<臨床>胃切除術後の単位体積当たりの骨密度の変化 : Dual energy X-ray absorptiometry (DXA) 法による検討

We used dual energy X-ray absorptiometry (DXA) to study changes in estimated volumetric bone mineral density (EstVBMD) of the lumbar spine after gastrectomy. The study group comprised 41 men and 32 women. When EstVBMD was compared according to sex among patients younger than 60 years of age, patients 60 to 69 years of age, and patients these three groups in men (0.185 g/cm_3, 0.187 g/cm_3, 0.187 g/cm_3, respectively). In contrast , EstVBMD was significantly lower in women 60 to 69 years of age (0.157 g/cm_3) and those 70 years of age or older (0.159 g/cm_3) than in women younger than 60 years (0.200 g/cm_3) (P<0.01). When the relation between EstVBMD and the number of months after gastrectomy was studied according to sex in patients younger than 70 years, EstVBMD negatively correlated with the interval after operation in men (r= -0.365, P<0.05), whereas ther e was no correlation between these variables in women. These results suggest that after gastrectomy bone mineral density decreases gradually in men younger than 70 years, but not in women. The lack of a consistent change in bone mineral density after gastrectomy in women is apparently caused by the marked effect on bone metabolism of decreased female hormone levels after menopause.胃切除後の腰椎の骨密度の変化を dual energy X-ray absorptiornetory （DXA） 法で測定し, 単位体積当たりの計測値（Estimated volumetric bone mineral density: EstVBMD）を求めることにより検討した. 男女別に60歳未満, 60歳代, 70歳以上の群で比較すると, 男性では 0.185 g/cm_3, 0.187 g/cm_3, 0.187 g/cm_3と大差がなかった. 一方, 女性では 0.200 g/cm_3, 0.157 g/cm_3, 0.159 g/cm_3 と60歳未満の症例と比較し60歳代, 70歳以上の症例では減少し有意差を認めた. 70歳未満の症例で男女別に術後月数と骨密度との関係をみると, 男性では経過期間とともに骨密度は減少し, 負の相関関係 （r= -0.365, P<0.05）が認められたが, 女性では両者は独立した関係であった. 70歳未満の男性では胃切術後に徐々に骨塩量が低下するが, 女性では閉経後の女性ホルモン減少が強く骨代謝に現れるため胃切術後の影響が個々で異なることが示唆された

Lateral transfer of tetrahymanol-synthesizing genes has allowed multiple diverse eukaryote lineages to independently adapt to environments without oxygen

Sterols are key components of eukaryotic cellular membranes that are synthesized by multi-enzyme pathways that require molecular oxygen. Because prokaryotes fundamentally lack sterols, it is unclear how the vast diversity of bacterivorous eukaryotes that inhabit hypoxic environments obtain, or synthesize, sterols. Here we show that tetrahymanol, a triterpenoid that does not require molecular oxygen for its biosynthesis, likely functions as a surrogate of sterol in eukaryotes inhabiting oxygen-poor environments. Genes encoding the tetrahymanol synthesizing enzyme squalene-tetrahymanol cyclase were found from several phylogenetically diverged eukaryotes that live in oxygen-poor environments and appear to have been laterally transferred among such eukaryotes

<原著>高齢者急性胆囊炎症例の臨床的検討

In recent years, an increase in average life expectancy has led to a rapid rise in the number of elderly patients undergoing surgeηr for acute cholecystitis. We studied the clinical characteristics of elderly patients (aged 7S years of more） undergoing surgery for acute cholecystitis, as compared with those of non-elderly patients (aged less than 75 years) undergoing similar procedures. Twenty-four of the patients were elderly, and 44 were non-elderly. [Results J Echography and abdominal computed tomography (CT) revealed no characteristic findings specific to elderly patients, but a smaller proportion of elderly patients showed a three-layered structure of the gallbladder wall. The leukocyte count on admission was significantly lower in elderly patients than in non-elderly patients. As for therapy, a significantly higher proportion of elderly patients underwent percutaneous transhepatic gallbladder drainage (PTG BD) + cholecystectomy+ choledochotomy/choledocholithotomy, as compared with non-elderly patients. In contrast, cholecystectomy alone was performed more frequently in non-elderly patients than in elderly patients. The main postoperative complications were psychic symptoms and respiratory tract infections. The postoperative hospital stay was significantly longer for elderly patients, in part because they requested to remain in the hospital until they were able to perform activities of daily living.[要旨]近年, 平均寿命の延長に伴い, 高齢者の急性胆嚢炎手術例も急増してきた. 高齢（75歳以上）と非高齢者（75歳未満）を比較し, 高齢者の急性胆嚢炎手術症例について臨床的特徴を検討した. 1989年4月より6年聞に急性胆嚢炎として手術した症例は68例であった. 高齢者は24例で, 非高齢者は44例であった. [成績] echo像, 腹部CT検査所見では, 特徴的な所見は得られなかったが, 壁の三層構造を示す症例が少なかった. 入院時の白血球数は非高齢者より有意に少なかった. 治療法では胆摘のみの症例よりもPTGBD＋胆摘＋総胆管切開術の症例が有意に多かった. 術後合併症では精神症状や呼吸器感染が多く認められた. また, 壊疽性胆嚢炎に胆嚢穿孔と胆汁性腹膜炎併発し, 術後多臓器不全で死亡した症例以外は前例救命しえた. 在院日数は日常生活が出来るまで在院させてほしいとの希望もあり有意に長かった

<臨床>Microdensitometory 法と dual energy X-ray absorptiometory 法を用いた胃切除術後骨障害の検討

We used microdensitometry (MD) and dual energy X-ray absorptiometry (DXA) to evaluate impaired bone metabolism in 79 patients who had undergone gastrectomy. With MD, radiographs are simultaneously taken of the second metacarpal bone and an aluminum step-wedge, and the images were analyzed by computer. DXA was used to measure the bone mineral density of the second through fourth vertebrae and the estimated volumetoric bone mineral density (EstVBMD) was assessed . Significant positive correlations were obtained between EstVBMD as determined by DXA and metacarpal index (MCI) (r=0.413, P<0.01), peak of the cortex (GSmax) (r=0.362, P<0.05), peak of the middle portion of the bone marrow (GSmin) (r=0.412, P<0.01), and metacarpal bone mineral density (mBMD) (r=0.413, P<0.01) as determined by MD. When EstVBMD was compared with MCI, GSmax, GSmin, and mBMD according to sex, age, type of operation, and interval after operation, generally similar trends were obtained. We conclude that the determination by MD of various indices of bone metabolism is useful in the diagnosis of osteopathy after gastrectomy

<症例>急性胃粘膜病変の併存により Borrmann 3 型進行胃癌様の画像を呈した早期胃癌の1例

An 87-year-old man diagnosed as having advanced gastric carcinoma was admitted to our hospital. In a barium X-ray examination of the stomach taken at another hospital, filling defects were obseved in the greater and lesser curvatures of the antrum, while the entire pyloric region was rigid and stenotic. The gastroscopic findings showed pronounced curvature and stenosis of the pylorus and the pyloric mucosa was edematous and sclerotic. Histopathological examination of a biopsy specimen from the pylorus indicated a group V The gastroscopic findings subsequent to admission displayed pronounced improvement with only sporadic shallow ulceration and erosion. The histopathological findings of the excised specimen showed that several depressed lesions in the antrum were active ulcers or their scars and the depressed lesions extending from the antrum to the pyloric ring were early gastric carcinoma. The findings of filling defects of the antrum and stenos is with ridigity of the pyloric region in the radiographic examination, and pronounced curvature and stenosis of the pylorus and sclerosis with edema of the pyloric mucosa in the gastroscopic examination were very similar to typical findings of advanced gastric carcinoma with pyloric stenosis. In addition, histopathological examination of a biopsy specimen from the pylorus indicating a group V made differentiation from advanced gastric carcinoma extremely difficult.急性胃粘膜病変（AGML）は粘膜炎といった表層性所見のほかに, 筋層炎または胃壁全層の炎症ため, 胃X線検査や内視鏡検査により進行胃癌との鑑別に難渋することがある. 今回, 早期胃癌にAGMLが併存したため, 進行胃癌との鑑別が困難であった1例を経験したので報告する. 症例は82歳の男性. 老人検診で胃X線検査および内視鏡検査を施行され, 胃癌の診断で当科に入院となった. 胃X線検査では, 立位充満像で幽門部大弯および小弯側に陰影欠損が認められ, 幽門部全体は硬直し, 幽門狭窄の状態であった. 胃内視鏡検査では, 幽門前庭部は強く屈曲し狭窄しており, 幽門粘膜は浮腫状で硬く, 前壁側に広く浅い潰瘍が広がっており, 所々に出血斑が認められた. 幽門前庭部からの生検でgroup V が得られた. 以上の所見より, 幽門狭窄を伴った Borrmann 3型進行胃癌の診断で当科に入院となった. 入院後, 初回の内視鏡検査から3週目に施行された胃内視鏡検査では, 幽門粘膜に軽度の硬さが残存しており, やや壁の伸展不良が認められたものの, 浮腫状変化は著明に改善しており, 所々に浅い潰瘍やびらんが散在しているのみであった. 幽門前庭部前壁のらんから, 印環細胞癌の診断が得られた. 以上の成績より, AGML に併存した早期胃癌と診断し, 広範胃切除術, D_1 リンパ節郭清を施行した. 本症例は, 早期胃癌に AGML が併存したため, 幽門狭窄を伴った Borrmann 3型進行癌との鑑別が困難な1例であった

<症例>受傷後4年を経過して発症した外傷性右横隔膜ヘルニアの1例 : 本邦鈍的外傷性横隔膜ヘルニアの統計的観察

We describe our experience with a patient in whom a traumatic right diaphragmatic hernia developed 4 years after sustaining injury and review cases of delayed diaphragmatic injury reported in Japan. The patient was a 28-year-old man who sustained a severe contusion of the right epigastric region and fractured a right rib in a traffic accident in September 1992. In August 1996, the patient presented with shortness of breath on effort or after meals. A chest roentgenogram revealed intestinal gas in the right side of the thoracic cavity. A right diaphragmatic hernia was diagnosed on the basis of a gastrointestinal series, and the patient was operated on. The hernial orifice extended anteriorly from the central tendon in an 11:00 direction and measured 11×6 cm. The small intestine, right side of the colon, and liver were herniated. A total of 297 cases of blunt traumatic diaphragmatic hernia were reported in Japan between 1981 and 1996, including 47 cases (left side, 32 cases; right side, 15 cases) of delayed diaphragmatic hernia, defined as occurring one month or more after injury. Diaphragmatic hernia should be considered as a possible diagnosis in patients with abnormal shadows in the thoracic region who have recently sustained injury or who have a past history of injury.受傷後4年を経過して発症した外傷性右横隔膜へルニアの1例と本邦の鈍的外傷性横隔膜へルニアの報告例の統計的観察について検討した. 【症例】28歳, 男性. 1992年9月交通事故により右肋骨骨折を伴う右上腹部の鈍的外傷を受けた. 1996年8月労作時や食後の息切れが出現した. 胸部X-P 写真およひ消化管造影検査で右横隔膜ヘルニアと診断し手術を施行した. 破裂部位は右横隔膜の腱中心の前方11時方向で, 筋線維方向に 11×6cm の破裂部位を認めた. 脱出臓器は小腸, 右結腸および肝右葉であった. また, 1981年から1996年までに本邦で鈍的外傷による横隔膜へルニアの報告例は297例であった. そのうち受傷後1ヶ月以降に発症した遅発性横隔膜ヘルニアは47例 （右32例, 左15例）であった. 受傷直後はもとより外傷の既往があり, 胸部異常陰影のある患者には本疾患を念頭におくことが大切である

PROTEIN CATABOLIC RATE SHOULD BE NORMALIZED BY IDEAL BODY WEIGHT NOT BY POST-DIALYSIS BODY WEIGHT.

Protein catabolic rate (PCR) is calculated by urea kinetic model thorough the dialysis session and it is recognized as expressing the protein intake in the steady state of dialysis patients. PCR is generally normalized by post-dialysis body weight (BW), expressed as nPCR, however, most dietary guidelines for protein intake are documented as PCR normalized by ideal BW (iPCR). We evaluated which is better nPCR or iPCR to estimate the impact on the patient survival and to use it for dietary education for dialysis patients. 119 chronic dialysis patients whose dialysis vintages were longer than 3 years were selected into this study. The mean age of them was 62.4years old and the mean dialysis vintage was 115.4 months. The patients were divided into 4 groups by each PCR value as less than 0.7, 0.7– 0.9, 0.9–1.1, greater than 1.1 g/Kg/day. Kaplan-Meier analysis was conducted to evaluate the 5–year patient survival in each PCR method. The difference in the patient survival between 4 groups in each PCR method was evaluated by Log-rank test. Among 119 patients 30 patients died and 9 patients were censored out, and the overall 5-year survival rate was 74.4%. There were no significant differences between 4 groups in nPCR. However, a significant risk in the group less than 0.7 g/Kg/day and a significant benefit in the group greater than 1.1 g/Kg/day were observed in iPCR. Both nPCR and iPCR were not independent significant risk factor on the patient survival. Only age and the serum level of CRP were significant risk factor. We concluded the PCR should be normalized by ideal BW not by post-dialysis BW

Diffenreces in mia related factors between hyperglycemic and normoglycemic dialysis patients

It is generally accepted that diabetic dialysis patients have nutritional problems more frequently than non-diabetic patients, which has a close relation to the shortness of their lifetime. We compared the MIA related factors between hyperglycemic and normoglycemic dialysis patients with diabetes.110 diabetic dialysis patients were enrolled in this study and they were divided into the next 2 groups; the hyperglycemic group as GA greater than or equal to 23%, and the normoglycemic group as GA less than 23%. Nutritional status was evaluated by MIS sheet originally established by Kalantar- Zadeh. Nutritional statuses were categorized as Normal, mild malnourished and moderately/severely malnourished based on the total point of MIS. In the normoglycemic group age, dialysis vintage and serum level of CRP were significantly increased as a nutritional category became worsened. On the other hand in the hyperglycemic group there were no significant differences in MIA related factors among the nutritional categories. Various specific issues which might worsen the nutritional status of hyperglycemic dialysis patients were identified. In the normoglycemic patients malnutrition might has progressed in the similar manner of MIA progression observed in non-diabetic dialysis patients. However, in the hyperglycemic patients malnutrition might has progressed by other specific issues and or hyperglycemia itself. The Patients with severe hyperglycemia cannot live long enough to develop MIA syndrome

<症例>肝原発性悪性線維組織球腫の1例

Malignant fibrous histiocytoma (MFH) is a rare disease. We describe a 68-year-old man admitted to the hospital because of malaise. On admission, hematologic and serum chemical examinations showed no abnormalities. A tumor measuring 6.0×6.0×5.5 cm was found in segment S6 of the right lobe of the liver. A computed tomographic scan of the abdomen revealed a mass surrounded by a capsule-like region with a nonuniform shadow at its margin. The mass contained a nonuniform low density area. A magnetic resonance imaging scan showed low intensity on T1-weighted images and high intensity on T2-weighted images. An angiograrn of the abdomen revealed a tumor with a darkly stained margin during the venous phase. Partial resection of the liver, including S6 and part of S7, was performed. On histopathological examination, this case was characterized by a storiform pattern. The inside of the tumor showed a storiform-pleomorphic pattern with inflammatory cell infiltration and partial mucinous degeneration. On immunohistochemical studies, the tumor cells stained positively for CD6. The diagnosis was MFH.肝原発の悪性線維性組織球（MFH）はまれな疾患である. 患者は68歳の男性. 主訴は倦怠感. 入院時検査では血液検査で異常を認めなかった. 腫瘍は肝右葉 S6 にあり大きさは 6.0×6.0×5.5cm 大であった. 腹部CT検査で辺縁部は不均一な造影効果を伴う被膜状のものを認め, 内部は不均一な low density area であった. MRI検査ではT1強調画像で low intensity, T2 強調画像で high intensity として描出された. 腹部血管造影は, 辺縁が静脈相で濃染される腫瘍像を認めた. S6 と S7 の一部を含む肝部分切除を施行した. 病理組織学的検査は, 線維芽細胞様細胞と組織球様細胞とからなる特徴的な storiform pattern （花むしろ模様）が見られ, 腫瘍内には炎症性細胞浸潤や一部粘液変性を伴う storiform pleomorphic type （花むしろ多形型）であった. 免疫組織化学的検査は CD68 に陽性を示したことより MFH と診断した

Protein nenrgy wasting (pew) is subclinically progressive in choronic dialysis patients

Protein energy wasting (PEW) is the most important problem on chronic dialysis patients because it is closely related to the shortness of their lifetime. However, there have been few reports that clarified the body composition changes in chronic hemodialysis patients.We retrospectively analyzed the changes in body composition evaluated by the bioelectrical impedance analysis for 2 years on 188 chronic hemodialysis patients whose dialysis vintage was more than 2 years. The patients were divided into the next 2 groups; the Group A, 108 patients with BW loss less than 2 %, Group B, 80 patients with BW loss greater than or equal to 2 %. The valuables which could estimate the progression of BW loss were determined using the Chi-square test by the comparison of the Group A and B.In all subjects the mean post-dialysis BW was significantly reduced from 57.3 Kg to 56.6 Kg and the LBM was also reduced from 43.1 Kg to 42.6Kg, but the fat volume didn’t change. In the Group A the LBM didn’t change but the fat volume significantly increased. In the Group B both the LBM and the fat volume were significantly reduced. Age was significantly higher and nPCR was lower in the Group B than A. In our facilities 42.5% of the patients reduced their BW but the difference was very small as -1.2 % from the basal level. The results of this study suggest PEW might subclinical progressive even if the patients can keep their BW as changing their muscle to fat on chronic hemodialysis patients. Higher age and lower protein intake are the risk of PEW so we should promote the proper intake of protein and energy especially for elder dialysis patients