Long-term Observation in Patients with Duchenne Muscular Dystrophy with Early Introduction of a Standing Program Using Knee-ankle-foot Orthoses.

Objectives: This study investigated the outcomes of the early introduction of a standing program for patients with Duchenne muscular dystrophy (DMD). Methods: This was a retrospective observational study of 41 outpatients with DMD aged 15-20 years. We introduced the standing program using knee-ankle-foot orthoses (KAFO) to slow the progression of scoliosis when ankle dorsiflexion became less than 0° in the ambulatory period. Results: Thirty-two patients with DMD were offered the standing program with KAFO; 12 continued the program until the age of 15 years (complete group) and 20 discontinued the program before the age of 15 years (incomplete group). The non-standing program group included 9 patients. The standing program with KAFO was significantly associated with the Cobb angle at the age of 15 years after adjustment for the duration of corticosteroid use and DMD mutation type (P=0.0004). At the age of 15 years, significant correlations were found between the ankle dorsiflexion range of motion (ROM) and non-ambulatory period (P=0.0010), non-ambulatory period and Cobb angle (P<0.0001), Cobb angle and percent predicted forced vital capacity (P=0.0004), and ankle dorsiflexion ROM and Cobb angle (P=0.0066). In the complete group, the age at ambulation loss (log-rank P=0.0015), scoliosis progression (log-rank P=0.0032), and pulmonary dysfunction (log-rank P=0.0006) were significantly higher than in the non-standing program group. Conclusions: The early introduction of a standing program for DMD patients may prolong the ambulation period and slow the progression of scoliosis and pulmonary dysfunction.

A Novel de novo KIF1A Mutation in a Patient with Ataxia, Intellectual Disability and Mild Foot Deformity.

Early-onset ataxias are often difficult to diagnose due to the genetic and phenotypic heterogeneity of patients. Whole exome sequencing (WES) is a powerful method for determining causative mutations of early-onset ataxias. We report a case in which a novel de novo KIF1A mutation was identified in a patient with ataxia, intellectual disability and mild foot deformity.A patient presented with sporadic forms of ataxia with mild foot deformity, intellectual disability, peripheral neuropathy, pyramidal signs, and orthostatic hypotension. WES was used to identify a novel de novo mutation in KIF1A, a known causative gene of neurodegeneration and spasticity with or without cerebellar atrophy or cortical visual impairment syndrome (NESCAVS).We report a novel phenotype of NESCAVS that is associated with a novel de novo missense mutation in KIF1A, which provides valuable information for the diagnosis of NESCAVS even in the era of WES. Early rehabilitation of patients with NESCAVS may prevent symptom worsening and improve the disease course.

Decreased Signal Intensity Ratio on MRA Reflects Misery Perfusion on SPECT in Patients with Intracranial Stenosis.

BACKGROUND AND PURPOSE: Acetazolamide reactivity on 123 I-IMP SPECT is used to detect misery perfusion due to intracranial atherosclerosis. Noninvasive fractional flow assessed by signal intensity ratio (SIR) on time of flight-magnetic resonance angiography (TOF-MRA) might offer a feasible alternative to identify high-risk intracranial stenosis. METHODS: Data from consecutive patients with unilateral middle cerebral artery (MCA) stenosis who underwent both TOF-MRA and acetazolamide reactivity on 123 I-IMP SPECT were retrospectively analyzed. Signal intensity was measured in the background and on the MCA proximal and distal to the stenotic lesion on TOF-MRA. Mean cerebral blood flow (CBF) at rest and cerebrovascular reactivity were measured in the target MCA territory. CBF patterns of the MCA were divided into three groups (Powers' stage 0-II). RESULTS: A total of 56 sets of diagnostic imaging in 33 patients were assessed. Four CBF patterns were stage II in four MCA territories, stage I in 31, and stage 0 in 21. Median SIR of the MCA was .53 (interquartile range .46-.69) for stage II, .78 (.63-.90) for stage I, and .91 (.85-.95) for stage 0. The optimal cutoff for SIR obtained from receiver operating characteristic curve analysis to predict stage II was < .56. CONCLUSIONS: In patients with unilateral MCA stenosis, decreased SIR was correlated with misery perfusion, providing a simpler, widely available predictor of high-risk intracranial stenosis.

High prevalence of small vessel disease long after cranial irradiation.

Accelerated atherosclerosis of intra- or extracranial large arteries is a major cause of radiation-induced strokes. Recent development of MRI techniques has enabled detection of another important vasculopathy: microinfarcts or microbleeds after cranial irradiation. The purpose of this study was to investigate the incidence and characteristics of small vessel disease after cranial irradiation. MR images and clinical records of 102 outpatients who had undergone cranial irradiation to brain tumors were retrospectively reviewed. Only those who had undergone T1WI, T2WI, FLAIR, and T2∗WI during follow-up were included. Small vessel disease including small subcortical infracts, microbleeds, and volume of white matter lesions were assessed on the latest MR images of each patient. Ischemic or hemorrhagic stroke during the follow-up period was also reviewed. Twelve patients (mean age at the latest MRI, 38.5years; 8men) were assessed. The total radiation dose was 52.3±9.7Gy in these patients, 9 of whom received whole brain irradiation. Small subcortical infarcts (mean 2.3) were detected in 8 patients, microbleeds (mean 19.4) were detected in 11, and white matter lesion volume was 38.3±11.6ml. During the follow-up period of 19.8±9.7years, 5 patients experienced stroke (4 lacunar, 1 hemorrhagic). These strokes occurred as long as a median 21.9 (range, 10.4-30.2) years after cranial irradiation. In conclusion, small vessel disease is not a rare complication after cranial irradiation, even in young patients. Patients after cranial irradiation should be followed up with MR imaging including a hemosiderin-sensitive sequence.

Acute Multiple Cerebral Infarction in a Patient with an Accessory Mitral Valve.

A 96-year-old woman developed hemiparesis 2 weeks after orthopedic surgery. Magnetic resonance imaging revealed multiple cerebral infarctions in the bilateral hemisphere. Transthoracic echocardiography revealed a mobile structure attached to the anterior mitral leaflet that protruded toward the left ventricular outflow tract. The structure was identified as an accessory mitral valve. Doppler echocardiography showed that there was no significant left ventricular outflow obstruction. This is a rare case of a silent accessory mitral valve that was detected after multiple cerebral infarctions.

Downregulation of microRNA-100/microRNA-125b is associated with lymph node metastasis in early colorectal cancer with submucosal invasion.

A majority of early colorectal cancers (CRCs) with submucosal invasion undergo surgical operation, despite a very low incidence of lymph node metastasis. Our study aimed to identify microRNAs (miRNAs) specifically responsible for lymph node metastasis in submucosal CRCs. MicroRNA microarray analysis revealed that miR-100 and miR-125b expression levels were significantly lower in CRC tissues with lymph node metastases than in those without metastases. These results were validated by quantitative real-time PCR in a larger set of clinical samples. The transfection of a miR-100 or miR-125b inhibitor into colon cancer HCT116 cells significantly increased cell invasion, migration, and MMP activity. Conversely, overexpression of miR-100 or miR-125b mimics significantly attenuated all these activities but did not affect cell growth. To identify target mRNAs, we undertook a gene expression array analysis of miR-100-silenced HCT116 cells as well as negative control cells. The Ingenuity Pathway Analysis, TargetScan software analyses, and subsequent verification of mRNA expression by real-time PCR identified mammalian target of rapamycin (mTOR) and insulin-like growth factor 1 receptor (IGF1R) as direct, and Fas and X-linked inhibitor-of-apoptosis protein (XIAP) as indirect candidate targets for miR-100 involved in lymph node metastasis. Knockdown of each gene by siRNA significantly reduced the invasiveness of HCT116 cells. These data clearly show that downregulation of miR-100 and miR-125b is closely associated with lymph node metastasis in submucosal CRC through enhancement of invasion, motility, and MMP activity. In particular, miR-100 may promote metastasis by upregulating mTOR, IGF1R, Fas, and XIAP as targets. Thus, miR-100 and miR-125b may be novel biomarkers for lymph node metastasis of early CRCs with submucosal invasion.

Life-threatening Arrhythmias in a Becker Muscular Dystrophy Family due to the Duplication of Exons 3-4 of the Dystrophin Gene.

We herein present a report of three patients with Becker muscular dystrophy in the same family who developed complete atrioventricular block or ventricular tachycardia with severe cardiomyopathy. Our cases became unable to walk in their teens, and were introduced to mechanical ventilation due to respiratory muscle weakness in their twenties and thirties. In all three cases, a medical device such as a permanent cardiac pacemaker or an implantable cardiac defibrillator was considered to be necessary. The duplication of exons 3-4 in the dystrophin gene was detected in two of the patients. In patients with Becker muscular dystrophy, complete atrioventricular block or ventricular tachycardia within a family has rarely been reported. Thus attention should be paid to the possibility of severe arrhythmias in the severe phenotype of Becker muscular dystrophy.

[Small vessel disease associated with cranial irradiation].

We report two cases of young patients with lacunar stroke who demonstrated multiple microbleeds (MBs) a long period after cranial irradiation. Case 1: a 44-year-old man developed dysarthria and left hemiparesis from a day before admission. Magnetic resonance imaging showed an acute lacunar infract in the right corona radiata. Case 2: a 28-year-old woman was admitted due to dysarthria and right hemiparesis. An acute lacunar infract was detected in the left corona radiata. T2* WI revealed multiple MBs in the region corresponding to the irradiation in both patients. Since these patients had no vascular risk factors except for smoking habit in the former one and dyslipidemia in the latter one. We speculated that lacunar stroke and MBs had resulted from past cranial irradiation. In addition to accelerated atherosclerosis of the large vessels, small vessel disease should be noted as an important long-term complication after cranial irradiation.

Coexistence of Amyotrophic Lateral Sclerosis and Myasthenia Gravis.

The mechanisms by which amyotrophic lateral sclerosis (ALS) causes motor neuron degeneration remain unknown. We present the case of a 77-year-old Japanese female with clinically probable ALS, who developed ALS symptoms 41 years after onset of myasthenia gravis (MG). We concluded that neither the relapse of MG nor the adverse effects of anti-cholinesterase medication aggravated her symptoms. Although MG and ALS are extremely rare, we reviewed several case reports describing their coexistence. We suggest that clinicians should consider the possibility of ALS occurring with MG. Further investigations will improve our understanding of the pathogenic relationship between ALS and MG.

Deterioration of glaucoma after carotid endarterectomy.

A 64-year-old man with a long history of untreated diabetes mellitus had suffered from visual disturbance in his right eye. Neovascular glaucoma in the right eye and diabetic retinopathy in both eyes were found, and ischemic ocular syndrome was suspected for the right eye. Neuroimaging revealed severe stenosis of the right internal carotid artery. He was first treated for diabetes and glaucoma, and then, after these conditions were stabilized, right carotid endarterectomy (CEA) was carried out. Although the operation was uneventful, he suffered from headache and his right sight was blurred on the day after surgery. Right intraocular pressure was markedly increased, and corneal edema and increased iris neovascularization were also recognized. Intensive ophthalmologic care was carried out, but his right vision worsened and was eventually lost. Ocular ischemia causes not only neovascularization of the iris, which leads to insufficient resorption of the aqueous humor, but also insufficient production of the aqueous humor. After CEA, production of the humor is immediately activated, but the resorption capacity does not change, which results in an extraordinary increase in intraocular pressure. Neurosurgeons should be aware that CEA not only improves or avoids worsening of vision in patients with ischemic oculopathy, but can also rarely cause paradoxical devastating visual deterioration.

Simulation-based medical education in clinical skills laboratory.

Clinical skills laboratories have been established in medical institutions as facilities for simulation-based medical education (SBME). SBME is believed to be superior to the traditional style of medical education from the viewpoint of the active and adult learning theories. SBME can provide a learning cycle of debriefing and feedback for learners as well as evaluation of procedures and competency. SBME offers both learners and patients a safe environment for practice and error. In a full-environment simulation, learners can obtain not only technical skills but also non-technical skills, such as leadership, team work, communication, situation awareness, decision-making, and awareness of personal limitations. SBME is also effective for integration of clinical medicine and basic medicine. In addition, technology-enhanced simulation training is associated with beneficial effects for outcomes of knowledge, skills, behaviors, and patient-related outcomes. To perform SBME, effectively, not only simulators including high-fidelity mannequin-type simulators or virtual-reality simulators but also full-time faculties and instructors as professionals of SBME are essential in a clinical skills laboratory for SBME. Clinical skills laboratory is expected to become an integrated medical education center to achieve continuing professional development, integrated learning of basic and clinical medicine, and citizens' participation and cooperation in medical education.

Ternary system of solution additives with arginine and salt for refolding of beta-galactosidase.

(L)-Arginine hydrochloride (Arg HCl) has been used for protein refolding as a universal aggregation suppressor for monomeric proteins. This paper presents an investigation of the refolding of tetrameric beta-galactosidase (beta-gal) using Arg HCl and other salts. In a binary system using only Arg HCl, the refolding yield of beta-gal increased with increasing concentration up to 0.2 M. However, the refolding yield sharply decreased above this concentration, reaching the level below the control yield of 5% at 0.5 M and near zero above 0.75 M, an observation unexpected from monomeric proteins. In a ternary system using both 0.2 M Arg HCl and another salt, the refolding yield increased up to 1.5-fold higher than that in the binary system. These data indicate that aggregation suppressive effects of protein increase with Arg HCl concentration, but also are deleterious to self-association of the protein. This dual nature of Arg HCl effects may have to be taken into account in its application for refolding of oligomeric proteins.

Photophysical properties of a novel Ni(II)-diporphyrin in presence of fullerenes: insights from experimental and theoretical studies.

The present paper highlights the photophysical aspects of the topologically new Ni(II)-diporphyrin (Ni(2)-1)/fullerene host-guest ensembles. Both absorption and fluorescence studies reveal that Ni(2)-1 undergoes efficient complexation with both C(60) and C(70) in toluene medium. In the fluorescence study, remarkable enhancement of the fluorescence intensity of Ni(2)-1 was observed by the addition of C(60), while normal quenching of fluorescence occurred in case of C(70). From the fluorescence and UV-vis studies, the binding constants of Ni(2)-1 with C(60) and C(70) were determined to be approximately 1.7 x 10(4) and approximately 2.7 x 10(4) dm(3) mol(-1), respectively. Ab initio theoretical calculations reveal that C(70)/Ni(2)-1 complex favor end-on orientation of C(70) rather than side-on approach.

Synthesis of porphyrin dimers fused with a benzene unit.

Bicyclo[2.2.2]octadiene-connected pyrrolo-porphyrins have been prepared by an inverse-type [3+1] porphyrin synthesis of a bicyclo[2.2.2]octadiene-fused dipyrrole with a tripyrrane dicarbaldehyde. Another [3+1] porphyrin synthesis of pyrrole-connected porphyrins with the same or other tripyrrane dicarbaldehydes gave bicyclo[2.2.2]octadiene-bridged diporphyrins, the central metals and/or peripheral substituents of which were different. Thermal decomposition of the bicyclo[2.2.2]octadiene skeleton to a benzene moiety gave pi-system-fused porphyrin dimers in a highly pure form.