Medical Students' Reflections on Their Experiences in a Trauma Chaplain Shadowing Program

The importance of spirituality in patient care is well recognized and efforts to develop educational opportunities to improve medical students' competency in spirituality and health are ongoing. In this regard, shadowing of healthcare chaplains has emerged as an experiential approach for providing exposure to and instruction in issues of spirituality in the patient experience and in patient care. Recently published data suggest that a 6-8 hour experience of shadowing a trauma chaplain is effective at introducing first-year medical students to healthcare chaplaincy, difficult spiritual conversations with patients and families, and interprofessional collaboration. As a follow-up to these data, this study provides a qualitative analysis of student reflections written immediately after their shadowing experience with the goal of further characterizing the educational impact of trauma chaplain shadowing. Qualitative analysis of 90 anonymous, student reflections indicated that trauma chaplain shadowing was an experience that provided insights about nature of chaplaincy, enabled opportunities to closely observe the relational skills of chaplains, allowed students to bear witness to suffering, fostered growth toward a professional identity, and facilitated recognition of shortcomings in medical education and clinical medicine. These data therefore provide further evidence of the value of chaplain shadowing in not only enhancing students' understanding of various dimensions of spirituality and medicine but also in promoting their development of a strong physician identity.

Prognostic value of estimating appendicular muscle mass in heart failure using creatinine/cystatin C

Objectives

As heart failure with concomitant sarcopenia has a poor prognosis, simple methods for evaluating the appendicular skeletal muscle mass index (ASMI) are required. Recently, a model incorporating anthropometric data and the sarcopenia index, that is, the ratio of serum creatinine to cystatin C (Cre/CysC), was developed to estimate the appendicular skeletal muscle mass. We hypothesized that this model would be superior to the previous model, which uses only anthropometric data to predict the prognosis. This study aimed to compare the prognostic value of low ASMI as defined by the biomarker and anthropometric models in patients with heart failure.

Methods

Among 847 patients, we estimated ASMI using an anthropometric model consisting of age, body weight, and height in 791 patients and a biomarker model that incorporates age, body weight, hemoglobin, and Cre/CysC in 562 patients. Patients were divided into low and non-low ASMI groups according to the ASMI estimated by each model, using the cut-off proposed by the Asian Working Group for Sarcopenia. The primary outcome was all-cause mortality.

Results

Overall, 53.4% and 39.1% of patients were diagnosed with low ASMI by anthropometric and biomarker models, respectively. The agreement of the diagnosis of low ASMI between the two models was poor, with a kappa coefficient of 0.56 (95% confidence interval: 0.49–0.63). Kaplan-Meier curves showed that a low ASMI was significantly associated with all-cause death in both models. However, this association was retained after adjustment for other covariates in the biomarker model (hazard ratio: 2.60, p=0.003), but not in the anthropometric model (hazard ratio: 0.70, p=0.257).

Conclusions and implications

Among patients hospitalized with heart failure, a low ASMI estimated using the biomarker model, but not the anthropometric model, was significantly associated with all-cause mortality.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical Research and Development

Validation and comparison of BIOSTAT risk score and AHEAD score for patients with acute heart failure

Background/Introduction

Acute heart failure (AHF) is one of the major causes of mortality, and identifying the patients at high risk of mortality at the time of admission is crucial to improve clinical outcomes. Although some risk prediction models for patients with AHF have been proposed mainly from randomized clinical trials, the patients in such studies tend not to be similar to those in the real world. Recently, BIOSTAT risk score and AHEAD score derived from two large-scale registry dataset are proposed as useful risk stratification tools for patients with AHF. However, these scores have not been well externally validated and their prognostic prediction performance has not been directly compared.

Purpose

To validate and compare prognostication of BIOSTAT risk score and AHEAD score in AHF patients.

Methods

Patients who consecutively admitted to the cardiac intensive-care unit in our institution with a diagnosis of AHF from 2007 to 2011 were analyzed. Among them, patients with acute coronary syndrome, dialysis, malignancy were excluded. BIOSTAT risk score was calculated using 5 factors (age, blood urea nitrogen, BNP, hemoglobin, prescription of beta blockers), and AHEAD score was also calculated with 5 factors (atrial fibrillation, hemoglobin, age, creatinine, and diabetes mellitus). We also developed AHEAD + BNP model incorporating BNP into AHEAD score. Endpoint was 1-year all-cause death.

Results

Overall, 591 eligible patients were enrolled (mean age was 70±14 years old, 64.8% were male) and 96 patients (16.2%) died during the follow-up of 1-year. The median [interquartile range] of AHEAD score and BIOSTAT risk score were 2 [1–3] and 3 [2–4], respectively. The areas under the curves of receiver operating characteristic curve (AUC) were 0.66 for AHEAD, 0.68 for AHEAD + BNP, and 0.72 for BIOSTAT, respectively. The calibration plots for AHEAD, AHEAD + BNP, and BIOSTAT models showed good calibration (Hosmer-Lemeshow test: p=0.89, 0.74, and 0.74, respectively). The BIOSTAT model's AUC was significantly higher compared to AHEAD (p=0.018) and marginally statistically higher compared to AHEAD + BNP (p=0.054). However, BIOSTAT model showed statistically significant net reclassification improvement compared to both AHEAD (NRI: 0.43, p<0.001) and AHEAD + BNP (NRI: 0.43, p<0.001).

Conclusion

The BIOSTAT score comprised of five readily available clinical variables predict 1-year mortality of patients with AHF with good discrimination and calibration.

ROC curves

Funding Acknowledgement

Type of funding source: None

Urinary biomarkers of kidney tubule injury, risk of acute kidney injury, and mortality in patients with acute ischaemic stroke treated at a stroke care unit

BACKGROUND AND PURPOSE

Urinary liver-type fatty-acid binding protein (L-FABP), which is a biomarker of kidney tubule injury, has been studied extensively and established as a risk marker of acute kidney injury (AKI). The aim of this study was to investigate whether kidney tubule injury is associated with the development of AKI and mortality in patients with acute ischaemic stroke.

METHODS

Acute ischaemic stroke patients hospitalized in the stroke care unit (SCU) within 24 h after symptom onset were prospectively investigated. AKI was defined on the basis of Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Baseline urinary L-FABP was measured on admission. We evaluated the associations among urinary L-FABP, incidence of AKI, and 90-day mortality adjusted for renal function, albuminuria and other potentially predictive variables, using multivariable analysis.

RESULTS

In total, 527 acute ischaemic stroke patients (342 men, median age 74 years) were enrolled in the study. Twenty-seven patients (5.1%) experienced AKI within 7 days of admission. In the univariate analysis, high urinary L-FABP level had positive associations with AKI [53.8 μg/g creatinine (Cr) vs. 3.9 μg/g Cr; P < 0.001] and 90-day mortality (15.5 μg/g Cr vs. 4.0 μg/g Cr; P < 0.001). In the multivariate analysis, elevated urinary L-FABP level (per 10-μg/g Cr increase) was independently associated with AKI (odds ratio 1.225, 95% confidence interval (CI) 1.083-1.454; P = 0.003) and 90-day mortality (hazard ratio 1.091, 95% CI 1.045-1.138; P < 0.001).

CONCLUSION

Urinary biomarkers of kidney tubule injury are independently associated with the development of AKI and 90-day mortality in patients with acute ischaemic stroke treated at the SCU.

Application of the Self- Assembling Peptide P11-4 for Prevention of Acidic Erosion

The aim of this study was to use ultrasonography to evaluate the effect of the self-assembling peptide P11-4 on acid erosion prevention. Curodont Repair (CR), which includes peptide P11-4, was used. Rectangular prisms of bovine enamel (4×1×1 mm) were immersed in pure orange juice for a period of 5 minutes six times per day for 28 days. These samples were divided into four groups of six specimens each and treated differently for an additional period of 28 days: 1) baseline group specimens were stored in artificial saliva; 2) CR group specimens were exposed to curodont without acid challenge; 3) NCRA (no curodont+acid challenge) specimens were treated with orange juice without curodont exposure; and 4) CRA (CR+acid challenge) specimens were treated with curodont before treatment with orange juice. The propagation time of longitudinal ultrasonic velocity (UV) was measured. Ultrastructural observation of each tested enamel surface was carried out using field-emission scanning electron microscopy (SEM). The UV data were analyzed using two-way analysis of variance with time and treatment as confounding factors. Post hoc pairwise tests among groups were performed using the Tukey honestly significant difference test. The average UV in intact bovine enamel for the baseline group ranged from 4,483 to 4,549 m/s and did not vary significantly within the test period. The average ultrasonic velocity (UV) in all samples decreased after the initial erosion. The UV in NCRA decreased further over time. Increased UVs were found for CR and CRA. For CR and CRA, there was no significant difference in UV at the end of the experiment from the initial value before erosion. In the results of SEM observation, the CR and CRA groups had similar morphologic features in that etching patterns were not clearly due to precipitation between the enamel rods. From the results of this in vitro study, it might be concluded that applying enamel matrix derivatives and self-assembling peptides on erosive lesions can improve remineralization.

Polymerization Behavior and Mechanical Properties of High-Viscosity Bulk Fill and Low Shrinkage Resin Composites

The present study determined the mechanical properties and volumetric polymerization shrinkage of different categories of resin composite. Three high viscosity bulk fill resin composites were tested: Tetric EvoCeram Bulk Fill (TB, Ivoclar Vivadent), Filtek Bulk Fill posterior restorative (FB, 3M ESPE), and Sonic Fill (SF, Kerr Corp). Two low-shrinkage resin composites, Kalore (KL, GC Corp) and Filtek LS Posterior (LS, 3M ESPE), were used. Three conventional resin composites, Herculite Ultra (HU, Kerr Corp), Estelite ∑ Quick (EQ, Tokuyama Dental), and Filtek Supreme Ultra (SU, 3M ESPE), were used as comparison materials. Following ISO Specification 4049, six specimens for each resin composite were used to determine flexural strength, elastic modulus, and resilience. Volumetric polymerization shrinkage was determined using a water-filled dilatometer. Data were evaluated using analysis of variance followed by Tukey's honestly significant difference test (α=0.05). The flexural strength of the resin composites ranged from 115.4 to 148.1 MPa, the elastic modulus ranged from 5.6 to 13.4 GPa, and the resilience ranged from 0.70 to 1.0 MJ/m3. There were significant differences in flexural properties between the materials but no clear outliers. Volumetric changes as a function of time over a duration of 180 seconds depended on the type of resin composite. However, for all the resin composites, apart from LS, volumetric shrinkage began soon after the start of light irradiation, and a rapid decrease in volume during light irradiation followed by a slower decrease was observed. The low shrinkage resin composites KL and LS showed significantly lower volumetric shrinkage than the other tested materials at the measuring point of 180 seconds. In contrast, the three bulk fill resin composites showed higher volumetric change than the other resin composites. The findings from this study provide clinicians with valuable information regarding the mechanical properties and polymerization kinetics of these categories of current resin composite.

Bisphenol a Inhibits Testicular Functions and Increases Luteinizing Hormone Secretion in Adult Male Rats

Effects of a xenoblotic estrogen, bisphenol A (BPA), on reproductive functions were investigated using adult male rats. BPA was dissolved into sesame oil and injected sc every day (1 mg/rat) for 14 days. Animals were killed by decapitation after the final administration of BPA, and the trunk blood, pituitary, and testes were collected. Plasma concentrations of prolactin were dramatically Increased and pituitary contents of prolactin were slightly increased in the BPA group compared to the control group. Plasma concentrations of testosterone were decreased and plasma concentrations of LH were increased in BPA-treated rats compared to control rats. Testicular contents of inhibin were decreased in BPA-treated rats compared to control rats, although plasma concentrations of inhibin were not changed after administration of BPA. The testicular response to hCG for progesterone and testosterone release was decreased in BPA-treated rats. Administration of BPA did not change the pituitary response to luteinizing hormone-releasing hormone (LH-RH) in castrated male rats treated with testosterone. Male sexual behavior also was not changed as a result of BPA treatment. These results suggest that BPA directly inhibits testicular functions and the increased level of plasma LH is probably due to a reduction in the negative feedback regulation by testosterone. The testis is probably a more sensitive site for BPA action than the hypothalamus–pitultary axis.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Valproic acid enhances the effect of bone marrow-derived mononuclear cells in a rat ischemic stroke model

Bone marrow derived mononuclear cell (MNC) transplantation is a potential therapy for ischemic stroke. Here, we hypothesized that valproic acid (VPA) would modulate transplantation effects of MNCs in a rat ischemic stroke model. Male Sprague-Dawley rats were subjected to transient 90min middle cerebral artery occlusion. Infarct volume, neurological outcome, and immunohistological assessments were performed 7 days after ischemia. MNCs injected 6 or 24h but not 48 or 72h after ischemia significantly reduced infarct volume and improved neurological deficits. We then tested whether the therapeutic window of MNC transplantation could be expanded through combination therapy with VPA. MNC transplantation at 48h combined with VPA injection three times at 47, 53, and 72h after ischemia significantly ameliorated infarct volume and neurological deficits compared to a vehicle group. Combination therapy reduced the number of myeloperoxidase-positive cells, ionized calcium binding adapter molecule 1-positive cells, tumor necrosis factor-α-positive cells, and von Willebrand factor-positive cells in the ischemic boundary zone. The number of engrafted MNCs that were fluorescently labeled with PKH 26, on day 7, was significantly higher after combination therapy than after that MNC transplantation alone. Our results demonstrated that combination therapy with VPA enhanced the anti-inflammatory and vasculo-protective effects against endothelial damage following ischemia, and increased the survival of transplanted cells, leading to expansion of the therapeutic time window for MNC transplantation. Together, these findings suggest that VPA may be an appropriate partner for cell-based treatment of ischemic stroke.

Pharmacoresistant convulsions and visual hallucinations around two weeks after selegiline overdose: a case report

A case of pharmacoresistant convulsions after selegiline overdose is reported. A 50-year-old male having been suffering from bipolar II disorder for 16 years attempted suicide by taking an overdose of 195 mg selegiline with other psychotropics. He developed recurrent pharmacoresistant seizure from 12th day to 19th day after selegiline overdose. He also had visual hallucinations and temporary high blood pressure. The authors suspect that the catecholamine-influenced convulsions and visual hallucinations that manifested during the period increased by the MAO-inhibiting action of selegiline which lasts about 2 weeks.

Electroconvulsive therapy for burning mouth syndrome

OBJECTIVE

Burning mouth syndrome (BMS) is an orofacial pain disorder characterized by a chronic, idiopathic burning sensation of the oral mucosa that mostly affects middle-aged women. Although both psychological and neuropathological factors have been postulated to underlie BMS, the pathogenic mechanism of the condition remains controversial, as do the treatment strategies.

METHOD

A single case was reported.

RESULTS

Ms A, a 66-year-old woman with BMS type 1, which is characterized by daily burning pain associated with circadian variation, underwent electroconvulsive therapy (ECT). After the completion of 12 ECTs, the pain markedly diminished and the pronounced ECT effect persisted over the subsequent 24-week period of observation.

CONCLUSION

To our knowledge, this is the first clinical report on the efficacy of ECT for treating pain associated with BMS. ECT can be considered to be an option for treating individuals with enduring and intractable intraoral burning pain.

Serum levels of P-selectin in men with high-functioning autism

Immune dysfunction has been proposed as a mechanism for the pathophysiology of autistic-spectrum disorders. The selectin family of adhesion molecules plays a prominent role in immune/inflammatory responses. We determined the serum levels of three types of soluble-form selectin (sP, sL and sE) in 15 men with high-functioning autism and 22 age-matched healthy controls by enzyme-linked immunosorbent assay. Levels of sP-selectin and sL-selectin were significantly lower in patients than in controls. Furthermore, sP-selectin levels were negatively correlated with impaired social development during early childhood.

An Advanced Engine Control System Using Combustion Pressure Sensors

While investigating high-efficiency responsive driveability accompanied by low exhaust emissions, a new concept in engine control has been developed. The method is based on the direct monitoring and controlling of combustion conditions in engines, using a newly developed combustion pressure sensor. Fibre-optic technology is adapted to this sensor to produce a high noise immunity and a simple structure that facilitates applications in automotive engines. A sensing method to obtain information on engine output, knocking or detonation and the combustion temperature from the signal of the combustion pressure sensor has been proposed. A control system for the engine and powertrain control using this sensing method has been put forth to provide a remarkable improvement in engine and powertrain characteristics.

Comparison of stent placement and colostomy as palliative treatment for inoperable malignant colorectal obstruction

BACKGROUND

Stent placement is a useful palliative treatment for inoperable acute malignant colorectal obstruction. However, data comparing stent placement with colostomy are scarce.

METHODS

We compared the clinical outcome of 18 patients who had stent placement and 17 patients who underwent only colostomy.

RESULTS

The postoperative hospital stay was 22.3 days for stent placement compared with 47.4 days for colostomy (p = 0.016). The duration to readmission was 129.2 days for stent placement and 188.4 days for colostomy. The estimated duration of primary stent patency was 106 days. Mean survival period was 134 days in patients with stent placement and 191 days in patients with colostomy.

CONCLUSION

Postoperative hospital stay was shorter in patients with stent placement but duration to readmission and survival were longer in patients with colostomy. However, stent placement increases the option of palliative treatment and is an effective treatment contributing to improving quality of life.

Reduced low-density-lipoprotein cholesterol causing low serum cholesterol levels in gastrointestinal cancer: a case control study

Several epidemiological studies suggested an inverse relation between serum cholesterol level and cancer mortality. We analyzed the relation between gastrointestinal cancers and serum cholesterol levels. A total of 631 patients were recruited as cancer-bearing cases, comprising 181 esophageal cancers, 251 gastric cancers and 199 colorectal cancers. A case-control analysis was conducted on the serum TC, HDL-C, LDL-C and TG levels. TC and LDL-C were significantly lower in cancer-bearers by approximately 15 mg/dl. Furthermore, analyses by cancer site also showed significantly lower TC and LDL-C levels in cancer-bearers than in controls for all three sites. In this analysis, early stage cancer-bearers showed a significant decrease in TC levels by approximately 11 mg/dl compared with controls, and also a similar decrease in LDL-C levels. These results suggest that low TC levels are not related to cancer stage. Furthermore, findings of no significant differences in HDL-C and TG between cancer-bearing cases and controls in addition to a specific decrease in LDL-C in cancer-bearers suggest that hypocholesterolemia observed in these cases stems from low LDL-C. However, cancer-bearers and controls showed a similar distribution of TC and LDL-C levels. We should be aware that latent cancer bearers may be present among subjects with hypocholesterolemia.

[A case of pneumonectomy for lung cancer associated with scleroderma]

A 60-year-old female, diagnosed as scleroderma, was referred to our hospital because of symptoms of common cold and abnormal findings on a chest X-ray. The chest X-ray and CT scan revealed a mass in the left upper field, suspected to invade left anterior chest wall. Moreover, fibrotic changes were observed in the lung field. Cytology by bronchofiberscopy showed squamous cell carcinoma. Evaluation of pulmonary function, including unilateral pulmonary artery occlusion test (UPAO), revealed possibility of lung resection. Subsequently, pneumonectomy with combined resection of left 1st rib was performed. Postoperative course was uneventful and she was discharged. She was admitted again four months after the operation with appetite loss and body weight loss. Further examinations revealed arrhythmia, renal failure, pancreatitis and liver metastasis. Her general conditions grew worse and she died five months after the operation. In conclusion, UPAO was a useful method to determine the functional lung resectability for the case with scleroderma. However, effects of surgical stress for the development of scleroderma remain to be elucidated.

THE EFFECTS OF BISOPROLOLA SELECTIVE β1-BLOCKERON GLUCOSE METABOLISM BY LONG-TERM ADMINISTRATION IN ESSENTIAL HYPERTENSION

Bisoprolol, a beta1-selective beta-blocker, was administered to 13 patients with mild to moderate essential hypertension once daily at doses of 5-10 mg for 24 weeks, and its long-term effects on blood pressure and glucose metabolism were investigated. The systolic, diastolic and mean blood pressures were significantly reduced. At the end of the treatment period, the blood glucose level and hemoglobin A1c were not significantly different from those at baseline. In the glucose tolerance test at the end of the treatment period, the blood glucose and plasma insulin levels after a glucose load of 75 g were not significantly different at any time point, and the sums of each were not significantly different from their baseline levels. Based on these results, bisoprolol appears to be a beta1-selective beta-blocker possessing a satisfactory hypotensive effect without any adverse effects on glucose metabolism for long-term use, and is therefore a safe and useful drug for the treatment of essential hypertension.

A proposal for the unification of five species of the cyanobacterial genus Microcystis Kützing ex Lemmermann 1907 under the rules of the Bacteriological Code

Genomic DNA homologies were examined from six Microcystis (cyanobacteria) strains, including five different species, Microcystis aeruginosa, Microcystis ichthyoblabe, Microcystis novacekii, Microcystis viridis and Microcystis wesenbergii. All DNA-DNA reassociation values between two strains of M. aeruginosa and the other four species exceeded 70%, which is considered high enough for them to be classified within the same bacterial species. It is proposed to unify these five species into M. aeruginosa under the Rules of the Bacteriological Code and NIES843T (= IAM M-247T) is proposed as the type strain. Two other species, Microcystis flos-aquae and Microcystis pseudofilamentosa, should be regarded as morphological variations of this unified M. aeruginosa. The current taxonomy of cyanobacteria depends too much upon morphological characteristics and must be reviewed by means of bacteriological methods as well as traditional botanical methods.

Regulation of calcitonin receptor by glucocorticoid in human osteoclast-like cells prepared in vitro using receptor activator of nuclear factor-kappaB ligand and macrophage colony-stimulating factor

Using mouse osteoclast-like cells (OCs), we have shown that treatment with glucocorticoids (GCs) resulted in an increase in calcitonin (CT) binding by enhancing CT receptor (CTR) gene transcription. Additionally, treatment with GCs demonstrated increased sensitivity to CT. There is, however, scant information on the effects of GC or CTR regulation by GCs in human osteoclasts. In this study we examined CTR regulation by GCs and the effects of GCs and CT together in human OCs. OCs were prepared by treatment of peripheral blood mononuclear cells in vitro with soluble receptor activator of nuclear factor-kappaB ligand and macrophage colony-stimulating factor. Treatment of mature OCs with dexamethasone (Dex) resulted in a dose- and time-dependent increase in [(125)I]salmon CT (sCT) binding capacity. Treatment with Dex enhanced CTR messenger RNA (mRNA) expression, suggesting that CTR up-regulation is at least partly due to an increase in de novo CTR synthesis. Triamcinolone and prednisolone reproduced the Dex effect on [(125)I]sCT-specific binding and CTR mRNA expression, but 17beta-estradiol, progesterone, dehydroepiandrosterone, and aldosterone did not. A Scatchard plot analysis showed that Dex enhanced CTR number with a minimal change in the affinity to sCT. Autoradiographic studies using [(125)I]sCT showed that Dex enhanced the CTR density on individual multinuclear OCs. Up-regulation of [(125)I]sCT-specific binding and CTR mRNA expression was seen even in the presence of sCT, but the enhancement diminished subsequently at later times (36-48 h after sCT removal), which was consistent with our previous observation in mouse OCs. This suggests that GCs and CTs act on CTR expression differently, consistent with our previous work using mouse OCs, in which we found that GCs increased transcription of CTR gene expression, whereas CT reduced CTR mRNA stability. The results obtained in this study show that GC increased CTR expression and sensitivity to CT in cells of the human osteoclast lineage and provide the basis for understanding the beneficial effects of combination treatment with GCs and CTs in malignancy-associated hypercalcemia.

[Hemodynamic and pulmonary effects of fluid resuscitation from hemorrhagic shock in the presense of mild pulmonary edema]

The hemodynamic and pulmonary effects of fluid resuscitation with crystalloid and colloid solutions in the presence of mild pulmonary edema were investigated. Anesthetized dogs received oleic acid to increase pulmonary capillary permeability, and one hour later bled to produce hemorrhagic shock. One hour after the shock, resuscitation was performed with Ringer's lactate, 6% hydroxyethyl starch (HES) solution, or dog's plasma. Resuscitation from hemorrhagic shock restored hemodynamics to pre-hemorrhagic levels with all of the above solutions. Ringer's lactate resuscitation resulted in increases in extravascular lung water volume (EVLWV) and oxygen consumption, and decreases in colloid osmotic pressure and oxygen delivery. Resuscitation with HES solution and plasma did not result in increases in EVLWV, but with HES solution resulted in decreases in colloid osmotic pressure to pre-hemorrhagic levels in two hours. This suggests that the resuscitation with HES solution can not maintain colloid osmotic pressure for more than two hours. The author concludes that the hemodynamic and pulmonary effects of HES solution and plasma are similar in mild lung injury cases.

Comparative study of the effects of magnetic versus electrical stimulation on inhibition of detrusor overactivity

OBJECTIVES

To perform a randomized comparative study investigating the urodynamic effects of functional magnetic stimulation (FMS) and functional electrical stimulation (FES) on the inhibition of detrusor overactivity.

METHODS

Thirty-two patients with urinary incontinence due to detrusor overactivity (15 men, 17 women; age 62. 3 +/- 16.6 years) were randomly assigned to two treatment groups (15 patients in the FMS group and 17 in the FES group). Stimulation was applied continuously at 10 Hz in both groups. For FMS, the magnetic stimulator unit was set on an armchair type seat and had a concave-shaped coil, so that the patients could sit during stimulation. For FES, a vaginal electrode was used in the women and a surface electrode on the dorsal part of the penis was used in the men. Cystometry was performed before and during the stimulation.

RESULTS

The bladder capacity at the first desire to void and the maximum cystometric capacity increased significantly during stimulation compared with prestimulation levels in both groups (P = 0.0054 and 0.0026, respectively, in the FMS group and P = 0.0015 and 0.0229, respectively, in the FES group). However, the increase in the maximum cystometric capacity was significantly (P = 0.0135) greater in the FMS group (114.2 +/- 124.1 mL or an increase of 105. 5% +/- 130.4% compared with the pretreatment level) than that in the FES group (32.3 +/- 56.6 mL or an increase of 16.3% +/- 33.9%). Detrusor overactivity was abolished in 3 patients in the FMS group but not in any patient in the FES group.

CONCLUSIONS

Although both treatments were effective, the inhibition of detrusor overactivity appeared greater in the FMS group than in the FES group.

[A case of MPO ANCA associated glomerulonephritis with interstitial pneumonitis complicated with lung tuberculosis and pericarditis]

The main target organs of myeloperoxidase (MPO) antineutrophil cytoplasmic antibodies (ANCA)-related disease are the kidney and lung. This report describes a 71-year-old man with rapidly progressive glomerulonephritis (RPGN) and interstitial pneumonitis associated with MPO ANCA. The patient was admitted to our hospital because of bloody sputum, low grade fever and appetite loss on October, 1998. He was diagnosed as having interstitial pneumonitis from the findings of chest X-ray and CT examinations. Moderate proteinuria and hematuria, renal dysfunction(serum creatinine: 5.6 mg/dl, BUN: 58.0 mg/dl) and positivity for MPO ANCA were noted. He was negative for anti-glomerular antibody and PR3-ANCA. Renal biopsy was performed and revealed crescentic glomerulonephritis without deposition of immunoglobulins. Therefore, the diagnosis of pauci immune type RPGN was made. Pulse therapy with methylprednisolone(1.0 g/day x 3 days) following oral administration of prednisolone (60 mg/day) found marked improvement of renal function maintenance and interstitial pneumonitis, respectively. However, he died because of lung tuberculosis and acute tuberculous pericarditis during treatment with prednisolone. In this case, MPO ANCA might have been directly associated with both RPGN and interstitial pneumonitis. Furthermore, chronic lung disease, such as interstitial pneumonitis, is important as a preceding disease of RPGN. MPO ANCA-related disease is more frequent in aged persons, therefore particular attention should be paid during their treatment with an immunosuppressant.

Calcitonin receptor regulation and responsiveness to calcitonin in human osteoclast-like cells prepared in vitro using receptor activator of nuclear factor-kappaB ligand and macrophage colony-stimulating factor

Using mouse osteoclast-like cells (OCs), we have shown that short exposure to calcitonin (CT) resulted in prolonged reduction of CT binding by inhibiting de novo CT receptor (CTR) synthesis. Additionally, CT-treated OCs demonstrated resistance to CT rechallenge on the inhibitory effect of CT in osteoclastic bone resorption. There is, however, scant information on CT effects on human osteoclasts. In this study, we examined the features of CTR down-regulation and its recovery after short exposure to CT of human OCs. OCs were prepared by treatment of peripheral blood mononuclear cells in vitro with osteoclast differentiation factor and macrophage colony-stimulating factor. Treatment of OCs with salmon CT (sCT) and human CT (hCT) resulted in a dose-dependent reduction in [125I]sCT binding capacity. Continued receptor occupancy by ligand was excluded by using a glycine-acid washing procedure. Treatment with sCT reduced CTR messenger RNA expression, suggesting that CTR down-regulation is, at least partly, attributable to an inhibition of de novo CTR synthesis. To investigate the intracellular signal transduction pathways that mediate these effects, we examined the effects of activation of the protein kinase (PK)A, PKC, and Ca2+-calmodulin-dependent kinases. Treatment with PKC activators mimicked CT, whereas neither activation of PKA nor elevation of intracellular Ca2+ did so. We further investigated the intracellular signaling pathways responsible for the inhibitory effects of CT on bone resorption, which showed that treatment with PKC activators reproduced the effects of CT. These data suggest that the PKC pathway plays an important role in homologous CTR down-regulation, as well as inhibition of bone-resorbing activity by CT, in human OCs. Short exposure of OCs to CT (10(-9) M, 1 h) reduced [125I]sCT-specific binding for a prolonged period, as we have shown previously in mouse OCs. The reduced specific binding, CTR messenger RNA levels, and CT-sensitive adenylate cyclase responsiveness returned to the control levels by 96 h after removal of CT. These results strongly support the notion that escape from CT inhibition of osteoclastic bone resorption in humans is attributable to the development of resistance by OCs to CT. This study also showed that even short exposure to CT induced prolonged desensitization to CT rechallenge, although the OCs eventually regained responsiveness to sCT rechallenge.

A patient of hypogonadotropic hypogonadism accompanied by growth hormone deficiency and decreased bone mineral density who attained normal growth

We present here a rare case of hypopituitarism accompanied by growth hormone (GH) deficiency and hypogonadotropic hypogonadism, in which the patient attained normal height but was of eunuchoid appearance. A 23-year-old man who had not reached puberty was referred to Saitama Medical School for hormonal evaluation. Basal hormonal data and hormone-stimulating tests revealed impaired secretion of GH, gonadotropins and adrenocorticotropic hormone (ACTH). Serum levels of testosterone, estrone, estradiol and estriol were all below the detectable ranges. The patient's plasma ACTH responded to corticotropin releasing hormone, but not to insulin-induced hypoglycemia. Serum GH showed a minimal response to GH-releasing hormone, but was unresponsive to insulin-induced hypoglycemia. Serum luteinizing hormone and follicle stimulating hormone did not respond to luteinizing hormone-releasing hormone. The results were compatible with a diagnosis of hypothalamic hypopituitarism. Magnetic resonance images of the brain showed a small anterior pituitary, an ectopic posterior lobe and transection of the pituitary stalk. Although the patient showed signs of hypopituitarism, he finally attained normal height, possibly because of failed epiphyseal maturation. His bone mineral density was markedly reduced to 0.647 g/cm2 in the lumbar spine; this level was 61.7% of the average level of healthy young males. Our findings were compatible with a recently advocated view that estrogen is important in promoting epiphyseal fusion and in determining bone density in males as well as females.

[Efficacy of antibiotic prophylaxis in clean neurosurgical operations: a comparison of seven-day versus one-day administration]

We compared seven-day and one-day administration of antibiotics as prophylaxis in clean neurosurgical operations. A total of 175 patients were examined. Seven-day administration (protocol A) was studied retrospectively from May 1997 to May 1998 in 87 patients of 46 craniotomies and 41 burr hole operations. One-day administration (protocol B) was studied prospectively from June 1998 to July 1999 in 88 patients of 39 craniotomies and 49 burr hole operations. Protocol A received 1.5 g of sulbactam/ampicillin = 1:2 (SBT/ABPC) preoperatively, and further doses were continued at 12-hour intervals for seven days after the operation. Protocol B received 1.5 g of SBT/ABPC preoperatively and intraoperative additional antibiotics were administered at 5-hour intervals, and only one single dose was administered after the operation. In both of the protocols, 60 mg of tobramycin was mixed with 500 ml of saline for irrigation of operative fields. No postoperative infection occurred in either of the two protocols. We conclude that one-day administration of prophylactic antibiotics is enough to prevent postoperative infections in clean neurosurgical operations.

Randomized, double-blind study of electrical stimulation for urinary incontinence due to detrusor overactivity

OBJECTIVES

To evaluate the usefulness of electrical stimulation for urinary incontinence due to detrusor overactivity in a randomized, double-blind manner.

METHODS

Sixty-eight patients (29 men, 39 women, 70.0 +/- 11.2 years) were studied. Detrusor overactivity was urodynamically defined as involuntary detrusor contractions of more than 15 cm H(2)O during the filling phase. Ten-hertz square waves of 1-ms pulse duration were used. A vaginal electrode was used in the women and an anal or surface electrode in the men. The stimulation was given for 15 minutes twice daily for 4 weeks. The efficacy was evaluated on the basis of a frequency/volume chart and urodynamic study before and after treatment.

RESULTS

Thirty-two patients in the active group and 28 in the sham group completed the study. The patient impressions were very good or good in 59% and 39% of the active and the sham group, respectively (P = 0.0354). On the cystometrogram, the bladder capacity at the first desire to void and the maximum desire to void increased significantly (P = 0.0104 and P = 0.0046, respectively) in the active group, but not in the sham group. Seven patients in the active group and 1 patient in the sham group were cured (P = 0.0324); 26 patients (81.3%) in the active group and 9 (32.1%) in the sham group improved (P = 0.0001). Of 17 patients in the active group, 13 remained cured or improved for an average of 8.4 months after completion of the 4-week treatment; in the sham group, 3 of 6 patients were cured or improved for an average of 4.7 months after completion of the 4-week treatment.

CONCLUSIONS

Electrical stimulation was useful in treating urinary incontinence due to detrusor overactivity.

Effect of functional continuous magnetic stimulation for urinary incontinence

PURPOSE

We evaluated the therapeutic efficacy of continuous magnetic stimulation on urinary incontinence by studying the urodynamic effect on urethral closure and bladder inhibition.

MATERIALS AND METHODS

A total of 11 patients with stress incontinence and 12 with urge incontinence (7 males and 16 females, mean age 55.8 years) were evaluated. In the pilot study urethral pressure profile was performed before and after 20 Hz. 15-minute (with 1-minute on/30-second off cycles) stimulation, and maximum intraurethral pressure was recorded during stimulation in stress incontinence cases. Cystometry was performed before and during 15-minute stimulation at 10 Hz. in urge incontinence cases. In the therapeutic study 8 females with stress incontinence, and 3 males and 5 females with urge incontinence were treated with magnetic stimulation twice a week for 5 weeks.

RESULTS

In the pilot study maximum intraurethral pressure increased by 34% during stimulation and maximum urethral closure pressure increased by 20.9% (p = 0.0409) after stimulation in stress incontinence cases. In urge incontinence cases significant increases in bladder capacities at first and maximum desire to void during stimulation were noted (p = 0.0164 and 0.0208, respectively). In the therapeutic study 86% of 7 patients with stress incontinence and 75% of 8 with urge incontinence were improved, and 1 dropped out of the study.

CONCLUSIONS

Continuous magnetic stimulation was effective on urethral closure and bladder inhibition, and as treatment of urinary incontinence.