Perioperative Management of Robotic-Assisted Gynecological Surgery in a Super Morbidly Obese Patient.

We report the perioperative management of a 32-year-old woman with super-morbid obesity (body mass index (BMI) of 60.9 kilograms per meter squared (kg/m2)) who underwent a robotic-assisted total laparoscopic hysterectomy in a hospital that was not specialized for obese patients. She successfully reduced her BMI by 10% using dietary restrictions in five weeks, and her surgery was performed two weeks later by consultation between gynecologists and anesthesiologists. This case demonstrates that the determination of the optimal time for surgery by consultation between physicians is crucial in the care of such a complex patient in hospitals that are not specialized for morbidly obese patients. Weight reduction in the preoperative period should be considered for super-morbid obesity patients with malignant diseases, even if the duration of preoperative optimization is shorter than four to eight weeks.

Buccally absorbed vs intravenous prochlorperazine for treatment of migraines headaches.

OBJECTIVE: To compare the efficacy of buccally absorbed prochlorperazine (BAP) to intravenous prochlorperazine (IVP) for the abortive treatment of migraine headaches. METHODS: Randomized double-blind trial. Eighty subjects aged 18-65 presenting with migraines to the ED of a safety-net, urban hospital. Subjects were randomized to receive either 6 mg BAP plus 2.25 mL saline IV placebo or 10 mg IVP and buccally absorbed saccharine pill placebo. A 100 mm visual analog scale (VAS) was used to assess pain, nausea, and sedation. Comparisons between groups were analyzed by the Mann-Whitney U test or Fisher's exact test. RESULTS: Eighty subjects were recruited from November 2016 to December 2017; 79 completed the study. Demographics: 60 women and 19 men with a mean age of 38 ± 12.2 years. Initial mean VAS pain scores were similar between groups (BAP: 78.5 ± 19.9 mm vs IVP: 76.9 ± 19.5 mm). The improvement in mean VAS pain scores over 60 minutes for the BAP group was not significantly different from the IVP group (-54.9 ± 29.7 mm vs -66.7 ± 23.2 mm, respectively; P = 0.08). No significant differences were found in rates of nausea or sedation. Nine subjects in the BAP group required rescue treatment compared to 1 in the IVP group. Five subjects reported symptoms consistent with akathisia in the IVP group while no adverse effects were reported in the BAP group. CONCLUSION: Buccally absorbed prochlorperazine (BAP) is an effective, non-invasive treatment for migraine headaches when compared to intravenous prochlorperazine (IVP).

Effects of Nonsteroidal Anti-inflammatory Drugs on the Self-renewal Capacity of Blast Progenitors in Hematological Malignancies.

BACKGROUND: With our newly established long-term suspension culture, we investigated the effects of nonsteroidal anti-inflammatory drugs (NSAIDs) on the self-renewal capacity of blast progenitors in seven hematological malignant cell lines. MATERIALS AND METHODS: Cyclo-oxygenase inhibitors NS-398 (NS) or indomethacin heptyl ester (indomethacin) at 30 µM was added to the cell culture. In U-937 cells, indomethacin was added at 0.3 or 3 µM. RESULTS: In all cell lines, the agents significantly and markedly inhibited blast colony formation (BCF) and telomerase activity, respectively. Significant exponential clonogenic cell growth was noted under all 23 conditions with or without the agent. The relative slope (SLP) of the line (SLPagent/SLPcontrol) reflects the level of self-renewal induced by the agent and self-renewal was inhibited (relative SLP at 0.9 or below) in four out of 16 conditions, including in U-937 cells treated with 0.3 or 3 µM indomethacin, in Daudi cells treated with indomethacin and in U-266 cells treated with NS. Indomethacin enhanced senescence, necrosis and apoptosis in U-937 and Daudi cells, whereas NS reduced apoptosis in U-937 cells and had no effect on senescence, necrosis and apoptosis in Daudi cells. In U-266 cells, NS enhanced senescence and necrosis, whereas indomethacin reduced apoptosis. There was no significant correlation between the control of BCF and relative SLP. CONCLUSION: NSAIDs enhance or reduce stress responses, inhibit telomerase activity and differentially regulate BCF and self-renewal.

A case of heatstroke complicated by persistent ventricular tachycardia.

BACKGROUND: Patients suffering from heatstroke often present with electrocardiograph abnormalities, but persistent ventricular tachycardia has not been reported previously. OBJECTIVE: This report is intended to demonstrate that rapid and effective cooling is critical to survival in patients experiencing heatstroke with ventricular tachycardia. CASE: We cared for a healthy 38-year-old man with environmentally induced heatstroke, who presented with ventricular tachycardia resistant to cardioversion until his core body temperature was reduced significantly. CONCLUSIONS: This case represents the first report of ventricular tachycardia occurring in a patient with heatstroke. Successful cardioversion could not be achieved until his core body temperature was lowered significantly, reinforcing the need for rapid temperature reduction that can be accomplished through noninvasive means.

Intravenous lidocaine for the emergency department treatment of acute radicular low back pain, a randomized controlled trial.

BACKGROUND: Acute radicular back pain is a frequent complaint of patients presenting to the Emergency Department. STUDY OBJECTIVE: Determine the efficacy of intravenous lidocaine when compared to ketorolac for the treatment of acute radicular low back pain. METHODS: Randomized double-blind study of 41 patients aged 18-55 years presenting with acute radicular low back pain. Patients were randomized to receive either 100 mg lidocaine or 30 mg ketorolac intravenously over 2 min. A 100-mm visual analog scale (VAS) was used to assess pain at Time 0 (baseline), and 20, 40, and 60 minutes. Changes in [median] VAS scores were compared over time (within groups) by the signed-rank test and between groups by the rank-sum test. A 5-point Pain Relief Scale (PRS) was administered at the conclusion of the study (60 min) and again at 1 week by telephone follow-up; [median] scores were compared between groups by rank-sum. RESULTS: Forty-four patients were recruited; 41 completed the study (21 lidocaine, 20 ketorolac). Initial VAS scores were not significantly different between the lidocaine and ketorolac groups (83; 95% confidence interval [CI] 74-98 vs. 79; 95% CI 64-94; p = 0.278). Median VAS scores from baseline to 60 min significantly declined in both groups (lidocaine [8; 95% CI 0-23; p = 0.003]; ketorolac [14; 95% CI 0-28; p = 0.007]), with no significant difference in the degree of reduction between groups (p = 0.835). Rescue medication was required by 67% receiving lidocaine, compared to 50% receiving ketorolac. No significant change in PRS between groups was found at the conclusion or at the follow-up. CONCLUSION: Intravenous lidocaine failed to clinically alleviate the pain associated with acute radicular low back pain.

Takotsubo cardiomyopathy secondary to intracranial hemorrhage.

Patients suffering from aneurysmal subarachnoid hemorrhage often present with electrocardiogram (ECG) abnormalities that mimic cardiac ischemia, but documented left ventricular regional wall-motion dysfunction has rarely been reported. This report is intended to raise the awareness of possible ECG changes secondary to subarachnoid hemorrhage (SAH). We cared for a 55-year-old female with an acute aneurysmal subarachnoid hemorrhage, whose evaluation was delayed and complicated by the presence of Takotsubo cardiomyopathy (TCM). Aneurysmal subarachnoid hemorrhage may induce Takotsubo cardiomyopathy that can present as an acute ST-elevation myocardial infarction. Physicians need to be aware of this possibility since it can lead to significant delays and treatment options for the patient.

Ascites as the initial presentation of gastrointestinal carcinoma.

BACKGROUND: The rapid development of ascites in a patient without known liver disease is an uncommon occurrence in the Emergency Department. Initial stabilization may include therapeutic peritoneal lavage to reduce diaphragmatic pressure and halt the progression of respiratory compromise. In the absence of liver disease, the differential diagnosis should include a search for malignancy, which has been reported to account for up to 10% of all cases of newly diagnosed ascites. OBJECTIVES: To discuss the differential diagnosis, evaluation, and treatment options associated with the development of acute malignant ascites. CASE REPORT: We report the case of an 86-year-old woman who presented with the chief complaint of an enlarging abdomen and worsening shortness of breath of 1 week's duration. Bedside ultrasound rapidly revealed a large amount of intraperitoneal free fluid as a cause for her abdominal distension and respiratory compromise. Laboratory analysis of her blood along with computed tomography scan of her abdomen and pelvis were unremarkable. Diagnostic and therapeutic peritoneal lavage was done and the patient's symptoms improved. Pathologic examination of the peritoneal fluid revealed metastatic gastrointestinal carcinoma. CONCLUSION: Rapidly progressing ascites may be the sole presenting symptom of metastatic gastrointestinal carcinoma.

[Examination of the quality of life in the cancer patients under immunotherapy].

In recent years, quality of life(QOL) has received much attention as a subjective health outcome by which to measure and adopt patient treatment. Few studies, however, have examined how the QOL of cancer patients differs depending on treatment methods, or the effects of immunotherapy on patients' QOL. Thus, this study aimed to reveal: 1) the differences in QOL between patients treated with immunotherapy and other methods, and 2) whether the QOL of cancer patients treated with immunotherapy improves in accordance with the duration of immunotherapy. Thirty-nine cancer patients receiving immunotherapy who completed a Quality of Life Questionnaire for Cancer Patients Treated with Anti-Cancer Drugs(QOL-ACD) were the subjects for statistical analyses. The result indicated that patients treated with immunotherapy exhibited a higher physical conditions score than did patients receiving chemotherapy (p<0.01). Given that the side effects of immunotherapy are fewer than those of chemotherapy, the results suggested that the presence of side effects during cancer treatment plays an important role in determining patients' QOL.

Resource utilization in the emergency department of a tertiary care university-based hospital in Tokyo before and after the 2011 Great East Japan earthquake and tsunami.

INTRODUCTION: The objective of this study was to determine the resource utilization of a tertiary care Japanese emergency department (ED) that was not immediately adjacent to the area of the 2011 Great East Japan earthquake and tsunami. METHODS: A retrospective chart review was performed at a tertiary care university-based urban ED located approximately 290 km from the primary site of destruction secondary to an earthquake measuring 9.0 on the Richter Scale and the resulting tsunami. All patients who presented for a period of twelve days before and twelve days after the disaster were included. Data were collected using preformed data collection sheets, and stored in an Excel file. Abstracted data included gender, time in the ED, intravenous fluid administration, blood transfusion, oxygen, laboratories, electrocardiograms (ECGs), radiographs, ultrasound, diagnoses, surgical and medical referrals, and prescriptions written. Ten percent of the charts were reviewed for accuracy, and an error rate reported. Data were analyzed using 2-tailed t-tests, Fisher's exact tests or rank sum tests. Bonferroni correction was used to adjust P values for multiple comparisons. RESULTS: Charts for 1193 patients were evaluated. The error rate for the abstracted data was 3.2% (95% CI, 2.4%-4.1%). Six hundred fifty-seven patients (53% male) were evaluated in the ED after the earthquake, representing a 23% increase in patient volume. Mean patient time spent in the ED decreased from 61 minutes to 52 minutes (median decrease from 35 minutes to 32 minutes; P = .005). Laboratory utilization decreased from 51% to 43% (P = .006). The percentage of patients receiving prescriptions increased from 48% to 54% (P = .002). There was no change in the number of patients evaluated for surgical complaints, but there was an increase in the number treated for medical or psychiatric complaints. CONCLUSION: There was a significant increase in the number of people utilizing the ED in Tokyo after the Great East Japan earthquake and tsunami. Time spent in the ED was decreased along with laboratory utilization, possibly reflecting decreased patient acuity. This information may help in the allocation of national resources when planning for disasters.

High expression of Pirh2, an E3 ligase for p27, is associated with low expression of p27 and poor prognosis in head and neck cancers.

Downregulation of the cyclin-dependent kinase inhibitory protein p27 is frequently observed in various cancers due to enhancement of its degradation. We recently reported that p53-inducible protein with RING-H2 domain (Pirh2) is a novel ubiquitin ligase for p27, required for the ubiquitylation and consequent degradation of p27 protein. However, there is no reports about the involvement of Pirh2 in both p27 downregulation and pathogenesis in human cancers. In the present study, we investigated them using cultured cell lines and surgical specimens derived from human head and neck squamous cell carcinoma (HNSCC). Depletion of Pirh2 by short interfering RNA induced accumulation of p27 and inhibited the growth of cultured HNSCC cells. By immunohistochemical analysis in 57 cases of HNSCC specimens, higher levels of Pirh2 expression (labeling index > or = 60%) were found in 61.4% of HNSCC in comparison with 0% of normal mucosa. In addition, 83.3% of HNSCC with lower p27 expression (labeling index < 20%) displayed high Pirh2 levels. Therefore, Pirh2 expression was inversely correlated with p27 expression. Finally, Pirh2 expression was well correlated with poor prognosis. These findings suggest that Pirh2 overexpression may have an important role in the development and maintenance of HNSCC at least partially through p27 degradation, and that Pirh2 may be a potential molecular target for human HNSCC.

Up-regulation of GPR48 induced by down-regulation of p27Kip1 enhances carcinoma cell invasiveness and metastasis.

A reduced expression level of the cyclin-dependent kinase inhibitor p27(Kip1) is associated with increased tumor malignancy and poor prognosis in individuals with various types of cancer. To investigate the basis for this relation, we applied microarray analysis to screen for genes differentially expressed between p27(+/-) and parental (p27(+/+)) HCT116 human colon carcinoma cells. Expression of the gene for G protein-coupled receptor 48 (GPR48) was increased in the p27(+/-) cells. Forced expression of GPR48 increased both in vitro invasive activity and lung metastasis potency of HCT116 cells. In contrast, depletion of endogenous GPR48 by RNA interference reduced the invasive potential of HeLa and Lewis lung carcinoma cells not only in vitro but also in vivo. Moreover, GPR48 expression was significantly associated with lymph node metastasis and inversely correlated with p27 expression in human colon carcinomas. GPR48 may thus play an important role in invasiveness and metastasis of carcinoma and might therefore represent a potential prognostic marker or therapeutic target.

Generation of a constitutively active mutant of human GPR48/LGR4, a G-protein-coupled receptor.

GPR48, also known as leucine-rich repeat (LRR)-containing G-protein-coupled receptor 4 (LGR4), is a member of the G-protein-coupled receptor (GPCR) family of proteins. However, its biological functions remain unclear, since neither its ligand nor signal transduction pathway have been identified, and it is usually difficult to solve the function of such orphan receptors. The aim of this study was to generate a constitutively active form of human GPR48, that would form a ligand-independent active conformation and may function in a similar manner to activated GPR48 following ligand binding. We introduced four independent mutations into transmembrane domains V and VI of a human GPR48 cDNA. The wild-type and mutant GPR48s were expressed in HEK293 cells by transient transfection of appropriate expression plasmids. Since ligand-activated receptors for gonadotropins, which are structurally similar to GPR48, stimulate adenylate cyclase and increase cellular cyclic AMP, we investigated, whether the GPR48-transfected cells showed altered cyclic AMP levels. The cellular cyclic AMP level in HEK293 cells was increased following transfection of wild-type GPR48 in a dose-dependent manner. Moreover, transfection of a GPR48-T7551 mutant, in which threonine-755 was replaced with isoleucine, dramatically increased the cyclic AMP level. Stable transformants derived from HCT116 cells that constitutively expressed the GPR48-T7551 mutant also showed high cyclic AMP levels. These results indicate that the GPR48-T7551 mutant is a constitutively active mutant. This mutant may be useful for studying the biological functions of GPR48 and GPR48-mediated signal transduction, even if the specific ligand remains unknown in the future.