Journal of Nippon Medical School
Online ISSN : 1347-3409
Print ISSN : 1345-4676
ISSN-L : 1345-4676
Volume 80, Issue 4
Displaying 1-11 of 11 articles from this issue
Photogravure
Review
  • Hiroshi Yoshida, Yasuhiro Mamada, Nobuhiko Taniai, Masato Yoshioka, At ...
    2013 Volume 80 Issue 4 Pages 252-259
    Published: 2013
    Released on J-STAGE: August 30, 2013
    JOURNAL FREE ACCESS
    Bleeding from gastric varices (GVs) is generally considered more severe than that from esophageal varices (EVs) but occurs less frequently. We review the risk factors for bleeding EVs and GVs. GVs were divided into 2 groups: cardiac varices (CVs, Lg-c) and fundal varices (FVs), i.e., varices involving the fundus alone (Lg-f) or varices involving both the cardia and fundus (Lg-cf). Elevated pressure in the portal vein is a risk factor for bleeding EVs. The portal pressure in patients with GVs and a gastrorenal shunt is lower than that in patients with EVs. The large size of varices is a risk factor for bleeding EVs. Red color signs are elevated red areas that are important for predicting the risk of variceal bleeding, and red wale markings, dilated venules oriented longitudinally on the mucosal surface, have been considered to be the sign with the highest risk. Red color signs are rare in FVs, possibly because of the pronounced thickness of the mucosal layer. Bleeding EVs are not associated with use of antiulcer drugs or nonsteroidal anti-inflammatory drugs (NSAIDs). Although, in patients with bleeding GVs, "occasional" use of an oral NSAID is an important step leading to variceal hemorrhage, especially from FVs, even if the mucosa is protected by antiulcer drugs. Constipation, vomiting, severe coughing, and excessive consumption of alcohol may precipitate rupture of EVs.
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Originals
  • Miharu Akao, Yasuhiro Katsube, Mitsuhiro Kamisago, Makoto Watanabe, Ma ...
    2013 Volume 80 Issue 4 Pages 260-267
    Published: 2013
    Released on J-STAGE: August 30, 2013
    JOURNAL FREE ACCESS
    Aims: We evaluated the systolic and diastolic functions of both ventricles from the early neonatal period to adolescence using color tissue Doppler imaging and 2-dimensional tissue tracking echocardiography.
    Methods: We examined 100 healthy children (aged 1-5 days, n=20; 1 month, n=20; 1 year, n=20; 6-7 years, n=20; and 12-13 years, n=20). Blood flow velocities in the mitral and tricuspid valves (E) were obtained with pulsed Doppler imaging, and longitudinal systolic (S') and early diastolic (E') peak velocities at the mid free wall segment of both ventricles were obtained with color tissue Doppler imaging. For longitudinal strain imaging, systolic peak values were obtained at the same position. In addition, peak systolic radial strain was obtained from a short-axis view of the left ventricle using the tissue tracking method. The E/E' ratio was calculated.
    Results: Regarding systolic indices, S' increased during development and stabilized at 6 to 7 years, and longitudinal strain reached values of the 12- to 13-year-old group at 1 year of age in both ventricles. Like longitudinal strain, radial strain in the left ventricle reached values of the 12- to 13-year-old group at the age of 1 year. Similarly, the E/E' ratio was high at 1 month or younger and decreased by 1 year.
    Conclusions: Systolic and diastolic variables change markedly from birth to 1 year of age and show only small changes thereafter.
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  • Takemitsu Matayoshi, Tokuya Omi, Noriyasu Sakai, Seiji Kawana
    2013 Volume 80 Issue 4 Pages 268-278
    Published: 2013
    Released on J-STAGE: August 30, 2013
    JOURNAL FREE ACCESS
    Background: A correlation between decreased blood coagulation factor XIII activity and the severity of organ disorders in pediatric Henoch-Schönlein purpura (HSP) has been demonstrated, but possible correlations in adult HSP have not been thoroughly investigated.
    Objectives: To investigate the association between factor XIII activity with varying clinical severities of HSP and the severity of organ disorders and to examine the efficacy of factor XIII substitution therapy.
    Methods: The distribution of purpura and the severities of joint, abdominal, and renal symptoms were scored in 44 adults with HSP. Plasma factor XIII activity was measured with the latex agglutination immunoturbidity method.
    Results: Reduced factor XIII activities were correlated with clinical severity scores (the total of all scores), organ disorder severity scores (the total score excluding the purpura score), joint symptom scores, and abdominal symptom scores but not with renal disorder scores. Factor XIII activities were increased in patients during posttreatment remission. Factor XIII substitution therapy was performed in 7 patients with severe organ disorders. Consequently, joint and abdominal symptoms markedly improved, but renal symptoms did not.
    Conclusion: Measurement of plasma factor XIII activity in adult HSP is clinically useful because it indicates disease severity and the severity of digestive tract and joint disorders. Factor XIII substitution therapy is effective for joint and abdominal symptoms but not for renal symptoms. Further investigation of the effect of this treatment on renal symptoms is necessary.
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  • Tomohiro Kaneko, Akira Shimizu, Shuichi Tsuruoka, Yasuhiko Iino, Yasuo ...
    2013 Volume 80 Issue 4 Pages 279-286
    Published: 2013
    Released on J-STAGE: August 30, 2013
    JOURNAL FREE ACCESS
    Background: The long-term prognosis of immunoglobulin A nephropathy is poor. Treatment is intended to achieve complete remission in the early stage or to preserve renal function in the advanced stages. In Japan, aggressive steroid pulse therapy following tonsillectomy (tonsillectomy-pulse therapy) has recently been used to treat early IgA nephropathy and has achieved favorable outcomes. However, steroid doses are sometimes limited because of adverse reactions s and the efficacy of tonsillectomy-steroid pulse therapy has not been established in patients with renal dysfunction. In our current treatment protocol, the total steroid dose has been significantly reduced through the use of the immunosuppressant mizoribine in combination with tonsillectomy-steroid pulse therapy for the treatment of active IgA nephropathy in patients with renal impairment.
    Methods: The subjects were 18 patients with active IgA nephropathy who were younger than 70 years and had an estimated glomerular filtration rate ≥20 and <60 mL/min/1.73 m2. After giving informed consent, the patients underwent bilateral tonsillectomy. One week later, intravenous methylprednisolone pulse therapy (500 mg/day) was administered for 3 days, followed by oral prednisolone in combination with mizoribine (100 to 150 mg/day). A renin-angiotensin system inhibitor was used before tonsillectomy in all cases. One year after tonsillectomy, the safety of this protocol and its effects on hematuria, proteinuria, and the progression of renal dysfunction were assessed.
    Results: The mean patient age was 48.4 years, and the mean time from disease onset to tonsillectomy was 8.4 years. After 1 year, urinary protein had decreased (1.80 ± 1.36 to 0.47 ± 0.75 g/g・Cr) in all cases but 1 and had resolved completely in 38.9% of cases. Hematuria had decreased in all cases and had resolved completely in 61.1% of cases. The estimated glomerular filtration rate also improved in all cases and the mean increased significantly from 42.4 ± 11.9 to 50.1 ± 15.9 mL/min/1.73 m2. No serious complications were found during follow-up. Steroid acne that required treatment occurred in 2 cases (11.1%) but was transient and mild.
    Conclusion: Steroid pulse therapy in combination with mizoribine following tonsillectomy is effective in improving urinary findings and preserving renal function in the treatment of IgA nephropathy, which remained active in patients with renal impairment (estimated glomerular filtration rate ≥20 and <60 mL/min/1.73 m2).
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  • Takuro Shinada, Noritake Hata, Nobuaki Kobayashi, Kazunori Tomita, Aki ...
    2013 Volume 80 Issue 4 Pages 287-295
    Published: 2013
    Released on J-STAGE: August 30, 2013
    JOURNAL FREE ACCESS
    Aim of the Study: Cardiopulmonary resuscitation and mild therapeutic hypothermia (MTH) have improved neurological outcomes after sudden cardiac arrest, but the factors affecting favorable neurological outcome remain unclear. The aim of this study was to clarify these factors in patients in cardiac arrest treated with MTH.
    Methods: Forty-six consecutive patients (mean age, 59.4 ± 14.3 years; 37 men and 9 women) who had had cardiogenic cardiac arrest from January 2008 through December 2011, including cases that were and were not shockable, were enrolled in this study, and the factors affecting favorable neurological outcome were retrospectively investigated. The interval from cardiac arrest to cardiopulmonary resuscitation, the return of spontaneous circulation (ROSC), the start of MTH, and the attaining of the target temperature were retrieved from the medical records. The relationship between the neurological outcome and clinical findings, including the causes of cardiac arrest and vital signs before MTH, were also investigated.
    Results: Blood pressure and body temperature before MTH were higher, the interval from cardiac arrest to ROSC was shorter, and MTH was started earlier in patients with favorable neurological outcomes than in those with unfavorable outcomes. A multivariate logistic regression model revealed that the presence of prehospital ROSC was predictive of a favorable neurological outcome. In addition, renal failure during MTH occurred more frequently in patients with unfavorable neurological outcomes.
    Conclusion: MTH is associated with favorable neurological outcomes after sudden cardiac arrest, including those with non-shockable rhythms, especially in patients with prehospital ROSC.
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Case Reports
  • Barış Saylam, Mehmet Onur Gülseren, Özge Han, ...
    2013 Volume 80 Issue 4 Pages 296-299
    Published: 2013
    Released on J-STAGE: August 30, 2013
    JOURNAL FREE ACCESS
    We report on a 49-year-old woman with cysts of the round ligament causing a nonreducible mass of the groin. Cysts of the round ligament are rare. Physical findings were similar to those of an inguinal hernia. Such cysts are usually not considered in the differential diagnosis of groin hernias and might be identified only at the time of herniorraphy.
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  • Ryuji Ohashi, Nozomu Wakayama, Masashi Kawamoto, Shinichi Tsuchiya, Ki ...
    2013 Volume 80 Issue 4 Pages 300-306
    Published: 2013
    Released on J-STAGE: August 30, 2013
    JOURNAL FREE ACCESS
    A solitary nasal schwannoma in a 31-year-old woman is described. The patient had a 10-year history of left nasal obstruction and presented with worsening symptoms. Computed tomography revealed a mass in the left nasal cavity extending into the ethmoidal and sphenoidal sinuses. A large, white polypoidal mass with a smooth surface was removed endoscopically piece by piece. Microscopic examination showed the tumor to be a benign spindle-cell neoplasm with predominantly mixed cellular pattern and with an indistinct focal mixture of hypercellular and hypocellular areas, likely representing Antoni A and B areas, respectively. Differential diagnoses included schwannoma, neurofibroma, solitary fibrous tumor, and meningioma. On immunohistochemical examination, the neoplastic cells showed diffuse and strong positivity for S-100. CD34 was positive primarily in the hypocellular area (Antoni B) but weak or negative in the hypercellular area (Antoni A). Staining for calretinin was focal and strong, and that for glial fibrillary acidic protein was diffuse and weak; however, stainings for estrogen receptor, epithelial membrane antigen, and α-smooth muscle actin were negative. This immunohistochemical profile confirmed the diagnosis of schwannoma. The combined use of immunostains (CD34, calretinin) could be useful for differentiating sinonasal schwannoma from its histological mimics when the typical features are weak or absent.
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  • Masato Miyauchi, Makiko Hayashida, Kimiko Hirata, Kiyotaka Hirata, Hir ...
    2013 Volume 80 Issue 4 Pages 307-311
    Published: 2013
    Released on J-STAGE: August 30, 2013
    JOURNAL FREE ACCESS
    Nicotine, which is found in tobacco, is one of the most toxic of all known poisons. A 31-year-old woman was brought to our emergency department 2 hours after ingesting a usually fatal dose of a tobacco extract. Although gastric lavage was once commonly used to treat poisoning cases of this type, lavage can lead to such complications as aspiration, hypoxia, oropharyngeal and gastric trauma, and electrolyte disturbances. Recent guidelines have suggested less-aggressive gastric-emptying procedures as initial treatments. Currently, there are no absolute indications for gastric lavage use. The present patient had a history of depressive episodes and had attempted suicide by ingesting an extract derived from 20 cigarettes mixed with alcohol. There was no evidence of vomiting or seizures occurring before arrival of the ambulance. Physical examination revealed no signs of sweating, although the patient appeared to be confused, which is often seen with nicotine intoxication. She admitted using 2 kinds of cigarette, each of which typically contain 11.2 mg of nicotine. The patient's nicotine level was suspected to be higher than 40 to 60 mg, which is normally fatal. To determine whether gastric lavage was indicated in this case, we performed ultrathin transnasal esophagogastroduodenoscopy, which neither requires sedation nor compromises the airways. Although 2 hours had passed since ingestion, the tobacco extract and food were directly visualized within the stomach. Subsequently, gastric lavage was performed with 2,000 mL of water administered through a nasogastric tube. Ultrathin esophagogastroduodenoscopy made it possible to directly observe the gastric lavage and to ensure the stomach contents had been completely removed. No changes were noted in the vital signs, and no obstruction of the airways was observed. The patient recovered quickly and was discharged the following day. Ultrathin esophagogastroduodenoscopy helped determine the diagnosis and ensure that gastric lavage had been performed without complications.
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  • Satoshi Mizutani, Takayuki Aimoto, Hideyuki Suzuki, Seiji Yamagishi, M ...
    2013 Volume 80 Issue 4 Pages 312-317
    Published: 2013
    Released on J-STAGE: August 30, 2013
    JOURNAL FREE ACCESS
    A surgical procedure is the only way to relieve intractable pain in patients with chronic pancreatitis and an inflammatory mass in the pancreas head. Although the Frey procedure is safer and more effective for pain relief than is standard pancreaticodudenectomy, it is often associated with such complications as pancreatic fistula and postoperative hemorrhage. A 64-year-old man was admitted to our hospital because of increasingly frequent episodes of epigastralgia. This patient had continued to abuse alcohol until recently and was regularly using painkillers to relieve severe pain due to chronic pancreatitis. The patient underwent the Frey procedure with the use of 2 types of ultrasonically activated scalpel. There were no surgery-related complications. The patient was discharged 18 days after the operation. Neither recurrence of pain nor locoregional complications have been observed for 2 years after the procedure. Herein we report the use of the Frey procedure to treat an enlarged mass of the pancreatic head and discuss the efficacy of the ultrasonically activated scalpel for excavation of the pancreatic head and long dichotomy of the pancreatic duct.
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  • Yoshikazu Kanazawa, Shunji Kato, Itsuo Fujita, Hiroyuki Onodera, Hidey ...
    2013 Volume 80 Issue 4 Pages 318-323
    Published: 2013
    Released on J-STAGE: August 30, 2013
    JOURNAL FREE ACCESS
    We report a case of advanced stomach cancer metastatic to the spermatic cord 1 year after curative distal gastrectomy. The patient underwent distal gastrectomy with D2 lymph node dissection. There was no metastasis to the liver or peritoneum, and cytologic examination of the peritoneal lavage fluid was negative for cancer cells (CY0). Histological examination revealed a moderately differentiated tubular adenocarcinoma that had penetrated the serosa (T4a). Postoperative staging was T4aN1M0, stage IIIA, according to the Japanese gastric carcinoma classification scale. One year after the operation, the patient was readmitted with right groin pain. Percutaneous fine needle aspiration biopsy of the inguinal tumor revealed a tubular adenocarcinoma. Extirpation of the inguinal tumor with wedge resection of the right iliac-femoral vein was performed. Pathological examination revealed a moderately differentiated tubular adenocarcinoma that had diffusely infiltrated the connective tissue surrounding the spermatic cord. Immunohistochemical studies showed the tumor cells were reactive for CK7 but not for CK20. These findings were consistent with the diagnosis of a spermatic cord tumor metastatic from a known gastric primary cancer. Laparoscopic exploration showed invagination of the peritoneum with small nodules from the median umbilical fold to the lateral umbilical fold and a markedly decreased distance between the folds. Pathological examination in this area revealed a tubular structure consisting of mesothelial cells within the cancer tissue which was associated with dense fibrosis, suggesting that the invagination of the peritoneum had been caused by minimal peritoneal metastasis.
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