Current status of hip bone densitometry in Japan: a nationwide survey

Hip fracture greatly impairs quality of life in patients with osteoporosis. Measurement of bone mineral density (BMD) in the hip, which is closely related to fracture risk, is therefore diagnostically important. Furthermore, since in some elderly individuals lumbar BMD may be overestimated because of vertebral fracture or spondylosis deformans, measurement of hip BMD is also important. However, hip BMD is unlikely to be measured as often as lumbar BMD in Japan. A questionnaire survey was conducted to determine how many institutions measure hip BMD. A total of 861 institutions responded to the survey, 596 (69%) of which performed hip bone densitometry. The number of such institutions per million population was calculated to be 4.7. Measurement of hip BMD was more frequent in university hospitals than in general hospitals, clinics, and non-medical institutions. Furthermore, 298 (51%) of 590 institutions measured hip BMD in more than 75% of all bone densitometry examinees. This is the first report on the current status of utilization of hip bone densitometry in Japan.     

Long-term Effects of Botulinum Toxin on Neuromuscular Function

Background: Recent reports indicate increased incidence of Clostridium botulinum infections, particularly among drug abusers and tissue allograft recipients. Botulinum toxin also has potential application in biochemical warfare. The neurotoxin-induced paralysis often requires mechanical ventilation with and without muscle relaxants. The authors investigated the long-term effects of botulinum toxin on muscle function, expression of nicotinic acetylcholine receptors (nAChRs), and their interaction with muscle relaxant, atracurium.

Methods: Rats (n = 30) were injected with varying doses (0.625, 2.5, and 10 U) of botulinum toxin into the tibialis muscle. Control animals (n = 9) received an equivalent volume of saline. At 128 days after injection, neuromuscular function, pharmacodynamics of atracurium, and nAChRs were evaluated.

Results: Nerve-evoked tensions, including tetanic tension and muscle mass, were decreased on the toxin-injected side in a dose-dependent manner relative to saline-injected controls as well as the contralateral side. Specific muscle tension and specific tetanic muscle tension (tensions/muscle mass) were not reduced. The ED10 of atracurium was reduced, the ED50 was unchanged, and the ED90 was increased in the highest (10-U) dose of toxin group. The atracurium plasma concentration to maintain a steady state 50% paralysis was significantly reduced in the 10-U toxin group. The nAChR concentrations in the tibialis muscle were significantly increased in a dose-dependent manner in all experimental groups.     

Initial efficacy of intramuscular injection of botulinum toxin type A against cervical dystonia and general muscular hypertonia in persons with severe motor and intellectual disabilities

We introduced an intramuscular injection of botulinum toxin type A (hereafter, BTX-A) in 5 cases of cervical dystonia (CD) with generalized muscular hypertonia (GMH). The patients all had severe motor and intellectual disabilities (SMID). The initial injections (first and second) of BTX-A exerted a focal muscular relaxant effect in all 5 cases. It is interesting that they decreased hypertonia in the lower extremities, which resulted in an improved activity of daily living (ADL) in 4 cases (80%). This fact reveals the involvement of many muscles in regard to CD and GMH, especially in patients with severe cerebral palsy. As for adverse effects, a mild increase of saliva and cough indicated transient misswallowing in 2 cases (40%) and changes in the pattern of head movement and posture in 2 cases (40%). These effects were all mild and did not disturb ADL in any patient. BTX-A is considered to be safer and worthier of trying to decrease complaints related to CD and GMH than we expected. Furthermore, a modified Tsui's score cannot explain the many benefits from BTX-A in the treatment of SMID. For a reliable assessment of BTX-A therapy used to treat CD and GMH, especially in persons with SMID, more expressible and specific assessment methods will need to be established.     

Prolonged peri-firing compression with a linear stapler prevents pancreatic fistula in laparoscopic distal pancreatectomy

Background  

Laparoscopic distal pancreatectomy (Lap-DP) is one of the most accepted laparoscopic procedures in the field of pancreatic surgery. However, pancreatic fistula remains a major and frequent complication in Lap-DP, as in open surgery. The aim of this retrospective study is to clarify the advantages of prolonged peri-firing compression (PFC) with a linear stapler for prevention of pancreatic fistula after laparoscopic distal pancreatectomy.     

A new active vitamin D3 analog, eldecalcitol, prevents the risk of osteoporotic fractures--a randomized, active comparator, double-blind study

Background

Eldecalcitol is an analog of 1,25-dihydroxyvitamin D₃ that improves bone mineral density; however, the effect of eldecalcitol on the risk of fractures is unclear. The objective of this study is to examine whether eldecalcitol is superior to alfacalcidol in preventing osteoporotic fractures. This trial is registered with ClinicalTrials.gov, number NCT00144456.

Methods and results

This 3 year randomized, double-blind, active comparator, superiority trial tested the efficacy of daily oral 0.75 μg eldecalcitol versus 1.0 μg alfacalcidol for prevention of osteoporotic fractures. 1054 osteoporotic patients 46 to 92 years old were randomly assigned 1:1 to receive eldecalcitol (n = 528) or alfacalcidol (n = 526). Patients were stratified by study site and serum 25-hydroxyvitamin D level. Patients with low serum 25-hydroxyvitamin D levels (< 50 nmol/L) were supplemented with 400 IU/day vitamin D₃. Primary end point was incident vertebral fractures. Secondary end points included any non-vertebral fractures and change in bone mineral density and bone turnover markers. Compared with the alfacalcidol group, the incidence of vertebral fractures was lower in eldecalcitol group after 36 months of treatment (13.4 vs. 17.5%; hazard ratio, 0.74; predefined 90% confidence interval [CI], 0.56–0.97). Eldecalcitol reduced turnover markers and increased bone mineral density more strongly than alfacalcidol. Eldecalcitol reduced the incidence of three major non-vertebral fractures, which was due to a marked reduction in wrist fractures by a post-hoc analysis (1.1 vs. 3.6%; hazard ratio, 0.29; 95% CI, 0.11–0.77). Among the adverse events, the incidence of increase in serum and urinary calcium was higher in the eldecalcitol group, without any difference in glomerular filtration rate between the two groups.

Conclusions

Eldecalcitol is more efficacious than alfacalcidol in preventing vertebral and wrist fractures in osteoporotic patients with vitamin D sufficiency, with a safety profile similar to alfacalcidol.     

New oily agents for targeting chemoembolization for hepatocellular carcinoma

PURPOSE: The evaluation of new oily agents for targeting chemoembolization for hepatocellular carcinoma. METHODS: Five types of oily preparation were injected into the hepatic artery of 54 rabbits inoculated with VX2 carcinoma cells in order to evaluate (1) the safety of these preparations, (2) their histologic distribution and the amount of agents remaining at tumor sites, and (3) computed tomographic (CT) images obtained. Of these preparations, three were made by mixing non-iodinated poppy seed oil and a thickener and then adjusted to have a viscosity lower than, equal to, or higher than that of lipiodol. A fourth preparation was a mixture of lipiodol and a thickener with a higher viscosity than lipiodol alone, and the fifth preparation was lipiodol alone. RESULTS: (1) No injury to the hepatic parenchyma was observed hematologically or histologically. (2) With increase in the viscosity, a significantly larger amount of agent remained at the tumor site. No agent was present at normal sites 14 days after intraarterial injection, regardless of which preparation was given. (3) On CT scans following intraarterial injection, tumor cells were visibly deeply stained in the non-iodinated preparation groups, while the lipiodol groups were not evaluable because of excessively high attenuation. CONCLUSION: The non-iodinated oily preparations and highly viscous oily preparations developed in the present study were more useful than lipiodol for treatment of hepatic tumors.     

Comparison of laparoscopic versus open cholecystectomy in patients with cardiac valve replacement

To evaluate the benefits and safety of laparoscopic cholecystectomy (LC) in patients with cardiac valve replacement (which frequently leads to cholelithiasis), 12 patients with cholelithiasis associated with cardiac valve replacement were studied. The patients were divided into two groups, of 6 patients each, according to the type of operation performed, open cholecystectomy (OC) or LC. The postoperative course was monitored with respect to laboratory data on postoperative days (POD) 1, 3, and 7. The mean duration of operation, blood loss, days to food resumption, length of hospital stay, and morbidity were compared between the two groups. Significant differences (P < 0.05) were found between the OC and LC groups in white blood cell counts on POD 1 (12 980 ± 3040/mm³ vs 8300 ± 1590/mm³), days to food resumption (2.7 ± 0.4 days vs 1.0 ± 0.7 days), and length of postoperative stay (15.8 ± 1.0 days vs 10.8 ± 1.6 days). There were no complications in the LC group, but 1 patient in the OC group had heart failure postoperatively. Our findings indicate the efficacy and safety of LC in patients with cardiac valve replacement. Received: August 14, 2000 / Accepted: December 22, 2000     

Antegrade selective cerebral perfusion combined with deep hypothermic circulatory arrest on cerebral circulation: comparison between pulsatile and nonpulsatile blood flows.

PURPOSE: In aortic arch surgeries, antegrade selective cerebral perfusion (SCP) combined with deep hypothermic circulatory arrest (DHCA) has been recently widely used in institutions as one of the most reliable methods for cerebral protection. However, some studies reported a 3.7-9.3% incidence of postoperative cerebral complications. To perform antegrade SCP more safely, we sought to examine the impact of pulsatile flow perfusion during DHCA on cerebral tissue metabolism, focusing on physiological effects of pulsatile flow perfusion. MATERIALS AND METHODS: Sixteen pigs were divided into 2 groups. In each group, antegrade SCP combined with DHCA was conducted. During circulatory arrest, for SCP, a pulsatile flow (group P) and a nonpulsatile flow (group N) were used. We compared results between group P and group N. Jugular venous oxygen saturation (SjO(2)) and cerebral tissue oxygen partial pressure (PtO(2)) were measured at baseline, and continuously throughout the extracorporeal circulation. Hematocrit (Ht), and concentrations of S-100 protein and CK-BB in blood and the cerebrospinal fluid (CSF) were measured at baseline (before the beginning of extracorporeal circulation), following SCP, and after rewarming. Following rewarming, each brain under perfused fixation was removed, and histopathological examinations were conducted using Kluver-Barrera and Tunnel staining methods, electron micrograph. RESULTS: SjO(2) was found to be within normal ranges until after SCP, but decreased with rewarming in both groups. In Group N, changes in SjO(2) were significant, with a decrease to < or =50%. In Group N, concentrations of S-100 protein and CK-BB in CSF after SCP and after rewarming were significantly higher than those in Group P. The time needed for rewarming to 36 degrees C in Group P was shorter than that in Group N. CONCLUSION: Our results suggest that the pulsatile flow circulation method shows cerebral protection effects with increasing blood flow in small cerebral tissues. In addition, it is effective for improving the imbalance between oxygen supply and demand, especially in the process of rewarming from hypothermic conditions. This method seems to be useful as an adjunct in hypothermic circulatory arrest procedures.     

Spontaneous closure of dural arteriovenous fistula after performing diagnostic angiography

The pathogenesis and clinical treatment of dural arteriovenous fistulas (DAVF) has been well established. However, only 15 cases of spontaneous closure of DAVFs have been reported. We describe a case of spontaneous closure of a DAVF. A 60-year-old male presented with pulsatile tinnitus. Selective cerebral angiography revealed a left posterior DAVF fed by the left occipital artery and the middle meningeal artery, which drained into the left transverse sinus and sigmoid sinus. Following the initial angiography, the patient exhibited vomiting with transient disorientation and amnesia. These symptoms, along with the tinnitus, disappeared by the following day. Seven days after the initial angiography, a second angiography was performed that revealed the complete disappearance of the DAVF. Previous reports have described a long period of closure for DAVFs following initial diagnosis. Possible mechanisms for spontaneous closure of DAVFs include the development of scar tissue or a sinus thrombosis that leads to occlusion of the DAVF In this case, the DAVF closure may have been due to a sinus thrombosis induced by sinus stenosis, since occlusion of the draining sinuses coincided with the spontaneous closure of the DAVF. In cases of non-traumatic DAVF without cortical venous reflex that do not present severe symptoms, a prudent course of treatment is necessary since there is a chance of spontaneous closure of the DAVF occuring.