Treatment for locally advanced esophageal carcinoma complicated by fistulas: Case report

Two cases of advanced esophageal carcinoma complicated by fistula formation, treated with esophageal prostheses followed by chemotherapy or concurrent chemoradiotherapy, are reported. Chemoradiotherapy may be indicated in esophageal carcinoma cases with fistulas if an excellent antitumor response is expected. However, the indication for prosthesis insertion should be limited due to the risk of perforation, which may be a lethal complication.     

Successful treatment of a young infant who developed high-titer inhibitors against VWF-cleaving protease (ADAMTS-13): important discrimination from Upshaw-Schulman syndrome

We report herein the case of a 9-month-old female infant with acquired thrombotic thrombocytopenic purpura (TTP), which was initially suspected to be either Upshaw-Schulman syndrome (USS or a congenital TTP) or hemolytic uremic syndrome (HUS) because of onset of clinical signs in infancy and accompanying diarrhea. She received combination therapy of plasma exchange, steroid pulse, and high-dose intravenous immunoglobulin infusion that was initiated before the definitive diagnosis, which resulted in excellent clinical improvement. The retrograde analysis of plasma ADAMTS-13 activity and its inhibitor showed a lack of this enzyme activity and the presence of a high-titer IgG inhibitor (200-320 Bethesda units/mL) to this enzyme activity. From our experience, it was suggested that we should recognize the possibility of the patient with acquired TTP in infancy and the importance of plasma exchange therapy for management of its clinical symptoms.     

Knowledge of medicine required for the exercise cure for prevention of fall and fracture in elderly people

The typical medicine constituting elderly people cause of a fall is the anxiolytic and hypnotic drugs of Benzodiazepines. The danger of the fall by the prolonged action type or the medicine with a strong line relaxation action is suggested especially. Moreover, anti-depressant drugs and anti-hypertensive drugs with alpha-adrenaline interception action also causes orthostatic hypotention, and induces a fall. In elderly, there are many complications and there is a tendency for combined use medicine to increase in number. Since the danger of fall increases in proportion to the number of medicines, much more cautions are required of the elderly people who have taken two or more medicines.     

Superior efficacy of MMCP regimen compared with VMCP and MMPP regimens in the treatment of multiple myeloma

OBJECTIVE: A newly designed combination chemotherapy for multiple myeloma, MMCP [ranimustine (MCNU), melphalan (MPH), cyclophosphamide (CPM) and prednisolone (PSL)], was analyzed and compared with the results of our previous randomized trial of VMCP [vincristine, MPH, CPM and PSL] and MMPP [MCNU, MPH, procarbazine and PSL]. METHODS: MCNU (33.3 mg/m2, div) on day 1 and MPH (4 mg/m2, po), CPM (66.7 mg/m2, po) and PSL (30 mg/m2, po) from day 1 to 4, were administered. Each cycle was repeated every 3 weeks. PATIENTS OR MATERIALS: From January 1991 until August 1995, 104 patients with multiple myeloma diagnosed at 10 hospitals of Nagoya Cooperative Study Group were enrolled. RESULTS: Of the 87 evaluable patients, partial response rate for MMCP was 65.5% and was significantly higher than that of VMCP (13/47=27.7%, p<0.0001) and that of MMPP (21/47=44.7%, p=0.0196). A plateau attainment was observed in 49.4%. The percentage of the patients who attained plateau was significantly increased in the MMCP arm than in the VMCP arm (19.1 %, p=0.0017) but was not in comparison with that of MMPP arm (42.6%, p=0.6790). Patients treated with MMCP survived significantly longer than those treated with VMCP or MMPP (p=0.0009 by generalized Wilcoxon test, p=0.0023 by log-rank test) with median survival for MMCP being 31.6 months, for VMCP 22.5 months, and for MMPP 22.9 months. No significant differences were observed with respect to adverse effects among the three regimens. CONCLUSION: The newly designed MMCP is a candidate as an induction chemotherapy for multiple myeloma.     

Pathology and pathophysiology of chronic obstructive pulmonary disease

A variety of pathological changes have been observed in the central airways, peripheral airways and lung parenchyma of patients with chronic obstructive pulmonary disease (COPD). The characteristic changes in the central airways include inflammatory cellular infiltration into the airway wall and mucous gland enlargement. In the peripheral airways, various morphological changes are observed, including mucous plugging, epithelial abnormalities, inflammatory cellular infiltrates, fibrosis and distortion; these changes lead to airway narrowing. In the lung parenchyma, emphysema defined as alveolar destruction and airspace enlargement is present. Although the major sites of airflow limitation in patients with COPD are most likely the peripheral airways, lesions in both the peripheral airways and the lung parenchyma contribute to chronic airflow limitations.     

Complete penetration of the optic chiasm by an unruptured aneurysm of the ophthalmic segment: case report

BACKGROUND: It is well known that aneurysms of the ophthalmic segment sometimes elevate the optic nerve or chiasm, and in case of large or giant aneurysms, the optic apparatus can be dramatically thinned. Nonetheless, they rarely penetrate the optic pathway completely. To our knowledge, no previous reports have dealt with the complete penetration of the optic chiasm by unruptured aneurysms of the ophthalmic segment. CASE DESCRIPTION: A 70-year-old woman presented with visual dysfunction in her left eye that she had experienced for several months. Her left visual acuity had rapidly deteriorated to the level of finger counting and visual field testing demonstrated nasal hemianopsia in the left eye and upper temporal quadrant hemianopsia in the right eye. Left internal carotid angiograms and three-dimensional digital subtraction angiograms showed an aneurysm of the ophthalmic segment projecting superomedially. Intraoperative findings revealed complete penetration of the optic chiasm by the fundus of the aneurysm. The optic pathway adjacent to the dome had become remarkably thin and dark yellow. After clipping was completed, the fundus of the aneurysm was punctured to decompress the optic chiasm. Postoperatively, patient's visual acuity in the left eye gradually recovered, but the visual field deficit persisted after the operation. CONCLUSION: This rare case demonstrates the potentially aggressive behavior of unruptured aneurysms of the ophthalmic segment. Patients with unruptured aneurysms of the ophthalmic segment who present with visual symptoms should be treated with surgical clipping to decompress the optic pathway as soon as possible.     

Usefulness of dynamic digitized cerebral parenchymography for cerebral vascular disease

Aortic arch injections according to Theron's method have been performed in patients with cerebral ischemia. Digital subtraction angiograms with modified windowing (low and narrow) have been used for better visualization of cerebral parenchymal condition. This "cerebral parenchymography" allows much easier understanding of cerebral parenchymal vascularization on angiographic imaging. Although further study is necessary to estimate accurate cerebral blood flow, this technique can enable an easy and quick understanding of the overall cerebral hemodynamics.     

Minilaparotomy approach to terminal ileal Crohn's disease

The feasibility and safety of a minilaparotomy approach to terminal ileal Crohn's disease have not been fully elucidated. The purpose of this study was to compare early outcomes utilizing this technique as an alternative to conventional approaches. Nine patients with terminal ileal Crohn's disease (but no complicating enteric fistulas) who underwent minilaparotomy between January 1998 and September 2000 were studied prospectively. The minilaparotomy approach entails a complete surgical procedure performed through a skin incision of less than 7 cm. Ten similar patients who underwent conventional laparotomy between January 1995 and December 1997 served as the control group. Age, gender, body weight, height, body mass index, number of prior laparotomies, operating times, operative blood loss, and types of operative procedure were similar for cases and controls. The length of the laparotomy incision in the minilaparotomy approach group was significantly shorter than that in the conventional approach group (median length 6.0 vs. 16.5 cm; p <0.05). Postoperative intervals until initial standing and walking were significantly shorter for minilaparotomy patients than conventional surgery patients (p <0.05 and p <0.05, respectively), whereas postoperative intervals until passing flatus, urinary catheter removal, and tolerance of liquids and solids did not differ for the two groups, nor did the analgesic requirement or postoperative hospital stay. Postoperative complications developed in two conventional-group patients; none was noted with the minilaparotomy approach. Our data suggest that the minilaparotomy approach to terminal ileal Crohn's disease without an enteric fistula is feasible, safe, and less invasive than the conventional approach.     

Dextrocardia: technical aspects of reoperative aortic and tricuspid valve replacement

Tricuspid and aortic valve replacement was performed on a 50-year old man with dextrocardia, situs solitus, D-ventricular looping, and normally related great arteries. Twenty-two years earlier the patient had undergone repair of an incomplete atrioventricu lar canal and mitral valve replacement. The anatomic issues and operative considerations are discussed for aortic and tricuspid valve replacement in this anatomic situation with special emphasis on tricuspid valve replacement through a right ventriculotomy. Six months after surgery, New York Heart Association functional class improved from class III preoperatively, to class II.     

Bcl-2 and GDNF delivered by HSV-mediated gene transfer after spinal root avulsion provide a synergistic effect

Proximal spinal nerve injury results in the death of motor neurons in ventral horn. We have previously demonstrated this cell death can be prevented by HSV-mediated transfer of the gene coding for the antiapoptotic peptide Bcl-2 7 days prior to injury, but that expression of Bcl-2 does not preserve ChAT expression in the lesioned cells. In the current study, we examined two related issues: whether Bcl-2 delivered by HSV-mediated gene transfer 30 min after injury could similarly protect motor neurons from cell death, and whether the additional HSV-mediated expression of the glial cell derived neurotrophic factor (GDNF) could improve the result. At 30 min after avulsion of the L4, L5, and L6 spinal nerves, replication defective genomic HSV-based vectors coding for Bcl-2, GDNF, a reporter transgene (lacZ), or the Bcl-2 and GDNF vectors together were injected into spinal cord. Transduction of motor neurons with either the Bcl-2-expressing vector or the GDNF-expressing vector resulted in a substantial increase in the number of surviving motor neurons, and coinjection of the two vectors together resulted in cell survival that was similar to the result obtained with either vector alone. Neither the Bcl-2-expressing vector nor the GDNF-expressing vector delivered alone protected choline acetyltransferase (ChAT) expression in lesioned neurons. However, simultaneous injection of the Bcl-2- and the GDNF-expressing vectors together resulted in a substantial increase in the number of ChAT in cells in the lesioned ventral horn. Together, these findings suggest an approach to improving cell survival and regeneration following proximal root injury.