Multidisciplinary attentive treatment for patients with chronic disorders of consciousness following severe traumatic brain injury in the NASVA of Japan.

Primary Objective: The aim of this study was to demonstrate the clinical outcomes of long-term multidisciplinary attentive treatment (MAT) in patients with chronic disorders of consciousness (DOC) due to severe traumatic brain injury (TBI) following automotive accidents.Research Design: Five hundred and ten patients (mean age: 40.4 years) were enrolled in this retrospective study.Methods and Procedures: Patients were provided MAT for one to several years in the eight medical facilities of the National Agency for Automotive Safety and Victims' Aid (NASVA) in Japan. Clinical status for consciousness, communication, and activities of daily living were evaluated using the NASVA grading system.Outcomes and results: Following MAT, NASVA scores at discharge were significantly improved compared to those at admission in every patient subgroup including sex, age, NASVA score, and association with/without hypoxic encephalopathy at admission. Younger age, shorter interval between injury and admission, and better neurocognitive function at admission were found to be significant and independent factors for a good prognosis.Conclusions: MAT can partially improve the cognitive and physical abilities of patients with chronic DOC. From the perspective of not only restoring a patient's daily life, but also reducing the caregiver's burden, this type of treatment program warrants more public attention.

Glasgow prognostic score predicts prognosis for cancer patients in palliative settings: a subanalysis of the Japan-prognostic assessment tools validation (J-ProVal) study.

PURPOSE: The Glasgow prognostic score (GPS), which uses C-reactive protein and albumin levels, is a good predictor of prognosis in cancer patients undergoing anti-tumor therapy. The objective of this study was to investigate the correlation between GPS and survival among cancer patients in palliative settings, as findings in such populations have not been well described. METHODS: This was a subanalysis of a multicenter, prospective, cohort study in patients who were adults, diagnosed with advanced cancer, and first referred to palliative care service in Japan. Patients who were not receiving anti-tumor therapy and who had undergone laboratory examinations were eligible. Clinical features were analyzed to investigate prognostic factors. RESULTS: A total of 1160 patients were enrolled (41.6 % female; median age, 72 years). The independent predictors were Eastern Cooperative Oncology Group performance status (ECOG PS) score of 4 (hazard ratio (HR), 1.54), liver metastasis (HR, 1.21), dyspnea (HR, 1.35), edema (HR, 1.25), prognostic performance index (HR, 1.56), neutrophil-lymphocyte ratio (HR, 1.43), and GPS of 2 (HR, 1.36). The sensitivity and specificity for 3-week prognosis of a GPS of 2 were 0.879 and 0.410. Median survival time with GPS of 0, 1, and 2 was 58 days (95 % confidence interval, 48-81), 43 days (37-50), and 21 days (19-24), respectively (log-rank test, p < 0.001). CONCLUSION: The GPS was a good prognostic indicator for cancer patients in palliative settings.

A laparoscopic splenectomy allows the induction of antiviral therapy for patients with cirrhosis associated with hepatitis C virus.

It is difficult to treat patients with cirrhosis-associated hepatitis C with pegylated interferon (PEG-IFN) and ribavirin because of thrombocytopenia-related hypersplenism. Both safety and clinical efficacy were retrospectively analyzed for patients who underwent a laparoscopic splenectomy (LS) from January 2003 to December 2007. A total of 35 patients with cirrhosis associated with hepatitis C virus had LS for thrombocytopenia before PEG-IFN and ribavirin therapy, and all patients had thrombocytopenia, which was a contraindication for antiviral therapy. The hepatopathy was Child A in 24 patients, Child B in 10 patients, and Child C in one patient. All 35 patients increased platelet count from 48,000 +/- 15,000 to 155,000 +/- 55,000/microl (P < 0.0001) after LS. The median hospital stay and blood loss were 13.0 days (range, 8 to 57 days) and 342.0 mL (range, 5 to 2350 mL). There was no postoperative death. Twenty-nine (83%) patients had PEG-IFN and ribavirin therapy after LS; 18 had complete therapy and 11 had partial therapy. Of these, nine had a sustained virologic response. A laparoscopic splenectomy for patients with cirrhosis associated with hepatitis C virus can be performed safely and allows induction of antiviral treatment.

A case of pathological complete response of advanced rectal cancer to preoperative chemoradiotherapy using S-1.

In patients with advanced rectal cancer, preoperative chemoradiotherapy is superior to postoperative chemoradiotherapy because of causing less toxicity and achieving higher rates of sphincter preservation and curative resection. We treated a patient who had advanced rectal cancer with preoperative chemotherapy using S-1 and concurrent radiotherapy. S-1 was orally administered at a dose of 100 mg/day during the first cycle (two-week on and one week off). During the third cycle, radiotherapy was initiated concurrently and a total dose of 45 Gy was given. The most severe adverse event was grade 3 leukopenia during the third cycle. On day 42 after completing radiotherapy, low anterior resection with diverting colostomy was performed. Histological examination found no viable cancer cells in the resected specimens, including the primary tumor site and lymph nodes. Thus, a pathological complete response was achieved. Postoperatively, anastomotic leakage occurred, but it was resolved with transanal drainage. Preoperative chemoradiotherapy using S-1 contributed to sphincter preservation and curative resection in this patient. This regimen was both effective and well-tolerated, suggesting that it could be useful for advanced rectal cancer.

[Palliative care team in National Hospital Organization Osaka Minami Medical Center].

Preparation of a system of palliative care support is called for by The Basic Act on Anti-Cancer Measures and The Basic Plans for National Cancer Strategy. The Organization of Hospitals for Cancer Treatment should play a very important role in the regional palliative care network. The palliative care team in the Organization of Hospitals for Cancer Treatment should promote palliative care support throughout regional hospitals. In 2007, we established a palliative care team at the National Hospital Organization Osaka Minami Medical Center. We have drawn up a detailed report on the activities of palliative care team in our medical center.

Trends in Policy on the Prevention and Control of Non-Communicable Diseases in Japan.

Abstract-For the past decades Japan has remained number one in a range of population health metrics including the world's longest healthy life expectancy. While this was achieved through various socioeconomic factors besides public health interventions, health promotion policies to prevent and control non-communicable diseases (NCDs) played a major role. Japan introduced its first comprehensive national plan to prevent and control NCDs in 1978 and has revised the plan every decade since. These 10-year policy packages were instrumental in galvanizing stakeholders, while adapting to changing social, behavioral, and epidemiological trends. In this article, we provide an overview of trends in policy on the prevention and control of NCDs in Japan with a focus on successes and challenges especially due to a rapidly aging population. Through this review we aim to share the lessons learned in Japan for other countries tackling or expecting to be challenged by NCDs. These lessons include the role of multisectoral approaches, clear goals and targets with effective monitoring and evaluation mechanisms, addressing social aspects, adjustment to the local context, and foreseeing future demographic transition. Japan is committed to contributing to the world as a forerunner of the health challenges posed by unprecedented demographic change, by sharing its lessons in the global quest to create a world where all people can live longer and healthier lives.

C-reactive protein, symptoms and activity of daily living in patients with advanced cancer receiving palliative care.

BACKGROUND: The association between C-reactive protein (CRP) level, symptoms, and activities of daily living (ADL) in advanced cancer patients is unclear. METHODS: Secondary data analysis of a multicenter prospective cohort study consisted of 2426 advanced cancer patients referred to palliative care settings was conducted to examine the cross-sectional relationships between CRP level, symptoms, and ADL disabilities. Laboratory data, symptoms, ADL, and manual muscle testing (MMT) results were obtained at baseline. Participants were divided into four groups: low (CRP < 1 mg/dl), moderate (1 = < CRP <5 mg/dl), high (5 = < CRP < 10 mg/dl), and very high CRP (10 mg/dl = < CRP). The proportions of eight symptoms, five ADL disabilities, and three categories of MMT according to the CRP groups were tested by chi-square tests. Multiple-adjusted odd ratios (ORs) were calculated by using ordinal logistic regression after adjustment for age, gender, site of primary cancer, metastatic disease, performance status, chemotherapy, and setting of care. RESULTS: A total of 1702 patients were analysed. Positive rates of symptoms and ADL disabilities increased with increasing CRP level. In the very high-CRP group, rates of positivity for anorexia, fatigue, and weight loss were 89.8%, 81.0%, and 79.2%, respectively, and over 70% of patients received assistance for bathing, dressing, going to the toilet, and transfer. The grade of MMT also deteriorated with increasing CRP level. Adjusted ORs for the accumulated symptoms significantly increased with increasing CRP level in the moderate-CRP, high-CRP, and very high-CRP groups [1.6 (95% confidence interval 1.2-2.0), P < 0.001; 2.5 (1.9-3.2), P < 0.001; 3.5 (2.7-4.6), P < 0.001, respectively]. Adjusted ORs for the accumulated ADL disabilities significantly increased in the very high-CRP groups [2.1 (1.5-2.9), P < 0.001]. CONCLUSIONS: Associations between CRP level, symptoms, and ADL were observed in advanced cancer patients receiving palliative care.

Eating-related distress and need for nutritional support of families of advanced cancer patients: a nationwide survey of bereaved family members.

BACKGROUND: A number of advanced cancer patients are suffering from physical and psychosocial burdens because of cancer cachexia, and these burdens also greatly impact on their family members and relationships between patients and family members. It is necessary to consider the psychosocial impact of cancer cachexia on family members of advanced cancer patients. METHODS: A cross-sectional anonymous nationwide survey was conducted involving 925 bereaved family members of cancer patients who had been admitted to 133 inpatient hospices throughout Japan. RESULTS: A total of 702 bereaved family members returned the questionnaires (response rate, 75.9%). Concerning eating-related distress, 'I served what the patient wanted without consideration of calories and nutritional composition' was highest (75.1%), and 'I tried making many kinds of meals for the patient' and 'I was concerned about planning meals for the patient every day' followed (63.0% and 59.4%, respectively). The top 5 of the 19 items were categorized as 'fighting back'. Need for nutritional support was high (72.2%), and need for explanations about the reasons for anorexia and weight loss of patients was moderate (41.4%). Explanatory factor analysis of eating-related distress identified the following four domains: (factor 1) feeling that family members forced the patient to eat to avoid death, (factor 2) feeling that family members made great efforts to help the patient eat, (factor 3) feeling that eating was a cause of conflicts between the patient and family members, and (factor 4) feeling that correct information was insufficient. Results of multiple logistic regression analysis showed that spouse, fair/poor mental status, factors 1, and 4 were identified as independent determinants of major depression {odds ratio [OR] 3.27 [95% confidence interval (CI) 1.24-8.60], P = 0.02; OR 4.50 [95% CI 2.46-8.25], P < 0.001; OR 2.51 [95% CI 1.16-5.45], P = 0.02; OR 2.33 [95% CI 1.13-4.80], P = 0.02, respectively}. CONCLUSIONS: A number of family members of advanced cancer patients experienced high levels of eating-related distress and had a need for nutritional support.

Recurrence of primary hepatocellular carcinoma after hepatectomy--differences related to underlying hepatitis virus species.

BACKGROUND/AIMS: Studies on post-hepatectomy prognoses by infecting viral species have only been rarely reported. METHODOLOGY: The patients who had undergone hepatectomy for primary hepatocellular carcinoma (HCC) over the past 10 years at our hospital were divided into three groups based on their underlying causal diseases: hepatitis B (B type), hepatitis C (C type), and non-viral hepatitis including alcoholic hepatitis, and their backgrounds and long-term results after hepatectomy were comparatively investigated. RESULTS: As for tumor factors, the tumor diameter was 3.7+/-2.1 cm in C type patients, which was significantly smaller than the 5.2+/-3.3 cm diameter in B type patients (p=0.01) and 7.9+/-5.6 cm in non-viral patients (p=0.001). However, the frequencies of intrahepatic metastasis, portal vein infiltration, capsule formation and capsule infiltration did not differ significantly among the three groups. Although there was no significant difference observed among the three groups for the recurrence-free survival time, HCC had recurred at as early a stage as within 1 postoperative year in 50% of non-viral patients. CONCLUSIONS: The size of a tumor upon hepatectomy and the presence or absence of intrahepatic metastasis were found to be significant factors contributing to the postoperative recurrence of HCC. It is possible that the recurrence-free postoperative survival time may be prolonged by earlier detection of HCC, particularly for the B type and the non-viral type in which the tumor size was already large at the time of surgery.

Clinicopathological features of malignant intraductal papillary mucinous tumors of the pancreas: the differential diagnosis from benign entities.

BACKGROUND: The accurate differential diagnosis of malignant intraductal papillary mucinous tumors (IPMTs) of the pancreas from benign IPMTs remains unclear. HYPOTHESIS: Predictive factors for differentiating malignant IPMTs from benign IPMTs can be documented. DESIGN: Retrospective study (1999-2003). SETTING: Wakayama Medical University Hospital, Wakayama, Japan. PATIENTS: Twenty-seven consecutive patients with IPMTs (11 with adenoma, 3 with dysplasia, 5 with adenocarcinoma, and 8 with invasive adenocarcinoma) who underwent surgery were retrospectively analyzed in terms of clinicopathological features. MAIN OUTCOME MEASURE: Clinical data, preoperative imaging findings, cytology, and tumor marker level, including carcinoembryonic antigen (CEA) and carbohydrate antigen (CA19-9), in serum and pure pancreatic juice. RESULTS: In preoperative imaging findings, the mean tumor size for the malignant IPMT group (81 +/- 18 mm) was significantly larger than that for the benign IPMT group (31 +/- 4 mm) (P =.002). The mean mural nodule size for the malignant IPMT group (9.8 +/- 4.4 mm) was significantly larger than that for the benign IPMT group (3.3 +/- 5.7 mm) (P =.002). The CEA levels in pure pancreatic juice in the malignant IPMT group (3051 +/- 7556 ng/mL) were significantly higher than in the benign IPMT group (41 +/- 80 ng/mL) (P =.003), although no significant differences in cytologic analyses and CA19-9 levels in pure pancreatic juice were found between the 2 groups. CONCLUSION: Our findings suggest that tumor size larger than 30 mm, mural nodule size larger than 5 mm, and CEA levels higher than 110 ng/mL in pure pancreatic juice were predictive factors for diagnosis of malignant IPMTs.

[Microwave coagulation therapy for unresectable colorectal metastatic liver tumor].

INTRODUCTION: We evaluate the utility of microwave coagulation therapy (MCT) for the patients with unresectable liver metastasis from colorectal cancers. METHODS: Forty-four patients unresectable synchronous colorectal hepatic metastasis between January 1, 1989 and December 31, 2000, were enrolled in the present study. The patients courses were followed until March, 2002. To evaluate the efficacy of MCT for unresectable liver metastasis from colorectal cancers, a retrospective comparative study was done between a MCT with CT (hepatic arterial trans-infusion chemotherapy and/or systemic chemotherapy) group and a CT group. The background factors were examined included the maximum tumor diameter, the number of liver metastasis and disease of other metastatic sites, which influenced the outcome. RESULTS AND CONCLUSION: The survival curves of the patients with unresectable synchronous colorectal hepatic metastasis undergoing MCT with CT and CT alone were significantly different (p = 0.03). No significant differences were found in the background factors that had a prognostic influence. It is confirmed that using MCT can prolong the survival rate for the patients with unresectable synchronous colorectal hepatic metastasis.

Laparoscopic splenectomy is a safe and effective procedure for patients with splenomegaly due to portal hypertension.

BACKGROUND/PURPOSE: This study was conducted retrospectively to examine whether laparoscopic splenectomy is an effective procedure for patients with splenomegaly due to portal hypertension in comparison to patients with a normal-sized spleen. METHODS: From September 1994 to May 2005, we performed laparoscopic splenectomy in 50 patients at Wakayama Medical University Hospital, Japan. Of these, 17 patients with splenomegaly due to portal hypertension and 17 patients with idiopathic thrombocytopenic purpura (ITP) with normal-size spleen were enrolled in this study, in which we compared the surgical outcome between patients with splenomegaly due to portal hypertension and those without splenomegaly (ITP group). RESULTS: The mean operative time (splenomegaly due to portal hypertension vs ITP; 171 vs 165 min; P = 0.7433) and estimated blood loss (248 vs 258 ml; P = 0.5396) were similar in the two groups. There were two patients with complications (11.8%) in the patients with splenomegaly due to portal hypertension and five patients with complications (29.4%) in those with ITP. All patients with splenomegaly due to portal hypertension showed appropriate increases in the platelet count following surgery. No perioperative mortality occurred. CONCLUSIONS: We concluded that laparoscopic splenectomy was an effective procedure for splenomegaly due to portal hypertension, with findings being similar to those observed in patients with a normal-sized spleen (such as patients with ITP).

Clinical significance of drainage tube insertion in laparoscopic cholecystectomy: a prospective randomized controlled trial.

BACKGROUND/PURPOSE: We aimed to investigate the appropriateness of inserting an intraperitoneal drainage tube after laparoscopic cholecystectomy (LC), based on postoperative pain and clinical courses, in a randomized comparative study. METHODS: One hundred and twenty patients who were to have LC were enrolled in this prospective randomized study. An 8-mm Penrose drain was retained below the liver bed for 42 h in each of 60 patients (group A), and no drain was retained in the remaining 60 patients (group B). Patients in each group were hospitalized for 4 days after operation, and the pain reported by the patients, using a visual analogue pain scale (VAS), and the time courses of changes in the highest body temperature, leukocyte count, and C-reactive protein (CRP) were studied comparatively for men and women. RESULTS: Mean VAS scores were significantly greater in group A than in group B at 24 h (P = 0.00004), and 48 h (P = 0.0014) after operation. When sex-stratified changes in mean VAS scores were compared within group A, females had more pain than their male counterparts at 24 h (P = 0.030), but group B showed no sex differences. When the number of patients who used analgesics postoperatively was compared between groups A and B, analgesics were used more frequently in group A. When changes in maximum body temperature were compared, the change was significantly higher in group A than in group B on day 2 after the operation (P = 0.017). CONCLUSIONS: Postoperative pain was intensified by the insertion of a drainage tube after LC. This tendency was stronger in women.

The evaluation of duct-to-mucosal pancreaticojejunostomy in pancreaticoduodenectomy.

This study was conducted to examine the efficacy of duct-to-mucosal pancreaticojejunostomy compared with external stented pancreaticojejunostomy in prevention of several complications, retrospectively. Seventy-six patients with pancreatic head resection (59 male; median age, 60.1 years) underwent pancreaticoduodenectomy at the Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan, between January 1, 1994, and March 31, 2002. In early postoperative status, the incidence of pancreatic fistula by duct-to-mucosal anastomosis (n = 45) was similar to that by external stent (n = 31); soft pancreas is a risk factor of pancreatic fistula compared with hard pancreas (p < 0.05). During the late postoperative period, however, no patients with duct-to-mucosal anastomosis showed pancreatic duct dilatation by computed tomography (CT). At the same time, 58.8% of patients with external stent followed by CT showed pancreatic duct dilatation (p < 0.01). The duct-to-mucosal anastomosis was more effective pancreaticojejunostomy than the external stent in terms of prevention of pancreatic duct dilatation, and it should be the surgical procedure of choice in pancreaticoduodenectomy.

Complications with reconstruction procedures in pylorus-preserving pancreaticoduodenectomy.

This study was conducted retrospectively to examine the efficacy of Traverso reconstruction compared with Billroth I reconstruction after pylorus-preserving pancreaticoduodenectomy, in the prevention of several complications. Pylorus-preserving pancreaticoduodenectomy is an aggressive surgery, and insufficiency of the pancreaticoenterostomy plays an important role in the postoperative progression. However, reports examining the correlation between pancreatic fistula and the type of reconstruction after pylorus-preserving pancreaticoduodenectomy have been limited. Sixty-four patients who underwent pylorus-preserving pancreaticoduodenectomy (33 reconstructed by the Traverso technique and 31 reconstructed by the Billroth I technique) were entered into this study to investigate whether the complications were related to the type of reconstruction procedure employed. Insufficiency of the pancreaticojejunostomy, including major leakage and pancreatic fistula, occurred in 18.2% of the reconstructions by Billroth I and 0% of the reconstructions by Traverso (p < 0.05). In addition, jejunal obstruction by recurrent tumor in the remnant pancreas was observed in 3 patients reconstructed by Billroth I, and required palliative bypass surgery. Reconstruction by the Traverso procedure after pylorus-preserving pancreaticoduodenectomy is a safe surgical method and has an advantage for advanced pancreatic cancer, which has high risk of jejunal obstruction by recurrent tumor in the remnant pancreas.

Human NTH1 physically interacts with p53 and proliferating cell nuclear antigen.

Thymine glycol (Tg) is one of predominant oxidative DNA lesions caused by ionizing radiation and other oxidative stresses. Human NTH1 is a bifunctional enzyme with DNA glycosylase and AP lyase activities and removes Tg as the first step of base excision repair (BER). We have searched for the factors interacting with NTH1 by using a pull-down assay and found that GST-NTH1 fusion protein precipitates proliferating cell nuclear antigen (PCNA) and p53 as well as XPG from human cell-free extracts. GST-NTH1 also bound to recombinant FLAG-tagged XPG, PCNA, and (His)6-tagged p53 proteins, indicating direct protein-protein interaction between those proteins. Furthermore, His-p53 and FLAG-XPG, but not PCNA, stimulated the Tg DNA glycosylase/AP lyase activity of GST-NTH1 or NTH1. These results provide an insight into the positive regulation of BER reaction and also suggest a possible linkage between BER of Tg and other cellular mechanisms.