Spontaneous hyperinflation of a giant bulla of the non-ventilated lung during laparoscopic cholecystectomy under one-lung ventilation: a case report.

BACKGROUND: Anesthetic management of non-thoracic surgery in patients with giant bullae is challenging. We present a case of laparoscopic cholecystectomy in a patient with a giant bulla managed with one-lung ventilation (OLV). CASE PRESENTATION: A 75-year-old man with a giant bulla occupying the lower half of the right hemithorax underwent laparoscopic cholecystectomy. We managed anesthesia with OLV to avoid positive pressure ventilation of the giant bulla. Surgery was completed uneventfully; however, postoperative chest radiography indicated a large lucency occupying the entire right hemithorax. Although we suspected a pneumothorax due to a ruptured bulla, chest computed tomography (CT) led to a diagnosis of giant bulla hyperinflation. The giant bulla deflated gradually to its preoperative size within three postoperative days. CONCLUSIONS: Managing laparoscopic cholecystectomy in a patient with a giant bulla with OLV resulted in spontaneous hyperinflation of the giant bulla. Chest CT ruled out a pneumothorax.

Accommodation in a refugee shelter as a risk factor for peptic ulcer bleeding after the Great East Japan Earthquake: a case-control study of 329 patients.

BACKGROUND: We have reported that the total number of peptic ulcers (PUs) had increased 1.5-fold after the Great East Japan Earthquake compared with those of the previous year, and that hemorrhagic ulcers were more prominently increased by 2.2-fold. The aim of this study is to determine the risk factors for bleeding ulcers after the Great East Japan Earthquake. METHODS: Clinical data of all peptic ulcer subjects endoscopically detected at the 7 major hospitals in the middle of the stricken area during the 3 months after the earthquake were retrospectively collected. Based on endoscopic and laboratory findings, peptic ulcer cases were divided into 227 bleeding ulcer cases and 102 non-bleeding controls. Other than ordinary risk factors for bleeding ulcers, the refugee shelter was included in the analysis as a unique confounder after the earthquake. Multiple logistic regression analyses were used to adjust for potential confounders. RESULTS: Eighty-seven (27%) of 329 PUs emerged from refuge shelters, and the majority (76 of 87) of PUs occurring in such shelters was the bleeding type. Multivariate regression showed that residence in a shelter was a strong risk factor for ulcer bleeding with OR (95% CI): 4.4 (2.1-9.6, p < 0.0001), independent of the progressiveness of ulcer diseases. CONCLUSIONS: Accommodation in a refugee shelter can be a strong risk factor for ulcer bleeding after a large-scale disaster. Since acid-suppressive drugs are supposed to decrease the risk for stress-induced ulcer bleeding, our results will encourage effective use of a limited medical resource in such catastrophic events.

Hemorrhagic ulcers after Great East Japan Earthquake and Tsunami: features of post-disaster hemorrhagic ulcers.

BACKGROUND: We investigated the characteristic features and treatment of hemorrhagic peptic ulcers after the Great East Japan Earthquake, which occurred on 11 March 2011. METHODS: Clinical data of patients with hemorrhagic peptic ulcers were retrospectively collected during the 3 months after the earthquake from seven major hospitals in the middle of the stricken area, and were compared with those during the same period of the previous year. RESULTS: After the earthquake, the number of hemorrhagic ulcers increased 2.2 fold as compared with the previous year, and gastric ulcers were significantly more frequent compared with duodenal ulcers (p < 0.05) and more often presented multiple forms (p < 0.05). Nonetheless, the proportion of re-bleeding cases after hemostasis treatment (8% in 2010 vs. 5% in 2011) or total mortality rate (2.5% in 2010 vs. 1.2% in 2011) was rather lower after the earthquake compared with that of the previous year. CONCLUSION: We clarified that post-disaster hemorrhagic ulcers existed frequently in the stomach, often as multiple ulcers at the same time. The Great East Japan Earthquake and Tsunami caused many cases of hemorrhagic ulcer. However, because of the high success rate of endoscopic hemostasis, the mortality remained as low as in the previous year. Our present study provides important information for large-scale disasters which can occur anywhere.

Peptic ulcers after the Great East Japan earthquake and tsunami: possible existence of psychosocial stress ulcers in humans.

BACKGROUND: Societal stress derived from an event that affects the whole society, e. g., a natural disaster, provides a unique, indirect way of determining the relationship between psychological stress and peptic ulcer disease in humans. In this study, we investigated the changing patterns of the incidence of peptic ulcers before and after the Great East Japan earthquake, which occurred on 11 March, 2011. METHODS: Clinical data of patients with peptic ulcers were retrospectively collected during the 3 months after the earthquake (2011) from 7 major hospitals in the middle of the stricken area, and were compared with the data for the same period of the previous year (2010). The eligible subjects were classified into four groups according to Helicobacter pylori infection status and intake of nonsteroidal anti-inflammatory drugs (NSAIDs). RESULTS: The incidence of all types of peptic ulcers was 1.5-fold increased after the earthquake, and in particular, the incidence of hemorrhagic ulcers was 2.2-fold increased; the gastric ulcer/duodenal ulcer ratio in hemorrhagic ulcers was also significantly increased (p < 0.05). Regarding the etiology of the peptic ulcers, the proportion of non-H. pylori and non-NSAID ulcers was significantly increased, from 13 % in 2010 to 24 % in 2011 after the earthquake (p < 0.05). CONCLUSION: In addition to the increased incidence of peptic ulcers, compositional changes in the disease were observed after the Great East Japan earthquake. The significant increase in the proportion of non-H. pylori and non-NSAID ulcers after the earthquake indicated that psychological stress alone induced peptic ulcers in humans independently of H. pylori infection and NSAID intake.

[A case of gastric cancer accompanied by disseminated carcinomatosis of bone marrow with DIC, and subdural hematoma successfully treated with sequential methotrexate and 5-fluorouracil therapy].

A 44-year-old man visited a nearby hospital because of severe headache. Brain MRI revealed a subdural hematoma, and he was transferred to the Department of Neurosurgery of our hospital. Burr hole surgery was performed on the second day of hospitalization because of an enlargement of the hematoma. Laboratory data on admission showed the presence of a disseminated intravascular coagulation(DIC). Bone marrow aspiration revealed metastases of signet ring cell carcinoma, and abdominalCT showed gastric cancer. He was diagnosed as having DIC with bone marrow metastases of advanced gastric cancer. Despite anti-DIC therapy and blood transfusion, his systemic bleeding tendency was not improved. The neurosurgeon therefore consulted with a palliative care team. Since the patient was still young, we considered that he should be treated with anti-cancer drugs. At first, his family did not accept chemotherapy because they were pessimistic about his prognosis. However, after he regained his consciousness, we were able to perform sequential MTX and 5-FU therapy with the consent of the patient and his family. The therapy was successful, and he recovered from DIC and was discharged on the 57th hospital day.

[Case of transient paralysis and paresthesia after epidural blood patch].

A 47-year-old woman with postdural puncture headache suffered from transient paralysis and paresthesia immediately after the epidural blood patch. After one and a half hour, these symptoms disappeared spontaneously. We suspect that the spinal cord or spinal nerve root was transiently pressed by the viscous blood mass, because blood sampling maneuver took a few minutes. With passing of time, the viscous blood spread through the epidural space, and neurological symptoms improved. Although the risks of epidural blood patch are relatively low, we should closely pay attention to unexpected side effects.

[Two cases of primary unresectable and/or recurrent gastrointestinal stromal tumors of small intestine presenting hemoperitoneum caused by administration of imatinib mesylate].

Case1 was a 52-year-old man who had recurrence of postoperative intra-abdominal disseminations from gastrointestinal stromal tumor (GIST) of the jejunum. Case2 was a 66-year-old man who had GIST of the jejunum with multiple liver metastases. Two cases presented hemoperitoneum caused by administration of imatinib mesylate, and we conducted emergent surgery. In spite of surgically non-curative cases, it is suggested that the surgical management for GIST of high grade group with peritoneal exposure should be followed by the administration of imatinib mesylate.

In situ androgen production in human gastric carcinoma--androgen synthesizing and metabolizing enzymes.

BACKGROUND: It is well known that the incidence of gastric carcinoma is lower in females than in males. Therefore, androgens have been proposed to play an important role in modifying the development of gastric carcinoma. 5Alpha-reductase (5alpha-reductase) types 1 and 2 and 17beta-hydroxysteroid dehydrogenase type 5 (17beta-HSD type 5) are considered important local regulators of androgen production in human androgen-responsive tissues and cancer. MATERIALS AND METHODS: The immunoreactivities of these steroidogenic enzymes, as well as of the androgen receptor (AR), were evaluated in human gastric carcinoma obtained from endoscopic mucosal resection (EMR) (n = 117). RESULTS: 17beta-HSD type 5 immunoreactivity was detected in 99 cases (85%), 5alpha-reductase type 1 in 69 cases (59%), 5alpha-reductase type 2 in 57 cases (49%) and AR in 46 cases (39%). CONCLUSION: These androgen-producing enzymes are expressed in human gastric carcinomas and are involved in the in situ production and possible regulation of androgenic activity in human gastric carcinoma.

Estrogen-related receptor alpha in human breast carcinoma as a potent prognostic factor.

Estrogen-related receptor alpha (ERRalpha) was identified as a gene related to estrogen receptor alpha (ERalpha) and belongs to a class of nuclear orphan receptors. ERRalpha binds to estrogen responsive element(s) (ERE) and is considered to be involved in modulation of estrogenic actions. However, biological significance of ERRalpha remains largely unknown. Therefore, we examined the expression of ERRalpha in human breast carcinoma tissues using immunohistochemistry (n = 102) and real-time reverse transcription-PCR (n = 30). ERRalpha immunoreactivity was detected in the nuclei of carcinoma cells in 55% of breast cancers examined, and relative immunoreactivity of ERRalpha was significantly (P = 0.0041) associated with the mRNA level. Significant associations were detected between ERalpha and ERE-containing estrogen-responsive genes, such as pS2 (P < 0.0001) and EBAG9/RCAS1 (P = 0.0214), in breast carcinoma tissues. However, no significant association was detected between ERalpha and pS2 (P = 0.1415) in the ERRalpha-positive cases (n = 56) or between ERalpha and EBAG9/RCAS1 (P = 0.8271) in the ERRalpha-negative group (n = 46). ERRalpha immunoreactivity was significantly associated with an increased risk of recurrence and adverse clinical outcome by both uni- (P = 0.0097 and P = 0.0053, respectively) and multi- (P = 0.0215 and P = 0.0118, respectively) variate analyses. A similar tendency was also detected in the group of breast cancer patients who received tamoxifen therapy after surgery. Results from our study suggest that ERRalpha possibly modulates the expression of ERE-containing estrogen-responsive genes, and ERRalpha immunoreactivity is a potent prognostic factor in human breast carcinoma.

Systemic distribution of estrogen-responsive finger protein (Efp) in human tissues.

Estrogen-responsive finger protein (Efp), a target gene product of estrogen receptor (ER), is considered essential for estrogen-dependent cell proliferation. The biological significance of Efp remains unclear in human tissues, and therefore, we examined systemic distribution of Efp in human adult and fetal tissues using RT-PCR and immunohistochemistry. Efp mRNA expression was marked in the placenta and uterus, high in the thyroid gland, aorta, and spleen in adult, and relatively low in other human adult and fetal tissues examined in this study. Efp immunoreactivity was detected in epithelium of various adult tissues, and was also detected in cytotrophoblasts of the placenta and splenic macrophages. Efp immunolocalization in human fetus was generally similar as that in adult. These Efp-positive cells were previously reported to be associated with ERalpha and/or ERbeta expression. Therefore, these results indicate that Efp is widely expressed and may play important roles in various human tissues possibly through ERs.