Analyses of laboratory data and establishment of reference values and intervals for healthy elderly people.

OBJECTIVE: Protein-energy malnutrition is a common disorder in the elderly. Although serum albumin is commonly used as a nutritional marker, data is lacking on serum albumin levels in the elderly. The purpose of this study was to determine whether serum albumin levels decrease with advancing age and to establish reference value and interval of laboratory data for elderly people (75 years and over). PARTICIPANTS: Blood samples from 13821 healthy people, 42064 outpatients, and 15959 inpatients were collected during 2008. Blood from 127 of our nutrition support team (NST) patients was also collected during August 2006 and May 2009, and analyzed. MEASUREMENTS: Serum albumin, hemoglobin, total cholesterol levels and lymphocyte count were determined. We analyzed the change in each parameter in accordance with age, compared the data for elderly people with younger people, and established new reference values. Clinical outcomes were examined depending on the improved reference values. RESULTS: Albumin was lower in older persons than in younger persons. The estimated reference value and interval were 42 (48-36) g/l in older persons and was much lower in NST patients. Hemoglobin was decreased while cholesterol and lymphocyte count were not changed in older persons: all were markedly decreased in NST patients. Terms of hospital stay were significantly longer and mortality rates were significantly higher in older persons, comparing from above to below using a new reference value of albumin (36 g/l). CONCLUSIONS: The serum albumin level decreases with advancing age, but it was maintained to some extent in healthy older people. Serum albumin levels related to the clinical outcome. Hemoglobin and cholesterol levels and lymphocyte count were all lower in NST patients. These measurements may be valuable markers of nutritional status and can help in guiding the need for nutritional support.

A study of the metabolism of methamphetamine and 4-bromo-2,5-dimethoxyphenethylamine (2C-B) in isolated rat hepatocytes.

The metabolism of methamphetamine (MA) and 4-bromo-2,5-dimethoxyphenethylamine (2C-B) in freshly isolated rat hepatocytes was investigated, and compared with in vivo results. A suspended hepatocyte culture, established from male Wistar rats using a collagenase perfusion technique, was incubated in the presence of MA or 2C-B. After enzymatic hydrolysis of the conjugated forms, the metabolites were extracted by liquid-liquid partition and analyzed by gas chromatography/mass spectrometry (GC/MS). Amphetamine, p-hydroxymethamphetamine and p-hydroxyamphetamine were detected in the culture fluids of the rat hepatocytes inoculated with MA. The alcohol derivative, carboxylic acid derivative, 2-O-desmethyl-2C-B, 2-O-desmethyl-N-acetyl-2C-B and 5-O-desmethyl-N-acetyl-2C-B were detected in the case of 2C-B. The major metabolite of MA in rat hepatocytes was p-hydroxymethamphetamine. This is in good agreement with the urinary excretion profile for rats that were fed MA. 2-O-Desmethyl-2C-B and the carboxylic acid derivative were the major recovered metabolites of 2C-B in the rat hepatocyte culture, a slight deviation from the in vivo findings, in which 5-O-desmethyl-N-acetyl-2C-B was found to be the main component. Metabolites with a hydroxy group were largely present in their conjugated forms in the culture fluids, except for 2-O-desmethyl-2C-B. Taking these results into consideration, a primary hepatocyte culture system has the potential to provide a quick and handy method for estimating the in vivo metabolic fate of abused drugs.

[Assessment of the psychological stress experienced before and after the use of a hearing aid in elderly patients].

Hearing aids are useful instruments for elderly patients with impaired hearing. However, the psychological effects of wearing a hearing aid have remained unclear until recently. A study was therefore performed at the Tokyo Metropolitan Geriatric Hospital to determine such effects. Eighteen out of 50 questions included in the "Psychological Stress Response Scale (PSRS)" were selected and used to produce a questionnaire. The questionnaire was then given to and completed by 31 elderly patients who received and willingly used hearing aids. Of these patients, 20 were female and 11 were male. Their average age was 80.4 years (+/- 5.3 years ranging from 66-89 years). The questionnaire was completed by each patient on two separate occasions: before the hearing aids were fitted and after. In addition to the PSRS questionnaires, a second "hearing satisfaction" questionnaire was also completed, both before and after the hearing aids were fitted. The scores for depression, anxiety and anger were significantly lower after the hearing aid had been fitted. The score for depression showed a particularly distinctive decrease. The statistics also showed that the use of a hearing aid produced a significant improvement in the level of satisfaction patient's felt regarding their hearing. We conclude that the use of hearing aids by elderly patients not only alleviates their dissatisfaction with being unable to hear, but has additional psychological advantages. These results suggest that the use of a hearing aid not only improves hearing but may also delay or offset the development of dementia. Accordingly, suitable hearing aids should be provided to elderly patients so that they may recover their hearing and benefit from the associated psychological advantages.

The operation of upper esophageal web in Plummer-Vinson syndrome: a case report.

Most cases of dysphagia associated with Plummer-Vinson syndrome are expected to improve with the oral administration of ferrous agents. When a web is the cause of the symptoms, surgical management is rarely necessary. However the surgical indication and technique for the web have been controversial. The patient was a 56-year-old woman who complained of restricted dietary habit because of an upper esophageal circumferential web associated with Plummer-Vinson syndrome. The circumferential and membranous web was resected with a surgical knife and scissors through the inner lumen of esophagus and the raw surface was sutured at five places with 4-0 proline thread under microlaryngosurgery. This surgical treatment resulted in diminished dysphagia and no recurrence of the web after the surgery.

Interobserver agreement on normal swallowing physiology as viewed by videoendoscopy.

This study examines the agreement of 2 observers in identifying selected normal oropharyngeal swallow events in the 1- and 5-ml swallows of 3 normal young adult males as identified by videoendoscopy at each of two endoscopic positions: (1) with the tip of the endoscope just at or below the tip of the uvula (high position), and (2) with the tip of the endoscope just below the tip of the epiglottis (low position), and thereby defines the needed focus for observer training in endoscopic assessment of swallowing. Overall, the more and less experienced examiners agreed on seeing or not seeing the onsets and terminations of the 12 events 83% of the time. Scope position affected observer agreement on several events while bolus volume did not.

[Malignant lymphoma occurring in a patient with neurofibromatosis type 1 (von Recklinghausen disease)].

Malignant lymphoma developed in a 65-year-old man with type 1 neurofibromatosis (von Recklinghausen disease). The patient visited the hospital for evaluation of generalized lymphadenopathy. A physical examination discovered café au lait spots, neurofibromas, and generalized enlargement of the superficial lymph nodes. A computed tomogram demonstrated enlarged mediastinal and para-aortic lymph nodes in the abdomen. Biopsy specimens from the right side of the patient's neck were examined, and a diagnosis of non-Hodgkin's lymphoma (diffuse mixed type, T cell type) was made. Although the patient achieved a partial response with combination chemotherapy, he died of pneumonia. Cases of malignant lymphoma associated with type 1 neurofibromatosis are rare in the literature.

Effects of head rotation on pharyngeal function during normal swallow.

This study quantified the effects of head rotation on pharyngeal swallowing in healthy subjects. Videofluoroscopic and oropharyngeal manometric examinations of pharyngeal swallowing were performed on seven volunteers with the head in neutral and rotated positions. Videofluoroscopic study revealed that head rotation swallow causes the bolus to lateralize away from the direction of head rotation. Pharyngeal manometric study indicated that the pharyngeal peak pressures toward the side of head rotation were significantly increased, whereas the pharyngeal pressures opposite the side of head rotation were not affected. Head rotation swallow produced a significant fall in upper esophageal sphincter (UES) resting pressure and a delay in UES closing. We concluded that the head rotation swallow in normal subjects not only alters the bolus pathway, but also has a useful effect on both pharyngeal clearance and UES dynamics.

Normal swallowing physiology as viewed by videofluoroscopy and videoendoscopy.

This study examines normal oropharyngeal swallow physiology in 8 young adult males with concurrent videofluoroscopy and videoendoscopy. Twelve swallows were examined for each subject, 3 swallows each of 1 and 5 ml of thin liquid at each of two endoscopic positions: (1) the tip of the endoscope just at or below the tip of the uvula (high position), and (2) the tip of the endoscope just below the tip of the epiglottis (low position). Results indicate that if the clinician is interested in laryngeal events occurring before and after swallow, videoendoscopy with the endoscope in the low position is the procedure of choice. To evaluate pharyngeal anatomy and/or the presence of food in the pharynx before or after swallow, either endoscopy with the endoscope in the high position or videofluoroscopy can be used. However, if the clinician is interested in pharyngeal physiology during swallow, videofluoroscopy is a better diagnostic procedure.

[Effect of posture strategies on preventing aspiration].

The purpose of this study was to determine the effect of postural change on preventing aspiration, and the types of swallowing disorder that were influenced by posture. Ninety-five patients that were examined by aspiration of barium during videofluoroscopic examination of oropharyngeal swallow assumed one of four postures (chin down, head rotation, chin down + head rotation, and head back to chin down). Postural strategies were successful in eliminating aspiration in 68(72%) of the 95 patients. Twenty five of the 68 patients, however, needed an additional change in bolus volume to eliminate aspiration. Effective postures eliminating aspiration were chin down for 43 patients, head rotation for 10 patients, chin down + head rotation for 12 patients, and head back to chin down for 3 patients. The successes rates of posture changes for each swallowing abnormality were 76% for reduced tongue base retraction, 74% for delay in triggering pharyngeal swallow, 74% for reduced laryngeal elevation, 73% for laryngeal paralysis, 68% for inefficient oral transit, and in 57% for cricopharyngeal dysfunction. Among individuals with cricopharyngeal dysfunction or with than three swallowing motility problems, the frequency of unsuccessful swallow despite postural change was significantly higher than that of successful swallow. These results indicated that the posture strategies in addition to control of bolus volume could prevent aspiration in more than 70% of patients, but the efficacy of posture techniques differed with the different types of swallowing disorder identified as causing the aspiration, and suggested that the posture strategies were less beneficial in individuals with cricopharyngeal dysfunction or exhibiting multiple swallowing disorders.

Effects of two breath-holding maneuvers on oropharyngeal swallow.

This study quantified the effects of the supraglottic maneuver (SGM) and super supraglottic maneuver (SSGM) on laryngeal and pharyngeal movements before and during swallow. Simultaneous videofluoroscopic and videoendoscopic examinations of oropharyngeal swallowing were performed in eight healthy volunteers with and without maneuvers. Data analysis compared 1) temporal relationships of oropharyngeal events, 2) airway conditions at the time of selected oropharyngeal events, and 3) biomechanical computer analysis of swallowing events. Using these maneuvers, normal subjects produced earlier cricopharyngeal opening, prolonged pharyngeal swallow, some degree of laryngeal valving before swallow, and change in extent of vertical laryngeal position before swallow. These changes are more successful and maintained longer with the SSGM than the SGM. We concluded that breath-holding maneuvers alter not only airway conditions before swallow but also both the temporal relationships and biomechanical events during oropharyngeal swallow.

Seasonal change in nagilactone contents in leaves inPodocarpus nagi forest.

Nagilactones isolated fromPodocarpus nagi (Thunb.) Zoll. et Moritz. are known by their physiological activities as a plant growth inhibitor or antiherbivory substance. As the first step in clarifying the nagilactone dynamics in a forest canopy, the seasonal variations in nagilactone contents in leaves and mass of nagilactones accumulated in the canopy were examined at Mt. Mikasa, Nara City, central Japan. Nagilactone content in mature leaves dropped sharply in May, when new leaves flushed. The nagilactone content of new leaves was far greater than that of mature leaves, implying a translocation of nagilactones from old leaves to new leaves. The total mass of nagilactones in the canopy was 3.9 kg/ha.

[Effects of transcutaneous silicon injection for aspiration caused by unilateral vocal cord paralysis].

The purpose of this study was to determine the effects of transcutaneous silicon injection on swallowing function in unilateral vocal cord paralysis with aspiration. The preoperative and postoperative swallowing function were evaluated by means of videofluoroscopy and pharyngeal manometry in eight patients who received injection of silicon into the laryngeal vestibule, ventricle and vocal cord. Data analysis compared 1) types of aspiration and pharyngeal clearance, 2) timing of laryngeal closure (complete closure between arytenoid and epiglottic base) that was correlated with the onset of cricopharyngeal (CP) opening as time zero, and 3) swallowing pressure in the pyriform sinus on the side of the paralyzed vocal cord. In seven of the 8 patients, a favorable clinical response was achieved and aspiration and/or penetration were not observed on the fluoroscopic images after the silicon injection. Timing of laryngeal closure could be quantified in six patients, and mean values of the times preceding the onset of CP opening were significantly earlier on the postoperative examinations than preoperative examinations. Pharyngeal clearance on the affected vocal cord side was improved in six of the 8 patients, and swallowing pressure in the pyriform sinus was significantly elevated in four patients following surgery. These results suggested that silicon injection therapy produced earlier laryngeal closure during the swallow and improvement of pharyngeal clearance on the affected side after the swallow, so that aspiration and/or penetration with vocal cord paralysis might be prevented.

Timing of glottic closure during normal swallow.

BACKGROUND: The purpose of this study was to determine the temporal characteristics and patterns of glottic closure during normal swallow using concurrent videofluoroscopy and videoendoscopy. METHODS: Three swallows each of four bolus types were examined in eight healthy volunteers with the endoscope in two positions: at the level of the uvula and at the laryngeal vestibule. Data analysis compared: (1) temporal relationships between laryngeal behaviors and oropharyngeal swallow events and (2) airway conditions at the time of key oropharyngeal events. RESULTS: Although arytenoid adduction and subsequent arytenoid contact occurred as one of the initial events during swallow, the timing of these events was highly variable. On the other hand, true vocal cord (TVC) closure occurred mainly after the onset of laryngeal elevation, and it was affected by bolus volume. CONCLUSIONS: In normal swallow, arytenoid closure did not always mean complete TVC closure, and complete TVC closure might be accomplished during the process of laryngeal elevation and arytenoid tilting.

[Rheumatoid arthritis terminating in multiple myeloma].

A 65-year-old woman with a 25-year history of rheumatoid arthritis (RA) was admitted because of acute pneumonia in January, 1991. Then she was pointed out M proteinemia (IgG 3,220 mg/dl, IgA 139 mg/dl, IgM 216 mg/dl) for the first time. Serum IL-6 was below 4.0 pg/ml. She was followed up because of lack of bone change. Plasma cell count in bone marrow were 14.6%. She was re-admitted because of development of bone lesions March, 1992. There was no joint pains, and serum IgG, IgA and IgM were 5,148 mg/dl, 114 mg/dl and 106 mg/dl, respectively. CRP was negative. Serological tests of rheumatoid factor and antinuclear antibody were both positive. Serum IL-6 was elevated to 14.8 pg/ml. Bone marrow aspiration disclosed 30.6% myeloma cells. Serum IgG, A, and M were 5,148 mg/dl, 114 mg/dl and 106 mg/dl, respectively. Serum immunoelectrophoresis showed monoclonal IgG with kappa type light chain. X-ray findings revealed radiolucent myelomatous foci. From these findings, IgG kappa-type multiple myeloma with RA was diagnosed.

Endoscopic laser surgery for subglottic and tracheal stenosis.

Seventeen patients with subglottic and tracheal stenosis were treated with laser surgery. Six patients had airway stenosis caused by malignant tumors. Out of 16 patients who required emergency endolaryngeal laser surgery, satisfactory results were achieved in 12, obtaining a sufficient lumen for ventilation. Five cases with airway tumors underwent laser surgery to increase the airway lumen, however, only one patient showed excellent results, with a sufficient airway lumen not being obtained in the others. Airway obstructions due to tumor can be treated satisfactorily by laser surgery, though long-term postoperative follow-up confirmed recurrence of tumor in some cases, which is a problem that must be overcome in the future.

Laryngeal closure at the level of the false cord for the treatment of aspiration.

A new procedure for aspiration which closes the larynx at the level of the false cords is reported. This method is not harmful to the vocal folds and maintains arytenoid movement, thus preserving phonatory function. With the advance of the operative technique for aspiration and swallowing rehabilitation, patients who have recovered from aspiration can be helped. Our procedure can be recommended for such cases.

[Relationship between cervical osteophytes and globus sensation--a study based on altered swallowing function].

The swallowing function of ten patients showing marked cervical osteophytes were studied by double contrast pharyngogram and manometric examinations. In five cases in which the pharyngeal clearance was B type according to Shuzaki's classification, a significant increase in the maximal swallowing pressure value on the oral side ipsilateral to the osteophytes was often observed. In five cases in which the pharyngeal clearance showed A + A' type (marked impairment), the frequency of significantly decreased maximal swallowing pressure on the oral side ipsilateral to the osteophytes and abnormal waveforms of the swallowing pressure were high. However, no definite correlation was noted between these changes in swallowing function and osteophyte site. Therefore, there are two possible outcomes of the changes in swallowing function caused by cervical osteophytes: one is a compensatory increase in pharyngeal constriction aimed at maintaining relatively good pharyngeal clearance, the other is impaired pharyngeal constriction and the pharyngeal clearance. These changes in swallowing function would impact on globus sensation.

[Laryngeal closure--a simple method and a reversible method for phonation preservation].

Patients with dysphagia due to a disorder in swallowing phase II are candidates for laryngeal closure operation. The operation prevents bolus drainage into the larynx and therefore permits oral feeding. Operative methods in general should be simple and reliable, and furthermore, with regards to this laryngeal closure procedure, they should preferably be reversible to maintain phonatory function, in the event that patients improve swallowing function later on. A laryngeal closure operation which satisfies both conditions has not been previously reported. We present two laryngeal closure operations. One is relatively simple and reliable but irreversible in terms of phonatory function. The other procedure requires more effort but is reversible and therefore allows for preservation of phonatory function. We performed one of these operations on two cases each and obtained good results. 1. Laryngeal closure at the vocal cords. (simple method) The frontal neck skin is incised vertically. The thyroid cartilage perichondrium is incised in the midline and retracted widely on both sides. Then the anterior thyroid lamina is removed at the crico-arytenoid joint. A control hole is opened into the laryngeal lumen by an incision made from the cricoarytenoid membrane to the anterior commissure. The larynx is cut horizontally from the anterior to posterior commissure between the upper and lower lips of the vocal cords. Finally the vocal cords are sutured at the top and bottom of the cut stump. 2. Closure at the false vocal cords. (reversible method for phonation preservation) After the vertical incision has been made, the laryngeal lumen is opened by laryngofissure.(ABSTRACT TRUNCATED AT 250 WORDS)

Change in the growth hormone (GH) response to GH-releasing factor (GRF) caused by exogenous GH in short children.

To determine whether exogenous GH induces feedback of GH release in children, growth hormone-releasing factor (GRP) tests were performed before and after 10-day GH administration. Sixteen non-obese short boys, aged 5-14 yr, with normal GH response to pharmacological tests were studied. Mean basal and peak serum GH levels in GRF tests before and after exogenous GH were not significantly different. The subjects were divided into two groups, A and B, according to the percent change in integrated areas under the GH curves in GRF tests (GH AUC) before and after 10-day GH administration. Group A consisted of 6 boys with decreased GH AUC and group B consisted of 10 boys with increased GH AUC. Mean peak GH in GRF tests and mean GH AUC were significantly higher before exogenous GH in group A than in group B. The boys in group A were all prepubertal, while 4 boys in group B had begun their early pubertal change. The mean age in group A (7.8 +/- 1.8 yr) was significantly lower than that of group B (11.9 +/- 2.4 yr). GH AUC before exogenous GH showed a significant correlation with the percent change in AUC (= -0.742, p less than 0.01). These data demonstrated that the exogenous GH suppressed the GH response to GRF in prepubertal children with good response to GRF before exogenous GH, while it exaggerated the GH response to GRF in older children with relatively poor response before GH.

Biological activities of synthesized 20K and 22K hGH in Nb2 bioassay and IM-9 radioreceptor assay.

We investigated the bioactivities of the recombinant DNA-derived methionyl 20K hGH (20K-Met-hGH) and methionyl hGH (22K-Met-hGH). The growth-promoting activities in Nb2 cells of 20K-Met-hGH and 22K-Met-hGH were 10.7% and 93.5% of pituitary hGH (P-hGH), respectively. In the IM-9 lymphocyte assay, the binding activities of 20K-Met-hGH and 22K-Met-hGH to hGH receptor were 29.0% and 87.1% of P-hGH, respectively. Our data demonstrate that 20K-Met-hGH may have weaker biological potency than P-hGH.