Psychological studies were made of 41 patients with indefinite complaints in outpatient clinic of general internal medicine compaired with 120 patients with respiratory diseases such as chronic obstructive pulmonary disease, bronchial asthma and hyperventilation syndrome and pulmonary symptoms such as idiopathic dyspnea and chest pain using three psychological screening tests of CMI (Cornell Medical Index), MAS (Manifest Anxiety Scale) and SDS (Self-rating Depression Scale).
In patients with indefinite complaints, III and IV areas of CMI characteristic of neurosis was 68.3%, more than 50 scores of SDS test characteristic of depression was 39% and more than 25 scores of MAS highly characteristic of anxiety was 43.8%. The proportion of these psychological screening tests was greater in patients with indefinite complaints than in any group of respiratory diseases.
In patients with indefinite complaints, minor tranquilizer was effective in 54.5% of patients with I and II groups of CMI, 42.1% with less than 49 scores of SDS and 50% less than 24 paints of MAS, but it had less effect on the groups of III and IV of CMI (20%), more than 50 scores of SDS (16.3%) and more than 25 scores of MAS (7.7%).
On the other hand, antidepressants were much more effective on the latter group than the former.
More than 50% of the patients with indefinite complaints were not improved by pharmacological treatment. Counselling and general psychological treatment should be applied to the treatment of such group of patients.

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The levels of nucleic acid bases in resected gastric tissues, were measured by HPLC and analyzed clinicopathologically. In 14 cases with gastric carcinoma, the sum of the base levels was high in tumor tissues and the mean level of each base in the tumor was as follows: cytosine (0.36mcg/g), thymine (0.72mcg/g), uracil (65.09mcg/g), adenine (11.29mcg/g) and guanine (8.32mcg/g). The levels of uracil was significantly higher in tumor tissue than in normal mucosa. Positive correlation was observed between the level of tumor and of normal mucosa (a coefficient of correlation of 0.66). Histologically, uracil showed a high concentration in cases with lymphatic invasion or lymph node metastasis. Negative correlation was observed between the survival time of 7 patients who died of progressive carcinoma of the stomach and their uracil level in tumor (a coefficient of correlation of -0.61). These results indicate that determination of uracil level in gastric carcinoma might provide useful information for the prognosis of cancer patients.

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An enzymatic method for the determination of polyamines as a whole has been developed by use of a reagent containing two kinds of amine oxidase and BCMA. A study was performed to ascertain the performance of this method for the assay of human blood polyamines. Within run precision as indicated by coefficients of variation ranged from 4.5% (10.7nmol/ml WB) to 4.8% (32.4nmol/ml WB). Between day coefficient of variation ranged from 7.4% (23.8nmol/ml WB)to 10.2% (7.0nmol/ml WB). Assay was linear to 300, 280 and 200nmol/ml for putrescine, spermine and spermidine, respectively. For polyamine, no interferrence by bilirubin, hemoglobin or turbidity was observed.
Polyamine levels in the whole blood of 228 patients with breast carcinoma prior to radical surgery, 4 recurrent cases of breast carcinoma and 17 patients with benign breast diseases were studied. Levels of polyamine in the whole blood of patients with breast carcinoma with lymphnode metastasis were significantly higher than those without metastasis. Further studies are necessary to determine if these assay may be helpful in monitoring tumor progression and metastatic involvement.

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Human serum albumin is a mixture of mercaptalbumin which has a sulfhydryl group, and nonmercaptalbumin which has a sulfide with cysteine and glutathion. The fraction of mercaptalbumin decreased in a variety of diseases including chronic renal failure, liver cirrhosis, and etc.. Human serum albumin preparations produced by three companies and serum albumin of healthy volunteers and liver cirrhosis patients were analyzed by HPLC on anion exchange column. The fractions of mercaptalbumin in the albumin preparations varied with lots and the companies. The fraction of mercaptalbumin in liver cirrhosis was significantly lower than that in healthy subjects. These results suggest the clinical usefulness of analysis of serum mercapt-nonmercaptalbumin.

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This symposium was timely organized to review and discuss on the health and medical care problems of the elderly with special reference to the role of national hospitals and sanatoriums that is becoming increasingly important in the coming years. At first chairmen pointed out four major problems in elderly care to be solved, that is, level-up of quality of medicine (geriatrics), new system build-up of hospitals and nursing homes for the elderly care, integration of medical care and services of health and welfare for the elderly and the acquisition of manpower. Following the opening remarks, five representative symposists reported their original works with relevant discussion on five medical problems in elderly medicare described below.
1) The role of general medical department in primary and emergency care—Dr. T. Takahashi (2nd Tokyo National Hospital)
2) The long term care of national hospitals and sanatoriums—Dr. T. Kachi (Chubu-Byoin National Sanatorium.)
3) The early rehabilitaion for the elderly patients with apoplexy-Dr. N. Shinozuka
(National Sanatorium Tokyo Hospital)
4) Palliative care program of terminal illness in national hospitals-Dr. Y. Shima (National Sanatorium Matsudo Hospital)
5) Ten-year strategy for the promotion of health and welfare for the elderly—Dr. T. Oida (Policy Planning and Evaluation Division, Ministry of Health and Welfare)
After all presentations, hot and enthusiastic discussion was made on individual and entire problems. It was finally concluded that in cooperation with civil institutions national hospital and sanatoriums should take possible concerted and immediate action in all fields to provide the increasing elderly with adequate medical and health care services.

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The elderly older than 65 years population of the Japnese people amounts to 11.9% of total population in 1990 and will rapidly increase for the next 10 years up to 2000 AD.
According to the patient survey in October 1990, total numbers of in-patients and outpatients in Japan were 1, 440, 000 and 6, 630, 000 and the ratio of elderly patients in in-patients was 42.9% and 27.1% in out-patients respectively. On the other hand, the number of patients receiving medical care was 6, 600 per 100, 000 population: this means one par 15.2 population received medical care or whatever.
Among the age-hierarchy of patients older than 65 years, the rate of population receiving medical care was 18, 105, that is, about three times as many as that of average population.
From the point of view of the cost of medical care, it totaled up to 20, 900 billion yen and that of the elderly up to 6, 000 billion yen (30% of the total cost).
The significance of the elderly patients in future medical care of Japan is acceleratedly increasing from all aspects of patient numbers, rate of population receiving medical care and its cost.
In this symposium, we discussed the clinical features and medical care for the elderly patients by picking up the representative clinical fields such as cardiovascular deseases, pulmonary diseases (Iung cancer), cancer of the digestive organs, bone and joint diseases and diabetes mellitus.
Problems of side effects of cardiovascular drugs for the elderly, indications of the operation for the elderly with lung cancer, choice of treatment for the elderly with hepatocellular carcinoma, features and treatment of femoral head fractures in osteoporosis and treatment of the elderly with diabetes mellitus were discussed by several symposists.

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A case of alpha-fetoprotein (AFP)-producing gastric cancer without liver metastasis was reported. The patient was 73-year-old female who was admitted to our hospital complaining of epigastric passage failure and upper gastrointestinal series revealed Borrmann type 3 tumor located at the cardia which was confirmed as Group V by biopsy. Except for a abnormally high 6885ng/ml serum AFP level, no abnormal findings were noted in blood biochemical examinations. And no other lesions were found by abdominal ultrasonography, computed tomography and angiography.
Then total gastrectomy with R₂ curettage was performed. Histopathological examination demonstrated well-to moderately differentiated adenocarcinoma partially admixed with poorly differentiated adenocarcinoma (medullary type), limited to tela subserosa with lymphnode metastasis n₁(+). Immunohistochemically, AFP was not demonstrated in the gastric cancer cells, but serum AFP level returned to normal value early after the operation.
Thus we considered that AFP in the serum was produced by gastric cancer cells. Because of high malignancy and high incidence of liver metastasis, the prognosis of AFP-producing gastric cancers is poorer than that of AFP non-producing ones. In view of these characteristics of AFP-producing gastric cancers, an establishment of more effective and more reliable combination therapy is expected.

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Sixteen patients with pancreatic pseudocysts since 1970 were analyzed after dividing them into two groups: a pancreatic group (8 with pancreatitis-associated pseudocyst; P group) and a traumatic group (8 with traumatic pseudocyst; T group).
The mean age was younger in the T group (27.8 years) than in the P group (55.1 years). In terms of the male-to-female ratio and the site and morphology of cysts, no differences among two groups were observed.
In the P group, 4 patients were treated conservatively, and 4 were treated surgically. In the T group, 5 patients were treated conservatively, and 3 were treated surgically.
Of the conservatively-treated patients, US-guided percutaneous pancreatic cyst drainage (PPCD) were performed in 2, percutaneous puncture of the cyst in 1, percutaneous transhepatc bile duct drainage in 1 and medication only in 5. The procedures of surgical treatment were external drainage in 3 patients, the cyst-gastrostomy in 2, the cyst-jejunostomy in 2, and excision of the cyst with distal pancreatectomy in 1.
In one patient in which the cyst persisted after external drainage, ethanol injection into the cyst reduced its size.
Spontaneous regression of the cyst was observed in 3 patients (18.8%) in the T group. Rupture of the cyst into the peritoneal cavity was observed in 2 patients (12.5%) in the P group and external drainage of the cyst were done.
These results indicate the recent increase in conservative treatment (chiefly with US-guided PPCD) for pancreatic pseudocyst and the necessity of considering the risk of spontaneous rupture of the cyst in the management of pancreatic pseudocyst.

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A 14-year-old boy was admitted to the hospital because of fever and bleeding tendency in May 1989. He was diagnosed as having Ewing's sarcoma of left tibia in April 1988. The sarcoma cells were positive for PAS staining but negative for neuron-specific enolase and leukocyte common antigen in immunohistochemical staining. After irradiation therapy and chemotherapy, the patient underwent a radical operation for Ewing's sarcoma. Histological examination of the surgical specimen showed complete necrosis and no vivid sarcoma cells. He was doing well until admission. Hematological findings on admission revealed as follows: white blood cells 5.4×10⁹/l with 57% blasts, hemoglobin 13.0g/dl, platelet count 17×10⁹/l, fibrinogen 318mg/dl and FDP 40mg/dl. Bone marrow aspiration showed hypercellular pictures and 92.8% of the cells were blasts. Blasts showed positivity for PAS, CD 10 and HLA-DR. Immunoglobulin rearrangement was demonstrated. The patient was diagnosed as having common type of acute lymphoblastic leukemia with disseminated intravascular coagulation. He entered complete remission in Aug. 1989. Remission continued for another 5 months, but a development of meningeal involvement and relapse occurred. The patient died from cerebral bleeding 17 months after the initial diagnosis of ALL. It was suggested that the patient suffered from the double cancer.

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The recent progress in chemotherapy has led to a remarkable decrease in patients with pulmonary tuberculosis, but the age of the patients has been advancing in such a steady way as the patients aged over eighty years represent no less than 100 of all patients of our hospital. There were 808 cases of pulmonary tuberculosis admitted in our hospital during a period from 1986 to 1990. Of these, ninety cases were over 80 years of age and we made clinical examinations of possible tubercle bacillus in sputum on admission, time period reaching to negative bacteriological examinations, chest X-ray findings, possible relapse, complications, length of hospitalization and so on to find out whether there were any features in those very old patients.
On admission, 83% of the patients showed positive bacteriological examinations, and 77% of the patients became bacteriologically negative by chemotherapy during the first 2 months. More than half of the patients had a past history of tuberculosis and chest X-ray films revealed cavity-positive (type I-II) findings in 48.9% of the cases, with grade 3 according to the classification of Japanese Society for Tuberculosis representing 21.8%. Except for nineteen patients who died during hospitalization, the length of hospitalization was shorter than 6 months in 42% of the cases and shorter than 1 year in 92%. Ninety percent of the patients had some complications requiring treatment and bedridden patients were not so uncommon.

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Thirty-one children with mediastinal masses were treated from 1978 to August of 1991 at our hospital. There were 18 malignant and 13 benign tumors. The most common malignant tumor in our series was neuroblastoma, and the second common was malignant lymphoma. Among the children under the age of 5 years, neurogenic tumor was the most common malignancy. Of these, 2 cases were detected by mass screening.
Chief complaints such as cough, fever, and fatigue were more common in malignant than in benign cases. However, more than half of the total cases were asymptomatic. Horner's syndrome was seen in 3 cases, superior vena cava obstruction in 2 cases, paresis of recurrent nerve in one case.
The posteroanterior and lateral chest X-ray films were most frequently diagnostic, and computed tomography of the chest turned out to be more useful in evaluating the mediasitnal tumor and preoperative resectability.
There was no early or late mortality in patients with benign tumors. Despite recent progress in treating other kinds of cancers, the principal treatment for the malignant mediastinal tumors (except lymphoma) is still complete excision of the tumor combined with irradiation and/or chemotherapy. In one case, preoperative PVB chemotherapy of a huge yolk sac tumor was followed by excision, and the prognosis of the patient was very good.
During a follow-up period of 3 months to 11 years and 2 months, 55.6% (10/18) of the patients with malignant tumors were alive. The survival curve showed a plateau at 49%

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We experienced a case of respiratory arrest due to paralytic shellfish poisoning. A 59-year-old male ate 30-40 pieces of patinopecten yessoensis. He developed numbness in his lip and limbs one hour after eating. His respiration became paralyzed two hours after eating. An endotracheal tube was intubated and artificial ventilation was done. Six hours after eating his paralysis was gradually recovered. The endotracheal tube was extubated 15 hours after eating. He was discharged without any sequelae.

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A rare case with malignant schwannoma in parapharyngeal space associated with von Recklinghausen's disease is reported. A 23-year-old male, with some deformities in his features including low position of right auricle, complained of a swelling in the parotid region. He had many café au lait spots and nodules in the skin, and the diagnosis of von Recklinghausen's disease was made. A CT-scan showed a large mass occupying the right parapharyngeal space, and the tumor was removed using external approach. The histological examination of the resected tumor revealed malignant schwannoma. Soon afterwards, the tumor recurred and another mass appeared in the neck. Although the removal of the tumor was tried several times with irradiation therapy, the tumor gradually enlarged and metastasized to the lungs. He died of respiratory failure caused by metastatic tumor in the lungs.
We also discussed other 5 cases arising from the parapharyngeal space operated on in these 12 years in our department.

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A concept of quality of life (QOL) has been recognized in medical and welfare fields. To investigate the real condition of elderly patients with cerebrovascular diseases and/or degenerative neurologic diseases, quality of life was assessed in 181 elderly patients using the QOL scale established by the research committee of the Ministry of Health and Welfare of Japan. Of these 181 cases, 56 were living at their own homes, 16 hospitalized, and the other 112 living at nursing homes,
There was no significant difference of QOL points between male and female and among the age classes. The QOL in patients with cerebrovascular disease and/or degenerative neurologic diseases was severely disturbed. The QOL scores in elderly patients with dementia were better than in patients without dementia. The results suggest that the scientific quantitative evaluation of QOL in elderly patients seems to be more important in medical care and welfar policy.

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Ten pediatric IDDM patients were successfully treated for diabetic ketoacidosis with continuous low dose insulin infusion therapy of 0.1U/kg/hour. The mean time required for attaining “normoglycemia” (250mg/dl) was 5.4 hours. The incidence and severity of hypokalemia increased. No severe complication was observed. This method is effective, safe, and simple to administer.
Twelve IDDM patients were treated on the four times-a-day insulin regimen. This multiple insulin injections with blood glucose self monitoring procedures were well accepted.

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