Use of Metronidazole Gel to Control Malodor in Advanced and Recurrent Breast Cancer

Intolerable malodor emanating from ulcerated tumors as a resultof anaerobic infection is a serious problem in the managementof advanced and recurrent breast cancer. Metronidazole can controlthis malodor, but its oral use may cause adverse reactions.We therefore formulated a metronidazole gel, since no equivalentpreparation is commercially available in Japan, and used itin five female patients (four with advanced cancer and one withrecurrent cancer) admitted to our hospital between March 1994and July 1995. The patients were aged between 47 and 71 (median:59) years, and the duration of morbidity in the four patientswith advanced cancer ranged from 10 months to four years. Inthree patients, the tumors were larger than 10 cm x 10 cm. Metronidazolegel was applied to the surface of ulcerated tumors once or twicedaily. Independent assessments by the patient, doctor and nursewere unanimous, and revealed that the malodor was alleviatedin one patient after three days, and removed in four patientsafter two to five (median: four) days of metronidazole gel treatment.Culture of swabs showed a decrease or disappearance of anaerobiccolonies. Adverse reactions characteristic of metronidazoledid not occur. The topical use of metronidazole in a gel formwill improve the quality of life for patients with malodorousulcerated tumors and facilitate intensive treatment of the underlyingdisease.     

Dilation of the stump of the esophagus and intestine with Doyen's intestinal clamp followed by application of lidocaine facilitates the stapling anastomoses

To avoid bowel tears on the esophagojejunal or colorectal mechanical anastomoses during insertion of the EEA stapler, we applied a local anesthetic to the stump of the bowel, then gently dilated the bowel with Doyen's intestinal clamp. This approach makes way for use of a larger cartridge and a more satisfactory anastomoses.     

The Repeated Appeal to Return Home in Older Adults with Dementia: Developing a Model for Practice

Dementia care has been trapped in a “trial and error” type of practice due to difficulty understanding the needs of older adults with severe dementia. Behavioral and Psychological Signs and Symptoms of Dementia (BPSD) can be quite difficult for residential staff. However, some experienced care workers succeed in establishing effective relationships. The goal of this study was to: 1) develop a process to identify needs behind BPSD; 2) find solutions using a team approach; and 3) apply the results to educate new workers. The KJ method was employed to reach decision-making about best practices in residential dementia care. This qualitative method is used to organize group data collected in the field and is based on understanding complex situations. A group process of 12 Japanese care workers experienced in understanding and responding to the “repeated appeal to return home” of residents in nursing care facilities is highlighted along with an illustrative case example. The workgroup met over two years. The study revealed five steps in understanding the needs behind the appeal, which include: (1) Listen to the voice and go with the flow of the behavior; (2) Learn about the inner experience; (3) Learn about the contextual environment of “here and now” situations; (4) Reflect on the care environment; and (5) Find the keyword. This needs identification process has application to other cultural contexts. The implications of this study for practitioners who work with people with dementia in residential settings will be discussed.     

Familial Progressive Bulbar-Spinal Muscular Atrophy: Case Report with Muscle Biopsy Study

A case of familial progressive bulbar and spinal muscular atrophy was presented. The patient was a 59–year-old male with chief complaints of gait disturbance and nasal voice. His illness started at the age of 39 and very slowly progressed over 20 years. The clinical symptoms and signs were characterized by muscle weakness and atrophy due to lower motor neuron disease in the brain stem below the lower pons and the spinal cord. The electromyograms and muscle biopsy findings are basically neurogenic. In spite of the bulbar signs, the course of the disease is extremely slow. The diagnostic criteria was proposed after reviewing eight other cases reported in the literature.     

Perivascular epithelioid cell tumor (PEComa) of the pancreas: Immunoelectron microscopy and review of the literature

A perivascular epithelioid tumor (PEComa) is a rare tumor probably arising from the perivascular epithelioid cells. Only three cases of pancreatic PEComa have been reported in the English-language literature. The present report describes an extremely rare case of pancreatic PEComa. A 47-year-old Japanese woman complained of lower abdominal pain and a well-demarcated solid tumor was found in the pancreatic head. There was no history of tuberous sclerosis complexes. Pylorus-preserving pancreaticoduodenectomy was thus performed. There was a well-demarcated, solid tumor measuring 17 mm in the pancreatic head. The tumor was composed of a diffuse proliferation of epithelioid tumor cells with many blood vessels but no adipose tissue. The tumor cells expressed HMB45 and α-smooth muscle actin. Ultrastructurally, the tumor cells possessed many membrane-bound granules that were positive for HMB45 on immunoelectron microscopy. The results of immunoelectron microscopy show that some PEComas possess not only typical melanosomes or premelanosomes but also aberrant melanosomes.     

Autocrine expression of neurotrophins and their receptors in prostate cancer

Previously, it has been demonstrated that the neurotrophins and their receptors are present in human prostate tissue, but neither their functional role nor localization is clearly understood. We studied the expression of neurotrophins and their receptors in prostate cancer. Between 1990 and 1999, 48 prostate cancer specimens were obtained from patients undergoing radical prostatectomy, of whom 25 received neoadjuvant hormonal therapy (NHT) and 23 were untreated. The specimens were analyzed immunohistochemically for neurotrophins (nerve growth factor, brain derived neurotrophic factor, neurotrophin 3, neurotrophin 4/5) and their receptors (TrkA, TrkB, TrkC, p75NTR). Immunohistochemical studies revealed that both benign and malignant prostate gland epithelial cells expressed the neurotrophins and their receptors to various degrees, but no obvious immunopositive reaction was observed in stromal cells. In benign epithelial cells, the neurotrophins were localized to secretory cells and the receptors were localized to basal cells. The neurotrophins, TrkA and TrkC were expressed to a similar extent in prostate cancer specimens obtained from patients both with and without NHT. In contrast, the expression of TrkB was down-regulated and the expression of p75NTR was up-regulated in prostate cancer after hormonal therapy. These findings suggest that neurotrophins are secreted by prostate cancer cells in an autocrine fashion. Neurotrophins may be involved, through their receptors, in the escape mechanism from cell death after androgen depletion found in prostate cancer.     

The Third Nationwide Survey in Japan of Vitamin K Deficiency in Infancy

The occurrence of hemorrhagic disease due to vitamin K (VK) deficiency beyond the neonatal period has come under investigation in Japan. In 1980 the 1st nationwide survey was conducted in Japan by Nakayama and others [1], and was followed by the 2nd nationwide survey in 1985 by Hanawa [2]. The present survey was designed to further monitor the incidence of this disease in Japan during the 3-year period from July 1985 to June 1988. Questionnaires were sent to 1,315 hospitals having more than 200 beds, located throughout Japan. Responses were received from 775 hospitals, for an answer rate of 58.9%. The total number of reported cases was 175, including 129 idiopathic type, 28 secondary type and 18 near-miss type. In this survey it was revealed that the incidence rate of the idiopathic type of vitamin K deficiency in infancy (VKDI) has decreased remarkably, to about one-fourth that reported in the first survey. The declining incidence rate of VK deficiency in Japan is considered to be the result of ever more widespread prophylactic administration of VK during the neonatal period, as most occurrences of VK deficiency in infancy are preventable by prophylactic administration of VK from the neonatal period. However, in 16 cases of the idiopathic type of VK deficiency found in the present survey, VK had been administered at least once during or after the neonatal period. This shows the heterogeneity of this condition.     

Radical lymphadenectomy for rectal cancer facilitated by a carbon particle infusion lymphangiography

For the intraoperative visualization of the para-aortic nodes and those around the iliac vessels, a fine carbon particle solution was infused into the bilateral pedal lymphatic vessels of 12 patients with rectal carcinoma. A low anterior resection with radical lymph node dissection was then performed while preserving pelvic autonomic nerves. Of 444 lymph nodes removed from the iliac arterial region, 430 were stained with carbon black (96.8%), even though the black staining was not perfect in the nodes of the inferior mesenteric arterial region. All of the lateral black stained nodes were clearly visible and hence could be easily excised. The average number of dissected nodes in one patient was 43.8 in this dissection with carbon particle infusion, which was larger than those of conventional lymph node dissection. We then examined the length of time that a postoperative indwelling bladder catheter was needed as an indication for autonomic nerve damage, and it was ascertained that less damage occurred in this operation compared to other types of dissections, such as conventional or extended lymph node dissection.