Haemostatic management of intraoral bleeding in patients with congenital deficiency of alpha2-plasmin inhibitor or plasminogen activator inhibitor-1

Haemostatic management of intraoral bleeding was investigated in patients with congenital alpha2-plasmin inhibitor (alpha2-PI) deficiency or congenital plasminogen activator inhibitor- 1 (PAI-1) deficiency. When extracting teeth from patients with congenital alpha2-PI deficiency, we advocate that 7.5-10 mg kg(-1) of tranexamic acid be administered orally every 6 h, starting 3 h before surgery and continuing for about 7 days. For the treatment of continuous bleeding, such as post-extraction bleeding, 20 mg kg(-1) of tranexamic acid should be administered intravenously, and after achieving local haemostasis 7.5 mg kg(-1) of tranexamic acid should be administered orally every 6 h for several days. In addition, when treating haematoma caused by labial or gingival laceration or buccal or mandibular contusion, haemostasis should be achieved by administering 7.5-10 mg kg(-1) of tranexamic acid every 6 h. Tranexamic acid can also be used for haemostatic management of intraoral bleeding in patients with congenital PAI-1 deficiency, but is less effective when compared with use in patients with congenital alpha2-PI deficiency. Continuous infusion of 1.5 mg kg(-1) h(-1) of tranexamic acid is necessary for impacted tooth extraction requiring gingival incision or removal of local bone.

Intravenous low-dose erythromycin administration for infants with feeding intolerance

BACKGROUND

This study was undertaken to determine the efficacy of low-dose intravenous erythromycin (EM) administration in infants with feeding intolerance.

METHODS

The subjects were 26 infants who would not accept enteral feeding within 5 days after birth. Fourteen infants (gestational age: 30.6+/-5.4 weeks and birthweight: 1466+/-825 g) were given EM intravenously at a dose of 1 mg/kg, three times daily (EM group). Doses were increased to 2 mg/kg in five infants who showed a poor response. Twelve infants (gestational age: 30.5+/-5.0 weeks and birthweight: 1317+/-672 g) were observed without EM administration (non-EM group). Blood concentrations of EM at 2 h after administration were measured on 8 (+/-2) days after the start of EM administration in the EM group.

RESULTS

Digestive perturbations and intestinal gasless and/or atonic shadows on X-ray findings markedly improved in the EM group soon after the treatment. Comparing the EM group and non-EM group, the postnatal ages at the start of successful enteral feeding were 9.1+/-3.2 days and 14.0+/-4.1 days, respectively (P<0.01). The postnatal ages at feeding of 100 mL/kg per day were 15.2+/-4.0 days and 23.4+/-6.2 days, respectively (P<0.01). The blood EM concentrations of 1 mg/kg and 2 mg/kg were 0.29+/-0.28 microg/mL and 0.57+/-0.20 microg/mL, respectively (P<0.05). No adverse effect on cardiac status or in blood examinations was observed in any infant in the EM group.

CONCLUSION

These results suggest that intravenous low-dose EM administration is a useful and safe treatment of feeding intolerance in infants including extremely low-birthweight infants.

Hypoglycemia associated with the production of insulin-like growth factor II in adrenocortical carcinoma

A 78-year-old woman was hospitalized for congestive heart failure and repeated hypoglycemic attacks. The laboratory data showed a serum insulin level within the normal range and an increased level of serum insulin-like growth factor (IGF) II. Abdominal ultrasonogram and computed tomography scan revealed a huge mass lying above the left kidney. She was diagnosed as having an adrenocortical carcinoma. After the removal of the tumor, the plasma glucose level and the serum level of IGF-II were normalized. The tumor cells stained positively for IGF-II immunohistochemically. These findings suggested that the hypoglycemia was due to IGF-II produced by the adrenocortical carcinoma.

Successful arthroscopic treatment of pigmented villonodular synovitis of the knee in a patient with congenital deficiency of plasminogen activator inhibitor-1 and recurrent haemarthrosis

We report the arthroscopic treatment of pigmented villonodular synovitis (PVNS) in a 13-year-old Japanese boy with congenital partial deficiency of plasminogen activator inhibitor-1 (PAI-1). He was admitted to our hospital with recurrent haemarthrosis of his right knee. Characteristic abnormalities of fibrinolysis included shortened euglobulin lysis time, low PAI-1 activity and low PAI-1 antigen levels. In addition, levels of "active PAI" in the plasma, which is a measure of total PAI bound to exogenous plasminogen activator, were very low. These parameters remained low after venous occlusion. The diagnosis of PVNS was established by synovial membrane biopsy, and arthroscopic synovectomy was performed with adjuvant administration of intravenous tranexamic acid. Subsequent bleeding episodes have been well controlled by oral administration of tranexamic acid on demand.

Expression of intrapulmonary surfactant apoprotein-A in autopsied lungs: comparative study of cases with or without pulmonary hypoplasia

To investigate the functional maturity of the lungs of infants with pulmonary hypoplasia, we measured the expression of surfactant apoprotein-A (SP-A) in the autopsied lungs. Autopsied lungs were taken from 16 infants who died at birth or soon after. A lung-to-body weight ratio of less than 1.2% was defined as pulmonary hypoplasia. Eight infants were classified as belonging to the normal group, and eight as belonging to the pulmonary hypoplasia group. Many of the pulmonary hypoplasia group were complicated not only by pulmonary hypoplasia, but also by amniotic fluid volume abnormalities or an anatomical malformation. We measured the expression of SP-A immunologically using murine anti-human SP-A MAb in the autopsied lung tissue, and subjected the tissue to SP-A staining by the direct staining method. The expression of SP-A was assessed as one of four grades: -, +/-, 1+, 2+. The staining intensity of SP-A was high at 1+ or stronger in five infants of the normal group. SP-A expression was significantly reduced, however, in all infants of the pulmonary hypoplasia group except for one infant with normal amniotic fluid volume and relatively mild pulmonary hypoplasia. There was a significant negative correlation between the staining intensity of SP-A and two factors: pulmonary hypoplasia and abnormal amniotic fluid volume (p = 0.039 and p = 0.0063, respectively). In the present study, we demonstrated that SP-A expression was significantly reduced in infants with pulmonary hypoplasia. We speculate that the functional maturity of the lungs of infants with pulmonary hypoplasia is also suppressed.

Four cases of bleeding diathesis in children due to congenital plasminogen activator inhibitor-1 deficiency

Congenital plasminogen activator inhibitor-1 (PAI-1) deficiency is an extremely rare disorder characterized by a bleeding diathesis that begins in childhood due to hyperfibrinolysis as a result of decreased PAI-1 activity. We now present 4 unrelated pediatric cases of congenital PAI-1 deficiency. All 4 patients had a history of recurrent episodes of subcutaneous bleeding beginning in early childhood. These episodes were characterized by abnormal prolonged bleeding after trauma, tooth extraction, and surgical procedures, as well as by rebleeding following initial hemostasis. The 2 female patients both had symptoms compatible with hypermenorrhea. The family history was positive in 2 of the 4 patients. Hemostatic screening studies in all 4 patients revealed no abnormalities. Testing for factor XIII antigen, von Willebrand factor antigen, ristocetin cofactor activity, alpha(2)-plasmin inhibitor (alpha2PI) activity, and plasminogen activity was normal. The euglobulin lysis times were shortened in all cases as compared with those in normal control subjects. None of the patients had elevated tissue plasminogen activator (tPA) antigen levels, but PAI activity was markedly decreased in all cases. Three of the patients also had reduced levels of PAI-1 antigen. There tended to be a reduction in tPA-PAI-1 complex in all cases. In addition, 2 patients had elevated PIC (plasmin-alpha2PI complex). Tourniquet tests were performed in 2 patients, with no appreciable rise in PAI-1 activity or PAI-1 antigen levels. The administration of tranexamic acid clearly improved hemorrhagic symptoms in these patients. We considered PAI-1 deficiency to be the likely etiology of the congenital bleeding diatheses in these 4 cases.

[The workload of computer system engineers and mental health]

The nature of labor in Japan is changing from work which is physically demanding to work in which mental activity requiring intellectual and psychological ability results in production. The author studied and analyzed the type of workload experienced by system engineers in informatics. The results of a health study of 2,396 system design engineers in informatics at our company were analyzed (only data on 2,169 males were analyzed). Workload related to the 'quality', or type of work done ('Workload of quality') was felt by 63.5%, with 36.0% feeling workload related to the amount of work ('Workload of quantity'). A very large number of workers felt workload related to the quality, or type of work rather than to the amount of work. The relationship between emotional health indices and workload showed insomnia in 25.5% of workers who felt a 'Workload of quality', and in 11.1% of those who did not feel such a workload. Similarly, depressive mood was seen in 40.3% of workers who felt a 'Workload of quality', and in 18.7% of workers who did not. Insomnia was seen in 42.8% of workers with a feeling of a 'Workload of quality', and in 26.3% of those without. The relationship between workload, related to the quality and quantity of work was also strong for other mental health indices. Workload related to the quality of work was particularly strong. Workload related to the quality or type or work comes from a myriad of factors including the variety of work required from workers in informatics, the still developing nature of the production process, and the rapid pace of technical progress with each type of work carrying a different set of factors. The ability and personality of each individual worker also plays an important role. The results of the survey showed the importance of carrying out occupational healthcare activities in health management from the standpoint of work related health hazards or "quality of work"; in other words, from the standpoint of work type, system operation and the individuality of the worker.

Sickness absence due to mental disorders in Japanese workforce

This study was conducted to elucidate sickness absence due to mental disorders in Japanese companies. Data on sickness absence taken for seven consecutive days or more at eight companies (total number of employees: 44,816) was used for the analysis. Diagnosis of mental disorders was based on medical certificates prepared by physicians. The frequency of absence due to all diseases and mental disorders was 3.0% and 0.3%, respectively. The proportion of frequency absence due to mental disorders compared to that for all diseases was 9.4%. Figures for absence prevalence were almost the same as those for frequency absence. The average length of absence due to mental disorders and non-mental disorders was 119.5 days and 47.3 days, respectively. Rate of absence days due to mental disorders compared to that for all diseases was 21.0%. Percent of sickness absenteeism was 0.4%. In one company, the proportion of frequency absence and rate of absence days due to mental disorders compared to those for all diseases had an increasing tendency over the last six years.

Neonatal erythema infectiosum

A report is presented of a patient with neonatal erythema infectiosum who developed petechiae, transient thrombocytopenia and transient cardiac failure due to transplacental transmission of human parvovirus B19 (HPV B19) infection. It is suggested that the thrombocytopenia was caused by platelet-associated IgG produced by the patient, and that the cardiac failure may have been caused by direct entry of HPV B19 into the cardiac tissue.

Hereditary partial deficiency of plasminogen activator inhibitor-1 associated with a lifelong bleeding tendency

We report a family with a partial deficiency of plasminogen activator inhibitor-1 (PAI-1). The affected family members had had lifelong bleeding episodes, such as rebleeding after tooth extraction and trauma. This bleeding tendency in the propositus was autosomally transmitted from grandfather to son. The characteristic abnormalities of fibrinolysis in the patients were shortened eugloblin lysis time, low PAI activity with low antigen levels of plasminogen activator inhibitor-1 in plasma and serum. Furthermore, plasma 'active PAI' which indicates the quantity of plasminogen activator inhibitor-1 bound with plasminogen activator added was very low in these patients. These parameters were markedly low after the venous occlusion test. Moreover, two of the affected members had a much lower level of platelet PAI-1 than the normal controls. Tranexamic acid (Transamine) was useful to control bleeding in these patients.

[Health appraisal for work adjustment of freshmen employees--information on health checkup just after entering the corporation and condition in the next fiscal year]

In 1990, 365 (males: 197, females: 168) freshmen employees at the headquarters of a large corporation were examined just after being hired in order to observe their health status. We collected (1) data of physical examinations and questionnaires for symptoms as an ordinary health checkup, (2) information on work adjustment, life patterns, and personal characteristics through interviews conducted by ten public health nurses, and (3) personal records, e.g. birth year. Statistical analyses revealed some notable findings as follows: (1) subjects with higher blood pressure had higher scores of extrovert personality among males, (2) female subjects with greater body mass index had higher scores in such manifestations of personal characteristics such as aggression and discontent with superiors, (3) higher scores of personal characteristics were noted among female subjects working in technical sections, (4) positive correlation between the scores of work adjustment and personal characteristics, (5) higher scores of undesirable life patterns among males and of work maladjustment among elder females, (6) unbalanced meal quality of subjects from rural areas, (7) higher mental tension among younger males from rural areas, and (8) higher scores of dependency and lower morale among younger female subjects. Information on health problems was collected over the 1.5 yrs that followed. More problems were detected among females than among males and among younger females than among elder females. Longitudinal analysis was carried out from just after entry into the company for approximately 1.5 yrs. Health problems in females could be predicted by the data on personal characteristics and work adjustment just after entry. Risk of health problems in male freshmen employees with hobbies and unhealthy drinking habits over the 1.5 yrs that followed was higher than in others. It was concluded that a health interview for freshmen employees by public health nurses is valuable for health care, obtaining information regarding work adjustment, life patterns, and personal characteristics.

Hepatocellular carcinoma with tumor thrombus in the inferior vena cava and right atrium

Tumor thrombus (TT) in the inferior vena cava (IVC) and right atrium (RA) is rarely encountered. We have diagnosed before death and treated a case of hepatocellular carcinoma (HCC) with TT in the IVC and RA, accompanied by a brain metastasis. The image characteristics on computed tomography (CT), magnetic resonance imaging (MRI), and conventional angiography are discussed.

Urinary hippuric acid excretion after use of spray ski-wax and remover

The biological monitoring for exposure to toluene is based on the measurement of urinary hippuric acid concentration (HA-U). In occupational health, workers exposed to toluene are examined for HA-U, because collection of urine samples is easy. The HA-U data of an engineer who did not use toluene occupationally showed relatively high values. It was indicated that he went to ski every weekend in winter and had used spray ski-wax and remover which contained toluene. The ski-club members of Tokai University, School of Medicine who used such sprays were examined for HA-U at the ski training camp. It was revealed that the use of these sprays elevated the HA-U values remarkably. Therefore, the use of sprays, especially in the winter season, can be one of confounding factors for biological monitoring of occupational exposure to toluene based on measurement of HA-U.

[Factors affecting subjective symptoms of VDT workers]

In 1983, 285 (male: 129, female: 156) VDT workers and 60 (male: 30, female: 30) control subjects were examined in order to detect the factors affecting the subjective symptoms of VDT workers. Biological information (for example: sex, age), life histories, information about VDT work, tests (for example: visual acuity), symptoms and interferences to daily life of VDT workers and control subjects were collected. The following results were obtained. Female VDT workers experienced more fatigue from commuting to work, stiffness in shoulders, distant blurred vision complaints of visual acuity and sum of the scores of ocular complaints than female control subjects. Only among female VDT workers, the longer the daily working hours, the greater were their ocular symptoms. A remarkable relationships were observed between psychological burden factors (for example: self-control of VDT work, sensation of excessive VDT work) and subjective symptoms of the VDT workers (both sexes). In particular, VDT workers who considered VDT work to be excessive had marked by greater subjective symptoms than those who did not.