[in Japanese]

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Cachexia is among the most debilitating and life-threatening aspects of cancer and is more common in children and elderly patients. Associated with anorexia, fat and muscle tissue wasting, psychological distress, and a lower quality of life, cachexia arises from a complex interaction between the cancer and the host. This process results from a failure of the adaptive feeding response seen in simple starvation and includes cytokine production, release of lipid-mobilizing and proteolysis-inducing factors, and alterations in intermediary metabolism. Cytokines play a pivotal role in long-term inhibition of feeding by mimicking the hypothalamic effect of excessive negative feedback signaling from leptin, a hormone secreted by adipose tissue, which is an integral component of the homeostatic loop of body weight regulation. This could be caused by persistent inhibition of the feeding-stimulatory circuitry including neuropeptide Y.
Cachexia should be suspected in patients with cancer if an involuntary weight loss of greater than five percent of premorbid weight occurs within a 3-6-month period. The two major options for pharmacological therapy have been either progestational agents or corticosteroids. However, knowledge of the mechanisms of cancer anorexia-cachexia syndrome has led to, and continues to lead to, effective therapeutic interventions for several aspects of the syndrome. These include antiserotonergic drugs, gastroprokinetic agents, branched-chain amino acids, eicosapentanoic acid, cannabinoids, melatonin, and thalidomide all of which act on the feeding-regulatory circuitry to increase appetite and inhibit tumor-derived catabolic factors to antagonize tissue wasting and/or host cytokine release.
Because weight loss shortens the survival time of cancer patients and decreases performance status, effective therapy would extend patient survival and improve quality of life.

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[in Japanese]

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We investigated the influence of brain atrophy and white matter lesions on cognitive function in elderly people. We selected 33 subjects (mean age, 79.2±5.1yrs) with a MMSE score from 14 to 30 who had no previous history of stroke from the outpatients in the Memory Clinic of our hospital. These subjects were divided into four groups on the basis of their MMSE score as follows: 14-20; moderate dementia (Moderate-D, n=9), 21-23; mild dementia (Mild-D, n=9), 24-27; mild cognitive impairment (MCI, n=10), 28-30; normal (Normal, n=5). Among these four groups, we compared the frequency of the associated risk factors for cerebral infarction (hypertension, diabetes mellitus, hyperlipidemia, heart disease), and the severity of brain atrophy and cerebral white matter lesion which were visually evaluated by MRI technique. Brain atrophy and white matter lesions were assessed by reviewing the cerebral cortex and hippocampus, and deep white matter lesion (DWML) and periventricular hyperintensity (PVH), respectively. Brain atrophy was divided into three grades (mild, moderate, severe) and white matter lesions were classified into four grades (0-3) using Fazekas's criteria. We performed statistical analysis to detect t parameters which correlate with and influence MMSE scores from among the MRI findings. The cases with dementia were all diagnosed as Alzheimer's disease. There were no significant differences among the four groups in mean age, the incidence of individual associated risk factors, the severity of cortical atrophy, or the grade of DWML (≤2) and PVH (≤2). However, the frequency of hippocampal atrophic change greater than a moderate grade increased in parallel with the exacerbation of reduced cognitive function (Normal; 20%, MCI; 40%, Mild-D; 56%, Moderate-D 89%), and approximately 76% with such a change were AD cases. Statistical analysis showed a significant negative correlation between the grade of hippocampal atrophy and MMSE score (r=-0.518, p<0.005) and a great influence of hippocampal atrophy on that score (stepwise regression analysis: r=0.518, p<0.005). From the above results, it was suggested that more than moderate atrophic change in the hippocampus might possibly be related with cognitive impairment and that both DWML and PVH less than the second grade had little influence on the decline of brain function.

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Medical decision-making involving elderly people with dementia often troubles care providers in Japan. Meanwhile, little attention has been paid to the routine medical care of nondementia illnesses in such patients. To understand the current situation surrounding the issue, we conducted a postal survey with nursing home directors across the nation. A self-administered questionnaire was sent to 1, 117 randomly selected nursing homes, one third of all such facilities in Japan, and 502 (44.9%) responded. Of the respondents, 291 (58.0%) said more than a half of their residents have difficulties in daily life because of dementia. Less than 20% of the facilities said that they routinely confirm residents' preferences in writing when they are admitted concerning each of the following items; terminal care, medical information disclosure, leaving a will, funerals and application for the guardian system. 206 (41.0%) facilities have difficulties in finding a hospital for the elderly with dementia when necessary. The Mann-Whitney U test showed no significant relation between facilities' characteristics and their difficulties in finding a hospital that would admit demented patients. At present, a number of nursing homes confirm their residents' preferences only some time after they are admitted. However, the way of confirming seems inappropriate under the circumstances in which more than a majority of residents have difficulties in daily life due to dementia. Though more than a half of nursing homes have difficulties in finding a hospital that would admit dementia patients, no significant relation was found between the difficulties and the facility-hospital relation. The problem seems to lie in the acceptance mechanism of hospitals.

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In this study, we focused on acceptance of memory impairment and satisfaction with life in patients with mild to moderate Alzheimer's disease (AD). We interviewed 71 consecutive patients with AD and asked (1) whether they had memory loss, (2) whether they found trouble in life, and (3) how their daily life was. We categorized the patients into three groups based on awareness of memory loss and reference to the cause of memory loss. Cognitive functions were lower in patients who were not aware of memory loss. The rate of satisfaction with life was the highest in patients who were not aware of memory loss, and was the lowest in patients who complained of memory loss with reference to the cause of memory loss, indicating that patients could hardly accept their lives when memory impairment was a serious issue. However, in these patients, depression scores were not high, suggesting that they may somehow adapt themselves to their current status by defining the reason for memory loss. In patients who complained of memory impairment but did not refer to the cause of memory loss, there was a variation in awareness of memory loss and satisfaction with life. The present study indicated that we have to provide individual care and support for AD patients considering their level of acceptance of memory impairment.

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To identify risk factors of urinary tract infection (UTI) in geriatric patients, the levels of serum uric acid, serum creatinine, and urine pH were compared between pyuria-positive and -negative patients in a geriatric ward. The level of serum uric acid was higher with lower urine pH level in the pyuria-negative patients than in positive patients. The level of serum creatinine was relatively higher in the pyuria-negative patients than in the positive patients. Even after matching for serum creatinine, serum uric acid was significantly higher in the pyuria-negative male patients. The results in the present study proposed an interesting hypothesis about backgrounds for UTI in geriatric patients. The relationships among serum uric acid, serum creatinine, urine pH, and pyuria should be examined further in a larger population and in experimental studies.

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An 86-year-old woman suffered sudden onset chest discomfort and dyspnea during sleep in the early morning of August 1, 2003. On admission, electrocardiography demonstrated complete atrioventricular block. Echocardiography showed severe hypokinesis in the left ventricular apex and hyperkinesis at the base. Serum cardiac deviant enzymes were slightly elevated. Based on these findings, acute myocardial infarction accompanied by complete atrioventricular block was suspected. Emergency coronary angiography performed under temporary pacing showed no significant stenosis in the coronary arteries. However, ventriculography demonstrated the presence of a foxhole-shaped left ventricular abnormality. A VDD type permanent pacemaker was implanted 5 days after the onset of the symptoms because the atrioventricular block had not improved. Following the implantation, pleural effusion and a temporary elevation of the body temperature occurred. The myocardial scintigraphy using ¹²³I-metaiodobenzylguanidine (¹²³I-MIBG) in the acute phase demonstrated extensive cardiac sympathetic nerve damage in the left ventricular apex. This condition was managed by medication including diuretics, angiotensin II receptor blocker and β-blocker. Three months later, echocardiography and ¹²³I-MIBG myocardial scintigraphy showed slight recovery of wall motion and sympathetic activity. However, mild pleural effusion persisted. A complete atrioventricular block was also present at this stage.
In view of these findings, this case suggested that the foxhole-shaped left ventricular abnormality induced complete atrioventricular block with delayed recovery of wall motion.

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A 75-year-old man first developed dyspnea and low-grade fever in late March. A chest X-ray film showed infiltration in the right lower lung field and blood gas analysis revealed severe hypoxemia. Accordingly, he was diagnosed as having pneumonia and was admitted to our hospital on March 11, 2003. Mechanical ventilation for progressive respiratory failure was started immediately after admission, and he was treated with antibiotics. Chlamydia pneumoniae pneumonia was diagnosed due to an increase of the Chlamydia pneumoniae antibody titer. He had prolonged respiratory failure despite antibiotic therapy. Therefore, steroid therapy was started on day 15 for respiratory failure. At 21 days after admission, the infiltration was found to be decreased on chest X-ray films and improvement of hypoxemia allowed extubation.
In conclusion, when severe community-acquired pneumonia occurs in elderly patients, we should remember the possibility of atypical pneumonia such as that due to Chlamydia pneumoniae infection.

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