Estimating nurses' workload using the Diagnosis Procedure Combination in Japan.

AIM: To examine the methods used to estimate nurse staffing levels in acute care settings with Diagnosis Related Groups, which in Japan are called the Diagnosis Procedure Combination (DPC). METHODS: For estimating staffing requirements, the study used four DPC groups: (1) acute or recurrent myocardial infarction (AMI) with stenting, (2) angina pectoris with coronary artery bypass grafting (CABG), (3) sub-arachnoid haemorrhage (SAH) with clipping surgery, and (4) cerebral infarction with carotid endarterectomy (CEA). Registered nurses with more than 3-year nursing experience in nine university hospitals in the Tokyo metropolitan area completed self-report questionnaires in order to obtain nursing care time and care intensity per each DPC. The concordance rate was measured by Kendall's coefficient of concordance. The relationship between the care time and the care intensity was examined by a time series graph per DPC. Care intensity consisted of professional judgement, mental effort for helping patients, professional skill, physical effort for providing activities of daily living support, and nurse stress, based on the Hsiao and colleagues' model of resource-based relative value scale. RESULTS: Twenty-five nurses in nine university hospitals answered for a hypothetical typical patient with AMI and with CABG, and 28 nurses in nine university hospitals answered for a hypothetical typical patient with SAH and with CEA. Kendall's coefficient of concordance was 0.896 for AMI, 0.855 for CABG, 0.848 for SAH, 0.854 for CEA. The time series data of the care time and the care intensity items showed different patterns for each DPC. CONCLUSION: The DPC for cardiovascular and cerebral surgical procedures can be used for estimating nurses' workload.

Significance of chemokine receptor expression in aggressive NK cell leukemia.

Natural killer (NK) cell-type lymphoproliferative diseases of granular lymphocytes can be subdivided into aggressive NK cell leukemia (ANKL) and chronic NK cell lymphocytosis (CNKL). One reason for the poor outcome in ANKL is leukemic infiltration into multiple organs. The mechanisms of cell trafficking associated with the chemokine system have been investigated in NK cells. To clarify the mechanism of systemic migration of leukemic NK cells, we enrolled nine ANKL and six CNKL cases, and analyzed the expression profiles and functions of chemokine receptors by flowcytometry and chemotaxis assay. CXCR1 was detected on NK cells in all groups, and CCR5 was positive in all ANKL cells. Proliferating NK cells were simultaneously positive for CXCR1 and CCR5 in all ANKL patients examined, and NK cells with this phenotype did not expand in CNKL patients or healthy donors. ANKL cells showed enhanced chemotaxis toward the ligands of these receptors. These results indicated that the chemokine system might play an important role in the pathophysiology of ANKL and that chemokine receptor profiling might be a novel tool for discriminating ANKL cells from benign NK cells.

Younger onset myeloperoxidase-specific antineutrophil cytoplasmic antibody- (MPO-ANCA) related glomerulonephritis accompanied with nephrotic syndrome.

It is known that nephrotic syndrome rarely accompanies myeloperoxidase-specific antineutrophil cytoplasmic antibody- (MPO-ANCA) related glomerulonephritis. We present a case of younger onset MPO-ANCA-related glomerulonephritis accompanied with nephrotic syndrome in a female patient. It was diagnosed through the renal biopsy and the detection of a high titer of MPO-ANCA and steroid therapy (intravenous steroid pulse therapy and oral administration), anticoagulant therapy and antiplatelet therapy were initiated. Since her nephrotic syndrome persisted in spite of the decrease of MPO-ANCA, we conducted a second renal biopsy. We found active necrotizing crescentic glomerulonephritis with a small deposition of immunoglobulin and fibrinogen on the glomeruli. To suppress her disease activity, we administered second steroid-pulse therapy and MPO-ANCA titer disappeared. However, as her nephrotic syndrome, which was accompanied by severe hyperlipidemia, persisted, we tried to treat her using low-density lipoprotein (LDL) apheresis. It was effective temporarily, but she finally fell into end-stage renal failure. We discuss here the possibility of double nephropathy by considering her clinical and renal pathologic features.

[A case of intrathoracic schwannoma derived from the left vagus nerve].

We report a case of schwannoma asymptomatic for 9 years, derived from the left vagus nerve in the middle mediastinum. This spindle-shaped tumor caused paralysis of the left recurrent nerve as an initial clinical manifestation with cough. T2-weighted magnetic resonance imaging (MRI) showed a neurogenic tumor with a characteristic target appearance and with constituents of different intensities: mucinous material in the peripheral zone and solitary tissue in the central zone. But, this different intensity is not directly reflected by the histopathologic features of Antoni types A and B. These findings suggest that MRI is useful for determining the parent nerve of a neurogenic tumor and is helpful for the diagnosis.

The effect of a hemofilter during extracorporeal circulation on hemodynamics in patients with SIRS.

OBJECTIVE: To evaluate the hypothesis that extracorporeal hemopurification with a hemofilter contributes to the stabilization of hemodynamics in patients with systemic inflammatory response syndrome (SIRS) due to a mechanism other than the removal of cytokines. DESIGN: Prospective study. SETTING: Intensive care unit (ICU) in a university hospital. PATIENTS: Seven critically ill patients who met criteria for SIRS with unstable hemodynamics requiring vasopressors after emergency surgery. INTERVENTIONS: Before initiation of continuous hemofiltration (CHF) extracorporeal circulation through the hemofilter (ECC) with a hollow-fiber polyacrylonitrile hemofilter was performed for 6 h. MEASUREMENTS AND RESULTS: Vital signs were monitored continuously and hemodynamics were evaluated intermittently. The blood level of endotoxin and the plasma levels of cytokines were measured at 0 and 6 h. Changes in plasma levels of cytokines passing through the hemofilter were evaluated at 3 h. A significant decrease of body temperature (P < 0.05 at 3 and 6 h vs 0 h), a significant elevation of mean arterial pressure (P < 0.05 at 0.5 h, P < 0.01 at 3 and 6 h vs 0 h), and a significant increase of urinary flow rate (P < 0.05 at 0 to 3 h vs -3 to 0 h) were observed with ECC. Neither the blood level of endotoxin nor the plasma levels of cytokines decreased. A significant increase of plasma IL-6 as it passed through the hemofilter was noted. CONCLUSIONS: The beneficial effects of hemopurification with a hemofilter on SIRS patients are possibly due to mechanisms other than the elimination of cytokines with ultrafiltration, diffusion, or adsorption.

Sex-dependent regulation of hepatic peroxisome proliferation in mice by trichloroethylene via peroxisome proliferator-activated receptor alpha (PPARalpha).

The mechanism of trichloroethylene-induced liver peroxisome proliferation and the sex difference in response was investigated using wild-type Sv/129 and peroxisome proliferator-activated receptor alpha (PPARalpha)-null mice. Trichloroethylene treatment (0.75 g/kg for 2 weeks by gavage) resulted in liver peroxisome proliferation in wild-type mice, but not in PPARalpha-null mice, suggesting that trichloroethylene-induced peroxisome proliferation is primarily mediated by PPARalpha. No remarkable sex difference was observed in induction of peroxisome proliferation, as measured morphologically, but a markedly higher induction of several enzymes and PPARalpha protein and mRNA was found in males. On the other hand, trichloroethylene induced liver cytochrome P450 2E1, the principal enzyme responsible for metabolizing trichloroethylene to chloral hydrate, only in males, which resulted in similar expression levels in both sexes after the treatment. Trichloroethylene influenced neither the level of catalase, an enzyme involved in the reduction of oxidative stress, nor aldehyde dehydrogenase, the main enzyme catalyzing the conversion to trichloroacetic acid. These results suggest that trichloroethylene treatment causes a male-specific PPARalpha-dependent increase in cellular oxidative stress.

Pulse steroid therapy in adult respiratory distress syndrome following petroleum naphtha ingestion.

CASE REPORT: A suicide attempt by a 23-year-old woman involved ingestion of 1000 mL of petroleum naphtha. Early chemical pneumonitis was complicated by life-threatening, diffuse interstitial lung consolidation with pneumatoceles. Pulse steroid therapy beginning on day 17 was associated with remarkable resolution of interstitial consolidation, although an enlarging secondarily infected pneumatocele ruptured to produce a bronchopleural fistula. Thoracic surgery and antibiotic therapy resulted in improvement of the patient's respiratory condition, and she was discharged with no residual respiratory symptoms. High-dose corticosteroid therapy appears to be a useful addition to aggressive supportive treatment in late adult respiratory distress syndrome following hydrocarbon ingestion.

[Infected emphysematous bullae in a patient with diabetes mellitus].

A 42-year-old woman with diabetes mellitus was admitted to our hospital because of fever, coughing, and dyspnea. Coarse crackles were audible and respiratory sounds were weak in the right lung field. Laboratory examination revealed a high erythrocyte sedimentation rate, a high level of serum C-reactive protein, a high blood sugar level, and hypoxemia. A chest roentgenogram revealed cystic lesions with fluid levels, and an infiltration shadow in the right lung field. A chest computed tomographic scan revealed many cystic lesions with fluid levels and an infiltration shadow. Our diagnosis was infected emphysematous bullae. A tube was inserted percutaneously for drainage and to allow injection of antibiotics into the cystic lesion. The cystic lesion then vanished. Percutaneous drainage and washing with antibiotics can be used to treat infected emphysematous bulla that have thick closed cystic walls.

[Pulmonary disease caused by Mycobacterium avium presenting as a solitary cavity with a thickened wall].

A 46-year-old man was admitted for evaluation of a solitary pulmonary cavity in the apey of the left lung. Because two transbronchial biopsies followed by brushing and washing and sputum cytology did not yield any diagnostic findings, the patient was treated with INH, RFP and SM under a tentative diagnosis of pulmonary tuberculosis. The shadow decreased over two months with combination therapy, but increased again after the dose of SM was decreased. We performed a left upper lobectomy to diagnose either multi-drug-resistant pulmonary tuberculosis or lung cancer. Pathological examination of the resected lung revealed epitheloid cell granulomas with areas of caseous necrosis. Smooth chromophoric colonies were isolated on an Ogawa egg medium, and were identified as M. avium by PCR and DDH. A diagnosis of pulmonary M. avium was made. A chest X-ray film taken two years later was normal. Pulmonary M. avium disease developed in this patient, who had no predisposing lung pathologies.

Thrombosed aneurysm of the middle cerebral artery with occlusion of the distal parent artery--case report.

A 54-year-old female presented with subarachnoid hemorrhage due to rupture of a small middle cerebral artery aneurysm, found to be thrombosed at surgery and not visualized on the preoperative angiograms. One major branch of the middle cerebral artery was found to be occluded near the trifurcation. The lumen of the branch proximal to the occlusion had appeared as the aneurysmal opacification on the preoperative angiograms.

[Clinical use of prostaglandin E1 during intracranial surgery].

Prostaglandin E1 was administered to 19 patients to induce hypotension during intracranial surgery. Urine volume during the operation and after the first day was well maintained, and serum BUN and creatinine were within normal ranges after the surgery. Serum GOT and GPT increased significantly on the 7th and 14th day after the operation compared with the control, but this did not seem to be the results of PGE1 administration. LDH and ALP showed no significant change. Thirty minutes and two hours after the administration of PGE1, arterial blood oxygen tension decreased significantly. These results suggest that PGE1 does not adversely affect the liver and kidneys, and it can be used safely and is useful to control blood pressure during intracranial operation.

[Efficacy and adverse effects of beta-interferon in the treatment of malignant glioma].

Sixteen patients with malignant glioma were treated by the intravenous administration of beta-interferon together with chemoradiotherapy. Five of the cases were recurrent gliomas. Seven of the 11 fresh cases were treated with beta-interferon, more than two months after cessation of the radiotherapy. Of the 16 cases, 12 cases showed partial regression of tumors, or no regrowth of tumors on CT scan, 2 cases showed no improvement, and 2 cases were unevaluable due to the short follow-up periods. IFN-beta is often administered, in combination with antineoplastic agents and radiotherapy, to patients with malignant glioma. Some patients have shown sufficient suppression of the growth of the malignant glioma only through administration of IFN-beta 1 x 10(6) IU once or twice a week. Some patients, however, have developed severe bone marrow suppression due to the combination therapy of IFN-beta and antineoplastic agents. Therefore, the blood of patients should be tested twice a week, and the data should be analyzed within the same day to determine the subsequent treatment. IFN-beta administration should be stopped if the platelet count drops below 1.0 x 10(5)/mm3 or half of the initial figure, and the course of disease of the patient should be carefully observed.

[Diagnosis of abnormal spine motion with cineradiography (author's transl)].

For the past one year, 13 patients were studied 20 times with cineradiography to diagnose abnormal spine motion, which was quite informative compared to usual plain spine X-ray pictures. The direct radiation dosis was only 2.35 rem/min on taking cineradiography at the speed of 60 frames/sec. The camera used was Cardoskop-U and the X-ray generator was Pandoros Optimatic, both of which were of Siemens make. It was keenly recognized that cineradiography was useful to diagnose 1) solidity of spine fusion, 2) effect of spinal traction, 3) efficacy of immobilizing apparatus for spine and 4) abnormal spine motion on dynamic way.

[Growth hormone, prolactin, LH and FSH secretion in tissue culture of pituitary adenomas (author's transl)].

We have performed tissue culture of pituitary adenomas (5 acromegalies, 7 non-acromegalies) and measured GH, PRL, LH and FSH in the media of tissue culture by radioimmunoassay (RIA) for 30-40 days. In addition, GH, PRL, LH and FSH were measured in the plasma and tumor tissue by RIA. GH concentration in the culture media was markedly high in all cases with acromegaly and high also in 2 out of 7 non-acromegaly cases (case 6 and 7). GH concentration in the media rapidly decreased almost as a straight line on a semilogarithmic scale until the 30-40 in day, when GH level became less than 10 ng/ml. PRL concentration in the culture media was high in 5 patients (3 acromegalies, 2 non-acromegalies). PRL concentration regressed more slowly than GH, but still remained higher than 10 ng/ml in all of the patients on the 25-40th day when the studies were discontinued. LH and FSH concentrations in the culture media was high in two patients. One patient was a pituitary adenoma secreting LH and FSH, and another case was a false high secreting one, possibly contaminated with gonadotropin in normal pituitary gland at surgical operation. LH and FSH concentrations rapidly decreased as that of GH. A rare case of primary LH and FSH secreting pituitary adenoma was demonstrated.

Human chorionic gonadotropin produced by ectopic pinealoma in a girl with precocious puberty. Case report.

A case is reported in which a human chorionic gonadotropin (HCG-)-producing ectopic pinealoma was found in a 5-year-old girl with precocious puberty. Physical examination revealed abnormal breast enlargement. Endocrinological study disclosed a high plasma HCG concentration of 1192 ng/ml with a normal follicular stimulating hormone (FSH) level. The HCG content of the tumor was as high as 400 ng/mg of acetone dried tissue, but no FSH was detectable. This is the first reported case of precocious puberty associated with pineal tumor in a female.

[A case of HCG-producing ectopic pinealoma in a girl with precocious puberty (author's transl)].

HCG-producing ectopic pinealoma of two cell pattern type was demonstrated in a 5-year old girl who presented precocious puberty and bilateral choked discs. The tumor was localized at the anterior third ventricle and suprasellar region. Endocrinological findings are as following: Plasma basal LH was markedly elevated to 306 mIU/ml and HCG was elevated to 1,192 ng/ml. Provocative test of hypophyseal function revealed low response. Plasma estrogen was not detectable. HCG content of resected tumor tissue was elevated to 400 ng/mg. FSH, however, was not detectable. Histological findings of this tumor showed atypical teratoma, so-called two cell pattern pinealoma. Electron microscopic findings revealed two types of cells, dark and clear cells. Many secreting granules were found in the dark cells. In this case, HCG in plasma, CSF and tumor tissue was remarkably elevated. In addition, plasma FSH was also elevated to 8.9 mIU/ml. Precocious puberty associated with tumor in the pineal-suprasellar region has been seen only in boys. There has been no case report of precocious puberty in girls. This case is the first female case is which HCG-producing ectopic penealoma is caused in precocious puberty.

[Studies on neurinomas and neurofibromas in tissue culture (author's transl)].

10 acoustic neurinomas, 2 spinal cord neurinomas and 3 neurofibromas of von Recklinghausen's disease were elaborately studied by monolayer tissue culture method and Gelfoam organ culture method. Four morphological types were found in the acoustic and spinal cord neurinoma. (1) multinucleated cells (type I), dividing into bipolar spindle-shaped cells. (2) bipolar spindle-shaped cells (type II), forming of palisade fashion in the monolayer tissue culture method. (3) fibroblastic cells (type III), tending to predominate in the long-term cultures. (4) round cells (type IV), gathering to the Gelfoam mesh in the organ culture method. Neurofibroma of von Recklinghausen's disease was divided into cells of two types in the tissue culture. (1) spindle-shaped cells, rarely observed, and have been thinking that the cells originated from schwann cells. (2) round cells, having the macrophagic character, are predominant in the long-term culture.