Relationship between left atrial spontaneous echo contrast and the features of middle cerebral artery territory in nonvalvular atrial fibrillation

Summary We investigated the relationship between left atrial spontaneous echo contrast (SEC) and cerebrovascular features in nonvalvular atrial fibrillation (NVAF). Few reports have been published to compare cardiac and cerebrovascular imaging in patients with NVAF. Forty-four patients with NVAF were studied using transesophageal echocardiography and noninvasive imaging including magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and transcranial color Doppler imaging (TCD) in the middle cerebral artery (MCA) territory. The symptomatic severity was divided into asymptomatic, transient ischemic attack (TIA), and stroke. The severity of the MRI findings was divided into normal, small, and large infarcts. The severity of the MRA findings was divided into normal, attenuation, and occlusion. MCA was bilaterally scanned and a side-to-side asymmetry ratio of pulsatility index (PI) was measured. The severity of SEC was divided into normal, SEC, and thrombi. Five patients with other thromboembolic risk or poor results of TCD were excluded. SEC and thrombi were detected in 12 (30%) and in 3 patients (5%), respectively. TIA and stroke were detected in 8 (21%) and in 17 patients (44%), respectively. Small and large infarcts were detected in 9 (23%) and in 18 patients (46%), respectively, on MRI. Attenuation and occlusion were detected in 14 (36%) and in 8 patients (21%), respectively, on MRA. PI ratio was 1.21 ± 0.25. SEC severity was highly associated with PI ratio and MRA severity in monovariate analysis (P < 0.005),P < 0.01, respectively). SEC severity was highly associated with PI ratio and MRA severity in stepwise multiple regression analysis (P = 0.0001,r = 0.630,n = 39). In patients with NVAF, left atrial SEC was highly related to attenuation or occlusion on MRA and imbalance of cerebral blood flow on TCD in the MCA territory.     

Waist circumference correlates with hepatic fat accumulation in male Japanese patients with non-alcoholic fatty liver disease, but not in females

Background and Aim:  Abdominal obesity, a component of metabolic syndrome, is a major risk factor for non-alcoholic fatty liver disease (NAFLD). In recent worldwide definitions of metabolic syndrome, waist measurement has been proposed as a simple and useful estimate of abdominal obesity, taking into account gender differences in waist circumference. The present cross-sectional study investigated the correlation of hepatic fat accumulation and waist circumference in Japanese NAFLD patients to determine if there are gender differences in this relationship.
Methods:  Consecutive patients ( n  = 2111) who had at least one of two criteria for liver disease (alanine aminotransferase [ALT] level >30 IU/mL and aspartate aminotransferase [AST]/ALT ratio <1) underwent abdominal ultrasonography. Patients positive for hepatitis B virus, hepatitis C virus or autoimmune antibodies and whose alcohol intake was >20 g/day were excluded. Patients with NAFLD underwent abdominal computed tomography. Hepatic fat accumulation was estimated by liver/spleen attenuation ratio (L/S ratio) and visceral adipose accumulation was measured as visceral fat area (VFA) at the umbilical level.
Results:  Of the 221 NAFLD patients, 103 were females. In males, the relationship between L/S ratio and waist circumference was negative ( r  =−0.356, P  < 0.01), and there was no correlation in the female group. The relationship between L/S ratio and VFA was negative in both groups (males: r  = −0.269, P  < 0.01; females: r  = −0.319, P  < 0.01). Subcutaneous fat area/total fat area ratio at the umbilical level was larger in females than in males ( P  < 0.01).
Conclusions:  In NAFLD patients, waist measurement is more susceptible to gender differences than VFA.     

Influence of diabetes mellitus on caregiver burden in home care: A report based on the Nagoya Longitudinal Study of the Frail Elderly (NLS-FE)

Background:   Because little attention has so far been paid to the impact of diabetes mellitus (DM) on caregiver burden in community settings, we sought to confirm the influence of DM on perceived caregiver burden among caregivers providing care to a home elderly person using data from the Nagoya Longitudinal Study of the Frail Elderly (NLS-FE).
Methods:   The NLS-FE is a large prospective study of 1875 community-dwelling elderly. A total of 1592 pairs of dependents and caregivers were included in the analysis. The data we used in this study included the Japanese version of the Zarit Caregiver Burden Interview (J-ZBI), characteristics of caregivers and dependents, and caregiving situation. The pairs were sorted into one control and three DM groups: (i) no DM; (ii) DM taking no medications; (iii) DM taking oral medication only; and (iv) DM taking insulin. The differences in dependent and caregiver characteristics among the groups were assessed.
Results:   Two hundred and twenty-eight dependents from the NLS-FE study had DM. Of these, 25% took no medication to treat it, 55% took oral medications only, and 20% used insulin. No statistical differences were found in age, gender or kinship among caregivers. No differences were found among the DM categories in levels of caregiver burden according to the J-ZBI, before and after adjusting for these baseline variables.
Conclusions:   Among the community-dwelling frail elderly, DM is not an independent predictor of caregiver burden.     

Sexually dimorphic expression of trkB, a Z-linked gene, in early posthatch zebra finch brain

Sexual differentiation of the zebra finch (Taeniopygia guttata) neural song circuit is thought to be initiated by sex differences in sex chromosome gene expression in brain cells. One theory is that Z-linked genes, present in the male's ZZ genome at double the dose of females' (ZW), are expressed at higher levels and trigger masculine patterns of development. We report here that trkB (tyrosine kinase receptor B) is Z-linked in zebra finches. trkB is the receptor for neurotrophic factors BDNF and neurotrophin 4, and mediates their influence on neuronal survival, migration, and specification. trkB mRNA is expressed at a higher level in the male telencephalon or whole brain than in corresponding regions of the female in adulthood, and at posthatch day (P) 6, when the song circuit is undergoing sexual differentiation. Moreover, this expression is higher in the song nucleus high vocal center (HVC) than in the surrounding telencephalon at P6, and in males relative to females. In addition, trkB protein is expressed more highly in male than female whole brain at P6. These results establish trkB as a candidate factor that contributes to masculine differentiation of HVC because of its Z-linkage, which leads to sex differences in expression. BDNF is known to be stimulated by estrogen and to be expressed at higher levels in males than females at later ages in HVC. Thus, the trkB-BDNF system may be a focal point for convergent masculinizing influences of Z-linked factors and hormones.     

Quantitative assessment of coronary stenosis by harmonic power Doppler with a simple pulsing sequence and vasodilator stress in patients

OBJECTIVES: We examined whether myocardial contrast echocardiography (MCE) with harmonic power Doppler (HPD) employing a simple ultrasound pulsing sequence enables estimation of the severity of coronary artery stenosis in patients. BACKGROUND: Contrast intensity (CI) during MCE with intravenous microbubble infusion is dependent on the myocardial blood flow velocity (MBFV) and pulsing interval (PI). METHODS: Based on an in vitro experiment, we devised the MBFV index calculated as the reciprocal of the magnitude of CI decay produced by abrupt PI shortening during intermittent imaging. In 68 coronary artery territories from 49 patients, myocardial HPD images were acquired during intravenous infusion of Levovist, while the long PI with 1:10 electrocardiographic gating was shortened to 1:1, both at baseline and during adenosine triphosphate infusion. The MBFV index in each coronary territory and MBFV reserve as the ratio between hyperemia and baseline were compared with the severity of corresponding coronary artery stenosis assessed by quantitative coronary angiography (QCA) or by pressure guide wire as the fractional flow reserve (FFR). RESULTS: Both the MCE-derived MBFV index during hyperemia and MBFV reserve exhibited significant negative correlations with the QCA-derived stenosis severity (r = -0.56 and r = -0.64, respectively). The MBFV reserve positively correlated with FFR (r = 0.89). By combining the cutoff values of the MBFV index during hyperemia and MBFV reserve, > or =75% of stenoses defined by QCA were determined, with a sensitivity of 77.3%, specificity of 93.4%, and accuracy of 88.3%. CONCLUSIONS: Shortening of PI during intravenous MCE with intermittent HPD imaging under vasodilator stress enables assessment of coronary artery stenoses in patients.     

Progression of primary biliary cirrhosis after proctocolectomy for ulcerative colitis

We report a case of progression of primary biliary cirrhosis (PBC) after proctocolectomy for ulcerative colitis. A 43-year-old woman underwent a total proctocolectomy after being diagnosed with ulcerative colitis. In the course of the preoperative investigation, liver function test results were within the normal range. Four months after the proctocolectomy, the patient showed a high level of alkaline phosphatase (2398 IU/l) and a positive anti-mitochondrial antibody titer (>1 : 160). There were no associated symptoms. A liver biopsy demonstrated expansion of all portal areas by infiltrates of lymphocytes and histiocytes. These appearances indicated chronic biliary disease and were compatible with PBC. The association of PBC and ulcerative colitis is rare. However, a review of the recent literature suggests that PBC and ulcerative colitis may be associated; this combination should be kept in mind. Received: October 4, 1999 / Accepted: February 25, 2000     

Neo-adjuvant therapy or definitive chemoradiotherapy can improve laryngeal preservation rates in patients with cervical esophageal cancer. A Japanese nationwide survey

Background

Various options are available to treat cervical esophageal cancer (CEC), including primary resection, neo-adjuvant therapy followed by surgery, and definitive chemoradiotherapy (dCRT). However, whether neo-adjuvant therapy or dCRT can improve larynx preservation rates in patients with CEC is unclear. This study investigated results of CEC treatment in clinical practice by a nationwide survey in Japan.

Patients and methods

We retrospectively investigated results of clinical practices for patients with resectable CEC treated between 2012 and 2014, using a mailed questionnaire as a nationwide survey to 308 institutions recognized by the Japan Esophageal Society and the Japan Broncho-Esophagological Society.

Results

We registered 792 patients from 93 institutions, of whom 11.1 % underwent endoscopic resection, 46.0 % underwent surgery, and 39.2 % underwent dCRT. Among patients with CEC who were considered to be poor candidates for laryngeal preservation at initial diagnosis, 24.5 % of the 139 patients treated with neo-adjuvant therapy, and 47.3 % of the 226 patients treated with dCRT preserved their larynxes.

Conclusions

This questionnaire survey revealed that multimodality treatment for CEC could decrease laryngectomy rates, especially among patients who were not considered to be laryngeal preservation candidates. These treatment strategies can lead to both laryngeal preservation and postoperative quality of life, and should become more widely used.

     

Non-medical palliative care and education to improve end-of-life care at geriatric health services facilities: A nationwide questionnaire survey of chief nurses

Background:   Geriatric health services facilities (GHSF) are expected to assume a growing role in caring for the dying elderly. However, research in this area has so far been scant. The purpose of the present study is to reveal the status of non-medical palliative care and staff education aiming at improving and enhancing end-of-life care at GHSF.
Methods:   The subjects were 2876 chief nurses of GHSF. Data was collected through a mailed questionnaire in 2003. The questionnaire covered the following: (i) staff perception of end-of-life care policies; (ii) staff education; and (iii) available non-medical care. To evaluate the factors correlated with end-of-life care policies at GHSF, we divided the facilities into two groups.
Results:   We analyzed the answers collected from 313 facilities with a progressive policy toward end-of-life care (PP group) and 818 with a regressive policy toward it (RP group). It was found that staff training was conducted more frequently among PP facilities. Generally, nurses in the PP facilities were more confident that they could provide comprehensive on-site end-of-life care and grieving support, but did not feel so sure about their ability to provide better end-of-life environments for dying residents and family by organizing outside support from voluntary and/or governmental organizations and religious organization for healing and to pursue appropriately a written follow-up communication with the bereaved family.
Conclusions:   Our results suggest that providing GHSF staff with education about end-of-life issues or setting up collaboration with the outside is an important factor to enhance overall end-of-life care at these facilities.     

A case of multiple bone and joint tuberculosis which had been misdiagnosed as the rheumatoid arthritis and treated with prednisolone for eleven months

A 34-year-old man had a multiple arthralgia for about eleven months. The swelling of his right wrist and foot had appeared in the dorsal side, and he had been misdiagnosed as the rheumatoid arthritis. He was treated with prednisolone in the dosages of 2.5 mg per day for one month, and 10 mg per day for ten months. When he admitted to our hospital, the bone X-ray examinations of the wrist and foot revealed the marked atrophy and destruction of the carpal and tarsal bones. The aspiration fluid from the swelling around his wrist and foot was positive for acid-fast bacilli on smear and Mycobacterium tuberculosis was found on culture. He was treated with isoniazid, rifampicin, ethambutol and pyrazinamide, however, these medication was not adequately effective to his complications of tuberculous arthritis. Curettage, irrigation and synovectomy of his right carpal and tarsal bone were performed in order to control his bone and joint infection. He recovered from his arthritis and tenosynovitis after these operations. The clinical practitioners should not omit tuberculosis from the differential diagnosis of persistent osteoarthralgia.