Intratumoral metastasis of sigmoid colon cancer to chromophobe renal cell carcinoma: a case report.

We herein report an extremely rare case of intratumoral metastasis of colon cancer to chromophobe renal cell carcinoma. A 71-year-old woman was diagnosed with lung metastasis of sigmoid colon cancer and underwent sigmoid colon resection with D3 lymph node dissection. Preoperative contrast-enhanced computed tomography (CT) revealed a left renal tumor; however, colon resection was prioritized, and the renal tumor was placed under observation. Two years later, CT revealed enlargement of the left renal tumor, and laparoscopic partial left nephrectomy was performed 1 month later. Histopathologic examination showed that the resected renal tumor was a chromophobe renal cell carcinoma with intratumoral metastasis of colon cancer to the renal tumor center, and adjuvant chemotherapy with bevacizumab plus SOX (L-OHP + S-1) was initiated. Because of severe chemotherapy-induced fatigue and nausea, the patient was switched to bevacizumab + S-1. However, the patient's nausea did not improve after this change, and postoperative adjuvant chemotherapy was discontinued at the patient's request 4 months after the partial nephrectomy. Two months after discontinuation of chemotherapy, CT showed no renal recurrence; however, increased lung metastases and a new bone metastasis in the left sciatic bone were observed. Palliative treatment was then initiated because of severe adverse events that made it difficult to continue treatment. In patients who have multiple cancers and an increase in renal tumor size, the possibility of intratumoral metastasis to the renal tumor should be considered.

TIM-3 expression induces resistance to PD-1 inhibitor in G-CSF-producing lung spindle cell carcinoma: A case report.

Lung spindle cell carcinoma is an aggressive subtype of pleomorphic lung cancer resistant to cytotoxic chemotherapy. Programmed cell death-1 (PD-1) inhibitors have been reported to have clinical effects in patients with spindle cell carcinoma; however, the resistance mechanism to PD-1 inhibitors is yet to be fully elucidated. Herein, we report the case of an 88-year-old man with G-CSF-producing spindle cell carcinoma who acquired resistance to PD-1/PD-ligand 1 (L1) inhibitor in an early setting after a remarkable response. A histopathological review of the resistant specimen revealed a low count of CD8+ T cells and a predominant presence of M2 and TIM-3+ macrophages, indicating the presence of an immunosuppressive microenvironment. Our findings suggest a novel resistance mechanism to PD-1/PD-L1 inhibitors in G-CSF-producing spindle cell carcinoma.

Bilateral vocal cord palsy induced by long-term use of small-bore nasogastric tube.

Background: Nasogastric tube syndrome is a rare but life-threatening complication of nasogastric tube placement due to acute upper airway obstruction caused by bilateral vocal cord paresis. Case Presentation: An 86-year-old woman was brought to the emergency department with acute stridor. She had been diagnosed with stroke 106 days prior, and an 8F nasogastric tube was placed on the day following the diagnosis. A laryngeal fiberscopy revealed bilateral laryngeal edema and bilateral vocal cord palsy. Nasogastric tube removal and intubation were carried out, and the stridor disappeared. Two days later, a tracheostomy was performed. Unfortunately, the patient's vocal cord function had not improved at the 1 month follow-up upon assessment with a laryngeal fiberscope. Conclusion: Long-term small-bore nasogastric tube placement can cause upper airway obstruction due to bilateral vocal cord palsy.

Intravascular Catheter Accidentally Placed into the Right Lumbar Vein from the Right Femoral Vein: A Case Report.

BACKGROUND Severe hypothermia has a high mortality rate and necessitates aggressive warming to save lives. One of the most effective treatments for severe hypothermia is intravascular rewarming. Intravascular recuperative warming can be delivered by inserting a catheter through the cervical or femoral veins. Catheter insertion through the femoral vein is a commonly performed procedure with fewer complications than catheter insertion through the internal jugular vein. This procedure is commonly conducted by inserting a central venous catheter through the femoral vein. When a catheter is inserted through the femoral vein, a frontal abdominal radiograph is often used to confirm the position of the catheter tip. CASE REPORT We present the case of a 58-year-old Japanese man who had severe hypothermia. Under ultrasound guidance, a catheter was inserted through the femoral vein into the inferior vena cava for active rewarming. A frontal abdominal radiograph showed that a catheter tip appeared to be in the inferior vena cava. However, a subsequent computed tomography scan revealed that the catheter tip had been misplaced into the right ascending lumbar vein. CONCLUSIONS Catheters may stray into the right ascending lumbar vein if they are placed through the right femoral vein. Frontal abdominal radiographs may be insufficient to confirm catheter placement.

Impact of non-pharmaceutical interventions for the COVID-19 pandemic on emergency department patient trends in Japan: a retrospective analysis.

AIM: The coronavirus disease (COVID-19) pandemic massively impacted emergency department (ED) visits. The unavailability of specific therapies or vaccines has made non-pharmaceutical interventions (NPIs) an alternative strategy for COVID-19. We assessed the impact of NPIs (nationwide school closures and state of emergency) on ED visits during the COVID-19 pandemic in Japan. METHODS: This retrospective study compared the trends in ED visits from 1 January to 25 May, 2020 (during the pandemic) with the average during 2015-2019 (before the pandemic). The primary end-point was the change in the number of ED visits during the COVID-19 pandemic with those from before the pandemic, with the NPI application stratified across four periods in 2020: Period 0 (1-15 January), no COVID-19 cases detected in Japan; Period I (16 January-1 March), initial COVID-19 outbreak; Period II (2 March-15 April), nationwide school closures; Period III (16 April-25 May), state of emergency. RESULTS: Compared with before the pandemic, the number of walk-in ED visits significantly decreased by 23.1%, 12.4%, and 24.0% (4,047 versus 3,111; 3,211 versus 2,813; and 3,384 versus 2,573; P < 0.001 for all) in Periods I, II, and III, respectively. The number of ambulance ED visits during the pandemic significantly increased by 8.3% in Period I (1,814 versus 1,964, P = 0.002), whereas there was no significant change in Periods II and III with 2.7% and -3.1% (1,547 versus 1,589 and 1,389 versus 1,346; P = 0.335 and P = 0.284, respectively). CONCLUSIONS: The application of an NPI during the COVID-19 pandemic could have significantly reduced patient attendance in the ED.

Reversible cerebral vasoconstriction syndrome: the importance of follow-up imaging within 2 weeks.

AIM: In patients with thunderclap headaches, reversible cerebral vasoconstriction syndrome (RCVS) should be considered as a differential diagnosis. However, RCVS diagnosis in the emergency department (ED) remains challenging. This report describes the clinical features and factors related to RCVS diagnosis and suggests diagnostic strategies for its management. METHODS: We retrospectively reviewed the medical records of eight patients diagnosed with RCVS from January 2010 to March 2019 (aged 18-69 years, 5 women). RESULTS: The median duration from the ED visit to RCVS diagnosis was 6 days (range, 1-11 days). Of the eight patients, seven were middle-aged, six had apparent triggers, six had subarachnoid hemorrhage (SAH), five had high systolic blood pressure, and none had any specific abnormality observed upon physical examination. At the initial visit, RCVS was diagnosed in only one patient who had a history of RCVS. Of the other patients, SAH was diagnosed in two, and primary headache was diagnosed in four patients with negative computed tomography (CT) findings. Based on follow-up angiography (e.g., magnetic resonance angiography), seven of eight patients with convexal SAH were diagnosed with RCVS (as the cause of SAH). CONCLUSION: Reversible cerebral vasoconstriction syndrome with negative CT findings at the ED visit was likely to be misdiagnosed as a primary headache. In patients with thunderclap headache and negative CT findings, physicians should consider RCVS as a differential diagnosis, inform patients of the risk of RCVS, and undertake follow-up imaging within 2 weeks.

Protective effects of a cystine and theanine mixture against acute radiation injury in rats.

This study aims to examine the effects of cystine and theanine (CT), which increases glutathione biosynthesis, on the survival rate and acute radiation injury of the small intestine and bone marrow using a rat model. CT pre-treatment (280 mg/kg for 5 days) significantly improved weight loss and survival rate of rats as compared with the control group after 5 Gy. CT pre-treatment significantly increased the rate of mucosa and crypt length, and decreased the number of apoptotic cells, TUNEL and cleaved caspase-3 positive cells, while increasing the number of mitotic cells and Ki-67 positive cells in jejunal crypts and villi compared to control rats post-irradiation. CT also suppressed bone marrow cell loss and reduced the number of apoptotic cells in bone marrow. These results suggest a protective effect of CT pre-treatment for acute injury after irradiation through apoptosis inhibition and increased proliferative activity in jejunal crypt cells and bone marrow cells.

Validation of the PECARN head trauma prediction rules in Japan: A multicenter prospective study.

BACKGROUND: Head trauma in children is one of the most common causes for emergency department visits. Although most trauma cases are minor, identifying those patients who have clinically important traumatic brain injury (ciTBI) is challenging. The Pediatric Emergency Care Applied Research Network (PECARN) head trauma prediction rules identifying children who do not require cranial computed tomography (CT) were validated and are used all over the world. However, these rules have not been validated with large cohort multicenter studies in Asia. OBJECTIVES: To investigate whether the PECARN rules can be safely applied to Japanese children. METHODS: We conducted a multicenter, prospective, observational cohort study. We included children younger than 16 with minor head trauma (Glasgow Coma Scale ≥14) who presented to the six participating centers within 24 h of their injuries between June 2016 and September 2017. The primary analysis was set to calculate the negative predictive value of the patients with very low risk by the PECARN rules, compared with a preset threshold of 99.85%. RESULTS: We included 6585 children of which 463 (7.0%) had head CT scans performed and 23 (0.35%) had ciTBI. There were two patients with ciTBI who were classified as very low risk. The negative predictive value, calculated as 99.96% (95%CI: 99.86-100.00; P = .019), was significantly superior compared with the preset threshold of 99.85%. CONCLUSIONS: The PECARN head trauma prediction rules seemed to be safely applicable to Japanese children. Further studies are needed to determine safety in hospitals where physicians do not have expertise in managing children.

Gastric mucormycosis complicated by a gastropleural fistula: A case report and review of the literature.

RATIONALE: Mucormycosis is a rare opportunistic fungal infection with poor prognosis. The incidence of mucormycosis has been increasing, and it is a threat to immunocompromised hosts. We present a case of gastric mucormycosis complicated by a gastropleural fistula during immunosuppressive treatment for adult-onset Still disease (AOSD). PATIENT CONCERNS: An 82-year-old woman diagnosed with AOSD who developed gastric ulcers during the administration of an immunosuppressive therapy with corticosteroids, cyclosporine, and tocilizumab complained of melena and epigastralgia. Esophagogastroduodenoscopy showed multiple ulcers covered with grayish or greenish exudates. DIAGNOSES: The patient diagnosed with mucormycosis based on culture and biopsy of the ulcers, which showed nonseptate hyphae branching at wide angles. Mucor indicus was identified using polymerase chain reaction. INTERVENTIONS AND OUTCOMES: Although liposomal amphotericin B was administered, gastric mucormycosis was found to be complicated by a gastropleural fistula. The patient died because of pneumonia due to cytomegalovirus infection, and autopsy revealed the presence of Mucorales around the fistula connecting the stomach and diaphragm. LESSONS: Gastric mucormycosis is refractory to treatment and fatal. Surgical resection, if possible, along with antifungal drugs can result in better outcomes.

Paraplesia after surfing in a young female novice surfer: a case report on surfer's myelopathy.

BACKGROUND: Surfer's myelopathy is a non-traumatic spinal cord injury that was first described in a publication in 2004. However, most emergency physicians are not familiar with this rare disease. CASE PRESENTATION: The patient was a 19-year-old female novice surfer. She had experienced back discomfort without trauma during her surfing lessons. The discomfort turned to dysesthesia of both legs. She could not walk after 1 h and was brought to our hospital. Physical examination revealed weakness and dysesthesia of both legs, absent deep tendon reflexes, bilaterally positive Babinski reflex, and bladder and rectal disturbance. Spine magnetic resonance imaging revealed T2 prolongation from T7 to the medullary cone. She was diagnosed with surfer's myelopathy and treated conservatively. She recovered well and was discharged on day 28. CONCLUSION: Emergency physicians must be better informed about surfer's myelopathy. Novice surfers and instructors should be educated on the early signs and symptoms of this condition.

Autoradiographic analysis of internal plutonium radiation exposure in Nagasaki atomic bomb victims.

BACKGROUND: Radiation doses received by Hiroshima and Nagasaki atomic bomb survivors has been evaluated from data related only to external exposure because there was no reliable evidence for internal exposure in atomic bomb victims. However, we assumed that the contribution of internal exposure cannot be ruled out. METHODS: Autoradiography was carried out with the 70-year old paraffin-embedded specimens taken from Nagasaki atomic bomb victims who died within 5 months after the bombing. After exposure to photo emulsion for 6 months alpha-tracks were revealed in the specimens. We confirmed the alpha-tracks were emitted from deposited plutonium (Pu) in reference to the track length of the 8.787 MeV alpha-particle of thorium series from Polonium-212. Radioactivity concentration of Pu was obtained by counting alpha-tracks. The absorbed dose of each cell nucleus penetrated by an alpha-particle was estimated by calculating the absorbed energy from the particle. RESULTS: Using old paraffin embedded sections processed about 70 years ago, we demonstrated for the first time that conditions in the aftermath of the bombing led to internal exposure to alpha-particles emitted from Pu, the fissile material of the Nagasaki atomic bomb. Dose rate of internal exposure was higher in the victims exposed outdoors than those indoors. Radioactivity concentration was relatively uniform among organs examined in a victim. CONCLUSION: Pu was deposited in the bodies of the Nagasaki A-bomb victims presumably via various routes. Organ dose from Pu of the Nagasaki A-bomb victims studied was during their surviving period, which is lower compared with external exposure. However, the impact to the individual cell nucleus by a single alpha-particle might not be negligible, It would be meaningful; to analyze the relationship of the impact of internal exposure at the cellular level and organ dose. The 70-year old pathological specimens utilized in our study are an invaluable source for understanding internal radiation exposure and are crucial in elucidating experimentally unreproducible phenomena.

Myositis Ossificans of the Hip Due to Pyogenic Arthritis Caused by Campylobacter fetus Subspecies fetus.

A 61-year-old woman was admitted with severe hip pain causing immobility and high serum levels of inflammatory markers. The patient had a medical history of diabetes. She had been scheduled to undergo right hip replacement surgery for the treatment of osteoarthritis associated with gradually progressive pain. On admission, an enhanced abdominal computed tomography scan showed an abnormal increase in synovial fluid surrounding the right ilium, with piriformis muscle calcification. Subsequent blood and specimen cultures identified Campylobacter fetus subspecies fetus. This is a rare report of a case of myositis ossificans followed by C. fetus pyogenic arthritis of the hip.

Norepinephrine enhances radiosensitivity in rat ileal epithelial cells.

We previously reported that the apoptosis index in jejunal crypt cells after X irradiation was greater in spontaneously hypertensive rats than in Wistar-Kyoto rats. Moreover, these same cells showed a suppression of apoptosis when reserpine was administered to induce sympathetic dysfunction in spontaneously hypertensive rats or Wistar-Kyoto rats. Whether the hyperfunction of the sympathetic nervous system is involved in the high susceptibility of the jejunal crypt cells to radiation-induced apoptosis was the subject of this study. The effect of norepinephrine (NE) on cell survival was examined using the colony formation assay after X-ray irradiation of rat ileal epithelial cells (IEC-18). The addition of 1 µM NE decreased the surviving fraction of cells irradiated with 6 Gy from 37% to 8%. The radiosensitivity of IEC-18 cells was enhanced by the addition of 1 µM of NE. The irradiation and treatment with NE also resulted in an increased cellular apoptotic rate. These results showing enhanced radiosensitivity of rat ileal epithelial cells by NE suggest that NE may be one of the factors which aggravate acute radiation injury in the intestine.

Basic fibroblast growth factor suppresses radiation-induced apoptosis and TP53 pathway in rat small intestine.

The effect of basic fibroblast growth factor (bFGF) was studied in radiation-induced apoptosis in rat jejunal crypt cells. Six-week-old male Wistar rats were administered 4 mg/kg bFGF intraperitoneally 25 h before receiving 8 Gy whole-body X rays. The jejunum was removed for analysis from time 0 to 120 h after irradiation. Villus length in control rats declined steadily until 72 h, while in bFGF-treated rats the villi were longer than in the controls until 48 h. Crypt lengths were similar to villi. bFGF treatment increased Ki-67-positive cells in the jejunal crypt at 0, 24 and 48 h. The treatment with bFGF reduced the number of apoptotic cells per jejunal crypt to 23% and 10% of the control values at 3 and 6 h, respectively, and increased numbers of mitotic cells significantly at 48 and 72 h. bFGF decreased the levels of TP53, CDKN1A, Puma and Cleaved caspase 3 at 3 h as detected by Western blot analyses. Our results suggest that bFGF protected against acute radiation-induced injury by suppressing the crypt apoptotic cells including the stem cells and promoted crypt cell proliferation. The inhibition of apoptosis thus might be related to suppression of the TP53 pathway.

First Japanese patient treated with parathyroid hormone peptide immunization for refractory hypercalcemia caused by metastatic parathyroid carcinoma.

Patients with unresectable parathyroid carcinoma develop severe hypercalcemia, bone fractures and renal failure, and become unresponsive to conventional treatments. It has been shown that successful induction of anti-parathyroid hormone (PTH) antibodies, using PTH peptide fragments for immunisation, normalized serum levels of calcium as well as improved clinical symptoms. Here, we report our experience of PTH immunization in a Japanese female suffering from refractory hypercalcemia and renal failure caused by unresectable metastatic parathyroid carcinoma. Upon immunization, there were apparent clinical responses including reduction of serum levels of Ca along with anti-PTH antibodies induction. Therefore, we concluded that PTH immunization was an effective treatment against hypercalcemia caused by metastatic parathyroid carcinomas that are unresponsive to conventional treatments.