms at long-term follow-up. Thus, despite a generally good prognosis, for a given individual SAH-NUD may be catastrophic with many residual symptoms persisting for the rest of the person's life.


Surgical management of unruptured intracranial aneurysms. Personal experience with 37 cases and discussion of the indications. The authors report a series of 37 cases of unruptured aneurysms, admitted and operated upon over a 5 year period (1985-1990), which represents an incidence of 18% of the total number of aneurysm patients operated upon during this period. These unruptured aneurysms were discovered in 4 types of circumstances: 1) Associated with a ruptured aneurysm but treated in a second procedure (9 cases); 2) After a transient ischaemic attack (6 cases); 3) After a cerebral haemorrhage of a different origin (3 cases), 4) After the onset of various neurological symptoms other than SAH (19 cases). Giant aneurysms (over 2.5 cm in diameter) are excluded from this series. Overall these 37 patients harboured 52 aneurysms, and 1 patient was operated upon on both sides. 27 aneurysms (52%) were located on the right side, 15 (29%) on the left side, and 10 (19%) on the midline. In the immediate post operative period, 1 patient died (2.6%) and 8 patients (21%) presented various complications. The outcome at 6 months was: death 2.6%, moderately disabled 8%, good recovery 89%. The arguments in favour of, or against, the surgical treatment of unruptured aneurysms are discussed in view of the literature. In favour of prophylactic surgery are: 1) The rather poor overall outcome following aneurysm rupture (including deaths before admission); 2) The rather good outcome of surgery in published series of unruptured aneurysms. The data of the natural history of the unruptured aneurysm are more questionable: in this view, surgery seems to be recommended in young patients with an easily accessible aneurysm and being in a good clinical condition.(ABSTRACT TRUNCATED AT 250 WORDS)


Dorsal internal carotid artery aneurysms with special reference to angiographic presentation and surgical management. Aneurysms arising from the dorsal wall of the internal carotid artery are rare. The authors surgically treated twenty dorsal internal carotid artery aneurysms. Pre-operative angiographic findings were reviewed and classified into three types. Eleven aneurysms projecting superiorly on the lateral angiogram were found to be adherent to the base of the frontal lobe by the pterional approach. Five aneurysms which had been superimposed with the internal carotid artery on the lateral angiogram were found adhered to the medial surface of the temporal lobe. Four aneurysms not seen on the angiogram had no adhesion. Two aneurysms, which had not been seen on the initial angiograms, were visualized on the angiograms taken during the period of vasospasm. This type of aneurysms can be the source of a subarachnoid haemorrhage of unknown origin and requires repeated examinations. Premature rupture occurred intra-operatively in five cases and postoperative bleeding was encountered in two. Clipping technique is discussed from the viewpoint of preventing intra- and postoperative rupture.


Risk of epilepsy after aneurysm operations. This prospective study was undertaken to evaluate the risk of epilepsy after aneurysm operations. The patients were discharged after operation without any anticonvulsant prophylactic treatment and followed-up for 12 months. Out of 128 such patients 121 were submitted for final evaluation. Epilepsy was diagnosed if two or more seizure attacks occurred during that time. Such attacks occurred in 8 patients, so the risk of epilepsy was estimated at 7% for the 12 months after operation in patients without prophylactic treatment. In another 3 patients single seizures occurred during the follow-up, they were not treated with anticonvulsant drugs; seizures did not recur for up to two years. Detailed analysis of the patients with late epilepsy revealed that most of them were pre-operatively in the 3rd clinical group according to WFNS scale. The rationale for the use of prophylactic anticonvulsants after aneurysm surgery seems to be doubtful in view of this study and data from the literature.


Iodine-125 interstitial irradiation for cerebral gliomas. In this retrospective review the outcome of 539 patients is evaluated, who from 1979 through 1991 underwent stereotactic biopsy and interstitial irradiation using iodine-125 implants. Permanent (lost) 125-I implants were used in 345 cases (64%) (1979-1985), temporary (removable) implants in 194 cases (36%) (1985-1991). The patients were selected for interstitial irradiation on the basis of histological classification, location and circumscription of their tumours (106 pilocytic astrocytomas, 251 astrocytomas WHO grade II, 29 oligodendrogliomas, 44 oligo-astrocytomas, 75 anaplastic astrocytomas and 34 glioblastomas). Diffusely infiltrative non-delineated gliomas and gliomas crossing the midline were excluded. Five-year survival rates were 77% for pilocytic astrocytomas, 65% for astrocytomas WHO II, 80% for oligo-astrocytomas, and 58% for oligodendrogliomas. The 2-year survival rates were 36% for anaplastic gliomas and 16% for glioblastomas. Operative morbidity due to stereotactic biopsy, implantation, and explantation of seeds was 3.9%. In the subgroups of patients with astrocytomas (WHO-II), pilocytic astrocytomas and malignant gliomas age was a significant factor predicting survival. Patients with astrocytomas WHO II who received temporary implants had a significantly better outcome than those with permanent implants. Radiation toxicity (3.1%) was seen mostly among the permanent (lost) implants. No patients required re-operation due to radionecrosis. The findings among this subgroup of gliomas indicate that interstitial implant irradiation using 125-I is effective in controlling tumour growth and is well tolerated. Patients with differentiated and circumscribed gliomas particularly benefit from the treatment.


Endoscopic treatment of suprasellar arachnoid cysts. Four cases of large suprasellar arachnoid cysts in children are described. The authors propose a large fenestration into the lateral ventricles and into the basal cisterns as the treatment of choice. A specific multipurpose cerebral endoscope has been designed by the first author. The endoscopic technique with different instruments and with the use of a laser is illustrated. Results and complications are discussed.


Medulloblastoma in children and in adults: a comparative study. We report on the clinical and pathological characters and factors influencing prognosis in a consecutive series of 20 cases of medulloblastoma presenting in childhood and of 20 cases of the tumour presenting in adulthood. The significant differences which emerged were compared with the findings of the largest published series. Medulloblastoma is more often lateral in site and desmoplastic in histology in adults than in children. On our evidence the age at tumour onset not affect survival.


The effect of ketanserin on cerebral blood flow and cerebrovascular CO2 reactivity in healthy volunteers. The effect of the anti-hypertensive agent ketanserin on the cerebral blood flow (CBF) and the cerebrovascular CO2 reactivity was examined in 10 healthy volunteers. Ketanserin was administered as an intravenous bolus of 10 mg followed by an infusion of 6 mg/h. Before administration CBF was measured by single photon emission computerized tomography (SPECT) of inhaled 133Xenon. Then arterial CO2 tension was subsequently decreased by voluntary hyperventilation and increased by breathing an air/CO2 mixture. The relative changes in CBF induced by the changes in arterial CO2 tension were estimated by the cerebral arterio-venous oxygen content difference method. One hour following the start of ketanserin infusion the SPECT measurement and CO2 manipulations were repeated. The CO2 reactivity (expressed as the slope of the regression line of the linear relation between CBF and PaCO2), was unchanged, i.e. 3.2%/0.1 kPa before ketanserin and 4.1%/0.1 kPa during ketanserin, respectively. Using regression lines from a semi-logarithmic plot the CO2 reactivity was also unchanged 3.4%/0.1 kPa and 3.5%/0.1 kPa, respectively. Ketanserin did not change CBF. The cerebral oxygen metabolism (CMRO2) was decreased 19% one hour after the start of infusion of ketanserin. In conclusion administration of ketanserin in a clinically relevant dose to healthy volunteers does not change the regional CBF not the cerebrovascular CO2 reactivity, but a decrease in CMRO2 was observed. However further studies are needed to clarify whether ketanserin in fact has a depressing effect on CMRO2 or whether the different results are caused by methodological errors or stochastic variation.


Intramedullary spinal cord ependymomas--a study of 45 cases with long-term follow-up. Of the 62 patients with intramedullary spinal cord ependymoma treated surgically at our Neurosurgery Division between January 1951 and December 1990 45 had a follow-up of at least 3 years and the longest 30 years. The 28 conus-cauda equina-filum ependymomas operated during the same period are not considered in this study. An analysis of our cases and of the larger published series shows that favourable prognostic factors, apart of course from total tumour removal, which is now usually possible, are a site below the high cervical segments and a mild pre-operative symptom pattern. Patient age at diagnosis, tumour size and "low dose" (< 40 Gy) radiotherapy seem to have no influence on the prognosis. Aggressive surgical removal is the treatment of choice and also for long-term recurrence.


Risk factors in postoperative neurosurgical infection. A prospective study. Four hundred and seventy patients who had undergone neurosurgical operations were studied prospectively. After defining post-operative infection so that is included all the infective complications irrespective of location occurring after surgery, the overall infection rate was 17%. The infection rate in 413 cases without pre-existing infection was 15%. Wound infection was recorded in 5% and meningitis in 6%. Risk factors which lead to a significant increase in the incidence of postoperative infection were found to be altered sensorium, multiple operations, pre-existing infection, emergency surgery, duration of surgery more than 4 hours, urinary catheterisation, cerebrospinal fluid leak, and ventilatory support.


Somatosensory evoked potential monitoring during intracranial surgery. In the neurosurgical approach to intracranial aneurysms which are often accompanied by arterial spasm and cortical ischaemia, monitoring procedures aim to obtain useful information on cerebral function. SEPs evoked by stimulation of the median nerve at the wrist and of the tibial nerve at the medial malleolus were registered in 45 patients with intracranial aneurysms during neurosurgical procedures. Our results show SEP abnormalities during different stages of neurosurgical procedures in 36 patients out of the monitored 45. Significant abnormalities of SEPs with respect to the control group were decrease of the amplitude of N 20-P 25 complex, lengthening of the absolute latency of the waves N 20- and P 25 and lengthening of the central conduction time (CCT) (N 13-N 20). The greatest SEP abnormalities were registered during the neurosurgical approach to aneurysm and during the clipping procedure. However, the changes were reversible in the majority of the patients. The aim of this paper was to focus on early detection of some cerebral function disturbances during the neurosurgical procedure as well as the prevention of possible brain damage.


The traumatic dural sinus injury--a clinical study. In a period of 13 years 978 cases of severe head injuries were operated on in our clinic. An analysis of the medical reports includes injuries of the superficial dural sinus (39 cases = 4%): among these injuries of the anterior and central part of the superior sagittal sinus (66 per cent), injuries of the transverse sinus (18 per cent), injuries of the posterior part of the superior sagittal sinus (8 per cent), and combined injuries of different dural sinuses (8 per cent). Clinical data, i.e. the causes of accident, radiological examination results, intracranial lesions, operation techniques and outcome are analysed and discussed. The analysis of cases with dural sinus injuries shows a high mortality rate (total mortality rate: 16 patients = 41%; intra-operative mortality rate: 8 patients = 20%).


Percutaneous pharyngostomy versus gastric tube placement in head injured patients. A prospective comparative study of 50 patients. The author reports a prospective comparative study in two groups of patients with head injuries where the complications of conventional nasal placement of nasogastric tubes are compared to placement by pharyngostomy. Percutaneous pharyngostomy is a simple procedure that eliminates some of the complications associated with the use of nasogastric tubes. It has particular advantages in patients with maxillofacial- and skull base injuries, is well tolerated in patients with a depressed level of consciousness and eliminates some of the infective complications associated with the use of nasogastric tubes.


Clinical analysis of post-traumatic vomiting. Post-traumatic vomiting was clinically analyzed. One hundred and forty seven patients with head injury came to our hospital consecutively from April 1991 to August 1991. Of 147 patients, 26 exhibited vomiting post-traumatically. The incidence of loss of consciousness, that of fractures on plain X-ray films, and that of traumatic intracranial lesions demonstrated on CT were compared between two patient groups, i.e., a group of patients with post-traumatic vomiting and another one without it. None of them were revealed to be significantly different between the two groups, respectively. It was concluded from the results that the existence of post-traumatic vomiting implied neither severe traumatic impact nor serious intracranial damage. The plausible mechanisms of post-traumatic vomiting are discussed, taking account of the statistical data on the patients' age, sites of impact, and past histories.


[The position of the tongue].

[The position of the tongue]. The authors describe anatomy, typologies, evolution of the tongue during growth. They pay attention at the modeling role of the lingual position and functions upon maxillofacial architecture. The bi-labial contact is the main factor for general functional equilibrium.


Susceptibility of anaerobic microorganisms to hypothiocyanite produced by lactoperoxidase. The susceptibility of Capnocytophaga ochracea, Eikenella corrodens, Eubacterium yurii, Fusobacterium nucleatum, Peptostreptococcus micros, Prevotella intermedia, Selenomonas sputigena, Wolinella recta to hypothiocyanite (OSCN-) produced by the lactoperoxidase system was tested. Results showed a decrease of bacterial survival rate after OSCN- exposure, with an intra- and inter-species variability from 0 to 95% for C. ochracea, 34-100% for E. corrodens, 0-83% for E. yurii, 1-15% for F. nucleatum, 8-61% for P. micros, 0-100% for P. intermedia, 0-44% for S. sputigena and 0-8% for W. recta. The survival rate did not correlate with the NADH/OSCN- oxidoreductase activity present in the lysed bacteria (r = -0.3248; N = 15; NS).


[Metastasis of pancreatic adenocarcinoma to the submandibular gland]. Metastases are rarely found in salivary glands. They are exceptional in the submaxillary gland. The authors report a case of a metastatic tumour in the submaxillary gland. The primitive tumour was found in the pancreatic head.


Arthrographic imaging of post-traumatic temporomandibular joint disorders. Clinical, arthrographic and surgical findings in 20 patients who showed persisting TMJ-pain or dysfunction after an acute traumatic event were reviewed and compared to findings in a control group of 65 patients who did not remember an acute post-traumatic onset of symptoms. Anterior disk displacement (82%), disk perforation (65%) and rotational anteromedial disk displacement (34%) were the most common abnormalities encountered. Other important abnormalities were joint adhesions and capsule perforation. When compared with the control group, all these abnormalities occurred more often in traumatised joints. Arthrography was found to be highly accurate in detecting most types of abnormalities found during surgery. Arthrography is reported to be more effective than MRI in detecting disk perforations, adhesions and capsule perforations, which points to its continuing importance as an imaging tool for evaluating post-traumatic temporomandibular joint disorders.


[Evaluation of a chronic pain syndrome]. Chronic pain, the pain which persists or appears after the initial lesions are healed, has recently been recognized as a medical entity called the "chronic pain syndrome". This condition may be differentiated from acute pain on the basis of biological finality, pathogenic mechanisms, autonomic reactions, affective and behavioural components but most of all of the therapeutic goals. It is important to remind that the experience of pain is the result of at least three interactive neuro-psychological determinants viz. the sensory-discriminative, the affective-motivational and the cognitive-evaluative systems. For this reason, when pain becomes treatment resistant, it is important to complete the usual diagnostic approach by an evaluation of pain as a phenomenon and to abandon a strictly "peripheral" model. Such evaluation is necessarily interdisciplinary.


[Case study: a calcified epithelial odontogenic tumor (Pindborg tumor)]. The calcifying epithelial odontogenic tumor is a benign but locally aggressive tumor. Occasionally the term Pindborg tumor is used after the Danish pathologist who first described this tumor as an entity. The clinical feature is most commonly a slow-growing painless swelling. The tumor may show considerable roentgenographic variation. Usually this tumor shows characteristic histological features. Some variants can mimic malignant neoplasms. The invasive nature is not so obvious as that of an ameloblastoma, nevertheless it has to be treated in the same way. A long follow-up period is indicated since recurrence can occur after many years. A patient with a characteristic Pindborg tumor is presented.


[Technique and interpretation of arthrography of the temporomandibular joint. Study of 120 cases]. The goal of the study was to assess the predictive value of inferior joint space arthrography for detection of abnormalities found during surgery. Therefore, a retrospective analysis of arthrographic and surgical findings in 120 joints was performed. Arthrography showed high accuracy for detection of anterior disk displacement (90%) and disk perforation (90.8%). The shape of the anterior recess proved to be the most valuable arthrographic criterium for detection of anterior disk displacement. Cinematographic registration of joint dynamics after injection of contrast material and arthrotomographic analysis of the shape of the superior margin of the anterior recess of the inferior joint space were necessary for an optimal evaluation of the disk position.


[Percutaneous Bacillus Calmette-Guerin perfusion of the upper urinary tract for carcinoma in situ]. We performed percutaneous perfusion of the upper urinary tract with Bacillus Calmette-Guerin (BCG) in 3 patients. Two of them had undergone unilateral nephrectoureterectomy for ureter carcinoma in situ and one had undergone radical cystectomy with bilateral ureterocutaneostomy for invasive bladder carcinoma. However, they suffered recurrent upper urinary tract carcinoma in situ within 2 years after their operation. Under ultrasound control a percutaneous nephrostomy tube was placed in the patient. Before BCG perfusion unobstructed flow from the renal pelvis to the bladder was confirmed and pyelovenous or pyelolymphatic back flow was excluded under fluoroscopy. A dose of 240 mg BCG was dissolved in 150 ml 0.9% saline. The flask was placed 20 cm above the kidney of the resting patient. A continuous flow of approximately 1 ml per minute was maintained. The perfusion was stopped after 2 hours and the nephrostomy tube was closed. Therapy was repeated at weekly intervals for a total of 6 perfusions (1 treatment course). In each of them urine cytology results became negative after 1 treatment course. No severe side effects were observed. Further investigation is also needed to determine whether BCG perfusion of the upper urinary tract could become a conservative treatment for carcinoma in situ of the upper urinary tract.


[Experimental and clinical evaluation of functional electrical stimulation of the anal sphincter]. To determine the most effective parameter of functional electrical stimulation of the anal sphincter (FES), the present study was carried out in female mongrel dogs anesthetized with alpha-chloralose urethane. When spontaneous and rhythmic micturition contractions of the bladder were present, they were more effectively inhibited by the stimulation with low frequency (5 to 10 Hz). Based on the results of this experiment 18 patients with urge incontinence were treated by maximal electrical stimulation with the following parameters. The duration for each stimulus was 0.2 msec, frequency 5 Hz, amplitude 30 to 150 volts. Every patient received ten treatments for two weeks, each lasting for 30 minutes. A clinical cure for urge incontinence was noted in 12 patients. As for urodynamic studies, FES increased significantly the volumes of the first desire to void (FDV) and maximum desire to void (MDV); however, it did not increase significantly the maximum urethral closure pressure or residual urine volume. Eighteen patients were divided into two groups; an unstable bladder group and a neurogenic bladder group. In the latter, the increases in volumes of FDV and MDV were significant. Second, 18 patients were divided into two groups according to the administration of lack of anticholinergic agents. For subjective symptoms, the rate of improvement of urge incontinence was significantly higher in the group administered the agents. These findings suggested that FES was very useful for the treatment of urge incontinence, with its efficacy augmented by the administration of anticholinergic agents.


[Operation of female stress incontinence--comparison between Raz procedure and Gittes procedure]. We performed Raz procedure and Gittes procedure for female stress incontinence since October 1986. Raz procedure was performed on 19 patients between October 1986 and February 1990, and Gittes procedure was performed on 18 patients between June 1990 and May 1991. We followed up 17 patients who underwent Raz procedure and all the patients who underwent Gittes procedure at the time August 1991. Disappearance or marked improvement of incontinence was confirmed in 12 patients by Raz procedure, and 16 patients by Gittes Procedure. No serious complications were recognized. The reason why the result of Raz procedure was not sufficient was due to our immature operative technique and incorrect patient selection in our early experience. From this experience, we believe that both procedures can be very useful and minimal invasive operation for female stress incontinence.


[Retroperitoneal fibrosis suspected to be ureteral tumor because of its localization at the unilateral distal ureter: a case report]. The patient was a 32-year-old female with the complaint of right flank pain. Drip infusion pyelogram showed right hydronephrosis and retrograde urogram demonstrated a marked stenosis about 2 cm in length at the right distal ureter. The passage of the ureteral catheter and the contrast medium through the narrowing portion of the ureter could not be performed. The abdominal computerized tomographic (CT)-scan disclosed renal subcapsular urinoma, although no abnormal findings which caused ureteral stenosis were revealed. A suspicion of right ureteral tumor was entertained and total nephroureterectomy was performed. Histopathological diagnosis was the idiopathic retroperitoneal fibrosis, which involved the right ureter. One hundred and fifty five cases of idiopathic retroperitoneal fibrosis in the Japanese literature were reviewed.


[Retroperitoneal malignant lymphoma showing follicular type: report of a case]. We report a case of retroperitoneal follicular malignant lymphoma. A 59-year-old man visited the hospital with the chief complaint of a loss of body weight and left epigastric tumor. CT revealed a tumor, 9 x 6 cm, with non-homogeneous density in the left retroperitoneum. Since no clinical metastasis was identified, the tumor and the left kidney were resected en bloc with para-aortic lymph node dissection. Pathological diagnosis was non-Hodgkin follicular lymphoma of mixed small cleaved and large cell type with lymph node metastasis (2/23). The CHOP adjuvant chemotherapy (cyclophosphamide, adriamycin vincristine, Prednisolone) and the radiation therapy were performed after the operation. Recurrence in the mediastinal lymph node occurred 7 months after operation and radiation and the same adjuvant chemotherapy were performed and resulted in complete remission. The patient remained free of the tumor for 27 months at present.


[A case of intimal dissection of the aorta during transfemoral angiography]. A 54-year-old man underwent right transfemoral angiography because of left renal hematuria. During angiography, dissection of abdominal aorta and thoracic aorta was encountered. It was initiated by intramural catheter passage at the bifurcation of the internal and external iliac artery. Transaxillary aortography about one month after the first angiography showed occlusion of the dissecting space in the thoracic aorta and existence of dissecting space in the abdominal aorta. Communicating orifices between the true space and the false space existed not only at the bifurcation of internal iliac artery and external iliac artery, but also at the abdominal aorta near the left renal artery. CT 1.5 months after the first angiography did not demonstrate more improvement. Surgery was performed. It was impossible to sew up and close the orifices of the space because of the fragility of the intima. Surrounding abdominal aorta and common iliac artery were wrapped near orifices with a dacron graft. A follow-up CT obtained 3 months postoperatively showed that the dissecting space in the abdominal aorta had disappeared. Wrapping was very useful to promote organization of the dissecting space.


[Renal cell carcinoma in a renal cyst--observation of changes during the year: report of a case]. We report a case of renal cell carcinoma within a renal cyst. A 45-year-old man visited our hospital with the chief complaint of left back pain. Ultrasonography was examined by a physician, and it revealed a right renal cyst by chance. Computed tomography demonstrated a thick wall in the cyst which showed enhancement of density with contrast medium. The physician followed the cystic lesion periodically, by ultrasonography and computed tomography. The cyst on volume did not change, but the thick wall had a tendency to develop to inner space. The patient was referred to our department. Angiography was performed, and it showed neovascularity and tumor staining. We diagnosed the renal tumor in a renal cyst. Transabdominal right radical nephrectomy was performed on 18 June, 1991. The resected specimen involved a mall tumor (2.5 x 2.0 cm) in the cyst. Histological examination of the tumor was renal cell carcinoma which was well capsulated by connective tissue without invasion to normal parenchyma and perirenal fat. We speculated that the renal cell carcinoma originated from the cyst wall and it developed to inner cystic space. The natural history of the renal cell carcinoma in a renal cyst is not clear. Our case shows a type of its history. We reviewed and discussed the types and diagnosis of the renal cell carcinoma in a renal cyst.


[Hypothyroidism followed by interferon-alpha as adjuvant therapy of renal cell carcinoma: a case report]. A 58-year-old male patient was admitted to the hospital complaining of weight loss. Abdominal computerized tomographic (CT) scan disclosed a mass shadow in the left kidney. From the results of further examination, including drip infusion pyelography (DIP) and angiography, he was preoperatively diagnosed as having a left renal tumor. Left radical nephrectomy was performed on March 15, 1990. The lesion was histologically diagnosed as renal cell carcinoma (clear cell subtype, grade 2) confined by the renal capsule (stage I). No distant metastases were detected. Interferon-alpha was administered every other day as adjuvant chemotherapy. After the patient experienced muscle pain in his thighs and shoulders after exercise on February 11, 1991, the serum creatine phosphokinase (CPK) level progressively increased up to 2,329 U/l. On the basis of the results of various examinations reflecting thyroid gland function, he was diagnosed as having primary hypothyroidism due to Hashimoto's disease. Thyroid function improved after administration of triiodothyronine and thyroxine. Interferon has been reported to influence thyroid function, and, in this case, interferon-alpha therapy may have induced the primary hypothyroidism associated with Hashimoto's disease.


[Contralateral ureteral metastasis from renal cell carcinoma: a case report]. A case of contralateral ureteral metastasis from renal cell carcinoma is reported. A 52-year-old man underwent left nephrectomy for renal cell carcinoma of November 20, 1986. He was clinically asymptomatic for 4 years 8 months after the operation. He was admitted on August 14, 1991, because of right loin pain. Right retrograde pyelography and percutaneous pyelography showed a filling defect in the right ureter at the level of L3. After the right ureter was explored, the tumor lesion of ureter was resected and end to end anastomosis of the ureter was performed. Histopathologic examination showed a metastatic clear cell carcinoma consistent with a renal primary. The contralateral ureteral metastasis from renal cell carcinoma is very rare and only 15 cases have been reported previously.


[An experience with augmentation sigmoid cystoplasty for urinary incontinence caused by sacral agenesis: a case report]. Sacral agenesis is an uncommon disease. About 50 cases have been reported in Japan since 1929. Neurogenic bladder is often accompanied with the disease. The patient was a 26-year-old man who had suffered from persistent urinary incontinence since his childhood. Kidney-ureter-bladder (KUB) revealed Type IV sacral agenesis according to the classification by Renshaw. The upper urinary tract remained normal. Urodynamics study showed a low compliance bladder with low urethral pressure. Pharmacotherapy failed to improve his continence. Augmentation sigmoid-cystoplasty was undertaken to enlarge vesical capacity and it has successfully overcome his urinary incontinence. Clinical aspects of sacral agenesis are discussed focusing on urological problems.


[Primary sclerosing lipogranuloma of the male genitalia: report of three cases]. Recently, genital sclerosing lipogranuloma having no history of trauma and foreign body infusion are more common in Japan. We report three cases recently encountered in which tumors were diagnosed as sclerosing lipogranuloma on histological examination. In case 1, lipid analyses of the tissues by infrared absorption spectrometry proved that it was endogenous in origin.


[Epidermoid cyst of the testis: a case of testis preservation]. A 19-year-old man complained of an asymptomatic right testicular mass. Physical examination revealed a firm, small-finger sized, mass lesion with a smooth surface in the right testis. The ultrasonographic appearance was hypoechoic and well-demarcated intratesticular lesion. All laboratory investigations, including tumor markers, were normal. The testis was explored through an inguinal incision. The mass was excised locally and the biopsy of the adjacent testicular tissue was done with gentle code clamping. The histological diagnosis was epidermoid cyst of the testis and the testicular tissue obtained was normal. About 90 cases of testicular epidermoid cyst have been reported in the Japanese literature, and are reviewed briefly here.


[Nerve-sparing retroperitoneal lymph node dissection for stage IIA testicular embryonal carcinoma: a case report]. A 32-year-old man who had left testicular embryonal carcinoma with low volume left para-aortic lymph node swelling was treated initially with 3 courses of cisplatin-based combination chemotherapy. Pathological findings of the primary lesion revealed no yolk sac element and no elevation of serum alpha fetoprotein (alpha-FP) and beta-human chorionic gonadotropin (beta-HCG) levels even before the left orchiectomy. Therefore, the retroperitoneal lymph node dissection (RPLND) was performed despite marked shrinkage of the enlarged nodes. The L1-3 lumber splanchnic nerves from the right sympathetic truncus were detected in the intra-aortocaval region to prevent impairment of ejaculatory function and the lymph nodes in the area were removed one by one between the preserved neurofibers. On the other hand, the left para-aortic lymphatic tissue which included enlarged nodes was dissected in en bloc manner. The pre-aortic lymphatic tissue caudally to the inferior mesenteric artery was preserved not to be touched. The patient ejaculated normally 3 weeks after the RPLND. Treatment of stage IIA disease with chemotherapy first might be helpful in performing RPLND, if necessary, with keeping both ejaculatory function and radicality.