Clinical features of Barré-Lièou syndrome and efficacy of trazodone for its treatment: A retrospective single center study

Barré-Lièou syndrome (BLS) is a manifestation of various autonomic and secondary symptoms including muscle stiffness, tinnitus, dizziness, and pain in various body parts. Although considered to be caused by hyperactivation of the autonomic nervous system due to trauma, there is currently no firmly established etiology or evidence on the treatment and clinical features of BLS. We retrospectively examined the clinical features of BLS and evaluated the efficacy of trazodone (TZD) for its treatment. We conducted a retrospective analysis of the data of 20 consecutive cases with suspected BLS who were treated in our hospital between 2016 and 2019. BLS symptoms were rated on a 10-point scale, and two groups were defined, that is, a mild-BLS group (BLS scores, 1-5) and a severe-BLS group (BLS scores, 6-10). Univariate analysis of patient factors was performed. The BLS score was 6.0 ± 1.7, and the maximum TZD dose was 80 ± 34 mg/day; nine patients (45%) were TZD free, and no TZD side effects were observed, while all patients had a good clinical outcome. There were significant differences between the mild-BLS and severe-BLS groups in the period from injury to diagnosis (p = 0.015), chest/back pain (p < 0.001), constipation (p = 0.001), and maximum TZD dose (p = 0.008). BLS involves posttraumatic autonomic symptoms accompanied by depression and insomnia. The sympathetic hypersensitivity theory could explain its etiology. TZD could effectively and safely treat BLS, and early diagnosis and treatment can contribute toward good clinical outcomes. Enhanced recognition and understanding of this disease are warranted.

Clinical usefulness of corrected QT intervals in diabetic autonomic neuropathy in patients with type 2 diabetes

BACKGROUND

It is recognized that QTc intervals reflect autonomic nerve function. To investigate the clinical usefulness of corrected QT intervals (QTc) in assessing autonomic nerve function in type 2 diabetes, we measured QTc intervals using Bazett's formula in 58 type 2 diabetic patients and 20 age-matched healthy subjects.

METHODS

We examined relationships between QTc intervals and the coefficient of variation of RR intervals (CV(RR)), systolic blood pressure response to standing, and sympathetic skin response (SSR) whose tests reflect autonomic nerve function. We also studied the correlation between QTc and blood pressure or serum lipid concentrations.

RESULTS

QTc intervals in diabetic patients were significantly longer than those in healthy subjects and showed a significant but weak negative correlation with CV(RR), as well as systolic blood pressure response to standing. No significant difference in QTc intervals was observed between patients with and without a detectable SSR. QTc intervals showed a significant positive correlation with systolic and diastolic blood pressure although it did not correlate with serum lipid concentrations. QTc also tended to be long in obese diabetic subjects (body mass index > 25).

CONCLUSION

QTc intervals might also be affected by other factors such as arteriosclerotic macroangiopathy and obesity, and not only autonomic nerve function. Therefore it might be considered as an overall index for complications, and not for pure autonomic impairment.

[Anti-thyroid peroxidase antibody]

Anti-thyroid peroxidase antibody(TPOAb) in patients with autoimmune thyroid diseases was identified with anti-microsomal antibody. Highly sensitive assays of TPOAb using radioimmunoassays and enzyme immunoassays have been developed following a hemagglutination assay technique. TPOAb is present in the serum of almost all patients with Hashimoto's thyroiditis, in more than 70% of those with Graves' disease, and, to a variable degree, in patients with nonthyroid autoimmune diseases and some normal subjects. There is a good correlation between the degree of lymphocytic infiltration of the thyroid gland and the titer of TPOAb. Postpartum thyroiditis, usually a transient disorder, occurs with high frequency in women who have TPOAb. TPOAb, in addition to anti-thyroglobulin antibody, was a clinically useful marker for defining autoimmune thyroid diseases and for detecting an underlying autoimmune process in the thyroid, however, its biological importance remains to be clarified at the present time.

[Laboratory tests in primary care medicine: "essential laboratory tests" (1). Urinalysis]

Japan Society of Clinical Pathology has formed a committee dealing with "lab. tests in primary care medicine". As the first step, they made "Essential Lab. Tests" which were composed of simple qualitative bed-side tests such as urinalysis, Complete blood count (CBC: Hb, Ht, WBC, RBC), CRP, or ESR (Erythrocyte sedimental rate), A/G ratio and biochemical tests if necessary (Table 1). We have performed "Essential Lab. Tests" on 1,026 outpatients who visited General Medicine Clinic for the first time. They consisted of 456 male (age 13-81), and 526 female (age 10-85). This report is the result of urinalysis from "Essential Lab. Tests" of 1,026 patients. 1) The result showed that overall positivity of the urinalysis was 21.3% (when more than one item of the qualitative tests was positive). 2) There was distinctive difference in the positivity of the urinalysis between the sex; i.e. protein and glucose were about twice frequently positive in male, where as occult blood and WBC (Esterase reaction) were 2-3 times more positive in female. 3) Urine protein shows positive in the individual 10-20 yrs old and more than 50 yrs old in both sexes. 4) Glucose was positive in over 40 yrs in male, and occult blood, 40-50 yrs or older in male. 5) WBC shows positive in all age groups in female and 50 yrs or older in male. 6) Positive WBC patients did not necessarily reflect urinary infection in female but nitrites roughly corresponded with urinary WBC in male of 50 yrs or older, meaning probable urinary infection associated with prostatic hypertrophy. 7) Abnormality of urinary sediment corresponded to the positive occult blood and WBC Erastase. 8) Urinalysis is an useful method of screening in primary care medicine.

Suppression of Trapped Energetic Ions Driven Resistive Interchange Modes with Electron Cyclotron Heating in a Helical Plasma

The resistive interchange mode destabilized by the resonant interaction with the trapped energetic ions is fully suppressed when the injected power of electron cyclotron heating exceeds a certain threshold. It is shown for the first time that the complete stabilization of the energetic-particle-driven mode without relaxing the energetic particle (EP) pressure gradient is possible by reducing the radial width of the eigenmodes δ_{w}, especially when δ_{w} narrows to a small enough value relative to the finite orbit width of EP.

The effects of a fixed-fee reimbursement system introduced by the Federal Government on laboratory testing in the United States

Rapid growth of health care expenditures during the 1970s in the United States led to implementation of a prospective payment system (PPS) based on diagnosis-related groups (DRG) for Medicare inpatient reimbursement in 1983. With the introduction of DRG/PPS, hospitals encouraged earlier discharges and discouraged admission of patients who may require expensive services. Patient care has moved into more outpatient and non-hospital settings which have been less regulated and paid on a cost-reimbursement basis. The change of reimbursement system has converted hospital laboratories from "profit center" under the fee-for-service reimbursement practice to possible "cost center" at least for inpatient laboratory services with the advent of DRG/PPS. Hospitals have reduced laboratory operating expenses by constraining laboratory growth and development. Laboratory testing in non-hospital settings such as physicians' office laboratories, which were exempt from license and quality control by governmental regulations, has increased exponentially since implementation of DRG/PPS. To improve the quality of laboratory testing in such unregulated laboratories, the federal government has promulgated the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88), requiring on-site survey and license under CLIA '88 for all laboratories in the United States regardless of the size, complexity, or location of laboratory. Implementation of DRG/PPS resulted in a temporary success in reducing Medicare Part A budget growth, but had only a small impact to slow the actual growth of total national health care expenditures or laboratory-related expenditures. Nevertheless, the change of reimbursement practice has created a large incentive to reduce unnecessary resource utilization, and cost-effective laboratory testing has become an essential concept during the DRG/PPS era.

[Clinical diagnosis and laboratory data]

Modern medicine can not be practiced without laboratory tests. Laboratory tests play a vital role from the initial stage of clinical examination. The Japanese Society of Clinical Pathology has formed a committee specifically dealing with the effective and economic use of lab tests without missing or duplicating the important tests. As is shown in table 1 in the main text "Essential Laboratory Tests" were initially agreed as those tests a patient should take when visiting a clinic regardless of the complaint. From an early stage, laboratory tests were done simultaneously with history-taking and physical examinations. Then the "Initial Impression" is obtained and "Organ-oriented 1st and 2nd screening tests" and confirmatory tests will be done to make the final diagnosis. To evaluate the validity of the "Essential Laboratory Tests", we performed the tests on 1026 patients who visited our general medicine clinic for the first time. We compared the Initial Impression with or without Essential Laboratory Tests. Cases in which a diagnosis could not be made by history-taking and physical examination were decreased from 17.4% to 8.0% by performing the essential laboratory tests. Diagnoses made without the essential laboratory tests were found to be mistaken in 10.4% and the additional use of the tests was suggested to lead to a more accurate diagnosis. In 110 cases, diseases unrelated to the chief complaints, were discovered. Even for the respiratory tract infection, CRP and WBC count, which were included in the essential laboratory tests, were very informative.

Opportunistic discovery of occult disease by use of test panels in new, symptomatic primary care outpatients: yield and cost of case finding

BACKGROUND

Diagnostic test panels have been advocated by the Japan Society of Clinical Pathology for evaluation of presenting complaints of new outpatients in primary care medicine. The tests have additional potential utility for opportunistic finding of asymptomatic diseases, but data are lacking on the number of new conditions identified by the test panels and on the cost per identified case.

METHODS

We studied 540 new, symptomatic patients at the Comprehensive Medicine Clinics of National Defense Medical College during 1991-1997. All underwent testing with the "Essential Laboratory Tests" panel (2) [ELT(2) panel]. This panel includes hematologic tests, urinalysis, total protein, C-reactive protein, albumin, cholesterol, triglycerides, glucose, urea nitrogen, creatinine, uric acid, serum protein fractionation, six enzymes, and optional tests, including x-rays, electrocardiogram, and fecal occult blood.

RESULTS

The ELT(2) panel uncovered 276 additional diagnoses of asymptomatic disease or abnormal health status. The most frequent occult condition was hyperlipidemia (100 cases) followed by liver dysfunction (53 cases). Clinical efficiency of the panel (occult diseases/patient) varied depending on the category of tentative initial diagnosis, with the highest efficiency in patients with cardiovascular disease. We created smaller panels by combining 11 basic tests [called the ELT(1) baseline panel] with one or more additional tests from the ELT(2) and analyzed their cost-effectiveness. Addition of four tests (total cholesterol, alanine aminotransferase, glucose, and uric acid) improved both clinical efficiency (0.41 occult disease/patient) and economic efficiency [ 2372 yen (approximately $22.50 US)/occult disease] at a cost-effectiveness of 177 yen per incremental case of occult disease. Addition of further tests decreased cost-effectiveness.

CONCLUSIONS

Although the ELT(2) panel has supplemental utility for opportunistic screening of some significant, occult diseases and conditions, universal utilization of the full panel is not supported by the cost-effectiveness found in this study.

[Validity of reticulocyte count testing in reimbursement practice: a cost-effectiveness analysis]

Recently reticulocyte count testing has markedly decreased in Japan. We studied the current status of the reduction of reimbursement for reticulocyte count testing and the cost-effectiveness of the test in an academic hospital. The orders of complete blood counts(CBC) accompanied by reticulocyte count testing in Tokai University Hospital declined from 58.9 to 13.3% during the last decade. Among a total of 15,538 test orders for reticulocyte count in outpatients, full reimbursement was refused in 123(0.79%) during a one year period from April 1999 to March 2000. The cost-effectiveness of reticulocyte count testing was evaluated in 719 new outpatients who visited Tokai University Hospital during this period. A useful result(UR) of testing was defined as that which contributed to a change in a physician's diagnosis- or decision-making, relating to a "tentative initial diagnosis" obtained from patient history and physical examination alone. Cost-effectiveness for either CBC alone or in combination with reticulocyte count testing was evaluated by calculating clinical effectiveness(the number of URs yielded by a test per patient), economic efficiency(cost required for a test per UR generated), and the cost-effectiveness values(cost required for additional test(s) per additional UR generated). There was a wide disparity in the clinical effectiveness of reticulocyte count twisting among the hospital departments, ranging from 0.53 UR/patient(Gastroenterology-2) to 0(Oral Surgery, Neurology, Urology). Poor clinical effectiveness shown in particular hospital departments endorsed the increasing percentages in reimbursement rejection by the payer of health insurance. The test should be ordered more carefully in consideration of reimbursement and in regard to its cost-effectiveness among different patients groups.

Development of a risk score model for 1-year graft loss after adult deceased donor liver transplantation in Japan based on a 20-year nationwide cohort

Aim

Using nationwide data collected over the past 20 years, we aimed to investigate deceased donor liver transplantation (DDLT) outcomes to develop a unique risk model that can be used to establish a standard for organ acceptance in Japan.

Methods

Data were collected for 449 recipients aged ≥18 years who underwent DDLT between 1999 and 2019. Least absolute shrinkage and selection operator (LASSO) regression analysis was utilized to develop an original risk score model for 1-year graft loss (termed the Japan Risk Index [JRI]). We developed risk indices according to recipient, donor, and surgery components (termed JRI-R, D, and S, respectively). The JRI was validated via a 5-fold cross-validation. We also compared DDLT outcomes and risk indices among Era1 (-2011), Era2 (-2015), and Era3 (-2019).

Results

The 1-year graft survival rate was 89.5% and improved significantly, reaching 84.7%, 87.6%, and 93.9% in Era1, Era2, and Era3, respectively. The JRI was calculated as JRI-R (re-transplantation, Model for End-Stage Liver Disease score, medical condition in intensive care unit) × JRI-D (age, catecholamine index, maximum sodium, maximum total bilirubin) × JRI-S (total ischemic time) × 0.84. The risk model achieved a mean C-statistic value of 0.81 in the validation analysis. The risk index was significantly lower in Era3 than in Era2.

Conclusion

Changes in the risk index over time indicated that avoiding risks contributed to the improved outcomes in Era3. The JRI is unique to adult DDLT in Japan and may be useful as a reference for organ acceptance in the future.

A rare case of a thyrotropin-secreting pituitary tumor which responded to methimazole

A 52-year-old Japanese male complained of palpitations and excessive sweating. He showed evidence of hyperthyroidism, but without suppression of the serum thyroid-stimulating hormone (TSH). On admission, the serum level of the alpha-subunit of TSH was elevated, but tests for thyroid autoantibodies were negative. The TSH response to thyrotropin-releasing hormone (TRH) was blunted. Imaging studies revealed a pituitary tumor 2 cm in diameter. Administration of methimazole lowered the serum levels of thyroid hormones, and elevated the serum level of TSH. These findings led to the diagnosis of a thyrotropin-secreting pituitary tumor. Immunohistochemical analysis and electron microscopic findings verified the diagnosis.

Artificial insemination using cryopreserved sperm in the silkworm, Bombyx mori

We report in this paper that female moths artificially inseminated with cryopreserved sperm (-196 degrees C) could oviposit eggs when the sperm was preserved for 356days, and that the fertilization rate and the number of eggs laid were almost equivalent to those obtained in normally mated moths. The optimal cooling rate for sperm freezing was 5-65 degrees C/min for maintaining a high fertility of sperm. The simple and reliable method of cryopreservation was to put the semen first in a deep freezer at -80 degrees C and thereafter put them in liquid nitrogen. When female moths of 'white 2' egg-color mutant strain were inseminated with a mixture of frozen-thawed sperm from males of normal-colored egg strain and non-frozen sperm from males of the 'white 2', female moths deposited a majority of 'white 2' eggs and a very small number of eggs of normal color. The result shows that there was a competitive fertilization of sperm between the two strains of the silkworm, and that sperm fertility was reduced to a considerable extent by freezing at -196 degrees C. These results may contribute not only to basic studies on fertilization in Lepidoptera but also to the development of long-term preservation procedure of genetic resources by using cryopreserved sperm of Bombyx mori.

Iron lamination and interlaminar insulation for high-frequency pulsed magnets

In high-frequency pulsed magnets, such as kickers in particle accelerators, it is essential to reduce eddy currents that could be induced in the magnet core during excitation not to distort and attenuate the magnetic field pulse. A novel iron lamination scheme with additional interlaminar insulation is proposed for the magnet core of such pulsed magnets. A laminated steel sheet core is formed by alternately stacking thin steel and insulation sheets. For application to matched kicker magnets for accelerators, test magnets with the new and conventional iron lamination were designed, assembled, and extensively evaluated. The pulsed magnetic field waveforms of two test magnets with the new lamination successfully matched to below 0.1% over the entire pulse duration, which was significantly better than those with the conventional lamination. Among the applications of the developed high-frequency pulsed magnets, beam injection kickers for the coming next generation light sources and future colliders, where suppression of the transient stored-beam oscillation during beam injection is crucial, are considered to be promising.

Improved survival of pediatric deceased donor liver transplantation recipients after introduction of the pediatric prioritization system: Analysis of data from a Japanese national survey

BACKGROUND

In Japan, there has never been a national analysis of pediatric deceased donor liver transplantation (pDDLT) based on donor and recipient factors. We constructed a Japanese nationwide database and assessed outcomes of pDDLT focusing on the pediatric prioritization system introduced in 2018.

METHODS

We collected data on pDDLTs (<18 years) performed between 1999 and 2021 from the Japan Organ Transplant Network and Japanese Liver Transplantation Society, identified risk factors for graft survival and compared the characteristics and graft survival in pDDLTs conducted before and after the introduction of the pediatric prioritization system.

RESULTS

Overall, 112 cases of pDDLT were included, with a 1-year graft survival rate of 86.6%. Four poor prognostic factors were identified: recipient intensive care unit stay, model for end-stage liver disease/pediatric end-stage liver disease score, donor cause of death, and donor total bilirubin. After the introduction of the system, allografts from pediatric donors were more reliably allocated to pediatric recipients and the annual number of pDDLTs increased. The 1-year graft survival rate improved significantly as did pDDLT conditions indicated by the risk factors.

CONCLUSIONS

Under the revised allocation system, opportunities for pDDLT increased, resulting in favorable recipient and donor conditions and improved survival.