Survey of Japanese physicians' attitudes towards the care of adult patients in persistent vegetative state

OBJECTIVES

Ethical issues have recently been raised regarding the appropriate care of patients in persistent vegetative state (PVS) in Japan. The purpose of our study is to study the attitudes and beliefs of Japanese physicians who have experience caring for patients in PVS.

DESIGN AND SETTING

A postal questionnaire was sent to all 317 representative members of the Japan Society of Apoplexy working at university hospitals or designated teaching hospitals by the Ministry of Health and Welfare. The questionnaire asked subjects what they would recommend for three hypothetical vignettes that varied with respect to a PVS patient's previous wishes and the wishes of the family.

RESULTS

The response rate was 65%. In the case of a PVS patient who had no previous expressed wishes and no family, 3% of the respondents would withdraw artificial nutrition and hydration (ANH) when the patient did not require any other life-sustaining treatments, 4% would discontinue ANH, and 30% would withhold antibiotics when the patient developed pneumonia. Significantly more respondents (17%) would withdraw ANH in the case of a PVS patient whose previous wishes and family agreed that all life support be discontinued. Most respondents thought that a patient's written advance directives would influence their decisions. Forty per cent of the respondents would want to have ANH stopped and 31% would not want antibiotics administered if they were in PVS.

CONCLUSIONS

Japanese physicians tend not to withdraw ANH from PVS patients. Patients' written advance directives, however, would affect their decisions.

Histological characterization of defective spermatogenesis in mice lacking the basigin gene

Basigin is a transmembrane protein belonging to the immunoglobulin superfamily. In the light of the fact that knockout mice lacking the basigin gene (Bsg) are azoospermic, the phenotype in the male reproductive system was extensively examined in this study. Spermatogenesis in Bsg (-/-) mice was found to be disrupted, and arrested at the metaphase of the first meiotic division. A few germ cells differentiated into young spermatids, but they were exfoliated. The lumens of the male reproductive system were filled with round degenerated cells. Using the TUNEL method and electron microscopy, some of the degenerated cells in the testis and epididymal head were shown to be apoptotic. Crystalloids of fine tubules and unusual ectoplasmic specializations were also observed in the Sertoli cells of Bsg (-/-) mice. These specializations displayed unusual 'circular' structures. Furthermore, unusual ectoplasmic specializations covering the spermatocytes rather than the mature spermatids were found. These structures were formed as a result of the lack of mature spermatids in the Bsg (-/-) testis. Results from analyses of azoospermia in the Bsg (-/-) mice suggest that basigin, through the interactions between germ cells and Sertoli cells, is an essential factor in the growth and/or survival of spermatids.

[Efficacy of three dimensional CT angiography (3D-CTA) for a first diagnosis of occlusive cerebrovascular disorders]

Patients with cerebrovascular disorders generally undergo computerized tomography (CT), even though magnetic resonance imaging (MRI) is available. We investigated the efficacy of three dimensional CT angiography (3D-CTA) for a first diagnosis of occlusive cerebrovascular disorders. Sixty-two patients, who were suspected of occlusive cerebrovascular disorder on the basis of neurological findings or initial plain CT findings, were reviewed. 3D-CTA was performed at the first medical examination. As a result, two patients were diagnosed with ICA (internal carotid artery) occlusion, nine with MCA (middle cerebral artery) occlusion, and one with BA (basilar artery) occlusion. All twelve patients underwent cerebral angiography immediately after those 3D-CTA in every case. Angiographical findings were the same as 3D-CTA. Interventional superselective thrombolytic therapy was performed in ten of the twelve patients, and recanalization resulted in four of them. 3D-CTA may also be able to determine whether the occlusive vessel is the chief cerebral artery or the perforating artery.

Analysis of synovial fluid components of hydrarthrosis in long-term hemodialysis patients

The synovial fluid components in long-term hemodialysis patients (HD; 43 knees in 43 patients) were investigated and compared with those in patients with osteoarthritis (OA; 21 knees in 21 patients) and rheumatoid arthritis (RA; 26 knees in 26 patients). The average ages in the three groups were, respectively, 60.7 years (range, 34-79 years), 63.2 years (range, 48-88 years), and 59.7 years (range, 37-76 years). The duration of hemodialysis in the HD group averaged 14.0 years (range, 4-24 years). The concentrations of hyaluronic acid, protein, and isomers of chondroitin sulfate (chondroitin 6-sulfate [C6S] and chondroitin 4-sulfate [C4S]) in the synovial fluid, and its viscosity were measured. Differences in each of the parameters were investigated according to disease clinical stage, roentgenological grade, and periods of dialysis in the HD group. The viscosity of the synovial fluid and the concentration of hyaluronic acid in HD patients were similar to those in OA patients; however, the C6S/C4S ratio in the synovial fluid of HD patients was similar to that in RA patients. The latter finding suggests that synovitis may be present in the hydrarthrosis of HD patients. The cause of this synovitis in HD patients remains to be elucidated.

Notochord-dependent expression of MFH1 and PAX1 cooperates to maintain the proliferation of sclerotome cells during the vertebral column development

During axial skeleton development, the notochord is essential for the induction of the sclerotome and for the subsequent differentiation of cartilage forming the vertebral bodies and intervertebral discs. These functions are mainly mediated by the diffusible signaling molecule Sonic hedgehog. The products of the paired-box-containing Pax1 and the mesenchyme forkhead-1 (Mfh1) genes are expressed in the developing sclerotome and are essential for the normal development of the vertebral column. Here, we demonstrate that Mfh1 like Pax1 expression is dependent on Sonic hedgehog signals from the notochord, and Mfh1 and Pax1 act synergistically to generate the vertebral column. In Mfh1/Pax1 double mutants, dorsomedial structures of the vertebrae are missing, resulting in extreme spina bifida accompanied by subcutaneous myelomeningocoele, and the vertebral bodies and intervertebral discs are missing. The morphological defects in Mfh1/Pax1 double mutants strongly correlate with the reduction of the mitotic rate of sclerotome cells. Thus, both the Mfh1 and the Pax1 gene products cooperate to mediate Sonic hedgehog-dependent proliferation of sclerotome cells.

Song-induced phosphorylation of cAMP response element-binding protein in the songbird brain

We have investigated the participation of cAMP response element-binding protein (CREB) in the response of the songbird brain to a natural auditory stimulus, a conspecific song. The cells in the two song control nuclei, the higher vocal center (HVC) and area X of zebra finches (Taeniopygia guttata), were intensely stained with an anti-CREB monoclonal antibody. Double-labeling studies showed that CREB immunoreactivity was detected only in area X-projecting neurons in the HVC. The cloned CREB cDNA from zebra finches (zCREB) is highly homologous to mammalian delta CREB. Phosphorylation of zCREB at Ser119 in area X-projecting HVC neurons was induced by hearing tape-recorded conspecific songs of zebra finches, but not by birdsongs of another species or white noise. These results raise the possibility that zCREB plays a crucial role in the sensory process of song learning.

[Dibucaine number (DN) and fluoride number (FN) of L330 I mutant recombinant cholinesterase by use of various substrates]

Dibucaine number (DN) and fluoride number (FN) of the recombinant 330 I mutant ChE (r330 I) expressed in human kidney cells (293 cell) were compared with recombinant usual ChE (rUU), by several assay kits and substrates. All of them showed lower the values compared with rUU. However, the r330 I/rUU ratios about FN determined by several substrates were higher than that determined by propionyl thiocholoneiodide (PTCI), which was recommended by American Association for Clinical Chemistry. In conclusion, commercially available assay kits may not be suitable for the determination of L330 I.

Multiple cardiovascular risk factors in obstructive sleep apnea syndrome patients and an attempt at lifestyle modification using telemedicine-based education

Severe obstructive sleep apnea syndrome (OSAS) is a typical 'lifestyle-related disease' characterized by a high incidence of cardiovascular risk factors, such as obesity, smoking, hypertriglyceridemia, and diabetes mellitus. Patients with OSAS tend to have eating disorders as a result of efforts to overcome the intolerable sleepiness. Treatment of OSAS should therefore aim to improve the lifestyle through encouraging weight reduction, physical activity increase, and tobacco avoidance, in addition to direct therapy such as continuous positive airway pressure for upper airway obstruction. The telemedicine system we developed was considered to be effective for providing home-based education on nutrition and exercise aimed at correcting multiple risk factors in OSAS patients

A novel in-frame deletion mutation in a case of lactate dehydrogenase (LD) H subunit deficiency showing an atypical LD isoenzyme pattern in serum and erythrocytes

OBJECTIVE

We report a case showing an atypical lactate dehydrogenase (LD) isoenzyme pattern involving deficiency only of LD-1 and LD-2 in serum and erythrocytes. LD activity in serum from this patient was extremely low, similar to complete LD-H deficiency, and also that in erythrocytes was low.

DESIGN

The DNA fragment containing exon 1 through 7 of the LD-H gene were amplified by PCR and directly sequenced. Total RNA was prepared from venous blood and the proportion of LD-H cDNA to total LD cDNA was semiquantified.

RESULTS

Genetic analysis by DNA sequencing detected a three base deletion (AAT) at codon 220 of exon 5, which caused a deletion of one asparagine. The present case did not show reduced LD-H expression at the mRNA level in whole blood. Residue 220 is involved in turning beta-J to alpha1-G and is not buried in the interior of the protein. The novel homozygous in-frame deletion mutation at codon 220 may cause a three-dimensional change of the subunit-binding domain.

Effects of T-588, a novel cognitive enhancer, on ADP-ribosylation of G(s alpha) by cholera toxin and cyclic AMP accumulation in rat cerebral cortex

We investigated the effects of R(-)-1-(benzo[b]thiophen-5-yl)-2-[2-(N,N-diethylamino)ethoxy]ethan ol hydrochloride (T-588), a novel cognitive enhancer, on trimeric GTP-binding proteins (G proteins) and cyclic AMP accumulation in rat cerebral cortex. T-588 (0.1-1.0 mM) inhibited the ADP-ribosylation of alpha subunit of Gs in a concentration-dependent manner. Auto-ADP-ribosylation of CTX was not inhibited by T-588. The stimulatory effect of guanosine 5'-(3-O-thio)triphosphate (GTPgammaS) on CTX-catalyzed ADP-ribosylation was attenuated by adding T-588 in assay mixture. ADP-ribosylation of Gi/Go by pertussis toxin was slightly inhibited by T-588. Isoproterenol-stimulated cyclic AMP accumulation was inhibited by adding 3 mM T-588 to rat cerebral cortical slices. Next, we investigated the effects of isoproterenol and T-588 on GTPgammaS binding. Membranes were first incubated with or without isoproterenol and T-588 in the presence of 0.2mM GTPgammaS, then cholate extract preparations were prepared from the washed membranes. Interestingly, the [32P]ADP-ribosylation of G(s alpha) was enhanced not only by isoproterenol but also by T-588. Although the obtained results are apparently inconsistent, T-588 seems to interact with G proteins, specifically Gs.

Influence of superstition on the date of hospital discharge and medical cost in Japan: retrospective and descriptive study

OBJECTIVES

To determine the influence of superstition about Taian (a lucky day)-Butsumetsu (an unlucky day) on decision to leave hospital. To estimate the costs of the effect of this superstition.

DESIGN

Retrospective and descriptive study.

SETTING

University hospital in Kyoto, Japan.

SUBJECTS

Patients who were discharged alive from Kyoto University Hospital from 1 April 1992 to 31 March 1995.

MAIN OUTCOME MEASURES

Mean number, age, and hospital stay of patients discharged on each day of six day cycle.

RESULTS

The mean number, age, and hospital stay of discharged patients were highest on Taian and lowest on Butsumetsu (25.8 v 19.3 patients/day, P=0.0001; 43.9 v 41.4 years, P=0.0001; and 43.1 v 33.3 days, P=0.0001 respectively). The effect of this difference on the hospital's costs was estimated to be 7.4 million yen (¿31 000).

CONCLUSION

The superstition influenced the decision to leave hospital, contributing to higher medical care costs in Japan. Although hospital stays need to be kept as short as possible to minimise costs, doctors should not ignore the possible psychological effects on patients' health caused by dismissing the superstition.

Stage-specific localization of basigin, a member of the immunoglobulin superfamily, during mouse spermatogenesis

Ablation of the transmembrane glycoprotein basigin leads to azoospermic mice, indicating that this gene is essential for spermatogenesis. To examine the functions of basigin in the testis, the precise localization of basigin during spermatogenesis was examined immunohistochemically. In the adult mouse testis, basigin immunoreactivity appeared on the cell surface of leptotene spermatocytes and gradually increased in intensity during the meiotic prophase. Cytoplasmic staining, as well as cell surface staining, was detected in spermatids. The most conspicuous reactivity was found in the spermatids at steps 9-11 and in the flagella of spermatids. Immuno-electron microscopic analysis demonstrated that basigin was localized not only on the plasma membranes of spermatocytes and spermatids, but also on the plasma membrane of the Sertoli cell processes which contact the spermatocytes and spermatids. Basigin immunoreactivity was also detected during postnatal development in spermatocytes and spermatids but not in spermatogonia. Experimental cryptorchid testes which contain only spermatogonia and Sertoli cells in the seminiferous epithelium showed no basigin immunoreactivity. Seven days after surgical reversal of the cryptorchid testis, spermatocytes reappeared in the tubules, along with basigin immunoreactivity. Furthermore, in sterile mutant mice, in which neither spermatocytes nor spermatids were generated, no basigin immunoreactivity was detected in the seminiferous tubules. These findings indicate that expression of basigin is concomitant with appearance of spermatocytes in the seminiferous tubule, and suggest that basigin is involved in the interaction between Sertoli cells and germ cells at specific stages of spermatogenesis.

[Two cases of traumatic-diaphragmatic hernia]

We report two cases of traumatic-diaphragmatic hernia caused by blunt injury. In case 1, abdominal findings were discovered on the 2nd day after the patient fell on the bottom from a horse, and in case 2, an emergency laparotomy was carried out due to the respiratory dysfunction which appeared immediately after a labor injury. The diaphragmatic ruptures at the left side observed in both cases, were closed directly. The prolapsed organs which shifted into the thoracic cavity were the stomach and colon in case 1, and the spleen and the tail part of the pancreas in case 2. In both cases, the organs were easily repositioned into the abdominal cavity without a hernial sac, but a splenectomy had to be performed because of splenic lacerations. In case 2, right rib fractures and lacerations of the left adrenal gland with retroperitoneal hematoma were observed. In the case of thoraco-abdominal blunt injuries, it is important to perform an early diagnosis and to consider the possibility of diaphragmatic hernia.

Quantification of relative expression of genes with homologous sequences using fluorescence-based single-strand conformation polymorphism analysis--application to lactate dehydrogenase and cyclooxygenase isozymes

The combination of reverse transcribed-PCR and fluorescence-based single strand conformation polymorphism analysis has been proposed for the quantitative determination of ratio of mRNA molecules with homologous sequences. We applied this procedure to lactate dehydrogenase subunits M and H, and cyclooxygenase 1 and 2. We designed fluorescence labeled common PCR primers in the sequences highly homologous between two subunit and isozyme cDNAs, and performed reverse transcribed-PCR and fluorescence-based single strand conformation polymorphism analysis. PCR efficiency was almost the same for the different target sequences, so analysis of mixtures of known amounts of lactate dehydrogenase M and H revealed linear and precise proportions of lactate dehydrogenase M mRNA. It was shown that template concentrations and number of PCR cycles did not affect the determination of proportions of lactate dehydrogenase M to total lactate dehydrogenase. The procedure was applicable to a determination of cyclooxygenase-2 proportion; furthermore, the present procedure could be easily applied to investigation of expression levels of genes encoding mRNAs with homologous sequences.

Increased expression of cyclooxygenase-2 to -1 in human colorectal cancers and adenomas, but not in hyperplastic polyps

BACKGROUND

Non-steroidal anti-inflammatory drugs can reduce the risk of colorectal cancer. Reportedly, mRNA expression of cyclooxygenase-2 (COX-2) is elevated in human colorectal cancers compared with accompanying normal mucosa. The present study was undertaken to establish a simple analytical procedure to quantify COX-2 expression levels and to characterize COX-2 expression levels in human colorectal cancers, adenomas and hyperplastic polyps.

METHODS

The combination of PCR using common primers designed in the highly conserved regions and fluorescence-based single-strand conformation polymorphism (F-SSCP) analysis of the products is used for quantitative determination of the proportions of COX-2 mRNA in human colorectal cancers, adenomas, hyperplastic polyps and accompanying normal mucosa.

RESULTS

The present F-SSCP analysis was a simple and powerful method for quantitative determination of the proportions of COX-2 mRNA. The proportion of COX-2 mRNA was higher in cancer tissues than in accompanying normal mucosa in 46 of the 50 cancers. There was no significant correlation between the increase of the COX-2 proportion and tumor location or stages. The enhanced COX-2 expression was also observed in colorectal adenomas. On the other hand, the proportion of COX-2 mRNA in hyperplastic polyps was not significantly different from that in normal mucosa.

CONCLUSIONS

The proportion of COX-2 to COX-1 expression was elevated in most human colorectal cancers and adenomas, but not in hyperplastic polyps. Therefore, the increased proportion of COX-2 expression might be an early event in the carcinogenesis of colorectal cancer.

Molecular dissection of the Rho-associated protein kinase (p160ROCK)-regulated neurite remodeling in neuroblastoma N1E-115 cells

A critical role for the small GTPase Rho and one of its targets, p160ROCK (a Rho-associated coiled coil-forming protein kinase), in neurite remodeling was examined in neuroblastoma N1E-115 cells. Using wild-type and a dominant-negative form of p160ROCK and a p160ROCK-specific inhibitor, Y-27632, we show here that p160ROCK activation is necessary and sufficient for the agonist-induced neurite retraction and cell rounding. The neurite retraction was accompanied by elevated phosphorylation of myosin light chain and the disassembly of the intermediate filaments and microtubules. Y-27632 blocked both neurite retraction and the elevation of myosin light chain phosphorylation in a similar concentration-dependent manner. On the other hand, suppression of p160ROCK activity by expression of a dominant-negative form of p160ROCK induced neurites in the presence of serum by inducing the reassembly of the intermediate filaments and microtubules. The neurite outgrowth by the p160ROCK inhibition was blocked by coexpression of dominant-negative forms of Cdc42 and Rac, indicating that p160ROCK constitutively and negatively regulates neurite formation at least in part by inhibiting activation of Cdc42 and Rac. The assembly of microtubules and intermediate filaments to form extended processes by inhibitors of the Rho-ROCK pathway was also observed in Swiss 3T3 cells. These results indicate that Rho/ROCK-dependent tonic inhibition of cell process extension is exerted via activation of the actomysin-based contractility, in conjunction with a suppression of assembly of intermediate filaments and microtubules in many cell types including, but not exclusive to, neuronal cells.

The effects of T-588, a novel cognitive enhancer, on noradrenaline uptake and release in rat cerebral cortical slices

Previously, we reported that (R)-(-)-1-(benzo[b]thiophen-5-yl)-2-[2-(N,N-diethylamino)-ethoxy]e thanol hydrochloride (T-588), a novel cognitive enhancer, stimulated noradrenaline (NA) release from rat cerebral cortical slices. In this study, we investigated the effects of T-588 on NA uptake and release, compared to the effects of desipramine, a blocker of the NA carrier on the plasma membrane. Both T-588 and desipramine caused dose-dependent inhibition of [3H]NA uptake into the slices. Addition of 3 mM T-588 stimulated [3H]NA release from the prelabeled slices even in the presence of 10 microM desipramine, which inhibited NA uptake completely. Tyramine, which accelerates NA carrier-mediated release, also stimulated [3H]NA release, and tyramine-stimulated release was inhibited by desipramine. These findings indicated that T-588-stimulated NA release was not mediated by 1) inhibition of reuptake or 2) reverse transport mediated by NA carriers. Reserpine, which interacts with the intracellular vesicular transport system, increased [3H]NA efflux from slices. High K+-, not T-588-, stimulated [3H]NA release was shifted upward by reserpine. These findings suggest that T-588 evokes NA release by a mechanism similar to that induced by reserpine. T-588 might act as a cognitive enhancer via neurotransmitter release in the brain.

Point mutations of ornithine decarboxylase gene are an infrequent event in colorectal cancer but a missense mutation was found in a replication error positive patient with hMSH2 germline mutation

BACKGROUND

Ornithine decarboxylase (ODC; EC 4.1.1.17) is the first rate-limiting enzyme in the biosynthesis of polyamines. ODC protein has a characteristic amino acid sequence, the PEST sequence, which is related to the enzyme's rapid degradation. ODC cDNA prepared from human hepatoma tissues has been reported to show nonsense or missense mutations.

METHODS

We examined somatic mutations of ODC cDNA by RT-PCR-SSCP analysis and mRNA expressions by RT-PCR in 50 colorectal cancer tissues to investigate the involvement of ODC gene alterations in colorectal cancers.

RESULTS

Increased expression of the ODC gene was observed in 36 cases (86%) out of the 42 examined by RT-PCR. In one case, a missense mutation was found in the cancer tissue but not in normal mucosa. The missense mutation from Asp to Asn at codon 424, in the PEST region, possibly stabilizes the ODC protein. In colorectal cancer, replication error and a germline mutation in hMSH2 gene were observed.

CONCLUSIONS

The missense mutation at codon 424 is speculated to be a cause of stabilization and a passenger mutation owing to the mutator phenotype. Since only one of 50 colorectal cancers exhibited a missense mutation of the ODC gene, mutations in ODC gene are not frequent in colorectal cancer. The increased expression of the ODC gene was noted in 86% of colorectal cancer tissues by RT-PCR, however, it was not due to point mutations in ODC coding exons.

[Analysis of genomic instability by fluorescence DNA sequencer]

Within the recent four years, there have been substantial advances in understanding the molecular pathogenesis of HNPCC. As one of the result of investigation, microsatellite instability has been observed in hereditary non-polyposis colorectal cancer (HNPCC) and other sporadic cancers. Moreover, there is strong supporting evidence that mismatch repair genes play a role in HNPCC. Here, we present our investigational results and discuss possible molecular mechanisms governing DNA mutation and genomic instability, leading to the development of neoplasm. We investigated replication error (RER) of 4 microsatellite markers (dinucleotide repeats) in 131 patients with colorectal cancer (10 met the criteria of HNPCC group B), using fluorescence-based DNA sequencer. We detected RER positivity (at more than two loci) in 12 of 131 patients (9.2%). PCR-SSCP and direct sequencing of the mismatch repair genes, hMSH2 and hMLH1, revealed that two patients in HNPCC group B had germline mutations of hMSH2. The fluorescence-based techniques, such as the present RER analysis do not require radioactive materials and specialized rooms, and can easily be performed in a clinical laboratory.

Prevalence of ischemic heart disease among patients with sleep apnea syndrome

We investigated the prevalence of ischemic heart disease (IHD) in sleep apnea syndrome (SAS) and the presence of coronary risk factors involved in the onset of IHD in 386 subjects with suspected SAS due to heavy snoring. The prevalence of IHD among patients with untreated SAS was found to be 23.8%, and the percentage of patients having SAS complicated with IHD was high among those with moderate or severe SAS. Sleep apnea syndrome patients with IHD also showed high prevalences of hypertension and hyperlipidemia. It appears that sleep apnea aggravates the factors that cause coronary vascular disorders, and is involved in the onset of IHD.

Large quantity production with extreme convenience of human SDF-1alpha and SDF-1beta by a Sendai virus vector

We describe a robust expression of human stromal cell-derived factor-1alpha (SDF-1alpha) and SDF-1beta, the members of CXC-chemokine family, with a novel vector system based upon Sendai virus, a non-segmented negative strand RNA virus. Recombinant SDF-1alpha and SDF-1beta were detected as a major protein species in culture supernatants, reached as high as 10 microg/ ml. This remarkable enrichment of the products allowed us to use even the crude supernatants as the source for biological and antiviral assays without further concentration nor purification and will thus greatly facilitate to screen their genetically engineered derivatives.