Predictive Ability of Seven Domains of the Kihon Checklist for Incident Dependency and Mortality.

The Kihon Checklist (KCL) is a structured questionnaire consisting of 7 domains to assess seniors' function in daily living. The aim of this study was to examine which domains of the KCL can predict incident dependency and mortality. The municipality sent a KCL questionnaire to independent seniors in Higashi-ura Town and collected the answers of the 5542 seniors who provided complete answers. Their incident dependency and mortality were followed-up for 2.5 years. A Cox proportional hazard model indicated that meeting any of the criteria in instrumental activities of daily living, physical, nutrition, and mood domains significantly predicted the risk of dependency, whereas meeting any of the criteria in physical, nutrition and socialization domains significantly predicted the risk of mortality. Category assessment by the KCL could be useful to predict incident dependency and all-cause mortality.

[Uncontrollable midbrain hemorrhage due to brain metastasis of pulmonary pleomorphic carcinoma].

A 54-year-old man who had been treated hypertension admitted our hospital due to midbrain hemorrhage. Pulmonary abnormal shadow was also found by chest radiological examinations and it was diagnosed as stage IB (T2N0M0) non-small-cell lung cancer. Right upper lobectomy with combined resection of azygos vein and parietal pleura facing to the tumor was conducted because the direct invasion of the tumor was strongly suspected. Pathological diagnosis was pleomorphic carcinoma. Although, postoperative course was uneventful, midbrain hemorrhage recurred 3rd postoperative day. Since the hemorrhage continued in spite of the conservative treatment, the craniotomy was performed on the 13th postoperative day. The pathological examination revealed the hemorrhage to be caused by the brain metastasis.

[Mediastinal granular cell tumor arising from the left recurrent nerve; report of a case].

Granular cell tumor is found in various organs but is rare in the mediastinum. We report a case of 36-year-old woman with a granular cell tumor in the left upper mediastinum. She was admitted to our hospital because of hoarseness. Laryngoscopic examination revealed left vocal cord paralysis. Chest computed tomography (CT) showed a 3.0 x 2.0 cm well circumscribed tumor at the left side of the trachea in the left upper mediastinum. As hoarseness was suspected to be attributable to the mediastinal tumor, tumor resection was performed. It was found that the tumor involved the left recurrent nerve. The tumor was completely excised with combined resection of the left recurrent nerve. Histopathologically, the tumor consisted of cells with eosinophilic granules and S-100 protein positive materials in the cytoplasm, and diagnosed a granular cell tumor.

[Interesting pulmonary metastasis from spindle cell carcinoma of the breast].

We experienced a case of interesting pulmonary metastasis from spindle cell carcinoma of the breast. A 68-year-old female who had undergone a radical mastectomy 32 months earlier was admitted to our hospital for the pulmonary tumor in the left S10 in January 2005. Pathological study of the breast tumor revealed mixture of carcinomatous portion and sarcomatoid portion with spindle cells. Because of the presence of transitional areas from one portion to the other, the tumor was diagnosed as spindle cell carcinoma of the breast. Partial resection of the left lower lobe was performed. Pathological examination of the pulmonary tumor revealed that the tumor was composed of the component similar to carcinomatous element of the breast cancer. In June 2005, She was admitted to our hospital again for the pulmonary tumor in the right S7. Partial resection of the right lower lobe was performed. The tumor was composed of both carcinomatous and sarcomatoid elements. After operation, as she complained of epigastralgia, a gastroscopic examination was performed. It showed 2 white polypi of the stomach. The biopsy specimen of the polypi were composed of the tumor similar to the sarcomatoid element of the breast cancer. She died of widespread metastasis 43 months after mastectomy.

Phase I clinical and pharmacokinetic study of a 14-day infusion of etoposide in patients with lung cancer.

PURPOSE: A phase I study was conducted to determine the maximum-tolerated dose (MTD) of a 14-day continuous infusion of etoposide, and to evaluate the pharmacokinetics in patients with lung cancer. PATIENTS AND METHODS: Etoposide was administered continuously through a central venous catheter using a pump. The starting dose level was 300 mg/m2 over 14 days, with dose escalations of 100 mg/m2 over 14 days until unacceptable toxicities occurred. Pharmacokinetic studies were performed in all patients. RESULTS: Twenty-one patients, 20 with non-small-cell lung cancer and one with refractory small-cell lung cancer, received 37 courses. No World Health Organization (WHO) grade III or greater toxicity occurred at doses up to 400 mg/m2 over 14 days. At 700 mg/m2 over 14 days, all four patients experienced grade III or IV leukocytopenia, and two developed grade III stomatitis. No cumulative toxicity was observed. A steady concentration of etoposide was achieved 24 hours after the start of chemotherapy, and it was significantly correlated with surviving fractions of leukocytes (r = -.64, P = .001) and platelets (r = -.68, P < .001). The leukocyte count at the termination of chemotherapy predicted the nadir count (r = .93, P < .001). CONCLUSION: Steady blood levels of etoposide were maintained for prolonged periods, during 14-day continuous infusions. Leukocytopenia and stomatitis were dose-limiting. Nadir counts and surviving fractions of leukocytes were predicted by the leukocyte count at the end of chemotherapy and the concentration of etoposide, respectively. The recommended dose for phase II trials is 600 mg/m2 over 14 days.

[New technique to determine graft length using the proximal anastomotic system during off-pump coronary artery bypass grafting].

For determining the graft length for an aortic connector, grafts to the circumflex (Cx) and the posterior descending (PD) regions often present problems. Difficulties in determining the appropriate distance between the aorta and coronary artery have been reported to be due to changes in the morphology of the heart following the evolution of Cx and PD. We set an intermediate point (IMP) in advance and then determine graft distance in 2 steps. When using the IMP method, determination of the graft length in the Cx region is not difficult. However, attention should be paid to determine the distance between the IMP and anastomosed site without deforming the heart, as the graft length becomes shorter if the heart as a whole is pulled up by traction of the diaphragm during evolution to the PD region.

Small caliber catheter drainage for spontaneous pneumothorax.

Excellent results have been reported after small caliber catheters were used for iatrogenic pneumothoraces. However, the value of using such catheters for spontaneous pneumothoraces is not clear. The purpose of this study, therefore, is to examine the efficacy of small caliber catheters in managing spontaneous pneumothoraces. Seventy six episodes of spontaneous pneumothorax were treated using a small caliber catheter (No. 5.5 or 7.0 French) connected to a Heimlich valve. All catheters were inserted by physicians. The treatment was considered successful when there was no air leakage and little or no residual pneumothorax. Before the lungs were fully expanded, four patients had died and one had refused to comply with further treatment. The remaining 71 episodes of pneumothoraces were evaluated for efficacy. The treatment was successful in 60 patients (84.5%) and ineffective in the remaining 11. The conventional large caliber tube was inserted in 10 of the 11 failures, but they were successful in only six. No major complications resulting from catheter insertion occurred, and no catheters became occluded. The catheter was easy to insert, and the scar that remained after removal of the catheter was very small. Not only are small caliber catheters effective for managing spontaneous pneumothoraces, they are the initial treatment of choice.

Evaluation of diffusely high uptake by the calvaria in bone scintigraphy.

The present study was undertaken to evaluate the finding of diffusely high uptake by the calvaria in a series of 994 consecutive whole body scans in regard to the incidence and degree, and to discuss the mechanism. A total of 86 patients had positive scans (73 women and 13 men) and there were 71 malignant (27 breast, 16 lung, and 28 other malignancies), and 15 benign disease cases (5 degenerative bone, 3 blood, and 7 miscellaneous diseases). Positive rate of the finding was 8.7% in total, 14.9% in women, and 2.6% in men. The difference between women and men was significant (P less than 0.001). The finding was significantly correlative with the ages of patients. Also the finding is shown to be predominant in women ranging 50-59 years of age. On the other hand, the same finding as was made by Creutzig and his coworker was confirmed in malignant cases under high-dose anticancer drug therapy. On the basis of these results, the finding may be not only a side effect of intensive cytotoxic medication on the skeleton, but also a physiological event relative to bone change with age and postmenopausal osteoporosis.

Evaluation of asialoglycoprotein receptor imaging agent as a marker of hepatic ischemia-reperfusion injury and recovery.

Protection of hepatocytes from ischemia-reperfusion injury is a clinically important issue. The purpose of this study was to evaluate changes in acute liver damage and recovery after ischemia-reperfusion in rats with asialoglycoprotein receptor (ASGP-R) ligand. Ischemia was induced by clamping the hepatoduodenal ligament for 90 min. At 1, 3, 24, 48 hr, 1 and 2 wk after reperfusion, I-125-GSA was injected. Five min after injection, blood samples were obtained and the liver was removed. Several regions from each lobe were dissected, weighed and counted. Mean uptakes (% dose/g) in the liver and blood samples were calculated. Histologic sections stained with hematoxylin-eosin (H-E) stain showed ischemic damage at 1 and 3 hr, and focal hepatocyte necrosis at 24 hr. Predominant massive necrosis was not seen. The mitotic index with H-E stain and proliferating cell nuclear antigen (PCNA) labeling index were highest at 1 wk, indicating liver regeneration. At 1 and 3 hr, liver uptake was significantly decreased, and blood uptake was significantly increased, indicating decreased tissue blood flow and ischemic damage. Liver uptake showed significant increases at 48 hr and 1 wk, and was the highest at 1 wk, indicating liver regeneration during the convalescence stage. ASGP-R binding may provide valuable information on ischemia-reperfusion injury and recovery.

Early and delayed Tc-99m ECD brain SPECT in SLE patients with CNS involvement.

We compared early and delayed Tc-99m ECD SPECT scans in 32 SLE patients (Group 1, definite neuropsychiatric disorders; Group 2, minor neurologic symptoms or normal) with those of normal controls by visual inspection and semi-quantitative evaluation. With visual interpretation, 13 out of 14 patients in Group 1 (93%) and 7 out of 18 patients in Group 2 (39%) had diffuse uneven decrease in early scans. Seven patients in Group 2 (39%) who had normal early scans demonstrated focal decrease in the medial frontal lobe in delayed scans. With cerebral region to cerebellar ratios, in early scans, the medial frontal lobe in Group 1 and Group 2 was significantly lower than in normal controls, and lateral frontal lobe and occipital lobes in Group 1 were significantly lower than in normal controls. Nevertheless, in delayed scans, every cortical region except for the parietal lobe in Groups 1 and 2 was significantly lower than in normal controls. The retention rates in all regions in SLE patients were significantly lower than in normal controls. No case showed SPECT improvement on follow-up studies in either group in spite of clinical improvement. Delayed Tc-99m ECD brain SPECT of high sensitivity might be useful in detecting CNS involvement. Although the SPECT findings did not correlate with the neuropsychiatric symptoms, early and delayed Tc-99m ECD SPECT seems to provide useful objective diagnostic information in SLE patients.

Simple and low-cost tele-nuclear medicine conference system with the e-mail protocol.

PURPOSE: Because of the recent innovative growth in computer technology, digital imaging, and the Internet, we can take advantage of these facilities for education and clinical work in nuclear medicine. We developed a tele-nuclear medicine conference system with electronic mail (e-mail) on the Internet. METHODS: Twenty-one physicians (20 radiologists, 1 neurologist), 6 technologists and 2 medical students in six university hospitals (Japan 5, Canada 1), 5 local hospitals in Japan participated in this project. We used digital still cameras (330 k pixels) equipped with a floppy disk drive and 10 x optical zoom to digitize images with JPEG compression (640 x 480 matrix). The images were attached to e-mail messages (containing a brief description of each case). The mail was sent simultaneously to all members on the mailing list. Scintigram and SPECT images as well as other radiological images were sent by e-mail. Reply mails about each case were sent to all members via the mailing list. RESULTS: During a period of 6 months, 18 cases (tumor/infection: 7, bone: 6, cardiovascular: 1, neurology; 3, endocrine: 1) with 144 e-mails (average 5.6/case) were submitted to the conference. The average period of discussion was 15.6 days. The number of attached images was 1 to 9 (average, 4.2/e-mails). JPEG compression rate was 1/10 to 1/20. The quality of the images was good enough for discussion. Some cases required additional images for further discussion. CONCLUSION: Our tele-nuclear medicine conference with an electronic mailing list and digital camera was simple and low-cost. The conference system was useful for education and clinical work.

[Comparison of cerebral blood flow in primary visual cortex by administration of 99mTc-ECD while having eyes open or closed].

Four healthy volunteers were administered 99mTc-ECD while having their eyes open or closed (by an eye mask) on different days and the accumulation of the tracer in their primary visual cortex was compared. The accumulation in the cerebellum and the primary visual cortex was about the same when the volunteers were administered the tracer while having their eyes closed. On the other hand, the accumulation was higher in the primary visual cortex than the cerebellum when the volunteers were administered the tracer while having their eyes open. In the primary visual cortex, the accumulation of the tracer was 15% higher on the average when the tracer was administered while having their eyes open than the value obtained while having their eyes closed. It was assumed that 99mTc-ECD depicted the increase of the regional cerebral blood flow at natural state of opened eyes without active stimuli such as photic stimulation.

[Clinical significance of regional cerebral blood volume and flow-to-volume ratio in ischemic cerebrovascular disease measured by SPECT].

Regional cerebral blood volume (rCBV) and flow-to-volume ratio (rCBF/rCBV) were evaluated for clinical significance in comparison to rCBF and findings in X-ray CT (XCT) and radionuclide (RNA) and contrast angiography (CAG). A total of 109 cases were studied within 90 days after cerebrovascular ischemic attack. CBV SPECT was performed following CBF SPECT with I-123-IMP and RNA with Tc-99m-RBC, and processed for subtraction of I-123 contamination fraction. CBF/CBV image was obtained as the count ratio of CBF to CBV image at the same slice-level. Parametric rCBV and rCBF/rCBV were estimated as the count ratio of the focus to the contralateral normal region of interest. Image findings were scored by visual judgement. Student's t-test was applied for statistical analysis with a significance level of p = 0.01. The rCBV-ratio was inversely proportional to rCBF/rCBV-ratio, and was different between the two groups with high and low score on flip-flop perfusion in RNA and among three groups with different postictal neurological course. The ratio was the highest for the group of improved course. The rCBF/rCBV-ratio was possibly correlated to rCBF-ratio, and was different between the two groups with high and low score on low density area in XCT, early perfusion in RNA and arterial stenosis in CAG. In the group of improved course, the ratio was different between the second and the third postictal week's duration. These results, therefore, suggest that rCBV-ratio reflects collateral perfusion, and is valuable for assessing postictal prognosis in cerebrovascular disease, and that rCBF/rCBV-ratio may reflect regional oxygen extraction fraction, and is valuable for speculating cerebral perfusion reserve.

[Off-pump coronary artery bypass grafting/beating coronary artery bypass grafting for a patient with low left ventricular ejection fraction].

Beating coronary artery bypass grafting could be performed for a 47-year-old man with left ventricular ejection fraction (LVEF) of 9.3%. Post-operative LVEF was improved to 51.6%. Conventional coronary artery bypass grafting (CABG) used to be contraindicative for patients with LVEF below 20%. Recently, such patients are involved to indication of off-pump CABG (OPCAB) or beating CABG, because we consider OPCAB are lower complications than conventional CABG. We were able to bypass the circumflex for the patient while we had been used percutaneous cardio-pulmonary support (PCPS). We could perform beating coronary artery bypass grafting for a patient of the low LVEF.

[Weekly hepatic arterial infusion of high dose 5-fluorouracil for liver metastasis from colorectal cancer].

A weekly infusion of high dose 5-fluorouracil by way of the hepatic artery has been performed in 23 cases with synchronous metastasis from colorectal cancer since 1993. The prognosis in these cases was compared with 94 cases treated without infusion chemotherapy in 94 cases before 1992. The overall one-year and three-year survival rate was 64.8% and 30.2%, respectively, in cases with infusion chemotherapy. The one-year and three-year survival rate was 42.8% and 18.6%, respectively, in cases without infusion chemotherapy. Overall survival rate was significantly different between cases with and without infusion chemotherapy (p < 0.05). In conclusion, weekly infusion chemotherapy resulted in a better survival rate than without infusion chemotherapy.

[A case of retroperitoneal liposarcoma].

We reported a case of retroperitoneal well differentiated liposarcoma, which consisted of lipoma-like type and sclerosing type. The latter was represented as solid density tumor on CT, which was difficult to differentiate from undifferentiated liposarcoma and other soft tissue tumors. Angiographically, ureteral artery developed and became a main feeder.