Recognition of Pulseless Ventricular Tachycardia Through the Second Analysis of Automated External Defibrillators, Leading to Successful Shock Delivery in a Patient With Dilated Cardiomyopathy: A Case Report.

The use of a defibrillator with a monitor is recommended for the shock indication algorithm for in-hospital cardiac arrest; however, it is likely that many medical facilities are still equipped only with automated external defibrillators (AEDs). We experienced a case of dilated cardiomyopathy (DCM) complicated by pulseless ventricular tachycardia (pVT) in which an AED was used, but shock was deemed unnecessary after the first analysis. We believe that this case is suggestive of resuscitating cardiac arrest, for which defibrillation is indicated and reported here. A 65-year-old man who had DCM and diabetic nephropathy was admitted to our institution because of worsening heart failure. In the hospital, he suddenly had syncope and was diagnosed with cardiac arrest. Thereafter, cardiopulmonary resuscitation (CPR) was performed using an AED, and the monitor on the AED showed pVT. The first analysis of the AED announced unnecessary shock delivery. The pads of the AED were pressed firmly against the chest wall while continuous high-quality CPR was administered for two minutes. The second analysis of the AED revealed the necessity of providing shock for shockable rhythm. The patient experienced the return of spontaneous circulation after shock delivery. We were reminded that there are some clinical cases in which AED shock is not indicated for pVT and that even in such cases, it is important to continue high-quality CPR without panicking.

Percutaneous Trans-Esophageal Gastrostomy for Oral Intake in a Case of Anastomotic Obstruction following Total Gastrectomy.

Gastric cancer is one of the most common diseases globally. Total gastrectomy is often performed surgically. However, late-stage anastomotic passage obstruction after total gastrectomy is relatively rare. Here, we report a case involving a 73-year-old male patient who experienced repeated aspiration pneumonia due to anastomotic passage obstruction 22 years after a total gastrectomy for gastric cancer. He was eventually hospitalized in the Department of Gastroenterology at our hospital because of difficulty eating. Computed tomography revealed prominent dilation of the esophagus and the blind end of the elevated jejunum. Upper gastrointestinal endoscopy revealed a poorly extended site on the main side of the elevated jejunum; however, the passage through the scope was good. A percutaneous trans-esophageal gastrostomy was performed for oral intake. The patient experienced decreased nausea and vomiting. He gained weight, and his general condition improved. He did not feel inconvenienced by percutaneous trans-esophageal gastrostomy and had no desire for surgery. Follow-up observations are currently being conducted, with tubes exchanged every 6 months. There are no reports of percutaneous trans-esophageal gastrostomy for oral intake for anastomotic passage obstruction following total gastrectomy; therefore, we report this as a reference when similar cases are encountered.

Single-incision laparoscopic surgery using the glove technique with improved maneuverability achieved through fulcrum creation via a simple ring technique.

INTRODUCTION: Single-incision laparoscopic surgery (SILS) is widely used in many surgical procedures in various specialties. Among the access methods used in SILS, the glove technique, which is typically similar to the multi-trocar approach, is simple, convenient, and inexpensive. However, given the absence of a fulcrum supporting the endoscopic surgical forceps, the technique is less advantageous than methods using commercially available access devices because of the poor maneuverability of the forceps. MATERIALS AND SURGICAL TECHNIQUE: By creating a fulcrum as a support to use with existing surgical forceps in the glove technique, we designed and used a novel method known as the "ring technique." This technique aimed to improve the maneuverability of endoscopic surgical forceps. DISCUSSION: Placing a fulcrum resulted in the improvement of the forceps' maneuverability, which helped to ameliorate a weakness of the glove technique. The ring technique could be a useful option as a method of access in SILS.

Usefulness of intraoperative neuromonitoring for preservation of an extralaryngeal bifurcation of the recurrent laryngeal nerve: A case report.

INTRODUCTION: Recurrent laryngeal nerve injury is a major complication of thyroid surgery. An endotracheal tube with electromyography electrodes attached to it was recently developed for intraoperative neuromonitoring during thyroid surgery. Here we describe the successful identification and preservation of an extralaryngeal bifurcation of the recurrent laryngeal nerve by intraoperative neuromonitoring in a patient undergoing thyroid surgery. PRESENTATION OF CASE: A 56-year-old woman presented for evaluation of a neck swelling found during a medical examination. Computed tomography (CT) revealed a tumor with a 5-cm diameter in the left thyroid lobe. Fine needle aspiration cytology revealed a Bethesda category III finding. Left thyroid lobe resection was scheduled. During surgery, the left recurrent laryngeal nerve was found to be adhered to the tumor. Careful exploration and intraoperative neuromonitoring allowed us to identify and preserve an extralaryngeal bifurcation of the recurrent laryngeal nerve. DISCUSSION: The recurrent laryngeal nerve can demonstrate various anomalies and bifurcations. Failure to notice and correctly identify extralaryngeal bifurcation leads to recurrent laryngeal nerve injury. Motor branch injury has a particularly large effect. Intraoperative neuromonitoring has been reported to be useful for identifying and preserving the recurrent laryngeal nerve and its aberrations as well as the external branch of the superior laryngeal nerve during thyroid surgery. CONCLUSION: The findings from this case suggest that an extralaryngeal bifurcation of the recurrent laryngeal nerve can be identified and safely preserved by intraoperative neuromonitoring.

Gallbladder metastasis of renal clear cell carcinoma 15 years after primary cancer excision: a case report.

BACKGROUND: Renal cell carcinoma is well-known for its propensity to metastasize to unusual sites. However, metastasis to the gallbladder has been rarely reported in the literature. CASE PRESENTATION: A 75-year-old Japanese (Asian) woman presented for further evaluation of a gallbladder polyp, 15 years after right radical nephrectomy for renal cell carcinoma. Computed tomography revealed a 12 mm enhancing pedunculated tumor in the gallbladder fundus. Open simple cholecystectomy was performed and the tumor was histologically confirmed as a metastasis of renal cell carcinoma to the gallbladder. Our patient is alive and has been disease-free for 3 years after cholecystectomy. CONCLUSIONS: Although metastasis of renal cell carcinoma is a rare differential diagnosis of gallbladder tumors, simple cholecystectomy is likely to offer a chance of long-term survival for patients with gallbladder metastases of renal cell carcinoma.

[A patient with prosopagnosia which developed after an infarction in the left occipital lobe in addition to an old infarction in the right occipital lobe].

A 66-year-old, right-handed male, was admitted to our hospital with difficulty in recognizing faces and colors. He had suffered a stroke in the right occipital region three years earlier that had induced left homonymous hemianopsia, but not prosopagnosia. A neurological examination revealed prosopagnosia, color agnosia, constructional apraxia, and topographical disorientation, but not either hemineglect or dressing apraxia. The patient was unable to distinguish faces of familiar persons such as his family and friends, as well as those of unfamiliar persons such as doctors and nurses. Brain MRI demonstrated an old infarction in the right medial occipital lobe and a new hemorrhagic infarction in the left medial occipital lobe, including the fusiform and lingual gyrus. It is unclear whether a purely right medial occipital lesion can be responsible for prosopagnosia, or whether bilateral medial occipital lesions are necessary for this occurrence. The current case indicated that bilateral medial occipital lesions play an important role in inducing porsopagnosia.

Age-related white matter hyperintensities attenuated by compression from a chronic subdural hematoma: possible contribution of brain interstitial fluid to the formation of leukoaraiosis.

The origin of patchy white matter hyperintensities commonly seen in the elderly on magnetic resonance (MR) images with long repetition time (TR) is still controversial. We describe MR findings in older patients in whom white matter hyperintensities were attenuated by compression of the cerebral hemisphere from a chronic subdural hematoma. These sequential MR findings substantiate the hypothesis that leukoaraiosis may arise when drainage of the bulk flow of brain interstitial fluid is disturbed.

[A fatal case of drug-induced hypersensitivity syndrome due to allopurinol].

A 83-years-old Japanese woman visited our hospital, complaining of fever, erythema over the entire body and erosion on the lips after taking allopurinol for a month. Laboratory examinations showed liver dysfunction and renal failure. The histological study showed dense lymphocytic and eosinophilic perivascular infiltrations in the upper dermis at the erythematous lesion. We withdrew administration and started steroid pulse therapy. The eruption subsided after a week, but liver dysfunction was not controlled by treatment with corticosteroid (PSL 15 mg/day). She suffered from sepsis and DIC, and despite of intensive therapy, she died of the disease. We measured blood concentration of allopurinol and oxypurinol after stopping drug administration. Blood concentration of oxypurinol was high for nine days at that time. We diagnosed this case as DIHS due to allopurinol because of a significant increase of anti HHV-6 and CMV IgG titer.

[Hyperintense optic nerve lesion on T2-weighted MRI imaging in the acute stage of Leber's hereditary optic neuropathy: a case report].

A 46-year-old man was admitted to our hospital for acute onset, bilateral visual disturbance. Neither papilledema nor optic atrophy was found. Brain MRI revealed a hyperintense lesion in the optic chiasm on T2-weighted imaging. No enhancement was detected in gadolinium-enhanced MRIs. Based on these results, a diagnosis of retrobulbar neuritis was made, and steroid pulse therapy was performed. However, the visual acuity did not improve at all. We therefore suspected Leber's hereditary optic neuropathy (LHON) and thus performed a PCR analysis of the mitochondrial DNA. It revealed a G to A transition at nucleotide position 11778 of the mitochondrial DNA, which has been frequently observed in LHON patients in Japan. Based on the above findings, when middle-aged patients present an acute onset of visual loss, LHON should be included in the differential diagnosis.

Linear accelerator radiosurgery for vestibular schwannoma: measuring tumor volume changes on serial three-dimensional spoiled gradient-echo magnetic resonance images.

OBJECT: The authors report on a series of 46 patients harboring vestibular schwannomas (VSs) treated using linear accelerator (LINAC) radiosurgery and an analysis of serial magnetic resonance (MR) imaging data, specifically the changes in tumor volume. METHODS: Fifty-three consecutive patients underwent LINAC radiosurgery for VS between 1993 and 2002. Seven of these patients were lost to follow up. Three-dimensional (3D) spoiled gradient-echo (SPGR) MR imaging was performed at 3- to 4-month intervals after radiosurgery. Tumor volume was measured on Gd-enhanced MR images of each slice. The median duration of follow-up MR imaging studies was 56.5 months (range 12-120 months). Follow-up imaging studies were conducted for longer than 1 year in 42 of 53 patients. Tumor volume changes were categorized into four types: enlargement (eight lesions [19%]), no change (two lesions [4.8%]), transient enlargement followed by shrinkage (19 lesions [45.2%]), and direct shrinkage (13 lesions [31%]). Two cases (4.8%) with twice the initial tumor volume required repeated radiosurgery. All cases of transient enlargement had subsequent shrinkage within 2 years after radiosurgery. Nine (21.4%) of 42 patients demonstrated ventricular enlargement on MR images obtained after radiosurgery. Three patients (7.1%) required placement of a ventriculoperitoneal shunt because of symptomatic hydrocephalus, and another four cases (9.5%) spontaneously resolved. CONCLUSIONS: Volume measurement on 3D-SPGR MR imaging was a suitable method to assess tumor changes. Volume changes beyond twofold or continuous enlargement for longer than 2 years after radiosurgery are key criteria in rating the effects of radiation. Some cases of hydrocephalus after radiosurgery resolved spontaneously and their rates of occurrence were similar to the typical incidence of hydrocephalus associated with VS.

Clinicopathologic features and prognostic factors of resected solitary small-sized hepatocellular carcinoma.

BACKGROUND/AIMS: Solitary small-sized HCCs tend to be considered as less aggressive cancer, and non-surgical treatments have recently been preferred. The aim of this study was to clarify the clinicopathological features and the prognostic factors of small-sized HCCs and to evaluate the significance of hepatic resection for them. METHODOLOGY: Eighty patients with HCC up to 2cm in diameter who had undergone hepatic resection were enrolled in this study. We investigated the clinicopathological features and evaluated the prognostic factors by univariate and multivariate analyses. RESULTS: The overall survival rates at 3, 5 and 10 years were 83%, 69% and 36%, respectively, and the corresponding disease-free survival rates were 63%, 41% and 10%. Well-differentiated, moderately differentiated and poorly differentiated HCC were detected in 29%, 65% and 6% of the patients, respectively. Furthermore, microscopic portal vein invasion (vp), hepatic vein invasion (vv) and intrahepatic metastasis (im) were positive in 15%, 4% and 10% of the patients, respectively. Multivariate analysis revealed that Child-Pugh classification (p=0.005) and vp (p=0.0008) were independent prognostic factors for survival rate and that platelet count (p=0.002) and tumor differentiation (p=0.0016) were independent prognostic factors for disease-free survival rate. CONCLUSIONS: Even solitary small-sized (up to 2cm in diameter) HCC already have the characteristics of advanced HCC. When hepatic function is well preserved, hepatic resection should be the first choice for local control, especially in cases of moderately to poorly differentiated HCC, because the frequency of microscopic vascular invasion is high.

Indication of hepatectomy for cirrhotic patients with hepatocellular carcinoma classified as Child-Pugh class B.

We clarified the indication of partial hepatectomy in hepatocellular carcinoma (HCC) patients with liver cirrhosis classified as Child-Pugh class B. Univariate analysis revealed that adverse prognostic factors were (1) the presence of ascites, (2) elevated total bilirubin (1.5 mg/dl or higher), (3) reduced choline esterase (160 IU/ or lower), (4) elevated alpha-fetoprotein (AFP) (400 ng/ml or higher), (5) microscopic vascular invasion, and (6) non-curative hepatectomy. Microvascular invasion was excluded in the multivariate analysis because this factor could not be predicted before hepatectomy. Multivariate analysis revealed that independent adverse prognostic factors were (1) elevated total bilirubin (1.5 mg/dl or higher), (2) presence of ascites, (3) elevated AFP (400 ng/ml or higher), and (4) non-curative hepatectomy. The overall 5-year survival rate of patients with none of or only one of the four adverse prognostic factors was 45.8%. The overall 5-year survival rate of patients with two or more adverse prognostic factors was only 7.0%. Partial hepatectomy is the first choice of treatment for patients with none of or only one of the four adverse prognostic factors, whereas orthotopic liver transplantation or other conservative treatment should be considered for patients with two or more adverse prognostic factors.

Indications of partial hepatectomy for transplantable hepatocellular carcinoma with compensated cirrhosis.

BACKGROUND: The appropriate treatment strategy for transplantable hepatocellular carcinoma (HCC) patients with compensated cirrhosis remains controversial. METHODS: Surgical outcomes were reviewed in 136 cirrhotic patients with transplantable HCC who had undergone partial hepatectomy. Transplantable HCC was defined as that corresponding to Milan's criteria. RESULTS: The adverse prognostic factors for both survival and disease-free survival were histologic surgical margin of 5 mm or less, Child-Pugh B, and the presence of hepatitis C virus infection. The overall 5-year survival and disease-free survival rates of patients with 1 or none of the adverse prognostic factors were 73% and 33%, respectively, whereas those of patients with 2 or 3 adverse prognostic factors were 36% and 17%, respectively. CONCLUSIONS: Transplantable HCC patients with 2 or 3 adverse prognostic factors should be considered candidates for liver transplantation, whereas patients with only 1 or none of the adverse prognostic factors are good candidates for partial hepatectomy.

Involvement of tumor necrosis factor-alpha receptor 1 and tumor necrosis factor-related apoptosis-inducing ligand-(TRAIL) receptor-2/DR-5, but not Fas, in graft injury in live-donor liver transplantation.

The pathway leading to cell death in clinical liver transplantation is not known. Eight liver transplant recipients and eight donors were enrolled in this study. Postoperative serum levels of alanine transferase had significantly increased in the recipients compared with those in the donors. Mild centri-lobular necrosis was observed in only liver tissues taken from the recipients. Tumor necrosis factor (TNF)-R1 and death receptor 5 expression levels had increased in liver tissues taken from the recipients. There were no changes in the levels of Fas/Fas ligand expression in liver tissues from either the donors or recipients. Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) expression was down-regulated in donor liver after hepatectomy and liver allograft after implantation. The results suggest that, although ischemic liver injury was not serious, due to the short ischemia time, TNF and TRAIL signals are associated with liver ischemic injury in live-donor liver transplantation but Fas signal is not.

Liver NK cells expressing TRAIL are toxic against self hepatocytes in mice.

Although it is known that activation of natural killer (NK) cells causes liver injury, the mechanisms underlying NK cell-induced killing of self-hepatocytes are not clear. We demonstrated that liver NK cells have cytotoxicity against normal syngeneic hepatocytes in mice. Polyinosinic-polycytidylic acid (poly I:C) treatment enhanced hepatocyte toxicity of liver NK cells but not that of spleen NK cells. Unlike NK cells in other tissues, approximately 30%-40% of liver NK cells constitutively express tumor necrosis factor-related apoptosis-inducing ligand (TRAIL). An in vitro NK cell cytotoxic assay revealed that hepatocyte toxicity of liver NK cells from both naïve and poly I:C-treated mice was inhibited partially by an anti-TRAIL monoclonal antibody (mAb) alone and completely by the combination with anti-Fas ligand (FasL) mAb and a perforin inhibitor, concanamycin A, indicating contribution of TRAIL to NK cell-mediated hepatocyte toxicity. The majority of TRAIL(+) NK cells lacked expression of Ly-49 inhibitory receptors recognizing self-major histocompatibility complex class I, indicating a propensity to targeting self-hepatocytes. Poly I:C treatment significantly upregulated the expression of Ly-49 receptors on TRAIL(-) NK cells. This might be a compensatory mechanism to protect self-class I-expressing cells from activated NK cell-mediated killing. However, such compensatory alteration was not seen at all in the TRAIL(+) NK cell fraction. Thus, liver TRAIL(+) NK cells have less capacity for self-recognition, and this might be involved in NK cell-dependent self-hepatocyte toxicity. In conclusion, our findings are consistent with a model in which TRAIL-expressing NK cells play a critical role in self-hepatocyte killing through poor recognition of MHC.

Intraoperative near-infrared spectroscopy for evaluating hepatic venous outflow in living-donor right lobe liver.

BACKGROUND: This study was performed to determine the usefulness of intraoperative near-infrared spectroscopy (NIRS) for evaluating the extent of congestion in the anterior segment of the graft after living-donor liver transplantation using right lobe grafts that do not have the middle hepatic vein. METHODS: Fifteen patients undergoing living-donor liver transplantation using a right lobe graft without the middle hepatic vein were enrolled in this study. During the course of harvesting and implantation, in vivo NIRS was performed on the liver grafts to determine hemoglobin (Hb) and cytochrome oxidase content in the hepatic tissues. RESULTS: The 15 cases were divided into three groups according to the caliber of the middle hepatic vein tributaries in the right lobe grafts: the small group (<4 mm), the intermediate group (4-7 mm), and the large group (>7 mm). After implantation, congestion (increase in tissue Hb) in the anterior segment was more severe than that in the posterior segment in the intermediate and large groups. However, well-preserved mitochondrial cytochrome oxidase redox state was observed in both segments except for two cases in the large group with severe congestion in the anterior segment. The extent of postoperative congestion in the anterior segment was significantly correlated with the tissue content of remaining Hb in that segment after ex vivo flushing. CONCLUSIONS: Intraoperative NIRS enables quantification of the extent of congestion in the anterior segment after implantation of a right lobe liver graft and even enables prediction of such congestion at the phase of ex vivo perfusion.

Interpretation of normal anatomic structures on chest radiography: comparison of Fuji computed radiography (FCR) 5501D with FCR 5000 and screen-film system.

The purpose of this study was to investigate the usefulness of Fuji Computed Radiography (FCR) 5501D by comparing it with FCR 5000 and a screen-film system (S/F). Posteroanterior chest radiographs of ten patients with no abnormality on chest CT scans were obtained with FCR 5501D, FCR 5000, and S/F. Six observers (three radiologists and three radio-technologists) evaluated the visibility of nine normal anatomic structures (including lungs, soft tissue, and bones) and overall visibility on each image. Observers scored using a five-point scale on each structure. FCR 5000 showed a significantly higher score in soft tissue and bone structures, and overall visibility compared with S/F, but, there was no significant difference between them in the visibility of all four normal lung structures. Compared with S/F, the score for FCR 5501D was higher in eight of the nine normal structures, including three of the four lung structures (unobscured lung, retrocardiac lung, and subdiaphragmatic lung), and overall visibility. Compared with FCR 5000, the score for FCR 5501D was higher in three normal structures, including two of the four lung structures (unobscured lung and subdiaphragmatic lung), and overall visibility. FCR 5501D was the best among the three techniques to visualize normal anatomic structures, particularly the obscured and unobscured lung.

Endovascular treatment for cervical carotid artery stenosis presenting with progressing stroke: three case reports.

BACKGROUND: Progressing stroke is said to occur when symptoms and signs worsen in cases of ischemic stroke. Although conservative methods using volume expansion with antithrombotic or anticoagulative agents are widely used for progressing stroke, in some hospitals, emergency carotid endarterectomy (CEA) has been performed for carotid stenosis, with mixed results. Here we report three cases with progressing ischemic stroke that were managed by endovascular surgical intervention. CASE DESCRIPTION: We performed endovascular surgery in three patients with cervical carotid artery stenosis presenting with progressing stroke or crescendo transient ischemic attacks. Endovascular treatment was less invasive and feasible for acute phase treatment. While local thrombolysis alone was found to be less effective, stent placement induced complete resolution of stenosis, but may result in hyperperfusion syndrome or hemorrhagic infarction. CONCLUSIONS: In an emergency, percutaneous transluminal angioplasty with proper dilatation is preferred, and then CEA or stenting should be considered after the patient's condition stabilizes.

[A case of basilar artery stenosis treated by stent placement].

Symptomatic basilar artery stenosis invariably has poor prognosis owing to limited treatment options. Modernized stent system delivery technology has paved the way for treating tortuous vascular segments of intracranial system. The authors hereby report on the use of intracranial stent to treat basilar artery stenosis. A-61-year old man presented with one month history of recurrent dizziness and dysarthria. He remained symptomatic despite having oral antiplatelets. Magnetic resonance image showed pontine ischemic lesion. Stenosis of proximal portion of basilar artery was detected by magnetic resonance angiography (MRA). Although balloon angioplasty was performed, restenosis was demonstrated by MRA four months later. Stenting was then performed with excellent angiographic results, and there were no procedural complications. The availability of new flexible intravascular stents, allowing access to tortuous proximal intracranial vessels, provides a new therapeutic approach to basilar artery stenosis cases. However long term follow-up is advised to assess the durability of this approach.

[Current status of radiation therapy--evidence-based medicine(EBM) of radiation therapy. Metastatic brain tumors].

The prognosis of patients with brain metastases is poor. Consequently, the purposes of treatment for such patients are also limited. One goal is to prevent the metastatic tumors from causing death, and another is to improve the neurological symptoms that are causing deterioration of the patient's quality of life. There are several treatment options for brain metastases: whole brain irradiation, surgery, stereotactic radiosurgery, and combinations of these. We reviewed recent reports that were based on the evidence obtained from various treatment strategies for this condition. We concluded that the final decision should be made by the patients themselves. We refer to the concept of narrative-based medicine(NBM).