Fragility Fracture Network-Japan: The challenge of establishment of a national hip fracture database and successful achievement of nationwide health system change for hip fracture care in Japan

BACKGROUND

In April 2022, a new reimbursement scheme for hip fracture was implemented by the Japanese health ministry. Japan is one of the world's most aged societies, facing a significant, rapidly growing burden of osteoporosis and fragility fractures. The incidence of hip fractures is projected to increase from 240,000 in 2020 to 320,000 by 2040. In 2015, Fragility Fracture Network-Japan (FFN-Japan) was formally established as a nonprofit organization in order to create the optimal fragility fracture care system in Japan.

METHODS

FFN-Japan launched the Japan National Hip Fracture Database (JNHFD) in 2017, initially with only eight participating hospitals across Japan. The number of patients enrolled from May 2017 to the end of 2020 in the JNHFD from the 16 hospitals registered the patients during this period with amounting to 4271 patients in total. FFN-Japan invited officials from the Ministry of Health, Labor and Welfare (MHLW) to participate in round table meetings to discuss the data collected in the JNHFD and to consider opportunities for nationwide improvement in hip fracture care.

RESULTS

The proportion of patients who underwent surgery within 36 h of arrival at hospital was 48.1% in 2018, 58.6% in 2019, and 44.9% in 2020 indicating the delay of surgery. Regarding secondary fracture prevention, initiation of osteoporosis treatment during the in-patients was 60.2% in 2018, 54.0% in 2019, and 64.5% in 2020 indicating the inadequate post fracture care. In April 2022, the Central Social Insurance Medical Council of the Japanese MHLW announced a new reimbursement scheme for hip fracture care including two key components: Early surgery (within 48 h from injury) and Secondary fracture prevention immediately after fracture.

DISCUSSION

The new reimbursement scheme of hip fracture care in Japan will catalyze and underpin major improvements on acute multidisciplinary care and post-fracture care with secondary fracture prevention. FFN-Japan played a key role on these policy changes to the health system by means the close collaboration and ongoing communication with the government.

CONCLUSION

Within five years of establishment of the JNHFD, FFN-Japan in collaboration with visionary leaders from the Japanese government have successfully achieved a major reform of the Japanese health system's reimbursement of hip fracture care. This reform has laid the foundation for transformation of management of this debilitating and life-threatening injury that currently afflicts almost a quarter of a million older Japanese citizens each year.

Postoperative Rotation Deformity of Head-Neck Fragments in Unstable Intertrochanteric Fractures Fixed with Intramedullary Nails

BACKGROUND

Our purpose was to quantify the postoperative rotation deformity (RD) after osteosynthesis of unstable intertrochanteric fractures (ITFx) using 3D-CT / image processing software, and to clarify the clinical meaning of RD.

METHODS

Forty-six consecutive patients with unstable intertrochanteric fractures were enrolled in this study. All were fixed with Gamma 3 Trochanteric nail and RC Lag Screw® (Stryker). We performed 3D-CT evaluations for the rotational deformity of head-neck fragments, the medial cortex support (MCS) between main fragments and bone healing at 3 months postoperatively.

RESULTS

The RD was significantly larger in the patients without the MCS (5.1 ± 4.0°, N = 9) than those with the MCS (2.4 ± 2.6°, N = 37) (P = 0.006*). Delayed healing (N=3) was observed in patients without the MCS, and the association between RD and delayed healing was significant (P = 0.003*, cut-off value 6.4°, sensitivity 100% and specificity 90.7%, AUC 0.91).

CONCLUSIONS

This study proposed a novel method of measuring postoperative RD. Lack of MCS may lead to RD and consequent delayed healing in unstable ITFx fixed with intramedullary nails.

Treatment of Capitellum and Trochlea Fractures Using Headless Compression Screws and a Combination of Dorsolateral Locking Plates

Introduction

This study aimed to evaluate the clinical outcomes of 16 patients with capitellum and trochlea fractures that were treated using isolated headless compression screws or a combination of dorsolateral locking plates and anterior-to-posterior screws. We also investigated the presence of lateral epicondyle fragments because this fragment is especially important when making decisions regarding the surgical approach and implants.

Materials and methods

We conducted a retrospective analysis of 16 patients with capitellum and trochlea fractures. Clinical, radiographic (based on CT scans), and elbow-specific outcomes, including the Mayo Elbow Performance Index (MEPI), were evaluated at a mean of 23.5 months postoperatively.

Results

The average MEPI scores in patients with Dubberley type A (non-posterior comminution) and type B (posterior comminution) fractures were 88 and 78, respectively (p=0.08). Headless compression screws were used in 10 cases of type A fracture and one case of type B fracture. A combination of dorsolateral locking plates and anterior-to-posterior screws was used in five cases of type B fracture. Hardware loosening was seen in one case of type B fracture with isolated screw fixation. The presence of a lateral epicondyle fragment was significantly associated with the type B group (6/6 patients; 100%). In contrast, patients in the type A group rarely had posterior comminution of the lateral epicondyle fragment (2/10 patients; 20%).

Conclusions

Capitellum and trochlea fractures with posterior comminution, which typically presented with lateral epicondylar fragments, were safely and effectively treated with a combination of dorsolateral locking plates and anterior-to-posterior screws through lateral approaches. Cases without posterior comminution were treated with headless compression screws with no complications. The Dubberley classification system provides helpful information to determine the fixation strategy.

Primary Hinged External Fixation of Terrible Triad Injuries and Olecranon Fracture-Dislocations of the Elbow

This study aimed to introduce a new treatment that apples primary hinged external fixation for complex fracture-dislocations of the elbow in 12 cases. We retrospectively assessed the functional outcomes of eight patients with terrible triad injuries and three patients with an olecranon fracture-dislocation of the elbow, who were treated at our hospital using a primary hinged external fixator between June 2012 and December 2014. Ten patients underwent repair or replacement of the radial head, while three underwent repair of the olecranon. In principle, they were treated without reconstruction of the coronoid fracture and collateral ligament injury. The patients were evaluated for a mean follow-up period of 16 months after the initial surgery. Early mobilization was encouraged while the hinged external fixator was in place. At the follow-up, the mean Mayo Elbow Performance Score was 93 points; the results were "excellent" in six cases and "good" in five. No patients had recurrent elbow instability. Only one patient needed an additional procedure after the initial operation. These results suggested that primary hinged external fixation without repair of the ligament and soft tissue is an effective minimally invasive surgery for the management of terrible triad injuries and olecranon fracture-dislocations of the elbow.

Postcomparison of [(18) F]-fluorodeoxyglucose uptake in the brain after short-term bright light exposure and no intervention

OBJECTIVE

Bright light therapy is widely used as the treatment of choice for seasonal affective disorder. Nonetheless, our understanding of the mechanisms of bright light is limited and it is important to investigate the mechanisms. The purpose of this study is to examine the hypothesis that bright light exposure may increase [(18) F]-fluorodeoxyglucose (FDG) uptake in olfactory bulb and/or hippocampus which may be associated neurogenesis in the human brain.

METHOD

A randomized controlled trial comparing 5-day bright light exposure + environmental light (bright light exposure group) with environmental light alone (no intervention group) was performed for 55 participants in a university hospital. The uptake of [(18) F]FDG in olfactory bulb and hippocampus using FDG positron emission tomography was compared between two groups.

RESULTS

There was a significant increase of uptake in both right and left olfactory bulb for bright light exposure group vs. no intervention group. After adjustment of log-transformed illuminance, there remained a significant increase of uptake in the right olfactory bulb.

CONCLUSION

The present findings suggest a possibility that 5-day bright light exposure may increase [(18) F]FDG in the right olfactory bulb of the human brain, suggesting a possibility of neurogenesis. Further studies are warranted to directly confirm this possibility.

A Predictive Model of Plasma Lamotrigine Levels

Introduction: Lamotrigine is one of several mood stabilizers and its effects for the treatment and prevention of depressive episodes, particularly in bipolar disorder, are generally accepted. Although the findings about a therapeutic window of lamotrigine are yet to be determined, it seems important to obtain information on individual pharmacokinetic peculiarities. This study was conducted to formulate the predictive model of plasma lamotrigine levels. Methods: Using the data of 47 patients whose lamotrigine levels, liver function, and renal function were measured, predictive models of lamotrigine levels were formulated by stepwise multiple regression analyses. The predictive power of the models was compared using another dataset of 25 patients. Results: Two models were created using stepwise multiple regression. The first model was: plasma lamotrigine level (μg/mL)=2.308+0.019×lamotrigine dose (mg/day). The second model was: plasma lamotrigine level (μg/mL)=0.08+0.024×lamotrigine dose (mg/day)+4.088×valproate combination (no=0, yes=1). The predictive power of the second model was better than that of the first model. Discussion: The present study proposes a prompt and relatively accurate equation to predict lamotrigine levels.

Infective Endocarditis Presenting as Right Shoulder Pain: A Case Report

Although cases of referred shoulder pain due to ischemic heart disease have been well documented, to our knowledge no reports on infective endocarditis accompanied by referred right shoulder pain have been published. A 43-year-old Japanese man presented with severe right shoulder pain and a body temperature of 38°C.Blood tests showed inflammation and liver dysfunction, although magnetic resonance imaging did not indicate septic shoulder arthritis. However, contrast-enhanced computed tomography showed renal, splenic, and hepatic infarctions. Moreover, a labile vegetation was detected on an echocardiogram. The patient was diagnosed with infective endocarditis and antibiotics were administered intravenously. Infective endocarditis is a serious condition that can result in complications if it is not diagnosed and treated at an early stage. Therefore, in cases with referred shoulder pain, physicians should carefully consider the presence of internal diseases that may cause this condition, as in the present case.

Effects of corticosteroids and hyaluronic acid on torn rotator cuff tendons in vitro and in rats

Corticosteroids (CS) or hyaluronic acid (HA) is used in subacromial injection for the conservative treatment of rotator cuff tears (RCT); this study addresses the question of how CS and HA affect the tendon tissue and fibroblasts in vitro and in rats. Cell proliferation assays were performed in human tendon fibroblasts from RCT. Rats underwent surgery to create RCT, and the surgical sites were injected with CS or HA. The rotator cuff tendons were subjected to biomechanical testing, microscopic and immunohistochemical analysis of proliferating cell nuclear antigen (PCNA), and ultrastructural analysis. Cell proliferation was significantly decreased with CS in vitro (p < 0.05). Maximal load of CS-treated tendons was significantly decreased compared with that of HA-treated tendons (p < 0.05), as well as PCNA(+) cells at 2 weeks (p < 0.05). Ultrastructural observations of the CS-treated rats detected apoptosis of tendon fibroblasts 24 h after surgery. Histological and biomechanical data 4 weeks after surgery were not significant among the three groups. Unlike HA, CS caused cell death, and inhibition of the proliferation of tendon fibroblasts, leading to a delay of tendon healing involved and a subsequent decrease of biomechanical strength at the surgical site.

Clinical outcomes of the Cadenat procedure in the treatment of acromioclavicular joint dislocations

We report our clinical experience using the modified Cadenat method to treat acromioclavicular joint dislocation, and discuss the usefulness of this method. This study examined 6 shoulders in 6 patients (5 males, 1 female) who were diagnosed with acromioclavicular joint dislocation and treated with the modified Cadenat method at our hospital. Average age at onset was 49.3 years (26-78 years), average time interval from injury until surgery was 263.8 days (10 to 1100 days), and the average follow-up period was 21.7 months (12 to 42 months). Post-operative assessment was performed using plain radiographs to determine shoulder joint dislocation rate and Japanese Orthopaedic Association (JOA) score. The average post-operative JOA score was 94.1 points (91 to 100 points). The acromioclavicular joint dislocation rate improved from 148.7% (72 to 236%) before surgery to 28.6% (0 to 60%) after surgery. Conservative treatment has been reported to achieve good outcomes in acromioclavicular joint dislocations. However, many patients also experience chronic pain or a sensation of fatigue upon putting the extremity in an elevated posture, and therefore ensuring the stability of the acromioclavicular joint is crucial for highly active patients. In this study, we treated acromioclavicular joint dislocations by the modified Cadenat method, and were able to achieve favorable outcomes.

Risk factors for shoulder re-dislocation after arthroscopic Bankart repair

BACKGROUND

Recent studies have shown effective clinical results after arthroscopic Bankart repair (ABR) but have shown several risk factors for re-dislocation after surgery. We evaluated whether patients are at a risk for re-dislocation during the first year after ABR, examined the recurrence rate after ABR, and sought to identify new risk factors.

METHODS

We performed ABR using bioabsorbable suture anchors in 102 consecutive shoulders (100 patients) with traumatic anterior shoulder instability. Average patient age and follow-up period was 25.7 (range, 14-40) years and 67.5 (range, 24.5-120) months, respectively. We evaluated re-dislocation after ABR using patient telephone interviews (follow-up rate, 100%) and correlated re-dislocation with several risk factors.

RESULTS

Re-dislocation after ABR occurred in nine shoulders (8.8%), of which seven sustained re-injuries within the first year with the arm elevated at 90° and externally rotated at 90°. Of the remaining 93 shoulders without re-dislocation, 8 had re-injury under the same conditions within the first year. Thus, re-injury within the first year was a risk for re-dislocation after ABR (P < 0.001, chi-squared test). Using multivariate analysis, large Hill-Sachs lesions (odds ratio, 6.77, 95% CI, 1.24-53.6) and <4 suture anchors (odds ratio, 9.86, 95% CI, 2.00-76.4) were significant risk factors for re-dislocation after ABR.

CONCLUSIONS

The recurrence rate after ABR is not associated with the time elapsed and that repair strategies should augment the large humeral bone defect and use >3 anchors during ABR.

A young woman with visual hallucinations, delusions of persecution and a history of performing arson with possible three-generation Fahr disease

OBJECTIVE

Fahr disease (FD) is a rare neurological and psychiatric disorder. The disease is classified by intracranial calcification of the basal ganglia with the globus pallidus region being particularly affected. We examined a young woman with visual hallucinations, delusions of persecution and a history of performing arson with possible third-generation FD.

METHOD

Case report of third-generation FD.

RESULTS

A 23-year-old woman was arrested for two arsons: i) The patient exhibited progressive psychotic symptoms, including visual hallucinations, delusion of injury, irritability, lability of mood, mental retardation and visual disorders and ii) Computed tomography (CT) imaging demonstrated bilateral calcifications of the basal ganglia (globus pallidus) in the patient, her mother and her grandmother.

CONCLUSION

We found a family with a three-generation history of FD who exhibited calcification in the brain and mental retardation. Compared to her mother, the patient described here displayed anticipation of disease onset.

Surgical treatment of vertically unstable sacral fractures using a new plate

Eighteen patients with vertically unstable sacral fractures in type C of AO classification, who underwent open reduction and internal fixation, were investigated. Vertically unstable sacral fractures were fixed using a M-Shaped Pelvic Plate prepared by the author with posterior longitudinal incision. The postoperative results were determined by Majeed's functional evaluation and radiography. Excellent in 12 and good in 3. Poor cases were infection and sciatic nerve paralysis. M transiliac plate fixation was achieved by rigid fixation with less invasion for vertically unstable sacral fractures.

Transcatheter arterial chemoembolization therapy combined with percutaneous ethanol injection for unresectable large hepatocellular carcinoma: an evaluation of the local therapeutic effect and survival rate

BACKGROUND/AIMS

This study was undertaken to evaluate the effectiveness of combination therapy with transcatheter arterial chemoembolization followed by percutaneous ethanol injection in patients with unresectable large hepatocellular carcinoma by comparing the use of this combined regimen with transcatheter arterial chemoembolization alone.

METHODOLOGY

Six hundred and thirty-one consecutive patients with hepatocellular carcinoma lesions observed from Jan 1989 to Dec 1999 (11 years) at the Internal Medicine Department, Saga Prefectural Hospital Koseikan were retrospectively enrolled in the study. The series included 120 patients with large unresectable hepatocellular carcinoma lesions, the largest of which were greater than 3 cm in largest dimension. Fifty-two patients underwent a single transcatheter arterial chemoembolization followed by percutaneous ethanol injection, which were compared with 68 patients treated by transcatheter arterial chemoembolization alone. Both groups of patients with hepatocellular carcinoma did not differ regarding the base-line characteristics. The overall survival rates and recurrence ratio of initially treated lesions were compared in both groups.

RESULTS

On overall survival rates by the Kaplan-Meier method, three- and five-year survival in the transcatheter arterial chemoembolization and percutaneous ethanol injection group (59.0%, 32.1%) proved to be significantly longer than those in the transcatheter arterial chemoembolization group (27.1%, 17.0%). In addition, during the follow-up local recurrence in the combination group (23.1%) was significantly lower than that in the transcatheter arterial chemoembolization group (50.0%).

CONCLUSIONS

The combined treatment with transcatheter arterial chemoembolization and percutaneous ethanol injection proved to be more effective and safer. Furthermore, a lower incidence of local recurrence was observed than transcatheter arterial chemoembolization alone which resulted in an increased survival of the patients associated with unresectable large hepatocellular carcinoma lesions.

Colour Doppler ultrasound for the evaluation of bowel wall thickening

We performed colour Doppler ultrasound to evaluate bowel wall thickening and to determine the effectiveness of this modality. 42 patients (aged 8-83 years old, mean age 43.5 years) with bowel disease underwent both grey scale and colour Doppler ultrasound examinations. The diagnoses were classified into three categories: inflammation, vasculitis or ischaemia. The bowel wall thickness, wall echotexture and location of the involved portion were all recorded by grey scale ultrasound, while the presence of an intramural colour Doppler flow and arterial signal was evaluated by colour Doppler ultrasound. The colour Doppler flow was graded as "absent", "mild", or "abundant", and the resistive index was also calculated. Bowel wall thickening was observed in the bowel diseases demonstrating inflammation, vasculitis and ischaemia. Patients with ischaemia were significantly older than those with inflammation. The difference in bowel wall thickness was not significant among the disease categories. Differences in bowel wall echotexture, colour Doppler flow, arterial signal and resistive index among the disease categories were significant. The absence of a colour Doppler flow and of an arterial signal suggested ischaemia, while in younger patients, an abundant colour Doppler flow and a stratified echotexture suggested inflammation. The mean resistive index in the ischemic group was significantly higher than that in the inflammatory group. In conclusion, both grey scale and colour Doppler ultrasound are considered to provide useful information for evaluating and differentiating bowel wall thickening in various bowel diseases.

Aspergillus osteomyelitis in a child who has p67-phox-deficient chronic granulomatous disease

Here we describe Aspergillus osteomyelitis of the tibia in a 9-year-old boy who has an autosomal recessive form of chronic granulomatous disease (CGD). The patient showed a p67-phagocyte oxidase (phox) deficiency, which is rare type of CGD in Japan. The initial treatment which consisted of surgical debridement and antibiotic therapy with amphotericin B (AMPH), did not control the infection. Aspergillus fumigatus (A. fumigatus) pure isolated from drainage fluid and necrotic bone tissue demonstrated less susceptible to antifungal agents, including AMPH, fluconazole and flucytosine. Recombinant interferon gamma was then administrated, and it was effective in controlling the course of severe invasive aspergillosis. This report indicates the use of interferon gamma might be helpful in control for Aspergillus osteomyelitis of the tibia in a child with CGD demonstrated p67-phox deficiency refractory to conventional therapy with AMPH.

Obstructive jaundice due to multiple hepatic abscesses

A 63-year-old Japanese male with diabetes mellitus developed obstructive jaundice following the onset of multiple hepatic abscesses. Percutaneous transhepatic cholangiography showed intrahepatic bile duct irregularity and dilatations accompanied by a complete obstruction of the right branch of the intrahepatic bile duct. Three kinds of organisms were cultured from the blood and the drained bile. The cholangiographic changes returned to the normal after the liver abscesses subsided following biliary drainage and the administration of intravenous antibiotics.

The value of colour Doppler ultrasonography for small bowel involvement of adult Henoch-Schönlein purpura

Three patients presented with a non-thrombocytopenic purpuric rash on their upper and lower limbs, abdominal pain, diarrhoea, and arthralgia. Grey scale ultrasound showed abnormally thickened walls of the small bowel. Colour Doppler showed blood flow signals in the diseased bowel wall in all patients. Subsequent barium and endoscopic studies showed oedematous bowel loops with petechial lesions. Biopsy from the purpuric rash of the skin demonstrated vasculitis of subdermal small vessels. The clinical diagnosis of Henoch-Schönlein purpura was made in each case. This paper describes the efficacy of grey scale and colour Doppler ultrasonography in the assessment of the small bowel involvement of Henoch-Schönlein purpura.

Stabilization of an acetabular fracture with cables for acute total hip arthroplasty

A critical stage of total hip arthroplasty for an acute acetabular fracture where extensive comminution, impaction, and osteopenia thwart the application of conventional open or closed methods, especially in the elderly, is stable fixation of the acetabulum. The use of 2-mm braided cables permits effective immobilization of the fracture for use in conjunction with a hybrid arthroplasty. The method is consistent with the use of a conventional arthroplastic incision and is suitable for other applications including the fixation of periprosthetic fractures, bulk allografts, and conventional acetabular fractures.

Comparison of systemic and renal hemodynamics measured by Doppler ultrasonography in canine experimental hypovolemia

The aim of this study was to examine renal hemodynamics at the hypovolemic and recovery phases in two different hypovolemic shock models using Doppler ultrasonography, and to compare this with systemic hemodynamics. In experiment 1, the hypovolemic phase was induced in 6 mongrel dogs by removing arterial blood at 30 ml/kg for 60 min. In the recovery phase, this blood was reinfused at 30 ml/kg over 60 min. In experiment 2, hypovolemia was induced in 12 beagle dogs by rapid blood removal until blood pressure decreased to 40 mmHg and was maintained at this pressure for 30 min. Six of the dogs were then infused with 20 ml/kg hydroxyethyl starch over 5 min, and the other 6 were infused with 60 ml/kg lactated Ringer's solution also over 5 min. Parameters for systemic and renal hemodynamics were measured by using a polygraph and the Doppler method, respectively. The decrease of diastolic blood flow, resulted in an increase of vessel resistance, and was detected in the hypovolemic kidney by the Doppler method. The rapid and large volume infusion of resuscitation fluids was effective for the recovery of both systemic circulation and renal blood flow, however this induced an increase of kidney vessel resistance, a result of the autoregulation mechanism of the kidney. The changes in these parameters at the main renal artery and interlobar artery were similar.

Doctor-shopping patients and users of alternative medicine among Japanese primary care patients

To describe the clinical characteristics of patients with doctor-shopping behavior (doctor-shopping patients) and users of alternative medicine among Japanese primary care patients, 1088 patients from the general medicine outpatient clinic of a medical school hospital answered an original questionnaire and 30-item General Health Questionnaire (GHQ). A random sample of patients was questioned in accordance with the Diagnostic Interview Schedule modified for use in Japan (DIS-JM). Twenty-three percent of these patients met our criteria for doctor-shopping patients, and 7.9% had used alternative medicine. Multivariate analysis showed no significant difference between the two groups of patients with regard to sex, age, residence, occupation, education, or marital status. The most striking characteristics of doctor-shopping patients were chronicity of illness (p < 0.005), inability to understand doctors' explanations (p < 0.005), disbelief of the doctor's diagnosis and treatment (p < 0.005), and high GHQ scores (p < 0.05). The major factor for alternative medicine users was high expectations of medical school hospitals (p < 0.01). DIS-JM interviews showed that doctor-shopping patients had a high lifetime prevalence of mental disorders. The lifetime prevalence of DSM-III somatization disorders was significantly higher in the two study groups. These results suggest that the risk factors for doctor shopping are strongly associated with chronic conditions and the doctor-patient relationship. Also, users of alternative medicine had high expectations of medical school hospitals as the symbol of modern medicine. Therefore, we emphasize the importance of accurate explanations and maintenance of good doctor-patient relationships by physicians providing care. We also suggest that when obtaining the patient's medical history, doctors ask how many prior visits the patient has made to medical facilities with the same complaint, and how many times the patient has used alternative medicine.

Cerebral infarction in a young adult associated with protein C deficiency. A case report

Protein C deficiency is a cause of thromboembolic disease. Venous thrombosis is the most common clinical manifestation. Arterial thrombosis is unusual and involvement of the intracranial arteries is especially rare. Herein the authors describe a case of cerebral [correction of cerebellar] infarction associated with protein C deficiency and review the relevant medical literature. A thirty-year-old man was hospitalized because of dysarthria, right limb ataxia, and a gait disturbance. Cranial computed tomography disclosed an infarction in the right cerebellar hemisphere and brachium pontis. Three months earlier the patient had had a transient ischemic attack with truncal ataxia and gait disturbances. On admission, the protein C antigen was 57% and protein C activity was 45%. Investigation of family members revealed protein C deficiency in an uncle. Literature review of stroke cases associated with protein C deficiency revealed that most had had a previous vascular event and/or a positive family history or had used oral contraceptives chronically. Protein C deficiency should be considered in young stroke patients with a positive family history of vaso-occlusive disease, previous ischemic events, or chronic oral contraceptive use.

Informative usefulness of age, sex and vital signs in the differential diagnosis of disturbed consciousness among 175 emergency outpatients

Final diagnoses were determined among 175 emergency patients with disturbed consciousness with a Glasgow Coma Scale (GCS) of less than 15 and diagnostic usefulness of basic information was assessed using clinico-epidemiological indices. Subject patients included 98 males and 77 females with average age 53.4 years. Final diagnoses were as follows: intracranial lesions in 69 patients (39.4%), metabolic and systemic diseases in 97 (55.4%), mental diseases in 4 (2.3%), and diseases of unknown origin in 5 (2.9%). Cerebrovascular disorders and epilepsy were most frequent among the intracranial lesions, and poisoning, hypoglycemia, acute alcoholism and hypoxic encephalopathy among the metabolic and systemic diseases. Informative usefulness of age, sex and vital sings in diagnosing cerebrovascular disorders was analyzed with the use of ROC curves, showing that cut-off points of age over 60 years and of systolic blood pressure greater than 160 mmHg were most useful.

Sonographic features of colon carcinoma seen with high-frequency transabdominal ultrasound

To assess the value of high-frequency ultrasonography as a diagnostic imaging procedure in patients with colon carcinoma, we first evaluated the sonograms of 37 patients who had been already diagnosed with contrast enema and/or colonoscopy as having colon carcinoma. As a result, the sonographic criteria for diagnosis of a possible colon carcinoma were (1) a localized and irregular thickening of the colonic wall with heterogenous low echogenicity, (2) an irregular contour, (3) a lack of demonstrable movement or change of configuration of the bowel on real-time scanning, and (4) absence of wall stratification. During the last 4 years, 41 consecutive patients had findings meeting our sonographic criteria. In 37 patients (90%), the presence of colon carcinoma was confirmed by contrast enema and/or colonoscopy. Our study suggests that high-frequency real-time ultrasonography may be a useful imaging technique in diagnosis of colon carcinoma.

Deep breathing test (DBT) in predicting white coat hypertension

We have evaluated the diagnostic value of deep breathing test (DBT) in detecting the patients with white coat hypertension on the outpatient basis. Thirty patients with untreated mild to moderate hypertension underwent 24-hour ambulatory blood pressure monitoring. Those who had a mean 24-hour blood pressure less than 135/80 mmHg were categorized as having white coat hypertension and the remainder were categorized as sustained hypertension. These two groups were compared with regard to the differences of office blood pressures before and after DBT (i.e., deep breathing 5 times for a minute in sitting position). Although the office systolic pressure significantly fell after DBT in both groups (p < 0.001 vs p < 0.05), there was no significant difference (p = 0.27) between the two groups. On the other hand, the office diastolic blood pressure significantly fell in the white coat hypertensives in contrast with no meaningful fall of it in the sustained hypertensives (p < 0.01 vs p = 0.66). At the cutoff level of -3%, -5% and -10% of the differences in office diastolic blood pressure before and after DBT, the sensitivity for the presence of white coat hypertension were 64.7%, 58.8% and 29.4%, respectively, and the specificity were 61.5%, 84.6% and 100%, respectively. These findings demonstrate that the deep breathing test is useful for identifying white coat hypertension in the outpatient clinic.

Intestinal anisakiasis: US in diagnosis

Eighteen consecutive patients with intestinal anisakiasis were studied with high-resolution ultrasound (US) and barium studies. US showed markedly thickened bowel loops associated with luminal narrowing, swelling of Kerckring folds, and decreased peristalsis. A small amount of ascitic fluid around the bowel loops was found, and cytologic examinations of the ascites revealed a dense infiltration of eosinophils. Barium studies demonstrated segmental mucosal edema of the small intestine: The most common site was the distal ileum, and the mean length of the edematous lesion was 19 cm. All patients underwent treatment of symptoms without laparotomy, and their symptoms disappeared by the eighth day after onset. Patients with acute abdominal symptoms should be asked about the intake of raw or undercooked fish. If the above US features are found, the diagnosis of intestinal anisakiasis must be seriously considered to avoid unnecessary surgical treatment.

[Information value of clinical signs and stat tests as indicators of female outpatient urinary tract infection]

This study was designed to evaluate signs and stat tests as an indicator of lower urinary tract infection in female subjects with urogenital complaints at an out-patient clinic. Of various symptoms including hematuria, pollakiuria, dysuria, urinary retention, and micturition pain, pain during micturition was present in 48% of 25 patients with urinary tract infections and in 4% of 27 patients without urinary tract infections, and was the sign with the highest positive predictive value. Comparison and discrimination of the infection and non-infection groups using a single laboratory valuable yielded significant F-statistics for urinary leukocyte esterase (14.5) and leukocyte count in urinary sediment (31.1), and revealed large Mahalanobis' distances for the same variables. Multivariate analysis using a discriminant function of categorical data (Hayashi's Suryoka type 2) revealed that combining occult blood with leukocyte esterase in the urine or combining red cell count with leukocyte count in sediment did not yield substantially smaller misclassification error than did leukocyte esterase alone or leukocyte count alone. It was concluded that neither urinary occult blood nor red cell count in sediment contribute substantially to the prediction of urinary tract infection. For the purpose of detecting urinary tract infection among outpatients, a receiver-operating characteristic analysis demonstrated that the optimal cut-off point in sediment was 3 or more leukocytes per microscopic high power field (x 400). Urinary leukocyte esterase was found to have limitations for use in screening, because its optimal decision level is equivalent to trace esterase reading on the dipstick test.

[Relationship between referral and patient characteristics]

In order to evaluate the relationship between referral and patient characteristics, 594 new patients utilizing Saga Medical School general clinic were studied using a questionnaire and chart review. Results obtained are as follows: 1) Fifty-eight patients (10%) came for follow-up of mass screening tests, 174 patients (29%) were self-referral, the remaining 362 patients (61%) were under previous care by other physicians. Only 64 patients (11%) had a referral letter. 2) Those patients who were not advised to visit our clinic by non-medical personnel, patients who were seriously ill, elderly patients, residents in distant area, and those with medical problems tended to have a referral letter. 3) Of the 64 patients having referral letters, 15 (23%) took the initiative in asking their previous doctor to write a referral letter. Patients who were highly educated had a greater tendency to request referral letters. 4) The reasons cited by the patients without a referral letter included "Did not think of the necessity" (22%), "Wanted to confirm diagnosis" (22%), "Did not want to make the doctor lose face" (16%), "No improvement in symptoms" (14%) These results indicate that education of patients and the general public, and establishing good physician-patient communication and trust are necessary for increasing the use of referral letter.

Fulminant hepatic failure during perinatal period in a pregnant woman with Wilson's disease

Wilson's disease associated with hepatic failure is not common and the underlying mechanism triggering the event is not known at present. We treated a 28-year-old Japanese woman with Wilson's disease who developed hepatic failure associated with hemolytic crisis just after delivery. She was diagnosed as having Wilson's disease at 12 years of age, at which time she started taking D-penicillamine. She had previously delivered two children without difficulty. When she found out she was pregnant this time, she stopped taking D-penicillamine in contrast to taking it faithfully during her first two pregnancies. On the day of delivery of her full-term baby, jaundice developed accompanied with severe hemolytic crisis. Plasma exchanges and blood transfusion were performed and D-penicillamine administration was started again. She gradually recovered and apparently was following a good clinical course. However, on day 30 the second hemolytic crisis occurred and subsequent liver failure led her to death on day 50. At autopsy her liver was cirrhotic and showed massive necrosis. Prophylactic oral administration of D-penicillamine and careful observation are therefore recommended to prevent hemolytic crisis during the perinatal period.

[A case of remission in metastatic lung tumor from hepatocellular carcinoma after combined CDDP and PSK therapy]

Discussed is the case of a 71-year-old man with multiple large hepatocellular carcinomas. His serum AFP level had markedly increased to 115 X 10(4) ng/ml. His AFP level also elevated and multiple lung metastatic tumors appeared after the second TAE therapy of 30 mg ADM, 10 mg MMC. To arrest these rises 100 mg of CDDP was given intravenously, followed by 3.0 g/day of PSK given orally. Five months later, shadows of the metastatic tumor disappeared and AFP to 540 ng/dl. As the mechanism responsible this improvement, it is felt that the CDDP attacked the metastatic tumors directly, and that this was aided by the follow-up immunotherapy with PSK. The abscopal effect of TAE also may have played a role.

Secretion of an interleukin 1-like activity by acute monocytic leukemia cells which inhibits growth of fibroblasts

Acute monocytic leukemia cells (AMoL cells), obtained by leukapheresis, were cultured in vitro. In response to lipopolysaccharide, AMoL cells produced a large amount of thymocyte proliferation activity. The crude supernatants from AMoL cells inhibited fibroblast growth, in a dose-dependent manner. Upon gel filtration, the thymocyte proliferation activity had a molecular mass of 37,000 and 17,000 daltons, and was heat labile and fairly resistant to freezing and thawing. The fractions containing thymocyte proliferation activity additionally possessed an inhibitory activity for the growth of fibroblasts. These results suggest that AMoL cells may participate in the progress of the disease (leukemia), by secreting these cytokines.

[A study of familial case histories of hepatocellular carcinoma--285 cases in Saga Prefectural Hospital]

We studied whether familial case histories of a liver cancers might be associated with the high mortality rate from liver cancers in Saga prefecture. Examined were 285 familial case histories of a hepatocellular carcinoma (HCC) incurred by parents, siblings, and children during the past 10 years. Familial case histories of patients with a gastric cancer and/or apoplexy also were studied as controls. The incidence of various types of cancers, including liver cancers and gastric cancers, in the family members of the HCC group was found to be the same as seen in family members of the gastric cancer group, but higher than in the families of the apoplexy group. Further, the HCC incidence rate in family members in the HCC group was not high as compared to the average for the whole of Japan. The HBsAg was not found to be associated with the rate of liver cancer in family members in the HCC group. Also, there was no high incidence of liver cancer was observed in children of parents with a liver cancer. From these results, we have concluded that high incidence of liver cancer seen in Saga prefecture was not associated with any familial clustering of HCC cases.

[Analysis of 293 cases of hepatocellular carcinoma of recent ten years--II. Diagnosis, therapy and prognosis]

Two hundred and ninety-three cases of hepatocellular carcinoma (HCC) of recent ten years during 1979 and 1988 were analysed on its diagnosis, therapy and prognosis. Angiography was the most useful diagnostic method for the first 5 years. During recent 5 years and for the tumor with size less than 2 cm, however, ultrasonography was the best method. 24.7% cases showed negative AFP and only 42.5% cases showed the level over 400 ng/ml. According to the tumor occupying-rate at the diagnosis, the number of cases of E1 had increased annually, the other cases being unchanged. 88.6% cases had liver cirrhosis microscopically as being reported previously. As a therapy TAE was most frequently performed, followed by operation, arterial infusion of antitumor drugs et al. The prognosis of the patients depended on the tumor occupying-rate. For the case of E1, the prognosis was the best by the therapy of ethanol injection therapy, operation and TAE. For the cases with tumor of larger than E1, frequent TAE was the best. From these results we concluded that we must make efforts to find small tumors to get the good prognosis.

[Analysis of 293 cases of hepatocellular carcinoma of recent ten years--I. Epidemiology, anamnesis and tumor occupying rate]

Two hundred and ninety-three cases of hepatocellular carcinoma (HCC) admitted to the key hospital of the rural area of western Japan, Saga Prefectural Hospital, during 10 years since 1979 to 1988 were analysed retrospectively. The male to female ratio was 3.7 to 1 and the ratio of HBs-Ag positive to negative was 3.5 to 1. The peak of the age distribution was seventh decade. The incidence increased annually, especially in HBs-Ag negative males. Their past history of blood transfusion was considered as an etiology of HCC in 19 (9.9%). The HCC was diagnosed approximately 10 years earlier in habitual drinkers than non-habitual drinkers of both positive and negative HBs-Ag. The incidence of small tumors is associated with the past history of chronic liver disease, negativity of HBs-Ag, lack of symptoms and old age.

An empty sella associated with hypopituitarism in a woman with rheumatoid arthritis

A 66-year-old woman with rheumatoid arthritis experienced severe hyponatremia and hypoglycemia of repeated occurrence. Endocrinologic examinations revealed hypopituitarism and the metrizamide computerized tomographic scan showed a primary empty sella. No evidence of a pituitary or suprasellar tumor was obtained. During the 5-year follow-up, she remains well under replacement therapy and there are no signs of an intracranial tumor. The possibility of an autoimmune mechanism linked to the development of hypopituitarism is discussed.

Kupffer cells may autoregulate interleukin 1 production by producing interleukin 1 inhibitor and prostaglandin E2

Rat Kupffer cells stimulated with bacterial lipopolysaccharide (LPS) produced high levels of interleukin 1 (IL-1), as determined by thymocyte proliferation assay. Indomethacin revealed a dose-dependent augmentation in IL-1 production, in parallel with a dose-dependent reduction in prostaglandin E2 production by Kupffer cells. The addition of exogenous prostaglandin E2, dibutyryl cAMP, or isoproterenol led to a dose-dependent suppression of IL-1 production. The supernatant from LPS-stimulated Kupffer cells also contained factors that inhibited IL-1-induced thymocyte proliferation. Upon gel filtration, two inhibitory peaks, at apparent MW of 27,000 and 6000, were obtained. The latter but not the former fraction also affected interleukin 2 (IL-2)-induced thymocyte proliferation. Increasing amounts of IL-1 overcame the inhibitory activity derived from the 27,000 MW fractions. These results suggest to us that prostaglandin E2 and IL-1 inhibitor released by Kupffer cells may be involved in negative self-control in regulating IL-1 production and its action.

Kinetics and parameters of the induction of interleukin 1 secretion by rat Kupffer cells

Rat Kupffer cells stimulated with bacterial lipopolysaccharide (LPS) produced high levels of interleukin 1 (IL-1), determined by assaying the thymocyte proliferating activity. The unstimulated Kupffer cells secreted no detectable activity. LPS-induced production of IL-1 activity was dose-dependent and as little as 0.1 micrograms/ml of LPS induced the IL-1 production. Thirty minutes were required for LPS to induce sufficient amounts of IL-1 activity. IL-2 activity was not detected in the Kupffer cell culture medium. Another soluble agent, N-acetylmuramyl-L-alanyl-D-isoglutamine, or phagocytable agents, silica and zymosan, also stimulated IL-1 production by Kupffer cells, whereas phorbol myristate acetate did not. Kinetic studies revealed a rapid increase in both intra- and extracellular IL-1 activity within 1 hr following the addition of LPS, with a peak at 6 hr. This IL-1 activity produced by Kupffer cells was heat labile, resistant to freezing and thawing and precipitated with 65% ammonium sulfate. Upon gel filtration, the activity was present in three peaks of approximately 110, 35 and 15 kd. The hepatocyte stimulating activity, when assayed by alpha 2-macroglobulin inducing activity, was detected in the first two peaks but not in the third peak. These studies suggest that LAF activity is distinct from hepatocyte stimulating activity at least in the molecular weight.

Human Ia-associated invariant chain gene has multiple transcription initiation sites in CLL cells

We show a northern transfer experiment revealed two mRNA of Ia-associated invariant chain (In) gene in chronic lymphocytic leukemia (CLL) cells which are approximately 1580 and 1440 nucleotides in length. Primer extension experiment shows that less prominent transcript was found to initiate 140 nucleotides upstream from the major cap site. The newly identified cap site was preceded by CG rich sequence but no typical promotor sequence. Southern hybridization analysis with In cDNA probe indicates no recombination or amplification of In gene in the CLL cells. This is the first documented example of such a mode of expression in malignant cells in vivo.

Production of hepatocyte stimulating factor of rat Kupffer cells induced by lipopolysaccharide: partial characterization and effects on alpha 2 macroglobulin gene expression in cultured adult rat hepatocytes

Primary cultured rat Kupffer cells stimulated with lipopolysaccharide (LPS) produced a hepatocyte stimulating factor (HSF), which enhanced the synthesis of acute phase protein, alpha 2-macroglobulin (alpha 2M), in adult rat hepatocytes. The Kupffer cell derived-HSF (KC-HSF), enhanced the synthesis of alpha 2M over 100 fold by primary cultured adult rat hepatocytes, in the presence of dexamethasone (Dex). The synthesis of albumin was not stimulated by the factor, even in the presence of Dex. The alpha 2M mRNA increased exponentially starting at 3 hr after addition of the factor. Therefore, the synthesis of alpha 2M stimulated by KC-HSF is probably controlled at the pretranslational phase. The LPS stimulated production of the KC-HSF was inhibited by actinomycin D. The HSF was precipitated between 35% and 65% saturation with ammonium sulfate and collected in the over 30,000 daltons fraction, by molecular sieving. Sephacryl S-200 gel chromatography revealed two distinct forms of HSF with apparent molecular weights of approximately 30,000 and 100,000 daltons. The majority of the activity was recovered in the latter fraction. Isoelectric chromatofocusing of the 100,000 daltons form of HSF yielded a single peak of activity with an apparent isoelectric point (pI) of 4.2. Each fraction contained the interleukin-1 (IL-1) activity, determined by thymocyte proliferation assay. These results show that Kupffer cells produce a cytokine, KC-HSF with IL-1 activity but different properties, as seen on the on Sephacryl S-200 gel filtration and isoelectrofocusing from known mouse or human IL-1.

Lack of evidence for a pyruvate kinase isozyme shift in hepatocytes of the regenerating rat liver

1. Pyruvate kinase isozyme shift in a regenerating rat liver was studied. Rats were subjected to a 70% hepatectomy and the liver homogenate or hepatocyte preparations were obtained from the regenerating liver. 2. Using thin layer polyacrylamide gel electrophoresis, liver homogenates from an intact normal rat appeared to contain the L-type isozyme in the greatest number and M2-type to a lesser extent. 3. The ratio of the M2- to L-type increased in the preparations obtained from the regenerating liver. 4. In the hepatocyte preparations prepared from a regenerating rat liver by the conventional method, a small amount of M2-type isozyme was detected. 5. However, the M2-type isozyme was hardly detected in the highly purified hepatocyte preparations prepared using Percoll. 6. Similar results were obtained by separation of the enzyme by DEAE cellulose column chromatography. 7. These results suggest that there is no pyruvate kinase isozyme shift from L- to M2-type in hepatocytes in the course of regeneration. 8. The increased M2-type isozyme in the regenerating rat liver is considered to originate from nonparenchymal cells.

Recovery after radiotherapy from severe interstitial pneumonia due to paraquat poisoning

A 51-year-old man was admitted 3 hours after ingesting approximately 50 ml of mixture of paraquat and organophosphate insecticide. His arterial oxygen pressure fell progressively to 44.6 mmHg. Diagnosed was paraquat-induced interstitial pneumonia. No improvement was observed after treatment with corticosteroid. The pneumonia, however, resolved after irradiation of both lungs and arterial oxygen pressure showed marked improvement. Radiotherapy to the lungs should be considered only in patients who showed progressive deterioration of respiratory function.

Kupffer cells modulate natural killer cell activity in vitro by producing prostaglandins

The effect of Kupffer cells on natural killer (NK) cell-mediated cytotoxicity was examined. Kupffer cells prepared from rat liver suppressed NK activity against K562 cells and other tumor cell lines through a soluble factor secreted into the culture supernatant. When human peripheral blood mononuclear cells were incubated with the Kupffer cell-culture supernatant, a significant reduction of the cytotoxic activity was observed in the 6-hr chromium-release assay. This activity was dose dependent and was evident at various effector/target cell ratios. Lipopolysaccharide stimulated generation of the suppressive factor released from Kupffer cells in a dose-dependent manner. Suppression of the NK activity was observed when the Kupffer cell-culture supernatant was present in the assay system, whereas pretreatment of effector/target cells with the supernatant had minimal inhibitory effects. Autologous monocytes in human peripheral mononuclear cells were not related to this suppression. The suppressive factor in the fraction had a molecular weight below 10,000. Indomethacin, an inhibitor of prostaglandin synthesis, ameliorated the suppressive effects. These results suggest that Kupffer cells may modulate NK activity by producing PGs (E1, E2, and F2 alpha).