The TriAGe+ Score for Vertigo or Dizziness: A Diagnostic Model for Stroke in the Emergency Department.

BACKGROUND: Vertigo or dizziness is a common occurrence, but it remains a challenging symptom when encountered in the emergency department (ED). A diagnostic score for stroke with high accuracy is therefore required. METHODS: A single-center observational study (498 patients) was conducted. The predictor variables were derived from a multivariate logistic regression analysis with Akaike information criterion. The outcome was the occurrence of stroke. We evaluated the utility of a new diagnostic score (TriAGe+) and compared it with the ABCD2 score. RESULTS: The cohorts included 498 patients (147 with stroke [29.4%]). Eight variables were included: triggers, atrial fibrillation, male gender, blood pressure ≥140/90 mm Hg, brainstem or cerebellar dysfunction, focal weakness or speech impairment, dizziness, and no history of vertigo or dizziness or labyrinth or vestibular disease. We derived the TriAGe+ score from these variables. In the cohort, the prevalence of stroke increased significantly using the diagnostic score: 5.9% for a score of 0-4; 9.1% for 5-7; 24.7% for 8-9; and 57.3% for 10-17. At a cutoff value of 10 points, the sensitivity of the score was 77.5%, the specificity was 72.1%, and the positive likelihood ratio was 3.2. When the cutoff was defined as 5 points, the score obtained a high sensitivity (96.6%) with a good negative likelihood ratio (.15). The new score outperformed the ABCD2 score for the occurrence of stroke (C statistic, .818 versus .726; P < .001). CONCLUSIONS: The TriAGe+ score can identify the occurrence of stroke in patients with vertigo or dizziness presenting to the ED.

Clinical benefits and tolerability of increased fill volumes in Japanese peritoneal dialysis patients.

BACKGROUND: Increasing fill volume is an effective means of improving clearances in patients on peritoneal dialysis (PD). Since Japanese PD patients are physically smaller than their Western counterparts, there is some concern that PD patients in Japan may be unable to tolerate larger fill volumes. OBJECTIVE: To determine patient tolerance and changes in solute clearance and net ultrafiltration resulting from increased fill volumes in Japanese patients on PD. DESIGN: Prospective double-blind study, randomizing patients to three different fill volumes (2.5% dextrose solution: 1.5 L, 2.0 L, or 2.5 L) administered in random order on three different occasions separated by 1 week. RESULTS: Twenty-one patients with a mean age of 55.4 +/- 2.1 years and a mean body surface area of 1.66 +/- 0.03 m2 were studied. On a scale of 0 to 10, patients' mean discomfort scores were 2.14 +/- 0.59, 3.48 +/- 0.54, and 3.81 +/- 0.63 (p = 0.047) at the end of the 1.5-L, 2.0-L, and 2.5-L dwells, respectively. There were no reports of cramps or shortness of breath with any fill volume. Patients were able to correctly guess the actual fill volume for only 34 of the 63 total exchanges (54.0%). Increasing fill volume resulted in an incremental improvement in peritoneal creatinine clearance, from 3.74 +/- 0.16 to 4.49 +/- 0.21 (p < 0.001, 2.0 L vs 1.5 L) to 5.12 +/- 0.20 mL/minute (p< 0.001, 2.5 L vs 2.0 L) for 1.5-L, 2.0-L, and 2.5-L dwells, respectively. Peritoneal urea clearance also increased significantly, from 5.65 +/- 0.13 to 7.04 +/- 0.17 (p < 0.001, 2.0 L vs 1.5 L) and 8.16 +/- 0.29 mL/minute (p < 0.001, 2.5 L vs 2.0 L), with incremental increases in fill volume. Similarly, net ultrafiltration in a 4-hour dwell increased significantly with fill volume, from 255.24 +/- 24 mL with 1.5 L, to 356 +/- 24 (p < 0.004, 2.0 L vs 1.5 L) and 392 +/- 29 mL (p < 0.086, 2.5 L vs 2.0 L) in patients receiving 2.0 L and 2.5 L, respectively. CONCLUSION: Increasing the fill volume results in improvement in solute clearance and net ultrafiltration in Japanese PD patients, with minimal increase in patient discomfort. A large percentage of patients were unable to identify the actual fill volume.

[The effectiveness of thin-section computed tomography in diagnosing bullous lesions in patients with spontaneous pneumothorax].

We investigated the effectiveness of thin-section computed tomography (CT) for the diagnosis of bullous lesions in patients with spontaneous pneumothorax. The study group consisted of 74 patients. Apical regions of the lung were scanned for lesions by thin-section CT prior to operation. The presence, number, and locations of bullous lesions were assessed. Bullous lesions were also classified into 2 groups according to their shape as demonstrated by CT findings. Operative findings confirmed that 73 of the 74 patients had bullous lesions. Of these, 33 had a single bulla and 40 had multiple bulla. Thin-section CT accurately detected the presence and location of the bullous lesions, accurately identified the number in all but 6 patients with multiple bulla (accuracy: 91.8%), and also classified them accurately by type. Precise evaluations of bullous lesions are crucial to the treatment of patients with spontaneous pneumothorax. The presence of bullous lesions, as well as their location and shape, are important factors in determining whether to operate or not. Such information also allows for a better understanding of the surgical options available. Our study demonstrated that thin-section CT of apical regions of the lung is an effective diagnostic procedure for patients with spontaneous pneumothorax.

[A case of marginal zone B-cell lymphoma].

A 60-year-old woman had an abnormal shadow in the right lower lung field on chest roentgenogram. Transbronchial lung biopsy revealed findings consistent with malignant lymphoma, and a right middle lobectomy was performed. Pathological findings showed that tumor cells had infiltrated the epithelium, forming so-called lymphoepithelial lesions. Flow cytometric analysis of the resected specimen revealed that B-cell associated antigens (CD 19, 20) were expressed, and that the tumor cells were CD 5-, CD 10-. A marked increase in the number of lymphocytes with an IgM kappa component suggested monoclonal origin for the tumor cells in the resected specimen. Southern blot analysis showed clonal rearrangement of the heavy chain of the immunoglobulin gene. A diagnosis of malignant lymphoma of bronchus-associated lymphoid tissue was made. This tumor was defined according to the revised European. American classification of lymphoid neoplasms as a marginal zone B-cell lymphoma.

Differences in thermal salivation between the FOK rat (a model of genotypic heat adaptation) and three other rat strains.

Rats secrete saliva in response to heat. In the present study, details of thermal salivation were investigated using the FOK rat in comparison with Sprague-Dawley (SD), Donryu, and ACI rats. The FOK rat is a strain inbred for genotypic heat adaptation and endures heat for long periods. Conscious rats of all four strains were exposed to 42.5 degrees C. The order of heat endurance times at this temperature was FOK >> SD > Donryu = ACI. FOK rats spread their saliva over their entire ventral surface, their faces, and their outside legs. This saliva area was wider than those made by the other three strains. SD rats spread in an area wider than those of the Donryu and ACI rats. Saliva spreading in the FOK rats continued for 4.0-4.5 h, far longer than in the other strains. Under ketamine anesthesia and exposure to 40 degrees C, the FOK rats secreted saliva at 1390+/-235 microL/100 g of body weight during a 60-min observation period. This was the highest rate among the four rat strains (p < 0.0001). The body temperature increase rate in anesthetized FOK and SD rats was lower than in the other two strains, suggesting a minor contribution of unknown factors. Ligation of the submandibular gland ducts abolished the thermal salivation of the FOK rats, whereas ligation of the parotid duct had no effect. The submandibular, sublingual, and lachrymal glands in the FOK rats were 1.3-1.5, 1.25-1.4, and 1.3-1.5 times heavier, respectively, than those in the other three strains, whereas the parotid gland of the FOK rats was not enlarged. These findings indicate that the rats' saliva spreading and ET values are significantly correlated. A potentiated and long-lasting salivation from the submandibular gland was acquired during development of genotypic heat adaptation. This salivation is actuated in response to heat. The pronounced thermal salivation is probably attributable to adaptive changes in the superior salivatory nucleus-chorda tympani-submandibular gland pathway.

Abdominal incisional hernia occurring after an esophagectomy reconstructed with a gastric tube through an antesternal route: report of a case.

A Japanese man, who had undergone a subtotal esophagectomy reconstructed with a gastric tube through an antesternal route for esophageal carcinoma 16 years previously, was admitted to our hospital because of an abdominal incisional hernia. The abdominal incisional hernia was in his upper abdomen and was difficult to push back into the intraabdominal cavity by hand. The hernia was successfully repaired by operation. We thus conclude that an abdominal incisional hernia is a rare but important late-phase complication occurring after an esophagectomy reconstructed with either an antesternal or retrosternal route, and an operation should be the treatment of choice.

Endoscopic submucosal tumorectomy for gastrointestinal submucosal tumors restricted to the submucosa: a new form of endoscopic minimal surgery.

BACKGROUND: Endoscopic minimally invasive therapy for submucosal tumors of the gastrointestinal tract by use of endoscopic ultrasound has not yet come into widespread use, and this technique has not been fully evaluated. We therefore investigated this method of treatment in patients with gastrointestinal submucosal tumors. METHODS: Forty-five patients with suspected gastrointestinal submucosal tumors (esophagus [5], stomach [1], duodenum [16], colon [23]) based on barium enema studies and endoscopy underwent endoscopic ultrasound by the water-filled or balloon method. The layer of origin and the internal echogenicity of the lesions were evaluated. After confirming that the tumors were submucosal, the lesions were resected using injection of physiological saline solution and electrocautery. RESULTS: Using a one-channel or two channel method, all tumors were completely resected without serious complications and the diagnosis was histologically confirmed. Ulceration at the site of resection healed within 2 to 4 weeks (mean 23 days) and there has been no local recurrence. CONCLUSIONS: Our technique of endoscopic submucosal tumorectomy appears to be a safe and useful diagnostic-cum-therapeutic procedure for gastrointestinal submucosal tumors.

Multicenter evaluation of a colorimetric microplate antimycobacterial susceptibility test: comparative study with the NCCLS M24-P.

A colorimetric test method using the microplate culture technique for the determination of susceptibility of Mycobacterium tuberculosis against antimycobacterial agents was developed and evaluated by the multicenter study. The test method utilizes an oxidation-reduction dye, 2,3-diphenyl-5-thienyl-(2)-tetrazolium chloride (STC), as an indicator of mycobacterial growth. When compared to the presently available test method, some modifications were also included; lower inoculum density (10-fold dilution), inclusion of an inoculum diluted 1:100 as a growth control, and the preparation of inoculum preincubated in Middlebrook 7H9 broth and spectrophotometrically adjusted to McFarland #1 turbidity. The test method evaluated was highly precise and reliable to detect antimycobacterial resistances when the ATCC reference strains were tested. Also, the interpretations of the test result were highly comparable to those determined by the method of NCCLS M24-P, the % agreements ranging from 76.1% (ethambutol) to 91.3% (streptomycin). The test results were also comparable to those determined by Ogawa media; > 90% agreed with susceptible, intermediate, or resistant. The appearance of mycobacterial colonies on the test media was easily read, and the test results were more comparable to those of NCCLS M24-P. With these results, it can be concluded that the colorimetric microplate susceptibility test method described will be more suitable for clinical mycobacteriology laboratories.

Correlation between tumor volume doubling time and histologic findings in gastric smooth muscle tumors: clinical implications of tumor volume doubling time.

To assess the clinical implications of the tumor volume doubling time of gastric smooth muscle tumors based on a comparison with the histologic findings, seven tumors (four leiomyomas and three leiomyosarcomas) were followed up by consecutive upper gastrointestinal studies between March 1985 and December 1993. The patients were four men and three women with an average age of 58 years (range: 50-71 years). The observation period ranged from 6 to 51 months, with an average of 35 months. All tumors were surgically resected and the histologic diagnosis was confirmed. The following microscopic features were evaluated: 1) mitotic rate, 2) nuclear atypia, and 3) cellularity. Each tumor was also evaluated for the presence or absence of necrosis, hemorrhage, and degeneration. The doubling time ranged from 5 to 27 months with a mean of 16 months. There was a strong negative correlation between the mitotic rate and the doubling time (r = -0.935, P = 0.0019). The doubling time was also significantly related to nuclear atypia, but the number of tumors studied was so small that its reliability was questionable. The doubling time was not related to any other histologic findings. This study shows that the doubling time is useful for estimating the malignant potential of gastric smooth muscle tumors, and that tumors with a doubling time of 16 months or less should be considered as malignant.

Gastric syphilis: case report and review of the literature.

A 35-year-old Japanese woman consulted our clinic with a one-month history of epigastric pain. Although a superficial depressed type of early gastric carcinoma was highly suspected from the results of upper gastrointestinal barium studies and gastroscopy, there was no evidence of malignancy in the biopsy specimen. Gastric syphilis was then considered based on skin lesions and serological studies. Diagnostic antisyphilitic therapy improved the symptoms and gastric lesion promptly. A review of the recent reports indicated that most cases of early phase gastric syphilis seem to present morphologically either as a narrowing lesion or shallow ulcero-nodular lesion at the pyloric antrum. Therefore, whenever such findings are recognized either radiologically or gastroscopically and no malignant cells are found in biopsy specimens, gastric syphilis and diagnostic antisyphilitic therapy should be considered.

Blind loop syndrome: multiple ileal ulcers following side-to-side anastomosis.

A 59 yr old woman who had multiple ileal ulcers following side-to-side anastomosis without bowel resection is reported. She had a surgical history of adhesive ileus 15 yrs earlier, and was admitted with a complaint of lower abdominal pain. A barium meal study showed a stagnant and dilated distal ileum. At laparotomy, a previously performed side-to-side ileal anastomosis was encountered, and a markedly dilated bypassed loop was recognized. The affected intestine was resected revealing multiple longitudinal ulcers and small shallow ulcers mostly located on the mesenteric side. This feature is similar to that of ischemic enteritis. This case further supports the fact that when side-to-side anastomosis is performed as a bypass operation, multiple ulcers may develop in a bypassed loop after a long period of time.

Immunosuppressive mechanism of 15-deoxyspergualin on sinusoidal lining cells in swine liver transplantation: suppression of MHC class II antigens and interleukin-1 production.

To elucidate the precise mechanism of action of 15-deoxyspergualin (DSG) in swine liver transplantation, the expression of MHC class II antigens (Ia) on hepatic sinusoidal lining cells (SLC) and their production of interleukin-1 (IL-1) were examined. In our previous study, we isolated sinusoidal endothelial cells (SEC) and Kupffer cells (KC) by enzymatic digestion and centrifugal elutriation, and demonstrated that both SEC and KC present alloantigens effectively and generated IL-1 in response to allogenic or lipopolysaccharide stimulation. Animals were divided into three groups: group 1, nontransplanted normal controls (n = 3); group 2, no immunosuppressive treatment following liver transplantation (n = 5); group 3, DSG (0.8 mg/kg/day) intravenously for 7 days following liver transplantation (n = 5). At 1 week after transplantation, the three liver grafts in groups 2 and 3 were processed for the study of Ia expression and IL-1 production on SEC and KC. The expression of Ia was detected in 21.5 +/- 4.7% of SEC and 24.3 +/- 11.1% of KC in group 1. In group 3, Ia expression was suppressed compared with group 2, being 3.6 +/- 2.8% versus 22.0 +/- 2.8% for SEC (P less than 0.02) and 15.5 +/- 11.3% versus 24.3 +/- 7.1% for KC. IL-1 production by SEC and KC was respectively 11,483 +/- 3311 cpm and 9077 +/- 2161 cpm in group 1. In group 3, IL-1 production was inhibited compared with that in group 2, being 7190 +/- 883 cpm versus 19,297 +/- 5182 cpm for SEC (P less than 0.05) and 16,130 +/- 3769 cpm versus 25,857 +/- 3963 cpm for KC.(ABSTRACT TRUNCATED AT 250 WORDS)