A nationwide survey of non-IgE-mediated gastrointestinal food allergies in neonates and infants.

BACKGROUND: Non-IgE-mediated gastrointestinal food allergies (non-IgE-GIFAs) seem to be increasing rapidly worldwide. However, nationwide studies have been limited to food-protein-induced enterocolitis (FPIES) and food-protein-induced allergic proctocolitis (FPIAP), with little attention to other non-IgE-GIFA subgroups. The aim of this study was to elucidate the clinical features of all patients with non-IgE-GIFAs, not just certain subgroups. METHODS: We conducted a nationwide cross-sectional survey of non-IgE-GIFAs in Japan from April 2015 through March 2016. A questionnaire was sent to hospitals and clinics throughout Japan. The questionnaire asked about the number of physician-diagnosed non-IgE-GIFA patients, the status of fulfillment of the diagnostic criteria, tentative classification into 4 clusters based on the initial symptoms, the day of onset after birth, complications, and the suspected offending food(s). RESULTS: The response rate to that questionnaire was 67.6% from hospitals and 47.4% from clinics. Analyses were conducted about "diagnosis-probable" patient cohort (n = 402) and the "diagnosis-confirmed" patients (n = 80). In half of the reported non-IgE-GIFA patients, onset occurred in the neonatal period. The patients were evenly distributed among 4 non-IgE-GIFA clusters. In Cluster 1, with symptoms of vomiting and bloody stool, the onset showed a median of 7 days after birth, which was the earliest among the clusters. Cow's milk was the most common causative food. CONCLUSIONS: In half of the patients, the onset of non-IgE-GIFAs was in the neonatal period. This highlights the importance of studying the pathogenesis in the fetal and neonatal periods.

Knowledge survey regarding blast wound education of student doctors at a local academic medical university in Japan.

Objectives: To improve knowledge about blast injury for medical student doctors or surgeons. In the modern uncertain era, education and training programs for blast injuries for medical student doctors or surgeons are recently necessary worldwide. Material and Methods: To understand primary corresponding ability to treat blast injuries, leading to improvement of the trauma education curriculum, a retrospective study by a knowledge survey was performed between 2018 and 2019. The subject had the title of Student Doctor (SD) at university. Results: The answers of 183 participants who answered the interview questionnaire with 16 questions were summarized. Although most SDs received basic lectures for trauma medicine and majority of SDs knew about mass casualty incidents and primary treatment, the existence of knowledge on soft targets is limited. One-fourth of the SDs knew the characteristics of blast wounds. Most SDs understood priority triage for a conscious person with massive bleeding from a limb with hemostasis to save lives. The 17% selected cardiopulmonary resuscitation first and 72% of SDs could explain hemorrhagic shock; however, only four could explain adequate hemostatic procedures. Most had no interest regarding necessity of their knowledge in the field of serious blast trauma wounds. Conclusion: Experience in trauma surgery training from stages in SDs and authorized education are important for raising students' knowledge of unexpected serious blast incidents.

Current status of trauma surgery at a Japanese prefectural academic institute: improved organization in a regional prefecture.

PURPOSES: Balancing scheduled surgery and trauma surgery is difficult with a limited number of surgeons. To address the issues and systematize education, we analyzed the current situation and the effectiveness of having a trauma team in the ER of a regional hospital. METHODS: This retrospective study analyzed the demographics, traumatic variables, procedures, postoperative morbidities, and outcomes of 110 patients who underwent trauma surgery between 2012 and 2019. The trauma team was established in 2016 and our university hospital Emergency Room (ER) opened in 2012. RESULTS: Blunt trauma accounted for 82% of the trauma injuries and 39% of trauma victims were transported from local centers to our institute. The most frequently injured organs were in the digestive tract and about half of the interventions were for hemostatic surgery alone. Concomitant treatments for multiple organ injuries were performed in 31% of the patients. The rates of postoperative severe complications (over Clavien-Dindo IIIb) and mortality were 10% and 13%, respectively. Fourteen (12.7%) of 24 patients who underwent damage-control surgery died, with multiple organ injury being the predominant cause of death. CONCLUSION: Systematic education or training of medical students and general surgeons, as well as the co-operation of the team at the regional academic institute, are necessary to overcome the limited human resources and save trauma patients.

Endoscopic filling with polyglycolic acid sheets and fibrin glue of persistent fistula after esophagectomy.

BACKGROUND: Treatment of anastomotic leakage in reconstruction after esophagectomy remains challenging. This report presents a new endoscopic filling method for persistent fistula after failure of conservative treatment of leakage caused by anastomotic insufficiency. METHODS: 10 of 14 patients, in whom post-esophagectomy leakage had failed to resolve after 2 weeks of conservative treatment, underwent endoscopic filling with polyglycolic acid (PGA) sheet and fibrin glue into the anastomotic leakage site, using a delivery tube and endoscopic catheter, respectively. RESULTS: Each patient underwent jejunostomy, to secure nutrition. The leakage was resolved in all 10 patients. The mean number of PGA - fibrin glue procedures was 1.7. The mean period from the first application to the resumption of oral intake was 31.6 days, from the final application it was 14.7 days. CONCLUSIONS: The reported filling method offers a new endoscopic approach for persistent fistula after esophagectomy when conservative treatment of leakage has failed.

Nasogastric administration of lenvatinib solution in a mechanically ventilated patient with rapidly growing anaplastic thyroid cancer.

SUMMARY: A 54-year-old woman was referred to our hospital with a cervical tumor. CT revealed a cervical tumor extending to the upper mediastinum, tracheal deviation and tumor infiltration in the cervical vessels. She was followed-up because no diagnosis of malignancy was made by cytology. However, 2 months later, a CT scan showed enlargement of the tumor and tracheal stenosis, and a surgical biopsy was performed and she was diagnosed with anaplastic thyroid cancer (ATC). The tracheal tube with tracheal stenosis could not be removed due to the rapid growth of the tumor, necessitating management by mechanical ventilation. Due to the difficulty of surgical resection, she was treated with lenvatinib. A lenvatinib solution was made and administered via a nasogastric tube. After lenvatinib treatment, the tumor volume decreased and the tracheal stenosis improved. The tracheal tube was removed and oral intake became possible. She was discharged and received ambulatory lenvatinib therapy. The tumor was significantly reduced in size, but gradually grew and was exposed through the cervical wound 6 months later. Esophageal perforation occurred 10 months after the start of treatment. Lenvatinib was re-administered via a nasogastric tube. Eleven months later, the patient died of massive bleeding from the exposed cervical tumor. Patients with advanced ATC may require management with mechanical ventilation for airway stenosis or with a nasogastric tube for esophageal stenosis and perforation. We experienced a case in which lenvatinib was safely administered via a nasogastric tube while performing mechanical ventilation. LEARNING POINTS: An anaplastic thyroid cancer patient under mechanical ventilator management was treated with lenvatinib via a nasogastric tube. The lenvatinib solution can easily be prepared and administered via a nasogastric tube. The lenvatinib solution was effective for a patient with difficulty in oral intake. Lenvatinib could also improve the prognosis of an anaplastic thyroid cancer patient with severe airway and esophageal trouble.

Japanese neonate with congenital chloride diarrhea caused by SLC26A3 mutation.

Congenital chloride diarrhea (CCD) beginning in utero is a rare autosomal recessive inherited disorder characterized by impairment of Cl(-) /HCO3 (-) exchange in an otherwise normal distal ileum and colon. Life-long secretory diarrhea is caused by mutations in solute carrier family 26, member 3, (SLC26A3), which disrupt epithelial Cl(-) /HCO3 (-) transport in the ileum and colon. Although 55 mutations in SLC26A3 have been identified throughout the world, few Japanese cases have been confirmed on genetic analysis. We report the successful treatment of a Japanese neonate with CCD caused by SLC26A3 mutation.

Gray matter volumetric MRI differences late-preterm and term infants.

Gray matter develops rapidly during the third trimester of pregnancy, which is a critical period for lipid deposition. We measured brain volume in term and late-preterm infants to determine if it is related to disabilities in late-preterm infants. In addition, we measured serum lipid concentrations to investigate the relationship between brain volume and lipid nutrition. Magnetic resonance imaging scans were obtained in 16 late-preterm and 13 term infants. We measured cerebrum, gray matter, and white matter volumes. We performed serum cholesterol, triglyceride (TG), and lipoprotein analyses in cord blood by high-performance liquid chromatography using gel permeation columns to assess lipid nutritional levels. The gray matter volume and percent cerebrum volume of gray matter were significantly smaller in late-preterm infants (p<0.001). Head circumference and cerebrum and white matter volume did not differ between the two groups. Gray matter volume correlated positively with gestational age (r=0.647, p<0.001), head circumference (r=0.688, p<0.001), and high-density lipoprotein (HDL)-TG levels (r=0.496, p=0.006). Late-preterm infants had a normal head circumference and a lower gray matter volume than term infants. Gestational age and head circumference were significantly associated with gray matter volume. Only HDL-TG levels were significantly associated with gray matter volume. HDL-TG might contribute to the transport of fatty acids and gray matter development during the postnatal period. Thus, delayed gray matter development may partly contribute to neurodevelopmental disabilities in late-preterm infants.

A case of D-lactic acid encephalopathy associated with use of probiotics.

A five year old girl was admitted to the hospital for evaluation of intermittent ataxia. She had undergone serial resections of the small intestine after birth, resulting in short bowel syndrome. Lactomin was prescribed for watery diarrhea at twice the regular dose 2 weeks before the onset of neurologic symptoms. D-lactic acidosis was diagnosed on the basis of a plasma D-lactate level of 5.537 mmol/l. Lactomin was discontinued, and she was treated with sodium bicarbonate and oral antibiotics. The probiotics the patient had taken were likely the cause of D-lactic acidosis and should therefore be avoided in patients with short bowel syndrome.