Metachronous solitary mediastinal lymph node metastases of hepatocellular carcinoma treated by video‐assisted thoracic surgery twice: Report of a case

Solitary mediastinal lymph node metastasis of hepatocellular carcinoma (HCC) is rare. We report a case of metachronically solitary mediastinal metastases of HCC treated by video‐assisted thoracic surgery (VATS) twice. A 66‐year‐old man underwent repeated laparoscopic radiofrequency ablation or trans‐arterial catheter chemo‐embolization against HCC for more than 10 years. The level of alpha fetoprotein protein was elevated, and radiological modalities including FDG‐PET revealed solitary mediastinal tumor metachronically. VATS was performed bilaterally twice. The postoperative course was uneventful and there had no recurrence of extra‐hepatic metastases and tumor markers are within normal limits at 18 months after second VATS. VATS is a minimally invasive and useful procedure for solitary mediastinal lymph node metastasis of HCC. If primary HCC was controlled and lymph node metastasis was solitary, mediastinum lymphadenectomy using VATS might give good short and long term results.     

Clinical analysis of the patients with hemodialysis associated with intracerebral hematoma

We treated 64 hemodialysis patients with cerebral hemorrhage over an 18-year period between 1986 and 2003. Clinical features, prognostic factors, and therapeutic strategy were reviewed in these cases. Thirty of the cases were in the 13-year period between 1986 and 1998, and 34 cases, in the 5-year period between 1999 and 2003. In recent years, the incidence of cerebral hemorrhage has risen with the increase in the number of hemodialysis patients. There were 21 patients with at least a 10-year history of hemodialysis. The underlying cause of renal failure was diabetic nephropathy in 25 patients and glomerulonephritis in 24 patients. The most frequent sites of bleeding were the basal ganglia and thalamus, the cerebellum being involved in only one patient. Many patients had severe bleeding with hematomas greater than 61 ml. Outcome assessment by the Glasgow Outcome Scale showed 24 patients with good recovery, 8 with moderate disability, 4 with severe disability, and 28 who died. Good recovery was seen more often in patients in their 50s and 60s, whereas death occurred more often in patients aged 70 and older. Although there is now less morbidity than previously, the prognosis is not uniformly favorable in all cases. Factors associated with a poorer prognosis included mixed hemorrhage, hematomas greater than 61 ml, and age 70 and older. Hematoma size and age were particularly important prognostic factors. Improved management and prognosis in these patients requires acute intensive treatment similar to that for hypertensive cerebral hemorrhage.     

Generalized tetanus with intractable autonomic cardiovascular instability in an aged woman

Tetanus is characterized by tetanic convulsions related to the actions of tetanospasmin produced by Clostridium tetani. Another important characteristic of tetanus is the instability of the cardiovascular system related to sympathetic hyperactivity in the autonomic nervous system, and it may be an important prognostic factor. We report a patient with tetanus in whose unstable circulatory kinetics made circulation management difficult. A 77-year-old woman who injured in a fall, 11 days after trismus appeared and 3 day after convulsion appeared. It was not severe case in the acuity classification. However, repeated generalized convulsions and autonomic imbalance involving the cardiovascular system were observed clinically, suggesting a severe case. Because of the unstable circulatory kinetics, the patient was carefully managed was performed in the intensive care unit (ICU), and she improved. ICU management may be essential for treating severe tetanus with cardiovascular complications. Acquired immunity is not achieved after the onset of tetanus, and since elderly people, in particular, as in our own caset, are easily injured when they fall, we recommend vaccination.     

Diagnosis of gastroesophageal reflux disease using a new questionnaire

BACKGROUND AND AIM: An early and accurate evaluation by a general practitioner is needed to screen out non-gastroesophageal reflux disease (GERD) patients. A recent questionnaire (QUEST) highlighted problems with specificity and complexity, so the aim of the present study was to design a simplified questionnaire. METHODS: When admitted to hospital to undergo an upper gastrointestinal endoscopy for suspected GERD, 333 patients completed a 50-item questionnaire requiring 'yes/no' answers to different combinations of questions relating to symptoms of upper gastrointestinal tract conditions (e.g. GERD, ulcers and functional dyspepsia) and psychosomatic symptoms. The endoscopic diagnosis was then correlated with the rate of positive answers to each question. RESULTS: Based on the analysis of the 50 items, the 8-10 questions most often answered affirmatively by each of the GERD and non-GERD groups were chosen for the simplified questionnaire. Three draft questionnaires were compiled. After calculating the sensitivity, specificity and accuracy in relation to the diagnosis of GERD and other conditions, it was found that questionnaire B (selection of persons answering 'yes' to at least one of questions 1-5 and exclusion of persons answering 'yes' to at least three of questions 7-10) had a high sensitivity, high specificity and low false positive rate. CONCLUSION: A novel questionnaire was developed. It was designed to detect the symptoms of GERD while simultaneously excluding non-GERD patients. This simplified nine-item simplified questionnaire had a sensitivity of 79.8%, a specificity of 53.6% and an accuracy of 63.4%.     

Pharmacokinetic/pharmacodynamic analysis of neutrophil proliferation induced by rhG-CSF in patients receiving antineoplastic drugs

In the present study, we analyzed the effect of recombinant human granulocyte colony-stimulating factor (rhG-CSF) on neutrophil counts in cancer patients undergoing chemotherapy using a previously developed pharmacokinetic/pharmacodynamic model.(7)) The time profiles of neutrophil counts in blood after repeated administration of rhG-CSF to lung cancer patients undergoing chemotherapy could be analyzed by this model by considering the inhibition of neutrophil production by antineoplastic drugs. Although deviation was observed between the predicted and observed neutrophil counts in ovarian cancer patients, it may be possible to use this model for determining a rational dosage regimen of rhG-CSF for patients undergoing chemotherapy.     

Rheumatoid vasculitis of crural muscles confirmed by muscle biopsy in the absence of inflammatory myopathy: histologic and MRI study

A 60-year-old man who had been diagnosed as rheumatoid arthritis admitted to our hospital by dysesthesia on his legs with edema. Nerve conduction velocity test led to diagnosis of mononeuritis multiplex. Magnetic resonance imaging (MRI) of lower legs showed high intensity in slow tau inversion recovery. Typical vasculitis with neutrophil-dominant cell infiltration was observed by muscle biopsy without inflammatory myopathy or fascitis. Diagnosis was made by rheumatoid vasculitis found in crural muscles. Intravenous cyclophosphamide with oral tacrolimus effectively improved dysesthesia with reduction of inflammatory response.     

Urinary carnitine excretion in patients with heart failure

To evaluate the fatty acid metabolism in heart failure, the semiquantitative analysis of urinary free carnitine and acylcarnitine was made by fast atom bombardment mass spectrometry (FABMS) in 22 patients (mean age 67.3 years) with heart failure and 19 age-matched healthy controls (average age 60.4 years). Urinary excretion of free carnitine was 0.20 ± 0.118 ratio/mg creatinine in the healthy controls and 1.32 ± 1.170 ratio/mg creatinine in the patients with heart failure. The latter value was significantly higher (p < 0.01 ). Patients with heart failure were classified into two groups according to the urinary free carnitine concentration. One was the high excretion group (2.19 ± 0.102 ratio/mg creatinine, 12 cases) and the other was the low excretion group (0.37 ± 0.212 ratio/mg creatinine, 10 cases). In the high excretion group, urinary acetylcarnitine was also increased, but no significant abnormalities were observed in the urinary organic acid profile. In the high group, 1 patient was classified as NYHA class III and 11 as NYHA class IV. Four patients died in the hospital. In the low excretion group, five patients were classified as NYHA class III and five as NYHA class IV. Only one patient died in the hospital. In the high group, patients with severe and prolonged heart failure tended to maintain higher values of urinary free carnitine. We could not find any abnormalities in fatty acid metabolism in patients with heart failure, but it is suspected that the patients who excrete large amounts of free carnitine into the urine, namely the patients with severe heart failure, have some possibility of carnitine deficiency.     

Development and evaluation of FSSG: frequency scale for the symptoms of GERD

Background The aim of this study was to produce a simplified questionnaire for evaluation of the symptoms of gastroesophageal reflux disease (GERD).Methods A total of 124 patients with an endoscopic diagnosis of GERD completed a 50-part questionnaire, requiring only yes or no answers, that covered various symptoms related to the upper gastrointestinal tract, as well as psychosomatic symptoms. The 12 questions to which patients most often answered yes were selected, and were assigned scores (never = 0; occasionally = 1; sometimes = 2; often = 3; and always = 4) to produce a frequency scale for symptoms of GERD (FSSG). Sensitivity, specificity, and accuracy of the FSSG questionnaire were evaluated in another group of patients with GERD and non-GERD. The usefulness of this questionnaire was evaluated in 26 other GERD patients who were treated with proton pump inhibitors for 8 weeks.Results When the cutoff score was set at 8 points, the FSSG showed a sensitivity of 62%, a specificity of 59%, and an accuracy of 60%, whereas a cutoff score of 10 points altered these values to 55%, 69%, and 63%. The score obtained using the questionnaire correlated well with the extent of endoscopic improvement in patients with mild or severe GERD.Conclusions This new questionnaire is useful for the objective evaluation of symptoms in GERD patients.     

A Case of Granular Lymphocyte Proliferation with T-Cell Phenotype

Immunological studies were conducted on a case of granular lymphocytosiswith benign clinical feature. A 60-year-old Japanese woman wasfound incidentally to have lymphocytosis when she had a commoncold. A complete blood count showed 47,200 leukocyte per mm³with 82% granular lymphocytes, 8% small lymphocytes and others.Hemoglobin was 11.5 g/dl and platelet count was 365 x 10³/mm³. Surface marker study revealed erythrocyte-rosettes 94%. Leu-159%, Leu-2a 70%, Leu-3a 14%, Leu-4 98%, Leu-7 57%, Leu-11 5%,HLA-DR 92%, BA-2 6%, common ALL antigen 4%, and surface immunoglobulin2%. These results suggest granular lymphocyte proliferationwith T-cell phenotype. Natural killer activity was 4.5%, butit was elevated to 11.4% after interleukin-2 stimulation by2 days' culture. Human T-cell lymphotropic virus-I antibodywas absent. No lymphadenopathy and no hepatosplenomegaly wereseen, except for bone marrow infiltration of granular lymphocytes.The patient has been in good health without any acute distress.The leukocyte count has gradually decreased to l2,300/mm³ with79% lymphocytes in 6 months of follow-up without any therapy. This case is suggestive of benign lymphocytosis, although similarcases have been reported previously as chronic lymphocytic leukemiawith T-cell marker and/or natural killer function.     

Prediction of DAS28-ESR remission at 6?months by baseline variables in patients with rheumatoid arthritis treated with etanercept in Japanese population

We tried to determine which baseline variables are responsible for remission induction at 6 months in unselected rheumatoid arthritis (RA) patients of Japanese population treated with etanercept. One hundred forty-one patients with RA who were administered etanercept were registered. Thirty-four patients were started on etanercept monotherapy, 60 patients on cotherapy with methotrexate (MTX) (MTX cotherapy), and 47 patients on cotherapy with other non-MTX nonbiologic disease-modifying antirheumatic drugs (DMARDs) (non-MTX cotherapy). None of the patients were treated with both MTX and non-MTX nonbiologic DMARDs at entry. Outcome was set as achievement of disease activity score 28 (DAS28)-ESR remission at 6 months. We examined association of gender, DAS at baseline, MTX cotherapy at baseline, non-MTX cotherapy at baseline, and prednisolone use at baseline with achievement of remission at 6 months by logistic regression analysis. All subjects were classified as having high (N = 109) or moderate disease activity (N = 32) at entry. One hundred twenty out of 141 patients (85.1%) continued treatment with etanercept at 6 months. Continuation rate was statistically higher in MTX cotherapy (93.3%) compared with etanercept monotherapy (73.5%), and tended to be higher than with non-MTX cotherapy (85.1%). Logistic regression analysis identified that MTX cotherapy at entry and moderate disease activity at entry were independent variables for remission induction at 6 months. Accordingly, DAS28-ESR at 6 months was significantly lower with MTX cotherapy as compared with etanercept monotherapy or non-MTX cotherapy. To a lesser extent, DAS28-ESR with non-MTX cotherapy at 6 months was lower than with etanercept monotherapy. In this study of unselected patients, use of MTX and moderate disease activity at entry were associated with higher likelihood of response to etanercept. Non-MTX nonbiologic DMARDs may be an alternative in RA patients administrated etanercept who are intolerant to MTX.