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This chapter presents examples of and advocates for the adoption of tunable solid-state (semiconductor) oscillator single-mode microwave flow reactors toward laboratory and larger-scale synthetic chemistry applications. Tunable solid-state oscillator single-mode microwave flow reactors are more versatile heaters that impart both better process control and energy efficiency than conventional magnetron oscillator flow reactors when operated in single-mode or multimode.

Microwave heating in chemical reactions was first reported in 1986. There have since been many reports employing microwave heating in organic chemistry, where microwave heating has afforded higher yields of products in shorter time periods. However, such reactions are challenging to scale in batch due to the limited penetration depth of microwaves as well as the wave propagation dependence on cavity size. Continuous flow has addressed both these issues, enabling scalability of microwave processes. As such, a host of reports employing microwave flow chemistry have emerged, employing various microwave heating and reactor configurations in the context of either custom-built or commercial apparatus. The focus of this review is to present the benefits of microwave heating in the context of continuous flow and to characterize the different types of microwave flow apparatus by their design (oscillator, cavity type and reactor vessel). We advocate the adoption of tunable, solid-state oscillator single-mode microwave flow reactors which are more versatile heaters, impart better process control and energy efficiency toward laboratory and larger-scale synthetic chemistry applications.

Background: Although diagnosis of isolated acute vestibular syndrome (AVS) via physical examination has been reported, a great deal of experience is needed to interpret the results. Patients with AVS often cannot participate in a physical examination, and not every emergency department (ED) is equipped with a magnetic resonance imaging machine. Therefore, in isolated AVS, clinical factors other than those used by general physicians and/or residents are required to identify strokes in these patients. The aim of this study was to determine those clinical factors useful in differentiating stroke patients from isolated AVS patients in the ED setting. Methods: We examined the records of 116 consecutive patients who presented to the ED between May 2010 and April 2013 with AVS (acute vertigo or dizziness, nystagmus, nausea/vomiting, head-motion intolerance, unsteady gait) and without auditory symptoms, head and/or neck pain, or neurological findings. Patients underwent diagnostic neuroimaging. Clinical characteristics and vital signs measured in the ambulance were assessed. Multivariate logistic regression analysis was performed to evaluate the associations of systolic blood pressure (SBP) ≥150 mmHg, diastolic blood pressure (DBP) ≥85 mmHg, heart rate, age ≥60 years, and dyslipidemia with stroke. Results: Stroke was diagnosed in eight of the 116 (6.9%) patients with isolated AVS. DBP ≥85 mmHg (odds ratio 29.0; 95% confidence interval 3.38–249) was the only significant and independent factor associated with stroke among patients with isolated AVS. Conclusion: This study identified DBP ≥85 mmHg to be a simple and useful clinical factor differentiating stroke from non-stroke isolated AVS.

AIM Atrial fibrillation (AF)-related cardioembolic stroke is a serious problem in the aging society. The present study examined the clinical characteristics and outcomes of AF-related cardioembolic stroke in patients aged ≥80 years. METHODS Between September 2011 and April 2014, consecutive patients with ischemic stroke and AF were retrospectively extracted from the multicenter database. Clinical characteristics were compared between patients aged ≥80 years and

We report the case of a 68-year-old man who suddenly developed right hemiparesis. MRI of the brain revealed a new infarction in the left corona radiata, and intravenous rt-PA was administered 100 minutes after the onset of symptoms. After the rt-PA infusion was started, his consciousness declined and the CT revealed bilateral intracerebral hemorrhage. His consciousness did not improve thereafter. He was diagnosed with ANCA-associated vasculitis owing to the high levels of MPO-ANCA and urinary protein and the presence of erythrocytes without any other cause of renal damage. Although ANCA-associated vasculitis rarely involves the central nervous system, intracerebral hemorrhage as well as cerebral infarction may occur. This case provides an important opportunity to explore the implications of intravenous rt-PA therapy for acute cerebral infarction in patients with ANCA-associated vasculitis.

Background We examined the association between pre-admission risk scores and severity on admission and functional outcome in acute ischemic stroke with atrial fibrillation (AF). Methods Between September 2011 and April 2014, we retrospectively extracted consecutive ischemic stroke patients with AF whose pre-admission modified Rankin Scale (mRS) score was 2 or less from our prospective database. Pre-admission CHADS 2 , CHA 2 DS 2 -VASc, and R 2 CHADS 2 scores were calculated in each patient, and their association with the National Institutes of Health Stroke Scale (NIHSS) score on admission or unfavorable outcome (mRS ≥3 at 3 months from the onset) was assessed. Results A total of 344 patients (189 were men; age, 77.7 ± 10.0 years) were included in the analysis. The median pre-admission CHADS 2 , CHA 2 DS 2 -VASc, and R 2 CHADS 2 scores were 2, 4, and 4, respectively. NIHSS score on admission was positively correlated with pre-admission CHADS 2 (ρ = .116, P = .031), CHA 2 DS 2 -VASc (ρ = .166, P = .020), and R 2 CHADS 2 scores (ρ = .106, P = .049). Receiver operating characteristic (ROC) curve analysis revealed that pre-admission CHADS 2 score of 2 or more (sensitivity, 80%; specificity, 45%; area under the ROC curve [AUC], .654), CHA 2 DS 2 -VASc score of 3 or more (sensitivity, 86%; specificity, 44%; AUC, .683), and R 2 CHADS 2 score of 4 or more (sensitivity, 61%; specificity, 62%; AUC, .657) were associated with unfavorable outcome. The pre-admission CHA 2 DS 2 -VASc score was better than the pre-admission CHADS 2 score in estimating unfavorable outcome ( P = .017). In multivariate analysis, cutoffs of these scores, female sex, higher NIHSS score, and internal carotid artery occlusion were associated with unfavorable outcome. Conclusions Pre-admission CHADS 2 , CHA 2 DS 2 -VASc, and R 2 CHADS 2 scores were associated with onset severity and functional outcome in acute ischemic stroke with AF.

Background: We aimed to determine the predictive factors for excellent or extremely poor functional outcome in patients with first-ever atrial fibrillation (AF)-related cardioembolic stroke. Methods: Retrospective observational study from a database. Patients with AF-related cardioembolic stroke with a premorbid modified Rankin Scale (mRS) score of 0 or 1 and without a previous history of stroke were included. Results: Factors associated with excellent functional outcome (mRS scores of 0 or 1; n = 77; 30.4% of patients) included age >78 years (OR 0.31, 95% CI 0.15-0.61), male sex (OR 2.16, 95% CI 1.04-4.60), absence of hypertension (OR 0.46, 95% CI 0.22-0.94) and initial National Institutes of Health Stroke Scale (NIHSS) score of >9 (OR 0.08, 95% CI 0.03-0.16). Factors associated with extremely poor functional outcome (mRS scores of 5 or 6; n = 63; 24.9%) included age >78 years (OR 3.30, 95% CI 1.54-7.39), initial NIHSS score of >9 (OR 12.38, 95% CI 5.40-32.56), congestive heart failure (OR 4.82, 95% CI 2.00-12.19) and ischemic heart disease (OR 4.02, 95% CI 1.18-14.69). Conclusions: Predictive factors exist to delineate excellent and extremely poor functional outcomes after a first-time stroke associated with AF.

症例は40歳，男性で，頭痛，嘔吐を主訴に救急搬送された．性転換術による精巣摘出の既往があり，来院1カ月前から女性化目的に経口避妊薬を内服していた．来院時の神経学的所見では，軽度の意識障害のみで局所徴候はなかった．血液検査では凝固系の亢進があり，頭部CTでは直静脈洞，上矢状静脈洞，左横静脈洞に高吸収域を認めた．MRVでは左横静脈洞の信号消失と右横静脈洞の信号低下があり，脳静脈洞血栓症と診断した．抗凝固療法を開始し，経過中に出血性梗塞を来したものの，再開通を得た．静脈血栓症の原因として経口避妊薬は知られているが，今回はさらにアンドロゲン低下による線維素溶解能の低下が素地にあったものと考えられた．

A 35-year-old woman developed recurrent aseptic meningitis three times over a period of 16 months. Each episode followed swelling of her cervical lymph nodes. During the third episode, microscopic findings of biopsied specimens from a cervical lymph node indicated subacute necrotizing lymphadenitis (SNL). While she responded poorly to NSAIDs, steroids rapidly improved her fever, headache and swollen lymph nodes. Since the first episode, anti-nuclear antibody (ANA) and anti-SS-A antibody was positive and the titer of ANA increased with each episode. SNL is a benign and self-limited disease, and the appearance of autoantibodies is usually transient. It is possible that a persistent immune abnormality is related to recurrences of aseptic meningitis with SNL.

We present a 71-year-old woman with hereditary hemorrhagic telangiectasia (HHT) who at age 69, had undergone total gastrectomy because of repeated upper gastrointestinal bleeding. A day prior to admission she began to demonstrate abnormal behavior. Examination showed she was restless and had higher brain dysfunction. Triphasic waves were seen on EEG, and a high signal in the globus pallidus on T1-weighted MRI. Plasma NH3 level was increased after a meal. Abdominal CT scan showed vascular anomalies including a portohepatic vein shunt. She was diagnosed with portosystemic encephalopathy. After treatment with a low-protein diet, lactitol, and branched chain-amino acids, her clinical condition, plasma NH3 level after a meal, and EEG returned to normal. Because portosystemic shunt is rare in HHT, there have been few reports of portosystemic encephalopathy with this condition. However, with aging, the possibility of portosystemic encephalopathy increases because of age-related increases in portosystemic shunt volume.

Background Pure dysarthria (PD) and dysarthria-facial paresis syndrome (DFP) mainly result from lenticulostriate artery territory infarction. PD and DFP are rare clinical entities, often grouped without distinction. The purpose of this study was to examine clinical and radiographic differences between PD and DFP due to unilateral internal capsule and/or corona radiata infarction. Methods Using a database that included consecutive patients with ischemic stroke admitted to the neurological stroke units of three hospitals within 7 days from onset between September 2011 and April 2014, we retrospectively extracted first-ever stroke patient data, who presented with PD or DFP with a single ischemic lesion localized in the internal capsule and/or corona radiata. Patients with weakness, ataxia, sensory deficit, or cortical symptoms were excluded. Ischemic lesion volume was calculated by the ABC/2 method on diffusion-weighted imaging (DWI). DWI images were normalized and superimposed to the template for PD and DFP. We compared patients' characteristics between PD and DFP. Results A total of 2126 patients, including 65 patients (3.1 %) with PD or DFP, were registered. Of these, 13 PD patients and 18 patients with DFP due to unilateral internal capsule and/or corona radiata infarction were included for analysis. Compared with DFP patients, PD patients had longer onset-to-door time (median 37.5 vs. 10.8 h, p = 0.031), shorter vertical length (C component) of ischemic lesions (median 12.0 vs. 18.8 mm, p = 0.007), and smaller ischemic lesion volume (median 285 vs. 828 mm3, p = 0.023). Ischemic lesions causing PD were located more frequently in the left hemisphere than DFP (92 % vs. 56 %, p = 0.045). The superimposed lesion pattern indicated that DFP had lesions more medial and involving posterior portions of the putamen and the caudate body, as well as more of the genu and posterior limb of the internal capsule, than PD. Ninety days after onset, symptoms disappeared in 21 (72 %) out of 29 patients. Conclusions In cerebral infarction limited to the internal capsule and/or corona radiata, PD is derived from smaller and left-sided lesions with delay in diagnosis compared with DFP. The clinical course of those with PD and DFP might be benign.

A 73-year-old man was admitted for evaluation of sudden onset of dizziness, bilateral shoulder pain, and brachial diplegia. Neurological examination revealed severe bilateral weakness of the triceps brachii, wrist flexor, and wrist extensor muscles. There was no paresis of the lower limbs. His gait was ataxic. Pinprick and temperature sensations were diminished at the bilateral C6-C8 dermatomes. Vibration and position senses were intact. An MRI of the head revealed a right cerebellar infarction and occlusion of the right vertebral artery. An MRI of the cervical spine on T₂ weighted imaging (T₂WI) showed cord compression at the C3/4-C5/6 level secondary to spondylotic degeneration without any intramedullary signal changes of the cord. On the following day, however, high-signal lesions on T₂WI appeared in the C5-C6 spinal cord, suggesting cord infarction. Unilateral vertebral artery occlusion does not usually result in cervical cord infarction because of anastomosis of arteries. Because of the long-term mechanical compression in our case, it was likely that cervical cord ischemia was present before the onset of symptoms. On the basis of chronic cord compression, our case suggests that occlusion of a unilateral vertebral artery could cause cervical cord infarction.

Acute autonomic and sensory neuropathy (AASN) is characterised by severe autonomic dysfunction, sensory deficit, and relatively well or fully preserved motor nerve function.1-4 The disease sometimes has a chronic course.2 4 Detailed information is limited because there have been so few reports of the postmortem examination of AASN.2-4 This case provides histopathological evidence for autonomic and sensory ganglionopathy in AASN. (A) Section from the lumbar dorsal root ganglia: There are only a few normal lumbar dorsal root ganglia neurons. (B) Section from the sympathetic ganglion: normal nerve cell bodies have disappeared and been replaced by clusters of cells (“nodules of Nageotte” (arrows)). Originally×100. A 30 year old Japanese man had abdominal pain and a rise in body temperature to 40°C on 1 January 1990. On 23 January, he felt prickling and paraesthesia in all his limbs. On 14 February he could no longer walk due to severe prickling of the entire body. On 2 March, he became bedridden because of orthostatic hypotension. He experienced mild weakness in the all limbs, dysarthria, and dysphagia. On 13 March, he was transferred to our hospital. Physical examination on admission showed anhidrosis, urinary retention, hyposalivation, and paralytic ileus. There was no history of intoxication by …

We report the case of a 59-year-old woman with primary Sjogren's syndrome who developed hypesthesia, hypalgesia, and neurogenic arthropathy in her lower limbs. Neurological examination and electrophysiological studies indicated involvement of the dorsal root ganglia. The immunohistochemistry of sections of rat dorsal root ganglion (DRG) showed that the IgG in the serum and cerebrospinal fluid (CSF) from the patient bound to the neuronal perikarya of small DRG neurons but not to the cerebellum or peripheral nerves. These results, consistent with particular impairment of pain and touch senses, suggest that dorsal root ganglionitis in primary Sjogren's syndrome is mediated by humoral autoimmunity.

This is the first report describing hypertrophic cranial pachymeningitis which developed in association with mixed connective tissue disease (MCTD).A 56-year-old man with a two-year history of MCTDgradually developed symptoms of headache and blurred vision. Bilateral papilledema and increased opening pressure and mild pleocytosis of the cerebrospinal fluid were noted. Magnetic resonance imaging of the brain revealed a diffuse thickening and a gadoliniumenhancement of the cranial dura mater. While five previous patients, diagnosed as idiopathic or infectious hypertrophic cranial pachymeningitis in our department, had either otitis media or sinusitis and showed multiple cranial nerve involvement, the present patient had neither otitis media nor sinusitis and did not show any cranial nerve involvement other than papilledema.(Internal Medicine 32: 510-512, 1993)

Two cases of proven thallium poisoning were studied with special reference to the neuromuscular changes. These cases showed a consistent pattern of symptomatology of peripheral sensorimotor neuropathy, encephalopathy, and alopecia. Light and electron microscopic studies of the sural nerve biopsies exhibited mainly axonal degeneration without concomitant segmental demyelination. The densities of both large and small myelinated fibers were mildly decreased. Biopsied peroneus brevis muscles showed distinct features of focal muscle fiber necrosis which has not been reported before. Muscle fibers with prominent central nucleation and fiber splitting were frequently seen. These findings are compatible with myopathic changes. In spite of the existence of severe axonal degeneration and muscle atrophy on clinical observation, no neurogenic muscle changes were found.

A chronic experimental allergic encephalomyelitis (EAE) was produced in Hartley guinea pigs with bovine white matter proteolipid protein (PLP), in which the levels of myelin basic protein (MBP) and galactocerebroside (GC) were less than 0.014% and 0.13%, respectively, by our method of purification. Cells of an MBP-specific T-cell line did not proliferate in the presence of 100 micrograms of PLP and antigen-presenting cells. Eleven animals were sensitized with 250 micrograms of PLP in Freund's complete adjuvant. Three guinea pigs developed paraplegia about 45 days after sensitization. Histological examination of the three animals revealed marked demyelinating lesions in the spinal cord, particularly in the dorsal columns and subpial regions of the lateral and anterior columns. Another guinea pig without apparent clinical symptoms had demyelinating plaques in the dorsal columns of the spinal cord and periventricular white matter of the brain. Antibodies to PLP were highly elevated in the animals with demyelinating plaques but antibodies to MBP and GC were not elevated in the serum samples. Skin response to PLP was positive in sensitized animals, but was not related to the clinical state. Since none of four strain 13 guinea pigs developed chronic EAE, it seems to be strain specific. These results suggest that PLP is encephalitogenic and produces demyelination in the central nervous system without contamination by MBP or GC in Hartley guinea pigs.