Relationship between Nutritional Scales and Prognosis in Elderly Patients after Acute Ischemic Stroke: Comparison of Controlling Nutritional Status Score and Geriatric Nutritional Risk Index.

BACKGROUND/AIMS: Undernutrition is common in patients after acute ischemic stroke (AIS) and predicts poor clinical outcomes. We assessed the relationship between undernutrition and prognosis after AIS. METHODS: We retrospectively assessed consecutively hospitalized AIS patients aged ≥65 years. A poor prognosis for patients after AIS was defined as a modified Rankin Scale (mRS) score of ≥3 at discharge. Nutritional status was evaluated based on the degree and risk of undernutrition as determined by the Controlling Nutritional Status (UND-CONUT) and Geriatric Nutritional Risk Index (UNR-GNRI) scores. RESULTS: Among 218 patients (male, 62.8%; median age, 77 years), 81 had a poor prognosis. A significant correlation was found between UND-CONUT and UNR-GNRI scores (p < 0.001, r = 0.433). Patients with a poor prognosis showed significant undernutrition based on UND-CONUT (p = 0.003) but not on UNR-GNRI (p = 0.218). Patients with undernutrition based on UND-CONUT showed poor outcomes: higher mRS scores at discharge, higher percentages of mRS scores of ≥2 and ≥3, and more complications associated with pneumonia. No significant differences were seen between cases with and without undernutrition risk based on UNR-GNRI. CONCLUSION: UND-CONUT appeared to be more useful than UNR-GNRI for predicting the prognosis of elderly patients with AIS at discharge.

A case of prosopometamorphopsia caused by infarction of the splenium of the corpus callosum and major forceps.

An adult female complained of enlargement of right eyes in other people. Diffusion-weighted imaging detected an abnormal high-intensity area in the region from the splenium of the corpus callosum to the major forceps on the right side. The patient reported that right eyes appeared larger in size, which suggested prosopometamorphopsia. Adichotic listening test identified left-ear deficit. Acombination of prosopometamorphopsia and left-ear deficit was not identified in the reported patients. Prosopometamorphopsia in most of the reported patients included the eye as did that in our patient. This result suggested the importance of information on the eye in recognizing faces.

Clinical Study of Thirteen Patients with Spinal Cord Infarction.

BACKGROUND: A concept of sensory tracts in the spinal cord has been established in relation to a dorsolateral pathway which is located in the posterior part of the lateral column and conveys the deep sense. METHODS: The clinical status at onset, neurological symptoms, and magnetic resonance imaging (MRI) findings in 13 patients of spinal cord infarction were studied. RESULTS: The clinical status was acute in 11 patients and subacute in 2 patients. Palsy of the extremities was noted in 11 patients. Segmental sensory disturbance was shown in all patients. One patient showed disturbance of all senses and paraplegia, which indicated transverse myelopathy. In the other 12 patients, 11 patients showed impairment of pain sense although joint position sense was preserved, excluding 1 patient whose sensory disturbance showed dysesthesia alone. In these 11 patients, soft touch and vibration senses were impaired in 7 patients. Abnormality of spinal cord MRI was detected 7 patients. The lesions were located in the cervical cord in 3 patients, cervical to thoracic cord in 1 patient, and thoracic cord in 3 patients. CONCLUSIONS: In the 11 patients in whom pain sense was impaired and joint position sense was preserved, involvement of the anterior spinal cord artery (ASCA) was the mainstay. Impairment of vibration sense was accompanied in 7 patients in patients of ASCA infarction. It was speculated that impairment of vibration sense can occur in patients with ASCA infarction whose ischemia spread to the dorsolateral pathway in the posterior part of the lateral column.

[Results of Palliative Resection in an Elderly Colorectal Cancer Patient].

With the aging of society, surgery for elderly colorectal cancer(CRC)patients is also increasing. We examined 11 elderly CRC patients who underwent palliative resection in our institute. The reasons other than age for which palliative resection was chosen, included dementia, basic disease, and social backgrounds such as living alone, etc. Although surgery was possible according to the ECOG PS and other examinations before surgery, 3 patients(27.3%)who developed respiratory or circulatory complications after surgery died in the hospital. From the viewpoint of retrospective P-POSSUM evaluation, unreasonable surgical decisions were not made. However, recovery was difficult once complications occurred in the subject group. The postoperative hospital stay, excluding inpatient deaths, was over 1 month due to rehabilitation, discharge adjustment, etc. Therefore, palliative treatment other than surgery should be considered for elderly CRC patients.

Clinical Study on 3 Patients with Infarction of the Vermis/Tonsil in the Cerebellum.

BACKGROUND: Infarction of the vermis and the tonsil in the cerebellum presents as truncal and gait ataxia. Acute rotatory vertigo is often present in infarction of the nodulus in the caudal vermis, which is closely associated with the vestibular pathway, but is minor in infarction of the rostral vermis. The rostral vermis receives input from the dorsal spinocerebellar tract (DSCT) which conveys unconsciousness proprioceptive signals from the ipsilateral lower trunk and leg. The present study investigated the characteristics of infarction of the vermis and the tonsil. PATIENTS AND METHODS: Neuroradiological findings of 3 patients whose lesions were located in the vermis or the tonsil were analyzed. RESULTS: All lesions were located in the anterior lobe in the rostral vermis, the nodulus in the caudal vermis, or the tonsil. Truncal and gait ataxia were exhibited by 3 patients. Rotatory vertigo was exhibited by 2 patients whose lesions were located in the nodulus and the tonsil, but absent in a patient with infarction of the anterior lobe. Lateropulsion opposite the lesion was apparent in a patient with infarction of the tonsil. Gaze-evoked nystagmus was observed in 2 patients with infarction of the nodulus and the tonsil. CONCLUSIONS: The tonsil and the nodulus were considered to have a close relationship with the vestibular pathway. Absence of rotatory vertigo indicated impairment of the DSCT. Our data suggested that the cause of truncal and gait ataxia differed between the rostral vermis and the caudal vermis/tonsil.

Perirhinal accumulation of neuronal alpha-synuclein in a multiple system atrophy patient with dementia.

We report the case of a 79-year-old Japanese woman who developed cerebellar ataxia followed by rigidity, dysautonomia and cognitive disorders, and was thus clinically diagnosed as having possible MSA with dementia. Neuropathological findings demonstrated not only olivopontocerebellar and striatonigral degeneration with frequent glial cytoplasmic inclusions (GCIs), but also degenerative changes in the parahippocampal region, accentuated in the anterior portion of perirhinal cortex, where neuronal cytoplasmic inclusions (NCIs) and NFTs were numerous while GCIs were limited. NCIs were frequent in the deep layer, whereas NFTs were more frequent in superficial cortical layers. Other hippocampal subregions including subiculum, dentate fascia and cornu ammonis were minimally involved. NCIs in the perirhinal cortex showed intense argyrophilia with the Campbell-Switzer silver impregnation method, but not argyrophilic with the Gallyas method. Most neuronal alpha-synuclein aggregates in dendrosomatic fraction formed globular/tadpole-like, and ultrastructurally comprised granular-coated fine fibrils 12-24 nm in diameter. To the best of our knowledge, alpha-synuclein-related neuronal pathology localized in the perirhinal region without hippocampal involvement has not been previously reported in MSA, and may provide clues to elucidate how neuronal pathology evolves in the hippocampal/parahippocampal regions in MSA, particularly in cases with dementia.

Clinical Study of 27 Patients with Medial Medullary Infarction.

BACKGROUND: Medial medullary infarction (MMI) is a rare ischemic stroke. Frequency of each neurological finding in MMI was different in each study. METHODS: We retrospectively evaluated the medical records of patients with cerebral infarction who were admitted between March 1998 and October 2015. Patients in our study were diagnosed as having MMI by magnetic resonance image examination. RESULTS: Of 2727 patients with ischemic stroke, 27 patients (20 males and 7 females) had MMI. The MMI was complicated by infarcts located in the pons (n = 6), cerebellum (n = 2), and lateral medulla (n = 1). One patient had bilateral MMI. Large-artery atherosclerosis was the most common etiology. Motor weakness of the extremities was the most common neurological finding. Diminished contralateral superficial sensation was more common than diminished contralateral vibratory sensation, and these 2 types of sensory disturbance were often complicated. The patients with large MMI significantly more often accompanied diminished touch (P = .003), pain (P = .017), and vibratory (P = .019) sensation. Facial weakness was shown more common contralateral to the infarcts than ipsilateral (n = 8 contralateral, n = 1 ipsilateral). Lingual palsy was also more common contralateral to the lesions (n = 3 contralateral, n = 1 ipsilateral). One patient alone fulfilled the classical Dejerine triad. CONCLUSIONS: In MMI, motor weakness of extremities was commonly shown, and complication of diminished sensations indicated the large infarcts. As for facial weakness and lingual palsy, the supranuclear type was more prominent than the infranuclear type.

[A Study of Gemctabine plus Nab-Paclitaxel Therapy for Advanced Local Progressive Pancreatic Cancer].

We studied the significance of gemcitabine plus nab-paclitaxel(GnP)therapy for locally progressive pancreatic cancer. We enrolled 10 patients with local progression without distant metastasis. We used GnP therapy for the ablative borderline resectable(BR)and unresectable(UR)cases based on images that followed NCCN pancreatic cancer treatment guidelines. In 1 case of resectable(R)pancreatic cancer, the tumor was located in the pancreas body but we determined that surgery was impossible because of the underlying disease detected on imaging analysis. The 10 cases involved R(n=1), UR(n=5), and BR(n=4). Treatment toxicities were reported in all cases. We withheld treatment in the R case because of toxicities. The objective response rate was 40%, and the tumor control rate was 70% with CR 0, PR 4, SD 3, and PD 2. Resection was possible in 5 cases. The response rate to the GnP therapy was 40%, with a tumor control rate of 70%, allowing excision of 50%. We believe GnP therapy is feasible for operative resistant cases.

[A Case of Advanced Gastric Cancer with a Pathological Complete Response after Neoadjuvant Chemotherapy(S-1/Oxaliplatin)].

A 63-year-old man was seen by his family doctor for epigastric distress, and he was referred to our hospital with a diagnosis of gastric cancer. Upper gastrointestinal endoscopy revealed type 3 gastric cancer(por1>tub2>tub1)at the lesser curvature of the stomach. Computed tomography suggested thickening of the wall of the stomach at the lesser curvature and bulky lymph node swelling. After a diagnosis of cT4a cN2M0, cStage III B advanced gastric cancer, we treated him with neoadjuvant chemotherapy consisting of 3 courses of SOX(oxaliplatin 100mg/m / 2 on day 1, S-1 120mg/day on day 1-14, followed by 7 days of rest). After the chemotherapy, because the primary tumor and lymph nodes were reduced, we performed distal gastrectomy with D2 lymph node dissection. Histopathological examination revealed no residual cancer cells, indicating a pathological complete response(Grade 3). We report a case of advanced gastric cancer with a pathological complete response after neoadjuvant chemotherapy.

[A Case of Hemodialysis Patients with Resected Synchronous Multiple Metastases from Colorectal Cancer Successfully Treated with CapeOX Therapy].

A 65-year-old man had been receiving hemodialysis for chronic renal failure. We diagnosed colonic ileus with transverse colon cancer and synchronous multiple liver metastases(liver segments 4 and 6)based on symptoms of abdominal pain and distension. After stent placement in the region of the colonic stenosis, left hemicolectomy was performed for transverse colon cancer. After surgery, the patient received capecitabine plus oxaliplatin(CapeOX)therapy. The dose of capecitabine was 1,250mg/m2, and the dose of oxaliplatin was 70 mg/m2 until the second course, after which it was increased to 100 mg/m2 for the third course. Peripheral neuropathy(Grade 1)was the only adverse event observed. After 6 courses of treatment, the size of the liver metastases and the levels of tumor markers had reduced. For control of liver metastases, partial hepatectomy (liver segments 4 and 6)was performed. We report this case with a review of the literature.

[Combination Chemotherapy Using Oxaliplatin plus S-1 for Well-Advanced Gastric Cancer].

We studied the clinical efficacy of pre-operative combination chemotherapy using S-1 plus oxaliplatin for advanced gastric cancer. Four patients hadclinical Stage IV disease, 1 patient had clinical Stage III C disease, 2 patients had clinical Stage III B disease, and 1 patient had clinical Stage III A disease. The patients received 2-8 courses of oxaliplatin(130mg/m2)on day 1, andS -1 on days 1-14 every 3 weeks. The response rate was 56%(5 PR, 1 PD, and2 SD), andthe disease control rate was 88%. Toxicities were Grade 2 anemia, Grade 1 peripheral neuropathy, Grade 1 fatigue, and anorexia. Five of the 8 patients underwent R0 surgery after SOX chemotherapy, and no severe complications occurred. Histological responses were Grade 3 for 2 cases, Grade 2 for 2 cases, andGrad e 1a for 1 case. The SOX regimen showeda high objective tumor response, andis one of the promising regimens in the neoadjuvant setting for well-advanced gastric cancer.

Quantitative Electroencephalographic Analysis in Patients with Chronic Hepatitis C Treated with Interferon-α: A Review Article.

This review article describes our results regarding the relationship between quantitative electroencephalographic (qEEG) changes and the administration of interferon (IFN) α. We prospectively and blindly assessed a serial cohort of chronic hepatitis C patients. A total of 168 consecutive patients with chronic hepatitis C were enrolled from 1995 to 2007. IFNα was administered intramuscularly at 9 × 106 IU daily for the first 4 weeks and then three times a week for the next 20 weeks. Consecutive EEGs obtained before, 2 and 4 weeks after treatment initiation, and 2-3 days after treatment termination were assessed. EEG recordings were obtained from each patient in the resting awake condition with their eyes closed. The absolute power for each frequency band was determined using qEEG techniques. Diffuse slowing was observed during IFNα treatment and was reversible after completion of treatment. A tendency to this qEEG change was generally observed in all patients. The patient's age and severity of chronic hepatitis were factors that influenced qEEG changes during IFNα treatment. The change in the Mini-Mental State Examination score and IFNα-induced depression were also related to qEEG changes. Such diffuse EEG changes indicated mild encephalopathy associated with IFNα treatment. © 2015 S. Karger AG, Basel.

[A Case of Gemcitabine Refractory Lung Metastasis after Distal Pancreatectomy for Pancreatic Cancer, Effectively Treated with S -1 as Second Line Chemotherapy].

A 64-year-old man was diagnosed with pancreatic cancer by abdominal computed tomography (CT). The examination showed a pancreatic tail cancer and a distal pancreatectomy was performed in 2010. Histopathologically, this tumor was a moderately-differentiated tubular adenocarcinoma. He received gemcitabine adjuvant chemotherapy for a year. In 2012, a chest CT scan revealed 4 nodules in the lower left lobe. We diagnosed gemcitabine-refractory lung metastases after distal pancreatectomy for pancreatic cancer. S-1 chemotherapy was administered as a second line chemotherapy for metastatic pancreatic cancer. After 2 courses of this regimen, the lung metastases were reduced. After 6 courses, a clinical complete response was obtained. Four years and 6 months after the operation, the patient is well without any signs of recurrence, and S-1 chemotherapy is still ongoing.

[A Case of Advanced Gastric Cancer with Peritoneal Dissemination Effectively Treated with S-1 and Docetaxel Combination Chemotherapy].

A 72-year-old man underwent surgery for advanced gastric cancer. Systemic chemotherapy was started, using a regimen of S-1/CDDP for 4 courses, followed by 8 courses of S-1. Three years and 8 months after the surgery, abdominal CT demonstrated ascites, and the serum CA19-9 level was abnormally high (1,165.1 U/mL). Adenocarcinoma cells were found in the ascites. Treatment with S-1/docetaxel (DOC) was started. After 10 courses, the ascites disappeared and the serum CA19-9 value returned to normal. Four years and 7 months after the operation, the patient has been in good health, with no signs of recurrence.

[A Case of Advanced Gastric Cancer with Long-Term Survival after Chemotherapy with Combined S-1 and CPT-11].

Here, we report a 54-year-old man diagnosed with type 3 advanced gastric cancer who underwent a total gastrectomy and splenectomy plus D2 lymphadenectomy. The pathologic diagnosis was Stage Ⅳ (T3N0H0P0CY1M1). Sixteen courses of combined S-1/CPT-11 chemotherapy were completed, at which time the CPT-11 was discontinued because of malaise, and S-1 alone was continued for a year. The patient is well and has been recurrence-free for 7 years. Thus, he is considered a long- term survivor who was treated with combination S-1/CPT-11 chemotherapy.

[A Case of Colon Cancer with Multiple Liver Metastases Successfully Treated with Capecitabine/Oxaliplatin plus Bevacizumab].

A 69-year-old woman was diagnosed with descending colon cancer with multiple liver metastases, and a left hemicolectomy was performed. The patient was treated with capecitabine/oxaliplatin (CapeOX) plus bevacizumab (Bmab). After 5 courses of chemotherapy, the number and size of liver metastases remarkably reduced, and after the 12th course, because of peripheral neuropathy, a "stop-and-go"fashion of administering oxaliplatin (L-OHP) was initiated. After 14 courses, the liver metastases had disappeared. After the 33rd course of L-OHP treatment, the patient started receiving capecitabine therapy. The patient is recurrence-free 3 years after surgery, 14 months after achieving a complete response (CR). We report a case of long-term CR after surgery for descending colon cancer with multiple liver metastases, followed by a "stop-and-go" method of administering L-OHP or CapeOX plus Bmab therapy.

[Two Cases of Liver Metastasis from Pancreatic Cancer with a Complete Response Owing to Chemotherapy].

Case 1: The patient was a 42-year-old man who was diagnosed with intraductal papillary-mucinous carcinoma with liver metastasis. After S-1+gemcitabine and S-1 chemotherapy, the liver metastasis had disappeared and we performed a pancreaticoduodenectomy( PD). Case 2: The patient was a 70-year-old woman who was diagnosed with pancreatic cancer with liver metastasis. After gemcitabine chemotherapy, the liver metastasis had disappeared and we performed a PD. The prognosis of pancreatic cancer is dismal compared to other types of cancer, and for a Stage Ⅳb cancers, the 5-year survival rate is reported to be approximately 3%. We report 2 cases of liver metastases from pancreatic cancer that disappeared in response to chemotherapy. Both patients underwent primary tumor resection after chemotherapy and experienced long-term survival.

Open-label study to evaluate the pharmacodynamics, clinical efficacy, and safety of meropenem for adult bacterial meningitis in Japan.

The aim of this study was to assess the efficacy, safety, and concentration of meropenem in cerebrospinal fluid when meropenem (2 g every 8 h) was administered to Japanese adult patients with bacterial meningitis. Five Japanese patients (mean age 60.6 years [range 35-71]) were enrolled. Infection with Streptococcus pneumoniae (three patients), Streptococcus salivarius (one patient), and Staphylococcus aureus (one patient) was confirmed by cerebrospinal fluid culture. Meropenem (2 g every 8 h) was administered to all five patients. Treatment duration ranged from 14 to 28 days (mean 22.6 days). All the patients were successfully treated. The concentration of meropenem in cerebrospinal fluid ranged from 0.27 to 6.40 µg/ml up to 8.47 h and was over 1 µg/ml 3 h after starting meropenem infusion. In each patient, the present study confirmed for the first time that the concentration of meropenem in cerebrospinal fluid exceeded the minimal inhibitory concentration for these pathogens. Eleven clinical and laboratory adverse events considered to be related to meropenem were observed in all patients, but no serious adverse event and no discontinuance of treatment due to adverse events occurred. Thus meropenem appeared to be a well-tolerated and effective agent for Japanese adult patients with bacterial meningitis. 2 g every 8 h of meropenem was delivered to CSF and its concentration was exceed in MICs for the detected pathogens.

Relationship between quantitative electroencephalogram and interferon-α-induced depression in chronic hepatitis C patients.

BACKGROUND: Quantitative electroencephalogram (qEEG) changes in chronic hepatitis C patients treated with interferon-α (IFN-α) have previously been reported. However, whether IFN-α-induced depression is related to changes in qEEG during IFN-α treatment remains unclear. METHOD: Fifty chronic hepatitis C patients were enrolled and IFN-α was administered intramuscularly at 9 × 10(6) IU daily for the first 4 weeks and then 3 times a week for the next 20 weeks. Serial EEGs obtained before and at 4 weeks after treatment were assessed. The absolute power for each frequency band was determined using qEEG techniques. Differences in the rate of change in absolute power for each of 6 frequency bands (δ, θ1, θ2, α1, α2 and ß) were assessed between patients with and without major depression using the Mann-Whitney U test. When significant differences in the rate of change in absolute power for each frequency band were observed, differences in the rate of change were also assessed between patients with and without psychological complications using the Mann-Whitney U test. RESULTS: Major depression due to psychological complications during IFN-α treatment was reported in 10 out of 50 patients. In the θ1 band, the difference in the rate of change was demonstrated to be significant (p = 0.0036). Moreover, at the central, frontal, parietal, and temporal locations, the rates of change were also significantly different. CONCLUSION: In IFN-α-treated chronic hepatitis C patients who were diagnosed with major depression, qEEG changes were more obvious and widely distributed.

Clinical Features of Acute Ischemic Stroke Patients with Hypoesthesia as an Initial Symptom.

This study aimed to evaluate the clinical characteristics of acute ischemic stroke (AIS) patients who experienced hypoesthesia as the initial symptom. We retrospectively analyzed the medical records of 176 hospitalized AIS patients who met our inclusion and exclusion criteria and evaluated their clinical features and MRI findings. Among this cohort, 20 (11%) patients presented with hypoesthesia as the initial symptom. MRI scans of these 20 patients identified lesions in the thalamus or pontine tegmentum in 14 and brain lesions at other sites in 6. The 20 hypoesthesia patients had higher systolic (p = 0.031) and diastolic blood pressure (p = 0.037) on admission, and a higher rate of small-vessel occlusion (p < 0.001) than patients without hypoesthesia. The patients with hypoesthesia had a significantly shorter average hospital stay (p = 0.007) but did not differ significantly from those without hypoesthesia in National Institutes of Health Stroke Scale scores on admission (p = 0.182) or the modified Rankin Scale scores for neurologic disability on discharge (p = 0.319). In the patients with acute onset hypoesthesia, high blood pressure, and neurological deficits were more likely to be due to AIS than other causes. Since most of the lesions in AIS patients with hypoesthesia as the initial symptom were found to be small, we recommend performing MRI scans with such patients to confirm AIS.