A pilot case-control study on the alveolar bone density measurement in risk assessment for bisphosphonate-related osteonecrosis of the jaw.

UNLABELLED: Alveolar bone mineral density (BMD) measured by radiography standardized by aluminum step wedge pasted on the film and digitized by a computer system was significantly higher around osteonecrosis lesions than in control cases in a pilot case-control study. High alveolar bone density appears useful as a local risk factor for bisphosphonate-related osteonecrosis of the jaw (BRONJ). INTRODUCTION: In an attempt to find a reliable test method predicting the occurrence of BRONJ in addition to various risk factors suggested, an increase of alveolar bone density near the necrotic lesions was found by computerized radiogrammetry using dental films pasted with an aluminum step wedge (Bone Right, Dentalgraphic.Com Company, Himeji) in six cases of BRONJ. METHODS: The bone mineral density surrounding the osteonecrosis lesions showed distinctly higher density in BRONJ cases compared with age-matched controls. In one subject on bisphosphonate treatment in whom two extractions were simultaneously carried out, BRONJ occurred only at the location with extremely high alveolar bone density, but not at the other site with normal density. CONCLUSION: This method may be useful in detecting a rise of alveolar BMD frequently occurring near the necrotic lesion in subjects with impending risk for BRONJ.

Research for improving the autopsy rate for infant death--medical economic assessment of the forensic autopsy system in Japan.

The rate at which autopsies are performed in Japan for cases of infant death is not adequate for diagnosing sudden infant death syndrome (SIDS). In Japan, it will be necessary to increase the autopsy rate at the time of infant deaths in order to improve the certainty of diagnosing SIDS and improving the accuracy of determining the cause of death with respect to infant death. The objective of this research is to provide basic documentation required for administrative implementation of this objective. In Japan, the Medical Examiner System and its related Approved Autopsy System are not deployed nationwide. The estimated budget in the case of deploying the Medical Examiner System nationwide for the purpose of improving the infant death autopsy rate is in excess of 5 trillion yen, and that in the case of deploying the Approved Autopsy System nationwide is estimated at roughly 130 million US dollars. However, since the rate of autopsies performed for SIDS has not changed following the implementation of approved autopsies, the efficacy of the Approved Autopsy System has come to be viewed questionably. In addition, it is also necessary to enact legislation that mandates the conducting of autopsies for all cases of infant death as is done in Scandinavia. The required cost in the case of performing autopsies for all cases of abnormal infant death is estimated at 200,000-700,000 US dollars and is considered to be within a range that could be implemented through local government regulations. In addition, the cost per body of an autopsy performed at the State Crime Laboratory in the State of Arkansas in the US in 1999 was about 6000 US dollars. In contrast, the same cost at the Tokyo Medical Examiner Office is much less at only about 4000 US dollars.

Effect of avicatonin (chicken carbocalcitonin) on galvanic skin response: a randomized, prospective, double-blind, controlled study for an objective assessment of pain.

In an attempt to objectively evaluate the analgesic effect of avicatonin (chicken carbocalcitonin), galvanic skin response (GSR) was recorded in 18 patients with osteoporosis or osteopenia and backache in a randomized, prospective, double-blind, controlled study. Backache on examination and in daily living was assessed weekly by scores utilizing a questionnaire. After two measurements 1 week apart on induction of backache with a maximum anterior flexion of the back from a supine position, either 20 units of avicatonin or inactive placebo was intramuscularly injected once a week for 4 consecutive weeks. In the avicatonin group but not in the placebo group, the area under the curve (AUC) of GSR tracing was decreased, giving a significant difference between the avicatonin and placebo groups after the second week. The pain score obtained by questionnaire decreased in both groups, suggesting a placebo effect. Galvanic skin response may provide a breakthrough to the objective and reliable evaluation of the biological response to pain which could not be accomplished by questionnaires based on subjective impression markedly influenced by emotional and psychological factors.

Assessment of cerebrospinal fluid levels of serum amyloid P component in patients with Alzheimer's disease.

Serum amyloid P component (SAP) is a normal plasma constituent that is observed both in senile plaque and in neurofibrillary tangle in brains of patients with Alzheimer's disease (AD). In this study, we evaluated the SAP levels in cerebrospinal fluid (CSF) of 72 patients with AD, 11 frontotemporal dementia and nine normal control subjects. There was no significant difference in the SAP levels between the AD group and other groups. However, among AD patients, cognitive function was rated using the Mini-Mental State Examination and was correlated with the SAP level (R = 0.38, P < 0.05). Our results suggest that measurement of the SAP levels in CSF can be useful for assessing the degree of cognitive impairment in AD patients.

[Actual situations and problems of patients receiving home IVH--trial use of an assessment chart for outpatients].

In order to improve the quality of life (QOL) and continue nursing, we used an assessment chart to investigate the actual situations and problems of the patients receiving home intravenous hyperalimentation (IVH). From January, 1997 to June, 1999, we investigated 20 patients with home IVH. To 7 patients among them, we asked questions using Kurihara's assessment chart for QOL, plus our original questions concerning IVH. The mean age of the patients was 61 years old, and 19 of them had advanced cancers. Forty percent of the patients maintained the IVH all by themselves and 10% of the patients needed the support of their family. The remaining 50% of the patients left all to their family. There were 9 incidents of trouble during the maintenance of the IVH. Almost all patients from whom informed consent had been received were satisfied with the home IVH. On the contrary, all patients who had not given informed consent were not satisfied with the home IVH. According to the results of the assessment chart, even if the total points were low, the points for the IVH were high in the patients had given informed consent. The main reason for lower QOL was pain. The points for the families were lower than those for the patients. They sometimes complained of uneasiness and dissatisfaction with the support they received. We conclude that therapies to improve symptoms and mental state are necessary to satisfy the patients, and that it is important to support not only the patients but also their families.

Assessment of a new triple agent regimen for the eradication of Helicobacter pylori and the nature of H. pylori resistance to this therapy in Japan.

BACKGROUND: Multiple regimens for the eradication of Helicobacter pylori have been tested, but the best therapy has not been determined yet. To determine the efficacy of a new triple agent regimen using a combination of lansoprazole, amoxicillin, and clarithromycin against Helicobacter pylori (H. pylori), and to examine H. pylori resistance to this therapy in ineffective cases. METHODS: We studied a total of 71 patients infected with H. pylori who had gastric ulcer (n = 37) or duodenal ulcer (n = 34) as confirmed by endoscopy. Patients received 1500 mg amoxicillin, 400 mg clarithromycin and 30 mg lansoprazole for 2 weeks followed by 30 mg lansoprazole for 6 weeks in patients with gastric ulcer or for 4 weeks in those with duodenal ulcer. Endoscopic examination was performed before treatment and at 1 month, 2 months, and 5 months after initiating treatment to check the status of ulceration and H. pylori infection. RESULTS: The eradication rate of H. pylori was 92% (CI, 83-100%) in the gastric ulcer group and 94% (CI, 86-100%) in the duodenal ulcer group at 5 months, as determined by per-protocol analysis. Resistance to clarithromycin was present in 1 of 71 (1%) patients before treatment and in 2 of 5 (40%) patients after treatment. No resistance to amoxicillin and lansoprazole was found in patients before or after treatment. The resistance to clarithromycin changed during the observation period. CONCLUSIONS: The new triple agent regimen was effective against H. pylori. Resistance to clarithromycin may not be permanent and it might be one of the risk factors which affect the efficacy of a clarithromycin-based therapy.

[Readmission among discharged psychiatric patients and it's correlates].

OBJECTIVE: This study investigated the incidence of readmission among discharged psychiatric patients and examined factors predicting early readmission. METHODS: A cohort of 343 patients, who had been hospitalized involuntarily to mental hospitals for medical care and custody, and who were discharged between April 1991 and September 1993, in two areas served by Fukuoka Prefectural Yamato Health Center (n = 163) and Tagawa Health Center (n = 180) were followed up until November 1994. RESULTS: The readmission rates within 6 months of discharge in Yamato Health Center and Tagawa Health Center were 17% and 22%, and within 1 year were 30% and 31% respectively. From Cox's proportional hazards model, alcohol/drug abuse, many of previous admission, long length of recent hospitalization, payment of medical care cost from public assistance, complication of physical disorders, living without a person responsible for custody after discharge, no request of health center's service by the hospital and discharge from a large-scale mental hospital were significantly related to increased risk of readmission. Not a few patients could not be followed up completely because of early drop-out of treatment. The drop-out rates within 1 month of discharge in Yamato Health Center and Tagawa Health Center were 10% and 26%, and within 1 year were 15% and 27% respectively. CONCLUSIONS: The rates of readmission and drop-out of treatment among discharged psychiatric patients were considerably high. This study clarified that rapid establishment of a mental health system supporting the mentally disabled in a community is an urgent need in Japan.

Focal liver hyperplasia in Alagille syndrome: assessment with hepatoreceptor and hepatobiliary imaging.

A child with Alagille syndrome, characterized by intrahepatic bile duct paucity, developed severe liver cirrhosis and was referred for liver transplantation. In the pre-transplantation evaluation, scintigraphic scans were performed using 99mTc-galactosyl serum albumin (99mTc-GSA) as a hepatoreceptor binding agent and 99mTc-pyridoxyl-5-methyl-tryptophan (99mTc-PMT) as a hepatobiliary agent. These studies demonstrated severe hepatobiliary dysfunction with an area of increased focal uptake in the liver. Histological examination at surgery confirmed that this focal lesion was an area of compensatory hyperplasia in advanced biliary cirrhosis. We present the usefulness of these tracers for detecting the focal hyperplasia of the liver.

[Circularity index of left ventricular shape in the assessment of heart disease].

Left ventricular volume and ejection fraction obtained by cineangiography are useful to evaluate global left ventricular function in humans. Left ventriculography provides evidence of the effect of coronary artery stenosis on regional wall motion in patients with coronary artery disease. Changes in left ventricular shape are also found in various heart diseases. The left ventricular cavity is normally ellipsoid in shape, but becomes flat in hypertrophic cardiomyopathy, globular in dilated cardiomyopathy, and aneurysmal in some patients with myocardial infarction. This study developed a new method to quantify regional and global left ventricular shape. Regional circularity index (RCI) was defined as GD divided by r (GD = distance from each 5-degree endocardial margin to the center of gravity, r = radius of the circle equal to left ventricular area). The global circularity index (GCI) was derived from the sum of magnitude of RCI-1. The end-systolic GCI was related to end-systolic left ventricular wall stress (r = 0.71, p < 0.001). The change in GCI during systole was related to left ventricular ejection fraction (r = 0.79, p < 0.001). In severe cases of dilated cardiomyopathy, the left ventricle became more spherical during ejection. End-systolic left ventricular moment around the minor axis had a good correlation with left ventricular ejection fraction (r = 0.81, p < 0.001). Quantification of regional and global left ventricular shape can be used to estimate left ventricular wall stress from left ventricular shape. Left ventricular shape change during systole and the moment around the left ventricular short axis contributes to left ventricular ejection.

[Assessment of left ventricular wall thickening with gated 99mTc-MIBI SPECT--value of normal file].

The wall thickening was assessed by regional count increase from end-diastole (ED) to end-systole (ES) in gated 99mTc-MIBI SPECT. The wall thickening index was calculated as (ES count--ED count)/ED count x 100 (% thickening). Gated SPECT was performed three hours after injection of 600 MBq of 99mTc-MIBI in 20 normal subjects to create normal files (ED, ES perfusion maps and % thickening map). In normal ED and ES perfusion maps, distribution in anterior and lateral regions were higher than other regions, indicating heterogeneous perfusion. In addition, the % thickening in apex was higher than anterior and lateral and septal regions, suggesting heterogeneous % thickening in normal subjects. Furthermore, the % thickening was different between male and female. We conclude that quantitative analysis of regional thickening can be performed by gated 99mTc-MIBI SPECT with normal files.

[Anti-osteoporotic programs in Japan].

On account of the unusually rapid aging of the population, osteoporosis became the most important health problem for the elderly in Japan. There are approximately 10,000,000 patients with osteoporosis in Japan and almost 1,000,000 patients are in bedridden state. Hip fracture is the second most frequent cause for the bedridden state. Ministry of Health and Welfare funded several projects to assess the current status of osteoporosis and to prevent osteoporotic fracture. Japan osteoporosis Foundation founded in 1991 concentrations its effort on public education and research support on osteoporosis.

[A record-linkage study on risk factors for cause-specific infant mortality].

Infant death certificates were linked with birth certificates for infants born to residents of Tohoku, Tokai and Kyushu regions in 1989 (n = 409, 679, or about one-third of all births in Japan), to examine the effects of variables, as reported on birth certificates, on cause-specific infant mortality. "Certain conditions originating in the perinatal period" and "congenital anomalies" accounted for nearly 90 percent of neonatal deaths, while "congenital anomalies", "injuries and poisoning" and "sudden infant death" were responsible for about 65 percent of postneonatal deaths. Mortality rates for almost all causes of infant deaths, except injuries and poisonings, increased as birth weight decreased not only in the neonatal period but also in the postneonatal period. This suggests that low birth weight places some infants at higher risk of death, and conditions that lead to low birth weight independently contribute to the risk of infant death. Cox's proportional hazards linear model was used to assess the effects of variables on infant mortalities by causes of death. An extremely strong birth weight effect was noted for "certain conditions originating in the perinatal period" and "congenital anomalies". Being a male infant and late order of birth in multiparity were other risk factors for deaths from "congenital anomalies", while being a male infant, resident of Tohoku region and maternal stillbirth experience related to deaths from "certain conditions originating in the perinatal period". Elevated risks of sudden infant death syndrome (SIDS), of which mortality rate in Japan was considerably lower than those in most developed Western countries, i.e. 0.23 per 1,000 live births in 1989, were associated with low birth weight, being a male infant, low maternal age, late order of birth in multiparity and illegitimacy. Low maternal age, late order of birth in multiparity and illegitimacy, also, related significantly to increased risk of infant deaths for "injuries and poisoning". These results suggest the independent contributions of socioeconomic factors to infant mortality, especially postneonatal mortality, from SIDS, "injuries and poisonings".

Preliminary Tl-201 SPECT for assessment of treatment efficacy in three patients with pancreatic cancer.

To evaluate treatment efficacy, Tl-201 SPECT was performed in three patients with pancreatic cancer. In all of the patients, the degree of Tl-201 uptake by tumor, evaluated from the tumor-liver uptake ratio of Tl-201 activity, correlated well with alterations in serum level of a tumor marker (CA 19-9, DUPAN-2) after treatment. One of the patients showed no tumor shrinkage on CT after treatment; however, Tl-201 SPECT demonstrated reduced uptake in the tumor coupled with a decreased level of CA 19-9. These results suggest that Tl-201 SPECT may become a new tool for assessing the efficacy of treatment in pancreatic cancer.

[Clinical assessment of 99mTc-HMPAO scintigraphy in thoracic tumors].

99mTc-hexamethylpropylene amineoxime (99mTc-HMPAO) scintigraphy was performed in 15 malignant tumors in 11 patients and a patient with bronchopneumonia. A high 99mTc-HMPAO affinity for the tumors was observed on SPECT, however, the mean tumor/contralateral normal lung ratios of 99mTc-HMPAO activity (1.26) was lower than that of 201Tl-chloride (2.29). 99mTc-HMPAO uptake was seen not only in the tumors but also in the bronchopneumonia, atelectasis, and irradiated lung (containing radiation fibrosis). Moreover, a diffuse uptake in the lung was seen in a patient received repeated chemotherapy. Therefore, it is emphasized that there is a non-specific 99mTc-HMPAO uptake in those various pulmonary conditions.

Practical assessment of natural heart function using echocardiography in mechanically assisted patients.

Left ventricular assist systems (LVAS) can maintain the systemic circulation of patients with acute, profound heart failure. The assessment of natural heart (NH) function, however, is difficult in the clinical setting. The authors introduced a new index, heart rate-corrected ejection time/left atrial pressure (ETc/LAP) using echocardiography to evaluate NH function in 15 adult patients on the original LVAS for greater than 2 days. Bypass flow (BF) was gradually decreased according to the recovery of NH. Five patients were weaned from LVAS within 15 days, and LV function was well maintained (Group 1). Another six patients were weaned from LVAS within 21 days but died within 2 weeks (Group 2). The other four patients died on LVAS without recovery of NH (Group 3). In Group 1 patients, ejection time/pre-ejection period (ET/PEP) with LVAS assist increased continuously. In Groups 2 and 3, ET/PEP increased slowly and reached a plateau at approximately 10 days or remained low. Group 1 patients reached an ETc/LAP of 35 +/- 10 on LVAS within 7 days. Group 2 and Group 3 patient values were 18 +/- 2 (p less than 0.05) and 9 +/- 6 (p less than 0.01), respectively, on the seventh day. Based on these data, this new index provides an estimate of global NH function and a prediction of the probability of NH recovery.

Assessment of hypertensive heart by 2-dimensional echocardiography in mass screening.

Two-dimensional echocardiography (2DE) was used in the mass screening of 3,017 participants (1,195 males, 1,822 females, mean age 59) living in 13 areas in Japan. The 2DE findings of left ventricular hypertrophy (LVH) and LV function were compared with the presence and severity of hypertension (Ht). Out of 1,100 patients who had an evident history of Ht above 160/95 mmHg (Ht group), 298 patients (27.4%) were complicated by LVH. In contrast, LVH was also recognized in 60 (11.2%) of 535 borderline Ht cases and in 87 (6.3%) of 1,382 normotension cases. LVH cases in the Ht group were divided into 3 groups: mild (220: 73.8%), moderate (63: 21.2) and severe (15: 5.0). Asymmetric septal hypertrophy (ASH) was recognized in 111 patients (37.2%) of the 298 LVH cases. The prevalence of ASH in these LVH patients was higher according to the severity of the LVH: mild LVH = 31%, moderate LVH = 51% and severe LVH = 67%. The prevalence of LVH was higher in males than in females. This was especially apparent in the moderate to severe LVH groups and also noted to be higher according to the increase of mean blood pressure. The prevalence of mild to moderate LVH was significantly higher in the poorly-controlled group than in the well-controlled group. In contrast, no significant difference in prevalence of severe LVH was noted between the well-controlled and poorly-controlled groups. The prevalence of LV dysfunction was significantly greater in moderate or severe LVH groups than in non or mild LVH groups. It tended to be higher in the poorly-controlled group compared with the well-controlled group. The regression of LVH was frequently detected in the well-controlled group by the follow-up study. We conclude that 2DE observation of LV performance in mass screening will be extremely valuable in the long term follow-up of Ht patients.