Review of combination of peritoneal dialysis and hemodialysis as a modality of treatment for end-stage renal disease.

Because the contribution of residual renal function (RRF) to total solute clearance is often significant in continuous ambulatory peritoneal dialysis (CAPD), loss of RRF over time can lead to inadequate dialysis if appropriate prescription management strategies are not pursued. Additionally, declines in ultrafiltration caused by increases in peritoneal permeability may limit continuation of CAPD therapy. Peritoneal dialysis and hemodialysis (PD + HD) combination therapy (complementary dialysis therapy) is an alternative method. This therapy allows the patient to maintain daily activities, as with CAPD, while undergoing once-a-week HD supplements for the insufficient removal of solutes and water. This therapy allows for the continuation of PD without shifting to total HD in PD patients who continue to have uremic symptoms even after individualization of the PD prescription. This treatment option is psychologically more acceptable to patients and may be expected to provide such accompanying beneficial effects as peritoneal resting, improvement of QOL and reduction in medical cost.

Current and future imaging of acute cerebral ischemia: assessment of tissue viability by perfusion imaging.

With the advances and availability of new imaging modalities, the role of imaging of acute stroke has been broadened from making diagnosis to providing valuable information for patient management. We need to have rapid diagnostic modalities that distinguish reversible ischemic tissue from irreversibly damaged tissue for successful thrombolytic therapy. Although diffusion imaging has been reported to have both high sensitivity and specificity for acute ischemia in clinical studies, previous reports do not conclude whether the diffusion abnormality is indicative of reversibly or irreversibly injured tissue. Perfusion imaging such as perfusion magnetic resonance imaging and single-photon emission computed tomography may have the potential for providing useful information that determines tissue viability and/or reversibility. Cerebral blood flow thresholds evaluated by pretreatment single-photon emission computed tomography provide important information that is potentially useful in the management of acute stroke patients with intra-arterial thrombolysis. Perfusion imaging, when combined with diffusion imaging, may thus be potentially useful in improving patient selection for thrombolytic therapy.

Severe occlusive carotid artery disease: hemodynamic assessment by MR perfusion imaging in symptomatic patients.

BACKGROUND AND PURPOSE: Cerebral hemodynamic status has been reported to influence the occurrence and outcome of acute stroke. The purpose of this study was to assess hemodynamic compromise in symptomatic patients with severe occlusive disease of the carotid artery by the use of echo-planar perfusion imaging. METHODS: Spin-echo echo-planar perfusion imaging was performed in 11 patients (two had bilateral disease) with severe stenosis or occlusion of the carotid artery who had experienced either a recent transient ischemic attack or minor stroke. Relative cerebral blood volume (rCBV) maps and relative mean transit time (rMTT) maps were generated from the time-concentration curve. Findings on T2-weighted images, angiograms, rCBV maps, and rMTT maps were compared and assessed qualitatively and quantitatively. RESULTS: Although the abnormalities on T2-weighted images were absent, minimal, and/or unrelated to the degree of stenosis or collateral circulation, rMTT maps showed much larger and more distinct perfusion abnormalities along the vascular distribution of the affected vessels in all 13 vascular territories of the 11 patients. Despite obvious abnormalities on rMTT maps, none of the patients had evidence of decreased rCBV in the affected brain tissue (increased in three, normal in eight). A statistically significant difference in rMTT values was found between the affected and unaffected brain tissue, whereas no significant difference was seen in rCBV values. CONCLUSION: Echo-planar perfusion imaging is a noninvasive and rapid method for evaluating the hemodynamics in severe occlusive carotid artery disease and the compensatory vascular changes, and it may be useful in patient management.

Hepatocyte growth factor in assessment of acute pancreatitis: comparison with C-reactive protein and interleukin-6.

Serum levels of hepatocyte growth factor (HGF), C-reactive protein (CRP), and interleukin-6 (IL-6) were determined at the time of admission in 38 patients with acute pancreatitis. The clinical utility of HGF for the detection of severe pancreatitis and for predicting prognosis, bacterial infection (infected pancreatic necrosis or sepsis), and organ dysfunction (liver, kidney, and lung) during the clinical course of acute pancreatitis was compared with the clinical utility of CRP and IL-6 by analysis of receiver operator characteristic (ROC) curves. The optimum cutoff levels of HGF for severity, prognosis, infection, hepatic dysfunction, renal dysfunction, and respiratory dysfunction were 0.9, 1.1, 1.0, 1.1, 1.1, and 1.0 ng/ml, respectively. HGF was as useful as CRP and more useful than IL-6 for detection of severe pancreatitis and for predicting hepatic dysfunction. Moreover, HGF was more useful than CRP or IL-6 for predicting prognosis, renal dysfunction, and respiratory dysfunction. However, for predicting infection, CRP was more useful than HGF. These results suggest that serum HGF levels on admission may be a useful new clinical parameter for determining the prognosis of acute pancreatitis and that HGF may be closely related to the organ dysfunction of acute pancreatitis.

Experimental assessment of newly devised transcatheter stent-graft for aortic dissection.

Despite recent advances, surgical results for Stanford type B dissection are not yet satisfactory because the procedure is so highly invasive. The aim of this study was to devise a new intraaortic (IA) graft that would offer less invasive treatment for type B dissection. To close the entry of type B dissections using transcatheter placement, we devised an IA graft (inner diameter, 15-20 mm; length, 40 to 60 mm) in which a self-expandable stent was covered with a thin, open-cell-structured polyurethane jacket. In acute animal experiments in which type B aortic dissections were prepared in 4 mongrel dogs, IA grafts were implanted to close the entry using a transfemoral catheter sheath, and closure of all the entries was confirmed by aortography. In chronic experiments, five IA grafts for normal descending aortas and one IA graft for an experimentally dissected aorta were implanted to observe histologic biocompatibility for up to 8 months. Histopathologic examination conducted at the projected sacrifice periods revealed that endothelialization of the luminal surface of the IA graft had begun as early as 1 month after implantation and was completed within 4 months. The prototype device that we developed may be promising as an effective, minimally invasive therapeutic intervention for closure of the entry site of type B dissection.

[Assessment of quality of life after transurethral resection of prostate for benign prostatic hyperplasia].

The quality of life (QOL) after transurethral resection of the prostate (TURP) was studied. A total of 113 patients were operated and released, and 86 (76%) cases responded to the TURP follow-up survey. The average age was 69 years and the average time elapsed after the operation was 220 days. Data regarding the patients undergoing TURP was gathered from a questionnaire consisting of 22 questions concerning the preoperative condition and 28 about the post-operative state. Performance status was not changed post-TURP. The patients showed improvements in nocturia, pollakisuria and dysuria. These urological symptoms were in accordance with the findings of uroflowmetry and American Urological Association Symptom Index. Ten questions addressing the patients mental and physical conditions revealed that good quality was generally retained. Sexual activity showed a tendency of gradual decrease in relation to increasing age. Ejaculatory function and actual satisfaction with the sexual act were obviously damaged by the operation. TURP showed no changes in regard to morning erection, sexual desire in an arousing atmosphere, penile hardness at sex and total satisfaction with the sexual life. Social life, family life and mental status were not influenced, but the physical status of 21 (26%) of the patients was decreased by the operation and hospital stay. Over all, 78% of the patients could maintain a good quality of life in post-TURP.

[Correlates associated with desire by caregivers to transfer elderly from home care to institutions].

A questionnaire survey was performed on 183 caregivers of elderly listed on a roster for utilization of day service or short stay service in nursing homes in order to elucidate the following; actual conditions of care at home; percentage desiring to transfer to institutionalized care in hospital, nursing homes and geriatric intermediate care facilities, reasons for continuing care at home; and factors relating to desire for transferring to institutionalized care. Results are as follows; Major items of troubles expressed by caregivers were; "high stress and mental fatigue" (55.7%), "unable to freely go out from home" (54.1%), and "loss of personal time" (46.4%), "heavy burden from food preparation, body discharge disposal and bathing of the elderly" (40.0%). 41.5% of caregivers expressed desire for transfer of elderly to institutional care. Of those who desire transfer to hospital care, 21.1% were continuing home care due to non-availability of appropriate hospital, 44.7% because of inability to meet the demand for assisting in the nursing of the elderly during hospitalization, 26.3% because they were turned away by the hospital. Where transfer to nursing homes was desired but not realized, 20.0% reported lack of nursing homes nearby. Where desire was for transfer to geriatric intermediate care facilities, lack of such facilities was reported by 37.5%. Analysis was performed to elucidate the factors that determine whether a caregiver would demand a transfer to an institutions. Main factors were age of caregiver, family relationships, family finance, the frequency of occurrence of problems with home care, and whether or not they themselves would accept institutional care when that time came. Main factors associated with the cared elderly desiring institutional care were eating ability, speaking ability and mental status score. Analysis of the problems related to desire to transfer to institutional care showed their factors such as whether or not there was room available for home care, financial family burden, perceived interference with personal time by the home care, and perception of appropriateness of coping with symptom change of elderly, all have significant relationships.

[A study of dental status and its contributing factors in mentally retarded persons institutionalized in welfare facilities].

Two hundred and forty-one mentally retarded persons, institutionalized in three private welfare facilities in Oita Prefecture, were assessed for dental status and tooth brushing ability. Information on their life style was also obtained by a questionnaire completed by their supervisors in the facilities. 1) Dental status of mentally retarded subjects was found to be inferior compared to the general Japanese population studied in the survey of dental disease in 1987 by the Ministry of Health and Welfare. Inferior dental status was characterized by a low score for filled teeth and a high score for missing teeth. 2) Both low tooth brushing ability and low intelligence quotient were associated with their poor dental status. 3) Discrepancy between supervisor assessment of tooth brushing ability and actual ability was observed. 4) Periodontitis was observed in young epileptics taking antiepileptic medication at a high rate. However there was no association between the taking of antiepileptic medication and missing teeth score. These results indicate a necessity for more active dental services including the teaching of tooth brushing and early treatment by dentists and supervisors.

[Assessment of occupational exposure to p-tert-butylphenol in synthetic resin factories].

Two cases of occupational vitiligo were observed in a resin factory where p-tert-butylphenol (PTBP) has been used as a starting material or an intermediate of synthetic resin. In this resin factory (A shop) and another resin factory (B shop), occupational exposure to PTBP was assessed in workers charging this chemical into the reaction vessel by means of a gas-chromatographic measurement of the environmental PTBP concentration and their urinary PTBP excretion. Assessment in A shop was made after the working condition was partly improved. Geometrical mean values of 8 h-time-weighted-average (8 h-TWA) of PTBP in air near the charger's breathing zone (personal air) were 0.215 mg/m3 in A shop and 2.12 mg/m3 in B shop. Continuous measurements of PTBP concentration in some stationary air of the shops showed that the maximum environmental PTBP values occurred during charging. Urinary PTBP concentration was increased to the maximum values 2 to 4 h after charging of this chemical and then rapidly decreased. Biological half-lives of urinary PTBP were estimated as 4.4 h in A shop and 4.8 h in B shop. The urinary PTBP concentration was correlated to 8 h-TWA of PTBP in the personal air. In particular, PTBP in urine collected at the end of the shift showed an excellent correlation to PTBP in the personal air (r = 0.84, n = 9, A shop; r = 0.88, n = 11, B shop). These results indicate that biological monitoring using urinary PTBP concentration is a suitable means of assessing exposure to this alkylphenol and the urine collected at the end of shift is the best sample for monitoring. In addition, the present environmental and urinary PTBP values were compared with those described in the literature and the relation of the occupational vitiligo with PTBP exposure is discussed.

Echocardiographic assessment of Qp/Qs in children with atrial septal defect or partial anomalous pulmonary venous connection.

In 24 children with atrial septal defect of the secundum type and/or partial anomalous pulmonary venous connection, the pulmonary to systemic blood flow ratio (Qp/Qs) was estimated by echocardiography. Using M-mode echocardiography, right ventricular diameter (RVD), left ventricular diameter (LVD), total cardiac diameter (TCD) and aortic root (AOR) were measured, and the following 5 indices were obtained: RVD/LVD, RVD/TCD, RVD/AOR, RVD/BSA (body surface area) and TCD/BSA. The single linear correlation coefficients between these 5 indices and Qp/Qs, obtained by the Fick method during cardiac catheterization, were 0.88, 0.80, 0.74, 0.75 and 0.55, respectively. Thus, RVD/LVD ratio was the most sensitive echocardiographic index to assess Qp/Qs in these children. Clinically, however, the multiple linear regression equation derived from 3 indices (RVD/BSA, RVD/LVD and TCD/BSA) might be more useful (r = 0.89). Although the abnormal motion of the interventricular septum was analyzed, the quantification of this motion as an index of Qp/Qs was difficult.