Gaucher disease carrier with gestational thrombocytopenia and anemia: a case report

Background

Gaucher disease is an autosomal recessive inborn error of metabolism that causes disorders of blood, bone, and central nervous system as well as hepatosplenomegaly. We present the case of a carrier of Gaucher disease with gestational thrombocytopenia and anemia that required blood transfusion therapy.

Case presentation

A 24-year-old Nepalese primipara was diagnosed with idiopathic thrombocytopenia at 12 weeks of gestation. Her platelet count had reduced to 30,000/µL at 21 weeks of gestation, and the hemoglobin content reduced to 7.6 g/dL at 27 weeks of gestation. As she did not respond to any medication, blood transfusion was performed. A female infant weighing 2677 g was delivered vaginally at 39 weeks of gestation. On the 78th day of puerperium, the platelet count of the mother recovered to 101,000/µL, and the hemoglobin content recovered to 12.5 g/dL. The infant had convulsions, respiratory depression, wheezing, systemic purpura, and exfoliation of the epidermis at birth. The infant was diagnosed with Gaucher disease at 37 days of age and passed away at 82 days of age. Subsequently, the parents were diagnosed as carriers of Gaucher disease.

Conclusion

As carriers of this disease do not usually show symptoms, it is imperative to provide information regarding disease management for future pregnancies.

Attitude changes toward prenatal testing among women with twin pregnancies after the introduction of noninvasive prenatal testing: A single-center study in Japan

Aim

This study aimed to evaluate changes in prenatal testing among women with twin pregnancies before and after the introduction of noninvasive prenatal testing (NIPT). To date, no consensus on prenatal testing for twin pregnancies has been reached in Japan.

Methods

Women pregnant with twins who requested prenatal testing at Kyushu Medical Center from 2005 to 2018 were included in this study. Genetic counseling was provided to all participants. Their chosen methods of testing were collected and classified as invasive diagnosis (ID), noninvasive screening (NIS), and no test requested (NR). Parity, chorionicity, and methods of conception were assessed as attributes. The study period was divided into three terms according to testing availability in our center.

Results

After NIPT was introduced in our center, the use of ID methods decreased and eventually disappeared while NIS came to the forefront. NR was also the preferred choice of women with twin pregnancies before the introduction of NIPT and decreased but did not disappear after introducing NIPT. Women with twin pregnancies who underwent assisted reproduction initially showed hesitation to undergo testing but showed a strong preference for NIS after the introduction of NIPT. Differences in choice according to parity, chorionicity, and methods of conception were found before the introduction of NIPT but disappeared after introducing NIPT.

Conclusion

Increasing information about NIPT has apparently influenced the attitudes of women with twin pregnancies to prenatal testing in Japan. In particular, those who conceive through assisted reproductive technologies exhibited a strong preference for NIPT.

Evaluation of the clinical performance of noninvasive prenatal testing at a Japanese laboratory

AIM

We aimed to evaluate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of noninvasive prenatal testing (NIPT) in high-risk pregnant women.

METHODS

Pregnant women who underwent GeneTech NIPT, the most commonly used NIPT in Japan, between January 2015 and March 2019, at Japan NIPT Consortium medical sites were recruited for this study. The exclusion criteria were as follows: pregnant women with missing survey items, multiple pregnancy/vanishing twins, chromosomal abnormalities in the fetus other than the NIPT target disease, and nonreportable NIPT results. Sensitivity and specificity were calculated from the obtained data, and maternal age-specific PPV and NPV were estimated.

RESULTS

Of the 45 504 cases, 44 263 cases fulfilling the study criteria were included. The mean maternal age and gestational weeks at the time of procedure were 38.5 years and 13.1 weeks, respectively. Sensitivities were 99.78% (95% confidence interval [95% CI]: 98.78-99.96), 99.12% (95% CI: 96.83-99.76), and 100% (95% CI: 88.30-100) for trisomies 21, 18, and 13, respectively. Specificities were more than 99.9% for trisomies 21, 18, and 13, respectively. Maternal age-specific PPVs were more than 93%, 77%, and 43% at the age of 35 years for trisomies 21, 18, and 13, respectively.

CONCLUSION

The GeneTech NIPT data showed high sensitivity and specificity in the detection of fetal trisomies 21, 18, and 13 in high-risk pregnant women, and maternal age-specific PPVs were obtained. These results could provide more accurate and improved information regarding NIPT for genetic counseling in Japan.

Retrospective details of false-positive and false-negative results in non-invasive prenatal testing for fetal trisomies 21, 18 and 13

OBJECTIVE

Maternal characteristics and neonatal outcomes associated with cell-free DNA (cfDNA) results were analysed retrospectively to assess the details of false-positive and false-negative results after initial blood sampling in non-invasive prenatal testing (NIPT).

STUDY DESIGN

A multicentre retrospective study was performed for women undergoing NIPT who received discordant cfDNA results between April 2013 and March 2018. The NIPT data obtained using massive parallel sequencing were studied in terms of maternal background, fetal fraction, z-scores, invasive procedure results and neonatal outcomes after birth.

RESULTS

Of the 56,545 women who participated in this study, 54 false-positive (0.095 %) and three false-negative (0.006 %) cases were found. Seven of the 54 false-positive cases (13.0 %) had vanishing twin on ultrasonography. Among the 18 false-positive cases of trisomy 18, confined placental mosaicism (CPM) was confirmed in three cases (16.7 %), while CPM was present in one of the three false-negative cases of trisomy 21.

CONCLUSION

These data suggest that the incidence of women with false-positive or false-negative results is relatively low, that such false results can often be explained, and that vanishing twin and CPM are potential causes of NIPT failure. Genetic counselling with regard to false results is important for clients prior to undergoing NIPT.

Effect of Membrane Trapping in Plasma Fractionator on Separative Characteristics

Several kinds of plasma fractionators have been introduced to actively separate protein fractions between albumin and globulins in double filtration plasmapheresis. However, relatively large molecular weight proteins are known to be partially trapped by the membrane in a plasma fractionator.

In this paper, effects of membrane trapping on separation characteristics in plasma fractionators were examined during in vitro and in vivo studies. All in vitro experiments were done with a closed circuit under constant-flow rate filtration. Protein concentration in feed tank kept constant at no filtration in AS-14H, Evaflux 4A and 2A, while 20-40% of IgG and 40-60% of β-lipoprotein in 2 liter plasma were removed by membrane trapping for 300 min when filtration fraction equaled 0.87. Protein plugging to the membrane seems to be a major factor in these proteins. And, Dead-end and Partially Discarded modalities with relatively high filtration fraction are effective for the separation between albumin and globulin.

Twenty-seven DFPP treatments in 13 patients with autoimmune diseases were done to allow us to estimate the effects of membrane trapping during an in vivo study. All treatments using 6 types of plasma fractionator were performed under constant operating conditions with Partially Discarded modality. In any plasma fractionator, β-lipoprotein was fairly trapped at 30 min after the start of treatment.

[Efficacy and safety of transdermal fentanyl patches for opioid initiation in patients with gastrointestinal obstruction]

The transdermal fentanyl patch (TDF) can be used when switching from other opioids; therefore, little is known about the efficacy and safety of TDF patches applied for opioid initiation. However, TDF patches have been applied for opioid initiation in gastrointestinal cancer patients with gastrointestinal obstruction. In this study, we retrospectively investigated 12 gastrointestinal cancer patients to evaluate the efficacy and frequency of adverse effects of TDF patches compared to oral oxycodone (OXY) for opioid initiation. The frequency of adverse effects such as nausea, somnolence, and constipation in the TDF patch group was 25%, 41.7%, and 8.3%, respectively. No severe adverse effects were observed, and there was no significant difference between the TDF patch and OXY groups. Moreover, according to the numerical pain rating scale(ranging from 0 [no pain] to 10 [worst possible pain]), the pain intensity in the TDF patch group decreased from 5.42 on the first day to 3.33 after 3 days (p=0.0377), and 2.67 after 7 days (p=0.0089), with no significant difference between groups. Our study results suggest that TDF patches applied for opioid initiation may be useful for gastrointestinal cancer patients with gastrointestinal obstruction.

[HIV infected pregnant women in Japan and prevention of mother-to-child transmission]

By the investigation of our study group 595 HIV infected pregnant women have been confirmed in Japan since 1984. In recent years, around 40 pregnant women a year were diagnosed as HIV positive. These HIV infected pregnant women were not concerned with a value of CD4 and received antiretroviral therapy such as zidovudine (AZT) monotherapy or highly active antiretroviral therapy (HAART) starting from the second trimester of pregnancy. According to recommendations and current data, cesarean delivery before the onset of labor is performed around 37 weeks of pregnancy and prophylactic AZT syrups are given to infants starting 8-12 hrs after birth for 6 weeks. These preventive managements such as antiretroviral therapy, elective cesarean delivery and formula feeding significantly reduced mother-to-child transmission (MTCT) of HIV. The transmission rate of HIV fell to 0.5% in Japan, but the problem of the teratogenicity of antiretroviral drugs remain unclear. Further studies are needed.

[Neoadjuvant chemotherapy with cisplatin and CPT-11 for advanced cervical cancer]

Neoadjuvant chemotherapy (NAC) is currently used for the treatment of advanced cervical cancer by many institutions. We investigated the value of NAC followed by radical surgery and/or radiotherapy for patients with locally advanced cervical cancer. Sixteen patients with stage Ib2-IIIb cervical cancer were enrolled in this study. CPT-11 (60 mg/m2) in 500 m/5% glucose was given intravenously on Days 1, 8, and 15, before cisplatin (60 mg/m2) in 500 ml normal saline. The treatment was repeated every 4 weeks for 2 or 3 cycles. All patients were evaluable for response and toxicity. Two achieved a clinical complete response (CR), 11 had a partial response (PR), 2 had no change (NC) and 1 had progressive disease (PD), for an overall response of 81.3%. Neutropenia was observed in 100% (> grade 3: 70.6%) and diarrhea was recorded in 55.9% (> grade 3: 5.9%). The combination of CPT-11 and cisplatin in locally advanced cervical cancer is thus an active regimen with a manageable toxicity as a neoadjuvant chemotherapy.

Comparative efficacies of a calcium antagonist and an alpha1 blocker in elderly hypertensive patients with stroke

We compared the effects of nilvadipine, a calcium antagonist, and terazosin. an alpha1 blocker, on the hemodynamics and quality of life (QOL) in 12 elderly hypertensive patients with stroke. Following a washout period of 2 weeks. nilvadipine or terazosin was administered for 2 weeks in a randomized crossover manner. At the end of control and treatment periods, we measured the 24-hour-ambulatory blood pressure (BP) and postural change of BP, and interviewed QOL. Terazosin treatment did not show consistent decrease of casual BP, but was associated with a transient decrease of systolic BP and an increase of pulse rate after standing, and enhanced postprandial decrease in BP. Nilvadipine decreased casual BP in a dose-dependent manner, but showed neither postural nor postprandial change of BP. There was no difference in QOL scores with either treatment. Results suggest that nilvadipine is preferable to terazosin for the treatment of elderly hypertensive patients with stroke.

Neoadjuvant intraarterial chemotherapy followed by radical hysterectomy and/or radiotherapy for locally advanced cervical cancer

OBJECTIVES

We assessed neoadjuvant intraarterial chemotherapy (NAC) followed by radical hysterectomy and/or radiotherapy in patients with locally advanced cervical cancer.

METHODS

Over 5 years, 48 consecutive women with International Federation of Gynecology and Obstetrics stage IIb-IVa cervical cancer were enrolled. Treatment consisted of bilateral internal iliac artery infusion of cisplatin (100 mg/m2, day 1) or carboplatin (400 mg/m2, day 1) and peplomycin (20 mg/m2, day 1) for two courses separated by 3 weeks. Doxorubicin (30 mg/m2, day 1) was added for patients with adenocarcinoma. Stage III patients who responded to NAC and Stage IIb patients underwent radical hysterectomy with pelvic lymphadenectomy. Stage III patients not responding to NAC and all stage IVa patients were treated with pelvic radiotherapy.

RESULTS

Complete response was achieved in 5 (10.4%) of 48 patients, while a partial response was noted in 32 (66. 7%) and stable disease in 11 (22.9%). Of 25 patients with stage IIIb disease, 16 (64.0%) were able to undergo surgery. The 4-year disease-free survival (DFS) was 80.0% in patients with stage IIb and 62.3% in patients with stage III. In stage IIIb, the 4-year DFS in patients receiving surgery (75.2%) was higher than the DFS for those receiving radiotherapy (44.4%) (P < 0.05). Grade 3 or 4 leukopenia developed in 17 (35.4%) patients. Nausea and vomiting of grade 2 or higher occurred in 34 (70.8%). Creatinine clearance transiently decreased (>/= grade 2) in 16.6%. Patients negative for serum squamous cell carcinoma-associated antigen (SCC) responded better to NAC than to SCC-positive cases, and SCC-negative survival was significantly better than SCC-positive survival (P < 0.05).

CONCLUSIONS

Neoadjuvant intraarterial chemotherapy with platinum was safely performed, and a survival benefit followed radical surgery with or without radiotherapy after response to NAC.

[Effect of 5'-DFUR used concurrently in radiotherapy and immunotherapy uterine cervical cancer--pilot study. Study of 5'-DFUR for Uterine Cervical Cancer]

We conducted a preliminary controlled study in order to evaluate 5'-DFUR dose dependency in efficacy and safety in combination therapy of radiotherapy, 5'-DFUR and SPG for patients with uterine cervical cancer, which was regarded as suitable for cases of radiotherapy. The patients were randomly allocated into group A (5'-DFUR 600 mg/body/day) and group B (5'-DFUR 800 mg/body/day), who underwent radiotherapy with simultaneous administration of 5'-DFUR and SPG (20 mg twice/week or 40 mg/ week). Those enrolled were 33 patients in stage II, III or IV a with histologically diagnosed primary squamous cell carcinoma of uterine cervix. CR was shown in 19, PR in 7, NC in 1, and PD in 2 out of 29 efficacy-evaluable cases, so the overall response rate was 89.7% (26/29, 95% CI 72.7%-97.8%). Regarding safety, some side effects were observed in 26 out of 33 safety-evaluable cases (81.3%, 95%, CI 63.6%-92.8%), but no serious cases. No significant difference in efficacy and safety was observed between the two treatment groups. These results suggested that the combination therapy of radiotherapy, 5'-DFUR and SPG might be one of the therapies whose effectiveness must be confirmed for advanced squamous cell carcinoma of uterine cervix. To confirm dose dependency of 5'-DFUR, it seems further consideration with more patients is needed.

[Combination of irinotecan hydrochloride (CPT-11) and cisplatin as a new regimen for patients with advanced ovarian cancer]

It has been reported that the antitumor effect of CPT-11 is manifested through the inhibition of topoisomerase I by SN-38 which is an active metabolite of CPT-11 produced by intracellular carboxylesterase, and that CPT-11 is effective against recurrent ovarian carcinoma. We investigated the antitumor effect and adverse reactions in the combined therapy with CPT-11 and CDDP in patients with prior chemotherapy for recurrent carcinoma, and in 7 patients without prior chemotherapy, consisting of 4 patients with postoperative adjuvant chemotherapy for clear cell carcinoma and 3 patients with metastatic ovarian carcinoma. CDDP was administered on day 1 and CPT-11 was administered three times on days 1, 8 and 15. The dose of both CDDP and CPT-11 was 50 mg/m2 or 60 mg/m2. Adverse reactions were investigated in all patients and the antitumor effect was assessed in 12 patients with recurrent carcinoma who had measurable lesions. (1) The DLF was neutropenia. The neutrophil count nadiar occurred on day 18 or 19. Grade 3 or 4 adverse reactions were observed in 60% or more of the patients, but they disappeared following short term administration of G-CSF. In patients with recurrent carcinoma given CDDP and CPT-11 at 60 mg/m2, the incidence of grade 3 or 4 adverse reactions and number of occasions on which CPT-11 administration had to be postponed were higher than those in patients given 50 mg/m2. (2) Mild platelet reduction was observed. (3) Grade 3 or 4 diarrhea was observed in 3.2% of patients with recurrent carcinoma and in 7.7% of patients with metastatic ovarian carcinoma. (4) The antitumor effect was evaluated in 12 patients with recurrent carcinoma: CR in 2 patients. PR in 3, NC in 6, and PD in one. The response rate was 41.7%. (5) An antitumor effect was observed in 2 patients with serous carcinoma and in one patient each with mucous carcinoma, clear cell carcinoma and endometrial carcinoma. In conclusion, adverse reactions caused by the combination therapy with CPT-11 and CDDP (CPT-11: 50-60 mg/m2 on days 1, 8 and 15, CDDP: 50-60 mg/m2 on day 1) can be relieved by short term administration of G-CSF and it is suggested that the combination therapy may be effective in treating ovarian carcinoma.

Efficacy of adjuvant chemotherapy for endometrial carcinoma with high-risk factor for recurrence

Between April 1989 and December 1992, 38 patients with endometrial cancer who were at high risk for recurrence entered a prospective study designed to evaluate the efficacy of adjuvant platinum (cisplatin), adriamycin (doxorubicin), and cytoxan (cyclophosphamide) (PAC) chemotherapy. Patients received cisplatin (50 mg/m(2)) doxorubicin (30 mg/m(2)) and cyclophosphamide (500 mg/m(2)) at 3-week intervals for 2-3 cycles. All patients completed the treatment, there were no life-threatening adverse events. The median duration of follow-up was 52.9+/-16.9 months. Six patients developed a recurrence, and 4 of them died after a median interval of 45.5 months. Five of the six patients with recurrence had stage IIIc disease. The 3-year progression-free survival was 83.3%, the overall survival rate was 89.2%. Results suggest that adjuvant chemotherapy with PAC may reduce the incidence of recurrence and improve the survival rate of patients with endometrial cancer.

[Mass-screening for ovarian cancer by transvaginal ultrasonography--study on ultrasonographic findings]

Mass-screening for ovarian cancer by means of transvaginal ultrasonography has been performed in Aomori Prefecture since 1989. To select appropriate candidates to receive the second screening, the findings in 614 ultrasonic pictures of pelvic tumors over 30mm recorded on a VTR were studied. The results were as follows: 1) At the first screening, the rate of solid tumors was similar in each age group, but that of mixed tumors was higher in the thirties. 2) When ultrasonic findings at the first screening with that of the second screening were compared, (1) Twenty to thirty per cent of all tumors detected in the first screening had disappeared or had become under 30mm in size at the second screening. (2) About 20% of solid tumors detected in the first screening were not ovarian tumors (uterine myomas or others) in the second screening, regardless of the tumor size. (3) The rate which decided the course of therapy or follow up at the time of the second screening was not related to the ultrasonic findings for tumors smaller than 50mm. At the present time, classification of transvaginal ultrasonic findings is insufficient, and so it is difficult to use it to select appropriate candidates to receive the second screening. But the ultrasonic findings are very important in deciding on the course of therapy and follow up.

[Mass-screening for ovarian cancer by transvaginal ultrasonography--study on tumor markers at the second screening]

Examination of tumor markers (CAMPAS) at the second screening in our mass-screening for ovarian cancer was evaluated. CAMPAS has been performed in 866 women with enlarged ovaries over 30mm in size among 20,242 who received the first screening by transvaginal ultrasonography. In those with semi-malignant and malignant ovarian tumor (ovarian cancer), their serum levels of CA125, CEA, CA19-9, AFP and L-LDH were also measured (Combination Assay) and CA125, CEA, CA19-9, AFP, CA602, CA54 and CA61 antigens in removed tumor tissues were studied by immunoperoxidase staining (Tumor Assay). The results were as follows: 1) Ten of the 866 women were positive for CAMPAS, however, only one of them was found to have ovarian cancer. 2) Of the 20,242 women, six were found to have ovarian cancer: all in stage I and all detected among these 866 women. 3) Of the 6 women with ovarian cancer, three had high serum levels in the Combination Assay, and 4 had positive finding in the Tumor Assay, but of the 4 women with a positive Tumor Assay, one had different kinds of tumor markers in serum and one did not have a high serum level. Thus, CAMPAS was not useful as the second screening method in our mass-screening system for ovarian cancer.

Prevalence in Sweden of human papillomavirus type 16 infection in CIN II-III cases assessed by a PCR method

The presence of human papillomavirus (HPV) 16 in cervical intraepithelial neoplasia (CIN)II-III cases was studied by means of a polymerase chain reaction (PCR)-based method applied to paraffin-embedded tissues. Twenty-two of 45 (49%) cases showed a positive signal determined by direct visualization on gel stained with ethidium bromide. Fourteen of these cases were confirmed by dot blot hybridization, which accords with a prevalence of HPV 16 infection in 31% of Stockholm patients with CIN II-III. The latter value is lower than that published elsewhere (Young et al. 1989; Maki et al. 1991; Skydberg et al. 1991).

Immature teratoma of the uterine fundus

An exceedingly rare case of extragonadal immature teratoma, which occurred primarily in the uterus, is described. The tumor developed into the pelvic cavity from the uterine fundus and consisted of ectodermal, mesodermal and endodermal derivatives. There were also significant amounts of immature elements; immature neuroepithelium with brisk mitotic activity, immature mesenchymal tissue, immature cartilage, immature striated muscle and immature hepatic tissue. Histologically, it was classified as a grade 3 immature teratoma. Treatment consisted of total simple hysterectomy followed by 2 courses of combination chemotherapy with vincristine, actinomycin D and cyclophosphamide (VAC). The patient was well and without evidence of recurrence at 5 years post-operatively.

Optimum albumin concentration of supplementation fluid for double filtration plasmapheresis

Until recently, the albumin concentration of supplementation fluid for double filtration plasmapheresis (DFPP) has been empirically determined. Inadequate albumin infusion often leads to hypoproteinemic symptoms such as edema. In the current study, an aimed condensation coefficient (CCaimed) was introduced in an attempt to estimate the appropriate plasma albumin level for each patient. This coefficient is theoretically derived from a one-compartment model for the patient's plasma albumin: CCaimed = CS/CD = 1 - (1 - CR)/[1 - exp(- CC.VR)] where CD and CS are albumin concentrations in discarded plasma and supplementation fluid. CR is the change ratio of albumin concentration in the patient's plasma during a DFPP treatment, and VR(= VS/VP) is the ratio of supplementation fluid volume (VS) to the patient's total plasma volume (VP). And CC denotes the albumin condensation coefficient in a DFPP line, which depends on the filtration fraction of the plasma fractionator (FFPF) and the sieving coefficients of both the plasma separator (SCPS) and the plasma fractionator (SCPF): CC = CD/CP = SCPS.(1 - FFPF.SCPF)/(1 - FFPF) where CP is the albumin concentration of the patient's plasma. From the above relations, CS can be determined as follows: CS = CC.CCaimed.CP Because many kinds of proteins are removed during a single DFPP treatment, a slightly higher albumin concentration in the supplementation fluid is needed to maintain an appropriate plasma level. Therefore, the CR value should be more than unity. For a patient with hematocrit (HCT) of 30%, body weight (BW) of 50 kg, and CP of 3.0 g/dl, who is receiving a DFPP treatment using AP-05H (SCPS of 0.970) and Evaflux 2A (SCPF of 0.526) under FFPF of 0.8 with VS of 500 ml, VP = BW(1- HCT/100)/13 = 50 x (1 - 30/100)/13 = 2.69 L, VR = 500/(2.69 x 1,000) = 0.186, CC = 2.81, and CCaimed = 1.25 assuming 1.1 for CR. Therefore, CS = 2.81 x 1.25 x 3.0 = 10.5 g/dl using the above equations.

Prevalence and etiology of dementia in a Japanese community

BACKGROUND AND PURPOSE

We sought to determine the type-specific prevalence of dementia and its risk factors in elderly persons from the Japanese community of Hisayama.

METHODS

We studied the prevalence of dementia in 887 Hisayama residents (353 men and 534 women) aged 65 years or older (screening rate, 94.6%) using various items of clinical information, neurological examination, and dementia scales. We also studied brain morphology in 50 of 59 determined to have dementia by computed tomography or autopsy during the subsequent 54-month period. Factors relevant to dementia were compared between 27 patients with vascular dementia and 789 control subjects without dementia in a retrospective fashion.

RESULTS

The prevalence rate of dementia among Hisayama residents aged 65 or older was estimated at 6.7%, with a females to males ratio of 1:2. Among 50 cases of dementia in which brain morphology was examined, the frequency of vascular dementia was 56%; this rate was 2.2 times higher than that for senile dementia of the Alzheimer type. Aging, hypertension, electrocardiographic abnormalities, and high hematocrit were significantly (p less than 0.05) and independently associated with the occurrence of vascular dementia.

CONCLUSIONS

Prevalence of dementia among the Hisayama residents was relatively identical to that previously reported, but vascular dementia was more predominant. Risk factors for vascular dementia were similar to those for lacunar infarcts. Control of hypertension may be a key to reducing dementia among the Japanese population.

[Mass-screening for ovarian cancer by means of transvaginal ultrasonography]

Since April, 1989 in Aomori Prefecture, mass-screening for ovarian cancer by means of transvaginal ultrasonography has been performed in a mass-screening car at the same time mass-screening for uterine cervical cancer. Subjects for this screening were self referred asymptomatic women 30 years of age or older. Real time ultrasonography was performed with a 5-MHz endovaginal transducer 5 sections for scanning were established by means of a transvaginal probe and all ultrasonic pictures obtained were recorded with an 8mm VTR. For women with abnormal ultrasonic findings, such as an ovary (tumor) over 30mm in size and massive ascites, a second screening or accurate examination was performed by retransvaginal ultrasonography, CT-scan, MRI and a combination assay of tumor markers. The results were as follows: The time required for the first screening, including bimanual examination, collection of Pap smear and ultrasonic examination, was about 60-70 seconds. The total number of screened women was 15,282, and 838 (5.5%) of them needed to receive the follow-up examinations. Laparotomy has been done for 48 women to date and 2 women were found to have premalignant and malignant ovarian tumors.

Prevalences of hepatitis B surface antigen carriers and liver damages in the general population of Hisayama, Japan

The prevalences of hepatitis B surface antigen (HBsAg) carriers and liver damages were studied in 2,411 residents aged 40 and over and living in Hisayama, Japan in 1983. Hepatitis B virus (HBV) associated markers were all measured by radioimmunoassay. HBsAg carriers were found in 2.3 per cent of the residents. Hepatitis B e antigen and antibody to hepatitis B e antigen were positive in 8.9 per cent and 80.4 per cent, respectively, of HBsAg carriers. The prevalences of liver damages in HBsAg carriers were compared with 1095 who had none of HBV markers (neither anti-HBc nor anti-HBs). The prevalences of abnormal aminotransferase level in sera were not different between HBsAg carriers and those who had none of HBV markers. A history of jaundice and/or hepatitis was evident in 32.3 per cent of male carriers and 24.0 per cent of female ones, being significantly more than those without HBV markers (13.1 per cent and 5.8 per cent, p less than 0.05 and p less than 0.005, respectively). These results indicate that, among HBsAg carriers aged 40 and over, few have active clinical signs of hepatitis, although about 20 per cent of them have histories of symptomatic hepatitis due to hepatitis B.

Exposure to hepatitis B virus in the general population of Hisayama, Japan: significance of isolated antibody to hepatitis B surface antigen in general population

Cross-sectional survey on the prevalence of hepatitis B serological markers was performed in 2,411 residents who accounted for 74.4% of the population aged 40 and over and living in Hisayama Town, Japan, in 1983. Overall prevalences were 40.7% for both anti-HBs and anti-HBc, 6.1% for isolated anti-HBs and 5.4% for isolated anti-HBc. The condition with isolated anti-HBs was different from those with isolated anti-HBc and both anti-HBc and anti-HBs as follows. The titer of anti-HBs in isolated anti-HBs positive samples was significantly lower than that in both anti-HBs and anti-HBc positive ones (46.2 +/- 5.4 vs. 83.2 +/- 2.8, mean +/- SE, p less than 0.001). The presence of isolated anti-HBs was neither significantly more frequent in males nor related to the risk of liver damages in contrast with that of anti-HBc with or without anti-HBs. These findings suggest that isolated anti-HBs pattern with the absence of anti-HBc in general population was not due to prior HBV infection, but due to natural immunization with HBsAg.

Detection of human papillomavirus (HPV) infections in Japanese women with and without abnormal cervical cytology by dot blot and Southern blot hybridization

The frequency of human papillomavirus (HPV) was investigated in 245 Japanese women (100 showing normal cytology and 145 showing abnormal cytology). A previously presented method for the detection and typing of HPV DNA was used, where a dot blot test excluded samples that did not hybridize with HPV DNA. Positive samples were further analyzed by a southern blot procedure, to give the HPV type. A mixture of subgenomic probes of the types 6, 11, 16, 18, 31, 33 and 35 was used. HPV DNA was detected in only 2% (2/100) of patients without abnormal cytology. In patients with abnormal cytology, the frequency was 30% (43/145). HPV was detected in 100% (2/2) of the patients with condyloma acuminatum, 39% (26/66) of those with mild to moderate dysplasia, 44% (7/16) of those with severe dysplasia to carcinoma in situ, and 70% (7/10) of those with invasive carcinoma. Young women (20-29 yr.) had the highest HPV frequency (71%). HPV types 16 and 18 were found in 39% of the patients with mild to moderate dysplasia, in 71% of those with severe dysplasia to carcinoma in situ and in 86% of those with invasive carcinoma. These may be considered as high risk types for development to cancer. HPV type 31 may be considered as a moderate risk, as it was detected in 37% (16/43) of the patients. HPV types 6 and 11 were found in 100% of patients with condyloma acuminatum (2/2). To clarify the natural history of the HPV infection in the uterine cervix, it is necessary to conduct further studies.

Smoking as cardiovascular risk factor in low cholesterol population: the Hisayama Study

Cigarette smoking as a risk factor for cerebro- and cardiovascular diseases was studied in a long-term prospective population survey which has been carried out in a Japanese rural community, Hisayama. In this population, the incidence of thrombotic brain infarction (TBI) was much higher than that of coronary heart disease (CHD) over a 26-year follow-up period. Cigarette smoking was strongly related to the occurrence of CHD but not to TBI. Comparing the incidence of CHD and TBI between first or early cohort (1961-74) and second or recent cohort (1974-87) during the 13-year follow-up, the incidence remained unchanged for CHD, while it significantly decreased for TBI in recent population. The prevalence of cigarette smoking as well as hypertension decreased in recent years, while hypercholesterolemia, obesity, and glucose intolerance increased. Smoking is a major contributor to CHD for men in both cohorts, but it is not any more for women in the recent cohort.

Torsion of parovarian cyst--report of two cases

A parovarian cyst oxiginates from the tissue of the broad ligament, predominantly from mesothelium covering the peritoneum but also from paramesonephric and mesonephric remnants. Clinically, torsion of a parovarian cyst is uncommon, and it is difficult to distinguish it from torsion of other adnexal masses, an ovarian accident, appendicitis, etc. Recently, we experienced two cases of torsion of parovarian cysts. In one case, it was associated with 32 weeks' intrauterine gestation. In this case, pelvic sonography during the first and second trimester showed no cystic lesions. In the other case, a lower abdominal pain continued about two weeks. A sonogram revealed a very small cyst like a follicle. These twisted parovarian cysts were removed at laparotomy. The clinical and pathological features of the torsion of parovarian cysts are briefly discussed and the literature is reviewed.

Causes of death in the elderly and their changing pattern in Hisayama, a Japanese community. Results from a long-term and autopsy-based study

The causes of death for the elderly were prospectively studied in Hisayama, Japan, a rural community. We compared 1,621 subjects, aged 40 years or over, recruited in 1961, and 2,053 subjects recruited in 1974. Each cohort was studied in a follow-up that lasted 10 years; they had autopsy rates of 82.1% and 86.1% during each 10-year period, respectively. The most common causes of death for those aged 70 years or over were cerebrovascular disease, malignant neoplasms, and pneumonia. Deaths due to cerebrovascular disease tended to decrease in the recent cohort, but the proportion of decline was more prominent in cases aged 40 to 69 years. There was a sex difference in the changing pattern of mortality from heart diseases including ischemic heart disease. Deaths by both heart diseases and ischemic heart disease increased in the more recent cohort of aged women, whereas they decreased in the aged men. Pneumonia was an important cause of death for the elderly in both cohorts. Deaths due to "senility" were rare, being only 1% of the deceased aged 70 or over. With prolonged lifespan, especially for women, the impact of atherosclerosis and its related disorders on the recent Japanese aged population appears to have increased.

Seasonal variation in stroke incidence in Hisayama, Japan

We investigated seasonal variation in the incidence of cerebral stroke among the general population aged greater than or equal to 40 years in November of 1961 in Hisayama, Japan. During the 24-year follow-up period, 311 cases of cerebrovascular diseases occurred. The date or month of onset was determined in 308 cases, of which 51 were classified as intracerebral hemorrhage, 223 as cerebral infarction, and 27 as subarachnoid hemorrhage. We observed a significant seasonality in the incidence of all stroke (p less than 0.01), of intracerebral hemorrhage (p less than 0.05), and of cerebral infarction (p less than 0.01), whereas subarachnoid hemorrhage had no significant seasonal pattern. Subjects less than 64 years of age showed a significant seasonal variation in the incidence of both intracerebral hemorrhage (p less than 0.05) and cerebral infarction (p less than 0.01). A significant seasonal pattern for the incidence of intracerebral hemorrhage was also noted among persons with hypertension (p less than 0.05) or a high serum cholesterol level (p less than 0.05), whereas such a pattern for cerebral infarction was documented among normotensive persons (p less than 0.05) and those with a low serum cholesterol level (p less than 0.01). In addition, the incidences of intracerebral hemorrhage and cerebral infarction were negatively correlated with mean ambient temperature (p less than 0.01 and p less than 0.05, respectively), and all stroke and intracerebral hemorrhage in men were significantly related to intradiurnal temperature change (p less than 0.05 and p less than 0.01, respectively). The significance of the seasonal occurrence of stroke is discussed in relation to relevant risk factors.

Incidence and prognosis of subarachnoid hemorrhage in a Japanese rural community

Twenty-six first episodes of subarachnoid hemorrhage occurred among 1,621 Hisayama residents aged greater than or equal to 40 years during the 22-year follow-up of a prospective study. Subarachnoid hemorrhage was confirmed by both clinical and autopsy findings. The average annual incidence (96.1/100,000 population) was 3-13 times higher than any previously reported and steeply increased with age in both sexes, being 2.3 times higher for women than for men after adjusting for age. Nine patients (35%) died less than or equal to 8 hours after the onset of subarachnoid hemorrhage. None was correctly diagnosed on the death certificates, and four of the nine (44%) were misdiagnosed as intracerebral hemorrhage. We found the survival rate of patients suffering subarachnoid hemorrhage to be much lower than previously reported because we detected a large number of sudden deaths due to subarachnoid hemorrhage through the high rate of autopsy in our cohort (81.4%).

A sensitive thyroid stimulating hormone assay for screening of thyroid functional disorder in elderly Japanese

The use of a screening test for thyroid functional disorder by sensitive thyroid stimulating hormone assay in the elderly was investigated. The basal thyroid stimulating hormone levels predicted the response of thyroid stimulating hormone to thyrotropin releasing hormone; it was suppressed in 99 (99.0%) of 100 hyperthyroid patients. Therefore, not only primary hypothyroidism but also hyperthyroidism can be excluded when the serum thyroid stimulating hormone levels are normal. An epidemiological study was then performed on 2,421 (76.7%) of the Japanese general population aged 40 or over recruited from the residents in Hisayama town and also in 122 residents between 20 and 40 years of age. Additional free T4 measurement was necessary in about 10% of the residents with abnormal TSH levels to confirm the diagnosis of hyperthyroidism or distinguish latent from overt hypothyroidism. There was a significant correlation between age and serum thyroid stimulating hormone levels after logarithmic conversion (r = 0.1533, P less than .001). The prevalence of thyroid dysfunction found in 1,026 males and in 1,395 females aged 40 or over was, respectively: hyperthyroidism, less than 0.1% and 0.2%, latent (subclinical) hypothyroidism, 3.2% and 5.5%, and overt hypothyroidism, 0.4% and 0.7%. We conclude that the screening with this sensitive thyroid stimulating hormone assay and additional free T4 measurement is useful for detection of patients with thyroid functional disorder.

Accuracy of diagnosis on death certificates for underlying causes of death in a long-term autopsy-based population study in Hisayama, Japan; with special reference to cardiovascular diseases

Major categorical diagnosis by International Classification of Diseases and type-specific diagnosis for cardiovascular diseases in death certificates were compared to the diagnosis made at autopsy in 864 consecutive autopsy cases aged 20 or over, among the Japanese residents in Hisayama town. Cerebral stroke was correctly diagnosed in 84%, malignant neoplasms in 78% and cardiac disease in 66%. Cerebral stroke and cardiac disease tended to be overdiagnosed, while malignant neoplasms were underdiagnosed. The validation of certified diagnosis was less reliable in the aged population, and in type-specific diagnosis of cardiovascular diseases. Cerebral hemorrhage with false negative or false positive diagnoses was usually classified into type unspecified stroke or different categories of cerebral stroke, while those misdiagnosed as cases of cerebral infarction frequently had no significant lesions in the autopsied brain. Finally, the relationship between the validation of diagnosis on the death certificates and the secular trend in cardiovascular disease in the Japanese vital statistics was discussed.

Prognosis and outcome of elderly hypertensives in a Japanese community: results from a long-term prospective study

A long-term prognosis and outcome study of elderly hypertensives (aged 60 years or over) was made based on the 20-year prospective population survey conducted in a Japanese rural community (Hisayama) and the results were compared with those for younger subjects (aged 40-59 years). The risk of cardiovascular mortality related to blood pressure level increased with the elevation of either systolic or diastolic pressure in both younger and elderly groups. Cardiovascular mortality increased markedly at a systolic pressure of greater than or equal to 160 mmHg, or a diastolic pressure of greater than or equal to 100 mmHg for those aged 40-59 years. There was no cut-off level for increased risk of cardiovascular mortality for either systolic or diastolic pressures for those aged 60 years or over. Stroke mortality was seven times higher in systolic, and 10 times higher in diastolic hypertensives than in normotensives (P less than 0.01) for the group aged 40-59 years. However, deaths due to stroke and heart disease were more frequently associated with borderline (relative risk 2.3 and 2.3, respectively; P less than 0.01), systolic (relative risk 3.2 and 3.7, respectively; P less than 0.01) and diastolic hypertension (relative risk 2.1 and 4.8, respectively; P less than 0.01), compared to normotension for those aged 60 years or over. Intracerebral hemorrhage and cerebral infarction occurred more frequently in diastolic hypertensives for both young (relative risk 9.8 and 4.8, respectively; P less than 0.01) and elderly subjects (relative risk 3.4 and 1.5, respectively; P less than 0.01) than in normotensives.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence and long-term prognosis of mild hypertensives and hypertensives in a Japanese community, Hisayama

The prognosis and outcome for mild hypertensives (90 mmHg less than or equal to diastolic pressure less than or equal to 104 mmHg) and hypertensives (diastolic pressure greater than or equal to 105 mmHg) was prospectively studied in Hisayama, Japan, and compared between 1621 subjects aged 40 years or over, recruited in 1961, and 2053 subjects recruited in 1974. Each cohort was studied in a follow-up which lasted 10 years. The pharmacological treatment of hypertension proved effective among residents recruited in 1974: the survival rate had favorably improved, and the rates of mortality from cerebral stroke and morbidity from intracerebral stroke and morbidity from intracerebral hemorrhage declined significantly in mild hypertensives and hypertensives in the more recently recruited population. The management of mild hypertension was considered more likely to be effective in reducing stroke than in reducing coronary heart disease in the Japanese general population.

[Comparison of the clinical features of uterine cervical cancers detected by mass screening and voluntary visit]

In order to identify the characteristics of uterine cervical cancers detected by mass screenings (mass group), these cancers were compared to cancers diagnosed in patients voluntarily visiting medical institutions (voluntary group), and the following results were obtained. 1. The mass group tended to show a higher incidence of cervical cancer, and the voluntary group had a higher incidence of endometrial cancer. 2. In the mass group having cervical cancer, the age was younger than that in the voluntary group. Also the incidence of cancer among relatives within the third generation and the frequency of previous participating in a mass screening were both significantly greater (p less than 0.01), compared to the voluntary group. 3. As compared to the voluntary group, many patients in the mass group having cervical cancer were asymptomatic and were diagnosed at an early stage, and even if symptomatic, there still were more early cancers in the mass group than in the voluntary group (p less than 0.01). 4. The incidence of lymph node metastases in advanced cervical cancer, that is beyond stage I b, was lower in the mass group than in voluntary group (p less than 0.01). 5. Cervical cancers in the mass group were surgically treated in 94.2% of cases, and the rate was higher than that in the voluntary group. In the surgical treatment, 77.4% of cases in the mass group underwent a simple hysterectomy and a semi-radical hysterectomy, and the frequency of surgical treatment was higher than that in the voluntary group (p less than 0.01). There also was a tendency toward a shorter time of operative procedures, less bleeding during operation, and fewer postoperative complications. 6. In the mass group having cervical cancers, the prognosis was favorable (p less than 0.01). By the clinical stage, in early cancers including stage 0 and stage I a, there was no significant difference in the prognosis between the mass group and voluntary group, and in the advanced cancer, the prognosis was more favorable in the mass group compared to the voluntary group (p less than 0.01). Asymptomatic patients had a better prognosis than symptomatic patients, and there was no difference between the two groups, but among symptomatic patients the prognosis was more favorable in the mass group than in the voluntary group.

Effect of membrane trapping in plasma fractionator on separative characteristics

Several kinds of plasma fractionators have been introduced to actively separate protein fractions between albumin and globulins in double filtration plasmapheresis. However, relatively large molecular weight proteins are known to be partially trapped by the membrane in a plasma fractionator. In this paper, effects of membrane trapping on separation characteristics in plasma fractionators were examined during in vitro and in vivo studies. All in vitro experiments were done with a closed circuit under constant-flow rate filtration. Protein concentration in feed tank kept constant at no filtration in AS-14H, Evaflux 4A and 2A, while 20-40% of IgG and 40-60% of beta-lipoprotein in 2 liter plasma were removed by membrane trapping for 300 min when filtration fraction equaled 0.87. Protein plugging to the membrane seems to be a major factor in these proteins. And, Dead-end and Partially Discarded modalities with relatively high filtration fraction are effective for the separation between albumin and globulin. Twenty-seven DFPP treatments in 13 patients with autoimmune diseases were done to allow us to estimate the effects of membrane trapping during an in vivo study. All treatments using 6 types of plasma fractionator were performed under constant operating conditions with Partially Discarded modality. In any plasma fractionator, beta-lipoprotein was fairly trapped at 30 min after the start of treatment.

Intracerebral hemorrhage in a Japanese community, Hisayama: incidence, changing pattern during long-term follow-up, and related factors

The incidence of intracerebral hemorrhage over 13 years is compared between two Hisayama cohorts. Among men aged 40 years or older, the annual incidence declined significantly from 3.1/1,000 in the early cohort (1961-1970) to 1.2/1,000 in the recent cohort (1974-1983). Massive ganglionic hemorrhage decreased, while small or medium-sized intracerebral hemorrhage increased in the recent cohort on pathologic or computed tomographic examination. These trends could be due to the reduced prevalence of hypertension in the Hisayama population. The association of serum total cholesterol with intracerebral hemorrhage is discussed based on the results during a 22-year follow-up period.

Transient cerebral ischemic attacks in a Japanese community, Hisayama, Japan

During a 20-year follow-up of 1,621 men and women aged 40 and over in Hisayama, Japan, 18 were found to have suffered transient cerebral ischemic attacks (TIAs) determined by clinical symptoms based on criteria proposed by the US Joint Committee for Stroke Facilities. The average annual incidence rate for the first TIA was 0.56 per 1,000 residents. Age and high blood pressure were strong determinants of TIAs for men. Nine of the 18 cases with TIAs (50%) subsequently developed cerebral infarction, an incidence significantly higher than that in the 1,603 subjects without TIAs (10.9%). Lacunar infarcts were most commonly found on pathologic examination of patients with TIAs who had had a subsequent stroke.

Severe disability related to cerebral stroke: incidence and risk factors observed in a Japanese community, Hisayama

To elucidate the incidence of severe disability due to cerebral stroke and its related factors, prospective data of 1,621 Hisayama residents aged 40 and over were examined. Severe disability resulting from stroke was defined as patients who were unable to dress, take care of their toilet needs, and feed themselves without assistance, or who required a wheel chair for ambulation three months after the most recent episode. During 20 years of follow-up 255 stroke patients were observed among the sample population. The annual incidence of stroke per thousand was 9.8, and rate of severe disability was 2.8 for men and 6.4 and 2.0 for women, respectively. Of the 74 cases with severe disability, approximately 92% were attributed to cerebral infarction. Related factors to severe disability due to cerebral infarction were recurrent attacks, hypertension, changes in ocular fundi and diabetes mellitus among predispositions and quadriplegia or muscular contraction, and intelligent or mental disorders among inhibiting factors for functional recovery. Furthermore, in 59 autopsy cases with multiple cerebral infarctions, the frequency of disability increased as the number of infarcts increased. Hypertension and diabetes mellitus, as risk factors for cerebral infarction and factors inhibiting post-ictal functional recovery were discussed.

Hematocrit as a risk factor of cerebral infarction: long-term prospective population survey in a Japanese rural community

To elucidate the relation of hematocrit (Hct) to the incidence of cerebral infarction, a prospective follow-up study of 16 years (1965-81) was performed in a general population sample of 1220 Hisayama residents aged 44 and over, of both sexes. Most of the subjects who died during the follow-up period were autopsied, the rate being 89.0%. Hct decreased with advancing age in men, but not in women. The average value for Hct was significantly lower in women than in men. According to the mean value +/- 1 SD of Hct, the subjects were grouped into 3, in each sex as follows: low (less than 35%), normal (35-45%) and high (greater than or equal to 45%) for men, and, low (less than 30%), normal (30-40%) and high (greater than or equal to 40%) for women. During the follow-up period, cerebral infarction occurred in 117 patients. The cumulative incidence of cerebral infarction in the low Hct group for men was the lowest, even after adjustments for age and blood pressure. Conversely, the incidence in the low Hct group of women was significantly higher than that in the normal Hct group and was consistently increased with time during 2-5 years of the follow-up. After the 6th year or later, however, the incidence was gradually but significantly increased in the high Hct group, compared with the normal Hct group. Since Hct levels were related with other variables such as serum total cholesterol, serum total protein, Quetelet index and prevalence of hypertension in both sexes, heavy alcohol consumption in men, and glucose intolerance in women, such variables were taken into account using Cox's proportional hazards regression model.(ABSTRACT TRUNCATED AT 250 WORDS)