Collaboration between Hepatologists and Primary Care Physicians in Treating Patients with Chronic Hepatitis C / Journal of Rural Medicine

<b>Objective:</b> The purpose of this study was to assess the treatment outcome in patients with chronic hepatitis C (CHC) using the current standard antiviral therapy when patient were treated in collaboration between hepatologists and primary care physicians (PCPs).<b>Patients and Methods:</b> One hundred and ten patients with CHC were treated with a combination therapy of peginterferon-alpha 2b and ribavirin. Among them, 25 patients were treated by a collaboration between hepatologists and PCPs (collaboration group), whereas 85 patients were treated with exclusively by hepatologists (noncollaboration group). The duration of the therapy was 48 weeks for 58 'difficult- to-treat' patients (genotype 1 with a high load of HCV-RNA; 1H patients) and 24 weeks for the remaining 52 patients (non-1H patients). In the collaboration group, antiviral therapy was initiated and adjusted, if needed, by hepatologists (visits every four weeks), whereas the weekly administration of peginterferon-alpha 2b was performed by PCPs. Clinical characteristics and the treatment outcome were compared between these two groups.<b>Results:</b> The two groups had similar baseline characteristics. By intention to treat, the two groups showed similar rates of treatment-related serious adverse effects (0% vs. 1%, respectively) and dropout rates for adverse effects (8% vs. 13%, respectively). Sustained virologic response rates were also similar between the two groups, being 42% vs. 39% in the 58 1H patients (NS) and 62% vs. 64% in the 52 non-1H patients (NS), respectively.<b>Conclusions:</b> Collaboration between hepatologists and PCPs may be a valid treatment alternative to treat patients with CHC using the current standard antiviral therapy.

Nosocomial Infection Management Using Web Site established in the LAN / 日本農村医学会雑誌

Nosocomial infection management is one of the most important subjects in terms of risk management in a hospital. To achieve the nosocomial infection management appropriately, both public relations and information gathering are important. When it comes to publicity, it is desirable that information is offered quickly and efficiently and the personnel are able to access the information easily anytime and wherever they are. As for information gathering, it is also important to collect the information concerning the nosocomial infection promptly, and to tell it quickly to infection management persons including infection control team members. The infection control committee of our hospital has engaged in both publicity and information gathering by using the committee web site established in the LAN of the hospital since January 2004. The web site carries notifications, organization chart, list of committee members, various manuals, guidance of educational activities, infection management, etc. It is also used for questions and answers, and gathering information concerning nosocomial infection. The number of times the web site was accessed was about 200 every month, and was considerable at night and on holidays. This method of using the web site seems to be useful to promote nosocomial infection management.

Hepatitis C Virus Infection in Outpatient Clinic / 日本農村医学会雑誌

The whole spectrum of patients infected with hepatitis C virus (HCV) who visited hospitals has not been fully clarified. It is also unknown whether such patients have visited the hospitals regularly thereafter for a long period. We studied 844 consecutive patients with liver diseases who visited our outpatient clinic located in the southern region of Ibaraki Prefecture. Five hundred eighty-three patients were HCV-infected. Among them, three patients were HBsAg-positive and another patient was IgM anti-HAV positive. Thus, 579 patients (68.6%) were considered to have HCV solely as a hepatotropic virus.Of these HCV patients, 60 were asymptomatic carriers and 15 others were unclassified because of the absence of either biopsy or imaging test records of the liver. As to the rest of the HCV patients, acute hepatitis was diagnosed in one patients, chronic hepatitis in 332 patients, cirrhosis in 130 patients and cancer of the liver in 41 patients.About half of the patients undergoing liver biopsy showed F1 in the degree of liver fibrosis. The rate of virological response to interferon mono-therapy in patients infected with genotype 2 was worse than the national average. The poor response was considered to be due to high viral load. It was suggested that the distribution of patients with each genotype was uneven in this region. After five years, the rate of patients still visiting our clinic were 68.1% for those with chronic hepatitis, and 50% for the healthy carriers. We deemed that it was important to clarify whether patients not visiting our clinic are followed up closely in other hospitals.

Analysis of Risk Factors in Lifestyle-related Disease in Farmers who Received Health Checkups in Our Agricultural Health Care Center / 日本農村医学会雑誌

Lifestyle-related diseases are defined as diseases which have close relations to indivisual lifestyle. The Agricultural Health Care Center in our hospital has been performing health checkups for 5, 000 members every year. However, analysis of data obtained has not been effectively used for the purpose of prevention of disease and health promoting education. Therefore, we built up data-base and analysed risk factors in lifestyle-related diseases. Results; 1) Total-cholesterol (T-Chol) level was higher in females than in males. The level of T-Chol showed a tendency to decrease in males and to increase in females with in creasing age. 2) Triglyceride (TG) level was higher in males than in females. TG level was most highest in younger males. 3) Blood pressure (BP) was higher in males than in females and elevated as their ages increase in both sexes. 4) HDL-cholesterol was lower in males than in females. 5) Diabetic pattern in blood suger (GL) level was more common in males than in females. 6) The incidence of obesity was slightly higher in males than in females. 7) Individuals with more than two risk factors accounted for 26% of the total. The Percentege for men alone was 31% which was higher than that for women. The education and advise to correct bad habits for prevention of diseases appear to be neccesary especially for males who are at higher risk than females are.

Gender Difference in Clinical Manifestations and Outcomes of Acute Myocardial Infarction / 日本農村医学会雑誌

There are many acquired and hereditary coronary risk factors, and the gender is known as a factor influencing the development of acute myocardial infarction (AMI). To evaluate the role of the gender in the occurrence of AMI, we compared patient backgrounds, their clinical manifestations, outcomes, and coronary angiographic findings between 390 male and 110 female AMI patients, who had been admitted to the coronary care unit (CCU) of the Tsuchiura Kyodo General Hospital and undergone coronary angiography on an emergency basis. The incidence of AMI was the highest in the age group of 60s for males, while for females in the age group of 70s. As coronary risk factors, smoking habit was more common in males, while hypertension, hyperlipidemia and diabetes meritus were more common in females. Coronary angiograms revealed no differences in the number of diseased vessels and location of infarction. Frequencies of urgent PTCA were also identical between the two groups. In clinical outcomes, elder females had poorer prognosis mainly due to a higher incidence of death caused by cardiac rupture. It has been reported that definite increase of AMI after menopause is attributable to disturbed lipid metabolism due to a reduced estrogen level. Our study showed that aged female AMI patients had poorer prognosis possibly due to associated multiple risk factors, mutiple organ disorders and delayed admission to hospital and higher risk of cardiac rupture. Therefore, in the treatment of aged female AMI patients, these tendencies must be taken into account.

Sudden Death in a Rural Area. Investigation into DOA and Autopsy Records / 日本農村医学会雑誌

Sudden death (SD), which unexpectedy occurs in the middle aged and the elderly, is a subject worth studying. Much about the cause of the demise remains shrouded in mystery from the standpoint of medicine and has a significantly great impact on the community.<BR>We conducted a fact-finding survey of SD by gathering data on dead-on-arrival (DOA) cases stored by five general hospitals affiliated with the National Welfare Federation of Agricultural Cooperatives. Examined were 292 DOAs that were registered between January 1993 and December 1993 and autopsy findings of 45 cases obtained from one of the hospitals over the past eight years. The results are summed up as follows:<BR>(1) The largest number of DOA cases was found in the age group of 70 to 79 years. About half of the total number was accounted for by people older than 70.<BR>(2) Cardiovascular disease topped the list of causative and basal ailments that might have led to SD. Especially ischemic heart disease was evident in many cases.<BR>(3) In many cases, death occurred during sleep or at rest.<BR>(4) Cardiopulmonary resuscitation was performed according to rule on most of the victims, but the priamry resuscitation ratio came out at 26%.<BR>From these observations, we concluded that for the prediction and prevention of SD and DOA it is necessary to work on measures to help prevent and cure ischemic heart disease.

Workload of Lotus Growers and Their Health Management / 日本農村医学会雑誌

In a series of studies of the workload of lotus growers and their health condition, we checked up on the results of group health screening of lotus growers in comparison with those of other farmers among Tsuchiura agricultural cooperative members in 1992. During that year, we also carried out a time study of lotus cultiration from planting through harvesting. In 1993, we investigated the lifestyle and behavioral pattern of lotus growers. In 1994, an index of cummulative fatigue symptoms was made for lotus growers and loads exerted on their circulatory system were examined.<BR>These studies brought to light hard facts about lotus growing. The farmers have to work in muddy fields laboriously, and for many hours at that, planting in the hottest season and harvesting in the coldest season for many hours. Even when they feel ill, they cannot afford to leave toiling off for their health. We found many signs and symptoms of physical disorder resulting from overwork and peculiar to lotus growing. To improve the working conditions of lotus growing, we recommended the use of the lotus center as a labor saving mode of work so as to facilitate the introduction of power harvesters or the use of greenhouses.<BR>Although there are many socioeconomic issues such as aging of the farming populace, lack of successors and decline in agricultural economy, we will continue to make efforts at health control to protect the health and welfare of farmers by accumulating our knowlege through studies of the state of lotus farming and the health condition of the lotus farmers in other areas as well.

Distribution of Cases of Hepatitis C Virus Infection by Subtypes and Results of Interferon Therapy in the Southern Region of Ibaraki Prefecture / 日本農村医学会雑誌

It has been made known that there isn't any significant regional difference in the frequencies of cases of viral hepatitis C by subtypes in our country. In the present study we investigated the subtypes in hepatitis C virus carring patients without blood transfusion history in the southern region of Ibaraki Prefecture to clarify the occurrence ratio of each subtype of the virus. The results of interferon therapy were also examined in those patients with chronic hepatitis C. The frequencies of subtypes 2, 3 and 4 were found to be 71%, 16% and 10%, respectively. Although these ratios were the same as the national average, a significantly high frequency (P>0.01) of subtype 3 was observed in the patients from Tsuchiura in the region, suggesting that there may have existed some particular source of infection other than blood transfusion. The effectiveness of interferon therapy was significantly higher (P>0.01) in the patients with subtype 3 (75%) than in those patients with subtypes 2 and 4 (23% and 43%, raspectively), suggesting that interferon is a remedy specific to subtype 3.

Physical Stress of Lotus Growers and Their Health Control. Assessment of Cardiovascular Overload / 日本農村医学会雑誌

During winter months, lotus growers have to harvest edible roots, waist-deep in the muddy fields. In addition to such an external factor as the cold, physical labor involved is so hard that a level of stress is considered high, especially on the cardiovascular system. In this study, we examined how hard the labor is on the cardiovascular system, based on the measurements of hemodynamic parameters taken in the fields while farmers were working. The subjects were comprised of a total of 18 lotus growers-11 men and 7 women-aged between 41 and 66 years (mean: 56.7 years old). During a week before the measurement was performed, a physical examination and an anaerobic threshold (AT) test were given. In the field, each examinee carried an ambulatory electrocardiograph with him or her and levels of blood Pressure (BP), heart rate (HR), and blood saturation-O<SUB>2</SUB> (SO<SUB>2</SUB>) were measured. During work, the heart rate was elevated significantly, but did not exceed the evaluated maximum heart rate in every case. Immediately after the work, the HR returned to the level measured before the work began. No significant fluctuation was noted in BP, pressure-rate-products (PRP) and SO<SUB>2</SUB> even during the work. Any sign associated with ischemia was not observed on ECG, either. Soon after the work began, the blood pressure level tended to lower in women compared with that in men and the PRP did not rise in women so much as it did in the opposite sex. However, in two elderly subjects of over 60 years, arrhythmia was noted along with the elevation of blood pressure soon after the stop of the work. These results showed that harvesting lotus roots did not bring about marked changes in the hemodynamic parameters and that the caraiovascular load was slight. However, an adequate health control system should be worked out for the lotus growers of advanced age over 60.

Effects of Assisted Kinesitherapy in Myocardial Infarction Patients during Convalescence / 日本農村医学会雑誌

As part of the rehabilitation program for myocardial infarction patients, assisted exercise under the eye of therapists is an effective rehabilitation therapy during the period from hospital discharge to the returning to work. Regrettably, however, this part of the program is not put into regular practice in rehabilitation centers yet.<BR>Under the circumstances, we have conducted this type of therapy for myocardial infartion convalescents, and assessed it significance and benefits by examining therapeutic effects and changes in the endurace test results as well as changes in the cardiac output during exercise.<BR>In this study, we used data obtained from 25 out of the 68 acute myocardial infarction patients treated in the coronary-care unit of our hospital between Nov. 1, 1990 and May 31, 1992.<BR>Exercises were performed three times a week for eight to 12 weeks, kinetic intensity correspond-ing to 70-80 % of the highest heart rate in stress tests. The heart rate, blood pressure and cardiac output were measured based on ECG recordings.<BR>As a result, it was found that the kinesitherapy helps (1) increase the tolerability to exercise, (2) lower the heart rate, blood pressure and double product and (3) elevate the stroke volume index during exercise.<BR>From these findings, it is safe to say that the kinesitherapy can be given to myocardial infarction victims without causing them anxiety and is very helpful for them to restore good health and normal cardiac function and to resume their place in society.

Prediction of cerebral apoplexy - Survey results / 日本農村医学会雑誌

Cerebrovascular disease is still considered a serious health problem in Japanese rural areas. The rate of death from the disease is very high. Many clinical and epidemiological studies have been conducted so far. However, they have failed to come up with answers effective for prediction and prevention of the scourge.<BR>As part of the agricultural coop commissioned research project entitled “Study of Cerebral Apoplexy: Its Prediction and Prevention, ” we took a questionnaire survey in 1985-86, to obtain data as regards patients' subjective symptoms, electrocardiographic observations, hematological findings and many others before the onset of cerebral apoplexy. Five medical research institutes affiliated with the national welfare federation of agricultural cooperatives responded to our questionnaire.<BR>As a result, the subjective symptoms that showed stochastically significant increases from one year to three months before the onset of the disease as a whole were fatigue, forgetfulness and insomnia. When it comes to cerebrovascular infarction, shortness of breath, angina, forgetfulness, and nocturia were particularly notable.<BR>All these symptoms are not peculiar to cerebral apoplexy, but it should be noted that these are the warning signals of the killer disease.

Stroke onset and heart disease / 日本農村医学会雑誌

Generally, valvular heart disease, pacemaker implantation and atrial fibrillation are considered to have some relationship to the onset of stroke, because of their tendency for intracardiac thrombus formation. But the factors which influence the stroke onset have not be clarified precisely. We examined underlying heart disease in patients with cerebral infarction whose clinical courses could be known clearly. Heart diseases were complicated in 11 cases of 25 patients with stroke. Tcese 11 cases consisted with myopathy (3 cases), valvular heart disesase (3 cases), pacemaker implantation (2 cases) and others (3 cases). In 14 cases with intracardiac thrombus, only 3 cases were revealed to become stroke. In 122 pacemaker implanted patients, 6 cases were died with stroke. Risk factors and genetic analysis of lipids were evaluated in both cerebral infarction and myocardial infarction. Although the rate of complication with hypertension was significantly higher in both cerebral infarction and myocardial infarction than in normal controls, the rate of complication with hyperlipidemia was lower in cerebral infarction. As the some specific genotypes of Apo-E were seen in myocardial infarction, they were never seen in cerebral infarction.

Prediction of impending attacks of cerebral stroke in rural areas and their prevention / 日本農村医学会雑誌

Cerebral stroke in rural areas is a very important disease both from medical and social aspects. Among strokes, infarction which occurs most frequently in elderly persons is liable to result from atherosclerosis. And for the development of atherosclerosis, essential hypertension is the most important predisposing factor. Other than hypertension, aging, diabetes mellitus, hyperlipemia, esp. low HDL/Tch ratio, increased hematocrit values, coronary insufficiency, cardiac failure, arythmia, esp. atrial fibrillation, are also accepted important risk factors. Affirmative of such findings, the authors are convinced of the fact that atrial fibrillation which is increasing recently is closely related to both cerebral thrombosis and embolism.<BR>But, in regard to cerebral infarction no signifying or trigger factor, similar to very high blood pressure, that trigger cerebral hemorrhage, is clarified as yet. It is made clear in this connection that cardiac failure predisposed by hypertensive heart disease in old age, assisted by pathophysiological and other environmental conditions, is the important factor. The authors also studied the clinical predisposing parameters and preventive measures about strokes.

Low back pain in cases of multiple myeloma / 日本農村医学会雑誌

We reviewed a total of 23 cases of multiple myeloma that were treated in our hospital during the six-year period between January 1978 and December 1983. It was found that the majority of the multiple myeloma patients (52.2%) had complained of pain in the lumbar spine area when they visited our office. It was also made clear that it had taken considerably long before definitive diagnosis for those patients with low back pain when compared with the patients with other complaints.<BR>Furthermore, we went over the results of some of the routine tests conducted at their first visits. These tests are often included in the mass health screening program.<BR>We found that ZTT levels were abnormal in 90.9% of the multiple myeloma patients, Ch-E in 82.6% and A/G ratio in 73.9%.<BR>These resuits suggest that doctors should suspect multiple myeloma and indicate further examinations when ZTT values were found abnormally high or low among elderly people complaining of low back pain by clinial or mass health examination.