Retrospective study for risk factors for febrile UTI in spinal cord injury patients with routine concomitant intermittent catheterization in outpatient settings.

STUDY DESIGN: Retrospective study. OBJECTIVES: The objective of this study was to investigate the clinical risk factors for febrile urinary tract infection (UTI) in spinal cord injury-associated neurogenic bladder (NB) patients who perform routine clean intermittent catheterization (CIC). SETTING: Rehabilitation Hospital, Kobe, Japan. METHODS: Over a 3-year period, we retrospectively assessed the clinical risk factors for febrile UTI in 259 spinal cord injury patients diagnosed as NB and performing routine CIC with regard to the factors such as gender, the presence of pyuria and bacteriuria, and the categories of the American Spinal Injury Association (ASIA) impairment scale. RESULTS: A total of 67 patients had febrile UTI in the follow-up period, with 57 cases of pyelonephritis, 11 cases of epididymitis and 2 cases of prostatitis, including the patients with plural infectious diseases. The causative bacteria were ranked as follows: Escherichia coli (74 cases), Pseudomonas aeruginosa (17 cases), Enterococcus faecalis (14 cases) and Klebsiella pneumoniae (12 cases). Antibiotic-resistant E. coli were seen, with 10.5% instances of extended-spectrum ß-lactamase (ESBL) production and 23.8% of fluoroquinolone resistance. Multivariate analyses of clinical risk factors for febrile UTI showed that gender (male, P=0.0431), and ASIA impairment scale C or more severe (P=0.0266) were significantly associated with febrile UTI occurrence in NB patients with routine CIC. CONCLUSION: Our data demonstrated gender (male) and ASIA impairment scale C or more severe were significantly associated with febrile UTI occurrence in NB patients using routine CIC. Further prospective studies are necessary to define the full spectrum of possible risk factors for febrile UTI in these patients.

Frontal midline theta rhythm is correlated with cardiac autonomic activities during the performance of an attention demanding meditation procedure.

Frontal midline theta rhythm (Fm theta), recognized as distinct theta activity on EEG in the frontal midline area, reflects mental concentration as well as meditative state or relief from anxiety. Attentional network in anterior frontal lobes including anterior cingulate cortex is suspected to be the generator of this activity, and the regulative function of the frontal neural network over autonomic nervous system (ANS) during cognitive process is suggested. However no studies have examined peripheral autonomic activities during Fm theta induction, and interaction of central and peripheral mechanism associated with Fm theta remains unclear. In the present study, a standard procedure of Zen meditation requiring sustained attention and breath control was employed as the task to provoke Fm theta, and simultaneous EEG and ECG recordings were performed. For the subjects in which Fm theta activities were provoked (six men, six women, 48% of the total subjects), peripheral autonomic activities were evaluated during the appearance of Fm theta as well as during control periods. Successive inter-beat intervals were measured from the ECG, and a recently developed method of analysis by Toichi et al. (J. Auton. Nerv. Syst. 62 (1997) 79-84) based on heart rate variability was used to assess cardiac sympathetic and parasympathetic functions separately. Both sympathetic and parasympathetic indices were increased during the appearance of Fm theta compared with control periods. Theta band activities in the frontal area were correlated negatively with sympathetic activation. The results suggest a close relationship between cardiac autonomic function and activity of medial frontal neural circuitry.

Emotional cognition without awareness after unilateral temporal lobectomy in humans.

To investigate the function of the amygdala in human emotional cognition, we investigated the electrodermal activity (EDA) in response to masked (unseen) visual stimuli. Six epileptic subjects were investigated after unilateral temporal lobectomy. Emotionally valenced photographic slides (10 negative, 10 neutral) from the International Affective Picture System were presented to their unilateral visual fields under either subliminal or supraliminal conditions. An interaction between hemispheres and emotional valences was found only under the subliminal conditions; greater EDA responses to negative stimuli compared with neutral ones were observed when stimuli were presented to the intact hemispheres. The findings suggest that nonconscious emotional processing is reflected in EDA in a different manner from conscious emotional processing. Medial temporal structures, including the amygdala, thus appear to play a critical role in the neural substrates for this automatic processing.

Unknown people believed to be known: the 'assoziierende Erinnerungs- fälschungen' by Kraepelin.

A male patient with epilepsy, who developed a unique form of paramnesia after an episode of zonisamide-induced psychosis is reported. The patient consistently mistook people who were quite new to him, such as staff of the hospital, for persons whom he had met long ago. However, he did not misidentify their names or other attributes, such as their occupations. This extraordinary form of misidentification does not fall into any known subcategory of misidentification syndromes. Rather, this paramnesia falls into the classical description of 'assoziierende Erinnerungsfälschungen' by Kraepelin. The neuropsychological interpretation of the reported patient is difficult. However, loss of familiarity with environmental objects due to his long sustained epileptic history is supposed to be a possible mechanism of paramnesia.

Glutamate-induced currents in acutely dissociated guinea pig locus coeruleus neurons.

To investigate the properties of L-glutamate (Glu) receptors in single locus coeruleus (LC) neurons at mature stage, we recorded the Glu-induced currents in the LC neurons acutely dissociated from adult guinea pigs, using the whole-cell patch-clamp technique. The concentration-current relationships show that Glu-induced currents in LC neurons might be predominantly mediated by non-NMDA receptors rather than NMDA receptors. The current-voltage relationship of NMDA or non-NMDA receptor-mediated currents indicated that both subtypes of the Glu-receptors operate non-selective cation channels, and that the NMDA receptor-operated channels but not the non-NMDA receptor-operated channels are permeable to Ca2+. These results suggest that in LC neurons, the normal excitatory neurotransmission may be mediated through non-NMDA receptors, and that NMDA receptors may be involved in intracellular signal transduction by their Ca2+ permeability.

The influence of psychotic states on the autonomic nervous system in schizophrenia.

Abnormal autonomic activity in patients with schizophrenia has been reported, but how psychotic states influence the autonomic nervous system (ANS) has remained unclear due to methodological limitations. The influence of psychotic states on ANS activity in patients with schizophrenia was investigated using a recently developed method of analysis based on heart rate variability which assesses cardiac sympathetic and parasympathetic function separately. Cardiac autonomic function (CAF), together with psychotic states, was assessed at the beginning and the end of an 8-week study period in 53 patients with chronic schizophrenia. The CAF in age- and sex-matched control subjects was also examined. There were no significant differences between the patients and the control subjects in the mean R-R interval (RRI) or in the indices of the sympathetic and the parasympathetic function. In the patients who changed in psychotic states, the parasympathetic index was significantly decreased without significant changes in the sympathetic index when their psychotic states were more pronounced, suggesting psychotic states suppressed the parasympathetic function without affecting the sympathetic function. In these patients, the mean RRI was smaller when their psychotic states were more pronounced. Our results demonstrate that psychotic states affect the ANS, suggesting a relationship between cerebral cognitive and peripheral ANS activities, and that this is presumably mediated through the parasympathetic nervous system. These findings are discussed in comparison with previous reports on the CAF in schizophrenia.

Seizure with prominent tonic initial signs followed by psychomotor features: a case report clinically manifesting an unusual ictal evolution.

A clinically tonic seizure phase, immediately followed by psychomotor features (right hand dystonic posture, left hand and oral automatisms), was recorded by video and EEG, in a patient who had gliosis of the left temporal lobe and left hippocampal atrophy. Interictal epileptiform discharges were frequently seen in the left temporal area, and at the time of the tonic seizure phase, ictal spike discharges were continuously observed at the left posterior temporal area, which was recognized only by applying a high frequency filter (HFF) of 15 Hz to the digitally recorded EEG because EMG artifacts totally obscured the EEG with a HFF of 60 Hz. It is most likely that tonic seizure can occur in an adult patient with temporal lobe epilepsy, and it is speculated that an epileptogenic focus might activate a certain brain area which is regarded as a symptomatogenic zone for tonic seizures. If the tonic seizure phase is immediately followed by psychomotor features as seen in the present patient, the former could be due to focal epilepsy.

Electroencephalographic findings in functional psychoses: state or trait indicators?

The clinical significance of electroencephalographic (EEG) changes in patients with functional psychoses is not yet clearly defined, particularly whether these changes are state indicators or trait indicators. In the present review, the EEG abnormalities in schizophrenia are discussed. In early EEG studies of schizophrenics, the various specific EEG patterns were suggested to be trait indicators, but those findings were not confirmed. The EEG patterns of some patients with catatonic schizophrenia, especially periodic catatonia, were thought to be episode or state indicators, and some of the patients diagnosed as having atypical psychoses in Japan were suggested to show state indicator EEG findings. As the computerized and spectral analyses of EEG have advanced, the contradictory findings of EEG in schizophrenia have been reported, interpreted as 'hyperstable' or 'hypernormal' EEG findings and 'hypofrontal' EEG findings (slow waves in the frontal region). However, no conclusion can be made as to whether these EEG findings are state or trait indicators. On the borderland of functional psychoses, the behavioral changes in temporal lobe epilepsy were described as a trait indicator, and the psychotic states in non-convulsive generalized status epilepticus and acute confusional states were suggested to be state indicators. Further studies of EEG abnormalities in schizophrenia are necessary from multi-dimensional perspectives, including in comparison with the symptomatic psychoses.

Temporal lobe epilepsy in a genius of natural history: MRI volumetric study of postmortem brain.

Kumagusu Minakata (1867-1941), a Japanese genius devoted to natural history and folklore, is famous for his immense range of works, including his discovery of many new varieties of mycetozoa, or slime molds. His diary reveals that he was affected by epilepsy. In this study of his brain, we adopted a method of measuring the volume of the hippocampi by MRI of postmortem brain and found evidence of right hippocampal atrophy. This finding, together with the striking parallels between his behavior and the known behavioral syndrome in temporal lobe epilepsy (TLE), suggests that he was affected by TLE. The postmortem imaging analysis of brain, as performed in this study, offers a bridge between neuroscience and classic psychopathologic approaches to the creativity of geniuses.

Interictal change in cardiac autonomic function associated with EEG abnormalities and clinical symptoms: a longitudinal study following acute deterioration in two patients with temporal lobe epilepsy.

The purpose of the present study was to investigate the ictal and interictal changes in cardiac autonomic function (CAF), and the relationship between the interictal change in CAF to the electroencephalogram (EEG) and clinical findings. In two patients with temporal lobe epilepsy (TLE) showing acute deterioration, a quantitative evaluation of their interictal CAF based on heart rate variability and their EEG using spectral analysis was conducted, and the findings compared with repeated clinical evaluations during the recovery period. The ictal heart rate changes and their temporal relationship to ictal discharge were investigated using simultaneous EEG/electrocardiogram (ECG) monitoring in one of the patients. Interictal parasympathetic function was decreased during the period of acute deterioration, but was increased in association with improvements in the EEG and clinical findings. In contrast, the sympathetic function showed no specific changes. The ictal discharges were preceded by a brief bradycardia, with a long delay of up to 40s. The results demonstrated that this decrease in parasympathetic function was closely related to the interictal changes in central nervous system function. On the other hand, the ictal discharges in one of the patients were thought to have caused a transient elevation of parasympathetic function. It is strongly suggested that patients with TLE have interictal as well as ictal changes in CAF that are mediated mainly through the parasympathetic nervous system.

Reduplicative paramnesia in patients with focal brain damage.

Reduplicative paramnesia (RP) has drawn attention as a distinct behavioral syndrome caused by focal brain damage. To elucidate the pathogenesis of RP, we assessed its prevalence among patients with focal brain damage and followed those patients with typical RP. Seventy-seven patients with focal brain damage (47 with left hemispheric, 21 with right hemispheric, and 9 with bilateral damage) were assessed for the presence of RP using a questionnaire intended to elucidate this condition. Two patients showed typical RP for place, and four patients showed atypical RP (three for place and one for person); altogether, these six patients constituted 7.8% of the sample. In three patients, the lesions were situated in the right hemisphere; in two, the lesions were bilateral (right dominant); and in one, the lesions were in the left hemisphere, indicating the relative importance of right hemispheric damage and a possible contributory role of additional left hemispheric damage in RP. The case studies of patients with typical RP suggest the heterogeneity of the underlying cognitive factors in RP.

Dreamy states and psychoses in temporal lobe epilepsy: mediating role of affect.

Among 104 patients with temporal lobe epilepsy treated in our clinic between 1992-1995, thirteen patients with repeated dreamy states were evaluated for affective manifestations of dreamy states and their relationship with psychotic states. The types of dreamy states were classified as déjà vu, jamais vu and reminiscence. The affective experiences during dreamy states were evaluated as positive, negative or neutral. As a result, seven patients had déjà vu and/or reminiscence: seizure manifestations in four of these patients were affectively evaluated as positive (familiar and/or pleasurable), and three as neutral. Six cases had experience of jamais vu: five of them were affectively evaluated as negative (mostly fear), and one as neutral. Psychiatrically, only four patients with jamias vu accompanied by feelings of fear had mental disorders: a chronic paranoid-hallucinatory state in two cases, a chronic paranoid state in one case, and obsessive-compulsive symptoms in one case. Other patients who had positive or neutral affect did not demonstrate psychiatric disturbances. Thus, most patients with jamais vu were accompanied by negative affect of fear, and those patients with jamais vu tended to show more psychotic symptoms than those with reminiscence or déjà vu, which were associated with positive or neutral affects. Based on these results, we discuss the possibility that repeated negative feelings associated with jamais vu are one of the causes for developing epileptic psychoses.

A new method of assessing cardiac autonomic function and its comparison with spectral analysis and coefficient of variation of R-R interval.

A new non-linear method of assessing cardiac autonomic function was examined in a pharmacological experiment in ten healthy volunteers. The R-R interval data obtained under a control condition and in autonomic blockade by atropine and by propranolol were analyzed by each of the new methods employing Lorenz plot, spectral analysis and the coefficient of variation. With our method we derived two measures, the cardiac vagal index and the cardiac sympathetic index, which indicate vagal and sympathetic function separately. These two indices were found to be more reliable than those obtained by the other two methods. We anticipate that the non-invasive assessment of short-term cardiac autonomic function will come to be performed more reliably and conveniently by this method.

Frontopolar ictal epileptiform discharges on scalp electroencephalogram in temporal lobe epilepsy.

We report 3 patients with medically intractable complex partial seizures (CPS) arising from the temporal lobe judged by surgical outcome, in whom scalp electroencephalogram (EEG) showed ictal epileptiform discharges at the frontopolar region. In all patients, results of cranial magnetic resonance imaging (MRI), positron emission tomography (PET), and ictal single photon emission computed tomography (SPECT) were consistent with those of temporal lobe epilepsy (TLE). The epileptogenic area was defined in the temporal lobe by chronic subdural recording in 2 patients. After surgical treatment (amygdalohippocampectomy, anterior temporal lobectomy, and temporal lesionectomy, respectively), all 3 patients became seizure-free and the interictal frontopolar epileptiform discharges on scalp EEG disappeared. Patients with TLE may show ictal scalp EEG with frontopolar onset. This is most likely explained by direction of dipolar orientation of epileptiform discharges in 1 of our patients; rapid spread of ictal activity to the frontopolar area can also be considered in the 2.

Functional psychosis mimicking acute confusional state: longitudinal neuropsychological assessment of an acute and transient psychotic patient.

One patient with acute and transient functional psychosis was assessed repeatedly using a brief neuropsychological assessment during his recovery from the psychotic episode. The psychotic features of the patient were characterized by perplexed behavior, attentional disturbance and emotional turmoil. Characteristic findings, including impairment of attention tests, dysgraphia and constructional disturbances, were seen. Findings improved in accordance with recovery on a behavioral level. We discussed the similarity of neuropsychological and behavioral abnormalities of this patient and those of patients in an acute confusional state.

[Three cases of vas deferens calcification].

Three patients with calcification of the bilateral vas deferens, revealed by plain X-ray, pelvic computerized tomography and/or vesiculography, are reported. Although they came to our department because of acute left epididymitis, right ureteral calculus and right undescended testis respectively, these diseases were not the causative factors for the calcification. Since no other probable causes including tuberculosis and diabetes-mellitus were found, the cause of disease was unknown.

[A case of genital tuberculosis occurring in the tunica albuginea and the tunica vaginalis].

We report a case of genital tuberculosis occurring in the tunica albuginea and the tunica vaginalis. A 29-year-old man came to our department with the complaint of a nodule in the right scrotum. The physical and radiological examinations revealed no signs of pulmonary or urogenital tuberculosis. The urine and the semen were clear and negative in culture of acid fast bacteria, but the tuberculin reaction was moderately positive. Surgical exploration revealed a white yellowish soybean sized nodule in the surface of the tunica albuginea of the right testicle apart from the epididymidis, and we therefore enucleated it. No abnormalities were found in other parts of the tunica vaginalis, epididymidis or the funiculus. Histopathological examination demonstrated typical tuberculomas in the tunica albuginea and the tunica vaginalis, but the seminiferous tubules were almost intact. We diagnosed this case as tuberculosis arising in the tunica albuginea and the tunica vaginalis and started antituberculosis therapy.

[Two cases of renal oncocytoma].

Two cases of renal oncocytoma are reviewed. A 67-year-old man and a 21-year-old man with a right renal mass were incidentally revealed by echography. Selective renal angiogram showed no spoke-wheel configuration of vessels in either case. Both cases were pathologically diagnosed as oncocytomas, constructed of large eosinophilic cells with granular cytoplasm and small regular nuclei. The electron micrograph showed cytoplasm packed abundantly with mitochondria. The two patients are in good condition 2.5 and 1.5 years after diagnosis.

[Two cases of renal cell carcinoma accompanied with ossification].

We report two cases of renal cell carcinoma accompanied with ossification. Case 1: A 40-year-old male visited a physician with the complaint of epigastric pain. Examination of the stomach revealed compression of the greater curvature. Abdominal radiography and CT scan revealed a left renal mass with calcification, which was a hypovascular tumor on angiography. A transperitoneal left nephrectomy was performed. The resected kidney was 700g in weight and the tumor, which was 12 x 10 x 10 cm in size and located in the upper pole of the kidney, was enveloped with a hard capsule and was extensively necrotized. Histopathological diagnosis was renal cell carcinoma (papillary type, mixed subtype). Case 2: A 69-year-old female was occasionally pointed out to have a left renal mass in ultrasonic examination. It was accompanied with calcification in CT scan and a hypervascular tumor in angiography. A transperitoneal left nephrectomy was performed. The resected kidney was 320 g in weight and the tumor located in the lower pole of the kidney, was 6 x 6 x 6 cm in size and necrotized. Histopathological diagnosis was renal cell carcinoma (alveolar type, clear cell subtype). Microscopically in both cases, ossified tissue existed among the fibrous tissue in the necrotized lesion of the tumor, but not near the cancer cells and, it was accompanied by calcification. During the ossification process, the connective tissue proliferates after the necrosis of the tumor, and metaplasia occurred from its juvenile plastic cells to osteoblastic cells.