Treatment Patterns for and Characteristics of Headache in Children and Adolescents Aged 6-17 Years in Japan: A Retrospective Cross-Sectional and Longitudinal Analysis of Health Insurance Claims Data

OBJECTIVE

To investigate the prescription patterns for patients aged 6-17 years with headaches in the REZULT database.

METHODS

We cross-sectionally investigated (Study 1) the pattern of prescription and the proportion of triptan overprescription (≥30 tablets/90 d of triptans) among patients diagnosed with headaches in 2020. Next, we longitudinally studied patients (Study 2) for more than two years from the initial headache diagnosis (July 2010 to April 2022). The number of prescribed tablets was counted every 90 days.

RESULTS

In Study 1, headache diagnoses were assigned to 62,568 of 543,628 (11.51%) patients, and 1524 of 62,568 (2.44%) patients received acute medication. Single nonsteroidal anti-inflammatory drugs and triptans were prescribed to 620/624 (99.36%) and 5/624 (0.80%) of patients aged 6-11 years, respectively, and 827/900 (91.89%) and 91/900 (10.11%) of patients aged 12-17 years, respectively. Triptan overprescription was observed in 11/96 (11.46%) patients, and 5/11 (45.45%) of those patients received prophylactic medication. In Study 2, 80,756/845,470 (9.55%) patients aged 6-17 years were diagnosed with headaches that persisted for at least two years. Over two years, 44/80,756 (0.05%) patients were overprescribed triptans, and 3408/80,756 (4.22%) patients were prescribed prophylaxis on at least one occasion.

CONCLUSIONS

Based on real-world data, the appropriate use of prophylactic treatment is still problematic. Overprescription of triptans was observed, although the number of patients was small.

Treatment patterns and characteristics of headache in patients in Japan: A retrospective cross-sectional and longitudinal analysis of health insurance claims data

BACKGROUND

The present study aimed to investigate prescription patterns for patients aged over 17 years with headaches in the REZULT database.

METHODS

We conducted a cross-sectional study (Study 1) of the proportion of over-prescription of acute medications (≥30 tablets/90 days for triptans, combination non-steroidal anti-inflammatory drugs (NSAIDs) and multiple types; ≥45 tablets/90 days for single NSAIDs) among patients with headache diagnosed in 2020. We longitudinally studied (Study 2) patients for >2 years from initial headache diagnosis (July 2010 to April 2022). The number of prescribed tablets was counted every 90 days.

RESULTS

In Study 1, headache was diagnosed in 200,055 of 3,638,125 (5.5%) patients: 13,651/200,055 (6.8%) received acute medication. Single NSAIDs were prescribed to 12,297/13,651 (90.1%) patients and triptans to 1710/13,651 (12.5%). Over-prescription was found in 2262/13,651 (16.6%) patients and 1200/13,651 (8.8%) patients received prophylactic medication. In Study 2, 408,183/6,840,618 (6.0%) patients were first diagnosed with headaches, which persisted for ≥2 years. Over time, the proportion of patients over-prescribed acute medications increased. Over 2 years, 37,617/408,183 (9.2%) patients were over-prescribed acute medications and 29,313/408,183 (7.2%) patients were prescribed prophylaxis at least once.

CONCLUSIONS

According to real-world data, prophylaxis remains poorly prescribed, and both acute and prophylactic treatment rates for headaches have increased over time.

Headache Education by E-Learning Through Social Networking Services (Social Media)

Introduction

Headache is a common public health problem, but its burden could be avoided by raising headache awareness and the appropriate use of acute medication and prophylactic medication. Few reports on raising headache awareness in the general public have been reported, and there are no reports on headache awareness campaigns through social networking services (SNS), or social media, in Japan. We prospectively performed a headache awareness campaign from March 2022 through 2 SNS, targeting nurse and wind instrumental musicians, because they are with high headache prevalence.

Methods

Through the 2 SNS, the article and video were distributed, respectively. The article and video described the 6 important topics for the general public about headaches, which were described in the Clinical Practice Guideline for Headache Disorders 2021. Just after reading or watching them as e-learning, we performed online questionnaire sheets to investigate the awareness of the 6 topics through the 2 SNS. The awareness of the 6 topics before and after the campaign was evaluated.

Results

In the SNS nurse-senka, we obtained 1191 responses. Women comprised 94.4%, and the median (range) age was 45 (20 to 71) years old. Headache sufferers were 63.8%, but only 35.1% had consulted doctors. In the SNS Creatone, we got the response from 134 professional musicians, with 77.3% of women. The largest number of respondents were in their 20s (range 18-60 years old). Headache sufferers were 87.9%. Of them, 36.4% had consulted doctors, 24.2% were medication-overuse headache. The ratios of individuals who were aware of the 6 topics significantly increased from 15.2%-47.0% to 80.4-98.7% after the online questionnaire in both SNS (p < 0.001, all).

Conclusion

E-learning and online survey via SNS can improve headache awareness.

Developing an artificial intelligence-based diagnostic model of headaches from a dataset of clinic patients' records

OBJECTIVE

We developed an artificial intelligence (AI)-based headache diagnosis model using a large questionnaire database from a headache-specializing clinic.

BACKGROUND

Misdiagnosis of headache disorders is a serious issue and AI-based headache diagnosis models are scarce.

METHODS

We developed an AI-based headache diagnosis model and conducted internal validation based on a retrospective investigation of 6058 patients (4240 training dataset for model development and 1818 test dataset for internal validation) diagnosed by a headache specialist. The ground truth was the diagnosis by the headache specialist. The diagnostic performance of the AI model was evaluated.

RESULTS

The dataset included 4829/6058 (79.7%) patients with migraine, 834/6058 (13.8%) with tension-type headache, 78/6058 (1.3%) with trigeminal autonomic cephalalgias, 38/6058 (0.6%) with other primary headache disorders, and 279/6058 (4.6%) with other headaches. The mean (standard deviation) age was 34.7 (14.5) years, and 3986/6058 (65.8%) were female. The model's micro-average accuracy, sensitivity (recall), specificity, precision, and F-values for the test dataset were 93.7%, 84.2%, 84.2%, 96.1%, and 84.2%, respectively. The diagnostic performance for migraine was high, with a sensitivity of 88.8% and c-statistics of 0.89 (95% confidence interval 0.87-0.91).

CONCLUSIONS

Our AI model demonstrated high diagnostic performance for migraine. If secondary headaches can be ruled out, the model can be a powerful tool for diagnosing migraine; however, further data collection and external validation are required to strengthen the performance, ensure the generalizability in other outpatients, and demonstrate its utility in real-world settings.

Developing an Artificial Intelligence-Based Pediatric and Adolescent Migraine Diagnostic Model

Introduction Misdiagnosis of pediatric and adolescent migraine is a significant problem. The first artificial intelligence (AI)-based pediatric migraine diagnosis model was made utilizing a database of questionnaires obtained from a previous epidemiological study, the Itoigawa Benizuwaigani Study. Methods The AI-based headache diagnosis model was created based on the internal validation based on a retrospective investigation of 909 patients (636 training dataset for model development and 273 test dataset for internal validation) aged six to 17 years diagnosed based on the International Classification of Headache Disorders 3rd edition. The diagnostic performance of the AI model was evaluated. Results The dataset included 234/909 (25.7%) pediatric or adolescent patients with migraine. The mean age was 11.3 (standard deviation 3.17) years. The model's accuracy, sensitivity (recall), specificity, precision, and F-values for the test dataset were 94.5%, 88.7%, 96.5%, 90.0%, and 89.4%, respectively. Conclusions The AI model exhibited high diagnostic performance for pediatric and adolescent migraine. It holds great potential as a powerful tool for diagnosing these conditions, especially when secondary headaches are ruled out. Nonetheless, further data collection and external validation are necessary to enhance the model's performance and ensure its applicability in real-world settings.

School-Based Stroke Education Through On-Demand E-learning During Coronavirus Disease 2019 Pandemic: Itoigawa Stroke Awareness Campaign

Introduction Raising stroke awareness is important to shorten the interval from onset to consultation. We performed a school-based stroke education by on-demand e-learning during the coronavirus disease 2019 pandemic. Methods We performed on-demand e-learning and distributed the online- and paper-based manga about stroke for students and parental guardians in August 2021. We carried out this in a manner similar to the prior effective online stroke awareness initiatives in Japan. An online post-educational survey in October 2021 was conducted to evaluate the awareness effects by asking participants about their knowledge. We also investigated the modified Rankin Scale (mRS) at the discharge of stroke patients who were treated in our hospital during the before- and after-campaign periods, respectively. Results We distributed the paper-based manga and asked to work on this campaign to all 2,429 students (1,545 elementary school and 884 junior high school students) who lived in Itoigawa. We acquired 261 (10.7%) online responses from the students and 211 (8.7%) responses from their parental guardians. The number of students who chose all correct answers in the survey significantly increased after the campaign (205/261, 78.5%) compared to that before the campaign (135/261, 51.7%) and those of parental guardians showed similar trends (before campaign 93/211, 44.1%; after campaign 198/211, 93.8%). We investigated 282 stroke patients (90 patients before and 192 patients after-campaign period), and their mRS at discharge after-campaign seemed to be improved. Conclusion Only 10.7% of students and 8.7% of the parental guardians worked on the online survey. However, the number of those who chose correct answers about stroke increased after the campaign. After this campaign, the mRS of stroke patients at discharge improved although it was unclear if this is a direct result of this activity.

Headache education by leaflet distribution during COVID-19 vaccination and school-based on-demand e-learning: Itoigawa Geopark Headache Awareness Campaign

OBJECTIVE

We prospectively performed the Itoigawa Headache Awareness Campaign from August 2021 to June 2022, with two main interventions, and evaluated its effectiveness.

BACKGROUND

Headache is a common public health problem, but its burden could be reduced by raising awareness about headache and the appropriate use of acute and prophylactic medication. However, few studies on raising headache awareness in the general public have been reported.

METHODS

The target group was the general public aged 15-64. We performed two main interventions synergistically supported by other small interventions. Intervention 1 included leaflet distribution and a paper-based questionnaire about headache during COVID-19 vaccination, and intervention 2 included on-demand e-learning and online survey through schools. In these interventions, we emphasize the six important topics for the general public that were described in the Clinical Practice Guideline for Headache Disorders 2021. Each response among the two interventions' cohorts was collected on pre and post occasions. The awareness of the six topics before and after the campaign was evaluated.

RESULTS

We obtained 4016 valid responses from 6382 individuals who underwent vaccination in intervention 1 and 2577 from 594 students and 1983 parents in intervention 2; thus, 6593 of 20,458 (32.2%) of the overall working-age population in Itoigawa city experienced these interventions. The percentage of individuals' aware of the six topics significantly increased after the two main interventions ranging from 6.6% (39/594)-40.0% (1606/4016) to 64.1% (381/594)-92.6% (1836/1983) (p < 0.001, all).

CONCLUSIONS

We conducted this campaign through two main interventions with an improved percentage of individuals who know about headache. The two methods of community-based interventions could raise headache awareness effectively. Furthermore, we can achieve outstanding results by doing something to raise disease awareness during mass vaccination, when almost all residents gather in a certain place, and school-based e-learning without face-to-face instruction due to the COVID-19 pandemic.

School-based online survey on chronic headache, migraine, and medication-overuse headache prevalence among children and adolescents in Japanese one city - Itoigawa Benizuwaigani study

BACKGROUND

We investigated the prevalence of headache, migraine, and medication-overuse headache (MOH) among children and adolescents through a school-based online questionnaire. We also investigated the triggers for migraine among them and the effect of the COVID-19 pandemic on headache frequency.

METHODS

Children and adolescents aged 6-17 y.o. completed an online questionnaire. Migraine, MOH was defined as The International Classification of Headache Disorders Third edition. Factor and clustering analyses were performed for migraine triggers. The effect of the coronavirus disease 2019 (COVID-19) pandemic on headache frequency was also asked.

RESULTS

Of the 2489 respondents, the prevalence of headache, migraine, and MOH were 36.44%, 9.48%, and 0.44%, respectively. Up to 70% of the respondents with headaches complained of the disturbance to daily life, but about 30% consulted doctors. The migraine triggers were grouped into 5 factors by factor analysis. The sensitivities of the migraineurs against the factors were divided into 3 clusters. Cluster 1 had stronger sensitivity for several triggers. Cluster 2 was sensitive to weather, smartphones, and video games. Cluster 3 had less sensitivity for triggers. Cluster 2 less consulted doctors even though the burden of migraine was enormous. During the COVID-19 pandemic, 10.25% of respondents increased headache attacks, while 3.97% decreased.

CONCLUSIONS

This is the first detailed study on headache prevalence in Japanese students from elementary school to high school in one region. The burden of headaches is large among children and adolescents, and the unmet needs of its clinical practice should be corrected.

Questionnaire-based survey on the prevalence of medication-overuse headache in Japanese one city-Itoigawa study

OBJECTIVE

The medication-overuse headache (MOH) prevalence has not been investigated in a general Japanese population. We performed questionnaire-based survey and revealed MOH prevalence and its characteristics. We also performed clustering to obtain insight for MOH subgrouping.

METHODS

In this cross-sectional study, the 15-64-year-old population was investigated in Itoigawa during their COVID-19 vaccination under the national policy. MOH was defined as ≥ 15 days/month plus self-report of use of pain medications ≥ 10 or 15 days/month in the last 3 months. Ward method and k-means +  + were used to perform clustering MOH patients.

RESULTS

Among 5865 valid responses, MOH prevalence was 2.32%. MOH was common among females and the middle-aged. Combination-analgesic is the most overused as 50%. MOH had aggravation by routine physical activity, moderate or severe pain, and migraine-like, compared to non-MOH. The 136 MOH patients could be grouped into 3 clusters. Age and frequency of acute medication use were essential factors for clustering.

CONCLUSIONS

This is the first study of MOH prevalence in Japan. Most MOH characteristics were similar to previous reports worldwide. Public awareness of proper headache treatment knowledge is still needed. Clustering results may be important for subtype grouping from a social perspective apart from existing clinical subtypes.

Paratracheal air cyst and bronchogenic cyst in patients with esophageal cancer who received thoracoscopic esophagectomy: A case series of three patients

INTRODUCTION AND IMPORTANCE

Mediastinal cystic lesions, such as paratracheal air cyst (PTAC) and bronchogenic cyst (BC), are rare anomaly usually found incidentally in thoracic imaging. Special attention is needed in the case of thoracic surgery.

CASE PRESENTATION

All three patients were male, 71, 73, and 76 years old. Preoperative CT showed each had a lobular cystic lesion at the right posterolateral side of trachea in the thoracic outlet 11, 14, and 19 mm in size, respectively, with air density and tracheal communication, leading to a diagnosis of PTACs. An oval cystic lesion, 7 mm in size, was found in one patient at the right lateral side of the upper esophagus with low density and without tracheal communication, leading to a diagnosis of paraesophageal BC. Intraoperative findings of the three PTACs demonstrated a soft bulge from the membranous portion of trachea that was left intact. The BC had an oval elastic structure, mimicking a metastatic lymph node, and was removed with the mediastinal lymph nodes. Histological examination showed ciliated columnar epithelium, confirming a diagnosis of BC.

CLINICAL DISCUSSION

PTACs are associated with increased intraluminal pressure due to chronic lung disease. BCs are congenital anomalies that originate from abnormal budding of the embryonic foregut.

CONCLUSION

PTACs and BCs need to be considered in preoperative image diagnosis in patients with esophageal cancer. PTACs should be left intact to avoid tracheal injury, while removal of isolated BCs is recommended as a diagnostic and therapeutic measure.

A Pilot Study of Prediction of Creatinine Clearance by Ellipsoid Volumetry of Kidney Using Noncontrast Computed Tomography

Introduction

Aging is associated with a decline in kidney volume and function. The purpose of this study is to investigate a direct relationship between kidney volume and function in the elderly population and to challenge whether kidney function could be predictable by using the kidney volume.

Methods

We conducted a chart review of 366 patients who underwent abdominal computed tomography (CT) and renal function measurement prior to gastrointestinal surgery. The kidney volume was calculated by the ellipsoid method using a coronal section of noncontrast CT images.

Results

The patients were 72.2 ± 13.2 years of age, and 39.0% were female. Their average measured creatinine clearance (mCCr) was 72.0 ± 21.5 mL/min. The average kidney volume was 100.3 ± 27.6 cm³ in the right kidney and 109.3 ± 30.9 cm³ in the left. There was a significant positive correlation between the total kidney volume and mCCr. Multivariate regression analysis showed that age, diabetes mellitus, and total kidney volume were dependent variables with which to predict mCCr. The use of total kidney volume predicted mCCr of ≥50 mL/min with moderate accuracy (area under the curve = 0.782; 95% confidence interval = 0.692-0.871).

Conclusions

These results indicate a direct relationship between kidney volume and function in the elderly and might provide a pilot method which estimates the renal function using kidney morphology obtained from pre-existing CT images.

Predictive factors for major complications after pancreaticoduodenectomy in patients aged 80 years or older

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Background: As the population ages, elderly patients are being diagnosed with periampullary tumors, and hence, it has been suggested that surgeons should consider the indications for pancreaticoduodenectomy (PD) in elderly patients. The aim of this study is to reveal risks and benefits of PD, and is to identify prognostic inflammatory biomarkers for major complications after PD in patients aged 80 years or older. Methods: We retrospectively analyzed the cases of 161 consecutive patients who underwent PD between January 2000 and December 2015, and compared the patients aged ≥ 80 years (n = 22) with those aged < 80 years (n = 139). Postoperative results and preoperative conditions such as nutrition status using controlling nutritional status (CONUT) score, hemoglobin level and comorbidity were assessed. Correlations were evaluated between major postoperative complications (Clavien-Dindo grade III or higher) and 6 systemic inflammation–based prognostic score such as Glasgow prognostic score (GPS), modified-GPS, High sensitive-mGPS, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio (PLR), and prognostic nutritional index in elderly patients. Results: There was no operative mortality. In elderly patients, preoperative hemoglobin level was lower and CONUT score was higher than in younger patients. The complication rates and the disease-specific survival did not differ significantly between the two groups. Ten patients (45%) experienced major complications in the elderly group. Among 6 systemic inflammation–based prognostic score, only PLR was revealed as predictor of major complications (p = 0.012) and optimal cutoff value was determined to be 145.3 (sensitivity = 33%, specificity = 100%, AUC = 0.842). Conclusions: PD could be performed safely in patients aged 80 years or older. The preoperative PLR was a simple and useful predictor of major complications after PD in elderly patients.

Age-dependent error in creatinine clearance estimated by Cockcroft-Gault equation for the elderly patients in a Japanese hospital: a cross-sectional study

The aim of this study is to assess the accuracy of creatinine clearance (CCr) calculated by the Cockcroft-Gault (CG) equation for elderly patients in a Japanese hospital. This study was a retrospective chart review of patients aged ≥ 55 years with a CCr measurement by a 24-h urine collection (24-h) prior to general surgery in our hospital between April 2009 and March 2017. In total, 1028 Japanese patients were included (mean age 73.0 ± 8.9 years). The serum creatinine value was 0.82 ± 0.24 mg/dL. The CCr estimated by CG and measured by 24 h was 64.2 ± 20.9 mL/min and 71.5 ± 21.0 mL/min, respectively. The CG CCr was significantly underestimated in patients aged ≥ 65 years, and the discrepancy exhibited an age-dependent character. The error was reached at 21.7 ± 13.2 mL/min in patients aged ≥ 90 years (P < 0.001). The age-dependent errors almost completely disappeared when the modified CG equation was used, in which the term of age in the original CG equation was constantly regarded as 65, if the patient was 65 years or older. Anesthesiologists and intensivists should pay attention to the potential risk of underestimating kidney function when using the CG equation for Japanese elderly patients.

Comparative utility of interferon-γ release assay, QuantiFERON® TB-GIT and T-SPOT®.TB in rheumatoid arthritis

SETTING

National hospital for tuberculosis (TB) and rheumatoid arthritis (RA) in Japan.

OBJECTIVE

To compare two interferon-γ release assays (IGRAs), QuantiFERON^®-TB Gold In-Tube (QFT) and T-SPOT^®.TB (T-SPOT), in RA patients for detecting latent tuberculous infection (LTBI).

DESIGN

QFT and T-SPOT were conducted concurrently in 230 prospectively enrolled RA patients.

RESULTS

There were no active TB patients. The percentage of QFT- and T-SPOT-positive patients was respectively 8.3% and 5.7%. In patients aged ⩾60 years, these proportions were respectively 12.3% and 7.2%. The percentage of QFT positivity and T-SPOT positivity at age <60 years was respectively 2.2% and 3.3%. After multivariate logistic analysis for QFT positivity, age ⩾60 years and TB suspected based on chest X-ray were selected as independent factors, with adjusted odds ratios of respectively 4.73 and 3.25. No factors were selected for T-SPOT positivity.

CONCLUSION

QFT had a higher positivity rate. In the light of the previous estimated rate of LTBI in Japan, both IGRAs underestimate LTBI, and neither IGRA has enough capability to detect LTBI.

Relapse-associated microRNA in gastric cancer patients after S-1 adjuvant chemotherapy

S-1 has been recommended as adjuvant chemotherapy in patients after curative surgery for gastric cancer. However, some patients suffer recurrence even after S-1 adjuvant chemotherapy. The present study was conducted to find a predictive marker of the efficacy of S-1 adjuvant chemotherapy. We examined the microRNA (miRNA) expression of 35 patients who underwent S-1 adjuvant chemotherapy after curative surgery (R0) for pathological stage II or III gastric cancer. miRNAs were extracted from formalin-fixed, paraffin-embedded specimens for analysis and miRNA expression was examined using miRNA oligo chips. Fifteen patients relapsed and 20 did not over 5 years. Five miRNAs (miR-92b, 422a, 4732-5p, 4758-3p and 221) were highly expressed according to the tumor/normal (T/N) ratio in the patients who relapsed but not in those who did not relapse (P-value <0.05) by microarray analysis. If tumors showed high expression of 4 miRNAs (miR-92b, 422a, 4732-5p and 4758-3p) their positive predictive value of relapse was 93.8% and negative predictive value was 92.3%. In this case, their disease-free survival rate and overall survival rate were very poor. Our findings indicate that miR-92b, miR‑422a, miR-4732-5p and miR-4758-3p are closely associated with relapse following S-1 adjuvant chemotherapy in gastric cancer.

Adenocarcinoma in long-segment Barrett's esophagus 44 years after total gastrectomy

Although Barrett's esophagus may occur without gastric acid, Barrett's adenocarcinoma after total gastrectomy is rare. Here, we present Barrett's adenocarcinoma in long-segment Barrett's esophagus after total gastrectomy. The patient was a 74-year-old male who underwent total gastrectomy 44 years ago. An endoscopic examination revealed long-segment Barrett's esophagus starting 17 cm from the incisors and continuing 20 cm to esophagojejunostomy, with irregular mucosa 27-31 cm from the incisors. Pathological diagnosis of a biopsied specimen was adenocarcinoma. We performed subtotal esophagectomy with lymph node dissection in the prone position and reconstructed the esophagus with ileocolic interposition. Postoperative pathological diagnosis from a Barrett's epithelial section was well differentiated adenocarcinoma. This case had the longest interval from total gastrectomy and smallest oral margin of Barrett's epithelium. Our case suggested that careful surveillance is needed for patients exhibiting recurrent bile reflux following total gastrectomy.

[Very elderly case of spontaneous esophageal rupture successfully treated by conservative treatment;report of a case]

A 94-year-old female patient presenting with vomiting and hematemesis, was transferred to our hospital. On a chest computed tomography (CT) image, mediastinal emphysema was seen with a little amount of bilateral pleural effusion, therefore, a diagnosis of spontaneous esophageal rupture was made. It took 6 hours to make a definite diagnosis of this disease, and conservative therapies were done including administration of antibiotics and proton-pump inhibitor. The patient was able to drink water on 4th hospital day, and was discharged on 19th hospital day. At about 2 months after the onset, a gastrointestinal fiberscope showed just only scar at the lower thoracic esophagus.

Rapid production of antigen-specific monoclonal antibodies from a variety of animals

Background

Although a variety of animals have been used to produce polyclonal antibodies against antigens, the production of antigen-specific monoclonal antibodies from animals remains challenging.

Results

We propose a simple and rapid strategy to produce monoclonal antibodies from a variety of animals. By staining lymph node cells with an antibody against immunoglobulin and a fluorescent dye specific for the endoplasmic reticulum, plasma/plasmablast cells were identified without using a series of antibodies against lineage markers. By using a fluorescently labeled antigen as a tag for a complementary cell surface immunoglobulin, antigen-specific plasma/plasmablast cells were sorted from the rest of the cell population by fluorescence-activated cell sorting. Amplification of cognate pairs of immunoglobulin heavy and light chain genes followed by DNA transfection into 293FT cells resulted in the highly efficient production of antigen-specific monoclonal antibodies from a variety of immunized animals.

Conclusions

Our technology eliminates the need for both cell propagation and screening processes, offering a significant advantage over hybridoma and display strategies.

[Left traumatic diaphragmatic hernia in the postoperative state of lung cancer: report of a case]

We report a case of left traumatic diaphragmatic hernia in the postoperative state of the lung cancer. A 68-year-old man underwent video-assisted partial resection of the left lung for lung cancer. One year after the operation, he experienced an accident of falling from a tree. Chest radiograph and chest computed tomography revealed the stomach herniating into the left thoracic cavity. An emergent operation was performed by the abdominal approach. The stomach was returned into the abdominal cavity, and the hiatus in the central tendon of the left diaphragm was primarily sutured. The postoperative course was uneventful.

[Effective chemotherapy with S-1 alone in a patient with lung metastases of breast cancer]

We report a 50-year-old female with pulmonary metastases from breast cancer who responded to S-1. In September 2003, she underwent surgery for breast cancer. Four years 8 months after the operation, lung relapse was detected. After the treatment failure of FEC60 (5-FU 500 mg/m², epirubicin 60 mg/m², cyclophosphamide 500 mg/m²) and taxane antitumor drugs, oral administration of S-1 80 mg/body/day was initiated. At the end of three courses, thoracic CT revealed the disappearance of the lung metastasis. Advanced reactions during the administration period were mild. After 14 courses of S-1 therapy (during 11 months), a complete response was clinically maintained. S-1 showed a good antitumor effect and tolerance, and it might be useful for treating metastatic and recurrent breast cancers.

Continuous irrigation with suction started at early days after pancreatic surgery prevents severe complications

The management of pancreatic leakage is important after pancreatic resection because such leakagge can be associated with additional complications. In this paper, we present a new therapy "irrigation with suction" after pancreatic surgery. The addition of suction permits the start of irrigation early after surgery and prevents severe post-operative complications. Between January 1995 and June 2003, 29 consecutive patients underwent surgical treatment of the pancreas for a variety of indications. Among them, 18 patients were treated with continuous irrigation with suction prophylactically. In these 29 patients, we did not encounter any additional complications such as intraabdominal hemorrhage or abscess formation. A representative case report demonstrates the application of this treatment. The irrigation with suction therapy was started on the first post-operative day after the pylorus-preserving pancreatoduodenectomy with left lobectomy of the liver. CT with irrigation of contrast reagent showed that the reagent did not spread to the uninvolved abdominal area, and the patient did not develop hemorrhage or abscess. It seems that continuous irrigation with suction therapy was effective in preventing additional serious complications after pancreatic resection.

[A successfully resected case of colorectal cancer with multiple liver metastases treated with FOLFIRI after failure of mFOLFOX6]

A sixty-year-old man was admitted with anorexia and abdominal mass. Colonoscopy revealed type 2 tumor at sigmoid colon. Computed tomography (CT) demonstrated multiple liver metastases. The patient was diagnosed as sigmoid colon cancer with multiple liver metastases. The patient was treated with mFOLFOX6 as neoadjuvant chemotherapy because the liver metastases were unresectable. However, after 2 cycles of mFOLFOX6, the level of CEA and CA19-9 much increased. The regimen was replaced by FOLFIRI. The level of CEA and CA19-9 decreased after 2 cycles of FOLFIRI. CEA and CA19-9 further decreased and colonoscopy and CT revealed a partial response after 5 cycles of FOLFIRI. The patient was subjected to curative resection. Sigmoidectomy and liver resection were performed. Histological response was Grade 1b at liver metastasis. The patient was discharged and had an uneventful recovery. Six months after surgery, CEA and CA19-9 decreased to normal level, and the patient is free of recurrence. Neoadjuvant chemotherapy for metastatic colorectal cancer may render some unresectable patients resectable, affording these patients the possibility of prolonged survival. However, the optimal approach is unknown.

A new guide technique for limited partial hepatectomy using a transhepatic tube

In order to maintain the adequate tumor margin in partial hepatectomy, we developed a new guide technique using a fine transhepatic tube. For instance, in a case of anterior segment tumor, a fine needle following a tube was inserted into the liver beside the anterior portal pedicle at hepatic hilus, and was put forward to the confluence of right and middle hepatic veins. After the needle was pulled out, both edges of the tube were tugged to the Rex Cantlie line. A separation was then started from the liver surface down to the transhepatic tube. Subsequently, the tube was pulled to the right side, and another separation was done. Adequate disease-free surgical margins were kept in thirteen out of 15 various types of partial hepatectomies. There were no complications including injury to the vessels and stabbing of the tumor. This technique facilitates cutting of the deep parenchyma.

Partial separating gastrojejunostomy for incurable cancer of the stomach or pancreas

BACKGROUND/AIMS

Advanced stomach or pancreas cancer with antral obstruction has been treated by gastrojejunostomy. The delayed return of gastric emptying, however, frequently occurs. The Devine exclusion procedure has been reported to be the better bypass operation in terms of oral intake, but it needs a drainage tube. In cases where the lesser curvature is invaded, this operation should be avoided. A method of gastroenterostomy, which is safe and shows good outcomes concerning oral intake, is desired.

METHODOLOGY

Among 15 patients with advanced stomach or pancreas cancer, 8 received conventional gastrojejunostomy (CG Group), 3 Devine exclusive gastrectomy with a drainage tube (DE Group) and 4 partial separating gastrojejunostomy (PG Group). The partial separating gastrojejunostomy was performed as follows. The stomach was partially partitioned using GIA from the side of the greater curvature. The posterior side of the proximal stomach was anastomosed with the proximal jejunum using a circular stapler instrument.

RESULTS

All patients in the DE and SG Groups could eat regular or semi-regular meals. The bleeding from tumor in the DE Group was less than that in the SG and CG Groups.

CONCLUSIONS

In cases where the lesser curvature is invaded by tumor or lymph node metastasis, partial separating gastrojejunostomy would be recommended as a substitute for the Devine procedure.

Allelic imbalance of 14q32 in esophageal carcinoma

It has been demonstrated that the accumulation of alterations in several oncogenes and tumor suppressor genes plays a role in the initiation and progression of esophageal carcinoma. However, to our knowledge, very few studies have described the molecular genetic changes of chromosome arm 14q in esophageal carcinoma. In this study, we examined 35 primary esophageal carcinomas for allelic imbalance on 14q32. Analysis of four polymorphic microsatellite markers identified 13 (37%) tumors exhibiting allelic imbalance on 14q32 in at least one locus. In particular, the allelic imbalance of the D14S267 marker that has been reported in various tumors as having a high frequency of deletion was observed in 10 of 26 informative cases (38.5%). The commonly deleted regions were delineated by markers D14S65 and D14S250 on 14q32. In regard to the macroscopic features of tumor, the 14q allelic imbalance rate of protruding type tumors was higher than that of the ulcerative type. These data suggest that potential suppressor loci on 14q32 are related to the development and progression of esophageal carcinoma.

[Clinical analysis of multidrug-resistant tuberculosis]

Forty-three patients with multidrug-resistant tuberculosis at National Chiba-Higashi Hospital were studied retrospectively. TB cases excreting tubercle bacilli which are resistant to both 0.1 microgram/ml of isoniazid and 50 micrograms/ml of rifampicin were defined as multidrug-resistant cases. From 1993 to 1997, we experienced 1627 patients with pulmonary tuberculosis, and among them 43 patients (23-79 years old, 35 males and 8 females) were proved to be multidrug-resistant. Six cases were initially treated cases and other 37 cases had been treated previously. On admission, 40 out of 43 cases (93.0%) were smear positive by sputum examination of mycobacteria and 38 out of 43 cases (88.4%) had cavitary lesions on chest X-ray. Six patients were complicated with diabetes mellitus, two with cancer, one with alcohol dependence, one with chronic hepatitis, and others did not have prominent complications. Three operated patients were cured, the fact shows that the surgical treatment is still a useful measure for cases with the indication. Sixteen patients were cured, eight were still under treatment, and thirteen were died of tuberculosis. One of reasons of poor prognosis of multidrug-resistant tuberculosis is that multidrug-resistant tubercle bacilli are usually resistant to other drugs, too. In case of multidrug-resistant tuberculosis, patients were obliged to be treated in a hospital long-term to prevent the spread of tubercle bacilli. Therefore, it is very important to find out new tuberculosis cases as an early as possible, treat them with proper regimen and prevent dropout by directly observed therapy, thus preventing the emergence of multidrug-resistant tuberculosis. Development of new antituberculous agents is strongly expected.

[Tuberculosis of the elderly (above the age of 75) in national hospitals]

In Japan tuberculosis is becoming rapidly the disease of the elderly. We studied the background, the type and level of hospital cares needed, and the outcome of patients with pulmonary tuberculosis (sputum smear and/or culture positive) above the age of 75 who were admitted to 8 national hospitals during the period from January 1 to December 31, 1997. The study included 150 patients (male: 109, female: 41, mean age: 81.6), of whom 25% needed care in a single-bed room, 84.3% had underlying diseases (cardiovascular diseases: 43.3%, malignant diseases: 20.9%, neuro-psychiatric diseases: 13.4%), and 47.6% needed cares mainly in feeding and excretions. 92 patients (62.6%) improved and 45 patients (30.6%) died, of whom the cause of death was directly related to tuberculosis in 42. The mean hospital stay was 4.7 months. However, in 42 patients whose cause of death was related to tuberculosis, 66% died within 3 months, while in 102 patients who were discharged 71% stayed more than 3 months. The same comparison was done in 508 patients with bacteriologically proven tuberculosis above the age of 75 admitted to National Tokyo Hospital during the period from 1990 to 1999. The result was almost the same, among 133 patients died in the hospital 60% died within 3 months, while in 375 patients who were discharged hospital stay was more than 3 months in 70%. In the near future, the elderly will occupy more than 25% of the beds of the tuberculosis ward in Japan and most of them have underlying diseases other than tuberculosis. Because tuberculosis, once the disease of the young, is becoming rapidly the disease of the elderly, it is imperative for us to make necessary adjustments to meet this inevitable trend.

[Clinical study on the cases in which INH or RFP was discontinued during treatment for pulmonary tuberculosis]

Short course regimens; 2HRZ (E)(S)/4HR (E), 6HRS (E)/3-6HR and 6-9HR have been accepted as a standard chemotherapy (SC) for initial treatment of pulmonary tuberculosis in Japan. We studied the frequency of the treatment completion, the causes of the treatment failure and the outcome of the patients in whom INH or RFP was discontinued within 6 months after starting SC. The subjects included 597 newly diagnosed culture positive pulmonary tuberculosis patients admitted to 16 national hospital in 1996. Results were as follows. 1. In 47 (7.9%) of the 597 patients, either INH (19; 3.2%) or RFP (33; 5.5%) was discontinued. These 47 cases were defined as a SC incompleted group and the other 550 as a SC completed group. 2. The patients in the SC incompleted group were seen more frequently in the ages of 20s (11.9%), 50s (10.9%), 60s (11.7%) or 70s (11.4%). 21 (13.6%) of 154 female patients and 26 (5.9%) of 443 male patients were in the SC incompleted group. 3. The causes of cessation of INH or RFP were drug side effects (33; 5.5%), drug resistance (10; 1.7%) and complications or underlying diseases (8; 1.3%). 4. Fever or eruption (19; 3.2%) and drug induced hepatitis (12; 2.0%) were frequently seen as drug related side effects causing the cessation of INH or RFP. 5. The rate of culture negative conversion of TB bacilli at 6 months after the start of the treatment was 98.9% in the SC completed and 88.9% in the SC incompleted group respectively. In the SC incompleted group, there were three cases continuously positive and two other patients who relapsed and became culture positive again. In these five patients, INH or RFP was discontinued because of drug resistance.

[A case of Behçet's disease presenting with Hughes-Stovin syndrome (multiple pulmonary arterial aneurysms remitting with corticosteroid therapy)]

A 32-year-old male suffering from thrombophlebitis of the right leg was admitted to our hospital because of massive hemoptysis. Chest radiography showed multiple rounded opacities in the right lung field. Pulmonary angiography revealed multiple aneurysms of the right pulmonary arteries and thromboembolism of the left pulmonary artery. Venography demonstrated obstruction of the deep veins of the right leg and the right femoral vein, and deep vein thrombosis was diagnosed. A more precise diagnosis was Hughes-Stovin syndrome, that is, venous thrombosis especially of the vena cava, accompanied by single or multiple pulmonary arterial aneurysms in young patients. Furthermore, the patient had an aphthous ulcer in the oral cavity, an ulcer in the genital region, leading to a diagnosis of the incomplete type of Behçet's disease. Chest radiographs 3 months after the initiation of corticosteroid showed complete resolution of the aneurysms. Repeated pulmonary angiography also showed partial recanalization of the occluded arteries. This report describes this very rare case of Behçet's disease presenting with Hughes-Stovin syndrome.

[Prevention of development of pulmonary tuberculosis in compromised host]

Recently compromised hosts have increased due to aging of population, advance of medical technology and therapy or changes in the dietary life and social life. Concomitantly the proportion of compromised hosts in the patients with pulmonary tuberculosis has also increased. Taking up diabetes mellitus, hemodialysis, collagen disease and lung cancer as the representatives of compromised hosts, we studied the propriety of chemoprophylaxis to prevent the development of tuberculosis and the standard for the subjects in the case of chemoprophylaxis being given. Diabetics top the patients in the high risk group of developing pulmonary tuberculosis. Therefore, giving chemoprophylaxis is considered necessary to prevent the development of tuberculosis from diabetics. Chemoprophylaxis to diabetics should be given only when healing of tuberculosis has been found despite the history of treatment for tuberculosis being absent. In the patients of hemodialysis, the total morbidity of tuberculosis is high, but the morbidity of pulmonary tuberculosis is not too high, so chemoprophylaxis for the patients on hemodialysis is not always necessary. However, chemoprophylaxis according to the same standard for diabetics is necessary for the patients with diabetic nephropathy. In the patients with collagen disease except rheumatoid arthritis under consideration for administration of corticosteroid preparations, chemoprophylaxis is considered desirable where doses of more than 10 mg in terms of prednisolone are administered over a long period of time. In the patients with lung cancer under consideration for administration of corticosteroid preparations, chemoprophylaxis is considered desirable where doses of more than 10 mg in terms of prednisolone are administered over a long period of time.

[A clinical study in the collagen disease patients developed pulmonary tuberculosis during corticosteroid administration]

The study subjects consisted of 14 pulmonary tuberculosis (PTB) patients with collagen disease. They are under corticosteroid treatment and the mean age is 56.4 years. The length of time from the development of collagen disease to the development of PTB averaged 4.1 years. The breakdown of collagen disease are SLE (6 patients), MCTD (3 patients), PN (2 patients), and PSS, PM, Sjogren syndrome (1 case, each). Thirteen cases were bacilli positive by the sputum examination on admission to our hospital. Chest X-ray findings on admission revealed cavitation in 3 cases and non-cavitation in 11 cases, of which 5 cases had miliary tuberculosis. Corticosteroid preparation had been administered to all of the 14 cases for more than one year. The mean dose of corticosteroid preparation administered when PTB developed was 13.9 mg (prednisolone) and it was more than 20 mg in 8 cases. The median duration from the start of the respiratory symptoms to diagnosis was 39.2 days. The delay in the discovery exceeding 1 month were seen in 9 cases. In the cases of collagen disease, when the disease course extends over a long period of time, and even when the dose of corticosteroid preparations are decreased, there is a need to be note on the risk of developing PTB. There are many non-cavitary cases with sputum smear positive. The fact suggested that an appropriate diagnosis is need so that the discovery of PTB should not be delayed.

[A study of patient's and doctor's delay in patients with pulmonary tuberculosis discovered by visiting doctors with symptoms in particular on doctor's delay]

Epidemiological trend of tuberculosis in Japan has reversed recently. The incidence of pulmonary tuberculosis (PTB) patients has increased again in Japan, and many outbreaks of PTB including nosocomial outbreaks in health-care facilities have been reported. The purpose of this study is to investigate patient's delay (interval between onset of the disease and first visit to a doctor) and doctor's delay (interval between first visit to a doctor and diagnosis as TB) in patients with PTB discovered by visiting doctors with symptoms, and especially, to investigate causes of doctor's delay in details. Of 236 PTB patients who were admitted to our hospital for treatment in 1997, 118 patients (85 males, 33 females) who were detected by their symptomatic visits were enrolled in to this study. 97 were initial treatment cases and the others were re-treatment cases. Among 34 initial treatment cases who were first seen at a general hospital and diagnosed as PTB by a close medical checkup after admission to our hospital, the 50 percentile of patient's delay was 17.0 days, and the 80 percentile was 36.4 days. The 50 percentile doctor's delay was 19.6 days, and the 80 percentile was 64.2 days. The average hospital stay was 16.2 days, the 50 percentile hospital stay was 7.8 days, and 80 percentile hospital stay was 23.5 days. On the sputum test for acid fast bacilli (AFB) performed on admission to our hospital, 26(76%) out of 34 cases were positive for tubercle bacilli, with 18 cases were positive for smear and 8 cases positive for culture. Therefore, risk of nosocomial infection was suspected. Doctor's delay had been attributed mainly to insufficient medical checkup. Among 25 initial treatment cases in whom doctor's delay as more than 4 weeks, 11 cases (44%) showed delay in chest X-ray examination and 8 cases (32%) ordered no sputum examination in spite of recognition of abnormal shadows on chest X-ray. On the sputum test for AFB on admission to our hospital, 22 (88%) out of 25 cases were positive for tubercle bacilli. Therefore, it is assumed that the delay in the adequate medical checkup was accountable for the doctor's delay. Shortening of the doctor's delay could be possible if hospitals perform the sputum examination for AFB and chest X-ray examinations properly for patients with respiratory symptoms.

[Management of pulmonary tuberculosis patients complicated with diabetes mellitus before diagnosis as pulmonary tuberculosis and feasibility of chemoprophylaxis]

We studied whether diabetics who are one of the high risk groups of developing pulmonary tuberculosis had undergone chest X-ray examination periodically. The feasibility of chemoprophylaxis in diabetics was also studied by investigating whether fibrotic lesions of tuberculosis can be found on previous chest X-ray films of these patients. Of the pulmonary tuberculosis patients admitted to our hospital for treatment, 78 patients complicated with diabetes mellitus were enrolled in this study. As to the mode of detection, the majority, 63 cases, are discovered, by undergoing medical examination because of respiratory symptoms, followed by 8 patients in whom pulmonary tuberculosis was found by health examination and only 1 patient was found by the periodic observation of diabetes mellitus. Of the 57 patients receiving the original treatment for pulmonary tuberculosis preceded by the discovery of diabetes mellitus, only 15 (26%) had undergone chest X-ray examination periodically. This fact shows that physicians treating diabetes mellitus have only a little concern on tuberculosis, thus the re-training of physicians dealing with diabetics on tuberculosis is considered to be necessary. According to chest X-ray films of 21 patients who had undergone chest X-ray examination and in whom the previous films were available, there were 6 patients without any lesion of pulmonary tuberculosis, 8 patients with fibrotic lesions and 7 patients with active lesions. The 8 patients showing fibrotic lesions have developed pulmonary tuberculosis on the average 15 years after they were diagnosed with diabetes mellitus, and the fact suggests that the prevention of the development of pulmonary tuberculosis among diabetics could be possible by chemoprophylaxis.

[The complication with tuberculosis of the central nervous system in patients with miliary tuberculosis]

The complication with tuberculosis of the central nervous system (CNS) were studied in 16 patients with miliary tuberculosis who were admitted to our hospital during a period of two years from April, 1997 to March, 1999, and were examined by head MRI. Twelve cases (75%) were diagnosed as having tuberculosis of CNS. Six cases had tuberculosis of CNS which was found during the screening of miliary tuberculosis cases, and all had only cerebral tuberculoma. Meningeal irritative symptoms led to the discovery of tuberculosis of CNS in the remaining six cases, in which cerebral tuberculoma was complicated with tuberculous meningitis. Of these cases of meningitis, three cases showing disturbance of consciousness died, but no cases of death was found in cases by the screening. The length of time from the onset of symptoms to the diagnosis of tuberculosis was long in many of the cases complicated with tuberculosis of CNS compared with the cases without such a complication. In the cases of miliary tuberculosis, the rate of complication with tuberculosis of CNS is high, and the possibility of patients developing serious symptoms suddenly even when they were asymptomatic at the time of diagnosis and the paradoxical expansion that becomes intensified after initiation of treatment have been reported. Therefore, it is necessary to make a close checkup of CNS when the diagnosis of miliary tuberculosis has been made.

[Frequency of complication of diabetes mellitus in pulmonary tuberculosis]

The frequency of complication of diabetes mellitus in patients with pulmonary tuberculosis is high, and the presence of diabetes mellitus plays an important role in the development of pulmonary tuberculosis. We studied the frequency of complication of diabetes mellitus by year, sex and age among patients with pulmonary tuberculosis who were discharged from our hospital during a period of 12 years from 1987 to 1998. The number of diabetic cases in patients with pulmonary tuberculosis was 588, namely 14.1% out of 4169 patients during the 12 years from 1987 to 1998. The frequency of complication of diabetes in every four years period showed an increasing trend; 144 cases (11.8%) out of 1225 cases from 1987 to 1990, 208 cases (14.5%) out of 1434 cases from 1991 to 1994, and 236 cases (15.6%) out of 1510 cases from 1995 to 1998. By sex, the frequency of complication with diabetes mellitus in male was about twice that of female, with 501 cases (16.0%) out of 3127 cases in male and 87 cases (8.3%) out of 1042 cases in female. By age, the frequency of complication of diabetes mellitus showed a peak in the 40s and 50s in male, being 21.3% and 23.4% respectively. In female, it showed a peak in the 60s, being 18.5%. In conclusion, in the 12 years the frequency of complication of diabetes mellitus in tuberculosis cases has been increasing, and the presence of diabetes mellitus has been playing more important role in the development of pulmonary tuberculosis.

[An outbreak of Mycobacterium tuberculosis infection among young adults in close contact]

We experienced an outbreak of tuberculosis among young adults in close contact. The index case (case 1) was 22-year-old builder and was symptomatic for 9 months before diagnosis as pulmonary tuberculosis (PTB). His sputum smear was positive for tubercle bacilli. On immediate family contacts examination carried out at our hospital, his brother and sister (case 3, case 4) were detected as having PTB. His mother (case 5) and father (case 6) were later detected as having PTB by their symptomatic visits after some months, as tuberculin test as not done at first examination. Case 7 was 19-year-old-man, and was undiagnosed for 5 months. His sputum smear was positive. Immediately, contacts examination for case 7 as carried out at our hospital, and his colleague (case 8) was detected as having PTB. By interview with the case 7, it was found that the case 1 and the case 7 were close friends and spent long time together. Case 10 was 30-year-old builder, and he was accidentally referred to our hospital and was diagnosed as PTB. By the interview with the case 10, it was found that the case 1 and case 10 were members of builders group. This fact was informed to the F health center, and contacts examination for other members of the group were carried out by the F health center, and two young men were detected as having PTB. Analysis of restriction fragment length polymorphism (RFLP) showed that the case 1, the case 5, the case 7, and the case 10 were caused by the same strain of M. tuberculosis. Based on these findings, it is highly suspected that this outbreak was origined from the case 1, and 13 developed tuberculosis and 13 were primarily infected among contacts. The characteristics of this outbreak was that the family and contacts examination were enforced and most of the cases were detected at our hospital. If the outbreak of tuberculosis highly suspected, physicians should actively cooperate with health centers for contacts examination.

[A case of pulmonary tuberculosis with acute renal failure caused by readministration of rifampicin]

We report a case of pulmonary tuberculosis with acute renal failure caused by readministration of Rifampicin (RFP). A 73 year-old man was admitted to a certain hospital complaining with dyspnea on exertion. As his sputum smear was positive for acid-fast bacilli, he was transferred to our hospital for the isolation and treatment. He was diagnosed as lung tuberculosis and was administrated RFP, Isoniazid (INH) and Ethambutol (EB). On the 20th day after the initiation of treatment, the administration of drugs were suspended, because of liver dysfunction. After recovery of liver dysfunction, we have readministered antituberculous drugs, starting with EB, then INH, and finally RFP. On the 22nd day after the readministration of RFP, acute renal failure was observed. All medications were suspended and we started treatment with hydration and furosemide. His renal function recovered after 7 weeks. Histopathological examination of the kidney revealed interstitial infiltration and tubular nephritis. According to the histopathological examination and the clinical course, we concluded acute renal failure was induced by the readministration of RFP. This case suggests that we have to pay attention to renal side effect of RFP in the course of readministration.

[Investigation of pulmonary hemodynamics and chest X-ray findings in hypercapnic patients with pulmonary tuberculosis sequelae]

We investigated pulmonary hemodynamics and chest X-ray findings to explore pathophysiological significance of chronic hypercapnia in patients with pulmonary tuberculosis sequelae. One hundred and seven patients underwent examinations of blood gases and right cardiac catheterization. The patients were divided into two groups, according to arterial carbon dioxide tension under room air breathing (PaCO2). Group I (n = 35) was defined as 45 Torr or lower of PaCO2, and Group II (n = 72) was the hypercapnic group whose PaCO2 was over 45 Torr. In addition, spirometry was done in 34 patients of Group I and 68 of Group II. First, the values of blood gases, spirometry and pulmonary hemodynamics were compared between the two groups. Secondly, between 22 of Group I and 50 of Group II, the values of pulmonary arteriolar resistance (PAR) before and after 100% oxygen breathing for 10 minutes were compared. These comparisons were made by exploratory data analysis. Lastly, we described in all cases with five items of chest X-ray findings and the extent of each finding we had defined. The items were emphysematous change; fibrosis, bronchiectasis, and/or cavity (hereafter abbreviated as "fibrosis"); lung resection and/or atelectasis; pleural thickening; and thoracoplasty. We explored the items of X-ray findings which may relate to hypercapnia by ridit (abbreviation for "relative to an identified distribution") analysis. The results were as follows. (1) Hypercapnic patients tended to have severer restrictive ventilatory impairment and hypoxemia. Under an even level of arterial oxygen tension (PaO2), tissue oxygenation was not poorer in Group II than in Group I. (2) Hypercapnic patients tended to have more unfavorable pulmonary hemodynamics. More than half of them had pulmonary hypertension defined as 20 mmHg or higher of pulmonary artery mean pressure (PAm). Under an even level of PaO2, PAm was higher in Group II. Although 34 patients of Group II showed PaO2 over 60 Torr, 23 of them had pulmonary hypertension. (3) PAR after oxygen breathing was more likely to decrease in Group II than in Group I. (4) As any mean ridit was standardized and adjusted to 0.5 in Group I, the maximum was the mean ridit of "pleural thickening" (= 0.67), next "fibrosis" (= 0.65) in Group II. The above two items of X-ray findings, in which each mean ridit was higher than in any other item, were more influential on hypercapnia. We conclude as follows. (1) Pulmonary hypertension is severer in hypercapnic patients with pulmonary tuberculosis sequelae; it may be mainly attributable to hypoxic pulmonary vasoconstriction. (2) An important cause of chronic hypercapnia may be pathological changes such as "pleural thickening" and "fibrosis" seen on the radiogram.

[Outbreak of multidrug-resistant Mycobacterium tuberculosis infection in the middle and advanced age]

We experienced a small outbreak of multidrug-resistant Mycobacterium tuberculosis infection (MDR-TB) among persons of in the middle and advanced age. The index case was 48-year-old man, and had complained productive cough since January 1996. He visited a doctor due to his symptom, and chest X-ray revealed cavitary lesion and sputum smear was positive for tubercle bacilli. He could not continue his admission because of his absence without leave and drinking, he was discharged on Day 54. The drug resistance was observed for INH (0.1 microgram/ml), RFP, and SM. Later, case 2, 52-year-old male, and case 3, 43-year-old-male, who were companions in mah-jongg with the index case, were diagnosed as pulmonary tuberculosis. The analysis of restriction fragment length polymorphism (RFLP) was done on 3 strains, and all showed the same pattern. Among other companions in mah-jongg with the index case, case 4, 28-year-old male, was treated as MDR-TB, and the drug resistance pattern was the same to that of the index case, but the details were unknown. Case 5, 65-year-old male, was diagnosed as drug sensitive pulmonary tuberculosis, thus he might incidentally suffer from pulmonary tuberculosis at the same time. Case 6, 46-year-old male, who had been treated for alcoholic liver cirrhosis, was introduced to our hospital as his sputum smear was positive, and the drug resistance pattern was observed similar to that of the index case. All the companions in mah-jongg suffered from MDR-TB except case 5. The RFLP analysis showed that the index case, case 2, and case 3 were caused by the same strain of M. tuberculosis. The drug resistance pattern of, case 4 and case 6 was the same to that of the index case. Based on these findings, it is highly suspected that this small outbreak was originated from the index case.

Loss of heterozygosity of 14q32 in colorectal carcinoma

Previous allelotyping studies on colorectal carcinoma suggest that loss of heterozygosity (LOH) on chromosome 14q may be a common genetic alteration in this tumor type. The purpose of this study was to determine precise frequency of LOH at 14q32 region in colorectal carcinomas and to define a minimal region of LOH. LOH at 14q32 in 66 primary colorectal carcinomas were analyzed by polymerase chain reaction-based deletion mapping using six highly polymorphic microsatellites. The average rate of informative data was 68.2% in all cases of colorectal carcinoma analyzed. The average rate of LOH at 14q32 was 44.1%, with the highest frequency of 50.0% at D14S267 locus in the informative cases. The minimal region of LOH was defined by markers D14S65 and D14S250 at 14q32. The present data provide useful information for the isolation of tumor suppressor genes from this region.

[Tuberculosis microepidemic in a commuter bus]

A tuberculosis microepidemic in a commuter bus was reported. Index patient was a 22-year-old woman who was an employee of an electronic company. An abnormal shadow was found on her chest roentgenogram during an annual medical check-up in June, 1996. As her sputum smear was Gaffky 6, she was admitted to our hospital for medication. Extraordinary examinations including PPD skin test and chest X-ray were carried out on 49 employees of the company in October, 1996. As the result of these examinations, the distribution of maximum diameters of erythema in PPD skin test showed bimodal distribution, and tuberculosis was discovered in two patients by Chest X-ray examination. Moreover, preventive administration of Isonicotinic acid hydrazide (INH) was indicated for 3 employees based on very strong skin reaction to PPD. These five employees were working separately from the index patient and had little contact with the patient in the work places, but using a same commuter bus. Therefore, we strongly suspect that they were infected from the index patient not in the work place but in the commuter bus. The air-conditioning of the bus used a closed recirculation system, hence insufficient ventilation in the bus contributed to the spread of tuberculosis infection.

[A case of pulmonary tuberculosis case with pancytopenia accompanied to bone marrow gelatinous transformation]

A 45-year-old man did not visit a doctor in spite of his complains, cough and sputum lasting, for six months, and he finally could not eat without beer, and as a result, he lost his body weight and currently 52 kg. He became unconsciousness, was carried to a hospital, and was referred to our hospital. His sputum examination for acid fast bacilli was smear positive, Gaffky 6, for M. tuberculosis. His chest roentogenogram revealed large cavitary lesions in bilateral lung fields. On blood examination, WBC was 1100/microL, RBC was 256 x 10(4)/microL, and PLT was 13.4 x 10(4)/microL. Total protein was 4.7 g/dl, albumin was 1.9 mg/dl, and total cholesterol was 65 mg/dl. We tried to aspirate bone marrow from his sternum, but it was impossible. Hence we did biopsy of his ilium. The pathology of his bone marrow revealed gelatinous transformation. It was thought that the marked delay in visiting a doctor caused general consumption and loss of apetite, thus led to gelatinous transformation and finally pancytopenia.

[Investigation of pulmonary hemodynamics and chest X-ray findings in patients with pulmonary tuberculosis sequelae and obstructive ventilatory impairment]

We investigated pulmonary hemodynamics and chest X-ray findings to explore significance of obstructive ventilatory impairment in patients with pulmonary tuberculosis sequelae. One hundred and two patients underwent examinations of blood gases, spirometry, and right cardiac catheterization. The patients were divided into two groups, according to forced expiratory volume in one second as the percentage of forced vital capacity (FVC), which was expressed as FEV1%. Group A (n = 38) had FEV1% of 55% or lower and Group B (n = 64), FEV1% above 55%. First, the values of blood gases and hemodynamics were compared between the two groups, regarding the percent predicted value of FVC as a covariate. Secondly, between 26 of Group A and 42 of Group B, the change of pulmonary arteriolar resistance (PAR) before and after 100% oxygen breathing for 10 minutes was compared. These comparisons were made by exploratory data analysis. Lastly, we described every case with five items of chest X-ray findings and the extent of each finding we had defined. The items were emphysematous change; fibrosis, bronchiectasis and/or cavity; pulmonary resection and/or atelectasis; pleural thickening; and thoracoplasty. We explored X-ray findings influenced on airway obstruction by ridit (abbreviation for "relative to an identified distribution") analysis, taking smoking status into consideration. The results were as follows. (1) The patients of Group A tended to show severer hypoxemia and tissue hypoxia than the patients of Group B. (2) The patients of Group A tended to show worse values of pulmonary hemodynamics than the patients of Group B. Under an even level of the arterial oxygen tension that was 60 Torr or lower, pulmonary artery mean pressure was higher in Group A than in Group B. (3) PAR after oxygen breathing was less likely to decrease in Group A than in Group B. (4) As any mean ridit was standardized and adjusted to 0.5 in Group B, every mean ridit of "emphysematous change" in Group A was the largest-0.63 in non-smokers, 0.74 in ex-smokers and 0.70 in current smokers. Therefore, "emphysematous change" was more influenced on airway obstruction than any other finding because of the largest mean ridit. We conclude as follows. Pulmonary hypertension is more serious in patients suffering from severe airway obstruction with pulmonary tuberculosis sequelae, and it may be attributable to reduction in capacity of anatomical pulmonary vascular bed rather than hypoxic pulmonary vasoconstriction. Pathological changes such as "emphysematous change" on the radiograph might be considered as an important cause of obstructive ventilatory impairment.

[A case of thymic carcinoma producing granulocyte colony-stimulating factor]

A 73-year-old man was admitted complaining of chest pain and weight loss. A chest X-ray film and chest CT scan showed a tumorous mass in the anterior mediastinum with moderate pleural effusion. Percutaneous needle biopsy specimens from the mass resulted in a diagnosis of poorly differentiated squamous cell carcinoma of the thymus. Laboratory findings on admission showed marked leukocytosis with no evidence of infection or bone marrow metastasis. The level of serum granulocyte colony-stimulating factor (G-CSF) was abnormally high (79.2 pg/ml, normal < 30). Carcinoma cells in the specimen showed positive staining with anti G-CSF monoclonal antibody, thus indicating that they produced G-CSF. Because multiple metastatic lesions on the chest wall and liver were detected, we performed combination chemotherapy with cisplatin, vindesine and mitomycin C. After 2 courses of chemotherapy, a decrease in tumor size was verified by CT scan. As the tumor size decreased, the patients white blood cell count and serum G-CSF concentration fell to normal levels.

[Survival and pulmonary hemodynamics in patients with sequelae of pulmonary tuberculosis who received antituberculosis chemotherapy and home oxygen therapy]

To date, the pulmonary hemodynamics of patients with sequelae of pulmonary tuberculosis have usually been examined as a unified set of criteria regardless of the treatments that patients undergo. Attracted by this subject, we studied the cerrelations between survival and pulmonary hemodynamics in patients with sequelae of pulmonary tuberculosis who were treated with antituberculosis drugs and home oxygen therapy (HOT). Our study examined 21 patients with a mean ages of 58.0 years, mean PaO2 of 59.3 +/- 11.4 mm Hg, and mean PaCO2 of 51.9 +/- 6.3 mm Hg. In pulmonary function tests, mean % VC was 44.1 +/- 16.3%, and mean FEV 1%, 66.6 +/- 23.0%. Twenty of the patients were given a diagnosis of pulmonary hypertension. Eighteen of the patients received HOT; as a group, their 3-year survival rate was 62.6%, which was not statistically significant compared to survival observed in post Japanese studies. Among the HOT patients, blood gases and pulmonary hemodynamics did not vary significantly between those who died within 2 years after right heart catheterization (short-term survivors) and those who lived for more than 5 years (long-term survivors). However, VC, % VC, and FVC values were significantly lower in the short-term survivors than in the long-term survivors. In conclusion, these findings revealed no statistically significant, differences compared with the data from past studies. Although pulmonary hypertension is associated with the poor prognosis for chronic obstructive pulmonary tuberculosis patients, in the patients we studied, the principle prognostic determinant was the seriousness of the restrictive ventilatory impairment, not pulmonary hypertension.

[A case of cutaneous tuberculosis associated with steroid therapy for mixed connective tissue disease]

Patients receiving immunosuppressive therapy, such as adrenocorticosteroids, are high risk groups of tuberculosis. We report a case of cutaneous tuberculosis associated with steroid therapy for mixed connective tissue disease. A 63-year-old female was hospitalized after 6 months' treatment with prednisolone for connective tissue disease and bilateral abnormal shadows were revealed on her chest X-ray films. As her sputum smear was positive for acid-fast bacilli, the patient was transferred to our hospital for isolation and treatment. After three months' treatment with INH, RFP and EB, she complained the swelling of her left palm, left arm, and right leg, and skin puncture was performed. As smears of fluid aspirated from the swelling showed acid-fast bacilli, and fluid PCR tests showed positive for M. tuberculosis, she was diagnosed as cutaneous tuberculosis (scrofuloderma). In spite of administration of antituberculous agents, the swelling showed little improvement. Therefore, the dose of prednisolone was reduced and cutaneous lesions were resected by surgery. High risk of tuberculosis should be considered when a patient administered immunosuppressive drugs, such as adrenocorticosteroids.

[A case of miliary tuberculosis with multiple cerebral tuberculoma and spinal tuberculosis owing to total delay]

We reported a case of miliary tuberculosis with multiple cerebral tuberculoma and spinal tuberculosis. The case was a 37 year old man. In the last sixteen months to the first visit to a hospital, he has been suffering from low grade fever, cough, and back pain, but he bared his symptoms without any therapy. At a hospital he first visited, he was told that he might have a malignant disease, which prevented him to visit the hospital because of a fear for his disease. Six months later, he was admitted to other hospital because of severe back pain. At last, he was diagnosed as tuberculosis and referred to our hospital. By the examinations on admission he was diagnosed as multiple cerebral tuberculoma and spinal tuberculosis, and anti-tuberculous therapy was started. It is thought that his severe disease status on admission is caused by the total delay, namely the delay in visiting a doctor and the doctor's delay in making diagnosis.