Influence of nurse work environment and psychological distress on resignation from hospitals: a prospective study

With the global nurse shortage, identifying nurse work environments that allow nurses to continue working is a common concern worldwide. This study examined whether a better nurse work environment (1) is associated with reducing nurses' psychological distress; (2) reduces nurse resignations; (3) weakens the influence of psychological distress on their resignation through interaction effect; and (4) whether psychological distress increases nurse turnover. Multilevel logistic regression analyses were performed using data obtained in 2014 from 2,123 staff nurses from a prospective longitudinal survey project of Japanese hospitals. The nurse work environment was measured by the Practice Environment Scale of the Nursing Work Index (PES-NWI) consisting of five subscales and a composite, and psychological distress by K6. All the PES-NWI subscales and composite (ORs 0.679-0.834) were related to K6, significantly. Regarding nurse turnover, K6 had a consistent effect (ORs 1.834-1.937), and only subscale 2 of the PES-NWI had a direct effect (OR 0.754), but there was no effect due to the interaction term. That is, (1) and (4) were validated, (2) was partly validated, but (3) was not. As better work environment reduces K6 and a lower K6 decreases nurses' resignation, high-level hospital managers need to continue improving the nurse work environment.

Factors associated with non-home discharge of patients hospitalized for hip fracture: A nationwide retrospective study using the Japanese diagnostic procedure combination database

In Japan, the length of stay in acute care hospitals has been shortened, home medical care has been promoted following national policy. However, many issues remain in promoting home medical care. The aim of this study was to clarify the profiles of patients with hip fractures, aged ≥ 65 years, who were hospitalized in acute care institutions at the time of discharge and the influence on nonhome discharge. This study used data from patients who satisfied all the following conditions: Patients aged ≥ 65 years who were hospitalized and discharged between April 2018 and March 2019; Patients with hip fractures, and; Patients who were admitted from home. The patients were classified into the home discharge and nonhome discharge groups. Multivariate analysis was conducted by comparing socio-demographic status, patient background factors, patient status at discharge, and hospital function. This study included 31,752 patients (73.7%) and 11,312 patients (26.3%) in the nonhome discharge group and home discharge group, respectively. Overall, the proportions of males and females were 22.2% and 77.8%, respectively. The average (standard deviation) age of the patients was 84.1 years (7.4) and 81.3 years (8.5) in the nonhome discharge and home discharge groups, respectively (P < .01). The following factors affected nonhome discharge: 75 to 84 years (odds ratio [OR] = 1.81, 95% confidence interval [CI] = 1.68-1.96), ≥85 years (OR = 2.17, 95% CI = 2.01-2.36), electrocardiography or respiratory treatment "(Factor A3) (OR = 1.44, 95% CI = 1.23-1.68), level of assistance with activities of daily living "(Factor B1)" (OR = 4.56, 95% CI = 4.22-4.92), and hospital where the patient-to-nurse ratio is 7:1 (OR = 2.12, 95% CI = 1.91-2.35). The results suggested that support from activities of daily living caregivers and implementing medical treatments such as respiratory care are required to advance home medical care. This study's method enables analysis focusing on aspiration pneumonia and cerebral infarction, which are common among older adults. Furthermore, specific measures for promoting home medical care for patients who are highly dependent on medical and long-term care may be developed.

Evaluation of the condition of inpatients in acute care hospitals in Japan: A retrospective multicenter descriptive study

This retrospective, multicenter, descriptive study aimed to evaluate the conditions of inpatients in acute care hospitals using the Severity of a Patient's Condition and Extent of a Patient's Need for Medical/Nursing Care tool. The study included 4 234 253 patients admitted to acute care hospitals in Japan between April 2019 and March 2020. Electrocardiographic monitoring, provision of respiratory care, and administration of antiarrhythmic agent injections and treatment were performed in a sterile room for >20%, >10%, and <1% of patient-days, respectively. More than 40% of inpatients needed support with performing activities of daily living, such as dressing and undressing, turning over, and oral care. The proportion of patients requiring daily medical/nursing care was generally high at the beginning of hospitalization, gradually decreased, and subsequently increased. Patients in acute care hospitals in Japan were not hospitalized unnecessarily early or for inappropriately long periods, and the efficiency of medical care improved over time. The Severity of a Patient's Condition and Extent of a Patient's Need for Medical/Nursing Care tool is useful for evaluating patient conditions in acute care hospitals.

Fractures within 2 years of an obstetric hospitalization: analysis of nationwide administrative data in Japan

INTRODUCTION

Pregnancy- and lactation-associated osteoporosis (PLO) is a condition in which young women develop fractures during pregnancy or breastfeeding. Though PLO is a severely debilitating disease, its pathophysiology and epidemiology have not been clarified and its treatment has not been established. We aimed to identify the incidence and factors associated with fractures occurring within 2 years following an obstetric hospitalization.

MATERIALS AND METHODS

We extracted data on fractures occurring within 2 years of an obstetric hospitalization from the Japanese Diagnosis Procedure Combination database. We analyzed the implementation of bone mineral density and bone metabolism marker tests, prescription status, and factors associated with fractures occurring within 2 years of an obstetric hospitalization.

RESULTS

Among 837,347 patients with a history of obstetric hospitalization from 2010 to 2014, 379 patients had a history of hospitalization due to a fracture occurring within 2 years (4.5/10,000 pregnancies). Among the patients with fractures occurring within 2 years of an obstetric hospitalization, 6.7% underwent bone mineral quantification or a bone metabolism marker test, and 7.5% were prescribed a lactation inhibitor or osteoporosis treatment. Factors associated with fractures occurring within 2 years following an obstetric hospitalization identified included Cushing syndrome, Charlson Comorbidity Index score ≥ 1, age ≥ 40 years old at pregnancy, smoking history, and steroid administration.

CONCLUSION

We investigated fracture cases occurring within 2 years of an obstetrics hospitalization. This finding may be useful in selecting preventative measures for patients at risk of fractures within 2 years after obstetric hospitalization, including PLO.

Impact of social support for mothers as caregivers of cerebral palsy children in Japan

PURPOSE

Social supports are critical to alleviate the psychological and physical burden of primary caregivers of children with disabilities. This study aims to (1) clarify how cerebral palsy in children affects caregiving burden of the mother, and (2) identify the social supports that can effectively reduce that burden.

DESIGN AND METHODS

This is a cross-sectional study in which mothers of children with cerebral palsy completed questionnaires and provided data regarding their child's condition, family support, social support usage, degree of satisfaction with supports, and caregiving burden.

RESULTS

We analyzed responses from 1190 mothers. Support usage, particularly of home-visit nursing, home care, home-visit rehabilitation, and mobility support, was higher in severely burdened groups. However, the proportion of satisfaction with social support in groups with light or no burden were higher, particularly in home care, home-visit rehabilitation, training/treatment, and short stays. Mothers whose children have an intellectual disability and gross exercise ≥1 in addition to tube feeding or intravenous nutrition especially felt a strong sense of burden. The most effective measure in reducing mother's sense of burden was short stays.

CONCLUSIONS

Mothers with children who can move and have an intellectual disability felt more burden compared with mothers of bedridden children. The findings clarify that supports, such as home care and short stays, have a significant impact on reducing the mother's sense of burden.

PRACTICE IMPLICATIONS

Due to the large sample size, we believe that the results can inform efforts to increase social support for caregivers.

Impact of orthogeriatric care management by orthopedic surgeons and physicians on in-hospital clinical outcomes: A difference-in-difference analysis

AIM

The orthopedic surgery unit in our suburb serves a large elderly trauma population in addition to providing elective surgeries. As patients with hip fractures have become older and at higher risk of medical complications, our hospital has initiated integrated co-management of these patients by orthopedic surgeons and geriatricians from the point of hospital admission. The aim of this study was to evaluate the impact of the hospital policy change on hip fracture management and clinical outcome indicators.

METHODS

Using the difference-in-difference approach, in total, 288 consecutive patients with hip fractures treated during the 1 year before and 2 years after transition to orthogeriatric care from a geriatric consultation model to integrated orthogeriatric care model were compared with 576 patients from other local hospitals.

RESULTS

Despite a seasonal trend toward increased length of hospital stay in winter, the intervention significantly reduced the change in mean length of stay (mean difference [95% confidence interval], -12.9 days [-21.5 to -4.3]; P = 0.007) and discharge to home tended to change less frequently (-12.6%; P = 0.10). There was no significant reduction in mean time to surgery (-0.2 days; P = 0.83), mortality (-0.8%; P = 0.62), or complications (-1.0%; P = 0.85).

CONCLUSIONS

Changing our hip fracture service from a geriatric consultation model of care to an integrated orthogeriatric model significantly reduced length of hospital stay probably due to a lower chance of discharge to home. To our knowledge, this is the first study in Japan to compare two orthogeriatric care models considering the nationwide improvement in hip fracture management.

AUTHOR

Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2022; ••: ••-••.

Association between hospital surgical volume and complications after total hip arthroplasty in femoral neck fracture: A propensity score-matched cohort study

BACKGROUND

For displaced femoral neck fractures (FNF), total hip arthroplasty (THA) or hemiarthroplasty (HA) is preferred rather than fracture fixation. THA for patients with FNF requires skilled operators since patient with FNF likely to have osteoporosis and a higher risk of complications. Several reports suggest that higher hospital surgical volume was associated with a lower risk of complications after THA for osteoarthritis. However, little is known concerning this association with THA for FNF. Herein, we investigated the association between THA and complication and the recovery of physical function after THA to optimize the quality of FNF.

METHODS

A nationwide retrospective cohort study of elderly undergoing THA between April 1, 2011, to March 31, 2018 was performed. The association between hospital surgical volume and complication after THA for FNF was visually described with the restricted cubic spline regression analysis. Then the risk of complications was quantified with propensity score matching analysis based on the cutoff point identified by the restricted cubic spline curve. Primary outcome was secondary revision surgery, and the secondary outcomes included surgical and systemic complications, and the recovery of physical function at hospital discharge.

RESULTS

By visualization of the spline curve, we identified 20 cases per year as cutoff point of low hospital surgical volume. Following 1,396 patients' propensity score-match analysis (mean age 75.2 [SD] 8.8, female 80.4%), the risk of secondary revision surgery was significantly higher among the low hospital surgical volume group (absolute risk difference (RD), 2.44%; p = 0.011). Also, the incidence of blood transfusion was higher in the low hospital surgical volume group (RD, 4.01%; p = 0.049). However, there was no significant difference in the recovery of the transferring and walking ability at discharge between high and low hospital surgical volume groups (63.5% vs 62.6%, 58.5% vs 57.5%; p = 0.74, 0.71, respectively).

CONCLUSION

Our research demonstrated that an increase in hospital surgical volume significantly reduced the incidence of secondary revision surgery after a certain inflection point, but not significantly improved short-term physical functions.

Dementia and patient outcomes after hip surgery in older patients: A retrospective observational study using nationwide administrative data in Japan

Objective

To investigate whether dementia is associated with incidence of adverse events and longer hospital stays in older adults who underwent hip surgery, after adjusting for individual social and nursing care environment.

Design and setting

Retrospective observational study using the linked data between the Japanese Diagnosis Procedure Combination database and the reports of the medical functions of hospital beds database in Japan (April 2016—March 2017).

Participants

A total of 48,797 individuals aged 65 and older who underwent hip surgery and were discharged during the study period.

Methods

Outcomes included in-hospital death, in-hospital pneumonia, in-hospital fracture, and longer hospital stay. We performed two-level, multilevel models adjusting for individual and hospital characteristics.

Results

Among all participants, 20,638 individuals (42.3%) had dementia. The incidence of adverse events for those with and without dementia included in-hospital death: 2.11% and 1.11%, in-hospital pneumonia: 0.15% and 0.07%, and in-hospital fracture: 3.76% and 3.05%, respectively. The median (inter quartile range) length of hospital stay for those with and without dementia were 26 (19–39) and 25 (19–37) days, respectively. Overall, the odds ratios (95% confidence interval (CI)) of dementia for in-hospital death, in-hospital pneumonia, and in-hospital fracture were 1.12 (0.95–1.33), 0.95 (0.51–1.80), and 1.08 (0.92–1.25), respectively. Dementia was not associated with the length of hospital stay (% change) (-0.7%, 95% CI -1.6–0.3%). Admission from home, discharge to home, and lower nurse staffing were associated with prolonged hospital stays.

Conclusions

Although adverse events are more likely to occur in older adults with dementia than in those without dementia after hip surgery, we found no evidence of an association between dementia and adverse events or the length of hospital stay after adjusting for individual social and nursing care environment.

Structure and process of dementia care and patient outcomes after hip surgery in elderly people with dementia: A retrospective observational study in Japan

BACKGROUND

Japan introduced the financial incentives for dementia special care at hospitals in the fee schedule in April 2016.

OBJECTIVE

To investigate whether the financial incentives for dementia special care contributed to better patient outcomes after hip surgery for older adults with dementia.

DESIGN

Retrospective observational study using the Diagnosis Procedure Combination database and the Reporting on medical functions of hospital beds data.

SETTING

Acute care hospitals adopting the Diagnosis Procedure Combination system in Japan.

PARTICIPANTS

A total of 20,393 eligible patients aged 65 years or older with dementia who underwent hip surgeries and discharged from 405 hospitals from April 2016 to March 2017.

METHODS

There are two levels of dementia care quality categories in the financial incentives for dementia special care as follows: Type 1 requires a multidisciplinary team with geriatric and dementia care expertise and Type 2 requires to assign trained nurses who underwent dementia training at every general ward. The outcomes were in-hospital mortality, readmission within 30 days, and length of hospital stay. We performed generalized estimating equation model or logistic generalized estimating equation models adjusting for individual and hospital characteristics.

RESULTS

Among the 405 hospitals, the numbers of hospitals without dementia care incentive, those with Type 1, and those with Type 2 were 207, 99, and, 99, respectively. Overall, the prevalence of in-hospital death and readmission within 30 days was 2.01% and 2.70%, respectively. Overall, the mean (standard deviation, SD) length of hospital stay was 32.0 (20.0) days. There were no significant associations between dementia special care and in-hospital mortality in Type 1 (adjusted OR [odds ratio] =0.87, 95% confidence interval [CI] = 0.66-1.16) and Type 2 (adjusted OR = 1.18, 95% CI = 0.92-1.52), and readmission within 30 days in Type 1 (adjusted OR = 1.11, 95% CI = 0.89-1.38) and Type 2 (adjusted OR = 1.03, 95% CI = 0.83-1.29). Length of hospital stay was not significantly different among hospitals with and without incentive, Type 1 (coefficient -0.23, 95% CI = -2.64-2.18.), and Type 2 (coefficient 0.87, 95% CI = -1.54-3.28). An increase in patient-to-nurse ratio was significantly associated with 2.25 days longer length of hospital stay (95% CI 1.00-3.51).

CONCLUSION

Dementia care incentive was not associated with better outcomes in elderly with dementia who underwent hip surgery in Japan, but the worse nurse workload was associated with longer length of hospital stay. Further long-term assessment is necessary.

The Effect of Branched Chain Amino Acids-Enriched Nutritional Supplements on Activities of Daily Living and Muscle Mass in Inpatients with Gait Impairments: A Randomized Controlled Trial

OBJECTIVE

To investigate the effects of continuous intervention with branched chain amino acids-enriched nutritional supplements from the acute phase to convalescent rehabilitation wards in inpatients with gait impairments.

DESIGN

Open-label, randomized, parallel-group comparison study (UMIN Clinical Trials Registry ID: UMIN000018640).

SETTING

Acute care and convalescent rehabilitation wards.

PARTICIPANTS

We studied 80 patients undergoing stand/gait training.

INTERVENTIONS

Participants in the intervention group (RJ group) received nutritional supplements (jelly foods comprising 2500 mg BCAA and 20 IU vitamin D) twice a day until hospital discharge.

MEASUREMENTS

The primary outcome was the motor components of the Functional Independence Measure (FIM-m), and the secondary outcome was skeletal muscle mass index.

RESULTS

Analyses were conducted on 55 patients who were able to perform stand/gait training continuously from the acute until the recovery phases. FIM-m was significantly elevated in the RJ group and the control group , but no difference was noted between the two groups. Only the RJ group showed a significant increase in skeletal muscle mass index, and the amount of variation was significantly different between the two groups (the control group decreased an average of 2.2% and the RJ group increased an average of 4.3%; P = 0.014). A significant decrease in body weight was found only in the control group (P = 0.084).

CONCLUSIONS

Nutritional interventions using branched chain amino acids (BCAA)-enriched nutritional supplements demonstrated no significant difference in activities of daily living; however, an increase in skeletal muscle mass was noted. Skeletal muscle mass and body weight differed significantly between the two groups, and BCAA-enriched nutritional supplements intake in acute and convalescent rehabilitation wards may be effective for the prevention of malnutrition and sarcopenia.

Prevention of surgical site infection via antibiotic administration according to guidelines after gynecological surgery

AIM

We modified the antimicrobial prophylaxis of surgical site infection (SSI) according to the guidelines of the Japanese Society of Chemotherapy and Japan Society of Infectious Diseases (hereinafter referred to as optimization) and measured outcomes.

METHODS

From April 2016 to March 2017, we performed cesarean section and open hysterectomy with optimization, and compared the outcome to that of surgery performed without optimization between April 2014 and March 2016. We measured the rates of antibiotic discontinuation, appropriate antibiotic selection, SSI incidence, resumption of antibiotic therapy and fever incidence, as well as the length of postoperative hospital stay and medical expenses for antibiotics to evaluate the appropriateness and outcomes of antibiotic prophylaxis.

RESULTS

Optimization resulted in a change in the method of selecting antibiotics for cesarean section, but there was no change in SSI incidence rate (0.74% vs 0.0%, P = 0.36). Optimization reduced the use of antibiotics and medical expenses of hysterectomy (median reduction of 50% and 78% for hysterectomy without or with lymphadenectomy, respectively). However, there was no change in outcome regarding SSI incidence (5.7% vs 0.0%, P = 0.11 and 7.8% vs 9.5%, P = 0.77, respectively).

CONCLUSION

Appropriate use of antibiotics according to guidelines reduced antibiotic dose and medical expenses, but there was no change in outcome regarding SSI incidence rate. These findings suggested that implementation of dosing regimens according to the guidelines would be useful to reduce antibiotic medicine costs and prevent resistant bacteria and complications associated with antibiotics.

Computer Assisted Image Analysis Using the Subtraction Method in Indocyanine Green Angiography

The choroidal vessels are three dimensionally distributed and very complex in their patterns. They often appear to be overlaid in indocyanine green (ICG) angiograms so it is harder to analyze ICG angiography than fluorescein angiography. When an earlier frame is subtracted from a later frame in a sequence of angiograms, the fluorescence which has increased during the time between the two frames can theoretically be demonstrated.

We applied computer-assisted image subtraction methods in selected clinical cases of directly acquired digital ICG angiography to demonstrate how this method works. We used software already installed in an IMAGEnet computer system (Topcon) for image subtraction. We applied the subtraction technique in 18 cases with various diseases. When two images with a time difference of several seconds were subtracted, filling of the choriocapillaris, the neovascularization or the pathological vessels could be observed. When the images had a time difference of several minutes, intrachoroidal dye leakage could be seen more clearly. This method is very helpful for analyzing pathological changes in ICG angiography in clinical cases, when two images are selected appropriately.

Digital Fluorescein Fundus Angiography with DFC-512 and Imagenet Systems

Image processing with direct acquisition digital fundus fluorescein angiography using the OIS DFC-512 and Topcon IMAGEnet were assessed. Fundus diseases included central and branch retinal vein occlusion, diabetic retinopathy, age-related macular degeneration, central serous choroidopathy and angioid streaks. Analogue images were taken with Kodak Tri-X 35 mm film as well. Although the resolution of the original image was less than that of 35 mm film, it was improved by image processing, particularly contrast enhancement. One type of contrast enhancement, available in both systems, exaggerated lack of light at the peripheral area of the original image. This drawback was not seen with another type of enhancement processing, available in IMAGEnet. However, the latter produced an artificial hypofluorescent area around an intensely hyperfluorescent lesion and also exaggerated hyper- and hypo-fluorescent patches of the background. Nevertheless, these processing methods were particularly useful in case of media opacity like cataract, even when the 35 mm film picture is not clear. Other processing techniques like pseudocolor and relief, etc. were used just for different ways of presentation. The two systems are basically equivalent, except for contrast enhancement. There was no problem for diagnosis in both systems, but the artificial effects must be borne in mind when interpreting the image.

Validity of diagnoses, procedures, and laboratory data in Japanese administrative data

Background

Validation of recorded data is a prerequisite for studies that utilize administrative databases. The present study evaluated the validity of diagnoses and procedure records in the Japanese Diagnosis Procedure Combination (DPC) data, along with laboratory test results in the newly-introduced Standardized Structured Medical Record Information Exchange (SS-MIX) data.

Methods

Between November 2015 and February 2016, we conducted chart reviews of 315 patients hospitalized between April 2014 and March 2015 in four middle-sized acute-care hospitals in Shizuoka, Kochi, Fukuoka, and Saga Prefectures and used them as reference standards. The sensitivity and specificity of DPC data in identifying 16 diseases and 10 common procedures were identified. The accuracy of SS-MIX data for 13 laboratory test results was also examined.

Results

The specificity of diagnoses in the DPC data exceeded 96%, while the sensitivity was below 50% for seven diseases and variable across diseases. When limited to primary diagnoses, the sensitivity and specificity were 78.9% and 93.2%, respectively. The sensitivity of procedure records exceeded 90% for six procedures, and the specificity exceeded 90% for nine procedures. Agreement between the SS-MIX data and the chart reviews was above 95% for all 13 items.

Conclusion

The validity of diagnoses and procedure records in the DPC data and laboratory results in the SS-MIX data was high in general, supporting their use in future studies.

•

Validity of DPC and SS-MIX data was tested using chart review results as references.

•

Specificity of DPC diagnoses was high; sensitivity was low and varied by conditions.

•

Procedure records in DPC data were highly sensitive and specific.

•

Accuracy of SS-MIX laboratory data exceeded 95% in all 13 items examined.

Weekly paclitaxel/5-fluorouracil followed by platinum retreatment for patients with recurrent ovarian cancer: a single institution experience

PURPOSE

Since the prognosis of recurrent ovarian cancer patients is still poor, we need to establish a useful treatment strategy to achieve their long-term survival. We treated recurrent ovarian cancer patients with weekly paclitaxel (PTX)/5-fluorouracil (5-FU) followed by platinum retreatment to investigate its clinical efficacy in a preliminary manner.

METHODS

Sixteen patients with recurrent ovarian cancer, pretreated with taxane and platinum, were treated with weekly paclitaxel (PTX)/5-fluorouracil (FU). PTX (80 mg/m2) on day 1, 8, and 15 was combined with a bolus injection of 5-FU (500 mg/m2) on day 2, 9, and 16. Chemotherapy was given every four weeks. Patients with stable disease or progressive disease were subsequently retreated with a platinum-containing regimen. Response was evaluated by RECIST criteria or CA125 criteria. Toxicities were evaluated according to the National Cancer Institute-common toxicity criteria (NCI-CTC) version 3.

RESULTS

Among five patients with sensitive disease, one of four patients with measurable tumor and one without measurable tumor responded to weekly PTX/5-FU. Among 11 patients with resistant disease, none of five patients with measurable tumor and three of six patients without measurable tumor responded to weekly PTX/5-FU. Overall objective response rate by weekly PTX/5-FU was 31.3% (5/16). Among 16 patients, 13 patients who showed no response or progressive disease (three with sensitive disease, ten with resistant disease) received platinum retreatment after weekly PTX/5FU. All three patients with sensitive disease and three of ten patients with resistant disease revealed response to platinum retreatment. Overall objective response rate by platinum retreatment after weekly PTX/5-FU was 46.2% (6/13).

CONCLUSIONS

Weekly PTX/5FU followed by platinum retreatment could be a useful treatment strategy for recurrent ovarian cancer patients. We need to establish the standard treatment strategy for recurrent ovarian cancer patients with a poor prognosis.

Acid-suppressive effects of various regimens of omeprazole in Helicobacter pylori-negative CYP2C19 homozygous extensive metabolizers: which regimen has the strongest effect?

To achieve more potent and long-lasting acid suppression, omeprazole was administered for 7 days in 5 regimens: 10, 20, and 40 mg once daily (od), and 10 and 20 mg twice daily (bid), in 7 healthy Helicobacter pylori-negative CYP2C19 homozygous extensive metabolizers, and intragastric pH was continuously measured. The median intragastric pH and percent time pH > 4.0 for 24 hours increased dose dependently with 10, 20, and 40 mg od. Ten and 20 mg bid wre comparable to 20 and 40 mg od, respectively. Concerning percent time pH > 4.0 in the nighttime (20:00-8:00 hours), 20 mg bid was significantly superior to 40 mg od (P < .05). In 4 of the 5 regimens, all 7 subjects had nocturnal acid breakthrough, whereas with 20 mg bid it occurred in only 3. We concluded that, considering nighttime acid suppression, omeprazole 20 mg bid had the strongest effect.

Macrophages and dendritic cells infiltrating islets with or without beta cells produce tumour necrosis factor-alpha in patients with recent-onset type 1 diabetes

AIMS/HYPOTHESIS

Type 1A diabetes results from autoimmune destruction of pancreatic beta cells. We examined the involvement of TNF-alpha and IL-1beta, as well as of T cells, macrophages and dendritic cells, in the destruction of beta cells in patients with recent-onset type 1 diabetes.

MATERIALS AND METHODS

We obtained pancreatic biopsy specimens from six patients with recent-onset type 1 diabetes and analysed these by immunohistochemistry.

RESULTS

T cell infiltration was less common in islets without beta cells (12.5 [0-33.3]%) than in those with beta cells (46.0 [17.4-83.3]%), while macrophages and dendritic cells showed a similar extent of infiltration into islets both with or without beta cells. TNF-alpha was detected in 25.0 (4.3-46.9)% of macrophages and 11.8 (0-40.0)% of dendritic cells infiltrating the islets in samples from each patient, but not at all in T cells. IL-1beta was detected in 1.8 (0-11.3)% of T cells infiltrating the islets with beta cells, while it was found in 19.2 (0-35.3)% of macrophages or 10.7 (0-31.3)% of dendritic cells infiltrating the islets in samples from each patient (all values median [range]).

CONCLUSIONS/INTERPRETATION

Macrophages and dendritic cells infiltrate the islets and produce inflammatory cytokines (TNF-alpha and IL-1beta) during the development of type 1A diabetes.

Which has superior acid-suppressive effect, 10 mg omeprazole once daily or 20 mg famotidine twice daily? Effects of single or repeated administration in Japanese Helicobacter pylori-negative CYP2C19 extensive metabolizers

Low-dose omeprazole is superior to full-dose famotidine in maintenance therapy for gastroesophageal reflux disease, whereas "on-demand" famotidine is more effective for relief of episodes of heartburn. To explain this apparent discrepancy, intragastric pH was measured for 24-hr seven times in eight Japanese Helicobacter pylori-negative cytochrome P450 2C19 extensive metabolizers; on Days 1, 8, and 15 of repeated administration of 10 mg of omeprazole once daily and of 20 mg of famotidine twice daily and before medication. During repeated administration of omeprazole, mean intragastric pH and % time that intragastric pH > 4.0 were significantly higher and became greater. With famotidine, although these parameters were significantly higher, the degrees became smaller. Consequently, acid-suppressive effect was in the order; omeprazole < famotidine on Day 1, omeprazole approximately famotidine on Day 8, and omeprazole >famotidine on Day 15. This discrepancy possibly results from the "potentiation" of acid-suppressive effect of omeprazole and the "tolerance" phenomenon in respect to famotidine.

Acid-suppressive effects of rabeprazole: comparing 10mg and 20mg twice daily in Japanese Helicobacter pylori-negative and -positive CYP2C19 extensive metabolisers

BACKGROUND

Rabeprazole 10mg b.i.d. is often administered as therapy for eradication of Helicobacter pylori (H. pylori) and is also proposed as therapy for refractory gastro-oesophageal reflux disease. However, there has not been a comprehensive assessment of its acid-suppressive effects.

AIMS

To compare the acid-suppressive effects of rabeprazole 10mg b.i.d. with 20mg b.i.d. considering H. pylori status.

SUBJECTS

Thirteen H. pylori-negative and eleven H. pylori-positive Japanese CYP2C19 extensive metabolisers (<35 years).

METHODS

Intragastric pH was measured for 24h three times in a randomised manner; on day 7 of the repeated administration of rabeprazole 10mg b.i.d. or 20mg b.i.d., or a placebo.

RESULTS

In median intragastric pH value and percent time of pH>3.0, >4.0, >5.0, >6.0, and >7.0 for 24h, no significant differences were observed between the two doses in either H. pylori-negative or H. pylori-positive subjects. At either dose, these parameters were significantly higher in H. pylori-positive subjects than in H. pylori-negative subjects. Nocturnal acid breakthrough occurred in seven and two of the thirteen H. pylori-negative subjects and one and two of the eleven H. pylori-positive subjects at each dose, respectively.

CONCLUSIONS

The effects of rabeprazole 10mg b.i.d. were equal to those of 20mg b.i.d. in H. pylori-positive subjects; whereas in H. pylori-negative subjects, 20mg b.i.d. was superior for prevention of nocturnal acid breakthrough.

Pancreatic beta and alpha cells are both decreased in patients with fulminant type 1 diabetes: a morphometrical assessment

AIMS/HYPOTHESIS

We have previously reported that fulminant type 1 diabetes is characterised by an absence of diabetes-related antibodies and a remarkably abrupt onset. However, little is known about the mechanism of beta cell destruction in this diabetes subtype, and to obtain insights into the aetiology of the disease, we investigated residual endocrine cells and the expression of Fas and Fas ligand in fulminant type 1 diabetes.

METHODS

Residual beta and alpha cells were morphologically assessed in pancreatic tissue obtained by biopsy from five patients with recent-onset fulminant type 1 diabetes and five patients with recent-onset typical autoimmune type 1 diabetes. In addition, the expression of Fas and Fas ligand was evaluated by immunohistochemistry.

RESULTS

In fulminant type 1 diabetes, beta and alpha cell areas were decreased significantly, compared with autoimmune type 1 diabetes and control subjects. In contrast, the alpha cell area was not decreased significantly in autoimmune type 1 diabetes, compared with that in control subjects. No Fas expression in islets and Fas ligand expression in CD3(+) cells in the exocrine pancreas were found in the fulminant type 1 diabetic patients who underwent this evaluation.

CONCLUSIONS/INTERPRETATION

Our study showed that beta and alpha cells are damaged in fulminant type 1 diabetes. In addition to the lack of Fas and Fas ligand expression, the results suggest that the mechanism of beta cell destruction in fulminant type 1 diabetes is different from that in autoimmune type 1 diabetes.

Fundus autofluorescence in patients with pseudoxanthoma elasticum

PURPOSE

To characterize changes in fundus autofluorescence in patients with pseudoxanthoma elasticum (PXE). Fundus autofluorescence intrinsically derives from lipofuscin, and the degree of autofluorescence is thought to indicate the degree of retinal pigment epithelium (RPE) metabolic activity.

METHODS

Twelve eyes of 6 patients (2 men, 4 women) with PXE were studied with a confocal scanning laser ophthalmoscope. Patient age ranged from 42 to 62 years. The autofluorescence of abnormal retinal areas was compared digitally with that of neighboring, presumed healthy control areas. When the average gray level of a fundus region was 2 SDs above or below the average gray level of a control area, autofluorescence of the fundus region was considered abnormal.

RESULTS

In all 12 eyes, some segments of the angioid streaks showed decreased fundus autofluorescence, and other segments of the streaks showed normal autofluorescence. Areas of peripapillary chorioretinal atrophy seen in 2 eyes and of disciform scarring seen in 3 eyes showed decreased autofluorescence. Solitary or multiple drusen-like spots showed increased autofluorescence in all 12 eyes.

CONCLUSION

Atrophic and degenerative RPE regions showed decreased fundus autofluorescence in areas of chorioretinal atrophy and in some segments of the angioid streaks. Some drusen-like spots showed increased autofluorescence. The characteristic changes in autofluorescence that we observed in PXE patients suggest that the content of the drusen-like substance differs from that of senile drusen and that the drusen-like lesions are similar to the sub-RPE deposits seen in macular dystrophy.

[The new experimental ulcerative colitis model in rats induced by subserosal injection of acetic acid]

We have developed a new experimental ulcerative colitis model in rats. Topical pathological change of a round or a ellips shape was induced by subserosal injection of acetic acid (20%, 0.02 ml) into the middle colon of rats. The size of the induced ulcer could directly be measured using a caliper gauge, and the result was expressed as the ulcer area (mm2). We determined the concentration of leukotriene B4 (LTB4), which is one of important clinical factors, in the ulcer region and found that the quantity of LTB4 was well correlated with the size of the ulcer area. Histopathological studies of the ulcer region demonstrated that there were some morphological similarities to the human form of ulcerative colitis, characterized by edema, necrosis, inflammatory cell infiltration, crypt abscess and granulation tissue formation. Effects of 5-aminosalicylic acid and sodium prednisolone phosphate were investigated by intrarectal administration in this colitis model. The predominant improvement of colitis was obtained from both treatments in the ranges of the clinical doses of each drug. In conclusion, we suggest that this colitis model provides a new way for quantitative evaluation of the efficacy of new therapeutic agents for ulcerative colitis.

Hepatocyte growth factor promotes epithelial morphogenesis and occludin linkage to the cytoskeleton in cultured retinal pigment epithelial cells

BACKGROUND

Although hepatocyte growth factor (HGF) is also known as scatter factor, it induces epithelial morphogenesis in cultured bovine retinal pigment epithelial (RPE) cells. To elucidate the mechanism of epithelial morphogenesis, we investigated the influence of HGF on occludin, a major component of tight junctions.

METHODS

RPE cells were plated on collagen type 1-coated chamber slides or dishes, 20 ng/ml HGF was added and the cells were incubated for 1 week. Cells were harvested at several time-points, and occludin expression was examined by immunohistochemistry. Detergent extraction protocols to identify the intensity of occludin linkage to the cytoskeleton were also used. Occludin expression was determined semiquantitatively by Western blotting.

RESULTS

Fluorescence microscopy revealed that HGF treatment increased the levels of insoluble occludin at the cell borders after detergent extraction. These level of insoluble occludin and the associated epithelial morphology were maintained for more than 3 weeks after withdrawal of HGF, whereas cells not treated with HGF had a fibroblastic appearance. Western blotting also showed that insoluble occludin was more abundant in HGF-treated cells. Furthermore, immunoreactive bands of insoluble occludin were somewhat larger than those of soluble occludin, suggesting that insoluble occludin may be modified in comparison to soluble occludin.

CONCLUSION

Our results suggest that HGF promotes linkage of occludin to the cytoskeleton. HGF may become a therapeutic candidate in physiological recovery of RPE cells and in preparation of RPE monolayers for transplantation.

Indocyanine green angiograms of choroidal nevi. comparison between confocal and nonconfocal scanning laser ophthalmoscope and fundus video camera

PURPOSE

A fundus video camera and a nonconfocal scanning laser ophthalmoscope (SLO) detect direct light and indirect light, whereas a confocal SLO detects mostly direct light. Differences in confocal and nonconfocal SLO images and fundus video camera images are most likely due to their different optical systems. These differences were examined in indocyanine green (ICG) angiograms of a choroidal nevus.

METHODS

A confocal SLO, a nonconfocal SLO, and a high resolution digital fundus video camera were used to obtain ICG angiograms of pigmented choroidal nevi in 4 patients for 30 minutes following dye injection.

RESULTS

All the angiograms showed a hypofluorescent region in the nevus until 10-14 minutes after dye injection, except in 1 patient in whom no hypofluorescent region was seen in an early confocal-SLO angiogram. From 20 minutes to 30 minutes postinjection, the hypofluorescent regions were still visible in all fundus video camera angiograms and nonconfocal SLO angiograms but not in confocal SLO angiograms.

CONCLUSIONS

Early angiograms taken with the three angiography systems showed a similar appearance of the choroidal nevus. However, late ICG angiograms with a confocal SLO showed different images from those taken with a nonconfocal SLO or a fundus video camera. It is suggested that the angiography system and the aperture size of an SLO should be selected according to the aspect of the pigmented choroidal nevus that is of interest in late-phase ICG angiography.

Pancreatic biopsy as a procedure for detecting in situ autoimmune phenomena in type 1 diabetes: close correlation between serological markers and histological evidence of cellular autoimmunity

To better understand the pathogenesis of type 1 diabetes, we have developed pancreatic biopsy under laparoscope for recent-onset type 1 diabetic patients. The patients included 29 acute-onset type 1 diabetic patients, 5 latent-onset type 1 diabetic patients, and 1 type 2 diabetic patient. Their median age was 28 years, and the duration of diabetes at the time of biopsy was approximately 3 months. In 31 of 35 patients, we could obtain the pancreas tissue by punching. No serious complications, such as heavy bleeding, peritonitis, or pancreatitis, have been experienced. Pneumoderma was observed in two patients, and abdominal dull pain had continued for 2 days in two patients. However, special treatment was not necessary for these complications. T-cell-predominant infiltration to islets (insulitis) and hyperexpression of major histocompatibility complex class I antigens on islet cells were the two major findings and were observed in 17 of 29 recent-onset type 1 diabetic patients. These findings could be regarded as evidence of immune attack against beta-cells, and their presence was closely correlated with the presence of either anti-GAD or anti-IA-2 antibodies (P = 0.02). In conclusion, pancreatic biopsy under laparoscope is a safe procedure without serious complications, according to our findings, for detecting in situ autoimmune phenomenon in recent-onset type 1 diabetic patients.

Age-related scattered hypofluorescent spots on late-phase indocyanine green angiograms

PURPOSE

Scattered hypofluorescent spots may be seen on indocyanine green (ICG) angiograms of regions that do not show abnormalities when viewed with an ophthalmoscope. Hypofluorescent spots are found in several pathologic conditions, typically in inflammatory diseases. In this report, we describe hypofluorescent spots in normal fundi and show that such spots can be age-related.

METHODS

Video-fundus camera ICG angiograms of 115 eyes of 109 patients aged 12 to 85 years with normal fundi or with only age-related maculopathy were reviewed. The relation between age and scattered hypofluorescent spots, and between age-related maculopathy and spots was examined utilising regression analysis.

RESULTS

Scattered hypofluorescent spots were seen throughout the posterior pole in 24 eyes of 23 patients and in a portion of the posterior pole in 30 eyes of 29 patients. The hypofluorescent spots were noted between 26 and 37 minutes after dye injection. Patient age ranged from 51 to 80 years, and regression analysis showed that the frequency of hypofluorescent spots increased significantly with aging (p < 0.05). However, age-related maculopathy did not show a significant relation to the spots.

CONCLUSION

Scattered hypofluorescent spots seen in the posterior pole during the late-phase of ICG angiograms can apparently be due to aging of the fundus.

Recombinant human betacellulin promotes the neogenesis of beta-cells and ameliorates glucose intolerance in mice with diabetes induced by selective alloxan perfusion

Betacellulin (BTC), a member of the epidermal growth factor family, is expressed predominantly in the human pancreas and induces the differentiation of a pancreatic acinar cell line (AR42J) into insulin-secreting cells, suggesting that BTC has a physiologically important role in the endocrine pancreas. In this study, we examined the in vivo effect of recombinant human BTC (rhBTC) on glucose intolerance and pancreatic morphology using a new mouse model with glucose intolerance induced by selective alloxan perfusion. RhBTC (1 microg/g body wt) or saline was injected subcutaneously every day from the day after alloxan treatment. The intraperitoneal glucose tolerance test revealed no difference between rhBTC-treated and rhBTC-untreated glucose-intolerant mice at 2-4 weeks. However, glucose tolerance was significantly improved and body weight was significantly increased in rhBTC-treated mice compared with untreated mice at 8 weeks. Islet-like cell clusters, consisting mainly of beta-cells, were increased in the pancreas and were localized in contact with the ductal lining cells and sometimes with acinar cells. In conclusion, administration of rhBTC improved glucose tolerance in this mouse model by increasing beta-cell volume, primarily through accelerated neogenesis from ductal lining cells.

Inadvertent corneal burn by using indirect wide-field contact lenses and different laser beam delivery systems during experimental fundus photocoagulation

BACKGROUND AND OBJECTIVE

At fundus photocoagulation by using a wide-field indirect contact lens, the laser radiant exposure may be increased at the anterior segment of the eye. We examined the likelihood of producing inadvertent corneal burn by using parfocal and sharped edge defocus laser delivery systems with various indirect contact lenses.

STUDY DESIGN/MATERIALS AND METHODS

The two laser delivery systems were used with four lenses of different viewing angles during fundus photocoagulation in a total 44 eyes of rabbits.

RESULTS

By using the lenses, the parfocal system increased corneal radiant exposure more than did the sharped edge defocus system. By using the Widefield PRP 165 lens of the widest viewing angle, there was no difference between the two systems in the corneal burns produced.

CONCLUSION

Some indirect contact lenses used in combination with the parfocal system caused inadvertent corneal burns more readily than did the same lenses in combination with the sharped edge defocus system.

Effect of retinoic acid on proliferation and polyamine metabolism in cultured bovine retinal pigment epithelial cells

Reports regarding the effect of all-trans-retinoic acid (RA) on the cell growth of retinal pigment epithelial cells (RPE) have been contradictory. The aims of this study are to clarify the in vitro effect of RA on RPE cells and to examine polyamine metabolism after RA stimulation. A 4-day incubation of fetal-calf-serum (FCS)-stimulated RPE cells with 10 or 25 microM RA significantly increased both cell number and [3H]thymidine incorporation. RPE cells grown over an extended period for 8 days also increased in number and reached full confluency. However, if the incubation was further extended to 12 days, no further increase in cell number was detected. RA treatment of FCS-stimulated RPE cells shifted the peak of ornithine decarboxylase (ODC) activity from 16 to 4 h. S-adenosylmethionine decarboxylase (SAMDC) activity and spermidine/spermine N1-acetyltransferase (SAT) activity of RA-treated RPE cells were significantly greater until 8 and 16 h after incubation, respectively. The putrescine content was significantly increased in RA-treated RPE cells up until 24 h, while spermidine, spermine and N1-acetylspermidine contents were significantly increased until 16 h. Our findings suggest that RA treatment increases the intracellular polyamine concentration of RPE cells via activation of ODC, SAMDC and SAT and that this results in the promotion of RPE cell growth until the cells reach full confluency.

The relationship between gap-junctional intercellular communication and the proliferative activity of retinal pigment epithelial cells

PURPOSE

To investigate the relationship between gap-junction mediated intercellular communication and the proliferative activity of retinal pigment epithelial cells in the retinal tear base. METHODS Retinal tears were created experimentally in white rabbits, and the changes of intercellular communication via gap junctions between retinal pigment epithelial cells in the retinal tear base were investigated using the dye-coupling method, which involves observing the spread of a fluorescent dye, Lucifer Yellow CH. In addition, the proliferative activity of these cells was investigated using an antibody for proliferating cell nuclear antigen and was compared with the changes in intercellular communication.

RESULTS

Immediately after the creation of retinal tears, extensive spreading of Lucifer Yellow CH into adjacent cells was observed, which was markedly reduced 1 week later. After 1 month, the spreading of dye to adjacent cells was observed again. On the other hand, proliferative activity was enhanced at 1 week after retinal tear creation and was reduced again after 1 month.

CONCLUSIONS

It is known that tumor cells with enhanced proliferative activity show decreased intercellular communication via gap junctions. The present study suggests a possible relationship between intercellular communication and the proliferative activity of retinal pigment epithelial cells in the base of retinal tears.

Organ-specific expression of β-glucuronidase activity driven by the Arabidopsis heat-shock promoter in heat-stressed transgenic Nicotiana plumbaginifolia

 The expression of the Arabidopsis heat-shock protein (HSP) 18.2 promoter β-D-glucuronidase (GUS) chimera gene was studied in various organs of the transgenic Nicotiana plumbaginifolia during the recovery phase at normal temperatures (20-22  °C) following heat-shock (HS) treatment. The optimum HS temperature for GUS activity in the anthers, petals and capsules was 42  °C, but in immature seeds and the placentas of capsules it was 36  °C and 39  °C, respectively. No apparent GUS activity was observed in any organs except for dry seeds after HS at 45  °C, although the activity in dry seeds was apparent even after HS at 48  °C. After HS at 42  °C, GUS activity in the flower tissues was the highest before anthesis and declined thereafter.

Delayed recovery of β-glucuronidase activity driven by an Arabidopsis heat shock promoter in heat-stressed transgenic Nicotiana plumbaginifolia

 The expression of the Arabidopsis heat shock protein (HSP) 18.2 promoter-β-D-glucuronidase (GUS) chimera gene was investigated in transgenic Nicotiana plumbaginifolia plants during the recovery phase at normal temperatures (20-22  °C) after a heat shock (HS) treatment. GUS activity increased during the recovery phase after HS at 42  °C for 2 h, and maximal GUS activity was observed after 12 h at normal temperatures, at levels 50-100 times higher than the activity immediately after HS. After HS at 44  °C, little GUS activity was observed during the first 20-24 h at normal temperatures, but the activity increased gradually thereafter, to reach a maximum at 40-50 h. After HS at 45  °C, no GUS activity was observed throughout the experimental period. RT-PCR analysis showed that GUS mRNA remained for 10 h after a 2-h HS at 42  °C and for 40 h after a 2-h HS at 44  °C. These findings demonstrate that brief HS treatment, especially at a sublethal temperature, induces a long-term accumulation of HSP-GUS mRNA during the recovery phase.

Incising the thick retrolental fibrovascular tissue with a hooked sclerotome in persistent hyperplastic primary vitreous

A technique for incising thick retrolental fibrovascular tissue and extensive cyclitic membrane is reported in a case of anterior persistent hyperplastic primary vitreous. A membranectomy was performed in a 1-month-old post-lensectomy baby via a limbal approach. A sclerotome tip was hooked to cut through an extremely thick fibrovascular tissue by rotating the sclerotome by its grip. Sutherland microscissors (Grieshaber, Switzerland) and a vitrectomy cutter were used for further membranectomy. The baby was followed-up until age 18 months. A total of 3 membranectomy sessions were required because of rapid cyclitic membrane formation, severe centripetal retraction of the membrane on the ciliary processes, and posterior synechia. Thorough membranectomy and cutting the iris edge maintained a clear pupillary area during the 13-month postoperative period. Extremely thick retrolental fibrovascular tissue is a challenging condition that can be dealt with by delicate instrumentation.

Fas and Fas ligand expression in inflamed islets in pancreas sections of patients with recent-onset Type I diabetes mellitus

AIMS/HYPOTHESIS

Type I (insulin-dependent) diabetes results mainly from T-cell-mediated autoimmune destruction of pancreatic beta cells. Cytotoxic T lymphocytes destroy target cells via a perforin-based or Fas-based mechanism. Our previous study indicated that the Fas-Fas ligand (FasL) pathway is required for the development of autoimmune diabetes in the NOD mouse. We now investigated whether or not the Fas-FasL system is involved in the beta-cell destruction in human Type I diabetes.

METHODS

We immunohistochemically analysed pancreas biopsy specimens of 13 recent-onset patients.

RESULTS

Pancreatic islets were identified but showed various degrees of reduction in beta-cell volume in all patients. Out of 13 patients 6 had insulitis. In these 6 patients Fas was expressed in both the islets and infiltrating cells but not in either cell type in the 7 other patients without insulitis. Double immunostaining showed that Fas was positive in 92.2 to 97.7 % of beta cells but only in 17.6 to 46.7 % of alpha cells in Fas-positive, insulin-remaining islets. We found FasL was expressed exclusively in islet-infiltrating cells in patients with insulitis. Double immunostaining revealed that the most prevalent phenotype of FasL-positive cells was CD8, which was followed by macrophages and CD4.

CONCLUSION/INTERPRETATION

The interaction between Fas on beta cells and FasL on infiltrating cells might trigger selective apoptotic beta-cell death in inflamed islets, leading to immune-mediated Type I diabetes. [Diabetologia (1999) 42: 1332-1340]

Fetal treatment of congenital heart block ascribed to anti-SSA antibody: case reports with observation of cardiohemodynamics and review of the literature

PROBLEM

Maternal anti-SSA(B) antibody crosses the placenta and causes fetal myocarditis, congenital heart block (CHB), hydrops fetalis, and intrauterine fetal death. The aim of this study was to evaluate corticosteroids' efficacy as a treatment for CHB.

METHOD OF STUDY

One fetus with complete CHB and one fetus with incomplete CHB due to anti-SSA(B) antibody received maternal prednisolone (PSL) and dexamethasone (DEXA) treatments. Heart rate, cardiothoracic ratio (CTR), left ventricular fractional shortening (FS), and preload index (PLI) were longitudinally measured by serial fetal echocardiograms.

RESULTS

In the former case, after maternal PSL/DEXA administration, improvement of cardiohemodynamics, i.e., the reduction of PLI from 1.7 to 0.4, CTR from 70 to 52%, and FS from 63 to 54% were observed. In the latter case, second degree 2:1 block was converted to 3:2 block/sinus rhythm, resulting in the increase of the fetal heart rate from 65 to 116 beats per minute (bpm).

CONCLUSIONS

We disclosed for the first time the beneficial effects of corticosteroids in the fetal cardiohemodynamics and conduction system of affected fetuses with the presence of maternal anti-SSA(B) antibodies.

Overexpression of the aldose reductase gene induces apoptosis in pancreatic beta-cells by causing a redox imbalance

To determine the role of the polyol metabolizing pathway under hyperglycemic conditions, the effects of aldose reductase (AR) on the cellular functions of pancreatic beta-cells were examined. Stable transfectants of rat AR cDNA were obtained with a pancreatic beta-cell line, HIT, in which a negligible amount of AR was originally expressed. Overproduction of AR triggered DNA fragmentation, as judged with the TUNEL method and agarose gel electrophoresis. Morphological analysis by electron microscopy also clearly showed apoptosis of the AR-overexpressing HIT cells. Induction by interleukin-1beta of gene expression such as those of an inducible form of nitric oxide synthase (NOS-II) and Mn-superoxide dismutase (Mn-SOD), was much lower in the transfectants than in the control cells, while the expression of constitutively expressed genes such as those for Cu,Zn-superoxide dismutase and insulin was not changed. The susceptibility to interleukin-1beta stimulation of the expression of the NOS II and Mn-SOD genes was due to suppressed NF-kappaB activity, which is essential for the expression of these genes. In addition, the intracellular NADPH/NADP+ ratio was considerably lower in the AR-transfected cells than in control cells. Thus, the overexpression of AR in pancreatic beta-cells induced apoptosis that may be caused by a redox imbalance.

Immunological abnormalities in islets at diagnosis paralleled further deterioration of glycaemic control in patients with recent-onset Type I (insulin-dependent) diabetes mellitus

AIMS/HYPOTHESIS

To determine whether the clinical heterogeneity observed in the development of Type I (insulin-dependent) diabetes mellitus correlates with immunohistochemical differences observed at diagnosis.

METHODS

Patients (n = 17) with recent-onset diabetes clinically considered to be insulin dependent (Type I), underwent pancreatic biopsy for immunohistological analysis. These patients were divided into two groups based on the presence or absence of islet immunological abnormalities (insulitis or hyperexpression of MHC class I antigens or both). The patients were also HLA typed and tested for islet cell antibodies and antibodies to glutamic acid decarboxylase (GAD-Ab). All patients were followed monthly for 2 years and their fasting plasma glucose, haemoglobin A1c and daily insulin doses were recorded. The clinical course of patients with islet immunological abnormalities was compared with that of patients without those abnormalities.

RESULTS

Patients with and without islet immunological abnormalities did not differ with regard to HLA type or islet cell antibodies. Antibodies to glutamic acid decarboxylase correlated with the presence of insulitis and MHC class I hyperexpression. These local immunological abnormalities were also associated with higher haemoglobin A1c values (p < 0.05) and a trend towards greater insulin requirements. Further, patients with the islet abnormalities had higher fasting plasma glucose concentrations 2 years after the biopsy than at the time of the biopsy (p < 0.05).

CONCLUSION/INTERPRETATION

The heterogeneous clinical course observed following diagnosis in patients with Type I diabetes correlates with islet immunological abnormalities. Insulitis and hyperexpression of MHC class I correlate with deteriorating glycaemic control.

Suppressed phenylalanine ammonia-lyase activity after heat shock in transgenic Nicotiana plumbaginifolia containing an Arabidopsis HSP18.2-Parsley PAL2 chimera gene

The activity of phenylalanine ammonia-lyase (PAL; EC 4.3.1.5) after heat shock (HS) in leaves and buds of transgenic Nicotiana plumbaginifolia containing an Arabidopsis HSP18.2 promoter-parsley phenylalanine ammonia-lyase 2 (HSP18.2-PAL2) chimera gene was examined. Immediately after HS treatment at 44 degrees C for 5 h, the PAL activity in both transgenic and normal (untransformed) plants was 35-38% lower than that before HS. At normal temperature (25-26 degrees C), the PAL activity recovered within 5 h of ending the HS treatment in normal plants, but not until 12-24 h in transgenic plants containing the HSP18.2-PAL2 gene. Reverse transcription-polymerase chain reaction (RT-PCR) analysis revealed the presence of parsley PAL2 mRNA in transgenic plants, which remained for 8-12 h following 5-h HS at 44 degrees C; the mRNA was not observed before HS. The content of chlorogenic acid (CGA; 3-caffeoylquinic acid) decreased drastically 8-12 h after HS in transgenic plants, but only slightly in normal plants. Thus, the decrease in PAL activity accompanied by expression of the parsley PAL2 gene after HS treatment corresponded to the decrease in CGA synthesis. These results might be attributed to post-transcriptional degradation of endogenous PAL mRNA triggered by transcription of the transgene.

Long-term follow-up of severe central serous chorioretinopathy using indocyanine green angiography

BACKGROUND

The severe types of central serous chorioretinopathy (CSC) have a chronic nature, suggesting that a pathological process persists subclinically. Indocyanine green (ICG) angiography recently revealed intrachoroidal dye leakage and its static nature in CSC. As the intrachoroidal dye leakage was suspected to be relevant to the disease process, the long-term persistence of intrachoroidal ICG leakage was examined in four patients of the severe types of CSC.

METHODS

ICG angiography was performed periodically over more than three years in three patients and two years in one patient. One patient had CSC with bullous retinal detachment, and the other three had chronic CSC or diffuse retinal pigment epitheliopathy.

RESULTS

Intrachoroidal ICG leakage persisted in all the patients. However, a change in location of persistent intrachoroidal leakage or disappearance of intrachoroidal leakage regardless of no progression of retinal pigment epithelial alteration was noted in one eye of two patients.

CONCLUSIONS

Pathology causing intrachoroidal ICG leakage persisted subclinically for a long period. However, location and extent of the intrachoroidal leakage could change during a long-term follow-up period.

Retinal sensitivity measurement over drusen using scanning laser ophthalmoscope microperimetry

BACKGROUND

Retinal sensitivity over drusen was examined using a scanning laser ophthalmoscope to confirm a previous report of no change in sensitivity over drusen.

METHODS

Microperimetry was performed using a scanning laser ophthalmoscope in 23 eyes of 19 subjects. Subject age ranged from 42 to 86 years (mean 68.5 years). Fifty-four drusen bigger than the diameter of a major retinal vein at the optic disc rim were examined, and drusen were classified as soft drusen and other large drusen.

RESULTS

Nine eyes of eight subjects showed a decrease in retinal sensitivity over drusen. The decrease in retinal sensitivity was more than 5 dB less than the sensitivity at a peripheral non-drusen area peripheral to the measurement point. The sensitivity decrease was noted over 15 of 29 large drusen and the decrease was statistically significant (P < 0.02). However, no relationship between the size of the drusen and the amount by which sensitivity decreased was found. Nevertheless, a decrease in retinal sensitivity was not seen over any of 25 soft drusen.

CONCLUSION

Large drusen may influence retinal sensitivity and function.

Molecular mechanisms of pancreatic beta-cell destruction in autoimmune diabetes: potential targets for preventive therapy

Mononuclear cell infiltration into the islets of the pancreas (insulitis) is characteristic of autoimmune diabetes. T lymphocytes are the predominant subpopulation seen in insulitis, and are involved in the autoimmune process. Insulin-producing beta cells are thought to be destroyed by cytotoxic T cells, cytokines or nitric oxide, and beta-cell death occurs, at least partly, via apoptosis. Beta-cell death induced by cytokines is inhibited by Bcl-2, suggesting its potential as a tool for gene therapy. The Fas/Fas-ligand system plays a critical role in inducing insulitis and overt diabetes in nonobese diabetic (NOD) mice, a model of autoimmune diabetes. T-cell receptor gene usage in infiltrating T cells is not restricted in NOD mice, but there are some observations indicating relative restriction in human IDDM patients. Preventive strategies might be developed by focusing on these molecules involved in beta-cell destruction. The establishment of screening techniques for detecting prediabetic patients is also necessary to allow successful intervention.

Acute retinal necrosis late in the second trimester

PURPOSE

To report treatment of a patient with acute retinal necrosis during pregnancy.

METHODS

A 24-year-old woman in her twenty-third week of gestation was diagnosed with acute retinal necrosis. A combination of acyclovir and interferon therapy was started at 25 weeks. Pars plana vitrectomy was performed during the 26th week of gestation.

RESULTS

The necrotizing retina became gliotic within 3 weeks of surgery. The patient's visual acuity improved to LE, 20/40. A healthy baby was delivered at 39 weeks of gestation.

CONCLUSION

Combination therapy of acyclovir and interferon followed by surgery partially restored the patient's vision without affecting fetal development.

Hypofluorescent spots in indocyanine green angiography of peau d'orange and fundus

PURPOSE

Hypofluorescent spots were seen in indocyanine green (ICG) angiography of peau d'orange fundus in eyes with angioid streaks. Origin of the hypofluorescent spots were examined with attention to their correlation with a peau d'orange appearance of the central fundus using a computer-assisted image comparison system.

METHODS

ICG angiography was performed in 5 patients having peau d'orange appearance of fundus using a scanning laser ophthalmoscope (SLO) and a digital video-fundus camera. The same central fundus areas corresponding to hypofluorescent spots in an ICG angiogram were then digitally identified in a fluorescein angiogram and in a red-free picture in all 10 eyes of the 5 patients. Monochromatic light observation was also performed with a dark field observation using an SLO to see subretinal or intrachoroidal pigment clumping.

RESULTS

In no patient, the areas identified with hypofluorescent spots did show relevant changes in fluorescein angiogram or red-free picture. SLO examination revealed no perfusion defect at the same areas. The dark field observation showed no pigment clumping at the peripapillary and papillomacular bundle regions where hypofluorescent spots were seen.

CONCLUSIONS

Hypofluorescent spots seen in ICG angiograms did not show exact consistency with peau d'orange changes in their location and shape. Perfusion defects or blocking by pigments were not a cause of hypofluorescent spots. The scattered hypofluorescent spots were considered to be relevant with irregular affinity of the fundus to ICG dye.

Requirement of Fas for the development of autoimmune diabetes in nonobese diabetic mice

Insulin-dependent diabetes mellitus (IDDM) is assumed to be a T cell-mediated autoimmune disease. To investigate the role of Fas-mediated cytotoxicity in pancreatic beta cell destruction, we established nonobese diabetic (NOD)-lymphoproliferation (lpr)/lpr mice lacking Fas. Out of three genotypes, female NOD-+/+ and NOD-+/lpr developed spontaneous diabetes by the age of 10 mo with the incidence of 68 and 62%, respectively. In contrast, NOD-lpr/lpr did not develop diabetes or insulitis. To further explore the role of Fas, adoptive transfer experiments were performed. When splenocytes were transferred from diabetic NOD, male NOD-+/+ and NOD-+/lpr developed diabetes with the incidence of 89 and 83%, respectively, whereas NOD-lpr/lpr did not show glycosuria by 12 wk after transfer. Severe mononuclear cell infiltration was revealed in islets of NOD-+/+ and NOD-+/lpr, whereas islet morphology remained intact in NOD-lpr/lpr. These results suggest that Fas-mediated cytotoxicity is required to initiate beta cell autoimmunity in NOD mice. Fas-Fas ligand system might be critical for autoimmune beta cell destruction leading to IDDM.

[QRS axis shift in deep breathing]

We examined changes in mean QRS axis of electrocardiogram during the deep breathing test in outpatients with hypertension, ischemic heart disease, and/or diabetes mellitus. The mean age of all patients (n = 596; male 327, female 269) was 63.0 years (male 62.7 years, female 63.4 years). The average of the mean QRS axis in all patients was shifted to the right during deep inspiration. The changes in mean QRS axis during deep breathing test were more than 60 degrees in 27 patients (4%) (mean age: 70.0 years), 30-59 degrees in 118 patients (20%) (mean age: 65.5 years), and 0-29 degrees in 451 patients (76%) (mean age: 61.9 years). These results suggest that the changes in mean QRS axis during deep breathing are greater in the aged patients.