Improvement of NASH with two-year treatment with oral polyenephosphatidylcholine / Journal of Rural Medicine

A 46-year-old female patient with non-alcoholic steatohepatitis (NASH) was administered nateglinide, an insulin secretagogue, for 7 months, and then polyenephosphatidylcholine, an anti-oxidant medication, in accordance with the two-step hypothesis of NASH, with insulin resistance as the initial pathogenesis and oxidative stress as the second. HOMA-R, an index of insulin resistance, improved, and hepatic marker levels improved markedly by four weeks after initiation of polyenephosphatidylcholine. The beneficial effects of treatment continued over the 24 months of the study. A liver biopsy evaluated using Brunt's criteria showed improvement from stage 2 to stage 0 after 9 months. These findings suggest the therapeutic efficacy of step by step treatment of NASH in accordance with the two-stage hypothesis.

Prevalence of Metabolic Syndrome in Rural Populace: A Study of Its Association With Adipocytokines / 日本農村医学会雑誌

The purpose of this study was to shed light on the prevalence of the metabolic syndrome (MetS) in a rural community and examine whether or not serum adipocytokine levels are associated with the Diagnostic Criteria for MetS and how many MetS components laid down in the standards subjects have. The subjects were 2,858 people (1,744men and 1,114 women, mean age 49.8+/-9.9 yrs) who had participated in our health screening program between April and December, 2005. After obtaining informed consent from them, we measured serum leptin, adiponectin and high-sensitivity C-reactive protein levels, while performing routine blood tests. In the present study, these measurements were used in combination with the number of MetS components applicable to the conditions of our subjects. Two hundred men (11.5%) and 25 women (2.2%) were diagnosed with MetS. The number of MetS women was extremely small. Those women who were above the standard waist circumference of above 90cm accounted for 8.7% of the total. Thus, most women subjects were excluded as MetS candidates here. The leptin levels of the MetS group were higher than those of the non-MetS group in accordance with the number of applicable components in the diagnostic standards for MetS. Especially, the MetS group which met three MetS criteria showed significantly high leptin levels (p/5=0.0081) of 5.26+/-1.86 (ng/ml) compared to 3.31+/-1.44 (ng/ml) of the non-MetS group with waist circumference below 85cm. On the other hand, no significant difference was noted between the groups in adiponectin level. However, in contrast to leptin levels, adiponectin levels were lower in the group having three MetS components than the non-MetS group 4.37+/-1.57 (ng/ml) as against 5.52+/-3.34 (ng/ml). High-sensitivity CRP levels did not show any significant difference between the two groups.As regards the cutoff value of women's waist circumference, further study needs to be done. It was suggested that serum leptin levels might be closely related to the diagnostic criteria for MetS and the number of MetS components applicable.

Evaluation of the Appropriateness of the Japanese Metabolic Syndrome Diagnostic Criteria on Routine Medical Health Checkups in a Rural Area / Journal of Rural Medicine

Objective: The diagnostic criteria for the metabolic syndrome (MetS) were published in Japan in April 2005. However, there have been no large-scale studies in rural areas to confirm these criteria. We examined the prevalence of MetS in subjects who had undergone a routine medical health checkup at our hospital, located in a rural area. This data was used to investigate the appropriateness of the diagnostic criteria for MetS.Subjects and Methods: The MetS status was examined retrospectively in 2340 subjects (1408 men, 932 women ; mean age 49.6 ± 9.7 years) who underwent a routine medical health checkup at our hospital between April 2004 and March 2005.Results: Of the 1408 men and 932 women, 209 men (14.8%) and 23 women (2.5%) were diagnosed with MetS. Forty-four men (3.1%) and 4 women (0.4%) met all three diagnostic criteria for metabolic disorders. In the female group, only 8.7% of the 932 women met the waist circumference criterion of ≥90 cm. Because this waist circumference criterion was used during the first screening but was not met by most of the women, they were eliminated from our study. Using receiver operating characteristic (ROC) analysis, the cutoff values for waist circumference were 85.0 cm (sensitivity 0.750, specificity 0.564) in men and 79.5 cm (sensitivity 0.787, specificity 0.709) in women. If the women's waist circumference criterion had been set at the value of ≥79.5 cm, this would have resulted in 48 (5.2%) women meeting the criterion.Conclusion: From the viewpoint of preventive medicine, the Japanese male MetS diagnostic criteria are fairly appropriate. However, for the women, the waist circumference criterion of ≥90 cm has been set too high and was not met by most of the female subjects. Therefore, the Japanese MetS criteria for women, particularly the cutoff value for waist circumference, requires further verification.

2005 Questionnaire Survey on Non-Smoking at Public Places, Schools, Nursery Schools and Post Offices in Mizunami (Comparison with 2004 Survey) / 日本農村医学会雑誌

This paper reports the findings of a follow-up survey on non-smoking carried out in 2005. The previous survey was conducted in 2004 by distributing questionnaires to public facilities, schools, nursery schools and post offices in Mizunami. Method:The questionnaires consisted of the same questions as the previous ones and were sent to the same 64 facilities. Results:The questionnaires were recovered from 59 facilities(92.2%). Compared with the results of the previous survey, the number of public facilities, schools, offices and resting rooms where smoking is totally prohibited increased. In post offices, smoking corners disappeared. Progress was also made remarkably in division of public space and a workplace into smoking and nonsmoking areas. The smoking ratio of employees in these facilities surveyed decreased from 20% to 17%. Conclusion:Our survey confirmed that nonsmoking has steadily won public acceptance in a matter of one year.

Effects of Vaccination Against Influenza Administered by Our Hospital: A 3-Year Retrospective Study / 日本農村医学会雑誌

To review the outcome of our vaccination program against influenza, an investigation was made into the incidence of this acute infectious disease in our community from 2002 through 2004.Enrolled for this retrospective study were 1) all vaccinated individuals, 2) those who underwent nasal examinations by use of the swab, and 3) patients diagnosed as contracting influenza.The number of those administered with influenza virus vaccines increased year after year during the period under review. Over 70% of them were those aged 65years or above. The mean age of those who caught influenza was 42.9±21.3 in 2002, 34.9±20.4 in 2003 and 45.4±20.2 in 2004. Compared with unvaccinated old people, many unvaccinated young and middle-aged people contracted influenza, but among the vaccinated old people, there were some who came down with the flu.Morbidity was low for the old people whose vaccination rate was high.Therefore, it can be said that vaccination was effective in achieving adequate immunity. Nonetheless, for all the preventive injection, the fact that people of advanced age could be infected should be taken note of.

Results of Questionnaire Survey on Cigarette Smoking in Public Facilities / 日本農村医学会雑誌

To investigate the attitude of personnel at public facilities toward cigarette smoking, a poll was taken at 27 municipal facilities, 14 schools, 15 nursery schools, and 10 post offices in Mizunami City. Questionnaires were distributed to a total of 936 employees, asking them whether they smoke and whether their workplaces are divided into smoking and nonsmoking areas.All the questionnaires were collected, with the names of facilities entered. Of the pollees, 20.0% was found smokers. At about 80% of the facilities surveyed, smoking was prohibited at offices and resting rooms for employees. As it turned out, nosmoking zones were limited to only 30% of public space utilized by citizens. At most of the nursery schools surveyed, smoking was banned, but in many schools, smoking was not prohibited in the resting rooms for the teaching and clerical staff. Post offices, compared to the other facilities surveyed, were too lax in regulating smoking. The survey also found that less than half of the facilities have a good knowledge of Article 25 of the Health Promotion Law.The findings of the latest survey were such that we deemed it necessary to conduct more positively a campaign against smoking in public facilities open to local residents.

Danger of Saponated Cresol Solution in the Tohno Area ; / 日本農村医学会雑誌

We experienced a clinical case of a patient with psychotic depression who ingested the residual saponated cresol solution from a 500ml bottle of cresol, a disinfectant, with the intention of committing suicide. Through this experience, we felt it neccessary to investigate the present commercial situation of cresol for domestic use, and to come up with some safty measares.All the 128 drugstores and pharmacies in four cities located in the Tohno area of Gifu Pref. (Mizunami, Toki, Tajimi and Ena) were queried by telephone about the sale and stock of cresol.Almost 80% of the drugstores in these four cities, excluding pharmacies, were found to deal in saponated cresol solutions. They carried a little more than two 500ml bottles of cresol on average. This volume exceeds an estimated adult lethal dose of 250ml.Although it is unlikely that an ordinary household will use the whole of 500ml bottle of the disinfectant at a time, the residual saponated cresol solution could increase the risk of accidental cresol poisoning at home.So, it would be desirable not to sell 500ml bottles in ordinary drugstores. Furthermore, before selling a bottle of cresol, the pharmacists, who have a specialized knowledge about it, should kindly explain to the user about its toxicity and usage.

A Survey of Attitude to Iyaku Bungyo Separation of Dispensing from Medical Practice / 日本農村医学会雑誌

Iyaku Bungyo means separation of dispensing from medical practice. Under this system, physicians provide outpatients with prescriptions, if need be, after examinations. The patients visit neighborhood drugstores and produce the prescriptions to pharmacists, who are authorized to accept patients covered by health insurance and to make up prescriptions. The prescribed medicines will be given to the patients in exchange for the payment. The pharmacists will also instruct the customers how to take in the prescribed medicines properly. The system has been so designed as to improve the quality of health care services with the physicians and pharmacists performing their respective roles as the specialists. However, the government office is promoting the Iyaku Bungyo system in favor of the pharmacies outside the hospitals in the name of the containment of medical costs, charging that the medical institutions prescribe and dispense so many kinds and quantities of medicines the patients can hardly take in, simply to make large profits from a comfortable margin between the market price for each pharmaceutical and the price at which it is actually purchased. Ministry of Health, Labor and Welfare officials and insurers have trumpeted the system as if it were an ideal scheme to curb health care costs. In reality, however, medical expenses have been boosted up. It can be taken for granted that the expenditure on national health care is increasing year after year with the population of the elderly on the rise and progress in medical technology. Notwithstanding, it is an important task to hold down increases in the cost of health care with the advent of an era of an aging population.

Screening for Colon Cancer---Present Situation and Problems Confronting Gifu Prefecture / 日本農村医学会雑誌

As a health care measure for the people in the prime of life, the Ministry of Health and Welfare (now the Ministry of Health, Labor and Welfare) of the Japanese government started off the first 5-year program for the senior citizens in 1983 with the enforcement of the Law Concerning Health and Medical Services for the Aged, followed by the second five-year program in 1988 and the third eight-year program in 1992. The screening project for colon cancer was incorporated in the third program with a target set of holding an increasing rate of morbidity at zero in a year-to-year comparison. The response rate to colon cancer screening (the ratio of the number of participants responding to colon cancer screening to the total number of qualified persons) was also to be raised steadily to reach a target of 30% in 1999. In Gifu Prefecture, the total number of examinees in 1999 increased twice the figure in 1992, but the response rate was 14.8%, which was only about half the target and below the national average of 15.3%. The detection ratio of colon cancer and the early cancer ratio in the prefecture were much the same as the national average. It could be taken that there is nothing wrong as far as the precision of screeming and management are concernd. To decrease the rate of mortality from cancer of the colon, the most important is to raise the response rate. For this purpose, we would like to propose that the cost should be covered by national health insurance in those health screening projects approved of by the competent authorities.

The Results of a Survey of Smoking in the Students of JA Gifu Kouseiren Nurses' School / 日本農村医学会雑誌

An unsigned questionnaire survey of smoking was taken on all 101 students of JA Gifu Kouseiren Nurses' School. The smoking rate of the students as of July 2001 worked out at 17.8%(18 in 101 students). Most student smokers said they smoke less than 15 cigarettes a day, each containing less than 0.9mg of nicotine, and their Fagerstrom Tolerance Questionnaire (FTQ) index came to 1.94±1.51, suggesting their nicotine dependence is not so much as we thought. Almost 80% of the students who habitually smoke said they wish to quit smoking. Almost 80% of the students who do not smoke said they feel unpleasant to other person's smoking, and in contrast the remaining 20% of them said they feel like start smoking. These results suggest that there is a pressing need for advising the nurse students not to form the smoking habit and bringing the harm of smoking home to them in class.

Evaluation of Medium-term Pharyngeal Candidiasis Rate after Switchover from Beclomethasone Dipropionate to Fluticasone Propinate in Elderly Patients with Bronchial Asthma / 日本農村医学会雑誌

[Background]: Fluticasone propinate (FP), an inhaled steroid agent, has greater clinical efficacy in bronchial asthma than Beclomethasone dipropionate (BDP), but it has been reported that the rate of oropharyngeal candidiasis becomes high. In this study, we evaluated the medium-term pharyngeal candidiasis rate in elderly patients after BDP was replaced with FP in maintenance therapy.<BR>[Method]: A total of 53 elderly patients 65 and over, who had previously received stable maintenance therapy with BDP, were switched to treatment with half doses of FP, and they were taught to gargle again.<BR>Eight weeks and six months later, pharyngeal swabs were taken for culture and assessment of candidiasis. These results were compared with those of 24 patients 64 and below. We also measured the inspiratory peak flow rate with inhaled FP.<BR>[Results]: Eight weeks later, candidiasis appeared in 11 patients in the advanced age group (20.8%), which was significantly high compared with only one patient in the age group under 65 (4.2%). Although the pharyngeal candidiasis of 8/11 patients became negative by teaching them thoroughly how to gargle with povidone-iodine, candidiasis appeared in another seven patients six months later, bringing the total up to 10/53 (18.9%).<BR>[Conclusion]: The appearance rate of pharyngeal candidiasis in the elderly patients, who changed for FP, was unexpectedly high. It was suggested that the frequncy of gargling after inhaling FP and the inspiratory peak flow rate when FP is inhaled could be big influential factors. When we use FP, it may be important to give medium and long term-persistent instructions to patients.

The Clinical Efficacy of Change of Medication from Beclomethasone Dipropionate to Fluticasone Propionate in Elderly Patients with Bronchial Asthma / 日本農村医学会雑誌

[Introduction] Fluticasone propionate (FP), an inhaled corticosteroid, has almost twice as much clinical efficacy as Beclomethasone dipropionate (BDP) in the management of asthma. The inhalation of FP dry powder by using a handy and portable inhalator is effective for young and middle-aged patients with bronchial asthma. However, the inhalator are not always easy for elderly patients to operate because it requires some manual dexterity and a knack for quick inhalation.<BR>[Methods] A total of 47 outpatients aged 65 years or above who had achieved a stable asthmatic condition were enrolled for this study, and changed the drugs from BDP to FP. The amount of FP to be taken at one time was equivalent to half the dose of BDP. Twelve check points of inhalation skills were repeatedly taught until patients understoodfully. We checked these points after 2-4 weeks and 8 weeks. We used a questionnaire to survey the patients' impression of FP and its adverse effects. We also evaluated peak flow values (PEF) in the morning and at night, results of pulmonry function tests and asthmatic grades.<BR>[Results] We found clear weak points for the 12 skills in the elderly patients. PEF both in the morning and at night significantly improved after 2-4 week treatment with FP, but pulmonary function tests found no statistically significant change. Eventually 71.4% of the patients in the 65-74 year age range and 50.0% of those of 75 years or above hoped to continue to receive FP therapy. The total number of the patients with adverse effects was 14 (29.8%): These were 7 cases of dryness in the mouth, 5 cases of hoarseness and 2 cases of nausea and vomiting.<BR>[Discussion] Although we confirmed the clinical usefulness of FP in elderly patients with asthma, we must recognize that it requires much time and labor for the eldrely to get used to FP inhalation and that it is important to give them repeated instruction.

Present State of Emergency Care in To-No District / 日本農村医学会雑誌

A survey was carried out on how the To-no District is coping with the need of first aid for patients requiring life-supporting treatment before hospitalization. Although there were cities in this district where statistics on first aid were not available, the survey found that, during the 4-year period from 1994 through 1997, bystander CPR (cardiopulmonary resuscitation) saved 11.2% of the lives of patients with CPA (cardiopulmonary arrest). Incidentally, 11.3% of the population attended CPR courses offered by public institutions. Gifu Prefecture has helicopters for use in rescue work, but the survey found that some cities had not ever sponsored drills using helicopters in life-saving operations. Our findings revealed the indifference of the general public as well as administrators in this district toward emergency care. Public recognition of the importance of the care of suddenly ill or injured patients must be gained. Furthermore, acquisition of skills required for first aid by lay people and technical improvement of these skills in professional rescuers are necessary. The authors think that these are the community educational responsibility of hospitals and other medical institutions.

A Case of Lemmel's Syndrome in which Endoscopic Sphincterotomy(EST) was Effective / 日本農村医学会雑誌

A 73-year-old man visited our hospital with complaints of fever, epigastric painand jaundice. Laboratory examinations showed elevation of GOT, GPT, ALP, LAP and amylase. Abdominal ultrasonography revealed gall bladder stones. Endoscopic findings showed parapapillary diverticulum, but the common bile duct stone was not revealed by endoscopic retrograde cholangiography. He was conservatively treated and then discharged. Two months after, the patient was readmitted for cholecystitis and underwent cholecystectomy. After further 2 months, he was again admitted for the same symptoms as those on first admission. We diagnosed this case as Lemmel's syndrome and performed emergency endoscopy. Endoscopic findings revealed the meal rest inside the parapapillary diverticulum. After we removed the meal rest obstructing the orifice of the papilla of Vater using grasping forceps, we performed EST. Purulent bile gushed out from the orifice. Two years have elapsed since them. Cholangitis has not recurred during this period. Therefore, we concluded that EST is effective in treating Lemmel's syndrome.

3 Cases of Student Suddent Death at School and Study to Prevent the Incidence / 日本農村医学会雑誌

We report 3 cases of sudden death while the students are at school. In Japan 120-150 cases, mainly related to sports, are reported in a year. In Gifu Prefecture (population: 2, 000, 000), only 1 or 2 cases probably occur in a year. While here in Mizunami City (population: 40, 000), we had 3 cases for the last 10 years. This is a higher occurrence rate than in other cities.<BR>The 1st case was caused by brain-stem bleeding; the 2nd, rupture of the wall of the aorta associated with Marfan syndrome, and the 3rd, fatal arrythmia related to Wolff-Parkinson-White syndrome.<BR>Measures to prevent the incidence are summed up as follows:<BR>(1) Teachers, school doctors and hospital staffs should have closer contact<BR>(2) We should critically review the standards for cardiac disease management and make a thorough examination of the heart at the time of regular health screening by several ways, such as UCG, Holter ECG and treadmill ECG, to find high-risk students.<BR>(3) 60% of the cases of sudden death were of cardiac origin, and 40% were due to central nervous system disorder, bronchial asthma etc., so we should also watch over these conditions.