Characteristics of epilepsy in severely mentally retarded individuals

In order to clarify the characteristics of epilepsy in patients with severe mentally retarded (SMR) subjects, we analyzed 52 SMR subjects with epilepsy from the institute for SMR subjects at Kikuchi National Hospital, Kumamoto, Japan. A total of 61.5% patients had uncontrolled seizures which were resistant to treatment. The most common combinations of seizure types in those not responding to conventional anticonvulsants were generalized tonic-clonic seizures (GTCS) with tonic seizure and GTCS with atypical absence. Their clinical features were characterized by spastic paralysis associated with a slower background electroencephalogram and abnormal computed tomography scans of the head, suggesting the involvement of cortical damage. These findings suggest that a large proportion of epilepsy in SMR subjects does not respond to treatment and that the severity of organic brain damage may therefore affect the natural course of epilepsy in such patients.     

Phosphorylation of MARCKS in Alzheimer disease brains

Activation of the amyloid beta-protein precursor, secretary pathway through alpha-secretase has been reported to increase the secretion of neuroprotective amyloid precursor protein and preclude the formation of amyloid beta-protein. Activation of protein kinase C has been shown to accelerate this secretory pathway. These results prompted us to focus on a potential links between protein kinase C and the amyloid beta-protein-related pathology of Alzheimer disease (AD). Although protein kinase C is reported to occur in senile plaques, its catalytic activity has not been investigated. As the phosphorylation of myristoylated alanine-rich C kinase substrate (MARCKS) has been used as a marker for activation of protein kinase C in vivo, we examined its phosphorylation in brain tissues obtained from seven AD patients and five non-demented subjects using an antibody that specifically recognized MARCKS phosphorylated by protein kinase C. Phosphorylation of MARCKS in cortical neurons in AD brains was weaker than that in control brains. Interestingly, however, phosphorylation of MARCKS was detected in microglia and dystrophic neurites within neuritic plaques, a mature form of amyloid beta-protein deposits. These results suggest that protein kinase C alteration is associated with AD pathology and that protein kinase C is activated in microglia and dystrophic neurites by amyloid beta-protein in AD brains.     

Late onset X-linked hydrocephalus with normal cerebrospinal fluid pressure

A family with X-linked hydrocephalus with normal cerebrospinal fluid (CSF) pressure and in which three brothers and a grandson of case 1, a proband, were affected is reported. The symptoms at onset were epileptic attacks that started in adulthood in the three brothers and at the age of 6 years in the grandson. In the three brothers, from 10 to 27 years after the onset of epileptic episodes, disorganization of intelligence and psychiatric deterioration were gradually noticed by their families. At the same time, they showed occasional urinary incontinence. Brain computed tomography (CT) scans revealed dilatation of the ventricular systems. Based on the results of the measurement of CSF pressure and radioactive-iodinated human serum albumin (RISA)-cysternography, two of the brothers were diagnosed as having normal pressure hydrocephalus (NPH), and they were treated neurosurgically. However, no obvious improvement in clinical symptoms was observed. Although the grandson had shown normal psychomotor development during his early childhood, temporal epilepsy and temper tantrums started at the age of 6 years. Computed tomography-scanning revealed dilatation of the ventricular system similar to the other three cases at the age of 8 years. With the diagnosis of NPH, the patient underwent a shunt operation, which resulted in no obvious effects. As it is reasonable to surmise that the pathological gene would have been transferred via the daughter of the proband to the grandson, it is suggested that the inheritance manner might be X-linked recessive. The cases presented here are different from the cases of hydrocephalus due to stenosis of the aqueduct Sylvius (HSAS) and other types of X-linked hydrocephalus reported previously in terms of the age of onset, course, symptoms, and CT findings. Thus, it is suggested that the present cases might be a new type of X-linked hydrocephalus.     

Culture-bound syndrome and a culturally sensitive approach: from a viewpoint of medical anthropology

Some aspects of the culture-bound syndrome are presented for discussion. From the psychiatric and medical anthropological viewpoints, kamidaari is described as an initiatory illness for seeing a shaman, and focus on clinical realities developing between different therapeutic subcultures in the same culture and the complementary practices of two epistemological ones, namely, the shamanistic and modern psychiatric system in the shamanistic climate. It is suggested that the culture-bound syndrome that reflects cultural influences on disease patterns and renders them difficult to place in a universal classificatory system should be seen as a vernacular bricolage or as tactics used by people within the web of their own local culture of origin. Therapists who treat patients in a cross-epistemological milieu should be aware of the subcultural-epistemological issues that may affect the clinical process. It should be recognized that, depending on the nature of a particular psychiatric crisis, the clinical encounter is straddling the boundaries of multiple clinical realities. At every stage in the clinical field, there is an intersection, consonance, or interruption of rejoinders in the open dialog by all those engaged in the clinical time. Aspects of climatic, culturally sensitive psychotherapy will be described, and the concept of the culture-bound syndrome will be reconsidered. Our approach could be seen as 'situation- and fudo-bound'.     

Usefulness of extension of disease as a prognostic factor in relapsed prostate cancer patients of stage D

OBJECTIVE: The prognosis of prostate cancer has been evaluated by clinical stage or pathological grade. PSA parameters including PSA density and PSA doubling time have not always precisely reflected the prognosis of prostate cancer. The aim of this study was to evaluate PSA parameters and extension of disease (EOD) grade as prognostic factors for relapsed prostate cancer. METHODS: The relationship between PSA parameters or EOD grade, and survival of 29 stage D patients with relapsed prostate cancer after initial hormone therapy was examined. RESULTS: Only EOD grade was an independent prognostic factor, even for cause-specific survival period and survival period after relapse. CONCLUSION: EOD grade was a significant prognostic factor, and in particular, very useful as a prognostic factor for patients with bone metastasis. PSA value was not always associated with tumor volume, and therefore it is not an independent prognostic factor.     

Treatment with TAE of subcapsular hematoma as a complication of extracorporeal shock wave lithotripsy (ESWL): a case report

A 58-year-old man with a left renal stone and with poor controlled hypertension was attacked by sudden onset of left renal colic pain, gross hematuria and nausea at 3 hours after ESWL. Ultrasonography and enhanced computed tomography revealed severe subcapsular hematoma, which compressed the left kidney. Since serum hemoglobin level continued to decrease in spite of 7 days of conservative therapy, we performed transfusion of red blood cells and selective transarterial embolization (TAE). Renal angiography showed multiple pseudo-aneurysms of arteriole at the lower pole of the left kidney. Embolization of left renal artery was effective to relieve patient's symptom and to stabilize the serum hemoglobin level.     

The accuracy of transcutaneous carbon dioxide monitoring during laparoscopic surgery

BACKGROUND: Laparoscopic procedures are considered relatively low-invasive. However, there exists a small but important risk of developing complications related to carbon dioxide (CO2) insufflation. End-tidal CO2 (PetCO2) monitoring may not be a sufficient guide to adjust pulmonary ventilation during laparoscopic surgery, and arterial CO2 (PaCO2) monitoring is not always indicated. We evaluated the accuracy and feasibility of transcutaneous CO2 (PtcCO2) monitoring during laparoscopic surgery. METHODS: Thirty adult patients undergoing abdominal or gynecological laparoscopic surgery were studied. PtcCO2, PaCO2 and PetCO2 were measured before laparoscopy, and 30 and 60 minutes after beginning of CO2 insufflation. PtcCO2 and PaCO2 were also measured in the recovery room under spontaneous respiration. RESULTS: During operation, the PtcCO2 values demonstrated a high degree of correlation with PaCO2 (r = 0.92), and PetCO2 values also demonstrated generally a good correlation with PaCO2 (r = 0.85). The PtcCO2 PaCO2 gradient was -0.6 +/- 2.2 mmHg, while the PetCO2-PaCO2 gradient was -3.9 +/- 2.7 mmHg. In the recovery room, PtcCO2 values still demonstrated a high correlation with PaCO2 (r = 0.91). CONCLUSIONS: The transcutaneous devices provide an effective method for non-invasive monitoring of PCO2 in situations where continuous monitoring of CO2 levels is desired such as peri-operative period of laparoscopic surgery.     

Flowcharts for the management of biliary tract and ampullary carcinomas

No strategies for the diagnosis and treatment of biliary tract carcinoma have been clearly described. We developed flowcharts for the diagnosis and treatment of biliary tract carcinoma on the basis of the best clinical evidence. Risk factors for bile duct carcinoma are a dilated type of pancreaticobiliary maljunction (PBM) and primary sclerosing cholangitis. A nondilated type of PBM is a risk factor for gallbladder carcinoma. Symptoms that may indicate biliary tract carcinoma are jaundice and pain in the upper right area of the abdomen. The first step of diagnosis is to carry out blood biochemistry tests and ultrasonography (US) of the abdomen. The second step of diagnosis is to find the local extension of the carcinoma by means of computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP). Because resection is the only way to completely cure biliary tract carcinoma, the indications for resection are determined first. In patients with resectable disease, the indications for biliary drainage or portal vein embolization (PVE) are checked. In those with nonresectable disease, biliary stenting, chemotherapy, radiotherapy, and/or best supportive care is selected.     

Case of tuberculous epididymitis caused by intravesical BCG therapy

Intravesical Bacillus Calmette-Guerin (BCG) therapy is commonly used against superficial urothelial carcinoma, especially carcinoma in situ (CIS). We report a case of tuberculous epididymitis that occurred during a course of intravesical BCG therapy. A 76-year-old man had received intravesical BCG therapy for multiple superficial bladder cancer and CIS in prostatic urethra after transurethral resection of bladder tumor (TUR-Bt). He recognized hard nodules in the left scrotum after 4 times intravesical BCG therapy. Skin fistula in scrotum occurred 5 months later. We performed left orchiectomy with scrotum skin resection. Histological diagnosis was tuberculous epididymitis. Postoperatively, he was administered chemotherapy consisting of isoniazid, refampin and ethambutol.