Reproducibility of 6- and 4-category faces pain scale to the assessment of temporomandibular joint pain and muscle in school-age children.

OBJECTIVE: The aim of this study was to compare the levels of reproducibility between two Faces Pain Scales (FPS) of 6 and 4 categories to the assessment of pain intensity on children with and without Temporomandibular joint and muscle pain. MATERIAL AND METHODS: A total of 29 children were recruited: 13 symptomatic (9.79 ± 1.36 years old) and 16 asymptomatic (8.69 ± 0.87 years old). One previously-trained examiner applied manual palpation to evaluate orofacial structures, and FPS to assess pain intensity. All children were initial evaluated using 6-category FPS and after 3 days using 4-category FPS. The children were assessed after a seven day time interval from initial and second sessions. Weighted Kappa coefficient was used to verify reproducibility levels. RESULTS: Similar levels of reproducibility (moderate and fair kappa values) have been verified with the application of the 6-category FPS on symptomatic and asymptomatic children. Similar results were verified using 4-category FPS on symptomatic and asymptomatic children (poor and fair kappa values). CONCLUSION: Higher levels of reproducibility were verified with the application of the 6-category FPS in both groups and considering symptomatic and asymptomatic as single group. In this way, the 6-category FPS should be preferred over the 4-category FPS to assess pain intensity on children's orofacial structures.

Differences in pain perception in children reporting joint and orofacial muscle pain.

PURPOSE: To determine changes in orofacial pain perception in community-based children by assessing the pressure pain threshold (PPT) with an algometer and pain intensity by manual palpation (MP). METHODS: A total of 100 children from the community aged 7 to 12 years were assessed. Thirty-eight children reported pain in the orofacial region. Of these children,10 reported joint pain (GJ), 12 reported joint and muscle pain (GJMM), 5 reported muscle pain (GMM), 11 reported pain during mastication (GMAST), and 62 reported no pain. An ANOVA (p < 0.05) was used to determine the differences in pain intensity and PPT among groups. RESULTS: Significantly higher pain intensity upon MP was observed for the temporalis muscle in the GJMM, GMAST and GJ groups compared to the remaining groups. The PPT values were significantly lower in the masseter temporalis muscles, TMJ and thenar region in the GJMM group compared to the other groups. CONCLUSION: MP more accurately differentiated symptomatic subjects from symptom-free TMD subjects, and PPT values were more sensitive to the discrimination of pain in the orofacial sites assessed. In addition, the changes in perception at a larger number of sites among children reporting mixed pain may suggest the presence of a possible mechanism of central sensitization.

Confiabilidade da fleximetria e goniometria na avaliação da amplitude de movimento cervical em crianças / Reliability of fleximetry and goniometry for assessing cervical range of motion among children

OBJETIVO: Determinar a confiabilidade intra e interexaminadores e correlacionar os valores de amplitudes de movimentos (ADM) cervical obtidas por fleximetria e goniometria em crianças. MÉTODOS: Participaram deste estudo 106 crianças saudáveis, 49 meninos (8,91±2,09 anos) e 57 meninas (9,14±1,46 anos), com idades entre seis e 14 anos, assintomáticas para disfunção cervical. Dois examinadores previamente treinados e dois auxiliares avaliaram a ADM cervical. Os examinadores coletaram as medidas por fleximetria e goniometria (confiabilidade interexaminadores) e repetiram as avaliações, após uma semana (confiabilidade intra-examinador). Todas as medidas foram registradas três vezes por cada examinador e o valor médio foi considerado para análise estatística. O coeficiente de correlação intraclasse (ICC 2,1 e 2,2) foi utilizado para verificação das confiabilidades e o coeficiente de correlação de Pearson (p<0,05) foi utilizado para verificação da correlação entre as medidas obtidas por ambas as técnicas. RESULTADOS: Foram observadas confiabilidades intra-examinador moderado e excelente para a fleximetria e moderada para a goniometria. As confiabilidades interexaminadores foram moderada e excelente para a fleximetria e pobre e moderada para a goniometria. Foi verificada correlação significativa e pobre entre todas as medidas de ADM cervical obtida pelas técnicas estudadas, exceto para o movimento de rotação à esquerda. CONCLUSÕES: A correlação pobre entre as mensurações de ADM cervical obtidas por fleximetria e goniometria demonstram que as técnicas não apresentam medidas intercambiáveis e, como a fleximetria apresentou maiores níveis de confiabilidade para avaliação da ADM cervical em crianças, seu uso é recomendado em relação à goniometria.

OBJECTIVE: To determine the intra and interrater reliability of fleximetry and goniometry in children and correlate the cervical spine range of motion (ROM) values obtained from these methods. METHODS: One hundred six children participated in this study: 49 males (8.91±2.09 years) and 57 females (9.14±1.46 years). Their ages ranged from six to 14 years and symptom-free to cervical dysfunction. Two previously trained raters and two assistants assessed neck ROM. The measurements were made using fleximetry and goniometry (interrater reliability) and repeated them one week later (intrarater reliability). All measurements were made three times by each rater and the mean value was used for statistical analysis. Intraclass correlation coefficients (ICC 2.1 and 2.2) were used to investigate reliability and Pearson's correlation coefficient (p<0.05) was used to investigate the correlation between measurements obtained from the two techniques. RESULTS: Moderate and excellent levels for intrarater reliability were observed for fleximetry and moderate reliability for goniometry. The interrater reliability was moderate and excellent for fleximetry and poor and moderate for goniometry. Significantly poor correlation was found among all neck ROM measurements obtained using both techniques, except for rotation to the left. CONCLUSIONS: The poor correlation between neck ROM measurements obtained from fleximetry and goniometry demonstrated that these techniques do not present interchangeable measurements. Since fleximetry presented higher reliability levels for assessments of neck ROM among children, the use of fleximetry rather than goniometry is recommended.

[Surgical experience of 6 multiple primary lung cancers].

Recently, we often meet multiple primary lung cancers with ground glass opacity (GGO). It is necessary for us to find suitable strategy to each case. We report a rare case with 6 lesions all of which were resected surgically. A 60-year old male visited our hospital for examination of abnormal shadows on the chest X-ray. Computed tomography (CT) scan showed 5 GGO lesions in the lung field (2 in the left lower lobe, 2 in the right upper lobe, 1 in the right middle lobe). He underwent left S6 segmentectomy as a 1st surgery, followed by wedge resection of the right upper lobe with right middle as a 2nd surgery. Pathologically, they were type A and B of the Noguchi classification. After 3-year follow-up, a new lesion developed in the right lower lobe and was resected by right lower lobectomy. It was invasive papillary adenocarcinoma. As a consequence, 6 lesions were all removed safely. The patient has been well without recurrence for 1 year after the last surgery.

[Clinical experience with aortic connector system].

From April to December 2002, 40 patients underwent coronary artery bypass grafting (CABG) using the St. Jude Medical (Minneapolis) Symmetry bypass system (aortic connector system: ACS). 59 proximal anastomoses (51 saphenous vein grafts, 8 radial artery grafts) were performed with the ACS. One saphenous vein graft occluded during operation. Postoperative evaluation of the anastomotic patency was carried out by angiography in 45 grafts. Five of the saphenous vein grafts were occluded (5/38). One patient who was shock state before operation presented with postoperative unconsciousness. Another patient died at 8th postoperative day caused by ventricular fibrillation. We conclude that the ACS produces a simple, quick way of performing the proximal anastomosis without the need for clamping the aorta, allows reducing risk of embolization by aortic manipulation. However, it is necessary to discuss sufficiently using the ACS, because the graft patency with the ACS is lower than with standard suturing technique.

Hearing results of canal wall reconstruction tympanoplasty for middle ear cholesteatoma in children.

OBJECTIVE: To investigate post-operative hearing results in children with middle ear cholesteatoma, and to analyze the correlation between hearing results and clinical factors and findings before and during the operation. PATIENTS AND METHODS: One hundred and twenty-four ears of 123 children were operated on for middle ear cholesteatoma at the age of 10 years or younger by canal wall reconstruction tympanoplasty and were followed up more than 1 year after the final operation. We evaluated the average air and bone conduction hearing levels at the speech ranges before the first operation (pre-operative hearing) and after the final operation (post-operative hearing). RESULTS: The mean of the average air conduction hearing level of 124 ears was significantly improved from 34.7 to 27.1 dB after the final operation. Among them, 84 ears (67.8%) showed a hearing level of 30 dB or less post-operatively. Post-operative hearing was better in the one-stage group than in the staged group. However, more than one-half of the ears which underwent type IV tympanoplasty in the staged group showed post-operative air conduction hearing level of < or =30 dB. Significant improvement in post-operative hearing was noted in ears with normal middle ear mucosa or middle ear effusion at the final operation. No correlation between hearing improvement and clinical factors such as age, type of cholesteatoma or presence of otitis media with effusion at the first operation was found. CONCLUSIONS: Children with middle ear cholesteatoma at the age of 10 years or younger exhibited good hearing post-operatively. Satisfactory hearing improvement is expected even in ears without the superstructure of the stapes if staged tympanoplasty is conducted. Canal wall reconstruction tympanoplasty for pediatric cholesteatoma was successful in terms of hearing results and the success was unrelated to various clinical factors.

Eosinophils are activated in middle ear mucosa and middle ear effusion of patients with intractable otitis media associated with bronchial asthma.

BACKGROUND: Although patients with intractable otitis media associated with bronchial asthma have extensive accumulation of eosinophils in the middle ear mucosa and middle ear effusion, systematic histological and immunohistochemical studies have not been performed. OBJECTIVES: To clarify the pathogenesis of middle ear diseases, we carried out immunohistochemical studies on middle ear specimens, particularly focusing on the characteristics of accumulated eosinophils. METHODS: Middle ear specimens obtained from eight adult patients and from 17 controls were immunohistochemically stained using monoclonal antibodies against EG1, EG2, mast cell tryptase, IgA and IgE. The concentration of eosinophil cationic protein (ECP) in middle ear effusion samples was also measured. RESULTS: In the asthmatic patients, severe round-cell infiltration was observed in the submucosa and most of the EG1-positive cells were also EG2-positive. In the control patients, the mucosa showed a fibrotic change with a few inflammatory cells, and EG1- or EG2-positive cells were quite few. The expression of IgE was found not only on the surface of mast cells but also within the plasma cells in the asthmatic patients, and the number of IgE-positive cells was about twice as high as that of mast cells. A significantly higher concentration of ECP was noted in middle ear effusion obtained from the asthmatic patients than that from the control patients. CONCLUSION: Most of the eosinophils in the middle ear mucosa and middle ear effusion were activated, resulting in degranulation and release of ECP, and local IgE production occurs in the middle ear mucosa, indicating that the intractable inflammation is closely associated with IgE-mediated late phase response with eosinophil accumulation.

Surgical treatment of primary cardiac tumors: 28 years' experience in Kanazawa University Hospital.

To examine the clinical features of primary cardiac tumors, 34 patients who underwent surgical treatment from 1973 to 2000 at the Kanazawa University Hospital were analyzed and the literature was reviewed. The 34 patients were divided into 3 categories: (i) myxomas; (ii) benign non-myxomas; and (iii) malignant tumors. Twenty-three patients (70%) were diagnosed with myxomas, including 22 left atrial myxomas and 1 right atrial myxoma. Seven patients (18%) were diagnosed with benign non-myxoma tumors, including 3 hemangiomas, 1 fibroma, 1 rhabdomyoma, 1 pheochromocytoma, and 1 lipoma. Four patients (12%) were diagnosed with malignant tumors, including 2 angiosarcomas, 1 rhabdomyosarcoma, and 1 malignant fibrous histiocytoma. Among the myxoma patients, in-hospital mortality was 9% (2/23), late mortality was 10% (2/21), and no recurrent myxomas have been identified. Among benign non-myxoma patients there were no perioperative deaths; however, 1 patient died 11 years after surgery, with no linked cause. No recurrent tumors have been identified. Among malignant tumor patients, 1 patient died the day following surgery and the rest died within 14 months. Early and late results of surgery were acceptable for those patients with benign tumors, while the prognosis for patients with malignant tumors was very poor.

[A case of congenital cystic adenomatoid malformation of the lung in a 4-year-old child].

A case of congenital cystic adenomatoid malformation (CCAM) of the lung is reported. A 3-year-old boy was admitted for elevation of infiltrative shadow in the right lower lung field on a chest X-ray. The clinical diagnosis was emphysematous bullae with inflammation. After 6 months, he had recurrent infected bullae, and was admitted. He received chemotherapy with antibiotics prior to the operation. Right lower lobectomy was performed on February 2, 1998. The resected lung was composed of multiple cysts with thin wall measuring 10-60 mm in diameter. The histological examination of specimen revealed CCAM (Stocker type I), which is rare in this age. The patient has been well for 16 months postoperatively.

Therapeutic angiogenesis with intramyocardial administration of basic fibroblast growth factor.

BACKGROUND: Basic fibroblast growth factor (bFGF) induces endothelial cell and smooth muscle cell proliferation and stimulates angiogenesis. This study was designed to evaluate the effects of intramyocardial administration of bFGF on myocardial blood flow, angiogenesis, and ventricular function in a canine acute infarction model. METHODS: Myocardial infarction was induced in 12 dogs by ligation of the left anterior descending coronary artery. Within 5 minutes after coronary occlusion, 100 microg of human recombinant bFGF in 1 mL of saline was injected into the infarct and border zone in 6 dogs, whereas saline alone was used in 6 control dogs. Myocardial blood flow was determined with colored microspheres before and immediately after coronary ligation and again 3, 7, 14, and 28 days after treatment and it was expressed as percent of normal. Angiogenesis was evaluated by immunohistochemical studies 28 days later. Cardiac function was evaluated by repeated echocardiographic measurement. RESULTS: Treatment with bFGF significantly increased the endocardial blood flow in the border zone (7 days after infarction, 75%+/-7% and 41% +/-7% in the bFGF and control groups, respectively, p<0.01) as well as epicardial blood flow in the infarcted zone. Treatment with bFGF significantly increased the capillary density (39.7+/-2.3 and 22.7+/-1.1 vessels per visual field in the bFGF and control groups, respectively, p<0.01) as well as arteriolar density in the border zone. Treatment with bFGF significantly reduced the change in ratio of thickness of the infarcted wall to the normal wall (44%+/-6% and 26% +/-5% in the bFGF and control groups, respectively, p<0.05). It improved the left ventricular ejection fraction (7 days after infarction, 0.54+/-0.02 and 0.37+/-0.03 in the bFGF and control groups, respectively, p<0.01). CONCLUSIONS: Intramyocardial administration of bFGF increased the regional myocardial blood flow, reduced thinning of the infarcted region, and improved ventricular function in acute myocardial infarction. Intramyocardial administration of bFGF may be a new therapeutic approach for patients with acute myocardial infarction.

[A case who needed additional Daggett's procedure for residual shunt after infarction exclusion technique for post-infarction ventricular septal perforation].

A 71-year-old woman had the surgical repair of post-infarction ventricular septal perforation with infarction exclusion technique. Three days after operation, residual shunt was observed by echocardiogram and she developed cardiac failure. Pulmonary to systemic flow ratio was 2.1, and pulmonary artery pressure was 42/23 (33) mmHg. Additional surgery for residual shunt was performed 22 days after the first operation. The part of Xenomedica patch was found loosely floating in the LV cavity. The infarcted myocardium was firm enough to closed directly, so a double Hemashield cardiovascular fabric was sutured on the left side of the perforated septum around VSP (Daggett's Procedure). The ventriculotomy was closed including the fabric with two felt strips. The postoperative course was uneventful. Though infarction exclusion technique has the advantage in many cases, much attention must be paid to prevent residual shunt.

[Early postoperative results of coronary revascularization with the radial artery: an analytical study of vascular diameter ratio of the graft and the coronary artery].

Between October 1996 and June 1988, radial artery grafts were used in 49 patients undergoing myocardial revascularization. There were three hospital deaths, none of them due to the use of radial artery. In 32 patients studied early, 33 of 34 radial artery grafts were patent (patency 97%), and 30 of 32 internal thoracic artery grafts (94%), 32 of 35 saphenous vein grafts (90%), 3 of 3 gastroepiploic artery grafts (100%) were patent respectively. The mean diameter ratio of graft and recipient coronary artery was 1.03 +/- 0.17 in radial artery, 0.92 +/- 0.16 in internal thoracic artery and 1.67 +/- 0.55 in saphenous vein graft. Our result suggest that the radial artery is an excellent conduit for myocardial revascularization, although a longer follow-up is mandatory.

Disappearance of complete atrioventricular block after chemotherapy for malignant lymphoma: a case report.

A 77-year-old man with malignant lymphoma presented with dizziness and exertional dyspnea. Physical examination revealed marked bradycardia (36 beats/min). Twelve-lead electrocardiography showed complete atrioventricular block with narrow QRS escape beats. Gallium scintigraphy demonstrated significant abnormal uptake in the heart. Transesophageal echocardiography showed a thick interatrial septum with increased echogenecity. He underwent chemotherapy under external temporary pacing with a suspected diagnosis of complete atrioventricular block secondary to cardiac invasion of malignant lymphoma. Atrioventricular conduction progressively improved and the complete atrioventricular block disappeared. He is currently well and has required no cardiac pacing for 6 months. We conclude that complete atrioventricular block may be reversible in some patients with malignant lymphoma, even in the elderly.

[Evaluation of the effect of ischemic preconditioning using near-infrared spectroscopy].

Ischemic preconditioning (IP) protects the myocardium from subsequent sustained ischemic insults. Temporary occlusion of the coronary artery is indispensable for anastomosing the graft vessel during coronary artery bypass operation without cardiopulmonary bypass. In the canine model of ischemia and reperfusion, we measured myocardial tissue oxygen saturation (SO2) continuously using near-infrared spectroscopy to determine the effect of IP on myocardial oxygen metabolism. Nine dogs underwent occlusion of the left descending coronary artery for three 5-minute periods, followed by three 5-minute periods of reperfusion. The dogs were then subjected to a 20-minutes periods of sustained coronary artery occlusion, followed by prolonged reperfusion. The myocardial SO2 was 82 +/- 2% at the baseline before coronary occlusion and was decreased to 74 +/- 2%, 76 +/- 2%, 77 +/- 3%, 77 +/- 3% at the first, second, third and sustained coronary occlusion, respectively. The increase in the minimum myocardial SO2 value at the second and third coronary occlusion suggested the effect of IP. Near-infrared spectroscopy is a useful method of continuously monitoring myocardial oxygenation and of evaluating the effect of IP during off-pump heart surgery.

Cartilage-bone replacement in endochondral ossification of mandibular condylar heads in young beagle dogs.

The cellular mechanisms of cartilage-bone replacement in endochondral bone formation, in mandibular condylar heads, are poorly understood. In particular, there is no definitive evidence indicating whether cartilage is resorbed by so-called chondroclasts. Using 3-week-old male beagle dogs, we examined the cartilage-bone replacement processes in mandibular condylar heads by means of light and electron microscopy. Calcification of the cartilage matrix occurred in the central area of the longitudinal septa but not in thin transverse septa. Chondrocytic lacunae were opened by the removal of transverse septa by perivascular rough-surfaced endoplasmic reticulum (RER)-rich mononuclear cells. These cells also phagocytosed calcified cartilage fragments in the surface layer of longitudinal septa. Shortly thereafter, a thin bone layer was deposited on the remaining longitudinal septa by invading osteoblasts. Preosteoclastic multinucleated cells in lacunar canals developed neither ruffled borders nor clear zones in the cartilage matrix, but once the bone layer had been deposited on the remaining cartilage, these structures formed. Our results suggest that the cartilage-bone replacement in mandibular condylar heads involves four sequential processes: 1) degradation of the transverse septal cartilage by RER-rich mononuclear cells, 2) phagocytosis of calcified cartilage fragments in the longitudinal septa by these cells, 3) bone deposition of the remaining longitudinal septa, and 4) degradation of both bone and calcified cartilage by differentiated osteoclasts.

[The replacement processes of growth plate cartilage to bone in endochondral ossification of mandibular condyle].

Using 3-week-old male beagle dogs, we examined the cartilage-bone replacement processes in the mandibular condyle by means of light and electron microscopy. Calcification of the cartilage matrix occurred in the central area of the longitudinal septa, but not in the transverse septa. Perivascular mononuclear cells absorbed the transverse septa which initiated the opening of the chondrocytic lacunae. These cells phagocytosed septal cartilage fragments. Shortly thereafter, a thin bone layer was deposited on the remaining longitudinal septa by invading osteoblasts. Osteoclasts in lacunae developed neither ruffled borders nor clear zones in the cartilage matrix, but once the bone layer has been deposited in the remaining cartilage, these structures formed. Our results suggest that the cartilage-bone replacement in mandibular condyle involves three sequential processes: 1) degradation and phagocytosis of cartilage fragments in the transverse septa by mononuclear cells, 2) bone deposition over the remaining longitudinal septa, and 3) degradation of both calcified cartilage and bone by osteoclasts.

[Two cases of chondrosacoma of rib].

Chondrosarcoma of rib origin is rare in Japan. We treated two cases of chondrosarcoma of rib origin. Case 1: A 68-year-old man with anterior chest wall mass and chest pain was underwent aspiration biopsy in Inami General Hospital. The histological examination showed Class V. Operation was done in our department and the histological diagnosis was chondrosarcoma. The tumor was 30 x 20 x 20 mm in size arising from the left fourth rib. The defect of bony chest wall was repaired with a double layer of Marlex mesh. His postoperative course was uneventful. Case 2: 66-year-old man noticed a tumor in left anterior part of the chest 7 months ago. He was underwent incisional biopsy and the histological diagnosis was chondrosarcoma. Radical resection was performed. The tumor was 70 x 50 x 50 mm in size arising from the left rib. His postoperative course was uneventful.

[A case of early hilar lung cancer combined with intralobar pulmonary sequestration, both of which were treated by limited lung resection].

A 59-year-old man complained of fever due to infection in the intralobar pulmonary sequestration. On bronchoscopic examination, squamous cell carcinoma was found out at orifice of the left upper division bronchus. His pre-operative pulmonary function test showed low pulmonary reserve because of myelopathy. He underwent left S1 + 2 + S3 sleeve segmentectomy and S9 + 10 segmentectomy for intralobar pulmonary sequestration. He is well without any evidence of recurrence 10 months after surgery.

[A comparison of sudden near maximal exercise test (dash method) and Bruce protocol for pediatric patients].

We examined 24 pediatric patients to evaluate the usefulness of sudden near maximal exercise test (dash method), where the subjects began to run at Bruce protocol of the last stage. 1) No considerable differences between two protocols were found in maximal oxygen consumption (V O2max), maximal heart rate (HRmax), maximal systolic blood pressure, and findings of electrocardiography. 2) The sudden maximal exercise test could be completed during a shorter period compared to Bruce protocol. 3) The sudden maximal exercise protocol reached 84% of HRmax and 47% of V O2max at one minute after the onset of the protocol, and produced 96% of HRmax and 89% of V O2max at two minutes after the onset. We considered that sudden maximal exercise protocol was useful to obtain a response similar to Bruce protocol at maximal exercise within a short period. We have to pay attention to the safety of the patients because their cardiopulmonary response to sudden maximal exercise protocol is dramatic.

[A resected case of gastric carcinoma with complete remission of Virchow's node metastasis by 5'-DFUR administration].

5'-DFUR was administered orally at 800 mg/day, for total dosage of 57.6 g to the gastric cancer patient, classified Borrmann Type 2, with Virchow's node metastasis. Gastric tumor had diminished in size on the fluoroscopy and the endoscopy. We then made distal gastrectomy. The resected stomach showed moderately differentiated tubular adenocarcinoma on the pathological examination. Side effect was diarrhea.