Successful treatment of gastric perforation with thyrotoxic crisis

Patients with thyrotoxic crisis presenting with another emergency are at a considerable risk. We report the successful treatment of a 55-year-old woman having gastric perforation with thyrotoxic crisis; the principle of treatment was delayed surgery after rapid preoperative restoration of thyroid function and cardiovascular status. The patient was admitted for severe abdominal pain and nausea with delirium, exophthalmos, diffuse goiter, tremulousness, diaphoresis, tabescence, pretibial edema, and atrial fibrillation. Computed tomography revealed free air over the liver surface. She had been diagnosed with uncontrolled hyperthyroidism 3 days before admission, with a free liothyronine (T₃) of 23.2 pg/mL, a free levothyroxine sodium (T₄) of greater than 7.78 ng/dL, and thyrotropin of less than 0.01 ng/mL. She was diagnosed with gastroduodenal perforation and thyrotoxic crisis, and we planned nonoperative management comprising nasogastric aspiration, cefmetazole sodium, omeprazole, thiamazole, and Lugol's solution. We also used landiolol, an ultrashort-acting β₁-adrenoceptor antagonist, and hydrocortisone. On the third day of admission, her thyroid function had improved with a free T₃ of 4.7 pg/mL and a free T₄ of 2.9 ng/dL; however, perforative peritonitis had worsened, and hence, omental patch repair was performed. She recovered uneventfully and was discharged after radioiodine administration. We discuss the management of a thyrotoxic patient with gastric perforation and focus on the importance of changing the management according to the patient's clinical course considering his thyroid function status and comparing the stress of surgery with that of perforative peritonitis in nonoperative management.     

Evaluation of the anti-Trichophyton activity of a prodigiosin analogue produced by γ-proteobacterium, using stratum corneum epidermis of the Yucatan micropig

Prodigiosins (PGs) are known to be a family of natural red pigments, characterized by a common pyrrolydipyrrolylmethane skeleton structure with a C-4 methoxy group, and some of these pigments have been isolated from some microorganisms. Members of the PG family have been reported to show several biological activities, such as immunosuppressive and cytotoxic activities. Recently, we discovered a bacterial strain (MS-02-063), from our microbial library, that produces large amounts of a PG analogue (PG-L-1). In this study, we examined the anti-Trichophyton activity of PG-L-1 (produced by strain MS-02-063) against clinically isolated Trichophyton spp., by a method using stratum corneum epidermis (SCE) of the Yucatan micropig, which is suitable for estimating the antifungal activity of drugs in vitro. In the National Committee for Clinical Laboratory Standards (NCCLS) method, PG-L-1 showed potent antifungal activity against nine clinically isolated strains of Trichophyton spp., although the minimum inhibitory concentration (MIC) values were slightly higher than those of bifonazole. In spite of the lower efficiency of PG-L-1 transfer into SCE from medium than that of bifonazole, PG-L-1 transferred into SCE showed more potent antifungal activity than bifonazole, at lower concentrations.     

Properties of R Factors from Bordetella bronchiseptica

Genetic properties and host ranges of R factors derived from Bordetella bronchiseptica of pig origin were examined. All of 61 R factors tested could confer resistance to streptomycin, sulfonamide, and aminobenzyl penicillin on their host bacteria. All of them were identified as fi⁻ (no fertility inhibition) type and were found to exhibit no restriction of phages λ, φ80, P1, P2, T1, T3, T6, T7, W31, and BF-23. They could confer macarbomysin susceptibility on their host cells when infected. An Rte16, a representative R factor, was incompatible with both RP4 and R40a, which are classified as compatibility groups P and C, respectively. An Rte16 was conjugally transmissible to B. bronchiseptica, Escherichia coli, Citrobacter freundii, Salmonella typhimurium, and Yersinia enterocolitica, but not to Shigella flexneri, S. sonnei, Proteus mirabilis, P. vulgaris, P. rettgeri, Klebsiella pneumoniae, and Pseudomonas aeruginosa.     

ESOPHAGOCARDIOPLASTY FOR ACHALASIA IN CLOSURE OF A COMPLICATED ESOPHAGOBRONCHIAL FISTULA

We report a rare case or benign esophagobronchial fistula associated with achalasia. The fistula healed spontaneously after esophagocardioplasty with a gastric patch, suggesting the utility of this procedure.     

The ratio of leptin to adiponectin can be used as an index of insulin resistance

The level of leptin increases with obesity, whereas that of adiponectin decreases with obesity. It is reported that the ratio of leptin to adiponectin (L/A) is associated with insulin resistance. It is difficult to evaluate insulin resistance in diabetic patients who have a dysfunction of insulin secretion. The aim of this study was to examine whether the L/A ratio is a useful marker for insulin resistance in diabetic patients. We examined L/A in the serum of a total of 139 Japanese patients with type 2 diabetes mellitus (66 women and 73 men) and 7 healthy individuals recruited in our hospital. Changes in the levels of leptin and adiponectin were observed using the oral glucose tolerance test and a hyper- and euglycemic clamp test. Twenty-one patients with type 2 diabetes mellitus were observed for more than 6 months after treatment with pioglitazone, and 31 patients with type 2 diabetes mellitus were observed for more than 6 months after the treatment with metformin. The mean value of L/A in 139 Japanese patients with type 2 diabetes mellitus was 1.22 +/- 1.41 (1.68 +/- 1.76 in women, 0.81 +/- 0.80 in men; P = .0002). In the clamp tests, L/A correlated with glucose infusion rate (GIR) (r(2) = 0.26, P = .0034). The correlation of L/A and GIR indicated a stronger correlation than either leptin (r(2) = 0.144, P = .03) or adiponectin alone (r(2) = 0.023, P = .41), or the homeostasis model assessment of insulin resistance (r(2) = 0.103, P = .08). The average hemoglobin A(1c) (HbA(1c)) improved from 10.2% +/- 1.2% to 9.2% +/- 1.6% (P = .0037) in 6 months after treatment with pioglitazone. Our results indicate pioglitazone to be effective for HbA(1c) improvement in subjects with high L/A and low L/A. The average HbA(1c) improved from 9.2% +/- 0.9% to 8.0% +/- 1.2% (P = .0002) in 6 months after treatment with metformin. Our results indicate metformin to be effective for HbA(1c) improvement in subjects with a low L/A. In conclusion, we demonstrate that L/A is different between male and female subjects. The correlation of L/A and GIR by the euglycemic hyperinsulinemic clamp test suggests that L/A is a useful indicator for the choice of drug to treat diabetes mellitus.     

Altered energy metabolism and oxidative injury following endotoxemia in rats with normal or cirrhotic livers

The release of oxygen-derived free radicals has been implicated in endotoxin-mediated hepatic injury. The effect of hepatic lipid peroxidation on tissue energy reserves in the livers of normal and cirrhotic rats was studied following administraton ofE. coli endotoxin. Before endotoxin injection, the basal hepatic energy charge was lower and levels of hepatic malondialdehyde (MDA) and total glutathione (GSH) higher in cirrhotic rats than in normal rats. Virtually identical levels of blood endotoxin were obtained in the two groups 24h after injection of LD50 doses of endotoxin (20 mg/kg and 1 mg/kg in normal and cirrhotic rats, respectively). Hepatic energy charge, tissue blood flow, GSH and glutathione peroxidase (GPX) were consistently or transiently decreased up to 24h after the injection of endotoxin in both normal and cirrhotic rats. MDA, significantly increased in normal rats 1 h after injection of endotoxin, returned to normal levels 3–12 h after endotoxin administration, but was again elevated at 24 h. Cirrhotic rats did not show any significant change in MDA following endotoxin injection. In normal rats, endotoxin appears to trigger the liberation of free radicals accelerating depletion of hepatic energy reserves, over and above the effect of decreased hepatic blood flow. In contrast, increased lipid peroxidation was not detected in cirrhotic rats despite GSH and GPX consumption during endotoxemia (indicating oxygen radical generation). Cirrhotic livers were apparently protected against oxygen radical injury by higher levels of endogenous GSH and GPX. Reduced hepatic blood flow may be mainly responsible for the alteration in energy metabolism of the cirrhotic liver.     

Successful outcome after resection of pancreatic cancer with a solitary hepatic metastasis

The presence of hepatic metastasis in pancreatic cancer has generally been considered to be a contraindication for surgery. However, the present case survived seven years after concomitant resection of pancreatic cancer and hepatic metastasis. This shows that hepatic metastasis may be a strong predictor of poor survival, but not a determinant of noncurability. Surgical resection may be an option for highly selected patients with pancreatic cancer complicated with hepatic metastasis.