Does scoring patient complexity using COMPRI predict the length of hospital stay? A multicentre case-control study in Japan

OBJECTIVE

To clarify the factors associated with prolonged hospital stays, focusing on the COMplexity PRediction Instrument (COMPRI) score's accuracy in predicting the length of stay of newly hospitalised patients in general internal medicine wards.

DESIGN

A case-control study.

SETTING

Three general internal medicine wards in Chiba Prefecture, Japan.

PARTICIPANTS

Thirty-four newly hospitalised patients were recruited between November 2017 and December 2019, with a final analytic sample of 33 patients. We included hospitals in different cities with general medicine outpatient and ward facilities, who agreed to participate. We excluded any patients who were re-hospitalised within 2 weeks of a prior discharge.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patients' COMPRI scores and their consequent lengths of hospital stay.

RESULTS

The 17 patients (52%) allocated to the long-term hospitalisation group (those hospitalised ≥14 days) had a significantly higher average age, COMPRI score and percentage of participants with comorbid chronic illnesses than the short-term hospitalisation group (<14 days). A logistic regression model (model A, comprising only the COMPRI score as the explanatory variable) and a multiple logistic regression model (model B, comprising variables other than the COMPRI score as explanatory variables) were created as prediction models for the long-term hospitalisation group. When age ≥75 years, a COMPRI score ≥6 and a physician with 10 years' experience were set as explanatory variables, model A showed better predictive accuracy compared with model B (fivefold cross-validation, area under curve of 0.87 vs 0.78). The OR of a patient with a COMPRI score of ≥6 joining the long-term hospitalisation group was 4.25 (95% CI=1.43 to 12.63).

CONCLUSIONS

Clinicians can use the COMPRI score when screening for complexity assessment to identify hospitalised patients at high risk of prolonged hospitalisation. Providing such patients with multifaceted and intensive care may shorten hospital stays.

The effect of TB treatment on health-related quality of life for people with advanced HIV

BACKGROUND: Study A5274 was an open-label trial of people with HIV (PLHIV) with CD4 cell count <50 cells/µL who were randomized to empirical TB treatment vs. isoniazid preventive therapy (IPT) in addition to antiretroviral therapy (ART). We evaluated health-related quality of life (HRQoL) by study arm, changes over time, and association with sociodemographic and clinical factors.METHODS: Participants aged >13 years were enrolled from outpatient clinics in 10 countries. HRQoL was assessed at Weeks 0, 8, 24 and 96 with questions about daily activity, hospital or emergency room visits, and general health status. We used logistic regression to examine HRQoL by arm and association with sociodemographic and clinical factors.RESULTS: Among 850 participants (424 empiric arm, 426 IPT arm), HRQoL improved over time with no difference between arms. At baseline and Week 24, participants with WHO Stage 3 or 4 events, or those who had Grade 3 or 4 signs/symptoms, were significantly more likely to report poor HRQoL using the composite of four HRQoL measures.CONCLUSION: HRQoL improved substantially in both arms during the study period. These findings show that ART, TB screening, and IPT can not only reduce mortality, but also improve HRQoL in PLHIV with advanced disease.

Minocycline treatment for HIV-associated cognitive impairment: results from a randomized trial

OBJECTIVE

We conducted a study of minocycline to assess its safety, tolerability, and efficacy for the treatment of HIV-associated cognitive impairment.

METHODS

HIV-1-infected individuals with progressive neurocognitive decline were enrolled in a double-blind, placebo-controlled study of minocycline. Participants were randomized to receive minocycline 100 mg or matching placebo orally every 12 hours. The primary efficacy measure was change in a neuropsychological test composite z score (NPZ-8) from baseline to week 24. Measures of safety included the frequency of adverse events and changes over time in laboratory tests. After 50% of participants completed the double-blind phase, an interim analysis of futility for the primary outcome measure was performed, and our Data and Safety Monitoring Board recommended early study termination.

RESULTS

A total of 107 HIV-1-infected individuals with cognitive impairment were enrolled. The minocycline group did not show improvement in the primary outcome measure (NPZ-8) (mean 24-week change = 0.12) compared to placebo (mean 24-week change = 0.17) (95% confidence interval = [-0.26, 0.39], p = 0.70). There were few severe adverse events or laboratory abnormalities in either treatment group.

CONCLUSION

Minocycline was safe and well-tolerated in individuals with HIV-associated cognitive impairment, but cognitive improvement was not observed. Classification of evidence. This interventional study provides Class II evidence for the safety, tolerability, and efficacy of minocycline for the treatment of HIV-associated cognitive impairment.

Ferroelectricity induced by spin-dependent metal-ligand hybridization in Ba₂CoGe₂O₇

We have investigated the variation of induced ferroelectric polarization under a magnetic field with various directions and magnitudes in a staggered antiferromagnet Ba₂CoGe₂O₇. While the ferroelectric polarization cannot be explained by the well-accepted spin current model nor the exchange striction mechanism, we have shown that it is induced by the spin-dependent p-d hybridization between the transition metal (Co) and ligand (O) via the spin-orbit interaction. On the basis of the correspondence between the direction of electric polarization and the magnetic state, we have also demonstrated the electrical control of the magnetization direction.

Indicators of pretreatment suicidal ideation in adults with major depressive disorder

OBJECTIVE

In order to evaluate the presence of treatment emergent suicidal ideation (SI), it becomes necessary to identify those patients with SI at the onset of treatment. The purpose of this report is to identify sociodemographic and clinical features that are associated with SI in major depressive disorder (MDD) patients prior to treatment with a selective serotonin reuptake inhibitor.

METHOD

This multisite study enrolled 265 out-patients with non-psychotic MDD. Sociodemographic and clinical features of participants with and without SI were compared post hoc.

RESULTS

Social phobia, bulimia nervosa, number of past depressive episodes, and race were independently associated with SI by one or more SI measure.

CONCLUSION

Concurrent social phobia and bulimia nervosa may be potential risk factors for SI in patients with non-psychotic MDD. Additionally, patients with more than one past depressive episode may also be at increased risk of SI.

Prognosis of patients after pulmonary artery plasty for non-small cell lung cancer

OBJECTIVE

We evaluated the clinical outcomes of patients after lung resection with pulmonary artery (PA) plasty for non-small cell lung cancer (NSCLC).

METHODS

From 1995 to 2006, 36 patients (26 males and 10 females) with NSCLC underwent lobectomy or segmentectomy with PA plasty at our institution. The mean age of the patients was 65.9 years old (range 45-87 years old). There were 17 left upper lobectomies, 10 right upper lobectomies, five left lower lobectomies, two right upper-and-middle bilobectomies, one right lower lobectomy, and one left upper division segmentectomy. Both bronchoplasty and PA plasty were performed in 15 patients. Six patients received preoperative chemotherapy, and one had preoperative radiotherapy.

RESULTS

The postoperative morbidity rate was 27.8 % (10/36), and the mortality rate (30 days) was 2.8 % (1/36). One patient underwent completion pneumonectomy on postoperative day 13. Macroscopic residual cancer was identified in two patients at the thoracic wall and aorta, respectively; microscopic residual cancers were identified in two patients at the stumps of the pulmonary artery and in one patient at the bronchial stump. Postoperative radiation therapy was additionally given to those four patients, except one. The 5-year survival rate for all patients was 51.8 %. There was no significant difference in the 5-year survival rate between clinical N (cN) 0-1 patients and cN2 patients. However, in pathological N (pN) 0-1 patients, the 5-year survival rate was significantly better than that of pN2 patients (71.9 % versus 0.0 %; P < 0.001).

CONCLUSIONS

PA plasty for NSCLC is acceptable and highly recommended for pN0-1 patients. Strict patient selection should be considered so as to avoid surgical operations in patients with pN2 staging.

Residual symptoms after remission of major depressive disorder with citalopram and risk of relapse: a STAR*D report

BACKGROUND

Many patients with major depressive disorder (MDD) who experience full symptomatic remission after antidepressant treatment still have residual depressive symptoms. We describe the types and frequency of residual depressive symptoms and their relationship to subsequent depressive relapse after treatment with citalopram in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial.

METHOD

Participants in primary (n=18) and psychiatric (n=23) practice settings were openly treated with citalopram using measurement-based care for up to 14 weeks and follow-up for up to 1 year. We assessed 943 (32.8% of 2876) participants who met criteria for remission to determine the proportions with individual residual symptoms and any of the nine DSM-IV criterion symptom domains to define a major depressive episode. At each visit, the 16-item Quick Inventory of Depressive Symptomatology, Self-Report (QIDS-SR16) and the self-report Frequency, Intensity, and Burden of Side Effects Rating (FIBSER) scale were used to assessed depressive symptoms and side-effects respectively.

RESULTS

More than 90% of remitters had at least one residual depressive symptom (median=3). The most common were weight increase (71.3%) and mid-nocturnal insomnia (54.9%). The most common residual symptom domains were sleep disturbance (71.7%) and appetite/weight disturbance (35.9%). Those who remitted before 6 weeks had fewer residual symptoms at study exit than did later remitters. Residual sleep disturbance did not predict relapse during follow-up. Having a greater number of residual symptom domains was associated with a higher probability of relapse.

CONCLUSIONS

Patients with remission of MDD after treatment with citalopram continue to experience selected residual depressive symptoms, which increase the risk of relapse.

Evidence for an electric-dipole active continuum band of spin excitations in multiferroic TbMnO3

The wide range optical spectra on a multiferroic prototype TbMnO3 have been investigated to clarify the origin of spin excitations observed in the far-infrared region. We elucidate the full band structure, whose high energy edge (133 cm;{-1}) exactly corresponds to twice of the highest-lying magnon energy. Thus the origin of this absorption band is clearly assigned to two-magnon excitation driven by the electric field of light. There is an overlap between the two-magnon and phonon energy ranges, where the strong coupling between them is manifested by the frequency shift and transfer of oscillator strength of the phonon mode.

Lack of inducible nitric oxide synthases attenuates leukocyte-endothelial cell interactions in retinal microcirculation

Aim:

To investigate the effect of inducible nitric oxide synthases (iNOS) on inflammatory reactions during endotoxin-induced uveitis (EIU) in mice by studying leukocyte–endothelial cell interactions.

Methods:

EIU was produced in immunosuppressed iNOS^−/− mice and C57BL/6 (normal) mice by footpad injection of lipopolysaccharide. Leukocytes were labelled with acridine orange. Leukocyte rolling in the retinal microcirculation was evaluated in vivo with acridine orange digital fluorography. The number of migrated leukocytes was counted in flat-mounted retina.

Results:

Both leukocyte rolling and migration peaked at 48 h after lipopolysaccharide injection. The maximal numbers of rolling leukocytes in the immunosuppressed iNOS^−/− mouse retina decreased by 98.2% (p<0.001) compared with that in the normal mouse retina at 48 h after lipopolysaccharide injection. In addition, the maximal numbers of migrated leukocytes in the immunosuppressed iNOS^−/− mouse retina decreased by 74.0% (p<0.001) compared with that in the normal mouse retina at 24 h after lipopolysaccharide injection. Furthermore, the diameters of major retinal veins of the immunosuppressed iNOS^−/− group were smaller at both 24 and 48 h after lipopolysaccharide injection than were those of the normal group (p<0.001, respectively).

Conclusions:

A lack of iNOS suppresses leukocyte–endothelial cell interactions in the retinas of mice with EIU. This suggests that iNOS may play a role in the management of patients with uveitis and other inflammatory conditions.

Neuroprotective effect of cilostazol against retinal ischemic damage via inhibition of leukocyte-endothelial cell interactions

BACKGROUND

Cilostazol, a selective platelet phosphodiesterase inhibitor, has been shown to reduce neuronal injury after transient cerebral ischemia. Its neuroprotective effect is thought to result from an antiplatelet function. This study was designed to evaluate the inhibitory effects of cilostazol against retinal ischemic damage focusing on leukocyte-endothelial cell interactions.

METHODS

Retinal ischemia was induced for 60 min in male Sprague-Dawley rats (n = 144) by temporary ligation of the optic sheath. Cilostazol was administered just before ischemia induction. Leukocyte behavior in the retinal microcirculation was evaluated in vivo with scanning laser ophthalmoscopy and ex vivo with fluorescence microscopy. Retinal expression of P-selectin, intracellular adhesion molecule-1 (ICAM-1), and vascular endothelial growth factor were evaluated by real-time quantitative reverse transcriptase-polymerase chain reaction. Ischemia-induced retinal damage was evaluated histologically.

RESULTS

Treatment with cilostazol significantly suppressed leukocyte-endothelial cell interactions; the maximal numbers of rolling leukocytes were reduced by 77.6% (P < 0.01) 12 h after ischemia. Twenty-four hours after ischemia, adherent and accumulated leukocytes were also suppressed by treatment with cilostazol (36.1% and 20.4% respectively, P < 0.01). The expressions of P-selectin and ICAM-1 mRNA were suppressed significantly in cilostazol-treated retinas (P < 0.05). The retinal histological examination demonstrated a significant protective effect of cilostazol against ischemia-induced retinal damage (P < 0.01).

CONCLUSIONS

The present study demonstrates that cilostazol attenuates retinal injury after transient ischemia via inhibition of leukocyte-endothelial cell interactions. This inhibitory effect on postischemic leukocyte-endothelial cell interactions might partially contribute to its neuroprotective effects.

Field-induced staggered magnetization and magnetic ordering in Cu2(C5H12N2)2Cl4

We present a 2D NMR investigation of the gapped spin-1/2 compound Cu2(C5H10N2D2)2Cl4. Our measurements reveal the presence of a magnetic field-induced transverse staggered magnetization (TSM) which persists well below and above the field-induced 3D long-range magnetically ordered (FIMO) phase. The symmetry of this TSM is different from that of the TSM induced by the order parameter of the FIMO phase. Its origin, field dependence, and symmetry can be explained by an intradimer Dzyaloshinskii-Moriya interaction, as shown by DMRG calculations on a spin-1/2 ladder. This leads us to predict that the transition into the FIMO phase is not in the BEC universality class.

Prospective 12-month course of bipolar disorder in out-patients with and without comorbid anxiety disorders

BACKGROUND

The impact of anxiety disorders has not been well delineated in prospective studies of bipolar disorder.

AIMS

To examine the association between anxiety and course of bipolar disorder, as defined by mood episodes, quality of life and role functioning.

METHOD

A thousand thousand out-patients with bipolar disorder were followed prospectively for 1 year.

RESULTS

A current comorbid anxiety disorder (present in 31.9% of participants) was associated with fewer days well, a lower likelihood of timely recovery from depression, risk of earlier relapse, lower quality of life and diminished role function over I year of prospective study. The negative impact was greater with multiple anxiety disorders.

CONCLUSIONS

Anxiety disorders, including those present during relative euthymia, predicted a poorer bipolar course. The detrimental effects of anxiety were not simply a feature of mood state. Treatment studies targeting anxiety disorders will help to clarify the nature of the impact of anxiety on bipolar course.

In vivo evaluation of ocular inflammatory responses in experimental diabetes

AIMS

Diabetic patients may have abnormal inflammatory reactions to foreign or endogenous stimuli. This study was designed to evaluate inflammatory reactions in the diabetic eye through retinal leucocyte dynamics in the inflamed eyes of diabetic rats.

METHODS

Three weeks after diabetes induction in Long-Evans rats, endotoxin induced uveitis was produced by footpad injection of lipopolysaccharide (LPS). After LPS injection, leucocyte behaviour was evaluated in vivo by acridine orange digital fluorography.

RESULTS

The number of rolling leucocytes increased in a biphasic manner at 12 hours and 48 hours. The number of leucocytes accumulating in the retina reached a peak at 72 hours. The maximal numbers of rolling and accumulating leucocytes in the diabetic retina decreased by 56.3% (p<0.01) and 46.7% (p<0.0001), respectively, compared with the non-diabetic retina. The levels of mRNA expression of adhesion molecules in the retina, which were upregulated after LPS injection, were also lower in diabetic rats than in non-diabetic rats.

CONCLUSION

This study is the first to show that endotoxin induced inflammation is disturbed in the diabetic eye, based on evidence that the leucocyte-endothelial cell interactions stimulated by LPS were suppressed in the diabetic retina. These findings support the theory that ocular inflammatory reactions are impaired in diabetic patients.

[Irrigation for the post-pneumonectomy empyema infected by methicillin-resistant Staphylococcus aureus without broncho-pleural fistula; report of a successful case]

It has been known that treatments of post-pneumonectomy empyema are difficult. We report a successful case of irrigation for the post-pneumonectomy. The patient was 68-year-old man with advanced lung cancer. He underwent induction chemoradiotherapy following by pneumonectomy of the right side. A few days later after the chest drain was withdrawn, spike fever appeared. Empyema was suspected, so a 28 Fr diameter double lumen chest drain was intubated again. Turbid effusion was discharged through the drain, in which methicillin-resistant staphylococcus aureus (MRSA) was cultured. Irrigation using a lot of saline and acid electrolyzed water started. A month later, irrigator through the drain was looking clear, however, MRSA was cultured so far. After putting minomycine into the irrigator, MRSA died away. This physical and chemical irrigations were effective.

[Progress of introduction of artificial respirator at home--the knowledge I have gained from a 19 year-old patient requiring a home respiratory management care and through the friendship with his family members]

The patient developed right cerebellar hemorrhage at the age of 15 and spent four years at hospital. The patient and the family members had a strong wish to bring the patient back home and the patient was admitted to the hospital to undergo guidance about home medical care. The patient had paralysis of right upper and lower extremities and generalized strong ataxic motion and was under gastric feeding and had underwent tracheotomy to cope with hypoventilation, which required use of an artificial respirator at night hours. Since the patient was still as young as 19, we want to have the patient "go home" as they wanted. Fortunately, the mother who had to play key roles was still young and the parents worked at home. It didn't take long for them to master the techniques though they had various anxieties. It is considered important in the guidance on home medical care to what degrees the caregivers accept the condition of the patient and can imagine the long lasting care at home. We provided assistance while repeatedly interviewing with the patient and family members considering the significance to confirm their willingness and psychological condition. As a result, the patient was discharged from the hospital in two months. Now, two years have passed, and the patient is still cared at home and the possibility of the patient is sought for. The progress is reported here in this article.

Magnetic superstructure in the two-dimensional quantum antiferromagnet SrCu2(BO3)2

We report the observation of magnetic superstructure in a magnetization plateau state of SrCu2(BO3)2, a frustrated quasi-two-dimensional quantum spin system. The Cu and B nuclear magnetic resonance (NMR) spectra at 35 millikelvin indicate an apparently discontinuous phase transition from uniform magnetization to a modulated superstructure near 27 tesla, above which a magnetization plateau at 1/8 of the full saturation has been observed. Comparison of the Cu NMR spectrum and the theoretical analysis of a Heisenberg spin model demonstrates the crystallization of itinerant triplets in the plateau phase within a large rhomboid unit cell (16 spins per layer) showing oscillations of the spin polarization. Thus, we are now in possession of an interesting model system to study a localization transition of strongly interacting quantum particles.

Recurrent palmar dislocation of the distal radioulnar joint. A case report

Recurrent palmar dislocation of the distal radioulnar joint is not a common injury. We report one case in a 73-year-old female. This injury was incorrectly diagnosed at the first presentation because there has been no distinct deformity at the wrist and extension-flexion was normal. The need for proper physical examination and accurate radiographic positioning is stressed. Distal diaphysis resection combined with distal radioulnar arthrodesis (modified Sauve-Kapandji procedure) was the preferred method of treatment in an old patient. Two years after the injury, the patient was asymptomatic.

[The treatment for the acute occlusion of a coronary artery by PTCA failure with the acute occlusion of a femoral artery by the IABP insertion]

A 68-year-old woman had the acute occlusion of a coronary artery by PTCA failure acute occlusion of a femoral artery by the IABP insertion. The patient underwent on pump beating coronary bypass and axillo-femoral bypass simultaneously.

An estimation of economic effects of tele-home-care: hospital cost-savings of the elderly

Tele-home-care (or tele-medicine) is being implemented by the application of multimedia such as CATV and ISDN. In this paper, by focusing on the so-called "social hospitalization of the aged," we carry out an estimation of the extent to which tele-home-care based on multimedia can help in saving the cost of hospitalization of the aged in the future. Estimation consists of the following two parts. First, we estimate the trends of the aged population and their hospital expenses using the regression analysis. Second, we assume that new technology such as multimedia and new medical instruments develop according to a logistic curve. Thus, we estimate the rate of diffusion of CATV and ISDN by logistic curves. Then, by multiplying this number by hospital costs per elderly patient as estimated previously, we have been able to calculate the extent to which hospitalization costs can be saved in the entire economy. Our results indicated that in the year 2050, US$257.3 billion, or nearly 7.4% of total hospitalization costs of the aged could be saved by tele-home-care.

Orexin depolarizes rat hypothalamic paraventricular nucleus neurons

Orexins, also called hypocretins, are newly discovered hypothalamic peptides that are thought to be involved in various physiological functions. In spite of the fact that orexin receptors, especially orexin receptor 2, are abundant in the hypothalamic paraventricular nucleus (PVN), the effects of orexins on PVN neurons remain unknown. Using a whole cell patch-clamp recording technique, we investigated the effects of orexin-B on PVN neurons of rat brain slices. Bath application of orexin-B (0.01-1.0 microM) depolarized 80.8% of type 1 (n = 26) and 79.2% of type 2 neurons tested (n = 24) in the PVN in a concentration-dependent manner. The effects of orexin-B persisted in the presence of TTX (1 microM), indicating that these depolarizing effects were generated postsynaptically. Addition of Cd(2+) (1 mM) to artificial cerebrospinal fluid containing TTX (1 microM) significantly reduced the depolarizing effect in type 2 neurons. These results suggest that orexin-B has excitatory effects on the PVN neurons mediated via a depolarization of the membrane potential.

Liver injury in acute pancreatitis and mitigation by continuous arterial infusion of an antibiotic via the superior mesenteric artery

Macrophage-derived inflammatory mediators, such as tumor necrosis factor-alpha (TNF-alpha), have been shown to play a central role in aggravation of acute pancreatitis (AP), but little is known about their roles in liver injury. We investigated the pathogenesis of the liver injury in AP and assessed the efficacy of arterial infusion of an antibiotic via the superior mesenteric artery (SMA). Infusion of saline (group A) or imipenem (group B) was started 6 hours after induction of AP in dogs by intraductal administration of autologous gallbladder bile. The survival rate in group B was significantly improved compared with group A. Serum alanine aminotransferase levels in peripheral blood and endotoxin levels in portal vein blood were both significantly higher at 18 hours in group A than in group B. When hepatocytes and Kupffer cells were isolated at 18 hours and cultured for 24 hours thereafter, there was significant exacerbation of the hepatocyte injury and significantly greater production of TNF-alpha in the coculture of hepatocytes and Kupffer cells in group A, indicating that the Kupffer cells had been activated. By contrast, both of these manifestations were significantly mitigated in group B. These findings suggest that TNF-alpha secreted by endotoxin-activated Kupffer cells contributes to liver injury in AP, and that SMA infusion of an antibiotic mitigates the liver injury by controlling endotoxin translocation.

Long-term enhancement of synaptic transmission induced by veratridine in rat CA3 hippocampal neurons

Veratridine is a neurotoxin that induces persistent activation of sodium channels in excitable cells. We investigated the effects of this toxin on excitatory synaptic transmission in CA3 neurons of juvenile rat hippocampus using whole-cell patch-clamp and field-potential recordings. The population spikes evoked by electrical stimulation of the mossy fiber were gradually enhanced after washout of veratridine (0.3 microM), but they were not enhanced by the co-application of veratridine and an N-methyl-D-aspartate (NMDA) receptor antagonist (D-APV, 30 microM). When a pipette solution contained QX-314 that antagonized the effect of veratridine in the recorded neuron, oscillatory membrane depolarization appeared in the early stage during bath-application of veratridine and gradually decreased in the late stage. After washout of veratridine, however, the oscillatory depolarization was gradually restored and maintained for at least 3 h. This oscillatory depolarization was also abolished by D-APV. We suggest that the activation of NMDA receptors is involved in the veratridine-induced long-lasting enhancement in the excitatory synaptic transmission in rat CA3 hippocampal neurons.

Nociceptin/orphanin FQ and [Phe(1)psi(CH2-NH)Gly2]nociceptin(1-13)NH2 modulates the activity of hypothalamic paraventricular nucleus neurons in vitro

Nociceptin, also known as orphanin FQ (N/OFQ), an endogenous ligand for the orphan opioid receptor-like(1) (ORL(1)) receptor, is moderately expressed in the hypothalamic paraventricular nucleus (PVN) involved in the integrative control of the function of the endocrine and autonomic nervous systems. Our previous study demonstrated that intracerebroventricular administration of N/OFQ elicits an inhibitory action on the function of the cardiovascular and sympathetic nervous systems in conscious rats. However, the effects of N/OFQ on PVN neurons have not been examined. We investigated the effects of N/OFQ on PVN neurons using a whole-cell patch-clamp recording technique in rat brain slices. N/OFQ (30-1000 nM) hyperpolarized membrane potentials in type 1 and type 2 neurons of the PVN classified by the electrophysiological property. [Phe(1)psi(CH2-NH)Gly2]nociceptin(1-13)NH2 (Phepsi) (1-9 microM), a presumed competitive antagonist of the ORL(1) receptor, also hyperpolarized membrane potential in both types of neurons. In voltage clamp studies, N/OFQ (3-3000 nM) activated a K+ current concentration-dependently in 69.7% of PVN neurons with an EC(50) of 72.4+/-12 nM. Phepsi (100-9000 nM) also activated a K+ current with an EC(50) of 818+/-162 nM in PVN neurons, and significantly reduced the amplitude of the N/OFQ-stimulated current. The N/OFQ-induced current was not antagonized by the classical opioid receptor antagonist naloxone and putative antagonist nocistatin. These findings suggest that N/OFQ may have a functional role in the PVN.

Low-lying magnetic excitation of the Shastry-Sutherland model

By using perturbation calculation and numerical diagonalization, the low-energy spin dynamics of the Shastry-Sutherland model is investigated with particular attention to the two-particle coherent motion. In addition to spin-singlet- and triplet-bound states, we find novel branches of coherent motion of a bound quintet pair, which are usually unstable because of repulsion. Unusual dispersion observed in neutron-scattering measurements is explained by the present theory. The importance of the effects of phonons is also pointed out.

Extracorporeal adsorption as a new approach to treatment of botulism

Botulism is a paralytic disease caused by a toxin produced by the bacterium Clostridium botulinum. Outbreaks of the illness take place with a mortality rate of 10%, and the potential terrorist use of the toxin has become a serious concern. The current treatment includes administration of antitoxin, which can cause serious allergic reactions. Recently, we have successfully treated a 64 year old woman with the illness with IMMUSORBA TR350 (Asahi Medical, Tokyo, Japan), an extracorporeal adsorptive column containing polyvinylalcohol-tryptophan as an adsorptive agent, which has been widely used in Japan to treat myasthenia gravis and Guillain-Barre syndrome. Initially, the patient developed ocular muscle weakness and a variant of the Guillain-Barre syndrome was suspected. After extracorporeal treatment, her neurologic symptoms remarkably improved. After a series of treatments, botulinum toxin type B was isolated in the food she had eaten, establishing the diagnosis. An in vitro study revealed that the adsorptive column removed botulinum toxin to a significant extent. Our recent findings suggest that treatment with the adsorptive column TR350 can be a feasible option for botulism, which is a rare but potentially lethal disease.

Effects of repeated stress on expression of interleukin-6 (IL-6) and IL-6 receptor mRNAs in rat hypothalamus and midbrain

We examined the effects of single and repeated stress on the expression of interleukin-6 (IL-6) and IL-6 receptor (IL-6R) mRNAs in the rat midbrain and hypothalamus using reverse transcriptase-polymerase chain reaction (RT-PCR). Following a single episode of restraint stress for 4 hours (1R) or 4 hours per day on two (2R) or three (3R) consecutive days, the hypothalamus and midbrain were removed immediately and the levels of IL-6 and IL-6R mRNAs in both regions were determined. Regional differences in stress-related changes in mRNA levels were noted. The expression of IL-6 mRNA in the hypothalamus did not change in 1R group but decreased in 2R and 3R groups. The expression of IL-6R mRNA in the same region significantly diminished in all groups. In the midbrain, the expression of IL-6 mRNA increased in 1R group and decreased in 2R and 3R, while the expression of IL-6R mRNA significantly diminished in 1R and 3R groups but was not different from control in 2R group. Our findings indicate that repeated stress in rats produce changes in IL-6 and IL-6R mRNAs in the midbrain and hypothalamus that are different than those of a single stress episode.

Effects of restraint stress on alpha(1) adrenoceptor mRNA expression in the hypothalamus and midbrain of the rat

We examined the effects of restraint stress on alpha(1) adrenoceptor mRNA expression in the rat brain using reverse transcriptase-polymerase chain reaction (RT-PCR). After rats had been restrained for 10, 30, 60, 120 or 240 min, the hypothalamus and midbrain were removed immediately and alpha(1) adrenoceptor mRNA levels in these regions were determined by RT-PCR. Blood samples were also collected for simultaneous measurement of serum adrenocorticotropic hormone (ACTH) and corticosterone. Restraint stress resulted in a variety of changes in the hypothalamus and midbrain. In the hypothalamus, 30 and 60 min of stress resulted in a significant fall in the level of alpha(1) adrenoceptor mRNA relative to the control. This was associated with a rise in serum ACTH and corticosterone. In the midbrain, significant elevation of alpha(1) adrenoceptor mRNA was noted after 60, 120 and 240 min of restraint stress. Our findings indicated that the influence of restraint stress on alpha(1) adrenoceptor mRNA level in the hypothalamus is different to that of the midbrain region in rats.

Effects of single and repeated stresses on the expression of mRNA for alpha1-adrenoceptors in the rat hypothalamus and midbrain

We examined the effects of single or repeated stress on the expression of mRNA for alpha1-adrenoceptors in the rat hypothalamus and midbrain using the reverse transcriptase-polymerase chain reaction (RT-PCR). Single stress significantly increased the mRNA level for alpha1-adrenoceptors in the midbrain, but had no effect on mRNA levels in the hypothalamus. Repeated stress significantly decreased mRNA levels for alpha1-adrenoceptors in both regions.

Hepatocellular carcinoma complicated by gastrointestinal hemorrhage caused by direct tumor invasion of stomach

A 65-year-old man with multiple hepatocellular carcinoma (HCC) underwent intra-hepato-arterial chemotherapy (IHAC) through an implantable port over a period of 10 months after transcatheter arterial embolization (TAE) had been performed three times. TAE was performed twice more, and radiotherapy (total dose, 30 Gy; given over a 3-week period) was given for progressive disease in the lateral segment of the liver. Three months after the radiotherapy had finished, the patient suddenly developed melena. Diagnostic imaging revealed gastrointestinal (GI) hemorrhage from HCC invading the stomach, and total gastrectomy and lateral segmentectomy of the liver were performed because the bleeding could not be controlled. The resected specimen disclosed a centrally necrotic tumor that had invaded the lesser gastric curvature and perforated into the lumen. Pathology examination revealed that the HCC had expansively invaded the gastric mucosa, resulting in exposure in the lumen. The possible mechanisms of direct GI invasion by HCC are briefly discussed, with a review of the literature. GI bleeding secondary to involvement by HCC is rare. The enteric radiation injury seems to have been largely responsible for the GI bleeding in this patient.

Prenatal diagnosis of peroxisomal D-3-hydroxyacyl-CoA dehydratase/D-3-hydroxyacyl-CoA dehydrogenase bifunctional protein deficiency

The prenatal diagnosis of peroxisomal D-3-hydroxyacyl-coenzyme A (CoA) dehydratase/D-3-hydroxyacyl-CoA dehydrogenase bifunctional protein (D-BP) deficiency was performed by peroxisomal beta-oxidation assay, indirect immunofluorescence staining, immunoblot analysis, and gene analysis of cultured amniocytes obtained from a fetus at 16 weeks' gestational age. beta-Oxidation activity, measured by [1-14C] lignoceric acid oxidation, was markedly decreased compared with the controls. Large peroxisomes were readily identified by immunofluorescence staining with anti-human catalase, as was found in the reported patients. Immunoreactive D-BP material was absent on immunoblot analysis and immunofluorescence staining with anti-human D-BP. Reverse transcriptase polymerase chain reaction (RT-PCR) analysis revealed the presence of the same 237-bp deletion in the cDNA as that detected in a sibling (the proband). The autopsied fetus showed the characteristic facial appearance and D-BP was deficient on immunoblot and immunohistopathological studies of the fetal tissues. No neuronal migration disorder was identified. This seems to be the first prenatal diagnosis of D-BP deficiency.

Clinical usefulness of and problems with three-dimensional CT angiography for the evaluation of arteriosclerotic stenosis of the carotid artery: comparison with conventional angiography, MRA, and ultrasound sonography

BACKGROUND

Prevention of stroke is aided by determination of the degree of carotid artery stenosis and progression of arterial sclerosis. Three-dimensional computed tomography (CT) angiography (3D-CTA) is a new method for evaluating the degree of arterial stenosis. The purpose of this study was to compare the accuracy of 3D-CTA with the "gold standard": conventional angiography, magnetic resonance angiography (MRA), and ultrasound sonography (US).

METHODS

A total of 128 carotid bifurcations in 64 patients (42 men and 22 women; mean age, 68.5 years) were examined by 3D-CTA because of symptoms of cerebral infarction, carotid bruit, or findings suggestive of arteriosclerotic carotid artery stenosis on MRA screening. The following were used to compare 3D-CTA with conventional angiography, MRA and US: 1) estimation of the degree of stenosis; 2) depiction of irregularities in arterial walls, including calcification, intimal thickening, ulcers and plaque; and 3) surgical planning for carotid endarterectomy (CEA) and percutaneous transluminal angioplasty (PTA), and postoperative evaluation.

RESULTS

A strong correlation was found between the degrees of stenosis estimated by conventional angiography and 3D-CTA MIP image (r = 0.987/p < 0.0001). On the other hand, stenosis was generally overestimated by MRA, which, however, has the advantage of being able to scan the carotid siphon to the middle cerebral artery at one time. Calcification and ulceration of the artery wall could be evaluated with 3D-CTA, whereas with US, progression of arterial sclerosis could be evaluated by differentiation of homogenous and heterogenous plaque. The anatomical relationships between the site of stenosis and the internal jugular vein and bony structures, which must be known before CEA, were confirmed by observation of rotated images using the shaded surface reconstruction (SSR) method. Because the hemodynamics of cross and collateral flows cannot be clearly imaged with 3D-CTA, standard angiography is needed to determine suitability for bypass surgery.

CONCLUSIONS

The current method used in our hospital for the diagnosis of stenosis of the internal carotid artery includes MRA or US for initial screening, 3D-CTA for evaluation of the degree of stenosis and for preoperative and postoperative evaluation of CEA and PTA, and conventional angiography for evaluation of hemodynamics and determination of the indications for a bypass surgery.

Adenocarcinoma arising in a tailgut cyst: report of a case

We report herein the unusual case of a 66-year-old woman found to have adenocarcinoma arising in a tailgut cyst. The patient had been observed for 6 months following the discovery of a presacral cystic mass measuring 10 x 9 cm for which she had refused surgery. The serum tumor marker, carcinoembryonic antigen, became slightly elevated, and diagnostic imaging distinctly revealed a tumorous lesion with papillary projection into the cyst lumen. The cystic mass was then excised through the transsacral approach. The pathological findings were compatible with moderately differentiated adenocarcinoma arising in a tailgut cyst. This entity is extremely rare, and only six cases, including our own, have been reported in the English literature. Early complete excision is advised because it is almost impossible to determine for certain whether presacral cystic masses are benign or malignant prior to surgery.

Effects of a long-term inhalation of fragrances on the stress-induced immunosuppression in mice

The aim of this study was to determine the effects of the long-term application of various fragrances on the suppression of immune response induced by high-pressure stress in mice. The immune response was analyzed based on plaque-forming cell (PFC) count, using mice sensitized with sheep red blood cells. The decreased PFC involving thymic involution induced by high-pressure stress in mice was restored by exposing the stressed mice to tuberose, lemon, oakmoss and labdanum for 24 h following exposure to stress. The decreased PFC and thymic involution from stress were restored by exposure to lemon and oakmoss, but not to tuberose and labdanum when the mice were exposed to those fragrances continuously for 3 weeks before the stress was given, followed by exposure to the same fragrances for 24 h after the stress. The decreased PFC and thymic involution from stress were restored by exposure to lemon and labdanum for 24 h after the stress, but not to tuberose over 3 weeks before the stress was given. These data suggest that the neuroimmunomodulatory effects of fragrances may be affected by tolerance depending on the kinds of fragrances in the case of a long-term application.