Tetanus Overlooked Due to the Involvement of Multiple Departments: A Case Report.

Tetanus is a fatal disease caused by a neurotoxin produced by the biotrophic anaerobic bacterium Clostridium tetani, which causes muscle hypertonia and autonomic neuropathy. The diagnosis is based on clinical findings and not the result of specific blood and imaging tests; hence, it is very difficult to diagnose at first sight, despite typical initial findings such as lockjaw, muscle spasms, and neck pain and stiffness. This article discusses the case of a 79-year-old woman who first consulted her local doctor because of a lack of jaw opening. Seeing no improvement, she visited our hospital and was suspected of having tetanus after consulting with nine different departments over seven days from the initial visit. In developed countries, tetanus prevalence has declined due to immunization, leading to clinicians' lack of experience in diagnosing it. Furthermore, the increasing specialization in general hospitals poses a risk of missing a tetanus diagnosis when a patient consults multiple departments.

A case of caffeine intoxication resulting in hypothermia.

A 30-year-old woman arrived at our hospital with polymorphic ventricular tachycardia and hypothermia. Later, it was found that the cause was an overdose of caffeine exceeding the lethal dose. Although it is common for toxidrome caused by caffeine intoxication to produce hyperthermia, here we report a case of hypothermia.

Pulmonary edema caused by inhalation of vapors from water-soluble paint.

AIM: To report the effects of inhaling vapor from water-soluble paint after a recent encounter with 16 patients treated in our emergency department. METHODS: We examined a series of chest computed tomography (CT) images from the 16 affected patients. Computed tomography was carried out on days 1, 2, 5, and 19 after the inhalation event. RESULTS: Twelve of the patients were found to have pulmonary edema, based on their CT findings. Patients with pulmonary edema were classified as its persisted period. In the severe group, its pulmonary edema persisted over 5 days include, exacerbated edema, delayed-onset edema (during the follow-up), or edema amelioration. One patient had exacerbated edema, three patients had delayed-onset edema, and one patient experienced amelioration of their edema in the severe group. In all cases, the pulmonary edema had disappeared from the CT images by day 19 after the inhalation event. Thirteen of the 16 patients had a fever of ≥37°C. Three kinds of solutes (ethylene glycol, titanium dioxide, and silicon oxide) had been blended in the water-soluble paint. The titanium dioxide was considered the probable cause of the pulmonary edema. CONCLUSION: Inhalation of vapors from water-soluble paints is considered relatively safe. However, our observations suggest that new lesions might develop and existing lesions could worsen, even if the edema is not severe immediately after the exposure. Thus, follow-up imaging is needed for approximately 2 weeks in such cases.

Clinical evaluation of dendritic cells vaccination for advanced cancer patients at Fukushima Medical University.

Dendritic cells (DCs) are powerful antigen-presenting cells (APCs) that have attracted attention in recent years from the viewpoint of DC vaccine therapy against cancer. However, the existence of a strongly immunosuppressed state in cancer-bearing individuals inhibits DC maturation, which is one of the problems facing anti-cancer DC vaccine therapy. Isolated DCs loaded with tumor antigen ex vivo and administered as a cellular vaccine have been found to induce protective and therapeutic anti-tumor immunity in experimental animals. In clinical trials of DC vaccination for cancer patients, induction of anti-tumor immune responses and tumor regression has been observed. In this study, eighty-one advanced cancer patients unsuccessfully treated by established treatment in individual cases were selected between January 2002 and May 2007 at Fukushima Medical University. The usefulness of DC therapy was investigated by intradermal injection of peptide pulsed DCs for an overall objective response rate of 28.0%. Furthermore, direct injection of immature DCs into tumor extracted an overall objective response rate of 35.7%, and especially 40.0% for advanced pancreatic cancer by using endoscopic ultrasound-guided fine-needle injection technique as a novel approach. These results indicate that DC-based vaccination could be a promising treatment modality for various cancers, however multiple hurdles must be cleared before the development of an affordable DC-based vaccination can be used worldwide.

[Case of neurocardiogenic syncope with asystole during insertion of epidural catheter].

A 25-year-old healthy woman was scheduled for enucleatic myomectomy under combined epidural and general anesthesia. During insertion of a lumbar epidural catheter, sudden loss of consciousness associated with asystole developed. This condition was quickly restored by rapid fluid infusion, administration of atropine sulfate (0.5 mg) and oxygen (6l x min(-1)). Diagnosis of neurocardiogenic syncope (NCS) was made by previous episodes of fainting revealed at that point. An epidural catheter was placed under sedation with midazolam 2 mg. Surgery was performed uneventfully under sevoflurane anesthesia. Since NCS occurs recurrently in a susceptible individual, it is important to identify previous syncopal episode preoperatively. If such an event is anticipated, prevention including proper communication to reduce patient's anxiety, careful vigilance on both patient and monitor during procedure, gentle maneuver to reduce pain and use sedative and/or anticholinergic agents must be considered.

[Effect of remifentanil on urine output during gynecological laparoscopic surgery].

BACKGROUND: We retrospectively examined the effect of remifentanil on urine output during gynecological laparoscopic surgery under general anesthesia performed from April 2006 to July 2007. METHODS: Forty six patients undergoing gynecological laparoscopic surgery under general anesthesia were divided into 2 groups. In group C (n=23), anesthesia was performed using sevoflurane and/or propofol with intermittent fentanyl. In group R (n=23), remifentanil was additionally used with the method of group C. RESULTS: Patient's demography was not different between the two groups. Intraoperative conditions were compatible in both groups. In group R, total dose of fentanyl is significantly lower than group C. BP and HR measured at 20 min after pneumoperitoneum were significantly lower in group R. Intraoperative urine output was significantly greater in group R than group C. CONCLUSIONS: A decrease in urine output is commonly seen particularly in laparoscopic surgery. Increased stress hormonal responses due to pneumoperitoneum have been explained as one of the causes of this phenomenon. Remifentanil has been reported to maintain urine output as well as to blunt hormonal responses in CABG surgery. Although we did not measure hormonal responses in the present study, increased urine output could be attributed to decreased catecholamine levels by remifentanil.

[Case of exostosis of the hard palate disturbing the insertion of Pro-Seal laryngeal mask].

We report a case of exostosis of the hard palate which had not bean ruled out in pre-operative examination and disturbed insertion of Pro-Seal laryngeal mask. The hard palate has canopy construction, and it is difficult to find this exostosis by routine physical examination. When we use Pro-Seal laryngeal mask, a careful inspection of the hard palate is indispensable.

[Verification of CTL assay and DTH used in monitoring of peptide-pulsed dendritic cell therapy].

CTL assay and DTH used in monitoring cases of peptide-pulsed DC subcutaneous vaccination therapy (with high value of serum CEA by HLA2402) using CEA652 (9) that carried out at our facilities were verified. One out of 10 cases (10%) was SD, and 3 out of 10 cases were the induction of the CTL precursor observed for CTL assay in the peripheral blood of patients after the completion of 1 cycle (administered three times). In 2 cases, positive conversion was observed for DTH reaction. For the SD case, both CTL induction and positive conversion for DTH was observed. A reduction of the CEA value was observed in 3 patients among the 9 cases of PD. While the usefulness of CTL assay and DTH in monitoring cannot be determined solely by the verification at this time, the possibility of observing many clinical reactions could be shown for CEA652 (9) in cases where positive conversion was observed.

[Two case reports on intra-tumor injection therapy of dendritic cells].

DC (dendritic cells) vaccine therapy against cancer has attracted attention in recent years. However, the existence of the immunosuppressive state in cancer individuals leads to anergy and failure in cytotoxic T cell (CTL) induction and DC migration to the target organ. It has been reported that injected intra-tumor DC is expected to work phagocytosis of the tumor as a localized effect, the consequent CTL induction in the tumor and the regional lymphnodes, resulting in a systemic effect. Two cases reported in this article were performed with intra-tumor DC injection therapy by means of EUS (endoscopic ultrasonography) which indicated interesting immunoreaction.

Effects of PSK on T and dendritic cells differentiation in gastric or colorectal cancer patients.

BACKGROUND: Vaccine therapy targeting tumor antigens recognized by cytotoxic T cells (CTL) has been tried extensively. However, in a cancer-bearing state, the Th1/Th2 balance shifts to Th2 dominance, and this has been the obstacle to vaccine therapy to induce the CTL. DC1/DC2 subsets have also been reported to control the differentiation of Th subsets. The key to tumor immunotherapy is how to activate the DC1-Th1 lineage. PATIENTS AND METHODS: Six normal adults and 14 patients with gastric or colorectal cancers, who gave informed consent, were studied. The Th1/Th2 and DC1/DC2 ratios were determined by FACS. IL-12 and IL-10 production from PBMC were measured by ELISA. RESULTS: The Th1/Th2 and DC1/DC2 ratios were all significantly lower in the patients with gastric or colorectal cancers compared to normal adults. After protein-bound polysaccharide K (PSK) therapy in cancer patients, the Th1/Th2 balance shifted to Th1 dominance and the DC1/DC2 balance to DC1 dominance. IL-10 production was significantly decreased by PSK therapy. CONCLUSION: In the cancer-bearing state, the Th1/Th2 and DC/1/DC2 balance becomes Th2- and DC2-dominant. PSK therapy results in a shift of the Th1/Th2 and DC1/DC2 balance towards Th1 and DC1 dominance. We plan to examine whether combining dendritic cells (DC) vaccination therapy with oral PSK enhances the induction of T cell and DC differentiation in cancer patients.

[A case of liver metastases from cecal cancer successfully treated with fluorouracil and folinic acid (UFT/LV)].

A 76-year-old man had undergone a right hemicolectomy for cecal cancer. Oral UFT (450 mg/day) administration alone was started 2 months following the operation. From a CT scan of the abdomen performed 3 months postoperatively, he was diagnosed with liver metastasis. Because the liver metastasis had progressed, combination oral administration of UFT+LV was started (UFT 450 mg/day, LV 75 mg/day, 4 weeks of therapy followed by a 1-week treatment break). After 1 cycle, a good partial response of that lesion was achieved. The pulmonary metastasis had almost disappeared to within normal limits. In conclusion, this treatment was very safe and effective.

[Anesthetic management for cesarean section in a patient with hydrops foetalis].

In cases of hydrops foetalis, respiratory management is frequently required after delivery. We experienced 7 anesthetic managements for cesarean section in patients with hydrops foetalis. Spinal anesthesia was performed in 3 patients, because the transition of local anesthesia through the placenta was little. On the other hand, general anesthesia was performed in 4 patients because of babies requiring endotracheal intubation or fetal anesthesia immediately after a delivery. Before surgery, we discussed perioperative and anesthetic management among pediatricians, pediatric surgeons, and obstetricians in a conference. Since the anesthetic drugs used for the cesarean section have great influences on the fetus, the choice of anesthesia should be performed based on fetal conditions.

[Case report on intra-tumor injection therapy of dendritic cells in advanced gastric cancer].

Dendritic cells (DC) are powerful antigen-presenting cells, and have attracted attention in recent years from the viewpoint of DC vaccine therapy against cancer. However, the existence of an immunosuppressive state in cancer individuals leads to anergy and failure in cytotoxic T cell (CTL) induction and DC migration to the target organ. It has been reported that injected intra-tumor DCs are expected to work phagocytosis of the tumor as a localized effect. Consequently CTL induction in the tumor and the regional lymphnodes results in a systemic effect. In this study, intra-tumor DC injection therapy was performed by means of endoscopic ultrasonography (EUS) in 2 gastric cancer cases. As a result, tumor markers and ascites of one case were on the decrease. The results indicate this method can be useful in advanced cancer patients.

Effect of PSK on the maturation of dendritic cells derived from human peripheral blood monocytes.

Dendritic cells (DCs) are powerful antigen-presenting cells (APCs) that have attracted attention in recent years from the viewpoint of DC vaccine therapy against cancer. However, the existence of a strongly immunosuppressed state in cancer-bearing individuals inhibits DC maturation, which is one of the problems facing anti-cancer DC vaccine therapy. Protein-bound polysaccharide K (PSK), which is extracted from the cultured mycelium of Coriolus versicolor (Fr.) Quél, is used as an anti-cancer agent in Japan. PSK is reported to improve the immunosuppressed state and might be associated with DC maturation directly. We examined the effect of PSK on the maturation of DC derived from CD14-positive cells obtained from human peripheral blood monocytes using a negative selection method. CD14-positive cells cultured in the presence of PSK significantly increased the expression of HLA class II antigen and CD40; significantly increased the number and expression of CD80-, CD86- and CD83-positive cells; decreased Fluorescein isothiocyanate (FITC)-dextran uptake, augmented IL-12 production; augmented the allogeneic mixed lymphocyte reaction; and induced antigen-specific cytotoxicity. These results indicate that PSK promotes both the phenotypic and functional maturation of DC derived from human CD14-positive mononuclear cells. The clinical significance of the combined use of PSK in DC vaccine therapy remains for study.

[Verification of guideline for gastric cancer treatment based on a questionnaire].

We reported the results of a questionnaire survey of doctors and patients in relation to the guideline for gastric cancer treatment which was first published 3 years ago. The purpose of this questionnaire was to know whether the degree of recognition and availability of this guideline is satisfactory or not. The results were as follows. 1) The recognition and availability of the guideline among doctors proved satisfactory. 2) For patients who underwent gastrectomy, this guideline is still unfamiliar. Reconsideration of the guideline contents is needed in accord with the medical level from time to time. Moreover, patients must be more and more educated regarding the guideline.

[Effect of DC therapy combined with chemotherapy in advanced cancer cases].

Dendritic cells (DC) are powerful antigen-presenting cells, and have attracted attention in recent years from the viewpoint of DC vaccine therapy against cancer. However, the existence of an immunosuppressive state in cancer individuals leads to anergy and immunotolerance, which has been reported to be caused by T cell and DC immunosuppressive subsets or cytokines such as Th2, Tc2, CD4+CD25+, DC2 and IL-10 against Th1, Tc1, DC1 and IL-12. Therefore, DC therapy could be incompatible with severe chemotherapy. Conversely, there are some reports that indicate tumor specific cytotoxicity in DC therapy could be augmentedly un exposure to tumor antigen caused by apoptosis in combination radiation or chemotherapy. In this study we examined the usefulness of DC therapy combined with chemotherapy and BRM (PSK) administration by analyzing the immunocyte subsets and cytokines as well as the combination effect. The results indicate this method can be useful in advanced cancer patients.