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Hyperhomocysteinemia, a well-recognized cardiovascular risk factor, is frequent in hemodialysis (HD) patients. A common polymorphism in the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene, C-->T substitution at nucleotide 677, is associated with homocysteine (Hcy) level elevation. We examined whether three factors involved in the methionine cycle could influence plasma Hcy concentrations in HD patients: MTHFR polymorphism; vitamin B12, an essential cofactor; and folate, the substrate. In a cross-sectional study, serum vitamin B12, folate, and plasma Hcy were measured and MTHFR genotyping was performed in 534 HD patients. Effects of MTHFR genotypes, vitamin B12, and folate on plasma Hcy levels were examined in 450 HD patients not administered vitamin B12 or folate. To examine the effect of vitamin B12 on plasma Hcy concentrations, we compared plasma Hcy concentrations in HD patients with and without vitamin B12 supplementation. To examine whether functional vitamin B12 deficiency exists even in HD patients with normal vitamin B12 concentrations, 15 HD patients (serum vitamin B12 concentrations, 250 to 2,100 pg/mL) were treated with vitamin B12 (mecobalamin, 1.5 mg/d) for 8 weeks. Serum concentrations of methylmalonic acid (MMA) and vitamin B12 were measured. Hcy levels were higher and folate levels were lower in patients with the TT and CT genotypes compared with patients with the CC genotype. Analysis of covariance to determine independent predictors of high Hcy levels identified low serum vitamin B12 and folate levels and high albumin (Alb) levels in CC-genotype patients, low folate levels and high Alb levels in CT-genotype patients, and low folate levels in TT-genotype patients. Plasma Hcy levels were lower in CC- and CT-genotype patients with vitamin B12 supplementation than in those without supplementation. Vitamin B12 supplementation for 8 weeks significantly reduced MMA concentrations in HD patients with normal serum vitamin B12 concentrations. These results indicate that MTHFR genotype influences the correlation of Hcy level with vitamin B12 and folate levels in HD patients. Functional vitamin B12 deficiency may exist, even in HD patients with normal vitamin B12 concentrations. The efficacy of vitamin B12 and folate supplementation on plasma Hcy levels may depend on MTHFR genotype.

Subdural hematoma of the posterior fossa is infrequent, but lethal in the newborn. We have already reported the successful surgical treatment of a case of posterior fossa subdural hematoma. The patient is now 27 months old and is still shunt dependent. Her body development is normal and her development quotient is 89. Since then, we experienced two other cases, but they died. The second case was a 6-hour-old male infant who was born with breech presentaion and 2nd degree of asphyxia was seen. Immediately after the birth, oxygen was administered to the patient who was in a syncope state. In 60 minutes, respiratory like movements were observed. One hour and a half later, grunting and twitching of the eyelids occurred. The patient died 26 hours postpartum. The third case was a 42-day-old male infant who was delivered by cesarean section. Two days before admission to the hospital vomiting, apneic spells and convulsions occurred. Subdural hematomas were present in the left frontal region and in the posterior fossa. He died 5 days after the operation. In the past 17 years, 134 autopsies with intracranial hemorrhages were carried out within 14 days after birth at the Dept. of Pathology and 18 cases of the posterior fossa subdural hematoma were discovered. Twenty one cases consist of 3 treated cases and 18 untreated cases, discovered at autopsy. Labour patterns are classified as follows; natural delivery 10, breech 5, forceps or vacuum 4 and cesarean section 2. From the standpoint of maturity, 10 cases are mature and 11 cases are premature infants. One of the clinical findings at admission is increased tension of the anterior fontanelle which is the foremost objective sign in the posterior fossa subdural hematoma of the newborn. Clinical diagnosis prior to autopsies were pulmonary hemorrhage 6, IRDS 4, intracranial hemorrhage 3 and others in the untreated cases. The average period of survival of 19 cases excluding case 1 and case 3 was 4.5 days and the range was 0 to 10 days. Case 3 was thought to be exceptional, because initial symptoms occured 40 days postpartum instead of within 15 days after birth. As for the hemorrhage site, these 21 cases can be divided into 4 groups. Group I : the hematoma is present mainly under the base of the brain and surrounding the brainstem. 10 cases belong to group 1. Group 1 cases are often complicated by serious supratentorial hemorrhages. In some cases, the whole brain was seen floating in the blood. Group II: the hematoma is present between the tentorium cerebelli and the superior surface of the cerebellum. Seven cases belong to this group. Group III: the hematoma is present under the lower surface of the cerebellum. Three cases belong to this group. Group IV: the hematoma is present on all the circumference of the cerebellum. One case belongs to this group. In this report, we want to emphasize that as far as the clinical diagnosis is concerned, ventriculography is important as a rule when the coronal subdural taps are negative and that reflux brachial angiography is needed lest the presence of hematoma in other sites should be overlooked.

The autopsy of a 10-month-old infant girl who died suddenly after a 2-day illness revealed acute pancreatitis and DIC. While the definitive etiology remains unknown, retention of pancreatic juice accompanying proliferation of papillary epithelium within the pancreatic duct adjacent to the ampulla Vater was suggested. Acute interstitial pancreatitis was assumed to have resulted from suppurative inflammation of the pancreatic duct. DIC was probably caused by the release of pancreatic enzymes.

This paper describes an unusual, familial bilateral papillary cystadenoma of the epididymis found in three siblings. The histological characteristics of the tumor were: 1) papillary proliferation of clear cells, consisting of both tall columnar and round ovoid cells, in the efferent duct epithelium; and 2) cystic dilatation of the duct with colloidal material. The present cases were unique in two respects: 1) familial bilateral papillary cystadenomas probably associated with Lindau's disease have not been reported previously: and 2) electron microscopic observations suggested that the tumors originated from the efferent duct.

頸椎後縦靱帯骨化症を伴う頸髄損傷患者18症例のADL運動能力の経時的変化より予後に関する検討を行った.ADLで改善をみたのは食事動作のみで,他の動作ではほとんど改善がみられなかった.食事動作自立群は訓練開始より2ヵ月以内に自立した.独歩可能群では受傷後2ヵ月以内に支持歩行が可能となり,ほとんどの症例が4ヵ月以内に自立した.また6ヵ月を経過して移動が全介助の症例は,改善がみられる可能性は少ないと思われた.移動能力,手指の巧緻性,上肢の随意性などが予後に関与していると思われた.阻害因子として,身体的因子,心理的・精神的因子に加えて老人特有の年齢的な因子が加わって予後を不良にしていると思われた.

A 47-year-old woman was admitted for evaluation of pain in the right upper quadrant of the abdomen. Seventeen years previously, she had undergone cholecystectomy for cholelithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) showed a cystic dilatation of the terminal portion of the common bile duct (CBD) protruding into the duodenal lumen and delaying the drainage of contrast medium. In this patient the CBD and the pancreatic duct had separate openings into the duodenum, so the relaitonship of the CBD to the pancreatic duct appeared to be unimportant in the formation of the cyst. Repeated changes in the radius of the cyst suggested dysfunction of the ampullary component of the sphincter of Oddi, with maintenance of normal function of the common duct component. The pathogenesis of the choledochocele in this patient is discussed in relation to dysfunction of the sphincter of Oddi. In addition, 2 criteria for the diagnosis of choledochocele by ERCP are proposed: [1] cystic dilatation of the terminal portion of the CBD protruding into the duodenal lumen, arrd [2] absence of the narrow segment of the CBD.

During the past 18 years, 134 autopsies of intracranial hemorrhages were performed in the Department of Pathology, and 2 cases of extradural hemorrhages were discovered (2.2%). 5 cases of extradural hemorrhage (2 of our own treated surgically and 3 untreated found at autopsy) are described in detail. 1 of the 2 cases treated surgically responded favorably to surgical treatment. The mechanism of hemorrhage into extradural spaces is investigated and reconsidered following review of the literature. The necessity for right reflux brachial angiography is emphasized for early diagnosis of extradural hemorrhage.