An unexpected case of tetanus in a fully immunized 20-year-old female: a case report.

BACKGROUND: Widespread vaccinations have significantly decreased the number of tetanus cases in developed countries. Today, most cases of tetanus affect the elderly and those with inadequate immunization in developed countries such as Japan. As vaccinations were believed to be nearly 100% effective in preventing tetanus, tetanus in young, immunized individuals were considered unlikely. However, unexpected tetanus infection has been reported in young adequately immunized individuals. CASE: We herein describe a 20-year-old immunized female who visited our emergency department with trismus and painful muscle spasms that started after receiving a puncture wound to her right foot. A physical examination revealed an elevated body temperature (38°C), trismus, muscle spasms in her right leg and neck, and a puncture wound at the sole of her right foot. Following the development of dyspnea after admission to the intensive care unit, the patient was intubated and mechanically ventilated. She fully recovered after six days in intensive care. CONCLUSION: The present case serves as a stark reminder that tetanus may still occur in young, immunized individuals. Patients with a history of immunization may have a better prognosis than those with no immunizations.

Acute Coronary Spasm Following Pelvic Fracture, Bleeding, and Shock in a Trauma Patient.

We report a case of a patient with severe pelvic fracture who showed concurrent ST elevation on electrocardiogram. A 70-year-old man incurred an unstable pelvic fracture from a motorcycle accident. On admission, he was hemodynamically unstable, and massive transfusion and noradrenaline were administered immediately. Although ST elevation was present in leads II, III, aVF, V5, and V6, cardiac function was preserved; thus, trans-arterial embolization and external fixation for pelvic fracture were given priority. Four days after the injury, he suffered a cardiac arrest, and coronary angiography revealed that the cause of ST elevation and cardiac arrest was coronary vasospasm. Physicians should be aware that pain-related stress and platelet activation as well as use of noradrenaline in severe trauma cases can induce coronary vasospasm.

The Restrictive Red Blood Cell Transfusion Strategy for Critically Injured Patients (RESTRIC) trial: a cluster-randomized, crossover, non-inferiority multicenter trial of restrictive transfusion in trauma.

BACKGROUND: The efficacies of fresh frozen plasma and coagulation factor transfusion have been widely evaluated in trauma-induced coagulopathy management during the acute post-injury phase. However, the efficacy of red blood cell transfusion has not been adequately investigated in patients with severe trauma, and the optimal hemoglobin target level during the acute post-injury and resuscitation phases remains unclear. Therefore, this study aimed to examine whether a restrictive transfusion strategy was clinically non-inferior to a liberal transfusion strategy during the acute post-injury phase. METHODS: This cluster-randomized, crossover, non-inferiority multicenter trial was conducted at 22 tertiary emergency medical institutions in Japan and included adult patients with severe trauma at risk of major bleeding. The institutions were allocated a restrictive or liberal transfusion strategy (target hemoglobin levels: 7-9 or 10-12 g/dL, respectively). The strategies were applied to patients immediately after arrival at the emergency department. The primary outcome was 28-day survival after arrival at the emergency department. Secondary outcomes included transfusion volume, complication rates, and event-free days. The non-inferiority margin was set at 3%. RESULTS: The 28-day survival rates of patients in the restrictive (n = 216) and liberal (n = 195) strategy groups were 92.1% and 91.3%, respectively. The adjusted odds ratio for 28-day survival in the restrictive versus liberal strategy group was 1.02 (95% confidence interval: 0.49-2.13). Significant non-inferiority was not observed. Transfusion volumes and hemoglobin levels were lower in the restrictive strategy group than in the liberal strategy group. No between-group differences were noted in complication rates or event-free days. CONCLUSIONS: Although non-inferiority of the restrictive versus liberal transfusion strategy for 28-day survival was not statistically significant, the mortality and complication rates were similar between the groups. The restrictive transfusion strategy results in a lower transfusion volume. TRIAL REGISTRATION NUMBER: umin.ac.jp/ctr: UMIN000034405, registration date: 8 October 2018.

A novel utility of 99mTc-GSA SPECT/CT fusion imaging: detection of inadequate portal vein embolization.

PURPOSE: Our aim was to determine the utility of Tc-99m-diethylenetriaminepentaacetic acid-galactosyl human serum albumin single-photon-emission computed tomography (99mTc-GSA SPECT/CT) fusion imaging for detecting incomplete portal vein embolization (PVE). MATERIALS AND METHODS: Fifty-five candidates underwent PVE. Among them, five underwent second PVE. Detectability of first inadequate PVE using CT and 99mTc-GSA SPECT/CT fusion imaging was analyzed. RESULTS: Cases of inadequate PVE were detected in three patients using CT and in five using 99mTc-GSA SPECT/CT fusion imaging. Fusion imaging detected two cases of insufficient PVE in which portal branches were apparently well embolized on CT. Median value for volumetric rate in the embolized liver was 63.3% after the first PVE and 54.7% after the second (P < 0.01). Median functional rate value in embolized liver was 60.1% after the first PVE and 49.4% after the second (P < 0.01). Median value for change of volumetric and functional rates in embolized liver after the second PVE was 7.1 and 10.3%, respectively, and change of functional rate was greater than that of volumetric rate (P < 0.01). CONCLUSIONS: 99mTc-GSA SPECT/CT fusion imaging was useful for detecting inadequate PVE, and second PVE was effective for increasing volumetric and functional rates.

Clinical effects of chemoradiotherapy in pursuit of optimal treatment of locally advanced unresectable pancreatic cancer.

OBJECTIVE: The treatment of locally advanced unresectable pancreatic cancer remains extremely challenging, particularly as the efficacy of concurrent chemoradiotherapy (CRT) remains unclear. METHODS: We studied 93 patients (8.0%) with locally advanced unresectable pancreatic cancer without distant metastases from among a total group of 1168 patients who were diagnosed with pancreatic cancer from March 2005 to November 2015 at the Kochi Health Sciences Center, Kochi, Japan. We therefore evaluated the clinical efficacy of CRT in patients with locally advanced unresectable pancreatic cancer. RESULTS: Of the 93 patients with locally advanced unresectable pancreatic cancer, 35 patients (37.6%) were subsequently classified as having resectable disease following CRT. The median overall survival of patients who received CRT alone for locally advanced unresectable pancreatic cancer was 8.0 months, and all died within 3 years. On the other hand, the overall 1-, 3- and 5-year survival rates in patients who were reclassified as having resectable tumour after CRT were 71.3%, 39.2% and 23.5%, respectively. Our pathological assessments after surgical resection suggested that CRT might be associated with a significant reduction in the risk of lymph node metastases in patients with locally advanced unresectable pancreatic cancer. CONCLUSION: The results of this study suggested that CRT is clinically effective in improving survival, particularly in association with the resultant possibility of curative resection. Advances in knowledge: The best treatment strategy for patients with locally advanced unresectable pancreatic cancer is the subject of considerable debate, and CRT is only recommended if cancer has only grown around the pancreas without any distant metastases.

Adenomyomatosis Concomitant with Primary Gallbladder Carcinoma.

Some clinicians have proposed a relationship between gallbladder (GB) cancer and adenomyomatosis (ADM) of the gallbladder, although the latter condition is not considered to have malignant potential. We retrospectively reviewed the surgical pathology database of patients who underwent resection for ADM of the gallbladder at our institution from March 2005 to May 2015. In total, 624 patients underwent surgical resection of the gallbladder with Rokitansky-Aschoff sinuses. Of these cases, 93 were pathologically diagnosed with ADM of the gallbladder, with 44 (47.3%) classified macroscopically as fundal-type ADM, 26 (28.0%) as segmental type, and 23 (24.7%) as diffuse-type ADM. In 3 of the 93 (3.2%) resected specimens, early-stage GB carcinoma was detected, although preoperative imaging did not suggest a malignant neoplasm of the gallbladder in any of these patients. GB cancer subsequently developed in the mucosa of the fundal compartment distal to the annular stricture of the segmental-type ADM in 2 of these patients and against the background of the fundal-type ADM in 1 patient. This study revealed the difficulty of early diagnosis of primary GB cancer in the setting of concurrent ADM, and clinicians should be aware of this frequent coexistence.

Liver function assessment using 99mTc-GSA single-photon emission computed tomography (SPECT)/CT fusion imaging in hilar bile duct cancer: A retrospective study.

BACKGROUND: The objective of this study was to determine the utility of Tc-99m-diethylenetriamine-penta-acetic acid-galactosyl human serum albumin ((99m)Tc-GSA) single-photon emission computed tomography (SPECT)/CT fusion imaging for posthepatectomy remnant liver function assessment in hilar bile duct cancer patients. METHODS: Thirty hilar bile duct cancer patients who underwent major hepatectomy with extrahepatic bile duct resection were retrospectively analyzed. Indocyanine green plasma clearance rate (KICG) value and estimated KICG by (99m)Tc-GSA scintigraphy (KGSA) and volumetric and functional rates of future remnant liver by (99m)Tc-GSA SPECT/CT fusion imaging were used to evaluate preoperative whole liver function and posthepatectomy remnant liver function, respectively. Remnant (rem) KICG (= KICG × volumetric rate) and remKGSA (= KGSA × functional rate) were used to predict future remnant liver function; major hepatectomy was considered unsafe for values <0.05. The correlation of remKICG and remKGSA with posthepatectomy mortality and morbidity was determined. RESULTS: Although remKICG and remKGSA were not significantly different (median value: 0.071 vs 0.075), functional rates of future remnant liver were significantly higher than volumetric rates (median: 0.54 vs 0.46; P < .001). Hepatectomy was considered unsafe in 17% and 0% of patients using remKICG and remKGSA, respectively. Postoperative liver failure and mortality did not occur in the patients for whom hepatectomy was considered unsafe based on remKICG. remKGSA showed a stronger correlation with postoperative prothrombin time activity than remKICG. CONCLUSION: (99m)Tc-GSA SPECT/CT fusion imaging enables accurate assessment of future remnant liver function and suitability for hepatectomy in hilar bile duct cancer patients.

Bleeding sites in elderly trauma patients who required massive transfusion: a comparison with younger patients.

INTRODUCTION: Among elderly patients with severe trauma, the sites of massive hemorrhage and their clinical characteristics are not well understood. Therefore, we investigated the sites of massive hemorrhage in patients with severe trauma, and compared the results for younger and elderly patients. METHODS: A cohort of severe trauma patients (Injury Severity Score ≥16) admitted from March 2007 to December 2014 was reviewed retrospectively. The inclusion criterion was massive bleeding, which was defined as bleeding that required the transfusion of ≥10 red cell concentrate units within 24 hours of admission, or as cases of early death that occurred despite continuous blood transfusion and before the patient could receive ≥10 red cell concentrate units within the first 24 hours after their admission. RESULTS: Eighty-four patients met our inclusion criterion. The younger group (<65 years old) included 40 patients (48%), whereas the older group (≥65 years old) included 44 patients (52%). The percentage of nondiagnosable cases at the primary survey (massive bleeding due to multisite damage caused by a bone fracture or contusion, retroperitoneal hematoma without a pelvic ring fracture and with stable pelvic ring fracture) was 14% in the younger group and 40% in the older group (odds ratio, 3.92; 95% confidence interval, 1.37-11.27, P = .017). CONCLUSIONS: Even if no abnormalities are observed at the primary survey of elderly patients with severe trauma, physicians should consider the possibility of massive bleeding.

Completion pancreatectomy for recurrent pancreatic cancer in the remnant pancreas: report of six cases and a review of the literature.

PURPOSE: There are no accepted surgical strategies for the treatment of pancreatic cancer recurrence in the remnant pancreas after initial resection. We retrospectively analyzed our experiences with patients undergoing completion pancreatectomy for recurrent pancreatic cancer in the remnant pancreas. METHODS: Six patients with recurrent pancreatic cancer in the remnant pancreas underwent completion pancreatectomy between March 2005 and December 2012. Operative, postoperative, and pathological data and long-term outcomes for these six patients were analyzed retrospectively. RESULTS: There was no operative morbidity or mortality associated with completion pancreatectomy. The median survival times were 49.0 and 27.5 months after initial resection and second pancreatectomy, respectively. However, all six patients died during follow-up. Five patients had recurrent pancreatic cancer at the time of death. One patient had no recurrence but had poor blood sugar control and eventually died after repeated bouts of cholangitis. CONCLUSIONS: Completion pancreatectomy is a safe and effective option in select patients with local pancreatic cancer recurrence in the remnant pancreas after initial pancreatectomy. It is essential to select patients who have a good performance status and can tolerate major surgery and the resultant apancreatic state.

Admission fibrinogen levels in severe trauma patients: A comparison of elderly and younger patients.

INTRODUCTION: Acute coagulopathy of trauma has been much discussed recently. However, the changes in coagulation markers after trauma in the elderly are unknown. Furthermore, the baseline fibrinogen level is high in elderly patients, and the question remains as to whether fibrinogen levels also decrease early and the degree of decrease in elderly trauma patients. The purpose of this study was to compare coagulation markers including the fibrinogen level on admission in younger and elderly severe trauma patients. METHODS: A cohort of severe trauma patients (Injury Severity Score (ISS) ≥16), admitted from January 2011 to June 2014, with coagulation markers including the fibrinogen level on admission available, was reviewed retrospectively. The patients were divided into a younger (16-64 years old) and an older (≥65 years old) group based upon their age at presentation. Activated partial thromboplastin time (aPTT), international normalized ratio (INR), fibrinogen, and D-dimer were compared between the younger and older groups. RESULTS: There were 251 patients who met the inclusion criteria for this analysis. The younger group included 117 patients and the older group included 134 patients. The median aPTT (26.3 vs 27.5s, P=0.001) and median D-dimer levels (18.8 vs 40.2 µg/dL, P=0.006) were significantly higher in the older group. However, the fibrinogen level (205 vs 248 mg/dL, P<0.001) was significantly higher in the older group. The regression lines of fibrinogen and age in non-massive transfusion and massive transfusion cases are given by Y=1.03 X+185 (r=0.24, r(2)=0.06, P<0.001) and Y=0.86 X+134 (r=0.25, r(2)=0.06, P=0.09) respectively, and the fibrinogen levels tended to increase with older age in severe trauma patients. CONCLUSIONS: The fibrinogen level did not show a low value as it can in younger patients in elderly patients. Therefore, the fibrinogen level is difficult to use as an early indicator of acute blood loss with haemorrhage in elderly severe trauma patients, as it can be used in younger patients. Thus, it is necessary to keep in mind that the fibrinogen level increases by approximately 1mg/dL when the age increases by 1 year and to carefully observe the fibrinogen level even if the admission level is not low.

Reconsideration about the aggressive surgery for resectable pancreatic cancer: a focus on real pathological portosplenomesenteric venous invasion.

BACKGROUND: Some clinicians have argued that combining pancreatic and portomesenteric venous resection could improve the rates of long-term survival. However, whether resection of the portosplenomesenteric vein could provide an acceptable survival benefit to patients with pancreatic cancer involving the portosplenomesenteric system remains controversial. The purpose of this study was to determine the significance of pathological portosplenomesenteric venous invasion on survival in patients who underwent surgical management for pancreatic adenocarcinoma. METHODS: Patients who underwent curative surgical treatment were divided into two subgroups: those with pathological invasion to the portosplenomesenteric vein (PV-positive group) and those without invasion (PV-negative group). RESULTS: Of 160 studied patients, the median overall survival was 48.0 months after pancreatic surgery in the PV-negative group and 18.0 months in the PV-positive group. The incidence of postoperative peritoneal dissemination was significantly lower in the PV-negative group than in the PV-positive group. Accordingly, patients in the PV-negative group showed a cumulative rate of pancreatic cancer recurrence at 2 years after pancreatic surgery of 54.4%, while this rate was 89.4% in the PV-positive group. Finally, an elevated presurgical serum CA19-9 level (>700 IU/mL) was found to be significantly associated with a poor outcome after surgery in pancreatic cancer patients with pathological portosplenomesenteric venous invasion. CONCLUSIONS: Pancreatic cancer carries a high risk of recurrence even if surgical resection is technically possible. The current study suggested that portosplenomesenteric involvement and preoperative high serum CA19-9 are poor prognostic indications; however, the findings provided little insight into the role of neoadjuvant therapy in such patients.

Right posterior approach for pancreaticoduodenectomy: a new technical approach.

CONTEXT: The major goals that must be achieved during pancreaticoduodenectomy (PD) include reduction of postoperative hemorrhage and/or operating time. We herein describe a new technique for PD examining right posterior approach PD. METHODS: From January 2012 to December 2013, 116 patients underwent PD for periampullary or pancreatic disease. Of these 116 patients, 56 cases were surgically treated for pancreas head or periampullary malignancy and were studied for blood loss volume and length of operation. RESULTS: An interesting issue in the present study was related to operating time and intra-operative blood loss. The median blood loss volume and operating time were 349 mL (35-3,636 mL) and 276 min (188-467 min), respectively, in patients who underwent a right posterior-approach PD. CONCLUSION: The estimated operative blood loss volume and operative time are lower in right posterior approach PD, probably due to clearly detection a route of the inferior pancreaticoduodenal artery from the SMA and following early ligation of the inferior pancreaticoduodenal artery and reduced congestion of the pancreatic head.

Long-term survival following pancreatectomy and s-1 chemotherapy for pancreatic acinar cell carcinoma with peritoneal dissemination: a case report and literature review.

Current case is the third report of S-1 chemotherapy against acinar cell carcinoma (ACC) of pancreas, and our patient has achieved the longest reported recurrence-free survival, longer than 6 years, despite the presence of disseminated nodules at laparotomy.A 77-year-old man presented with abdominal discomfort. Computed tomography showed a low-density tumor in the pancreas tail and the patient was referred for surgery. A 3-cm sized pancreatic tumor, with localized disseminated nodules, was detected on laparotomy. Distal pancreatectomy with concomitant resection of disseminated nodules was performed, and histopathological examination revealed an ACC. Oral S-1 chemotherapy was administered postsurgery, and the patient showed no sign of recurrence during 73 months of follow-up. This is the first report of long-term survivor of pancreatic ACC with peritoneal dissemination, following pancreatectomy and S-1 chemotherapy.Current case suggests a beneficial effect of S-1 chemotherapy in cases of ACC.

Epiploic gonadal vein as a new bypass route for extrahepatic portal venous obstruction: report of a case.

A 61-year-old man was referred to our hospital to treat extrahepatic portal venous obstruction. Endoscopic injection sclerotherapy (EIS) was performed for the esophageal varices; however, the patient returned with massive hematemesis from gastric varices 6 months after treatment. Although the varices were treated with EIS, gastric devascularization and splenectomy concomitant with shunt surgery were required to treat uncontrollable, frequent diarrhea and abdominal distension. Because the splenic vein, left gastric vein, left portal vein, and inferior vena cava were inadequate for anastomosis, an epiploic gonadal vein bypass was performed. The bypass graft remains patent 7 months after surgery, and the patient is in good health without any clinical symptoms. We describe a new bypass route for extrahepatic portal venous obstruction.

Resected xanthogranulomatous pancreatitis.

Xanthogranulomatous changes in the pancreas are extremely rare. A 66-year-old man presented with a 2-year history of epigastralgia. Computed tomography scan revealed a 4-cm low-density area around the body of the pancreas. Magnetic resonance imaging demonstrated that the mass appeared hyperintense on a T2-weighted image and isointense on a T1-weighted image. Based on a diagnosis of invasive ductal carcinoma of the pancreas, distal pancreatectomy and splenectomy were performed. Sections examined from the mass showed an aggregation of many foamy histiocytes, lymphocytes, and plasma cells. The surrounding pancreatic tissue showed fibrosis and chronic inflammation. These findings suggested a xanthogranulomatous inflammation, and resulted in a diagnosis of xanthogranulomatous pancreatitis.