Female hepatology:Favorable role of estrogen in chronic liver disease with hepatitis B virus infection

Chronic hepatitis B virus (HBV) infection is the most common cause of hepatic fibrosis and hepatocellular carcinoma (HCC),mainly as a result of chronic necroinflammatory liver disease. A characteristic feature of chronic hepatitis B infection,alcoholic liver disease and nonalcoholic fatty liver disease (NAFLD) is hepatic steatosis. Hepatic steatosis leads to an increase in lipid peroxidation in hepatocytes,which,in turn,activates hepatic stellate cells (HSCs). HSCs are the primary target cells for inflammatory and oxidative stimuli,and these cells produce extracellular matrix components. Chronic hepatitis B appears to progress more rapidly in males than in females,and NAFLD,cirrhosis and HCC are predominately diseases that tend to occur in men and postmenopausal women. Premenopausal women have lower hepatic iron stores and a decreased production of proinflammatory cytokines. Hepatic steatosis has been observed in aromatase-deficient mice,and has been shown to decrease in animals after estradiol treatment. Estradiol is a potent endogenous antioxidant which suppresses hepatic fibrosis in animal models,and attenuates induction of redox sensitive transcription factors,hepatocyte apoptosis and HSC activation by inhibiting a generation of reactive oxygen species in primary cultures. Variant estrogen receptors are expressed to a greater extent in male patients with chronic liver disease than in females. These lines of evidence suggest that the greater progression of hepatic fibrosis and HCC in men and postmenopausal women may be due,at least in part,to lower production of estradiol and a reduced response to the action of estradiol. A better understanding of the basic mechanisms underlying the sex-associated differences in hepatic fibrogenesis and carciogenesis may open up new avenues for the prevention and treatment of chronic liver disease.

Effects of estradiol and progesterone on the proinflammatory cytokine production by mononuclear cells from patients with chronic hepatitis C

AIM:To investigate the effects of estradiol (E2) and progesterone on the unstimulated and oxidative stressstimulated production of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-8, and macrophage chemotactic protein (MCP)-1 by peripheral blood mononuclear cells (PBMCs) from patients with chronic hepatitis C and healthy controls. METHODS:The PBMCs were separated from agematched 72 males and 71 females with and without chronic hepatitis C, who were divided into two groups based on a mean menopausal age of 50 years. Oxidative stress was induced by hydrogen peroxide in the cells incubated in serum-free media. Cytokines in the culture supernatant were measured by an enzyme-linked immunosorbent assay. RESULTS:The highest levels of the spontaneous production of TNF-α, IL-1β, IL-8, and MCP-1 by the unstimulated PBMCs were in the older male patients with chronic hepatitis C and the lowest levels were in the premenopausal female healthy controls. E2 inhibited the cytokine production by the unstimulated PBMCs from the older male and post-menopausal female patients, which was further stimulated by progesterone. The exposure to hydrogen peroxide in the PBMCs from the younger male and pre-menopausal female healthy subjects induced the production of cytokines. The change rates of the hydrogen peroxide-stimulated cytokine production were suppressed by E2 and enhanced by progesterone. CONCLUSION:These findings suggest that E2 may play a favorable role in the course of persistent liver injury by preventing the accumulation of monocytes-macrophages and by inhibiting proinflammatory cytokine production, whereas progesterone may counteract the favorable E2 effects.

Seroprevalence of Helicobacter pylori in dyspeptic patients and its relationship with HIV infection,ABO blood groups and life style in a university hospital,Northwest Ethiopia

AIM： To determine the prevalence of Helicobacter pylori （H pylori） among dyspeptic patients and to assess the relationship between Hpylori infection, blood group, HIV infection and life style of the patients. METHODS： In a hospital-based cross-sectional study, patients attending Outpatient Department of University of Gondar Hospital were enrolled. Socio-demographic information was collected using questionnaires. Serum was analyzed for anti-H pylori IgG antibodies using a commercial kit. HIV serostatus was determined by enzyme-linked immunosorbent assay （ELISA）. Blood grouping was performed by slide agglutination tests. RESULTS： A total of 215 dyspeptic patients were included in the study. One hundred and sixteen patients （54%） were females and 99 （46%） were males. Anti-H pylori IgG antibodies were detected in sera of 184 （85.6%） patients. The prevalence was significantly higher in patients aged 50 years and above. Twenty point five percent of the patients were found to be seropositive for HIV. No significant association was found between sex, ABO blood groups, consumption of spicy diets, socioeconomic status and seropositivity for Hpylori. However,alcohol consumption was significantly associated with H pylori serology. CONCLUSION： The prevalence of H pylori infection is associated with a history of alcohol intake and older age. The effect of different diet, alcohol and socioeconomic status as risk factors for H pylori infection needs further study.

Sleep conditions and quality of life among patients with ischemic heart disease after elective percutaneous coronary intervention

In Japan, percutaneous coronary intervention (PCI) is a major therapeutic intervention for ischemic heart disease (IHD). Previous studies suggested that an association of the risk of IHD caused by sleep duration was related to factors closely associated with daily activities. However, in Japan, there is no study about this relationship objectively measured using the actigraphy in patients with IHD. Moreover, there is little reported data about sleep condition and early outcomes of patient’s Health-Related Quality of Life (QOL) after PCI. This study determines the correlations between sleep conditions and QOL (measured by SF36 version 2) of 25 patients with IHD who underwent elective PCI. Data were collected seven days after PCI using night-sleep condition. Using Spearman’s rank test, the results revealed positive correlation between vitality score and longest sleep duration (ρ = 0.43, p = 0.031): social functioning (SF) score and duration of night-time sleep (ρ = 0.42, p = 0.037);total sleep duration (ρ = 0.45, p = 0.026), and longest sleep duration (ρ = 0.44, p = 0.024);mental health score and longest sleep duration (ρ = 0.54, p = 0.006). However, negative correlation was found between physical functioning score and arousal during sleep (ρ = -0.44, p = 0.027). Sleep condition was significantly correlated with QOL. In particular, SF score was positively related to night-time sleep. This seems to indicate that SF score might be related to night-time sleep condition. Moreover, the longest sleep durations were correlated with the mental component summary. The results of the study suggest that not only the length of whole sleep durations leads to better QOL, but also the increase the amount of uninterrupted sleep.

Three-Dimensional Computed Tomography Assessment and Planning for Severe Lower Limb Deformities: A Case Report of Bilateral Fibular Hemimelia

To correct a lower limb deformity, orthopedic surgeons must have an exact understanding of the deformity. In general, preoperative planning is carried out using anterior-posterior (AP) and lateral radiographs. However, for severe cases with a combination of angular and rotational deformities of the lower limb, obtaining true AP and lateral radiographs is difficult and accurate calculation of the rotational deformity from radiographs is impossible. In this report, we propose to focus on preoperative assessment using three-dimensional (3D) reconstruction images of computed tomography (CT) scans for severe lower limb deformity in a patient with bilateral fibular hemimelia type II according to the Achterman- Kalamchi classification. She underwent bifocal deformity corrections of the bilateral tibiae using Taylor spatial frames in combination with the Ilizarov external fixator. Complete bony union was achieved, without angular deformity or limb length discrepancy.

Current status of single-balloon enteroscopy: Insertability and clinical applications

The single-balloon enteroscopy(SBE) system was launched in 2007, proposed as a simpler method than double-balloon enteroscopy(DBE). Controversy surrounds whether the SBE system has the same insertability as DBE. However, many methods have been proposed to improve the depth of insertion with the SBE system, involving several techniques and endoscopic accessories. SBE is used for investigating not only small bowel diseases, but also diseases of the pancreatobiliary and colonic structures. SBE is a necessary advancement for many endoscopic procedures and applications in modern clinical practice. In our review, we summarized the current literature concerning the insertability of SBE and described the technical aspects of improving the rate of deep insertion in SBE procedures. In addition, the recent applications of SBE to diseases besides those of the small bowel are described.

The relationship between body mass index, thickness of subcutaneous fat, and the gluteus muscle as the intramuscular injection site

An intramuscular injection (IMI) is an injection given directly into the central area of a specific muscle. Certain medicines need to be administered by the gluteal route for these to be effective. The aim of this study was to determine the influence of body mass index (BMI), subcutaneous fat, and muscular thickness of the dorsogluteal IMI site among healthy Japanese women. There were 39 healthy female subjects who volunteered and met the criteria. Their ages ranged from 40s to 60s (50.82 ± 6.04). With the data collected using the B-mode ultrasound images of the dorsogluteal site, it was found that the distance from the epidermis to the under-fascia (DEUF) of the gluteus maximus was dissimilar between the subject’s right and left buttocks. It was found that the distance from the epidermis to the iliac bone (DEI) was significantly more on the right than on the left buttocks. In the case of an adult Japanese woman with a BMI of 21 or more, the DEUF of the gluteus medius was found to be about 30 mm, and the DEI was approximately 50 mm or more. Based on these findings, it is recommended that a needle length of 38 mm (1.5 inches) can be safely used to administer IMIs to the gluteus medius muscle to effectively and efficiently deliver medications through the IMI route.

Characteristics of Nursing Care for Terminally Ill Patients in Hospice/Palliative Care Unit

The purpose of this study was to clarify the characteristics of nursing care for patient with terminally ill in the hospice/palliative care units. Semi-structured interviews on “communication, care, spiritual pain care and prediction of worsening of symptoms” were conducted, incorporating items indicated as important principles of palliative care by Lugton et al. Sixteen nurses at five hospice/ palliative care facilities in urban areas of Japan were surveyed in 2013, and results were analyzed qualitatively. Following characteristics by hospice/palliative care nurses (HPN) were categorized as [HPN sharing meaningful time with the patient] and [HPN’s continual attempts to understand the world in which the patient lives] in the communication;as [HPN providing comfortable care so that patients can value their last moments] and [HPN’s efforts to attend to patients so they can die as they hope to] in the care;and as [HPN’s observation in a range that does not interfere with the patient’s comfort] and [HPN senses that something is different from before] in the prediction of worsening of symptoms. Common characteristic was 【HPN’s support for patients approaching a natural death】. In this study, spiritual pain care was included in the communication and care, and could not be extracted alone. It was suggested that an HPN provides communication, care and prediction of worsening of symptoms with excellent judgment and technological competency, while placing importance on offering support for the patient’s natural death.

Early Results of Omitting Completion Axillary Lymph Node Dissection in Sentinel Lymph Node Metastasis-Positive Breast Cancer Patients

Background: We investigated the early results of omitting completion axillary lymph node dissection (ALND) for axillary node metastasis-negative (N0), sentinel node (SN) metastasis-positive breast cancer patients. Patients and Methods: 489 patients had invasive N0 breast cancer treated without completion ALND, regardless of their SN metastasis status. Analyses included the associations between the SN metastasis status, clinicopathological findings and recurrence, between recurrence and clinicopathological findings, and recurrence-free survival. Results: 430 patients were SN biopsy (SNB)-negative, and 59 were SNB-positive. The SNB-positive patients received significantly more potent adjuvant therapy than the SNB-negative patients. Median follow-up was 3.7 years, and the axillary node recurrence was seen in 6 patients (1.2%) and recurrence in 21 patients. The SN status showed no associations with the clinicopathological findings or recurrence. Univariate analysis showed recurrence was associated with absence of hormonal therapy, ER-negative, PgR-negative, HER2-positive or triple-negative (TNBC) disease, a tumor ≥2.1 cm and higher nuclear grade. Multivariate analysis showed recurrence was associated with absence of hormonal therapy and a tumor ≥2.1 cm. Cox proportional hazards model showed recurrence was extremely early in ER-negative and TNBC patients. Conclusion: Completion ALND can be skipped in N0 breast cancer patients even if they are SNB-positive, but adjuvant therapy is essential.

Ultra-High Molecular Weight Polyethylene Tape Applied for Distal Humeral Condyle Fracture around Total Elbow Arthroplasty in Patients with Rheumatoid Arthritis: Report of Two Cases

Managing fractures of distal humerus in patients with rheumatoid arthritis (RA) is technically challenging. Total elbow arthroplasty (TEA) is one of the treatment options for these fractures. While elbow motion is largely regained by TEA, comminuted condyle fragments are often ignored. Although numerous approaches for repair of condylar fragments around TEA are described, any universal fixation strategy for these fractures has not been established. This report describes, for the first time, application of an ultra-high molecular weight polyethylene (UHMWPE) tape for the treatment of distal humerus fracture in 2 patients with rheumatic elbow arthropathy. The post-operative clinical courses were good. Radiographs showed bony union of the condylar fragments without loosening in two cases. Because of its flat configuration, softness, and flexibility, UHMWPE tape is a promising material for stabilizing fracture of the distal humerus associated with TEA.

Optimal needle insertion length for intramuscular injection of risperidone long-acting injectable (RLAI)

Risperidone long-acting injectable (RLAI) is approved for the treatment of schizophrenia in many countries. The suggested site is the gluteal muscle with a needle length of two inches (50 mm) in Japan, which is longer than the ordinarily used needle for intramuscular injections. The aim of this study was to determine the optimal needle insertion length for accurate delivery of RLAI procedure among subjects who have normal body mass index (BMI: 18 to 25) and high BMI (>25). Thirty-seven patients with schizophrenia were administered RLAI intramuscularly into the dorsogluteal muscle. The standard procedure required inserting 80% of the two inch needle. By using data collected by ultrasonography, the findings confirmed that the median needle insertion lengths for subjects with normal and high BMI were 39.0 and 45.5 mm, respectively. To deliver RLAI effectively and safely, the authors strongly recommend that a specialized needle be used that is “marked” at the 40 mm point from the tip of the needle to the base. In this way regardless of subcutaneous fat content, the RLAI can be safely delivered into the muscle without causing untoward or side effects.

Characteristics of Male Family Caregivers in Japan and Their Sense of Care Burden, Capacity to Deal with Stress, and Subjective Sense of Well-Being

This study aimed to clarify the characteristics of Japanese male family caregivers in terms of their sense of care burden, their capacity to deal with stress, and their subjective sense of well-being. A survey consisting of questionnaires and interviews was conducted from March to May 2014 in the subjects’ homes. Subjects were 27 Japanese males (the age range: 54 - 85) who provided home care for their family member. Caregivers who were good at relieving stress or who had a subjective sense of well-being were found to have a low care burden. The types and seriousness of diseases of the care recipients were not related to the caregivers’ sense of burden, capacity to deal with stress, or subjective sense of well-being. Based on the interview results, caregivers were found to have the following characteristics: they were particular about methods of care;they learned how to provide home care by themselves;they used their social intelligence in home care;they always provided home care while keeping the future in mind;and most notably, they considered home care to be their primary occupation. On the whole, male caregivers were found to alleviate the burdens of home care by making use of the nursing-care service systems that enabled them to relieve stress and enjoy their leisure time. Caregivers considered home care to be their occupation and used their past social experiences. The workforce helped them deal with the care recipients’ health conditions or day-to-day changes so that they could overcome the care burden.

A family history of diabetes is not associated with arterial stiffness in non-diabetic Japanese population

Prevalent diabetes is at high risk for cardiovascular diseases and has a high familial inheritance. However, little is known whether a non-diabetic subject with a family history of diabetes is at high risk for vascular damage or not. The purpose of this study was to evaluate the association between a family history of diabetes and arterial stiffness in adult non-diabetic Japanese population. We analyzed eligible 787 non-diabetic subjects (502 men and 285 women) aged 35-69 years who enrolled in the baseline survey of a cohort study in Tokushima Prefecture, Japan and who underwent a brachial-ankle pulse wave velocity (ba-PWV) measurement. Information on individual life-style characteristics including medical history and treatment for diseases and a first-degree family history of diabetes was obtained through a structured self-administered questionnaire. Analysis of covariance and logistic regression analyses were used to evaluate the association between a family history of diabetes and ba-PWV. We found no differences in age-and-systolic blood pressure-adjusted and multivariate-adjusted means of ba-PWVs between subjects of both sexes with and without a family history of diabetes. Logistic regression analyses including both sexes also revealed that subjects with a family history of diabetes showed no differences in age-and-systolic blood pressure-adjusted and multivariate-adjusted odds ratios for high ba-PWV compared to those without that trait. Our results suggest that a family history of diabetes itself is not associated with arterial stiffness in adult non-diabetic Japanese population.

Changes before and after improvement of subjective sleep state of a man diagnosed with pre-diabetes and sleep disorder

The purpose of this case study was to examine the changes before and after improvements of the subjective sleep status of Mr A, a 40-year-old man diagnosed with pre-diabetes and a sleep disorder. Data were collected using a Holter monitor for 24 hours a day for 3 days to assess autonomic nervous activity by recording bed-time and waking time activity (activity counts: ACs). Mr. A kept a diary of activities and completed the Pittsburgh Sleep Quality Index (PSQI) questionnaire. The study revealed that subjective sleeping hours correlated almost precisely with those measured by the actigraph and as described in the diary. Both the parasympathetic and sympathetic nervous system activities were imbalanced. However, no correlation was observed between the ACs and autonomic nervous activity. Subjective sleep state according to the PSQI score improved remarkably by dietary and exercise therapy from 13 to 3 points, after six months, with corresponding high level sleep satisfaction level. Significant correlations were observed between ACs and high-frequency spectral power of R-R intervals, and between ACs and the low-frequency/high frequency ratio of spectral power of R-R intervals. Although Mr. A’s sleep satisfaction level has improved, the autonomic nervous system activity remained different from that of healthy people.

Development of Algorithm and System for Automatic Generation of Nursing Summaries from Nursing Care Plans

A nursing care planning system that automatically generated nursing summaries from information entered into the Psychiatric Outcome Management System (PSYCHOMS?, Tanioka et al.), was developed to enrich the content of nursing summaries at psychiatric hospitals, thereby reducing the workload of nurses. Preparing nursing summaries entails finding the required information in nursing records that span a long period of time and then concisely summarizing this information. This time consuming process depends on the clinical experience and writing ability of the nurse. The system described here automatically generates the text data needed for nursing summaries using an algorithm that synthesizes patient information recorded in electronic charts, the Nursing Care Plan information or the data entered for North American Nursing Diagnosis Association (NANDA) 13 domains with predetermined fixed phrases. Advantages of this system are that it enables nursing summaries to be generated automatically in real time, simplifies the process, and permits the standardization of useful nursing summaries that reflect the course of the nursing care provided and its evaluation. Use of this system to automatically generate nursing summaries will allow more nursing time to be devoted to patient care. The system is also useful because it enables nursing summaries that contain the required information to be generated regardless of who prepares them.

Improvement of Scalp Condition and Quality of Life through Proper Skin Care of Dry Scalp

Introduction: Appropriate skin care for dry scalp includes treatment for dandruff and itchiness. However, little is known about the appropriate washing methods for subjects with dry scalp. Me- thods: A scalp moisturizing lotion was used for 8 weeks on 30 outpatients at the Tokushima University Hospital who had dry scalp. All subjects were given the same hair shampoo/conditioner and instructions on how to wash their hair. Scalp symptoms were observed before and after the testing period. Indigenous bacteria were collected from the scalp for quantitative assessment. A survey was conducted to assess the quality of life (QOL). Results: All scalp condition items (dryness, scales and desquamation, itchiness, excoriation, and erythema) improved significantly after the testing period;the levels of Malassezia and bacterial colonization also decreased significantly. The QOL evaluation indicated significant improvements in “symptoms”, “emotions”, and “global” measures. A correlation was found between the extent of dryness at the start of the test and the level of Malassezia colonization, as well as QOL scores. Conclusion: Using a scalp moisturizing lo- tion, washing hair with a shampoo and conditioner that cause low irritation levels, and using a hair washing method that avoids irritation led to improvement in scalp condition, QOL, and pa- tient satisfaction.

Usefulness of the SNR Using the Subtraction Method and Image Visibility Using the Howlett Chart Method in X-Ray Fluoroscopic System

X-ray fluoroscopy has been used not only for diagnoses but also for treatment, as in interventional radiology. The aim of this study is to assess the usefulness of the signal-to-noise ratio (SNR) using the subtraction method, which is used in the quality assurance/quality control (QA/QC) of magnetic resonance imaging (MRI) equipment, and image visibility using the Howlett chart method in the fluoroscopic examination. The fluoroscopy unit has a detector with an image intensifier and a color liquid crystal display. A 2620 dosimeter and an ionization chamber were selected for the dose measurement. Fluoroscopic images for visual and physical evaluations were collected as dynamic data. The skin surface absorbed dose rates for each tube current were measured using a dosimeter. The SNR using the subtraction method and image visibility using the Howlett chart method were examined. The results from both indicate that as the SNR improves, visual evaluation increases, but the rate of increase gradually saturates. Therefore, physical and visual evaluations are possible with the SNR using the subtraction method and the image visibility using the Howlett chart method.

Reliability Verification and Practical Effectiveness Evaluation of the Nursing Administration Analysis Formulae Based on PSYCHOMS^(■)

In psychiatric hospitals, the ratios between patients versus physician and patients versus nurse are low as compared to those in general hospitals. Furthermore, usages of electronic medical records are also low so that nurse administrators are limited in their ability to compile, analyze, and generate patient care staffing information for their administrative use. Psychiatric nurse administrators anticipate the development of a nursing administration analysis system that could perform personnel data simulation, manage information on nursing staff, and manage ward/ practice operations. Responding to this situation, the authors developed a nursing administration analysis system utilizing formulae from the Psychiatric Outcome Management System, PSYCHOMS®to aid nurse administrators. Such formulae are awaiting patent approval. The purpose of this study was to examine the validity of the formulae and the Structured Query Language (SQL) statement, and its practical effectiveness of analyzing data. The study findings showed that two kinds of computation expressions—a classification and extraction were able to display required information desired by nurse administrators. Moreover, significant information critical to assigning staff was validated to ensure high quality of nursing care according to the function and characteristic of the hospital ward.

胸腺瘤放疗的相关定义和报告指南

放疗在胸腺肿瘤的治疗中仍然占有重要地位，但是很多细节没有明确的定义。例如，如何放疗、如何确定放疗范围、哪些患者需要放疗和如何报告放疗结果都没有统一的标准。ITMIG的成立，给解决这些问题创造了机会。但是先决条件是制定统一的定义和方法，使不同结果能被理解和比较，这也是本文的主旨。文献和形成初步建议，再提交给下一个扩展工作组（Charles hTomas, Lynn Wilson, Gregory Videtic. James Metz, Harun Badakhshi, Clifton Fuller, Franc-oie Mornex, Conrad Falkson, David Ball, and Ken Rosenzweig）审议，之后将建议提交给ITMIG多学科组进一步讨论，形成初稿（包含推荐方法和标准操作流程）后分发给所有ITMIG成员更进一步讨论并反馈意见，最终版本经ITMIG批准并被采用。

胸腺恶性肿瘤Masaoka-Koga分期相关术语的说明与定义

目前，胸腺恶性肿瘤尚无国际抗癌联盟（International Union Against Cancer, UICC）和美国癌症联合委员会（American Joint Committeeon Cancer, AJCC）的官方分期。在2017年新版国际肿瘤分期提出较为广泛接受的分期之前，国际胸腺肿瘤协作组织（International Thymic Malignancy Interest Group, ITMIG）仍然建议选用经Koga等修订的Masaoka分期[1-3]。然而， Masaoka和Koga分期都存在一些模糊的术语定义，尤其是对某些细节未作出明确的定义，造成学术界的许多混乱。为此，ITMIG首先由核心工作组起草推荐定义，再交由扩展工作组提炼，并于2010年11月16日ITMIG举办的定义和术语研讨会上进行了进一步修订，最终经ITMIG全体成员讨论后于2011年2月经ITMIG批准并被采用。其灵魂内容是ITMIG对Masaoka-Koga分期系统的许多细节问题给出了较明确定义与解释，旨在使得大家在应用Masaoka-Koga分期的过程中更加一致，以利于相互合作、资源共享，同时便于前瞻性数据的正确收集，最终提出更合理的分期系统供临床使用。本文就此作一综述。