Association between underlying disease and serious events on a world cruise ship: A prospective cohort study.

BACKGROUND: This study aimed to clarify the effects of underlying diseases on clinical outcomes of patients aboard a world cruise ship. METHODS: This prospective cohort study included patients who sought physician consultations at an onboard clinic on a 105-day world cruise (September-December 201X) on a ship chartered by a Japanese travel agency. Multivariable logistic regression analysis was performed to ascertain whether any concurrent disease, such as hypertension, was associated with additional onboard treatment by the primary physician or serious events, including unexpected final disembarkation, temporary disembarkation for hospitalization ashore, shore-side referral, and onboard clinic admission. RESULTS: Of 313 patients, 182 (58%) had at least one underlying disease. Sixty-eight (22%) required additional treatment, and 24 (8%) experienced serious events. After adjusting for age, sex, and underlying diseases, the 60-69- and 70-74-year age groups had a lower risk of serious events than the ≤59-year age group (odds ratio [OR], 95% confidence interval [CI]: 0.24, 0.069-0.81; p = 0.022 and 0.045, 0.0051-0.47; p = 0.0055). Underlying disease was associated with serious events (OR, 95% CI: 3.2, 1.1-9.5; p = 0.036). CONCLUSIONS: Unexpected events can occur in patients on world cruises regardless of age. Preexisting diseases may confer higher risk of serious events.

A study of the usefulness of inspection of radiology reports in the emergency room.

AIM: The aim of this study was to better understand the usefulness of retrospective inspection of radiology reports of CT (computed tomography) or MRI (magnetic resonance imaging) by emergency doctors in the emergency room. METHODS: Between April 2018 and March 2019, patients who went home after CT or MRI who needed to change their treatment plans and subsequent corresponding procedures after inspection of radiology reports by emergency doctors were reviewed. RESULTS: Among 7,661 CT or MRIs performed on 5,917 patients, there were 131 patients (133 CT or MRI or 1.7% among 7,661 examinations) who required a change in their treatment plans after inspection of radiology reports. Of the 133 CT or MRI performed, there were 51 (38.3% among 133 CT or MRI, 0.7% among 7,661 examinations) CT or MRI performed, which indicated findings to suspect a tumor (11.8% in the head, 41.2% in the chest, 35.3% in the abdomen, and 11.8% in others). With the need to make important changes in treatment plans, making appointments for outpatient clinics was necessary for 52 CT or MRI findings, and requiring the patients to return to the clinic or be admitted was necessary for 9 (totally 61; 0.8% among 7,661 examinations). CONCLUSION: Data from this study suggest that inspection of radiology reports of CT or MRI by emergency doctors after patients went home is useful in finding characteristics suggestive of tumors in 0.7% of all radiology reports and is necessary to identify important changes that should be made in treatment plans in 0.8% of all radiology reports.

A study of the effect of introduction of JTAS in the emergency room.

Aim: The purpose of this study was to better understand the effects of introducing the Japan Triage and Acuity Scale (JTAS) in the emergency room for walk-in patients. Methods: A simple triage was used in Term A (from April 2006 to December 2010, 4 years and 9 months) and the JTAS was introduced in Term B (from January 2011 to September 2015, 4 years and 9 months). The number of patients who had a sudden turn for the worse after arrival in the emergency room and the time between attendance and emergency catheterization (TBAEC) due to acute coronary syndrome were reviewed. Results: There were 653 patients in Term A and 626 patients in Term B who were finally diagnosed as having serious causes. There was no significant difference in the frequency of a sudden turn for the worse between the two terms. There were 182 patients in Term A and 167 patients in Term B who underwent emergency catheterization due to acute coronary syndrome. When ST elevation was recognized in the first electrocardiogram, the median time between attendance and medical attention during Term B improved significantly, by 4.5 min. However, there was no significant difference in medians for TBAEC. When ST elevation was not recognized, there was no significant difference between the two terms, neither in terms of median time between attendance and medical attention, nor TBAEC. Conclusion: The data suggests that the effects of introducing the JTAS in the emergency room were restrictive in these two aspects.

Diagnosis of Ingested Foreign Body in the Stomach by Point-of-Care Ultrasound in the Upright and Slightly Forward Tilting Position (Bowing Position).

We report a case involving accidental ingestion of a marble that was detected by point-of-care ultrasonography of the abdomen with the patient in the upright and slightly forward tilting position, which we term the "bowing position." Using this position for abdominal ultrasonography may be more useful than the usual supine position for such patients.

Experimental and computational studies of the roles of MgO and Zn in talc for the selective formation of 1,3-butadiene in the conversion of ethanol.

The one-step conversion of ethanol to 1,3-butadiene was performed using talc containing Zn (talc/Zn) as a catalyst. The influence of the MgO and Zn in the talc on the formation rate and selectivity for 1,3-butadiene were investigated. MgO as a catalyst afforded 1,3-butadiene with a selectivity that was nearly the same as talc/Zn at ∼40% ethanol conversion at 673 K, although the rate of 1,3-butadiene formation over MgO was about 40 times lower than that over the talc/Zn. The introduced Zn cations were located in octahedral sites in place of Mg cations in the talc lattice. The Zn cations accelerated the rate of CH3CHO formation from ethanol, resulting in an increase in the rate of 1,3-butadiene formation. However, the rate of CH3CHO consumption to form crotonaldehyde was not influenced by Zn, although the distribution of crotonaldehyde was decreased with increasing Zn concentrations. X-ray photoelectron spectra of talc/Zn showed that the O1s binding energy was increased by increasing the concentration of Zn, while those of both Mg2p and Si2p were hardly influenced. DFT calculations were used to estimate the atomic charges on the O, Mg, Si, and Zn atoms when an atom of Zn per unit cell of talc was introduced into an octahedral site. On the basis of the results for the conversion of ethanol into 1,3-butadiene and the corresponding DFT calculations, the roles of the O, Zn, Mg, and Si atoms in the talc catalyst for the formation of 1,3-butadiene from ethanol were discussed.

Paradoxical surge of corticotropin after glucocorticoid replacement in central adrenal insufficiency.

A 78-yr-old man was admitted in emergency with fatigue, anorexia, vomiting, hypothermia (35.1 °C on a hot August day), hypotension (89/56 mmHg) and hyponatraemia (126 mEq/l). Plasma corticotropin and cortisol were severely depressed: 0.84 pmol/L and 33.1 nmol/L respectively (reference range, 1.5-13.9 pmol/L and 110-505 nmol/L, respectively). Thyroid stimulating hormone was low-normal and free-triiodothyronine and free-thyroxine were subnormal. Magnetic resonance imaging revealed swelling of the pituitary gland and the stalk. The patient recovered after glucocorticoid replacement (200 mg/day intravenous hydrocortisone on Day 1 followed by tapering). Central diabetes insipidus which had become apparent had been treated with 1-desamino-8-D-arginine vasopressin. A surge of corticotropin and cortisol, 19.4 pmol/L and 712.1 nmol/L respectively, was found on Day 5 when luteinizing hormone, follicle stimulating hormone, and testosterone were subnormal and prolactin was slightly elevated. Subsequently, corticotropin and cortisol levels normalized together with normalization of luteinizing hormone, follicle stimulating hormone, anti-diuretic hormone, thyroid stimulating hormone, prolactin, testosterone and thyroid hormone levels. Shrinkage of the pituitary gland occurred after one month. Serum immunoglobulin G4 was elevated (3.21 and 6.02 g/l at 1- and 3-month follow-ups respectively). In conclusion, a paradoxical surge of corticotropin after glucocorticoid replacement was observed in a patient with central adrenal insufficiency due to immunoglobulin G4-related hypophysitis. Surge of ACTH in central adrenal insufficiency after glucocorticoid replacement has rarely been reported, and this is the second such case report.

Gamma knife thalamotomy for Parkinson disease and essential tremor: a prospective multicenter study.

BACKGROUND: No prospective study of gamma knife thalamotomy for intractable tremor has previously been reported. OBJECTIVE: To clarify the safety and optimally effective conditions for performing unilateral gamma knife (GK) thalamotomy for tremors of Parkinson disease (PD) and essential tremor (ET), a systematic postirradiation 24-month follow-up study was conducted at 6 institutions. We present the results of this multicenter collaborative trial. METHODS: In total, 72 patients (PD characterized by tremor, n = 59; ET, n = 13) were registered at 6 Japanese institutions. Following our selective thalamotomy procedure, the lateral part of the ventralis intermedius nucleus, 45% of the thalamic length from the anterior tip, was selected as the GK isocenter. A single 130-Gy shot was applied using a 4-mm collimator. Evaluation included neurological examination, magnetic resonance imaging and/or computerized tomography, the unified Parkinson's disease rating scale (UPDRS), electromyography, medication change, and video observations. RESULTS: Final clinical effects were favorable. Of 53 patients who completed 24 months of follow-up, 43 were evaluated as having excellent or good results (81.1%). UPDRS scores showed tremor improvement (parts II and III). Thalamic lesion size fluctuated but converged to either an almost spherical shape (65.6%), a sphere with streaking (23.4%), or an extended high-signal zone (10.9%). No permanent clinical complications were observed. CONCLUSION: GK thalamotomy is an alternative treatment for intractable tremors of PD as well as for ET. Less invasive intervention may be beneficial to patients.

Hypoglycaemic coma due to adrenal failure in a chronic haemodialysis patient.

A 62-year-old man, receiving chronic haemodialysis and suffering from alcoholic liver cirrhosis and chronic pancreatitis, presented with hypoglycaemic coma. Plasma cortisol was undetectable (< 5.5 nmol/L) with suppressed adrenocorticotropic hormone (ACTH), which established a diagnosis of adrenal failure due to ACTH deficiency. Twenty-five milligrams of oral hydrocortisone eradicated hypoglycaemia. Presentation of adrenal failure in this patient was atypical because he was hypertensive, serum electrolytes including sodium were normal and anaemia was unremarkable, which were all due to end-stage renal disease and its treatment with haemodialysis. As far as we are aware, this is the first case report of hypoglycaemic coma due to adrenal failure in a chronic haemodialysis patient.

Key role of the pore volume of zeolite for selective production of propylene from olefins.

A plausible reaction mechanism for propylene (C(3)H(6)) production from ethylene (C(2)H(4)) was investigated, based on the amounts of effluent hydrocarbons and hydrocarbons produced in the pores of SAPO-34. Propylene was produced via an oligomerization-cracking mechanism. On the basis of this mechanism, the conversions of C(2)H(4), pentenes, and hexenes were examined. The catalytic performance was compared, in order to investigate the role of the pore volume of zeolites with 8-, 10-, and 12-membered rings in the selective production of C(3)H(6). The selectivity for C(3)H(6) was crucially dependent upon the pore volume of the zeolite. Highly selective production of C(3)H(6) from olefins (C(2)H(4), pentenes, and hexenes) can be accomplished by employing a new concept: adjusting the pore volume of a zeolite to accommodate the volume of an olefin and/or its carbenium cations, as opposed to a conventional molecular sieve approach. For example, an unimolecular cracking of pentenes into C(3)H(6) and C(2)H(4) involving primary cations can be controlled by the pore volume of a zeolite.

Influence of Si distribution in framework of SAPO-34 and its particle size on propylene selectivity and production rate for conversion of ethylene to propylene.

To investigate the effect of SAPO-34 particle size (with a fixed Si mole fraction in its framework) and that of the Si mole fraction (in a SAPO-34 framework with fixed particle size) on propylene selectivity and production rate for the conversion of ethylene to propylene, SAPO-34 was prepared by hydrothermal synthesis using tetraethyl ammonium hydroxide or morpholine as a structural agent. The conversion of ethylene was carried out at 473 K using SAPO-34. The selectivity for propylene, the rate of propylene production, and the lifetime of the catalyst were strongly influenced by the catalyst crystal size. The SAPO-34 with a approximately 2.5 microm particle size had the highest selectivity for propylene (approximately 80%) up to a high conversion of ethylene (approximately 70%), while SAPO-34 with smaller particles had a longer catalyst lifetime, implying that catalyst deactivation was suppressed. The mole fraction of Si in the SAPO-34 framework with fixed particle size had little influence on the selectivity for propylene, indicating that the acid strength of SAPO-34 is independent of the Si mole fraction and all protons in SAPO-34 behave equivalently. Furthermore, the acid strength of protons determined by the measurements of NH(3)-TPD (temperature-programmed desorption) spectra did not depend on either the Si mole fraction or the SAPO-34 particle size. This result was also evident in the cracking rate of n-butane, which increased proportionally with increasing number of protons in SAPO-34.The number of protons generated by the incorporation of Si4+ into the SAPO-34 lattice increased proportionally, up to one Si atom introduced into every cage of SAPO-34, but did not continue to increase with further introduction of Si4+ into the lattice.

Subtle computed tomography abnormalities in cerebral deep sinus thrombosis.

A patient with cerebral deep sinus thrombosis, which was not diagnosed on the first examination, is reported. A 46-year-old woman presented with headache and vomiting. Neurological examination and a brain computed tomography (CT) scan showed no obvious abnormal findings. The patient suffered disturbed consciousness on the day after the examination, and was admitted to our emergency centre. A CT scan and magnetic resonance imaging revealed an ischaemic lesion in the left basal ganglia, suggesting deep sinus occlusion. Anticoagulant therapy was administered. One day after admission, a CT scan showed a haematoma and severe brain swelling in the same region. Cerebral angiography demonstrated a straight sinus occlusion. Intracranial pressure was not controlled with hypothermia, and the patient died 25 days after admission. Review of the initial CT scan revealed subtle, early findings of deep venous thrombosis that were missed on first examination.

Factors affecting the prognosis of anatomical liver resection for liver metastases from colorectal cancer.

BACKGROUND/AIMS: Liver resection has improved the survival of colorectal cancer patients with metastases. However, there are groups at high risk of recurrence after liver resection. This report reviews our results using anatomical liver resection and analyzes the prognostic factors. METHODOLOGY: We analyzed 78 patients who underwent anatomical liver resection of liver metastases from colorectal cancer between June 1988 and March 2002. RESULTS: Twenty-nine patients had synchronous metastases, and 49 had metachronous. The 5-year overall survival rate was 43%. Patients with more than three metastatic tumors had a significantly poorer 5-year recurrence-free survival rate. There was no statistical difference in the 5-year overall survival rate between patients with metachronous metastases (41%) and those with synchronous (44%) metastases. The 5-year overall survival rate was significantly poorer for patients with an interval of 1 year or less between colorectal and liver resections than for patients with a longer interval. Recurrence after liver resection occurred in 38 patients (49%). The recurrences occurred in the lung in 18 patients, in remnant liver in 15 patients, in lymph nodes in 7 patients, and in other organs in 6 patients. CONCLUSIONS: We conclude that anatomical liver resection of liver metastases from colorectal cancer improves survival. Liver metastases that occur within 1 year of colorectal resection may need an interval of observation before liver resection.

Beneficial effects of protein-bound polysaccharide K plus tegafur/uracil in patients with stage II or III colorectal cancer: analysis of immunological parameters.

Protein-bound polysaccharide K (PSK) increased the 5-year disease-free survival rate and reduced the risk of recurrence in a randomised, controlled study for stage II and III colorectal cancer. In order to elucidate the disease-free survival benefits with PSK and what immunological markers could indicate a PSK responder, serial changes in immunological parameters were monitored in the study. PSK decreased the mean serum immunosuppressive acidic protein (IAP) level, and increased the mean population of natural killer (NK) cells compared with the controls. The 5-year disease-free and overall survival rate for patients with serum IAP values or=8% at 3 months after surgery, PSK conferred a significantly better (p=0.038) 5-year disease-free survival (86.7%; 95% CI: 74.5-98.8%) compared to the control group (60.0%; 95% CI: 29.6-90.4%). In the proportional hazards model, the presence of regional metastases (relative risk, 3.595; 95% CI: 1.518 to 8.518; p=0.004) and omission of PSK treatment (relative risk, 3.099; 95% CI: 1.202 to 7.990; p=0.019) were significant indicators of recurrence. PSK acts as an immunomodulatory activity and biochemical modulator in stage II or III colorectal cancer. Pre-operative serum IAP values or=8% at 3 months after surgery are possible PSK response predictors.

Middle cerebral artery occlusion associated with acute myocardial infarction in the perioperative period--case report.

A 68-year-old woman with no history of cardiac events suffered acute myocardial infarction after surgery for middle cerebral artery (MCA) occlusion manifesting as transient left motor weakness. Diffusion-weighted magnetic resonance imaging revealed multiple infarctions in the right cerebral hemisphere. Magnetic resonance angiography and cerebral angiography demonstrated an occlusion at the horizontal segment of the right MCA and no collateral circulation. Cerebral blood flow study 6 weeks after the initial presentation indicated decreased blood flow in the right cerebral hemisphere. Superficial temporal artery-MCA anastomosis was conducted to prevent recurrent cerebral infarction. Two hours after surgery, her systolic blood pressure fell to 60 mmHg and her consciousness worsened. Emergency coronary angiography indicated occlusion of the right coronary artery. Percutaneous coronary intervention was successfully performed and the subsequent course was uneventful. Preoperative evaluation of the coronary artery may be necessary before surgery for cerebral ischemic disease in both the intracranial and extracranial arteries.

A saccular-like dissecting aneurysm of the anterior cerebral artery that developed 2 years after an ischemic event.

BACKGROUND: A rare case of a growing dissecting aneurysm, which was located at the horizontal (A1) segment of the anterior cerebral artery (ACA), is reported. CASE DESCRIPTION: A 53-year-old woman experienced left hemiparesis and alien hand syndrome. A computerized tomography scan showed an infarction in the right frontal lobe, and cerebral angiography revealed a false lumen and intimal flap at the A1 segment of the ACA. Magnetic resonance angiography demonstrated that the stenosis progressed 6 months later and improved 1 year later. Cerebral angiography showed a saccular-like aneurysm 2 years later. The surgery was planned for prevention of aneurysmal rupture. The aneurysm, which was cocoon shaped, was exposed surgically and was resected. Histological examination of the aneurysm showed arterial dissection. The postoperative course was uneventful without additional neurological deficits. CONCLUSION: This is the first case report of A1 dissecting aneurysm presenting with an ischemic event in the literature. The sequential change of the configuration was curious to develop aneurysmal dilatation in 2 years. Long-term follow-up is necessary even after disappearance of the arterial dissection.

Re-occlusion of the superior sagittal sinus after surgical recanalisation.

A 24-year-old woman was struck on the head by a hammer. Because of early signs and symptoms of intercranial hypertension, she underwent surgery for elevation of the depressed fragments which was compressing the superior sagittal sinus (SSS). After operation, the intracranial pressure (ICP) once decreased, but it gradually increased again. After hypothermia and barbiturate therapy, she recovered fully except for partial visual field defect due to brain contusion. A carotid angiogram 28 days after injury revealed complete occlusion of the whole SSS with good collateral circulation. After brain edema had subsided, a follow-up angiogram revealed normal blood flow through the SSS. Elevation of depressed bony fragments is required for a case presenting with early signs and symptoms of intracranial hypertension due to sinus compression. In a case with severe destruction of the SSS, one needs to know that re-occlusion of the dural sinus may occur after surgical recanalisation.

Mutational analysis of the BAK gene in 192 advanced gastric and colorectal cancers.

The evasion of apoptosis has been linked to the development of cancer. A recent study of a small number of gastric and colorectal cancers found that the BAK gene, which encodes a pro-apoptotic protein, contained somatic mutations in approximately 17% of the samples analyzed. To investigate the precise frequency of BAK mutations, we examined the entire coding sequence of the BAK gene in gastric and colorectal cancers, using polymerase chain reaction-single-strand conformational polymorphism (PCR-SSCP) analysis and direct sequencing. We could not detect any somatic mutations of the BAK gene in 192 colorectal and gastric cancers. We found only four single-nucleotide substitutions in the coding sequences, which were also found in corresponding normal samples. We conclude that somatic alterations of the BAK gene are rare in colorectal and gastric cancers.

Mutation and expression of the beta-catenin-interacting protein ICAT in human colorectal tumors.

BACKGROUND: Aberrant activation of Wnt signaling caused by mutations in the tumor suppressor adenomatous polyposis coli or beta-catenin is a critical event in the development of human colorectal tumors. We have recently identified the ICAT gene, which encodes a small protein that interacts with beta-catenin and represses Wnt signaling. METHODS: We examined the prevalence of mutations in the entire ICAT coding sequence and intronic splice donor and acceptor regions of ICAT by PCR-SSCP and also the expression of the ICAT gene by RT-PCR. RESULTS: The ICAT gene was mapped to chromosome 1p36.1-p36.2, which is implicated in the pathogenesis of various types of cancers. However, no mutations in ICAT were detected among 128 colorectal tumors. Instead, ICAT was found to be overexpressed in almost half of colorectal carcinomas. Cases exhibiting ICAT overexpression showed a significantly higher incidence of well-differentiated adenocarcinoma and positive lymphatic permeation. CONCLUSION: Our results suggest that ICAT is not the putative tumor suppressor on 1p36.1-p36.2, although aberrant overexpression of ICAT may play a role in the pathogenesis of colorectal carcinomas.

Frameshift mutations in the MBD4/MED1 gene in primary gastric cancer with high-frequency microsatellite instability.

MBD4/MED1 is a newly identified mismatch repair gene, which is mutated in colon, endometrial, and pancreatic high-frequency microsatellite instability (MSI-H) tumors. To assess its role in gastric cancers, we investigated MBD4/MED1 mutations in sporadic gastric cancers, compared with colon cancers. Frameshift mutations were found in 29% of gastric and 20% of colon MSI-H cancers, but not in any low-frequency microsatellite instability/microsatellite stable cancers. MBD4/MED1 is mutated in gastric cancers as frequently as in colon cancers; these mutations reduce the accuracy of DNA repair, and may lead to cancer progression.

A hemophagocytic syndrome-like condition after emergency colectomy for perforated colon cancer: report of a case.

Hemophagocytic syndrome is a rare but often fatal condition, and little is known about why this disorder can occur following surgery. We report herein the case of a patient successfully treated for a hemophagocytic syndrome-like condition that developed after emergency right hemicolectomy for a retroperitoneal abscess secondary to perforated colon cancer. The 62-year-old man initially presented after the sudden development of severe right back pain, and computerized tomography scans revealed a retroperitoneal abscess continuous with a tumor in the ascending colon. An emergency right hemicolectomy was subsequently performed. On postoperative day (POD) 2, his blood platelet count suddenly dropped to 1 x 10(4)/microl and histological examination of a bone marrow specimen taken on POD 5 showed abnormal histiocytes that had phagocytosed not only megakaryocytes, but also erythrocytes and leukocytes, and a normocellular marrow with a normal number of megakaryocytes. Hemophagocytic syndrome was suspected, and predonine was administered. The patient's condition improved remarkably and he was discharged on POD 51.