Impact of elemental diet on early recovery after laparoscopic colectomy: findings of a randomized controlled trial.

PURPOSE: An amino acid-containing elemental diet (ED) does not require digestion for nutritional absorption, making it a good option for patients with gastrointestinal malabsorption. We conducted a randomized trial to confirm that perioperative ED enhanced the recovery of patients undergoing laparoscopic colectomy. METHODS: Patients in the intervention arm received commercially available ED from the day prior to surgery until postoperative day (POD) 3, whereas patients in the control group received a conventional perioperative diet program. To verify the endpoints, "estimated minimum length of stay in hospital after surgery" (emLOS) was defined as the number of days necessary to reach all the five criteria; namely, "sufficient oral intake", "sufficient pain control", "withdrawal of intravenous alimentation", "no abnormal findings in routine examinations", and "no rise in fever". RESULTS: A total of 102 patients were randomized, 94 of whom were analyzed (ED 45, control 49). There was no morbidity or mortality. Shorter emLOS (POD 4 vs. POD 7; p = 0.018), earlier resumption of sufficient oral intake (POD 3 vs. POD 4; p = 0.034) and faster recovery to defecation (2.2 vs. 3.1 days; p = 0.005) were observed in the ED group vs. the control group. CONCLUSIONS: The perioperative ingestion of ED by patients undergoing laparoscopic colectomy is safe and can reduce the postoperative hospital stay by supporting the acceleration of oral intake.

[Transmanubrial Osteomuscular-sparing Approach for Resection of Superior Mediastinal Schwannoma].

Various approaches can be applied to resect superior mediastinal tumor. It is important to choose the procedure according to the location, size, and characteristics of the tumor in order to perform safe procedure surgery because of distinctive anatomy of this site. We hereby report on a case of Schwannoma of the superior mediastinum resected by the transmanubrial approach. A 67-year-old woman was referred to our department to examine an abnormal chest shadow found at a regular health checkup. Computed tomography revealed a tumor 58×52 mm in size extending from the left supraclavicular fossa to the upper border of the aortic arch. The surgery was performed under the diagnosis of neurogenic tumor using the transmanubrial approach. The tumor was resected safely and the pathological diagnosis was a Schwannoma. Transmanubrial approach was found to be quite useful in securing an adequate visual field and enabling the safe separation of blood vessels and nerves from the tumor.

Surgical resection of solid gallbladder adenocarcinoma presenting as a large mass: report of a case.

This report describes a case of a patient with a large solid gallbladder adenocarcinoma that was completely resected through aggressive surgery. The patient was a 57-year-old woman who had been diagnosed with advanced gallbladder cancer, had no indications for surgical resection and was scheduled to undergo systemic chemotherapy. She presented to our hospital for a second opinion. At the time of assessment, her tumor was large but was well-localized and had not invaded into the surrounding tissues, indicating that surgical resection was a reasonable option. Subsequently, the tumor was completely extracted via right hepatectomy with en bloc resection of the caudate lobe and extrahepatic bile duct. Histopathologically, the tumor was a solid adenocarcinoma. Although there are relatively few reports in the literature regarding solid gallbladder adenocarcinoma, well-localized growth appears to be a characteristic feature. On the basis of a tumor's progression behavior, aggressive surgical treatment might be indicated even when the tumor has grown to a considerable size.

Transabdominal impalement injury by an iron pipe - A case report.

Impalement injuries are rare and complex problems, often involving multiple organ injuries. An 18-year-old male was admitted to our emergency department after a car accident. Positioned in the right-side recumbent position, he had a 4.5 cm diameter pipe penetrating from his left abdomen to his back. Given the pipe's length exceeding the CT gantry's capacity, further imaging tests were not feasible. Consequently, the patient proceeded directly to the operating room without preoperative imaging. Before laparotomy, a left thoracotomy was conducted for aortic cross-clamping, anticipating uncontrollable bleeding during pipe removal. The subsequent laparotomy, with the patient in the right-side recumbent position, revealed the pipe impaling through the mesentery of the descending colon without evident major vessel injury. The pipe was cautiously extracted. The patient was subsequently discharged on day 26. The absence of imaging feasibility emphasized that current hemodynamic stability does not rule out the potential for significant vessel injury. Therefore, the sequential approach of left thoracotomy for aortic cross-clamping followed by laparotomy emerges as a potentially beneficial strategy in cases of transabdominal impalement. The impalement injury requires our preparedness and flexibility, which should be tailored to the individual case.

Activation of an oncogenic TBC1D7 (TBC1 domain family, member 7) protein in pulmonary carcinogenesis.

To develop novel biomarkers and therapeutic agents for lung cancers, we screened molecules that were highly expressed in lung cancers by means of cDNA microarray analysis and found an elevated expression of TBC1 domain family, member 7 (TBC1D7) in the majority of lung cancers. Northern-blot analysis using mRNAs from 16 normal tissues detected its expression only in testis. Immunohistochemical staining using tumor tissue microarrays consisting of 261 archived non-small cell lung cancer (NSCLC) specimens suggested an association of TBC1D7 expression with poor prognosis for NSCLC patients (P = 0.0063). Treatment of lung cancer cells using siRNA against TBC1D7, suppressed its expression and resulted in inhibition of the cell growth. Furthermore, the induction of exogenous expression of TBC1D7 conferred growth-promoting activity at in vitro and in vivo conditions. We also identified TBC1D7 to interact with TSC1 protein in lung cancer cells. TSC1 introduction into cells increased the level of TBC1D7 protein, whereas knockdown of TSC1 expression decreased the level of TBC1D7 protein, suggesting that TBC1D7 is stabilized probably through interaction with TSC1. In addition, inhibition of the binding between TBC1D7 and TSC1 by a TBC1D7-derived 20-amino acid cell-permeable peptide (11R-TBC1D7(152-171)), which corresponded to the binding domain to TSC1, effectively suppressed growth of lung cancer cells. Selective suppression of TBC1D7 and/or inhibition of the TBC1D7-TSC1 complex formation could be promising therapeutic strategies for lung cancer therapy.

Activation of placenta-specific transcription factor distal-less homeobox 5 predicts clinical outcome in primary lung cancer patients.

PURPOSE AND EXPERIMENTAL DESIGN: To identify novel biomarkers and therapeutic targets for lung cancers, we screened for genes that were highly transactivated in lung cancers using a cDNA microarray representing 27,648 genes. DLX5 gene, a member of the human distal-less homeobox transcriptional factor family that is expressed during early embryonic development, was found to be overexpressed in the great majority of lung cancers. Tissue microarray consisting of archival non-small cell lung cancer samples from 369 patients was applied to examine the clinicopathologic significance of DLX5 protein. A role of DLX5 in cancer cell growth and/or survival was investigated through small interfering RNA experiments. RESULTS: Northern blot and immunohistochemical analyses detected expression of DLX5 only in placenta among 23 normal tissues examined. Immunohistochemical analysis showed that positive immunostaining of DLX5 was correlated with tumor size (pT classification; P = 0.0053) and poorer prognosis of non-small cell lung cancer patients (P = 0.0045). It was also shown to be an independent prognostic factor (P = 0.0415). Treatment of lung cancer cells with small interfering RNAs for DLX5 effectively knocked down its expression and suppressed cell growth. CONCLUSIONS: These data implied that DLX5 is useful as a target for the development of anticancer drugs and cancer vaccines as well as for a prognostic biomarker in clinic.

Activation of Holliday junction recognizing protein involved in the chromosomal stability and immortality of cancer cells.

We identified a novel gene HJURP (Holliday junction-recognizing protein) whose activation seemed to play a pivotal role in the immortality of cancer cells. HJURP was considered a possible downstream target for ataxia telangiectasia mutated signaling, and its expression was increased by DNA double-strand breaks (DSB). HJURP was involved in the homologous recombination pathway in the DSB repair process through interaction with hMSH5 and NBS1, which is a part of the MRN protein complex. HJURP formed nuclear foci in cells at S phase and those subjected to DNA damage. In vitro assays implied that HJURP bound directly to the Holliday junction and rDNA arrays. Treatment of cancer cells with small interfering RNA (siRNA) against HJURP caused abnormal chromosomal fusions and led to genomic instability and senescence. In addition, HJURP overexpression was observed in a majority of lung cancers and was associated with poor prognosis as well. We suggest that HJURP is an indispensable factor for chromosomal stability in immortalized cancer cells and is a potential novel therapeutic target for the development of anticancer drugs.

[Clinical examination of challenge test to local anesthetics].

BACKGROUND: Although adverse reactions to local anesthetics are often diagnosed as local anesthetic allergy, there is evidence that most of these reactions occur via non-allergic mechanisms. METHODS: To evaluate allergic reactions to local anesthetics, challenge tests were performed in 20 patients who had a history of adverse events to local anesthetics for whom dental treatment was planned. The diagnostic protocol of this challenge test consisted of skin prick and intracutaneous tests, as well as subsequent incremental subcutaneous challenge tests with local anesthetics such as lidocaine. RESULTS: 17 patients (85%) showed no immediate allergic response to lidocaine, which could then be used for dental treatment. Three patients (15%) reacted positively to lidocaine: one had local erythema at the site of the skin prick, and two reacted to subcutaneous challenge. CONCLUSION: The proportion of immediate-type reactions to local anesthetics is small but not rare in patients suspected of having local anesthetic allergy. This result suggests that the diagnostic approach to confirm allergy to local anesthetics is clinically important and requires further study in a larger population.

[Prognostic significance of neutrophil elastase inhibitor in patients with acute lung injury and interstitial pneumonia].

The prognostic significance of a neutrophil elastase inhibitor, sivelestat sodium hydrate (SSH), was evaluated in patients on mechanical ventilation due to acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) associated with systemic inflammatory response syndrome (SIRS). We studied 20 consecutive patients in our hospital, where patients complicated with interstitial pneumonia (IP) were separately analyzed (ARDS group, n = 10; IP group, n = 10). There was no significance difference between the two groups in the average lung injury score (3.0 in the ARDS group versus 2.8 in the IP group), the mean P/F ratio (96.3 mmHg in the ARDS group versus 96.7 mmHg in the IP group), plateau pressure (30.5 mmHg in the ARDS group versus 27.0 mmHg in the IP group), ventilator-free days, the duration of intensive care unit stay, and the hospitalization period. Four ARDS patients and 5 IP patients were treated with SSH within 3 days from SIRS onset. In the ARDS group, 5 patients (50%) were complicated with 4 or more organ dysfunctions and 3 patients (30%) died. IP patients all received corticosteroid, but the mortality was significantly higher among patients with IP than among those with ARDS by Kaplan-Meier survival curves. Of the clinical variables, only the diagnosis of IP was found to be independently related to mortality by a multivariate Cox proportional-hazards analysis. We conclude that IP patients have poor life expectancy if they are treated with SSH.

[A pregnant woman with severe asthma effectively treated by inhalational lidocaine therapy].

We report a case of a pregnant woman with severe asthma that was not controlled with ordinary medications but was effectively treated by inhalational lidocaine treatment. The case was a 27-year-old woman who had been repeatedly hospitalized due to acute asthma since her infancy. The patient had an episode of asthma attack caused by the use of aspirin. The daily medication for controlling her asthma included 1.5mg betamethasone. In February, 2004, she was hospitalized because of asthma exacerbation during her 11th week of pregnancy. Despite intensive treatments including repetition of inhaled beta2-agonist and anti-cholinergic drugs, intravenous injection of betamethasone and theophylline, and a leukotriene receptor-antagonist, no obvious improvement in severe cough, wheeze, or hypoxemia was observed for more than 3 weeks. Then inhalational lidocaine was introduced according to the method described by Mayo Clinic, USA. Namely, following inhalation of beta2-agonist, 40 to 100mg lidocaine was given via an ultrasonic nebulizer 5 times a day. Interestingly, symptoms such as wheezing or cough and also her hypoxemia dramatically improved following this treatment and reduction of systemic corticosteroid became possible. Finally, she was delivered of a girl by caesarean section. Nebulized lidocaine treatment may be an useful option as supplementary treatment for refractory asthma especially in pregnant cases.

[A case of pulmonary Mycobacterium avium complex disease, mimicking hot tub lung].

A 56-year-old man in whom reticulonodular shadows had been noted on a previous chest radiography study was admitted to our hospital with complaint of exertional dyspnea in March 2004. His thoracic computed tomography (CT) showed diffuse ground-glass opacities and multiple centrilobular small nodules in both lung fields. Lymphocytes occupied a high proportion in the cells recovered from the bronchoalveolar lavage fluid. These findings were compatible with those for hypersensitivity pneumonitis. Histopathological findings observed in the video-assisted thoracoscopic surgical biopsy specimens included necrotizing granulomas, organizing pneumonia associated with collective epithelioid cell granulomas without necrosis, and alveolar septal thickening with lymphocyte infiltration that showed a centrilobular distribution. These findings were also compatible with those for hot tub lung. Further information that supported the diagnosis were the identifications of Mycobacterium avium complex in his sputum by acid-fast bacteriological culture as well as positive for Mycobacterium avium polymerase chain reaction in lung specimen. He responded well to corticosteroid therapy, resulting in improvement in his clinical condition as well as in his chest radiographs. He was later put on an antituberculosis therapy, and the corticosteroid therapy was discontinued. This led to an exacerbation of his disease and corticosteroid therapy was restarted. It is not long time since the disease was first recognized, and thus few cases have been reported in Japan. Our report may provide valuable information on the disease in this country.

Paraneoplastic extralimbic encephalitis associated with thymoma: a case report.

Here we a report a rare case of extralimbic encephalitis associated with thymoma. A 66-year-old woman was admitted to our hospital with cramping in her right leg and inability to walk. Magnetic resonance imaging of the brain showed multifocal high intensity signals on T2 flare images in the cerebral cortex, and chest computed tomography showed a 5-cm anterior mediastinal mass, which was considered to be a thymoma. We speculated that she had paraneoplastic encephalitis associated with thymoma. She underwent a thymectomy and was diagnosed with type B1 thymoma. On postoperative day 6, her neurological symptoms began to improve. On postoperative day 31, she was discharged without complications. Limbic encephalitis is a paraneoplastic neurological syndromeassociated with thymoma, but extralimbic encephalitis has been described in the literature very rarely. We report the case of extralimbic encephalitis associated with thymoma along with a literature review.

Inhibition of Eph receptor A4 by 2,5-dimethylpyrrolyl benzoic acid suppresses human pancreatic cancer growing orthotopically in nude mice.

Ephrin receptor A4 (EphA4) is overexpressed in human pancreatic adenocarcinoma (PDAC) and activate cell growth. Recent studies have identified small molecules that block EphA4. In this study, we investigated the correlation between EphA4 expression and the prognosis of patients with PDAC. We also examined the cytostatic efficacy of 2,5-dimethylpyrrolyl benzoic acid (compound 1), a small molecule that blocks EphA4, in PDAC cells. Overall survival of patients with EphA4 positivity was significantly shorter than that of patients with EphA4 negativity (P = 0.029). In addition, multivariate analysis revealed that EphA4 expression was an independent prognostic factor in PDAC patients (P = 0.039). Compound 1 showed a cytostatic efficacy in PDAC cells expressing EphA4 in vitro and in vivo. Our study indicated that compound 1 suppressed both EphA4 and Akt phosphorylations, and induced apoptosis in PDAC cells expressing EphA4. In conclusion, compound 1 has a high potential as a therapeutic agent for patients with PDAC.

Poor prognosis and related factors in adults with Eisenmenger syndrome.

BACKGROUND: Little information is available regarding the clinical history and long-term prognosis of patients with Eisenmenger syndrome without diagnosis until adulthood. The purpose of this study was to investigate the long-term prognosis and factors predictive of the prognosis in patients with Eisenmenger syndrome diagnosis in adulthood. METHODS AND RESULTS: We retrospectively reviewed the clinical data of 106 patients with Eisenmenger syndrome diagnosis in adulthood. Presence of congenital heart defects had neither been noticed nor confirmed with cardiac catheterization until adulthood in most of the patients in our study. After the diagnosis was confirmed, 42 patients died during a mean follow-up period of 7.6 years. The mean survival time from diagnostic catheterization to death was 5.4 years in nonsurvivors. Survival rate was 98% at 1 year, 77% at 5 years, and 58% at 10 years, with the Kaplan-Meier method. Elevated right atrial pressure (>7 mm Hg) and reduced systemic blood flow (<2.9 L/min) were independently associated with increased mortality rate of adults with Eisenmenger syndrome. CONCLUSION: Patients with Eisenmenger syndrome without diagnosis until adulthood had a poor prognosis. Reduced systemic blood flow and elevated right atrial pressure were associated with high mortality rates in adults with Eisenmenger syndrome.

Increase in thrombomodulin concentrations after pulmonary thromboendarterectomy in chronic thromboembolic pulmonary hypertension.

STUDY OBJECTIVES: The objectives of the study were as follows: (1) to identify differences in endothelial dysfunction and altered hemostasis in patients with chronic thromboembolic pulmonary hypertension (CTEPH) compared with patients with acute pulmonary thromboembolism (APTE) uncomplicated by pulmonary arterial hypertension, by measuring the concentrations of thrombomodulin (TM), a receptor for thrombin and a major anticoagulant proteoglycan on the endothelial membrane, and other plasma factors of coagulation and fibrinolysis; and (2) to examine the effects of thromboendarterectomy on TM levels as a parameter of endothelial cell injury leading to abnormal hemostasis as well as to examine the clinical significance of TM as a marker of endothelial injury. DESIGN: Prospective comparison of concentrations of TM and other plasma parameters among patients with CTEPH or APTE and control subjects. PARTICIPANTS: We studied 22 healthy subjects (ie, control subjects), 22 patients who had been clinically stabilized after APTE, and 44 patients with CTEPH. In 21 of the patients with CTEPH, measurements were repeated after they had undergone pulmonary thromboendarterectomy. MEASUREMENTS AND RESULTS: Plasma concentrations of soluble TM in patients with CTEPH were measured and compared with those in patients with APTE. The mean (+/- SD) TM concentration in the CTEPH group (2.5 +/- 0.7 ng/mL) was significantly lower than that in the control group (4.0 +/- 0.6 ng/mL; p < 0.05). In contrast, the mean plasma TM concentration in the APTE group (4.6 +/- 1.9 ng/mL) was similar to that in the control group. After patients underwent pulmonary thromboendarterectomy, the mean TM concentration increased from 2.0 +/- 0.4 to 2.9 +/- 0.7 ng/mL (p < 0.05). In the CTEPH group, the plasma TM concentration was negatively correlated with mean pulmonary arterial pressure and total pulmonary resistance (p < 0.05). CONCLUSIONS: A decreased plasma TM concentration may reflect pulmonary vascular endothelial dysfunction leading to altered anticoagulant and fibrinolytic function in CTEPH, which rarely develops after APTE. Plasma TM measurements may be useful in distinguishing CTEPH with severe pulmonary hypertension from recurrent APTE.

[A case of desquamative interstitial pneumonia with bilateral hilar and mediastinal lymphadenopathy].

A 53-year-old man in whom reticulonodular shadows had been noted since 1999 in chest radiographs was admitted to our hospital in January 2003 with a complaint of persistent cough. His thoracic computed tomography (CT) showed diffuse ground-glass opacities in both lung fields and bilateral hilar and mediastinal lymphadenopathy. Histopathological findings from video-assisted thoracoscopic surgical biopsy included diffuse, monotonous interstitial pneumonia with accumulation of macrophages in the alveolar spaces and many lymphoid follicles, which was compatible with desquamative interstitial pneumonia (DIP). There was follicular hyperplasia in the enlarged lymph node without a suggestion of granulomous disease. He responded well to corticosteroid administration, resulting in an improvement of his clinical condition associated with a decrease in the ground-glass opacities. The bilateral hilar and mediastinal lymphadenopathy was slightly reduced. Since we could find no literature reporting DIP with bilateral hilar and mediastinal lymphadenopathy on thoracic CT, we consider the diagnostic problems and therapeutic response of this case to warrant a brief report.

[A case of chronic pigeon breeder's disease accompanied with progressive pulmonary cysts and recurrent pneumothorax].

We followed up a case of chronic pigeon breeder's disease with progressive pulmonary cysts and recurrent pneumothorax. The patient was a 48-year-old man who started to breed pigeons 14 years ago. He was diagnosed 7 years ago as having hypersensitivity pneumonitis due to pigeons, but he refused to stay away from the birds until he experienced episodes of dyspnea on exertion 3 years ago. A chest CT scan showed multiple cysts and peribronchial fibrosis in both lungs. The pathological findings of video-assisted-tracheoscopic surgery showed a centribronchial granuloma with lymphocyte infiltrations. Tests for antibodies against pigeon extracts of droppings were positive. Even after steroid treatment and avoidance of pigeons 3 years ago, there have been progressive cysts and fibrosis in the lungs. Progressive pulmonary cysts with recurrent pneumothorax is a rare manifestation as a chronic pigeon breeder's disease.

[Usefulness of Streptococcus pneumoniae urinary antigen detection kit and the duration and intensity of reactivity with urinary antigen in patients with pneumonia].

We evaluated a rapid urinary antigen detection kit, Binax Now Streptococcus pneumoniae (Binax Inc., USA), which detects S. pneumoniae antigen in urine by immunochromatographic membrane assay, in 379 patients with presumptive pneumonia (total: 454 urine samples). S. pneumoniae antigen was detected in 64 (34%) of 188 patients. In all 64, pneumonia was diagnosed clinically, and there were 11 intense reactivity cases, 27 intermediate cases, and 26 weak cases. We found only two patients with positive sputum cultures for S. pneumoniae among 26 patients with weak reactivity to urinary antigen. The weak urinary antigen reactivity seems to include a false-positive result for S. pneumoniae pneumonia. There were five patients with negative results in whom S. pneumoniae was isolated (false-negative). We took intense and intermediate reactivity to be positive in order to diagnose pneumococcal pneumonia, and the kit showed a sensitivity of 72% and a specificity of 94% in 379 patients. The urinary antigen kit allowed us to diagnose 80% more patients with pneumococcal pneumonia than the use of conventional bacteriological diagnosis alone. There was no significant difference in the initial clinical characteristics, or in the severity of pneumonia among the three groups, according to the color intensity reached using the kit--weak, intermediate, and intense for the reactivity of urinary antigen. The duration of reactivity with S. pneumoniae urinary antigen did not correlate with the clinical characteristics or the severity of pneumonia. We concluded that S. pneumoniae urinary antigen detection kit is a useful adjunct to culturing for determining the etiology of pneumonia.

[Ct findings of drug-induced pneumonitis--characteristic CT findings by histological group and subgroup].

We examined the chest CT results of 27 cases of drug-induced pneumonitis. We classified the subjects into 3 groups in accordance with the clinicopathological findings: eosinophilic pneumonia (EP) group (5 cases), diffuse alveolar damage (DAD) group (3 cases), and interstitial pneumonia (IP) group (19 cases). We evaluated the CT findings in each group, and made a further subclassification. In the EP group, the CT findings were subdivided into two, namely, type A, with diffuse distribution consistent with CT findings of acute eosinophilic pneumonia; and type B, with subpleural distribution consistent with chronic eosinophilic pneumonia. In the DAD group, the CT findings were diffuse distribution of mixed ground-glass attenuation and air-space consolidation, with or without traction bronchiectasis, and without shrinking of the lung. In the IP group, the CT findings were subdivided into 3, namely type A, with ground-glass attenuation dominant, without traction bronchiectasis or shrinking of the lung, consistent with the CT findings of IP without fibrosis; type B, with air-space consolidation dominant, with traction bronchiectasis and shrinking of the lung, consistent with the CT findings of IP with fibrosis; and type C with multiple nodules dominant. Radiological differentiation of the DAD group from IP-type B may be possible by the presence or absence of a shrinking lung pattern. We concluded that the subgroups of CT findings in drug-induced pneumonitis may be useful for diagnosis of this disease, and for prognosis.