[A case of angioedema with dysarthria mimicking transient ischemic attack].

An 85-year-old woman was transported to our emergency room by ambulance with a complaint of slurred speech. Neurological examination revealed dysarthria only. We considered that lingual edema identified on physical examination might have influenced dysarthria. However, we were unable to perform sufficient evaluation, since she could not open her mouth widely or push the tongue out beyond the lips. We considered the incidence of acute cerebrovascular disease because of the acute onset, and performed emergency brain MRI. Imaging revealed that although no abnormality was present in the brain parenchyma, edema of the tongue and soft palate was evident on T2-weighted sagittal imaging. We confirmed the dysarthria was caused by tongue edema due to angioedema. In addition, we diagnosed angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema, because ACEI had been started 2 months earlier as pharmacotherapy for hypertension. Tongue swelling due to angioedema should be considered when examining patients with dysarthria.

Sarcopenia is a predictive factor for prolonged intensive care unit stays in high-energy blunt trauma patients.

Aim: Sarcopenia has been increasingly reported as a prognostic factor for outcome in settings such as cirrhosis, liver transplantation, and emergent surgery. We aimed to elucidate the significance of sarcopenia in severe blunt trauma patients. Methods: We retrospectively analyzed 84 patients emergently admitted to the intensive care unit at Kyushu University Hospital (Fukuoka, Japan) from May 2012 to April 2015. We assessed the amount of skeletal muscle present according to computed tomography and its relevance to ventilation-free days, patients' length of stay in the intensive care unit, and 28-day mortality. Results: Twenty-five (29.7%) patients were defined as sarcopenic. Sixteen (19.7%) patients required 15 days or more in the intensive care unit. The major reason was a prolonged ventilation requirement due to flail chest (n = 7) or pneumonia (n = 3). Sarcopenic patients' stays in intensive care were significantly longer than those of non-sarcopenic patients (18.7 versus 6.4 days, respectively; P < 0.001). Univariate and multivariate analyses showed sarcopenia to be a significant risk factor for prolonged intensive care unit stay. Conclusion: Sarcopenia is a risk factor that predicts prolonged intensive care unit stay in high-energy blunt trauma patients.

Case of a Cardiopulmonary Arrest Due to Postoperative Subglottic Stenosis Developed on the Second Day after Lung Surgery.

We experienced a case of the cardiopulmonary arrest due to subglottic stenosis developed on the second day after lung cancer surgery. Case : A 73-year-old female who was diagnosed with primary lung cancer was referred to our department for surgery. The second day after left lung segmentectomy, she showed respiratory discomfort symptoms and exhibited hoarseness and stridor, which were revealed as the subglottic stenosis by bronchoscopy. During the emergency airway management, she went into cardiopulmonary arrest. We performed cardiopulmonary resuscitation and simultaneous urgent tracheotomy.

Treatment results of two-stage operation for the patients with esophageal cancer concomitant with liver dysfunction.

PURPOSE: The aim of this study was to clarify the usefulness of two-stage operation for the patients with esophageal cancer who have liver dysfunction. METHODS: Eight patients with esophageal cancer concomitant with liver dysfunction who underwent two-stage operation were analyzed. The patients initially underwent an esophagectomy, a cervical esophagostomy and a tube jejunostomy, and reconstruction with gastric tube was performed after the recovery of patients' condition. RESULTS: The average time of the 1(st) and 2(nd) stage operation was 410.0 min and 438.9 min, respectively. The average amount of blood loss in the 1(st) and 2(nd) stage operation was 433.5 ml and 1556.8 ml, respectively. The average duration between the operations was 29.8 days. The antesternal route was selected for 5 patients (62.5%) and the retrosternal route was for 3 patients (37.5%). In the 1(st) stage operation, no postoperative complications were observed, while, complications developed in 5 (62.5%) patients, including 4 anastomotic leakages, after the 2(nd) stage operation. Pneumonia was not observed through two-stage operation. No in-hospital death was experienced. CONCLUSION: A two-stage operation might prevent the occurrence of critical postoperative complications for the patients with esophageal cancer concomitant with liver dysfunction.

The changes in treatment strategies in ABOi living donor liver transplantation for acute liver failure.

INTRODUCTION: Living donor liver transplantation (LDLT) using ABO-incompatible (ABOi) graft for acute liver failure (ALF) is a developing treatment modality. METHODS: We reviewed the changes in our treatment strategies in applying ABOi LDLT for FH over our fourteen years of experience. RESULTS: Five patients with ALF received LDLT in adults using ABOi grafts, with different but gradually renewed protocols. The etiologies for acute liver failure included autoimmune hepatitis (n=3) and unknown (n=2). The desensitization protocol for ABOi barrier included Case #1; local infusion (portal vein)+plasma exchange (PE), Case #2; local infusion (hepatic artery)+rituximab+PE, Case #3 and #4; rituximab+PE, and Case #5; rituximab+PE under high-flow continuous hemodiafiltration. Local infusion was abandoned since Case #3, because Case #1 had portal vein thrombosis resulting in graft necrosis and Case #2 had hepatic artery dissection. The patients (Case #2 and #3), who received rituximab within 7 days before LDLT, experienced antibody-mediated rejection. Thus, the most recent protocol for ABOi-LDLT is that rituximab is given 2 weeks before LDLT, followed by high-flow continuous hemodiafiltration to obstacle hepatic encephalopathy until LDLT. The four patients except Case #1 are doing well with good graft function over 3.8±3.7 years. CONCLUSION: Rituximab-based ABOi-LDLT, most-recently under high-flow hemodiafiltration for treating encephalopathy, is a feasible option for applying LDLT for ALF.

Risk Factors Associated with Stenotrophomonas maltophilia Bacteremia: A Matched Case-Control Study.

Stenotrophomonas maltophilia is an important nosocomial bacterial pathogen, as is Pseudomonas aeruginosa. Differentiation of these bacteria as bacteremic agents is critical in the clinical setting and to define a therapeutic strategy; however, the associated factors and prognosis for S. maltophilia bacteremia have not been fully evaluated to adequately characterize these factors. We first conducted a matched case-control study to clarify these questions. A total of 30 case patients with S. maltophilia bacteremia were compared with 30 control patients with P. aeruginosa bacteremia between January 2005 and August 2014, according to matching criteria based on underlying disease, age, and gender. The 30-day mortality rate for the case patients (53.3%) was significantly higher than that of the control group (30.0%) (P = 0.047, using the log-rank test). Conditional logistic regression analysis showed that the predisposing factors specific for the detection of S. maltophilia bacteremia were indwelling artificial products other than a central venous catheter, ICU stay, and previous use of anti-MRSA drugs. The high severity of illness was associated with mortality in both case and control patients. Interestingly, inappropriate antimicrobial treatment was an additional independent risk factor for mortality in only the case patients with S. maltophilia bacteremia (odds ratio = 13.64, P = 0.048). Monotherapy with fluoroquinolones inactive against the S. maltophilia isolates was mainly responsible for the inappropriate treatment. These results suggest that more precise prediction and more appropriate treatment might improve the prognosis of patients with S. maltophilia bacteremia.

Clinical outcomes and prognostic factors after surgery for non-occlusive mesenteric ischemia: a multicenter study.

BACKGROUND: To date, no large-scale study has been undertaken to understand the clinical features of non-occlusive mesenteric ischemia (NOMI) after surgery. We thus performed a multicenter investigation to clarify the clinical outcomes and prognostic factors of NOMI. PATIENTS AND METHODS: Clinical databases from 22 Japanese facilities were reviewed for evaluation of patients who received surgery for NOMI between 2004 and 2012. NOMI patients (n = 51) were divided into two groups: group I (n = 28) consisted of patients who survived, and group II (n = 23) consisted of patients who did not survived. Prognostic factors were compared between the two groups. RESULTS: NOMI surgery represented 0.04% of the total number of operations performed in this time period. The overall mortality rate for NOMI surgery was 45%. Hemodialysis was a significant negative prognostic factor (p = 0.027). Preoperative elevation of transaminases, potassium, and white blood cell count, as well as metabolic acidosis and colon ischemia was poor prognostic factors. The mean Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) score of group I versus group II was 54.5 ± 3.6 and 85.2 ± 4.1, respectively (p < 0.001). CONCLUSIONS: Currently, NOMI surgery has a 45% mortality rate. POSSUM scores can be used to predict the clinical outcome of patients who receive NOMI surgery.

Lung injury and renal failure caused by potassium cyanide poisoning.

Our objective is to show that cyanide poisoning presents with various symptoms, and that recognition of these symptoms is required for appropriate management of the condition. A 54-year-old man drank about 2.5 times the normal fatal dose of potassium cyanide in a suicide attempt. On arrival at hospital (day 0), the patient was restless and in a state of shock. We administered 100% oxygen and performed immediate detoxification. Ground-glass attenuation appeared on the evening of day 1 and lung injury due to cyanide was suspected. Inflammation improved slowly with the use of artificial ventilation, but anuria continued and sudden renal failure occurred on day 2. We suspected that renal failure was due to cyanide metabolites, and continuous haemodiafiltration (CHDF) was initiated. Renal function improved slowly and CHDF was discontinued on the sixth day. Symptoms of cyanide poisoning may include lung injury and renal damage, in addition to disturbance of consciousness.

Current status of Japanese emergency medicine based on a cross-sectional survey of one prefecture.

OBJECTIVE: To ascertain the current status of emergency medicine at certified emergency hospitals in Fukuoka, a Japanese prefecture. Fukuoka prefecture has the 9th largest population volume of the 46 prefectures throughout Japan. METHODS: Written questionnaire sent to 146 certified emergency hospitals. RESULTS: A total of 132 of 146 (90.4%) emergency hospitals replied. Data were complete from 131. Nineteen of 131 hospitals (14.5%) were qualified by the Japanese Association for Acute Medicine, whereas 85 of 131 (64.9%) were certified by other medical associations. In 32 of 131 hospitals (24.4%), there was an emergency medicine specialist or acute care physician, whereas 117 hospitals (89.3%) had a specialist doctor qualified by another medical association. In 33 of 131 hospitals (25%), there were doctors who undertook training in emergency medicine of surgery-related courses, and 66 (50%) undertook internal medicine-related courses. CONCLUSION: The current status of emergency medicine practice in the Fukuoka prefecture is poor. Medical associations relevant to emergency medicine should collaborate with each other to share information, as well as provide help to solve problems associated with emergency medicine manpower. This collaboration should occur as a national effort within the Japanese Association for Acute Medicine.

Clinicopathologic significance in serum presence of anti-p53 antibody in patients with colorectal carcinoma.

BACKGROUND/AIMS: Alteration of p53 gene links to the appearance and detection of anti-p53 antibodies in the serum. The aim of this study is to find the clinicopathologic significance for serum presence of anti-p53 antibodies in patients with colorectal carcinoma. METHODOLOGY: Serum presence of anti-p53 antibodies was examined for sera of 36 patients with colorectal carcinoma using enzyme-linked immunosorbent assay. RESULTS: Frequency of serum presence of anti-p53 antibodies was 47.2% (17 of 36). Incidence of lymph node metastasis and lymphatic invasion in tumors coexisting with serum presence of anti-p53 antibodies (70.6%, 12 of 17 and 94.1%, 16 of 17) were significantly higher than those in tumors without serum presence of anti-p53 antibodies (17.6%, 3 of 17 and 68.4%, 13 of 19; p = 0.007 and p = 0.041, respectively). Stages of the tumors were significantly more advanced in carcinomas coexisting with serum presence of anti-p53 antibodies (p = 0.023). Frequency in serum presence of anti-p53 antibodies among patients with tumors expressing p53 (73.7%, 14 of 19) was significantly higher than that among patients with tumors without p53 expression (17.6%, 3 of 17; p = 0.0005). CONCLUSIONS: Preoperative serum appearance of anti-53 antibodies can be an indicator for more malignant potential of colorectal carcinoma.

Experimental evidence for the efficacy of combined therapy of CPT-11 and hyperthermia for squamous cell carcinoma of the esophagus.

BACKGROUND/AIMS: The aim of the current study was to show an anti-tumor effect for esophageal squamous carcinoma cells derived from a combination of hyperthermia and CPT-11, which would ultimately lead to the clinical usage of this therapeutic modality for patients with squamous cell carcinoma of the esophagus. METHODOLOGY: Survival fraction of esophageal squamous carcinoma cells after administrating SN-38, active metabolite of CPT-11, and combination of hyperthermia and SN-38 was compared using data measured by MTT assay. RESULTS: Reduction of cell survival fraction derived by simultaneous induction of hyperthermia and SN-38, in many combinations of the temperature and charging period, was significantly greater than that acquired by SN-38 alone. CONCLUSIONS: Combination of hyperthermia and CPT-11 can exert a synergic anti-tumor efficacy for SCC of the esophagus.

Geriatric patients presenting to the emergency department of a Japanese university hospital.

To evaluate the trend of elderly patients visiting the emergency department of a Japanese University Hospital, out patient-based records were reviewed of the emergency department of Kyushu University Hospital from 2000 to 2004. A total number of 7610 emergency patients visited the department during the five year period. The median (25%, 75%) of age was 32 (22, 56). Patients aged 65 years and over accounted for 16% of all attendances. All the patients were classified into 6 groups according to the diagnosis, (1) Respiratory, (2) Circulatory, (3) Central nervous system, (4) Abdominal, (5) Trauma, and (6) Others. The median age in each group was (1) 27 (15, 49), (2) 66 (53, 76), (3) 51 (27, 67), (4) 33 (22, 56), and (5) 26 (20, 46), respectively. There was a statistically significant difference observed, reciprocally except between (1) and (5) (P < 0.05). The patients showed statistically significant difference in the annual transition of the disease (P < 0.0001). In the elderly, the annual transition of the disease showed statistically significant decreases in Circulatory (P = 0.0015) and in Central nervous (P < 0.0001), and an increase in Abdominal (P < 0.0001), respectively. Death rate at the outpatient clinic in the elderly showed much higher than in the younger (P < 0.0001). Admission rate was also much higher in the elderly than in the younger (P < 0.0001). Elderly emergency patients have both internal and external intrinsic factors. They have to be treated carefully since their condition easily deteriorates. Provisions for the problems surrounding the elderly should be made as a nationwide effort.

Fas ligand expression is correlated with metastasis in colorectal carcinoma.

The Fas/Fas ligand (FasL) system is one apoptotic pathway through which malignant tumors can evade immune surveillance. While FasL is expressed in malignant tumors, Fas is conversely downregulated to escape host immune attack, resulting in tumor invasion. The aim of the current study was to find out further clinicopathological significance of FasL expression in carcinoma of the colon and rectum. FasL expression was investigated using immunohistochemical staining in 143 consecutive patients with primary colorectal carcinomas. Seventy-nine carcinomas (55.2%) expressed FasL. The incidence of lymph node and distant metastases in carcinomas expressing FasL was significantly higher than in carcinomas that did not express FasL (p = 0.031 and p = 0.0003, respectively). Although univariate analysis showed that survival in patients with carcinomas expressing FasL was significantly poorer than that in patients with carcinomas without FasL expression (p = 0.001), only Dukes' stage was an independent prognosticator by multivariate analysis. FasL expression was found to be correlated with lymph node involvement and distant metastases in colorectal carcinoma.

MnSOD expression within tumor cells is closely related to mode of invasion in human gastric cancer.

Manganese superoxide dismutase (MnSOD) plays an important role in protecting cells from injury due to oxidative stress. We used immunohistochemical techniques to evaluate the expression of MnSOD in specimens obtained from 61 patients with gastric cancer. Immunostaining for MnSOD in tumor cells was compared to that of corresponding normal epithelial tissue. Staining for MnSOD was restricted to the cytoplasm of cells, and overexpression was observed more frequently among the normal mucosa than among tumor cells. Either absent or less intense MnSOD staining was observed in the cells of 44 (72.1%) tumors compared to that of the normal mucosa (group A). MnSOD staining of equal or greater intensity than that observed in the normal mucosa was observed in 17 (27.9%) tumors (group B). There was no association of MnSOD expression with metastatic behavior and prognosis, however decreased MnSOD expression in tumor cells (group A) was correlated with a greater probability of infiltrative type or undifferentiated type adenocarcinomas. Multivariate analysis found that gross appearance (mode of invasion) of the tumor was a significant factor related to MnSOD expression (p<0.05). These findings suggested that variations in MnSOD expression among different types of tumors might occur secondary to cell differentiation and/or proliferation.

Prognostic significance of serum superoxide dismutase activity in patients with gastric cancer.

BACKGROUND: Although superoxide dismutase (SOD) may play an important role in helping to protect against carcinogenesis or tumor progression, little information is available regarding the clinical evaluation of antioxidant defense in patients with gastric cancer. METHODS: Serum SOD activity in 34 patients with gastric cancer was estimated and the data compared with clinicopathological parameters. RESULTS: The mean serum SOD activity in the patients was 15.9% +/- 2.6%, which was higher than the value obtained in healthy donors. The serum SOD activity in patients over 70 years of age was 14.5% +/- 3.0%, which was significantly lower than the value of 16.6% +/- 7.3% in those under 70 years of age (P < 0.01). According to the stage of disease, the reduction in SOD activity in the patients aged over 70 years was significant in those with far advanced tumor, classified as stage IV (P < 0.01), but not in those with stage I-III disease. When the cutoff value for high- and low-SOD groups was determined as 18.0%, based on the median value for serum SOD activity in 15 patients with stage IV gastric cancer, the survival rate of patients with stage IV tumor was significantly higher in the high-SOD group than in the low-SOD group (P < 0.05). CONCLUSION: These findings suggested that the reduction in serum SOD activity in elderly patients may be due to weakness of the antioxidant defense of the host, thus resulting in a poor prognosis in those with far-advanced (stage IV) gastric cancer.

Overexpression of cyclin B1 in gastric cancer and its clinicopathological significance: an immunohistological study.

PURPOSE: Cyclin B1 is a key regulator of progression through the G2/M transition during the cell cycle. Although cyclin B1 proteins are overexpressed in various types of human cancers, the relationship between cyclin B1 status in gastric cancer and its clinical significance remains unknown. METHODS: We examined cyclin B1 expression by immunohistological means in 61 patients with gastric cancer in terms of histological type, tumor invasion, and metastatic behavior. Specimens were considered positive when the cytoplasm of over 10% of the cancer cell population was stained. RESULTS: Cyclin B1 was overexpressed in 32 (53%) of 61 patients with gastric cancer. Tumors that expressed cyclin B1 were predominant in older patients, in well- and moderately differentiated adenocarcinomas and in expanding-growth type tumors. Conversely, expression of cyclin B1 was lower in poorly differentiated adenocarcinomas, and in those of the infiltrative growth type. Moreover, the disease was more advanced (stages III and IV) and widespread nodal involvement was more frequent when cyclin B1 expression was low. Logistic regression analyses showed that histological type is a significant factor related to cyclin B1 protein expression. CONCLUSIONS: These findings suggested that cyclin B1 protein overexpression is closely associated with less aggressive tumor behavior. Therefore, G2/M cyclin alternatives and the possible role of cyclins in cancer development warrants further attention.

Immunohistochemical expression of cytokine induced nitric oxide synthase in colorectal carcinoma.

Significance of expression of cytokine induced nitric oxide synthase (iNOS) in colorectal carcinoma remains controversial. The aim of the current study was to elucidate the significance of immunohistochemical expression of iNOS in colorectal carcinoma. The subjects were the 54 patients with colorectal carcinoma, including 13 with obstructing carcinoma. The immunohistochemical expression of iNOS was examined and the clinicopathological data were compared between iNOS-positive and iNOS-negative carcinomas. Of 54 colorectal carcinomas, there were 27 tumors with iNOS expression. The proportion of tumors occurring in the rectum was significantly lower in iNOS-positive carcinomas than in iNOS-negative carcinomas (p=0.028). The incidence of lymph node metastasis and lymphatic invasion in colorectal carcinomas with iNOS expression (63.0%, 17 out of 27 and 96.3%, 26 out of 27, respectively) were significantly more frequent than those in carcinomas without iNOS expression (29.6%, 8 out of 27 and 70.4%, 19 out of 27, respectively) (p=0.013 and p=0.011, respectively). The proportion of obstructing carcinoma in tumors with iNOS expression (37.0%, 10 out of 27) was significantly higher than that in tumors without iNOS expression (11.1%, 3 out of 27; p=0.020). Our results could suggest that iNOS expression can be an indicator of malignant potential in colorectal carcinoma and that it may be one of the biological features of obstructing carcinoma of the colon and rectum. Moreover, our results demonstrated that nitric oxide might be associated with the difference in the mechanism of carcinogenesis in the colon and the rectum.

Impaired antioxidant defense system of colonic tissue and cancer development in dextran sulfate sodium-induced colitis in mice.

BACKGROUND: The mechanisms underlying the frequent development of carcinomas associated with ulcerative colitis (UC) are not understood. Cellular antioxidants play a crucial role in protection against neoplastic disease. The purpose of this study is to investigate a critical balance between free radical activity and the antioxidant defense system in carcinogenesis associated with UC, using a model of experimental colitis induced in mice by dextran sulfate sodium (DSS) treatment. METHODS: Chronic colitis was induced by feeding the mice for 7 days with 4% DSS, followed by drinking water alone for the subsequent 14 days. Animals were sacrificed after one, two, three, or four cycles of DSS administration. Development of dysplastic epithelium and invasive carcinoma was histologically examined. Lipid peroxide level was estimated by measuring malondialdehyde (MDA) content. Alterations in MDA content and superoxide dismutase (SOD) activity in colonic tissues together with production of serum tumor necrosis factor (TNF)-alpha were determined. RESULTS: Colonic neoplasms including dysplastic epithelium and invasive carcinoma developed in 28.6 and 25.0% of the animals at the end of the third and fourth cycles, respectively. In accordance with elevation of serum TNF-alpha level, there was a substantial increase in MDA in the colonic mucosa, while tissue SOD activity tended to be suppressed during the DSS treatment periods. Dysplastic epithelium and invasive carcinoma revealed significantly lower SOD levels compared with colonic colitis, although MDA levels were not statistically different among these colonic diseases. CONCLUSIONS: The results obtained in this experimental model suggest that an impaired antioxidant defense system might be critical for cancer development associated with UC.