VOLUME 77 NUMBER 1,2 February 2015

Current Issue

ISSN 2186-3326
(Online ISSN)
ISSN 0027-7622
(Print ISSN--v.72no.3/4)

Impact Factor(2013)  0.803

EndNote Output Style

INVITED COMMENTARY

Iron Metabolism and Autophagy: A Poorly Explored Relationship that has Important Consequences for Health and Disease

SUKRITI KRISHAN, PATRIC J. JANSSON, ELAINE GUTIERREZ, DARIUS J.R. LANE, DES RICHARDSON and SUMIT SAHNI
pg(s) 1 - 6

<Abstract> - < PDF >

Autophagy is an important cell survival pathway which is up-regulated under stress conditions. It is a well regulated catabolic process and enables the cell to recycle its constituents and organelles for re-use. Autophagy has been implicated to play an important role in a variety of disorders such as cancer and protein aggregatory neurodegenerative diseases e.g., Alzheimer’s disease, Parkinson’s disease and Huntington’s disease. Iron is a critical metal required for normal cellular functioning. A very tightly regulated balance of iron levels is required for the normal physiological functioning of the cell. Both an excess and deficiency of iron can lead to cellular stress, and thereby, alters the autophagic status within the cell. Thus, it is important to completely understand how iron can affect the autophagic pathway and its potential implications under physiological as well as pathological conditions.

INVITED REVIEW ARTICLE

FLT3 Inhibitors: Recent Advances and Problems for Clinical Application

HITOSHI KIYOI
pg(s) 7 - 17

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FLT3, a type III receptor tyrosine kinase, expresses on most acute leukemia cells as well as normal hematopoietic stem/progenitor cells. Mutation in the FLT3 gene is the most frequent genetic alteration in acute myeloid leukemia (AML) and is well known as an important driver mutation for the development of myeloid malignancies. FLT3 mutation is a strong poor prognostic factor for the long-term survival in AML patients, while neither high-dose chemotherapy nor allogeneic hematopoietic stem cell transplantation can overcome a poor prognosis. Development of an FLT3 inhibitor is, therefore, much awaited. To date, several potent FLT3 inhibitors have been developed and some of them were evaluated for efficacy in clinical trials, although no FLT3 inhibitor has been yet approved. Moreover, several problems for clinical use, such as adverse effects, blood concentration and resistance have been apparent. Recently developed AC220 is a highly selective and sensitive FLT3 inhibitor. In Phase I and II trials, AC220 so far showed the best efficacy of AML cells harboring FLT3 mutation among clinically evaluated FLT3 inhibitors, while severe bone marrow suppression and QTc prolongation should be resolved for the clinical use. In this review, I summarize the characteristics of FLT3 inhibitors in clinical development and discuss important issues to be resolved for clinical use.

REVIEW ARTICLE

Roles of Public Health Centers (Hokenjo) in Tuberculosis Control in Japan

NOBUYUKI KATSUDA, TOMOYA HIROSAWA, JOSHUA A REYER and NOBUYUKI HAMAJIMA
pg(s) 19 - 28

<Abstract> - < PDF >

Public health centers (PHCs, hokenjo in Japanese) are local government authorities responsible for public health in Japan. PHCs have an important role in tuberculosis (TB) control. Typically, their responsibilities include 1) the recommendation to admit infectious TB patients to an isolation ward, 2) health checkups with chest X-ray of those in a close contact with infectious TB patients, and 3) public subsidy of medical expenses for TB treatments. Facing the emergence of multi-drug resistant tuberculosis (MDR-TB), the national TB control program was drastically changed; the Japanese version of the Directly Observed Treatment in Short-course (DOTS) strategy was started in 2005. New roles were added to PHCs’ responsibilities; 1) active screening of latent TB infection by interferon gamma release assays for those in a close contact with infectious TB patients, 2) community DOTS to promote treatment adherence to outpatients, 3) cohort analysis of outcomes of TB treatment, and 4) national MDR-TB surveillance. These roles are important in preventing MDR-TB and eliminating TB in Japan.

ORIGINAL PAPERS

Factors Associated with Access to Antiretroviral Therapy among People Living with HIV in Vientiane Capital, Lao PDR

THAMMACHAK CHANVILAY, YOSHITOKU YOSHIDA, JOSHUA A REYER and NOBUYUKI HAMAJIMA
pg(s) 29 - 39

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Since 2001, antiretroviral therapy (ART) has been available for people living with HIV (PLHIV) in Lao People’s Democratic Republic (PDR). Over 10 years of the ART program many HIV patients were found with advanced-stage AIDS in health care service facilities. This study aimed to examine factors associated with delayed access to ART among PLHIV in the capital of Vientiane. A cross-sectional study was conducted with 283 respondents (131 males and 152 females) aged 15 years or over. In this study, delayed access to ART was defined by a CD4 cell count of less than 350 cells/mm3 at the first screening, or those who presented with advanced AIDS-related symptoms. The odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by a logistic model. After adjustment, young people (OR=2.17; 95% CI: 1.00–4.68; p=0.049), low education (OR=0.23; 95% CI: 0.10–0.55; p=0.001) and duration between risk behavior and HIV test (OR=3.83; 95% CI: 1.22–12.00; p=0.021) were significantly associated with delayed access to ART. Low perception of high risk behaviors was one of the obstacles leading to delayed testing and inability to access ART. Almost all reported feeling self-stigma, and only 30.5% of men and 23.7% of women disclosed the HIV status to his/her partner/spouse. In conclusion, delayed access to ART was associated with individual factors and exposure to health care facility. In order to improve early detection HIV infection following access to ART, an improvement in perceptional knowledge of HIV, as well as reduction of HIV/AIDS-related stigma, might be needed.
Tuberculosis and Rifanpicin Resistance among Migrants in Kyrgyzstan: Detection by a New Diagnostic Test

AIGUL BARMANKULOVA, MICHIYO HIGUCHI, MOHAMMAD ABUL BASHAR SARKER, MD. ABDUL ALIM and NOBUYUKI HAMAJIMA
pg(s) 41 - 49

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This cross-sectional study aimed to describe suspected tuberculosis (TB) cases among migrants in Kyrgyzstan and to estimate the accuracy of Xpert MTB/RIF, which has been operated in Kyrgyzstan since 2012. Characteristics of 3,714 suspected cases among migrants were analysed. In addition, by using data of 300 cases with culture results, sensitivity and specificity of Xpert MTB/RIF, both for detection of TB and rifampicin susceptibility, were assessed. Among 3,714 suspected cases, 56.1% were male, and the median age was 35 years old. Of the suspected cases, 17.2% were previously-treated. In total, 809 (21.8%) were smear-positive; 36.8% among previously-treated cases and 18.7% among new cases. Among 300 selected participants, 235 (78.3%) were culture-positive. Of those who were confirmed as TB positive, recurrent cases showed a higher proportion of rifampicin resistance than new cases (59.3% vs 42.6%). For detection of TB, the sensitivity and specificity of XpertMTB/RIF (81.3% and 98.2%) were higher than those of microscopy (70.2% and 71.4%). Sensitivity and specificity for detection of rifampicin resistance were 96.8% and 91.8%, respectively. The rifampicin resistance rate in the study population was higher than the national average. Xpert MTB/RIF showed higher accuracy in detecting TB cases than microscopic diagnosis. Higher accuracy and earlier detection of drug susceptibility is especially important for those who have difficulty in accessing healthcare and those who are easily lost from tracking, including migrants.
Surgical Skills Training for Primary Total Hip Arthroplasty

YUKIHARU HASEGAWA and TAKAFUMI AMANO
pg(s) 51 - 57

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A total of 483 hips treated by primary total hip arthroplasty (THA) were investigated to evaluate the surgical skill of the performing surgeon. Surgical trainees operated on 259 hips and instructors on 224 hips. The average age of the patients at the time of THA in the trainee and instructor group was 61.9 and 60.8 years old, respectively. The average follow-up duration was 5.1 years. The operative time in the trainee group and instructor group was 87.0 and 73.1 min, respectively (p=0.031). Complications were noted in 11 hips (3.5%) in the trainee group; acetabular fracture, 3 hips; dislocation, 3 hips; femoral artery lacerations that needed repair surgery, 2 hips; sciatic nerve palsy, 2 hips; and skin necrosis, 1 hip. Complication were noted in three hips (1.3%) in the instructor group; femoral fracture, 1 hip; acetabular fracture, 1 hip; dislocation, 1 hip. Complication rate in the trainee group was higher than in the instructor group. The monitored quality of the surgeries performed by trainees and instructors was not significantly different. Poor quality was identified in 14 hips in the trainee group and 6 hips in instructor group. No significant difference was found in the hip score between the trainees and instructors before and after surgery. Revision arthroplasty was defined as the end-point for primary THA. Kaplan-Meier survivorship at 5 years after primary THA was 97.2% in trainee group and 97.3% in the instructor group. Short-term clinical and radiographic results of primary THA in the trainee and instructor groups were considered safe and satisfactory.
Burden of Bacterial Meningitis: A Retrospective Review on Laboratory Parameters and Factors Associated with Death in Meningitis, Kelantan Malaysia

REHANA BASRI, ABDEL RAHMAN ZUETER, ZEEHAIDA MOHAMED, MOHAMMAD KHURSHEED ALAM, BACHOK NORSA’ADAH, SITI ASMA HASAN, HABSAH HASAN and FADZILAH AHMAD
pg(s) 59 - 68

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To describe the clinical characteristics and the risk factors associated with mortality in patients with meningitis. This is a retrospective review of patients diagnosed to have meningitis with positive culture of the cerebrospinal fluid (CSF) specimen. All cases aged 19 > years who were admitted to Hospital USM between January 2004 and December 2011 were included in the study. The CSF results database were obtained from the Department of Medical Microbiology and Parasitology, Hospital USM, Kelantan. A checklist was used to record the clinical characteristics. A total of 125 cases met the inclusion criteria. The age of patients ranged between newborn and 19 years old (Mean±SD, 74.5±80.6 months). The majority of them were males (65.6%). Fever was the most common presentation (73.6%) followed by poor oral intake (48.0%), seizure (36.0%) and headache (24.8%). The mortality rate was 31.2%. Coagulase negative staphylococcus was the most frequent pathogens isolated (21.6%), followed by Acinetobacter spp. (17.6%), Staphylococcus aureus (13.6%), Streptococcus spp. (11.2%) and Klebsiella pneumoniae (6.4%). There were significant association of in-hospital death with age (p=0.020) and conscious level (p=0.001). Infectious meningitis is a big health concern, especially among children. We found that coagulase negative staphylococcus, Acinetobacter species, S. aureus, Streptococcus spp and K. pneumoniae were prevalent in our hospital. These microorganisms were hospital associated pathogens. The 31% mortality linked to hospital acquired meningitis specifies the need for focused physician attention especially among younger aged patients.
Delivery Care Satisfaction at Government Hospitals in Xiengkhuang Province under the Maternal and Child Health Strategy in Lao PDR

PHOMMACHANH KHAMMANY, YOSHITOKU YOSHIDA, MOHAMMAD ABUL BASHAR SARKER, CHANTHALANGSY TOUY, JOSHUA A REYER and NOBUYUKI HAMAJIMA
pg(s) 69 - 79

<Abstract> - < PDF >

Satisfaction with delivery care for mothers giving birth at medical facilities, particularly hospitals, affects birth place selection. Lao PDR faces high maternal and infant mortality, and the government had introduced the Maternal and Child Health Strategy to Xiengkhuang Province in 2009 to combat high maternal and infant mortality there. This study aimed to determine the levels of delivery care satisfaction among mothers who gave birth in hospitals and examine the associations between satisfaction and background factors. This was a cross-sectional study, conducted from July to August of 2013, for 246 mothers who gave birth at three hospitals. A logistic regression model was applied to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of the factors. The majority of respondents were ≤ 25 years of age (57.3%), educated in ≤12 years (64.2%), unemployed (77.6%), and with more than one child (60.2%). Most mothers (93.5%) received antenatal care at least one time. Among the 16 components of satisfaction, less than half of the respondents were satisfied with sanitary facilities (22.0%), cleanliness (39.4%), their infant’s health condition (42.7%), opportunity to clarify doubts about baby care (48.8%), their own health condition (43.5%), and privacy maintained during care (45.5%). The components with more than 80% satisfaction among the respondents were the politeness and respect shown by midwives (88.6%), nurses (85.4%), and doctors (80.1%) as well as medical service facilities (81.7%). Overall satisfaction was significantly associated with higher husband’s education (OR=2.36, 95% CI=1.07–5.19) and longer hospital stay (OR=2.30, 95% CI=1.28–4.14) when 15 background factors were adjusted. In conclusion, mothers who gave birth at hospitals in Lao PDR were generally satisfied, except for sanitary facilities, and cleanliness of facilities.
Efficacy and Safety of Celecoxib Compared with Placebo and Etodolac for Acute Postoperative Pain: A Multicenter, Double-Blind, Randomized, Parallel-Group, Controlled Trail

NAOKI ISHIGURO, AKIO HANAOKA, TOSHIYUKI OKADA and MASANORI ITO
pg(s) 81 - 93

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Celecoxib is a nonsteroidal anti-inflammatory drug (selective cyclooxygenase-2 inhibitor) that is widely used. The efficacy and safety of celecoxib for treatment of acute postoperative pain were evaluated in Japanese patients. The objective was to assess whether celecoxib showed superiority over placebo treatment and non-inferiority versus etodolac (another selective cyclooxygenase-2 inhibitor) that has been widely used for the management of acute pain. A multicenter, double-blind, randomized, parallel-group, controlled study was performed, in which 616 patients with postoperative pain received celecoxib, etodolac, or placebo. Their impressions of study drug efficacy (overall assessment) and pain intensity were evaluated. Based on each patient’s overall assessment of pain, the efficacy rate was 63.7% in the placebo group, 76.2% in the celecoxib group, and 68.0% in the etodolac group, with these results demonstrating superiority of celecoxib to placebo and noninferiority versus etodolac. The efficacy rate was significantly higher in the celecoxib group than in the etodolac group. There were no adverse events specific to celecoxib, and the safety of celecoxib was similar to that of placebo. Celecoxib was superior to etodolac for controlling acute postoperative pain.
Effects of a Custom-Made Hinged Knee Brace with Knee Flexion Support for Patients with Knee Osteoarthritis: A Preliminary Study

SUSUMU OTA, AKIRA KANAI, YOSHIYA TORII, HIROYUKI TANIYAMA, FUMIO IMAIZUMI and YASUMOTO MATSUI
pg(s) 95 - 101

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A knee brace for medial knee osteoarthritis (OA) is required to restrict knee adduction moment (KAM), but must not restrict knee flexion during swing phase. There is no report of a knee brace with both functions. The purpose of this study is to investigate the effect of the custom-made hinged knee brace for patients with knee OA compared to the hinged knee brace generally used, and to assess the KAM and knee flexion angle during swing phase. Fifteen patients (average age: 71.6 ± 7.8 years old) with medial knee OA participated. Gait analysis was performed using a 3-D motion analysis system to measure two conditions: hinged knee brace (KB), and a custom-made hinged knee brace with knee-flexion supportequipped rubber tubes at the posterior of the lateral and medial side poles (KBF). The peak KAM with KBF was significantly smaller than those with the KB (P=0.004, the difference between these conditions of KAM: 0.06 Nm/kg). The peak knee flexion angles during swing phase with KBF were also significantly larger than those with the KB (P=0.004, the difference between these conditions of knee flexion angle: 1.5 degrees). The custom-made brace with one type of tube actuator in the present study could decrease KAM and make for a small increase of knee flexion angle as opposed to the hinged knee brace.
Clinical Features, Current Treatments and Outcome of Pregnant Women with Preeclampsaia/ Eclampsia in Northern Afghanistan

SAYED SHIR MOHAMMAD AHADI, YOSHITOKU YOSHIDA, MIRWAIS RABI, MOHAMMAD ABUL BASHAR SARKER, JOSHUA A. REYER and NOBUYUKI HAMAJIMA
pg(s) 103 - 111

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In Afghanistan, preeclampsia/eclampsia is the second leading cause of maternal deaths following maternal hemorrhage. This study aimed to describe clinical features, current treatments, and outcome among preeclampsia and eclampsia patients in the north region of Afghanistan. This was a retrospective study based on medical records of four center hospitals (one regional hospital and three provincial hospitals) in the north region of Afghanistan. Subjects were 322 patients with preeclampsia/eclampsia, admitted from March 2012 to March 2013. Out of 322 cases, 72.7% were diagnosed as preeclampsia and the rest as eclampsia. Those aged 30–39 years were 41.0% among preeclampsia patients and 29 years and younger were 35.2% among eclampsia patients (p= 0.002). The first delivery was significantly higher (p=0.045) among eclampsia patients (51.1%) than among preeclampsia patients (36.8%). While none died among the preeclampsia patients, 12 out of 88 eclampsia patients died in the hospitals. The causes of the 12 deaths were pulmonary edema (6 patients), renal failure (3 patients), cerebrovascular attack (2 patients), and hemorrhage (1 patient). There were no clinical findings at admission significantly associated with the deaths within the eclampsia patient group. Although the sample size was not large enough, patients admitted to the regional/provincial hospitals at the stage of preeclampsia had a low risk of death. Access at the stage of preeclampsia and improvement in treatments for eclampsia would reduce maternal mortality in Afghanistan.
Evaluation of Emphysema Using Three-Dimensional Computed Tomography: Association with Postoperative Complications in Lung Cancer Patients

KENICHI KAWAKAMI, SHINGO IWANO, NAOZUMI HASHIMOTO, YOSHINORI HASEGAWA and SHINJI NAGANAWA
pg(s) 113 - 122

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Three-dimensional computed tomography (3D-CT) enables in vivo volumetry of total lung volume (TLV) and emphysematous low-attenuation volume (LAV) in patients with chronic obstructive pulmonary disease (COPD). We retrospectively investigated the correlation between preoperative 3D-CT volumetry and postoperative complications in lung cancer patients. We searched our institution’s surgical records from December 2006 to December 2009 and selected patients who had undergone pulmonary lobectomy for primary lung cancer. From 3D-CT data, TLV and LAV <–950 HU of thresholds were retrospectively measured. The LAV% was calculated as follows: LAV% = LAV/TLV*100. The associations between the seven independent variables (LAV%, age, gender, body mass index, smoking history, forced expiratory volume in 1 second as percent forced vital capacity [FEV1%], and resected lobe) and the two outcomes (postoperative complications and prolonged postoperative stay [PPS]) were compared using logistic regression analysis. A total of 309 patients (222 males, 87 females; mean age, 67 years; range, 40–87 years) were evaluated. On multivariate analysis, age and LAV% were significantly correlated with postoperative complications (p = 0.006 and p = 0.006, respectively), and LAV% was significantly correlated with PPS (p = 0.031). LAV% measured using 3D-CT is more sensitive for predicting complications after lobectomy for lung cancer than FEV1%.
Patients’ Level of Medical Term Recognition as Estimated by Healthcare Workers

YASUKO YOSHIDA and YOSHITOKU YOSHIDA
pg(s) 123 - 132

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To render risk communication between patients and healthcare workers more effective, gaps in the patients’ level of medical term recognition as estimated by healthcare workers was examined. This was a cross-sectional study conducted via an Internet survey. A total of 244 nurses and 211 medical doctors were surveyed. We examined 90 medical terms, including 57 medical terms examined by the National Institute for Japanese Language and 33 newly added medical terms. Differences between medical doctors and nurses with respect to the estimation of patients’ level of medical term recognition were assessed. The level of medical term recognition by patients was higher when estimated by nurses than when estimated by medical doctors. As members of team care, nurses must consider that patients find technical medical terms to be more difficult than anticipated and that patients are aware of these terms only to a certain extent while receiving healthcare information, such as drug information. Currently, nurses are expected to perform activities as clinical research coordinators and also are requested to work as home-visiting nurses. Therefore they also need ensure that patients understand the medical information provided to them.
Factors Influencing Non-institutional Deliveries in Afghanistan: Secondary Analysis of the Afghanistan Mortality Survey 2010

MOHAMMAD DAUD AZIMI, SAID AHMAD MAISAM NAJAFIZADA, INN KYNN KHAING and NOBUYUKI HAMAJIMA
pg(s) 133 - 143

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Home delivery in unhygienic environments is common among Afghan women; only one third of births are delivered at health facilities. Institutional delivery is central to reducing maternal mortality. The factors associated with place of delivery among women in Afghanistan were examined using the Afghanistan Mortality Survey 2010 (AMS 2010), which was open to researchers. The AMS 2010 data were collected through an interviewer-led questionnaire from 18,250 women. Odds ratio (OR) and 95% confidence interval (CI) of non-institutional delivery were estimated by logistic regression analysis. When age at survey, education, parity, residency, antenatal care frequency, remoteness, wealth and regions were adjusted, the OR of non-institutional delivery was 8.37 (95% CI, 7.47–9.39) for no antenatal care relative to four or more antenatal care visits, 4.07 (95% CI, 3.45–4.80) for poorest household relative to women from richest household, 2.02 (95% CI, 1.43–2.84) for no education relative to higher education, 1.78 (95% CI, 1.52–2.09) for six or more deliveries relative to one delivery, and 1.50 (95% CI, 1.36–1.67) for rural relative to urban residency. Since antenatal care was strongly associated with non-institutional delivery after adjustment of the other factors, antenatal care service may promote institutional deliveries, which can reduce maternal mortality ratio in Afghanistan.
Protective Effects of Phyllanthus Emblica Leaf Extract on Sodium Arsenite-mediated Adverse Effects in Mice

SADIA SAYED, NAZMUL AHSAN, MASASHI KATO, NOBUTAKA OHGAMI, ABDUR RASHID AND ANWARUL AZIM AKHAND
pg(s) 145 - 153

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Groundwater contamination of arsenic is the major cause of a serious health hazard in Bangladesh. No specific treatment is yet available to manage the large number of individuals exposed to arsenic. In this study, we evaluated the protective effects of Phyllanthus emblica (Indian gooseberry or Amla) leaf extract (PLE) on arsenic-mediated toxicity in experimental mice. Male Swiss albino mice were divided into three different groups (n=6/group). ‘Control’ mice received arsenic free water together with normal feed. Mice in the remaining two groups designated ‘SA’ and ‘SA+PLE’ were exposed to sodium arsenite (SA, 10 μg/g body weight/day) through drinking water in addition to receiving normal feed and PLE-supplemented feed, respectively. The weight gain of SA-exposed mice was decreased compared with the controls; however, this decrease in body weight gain was prevented when the feed was supplemented with PLE. A secondary effect of arsenic was enlargement of the liver, kidney and spleen of SA-group mice. Deposition of arsenic in those organs was demonstrated by ICP-MS. When PLE was supplemented in the feed the enlargement of the organs was minimized; however, the deposition of arsenic was not significantly reduced. These results indicated that PLE may not block arsenic deposition in tissue directly but rather may play a protective role to reduce arsenic-induced toxicity. Therefore, co-administration of PLE in arsenic-exposed animals might have a future therapeutic application for protecting against arsenic-mediated toxicity.
Left Ventricular Dyssynchrony in Patients with Moderate Coronary Stenosis and Border Line Fractional Flow Reserve

YOHEI SHIBATA, TAKAHITO SONE, HIDEYUKI TSUBOI, SATOSHI ISOBE, HIDEKI ISHII, SUSUMU SUZUKI, MUTSUHARU HAYASHI and TOYOAKI MUROHARA
pg(s) 155 - 166

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The cutoff values of fractional flow reserve (FFR) to detect physiological myocardial ischemia are still controversial. Some studies have reported that left ventricular (LV) dyssynchrony occurs in patients with coronary artery disease (CAD). The purpose of this study was to investigate LV dyssynchrony in patients with moderate coronary stenosis and borderline FFR, using stress electrocardiographically-gated myocardial perfusion single-photon emission computed tomography (SPECT). The study population comprised 10 patients with moderate (50–75% diameter) stenosis and an FFR in the range 0.75–0.90, who were compared to 10 control subjects. All underwent stress myocardial 99mTc-sestamibi (MIBI) or tetrofosmin SPECT imaging. The regional time to end systole (TES), time to peak ejection (TPE), and time to peak filling (TPF) were obtained as indexes of perfusion and function, using gated SPECT (pFAST) in combination with Cardio Gated SPECT Regional Assessment for LV Function (cardioGRAF). The dyssynchrony index (DI) was also calculated. The DI of post-stress TES was significantly greater than that of rest in patients with moderate CAD (4.8 ± 2.8 vs. 2.7 ± 1.5, P = 0.01), but there were no significant differences in the control subjects (3.0 ± 1.7 vs. 2.9 ± 1.9, P = 0.99). There were no significant differences in TPE and TPF between the groups. In conclusion, LV dyssynchrony may occur after stress in patients with coronary stenosis and borderline FFR, even without a significant reduction in perfusion.
Solitary Fibrous Tumors in the Extremities: Imaging Findings for Six Patients

RYOTA HYODO, TOMOHIRO KOMADA, AKIRA TAKADA, HISASHI KAWAI, SHINJI ITO, YOSHIHIRO NISHIDA and SHINJI NAGANAWA
pg(s) 167 - 178

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The purpose of this study was to describe the magnetic resonance imaging (MRI) and computed tomography (CT) findings for solitary fibrous tumors (SFTs) in the extremities in correlation with histopathological findings. Between 2006 and 2013, 6 consecutive patients with SFT in an extremity were studied with MRI (6 patients) and CT (4 patients). Diffusion-weighted images were also performed in 3 patients and dynamic contrast-enhanced CT in 2 patients. All 6 tumors were diagnosed after surgical excision, and the pre-surgical imaging findings were correlated with the histopathological findings. As a result, all 6 patients were female, and each had a clearly palpable, well-circumscribed, round or oval mass adjacent to fascia in an extremity, of less than 10 cm maximum diameter in 5 patients. On MRI, the tumors were iso-intense with muscle on T1-weighted image, and appeared heterogeneous and high-intensity on T2-weighted image. After injection of a contrast agent, the tumors demonstrated strong enhancement. A vascular pedicle was detected in 4 patients with tumors having a maximum diameter more than 5 cm. Diffusion-weighted images demonstrated high signal intensities, and apparent diffusion coefficient values were iso to high compared to muscle (from 1.41–2.10×10–3 mm2/s). All the tumors were benign histopathologically and clinically. In 1 patient, the imaging appearance revealed underlying histopathological components, including fibrous-rich, cellular-rich, and myxoid change areas. In conclusion, a SFT in an extremity comprises a well-circumscribed mass adjacent to fascia having a fibrous-dominant area, strong contrast enhancement, and a vascular pedicle.
Progress toward Measles Elimination in Kyrgystan

AKBAR SUVANBEKOV, GULZHAN KITAROVA, JOSHUA A REYER and NOBUYUKI HAMAJIMA
pg(s) 179 - 188

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Measles is one of the most severe infectious diseases of childhood, and one of the major causes of mortali-ty, especially in developing countries. Despite rare measles outbreaks in recent years, Kyrgyzstan seeks to show its commitment towards the global anti-measles campaign. The aim of this article is to summarize the scattered information on the recent status of measles, valid surveillance system, and measles elimination strategies in Kyrgyzstan, based on sources that include non-confidential but usually inaccessible governmental data. Infor-mation was extracted from the reports to the Ministry of Health and documents on the national surveillance system, in addition to outbreak cases extracted from the Republican Infectious Diseases Hospital’s archive. To tackle the worsening measles situation in Kyrgyzstan, the Ministry of Health established the Republican Center for Immunoprophylaxis in 1994. Measles related death, which was rampant up until 1992, has not been registered since 2000 due to improved routine vaccination coverage, increasing from 88% in 1994 to 97% and over in 1997. The national surveillance system was modernized thanks to the World Health Organization, helping to detect measles cases and prevent major outbreaks. The system identified 222 cases in the outbreak of 2011, and the case cards in the hospital provided the findings of 69 admitted cases (42 infants, 22 children aged 1 to 14 years, and 5 aged 15 years or over), including 32 severe cases. This article provides a whole view on measles in Kyrgyzstan, which would be useful to control measles worldwide.
Minimally Invasive Extraction of a Foreign Body from the Small Intestine Using Double-Balloon Endoscopy

MASANAO NAKAMURA, YOSHIKI HIROOKA, OSAMU WATANABE, TAKESHI YAMAMURA, ASUKA NAGURA, TORU YOSHIMURA, ARIHIRO NAKANO, TAKAFUMI ANDO, NAOKI OHMIYA and HIDEMI GOTO
pg(s) 189 - 194

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Double-balloon endoscopy (DBE) can be used to treat disorders of the small intestine and can also be used to retrieve foreign bodies from the small intestine without surgery. We describe the findings of 22 cases in which DBE was used to try and retrieve foreign bodies from the small intestine. The foreign bodies included 12 capsule endoscopes, 3 artificial teeth, 3 medical tubes, 2 worms, 1 press-through packet of medicine, and 1 intestinal stone. The retrieval success rate was 86.3% (19/22), and there were no complications related to the retrieval procedures. Snare forceps were the most useful device for grasping the foreign bodies, and DBE was usually performed via an oral route. If an anal route is selected in cases involving stenosis of the small intestine, endoscopic balloon dilation will be necessary to reach the target. In conclusion, DBE is very useful for extracting foreign bodies from the small intestine, and the careful selection of the DBE route and the removal device are important for successfully retrieving foreign bodies.
Minimal inflammogenicity of pristine single-wall carbon nanotubes

SHINYA TOYOKUNI, LI JIANG, RYO KITAURA and HISANORI SHINOHARA
pg(s) 195 - 202

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Carbon nanotubes (CNTs) are a novel synthetic material comprising only carbon atoms. Based on its rigidity, its electrical and heat conductivity and its applicability to surface manufacturing, this material is expected to have numerous applications in industry. However, due to the material’s dimensional similarity to asbestos fibers, its carcinogenicity was hypothesized during the last decade, and indeed, we have shown that multi-wall CNTs (MWCNTs) of 50 nm in diameter are potently carcinogenic to mesothelial cells after intraperitoneal injection. Additionally, we suggested that inflammogenicity after intraperitoneal injection can predict mesothelial carcinogenesis. However, few data have been published on the intraperitoneal inflammogenicity of single-wall CNTs (SWCNTs). Here, we conducted a series of studies on SWCNTs using both intraperitoneal injection into rats and MeT5A mesothelial cells. Intraperitoneal injection of 10 mg SWCNTs caused no remarkable inflammation in the abdominal cavity, and the exposure of MeT5A cells to up to 25 μg/cm2 SWCNTs did not alter proliferation. MWCNTs of 50 nm in diameter were used as a positive control, and tangled MWCNTs of 15 nm in diameter were used as a negative control. The results suggest that SWCNTs are a low-risk material with respect to mesothelial carcinogenesis.
Health Care Expenditure of Households in Magway, Myanmar

INN KYNN KHAING, AMONOV MALIK, MYO OO and NOBUYUKI HAMAJIMA
pg(s) 203 - 212

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Myanmar has a high proportion of out-of-pocket (OOP) health care expenditures with limited cost-sharing mechanisms. In Myanmar, there were limited data on the frequency of catastrophic health expenditure (CHE) due to OOP payments, as well as on the factors associated with CHE. This study aimed to investigate health care expenditure, the frequency of CHE, and the factors influencing CHE among households in Magway, Myanmar. A cross-sectional household survey was conducted in 2012 for 700 households (350 in urban areas and 350 in rural areas) in Magway. CHE was defined as a condition wherein the total amount of household health care expenditure was 40% or more of non-food expenditure in the past year. Multiple logistic regression analysis was applied to estimate odds ratios (ORs) and 95% confident intervals (CIs) of CHE. In the previous year, 28.3% of 350 urban households and 51.4% of 350 rural households utilized outpatient services. Households with at least one member admitted to a medical facility were 10.0% and 12.9%, respectively. Those with CHE were 25.2% in the urban areas and 22.7% in the rural areas. The adjusted OR of CHE was 7.79 (95% CI 3.73–16.26) for hospitalization and 1.08 (95% CI 0.36–3.23) for outpatient care, relative to no services used. These findings indicated that nearly one fourth of households in Magway faced CHE due to inpatient care. A safety-net mechanism to protect households from CHE in Myanmar seems essential.
Treatment Outcomes of Intradiscal Steroid Injection/Selective Nerve Root Block for 161 Patients with Cervical Radiculopathy

KEIGO ITO, YASUTSUGU YUKAWA, MASAAKI MACHINO, TARO INOUE, JUN OUCHIDA, KEISUKE TOMITA and FUMIHIKO KATO
pg(s) 213 - 219

<Abstract> - < PDF >

Patients with cervical radiculopathy (CR) were treated with intradiscal injection of steroids (IDIS) and/ or selective nerve root block (SNRB) at our hospital. We retrospectively report the outcomes of these nonsurgical treatments for CR. 161 patients who were followed up for >2months were enrolled in this study. Patients’ clinical manifestations were classified as arm pain, arm numbness, neck and/or scapular pain, and arm paralysis. Improvement in each manifestation was classified as “disappeared,” “improved,” “poor,” or “worsened.” Responses of “disappeared” or “improved” manifestations suggested treatment effectiveness. Final clinical outcomes were evaluated using the Odom criteria. Changes in herniated disc size were evaluated by comparing the initial and final MRI scans. On the basis of these changes, the patients were divided into regression, no-change, or progression groups. We investigated the relationship between the Odom criteria and changes observed on MRI. Effectiveness rates were 89% for arm pain, 77% for arm numbness, 82% for neck and/or scapular pain, and 76% for arm paralysis. In total, 91 patients underwent repeated MRI. In 56 patients (62%), the size of the herniated disc decreased, but 31 patients (34%) exhibited no change in disc size. The regression group showed significantly better Odom criteria results than the no-change group. In conclusion, IDIS and SNRB for CR are not widely performed. However, other extremely effective therapies that can rapidly improve neuralgia should be considered before surgery.
Range of Motion Determined by Multidetector-Row Computed Tomography in Patients with Cervical Ossification of the Posterior Longitudinal Ligament

KEIGO ITO, YASUTSUGU YUKAWA, MASAAKI MACHINO, AKINORI KOBAYAKAWA and FUMIHIKO KATO
pg(s) 221 - 228

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The purpose of this study was to measure range of motion (ROM) in patients with cervical ossification of posterior longitudinal ligament (C-OPLL) by multidetector-row computed tomography (MDCT), and to investigate the influence of dynamic factors. The study included 101 patients with C-OPLL and 99 normal control patients. Preoperative MDCT were taken in all subjects in maximum neck flexion and extension. ROM at each disc level between C2/3 and C7/T1 in sagittal view was measured. Ossification morphology at each disc segment was divided into 6 groups: covered disc, covered vertebra, unconnected vertebra, connected vertebra (continuous), connected vertebra (localized), and others. The relationship between ROM and the group of ossification morphology was also investigated. ROM of adjacent intervertebral disc in connected vertebrae (continuous and localized) and those of others were investigated for each group. The average ROM of covered disc group was significantly higher than that of connected vertebra (continuous, localized). The average ROM of connected vertebra (continuous) group was significantly lower than that of covered disc group, others group, and normal control. There was no significant difference between ROM of adjacent intervertebral disc in connected vertebrae and others, but the average ROM of the connected vertebra group was significantly lower than that of the covered disc group and normal control group. Dynamic factor was reduced at continuous segment, but it was not increased in adjacent intervertebral disc.
The Renal Tumor Morphological Characteristics that Affect Surgical Planning for Laparoscopic or Open Partial Nephrectomy

YASUHITO FUNAHASHI, KENTA MUROTANI, YASUSHI YOSHINO, NAOTO SASSA, SHOHEI ISHIDA and MOMOKAZU GOTOH
pg(s) 229 - 235

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The purpose of this study is to investigate the morphological characteristics of renal tumors which affect the surgeons’ decision-making for the selection of open or laparoscopic partial nephrectomy. We included 147 patients who underwent partial nephrectomy for renal masses with elective indications in this study. Laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) were performed in 72 and 75 patients, respectively. Preoperative trans-sectional images were used to assess tumor characteristics such as tumor size, endophyticity, distance from the sinus, distance from the kidney equator, hilar designation, inside designation, and R.E.N.A.L. nephrometry score. Univariate logistic regression analyses demonstrated that tumor size, endophyticity, distance from the sinus, hilar designation, inside designation, and R.E.N.A.L. nephrometry score were associated with decision of laparoscopic partial nephrectomy. Among these factors, multiple regression analyses showed that endophyticity (odds ratio = 0.92, p = 0.007) and distance from the sinus (odds ratio = 1.201, p < 0.001) had statistically significant associations with the type of operation performed. ROC analyses demonstrated cut-off values of 16 mm for endophyticity (sensitivity 69%, specificity 77%) and of 4 mm for distance from the sinus (sensitivity 79%, specificity 65%) for predicting the selection of laparoscopic surgery. In conclusion, this study revealed that endophyticity and distance from the sinus were important for the surgical planning of partial nephrectomy.
Suitability of Surveillance Colonoscopy for Patients with Ulcerative Colitis to Detect Colorectal Cancer: Current Guidelines Miss Some Early-Sage Cases

TORU KAMIYA, TAKAFUMI ANDO, OSAMU WATANABE, MASANAO NAKAMURA, TAKESHI YAMAMURA, RYOJI MIYAHARA, YOSHIKI HIROOKA and HIDEMI GOTO
pg(s) 237 - 244

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Surveillance colonoscopy (SC) is considered important for the early detection and treatment of colorectal cancer (CRC) in patients with ulcerative colitis (UC). Here, we investigated whether current guidelines are appropriate in preventing UC patients from being diagnosed with CRC at an incurable stage. Among 1583 patients under treatment for UC, 27 patients were diagnosed with CRC. Of these, we excluded two patients who had not undergone colonoscopy before CRC diagnosis. We then divided the remaining patients into three groups based on colonoscopy interval (A, 1 year or less; B, between 1 and 2 years; and C, 2 years or longer). Fifteen patients had tubular adenocarcinomas, and 10 had other types (8 poorly differentiated adenocarcinomas, 1 mucinous adenocarcinoma, 1 endocrine cell carcinoma). Five (20%) of 25 patients developed CRC within 8 years after the onset of UC, of which one case was detected at stage IV. Six patients were classified into group A, 8 into group B, and 11 into group C. On distribution by histologic type, tubular adenocarcinomas were detected in stages 0 - II in 100% in group A, 100% in group B, and 57.1% in group C. In contrast, other types of carcinomas were detected in stage 0 - II in 100% in group A, 40% in group B, and 0% in group C. Current guideline recommendations for SC are not sufficient for the detection of early stage CRC in patients with UC. SC should be commenced earlier than recommended in the current guidelines and repeated annually.
High Osmolarity Effect of Intravitreal Plasmin Enzyme on Rabbit Retina

TETSU ASAMI, SHU KACHI, USAMA ALI MOHAMED, YASUKI ITO and HIROKO TERASAKI
pg(s) 245 - 252

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We conducted a study of the effect of intravitreal plasmin on retinal thickness in rabbits. Forty rabbit eyes were injected with 0.4, 1, 2, and 5 IU of plasmin (8 eyes/group). The same volume of BSS-plus® was injected in control eyes. Four eyes in each group underwent vitrectomy 60 minutes after the injections. The retinal thickness was measured in optical coherence tomographic (OCT) images before, 30 minutes, and 1 week after the injection. To study the effect of hyperosmolarity, 4 eyes received an injection of mannitol solution whose osmolarity was the same as the plasmin solutions. Thirty minutes after the plasmin injection, 4 eyes developed a serous retinal detachment (SRD). The mean retinal thickness including SRD was increased at 30 minutes in a dose-dependent way. The increase in eyes with 5 IU of plasmin was significantly greater than that in eyes with BSS-Plus® or 0.4 IU of plasmin (P = 0.0266, P = 0.0371, respectively). One week after the injection, SRD disappeared, and the mean retinal thickness decreased. The eyes injected with mannitol, the same osmolarity of 1, 2, 5 IU of plasmin, developed SRD at 30 minutes, and it disappeared after 1 week in all eyes. The results of this study demonstrated that an intravitreal injection of plasmin increases the retinal thickness in a dose-dependent way in rabbit eyes. The results with mannitol suggest that the increase in retinal thickness following plasmin is most likely caused by the hyperosmolarity of plasmin solution.
Successful Transplantation of Motoneurons into the Peripheral Nerve Depends on the Number of Transplanted Cells

SHUICHI KATO, SHIGERU KURIMOTO, TOMONORI NAKANO, HIDEMASA YONEDA, HISAO ISHII, SATOKA MITA-SUGIURA and HITOSHI HIRATA
pg(s) 253 - 263

<Abstract> - < PDF >

Transplantation of motoneurons (MN) into the peripheral nerve to provide a source of neurons for muscle reinnervation, termed motoneuron integrated striated muscle (MISM), may provide the potential to restore functional muscle activity, when combined with computer-programmed functional electrical stimulation (FES). The number of MNs required to restore innervation to denervated muscles in adult Fischer 344 rats was investigated by comparing two groups, one transplanted with 2 × 105 cells (group A) and the other with 1 × 106 cells (group B). Twelve weeks after transplantation, electrophysiological analysis, muscle function analysis, and tissue analysis were performed. The mean motor nerve conduction velocity was faster (12.4 ± 1.0 m/s vs. 8.5 ± 0.7 m/s, P = 0.011) and the mean amplitude of compound muscle action potential was larger (1.6 ± 0.4 mV vs. 0.7 ± 0.2 mV, P = 0.034) in group B. The dorsiflexed ankle angle was larger in group B (27 ± 5° vs. 75 ± 8°, P = 0.02). The mean myelinated axon number in the peroneal nerve and the proportion of reinnervated motor end plates were also greater in group B (317 ± 33 vs. 104 ± 17, 87.5 ± 3.4% vs. 40.6 ± 7.7%; P < 0.01, respectively). When sufficient MNs are transplanted into the peripheral nerve, MISM forms functional motor units. MISM, in conjunction with FES, provides a new treatment strategy for paralyzed muscles.
Impact of the Intraoperative Use of Fibrinogen Concentrate for Hypofibrinogenemia during Thoracic Aortic Surgery

YOSHIMORI ARAKI, AKIHIKO USUI, HIDEKI OSHIMA, TOMONOBU ABE, KAZURO FUJIMOTO, MASATO MUTSUGA, YOSHIYUKI TOKUDA, SACHIE TERAZAWA, KEI YAGAMI and HIDEKI ITO
pg(s) 265 - 273

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Thoracic aortic surgery often causes massive bleeding due to coagulopathy. Hypofibrinogenemia is one of the major causative factors, but the utility of the intraoperative administration of fibrinogen concentrate has not yet been proven. The aim of this study was to estimate incidence of hypofibrinogenemia and to evaluate efficacy of using fibrinogen concentrate intraoperatively. The perioperative serum fibrinogen levels (SFL) had routinely been measured in consecutive 216 thoracic aortic surgeries performed from 2010 to 2012. Fibrinogen concentrate was principally used for hypofibrinogenemia (< 150 mg/dl of SFL) at cardiopulmonary bypass (CPB) termination. The patients who received fibrinogen concentrate (FIB group) were compared with the patients who did not received (non Fib group). There were 147 patients (68%) in FIB group at a dose of 5.5±3.5 g. The SFL were dramatically decreased with values of 164±71 mg/dl at CPB termination, compared to the preoperative SFL of 352±131 mg/dl. In the FIB group, the intraoperative and postoperative SFLs were 139±53 and 262±75 (mg/dl), respectively. Thus the SFL was recovered quickly by the administration. 110 cases (51%) showed hypofibrinogenemia at the termination of CPB. The predictors of hypofibrinogenemia were preoperative SFL < 250 mg/dl, emergency surgery and thracoabdominal aortic surgery. Hypofibrinogenemia frequently was observed at the termination of CPB during thoracic aortic surgery. Administering intraoperative fibrinogen concentrate appears to be a useful option to treat coagulopathy.
Roles of Oxidative Stress and the Mineralocorticoid Receptor in Cardiac Pathology in a Rat Model of Metabolic Syndrome

KEIJI TAKAHASHI, TAMAYO MURASE, MIWA TAKATSU, NATSUMI MATSUURA, KAI NAGASAWA, TAKUYA HATTORI, SHOGO WATANABE, TOYOAKI MUROHARA and KOHZO NAGATA
pg(s) 275 - 289

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Oxidative stress and the mineralocorticoid receptor (MR) are implicated in the pathogenesis of saltinduced left ventricular (LV) diastolic dysfunction associated with metabolic syndrome (MetS). We recently characterized DahlS.Z-Leprfa/Leprfa (DS/obese) rats, derived from a cross between Dahl salt-sensitive and Zucker rats, as a new animal model of MetS. We investigated the pathophysiological roles of increased oxidative stress and MR activation in cardiac injury with this model. DS/obese rats were treated with the antioxidant tempol (1 mmol/L in drinking water) or the selective MR antagonist eplerenone (15 mg/kg per day, per os) for 5 weeks beginning at 10 weeks of age. The increased systolic blood pressure and LV hypertrophy that develop in untreated DS/obese rats were substantially ameliorated by eplerenone but not by tempol. Eplerenone also attenuated LV fibrosis and diastolic dysfunction more effectively than did tempol in DS/obese rats, whereas cardiac oxidative stress and inflammation were reduced similarly by both drugs. Both the ratio of plasma aldosterone concentration to plasma renin activity and cardiac expression of the MR and serum/glucocorticoid–regulated kinase 1 genes were decreased to a greater extent by eplerenone than by tempol. Our results indicate that both increased oxidative stress and MR activation in the heart may contribute to the development of LV remodeling and diastolic dysfunction in DS/obese rats. The superior cardioprotective action of eplerenone is likely attributable to its greater antihypertensive effect, which is likely related to its greater inhibition of aldosterone-MR activity in the cardiovascular system.

CASE REPORTS

Laparoscopic Partial Gastrectomy of a Huge Gastric Duplication Cyst in an Infant

SHINYA TAKAZAWA, HIROO UCHIDA, HIROSHI KAWASHIMA, YUJIRO TANAKA, KAORI SATO, TAKAHIRO JIMBO and TADASHI IWANAKA
pg(s) 291 - 296

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Gastric duplication cyst is a rare anomaly, and most cases are recognized during childhood. Recently, several pediatric cases with small gastric duplication cysts treated by laparoscopic resection have been reported. Here, we describe an infant in whom we successfully performed laparoscopic partial gastrectomy for the treatment of a huge gastric duplication cyst. To the best of our knowledge, this is the largest gastric duplication cyst treated by laparoscopic surgery among infants. We introduce our procedure and some tips.
Recurrent Ectopic Craniopharyngioma in the Sylvian Fissure Thirty Years after Resection through a Pterional Approach: A Case Report and Review of the Literature

SHANNON W. CLARK, TYLER J. KENNING and JAMES J. EVANS
pg(s) 297 - 306

<Abstract> - < PDF >

Local recurrence of craniopharyngiomas after apparently complete resection occurs frequently. Ectopic recurrence remote from the original site has been reported in 18 adult patients. The interval between the original diagnosis and the time of recurrence varies widely in these reports (1–26 years). We report a case of an ectopic recurrence in the sylvian fissure of an adamantinomatous type craniopharyngioma 34 years after the initial presentation and 30 years after the last surgical resection. In addition to this being the latest reported ectopic recurrence, the location of this new lesion in the sylvian fissure is fairly rare, having been reported in only three other cases. We also reviewed the English literature for reports of ectopic recurrent craniopharyngiomas in order to conduct an analysis of surveillance and treatment strategies.
A Case of Ruptured Intrameatal Aneurysm Successfully Treated with Coil Embolization

SHUNSAKU GOTO, TOMOTAKA OHSHIMA, TAIKI YAMAMOTO, MASAHIRO NISHIHORI, TOSHIHISA NISHIZAWA, SHINJI SHIMATO and KYOZO KATO
pg(s) 307 - 313

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Aneurysms within the internal acoustic canal are rare. We report the case of a 71-year-old female with subarachnoid hemorrhage resulting from a ruptured distal anterior inferior cerebellar artery which was not detected on initial radiological examination. A second rupture was detected by contrast-enhanced computed tomography and successfully treated by endovascular coil embolization. The patient recovered without neurological deficits. To the best of our knowledge, this is the first report of an intrameatal aneurysm treated by endovascular coil embolization. We suggest endovascular coil embolization as an alternative to open surgery, even in cases of deep intrameatal aneurysm.
Grafted Vertebral Fracture after Implant Removal in a Patient with Spine-Shortening Vertebral Osteotomy

HIROAKI NAKASHIMA, YASUTSUGU YUKAWA, KEIGO ITO, MASAAKI MACHINO, SHUNSUKE KANBARA, DAIGO MORITA, SHIRO IMAGAMA, NAOKI ISHIGURO and FUMIHIKO KATO
pg(s) 315 - 320

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We experienced the rare complication of a vertebral fracture that was caused by implant removal after bony fusion had been achieved in a patient who underwent spine-shortening osteotomy (SSO) for tethered cord syndrome (TCS). We propose that the removal of the implant used for SSO should be contraindicated. The patient (a 27-year-old female) presented to our institution with a history of progressive severe lower back pain, gait disturbance, and urinary incontinence. As an infant, she had undergone surgery for spina bifida with lipoma. Magnetic resonance imaging of the spine revealed tethering of the spinal cord to a lipoma. We performed SSO at the level of the L1 vertebra level. After spine shortening and fixation using a posterior approach, the L1 vertebral body was completely removed anteriorly and replaced with a left iliac bone graft. The patient’s symptoms improved after surgery. After bony fusion was achieved after surgery, we decided to remove the spinal implant after we explained the advantages and disadvantages of the procedure to the patient. We performed implant removal surgery safely 2 years later; however, the patient complained of severe lower back pain 10 days after the surgery without any history of trauma. Reconstruction computed tomography showed fracture of the grafted vertebra. We performed a repeat posterior fixation, which relieved the lower back pain; she has experienced no complications in the subsequent 5 years. In summary, we report a case of a rare complication of the fracture of a grafted vertebra after removal of an implant used in SSO for TCS. Spinal stability could not be maintained without the spinal posterior implant after SSO. Postoperative fracture after spinal implant removal is rare but possible, and patients must be informed of this potential risk.
Rhabdoid Glioblastoma: An Aggressive Variety of Astrocytic Tumor

HIROYUKI MOMOTA, JIRO OGINO, AKIRA TAKAHASHI, TADASHI HASEGAWA and TOSHIHIKO WAKABAYASHI
pg(s) 321 - 328

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Rhabdoid glioblastoma (RGBM) is rare, but the most malignant among astrocytic tumors. Accumulating evidence indicates its highly aggressive nature and distinct histopathological features. Here, we report a new case of RGBM and review previously reported cases of astrocytic tumors with rhabdoid components. We describe a 58-year-old man who presented with aphasia and right-sided weakness. Magnetic resonance imaging revealed a well-delineated intramedullary tumor in the left cerebral hemisphere. Partial resection of the tumor was performed. The tumor was histologically found to contain two distinct areas: a typical glioblastoma, and a rhabdoid component. Immunohistochemical analyses revealed expression of glial fibrillary acidic protein (GFAP) and focal loss of the INI1 protein in rhabdoid cells, although fluorescence in situ hybridization analysis showed no loss of the INI1 gene. Despite subsequent radiochemotherapy for the glioblastoma, the patient died 4.3 months after surgery. Our literature review illustrates the aggressive clinical course and histopathological features of these tumors with GFAP and INI1 expression. INI1 protein dysfunction may be a possible cause of the rhabdoid phenotype. Gross total resection of the tumor and intensive radiochemotherapy may lead to better survival outcomes.