Dysphagia Rehabilitation in Dysphagic Patients with Acute or Critical Illness: A Systematic Review and Meta-Analysis

Dysphagia or swallowing dysfunction is common in patients with acute or critical illness, and diverse methods of dysphagia rehabilitation are provided worldwide. We aimed to examine the efficacy of rehabilitation to treat dysphagia in patients with acute or critical illness. We searched PubMed, ICHUSHI, and Cochrane Central Register of Controlled Trials databases from inception to November 22, 2023 for relevant randomized controlled trials. We focused on dysphagic patients with acute or critical illness who were not orotracheally intubated. Our target intervention included conventional rehabilitation and nerve stimulation/neuromodulation techniques as dysphagia rehabilitation. Comparators were conventional or standard care or no dysphagia interventions. Primary outcomes included mortality, incidence of pneumonia during the study period, and health-related quality of life (HRQoL) scores within 90 days of hospital discharge. We pooled the data using a random-effects model, and classified the certainty of evidence based on the Grading of Recommendations, Assessment, Development, and Evaluation system. Nineteen randomized controlled trials involving 1,096 participants were included. Dysphagia rehabilitation was associated with a reduced incidence of pneumonia (risk ratio [RR], 0.66; 95% confidence interval [CI], 0.54-0.81; moderate certainty), but not with reduced mortality (RR, 0.92; 95% CI, 0.61-1.39; very low certainty) or improved HRQoL scores (mean difference, -0.20; 95% CI, -20.34 to 19.94; very low certainty). Based on the available moderate- or very low- quality evidence, while dysphagia rehabilitation had no impact on mortality or HRQoL, they might reduce the incidence of pneumonia in dysphagic patients with acute or critical illness.

Impact of the health policy for interdisciplinary collaborative rehabilitation practices in intensive care units: A difference-in-differences analysis in Japan

BACKGROUND

Early rehabilitation in intensive care units (ICUs) may be beneficial but is not routinely performed for adults with critical illness. In April 2018, the Japanese government introduced a health policy to provide financial incentives to hospitals that met the requirements of interdisciplinary collaboration and had teams specialized in ICU rehabilitation practices.

OBJECTIVES

The present study aimed to investigate whether the health policy is associated with improved clinical practices of ICU rehabilitation.

METHODS

Using a nationwide administrative inpatient database and hospital statistics data from Japan, we identified hospitals that admitted adult patients to the ICU within two days of hospital admission from April 2016 to March 2019. Using hospital-level propensity score matching, we created matched cohorts of 101,203 patients from 108 intervention hospitals that introduced the health policy, and 106,703 patients from 108 control hospitals that did not. We then conducted patient-level difference-in-differences analyses to examine changes in the percentage of patients from the intervention and control hospitals, who underwent early ICU rehabilitation within two days of ICU admission before and after the implementation of the health policy.

RESULTS

In the intervention group, patients undergoing early ICU rehabilitation increased from 10% and 36% after the policy implementation. In the control group, it increased from 11% to 13%. The difference-in-difference in the percentage of patients who underwent early ICU rehabilitation between the two groups was 24% (95% confidence interval, 19%-29%).

CONCLUSIONS

Early ICU rehabilitation can be facilitated by financial incentives for hospitals that engage in interdisciplinary collaboration with specialist teams.

IMPLICATIONS FOR CLINICAL PRACTICE

Our Findings are relevant for hospital administrators, professional organizations, and policymakers in other nations considering strategies to support the additional deployment burdens of early ICU rehabilitation. Future studies need to explore the long-term effects and sustainability of the observed improvements in ICU rehabilitation practices.

Japanese Clinical Practice Guidelines for Rehabilitation in Critically Ill Patients 2023 (J-ReCIP 2023)

Providing standardized, high-quality rehabilitation for critically ill patients is a crucial issue. In 2017, the Japanese Society of Intensive Care Medicine (JSICM) promulgated the "Evidence-Based Expert Consensus for Early Rehabilitation in the Intensive Care Unit" to advocate for the early initiation of rehabilitations in Japanese intensive care settings. Building upon this seminal work, JSICM has recently conducted a rigorous systematic review utilizing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This endeavor resulted in the formulation of Clinical Practice Guidelines (CPGs), designed to elucidate best practices in early ICU rehabilitation. The primary objective of this guideline is to augment clinical understanding and thereby facilitate evidence-based decision-making, ultimately contributing to the enhancement of patient outcomes in critical care settings. No previous CPGs in the world has focused specifically on rehabilitation of critically ill patients, using the GRADE approach. Multidisciplinary collaboration is extremely important in rehabilitation. Thus, the CPGs were developed by 73 members of a Guideline Development Group consisting of a working group, a systematic review group, and an academic guideline promotion group, with the Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the JSICM at its core. Many members contributed to the development of the guideline, including physicians and healthcare professionals with multiple and diverse specialties, as well as a person who had been patients in ICU. Based on discussions among the group members, eight important clinical areas of focus for this CPG were identified. Fourteen important clinical questions (CQs) were then developed for each area. The public was invited to comment twice, and the answers to the CQs were presented in the form of 10 GRADE recommendations and commentary on the four background questions. In addition, information for each CQ has been created as a visual clinical flow to ensure that the positioning of each CQ can be easily understood. We hope that the CPGs will be a useful tool in the rehabilitation of critically ill patients for multiple professions.

Toward developing care outcome quality indicators for home care for older people: A prospective cohort study in Japan

INTRODUCTION

Care quality in Japan's long-term care (LTC) agencies, including home care, is the responsibility primarily of individual agencies, and the evaluation of service processes and outcomes is minimal.

OBJECTIVES

To describe the development of quality indicators for LTC (QIs-LTC) in Japan.

METHODS

QIs-LTC were developed through literature review and expert panel discussions and then were piloted and used in a 2-year longitudinal survey. The survey (launched in September 2019) targeted older people receiving home care (n = 1450), their family members (n = 880), their professional home care providers (n = 577), and managers of home care agencies (n = 122).

RESULTS

Across eight domains (maintaining dignity, minimizing symptoms and disease deterioration, maintaining nutritional status, maintaining bladder/bowel control, encouraging physical activities, experiencing sound sleep, maintaining serenity and contentedness, and maintaining family's well-being), 24 care quality objectives were set with 24 outcome QIs-LTC and 144 process QIs-LTC. In the survey, 84.8% of clients were using home care nursing, 26.3% were living alone, and 39.5% had dementia. In the month preceding the data collection, 13.9% of clients had a new disease or worsening of an existing disease, 8.8% were hospitalized at least once, and 47.9% did not participate in activities of interest. About 20% of clients' families were unable to spend time peacefully, and 52.8% were exhausted from the client's care.

CONCLUSIONS

The QIs-LTC developed in the current study are generic and client- and family-centered. They encompass objective and subjective information and would facilitate standardized monitoring if adopted and comparison between LTC settings, including home care. In addition, future research directives are outlined. Geriatr Gerontol Int 2023; 23: 383-394.

Family-oriented interventions in long-term care residential facilities for older people: A scoping review of the characteristics and outcomes

INTRODUCTION

Family-oriented interventions in long-term care (LTC) residential facilities are heterogenous in design, characteristics, and outcomes.

OBJECTIVES

To synthesize characteristics (e.g., type, provider, and duration) and outcomes of family-oriented interventions in LTC residential facilities.

METHODS

We followed the JBI methodology and searched seven databases for quantitative, qualitative, and mixed method studies that reported family-oriented interventions in LTC residential settings for older people; defined in this review as ≥60 years. Interventions that included residents, resident families, health professionals, or any combinations of these three were included if the study reported post-intervention assessment of at least one family-related outcome.

RESULTS

Thirteen studies met the inclusion criteria. Interventions were found to be multifaceted, and education was the most common element. Nurses were the most common intervenors, and most interventions had more than one target (residents, resident families, or staff). Most outcomes were related to family involvement, satisfaction with care, quality of life, communication, symptom management, and shared decision making, and none of the studies reported a negative impact.

CONCLUSIONS

Family-oriented interventions were associated with high care quality and better resident-staff-family partnership. Staff education and staff-family conversation are relatively cheap interventions to help family involvement, facilitate shared decision-making, and improve family satisfaction.

Association Between Advance Care Planning for Older Adults and Family Caregivers’ Sense of Security

Family caregivers’ (FCs’) sense of security benefits older adults who receive homecare. Advance care planning (ACP) is reported to have positive effects on FC’s experience, but it might differ depending on FCs’ kin relationships with the older adults. We examined whether ACP for older adults in homecare settings is associated with FCs’ sense of security. Further, we assessed whether such an association depends on their status as spouses or as adult children. We conducted a secondary analysis of data from a prospective cohort study in Japan. The participants were older adults who used home-visit nursing services, their FCs, and the nurses who cared for them. The FCs were asked to answer a sense of security questionnaire, and nurses were asked whether ACP was conducted. Multivariate logistic regression analyses were performed to examine the association between ACP implementation and positive changes in the sense of security scores after three months. Data from 169 cases were analyzed. Of the FCs, 28.1% were men and 55.6% were spouses. ACP was performed in 53.8% of the cases. The results of the multivariate analyses showed an interactive effect between ACP implementation and FC kin relationships. For spouses, ACP was significantly associated with a positive change in their sense of security. For adult children, such an association was not found. ACP might have a positive effect on caregiving spouses’ sense of security. Adult child caregivers, who often have multiple responsibilities and have difficulties facing their parents’ physical decline, may need support, in addition to ACP.

Family-oriented interventions in long-term care residential settings: a scoping review protocol

OBJECTIVES

The objective of this review will be to identify the characteristics (eg, type, duration, and provider) of family-oriented interventions in long-term care residential settings. The authors will also identify which outcomes are reported in the literature when implementing family-oriented interventions.

INTRODUCTION

An array of family-oriented interventions in long-term care residential settings exist. Given the heterogeneity of current literature, mapping characteristics and intended outcomes of family-oriented interventions is an essential step to inform how best to support families of patients in long-term care residential settings.

INCLUSION CRITERIA

This review will consider studies describing family-oriented interventions for families of elderly patients in long-term care residential settings, with no exclusion based on country, gender, or comorbidities. Interventions that address any family-related issue, such as quality of life, psychological burden, and family involvement in patient care, are eligible for inclusion. Studies will be excluded if the patients are cared for at their own homes or institutionalized care is provided on a temporary basis. Quantitative, qualitative, and mixed method study designs will be considered for inclusion.

METHODS

A scoping review will be conducted using the JBI methodological approach. Seven databases will be systematically searched: MEDLINE, CINAHL, Scopus, Evidence-Based Medicine Reviews including Cochrane Library, PsycINFO, OpenGrey, and the Grey Literature Report. Citations will be screened against the inclusion criteria by two reviewers independently. Relevant data will be extracted from the included studies, and will be synthesized, summarized, and reported following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Findings will be published in a peer-reviewed journal.

Physical Restraint of Older Adults at Home: Preliminary Analysis of a Prospective Cohort Study

Our study aimed to explore the prevalence and factors of physical restraints among frail to dependent older adults living at home. We conducted an online survey to ask about the physical/mental conditions, demographics, service utilization, and physical restraints of community-dwelling older adults. Either home care nurse or care managers who were responsible for the older adult answered the survey that were conducted at baseline and one month later. We obtained data from 1,278 individuals. Physical restraint was reported for 53 (4.1%) participants. Multiple logistic regression revealed the factors associated with physical restraints at home: having been restrained at baseline, having pneumonia or heart failure, receiving home bathing, or using rental assistive devices were associated with physical restraints at one month. The findings could be used to promote discussion about which services prevent physical restraints and what we should do to support clients and their family to stay at home safely.

Evaluation of the site specificity of acute disuse muscle atrophy developed during a relatively short period in critically ill patients according to the activities of daily living level: A prospective observational study

INTRODUCTION

In critically ill patients, excessive bed rest and immobilisation have been shown to cause disuse muscle atrophy, which contributes to prolonged hospitalisation and decreased activity of daily living (ADL) levels. However, the degree and site specificity of acute disuse muscle atrophy in critically ill patients during a relatively short intensive care unit (ICU) stay have not been fully elucidated.

METHODS

Critically ill patients, who required bed rest on ICU admission, were eligible for this study. The degree of skeletal muscle atrophy was evaluated on the day of, and 72 and 144h after ICU admission by measuring the limb circumference in ADL-dependent or -independent patients separately at five different sites: the midpoint of the upper limb between the acromion and the olecranon, the maximum diameter of the triceps surae in the lower leg, and three different sites in the thigh at 5, 10, and 15cm above the superior pole of the patella. Value of the limb circumference was presented as a percentage relative to the baseline (median).

RESULTS

In ADL-dependent patients, limb circumferences at all five sites were decreased significantly at 144h compared with the baseline (98.9-100% in the upper limbs, 97.1-97.2% in the lower legs, and 96.5-99.1% in the thighs), but not at 72h. In contrast, the limb circumferences at almost all sites decreased significantly at both 72 and 144h (100% in the upper limbs, 94.5-94.7% in the lower legs, and 89.7-94.7% in the thighs), compared with the baseline in ADL-independent patients. Muscle atrophy was greater at the four different lower-limb sites compared to the upper limb during 144h in the ICU in the ADL-independent, but not in the ADL-dependent patients.

CONCLUSIONS

Compared to ADL-dependent patients, ADL-independent patients are prone to develop muscle weakness, especially in the lower limbs.

Chemical Structure of Native Oxide Grown on Hydrogenterminated Silicon Surfaces

Chemical bonding features and suboxide compositions in native oxide grown on chemically-cleaned hydrogen-terminated Si(100) surfaces stored in pure water have been studied by using surface sensitive infrared spectroscopy and x-ray photoelectron spectroscopy. The LO phonon peak for the native oxide is located at 1210cm−1, which is shifted to a significantly lower wavenumber side than the ultrathin thermal oxide peak at 1250cm−1. This is because an appreciable amount of SiHx bonds are incorporated in the native oxide/Si interface and such hydrogen termination in the network dramatically reduces strained bonds in the interface. Very weak Si2+ suboxide signal from the oxide grown in pure water is also explained by the incorporated SiHx bonds which interrupt the Si2+ suboxide formation in the interface.

Cleaning and Oxidation of Heavily Doped Si Surfaces

HF-treated Si surfaces and the oxidation kinetics in pure water or in clean room air have systematically been studied by x-ray photoelectron spectroscopy (XPS). The oxidation of heavily-doped n-type Si appears to proceed parallel to the surface, resulting in the layer-by-layer oxidation. The oxide growth rate in pure water for heavily-doped n-type Si is significantly higher than that of heavily-doped ptype Si. This is explained by the electron tunneling from the Si conduction band to adsorbed O2 molecules to form the O2 state. O2 ions easily decompose and induce a surface electric field, enhancing the oxidation rate. The growth rate of native oxide on heavily-doped n-type Si is less sensitive to the crystallographic orientations than the case of lightly doped Si where the steric hindrance against oxygen molecules significantly lowers the oxidation rate of the (110) and (111) surfaces. We suggest that the decomposed oxygen can penetrate into Si without steric hindrance. It is also found that the oxidation of heavily-doped n-type Si in pure water is effectively suppressed by adding a small amount (10 ∼ 3600 ppm) of HCI.

Layer-by-Layer Oxidation of Silicon

Growth kinetics of native oxide on HF-treated Si surfaces terminated with Si-H bonds has been studied by angle-resolved x-ray photoelectron spectroscopy. The oxide growth rate in pure water for an n+ Si(100) surface is significantly high compared to that of p+, and the n or p type Si oxidation rate is in between. This is explained by the formation of ions through electron transfer from Si to adsorbed O2 molecules and the resulting enhancement of the oxidation rate. The oxide growth on Si(100) is faster than (110) and (111) as interpreted in terms of the steric hindrance for molecular oxygen adsorption on the hydrogen terminated silicon 1×1 surface structures.

Structural Characterization of Porous Silicon Fabricated by Electrochemical and Chemical Dissolution of Si Wafers

The structure of porous silicon exhibiting efficient visible photoluminescence has been characterized by using Fourier transformed infrared absorption, Raman scattering and x-ray diffraction. It is shown that the lattice spacing in the porous Si layer expands by about 0.3% in the direction perpendicular to the surface and also a partially disordered structure is existing. Electron beam irradiation causes desorption of hydrogen and fluorine bonds which terminate the surface, resulting in the quenching of the visible luminescence. The chemical etching of such layer has led to complete recovery of the luminescence intensity as well as the hydrogen and fluorine bonds termination.

Action of neuropeptide Y on nociceptive transmission in substantia gelatinosa of the adult rat spinal dorsal horn

Effects of neuropeptide Y (NPY) on substantia gelatinosa neurons were investigated in adult rat spinal cord slices using blind whole-cell patch-clamp technique. Bath application of NPY (1 microM) induced a membrane hyperpolarization, resulting in a suppression of the dorsal root stimulation-induced action potentials in 24% of the substantia gelatinosa neurons tested. In voltage clamp mode, NPY produced an outward current dose-dependently in about one third of substantia gelatinosa neurons at the holding potential of -60 mV, which was not affected by tetrodotoxin (1 microM). The NPY-induced current was suppressed by perfusion with a Ba2+-containing external solution and a Cs2SO4 or tetraethylammonium-containing pipette solution. In addition, The NPY-induced outward currents reversed its polarity near the equilibrium potential of K+ ions (-93 mV). The response to NPY recorded with guanosine-5'-O-(2-thiodiphosphate)-beta-S (GDP-beta-S) containing pipette solution was abolished 30 min after patch formation, suggesting that the response was mediated by the G-protein-coupled receptors. Application of an NPY-Y1 selective agonist, [Leu(31), Pro(-34)]-NPY (1 microM), for 30 s also induced an outward current with a similar time course and amplitude to that induced by NPY. On the other hand, the NPY response was blocked by a simultaneous application of NPY-Y1 selective antagonist, BIBP 3226 (1 microM). No significant changes were found in amplitude and frequency of miniature excitatory postsynaptic currents and dorsal root evoked excitatory postsynaptic currents by NPY. In addition, NPY did not affect both of the miniature inhibitory postsynaptic currents and evoked inhibitory postsynaptic currents, mediated by either the GABA or glycine receptor. These findings, taken together, suggest that NPY produces an outward current in substantia gelatinosa neurons through G-protein coupled, and NPY-Y1 receptor-mediated activation of K+ channels without affecting presynaptic components. The inhibition of the synaptic transmission from the primary fibers to the substantia gelatinosa neurons is considered to contribute to the antinociceptive effects of NPY.

Prolonged effects of polyriboinosinic:polyribocytidylic acid on spontaneous running wheel activity and brain interferon-alpha mRNA in rats: a model for immunologically induced fatigue

Following 2 weeks acclimation to the running wheel in the home cages, an i.p. injection of a synthetic double-stranded RNA, polyriboinosinic:polyribocytidylic acid (poly I:C, 3 mg/kg), was performed to produce the immunologically induced fatigue in rats. The daily amounts of spontaneous running wheel activity decreased to about 40-60% of the preinjection level until day 9 with normal circadian rhythm, then gradually returned to the baseline level by day 14. Rats given a heat exposure (36 degrees C for 1 h) for the consecutive 3 days showed an increase in activity except for the first day. In the open field test, the total moving distance and the number of rearing of the poly I:C-injected rats decreased on day 1, but they were not different from the saline-injected group on day 7, suggesting that the poly I:C-induced fatigue on day 7 was not due to the peripheral problems such as muscle/joint pain, but involved the CNS. Quantitative analysis of mRNA levels using a real-time capillary reverse transcriptase-polymerase chain reaction (RT-PCR) method revealed that interferon-alpha (IFN-alpha) mRNA contents in the cortex, hippocampus, hypothalamic medial preoptic, paraventricular, and ventromedial nuclei were higher in the poly I:C group than those in the saline and heat-exposed groups on day 7, although the amount of interleukin-1 beta mRNA showed no differences. Serum adrenocorticotropic hormone and catecholamine levels were not significantly different between groups. The present results indicate that the prolonged fatigue induced by poly I:C, which is evaluated by the spontaneous running wheel activity, can be used as an animal model for the immunologically induced fatigue associated with viral infection, and suggest that brain IFN-alpha may play a role in this model.

Natural progression of untreated hepatolithiasis that shows no clinical signs at its initial presentation

GOALS

To elucidate the natural progression of hepatolithiasis that showed no signs at the time of initial presentation.

STUDY

Over a 17-year period, we observed 122 of 311 patients with hepatolithiasis who reported no symptoms and, thus, who received no treatment at initial presentation. The follow-up period was for up to 15 years (mean, 10.08 years).

RESULTS

Fourteen of 112 patients (11.5%) developed some symptoms attributed to hepatolithiasis. The interval until the onset of symptoms ranged from 9 months to 7.33 years (mean, 3.42 years ). The developing symptoms included abdominal pain, hepatic abscess, cholangitis, and cholangiocarcinoma. Nine of the 14 patients (64.3%) developed stone migration to the extrahepatic bile duct at the onset of clinical symptoms. The incidence of lobar liver atrophy on computed tomography in the patients with symptomatic hepatolithiasis (13 of 14 patients; 92.9%) was significantly higher than that in the patients with asymptomatic hepatolithiasis (14 of 108 patients; 13.0%). The prognosis of the patients with symptomatic hepatolithiasis were as follows: 2 died of cholangiocarcinoma, 1 died of hepatic failure, and 11 survived. Fifteen of asymptomatic patients died, but none of these deaths were attributed to hepatolithiasis.

CONCLUSIONS

Close observation is an alternative management at initial presentation for patients with asymptomatic hepatolithiasis without extrahepatic stones or lobar liver atrophy.

Long-term results of hepaticojejunostomy for hepatolithiasis

The results of a hepaticojejunostomy as a biliary-enteric bypass for benign disease are usually excellent. On the other hand, hepatolithiasis features a high rate of residual and recurrent stones with cholangitis after surgery. This study aims to evaluate the long-term results of a hepaticojejunostomy for hepatolithiasis regarding both the degree of the occurrence of postoperative cholangitis and the outcome. The clinical records of 159 patients with hepatolithiasis who underwent surgical treatment over a 23-year period were also retrospectively reviewed. Ninety-four of 159 patients underwent a hepatecetomy and 65 patients were subjected to liver-preserving surgery by means of intra- and postoperative endoscopic lithotripsy. In addition 72 patients underwent a hepaticojejunostomy. The rate of residual or recurrent stones was 31.4 per cent after complete stone removal. Twenty-two (30.6%) of the 72 patients developed some kind of cholangitis. This rate was significantly higher than that (three of 87 patients) of the non-biliary-enteric anastomosis group regarding the occurrence of biliary complications. We conclude that the use of a hepaticojejunostomy for patients with possible residual stones or intrahepatic bile duct lesions remains controversial.

Apoptosis involved in density-dependent regulation of rat fibroblastic 3Y1 cell culture

When rat 3Y1 fibroblastic cells are cultured toward confluency, the cells go through maximum cell density (overshoot) before reaching post-confluence stationary cell density. After overshooting, a number of floating cells are found in the medium. In a long-term culture, a cyclic change in cell number, an increase after each medium refreshment and subsequent cell loss within a few days has been observed so that the cell populations in the monolayer maintain post-confluence stationary cell density at a constant level. The floating cells excluded trypan blue, but they had no ability to attach to the substrate and to form colonies after being reseeded in fresh medium. They had condensed and uniformly electron-dense chromatin with sharply circumscribed edges. Their DNA contained a laddering pattern in harmony with internucleosomal cleavage. The features were those of apoptosis. When floating cells appeared, apoptotic bodies were also observed in the monolayer. Most of them were found within the cytoplasm of intact cells, suggesting that apoptotic bodies were also faded away from the culture by being rapidly engulfed by neighboring intact cells. These suggest that apoptosis and subsequent detachment from the monolayer or engulfment by neighboring intact cells, in addition to inhibition of cell division, are basic mechanisms on the process of density-dependent regulation in monolayer culture of rat 3Y1 cells.

[Selection of treatment in primary hepatolithiasis (PHL)]

Two hundred and three patients with PHL were encountered for the last 10 years. In order to select treatment of PHL, we classified PHL on the basis of atrophy of hepatic parenchyma (AHP), existence of extrahepatic gallstone and dilatation of extrahepatic bile duct (DEBD). For the case with AHP hepatic resection must be performed, because there is often chronic proliferating cholangitis and improvement in hepatic function can not be expected in view of AHP. For the case with extrahepatic gallstone without AHP hepatic resection. For the case with DEBD and without AHP extrahepatic gallstone must be removed. For the patient with extrahepatic gallstone and DEBD without AHP, indication of the removal of stones, depends on the existence of symptoms. Twenty-two cases treated by biliary drainage procedure often had some complications in postoperative course, that is 5 patients had cholangitis and 7 patients liver abscess. It was suggested, therefore, that biliary drainage procedure was contraindicated in PHL.

Isolation and identification of urinary nucleosides. Applications of high-performance liquid chromatographic methods to the synthesis of 5'-deoxyxanthosine and the simultaneous determination of 5,6-dihydrouridine and pseudouridine

Modified nucleosides from pooled normal human urine were extracted using a boronate affinity gel column and fractionated by reversed-phase high-performance liquid chromatography (RP-HPLC). The major constituents in each of the 30 RP-HPLC fractions were determined by gas chromatography-mass spectrometry of the trimethylsilyl derivatives of the fractions. The same RP-HPLC method was used in the synthesis of 5'-deoxyxanthosine from authentic 5'-deoxyadenosine. In addition, the simultaneous determination of urinary 5,6-dihydrouridine (D) and pseudouridine (psi) was carried out by RP-HPLC using two ODS columns in series. The level of D in pooled normal urine was 4.87 nmol/mumols creatinine. The RP-HPLC method was applied to the measurement of D and psi levels in urines collected before and after surgery from four patients with gastrointestinal cancer. A large decline in both nucleoside levels in urines after surgery was observed in three of the four cancer patients.

The identification of 5,6-dihydrouridine in normal human urine by combined gas chromatography/mass spectrometry

The identification of 5,6-dihydrouridine in normal human urine is reported. Partial purification and isolation of the compound by boronate gel affinity chromatography and reversed-phase high-performance liquid chromatography preceded its characterization as a trimethylsilyl derivative by combined gas chromatography/mass spectrometry. Structure proof is based upon a comparison of mass spectral and chromatographic features of the urinary component to that of an authentic reference sample. Additional data derived from high resolution mass measurements and deuterium isotope-labeling experiments provide confirmation of fragment ion structure. The poor detectability inherent in the HPLC/uv analysis of nucleosides is also discussed.

Functional heterogeneity of human monocytes--with a special reference to flow cytometric assays

A large number of human mononuclear cells were simultaneously separated into fractions enriched in B cells, T cells, large granular lymphocytes (LGL) and monocytes by centrifugal elutriation. Lymphocyte populations were analyzed using monoclonal antibodies. In particular, highly enriched natural killer cells, Leu7+ cells, were collected in the intermediate fractions. Monocytes, which were identified as esterase positive cells, and Leu M3 cells were collected at higher counterflow rates and in the final fraction. The purity of monocytes in the final fraction was 81%. The oxidative metabolic activity (H2O2 production) and non-specific esterase activity of individual monocytes was estimated in the analysis of functional heterogeneity of monocytes using flow cytometry. 2',7'-dichlorofluorescein diacetate (DCFH-DA) and fluorescein diacetate (FDA) were used as indicators in the measurement of H2O2 generation and esterase activity. Intracellular generation of a fluorescence product (H2O2 Production; average percentage of fluorescence positive cells) of monocytes in the stimulation of phorbol myristate acetate (PMA, 100 ng/ml) was greater in larger than smaller cells. H2O2 production gradually increased from 6% and 25-38% and 60% in the intermediate and final fractions respectively. Furthermore, the average fluorescence intensity of the large monocyte population in the final fraction was 1.13-1.31 fold more active than that of the smaller cells. Thus, the functional heterogeneity of human monocytes was further confirmed in the assays of H2O2 production exposed to PMA and FDA hydrolysis using flow cytometry. Furthermore, the CCE system can isolate lymphocyte subsets and LGL.

Mechanism of furosemide resistance in analbuminemic rats and hypoalbuminemic patients

To elucidate the mechanism of resistance of hypoalbuminemic patients to furosemide, the effect of this diuretic on urine volume of normal and analbuminemic rats (NAR) and of hypoalbuminemic patients was studied. Intravenous administration of furosemide rapidly enhanced sodium diuresis in normal rats but not in NAR. Total plasma clearance and distribution volume of furosemide were much larger in NAR than in normal rats, while no significant difference in these pharmacokinetic parameters was observed for the unbound fraction of the diuretic between the two animal groups. In contrast, urinary secretion of furosemide was significantly lower in NAR than in normal rats. Injected furosemide bound to albumin markedly promoted diuresis in NAR, while the same dose of albumin alone had no effect, indicating that binding to albumin is essential for the delivery of furosemide to the kidney, the site for its action. Injection of the complex rapidly increased the urine volume of hypoalbuminemic patients who showed a marked resistance to this diuretic. Thus, the resistance to furosemide in both NAR and hypoalbuminemic patients may be explained on the same basis.

Further studies of lipid peroxidation in human paraquat poisoning

In patients with subacute toxic reactions from paraquat poisoning (death within 11 to 41 days), the extent of lipid peroxidation, expressed as serum malondialdehyde level, was 2.7-fold higher (12.33 +/- 4.42 nmole/mL) before pulmonary fibrosis than that in normal controls (4.55 +/- 1.23 nmole/mL). The extent of lipid peroxidation in patients with acute toxic reactions (death within one to three days) was not elevated; these patients died of pulmonary edema and hemorrhage (acute respiratory distress), liver failure, renal failure, and adrenal necrosis. Remarkable high levels of paraquat (greater than 5 mg/L) were found in the urine, serum, and tissues of patients with acute toxic reactions; a small amount of paraquat was found in the serum or urine of patients with subacute toxic reactions five to 11 days after ingestion. Patients who survived had no elevation in lipid peroxidation. Administration of vitamin E (100 to 4,000 mg/day from the first hospital day) had no effect on survival.

Reversed-phase liquid chromatographic investigation of nucleosides and bases in mucosa and modified nucleosides in urines from patients with gastrointestinal cancer

Reversed-phase high-performance liquid chromatography (HPLC) has been used to determine the level of nucleic acid metabolites in perchloric acid extracts of gastrointestinal mucosa. By comparing the levels of these compounds in the normal portion with the levels in the neoplastic portion of mucosa resected from patients with malignant cancer, it was found that uracil was significantly elevated in the neoplastic colorectal mucosa (adenocarcinoma) of eight patients with colorectal cancer (P less than 0.01, statistically significant with the paired t test). The mean level of uracil in neoplastic colorectal mucosa was 2.7-fold higher than that in normal mucosa. However, in neoplastic gastric mucosa, only one out of four patients with gastric cancer showed elevated uracil. In neoplastic mucosa, the levels of hypoxanthine and uridine for colorectal cancer, and inosine for gastric cancer, were also significantly higher than those in normal mucosa (P less than 0.05, with the paired t test). The urinary modified nucleosides were prefractionated with a boronate affinity gel column, and their levels determined by the same HPLC method. No significant differences in the concentrations of pseudouridine, 1-methylguanosine, N2-methylguanosine or N2,N2-dimethylguanosine were observed in pre- and post-operative urines from patients with colorectal cancer and normal urines.

Reversed-phase high-performance liquid chromatographic investigation of mucosal nucleosides and bases and urinary modified nucleosides of gastrointestinal cancer patients

Reversed-phase high-performance liquid chromatography (HPLC) was used to determine the levels of nucleosides, bases and their metabolites in perchloric acid extracts of gastrointestinal mucosa. By comparing the levels of these compounds in the normal portion with the neoplastic portion of mucosa resected from malignant cancer patients, it was found that there was significant elevation of the uracil level in the neoplastic mucosa of all eight patients with colorectal cancer (2.7-fold in normal mucosa), but only in the neoplastic mucosa of one out of four patients with gastric cancer. The levels of hypoxanthine and uridine in the colorectal cancer mucosa samples and the inosine in gastric cancer samples were also significantly higher than those in normal mucosa. The urinary modified nucleosides were prefractionated with a boronate affinity gel column, and their levels were determined by the same HPLC method. There was no significant difference in the concentrations of pseudouridine, 1-methylguanosine N2-methylguanosine and N2,N2-dimethylguanosine between urine samples taken before and after surgery from eight patients with malignant colorectal cancer. Contrary to other reports, no significant differences in modified nucleoside levels were observed between urine samples from patients with colorectal cancer and those from normal subjects.

Vibrio vulnificus septicemia

A 33-year-old Japanese male, who had a three year history of biopsy-proved liver cirrhosis, was admitted to the hospital on June, 24, 1983 with a sudden onset of fever (38.6 degrees C), chills, generalized pain, nausea, anorexia, weakness, and eruption over the entire body. The patient went into shock and died about 7 hours after admission. Blood cultures before death were positive for V. vulnificus. Postmortem microscopic examination revealed "necrotizing vasculitis" in the small and large intestines, stomach, and skin, and also showed marked toxic epidermal necrolysis. This case matches the primary septicemia caused by V. vulnificus described by Blake et al. In addition, this case suggests that the septicemia was acquired through the gastrointestinal tract, especially the small intestine, because the V. vulnificus was isolated from blood and numerous Gram-negative bacilli around the submucosal vessels were observed in the area with acute necrotizing vasculitis.

Acute renal failure in primary macroglobulinemia with small-molecule IgM

Primary macroglobulinemia with acute renal failure developed in a 46-year-old man after administration of contrast medium (containing diatrizoate sodium and meglumine [Urografin]) for intravenous pyelography. On admission, the monoclonal protein peak could not be detected in serum by cellulose acetate electrophoresis, but the serial electrophoresis revealed a gradual increase in monoclonal protein peak, which later became two peaks. The serum of the patient contained the monoclonal small-molecule IgM kappa-chain protein with 13 to 14 Svedberg units in sedimentation constants, which is antigenetically the same as native IgM heavy chain. Although acute renal failure is extremely rare in primary macroglobulinemia, the small-molecule IgM seems to be one factor that induces acute renal failure.

Familial adult T-cell leukemia

Two siblings who developed adult T-cell leukemia (ATL) are presented. The patient and 7 of 26 healthy family members examined had the serum antibodies against ATL-associated antigens (ATLA). This family study shows that two main routes of transmission of human T-cell leukemia virus (HTLV) may be involved: one is the route from parents to children and the other is horizontal transmission among spouses, especially from husband to wife; the anti-ATLA-positive family is considered to be a high-risk group for ATL.

Immunopathological characterization of the delayed hypersensitivity skin reaction to carrier protein

Characteristics of the allergic skin reaction to free carrier protein in sensitized guinea pig with hapten-carrier conjugate have been studied. The animals sensitized with a low dose (4 micrograms) of dinitrophenylated bovine gamma globulin with Freund's complete adjuvant demonstrated a dermatitis when challenged intradermally with a small dose (10 micrograms) of bovine gamma globulin on the 10th or 14th day. The dermatitis was grossly and histologically similar to the classical form of delayed-type hypersensitivity skin reaction except lesser induration and less abundant neutrophil infiltration in the former. This reaction was clearly different from cutaneous basophil hypersensitivity because of the long lasting time course and fewer basophil infiltration in the former. No humoral antibody to carrier protein was detected in the sera of the sensitized animals by passive cutaneous anaphylaxis or by immunodiffusion in agar plates, and the state of the hypersensitivity could be passively transferred with peritoneal exudate cells and spleen cells. These observations indicated that the skin reaction to carrier protein might be of primarily delayed-type hypersensitivity. The vascular permeability change at the reaction sites was observed as a single phase delayed response and preceded the maximum erythema by about ten hours.

On the calculation of a "reference change" for comparing two consecutive measurements

We describe a statistical method for calculating a "reference change," defined as that difference between two consecutive test results in an individual that is statistically significant in a given proportion of all similar persons. By allowing for variation in within-person variances, this procedure computes a reference change that is more specific (i.e., less prone to false positives) than that obtained directly from the distribution of observed differences between measurements. Moreover, the method may easily be extended to a test for trend in three successive measurements. The method has been applied to semi-annual measurements of serum calcium and alkaline phosphatase in 698 men and women enrolled in a large health-maintenance program. We believe that these ideas may also be usefully applied to successive laboratory tests in carefully defined patient populations--but this introduces special problems, which are discussed briefly.

On the calculation of a "reference change" for comparing two consecutive measurements

We describe a statistical method for calculating a "reference change," defined as that difference between two consecutive test results in an individual that is statistically significant in a given proportion of all similar persons. By allowing for variation in within-person variances, this procedure computes a reference change that is more specific (i.e., less prone to false positives) than that obtained directly from the distribution of observed differences between measurements. Moreover, the method may easily be extended to a test for trend in three successive measurements. The method has been applied to semi-annual measurements of serum calcium and alkaline phosphatase in 698 men and women enrolled in a large health-maintenance program. We believe that these ideas may also be usefully applied to successive laboratory tests in carefully defined patient populations--but this introduces special problems, which are discussed briefly.

Enrichment by counterpart centrifugal elutriation of human lymphocytes cytotoxic to human tumour cells

The enriched fractions of cytotoxic cells responsible for natural killer (NK) activity against both human sarcoma and neuroblastoma (LA-N2) cell lines were readily obtained by countercurrent centrifugal elutriation (CCE). The NK cells were obtained in the larger lymphocyte fractions (fraction 6 +/- 1), having a mean cell volume of 180 u3. The cytotoxic-enriched fraction contained 51% large lymphocytes having cytoplasmic granules. On the other hand, monocytes were purified to greater than 90% and isolated in another fraction (final fraction) and these cells had the lowest NK activity against both human tumour cell lines. However, compared with the lymphocyte fractions, small and large monocytes displayed greater antibody-dependent cellular cytotoxicity (ADCC) activity against human B erythrocytes. These results indicate that NK found to have activity against both tumour cells lines were larger lymphocytes, not small monocytes. Thus, countercurrent centrifugal elutriation (CCE) can provide a sensitive method to obtain enriched fractions of large lymphocytes contained tumoricidal activity against human sarcoma and neuroblastoma cell lines.

Monocyte aggregation and superoxide anion release in response to formyl-methionyl-leucyl-phenylalanine (FMLP) and platelet-activating factor (PAF)

Like the PMN, human peripheral blood monocytes were capable of aggregating in response to FMLP and PAF. Monocyte aggregation was dependent on glycolysis and the presence of divalent cations. Unlike the PMN, monocyte aggregation in response to FMLP was not accompanied by degranulation, nor was it potentiated by cytochalasin B. Furthermore, cytochalasin B and its cogenitor, dihydrocytochalasin B, inhibited aggregation in response to PAF. PAF and FMLP appeared to react with the monocyte at separate receptors because sequential challenge of the monocyte with the same agents failed to elicit further aggregation, whereas rechallenge with the alternative agent induced further aggregation. Because the monocyte will aggregate to chemotactic agents in vitro, it is likely that the cell will be affected by these agents in vivo, which could lead to leukoembolization of circulating monocytes.

Monocyte aggregation and superoxide anion release in response to formyl-methionyl-leucyl-phenylalanine (FMLP) and platelet-activating factor (PAF)

Like the PMN, human peripheral blood monocytes were capable of aggregating in response to FMLP and PAF. Monocyte aggregation was dependent on glycolysis and the presence of divalent cations. Unlike the PMN, monocyte aggregation in response to FMLP was not accompanied by degranulation, nor was it potentiated by cytochalasin B. Furthermore, cytochalasin B and its cogenitor, dihydrocytochalasin B, inhibited aggregation in response to PAF. PAF and FMLP appeared to react with the monocyte at separate receptors because sequential challenge of the monocyte with the same agents failed to elicit further aggregation, whereas rechallenge with the alternative agent induced further aggregation. Because the monocyte will aggregate to chemotactic agents in vitro, it is likely that the cell will be affected by these agents in vivo, which could lead to leukoembolization of circulating monocytes.

Comparing multivariate and univariate subject-specific reference regions for blood constituents in healthy persons

We examined the comparative behavior of subject-specific multivariate and univariate reference regions, using both computer-generated data and serial (semi-annual) measurements of selected analytes in subjects from a large health-maintenance program. Univariate studies under both homeostatic and random-walk time-series models were helpful in defining expected results, but only the homeostatic model was used in multivariate as well as univariate forms. Analysis of the computer-generated data and the real biochemical series produced similar findings, which showed the multivariate subject-specific reference region to be much more conservative than corresponding univariate intervals. That is, a multidimensional point of p correlated observations is quite likely to lie within the individual's multivariate reference region (based on past observation vectors), even when one or more of the observations lie outside their separate reference intervals for that individual. One consequence of this high specificity against univariate false positives in a large surveillance program is a higher than expected proportion of positive multivariate vectors in which none of the values lie outside their univariate ranges. Thus, although the development of multivariate reference regions should be encouraged, they should be used in conjunction with, not instead of, univariate ranges.

Comparing multivariate and univariate subject-specific reference regions for blood constituents in healthy persons

We examined the comparative behavior of subject-specific multivariate and univariate reference regions, using both computer-generated data and serial (semi-annual) measurements of selected analytes in subjects from a large health-maintenance program. Univariate studies under both homeostatic and random-walk time-series models were helpful in defining expected results, but only the homeostatic model was used in multivariate as well as univariate forms. Analysis of the computer-generated data and the real biochemical series produced similar findings, which showed the multivariate subject-specific reference region to be much more conservative than corresponding univariate intervals. That is, a multidimensional point of p correlated observations is quite likely to lie within the individual's multivariate reference region (based on past observation vectors), even when one or more of the observations lie outside their separate reference intervals for that individual. One consequence of this high specificity against univariate false positives in a large surveillance program is a higher than expected proportion of positive multivariate vectors in which none of the values lie outside their univariate ranges. Thus, although the development of multivariate reference regions should be encouraged, they should be used in conjunction with, not instead of, univariate ranges.

The role of polymorphonuclear leukocytes in delayed hypersensitivity skin reactions: suppressive effects of anti-polymorphonuclear leukocyte serum

Rabbit antisera (APS) against normal guinea pig peritoneal exudate polymorphonuclear leukocytes (PMN), when injected intraperitoneally three times within 24 h into guinea pigs, lead to a marked fall in the blood PMN count (below 100/mm3) 24-72 h after the injection and a mild depression in the number of circulating mononuclear leukocytes (MNC) at 36-72 h. APS treatment of guinea pigs led to a marked suppression of delayed hypersensitivity skin reactions in response to dinitrophenylated bovine gamma-globulin. The volume, induration, mean diameter of the reaction and leukocyte (both PMN and MNC) emigration into local sites were suppressed, as was, to a lesser extent, vascular permeability. Based on these observations it appears that circulating PMN are required for the full expression of delayed hypersensitivity reaction engendered by bovine gamma-globulin.

Functions of human monocyte and lymphocyte subsets obtained by countercurrent centrifugal elutriation: differing functional capacities of human monocyte subsets

Two monocyte subsets from the peripheral blood of healthy humans were isolated by countercurrent centrifugal elutriation (CCE), and their functional heterogeneity was assessed. Cell volume of the smaller monocyte population was (332 +/- 32 mu 3), compared with the larger monocytes (380 +/- 30 mu 3). Superoxide release by large monocytes exposed to opsonized zymosan was 1.5-fold more active than those of small monocytes. Furthermore, the production of colony-stimulating factor (CSF) and myeloperoxidase activity by the larger monocytes was 2-fold and 1.4-fold greater than that of small monocytes, respectively. Thus, CCE provides a useful means to isolate 2 subsets of monocytes with similar functional properties but quantitatively different activities. This suggests that the 2 subsets may be closely related in their developmental spectrum.

Functions of human monocyte and lymphocyte subsets obtained by countercurrent centrifugal elutriation: differing functional capacities of human monocyte subsets

Two monocyte subsets from the peripheral blood of healthy humans were isolated by countercurrent centrifugal elutriation (CCE), and their functional heterogeneity was assessed. Cell volume of the smaller monocyte population was (332 +/- 32 mu 3), compared with the larger monocytes (380 +/- 30 mu 3). Superoxide release by large monocytes exposed to opsonized zymosan was 1.5-fold more active than those of small monocytes. Furthermore, the production of colony-stimulating factor (CSF) and myeloperoxidase activity by the larger monocytes was 2-fold and 1.4-fold greater than that of small monocytes, respectively. Thus, CCE provides a useful means to isolate 2 subsets of monocytes with similar functional properties but quantitatively different activities. This suggests that the 2 subsets may be closely related in their developmental spectrum.

Acceleration of lipid peroxidation in human paraquat poisoning

A 20-year-old man ingested approximately 15 to 20 mL of a 24% solution of paraquat. Acute renal and liver failure developed. The patient began undergoing hemodialysis and receiving vitamin E, but he died of pulmonary fibrosis the 27th day after the ingestion. During a two-week period of observation, evidence of lipid peroxidation in his serum was noted by determining malondialdehyde levels. Guinea pigs exposed to paraquat showed similar patterns of malondialdehyde presence in plasma. These results indicate that increased serum or plasma levels of lipid peroxide occurring in paraquat poisoning might reflect production of highly reactive oxygen free radicals and that, possibly, levels of lipid peroxides could serve as indicators of the efficacy of therapy directed toward scavenging free radicals.

Estimation of subject-specific normal ranges based on some statistical models of an individual's physiological variations

Three statistical models of the individual's physiological variations, proposed by Dr Eugene K. Harris, were applied to the long-term series of individual test results in our health control system. It was found from this study that, in most cases, the homeostatic model shows the best fit to the population level from comparing correlation coefficients between the observations and estimations made based on Harris's three models. It was also found that for most cases, the homeostatic model gives the most reliable estimates in individual's level from the comparison of the chi-square values between the observations and estimations made for the individual's successive test results. Further, for a group of members with hyperglycaemia, the proportion of individuals in whom the random-walk model produced the most accurate predictions was increased to the proportion in the normal group. In the age group under 39 years of age, the autoregressive model showed a relatively high degree of predictive success, while the homeostatic model showed a relatively low degree in comparison with the results found in other age groups. From these investigations, it was found that the physiologically normal state shows strict homeostatic stability.