A questionnaire survey was conducted to coordinate the discussion about “Problems in National Hospitals in Japan” at the Annual Meeting of the Councils of General Directors of all National Hospitals in Japan held on Sept. 29, 1993 in Sapporo.
The main questions were as follows: What is the most important requirement for a director of a National Hospital? What do you think about the future of National Hospitals?
This paper presents a summary of 90 directors' answers to the questionnaire and of their free discussion at the Annual Meeting.

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We studied electrocardiographic findings in 207 patients with chronic pulmonary diseases under chronic stable conditions. All patients underwent right heart catheterization within one week of ECG recording. Incidence of ECG findings was as follows; 1) voltage of lead I≤3mm 33.8%, 2) right axis deviation (RAD, +90°) 28.6%, 3) S-V5≥7mm 23.5%, 4) sinus tachycardia 20.5%, 5) R/S-V5≤1 18.9%, and 6) pulmonary-P (IIP≤2.5mm) 18.5%. Patients with pulmonary tuberculosis sequelae (TB, n=78) had a high incidence of RAD (46.3%) and pulmonary-P (26.9%). On the contrary patients with chronic pulmonary emphysema (PE, n=80) had a high incidence of low voltage of lead I (50%). There was a significant difference between patients with pulmonary hypertension (PH, pulmonary artery mean pressure ≥20mmHg, n=80) and those without PH (n=125) in the incidence of RAD (40% vs 21.4%, p<0.01) alone. Sensitivity of ECG findings in diagnosing PH was very low (18.2-40%). Transitional Zone of chest leads showed clockwise rotation in 37.5% of PE. ECG findings in PE were correlated not with pulmonary artery mean pressure but with FEV 1%. Therefore ECG findings in chronic pulmonary diseases were influenced not only by PH but also by obstructive change (lung overinflation) which is specific to PE and deviation of mediastinum which is frequent in TB.

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Malabsorption of D-xylose shown in most of pancreatic cancer patients suggests the usefulness of intravenous hyperalimentation (IVH) for treatment of pancreatic cancer. Therefore, on the usefulness of IVH we examined autopsy cases of pancreatic cancer (tubular adenocarcinoma) who were admitted and treated at the National Kyushu Cancer Center for 20 years from 1972 to 1991. IVH started at our institute from around 1980 and has been performed in all the patients with pancreatic cancer since 1985. Frequency of patients treated at home after the first time admission increased from 5.5% in the period before 1950 to 30% thereafter. The survival time (from admission to death date) was 8.1±0.89 (mean±SE) months in 62 cases treated with IVH and 4.8±0.62 months in 30 cases without IVH. There was a marginal significant difference between the survival time of the two groups. Then, the multivariate survival analysis showed that the hazard ratio for IVH treatment was 0.62 and the 95% confidence interval was 0.28-1.38. In conclusion, IVH used for treatment of pancreatic cancer has a good effect on prognosis, though it is not so significant according to statistical analysis.

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In order to investigate time course of effects of chemotherapy and radiotherapy on pancreatic cancer, we used the monolayer culture of a human pancreatic cancer cell line, SUIT-2 which produces CEA and CA19-9. Into the culture various kinds of anti-cancer drugs (MMC, ADR, FAR, 5FU, FT, CDDP, CPT-11) were administered for a period of 2 days, followed by irradiation with ⁶⁰Co. Observation period was 20 days, during which we measured LDH, CEA and CA19-9 in medium, DNA, protein, CEA and CA19-9 in cells in addition to observation of cells through microscope. Effects of anti-cancer drugs on pancreatic cancer cells were more greater than those of irradiation when doses of anticancer drugs were enough. By using a lot of anti-cancer drugs, LDH value in medium increased at early time and decreased later. CEA and CA19-9 values in medium decreased with the lapse of time, while they were increased later when small doses of the drugs had been administered. DNA, protein, CEA and CA19-9 values in cells showed a decrease in accordance with increased doses of the drugs. Effects of ET and CPT-11 were marginal compared with the other drugs.

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In order to avoid allogeneic blood transfusion, autologous blood collection and transfusion was tried in 90 patients with gynecological tumors. Preoperative blood collection was performed several times and the volume of blood collection was decided by estimated blood loss, hemoglobin value and general condition. The cases were divided into 3 groups (I, II and III) according to intraoperative blood loss (<600ml, 600≤ <1200ml, and 1200ml≤, respectively). Autologous blood transfusion was sufficient for group I. Additional allogeneic blood transfusion was required only in 4.7% of group II and 30.8% of group III. The decrease of hemoglobin level after blood collection was negligible and did not influence the systemic condition nor require a change in the operating schedule. These results suggest that autologous blood transfusion contributes to avoidance of allogeneic blood transfusion.

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Using the human peripheral blood normal neutrophils and the promyelocytic leukemia cell line (HL-60), the antigen of anti-neutrophil antibodies (ANA) in patients with copper deficiency was investigated. These patients were classified as group A and group B; Group A was ANA positive with neutropenia while group B was ANA positive without neutropenia. 1) The serum containing ANA from group A showed low binding (0-6.1%) to HL-60 cells, but that from group B bound to HL-60 (64.2-87%). 2) Induced differentiation of HL-60 by DMSO enhanced expression of CD 16 and CD 11b. The binding of ANA from group A patients to differentiated HL-60 was increasd (10.0-14.6%). 3) The monoclonal antibody of CD 16 showed the inhibition of ANA binding of group A to the peripheral neutrophils, but not that of group B. These data suggested that ANA in patients with copper deficiency and neutropenia were recognizing Fcγ receptor III as antigen.

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Four kinds of HIV-1 specific serum antibodies were quantitatively measured by biotinstreptavidin ELISA using p24, p17, RT (reverse transcriptase) proteins of recombinant structural gene products and nef (negative factor) protein of regulatory gene product of HIV-1 as antigens. Serum samples were collected serially for more than four years from 22 hemophiliac asymptomatic HIV-1 carriers (AC) including 2 cases seroconverted in 1985, and from 2 hemophiliac AIDS cases. Following results were obtained: (1) Antibody levels to both p24 and p17 antigens were relatively well correlated to the changes in CD4⁺ (T lymphocyte) cell counts. Decrease in CD4⁺ cell counts related to the decreases in anti-p24 and anti-p17 antibody levels. (2) High levels of binding anitbody to HIV-1 RT protein were maintained in all of the HIV-1 infected hemophiliac patients including AIDS cases, regardless of their CD4⁺ cell counts. (3) Nef antibody levels were relatively high in early few years of HIV-1 infection, thereafter the antibody levels were variable individually and less correlated to CD4⁺ cell counts and other antibody levels. Continuous oral administration of glycyrrhizin (GL) to HIV-1 seropositive AC patients and the one of the two seroconverters from an early stage of HIV-1 infection seemed to be effective to maintain the high levels of p24 and p17 antibodies, compared with another seroconverter and other seropositive patinets without administration of GL.

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We attempted bronchial embolization with Oxycel cotton via a bronchofiberscope in a case of spontaneous pneumothorax. A 65-year-old man had been suffering from lung emphysema since 1988. Because he developed right pneumothorax twice, S₁ and S₈ bullectomy was done. Air-leakage per sisted, however, and bronchial embolization was done, First, fibrin glue was applied, but it was not effective. Oxycel cotton was applied next, and it was effective.

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A 21-years-old male was admitted to South Wakayama National Hospital with injuries of occipital region and upper and lower extremities. The occipital injury was sutured, and the patient was discharged. Three days later, he visited a doctor because of high fever and clouding of consciousness, he was transferred in an ambulance to South Wakayama National Hospital. He had a severe hypoxemia at admission, and the cnltures of blood and tracheal sputa were negative for bacteria. Chest X-ray displayed a typical pulmonary edema with butterfly and diffuse shadows.
We diagnosed that a sepsis cansed by unidentified bacteria introduced by multiple trauma induced ARDS. We treated ARDS with PEEP and Pressure Support ventilations. And we used Metyl-PSL, antibiotics and urinatin. Despite the cansative pathogen of sepsis was not identified, broad spectrum antibiotics were effective.

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A case of eosinophilic enteritis causing intestinal obstruction is described. The patient was a 61-year-old male who was emergently admitted to our hospital for surgical treatment of intestinal obstruction.
On celiotomy, the cause of the intestinal obstruction was found not to be postoperative adhesion which is usual origin, but to be hypertrophic change of terminal ileal wall. Then, ileocecal resection including obstructive region was performed. Resected specimen demonstrated hypertrophy of the terminal ileal wall and Bauhin's valve.
Histopathologically, the entire eayers of the thickened wall of the terminal ileum showed hemorrhagic change with fibrinoid material and severe inflammatory infiltrates mainly composed of eosinophils. These findings led to the diagnosis of eosinophilic enteritis. Generally, it is very difficult to confirm a correct diagnosis of eosinophilic gastroenteritis confined to the small intestine preoperatively. Efforts to elucidate the cause of eosinophilic gastroenteritis and to accomplish a preoperative reliable diagnostic method and an effective conservative treatment based on its cause must be emphasized.

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A case of gastric cancer detected 13 years after selective proximal vagotomy for gastric ulcer in a 73-year-old man is reported. In 1981, the patient was admitted to our hospital because of gastric ulcer. He underwent selective proximal vagotomy, pyloroplasty and excision for gastric ulcer.
In 1994, an abnormality of stomach was detected by a health examination center. As a result, a Borrmann III type gastric cancer was found in the anterior wall of the body and total gastrectomy (D2) was performed. Histologic findinds were poorly differentiated adenocarcinoma, se, n (-), ly 2, v1.

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We report a case of hypothyroidism with unexpectedly low levels of serum T3 and free T3 probably due to impaired thyroxine conversion.
The patient was 76 year-old blind male. His serum levels of T4, T3 and TSH were 0.5μg/dl, less than 0.5ng/ml and 44.9μIU/ml, respectively, and his illness was diagnosed as primary hypothyroidism in August 1991. With the increasing doses of thyroxine replacement (25 to 125μg/day), serum level of TSH decreased to 8.3μIU/ml and those of T4 and free T4 increased to normal ranges. However, serum level of T3 was still less than 0.5ng/ml and that of free T3 was also low (0.8pg/ml). He had not received iodide contrast media or taken excess iodide. Also he had no hypo-albuminemia, drugs inducing impaired thyroxine-metabolism, anti-T3 antibody, TBG deficiency or low T3 syndrome. The etiology of low level of serum T3 of this patient may be due to the impaired conversion (deiodination) of T4 to T3.

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Methicillin-resistant Staphylococcus aureus (MRSA) infection. among hospitalized patients with hematological diseases in Kyoto National Hospital during past five years was studied. The incidence of infection was significantly higher among patients with hematological diseases than those with non-hematological diseases in the same ward. There were 11 patients 5 with myeloma, 3 with acute leukemia and 3 with malignant lymphoma. Ten patients were older than 50 years and 8 were male.
MRSA was cultured mostly from sputa and throat exudates. Urine was the following source in frequency. MRSA positive patients tended to cluster during certain periods, which suggested nosocomial tranomission. No relation was found between MRSA infection and patients' leukocyte or granulocyte count. MIND, IPM/CS or VCM were used and MRSA was eradicated in 7 cases. Four patients died of complicated MRSA infections.

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We reported a 1 year old girl who had epileptic seizures since the age of 6 months. Phenobarbital, valproic acid and clonazepam were ineffective for the seizures. However, she became seizure-free after institution of carbamazepine.
She was well until she started seizing at 6 month of age. Her development was normal. The seizures tended to occur in clusters. The interictal EEGs were normal. Clinically, the seizures were usually generalized tonic-clonic, although they were sometimes asymmetric and preceded by blank staring. Her seizure was similar to benign partial epilepsy in infancy (Watanabe et al., 1993) or benign infantile convulsion (Fukuyama, 1963). We think that carbamazepine is one of the choices for antiepileptic drugs for so-called benign infantile epilepsy.

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Before May 1994, 74 early breast cancer patients were treated with conservative surgery and radiotherapy. The majority of patients received quadrantectomy. The mean dose was 50 Gy for the whole breast and 20 Gy for the tumor bed. All patients received adjuvant systemic chemotherapy and hormonal therapy. The patients had a mean follow-up of 22 months and no locoregional relapse or distant metastasis.
The multicentricity of 94.7% in stage II breast cancer was statistically higher than 61.2% in stage I breast cancer. Of the 75 tumors, 9 (47.7%) had positive margins in stage II breast cancer and 15 (30.6%) in stage I breast cancer. Only two patients, having cancer extend to surgical margin from tumor, underwent mastectomy. But they had no evidence of further residual diseases.
The patients who received breast conserving surgery had less depression or anger than the patients who received mastectomy in psychological test CMI.

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The number of patients receiving breast-conserving therapy is increasing because such therapy has achieved an survival as well as disease-free rate equivalent to those with total mastectomy in various studies.
Our criteria for breast-conserving therapy are T1, small T2, N0 or N1a breast cancer without diffuse micro-calcification on mammography.
From August 1991 to May 1994, 22 patients underwent breast-conserving therapy for breast cancer.
One of the 22 patients required total mastectomy after lumpectomy, because of extensive intraductal spread and diffuse tumor invasion.
This paper stressed the difficulty and importance of determining the extent of tumor invasion in patients who are scheduled to receive breast-conserving therapy.

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Although there have been no definite ways in which we should care for the children with malignant disease in terminal stage, they must be free from the pain first of all. In most of the cases mild pain can be treated successfully with aspirin, acetaminophen or codeine phosphate. When pain is more severe, morphine hydrochloride is given orally, per rectum or subcutaneously; however, medication is not completely effective when given intermittenthz. We report 3 children with malignant disease in terminal stage who were treated with continuous intravenous infusion of morphine hydrochloride.

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