Impact of fee-revision policy for gastrostomy on its implementation among older adults with dementia in Japan

OBJECTIVES

This study aimed to evaluate the impact of the policy to reduce the reimbursement fee for percutaneous endoscopic gastrostomy (PEG) on the number of PEG procedures performed among older adults with dementia.

STUDY DESIGN

Interrupted time series (ITS).

METHODS

We used the monthly aggregated data of the number of PEG procedures in older adults with dementia (both broad and narrow definitions), between 2012 and 2018, from the claims data in Fukuoka Prefecture, Japan. A single ITS design was used to estimate changes in the outcome following each intervention (i.e., first, second, and third interventions performed in 2014, 2015, and 2016, respectively). A controlled ITS design was applied to estimate the effects after the sequence of interventions (pre-intervention: 2012-2014; post-intervention: 2016-2018). The control group comprised patients with malignant head and neck tumors who underwent PEG procedures outside the scope of this policy restriction.

RESULTS

The number of PEG procedures decreased significantly only in the month wherein the third intervention was introduced (broad definition: IRR = 0.11, CI = 0.03-0.49; narrow definition: IRR = 0.15, CI = 0.03-0.75). No significant difference was observed between the treatment and control groups during the post-intervention phase.

CONCLUSIONS

The impact of fee-revision policy for PEG on the decrease in PEG procedures among older adults with dementia is remarkably minimal. It is difficult to reduce unnecessary PEG procedures by relying on this financial incentive alone. Policy decision-makers should consider methods to prevent inappropriate use of artificial nutrition for older adults at their end-of-life stage by reforming the health delivery system.

The Impact of Continuous Use of Home Health Care Resources on End-of-Life Care at Home in Older Patients with Cancer: A Retrospective Cohort Study in Fukuoka, Japan

This study aimed at examining the effect of continued use of home health care resources on end-of-life care at home in older patients with cancer. This retrospective cohort study was conducted using medical and long-term care claims data of 6435 older patients with cancer who died between April 2016 and March 2019 in Fukuoka Prefecture. The main explanatory variables were enhanced home care support clinics and hospitals (HCSCs), enhanced HCSCs with beds, conventional HCSCs, other HCSCs, and home visit nursing care. The covariates were sex, age, required level of care, and the Charlson Comorbidity Index. A logistic regression model was used. The results of the multilevel logistic regression analysis showed that the following were significantly associated with end-of-life care at home: use of enhanced HCSCs with beds (odds ratio, OR: 8.66; 95% confidence interval, CI: [4.31-17.40]), conventional HCSCs (OR: 5.78; 95% CI: [1.86-17.94]), enhanced HCSCs (OR: 4.44; 95% CI: [1.47-13.42]), home-visit nursing care (OR: 1.86; 95% CI: [1.42-2.44]), and a severe need for care (OR: 3.89; 95% CI: [2.92-5.18]). The results suggest that the continued use of home health care resources in older patients with cancer who require out-of-hospital care may lead to increased end-of-life care at home. Particularly, use of enhanced HCSCs with beds is most strongly associated with end-of-life care at home.

Impact of amino acid 233 in Tax on bovine leukemia virus infection in Japanese Black cattle

Bovine leukemia virus (BLV) is an economically important pathogen that both causes fatal enzootic bovine leukosis (EBL) and reduces lifetime milk production, reproductive efficiency, carcass weight, and longevity in dairy cows. The virus can be divided into two categories based on the amino acid at position 233 in Tax protein, which activates viral transcription and probably plays crucial roles in leukemogenesis. We recently reported that early-onset EBL in Japanese Black (JB) cattle was frequently caused by L233-Tax-carrying virus. This study examined the impact of BLV infection, the proviral load (PVL), and amino acid 233 in Tax on the outcomes of JB cattle. We measured PVL in cattle enrolled between February 2016 and December 2018, determined the Tax type of the isolates, and performed follow-up until March 2022. The results demonstrated that BLV infection increased the risk of involuntary culling and mortality in JB cattle in a PVL-dependent manner. Infection with L233-Tax-carrying virus increased the likelihood of mortality by 1.6-fold compared with the effects of P233-Tax-carrying virus infection. Intrauterine and perinatal infections were frequently caused by L233-Tax-carrying virus, and these infections were likely to influence the early onset of EBL in JB cattle. Conversely, breeding cows infected with P233-Tax-carrying virus were often eliminated by involuntary culling. These findings indicate that amino acid 233 in Tax has importance in terms of preventing economic loss attributable to EBL in JB cattle.

Association between care rehabilitation and the risk of fracture hospitalization in people with Parkinson's disease

AIM

This study examined whether there is an association between continuous care rehabilitation (CR) and the risk of fracture hospitalization among people with Parkinson's disease (PwP) aged >75 years with mild-to-moderate care needs level.

METHODS

A retrospective study design based on the merging of medical claims and long-term care insurance claims data was used. Before propensity score matching, of the 2177 participants, 222 received continuous CR, whereas 1955 did not. After matching using a 1:4 ratio, we identified 222 patients in the CR group and 888 patients in the non-CR groups. We carried out a survival analysis to clarify the association between CR and the risk of fracture hospitalization.

RESULTS

After matching, there was a significant difference between the CR and non-CR groups in 3 years (stratified log-rank test by age P = 0.036) and in 4 years (stratified log-rank test by age P = 0.011). The CR group was significantly associated with delays of hospital admission due to fracture within 3 years (hazard ratio 0.54; 95% confidence interval 0.29-0.99; P = 0.047) and within 4 years (hazard ratio 0.52; 95% confidence interval 0.30-0.88; P = 0.010).

CONCLUSIONS

Our study showed that older people with Parkinson's disease who continuously received CR had a lower risk of fracture hospitalization in 3 and 4 years than those who did not receive CR or received interrupted CR. Considering our participants with a mild-to-moderate care needs level, a sustainable CR service might benefit people with Parkinson's disease from an early time when their activities of daily living are still intact and cognitive function has not deteriorated. Geriatr Gerontol Int 2022; ••: ••-••.

Impact of income and eating speed on new-onset diabetes among men: a retrospective cohort study

OBJECTIVE

To examine the impact of income and eating speed on new-onset diabetes among men.

DESIGN

This was a retrospective cohort study.

SETTING

We used the administrative claims and health check-up data for fiscal years 2010-2015 obtained from the Fukuoka branch of the Japan Health Insurance Association.

PARTICIPANTS

Participants were 15 474 non-diabetic male employees, aged between 40 and 74 years. They were categorised based on their eating speeds (ie, fast, normal and non-fast).

PRIMARY AND SECONDARY OUTCOME MEASURES

To calculate the OR of the development of diabetes, we created generalised linear regression models with diabetes onset as the dependent variable and eating speed and income as covariates and calculated corresponding 95% CI values. The analyses were performed after adjusting the data for age, obesity and comorbidities.

RESULTS

Of the total participants, 620 developed diabetes during the 5-year study period. A univariate analysis using the generalised linear regression model revealed that eating fast (OR: 1.35, 95% CI 1.17 to 1.55) and having a low income wereincome (OR: 1.47, 95% CI 1.24 to 1.74) were significantly associated with the onset of diabetes. After adjusting for age, obesity and comorbidities, both eating fast (OR: 1.17, 95% CI 1.02 to 1.35) and having a low income (OR: 1.24, 95% CI 1.03 to 1.50) were recognised as independent risk factors for diabetes onset.

CONCLUSIONS

The study revealed that eating fast and having a low income were independent risk factors, leading to the development of diabetes. While it is difficult to address income differences, it may be possible to address the factors that contribute to income differences to manage diabetes appropriately and at low healthcare costs. However, eating speed can be controlled. Hence, the provision of education and coaching on dietary habits, including eating speed, may be effective in preventing diabetes onset.

Intralesional steroid injection to prevent stricture after endoscopic submucosal dissection for esophageal cancer: a controlled prospective study

BACKGROUND AND STUDY AIMS

The frequency of stricture after endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma with a mucosal defect involving more than three-quarters of the circumference is 70% - 90%. Stricture decreases quality of life and requires multiple endoscopic balloon dilation (EBD) sessions. We investigated the efficacy and safety of a single session of intralesional steroid injections to prevent post-ESD stricture.

PATIENTS AND METHODS

We conducted a prospective study on 30 patients with esophageal squamous cell carcinoma treated by ESD, who had a more than three-quarter but less than whole circumferential defect. A single session of intralesional steroid injections was undertaken immediately after ESD. Esophagogastroduodenoscopy was performed whenever patients reported dysphagia and 2 months after ESD in patients without dysphagia. Results were compared with a historical control group of 29 patients who underwent ESD without intralesional steroid injection. The primary endpoint was the post-ESD stricture rate. Secondary endpoints were the number of EBD sessions and the complication rate.

RESULTS

Compared with the historical control group, the study group had a significantly lower stricture rate (10%, 3/30 patients vs. 66%, 19/29 patients; P < 0.0001) and a lower number of EBD sessions (median 0, range 0 - 2 vs. median 2, range 0 - 15; P < 0.0001). The study group had a complication rate of 7 % (2 /30 patients), comprising a submucosal tear in one patient and bleeding in another, which were not a direct result of EBD.

CONCLUSIONS

A single session of intralesional steroid injections showed promising results for the prevention of stricture after ESD for esophageal cancer.

Study of Crystal Growth in Grain-Filters for Location-Controlled Excimer Laser Crystallization

Amorphous silicon films were transformed into large-grain polycrystalline silicon films by excimer laser induced rapid melting and solidification. Growth is seeded by residual unmolten silicon left in a grid of holes made in the underlying silicon oxide layer. Growth thus starts with a vertical growth phase, during which occlusion of grains occurs, ideally filtering out only a single grain that subsequently seeds the lateral growth. Yield was increased by sharpening the edges of the hole to improve the filtering mechanism and very uniform polycrystalline layers were obtained. Furthermore, simulations were performed to analyze parameters such as growth velocity and melt depth. It was found that heat from laser light absorbed in the neighborhood of the hole strongly contributes to melt depth and thus to the filtering mechanism. Substrate heating or longer pulse durations can be utilized to ensure the occlusion of grains during vertical growth, to reduce thermal stresses, and to increase grain size to a value sufficient for single crystal thin-film transistors.

Comparison of definitive chemoradiotherapy and esophagectomy for stage I esophageal squamous cell carcinoma

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Background: Chemoradiotherapy (CRT) of esophageal cancer has been proposed as an alternative to esophagectomy given the favourable survival rate and mild toxicity. However, no comparative study is reported between esophagectomy and CRT in stage I esophageal squamous cell carcinoma.

Methods: A total of 54 patients treated by definitive CRT and 116 patients treated by esophagectomy at out institution between February 1995 and August 2008 were included in the analysis. Overall survival and recurrence rates were evaluated.

Results: Of 170 patients who had clinical stage I esophageal squamous cell carcinoma and treated by definitive CRT or esophagectomy, 169 patients (99%) were completely followed up. CRT mainly consisted of two cycles of cisplatin and fluorouracil with concurrent radiotherapy of 60 Gy in 30 fractions. Median (range) observation period was 67 (10–171) months in SURG group and 30 (4–77) months in CRT group. In CRT group grade 3 or grade 4 hematological or non-hematological adverse effects were seen in 24 (44.4%) patients. 1-year and 3-year overall survival rates were 97.4% and 85.5% in the SURG group and 98.1% and 88.7% in the CRT group (P = 0.78). By using Cox proportional hazards modelling, overall survival was comparable between the 2 groups after adjusting for age, sex, and size of cancer. Hazard ratio of CRT for overall survival was 0.95 (95% CI: 0.37-2.47). The incidence or local recurrence including metachronous esophageal cancer was significantly higher in the CRT group than the SURG group (P < 0.0001). All recurrences were intramucosal carcinomas and all of them were cured after the salvage treatment mainly using endoscopy.

Conclusions: Overall survival rate of CRT was comparable with esophagectomy despite high local recurrence rate. Local recurrent carcinoma is endoscopically treatable in all patients without influence on overall survival. CRT appears to be a reasonable alternative to esophagectomy in patients with stage I esophageal cancer.

No significant financial relationships to disclose.

Do interventions to prevent lifestyle-related diseases reduce healthcare expenditures? A randomized controlled clinical trial

BACKGROUND

In 2008, the Japanese government implemented a program of health lifestyle interventions to reduce health care expenditure. This study evaluated whether these interventions decreased health care expenditures.

METHODS

The study enrolled 99 participants insured by Japanese National Health Insurance, who, in our previous study conducted in 2004, were allocated by random sampling into an intervention group (50 participants) and a control group (49 participants). In the intervention group, we used a health support method that facilitated the attainment of goals established by each participant. The control group received instruction in exercise, as well as health support using publically available media. Although 3 participants in the intervention group and 9 participants in the control group did not participate in a follow-up health examination 1 year after the intervention, the health care expenditures of all initial participants were assessed. Expenditures before and after the intervention were compared within and between groups. Data on health care expenditures were obtained from inpatient, outpatient, pharmacy, and dental health insurance claims.

RESULTS

After the intervention, the pharmacy and dental expenditures were significantly higher in the intervention group, while the pharmacy expenditure was significantly higher in the control group. However, there was no significant difference in any medical expenditure item between the intervention and control groups before or after the intervention.

CONCLUSIONS

No significant differences were observed in short-term medical expenses for any medical expenditure item after a lifestyle intervention.

Clinical features and outcomes of delayed perforation after endoscopic submucosal dissection for early gastric cancer

Perforation is a major complication of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). However, there have been no reports on delayed perforation after ESD for EGC. We aimed to elucidate the incidence and outcomes of delayed perforation after ESD. Clinical courses in 1159 consecutive patients with 1329 EGCs who underwent ESD were investigated. Delayed perforation occurred in six patients (0.45 %). All these patients had complete en bloc resection without intraoperative perforation during ESD. Five of six perforations were located in the upper third of the stomach, while one lesion was found in the middle third. Symptoms of peritoneal irritation with rebound tenderness presented within 24 h after ESD in all cases. One patient did not require surgery because the symptoms were localized, and recovered with conservative antibiotic therapy by nasogastric tube placement. The remaining five patients required emergency surgery. There was no mortality in this case series.

Infrared endoscopy in the diagnosis and treatment of early gastric cancer

Infrared endoscopy combined with indocyanine green injection allows visualization of the vessels in the gastrointestinal tract. The depth of gastric cancer invasion has been diagnosed through evaluation of the submucosal vessels using this method. Small-scale retrospective studies have reported an accuracy for infrared endoscopy of > 80 % for the diagnosis of the depth of cancer invasion, regardless of ulcerative changes. This endoscopic technique should thus be considered as an additional diagnostic modality for determining the depth of gastric cancer, particularly in cases with ulcerative changes. However, the risk of a toxic reaction to indocyanine green must be addressed before the widespread use of infrared endoscopy can be implemented. Infrared fluorescence endoscopy utilizes the fluorescence of indocyanine green, and has been used not only for diagnosing the depth of gastric cancer invasion, but also for detecting neoplasia. Labeling and visualization of cancer in a resected specimen were possible following pre-treatment with anti-carcinoembryonic antigen antibody labeled with an indocyanine green derivative. A critical requirement for the detection of cancer using infrared fluorescence endoscopy is the identification of a safe labeling substance that attaches to the cancer with high affinity. It was possible to detect sites of bleeding during endoscopic resection of gastric cancers by submucosal injection or flushing of the bleeding site with indocyanine green solution. The dose of indocyanine green required by these methods is relatively low, and they can therefore be used to improve the safety of endoscopic resection with no increased risk of toxicity.

Endoscopic submucosal dissection for early gastric cancer performed by supervised residents: assessment of feasibility and learning curve

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) is feasible as a treatment for early gastric cancer (EGC) when it is performed by an experienced endoscopist. We investigated whether it was feasible for novice endoscopists to perform ESD for EGC, and how difficult it was to learn the procedure.

METHODS

This case series study was performed in a cancer referral center. Three resident endoscopists, who had already learned basic procedures, performed ESD under supervision for 30 consecutive lesions, and their procedures were analyzed. The procedure was divided for assessment into (i) mucosal incision and (ii) submucosal dissection by completion of the circumferential mucosal cut. An insulated-tip knife was used for mucosal incision and submucosal dissection. A total of 90 mucosal EGCs (< or = 2 cm) without ulcers or scars in 87 patients were included. Outcomes were: rates of complete resection, complications, and self-completion; operation time; learning curve; and reasons for change of supervisor as an indicator of difficulty.

RESULTS

Among the 90 procedures, there was a good overall complete resection rate of 93 %, with an acceptable complication rate of 4.4 %; the complications were delayed hemorrhage in two patients, and perforations in another two patients that were repaired successfully by endoscopic clipping. The self-completion rate and operation time were significantly worse for submucosal dissection than for mucosal incision. Two of the three operators showed a flat learning curve for submucosal dissection. Difficulty with the procedure was related mainly to uncontrollable hemorrhage.

CONCLUSIONS

With appropriate supervision, gastric ESD by residents is feasible, with equivalent complete resection rates and acceptable complication rates compared with those of experienced endoscopists, although there was difficulty in achieving sufficient self-completion rates in submucosal dissection. Better control of bleeding during submucosal dissection may be a key to improving the procedure.

Prognostic value of heart rate variability in patients with renal failure on hemodialysis

BACKGROUND

In patients with renal failure on hemodialysis cardiovascular disease is a major cause of death. It has been reported that diminished heart rate variability (HRV) relates to the unfavorable prognosis in post-infarction and/or heart failure patients. However, the prognostic value of HRV in hemodialysis patients has not been fully established.

METHODS AND RESULTS

Time- and frequency-domain analysis of HRV on 24-hour ambulatory electrocardiography recording was assessed prospectively in 383 chronic hemodialysis patients (220 men and 163 women, mean age 57+/-13 years, ejection fraction 65+/-12%). During 2110+/-903 days of follow up, 146 patients died (31 congestive heart failure, 13 fatal myocardial infarction, 13 sudden deaths, 26 stroke, and 63 non-cardiovascular deaths). A Cox univariate analysis identified the following factors as predictors of both all-cause and cardiovascular death: age, gender, ejection fraction, presence of diabetes, and HRV parameters calculated in the time- and frequency-domain. In multivariate analysis, a low standard deviation of all normal RR intervals (SDNN) value was the strongly associated with both all-cause and cardiovascular death (hazard ratios [95% confidence intervals] 0.988 [0.982-0.994] and 0.984 [0.974-0.993], respectively). From Kaplan-Meier survival curves, the incidence of all-cause and cardiovascular death was much greater in patients with a low SDNN (<75 msec), even after adjusting for the presence of diabetes (P<0.0001).

CONCLUSIONS

Decreased HRV on 24-hour ambulatory electrocardiography is an independent predictor of mortality in chronic hemodialysis patients.

Helicobacter pylori-induced atrophic gastritis progressing to gastric cancer exhibits sonic hedgehog loss and aberrant CDX2 expression

BACKGROUND

The loss of sonic hedgehog is an early change that occurs in the mucosa prior to neoplastic transformation and correlates with the type of intestinal metaplasia. Aberrant expression of CDX has also been shown to correlate with the development of intestinal metaplasia.

AIM

To examine CDX2 expression in the non-cancerous mucosa of patients with gastric cancer and compared it to CDX2 expression in controls with intestinal metaplasia.

METHODS

Sixty patients who had undergone endoscopic mucosal resection for early gastric cancer and 60 gender- and age-matched controls were studied. Two specimens each were obtained from the greater and lesser curves of the corpus and from the greater curve of the antrum. Expression of CDX2 and sonic hedgehog were evaluated by immunostaining.

RESULTS

Gastric cancer was associated with a higher frequency of incomplete intestinal metaplasia (OR = 8.3; 95%CI, 3.7-18.9, P < 0.001). CDX2 negatively correlated with sonic hedgehog expression, however, multivariate analysis revealed that CDX2 correlated with the intestinal metaplasia scores. Sonic hedgehog indices were lower and CDX2 staining in the corpus lesser curve was higher in the cancer group than in the controls. Sonic hedgehog indices in the corpus decreased and CDX2 indices in both areas increased in patients in the ascending order of those without intestinal metaplasia, those with complete intestinal metaplasia and those with incomplete intestinal metaplasia (P < 0.001).

CONCLUSIONS

Loss of sonic hedgehog expression and aberrant expression of CDX2 correlates with the type of intestinal metaplasia and may play a role in carcinogenesis.

[Study of relationships between state of mental health and indicators of medical expenses]

OBJECTIVE

The purpose of this study is to determine the relationships between the state of mental health and indicators of medical expenses for inpatient, outpatient and dental services.

METHODS

This study was conducted using data from 140 people (54 males and 86 females) who participated in a lifestyle intervention program. The result of General Health Questionnaire (GHQ)-30 survey performed in August 2003 was used as the indicator of mental health, whereas diagnoses based on International Classification of Diseases (ICD) 10 from medical expense claims in the 2003 fiscal year were used for disease classification by the Proportional Disease Magnitude (PDM) method. The subjects were classified into two groups by GHQ-30 score: low-score group (n=96) and high-score group (n=44). The differences between the two groups were compared by an unpaired t-test.

RESULTS

For outpatient service in the high-score group, the medical expenses and the numbers of consulting days, medical expense claims and consultation cases at least two per month were significantly higher (p < 0.05) than those in the low-score group. However, there were no significant differences in the same indicators between inpatient and dental services. In the high-score group, the medical expenses of the XVIII group (symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified) of ICD10 were also significantly higher (p < 0.05) than those of the low-score group.

CONCLUSIONS

The state of mental health is significantly associated with indicators of medical expenses for outpatient service. The medical expenses of a problematic non-mentally healthy group are significantly higher than those of a mentally healthy group.

Association study between kynurenine 3-monooxygenase gene and schizophrenia in the Japanese population

Several lines of evidence suggest that metabolic changes in the kynurenic acid (KYNA) pathway are related to the etiology of schizophrenia. The inhibitor of kynurenine 3-monooxygenase (KMO) is known to increase KYNA levels, and the KMO gene is located in the chromosome region associated with schizophrenia, 1q42-q44. Single-marker and haplotype analyses for 6-tag single nucleotide polymorphisms (SNPs) of KMO were performed (cases = 465, controls = 440). Significant association of rs2275163 with schizophrenia was observed by single-marker comparisons (P = 0.032) and haplotype analysis including this SNP (P = 0.0049). Significant association of rs2275163 and haplotype was not replicated using a second, independent set of samples (cases = 480, controls = 448) (P = 0.706 and P = 0.689, respectively). These results suggest that the KMO is unlikely to be related to the development of schizophrenia in Japanese.

A new method of diagnosing gastric intestinal metaplasia: narrow-band imaging with magnifying endoscopy

BACKGROUND AND STUDY AIMS

With endoscopy, there is a high rate of interobserver variability in the identification of gastric intestinal metaplasia, and the endoscopic findings correlate poorly with the histological findings. Previous studies by our group investigating the use of a narrow-band imaging system with magnifying endoscopy (NBI-ME) in the gastric mucosa suggested that the appearance of a light blue crest (LBC) on the epithelial surface may be a distinctive endoscopic finding associated with the presence of intestinal metaplasia. The aim of the present study was to clarify the value of NBI-ME for diagnosing gastric intestinal metaplasia.

PATIENTS AND METHODS

The LBC was defined as a fine, blue-white line on the crests of the epithelial surface/gyri. To investigate the histology underlying the appearance of LBC, 44 biopsy specimens were obtained from regions containing LBC and 44 from non-LBC mucosa in 34 patients with atrophic gastritis. Three endoscopists then carried out NBI-ME in 107 consecutive patients to validate the diagnostic accuracy of the novel endoscopic technique. The degree of correlation between the LBC grading and the histological parameters of intestinal metaplasia was then assessed.

RESULTS

The LBC grading correlated with cells that were positive for CD10 ( P = 0.0001) and Alcian blue ( P = 0.036). The appearance of LBC correlated with histological evidence of intestinal metaplasia with a sensitivity of 89 % (95 % CI, 83 - 96 %), a specificity of 93 % (95 % CI, 88 - 97 %), a positive predictive value of 91 % (95 % CI, 85 - 96 %), a negative predictive value of 92 % (95 % CI, 87 - 97 %), and an accuracy of 91 % (95 % CI, 88 - 95 %).

CONCLUSIONS

In narrow-band imaging with magnifying endoscopy, observation of a light blue crest on the epithelial surface in the gastric mucosa is a highly accurate sign of the presence of histological intestinal metaplasia.

[Relationship between the change of mental health and the improvement of lifestyle and physical health]

OBJECTIVES

The purpose of this study was to clarify the relationship between the change of mental health and the improvement of lifestyle and physical health in the lifestyle intervention program.

METHODS

The study was conducted using data from 126 persons (50 males and 76 females) who participated in the 6-month lifestyle intervention program. We used the result of the General Health Questionnaire (GHQ)-30 as the indicator of mental health, the number of steps, surveys concerning caloric intake, and sleeping hours as the indicator of lifestyle, and body weight, BMI, blood pressure, triglycerides, total cholesterol, LDL cholesterol, HDL cholesterol and HBA1c. The subjects were classified into four groups based on the change of mental health: Group-GG, change from good to good (n = 80); Group-PG, change from poor to good (n = 25); Group-PP, change from poor to poor (n = 13); and Group-GP, change from good to poor (n = 8). The changes between pre-intervention and post-intervention were compared for each group by the paired t-test, and among the 4 groups by ANCOVA.

RESULTS

In Group-GG, the number of steps (p < 0.01), calorie intake (p < 0.05) and sleeping hours (p < 0.01) were significantly improved, triglyceride was significantly decreased (p < 0.01), and total and HDL cholesterol were significantly increased (p < 0.01). However there were no significant changes in Group-GP.

CONCLUSION

The state and change of mental health were found to be significantly associated with the improvement of lifestyle and physical health.

Comparison of new different assay systems for thyrotropin receptor antibodies with reference to thyroid-stimulating antibodies and thyroid stimulation-blocking antibodies in Graves' disease

The aim of our study was to evaluate the diagnostic sensitivity of the new thyrotropin receptor antibody (TRAb) assays (Cosmic TRAb CT, ELISA and Yamasa DYNOtest TRAb). TRAb was positive in 43 of 44 (97.7%) untreated patients with Graves' disease by both TRAb CT and/or ELISA and NYNOtest TRAb. Thus the new TRAb assays were clearly more sensitive than the conventional assay (positivity: 85%). There was a strong positive correlation between the data obtained in TRAb CT and/or ELISA and those obtained in DYNOtest TRAb (r = 0.942, p < 0.0001). There was a significant correlation between the new TRAb and TSAb (r = 0.696, p < 0.0001). Although there was a significant correlation between the new TRAb and thyroid stimulation-blocking antibody (TSBAb), the correlation coefficient was low (r = 0.605, p < 0.0001). The increased sensitivity of the new TRAb assays for Graves' disease provides an advantage over conventional assay.

A case of clinically and neuropathologically atypical corticobasal degeneration with widespread iron deposition

A 65-year-old woman was admitted to our hospital for forgetfulness, depression and eccentric behavior that had been first noticed 2 years prior to admission. She showed memory impairment, perseveration and repeated violent actions, but no limb-kinetic apraxia. She died 12 years after the onset of symptoms. At autopsy, the unfixed brain weighed 820 g. Atrophy was circumscribed in the frontal lobe on both sides. The globus pallidus and the caudate nucleus were markedly atrophic and gold yellow in color, and the substantia nigra was strikingly pale. The cortical area showed neuronal loss and status spongiosus of the second and third cortical layers with ballooned neurons. Marked neuronal loss was observed in the dorsomedial nucleus of the thalamus, Meynert basal nucleus and substantia nigra. With Holzer stain, fibrillary gliosis was found to be severe in the frontal lobe, globus pallidus, subthalamic nucleus, hippocampus, dorsomedial nucleus of thalamus, substantia nigra, pontine tegmentum and inferior olivary nucleus. With Bielschowsky-Hirano stain, neurofibrillary tangles were observed in the cortex, hippocampus, substantia nigra, dentate nucleus, subthalamic nucleus, pontine nucleus, the inferior olivary nucleus, dorsomedial nucleus of the thalamus and, to a lesser extent, the neostriatum. Strikingly numerous argyrophilic and tau-positive threads were present in the cerebral white matter. These neuropathological findings corresponded to corticobasal degeneration, but lesions characteristic of progressive supranuclear palsy were also found. Moreover, widespread iron deposition throughout the central nervous system was the most striking finding of the present case. To our knowledge, such a case has not been reported in the literature to date.

Measurement of flecainide in hair as an index of drug exposure

We report a method for measuring the concentration of flecainide in hair. An animal study, in which flecainide (1, 5, and 10 mg/kg/day) was orally administered for 1, 2, and 3 weeks to pigmented rats, showed that flecainide concentration in rat hairs newly regrown after administration significantly correlated with both the daily dose and the dosing period. The part of hair containing flecainide continued to grow upward, retaining the drug within the hair structure that had been formed at the time of drug exposure. Flecainide was also determined in human scalp hairs collected from patients treated with flecainide. The drug content of white hairs was much less than that black hairs collected from the same rats and subjects, suggesting the determinant effect of hair pigment on flecainide accumulation in hair. These findings suggest that the analysis of flecainide in hair may be useful for assessing exposure to drug qualitatively.

Activation mechanism of brain microglia in patients with diffuse neurofibrillary tangles with calcification: a comparison with Alzheimer disease

Diffuse neurofibrillary tangles with calcification (DNTC) is an atypical dementia and is characterized pathologically by diffuse neurofibrillary tangles (NFTs) without senile plaques (SPs). In this study, we investigated the distribution of human leukocyte antigen (HLA)-DR-positive activated microglia in postmortem brain tissue of six patients with DNTC and six patients with Alzheimer disease (AD). HLA-DR-positive activated microglia were observed to associate with SPs in AD. In the DNTC brain, which lacks SPs, HLA-DR-positive microglia were mainly accumulated around weakly tau-positive NFTs, which were also positive for anti-amyloid-P and anti-C3d antibodies. The results of this study suggest that the complement pathway is also activated in the DNTC brain and that immune and inflammatory responses, including microglia activation, may occur around extracellular NFTs in DNTC patients.

ELISA for urinary trehalase with monoclonal antibodies: a technique for assessment of renal tubular damage

BACKGROUND

alpha,alpha-Trehalase, located on renal proximal tubules, is a glycoprotein that hydrolyses alpha,alpha-trehalose to two glucose molecules. Urinary trehalase reflects damage to renal proximal tubules, but its activity has not been measured routinely because measurement of catalytic activity is rather complicated and because conventional assays for enzyme activity might not reflect all of the trehalase protein because of enzyme inactivation in urinary samples.

METHODS

We established novel monoclonal antibodies for human trehalase and a sandwich ELISA for quantification of urinary trehalase. We determined the urinary trehalase protein concentration with this ELISA and trehalase catalytic activity, and the results of these two methods were compared.

RESULTS

The ELISA system was more sensitive than the detection of enzyme activity and could detect a subtle difference in the amount of trehalase present in renal diseases. The within- and between-assay CVs in the ELISA were 6.7-7.6% and 6.2-8.2%, respectively. Highly significant increases in both the quantity and activity were seen in patients with nephrotic syndrome (acute phase), Lowe syndrome, and Dent disease. The quantities were 70- to 200-fold greater, whereas enzyme activities were, at most, 10-fold higher than those of control subjects. In the detection of small amounts of trehalase in patients with chronic glomerulonephritis and renal anomalies, quantities were better than enzyme activities.

CONCLUSIONS

We have established an ELISA system for quantification of urinary trehalase that uses novel monoclonal antibodies. Our ELISA system is simpler and more sensitive than a conventional activity assay and reflects trehalase protein. This ELISA can be a useful as a common tool for clinical assessment of renal proximal tubular damage.

An autopsy case with clinically and molecular genetically diagnosed Huntington's disease with only minimal non-specific neuropathological findings

An autopsy case with clinically and molecular genetically diagnosed Huntington's disease (HD) accompanied with minimal non-specific neuropathological features was reported. When the patient was 45 years old, he had faulty memory, mood swing, personality change and agitation. Neurological and psychiatric examinations revealed choreoathetoid movements in limbs and trunk, generalized hyperreflexia and mental deterioration. However, cerebellar ataxia and muscle rigidity were not disclosed. Neuroimaging study did not show a definite atrophy of heads of caudate nuclei. Neuroacanthocytosis and Wilson's disease were ruled out by the peripheral blood examination and serum Cu and ceruloplasmin examination. At the age of 55 he died of pneumonia. Post-mortem examination revealed minimal non-specific neuropathological features for HD (Vonsattel's grade 0), that is, no visible fibrillary gliosis in the striatum, and few neuronal loss and only proliferation of astrocytes (astrocytosis) in the striatum. Molecular-genetic study the patient's brain tissues and his youngest son's blood was performed. These studies revealed 40 CAG repeats in the patient, 56 CAG repeats in his youngest son. These results suggest they may be HD. Vonsattel et al. [ 1998] insist that grade 0 comprises 1% of all HD brains, and grade 1 comprises 4% of all HD brains. But we could not find any reports in which the clinical and neuropathological features were described in detail on the cases with clinically and molecular genetically diagnosed HD without specific pathological findings. Therefore, we present in detail the clinical and neuropathological features of such case.

cDNA and deduced amino acid sequences of apolipophorin-IIIs from Bombyx mori and Bombyx mandarina

The cDNA sequence for apolipophorin-III from two strains of Bombyx mori (N4 and P50) and the Japanese and Chinese strains of Bombyx mandarina were determined. Both the cDNA and deduced amino acid sequences of the four apolipophorin-IIIs were highly similar (95-98%). The four Bombyx sequences also showed significant similarity to the sequence of apolipophorin-III from another lepidopteran, Manduca sexta (83-84%), particularly in the five amphipathic alpha-helices that are proposed to play a critical role in the binding of apolipophorin-III to lipophorin. In the coding region, the nucleotide sequences for the Chinese strain of B. mandarina and the P50 strain of B. mori were identical, supporting the suggestion that P50 is the current strain most closely related to the original domesticated strain. The N4 strain of B. mori is more closely related to these two strains than is the Japanese strain of B. mandarina, suggesting that Japanese strain of B. mandarina separated from the Chinese strain of B. mandarina before domestication of B. mori. Arch.

[Antimicrobial activities of meropenem against clinically isolated strains in 1997]

In order to evaluate antimicrobial activity of meropenem (MEPM), minimum inhibitory concentrations (MICs) of MEPM and control drugs were determined against clinical isolates in 1997. The results were as follows; 1. Antimicrobial activities of MEPM against Gram-positive bacteria were stronger than those of cephems (CEPs) and were approximately equal to those of imipenem (IPM) and panipenem (PAPM). 2. Carbapenems showed strong antimicrobial activities against Enterobacteriaceae, Glucose non-fermentative Gram-negative rods and Bacteroides fragilis group that were multiple drug resistant including the third generation CEPs. Antimicrobial activities of MEPM against these organisms were stronger than those of IPM and PAPM. By comparing antimicrobial activities of MEPM against Gram-negative bacteria in 1997 with those obtained in 1993, increase of resistance was not observed. 3. MIC-ranges of MEPM were low against the resistant strains of Pseudomonas aeruginosa to IPM and PAPM. It was considered that these resistant strains were not expressing oprD products (D2 porin protein), forming main outer membrane porin channels of carbapenems and basic amino acids.

Androgens rescue avian embryonic lumbar spinal motoneurons from injury-induced but not naturally occurring cell death

The regulation of survival of spinal motoneurons (MNs) has been shown to depend during development and after injury on a variety of neurotrophic molecules produced by skeletal muscle target tissue. Increasing evidence also suggests that other sources of trophic support prevent MNs from undergoing naturally occurring or injury-induced death. We have examined the role of endogenous and exogenous androgens on the survival of developing avian lumbar spinal MNs during their period of programmed cell death (PCD) between embryonic day (E)6 and E11 or after axotomy on E12. We found that although treatment with testosterone, dihydrotestosterone (DHT), or the androgen receptor antagonist flutamide (FL) failed to affect the number of these MNs during PCD, administration of DHT from E12 to E15 following axotomy on E12 significantly attenuated injury-induced MN death. This effect was inhibited by cotreatment with FL, whereas treatment with FL alone did not affect MN survival. Finally, we examined the spinal cord at various times during development and following axotomy on E12 for the expression of androgen receptor using the polyclonal PG-21 antibody. Our results suggest that exogenously applied androgens are capable of rescuing MNs from injury-induced cell death and that they act directly on these cells via an androgen receptor-mediated mechanism. By contrast, endogenous androgens do not appear to be involved in the regulation of normal PCD of developing avian MNs.

Nosema tyriae n.sp. and Nosema sp., microsporidian parasites of Cinnabar moth Tyria jacobaeae

Nosema tyriae n.sp. was found in 63% of a population of Cinnabar moth larvae (Tyria jacobaeae). The infection was found in the gut wall, silk glands, and fat body and was probably generalized but appeared to be of low pathogenicity. Merogony and sporogony were by binary fission of diplokaryotic stages. Fresh spores were elongate, slightly pointed at the anterior end, and measured 4.7 x 2.0 microm. Ultrastructural features of special interest were 20-nm tubules connecting the surface of sporonts with host cell cytoplasm and, in the spores, a deeply domed polar sac, polaroplast consisting of closely packed longitudinally arranged membranes and loosely packed horizontally arranged membranes, and 10.5-14 coils of the polar tube in a single rank. The 16S rRNA genes of N. tyriae and Nosema bombycis from silkworms, Bombyx mori, differed by only six nucleotides and N. tyriae spores gave a moderately positive reaction with a monoclonal antibody raised to N. bombycis. N. tyriae was infective to B. mori but was less virulent than N. bombycis. However, no amplification product was obtained by PCR using N. tyriae DNA and primers considered to be specific for N. bombycis. Also, the spores of the two species are of entirely different shapes. A second diplokaryotic microsporidium, Nosema sp., found as a light infection in only one of the larvae had much smaller developmental stages and spores measuring 3.8 x 2.0 microm (fixed). Ultrastructurally it was distinguished by an abundance of dense membranes in cytoplasmic vesicles in both meronts and sporonts. Spores with up to 15 coils of the polar tube in irregular clusters or with about 12 coils in a single rank were observed in the tissues fixed from the one larva infected with this parasite. As this larva had been kept with N. tyriae-infected larvae for a few days before examination, it is possible that the two types of spores resulted from a double infection.

[Clinical and bacteriological effects of cefetamet pivoxil against community-acquired respiratory tract infections. Part III]

We investigated clinical and bacteriological effects of cefetamet pivoxil (CEMT-PI) on community-acquired respiratory tract infection and obtained the following results: This method of investigation was almost the same to those adopted in 1994 and 1996. 1. 512 cases of respiratory tract infection were treated with CEMT-PI under the same protocol at a total of 53 institutions in Tokyo, Kanagawa, Saitama, Chiba and Yamanashi prefectures from January, 1, 1998 over March, 31, 1998. Outpatients accounted for 99.7% of all subjects. Diagnoses given to these patients included pharyngolaryngitis (51.4%), tonsillitis (37.7%), and acute bronchitis (10.1%). 2. For the bacteriological study, a manual detailing the method of collecting specimens, storage and transport was distributed to the above-mentioned institutions. The isolation and identification of suspected causative bacteria, determination of minimum inhibitory concentrations (MICs), and investigation of beta-lactamase production were conducted all together at Section of Studies, Tokyo Clinical Research Center. Suspected causative bacteria were detected in 144 (37.2%) out of 387 cases that were the analytical subjects of the clinical efficacy. The major bacteria identified were 32 strains of Streptococcus pyogenes and 19 strains of Haemophilus influenzae. The clinical efficacy (the ratio of improvement) of CEMT by suspected causative bacterium was 84.4% against CEMT-indicated organisms and 81.2% against CEMT-non-indicated organisms. 3. We investigated clinical efficacy rates (the ratio of "markedly improved" + "improved") by disease. The improvement rate was 78.4% in pharyngolaryngitis, 87.0% in tonsillitis, and 79.5% in acute bronchitis. The clinical efficacy rate was an average of 81.9% in all CEMT-PI indicated diseases.

[Antimicrobial activities of cefetamet against clinically isolated strains from community acquired respiratory tract infections. Part III]

Antimicrobial activities of cefetamet (CEMT) against clinically isolated strains from patients with community acquired respiratory tract infections were investigated in comparison with those of other oral beta-lactam antibiotics during the period from January to March, 1998. The results are summarized as follows; 1. CEMT showed strong antimicrobial activities against three major pathogens causing community acquired respiratory tract infections, Streptococcus pyogenes, Streptococcus pneumoniae and Haemophilus influenzae. However, antimicrobial activities of CEMT against penicillins (PCs)-intermediate S. pneumoniae (PISP) and PCs-resistant S. pneumoniae (PRSP) were slightly weaker than those of some of the reference antibiotics. 2. No chronological changes of CEMT-MIC level were observed in the antimicrobial activities against S. pyogenes, H. influenzae, Moraxella subgenus Branhamella catarrhalis or Klebsiella pneumoniae subsp. pneumoniae. In contrast to this, due to the increase of PISP and PRSP strains, resistance to CEMT appears increasing with time.

Lipid transfer particle catalyzes transfer of carotenoids between lipophorins of Bombyx mori

The yellow color of Bombyx mori hemolymph is due to the presence of carotenoids, which are primarily associated with lipophorin particles. Carotenoids were extracted from high density lipophorin (HDLp) of B. mori and analyzed by HPLC. HDLp contained 33 micrograms of carotenoids per mg protein. Over 90% of carotenoids were lutein while alpha-carotene and beta-carotene were minor components. When larval hemolymph was subjected to density gradient ultracentrifugation, a second minor yellow band was present, which was identified as B. mori lipid transfer particle (LTP). During other life stages examined however, this second band was not visible. To determine if coloration of LTP may fluctuate during development, we determined its concentration in hemolymph and compared it to that of lipophorin. Both proteins were present during all life stages and their concentrations gradually increased. The ratio of lipophorin: LTP was 10-15:1 during the fourth and fifth instar larval stages, and 20-30:1 during the pupal and adult stages. Thus, there was no correlation between the yellow color attributed to LTP and its hemolymph concentration. It is possible that yellow coloration of the LTP fraction corresponds to developmental stages when the particle is active in carotene transport. To determine if LTP is capable of facilitating carotene transfer, we took advantage of a white hemolymph B. mori strain which, when fed artificial diet containing a low carotene content, gives rise to a lipophorin that is nearly colorless. A spectrophotometric, carotene specific, transfer assay was developed which employed wild type, carotene-rich HDLp as donor particle and colorless low density lipophorin, derived from the white hemolymph strain animals, as acceptor particle. In incubations lacking LTP carotenes remained associated with HDLp while inclusion of LTP induced a redistribution of carotenes between the donor and acceptor in a time and concentration dependent manner. Time course studies suggested the rate of LTP-mediated carotene transfer was relatively slow, requiring up to 4 h to reach equilibrium. By contrast, studies employing 3H-diacylglycerol labeled HDLp as donor particle in lipid transfer assays revealed a rapid equilibration of label between the particles. Thus, it is plausible that the slower rate of LTP-mediated carotene transfer is due to its probable sequestration in the core of HDLp.