Cauda Equina and Filum Terminale Arteriovenous Fistulas: Anatomic and Radiographic Features.

Intradural AVF below the conus medullaris may develop either on the filum terminale or the cauda equina (lumbosacral and coccygeal radicular nerves). Although not a few filum terminale AVFs are found in the literature, only 3 detailed cauda equina AVFs have been reported. Here, we analyze the angiographic and MR imaging findings of our cauda equina and filum terminale AVF cases, supplemented with literature research to characterize the radiologic features of the 2 entities. On angiography, filum terminale AVFs were invariably supplied by the extension of the anterior spinal artery accompanied by a closely paralleling filum terminale vein. Cauda equina AVFs were fed by either a radicular or a spinal artery or both arteries, often with a characteristic wavy radicular-perimedullary draining vein. On thin-section axial MR imaging, the filum terminale AVF draining vein joined the spinal cord at the conus medullaris apex, but that of the cauda equina AVF joined above the conus medullaris apex.

Bifidobacterium breve prevents necrotising enterocolitis by suppressing inflammatory responses in a preterm rat model.

Necrotising enterocolitis (NEC) is associated with inflammatory responses and barrier dysfunction in the gut. In this study, we investigated the effect of Bifidobacterium breve M-16V on factors related to NEC development using an experimental rat model. Caesarean-sectioned rats were given formula milk with or without B. breve M-16V by oral gavage thrice daily, and experimental NEC was induced by exposing the rats to hypoxic conditions. Naturally delivered rats that were reared by their mother were used as healthy controls. The pathological score of NEC and the expression of molecules related to inflammatory responses and the barrier function were assessed in the ileum. B. breve M-16V reduced the pathological scores of NEC and resulted in some improvement in survivability. B. breve M-16V suppressed the increased expression of molecules related to inflammation and barrier function that resulted from NEC induction. B. breve M-16V normalised Toll-like receptor (TRL)4 expression and enhanced TLR2 expression. Our data suggest that B. breve M-16V prevents NEC development by modulating TLR expressions and suppressing inflammatory responses in a rat model.

Impact of recipient aging on kidney allograft in living donor transplantation.

BACKGROUND: The aging of recipients is becoming increasingly important in organ transplantation. PATIENTS AND METHODS: We analyzed outcomes in 215 consecutive adult kidney transplant recipients from living donors who underwent transplantation at our center between November 1988 and March 2012. The list of recipients was divided by age at transplantation into those aged 16 to 29 years (n = 61), 30 to 39 years (n = 69), 40 to 49 years (n = 33), 50 to 59 years (n = 29), and those 60 years or older (elderly group, n = 23). Cox proportional hazards analysis was used to calculate the relative risk (RR) of patient death and graft failure, with recipient age included as a continuous variable. RESULTS: Univariate analysis showed that recipient age did not significantly affect the risk of graft failure, either uncensored (RR = 1.01, P = .312) or censored for death (RR = 0.993, P = .587). Multivariate analysis, however, showed that recipient age was an independent risk factor for patient death (RR = 1.053, P = .024). The patient survival rate was the poorest in elderly group (87.0%, P = .036), whereas the both death uncensored and censored graft survival rates of this group were 78.1% and 91.3%, respectively, comparable to those of other age groups (P = .567 and P = .696). Mean estimated glomerular filtration rate (eGFR) 1 year after transplantation was lower in elderly groups than in other groups (46.1 ± 13.0 mL/min/1.73 m(2), P = .014). However, mean δeGFR, defined as the difference between pretransplantation eGFR of the donor and eGFR of the recipient 1 year post-transplantation, did not differ significantly among age groups. CONCLUSION: Recipient age did not affect allograft deterioration in living donor kidney transplantation, although it was an independent risk factor of recipient death.

Double ophthalmic artery visualized with new technology.

The anatomy of the double ophthalmic artery was visualized using fused imaging. The images demonstrate the first angiographic visualization of the course of the vessel.

Swine hybrid aneurysm model for endovascular surgery training.

The aim of this study was to develop a technically simple swine aneurysm-training model by inserting a silicone aneurysm circuit in the cervical vessels. A silicone aneurysm circuit was created by designing multiple aneurysms in size and configuration on a silicone vessel. Five swine underwent surgical implantation of this circuit in the cervical vessels: one end in the common carotid artery and the other in the external jugular vein. Using this model, an aneurysm coiling procedure was simulated under fluoroscopic guidance, roadmapping and digital subtraction angiography. Creating an aneurysm model for training purposes by this method was technically simple and enabled the formation of a wide variety of aneurysms in a single procedure. The quality of the model was uniform and the model was reproducible. Coiling training using this model resembled a realistic clinical situation. The swine hybrid aneurysm-training model was advantageous from the standpoint of technical simplicity in the creation and variety of aneurysms it provided. The swine hybrid aneurysm model may be an additional option for aneurysm coiling training.

A bipolar spindle of antiparallel ParM filaments drives bacterial plasmid segregation.

To ensure their stable inheritance by daughter cells during cell division, bacterial low-copy-number plasmids make simple DNA segregating machines that use an elongating protein filament between sister plasmids. In the ParMRC system of the Escherichia coli R1 plasmid, ParM, an actinlike protein, forms the spindle between ParRC complexes on sister plasmids. By using a combination of structural work and total internal reflection fluorescence microscopy, we show that ParRC bound and could accelerate growth at only one end of polar ParM filaments, mechanistically resembling eukaryotic formins. The architecture of ParM filaments enabled two ParRC-bound filaments to associate in an antiparallel orientation, forming a bipolar spindle. The spindle elongated as a bundle of at least two antiparallel filaments, thereby pushing two plasmid clusters toward the poles.

Wire-probing technique to revascularize subacute or chronic internal carotid artery occlusion.

During endovascular revascularization of subacute and chronic occlusion of the cervical internal carotid artery (ICA) it may be difficult to penetrate the lesion. Selecting the appropriate "true lumen", a remnant of what had been the arterial lumen, at the initial step may facilitate the procedure. Because plaque at the carotid bifurcation is known to propagate from the posterior wall, a gateway to this "true lumen" should exist in the anterior side of the occluded stump. This hypothesis was studied retrospectively in our series of revascularizing ICA subacute and chronic occlusion. Eleven patients underwent endovascular revascularization for symptomatic cervical ICA occlusion. Procedures were performed by initially penetrating the occluded stump with a guidewire, followed by supporting catheter advancement through the occluded segment to secure the distal normal arterial lumen. Cases were analyzed with regard to the location of initial guidewire penetration. Eight patients underwent successful revascularization. In five cases, the entry point to the occluded stump was located at the anterior side, and in three, at the posterior side. Two posterior stump penetration cases were met with resistance in guidewire advancement, whereas penetration was smooth in the anterior cases. In addition, two posterior stump penetration cases resulted in contrast stasis in the posterior ICA wall. In our series of revascularizing cervical ICA subacute and chronic occlusion, initially targeting the anterior side of the occluded stump resulted in favorable results. This may be the result of selecting the "true lumen" at the beginning of the procedure.

A prevalent founder mutation and genotype-phenotype correlations of OTOF in Japanese patients with auditory neuropathy.

Auditory neuropathy is a hearing disorder characterized by normal outer hair cell function and abnormal neural conduction of the auditory pathway. Aetiology and clinical presentation of congenital or early-onset auditory neuropathy are heterogeneous, and their correlations are not well understood. Genetic backgrounds and associated phenotypes of congenital or early-onset auditory neuropathy were investigated by systematically screening a cohort of 23 patients from unrelated Japanese families. Of the 23 patients, 13 (56.5%) had biallelic mutations in OTOF, whereas little or no association was detected with GJB2 or PJVK, respectively. Nine different mutations of OTOF were detected, and seven of them were novel. p.R1939Q, which was previously reported in one family in the United States, was found in 13 of the 23 patients (56.5%), and a founder effect was determined for this mutation. p.R1939Q homozygotes and compound heterozygotes of p.R1939Q and truncating mutations or a putative splice site mutation presented with stable, and severe-to-profound hearing loss with a flat or gently sloping audiogram, whereas patients who had non-truncating mutations except for p.R1939Q presented with moderate hearing loss with a steeply sloping, gently sloping or flat audiogram, or temperature-sensitive auditory neuropathy. These results support the clinical significance of comprehensive mutation screening for auditory neuropathy.

Difference in dental arch size between obese and non-obese patients with obstructive sleep apnoea.

A large tongue is recognised as a factor that increases the collapsibility of the upper airway in obstructive sleep apnoea (OSA) patients. We hypothesised that the propensity to develop severe OSA could be minimised if the dental arches were enlarged in obese OSA people who are thought to have a large tongue. We therefore compared the size of the dental arches in obese and non-obese OSA patients. Using a lateral cephalogram and study models, we compared the sizes of the tongue and dental arches in 23 obese and 23 non-obese Japanese male OSA patients, who were matched for age, apnoea hypopnea index (AHI) and maxillomandibular size. The median age (years) and AHI (events per hour) for the obese and non-obese groups were 36·5 and 39·0, and 13·4 and 14·3, respectively. The maxillomandibular size was matched with regard to SNA, SNB and lower face cage obtained from cephalometric measurements. The parameters that were measured for the study model included dental arch width, dental arch length, overjet and overbite. Tongue size (P < 0·05) and both upper (P < 0·01) and lower (P < 0·05) dental arch widths were significantly larger in obese than in non-obese OSA patients, and there was no difference in the severity of OSA between the two groups. These findings suggest that the tongue was larger and dental arches were enlarged in obese patients compared with non-obese patients under the same disease severity. Wider dental arches in obese OSA patients may help to offset the impact of the enlarged tongue on upper airway patency.

Protected endovascular revascularization of subacute and chronic total occlusion of the internal carotid artery.

BACKGROUND AND PURPOSE: The natural course of symptomatic carotid artery occlusion with hemodynamic impairment is poor. Surgical revascularization may improve the outcome; however, its efficacy has not been established yet. The goal of this study was to characterize the technical and clinical outcomes following endovascular recanalization of the ICA under cerebral circulatory protection. MATERIALS AND METHODS: Endovascular recanalization was attempted in 8 patients with symptomatic ICA occlusions. The duration of the occlusion ranged from 7 days to 7 months (mean, 2.5 months), and the mean length of the occlusion was 95 mm. Cerebral hemodynamics ipsilateral to the side of the occlusion were severely impaired in all patients. The endovascular procedure was performed under total cerebral circulatory protection, beginning with proximal protection with a subsequent switch to distal protection after successful guidewire passage. RESULTS: The occlusion was recanalized successfully in 7 of 8 patients (88%), resulting in improvement of ipsilateral cerebral hemodynamics without symptomatic stroke. Small asymptomatic ischemic lesions were detected in 6 of 8 patients (75%) on DWI, and 1 patient developed a mild groin hematoma. Ischemic episodes did not recur during the mean follow-up period of 19 months. However, 1 patient experienced asymptomatic reocclusion, which was re-treated successfully without complications, while another patient developed mild retinal hemorrhage at 3 months after the procedure due to the combination of antiplatelet and anticoagulant therapy. CONCLUSIONS: Endovascular revascularization of an ICA occlusion is feasible and well-tolerated in patients with subacute or chronic total occlusion of the ICA.

Optimal positive airway pressure predicts oral appliance response to sleep apnoea.

Patients with less severe obstructive sleep apnoea (OSA) are usually prescribed oral appliances and/or smaller optimal nasal continuous positive airway pressure (P(nCPAP)) in nCPAP therapy. We hypothesised that OSA patients with greater P(nCPAP) would not respond favourably to oral appliances. Oral appliances were inserted in nCPAP users after washing-out the nCPAP effect. Follow-up polysomnography was undertaken with the adjusted oral appliance in place. The predictability of P(nCPAP) was evaluated with receiver-operating characteristic (ROC) curves. The median baseline apnoea/hypopnoea index (AHI) was reduced with the oral appliance from 36 to 12 events.h(-1) in 35 patients. When responders were defined as patients showing a follow-up AHI of <5 events.h(-1) with >50% reduction in baseline AHI, the area under the ROC curve for P(nCPAP) was 0.76. The best cut-off value of P(nCPAP) turned out to be 10.5 cmH(2)O with a high negative predictive value (0.93) and a low negative likelihood ratio (0.18). OSA patients with a P(nCPAP) of >10.5 cmH( 2)O are unlikely to respond to oral appliance therapy. This prediction is clinically helpful to both OSA patients and medical personnel in discussing oral appliances as a temporary substitute and/or alternative for nCPAP.

Use of Dyna-CT Angiography in Neuroendovascular Decision-Making. A Case Report.

SUMMARY: A successful neuroendovascular procedure depends on accurate anatomical understanding of a target vessel in relation to surrounding anatomical structures or endovascular devices, such as coils and stents. During an endovascular procedure, with conventional or three dimensional (3D) rotational angiography, this type of information is extremely difficult to obtain in a timely manner. To overcome this drawback, a DynaCT was combined with low dose contrast injection to create CT angiography (CTA)-like images (DynaCTA). The images obtained were similar to those of conventional CTA but with better quality in analyzing vessels to surrounding anatomical structures and endovascular devices while the patient was on the table. The authors present three illustrative cases in which information added by the DynaCTA helped improve understanding of anatomy, and affected our clinical decision-making. Although better quality images may be obtained by other imaging modalities or careful angiographic interpretations, DynaCTA can be an easy and effective rescue technique worth keeping in mind in clarifying the relation of a vessel to surrounding anatomy.

Re-evaluation of heterogeneity in HLA-B*510101 associated with Behçet's disease.

Behçet's disease (BD) is a chronic inflammatory disease characterized by oral aphthous ulcers, genital ulcers, uveitis and skin lesions. Etiology and pathogenesis of BD are not fully elucidated, but the association with human leukocyte antigen (HLA)-B51 or B*5101 has been repeatedly reported. Previous studies have shown that there are few sequence variations in the protein-coding region of B51, while there is a report on many variations in the 5'-flanking region and intron. In this study, HLA-B*5101 gene from 37 individuals including Japanese, Turkish, Jordanian and Iranian patients and healthy controls were fully sequenced to further clarify the B*5101 gene in association with BD. We found that all the patients and healthy controls carried B*510101 with no variation in the 5'-flanking region, exon and intron. However, seven polymorphisms were found in the 3'-flanking region. These polymorphisms composed of six haplotypes that were shared and stretched over the ethnic groups, suggesting that the susceptibility to BD was conferred by the B*510101 itself and not by any genes in linkage disequilibrium with B*510101. In addition, phylogenetic analyses of B*510101 showed that the 3'-flanking sequences followed an evolutional divergence differently from that of the other regions, implying that a unifying selection might operate to conserve B*510101.

Mutation screening of the CARD15 gene in sarcoidosis.

CARD15 was first identified as a susceptibility gene for Crohn's disease. More recently, CARD15 mutations were shown to be associated with the pediatric granulomatous inflammatory diseases, Blau syndrome and early-onset sarcoidosis (EOS). The aim of the present study was to evaluate whether CARD15 variants also play a role in patients with ordinary sarcoidosis other than EOS. We enrolled 135 Japanese sarcoidosis patients with uveitis as well as 95 healthy individuals and performed mutation analysis by direct sequencing of CARD15 exon 4. Direct DNA sequencing in the sarcoidosis patients showed eight CARD15 variants, including five novel mutations (13402C>T, 13543C>T, 13775C>A, 13937G>A, and 14079C>T). Compared with healthy individuals, CARD15 mutations are not common in the Japanese patients with sarcoidosis. Based on the results, we examined the clinical manifestations in patients with sarcoidosis according to their CARD15 mutations. Sarcoidosis patients with these mutations have no specific clinical features with regard to course of the disease or disease severity. Our results indicate that in general, CARD15 mutations may not contribute to the risk of sarcoidosis.

An improved computer-aided diagnosis scheme using the nearest neighbor criterion for determining histological classification of clustered microcalcifications.

OBJECTIVES: Our purpose was to evaluate the potential usefulness of the nearest neighbor case which was assumed to be the similar case in a CAD scheme for determining the histological classification of clustered microcalcifications. METHODS: Our database consisted of current and previous magnification mammograms obtained from 93 patients before and after three-month follow-up examination. It included 11 invasive carcinomas, 19 noninvasive carcinomas of the comedo type, 25 non-invasive carcinomas of the noncomedo type, 23 mastopathies, and 15 fibroadenomas. Six objective features on clustered microcalcifications were first extracted from each of the current and the previous images. The nearest neighbor case was then identified by the Euclidean distance in the previous and current feature-space. The histological classification of an unknown new case in question was assumed to be the same as that of the nearest neighbor case which has the shortest Euclidean distance in our database. RESULTS: The classification accuracies were 90.9% for invasive carcinoma, 89.5% for noninvasive carcinoma of the comedo type, 96.0% for noninvasive carcinoma of the noncomedo type, 82.6% for mastopathy, and 93.3% for fibroadenoma. These results were substantially higher than those with our previous CAD scheme. CONCLUSION: The nearest neighbor criterion was useful in a CAD scheme for determining the histological classification.

A new hemostasis valve for neuroendovascular procedures.

SUMMARY: A hemostasis valve is routinely used in neuroendovascular procedures to decrease the risk of thromboembolism (1,2) . Recently, a new hemostasis valve that is designed to minimize blood loss has been introduced. We report our initial experience in using this new hemostasis valve. In neuroendovascular procedures, a hemostasis valve is commonly used for continuous irrigation of guide and microcatheters to decrease the risk of thromboembolism(1,2,3). A conventional hemostasis valve has a rotating seal at the end, which is turned open or closed each time a wire or microcatheter/guidewire is introduced or extracted. Often this results in significant back bleeding. When a rotating seal is adjusted suboptimally during a wire or microcatheter manipulation, leakage of pressurized saline from the end of a hemostasis valve results in stagnation of blood within a guiding catheter, which becomes a potential source of emboli during a procedure. The Guardian Haemostasis Valve (Zerusa Limited, Galway, Ireland) is a new hemostasis valve that is designed to minimize blood loss during interventional procedures by minimizing the opening time of the valve during wire or microcatheter insertion. A continuous sealing mechanism during wire or microcatheter positioning minimizes blood loss and stagnation of blood within the guide catheter. We report our initial experience with the Guardian hemostasis valve.

Treatment of cerebral aneurysms with hydrogel-coated platinum coils (HydroCoil): early single-center experience.

PURPOSE: The authors report their experience using HydroCoils in the treatment of cerebral aneurysms. METHODS: We performed a retrospective review of the first 100 nonrandomized patients (104 coiled saccular cerebral aneurysms) treated with HydroCoils during a 27-month period. RESULTS: The average percentage of HydroCoil by length detached in treated aneurysms was 45.5% (range, 9.9-100%). Immediate postprocedure angiography demonstrated complete aneurysm occlusion in 34%, neck remnant in 35%, and incomplete occlusion in 32%. Immediate procedure-related morbidity and mortality rates were 5.8% and 0%, respectively. Angiographic follow-up was obtained in 51% (51/100 patients; 53/104 aneurysms; average, 10.3 months; range, 0-31 months). In these 53 angiographically followed aneurysms, the overall recanalization rate was 21%: no recanalization occurred in 23 aneurysms with small size (<10 mm)/small neck (<4 mm) (S/S); 4 recanalizations occurred in 7 aneurysms with small size/wide neck (>4 mm) (S/W); 6 recanalizations (27%) occurred in 22 large (L) aneurysms (>10-25 mm, 70% angiographic follow-up); and 1 giant (G) (>25 mm) aneurysm recanalized. A large proportion of aneurysms that were not initially completely occluded were completely occluded on follow-up (15/43 [35%]). Clinical follow-up was obtained in 73 patients (73%; average, 5.3 months; range, 0-24 months): 93% of these patients were neurologically improved or unchanged. Three patients rehemorrhaged and 3 patients with unruptured aneurysms developed delayed hydrocephalus. CONCLUSIONS: The overall safety profile of HydroCoils appears acceptable. Preliminary midterm observations suggest less coil compaction/aneurysm recanalization in large aneurysms. However, HydroCoil-related delayed hydrocephalus is a concern.

Alpha-MSH regulates protein ubiquitination in T cells.

The neuropeptide alpha-melanocyte stimulating hormone (alpha-MSH) suppresses IFN-gamma + T cells from mice. We discovered, however, that despite this significant production by DTH-mediating effector CD4 supression of IFN-gamma production, alpha-MSH-treated effector T cells had the same level of IFN-gamma mRNA expression and intracellular IFN-gamma protein as untreated activated T cells. In order to explain why IFN-gamma production was suppressed in the face of unchanged mRNA and intracellular IFN-gamma levels, we looked for mechanisms that could increase the degradation of IFN-gamma within the alpha-MSH-treated T cells. Among the known pathways of post-translational intracellular protein modification, the ubiquitin-proteosome system was examined in alpha-MSH-treated T cells to see if a post-translational protein modification occurred to prevent IFN-gamma secretion from the cell. Immunoblots from alpha-MSH-treated T cells showed higher levels of protein ubiquitination when compared to untreated T cells. Resting T cells treated with alpha-MSH also demonstrated enhanced protein ubiquitination. We found that IFN-gamma is one of the ubiquitinated proteins in the alpha-MSH-treated activated T cells. Our results demonstrate that one of the mechanisms by which alpha-MSH regulates T cell activity is through mediating a change in the pattern of protein ubiquitination in T cells.