Clinical Characteristics Associated with the Development of Diabetic Ketoacidosis in Patients with Type 2 Diabetes

Objective This study analyzed the clinical and laboratory parameters that might influence the clinical outcomes of patients with type 2 diabetes who develop diabetic ketoacidosis (DKA), which has not been well investigated. Methods We reviewed the clinical and laboratory data of 158 patients who were hospitalized due to DKA between January 2006 and June 2019 and compared the data of patients stratified by the type of diabetes. In addition, the patients with type 2 diabetes were subdivided according to age, and their clinical and laboratory findings were evaluated. Results Patients with type 2 diabetes had a longer symptom duration associated with DKA, higher body mass index (BMI), and higher C-peptide levels than those with type 1 diabetes (p＜0.05). Among patients with type 2 diabetes, elderly patients (≥65 years old) had a longer duration of diabetes, higher frequency of DKA onset under diabetes treatment, higher effective osmolarity, lower BMI, and lower urinary C-peptide levels than nonelderly patients (＜65 years old) (p＜0.05). A correlation analysis showed that age was significantly negatively correlated with the index of insulin secretory capacity. Conclusion Patients with DKA and type 2 diabetes had a higher BMI and insulin secretion capacity than those with type 1 diabetes. However, elderly patients with type 2 diabetes, unlike younger patients, were characterized by a lean body, impaired insulin secretion, and more frequent DKA development while undergoing treatment for diabetes.     

Epidemiology,Molecular Epidemiology and Evolution of Bovine Respiratory Syncytial Virus

The bovine respiratory syncytial virus (BRSV) is an enveloped, negative sense, single-stranded RNA virus belonging to the pneumovirus genus within the family Paramyxoviridae. BRSV has been recognized as a major cause of respiratory disease in young calves since the early 1970s. The analysis of BRSV infection was originally hampered by its characteristic lability and poor growth in vitro. However, the advent of numerous immunological and molecular methods has facilitated the study of BRSV enormously. The knowledge gained from these studies has also provided the opportunity to develop safe, stable, attenuated virus vaccine candidates. Nonetheless, many aspects of the epidemiology, molecular epidemiology and evolution of the virus are still not fully understood. The natural course of infection is rather complex and further complicates diagnosis, treatment and the implementation of preventive measures aimed to control the disease. Therefore, understanding the mechanisms by which BRSV is able to establish infection is needed to prevent viral and disease spread. This review discusses important information regarding the epidemiology and molecular epidemiology of BRSV worldwide, and it highlights the importance of viral evolution in virus transmission.     

Factors Influencing the Long-Term Survival in Patients with Esophageal Cancer Who Underwent Esophagectomy After Chemoradiotherapy

Background

Salvage esophagectomy is potentially the only treatment available that can offer a chance of long-term survival when definitive chemoradiotherapy (CRT) fails to achieve local control for patients with esophageal squamous cell carcinoma (ESCC). However, salvage esophagectomy is a highly invasive procedure with various postoperative complications compared to planned esophagectomy after neoadjuvant chemoradiotherapy (CRT). We hypothesize that severe postoperative complications may affect not only surgical mortality but also tumor recurrence and long-term survival for patients with salvage esophagectomy after definitive CRT.

Methods

For the present study we reviewed the surgical procedures, postoperative complications, and the prognosis of 65 consecutive patients with thoracic ESCC who underwent the esophagectomy after neoadjuvant (neoadjuvant group: n = 40) or definitive (salvage group: n = 25) CRT.

Results

Most patients underwent right-transthoracic extended esophagectomy and reconstruction using gastric conduit by way of subcutaneous route with left cervical anastomosis. The incidence of postoperative pneumonia was found to be higher in the salvage group than in the neoadjuvant group. In both groups, the survival of patients with R0 resection was significantly better than those with R1/R2 resection. Moreover, in the salvage group, the postoperative survival rate of patients with pneumonia or bacteremia/sepsis was significantly lower than that for patients who did not suffer the same complications. In the neoadjuvant group, R0 resection was selected to be the only independent prognostic factor in univariate and multivariate analysis. In contrast, in the salvage group, R0 resection and bacteremia/sepsis remained significant and were independent of the other factors in multivariate analysis.

Conclusions

This study reveals that postoperative morbidity affects not only the perioperative mortality but also the long-term survival of patients with ESCC who undergo salvage esophagectomy after definitive CRT.     

Novel method for emergency craniostomy for rapid control and monitoring of the intracranial pressure in severe acute subdural hematoma

Acute subdural hematoma (ASDH) is a critical condition following the onset of traumatic brain injury, and it is essential to immediately reduce elevated intracranial pressure (ICP). Single burr hole surgery/twist drill craniostomy is commonly performed in patients with ASDH as an emergency surgical intervention, usually preceding decompressive craniotomy. A novel method using a cerebrospinal fluid (CSF) drainage catheter kit for rapid drainage of ASDH is described. Percutaneous twist drill craniostomy using a CAMINO(?) micro ventricular bolt pressure-temperature monitoring kit was performed in the emergency room in 12 patients with severe ASDH. The kit contained a closed-system CSF drainage and pressure-temperature monitoring catheter, which allowed aspiration of the hematoma and monitoring of the ICP. The tip of the catheter was inserted into the hematoma from the forehead. The mean initial ICP was 61 mmHg, with a range of 31 to 120 mmHg. The liquid hematoma was aspirated, and the ICP was temporarily controlled to the normal range. Pupil dilation recovered immediately after aspiration of the hematoma in 3 patients. No complications occurred either during or after the operation. This new method for craniostomy is easy, safe, and effective to monitor and rapidly control ICP in the emergency room. This technique also offers the possibility of evaluating the patient's prognosis and determining indications for further decompressive craniectomy by the continuation of ICP control under ICP monitoring and evaluation of the reversibility of pupillary findings in ASDH patients.     

Idiopathic Granulomatous Appendicitis Treated Surgically with Long-Term Follow-Up: Report of a Case

Isolated granulomatous inflammation of the appendix is extremely rare, and its etiology is still unknown. Thus, differentiating between idiopathic granulomatous appendicitis and isolated appendiceal Crohn's disease is difficult. We report a case of idiopathic granulomatous appendicitis with long-term follow-up after surgery. A 26-year-old woman was referred to our hospital for investigation of persistent right lower abdominal pain. Abdominal computed tomography showed a mass, suggesting an inflammatory tumor around the appendix; thus, we suspected subacute appendicitis and performed laparoscopically assisted ileocecal resection. Histological examination of the resected specimen revealed several noncaseous epithelioid granulomas in the wall of the appendix, but no foreign bodies, obstructing lesions, or parasites. Stains for acid-fast bacillus and fungi, and serology for yersinia were all negative. The patient has been followed up for 9 years and remains asymptomatic. This clinical course suggests that her isolated granulomatous appendicitis was idiopathic granulomatous appendicitis unrelated to Crohn's disease.     

Hybrid repair of thoracoabdominal aortic aneurysm in high-risk patients using a quadrifurcated graft

Surgical treatment for thoracoabdominal aortic aneurysm is still challenging and is associated with a high risk of paraplegia. Hybrid repair with stent graft insertion for the thoracoabdominal aorta excluding the branches of the lumbar and visceral arteries and bypass grafting to the visceral branches has been introduced as a less invasive treatment that reduces the risk of paraplegia. For hybrid repair, it is important to have appropriate management of the revascularized grafts to the 4 visceral arteries with sufficient inflow. We have recently adopted a knitted quadrifurcated graft applied inversely from the abdominal aorta or the iliac artery to the 4 visceral arteries; the celiac, superior mesenteric, and bilateral renal arteries. To date, we have used the graft in hybrid repair of thoracoabdominal aortic aneurysm in 2 high-risk elder patients who had disseminated intravascular coagulopathy and severe renal failure, respectively. We found that a knitted quadrifurcated graft was easy to handle and useful for reducing the number of anastomoses, which were expected to shorten the operation time. Postoperative courses were uneventful without paraplegia in either patient. Postoperative computed tomography showed excellent patency of the inversely applied quadrifurcated graft without any endoleak or migration in the thoracoabdominal stent. In conclusion, revascularization of 4 visceral arteries using a quadrifurcated graft should be considered a preferable option in hybrid treatment for thoracoabdominal aortic aneurysm.     

A large-sized bubbling appearance of the glomerular basement membrane in a patient with pulmonary limited AL amyloidosis and a past history of lupus nephritis

We report an unusual pathological finding, a large-sized bubbling appearance of the glomerular basement membrane (GBM), in a patient with pulmonary limited AL amyloidosis and a past history of lupus nephritis. The first renal biopsy specimen from 10 years ago, when systemic lupus erythematosus was diagnosed, demonstrated mild mesangial proliferation and subepithelial deposits (WHO classification: III + V). Light microscopy of the current biopsy using periodic acid methenamine silver (PAMS) stain demonstrated a large-sized bubbling appearance of the GBM; however, very weak immunoglobulin and complement deposition was observed in immunofluorescence studies. Routine electron microscopy demonstrated partial subendothelial expansion with electron-lucent materials, but no electron-dense deposits or amyloid fibrils. Electron microscopy with PAMS stain revealed electron-lucent endothelial scalloping, including some cellular components and microspheres in the GBM; however, it is not clear if these materials are derived from endothelial cells. One possibility is that these unique findings represent a recovery phase of lupus membranous nephritis; another is that these findings correspond to a new disease entity.