Effectiveness of antipsychotics for managing agitated delirium in patients with advanced cancer: a secondary analysis of a multicenter prospective observational study in Japan (Phase-R)

PURPOSE

Delirium is a common and serious comorbidity in patients with advanced cancer, necessitating effective management. Nonetheless, effective drugs for managing agitated delirium in patients with advanced cancer remain unclear in real-world settings. Thus, the present study aimed to explore an effective pharmacotherapy for this condition.

METHODS

We conducted a secondary analysis of a multicenter prospective observational study in Japan. The analysis included patients with advanced cancer who presented with agitated delirium and received pharmacotherapy. Agitation was defined as a score of the Richmond Agitation-Sedation Scale for palliative care (RASS-PAL) of ≥ 1. The outcome was defined as -2 ≤ RASS-PAL ≤ 0 at 72 h after the initiation of pharmacotherapy. Multiple propensity scores were quantified using a multinomial logistic regression model, and adjusted odds ratios (ORs) were calculated for haloperidol, chlorpromazine, olanzapine, quetiapine, and risperidone.

RESULTS

The analysis included 271 patients with agitated delirium, and 87 (32%) showed -2 ≤ RASS-PAL ≤ 0 on day 3. The propensity score-adjusted OR of olanzapine was statistically significant (OR, 2.91; 95% confidence interval, 1.12 to 7.80; P = 0.030).

CONCLUSIONS

The findings suggest that olanzapine may effectively improve delirium agitation in patients with advanced cancer.

A revision of JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements

OBJECTIVE

The Japanese Psycho-Oncology Society and the Japanese Association of Supportive Care in Cancer have recently revised the clinical practice guidelines for delirium in adult cancer patients. This article reports the process of developing the revised guidelines and summarizes the recommendations made.

METHODS

The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multi-disciplinary members, created three new clinical questions: non-pharmacological intervention and antipsychotics for the prevention of delirium and trazodone for the management of delirium. In addition, systematic reviews of nine existing clinical questions have been updated. Two independent reviewers reviewed the proposed articles. The certainty of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development, and Evaluation system. The modified Delphi method was used to validate the recommended statements.

RESULTS

This article provides a compendium of the recommendations along with their rationales, as well as a short summary.

CONCLUSIONS

These revised guidelines will be useful for the prevention, assessment and management of delirium in adult cancer patients in Japan.

Economic costs for outpatient treatment of eating disorders in Japan

BACKGROUND

Few studies have examined the economic costs of outpatient care for eating disorders in Japan. This study aimed to clarify the reimbursement for outpatient treatment of eating disorders and compare the costs between the departments of Psychosomatic Medicine and Psychiatry in Japan.

METHOD

A multicenter, prospective, observational study of patients with an eating disorder was conducted in the Psychosomatic Medicine departments of three centers and the Psychiatry departments of another three centers in Japan. We analyzed medical reimbursement for an outpatient revisit, time of clinical interviews, and the treatment outcome measured by the Eating Disorder Examination Questionnaire (EDE-Q) global scores and body mass index (BMI) at 3 months. Multivariate linear regression models were performed to adjust for covariates.

RESULTS

This study included 188 patients in the Psychosomatic Medicine departments and 68 in the Psychiatry departments. The average reimbursement cost for an outpatient revisit was 4670 yen. Even after controlling for covariates, the Psychosomatic Medicine departments had lower reimbursement points per minute of interviews than the Psychiatry departments (coefficient = - 23.86; 95% confidence interval = - 32.09 to - 15.63; P < 0.001). In contrast, EDE-Q global scores and BMI at 3 months were not significantly different between these departments.

CONCLUSIONS

This study clarifies the economic costs of treating outpatients with eating disorders in Japan. The medical reimbursement points per interview minute were lower in Psychosomatic Medicine departments than in Psychiatry departments, while there were no apparent differences in the treatment outcomes. Addressing this issue is necessary to provide an adequate healthcare system for patients with eating disorders in Japan.

[Management of Delirium in Patients with Cancer]

Delirium is a condition in which the main symptom is a mild disturbance of consciousness caused by a physical abnormality or medication, and various symptoms such as cognitive dysfunction, hallucinations, delusions, and mood swings appear with any disease. Delirium is frequently observed in patients with cancer, especially in the terminal stage, and is observed in about 90% of patients just before death. Hypercalcemia due to bone metastases, brain metastases, and the use of opioids and steroids for symptom relief are direct factors in the development of delirium. Furthermore, there are many opportunities to encounter delirium at the end of life caused by conditions that are difficult to recover from, such as brain metastasis, liver failure, and hypoxic encephalopathy. In the management of delirium, "search for the cause(s)and its treatment"and"environmental adjustment"are the most important. Then, pharmacotherapy is considered to reduce the severity of delirium. Antipsychotics are the basic medication of choice. The route of administration, half-life, dosage form, adverse events of medication, as well as patient factors such as the presence or absence of diabetes and the subtype of delirium should be comprehensively considered when selecting a medication. The timing of medication discontinuation should also be kept in mind once medication therapy is initiated. On the other hand, when delirium is caused by factors that are difficult to recover from, the goal of treatment is to alleviate the painful symptoms caused by delirium, and it is important to take a holistic approach for patients and family members.

Trajectories of objectively measured physical activity and mood states in older Japanese adults: longitudinal data from the Nakanojo Study

Background

Japan, like many developed countries, now faces fiscal problems from the escalating health-care expenditures associated with an aging population. Mental health problems such as depression contribute as much to these growing demands as physical disease, and measures to prevent depression are important to controlling costs. There are few longitudinal studies examining the relation between objectively measured physical activity and depressive symptoms. Therefore, the aims of our study were to explore the patterns of change of physical activity in older Japanese adults for 5 years through the use of trajectory analysis and to examine the relation between physical activity trajectories and depressive mood states.

Main body

Ninety-two male and 99 female volunteers aged 65–85 years were asked to equip themselves with an electronic accelerometer with a 60-day storage capacity for at least 5 years. The parameters calculated each July for the 5 years were the average daily step count and the average daily duration of activity > 3 METs (moderate to vigorous physical activity: MVPA). Hospital Anxiety and Depression Scale (HADS) assessed corresponding mood states (HADS-A and HADS-D). Trajectories of the accelerometer data were analyzed and fifth-year HADS-D and HADS-A scores were compared among trajectory groups using an analysis of covariance (ANCOVA) that controlled for baseline scores and for baseline scores and age. Six and five distinct trajectories were identified for daily step count and for daily duration of MVPA, respectively. Using ANCOVA controlling for baseline scores, HADS-D scores differed significantly among trajectory groups classed by daily duration of MVPA (p = 0.04), and Tukey’s multiple comparison tests showed significant differences between group 2, whose pattern was stable with the middle duration of MVPA, and group 1, whose pattern was stable with the lowest duration of MVPA (p = 0.02), while the results were not significant controlling for both baseline scores and age.

Conclusions

Older people with less MVPA continued to do less MVPA over the 5 years of study, which may be related to a future more depressive mood. Further clinical studies will be necessary to clarify these findings.

Diets with high carbohydrate contents were associated with refeeding hypophosphatemia: A retrospective study in Japanese inpatients with anorexia nervosa

OBJECTIVE

Refeeding hypophosphatemia (RH) is a potentially fatal complication in patients with anorexia nervosa (AN), and its dietary preventive strategy is not well established. We aimed to examine the association between carbohydrate content in the diet and the occurrence of RH in inpatients with AN via retrospective medical chart review.

METHOD

We performed a chart review to collect data of patients with AN hospitalized at the Department of Psychosomatic Medicine of the University of Tokyo Hospital between April 1, 2012, and February 29, 2020. Receiver operating characteristic (ROC) analysis was performed to determine the cutoff point of the percentage of carbohydrate content in the diet for the occurrence of RH. Multivariate logistic regression analysis was performed with occurrence of RH as the dependent variable and the carbohydrate content of more than the identified cutoff point as the independent variable adjusting for the risk factors for RH.

RESULTS

The percentage of carbohydrate content that is higher than the cutoff point obtained from the ROC analysis (58.4%) was significantly associated with the occurrence of RH, even after adjusting for variables associated with RH in univariate logistic regression analysis (age and body mass index) as well as the average daily calorie intake (odds ratio, 5.37; 95% confidence interval, 1.60-18.1; p = .0066).

DISCUSSION

We identified that diets with higher carbohydrate contents were associated with RH in inpatients with AN, even after adjusting for known risk factors. Our findings may promote the development of dietary preventive strategies against RH in inpatients with AN.

JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements

BACKGROUND

The Japanese Psycho-Oncology Society and Japanese Association of Supportive Care in Cancer recently launched the clinical practice guidelines for delirium in adult cancer patients. The aim of the guidelines was to provide evidence-based recommendations for the clinical assessment and management of delirium in cancer patients. This article reports the process of developing the guideline and summarizes the recommendations made.

METHODS

The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multidisciplinary members, formulated nine clinical questions. A systematic literature search was conducted to identify relevant articles published prior to through 31 May 2016. Each article was reviewed by two independent reviewers. The level of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development and Evaluation system. The modified Delphi method was used to validate the recommendation statements.

RESULTS

This article provides a summary of the recommendations with rationales for each, as well as a short summary.

CONCLUSIONS

These guidelines will support the clinical assessment and management of delirium in cancer patients. However, additional clinical studies are warranted to further improve the management of delirium.

Body mass index cut-off point associated with refeeding hypophosphatemia in adults with eating disorders

OBJECTIVE

Refeeding hypophosphatemia (RH) is a life-threatening complication in underweight patients with eating disorders (EDs). Although a lower body mass index (BMI) has been reported as a risk factor for RH, the exact BMI cut-off point is not known. Herein, we aimed to identify the optimal BMI cut-off point for RH in adults with EDs.

METHOD

The medical charts of Japanese inpatients with EDs at our hospital between April 1, 2012 and March 31, 2017 were retrospectively reviewed. The optimal BMI cut-off point for RH was determined via receiver operating characteristic analysis. Logistic regression analysis was subsequently performed to assess the association between RH and the BMI cut-off point after adjusting for the propensity score, which was based on known risk factors for RH.

RESULTS

The optimal BMI cut-off point was identified as 12.6 kg/m² . A BMI lower than the cut-off point significantly correlated with the occurrence of RH after adjusting for the propensity score.

DISCUSSION

The optimal BMI cut-off point for the occurrence of RH was 12.6 kg/m² in adults with EDs. The findings of the present study may facilitate clinical decision making and early identification of patients who require prophylactic treatment for RH.

Preceding psychological factors and calorie intake in patients with type 2 diabetes: investigation by ecological momentary assessment

BACKGROUND

Psychological factors have been reported to have influence on the eating habits of patients with diabetes. However, previous studies have used questionnaires to investigate the association, and thus include recall bias. To overcome this disadvantage, ecological momentary assessment (EMA) can be used to record subjective symptoms and behavior in subjects' daily lives. Therefore, the aim of the present study was to investigate the influence of preceding psychological factors on calorie intake using computerized EMA for 6 months.

METHODS

The participants were nine outpatients with type 2 diabetes, aged 34-72. They were instructed to use a personal digital assistant as an electronic diary for 6 months to record subjective symptoms, such as psychological stress, anxiety, and depressive mood, and the food and drink that they consumed. The association between a preceding psychological factor and calorie intake within 5 hours was investigated using multilevel modeling.

RESULTS

Preceding psychological stress was positively associated with calorie intake from snacks. Preceding psychological stress, anxiety, and depressive mood were negatively associated with calorie intake from regular meals.

CONCLUSIONS

Preceding psychological factors influence the calorie intake of patients with type 2 diabetes. Understanding the role of these factors will be useful for developing psychological interventions to prevent overeating.

TRIAL REGISTRATION

The trial registration number: UMIN000002992. Date of registration: 2010/01/07.

Pilot Study for the Development of a Self-Care System for Type 2 Diabetes Patients Using a Personal Digital Assistant (PDA)

PURPOSE

The primary objective of the present pilot study was to investigate the feasibility and acceptability of the newly developed self-care system using personal digital assistance in patients with type 2 diabetes. The secondary objective was to investigate changes in daily calorie intake, body weight, and hemoglobin A1c after using the system for 6 months.

METHOD

The participants were nine outpatients with type 2 diabetes, aged 34-72 and living in Tokyo or surrounding prefectures. They were instructed to use the electronic food diary and to review the graphs of the total energy intake to control food intake under their own target value for 6 months. After they completed the study, the feasibility indicated by adherence rate for food recording and acceptability of the system rated with 6-point Likert scale from 1 (worst) to 6 (best) by the participants were investigated.

RESULTS

Seven participants out of nine completed the study protocol. The median adherence rate for food recording was 80.6 %. Regarding the acceptability, six patients rated 6 for desire to use the system while one rated 5. In addition, regarding improvement in self-care for diabetes, the median score was 5. Daily calorie intake, body weight, and HbA1c, however, did not change significantly over the 6-month period.

CONCLUSION

The newly developed self-care system might be feasible and acceptable in diabetes patients, which could be applied as an ecological momentary intervention tool, although there was some room to refine it to raise adherence.

A series of patients with purging type anorexia nervosa who do "tube vomiting"

Background

It is important for clinicians to assess their patients’ purging behavior. Various methods of purging, such as self-induced vomiting are well-known. Because patients do not always report their purging behavior, knowing the clinical signs that indicate the behavior is useful. However, we have experienced patients who did not have the reported physical signs of self-induced vomiting because they used hoses instead of their fingers to purge their stomach contents, which they call “tube vomiting”. No other previous studies have reported the use of hoses as a purging tool.

Case presentation

We present as our main case a 20-year-old Japanese woman with anorexia nervosa who engaged in “tube vomiting.” Although she recovered well under medical treatment in our hospital, she began to lose weight and blood potassium soon after discharge. We found that she used a garden hose instead of her fingers to perform self-induced vomiting,. She inserted the hose into her stomach and evacuated the stomach contents through it, without pain. She learned this technique through a blog about eating disorders. We also present two other similar cases. In fact, many patients discuss “tube vomiting” on the internet.

Conclusion

Our experience suggests that a sudden decrease in the weight and blood potassium level could indicate “tube vomiting”. In addition, because many information resources are available on the internet, medical practitioners should be aware of these sites.

Percutaneous Embolization of Ruptured Splanchnic Artery Pseudoaneurysms

The usefulness of emergent embolotherapy was evaluated in 17 patients with life-threatening hemorrhage from 18 ruptured splanchnic artery pseudoaneurysms. Complete hemostasis was obtained in 16 out of 17 patients by embolotherapy. Of the 12 initial embolization procedures with permanent embolic materials including stainless steel coils, microcoils, and Ivalon, complete cessation of bleeding was obtained in 11. On the other hand, 6 out of 9 initial embolization procedures with Gelfoam particles failed to halt bleeding, and additional embolization with permanent embolic materials was required. Emergent embolization with permanent embolic materials using superselective catheterization should be considered the initial treatment of choice for ruptured splanchnic artery pseudoaneurysms.

Assessment of Cancer-Related Fatigue, Pain, and Quality of Life in Cancer Patients at Palliative Care Team Referral: A Multicenter Observational Study (JORTC PAL-09)

INTRODUCTION

Cancer-related fatigue greatly influences quality of life in cancer patients; however, no specific treatments have been established for cancer-related fatigue, and at present, no medication has been approved in Japan. Systematic research using patient-reported outcome to examine symptoms, particularly fatigue, has not been conducted in palliative care settings in Japan. The objective was to evaluate fatigue, pain, and quality of life in cancer patients at the point of intervention by palliative care teams.

MATERIALS AND METHODS

Patients who were referred to palliative care teams at three institutions and met the inclusion criteria were invited to complete the Brief Fatigue Inventory, Brief Pain Inventory, and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 15-Palliative.

RESULTS

Of 183 patients recruited, the majority (85.8%) were diagnosed with recurrence or metastasis. The largest group (42.6%) comprised lung cancer patients, of whom 67.2% had an Eastern Cooperative Oncology Group Performance Status of 0-1. The mean value for global health status/quality of life was 41.4, and the highest mean European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 15-Palliative symptom item score was for pain (51.0). The mean global fatigue score was 4.1, and 9.8%, 30.6%, 38.7%, and 20.8% of patients' fatigue severity was classified as none (score 0), mild (1-3), moderate (4-6), and severe (7-10), respectively.

DISCUSSION

Cancer-related fatigue, considered to occur more frequently in cancer patients, was successfully assessed using patient-reported outcomes with the Brief Fatigue Inventory for the first time in Japan. Results suggested that fatigue is potentially as problematic as pain, which is the main reason for palliative care.

A CASE OF EOSINOPHILIC LYMPHFOLLICULOSIS OF THE SKIN (KIMURA'S DISEASE)

Eosinophilic lymphfolliculosis of the skin (Kimura's disease) in a 31-year-old male is reported. He had two subcutaneous tumors, 10 x 9 x 3 cm and 9 x 7 x 2 cm in size, in the right retroauricular and submaxillary areas respectively. Histopathologic examination of the tumors showed marked infiltration of eosinophils, mast cells and lymphocytes, and angiomatous proliferation of blood vessels from the dermis to the skeletal muscular tissue. In subcutaneous adipose tissue, there were numerous lymphfollicles with germinal centers in which IgE deposition with reticular appearance was observed by immunofluorescent technique. Study of the peripheral blood showed marked eosinophilia and an increase of serum IgE level. These findings suggest the possibility that Type 1 allergic reaction may be involved in the histogenesis of eosinophilic lymphfolliculosis of the skin, although there is no direct evidence for the existence of antigens which react to IgE antibody in the skin lesion.

Development of an ecological momentary assessment scale for appetite

Background

An understanding of eating behaviors is an important element of health education and treatment in clinical populations. To understand the biopsychosocial profile of eating behaviors in an ecologically valid way, ecological momentary assessment (EMA) is appropriate because its use is able to overcome the recall bias in patient-reported outcomes (PROs). As appetite is a key PRO associated with eating behaviors, this study was done to develop an EMA scale to evaluate the within-individual variation of momentary appetite and uses this scale to discuss the relationships between appetite and various psychological factors.

Methods

Twenty healthy participants (age 23.6 ± 4.2 years old) wore a watch-type computer for a week. Several times a day, including just before and after meals, they recorded their momentary psychological stress, mood states, and ten items related to appetite. In addition, they recorded everything they ate and drank into a personal digital assistant (PDA)-based food diary. Multilevel factor analysis was used to investigate the factor structure of the scale, and the reliability and validity of the scale were also explored.

Results

Multilevel factor analyses found two factors at the within-individual level (hunger/fullness and cravings) and one factor at the between-individual level. Medians for the individually calculated Cronbach’s alphas were 0.89 for hunger/fullness, 0.71 for cravings, and 0.86 for total appetite (the sum of all items). Hunger/fullness, cravings, and total appetite all decreased significantly after meals compared with those before meals, and hunger/fullness, cravings, and total appetite before meals were positively associated with energy intake. There were significant negative associations between both hunger/fullness and total appetite and anxiety and depression as well as between cravings, and depression, anxiety and stress.

Conclusions

The within-individual reliability of the EMA scale to assess momentary appetite was confirmed in most subjects and it was also validated as a useful tool to understand eating behaviors in daily settings. Further refinement of the scale is necessary and further investigations need to be conducted, particularly on clinical populations.

Thrombopoietin and thrombocytopenia in anorexia nervosa with severe liver dysfunction

OBJECTIVE/METHOD

Patients with anorexia nervosa (AN) display various physical complications. One such problem is thrombocytopenia. However, no studies have investigated links between AN and thrombopoietin (TPO), which is the primary regulator of megakaryocyte and platelet production produced mainly in the liver, although TPO has been recently reported to play a role in thrombocytopenia in liver diseases. We therefore clarified temporal relationships between platelet counts and TPO level in a woman with AN and severe liver dysfunction in whom platelet count decreased to 53 x 10⁹/L.

RESULTS

While international normalized ratio (INR) was low, serum TPO level was relatively low despite low platelet counts. After INR and liver enzymes improved in conjunction with improved nutritional status, a rapid increase in TPO was observed and platelet count began to rise.

DISCUSSION

These findings thus suggest that decreased TPO production accompanying liver dysfunction may be related to thrombocytopenia besides myelosuppression in AN with malnutrition.

Comparison of temporal changes in psychological distress after hematopoietic stem cell transplantation among the underlying diseases of Japanese adult patients

BACKGROUND

Although hematopoietic stem cell transplantation (HSCT) can potentially cure some hematological malignancies, patients who undergo HSCT experience psychological distress. However, there have been few studies on the short-term influence of HSCT on psychological distress.

METHODS

The subjects were 71 patients with hematological malignancies who underwent HSCT: 33 with acute leukemia, 19 with chronic leukemia, nine with myelodysplastic syndrome, and 10 with malignant lymphoma. Psychological distress was assessed prior to HSCT and on the seventh day after HSCT using the Profile of Mood States (POMS).

RESULTS

With regard to Anger-Hostility, the interaction of time (pre- and post-HSCT) and group (the four groups) was significant in male patients (p = 0.04), but not in female patients. With regard to the other subscales of POMS, there was no significant main effect or interaction in male or female patients.

CONCLUSION

It may be important to provide psychological support to patients throughout the period of HSCT in consideration of differences in mood changes associated with the underlying disease and patient sex in order to provide efficient psychiatric intervention for both better psychiatric and survival outcomes.

Connexins in the sinoatrial and atrioventricular nodes

The sinoatrial node (SAN) and the atrioventricular node (AVN) are specialized tissues in the heart: the SAN is specialized for pacemaking (it is the pacemaker of the heart), whereas the AVN is specialized for slow conduction of the action potential (to introduce a delay between atrial and ventricular activation during the cardiac cycle). These functions have special requirements regarding electrical coupling and, therefore, expression of connexin isoforms. Electrical coupling in the center of the SAN should be weak to protect it from the inhibitory electrotonic influence of the more hyperpolarized non-pacemaking atrial muscle surrounding the SAN. However, for the SAN to be able to drive the atrial muscle, electrical coupling should be strong in the periphery of the SAN. Consistent with this, in the center of the SAN there is no expression of Cx43 (the principal connexin of the working myocardium) and little expression of Cx40, but there is expression of Cx45 and Cx30.2, whereas in the periphery of the SAN Cx43 as well Cx45 is expressed. In the AVN, there is a similar pattern of expression of connexins as in the center of the SAN and this is likely to be in large part responsible for the slow conduction of the action potential.

Clinical characteristics of Japanese patients with anti-PL-7 (anti-threonyl-tRNA synthetase) autoantibodies

OBJECTIVE

The clinical and laboratory features of seven Japanese patients with anti-aminoacyl-tRNA synthetase (ARS) autoantibodies against PL-7 (anti-threonyl-tRNA synthetase) were analyzed and compared with previously published findings.

METHODS

Serum samples from 1,135 Japanese patients with various autoimmune diseases were screened for anti-PL-7 antibodies using RNA and protein immunoprecipitation assays. The patients whose sera contained anti-PL-7 antibodies were assessed regarding clinical symptoms and clinical course.

RESULTS

Sera from seven patients were found to have anti-PL-7 antibodies. These autoantibodies were associated with polymyositis/dermatomyositis (PM/DM) and/or interstitial lung disease (ILD). The clinical diagnoses of these seven patients were PM - systemic sclerosis (SSc) overlap (5 patients), DM (1 patient) and idiopathic pulmonary fibrosis (IPF) (1 patient). All patients had ILD with a chronic course and six also had arthritis (85%) and five sclerodactyly (71%).

CONCLUSIONS

These results indicate that anti-PL-7 autoantibodies are closely associated with PM-SSc overlap as well as ILD, arthritis and sclerodactyly in our series of Japanese patients.

Erythropoietic protoporphyria--report of a family and clinical review

Three cases of erythropoietic protoporphyria are reviewed. The three patients constitute members of one family. The protoporphyrin content of the red blood cells was high, but porphyrins and their precursors in the urine and faeces were not excessive. Other normal members of the family did not reveal high protoporphyrin content in the red blood cells. Clinical symptoms were itching, swelling, shallow depressed scars and waxy yellow discoloration on the face and brown pigmentation and thickness on the back of the hands after exposure to the sun. The microscopic findings from skin biopsy specimens of the lesions resembled changes of the lipoid proteinosis.

Sarcoplasmic reticulum Ca2+ release is not a dominating factor in sinoatrial node pacemaker activity

Recent work on isolated sinoatrial node cells from rabbit has suggested that sarcoplasmic reticulum Ca2+ release plays a dominant role in the pacemaker potential, and ryanodine at a high concentration (30 micromol/L blocks sarcoplasmic reticulum Ca2+ release) abolishes pacemaking and at a lower concentration abolishes the chronotropic effect of beta-adrenergic stimulation. The aim of the present study was to test this hypothesis in the intact sinoatrial node of the rabbit. Spontaneous activity and the pattern of activation were recorded using a grid of 120 pairs of extracellular electrodes. Ryanodine 30 micromol/L did not abolish spontaneous activity or shift the position of the leading pacemaker site, although it slowed the spontaneous rate by 18.9+/-2.5% (n=6). After ryanodine treatment, beta-adrenergic stimulation still resulted in a substantial chronotropic effect (0.3 micromol/L isoproterenol increased spontaneous rate by 52.6+/-10.5%, n=5). In isolated sinoatrial node cells from rabbit, 30 micromol/L ryanodine slowed spontaneous rate by 21.5+/-2.6% (n=13). It is concluded that sarcoplasmic reticulum Ca2+ release does not play a dominating role in pacemaking in the sinoatrial node. The full text of this article is available at http://www.circresaha.org.

Survey of antibiotic resistance in Pseudomonas aeruginosa by The Tokyo Johoku Association of Pseudomonas Studies

Pseudomonas aeruginosa resistance (minimum inhibitory concentration [MIC], > or =16 microg/ml defined as resistant) to meropenem, imipenem, panipenem, piperacillin, ceftazidime, cefozopran, cefoperazone, sulbactam/cefoperazone, amikacin, and tobramycin, as well as cross-resistance profiles, were investigated in P. aeruginosa strains isolated at eight hospitals in the Johoku area, Tokyo, during November 1998. Overall, 8.3% of isolates were imipenem-resistant and 4.6% were ceftazidime-resistant. However, the incidence of antibiotic-resistant P. aeruginosa was distinctly different at each hospital. P. aeruginosa resistance to imipenem ranged from (MIC) 1 to 64 microg/ml (MIC90 32 microg/ml), and its resistance to ceftazidime ranged from 2 to more than 128 microg/ml (MIC90, 64 microg/ml). Meropenem (MIC range, < or =0.25 to 16 microg/ml) was more active than panipenem (MIC range, 2 to 64 microg/ml). Cefozopran was more active than piperacillin, cefoperazone, or sulbactam/cefoperazone, but many strains were resistant to cefoperazone (17/57). Our analysis found cross-resistance to many beta-lactams, but the degree of cross-resistance was very variable.

[A case of disseminated intravascular coagulopathy (DIC) and multiple organ failure (MOF) after ingestion of hydrochloric acid]

Ingestion of caustic materials causes systemic damages and requires treatment in an intensive care unit. This report presents a case of disseminated intravascular coagulopathy (DIC) and multiple organ failure after ingestion of hydrochloric acid in an attempted suicide. The patient was admitted to the emergency ward within 1 hr after ingestion of 60 ml of 35% hydrochloric acid. Initial blood examination suggested hemolysis without anemia or thrombocytopenia. Arterial blood gas analysis exhibited evident metabolic acidosis with hypoxia. Two hours after ingestion, severe hemolysis, anemia, thrombocytopenia emerged with abnormal results from clotting and fiblinolysis tests, and a diagnosis of DIC was made. Subsequently, conjugate deviation and severe bleeding diathesis appeared. No evidence for gastrointestinal bleeding and brain hemorrhage was obtained in our abdominal echography and brain computed tomography, respectively. In spite of vigorous suppurative therapy including transfusion of blood, fresh frozen plasma, and catecholamines, the patient expired 29 hrs after ingestion. Autopsy was not carried out. Rapid progressive DIC as an acute complication of acid ingestion must be born in mind.

A novel single-nucleotide polymorphism at the 5'-flanking region of SAA1 associated with risk of type AA amyloidosis secondary to rheumatoid arthritis

OBJECTIVE

To address whether the gamma haplotype at exon 3 of the SAA1 gene is directly associated with type AA amyloidosis or is merely in linkage with an unknown polymorphism that is primarily associated with disease risk, we examined the SAA1 gene for new polymorphisms.

METHODS

We analyzed DNA samples from 44 rheumatoid arthritis (RA) patients with AA amyloidosis (amyloid group), 55 RA patients without AA amyloidosis (RA group), and 58 non-RA healthy subjects (non-RA group). We also examined DNA samples from 50 Caucasians to compare linkage disequilibrium relationships involving SAA1 region polymorphisms between Japanese and Caucasoid populations.

RESULTS

We observed 3 novel single-nucleotide polymorphisms (SNPs) in the 5'-flanking region of SAA1: -61C/G, -13T/C, and -2G/A. Comparison of allele frequencies and ratios of individuals with particular alleles between the study groups revealed statistically significant differences between the amyloid and RA groups and between the amyloid and non-RA groups. Statistical analysis revealed that the -13T/C SNP was strongly associated with AA amyloidosis. In addition, we found tight linkage between the -13T allele and the alpha haplotype, rather than the beta haplotype, at exon 3 in the Caucasoid population, while -13T was closely linked to the gamma and beta haplotypes, rather than the alpha haplotype, in the Japanese population. Since the linkage disequilibrium relationship was reversed between the Japanese and Caucasoid populations, different exon 3 haplotypes of SAA1 are found to be associated with the risk of AA amyloidosis in different ethnic groups.

CONCLUSION

Our data suggest that the SAA1 -13T allele, rather than SAA1 exon 3 haplotypes, is primarily associated with AA amyloidosis risk.

Involvement of cortical microtubules in plastic extension regulated by gibberellin in Lemna minor root

We aimed to analyze the rheological characteristics during elongation of the root segments in Lemna minor. The elastic component of segment elongation (EC) increased for the first 6 h, and then almost stopped. However, the plastic component of the segment elongation (PC) began to rapidly increase from 6 h onwards. Uniconazole-P, a gibberellin biosynthesis inhibitor, inhibited the total elongation of root segments (TE), and this inhibition was mainly caused by suppression of the rapid increase in the PC after 6 h. Concomitant with this inhibition, the cortical microtubule (CMT) array within root epidermal cells became disorganized in the presence of uniconazole-P from 6 h onwards. Adding GA3 abolished the inhibition of TE by uniconazole-P treatment, and this recovery was caused not by the increase in the EC but by an increase in the PC. Furthermore, the CMT arrays also recovered their characteristic organization in the presence of GA3. These findings suggest that endogenous gibberellin accelerates TE by activating the PC via control of CMT arrays. This conclusion is also supported by rheological analysis where propyzamide was used to disrupt microtubules. We suggest that endogenous gibberellin controls the PC via its influence over the transverse arrangement of CMTs.

Pacemaker shift in the rabbit sinoatrial node in response to vagal nerve stimulation

Effects of brief postganglionic vagal nerve stimulation on the activation sequence of the rabbit sinoatrial (SA) node were investigated. Activation sequences in a small area (7 mm x 7 mm) on the epicardial surface were measured in a beat-to-beat manner using an extracellular potential mapping system composed of 64 modified bipolar electrodes with high-gain and low-frequency band-pass filtering. The leading pacemaker site was recognised clearly from both the activation sequence and the characteristic morphology of the potentials. Vagal stimulation resulted in a short-lasting initial slowing of spontaneous rate followed by a long-lasting secondary slowing; a brief period of relative or absolute acceleration was interposed between the two slowing phases. During these changes of spontaneous rate, the leading pacemaker site shifted in a complex beat-to-beat manner by 1-6 mm alongside the crista terminalis in the superior or inferior direction. For the first spontaneous excitation following stimulation, the greater the slowing, the larger the distance of the pacemaker shift. There was no such linear relationship between the extent of slowing and the distance of pacemaker shift for the subsequent beats. These changes in the leading pacemaker site in response to vagal stimulation may be the result of the functional and morphological heterogeneity of the mammalian SA node in terms of innervation, receptor distribution and ion channel densities. Experimental Physiology (2001) 86.2, 177-184.

Humoral immune-mediated acute, antigen-induced arthritis in rats is suppressed by the inducing antigen administered orally before, but not after, immunization

Acute ovalbumin-induced arthritis (OIA), which is mediated by Arthus reaction to ovalbumin (OVA) in the joint space, can be induced by immunization of rats with OVA followed by the intraarticular injection of OVA. Because oral administration of antigen induces immunological unresponsiveness, we studied for the first time the effects of oral administration of OVA on acute OIA. The oral administration of OVA before immunization significantly suppressed the development of acute OIA, in accordance with decreases in both the anti-OVA IgG antibody production and in vitro lymphocyte proliferative responses to OVA. However, the oral administration of OVA after immunization did not show any decrease in antibody production or in vitro lymphocyte proliferation to OVA, or in the severity of acute OIA. These results indicate that the induction of oral tolerance to OVA in OIA is possible by oral administration of OVA before, but not after, immunization with the antigen. This supports the concept of using antigen feeding as a treatment for certain humoral immune-mediated diseases.

CTLA-4 gene polymorphism in Japanese patients with rheumatoid arthritis

OBJECTIVE

To examine whether CTLA-4 gene confers susceptibility to rheumatoid arthritis (RA) in Japanese.

METHODS

We investigated the distribution of a CTLA-4 gene polymorphism in 85 Japanese patients with RA and 200 controls. An A/G transition at position 49 of exon 1 was analyzed by the polymerase chain reaction (PCR)-restriction fragment length polymorphism method. The patients were also analyzed with respect to HLA-DR status. HLA-DR typing was performed by PCR sequence-specific oligonucleotide typing.

RESULTS

The distribution of genotype frequencies differed between RA and controls (chi-squared 8.63, 2 df, p = 0.013). The CTLA-4 AG genotype occurred more frequently in patients with RA (59 vs 44%), and the presence of at least one G allele (GG or AG) conferred an odds ratio of 2.53 (95% CI 1.74-3.32). When the patients were analyzed with respect to HLA-DR status, this association was restricted to patients carrying the susceptible HLA allele (HLA-DRB1*0405).

CONCLUSION

The CTLA-4 gene is associated with Japanese patients with RA carrying the susceptible HLA allele.

Regulation of elongation growth by gibberellin in root segments of Lemna minor

Hormonal control of elongation growth was analyzed in segments excised from the elongation zone of Lemna roots. Exogenous GA3 did not promote the segment elongation but rather inhibited it. Uniconazole-P, a gibberellin biosynthesis inhibitor, significantly inhibited the segment elongation, and the inhibitory effect was completely nullified by GA3. In the epidermis, cell elongation was inhibited, but lateral cell expansion was not affected by uniconazole-P. Orientation of cortical microtubules of epidermal cells was disturbed by treatment with uniconazole-P for 12 h, and the disorganization of cortical microtubules was ameliorated by GA3. These findings suggested that disorganization of cortical microtubules induced inhibition of elongation growth of root. However, stabilization of cortical microtubules by taxol, a microtubule-stabilizing agent, did not affect the inhibition of segment elongation by uniconazole-P. These results suggested that endogenous gibberellin controls the elongation growth of root by regulating cell elongation.

Regulation of root growth by gibberellin in Lemna minor

Hormonal control of root growth was studied in Lemna minor. Although addition of gibberellic acid (GA3) to the culture medium did not promote the root growth, a gibberellin biosynthesis inhibitor, uniconazole P (Un-P), significantly inhibited root growth. Both length and diameter of roots in Un-P-treated plants were significantly smaller than those in control plants, mainly caused by inhibition of cell division. In epidermal cells, the length was slightly decreased and the width increased by Un-P treatment, indicating inhibition of elongation growth. GA3 completely nullified the inhibition caused by Un-P. Transverse cortical microtubules (CMTs) of epidermal cells in the elongation zone were significantly fragmented by treatment with Un-P, but not by that in the presence of GA3. The cellulose microfibril array in the Un-P-treated cells was more random and more oblique than that in the control cells. These results suggested that root growth in L. minor is regulated by endogenous gibberellin.

[Utility of Ringer's acetate solution as an intraoperative fluid during cardiovascular surgery with cardiopulmonary bypass]

This study aimed to clarify the difference in the effects of Ringer's acetate (AR) and Ringer's lactate (LR) administration during cardiovascular surgery with cardiopulmonary bypass. We evaluated their effects on intra and postoperative metabolism, liver functions, blood gas and hemodynamic states. Twenty patients were divided into two groups; AR group (n = 10) and LR group (n = 10). Intraoperative serum D-lactate levels in LR group were significantly higher than those in AR group from the beginning of the operation to awakening. Serum acetate levels showed no increase in both groups. The arterial ketone body ratio (AKBR) in AR group was higher than that in LR group, but the difference was not significant. Serum glutamic pyruvic transaminase (GPT) and alkaline phosphatase (ALP) levels in LR group were significantly higher than those in AR group from the induction of the anesthesia. It has been reported that acetate has a greater vasodialatory effect than lactate. However, our findings indicate no significant difference in hemodynamics between the two groups. These results suggest that AR may be more useful than LR during cardiovascular surgery with cardiopulmonary bypass.

[Hypersensitivity peumonitis in a patient with rheumatoid arthritis]

We report a case with rheumatoid arthritis and hypersensitivity pneumonitis. A 66-year-old female was admitted to our hospital because of fever, cough, and progressive dyspnea on October 10, 1997. She had a history of rheumatoid arthritis from 1987 and was treated with cyclophosphamide when she developed pulmonary symptoms in September 1997. On admission arthritis was subsided. Fine crackles on ausculation of lung, hypoxia, ground-glass appearance on chest X-ray were detected. The computed tomography of the chest disclosed diffuse interstitial shadow with patchy destruction of alveolar structures. Bronchoalveolar lavage demonstrated an increase in lymphocytes with predominance of suppressor-cytotoxic T cell subset (CD 8+). The histopathological examination of transbronchial lung biopsy showed interstitial inflammation with marked predominance of lymphocyte with intraalveolar exudate. Her condition got better and she discharged without definitive diagnosis and treatment for her respiratory symptoms. Eight hours after she went back home, she suddenly presented high fever and cough and gradually developed dyspnea. She was readmitted 5 days after the previous discharge. Although no specific precipitin antibody against various microorganisms was detected in her sera, the diagnosis of hypersensitivity pneumonitis was made. Thirty mg per day of prednisolone was resolved her symptoms promptly. There was no reported case with hypersensitivity pneumonitis and rheumatoid arthritis of other collagen diseases. The clinical course that arthritis and pulmonary symptoms appeared alternatively is of considerable interest to investigate for the pathogenesis of these two immune disorders.

An evaluation of malignancy and prognostic factors based on mode of lymph node metastasis in esophageal carcinoma

This study was conducted to evaluate lymph node metastasis as a key prognostic factor in esophageal cancer. Metastatic lesions in lymph nodes were grouped by histological morphology as intracapsular or extracapsular, and the significance of lymph node metastasis was evaluated by relating metastatic lesions to clinical pathologic factors and patient prognosis. In our hospital, 46 of 81 patients who underwent resection of esophageal cancer developed lymph node metastasis. These 46 patients were enrolled in a study analyzing the relationship between the metastatic mode and the clinicopathological factors. The frequency of extracapsular metastasis was significantly high in patients with a profound depth of cancer, three or more metastases, distant metastasis (n3 and n4), or severe lymphatic invasion. The prognosis was significantly worse in patients with extracapsular metastasis, and this tendency was also seen even in patients with three or more metastases, limited metastasis (n1 and n2), or mild lymphatic invasion (ly0 and ly1). These findings suggest that the metastatic mode reflects the degree of esophageal cancer progression and is an important prognostic factor.

Influence of genotypes at SAA1 and SAA2 loci on the development and the length of latent period of secondary AA-amyloidosis in patients with rheumatoid arthritis

To examine whether polymorphism at the SAA loci is associated with the development of amyloid protein A (AA)-amyloidosis, we determined the genotypes at the SAA1 and SAA2 loci in 43 AA-amyloidosis patients (amyloidosis population) and 77 patients with rheumatoid arthritis (RA) who had been ill for less than 5 years (early RA population). We also compared the frequencies of the genotypes at the SAA1 locus among 90 Korean, 95 Taiwanese, and 103 Japanese healthy subjects. The frequencies of the gamma/gamma genotype and gamma alleles at the SAA1 locus were significantly higher in the amyloidosis population than in the early RA population (34.9% versus 7.8%, and 58.1% versus 33.8%, chi2 test P=0.0001). The frequencies of the gamma allele at the SAA1 locus in Koreans, Taiwanese, and Japanese were 41.6%, 35.6%, and 37.4%, respectively. The length of the latent period of AA-amyloidosis was significantly longer in the patients with smaller numbers of the gamma allele at the SAA1 locus (Spearman's correlation coefficient: -0.42, P<0.05). On the other hand, the mean C-reactive protein (CRP) level during 2 years prior to the diagnosis of AA-amyloidosis was significantly higher in the patients with larger numbers of the gamma allele at the SAA1 locus (Spearman's correlation coefficient: 0.34, P<0.05). No significant association was found between amyloidosis and polymorphism at the SAA2 locus. We postulate that the allele SAA1gamma renders an RA patient susceptible to amyloidosis, possibly by affecting the severity of inflammation in RA.

Evaluation of malignancy and the prognosis of esophageal cancer based on an immunohistochemical study (p53, E-cadherin, epidermal growth factor receptor)

The subjects in this study consisted of 40 preoperative untreated esophageal squamous cell carcinoma patients. While p53 did not significantly correlate with the clinicopathological factors, E-cadherin significantly correlated with lymphatic invasion, vascular invasion, the depth of invasion, the degree of lymph node metastasis, the histological stage, and the number of lymph node metastases. Epidermal growth factor receptor (EGFR) significantly correlated with age, the depth of invasion, and the number of lymph node metastases. The 5-year cumulative survival rate was 45.7% in the p53-positive cases and 61.9% in the p53-negative cases, with no significant difference, and 87.8% in the E-cadherin-positive cases and 19.1% in the -negative cases, and the difference was significant. The prognosis was significantly poor in EGFR-positive subjects: the 5-year survival rate was 38.6% in EGFR-positive cases and 68% in -negative cases. The 5-year survival rate in E-cadherin-negative, EGFR-positive cases was 0%, while it was 91.7% in the reverse pattern, and this difference was significant. These findings suggest that both E-cadherin and EGFR are important prognostic factors, and a more precise prognosis can thus be obtained by combining them. Such a combined technique may be very useful as an indicator for grading the biological malignancy of esophageal cancer.

Rheumatoid arthritis associated with methotrexate-induced pneumonitis: improvement with i.v. cyclophosphamide therapy

Pneumonitis is one of the most serious adverse effects associated with low-dose weekly methotrexate (MTX) therapy. Immediate cessation of MTX, and the introduction of oxygen therapy and glucocorticoids usually results in a dramatic improvement in the pulmonary toxicity. We report here a case of MTX-induced pneumonitis in a patient with rheumatoid arthritis (RA). Severe hypoxemia and interstitial infiltration in both lung fields did not respond to the withdrawal of MTX and the administration of oxygen and steroid pulse therapy. When intravenous cyclophosphamide (CYC) pulse therapy was initiated, however, rapid physiologic and radiographic improvement was seen. Our case suggests that CYC treatment may have a beneficial effect on MTX-induced pneumonitis that is resistant to steroid therapy.

[Pneumoperitoneum with systemic sclerosis]

We report a case of systemic sclerosis (SSc) complicated with benign pneumoperitoneum without apparent pneumatosis cystoides intestinalis (PCI). A 43-year-old woman was admitted to our hospital because of prominent abdominal distension in April 1997. Raynaud's phenomenon has been detected since 1991. She was suffering from recurrent diarrhea, constipation, and subileus. The diagnosis of SSc was made in 1996 based on the sclerosis in her face, forearms, and chest, and hypomotility of the esophagus. On admission, she presented no signs of peritoneal irritation. The laboratory data revealed that white blood cell count was 7,400/mm3 and C-reactive protein was 0.1 mg/dl. Chest and abdominal roentgenograms showed massive free air under the diaphragm, dilatation of small and large intestine, and air-fluid level. PCI was not apparent. Pneumoperitoneum was improved after four weeks with intravenous hyperalimentation. But she presented recurrent severe diarrhea and high fever whenever she tried to take food orally. Klebsiella pneumoniae was proved in her jejunal juice by bacteriologic examination. Intravenous prostaglandin F2 alpha and oral fosfomycin calcium intake made her condition better. Benign pneumoperitoneum without PCI is rarely reported in the patients with SSc. In her condition, weakness of intestinal wall, hypomotility of intestine, unusual bacterial overgrowth, and elevated intraluminal pressure made intraluminal gas go through the wall of the fragile intestine of SSc. As operation of intestine of SSc usually cause miserable outcome, pneumoperitoneum accompanied with SSc even if PCI is apparent or not must be treated with conventional manner while there is no signs of peritoneal irritation.