Pharmacotherapy for elderly patients with delirium in a general ward setting: A retrospective study

Antipsychotic medications are widely used in patients with delirium. However, antipsychotics may lead to various adverse events including cardiac arrythmias, extrapyramidal side effects, and oversedation. This study aimed to investigate whether non-antipsychotic medications including ramelteon, suvorexant, and trazodone are useful for the treatment of elderly inpatients with delirium in a general ward setting. This was a retrospective cohort study using medical chart reviews of all consecutive inpatients with hyperactive forms of delirium who were admitted to a regional general hospital. The primary outcome of this study was to evaluate whether non-antipsychotic medication (ramelteon, suvorexant, and trazodone) is inferior, in terms of efficacy and safety, to antipsychotic medication in delirium treatment. Of 154 patients who consulted psychiatrists during the study period, 33 patients were diagnosed with hyperactive delirium. Of these patients, 21 were categorized into the antipsychotic medication group, and 12 were categorized into the non-antipsychotic medication group. The duration of delirium after pharmacological treatments was not statistically different between the two groups. However, the rates of adverse events related to psychotropic medications in the antipsychotic medication group were significantly higher than that in the non-antipsychotic medication group. This study demonstrated that, in the treatment of elderly patients with delirium, non-antipsychotic drugs, such as suvorexant, ramelteon, and trazodone, could be more useful than antipsychotics in terms of efficacy and safety.

The perspective of management of sleep disorders in Japan

Increases in psychosocial stress and disruption of the biological clock due to irregular sleep-wake schedules as well as an increase in the elderly population have resulted in an increase in sleep disorders, most notably insomnia. In order to manage insomnia, correction of a poor sleep environment is of primary importance. We now have many good GABA A receptor agonists such as benzodiazepines and cyclopyrrolones (zopiclone) for use as hypnotics, but to achieve improvements in nocturnal sleep and restoration of daytime functions, short- or ultra-short acting hypnotics are recommended. Zopiclone has been reported to show weaker effects on sleep architecture than other benzodiazepines and does not exacerbate mild or moderate sleep apnea syndrome. Some patients are therapeutic-dose dependent on hypnotics or anxiolytics without showing detectable side effects. It may be possible for some insomniacs, particularly forelderly people, to use the minimum necessary dose of hypnotics to achieve good sleep and live a happy life from the standpoint of good quality of life.

Electrochemical tuning of the optical properties of nanoporous gold

Using optical in-situ measurements in an electrochemical environment, we study the electrochemical tuning of the transmission spectrum of films from the nanoporous gold (NPG) based optical metamaterial, including the effect of the ligament size. The long wavelength part of the transmission spectrum around 800 nm can be reversibly tuned via the applied electrode potential. The NPG behaves as diluted metal with its transition from dielectric to metallic response shifted to longer wavelengths. We find that the applied potential alters the charge carrier density to a comparable extent as in experiments on gold nanoparticles. However, compared to nanoparticles, a NPG optical metamaterial, due to its connected structure, shows a much stronger and more broadband change in optical transmission for the same change in charge carrier density. We were able to tune the transmission through an only 200 nm thin sample by 30%. In combination with an electrolyte the tunable NPG based optical metamaterial, which employs a very large surface-to-volume ratio is expected to play an important role in sensor applications, for photoelectrochemical water splitting into hydrogen and oxygen and for solar water purification.

Safety of polypropylene mesh for incarcerated groin and obturator hernias: a retrospective study of 110 patients

PURPOSE

The purpose of this study was to evaluate the mesh repair for an incarcerated groin hernia.

METHODS

A total of 110 patients who underwent emergency surgery for incarcerated hernias were retrospectively analyzed using a multivariate analysis.

RESULTS

The postoperative complications were associated with bowel resection, odds ratio (OR) 2.984, and 95 % confidence interval (CI) 1.273 to 6.994. The risk factors for bowel resection were femoral hernia, (OR 5.621, 95 % CI 2.243 to 14.082), and late hospitalization (24 h<), (OR 2.935, 95 % CI 1.163-7.406). The hernias were repaired with mesh in ten of the 39 (25.6 %) patients with bowel resection and sixty-four of the 71 (90.1 %) patients without bowel resection. The complication rate of the patients with bowel resection was 53.8 % and was 26.8 % in those without. The ratios of wound infection were 23.1 and 0.0 %, respectively. Wound infections were detected in two (20 %) of the ten patients who underwent bowel resection with mesh repair; however, there were no patients in whom the mesh was withdrawn due to infection.

CONCLUSIONS

No wound infections in patients without bowel resection were detected, and mesh repair could be safely performed. Mesh repair for the patients with bowel resection is not contraindicated, as long as the clean-contamination of the wound was maintained during surgery.

Pressure and magnetic field dependence of valence and magnetic transitions in EuPtP

The hexagonal layered compound, EuPtP, exhibits two valence transitions, at T₁ = 235 K and T₂ = 190 K, and an antiferromagnetic order at T(N) = 8.6 K. We have examined the effects of magnetic field and pressure, and the specific heat. Analysis of the high-field experiments confirms that half of Eu are in a divalent state at the lowest temperature, and that the number of Eu(² + ) increases discontinuously at T₂ and T₁ with increasing temperature. The magnetic entropy reaches ~ 22 J K⁻¹ mol⁻¹ at room temperature, which is larger than that expected for J = 7/2 of Eu(²+ ) (17.3 J K⁻¹ mol⁻¹). This is in good agreement with the magnetic entropy deduced from the interconfigurational fluctuation model, which explains the valence transition in Eu(Pd(₁- x)Pt(x))₂Si₂. The application of pressure shifts T₁ and T₂ higher and suppresses the intermediate phase (β phase, T₂ < T < T₁), whereas it does not change the properties of the low-temperature phase (γ phase, T < T₂) and the T(N).

Assessment of early treatment response after CT-guided radiofrequency ablation of unresectable lung tumours by diffusion-weighted MRI: a pilot study

The aim of this study was to evaluate prospectively the early treatment response after CT-guided radiofrequency ablation (RFA) of unresectable lung tumours by MRI including diffusion-weighted imaging (DWI). The study protocol was approved by the ethics committee of our hospital and signed consent was obtained from each patient. We studied 17 patients with 20 lung lesions (13 men and 4 women; mean age, 69+/-9.8 years; mean tumour size, 20.8+/-9.0 mm) who underwent RFA using a LeVeen electrode between November 2006 and January 2008. MRI was performed on a 1.5T unit before and 3 days after ablation. We compared changes in the apparent diffusion coefficient (ADC) on DWI and response evaluation based on subsequent follow-up CT. 14 of the 20 treatment sessions showed no local progression on follow-up CT, whereas 6 treatment sessions showed local progression (range, 3-17 months; mean, 6 months). For the no-progression group, the ADC pre- and post-RFA were 1.15+/-0.31 x 10(-3) mm(2) s(-1) and 1.49+/-0.24 x 10(-3) mm(2) s(-1), respectively, while the respective ADC values for those that showed local progression were 1.05+/-0.27 x 10(-3) mm(2) s(-1) and 1.24+/-0.20 x 10(-3) mm(2) s(-1). The ADC of the ablated lesion was significantly higher than before the procedure (p<0.05). There was a significant difference in the ADC post-RFA between no-progression and local progression groups (p<0.05). Our prospective pilot study showed that the ADC without local progression was significantly higher than with local progression after RFA, suggesting that the ADC can predict the response to RFA for lung tumours.

Class A scavenger receptor (CD204) attenuates hyperoxia-induced lung injury by reducing oxidative stress

To clarify the role of macrophage class A scavenger receptors (SR-A, CD204) in oxidative lung injury, we examined lung tissue of SR-A deficient (SR-A(-/-)) and wild-type (SR-A(+/+)) mice in response to hyperoxic treatment. Protein levels of bronchoalveolar lavage fluid (BALF) and pulmonary oedema (wet : dry weight ratios) were higher in SR-A(-/-) mice than those in SR-A(+/+) mice. Cumulative survival was significantly decreased in SR-A(-/-) mice. However, there were no differences in BALF macrophage and neutrophil count between the two groups. Real-time reverse transcriptase-polymerase chain reaction (RT-PCR) revealed that messenger RNA (mRNA) levels of the inducible nitric oxide synthase (iNOS) were increased during hyperoxic injury, and this increase was more prominent in SR-A(-/-) mice. Expression levels of iNOS in alveolar macrophages after hyperoxia in vivo and in vitro were higher in SR-A(-/-) macrophages compared with SR-A(+/+) macrophages. Immunohistochemistry using anti-nitrotyrosine antibodies revealed distinctive oxidative stress in the injured lung in both groups, but it was more remarkable in the SR-A(-/-) mice. After hyperoxic treatment, pulmonary mRNA levels of tumour necrosis factor-alpha(TNF-alpha) were elevated more rapidly in SR-A(-/-) mice than in SR-A(+/+) mice. Together these results suggest that SR-A expression attenuates hyperoxia-induced lung injury by reducing macrophage activation.

Adult case of squamous cell carcinoma arising on congenital esophageal stenosis due to fibromuscular hypertrophy

This study relates to an adult case of squamous cell carcinoma arising on congenital esophageal stenosis. The patient was a 65-year-old man who had suffered from dysphagia and vomiting since birth and was diagnosed as having congenital esophageal stenosis. The patient had not received any treatment because his symptoms were mild. The patients suffered from severe dysphagia since he was 20 years old and had received balloon therapies several times; however, the effects were transient. After admission to our hospital, he underwent a transhiatal esophagectomy without thoracotomy. Histopathological examination of the resected specimen revealed a thick muscular mucosae associated with hypertrophic fibromuscular components and poorly to moderately differentiated squamous cell carcinoma in the region of stenosis. This case report is the first of a patient with squamous cell carcinoma arising on congenital esophageal stenosis.

Risk stratification using serum concentrations of cardiac troponin T in patients with end-stage renal disease on chronic maintenance dialysis

BACKGROUND

It has been recently suggested that cardiac troponin T (cTnT) may be more sensitive than troponin I (cTnI) for subclinical myocardial cell injury in patients on chronic dialysis.

METHODS

We prospectively compared the predictive value of cTnT with cTnI, atrial (ANP) and brain natriuretic peptide (BNP) in 100 consecutive outpatients on chronic dialysis without acute coronary syndromes over a period of 3 months, and assessed whether the combination of cTnT with clinical information including age, duration of dialysis, and medical histories was useful for risk stratification of these patients. During the 2-year follow-up period, 19 patients died, mostly due to cardiac causes (53%).

RESULTS

The area under the receiver operator characteristic (ROC) curve for the cTnT as predictor of both overall and cardiac death was significantly greater than the area under the cTnI curve (p < 0.0001 and p = 0.01), the BNP curve (p < 0.001 and p < 0.01) or the ANP curve (p < 0.0001 and p < 0.005). In a stepwise multivariate Cox regression analysis, only cTnT (p < 0.05 and p < 0.01) and a history of heart failure requiring hospitalization (p < 0.05 and p < 0.005) were independent predictors of both all cause and cardiac mortality. Using parameters of cTnT > or =0.1 microg/l and/or history of heart failure, the overall and cardiac mortality rate for the low risk group (n=66) were 4.5% and 1.5%, respectively, 40% and 16% for the intermediate risk group (n=25), and 67% and 56% for the high risk group (n=9).

CONCLUSION

cTnT concentrations offer a higher prognostic accuracy than cTnI, ANP and BNP in patients on chronic dialysis. The combination of elevated cTnT and a history of heart failure may be a highly effective means of risk stratification of these patients.

Ground performance of air conditioning and water recycle system for a Space Plant Box

Researchers from 5 Japanese universities have developed a plant growth facility (Space Plant Box) for seed to seed experiments under microgravity. The breadboard model of the Space Plant Box was fabricated by assembling subsystems developed for microgravity. The subsystems include air conditioning and water recycle system, air circulation system, water and nutrient delivery system, lighting system and plant monitoring system. The air conditioning and water recycle system is simply composed of a single heat exchanger, two fans and hydrophilic fibrous strings. The strings allow water movement from the cooler fin in the Cooling Box to root supporting materials in the Plant Growth Chamber driven by water potential deficit. Relative humidity in the Plant Growth Chamber can be changed over a wide range by controlling the ratio of latent heat exchange to sensible heat exchange on the cooling fin of the heat exchanger. The transpiration rate was successfully measured by circulating air inside the Plant Growth Chamber only. Most water was recycled and a small amount of water needed to be added from the outside. The simple, air conditioning and water recycle system for the Space Plant Box showed good performance through a barley (Hordeum vulgare L.) growth experiment.

Microbial contamination of enteral feeding formulas and diarrhea

Twenty-five medical and surgical patients receiving liquid ready-to-use sterile enteral formulas were evaluated prospectively to investigate the relation of diarrhea to serum albumin level, total lymphocyte count, delayed hypersensitivity to purified protein derivative, antibiotic therapy, administration rate and site of enteral formula, and microbial contamination of enteral feeds. Formulas were administered to 6 patients with hang times of up to 6 h by pump-assisted continuous drip and to 19 patients with hang times of up to 3 h as a bolus feeding. Samples of formulas for microbial culture were obtained aseptically before and after feeding on the first and eighth day of the study period. The incidence of microbial contamination of the formula before and after feeding was 1 of 49 samples (2.0%) and 10 of 48 samples (20.8%), respectively. There were 2 patients with diarrhea, which occurred on the second day. Formula samples from 2 patients (100%) with diarrhea and 2 samples from 23 patients (8.7%) without diarrhea were contaminated with 10(4) cfu/mL or more, respectively. A significant difference (P = 0.04) was detected between the two groups. The other factors studied showed no significant association with the incidence of diarrhea. In conclusion, contaminated formula appears to play a significant role in the etiology of diarrhea in patients receiving enteral feeding.

Association between delta waves during sleep and negative symptoms in schizophrenia. Pharmaco-eeg studies by using structurally different hypnotics

We examined the effects of benzodiazepine (BZD) hypnotics and zopiclone (ZPC), a nonbenzodiazepine hypnotic, on sleep and psychiatric symptoms in schizophrenia, as well as the clinical correlates of these variables. Seven male schizophrenic patients chronically taking neuroleptics together with BZD were studied. We replaced BZD with ZPC and performed polysomnography (PSG) and Brief Psychiatric Rating Scale (BRPS) scoring before and after an 8-week ZPC treatment. The replacement of BZD with ZPC increased the mean amplitude of high-amplitude low-frequency delta waves on the frontal derivation recognized by period-amplitude analysis, and it decreased the BPRS negative-symptom score. Under the BZD treatment, the negative-symptom score correlated inversely with the mean amplitude of high-amplitude low-frequency delta waves. This correlation was weak and not significant under the ZPC treatment. Therefore, delta waves during sleep have a close correlation to negative symptoms in schizophrenia, and such a correlation could be influenced by hypnotics. Although these are preliminary findings, it was suggested that, compared with BZD, ZPC might be a beneficial hypnotic in regard to both sleep and negative symptoms of chronic schizophrenic patients.

Chemotherapy-induced apoptosis of lymphocytes in esophageal cancer worsens outcome

BACKGROUND/AIMS

Chemotherapy has been shown to induce apoptosis in esophageal cancer. However, no windows of opportunity exist to selectively kill tumor cells without killing host cells. Due to the concern that tumor-infiltrating lymphocytes may be killed by chemotherapy, we examined the significance of the effect of treatment on the density of tumor-infiltrating lymphocytes and apoptosis in the tumor itself and in the tumor-infiltrating lymphocytes.

METHODOLOGY

In 93 patients with esophageal cancer including 50 with neoadjuvant chemotherapy, esophagectomy specimens were examined for density of tumor-infiltrating lymphocytes and for apoptosis in both tumor cells and tumor-infiltrating lymphocytes.

RESULTS

Apoptotic index was increased by neoadjuvant chemotherapy only in tumor-infiltrating lymphocytes, apoptotic index was > or = 4 only in chemotherapy patients. The density of tumor infiltrating lymphocytes was a significant positive prognostic factor in chemotherapy and non-chemotherapy groups, and the high apoptotic index in tumor-infiltrating lymphocytes was an independent negative prognostic factor in the chemotherapy group.

CONCLUSIONS

Apoptosis in tumor-infiltrating lymphocytes was induced by chemotherapy in some patients in association with a poor prognosis. Unexpectedly, chemotherapy did not increase apoptosis in tumor cells. Both findings suggest a need for improved regimes and individualized treatment.

Asymmetric interhemispheric delta waves during all-night sleep in humans

OBJECTIVE

In order to better understand the asymmetry of brain function during sleep, period-amplitude analysis of delta EEG activity was performed on polysomnograms (PSGs) in normal humans. Twenty healthy, right-handed male volunteers aged 22-35 years (mean age 27.2 years) served as subjects in this study.

METHODS

EEGs were recorded from disc electrodes placed at bilateral frontal, central, parietal, occipital, anterotemporal and posterotemporal (10-20 electrode system) sites using A1+A2 for reference. Period-amplitude analysis was performed by the zero-crossing method using the Medilog Sleep Analyzing Computer.

RESULTS

Delta counts in the right frontal and central regions during all-night sleep were significantly greater than in those of the left; total delta counts of the right frontal region were greater than those of the left in 18 of the 20 subjects. There were no significant differences in delta counts between the left and right hemispheres in parietal, occipital, anterotemporal, and postero-temporal regions.

CONCLUSIONS

These results suggest distinct laterality in the number of delta waves in the frontal and central regions, reflecting functional asymmetry of the brain during sleep.

Mediastinal growing teratoma syndrome

A 27-year-old man had undergone orchiectomy and chemotherapy for testicular cancer. Despite normalization of raised tumor marker levels after postoperative chemotherapy, computed tomographic scanning demonstrated multiple swellings of the para-aortic lymph nodes with extension from beneath the aortic arch to the bifurcation of the descending aorta. Open biopsies of the para-aortic lymph nodes disclosed mature teraroma without malignant cells. The patient presented the typical features of mediastinal and retroperitoneal growing teratoma syndrome. A two stage resection of the tumors was performed via laparotomy and left thoracotomy. Histological examination of the resected specimens revealed a mature teratoma component without malignant cells. Upon follow-up sixteen months later, the patient was well and without recurrence.

The prognostic significance of cell cycle markers in esophageal cancer after neoadjuvant chemotherapy

Proliferating cell nuclear antigen (PCNA), p27 and cyclin A were analyzed by immunohistochemistry in 89 patients (untreated control n = 40, neoadjuvant chemotherapy n = 49) with esophageal cancer invading the submucosal lesion. The mitotic index (MI) was calculated as the percentage of mitotic cells. In control subjects, the mean PCNA, p27, cyclin A and MI were, respectively, 60.4%, 18.0%, 19.9% and 1.7%; in the chemotherapy group, these values were 46.8%, 15.1%, 18.0% and 1.2% respectively. Neoadjuvant chemotherapy decreased PCNA and the MI significantly. As prognostic indicators, PCNA and the MI were significant in control subjects and p27 and cyclin A were significant in the chemotherapy group. Using multivariate analysis, p27 was a prognostic factor in both groups and cyclin A was prognostic only in the chemotherapy group. Although PCNA and the MI were useful growth and prognostic markers in untreated control subjects, their significance was lost after neoadjuvant chemotherapy. p27 and cyclin A were determined to be significant markers in the neoadjuvant chemotherapy group, especially p27, which was independent in both groups.

Does neoadjuvant chemotherapy for carcinoma in the thoracic esophagus increase postoperative morbidity?

OBJECTIVES

The aims of this study were to examine whether neoadjuvant chemotherapy for a carcinoma in the thoracic esophagus increased the incidence of postoperative complications, and which clinicopathological factors may affect postoperative complications after esophagectomy.

SUBJECTS AND METHODS

One hundred and forty-four patients who underwent neoadjuvant chemotherapy followed by esophagectomy for a carcinoma in the thoracic esophagus were reviewed in a retrospective study. Ninety-six patients received neoadjuvant chemotherapy and 48 did not. The postoperative complications were grouped either general complications (Complications A) or surgery-related complications (Complications B). Complications A consisted of pulmonary, cardiac, hepatic, renal, and neurological complications, and catheter sepsis. Complications B consisted of a gastrointestinal tract leak, gastrointestinal tract necrosis, an intrathoracic or intraabdominal abscess, hemorrhage, ileus, and vocal cord palsy. In these two categories of complications, 17 factors obtained from subjects were compared between patients with complications and those without by univariate and multivariate analyses.

RESULTS

The patient characteristics did not differ between patients who received neoadjuvant chemotherapy and those without. The preoperative serum albumin level was higher in patients without complication than in those with complication in both two categories of complications (Complications A: p = 0.001, Complications B: p = 0.05). The proportion of patients who received neoadjuvant chemotherapy did not differ between patients with complication and those without complication in either category of complications. Multivariate analysis showed that preoperative Onodera's Prognostic Nutritional Index was the only factor reducing the incidence of complications A (p = 0.02, Odds ratio: 0.63).

CONCLUSION

Neoadjuvant chemotherapy was well tolerated and was not associated with any increased morbidity or mortality after esophagectomy for a carcinoma in the thoracic esophagus.

Laterality of delta waves during all-night sleep

In order to clarify the functional asymmetry of the brain function during sleep, period-amplitude analysis of delta electroencephalogram activity was performed on polysomnograms in 12 right-handed healthy males. Electroencephalograms were recorded from disc electrodes placed at C3, C4, O1 and O2 (10-20 electrode system), using A1 +A2 for reference. Although there were no significant differences in delta counts between O1 and O2, delta counts of C3 were significantly larger than those of C4. These results suggest that there exists distinct laterality in the number of delta waves in the central region, reflecting the functional asymmetry of the brain during sleep.

Indications for three-field dissection followed by esophagectomy for advanced carcinoma of the thoracic esophagus

OBJECTIVE

The aim of this study was to evaluate the indication for 3-field lymphadenectomy (3-field dissection) followed by esophagectomy for locally advanced carcinoma of the thoracic esophagus in the presence of lymph node metastasis.

METHODS

From January 1983 to December 1995, 86 patients with thoracic esophageal carcinoma invading muscularis propria or adventitia underwent radical subtotal esophagectomy after preoperative chemotherapy. Forty-six of the 86 patients underwent a 2-field dissection (mediastinal and abdominal nodes, group A), and 40 patients underwent a 3-field dissection (bilateral cervical, mediastinal, and abdominal nodes, group B). Survival curves were compared between the 2 groups after stratification according to the degree of lymph node involvement (number of positive nodes and involvement of intrathoracic or intrathoracic recurrent nerve chain nodes). Potential prognostic factors of these 86 patients were evaluated by means of Cox regression analysis.

RESULTS

There were no significant differences in age, sex ratio, depth of tumor invasion, pTNM classification, or number of positive nodes between the 2 groups. Among patients with positive intrathoracic nodes, the 5-year survival of group B (42%) was significantly longer than that of group A (13%, generalized Wilcoxon test P =.02). Among patients with 1 to 4 positive nodes, the 5-year survival of group B (54%) was significantly higher than that of group A (22%, P =.01). Multivariate analysis revealed the number of positive nodes, age, and pT4 stage to be significant predictors of survival in patients with thoracic esophageal carcinoma.

CONCLUSIONS

Three-field dissection for advanced carcinoma of the thoracic esophagus is effective in patients with 1 to 4 positive nodes.

In vitro SUMO-1 modification requires two enzymatic steps, E1 and E2

The SUMO-1 has been identified as a protein that is highly similar to ubiquitin and shown to conjugate to RanGAP1, PML, Sp200 and I kappa B alpha. The conjugation steps are thought to be similar to those of ubiquitination; and human Ubc9, which is homologous to the E2 enzyme for the ubiquitin conjugation step, was identified and shown to be necessary for the conjugation of SUMO-1 to its target protein. Other essential enzymes involved in this modification, however, remain to be clarified. Here we cloned human Sua1 (SUMO-1 activating enzyme) and hUba2, which are human homologs of yeast Saccharomyces cerevisiae Aos1 and Uba2, respectively. The recombinant proteins, Sua1p and hUba2p, formed a complex. In this complex, hUba2 bound SUMO-1 and this complex had the activity of the SUMO-1 activating enzyme. Furthermore, in an in vitro system, RanGAP1 was modified by SUMO-1 in the presence of Sua1p/Uba2p and hUbc9p, showing that the modification of SUMO-1 could be catalyzed by two enzyme steps, although ubiquitination usually requires three enzyme steps.

A polysomnographic study of sleep patterns in normal humans with low- or high-anxiety personality traits

To clarify the effects of anxiety-related personality traits on sleep patterns, polysomnographic examinations (PSG) were performed over 4 consecutive nights on normal humans who tested within the low- or high-anxiety ranges. The subjects consisted of two groups of six male university students who scored either less than 45 points (low-anxiety group) or more than 55 points (high-anxiety group) on the Spielberger's State Trait Anxiety Inventory. Compared to the levels of sleep change in the high-anxiety group, the low-anxiety group exhibited a greater change in REM sleep and stage 2 sleep. The REM sleep in the low-anxiety group was shorter on the first and second nights compared to the third and fourth nights, and the stage 2 sleep was longer on the first night than on the remaining three nights. Thus, the low-anxiety group showed a first-night effect followed by partial recovery on the second night, while the high-anxiety group exhibited no obvious first-night effect. These results suggest that there is a difference in sleep patterns, assessed by consecutive PSG, between those with low- and high-anxiety traits, and that anxiety-related personality traits attenuate the occurrence of the first-night effect, reflecting a lower adaptability to a novel environment.

A history of investigation on the mood stabilizing effect of carbamazepine in Japan

A history of investigation on the antimanic and prophylactic effects of carbamazepine in Japan is described. Following the initial open trials in the early 1970s in which the antimanic and prophylactic effects of carbamazepine were indicated for the first time in the world, the mood stabilizing effect was confirmed by the double blind studies which were performed with a multi-institutional cooperation in Japan in the late 1970s. During the course of the double blind trials, the problem of different therapeutic dosages of psychotropic drugs between Japan and Western countries emerged; that is, the doses of chlorpromazine and lithium carbonate, which were used as the control drugs to carbamazepine in the two double-blind group-comparison studies in Japan, were both much lower than the dosage used in most of the Western countries. The low dosage of control drugs made the evaluation of the results of the double blind studies performed in Japan difficult, and caused a delay of publication in the Western journals of the results. Whether the difference is due to biological factors or to psychosocial and cultural factors is an important problem in psychopharmacology and should be investigated further.

[Study of diazepam with quantitative EEGs taken with eyes opened and topography]

Diazepam is a representative drug of benzodiazepines. The subjects were 9 right-handed healthy male volunteers 21 25 years of age. Double blind crossover trials with placebo control were conducted in a random sequence at an interval of 1 week. Diazepam 10 mg and placebo were administered as single oral doses. Three-minute EEGs were recorded with subjects' eyes opened before and 2 h after drug administration. One-minute out of the 3-minute EEGs was analyzed with FFT, and the absolute amplitude power (microV) was calculated. These results were subjected to Student's t-test (double difference) and displayed with topographic maps (t statistic significance probability mapping). Diazepam decreased the delta absolute amplitude power over left-parietal dominance, theta absolute amplitude power diffusely and alpha absolute amplitude power over parietal region dominance. It also increased the beta absolute amplitude power over left-antero-temporal region dominance. The EEG profiles taken with subjects' eyes open were different from those of diazepam with eyes-closed vigilance controlled concerning the degree of decrease of delta and beta activities and region of the effect on alpha activity.

Zopiclone versus diazepam effects on EEG power maps in healthy volunteers

EEG effects of zopiclone (7.5 mg), a cyclopyrrolone derivative with hypnotic action, were compared with effects of diazepam (10 mg). Multichannel EEG recordings, double-blind crossover trials with placebo, and oral single doses were used in healthy volunteers. Vigilance-controlled EEG before and after zopiclone (and placebo), and before and after diazepam (and placebo) were analyzed into FFT power spectra. Effects were assessed as placebo-referred pre-post-medication power differences in four frequency bands. Overall statistics showed significant (P < 0.007) global differences between medication effects in the delta frequency band (0.5-3.5 Hz). After zopiclone, fronto-central delta increased bilaterally, whereas after diazepam delta decreased over centro-parietal to right temporo-occipital regions. These spatially different brain electric effects show that different neuronal populations must have become active in response to zopiclone and diazepam.

Relationship between the effects of a hypnotic drug, zopiclone, on polysomnography and on daytime EEGs

The correlation between the effects of zopiclone (ZPC), a nonbenzodiazepine hypnotic drug, on sleep polysomnograms and on daytime EEGs was examined in 12 healthy adult male volunteers. Sleep polysomnograms were recorded after a single oral administration of ZPC 10 mg or placebo according to the double-blind crossover method. Daytime EEGs were recorded after the administration of ZPC, 7.5 mg, or placebo in the same manner, and recorded for 3 min with closed eyes at rest. Then, square roots of the absolute power (amplitude) of the delta-, theta-, alpha-, and beta-activities were calculated from the power spectrum obtained by the fast Fourier transform method. As a result, ZPC decreased the percentage of stage 1 sleep in total sleep time, while it increased the percentage of stage 2, total sleep time, and time of slow wave sleep in the first and second sleep cycles (SWS 1 and 2). Changes in SWS 1 and 2 correlated positively with the amplitude changes in daytime resting delta-activity. This indicates that the increase of SWS due to ZPC could be related to the change of delta-activity in the daytime resting EEG.

Zopiclone pharmacodynamics: by monitoring event-related potentials and psychometric scores

To investigate the pharmacological effects of zopiclone in the central nervous system, we monitored event-related potentials (ERPs, N100 and P300), the reaction time and the scores for subjective mental and emotional state (by using the Polarity Profile Questionnaire, PPQ) on 10 healthy right-handed male volunteers between 21 and 32 years old. Subjects were randomly allocated to receive a single oral administration of zopiclone 7.5 mg or placebo at the first-session, and the drug was crossed over at the second session 1 week later. ERPs, the reaction time and the psychometric scores were monitored at pre-drug, and 1, 3 and 5 hours after drug administration. In the zopiclone group, the reaction time was prolonged significantly at 1 hour after drug administration, the amplitudes of the ERPs significantly decreased at 1 and 3 hours after, and the PPQ scores showed significant changes. Maximum effects on the psychometric scores appeared later than those on ERPs and reaction time. Zopiclone decreased the arousal level and sensory sensitivity, and induced sedation through changes in subjective mental and emotional states.

[Study of zopiclone with quantitative EEG analysis and topography]

Zopiclone is a cyclopyrrolone derivative which possesses hypnotic activity. This drug is known to increase the slow sleep stage compared to benzodiazepines in polysomnography. The subjects were 10 right-handed healthy male volunteers aged 21-23 years. Double-blind crossover trials with placebo control were conducted in a random sequence at intervals of 1 week. Zopiclone 7.5 mg and placebo were administered as single oral doses. Three-minute vigilance controlled EEGs at before and at 1, 3, and 5 h after drug administration, and the response times were recorded. One minute out of the 3-minute EEGs was analyzed with FFT and the power spectrum was obtained. Then the absolute amplitude power (microV) was calculated. These results were subjected to Student's t-test (double difference) and displayed with topographic maps (t statistic significance probability mapping). Zopiclone prolonged the latency of the response time, and increased the amount of delta absolute amplitude power over the right central region, beta 1 absolute amplitude power over the left central region and beta 2 absolute amplitude power over the right central area along with decreased alpha absolute amplitude power over the occipital region and theta power over the left frontal pole area after 1 h, when the peak pharmacological effect was expected. The EEG profiles of zopiclone were different from that of diazepam reported previously concerning the increase in delta activity.

The present and the future of sleep research in Asia

In recent years, recognition of the importance of sleep, not only as a health problem but also as a social problem, has brought about worldwide growing interest in sleep and sleep research. In Asian countries, the number of sleep researchers is increasing rapidly and as a result the Asian Sleep Research Society (ASRS) was founded in 1994. This paper reviews the main topics of basic and clinical sleep research which have been investigated recently in Japan and in Asian countries. The subjects of sleep research in Asia in the future will be, in principle, similar to those in other countries of the world. However, the author suggests several subjects which are more or less specific to Asia and which should be studied in association, such as epidemiological longitudinal study of sleep disorders in developing countries, characteristics of sleep and dreaming in oriental culture and philosophy, etc. The roles of ASRS in dissemination of information, promotion of training and education, and enlightenment of public and government were also emphasized.

A quantitative sleep-EEG study on the effects of benzodiazepine and zopiclone in schizophrenic patients

Polysomnographic examinations (PSG) were performed on 6 male schizophrenic outpatients who were being treated with benzodiazepine (BZD) hypnotics in combination with neuroleptics and 6 healthy male volunteers. In schizophrenic subjects, zopiclone (ZPC), 15 mg/day, was substituted for the BZD hypnotics, and PSGs were recorded again during ZPC therapy. All-night sleep stage scoring was carried out by visual analysis, and computerized period-amplitude analysis of sleep EEG was also performed. The schizophrenics showed marked reduction in the amount of slow-wave sleep (SWS) and in the number of delta half-waves during all-night sleep, especially those with higher amplitude, as compared to the normals. The number of delta half-waves in the patients was markedly reduced during the first sleep cycle. The average amplitude of delta half-waves during all-night sleep in the schizophrenics was significantly lower than that in the normals. The half-wave count of total delta waves in the schizophrenics was higher during treatment with ZPC than with BZDs, although no significant differences were observed in the amount of SWS between the two treatments. Soundness of sleep in the subjective sleep assessment was better evaluated during treatment with ZPC than BZDs. These results suggest that reduction of SWS in schizophrenia may be attributable mainly to the decrease in the number of delta waves with higher amplitude and that ZPC may induce deeper sleep in schizophrenics than BZDs.

Insulin-like growth factor-I prevents gut atrophy and maintains intestinal integrity in septic rats

BACKGROUND

The effects of insulin-like growth factor-I (IGF-I) on gut metabolism, structure, and barrier function as well as its general anabolic effects were investigated in septic rats.

METHODS

Thirty-three male Wistar rats that underwent cecal ligation were randomly divided into one of the following two groups: (1) received only total parenteral nutrition (control group) or (2) received total parenteral nutrition with IGF-I (IGF group) at a dose of 4 mg/kg/d for 3 days.

RESULTS

During the 3-day period, the body weight of rats in the IGF group increased significantly over that of rats in the control group (17.1 +/- 2.6 vs 5.8 +/- 4.6 g, p < .01). The total and free IGF-I plasma concentrations were significantly higher in the IGF group than in the control group. The cumulative nitrogen balance was significantly more positive for the IGF group (423.9 +/- 24.3 mg of nitrogen) than for the control group (290.8 +/- 26.0 mg of nitrogen). The weights of thymus, spleen, and kidneys were significantly increased in the IGF group compared with weights in the control group. Treatment with IGF-I improved the gut mucosal weight in all regions of the gut examined, including duodenum, jejunum, ileum, and colon. Histologic and biochemical analyses of the jejunum showed greater villus height and crypt depth and higher mucosal DNA and protein content in the IGF group. The arterial concentration of endotoxin was not significantly different between the two groups, whereas its level in portal blood was significantly lower in the IGF group (23.2 +/- 9.9 pg/mL) than in the control group (95.5 +/- 37.9 pg/mL), an indication that IGF-I treatment decreased the amount of endotoxin that traversed the gut barrier.

CONCLUSIONS

These results indicate that IGF-I can improve gut metabolism and reduce mucosal atrophy and that it may play a role in maintaining the gut barrier function in sepsis.

Preoperative chemotherapy for esophageal cancer based on chemosensitivity testing

To examine the role and significance of in vitro chemosensitivity testing on cells cultured from endoscopic biopsy specimens, we evaluated outcomes in 57 patients with squamous cell carcinoma of the thoracic esophagus. Over 3 1/2 years, 57 patients were treated with a single course of preoperative combination chemotherapy based on the results of chemosensitivity testing utilizing eight antineoplastic agents. A radiologically evident response (partial response) was seen in 23 patients (40.4%) and histologic effects on grade IIb tumors were seen in six patients (10.5%). The median survival time of all 57 patients was 16.3 months. The median survival time of nine patients who received palliative resection was 4.5 months. The median survival times after curative resection of the 19 patients with a partial response and 29 patients with no response were 27.7 months and 17.3 months, respectively (p < 0.009). The most frequent combination chemotherapy used was cis-dichlorodiammine platinum (II) vindesine/5-fluorouracil, and a high rate of response was noted after therapy with etoposide and 4'-D-tetrahydropyranyl-doxorubicin. Chemosensitivity testing appears to be useful in selecting preoperative chemotherapeutic agents for patients with esophageal cancer, decreasing tumor recurrence after surgery and resulting in more partial responses than conventional chemotherapy.

Effects of zopiclone on sleep and symptoms in schizophrenia: comparison with benzodiazepine hypnotics

Sleep variables and psychiatric symptoms were investigated in 6 male chronic schizophrenic outpatients. The patients were being treated with benzodiazepine (BZD) hypnotics for more than 8 weeks, and BZDs were replaced with zopiclone (ZPC) 15 mg/day. Polysomnographic examinations, subjective sleep assessments and BPRS scoring were performed during BZD therapy and at the end of 8 weeks of ZPC therapy. The doses of neuroleptics and anticholinergic agents remained fixed throughout the study. The amount of slow-wave sleep (SWS) was markedly small and that of stage 1 sleep was moderately large during BZD therapy. The amount of stage 1 was smaller and that of stage 2 was larger during treatment with ZPC than BZDs. There were no significant change in the amount of SWS between the treatment. Half of the patients exhibited a sleep-onset REM period (SOREMP) during ZPC therapy. Both total BPRS score and negative symptom score were lower during treatment with ZPC than BZDs. These results suggest that ZPC may be more beneficial in treating schizophrenic insomnia than BZD hypnotics and that reduced SWS and SOREMP may be partly involved in the pathophysiology of schizophrenia.

Total parenteral nutrition supplemented with L-alanyl-L-glutamine and gut structure and protein metabolism in septic rats

The effects of administering total parenteral nutrition (TPN) supplemented with the dipeptide of L-alanyl-L-glutamine (Ala-Gln) on gut structure, barrier function, and protein metabolism were investigated in septic rats. Sepsis was induced by the continuous intraperitoneal administration of endotoxin via a miniosmotic pump. Twenty-three rats were divided into two groups and fed parenterally for 5 days. The Ala-Gln group (n = 11) received a conventional TPN solution supplemented with 2% Ala-Gln, whereas the control group (n = 12) received conventional TPN solution alone. One rat in each group died of endotoxemia. The groups showed similar nitrogen balance, urinary excretion of 3-methylhistidine, and plasma concentration of endotoxin in the portal vein. The groups showed similar incidence of bacterial translocation from the gut to the mesenteric lymph nodes. The intestinal mucosal weight and villous height were significantly greater in the Ala-Gln group than in the control group. Pathological derangement of the mucosal structure was more marked in the control group than in the Ala-Gln group. These results suggest that TPN supplemented with Ala-Gln preserves the gut structure without decreasing the nitrogen balance under septic conditions.

Glutamine-supplemented parenteral nutrition improves gut mucosa integrity and function in endotoxemic rats

The effects of glutamine-supplemented parenteral nutrition on protein metabolism, small intestinal mucosal metabolism, morphology, and barrier function were studied in endotoxin-treated rats. Forty-six male Wistar rats were randomized to two groups of 23 animals each and received total parenteral nutrition solutions supplemented with either glutamine (GLN group) or glycine (GLY group) at 2% wt/vol. Endotoxemia was induced by continuous intravenous infusion of endotoxin at a dose of 2 mg/kg per day throughout the 4-day study period. The GLN group had a less-negative cumulative nitrogen balance (-14.0 +/- 132.8 mg of nitrogen in the GLN group and -86.8 +/- 161.7 mg of nitrogen in the GLY group, p < .05) and less cumulative excretion of urinary 3-methylhistidine (2910 +/- 593 nmol) than the GLY group (4447 +/- 933 nmol, p < .01). Jejunal mucosal glutaminase activity and the arterio-portal venous blood glutamine concentration differences were significantly higher in the GLN group compared with the GLY group (15.6 +/- 2.3 vs 11.1 +/- 1.9 mumol/g per minute, p < .05, and 181 +/- 52 vs 147 +/- 36 nmol/mL, p < .05, respectively). The morphology of the jejunal mucosa in the GLN group was significant for having greater mucosal weight (23.4 +/- 3.1 vs 17.6 +/- 2.5 mg/cm), villus height (445 +/- 75 vs 357 +/- 57 microns), crypt depth (197 +/- 34 vs 161 +/- 28 microns), and wall thickness (751 +/- 77 vs 648 +/- 102 microns) than the GLY group (p < .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmaco-EEG mapping of diazepam effects using different references and absolute and relative power

The effects of diazepam on the EEG were studied by means of EEG topographic mapping, using recordings with four different references. Subjects were ten healthy, right-handed, male volunteers aged 21-25 years. Double-blind crossover trials with a single oral dose of 10 mg diazepam and placebo controls were conducted in random sequence at intervals of one week. Four referential derivations--ipsilateral earlobe (A1A2), average reference (AV), source derivation (SD), and balanced noncephalic electrode (BNE)--were used. One-minute vigilance-controlled EEGs before drug administration and two hours after drug administration were analyzed using Fourier transformation; absolute power and relative power were calculated for four frequency bands. Diazepam caused a widespread increase of beta-frequency relative power, and a widespread decrease of theta-frequency absolute power when A1A2 and SD were taken as references. From the comparison of different reference electrodes we conclude that the selection of the reference and of spectral parameters (absolute power or relative power) play an important role in pharmaco-EEG studies.

Prognosis in esophageal carcinoma with cervical lymph node metastases

BACKGROUND

The purpose of this study was to assess cervical lymph node (C-LN) metastases and to examine whether the site of the C-LN metastasis impacts on survival of the patient with thoracic esophageal cancer.

METHODS

Transthoracic esophagectomy and three-field dissection (mediastinal, abdominal, and C-LN) followed by esophageal reconstruction were performed on 68 patients with squamous cell carcinoma of the thoracic esophagus who were seen at our institution from 1983 to 1990.

RESULTS

C-LN metastasis was seen in 20 (29.4%) patients, and the survival curve of the 20 patients with positive C-LN metastasis was not significantly different from that of the 48 patients without positive C-LN metastasis. The survival curve of patients (n = 7) with positive node limited to recurrent laryngeal nerve chain node (RLN group) was significantly better than that of patients (n = 13) with positive internal jugular nodes including supraclavicular nodes (IJN group) (p = 0.010; generalized Wilcoxon). This was because there were more patients in the IJN group (84.6%) than in the RLN group (28.6%) (p = 0.022) who had five or more positive nodes in the three fields.

CONCLUSIONS

The results suggest that RLN should not be defined as M1 but as N1 in thoracic esophageal cancer.

Memory and cognitive impairments in a case of long-term trihexyphenidyl abuse

We present a case of long-term trihexyphenidyl (THP) abuse in which memory and cognitive impairments were observed 23 years after the commencement of medication. This case showed a dramatic improvement after withdrawal of THP. Clinical course during admission was followed with psychometric testing and laboratory examinations. The fact that the patient showed no evidence of lowered alertness during the clinical course raises the possibility that THP can primarily induce impairment of memory and cognitive functions. This is supported by the findings on the resting EEG of the patient. This case emphasizes the need to exercise caution in prescribing high doses of anticholinergic agents for long periods, particularly in elderly patients with underlying brain pathology.

Preoperative in vitro chemosensitivity test of esophageal cancer with endoscopic specimens

BACKGROUND

From January 1990 to June 1991, the authors tested in vitro chemosensitivity before surgery with endoscopic biopsy specimens from 23 patients with intrathoracic esophageal cancer.

METHODS

The authors tested eight anticancer agents using the dye exclusion method, and all 23 patients received chemotherapy with the most sensitive three drugs according to the results of the chemosensitivity test.

RESULTS

Ten patients (43.5%) had a tumor reduction of more than 50% on radiologic studies, and 4 patients (17.4%) had a good histologic effect.

CONCLUSIONS

The chemosensitivity test is useful in selecting preoperative chemotherapeutic agents for patients with esophageal cancer.

Effects of carbamazepine and lithium on affective disorders

Characteristics of the responders and nonresponders to prophylactic treatment with carbamazepine (CBZ) or lithium (Li) were investigated in a retrospective study of 215 bipolar disorder patients who had received more than 2 years of CBZ or Li treatment in Japan. Patients of mania-dominant type, with isolated occurrence of manic and depressive episodes, with onset of the illness below 30 years of age, and with atypical symptomatology, tended to respond favorably to CBZ. Rapid cyclers and patients with a past history of rapid cycling and with a continuous recurrence of episodes responded unfavorably to CBZ. Patients of mania-dominant type also showed a favorable response to Li, while patients with a continuous-type course, with rapid cycling, and a past history of rapid cycling, as with CBZ, tended to respond unfavorably to Li.

On the psychophysiology of dreaming: a sensory image--free association hypothesis of the dream process

A psychophysiological hypothesis of the dream process during REM sleep called "a sensory image-free association hypothesis" is proposed. It is assumed that a state with a sustained EEG pattern of drowsiness (non-REM stage-1) and muscle atonia produces a stream of disorganized and vague thinking as a background mentation during the REM sleep. The phasic excitation of the brain occurring concurrently with the burst of rapid eye movements (REMs) activates the hippocampal-neocortical memory system and draws out sensory images from the memory reservoir of the brain. The dreamer makes a freely organized association about the successive sensory images and makes up a dream story. This hypothesis is compatible not only with the recent neurophysiological findings but also with traditional psychological interpretation of the dream content.