Doctor-shopping patients and users of alternative medicine among Japanese primary care patients

To describe the clinical characteristics of patients with doctor-shopping behavior (doctor-shopping patients) and users of alternative medicine among Japanese primary care patients, 1088 patients from the general medicine outpatient clinic of a medical school hospital answered an original questionnaire and 30-item General Health Questionnaire (GHQ). A random sample of patients was questioned in accordance with the Diagnostic Interview Schedule modified for use in Japan (DIS-JM). Twenty-three percent of these patients met our criteria for doctor-shopping patients, and 7.9% had used alternative medicine. Multivariate analysis showed no significant difference between the two groups of patients with regard to sex, age, residence, occupation, education, or marital status. The most striking characteristics of doctor-shopping patients were chronicity of illness (p < 0.005), inability to understand doctors' explanations (p < 0.005), disbelief of the doctor's diagnosis and treatment (p < 0.005), and high GHQ scores (p < 0.05). The major factor for alternative medicine users was high expectations of medical school hospitals (p < 0.01). DIS-JM interviews showed that doctor-shopping patients had a high lifetime prevalence of mental disorders. The lifetime prevalence of DSM-III somatization disorders was significantly higher in the two study groups. These results suggest that the risk factors for doctor shopping are strongly associated with chronic conditions and the doctor-patient relationship. Also, users of alternative medicine had high expectations of medical school hospitals as the symbol of modern medicine. Therefore, we emphasize the importance of accurate explanations and maintenance of good doctor-patient relationships by physicians providing care. We also suggest that when obtaining the patient's medical history, doctors ask how many prior visits the patient has made to medical facilities with the same complaint, and how many times the patient has used alternative medicine.

Cerebral infarction in a young adult associated with protein C deficiency. A case report

Protein C deficiency is a cause of thromboembolic disease. Venous thrombosis is the most common clinical manifestation. Arterial thrombosis is unusual and involvement of the intracranial arteries is especially rare. Herein the authors describe a case of cerebral [correction of cerebellar] infarction associated with protein C deficiency and review the relevant medical literature. A thirty-year-old man was hospitalized because of dysarthria, right limb ataxia, and a gait disturbance. Cranial computed tomography disclosed an infarction in the right cerebellar hemisphere and brachium pontis. Three months earlier the patient had had a transient ischemic attack with truncal ataxia and gait disturbances. On admission, the protein C antigen was 57% and protein C activity was 45%. Investigation of family members revealed protein C deficiency in an uncle. Literature review of stroke cases associated with protein C deficiency revealed that most had had a previous vascular event and/or a positive family history or had used oral contraceptives chronically. Protein C deficiency should be considered in young stroke patients with a positive family history of vaso-occlusive disease, previous ischemic events, or chronic oral contraceptive use.

Informative usefulness of age, sex and vital signs in the differential diagnosis of disturbed consciousness among 175 emergency outpatients

Final diagnoses were determined among 175 emergency patients with disturbed consciousness with a Glasgow Coma Scale (GCS) of less than 15 and diagnostic usefulness of basic information was assessed using clinico-epidemiological indices. Subject patients included 98 males and 77 females with average age 53.4 years. Final diagnoses were as follows: intracranial lesions in 69 patients (39.4%), metabolic and systemic diseases in 97 (55.4%), mental diseases in 4 (2.3%), and diseases of unknown origin in 5 (2.9%). Cerebrovascular disorders and epilepsy were most frequent among the intracranial lesions, and poisoning, hypoglycemia, acute alcoholism and hypoxic encephalopathy among the metabolic and systemic diseases. Informative usefulness of age, sex and vital sings in diagnosing cerebrovascular disorders was analyzed with the use of ROC curves, showing that cut-off points of age over 60 years and of systolic blood pressure greater than 160 mmHg were most useful.

Sonographic features of colon carcinoma seen with high-frequency transabdominal ultrasound

To assess the value of high-frequency ultrasonography as a diagnostic imaging procedure in patients with colon carcinoma, we first evaluated the sonograms of 37 patients who had been already diagnosed with contrast enema and/or colonoscopy as having colon carcinoma. As a result, the sonographic criteria for diagnosis of a possible colon carcinoma were (1) a localized and irregular thickening of the colonic wall with heterogenous low echogenicity, (2) an irregular contour, (3) a lack of demonstrable movement or change of configuration of the bowel on real-time scanning, and (4) absence of wall stratification. During the last 4 years, 41 consecutive patients had findings meeting our sonographic criteria. In 37 patients (90%), the presence of colon carcinoma was confirmed by contrast enema and/or colonoscopy. Our study suggests that high-frequency real-time ultrasonography may be a useful imaging technique in diagnosis of colon carcinoma.

Deep breathing test (DBT) in predicting white coat hypertension

We have evaluated the diagnostic value of deep breathing test (DBT) in detecting the patients with white coat hypertension on the outpatient basis. Thirty patients with untreated mild to moderate hypertension underwent 24-hour ambulatory blood pressure monitoring. Those who had a mean 24-hour blood pressure less than 135/80 mmHg were categorized as having white coat hypertension and the remainder were categorized as sustained hypertension. These two groups were compared with regard to the differences of office blood pressures before and after DBT (i.e., deep breathing 5 times for a minute in sitting position). Although the office systolic pressure significantly fell after DBT in both groups (p < 0.001 vs p < 0.05), there was no significant difference (p = 0.27) between the two groups. On the other hand, the office diastolic blood pressure significantly fell in the white coat hypertensives in contrast with no meaningful fall of it in the sustained hypertensives (p < 0.01 vs p = 0.66). At the cutoff level of -3%, -5% and -10% of the differences in office diastolic blood pressure before and after DBT, the sensitivity for the presence of white coat hypertension were 64.7%, 58.8% and 29.4%, respectively, and the specificity were 61.5%, 84.6% and 100%, respectively. These findings demonstrate that the deep breathing test is useful for identifying white coat hypertension in the outpatient clinic.

Intestinal anisakiasis: US in diagnosis

Eighteen consecutive patients with intestinal anisakiasis were studied with high-resolution ultrasound (US) and barium studies. US showed markedly thickened bowel loops associated with luminal narrowing, swelling of Kerckring folds, and decreased peristalsis. A small amount of ascitic fluid around the bowel loops was found, and cytologic examinations of the ascites revealed a dense infiltration of eosinophils. Barium studies demonstrated segmental mucosal edema of the small intestine: The most common site was the distal ileum, and the mean length of the edematous lesion was 19 cm. All patients underwent treatment of symptoms without laparotomy, and their symptoms disappeared by the eighth day after onset. Patients with acute abdominal symptoms should be asked about the intake of raw or undercooked fish. If the above US features are found, the diagnosis of intestinal anisakiasis must be seriously considered to avoid unnecessary surgical treatment.

[Information value of clinical signs and stat tests as indicators of female outpatient urinary tract infection]

This study was designed to evaluate signs and stat tests as an indicator of lower urinary tract infection in female subjects with urogenital complaints at an out-patient clinic. Of various symptoms including hematuria, pollakiuria, dysuria, urinary retention, and micturition pain, pain during micturition was present in 48% of 25 patients with urinary tract infections and in 4% of 27 patients without urinary tract infections, and was the sign with the highest positive predictive value. Comparison and discrimination of the infection and non-infection groups using a single laboratory valuable yielded significant F-statistics for urinary leukocyte esterase (14.5) and leukocyte count in urinary sediment (31.1), and revealed large Mahalanobis' distances for the same variables. Multivariate analysis using a discriminant function of categorical data (Hayashi's Suryoka type 2) revealed that combining occult blood with leukocyte esterase in the urine or combining red cell count with leukocyte count in sediment did not yield substantially smaller misclassification error than did leukocyte esterase alone or leukocyte count alone. It was concluded that neither urinary occult blood nor red cell count in sediment contribute substantially to the prediction of urinary tract infection. For the purpose of detecting urinary tract infection among outpatients, a receiver-operating characteristic analysis demonstrated that the optimal cut-off point in sediment was 3 or more leukocytes per microscopic high power field (x 400). Urinary leukocyte esterase was found to have limitations for use in screening, because its optimal decision level is equivalent to trace esterase reading on the dipstick test.

[Relationship between referral and patient characteristics]

In order to evaluate the relationship between referral and patient characteristics, 594 new patients utilizing Saga Medical School general clinic were studied using a questionnaire and chart review. Results obtained are as follows: 1) Fifty-eight patients (10%) came for follow-up of mass screening tests, 174 patients (29%) were self-referral, the remaining 362 patients (61%) were under previous care by other physicians. Only 64 patients (11%) had a referral letter. 2) Those patients who were not advised to visit our clinic by non-medical personnel, patients who were seriously ill, elderly patients, residents in distant area, and those with medical problems tended to have a referral letter. 3) Of the 64 patients having referral letters, 15 (23%) took the initiative in asking their previous doctor to write a referral letter. Patients who were highly educated had a greater tendency to request referral letters. 4) The reasons cited by the patients without a referral letter included "Did not think of the necessity" (22%), "Wanted to confirm diagnosis" (22%), "Did not want to make the doctor lose face" (16%), "No improvement in symptoms" (14%) These results indicate that education of patients and the general public, and establishing good physician-patient communication and trust are necessary for increasing the use of referral letter.

Fulminant hepatic failure during perinatal period in a pregnant woman with Wilson's disease

Wilson's disease associated with hepatic failure is not common and the underlying mechanism triggering the event is not known at present. We treated a 28-year-old Japanese woman with Wilson's disease who developed hepatic failure associated with hemolytic crisis just after delivery. She was diagnosed as having Wilson's disease at 12 years of age, at which time she started taking D-penicillamine. She had previously delivered two children without difficulty. When she found out she was pregnant this time, she stopped taking D-penicillamine in contrast to taking it faithfully during her first two pregnancies. On the day of delivery of her full-term baby, jaundice developed accompanied with severe hemolytic crisis. Plasma exchanges and blood transfusion were performed and D-penicillamine administration was started again. She gradually recovered and apparently was following a good clinical course. However, on day 30 the second hemolytic crisis occurred and subsequent liver failure led her to death on day 50. At autopsy her liver was cirrhotic and showed massive necrosis. Prophylactic oral administration of D-penicillamine and careful observation are therefore recommended to prevent hemolytic crisis during the perinatal period.

[A case of remission in metastatic lung tumor from hepatocellular carcinoma after combined CDDP and PSK therapy]

Discussed is the case of a 71-year-old man with multiple large hepatocellular carcinomas. His serum AFP level had markedly increased to 115 X 10(4) ng/ml. His AFP level also elevated and multiple lung metastatic tumors appeared after the second TAE therapy of 30 mg ADM, 10 mg MMC. To arrest these rises 100 mg of CDDP was given intravenously, followed by 3.0 g/day of PSK given orally. Five months later, shadows of the metastatic tumor disappeared and AFP to 540 ng/dl. As the mechanism responsible this improvement, it is felt that the CDDP attacked the metastatic tumors directly, and that this was aided by the follow-up immunotherapy with PSK. The abscopal effect of TAE also may have played a role.

Secretion of an interleukin 1-like activity by acute monocytic leukemia cells which inhibits growth of fibroblasts

Acute monocytic leukemia cells (AMoL cells), obtained by leukapheresis, were cultured in vitro. In response to lipopolysaccharide, AMoL cells produced a large amount of thymocyte proliferation activity. The crude supernatants from AMoL cells inhibited fibroblast growth, in a dose-dependent manner. Upon gel filtration, the thymocyte proliferation activity had a molecular mass of 37,000 and 17,000 daltons, and was heat labile and fairly resistant to freezing and thawing. The fractions containing thymocyte proliferation activity additionally possessed an inhibitory activity for the growth of fibroblasts. These results suggest that AMoL cells may participate in the progress of the disease (leukemia), by secreting these cytokines.

[A study of familial case histories of hepatocellular carcinoma--285 cases in Saga Prefectural Hospital]

We studied whether familial case histories of a liver cancers might be associated with the high mortality rate from liver cancers in Saga prefecture. Examined were 285 familial case histories of a hepatocellular carcinoma (HCC) incurred by parents, siblings, and children during the past 10 years. Familial case histories of patients with a gastric cancer and/or apoplexy also were studied as controls. The incidence of various types of cancers, including liver cancers and gastric cancers, in the family members of the HCC group was found to be the same as seen in family members of the gastric cancer group, but higher than in the families of the apoplexy group. Further, the HCC incidence rate in family members in the HCC group was not high as compared to the average for the whole of Japan. The HBsAg was not found to be associated with the rate of liver cancer in family members in the HCC group. Also, there was no high incidence of liver cancer was observed in children of parents with a liver cancer. From these results, we have concluded that high incidence of liver cancer seen in Saga prefecture was not associated with any familial clustering of HCC cases.

[Analysis of 293 cases of hepatocellular carcinoma of recent ten years--II. Diagnosis, therapy and prognosis]

Two hundred and ninety-three cases of hepatocellular carcinoma (HCC) of recent ten years during 1979 and 1988 were analysed on its diagnosis, therapy and prognosis. Angiography was the most useful diagnostic method for the first 5 years. During recent 5 years and for the tumor with size less than 2 cm, however, ultrasonography was the best method. 24.7% cases showed negative AFP and only 42.5% cases showed the level over 400 ng/ml. According to the tumor occupying-rate at the diagnosis, the number of cases of E1 had increased annually, the other cases being unchanged. 88.6% cases had liver cirrhosis microscopically as being reported previously. As a therapy TAE was most frequently performed, followed by operation, arterial infusion of antitumor drugs et al. The prognosis of the patients depended on the tumor occupying-rate. For the case of E1, the prognosis was the best by the therapy of ethanol injection therapy, operation and TAE. For the cases with tumor of larger than E1, frequent TAE was the best. From these results we concluded that we must make efforts to find small tumors to get the good prognosis.

[Analysis of 293 cases of hepatocellular carcinoma of recent ten years--I. Epidemiology, anamnesis and tumor occupying rate]

Two hundred and ninety-three cases of hepatocellular carcinoma (HCC) admitted to the key hospital of the rural area of western Japan, Saga Prefectural Hospital, during 10 years since 1979 to 1988 were analysed retrospectively. The male to female ratio was 3.7 to 1 and the ratio of HBs-Ag positive to negative was 3.5 to 1. The peak of the age distribution was seventh decade. The incidence increased annually, especially in HBs-Ag negative males. Their past history of blood transfusion was considered as an etiology of HCC in 19 (9.9%). The HCC was diagnosed approximately 10 years earlier in habitual drinkers than non-habitual drinkers of both positive and negative HBs-Ag. The incidence of small tumors is associated with the past history of chronic liver disease, negativity of HBs-Ag, lack of symptoms and old age.

An empty sella associated with hypopituitarism in a woman with rheumatoid arthritis

A 66-year-old woman with rheumatoid arthritis experienced severe hyponatremia and hypoglycemia of repeated occurrence. Endocrinologic examinations revealed hypopituitarism and the metrizamide computerized tomographic scan showed a primary empty sella. No evidence of a pituitary or suprasellar tumor was obtained. During the 5-year follow-up, she remains well under replacement therapy and there are no signs of an intracranial tumor. The possibility of an autoimmune mechanism linked to the development of hypopituitarism is discussed.

Kupffer cells may autoregulate interleukin 1 production by producing interleukin 1 inhibitor and prostaglandin E2

Rat Kupffer cells stimulated with bacterial lipopolysaccharide (LPS) produced high levels of interleukin 1 (IL-1), as determined by thymocyte proliferation assay. Indomethacin revealed a dose-dependent augmentation in IL-1 production, in parallel with a dose-dependent reduction in prostaglandin E2 production by Kupffer cells. The addition of exogenous prostaglandin E2, dibutyryl cAMP, or isoproterenol led to a dose-dependent suppression of IL-1 production. The supernatant from LPS-stimulated Kupffer cells also contained factors that inhibited IL-1-induced thymocyte proliferation. Upon gel filtration, two inhibitory peaks, at apparent MW of 27,000 and 6000, were obtained. The latter but not the former fraction also affected interleukin 2 (IL-2)-induced thymocyte proliferation. Increasing amounts of IL-1 overcame the inhibitory activity derived from the 27,000 MW fractions. These results suggest to us that prostaglandin E2 and IL-1 inhibitor released by Kupffer cells may be involved in negative self-control in regulating IL-1 production and its action.

Kinetics and parameters of the induction of interleukin 1 secretion by rat Kupffer cells

Rat Kupffer cells stimulated with bacterial lipopolysaccharide (LPS) produced high levels of interleukin 1 (IL-1), determined by assaying the thymocyte proliferating activity. The unstimulated Kupffer cells secreted no detectable activity. LPS-induced production of IL-1 activity was dose-dependent and as little as 0.1 micrograms/ml of LPS induced the IL-1 production. Thirty minutes were required for LPS to induce sufficient amounts of IL-1 activity. IL-2 activity was not detected in the Kupffer cell culture medium. Another soluble agent, N-acetylmuramyl-L-alanyl-D-isoglutamine, or phagocytable agents, silica and zymosan, also stimulated IL-1 production by Kupffer cells, whereas phorbol myristate acetate did not. Kinetic studies revealed a rapid increase in both intra- and extracellular IL-1 activity within 1 hr following the addition of LPS, with a peak at 6 hr. This IL-1 activity produced by Kupffer cells was heat labile, resistant to freezing and thawing and precipitated with 65% ammonium sulfate. Upon gel filtration, the activity was present in three peaks of approximately 110, 35 and 15 kd. The hepatocyte stimulating activity, when assayed by alpha 2-macroglobulin inducing activity, was detected in the first two peaks but not in the third peak. These studies suggest that LAF activity is distinct from hepatocyte stimulating activity at least in the molecular weight.

Human Ia-associated invariant chain gene has multiple transcription initiation sites in CLL cells

We show a northern transfer experiment revealed two mRNA of Ia-associated invariant chain (In) gene in chronic lymphocytic leukemia (CLL) cells which are approximately 1580 and 1440 nucleotides in length. Primer extension experiment shows that less prominent transcript was found to initiate 140 nucleotides upstream from the major cap site. The newly identified cap site was preceded by CG rich sequence but no typical promotor sequence. Southern hybridization analysis with In cDNA probe indicates no recombination or amplification of In gene in the CLL cells. This is the first documented example of such a mode of expression in malignant cells in vivo.

Production of hepatocyte stimulating factor of rat Kupffer cells induced by lipopolysaccharide: partial characterization and effects on alpha 2 macroglobulin gene expression in cultured adult rat hepatocytes

Primary cultured rat Kupffer cells stimulated with lipopolysaccharide (LPS) produced a hepatocyte stimulating factor (HSF), which enhanced the synthesis of acute phase protein, alpha 2-macroglobulin (alpha 2M), in adult rat hepatocytes. The Kupffer cell derived-HSF (KC-HSF), enhanced the synthesis of alpha 2M over 100 fold by primary cultured adult rat hepatocytes, in the presence of dexamethasone (Dex). The synthesis of albumin was not stimulated by the factor, even in the presence of Dex. The alpha 2M mRNA increased exponentially starting at 3 hr after addition of the factor. Therefore, the synthesis of alpha 2M stimulated by KC-HSF is probably controlled at the pretranslational phase. The LPS stimulated production of the KC-HSF was inhibited by actinomycin D. The HSF was precipitated between 35% and 65% saturation with ammonium sulfate and collected in the over 30,000 daltons fraction, by molecular sieving. Sephacryl S-200 gel chromatography revealed two distinct forms of HSF with apparent molecular weights of approximately 30,000 and 100,000 daltons. The majority of the activity was recovered in the latter fraction. Isoelectric chromatofocusing of the 100,000 daltons form of HSF yielded a single peak of activity with an apparent isoelectric point (pI) of 4.2. Each fraction contained the interleukin-1 (IL-1) activity, determined by thymocyte proliferation assay. These results show that Kupffer cells produce a cytokine, KC-HSF with IL-1 activity but different properties, as seen on the on Sephacryl S-200 gel filtration and isoelectrofocusing from known mouse or human IL-1.

Lack of evidence for a pyruvate kinase isozyme shift in hepatocytes of the regenerating rat liver

1. Pyruvate kinase isozyme shift in a regenerating rat liver was studied. Rats were subjected to a 70% hepatectomy and the liver homogenate or hepatocyte preparations were obtained from the regenerating liver. 2. Using thin layer polyacrylamide gel electrophoresis, liver homogenates from an intact normal rat appeared to contain the L-type isozyme in the greatest number and M2-type to a lesser extent. 3. The ratio of the M2- to L-type increased in the preparations obtained from the regenerating liver. 4. In the hepatocyte preparations prepared from a regenerating rat liver by the conventional method, a small amount of M2-type isozyme was detected. 5. However, the M2-type isozyme was hardly detected in the highly purified hepatocyte preparations prepared using Percoll. 6. Similar results were obtained by separation of the enzyme by DEAE cellulose column chromatography. 7. These results suggest that there is no pyruvate kinase isozyme shift from L- to M2-type in hepatocytes in the course of regeneration. 8. The increased M2-type isozyme in the regenerating rat liver is considered to originate from nonparenchymal cells.

Recovery after radiotherapy from severe interstitial pneumonia due to paraquat poisoning

A 51-year-old man was admitted 3 hours after ingesting approximately 50 ml of mixture of paraquat and organophosphate insecticide. His arterial oxygen pressure fell progressively to 44.6 mmHg. Diagnosed was paraquat-induced interstitial pneumonia. No improvement was observed after treatment with corticosteroid. The pneumonia, however, resolved after irradiation of both lungs and arterial oxygen pressure showed marked improvement. Radiotherapy to the lungs should be considered only in patients who showed progressive deterioration of respiratory function.

Kupffer cells modulate natural killer cell activity in vitro by producing prostaglandins

The effect of Kupffer cells on natural killer (NK) cell-mediated cytotoxicity was examined. Kupffer cells prepared from rat liver suppressed NK activity against K562 cells and other tumor cell lines through a soluble factor secreted into the culture supernatant. When human peripheral blood mononuclear cells were incubated with the Kupffer cell-culture supernatant, a significant reduction of the cytotoxic activity was observed in the 6-hr chromium-release assay. This activity was dose dependent and was evident at various effector/target cell ratios. Lipopolysaccharide stimulated generation of the suppressive factor released from Kupffer cells in a dose-dependent manner. Suppression of the NK activity was observed when the Kupffer cell-culture supernatant was present in the assay system, whereas pretreatment of effector/target cells with the supernatant had minimal inhibitory effects. Autologous monocytes in human peripheral mononuclear cells were not related to this suppression. The suppressive factor in the fraction had a molecular weight below 10,000. Indomethacin, an inhibitor of prostaglandin synthesis, ameliorated the suppressive effects. These results suggest that Kupffer cells may modulate NK activity by producing PGs (E1, E2, and F2 alpha).