Squamous Cell Carcinoma after Endoscopic Injection Sclerotherapy for Esophageal Varices

We report two cases of squamous cell carcinoma of the esophagus following endoscopic injection sclerotherapy for esophageal varices. The interval between sclerotherapy and the development of carcinoma was 24 months in case 1 and 21 months in case 2. The sclerosant was 5% sodium morrhuate in case 1 (total dose, 10 ml) and 5% ethanolamine oleate in case 2 (45.5 ml). Although no recurrent variceal bleeding occurred after sclerotherapy, we could not perform any curative surgical treatment for esophageal cancer because of the advanced stage of the cancer and the severity of the accompanying liver dysfunction. It is difficult to determine the relationship between sclerotherapy and carcinoma; however, long-term surveillance is essential to avoid overlooking a neoplasm in the esophagus after endoscopic injection sclerotherapy.     

Myasthenia Gravis Presenting with Myasthenic Crisis Mimicking Status Asthmatics

A 23-year-old woman was transferred to our hospital due to exacerbating dyspnea with wheeze. After admission, we started mechanical ventilation immediately, and she was diagnosed with status asthmatics. On the following day, she was able to be weaned from the ventilator. However, she required re-intubation because of an unstable respiratory condition just after extubation. Detailed neurological investigations identified blepharoptosis and muscle weakness with easy fatigability. An edrophonium test was positive. Anti-acetylcholine receptor antibody was detected in her serum. She was finally diagnosed with myasthenia gravis and successfully treated with neostigmine and a low-dose corticosteroid.     

Case of Hashimoto's encephalopathy with diffuse white matter lesions on diffusion-weighted MRI]

A 65-year-old woman was admitted to our hospital because of subacute deterioration of cognitive function. On admission, she presented with marked disorientation of time and place and inability to carry out commands. Mini-Mental State Examination score was 5/30. Although routine laboratory examinations including thyroid function, vitamin B1 and B12, serum syphilitic reaction, sIL-2 receptor level, titers of herpes simplex and zoster viruses, and HIV antibody were normal, titers of anti-thyroglobulin (TG) antibodies and thyroid peroxidase (TPO) antibodies were elevated. Cerebrospinal fluid showed normal findings. Brain MRI revealed diffuse high intensity in the white matter on diffusion- and T2-weighted images, mimicking leukoencephalopathy. We made a diagnosis of Hashimoto's encephalopathy, based on clinical features and high titers of anti-thyroid antibodies. Following administration of steroid hormone, her cognitive impairment gradually improved, associated with decrease of the white matter abnormality on MRI. Hashimoto's encephalopathy should be kept in mind in the differential diagnosis of subacute leukoencephalopathy with cognitive decline.     

A case of multiple sclerosis with bilateral useless hand syndrome as a main clinical feature]

A 41-year-old, right-handed man was admitted to our hospital on September 12, 2002, due to progressive clumsiness in both hands. The patient had been diagnosed as having multiple sclerosis three years prior to admission. He noticed difficulty in manipulating objects three months before admission. Cervical T2-weighted MRI showed a high signal intensity at the level of C3-4 which was enhanced on T1-weighted image with gadolinium. On admission, neurological examinations revealed impairment of dexterity, deep sensory disturbance, and astereognosis in both hands. The clumsiness of complex finger movements was predominant on the left side, and was exaggerated with the eyes closed in association with pseudoathetosis. After steroid therapy, his clumsy hands improved gradually. This type of clumsiness in multiple sclerosis had been described as useless hand syndrome by Oppenheim. In accordance with our case, useless hand syndrome has been reported to arise from high cervical (C2-4) lesions, mainly involving the posterior cord ipsilateral to the clumsy hand. Although the majority of reported cases with useless hand syndrome had other neurological complications, such as hemiparesis, tetraparesis, and truncal ataxia, our patient exhibited a pure form of useless hand syndrome. In addition, useless hand syndrome is usually unilateral, and bilateral useless hand syndrome is very rare. Clumsiness of fine finger movements with astereognosis in our patient is similar to numb clumsy hands or limb-kinetic apraxia due to cervical spondylosis or postcentral gyrus lesion, respectively. This indicates an important role of the high cervical posterior cord in conveying a kinesthetic sense necessary to guide fine finger movements. It should be kept in mind that high cervical lesions in multiple sclerosis causes clumsy hands mimicking limb-kinetic apraxia.     

Combination Chemotherapy with Tegafur-Uracil (UFT), Etoposide, Adriamycin and Cisplatinum (UFT-EAP) for Advanced Gastric Cancer

Thirty-four patients with advanced gastric cancer were treatedwith combination chemotherapy employing Tegafur-Uracil (UFT),etoposide, Adriamycin, and Cisplatinum (CDDP) (UFT-EAP therapy).An objective partial response was obtained in 16 patients (47%)and the median duration of remission was 12.2 months. The 50%survival time for all 34 patients was 10 months. Patients withmoderately or well differentiated adenocarcinoma responded well(13/19, 68%), while those with undifferentiated adenocarcinomashowed a poor response (3/15, 20%). Six responding patientswere noted to have no evidence of viable cancer at the primarysite by endoscopic biopsy, and underwent gastrectomies. Theresected specimens showed complete disappearances of the primarytumors in four patients. The median survival time for the patientsreceiving gastrectomies was 24 months. The regimen was verywell tolerated, apart from moderate bone marrow suppression.Our results suggest that patients with advanced gastric cancercan be effectively treated with UFT-EAP chemotherapy     

Vaccine-associated paralytic poliomyelitis caused by contact infection

We encountered an adult patient with acute anterior poliomyelitis (AAP), whose monoparesis developed 28 days after his son's immunization with oral poliovirus vaccine (OPV). Neurological and electrophysiological examinations suggested that his muscular wasting of the left lower limb was due to a lower motor neuron disorder, and magnetic resonance imaging revealed the responsible lesion in the left anterior horn at the thoracolumbar junction. His stool was found to include poliovirus type 3, mainly originating from Sabin 3 by neutrization antibody and PCR-restriction fragment length polymorphism method. This indicated that the AAP resulted from contact with his son. This patient raises the question about OPV in polio-free countries.     

Effective use of the Japan Narrow Band Imaging Expert Team classification based on diagnostic performance and confidence level

Five years have passed since the Japan Narrow Band Imaging Expert Team (JNET) classification was proposed in 2014. However, the diagnostic performance of this classification has not yet been established. We conducted a retrospective study and a systematic search of Medical Literature Analysis and Retrieval System On-Line. There were three retrospective single center studies about the diagnostic performance of this classification. In order to clarify this issue, we reviewed our study and three previous studies. This review revealed the diagnostic performance in regards to three important differentiations. (1) Neoplasia from non-neoplasia; (2) malignant neoplasia from benign neoplasia; and (3) deep submucosal invasive cancer (D-SMC) from other neoplasia. The sensitivity in differentiating neoplasia from non-neoplasia was 98.1%-99.8%. The specificity in differentiating malignant neoplasia from benign neoplasia was 84.7%-98.2% and the specificity in the differentiation D-SMC from other neoplasia was 99.8%-100.0%. This classification would enable endoscopists to identify almost all neoplasia, to appropriately determine whether to perform en bloc resection or not, and to avoid unnecessary surgery. This article is the first review about the diagnostic performance of the JNET classification. Previous reports about the diagnostic performance have all been retrospective single center studies. A large-scale prospective multicenter evaluation study is awaited for the validation.     

Usefulness of free-angle M-mode echocardiography in assessing left ventricular dimension and left ventricular systolic function

Objectives To assess the usefulness of free-angle M-mode echocardiography in measuring left ventricular (LV) dimension and global systolic function. Background The validity of conventional M-mode echocardiography in assessing LV dimension and global systolic function is well known; the incidental angle between the M-mode cursor and true LV minor axis diameter, however is a potential cause of measurement error. Free-angle M-mode echocardiography may overcome the limitation of M-mode cursor arrangement in conventional M-mode echocardiography. Methods Thirteen normal volunteers and 10 patients in whom abnormal left ventricular wall motion was not detected by echocardiography (mean age, 53±17 years) were enrolled in this study. Conventional and free-angle M-mode echocardiographic images of the LV were obtained by echocardiography (ALOKA SSD-5500) using a 2.5-MHz transducer, and the LV end-diastolic (LVDd) and end-systolic (LVDs) dimensions were measured by the leading edge method. LV end-diastolic and end-systolic volumes were calculated using a formula by Teichholz, and the LV ejection fraction (LVEF) was obtained. Data from conventional M-mode echocardiography and free-angle M-mode echocardiography were then compared. Results Measurements obtained with conventional M-mode and free-angle M-mode echocaardiography were strongly correlated. Correlation coefficients for LVDd, LVDs, and LVEF were 0.98, 0.98, and 0.96, respectively (p<0.001 in each case). Conclusions Assessment of left ventricular dimension, and global systolic function with free-angle M-mode can be as accurate as conventional M-mode in subjects in whom left ventricular wall motion abnormality is not detectable by echocardiogram. Moreover, when there is improper M-mode cursor direction in conventional echocardiography, free-angle M-mode echocardiography can assess global left ventricular systolic function more accurately and conveniently than conventional M-mode echocardiography.