Financial assistance in promoting occupational health services for small-scale enterprises in Japan

In spite of the diversified views on the governmental financial assistance in promoting occupational health services (OHS) for small-scale enterprises (SSE), the issue has not been much studied. Considering the large differences between countries in the degree of governmental financial assistance, the international comparative research will provide insight into its advantages and disadvantages. In order to conduct such comparative research, the status of each country must first be clarified. This informative piece of study aims at stimulating researchers in other countries to share their experiences and facilitate future comparative studies. This study was conducted to clarify the financial assistance of the Japanese government for SSE. Published reports on financial assistance for SSE were collected and used for the study. The Ministry of Labor initiated the policy of subsidizing OHS for SSE in the early 1960s. Activities to be subsidized through four routes included primary and secondary prevention of occupational injuries and diseases. The amount of subsidy was limited from one-third to two-thirds of costs. There was a fourteen-fold increase in the amount of subsidies for SSE from US$ 7 million in 1986 to US$ 98 million in 1998. The long history of financial assistance for SSE and the increasing amount of subsidies suggest that the Ministry of Labor recognizes the importance of financial assistance in promoting OHS in small scale enterprises.

Elongation of the pi-system of phthalocyanines by introduction of thienyl substituents at the peripheral beta positions. Synthesis and characterization

1,4,8,11,15,18,22,25-octabutoxyphthalocyanines ((OBu)8Pcs) having eight 2-thienyl (1) and [2,2'-bithiophene]-5-yl (2) groups at beta positions and their zinc(II) and cobalt(II) derivatives were prepared from 2-thienyl- (3) or [2,2'-bithiophene]-5-yl (4)-substituted phthalonitriles in moderate to good yields. The electronic absorption spectra of the Pcs showed red-shifted Q-bands relative to beta-unsubstituted (OBu)8Pcs. The longer substituent, the [2,2'-bithiophene]-5-yl group, is more effective than the 2-thienyl group in enlarging the pi-conjugated system of the Pcs. The ring oxidation potential obtained by cyclic voltammetry shifted cathodically with increasing chain length, indicating destabilization of the HOMOs. Due to the shift of the Q-band, 2-thienyl- and [2,2'-bithiophene]-5-yl-substituted Pcs exhibit a remarkable color change from the original green color.

Clustered cancer cells show a distinct adhesion behavior from single cell form under physiological shear conditions

It remains a question whether hematogeneous metastasis arises from a single cancer cell attached to the local endothelium or from a cluster of cancer cells trapped in the vascular bed in the target organ. Adhesive interaction of the single cell form and the clustered form of cancer cells was examined under flow conditions, using two subclones of mouse colon adenocarcinoma Colon 26. A subclone NL17, but not NL14, formed many clusters composed of tumor cells and platelets just after the addition of platelet rich plasma (PRP). Under the shear of 1.0 dyn/cm3, the clustered form of NL17 tethered on laminin or mouse endothelial cell line in hepatic sinusoids (HSE) more frequently than the single cell form of NL17 and NL14. However, all of the clusters showed only transient attachment and never underwent stable arrest on coated laminin, while the single cell form of NL14 and NL17 underwent immediate arrest under shear conditions. On HSE stimulated with TNF-alpha, a small number of NL17 clusters made stable adhesion, although all the clusters detached if the shear stress was increased above 4.0 dyn/cm2. In contrast, the single form of arrested NL17 as well as NL14 remained adherent even at shear of 8.0 dyn/cm2. Compared with single cell, binding of cancer cell clusters to laminin and HSE showed lower resistance to shear stress, although they had adhesive interactions more frequently in flow condition. Since NL17 cells form significantly more metastases by intravenous injection in vivo, our data suggest that "stable adhesion" observed in our flow assay system is not always a prerequisite for clustered cancer cells to develop into metastatic lesions.

Neck muscle responses to abrupt vertical acceleration in the seated human

The control of neck muscle during marked changes in "g" loading must be to protect head-trunk orientation. However, little is known about the organization of reflexes. We therefore investigated the shortest latency in neck muscle evoked by abrupt ascending and descending vertical acceleration with a stroke of 20 cm and peak acceleration 0.4xg in six healthy subjects. The subjects were seated upright and restrained on a chair driven by a hydraulic servo system. Ascent induced small responses in sternocleidomastoid muscles (SCMs) with a latency of 24.0 ms (SE 1.7) from onset of head acceleration, followed by larger responses of 100 ms in duration. In comparison the responses in SCMs evoked by descent were significantly delayed, with greater interindividual variations at 44.1 ms (SE 3.1) and smaller in amplitude than responses in ascent. Latencies were consistent and showed no habituation. In order to eliminate stretch components, we measured the neck responses to vertical acceleration with the head fixed by cervical collar. The latency of the fast response of SCM evoked by ascent was not significantly different from the latency of SCMs without the collar. These results may indicate that the fast responses of SCMs to sudden ascent may be composed of a vestibular-collic reflex for making the neck and head rigid for defense to sudden gravitational change.

Infected abdominal aortic aneurysm presenting with sudden appearance: diagnostic importance of serial computed tomography

The case of an 86-year-old man with an infected abdominal aortic aneurysm (AAA) that developed suddenly over 3 weeks is presented here. Previous reports on the diagnosis of infected AAA have focused mainly on the findings of single computed tomography (CT). These include the presence of a saccular aneurysm with an irregular lumen, perianeurysmal fluid, gas and/or hematoma, osteomyelitis in adjacent vertebral bodies, disruption of intimal calcification, and obscuring of the aortic wall. Our case report presents a useful diagnostic technique for the diagnosis of infected AAA, emphasizing the importance of serial CT for suspected cases, even if the initial scan does not demonstrate the findings listed above.

Randomized, controlled trial of lateral node dissection vs. nerve-preserving resection in patients with rectal cancer after preoperative radiotherapy

PURPOSE

The effectiveness of preoperative radiation therapy for advanced lower rectal carcinoma to preserve the function of pelvic organs and reduce local recurrences was examined in a prospective, randomized, controlled study.

METHODS

Fifty-one patients with a diagnosis of localized and resectable adenocarcinoma of the lower rectum undergoing 50 Gy of preoperative radiotherapy were recruited into the trial between April 1993 and March 1995. The patients were randomly allocated to complete autonomic nerve-preserving surgery without lateral node dissection (D1), or surgery with dissection of the lateral lymph nodes including autonomic nerves (D2) followed by oral administration of carmofur for one year.

RESULTS

No difference was observed in either survival or disease-free survival between D1 and D2 groups. There was no difference between the two groups in terms of recurrence rate. A significant difference was observed in urinary and sexual function (P = 0.02 and 0.02, respectively) one year after surgery between D1 and D2 groups.

CONCLUSION

This study suggests that lateral node dissection is not necessary in terms of curability for patients with advanced carcinoma of the lower rectum who undergo preoperative radiotherapy.

Colorectal cancer statistics in Japan: data from JSCCR registration, 1974-1993

Japanese colorectal cancer statistics from 1974 to 1993 are reported, based on the accumulated data registered by the member institutions of the Japan Society for Cancer of the Colon and Rectum (JSCCR). Both colon and rectal cancers were more prevalent in men than in women. In both sexes, colonic cancers were more prevalent than rectal cancers, and a greater increasing trend was seen in colonic cancers. Moderately differentiated adenocarcinoma seemed to have increased in recent years. The resectability and operative death rates improved slightly, but the ratio of stage I + II/III + IV cancers (both colonic and rectal) did not change at all during the 20-year period reported. The yearly improved survival in both colonic and rectal cancers, particularly in stages II and III, may well reflect improved surgical techniques.

Proliferative activity of intrahepatic colorectal metastases after preoperative hemihepatic portal vein embolization

Although hemihepatic portal vein embolization (PVE) has been used preoperatively to extend indications for hepatectomy in patients with colorectal metastases, the effects of this procedure on tumor growth and outcome remain controversial. To address this issue, we assessed the proliferative activity of intrahepatic metastases after PVE and the long-term outcome of this procedure. Eighteen patients with colorectal metastases underwent preoperative PVE between 1996 and 2000 (PVE group). Twenty-nine patients who underwent major hepatic resection without PVE served as control (non-PVE group). The hepatic parenchymal fraction of the left lobe had significantly increased from 38.1 +/- 3.2% to 45.9 +/- 2.9% 3 weeks after PVE (+20.5%, P <.0001). Tumor volume and percent tumor volume had also significantly increased from 223 +/- 89 mL to 270 +/- 97 mL (+20.8%, P =.016) and from 13.7 + 4.3% to 16.2 + 4.9% (+18.5%, P =.014), respectively. There was no apparent correlation between the increase in parenchymal volume and that in tumor volume. The Ki-67 labeling index of metastatic lesions was 46.6 +/- 7.2% in the PVE group and 35.4 +/- 12.6% in the non-PVE group (P =.013). Long-term survival was similar in the PVE and non-PVE groups, however, disease-free survival was significantly poorer in the PVE group than in the non-PVE group (P =.004). We conclude that PVE increases tumor growth and probably is associated with enhanced recurrence of disease. Although PVE is effective in extending indications for surgery, patient selection for PVE should be cautious.

Safety and efficacy of granulocyte and monocyte adsorption apheresis in patients with active ulcerative colitis: a multicenter study

Active ulcerative colitis (UC) is characterized by activation and infiltration of granulocytes and monocytes/macrophages into the colonic mucosa. The infiltrated leukocytes can cause mucosal damage by releasing degradative proteases, reactive oxygen derivatives, and proinflammatory cytokines. The aim of this trial (conducted in 14 specialist centers) was to assess safety and efficacy of granulocyte and monocyte adsorption apheresis in patients with active UC most of whom were refractory to conventional drug therapy. We used a new adsorptive type extracorporeal column (G-1 Adacolumn) filled with cellulose acetate beads (carriers) of 2 mm in diameter, which selectively adsorb granulocytes and monocytes/macrophages. Patients (n = 53) received five apheresis sessions, each of 60 minutes duration, flow rate 30 ml per minute for 5 consecutive weeks in combination with 24.4 +/- 3.60 mg prednisolone (mean +/- SE per patient per day, baseline dose). During 60 minutes apheresis, 26% of granulocytes, 19.5% of monocytes and 2% of lymphocytes adsorbed to the carriers. At week 7, 58.5% of patients had remission or improved, the dose of prednisolone was reduced to 14.2 +/- 2.25 mg (n = 37). The apheresis treatment was fairly safe, only eight non-severe side effects (in 5 patients) were reported. Based on our results, we believe that in patients with active severe UC, patients who are refractory to conventional drugs, granulocyte and monocyte adsorption apheresis is a useful adjunct to conventional therapy. This procedure should have the potential to allow tapering the dose of corticosteroids, shorten the time to remission and delay relapse.

[Current status of adjuvant endocrine therapy for hormone responsive breast cancer]

Three important meetings on adjuvant hormone therapy for breast cancer were held recently: the 5th EBCTCG Meeting, NIH Consensus Meeting, 7th International Conference on Adjuvant Therapy of Primary Breast Cancer. The conclusions of these meetings are: 1. adjuvant hormone therapy should be indicated only for patients with estrogen/progesterone receptor positive cancer, 2. five years of tamoxifen is the standard care at present, 3. ovarian ablation by any means has been proved effective in premenopausal patients and LH-RH agonist should be given at least two years, and 4. aromatase inhibitors should not be used in clinical practice, because several prospective randomized trials are ongoing at present. The patients treated with LH-RH agonist combined with tamoxifen showed better relapse-free survival compared with LH-RH agonist alone in the INT-0101 trial. This was an important trial because combined hormone therapy had not been proven more effective than individual hormone therapy previously. Combined hormone therapy including LH-RH agonist may be considered in premenopausal patients. There is a growing consensus that chemotherapy is effective through the ovarian suppression. In this sense, hormonal therapy should be considered first for hormone responsive patients. On the contrary, standard chemotherapy has shifted from CMF combination to an anthracycline containing regimen. Chemoendocrine therapy may be considered in high risk patients.

Transient intraocular pressure elevation after trabeculotomy and its occurrence with phacoemulsification and intraocular lens implantation

PURPOSE

To elucidate the characterization of intraocular pressure (IOP) spike after trabeculotomy, and after the combined procedure of phacoemulsification and aspiration (PEA) and intraocular lens (IOL) implantation.

METHODS

Included in this study were 39 patients (53 eyes) with primary open-angle glaucoma with IOPs uncontrolled even with anti-glaucoma medication. We conducted a retrospective study for the following two groups: Patients who underwent trabeculotomy alone (25 eyes) and patients undergoing trabeculotomy combined with PEA and implantation of an IOL (28 eyes).

RESULTS

In 7 (28%) of the 25 eyes after trabeculotomy alone and 7 (25%) of the 28 eyes after the combined procedure, transient IOP elevation was found postoperatively. The incidence of hyphema-related IOP spike was significantly higher in eyes after trabeculotomy alone (16%) than after the combined procedure (0%). After removal of the blood present in the anterior chamber in eyes with hyphema-related IOP spikes, the IOP levels were well controlled.

CONCLUSIONS

Hyphema-related IOP spike is one of the common complications in eyes after trabeculotomy alone, and the combined procedure decreases the incidence of this complication. It is thought that removal of prolonged massive hyphema is effective as treatment for hyphema-related IOP spike.

[The significance of extracurricular activities in the life of junior high school students]

In this study, the significance of extracurricular activities in the life of junior high school students were examined. Seventh and eighth graders participated in a two-stage questionnaire survey, administered in May and October. Based on developmental stage-environment fit theory (Eccles, Wigfield, & Schiefele, 1998), how well extracurricular activity settings fit needs of the students was analyzed. In support of the theory's hypothesis, results indicated that whether an extracurricular activity satisfied the student's developmental needs affected his/her sense of fulfillment and satisfaction in school life. In addition, the effect of seventh graders' commitment to extracurricular activities on their satisfaction of school life was stronger in October than in May. The findings suggested that for students who felt uneasy in class for whatever reasons, extracurricular activities provided an opportunity for relief.

Cloning and characterization of FGF23 as a causative factor of tumor-induced osteomalacia

Tumor-induced osteomalacia (TIO) is one of the paraneoplastic diseases characterized by hypophosphatemia caused by renal phosphate wasting. Because removal of responsible tumors normalizes phosphate metabolism, an unidentified humoral phosphaturic factor is believed to be responsible for this syndrome. To identify the causative factor of TIO, we obtained cDNA clones that were abundantly expressed only in a tumor causing TIO and constructed tumor-specific cDNA contigs. Based on the sequence of one major contig, we cloned 2,270-bp cDNA, which turned out to encode fibroblast growth factor 23 (FGF23). Administration of recombinant FGF23 decreased serum phosphate in mice within 12 h. When Chinese hamster ovary cells stably expressing FGF23 were s.c. implanted into nude mice, hypophosphatemia with increased renal phosphate clearance was observed. In addition, a high level of serum alkaline phosphatase, low 1,25-dihydroxyvitamin D, deformity of bone, and impairment of body weight gain became evident. Histological examination showed marked increase of osteoid and widening of growth plate. Thus, continuous production of FGF23 reproduced clinical, biochemical, and histological features of TIO in vivo. Analyses for recombinant FGF23 products produced by Chinese hamster ovary cells indicated proteolytic cleavage of FGF23 at the RXXR motif. Recent genetic study indicates that missense mutations in this RXXR motif of FGF23 are responsible for autosomal dominant hypophosphatemic rickets, another hypophosphatemic disease with similar features to TIO. We conclude that overproduction of FGF23 causes TIO, whereas mutations in the FGF23 gene result in autosomal dominant hypophosphatemic rickets possibly by preventing proteolytic cleavage and enhancing biological activity of FGF23.

Associations of distinct variants of the intestinal mucin gene MUC3A with ulcerative colitis and Crohn's disease

Ulcerative colitis (UC) and Crohn's disease (CD), the major forms of inflammatory bowel diseases (IBDs). are multifactorial disorders of unknown etiology. We reported a possible association of rare variable number of tandem repeat (VNTR) alleles of the "MUC3" gene with a susceptibility to UC. However, an entire structure of "MUC3" is still unknown because the long stretches of tandem repeats in this "gene" make its cloning extraordinarily difficult. In this study, we report evidence that "MUC3" consists of two genes, MUC3A and MUC3B, both of which encode membrane-bound mucins with two epidermal growth factor-like motifs, and we describe the complete 3'-terminal structures of these two genes. We have also analyzed the single nucleotide polymorphisms (SNPs) in the exonic sequences of the 3' portions of these two genes to investigate whether sequence variations in these regions can cause person-to-person differences in the susceptibility to IBDs, and report here that non-synonymous SNPs of MUC3A, involving a tyrosine residue with a proposed role in cell signaling, may confer genetic predisposition to CD (P = 0.0132). Our findings suggest that variants of MUC3A may be involved in the occurrence of UC and CD in distinct manners.

[Future figures of specialties in the surgical field]

A quarter of century has passed since specialties and their governing boards were established in the surgical field. It is now time to reestablish more definitive and rational specialties as we begin the 21st century. The specialty of general surgery should be the first step and require general surgical training of four years or more. The subsequent specialties (subspecialties) would be gastroenterological surgery, cardiovascular surgery, respiratory organ surgery, and pediatric surgery. In addition, the numerous medical associations in Japan could be overseen by a newly created Japan Board of Medical Specialties (proposed name) to manage the various specialties.

Risk factors for rupture of abdominal aortic aneurysm based on three-dimensional study

PURPOSE

Factors influencing the development or rupture of abdominal aortic aneurysms (AAAs) have not yet been confirmed. This study delineated the risk factors for rupture of AAAs as evaluated by means of a combination of three-dimensional (3D) reconstruction and clinical data analysis.

METHODS

The study population comprised Japanese patients in whom an atherosclerotic AAA had been diagnosed between January 1980 and December 1997. We obtained 3D-based data by means of computer-aided 3D reconstruction from computed tomography studies of AAAs. The data included the tortuosity of the aneurysm, maximum transverse diameter, length of the aneurysm, aneurysmal volume, aneurysmal surface area, largest aneurysmal cross-sectional area, ratio of transverse aneurysmal diameter to the length of the aneurysm (T/L), and amount of mural thrombus. Clinical data were collected from patient files. All data were assessed by means of multivariate analysis for their predictive value for expansion or rupture of AAA.

RESULTS

The most efficient predictor of annual expansion rate of maximum transverse diameter (EX-D) was a combination of largest aneurysmal cross-sectional area, tobacco use, and tortuosity. The most efficient predictor of annual expansion rate of aneurysmal volume (EX-V) was a combination of aneurysmal volume and blood urea nitrogen level. The most efficient predictors of aneurysmal rupture was a combination of EX-D, diastolic blood pressure, and T/L.

CONCLUSION

Three-dimensional-based data on aneurysmal morphology, including T/L, largest aneurysmal crosssectional area, and aneurysmal volume, had strong predictive value for expansion and rupture of AAAs.

Role of esophagectomy in treatment of esophageal carcinoma with clinical evidence of adjacent organ invasion

With carcinoma of the thoracic esophagus, clinical evidence of invasion of adjacent organs (T4) indicates a highly advanced stage, and most surgeons avoid esophagectomy. Although the therapeutic strategy for such disease is generally selected based on preoperative evaluation and intraoperative inspection, their accuracy and the relation to survival outcomes after esophagectomy have seldom been analyzed on the basis of exact histopathologic evidence. We performed esophagectomy, with perioperative adjuvant therapy when possible, on patients with clinical-T4 tumors unless absolutely unresectable conditions were detected. Among the 500 patients who underwent esophagectomy, the 78 patients whose tumors were confirmed to be T4 pathologically were compared with patients whose tumors were assessed as T4 preoperatively or intraoperatively to evaluate the role of esophagectomy for clinical-T4 carcinoma. Esophagectomy was possible for 99% of the pathologic-T4 tumors preoperatively assessed as resectable, but the resection was grossly incomplete in 35%. The true-positive rates in tumors preoperatively and intraoperatively assessed as T4 were 51% and 84%, respectively. The hospital mortality rate in patients with pathologic-T4 tumors was 4%. The overall 5-year survival rate for patients with pathologic-T4 tumors was 14%, compared with 60% for those with tumors assessed as T4 intraoperatively but not pathologically. Esophagectomy with perioperative adjuvant therapy yielded occasional cure with an acceptable mortality rate for patients with pathologic-T4 tumors assessed as technically resectable. Preoperative assessment and intraoperative macroscopic inspection had limitations for predicting pathologic-T4 disease and incomplete resection. Only patients with definitive evidence of unresectability should be excluded from esophagectomy.

[To err is human but error can be prevented]

It is believed that behind each reported medical error 29 unreported errors are hidden and in addition 300 irregularities are present. To prevent medical errors, one should learn from those latent errors to reorganize or correct systems and procedures. The Risk Management Committee is in charge of taking measures to prevent errors based on the analyzed data reported by risk managers and/or on incident/accident reports. The incident/accident reports should be made under a blame-free system and the concept should be thoroughly understood by all hospital staff. A lack of mutual communication, lack of a system to prevent medical errors, and lack of seriousness in everyday practice among physicians and nurses were found to be underlying causal factors in medical errors based on the lessons learned in our institution.

Psoas abscess complicating Crohn's disease: report of a case

We describe herein the case of a psoas abscess complicating Crohn's disease, and present a review of the literature on this unusual disease entity. A 22-year-old Japanese man with a 5-year history of Crohn's ileocolitis presented with right lower abdominal and hip pain, and a diagnosis of right psoas abscess was subsequently made by abdominal computed tomography (CT). Following the administration of antibiotics and CT-guided percutaneous drainage of the abscess, the patient's symptoms temporarily improved; however, 2 weeks later, the abscess cavity was found to have extended around the periarticular tissue of the right hip joint. To prevent the development of septic arthritis of the hip joint, surgical drainage of the abscess cavity and ileocecal resection were immediately performed, after which the patient's condition greatly improved. The resected specimen showed Crohn's ileocolitis with an external fistula in the terminal ileum which was considered to have caused the psoas abscess. Since psoas abscess in Crohn's disease can result in serious complications such as septic arthritis of the hip joint if left untreated, aggressive treatment should be initiated without delay.

Tacrolimus in corticosteroid-resistant ulcerative colitis

We report a case of refractory ulcerative colitis treated with tacrolimus. The patient was a 73-year-old woman with a 45-year history of ulcerative colitis. An attack unresponsive to intravenous corticosteroid therapy occurred when she was age 73. Leukocytapheresis therapy was attempted, but was discontinued because of the patient's poor general condition. Cyclosporine A therapy brought about fair control of the disease. A liver injury that was suspected to be associated with this agent, however, occurred within 5 weeks of its initiation. At that time, the cyclosporine A was discontinued and azathioprine treatment was started. Within 6 weeks, signs of exacerbation of the ulcerative colitis became apparent. Tacrolimus administered at that time brought about remission of the disease, and the corticosteroid dose was then reduced. Tacrolimus, like cyclosporine A, appears to be effective for the treatment of attacks of ulcerative colitis.

NMR identification of the Tom20 binding segment in mitochondrial presequences

Many mitochondrial proteins are synthesized in the cytosol as precursors with N-terminal presequences, and are imported into mitochondria with the aid of translocator protein complexes containing presequence-binding proteins. Tom20, a receptor protein which functions in an early step of the mitochondrial protein import, recognizes presequences with divergent amino acid sequences. Here, we report the identification of the segments involved in binding to Tom20 in mitochondrial presequences. We monitored the chemical shift perturbation of the NMR signals of five different 15N-labeled presequence peptides by the addition of the cytosolic receptor domain of rat or yeast Tom20. The perturbed segments occupy different positions, either near the N terminus or at the C terminus, in the presequences. Spin label experiments revealed that this is not due to different orientations of the presequence peptides bound to Tom20. The results presented here will offer a starting point to perform detailed analyses of Tom20-binding elements by systematic amino acid replacements.