Tokyo University Hospital Research Articles

Mid-term outcome of permanent prostate iodine-125 brachytherapy in Japanese patients

To analyze mid-term oncological outcomes of low-dose rate brachytherapy in Japanese patients. Between 2003 and 2010, 604 consecutive patients with clinically localized prostate cancer were treated with low-dose rate brachytherapy at Jikei University Hospital in Tokyo, Japan. Median follow up was 48 months. Of these patients, 260 (43%) were treated with neoadjuvant therapy, 45 (7.5%) with adjuvant hormonal therapy and 75 (12.4%) with supplemental external beam radiation therapy. Biochemical recurrence was defined as the prostate-specific antigen nadir plus 2 ng/mL. Of the 604 patients, 219 (36.2%) were low risk, 361 (59.8%) were intermediate risk and 24 (4.0%) had high-risk disease. The median biologically effective dose was 174.4 Gy2. At 8 years, biochemical recurrence-free survival, cancer-specific survival, and overall survival were 82.2%, 100% and 95.6%, respectively. Biochemical recurrence-free survival at 8 years was 89.9%, 79.4% and 52.5%, for the low-, intermediate-, and high-risk groups, respectively. Biochemical recurrence-free survival for the high-risk group was significantly lower than the low- and intermediate-risk groups (P < 0.001). Biochemical recurrence-free survival did not differ significantly by biologically effective dose stratification. In multivariate analysis, younger age (P = 0.045), higher prostate-specific antigen (P = 0.004), higher Gleason score (P = 0.006) and higher clinical T stage (P = 0.008) were significant covariates associated with biochemical recurrence. The addition of hormonal therapy or external beam radiation therapy was associated with significantly better outcomes than low-dose rate brachytherapy monotherapy (P = 0.0021 and 0.010). Just four patients experienced G3 genitourinary or gastrointestinal toxicity. Low-dose rate brachytherapy results in excellent mid-term oncological outcomes and acceptable toxicity in Japanese patients. In our experience, biologically effective dose does not represent a significant predictor for biochemical recurrence.

Exposure to pyrethroids insecticides and serum levels of thyroid-related measures in pregnant women

Possible association between environmental exposure to pyrethroid insecticides and serum thyroid-related measures was explored in 231 pregnant women of 10–12 gestational weeks recruited at a university hospital in Tokyo during 2009–2011. Serum levels of free thyroxine (fT4), thyroid stimulating hormone (TSH) and thyroid biding globulin (TBG) and urinary pyrethroid insecticide metabolite (3-phenoxybenzoic acid, 3-PBA) were measured. Obstetrical information was obtained from medical records and dietary and lifestyle information was collected by self-administered questionnaire. Geometric mean concentration of creatinine-adjusted urinary 3-PBA was 0.363 (geometric standard deviation: 3.06)μg/g cre, which was consistent with the previously reported levels for non-exposed Japanese adult females. The range of serum fT4, TSH and TBG level was 0.83–3.41ng/dL, 0.01–27.4μIU/mL and 16.4–54.4μg/mL, respectively. Multiple regression analysis was carried out by using either one of serum levels of thyroid-related measures as a dependent variable and urinary 3-PBA as well as other potential covariates (age, pre-pregnancy BMI, parity, urinary iodine, smoking and drinking status) as independent variables: 3-PBA was not found as a significant predictor of serum level of thyroid-related measures. Lack of association may be due to lower pyrethroid insecticide exposure level of the present subjects. Taking the ability of pyrethroid insecticides and their metabolite to bind to nuclear thyroid hormone (TH) receptor, as well as their ability of placental transfer, into consideration, it is warranted to investigate if pyrethroid pesticides do not have any effect on TH actions in fetus brain even though maternal circulating TH level is not affected.

Validity of a self‐administered diet history questionnaire for estimating vitamin D intakes of Japanese pregnant women

Maternal vitamin D status is important for fetal development and the prevention of pregnancy complications. Mothers require both sufficient intakes and skin production of this vitamin. We investigated the validity and test-retest reliability of a self-administered diet history questionnaire (DHQ) to establish a method of assessing vitamin D intakes of Japanese pregnant women, using a serum marker. A total of 245 healthy pregnant women in the second trimester, who were not taking vitamin D supplements, were recruited at a university hospital in Tokyo between June 2010 and July 2011. Serum 25-hydroxyvitamin D [25(OH)D] concentrations were measured as an indicator of vitamin D status. To assess the test-retest reliability of the DHQ, 58 pregnant women completed it twice within a 4-5-week interval. Significant positive correlations between intakes and serum concentrations of vitamin D were found (r = 0.266 for daily intakes and r = 0.249 for energy-adjusted intakes). In the winter investigation in which the serum 25(OH)D concentrations were less likely to be affected by sunlight exposure, the correlation coefficients were 0.304 for both daily and energy-adjusted intakes. After excluding participants with pregnancy-associated nausea, the coefficients increased. The intraclass correlation coefficient between vitamin D intakes estimated from the two-time DHQ was 0.638. The DHQ provides an acceptable validity and reliability of the vitamin D intake of Japanese pregnant women. However, the data of women with nausea should be interpreted with caution. We believe that the DHQ is a useful questionnaire to grasp and improve vitamin D intakes during pregnancy.

Laparoscopy-assisted surgery for male imperforate anus with rectourethral fistula

Laparoscopically assisted anorectal pull-through (LAARP), first described by Georgeson, is now considered to be the radical surgical treatment of choice for rectourethral fistula (RUF) in boys with high/intermediate-type imperforate anus. Accurate positioning of the pull-through canal, with pelvic floor muscles surrounding it symmetrically, is well recognized as the most important prognostic factor irrespective of the procedure performed. Surgical intervention should be LAARP with intraoperative measurement of the RUF, with follow-up focused on bowel habit. Complications such as diverticulum formation, have been reported with increasing frequency after LAARP and are most likely related to incomplete excision of the RUF, especially in bulbar cases. Thus, complete excision, while technically challenging, is crucial. Based on the results of a multicenter study comparing LAARP with other surgery, the most reliable investigation for detecting the presence of a diverticulum is MRI. At Juntendo University Hospital in Tokyo, Japan, blunt dissection with mosquito forceps to identify the potential pull-through canal, measuring the length of the RUF directly, and closer placement of trocars (in bulbar fistula cases) are homegrown refinements that we feel improve outcome and we present a review of our approach to the surgical management of ARM.

Non‐invasive objective evaluation of radiotherapy‐induced dry mouth

Dry mouth is a common complaint in patients undergoing radiotherapy. Here, we employed the oral moisture meter Mucus III to evaluate dry mouth in head and neck tumor patients before and after they underwent radiotherapy. We recruited 17 newly diagnosed patients with pharyngeal squamous cell carcinoma or unknown primary squamous cell carcinoma, who received head and neck radiation therapy at Tokyo University Hospital in 2008-2010. The primary sites were the epipharynx (n = 1), oropharynx (n = 6), or hypopharynx (n = 5); it was unknown in five cases. Salivary function was assessed by a dry mouth questionnaire, resting saliva test, chewing gum test, and Mucus III, before (n = 17), immediately after radiotherapy (n = 10), and at 3 (n = 9) and 12 months after radiotherapy (n = 11). The questionnaire, resting saliva test, and chewing gum test at 3 and 12 months after radiotherapy indicated a significantly decreased resting and stimulated whole saliva flow rate than prior radiotherapy (P < 0.05 and P < 0.001). In contrast, Mucus III results showed significant worsening of xerostomia at 12 months after radiotherapy (P < 0.05). Mucus III has been proven to be an objective diagnostic tool for patients with serious dry mouth, such as in patients with Sjogren's syndrome. However, we did not find a perfect correlation between Mucus III and other objective (resting saliva and chewing gum) and subjective (questionnaire) measures of dry mouth. To precisely diagnose radiotherapy-induced dry mouth, further improvement to the method is needed.

Estimation of eicosapentaenoic acid and docosahexaenoic acid intakes in pregnant Japanese women without nausea by using a self-administered diet history questionnaire

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) intakes during pregnancy affect fetal development and maternal mental health; therefore, an accurate assessment of EPA and DHA intakes is required. We hypothesized that a self-administered diet history questionnaire (DHQ) that was developed for non-pregnant adults could be used for estimating EPA and DHA intakes in pregnant Japanese women; thus, we evaluated the validity and reproducibility of the DHQ during pregnancy. We recruited 262 healthy participants with singleton pregnancies during their second trimester at a university hospital in Tokyo between June 2010 and July 2011. Plasma concentrations of EPA and DHA were measured as reference values. Fifty-eight women completed the DHQ twice, within a 4- to 5-week period to assess the reproducibility of the results. Among the participants without pregnancy-associated nausea (n = 180), significantly positive correlations were observed between energy-adjusted intakes and plasma concentrations of EPA (rs = 0.388), DHA (rs = 0.264), and EPA + DHA (rs = 0.328). More than 60% of the participants without nausea fell into the same or adjacent quintiles according to energy-adjusted intakes and plasma concentrations of EPA, DHA, and EPA + DHA. Meanwhile, among the participants with nausea, a low correlation for EPA and no correlation for DHA and EPA + DHA were found. Intraclass correlation coefficients for the 2-time DHQ measurements were 0.691 (EPA) and 0.663 (DHA). The results indicate that the DHQ has an acceptable level of validity and reproducibility for assessing EPA, DHA, and EPA + DHA intakes in pregnant Japanese women without nausea.

Validity of a diet history questionnaire estimating β-carotene, vitamin C and α-tocopherol intakes in Japanese pregnant women

We investigated the validity and reproducibility of a self-administered diet history questionnaire (DHQ) that estimates the intakes of β-carotene, vitamin C and α-tocopherol. Ninety-five healthy women with singleton pregnancies in the second trimester were examined at a university hospital in Tokyo. The intakes of β-carotene, vitamin C and α-tocopherol assessed by the DHQ were compared to the corresponding serum concentrations. To assess the reproducibility, 58 pregnant women completed it in two sessions within a 4–5 week interval. We found significantly positive correlations between the energy-adjusted intakes and serum concentrations of β-carotene and vitamin C (r = 0.254 and r = 0.323, respectively). However, α-tocopherol intake was not associated with the corresponding serum concentration. The intraclass correlation coefficients of the two-time DHQ were 0.743 (β-carotene), 0.665 (vitamin C) and 0.718 (α-tocopherol). DHQ has acceptable validity and reproducibility for β-carotene and vitamin C intakes in Japanese pregnant women.

Does laparoendoscopic single-site adrenalectomy increase surgical risk in patients with pheochromocytoma?

LESS (laparoendoscopic single-site) surgery has been developed as a treatment option for adrenal tumors that has less postoperative pain and greater cosmetic benefits. Some reports proposed that patient selection criteria should be stringent, and pheochromocytoma (PHE) should be taken as an advanced indication. The aim of this study is to compare LESS adrenalectomy (ADX) with conventional adrenalectomy (CL-ADX) in patients with PHE, with attention paid not only to immediate postoperative outcomes but also to the intraoperative hemodynamic changes that occur with each technique. The records of 265 consecutive patients who underwent laparoscopic ADX at Keio University Hospital in Tokyo from January 2001 to June 2011 were entered into a database. Surgical procedures were performed or supervised by two experienced laparoscopic surgeons, who performed more than 100 cases of urologic laparoscopic surgery in 2011. Twenty consecutive patients who underwent LESS-ADX from December 2009 to October 2011 were compared with patients who underwent CL-ADX (controls, n = 30) to look at differences in hemodynamic parameters and surgical outcomes in a case-control analysis. Each group was equivalent with respect to age, sex, and BMI. The mean size of 50 PHE was 45.1 ± 4.0 mm, the mean operative time was 151.8 ± 10.6 min, and there was no significant difference between the two groups. In one case of LESS-ADX, two additional ports were added. There was no significant difference between the CL-ADX and LESS-ADX groups in terms of operation time, total fluid during the operation, estimated blood loss, first oral feeding, postoperative stay in the intensive care unit, or postoperative hospital stay. We consider the safety of LESS-ADX of PHE as similar to that of CL-ADX. With appropriate pre- and intraoperative hemodynamic control and experienced hands, LESS-ADX could become one of the treatments of choice for resection of PHE.

Early Parenting Program as Intervention Strategy for Emotional Distress in First-Time Mothers: A Propensity Score Analysis

The purpose of this study is to evaluate the effectiveness of a single session intervention designed to reduce emotional distress in first-time mothers. We held a parenting class for first-time mothers who had given birth at a university hospital in Tokyo, Japan. The program of the class consists of lectures on infant care and group discussion, which is a common form of intervention in Japan. The effectiveness of intervention is assessed according to differences in emotional distress experienced by class participants and nonparticipants, and analyzed by the use of a propensity score method to avoid self-selection bias. In order to be more confident about our results, we employ several variations of this method. Results from statistical analysis show that although the effectiveness of the intervention was limited, it was able to alleviate subjects’ loss of self-confidence as mothers. Because this outcome shows a good degree of consistency across methods, it can be considered robust. Moreover, it is roughly consistent with previous studies. Effectiveness can probably be increased by developing a program that improves upon the intervention.

Validity and reproducibility of folate and vitamin B12 intakes estimated from a self-administered diet history questionnaire in Japanese pregnant women

BackgroundNo validated dietary questionnaire for assessing folate and vitamin B12 intakes during pregnancy is available in Japan. We evaluated the validity and reproducibility of intakes of folate and vitamin B12 estimated from a self-administered diet history questionnaire (DHQ) in Japanese pregnant women.MethodsA sample of 167 healthy subjects with singleton pregnancies in the second trimester was recruited at a private obstetric hospital in metropolitan Tokyo from June to October 2008 (n = 76), and at a university hospital in Tokyo from June 2010 to June 2011 (n = 91). The dietary intakes of folate and vitamin B12 were assessed using the DHQ. The serum concentrations of folate and vitamin B12 were measured as reference values in the validation study. To assess the reproducibility of the results, 58 pregnant women completed the DHQ twice within 4-5 week interval.ResultsSignificantly positive correlations were found between energy-adjusted intakes and serum concentrations of folate and vitamin B12 (r = 0.286, p < 0.001 and r = 0.222, p = 0.004, respectively). After excluding the participants with nausea (n = 121), the correlation coefficient for vitamin B12 increased to 0.313 (p = 0.001). When participants were classified into quintiles based on intakes and serum concentrations of folate and vitamin B12 , approximately 60% were classified in the same or adjacent quintile. The intraclass correlation coefficients of the two-time DHQ were 0.725 for folate and 0.512 for vitamin B12 .ConclusionThe present study indicated that the DHQ had acceptable validity and reproducibility for assessing folate and vitamin B12 intakes in Japanese pregnant women.

Peritoneal Morphology after Long-Term Peritoneal Dialysis with Biocompatible Fluid: Recent Clinical Practice in Japan

Morphology changes of the peritoneal membrane after long-term peritoneal dialysis (PD) consist of denudation of peritoneal mesothelial cells, interstitial sclerosis, and hyalinizing vasculopathy. Those changes are considered to be the result of uremia and bioincompatible effects of conventional acidic lactate-buffered dialysate with glucose degradation products (GDPs). In the last decade, biocompatible dialysate with neutral pH and low GDPs has become widely used. Clinical practice has been modified in Japan, especially for anuric patients, and now includes the use of hybrid therapy. The impact on peritoneal morphology has not been well reported. The aim of the present study was to investigate the long-term effect on peritoneal morphology and function of biocompatible fluid use and current clinical practice in Japan, including hybrid dialysis therapy. We evaluated peritoneal biopsy specimens from patients who had undergone PD for more than 3 years. We used the average peritoneal thickness (APT) of the submesothelial compact zone as a marker of interstitial sclerosis and the lumen/vessel diameter ratio (L/V ratio) at postcapillary venules as a marker of hyalinizing vasculopathy. Demography and other data for the patients, including dialysate-to-plasma (D/P) ratio of creatinine, were obtained at baseline and every 6 months by peritoneal equilibration test. Between 2002 and 2009, 110 patients started PD therapy with biocompatible dialysate at Tokyo University Hospital. Among them, 11 patients (8 men, 3 women; age: 54.2 ± 11.8 years; 1 with diabetes mellitus) were enrolled into this morphology study. The mean duration of PD in this group was 61 ± 11.3 months, and the mean time to peritoneal biopsy was 58 ± 15.1 months. The median APT was 180 μm (96 - 1424 μm), and the median L/V ratio was 0.66 (0.46 - 0.74). No obvious correlations between APT, L/V ratio, and PD duration were detected. The D/P creatinine of the 11 patients was maintained at a favorably low value, comparable with that of the other 99 patients. Peritoneal dialysis therapy using biocompatible dialysate in conjunction with modification of clinical practice may minimize the progression of peritoneal interstitial sclerosis and hyalinizing vasculopathy, preserving favorable peritoneal function for more than 3 years.

Dynamic change in respiratory resistance during inspiratory and expiratory phases of tidal breathing in patients with chronic obstructive pulmonary disease

Background and objectiveChronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitation consisting of airway obstruction and parenchymal emphysema, with loss of elastic recoil. The forced oscillation technique can detect impairment of lung function by measuring lung impedance during normal tidal breathing. Respiratory resistance (Rrs) in COPD has been well-studied, but the differences in Rrs in the inspiratory and expiratory phases between mild and moderate COPD remain poorly understood. Since airway obstruction in COPD is known to change dynamically during tidal breathing and might affect Rrs, the differences in Rrs during tidal breathing between mild and moderate COPD were evaluated.MethodsMild (n = 13) and moderate (n = 13) COPD patients were recruited at Tokyo University Hospital (Tokyo, Japan). Rrs was measured using MostGraph-01 (Chest MI, Inc, Tokyo, Japan), which depicted Rrs in a frequency-and respiratory cycle-dependent manner in three-dimensional graphics. Rrs was evaluated at 4–35 Hz during tidal breathing.ResultsRrs changed dynamically during tidal breathing in COPD. The mean Rrs values were significantly greater in the moderate COPD group than in the mild group. The maximal and minimal Rrs values at higher frequencies in the respiratory cycle were significantly greater in moderate COPD. In inspiratory–expiratory breath analysis, the maximal and minimal Rrs values at 20 Hz and 35 Hz were significantly greater in the moderate group, whereas at 4 Hz they did not differ significantly between the groups.ConclusionRrs changed dynamically during tidal breathing in patients with COPD. The Rrs values at higher frequencies were greater in moderate COPD than in mild COPD. Rrs at higher frequencies might reflect the degree of airway obstruction in tidal breathing in patients with COPD and might be a useful marker for evaluation of airway obstruction at an early stage of COPD.

Usefulness of Contrast-Enhanced Intraoperative Ultrasound Using Sonazoid in Patients With Hepatocellular Carcinoma

To assess the usefulness of contrast-enhanced intraoperative ultrasound (CE-IOUS) using Sonazoid (gaseous perflubutane) in patients with hepatocellular carcinoma (HCC). Contrast-enhanced intraoperative ultrasound using Sonazoid, a novel ultrasonic contrast agent enabling Kupffer imaging, may enable differentiation of HCC among new focal liver lesions found during fundamental intraoperative ultrasound (fundamental-NFLLs). Between February 2007 and February 2009, a total of 192 consecutive patients were enrolled. Fundamental intraoperative ultrasound and CE-IOUS were performed successively after laparotomy. The vascularity of 1 representative lesion was examined in harmonic mode for approximately 1 minute after the intravenous injection of Sonazoid (vascular phase). Approximately 15 minutes after the vascular phase, total liver scanning in the harmonic mode was commenced (Kupffer phase). One additional injection of Sonazoid was allowed to examine the vascularity of another lesion, if necessary. A tentative diagnosis of HCC was made when a lesion was either hypervascular during the vascular phase or hypoechoic during the Kupffer phase. A final diagnosis of HCC was made on the basis of the results of a histological examination or dynamic computed tomography findings obtained during the 12-month postoperative period. Seventy-nine fundamental-NFLLs were found in 50 patients (26%), 17 (22%) of which were finally diagnosed as HCC. The sensitivity, specificity, and accuracy of CE-IOUS for differentiating HCC among fundamental-NFLLs were 65%, 94%, and 87%, respectively. Contrast-enhanced intraoperative ultrasound identified 21 additional new hypoechoic lesions in 16 patients, of which 14 lesions (67%) in 11 patients were finally diagnosed as HCC. This prospective study protocol was approved by the institutional review board of the Tokyo University Hospital. An English-language summary of the protocol was submitted (registration ID: UMIN000003046) to the Clinical Trials Registry managed by the University Hospital Medical Information Network in Japan (http://www.umin.ac.jp/ctr/index.htm). With help of CE-IOUS using Sonazoid, more accurate intraoperative staging for HCC can be performed.

Abstract 252: Negative D-dimer Test for Acute Aortic Dissection

OBJECTIVE: Recent studies have indicated the effectiveness of D-dimer values as a negative predictor to rule out a diagnosis of acute aortic dissection (AAD) in patients with chest pain. In contrast, there are several other studies suggesting D-dimer levels are not always elevated in dissecting patients in emergency settings. The aim of the present study is to identify the independent predictors relating to negative results of D-dimer testing for AAD. METHODS: Single center prospective observational study was performed for 5 years in an emergency department of a university hospital in Tokyo. Consecutive 49 patients with AAD (32 males, median age: 63 y/o) were enrolled in this study. Diagnosis of AAD was confirmed by enhanced computed tomography (CT) in all patients. Of those, 18 patients presented Stanford type A and 22 patients had thrombosed false lumen. Venous blood was drawn soon after patients' arrival (all performed within 24 hrs from symptom onset, median time: 50 min), and WBC, CRP, and D-dimer levels were obtained. Dissection lengths were measured using CT by another physician in a blinded fashion. Univariate anlyses were performed by t-test or chi-square test where appropriate, and a Logistic regression analysis was used as a multivariate analysis. RESULTS: Medain (IQR) of plasma D-dimer levels of a consecutive series of 49 patients were 7.8 (0.3 to 113.8) μg/ml. Of the 49 patients, 5 (10.2%) showed negative D-dimer test results (&lt; 0.5μg/ml). Although age, sex, Stanford types, false lumen conditions, WBC, and CRP levels in these 5 patients were similar to those in other 44 patients with positive results, dissection length was significantly shorter in 5 negative results patients (132±119 vs 314±147 mm in positive results patients, P=0.01). The Logistic regression analysis using a backward elimination model revealed age and dissection length were identified as independent predictors for a negative D-dimer test result (Odds ratio and [95% CI]: 0.89 [0.79 to 0.99], 0.98 [0.96 to 0.99], respectively). CONCLUSION: In the present patient registry, 10% of patients with acute aortic dissection in emergency settings showed negative D-dimer test results. The negative D-dimer results were related to younger age and shorter dissection length.

Abstract 77: Predictive Power of Early Lactate Clearance Regarding 30-Day Neurological Outcome After Cardiac Arrest with Cardiopulmonary Bypass

Objective: Early lactate clearance has been reported to be associated with improved mortality in patients with post cardiac arrest syndrome (PCAS). Recently, cardiopulmonary bypass (CPB) has significantly improved prognosis of those patients, however, it has been still unknown whether early lactate clearance could predict for neurological outcome in PCAS with CPB. We aimed to investigate the usefulness of the early lactate clearance in a cardiac arrest of patients resuscitated and treated with CPB. Methods: Retrospective observational study. Between January 2000 and March 2011, 46 cardiac arrest patients with cardiac causes underwent CPB in a university hospital in Tokyo. Of those, serial arterial lactate concentrations (at ICU admission and 6 hours after ICU admission) were obtained from 21 patients (19 Males, median 61 y/o). Lactate clearance was defined as the percent change after 6 hours from baseline. The patients were divided into two groups (high lactate clearance group or low lactate clearance) by median lactate clearance. Results: The lactate clearance in the high lactate clearance group was 50.3±13.1% (mean±SD) and the low lactate clearance group -14.7±23.9%. There were no significant differences between the groups for demographics, laboratories (except platelets, baseline PaO 2 ), baseline lactate (the high lactate clearance group: 11.3±3.5mg/dl, the low lactate clearance group:10.8±4.2mg/dl), baseline arterial pressure (99.9±41.1mmHg, 96.1±26.7mmHg), use of catecholamine. In the high clearance group, there was significantly higher for favorable CPC (&lt;=2) rate (44% vs 0%, OR 2.8, 95%CI [1.48-5.40]) and Kaplan-Meier survival analysis showed a survival benefit over 30 days (log-rank; p=0.02). Cut-off points with 95% specificity in predicting favorable outcome was 67.4% for early lactate clearance (sensitivity 75%). CONCLUSIONS: Early lactate clearance is specific but only moderately sensitive markers of 30-day neurological outcome. These findings suggest that post arrest tissue hypoperfusion during CPB contributes lactate clearance, regardless CPB.

Kenji Shibuya: promoting global health in Japan

Kenji Shibuya: promoting global health in Japan

The Gift That Comes With Tragedy

I was working on my research at a university hospital in Tokyo when the earthquake hit eastern Japan. Two weeks later, I went to Minami-Sanriku township as part of a medical assistance team.

Improvements in both psychosis and motor signs in Parkinson's disease, and changes in regional cerebral blood flow after electroconvulsive therapy

Psychotic symptoms in Parkinson's disease (PD) are relatively common and, in addition to creating a disturbance in patients' daily lives, have consistently been shown to be associated with poor outcome. The use of anti-PD medications has been the most widely identified risk factor for PD psychosis (PDP). However, the pathophysiology of PDP remains unclear. Although the efficacy of electroconvulsive therapy (ECT) for PD had been pointed out, only one study has demonstrated the effectiveness of ECT on both psychotic symptoms and motor symptoms. The aim of this study was to examine the acute effectiveness of ECT on PD and to identify the brain areas associated with PDP. The study was conducted at Juntendo University Hospital in Tokyo. Eight patients with L-DOPA- or dopamine (DA) agonist-induced PDP, who were resistant to quetiapine treatment, were enrolled. Severity of PD was evaluated using the Hoehn and Yahr stage. Psychotic symptoms were evaluated using multiple measures from the Scale for the Assessment of Positive Symptoms (SAPS). Technetium-99m ethyl cysteinate dimer single photon emission computed tomography (99mTc ECD SPECT) was used to assess regional cerebral blood flow (rCBF) before and after a course of ECT. A voxel-by-voxel group analysis was performed using Statistical Parametric Mapping (SPM5). Our study clearly demonstrated that PDP was significantly less severe after ECT than before ECT, as indicated by change in mean SAPS total domain score (t=7.2, P=0.0002). Furthermore, the patients showed significant improvement in Hoehn and Yahr stage after ECT (t=11.7, P<0.0001). A further notable observation was significant increase in rCBF in the right middle frontal gyrus after ECT. We conclude that a course of ECT produced notable improvements not only in PDP but also in the severity of PD. The findings of change in rCBF suggest implications for dysfunction in the middle frontal region for patients with PDP.

Sa1495 The Final Report of WATCH Study; Comparison of Covered WAllflex StenT With Covered Wallstent As Historical Control by Japanese Multicenter Study in Cases With Malignant Distal Biliary Obstruction. (UMIN000002293)

Previous model of covered Wallstent (CWS) showed long patency and low occlusion rate but increased complications such as migration, cholecystitis and pancreatitis. These complications might be caused by properties of CWS. Newly developed partially covered WallFlex stent (CWX) is made from nitinol wire with platinum core. The axial force (AF) of CWX is 30% reduced, and both ends are looped and flared as anti-migration anchors. We conducted the multicenter study to evaluate CWX in comparison with CWS. Material & Study design; prospective consecutive study with historical control, Patients; unresectable malignant distal biliary obstruction, Insertion methods; conventional endoscopic placement of CWX after sphincterotomy, Observation period; at least 6 months after CWX placement, Main outcome; Patency, Secondary outcome; occlusion rate, incidence of complication, time to dysfunction (TTD; occlusion, migration and non-occlusion cholangitis), survival and success rate of stent removal, Comparison analysis; result of CWX compared with historical control from Tokyo university hospital and 4 affiliate hospitals. One hundred and forty-one cases were included in 20 referral centers between April 2009 and March 2010, and were compared with 138 cases with CWS placement between May 2001 and 2005 as a historical control. The baseline characteristics did not show significantly differences, median age; 72/79, males; 82/84, causative disease; pancreas cancer 104/93, cholangiocarcinoma 15/25, gallbladder cancer 5/2 and others 17/18, liver metastasis; 39/41 and ascites; 22/16, respectively. There were significantly differences in PS (0/1/2-4: 60/37/44 vs. 32/54/52; p=0.002) and pathologically confirmation (116 vs. 94; p=0.008). There were no significantly differences in median survival (229 vs. 219 days) and patency (436 vs. 369 days), but median TTD in CWX was longer than CWS (311 vs. 179 days; p=0.008). There were no significantly differences in occlusion (36/29; 25.5%/21.0%; sludge18/15, food impaction 9/6, tumor overgrowth 5/8 and unknown 4/0), cholecystitis 14/9 and pancreatitis 8/5, respectively. The incidence of migration of CWX was significantly lower than CWS (11/24; 7.8%/17.4%; p=0.019). The success rate of stent removal was 96% (26/27) and 100% (35/35), respectively. CWX showed similar patency, but longer TTD with lower migration rate than CWS. Reduction of AF and flared ends may lead to better outcomes.

Translation and Validation Study of the Japanese Versions of the Coronary Revascularisation Outcome Questionnaire (CROQ-J)

Assessing the health related quality of life (HRQOL) in patients with a disease specific scale is essential. The purpose of this study was to develop the Japanese version of the coronary revascularisation outcome questionnaire (CROQ), a disease-specific scale to measure HRQOL before and after coronary revascularisation. The English version of the questionnaire was translated into Japanese; some terms were revised, and some items were eliminated to suit the Japanese medical environment. Eight patients filled out the questionnaire, which was then analyzed for face validity. In the field study, subjects were recruited from a university hospital in Tokyo, and questionnaires were given to fill out. In terms of statistical analysis, factor analysis, internal consistency, known-groups validity, concurrent validity with using Short-Form36 (SF-36) and Seattle Angina Questionnaire-Japanese version (SAQ-J), and test-retest reliability were assessed. Informed consents were obtained from 356 patients, and out of 325 patients responded in the field study (91.3%). The factor structure of CROQ-Japanese version (CROQ-J) was similar to that of the original version. Cronbach's α ranged from 0.78 to 0.92. The concurrent validity was mostly supported by the pattern of association between CROQ-J, SAQ-J, and SF-36. Patients without chest symptoms had significantly higher scores of CROQ-J than those with chest symptoms. On the basis of analysis of the test-retest reliability, intra-class correlation coefficients were close to 0.70. The Japanese translation of CROQ is a valid and reliable scale for assessing the patient's HRQOL in CAD.