Difficulty in the Diagnosis of Biliary Atresia Splenic Malformation Syndrome In Utero

The fetus of a 30-year-old pregnant Japanese woman was diagnosed with absence of inferior vena cava (IVC) and azygos continuation of interrupted IVC without cardiac anomalies at 34 weeks of gestation, and a healthy male neonate weighing 2,910 g was delivered at 37 weeks of gestation. On day 42 after birth, direct bilirubin predominant hyperbilirubinemia and high serum gamma-GTP levels were detected. Computed tomography revealed the presence of a lobulated and accessory spleen, and laparotomy demonstrated type III biliary atresia (BA), confirming the final diagnosis of BA splenic malformation (BASM) syndrome. In retrospect, non-visualization of the gallbladder was missed in utero. The combination of the absence of IVC and BA without cardiac anomalies is far less likely to occur in left isomerism. Although BA remains difficult to detect in utero, special attention should be paid to cases of BA associated with findings of left isomerism, including the absence of IVC, to enable early diagnosis and treatment of BASM.

Diagnostic accuracy of amniotic fluid interleukin-6 for fetal inflammatory response syndrome

AIM

This study aimed to clarify the diagnostic accuracy of amniotic fluid interleukin-6 for fetal inflammatory response syndrome (FIRS).

METHODS

This retrospective cohort study was conducted in a single institution and targeted cases of preterm birth within 24 h after amniocentesis among singleton cases that underwent amniocentesis at our hospital for suspected intraamniotic inflammation (IAI) from gestational ages of 22-36 weeks between August 2014 and March 2020. FIRS was defined as >11.0 pg/mL of umbilical cord blood interleukin-6.

RESULTS

The analysis included 158 pregnant women. There was a strong correlation between amniotic fluid interleukin-6 and umbilical cord blood interleukin-6 (r = 0.70, p < 0.001). The area under the receiver operating characteristic curve of amniotic fluid interleukin-6 for FIRS was 0.93, with a cutoff value of 15.5 ng/mL, and showed high sensitivity and specificity (0.91 and 0.88, respectively). An amniotic fluid interleukin-6 cutoff value of ≥15.5 ng/mL was associated with a significant risk of FIRS (adjusted odds ratio: 27.9; 95% confidence interval: 6.3-123.0; p < 0.001).

CONCLUSIONS

The results of this study show that amniotic interleukin 6 alone can be used to diagnose FIRS prenatally. While there is a need for validation, it may be possible to treat IAI while preventing damage to the central nervous and respiratory systems in the uterus by keeping the amniotic fluid interleukin-6 below the cutoff value.

Estimated time to emergence of secondary intra-amniotic infection or inflammation since the onset of the preterm premature rupture of membranes

OBJECTIVE

Prematurity is the most important prognostic factor for infants born following preterm premature rupture of membranes (PPROM). Therefore, when PPROM occurs between 22 and 33 weeks of gestation, prolonging pregnancy is recommended. Determination of management strategies requires screening for the presence of intra-amniotic infection or inflammation at the time of PPROM diagnosis. If intra-amniotic infection/inflammation is not detected, it is important to monitor the patient to diagnose any new infection/inflammation. We examined the period from PPROM to secondary intra-amniotic infection/inflammation and associated factors.

MATERIALS AND METHODS

This retrospective study was conducted at a single facility. We examined 26 patients who experienced PPROM between 26 and 33 weeks of gestation and were negative for intra-amniotic infection/inflammation at the time of diagnosis and underwent serial amniocentesis. Antibiotic therapy comprising ampicillin, amoxicillin, and clarithromycin for 7 days was started after the first amniocentesis. The period from PPROM to secondary intra-amniotic infection/inflammation was analyzed using a Kaplan-Meier survival curve. The onset of intra-amniotic infection/inflammation was considered as the time at which amniotic fluid bacterial culture results became positive, the time when amniotic fluid Interleukin (IL)-6 increased beyond 2.6 ng/mL, or the day of delivery if histological chorioamnionitis was observed in the delivered placenta. Patients were treated as censored if no intra-amniotic infection/inflammation could be confirmed in the amniotic fluid and delivered placenta.

RESULTS

The median time from PPROM to secondary intra-amniotic infection/inflammation was 18 days. Six patients developed intra-amniotic infection/inflammation, while 13 patients without intra-amniotic infections/inflammation delivered fewer than 7 days after PPROM. No confounding factors at the time of PPROM diagnosis were associated with the time from PPROM until secondary intra-amniotic infection/inflammation.

CONCLUSIONS

The time between PPROM and onset of secondary intra-amniotic infection/inflammation appears prolonged. Treatments other than antimicrobial agents may need to be added to prolong pregnancy.

Amniotic fluid Gram stain and interleukin-6 can predict early-onset neonatal sepsis

AIM

To clarify whether amniotic fluid findings (Gram stain and interleukin [IL]-6 level) can predict early-onset neonatal sepsis (EONS) before delivery.

METHODS

We compared the sensitivity and specificity and the values of the area under the receiver-operating characteristic (AUROC) curve of maternal inflammatory responses and amniotic fluid findings using IL-6 and Gram stain to predict EONS. Patients who underwent amniocentesis for suspected intra-amniotic infection (IAI) after 22 weeks and 0 days of gestation and delivered on the same day at our hospital between January 2013 and December 2018 were included.

RESULTS

Out of 200 patients, EONS developed in 9 patients. The AUROC curves of maternal white blood cells count, C-reactive protein and body temperature were low (range, 0.6-0.7), whereas that of amniotic fluid IL-6 was high (0.90). Sensitivity and specificity for amniotic fluid findings were, respectively, 100% and 67% for IL-6 (cut-off value: 17.4 ng/mL) and 100% and 88% for the Gram stain; these values were superior to those of maternal inflammatory responses. When examining the accuracy of the amniotic fluid Gram stain separately before and after 34 gestation weeks, similar results were obtained. Amniotic fluid IL-6 before 34 gestation weeks showed specificity similar to that of the Gram stain; however, there were large differences in cut-off values based on gestational age.

CONCLUSION

Gram stain results of amniotic fluid can predict EONS with high sensitivity and specificity when IAI is suspected. False-negative amniotic fluid Gram stain results can be prevented by measuring amniotic fluid IL-6 simultaneously.

Continuous amnioinfusion for treatment of mid-trimester preterm premature rupture of membranes with oligoamnios

AIM

Given the scarcity of relevant reports, this study aimed to elucidate whether pregnancy can be prolonged by maintaining the amniotic fluid volume with continuous transabdominal amnioinfusion (TA) for patients with mid-trimester preterm premature rupture of membranes (PPROM) and oligoamnios.

METHODS

We retrospectively examined patients who were managed during hospitalization at our department after developing PPROM between week 22 day 0 and week 25 day 6 of gestation and subsequent oligoamnios (amniotic fluid index [AFI] <5 cm) within 7 days after PPROM onset. Cases between 2006 and 2011 comprised the conventional management group (n = 14); cases administered continuous TA between 2012 and 2017 comprised the continuous TA group (n = 14). The primary outcome was the number of days between PPROM and delivery. The secondary outcomes were the proportion of normal amniotic fluid volume (AFI ≥ 5 cm) maintained between PPROM and delivery and the perinatal prognosis for the mother and infant.

RESULTS

The continuous TA group had significantly more days between PPROM and delivery and a significantly higher proportion of days that a normal amniotic fluid volume was maintained during that period, regardless of antimicrobial agents administered. Although no significant differences in the perinatal prognosis of disease were found between groups, there was a decreasing trend of composite perinatal mortality and morbidity, and the incidence rates were reduced by half.

CONCLUSION

Continuous TA for PPROM with oligoamnios may allow significant prolongation of the gestation period while maintaining the amniotic fluid volume and may lead to improved perinatal prognosis.

Sagittal alignment and mobility of the thoracolumbar spine are associated with radiographic progression of secondary hip osteoarthritis

OBJECTIVE

To identify predictors of radiographic progression of hip osteoarthritis (OA) over 12 months among functional hip impairments and spinal alignment and mobility.

DESIGN

Fifty female patients with secondary hip OA, excluding those with end-stage hip OA, participated in this prospective cohort study. Joint space width (JSW) of the hip was measured at baseline and 12 months later. With radiographic progression of hip OA over 12 months (>0.5 mm in JSW) as dependent variable, logistic regression analyses were performed to identify predictors for hip OA progression among functional impairments of the hip and spine with and without adjustment for age, body mass index (BMI), and minimum JSW at baseline. The independent variables were hip pain, Harris hip score (HHS), hip morphological parameters, hip passive range of motion (ROM) and muscle strength, and alignment and mobility of the thoracolumbar spine at baseline.

RESULTS

Twenty-one (42.0%) patients demonstrated radiographic progression of hip OA. Multivariable logistic regression analysis showed that larger anterior inclination of the spine in standing position (adjusted OR [95% CI], 1.37 [1.04-1.80]; P = 0.028) and less thoracolumbar spine mobility (adjusted OR [95% CI], 0.96 [0.92-0.99]; P = 0.037) at baseline were statistically significantly associated with radiographic progression of hip OA, even after adjustment for age, BMI, and minimum JSW.

CONCLUSIONS

The findings suggest that spinal alignment and mobility should be considered when assessing risk and designing preventive intervention for radiographic progression of secondary hip OA.

Daily cumulative hip moment is associated with radiographic progression of secondary hip osteoarthritis

OBJECTIVE

To investigate whether higher daily cumulative hip moment at baseline is associated with subsequent radiographic progression of hip osteoarthritis (OA) over 12 months.

DESIGN

Fifty patients with secondary hip OA, excluding patients with end-stage hip OA, participated in this prospective cohort study. Joint space width (JSW) of the hip was measured at baseline and 12 months later. With radiographic progression of hip OA (>0.5 mm/year in JSW) as dependent variable (yes/no), univariable and multivariable logistic regression analyses were performed to assess the association between load-related parameters during gait (i.e., peak hip moment, hip moment impulse, and daily cumulative hip moment [product of hip moment impulse and mean steps/day]) and hip OA progression with and without adjustment for age, body weight, and minimum JSW.

RESULTS

Of the 50 patients (47.4 ± 10.7 years old), 21 (42.0%) were classified into the progression group. The higher daily cumulative hip moment in the frontal plane at baseline was statistically significantly associated with radiographic progression of hip OA (adjusted odds ratio (OR) [95% confidence interval (CI)], 1.34 [1.06-1.70]; P = 0.013). The higher daily cumulative hip moment in the sagittal plane was also approaching significance in its association with hip OA progression (adjusted OR, 1.80 [0.99-3.26]; P = 0.052).

CONCLUSIONS

In the female patients with secondary hip OA, higher daily cumulative hip moment, particularly in the frontal plane, was a predictor of radiographic progression of hip OA over 12 months. Reduction in daily cumulative hip moment by modification in gait and physical activity may potentially slow hip OA progression.

Lowering levels of bed occupancy is associated with decreased inhospital mortality and improved performance on the 4-hour target in a UK District General Hospital

OBJECTIVE

To evaluate whether there is an association between an intervention to reduce medical bed occupancy and performance on the 4-hour target and hospital mortality.

METHODS

This before-and-after study was undertaken in a large UK District General Hospital over a 32 month period. A range of interventions were undertaken to reduce medical bed occupancy within the Trust. Performance on the 4-hour target and hospital mortality (hospital standardised mortality ratio (HSMR), summary hospital-level mortality indicator (SHMI) and crude mortality) were compared before, and after, intervention. Daily data on medical bed occupancy and percentage of patients meeting the 4-hour target was collected from hospital records. Segmented regression analysis of interrupted time-series method was used to estimate the changes in levels and trends in average medical bed occupancy, monthly performance on the target and monthly mortality measures (HSMR, SHMI and crude mortality) that followed the intervention.

RESULTS

Mean medical bed occupancy decreased significantly from 93.7% to 90.2% (p=0.02). The trend change in target performance, when comparing preintervention and postintervention, revealed a significant improvement (p=0.019). The intervention was associated with a mean reduction in all markers of mortality (range 4.5-4.8%). SHMI (p=0.02) and crude mortality (p=0.018) showed significant trend changes after intervention.

CONCLUSIONS

Lowering medical bed occupancy is associated with reduced patient mortality and improved ability of the acute Trust to achieve the 95% 4-hour target. Whole system transformation is required to create lower average medical bed occupancy.

Functional performance of female patients more than 6 months after total hip arthroplasty shows greater improvement with weight-bearing exercise than with non-weight-bearing exercise. Randomized controlled trial

BACKGROUND

Impaired functional performance and decreased muscle strength and muscle atrophy generally persist for a long period after total hip arthroplasty (THA).

AIM

To investigate the effects of weight-bearing (WB) and non-weight-bearing (NWB) exercises on functional performance, Harris hip score (HHS), muscle strength and muscle thickness in women after THA.

DESIGN

A randomised, controlled trial.

SETTING

Community.

POPULATION

Sixty-five women who had undergone unilateral or bilateral THA at least 6 months before enrolment in the study.

METHODS

Participants were randomly allocated to the following groups: WB (n = 22), NWB (n = 21) and control (n = 22) groups. Participants in the WB and NWB groups performed daily home exercise programs for 8 weeks. Functional performance (timed up and go, sit-to-stand, stair climbing, walking speed and 3-min walk test), HHS, isometric muscle strength of the hip and knee muscle and gluteus and quadriceps muscle thickness were measured at baseline and after 8 weeks.

RESULTS

An intention-to-treat analysis revealed that both the intervention groups exhibited significant improvements in almost all functional performance measures compared with the control group. Furthermore, the WB group showed significantly greater pre-post changes in the sit-to-stand and 3-min walk test compared with the NWB group. In terms of HHS, only the WB group showed significantly greater improvement compared with the control group. Relative to the control group, improvements in all isometric strength measures were observed in both the intervention groups. Significant improvement in quadriceps muscle thickness was observed in the WB group compared with the control group. However, no significant difference was observed among the three groups in pre-post changes in gluteus muscle thickness.

CONCLUSION

WB and NWB home exercise programs were both effective for improving functional performance and muscle strength in women after THA. However, the WB exercise was more effective than the NWB exercise for improving sit-to-stand ability and walking endurance.

CLINICAL REHABILITATION IMPACT

In this study, we demonstrated that the WB exercise was more effective than the NWB exercise for improving functional performance in patients after THA.

Revision total hip arthroplasty using a Kerboull-type acetabular reinforcement device with bone allograft

We retrospectively reviewed 40 hips in 36 patients who had undergone acetabular reconstruction using a titanium Kerboull-type acetabular reinforcement device with bone allografts between May 2001 and April 2006. Impacted bone allografts were used for the management of American Academy of Orthopaedic Surgeons Type II defects in 17 hips, and bulk bone allografts together with impacted allografts were used for the management of Type III defects in 23 hips. A total of five hips showed radiological failure at a mean follow-up of 6.7 years (4.5 to 9.3), two of which were infected. The mean pre-operative Merle d’Aubigné score was 10 (5 to 15) vs 13.6 (9 to 18) at the latest follow-up. The Kaplan-Meier survival rate at ten years, calculated using radiological failure or revision of the acetabular component for any reason as the endpoint, was 87% (95% confidence interval 76.3 to 97.7). A separate experimental analysis of the mechanical properties of the device and the load-displacement properties of bone grafts showed that a structurally hard allograft resected from femoral heads of patients with osteoarthritis should be preferentially used in any type of defect. If impacted bone allografts were used, a bone graft thickness of < 25 mm was acceptable in Type II defects.

This clinical study indicates that revision total hip replacement using the Kerboull-type acetabular reinforcement device with bone allografts yielded satisfactory mid-term results.

Malignant fibrous histiocytoma complicating nephrogenic systemic fibrosis post liver transplantation

A 46-year-old man with cirrhosis secondary to hepatitis C virus infection and alcohol underwent orthotopic liver transplantation, which required urgent re-grafting because of biliary sepsis from necrosis of the left liver lobe. Recovery was complicated by renal failure and nephrogenic systemic fibrosis (probably related to intravenous gadolinium exposure). He subsequently developed a malignant fibrous histiocytoma. We present this case highlighting the occurrence of two rare conditions in the same patient following liver transplantation. We believe this is the first case of its kind to be reported.

Tolcapone enhances food-evoked dopamine efflux and executive memory processes mediated by the rat prefrontal cortex

BACKGROUND AND RATIONALE

Genetic variations in catechol-O-methyl transferase (COMT) or administration of COMT inhibitors have a robust impact on cognition and executive function in humans. The COMT enzyme breaks down extracellular dopamine (DA) and has a particularly important role in the prefrontal cortex (PFC) where DA transporters are sparse. As such, the beneficial cognitive effects of the COMT inhibitor tolcapone are postulated to be the result of increased bioavailability of DA in the PFC. Furthermore, it has been shown previously that COMT inhibitors increase pharmacologically evoked DA but do not affect basal levels in the PFC.

OBJECTIVES

The current study characterized the ability of tolcapone to increase DA release in response to behaviorally salient stimuli and improve performance of the delayed spatial win-shift (DSWSh) task.

RESULTS AND CONCLUSIONS

Tolcapone enhanced PFC DA efflux associated with the anticipation and consumption of food when compared to saline controls. Chronic and acute treatment with tolcapone also reduced the number of errors committed during acquisition of the DSWSh. However, no dissociable effects were observed in experiments designed to selectively assay encoding or recall in well-trained animals, as both experiments showed improvement with tolcapone treatment. Taken together, these data suggest a generalized positive influence on cognition. Furthermore, these data support the conclusion of Apud and Weinberger (CNS Drugs 21:535-557, 2007) that agents which selectively potentiate PFC DA release may confer cognitive enhancement without the unwanted side effects produced by drugs that increase basal DA levels in cortical and subcortical brain regions.

The olfactory conditioning in the early postnatal period stimulated neural stem/progenitor cells in the subventricular zone and increased neurogenesis in the olfactory bulb of rats

The olfactory memory acquired during the early postnatal period is known to be maintained for a long period, however, its neural mechanism remains to be clarified. In the present study, we examined the effect of olfactory conditioning during the early postnatal period on neurogenesis in the olfactory bulb of rats. Using the bromodeoxyuridine-pulse chase method, we found that the olfactory conditioning, which was a paired presentation of citral odor (conditioned stimulus) and foot shock (unconditioned stimulus) in rat pups on postnatal day 11, stimulated the proliferation of neural stem/progenitor cells in the anterior subventricular zone (aSVZ), but not in the olfactory bulb, at 24 h after the conditioning. However, the number of newborn cells in the olfactory bulb was increased at 2 weeks, but not 8 weeks, after such conditioning. Neither the exposure of a citral odor alone nor foot shock alone affected the proliferation of neural stem/progenitor cells in the aSVZ at 24 h after and the number of newborn cells in the olfactory bulb at 2 weeks after. The majority of newborn cells in the olfactory bulb of either the conditioned rats or the unconditioned rats expressed the neural marker NeuN, thus indicating that the olfactory conditioning stimulated neurogenesis in the olfactory bulb. These results suggest that olfactory conditioning during the early postnatal period temporally stimulates neurogenesis in the olfactory bulb of rats.

Urgent liver transplantation for acute liver failure due to parvovirus B19 infection complicated by primary Epstein?Barr virus and cytomegalovirus infections and aplastic anaemia

An 11-year-old boy presented with hepatic failure secondary to parvovirus B19 infection, requiring urgent liver transplantation. His recovery was complicated by primary Epstein-Barr virus and cytomegalovirus infections. He subsequently developed aplastic anaemia that has been refractory to antithymocyte globulin and cyclosporine therapy and may now require bone marrow transplantation. We present this case to emphasize parvovirus as a rare cause of hepatic failure and of aplastic anaemia as a complication of the virus.

Comparative Analysis of Learning Effect for Students who Experienced both Lecture-based Learning and Problem-based Learning in a Complete Denture Course

PURPOSE

The purpose of this study was to analyze the difference in educational effect on students who experienced both lecture-based learning (LBL) and problem-based learning (PBL) in a complete denture course. The analysis focused on differences between the two methods concerning self study, ability to understand clinical inference, and appraisal of class contents and tutors.

METHODS

In the complete denture preclinical course, the class of 2003 received LBL in 3rd grade and PBL in 4th grade. PBL was planned to present five cases in five consecutive classes. Group discussion was carried out for each case, and a summary was required to be produced two times as a group, two times as an individual report and one time by group presentation. A questionnaire regarding the educational effect of LBL and PBL and assessment of tutors was administered. Factor analysis was carried out to classify the questionnaire items and each item was analyzed between LBL and PBL (Paired-t test).

RESULTS

Factor analysis revealed that the questionnaire items could be classified into four components. Comparing lecture type and PBL: "study attitude" (4 out of 7 items), "clinical inference ability" (all items), "class contents" (5 out of 7 items) and "tutor appraisal" (2 out of 5 items) showed significant assessment with PBL. Eighteen of 27 items (66.6%) indicated the significant usefulness of PBL.

CONCLUSION

PBL improves the educational effect of self study and clinical inference ability, in comparison with LBL. However, since students are passive about taking the same system class repeatedly, a strategy to improve their attitude needs to be considered.

Randomized controlled clinical trial for verifying the effect of silicone-based resilient denture liner on the masticatory function of complete denture wearers

PURPOSE

The purpose of this study was to investigate whether application of permanent silicone-based resilient denture liner (SR) to mandibular complete dentures significantly improves patients' masticatory ability compared to conventional heat-activated acrylic resin (AR).

MATERIALS AND METHODS

Twenty-eight edentulous patients were randomly placed into 1 of 2 crossover groups (AR-SR/SR-AR) by using a random permuted block within strata method. The AR-SR group received AR denture treatments followed by SR denture treatments. The SR-AR group received treatments in the reverse sequence. The outcomes were classified by matiscatory performance, mandibular movement, electromyographic activity, and maximum occlusal force.

RESULTS

No significant differences were observed in any of the baseline characteristic measurements between groups. SR denture wearers exhibited significantly higher masticatory performance than AR denture wearers. SR denture wearers exhibited a longer early-stage occluding period than AR denture wearers. There were no differences in electromyographic activity between the AR and SR groups. There were no significant differences in maximum occlusal force between the AR and SR groups.

CONCLUSION

This study showed that the application of SR to mandibular complete dentures resulted in significant improvements to the patients' masticatory ability compared to AR.

Influence of occlusal contact on cervical muscle activity during submaximal clenching

The aim of this study was to clarify the relationship between changes in the occlusal contact area and cervical muscle activity. A decreases in the occlusal contact area using bite planes (stage 1: full contact bite plane, stage 2: bilateral molar removed from contact, and stage 3: bilateral molar and premolar removed from contact) was experimentally simulated in seven subjects (aged 23-25 years) with normal dentition, and muscle activity of the sternocleidomastoid muscle (SCM) and trapezius muscle (TRM) during 50 and 10% of maximum voluntary contraction (MVC) was measured by surface electromyography. The SCM activity during 50% MVC was stage 1: 31.2 +/- 9.4 microV and stage 3: 35.3 +/- 12.3 microV. The TRM activity during 50% MVC was stage 1: 15.2 +/- 0.7 microV and stage 3: 18.3 +/- 2.9 microV. At the 50% MVC, stage 3 showed significant differences in comparison with stage 1 (P < 0.05, anova). These findings suggested that the sternocleidomastoid and TRM play roles in the exertion of occlusal force, and decreases in the occlusal contact area influence the amount of SCM and TRM activity.

[Standard values of inter-inner canthal, inter-outer canthal, and inter-pupillary distances in normal Japanese infants and children]

PURPOSE AND MATERIALS: We studied inter-inner canthal distance(DIC), inter-outer canthal distance (DOC), and inter-pupillary distance (PD) in 1,006 normal Japanese infants and children to establish the normal ratio of DIC/PD and DOC/DIC for the diagnosis of congenital anomalies such as Waardenburg syndrome.

RESULTS

DIC, DOC, and PD increased significantly from one month after birth to 12 years of age. DIC and DOC were stable but PD increased from 13 years of age to 15 years of age in junior high school. The DIC/PD and DOC/DIC averages were 0.61 and 2.73, respectively, one month after birth and 0.63 and 2.69 at three months after birth. On the other hand, DIC/PD and DOC/DIC were stable at 0.55-0.59 and 2.45 from 8 to 15 years of age.

CONCLUSION

Since there have been no reports on standard values of DIC, DOC and PD in infants, we established the standard values in this study. These values are expected to be very useful in the diagnosis of neural crest cell migration anomalies, such as Waardenburg syndrome.

Direct medical costs of chronic obstructive pulmonary disease: chronic bronchitis and emphysema

In this study we aimed to estimate direct medical costs of Chronic Obstructive Pulmonary Disease (COPD) by disease type; chronic bronchitis and emphysema. This study estimates direct costs in 1996 dollars using a prevalence approach and both aggregate and microcosting. A societal perspective is taken using prevalence, and multiple national, state and local data sources are used to estimate health-care utilization and costs. Chronic bronchitis and emphysema together account for $14.5 billion in annual direct costs. Inpatient costs are greater than outpatient and emergency costs ($8.3 vs. $7.8 billion) and hospital and medication costs account for most resources spent. The high prevalence of chronic bronchitis accounts for its larger total costs ($11.7 billion) compared with emphysema ($2.8 billion). Emphysema, which is more severe, has higher costs per prevalent case ($1341 vs. $816). Hospital stays account for the highest costs, $6.0 billion for chronic bronchitis and $1.9 billion for emphysema. The hospitalization rate, length of stay and average cost per prevalent case are higher for emphysema than for chronic bronchitis. Medication costs are the second highest cost category ($4.4 billion for chronic bronchitis, $0.693 billion for emphysema). The high hospitalization and low home care costs (0.2% of total) suggest underuse of home care and room to shift from acute to preventive care. More attention to healthcare management of chronic bronchitis and emphysema is suggested, and improving inhaler and anti-smoking compliance might be important targets.

Immunohistochemistry for hMLH1 and hMSH2: a practical test for DNA mismatch repair-deficient tumors

Inactivation of deoxyribonucleic acid (DNA) mismatch repair genes, most commonly human mutL homologue 1 (hMLH1) or human mutS homologue 2 (hMSH2), is a recently described alternate pathway in cancer development and progression. The resulting genetic instability is characterized by widespread somatic mutations in tumor DNA, and is termed high-frequency microsatellite instability (MSI-H). Although described in a variety of tumors, mismatch repair deficiency has been studied predominantly in colorectal carcinoma. Most MSI-H colorectal carcinomas are sporadic, but some occur in patients with hereditary nonpolyposis colorectal cancer (HNPCC), and are associated with germline mutations in mismatch repair genes. Until now, the identification of MSI-H cancers has required molecular testing. To evaluate the role of immunohistochemistry as a new screening tool for mismatch repair-deficient neoplasms, the authors studied the expression of hMLH1 and hMSH2, using commercially available monoclonal antibodies, in 72 formalin-fixed, paraffin-embedded tumors that had been tested previously for microsatellite instability. They compared immunohistochemical patterns of 38 MSI-H neoplasms, including 16 cases from HNPCC patients with known germline mutations in hMLH1 or hMSH2, with 34 neoplasms that did not show microsatellite instability. Thirty-seven of 38 MSI-H neoplasms were predicted to have a mismatch repair gene defect, as demonstrated by the absence of hMLH1 and/or hMSH2 expression. This included correspondence with all 16 cases with germline mutations. All 34 microsatellite-stable cancers had intact staining with both antibodies. These findings clearly demonstrate that immunohistochemistry can discriminate accurately between MSI-H and microsatellite-stable tumors, providing a practical new technique with important clinical and research applications.

[A study of hypertriglyceridemia occurring in patients with chronic hepatitis C during administration of interferon beta]

The prevalence and risk factors of hypertriglyceridemia during the administration of interferon (IFN) were examined in 78 patients with chronic hepatitis C who were treated with 6 MU of IFN-beta once or 3 MU of IFN-beta twice a day for 6 weeks. Hypertriglyceridemia (serum triglyceride (TG) above 150 mg/dl) was found before the start of IFN treatment in 9% of the patients. During the administration of IFN, elevation of serum TG above 150 mg/dl was found in 82% of patients. In addition, serum TG level exceeded 500 mg/dl at least once during the administration of IFN in 13% of patients. On stepwise multiple regression analysis, three risk factors, high serum TG value before the administration of IFN, high ALT value before the administration of IFN, and divided administration of IFN-beta twice daily were found to be associated with hypertriglyceridemia during IFN administration.

Cervical myelocystocele with Chiari II malformation: magnetic resonance imaging and surgical treatment

BACKGROUND

The myelocystocele is a rare clinical entity, and there have only been six case reports concerning the cervical myelocystocele, including ours.

METHODS

The case of a female neonate with cervical myelocystocele, who presented with respiratory distress beginning at birth is reported.

RESULTS

Magnetic resonance (MR) imaging disclosed a cystic lesion surrounded by two layers of membrane, which were recognized to be the dural and arachnoid layer and the ependymal lining layer, respectively, during operation and on histopathologic examination. Hydromyelia at C2-C7 with Chiari II malformation was also observed. After a thorough repair and untethering surgery, the hydromyelia was diminished on a follow-up MR examination. The patient's respiratory status normalized several days postoperatively, and her growth and development were within normal limits at the 2-year follow-up.

CONCLUSIONS

In cases of cervical myelocystocele with Chiari II malformation, untethering through intradural exploration to treat the tethered cord and outer decompression of the foramen magnum are needed. MR imaging is the best modality for preoperative determination of anatomic relationships.

[Percutaneous microwave coagulation therapy for hepatocellular carcinoma--study on its therapeutic effect in surgical cases]

Six patients with hepatocellular carcinoma were subjected to percutaneous microwave coagulation therapy (PMCT) by ultrasonic guiding. The size of the main tumor in the present cases was limited to not more than 2 cm. From 18 to 48 days after PMCT, each patient was subjected to surgery and pathological examination. By macroscopic observation, the PMCT area including both non-tumor and tumor regions looked yellowish white, and the boundary was clearly recognized. In the histological examination, the coagulation area surrounded by fibrous capsule was found, and deletion of nuclei and changes in stainability were observed in the marginal region. These changes indicated obvious coagulation necrosis, but the changes became less intense toward the center in the area, and in some portions, the tissue was indistinguishable from viable cells by light microscopy. In 2 cases out of the 6, part of the tumor remained outside the coagulation area. Since only the area determined by the microwave electrode is coagulated to cause necrosis on PMCT, sufficient safety margin should be required.

[Angiographical frequency of unruptured incidental intracranial aneurysms]

We reviewed cerebral angiograms studied between May 1985 and December 1992 focusing on unruptured incidental intracranial aneurysms. In a total of 605 cases of cerebral angiograms except for patients with SAH, 43 patients (7.1%) were found to have unruptured aneurysms. In the 72 patients with headache, 11 patients (15.3%) were found to have unruptured aneurysms. This high frequency of unruptured aneurysms in headache patients is significant as a factor showing that headache may be due to unruptured aneurysms. The result of this observation is that as a screening study for headache patients, cerebral angiography may be required in spite of the invasive and high-risk method. But we think that MR angiography is, at present, a useful screening study only for detecting cerebral aneurysms with a diameter of over 5mm, and which are considered to need an operation.

Duodenal adenomas in familial adenomatous polyposis: relation of cell differentiation and mucin histochemical features to growth pattern

We performed a clinicopathologic analysis of 74 periampullary and duodenal adenomas from 30 patients with familial adenomatous polyposis to evaluate the growth pattern, mucin histochemical profile, and degree and significance of Paneth cell and endocrine cell differentiation in these lesions. A trend toward more numerous adenomas was seen in patients with the longest intervals since their previous colectomies. Adenomas were most often clustered in the periampullary region and were numerous (> 20) in 40% of patients. Periampullary and duodenal adenomas were morphologically similar; both exhibited the same size-villous shape-dysplasia relationship as sporadic and familial adenomatous polyposis-associated colonic adenomas. Adenomas showed a heterogenous pattern of mucin production (mixed small intestinal-large intestinal types), with a shift toward the colonic type (sulfomucin) in lesions that were larger, villous, or severely dysplastic. Ninety-two percent of adenomas showed Paneth cell differentiation (average n Paneth cells/high power field = 24.5), and 99% showed endocrine cell differentiation (average n endocrine cells/high power field = 64.4). In general, the proportion of these specialized cell types was inversely related to size, villous shape, and degree of epithelial dysplasia. These results suggest that periampullary and duodenal adenomas in familial adenomatous polyposis arise from the neoplastic transformation of an undifferentiated stem cell that retains its ability for multidirectional differentiation.

Studies on prostaglandin and luteolysis in the pseudopregnant rabbit

The ability of pulsatile infusion of prostaglandin F2 alpha (PGF2 alpha) or 13, 14-dihydro prostaglandin F2 alpha to induce corpus luteum regression was examined in the pseudopregnant rabbit. Each prostaglandin was infused in 5, 1-hour pulses (1 per 6 hours) during a 25-hour period starting day 9 or 10 of pseudopregnancy. Although both prostaglandins were capable of inhibiting progesterone secretion, pulse administration was no more effective than continuous infusion. To determine if PGF2 alpha was released into the systemic circulation during spontaneous luteolysis, starting day 12 of pseudopregnancy serial blood samples were collected every 90 minutes from the jugular vein. Prostaglandin F levels remained steady (1-2 ng/ml over the collection period with no apparent increase associated with functional luteolysis. Although prostaglandins may be involved in luteolysis in the rabbit, the present results suggest that it is unlikely that PGF2 alpha by itself is responsible for the sustained fall in progesterone secretion at the end of the pseudopregnancy.

[The clinical examination for posttransfusion hepatitis]

We studied viral hepatitis, type A, type B, type D and type non A non B. Type A hepatitis was diagnosed by the serological examination for IgM type anti-HA and total anti-HA. Several cases were negative for IgM type anti-HA within 2 weeks after the onset of type A hepatitis. Type B hepatitis was diagnosed by RIA for serum HBs antigen. Several cases of type B hepatitis were negative for serum HBs antigen but positive for IgM type anti-HBc, or hepatocytes were positive for HBs antigen. These cases had high titer of total anti-HBc. Type D hepatitis was diagnosed by RIA for anti-delta in serum and by PAP stain for delta antigen in hepatocytes. All cases of type D hepatitis were positive for anti-delta in their serum and positive for delta antigen in their hepatocytes, they were positive for HBs antigen. Incidence of HDV infection was 0.7% in HBV carrier. The incidence of non A non B hepatitis was 27.6% in 105 recipients and the incidence of its progression to the chronicity was 20.0%.

[A case of cerebral embolism caused by atrial myxoma--superselective fibrinolytic therapy]

A 37-year-old man was admitted to our clinic 3 hours after the onset of cerebrovascular accident with right hemiparesis and total aphasia. On admission, we started combined administration of mannitol, vitamin E, phenytoin (Sendai Cocktail) and perfluorochemicals to protect ischemic brain. Left cerebral angiography revealed occlusion of the left middle cerebral artery involving its perforating arteries. Following the performance of angiography, vascular balloon catheter was introduced into the embolus, and fibrinolytic agent (urokinase) was continuously injected. Soon after the injection of 240,000 unit urokinase, recanalization of left middle cerebral artery was shown by repeated cerebral angiography performed 5.5 hours after the onset. On his clinical course, left hemiparesis and aphasia were improved step by step, and 1 week later, he could walk by himself with minor neurological deficits. Further examination revealed that myxoma was located on left atrium by echocardiography. Within 1 week, the patient was transferred to cardio-surgical unit, and myxoma was successfully removed. Now he is in good health and has returned to his job. Usually cerebral embolisms result from atrial myxoma cause severe cerebral infarction. Here we reported a case of cerebral embolism by myxoma and recanalized using fibrinolytic agent by balloon catheter injection. The damage will be reduced if the duration of occlusion is limited, so this method will be helpful to treat cerebral embolism.

[A new superselective balloon catheter--all-silicone catheter with a floppy tip]

We have introduced concept of "chemical" embolization and have tried to develop a new agent which would enable us to embolize the lesion with one-shot injection. Such an agent must be able to occlude diffusely the lesion distal to the catheter. This has made it mandatory to develop a new catheter which can be introduced into the vessel as close to the lesion as possible with fewer risks of clot formation and/or vessel damage. A new superselective balloon catheter for angiography and infusion of liquid embolizing materials has been developed. This catheter consists of a proximal relatively stiff silicone catheter, a short distal thin-walled flexible silicone catheter and silicone balloon. These three silicone components are connected by silicone adhesives. The distal catheter allows us to catheterize fine arteries such as lenticulostriates, while the proximal catheter assures easy manipulation. This balloon catheter can be used for superselective angiography and infusion of liquid embolizing materials. It has been used on nine patients; one with a dural arterio-venous malformation (AVM), four with meningiomas, and four with brain and spinal cord AVMs. In the case of dural AVM and meningiomas, it was possible to easily introduce into the middle meningeal artery distal to the foramen spinosum. In addition, in one of the cases of meningioma, we were able to catheterize one of the main feeding pedicles beyond the pterion. Chemical embolization was carried out in 5 cases with good results. In the case of brain and spinal cord AVM, useful information was obtained from the superselective angiography.(ABSTRACT TRUNCATED AT 250 WORDS)