A rare case of severe acute pancreatitis complicated with pancreatic pseudocysts, obstructive jaundice and intraperitoneal hemorrhage

A 58-year-old man visited our hospital because of back pain. Blood examinations revealed the presence of acute inflammation and an increase of pancreatic enzymes. Abdominal computed tomography indicated pseudocysts in the pancreas. The patient was diagnosed as having acute pancreatitis with pseudocysts formation. During the course of the disease, a newly formed pseudocyst in the pancreatic head compressed the common bile duct, leading to the obstructive jaundice. In addition, the rupture of a pseudocyst in the pancreatic tail caused intraperitoneal hemorrhage. This is an interesting case of acute pancreatitis with pseudocysts in which two rare complications developed.

[The US Health Care and the reform]

Securing access to medical services, controlling costs and improving quality are goals of health care system. Although they are all the same all over the country, each country has its own culture, health care system and health care problems. In the United States, employer-based and individual purchases of private health insurance coverage play a major role, although governmental programs such as Medicaid and Medicare exist for the poor and the elderly. Private health insurance had traditionally secured patients' freedom of choice of health care providers and physicians' professional freedom and had paid providers on a fee-for-service basis. Now, the U.S. has 40 million uninsured persons who do not have access to medical services, although it spends as much as its 14% of GNP on health care. In the early 1990s, this became a major political problem. President Clinton proposed the 'Health Security Act' which would enable any American to have access to comprehensive health care with managed competition to activate the health care market, but it was not enacted. Nevertheless, it is clear that managed care and managed competition will dominate and that traditional fee-for-service plan will be eroded in the health care market. Japan has a universal health care system. We do not have any uninsured or high medical costs. However, it is difficult to improve the quality of health care services within the present system. Japan can learn the system about disclosure of health care information from the managed care in the U.S.

Specialty choice and understanding of primary care among Japanese medical students

To assess specialty choice and understanding of primary care among Japanese medical students, all students from seven Japanese medical schools (three public and four private) were surveyed, using a written questionnaire. A total of 3377 students provided data for the study. Of the students surveyed, 89.8% wanted to become clinicians, and 79.3% wanted to have general clinical ability. About half of the respondents, 54.9%, replied that they had some, or great, interest in primary care, but it was found that their understanding of primary care was inadequate. Almost half (56.3%) of the students answered that they had some idea of what a general practitioner did. This proportion was nearly the same through all years of medical school. While 1245 (36.9%) students (most of them in the fifth or sixth year) replied that they had received some clinical training while working in hospitals, only 203 (6.0%) students had worked in private clinics (the sites where most primary care is still provided), and 129 (3.8%) students had experience in providing home visits and home care. An even greater number, 64.3%, replied that they had inadequate information about the career options available to them. The study found that although many Japanese medical students want to obtain broad clinical competence, their understanding of primary care is insufficient. In order to increase the number of primary care providers the system of medical education in Japan must provide primary care doctors to act as role models, and must make available information about postgraduate primary care programmes. These programmes need to be increased, as do rewarding positions for programme graduates.

Two novel mutations in a Japanese patient with the late-infantile form of metachromatic leukodystrophy

Two novel mutations in the arylsulfatase A (ASA) gene from a Japanese patient with the late-infantile form of metachromatic leukodystrophy (MLD) were identified. One mutation was a G to C transversion at nucleotide 608 of the ASA gene (designated 608C) located at the 3' end of exon 2, which resulted in an amino acid substitution of Gln 153 to His. Although the 608 mutation resulted in a change in the exon-intron boundary consensus sequence, analysis of cDNA from the patient did not reveal the presence of aberrant splicing. The second mutation, a G to T transversion at nucleotide 1572 in exon 5 (designated 1572T), resulted in an amino acid substitution of Gly 308 to Val. This could potentially result in a conformational change in ASA protein structure. The patient was heterozygous for these two new mutations which were not present in 18 Japanese MLD alleles examined. A transient expression study in COS-1 cells showed no residual activity in either mutation. These results indicate that the 608C and 1572T mutations are responsible for the occurrence of the late-infantile form of MLD.

Clinicopathologic characteristics of polymyositis patients with numerous tissue eosinophils

INTRODUCTION

We evaluated associated clinicopathologic features of polymyositis (PM) patients with numerous tissue eosinophils.

MATERIALS AND METHODS

680 muscle biopsies were examined in our institution and eight were identified with greater than 0.3 eosinophils per square millimeter in the inflammatory infiltrate without concomitant peripheral eosinophilia.

RESULTS

All eight patients had typical PM, but neither dermatomyositis nor inclusion body myositis was identified. Clinically, a large number of PM patients with eosinophils manifested an acute- or subacute-onset of symptoms, myoglobinuria, a marked elevation of serum creatine kinase, a good response to steroid therapy, and a relatively benign course compared with 26 PM patients without eosinophils. Muscle biopsies demonstrated necrotic fibers more frequently in PM patients with eosinophils than in PM patients without eosinophils. Hypertrophic fibers, fiber splitting, basophilic fibers, and lobulated fibers were less frequently observed in PM patients with eosinophils.

CONCLUSION

These results suggest that the majority of PM patients with eosinophils may be steroid-responsive and suffer an acute or subacute onset of PM.

[Swyer-James syndrome with pneumomediastinum and subcutaneous emphysema due to bronchial asthma]

A 24-year-old woman was admitted to our hospital due to moderate asthmatic attacks. Dyspnea and hypoxemia progressed gradually despite medication. A chest roentgenogram revealed left unilateraly hyperlucency with pneumomediastiumn and subcutaneous emphysema. Swyer-James syndrome was diagnosed. Several cases of Swyer-James syndrome with bronchial asthma airway hyperresponsiveness have been reported, but we know of no reports of Swyer-James syndrome with pneumomediastinum and subcutaneous emphysema due to prolonged asthmatic attacks. Pneumomediastinum and subcutaneous emphysema may be caused by abnormally high pressures in the bronchial lumen and alveolar space during asthmatic attacks, because the emphysematous lesion may be structurally weak.

Sarcoidosis presenting as bilateral hydronephrosis

We report an unusual case of sarcoidosis associated with bilateral hydronephrosis. The patient was a 53-year-old Japanese woman who presented with dysuria and urinary incontinence. Computed tomography of the abdomen showed bilateral hydronephrosis caused by a retroperitoneal mass, surrounded by enlarged retroperitoneal lymph nodes. Histological examination of the mass demonstrated noncaseating epithelioid cell granulomas involving the retroperitoneal lymph nodes. Corticosteroid therapy led to complete resolution of the retroperitoneal mass and hydronephrosis. This case emphasizes that sarcoidosis should be included in the differential diagnosis of a retroperitoneal mass.

Intergenerational instability of the CAG repeat of the gene for Machado-Joseph disease (MJD1) is affected by the genotype of the normal chromosome: implications for the molecular mechanisms of the instability of the CAG repeat

Machado-Joseph disease (MJD) is an autosomal dominant neurodegenerative disorder caused by unstable expansion of a CAG repeat in the MJD1 gene at 14q32.1. To identify elements affecting the intergenerational instability of the CAG repeat, we investigated whether the CGG/GGG polymorphism at the 3' end of the CAG repeat affects intergenerational instability of the CAG repeat. The [expanded (CAG)n-CGG]/[normal (CAG)n-GGG] haplotypes were found to result in significantly greater instability of the CAG repeat compared to the [expanded (CAG)n-CGG]/[normal (CAG)n-CGG] or [expanded (CAG)nGGG]/[normal (CAG)n-GGG] haplotypes. Multiple stepwise logistic regression analysis revealed that the relative risk for a large intergenerational change in the number of CAG repeat units (< -2 or > 2) is 7.7-fold (95% CI: 2.5-23.9) higher in the case of paternal transmission than in that of maternal transmission and 7.4-fold (95% CI: 2.4-23.3) higher in the case of transmission from a parent with the [expanded (CAG)n-CGG]/[normal (CAG)n-GGG] haplotypes than in that of transmission from a parent with the [expanded (CAG)n-CGG]/[normal (CAG)n-CGG] or [expanded (CAG)n-GGG]/[normal (CAG)n-GGG] haplotypes. The combination of paternal transmission and the [expanded (CAG)n-CGG]/[normal (CAG)n-GGG] haplotypes resulted in a 75.2-fold (95% CI: 9.0-625.0) increase in the relative risk compared with that of maternal transmission and the [expanded (CAG)n-CGG]/[normal (CAG)n-CGG] or [expanded (CAG)n-GGG]/[normal (CAG)n-GGG] haplotypes. The results suggest that an inter-allelic interaction is involved in the intergenerational instability of the expanded CAG repeat.

[Causal inference in medicine--a historical view in epidemiology]

Changes of causal inference concepts in medicine, especially those having to do with chronic diseases, were reviewed. The review is divided into five sections. First, several articles on the increased academic acceptance of observational research are cited. Second, the definitions of confounder and effect modifier concepts are explained. Third, the debate over the so-called "criteria for causal inference" was discussed. Many articles have pointed out various problems related to the lack of logical bases for standard criteria, however, such criteria continue to be misapplied in Japan. Fourth, the Popperian and verificationist concepts of causal inference are summarized. Lastly, a recent controversy on meta-analysis is explained. Causal inference plays an important role in epidemiologic theory and medicine. However, because this concept has not been well-introduced in Japan, there has been much misuse of the concept, especially when used for conventional criteria.

Levels of Cd, Hg, As, Cu, Mn, and Zn in Japanese restaurant and box lunches

Intakes of selected elements from restaurant and box lunches in Shiga Prefecture (Japan) were investigated in 1993 and 1994, respectively. Average intakes of these elements from restaurant and box lunches were, respectively, 14 and 12 micrograms for Cd, 4.6 and 4.5 micrograms for Hg, 85 and 91 micrograms for As, 461 and 561 micrograms for Cu, 1268 and 1235 micrograms for Mn, and 3612 and 2688 micrograms of Zn. There were no great differences between the intakes from the restaurant lunches in 1993 and the box lunches in 1994. The proportion of elements from the lunches constituted 25-38% of the daily intake for Cd, As, Mn, and Zn and 51-65% of the daily intake for Hg.

Preparation of virus-infection-associated (VIA) antigen of foot-and-mouth disease (FMD) virus from inactivated vaccine

Virus-infection-associated (VIA) antigen of foot-and-mouth disease (FMD) virus was prepared from an inactivated FMD vaccine. The VIA antigen coupled with an adjuvant of aluminium hydroxide gel supplemented vaccine was efficiently eluted by suspending and stirring in high concentration of phosphate buffer solution (0.3M, pH 7.6). The final elute purified by DEAE-Sephadex A50 from the vaccine was concentrated in 1/500-1/1,000 of the original volume. VIA antigens prepared from two kinds of vaccine (Type O and Asia-1) were antigenically identical to one prepared from a cell culture infected with live virus. Two cattle were infected with FMD virus (Type O) and sera were obtained from each cattle every week. The VIA antigens from the inactivated vaccine were compared with the ones from the cell culture infected with live virus in agar gel diffusion tests using sera from cattle infected with live virus. The antibodies against the VIA antigen were detected between the second week and the 13th or 14th week after infection. The VIA antigen from an inactivated vaccine would be very useful in FMD free countries like Japan to avoid the risk of using live FMD viruses.

[Pollen dispersion of Cryptomeria japonica in autumn]

To clarify the significance of pollen dispersion of Cryptomeria japonica in autumn, the distribution pattern of pollen dispersion using specimens collected from 1987 to 1995 by Durhum collector was examined. After the dispersion period in the spring, the pollen count was suddenly decreased. The total pollen count from October to December showed no relation to the total pollen count for that of in spring of the same year; but it was closely correlated (r = 0.877) with the total pollen count during the dispersion period in the spring of the next year. In particular, accurate correlation between the total pollen count during November and that in January to May of the following year was observed with the correlation index of r = 0.909. Patients with a pollinosis probably for Cryptomeria japonica were also observed in the autumn. These results suggest that we can forecast the degree of pollen dispersion of Cryptomeria japonica in the coming year from the total pollen count during November of the year before.

Comparison of Two Questionnaires on Respiratory Symptoms in a Nicaraguan Population: Value in Diagnosis of Chronic Bronchitis

Two questionnaires about respiratory symptoms were evaluated for reliability and ability to diagnose chronic bronchitis in a study population of 129 Nicaraguans (110 workers and 19 patients with chronic bronchitis). The first questionnaire (AQ) had symptom questions that were based on British Medical Research Council (MRC) questions, adapted to local Spanish. The second questionnaire (MRCQ) contained MRC symptom questions translated directly into Spanish. The reliability of the questions was measured in a test-retest procedure. The questionnaire-based diagnosis of chronic bronchitis was compared with the diagnosis made by a physician (for workers) or from the hospital records (for patients). The questions concerning symptoms in both questionnaires were of acceptable reliability. For the diagnosis of chronic bronchitis in workers, the AQ showed similar sensitivity, a somewhat higher specificity, and a substantially higher positive predictive value (90%) than the MRCQ (57%). Among the patients, the AQ identified 17 patients as positive (sensitivity 89%), while the MRCQ identified 15 (sensitivity 79%). respiratory questionnaire; reliability; chronic bronchitis; Nicaragua Hanley & Belfus, Inc. Int J Occup Environ Health 1077-3525 2 2 1996 April/June Chronic Exposure to Cigarette Smoke Inhibits the Stimulating Effects of Mineral Fibers on the Production of Tumor Necrosis Factor by Alveolar Macrophages of Rats 95 98 EN Yasuo Morimoto Department of Environmental Health Engineering, University of Occupational and Environmental Health, Japan 1-1, Iseigaoka, Yahatanishiku, Kitakyushu 807, Japan. Ziro Nambu Hajime Hori Tohru Tsuda Hiroshi Yamato Toshiaki Higashi Yasuyuki Yokosaki Masamitsu Kido Isamu Tanaka The objective of this study was to evaluate the chronic combined effects of mineral fibers and cigarette smoke on the production of tumor necrosis factor (TNF) by alveolar macrophages. The authors chronically exposed ten rats to cigarette smoke in vivo and measured the production of TNF by alveolar macrophages in the presence of mineral fibers in vitro. For smoke exposure, rats were divided into two groups. Five rats were exposed daily to a concentration of 10 mg/m(3) of cigarette smoke for six hours a day, five days a week, for four weeks, and five rats (control) were not exposed to smoke. A broncho-alveolar lavage was performed after the smoke exposure, and the recovered alveolar macrophages were incubated with either chrysotile or ceramic fibers on a microplate for 24 hours. TNF activity in the supernatant was determined by the L929 bioassay. When alveolar macrophages were not stimulated by mineral fibers, TNF production tended to be lower in smoke-exposed alveolar macrophages than in unexposed ones, although the difference was not significant statistically. When alveolar macrophages were stimulated in vitro by chrysotile or ceramic fibers, both fibers stimulated TNF production, but TNF production in smoke-exposed alveolar macrophages was lower than that in unexposed macrophages. These results revealed that long-term exposure to cigarette smoke inhibited the stimulating effect of mineral fibers on the production of TNF.

[Pulmonary and endobronchial tuberculosis with subclavian artery-pulmonary artery shunts]

A 77-year-old woman with a productive cough and fever was admitted to the hospital. Pulmonary and endobronchial tuberculosis, pneumonia of the left upper lobe, and stenosis of the left main bronchus were diagnosed. She was given the antimycobacterial drugs isoniazid, rifampin, and streptomycin, and her condition improved. Two months later, bronchoscopy revealed semilunar-shaped stenosis of the left main bronchus, and auscultation revealed wheezing in the middle-end expiratory phase. A continuous flow murmur (Levine III) was also heard at the left anterior chest wall. Cardiac catheterization with subclavian arteriography revealed two left subclavian-pulmonary shunts. In a case of systemic-pulmonary shunt such as this, the bronchial stenosis could be surgically repaired, but the result would be an increase in dead space. If left untreated, the pulmonary hypertension would progress and symptoms of pulmonary disease would become more severe. Subclavian-pulmonary artery shunt is a very rare complication of pulmonary tuberculosis. Surgical treatment should consist of open bronchoplasty along with lobectomy and removal of the shunt, rather than embolization of the shunt and endoscopic bronchoplasty.

[Mucin gene--regulation of the expression of MUC2 and MUC3 mucin gene in the airway]

Mucus hypersecretion is a characteristic feature of several human airway diseases, including chronic bronchitis, cystic fibrosis and asthma. Analysis of rat disease models has suggested that mucin synthesis is up-regulated as part of the disease process. To understand the primary structure of secretory mucins, several cDNAs encoding airway mucin have been isolated. In most cases, full-length sequences have not been obtained. In this review, we focused on the MUC2 and MUC3 mucin gene. MUC2 mucin has been reported to be expressed in the human lung with airway disease and in the rat lung with infection and exposure to irritant such as SO2. MUC3 is also expressed in the bronchus. Less is known about the structure and the expression pattern of the MUC3 mucin gene. Recent findings show that the expression pattern of the MUC2 and MUC3 mucin genes differ strikingly, suggesting that they play distinct functional roles in the airway and intestine. Functional analysis of mucin gene promoter will provide better understanding of the regulation of its expression in the airway under both normal and pathological conditions.

Is diabetic heart muscle disease related to cardiac ischemia or autonomic neuropathy?

Whether diabetic heart muscle disease is related to cardiac ischemia or autonomic neuropathy was investigated employing thallium-201 and [123I]meta-iodobenzylguanidine (MIBG) myocardial scintigraphy. Among ischemic hearts, displayed by TI201 scintigraphy, a distinctly dilated and hypokinetic left ventricle could not be detected. In autonomically denervated hearts, however, well demonstrated by MIBG imaging, distinct dysfunction was found. But, even in these hearts, interacting effects of some concomitant complications could not be excluded.

[A case of diaphragmatic paralysis following herpes zoster]

We report a case of diaphragmatic paralysis after herpes zoster. A 82-year-old woman developed shortness of breath on effort after about two months of a typical herpes zoster eruptions affecting the C4 and C5 dermatomic areas on the right side. A chest x-ray showed an elevated right diaphragm. The diaphragmatic evoked potential by stimulation of the right phrenic nerve at the posterior border of the sternocleidomastoid muscle was not elicited. Chest CT and cervical MRI were normal. The viral antibody titers of herpes zoster were elevated in the serum. Cervical herpes zoster should be considered as a possible cause of hemidiaphragmatic paralysis.

The defective secretion of a naturally occurring alpha-1-antichymotrypsin variant with a frameshift mutation

A newly found variant alpha-1-antichymotrypsin (ACT), ACT Isehara-2, has a deletion of two bases (AA) at codon 391 near the carboxyl terminus. This frameshift mutation caused a change in the amino acid sequence and generated 10 extra amino acids (408 amino acids total) [Tsuda, M., Sei, Y., Matsumoto, M., Kamiguchi, H., Yamamoto, Y., Shinohara, Y., Igarashi, T. & Yamamura, M. (1992) Hum. Genet. 91. 467-468]. The serum ACT levels in three unrelated heterozygotes with this mutant ACT gene were 37% 49% and 54% that of the normal individuals. To examine the reduced serum levels, the normal ACT and the mutant ACT created by site-directed mutagenesis were transfected into COS-7 cells for comparison. The value for the retention rate (intracellular ACT/total ACT) was apparently higher in the cells expressing mutant ACT Isehara-2 than those bearing the normal gene. In the pulse-chase experiments, the secretion of the synthesized mutant ACT into the medium was not observed, whereas the normal ACT was mostly secreted as a 64-kDa form. The endoglycosidase H digestion and an electron microscopic analysis indicated that the retained mutant ACT was present in the endoplasmic reticulum. These results provide the biochemical basis for the decreased serum ACT level of individuals with ACT Isehara-2, and suggest the importance of the carboxyl-terminal region for its secretion.

Left-right asymmetric localization of flectin in the extracellular matrix during heart looping

The early embryo is initially bilaterally symmetrical. One of the first distinct indications of asymmetry in the embryo occurs during heart looping. The midline tubular heart begins to bend to the right to form a C-shaped structure around 30 hr of development in the avian model. A molecular basis for heart asymmetry and direction of looping is not known, although factors inherent to the myocardium are believed to underlie looping. A left-right asymmetric localization of a specific molecule in the bilateral heart forming regions has not been reported previously. One molecule that we are calling flectin (flectere, in L., to bend or to loop) shows a bilateral asymmetric localization early in the heart forming mesoderm and continues to be expressed asymmetrically in a highly organized manner in the cardiac jelly during heart looping. This large extracellular matrix molecule has been identified using a monoclonal antibody F-22 (Mieziewska et al., 1994a,b). Flectin shows a discrete spatiotemporal pattern of extracellular matrix expression during avian heart development. An asymmetric expression of flectin is observed during heart development at stage 7+/8- (approximately at 24 hr of development around the 3-somite stage). It is predominantly expressed in the left precardiac mesoderm at this developmental period. Between stages 12 and 14, flectin continues to be asymmetrically expressed in the myocardium and is localized at high levels on the basal side of the myocardium and within the cardiac jelly extending to the endocardial cell surfaces. In the same plane of the looping part of the heart it is differentially organized within the cardiac jelly on the convex side and in the outer loop areas. A reduced expression is apparent anteriorly and posteriorly along the tubular heart. The initial asymmetry of localization is maintained throughout the tubular heart. At stage 22 (Embryonic Day 3.5), intensity of immunolocalization of flectin is significantly decreased, with left-right asymmetry becoming less discernible or absent. It again is expressed in Day 10 embryonic hearts. Flectin expression appears to be modulated by retinoids. In vitamin A-deficient quail embryonic hearts that do not loop (Dersch and Zile, 1993; Twal et al., 1995), flectin protein expression is decreased and disorganized, as are other extracellular matrix components comprising the cardiac jelly.

A prospective study of the clinical utility of ApoE genotype in the prediction of outcome in patients with memory impairment

Given the relationship between the presence of ApoE epsilon 4 and Alzheimer's disease (AD), were studied whether knowledge of epsilon 4 status would predict which memory-impaired patients would develop AD over time. One hundred seven patients who presented with memory impairment but not dementia were referred to the study by their family physicians. These patients were followed prospectively over a 2-year period. Twenty-nine patients developed AD, while 78 did not develop dementia. We found that ApoE genotype was a reliable prognostic indicator of who developed AD in this group only when memory test performance was included in the predictive model. These findings indicate that limitations of ApoE genotyping in isolation as a prognostic indicator of AD. Because this study included prospectively selected patients who were followed longitudinally, our findings are likely to have more relevance in the clinical setting than those obtained from currently available retrospective studies.