Intentional Stent Stenosis to Prevent Hyperperfusion Syndrome after Carotid Artery Stenting for Extremely High-Grade Stenosis.

BACKGROUND AND PURPOSE: Intracranial hemorrhage due to hyperperfusion syndrome is a severe carotid artery stent placement complication of extremely high-grade stenosis, causing hemodynamic insufficiency. To prevent hyperperfusion syndrome, we attempted intentional residual stent stenosis and implemented "gentle" carotid artery stent placement, defined as carotid artery stent placement using a closed-cell stent coupled with slight balloon predilation, without balloon postdilation. Gradual stent expansion was expected. We investigated the incidence of hyperperfusion syndrome and long-term outcomes after gentle carotid artery stent placement. MATERIALS AND METHODS: We included patients who underwent carotid artery stent placement for extremely high-grade stenosis from January 2015 to March 2019. We defined extremely high-grade stenosis as carotid stenosis with conventional angiographic "slow flow" and a reduced MCA signal intensity on MRA. A reduced MCA signal intensity was defined as MCA with a relative signal intensity of <0.9 in the ipsilateral compared with the contralateral MCA. We evaluated the stent diameter, CBF on SPECT, hyperperfusion syndrome, and intracranial hemorrhage. We defined hyperperfusion syndrome as a triad of ipsilateral headache, seizure, and hemiparesis. RESULTS: Twenty-eight of the 191 patients met our inclusion criteria. After carotid artery stent placement, their median minimal stent diameter was 2.9 mm, which expanded to 3.9 mm at 4 months. Neither cerebral hyperperfusion syndrome nor intracranial hemorrhage occurred. CONCLUSIONS: The gentle carotid artery stent placement strategy for intentional residual stent stenosis may prevent hyperperfusion syndrome in high-risk patients. Stents spontaneously dilated in 4 months.

Clinicopathologic Impact of Early Medullary Ray Injury in Patients Following Kidney Transplantation.

BACKGROUND: Previously, we explored the histopathologic characteristics of medullary ray injury (MRI) inducing interstitial fibrosis and tubular atrophy (IF/TA) to determine its etiologies, which include calcineurin inhibitor (CNI) toxicity and urologic complications. However, we did not examine the effects of these etiologies on long-term kidney allograft prognosis, because biopsy timing differed among cases. AIM: We examined the influence of early MRI on kidney allograft prognosis using protocol biopsies taken within a 3-month time frame. METHODS: We defined early MRI as tubular degeneration with interstitial edema or mild fibrosis localized to the medullary ray. We divided 53 protocol biopsies into 2 groups, with and without early MRI. Early MRI+ cases with isometric vacuolization were classified as CNI toxicity; those with Tamm-Horsfall protein in the interstitium and a thyroidlike appearance were classified as urinary tract system abnormalities; remaining cases were classified as "others." We compared changes in serum levels of creatinine (sCr) over 3 years and fibrosis extent at 1 year. RESULTS: The sCr levels were significantly higher in the MRI+ group than the MRI- group at 3 years (P = .024). Examining the 3 MRI+ subgroups, only the MRI+ urinary tract system abnormalities group had significantly high sCr levels compared to the MRI- group (P = .019). The MRI+ group showed significant signs of IF/TA at 1 year. CONCLUSIONS: Early MRI after kidney transplantation was significantly more likely to develop IF/TA at 1 year and had higher sCr levels at 3 years. In such cases, intervention might preserve graft function over the long term.

Successful treatment of monomorphic primary central nervous system post-transplantation lymphoproliferative disorder 5 years after kidney transplantation.

A 31-year-old man underwent living-related kidney transplantation in 2004 as a consequence of primary focal segmental glomerulosclerosis (FSGS). Four years after the transplantation, we confirmed nephrotic syndrome caused by recurrent FSGS. We performed plasmapheresis and low-density lipoprotein adsorption. We also combined steroid therapy with a reduction in the dose of tacrolimus and an increased dose of mycophenolate mofetil. The nephrotic syndrome improved dramatically with this combined therapeutic approach. However, 10 months after these treatments, he revisited our hospital because of altered consciousness. We detected multiple tumor masses in his brain that were ring enhanced on contrast magnetic resonance imaging. Consequently, we suspected primary central nervous system post-transplantation lymphoproliferative disorder (CNS-PTLD). We performed a craniotomy to biopsy the brain tumors. The biopsy specimen showed Epstein-Barr virus-associated diffuse large B-cell lymphoma. There is no definitive treatment for CNS-PTLD. Therefore, we treated the primary CNS-PTLD successfully with whole-brain radiation and discontinuation of immunosuppression therapy.

Clinical impact of a combined therapy of peritoneal dialysis and hemodialysis.

AIMS: Although peritoneal dialysis (PD) is recommended as the first-line treatment for end-stage renal disease, limitations exist to achieving good clinical status when the residual renal function (RRF) has declined. Combined therapy with PD and hemodialysis (HD) is the treatment of choice for patients who cannot control body fluid status and/or cannot obtain adequate solute removal by PD alone. The aim of this study was to evaluate the clinical efficacy of this combined therapy. METHODS: In this retrospective study, 53 patients on PD and diagnosed with underdialysis and/or overhydration with declining RRF were recruited. Parameters of volume control, uremic solute removal, anemia, and predictors for encapsulating peritoneal sclerosis (EPS) were compared before and 1 year after combined therapy. RESULTS: The patients' hydration status improved significantly with reductions in atrial natriuretic peptide and blood pressure. Serum creatinine and beta2 microglobulin also decreased significantly. The hemoglobin level increased remarkably from 8.2 ± 1.6 to 10.7 ± 1.2 g/dl (p < 0.01) and the reticulocyte count also increased significantly, even though at the same time the dose of recombinant human erythropoietin decreased significantly. The dialysate to plasma creatinine ratio obtained from the fast peritoneal equilibration test (PET) decreased significantly from 0.65 ± 0.11 to 0.59 ± 0.13, and the level of interleukin 6 in PET drainage also significantly decreased. Furthermore, serum C-reactive protein and fibrinogen decreased significantly. CONCLUSIONS: Combined therapy with PD and HD is an effective way to control fluid status and to correct inadequate solute removal, leading to improvement in inflammation, peritoneal function and anemia.

Mitotic arrest caused by an X-ray microbeam in a single cell expressing EGFP-aurora kinase B.

Although the highest radiosensitivity of cells in the M phase among the other cell phases, such as the G(1), S and G(2) phases, has been known, the exact mechanism of radiosensitivity in mitotic cells remains unclear. Recently, mitotic arrest caused by DNA-damaging reagents has been shown, and the molecular mechanism in the arrest has been discussed in detail. In this study, abnormal cell-cycle progression in the M phase was investigated when a single mitotic cell in each mitotic stage was irradiated with a 5.35 keV X-ray microbeam focused on the cell nucleus. An X-ray microbeam irradiation system installed at BL-27 in Photon Factory, High Energy Accelerator Research Organization (HEARO, Tsukuba) was used. HeLa cells, genetically modified and expressing enhanced green fluorescent protein-tagged aurora kinase B, were used as irradiated samples in order to recognise the stage of each cell in the M phase. Thus, 10 Gy irradiation concentrated at the nucleus of a single cell elongated the cell-cycle progression in the M phase by delaying the metaphase/anaphase transition. The dose dependence of the elongation of the M phase was also examined. An irregular distribution of DNA in anaphase cells was observed after irradiation.

Simple biodosimetry method for cases of high-dose radiation exposure using the ratio of the longest/shortest length of Giemsa-stained drug-induced prematurely condensed chromosomes (PCC).

The aim was to develop a simple biodosimetry method for as rapid as possible estimation of absorbed radiation doses in victims of radiation accidents, in particular after high-dose exposure. Human peripheral blood lymphocytes (PBL) were gamma-irradiated in vitro with several doses up to 40 Gy stimulated with phytohaemagglutinin-P (PHA-P) for 2 days and their chromosomes condensed prematurely using 50 nm calyculin A. Chromosome lengths of Giemsa-stained G2 prematurely condensed chromosomes (PCC) were measured using image analysing software and the ratio of the longest/shortest chromosome length was calculated. The length ratio (LR) of the longest/shortest Giemsa-stained chromosome s increased with a good correlation to the square root of the radiation dose (D) up to 40 Gy, i.e. LR = (4.90 x D0.5) + 2.14. The LR of the longest/shortest chromosome might be used as an index for estimating the radiation dose. The blood samples should not be cooled until the start of separation/stimulation of the lymphocytes. A rapid and easy estimation of large doses after whole-body exposure was identified by measuring the ratio of the longest/shortest length of Giemsa-stained G2-PCC induced by calyculin A. This simple protocol will be particularly useful for making therapy decisions for victims of ionizing radiation exposure and has potential for use as a biodosimeter for partial-body exposure accidents.

Simple biodosimetry method for use in cases of high-dose radiation exposure that scores the chromosome number of Giemsa-stained drug-induced prematurely condensed chromosomes (PCC).

There is a need for quick dose estimation by a simple method in radiation accidents. This study develops a simple and rapid dose estimation protocol for victims of such accidents, in particular those involving high radiation doses. Human peripheral blood lymphocytes (PBL) were gamma-irradiated in vitro at several dose points up to 60 Gy, and were stimulated with phytohaemagglutinin-P (PHA-P) for 2 days to obtain dividing cells. PBL were then forced to condense prematurely, using 50 nM calyculin A, and the obtained chromosome spreads were Giemsa stained. The G2-PCC (prematurely condensed chromosomes) index and chromosome number for each radiation dose point were scored. G2-PCC were stably induced using calyculin A within 24 h delays in stimulation of PBL with PHA-P. The chromosome number of G2-PCC increased steeply with radiation doses up to 30 Gy at a rate of 0.31 Gy(-1) and then decreased at 0.30 Gy(-1) up to 40 Gy. More than 10% of G2-PCC index remained up to a 15 Gy dose. Even after 40 Gy irradiation, about 2% PCC index was obtained, and this value was enough to score a sufficient number of chromosome spreads for analysis. Therefore, the combined use of chromosome number and G2-PCC index allows biodosimetry to be done easily and rapidly. If PCC are not induced using calyculin A, it is strongly suggested that the radiation dose is over 50 Gy. A rapid and easy dose estimation for large dose exposure whole-body was realized by combined analysis of Giemsa-stained chromosome number of G2-PCC and PCC index using calyculin A. This simple method will be of use for rapid decision making of therapy for radiation accident victims. This method also has potential for use as a biodosimeter for partial-body exposure accidents.

Changes in peripheral lymphocyte subpopulations after direct moxibustion.

We measured peripheral lymphocyte subpopulations after direct moxibustion using moxa cones the size of a half-rice grain. In humans at 2 hrs after the direct moxibustion, NK cell percentage decreased and CD4/CD8 ratio increased significantly. Although the same trends were observed in the control session, those changes were not statistically significant. In rabbits at 3 and 12 hrs after direct moxibustion, CD4/CD8 ratio significantly increased, and recovered at between 24 and 72 hrs after treatment. Similarly, the CD4/CD8 ratio significantly increased in the control session, but they seemed to have a shorter duration. Although it is not yet clear whether the effects are beneficial, we found that direct moxibustion influences the immune system at least transiently.

Systematic review of adverse events following acupuncture: the Japanese literature.

CONTEXT: Many Japanese cases of adverse events after acupuncture are not listed in medical databases such as Medline. Therefore, they are not easily accessible to researchers outside Japan. OBJECTIVE: To complement existing reviews of adverse events after acupuncture in the West and to provide more detailed discussion and analysis. DATA SOURCES: Literature search using 'Igaku Chuo Zasshi (Japana Centra Revuo Medicina) CD-ROM version' covering the period of 1987-1999. STUDY SELECTION: Case reports of adverse events, which were suspected to be due to acupuncture treatment, were included. Experimental studies, surveys, and news articles were excluded. DATA EXTRACTION: Two independent reviewers extracted data from located articles in a pre-defined structured way, and assessed likelihood of causality in each individual case. DATA SYNTHESIS: 89 articles which reported 124 cases were located. The most frequent adverse events were: pneumothorax (25 cases), spinal cord injury (18 cases), acute hepatitis B (11 cases), and localized argyria (10 cases). There were two fatalities from infections. Forty-eight events were caused by needle breakage including 26 cases of intentionally embedded needle and 16 cases of accidental breakage. There were also 10 cases of injury from self-treatment. CONCLUSION: Although it has already been demonstrated that severe adverse events seem to be uncommon in standard practice, many serious cases of negligence have been found in the present review, suggesting that training system for acupuncturists (including medical doctors) should be improved and that unsupervised self-treatment should be discouraged.

Sleep-wake rhythm during stay in an intensive care unit: a week's long-term recording of skin potentials.

To monitor the sleep-wake cycle of patients during their stay in the intensive care unit (ICU), we tried continuous and long-term recording of skin potential (SP) levels in patients after surgery. A graph of the week-long SP showed the sleep-wake pattern to be evident until the fourth day. It disappeared beginning on the fifth day, resulting finally in delirium with a relatively high mean SP level. In another record, the administration of sedative agents to calm the excitement lowered the mean SP level and suppressed SP responses evoked by frequent day and night treatment or nursing care. Continuous monitoring of arousal level by SP will be of help in prevention of ICU syndrome.

Incidence of adverse reactions associated with acupuncture.

OBJECTIVES: To determine the type, severity, and incidence of acupuncture adverse reactions that are observed in standard practice. DESIGN: A survey based on observation and interview by the therapists. SETTING: Tsukuba College of Technology Clinic in Japan. SUBJECTS: All patients who underwent acupuncture treatment during a period of 4 months from April to July 1998. OUTCOME MEASURES: Type, severity, and incidence of acupuncture adverse reactions. RESULTS: A total of 391 patients were treated in 1,441 sessions, involving a total of 30,338 needle insertions. The incidence of recorded systemic reactions in individual patients was: tiredness (8.2%); drowsiness (2.8%); aggravation of preexisting symptoms (2.8%); itching in the punctured regions (1.0%); dizziness or vertigo (0.8%); feeling of faintness or nausea during treatment (0.8%); headache (0.5%); and chest pain (0.3%). The incidence of recorded local reactions, expressed as a percentage of needle insertions, was: minor bleeding on withdrawal of the needle (2.6%); pain on insertion of the needle (0.7%); petechia or ecchymosis (0.3%); pain or ache in the punctured region after the treatment (0.1%); subcutaneous haematoma (0.1%); and pain or discomfort in the punctured region during the needle retention (0.03%). CONCLUSION: Although some adverse reactions associated with acupuncture were common even in standard practice, they were transient and mild compared to cases such as pneumothorax, cardiac injury, infection, or spinal lesions reported in other studies.

[Clinical evaluation of cases with massive ascites accumulation after discontinuation of CAPD: an attempt to establish the concept of the pre-sclerosing encapsulating peritonitis(pre-SEP) state].

Sclerosing encapsulating peritonitis(SEP) is a most serious complication of continuous ambulatory peritoneal dialysis(CAPD). Although the criteria of diagnosis and guidelines for therapy of SEP have been proposed by the Japanese SEP Study Group already, SEP is refractory to treatment when the disease process is complete. It is important to detect the latent phase of SEP(pre-SEP state) in order to treat patients at an early stage. We evaluated the characteristics of ascites in four patients with massive ascites accumulation after discontinuation of CAPD. Age and the duration of CAPD of the subjects were 53.3 +/- 9.7 years and 126.5 +/- 6.8 months, respectively. However, the patients were withdrawn from CAPD because of peritonitis or ultrafiltration failure. We also followed cytokines and parameters of collagen metabolism of ascites in two patients during adrenocorticosteroid therapy and conducted a histopathological evaluation of the peritoneum of an autopsy case who had died of pneumonia. Ascites seems to be exudative because of the high concentration of protein, cytokines and parameters of collagen metabolism such as interleukin-1 beta, interleukin-6, transforming growth factor-beta 1, procollagen 3 peptide, and type IV collagen 7S, the levels of which were 21.3 +/- 9.3 pg/ml, 8,153 +/- 7,327 pg/ml, 6.7 +/- 3.6 ng/ml, 89.3 +/- 67.8 U/ml, and 59.0 +/- 36.2 ng/ml, respectively. The histopathological findings of the peritoneum from the autopsy case showed dense fibrous tissue permeated with inflammatory infiltration and widespread infiltration of fibrin. These findings suggested that the peritoneum was inflamed when massive ascites accumulated. The amount of ascites and concentration of cytokines and parameters of collagen metabolism of ascites diminished during adrenocorticosteroid therapy. We concluded that massive and refractory accumulation of ascites appearing after the discontinuation of CAPD should be regarded as a sign of the pre-SEP state, and prophylactic treatment should be started at this stage of disease.

[L-selectin expressed on peripheral monocytes and soluble L-selectin in sera in atopic diseases].

For the purpose of assessing the involvement of L-selectin in atopic diseases, we measured L-selectin expressed on peripheral monocytes and serum soluble L-selectin (sL-selectin). We enrolled 7 patients with atopic bronchial asthma(BA), 6 patients with atopic dermatitis, 12 patients with Japanese cedar pollinosis(P), and 9 healthy controls(C). L-selectin expressed on peripheral monocytes was detected and analyzed by using flow cytometry. Serum sL-selectin was measured by enzyme-linked immunosorbent assay. Compared with the group C (81.7 on average), mean fluorescence intensity of CD 62 L on monocytes in the group BA was significantly higher (110.4 on average, p < 0.05). The group AD also showed higher tendency (101.3 on average, p < 0.08). No significant difference was found in serum sL-selectin levels among the four groups(BA: 1086 ng/mL, AD: 1226 ng/mL, P: 945 ng/mL, C: 1052 ng/mL, on average). There was a negative correlation (r = -0.69) between serum sL-selectin and age in all subjects (BA + AD + P + C). The results suggest that L-selectin is involved in the extravasation of monocytes toward local inflammatory sites in atopic diseases. Serum sL-selectin seems to stay at normal level in mild and stable atopic diseases, while the trend of high serum sL-selectin level in children may participate in the pathogenesis.

[Construction of scales to measure thematic tendencies of paranoid ideation].

In order to measure thematic tendencies of paranoid ideation in non-clinical samples, Delusional Ideation Checklist (DICL) was developed. A wide range of items indicating themes of delusion were collected. From the results of factor analysis on the data of 308 college students, eight scales were constructed. They were: alienation, belittlement, persecution, other-harming, guardedness, self-conceit, favoredness, and other-manipulation. These scales could be classified in terms of emotion: positive versus negative, and direction: self versus others, and could deal with themes of paranoid ideation in a comprehensive and systematic way. Alpha coefficients of the scales were between .66 and .87, and test-retest reliability between .49 and .71. To examine content validity, ten psychiatrists were asked to rate diagnostic importance for each scale item. Six scales were rated as significantly more important in the diagnosis of paranoid schizophrenia than that of anxiety neurosis. Current data revealed that ordinary students experienced delusional ideation more frequently than psychiatrists would expect.

Localization of huntingtin-interacting protein-2 (Hip-2) mRNA in the developing mouse brain.

Huntingtin-interacting protein-2 (Hip-2) was identified as a human protein specifically associated with huntingtin in vitro, a gene product affected in patients with Huntington disease (HD). It is a ubiquitin-conjugating enzyme identical to the previously characterized bovine E2-25k. We identified the mouse Hip-2 homologue (mHip-2) and examined its distribution patterns in the developing mouse brain in order to gain an insight into the functional significance of the Hip-2 protein in the normal brain as well as in the pathogenesis of HD. As reported with huntingtin, the mHip-2 mRNA expression developed in parallel with neuronal maturation and became distributed widely in the postnatal mouse brain. This spatiotemporal pattern of mHip-2 mRNA expression resembled that of huntingtin. We further demonstrated that mHip-2 mRNA was colocalized with huntingtin-like immunoreactivity in a single neuron. These findings suggested that the Hip-2 interacted with huntingtin in vivo and played an important role in HD pathogenesis.

[Factors influencing residual renal function of CAPD patients].

It is generally accepted that residual renal function has significant meaning in dialysis adequacy of CAPD patients. However, the factors influencing the residual renal function have not been investigated yet. We evaluated the consequences of following factors on residual urine volume in 50 CAPD patients: deterioration rate of renal function (slope of I/serum creatinine) before dialysis, renal creatinine clearance at the initial point of dialysis and the episodes of rapid reduction of residual urine volume. There was no correlation between the deterioration rate of renal function before dialysis and the residual urine volume. On the contrary, there was significant correlation between renal creatinine clearance at the initial point of dialysis and the residual urine volume in the first 4 years on CAPD. We recognized 67 episodes of rapid reduction of residual urine volume after initiation of CAPD. Inappropriate management or complications attributed to the rapid urine volume reduction in 50 episodes. The residual urine volume did not recover to the previous level in 40 episodes. We concluded that early initiation of CAPD and evasion of decreasing residual urine volume caused by inappropriate management or complications have important meaning and will preserve residual renal function of CAPD patients.

Expression of sonic hedgehog signal transducers, patched and smoothened, in human basal cell carcinoma.

In basal cell nevus syndrome (BCNS) patients, mutations of a gene, patched (ptc), which encodes a putative signal transducer of sonic hedgehog protein (SHH), were found and are thought to be one of the major causes of BCNS. The SHH signaling pathway is an important developmental pathway, and ptc protein (PTC) is a suppressive component serving as a receptor for the secreted SHH. Another transmembrane protein, smoothened (SMO), forms a complex with PTC and regulates this signaling pathway. Recent transgenic studies have strengthened the importance of the SHH signaling system in the etiology of basal cell carcinoma (BCC). In this study, we examined the expression patterns of mRNA for ptc and smo in two different BCC subtypes and normal skin. We found that the expressions of ptc and smo mRNA were enhanced in the tumor nests of the nodular BCC, especially at the advancing portions, but were under the detectable level in the superficial BCC cases examined, indicating that ptc and smo mRNA expressions might be associated with BCC tumor progression and divide the BCC histologic types into two subtypes, superficial and nodular types. In addition, no obvious signals for ptc and smo mRNA were detected in the normal human epidermis, appendages, or seborrheic keratosis, indicating that the abnormal proliferation of follicular epithelial cells caused by ptc, smo and/or other genetic changes, which also cause ptc and smo overexpressions, might result in BCC tumor formation.

The signal detection ability of patients with auditory hallucination: analysis using the continuous performance test.

Signal detection theory is appropriate for analyzing the problem of whether auditory hallucination arises from a sensory or judgmental disorder. In the present study the sensory discrimination ability and decision bias of psychiatric patients with auditory hallucination was investigated by using the visual continuous performance test. Based on signal detection theory the d' (d prime) and the lnbeta value (the natural logarithm of the beta value) were calculated. The d' is indicator of discriminating ability, whereas the lnbeta value is an indicator of decision bias. The psychiatric inpatients with the diagnosis of schizophrenia mainly were divided into 11 patients with auditory hallucinations (AH(+)) and 11 patients without hallucinations (AH(-)). As compared with the AH(-) group, the AH(+) group showed the same d' value and a significantly lower lnbeta value. As compared with the normal control group, the AH(+) group showed a significantly lower d' value and a nearly normal lnbeta value. These results suggest that auditory hallucination is characterized by a cognitive deficit of unreasonably maintaining a relatively risk-taking decision bias in spite of decreased discriminating ability, which opposes the interpretation of Bentall and Slade (1985). The AH(+) group was divided into subgroups with bizarre delusions (BD(+)) and without bizarre delusions (BD(-)). The BD(+) group showed a stronger tendency toward a lower d' value and normal lnbeta value, which the AH(+) group had.

Aberrant judgmental pattern of schizophrenic patients in weight discrimination.

Sixteen chronic schizophrenics and 16 normal controls were tested on a weight discrimination task in various categories and hand conditions. Schizophrenics made significantly more errors than normals when the 'equal' category was included, whereas schizophrenics' performance could approximate the normals' discriminations when the 'equal' category was excluded. In the former condition, the more inaccurate performance of schizophrenics was ascribed to the selective increase in the errors by the 'equal' judgments, which was not due to an increase in 'doubtful' judgments. These findings were assumed to reflect schizophrenics' preference to equal judgments, which seemed to be their fundamental cognitive attitude, because the same tendency was found on the various discrimination tasks of other sensory modalities. Furthermore, the present results supported neither left hemisphere dysfunction nor interhemispheric transfer deficit in schizophrenia, because schizophrenics failed to show consistently more errors in the right hand and the bimanual conditions.