Alteration in faecal bile acids, gut microbial composition and diversity after laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a well established treatment for severe obesity and type 2 diabetes. Although the gut microbiota is linked to the efficacy of LSG, the underlying mechanisms remain elusive. The effect of LSG for morbid obesity on the gut microbiota and bile acids was assessed here. METHODS: Severely obese subjects who were candidates for LSG were included and followed until 6 months after surgery. The composition and abundance of the microbiota and bile acids in faeces were assessed by 16S ribosomal RNA sequencing, quantitative PCR and liquid chromatography-mass spectrometry. RESULTS: In total, 28 patients with a mean(s.d.) BMI of 44·2(6·6) kg/m2 were enrolled. These patients had achieved excess weight loss of 53·2(19·0) per cent and showed improvement in metabolic diseases by 6 months after LSG, accompanied by an alteration in the faecal microbial community. The increase in α-diversity and abundance of specific taxa, such as Rikenellaceae and Christensenellaceae, was strongly associated with reduced faecal bile acid levels. These changes had a significant positive association with excess weight loss and metabolic alterations. However, the total number of faecal bacteria was lower in patients before (mean(s.d.) 10·26(0·36) log10 cells per g faeces) and after (10·39(0·29) log10 cells per g faeces) operation than in healthy subjects (10·83(0·27) log10 cells per g faeces). CONCLUSION: LSG is associated with a reduction in faecal bile acids and greater abundance of specific bacterial taxa and α-diversity that may contribute to the metabolic changes.

ANTECEDENTES: La gastrectomía vertical laparoscópica (laparoscopic sleeve gastrectomy, LSG) es un tratamiento bien establecido para la obesidad grave y la diabetes tipo 2. Aunque la microbiota intestinal se ha vinculado con la eficacia de LSG, los mecanismos subyacentes siguen siendo poco conocidos. En este estudio se evaluó el efecto de LSG en la obesidad mórbida sobre la microbiota del intestino y de los ácidos biliares (bile acids, BA). MÉTODOS: Tras la aprobación del Comité ético y la obtención del consentimiento informado, los sujetos con obesidad grave que eran candidatos para LSG fueron incluidos en el estudio y seguidos durante 6 meses después de la operación. Se evaluaron la composición y abundancia de la microbiota y BA en las heces mediante secuenciación del gen 16S rRNA, PCR cuantitativa y cromatografía líquida-espectrometría de masas. RESULTADOS: En total, 28 pacientes con una mediana (rango) del IMC de 43,9 kg/m2 (35,0-61,9) fueron reclutados y a los 6 meses tras una LSG, consiguieron una pérdida del exceso de peso de 47,3% (20,7-95,1) y mejoría de las enfermedades metabólicas acompañada de una alteración en la comunidad microbiana fecal. El aumento en la diversidad α y abundancia de especies taxonómicas específicas como Rikenellaceae y Christensenellaceae, se asociaba fuertemente con niveles fecales reducidos de BA. Estos cambios se asociaban de manera positiva y significativa con la pérdida del exceso de peso y las alteraciones metabólicas. Sin embargo, el número total de bacterias fecales en los pacientes fue inferior al de los sujetos sanos (10,84 log10 células/g heces (9,46-11,35)) antes de la operación (10,26 log10 células/g heces (9,44-10,91)) y después de la misma (10,42 log10 células/g heces (9,57-10,96)). CONCLUSIÓN: LSG se asoció con menos BA fecal y mayor abundancia de especies bacterianas específicas y diversidad α lo que puede contribuir a los cambios metabólicos.

Predicting the characteristics of the aetiological agent for Kawasaki disease from other paediatric infectious diseases in Japan.

Although Kawasaki disease (KD), which was first reported in the 1960s, is assumed to be infectious, its aetiological agent(s) remains unknown. We compared the geographical distribution of the force of infection and the super-annual periodicity of KD and seven other paediatric infectious diseases in Japan. The geographical distribution of the force of infection, which was estimated as the inverse of the mean patient age, was similar in KD and other paediatric viral infections. This similarity was due to the fact that the force of infection was determined largely by the total fertility rate. This finding suggests that KD shares a transmission route, i.e. sibling-to-sibling infection, with other paediatric infections. The super-annual periodicity, which is positively associated with the sum of an infectious disease's incubation period and infectious period, was much longer for KD and exanthema subitum than other paediatric infectious diseases. The virus for exanthema subitum is known to persist across the host's lifespan, which suggests that the aetiological agent for KD may also be capable of persistent infection. Taken together, these findings suggest that the aetiological agent for KD is transmitted through close contact and persists asymptomatically in most hosts.

Severe hyponatremia caused by syndrome of inappropriate secretion of antidiuretic hormone developed as initial manifestation of human herpesvirus-6-associated acute limbic encephalitis after unrelated bone marrow transplantation.

Severe hyponatremia is a critical electrolyte abnormality in allogeneic stem cell transplantation (allo-SCT) recipients and >50% of cases of severe hyponatremia are caused by the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Here, we present a patient with rapidly progressive severe hyponatremia as an initial sign and symptom of human herpesvirus-6-associated post-transplantation acute limbic encephalitis (HHV-6 PALE) after allo-SCT. A 45-year-old woman with acute lymphoblastic leukemia received unrelated bone marrow transplantation from a one locus-mismatched donor at the DR locus. On day 21, she developed a generalized seizure and loss of consciousness with severe hyponatremia, elevated serum antidiuretic hormone (ADH), and decreased serum osmolality. A high titer of HHV-6 DNA was detected in cerebrospinal fluid. Treatment with foscarnet sodium and hypertonic saline was started with improvement of neurological condition within several days. Although an elevated serum ADH, low serum osmolality, and high urinary osmolality persisted for 2 months, she had no other recurrent symptoms of encephalitis. Our experience suggests that hyponatremia accompanied by SIADH should be recognized as a prodromal or concomitant manifestation of HHV-6 PALE, and close monitoring of serum sodium levels in high-risk patients for HHV-6 PALE is necessary for immediate diagnosis and treatment initiation.

Acetabular and proximal femoral alignment in patients with osteoarthritis of the dysplastic hip and its influence on the progression of disease.

In order to evaluate the relationship between acetabular and proximal femoral alignment in the initiation and evolution of osteoarthritis of the dysplastic hip, the acetabular and femoral angles were calculated geometrically from radiographs of 62 patients with pre-arthrosis and early osteoarthritis. The sum of the lateral opening angle of the acetabulum and the neck-shaft angle was defined as the lateral instability index (LII), and the sum of the anterior opening angle of the acetabulum and the anteversion angle of the femoral neck as the anterior instability index (AII). These two indices were compared in dysplastic and unaffected hips. A total of 22 unilateral hips with pre-arthrosis were followed for at least 15 years to determine whether the two indices were associated with the progression of osteoarthritis. The LII of the affected hips (197.4 (sd 6.0)) was significantly greater than that of the unaffected hips (1830 (sd 6.9)). A follow-up study of 22 hips with pre-arthrosis showed that only the LII was associated with progression of the disease, and an LII of 196 was the threshold value for this progression.

Effect of PVP on sperm capacitation status and embryonic development in cattle.

The objective of this study was to investigate the effects of polyvinylpyrrolidone (PVP) on sperm capacitation status and embryonic development in cattle (Bos taurus). Acrosome-reacted sperm (chlortetracycline stain) and the fertilization rate after intracytoplasmic sperm injection (ICSI) were enhanced (P<0.05) when sperm were cultured in a medium containing 10% PVP. However, injection of bovine in vitro-produced (IVP) embryos with medium containing 10% PVP suppressed development of these embryos to the 2-cell, morula, and blastocyst stages and cell number at the blastocyst stage (P<0.01) but did not affect chromosomal integrity (P>0.05). Embryo developmental capacity differed (P<0.01) among PVP from three suppliers, but there were no significant differences among three solvent media. The PVP remained localized in 40.9% of PVP-injected IVP embryos. In conclusion, PVP affected the acrosome reaction and enhanced the fertilization rate after ICSI. However, PVP remained detectable in IVP embryos and suppressed their developmental capacity.

Mammographic density and the risk of breast cancer in Japanese women.

Using an automated method for detecting mammographic mass, the authors evaluated the relation between quantitatively measured density and the risk of breast cancer in a case-control study among Japanese women. The case subjects were 146 women newly diagnosed and histologically confirmed with breast cancer at a general hospital. A total of 659 control women were selected from those who attended a breast cancer mass screening at this hospital. Significantly increased odds ratios (ORs) of breast cancer were observed for breast densities of 25-49 and 50-74%, but not for densities of 75-100% as compared with 0% in premenopausal women after controlling for covariates (ORs = 4.0, 4.3, and 1.4, respectively). In postmenopausal women, ORs were significantly increased for breast densities of 25-50% (OR = 3.0) and 50-100% (OR = 4.2). Total breast area was significantly associated with the risk of breast cancer independent of density percent or dense area in postmenopausal women. These data suggested that mammographic density was associated with the risk of breast cancer in Japanese women as is the case in Caucasian women. However, the associations of the risk of breast cancer with breast size and a high breast density greater than 75%, needs to be confirmed in future studies.

A cohort study of chronic liver disease in an HCV hyperendemic area of Japan: a prospective analysis for 12 years.

A mass screening in 1990 of H town in Japan demonstrated a high prevalence of hepatitis C virus (HCV) infection in our previous studies. The purpose of the present study was to evaluate the prognosis and natural history of liver disease among the same residents after 12 years. Of 509 residents, 69 people had died, and 55 people had moved to other regions. In all, 139 persons of the remaining 385 residing in H town were examined for liver function tests, antibodies to HCV (anti-HCV), serum HCV RNA, and hepatitis B virus surface antigen (HBsAg). The data of 14 of these 385 people were collected from medical records. The cause of death of the 69 individuals was investigated. The prognosis of liver disease could be clarified after 12 years in 222 of the 509 residents. Most of the residents with liver disease had an advanced stage of disease. Of the 69 persons who died, the mortality rate caused by liver cirrhosis or hepatocellular carcinoma (HCC) was 44 and 53%, respectively, among 25 persons with positive anti-HCV, and 19 with positive HCV RNA. One person with positive HBsAg died of HCC. Persons with chronic HCV or HBV infection had significantly higher mortality rates from liver cirrhosis and HCC than those without infection (P<0.00001). The present study suggests that early detection and treatment for HCC should be carried out as HCV carriers age. Furthermore, persistent HCV carriers should receive therapy for suppression of the development of HCC. The eradication of HCC should be considered a national goal.

Evaluation of styrene oligomers eluted from polystyrene for estrogenicity in estrogen receptor binding assay, reporter gene assay, and uterotrophic assay.

Styrene dimers (SDs) and styrene trimers (STs) eluted a little from polystyrene have been suspected of having estrogenic activity in the Wingspread Declaration [Our Stolen Futures, 1996] despite the lack of scientific analysis. Therefore, we have studied and reported styrene oligomers to have no endocrine disrupting effects [J. Food Hygienic Soc. Japan 40 (1999) 36; 41 (2000) 109; Yuki Goseikagaka Kyokaishi 57 (1999) 58; Bunseki Kagaku 49 (2000) 493, 857; Food Chem. Toxicol. 39 (2001) 1233; 40 (2002) 129]. However, Ohyama et al. reported that certain styrene oligomers have estrogenic effects in E-SCREEN and estrogen receptor (ER) binding assay [Environ. Health Perspect. 109 (2001) 699]. Recently, several assay systems have been developed, and a few of them can show false positive reactions at the high concentrations to which test compounds are precipitated [J. Health Sci. 48 (2002) 83]. In order to assess the estrogenic effect of SDs and STs in more detail, we examined the accuracy of the binding assay system and tested SDs and STs by three types of ER binding assay. In one ER binding assay, the same method that Ohyama et al. performed, SDs and STs showed a little estrogenic activity at high concentration; they did not dissolve, but this assay system tended to detect false positive effects at high concentration. In contrast, in the other assay systems, SDs and STs did not show any binding affinity to ER. In addition, luciferase reporter gene assay in HeLa cells transfected with ER expression plasmid and reporter plasmid, as a newly developed standard assay, and immature rat uterotrophic assay were conducted. In these tests, styrene oligomers showed no estrogenic activity.

A case of muscular hamartoma of the breast.

We describe a 74-year-old female presenting with a right breast mass. She had found the mass on self-examination. Physical examination revealed a 2.2 x 2.5 cm, firm, smooth, and mobile lump in the upper medial portion of the right breast. Mammography revealed a well marginated, oval-shaped, and isodense nodule. Calcification was not evident. On ultrasonography, the lesion was 17 x 18 x 9 mm and located 5 mm below the overlying skin. Excisional biopsy under local anesthesia was performed. The tumor was easily excised. Histopathologically, the lesion was composed of intersecting bundles of spindle-shaped smooth muscle cells, and involved peripheral ducts and fat tissue. Immunohistochemical staining showed positivity for alpha-smooth muscle actin (SMA), but was negative for S-100 protein, myoglobin, keratin, and vimentin. From these findings a muscular hamartoma of the breast, a rare subtype of hamartoma, was diagnosed.

Establishment of a simple method for measurement of chronic blood flow in uterine artery of pregnant cows.

Blood flow to the gravid uterine horn of seven multiparous Holstein cows (mean +/- SD, BW = 625.5 +/- 82.4 kg; age = 4.7 +/- 1.7 yr; parity = 2.9 +/- 1.1 yr) was measured from d 225 of gestation to parturition using transit-time ultrasonic blood flow probes placed around the middle uterine artery. Surgery was conducted on d 215 of gestation. The cows were sedated with xylazine and local anesthesia (procaine or bupivacain hydrochloride) during surgery. The surgical operations were conducted at the flank of standing cows. A transit time ultrasonic flow probe ("S" series, diameter 12 or 14 mm, Transonic Systems Inc., Ithaca, NY) was fitted surgically around the uterine artery of each cow. Surgery was completed within 2 h of anesthesia, and the animals recovered rapidly following surgery. Uterine blood flow (UBF, L/min) was recorded at 10-s intervals for 1395 min; these values were averaged to determine UBF. Cows exhibited normal gestation lengths (279.1 +/- 7.4 d), gave birth to normal healthy calves (birth weight = 40.6 +/- 6.6 kg), and had no retained placentas. The UBF increased significantly (P < 0.01) from d 225 (6.67 +/- 2.47) to d 249 (8.23 +/- 2.89) of gestation, but the latter UBF was similar to that of d 266 (8.38 +/- 2.70). The increased UBF after d 225 indicates increased demand of nutrients of fetus with the progress of gestation. The range of mean UBF varied widely among individual cows from 4.1 L/min to 12.2 L/min. Our method is useful for chronic measurement of UBF in cows for nutritional or physiological studies and does not require sophisticated facilities or special surgical technique.

Retreatment with interferon-alpha at dosages or period increased by 1.3 times is effective for treatment for transient responders and non-responders in chronic hepatitis C patients.

The objectives of retreatment with interferon (IFN) in chronic hepatitis C (CH-C) patients are sustained response and a reduction in the risk of hepatocellular carcinoma (HCC). However, it is still unclear, as to which patients are candidates for retreatment with IFN. Eighteen transient responders (TRs) and 15 non-responders (NRs) to IFN therapy in CH-C received retreatment with IFNalpha. Of the 18 TRs, five showed sustained disappearance of hepatitis C virus, two showed sustained biochemical response, 10 continued as TR and one was a NR. Of the 15 NRs, six showed a TR while nine continued as NRs. Responsive cases, which included the virologically or biochemically sustained and transient responders, received either a dose of IFN 1.3 times greater or were treated for a period of 1.3 times longer in the retreatment than the original treatment. We submit that IFN treatment consisting of either a time period or a dosage 1.3 times those of the original IFN administration may be beneficial in the case of TR and NR in chronic hepatitis C patients.

Time course profile and cell-type-specific production of monokine induced by interferon-gamma in Concanavalin A-induced hepatic injury in mice: comparative study with interferon-inducible protein-10.

BACKGROUND: We have previously shown that interferon-inducible protein-10 (IP-10), a chemokine for activated lymphocytes, was specifically induced in the liver of Concanavalin A (Con A)-treated mice. The aim of this study was to investigate the time course profile and cell-type-specific hepatic production of monokine induced by interferon-gamma (MIG), a chemokine which shares its receptor and most of its activity with IP-10, in Con A-treated mice and to compare them with those of IP-10. METHODS: Hepatic mRNA expression of MIG and IP-10 was studied by means of Northern blot analysis and in situ hybridization in Con A-treated mice. The levels of MIG and IP-10 in the serum and culture supernatants of murine hepatoma-, hepatic sinusoidal endothelial cell-, hepatic stellate cell- and macrophage-derived cell lines were determined by means of specific enzyme-linked immunosorbent assays. RESULTS: The serum level of MIG slowly reached a maximum at 12 h after Con A injection and remained elevated for a long time, whereas that of IP-10 reached a maximum at 3 h and declined quickly, a finding supported by Northern blot analysis. Using in situ hybridization, the mRNA of MIG as well as IP-10 was found to be expressed in hepatocytes and hepatic non-parenchymal cells. Similar to IP-10, MIG was produced by hepatoma-, hepatic sinusoidal endothelial cell-, hepatic stellate cell- and macrophage-derived cell lines in vitro. CONCLUSIONS: Although both MIG and IP-10 were produced by hepatocytes and hepatic non-parenchymal cells in Con A-treated mice, the time course profile of MIG was distinguishable from that of IP-10. The fact that hepatic MIG and IP-10 were produced sequentially in this hepatitis model may suggest that a non-redundant role is played by these two chemokines in the process of hepatic necro-inflammation.

Dexamethasone enhances mallory body formation in drug-primed mouse liver.

In a clinical study in which patients with alcoholic hepatitis were treated with prednisone for 1 month, posttreatment liver biopsies showed diminished inflammation, but Mallory bodies were not diminished. This suggested that steroid treatment may reduce inflammation by inhibiting NFkappaB activation. Sparing of Mallory bodies suggests that NFkappaB activation may not be involved mechanistically in Mallory body formation. To test this idea, we induced Mallory body formation in drug-primed mice with or without dexamethasone treatment. As predicted, dexamethasone decreased NFkappaB activation; however, Mallory body formation was increased. Surprisingly, TNFalpha and iNOS, which normally increase as a result of NFkappaB activation, were upregulated by the dexamethasone treatment. It was concluded that NFkappaB activation is not involved in Mallory body formation. Despite this, induced increases in TNFalpha, iNOS, c-jun/API and c-myc expression indicate that oxidative stress is likely involved in Mallory body formation.

Urinary trypsin inhibitor reduces C-X-C chemokine production in rat liver ischemia/reperfusion.

BACKGROUND AND AIM: Protease inhibitors attenuate ischemia/reperfusion injury. However, the underlying mechanisms by which protease inhibitors prevent reperfusion injury remain obscure. Neutrophils play an important role in reperfusion injury. We studied the effects of urinary trypsin inhibitor (UTI) on production of the C-X-C chemokine, cytokine-induced neutrophil chemoattractant (CINC), by Kupffer cells during ischemia/reperfusion of the liver. METHODS: Liver ischemia was induced in rats by occlusion of the portal vein for 30 min. UTI (50,000 U/kg) was injected intravenously 5 min before vascular clamping. Serum CINC concentrations were measured by enzyme-linked immunosorbent assay. Levels of CINC mRNA in the liver were determined by Northern blot analysis. We also examined the inhibitory effects of UTI on in vitro CINC production by peritoneal macrophages in response to neutrophil elastase (NE). RESULTS: Serum CINC concentrations increased and peaked 6 h after reperfusion. However, pretreatment of animals with UTI blunted this increase in CINC and significantly reduced CINC mRNA levels in the liver after ischemia/reperfusion. UTI also decreased neutrophil accumulation in the liver 24 h after reperfusion. In vitro CINC production by Kupffer cells from rats pretreated with UTI 3 h after ischemia/reperfusion was significantly decreased compared to those from untreated animals. UTI reduced NE activity in vitro in a dose-dependent manner, and UTI significantly reduced in vitro CINC production by peritoneal macrophages stimulated with NE. CONCLUSION: UTI reduces the production of CINC by Kupffer cells stimulated with NE, attenuating ischemia/reperfusion injury of the liver.

Histopathological and immunohistochemical study of oral lichen planus-associated HCV infection.

Background: In recent years, it has been suggested that oral lichen planus (OLP), a chronic inflammatory keratotic lesion, is related to hepatitis C virus (HCV) infection. Therefore, we evaluated whether the presence or absence of HCV infection caused any histopathological differences in OLP tissues. Methods; The subjects consisted of 31 patients with HCV-related liver disease complicated by OLP (32 OLP lesions) and ten OLP patients without complications due to either HCV infection or liver disease (control). A histopathological evaluation was performed in these patients. In addition, immunostaining was done on nine OLP tissues infected with HCV and on six OLP tissues without HCV infection in order to evaluate lymphocyte subsets (T cells or B cells) infiltrating into topical regions with OLP. Furthermore, the severity of hepatic fibrosis and inflammation was evaluated in liver tissues obtained by liver biopsy from six patients with HCV-related liver disease to evaluate whether there were any relationships between the severity of hepatic fibrosis or inflammation and OLP tissues. Results: There were no significant differences in the histopathological characteristics specific to OLP or in the ratios of T and B cells among infiltrating lymphocytes regardless of the presence or absence of HCV infection. Moreover, there were no certain relationships between the severity of hepatic fibrosis or inflammation and the severity of lymphocytic infiltration in OLP. Conclusions: HCV infection does not appear to influence the histopathological and immunohistochemical features of OLP.

DMSO and glycerol reduce bacterial death induced by expression of truncated N-terminal huntingtin with expanded polyglutamine tracts.

Huntington's disease (HD) is caused by CAG repeat expansion in exon 1 of a large gene, IT15, possessing 67 exons. Transgenic mice expressing a truncated N-terminal peptide of huntingtin with an expanded polyglutamine tract translated only from exon 1 develop symptoms similar to Huntington's disease. In the present study, a bacterial system (Escherichia coli) was used to express truncated peptides of huntingtin translated from exon 1 of the HD gene. Bacterial death was observed after the induction of peptides with expanded polyglutamine tracts, and both sodium dodecyl sulfate (SDS)-soluble peptides and insoluble aggregated material were detected by immunoblotting in the homogenates of such E. coli. E. coli death was partially reduced by the addition of dimethylsulfoxide (DMSO) or glycerol to the medium, with a consequent decrease in aggregated material and an increase in SDS-soluble peptide in the homogenate. These results suggest that DMSO and glycerol may decrease the toxicity of huntingtin with expanded polyglutamine tracts by acting as chemical chaperones.

Detection of hepatitis C virus RNA in oral lichen planus and oral cancer tissues.

Hepatitis C virus (HCV) infection not only causes chronic liver diseases but shows extrahepatic manifestations as oral lichen planus (OLP) and oral cancer. To elucidate the direct relationships among these diseases and HCV infection, we investigated the detection of positive- and negative-strand HCV-RNA from serum, OLP (n=19), and oral cancer (n=17) tissues. We used a sensitive reverse transcription to polymerase chain reaction (RT-PCR) method, and analyzed sequences from the HCV El/E2 region of the genome from serum and tissue. Positive and negative HCV-RNA strands were observed in 13 (92.9%) and 3 (21.4%) OLP tissues, respectively. In oral cancer tissues, positive HCV-RNA strands were detected in all tissues from anti-HCV positive patients. Negative HCV-RNA strands were observed in 5 of 7 (71.4%) patient's tissues. Furthermore, it was confirmed that the sequence from one of each OLP and oral cancer patient differed between serum and tissue HCV-RNA. These results may indicate that HCV persists and replicates in these lesions, suggesting a pathological role for HCV, although the mechanisms are unclear.

Comparison of the inpatients admitted during the recent 5 years (January 1994-December 1998) with those admitted during the previous 5 years (January 1989-December 1993): a clinico-statistical study.

As society ages, the composition of the diseases that occur within it changes accordingly. With that in mind, we examined the characteristics and trends in the recent inpatients and compared these recent inpatients with those of a previous report to identify the changes that accompany the aging of society. Subjects were 1,534 cases (men 56.9%, female 43.1%, average age 47.1 years) who were hospitalized at Kurume University Hospital for treatment during the 5-year period from January 1st, 1994 through December 31st, 1998. The ratio of inpatients over 65 years old was about 1.8 times higher than in the previous study, showing a clear trend toward an increased overall age of inpatients. As for the types of disease observed, the most common malignancies were epithelial tumor, followed by other benign tumors, as well as 76 cases which included diseases resembling tumor (epulis and exostosis etc.). A majority of the patients (55.6%) were directed to the Hospital by their dentist, a finding similar to that of the previous report. As for geographical distribution, 93.3% of the inpatients lived within 40 km of the center of Kurume City where our oral surgery is located, an increase of about 10% from the last report. In other words, our results showed a reduction in the sphere of treatment distribution.