Prospect of Endoscopic Mucosal Resection for Early Gastric Cancer: Our Devices in Insulated‐Tip Electrosurgical Knife Method

In Kobe University Hospital, a new method for endoscopic mucosal resection (EMR) using insulated‐tip electrosurgical knife (IT‐EMR) for early gastric cancer (EGC) was introduced from November 2001. To achieve an effective and safe IT‐EMR procedure, we use a high‐frequency surgical unit for cutting and coagulation (ERBOTOM ICC 200) with automatically controlled cutting mode (ENDOCUT). In this study, we show not only our results of IT‐EMR for EGC in comparison with those of the conventional strip biopsy method, but also the optimal conditions for the apparatus of a high‐frequency surgical unit to prevent complications such as bleeding and perforation.     

Chemotherapy in the treatment of advanced or recurrent olfactory neuroblastoma

Background: Olfactory neuroblastoma is a rare sino‐nasal tumor arising from the olfactory epithelium and is often characterized by local invasion or metastasis. The role of chemotherapy in the treatment of this tumor is unclear. The purpose of this study was to review our institution’s experience of chemotherapy for advanced or recurrent olfactory neuroblastoma. Methods: Twenty‐one patients with histologically proven olfactory neuroblastoma were treated at our institution between 1992 and 2002. Twelve of these patients received chemotherapy in the setting of unresectable or recurrent disease and were retrospectively reviewed for clinical characteristics, treatment outcome or survival. Results: Eight patients of the 12 patients received cisplatin‐based chemotherapy and the remaining four patients received chemotherapy consisting of docetaxel plus irinotecan (three patients) or cyclophosphamide, doxorubicin, and vincristine (1 patient). A partial response was achieved in five patients, with an overall response rate of 42%, although the chemotherapeutic regimens were heterogeneous. Two partial responses were obtained among the three patients who received docetaxel plus irinotecan. The response rate to chemotherapy was 83% in the younger age group (<40 years), as opposed to 0% in the older age group (≥40 years), and the difference between the two groups was statistically significant (P = 0.02). Conclusion: Our study indicated that olfactory neuroblastoma would be sensitive to chemotherapy, especially with young patients. Docetaxel plus irinotecan has the possibility of showing favorable response, and warrants further investigation.     

Event-related potential correlates of functional hearing loss: Reduced P3 amplitude with preserved Nl and N2 components in a unilateral case

Abstract A female patient exhibiting functional hearing loss in her left ear demonstrated reduced amplitude of P3 component in event-related potentials (ERP) to left monaural stimulation, with preserved N1 and N2 components to stimulation of either ear. This result suggested that stimuli in the affected ear were conducted successfully up to the auditory cortex but that further processing in higher brain regions was 'repressed'. Event-related potential examination for such hysterical disorders could be useful in clarifying their brain mechanism and offer a useful diagnostic clue to its nature.     

Transesophageal Echocardiographic Analysis of the Systolic Pattern of the Anterior Mitral Leaflet in Patients with Flat Chest

Transesophageal echocardiography was conducted to determine the systolic pattern of the anterior mitral leaflet in patients with flat chest, and to differentiate it from that associated with mitral valve prolapse. The fronto-sagittal index (an index of chest flattening) was determined in 50 subjects using chest radiographs, and was used to classify them into a flat chest group (index < 0.38, n = 28) and a normal chest group (index ≥ 0.38, n = 22). We then used transesophageal echocardiography to examine the anterior leaflet in these subjects. A significant positive correlation was observed between the fronto-sagittal index and the short-to long-axis diameter ratio of the left ventricle in all patients. These parameters, and the left atrial dimension were lower in the flat than the normal chest group. The clear zone area of the anterior leaflet during mid-to late-systole was significantly larger in the flat chest group. However, no intergroup differences existed in the rough zone area of the anterior leaflet or in the middle scallop area of the posterior leaflet. Mitral regurgitation was observed in 20 and 12 subjects in the flat and normal chest groups, respectively. The maximum mitral regurgitant area did not differ between the two groups. The clear zone area of the anterior leaflet increased significantly following inhalation of amyl nitrite in 22 subjects of both groups, but the other areas did not increase. The mitral regurgitant area decreased or disappeared after amyl nitrite at a similar rate in each group. Thus, the decrease in the antero-posterior dimension of the thorax in subjects with flat chest affects the systolic pattern of the clear zone of the anterior leaflet more than that of the rough zone of the anterior leaflet or the posterior leaflet. This systolic pattern in such patients differs from that associated with mitral valve prolapse.     

Proliferation and cellular kinetics of villous epithelial cells and M cells in the chicken caecum

The proliferation sites and cellular kinetics of villous epithelial cells and M cells in the intestine of the adult chicken have never been clarified. In this study, we determined the proliferation sites in the chicken caecum using colchicine treatment and detection of proliferative cell nuclear antigen (PCNA). The cellular kinetics of these cells were also studied using bromodeoxyuridine (BrdU) as a tracer. Enterocytes in their mitotic period were observed along the entire length of the intestinal crypt of the caecum, with a denser distribution in the middle portion of the crypt, except for the caecal tonsil. The centres of distributions were at 49% of the distance from the bottom of the crypt in the base and 41% in the apex of the caecum. In the caecal tonsil, the centres of distributions were at 64% in the long type of crypt from the bottom of the crypt and at 44% in the short type of crypt. On the other hand, the PCNA-positive enterocytes were distributed more densely at the bottom of the crypt, except for the caecal tonsil. The centres of distributions were at 36% in the base from the bottom of the crypt, 37% in the body, and 34% in the apex. In the caecal tonsil, they were at 54% in the long type of crypt and 44% in the short type. The BrdU-labelled enterocytes reached to the basement of the intestinal villi in all caecal portions at 1 d after the BrdU administration. The leading edge of the labelled enterocytes disappeared from the villous tips at 4 d in the base and the body and 3 d in the apex. In the caecal tonsil, the BrdU-labelled microvillous epithelial cells and the M cells appeared near the orifice of the crypt at 1 d, and BrdU-labelled M cells were not observed in the crypt. Thereafter, almost all of these cells disappeared at 5 d from the follicle associated epithelium (FAE). These results suggest that M cells are transformed from their precursors within 1 d, and the turnover time for M cells occurs within 4 d after the cell division of the precursors.     

Risk Factor Analysis of Facet Fusion Following Cervical Lateral Mass Screw Fixation with a Minimum 1-Year Follow-up: Assessment of Maximal Insertional Screw Torque and Incidence of Loosening

Posterior stabilization is a common surgical procedure, which aims for rigid stabilization by facet fusion. Facet non-union has a potential risk of the screw loosening and malalignment. Although some authors have reported the influencing factors about screw loosening in the lumbar spine, there are few reports about the risk factor contributing to the facet non-union in the cervical spine. In all, 22 patients (78 facets and 122 screws) with degenerative cervical kyphosis or spondylolisthesis who underwent decompression and lateral mass screw (LMS) fixation were analyzed. Age, gender, smoking, bone mineral density (BMD), the degree of facet decortication with bone packing, and screw loosening were investigated as risk factors contributing to the facet non-union at each segmental fused level. Facet fusion rate was 85.9% (67/78 facets) and the incidence of loosening was 4.9% (6/122 screws, 4 patients). Insufficient facet decortication with bone packing is a significant risk factor of facet non-union (p <0.05, odds ratio: 26.5). All six loosened screws were associated with bony non-union of the facet and were located in the uppermost or lowermost vertebrae. Comparing loosened screws and stable screws, the average maximal insertional screw torque (MIT) was 9.8 cNm and 39.5 cNm, respectively (p <0.05). Additionally, the length of the stable screws was significantly longer versus the loosened screws (p <0.05). Lower MIT and shorter screw length located near the ends of the lateral mass may predict loosening, which can lead to facet non-union. Sufficient facet decortication with bone packing is one of the important factors contributing to the facet fusion.     

Characteristics of juvenile dermatomyositis in Japan

Questionnaires were sent to 1290 hospitals in Japan asking for data on patients with juvenile dermatomyositis (JDM) diagnosed between June 1984 and May 1994. Of the 204 patients identified by these questionnaires, 102 met the criteria for JDM. JDM is categorized into three subtypes: Banker-type JDM , Brunsting-type and fulminant-type; patients with the latter exhibit markedly elevated serum levels of creatinine phosphokinase (> 10 000 U/mL) and appear to be at risk of renal failure. Cutaneous manifestations were present in 98% of patients and preceded the appearance of other symptoms. This tendency is one of the reasons for the difficulty in some cases in diagnosing the onset of JDM. Better criteria for early treatment of JDM are needed. The results of the present study suggest that itching and calcinosis are factors that indicate a poor prognosis in patients with JDM. Muscle enzyme levels do not always reflect disease activity, suggesting that methods other than measurement of muscle enzymes, such as measurement of the levels of neoprerin and von Willebrand factor antigen, as well as magnetic resonance imaging should be used to be evaluate disease severity. Patients with Brunsting-type JDM who exhibit dysphagia and antinuclear antibody positivity and patients with Banker-type JDM should be treated aggressively. Pulse therapy should be selected as the initial therapy in patients with fulminant-type JDM.     

Reflex sympathetic dystrophy in childhood: A case report

A case report is presented of a 15-year-old girl with reflex sympathetic dystrophy (RSD). She was referred to hospital because of left upper limb pain. Her left upper limb was cold, edematous and blue with a limited active range of movement. The serum concentration of noradrenaline was lower on the painful side than on the healthy side, and neurotropin, which has an antinociceptive effect to hyperalgesia, was clearly effective. Early diagnosis and management is essential in the treatment of RSD and administration of neurotropin is a useful and non-invasive treatment without severe adverse effects.     

A case of West syndrome with atypical massive gray matter heterotopia that is well controlled by ACTH therapy

A 4 month old female infant with atypical asymmetrical massive gray matter heterotopia diagnosed as West syndrome is described. Her seizure initially appeared as afebrile general tonic and clonic convulsion and progressed to typical West syndrome consisting of clusters of myoclonic spasms of the extremities, mainly on the left side, accompanied by head and eye deviation to the right side. Electroencephalogram (EEG) presented typical hypsarrhythmia and cranial computerized tomography (CT) and magnetic resonance imaging (MRI) showed massive heterotopic gray matter in the right hemisphere with the same density or intensity as cortical gray matter. Single photon emission computed tomography (SPECT), using N-isopropyl-p-¹²³I-iodoamphetamine (¹²³I-IMP), demonstrated decreased blood flow in the ectopic lesion. Although clinical response to several anti-epileptic drugs was poor, her seizures were well controlled by relatively low dose adrenocorticotropic hormone (ACTH) therapy of 0.015 mg/kg per day followed by a combination of valproic acid and clonazepam.