The effect of an introduction of a new consent form on settlement of the doctrine "informed consent".

Paternalism has been criticized lately in the japanese medical world, but it remained rather unfamiliar for a majority of the medical doctors to exercise the informed consent in the daily practice. It seemed that a consent form was one of the ways by which the medical and co-medical staffs became aware of importance of the informed consent. As it has been believed in Japan to be too formal to obtain a signature from the patient only for the evidence of the consent, it was worth while directing attentions of both the attending staffs and their patients to a renewed form, making them know that the doctrine of the informed consent had been introduced in the daily practice. Although it was an effective way, it turned out to be rather time-consuming process for a practical understanding of the informed consent.

Analysis of the transport of valproic acid into saliva from serum.

A study was conducted to explore whether a positive correlation between serum and salivary concentrations of the well-known antiepileptic drug, valproic acid (VPA), in epileptic patients could be explained by facilitated diffusion. The total concentration in saliva (Cs) would be related to the apparent ratio (R(app)++ = 100.Cs/Ct) of Cs to the total concentration in serum (Ct) as follows: Cs = A.R(app)B. This equation can be illustrated with microcomputer-simulated figures by assuming a process of facilitated diffusion for the transport of VPA into saliva from blood by the mechanism of monocarboxylic acid absorption through the intestinal brush-border membrane vesicles. The above equation has been proved to be valid when applied to the data reported separately by Gugler and coworkers and by Nitsche and Mascher, who evaluated the pharmacokinetics of VPA. Moreover, we can estimate the serum concentration with the salivary concentration using the above equation.

[Delayed vasospasm complicated with the postoperative stage of the meningioma: a case report].

Though it has been reported infrequently that delayed vasospasm may appear in head-injured patients, it is rather rarer to see it as a complication arising from tumor removal. Such a case was presented and gave rise to speculation of a possible underlying pathophysiology. A 46-year-old female patient was admitted to our neurosurgical service, complaining of aching pain in the forehead. No neurological deficits were elicited on admission. CT scans as well as MR imagings confirmed the existence of a left sphenoid wing meningioma whose gross total removal was accomplished. She was doing well till the 3rd postoperative day, when she developed transcortical motor aphasia. 123I-IMP SPECT revealed low perfusion over the left middle cerebral artery territory, and CT scans also showed low density areas in the same region, including the putamen, corona radiata and temporal lobe on the left side. Left carotid angiography disclosed diffuse arterial narrowings involving C1, C2, A1 and M1 portions. The authors suspect that indirect injury to those arteries and/or some kind of inflammatory process might have played a role.

Patient's comprehension of the medical informations presented before the invasive procedures.

The requirement of an informed consent has become a major issue even in the rural area of Japan. Particular interests were focussed on understanding of the information and the effect of pre-existing anxiety on that understanding. Nineteen neurological patients who were going to have either surgeries or invasive diagnostic procedures, agreed to cooperate with the study. Results of the study revealed the followings; (1) comprehension of medical disclosure varied widely from one patient to another, (2) assistance from co-medical staff (a registered nurse in the study) could not facilitate greater comprehension, and (3) the more anxious patients comprehended more. It seemed to remain a question as to how much adults of sound mind actually comprehended it even when the medical disclosure was presented fully and in a simple style.

The impact of an increased number of the foreign inpatients to the rural public hospital of Japan.

A rapid inflow of the foreign laborers into Japan has become obvious since a couple years ago when a serious shortage of labor had to be repaired urgently. A sudden increased number of the foreign inpatients had resulted in the problems for a rural public hospital, which sought sound solutions for them. Difficulty in communication with those whose mother tongue was not English, was one of them. Though it was not serious yet, a payment for medical care they had received, had been a burden both for them and for the hospital. This was because there was not private health insurance available for them. Asymptomatic infectious disease such as pulmonary tuberculosis was another problem, for which a routine physical examination would be required before or immediately after their entry into Japan.

[Long-term prognosis of nonoperative acute epidural hematoma in children].

Computed tomography(CT) scan has revealed that certain acute epidural hematomas(AEH) don't need operative therapies. But, it is difficult to determine especially in childhood, whether AEH compressing the brain for a short-term would or would not effect the function of the central nervous system in the future. For this reason, the authors report the long-term prognosis of nonoperative AEH in children. Twelve children suffering from AEH were transported to our clinic. On admission, they had no neurological deficits and CT scan revealed hematomas that had maximum thickness of 5-19 mm without midline shift. With nonoperative therapy they were discharged and the hematomas disappeared within 3-12 weeks. After long-term follow-up (3-10 years), it was shown that they had no epileptic episodes, and no changes in their school study records. Also, the Yatabe-Guilford personality test revealed no abnormal data. These data suggest that children can be cured who suffer from AEH with no neural deficits, and in whom the maximum thickness of the AEH is less than 20 mm, and in whom there is no midline shift in CT scan, can be cured without undergoing an operation, and will have a good long-term prognosis.

Informed consent in the regional hospital of Japan--with a particular reference to consent forms.

A consent form is a part of medical record, from which one would know how much attention is paid to informed consent. A survey of the consent forms from the various hospitals in the regional area of Japan, Shizuoka prefecture, indicated that the satisfactory consent forms are prepared in the large leading hospitals.

Multilevel anterior cervical fusion using skull bone grafts. Case report.

The successful use of autogenous skull bone grafts for a C3-7 anterior cervical fusion is reported and compared with results using other bone grafts. A 51-year-old man with C4-7 anterior cord compression due to spurs and ossified posterior longitudinal ligaments developed progressive tetraparesis following a minor head injury. He underwent anterior decompression and fusion. On two occasions an iliac graft had failed; however, a graft of autogenous skull bone was successful. The skull bone was found superior to bone from other sites, such as the iliac crest, rib, tibia, and fibula, showing sufficient strength and less morbidity. The skull may be a better source of graft material for multilevel anterior cervical fusion, which requires long and strong grafts.

Cerebellar ganglioglioma--case report.

A 14-year-old boy presented with cerebellar ganglioglioma manifesting as severe headache and confusion. Computed tomographic scans showed a huge, partly enhanced cystic cerebellar tumor. The tumor was totally removed. Histological examination disclosed glial cells and mature ganglion cells. The latter were identified by Nissl's staining and immunostaining for neurofilaments. Ganglion cells were present in the cerebellum and the surrounding subarachnoid space. This heterotopic growth of ganglion cells enabled a firm diagnosis of cerebellar ganglioglioma.

[Involuntary movement complicated with the postoperative stage of ruptured aneurysm: a case report].

Involuntary movement complicated with the postoperative stage of the ruptured cerebral aneurysm is extremely rare. And, the pathophysiology of the involuntary movement has not been established yet. The authors report such a case because of its rarity and to make the mechanism of its appearance clear. The case was a 45-year-old female who was transported to our clinic after the onset of sudden headache. On admission, she had no neurological deficits without severe headache. CT scan revealed subarachnoid hemorrhage, and left carotid angiogram showed an aneurysm at the bifurcation of the left internal carotid artery. On the day of admission, neck clipping for the aneurysm was successfully performed. Postoperative course was uneventful without mild right hemiparesis which diminished until two weeks after operation. Since the 24th day from operation, athetoid involuntary movement occurred to her four toes. 123I-IMP SPECT revealed low perfusion from left frontal base to caudate, and CT scan showed atrophy of the left caudate. Athetoid involuntary movement as postoperative complication of ruptured cerebral aneurysm has not been reported without our case. We suppose it was caused by the ischemic effect of the left caudate due to the operative retraction or the delayed vasospasm after subarachnoid hemorrhage.

Post-irradiation vasculopathy of intracranial major arteries in children--report of two cases.

We report two rare cases of post-irradiation vasculopathy of intracranial major arteries in children. A 13-year-old girl suffered from transient right hemiparesis 1 year after irradiation for suprasellar germinoma. Left carotid angiograms revealed marked stenoses of the intracranial internal carotid, middle cerebral, and anterior cerebral arteries, which were previously normal, and moyamoya vessels. A 2.5-year-old girl underwent internal irradiation with 198Au colloid for cystic craniopharyngioma. At the age of 10 years, she suddenly became unconscious after vomiting. Computed tomographic scans showed a right frontal intracerebral hematoma. Right carotid angiograms disclosed complete obstruction of the intracranial internal carotid, middle cerebral, and anterior cerebral arteries and moyamoya vessels, previously not present. The danger of radiation therapy causing occlusive vasculopathy in small and major cerebral arteries in children is emphasized. To prevent permanent ischemic neurological deficits, vasculopathy should be treated either medically or surgically as early as possible.

[A case of hydrocephalus with hypacusis due to hemangioblastoma].

A case of a brain stem hemangioblastoma with recurrent episodes of hypacusis due to progression of hydrocephalus is reported. The patient was a 25-year-old female, admitted to the department of otorhinolaryngology with complaints of hearing difficulty, headache and blurred vision. Neuroradiological studies showed a tumor from the medulla oblongata, obliterating the IVth ventricle, and a secondary hydrocephalus. Hearing loss fluctuated as hydrocephalus progressed. Multiple V-P shunting procedures relieved episodic hypacusis. The patient remains asymptomatic at present and has resumed normal activity. The mechanism of episodic hearing loss due to hydrocephalus is though to be due to the fact that through the ductus perilymphaticus and the ductus endolymphaticus, especially the former, increased intracranial pressure is transmitted to the inner ear. Through the ductus perilymphaticus there is communication between the perilymphatic space and the intracranial subarachnoid space. Through the ductus endolymphaticus there is communication with the subdural space. Increased ICP effects the inner ear. It is suspected that, in this particular case, the progression of hydrocephalus effected the patient's hearing.

Effect of pinealectomy on cortically kindled rats.

Cortical kindling in pinealectomized rats was studied to observe the effect of pinealectomy on local afterdischarge thresholds and seizure development. Although the local afterdischarge thresholds were not affected by pinealectomy, the kindling process itself was hastened. These results suggest that the anticonvulsive function of the pineal body is due not to a decrease in local afterdischarge thresholds, but to retardation of secondary generalization.

Line-drawing test across ages.

A line-drawing test was standardized for normal subjects to examine effects of normal aging. For this purpose, the results of the test for 168 normal volunteers were quantified using a digitizer and a microcomputer across ages from 9 to 78 yr. Three sets of parallel vertical lines were presented to every subject, the distances between the parallel vertical lines (5, 10, and 15 cm) differed in the three sets. A subject drew an horizontal line starting exactly on the left vertical line and stopped exactly on the right one, and the computer could detect minute inaccuracy at the start and at the stop, which inaccuracy was expressed in mm. In this study, effects of four parameters were evaluated, i.e., ages, sex, distances from the paired vertical lines, and order of trials; all were nonsignificant. The normal range of the deviations was within 2.1 mm (average + 2 SD).

The finger-tapping test. A quantitative analysis.

A quantitative analysis of the so-called finger-tapping test was performed on 111 normal subjects. Quantitative analysis was also performed on 17 patients with cerebellar diseases, 14 with parkinsonism, and 14 with hemiparesis. All analyses were performed in a simple fashion using an 8-bit microcomputer fed through an electrocardiographic apparatus. The results in normal subjects were as follows: (1) tapping frequency lowered with advancing age; (2) men tapped faster than women; and (3) tapping with the dominant finger was faster than tapping with the nondominant finger in normal subjects. Tapping frequency can distinguish patients with motor dysfunctions of cerebellar, basal ganglia, and cerebral origins from normal subjects. Only the time-sequential histograms of tapping intervals could distinguish the motor dysfunctions studied.

Lipoma in the cerebellopontine angle--case report.

The authors report a case of a cerebellopontine (CP) angle lipoma with a very unusual histological appearance. The 38-year-old male patient suffered vertigo, left tinnitus, and left hearing disturbance. Computed tomography and magnetic resonance imaging showed a nonenhanced low-density area and a high-intensity region in the left CP angle, respectively. The tumor, which was only partially removed because of its tight adhesion to the VIIIth nerve and brainstem, consisted of mature lipocytes and contained a piece of cartilage, which is highly unusual.

[Angiographic findings of vertebral dissecting aneurysm. Report of two cases and review of literature].

The authors report two cases of vertebral dissecting aneurysm. The first case, a 49-year-old female, developed severe headache and computed tomography scan showed subarachnoid hemorrhage (SAH), but 4-vessel cerebral angiography failed to show an aneurysm. The second angiograms obtained 2 weeks later showed possible aneurysmal dilatation on the right vertebral artery. The third angiograms, 2.5 months after SAH, disclosed a right vertebral fusiform aneurysm on the arterial phase and it was diagnosed as a dissecting aneurysm since the contrast medium remained until the very late venous phase. The previous angiograms were reviewed using the subtraction technique, which revealed retention of the contrast medium. The second case, a 42-year-old female, suffered from SAH. Left vertebral angiography revealed a fusiform aneurysmal tapered narrowing just distal to the aneurysm, which was a typical "pearl and string sign." The subtraction film of the venous phase also showed retention of the contrast medium in the aneurysmal portion. These findings accurately diagnosed dissecting aneurysm of the vertebral artery. Since the classical true diagnostic "double lumen sign" was rarely observed in the angiograms, it was not easy to diagnose dissecting aneurysm of the vertebral artery. The authors emphasize the angiographic findings of retention of the contrast medium in the venous phase as a "true diagnostic sign" for correct diagnosis of dissecting aneurysm.

[Significance of "on-off phonation test" to detect oral diadochokinesia in dysarthric patients].

Oral diadochokinetic abilities in 6 patients with ataxic dysarthria (ATAXICs), 6 with spastic dysarthria (SPASTICs), 3 with parkinsonism (PARKINs), and 6 normal subjects (NORMALs) were investigated using repetition of monosyllable /pa/ and "on-off phonation test" in which they had been requested to repeat interrupted vowel /a/ as fast as possible. Oscillographic as well as photographic records of the speech acoustic signal were obtained to analyse interval for a syllable, which consisted of voiced and unvoiced intervals, and peak-value of voiced interval. The results were as follows: 1) ATAXICs and SPASTICs showed prolonged interval for a syllable, yet that of PARKINs was within normal range, when tested either in /a/ or in /pa/. 2) Standard deviation and coefficient of variation for intervals of syllable and those of peak-values in voiced interval could not distinguish their characteristics among ATAXICs, SPASTICs, and PARKINs. 3) In "on-off phonation test", ATAXICs showed prolonged unvoiced intervals, while SPASTICs did prolonged voiced intervals. Results suggested that hypotonic laryngeal muscles in ATAXICs might result in prolongation of unvoiced interval, but that prolonged voiced interval related to biased hypertonus of laryngeal adductor. It is concluded that "on-off phonation test" could, with reasonable sensitivity, reflect the phonatory dynamics of laryngeal muscles in dysarthric patients.

[Unilateral nerve deafness due to rupture of a right vertebral artery aneurysm. Case report].

A 49-year-old female with no history of hearing disturbance developed sudden onset of headache and was admitted with no neurological deficits other than mild nuchal rigidity. Computed tomography (CT) showed subarachnoid hemorrhage. Four-vessel cerebral angiography disclosed no aneurysm. A second angiogram obtained on the 14th day showed vasospasm of the bilateral posterior cerebral arteries and right anterior inferior cerebellar artery, but still failed to demonstrate an aneurysm. Following the second angiography, she developed mild disturbance of consciousness and cerebellar ataxia of the right limbs, and repeat CT showed an infarct in the right cerebellar hemisphere. When she regained consciousness a few days later, she was completely deaf on the right side. The third angiography revealed a right vertebral artery dissecting aneurysm. Following clipping of the proximal portion of the right vertebral artery, she did well and was discharged, although right cerebellar ataxia and deafness persisted. Neuro-otological evaluation, including pure-tone audiography, auditory brainstem responses, electrocochleography, and caloric testing, indicated that her deafness resulted from ischemia in the territory of the right internal auditory artery due to vasospasm.