Underlying pathologies and their associations with clinical features in terminal delirium of cancer patients.

Delirium is a common complication in terminally ill cancer patients. Identification of underlying pathologies and prediction of clinical features may improve effective symptom alleviation. This study aims to clarify precipitating factors and their associations with clinical features of terminal delirium. Consecutive hospice inpatients who developed delirium were prospectively evaluated following a structured protocol. Among 237 patients followed until death, 245 episodes of delirium were identified in 213 patients. Precipitating factors for delirium were disclosed in 93% of the 153 cases in which investigations were completed. Mean number of etiologies was 1.8 +/- 1.1 per patient, and two or more factors were recognized in 52%. The main pathologies identified were hepatic failure, medications, prerenal azotemia, hyperosmolality, hypoxia, disseminated intravascular coagulation, organic damage to the central nervous system, infection, and hypercalcemia. Occurrence of hyperactive delirium and the requirement for symptomatic sedation significantly correlated with hepatic failure, opioids, and steroids, while dehydration-related pathologies were significantly associated with hypoactive delirium. Complete recovery was frequently achieved in cases with medication- and hypercalcemia-induced delirium, whereas a low remission rate was related to hepatic failure, dehydration, hypoxia, and disseminated intravascular coagulation. In conclusion, standard examinations can confirm factors potentially contributing to delirium and thereby predict the severity of agitation and clinical outcomes.

Determinants of the sensation of thirst in terminally ill cancer patients.

While a sensation of thirst causes severe distress for a certain proportion of cancer patients in the terminal stage, the factors contributing to this symptom have not been established. To clarify the association between sensation of thirst and medical factors, especially dehydration, a cross-sectional observational study was performed on terminally ill cancer patients receiving inpatient hospice care. On admission to a palliative care unit, 88 consecutive patients underwent blood sampling and were requested to rate the intensity of thirst on a visual analogue scale (VAS). Physicians prospectively evaluated factors that might potentially be contributing to the symptom. The mean VAS score for thirst was 5.0+/-2.8, and 18% of the patients complained of severe thirst with a VAS score of > or = 8. No significant correlations were observed between the VAS score for thirst and the values of total protein, blood urea nitrogen (BUN), creatinine, sodium, osmolality, hematocrit, atrial natriuretic peptide (ANP), and biochemical dehydration defined by the levels of BUN, creatinine, sodium and osmolality. On the other hand, dehydration defined by ANP level (< or = 15 pg/ml), hyperosmolality (> or = 300 mosmol/kg), gastrointestinal cancer, survival, performance status, oral intake, vomiting, and stomatitis were significantly associated with the severity of thirst. In addition, mouth breathing and opioids were determined to be a potential clinical cause of severe thirst when a retrospective chart review was carried out. In conclusion, sensation of thirst is a frequent symptom in terminally ill cancer patients and is associated with dehydration, hyperosmolality, poor general conditions, stomatitis, oral breathing, and opioids. Careful assessments and treatment of underlying causes is important to alleviate patients' distress.

[Urolithiasis associated with Crohn's disease: a case report].

We report a case of urolithiasis caused by surgical treatment for Crohn's disease. A 28-year-old woman was referred to our department for further examination of renal stones from the medical department in September, 1995. She suffered from Crohn's disease and had a history of jejuno-ileal resection because of perforation of the ileum in 1988. Radiographs revealed multiple bilateral renal stones, and the urine oxalate concentration was elevated. She was treated with extracorporeal shock wave lithotripsy and the administration of sodium bicarbonate and citrate, but these treatments did not prevent recurrence and enlargement of stones. Renal function was gradually worsened and we performed transurethral lithotomy and percutaneous nephrolithotripsy. The stones were mainly composed of oxalate calcium monohydrate. A renal biopsy was performed at the operation, showing deposition of crystals in almost all renal tubules. Diet therapy (low oxalate and low fat) and the administration of sodium bicarbonate and citrate were performed strictly and recurrence was not recognized 10 months after complete removal of the stones.

Double infection with Giardia lamblia and Salmonella paratyphi A associated with acute renal failure.

While traveling in India, a previously healthy twenty-year-old man had febrile diarrhea. The patient was prescribed medical therapy, and all symptoms were resolved. Fourteen days later, however, similar symptoms recurred. The patient was admitted to a local hospital, but was transferred to our department because of oliguria. Salmonella paratyphi A was isolated from blood and stool specimens, and Giardia lamblia was identified in his stool. The patient's condition was complicated by acute renal failure. The patient received tosufloxacin and metronidazole. Renal function recovered completely without hemodialysis. Paratyphoid fever and giardiasis were resolved. It is suggested that giardiasis exacerbated the paratyphoid fever.

[Inhibitory mechanism of experimental stress ulcer in spontaneously hypertensive rats (SHR) from the view point of mucosal blood flow].

Stress ulcer formation is reportedly much less frequent in SHR than in normotensive control rats (Wistar Kyoto Rat: WKY). The purpose of this study was to investigate the mechanism of maintenance of gastric mucosal blood flow (GMBF) during imposed stress in SHR. In stressed-only SHR, GMBF did not significantly change during water immersion and restraint conditions and ulcer index (UI) was significantly lower than that of WKY. Stress conditions led to a fall in blood pressure and a gradual fall in heart rate in WKY and SHR. It was assumed that the changes in blood pressure and heart rate during stress were due to vagal hyperfunction. The catecholamine level in the fundic gland of the gastric tissue was higher in the non-stressed SHR than in the non-stressed WKY. The administration of 6-hydroxydopamine to SHR produced a significant reduction in GMBF during stress conditions and UI was significantly higher in this group than in the stressed-only SHR. In SHR treated with nifedipine, UI was lower than that of the control group and GMBF showed no significant change compared with the stressed-only SHR. However, the administration of verapamil produced a significant reduction in GMBF during stress conditions and increased UI. The norepinephrine and dopamine levels of the groups treated with verapamil were significantly lower than those in the groups treated with nifedipine. These results suggest that local regulation of gastric mucosa mediated by sympathetic hyperfunction in SHR is more important for the maintenance of GMBF during stress conditions than changes in peripheral artery resistance.

Salty food intake and risk of Helicobacter pylori infection.

To clarify the risk factors for Helicobacter pylori infection, which is considered to play an etiologic role in atrophic gastritis, duodenal ulcer and gastric cancer, various parameters including diet and socioeconomic characteristics were compared between H. pylori-infected and non-infected men. In a cross-sectional study of 634 men aged 40 to 49 years selected randomly from five areas with different rates of gastric cancer mortality, 474 of 628 men evaluated were positive for IgG antibody against H. pylori. After logistic regression analysis adjusted for area, the results showed a significant association between frequent intake of pickled vegetables and prevalence of H. pylori antibody (odds ratios against men who consume < 1 day/week 1.19 for 1-2 days/week, 1.92 for 3-4 days/week, 1.90 for 5-7 days/week; P for trend = 0.02). Daily consumption of miso soup was also associated with an increased risk (odds ratio against non-daily consumer = 1.60, 95% confidence interval = 1.03-2.49). Occupation, number of siblings, education, smoking and alcohol drinking, and other dietary habits were not significantly associated with the prevalence of infection in this population. Although there are limitations in a cross-sectional study such as this, consumption of salty foods appears to increase the risk of H. pylori infection, which could be a marker of salty food intake or an intermediate risk factor in the etiologic sequence between salty food intake and gastric cancer.

Helicobacter pylori, dietary factors, and atrophic gastritis in five Japanese populations with different gastric cancer mortality.

In a cross-sectional study of 634 men aged 40 to 49 years, randomly selected from five areas of Japan with different rates of gastric cancer mortality, 121 men of 624 evaluated were diagnosed as having atrophic gastritis through serum pepsinogen I < 70 ng/ml and the pepsinogen I (PGI)/pepsinogen II (PGII) ratio < 3.0. We examined the relation of Helicobacter pylori (H. pylori) antibodies and dietary factors, including plasma level of antioxidant micronutrients, to the presence of atrophic gastritis. Presence of H. pylori IgG antibodies was associated with increased risk of atrophic gastritis (odds ratio [OR] = 1.9, 95 percent confidence interval [CI] = 1.1-3.3). As the level of plasma beta-carotene increased, we found a steady decrease in the risk of atrophic gastritis (OR for second quartile = 0.7, third quartile = 0.6, fourth quartile = 0.4, with CI = 0.2-0.8). Frequent intake of yellow vegetables also was associated with lower risk, while frequent intake of soybean products was related to increased risk. Although H. pylori antibodies, beta-carotene level, and intake of soybean products were all significant in the multivariate analysis, these factors did not explain the differences in atrophic gastritis prevalence among the five regions. The analysis of these risk factors in relation to each pepsinogen marker showed that although both H. pylori infection and low plasma beta-carotene were associated with the decreased level of serum PGI/II ratio, the former was derived from the increase of PGII, which is common in early stage of atrophic gastritis, and the latter from the decrease of PGI, which is specific to severe atrophic gastritis.(ABSTRACT TRUNCATED AT 250 WORDS)

Abscessed leiomyosarcoma of the ileum.

A-49-year-old man was admitted because of a lower abdominal mass. During the five days prior to admission, he had noted fever and lower abdominal pain. Palpation of the abdomen revealed a tender mass, 10 cm in diameter, in the suprapubic region. An x-ray revealed an irregular collection of gas, 9 cm in diameter, in the pelvic cavity, which appeared as a mirror image when the patient was upright. Based on the physical finding and the results of a barium enema, abdominal CT, MRI, and small intestine imaging, a diagnosis of leiomyosarcoma of the ileum was made. Excision of the tumor and part of the small intestine was performed. A saccular tumor, 11 x 6 x 5 cm, was found 1.0 m from the cecum and growing out of the wall of the ileum. A large amount of pus was found inside the cavity. The pathological diagnosis was leiomyosarcoma.

Heterogeneity of protein kinase NII from rat liver nuclei.

Protein kinase NII from rat liver nuclei was resolved into two fractions, NIIa and NIIb, by DEAE-Sephadex column chromatography. NIIa was eluted at 151 mM (NH4)2SO4 and NIIb at 175 mM. They had an identical molecular size (125,000 daltons, 7.0S) and subunit composition (alpha alpha' beta 2). However, they showed significantly different Km values and turnover numbers for casein substrate. Furthermore, NIIa was found predominantly as a form bound to the chromatin, while NIIb was in the nucleoplasmic-soluble fraction in addition to the chromatin-bound fraction. These observations suggest that NII consists of a heterogeneous population of at least two molecular species, differing in the activity and functional states in the cell nucleus.

[The value of estimation of serum pancreatic elastase in experimental pancreatic disorders in rats].

The elastase levels in rat serum were measured in experimental pancreatic disorders by radioimmunoassay. After the induction of acute pancreatitis either by trypsin or normal saline, the serum elastase levels increased significantly. The serum elastase levels in trypsin induced pancreatitis were significantly higher than in normal saline induced pancreatitis. The levels in ascitic fluid were also higher in trypsin induced pancreatitis than in normal saline induced pancreatitis. Microscopically, haemorrhagic pancreatitis was found in trypsin induced pancreatitis and edemotous pancreatitis was found in normal saline induced pancreatitis. The serum elastase levels decreased significantly in rats who were treated by ethionine for long period. Microscopically, atrophic pancreas was found in those rats. These results suggest that the measurement of pancreatic elastase in either blood or ascitic fluid by radioimmunoassay is a useful diagnostic method for pancreatic disorders, especially in acute pancreatitis.

Thallium-201-chloride thyroid scintigraphy to evaluate benign and/or malignant nodules: usefulness of the delayed scan.

The purpose of this study is to evaluate benign and/or malignant thyroid tumors with 201TI thyroid scan. We studied 76 cases of histologically verified thyroid tumors, all seen as cold nodules on the 123I thyroid scan. 201TI thyroid scan was performed 5-15 minutes (early scan) and 3-5 hours (delayed scan) after intravenous administration of 1.5-2.0 mCi of 201TI. In 35 (94.6%) of 36 malignant tumors (anaplastic carcinoma, six; papillary carcinoma 23; follicular carcinoma, five; epidermoid carcinoma, one; malignant lymphoma, 1) 201TI accumulated in the cold nodule of the 123I thyroid scan on both early and delayed scans. On the other hand, the delayed 201TI scan was negative in 35 out of 39 (89.7%) benign tumors. Employing early and delayed 201TI scans, we were able to differentiate most malignant thyroid tumors from those which were benign. False-negative and -positive cases are discussed.

Effect of progesterone and FSH on testes of immature chickens.

The effect of progesterone (P), estradiol benzoate (EB) plus P, and FSH on the testicular weight, macromolecular content, and incorporation of 3H-leucine, 3H-uridine and 3H-thymidine into macromolecules was examined in the testes of immature chickens. Not P alone but EB plus P lowered the testicular weight, and content of protein and RNA in the tissues, whereas FSH brought about an increase in the weight, and content of the two macromolecular elements. The DNA content was not affected by any hormones used. P, EB plus P and FSH brought about a decrease in the incorporation of radioactive leucine, uridine and thymidine into the macromolecules in the testes, with the exception of no change in the incorporation of 3H-uridine after EB plus P treatment and 3H-thymidine after FSH treatment. These results suggest that P, alone or in combination with estrogen, and FSH cause several changes in metabolic activity in the testes of immature chickens.

Carcinoembryonic antigen-like activity in gastric juice and plasma in patients with gastric disorders.

Carcinoembryonic antigen (CEA)-like activity in gastric juice and plasma was examined in patients with gastric disease. There was no statistical difference in plasma CEA in normal subjects and in patients with benign gastric cancer. However, four patients with advanced gastric cancer, one with stage III and three with stage IV disease had a very high plasma CEA level. There was significant differences in CEA-like activity in gastric juice in patients with benign gastric disease and early gastric cancer (p less than 0.01) and patients wih benign and advanced gastric cancer (p less than 0.001). These results suggest that measurement of CEA-like activity in gastric juice is a useful adjunct to the diagnosis of early malignant changes in the stomach.