VOLUME 76 NUMBER 1,2 February 2014

Current Issue

ISSN 2186-3326
(Online ISSN)
ISSN 0027-7622
(Print ISSN--v.72no.3/4)

Impact Factor(2016)
 0.619

EndNote Output Style

Invited Review Article

Carboplatin Dosing for Adult Japanese Patients

YUICHI ANDO, TOMOYA SHIMOKATA, YOSHINARI YASUDA, and YOSHINORI HASEGAWA
pg(s) 1 - 9

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Carboplatin is a platinum-based anticancer drug that has been long used to treat many types of solid cancer. Because the clearance of carboplatin strongly correlates with the glomerular filtration rate (GFR), its dosage is calculated with the Calvert formula on the basis of the patient’s GFR to achieve the target area under the plasma drug concentration-time curve (AUC) for each patient. However, many lines of evidence from previous clinical studies should be interpreted with caution because different methods were used to estimate drug clearance and derive the dosage of carboplatin. There is a particularly high risk of carboplatin overdosing when the dosage is determined on the basis of standardized serum creatinine values. When deciding the dose of carboplatin for adult Japanese patients, preferred methods to assess renal function instead of directly measuring GFR include (1) 24-h urinary collection-based creatinine clearance adjusted by adding 0.2 mg/dl to the serum creatinine concentration measured by standardized methods, and (2) equation-based GFR (eGFR) with a back calculation to units of ml/min per subject. Given the limitations of serum creatinine-based GFR estimations, the GFR or creatinine clearance should be directly measured in each patient whenever possible. To ensure patient safety and facilitate a medical-team approach, the single most appropriate method available at each institute or medical team should be consistently used to calculate the dose of carboplatin with the Calvert formula.

Original Papers

Retrospective Case Series of 15 Patients Treated with Chemoradiation Using 5-FU and Nedaplatin for Gynecological Malignancy: With Regard to Hemotoxicity

YOSHIYUKI ITOH, MITSURU IKEDA, NAOKI HIRASAWA, SHUNICHI ISHIHARA, TAKAHITO OKUDA, TAKAYUKI MURAO, SEIJI KUBOTA, TOHRU OKADA, SHINJI NAGANAWA, and TAKEO ISHIGAKI
pg(s) 11 - 16

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We conducted a retrospective comparison of the hemotoxicity of the sequential administration of 5-Fluorouracil (5-FU) prior to Nedaplatin (NDP) (FN therapy) and that of its reverse sequence (NF therapy) for gynecological malignancy. From February 2002 to November 2004, a total of 15 gynecological malignancy patients were treated with radiation therapy combined with NDP and 5-FU. Of these 15 patients, 5 were treated with NF therapy, and 10 were treated with FN therapy. No significant differences were detected between the FN and NF groups with regard to white blood cell count (WBC), hemoglobin level (Hb), and platelet count. The results of this study do not show that the FN group has a lesser degree of hemotoxicity than the NF group.
Family Support for Women’s Health-Seeking Behavior: a Qualitative Study in Rural Southern Egypt (Upper Egypt)

AYUMI OHASHI, MICHIYO HIGUCHI, SHOKRIA ADLY LABEEB, ASMAA GHAREEB MOHAMED, CHIFA CHIANG, and ATSUKO AOYAMA
pg(s) 17 - 25

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This qualitative study investigated the influence of family support on women’s health-seeking behavior in rural southern Egypt (Upper Egypt). We carried out separate focus group discussions (FGDs) with 3 groups (6 women with children under 5 years old, 6 men, and 4 elderly women, respectively) in a village in Assiut Governorate, an underprivileged region in Upper Egypt. The FGDs aimed to identify how different types of family support affected women’s health-seeking behavior in areas including maternal health and common illnesses of women and children. Our results showed that maternal health issues were often discussed by husbands and wives, while mothers-in-law had little apparent influence. We also found that women could access support resources more easily than expected through their extended families. Our study showed that husbands had an important role in encouraging women’s health in the family, while the effect of mothers-in-law on women’s health-seeking behavior was not substantial. The study indicated that women received considerable support from co-resident family members, their natal family, and their neighbors, which helped women in seeking health services.
Useful Base Plate to Support the Head During Leksell Skull Frame Placement in Gamma Knife Perfexion Radiosurgery

HISATO NAKAZAWA, YOSHIMASA MORI, MASAHIRO HAGIWARA, TAKAHIKO TSUGAWA, YUTA SHIBAMOTO, TATSUYA KOBAYASHI, and CHISA HASHIZUME
pg(s) 27 - 33

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We developed an original base plate to support both the patient’s head and a Leksell stereotactic skull frame during frame placement in the supine position. The base plate is made of transparent acrylic board with holes at the posterior posts for injection of local anesthetics and maneuver of fixation screws through them. A stable and comfortable position of the patient’s head in a supine position is obtained and maintained on this base plate with an air-pressure cuff beneath the patient’s head. The patient is able to keep a stable, relaxed and comfortable posture during the procedures of skull frame placement.
Premature Cardiac Senescence in DahlS.Z-Lepr fa/Lepr fa Rats as a New Animal Model of Metabolic Syndrome

KEIJI TAKAHASHI, MIWA TAKATSU, TAKUYA HATTORI, TAMAYO MURASE, SAE OHURA, YUURI TAKESHITA, SHOGO WATANABE,TOYOAKI MUROHARA, and KOHZO NAGATA
pg(s) 35 - 49

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Aging is accelerated by metabolic and cardiovascular diseases, and the risk of these diseases increases with age. Obesity is an important risk factor for many age-related diseases and is linked to reduced telomere length in white blood cells. We investigated whether cardiac senescence might be enhanced in DahlS.Z-Lepr fa/Lepr fa (DS/obese) rats, which we recently established as a new animal model of metabolic syndrome. The heart of DS/obese rats was compared with that of homozygous lean littermates (DahlS.Z-Lepr+/Lepr+, or DS/lean, rats). DS/obese rats manifested hypertension as well as left ventricular hypertrophy, fibrosis, and diastolic dysfunction at 18 weeks of age. Myocardial oxidative stress and inflammation were increased in DS/obese rats compared with DS/lean rats. Telomere length in myocardial cells did not differ between the two rat strains, whereas telomerase activity and expression of the telomerase reverse transcriptase gene were increased in DS/obese rats. Expression of the senescence-associated genes for checkpoint kinase 2 (Chk2), p53, and p21 as well as that of genes related to the renin-angiotensin-aldosterone system were also up-regulated in the DS/obese rat heart. Our results indicate that DS/obese rats undergo premature cardiac senescence as well as cardiac remodeling in association with the development of diastolic dysfunction in these animals.
A Learning Curve in Aortic Dissection Surgery with the Use of Cumulative Sum Analysis

MIN-HO SONG
pg(s) 51 - 57

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This study demonstrates the risk adjusted cumulative sum analysis of an individual surgical learning curve for acute type A aortic dissection surgery. Thirty consecutive patients were operated by a single surgeon for acute type A aortic dissection from April 2001 to March 2008. Operative variables, mortality, and major morbidities were analyzed. The learning curve was calculated by cumulative sum analysis. The anticipated 30-day operative mortality rate was 20.2±12.7% (range, 3.3–56.7%) and the expected 30-day mortality and morbidity rate was 47.0±13.3 % (range, 21.7–70.6%) according to the Japan SCORE calculator. The observed operative and in-hospital mortality rate was 6.67% (two patients), and the observed major postoperative morbidity rate was 10.0% (three patients). Risk-adjusted cumulative sum analysis revealed that no excess deaths occurred beginning at the seventh case and thereafter. The surgeries for acute type A aortic dissection could be performed at the professionally permissive level from the beginning. Risk-adjusted cumulative sum analysis was a useful tool to monitor the performance of the surgical procedure.
Glucocorticoids Activate Cardiac Mineralocorticoid Receptors in Adrenalectomized Dahl Salt- Sensitive Rats

MASAFUMI OHTAKE, TAKUYA HATTORI, TAMAYO MURASE, KEIJI TAKAHASHI, MIWA TAKATSU, MAYUKO OHTAKE, MASAAKI MIYACHI, SHOGO WATANABE, XIAN WU CHENG, TOYOAKI MUROHARA, and KOHZO NAGATA
pg(s) 59 - 72

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We previously showed that selective mineralocorticoid receptor (MR) blockade by eplerenone is cardioprotective in Dahl salt-sensitive (DS) rats. To clarify the consequences of glucocorticoid-mediated MR activation in these animals, we investigated the effects of exogenous corticosterone on blood pressure as well as cardiac remodeling and function after adrenalectomy. DS rats were subjected to adrenalectomy at 6 weeks of age and thereafter fed a high-salt diet and administered corticosterone (20 mg/kg per day) or vehicle. Systolic blood pressure was higher in the corticosterone group than in the vehicle group at 7 weeks and thereafter. By 11 weeks, corticosterone had reduced left ventricular (LV) mass and induced LV diastolic dysfunction. The ratio of collagen type I to type III mRNA levels in the left ventricle was increased in the corticosterone group compared with the vehicle group. Administration of a non-antihypertensive dose of the MR antagonist spironolactone (20 mg/kg per day) from 6 weeks inhibited the effects of corticosterone on both the collagen type I to type III mRNA ratio and diastolic function without affecting the decrease in LV mass. Spironolactone attenuated both the increase in NADPH oxidase activity in the left ventricle and coronary vascular inflammatory responses apparent in the corticosterone group. These results indicate that exogenous glucocorticoids induce hypertension, cardiac remodeling, and diastolic dysfunction in adrenalectomized DS rats fed a high-salt diet. The cardiac effects of exogenous glucocorticoids are likely attributable, at least in part, to myocardial oxidative stress and coronary vascular inflammation induced by glucocorticoid-activated MRs..
A Novel Method for Managing Water and Electrolyte Balance after Transsphenoidal Surgery: Preliminary Study of Moderate Water Intake Restriction

KAZUHITO TAKEUCHI, TETSUYA NAGATANI, ERIKO OKUMURA, and TOSHIHIKO WAKABAYASHI
pg(s) 73 - 82

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Hyponatremia is a common and potentially serious complication of transsphenoidal surgery (TSS). Since September 2009, we have implemented moderate water intake restriction (<2500 mL/day) after TSS in an attempt to prevent this complication. The aim of this study was to investigate the efficacy of a combination of moderate restriction of water intake plus antidiuretic hormone (arginine vasopressin [AVP]) replacement therapy in patients with diabetes insipidus (DI) for reducing the incidence of delayed hyponatremia after TSS. Patients treated from September 2005 to August 2009 were allowed to drink water freely after surgery (the control group), while patients treated from September 2009 to June 2012 were restricted to less than 2500 mL water per day (the water restriction group). To reduce the occurrence of hypernatremia, AVP replacement therapy was provided immediately after the development of DI. We retrospectively analyzed the incidence of hyponatremia, DI, and hypernatremia in patients following TSS. Hyponatremia incidence was significantly lower in the water restriction group (P = 0.017); however, there were no significant differences in DI incidence and hypernatremia incidence between the 2 groups. Under DI control with AVP replacement therapy, the water restriction group showed no significant difference in the daily self-rated thirst level for the patients with and without DI. Moderate water intake restriction in addition to AVP replacement therapy significantly decreases the incidence of hyponatremia without patient discomfort (extreme thirst) and other complications. However, further studies are required to determine the most effective amount of water and the optimal duration of postoperative water restriction.
Unexpected Ovarian Malignancy Found after Laparoscopic Surgery in Patients with Adnexal Masses –A Single Institutional Experience–

SHIGEKO SAITO, HIROAKI KAJIYAMA, YOKO MIWA, MIKA MIZUNO, FUMITAKA KIKKAWA, SHIHO TANAKA, and TOMOMITSU OKAMOTO
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Laparoscopy has become the standard surgery for the treatment of benign ovarian tumors. The aim of this study was to evaluate the appropriateness of laparoscopy for ovarian tumors, including those with malignant potential. A total of 487 patients with adnexal masses underwent laparoscopic surgery in Social Insurance Chukyo Hospital from January 2000 to December 2012.We reviewed 471 cases that fulfilled the criteria set for this study, and examined 10 cases with unexpected ovarian malignancy to analyze their preoperative diagnosis, second surgery, postoperative chemotherapy, and prognosis. The ages of the 471 patients ranged from 13 to 50 years, with a median of 31. Nulliparous patients numbered 321(68.1%). Of all, 436 patients mostly consisted of those with endometrioma, benign ovarian neoplasm or functional cyst. In all, we histologically identified 10 women with malignancy: 6 with borderline ovarian tumors (BOT), 2 with ovarian cancer, and 2 with histologically rare tumors (immature teratoma and granulosa cell tumor). All patients with BOT were diagnosed with a mucinous histology. Two patients underwent both second radical surgery (hysterectomy and contra- or bilateral salpingo-oophorectomy) and chemotherapies that consisted of CBDCA and PTX or DTX. Thus, 2 patients underwent staging procedures, but the remaining 8 cases did not. None of them had evidence of recurrences. With accurate staging and careful postoperative follow-up, laparoscopic surgery could be a feasible initial operation for patients with adnexal masses including early-stage ovarian malignancy.
External Beam Radiotherapy for Painful Bone Metastases from Hepatocellular Carcinoma: Multiple Fractions Compared with an 8-Gy Single Fraction

SHINYA HAYASHI, HIDEKAZU TANAKA, and HIROAKI HOSHI
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External beam radiotherapy (EBRT) for hepatocellular carcinoma (HCC) bone metastases has not been popular in palliative therapy, and optimum dose schedules have not been decided because of limited published reports. We here evaluated the palliative effect of EBRT for HCC bone metastases and compared the dose–response relationship between multiple fractions (MFs) and an 8-Gy single fraction (SF). Twenty-eight patients (42 sites) with painful bone metastases who received EBRT and were analyzed retrospectively. Eight patients (12 sites) received SF. Of the remaining 20 patients (30 sites), 10 received MFs at moderate doses (20–30 Gy; 17 sites) and 10 received MFs at high doses (36–52 Gy; 13 sites). Overall response was achieved at 83% (35) of all sites; 75% (9) and 87% (26) for the SF and MF patients (88%, moderate dose; 85%, high dose), respectively. No significant differences in overall response were observed between each fraction schedule. Response duration was significantly longer for the high-dose MF patients than for the SF patients and moderate-dose MF patients (P < 0.05). SF was as effective as MF radiotherapy in terms of pain relief, but high-dose MF delivery relieved pain for a significantly longer duration.
The Results of Volar Locking Plate Fixation for the Fragility Fracture Population with Distal Radius Fracture in Japanese Women

SHUICHI KATO, MASAHIRO TATEBE, MICHIRO YAMAMOTO, KATSUYUKI IWATSUKI, TAKANOBU NISHIZUKA, and HITOSHI HIRATA
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The purpose of this study was to determine whether volar locking plate fixation for distal radius fracture benefits the fragility fracture population as much as it benefits the non-fragility fracture population. This matched case-control study was conducted based on a multi-center clinical prospective cohort. A comparison of treatment outcomes after volar locking plate fixation was made between females 55 years of age and older (fragility fracture population) and males less than 75 years of age (non-fragility fracture population) by evaluating clinical, radiological, and subjective outcomes using Hand20, a validated patient-rated disability instrument. A total of 170 patients were enrolled in this study. The two cohorts were matched in terms of AO fracture type. The fragility fracture population group and the non-fragility fracture population group each consisted of 50 patients. All objective measurements including wrist range of motion and radiological evaluations, but excluding grip strength, were not significantly different between the two groups. However, the Hand20 at 18 months after surgery was worse in the fragility fracture population group than in the non-fragility fracture population group. Carpal tunnel syndrome was the most frequently encountered complication in the fragility fracture population group, with one case (2%) in the non-fragility fracture population group and six cases (12%) in the fragility fracture population group, but the difference was not significant. In conclusion, there was a significant deficit in the improvement in disability despite favorable radiological and functional outcomes in fragility fracture population patients. Therefore, the fragility fracture population, especially middle-aged or older women, needs to be informed about prolonged disability and the higher risk of upper extremity disorders prior to surgery.
Polymorphisms of Nrf2, an Antioxidative Gene, are Associated with Blood Pressure in Japanese

YASUHIKO SHIMOYAMA, YOKO MITSUDA, NOBUYUKI HAMAJIMA, and TOSHIMITSU NIWA
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Nuclear factor-erythroid 2 (NF-E2)-related factor 2 (Nrf2) is a transcription factor that regulates the expression of antioxidant genes by activating Nrf2-antioxidant response element (ARE) pathway. This study aimed to investigate association of Nrf2 gene single nucleotide polymorphisms (SNPs), rs35652124 (A→G) and rs6721961 (C→A), with various laboratory data in 464 health evaluation examinees. The genotyping of these SNPs was performed using polymerase chain reaction with confronting two-pair primers (PCR-CTPP) assay. The genotype frequencies of rs35652124 SNP were 21.1% for AA, 44.0% for AG, and 34.9% for GG. The frequency of A allele was 0.431. In male subjects, cholinesterase was significantly high, and HDL cholesterol was significantly low in (AG+GG) carriers. In female subjects, diastolic blood pressure (BP) was significantly low in (AG+GG) carriers. The genotype frequencies of rs6721961 SNP were 55.2% for CC, 34.7% for CA, and 10.1% for AA. The frequency of A allele was 0.275. In male subjects, systolic BP, diastolic BP and cholinesterase were significantly low, and iron was significantly high in (CA+AA) carriers. In female subjects, cholinesterase was significantly high in (CA+AA) carriers, and diastolic BP was significantly high in AA carriers. In conclusion, Nrf2 polymorphisms are associated with BP in Japanese.
A Long-term Follow-up of Patients with Retinopathy of Prematurity Treated with Photocoagulation and Cryotherapy

SAYOKO IWASE, HIROKI KANEKO, CHIEKO FUJIOKA, KOTA SUGIMOTO, MINEO KONDO, YOSHIKO TAKAI, SHU KACHI, and HIROKO TERASAKI
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To evaluate the refractive characteristics of adults diagnosed with retinopathy of prematurity (ROP) treated with ablation treatment as children, we measured best corrected visual acuity (BCVA, logMAR), spherical equivalent refraction (SER), axial length (AL), lens thickness (LT), anterior chamber depth (ACD) and the corneal curvature radius (CCR) from 46 eyes, 24 patients (15–30 years old) that were diagnosed with ROP. Patients were divided into two groups dependent on the size of the treated retina at the time of ablation treatment; i.e., 360° group (treatment over the whole circumference of the retina; n=18) and partial group (treatment over part of the retina; n=28). The study showed that LT was significantly larger (P<1×10–4) and ACD was significantly shorter (P<1×10–3) in 360° group (4.26±0.40 mm and 2.92±0.48 mm, respectively) than those in partial group (3.71±0.34 mm and 3.42±0.26 mm, respectively). However, there were no differences in SER (–6.52±3.54 diopter vs. –5.95±4.12 diopter, P=0.31), AL (23.9±1.42 mm vs. 25.0±1.48 mm, P=0.08) and CCR (7.59±0.37 mm vs. 7.59±0.19 mm, P=0.86). These results indicated that the eyes in the 360° group had larger LTs but did not have extended ALs compared with the partial group.
Factors Associated with Early Postpartum Maternity Blues and Depression Tendency among Japanese Mothers with Full-term Healthy Infants

YUKI TAKAHASHI, and KOJI TAMAKOSHI
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Maternity blues and postpartum depression are common mental health problems during the early postpartum period. However, few studies have examined the factors associated with maternity blues and postpartum depression in healthy mothers with spontaneous births of healthy full-term infants. This study aimed to determine the demographic and obstetric factors, various feelings during pregnancy, and psychological factors by using the Maternity Blues Scale (MBS) and Edinburgh Postnatal Depression scale (EPDS) among healthy Japanese mothers. We distributed the MBS and EPDS self-administered questionnaires to 100 Japanese mothers during their 4–5 day hospitalization and at a health check-up 1-month after delivery, respectively. Multiple regression analyses were performed including the above-mentioned variables as independent variables and the maximum MBS or EPDS scores as dependent variables. The answers “Having a friend I can talk to about maternity life or child rearing” [β (95% confidence interval) = –1.53 (–2.68 – –0.378)] and “Satogaeri bunben”, a Japanese traditional support system wherein a postnatal woman lives with her husband/parents [–2.82 (–4.73 – –0.898)] were significantly associated with MBS scores. The answer “Having a friend I can talk to about maternity life or child rearing” [–2.83 (–4.76 – –0.903)] was also significantly associated with EPDS scores, although the association between the partner’s age and these scores was marginally significant [–0.106 (–0.008 – 0.221)]. This study shows that it is important to provide support for healthy women without delivery complications, both at home and in the community.
Biochemical Staging of the Chronic Hepatic Lesions of Wilson Disease

YOSHIAKI KATANO, KAZUHIKO HAYASHI, AI HATTORI, YASUAKI TATSUMI, JUN UEYAMA, SHINYA WAKUSAWA, MOTOYOSHI YANO, HIDENORI TOYODA, TAKASHI KUMADA, NAOKI MIZUTANI, HISAO HAYASHI, and HIDEMI GOTO
pg(s) 139 - 148

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Background: Copper toxicity steadily affects the livers of patients with Wilson disease. However, the toxic effect of copper on serum aspartate and alanine aminotransferase levels remains to be clarified as a prerequisite for diagnostic tests. The clinical records of 33 cases were analyzed to clarify the natural history of Wilson disease. Phenotypes were simplified into hepatic, acute, and neurologic. The bio-low stage of both enzymes was less than 40 IU/L, the bio-moderate stage was intermediate between 40 and 200 IU/L, and the bio-high stage was more than 200 IU/L of either or both enzymes. Rebounded enzyme levels at the recovery period from anemia were presumed to be the chronic baselines when pre-anemic enzyme levels were not available in the acute phenotype. We investigated whether these enzyme levels may provide information useful for screening patients. The natural history of chronic Wilson disease consisted of the first increasing and second decreasing phases. The clinical courses of a 4-year-old boy and 12-year-old girl were representative of the 2 phases, respectively. All but one patient were in the decreasing phase. Negative correlations were obtained between age and enzyme level in the decreasing phase. The hepatic phenotype may be a prototype found throughout the 2 phases, and acute and neurologic phenotypes may be major complications in the bio-moderate and bio-low stages of the decreasing phase, respectively. Biochemical staging may provide a better understanding of Wilson disease when combined with phenotypes. Bio-high stage patients should be referred to a medical center for diagnosis.
Rat model demonstrates a high risk of tremolite but a low risk of anthophyllite for mesothelial carcinogenesis

DILINUER AIERKEN, YASUMASA OKAZAKI, SHAN HWU CHEW, AKIHIRO SAKAI, YUE WANG, HIROTAKA NAGAI, NOBUAKI MISAWA, NORIHIKO KOHYAMA, and SHINYA TOYOKUNI
pg(s) 149 - 160

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Asbestos was abundantly used in industry during the last century. Currently, asbestos confers a heavy social burden due to an increasing number of patients with malignant mesothelioma (MM), which develops after a long incubation period. Many studies have been conducted on the effects of the asbestos types that were most commonly used for commercial applications. However, there are few studies describing the effects of the less common types, or minor asbestos. We performed a rat carcinogenesis study using Japanese tremolite and Afghan anthophyllite. Whereas more than 50% of tremolite fibers had a diameter of < 500 nm, only a small fraction of anthophyllite fibers had a diameter of < 500 nm. We intraperitoneally injected 1 or 10 mg of asbestos into F1 Fischer-344/Brown-Norway rats. In half of the animals, repeated intraperitoneal injections of nitrilotriacetate (NTA), an iron chelator to promote Fenton reaction, were performed to evaluate the potential involvement of iron overload. Tremolite induced MM with a high incidence (96% with 10 mg; 52% with 1 mg), and males were more susceptible than females. Histology was confirmed using immunohistochemistry, and most MMs were characterized as the sarcomatoid or biphasic subtype. Unexpectedly NTA showed an inhibitory effect in females. In contrast, anthophyllite induced no MM after an observation period of 550 days. The results suggest that the carcinogenicity of anthophyllite is weaker than formerly reported, whereas that of tremolite is as potent as major asbestos as compared with our previous data.
Dimensions of Women’s Empowerment and Their Influence on the Utilization of Maternal Health Services in an Egyptian Village: A Multivariate Analysis

LEO KAWAGUCHI, NAWAL ABDEL MONEIM FOUAD, CHIFA CHIANG, INASS HELMY HASSAN ELSHAIR, NAGAH MAHMOUD ABDOU, SANEYA RIZK EL BANNA, and ATSUKO AOYAMA
pg(s) 161 - 171

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This study investigated the association between women’s empowerment and the utilization of maternal health services by women in Egypt and analyzed the dimensions of women’s empowerment that are associated with increased health service utilization. A cross-sectional survey was conducted in a village in Egypt in November 2007. A total of 189 women, who had ever been married and had at least one child, were interviewed to collect data on the utilization of maternal health services, such as the number of antenatal care (ANC) visits during their pregnancies and whether delivery of their child was attended by skilled health personnel. Proxy variables on five different dimensions of women’s empowerment were obtained by principal component analysis, and were tested for an association with the utilization of maternal health services, using logistic regression models. The five dimensions extracted from the data were freedom of movement, economic security and stability, support by family and freedom from domination, decision-making in daily life, and relationship with the community / participation in society. Among these dimensions, support by family and freedom from domination was the only factor that was positively associated with maternal health service utilization (regular ANC: OR=1.38, P=0.05; deliveries assisted by skilled health personnel: OR=1.71, P=0.01). Current age was also associated with the latter, possibly influenced by the recent rapid increase in the provision of health services in the village studied. Furthermore, this study revealed that a relatively high proportion of younger women still only limited access to maternal health services in Egypt.

Case Reports

Multidisciplinary Management of Small Cell Carcinoma of the Breast: A Case Report

TORU MURATA, MASAHIRO FUJII, KAZUHISA AKAHANE, KOJI ODA, TOSHIHIRO OHAMA, YASUSHI YATABE and KENJI KAWADA
pg(s) 173 - 180

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We report a case of primary small cell carcinoma (SCC) of the breast in a 59-year-old female. To the best of our knowledge, there are only 44 cases of this disease reported in the English literature. The patient also had regional nodal metastases, but no distant metastases. She underwent neoadjuvant chemotherapy according to a regimen of pulmonary SCC, and combination of cisplatin and etoposide (CDDP+VP16). The tumor partially responded to neoadjuvant chemotherapy. The treatment was followed by modified radical mastectomy and adjuvant chemotherapy, i.e., EC therapy (epirubicin and cyclophosphamide). She was also administered in total 50 Gy of radiation treatment to the chest wall. At this writing, the patient has evidenced no recurrence 36 months after her diagnosis.
Human Laryngitis Caused by Clinostomum Complanatum

HIROTAKA HARA, YUJI MIYAUCHI, SHINSAKU TAHARA, and HIROSHI YAMASHITA
pg(s) 181 - 185

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A 64-year-old Japanese man visited our outpatient department complaining of an irritable sensation in the throat, occurring two days after eating raw freshwater fish (carp sashimi) at a Japanese-style inn. During laryngeal endoscopy, a slow-moving worm (fluke) was found attached to the surface of the right aryepiglottic fold. After inhalation of 4% lidocaine, the fluke was removed using endoscopic forceps. Patient’s throat symptoms immediately improved. The worm was microscopically identified as Clinostomum complanatum. C. complanatum is a digenetic trematode that usually infects fish-eating water birds. Clinostomum infections in humans are rare, and only 21 cases have been described in Japan and Korea. C. complanatum infection is known to occur after eating raw freshwater fish, which is a secondary intermediate host. In humans, the metacercariae are released into the stomach and migrate through the esophagus before lodging in the throat. Primary therapy involves endoscopic removal of the worm.
Gamma Knife Radiosurgery of Brain Metastasis from Malignant Pleural Mesothelioma – Report of Three Cases with Autopsy Study in a Case –

TATSUYA KOBAYASHI, TAKAHIKO TSUGAWA, CHISA HASHIZUME, TAKANOBU TORIYAMA, MASAMI ASAI, YOSHIMASA MORI, and YUTA SHIBAMOTO
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The median survival time of malignant pleural mesothelioma (MPM) has been 9 months. Given the short survival, there have been only few cases in which brain metastases have been diagnosed and treated before death. Three cases of brain metastases treated by gamma knife radiosurgery (GKR) are reported. Case 1 showed a metastatic lesion in the right frontal lobe which was treated by GKR two years after diagnosis of MPM. The lesion markedly reduced and the symptoms were improved, But the patient died of progression of pleural tumor four months after GKR. A year and three months after the diagnosis, asymptomatic bifrontal lesions were treated with GKR. However, Case 2 died of abdominal mass a month after. Case 3 showed headache one and half year after the diagnosis. Three brain lesions were treated by GKR, which disappeared in 4 months. The patient died of new multiple brain metastases and periventricular dissemination seven months after. The autopsy revealed a MPM occupying the left pleural cavity. No neoplastic lesion was found in gamma knife-treated sites. The cause of death was the mass effect by new metastatic lesions. GKR was found effective also for the treatment of brain metastasis of MPM.
Chronic Spontaneous Lumbar Epidural Hematoma Simulating Extradural Spinal Tumor : A Case Report

HIROKI MATSUI, SHIRO IMAGAMA, ZENYA ITO, KEI ANDO, KENICHI HIRANO, RYOJI TAUCHI, AKIO MURAMOTO, TOMOHIRO MATSUMOTO, and NAOKI ISHIGURO
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Spinal epidural hematoma (SEH) is an uncommon disorder, and chronic SEHs are rarer than acute SEHs. However, there is few reported involving the bone change of the vertebral body in chronic SEHs. We present a case report of lumbar epidural hematoma that required differentiation from extramedullary spinal tumors by a long process because the CT scan revealed scalloping of the vertebral body and review the relevant literature. A 78-year-old man had experienced a gradual onset of low back pain and excruciating pain in both legs. Lumbar MRI on T1-weighted images revealed a space-occupying lesion with a hyperintense signal relative to the spinal cord with no enhancement on gadolinium adminisration. Meanwhile, T2-weighted images revealed a heterogeneous intensity change, accompanying a central area of hyperintense signals with a hypointense peripheral border at the L4 vertebra. Moreover, the CT scan demonstrated scalloping of the posterior wall of the L4 vertebral body which is generally suspected as the CT finding of spainal tumor. During the epidural space exploration, we found a dark red-colored mass surrounded by a capsular layer, which was fibrous and adhered to the flavum and dura mater. Microscopic histological examination of the resected mass revealed a mixture of the relatively new hematoma and the hematoma that was moving into the connective tissue. Accordingly, the hematoma was diagnosed as chronic SEH. The particular MRI findings of chronic SEHs are helpful for making accurate preoperative diagnoses of this pathology.
Intraoperative Migration of the Trial Femoral Head into the Pelvis during Total Hip Arthroplasty –Report of Two Cases–

KAZUMA IKEUCHI, YUKIHARU HASEGAWA, HIDEKI WARASHINA, and TAISUKE SEKI
pg(s) 203 - 210

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Various complications occur during total hip arthroplasty (THA). It is common to implement trial treatments of various implants during THA. Here we report on 2 cases in which the trial femoral head fell into the pelvis and migrated during THA. The trial head was not retrieved but left inside in one case, while the other presented the opportunity for a possible retrieval. It is important to recognize the existence of such rare complications.
Partial Necrosis of the Lunate after a Translunate Palmar Perilunate Fracture Dislocation

MAO AKANE, MASAHIRO TATEBE, KAZUHITO IYODA, KYOTARO OTA, KATSUYUKI IWATSUKI, MICHIRO YAMAMOTO, and HITOSHI HIRATA
pg(s) 211 - 216

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We present an extreme rare case of traumatic partial avascular necrosis of the lunate after palmar perilunate dislocation with lunate fracture. A 32-year-old female was injured by motorcycle accident with palmar perilunate fracture dislocation and lunate fracture. Scapholunate and lunotriquetrum dislocations were reduced and fixed temporarily. The torn dorsal ligament was repaired. Considering close observation with both arthroscopy and fluoroscopy, we decided not to conduct open reduction and internal fixation for the lunate. Partial avascular necrosis of the lunate appeared gradually in follow-up.
Recurrence of Solitary Fibrous Tumor of the Cervical Spinal Cord

KAZUYOSHI KOBAYASHI, SHIRO IMAGAMA, ZENYA ITO, KEI ANDO, JUNICHI UKAI, AKIO MURAMOTO, RYUICHI SHINJO, TOMOHIRO MATSUMOTO, HIROAKI NAKASHIMA,YUKIHIRO MATSUYAMA, and NAOKI ISHIGURO
pg(s) 217 - 223

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Solitary fibrous tumor (SFT) mostly originates from the pleura because of proliferation of fibroblast cells. It is extremely rare for the tumor to originate from the spinal cord. Here, we report a rare case of SFT in the spinal cord that recurred repeatedly and progressed from intramedullary to extramedullary. A 40-year-old man underwent C4-5 intramedullary and extramedullary tumor resection in another hospital. Eighteen years later, he experienced symptoms of myelopathy because of tumor recurrence; therefore, he consulted with our hospital and underwent tumor resection again. During surgery, we found that the tumor had an intramedullary and extramedullary location. Only partial resection was possible because of intraoperative deterioration in the compound motor action potential (CMAP). After resection, the pathological diagnosis was SFT. The postoperative course was good. However, two years later, a third tumor resection was required because of dysuria and tumor growth. In this surgery, total resection of the tumor was possible without intraoperative deterioration of the CMAP. The tumor has not subsequently recurred. However, SFT recurrence is relatively common and careful follow-up is required for early detection of recurrence, even after successful removal of the tumor.
A Case of Mediastinal Embryonal Carcinoma Successfully Treated by Integrative Therapy

KATSUHISA KAWANAMI, NORIMITSU WAKAO, MITSUHIRO KAMIYA, MIKINOBU TAKEUCHI, ATSUHIKO HIRASAWA, EMIKO TAKAHASHI, and KEIJI SATO
pg(s) 225 - 233

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Mediastinal embryonal carcinoma is rare, and the life prognosis of this disease is assumed to be relatively short. We encountered a case of mediastinal embryonal carcinoma for which we could perform radical surgical resection. The patient was male, aged 16 years, and acutely aware of back pain. Because the pain increased during the same year, he visited a local doctor, and an expanding neoplastic lesion was detected in the right thoracic wall by computed tomography (CT). Then he was referred to our institution. Magnetic resonance imaging (MRI) showed a dumbbell type tumor (Eden type 3) at the Th7/8 level. Malignant disease was suspected, so the authors planned and performed CT-guided biopsy. The result showed that this tumor pathologically corresponded to malignant peripheral nerve sheath tumor (MPNST). Therefore, chemotherapy was considered the main treatment. After 2 courses of chemotherapy, the tumor size decreased dramatically. The authors thought that radical resection is possible if there is no intrathoracic tumor dissemination as a result of a favorable response to chemotherapy. We thus perfomed surgical resection after we confirmed by a thoracoscopic exploratory thoracotomy that there was no intrathoracic tumor dissemination. Pathological findings were consistent with an embryonal carcinoma. Both the cutting ends of the thoracic wall and the epidural lateral sides of the excised lesion were negative for tumor cells. There is no image finding from the MRI and PET-CT suggesting metastasis or recurrence in the MRI and PET-CT 18 months after surgical resection. Therefore, the long-term vital prognosis can be expected in this patient.