Coefficient Alpha and Interculture Test Selection

The internal consistency reliability of a measure can be a focal point in an evaluation of the potential adequacy of an instrument for adaptation to another cultural setting. Cronbach’s alpha (α) coefficient is often used as the statistical index for such a determination. However, alpha presumes a tau-equivalent test and may constitute an inaccurate population estimate for multidimensional tests. These notions are expanded and examined with a Japanese version of a questionnaire on nursing attitudes toward suicidal patients, originally constructed in Sweden using the English language. The English measure was reported to have acceptable internal consistency (α) albeit the dimensionality of the questionnaire was not addressed. The Japanese scale was found to lack tau-equivalence. An alternative to alpha, “composite reliability,” was computed and found to be below acceptable standards in magnitude and precision. Implications for research application of the Japanese instrument are discussed.

Annual variation of natural 15N abundance in tea leaves and its practicality as an organic tea indicator

To obtain basic knowledge about the relationship between the application of organic fertilizers and the δ15N values of leaves of organically grown tea plants, annual variations in the δ15N values of the tea leaves were investigated. Although variations did not immediately arise after the application of organic fertilizers, differences in the δ15N values between organic and conventional cultivations appeared basically after three years from the beginning of the organic cultivation except when an organic fertilizer with a low δ15N value was applied, and the variation depended on the δ15N values of the fertilizers. In addition, the effectiveness of the δ15N values as a practical indicator of organic teas was examined. The tea leaves collected from organic farms did not always have higher δ15N values than the commercially available nonorganic teas. This result demonstrates that it is not easy to discriminate organic teas from nonorganic teas simply by their δ15N values.

Attitudes of Japanese nursing personnel toward patients who have attempted suicide

OBJECTIVE

The aim of this study was to examine the attitudes among Japanese nurses together with their perceived need for training in relation to understanding the nature of suicidal behavior and preventive strategies.

METHODS

The Understanding Suicidal Patients scale together with additional questions reflecting training and the psychiatric treatment of suicide attempters were administered.

RESULTS

A total of 323 nurses attended this study. Overall, the nurses thought patients who attempted suicide were not treated well. The nurses who worked in the psychiatric unit or had the experience in psychiatric nursing had more favorable attitudes toward suicidal patients and viewed themselves as having more relevant skill training in dealing with suicidal patients than those who did not. The nurses who worked at emergency care/intensive care unit were less likely to understand suicidal patients, and were less inclined to be sympathetic and to verbally interact with suicidal patients concerning their problems. The nurses who have confidence in the psychiatric care of suicidal patients, confidence in their own skills, and have a need for more training had the more positive attitudes.

CONCLUSIONS

The results suggest that less favorable attitudes may to some extent be the result of lack of knowledge regarding suicidal patients. Future studies should focus on the evaluation of educational experiences on attitudes and skill acquisition of nurses.

Constituents of the green tea seeds of Camellia sinensis

Green tea (Camellia sinensis) leaves are known to contain active ingredients such as catechins and caffeine, and are widely useful materials. Recently, green tea flowers also have been in the spotlight. However, little attention has been paid to the tea seeds. In this work, the constituents of green tea seeds and green tea leaves were compared. Caffeine was found in the seeds, whereas catechins (usually obtained from green tea leaves) were not observed. Next, we investigated the constituents of hexane extracts and methanol extracts of green tea seeds. We found that the hexane extracts contained high amounts of oleic glyceride (79.9%) in addition to linoleic glyceride (20%). We confirmed the structures of these glycerides by NMR spectroscopy and by synthesis from a fatty acid and glycerol. The methanol extract was found to contain naringenin glucosides by mass spectrometry and NMR spectroscopic analysis.

Constituents of the Green Tea Seeds of Camellia sinensis

Green tea ( Camellia sinensis) leaves are known to contain active ingredients such as catechins and caffeine, and are widely useful materials. Recently, green tea flowers also have been in the spotlight. However, little attention has been paid to the tea seeds. In this work, the constituents of green tea seeds and green tea leaves were compared. Caffeine was found in the seeds, whereas catechins (usually obtained from green tea leaves) were not observed. Next, we investigated the constituents of hexane extracts and methanol extracts of green tea seeds. We found that the hexane extracts contained high amounts of oleic glyceride (79.9%) in addition to linoleic glyceride (20%). We confirmed the structures of these glycerides by NMR spectroscopy and by synthesis from a fatty acid and glycerol. The methanol extract was found to contain naringenin glucosides by mass spectrometry and NMR spectroscopic analysis.

Japanese version of the Delirium Rating Scale, Revised-98 (DRS-R98-J): reliability and validity

BACKGROUND

Delirium is a common neuropsychiatric disorder in medical and surgical inpatients of all ages. It is associated with increased long-term mortality, longer length of hospital stay, poor functional recovery, and increased likelihood of nursing home placement.

OBJECTIVE

The aim of this study was to investigate the reliability and the validity of the Japanese translation of the Delirium Rating Scale, Revised-98 (DRS-R-98).

METHOD

Psychiatric-consultation patients were assessed to compare groups of delirium, dementia, and non-delirium.

RESULTS

Mean Total and Severity scores significantly distinguished delirium from the other groups. The scale had high interrater reliability and high internal consistency. Mean Severity scores during delirium differed from the posttreatment scores. Stratum-specific likelihood ratios showed that the DRS-R98-J is a reliable diagnostic tool.

CONCLUSION

This study indicates that the Japanese version of the DRS-R-98 has high reliability and validity, and is a useful tool for assessing delirium among Japanese medically ill populations.

The INTERMED Japanese version: inter-rater reliability and internal consistency

OBJECTIVE

The intent of this study was to establish the inter-rater reliability and the internal consistency of the Japanese version of the INTERMED.

METHODS

The study included a series of patients referred to psychiatric consultation service or palliative care service. The study participants were independently scored using the INTERMED by the raters.

RESULTS

The INTERMED-Japanese version had high inter-rater reliability (intraclass correlation coefficient=0.98) and high internal consistency (alpha=.89). All four domains (biological, psychological, social, and health care domains) were positively correlated. Based on a cutoff score of 20/21, a κ of 0.79 was found.

CONCLUSIONS

The INTERMED is an easy and useful proactive biopsychosocial screening tool, which could be a reasonable utility under the current Japanese health care situations. Future studies focusing on the INTERMED utility in improving health care delivery for patients with complex biopsychosocial care needs has to be demonstrated in various medical settings in Japan.

[The current state and further development of consultation-liaison psychiatry in general hospitals]

Psychiatric disorders are more commonly seen in general medical inpatient settings than in community settings. These inpatients are at particular risk for general medical and psychiatric treatment resistance, increased complications of disease, high health care service use, and disability. It is time to focus on improving the consultation-liaison psychiatry service system through care coordination strategies. In order to deliver high quality, effective, and efficient integrated care for medically complex patients, the appropriate assessment of health risks, resulting in coordinated care and effective communication, is the first step toward establishing a systematic approach in general hospital settings.

Discovery of a potent, metabolically stabilized resorcylic lactone as an anti-inflammatory lead

With bioactivity-guided phenotype screenings, a potent anti-inflammatory compound f152A1 has been isolated, characterized and identified as the known natural product LL-Z1640-2. Metabolic instability precluded its use for the study on animal disease models. Via total synthesis, a potent, metabolically stabilized analog ER-803064 has been created; addition of the (S)-Me group at C4 onto f152A1 has resulted in a dramatic improvement on its metabolic stability, while preserving the anti-inflammatory activities.

Medical and psychiatric comorbidity in psychiatric beds in general hospitals: a cross-sectional study in Tokyo

AIMS

Although somatic diseases in psychiatric patients are increasing with the increase of the aged population, psychiatric wards in general hospitals in Japan have progressively been decreasing. The purpose of this cross-sectional study was to clarify whether psychiatric beds in general hospitals play sufficient roles in medical comorbidities of psychiatric patients or not.

METHODS

This was a cross-sectional study performed all over Tokyo during the 2-month period from April to May 2007. The total number of patients who require admission due to both somatic and psychiatric diseases was investigated with their demographic and clinical characteristics.

RESULTS

The total number of patients admitted to psychiatric beds in general hospitals for the above-mentioned reason was 326, while the number of patients who could not be admitted to them despite the same reason was 88. The rate of surgical diseases in the latter group was higher than that in the former group. In the latter group, diseases requiring orthopedic surgery (22%) and abdominal surgery (22%) were the most frequent, followed by gastrointestinal and hepatic diseases (8%), and gynecological diseases (7%). Patients who had attempted suicide were included more in the latter group than in the former group. Even in the former group, general hospitals could not respond to 34% of requests for emergency admission.

CONCLUSION

Psychiatric beds in general hospitals do not necessarily function for medical comorbidities in psychiatric patients, especially in severe and emergency cases. Not only the quantity but also the quality of psychiatric wards in general hospitals should be reconsidered.

Misdiagnosed delirium in patient referrals to a university-based hospital psychiatry department

The authors examined the factors associated with referral errors in which the presence of delirium was ostensibly not recognized by medical staff personnel. Medical records of 541 university-hospital patients consecutively referred for psychiatric consultation were scrutinized for extant delirium. The data indicated that a greater likelihood of a missed diagnosis was associated with younger age; referrals outside of family practice service; orientation as to person, place, and time; and a history of bipolar affective disorder or psychosis. The ramifications of failure to diagnose existing delirium include increased morbidity and mortality, longer length of hospital stay, and increased healthcare costs.

Blood eosinophilia after living donor liver transplantation for hepatitis C virus-related cirrhosis

BACKGROUND

Differentiating between acute cellular rejection (ACR) and recurrent hepatitis C virus after liver transplantation in hepatitis C virus-positive patients is difficult, but vital for preventing graft loss.

METHODS

The blood eosinophil counts 3 days before or on the day of biopsy were retrospectively reviewed to evaluate their value for predicting ACR in 91 biopsy samples from 45 patients.

RESULTS

Eosinophil counts on the day of biopsy were significantly higher in the ACR group (n = 20) than in the non-ACR (n = 71) group, although the difference was negligible 3 days before the biopsy. A relative eosinophil count of 2% or an absolute eosinophil count of 200 cells/mm(3) predicted ACR with a specificity of 94% or 96%, respectively.

CONCLUSIONS

Blood eosinophil count on the day of biopsy can be helpful in the diagnosis of ACR in patients who underwent living donor liver transplantation for hepatitis C virus-related cirrhosis.

Delirium: patient characteristics that predict a missed diagnosis at psychiatric consultation

OBJECTIVE

This study evaluates patient characteristics that might predict a missed diagnosis of delirium prior to being seen by a psychiatric consultant.

METHOD

Study participants were assessed using quantitative standardized scales of cognitive function, delirium and physical impairment.

RESULTS

Referring service personnel missed the diagnosis of delirium in 46% of psychiatric consultations. Two factors were associated with their failure to identify delirium accurately: use of a past psychiatric diagnosis to explain delirium symptoms and the presence of pain. Symptoms of delirium and quantitative scale scores did not distinguish between patients with whom diagnosis had been missed and those with accurate diagnoses.

CONCLUSION

The consulting physicians of patients with delirium often incorrectly turn to past psychiatric diagnoses and/or are distracted by the presence of pain and, thus, fail to accurately diagnose delirium.

Submucosal connective tissue-type mast cells contribute to the production of lysophosphatidic acid (LPA) in the gastrointestinal tract through the secretion of autotaxin (ATX)/lysophospholipase D (lysoPLD)

Lysophosphatidic acid (LPA) is involved in a broad spectrum of biological activities, including wound healing and cancer metastasis. Autotaxin (ATX), originally isolated from a melanoma supernatant as a tumor cell motility-stimulating factor, has been shown to be molecularly identical to lysophospholipase D (lysoPLD), which is the main enzyme in the production of LPA. Although ATX/lysoPLD is known to be widely expressed in normal human tissues, the exact distribution of ATX-producing cells has not been fully investigated. In this study, we evaluated ATX/lysoPLD expression by immunohistochemical staining using a rat anti-ATX mAb in the human gastrointestinal tract and found that submucosal mast cells (MC) highly expressed this enzyme. This was confirmed by immunofluorescent double staining using mAbs to tryptase and chymase. Then, we isolated MC from human gastric tissue by an immunomagnetic method using CD117-microbeads and showed that a subpopulation of CD203c-positive MC showed positive staining for intracellular ATX/lysoPLD on flowcytometry. This was confirmed by Western blotting of the isolated cells. Moreover, a significant level of ATX/lysoPLD release could be detected in the culture supernatants of human MC by Western blot analysis. Our data suggest that submucosal MC play significant roles in various aspects of pathophysiology in the gastrointestinal tract by locally providing bioactive LPA through the production of ATX/lysoPLD.

Three-dimensional computed tomography for planning donor hepatectomy

BACKGROUND

An accurate estimation of preoperative volumetric measurements of the donor liver is essential in living donor liver transplantation.

METHODS

Three-dimensional (3-D) computed tomography (CT) was applied to 56 living donors. 3-D images of the liver were constructed using the region-growing method and the volume of each sector was measured.

RESULTS

The median volume ratios of the left liver, caudate lobe, right paramedian, and lateral sectors were 34%, 4%, 38%, and 25% of the total liver volume, respectively. The shape of the congestive area in the right paramedian sector was properly demonstrated by 3-D CT. The volume of the region corresponded to 32% of the right liver. The actual volume of the graft correlated well with the estimated graft volume (n = .86).

CONCLUSIONS

The region-growing method was useful for graft selection and for determining the indication of middle hepatic vein reconstruction in right liver grafts.

Autotaxin (NPP-2) in the brain: cell type-specific expression and regulation during development and after neurotrauma

Autotaxin is a secreted cell motility-stimulating exo-phosphodiesterase with lysophospholipase D activity that generates bioactive lysophosphatidic acid. Lysophosphatidic acid has been implicated in various neural cell functions such as neurite remodeling, demyelination, survival and inhibition of axon growth. Here, we report on the in vivo expression of autotaxin in the brain during development and following neurotrauma. We found that autotaxin is expressed in the proliferating subventricular and choroid plexus epithelium during embryonic development. After birth, autotaxin is mainly found in white matter areas in the central nervous system. In the adult brain, autotaxin is solely expressed in leptomeningeal cells and oligodendrocyte precursor cells. Following neurotrauma, autotaxin is strongly up-regulated in reactive astrocytes adjacent to the lesion. The present study revealed the cellular distribution of autotaxin in the developing and lesioned brain and implies a function of autotaxin in oligodendrocyte precursor cells and brain injuries.

New-onset diabetes mellitus after living donor liver transplantation: possible association with hepatitis C

BACKGROUND

The relationship between hepatitis C virus (HCV) infection and new-onset diabetes mellitus (NODM) after liver transplantation is a controversial issue.

METHODS

A total of 223 adult living donor liver transplantation (LDLT) recipients followed for more than 6 months were analyzed for the prevalence of NODM. The prevalence was compared between 62 HCV-positive and 161 HCV-negative patients. All the HCV-positive patients underwent preemptive antiviral treatment with interferon alpha2b and ribavirin.

RESULTS

Preoperative diabetes mellitus was more frequently observed in HCV-positive patients (18% vs 4%, P = .001). NODM occurred more frequently in HCV-positive patients (41% vs 22%, P = .003). Multivariate analysis, however, revealed that HCV was not a predictor for NODM. A comparison of 14 HCV-positive patients with persistent NODM and 48 patients without persistent NODM indicated that there was no significant difference in the frequency of the viral response to antiviral therapy nor in HCV-RNA levels. Impaired glucose tolerance did not impact postoperative survival after LDLT.

CONCLUSIONS

HCV was not associated with the prevalence of NODM after LDLT. NODM did not influence patient survival.

Clinicopathological features of pyothorax-associated lymphoma; a retrospective survey involving 98 patients

To investigate clinicopathological features of pyothorax-associated lymphoma (PAL), we examined medical records of 98 patients (88 males and 10 females) with PAL at a median age of 70 years (range 51-86). Seventy-nine patients had a history of artificial pneumothorax. Median interval between diagnosis and artificial pneumothorax was 43 years (range 19-64). At diagnosis, performance status (PS) was 0-1 (n=56) and 2-4 (n=42). Clinical stages were I (n=42), II (n=26), III (n=8) and IV (n=22). Pathological diagnosis comprised diffuse large-B-cell (n=78) and peripheral T-cell lymphoma (n=1). Seventeen were treated supportively. The other 81 received aggressive treatments; chemotherapy (n=52), radiotherapy (n=7), surgery (n=4) and combination (n=18). Five-year overall survival (OS) was 0.35 (95% confidence interval, 24% to 45%). Causes of deaths were PAL (n=39), respiratory failure (n=13) and others (n=12). Multivariate analysis identified prognostic factors for OS; lactate dehydrogenase levels [hazard ratio (HR)=2.36; P=0.013], sex (female versus male) (HR=0.15; P=0.01), PS (2-4 versus 0-1) (HR=2.20; P=0.02), clinical stages (III/IV versus I/II) (HR=1.95; P=0.037) and chemotherapy (HR=0.31; P=0.01). Most patients with PAL are elderly and have comorbidities, while some of them achieve durable remission with appropriate treatments. These findings prompt us to establish an optimal treatment strategy on the basis of risk stratification of individual patients.

Autotaxin stabilizes blood vessels and is required for embryonic vasculature by producing lysophosphatidic acid

Autotaxin (ATX) is a cancer-associated motogen that has multiple biological activities in vitro through the production of bioactive small lipids, lysophosphatidic acid (LPA). ATX and LPA are abundantly present in circulating blood. However, their roles in circulation remain to be solved. To uncover the physiological role of ATX we analyzed ATX knock-out mice. In ATX-null embryos, early blood vessels appeared to form properly, but they failed to develop into mature vessels. As a result ATX-null mice are lethal around embryonic day 10.5. The phenotype is much more severe than those of LPA receptor knock-out mice reported so far. In cultured allantois explants, neither ATX nor LPA was angiogenic. However, both of them helped to maintain preformed vessels by preventing disassembly of the vessels that was not antagonized by Ki16425, an LPA receptor antagonist. In serum from heterozygous mice both lysophospholipase D activity and LPA level were about half of those from wild-type mice, showing that ATX is responsible for the bulk of LPA production in serum. The present study revealed a previously unassigned role of ATX in stabilizing vessels through novel LPA signaling pathways.

Preoperative Estimation of Right Lateral Sector Graft by Three-Dimensional Computed Tomography

The right lateral sector is an alternative graft for living donor liver transplantation. Three-dimensional image reconstruction of right lateral sector grafts was performed to reveal vascular anatomy and volume using three-dimensional computed tomography software in three donors. There was a correlation between actual and estimated volume (r=.93), although actual graft volume tended to be larger than the preoperative estimated volume. In one donor, a portal branch of the right lateral sector was independently ramified. The branch was sacrificed in the operation because its territory volume was only 44 cm3. Three-dimensional images matched the shape of the right lateral sector graft. Three-dimensional computed tomography might be useful before donor hepatectomy, providing important information for decisions regarding the operative procedure.

What should non-US behavioral health systems learn from the USA?: US behavior health services trends in the 1980s and 1990s

Several countries, such as the USA, inadvertently created a different behavioral health payment system from the rest of medicine through the introduction of diagnostic-related group exemptions for psychiatric care. This led to isolation in the administration and delivery of care for patients with mental health and substance abuse disorders from other medical services with significant, yet unintended, consequences. To insure an efficient and effective health-care system, it is necessary to recognize the problems introduced by segregating behavioral health from the rest of medical care. In this review, the authors assess trends in behavioral health services during the last two decades in the USA, a period in which independently managed behavioral health care has dominated administrative practices. During this time, behavioral health has been an easy target for aggressive cost cutting measures. There have been no clinically significant improvements in the number of adults receiving minimally adequate treatment or in the percentage of the population with behavior health problems receiving psychiatric care with the possible exception of depression. While decreased spending for behavioral health services has been well documented during this period, these savings are offset by costs shifted to greater medical service use with a net increase in the total cost of health care. Targeting behavioral health for reduction in health-care spending through independent management, starting with diagnostic procedure code or diagnostic-related group exemption may not be the wisest approach in addressing the increasing fiscal burden that medical care is placing on the national economy.

Autotaxin is overexpressed in glioblastoma multiforme and contributes to cell motility of glioblastoma by converting lysophosphatidylcholine to lysophosphatidic acid

Autotaxin (ATX) is a multifunctional phosphodiesterase originally isolated from melanoma cells as a potent cell motility-stimulating factor. ATX is identical to lysophospholipase D, which produces a bioactive phospholipid, lysophosphatidic acid (LPA), from lysophosphatidylcholine (LPC). Although enhanced expression of ATX in various tumor tissues has been repeatedly demonstrated, and thus, ATX is implicated in progression of tumor, the precise role of ATX expressed by tumor cells was unclear. In this study, we found that ATX is highly expressed in glioblastoma multiforme (GBM), the most malignant glioma due to its high infiltration into the normal brain parenchyma, but not in tissues from other brain tumors. In addition, LPA1, an LPA receptor responsible for LPA-driven cell motility, is predominantly expressed in GBM. One of the glioblastomas that showed the highest ATX expression (SNB-78), as well as ATX-stable transfectants, showed LPA1-dependent cell migration in response to LPA in both Boyden chamber and wound healing assays. Interestingly these ATX-expressing cells also showed chemotactic response to LPC. In addition, knockdown of the ATX level using small interfering RNA technique in SNB-78 cells suppressed their migratory response to LPC. These results suggest that the autocrine production of LPA by cancer cell-derived ATX and exogenously supplied LPC contribute to the invasiveness of cancer cells and that LPA1, ATX, and LPC-producing enzymes are potential targets for cancer therapy, including GBM.

Hepatofugal portal flow due to acute cellular rejection

We describe a case of living donor liver transplantation with hepatofugal portal flow caused by acute cellular rejection. The reversed portal flow was corrected by splenectomy and ligation of the residual collateral veins. Hepatofugal flow causes ischemic damage to the graft, which does not normalize spontaneously. In this particular case, meticulous Doppler ultrasound examination and prompt response to reversed portal flow salvaged the graft.

Intestinal thrombotic microangiopathy following reduced-intensity umbilical cord blood transplantation

Thrombotic microangiopathy (TMA) is a significant complication after hematopoietic stem-cell transplantation (HSCT); however, there is little information on it following reduced-intensity cord blood transplantation (RI-CBT). We reviewed the medical records of 123 adult patients who received RI-CBT at Toranomon Hospital between January 2002 and August 2004. TMA was diagnosed in seven patients based on intestinal biopsy (n = 6) or autopsy results (n = 1). While these patients showed some clinical symptoms such as diarrhea and/or abdominal pain, mental status alterations or neurological disorders were not observed in any of them. Laboratory results were mostly normal at the onset of TMA; >2% fragmented erythrocytes (n = 1), <10 mg/dl haptoglobin (n = 1), and >200 IU/dl lactic dehydrogenase (LD) (n = 4). On endoscopic examination, TMA lesions, consisting of ulcers, erosions, and diffuse exfoliation, were distributed spottily from terminal ileum to rectum. Intestinal graft-versus-host disease (GVHD) and cytomegalovirus (CMV) colitis were confirmed in five and four patients, respectively. With therapeutic measures including supportive care (n = 4), fresh frozen plasma (n = 1), and a reduction of immunosuppressive agents (n = 1), TMA improved in four patients. The present study demonstrates that intestinal TMA is a significant complication after RI-CBT. Since conventional diagnostic criteria can overlook TMA, its diagnosis requires careful examination of the gastrointestinal tract using endoscopy with biopsy.

Long-Term Survival and Causes of Late Graft Loss After Adult-to-Adult Living Donor Liver Transplantation

The vast amount of experience with deceased donor liver transplantation allows for the evaluation of the causes underlying late graft loss and the adoption of strategies for its prevention. In contrast, the long-term results or causes of late graft loss after adult-to-adult living donor liver transplantation have not been fully examined. Thus, we analyzed 176 adult recipients who survived at least 1 year after living donor liver transplantation. The median follow-up period was 33 months. Of the 176 recipients, eight died and three others underwent retransplantation. The most common cause of graft loss in our series was cholangitis (n = 4), which might be due partly to technical problems. The 3-year and 5-year patient survival rates of the subjects were 95% and 90%, respectively. Long-term survival after living donor liver transplantation was satisfactory in our series. Further improvement of surgical techniques for biliary reconstruction may reduce late graft loss.

Comparison between reduced intensity and conventional myeloablative allogeneic stem-cell transplantation in patients with hematologic malignancies aged between 50 and 59 years

To evaluate the efficacy of reduced-intensity stem-cell transplantation (RIST), we retrospectively compared outcomes of 207 consecutive Japanese patients aged between 50 and 59 years with hematologic malignancies who received RIST (n=70) and conventional stem-cell transplantation (CST) (n=137). CST recipients received total body irradiation (TBI)-based or busulfan/cyclophosphamide-based regimens. RIST regimens were purine analog-based (n=67), 2 Gy TBI-based (n=2), and others (n=1). Most CST recipients (129/137) received calcineurin inhibitors and methotrexate as graft-versus-host (GVHD) prophylaxis, while 32 RIST recipients received cyclosporin. In all, 23 CST and five RIST recipients died without disease progression within 100 days of transplant. Grade II to IV acute GVHD occurred in 56 CST and 38 RIST recipients. There was no significant difference in overall survival (OS) and progression-free survival between CST and RIST. On multivariate analysis on OS, five variables were significant: preparative regimens (CST vs RIST) (hazard ratio=1.92, 95% confidence interval, 1.25-2.97; P=0.003), performance status (2-4 vs 0-1) (2.50, 1.51-4.16; P<0.001), risk of underlying diseases (1.85, 1.21-2.83; P=0.004), acute GVHD (2.57, 1.72-3.84; P<0.001), and CML (0.38, 0.21-0.69; P=0.002). We should be careful in interpreting results of this small-sized retrospective study; however, reduced regimen-related toxicity might contribute to better survival in RIST. The low relapse rates following RIST suggest a strong antitumor activity through allogeneic immunity.

Induction of autotaxin by the Epstein-Barr virus promotes the growth and survival of Hodgkin lymphoma cells

A proportion of patients with Hodgkin lymphoma carry Epstein-Barr virus (EBV), an oncogenic herpesvirus, in their tumor cells. Although it is generally assumed that EBV contributes to the malignant phenotype of Hodgkin lymphoma cells, direct evidence in support of this is lacking. Here we show that EBV infection of Hodgkin lymphoma cells results in the induction of autotaxin, a secreted tumor-associated factor with lysophospholipase-D activity. Up-regulation of autotaxin increased the generation of lysophosphatidic acid (LPA) and led to the enhanced growth and survival of Hodgkin lymphoma cells, whereas specific down-regulation of autotaxin decreased LPA levels and reduced cell growth and viability. In lymphoma tissues, autotaxin expression was mainly restricted to CD30+ anaplastic large-cell lymphomas and Hodgkin lymphoma; in the latter, high levels of autotaxin were strongly associated with EBV positivity (P = .006). Our results identify the induction of autotaxin and the subsequent generation of LPA as key molecular events that mediate the EBV-induced growth and survival of Hodgkin lymphoma cells and suggest that this pathway may provide opportunities for novel therapeutic intervention. (Blood. 2005;106:2138-2146)

Optimal initial dose of oral cyclosporine in relation to its toxicities for graft-versus-host disease prophylaxis following reduced-intensity stem cell transplantation in Japanese patients

Since the introduction of reduced-intensity stem-cell transplantation (RIST), allogeneic stem-cell transplantation has become available for elderly patients. While pharmacokinetics of cyclosporine might differ according to age or other factors, cyclosporine is uniformly started at an oral dose of 6 mg/kg/day. We retrospectively reviewed medical records of 35 patients aged between 32 and 65 (median 52) years who had undergone RIST. Doses of cyclosporine were adjusted to the target blood trough level of 150-250 ng/ml. Cyclosporine dosages were changed in 33 patients (94%). Dose reduction was required in 32 patients because of high blood levels (n=25), renal dysfunction (n=3), hepatic dysfunction (n=2), and hypertension (n=2). Cyclosporine doses were increased in one because of the suboptimal level. The median of the achieved stable doses was 3.1 mg/kg/day (range, 1.0-7.4). Five patients sustained Grade III toxicities according to NCI-CTC version 2.0: renal dysfunction (n=4), hyperbilirubinemia (n=2), and hypertension (n=2). No patients developed grade IV toxicity. There was no statistically significant difference in the frequency and severity of cyclosporine toxicities between patients aged 50 years and above and those below 50 years. The initial oral cyclosporine dose of 6 mg/kg/day was unnecessarily high irrespective of age. The possible overdose of cyclosporine might have aggravated regimen-related toxicities.

Reduced-intensity stem-cell transplantation for adult acute lymphoblastic leukemia: a retrospective study of 33 patients

Efficacy of reduced-intensity stem-cell transplantation (RIST) for acute lymphoblastic leukemia (ALL) was investigated in 33 patients (median age, 55 years). RIST sources comprised 20 HLA-identical related donors, five HLA-mismatched related, and eight unrelated donors. Six patients had undergone previous transplantation. Disease status at RIST was first remission (n=13), second remission (n=6), and induction failure or relapse (n=14). All patients tolerated preparatory regimens and achieved neutrophil engraftment (median, day 12.5). Acute and chronic graft-versus-host disease (GVHD) developed in 45 and 64%, respectively. Six patients received donor lymphocyte infusion (DLI), for prophylaxis (n=1) or treatment of recurrent ALL (n=5). Nine patients died of transplant-related mortality, with six deaths due to GVHD. The median follow-up of surviving patients was 11.6 months (range, 3.5-37.3 months). The 1-year relapse-free and overall survival rates were 29.8 and 39.6%, respectively. Of the 14 patients transplanted in relapse, five remained relapse free for longer than 6 months. Cumulative rates of progression and progression-free mortality at 3 years were 50.9 and 30.4%, respectively. These findings suggest the presence of a graft-versus-leukemia effect for ALL. RIST for ALL is worth considering for further evaluation.

Conversion to cyclosporine provides valuable rescue therapy for living donor adult liver transplant patients intolerant to tacrolimus: A single-center experience at the University of Tokyo

Tacrolimus-based immunosuppression is currently accepted as mainstream therapy in many transplant centers worldwide due to its potent immunosuppressive activity compared to cyclosporine. A tacrolimus-based regimen has been successfully used for our living donor liver transplantation (LDLT) recipients. Adverse effects such as neurotoxicity, nephrotoxicity, and new-onset diabetes mellitus, however, have limited its clinical application. In deceased donor liver transplantation, cyclosporine rescue therapy is valuable for such complications, but few reports have described a strategy for conversion in LDLT. Herein, we present our experience of conversion from tacrolimus to cyclosporine therapy in adult LDLT recipients. Among 203 recipients, 37 patients (18%) required conversion, primarily for neurotoxicity (41%), diabetes mellitus (16%), hematopoietic disorder (16%), and gastrointestinal intolerance (11%). Primary adverse events resolved within 2 months after conversion in 35/37 (94%) of the patients. For LDLT recipients unable to maintain effective immunosuppression with tacrolimus, conversion to cyclosporine is an effective option.

Value of surveillance blood culture for early diagnosis of occult bacteremia in patients on corticosteroid therapy following allogeneic hematopoietic stem cell transplantation

Bloodstream infection (BSI) is a significant complication following allogeneic hematopoietic stem cell transplantation (allo-SCT). Corticosteroids mask inflammatory responses, delaying the initiation of antibiotics. We reviewed medical records of 69 allo-SCT patients who had been on >0.5 mg/kg prednisolone to investigate the efficacy of weekly surveillance blood cultures. A total of 36 patients (52%) had positive cultures, 25 definitive BSI and 11 probable BSI. Pathogens in definitive BSI were Staphylococcus epidermidis (n=7), S. aureus (n=4), Entrococcus faecalis (n=3), Pseudomonas aeruginosa (n=5), Acenitobacter lwoffii (n=4), and others (n=10). The median interval from the initiation of corticosteroids to the first positive cultures was 24 days (range, 1-70). At the first positive cultures, 15 patients with definitive BSI were afebrile. Four of them remained afebrile throughout the period of positive surveillance cultures. Patients with afebrile BSI tended to be older (P=0.063), and had in-dwelling central venous catheters less frequently than febrile patients (P<0.0001). Bloodstream pathogens were directly responsible for death in two patients with afebrile BSI. This study demonstrates that cortisosteroid frequently masks inflammatory reactions in allo-SCT recipients given conrticosteroids, and that surveillance blood culture is only diagnostic clue for 'occult' BSI.

Reduced-intensity hematopoietic stem-cell transplantation for malignant lymphoma: a retrospective survey of 112 adult patients in Japan

We conducted a nation-wide survey of 112 adult Japanese patients who underwent reduced-intensity stem cell transplantation (RIST) from 1999 to 2002. Underlying diseases included indolent (n=45), aggressive (n=58) and highly aggressive lymphomas (n=9). Median age of the patients was 49 years. A total of 40 patients (36%) had relapsed diseases after autologous stem cell transplantation and 36 patients (32%) had received radiotherapy. RIST regimens were fludarabine-based (n=95), low-dose total body irradiation-based (n=6) and others (n=11). Cumulative incidences of grade II-IV acute graft-versus-host disease (GVHD) and chronic GVHD were, respectively, 49 and 59%. Cumulative incidences of progression and progression-free mortality were 18 and 25%, respectively. With a median follow-up of 23.9 months, 3-year overall survival rates were 59%. A multivariate analysis identified three significant factors for progression, which are history of radiation (relative risk (RR) 3.45, confidential interval (CI) 1.12-10.0, P=0.03), central nervous system involvement (RR 6.25, CI 2.08-20.0, P=0.001) and development of GVHD (RR 0.28, CI 0.090-0.86, P=0.026). RIST may have decreased the rate of transplant-related mortality, and GVHD may have induced a graft-versus-lymphoma effect. However, whether or not these potential benefits can be directly translated into improved patient survival should be evaluated in further studies.

Relation Between the Middle Hepatic Vein Drainage Area Volume and Alanine Aminotransferease After Left Liver Harvesting

Complete outflow is impossible to maintain on both sides in donors undergoing hemiliver graft harvesting, because the middle hepatic vein (MHV) can be preserved on only one side. The area in which outflow veins are disrupted becomes congested and does not sufficiently regenerate. The relation between changes in alanine aminotransferase (ALT) and the congestive area volume of the congestive area is unknown. The 64 subjects presented herein were living donors who provided the left liver with the caudate lobe and MHV trunk. The midpoint between the tributaries of the MHV and the right hepatic vein was determined preoperatively using computed tomography. The midpoint between the tributaries of the MHV and right hepatic vein and the borderline between the right and left liver were used to predict the MHV drainage area volume. ALT was measured in donors on postoperative days 1, 3, 5, 7, 10, and 14. The patients were divided into three groups according to the ratio of calculated MHV drainage area volume in the remnant right liver: less than 15% (n = 21, group A); greater than 15% and less than 20% (n = 18, group B); greater than 20% (n = 25, group C). There were significant differences in the ALT levels between groups (P = .004). MHV drainage area volume, calculated using the present method, was associated with high ALT levels after left liver harvesting with the MHV. The present study suggests that persistently high ALT levels are associated with the volume of the interrupted MHV drainage area.

Two cases of recurrent IgA nephropathy following kidney transplantation

Recurrence of immunoglobulin (Ig) A nephropathy following kidney transplantation has been described as occurring in 40% to 60% of cases. Although this type of recurrence was considered a benign condition for a long time, more recent data showed that recurrent transplant IgA nephropathy may be a significant contributor to graft loss. We present 2 cases of recurrent IgA nephropathy following kidney transplantation. In case 1, renal function remained stable with a creatinine level of 1.2 mg/dL at 5 months after diagnosis and 61 months after transplantation. In case 2, the patient lost his graft and returned to regular hemodialysis at 36 months after diagnosis and 125 months after kidney transplantation.

Living donor liver transplantation for end-stage hepatitis C

Living donor liver transplantation is important for patients with end-stage viral hepatitis because of the shortage of organs from deceased donors. However, preliminary results indicate that living liver donation might be disadvantageous for hepatitis C virus-positive patients. Twenty-seven patients who underwent living donor liver transplantation for hepatitis C virus cirrhosis preemptively received antiviral therapy using interferon-alpha2b and ribavirin, which was started an average of 32 days after the operation and continued for at least 6 months thereafter. The serum hepatitis C virus RNA became negative in the 8 of 16 patients with more than 1 year follow-up. The cumulative 3-year patient survival was 85%, which was comparable to that of hepatitis C virus negative patients (n = 93; 90%). Preemptive antiviral therapy after transplantation may be necessary for satisfactory results after living donor liver transplantation.

Regimen-related toxicity following reduced-intensity stem-cell transplantation (RIST): comparison between Seattle criteria and National Cancer Center Common Toxicity Criteria (NCI-CTC) version 2.0

Acute regimen-related toxicity (RRT) is minimal in reduced-intensity stem-cell transplantation (RIST). However, the Seattle RRT grading (Bearman et al), developed in the context of conventional-intensity transplantation, is frequently applied to RIST. We compared the National Cancer Institute Common Toxicity Criteria (NCI-CTC) version 2.0 with the Seattle criteria after RIST in 86 patients. RRT within 30 days of transplant graded by both sets of criteria were significantly associated with the outcome confirming the predictive value of both the systems. A total of 15 patients died of disease progression, and 12 of transplant-related mortality: RRT (n = 2), graft-versus-host disease (GVHD) (n = 7), infection (n = 1), and others (n = 2). GVHD-related deaths primarily resulted from infections after steroid treatment (n = 6) and bronchiolitis obliterans (n = 1). This study shows that NCI-CTC is appropriate in toxicity evaluation of RIST, and that its application to RIST enables a toxicity comparison between RIST and other types of cancer treatments. Since GVHD is a significant problem in RIST, modifications are required to evaluate immunological complications following RIST.

Cryptococcosis after living donor liver transplantation: report of three cases

Cryptococcosis is the third most common invasive fungal infection in solid organ transplantation, which usually occurs more than 6 months after the primary operation. In our series of 180 consecutive adult living-donor liver transplantation recipients, three (1.5%) had cryptococcosis and one of these patients died. The serum cryptococcal antigen examination was positive in all three patients who suffered from cryptococcosis. The serum cryptococcal antigen test might contribute to the early detection and treatment of cryptococcosis.

General medical and pharmacy claims expenditures in users of behavioral health services

OBJECTIVE

To quantify the magnitude of general medical and/or pharmacy claims expenditures for individuals who use behavioral health services and to assess future claims when behavioral service use persists.

DESIGN

Retrospective cost trends and 24-month cohort analyses.

SETTING

A Midwest health plan.

PARTICIPANTS

Over 250,000 health plan enrollees during 2000 and 2001.

MEASUREMENTS

Claims expenditures for behavioral health services, general medical services, and prescription medications.

MAIN RESULTS

Just over one tenth of enrollees (10.7%) in 2001 had at least 1 behavioral health claim and accounted for 21.4% of total general medical, behavioral health, and pharmacy claims expenditures. Costs for enrollees who used behavioral health services were double that for enrollees who did not use such services. Almost 80% of health care costs were for general medical services and medications, two thirds of which were not psychotropics. Total claims expenditures in enrollees with claims for both substance use and mental disorders in 2000 were 4 times that of those with general medical and/or pharmacy claims only. These expenditures returned to within 15% of nonbehavioral health service user levels in 2001 when clinical need for behavioral health services was no longer required but increased by another 37% between 2000 and 2001 when both chemical dependence and mental health service needs persisted.

CONCLUSIONS

The majority of total claims expenditures in patients who utilize behavioral health services are for medical, not behavioral, health benefits. Continued service use is associated with persistently elevated total general medical and pharmacy care costs. These findings call for studies that better delineate: 1) the interaction of general medical, pharmacy, and behavioral health service use and 2) clinical and/or administrative approaches that reverse the high use of general medical resources in behavioral health patients.

Are the patients with post-transplant psychiatric consultation different from other medical-surgical consultation inpatients?

The present study examines the characteristics of post-transplant patients compared with non-transplant patients seen by consultation psychiatrists. Medical records of 541 consecutive psychiatric consultation patients at a university teaching hospital in 2001 were reviewed. Of the 541 patients who were evaluated, 67 were post-transplant patients. Post-transplant psychiatric consultation is different in some aspects from other psychiatric consultation. Post-transplant patients suffer complicated medical, psychiatric, and social burdens.

Simultaneous hepatic artery and portal vein thrombosis after living donor liver transplantation

Simultaneous hepatic artery and portal vein thrombosis rarely occurs after liver transplantation. The etiology is unknown. Of 213 patients (72 children and 141 adults) that underwent living donor liver transplantation (LDLT) from January 1996 to March 2003, 4 (2%) developed simultaneous thrombosis at 3 hours to 7 days (median, 4 days) after the operation. Emergent thrombectomy was performed in three patients; the remaining patient was registered in the Japan organ transplant network. All of the patients died due to hepatic failure (range, 18 hours to 6 days after the diagnosis; median, 2 days). Portal vein, hepatic artery, and hepatic vein velocity in the liver graft were measured every 12 hours by Doppler ultrasonography for 2 weeks after liver transplantation. These parameters were stable until just before the simultaneous thrombosis. These findings indicate that protocol Doppler ultrasonography can diagnose, but not predict, this fatal complication.

Classification of portal vein anatomy for partial liver transplantation

The anatomy of the portal vein is usually classified as 3 to 5 patterns and simple compared with the anatomy of the hepatic artery. The variety of portal vein anatomy was examined in 287 living donors for liver transplantation. More than 90% of donors showed a normal bifurcation type; 6% showed the trifurcation type. Only 3% displayed a separate origin of the right paramedian and the right lateral branches. There was no anomalous pattern that had not been reported previously. In our series, we conclude that it is rare for 2 or more stumps of portal vein to appear in partial liver transplantation. The frequency is much less if the left liver or the right lateral liver graft is used for adult-to-adult living donor liver transplantation.