Association of Lower-Extremity Muscle Performance and Physical Activity Level and Intensity in Middle-Aged and Older Adults: A Doubly Labeled Water and Accelerometer Study.

OBJECTIVES: The purpose of this study was to examine if there is a relationship between lower-extremity muscle performance (LEMP) and physical activity, especially the physical activity level (PAL) value, in community-dwelling middle-aged and older adults. DESIGN: Cross-sectional study. SETTING: Community-based. PARTICIPANTS: Participants were 54 community-dwelling and independent middle-aged and older individuals (aged 54-89 years). MEASUREMENTS: Physical activity level was calculated from the total energy expenditure of each participant obtained using the doubly labeled water method (PALDLW) and estimated basal metabolic rate. Daily step count and intensity of physical activity was monitored with a triaxial accelerometer, and LEMP was assessed using the five-repetition sit-to-stand test (STS-5) and vertical jumping (VJ). RESULTS: The results of STS-5 nearly negatively correlated with those of PALDLW when analysing the middle-aged and older man and woman, separately. VJ positively correlated with PALDLW when analysing the middle-aged and older men and woman, separately. The relationship between LEMP (e.g. STS-5 and VJ) and PAL were maintained, regardless of sex and body composition. PALDLW was significantly positively correlated with LPA, MVPA, and steps, and significantly negatively correlated with sedentary time. The relationship PALDLW and steps was described as following equation: PALDLW = 0.0000392 × steps +1.531. CONCLUSIONS: These findings suggest that PALDLW is a key contributor to increasing LEMP among middle-aged and older adults. Maintaining high PALDLW may be beneficial to independent living, and participation in recreational and social activities in middle-aged and older adults.

Complex genetic nature of sex-independent transmission ratio distortion in Asian rice species: the involvement of unlinked modifiers and sex-specific mechanisms.

Transmission ratio distortion (TRD), in which one allele is transmitted more frequently than the opposite allele, is presumed to act as a driving force in the emergence of a reproductive barrier. TRD acting in a sex-specific manner has been frequently observed in interspecific and intraspecific hybrids across a broad range of organisms. In contrast, sex-independent TRD (siTRD), which results from preferential transmission of one of the two alleles in the heterozygote through both sexes, has been detected in only a few plant species. We previously reported an S(6) locus-mediated siTRD, in which the S(6) allele from an Asian wild rice strain (Oryza rufipogon) was transmitted more frequently than the S(6)(a) allele from an Asian cultivated rice strain (O. sativa) through both male and female gametes in heterozygous plants. Here, we report on the effect of a difference in genetic background on S(6) locus-mediated siTRD, based on the analysis using near-isogenic lines and the original wild strain as a parental strain for crossing. We found that the degree of TRD through the male gametes varied depending on the genetic background of the female (pistil) plants. Despite the occurrence of TRD through both male and female gametes, abnormality was detected in ovules, but not in pollen grains, in the heterozygote. These results suggest the involvement of unlinked modifiers and developmentally distinct, sex-specific genetic mechanisms in S(6) locus-mediated siTRD, raising the possibility that siTRD driven by a single locus may be affected by multiple genetic factors harbored in natural populations.

Multicenter phase II study of FOLFOX for metastatic colorectal cancer (mCRC) in Japan; SWIFT-1 and 2 study.

BACKGROUND/AIMS: This study assessed the efficacy and toxicity of the FOLFOX4 (SWIFT1) and mFOLFOX6 (SWIFT2) regimens in Japanese patients with metastatic colorectal cancer (mCRC). METHODOLOGY: Patients with mCRC were required to have ECOG performance status of 0 to 1, and to have adequate organ function. Two multicenter Phase II studies (SWIFT1/SWIFT2) were conducted in chemotherapy naive patients with mCRC. RESULTS: 112 patients were enrolled in these studies (SWIFT1: 54 patients / SWIFT2: 58 patients). The disease sites for each study were the colon in 27 patients and 28 patients, and the rectum in 27 patients and 30 patients, respectively. All patients received a median of 8 courses. After a median follow-up period of 35 months, 54 patients and 58 patients were evaluable in the respective studies, and the overall response rate was 50.0% (CR:31 PR:53). The response rate according to the sites of metastasis were as follows: liver, 54.1% (46/85); lung, 17.4% (4/23); and lymph node, 23.3% (7/30). Grade 3/4 neutropenia occurred in 14 patients (12.5%), while Grade 3/4 non-hematological toxicities were observed in 16 patients (31.0%) and Grade 3 neurotoxicity was observed in 6patients (5.4%) and 5 patients (4.5%), respectively. CONCLUSIONS: FOLFOX4 (SWIFT1) and mFOLFOX6 (SWIFT2) regimens complying with the international standard dosage and schedule can also be administered safely and effectively in Japan.

The significance of gastrectomy in advanced gastric cancer patients with non-curative factors.

BACKGROUND: The role of gastrectomy in the treatment of advanced gastric cancer patients with non-curative factors remains controversial. We investigated prognostic factors and evaluated the role of gastrectomy in such patients. PATIENTS AND METHODS: Eighty-eight advanced gastric cancer patients with non-curative factors were prospectively studied. The patients were categorized into the following two groups: Group A: 52 patients who underwent gastrectomy and subsequently received chemotherapy, Group B: 36 patients who received chemotherapy alone. RESULTS: The median survival times of group A and B patients were 351 and 182 days, respectively (p=0.008). Multivariate analysis showed that gastrectomy was the only positive independent prognostic factor, with no effect on the results of chemotherapy. There was no significant difference in the duration of hospital stay between patients of the two groups, while significantly longer maintenance of oral intake was observed for group A. CONCLUSION: In advanced gastric cancer patients with non-curative factors, gastrectomy was beneficial for survival with longer maintenance of oral intake.

Discal cysts of the lumbar spine: a case report.

Discal cysts--intraspinal cysts communicating with an adjacent intervertebral disc--are an uncommon cause of lumbar radiculopathy. We report a case of discal cyst of the lumbar spine. The cyst contents were bloody and clotted rapidly; no disc materials were seen. Communication between the cyst and the intervertebral disc was detected. Histopathology of the cyst wall revealed fibrous connective tissue without synovial lining cells. We hypothesise that the discal cyst was formed by haemorrhage of the epidural venous plexus caused by separation of the peridural membrane by mechanical force transmitted by an annulus fibrosis fissure. The minute segmental motion caused by the affected disc may have stimulated continuous bleeding.

Solitary myofibroma of the lumbar vertebra: adult case.

We present the first known adult case of solitary myofibroma of bone, which affected a lumbar vertebra in a 33-year-old male. Radiography identified a purely lytic lesion with a sclerotic rim in the right pedicle of L1. CT showed an expansile lytic lesion with a sclerotic rim. MRI of the lesion revealed an isointense signal on T1-weighted images, an inhomogeneously hyperintense signal on T2-weighted images, and marked enhancement with gadolinium. Pathological study showed a mixed picture of nodular proliferation of spindle-shaped myoid cells and hemangiopericytomatous proliferation of short spindle/small round cells. The tumor cells were immunoreactive for smooth muscle actin and immunonegative for desmin. This case of solitary myofibroma of bone is exceptionally rare because of its occurrence in an adult older than 20 years of age and its location at an extra-craniofacial site.

Clinical usefulness of oral granisetron hydrochloride for alleviation of delayed nausea and vomiting induced by CPT-11.

This open label pilot study evaluated the safety and efficacy of the oral 5-HT3 receptor antagonist granisetron for prophylaxis of delayed chemotherapy-induced nausea and vomiting (CINV) in 30 patients with advanced or recurrent colorectal cancer. Patients were studied during two cycles of a 5-week regimen with irinotecan (CPT-11) and UFT. Patients received prophylactic anti-emetic therapy that included intravenous granisetron. If Grade 1 or higher severity gastrointestinal symptoms occurred during 6 days after CPT-11 administration in Cycle 1, then oral granisetron was administered daily for the following 5 days of CPT-11 in Cycle 2. Sixteen patients (53.3%) experienced delayed CINV in Cycle 1. The incidence of Grade 2 or higher vomiting was 32.1% and 27.7% in Cycles 1 and 2 in males (P = 0.554) respectively, and 54.6% and 32.4% in females (P = 0.001) respectively. Granisetron is effective against delayed Grade 2 or higher vomiting induced by CPT-11/UFT in female patients, although granisetron alone may not sufficiently control nausea induced by this regimen.

Association between hydration volume and symptoms in terminally ill cancer patients with abdominal malignancies.

BACKGROUND: To explore the association between hydration volume and symptoms during the last 3 weeks of life in terminally ill cancer patients. PATIENTS AND METHODS: This was a multicenter, prospective, observational study of 226 consecutive terminally ill patients with abdominal malignancies. Primary responsible physicians and nurses evaluated the severity of membranous dehydration (dehydration score calculated from three physical findings), peripheral edema (edema score calculated from seven physical findings), ascites and pleural effusion (rated as physically undetectable to symptomatic), bronchial secretion, hyperactive delirium (Memorial Delirium Assessment Scale), communication capacity (Communication Capacity Scale), agitation (Agitation Distress Scale), myoclonus and bedsores. RESULTS: Patients were classified into two groups: the hydration group (n=59) who received 1 l or more of artificial hydration per day, 1 and 3 weeks before death, and the non-hydration group (n=167). The percentage of patients with deterioration in dehydration score in the final 3 weeks was significantly higher in the non-hydration group than the hydration group (35% versus 14%; P=0.002), while the percentages of patients whose symptom scores for edema, ascites and pleural effusion increased were significantly higher in the hydration group than the non-hydration group (44% versus 29%, P=0.039; 29% versus 8.4%, P <0.001; 15% versus 5.4%, P=0.016; respectively). After controlling for multiple covariates and treatment settings, the association between hydration group and dehydration/ascites score was statistically significant. Subgroup analysis of patients with peritoneal metastases identified statistically significant interaction between hydration group and dehydration/pleural effusion score. There were no significant differences in the degree of bronchial secretion, hyperactive delirium, communication capacity, agitation, myoclonus or bedsores. CONCLUSIONS: Artificial hydration therapy could alleviate membranous dehydration signs, but could worsen peripheral edema, ascites and pleural effusions. It is suggested that the potential benefits of artificial hydration therapy should be balanced with the risk of worsening fluid retention symptoms. Further clinical studies are strongly needed to identify the effects of artificial hydration therapy on overall patient well-being, and an individualized treatment and close monitoring of dehydration and fluid retention symptoms is strongly recommended.

Novel and global approach of the complex and interconnected phenomena related to the contact line movement past a solid surface from hydrophobized silica gel.

In this work a generalized hydrodynamic theory for water flow into a mesoporous matrix from hydrophobized silica gel is suggested. Although we examine a fluid dynamics problem, the motion of the water-gas-solid contact line past a hydrophobized silica gel surface, motivation for such research derives from the investigation of a novel principle of mechanical energy dissipation, called surface dissipation, and its attached machine element, named a colloidal damper (CD). Similar to a hydraulic damper, this absorber has a cylinder-piston structure, but oil is replaced by a colloid consisting of a mesoporous matrix and a lyophobic liquid. Here, the mesoporous matrix is from silica gel modified by linear chains of alkyldimethylchlorosilanes and water is the associated lyophobic liquid. Mainly, the colloidal damper energy loss can be explained by the dynamic contact angle hysteresis in advancing (liquid displaces gas) and receding motion (gas displaces liquid); such hysteresis occurs due to the geometrical and chemical heterogeneities of the solid surface. Although this new kind of dissipation could be attractive for many applications, the subject remains almost unexplored in the scientific literature. Many different, complex, and interconnected aspects are related to this subject: capillary hydrodynamics, slippage effect, contact angle hysteresis, estimation of dissipated energy, thickness optimization of the grafted layer on the surface of the mesoporous matrix, etc. For this reason, a novel and global approach to all the complex and interconnected phenomena related to the contact line movement past a solid surface from hydrophobized silica gel is proposed. Our approach has a modest experimental basis but this is compensated for with rich references to other experimental and theoretical work oriented to the study of surface phenomena in such systems. We tried to sort the existing results and to find the right place for each in building our global view of the problem. This work is structured as follows. The measurement technique of the hysteresis loop is described. From experimental data one calculates the dissipated energy versus length of the grafted molecule on the silica gel surface. These results are justified by flow analysis. Generalized hydrodynamic theory means here that the basic structure of the Navier-Stokes equations is kept, but in order to include the relation between macroscopic flow and molecular interactions, slip is allowed on the solid wall. The nanopillar architecture of the silica gel hydrophobic coating is described. Concepts of slip and contact angle hysteresis are detailed and their connection is revealed. During adsorption, water penetrates the pore space by maintaining contact with the top of the coating molecules (region of -CH(3) groups); after that, water is forced into and partially or totally fills the space between molecules (region of -CH(2) groups). In such circumstances, at the release of the external pressure, desorption occurs. An original energetic-barriers approach is proposed to understand the filling of the nanosize canals which occur in the hydrophobic grafted layer. Employing this energetic-barriers approach, one finds the optimum length of the grafted molecule which maximizes the dissipated energy of the CD reversible cycle. Such results are useful for the appropriate design of ultrahydrophobic surfaces in general, and for the optimal design of a hydrophobic coating of a mesoporous matrix destined for CD use.

Communication about the ending of anticancer treatment and transition to palliative care.

BACKGROUND: Communication about the ending of anticancer treatment and transition to palliative care is a difficult task for oncologists. The primary aims of this study were to clarify family-reported degree of emotional distress and the necessity for improvement in communication methods when communicating about the ending of anticancer treatment, and to identify factors contributing to the levels of emotional distress and the necessity for improvement. METHODS: A multi-center questionnaire survey was conducted on 630 bereaved family members of cancer patents who received specialized palliative care in Japan. A total of 318 responses were analyzed (effective response rate, 62%). RESULTS: Thirty-nine percent of the bereaved family members reported that they were 'very distressed' in receiving information about the ending of anticancer treatment, and 19% reported 'considerable' or 'much' improvement was necessary in the communication methods. High-level emotional distress was significantly associated with younger patient age, female family gender, the experience of the physician stating she/he could do nothing for the patient, the physician's unwillingness to explore their feelings, and prognostic disclosure of definite survival periods without probabilities or ranges. High levels of perceived necessity for improvement in the communication methods were significantly associated with the experience of the physician stating she/he could do nothing for the patient, physicians not explaining treatment goals in specific terms, physicians not pacing the explanation with the state of family preparation, physicians not being knowledgeable about the most advanced treatments, and the atmosphere not being relaxing enough to ask questions. CONCLUSIONS: In receiving the information about ending anticancer treatment, a considerable number of families experienced high levels of emotional distress and felt a need for improvement of the communication methods. The strategies to alleviate family distress could include: (i) assuring that physicians will do their best to achieve specific goals, without saying that they can do nothing for the patient; (ii) providing information, including estimated prognosis, in careful consideration of families' preparation and the uncertainty for each patient; (iii) exploring families' emotions and providing emotional support; (iv) acquiring knowledge about advanced treatments; and (v) making the atmosphere relaxing enough to allow families to ask questions.

Pharmacokinetics of flunixin in the cat: enterohepatic circulation and active transport mechanism in the liver.

The plasma and urine pharmacokinetics of flunixin-meglumine (FNX) in cats were examined using a total of 12 adult animals. After an intravenous injection of FNX (2 mg/kg), the plasma concentration time curves showed a profile of a two-compartment open model with an elimination half-life of 6.6 h. In spite of high plasma protein binding (>99%), the V(d)beta was unusually large, 0.7 L/kg. Although the recovery of FNX from urine was only 0.4% of the dose, the estimated inherent renal clearance closely corresponded to the renal plasma flow rate, indicating that a renal active tubular secretion was involved in the pharmacokinetics of FNX. Cholestyramine (ChSA), an anion exchanger, was orally administered immediately before the FNX injection in order to determine the involvement of enterohepatic circulation in FNX pharmacokinetics. The elimination phase of the profile of FNX was prevented by the concomitant administration of ChSA, so it was concluded that the drug undergoes enterohepatic circulation in cats. Pravastatin (PV) is a specific substrate of the type-2 organic anion transporting polypeptide transporter (OATP-2) in human liver cells. The effect of a concomitant intravenous injection of PV with FNX was examined in order to determine the involvement of OATP-2 like transporter in the pharmacokinetics. The V1 and total body clearance were decreased after the injection of PV. In conclusion, at least two active transport mechanisms are involved in the pharmacokinetics of FNX in cats. One pathway is renal tubular secretion and the other is sinusoidal active uptake by liver cells. The latter may be responsible for the enterohepatic circulation of FNX in cats.

[Significance of liver resection for multiple hepatic metastases from colorectal cancer].

In colorectal cancer, liver metastasis is the most common and most important prognostic factor. To elucidate the significance of liver resection, we examined 72 cases (H2: 29 cases, H3: 43 cases). The 3-year survival rate for H2 and H3 patients was 71.5% and 4.5%, respectively. The liver resection rate in H2 and H3 patients was 58.6% (17/29) and 16.3% (7/43), respectively. In H2 patients the 3-year survival rate of those with liver resection and non-resection was 71.3% and 9.2%, respectively (p < 0.001). However, in H3 patients the 3-year survival rate in liver resection and non-resection patients was 80.0% and 43.9%, respectively (not significant). Many therapies, such as liver resection, hepatic arterial infusion, and systemic chemotherapy, were attempted for patients with hepatic metastases. Our data show that liver resection can prolong the survival of H2 patients only. On the other hand, hepatic arterial infusion therapy prolongs the survival of H3 patients only. Systemic chemotherapy does not prolong the survival of either H2 or H3 patients.

[Diagnosis of the postoperative local recurrence of rectal cancer by FDG-PET--a case report].

Positron emission tomography (PET) using 18F-fluorodeoxyglucose (FDG) as the tracer of glucose metabolism was performed to identify a postoperative recurrent lesion of rectal cancer. A 66-year-old-man underwent trans-sacral local resection of the rectum for rectal cancer in 1992. A local recurrent mass was discovered, and abdomino-perineal resection of the rectum was performed in 1999. The serum CEA level increased gradually August in 2000, but there was no sign of recurrence on CT or MRI. FDG-PET was performed to reveal a presacral recurrent lesion. Total pelvic evisceration combined with resection of the sacrum, and a bilateral ureterostomy were performed in April 2001. The beneficial role of FDG-PET in the diagnosis of the postoperative local recurrence of rectal cancer is emphasized.

[Tumor markers for colorectal cancer].

CEA and CA19-9 are the two most common tumor markers for colorectal cancer that are currently utilized clinically. The positive rate of CEA is 40-60% and that of CA19-9 is 30-50%. Simultaneous use of the two markers is useful in evaluating the therapeutic effect and monitoring the recurrence of advanced colorectal cancer. Surgical specimens may also provide useful information for the appropriate treatment of patients. Using surgically resected lymph nodes, we examined micrometastasis to assess the spread of the cancer cells and the malignant potential of colorectal cancer. Immunohistochemical analysis using anti-cytokeratin antibody revealed no significant impact of micrometastasis on patient prognosis, while RT-PCR assay using CEA as a genetic marker suggested a positive value in predicting a rapid recurrence. Among various molecular markers, we found that CDC25B phosphatase was a powerful prognostic factor for colorectal cancer. Diagnosis of the existence and malignant potential of cancer cells, together with serum tumor marker levels, may help to construct a more useful system for the better treatment of colorectal cancer.

[Informed consent on pain management].

Informed consent is an essential concern to provide medical services centered on patient's needs. Its significant role is not to avoid legal responsibility but to respect patient's individuality. It emphasizes the necessities for sharing medical information including its uncertainty, listening carefully to a patient about his/her questions and anxieties and being worried with him/her in regard to the best ways coping with sufferings. In this article we describe important aspects concerning informed consent on pain management at clinical situations. It is necessary for physicians not only to have knowledge for pain management but also to get technique for appropriate explanation about analgesics.

Genetic changes induced in human cells in Space Shuttle experiment (STS-95).

BACKGROUND: Results of past space experiments suggest that the biological effect of space radiation could be enhanced under microgravity. To assess the radiation risk for humans during long-term spaceflight, it is very important to clarify whether human cells exhibit a synergistic effect of radiation and microgravity. HYPOTHESIS: If significant synergism occurs in human cells, genetic changes induced during spaceflight may be detected by using human tumor HCT-116 cells which are hypermutable due to a defect in the DNA mismatch repair system. METHODS: Cultured HCT-116 cells were loaded on the Space Shuttle Discovery (STS-95) and grown during the 9-d mission. After landing, many single-cell clones were isolated, microsatellite repetitive sequences in each clone were amplified by PCR, and mutations in the microsatellite loci were detected as changes in the length of PCR fragments. Mutation frequencies of ouabain-resistant phenotype were also analyzed. RESULTS: The frequencies of microsatellite mutations as well as ouabain-resistant mutations in the flight sample were similar to those of the ground control samples. Some cells were treated in space with bleomycin which mimics the action of radiation, but the frequencies of microsatellite mutations were not significantly different between the flight and the ground control samples. CONCLUSION: Under the present flight conditions, neither space radiation (about 20 mSv during this mission) nor microgravity caused excess mutations in human cells.

[Clinical significance of micrometastasis to lymph nodes in gastrointestinal tract cancers].

Surgery is the main therapy for malignancies of the gastrointestinal tract. Lymph node metastasis is one of the major factors in predicting patients' clinical course and choosing appropriate adjuvant therapy after surgery. The concept of micrometastasis to regional lymph nodes emerged over 10 years ago, but its significance has been controversial. To clarify the relevance of micrometastasis of gastrointestinal tract cancers, we have established RT-PCT based-diagnostic methods using multi-markers such as CEA, CK20, and Mage 3. Prospective studies have shown that not a few micrometastasis-positive patients with carcinoma of the colon, stomach, and esophagus suffered disease recurrence, even though they did not show histologically positive lymph node metastasis. They were initially diagnosed as node-negative, and thus predicted to be disease free. A retrospective study of 62 patients with stage II node-negative colorectal cancer showed that 5-year overall survival was 78.2% among micrometastasis-positive patients, against 95.3% micrometastasis-negative patients. Moreover, there was a marked difference in 5-year disease-free survival, with 61.4% versus 88.4%, respectively. These data warrant further prospective study with a large population since RT-PCR based detection systems for micrometastasis appear to have the potential to improve conventional diagnosis and therapy for colorectal cancer.

Expression of second class of KIP protein p57KIP2 in human colorectal carcinoma.

p57KIP2, the second class of KIP family protein, is one of the negative regulators of the cell cycle. To elucidate the role of p57KIP2 in colorectal normal mucosa and cancer, we examined the expression of p57KIP2 protein in 110 pairs of colorectal non-tumor and cancer tissues. Immunohistochemical analysis showed that p57KIP2 was weakly detected in the normal colonic epithelium and lymph follicles. A unique expression pattern of p57KIP2 was exclusively noted in the elastic fibers within the walls of relatively large blood vessels (diameter > 100 microm). In cancer tissues, p57KIP2 protein was localized mainly in nuclei. Using the mean percentage of nuclear p57KIP2 expression (25%) as the cut-off value, we divided our cases into those with high expression (n = 44, 40%) and low expression (n = 66, 60%) of p57KIP2 among 110 colorectal cancer cases tested. The clinical and pathological survey showed a significant correlation between low expression of p57KIP2 and large tumor size (p < 0.05) or the presence of tumors in females (p < 0.01). Survival analysis showed that p57KIP2 expression did not influence prognosis. RT-PCR analysis was also performed using RNA extracts from 6 colorectal cancer tissues. When the levels of p57KIP2 mRNAs were compared with expression of p57KIP2 protein, a clear correlation was found, suggesting that expression of the p57KIP2 protein may be regulated at the transcription level. The present study revealed p57KIP2 expression in colorectal cancer and suggests that p57KIP2 may not play a central role in the progression of colorectal cancer.

Useful applications of DNA repair tests for differential diagnosis of atypical dyschromatosis symmetrica hereditaria from xeroderma pigmentosum.

Dyschromatosis symmetrica hereditaria (DSH) is a hereditary skin disease characterized by the presence of pigmented and hypopigmented macules on the extremities and freckles on the face. However, if clinical features are not fully developed in infantile patients, it is difficult to differentiate DSH from xeroderma pigmentosum by clinical features alone. A 2-year-old boy (patient 1), revealed atypical features of DSH with slight susceptibility to sunburn. However, his grandfather (patient 4) who was 67 years old, revealed typical features of DSH, which helped to make an exact diagnosis in patient 1. For patient 2, a 5-year-old boy, and patient 3, a 3-year-old girl, it was more difficult to make a diagnosis because there were no family members with DSH features. DNA repair ability was tested for all four cases by means of unscheduled DNA synthesis and colony formation of skin fibroblasts after ultraviolet light irradiation, which resulted in an accurate diagnosis of DSH. We propose that these tests be performed to make a diagnosis of DSH in the case of poor or atypical clinical symptoms.