International promotion of Japanese aging-related health services and products: Perspective of an international agency

Asia is at a critical juncture of health development. The population is aging and shrinking. At the same time, the economy is developing rapidly. These two factors, which necessitate a new paradigm of health development: departing from dependence on Official Development Assistance (ODA) and transitioning towards a model with more involvement of industries (private sector), academia, and health care providers, the so-called public-private partnership (PPP) model. The Economic Research Institute for ASEAN and East Asia (ERIA) is studying the potential for broader application of the new concept for collaboration between Asian countries and Japan. In this article, the authors attempt to introduce the complete picture of a new health ecosystem advocated by Japan. We first look at the impacts of population aging and shrinking, followed by introducing two new approaches; regional and country-specific, with the involvement of ERIA. Then, the outcomes of the projects and Japanese technology, services and products relevant to the older population are introduced. Finally, based on the various projects and products, we focus more closely on the new health development model, the PPP model. We start from the theory and move to examine a tool for implementation, which is the formulation of a dialogue forum named the MEX (Medical Excellence X, where X can be substituted by the acronym of any participating country) project. The experience of these projects and case studies will benefit all ASEAN member countries and beyond. ERIA finds that the facilitation works of the Institute catalyze the progress. ERIA will remain committed to helping the endeavors initiated by Japan for the benefit of all.

Ageing and shrinking population: The looming demographic challenges of super-aged and super-low fertility society starting from Asia

The world is generally getting more prosperous and healthier, and people live longer. Japan, with the world's most advanced population ageing, has made various efforts over the past half-century to prepare for the ageing society. Globally, many countries observe today's rapid demographic changes accompanied by low birth rate and start acknowledging population shrinkage as a looming challenge beyond that of population ageing. The world will face dual challenges of population ageing and shrinkage, but these two issues have been considered in isolation. In addition, the progression differs from region to region and country to country, preventing policymakers from taking a future-back approach to address the core challenges. This issue of Global Health & Medicine carries two valuable articles on population ageing and related policies reported by staff members of the WHO Western Pacific Regional Office (WPRO) and the United Nations Population Fund (UNFPA). This paper will consider the importance of ageing and low fertility rate (declining birthrate) as global issues by placing the WHO and UNFPA articles in a broader context. Population ageing and shrinkage overlap and significantly impact society through health issues. Still, the impact on countries, regions, and the world will become obvious with a time lag. Therefore, this paper advocates analyzing and critically reviewing the experience of countries in which demographic changes are already well advanced, and sharing them with the world. This will contribute significantly to those regions and countries that will walk the same path in the future.

Approach of Medical Excellence JAPAN to create platforms of collaboration in Asia

Medical Excellence JAPAN (MEJ) is a general incorporated association established in 2011 in Japan. It aims to serve as a central hub and a platform to promote international health business jointly with governments, medical communities, academic organizations, and healthcare industries. This article introduces the works of MEJ in the broader context of Japan Revitalization Strategy. The Act on Promotion of Healthcare Policy (2014 Act No. 48) established the Headquarters for Healthcare Policy, chaired by the Prime Minister and supported by dedicated secretariats in the Cabinet Office. The Headquarters aimed at policy coordination across ministries but learned hard lessons from COVID-19, such as delay of domestic vaccine production. This highlights our systematic weakness of the trajectory from R&D to public availability, and this is the field in which MEJ can play further roles. The value and feasibility of developing MEJ-like mechanisms in Asia with a rapidly growing healthcare sector is discussed.

COVID-19 handling report for pre-case, case (pre-hospital and hospital), and post-case phases in the elderly as vulnerable populations in 6 Asia Pacific countries

In this current COVID-19 pandemic, the elderly (60 years and over) are more vulnerable populations to be infected and become victims. In a disaster cycle, the various parts are usually divided into three stages, consisting of the pre-impact stage, the trans-impact stage, and the post-impact stage. It is necessary to explain how to handle the COVID-19 disaster for the elderly at each step (explain the meaning of pre-case, case (pre-hospital and hospital), and post-case phases, respectively). This paper presents the handling of COVID-19 for elderly in pre-case, case, and post-case phases in six Asia-Pacific countries (Indonesia, Thailand, Singapore, Malaysia, Vietnam, and Japan). The data and information come from COVID-19 official websites of each country, including information from World Health Organization (WHO), United States Centers for Disease Control and Prevention (CDC), mass media, and professional associations. The handling of COVID-19 in the pre-case phase has been done correctly for the elderly, especially in Indonesia, Japan, Thailand, and Singapore. In the case phase (pre-hospital and hospital), only Indonesia, Japan, and Thailand have followed special handling protocols for the elderly, particularly for those who have comorbidities and respiratory diseases. For the post-case phase, all countries have the same treatment protocol for all age groups, with none specific for the elderly.

Global health landscape challenges triggered by COVID-19

The COVID-19 pandemic highlighted the vulnerability of every aspect of the globalized world, including R&D. Potentially critical R&D areas have been neglected because of the lack of market-driven incentives. However, new initiatives are emerging to address the present crisis of COVID-19 and possibly future similar incidents that will threaten humanity. In this paper, the global health landscape of R&D is discussed in terms of research focus and funding, illustrating under-funding in communicable diseases with the exception of three major infections: HIV/AIDS, tuberculosis, and malaria. The initiatives triggered by the COVID-19 pandemic and the novel emphasis on "access" are discussed. Finally, the authors propose a new funding model to address R&D in the case of market failure, by forming alliance between government, industry, and international philanthropic organization (GHIT model), and define clear strategy of enhancing access as the way forward.

Population aging in Japan: policy transformation, sustainable development goals, universal health coverage, and social determinates of health

Japan is aging rapidly, and its society is changing. Population aging and social change are mutually linked and appear to form a vicious cycle. Post-war Japan started to invest intensively in infectious disease control by expanding health services and achieving universal medical insurance coverage in 1961. The high economic growth in the 1960s contributed to generate a thick middle class layer, but the lingering economic slump after the economic bubble crisis after 1991 and globalization weakened this segment of society. Health disparity has been acknowledged and social determinates of health have been focused. In this article, the author reviewed the response course to health challenges posed by population aging in Japan, and aims to offer lessons to learn for Asian nations that are also rapidly aging. The core viewpoints include: i) review health policy transformations until the super-aged society, ii) discuss how domestic issues in aging can be a global issue, iii) analyze its relationship with Japanese global health engagement, iv) debate the context of social determinates of health, and v) synthesize these issues and translate to future directions.

Application of Seizon and Life Sciences to Global Public Health Challenges: An International Symposium

The JMA HSPH Taro Takemi Memorial International Symposium “Community Health Systems and Innovations: Building the Foundation for Universal Health Coverage” was held on February 17, 2018. The symposium was co-organized by the Japan Medical Association, Harvard T.H. Chan School of Public Health, the Tokyo Medical Association, and Takemi Memorial Trust for Research of Seizon and Life Sciences. The aim of this symposium was to offer a forum for medical associations, academia, health policy makers, and other stakeholders to discuss the way forward to expand universal health coverage (UHC) in a rapidly changing environment surrounding health and human well-being, a concept that can be traced to the philosophy of late Dr. Taro Takemi. The three keynote lectures provided wide social and ethical as well as historic and global perspectives on health. They were followed by three sessions that each addressed one central theme: lessons learnt from the Japanese experience of responding to unprecedented demographic challenges (Session 1), how innovations can link national and global health policies with people’s well-being (Session 2), and how these efforts can be sustained (Session 3). Finally, a concluding lecture attempted to apply the philosophy of Dr. Taro Takemi, known as Seizon and Life Sciences, to UHC based on the discussions of the symposium. In our opinion, Dr. Taro Takemi’s foresight and philosophy should be revisited when we attempt to address present and future challenges; therefore, this symposium will be remembered for opening new ways of thinking.

Drug-induced oral lichenoid reaction during nivolumab therapy

Oral lichenoid reaction, an immune-related adverse event of immunotherapy, has been reported in very few patients receiving anti-programmed cell death receptor-1 (anti-PD-1) therapy. Here, we describe a case of severe stomatitis (grade ≥3 by the Common Terminology Criteria for Adverse Events, version 4.0) accompanied by pharyngolaryngitis that was observed in a patient receiving nivolumab therapy. The stomatitis was diagnosed as drug-induced lichenoid reaction. Nivolumab therapy was discontinued, and the patient was administered systemic prednisolone (1mg/kg). Most of the patient's mucosal changes in the oral cavity and pharyngolarynx resolved within approximately 3 weeks after starting the prednisolone. Clinicians should be aware that severe oral lichenoid reactions can occur in patients receiving anti-PD-1 therapy.

Global Strategies for the Prevention and Control of Infectious Diseases and Non-Communicable Diseases

This article on global health reviews the environment surrounding health strategies and plans, as well as lessons learned from the first 15 years of the 21st century, followed by a discussion on the quest for a new paradigm for disease control efforts and challenges and opportunities for Japan.

A two-step hybrid technique for accurately localizing acoustic source in anisotropic structures without knowing their material properties

Acoustic source localization techniques generally assume straight line propagation of waves from the acoustic source to the sensor. However, it is well-known that in anisotropic plates the acoustic energy does not always propagate in straight lines. Even for isotropic plates containing a cavity or an inclusion between the acoustic source and the sensor the straight line propagation assumption is violated. In such cases only options available in localizing acoustic source is to use relatively expensive distributed sensor systems, or to follow time reversal techniques based on the impulse response functions which is labor intensive and computationally demanding. A two-step hybrid technique is proposed in this paper for predicting acoustic source in anisotropic plates. During the first step it was assumed that the waves propagated along straight lines from the acoustic source to the sensor. The source was localized with this simplifying assumption. Then this first prediction was improved in the second step by solving an optimization problem. Experimental results showed that the second step always moved the estimates towards the actual source location. Thus it always reduced the prediction error irrespective of whether the final prediction coincided with the actual source location or not.

WHO and the future of disease control programmes

Huge increases in funding for international health over the past two decades have led to a proliferation of donors, partnerships, and health organisations. Over the same period, the global burden of non-communicable diseases has increased absolutely and relative to communicable diseases. In this changing landscape, national programmes for the control of HIV/AIDS, tuberculosis, malaria, and neglected tropical diseases must be reinforced and adapted for three reasons: the global burden of these communicable diseases remains enormous, disease control programmes have an integral and supporting role in developing health systems, and the health benefits of these control programmes go beyond the containment of specific infections. WHO's traditional role in promoting communicable disease control programmes must also adapt to new circumstances. Among a multiplicity of actors, WHO's task is to enhance its normative role as convenor, coordinator, monitor, and standard-setter, fostering greater coherence in global health.

Evaluation of an automatic fogging disinfection unit

A new fogging disinfection method was evaluated as a means of disinfecting ward rooms and operating theaters. A temporary room was established where the disinfection effect of fogging was examined. Based on the results, an automatic fogging disinfection unit was developed. This unit was then used in the disinfection of operating theaters, where its safety and effectiveness were examined.To evaluate the results of disinfection, bacterial culture tests were performed on the floor, walls and other areas of the operating theater, and the number of colony forming units was used as an index of effectiveness. Benzalkonium chloride, alkyldiaminoethylglycine, sodium hypochlorite, glutaral and acidic electrolytic water were used for the operating theaters. The average disinfection effect was 90% or better for all disinfectants, except acidic electrolytic water.The newly developed automatic fogging disinfection unit enables safe and effective disinfection, and may be suitable for disinfecting ward rooms and operating theaters.

A Novel Therapeutic and Prophylactic Vaccine (HVJ-Envelope / Hsp65 DNA + IL-12 DNA) against Tuberculosis Using the Cynomolgus Monkey Model

We have developed a novel tuberculosis (TB) vaccine; a combination of the DNA vaccines expressing mycobacterial heat shock protein 65 (HSP65) and interleukin 12 (IL-12) delivered by the hemagglutinating virus of Japan (HVJ)-envelope and -liposome (HSP65 + IL-12/HVJ). An IL-12 expression vector (IL-12DNA) encoding single-chain IL-12 proteins comprised of p40 and p35 subunits were constructed. This vaccine provided remarkable protective efficacy in mouse and guinea pig models compared to the BCG vaccine on the basis of C.F.U of number of TB, survival, an induction of the CD8 positive CTL activity and improvement of the histopathological tuberculosis lesions. This vaccine also provided therapeutic efficacy against multi-drug resistant TB (MDR-TB) and extremely drug resistant TB (XDR-TB) (prolongation of survival time and the decrease in the number of TB in the lung) in murine models. Furthermore, we extended our studies to a cynomolgus monkey model, which is currently the best animal model of human tuberculosis. This novel vaccine provided a higher level of the protective efficacy than BCG based upon the assessment of mortality, the ESR, body weight, chest X-ray findings and immune responses. All monkeys in the control group (saline) died within 8 months, while 50% of monkeys in the HSP65+hIL-12/HVJ group survived more than 14 months post-infection (the termination period of the experiment). Furthermore, the BCG priming and HSP65 + IL-12/HVJ vaccine (booster) by the priming-booster method showed a synergistic effect in the TB-infected cynomolgus monkey (100% survival). In contrast, 33% of monkeys from BCG Tokyo alone group were alive (33% survival). Furthermore, this vaccine exerted therapeutic efficacy (100% survival) and augmentation of immune responses in the TB-infected monkeys. These data indicate that our novel DNA vaccine might be useful against Mycobacterium tuberculosis including XDR-TB and MDR-TB for human therapeutic clinical trials.

Modification of lipoxygenase by hydrogen peroxide and photooxidation

The kinetic study of fluorescence stopped-flow method suggested that the interaction between lipoxygenase and H2O2 is consistent with a simple irreversible one-step mechanism. The activation energy of the reaction was 7.2 kcal/mol. Participation of an ionizable group with pK about 8.8, possibly a histidine residue, was suggested from the pH-dependence of the rate constant. No further fluorescence quenching of lipoxygenase was observed when the product was added to the lipoxygenase solution before mixing the lipoxygenase and H2O2 solutions. The fluorescence quenching of lipoxygenase by H2O2 was in parallel with the inactivation of the enzyme. Hydroperoxylinoleic acid strongly protects the inactivation of lipoxygenase caused by H2O2. These results are consistent with an interpretation that OH- and/or O- - are produced when the iron of the enzyme is oxidized by H2O2, which in turn will attack some amino acid essential for the enzyme activity. The pH-dependence of the inactivation rate constant of photooxidation of lipoxygenase sensitized by methylene blue indicated that an ionizable group with pK about 8.8 is concerned with the enzymatic activity. In contrast to the inactivation of lipoxygenase by H2O2, the product protected the inactivation of the enzyme by photooxidation only at high concentration.

High prevalence of bipolar disorder comorbidity in adolescents and young adults with high-functioning autism spectrum disorder: a preliminary study of 44 outpatients

BACKGROUND

Psychiatric comorbidity of autism spectrum disorder (ASD) has not been well examined.

METHODS

Mood disorders in 44 consecutive outpatients with high-functioning ASD were examined at a university hospital according to DSM-IV. Inclusion criteria were an IQ of 70 or higher on the Wechsler Intelligence Scale and age of 12 years or over.

RESULTS

Sixteen patients (36.4%) were diagnosed with mood disorder. Of these 16 patients, four were diagnosed as having major depressive disorder, two patients as bipolar I disorder, six patients as bipolar II disorder, and four patients as bipolar disorder not otherwise specified. Bipolar disorder accounted for 75% of cases. Twelve patients had Asperger disorder and four patients had pervasive developmental disorder not otherwise specified. None of the patients had autistic disorder.

LIMITATIONS

The sample size was small. We could not use Autism Diagnostic Interview - Revised. Referral bias could not be avoided in this study.

CONCLUSIONS

The major comorbid mood disorder in patients with high-functioning ASD is bipolar disorder and not major depressive disorder. The autistic spectrum may share common vulnerability genes with the bipolar spectrum.

Research and control of parasitic diseases in Japan: current position and future perspectives

Between 1950 and 1980, Japan eliminated several major parasitic diseases. In 1998, the Japanese Hashimoto Initiative was the first global programme to target parasitic diseases. Thereafter, Japan expanded its international cooperation to cover infectious diseases through integrated development programmes to improve health, to alleviate poverty and to help to achieve the Millennium Development Goals of the United Nations. Parasite control remains a major component of all subsequent operations. Opportunities to build upon past successes in order to improve the situation in the developing world - in addition to tackling emerging national threats - are promising. Substantial challenges remain and Japan has introduced major national reforms to try to overcome them.

Targeted in vivo expression of nicotinic acetylcholine receptors in mouse brain using lentiviral expression vectors

Nicotinic acetylcholine receptors (nAChRs) in the brain exhibit diverse functional properties and ubiquitous distribution. Yet, except for providing a receptor for the exogenously applied nicotine of tobacco products, their role in the normal functioning of the brain has remained elusive. We have used a lentiviral expression vector to re-express the beta2 subunit specifically in the ventral tegmental area (VTA) of beta2-/- mice. The viral vector efficiently expresses beta2- subunit protein leading to new nAChR-binding sites. VTA neurons transduced by the lentiviral vector are responsive to intravenous nicotine when analyzed using in vivo electrophysiology. Nicotine-induced dopamine release from the nucleus accumbens (NuAcc) was also restored in re-expressing beta2-/- mice. Intra-VTA injection of nicotine was found to be reinforcing in both wild-type and beta2-subunit re-expressing beta2-/- mice, but not in beta2-/- mice. Furthermore, in the absence of applied nicotine, the spontaneous slow exploratory behavior of the mice was restored, whereas fast navigation did not change. This latter behavioral analysis suggests a role for beta2* nAChR, specifically expressed in the VTA, in mammalian cognitive function.

Application of ligating loops to control bleeding during endoscopic surgery for a highly vascular hypopharyngeal tumour

Endoscopic treatment of hypervascular lesions of the hypopharynx is challenging because of difficulty in controlling bleeding during surgery. We report a highly vascular hypopharyngeal solitary fibrous tumour treated by endoscopic laser surgery combined with ligating loops. Application of dual ligating loops provided easy and secure haemostasis of the feeding artery before resection. Since the endoscopic approach is less invasive than the external approach, we confirm that it is worthwhile to attempt an endoscopic approach using ligating loops before resorting to the external approach in the treatment of hypervascular hypopharyngeal lesions.

Cervicothoracic malignant peripheral nerve sheath tumor in a 12-year-old girl with neurofibromatosis type 1

We encountered a 12-year-old girl with neurofibromatosis type 1 (NF1) who developed a low-grade cervicothoracic malignant peripheral nerve sheath tumor (MPNST). Computed tomography of the neck showed an elastic firm tumor measuring 7 x 6 x 4 cm and arising from the upper mediastinum. She had no pain or neurological symptoms, but the tumor enlarged to ca. 8 x 8 x 4 cm over the following 7 months. Although we had diagnosed a neurofibroma by preoperative incisional biopsy, the resected tumor showed low-grade MPNST in the central portion of the tumor. In treating a tumor in a patient with NF1, we must recognize that partial biopsies do not necessarily establish a definitive diagnosis and that a growing tumor may indicate malignant transformation.

Characteristics of a medical care program for specific diseases in Japan in an era of changing cost-sharing

The Medical Care Program for Specific Diseases (Specific Diseases Program) was initiated in 1972. The Program has two major components; research grant for specific diseases and medical cost subsidy for specific diseases. The research grant component now targets 118 diseases, and the medical cost subsidy component supports all or part of the co-payments of medical expenses for patients of 44 out of the 118 research target diseases. The present study reviewed public assistance programs for the vulnerable population in Japan, particularly those with designated Specific Diseases, in the context of the wider social security system. Existing governmental information were abstracted and analyzed. The results showed that the recent reform of the Specific Disease Program, which requires the patients in this Program to share a small portion of the medical costs, influenced the number of patients and health services utilization. Other health insurance reforms also have significant effects on the number of patients registered in the Specific Diseases Program, reflecting the relative merit/demerit of the Program in comparison with the general health insurance scheme. Therefore, in an environment of social security reform, formulation of health care policies for specific programs should take into account the relative merits and demerits of the Program in question, in comparison with the general health insurance scheme, to avoid misestimating the number of patients covered by the Program and their utilization of health care services.

Development of vaccination policy in Japan: current issues and policy directions

Until November 2001, eight vaccinations had been offered to Japanese children on a routine basis; namely, diphtheria-tetanus-pertussis, polio, measles, rubella, Japanese encephalitis, and BCG. The 2001 amendment of the Immunization Law introduced an influenza vaccine for the elderly population. This paper reviews the progress of the immunization program in the broader context of infectious disease control in Japan. There are two recent major policy changes in the field of infectious disease control in Japan. One is the strengthening and revitalization of the infectious disease control program, particularly surveillance, by the enactment of new 1999 legislation entitled "Law concerning the Prevention of Infectious Diseases and Patients with Infectious Diseases". The other major policy change is a review of existing immunization programs and the amendment of the Immunization Law in 2001. In this article, the present routine vaccination program, as well as the recent amendments to the law, are described. Current policy issues are then discussed, including polio vaccination after the WHO "Zero Polio" announcement in the Western Pacific Region in 2000; strategies for changes in measles, rubella, tuberculosis, and influenza control; as well as adverse reaction monitoring/surveillance and feedback for improving vaccine safety. Finally, the future prospects of intended/planned changes in the vaccination policy are considered.

[Relation between intraoperative salvaged blood transfusion and postoperative infection after cardiac surgery]

In cardiac surgery, several studies have shown bacterial contamination rates of intraoperative salvaged blood ranging from 12.7 to 96.8%. We evaluated the relation between intraoperative salvaged blood transfusion produced by the Cell Saver 5 device (Haemonetics Corp., Braintree, MA, USA) and postoperative infection determined by bacteriological study and the postoperative clinical course after cardiac surgery. Seven cases of cardiac surgery were investigated by bacteriological study. Although bacteria were cultured from all salvaged blood, no bacteria were cultured from the patients' blood 24 hours after salvaged blood infusion. Another 26 patients who underwent cardiac surgery, were divided into groups: group CS (n = 15) with salvaged blood transfusion after operation and group N (n = 11) without salvaged blood transfusion, and were evaluated in relation to the postoperative clinical course. There were no statistically significant differences between group CS and group N in the data of WBC, CRP and maximum body temperature. One case of deep sternal wound infection and 2 cases of local wound infection were observed in group CS, but none in group N (p = 0.18). These complications were treated by primary closure without muscle flaps. We conclude that salvaged blood autotransfusion was not related to postoperative infections in cardiac surgery.

Epidemiological transition of tuberculosis and future agenda of control in Japan: results of the Ad-Hoc National Survey of Tuberculosis 2000

SETTING

In Japan, the incidence of tuberculosis (TB), which had improved continuously from 1951, has shown an upturn since 1997.

OBJECTIVE

An Ad-Hoc National Survey was conducted to review the issues of TB control in Japan and to discuss the future direction of change.

METHODS

TB registries kept at health centres in all prefectures were reviewed for the year 1998. Vital statistics and BCG vaccination records were reviewed separately.

RESULTS

The survey revealed a 34.7% under-estimation of TB deaths in TB registers, and a 11.2% over-estimation of TB cases registered due to a change in diagnosis after registration. For treatment, the four-drug regimen advocated for smear-positive cases was used in only 54.8% of indicated cases, and treatment duration was very long; for example, 18.4% of first-time hospitalised cases over 15 years of age received in-patient care for more than 6 months and 29.8% continued treatment for more than 12 months. Apart from an increasingly elderly population, other factors contributing to an increase in TB included underlying health risk factors for increased susceptibility to TB and socio-economic risk factors for treatment failure. Regarding preventive measures, active case finding by health screening contributed to detection of only 8.7% of new cases aged over 60 years, but BCG vaccination appeared to be preventive among infants under 1 year of age.

CONCLUSION

The National Survey revealed a changing profile of TB in Japan and suggested a need to review and revitalise the TB control programme.

[Bacterial contamination of salvaged blood in open heart surgery: is that an airborne contamination or a normal skin flora contamination?]

We investigated sources of bacterial contamination of intraoperative salvaged blood producted by autologous transfusions device (CS; CELL SAVER 5, Heamonetics Corp., Braintree, MA). Eleven patients undergone open heart surgeries including 2 emergency operations with a median sternotomy enrolled in this study. Blood samples were drawn from salvaged blood bags. Airborne contaminants (AB) were collected by a blood agar plate put besides the operation bed for 30 minutes. The median wounds samples were collected by a swab. Bacterial growth was detected in 81.8% of salvaged blood samples. Twenty-nine bacterium were isolated from CS, 72.4% of those were Staphylococci. 9.1% of sample was positive in wound swabs. Forty bacterium were isolated from plate cultures. 65% of them were Staphylococci. Staphylococcus epidermidis and coagulase negative Staphylococcus isolated both CS and AB in the 2 cases had the same identify codes, and incubated from several AB cultures. Corynebacterium sp. is also isolated from both CS and AB cultures in other 2 same cases. In 7 out of 8 cases (87.5%), from which Staphylococci isolated in CS, the Staphylococci were cultured from AB in not the same but the other cases. In conclusion, highly incidence of the identification in identical code of Staphylococci indicated that the main source of CS contamination was highly suspected to AB.

Detection of nerve action potentials under low signal-to-noise ratio condition

We propose a method for detection of action poten. tials (APs) under low signal-to-noise ratio condition. It is based on multiresolution analysis. Three parameters are used for detection. Two of them are for determining if there is an AP or not, and the other is for the estimation of waveforms. Our method provides better estimated waveforms than the conventional de-noising approach.

Analysis of glycosidase-catalyzed transglycosylation reaction using probabilistic model

General mechanism of transglycosylation reaction by glycosidases contains branched paths to form and destroy the glycosylated intermediate. The probabilistic model was applied for the simulation and analysis of the transglycosylation mechanism. The model is composed of a single enzyme molecule and finite amounts of substrates and water molecules mimicking the possible smallest enzyme-catalyzed reaction system in a microcompartment. Using random numbers and probabilities, progress of distribution of reactants and products can be simulated and predicted with minimum adjustable parameters. Experimental data of beta-xylosidase and beta-glucosidase reactions were quantitatively analyzed with the simple scheme. Since the algorithm and simulation procedures are simple, the model is applicable to related complicated enzyme mechanisms containing many branched reaction paths.

Cathepsin L activity and its inhibitor in human otitis media

OBJECTIVE

We examined cathepsin L activity, expression of cystatin A, and copper- and zinc-containing superoxide dismutase in human chronic otitis media. The relationships of our findings to clinical findings (e.g., grade of bone destruction) were also studied.

DESIGN

Retrospective basic and clinical study.

SETTING

Department of Otolaryngology and First Department of Biochemistry, Kinki University School of Medicine, Osaka, Japan.

METHOD

The human middle ear tissues evaluated in this study were surgically obtained from seven patients with cholesteatoma epithelium, three patients with granulation tissues in cholesteatoma, three patients with granulation tissues in noncholesteatoma, and three patients with intact mucous membrane of the middle ear.

MAIN OUTCOME MEASURES

Cathepsin L activities in cholesteatoma epithelium, granulation tissues in cholesteatoma, or granulation tissues in noncholesteatoma were measured using Barrett's method. Cystatin A expressions were observed by Western blot analysis. Copper- and zinc-containing superoxide dismutase in cholesteatoma was examined immunohistochemically.

RESULTS

Mean cathepsin L activity was higher in diseased tissues than in intact mucous membranes of the middle ear. Granulation tissues with high cathepsin L activity resulted in extensive bone destruction in both cholesteatomas and noncholesteatomas of the middle ear. All cases with intact mucous membrane of the middle ear exhibited no expression of cystatin A. Seven of 10 cases with diseased tissues expressed cystatin A in cholesteatoma epithelium, granulation tissues in cholesteatoma, or granulation tissues in noncholesteatoma. No relationships were found between cystatin A expression and grade of cathepsin L activity. Copper- and zinc-containing superoxide dismutase was more strongly positive in cholesteatoma epithelium regions than in granulation tissues.

CONCLUSION

These results suggest that copper- and zinc-containing superoxide dismutase in cholesteatoma epithelium prevents complications by suppressing cathepsin L activity.

Oblique aortic valve replacement and coronary artery bypass grafting for severely calcified narrow aortic root with unstable angina

We report an 84-year-old woman diagnosed with aortic stenosis and regurgitation with a severely calcified narrow aortic root and left main coronary artery trunk stenosis with triple-vessel coronary artery disease. Emergency aortic valve replacement and triple coronary artery bypass grafting were successful. The aortic annulus was small and heavily calcified, and the ascending aorta, the sinus of valsalva and the anterior leaflet of the mitral valve were severely calcified. A St. Jude Medical valve 19A (St. Jude Medical Inc., St. Paul, MN) was inserted obliquely along the noncoronary sinus. This technique is a useful alternative in cases where the patient's life is at risk in situations involving severe extensive calcification of a narrow aortic root.

[Maze procedure for atrial fibrillation associated with aortic valve disease in an elderly patient: report of a case]

The choice of a valve substitute in elderly patients remains controversial. Moreover, the combined use of the maze procedure in elderly patients raises further discussion. We report a case of bioprosthetic aortic valve replacement concomitant with the maze procedure in a 74-year-old man. With symptom of orthopnea and short of breath, he was diagnosed as aortic stenosis and regurgitation with atrial fibrillation. We performed the bioprosthesis aortic valve replacement and the maze procedure in this patient. He was extubated next day and discharged on the fifteenth day after the operation without any complications. Postoperatively he gained a sinus regular rhythm and A wave of transmitral flow was detected by Doppler echocardiography. Now, he enjoys his better quality of life without any drugs including warfarin. Although combined aortic valve replacement and maze procedure are more invasive for elderly patients, these procedures provides better quality of life after the operation.

Axonal projection of olfactory sensory neurons during the developmental and regeneration processes

We have studied the projection of olfactory sensory neurons (OSNs), during the developmental and regeneration processes, using the transgenic mouse carrying the differently tagged odorant receptor genes, MOR28. We have found that the axon terminals of the two sets of MOR28-positive OSNs, one expressing the lacZ tag and the other expressing the green fluorescent protein gene, are dispersed and intermingled at early developmental or regeneration stages. Projection areas become more distinct and separated at later stages, however, two sets of axon fibers are not typically bundled or segregated during pathfinding. It appears that segregation of axons mainly occurs when they target at the olfactory bulb to form the glomerular structure.

Left vocal cord paralysis associated with long-standing patent ductus arteriosus

SUMMARY

Left vocal cord paralysis in association with patent ductus arteriosus is unusual. We report a patient with long-standing patent ductus arteriosus (PDA) in whom CT studies obtained before and after paralysis developed showed an interval increase in size of the pulmonary trunk. The pathogenesis of left vocal cord paralysis in association with long-standing PDA is discussed.

[Is open heart surgery clean: bacteriologic analysis of salvaged blood]

In this prospective study, we evaluated contamination of surgical fields in open heart operations by salvaged blood culture used in autologous transfusions device (Cell Saver 5, Heamonetics Corp., Braintree, MA, USA). And also, we prospectively investigated an efficacy of pre- and intra-operative prophylactic antibiotics administrations (cefazolin). Thirty patients undergone open heart surgeries with median sternotomy enrolled in this study. The patients were divided into two groups, group A (n = 15); without prophylactic antibiotics administration, group B (n = 15); with pre- and intra-operative prophylactic antibiotics administrations. Blood samples were drawn through the right atrium after the discontinuation of CPB and from salvaged blood bags. Bacterial growth was detected in 80.0% of salvaged blood samples in group A, 86.7% in group B (p = 0.62). Whereas no bacterial growth detection in blood samples though the right atrium. Quantitative estimates of contaminations showed 1.06 +/- 1.41, 0.90 +/- 1.24 cfu/ml, respectively (p = 0.22). Although bacterial growth rate were not statistically significant difference between groups, detective rate of Staphylococci was remarkably decreased (p = 0.005) in group B. Pre- and intra-operative prophylactic antibiotics administrations were effective for Staphylococci, but not whole microorganisms. In conclusion, salvaged blood used in autologous transfusions was highly contaminated and it suggests that surgical fields were not clear. Prophylactic antibiotics administrations were effective especially for Staphylococci.

Neurofibroma of the larynx in neurofibromatosis: preoperative computed tomography and magnetic resonance imaging

Neurofibromas of the larynx are extremely rare. They occur in association with neurofibromatosis less frequently than solitary neurofibromas. However, most laryngeal tumors in neurofibromatosis are neurofibromas. This disorder has 2 histological subtypes, which require different surgical approaches because of their biological differences. Few cross-sectional imaging studies have been performed in neurofibroma of the larynx. We describe a 44-year-old man with neurofibromatosis and nonplexiform neurofibroma of the larynx and discuss the role of preoperative computed tomography and magnetic resonance imaging in this case. The tumor was removed completely using an endolaryngeal approach without an external incision. It was possible to distinguish subtypes preoperatively on cross-sectional imaging. Magnetic resonance imaging provided more sensitive information in the diagnosis of this tumor than computed tomography. Preoperative cross-sectional imaging should be performed to help the surgeon diagnose and choose an appropriate surgical approach for this disorder.

Monoallelic expression of the odourant receptor gene and axonal projection of olfactory sensory neurones

BACKGROUND

We have previously generated transgenic mice carrying the murine odourant receptor gene, MOR28, tagged with lacZ. In this animal, the endogenous MOR28 is differently tagged with GFP. It was found that the transgenic and endogenous MOR28 genes are expressed in a mutually exclusive manner and that the two sets of olfactory sensory neurones (OSNs), each expressing either the transgenic or the endogenous MOR28, project their axons to separate glomeruli.

RESULTS

Our fluorescent in situ hybridization (FISH) revealed that the two endogenous alleles of MOR28 are also mutually excluded for their transcriptional activation. Therefore, we studied whether there would be any segregation in the projection of the two subsets of OSNs: one set expressing the paternal and the other expressing the maternal allele. It was found that the OSNs for both alleles shared the same glomerulus for their projection, but the projection targets were segregated within the glomerular structure.

CONCLUSION

Two subsets of neurones expressing either the transgenic or the endogenous MOR28 target their axons to two separate glomeruli based on the differences in the genetic backgrounds, nature of tagging, and chromosomal locations. In contrast, neurones expressing a maternal or paternal allele share the same glomeruli, but tend to target to segregated areas within the glomerular structure. The segregation was more prominent with increased differences in the genetic background between the two alleles.

Sarcoidosis with vocal fold involvement and hypercalcaemia

Sarcoidosis affects many different organ systems. However, laryngeal involvement is rare and most cases with laryngeal involvement affect the supraglottis, occasionally secondarily extending to the vocal fold. The features of sarcoidosis in the supraglottic region have been described in several reports, but vocal fold involvement has not been presented in detail. We report an unusual case of laryngeal sarcoidosis initially involving the vocal folds in a 66-year-old man, associated with hypercalcaemia. Our report describes characteristics of the involved vocal folds. Hypercalcaemia is one of the characteristics of sarcoidosis. We concluded that laryngeal sarcoidosis should be added to the differential diagnosis of vocal fold lesions, particularly in patients with hypercalcaemia.

Mutually exclusive expression of odorant receptor transgenes

To study the mutually exclusive expression of odorant receptor (OR) genes, we generated transgenic mice that carried the murine OR gene MOR28. Expression of the transgene and the endogenous MOR28 was distinguished by using two different markers, beta-galactosidase and green fluorescent protein (GFP), respectively. Double staining of the olfactory epithelium revealed that the two genes were rarely expressed simultaneously in individual olfactory neurons. A similar exclusion was also observed between differently tagged but identical transgenes integrated into the same locus of one particular chromosome. Although allelic inactivation has been reported for the choice between the maternal and paternal alleles, this is the first demonstration of mutually exclusive activation among non-allelic OR gene members with identical coding and regulatory sequences. Such an unusual mode of gene expression, monoallelic and mutually exclusive, has previously been shown only for the antigen-receptor genes of the immune system.

[A successful case of hybrid therapy for the left main trunk and triple coronary vessel lesions with acute myocardial infarction and cardiogenic shock]

A 86-year-patient who had acute myocardial infarction and critical cardiogenic shock was diagnosed to have the left main trunk (LMT) and triple vessel disease. Emergent coronary artery bypass grafting to the left anterior descending artery was performed using saphenous vein graft without cardiopulmonary bypass through median sternotomy. On the 41st postoperative day, catheter intervention was performed to the remaining lesions by stenting of LMT and percutaneous transluminal coronary angioplasty to the right coronary artery lesions. Tl scintigraphy showed remarkable reduction of myocardial ischemia. Hybrid therapy is the effective new strategy for critical cases which cannot be successfully and securely treated by medical or surgical approach alone.

Improved recording techniques of antidromic facial nerve response for outpatient clinical use

OBJECTIVE

The purpose of this study was to obtain an analyzable wave of the antidromic facial nerve response (ADFNR) without interference of the compound muscle action potential (CMAP) at the outpatient clinic setting.

BACKGROUND

To evaluate intratemporal facial nerve function with the ADFNR, it is necessary to analyze the waveform of propagating nerve impulses in the temporal bone. However, this small nerve response is easily disturbed by the CMAP, which is simultaneously evoked by electrical stimulation.

METHODS

The ADFNR was recorded at the entrance of the external ear canal and simultaneously at the anulus tympanicus. Subtraction between the responses evoked at both sites was performed to eliminate the CMAP.

RESULTS

The ADFNR was recorded after subtraction of the response recorded at the entrance of the external ear canal from that at the anulus tympanicus. The normal ADFNR had a triphasic waveform. With the placement of the reference electrode at the entrance of the external ear canal, the responses were similar to the subtracted responses.

CONCLUSIONS

We recommend the subtraction method and placement of the reference electrode at the entrance of the external auditory canal to record an analyzable ADFNR and to simplify the recording techniques.

Monte Carlo simulation of 4-alpha-glucanotransferase reaction

4-alpha-Glucanotransferase (GTase, D-enzyme) catalyzes disproportionation between two short polymers of maltooligosaccharides linked by alpha-1,4-glucoside bonds. Using action modes of the potato GTase for the donor and acceptor substrates, the Monte Carlo method was applied to simulate the GTase reaction. The simulation starts from a single enzyme molecule and a finite number (10(5)) of substrate molecules. All selection processes were performed using random numbers produced by computer. The initial substrates were from trimer to 10-mer. In every case, the final stage was the steady-state distribution of polymers. The steady-state distribution by the potato GTase reaction was different from those by the hypothetical random disproportionation reaction. The simulated data from the reaction of potato GTase and trimer almost quantitatively agreed with experimental data. The mechanism of the GTase reaction was accumulation of probabilistic processes and was well simulated by the Monte Carlo method. GTase randomizes the overall distribution of chain length of the substrate. Therefore the GTase reaction is an entropy-driven process.