Three layers in spinal canal.

Contrast-enhanced computed tomography revealed spontaneous spinal epidural hematoma, which mimicked aortic dissection.

Squawks as an important physical finding for differentiation of diffuse panbronchiolitis from asthma in children: A case report.

Diffuse panbronchiolitis (DPB) is an idiopathic chronic inflammatory pulmonary disease clinically characterized by cough, sputum, and chronic sinusitis. Although the average age of onset is 40 years, DPB occasionally occurs in children and is often misdiagnosed as asthma. Long-term therapy with macrolide antibiotics significantly improves survival in DPB. Herein, we report the case of a 16-year-old man who had been treated for asthma and was referred to our department as transition from the Department of Pediatrics. Adequate auscultation to detect squawks and history taking of purulent sputum led to the correct diagnosis and appropriate treatment, which improved his quality of life.

Lower serum phosphate levels in patients with Legionella pneumonia relative to patients with non-Legionella pneumonia.

INTRODUCTION: Few studies have evaluated serum phosphate levels in patients with Legionella pneumonia admitted to hospitals in Japan. This study aimed to assess serum phosphate levels among inpatients with Legionella pneumonia on admission and compare them to those of inpatients with non-Legionella community-acquired pneumonia. METHODS: This case-control study included patients aged ≥16 years who were treated for Legionella pneumonia from April 2011 through March 2017 and those aged ≥16 years who were treated for non-Legionella community-acquired pneumonia from August 2014 through July 2015. Legionella pneumonia was diagnosed based on a positive result on the urinary antigen test, as well as radiographic examinations. Serum phosphate levels on admission were compared between Legionella and non-Legionella patients. In addition, serum phosphate levels on admission and on hospital day 5-7 were compared in Legionella patients. RESULTS: We evaluated 8 Legionella patients and 61 non-Legionella patients. Median serum phosphate levels on admission were 1.90 and 2.80 mg/dL in Legionella and non-Legionella patients, respectively (P = 0.008). By hospital day 5-7, serum phosphate levels in Legionella patients had increased to 2.61 mg/dL (P = 0.029, relative to admission), which did not significantly differ from those of non-Legionella patients on admission (P = 0.372). CONCLUSION: Serum phosphate levels on admission were approximately 32% lower in Legionella pneumonia patients compared to non-Legionella pneumonia patients, but both were comparable by hospital day 7.

An Autopsy Case of TAFRO Syndrome with Type II Respiratory Failure.

BACKGROUND TAFRO syndrome (thrombocytopenia, anasarca, fever, myelofibrosis, renal dysfunction, and organomegaly) is a systemic inflammatory disorder. The histological features of TAFRO syndrome are not fully understood and few autopsy cases have been reported. CASE REPORT A 66-year-old man with type II respiratory failure was diagnosed with TAFRO syndrome. He was initially treated with tocilizumab. Although some improvements were observed, his condition worsened, and the medication was switched to rituximab. His condition remained steady for 1 year with intermittent artificial ventilation. However, he died due to exacerbation of respiratory failure about 20 months after diagnosis. An autopsy revealed mucous fluid retention in the spaces between the axis cylinder and the myelin sheath of peripheral nerves and among the peripheral nerves, suggesting that this retention contributed to neurodegeneration with demyelination. Skeletal muscles, including respiratory muscles, were highly atrophic, which could have led to type II respiratory failure. CONCLUSIONS Fluid accumulation other than pleural effusion and ascites could occur in intra-organs at a cellular level.

Elderly patients with lower-jaw mobility require careful food texture modification: A cohort study.

BACKGROUND: Few studies have investigated the relationship between lower-jaw mobility and oral ingestible food texture choices in elderly patients. This study aimed to evaluate whether lower-jaw mobility affects levels of food texture modification. METHODS: This prospective cohort study targeted inpatients aged ≥65 years with pneumonia or urinary tract infection from August 2014 through July 2015. We defined "lower-jaw mobility" as movement of the lower jaw (more than about 1 cm) when gently supported from both sides of the mandibular angle with index fingers. The primary outcome was food texture at discharge, which was evaluated using "Japanese Dysphagia Diet 2013": non per os, codes 0-4 (in the order of increasing swallowing difficulty), and normal meal. RESULTS: We evaluated 38 patients in the mobility group (mean age: 86.5 years) and 251 patients in the nonmobility group (mean age: 83.2 years). Percentages of patients capable of ingesting each food texture were as follows (mobility vs nonmobility): normal meal, 5.3% vs 50.1%; code 4, 39.5% vs 31.9%; code 3, 5.3% vs 8.8%; code 2, 10.5% vs 4.4%; code 1, 2.6% vs 0.8%; code 0, 0.0% vs 0.4%; and non per os, 36.8% vs 2.8%. Food texture codes were lower in the mobility group (P < 0.001). These relationships remained significant even after adjusting for potential confounding factors in multivariate analysis (P < 0.001). CONCLUSION: Elderly patients with lower-jaw mobility were restricted to texture-modified foods. Lower-jaw mobility can be assessed easily even by nonmedical personnel, and regular assessment could help identify elderly patients requiring dietary adjustment.

A 3-year follow-up study of radiotherapy using computed tomography-based image-guided brachytherapy for cervical cancer.

Outcomes for patients with Stage IB1-IVA cervical cancer treated with computed tomography (CT)-based image-guided brachytherapy (IGBT) were examined in this study. A total of 84 patients were analyzed between March 2012 and June 2015. Whole-pelvic radiotherapy with a central shield was performed for each patient, and the total pelvic sidewall dose was 50 Gy. IGBT was delivered in 2-4 fractions. The initial prescription dose (6.8 Gy) was delivered at Point A, and the dose distribution was modified manually by graphical optimization. The total dose was calculated as the biologically equivalent dose in 2 Gy fractions (EQD2). Concurrent chemotherapy was administered to 64 patients (76%). The median follow-up period was 36 months (range 2-62 months). The 3-year overall survival, local control, and progression-free survival rates were 94%, 89% and 81%, respectively. The mean EQD2 for HR-CTV D90 was 73.4 Gy, and the EQD2 for HR-CTV D90 was not significantly associated with the local control rate. In multivariate analysis, adenocarcinoma (P = 0.03) and tumor size ≥45 mm (P = 0.06) were risk factors for local control. The patients were divided into four groups based on histology (squamous cell carcinoma vs adenocarcinoma) and tumor size (<45 vs ≥45 mm). Those with large adenocarcinomas had significantly worse outcomes. In conclusion, CT-based IGBT achieved favorable local control, but different treatment strategies may be necessary for large adenocarcinomas.

Disease Exacerbation after the Cessation of Fingolimod Treatment in Japanese Patients with Multiple Sclerosis.

Objective In Japan, following the launch of dimethyl fumarate (DMF) after fingolimod as a disease-modifying drug in multiple sclerosis (MS), some patients switched from fingolimod to DMF. The aim of this study was to determine the follow-up status of MS patients who switched to DMF after fingolimod cessation. Methods Clinical and magnetic resonance imaging (MRI) data in 19 patients with MS who switched to DMF were collected for at least for 6 months after fingolimod cessation. Results Ten patients (52.6%) experienced clinical or MRI exacerbation after fingolimod cessation. The peripheral blood lymphocyte counts at the time of fingolimod cessation in those with disease exacerbation were significantly lower than in those without exacerbation. The patients with disease exacerbation were further classified into three groups based on MRI findings: those with some new T2-weighted lesions with or without gadolinium (Gd) enhancement (group I), those with more new and/or enlarged T2-weighted lesions with Gd enhancement compared to pre-fingolimod induction (group II), and those with multifocal tumefactive demyelinating lesions. In group II, the clinical disease activity, which was similar to that at fingolimod initiation in group I, was higher than the clinical disease activity observed before fingolimod initiation. Conversely, group III exhibited unexpected new MRI findings that were not evident before fingolimod initiation. Conclusion Cessation of fingolimod might precipitate rebound or reactivation of clinical disease in patients with MS, and careful follow-up is necessary for patients who discontinue fingolimod.

Tocilizumab-resistant TAFRO Syndrome Complicated by Type II Respiratory Failure.

A 66-year-old man with a several year history of thrombocytopenia, pleural effusion and ascites, anasarca, and organomegaly presented with general fatigue, appetite loss, dyspnea with type II respiratory failure. The precise history of the patient and the re-evaluation of lymph node and bone marrow biopsies conducted by the previous physician indicated TAFRO syndrome. The patient's laboratory data improved for a year with tocilizumab, but then worsened to the point that the patient required artificial ventilation due to the deterioration of type II respiratory failure. The replacement of tocilizumab with rituximab yielded a steady improvement, but it was necessary to address the patient's persistent respiratory failure. Peripheral nerve disorder might have been involved with the patient's respiratory failure.

Predictors of distant relapse in patients with FIGO stage IIB-IVA cervical cancer treated with definitive radiotherapy.

AIM: To investigate the predictors of distant relapse in International Federation of Gynecology and Obstetrics (FIGO) stage IIB-IVA cervical cancer patients treated with definitive radiotherapy (RT). METHODS: The clinical data of 219 patients with FIGO stage IIB-IVA cervical cancer treated with definitive RT between January 1997 and December 2011 were retrospectively reviewed. The cumulative distant relapse, progression-free survival (PFS) and overall survival (OS) rates were calculated using the Kaplan-Meier method and compared using the log-rank test. A Cox proportional hazards regression model was used to investigate the predictors of distant relapse in patients. RESULTS: Following treatment with definitive RT, 61 of the 219 (27.9%) patients developed distant relapse with median PFS and OS rates of 9.9 and 32.8 months, and estimated five-year PFS and OS rates of 4.9% and 21.3%, respectively. Multivariate analysis revealed that pelvic node metastasis, pretreatment leukocytosis and pretreatment neutrophilia were significant predictors of distant relapse. The risk of developing distant relapse was found to be associated with the number of predictors that the patients displayed: the estimated five-year distant relapse rates of the patients with no predictors, one predictor and two predictors were 20.3%, 35.5% and 88.9%, respectively. CONCLUSIONS: Roughly 28% of patients with FIGO stage IIB-IVA cervical cancer developed distant relapse after definitive RT. Pelvic lymph node metastasis and pretreatment leukocytosis/neutrophilia are independent predictors of distant relapse.

Effects of Establishing a Department of General Internal Medicine on the Length of Hospitalization.

OBJECTIVE: This study aimed to evaluate the effects of establishing a Department of General Internal Medicine (DGIM) on the length of hospitalization. We evaluated the length of hospitalization associated with diseases for which full-time specialists were not available and were instead treated by physicians of the DGIM after its establishment. METHODS: A retrospective cohort study was conducted with a review of the subjects' medical records. The subjects included patients ≥16 years of age who were hospitalized with pneumonia or cerebral infarction and treated by a physician with a specialty in internal medicine as the disease outside their specialty prior to DGIM establishment (October 1, 2006 to September 30, 2008) or by a physician of the DGIM after its establishment (October 1, 2009 to September 30, 2011). The primary outcome was the change in the length of hospitalization. The length of hospitalization for heart failure, which was treated by specialists (cardiologists) in both study periods, was also examined for comparison. RESULTS: We evaluated 322 and 423 cases of pneumonia treated before and after the establishment of the DGIM, as well as 223 and 229 cases of cerebral infarction and 132 and 206 cases of heart failure, respectively. The length of hospitalization before and after establishment of the DGIM was 21.6 and 16.0 days for the pneumonia patients (p<0.001) and 24.2 and 19.9 days for the cerebral infarction patients (p<0.001), respectively. On the other hand, the change in the length of hospitalization for the heart failure patients was not statistically significant (19.9 vs. 17.6 days; p=0.281). CONCLUSION: The establishment of the DGIM reduced the length of hospitalization associated with diseases for which full-time specialists were not available by over 17%.

Paraganglioma-induced alveolar hemorrhage.

A 21-year-old man twice developed sudden dyspnea during running examinations for promotion. Chest computed tomography (CT) revealed lobular ground-glass opacity and centrilobular shadows bilaterally. The bronchoscopy findings were consistent with alveolar hemorrhage, and echocardiography showed severe hypokinesia a few hours later. A mass was subsequently identified along the abdominal aorta on enhanced CT and iodine-131 metaiodobenzylguanidine scintigraphy. Catecholamine oversecretion, which was later confirmed, may have increased the pulmonary vein pressure, thus resulting in the development of an alveolar hemorrhage, and damaged the cardiac muscles as manifested by hypokinesia. Since the patient had not previously developed alveolar hemorrhage during usual exercise, emotional stress superimposed on the physical activity may have triggered the paraganglioma to secrete excessive catecholamines, thus resulting in the observed symptoms.

Early diagnosis of Lemierre's syndrome based on a medical history and physical findings.

A 37-year-old woman presented with fever and rigor after experiencing respiratory symptoms the previous week that had resolved within a few days. On presentation, her neck was swollen along the right sternocleidomastoid muscle, and chest CT showed pulmonary septic embolisms. Lemierre's syndrome was strongly suspected based on the patient's medical history and physical findings. Further examination revealed venous thrombus, and Fusobacterium necrophorum was later isolated from blood cultures. Antibiotics for anaerobes were administered before a final diagnosis was made, and the patient's symptoms thereafter improved. A rapid diagnosis is essential, since Lemierre's syndrome can be fatal with a diagnostic delay.

Intraductal papillary neoplasm of the bile duct in liver cirrhosis with hepatocellular carcinoma.

A case of intraductal papillary neoplasm of the bile duct (IPNB) arising in a patient with hepatitis B-related liver cirrhosis with hepatocellular carcinoma (HCC) is reported. A 76-year-old man was admitted to our hospital with recurrent HCC. Laboratory data showed that levels of carcinoembryonic antigen and carbohydrate antigen 19-9 were elevated. He died of progressive hepatic failure. At autopsy, in addition to HCCs, an intraductal papillary proliferation of malignant cholangiocytes with fibrovascular cores was found in the dilated large bile ducts in the left lobe, and this papillary carcinoma was associated with an invasive mucinous carcinoma (invasive IPNB). Interestingly, extensive intraductal spread of the cholangiocarcinoma was found from the reactive bile ductular level to the interlobular bile ducts and septal bile ducts and to the large bile ducts in the left lobe. Neural cell adhesion molecule, a hepatic progenitor cell marker, was detected in IPNB cells. It seems possible in this case that hepatic progenitor cells located in reactive bile ductules in liver cirrhosis may have been responsible for the development of the cholangiocarcinoma and HCC, and that the former could have spread in the intrahepatic bile ducts and eventually formed grossly visible IPNB.