The perfusion index derived from a pulse oximeter for predicting low superior vena cava flow in very low birth weight infants.

OBJECTIVE: Superior vena cava (SVC) flow is used as an index for evaluating systemic blood flow in neonates. Thus far, several reports have shown that low SVC flow is a risk factor for intraventricular hemorrhage (IVH) in the preterm infant. Therefore, it is likely to be a useful index in the management of the preterm infant. The perfusion index (PI) derived from a pulse oximeter is a marker that allows noninvasive and continuous monitoring of peripheral perfusion. The objective of this paper was to determine the accuracy of the PI for detecting low SVC flow in very low birth weight infants born before 32 weeks of gestation. STUDY DESIGN: We studied the correlation between PI and SVC flow 0 to 72 h after birth in very low birth weight infants born before 32 weeks of gestation. The best cut-off value for low SVC flow was calculated from the respective receiver-operating characteristic curves. RESULT: A positive correlation was found between the PI and SVC flow (r=0.509, P<0.001). The best cut-off value for the PI to detect low SVC flow was 0.44 (sensitivity 87.5%, specificity 86.3%, positive predictive value 38.9%, negative predictive value 98.6%). CONCLUSION: This study found that the PI was associated with SVC flow, and it was a useful index for detecting low SVC flow in very low birth weight infants born before 32 weeks of gestation. Therefore, use of the PI should be evaluated in the cardiovascular management of the preterm infant.

Perforator flaps in lower extremity reconstruction.

Perforator flaps are defined as skin flap without fascia or muscle and they are nourished by one or more perforating vessels perforating the fascia, muscle, or intermuscular septum. As early as 1985 in Japan, we proposed this concept over that of the fasciocutaneous flap, which was believed to be nourished by fascial plexus. The pedicle perforators are classified as septocutaneous, muscular (intermuscular), periosteal, and intertendinous perforators. As useful perforator flaps in the lower extremity, posterior tibial perforator island flaps, saphenous island flaps, peroneal island flaps, malleolar island perforator flaps, deep inferior epigastric perforator free flap (DIEP flap), anterolateral thigh free flap (ALT flap), and latissimus dorsi muscle free perforator flap (thoracodorsal artery perforator flap, T-DAP or TAP flap) were described. These flaps have the advantage of minimal donor-site morbidity, relatively rapid dissection and flap elevation, and reliable skin territory.

Free vascularized nail graft under digital block.

Vascularized toenail grafts with long vascular pedicles have usually been transferred under general anesthesia. In this paper, a minimally invasive vascularized nail graft with a short pedicle and small cutaneous flap, which was successfully transferred under digital block of the finger and toe, is described.

Electroretinographic assessment of early changes in ocular siderosis.

We examined a patient with an iron intraocular foreign body and recorded electroretinograms (ERGs) before and after the removal of the foreign body by vitrectomy. The amplitudes of the rod and cone ERGs and the oscillatory potentials (OPs) in the injured eye were reduced before the operation. In addition, the photopic on-responses (b wave) were more reduced than off-responses (d wave). One year after surgery, the amplitudes of the rod, cone and photopic on- and off-responses were markedly improved to within the low normal limit. However, the OP amplitudes remained unchanged with lower values. These findings suggest that iron retinotoxicity leads to a dysfunction of all layers but the changes may be reversible in the early period of the disease. The late period iron toxicity produces more severe damage to the inner retina than the outer retina.

Alternate magnetic fields potentiate monoamine oxidase activity in the brain.

Catecholamines and serotonin, which act as neurotransmitters and regulate blood circulation, are degraded by monoamine oxidase (MAO) [EC 1.4.3.4.] which exists two iso-enzymes named MAO-A and MAO-B. In this study, the effects of magnetic fields on MAO activity in the rat brain were examined. MAO-A activity was not changed in static magnetic fields (0.1-340 mT) or in 10-500 mT/s of alternate isosceles triangular magnetic fields (AITMF) (50 Hz). MAO-B activity was not changed in static magnetic fields (0.1-340 mT) and in 10, 34, 340, 95, 105, 110, and 340 mT/s of AITMF. However, it was increased to 114% in the 100 mT/s of AITMF. In 100 mT/s, Michaelis constant (K(m)) significantly decreased to 72%, suggesting that the affinity of the substrate to the enzyme also increased. These results indicate that only MAO-B was influenced by AITMF with 'active window' phenomenon, and suggest that AITMF might affect neural activity and hemodynamics by altering MAO-B.

[Adenomatoid tumor of the tunica albuginea: a case report].

A case of male adenomatoid tumor of tunica albuginea of the testis is reported. A 45-year-old man referred to our hospital because of intrascrotal mass on the right side. The mass increased in size for eight months. Then we excised the tumor, and spared the right testis. The tumor was arising from the tunica albuginea of the testis with a pedicle. The histological diagnosis was adenomatoid tumor. Adenomatoid tumor is a rare benign tumor. A total of 97 cases of adenomatoid tumor of epididymis have been reported in males, but only 23 cases of adenomatoid tumor of the testis have been reported in Japan. Herein, 24 cases of adenomatoid tumor of testis including our case are discussed and reviewed.

Epileptic negative myoclonus induced by carbamazepine in a child with BECTS. Benign childhood epilepsy with centrotemporal spikes.

A 7-year-old female with benign childhood epilepsy with centrotemporal spikes developed epileptic negative myoclonus (ENM) seizures during carbamazepine (CBZ) treatment. She had experienced nocturnal partial seizures since 5 years of age. Interictal electroencephalography demonstrated typical rolandic discharges. Valproate was first initiated at 6 years of age, but the seizures were uncontrollable. Carbamazepine was added and valproate withdrawn. The frequency of partial seizures did not decrease. Moreover, she had brief episodes of tone loss in each or both arms and eye blinking several weeks after CBZ introduction. Unilateral loss of arm tone corresponded to spike-and-wave discharges in the contralateral centrotemporal region, and a loss of tone in arms was associated with bilateral synchronous discharges. Eye blinking was also related to bilateral synchronous discharges and classified as a myoclonic seizure. The ENM and myoclonic seizures disappeared soon after CBZ withdrawal. Therefore the authors concluded that CBZ induced the ENM and myoclonic seizures in this patient. CBZ sometimes induces generalized seizures in the treatment of partial epilepsy and generalized epilepsy. CBZ-induced ENM seizures should be considered when a brief lapse of tone appears during CBZ treatment.

[Histopathological findings and clinical effects for acute rejections].

We reviewed 115 cases of acute rejection following renal transplantation. All cases were diagnosed after graft biopsy, and showed histopathological evidence of acute rejection. They were treated with administration of OKT3, 15-deoxyspergualin (DSG), anti-lymphocyte globulin (ALG) or methylprednisolone (MP). All rejections were histopathologically classified according to the Banff working classification. The clinical effects of each drug were evaluated both at 1 month and 1 year following the therapy for rejection, by measurement of serum creatinine level. The effective rate both at 1 month and 1 year was related with the Banff working classification ( p < 0.0001). At 1 month after treatment, there were no significant differences between the OKT3, DSG or ALG group and MP group in cases of borderline change and AR grade I. In cases of grade II and grade III, a significant difference was observed between the OKT3 or ALG group and MP group (p < 0.05). The DSG group showed a slightly better outcome than the MP group, although the difference was not significant. In conclusion, the Banff schema is shown to be valid for classification of acute renal allograft rejection, and it is necessary to determine the treatment for acute rejection according to histopathological classification.

Expression of osteonectin in articular cartilage of osteoarthritic knees.

The expression of osteonectin (ON) in osteoarthritic articular cartilage was investigated by enzyme immunohistochemistry and colloidal gold immunoelectron microscopy. A total of 96 specimens from 9 knees of 8 patients with osteoarthritis (OA) were examined. In OA cartilage, ON-positive cells varied in distribution and were not seen in all the specimens obtained from the same patient. However, in over half of the specimens (56 of 96), especially in the specimens on Mankin's grades from 4 to 9, which corresponds to relatively early stages of OA, ON was expressed in the cartilage above the calcified layer. On the other hand, ON was detected only in the calcified layer below the tidemark in normal articular cartilage. In addition, colloidal gold immunoelectron microscopy revealed ON in chondrocytes and matrix vesicles (MVs). These findings suggest that ON acts through MVs in the early stages of OA as a significant pathogenetic factor involved in intracartilage calcification, which is known to have a close relationship to the progression of OA.

Endoscopic carpal tunnel pressure measurement: a reliable technique for complete release.

Carpal tunnel syndrome is diagnosed by clinical symptoms, Tinel's sign, Phalen's test and electromyography. Carpal tunnel pressure measurement can also aid in the precise identification of excessive pressure sites that indicate locations for release. In this study, pressure measurements made during endoscopic carpal tunnel release at 5 points were significantly higher anywhere in the carpal tunnel than outside the tunnel and decreased markedly after release. We concluded that our measurement technique can improve the reliability of endoscopic carpal tunnel release by decreasing the likelihood of missing any nerve entrapment sites.

Non-traumatic paralysis of the posterior interosseous nerve.

We treated 31 patients with non-traumatic paralysis of the posterior interosseous nerve over 15 years. There were 10 men and 21 women of mean age 40.3 years (17 to 71). Six were managed conservatively, and 25 by operation. In 14 patients entrapment occurred at the supinator, including three who had double compression at both the entrance and exit from the muscle. In four it was caused by a ganglion, in one by a lipoma, in one by a dislocated radial head and in two by a marked constriction in the nerve of unknown cause. The remaining three patients were retrospectively diagnosed as having neuralgic amyotrophy, the only observable change at operation being slight oedema of the nerve. Paralysis recovered in 24 out of the 25 patients at between 2 to 18 months (mean 5.6) after operation, and the one failure was treated later by tendon transfer.

Intraneural ganglion of the posterior interosseous nerve with lateral elbow pain.

We report an intraneural ganglion of the posterior interosseous nerve causing lateral elbow pain. The cystic lesion was identified by magnetic resonance imaging, and surgical exploration using the microscope permitted complete extirpation of the cyst without damage to nerve tissue. The patient experienced complete relief from pain, with full preservation of function.

[Two cases of post-encephalitic epilepsy characterized by auditory cognitive dysfunction; comparison with "a peculiar type of post-encephalitic/encephalopathic epilepsy"].

Two cases of post-encephalitic epilepsy mainly characterized by auditory cognitive dysfunction were reported. In acute phase they only showed slight pleocytosis of CSF, and serum antiviral antibodies were all negative. Although their seizures were partial seizures with secondary generalization, their EEG and radiographic imaging did not show any lesions. Their waking state EEG continuously showed slowing with decrease of alpha activities. After clusters of convulsions, they showed delirium and aggressiveness. Both of them were thought to have post-encephalitic epilepsy with pathogen unknown and they were compatible with "a peculiar type of post-encephalitic/encephalopathic epilepsy" reported by Fukuyama and Awaya. The presented two cases were characterized by auditory cognitive dysfunction and intractable epilepsy with secondary generalization.

Pseudomyxoma peritonei due to adenocarcinoma of the lung: case report.

A rare case of pseudomyxoma peritonei whose primary site was presumed to be the lung is reported. A 76-year-old woman was admitted to Hospital presenting with progressive abdominal distention. She had been admitted twice, 2 and 1 year previously for the evaluation of high plasma carcinoembryonic antigen (CEA) level, of 11.6 ng/ml. Chest computed tomography (CT) scan and chest X-ray film on the third admission revealed a nodular lesion in the left lower lung field, and transbronchial lung biopsy (TBLB) revealed mucus-producing tall columnar epithelial carcinoma. Paracentesis revealed gelatinous ascitic fluid. At laparotomy, appendix and ovary were normal, and there were many small cystic tumors on the peritoneal surface and omentum. The patient died 2 years later, after repeated episodes of dynamic ileus. The lung and abdominal tumors gradually increased in size during the 2-year period, but she developed no respiratory symptoms. Based on both the clinical and pathophysiological findings, the final diagnosis made was pseudomyxoma peritonei whose origin was a lung adenocarcinoma.

[Studies on the mechanism of late asthmatic response by Candida antigen inhalation using bronchoalveolar lavage].

To elucidate the mechanism of late asthmatic response (LAR), which is related to intractable asthma attack, the cellular and humoral components of LAR were examined in bronchoalveolar lavage fluid (BALF) obtained after bronchial inhalation tests with Candida allergen on Candida-sensitive asthma patients. BAL examination was carried out 2 hours after remission of LAR, and differential cell counts and measurements of leukotrienes (LTs) by high performance liquid chromatography were investigated in BALF and peripheral blood. The number of neutrophils and basophils in circulating blood showed a peak before LAR, and then decreased markedly at LAR. And an increase in the percentage of eosinophils (p less than 0.01) and neutrophils was evident in BALF after LAR compared with the level in the non-attack state. The percentage of basophil-mast cells, however, did not change in the same manner. The serum level of LTC4 increased significantly at LAR in comparison with its level in the phase before LAR. And the level of LTC4 was also significantly higher in BALF after LAR (p less than 0.01). However, LTD4 and LTB4 were at almost undetectable levels in BALF in the non-attack state and after LAR. The results indicate that neutrophils as well as eosinophils may accumulate and release several kinds of leukotrienes at local sites in late asthmatic response provoked by the inhalation of Candida antigen; this gives clues as to the mechanism of severe and intractable asthma attacks.

[Studies on IgG subclass antibodies in adult asthma. 1. Serum antigen specific IgG subclass antibodies in asthmatics with late asthmatic response].

It is clear that immediate asthmatic response is mediated by IgE-dependent mechanisms. However, late asthmatic response is induced by inhalation of antigens without antigen specific IgE antibodies in some asthmatics, especially in intractable asthma induced by Candida antigen. To elucidate the relationship between those bronchial responses and antibodies, antigen specific IgG subclass antibodies in sera from asthmatics were measured and compared with IgE antibody. The results were as follows. 1. Avidin-biotin ELISA (enzyme-linked immunosorbent assay) method was established for the measurement of specific IgG and IgG subclass antibodies to mite or Candida antigen. 2. Serum levels of antigen specific IgG and IgG1 antibodies in asthmatics with LAR provoked by mite or Candida antigen were significantly higher than those in asthmatics without LAR (p less than 0.01). 3. Serum levels of specific IgE antibody to these antigens in asthmatics with LAR provoked by mite or Candida antigen were slightly lower than those in asthmatics without LAR, though the difference is not significant. These results suggest that high serum levels of specific IgG and IgG1 antibodies to these antigens play a role in inducing LAR in asthmatics with LAR.

Assessment of daily physical activity levels of severely disabled persons using heart rate series.

Daily physical activity levels of severely disabled persons were assessed by means of a statistical analysis of their heart rate during a 24-h period. A non-Gaussian probability density function of the heart rate was calculated and separated into two levels of heart rate distributions, i.e. a relatively lower heart rate for basic daily activity and a relatively higher heart rate relating to vigorous activity. Disabled persons with low ambulatory ability showed daily activity levels similar to normal subjects in the length of time and the level of the heart rate. Their daily activity satisfied their needs for maintaining good health. However, more prolonged vigorous activity in daily living was necessary to improve cardiovascular fitness. For severely disabled persons without ambulatory ability, almost all of the heart rates during daily activity were categorized into the lower heart rate distribution. Their low level of physical activity may lead to a serious decrease in cardiovascular function with its attendant risk of cardiopulmonary disease.